PSA Test and Prostate Health: What Every Man Should Know

The PSA test is one of the most debated screening tools in medicine. It's simple — a single blood draw — but what the results mean can be surprisingly complex. If you're a man over 40, considering testosterone therapy, or just trying to stay ahead of prostate problems, understanding PSA is worth your time.

What PSA Is

PSA stands for prostate-specific antigen. It's a protein produced by the prostate gland — a small, walnut-sized organ that sits below the bladder and produces fluid that becomes part of semen.

All men have PSA in their blood. The prostate makes it continuously, and small amounts leak into the bloodstream. The PSA test measures the concentration of this protein in your blood.

Key point: PSA is prostate-specific, not cancer-specific. Any condition that irritates, inflames, or enlarges the prostate can raise PSA. An elevated PSA does not mean you have cancer — but it does mean something is going on with your prostate that warrants attention.

Normal PSA Ranges

PSA levels naturally increase with age as the prostate grows:

| Age | Generally Accepted Upper Limit |

|-----|-------------------------------|

| 40-49 | 2.5 ng/mL |

| 50-59 | 3.5 ng/mL |

| 60-69 | 4.5 ng/mL |

| 70-79 | 6.5 ng/mL |

The traditional cutoff of 4.0 ng/mL is widely used, but it's an imperfect threshold. Some men with PSA below 4.0 have prostate cancer. Some with PSA above 4.0 don't. The test is a screening tool, not a diagnostic one.

What Causes Elevated PSA

Benign Prostatic Hyperplasia (BPH)

The most common cause of elevated PSA. BPH is a non-cancerous enlargement of the prostate that affects roughly 50% of men by age 50 and up to 90% by age 80. A bigger prostate produces more PSA. BPH causes urinary symptoms — frequency, urgency, weak stream, getting up at night — but is not cancerous.

Prostatitis

Inflammation or infection of the prostate can dramatically elevate PSA, sometimes to levels that look alarming. Acute prostatitis can raise PSA to 20, 30, or higher. Once the infection is treated, PSA typically returns to normal. If your PSA is elevated and you have urinary symptoms, pain, or fever, prostatitis should be considered before assuming the worst.

Recent Activity

Several activities can temporarily raise PSA:

• Ejaculation within 24-48 hours of the blood draw
• Vigorous exercise (particularly cycling)
• Recent digital rectal exam
• Urinary catheterization or cystoscopy
• Prostate biopsy (can elevate PSA for weeks)

This is why your doctor may ask you to abstain from ejaculation for 48 hours before the test and may recheck an elevated value before pursuing further workup.

Prostate Cancer

This is the reason PSA screening exists. Prostate cancer can elevate PSA, and the test can detect cancer years before symptoms appear. However, the relationship between PSA level and cancer risk is graded, not binary:

• PSA below 4.0: About 15% chance of prostate cancer (most would be low-grade)
• PSA 4.0-10.0: About 25% chance of prostate cancer (the "gray zone")
• PSA above 10.0: About 50% chance or higher

Beyond the Number: PSA Velocity and Density

A single PSA value tells you less than you might think. Doctors use additional metrics to refine the picture:

PSA Velocity

How fast your PSA is rising over time. A PSA that goes from 1.0 to 1.5 over five years is very different from one that jumps from 2.0 to 5.0 in one year. Rapid increases — more than 0.75 ng/mL per year — warrant closer evaluation regardless of the absolute value.

PSA Density

Your PSA level divided by the volume of your prostate (measured by ultrasound). A large prostate naturally produces more PSA, so a PSA of 6.0 in a man with a 100cc prostate is less concerning than a PSA of 6.0 in a man with a 30cc prostate.

Free PSA

PSA circulates in the blood in two forms — bound to proteins and free (unbound). Cancer tends to produce more bound PSA, while BPH produces more free PSA. A free PSA percentage above 25% suggests BPH is more likely. Below 10%, cancer risk is higher.

PSA and Testosterone Therapy

If you're considering or currently on testosterone replacement therapy (TRT), PSA is a mandatory part of your monitoring. Here's why:

The old concern: For decades, it was believed that testosterone "fuels" prostate cancer, and raising testosterone levels would increase cancer risk. This belief was based on research from the 1940s that has since been largely overturned.

What current evidence shows: Studies over the past 20 years have not demonstrated that TRT increases the risk of developing prostate cancer in men with normal prostates. Testosterone therapy does, however, stimulate the prostate gland and can raise PSA modestly — typically by 0.3 to 0.5 ng/mL in the first 6-12 months.

What we check before starting TRT:

• Baseline PSA
• Digital rectal exam (when indicated)
• If PSA is above 4.0 or there are other risk factors, referral to urology before initiating testosterone

Monitoring on TRT:

• PSA checked at 3-6 months after starting therapy
• Then every 6-12 months
• If PSA rises more than 1.4 ng/mL within 12 months of starting TRT, further evaluation is needed
• If PSA exceeds 4.0, urological referral is recommended

TRT and existing prostate cancer: Testosterone therapy is contraindicated in men with untreated or active prostate cancer. Men who have been treated for prostate cancer and are cancer-free may be candidates for TRT under careful urological supervision, but this requires case-by-case evaluation.

The PSA Screening Debate

PSA screening has saved lives by detecting aggressive prostate cancers early. But it has also led to overdiagnosis — finding slow-growing cancers that would never have caused symptoms or death, leading to unnecessary biopsies and treatments with real side effects (incontinence, erectile dysfunction).

Current guidelines from the American Urological Association:

• Under 40: Not recommended
• 40-54 at average risk: Not recommended routinely; consider if higher risk (African American men, family history)
• 55-69: Shared decision-making — discuss benefits and risks with your doctor
• 70+: Not recommended for routine screening; individualized based on health status

The key takeaway: PSA screening is a conversation, not an automatic test. The decision to screen should be informed, and an elevated result should be interpreted thoughtfully — not panicked over.

How Coral Handles PSA Testing

At Coral, PSA is a standard part of our men's health labs, particularly for patients considering or on testosterone therapy. We check a baseline before starting treatment and monitor regularly. We don't just report the number — we explain what it means, whether it's changed, and what (if anything) needs to happen next.

Prostate health is an important part of men's health care, and it shouldn't be something that only comes up when there's a problem.

Ready to get a comprehensive men's health evaluation? Start your visit with Coral.

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