Urology
Pathways
This page provides updates on urology pathways, clinical guidance and clinical decision making.
Prostate cancer and PSA testing
Routine PSA testing is not presently available in the NHS. Current available evidence (Meta-analysis – Merrier et al, 2022) suggests PSA is highly sensitive but poorly specific for prostate cancer detection.
It might instead lead to unnecessary invasive investigations or false positive PSA tests. Also, roughly 15% of people with prostate cancer have a normal PSA level (CRUK 2024)
The NHS is part of the TRANSFORM trial, the largest prostate cancer screening trial in 20 years, which is testing new methods to screen for the disease. It aims to find the most effective way to combine PSA blood tests with MRI scans to improve early detection and reduce false positives that lead to unnecessary treatments.
Current advice and evidence
To follow is information the Northern Cancer Alliance has collated, based on the current national advice and evidence regarding PSA testing for prostate cancer.
Men of any age may present to discuss prostate testing.
Symptomatic patients:
- Lower urinary tract symptoms: urinary urgency, hesitancy, terminal dribbling, nocturia, bone pain. Symptomatic people with a prostate, of any age can request a test.
Asymptomatic patients over the age of 50:
- Should be given the opportunity to have a PSA blood test after a clinical discussion OR after reading the PSA shared decision making (SDM see below) leaflet.
Asymptomatic patients over the age of 45 yrs should be tested (following discussion) if they have risk factors:
- Black men aged 45 -70yrs
- Men with a family history of prostate or breast cancer aged 45 -70 yrs
Patients over the age of 80:
There is a risk of over-diagnosing and overtreating prostate cancer in men over 80 where the prevalence of cancer is highest, but the proportion of cancers that are clinically significant is lowest. (Academy of Royal Medical Colleges, January 2024)
Men over the age of 80 with PSA greater than 20 could have an urgent suspected cancer referral within NG12 guidance, but GPs may wish to use clinical judgement and SDM.
If the initial PSA test is between 7.5 – 20 ng/L and there are no symptoms suggestive of metastatic disease, repeat PSA ONCE after 6 months in primary care and offer referral via the suspected cancer pathway if:
- PSA has more than doubled
- Or the PSA is now above 20
Recent statements (latest update October 2025) from BAUS and Prostate Cancer UK highlight that the digital rectal examination (DRE) is a poor standalone test for detecting prostate cancer and should no longer be used routinely for diagnosis.
This statement should be interpreted in the context of men seeking help to rule out prostate cancer. This does not apply to men with lower urinary symptoms or other benign conditions needing DRE assessment.
Following discussion at the Regional Urology Pathway Board, the consensus remains that DRE continues to have a selective but important role in primary care assessment.
Key Messages for Primary Care
- DRE is not routinely required when PSA is raised.
- Offer DRE when PSA is normal but suspicion remains.
- Do not delay referral awaiting DRE results.
- Continue to apply shared decision making and good documentation.
Useful Resources
Clinical information:
👉 NICE Guidance (NG131) Prostate cancer: diagnosis and management
👉 CRUK Prostate Cancer Recognition and Referral Guide
👉 PSA Testing Summary Guidance for GPs
👉 PSA Testing Systematic Review – Merriel et al
👉 Academy of Royal Medical Colleges – Clinical Recommendations on Testing
👉 Cancer Research UK – PSA Testing
👉 Prostate Cancer UK
Patient information:
👉 gov.uk – PSA testing and prostate cancer advice for men without symptoms
👉 Cancer Research UK – prostate cancer
👉 Cancer Research UK – what is the PSA test?
👉 Cancer Research UK – prostate cancer awareness leaflet
Learning and Development
Prostate cancer case finding was included in the PCN DES for 2022/23 due to COVID-related referral delays but is not a current priority.
PCNs and practices may wish to promote symptom awareness, but this should always be guided by local data and in consultation with secondary care.
Targeted awareness raising should focus on higher risk groups:
- Black men aged 45-69.
- Men aged 45-69 family history of prostate, breast, or ovarian cancer.
- Men aged 50-69 from other ethnic backgrounds.
General principles recommended by the Northern Cancer Alliance are:
- PSA testing can be arranged regardless of symptoms as most early prostate cancers do not have symptoms.
- PSA case finding work should target patients over 50 (or over 45 if in a higher risk group) to promote the opportunity for a PSA test and leaflet.
- Any patient requesting PSA should be given the opportunity to have a PSA blood test, after reading the PSA shared decision making leaflet (see above).
- PSA testing can be offered directly if the patient has read the prostate SDM leaflet.
- Normal PSA results do not require any further clinical input.
- Raised PSA results will require clinical review to determine onward referral, in line with NICE guidelines.
- Raised PSA results above referral threshold do NOT require a digital rectal examination (DRE) prior to referral.
- We suggest patients >80 years old, with PSA over 20, could have Urgent Suspected Cancer referral within NG12 guidance, but GPs may wish to use clinical judgement and SDM.
- We have no guidance as to repeat PSA testing timeframes as this isn’t a screening programme. Therefore, clinical judgement is required and expect annually testing as minimal timing.
- Patients with prostatism symptoms would require a clinical review to evaluation and consider investigations and potential treatments.
Useful Resources and Information
We are supporting an active programme of work linked to the 👉 PCN Cancer DES 2025/26.
Linked to this piece of work is the bladder cancer toolkit and educational updates.
