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This patient with a raised PSA of 16 ng/ml with few LUTS, I would take fullhistory, inluding !/" #isi$le hematuria, urgeny, perennial pain,%ia$etes,mediations, e#aluate fre&ueny #olume hart and IPSS, with a flow test andP'S, on arri#al to out patient lini on an urgent $asis(US)*+

I would perform a %-, will note, si.e, nature of prostate,$enign feeling, or

tender $oggy Prostate suggesting Prostatitis,raggy, hard et, nodularity, ifthere is etent(T0/T et*,keeping in mind that 2345 of a$normal %-s areassoiated with prostate aner, the remainder$eing $enign hyperplasia, prostati aluli, hroni prostatitis, orpostradiotherapy hange+ "nly 745 of aners diagnosed $y %-will $e organonfined+The auray of %- alone in men with palpa$le lesionsapproimates 345 and of those indi#iduals diagnosed $y this modality alonemore than 845 will $e upstaged at the time of pathologial eamination+%- alone detets less than 1+85 of all diagnosed prostate aners e#enwhen there is a high inde of suspiion of glandular a$normalities+

I would perform a full neurologial eamination with regard to $ak pain+

!is symptoms of fre&ueny ould $e due to lower trat infetions, in this ase,to elude Prostatitis+, 9"", $enign enlargement of prostate, urethral striture:detrusor o#erati#ity!is noturia ould $e due to eessi#e fluid intake, noturnal polyuria (;45 ofdaily urine prodution ours at night time hours*+

I would like to see !$, inflammatory markers, renal funtion, reatinine, -S,Alkaline phospahate+ I would hek Urine dips, to rule out infetion, (if there is

would treat it* or see presene of 9)s, in the later ase, I would re&uest as raised PSA, ;345 of patients ha#e etra prostatidisease if PSA ;14ng/ml+?35 of patients ha#e lymph node metastases and only 15 ha#e $onemetastases if PSA ?04ng/ml+PSA is prostatespeifi, $ut not prostate anerspeifi+

@o partiular LUTS are speifi for prostate aner+ Patient>s symptoms might$e due to oeistent 9P! or some other LUT pathology+

The presene of LUTS, a low flow rate, an enlarged prostate, and old age areassoiated with an inreased risk of urinary retention+The serum PSA le#el alone annot $e used to relia$ly predit the pathologialstage of disease+ Approimately 845 to 45 of patients with loally ad#anedprostate aner ha#e a serum PSA le#els >14 ng/mL+I would perform an urgent TUS $iopsy in this ase after informed onsent, ina$sene of Prostatitis+ As patients with a Bleason sore of 6 or higher are likelyto progress to ad#aned aner (if they ha#e not already done so*, as arepatients with a prostatespeifi antigen (PSA* #alue of 14ng/mL or higher+The Bleason $iopsy sore may ha#e more prediti#e #alue in prediting theetent of disease+Although a higher perentage of aners are hypoehoi, prostate aner analso $e hyperehoi or isoehoi on transretal ultrasound imaging+

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TUS $iopsy result has prognosti information a$out o#erall disease $urden+The Bleason sore of the $iopsy speimen is the most important prognostifator forapsular etension of disease+ Additionally, the perent of ore in#ol#ed andthe num$er of ores in#ol#ed an gi#e prediti#e information for apsularetension and lymph node in#ol#ement+

In this particular patient, where a suspicion of bony mets is there, Iwould request a Bone scintigraphy, as itis muh more sensiti#e than plainradiography for detetion of $ony metastases+ Plain radiography generallyre&uires a 345 hange in the ortial $one density and of 14 to 13 mm indiameter to diagnose a $ony metastasis, whereas $one sintigraphy an detetdisease with as little as 145 hange in the ortial $one density+ @inetyfi#eperent of $one lesions due to prostate aner are osteo$lasti, whereas fi#eperent are osteolyti+

%iagnosti auray of 9one San is a$out C35 for skeletal metastatidisease+oughly a third of patients with prostate aner ()AP* willpresent with skeletal metastases+

Skeletal spread is unommon (?05* in )AP patients with a PSA of ?0 ng/mLand present in ;C45 of ases with a PSA ;34 ng/mLD 9one sans may also ha#e a prognosti role in that the mortality at 0 years inpatients with and without a positi#e san at presentation is 735 and 045,respeti#ely+D -ndorine treatment does influene $one san results, with patients on

hormonal manipulation for a period either demonstrating a negati#e $one san(after $eing positi#e initially* or showing progression with appearane of newlesions+

Abdominal or pelvic CT scanning or MRImay re#eal etraapsularetension, seminal #esial in#ol#ement, pel#i lymph node enlargement, li#ermetastases, and hydronephrosis (due to result of distal ureteral o$strution* inpatients suspeted of ha#ing loally ad#aned disease+EI sanning is now the prinipal imaging tehni&ue for )AP+ The o#erallauray of E for the prostati adenoarinoma lies $etween 315 and 05+

E must $e deferred for at least 7 weeks in patients following TUS $iopsy orTUP+)T annot distinguish $etween the #arious grades of organ onfined disease+)T a$le to detet loal in#asion into $ladder or seminal #esiles and thepresene of gross lymphadenopathy"#erall auray of )T in the staging of prostate aner #aries $etween 345and 45)T una$le to differentiate onfidently $etween malignant and $enign onditionsin#ol#ing the prostate+

Alpha $lokers are not always effeti#e with a high tumour $urden in theprostate, $ut in this patient, if flow rare is low, with high P', eg+ ; 044 mls, Iwould start Alpha $loker(Tamsulosin, $y eplaining the side effets*, and starthim on hormonal treatment, one I ha#e eluded infetion or other auses of

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raised PSA+