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    Old 11-26-2019, 12:17 PM   #1
    Overthinker74
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    Unhappy Acute Prostatitis, with recurrent high PSA after several months

    Hello all,

    This is a terrific board, and I very much appreciate everyone's thoughtful comments and information. I have read so much in the recent weeks about this condition due to my own perplexing and concerning situation.

    To start, I am 45 years old and have likely since my 20's been someone who frequently has to urinate. I've gone to the doctor back in my later 20's and even been referred to a urologist once before without much input beyond practical recommendations about drinking at night and so on. He gave me a DRE back then and that was about it.

    Fast forward then to this summer in June and I came down with a low grade fever (about 100-101) and some even more difficult urination symptoms and went to the nearby clinic when after testing my urine (and identifying an infection), recommended I go to the ER. There, they performed a battery of tests including a CT scan, to assess whether or not there was an infective abcess on my prostate, diagnosed me as having acute bacterial prostatitis. The CT of my pelvic area confirmed inflammation to the prostate (through tissue stranding and trace pelvic fluid), but everything else looked good. After suffering terribly in bed for the next couple days, I felt much better afterwards. After about a 10 day prescription of antibiotics, I went to my primary care doctor for a follow-up. They decided to perform follow-up blood tests including a PSA after 3 weeks from my visit to the ER (about mid July). Those tests showed a very slightly lower RBC and WBC count, but most alarmingly, my PSA was at a 16. So, then they decided to recheck me in another 3 weeks in mid August figuring that my previous infection was still effecting my PSA. On that second test, my blood tests are improved across the board, but by PSA raises to almost 25! (I did realize that I still had some odd symptoms slowing resolving during this time including a heavier feeling in the rectum...)

    Obviously, I'm very concerned and am referred to a urologist. I visit them in a couple of weeks, and she reassures me and believes that I still have infection issues, so she prescribes 2 more 2 weeks of antibiotics, and directs me to return for a follow-up PSA about a week ago. That PSA test showed a reduction, but only back down to a 16. Almost all of my symptoms have resolved from the acute prostatitis issue in June, save for my urinary frequency that I've always had. (it's not terrible, but I probably urinate 6-9 times a day and maybe 1-2 times at night; on the upper end when I'm stressed) I was given a DRE which showed my prostate (and seminal vesicles) felt fine.

    Unfortunately, I've never had a baseline PSA test in my younger years, so I don't know what my PSA should look like, but obviously, even at a PSA which is 16, I'm concerned. I'm scheduled to have an MRI next month with a biopsy to follow. I know there are no answers at the present moment, but it's all just overwhelming at this point. My family on both sides has no history of PCa, and at 45y/o, I guess this took me for a loop.

    I'm trying to be positive and hopeful that maybe the prostatitis is lingering, or alternatively, if I have PCa, maybe I'm lucky that this was perhaps caught early? My mind tends to go in all sorts of directions unfortunately. I just seem in bad shape with a PSA this high. (i.e. 16-25-16)

    Thanks for allowing me to vent a little bit! I realize this can go in either direction at this point, but what a deal.

     
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    Old 11-29-2019, 11:22 AM   #2
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Hi Overthinker 74 and welcome to the Board!

    It seems to me that you are getting good care, but itís hard to be calm when you are thinking of prostate cancer as a possible explanation for that elevated series of PSA readings.

    First of all, that substantial PSA decline from 25 to 16 pretty much proves, from my laymanís viewpoint, that infection is a major cause of your PSA elevation. There was a really remote chance, "remote" mainly because of the evidence of infection, that the increase from 16 to 25 in about a month could have been a very aggressive prostate cancer with a very short doubling time as cancer cells divided, reflected in the PSA, but cancer does not respond to antibiotics and just keeps increasing at an ďexponentialĒ rate, whereas your PSA fell, and fell substantially. PSA that stems from cancer doesnít fall, unless under treatment or management tactics. Infection/inflammation can easily raise PSA to high levels and do it fast. (The highest Iíve heard of is a PSA of 200, which later recovered to normal after an appropriate antibiotic was found.)

