ORIGINAL ARTICLE

Effect of Different Manipulations on Serum Prostate-Specific Antigen

(PSA) Level in Patients with Symptomatic Benign Prostatic Hyperplasia
and Suspicion of Carcinoma Prostate
ASHFAQ AHMAD1, MUHAMMAD IQBAL2, SOHAIL HASSAN3, SHAH JEHAN-UR-REHMAN4, AMMAR BASHIR5
1
Associate Prof. of Urology
2
AP Urology, Social Security Teaching Hospital Lahore
3
Associate Prof. Social Security Teaching Hospital Lahore
4
AP Urology Lahore General Hospital, Lahore
5
Resident Urology AFIU Rawalpindi
Correspondence: Dr. Ahfaq Ahmad, Email: [email protected]

ABSTRACT
Background: Prostate specific antigen is an organ specific marker. A temporary rise in prostate specific antigen serum
level has been reported in various situations like, digital rectal examination, urethral catheterization, transurethral
resection of prostate and transrectal ultrasound guided prostatic needle biopsy.
Methodology: This comparative study is conducted at Department of Urology and Renal Transplantation Div, HQ.
Teaching Hospital Mirpur Azad Kashmir from 1st June 2017 to 31st May 2018. Patients with symptomatic benign prostate
hyperplasia and suspicion of carcinoma prostate on digital rectal examination with age above 50 years were included. All
patients were divided into four groups. Group A comprised, patients who underwent digital rectal examination. Group B
comprised, patients who underwent transurethral resection of prostate. Group C comprised, patients who underwent
transurethral Foley catheterization due to retention of urine. Group D comprised, patients who underwent transrectal
ultrasound guided prostatic needle biopsy for suspicion of ca prostate on digital rectal examination. Serum PSA was
detected by enzyme linked immunosorbent serum assay (ELISA) method.
Results: In group A pre manipulation mean serum PSA level was 1.22ng/ml, after 30 minutes it was 2.52ng/ml, where as
after 72 hrs mean serum PSA level was 1.56ng/ml and after one week it dropped to 1.1ng/ml.In group B pre manipulation
mean serum PSA level was 3.41ng/ml, after 30 minutes of manipulation it was 29.89ng/ml, after 72 hours and one week
of manipulation it was 8.22ng/ml and 4.25ng/ml respectively and after 2 weeks it dropped to 3.78ng/ml. In group C pre
manipulation mean serum PSA level was 2.81ng/ml, after 30 minutes it was 4.54ng/ml, where as after 72 hrs and 1 week
of manipulation it was 3.76ng/ml and 2.40ng/ml respectively. In group D pre manipulation mean serum PSA level was
2.61ng/ml, after 30 minutes it was 4.53ng/ml, where as after 72 hrs and 1 week of manipulation it was 3.42ng/ml and
2.56ng/ml respectively.
Conclusion: There is significant rise in serum prostate specific antigen after different manipulations except DRE.
Key words: Prostatic specific antigen, benign prostatic hyperplasia, Carcinoma prostate.

INTRODUCTION developed to measure the human serum level of prostate

specific antigen.13 It is expressed in both benign and malignant
Prostate-specific antigen (PSA) is a tumor marker helpful in the disease processes involving epithelial cells of the prostate
diagnosis and follow-up of prostate cancer. PSA level may rise gland. Under normal physiological conditions, it is secreted into
due to other causes than prostate cancer such as benign the Lumina of the prostatic ducts and present in the seminal
prostatic hyperplasia (BPH), acute and chronic prostatitis.1 plasma in high concentration14.
Benign prostatic hyperplasia is by far the most common The objective of the study was to determine the influence
pathological process affecting the prostate gland. Its incidence of transurethral catheterization, digital rectal examination and
is approximately 20% in men at 40 years of age that increases transurethral resection of prostate on serum prostate specific
to 70% by the age of 60 and to 90% by the age of 70 years2. antigen,.to determine the influence of transrectal ultrasound
Early diagnosis of prostate carcinoma has led to more guided prostatic needle biopsy on serum prostate specific
potentially curable cases.3 Prostate carcinoma is a significant antigen level in patients with suspicion of carcinoma prostate
cause of morbidity and mortality. It is the most common on digital rectal examination. to determine the time interval
malignancy amongst men.4 Prostate cancer is second leading when serum prostate specific antigen level returns the base
cause of death in America, second to lung cancer. It has line after respective manipulation and to determine correlation
become one of the leading male cancers in Asian countries as between the size of prostate, amount of tissue resected and
well.5 Prostate cancer is also common in Pakistan. It is the serum prostate specific antigen level.
third most common cancer occupying about 7% of all
malignancies.6 Prostate specific antigen is a proteolytic
enzyme currently used as a serum tumor marker for cancer of
RESULTS
prostate. It is produced and secreted by the epithelial cells Group A was comprised of 15 patients with age range 52-70
lining the acini and ducts of the prostate. It forms the part of years; mean 58.86 years. The size of prostate in this group
seminal ejaculate.7 Its biological function is the hydrolysis of varied from 20-50grams, mean 35.33 grams. Pre-manipulation
the high molecular weight seminal proteins seminogelin and (DRE) mean serum PSA was 1.22+0.57ng/ml. After 30
fibronectin. This action leads to liquefaction and liberating the minutes of manipulation mean serum PSA level increased to
spermatozoa from the jelly like coagulum8. 2.52+0.64ng/ml, after 72 hrs it was 1.56+0.60ng/ml and after
Prostate specific antigen is a single chain glycoprotein of one week of DRE mean serum PSA level dropped to
237 amino acids and four Carbohydrate side chains. 11 It has 1.11+0.42ng/ml. Pre and post-manipulation mean serum PSA
molecular weight of 34 kilo Dalton. 12 A serological test was difference after 30 minutes was 1.30ng/ml and after 72 hours it

