Lowering PSA - Safe to relax?

[u/VaderJim]

Hey everyone, posted about a month ago and has been a bit of development, just wondering how to interpret the news before I speak to my urologist (they're sending me a letter apparently, thanks NHS)

Quick Stats

• Age: 37
• PSA Timeline:
• July: 4.3 (tested during an ED checkup)
• August: 5.4 (PSA density 0.11) — worth noting this blood draw was done within 24 hours of ejaculation and right after a DRE
• October: Dropped to 3.1
• MRI: PI-RADS 3 (equivocal finding in one area.

What happened

After my first PSA came back at 4.3, I got referred to urology. They repeated the PSA (5.4) and booked me for an MRI. The MRI picked up a PI-RADS 3 finding, and the clinic told me to repeat the blood test in a month.

Around that same time, I started getting some suspected bladder pain and frequent urination. Standard urine cultures and STI panels all came back completely negative. Worried that prostate inflammation or a hidden infection was artificially spiking my numbers and pushing me toward an unnecessary biopsy, my doctor put me on a 2-week course of Ofloxacin. About a week after finishing the antibiotics, I had my repeat PSA done and it dropped down to 3.1.

I haven't had my follow-up appointment with urology to review this yet, but I'm trying to make sense of where I stand.

A couple of things I'm wondering: * Is a drop from 5.4 to 3.1 after antibiotics/time as reassuring as it feels, or am I getting ahead of myself? * If the antibiotics are what helped lower it, but no infection was ever detected on tests, how do I truly know the infection is fully gone? * What is likely to happen next at urology? Will they typically want to repeat the PSA in a few months to ensure it stays level or continues to drop, or do they still tend to push for a biopsy with a PI-RADS 3?

[u/parttimephotoguy]

I had an appt with my radiologist yesterday. We talked about PSA as a marker for prostate cancer. He told me a few stories. One story comes to mind after reading yours... He told me that a lot of guys see a lowering PSA and assume it's all good and maybe even the cancer is gone or leaving the body. Quite the opposite. Sometimes (I'm not saying all...) the cancer is so invasive that it's taken over the prostate. He told me that the guy went in for additional tests and that is in fact what happened. I'm not saying this to scare you but keep in mind that the PSA test is somewhat inherently flawed and is only one of many in evaluation tests used. Please get a biopsy asap!

[u/VaderJim → u/parttimephotoguy]

While I do appreciate that is a possibility, I'm hoping that if it was that advanced it would have shown up as more than 1 lesion with a pirads score of 3 on my MRI, scary stuff though!

Like how do they even detect it in cases like that if they aren't already aware that there is an issue.

[u/parttimephotoguy → u/VaderJim]

You can't go by the PI-RADS score, at least in my experience. My last MRI was either "zero" or "non-detectable." Yet here I am, starting radiation in 2 weeks with a 4+4 Gleeson score.

[u/KReddit934]

In general, if antibiotics lower the PSA, then the rise was very likely due to infection. At your age and with these numbers, I cannot see undertaking anything but active surveillance. Monitor PSA every three months for year and then decide. (NOT a doctor.)

[u/ChillWarrior801]

IANAD

The best clinical evidence I've seen is that if a guy who's never had a biopsy presents with a PI-RADS 3 lesion and a PSA Density less than 0.10, that a biopsy is unwarranted. Unless you've got an unfavorable family history or genetic history, I'd just repeat the PSA test at whatever interval your doc suggests.

[u/VaderJim → u/ChillWarrior801]

PSA density at 5.3 PSA was 0.11. By my math unless the prostate has shrunk by more than 36% at a PSA of 3.1 I'm now below 0.10.

Feeling positive about that result at least, now I just need to wait for the letter from the urology team to see what they suggest.

[u/ChillWarrior801 → u/VaderJim]

Your math is spot on. Your urologist may still insist on a biopsy, though. Your best move at that point is to insist on a transperineal (as opposed to transrectal) biopsy under sedation. Less risk of infection, less risk of false negatives, most comfortable way to get it done. Only a minority of urologists are equipped for all that. If yours can do it and insurance covers it, that wouldn't be the worst thing. Otherwise, you gotta push back hard.

Good luck!

[u/callmegorn]

They're sending a letter? Is it 2026 or 1926? LOL

If I was in your situation, I wouldn't jump into a biopsy. Give it a few months and test again. The PSA spike can come from all sorts of things. You have other symptoms that suggest various infections and inflammations rather than cancer, so taking your time is warranted.

