Your PSA came back high. Here's what that actually means.

What PSA actually is

The prostate makes a protein called PSA that helps liquify semen. A small amount leaks into the bloodstream, where we can measure it. PSA levels normally increase with age and prostate size. There is no single "normal" PSA — what's normal depends on your age, prostate size, ethnicity, and family history.

As a very rough guide, the traditional PSA cutoffs are:

• Under age 50: less than 2.5 ng/mL
• Age 50–59: less than 3.5 ng/mL
• Age 60–69: less than 4.5 ng/mL
• Age 70+: less than 6.5 ng/mL

These are rough guides. Modern decisions are based on more than one number — the trend over time matters more than any single value.

Why PSA can be elevated without cancer

Plenty of non-cancer things can raise PSA. The most common causes:

• BPH (enlarged prostate) — a bigger prostate makes more PSA. This is the most common non-cancer cause.
• Prostatitis (inflammation or infection) — can raise PSA dramatically, sometimes into the dozens. Treatable; PSA usually returns to baseline after a few weeks.
• Urinary tract infection — similar mechanism. Usually temporary.
• Recent sexual activity / ejaculation — can raise PSA slightly. Abstain for 48 hours before testing.
• Vigorous exercise especially cycling can elevate PSA temporarily.
• Recent procedures like catheterization, cystoscopy, or a digital rectal exam can cause small transient elevations.

What the workup typically looks like

Step 1: Repeat the PSA

If there's no obvious reason for elevation, we usually repeat the PSA after 4–6 weeks, preferably avoiding sexual activity for 48 hours beforehand and confirming no recent infection. About 20–30% of the time, the repeat PSA is normal — reassuring, no further workup needed.

Step 2: Advanced blood tests

If the repeat PSA is still elevated, we often add more sophisticated tests to refine risk:

• Free PSA percentage — the ratio of "free" to "bound" PSA. A lower percentage is associated with higher cancer risk.
• PHI (Prostate Health Index) or 4Kscore — more specialized blood tests that improve accuracy beyond PSA alone.
• PSA density — PSA divided by prostate volume, calculated from MRI or ultrasound.

Step 3: Prostate MRI

A multi-parametric MRI of the prostate has transformed how we work up an elevated PSA. It can identify suspicious areas with surprisingly good accuracy. A "negative" MRI (no significant lesions) reduces the likelihood of clinically important cancer substantially — we may be able to avoid a biopsy in that case.

Step 4: Prostate biopsy (when needed)

If MRI shows a suspicious area, or if the numbers remain concerning despite a negative MRI, a prostate biopsy is the definitive test. Modern biopsy techniques are targeted (guided by MRI findings) and much more accurate than the older random-sampling approach. The procedure is done in the office with local anesthesia, takes about 20 minutes, and patients go home immediately.

If you do have prostate cancer

Most prostate cancers, even when diagnosed, are slow-growing and don't require immediate treatment. We now classify cancers by risk group (low, intermediate, high) and often recommend active surveillance — periodic monitoring rather than immediate treatment — for low-risk cases. Only when the cancer shows signs of growing or becoming more aggressive do we treat.

For cancers that do need treatment, the main options are surgery (radical prostatectomy), radiation therapy (external beam or brachytherapy), or sometimes newer focal therapies. Dr. Childs does not perform radical prostatectomy himself — he would refer you to a fellowship-trained prostate cancer specialist if treatment becomes necessary. But he coordinates your workup, your monitoring, and helps you think through the decision clearly.

The honest truth about PSA screening

PSA screening is controversial because it can identify slow-growing cancers that would never have caused problems during a man's lifetime. Treating those cancers exposes men to the side effects of treatment (incontinence, erectile dysfunction) without meaningful benefit.

Modern practice tries to limit this problem in two ways: (1) using better diagnostic tools (MRI, advanced blood tests) before committing to biopsy, and (2) using active surveillance for low-risk cancers rather than treating every detected cancer.

The decision to screen and how aggressively to work up an elevated result is a conversation — it depends on your age, family history, ethnicity, life expectancy, and how you feel about the trade-offs. Dr. Childs will walk through this with you honestly.