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.

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

PSA: Not Perfect But Vital

Three letters that many men fear are PSA.  These letters stand for Prostate Specific Antigen, a chemical produced by the prostate which is checked via a blood test to look for prostate cancer.  PSA has been an extremely important tool for doctors in identifying early prostate cancer.  Before PSA, prostate cancer could only be identified by means of a yearly rectal exam.  As prostate cancer is often advanced by the time it can be felt on an exam as a mass, many men at that time were diagnosed with prostate cancer after it had already spread outside of the prostate and could no longer be cured.  As a result, Urology wards in hospitals were often filled with men suffering from painful bone metastases that had no hope of cure.  After the advent of PSA, prostate cancer became a much more manageable disease.  Today, men are often diagnosed when just a few cells of prostate cancer are found in the prostate, making the cancer very curable and avoiding the unnecessary pain and suffering of metastatic disease.

While very beneficial, however, PSA is far from perfect.  First, PSA is not specific for prostate cancer.  As I previously mentioned PSA is a functional enzyme NORMALLY produced by the prostate.  In other words, PSA is not JUST produced by prostate cancer.  As a result, many factors can cause an elevation in the PSA test.  The most common cause of an elevated PSA that is NOT caused by prostate cancer is sexual intercourse.  Men who have any type of sex that results in ejaculation within 2-3 days of giving a blood sample usually demonstrate an elevated PSA.  This elevation of  PSA is caused by natural production and secretion of PSA by the prostate for sex rather than by prostate cancer.  Other causes of an elevated PSA  include a urinary tract infection (that may be asymptomatic), retention of urine, and even riding a motorcycle.  As a Urologist I have countless patients referred to me by their primary doctors for an elevated PSA test. Unless I feel an abnormality of the prostate during a rectal exam, I almost always repeat the PSA test, making sure that the patient does not have sex for 2-3 days prior to the test.  I also have the patient give a urine test at the same time to make sure that there is no infection.  In at least 50% of my patients, a repeat PSA test comes back as normal.  Multiple academic studies have demonstrated the same likelihood of what is called a false positive PSA test.  This means that over half of men with a single elevated PSA could avoid unnecessary procedures and worry by simply repeating the test in the right way!

Another problem with PSA is that sometimes it is too sensitive, meaning that it does too good a job in finding prostate cancer.  Studies have shown that 80% of men over the age of eighty have prostate cancer.  Because prostate cancer is usually slow growing, most of these men will never be symptomatically affected by the disease and so will die with it rather than from it.  They will die from more aggressive diseases such as heart disease or stroke.  To some extent, the same situation can be applied to younger men as well.  For example, a 70 year old man found to have a tiny amount of moderately aggressive prostate cancer may live into his 80s or 90s before that prostate cancer grows to any significant extent.  Many studies both conducted in the United States and in Europe have recently demonstrated that many men are diagnosed and treated for prostate cancer as a result of an elevated PSA test that would otherwise never have been significantly affected by prostate cancer within their lifetimes.

So what do all of these problems with the PSA test mean?  Should we get rid of it altogether?  I definitely think not.  While PSA is not a perfect test, it is vitally important if used the right way.  As I mentioned before, prior to PSA, many more men were needlessly dying of metastatic prostate cancer.  In addition, while identifying prostate cancer in 80 year old men MAY not be useful, finding any prostate cancer in healthy, 50 or 60  year old men while the cancer is still contained is VITAL.  PSA can help doctors identify CLINICALLY SIGNIFICANT prostate cancer that WILL affect and possibly shorten the lives of men who suffer from it. 

The real question then is how do we use PSA appropriately and for the most benefit.  First, as I mentioned previously, care must be taken to make sure that the PSA reading is actually real.  Elevated PSA tests should be repeated while minimizing the effects of other factors causing elevation of the test such as sexual intercourse.  In addition, current recommendations are for men over the age of 75 to stop getting PSA tests altogether.  The thinking behind this recommendation is that, because prostate cancer grows slowly, men in their mid to late seventies are unlikely to live long enough for a small amount of prostate cancer to grow enough to significantly affect them.  I don’t completely agree with this thinking because I treat many men in their 70s who are very healthy and will most likely live for at least 20 years.  As a result, I think the decision of whether to do  PSA testing should be tailored to the individual health and wishes of each patient and should entail a detailed discussion between men and their doctors.  I think that this approach should be applied to all patients who undergo PSA tests.  You and your doctor should take many factors into account when deciding whether to get a PSA test and how to interpret the results of that PSA test including your age, health, and desires.  If used in this patient specific manner rather than a “knee-jerk” fashion the PSA test can help save many lives while avoiding unnecessary procedures, pain, and worry. 

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy

Meet the Prostate

A great place for a prostate blog to start would be to explain what the prostate actually is and what it does.  The prostate is a gland the size of a walnut (or, at times, a grapefruit) that lives under your bladder.  Imagine the bladder as an upside down jug with a narrow spout.  The prostate is like a donut that sits underneath the bladder and allows urine to flow from the bladder and out the penis.  When the prostate gets enlarged in conditions such as BPH(benign prostatic hypertrophy) the donut hole gets smaller and smaller which lets less and less urine through when you urinate. This smaller donut hole also makes the urine come out slower in men with BPH. 

The prostate is a sexual organ.  Despite popular belief, it does not cause erections, however.  Instead, it is responsible for the production of semen.  Believe it or not, when men ejaculate after sex, most of the semen coming out does not come from the testicles.  In fact, they produce only about 10% of the liquid that is ejaculated.  The reason for this is that the testicles only produce sperm.  The rest of the semen is made of important nutrients and enzymes that protect and nurture the sperm during their journey to find an egg.  The prostate and some nearby organs called the seminal vesicles produce most of the semen.  When men ejaculate, sperm sent from the testicles are released into the donut hole of the prostate, mixed with semen produced by the prostate and seminal vesicles and ejected out of the penis through contraction of some very strong muscles in the pelvis.  This contraction is what gives the feeling of an orgasm.

Ironically, problems with the prostate usually occur long after men really need it.  BPH and Prostate Cancer usually start occurring in men in their fifties, often long after they have any desire to have more children.  By then, the prostate becomes much more of a nuisance than an asset.  Nonetheless, the problems created by the prostate can be overcome as we shall see in forthcoming posts!

Check out my new Book: 

   Prostate Doc’s Guide to Life After Prostatectomy