top of page
Osce-Talk-logo

PSA Testing & Prostate Counselling Guide

This page follows on from the LUTS / BPH History Guide and the Urology Red Flags Guide.
In this station, you may be asked to speak to a man with urinary symptoms who is worried about prostate cancer, or who wants to know whether he should have a PSA test.

In a PSA counselling station, the examiner wants to see that you can:

 

  • Explain what PSA is in simple language

  • Discuss the benefits and limitations of PSA testing

  • Explain that PSA can be raised for non-cancer reasons

  • Explain that a normal PSA does not completely rule out prostate cancer

  • Mention what happens if PSA is raised, including possible referral, MRI or biopsy

  • Explore the patient’s concerns and support shared decision-making

  • Safety-net for concerning symptoms such as haematuria, weight loss or bone pain

What this Station is Testing?

Osce-Talk-logo

OSCE Talk Tip

PSA counselling is about shared decision-making.


Your job is not to tell the patient what to do. Your job is to explain the benefits, limitations and possible consequences of the test, then help them make an informed decision.


PSA can sometimes help pick up prostate cancer early, but it can also be raised for non-cancer reasons, miss some cancers, or lead to further tests and anxiety.

Opening the Consultation

Start as usual:


“Hello, my name is Peter. I’m one of the medical students. Could I just check your name and date of birth please?”


“Today I’d like to talk with you about the PSA test, explain what it can and cannot tell us, and answer any questions you have. Is that okay?”

Check understanding and ICE

Before explaining, check what the patient already understands.


“What have you been told about the PSA test so far?”


“Has anything made you worried about prostate cancer?”


“Is there anything in particular you were hoping the test would tell us?”


This helps you focus the explanation on what matters to the patient.

Take a Brief Focused History if Appropriate

The amount of history depends on the station.


In a short station, keep this brief. In a longer station, you may have time to ask more about urinary symptoms, red flags, risk factors and anything that could affect the PSA result.


Useful questions include:

 

  • “Can I quickly check what urinary symptoms you’ve been having?”

  • “Have you noticed any blood in your urine or semen?”

  • “Have you had any weight loss or new bone pain?”

  • “Is there any family history of prostate cancer?”

  • “Have you had a recent urine infection, catheter, prostate procedure, ejaculation or vigorous exercise?”


The aim is not to take a full LUTS history unless the station asks for it. Focus on whether PSA testing is appropriate today or should be delayed.

Explain the Prostate and PSA

Keep the anatomy simple.


“The prostate is a small gland that sits just below the bladder. The tube you pass urine through runs through the prostate, so if the prostate becomes enlarged or abnormal, it can affect passing urine.”


You can link this to symptoms:


“As men get older, the prostate commonly enlarges. This can cause symptoms like a weak stream, difficulty getting started, dribbling after passing urine, passing urine more often, or getting up at night.”


Then explain PSA:


“PSA stands for prostate-specific antigen. It is a protein made by the prostate gland, and we can measure it with a blood test.”


“The PSA test can help us decide whether the prostate needs further assessment.”

Explain the Benefits and Limitations of PSA Testing

The main benefit of PSA testing is that it can sometimes help pick up prostate cancer early, before it has caused more serious symptoms or spread.


However, PSA is not a perfect cancer test.


A raised PSA does not automatically mean cancer. It can also be raised by non-cancer causes, such as:

 

  • Benign enlargement of the prostate

  • Prostatitis

  • Urinary tract infection

  • Recent ejaculation

  • Vigorous exercise, especially cycling

  • Recent catheterisation

  • Recent prostate or urinary tract procedures

  • A normal PSA does not completely rule out prostate cancer either.


This means PSA testing can sometimes lead to worry, repeat blood tests, referral, MRI scans or biopsies, even when cancer is not found.


Another difficulty is overdiagnosis. Some prostate cancers grow very slowly and may never cause symptoms or shorten someone’s life. Testing can pick up these slower cancers, which can lead to difficult decisions about monitoring or treatment.


The balance is important: some prostate cancers are slow-growing, but others are aggressive and need treatment. PSA testing is about helping the patient understand the pros and cons so they can make an informed decision.

Explain How to Prepare for the Test

To make the PSA result more reliable, explain:

 

  • “Before the test, we usually advise avoiding ejaculation and vigorous exercise for 48 hours.”

  • “If you have symptoms of a urine infection, we would usually treat that first and delay the PSA test.”

