Prostate Cancer: Diagnosis, Grade, Treatment and Recovery

By Mr Neil Haldar, Consultant Urological Surgeon

Medical review date: July 2026

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Understanding prostate cancer

Being told that you may have prostate cancer—or that prostate cancer has been confirmed—can be frightening. It is natural for patients and their families to hear the word “cancer” and immediately fear the worst.

Prostate cancer, however, is not a single disease with a single predictable outcome.

Some prostate cancers grow so slowly that they are unlikely to affect a man’s health or lifespan. Others are more aggressive and need timely treatment. The purpose of modern prostate cancer assessment is therefore not simply to establish whether cancer is present. It is to understand:

• how much cancer there is;
• how aggressive it appears;
• whether it is confined to the prostate;
• whether it is likely to cause harm;
• which treatment, if any, offers the best balance between cancer control and quality of life.

Prostate cancer frequently causes no symptoms in its early stages, and not every prostate cancer requires immediate treatment. Modern care is increasingly based on accurate MRI imaging, targeted biopsy, individual risk assessment and shared decision-making.

This guide explains the journey from initial PSA testing through diagnosis, grading, treatment and recovery. It is intended for men undergoing investigation, those who have recently been diagnosed, and the partners or relatives supporting them.

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Prostate cancer in brief

Prostate cancer begins when cells in the prostate start to grow abnormally.

The most important points to understand are:

• early prostate cancer usually causes no symptoms;
• a raised PSA does not automatically mean cancer;
• MRI is normally used before deciding whether a biopsy is needed;
• the biopsy establishes the Grade Group and helps assess aggressiveness;
• PSA, Grade Group and stage are combined into a risk category;
• lower-risk disease may be safely monitored;
• surgery and radiotherapy can both provide effective curative treatment;
• treatment decisions should consider continence, sexual function, bowel function and general health as well as cancer control;
• advanced prostate cancer is increasingly treated as a controllable long-term illness.

There is rarely one treatment that is automatically right for every patient.

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What is the prostate?

The prostate is a gland situated below the bladder. It surrounds the upper part of the urethra, which is the tube carrying urine from the bladder through the penis.

In younger men, the prostate is commonly described as being approximately the size of a walnut. Its main function is to produce some of the fluid that combines with sperm to form semen.

The prostate often enlarges naturally with age. This is known as benign prostatic enlargement or benign prostatic hyperplasia—BPH.

BPH is not prostate cancer. However, because the prostate surrounds the urethra, benign enlargement can cause:

• a weaker urinary stream;
• difficulty starting urination;
• needing to urinate more frequently;
• urgency;
• getting up at night to pass urine;
• a sensation that the bladder has not completely emptied.

These symptoms are common and are more frequently caused by benign enlargement than by prostate cancer.

Three different prostate conditions

It is useful to distinguish between:

Benign prostatic enlargement: non-cancerous growth of the prostate, usually associated with ageing.

Prostatitis: inflammation or infection involving the prostate.

Prostate cancer: uncontrolled growth of abnormal cells within the prostate.

These conditions are different, although more than one may occasionally be present at the same time.

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What is prostate cancer?

Prostate cancer develops when cells within the prostate acquire changes that allow them to grow and divide in an uncontrolled way.

Most prostate cancers are adenocarcinomas, arising from the glandular cells of the prostate. Less common forms exist, but they behave differently and require individual specialist advice.

What distinguishes prostate cancer from many other cancers is the very wide variation in its behaviour.

At one end of the spectrum are small, low-grade cancers that may grow extremely slowly. These cancers can often be monitored without immediate treatment.

At the other end are higher-grade cancers that may:

• grow more quickly;
• extend beyond the prostate;
• involve nearby structures or lymph nodes;
• spread to the bones or other parts of the body.

The central task is therefore to distinguish cancer that is unlikely to cause harm from cancer that requires active treatment.

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Who is at greater risk of prostate cancer?

There is no single cause of prostate cancer, but several factors are associated with an increased risk.

Age

Age is one of the most important risk factors. Prostate cancer mainly affects men over the age of 50, and the likelihood increases with age.

Family history

Risk is higher in men with a close relative—particularly a father or brother—who has had prostate cancer.

The age at which a relative was diagnosed and the number of affected relatives are also relevant. A wider family history of breast, ovarian or pancreatic cancer may indicate an inherited cancer predisposition.

