A prostate biopsy is an exam required for the diagnosis of prostate cancer. It is helpful for staging and making decisions based on the findings. It is useful in patients with alarmingly high PSA levels and a suspicious mass in the prostate.
Other patients in the gray zone undergo additional tests before thinking about a prostate biopsy. Even among doctors, there is some reluctance to use a prostate biopsy, and scientific literature is often worried about the excessive and incorrect use of this diagnostic tool.
But prostate cancer is a severe health problem, and some people reason that testing is better than not testing. However, the problem with prostate biopsies is their side effects. Doctors use them carefully and only in patients with considerable risk. We want to avoid causing pain to patients who are unlikely to have prostate problems in their lifetime. They would end up with the side effects of a prostate biopsy and no positive change in their prognosis.
Thus, health authorities have created and renewed protocols to identify who needs a prostate biopsy and who doesn’t. All of this procedure is meant to spare patients who are not at risk from the side effects. But are they really that bad? If your doctor recommended a prostate biopsy, what should you consider, and what do you need to know first? It is imperative to talk about the pros and cons of prostate biopsies with your doctor. But we’re here to give you some background and valuable insight into the procedure. The more tools and accurate information you have about this procedure, the better decisions you can make alongside your doctor.
With that in mind, let’s talk about biopsies, what to expect, what is the associated risk, and if there is an alternative.
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What are the different types of a prostate biopsy procedures?
A prostate biopsy is one of the last steps down the road after measuring prostate-specific antigen (PSA) in the blood, performing a digital rectal examination, and considering each patient’s risk factors and symptoms.
The main goal is to obtain a prostate sample, especially if there is a visible lesion or tumor. But there are several ways to get this biopsy sample. The most common types are as follows:
Transrectal ultrasound–guided prostate biopsy (TRUS biopsy)
This type is by far the most common procedure to obtain a prostate sample. It is a transrectal approach because the prostate is located next to the rectum. What the doctor does first is asking the patient to adopt a fetal position on the table. The position is similar to that adopted in a digital rectal exam. This exposes the rectum and relaxes the muscles to facilitate the procedure. A very small ultrasound probe is inserted into the rectum to see the prostate gland.
Once located, the doctor injects local anesthetics to numb the prostate and its vicinity. You may feel slight burning pain when intrarectal lidocaine is injected for periprostatic nerve block. After that, the area will be sedated, and you may only feel some discomfort and pressure. Next, a biopsy needle is inserted and guided through ultrasound to reach the prostate. 10-15 tissue samples are taken and prepared for biopsy. The procedure only takes 20 minutes or less than that (1)
Transurethral prostate biopsy
One of the main problems of a transrectal prostate biopsy is related to its reach. This procedure is only helpful to take samples of the posterior part of the prostate. If there is a tumor in the anterior prostate, it would not be reached easily. The needle is usually 17 mm long, not enough to penetrate that area. Most prostate cancer tumors are located posteriorly, but some of them are not. That’s why the transrectal biopsy of the prostate gland has 20-30% of false-negative results.
An alternative to the transrectal approach is the transurethral prostate biopsy. A similar procedure is used for radical prostatectomy. This time it uses a cystoscope with a camera into the urethra. This is more uncomfortable for the patient and often requires sedation in the area and using sufficient lubricant. Similar to the transrectal prostate biopsy, this procedure collects several samples of the prostate. It does so through the walls of the urethra.
Transperineal prostate biopsy
The transperineal biopsy is another option if you want to obtain samples from the anterior and posterior prostate. It is also very accurate to get samples from the transition zone, which accounts for up to 55% of the tumors. Thus, this method is becoming very popular, but it is only used in some patients.
For a transperineal prostate biopsy, your doctor will use a special table, and you will be lying in a position similar to that adopted by women in labor. This exposes the perineal area and allows the doctor to locate the nerves and block them with anesthesia. A small incision is made in the pelvic floor, and a small ultrasound probe is inserted into the rectum to obtain ultrasound images. Then, a needle is used and guided by ultrasound to reach the prostate and take multiple samples (2).
MRI–guided prostate biopsy
This is a more recent approach to a prostate biopsy and uses MRI technology and ultrasound simultaneously. This allows for a targeted biopsy when there are very specific and often small regions to sample. The detection rate of an MRI-guided prostate biopsy is higher. Thus, not so many samples need to be taken. Therefore, this type is better for patients who need to perform repeated biopsies. It has fewer false-negative and requires fewer samples, hence its clinical significance (3).
