Prostate health: what is a normal PSA level?

What does PSA mean? High PSA levels indicate an elevated risk of prostate cancer, prostate enlargement and prostatitis. However, although PSA testing can help detect prostate health conditions early, screening all men for their PSA levels has proven a thorny subject in medicine. There are several reasons for this, which we will explore in this article.

When we talk about prostate values, we usually talk about the PSA value (prostate-specific antigen), which can be determined with a blood test. Depending on the measurement, your PSA value indicates changes in the prostate gland – which could be related to prostatitis (prostate inflammation), prostate enlargement and, above all, prostate cancer.

Read in our article about what a prostate-specific antigen value tells us, what a normal PSA value is and how and in which instances you might have high prostate values. We also explore the role prostate values play in cancer prevention and why PSA measurement is highly controversial in medicine. 

What does PSA mean?

PSA stands for protein-specific antigen; it is a protein that is formed almost exclusively in the prostate. Veery little PSA is usually released into the blood – the amount, however, changes depending on your age and how healthy your prostate is.

For example, in cases of cancer, the tumour in the prostate will cause much more PSA to be released into the blood. That is why PSA levels in the blood increase in such instances. An enlarged prostate also leads to a higher PSA value, as does an inflamed prostate.^[1]

When should you get a PSA test?

In the United Kingdom, there’s currently no national screening programme for prostate cancer. Instead, the NHS offers a programme called ‘Prostate Cancer Risk Management Programme’ for healthy men over the age of 50 who inquire with their GP about PSA tests. This programme ensures that men can be well-informed about the pros and cons of getting a PSA test prior to doing so.

If you do decide to have your PSA levels checked after discussing your options with a GP, this can be arranged for free on the NHS. However, you can also order a PSA test online to use at home – in this case, you usually take a small blood sample from your fingertip yourself, which is then examined in a medical laboratory.

Before you take a PSA test, you should be take care to avoid the following, as they may lead to an inaccurate PSA measurement:^[10]

• ejaculation in the past 48 hours
• moderate exercise in the past 48 hours
• a urinary infection
• a prostate biopsy in the past 6 weeks

Prostate cancer runs in the family. The risk of developing a tumour in the prostate is influenced by genes. So, if there are cases of prostate cancer in your family, this would be an argument for taking a PSA test.

PSA levels chart: what do PSA values mean?

Your PSA value provides you with an initial indication you may have prostate cancer, prostate enlargement or prostatitis.

This PSA value is measured in nanogrammes per millilitre (ng/ml) in your blood. The most important function of this value is to detect prostate cancer early – but elevated values can also indicate benign prostate enlargement (prostatic hyperplasia) and prostatitis (prostate inflammation).

PSA levels chart: What do PSA values mean?^[2]

* recommendations apply to men over the age of 45

What is a normal PSA level?

A PSA value is measured in nanogrammes per millilitre of blood (ng/ml). Generally, a PSA value of up to 4 ng/ml is considered normal – even though, in rare cases, prostate cancer can exist despite lower PSA values. However, other factors also play a role. For example, if PSA levels have risen significantly in a short period of time, doctors would initiate further tests. A very low PSA level, on the other hand, is not considered problematic.

Please note: A value of more than 4 ng/ml is by no means a cancer diagnosis! If you have received such a result from a PSA test, visit a urologist to discuss your prostate values more precisely and have further examinations carried out. There may be other reasons for these high values. 

What is a high PSA level?

When it comes to your PSA value, prostate cancer usually comes up in conversation. However, there are a number of other causes for high prostate values. These include the following.^[5]

• Acute prostatitis, inflammation of the prostate, is usually caused by a bacterial infection. Bladder inflammation can also increase your PSA value and can occur in men. However, both types of inflammation are usually hard to miss because they can be very painful.

• Benign prostate enlargement (prostatic hyperplasia) is very common in old age. It does not increase the likelihood of prostate cancer, but it can cause discomfort – for example, problems when urinating. Both an enlarged prostate and medications prescribed for it can increase your PSA levels.

• Pressure on your prostate also increases the PSA. This can happen, for example, when you ride a bike or strain when you have a bowel movement or during a doctor’s palpation. For this reason, doctors should never take blood for a PSA test after a rectal examination – either the blood sample is taken first or there are at least four weeks in between.

• Sex and ejaculation can also raise PSA levels. Therefore, you should refrain from sexual intercourse and masturbation in the 24 hours before a PSA test.

What is the next step after a high PSA test?

First, doctors usually order another PSA test – especially, if the patient is young and healthy, and there were no abnormalities in a digital rectal examination (DRE). If considered necessary, an MRI or biopsy will be performed. A biopsy is a procedure in which doctors remove tissue from the prostate, which is then examined in a laboratory.^{[2, 3]}

The risk of developing prostate cancer increases significantly with age. The diagnosis is most common in men aged 65 and older. Cases in men under 50 occur, but these are rare. According to data from the German Robert Koch Institute, the risk of a 45-year-old developing prostate cancer in the following 10 years is 0.4 per cent.^[4]

Criticism: how often are PSA tests wrong?

What are the problems with using a PSA test as a method of diagnosing prostate cancer? The extent to how beneficial carrying out a PSA test is to screen for cancer is still a controversial topic in medicine.

