What Is a Prostate Biopsy?

What to expect when undergoing this test

A doctor may recommend a prostate biopsy if you have an elevated prostate-specific antigen (PSA) test or abnormal digital rectal exam, which can indicate prostate cancer. While screening tests may suggest there is a problem, a prostate biopsy is needed to make a prostate cancer diagnosis and determine the aggressiveness of the disease. In this procedure, a needle is inserted into the prostate gland (most commonly through the rectum) to obtain samples of tissue. This may be done randomly or with the guidance of imaging.

what to expect during a prostate biopsy
Illustration by Emily Roberts, Verywell

Purpose of Test

When a prostate-specific antigen (PSA) test and/or digital rectal exam are abnormal, a doctor needs to advance to a prostate biopsy in order view the prostate tissue and look for actual evidence of prostate cancer; screening tests are suggestive, but not definitive. The biopsy will also help set the course for treatment.

Reasons to do this test may include:

  • An elevated PSA test
  • An abnormality on a digital rectal exam, such as a lump
  • An abnormality on a transrectal ultrasound (TRUS)
  • When a previous prostate biopsy is negative, but the PSA test remains elevated

A prostate biopsy may also be done in men with known prostate cancer to look for progression of the disease.

Types

Prostate biopsies can vary both in the method used and the site where the biopsy is done.

In the past, a random 12-core biopsy was more commonly done. In this procedure, samples are taken from 12 random areas of the prostate gland.

Imaging tests with targeted biopsies are becoming more common and may have greater sensitivity, as well as fewer complications (though they are costlier). In these procedures, abnormal areas are first detected by the use of rectal ultrasound (TRUS), multiparametric MRI, or MRI-TRUS fusion (a combination of rectal ultrasound and mpMRI), and these abnormal regions are then selectively biopsied.

The most common biopsy is transrectal, in which the biopsy needles are introduced into the prostate gland via the rectum.

Another option is transperineal, in which an incision is made between the scrotum and rectum, and the biopsy needles are introduced into the prostate from this region. The transperineal approach may be needed if a doctor is suspicious about a cancer in the front of the prostate gland, or if a man has had previous rectal surgery.

Much less commonly, a transurethral approach may be used, in which the biopsy needles are inserted into the prostate gland from the urethra during a cystoscopy.

Limitations

Like many medical tests, a prostate biopsy can have both false negatives (results that are normal even though a cancer is present) and false positives (results that suggest a cancer is present when one is not).

With regard to false negatives, prostate biopsies miss about 20 percent of prostate cancers. Fortunately, most prostate cancers are slow growing, and if a PSA remains elevated, a repeat biopsy is often recommended. It's thought that MRI/targeted biopsies may enhance the accuracy of results and miss fewer cancers, but since this is a relatively new technique, there is a learning curve associated with its use.

The issue of false positives has led to significant debate and controversy in recent years. False positives (overdiagnosis) may result in overtreatment, which exposes men to challenging side effects without any benefit. It's thought that random biopsies, in particular, frequently overdiagnose harmless Gleason 6 tumors (see below).

Alternatives

Many men have wondered whether it is possible to substitute a scan for a biopsy. At the current time, multiparametric MRI (as well as some enzyme tests) may help reduce the number of unnecessary biopsies done, but a biopsy is still needed both to diagnose the disease and determine its aggressiveness.

Risks and Contraindications

As with other medical tests, a prostate biopsy carries potential risks, as well as reasons why the test should not be performed.

Potential Risks

Some of the risks of a prostate biopsy may be more of a concern for certain individuals than others, so be sure to discuss them with your doctor.

  • Difficulty passing urine: Some men may have difficulty or an inability to pass urine after the procedure, and a catheter may be needed until the swelling goes down (usually two to three days).
  • Rectal bleeding: Sometimes rectal bleeding may be excessive and require treatment such as surgery.
  • Infection: Local or body-wide infections (sepsis) may occur and are responsible for about 75 percent of hospitalizations in the 30 days following a prostate biopsy, making it the most common cause of being admitted for complications. Infections appear to be less common with MRI/targeted biopsies (because fewer samples are taken), but, at the current time, infections related to prostate biopsies are increasing.
  • With MRI/targeted biopsies, there is a rare risk of nephrogenic systemic fibrosis—a rare, sometimes fatal disease that affects the skin and organs—due to the contrast material used (gadolinium), but the risk is primarily of concern for men with very poor kidney function.

These potential risks need to be weighed against the potential benefit of the procedure. Since prostate cancer is usually slow growing, it's recommended that men not have a PSA test (and potentially a biopsy) if they aren't expected to live more than 10 to 15 years.