How do you prepare for a prostate biopsy?
If you were ordered a prostate biopsy, it’s because your doctor examined your case and determined that you’re a candidate. He has probably told you what it is about, which method he’s going to use, and how it will be like. But if you haven’t discussed everything with your doctor, that is one of the first things on your list. Talk to your doctor and ask him any question you have. Every one of us has different traits and risk factors. You may need specific advice according to your case.
You will probably undergo these preparation steps before a prostate biopsy:
Your doctor needs to know the list of medications that you’re taking. If you suffer from any chronic disease and regularly use prescription drugs, it is crucial to inform your doctor. Some medicines can make a prostate biopsy dangerous. For example, warfarin and other anticoagulants can make you bleed uncontrollably. Do not suspend the medications on your own. Your doctor may need to weigh the benefits of the procedure against the risk of temporarily suspending your meds.
Follow the antibiotic schedule
Your doctor will probably prescribe antibiotics before the procedure. They are meant to prepare your body to destroy any bacteria that comes through. Doses are essential here, and you need to take the antibiotics as instructed. Otherwise, it can be dangerous for you, and the risk of complications will be higher.
It is important to do what you’re doing right now. Getting reliable information from a trustworthy source is fundamental. That way, you will know what to expect and what will happen during and after a prostate biopsy. The best source of information is your doctor because only he knows the procedure and techniques used in your case.
Prepare for the immediate complications
A prostate biopsy usually has the primary complication of bleeding. You can see blood in the urine, in the stool, or in your semen. Also, you may feel pain in your pelvic floor for up to one week. You need to understand before the procedure why this happens. That way, you will be able to tell when the bleeding is too much. Be sure to ask your doctor what to expect in your case.
Is a prostate biopsy painful?
A prostate biopsy is a surgical procedure, and what people feel after is very similar to what people feel after surgery. After any surgical procedure and when the anesthesia wears off, people feel pain. They need to use anti-inflammatory drugs to manage their symptoms, and the intensity is variable. You have people who manage their pain efficiently and others who are significantly affected by the symptom. Something similar happens after a prostate biopsy.
Anesthesia is not always used in a transrectal ultrasonography-guided biopsy. So, it might be a good idea to ask your doctor if he’s going to use anesthesia or not. Certain studies show that there’s no significant difference in pain symptoms with and without anesthesia. Others mention that anesthesia reduces the sensation of pain significantly. Due to diverging studies, anesthesia use is not explicitly written in the protocol, and some doctors prefer not to use it. However, it is essential to achieve adequate pain management in this procedure in any way or another. Ask your doctor what will be the method he will use to manage pain (4).
What the studies say
In a Finnish survey about prostate biopsies and the need for rebiopsy, 18% of men said they would not accept a new biopsy, and the leading cause was pain. This symptom is sometimes as severe as causing tension and anxiety in men. Many of them end up with an unfavorable attitude to the procedure. Others are adequately treated or maintain close contact with the doctor reporting their symptoms and adjusting the doses. When patients achieve relief, they are more likely to accept a new biopsy if needed in the future.
Pain measurement studies in prostate biopsy use different methods to assess pain. The most common is a scale from 0 to 10, known as the visual analog scale. Other instruments can simply measure the respiratory rate, serum cortisol levels, or blood pressure. According to these studies, when patients feel very anxious, their perception of pain increases. Thus, the more nervous the patient is, the higher the need for anesthesia.
However, most studies mentioned above evaluate pain during the procedure and shortly after. As noted above, feeling pain is natural after any surgical procedure and not an alarming sign at all. Pain should go away after a few days or one week, and it is easier to manage as the days go by. If you still have significant pain symptoms one or two weeks after a prostate biopsy, it will be a good idea to talk to your doctor. You might have a complication -usually an infection- that is not allowing for a complete recovery.
Factors that may worsen the pain
- Anxiety levels: It is a fact that anxious individuals have a lower pain threshold. In other words, they are more susceptible and reactive to pain symptoms. Thus, along with painkillers, patients should also use alternative treatments to relieve anxiety levels. Music, aromatherapy, and herbs to wind down are very effective for some.
- Prostate volume: An enlarged prostate is more likely to add pressure to the nerves and cause significant pain. It is usually affected by inflammation (especially in prostatitis) and prone to swelling and becoming tender.