Ethnicity

Men of Black African or Black Caribbean heritage have a higher risk of developing prostate cancer and may develop it at a younger age.

Inherited genetic changes

Inherited variants in genes including BRCA2 can increase prostate cancer risk and may be associated with more aggressive disease.

Genetic testing is not required for every patient. It may be considered when there is:

• a strong family history;
• prostate cancer diagnosed at a relatively young age;
• metastatic or particularly aggressive disease;
• a family history suggestive of an inherited cancer syndrome;
• a tumour finding that may have implications for inherited risk or targeted treatment.

The result can sometimes influence treatment and may also be relevant to relatives.

General health and lifestyle

Obesity is associated with a higher risk of aggressive prostate cancer. Maintaining a healthy weight, exercising regularly, not smoking and following a balanced diet all support general health during investigation, treatment and recovery.

No diet, supplement or lifestyle intervention can guarantee that prostate cancer will be prevented.

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What are the symptoms of prostate cancer?

Early prostate cancer often causes no symptoms

This is one of the most important facts about prostate cancer.

Cancer frequently begins in the outer part of the prostate, away from the urethra. It may therefore be present without affecting urination.

Waiting for urinary symptoms is not a reliable way of detecting prostate cancer early.

Possible urinary symptoms

When symptoms occur, they may include:

• difficulty starting urination;
• a weak urinary stream;
• stopping and starting;
• needing to urinate more frequently;
• needing to urinate urgently;
• getting up repeatedly at night;
• feeling that the bladder has not fully emptied.

These symptoms are much more commonly caused by benign prostate enlargement than by cancer.

Other symptoms that should be assessed

Other possible symptoms include:

• blood in the urine;
• blood in the semen;
• new erectile difficulties;
• persistent pelvic discomfort;
• unexplained weight loss;
• persistent back, hip or bone pain.

Back pain is extremely common and is usually unrelated to prostate cancer. Nevertheless, persistent or unexplained symptoms—particularly in someone with a known prostate cancer diagnosis—should be discussed with a doctor.

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How prostate cancer is investigated

The modern diagnostic pathway has changed considerably.

In the past, men with a raised PSA often proceeded directly to a systematic prostate biopsy. Today, MRI is normally used first to identify suspicious areas, estimate the likelihood of clinically significant cancer and help determine whether biopsy is necessary.

The PSA blood test

PSA stands for prostate-specific antigen. It is a protein produced by prostate cells and can be measured in the blood.

A raised PSA may be associated with prostate cancer, but it may also be caused by:

• benign enlargement;
• prostatitis or a urinary infection;
• recent ejaculation;
• vigorous physical activity;
• cycling;
• recent prostate examination or instrumentation;
• urinary retention;
• increasing age.

A PSA result is therefore not a diagnosis of cancer.

It is a marker that must be interpreted in context. Relevant factors include:

• the absolute PSA value;
• age;
• prostate size;
• previous PSA results;
• PSA density;
• family history;
• ethnicity;
• examination findings;
• urinary infection or inflammation;
• MRI findings.

The NHS advises avoiding ejaculation, cycling and strenuous exercise for 48 hours before PSA testing. Testing should usually be delayed for several weeks after a urinary infection because infection can temporarily increase the result.

What happens if the PSA is raised?

Depending on the result and the clinical circumstances, your doctor may recommend:

• repeating the PSA;
• checking a urine sample;
• examining the prostate;
• referring you for a prostate MRI;
• arranging specialist urological assessment.

A high PSA does not necessarily mean that cancer is present. Equally, a PSA within the expected range cannot exclude every prostate cancer.

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Digital rectal examination

A digital rectal examination—DRE—allows a doctor to feel the back surface of the prostate through the rectum.

The examination may identify:

• unusual hardness;
• a nodule;
• asymmetry;
• an irregular surface;
• marked enlargement.

It is usually brief. A normal examination is reassuring but does not exclude prostate cancer, because not every part of the prostate can be felt and some cancers do not alter its texture.

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Multiparametric MRI of the prostate

Multiparametric MRI is now a central part of prostate cancer diagnosis.

NICE recommends multiparametric MRI as the first-line investigation for people with suspected clinically localised prostate cancer who would potentially be suitable for radical treatment. The MRI is commonly reported using a five-point Likert or PI-RADS scale.