Contraindications

A relative contraindication to a prostate biopsy is the use of blood thinners that cannot be stopped for the procedure. When this occurs, the risk of bleeding during the procedure needs to be weighed against the risk of stopping the blood thinner. Never stop taking a prescribed medication without your doctor's OK.

A prostate biopsy should not be done in men that have a rectal fistula (an abnormal connection between the rectum and another region, such as the skin of the buttocks) or who no longer have a rectum due to surgery.

Before the Test

A major consideration before a prostate biopsy is if, and when, to do the test. It's important to talk to your doctor and make sure you understand the procedure, its risks, and possible benefits for you as an individual.

Your doctor will need to know about any medical conditions you have, and, if an MRI/targeted biopsy is planned, whether you have any metal in your body such as a pacemaker or joint replacement.

Timing

The actual prostate biopsy procedure takes only 10 to 20 minutes, but you should plan on setting aside at least a few hours for the test. This will include time to fill out forms, receive the contrast dye (if applicable), and for a nerve block and/or local anesthesia to be given.

Location

Prostate biopsies are usually performed in the radiology department of a hospital or urology clinic.

What to Wear

You will be asked to change into a gown during your procedure, but it's a good idea to wear loose slacks and loose underwear or boxers for after your biopsy. If you will be having an MRI or MRI-TRUS fusion biopsy, you will want to avoid wearing any items with metal, such as a watch.

Preparation

Though there is some controversy over the benefit, most doctors will instruct you to use an enema either at home or at the office to prepare for your biopsy. The timing of this can vary, with some physicians recommending an enema the night before and others recommending this be done two hours or less before the procedure.

Food and Drink

Most physicians advise drinking only clear liquids on the morning of the procedure. It's also important to drink a large amount of water or other clear fluids in the hours leading up to your test. A full bladder can make it easier for your doctor to visualize your prostate and surrounding structures on ultrasound.

Medications

You should give your doctor a full list of any medications you may be taking, especially any blood thinners (anticoagulants or anti-platelet drugs). Drugs such as Coumadin (warfarin), Plavix (clopidogrel), aspirin, heparin, and more can increase the risk of bleeding during a biopsy. You may be advised to stop these, but make sure to talk to the doctor that prescribed the blood thinners.

Keep in mind that some over-the-counter drugs, as well as dietary supplements, can act as blood thinners as well, and it's important to talk to your doctor about any of these preparations you are taking.

In addition to your regular medications, most physicians will prescribe a short course of antibiotics to be started the night before or the morning of your biopsy.

Cost and Health Insurance

Most private health insurance companies, as well as Medicare, will cover the cost of a prostate biopsy, though coverage may vary with the particular procedure. In some cases, you may need to obtain prior authorization before the test, especially with the newer procedures such as MRI-TRUS fusion biopsies.

The cost of a prostate biopsy can be challenging to figure out, as you may be billed separately for the procedure, labs, and pathology. According to a 2017 review, the average cost of a random 12-core biopsy was $6,521, and that of an MRI-TRUS fusion with targeted biopsy, $16,858.

When looking at this cost difference, however, it's important to consider other costs as well. An MRI-TRUS fusion procedure is more sensitive, and it's less likely that you would need a repeat biopsy after having one. In addition, men who have the MRI-TRUS fusion with targeted biopsy have a lower incidence of sepsis. Not only is sepsis a life-threatening infection, but it can result in a costly hospitalization.

For those who do not have insurance, your physician or a social worker at your clinic can help you explore options. Some clinics offer a reduced cost when a payment plan is set up prior to the procedure. If it is likely that your biopsy will show cancer, a cancer organization may also be able to help you find some type of financial assistance for people with cancer.

What to Bring

If you can, bring along someone to take you home in the event you are given any medications for pain or sedation that affect your ability to drive.

Other Considerations

When arranging your prostate biopsy, it's helpful to have someone you can talk to about what the test might mean for you and how you are coping emotionally. The uncertainty of not knowing what a prostate biopsy might show is sometimes as difficult to cope with as a diagnosis of prostate cancer.

During the Test

When you have your prostate biopsy, there will be a number of people present. A radiology technician and/or nurse, a doctor who treats prostate cancer (usually a urologist), and often a radiologist.

Pre-Test

When you are ready for your biopsy, you will be asked to sign an informed consent form. This form indicates that you understand the purpose of the biopsy as well as any potential risks. A urine test will be checked to make sure there is no evidence of an infection; if there is, the test may need to be delayed. You may also be given antibiotics 30 to 60 minutes before the procedure if you did not receive them the night before the test.

