Friday, March 11, 2011

The Prostate Biopsy: What to Expect

Whenever I tell one of my patients that he needs a prostate biopsy, the same look of fear usually comes over his face.  Fortunately, a prostate biopsy no longer has to be the painful, embarrassing procedure that it has been known for in the past.  In this post I want to provide the answers to common questions I hear from my patients about prostate biopsies:

1)      Why do I need a prostate biopsy?

A prostate biopsy needs to be performed when there is a suspicion that you may have prostate cancer.  That suspicion may be from an elevated PSA blood test (see previous post) or an abnormality of the prostate felt during a rectal exam.  It is the most definitive way to determine whether there is cancer in your prostate.

2)      Do I need any preparation for the biopsy?

Yes.  You will need to take oral antibiotics and some enemas around the time of your biopsy.  Every Urologist has a different preparation but most will involve 1-2 days of oral antibiotics around the time of the biopsy.  Most will also have you do an enema the night before and the morning of the biopsy.  An important aspect of preparation is to avoid any blood thinners like Aspirin, Motrin, Aleve, Ibuprofen, Plavix, or Coumadin for 7-10 days prior to the biopsy.  If you take any of these medicines, make sure that you let your Urologist know well in advance of the biopsy.  Something not well known is that some vitamins and supplements such as Vitamin E, Fish Oil, and Glucosamine also have blood thinning properties and should also be stopped prior to a biopsy.

3)      What are the risks of a biopsy?

The main risks of a biopsy are bleeding and infection.  After a biopsy, you may notice blood in your urine or your stool for several days.  This blood usually goes away on its own if you drink lots of water.  If you have severe bleeding, make sure to let your doctor know or go the Emergency Room right away.  Blood in the semen is also a very common side effect of a biopsy that is rarely discussed.  Because semen is produced in the prostate, a prostate biopsy almost always leads to blood in the semen for several weeks.  It usually starts off red and then becomes a rust color.  It is absolutely nothing to worry about but you may want to wear a condom for a week or two during sex as it may be a little disturbing to you and your partner.

A fever is always concerning after a biopsy as it could mean that there is an infection of the prostate.  This infection can spread into the bloodstream and make you feel very sick.  If you have a fever after a biopsy, it is very important that you go to the Emergency Room right away as you may need intravenous antibiotics.  Fortunately, this complication is seen very rarely after a prostate biopsy.

4)      What should I expect during my biopsy?

The whole process should take about 20-30 minutes.  You will first be checked in by a nurse who will take your blood pressure and have you sign a consent form for the biopsy.  The nurse will also probably make sure that you have taken the preparation discussed above.

After you are checked in you will be asked to change into a gown and empty your bladder.  You will then be asked to lie down on a table.  The position you are in during the procedure depends on your doctor. Some Urologists(including myself) will have you lie on your side with your knees bent towards your chest while others will have you lie on your back and place your legs in stirrups(less common).  The doctor will then perform a rectal exam like you received in the clinic during your initial visit.  He will apply some topical anesthetic cream to your anus and prostate.  Once the cream has been applied, the doctor will then place an ultrasound probe inside the rectum.  This is a little bigger than a finger and may feel like a little more pressure in the rectum.  The doctor will then measure your prostate with the ultrasound.  While he is able to see the prostate during the procedure, the doctor will not be able to really see any cancer within the prostate unless it is very obvious.  After the measurements are taken, your doctor will give you some local anesthetic to numb the prostate.  This will feel like pinching and burning in your prostate not unlike when you get anesthetic at the dentist’s office.  After a minute or two, your doctor will start the biopsy.  You will hear some loud clicks as the biopsy gun deploys.  You may feel a slight pinch with each biopsy.  A total of 12 biopsies are done.  The whole process usually lasts between two and five minutes.  After the procedure is completed the ultrasound will be removed from the rectum and you will be asked to get dressed.

5)      What should I expect after the biopsy?

After the biopsy, most people say that they feel a little sore in their rectum.  Usually some Tylenol will help relieve the discomfort.  Make sure not to take Aspirin, Ibuprofen, or other blood thinners as this will cause bleeding.  As mentioned above, some blood in the urine or stool is normal after the procedure.  It may look frightening at first, but it should go away fairly soon.  You should try to take it easy for the next day or so to let everything settle down.  I would recommend that you avoid any sexual activity for at least a week after the biopsy.
As I mentioned before, fever after a biopsy is NOT NORMAL.  If you have a fever, make sure that you get medical attention right away.

6)      When do I find out the results?

Your doctor will generally call you within a week with the results of your biopsy.

I hope that this post was helpful for those of you about to undergo a prostate biopsy.  Although any kind of biopsy can be stressful, a prostate biopsy does not need to be a horrible experience.  Most of my patients tolerate the biopsy very well.  In fact, most tell me the same thing after the procedure is finished: the anticipation was the worst part.

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  1. Why don't urologists do conscious sedation (versed/fentanyl, for example) more often, for prostate biopsy? I guess it would cost more and take a bit longer, but should be better tolerated and less unpleasant that way. I read a study last year, from Israel, comparing patient reactions to the biopsy among those who had been sedated and those who received only lidocane. The sedated group was much happier and more willing to do it again, if necessary. And wouldn't the doc rather have a sedated patient, who won't move around during the procedure?

    As an alternative, do you ever recommend valium before -- to the take the edge off -- or a prescription painkiller an hour or so before?

  2. chamorgadol: most of my patients do fine with just the local anesthetic. That being said some patients are very nervous in which case I do give them a valium or painkiller prior as long as they have someone to drive them. For about 1% of my patients who simply cannot tolerate such a procedure I actually do perform it under sedation. The problem with doing all biopsies under real anesthesia is that, at least in my practice, it would lead to me doing much fewer biopsies each day which would make my patients wait longer for an appointment. That is not a great proposition for a patient who is waiting to find out if he has prostate cancer.

  3. Hi. My 85 year old grandfather just had a prostate biopsy and a few hour after, he got fever. The doctor prescribed some strong antibiotics (Augmentin), but hasn't called him to the hospital.
    Should I be worried and call a different dr. for a second opinios? Will the fever go away only with farmacy antibiotics?
    I would really appreciate an answer. Thanks.

  4. miahai: while I cannot give specific advice I can say that fever after prostate biopsy could represent a serious infection which usually requires prompt medical attention, evaluation, and treatment.

    Prostate Doc

  5. What would cause a disappearance of semen odor following a prostate biopsy?

  6. I just had my first biopsy today and it went much better than I expected - thanks, I'm sure, to concious sedation and a skilled doctor and anesthiologist. I was concious the whole time and there was only slight sensation when they fired the 12 needles into my prostate. Inserting the probe was the worst part but that's right when they started the IV so it soon became tolerable. It was a fast procedure once I was in the ultrasound room - maybe 15 minutes tops although my sense of time was probably affected by the drugs. The best thing is that it didn't really hurt at all afterwards - just a little sore and almost no blood in my urine (actually none after the first void). I dreaded this for so long - I would now say go for it as long as you have concious sedation. Let's face it, no one wants to have this procedure but it was quick, relatively tolerable and it just might save your life...but get the concious sedation to avoid pain (real pain!).

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