Name of the Condition

• Elevated Prostate Specific Antigen (PSA)
• Medical term: Elevated PSA level

Summary

Elevated PSA refers to a higher-than-normal level of prostate-specific antigen in the blood, a protein produced by both normal and malignant cells in the prostate gland.

Causes

• Aging and enlargement of the prostate
• Prostatitis (inflammation of the prostate)
• Urinary tract infections
• Recent prostate examination or procedure
• Prostate cancer

Risk Factors

• Age, especially men over 50
• Family history of prostate conditions
• Certain medications or medical procedures affecting the prostate
• Lifestyle factors such as diet and exercise habits

Symptoms

Elevated PSA itself does not cause symptoms. However, underlying conditions associated with elevated PSA, like prostate enlargement or cancer, may present symptoms such as difficulty urinating, frequent urination, or pelvic discomfort.

Diagnosis

• Blood test to measure PSA levels
• Digital rectal exam (DRE) to check prostate abnormalities
• Further testing like prostate biopsy or imaging if PSA levels are significantly elevated

Treatment Options

• Monitoring and regular testing for mildly elevated PSA without symptoms
• Medications to manage underlying conditions, like antibiotics for infections
• Surgical options if due to prostate cancer or severe enlargement
• Lifestyle changes to improve prostate health

Prognosis and Follow-Up

• Regular monitoring of PSA levels to track changes over time
• Prognosis varies based on underlying cause; early detection of prostate cancer can improve outcomes
• Continuous follow-up is crucial for early intervention

Complications

• Anxiety or stress over elevated PSA and potential serious diagnoses like cancer
• Possibility of invasive procedures with their own risks if PSA levels remain high

Lifestyle & Prevention

• Healthy diet rich in fruits, vegetables, and whole grains
• Regular physical activity to maintain general health
• Routine medical check-ups for early detection and guidance

When to Seek Professional Help

• Sudden increase in PSA levels
• Symptoms like painful urination, blood in urine, or severe pelvic pain
• Concerns following a routine PSA test result

Additional Resources

• American Urological Association (AUA)
• Prostate Cancer Foundation for patient education and support
• National Institutes of Health (NIH) resources on prostate health

Tips for Medical Coders

• Ensure accurate documentation of associated conditions causing elevated PSA
• Be mindful of differentiating between elevated PSA and confirmed prostate cancer
• Avoid coding errors by verifying if elevated PSA is an incidental finding or linked to a specific diagnosis