    It is good, of course, that the DRE result was fine.

    The MRI is a good next step. Iím thinking it will be a multiparametric MRI (mpMRI), but sometimes a regular MRI is done in your circumstances. I expect that the result of the scan will be continuing evidence of infection but not of prostate cancer. However, there is a possibility that you have both an infection AND prostate cancer. While antibiotic therapy clearly worked, sometimes more than one bacterium is causing the problem, and Iím thinking there is a strong possibility that one or more other bacteria were not eliminated by the antibiotic you were on; another possibility is that you just need to be on the antibiotic regimen for a longer time.

    Even if it turns out that you do have prostate cancer, with the technology we have these days survival prospects are outstanding for almost all patients, though some of us will experience some continuing burden, often quite tolerable, from side effects.

    Good luck!

     
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    Old 11-29-2019, 02:17 PM   #3
    Overthinker74
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    I agree with your assessment and really appreciate your response. Of course Iím hopeful itís just a difficult infection, but after my review of a many studies (primarily on prostatitis and its impacts on PSA with PCa), itís still seems a little high as Iím certainly not in an acute bacterial stage (likely chronic?) and I think it should have fallen more ( or ďnormalizedĒ) after the last PSA 16 about 3 months ago.

    As much as I tell myself to be mentally and emotionally prepared for the PCa diagnosis, itís very hard to wrap my head around it. At this point, I guess Iím just a little hopeful that perhaps the infection has inflated the last PSA score slightly, which could slightly improve my prognosis assuming I do have it.

    My view of this disease is that itís lifelong challenge regardless of how well you responded to initial treatments and subsequent recurrences. Since the chemical recurrence rate appears relatively high (after analyzing likely scenarios with the Sloan Kettering risk calculators), the concept of vigilance hardly captures the situation. And wow, the wait between appointments, testing and results will be excruciating for someone like me, as they already have been.

    My wife and I are certainly anticipating negative news, obviously(probably me more than her). Itís very hard though. I just wish I started PSA testing earlier in my life, I guess, so as to be more personally aggressive in my health approach (like I am with everything else, as I eat almost no processed foods and mostly vegetables and fruit and exercise quite often). Iíll be the poster boy for why eating right, exercising being fit your whole life may not matter as much as some folks may suggest. Sorry for the vent! I do very much appreciate your thoughtful response, positivity, and kind words. Itís very helpful. All your contributions to this board are amazing(as Iíve read quite a bit).

    Thanks again.

     
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    Old 11-30-2019, 03:45 PM   #4
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Hi again,

    I am a bit puzzled by your statement: "My view of this disease is that itís lifelong challenge regardless of how well you responded to initial treatments and subsequent recurrences. Since the chemical recurrence rate appears relatively high ...."

    These days, with modern management and therapy, my view is that recurrence rates are not relatively high with well-chosen therapy. On the flip side, cure rates strike me as quite high relative to other cancers. It may depend on the phrase "relatively high." For example, "intermediate-" and "high-risk" patients treated with an excellent radiation program can expect their recurrence risk to be "as low as" 20%, with some studies indicating even lower risk. To me, that is really good, though we would like it to go lower, which seems to be gradually happening as technology continues to improve. The context, for me personally, is that I expected for years that recurrence rates for high-risk cases would be well over 50%, so current rates look really good based on that viewing point.

    I am now at the 6 1/2 year point since a curative attempt with radiation, which appears to have been successful. I am now comfortable and relaxed about my situation, not feeling challenged, though I still have labs every three months and an exam every half year, and I employ some mild anti-recurrence tactics daily, now a normal, routine part of my lifestyle. I feel attentive, but not at battle stations, and that is probably how many of us feel after having no recurrence for a number of years after treatment. Should you turn out to have prostate cancer, that good outcome is probably what you will experience in time. It is naturally tough for you and your wife right now with those PSA alarm bells clanging. I expect the vast majority of us "veterans" remember those days well and are very glad to be past them. Hopefully, you will be able to relax soon, or, if necessary, after treatment.

