BPH: when to rule out carcinoma of the prostate.

With the inevitable increase in non-surgical management of the many thousands of patients with assumed benign prostatic enlargement, the issue of undiagnosed prostatic cancer needs to be addressed. Currently our knowledge is incomplete in many areas, especially that pertaining to the outcome of therapy of incidentally discovered prostate cancers. Nonetheless common sense dictates that all patients presenting with clinical BPH should undergo DRE and those with palpable induration or asymmetry should be biopsied in the knowledge that around a third will prove positive. Ideally all patients with clinical BPH should also have a PSA determination, however, the result should be interpreted with care, taking into account the age and estimated life-expectancy of the patient. Patients younger than 75 with a PSA > 10 ng/ml should probably be biopsied routinely--around half will have cancer. Patients with PSA values between 4 and 10 (around 50% of cases of BPH) may legitimately be carefully observed for a period. Biopsy should be performed if an increase of > 20% in the PSA occurs during the year of follow-up especially in younger patients. Evidence is mounting that TRUS has serious deficiencies in identifying prostate cancers, nonetheless it does provide the most effective means of accomplishing transrectal prostatic biopsy. Further studies are required to critically evaluate the competing claims for improved diagnostic accuracy of PSAD, PSAV and age-adjusted PSA, the last of which does have the advantage of practicability.