Anorectal application of 5% lidocaine cream reduces pain prior to periprostatic nerve block during transrectal ultrasound guided prostate biopsy: Randomized, prospective controlled study

Objectives: Trans rectal ultrasound guided prostate biopsy with periprostatic nerve block (PPNB) is performed following probe insertion and manipulation leaving these initial maneuvers uncovered in terms of pain control. We evaluated whether topical analgesia reduces pain during early stages of the procedure. Patients and methods: Seven group prospective, randomized controlled study: groups 1–3: nerve block with 5 ml 1% lidocaine bilaterally plus perianal topical application of 10 ml 5% lidocaine cream. Groups 4–6 as in 1–3 plus digital application of 10 ml 5% lidocaine cream internally on rectal walls. For each approach exposure times were 5 (groups 1 and 4), 10 (groups 2 and 5) and 20 (groups 3 and 6) min, respectively. The control group (7) received PPNB only. Patients filled a 0–10 visual analogue scale (VAS) at five points: after probe insertion, during probe manipulation, following PPNB, after prostate biopsies and a global pain estimation. Results: Two hundred and fifty-two patients were enrolled. Significant differences in VAS between all study groups and controls were observed at the pre-biopsy stages of the procedure. In multivariate analysis adjusted for prostate specific antigen, diabetes mellitus status, spinal disease, abnormal digital rectal examination and non- benign prostate hyperplasia histology, significance remained for probe insertion and intra-rectal manipulation. For each exposure time no significant differences were observed between topical application and topical + intra-rectal application. After PPNB, differences between study and control groups disappeared. Conclusion: Topical anesthesia significantly reduces pain during early stages of prostate biopsy. Perianal application sufficed whereas intra-rectal application of local anesthetics does not add to pain control. Perianal application for 10 min seems to be optimal.