Mind you, a spike like yours could indeed be associated with cancer. In my own case, in four consecutive tests I went from 4.6 to 7.1 to 5.6 to 7.5. My interpretation of this (not confirmed by anybody, so just my guess) is the spikes had to do with my two tumors breaching the capsule, first one and then the other, causing increased irritation for a period and then dropping back to baseline.

But, a spike like that can come from completely benign sources. This is what makes PSA alone a poor diagnostic tool.

[u/Frosty-Growth-2664]

PSA present due to cancer doesn't usually drop by itself assuming you aren't being treated, so if you see a PSA drop, the previous level probably had something contributing to it which wasn't cancer.

Many antibiotics also act as anti-inflammatory drugs, and when inflammation is present for any reason, it can be the anti-inflammatory effect which reduces PSA rather than the antibiotic acting on a bacteria. (It's this which can give temporary relief from a UTI or bacterial prostatitis, even when it was the wrong antibiotic for the bacteria, but in that case, the relief can be short-lived.)

Some viruses (notably COVID) will temporarily increase PSA for a month or so afterwards. Some COVID vaccinations have done too, but I don't know if the current ones do.

[u/callmegorn → u/Frosty-Growth-2664]

As described in my comment, it may not be a "drop", but rather a reversion to baseline. In other words, the brief higher reading can be a spike associated with cancer (or something else) causing a temporary irritation. That irritation can then go away, but the cancer is still there and will continue to grow.

[u/IndyOpenMinded]

In my opinion, not a doctor, PIRADS 3 = Biopsy. I did not, and had a repeat MRI about a year later and had a biopsy then. The biopsy showed Gleason 9, very aggressive. Wish I would have had it the year earlier. Everyone is different though.

[u/everydaychump]

I'm not a doctor. I'm a prostate cancer survivor. If I were in your position, I might want to do the biopsy to get a more definitive answer. Your PSA is a bit high for age 37. PSA can be elevated for a number of reasons other than cancer. Infection is one reason. Also, ejaculation and/or a DRE right before your blood draw could possibly cause a temporary rise in PSA blood levels. Given your PI-RADS 3 and recent PSA results, I'd lean towards getting the biopsy done. But, that's just my take. I tend to be a worrier. I hope that your next consult with your urologist brings you more answers and reassurance.

[u/VaderJim → u/everydaychump]

Spoke to my urology team today, they're pleased with the drop, and believe the antibiotics / infection theory is the most likely, and want me to get another psa in 6 weeks to see where it's going.

I think that's reasonable, and I think my low PSA density is reassuring.

I think in 6 weeks if the numbers haven't done down even more I'll be talking about biopsy with them.

[u/everydaychump → u/VaderJim]

It sounds like you and your doctors have a plan. That's great! I think the most important thing is to stay on top of things. Best wishes going forward!!!

[u/Commercial-Cap8174]

I had a similar experience with a high psa (18) treated with antibiotics and we monitored the psa for close to nine months. Levels zig-zagged moving up, down and sideways but never dropped close to my baseline of 1.2 and leveled off at 4. At that point had an MRI that showed a PIRADS 3. Radiologist said inflammation from infection and pca can be hard to differentiate on an MRI. My uro said psa was likely elevated due to prostatitis but I went ahead and had the biopsy which was negative and six months later my psa had returned to my baseline. I was 20 years older than you at the time. I think your current plan makes sense. Good luck.

[u/Olorin77P]

I think your PSA is still high for 37. My PSA was only 3.5 at 67 years old. MRI showed Pi-RADS 3 one lesion and I ended up having Gleason 4+3 with cribiform. Don’t be afraid of a biopsy.

[u/Maleficent_Break_114]

Yeah, I’m not sure it’s gonna help you much but if you survive taking Cipro, then I envy you man because I took that stuff and I damn near. I don’t know if I ever really recovered. I don’t know why you know people forget like some guy nutmeg told me it’s all a game and it’s all percentages in urologist playing playing your odds you know so that’s how that’s how this game is sorry

[u/VaderJim → u/Maleficent_Break_114]

You made me realise autocorrect had changed it to Cipro, the antibiotic was Ofloxacin, not sure of the difference but I did read stories about these having serious side effects, fortunately I'm a few weeks after the course and fingers crossed nothing I'm aware of.