- The number of biopsy cores: In other words, the more samples the doctor needs to take, the more likely it will cause pain. Each sample requires a new insertion of the needle and increases the chance of inflammation and pain.
- Younger age: Younger patients can be more sensitive to pain than older adults. There is also the case of early-onset prostate cancer, which is more dangerous and may lead to significant inflammation of the prostate. In these patients, the prostate will be significantly tender after the procedure.
- Positioning: According to certain authors, adopting the left lateral decubitus position is slightly better than a lithotomy position.
What are the risks?
Besides pain, doctors avoid performing a prostate biopsy for everybody because it has significant risks and side effects. This won’t happen to everybody, and many patients have a good experience with no side effects. But if we sort out every possible scenario, we can have these complications (4):
It is the most frequent symptom during and after a prostate biopsy. You could see blood in the urine, in the stool, or in your semen. This is expected for a few days to 6 weeks in the case of semen. Most men have minor blood in the urine without any other side effects (5).
The rate varies depending on the number of samples taken during the biopsy procedure (5).
This is a side effect in people who had to discontinue anticoagulation drugs before surgery. If this medication was keeping their blood from clotting, they could experience a thromboembolic event.
It is a common complication, but the incidence reduces if you follow antibiotic prophylaxis. Infectious complications can cause hospitalization in up to 6% of these patients (6).
Lower urinary tract symptoms
After a biopsy, you could experience urinary retention, dysuria, and other urinary symptoms. The risk of urinary retention is lower than 2%. Other urinary symptoms can worsen in around 25% of patients (7).
Some patients experience temporary erectile dysfunction that resolves after one month. In other cases, recovery takes a longer time. However, the studies have many confounders, and erectile dysfunction can also be triggered by psychogenic causes (7).
Only a few rare cases end up in sepsis, Fournier’s gangrene, and very severe and life-threatening bleeding. They are all atypical biopsy side effects.
Alternatives to a prostate biopsy
When you need a prostate biopsy to complete the diagnosis and the Gleason score, no other diagnostic tool has the same value. However, there is a “gray zone,” in which doctors are not sure if the patient has prostate cancer or not. Many patients in this gray zone undergo a prostate biopsy that could be avoided by considering other options.
Depending on your case, one of these alternatives could rule out the suspicion of prostate cancer and disregard the need for a prostate biopsy:
- Advanced PSA test measures such as PSA density or PSA velocity, especially in patients with known benign prostatic hyperplasia
- A prostate MRI scan to see a more detailed picture of the prostate
- Additional prostate markers such as PCA3, T2:ERG, and the MIPS prostate score
- Watchful waiting, which is recommended for some patients in the gray zone
Our Natural & Non-Invasive Prostate Biopsy Alternative
In our opinion, a far safer and gentler prostate biopsy alternative is our Advanced Prostate Cancer Risk Assessment (APCRA). This consists of non-invasive blood tests and specialized color Doppler scans.
The variety and sophistication of some of these new blood tests make this a very realistic alternative to a prostate biopsy, especially if you have a preference for non-invasive diagnostics and treatments.
After this testing, you will receive a thorough, 3-hour consultation from a Naturopathic Physician who is also a Professor of Urology and a very detailed, written report of your results to be discussed during the appointment.
He will walk you through the results of his assessment and explain every aspect and each option available to you, while also answering any questions that you may have. Your consultation will be like an educational mini-seminar about the real issues facing you as a patient.
Most urologists will have a preference for the particular treatment that they provide. However, the consultant you will see has no agenda and is completely free to offer honest, independent advice.
He will try and help with any information you need in order to arrive at your decision. But he will not try to sway you one way or the other.
Aside from that, the greatest additional benefits of the APCRA are that it is non-invasive, does no damage, and does not close off any avenues for future treatment.
Is a prostate biopsy painless? Asking for a painless prostate biopsy would be similar to asking for painless surgery. There’s no such thing. There is always discomfort and some pain after a surgical procedure. What’s essential in this case is managing the pain with the appropriate treatment.
There are different procedures to obtain a needle biopsy, but the most common is a transrectal ultrasound-guided prostate biopsy. It is recommended by the urologist if you have a high risk and want to detect cancer cells in the prostate tissue.
Side effects include bleeding, pain, and urinary symptoms. They are usually temporary, but some of them can be very bothering or severe. However, a prostate biopsy provides valuable insight into cancer and guides the treatment protocol. Thus, the best approach is to manage pain symptoms instead of avoiding prostate biopsies in high-risk patients who really need them.