If you are not having any prostate problems and your PSA is 9, an explanation needs to be found. Assuming that you do not have enlargement of the prostate gland, known as BPH, or an infection in the prostate gland, known as prostatitis, there may be cancer present in the prostate gland that has not yet been found. The rate of change of your PSA over the years is somewhat worrisome as well. The values you listed in the question reflect an average change of of about 0.8 to 1 ng/mL (nanograms per milliliter) of PSA per year, which is a bit above the normal ranges we see due to benign enlargement of the gland as we get older.

On rare occasions, men who have had several negative prostate biopsies for cancer, but still have a rising PSA may have a so-called "anterior tumor." This means the cancer is located in the front part of the prostate gland, furthest away from a prostate biopsy needle.

In this situation, I often suggest that the man have an endorectal magnetic resonance imaging (MRI) evaluation of the prostate gland to look for abnormalities in the front portion. If the MRI shows some abnormality, a repeat biopsy directed at that area may be more conclusive. Also, if another biopsy is performed, I encourage the urologist to do a saturation biopsy (20 or more biopsy pieces). This means a greater portion of the prostate gland is sampled, as opposed to the usual 10 or 12 biopsies that are routinely taken.

Also, on occasion, prostate tumors can develop from the central portion of the prostate gland known as the transition zone. This area should also be sampled during the biopsy procedure.

Oftentimes, we can't find the explanation for an elevated PSA, but continued physical examinations of the prostate gland and repeat PSAs should be done on a regular basis, and repeat biopsies should be considered if necessary.