The scan helps assess:

• the size of the prostate;
• whether a suspicious lesion is present;
• where the lesion is located;
• the likelihood of clinically significant cancer;
• whether there are signs of cancer extending beyond the prostate;
• which areas should be sampled if biopsy is required.

A reassuring MRI may allow some men to avoid immediate biopsy after discussing the advantages and limitations with their specialist.

MRI is very useful, but it is not infallible. A small proportion of clinically important cancers may not be clearly visible. The decision to omit biopsy should therefore also take account of PSA density, examination findings, family history and overall clinical risk.

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Prostate biopsy

A prostate biopsy involves taking small tissue samples that can be examined under a microscope.

Biopsy is normally recommended when the overall assessment suggests a significant possibility of clinically important cancer.

Transperineal biopsy

Prostate biopsies are increasingly performed through the perineum—the skin between the scrotum and anus.

Advantages include:

• a lower risk of serious infection than biopsy through the rectum;
• improved access to the front of the prostate;
• accurate sampling of MRI abnormalities;
• the ability to combine targeted and systematic samples.

Suspicious areas identified on MRI can be targeted using visual or software-assisted fusion with ultrasound imaging.

Why are systematic samples sometimes taken?

Prostate cancer can be multifocal, meaning that separate areas of cancer may exist within the gland.

For this reason, the urologist may take:

• targeted samples from the MRI lesion;
• systematic samples from other parts of the prostate;
• or a combination of both.

The biopsy confirms whether cancer is present and provides information about its Grade Group.

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Understanding the biopsy result

Gleason score and Grade Group

The pathologist examines the architecture of the prostate cancer under a microscope.

Cancer patterns are traditionally graded from 3 to 5. The two most prominent patterns are added together to create the Gleason score.

For example:

• Gleason 3+3=6
• Gleason 3+4=7
• Gleason 4+3=7
• Gleason 4+4=8

The first number is important because it represents the predominant pattern. Gleason 3+4 and 4+3 both total seven, but 4+3 contains more higher-grade pattern 4 disease and generally behaves less favourably.

The Grade Group system simplifies this information:

Grade Group	Typical Gleason score	General interpretation
1	3+3=6	Lowest-grade prostate cancer
2	3+4=7	Predominantly pattern 3 with some pattern 4
3	4+3=7	Predominantly pattern 4
4	8	High-grade cancer
5	9–10	Highest-grade cancer

Grade is only one part of the assessment. The amount of cancer in the biopsy samples, MRI findings, PSA and clinical stage are also important.

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Staging: has the cancer spread?

Staging describes where the cancer is located.

The TNM system considers:

• T—tumour: the extent of cancer within or immediately around the prostate;
• N—nodes: whether regional lymph nodes are involved;
• M—metastases: whether cancer has spread to distant sites.

In practical terms, prostate cancer may be described as:

Localised prostate cancer

The cancer appears confined to the prostate.

Locally advanced prostate cancer

The cancer has extended through the outer boundary of the prostate or into nearby structures, such as the seminal vesicles.

Node-positive prostate cancer

Cancer is present in regional pelvic lymph nodes.

Metastatic prostate cancer

Cancer has spread to distant lymph nodes, bones or, less commonly, other organs.

Depending on the grade and risk level, staging may involve:

• MRI;
• CT scanning;
• bone scanning;
• PSMA PET-CT.

Not every patient requires every type of scan. The investigations are selected according to the likelihood that the result could alter treatment.

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Cambridge Prognostic Groups: CPG 1 to CPG 5

In the UK, NICE uses the Cambridge Prognostic Group system to classify localised and locally advanced prostate cancer.

It combines:

• PSA;
• Grade Group;
• clinical stage.

The five groups range from CPG 1, representing the most favourable category, to CPG 5, representing the highest-risk category.

Broadly:

CPG category	General meaning	Common management considerations
CPG 1	Lowest-risk localised disease	Active surveillance is usually preferred
CPG 2	Favourable but clinically significant disease	Surveillance, surgery or radiotherapy may be considered
CPG 3	Intermediate-risk disease	Surgery or radiotherapy are commonly recommended; surveillance may occasionally be considered
CPG 4	High-risk disease	Radical treatment is normally considered
CPG 5	Highest-risk localised or locally advanced disease	Combined or intensified treatment may be required

NICE recommends active surveillance for CPG 1 disease, a choice of surveillance or radical treatment for appropriate CPG 2 patients, and radical surgery or radiotherapy for most suitable CPG 3–5 patients. Active surveillance is not recommended for CPG 4 or 5 disease.

