Feeling Prepared Before a Prostate Biopsy

A prostate biopsy has long been the standard of care for diagnosing prostate cancer. While it is generally considered safe, a prostate biopsy is an invasive procedure that some people are reluctant to undergo due to fear of pain and possible side effects.

In 2020, the American Urological Association (AUA) revised its guidelines and now recommends a noninvasive magnetic resonance imaging (MRI) scan as the first step in the diagnosis. Should the MRI findings indicate the possibility of prostate cancer, a biopsy would then be performed to confirm the diagnosis.

This reduces the risk of a needless biopsy and has proven far more accurate in diagnosing prostate cancer.

This article explains why and when a prostate biopsy is performed, the possible side effects, and what to expect when undergoing the procedure. It also walks you through what the findings mean and what happens next if cancer is found.

what to expect during a prostate biopsy

Illustration by Emily Roberts, Verywell

Goals of Prostate Biopsy

A prostate biopsy is used to diagnose prostate cancer, a disease affecting more than 275,000 people in the United States annually. As with all biopsies, it involves the extraction of tissue for evaluation by a lab pathologist.

By obtaining a sample of the cancerous tumor, the pathologist can diagnose the disease and begin the process of staging (determining how advanced the cancer is) and grading (determining how aggressive the cancer is).

The two methods commonly used for a prostate biopsy are:

  • Transrectal ultrasound-guided (TRUS) biopsy: This is the most common method. It involves the insertion of an ultrasound probe through the anus to direct the accurate placement of the biopsy needle into the tumor.
  • Transperineal biopsy (TPB): This is an increasingly popular technique. It also uses a transrectal ultrasound probe to direct the accurate placement of the biopsy needle through a small incision in the perineum (the space between the genitals and anus).

A transurethral biopsy (TUB) is an older, more invasive procedure no longer included in the AUA screening guidelines. It involves the insertion of a fiberoptic scope into the urethra (the tube through which urine exits the body) to access the prostate gland through the wall of the urethra.

When Is a Prostate Biopsy Needed?

A prostate biopsy is one of the steps involved in the diagnosis of prostate cancer and ultimately the one that can definitively diagnose the disease.

The decision to pursue the biopsy is largely directed by the prostate-specific antigen (PSA) test. This is a blood test that detects a protein released in greater quantities when the prostate gland is inflamed. The test does not detect cancer, but very high PSA levels indicate that prostate cancer may be involved.

Your healthcare provider may recommend a prostate biopsy if any of the following apply:

  • Your PSA is significantly elevated.
  • A lump or other abnormality is found on a digital rectal exam.
  • An abnormality is found on a transrectal ultrasound.
  • A previous prostate biopsy was negative, but your PSA level remains high.

If prostate cancer is suspected based on these findings and other risk factors—such as being over 50, having a family history of prostate cancer, or having Black ancestry—you would first undergo a special type of MRI called a multi-parametric MRI (mpMRI).

The mpMRI produces a more detailed, three-dimensional (3D) image of your prostate gland than a standard MRI would. It is used first not only because it is noninvasive but also because it visualizes the prostate as a whole rather than "poking around" for random samples with a biopsy.

While a biopsy would still be needed to confirm the diagnosis, the mpMRI better ensures that unnecessary biopsies are avoided.

A 2019 study in the Canadian Medical Association Journal found that a mpMRI has a 93% accuracy in correctly diagnosing prostate cancer compared to 48% for a TRUS biopsy. This translates to a 38% reduction in unnecessary biopsies.

When Is a High PSA a Sign of Cancer?

There is no hard-and-fast rule as to when a PSA is a sign of cancer. While a PSA of 4 nanograms per milliliter (ng/mL) is generally considered normal in a person with a prostate, 15% of people with prostate cancer have a PSA under 4.

The odds of prostate cancer increase to 25% when the PSA is between 4 and 10, and to 50% when the PSA is over 10.

How Painful Is a Prostate Biopsy?

The prostate biopsy itself should cause little if any pain once the effects of the local anesthetic or nerve block have kicked in. You may feel pressure and even uncomfortable sensations, but no outright pain. If you do, let the surgeon know.

Immediately after the procedure, you may feel fine, but pain may soon develop as the effects of the anesthetic start to wear off. This is why you are likely to be advised to avoid driving yourself home after the biopsy.

How Long Do Local Anesthetics Last?

