Station 51
Adetokunbo Ademola
Age: 56 years old male
Examiner
Marking Scheme
Data Gathering and Diagnosis
- Ask the patient why the blood tests were done
- Ask about current urinary symptoms, including: nocturia, frequency, urgency, poor stream, intermittency, straining, dribbling after urination, incomplete emptying, and any accidental leakage
- Ask if there has been any visible or blood-stained urine (haematuria)
- Ask about any associated back pain
- Ask if the patient has experienced any fever, abdominal pain, or discomfort in the rectal or pelvic area, to help rule out prostatitis
- Ask about red flag symptoms such as night sweats or weight loss
- Ask about family history of prostate cancer
- Ask about lifestyle factors including smoking, alcohol intake, and occupation
- Ask if the patient followed any pre-test instructions before the PSA blood test, for example, avoiding ejaculation or vigorous exercise (such as cycling) within the previous 48 hours
- Explain raised PSA blood test results
Example of explanation to patient
Toks, thank you for joining the video call today. I can see that these waterworks symptoms have been really uncomfortable for you, especially waking up at night and feeling like you’re not fully emptying your bladder. That’s understandably frustrating and can really affect your quality of life, so I want to make sure we get to the bottom of it and support you properly.
The blood test we did to check your prostate, called the PSA test, has come back higher than we’d normally expect. Now, this can sometimes be explained by having an enlarged prostate, which you already have. But a high PSA level can also be a sign that something more serious might be going on, such as prostate cancer.
I’m not saying that you definitely have cancer, and it may well turn out to be something less serious, but it’s important that we don’t miss anything, so we can make sure you get the right care as early as possible.
Because of this, I’d like to refer you urgently to see a specialist called a urologist, who can do some more focused tests like an MRI scan or small tissue sample called a biopsy, to find out what’s causing the raised PSA.
You mentioned you were hoping for some treatment to shrink the prostate, it’s really important we rule out anything serious before we start any new medication to shrink the prostate, because certain treatments can affect the results of those specialist tests.
I completely understand that waiting can be worrying, especially when you’re feeling uncomfortable. But I want to reassure you that this referral is urgent, the hospital will usually see you within two weeks. In the meantime, if you develop any new symptoms like pain, blood in your urine, or if you’re unable to pass urine at all, please let us know straight away.
You’re not alone in this, and I’ll be here to support you throughout. Once we get more clarity from the specialist, we can talk again about the best way to manage your symptoms and help you feel more comfortable.
How are you feeling about what I’ve just said?
Management
Management
- Offer a referral to the two-week wait (2WW) urology pathway and explain that this is important due to the raised PSA result, which could indicate a possibility of prostate cancer.
- Explain that the urologist may carry out further investigations, such as an MRI scan of the prostate and possibly a biopsy (a small tissue sample) to help make a clear diagnosis.
- Provide cancer safety netting advice: if the patient has not heard anything or been seen within two weeks, advise him to contact the GP surgery immediately so the referral can be chased up.
- Do not prescribe finasteride at this stage, as it can artificially lower PSA levels and affect the interpretation of results. Gently explain that although it may help symptoms, it’s important not to start it until the specialist has assessed the situation.
- Offer a follow-up appointment after the urology consultation to review the outcome, provide ongoing support, and discuss next steps in management based on the urologist’s findings.
Learning point from this station:
When a patient presents with lower urinary tract symptoms (LUTS) and is found to have a raised PSA, it’s important to balance symptom relief with appropriate cancer risk assessment. While benign prostatic hyperplasia (BPH) is common and may explain the symptoms, a significantly elevated PSA, as in this case, must prompt urgent referral under the two-week wait (2WW) pathway to rule out prostate cancer.
It is crucial not to initiate medications like finasteride at this stage, as they can lower PSA levels and interfere with further diagnostic testing. Instead, explain the reasoning clearly and offer reassurance through timely referral, safety netting, and planned follow-up.
Understanding when to refer, when not to treat immediately, and how to communicate uncertainty compassionately are key skills in managing prostate-related concerns in primary care.