For those who will be having an MRI procedure, gadolinium contrast will be given (gadolinium is usually safe for people with allergies to contrast dye). A blood test to check your kidneys may also be done due to the rare gadolinium reaction that may occur in people with kidney disease. A technician will again confirm that you don't have any metal on your body or reasons why an MRI cannot be done.

During this time, your doctor will also talk about pain control during the procedure. Physicians vary in their approach to controlling discomfort due to a prostate biopsy, with options including injected lidocaine, topical lidocaine gel, a periprostatic or pelvic plexus nerve block, and/or oral pain medications such as Ultram (tramadol).

With a nerve block, anesthesia is injected near the nerves supplying the prostate to numb a larger region of tissue. A 2014 study looking at lidocaine versus a periprostatic nerve block found that a combination of both provided better pain control than either method used alone. According to a 2017 study, a pelvic plexus nerve block may be even more effective than a periprostatic block.

Throughout the Test

Once you get into the procedure room, your doctor will instruct you to lay on your side (usually your left side) with your knees pulled up to your chest.

With a transrectal biopsy, the area around your rectum will be cleaned with an antiseptic and a local anesthetic (lidocaine) will be injected or placed on the rectal wall. A periprostatic nerve block or pelvic plexus block may also be done. If so, you may feel a sharp pinch with the injection of anesthetic.

A thin, lubricated ultrasound probe will then be placed into your rectum in order to obtain an image of the prostate and surrounding structures, and it will be left in place during the procedure. With an MRI procedure, an endorectal coil (a metal wire covered with latex material) will be inserted into the rectum.

The biopsy specimens are then taken by inserting very thin, spring-loaded hollow needles into the prostate. In a random biopsy, samples from 12 areas of the prostate will be taken to be sure that the whole prostate is checked for cancer. With an MRI or MRI-TRUS procedure, selective biopsies will be taken from areas that appear abnormal on the imaging test. It is normal to have some pain and discomfort for a moment as the biopsies are being taken, despite the numbing medication. From start to finish, the whole procedure usually lasts no more than 20 minutes.

A transperineal procedure is similar, but the skin between the scrotum and rectum is cleaned and anesthetized and biopsies taken through this region after making a small incision.

A transurethral approach is somewhat different and is often done in the operating room under general anesthesia. A cystoscope is inserted into the urethra and biopsies are done through the wall of the urethra.

Post-Test

When the procedure is done, the ultrasound probe or endorectal coil will be removed and the biopsy samples sent to a laboratory where a pathologist will determine if cancer or another condition is present. You can then head home with your driver companion or hired transportation.

After the Test

Your physician will give you specific instructions about what you need to do after your procedure, but you will usually be allowed to return to a normal diet and normal bathing practices when you return home. It's a good idea to drink extra water over the first few days to clean out your urinary system.

You may also be advised to continue taking a course of antibiotics until completed. If you were on blood thinners that were stopped for the procedure, you will probably be asked to hold off on resuming these for at least a few days.

Managing Side Effects

After your biopsy, you may have some rectal soreness for a few days. This can be alleviated with warm soaks or compresses to the area. Some men experience light bleeding or spots of blood in their stool or urine. If the amount of bleeding is small and it stops after a few days, this is considered normal. Spots of blood in semen are also common and may persist for several weeks after the biopsy.

You should call your doctor if you notice any moderate or heavy bleeding (more than a teaspoon at a time) from your rectum, bladder, or in your semen. You should also see your doctor right away if you experience fever or chills, significant abdominal or pelvic pain, difficulty passing urine, or non-specific symptoms such as lightheadedness or dizziness.

Interpreting Results

The results of a prostate biopsy usually take two to three days to come back, and your doctor may deliver them over the phone or ask you to come in for a consultation.

The report will include:

  • The number of biopsy samples taken
  • Whether the samples are negative, have benign findings, are suspicious (and if so, why), or cancer
  • If cancer is present, the percent of cancer in each of the samples
  • The Gleason score, which indicates the cancer's aggressiveness

Let's look at the possible sample results in greater depth.

Negative

A negative biopsy means that there is no evidence of benign changes, suspicious looking cells, or cancer cells in the area biopsied.

Benign Changes

There are a number of benign findings that may be noted on a biopsy. Some of these include:

  • Atrophy: Atrophy (including focal atrophy or diffuse atrophy) simply refers to the shrinkage of prostate tissue and is common in men who have had hormonal therapy.
  • Inflammation: Both chronic or acute prostatitis may be noted.
  • Adenosis: Atypical adenomatous hyperplasia, or adenosis, is another benign finding.

