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Prostate Diseases Diagnosis and Tests

Urology: Urinary & Reproductive Disease Diagnosis & Treatment

Urology treats urinary tract diseases in all genders and male reproductive issues, covering the kidneys, bladder, prostate, urethra, from infections to complex cancers.

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Diagnostic Protocol at Liv Hospital

Prostate Diseases

The Liv Hospital Department of Urology employs a “Precision Diagnostics” approach. We move beyond simple screening to comprehensive risk stratification, using genomic markers, advanced imaging, and fusion technologies to differentiate between benign enlargement, indolent cancer, and clinically significant malignancy. Our goal is to minimize overdiagnosis and over-treatment while ensuring lethal cancers are not missed.

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Clinical Assessment

  • Digital Rectal Examination (DRE): The urologist inserts a lubricated, gloved finger into the rectum to palpate the posterior surface of the prostate. This exam provides critical information about the gland’s consistency.
    • BPH Findings: A smooth, symmetric, enlarged, rubbery gland with a preserved median sulcus.
    • Cancer Findings: A hard nodule, asymmetry, induration, or obliteration of the median sulcus.
    • Prostatitis Findings: A boggy, hot, and exquisitely tender gland. (Note: Vigorous massage is avoided in acute prostatitis to prevent bacteremia.
    • IPSS (International Prostate Symptom Score): A validated 7-question survey evaluating symptoms like incomplete emptying, frequency, intermittency, urgency, weak stream, straining, and nocturia. A score of 0-7 is mild, 8-19 is moderate, and 20-35 is severe. This helps quantify the burden of disease and track response to treatment.
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Laboratory Investigations

  • Prostate-Specific Antigen (PSA): PSA is a glycoprotein enzyme secreted by epithelial cells. It is organ-specific but not cancer-specific.
    • Standard Range: Traditionally <4.0 ng/mL, but age-adjusted ranges are now used (e.g., <2.5 for men under 50) to increase sensitivity in younger men.
    • PSA Velocity: The rate of PSA rise over time. A rapid rise (>0.75 ng/mL/year) is more suspicious for cancer or inflammation than a stable elevated level.
    • Free-to-Total PSA Ratio: PSA circulates either bound to proteins or in the free form. Cancer cells produce more bound PSA. If Total PSA is in the “gray zone” (4-10 ng/mL), a Free PSA <10% indicates a high probability of cancer, whereas a Free PSA>25% suggests a likely benign cause (BPH).
    • PSA Density: Total PSA divided by Prostate Volume. Higher density (>0.15) suggests cancer because BPH tissue produces less PSA per gram than cancer tissue.
  • Urinalysis: To rule out urinary tract infections or microscopic hematuria, which can mimic prostate symptoms.
  • Genomic Biomarkers (Liquid Biopsy): Tests like PCA3 (urine), 4Kscore (blood), SelectMDx (urine), or ExoDx (urine) provide a genetic risk score. These are used in “gray zone” cases to determine whether a biopsy is necessary, helping avoid unnecessary procedures.

Advanced Imaging

  • Transrectal Ultrasound (TRUS): Primarily used to measure prostate volume (essential for BPH treatment planning) and guide biopsy needles. It is generally poor at visualizing tumors directly, as many cancers are isoechoic.
  • Multiparametric MRI (mpMRI) of the Prostate: This is the game-changer in prostate diagnosis. Unlike standard ultrasound, mpMRI evaluates the gland using three sequences:
    • T2-Weighted Imaging: Visualizes anatomy; tumors typically appear dark (hypointense).
    • Diffusion-Weighted Imaging (DWI): Measures the movement of water molecules. Cancer cells are densely packed, restricting water movement (Restricted Diffusion).
    • Dynamic Contrast Enhancement (DCE): Measures blood flow. Tumors are highly vascular and take up contrast dye rapidly (Wash-in/Wash-out).
    • PI-RADS Score: Radiologists assign a score from 1 (Very Low Risk) to 5 (Very High Risk) to suspicious lesions. This allows us to target biopsies precisely or observe low-risk lesions.

