Case Study #1: A Single Elevated PSA

This case is hypothetical and written for teaching, to help you understand how I think through decisions about elevated PSA. It is not based on any real patient.

History

Bob is a 57-year-old man who came in after a routine physical showed an elevated PSA. He feels well and reports no urinary symptoms. His prostate exam was normal. He is otherwise healthy and takes no daily medications.

PSA trend

2021 — 2.8 ng/mL

2022 — 3.1 ng/mL

2023 — 2.9 ng/mL

2024 — 3.3 ng/mL

2025 — 3.0 ng/mL

October 2026 — 6.5 ng/mL

Five years of stable readings under 4, then a single spike to 6.5.

Secondary testing

No secondary testing was performed.

Previous biopsy

Bob has never had a prostate biopsy.

Family history

No family history of prostate cancer.

Other health considerations

None — Bob is healthy, with no conditions or medications that affect the decision.

___________________________________________________

What I would recommend for this patient

Repeat the PSA in four weeks. For 2 to 4 days before the recheck, avoid ejaculation and activities that can raise PSA, such as bike riding or riding a lawnmower.

Rationale

Bob has five years of PSAs under 4 and one sudden reading of 6.5. A single spike like that can be noise rather than a new normal — 20 to 40% of newly elevated PSAs come back down on a recheck. PSA also varies with lab differences, recent ejaculation, or a prostate infection, which is why the first step is simply to repeat the test rather than ordering an MRI or scheduling a biopsy. Acting on one reading alone risks putting Bob through procedures he may not need.

A few practical points: allow 4 to 6 weeks between the two readings so enough time has passed, and avoid ejaculation and activities that can raise PSA — like bike riding or riding a lawnmower — for 2 to 4 days before the draw. Antibiotics aren't needed unless a urine test actually shows an infection.

If the repeat comes back down, we watch. If it confirms the elevation, then we talk about next steps.

By Chad Ellimoottil, MD — urologist at Michigan Medicine specializing in prostate cancer detection.

Disclaimer: This information is for general educational purposes only and is not medical advice. Please consult a qualified healthcare professional about any medical condition, diagnosis, or treatment decision.