New to this forum, currently undiagnosed for PCa, terrified

Hello,

During a comprehensive physical in November (required in order to adopt a child), I had blood work including a PSA test. I had this same physical and blood work last year, as well. My PSA came back 4.4, and last year it was under 1 (don't have the exact number at the moment), or "normal", according to my general physician.

I went to see a urologist, and he performed the DRE, which was "normal". Because of my PSA and family history (my Dad was diagnosed with PCa a little over a year ago, at age 71), the doctor recommended a biopsy on December 2. I asked about another blood test (even a PHI test), and he basically said I'd be "fishing for a lower number" with another test (which is true!), but that he'd still ultimately recommend a biopsy.

However, I developed a chest infection on December 1 that included a fever, so they cancelled the biopsy and rescheduled it to February 10.

I am terrified, but not because of a possible cancer diagnosis. Instead, I am irrationally terrified of possible infection/sepsis after the biopsy.

My current urologist (Dr. Mark Delworth, of The Urology Group in Cincinnati, Ohio) only performs transrectal biopsies. The Urology Group is the largest group of doctors in Cincinnati (and one of the larger in the country), and apparently none of them do transperineal biopsies. It is my understanding that the transperineal approach is not only more accurate for detection, but has a much lower risk of infection and other complications.

I guess I'm posting this to see if there is anyone that has any advice, or perhaps recommendations of urologists who perform the transperineal biopsy in, and around, Cincinnati, Ohio. I'd certainly be willing to travel a couple of hours in any direction, too (realizing that this type of biopsy also requires a short hospital stay).

If this isn't the proper forum for this, or if I haven't met forum protocol, I apologize.

Allan

Hello Allan,

Sorry you have worries. Hope we can help.

Actually, fishing for a lower number isn't always a bad idea. There are a number of non-prostate-cancer things that can cause an elevated PSA reading -- sex within the 24 hours prior to having your blood drawn, drawing blood after doing a DRE, prostate infections, bicycle riding the day before, bullriding, etc., etc..

It is usually worth doing another PSA just to confirm the number and often a urologist will prescribe an antibiotic between the PSA tests -- if the antibiotic makes the number go down then it is less likely to be prostate cancer.

You might also ask your doctor about your free-PSA levels. Sometimes that can provide more information which will occasionally allow a biopsy to be avoided.

Good luck with that adoption.

I'm a big believer in eliminating all higher probability causes for a rapidly elevated PSA before rushing into a biopsy. A 10-day course of Cipro and a re-test seems to me a very minimal precaution.

I would certainly get that PHI test anyway (after the Cipro) - what's wrong with a lower number? Not every urologist can do them, so you have to call their number and they'll give you a list of local uros who give the test. The test is covered by insurance and is fairly inexpensive, but you might have a co-pay for the urologist. PHI includes both PSA and free PSA, so there's no need to get those tests separately.

I think you are right that a transperineal biopsy has a lower infection rate and can hit areas that transrectal might not. But you may have trouble finding a uro willing to do that on a first biopsy. I had a periprostatic nerve block on my last TRUS biopsy, and it was a piece of cake - no pain and no drugged out feeling from anesthesia. I've read about a new technique called a "pelvic plexus block" that they say is even better. As for the risk of infection, some are now taking a rectal swab first to detect resistant bacteria. Others are applying something like chlorhexidine-alcohol or povidone-iodine to the rectal wall before the biopsy.

- Allen

I remember my oncology urologist state that less than 5% of biopsy incur infection and a few of those require hospitalization and IV antibiotic. It is standard protocol to give you an prophylactic antibiotic (usually cipro) prior to the biopsy.

Hi and Welcome, Allen. I can't help with recommendations of other Urologists, but fwiw I've been a patient of Dr. Delworth's for over four years - from DRE to biopsy, robotic surgery thru after care.

Feel free to email me if I can answer any questions from a patient's perspective.

Wish you the best.

The TRUS biopsy isn't all that big a deal, the worst part for me was this scene:

Sitting in the exam room, nurse comes in and asks some questions and notes that I'm allergic to penicillin. She vanishes and comes back with a full syringe and then this conversation:

ME: (rolling up my sleeve) "lets get this over with"
NURSE: Nope, come over here and drop trou!
ME: Oh great...

The cipro in the butt hurt way worse than the biopsy. And then passing the first blood clot that afternoon hurt like the dickens.

I don't think you should do a biopsy after one high PSA reading. First you want to eliminate any possible causes of the high reading (due to having sex, bike riding, infection) and I'd also want to have a least one confirming additional PSA test before the invasiveness of a biopsy. As to your Dad having prostate cancer at age 71, probably half of 70-year-old men have prostate cancer so that doesn't strike me as a strong connection. (Glad he's doing well!)

Lastly, prostate cancer is very slow growing so in the event that you did have it, waiting for more info is highly unlikely to make a difference. Good luck to you!

Allan H said...
I read that the rate of infection after TRUS has grown quite a bit in the past decade, and is now up between 7-10% (a lot of which has to do with increased antibiotic resistance). A 1 in 14 to a 1 in 10 chance sounds pretty high to me, and is primarily the reason I'm so concerned. The rate of hospitalization is supposedly over 4% due to sepsis or very serious infection, and that's around 1 in 25, which seems way too high to me. Are those numbers correct, or in the ballpark?

The last I read it was 7% and rising, but that may have been a couple of years ago. That's why some doctors are doing resistant bacteria checks beforehand and cleaning the area, as I described. Ask your Uro if he's willing to do that.

Allan H said...
Speaking of antibiotics, if I were to go on an antibiotic regimen just in case it might be some sort of infection, wouldn't that increase the likelihood of antibiotic resistance if I then eventually need a biopsy, as I mentioned above?

That's certainly a risk, but not a real big one if you complete the full course. It's much more of a risk in guys who have taken Cipro for prostatitis or UTIs intermittently. There's no risk if he does a bacteria check before the biopsy.

- Allen

Welcome Allen, I am one of the newbies (...a wife looking to help her hubby) here so while I cannot offer you much in the way of advice I can offer you open arms and the opportunity to utilize the wealth of information from the caring members of this board. You are in good hands now. Good luck...

Just saying, think about it . . . .

http://www.mcancer.org/prostate-cancer/screening