The prostate-specific antigen (PSA) test plays a crucial role in identifying prostate cancer at an early, asymptomatic stage. However, some men are only diagnosed once symptoms develop. To better understand how doctors differentiate prostate cancer from other noncancerous prostate conditions, we consulted Dr. Marc B. Garnick, the Gorman Brothers Professor of Medicine at Harvard Medical School and Beth Israel Deaconess Medical Center, and editor-in-chief of the Harvard Medical School Guide to Prostate Diseases. His expertise sheds light on how physicians evaluate test results and symptoms to ensure accurate diagnosis and appropriate treatment.
Early Symptoms of Prostate Cancer in Men
It’s important to note that most men diagnosed with prostate cancer—even in advanced stages—often do not experience any noticeable symptoms. When early-stage prostate cancer does produce signs, they usually relate to urinary function. These are known as lower urinary tract symptoms (LUTS) and can include increased frequency of urination, sudden urges to urinate, difficulty starting or stopping the urine stream, waking up multiple times at night to urinate, or the sensation of not fully emptying the bladder.
These symptoms typically occur when a tumor grows large enough to partially block the urethra, the tube responsible for carrying urine out of the body. Additionally, an enlarged or diseased prostate can press against the bladder, reducing its ability to hold urine comfortably.
Understanding Urinary Symptoms and Prostate Health
More often than not, urinary symptoms are caused by noncancerous prostate issues. For example, benign prostatic hyperplasia (BPH) is a natural enlargement of the prostate that occurs in most men as they age. In some cases, inflammation of the prostate and surrounding tissues—known as prostatitis—can also lead to lower urinary tract symptoms (LUTS). Meanwhile, if a man experiences a burning sensation during urination, the problem is usually related to the bladder rather than the prostate. Any man experiencing these urinary issues should seek evaluation by a healthcare professional.
How Doctors Narrow Down the Diagnosis
Once conditions like prostatitis and bladder disease are ruled out, doctors focus on distinguishing prostate cancer from BPH. Men with BPH generally present with two types of urinary symptoms:
Voiding symptoms caused by obstruction at the bladder outlet, such as a weak or intermittent urine stream and difficulty fully emptying the bladder.
Storage symptoms caused by an overactive bladder, including a sudden urge to urinate or needing to urinate frequently during the day or night.
A potential warning sign for prostate cancer is the presence of storage symptoms alone or urinary symptoms that develop rapidly, which is uncommon for BPH-related LUTS. To assess the severity and type of symptoms, doctors often use the American Urological Association Symptom Score (AUA-SS) questionnaire.
Digital Rectal Exam and Its Role in Diagnosis
A digital rectal examination (DRE) is another tool doctors use to evaluate the prostate. If the prostate feels symmetrically enlarged—meaning the gland is uniformly bigger—this supports a diagnosis of BPH. However, if the doctor detects asymmetry or a hard nodule, the patient should be referred to a urologist for further testing. Although DREs are performed less frequently today and many physicians have limited training in the technique, they remain a crucial part of the physical exam.
It’s also important to understand that untreated BPH can lead to serious complications, including acute urinary retention (a sudden inability to urinate) and even kidney failure. Early evaluation and management are essential to prevent these outcomes.
Using PSA to Differentiate Between BPH and Prostate Cancer
Prostate-specific antigen (PSA) testing can help distinguish BPH from prostate cancer, though levels can be elevated in both conditions. A larger or irritated prostate releases more PSA into the bloodstream. Typically, doctors may start BPH medications that improve urinary flow and lower PSA levels. After approximately six weeks, PSA is rechecked.
If PSA remains elevated, the next step often involves a prostate MRI. A normal MRI, along with PSA levels proportionate to prostate size, helps rule out cancer. In such cases, a prostate biopsy may be deferred, with ongoing PSA monitoring instead.
Symptoms of Advanced Prostate Cancer
As prostate cancer progresses and metastasizes, symptoms may extend beyond the urinary tract. These can include bone pain, swelling in the legs, unexplained weight loss, fatigue, and back or hip pain due to cancer spreading to the bones. Recognizing these signs early is vital for timely intervention.
Advanced Prostate Cancer: Symptoms and Detection
Even in advanced stages, many men with prostate cancer remain completely asymptomatic. Fortunately, advances in imaging and treatment have significantly improved the ability to detect and manage even small cancer deposits.
When symptoms do appear, particularly if the cancer has spread to the bones, men often experience pain in the back or shoulders. This pain typically occurs where metastases develop near bones and nerves. Men with persistent or worsening back pain despite standard treatments should undergo further evaluation, such as X-rays or MRI scans, to assess for bone involvement.
Fatigue and Weight Loss
While fatigue and unexplained weight loss are common in cancers like colon, lung, or lymphoma, they are rare in prostate cancer unless the disease is very advanced and widely metastatic.
Key Takeaways
Diagnosing prostate issues can be challenging because urinary symptoms often overlap between prostate cancer and benign conditions like BPH. Careful evaluation—including PSA testing, digital rectal exams, imaging, and symptom assessment—is crucial for accurate diagnosis and timely treatment. Understanding these distinctions helps both patients and physicians navigate prostate health effectively.
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