These categories guide treatment, but they do not replace individual judgement.

Age, general health, life expectancy, urinary symptoms, sexual function, MRI appearances and personal priorities all remain important.

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How is prostate cancer treatment decided?

Most prostate cancer cases should be discussed by a specialist multidisciplinary team—MDT.

The team may include:

• urological surgeons;
• clinical oncologists;
• radiologists;
• pathologists;
• nuclear medicine specialists;
• clinical nurse specialists;
• medical oncologists;
• specialist allied healthcare professionals.

The purpose of the MDT is to review the diagnosis and identify appropriate treatment options.

The final decision should then be made through a detailed discussion with the patient.

In my experience, the most difficult part for many men is not understanding that several treatments exist. It is deciding which trade-offs matter most to them personally.

Two men with apparently similar cancers may make different but equally reasonable decisions because they have different:

• ages and levels of general health;
• existing urinary function;
• sexual priorities;
• attitudes towards surgery;
• attitudes towards radiation;
• feelings about continued surveillance;
• family responsibilities;
• preferences regarding certainty and risk.

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Treatment options for localised prostate cancer

Active surveillance

Active surveillance is intended for prostate cancer that appears unlikely to cause immediate harm.

It does not mean ignoring the cancer or abandoning treatment.

Instead, the cancer is monitored so that treatment can be introduced if there are signs that it is progressing.

Monitoring may include:

• regular PSA tests;
• assessment of PSA changes over time;
• repeat MRI scans;
• clinical review;
• repeat biopsy when indicated.

NICE recommends active surveillance for CPG 1 disease and considers it an option for selected CPG 2 patients. It may occasionally be considered in CPG 3 disease when a patient does not wish to have immediate radical treatment.

Advantages

• avoids or delays urinary, sexual and bowel side effects;
• preserves quality of life;
• allows treatment to be reserved for cancer showing evidence of progression;
• avoids treating cancers that may never become harmful.

Limitations

• requires continuing tests and appointments;
• repeat MRI or biopsy may be necessary;
• some men find living with an untreated cancer psychologically difficult;
• treatment may eventually be required.

For the right patient, surveillance is an active treatment strategy rather than “doing nothing.”

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Watchful waiting

Watchful waiting is different from active surveillance.

It is usually considered for older men or those with significant health problems whose prostate cancer is unlikely to affect their lifespan.

The objective is not repeated testing with the intention of offering later curative treatment. Instead, the patient is observed and treatment is introduced if symptoms develop.

This treatment may include hormone therapy or other measures designed to control the cancer and maintain comfort.

The NHS distinguishes active surveillance, involving regular hospital tests and scans, from watchful waiting, which generally involves less intensive monitoring.

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Radical prostatectomy

A radical prostatectomy removes:

• the entire prostate;
• the seminal vesicles;
• and sometimes nearby lymph nodes.

It is a potentially curative treatment for selected men with localised or locally advanced prostate cancer.

Robotic prostatectomy

Most radical prostatectomies in the UK are now performed using robot-assisted keyhole surgery.

The robotic system allows the surgeon to operate through small incisions using magnified three-dimensional vision and highly controlled instruments.

Potential perioperative advantages over traditional open surgery include:

• smaller incisions;
• less blood loss;
• shorter hospital stay;
• quicker early recovery;
• improved access and visualisation within the pelvis.

The robot does not perform the operation independently. The result depends on the surgeon, the cancer, the anatomy and the patient’s pre-existing function.

Long-term cancer control is determined primarily by:

• the biology and extent of the cancer;
• whether it can be completely removed;
• the pathological findings;
• the need for additional treatment.

Nerve-sparing surgery

The nerves involved in erections pass very close to the prostate.

Where the cancer location and extent allow, the surgeon may preserve one or both nerve bundles.

Whether nerve sparing is appropriate depends on:

• MRI findings;
• biopsy location and grade;
• clinical stage;
• pre-existing erectile function;
• the need to obtain adequate cancer clearance.