Suspicious

It's not uncommon for cells on a biopsy to be in the gray area between normal and cancer. These cells do not look entirely normal, but don't have all the characteristics of cancer cells either. Some conditions that may result in a suspicious biopsy include:

  • Prostatic intraepithelial neoplasia (PIN): PIN may be considered either high grade or low grade. Low-grade PIN is similar to a negative biopsy in many ways, with the cells mostly appearing normal. With high-grade PIN, there is a 20 percent chance that cancer is present somewhere in the prostate gland.
  • Glandular atypia: Atypical glandular proliferation or atypical acinar cell proliferation means that it looks like cancerous cells are present, but there are only a few of them. With glandular atypia, there is often a good chance that cancer is present somewhere in the prostate.
  • Proliferative inflammatory atrophy: This refers to the finding of inflammation and small cells on one of the samples, and is linked with a higher risk of developing prostate cancer in the future.

Cancer

If there is evidence of cancer on a biopsy specimen, the report will include a notation regarding the percent of cancer present in each of the samples. In order to determine the aggressiveness of a prostate cancer, and hence, the most appropriate treatment options, biopsies are also given a Gleason score and a grade score after further evaluation.

Gleason Score

The Gleason score is determined by looking at the prostate cancer cells in two different areas of the tumor and assigning each a grade of 1 to 5 based on what they look like under the microscope. A score of 5 indicates that the cells are highly abnormal appearing (poorly differentiated), whereas a score of 1 means the cells look very similar to normal prostate cells (well-differentiated). Note: Scores of 1 and 2 are usually not recorded.

Two samples are used as prostate cancers are often heterogeneous, meaning that different parts of a tumor may be more aggressive than others. These two scores are added together to get the final Gleason score:

  • Gleason 6: Defines low-grade cancer in which the cells appear much like normal prostate cells; tumors are unlikely to grow or spread.
  • Gleason 7: Defines medium-grade cancers; cells are moderately abnormal appearing.
  • Gleason 8 to 10: Considered high-grade cancers that are more likely to grow and spread; cells appear very different from normal prostate cells.

It's important for men to understand that "low-grade" cancers often behave like normal tissue, and there is controversy over whether these tumors should even be called cancer.

Grade Group

Using Gleason scores, prostate cancers are also placed into grade groups:

  • Grade group 1: Gleason 6 tumors
  • Grade group 2: Gleason 7 tumors that are made up of primarily well-formed glands
  • Grade group 3: Another type of Gleason 7 tumors that are primarily made up of poorly-formed glands
  • Grade group 4: Gleason 8 tumors
  • Grade group 5: Gleason 9 and Gleason 10 tumors

Follow-Up

The recommended follow-up after your biopsy will depend on the results of your test.

While a negative result is reassuring (there is an 80 percent to 90 percent chance you do not have prostate cancer), it does not guarantee that prostate cancer isn't present in areas that were not biopsied. If your PSA is very high or remains high, a repeat biopsy may be recommended.

With benign findings, your doctor will discuss what these mean, but most often follow-up will be the same as with a negative result. (Prostatitis found on a biopsy does not usually require treatment.)

If suspicious findings are noted, next steps will depend on exactly what is seen. With low-grade PIN, follow-up is essentially like that of a negative biopsy. But for high-grade PIN or glandular atypia, a repeat biopsy in a few months may be recommended.

If cancer is found, follow-up and treatment will depend on the Gleason score. For lower scores, a period of watchful waiting/active surveillance may be recommended, whereas with a high Gleason score, immediate treatment with surgery or radiation therapy may be the best option.

As far as PSA tests and digital rectal exams after a prostate biopsy go, recommendations will vary. In the past, with a negative biopsy, screening tests were usually recommended a year after the procedure. But there is significant controversy over this practice today, and different organizations have different recommendations.

With a biopsy result that suggests an increased risk of prostate cancer in the future, some physicians may recommend getting a PSA test in three to six months, but again, this will vary. With prostate cancer, the frequency of testing will depend on the Gleason score, treatments, and more.

A Word From Verywell

Scheduling and then receiving the results of a prostate biopsy can cause a tremendous amount of anxiety, especially with prostate cancer being the most commonly diagnosed cancer in men. Taking time to educate yourself about both the diagnosis and treatment of prostate cancer can help you feel more in control, and is even more important amidst the controversy surrounding options. Being your own advocate can begin with discussing diagnostic concerns such as the difference between and random and targeted biopsies, as well as the best options for pain control during the biopsy.

Finding an experienced physician is just as important as choosing the best treatment if your biopsy shows cancer, and getting a second opinion—even if you are comfortable with a proposed treatment plan—is not only encouraged, but expected. Seeking out an opinion at a National Cancer Institute-designated cancer center can help ensure you have the opportunity to talk with physicians who are familiar with the latest advances in treatment.

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