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Ashfaq Ahmad, Muhammad Iqbal, Sohail Hassan et al

was 0.34ng/ml (Table 1). Pre and post-manipulation (DRE) Group C was comprised of 15 patients with age
serum PSA difference showed that there was statistically range 55-78 years mean 63 years. The size of prostate varied
insignificant rise in serum PSA after 30 minutes of from 30-70gms mean 46.6 grams. These patients underwent
manipulation (P <0.05). Post manipulation mean serum PSA transurethral catheterization due to retention of urine. Pre
rise was also calculated according to size of the prostate in this catheterization blood sample for serum PSA was taken in all
group. In patients where prostate size ranged from 20-30gms, these patients. After Foley catheterization samples of blood
mean rise of serum PSA was 2.44+0.64ng/ml, in patients with were taken at 30 minutes, 72 hours and after 1 week. Pre-
31-40gms of prostate mean serum PSA rise was catheterization mean serum PSA level was 2.85+0.56ng/ml, 30
2.45+0.30ng/ml and in patients with 41-50gms of prostate size minutes post-catheterization mean of PSA increased to
mean serum PSA rise was 2.73+0.95ng/ml after 30 minutes of 4.50+0.80ng/ml after 72 hours of catheterization mean serum
manipulation (Table 2). PSA was 3.70+0.63ng/ml and after 1 week of catheterization
Group B was comprised of 15 patients with age range of mean serum PSA dropped to 3.20+0.57ng/ml. Pre and post-
56-83years means 69.26 years. The size of prostate varied manipulation mean serum PSA difference after 30 minutes
from 25-65gms mean 42gms.Ten patients presented with was 1.65ng/ml and after 72 hours it was 0.85ng/ml, after one
retention of urine where as five patients presented with severe week of catheterization serum PSA level dropped to baseline
LUTS. All these patients underwent TURP. Prior to TURP 0.35ng/ml (Table 6). The results showed that a significant rise
mean serum PSA level was 3.41+0.65ng/ml. After 30 minutes in mean PSA after 30 minutes and 72 hrs of Foley
of TURP mean Serum PSA increased to 30.69+6.28ng/ml, catheterization (P <0.05). Post manipulation mean serum PSA
after 72 hours and one week after TUR-P mean serum PSA rise was also calculated according to size of the prostate in this
was 8.22+0.97ng/ml &4.25+0.45ng/ml respectively. After 2 group. In patients where prostate size ranged from 30-40gms,
weeks of TUR-P mean serum PSA level dropped to mean rise of serum PSA was 4.37+0.23ng/ml, in patients with
3.78+0.42ng/ml (Figure 12). Five patients had resected tissue 41-50gms of prostate mean serum PSA rise was
in the range of 10-20gms; eight had in the range of 21-30gms 3.50+0.0ng/ml, in patients with 51-60gms of prostate size
while two had in range of 31-40gms. Pre and post- mean serum PSA rise was 4.38+1.04ng/ml and in patients with
manipulation(TUR-P) mean serum PSA difference after 30 61-70gms of prostate size mean rise in serum PSA was
minutes was 27.28ng/ml and after 72 hours it was 4.81ng/ml, 4.83+0.73ng/ml after 30 minutes of manipulation (Table 7).
after one week serum PSA difference was 0.84ng/ml and after Group D was comprised of 15 patients with age range 57-79
2 week of post-manipulation mean serum PSA difference was years mean 65 years with suspicion of CA prostate on DRE.
0.37ng/ml (Table 3). The results showed that there was a The size of prostate varied from 25-55gms mean 37 grams.
statistical significant rise in mean serum PSA levels after 30 These patients underwent TRUS guided prostatic needle