Cancer control must take priority over nerve preservation when the two objectives conflict.

Possible effects of prostatectomy

The principal functional effects are:

• urinary leakage;
• erectile dysfunction;
• loss of ejaculation;
• infertility;
• changes in orgasm.

The NHS advises that radical prostatectomy can cause incontinence, erectile dysfunction, altered orgasm and permanent loss of natural fertility.

Most men experience leakage immediately after the catheter is removed. Continence commonly improves over the following weeks and months, although the speed and degree of recovery vary.

Erectile recovery depends on age, function before surgery, cancer position, nerve sparing and individual healing. Recovery can take many months and may continue for two years or longer.

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Radiotherapy

Radiotherapy uses high-energy radiation to destroy cancer cells.

It can be used as curative treatment for:

• localised prostate cancer;
• locally advanced prostate cancer;
• selected node-positive disease.

It can also be used to control symptoms or treat particular cancer sites in advanced disease.

External beam radiotherapy

External beam radiotherapy is delivered by a machine directing radiation towards the prostate and surrounding treatment area.

Modern techniques allow increasingly accurate targeting while limiting radiation exposure to nearby tissues.

Treatment may be delivered using:

• conventional or moderately hypofractionated radiotherapy;
• stereotactic ablative radiotherapy—SABR—in suitable patients;
• wider pelvic radiotherapy when lymph-node treatment is indicated.

In June 2026, NHS England announced national availability of SABR for eligible men with early prostate cancer. SABR is typically delivered in five treatments over approximately two weeks, although it is not suitable for every patient.

Brachytherapy

Brachytherapy places radiation within the prostate.

It may involve:

• permanent low-dose radioactive seeds;
• temporary high-dose-rate treatment.

Suitability depends on prostate size, urinary function, anatomy and cancer risk.

Hormone therapy with radiotherapy

Radiotherapy is often combined with androgen-deprivation therapy for intermediate, high-risk or locally advanced cancer.

The duration of hormone therapy depends on the cancer category and treatment plan.

Potential radiotherapy effects

These may include:

• urinary frequency or urgency;
• discomfort passing urine;
• temporary bowel looseness or rectal irritation;
• fatigue;
• blood in the urine or bowel at a later stage;
• gradual reduction in erectile function;
• effects from accompanying hormone therapy.

Unlike surgery, radiotherapy does not remove the prostate. PSA therefore usually falls gradually rather than becoming immediately undetectable.

Rectal spacers

Some men having external beam radiotherapy may be offered a biodegradable rectal spacer.

This is placed between the prostate and rectum to increase their separation and reduce the amount of radiation reaching the front wall of the rectum.

Rectal spacers are not necessary or appropriate for every patient. Their potential benefits and risks should be discussed with the treating radiotherapy team.

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Surgery or radiotherapy: which is better?

For many localised prostate cancers, both surgery and radiotherapy offer an effective possibility of long-term cancer control.

The decision is rarely based on a simple claim that one is universally superior.

Surgery may be attractive because:

• the prostate is removed;
• the complete prostate can be examined by a pathologist;
• PSA should normally fall to an extremely low or undetectable level;
• further radiotherapy remains possible if required;
• some men prefer a single operative treatment.

Radiotherapy may be attractive because:

• it avoids major surgery;
• it is suitable for some men who are not good surgical candidates;
• immediate urinary leakage is less common;
• it can treat disease immediately outside the prostate;
• modern schedules may involve relatively few hospital visits.

Important trade-offs

Surgery has a greater immediate effect on continence and erectile function.

Radiotherapy more commonly causes temporary urinary and bowel irritation, may require hormone therapy, and can produce gradual sexual or urinary effects over time.

Salvage treatment after radiotherapy can be more technically complex than treatment after surgery.

The right comparison must therefore be individual.

When I discuss surgery, I consider not only whether the cancer can be removed, but also the patient’s existing urinary and sexual function, the feasibility of nerve sparing and the possibility that additional treatment could eventually be required.

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Focal therapy

Focal therapy treats a selected area of cancer rather than the whole prostate.

Methods include:

• high-intensity focused ultrasound—HIFU;
• cryotherapy;
• other less widely available ablative techniques.

The objective is to control the significant cancer while reducing damage to surrounding prostate tissue.

Who may be suitable?

Focal therapy is only appropriate for carefully selected patients.

