Korean J Radiol.  2014 Oct;15(5):543-553. 10.3348/kjr.2014.15.5.543.

Pain during Transrectal Ultrasound-Guided Prostate Biopsy and the Role of Periprostatic Nerve Block: What Radiologists Should Know

• Nazir B

• KMID: 1734940
• DOI: http://doi.org/10.3348/kjr.2014.15.5.543

Abstract

Early prostate cancers are best detected with transrectal ultrasound (TRUS)-guided core biopsy of the prostate. Due to increased longevity and improved prostate cancer screening, more men are now subjected to TRUS-guided biopsy. To improve the detection rate of early prostate cancer, the current trend is to increase the number of cores obtained. The significant pain associated with the biopsy procedure is usually neglected in clinical practice. Although it is currently underutilized, the periprostatic nerve block is an effective technique to mitigate pain associated with prostate biopsy. This article reviews contemporary issues pertaining to pain during prostate biopsy and discusses the practical aspects of periprostatic nerve block.

Keyword

Prostate cancer; Transrectal ultrasound; Transrectal ultrasound guided prostate biopsy; Periprostatic nerve block

MeSH Terms

*Biopsy, Needle
Humans
Lidocaine
Male
*Nerve Block
Pain Measurement
Prostate/anatomy & histology/*surgery/ultrasonography
Prostatic Neoplasms/*pathology/ultrasonography
Ultrasound, High-Intensity Focused, Transrectal
Lidocaine

Figure

• 

  Fig. 1 Dentate or pectinate line. Dentate or pectinate line is located within anal canal just above level of anal crypts/valves (arrowheads). It is watershed junction between splanchnic and somatic innervations of ano-rectum. Above this line, there is predominantly splanchnic innervation and mucosa is relatively insensitive to pain, while segment below this line is extremely pain-sensitive due to somatic innervation via inferior rectal nerve.

• 

  Fig. 2 Neurovascular supply of prostate gland. Prostate gland receives sensory and autonomic fibers from sacral 2-5 caudal nerve roots and sympathetic chain via presacral and hypogastric neural plexuses. Along with branches of inferior vesical artery and dorsal vein, they form neurovascular bundles at base and apex of prostate gland. Branches ramify between capsule and Denonvillier's fascia and decussate extensively to form prostate plexus around prostate gland.

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  Fig. 3 Axial anatomy at level of base of prostate. Major neurovascular bundles are located at 5 and 7 o'clock positions (arrows) of base of prostate when viewed in transverse plane. In axial section, they are located between levator ani (LA) muscle and prostate capsule. For bi-basal periprostatic nerve block, needle is directed towards these sites under ultrasound guidance and local anesthetic agent is deposited around bundles.

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  Fig. 4 Bibasal injection. A. Ultrasound image in parasagittal plane showing triangular echogenic "Mount Everest sign" at site of neurovascular bundle (*). B. Schematic diagram demonstrating site of bi-basal injection in parasagittal plane (arrow). C. Parasagittal ultrasound image with biopsy trajectory guide-lines (dotted lines) to direct needle passage during bi-basal injections.

• 

  Fig. 5 Axial anatomy at level of apex of prostate. At apex, thinner neurovascular bundles are located between levator ani muscle and apex of prostate (arrows). These bundles are targeted by bi-apical periprostatic nerve block. Periprostatic nerve block needle and biopsy needle traverse rectal mucosa below level of dentate line, thus resulting in intense pain during apical biopsy.

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  Fig. 6 Optimal position of ultrasound transrectal transducer with biopsy-guide attachment for periprostatic nerve block. Tip of ultrasound transducer is pressed against prostate and anterior rectal mucosa. Transducer is manipulated to direct needle towards neurovascular bundles at base and apex of prostate (circles) and local anesthetic drug is injected around bundles.

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