What is a Prostate Biopsy?
My urologist is recommending I get a prostate biopsy, what is that?
A prostate biopsy is a procedure performed in the urologist’s office to get tissue from the prostate to check for prostate cancer. This usually involves having an ultrasound put in your rectum and then 10-12 samples of the prostate will be taken. These samples will get sent over to the pathologist to see if there is cancer there or not.
Why is he recommending a prostate biopsy?
There are two reasons to have a prostate biopsy performed
1. Abnormal prostate exam (digital rectal exam)
This is the ‘finger up the butt’ test. Your urologist will feel the prostate and specifically try and feel if there is a ‘nodule’ or a hard lump. If a nodule is felt, then it doesn’t really matter what your bloodwork shows because this could be a sign of prostate cancer. This by itself is an indication for a prostate biopsy.
2. Abnormal PSA blood test
If your PSA level is high or rising, then this could be a sign of prostate cancer.
There are a whole bunch of variables to consider when determining if a PSA blood test result is abnormal. If you have questions in more detail about the PSA, click here.
How should I prepare for the prostate biopsy?
This is a procedure done in the urologist’s office and you are awake when it is being performed so there is no need to be fasting.
The biggest risk that we try and avoid is to develop an infection from the biopsy. As such, during the morning of the biopsy, you will insert a fleet’s enema. An enema is a laxative that you insert in your rectum to help you poop. There are a couple reasons we recommend you do this. The first reason is that it reduces the amount of bacteria in the rectum to reduce the chance for infection. The other reasons is that by evacuating the rectum, it gives us a better picture from the ultrasound when we are doing the biopsy.
The other prep that you will do at home is to take antibiotics that will have been prescribed by the urologist. With these, and certain other measures, the risk of infection in my practice is now down to ~2% of cases.
**Make sure to review your medication list**
For me personally, I will not stop Aspirin 81 mg prior to your biopsy. However, there are many urologists that will ask you to do so. If he/she does, you will need to stop this ~7 days prior.
There are many “blood thinner” medications that you will need to temporarily stop around the time of the biopsy. Typically, we will ask that you communicate the safety of stopping on these medications with your prescriber (primary care physician, cardiologist, or hematologist) to double check that it is safe for you to stop taking these medications for a short period of time. The reason we ask you to hold these medications is to limit your risk of significant bleeding after the biopsy.
Here is a list of common blood thinner medications and how far in advance you need to stop taking them
Warfarin (Coumadin) –> stop 5 days prior
Clopidogrel (Plavix) –> stop 5 days prior
Rivaroxaban (Xarelto) –> stop 3-5 days prior
Ticagrelor (Brillenta) –> stop 5 days prior
Apixaban (Eliquis) –> stop 2 days prior
Dabigatran (Pradaxa) –> stop 2 days prior
How do I use the fleet's enema?
- Positioning: Either lie down on your side with your top knee bent or kneel down as if you were prostrating. Look at the package insert in the kit to see a good image for this or click here.
- Remove the sheath from the tip of the enema catheter
- With steady pressure, insert the tip into the rectum using a side to side motion and aim the tip towards your belly button
- If it is painful or to hard to insert, stop, pull back and try again. If this is still too painful then call the urologist’s office to see what to do
- Once this has been inserted, squeeze the bottle all the way until the liquid is almost all gone
- Remove the catheter.
- You will likely need to have a bowel movement within a couple minutes
How is the prostate biopsy actually performed?
This is a procedure done in the urologist’s office. You will go to the procedure room and will be asked to lay down on your side.
The best positioning for this is to be in the fetal position with your knees scrunched up towards your chest. This sets up your pelvis in the best way to properly image the prostate.
Next is the tough part. The urologist will insert a probe, called a transrectal ultrasound probe, into your anus. This is the most uncomfortable part of the procedure but after it is inserted, usually that intense pressure feeling will go down.
The urologist will then use this probe to perform an ultrasound, which is a form of imaging, of the prostate and the structures next to the prostate. He/she will then inject numbing medication, or anesthetic, around the prostate. So you will feel a ‘poke and a burn’ while the anesthetic is being administered. Think of going to the dentist and when they numb up your mouth. You will feel that pinch and then some discomfort, but the actually numbing is a quick process and only takes a couple seconds.
While the anesthetic starts to work, the urologist will then take measurements and evaluate the prostate. He/she is looking to measure the size of the prostate, look for any ultrasound changes in the prostate, and evaluate the seminal vesicles which are structures that insert into the prostate and can sometimes be involved with prostate cancer.
Once the anesthetic has been in place, you will hear loud snapping sounds and will feel another sharp poke. This is the actual biopsy where samples will be taken.
On average, the urologist will take 10-12 of these samples or ‘cores’. Even though you have had the anesthetic, it will still hurt. All in all, the procedure should take 5-10 minutes depending on the urologist.
How will I feel after the prostate biopsy is over?
Surprisingly, the discomfort gets better pretty fast. The pressure feeling gets better almost immediately as the probe comes out. The afternoon after the biopsy you will have a pressure feeling in your pelvis, but many of my patients are able to work and go about normal daily activities afterwards.
Each patient is different, however on average, most people will see blood in his urine or when they wipe after a bowel movement for around 3-5 days.
If you masterbate or have sex, the ejaculate will look brownish or reddish for up to a month as the prostate heals from the biopsy. It’s safe to do both, just know that the color will look kinda alarming for the first several weeks.
How long does it take to get the results?
The urologist will typically see you back in 7-10 days and go over the pathology results. For full overview of how to interpret the biopsy, read this post.