How to make your prostate biopsy go
better—before, during, and after
Harvard Men’s Health Watch | March 2015 www.health.harvard.edu
Here is what men need to know to minimize discomfort and get the best results.
Many men choose to have prostate-specific antigen (PSA) blood tests to check for hidden prostate cancer, despite the uncertain benefits. Having an abnormal PSA test result often leads to a prostate biopsy—the only way to con- firm the presence of cancer. Biopsies are invasive, but they have become routine. To reduce discomfort and get the best results, discuss the procedure in detail with your doctor. Certain practices can improve the overall outcome— for example, make sure you get a shot of anesthetic into the prostate to numb pain during the procedure. "Local anesthesia makes a world of difference between having a tolerable biopsy experience and an unpleasant one," says Dr. Marc B. Garnick, Gorman Brothers Professor of Medicine and a prostate cancer expert at Harvard-affiliated Beth Israel Deaconess Medical Center.
BIOPSY: HOW IT WORKS
The instrument used to perform most prostate biopsies today is a spring-loaded device that pokes a hollow needle through the rectal wall to collect small samples of prostate tissue, guided by an ultrasound image. A newer technique using MRI scans for guidance is also available but is not the standard technology.
The samples are quite small—just several times the diameter of the lead in a mechanical pencil. Later, a pathologist checks the samples under a microscope for signs of cancer.
Prostate biopsy comes with certain risks. For example, when the biopsy needle passes through the rectal wall to reach the prostate, it can spread bacteria or an infection to the prostate gland or bloodstream.
HOW TO GET THE BEST RESULTS
Most men do not find prostate biopsy excessively painful or uncomfortable, and the complications are usually not serious— but can be. Certain steps taken before, during, and after the procedure can improve the outcome:
• TAKE ANTIBIOTICS. Taking preventive antibiotics—before and after the procedure— cuts the risk of infection substantially. Most infections are not dangerous but could become so if they get out of control. The overall chance of being hospitalized with an infection after prostate biopsy is 1% to 3%.
• SKIP THE ENEMA. The latest science says that it's unnecessary to have an enema before the biopsy to reduce the chance of infection. The body can fight infection, especially if you take preventive antibiotics. Some doctors may do a test to identify the types of bacteria living in the rectum and use that information to select the best antibiotic to use.
• REVIEW MEDICATIONS. Before the biopsy, your doctor may advise you to stop taking daily low-dose aspirin or an anticoagulant (blood thinner) such as warfarin (Coumadin), dabigatran (Pradaxa), edoxaban (Savaysa), rivaroxaban (Xarelto), or apixaban (Eliquis). These drugs reduce the blood's ability to clot. Your doctor will weigh the chance of bleeding against the need for anticoagulants to prevent heart problems or stroke.
• EXPECT ANESTHESIA. Get local anesthesia for the biopsy. This means an injection of a numbing drug into the prostate gland to reduce pain during the biopsy.
HOW MANY CORES?
A core is the sample each poke of the biopsy needle removes from the prostate gland. The older "sextant" biopsy took only three cores from each side of the prostate (for a total of six), but this is not enough. "Expect at least 10 and hopefully 12," Dr. Garnick says. That means removing five to six cores on each side of the gland.
You don't necessarily need a saturation biopsy, which can collect up to 24 samples. Saturation biopsy may help only in certain circumstances, like when the prostate is unusually large or if an initial biopsy turns up nothing, yet the doctor still strongly suspects cancer.
WHAT TO WATCH FOR AFTERWARD
Here are the most common complications of prostate biopsy:
• Pain in the area between the anus and scrotum for a few days to a week.
• Blood in your urine for a few days to several weeks.
• Blood in the stool for a day or so. If it lasts longer, notify your physician.
• Blood in the semen for three to six weeks, and possibly longer.
Make sure to notify your doctor if rectal or urinary bleeding get worse. Also, be on guard in the first 24 to 48 hours for signs of a serious infection in the urinary tract or prostate gland. "The alarm signs are fever or chills," Dr. Garnick says. "If you experience this, get to a hospital immediately for intravenous antibiotics." A runaway infection can be dangerous, so don't ignore the signs.
Another uncommon but dangerous complication is urinary retention—the inability to pass urine caused by an infection. Seek care immediately if you stop being able to urinate after a biopsy.