    Again, good luck!

     
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    Old 12-09-2019, 02:09 PM   #5
    Overthinker74
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    Post Re: Acute Prostatitis, with recurrent high PSA after several months

    Hello all,

    So I had my MRI last week, and the radiologist strongly believes there may be "significant prostate cancer" and of course a "biopsy is recommended." It looks like it was a 2T multiparametric MRI with and without contrast.

    First, he noted my prostate was about 32cc. He indicated no mass or abnormal diffusion restriction within the peripheral zone. The then indicated that there is a large region of abnormal diffusion restriction in the left central zone and peripheral zone at the base of the prostate, noting it was associated with mild hyperemia. He also noted that there is some abnormal diffusion restriction in and to the right of the midline at the based of the prostate within the transition zone more anteriorly. He believed that the foci of abnormal diffusion restriction measured about 2 x 3 cm in aggregate (sheesh that's big!). The seminal vesicles appear normal. The neurovascular bundle regions appear normal. There is no pelvic lymphadenopathy. No suspicious bone lesions is seen. Pi-Rads 5. (again, ugh)

    So that sucks. It looks like it's a fairly large spot towards the middle base of the prostate towards the front, but perhaps not so much on the perimeter? I guess it sounds like it's contained also. The urologist's NP reminded me that it's not anything until it's confirmed by a microscope.

    I have obviously been weighing out all sorts of treatments in light of the impending biopsy I will likely have very soon. The brachytherapy with EBR and ADT does look like a statistically good performer based on where it looks like I'll be in terms of staging and risk, although it's hard to statistically measure treatments like this longer than 12-15 years, and it seems people frequently report on the internet and social media when things go badly. Obviously, I'm hoping to get past this thing and live out a somewhat normal life span, but I'm very nervous of course, and it doesn't feel like I'm thinking about much else right now.

    I'd appreciate feedback and any advice at this point. I know learning the Gleason score (along with the PCa confirmation) from the biopsy is the next important next step.

     
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    Old 12-11-2019, 02:01 PM   #6
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Your application to join our elite club looks pretty good, but until you get that positive biopsy, we wonít accept you as a member. I know that is probably disappointing as you no doubt are eager to join so you can experience all the rights, benefits, privileges, and honors. And Iím still thinking that a substantial part of your PSA elevation is due to infection, which, if true, might lower your risk assessment a bit if your biopsy is positive. About your screenname, ďOverthinker74Ē: while it is possible to overthink prostate cancer, overthinking might be a synonym for ďempowerment,Ē and I am convinced that is a highly desirable state for a prostate cancer patient and loved ones.

    Seriously, that PI-RADS of 5 gives you, unfortunately, high odds of joining our club, but on the fortunate side, there has been enormous progress in assessing, managing and treating prostate cancer over the past three decades, and you will very likely benefit a lot from that progress. You are lamenting not starting PSA tests earlier, but at age 45 itís likely the vast majority of men are in the same boat. While, if you do have prostate cancer, earlier detection is better, what is really important is to catch it EARLY ENOUGH, and what you have posted suggests you have done that, giving you much improved survival prospects and more good options and prospects. Based on what you know so far, it looks like you do not have detectable lymph node or bone mets, at least based on the technology that was employed.

    You are hoping to enjoy decades more of life, and studies I know of just havenít followed a large group of patients over several decades after diagnosis so that we could have good statistics about very long-term survival of men diagnosed at a young age like 45. On the other hand, we do have solid numbers indicating that survival for prostate cancer compared to our age-matched peers is excellent overall and the best of any major cancer, which is a huge improvement from the situation in the 1970s. In fact, data from what is known as the SEER database shows that, in the US, survival of all men who develop prostate cancer is about 95% AT THE FIFTEEN YEAR POINT SINCE DIAGNOSIS! That doesnít mean those surviving fall off the cliff at 16 years, it just means that statistics for longer survival are not available or hard to find for those longer periods. For instance, I am now a 20 year survivor of a once life-threatening case, apparently cured and going strong at age 76. Basically, even those with regional spread of prostate cancer that is properly treated can expect long years of survival, probably in or close to that 95% group at fifteen years. Moreover, research on prostate cancer, already extensive, continues at a fast pace. There is substantial progress virtually every year, and you should enjoy the fruits of that progress, both at the time of your biopsy and through the coming years.

