FAQ: Prostate Biopsy, Prostate exam (DRE) and Gleason Scores
1. Q: What is involved in a prostate biopsy?
A: A prostate needle biopsy is not a pleasant experience, but it is not that bad either because prostate biopsies are now done with local anesthesia. You prepare for it by taking antibiotics by mouth and a Fleets enema before going to the doctor’s office. You lie on your left side and the doctor does a digital rectal examination of the prostate gland and then inserts the ultrasound probe into the rectum. The doctor injects a local anesthetic through the probe into the tissues on each side of the prostate – and then scans are taken of the prostate gland from several angles.
The volume of the prostate gland is measured from the scans. After the local anesthetic has had a chance to work, a biopsy gun is used to take 12 to 20 or more biopsy cores through the ultrasound probe. You can feel the manipulation and the clicking, but you should not feel pain. You take antibiotics for two days after the biopsy procedure. Complications such as fever and heavy bleeding occur in fewer than 1% of patients. You might have blood in your urine, bowel movements, and ejaculate for days or weeks following the procedure. Patients may resume normal activity after the procedure but should take it easy for 24 to 48 hours.
2. Q: How long should the urologist wait after administering the local anesthetic before taking biopsy samples?
A: The longer the better, but at least 5 minutes. If the anesthetic is injected at the beginning of the ultrasound scan procedure, a good time to begin the biopsy sampling is after all the scans have been printed and measurements taken.
3. Q: Does needle biopsy of the prostate spread prostate cancer cells?
A: Evidence suggests the answer is no. And countless patients have been cured of prostate cancer after having had many needle biopsies.
4. Q: How soon after ultrasound and rectal needle biopsies can a man have sex?
A: We recommend waiting for one week. It is not uncommon for blood to be in the semen weeks to months after biopsy, but this blood is not harmful to either sexual partner.
5. Q: Why do men need a digital rectal examination (DRE) if they take the PSA blood test?
A: Some very early cancers can be felt on a rectal exam before they cause the PSA level to be elevated. Other cancers will elevate the PSA level before they can be detected on the rectal exam. To maximize the accuracy of screening, it’s best to have both the test and the examination. In addition, some high-grade or Neuroendocrine forms of prostate cancer do not produce much PSA. They can be detected on the DRE before the PSA becomes elevated.
6. Q: What are grade levels for prostate cancer? What is a Gleason grade?
A: Prostate cancers when looked at under the microscope can look like normal prostate tissue or they can look wild and disorganized. When these disorganized-looking cells (cancer cells) are found, they are graded on a scale called the Gleason grade of between 2 and 10. Two is the very best – a low grade, slow growing prostate cancer. Ten is the worst – a rapidly progressing, very aggressive prostate cancer. It turns out that only about 10 percent of tumors are grade 2, 3, and 4; 10 percent are 8, 9 and 10; and the vast majority are Gleason grades 5, 6 and 7.
7. Q: Should a biopsy of the prostate be done at the same time a TURP is performed to relieve symptoms of an enlarged prostate?
A: A biopsy should normally be performed before the procedure, because, if the patient has prostate cancer, the TURP might complicate the subsequent treatment with surgery or radiation.
8. Q: My doctor says that he is going to take a 12-core biopsy and that he will use anesthetic for the procedure. How does the anesthetic work?
A: The need for repeat prostate biopsies was a common occurrence in men with elevated PSA levels or a suspicious digital examination whose initial biopsies did not show prostate cancer. Now, with the ability to perform a local anesthetic block of the prostate, more biopsy cores are obtained with less discomfort to the patient. Using this technique, it is likely that fewer cancers would be missed on initial biopsy sessions and the need for repeat biopsies decreases. Men should confirm that their biopsy will be done with a local anesthetic and that at least 12 biopsy cores will be taken. The urologist should wait at least 5 minutes after administering the local anesthetic before taking biopsy samples, but the longer the better. If the anesthetic is injected at the beginning of the ultrasound scan procedure, there is usually good anesthesia by the time that all of the scans have been printed and measurements have been taken.
9. Q: What is the best thing to do in handling the pain of a biopsy? I have heard of two options: A gel absorption method and an injection method to the nerve bundles.
A: An injection is far more effective.
10. Q: What is meant by a soft prostate?
A: The normal prostate is soft and spongy, so a soft prostate is a benign-feeling prostate. With cancer, the prostate often becomes hard and unyielding. A "doughy" prostate sometimes refers to a swollen, congested prostate that can occur with inflammation.
11. Q: How or can a doctor tell if prostate cancer is confined to the prostate from a biopsy if the biopsy doesn't include tissue surrounding and outside the prostate?
A: One cannot tell for certain. The doctor is guided by the findings on digital rectal examination, trans-rectal ultrasonography performed in conjunction with the biopsy, abdominal-pelvic CT or MRI scan, bone scan, PSA level, Gleason grade, and amount of cancer present in the biopsy cores. Taken together, and sometimes used in tables or nomograms, they provide a fairly accurate estimate of whether the tumor is confined.
12. Q: Why can't an MRI be used to confirm prostate cancer instead of a biopsy?
A: There is no imaging study, including PET scan, MRI scan or spectroscopy that can identify microscopic prostate cancer with the same degree of certainty as a biopsy. Since critical treatment decisions often follow biopsy results, biopsy remains the gold standard for prostate cancer diagnosis.
13. Q: My husband's doctor found a nodule on his prostate gland during a routine physical. His PSA test was not elevated. So, his physician advised him to wait six months and if the nodule is still there, he'll order a biopsy. Is it risky to wait for a biopsy?
A: It is risky to wait for a biopsy, even if the PSA test is low. (See other questions and articles on this site relating to the importance of the digital rectal exam.) There are some prostate cancers that can be very aggressive but do not produce much PSA. The only hope of diagnosing these cancers are through a digital rectal examination and appropriate follow-up. Accordingly, I would not advise waiting 6 months to see whether the nodule is still present.
14. Q: Could the PSA go up for a certain time after a prostate biopsy due to inflammation?
A: Yes, always. Sometimes it can remain elevated for many months.