Diagnosing Prostate

A Prostate Exam Is Your Best Defense

Getting screened is usually your first and quickest indicator of knowing if you have prostate cancer. Tumors in the prostate typically grow slowly without pushing against anything to cause pain. Therefore, the disease has few early warning signs and can remain silent for years. Prepare yourself to discuss your prostate health with your doctor by learning about the signs of prostate cancer, types of testing and steps to take when facing a possible prostate cancer prognosis.

Cautionary Signs & Advanced Prostate Cancer Symptoms

If you start experiencing the following symptoms, schedule an appointment with your doctor to examine and discuss potential causes.

  • Difficulty urinating, including a slow, weak, dribbling or interrupted urinary stream
  • Bloody urine or semen
  • Erectile dysfunction
  • Painful ejaculation
  • Swelling in pelvic area or legs
  • Pressure or pain in the rectum
  • Weakness or numbness in legs or feet
  • Loss of bladder and/or bowel control
  • Fatigue
  • Unexplained weight loss

Bone Metastasis Signs & Symptoms

If prostate cancer metastasizes, about 80% of the time it will spread to the hip, spine and pelvic bone. Once this occurs, the cancer is likely in Stage 4 and your symptoms might become more widespread and affect other areas of the body.

  • Bone pain
  • Weak bones increasing your risk for fractures
  • Spinal cord compression and related weakness or numbness
  • High blood calcium levels, which can trigger vomiting, dehydration, confusion and abdominal discomfort
  • Stiffness or pain in the hip, thighs, or back

When to Schedule a Regular Prostate Exam

Start talking with your doctor at the age of 40 to determine the best prostate care plan for you. Based on your risk factors, your doctor might recommend you hold off on testing or suggest one or two of the preliminary tests.

Standard Age to Start Prostate Exams

40 Highest risk.

If you have a family history, more than one first-degree relative (father, brother, son) diagnosed at an early age (younger than 65) or an inherited genetic mutation linked to prostate cancer.

45 High risk.

If you are African American or have a first-degree relative diagnosed with prostate cancer at an early age.

50 Average risk.

If you have no family history and are not African American.

Over 50 Discuss with your doctor.

Recommendations may vary based on age, health and other personal health issues.

What to Expect During a Prostate Exam

Depending on the type of testing, precautions recommended by your doctor and previous exam results, you may take one or more of these exams.

Digital Rectal Exam (DRE)

During a digital rectal exam, your doctor will ask you to bend over or lie in a fetal position on the exam table. He or she will insert a gloved, lubricated finger into your rectum to check for abnormalities. If he or she feels a bump, hard or soft spot or if your prostate is enlarged, further testing may be recommended. This exam only takes a couple of minutes but can be uncomfortable, especially if you have hemorrhoids.

Prostate-Specific Antigen (PSA) blood test

PSA is a protein produced by the prostate and found mostly in semen and in very small amounts released into the bloodstream. While not mutually exclusive, PSA levels tend to rise when there’s a problem with the prostate. Elevated levels can act as a smoke alarm for you and your doctor to explore additional testing. Results usually take 1 to 2 weeks to process.

Transrectal Ultrasound (TRUS)

During this typically pain-free, 15-minute outpatient procedure, a small probe will pass through your rectum and the ultrasound machine will send out sound waves to create an image of your prostate gland. This image will help your urologist tell the difference between non-cancerous and cancerous changes in your prostate and the size of the area in concern. This visual guide will also be used to biopsy the site in TRUS-guided biopsy. An enema the night before may be required and some blood in your urine may occur afterwards. You can expect results within a week.

Prostate Cancer Biopsy

This outpatient procedure requires a small injection to numb the site. Anesthesia may be required for larger samples. In a TRUS-guided biopsy, your urologist will quickly insert a thin, hollow needle through the rectum and into the prostate to collect core tissue samples from different parts of the prostate. Most urologists will take around 12 core samples to increase their chances of catching any abnormal cells. A biopsy sample can also be obtained through a trans-perineal biopsy in which a needle is placed through the perineum or skin between the scrotum and anus. The pathologist will examine the samples under a microscope to grade the cancerous cell patterns present in your tissues and to determine your Gleason score, a scale from 2 to 10 that rates the aggressiveness of your cancer in your prostate cells.

Detection & Prostate Cancer Diagnosis

Based on your specific test results, your doctor may recommend additional testing or more frequent appointments to keep an eye on results that need to be monitored.

Common Scenarios

1) Elevated PSA Levels

Try not to panic if your test results come back slightly higher than normal. Several other factors can increase and decrease your PSA levels. In fact, some studies have shown 75% of men whose levels are elevated don’t have cancer. Two of the most common causes are BPH (Benign Prostatic Hyperplasia, a non-cancerous enlargement of the prostate) and Prostatitis (infection or inflammation of the prostate gland).

General Reading of PSA Levels

< 2.5 Based on your age and other risk factors, may only need to get retested every two years
> 2.5 Annual screening commonly recommended
4-10 One in four chance of being diagnosed with prostate cancer
> 10 Chance of a prostate cancer diagnosis rises to over 50%
>20 Advanced prostate cancer in many cases

Other factors shown to affect PSA levels:

Increase PSA Levels Decrease PSA Levels

BPH: Benign Prostatic Hyperplasia, a non-cancerous enlargement of the prostate

Prostatitis: Infection or inflammation of the prostate gland

Age: PSA levels normally go up as you get older.