    Regarding your referral to a urologist: urologists, who are surgeons by trade, are the gatekeepers for prostate cancer as they do the biopsies. HOWEVER, especially if the case has elevated risk, I am convinced that radiation oncologists and often medical oncologists, two separate additional medical specialties, can and usually should play the key roles in decision making, with the patient, and treatment/dealing with side effects. Some urologists do an excellent job of providing an objective view of options, but many basically act as salesmen who try to steer their patients toward surgery without considering radiation or other options. Itís too early to go deep here, but donít be snowed by the urologist who does your biopsy. These days, surgery is no longer the gold standard for prostate cancer, and radiation, possibly supported by hormonal therapy (aka Androgen Deprivation Therapy, ADT), is at least equally as good for the vast majority of patients. That said, chronic prostatitis is one condition where patients probably will do better with side effects with surgery, and it appears you may suffer from that. This is an issue to discuss with, hopefully, both the urology and radiation specialties.

    From my layman's viewpoint, and aside from the possibly key issue of chronic prostatitis, external beam plus seed radiation, likely supported by ADT and perhaps other drugs, looks like an excellent program if your risk level, determined after the biopsy, is at least ďintermediateĒ. If you go that route, be sure to look into the benefits of the drug metformin, an old but still widely used diabetes drug, to help.

    Good luck with the biopsy Ė hoping you wonít be joining our club.

    Jim

     
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    Old 12-22-2019, 01:38 PM   #7
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Hello all,

    Well, it looks like I fortunately do not get my membership packet! My biopsy from Thursday as reported back by my urologist last night came back all negative! (so wonderful of him to personally call me off hours, too) Incredible. The doctor indicated that they didn't even find any PIN (pre-cancerous cells), but they did find considerable amounts of inflammation. In the biopsy, he both took targeted cores from the areas of concern from the MRI as well as other areas. I wasn't counting but I'm sure he took more than a dozen samples. He did indicate during our phone call that he intends on watching me very closely with additional testing which I'm totally fine with.

    In the lead up to learning these results, I did considerable research on prostate MRI's, and I learned about areas where prostate cancer typically happens and issues involving certain places where prostate cancer can appear and mimic based upon MRI results. Here's a few links that I came upon:

    https://cdn.ymaws.com/www.abdominalradiology.org/resource/resmgr/EduPosters/2016posters/186_Yu.pdf

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4075530/

    https://radiologykey.com/multiparametric-mri-and-prostate-cancer-pitfalls-and-tricks/

    In each of the aforementioned articles, I learned about normal, but displaced, central zones due to BPH (from the transition zone), as well as more prominent or hypertrophic anterior fibromuscular stroma's affecting MRI's. These are two potential mimics for prostate cancer (amongst others) apparently, and likely applied to me. Again, the two areas of concern from my radiologist suggested I had areas of abnormal diffusion restriction in at the base of my prostate in the central zone (towards the peripheral zone) and then at the midline in the transitional zone. I also learned that each of these specific areas are very rare for origination of prostate cancer, respectively at less than 5% each, which set off certain suspicions. And I'm actually glad that the MRI looked at these areas because many times these areas are not well viewed by ultrasound or otherwise, if any prostate cancer was present.