The length of time that it takes for a local anesthetic to wear off depends on the type of anesthetic used. Some, like lidocaine gel, are relatively short-acting, with the numbing effects starting to wear off soon after the procedure. Nerve blocks generally last longer but can cause temporary leg numbness and weakness that can impair driving.

Once you are safely home, you can expect to have some rectal pain and pain with urination (dysuria). These side effects tend to be relatively manageable and persist for no more than a few days.

However, some people may experience severe post-biopsy pain. This may be due to physical factors such as:

  • Larger prostate size
  • Larger tumor size
  • Longer time taken in performing the biopsy
  • A tumor situated in the lower portion (apex) of the prostate
  • A higher number of tissue samples taken from the prostate
  • Younger age (due to greater tension of the anal sphincter muscle)

The pain may also be complicated by emotional factors such as embarrassment and stress before undergoing a digital rectal examination, stress before the biopsy itself, and fear of sexual dysfunction or a cancer diagnosis.

Coping With Anxiety and Anticipatory Pain

Anticipatory pain is when your perception of pain is intensified by thoughts of how painful a procedure or treatment will be. It is common with prostate biopsies.

While pain perception can be increased with strong negative emotions—referred to as the nocebo effect—it can also be decreased with strongly positive ones.

This is evidenced by a 2021 study from China. It showed comforting stimuli, such as having your hand held during a prostate biopsy, keeps blood pressure and heart rate more stable than not having your hand held. Moreover, people who had their hands held were 17 times more willing to undergo a repeat biopsy if needed.

This is not to say that you should ask for someone to hold your hand during the procedure. But it does suggest there are ways to calm yourself and minimize the nocebo effect if you are scheduled to undergo a prostate biopsy.

As a general rule:

  • Ask your healthcare provider to walk you through the procedure while you ask many questions as you need to overcome the fear of the unknown.
  • Share your feelings and concerns with your healthcare provider or a therapist rather than keeping them to yourself.
  • Avoid searching the Internet for medical information that can add to your anxiety.
  • Think positively about the procedure, reminding yourself that the benefits outweigh the risks.

Other Short- and Long-Term Effects 

While pain is the side effect many people associate with prostate biopsy, there are other, far more common ones like blood in the urine (hematuria), blood in sperm (hematospermia), and rectal bleeding. Even so, these side effects are typically mild and resolve on their own. Most do not require medical treatment.

With that said, up to 25% of people who have undergone a TRUS biopsy will experience a mild to moderate urinary tract infection (UTI), while less than 2% will experience urinary retention (difficulty emptying the bladder). The risk of these complications is even lower with a TPB.

Rare complications include the risk of urosepsis caused when a severe, untreated UTI spreads into the bloodstream. Even rarer is nephrogenic systemic fibrosis caused when a reaction to the MRI contrast dye gadolinium damages the kidneys and other organ systems.

Can Prostate Biopsy Cause Erectile Dysfunction?

A 2021 review involving 54 published studies found no association between prostate biopsy and erectile dysfunction (ED). While there may be a transient loss in the ability to get or sustain an erection during the first month, the difficulty almost invariably resolves itself within three months.

Who Doesn’t Need a Prostate Biopsy?

According to the AUA, there are situations in which a prostate biopsy can be skipped and cancer treatment delivered as a matter of urgency. This includes:

Step-by-Step Process of Prostate Biopsy

A TRUS biopsy is a common outpatient procedure performed by a specialist in the male reproductive tract known as a urologist. The biopsy takes around 15 to 30 minutes to complete and may be performed in a clinic, hospital, or a healthcare provider's office.

Before the Procedure

While there are no food restrictions or extensive bowel preparations needed for a TRUS biopsy, your urologist will ask you to make the following special preparations before undergoing the procedure:

  • Medications: Stop taking anticoagulants (blood thinners) like Jantoven or Coumadin (warfarin), Plavix (clopidogrel), or aspirin 7 to 10 days before the procedure to avoid excess bleeding.
  • Bowel prep: You may be asked to use an over-the-counter (OTC, obtained without a prescription) enema (like Fleet Saline Laxative Enema) the night before the biopsy or 2 to 3 hours before your arrival.
  • Antibiotics: Your urologist may prescribe an antibiotic like Cipro (ciprofloxacin) to take immediately before and soon after the procedure. This helps prevent postoperative infection.
  • Urinate: You may be asked to empty your bladder immediately before the procedure.