minutes,72 hours and one week of TURP (P <0.05). Post biopsy. Pre-manipulation (biopsy) mean serum PSA was
manipulation mean serum PSA rise was also calculated 2.48+1.46ng/ml. Post-manipulation (biopsy) mean serum PSA
according to size of the prostate in this group. In patients level after 30 minutes was 4.64+2.38ng/ml, after 72 hours of
where prostate size ranged from 25-35gms, mean rise of manipulation mean serum PSA was 4.37+2.09ng/ml. After 1
serum PSA was 23.88+1.36ng/ml, in patients with 36-45gms of week of manipulation mean serum PSA level was
prostate mean serum PSA rise was 30.95+2.92ng/ml, in 2.65+1.48ng/ml. Pre and post-manipulation (biopsy) mean
patients with 46-55gms of prostate size mean serum PSA rise serum PSA difference after 30 minutes was 2.16ng/ml, after 72
was 38.30+1.27ng/ml and in patients with 56-65gms of hours it was 1.89ng/ml, and after one week serum PSA
prostate size mean rise in serum PSA was 39.30+1.98ng/ml difference dropped to baseline 0.17ng/ml. The results showed
after 30 minutes of manipulation (Table 4). The patients, who a significant rise in mean PSA after 30 minutes of TRUS
had resected tissue in the range of 10-20grams, mean serum guided biopsy (P <0.05). Post manipulation mean serum PSA
PSA rise was 23.88+1.36ng/ml after 30 minutes of TUR-P. rise was also calculated according to size of the prostate in this
Those patients who had resected tissue in the range of 21-30 group. In patients where prostate size ranged from 25-35gms,
grams, mean serum PSA rise was 32.79+4.23ng/ml where as mean rise of serum PSA was 6.32+3.65ng/ml, in patients with
those patients who had resected tissue in the range of 31- 36-45gms of prostate mean serum PSA rise was
40gms had mean serum PSA rise of 39.30+1.98ng/ml after 30 3.78+0.91ng/ml and in patients with 46-55gms of prostate size
minutes of resection (Table 5). mean serum PSA rise was 2.85+0.35ng/ml after 30 minutes of
manipulation (Table 8).
Table 1 (Group A): Serum PSA Elevation after DRE
Category Mean± SD Category Mean± SD Diff.
Pre-Manipulation 1.22±0.57 30 Minutes after Manipulation 2.52±0.64 1.30
Pre-Manipulation 1.22±0.57 72 Hours after Manipulation 1.56±0.60 0.34
Pre-Manipulation 1.22±0.57 One Week 1.11±0.42 -0.11
*P<0.05
Table 2 (Group A): Mean rise of PSA 30 minutes after DRE according to size of prostate
Size of prostate No. Mean rise after 30 minutes with SD
20–30gm 7 2.44+0.64ng/ml
31–40gm 4 2.45+0.30ng/ml
41–50gm 4 2.73+0.95ng/ml
*p<0.05
Table 3 (Group B): Mean rise of PSA 30 minutes after TUR-P according to size of prostate
Size of prostate No. Mean rise after 30 minutes with SD
25–35gm 5 23.88+1.36ng/ml
36–45gm 6 30.95+2.92ng/ml
46–55gm 2 38.30+1.27ng/ml
56–65gms 2 39.30+1.98ng/ml

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 Effect of Different Manipulations on Serum PSA Level in Symptomatic BP Hyperplasia

Table 4 (Group B): Comparison of means using Tukey test

Size of prostate Mean± SD Category Mean± SD Mean difference
10-20 23.88±1.36 21-30 32.79±4.23 8.90
10-20 23.88±1.36 31-40 39.30±1.98 15.42
21-30 32.79±4.23 31-40 39.30±1.98 6.51
*P<0.05

Table 5 (Group C): Comparison of means using Tukey test

Category Mean±SD Category Mean± SD Mean difference
Pre-Manipulation 2.85±0.56 30 Minutes after Manipulation 4.50±0.80 1.65
Pre-Manipulation 2.85±0.56 72 Hours after Manipulation 3.70±0.63 0.85
Pre-Manipulation 2.85±0.56 One Week 3.20±0.57 0.35
*P<0.05