Assessment usually requires:

• high-quality MRI;
• accurate targeted and systematic biopsy;
• clear localisation of the clinically significant cancer;
• confidence that untreated areas can be safely monitored.

Potential advantages

Focal treatment may offer a lower risk of:

• urinary leakage;
• erectile dysfunction;
• some bowel effects.

Important limitations

The prostate remains in place, and cancer can persist or develop in untreated tissue.

Patients require continuing surveillance, which may involve:

• PSA testing;
• repeat MRI;
• repeat biopsy.

Further focal treatment, surgery or radiotherapy may eventually be required.

NICE states that the safety evidence for focal HIFU is adequate but that evidence regarding efficacy remains limited. It therefore recommends special arrangements for clinical governance, consent, audit or research. NICE gives similar caution regarding focal cryoablation because prostate cancer is often multifocal and long-term comparative evidence remains limited.

Focal therapy can be valuable in selected cases, but it should not be presented as a universally less invasive replacement for established radical treatment.

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Hormone therapy

Prostate cancer cells commonly depend on testosterone signalling.

Androgen-deprivation therapy reduces the production or activity of testosterone and can slow prostate cancer growth.

It may be used:

• with radiotherapy for higher-risk localised disease;
• for node-positive disease;
• for metastatic cancer;
• when cancer returns after previous treatment;
• to control symptoms.

Hormone therapy alone does not usually cure localised prostate cancer, although hormone therapy combined with radiotherapy may form part of curative treatment.

Possible side effects

These can include:

• hot flushes;
• loss of libido;
• erectile dysfunction;
• fatigue;
• loss of muscle mass;
• weight gain;
• reduced bone density;
• increased fracture risk;
• metabolic changes;
• mood changes;
• breast tenderness or enlargement.

Many effects can be reduced or actively managed, although they may remain significant.

Exercise—particularly resistance training—weight management, cardiovascular risk assessment and bone-health monitoring can all be important.

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Treatment for advanced prostate cancer

Advanced prostate cancer has spread beyond the prostate to distant lymph nodes, bones or other organs.

Although metastatic prostate cancer is not usually considered curable, treatment has advanced considerably.

Many men now live for years with prostate cancer controlled as a long-term condition.

Treatment may include:

• androgen-deprivation therapy;
• newer androgen-receptor pathway treatments;
• chemotherapy;
• radiotherapy to the prostate in selected newly metastatic cases;
• radiotherapy to painful or threatening bone metastases;
• bone-protecting treatment;
• targeted treatment for cancers with particular genetic changes;
• radioligand therapy in suitable circumstances;
• clinical trials.

Modern treatment frequently involves combining therapies rather than relying on hormone treatment alone.

The appropriate plan depends on:

• how much cancer is present;
• where it has spread;
• whether it was metastatic at first diagnosis;
• previous treatments;
• symptoms;
• genetic or molecular findings;
• general health.

Supportive and palliative care can be introduced alongside active cancer treatment. Its purpose is to manage symptoms and improve quality of life, not merely to provide care at the end of life.

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Comparing the main prostate cancer approaches

Approach	Commonly considered for	Principal advantage	Important consideration
Active surveillance	CPG 1 and selected CPG 2 disease	Avoids or delays treatment effects	Requires continuing PSA, MRI and sometimes biopsy
Watchful waiting	Older or less medically fit patients	Avoids burdensome investigation or radical treatment	Treatment is directed towards symptoms rather than cure
Radical prostatectomy	Selected localised or locally advanced disease	Removes the prostate and provides complete pathology	Continence, erection, ejaculation and fertility effects
External beam radiotherapy	Localised, locally advanced and selected node-positive disease	Effective non-surgical radical treatment	Urinary, bowel, sexual and hormone-related effects
Brachytherapy	Selected localised disease	Radiation concentrated within the prostate	Suitability depends on cancer, prostate size and urinary function
Focal therapy	Carefully selected localised cancer	May reduce some functional effects	Continuing MRI and biopsy surveillance; retreatment may be required
Systemic treatment	Node-positive, recurrent or metastatic disease	Treats cancer throughout the body	Whole-body side effects and continuing treatment
Palliative radiotherapy	Symptomatic advanced disease	Can relieve pain or treat threatened areas	Does not treat every cancer site simultaneously

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Life during and after treatment

Successful prostate cancer care is about more than controlling the cancer.