You will be asked to undress and change into a hospital gown, after which you will be escorted into the procedure room.

A prostate biopsy is performed on a procedure table while lying on your side or back. Local or regional anesthesia is most commonly used to reduce pain and discomfort.

Anesthesia options include:

  • Intrarectal lidocaine: This numbing agent, made with 2% lidocaine gel, is injected directly into the rectum with a syringe.
  • Perianal anesthesia: This is an injection of a local anesthetic into the anal and perineal area with a needle and syringe.
  • Periprostatic nerve block: This is an injection of a local anesthetic into the base of the prostate gland using a syringe and needle.
  • Pudendal nerve block: This is an injection of a regional anesthetic into the pudendal nerve situated at the base of the spine. This is the nerve that provides sensations to the pelvis.

Once the area is amply numbed, the procedure can begin.

During the Procedure

TRUS and TPB are two options for a prostate biopsy. While a TRUS biopsy is the more commonly used procedure, some health experts prefer the TPB for its lower rate of complications.

The TRUS biopsy is performed in the following steps:

  1. You are placed on your side on the procedure table with your knees pulled toward your chest.
  2. Iodine is brushed over the skin of the anus and perineum.
  3. The urologist lubricates the anus and insets a wand-like device, called an ultrasound transducer, into the rectum.
  4. The transducer is placed next to the prostate gland. The device produces images on an external monitor using high-energy sound waves.
  5. Once the tumor is located, a hollow needle is fed through the neck of the transducer and inserted into the tumor to obtain a tissue sample (called a core).
  6. Generally, 10 to 12 cores are obtained. There may be a sensation of pressure as the needle is inserted, but no outright pain.
  7. Once enough cores are obtained, the ultrasound transducer is removed.

The TPB procedure is performed in the following steps:

  1. You lie on your back with your legs spread and calves placed in elevated stirrups.
  2. Iodine is brushed over the skin of the perineum.
  3. The urologist inserts the ultrasound transducer into the rectum.
  4. Once the tumor is located, one or two skin punctures are strategically made in the perineum.
  5. A thin plastic tube called a cannula is then inserted into each skin puncture. These serve as portals through which biopsy needles can be repeatedly inserted.
  6. Once 10 to 12 cores are obtained, the cannulas and transducer are removed.
  7. Stitches are generally not needed, but the puncture sites may be covered with surgical tape.

After the Procedure

After the biopsy is completed, you can usually get dressed and return home. Most urologists advise people not to drive themselves home due to the pain and lingering effects of certain anesthetics. If a pudendal nerve block was used, you should not drive.

Before leaving, you may be given an OTC painkiller like Tylenol (acetaminophen) to help manage pain, Some urologists will also prescribe a short course of an alpha-blocker like Flomax (tamsulosin) to improve urine flow while you heal.

Recovery Time and Aftercare

Most urologists recommend getting plenty of rest 24 to 48 hours after the biopsy. If you were prescribed antibiotics, you would take the second and final dose 12 hours after the procedure.

For the first three days, drink extra amounts of fluid to help flush out the bladder, prevent infection, and minimize the amount of blood in your urine. Water is best. Coffee, alcohol, and high-sugar beverages can irritate the urinary tract and should either be avoided or kept to a minimum.

Sex should also be avoided for the first three days. Sports and heavy lifting (more than 10 pounds) should be suspended for five days as both can increase the risk of bleeding.

It is not uncommon for there to be traces of blood in your urine for up to 14 days. Your semen can also look rust-colored for up to 12 weeks as the prostate gland (which supplies fluids to semen) slowly heals itself.

If these symptoms worsen or you develop any new symptoms, call your healthcare provider.

When to Seek Medical Care

Severe infections following a prostate biopsy are rare but can occur. Call your healthcare provider immediately if you experience:

  • High fever with chills
  • Increased blood in the urine
  • Increased rectal bleeding
  • Difficulty or rapid breathing
  • Rapid heart rate
  • Severe lower abdominal pain
  • Nausea or vomiting
  • Inability to urinate

Prostate Biopsy Results

The results of your biopsy should be received within five to seven days. The pathology report will describe all of the lab's findings, including the histological findings seen under the microscope.