Table 6 (Group C): Mean rise of PSA 30 minutes after Foley Catheterization according to size of prostate
Size of prostate No. Mean rise after 30 minutes with SD
30 – 40gms 3 4.37+0.23ng/ml
41 – 50gms 1 3.50+0.00ng/ml
51 – 60gms 5 4.38+1.04ng/ml
61 – 70gms 6 4.83+0.73ng/ml

Table 7 Group D: Comparison of means using Tukey test

Category Mean± SD Category Mean ±SD Difference
Pre-Manipulation 2.48±1.46 30 Minutes after Manipulation 4.64±2.38 2.16
Pre-Manipulation 2.48±1.46 72 Hours after Manipulation 4.37±2.09 1.89
Pre-Manipulation 2.48±1.46 One Week 2.65±1.48 0.17
*P<0.05

Table 8 Group D: Mean rise of PSA 30 minutes after TRUS Guided Prostatic Needle Biopsy According to size of prostate
Size of prostate No. Mean rise after 30 minutes with SD
25–35gms 5 6.32+3.65ng/ml
36–45gms 8 3.78+0.91ng/ml
46–55gms 2 2.85+0.35ng/ml

DISCUSSION Blood tests were taken from every patient previously and 30
min after manipulation. A total cPSA levels were estimated
In our study pre manipulation (DRE) mean serum PSA was utilizing proper tests. There was no significant increment in
1.22+0.57ng/ml and post manipulation DRE mean serum PSA cPSA levels after flexible cystoscopy and computerized rectal
was 2.52+0.64ng/ml. Our result showed no statistically examination, yet prostate biopsy caused a measurably critical
significant rise in serum PSA after DRE in patients having albeit insignificant ascent in cPSA level. These findings co-
clinically symptomatic benign prostatic enlargement (P >0.05). relate well with our study.
In 1992, Breul et al15 conducted a study to evaluate the In our study pre manipulation (TURP) mean serum
effect of DRE on serum PSA. No noteworthy contrast was PSA level was 3.41+0.65ng/ml whereas after 30 minutes it was
seen in PSA values before and after DRE when blood tests 30.69+6.28ng/ml which showed that significant rise in serum
were taken 1-3 min after palpation of the prostate, which PSA 30 minutes after TURP (P <0.05). In TRUS guided
corelates well with our study. prostatic needle biopsy pre manipulation mean serum PSA
Klomp et al16 conducted a study to see the effect of level was 2.61+1.49ng/ml whereas after 30 minutes of
TRUS and DRE on serum PSA level. PSA was firm in patients manipulation it was 4.50+2.47ng/ml which showed significant
immediately and after 1 week after TRUS and DRE. In some rise in serum PSA 30 minutes after TRUS guided prostatic
group of patients PSA was firm at various times after DRE and needle biopsy (p <0.05).
TRUS. The PSA showed a significant rise of 20% immediately Oesterling et al18 conducted a study in 1993 to survey the
after DRE and TRUS. After 7 days PSA had returned to their impact of cystoscopy, prostate biopsy and transurethral
initial levels. When applying the diagnostic triad PSA, DRE and resection of the prostate (TURP) on the serum prostate-explicit
TRUS blood samples for PSA should first taken before DRE, antigen (PSA) focus, 101 patients were assessed. For
TRUS guided Prostatic needle biopsy. Our study showed no cystoscopic examination, 69 men were randomized in a
significant rise in serum PSA after DRE whereas after TRUS forthcoming way to one of three gatherings: flexible
guided prostatic needle biopsy statistically significant rise in cystoscopy, inflexible cystoscopy and a control cohort. The
serum PSA (P <0.05). So the blood sample must be taken middle change in serum PSA was 0.1ng/ml following flexible
before TRUS to avoid false positive results. Another cystoscopy 0.05ng/ml after unbending cystoscopy and
explanation is that the combination of DRE and TRUS implies 0.05ng/ml for the control bunch in which two serum PSA
a more serious manipulation of the prostate than DRE alone. assurance were acquired without an interceding cystoscopy.
Lynn et al17 did a study to evaluate the impact of The contrasts between the three groups were not significant.
prostatic control on complexed prostate-explicit antigen The impact of prostate biopsy and TURP was analyzed in 32
(cPSA), as different types of prostatic control are known to men. Prostate biopsy caused a quick rise in the serum PSA
increase the serum free and complete PSA level. A study of 92 level with a middle increment of 7.9ng/ml (p <0.0001). Also
men (58 after prostatic biopsy, 16 after advanced rectal TURP delivered a rise in the serum PSA fixation with a median
examination and 18 after flexible cystoscopy) were evaluated.

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Ashfaq Ahmad, Muhammad Iqbal, Sohail Hassan et al

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