Urinary function, sexual function, bowel health, energy, emotional wellbeing and relationships should all be considered.

Urinary control

Urinary leakage is common immediately after radical prostatectomy and normally improves over time.

Pelvic floor exercises are commonly started before surgery and continued afterwards. Correct technique is important; repeatedly stopping the urinary stream is not the recommended way to exercise the pelvic floor.

Persistent leakage can be treated.

Options may include:

• specialist pelvic-floor physiotherapy;
• continence devices;
• medication in selected circumstances;
• male sling surgery;
• an artificial urinary sphincter.

Urinary symptoms after radiotherapy are more likely to involve frequency, urgency or discomfort. These often improve but should be reported if persistent.

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Sexual function

Sexual effects vary between treatments.

After prostatectomy

The operation causes permanent loss of ejaculation and natural fertility.

Orgasm may still be possible, but it will be dry. Some men notice:

• reduced orgasm intensity;
• discomfort during orgasm;
• urine leakage during sexual activity;
• altered penile length;
• difficulty achieving erections.

After radiotherapy

Erectile function may decline gradually over time.

Ejaculatory volume usually reduces, and fertility can be affected. Hormone therapy may also markedly reduce libido.

Available support

Treatment may include:

• tablets such as PDE5 inhibitors;
• vacuum erection devices;
• penile injections;
• intraurethral medication;
• psychosexual counselling;
• penile prosthesis surgery when other treatments are unsuccessful.

Early discussion allows realistic expectations and timely access to support.

Recovery is variable and can take many months. Treatment should be tailored to whether the nerves were preserved, pre-treatment function, relationship needs and individual preferences.

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Bowel function

Bowel symptoms are more often associated with radiotherapy than with surgery.

They may include:

• increased frequency;
• urgency;
• looser stools;
• rectal discomfort;
• occasional bleeding.

Modern radiotherapy planning has reduced bowel exposure, but persistent symptoms should be assessed rather than accepted as inevitable.

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Emotional wellbeing

A prostate cancer diagnosis can cause:

• anxiety;
• low mood;
• sleep disturbance;
• fear of recurrence;
• difficulty concentrating;
• changes in identity or self-confidence;
• strain within relationships.

Partners and relatives may also experience uncertainty and distress.

Support may come from:

• clinical nurse specialists;
• counselling;
• psychological services;
• support groups;
• cancer charities;
• sexual and relationship therapists;
• family and friends.

Seeking emotional support is part of good cancer care, not an indication that someone is failing to cope.

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Follow-up after prostate cancer treatment

PSA testing is the main method used to monitor prostate cancer after treatment.

PSA after radical prostatectomy

Because the prostate has been removed, PSA would normally be expected to become undetectable or extremely low.

A persistently detectable or subsequently rising PSA may indicate residual or recurrent prostate cancer and should be assessed.

Depending on the circumstances, further treatment may include:

• radiotherapy to the prostate bed;
• hormone therapy;
• imaging;
• systemic treatment.

PSA after radiotherapy

The prostate remains in place after radiotherapy, so PSA does not usually become completely undetectable.

Instead, it falls gradually and may take a considerable time to reach its lowest level.

A temporary PSA bounce can occur after radiotherapy or brachytherapy. A single rise does not necessarily mean that cancer has returned.

The pattern over time is more informative than one isolated result.

Follow-up during active surveillance

Active surveillance usually includes repeated PSA testing, review of PSA kinetics, MRI and biopsy when indicated.

NICE provides a structured follow-up protocol and recommends reassessment with MRI and/or biopsy if there is concern about clinical or PSA changes.

Patients should not wait for their next routine appointment if they develop new symptoms or concerns.

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PSA testing and prostate cancer screening

England has historically not offered population-wide PSA screening to all men.

The reason is that PSA testing can detect aggressive cancers early, but it can also identify slow-growing cancers that would never have caused harm. This can lead to further investigations, anxiety and treatment side effects.

Men can discuss the potential advantages and limitations of PSA testing with their GP, even if they do not have symptoms.

Targeted BRCA2 screening

On 2 June 2026, ministers in England agreed to introduce a nationally managed targeted prostate cancer screening programme.