  • “If you have recently had a catheter, prostate procedure, biopsy or urinary tract procedure, we may also need to wait before checking PSA.”


If a digital rectal examination is being performed, the PSA blood test should ideally be taken before the rectal examination.

Explain DRE

A digital rectal examination, or DRE, may be part of the assessment.


You could say:

 

  • “We may also examine the prostate by gently feeling it through the back passage. This is called a digital rectal examination.”

  • “We would explain it properly, ask for your consent, use lubricant and have a chaperone present.”


A smoothly enlarged prostate may fit with benign enlargement.


A hard, irregular, nodular or asymmetrical prostate is more concerning

.
Be clear that DRE is not perfect either, and PSA and DRE are often interpreted together.

What happens if the PSA is raised?
 

Explain without frightening the patient.

 

  • “If the PSA is raised, it does not automatically mean you have cancer.”

  • “We would interpret the result in the context of your age, symptoms, risk factors and prostate examination.”

  • “Depending on the result, we may refer you to a urologist. They may arrange further tests, such as an MRI scan of the prostate, and sometimes a biopsy if needed.”


You can also say:


“Even if you are referred, that still does not mean you definitely have prostate cancer. It means we need to investigate properly.”

Risk Factors for Prostate Cancer

Important risk factors include:

 

  • Increasing age

  • Black ethnicity

  • Family history of prostate cancer

  • Certain inherited cancer genes, such as BRCA-related risk


Symptoms that increase concern include:

 

  • Visible blood in the urine

  • Blood in semen

  • Erectile dysfunction

  • Weight loss

  • Bone pain, especially back, hip or pelvic pain

  • Abnormal prostate examination

How to Answer: “Do I have Cancer?”
 

Do not dismiss the concern.


You could say:


“I can understand why you are worried about that. Your symptoms do not automatically mean cancer, and there are common benign causes such as prostate enlargement. But prostate cancer is something we take seriously, so we would assess your symptoms, examine you, and consider PSA testing where appropriate.”


This validates the concern without giving false reassurance

Example Counselling Script

“From what you’ve told me, you’re having urinary symptoms and you’re worried about prostate cancer. That is completely understandable.


The prostate is a small gland that sits below the bladder, and the tube you pass urine through runs through it. As men get older, the prostate commonly enlarges, and this can cause symptoms like a weak stream, difficulty getting started, dribbling, passing urine more often, or getting up at night.


A PSA test is a blood test that measures a protein made by the prostate gland. It can be useful because it may help pick up prostate cancer early or show that we need to investigate the prostate further.


However, it is not a perfect cancer test. PSA can be raised in prostate cancer, but it can also be raised by benign prostate enlargement, urine infection, prostatitis, recent ejaculation, vigorous exercise, catheterisation or recent prostate procedures. Also, a normal PSA does not completely rule out prostate cancer.


So the decision to do the test is usually about weighing up the pros and cons. The benefit is that it can sometimes detect cancer early. The downside is that it can lead to worry and further tests, even when there is no cancer, and sometimes it can pick up slow-growing cancers that may never have caused problems.


To make the result more reliable, we usually advise avoiding ejaculation and vigorous exercise for 48 hours before the test. If there are symptoms of a urine infection, we would usually treat that first and delay the PSA test.


If the PSA is raised, it does not automatically mean cancer. We would look at the result alongside your age, symptoms and prostate examination. If needed, we may refer you to a urologist for further assessment, such as an MRI scan and sometimes a biopsy.


How does that sound so far? Is there anything about the test or prostate cancer that you are particularly worried about?”

Key Message

PSA counselling is about balance.


The test can be useful, but it is not perfect. It can help detect prostate cancer, but it can also cause worry, over-investigation and difficult decisions.


In an OSCE, explain the test clearly, discuss the pros and cons, check the patient’s concerns, and support them to make an informed decision.

Quick Structure to Remember

A focused PSA counselling station can be structured around:

 

  1. Check understanding and concerns

  2. Explain the prostate and PSA

  3. Explain why the test may be useful

  4. Explain the limitations, including false positives and false negatives

  5. Explain non-cancer causes of raised PSA

  6. Mention overdiagnosis and further tests

  7. Explain preparation, including avoiding ejaculation and vigorous exercise

  8. Explain DRE and what happens if PSA is raised

  9. Explore ICE, support shared decision-making and safety-net

bottom of page