Escaping the "PSA Test Loop": How PSA Testing Overshadows Male LUTS Treatment and Management in Primary Care

Lower urinary tract symptoms (LUTS) affect up to 90% of men aged >50 yrs, but few (around 10%) receive appropriate treatment. Research indicates that men with LUTS are mostly poorly informed about their urinary symptoms and view LUTS as largely unworthy of clinical attention. As a result, many men endure symptoms for lengthy periods without seeking support. In this uninformed and untreated context, men with LUTS are susceptible to anxiety about prostate cancer, fueled by widespread misconceptions about the association between prostate cancer and LUTS. Prostate cancer fear drives a sizeable proportion of male LUTS primary care consultations. This mini review examines the hitherto largely unrecognized "PSA test loop"-whereby over time, men with LUTS undergo repeated cycles of prostate-specific antigen (PSA) testing with negative results, but do not receive clinically recommended information or guidance within primary care to support their urinary symptoms. This concept arose through qualitative research, which was part of a large UK randomized controlled trial of conservative management for male LUTS [TRIUMPH study: ISRCTN11669964]. The PSA test loop is set in motion when men with LUTS attend primary care with a focus on prostate cancer and PSA testing, and when general practitioner (GP) attention subsequently shifts away from urinary symptoms and the provision of appropriate information, guidance and treatment to support male LUTS. The effect is compounded by GP consultation time constraints and by limitations in GPs' attitudes and knowledge in relation to the self-management of male LUTS. The PSA test loop is activated when men with LUTS receive negative PSA results, often by telephone, and experience relief in relation to their prostate cancer concerns, leading them to exit primary care-without follow-up and without receiving guidance to support their untreated urinary symptoms. Over time, as symptoms persist and prostate cancer fears resurface, the cycle repeats. The TRIUMPH study has demonstrated that a structured and tailored self-management intervention can be effectively delivered in primary care, outside of GP consultation time (eg, by trained health care assistants or nurses), and can provide information, guidance, reassurance and symptom relief. We propose prioritizing self-management guidance for men with LUTS in primary care, especially following negative PSA testing, to better inform men, to alleviate untreated urinary symptoms and associated prostate cancer concerns, and to deactivate the PSA test loop cycle. PATIENT SUMMARY: Older men with urinary symptoms can become trapped in cycles of prostate cancer testing (prostate-specific antigen - or 'PSA' - tests), without receiving proper advice to help relieve their symptoms. We explain how this can happen and propose offering men who receive negative PSA results a follow-up appointment in primary care with a trained nurse or health care assistant. The follow-up appointment would be an opportunity to provide men with up-to-date information on their urinary symptoms and tailored guidance, based on clinically trialed and recommended self-help techniques, to help men manage their urinary symptoms.