The programme is intended to offer PSA testing every two years to men aged 45 to 61 who:

• have a pathogenic germline BRCA2 variant; and
• have a relevant family history of breast, ovarian, pancreatic or prostate cancer.

This is a targeted programme for a defined high-risk population, not universal screening for all men.

Men who are concerned because of their age, Black ethnicity, family history or urinary symptoms should discuss their individual circumstances with their GP or urologist.

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Questions to ask your prostate cancer specialist

Coming to an appointment with written questions can make it easier to understand the diagnosis and participate in decisions.

Useful questions include:

1. What is my exact PSA result and how has it changed?
2. What did my MRI show?
3. What is my Gleason score and Grade Group?
4. What is my clinical stage?
5. Which Cambridge Prognostic Group am I in?
6. Is the cancer confined to the prostate?
7. Do I need any further staging scans?
8. Is active surveillance safe in my case?
9. What are my reasonable treatment options?
10. What would be the advantages and disadvantages of surgery?
11. What type of radiotherapy could I have?
12. Would hormone therapy be required?
13. Is nerve-sparing surgery oncologically appropriate?
14. How might treatment affect continence, erections, ejaculation and fertility?
15. Would focal therapy be suitable, and what surveillance would follow?
16. How experienced is the treating team?
17. Is there enough time to obtain a second opinion?
18. What treatment could be offered if the cancer returned?

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Frequently asked questions

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When should you seek medical advice?

Speak to your GP if you have:

• new or worsening urinary symptoms;
• blood in the urine;
• blood in the semen;
• unexplained weight loss;
• persistent bone or back pain;
• concerns about your family history;
• a known BRCA2 variant;
• concerns about whether PSA testing is appropriate.

These symptoms do not necessarily indicate cancer, but they should not be ignored.

Anyone already receiving prostate cancer treatment should contact the treating team about significant new symptoms or side effects rather than waiting for the next routine appointment.

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A final word

A diagnosis of prostate cancer can initially feel overwhelming, but most patients have time to understand their results, consider their options and obtain the information they need.

The most important step is to establish exactly what type of prostate cancer is present.

That means understanding:

• the PSA;
• the MRI;
• the Grade Group;
• the stage;
• the Cambridge Prognostic Group;
• the advantages and limitations of each reasonable treatment.

There is rarely one decision that is right for every man.

Good prostate cancer care combines sound cancer control with careful consideration of continence, sexual function, bowel function, emotional wellbeing and the patient’s own priorities.

After more than 25 years as a consultant urological surgeon, I have found that patients make the most confident decisions when they are given clear information, realistic expectations and an opportunity to discuss the alternatives without feeling rushed.

Men seeking specialist assessment or a second opinion regarding raised PSA, prostate MRI, biopsy results, active surveillance or prostate cancer treatment can arrange a consultation with Mr Neil Haldar in Buckinghamshire or the wider Thames Valley.

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About Mr Neil Haldar

Mr Neil Haldar is a Consultant Urological Surgeon with more than 25 years’ consultant experience.

His practice includes prostate cancer diagnosis, prostate MRI and biopsy assessment, robotic and open radical prostatectomy, active surveillance, complex treatment decision-making and long-term follow-up.

He works with multidisciplinary prostate cancer teams and supports patients in understanding both the cancer-control implications and the quality-of-life effects of treatment.

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Medical disclaimer: This article provides general educational information and does not replace individual medical advice. Prostate cancer assessment and treatment must be tailored to the individual patient. Always discuss your own symptoms, results and treatment options with an appropriately qualified healthcare professional.

Concerned About Your PSA or Prostate Cancer Diagnosis?

If you have a raised PSA, an abnormal prostate MRI, a recent prostate cancer diagnosis, or would like a second opinion before deciding on treatment, I would be happy to review your case.

Prostate cancer treatment is rarely a one-size-fits-all decision. The right approach depends on the grade and stage of the cancer, your general health, your urinary and sexual function, and what matters most to you personally.

During a consultation, I can review your PSA history, MRI and biopsy results, explain your Cambridge Prognostic Group and discuss the advantages and disadvantages of the treatment options available to you—including active surveillance, robotic or open radical prostatectomy, radiotherapy and, where appropriate, focal treatment.

Arrange a consultation with Mr Neil Haldar, Consultant Urological Surgeon, for a specialist assessment or prostate cancer second opinion.