What is clear is that PSA tests help to detect some cancers earlier – which can be life-saving in some cases. Critics, however, say that it is not clear how significant the impact of early detection on prostate cancer mortality really is. The test also leads to many false-positive results and overtreatment. False-positive means that a PSA value that is too high indicates a potential health problem, even though you are perfectly healthy. In fact, around 75 per cent of men with a high PSA level will not have cancer, according to data collected.^[11]

What is meant by overtreatment? Prostate cancer often affects men in old age. But even though this cancer is so common among this age group, relatively few die from it. This is because prostate cancer progresses slowly, and many sufferers die of other causes before the tumour becomes problematic. A common treatment option is therefore actually to wait and see. After all, treatment can also have strong side effects and bring with it emotional distress.

Is a PSA test a good idea?

In 2019 there was a survey conducted in Germany by the Institute for Quality and Efficiency in Health Care that concluded that PSA testing does men more harm than good because of many false-positive diagnoses, psychological distress and operations that might not have been absolutely necessary. Procedures on the prostate can have complications such as impotence and incontinence, which then burden those affected for the rest of their lives.^[6]

However, some professional urological associations are in favour of PSA tests, believing that the lack of early detection would lead to more late-stage cancers. Urologists emphasise above all the importance of individual screening and that men should not be made uncertain and discouraged from seeking advice from specialists and engaging in cancer screening.^{[7, 8]}

If you have a prostate and are over 45 years old, you may find targeted early prostate cancer detection worthwhile. Whether regular PSA tests are right for you is something you have to decide for yourself. What you should consider is that a PSA test can lead to you receiving a result that wrongly classifies you as having cancer, which can be enormously stressful and is often followed by further medical examinations. On the other hand, the test increases your chances of detecting a potentially fatal cancer at an early stage.

What is a normal PSA level – at a glance

What does PSA mean?

PSA stands for protein-specific antigen; it is a protein that is formed almost exclusively in the prostate. Veery little PSA is usually released into the blood – the amount, however, changes depending on your age and how healthy your prostate is.

What is a normal PSA level?

A PSA value is measured in nanogrammes per millilitre of blood (ng/ml). Generally, a PSA value of up to 4 ng/ml is considered normal – even though in rare cases, prostate cancer can exist despite lower values. However, other factors also play a role. For example, if PSA levels have risen significantly in a short period of time, doctors would initiate further tests. A very low PSA level, on the other hand, is not problematic.

When should you do a PSA test?

In the United Kingdom, there’s currently no national screening programme for prostate cancer. Instead, the NHS offers a programme called ‘Prostate Cancer Risk Management Programme’ for healthy men over the age of 50 who inquire with their GP about PSA tests. Those with a history of prostate cancer in their family should consider getting a PSA test, as they are more at risk of this cancer.

Sources

^[1]         ‘Prostate-Specific Antigen (PSA) Test - National Cancer Institute’, 25 February 2021, available at https://www.cancer.gov/types/prostate/psa-fact-sheet, accessed on 28 September 2021.

^[2]         A. (AZQ) Haring, ‘S3-Leitlinie Prostatakarzinom’, p. 371, 2021.

^[3]         K. Krebsforschungszentrum Deutsches, ‘Prostatakrebs: Symptome, Früherkennung, Behandlung, Nachsorge’, available at https://www.krebsinformationsdienst.de/tumorarten/prostatakrebs/index.php, accessed on 27 September 2021.

^[4]         Robert-Koch-Institut, ‘Krebs in Deutschland | 2015/2016’, p. 163.

^[5]         ‘Erhöhter PSA-Wert - 6 Gründe, die nicht Prostatakrebs heißen’, available at https://www.prostata-hilfe-deutschland.de/prostata-news/erhoehter-psa-wert-ohne-prostatakrebs, accessed on 27 September 2021.

^[6]         ‘^[S19-01] Prostatakarzinom-Screening mittels PSA-Test | IQWiG.de’, Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (IQWiG), available at https://www.iqwig.de/projekte/s19-01.html, accessed on 27 September 2021.

^[7]         ‘Urologenportal: Postitionspapier der Deutschen Gesellschaft für Urologie zum Vorbericht: Prostatakrebsscreening mittels PSA-Test (S19-01) des IQWiG (13.01.2020)’, available at https://www.urologenportal.de/pressebereich/pressemitteilungen/presse-aktuell/postitionspapier-der-deutschen-gesellschaft-fuer-urologie-zum-vorbericht-prostatakrebsscreening-mittels-psa-test-s19-01-des-iqwig-13012020.html, accessed on 27 September 2021.

^[8]         Österreichische Krebshilfe, ‘Prostatakrebs-Früherkennung’, available at https://www.krebshilfe.net/information/krebsfrueherkennung/prostatakrebs-frueherkennung, accessed on 29 September 2021.

^[9]         Krebsliga Schweiz, ‘Prostatakrebs’, available at https://www.krebsliga.ch/ueber-krebs/krebsarten/prostatakrebs, accessed on 29 September 2021.

^[10]         National Health Service ‘PSA testing: Prostate cancer’, available at https://www.nhs.uk/conditions/prostate-cancer/psa-testing/, accessed on 16 November 2021.

^[11]         National Health Service ‘Should I have a PSA test? Prostate cancer.’, available at https://www.nhs.uk/conditions/prostate-cancer/should-i-have-psa-test/, accessed on 16 November 2021.