Three possible outcomes of a prostate biopsy are:

  • Negative: This means that no cancer or abnormal cells were found in the tissue samples. The finding is also sometimes referred to as benign, meaning noncancerous.
  • Atypical: This means that suspicious cells were found. One possible cause is a condition called prostatic intraepithelial neoplasia (PIN), in which prostate cells look and act abnormally. Low-grade PIN usually means nothing, but high-grade PIN is commonly accepted as precancer.
  • Positive: This means that cancer cells were found in the tissue samples and that treatment is needed by a cancer specialist known as an oncologist.

Suspicious or Cancerous Prostate Biopsy Results: What Happens Next? 

Additional action is needed if the pathology report returns anything but a negative result. In some cases, even a negative result needs follow-up.

Atypical or Suspicious Results

If your pathology report delivers an atypical finding, it may mean that you are at risk of developing prostate cancer, or it may mean nothing. In the end, a lot of things can look like cancer under the microscope and not actually be cancer.

In such cases, your urologist may recommend a repeat prostate biopsy in 3 to 6 months. Alternatively, you may be routinely monitored with blood, urine, and MRI tests. The decision is largely based on how abnormal the findings are and whether you have other risk factors for prostate cancer.

Positive Results

If your biopsy is positive, the next step is to grade the cancer based on how abnormal the cells look under the microscope. The traditional method is the Gleason scoring system, which assigns a score of 3 to 5 from two different locations on the tissue sample. The numbers from each section are then added up to get the final score.

Gleason scores range from 6 to 10, with 6 being the least abnormal and 10 being the most abnormal. These findings will help establish how aggressive the tumor is and what cancer treatments are most appropriate.

Not every case needs immediate treatment. In some cases, a low Gleason score may warrant a watch-and-wait approach.

How Many Prostate Biopsies Are Cancer?

A 2017 report in the European Medical Journal found that 70% of prostate biopsies are negative but that 30% to 43% of these turn out positive after a repeat biopsy. Although MRIs have greatly improved the accuracy of prostate cancer screenings, they still have a false negative rate of between 4% and 14%.

What this suggests is that suspicious findings (such as rising PSA levels) should always be investigated even if the initial biopsy result is negative.

Summary

A prostate biopsy is performed when there is a suspicion of prostate cancer. It involves the extraction of tissues either through the rectum (transrectal ultrasound-guided biopsy, or TRUS) or the perineum (transperineal biopsy, or TPB). The outpatient procedure takes 15 to 30 minutes to complete, typically under local or regional anesthesia.

Side effects tend to be mild and transient. Rectal pain and pain with urination tend to ease within several days.

In 2020, the American Urological Association recommended that people suspected of having prostate cancer first undergo a magnetic resonance imaging (MRI) scan before a prostate biopsy is considered.

The MRI cannot diagnose cancer but is able to detect abnormalities consistent with cancer with a high degree of accuracy. Performing the MRI first reduces the risk of unnecessary biopsies while increasing the accuracy of prostate cancer screening.

29 Sources
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  1. Bjurlin MA, Carroll PR, Eggener S, et al. Update of the standard operating procedure on the use of multiparametric magnetic resonance imaging for the diagnosis, staging, and management of prostate cancer. J Urol. 2020;203(4):706-712. doi:0.1097/JU.0000000000000617

  2. Eklund M, Jaderling F, Discacciati A, et al. MRI-targeted or standard biopsy in prostate cancer screening. N Engl J Med. 2021; 385:908-920. doi:10.1056/NEJMoa2100852

  3. National Cancer Institute. Cancer fast stats: prostate cancer.

  4. Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):45-53. doi:10.1097/JU.0000000000003491

  5. Fenton JJ, Weyrich MS, Durbin S, Liu Y, Bang H, Melnikow J. Prostate-specific antigen-based screening for prostate cancer: evidence report and systematic review for the US Preventive Services Task ForceJAMA. 2018;319(18):1914-1931. doi:10.1001/jama.2018.3712

  6. Cheung DC, Finelli A. Magnetic resonance imaging diagnosis of prostate cancer: promise and caution. CMAJ. 2019;191(43):E1177–E1178. doi:10.1503/cmaj.190568

  7. American Cancer Society. Screening tests for prostate cancer.

  8. Lee HS. Recent advances in topical anesthesia. J Dent Anesth Pain Med. 2016;16(4):237–244. doi:10.17245/jdapm.2016.16.4.237

