Intrarectal Lidocaine Jelly Alone is Insufficient for Transrectal Prostate Biopsy
Intrarectal lidocaine gel alone does not provide adequate pain control during transrectal prostate biopsy and should not be used as the sole anesthetic technique. The NCCN guidelines explicitly state that topical lidocaine is more efficacious only for reducing pain during probe insertion, whereas periprostatic injection reduces pain during the actual biopsy itself, and these anesthetic techniques should be considered in all patients 1.
Evidence Against Lidocaine Gel as Monotherapy
Guideline Recommendations
The NCCN Clinical Practice Guidelines advise against relying solely on lidocaine gel, as it only addresses probe insertion pain and does not adequately control pain during the actual biopsy sampling 2.
The guidelines emphasize that periprostatic injection is superior for pain control during the biopsy procedure itself, particularly with extended biopsy templates 2.
Comparative Research Evidence
A prospective study demonstrated the superiority of ultrasound-guided periprostatic nerve block versus lidocaine jelly, with 95% of patients reporting pain during prostate biopsy without adequate anesthesia 2.
A randomized controlled trial of 100 patients comparing intrarectal lidocaine gel versus periprostatic nerve block found that periprostatic block provided significantly lower pain scores (DVS score 2.15 vs 2.5, p < 0.001), demonstrating that lidocaine gel alone is insufficient 3.
Another randomized trial of 473 patients showed mean pain scores during biopsy (VAS-2) were significantly higher with intrarectal lidocaine gel alone (4.54 ± 1.02) compared to periprostatic nerve block plus gel (2.06 ± 0.79, p = 0.001) 4.
The Role of Lidocaine Gel in Combination Therapy
While lidocaine gel alone is insufficient, it does provide additive benefit when combined with periprostatic block:
A randomized trial of 203 patients found that adding intrarectal lidocaine gel before periprostatic nerve block produced a significant additional analgesic effect during biopsy (p < 0.01) 5.
The procedure is simple, safe, and rapid, and should be considered in all patients undergoing transrectal ultrasound-guided prostate biopsy as an adjunct to periprostatic block 5.
Recommended Approach
The optimal pain management strategy combines both techniques:
Apply 10 cc of 2% intrarectal lidocaine gel 5-10 minutes before the procedure to reduce probe insertion pain 6.
Follow with periprostatic nerve block using 1% lidocaine solution injected bilaterally at the prostate apex to control pain during needle sampling 3, 4.
For exceptional cases (anal strictures, inadequate pain control with periprostatic injection, or saturation biopsies >20 cores), consider intravenous sedation or general anesthesia 1, 2.
Common Pitfalls
Do not use lidocaine gel as the sole anesthetic agent - this leaves patients with inadequate pain control during the most painful part of the procedure (needle sampling) 2.
Up to 90% of men report discomfort during prostate biopsy, making adequate anesthesia essential for procedure acceptability 1.
The combination approach addresses pain at all procedural steps: probe insertion (gel), nerve block injection (gel), and biopsy sampling (periprostatic block) 5.