Is a periprostatic block with local anesthetic (e.g. lidocaine or ropivacaine) standard for local prostate biopsy versus lidocaine jelly alone?

Periprostatic Block is Superior to Lidocaine Jelly Alone for Prostate Biopsy

Periprostatic nerve block with local anesthetic (lidocaine or ropivacaine) should be the standard anesthetic technique for transrectal ultrasound-guided prostate biopsy, as it provides significantly superior pain control compared to lidocaine jelly alone during the actual biopsy procedure. 1

Evidence Supporting Periprostatic Block

Guideline Recommendations

The NCCN Clinical Practice Guidelines explicitly state that periprostatic injection reduces pain during the biopsy itself, whereas topical lidocaine is more effective only for probe insertion pain. 1 These anesthetic techniques should be considered in all patients undergoing prostate biopsy, particularly with extended biopsy templates. 1

The Mayo Clinic Proceedings guideline from 2005 notes that a prospective study demonstrated the superiority of ultrasound-guided periprostatic nerve block versus lidocaine jelly enema, with 95% of patients reporting pain during prostate biopsy without adequate anesthesia. 1

Research Evidence Demonstrating Superiority

A meta-analysis of 16 randomized trials involving 1,276 subjects found that periprostatic block resulted in a weighted mean difference in visual analog pain scores of -1.66 (95% CI -2.03 to -1.29) compared to no block, representing a statistically and clinically significant reduction in pain. 2

Direct comparison studies consistently favor periprostatic block:

• Periprostatic infiltration with 1% lidocaine produced mean pain scores of 2.4 versus 3.7 with intrarectal lidocaine gel (p = 0.00002). 3
• Another randomized trial showed mean VAS scores of 1.4 with periprostatic anesthetic versus 4.5 in controls (p < 0.0001), with only 3.7% of patients receiving local anesthetic reporting moderate pain and none reporting severe pain. 4
• While lidocaine gel showed less pain during gel administration itself (VAS 0.1 vs 1.4), there was no significant difference in pain during the actual biopsy procedure (VAS 2.0 vs 2.1) between gel and periprostatic injection. 5

Optimal Anesthetic Approach

Combination Therapy Provides Best Results

The combination of perianal-intrarectal lidocaine-prilocaine cream plus periprostatic nerve block provides superior pain control compared to either modality alone (mean VAS 0.77 vs 1.27 for either single modality, p < 0.001), particularly in younger patients (≤65 years), those with larger prostates (>49 cc), and those with lower anorectal compliance. 6

Technical Considerations

• Periprostatic block should be administered via ultrasound guidance using a 7-inch spinal needle placed through the transrectal ultrasound biopsy guide. 4
• Lidocaine gel (15 mL of 2% concentration) should be administered intrarectally 10 minutes before the procedure to reduce probe insertion discomfort. 5
• The periprostatic injection should be given 4 minutes before biopsies to allow adequate time for anesthetic effect. 5

Clinical Context and Importance

Pain Without Anesthesia

Up to 96% of patients undergoing prostate biopsy report pain without anesthesia, with 28.6% reporting moderate pain and 28.6% reporting severe pain. 4 This significant discomfort historically led to attitudes against anesthesia use, but recent evidence has shifted clinical practice. 1

Safety Profile

Periprostatic block is relatively easy to administer and does not appear to be associated with increased morbidity. 2 No difficulty was encountered from scarring in patients who subsequently underwent nerve-sparing radical retropubic prostatectomy following local anesthetic injection. 4 The overall complication rate is similar regardless of anesthetic technique used. 6

Special Circumstances

For exceptional cases such as men with anal strictures or patients who receive inadequate pain block with periprostatic injection, intravenous sedation or general anesthesia may be necessary. 1 This becomes particularly important with saturation biopsy techniques (>20 cores), where some form of regional or general anesthesia is typically required. 1

Common Pitfalls to Avoid

• Do not rely solely on lidocaine gel, as it only addresses probe insertion pain and does not adequately control pain during the actual biopsy sampling. 1
• Allow adequate time for the periprostatic block to take effect (approximately 4 minutes) before proceeding with biopsies. 5
• Consider combination therapy rather than single-modality anesthesia, especially in younger patients or those with larger prostates. 6
• Do not assume that because the procedure is brief, anesthesia is unnecessary—the evidence clearly demonstrates significant pain reduction with proper anesthetic technique. 2