PSMA PET-CT: A highly advanced molecular imaging scan used for staging high-risk cancer. It uses a radioactive tracer (Gallium-68 or Fluorine-18) that binds to Prostate-Specific Membrane Antigen found on the surface of cancer cells. It is the most sensitive test in the world for detecting microscopic metastases in lymph nodes or bones, far superior to traditional CT or bone scans.

Prostate Biopsy Techniques

Prostate Diseases

If cancer is suspected, a tissue sample is required for histological confirmation.

  • MRI-Ultrasound Fusion Biopsy: Liv Hospital specializes in this state-of-the-art technique. The MRI images (showing the suspicious lesion) are digitally fused with live ultrasound images during the procedure. This allows the urologist to guide the needle directly into the suspicious area with millimeter precision, significantly increasing the detection rate of high-grade cancer while reducing the diagnosis of insignificant cancer.
  • Transperineal Biopsy: The needle is passed through the skin of the perineum (the space between the scrotum and anus) rather than through the rectal wall. This avoids puncturing the rectum, significantly reducing the risk of severe infection (sepsis) to near zero and allowing better sampling of the anterior prostate.

Functional Testing (Urodynamics)

  • Uroflowmetry: The patient urinates into a specialized funnel. It measures Qmax (maximum flow rate). A “bell-shaped” curve is standard; a flattened, prolonged curve suggests obstruction.
  • Post-Void Residual (PVR): Ultrasound measurement of urine left in the bladder after voiding. High residuals indicate pump failure or severe blockage.
  • Pressure-Flow Studies: Invasive catheters measure bladder pressure during voiding. This is the gold standard to differentiate between Bladder Outlet Obstruction (High Pressure/Low Flow) and Detrusor Underactivity (Low Pressure/Low Flow). It is essential to consider this before invasive BPH surgery in complex cases or those with neurological diseases.

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Prof. MD. Uğur Boylu Prof. MD. Uğur Boylu Urology
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FREQUENTLY ASKED QUESTIONS

Can I have prostate cancer if my PSA is low?

 Yes, approximately 15% of men with prostate cancer have a PSA below 4.0 ng/mL. Some very aggressive forms of cancer (like neuroendocrine tumors or high-grade Gleason 10) differentiate so poorly that they stop producing PSA entirely. This is why the Digital Rectal Exam (DRE) and family history review are vital components of screening.

PSA can spike due to benign reasons unrelated to cancer. Common causes include BPH (larger gland = more PSA), Urinary Tract Infection, Acute Prostatitis, recent ejaculation (within 48 hours), urinary retention, or vigorous bicycle riding. We typically repeat the test after 4-6 weeks and a course of antibiotics to rule out transient inflammation.

MRI is a non-invasive imaging test, while a biopsy is an invasive procedure. MRI helps us decide who needs a biopsy and where to aim. Using MRI first (the “MRI-First Pathway”) allows approximately 27% of men to avoid a biopsy altogether if the scan is clean, as the negative predictive value is very high (~90-95%).

The Gleason Score is the grading system pathologists use to describe how aggressive the cancer cells appear under a microscope compared to normal glands. It ranges from 6 to 10.

  • Gleason 6 (3+3): Low-grade, indolent behavior.
  • Gleason 7 (3+4 or 4+3): Intermediate grade.
  • Gleason 8-10: High grade, poorly differentiated, requires aggressive treatment.
  • ISUP Grade Groups: A newer, clearer system (Group 1 to 5) that corresponds to Gleason scores to simplify patient communication.

No. Cystoscopy involves using a camera to look inside the urethra and bladder. It is excellent for detecting urethral strictures, bladder stones, or large BPH lobes that obstruct the channel, but it examines the inner lining (urothelium). Prostate cancer usually grows on the outside periphery of the gland and cannot be seen with a scope.

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