Total PSA and Free PSA are very important screening tests to evaluate prostate health.
However, they should not be routinely applied to everybody. But why is that? This is a screening method for prostate cancer. So, why do doctors choose who is a candidate for a PSA test?
As you will see in this article, PSA levels can be tricky to interpret. They can lead to false positives if not correctly used. Many factors can interfere and cause a temporary PSA elevation in a healthy person. But can stress affect PSA levels? Let’s find it out.
What is PSA?
PSA stands for Prostate Specific Antigen. It is a substance produced by the prostate gland. This gland is located below the bladder, surrounding the bladder neck.
The function of the prostate is to provide a liquid that helps sperm in the process of conception. One of the substances the prostate releases along with the sperm, is the PSA. This is a particular protein that breaks down the agglomerations of sperm. Thus, the resulting sperm is more fluid and moves more easily in the vagina and the uterus.
PSA is meant to be released to the sperm. However, it is normal to find a small fraction in the blood as well. A given proportion of PSA always leaks to the blood, but the amount is usually minimal. However, this proportion can be affected by various factors. For example, when prostate cells undergo inflammation and other prostate problems (1).
Younger men usually have lower PSA levels because they don’t have any prostate problems. As they grow older, it is normal to have increasing levels of PSA. This is usually because the prostate becomes slightly enlarged as we age.
However, after reaching certain levels, and in certain people, a higher PSA may reflect, we need treatment for a prostate condition.
What is the significance of a high PSA level?
High PSA levels can be indicative of a slightly enlarged prostate that is still healthy. It can also indicate a person has prostate cancer.
Or they simply experienced inflammation or a procedure in a normal prostate. As you can see, there’s a wide variety of conditions and circumstances. Thus, an elevated PSA level is not always indicative of cancer.
In short, we can say that PSA can become elevated in these circumstances:
- Prostate cancer: PSA is usually higher in cases of prostate cancer. In most cases, prostate cancer cells have a similar function and create PSA. As the gland grows bigger, it produces and leaks more PSA to the blood. A slight increase may be seen in early prostate cancer. In advanced prostate cancer, the difference tends to be more dramatic. However, there are many cases of prostate cancer without PSA elevation (2).
- Biochemical recurrence of prostate cancer: PSA elevation after hormone therapy or radiation therapy can be due to a biochemical recurrence of prostate cancer. In these cases, patients may not have symptoms of prostate cancer. However, their PSA levels should be estimated to evaluate recurrence (3).
- Benign prostatic hyperplasia: Most cases of PSA elevations are due to benign prostatic hyperplasia. It is commonly known as BPH. This is expected, especially in older adults, after 60 years old. 90% of patients over 80 years old have BPH. Thus, it is very likely men will get a higher reading at some point in their lifetime (4).
- Enlargement of the aging prostate: Even if men do not have BPH, they do experience an enlargement of the prostate as they age. Thus, it is expected to have rising levels of PSA as we age. Thus, it is important to perform a PSA exam and use it as a baseline. This measure helps doctors create a PSA level history and detect an alteration (4).
- Inflammation and other prostate conditions: Prostate disease causes a higher PSA level. Especially when there is infection or inflammation of the prostate. This is known as prostatitis and can be a cause of an elevated PSA concentration. Other inflammatory conditions can have the same effect. For example, urinary tract infections (1).
- Medical procedures that involve the prostate gland: Besides prostate disease, certain medical procedures can increase PSA levels. One classic example is a digital rectal exam or prostate massage (5).
- Other factors: A variety of additional factors can affect the concentration of PSA in the blood. Thus, it is recommended to evaluate each patient separately. An increase in PSA can be due to an error of measurement. That’s why some doctors prefer to have a second measurement from another lab.
As you can see, there’s not one single significance of high PSA. It can be a variety of things and factors that come into play in a given individual at a given time. That’s why it can be some uncertainty as to when to use PSA measures. And some people may question how accurate it is to detect prostate cancer.
Is the PSA test accurate?
PSA test accuracy is questionable because there many factors interfere with the measurement. A false measurement can be misleading and prompt a prostate biopsy. This procedure is useful for detecting prostate cancer. However, it has consequences that affect the quality of life of patients.
A prostate biopsy can cause chronic bleeding and chronic pain. The site of the procedure can become infected and bring along other problems. There would be no point if the result was a false positive, and the patient stays with pain and bleeding for a long period. Thus, PSA accuracy is very important if we want to use PSA screening for prostate cancer.
Since this test can sometimes be misleading, PSA testing is recommended for some patients. If you have urinary symptoms or risk factors for prostate cancer, you’re a candidate. However, every patient presents a different case, and you will need the opinion of an expert.
Stil, PSA is beneficial for urologists. Along with the Gleason score, it is used to evaluate how aggressive cancer is. It can help your urologist to decide if he’s going to perform a radical prostatectomy. It is also very useful for patients during active surveillance. This is a watch and see approach doctors use in senior patients with non-aggressive cancer (6).
But that’s for prostate cancer patients. What about people who just want to rule out cancer? In these cases, we can also increase the accuracy of the PSA test. It is done by combining different complementary measurements. For example (6):
- PSA velocity: It is constant monitoring of the PSA. After obtaining results and comparing them with a time table, we can see how fast PSA levels rise. A very rapid increase can be indicative of prostate cancer.
- PSA density: It combines the measurement of the prostate and that of the PSA. It is simply dividing the total PSA by the prostate volume in ml.
Can stress affect PSA levels?