    And later on, I actually found another person who had almost exactly the same MRI, Pi-rad score of 5, and later, the same negative biopsy results:

    https://patient.info/forums/discuss/pi-rad-score-of-5-613323

    So speculatively, it would appear that I have some BPH from the transition zone that asymmetrically displaced my central zone which would appear as a large area of abnormal diffusion restriction on the MRI. In addition, it would also seem that my anterior fibromuscular stroma (or band) also appeared as an area of abnormal diffusion restriction on the MRI. These are of course my deductions based upon the aforementioned studies, the MRI results, and the subsequent targeted/TRUS biopsy. (my previous CT scan from my bout of acute bacterial prostatitis also suggested asymmetry of my slightly enlarged prostate which was helpful; likely less enlarged now from then) I also learned that the radiologist, while very experienced, was not necessarily someone that specialized in prostate MRI's. Quite the contrary, it appeared that he wrote articles on everything from heart valves to colons. In reading other folks' discussions on this issue from the discussion string I referenced above, it sounds like prostate MRI reviews is a specialized area.

    So at the end of the day, I'm very grateful for these results, but also looking to be vigilant at hopefully resolving whatever is raising my PSA levels (wherever they're presently at). It looks likely at this time that it's probably vestiges of my past issues with acute prostatitis and potentially issues involving ongoing chronic prostatitis. It's my understanding that this particular issue of prostatitis is not well understood, diagnosed or treated.

    Jim- thank you so very much for all of your support and considerable knowledge you share with this board and of course to me in my situation. (hopefully, I remain a supportive non-member of the "club" for a while ) It is so very helpful to read many of your past informative posts, including one where you mentioned you had attended a seminar on prostatitis. While I've read so much from the online materials, there doesn't appear to be a lot of really helpful information on treatment, beyond antibiotics. And while I've had the initial 10 day treatment after the acute bout of prostatitis and subsequent 14 day treatment in August, I've seen some doctors recommend treatments for chronic prostatitis usually from 4-6 weeks as long as 6 months! (and some folks suggest it can take as long as 6 months [after the infection is addressed] for the PSA to come down) I'm wondering if I need a longer term treatment to knock out any infection/inflammation. I'm also wondering if we need to look at other kinds of methods to assess whether any infection is in fact present.

    I wanted to share all of this information for folks that may experience what I have. I found that learning from other people's experiences really helped me.

     
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    Old 12-22-2019, 10:00 PM   #8
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Prostatitis can be a very frustrating condition for the patient as well as doctors. A lot of the time, its non-bacterial, which makes it a lot more difficult to get relief.

    I had burning during urination, back in the day, for several years. Drink a lot of water, cranberries, it does provide some help.

    But the good thing is that prostatitis and prostate cancer are two different birds.

    And PSA readings aren't specific to cancer.

     
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    Old 12-23-2019, 02:12 AM   #9
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    Re: Acute Prostatitis, with recurrent high PSA after several months

    Stay on top of it. Biopsies have a high false negative rate sometimes as high as 50% on enlarged prostates. A chronically inflamed prostate is not a happy prostate and may be an indicator of future issues.

    Do not dismiss this if your PSA continues to remain elevated or to rise despite fluctuations and spikes. Normal is well below 4.0 for a young man. While elvated numbers and spikes can frustrate you if it never returns to former levels, but slowly continues to rise underneath the spikes you have an issue.

    Also, be careful of the use of antibiotics. Their overuse has become the source of resitant bacteria and overuse can create complications with future biopsies.

    The use of a higher power 3TMRI and a software fusion biopsy for more accuracy is the current state of the art. You may consider seeking out a more current level of care if these techniques were not available to you. Your extremely high PSA and long term issues are red warning flags.

    You have done well. Be ruthlessly persistent. This is not going away. Multiple biopsies are sometimes necessary.
    __________________
    Born 1953; family w/PCa-grandfather, 3 brothers;
    7-12-04 PSA 1.9; 7-10-06 PSA 2.0; 8-30-07 PSA 3.2; 12-1-11 PSA 5.7; 5-16-12 PSA 4.76; 12-11-12 PSA 5.2; 3-7-16 PSA 7.2;
    3-14-16 TRUS biopsy, PCa 1%-60% across 8 of 12 samples, G3+3;
    5-4-16 DaVinci RP, Path-65g, lymph nodes, seminal vesicles, capsule, margin all neg, G3+4, T vol 35%, +pT2c, No Incontinence-6mos, Erections-14 months;
    6-30-20 PSA less than 0.02, zero club 4 yrs

     
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