Ejaculation: Doctors might recommend abstaining from ejaculation 1 to 2 days before testing.

Riding a bike: Some studies have suggested cycling may have an effect.

Certain prostate procedures: Doctors may advise having blood drawn before having a DRE, prostate biopsy or cystoscopy.

Certain medicines: Male hormones or medicines that raise testosterone levels.


5-alpha reductase inhibitors: Certain drugsused to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart).

Statins: Long-term use of cholesterol-lowering drugs, such as atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor).

Thiazide diuretics: Water pills often used to treat high blood pressure.

Other: Herbal mixtures, obesity and aspirin.

Possible Next Steps

If your PSA levels are mildly elevated, there are other supplementary tests, PSA-based markers and considerations available to rule out other causes and decide if a biopsy is necessary.

  • Free PSA test: Lower percentage indicates greater risk of having cancer.
  • PSA velocity or the rate of rise over time: Faster increase means more risk.
  • PSA density or level per volume of prostate: Higher density means more risk.
  • Digital Rectal Exam (DRE): Feel for enlargements, bumps and hard or soft areas.
  • Prostate Health Index (PHI): Measurement based on a combination of three forms of the PSA protein to help calculate the probability of cancer.
  • 4K Score: Blood test measuring of four different prostate-related proteins that provides a percent risk score of having an aggressive prostate cancer.
  • Urinary PCA3 gene test: Higher levels increase chances of cancer.
  • Magnetic resonance imaging (MRI): More detailed set of images than an ultrasound.

2) Abnormal Biopsy Results

Biopsies of the prostate can reveal results other than prostate cancer. Some of the most common results are a 1) benign enlargement, 2) inflammation and 3) PIN (Prostatic Intraepithelial Neoplasia, which is a type of cell change that looks abnormal and could become cancer). If PIN is detected, a pathologist will report the cells as “suspicious” and more than likely recommend a biopsy of another portion of the gland because there is a 30% to 50% chance of finding prostate cancer in a follow-up biopsy when high-grade PIN is initially spotted.

Grading Your Tumor Cells

After a biopsy, a pathologist will examine your tissue samples under the microscope to determine the aggressiveness of your cancer based on the amount of cellular deviation from normal prostate cells. He or she will assign two separate grades to the two most predominant cancerous cell patterns present in your tissue samples. Each cell pattern receives a grade between 1 and 5 using the cellular grading criteria below.

Prostate Cancer Cell Grades

Grade 1 Small, uniform cells packed together much like normal prostate cells

Grade 2* Cells of various shapes loosely packed together

Grade 3* More irregularities in cell size and shape with signs of fusion between cells beginning

*Patterns in these grades can vary greatly as some cells look more normal than other cells.

Calculating Your Gleason Score

Your Gleason score (a scale from 2 to 10) is the sum of the grades of your two most predominant cancer cell patterns. This score is ultimately used to gauge the likelihood and risk of your prostate cancer growing and spreading.

Gleason Score Prostate Cancer Diagnosis

Low Risk Medium Risk High Risk
Gleason Scores 2-5 Gleason Scores 6-7 Gleason Scores 8-10
Early stage tumor. Usually unlikely to grow or spread to other tissues or organs for years. Many men choose to monitor their prostate cancer with more frequent checkups and testing.

Possible Next Steps:

– Active surveillance

– DREs

– PSA tests

– Ultrasound/other imaging

– Additional biopsies

Most prostate cancers fall in this category. Cancer is still typically unlikely to grow or spread for several years. However, treatment might be recommended based on a man’s age, health and personal preferences.

Possible Next Steps:

– Active surveillance

– Surgery

– Radiation/proton therapy

– Medication

– Combination

More advanced tumor. High risk of spreading aggressively. Some of these cells can also be “poorly differentiated” or early-stage cancer that has not spread but is likely to within a few years.

Possible Next Steps:

– Surgery

– Radiation/proton therapy

– Medication

– Combination

Learn More About Your Prostate Cancer Treatment Options

Other Prostate Cancer Diagnosis Testing

Your Gleason Score is one way to determine the growth rate, aggressiveness and severity of your prostate cancer. Additional tests may be performed to help better assess whether or not treatment is needed now and in the future and the type of treatment. Some of these tests include Prolaris (assess the aggressiveness of your cancer by measuring how fast the cells in your tumor are dividing) and Oncotype DX (genomic test proven to predict how your body will respond to chemotherapy).

Dealing with a Prostate Cancer Prognosis

A cancer diagnosis can be lifechanging. Luckily, very few prostate cancers require urgent treatment. Most men have time to figure out the best course of action for them. The best thing you can do is educate yourself on the types of treatments available, find a doctor you’re comfortable with, make smart lifestyle choices to improve your ability to fight off cancer and stay positive.

Thanks to advancements in technology, treatments like proton therapy are helping provide prostate cancer patients with strong cure rates, reduced side effects and improved outcomes, such as a lower risk of impotence and incontinence. In fact, recent studies show the stats are getting even better as treatments continue to improve.

Learn More About Proton Therapy for Prostate Cancer Treatment

Relative Prostate Cancer Survival Rates*

99% 98% 96%
5 years 10 years 15 years

*Percentages include all stages of prostate cancer