  9. Xu J, Zhou R, Su W, et al. Ultrasound-guided bilateral pudendal nerve blocks of nulliparous women with epidural labour analgesia in the second stage of labour: a randomised, double-blind, controlled trial. BMJ Open. 2020;10(8):e035887. doi:10.1136/bmjopen-2019-035887

  10. Prostate Cancer UK. What are the side effects of a biopsy?

  11. Rempega G, Rajwa P, Kepinski M, et al. The severity of pain in prostate biopsy depends on the biopsy sector. J Pers Med. 2023;13(3):431. doi:10.3390/jpm13030431

  12. Li W, Mao Y, Gu Y, et al. Effects of hand holding on anxiety and pain during prostate biopsies: a pilot randomized controlled trial. Patient Prefer Adherence. 2021;15:1593–1600. doi:10.2147/PPA.S321175

  13. Manai M, van Middendorp H, Veldhuijzen DS, Huizinga TWJ, Evers AWM. How to prevent, minimize, or extinguish nocebo effects in pain: a narrative review on mechanisms, predictors, and interventions. Pain Rep. 2019;4(3):e699. doi:10.1097/PR9.0000000000000699

  14. Efesoy O, Bozlu M, Cayan S, Akbay E. Complications of transrectal ultrasound-guided 12-core prostate biopsy: a single center experience with 2049 patients. Turk J Urol. 2013;39(1):6–11. doi:10.5152/tud.2013.002

  15. Loeb S, Vellekoop A, Ahmed U, et al. Systematic review of complications of prostate biopsy, Europ Urol, 2013;64(6):876-892. doi:10.1016/j.eururo.2013.05.049

  16. Berry B, Parry MG, Sujenthiran A, et al. Comparison of complications after transrectal and transperineal prostate biopsy: a national population-based study. BJU Int. 2020;126(1):97-103. doi:10.1111/bju.15039

  17. Ramalho J, Semelka RC, Ramalho RH, AlObaidy M, Castillo M. Gadolinium-based contrast agent accumulation and toxicity: an update. AJNR Am J Neuroradiol. 2016;37(7):1192-1198. doi:10.3174/ajnr.A4615

  18. Mehta A, Kim WC, Aswad KG, Brunckhorst O, Ahmed HU, Ahmed K. Erectile function post prostate biopsy: a systematic review and meta-analysis. Urology. 2021;155:1-8. doi:10.1016/j.urology.2021.01.035

  19. Harvey CJ, Pilcher J, Richenberg J, Patel U, Frauscher F. Applications of transrectal ultrasound in prostate cancer. Br J Radiol. 2012;85(Spec Iss 1):S3–S17. doi:10.1259/bjr/56357549

  20. Canadian Cancer Society. Transrectal ultrasound (TRUS).

  21. Memorial Sloan Kettering Cancer Center. About your prostate biopsy with ultrasound.

  22. Sahin A, Ceylan C, Gazel E, Odabas O. Three different anesthesia techniques for a comfortable prostate biopsy. Urol Ann. 2015;7(3):339–344. doi:10.4103/0974-7796.152014

  23. Hong A, Hemmingway S, Wetherell D, Dias B, Zargar H. Outpatient transperineal prostate biopsy under local anaesthesia is safe, well tolerated and feasible. ANZ J Surg. 2022;92(6):1480–1485. doi:10.1111/ans.17593

  24. Thomson A, Li M, Grummet J, Sengupta S. Transperineal prostate biopsy: a review of technique. Transl Androl Urol. 2020;9(6):3009–3017. doi:10.21037/tau.2019.12.40

  25. Alberta Health Services. Sympathetic nerve block: before your procedure.

  26. American Cancer Society. Your prostate pathology report: cancer (adenocarcinoma).

  27. American Society of Clinical Oncologists. Prostate cancer: stages and grade.

  28. American Urological Association. Clinically localized prostate cancer: AUA/ASTRO/SUO guideline.

  29. Rivas JG, Alvarez-Maestro M, Czarniecki M, Czarniecki S, Rodriguez Socarras M, Loeb S. Negative biopsies with rising prostate-specific antigen. What to do? EMJ Urol. 2017;5[1]:76-82. doi:10.33590/emjurol/10314704

By James Myhre & Dennis Sifris, MD
Dennis Sifris, MD, is an HIV specialist and Medical Director of LifeSense Disease Management. James Myhre is an American journalist and HIV educator.