Elevated PSA as Differential Diagnostic Error-Source in Prostate Cancer with Consequences in Medical Law

Abstract

Misinterpretations of elevated prostate-specific antigen (PSA) levels may represent possible sources of errors in the differential diagnosis between infection/inflammation, i.e., urinary tract infections (UTI), prostatitis, epididymitis, on one side, and prostate cancer on the other side, which in some cases may even lead to issues in medical law. Two cases with elevated PSA levels are presented in which the misinterpretation in the differential diagnosis has protracted the final diagnosis of prostate cancer for such a long time that both cases ended as issues of medical law in court. Literature was reviewed and the best approach to avoid misinterpretations was discussed. The following results could be assessed: (i) elevated PSA levels can only be explained by a direct alteration of the prostate gland, such as infection, inflammation, or cancer; (ii) febrile urinary tract infections (UTI) (temperature >38 °C and related symptoms) often show prostatic involvement with elevated PSA levels which may return to normal after treatment which, however, will take some time; (iii) the same applies for acute and chronic bacterial prostatitis/epididymitis; (iv) empiric antibiotic therapy is only indicated if either acute or chronic bacterial infection of the prostatitis/epididymitis or febrile UTI is positively diagnosed; (v) antibiotic differential therapy in order to lower the PSA levels in case of asymptomatic bacteriuria, simple UTI, or even just ex juvantibus must be considered obsolete nowadays; (vi) elevated PSA levels unexplained by other direct prostate involvement, such as febrile UTI or bacterial prostatitis/epididymitis, remain always suspicious of prostate cancer and need final clarification by prostate biopsy and sometimes by additional endoscopy/imaging; and (v) the patient and his family physician need to be fully informed about the strong suspicion of prostate cancer in case of otherwise unexplained elevated PSA levels. Elevated PSA levels are only due to a direct alteration of the prostate gland, such as prostate cancer, acute and chronic prostatitis/epididymitis, and febrile UTI with direct involvement of the prostate. Antibiotic therapy is only indicated if such an infection of the prostate/epididymis and the urinary system is positively diagnosed. Differential antibiotic therapy to possibly lower increased PSA levels and to save thus prostate biopsy is contraindicated, because the final diagnosis will often be protracted far too long. The patient always has to be fully informed about the strong suspicion of a prostate cancer in case of elevated PSA levels.