31st December 2024

Presentation of prostate cancer

Patients may present symptomatically with lower urinary tract symptoms (LUTS) such as urgency, frequency, hesitancy, nocturia and retention, although LUTS usually indicate coincident benign prostatic hyperplasia. They also may present with systemic symptoms such as weight loss, poor appetite, and fatigue. However, the majority of new diagnoses are entirely asymptomatic, with referral made on the basis of an elevated age-adjusted prostate-specific antigen (PSA) and/or abnormal findings on digital rectal examination (DRE), such as a nodular or irregular prostate. The role of PSA in screening is controversial as it is non-specific to malignancy (may be elevated secondary to DRE, ejaculation, or benign pathology such as prostatitis).

A minority of patients present with symptoms and/or complications of metastatic disease, e.g. bone pain, fragility fractures, obstructive renal failure and rectal bleeding. Metastatic spinal cord compression may be the first presentation of metastatic prostate cancer and is an oncological emergency. Back pain which is new, progressive and/or severe is usually the primary feature and any additional neurological deficit is usually a late sign. Any clinical suspicion warrants urgent investigation with an MRI whole spine.