Stress can affect many health parameters. We have clear examples like inflammatory arthritis or psoriatic arthritis. These and other inflammatory conditions are triggered by stress. If not triggered, they can also be worsened, causing severe flare-ups.
Does the same happen with prostate patients? Chronic or acute stress likely causes an inflammatory process. This inflammatory process may affect the prostate and increase PSA levels. But while it appears reasonable in theory, there is not sufficient evidence to back it up.
Still, some sources of physical stress will definitely cause a rise in PSA. For example, a surgical procedure, and undergoing trauma as in a car crash, are more likely associated with a high PSA. This is particularly the case if the surgical procedure or trauma affects the prostate. Psychological stress, on the other hand, has a different association with PSA. It is more indirectly associated with prostate problems, more than PSA (5).
To evaluate this relationship, a study was performed at the University of Iowa. There were patients with BPH medications. Others were not taking any medication. They were evaluated thoroughly and answered questions about stress. Researchers found that people with a higher level of stress were more likely to suffer from BPH symptoms. If they already had BPH, their symptoms were significantly worse (7).
Additionally, there’s an association between stress and the occurrence of different types of cancer. However, in this particular field, we should keep in mind that stress is never an independent risk factor. It may be involved, but does not cause prostate cancer directly. Thus, we can’t say that stress causes a direct increase in BPH.
The reverse is true because PSA measurements can cause stress. This is especially the case when patients are scared about their results and do not know much about prostate cancer. This can be counterproductive because, as we explained above, this can make their symptoms worse. Realizing that doctors can be easily fooled by symptoms aggravated by stress.
The possibility that stress triggers inflammatory reactions in the prostate, similar to arthritis, is still debatable. It is reasonable but not yet proven as a fact. Thus, to avoid the possibility, it is always appropriate to reduce stress and anxiety when testing for PSA levels.
It often comes from thinking about prostate cancer and not knowing what will happen. But rest assured that you’re in good hands and already doing what you’re meant to do in favor of your health.
What other factors can influence PSA?
Many other factors can influence PSA levels at a higher and measurable rate. You can have a high PSA level in the following cases:
- High levels of parathyroid hormone: Hormonal levels can affect the function of the prostate gland. The parathyroid hormone regulates the balance of calcium in the body. A very high level can also increase the chance of BPH and prostate cancer. Thus, people with a high level of parathyroid hormone are at a higher risk. They may have a higher chance of getting a high PSA reading (8).
- After ejaculation: Ejaculation and sexual activity directly stimulate the prostate gland. It releases its contents and may also leak PSA to the blood. Thus, it is not appropriate to perform a PSA test after ejaculation or any sexual activity. Remember that during sex, there are also micro ejaculations. These may also affect the results of a PSA test, even if there’s no actual climax.
- Medications: Some medications affect your PSA levels. And, ironically, some of them are used to relief prostate symptoms. For example, finasteride is commonly used to improve urinary problems in BPH. This drug will also reduce the level of PSA. The end result is a lower PSA, but not because the problem is getting better. It is a skewed result that may confuse doctors and patients. That’s why your doctor will probably advise to stop finasteride treatment before testing your PSA levels (9).
There are still other factors that influence BPH and may indirectly modify PSA levels. We all have to look out for additional risk factors and try to prevent (2):
- Smoking: According to studies, cigarette smoking can increase the risk of BPH. The increase is surprising in people who smoke heavily (35 cigarettes a day). These are 50% more likely to suffer from severe BPH symptoms. Other studies have also confirmed these findings. It is clear, then, that this is a lifestyle factor we want out.
- Obesity: The same study that evaluated smoking also evaluated obesity as a risk factor. Having a waistline of 43 inches and more can increase your BPH risk more than twice the normal risk. Thus, the recommendation of physical activity and weight control is fundamental. It does not only improve your cardiovascular health. It is also associated with a reduction of prostate risk.
- Low exercise levels: Interestingly, living a sedentary life can affect your prostate, too. Physical activity has the opposite effect of stress in the nervous system. It may actually improve urinary symptoms and help patients recover. It is also associated with a 25% reduction in the risk of BPH. You don’t need to engage in strenuous physical activity. It is enough with 15 to 30 minutes of walking every day.
- Alcohol: Naturally, this drink is heavily diuretic. It makes you increase the urinary output and worsens the symptoms of BPH. Thus, it may be appropriate to limit alcohol consumption. This won’t increase your PSA levels, but it is a lifestyle modification we should also consider.
Prostate cancer screening is essential to rule out cancer. However, it should not be performed in each and every patient. That’s because false positives are always a possibility, especially when it comes to PSA screening.
Young people are more likely to have normal PSA levels. But as we age, these levels increase. This is completely normal but reduces PSA’s accuracy if we don’t have a baseline level to compare. That’s why other tools are made available to increase the accuracy of PSA measurements.
Still, it is crucial to prevent a false PSA reading, which may arise from various factors. Inflammation and infection increase your PSA levels when they affect the prostate. Even a urinary tract infection can cause a higher PSA level. Sexual activity, manipulation of the prostate, and some medications may also modulate the PSA level.
Stress can also play a role. Similar to what happens in chronic inflammatory problems, stress can trigger the immune system. In a theoretical scenario, it may cause prostate inflammation and PSA release to the blood. However, there’s no clear evidence that this is the case.
What we do know for sure is that PSA screening often puts patients in a stressful situation. If you feel any sort of stress before a PSA screening, information might be the key to relieving that stress. Ask your doctor about your current health problem and why is he asking a PSA measure. Try not to feel alarmed without reason, and remember that you’re doing the right thing by following recommendations by your doctor.