Effects of prostate biopsy on voiding and erectile function

A new study from a German research group is likely to fuel concerns about some of the risks associated with prostate biopsy.

This newly published study by Klein et al. reports on the adverse effects associated with multiple core prostate biopsy, and most particularly the effects on voiding of urine and erectile function in the 3-month period immediately following biopsy. Additional commentary is also available in a Reuters Health report on the Yahoo News web site.

Klein et al. report on information gathered from a series of 198 men who received prostate biopsies with local (lidocaine) anesthesia between September 2008 and January 2009. The patients were categorized into one of three groups:

  • Patients in Group 1 ( n = 71) all received a standard 10-core TRUS-guided biopsy.
  • Patients in Group 2 (n = 74) all received a standard 10-core TRUS-guided biopsy but with a periprostatic nerve block (using prilocaine hydrochloride).
  • Patients in Group 3 (n = 53) all had a history of prior negative biopsy and received a 20-core saturation biopsy with a periprostatic nerve block (again using prilocaine hydrochloride).

Eighty of the original 198 patients were diagnosed with prostate cancer based on their biopsy results and were therefore excluded from further analysis of the complications of biopsy since most went on to receive some form of therapy that is known to affect erectile and voiding function (even if only transiently).

The basic results of this study are therefore based on the 118 patients who had a negative biopsy, as follows:

  • Compared to pre-biopsy levels, the median International Prostate Symptom Score (IPSS) was significantly increased in all patients at 1 week post-biopsy.
  • This effect was still evident at 4 weeks and 12 weeks post-biopsy among the patients in Group 3 (the saturation biopsy patients).
  • Compared to pre-biopsy levels, patients in Group 2 also had a higher median IPSS score at 4 and 12 weeks post-biopsy, but this effect was not statistically significant.
  • Compared to pre-biopsy levels, the median International Index of Erectile Function (IIEF-5) score was significantly decreased in all patients at week 1 post-biopsy.
  • This effect was still evident at 4 weeks post-biopsy in Groups 1 and 2 but (perhaps surprisingly) not in Group 3.
  • Quality of life was significantly affected at all times after biopsy for patients in Group 3.

The authors conclude that prostate biopsy causes impaired voiding function in all patients, but particularly in those who receive a periprostatic nerve block and/or a saturation biopsy, where the effect appears to last for several weeks. In  addition, prostate biopsy also affects erectile function, regardless of the use of periprostatic function or the number of biopsy cores.

This paper includes a significant amount of more detailed information. Like some other recent papers it appears to give us much greater insight into issues that have rarely been addressed before but which have significant potential to impact the appropriateness and the frequency of the use of prostate biopsy in individuals.

It has been well understood that prostate biopsy comes with a variety of risks, among them being risks for intraprostatic bleeding and hematuria, pain, and infection. The association of prostatic biopsy with voiding dysfunction has been studied in the past, but these have been very few data on the risk for erectile dysfunction.

This study would seem to suggest that voiding dysfunction and erectile dysfunction are generally temporary, short-term complications of a prostate biopsy. However, The “New” Prostate InfoLink would concur with the authors of this article that patients need to be made aware of the potential complications of prostate biopsy before agreeing to this procedure. Most importantly, patients undergoing saturation biopsy need to be fully informed about the risk for prolonged difficulty with voiding of urine. With these reservations, TRUS-guided biopsy remains a relatively well-tolerated procedure that is essential for the appropriate diagnosis of localized prostate cancer at the present time.

12 Responses

  1. Great!

    The ““New” Prostate InfoLink” found a new reason to oppose biopsies. Is the opinion of the “New” Prostate InfoLink” that several weeks of erectile dysfunction warrant incurring the risk of NOT detecting prostate cancer?

    The study makes no mention of the “variety of risks, among them being risks for intraprostatic bleeding and hematuria, pain, and infection” that’s The “New Prostate InfoLink” mentions.

    A large number of posts seem to be intended to discourage men from taking action to diagnose prostate cancer early by taking PSA tests and, if necessary biopsies.

    I am at loss to understand why a site dedicated to fighting prostate cancer will take such a tack.

    Perhaps Sitemaster would kindly explain his position.

  2. Dear Reuven:

    You are putting words in our mouth that we have never expressed and you are making assumptions that are not based on fact.

    First, the comment about “variety of risks, among them being risks for intraprostatic bleeding and hematuria, pain, and infection” comes from the full article in the Journal of Urology — which we have access to but which is not available unless you have a subscription to the journal. We would point out that these are well known and common complications of prostate biopsy. We are sorry if you were not aware of this.

    Second, we absolutely don’t state that men shouldn’t have biopsies. We state the results of a study carried out by a German research team that apparently specializes in the management of prostate cancer and bring the results of this study to the attention of the reader.

    Our opinions are restricted to two statements. The first is at the beginning, where we state that the data from this study “is likely to fuel concerns about some of the risks associated with prostate biopsy.” Don’t you think people like Dr. Brawley will use this study to express their opinion that prostate cancer is “over-diagnosed?” The second is at the end, where we express the opinion that patients should be aware of the risks associated with biopsies before they have them. Don’t you think patients should be well informed?

    We have absolutely no desire to “oppose biopsies.” The last sentence of the commentary above clearly states that “TRUS-guided biopsy remains a relatively well-tolerated procedure that is essential for the appropriate diagnosis of localized prostate cancer at the present time.” We do, however, wish to ensure that any patient considering any form of procedure does so with all relevant information he or she cares to seek. And we have long been warning patients of the risks associated with saturation biopsies and overly frequent multiple biopsies.

    Being an advocate for the appropriate and sound diagnosis and management of prostate cancer does not necessarily equate to the belief that every man over 30 with a PSA of 2.5 ng/ml should get a biopsy tomorrow, let alone multiple repeat biopsies if the first one happens to be negative.

  3. My husband had a biopsy for an elevated PSA 6 years ago. Thankfully it was negative. However, he has not been able to urinate since.

    After many emergency room trips he has learned to catheterize himself. Neither his urologist, surgeon, or specialist has found the problem. He catheterizes himself 6-8 times a day. Our insurance company (Humana) has refused to pay for his catheters due to no clear diagnosis.

    His PSA is once again elevated. His urologist is suggesting another biopsy. I prefer he have the EPCA-2 blood test.

  4. I would suggest you ask for (a) a free PSA test and (b) a PCA3 test before doing anything else. These should be covered by insurance. The EPCA-2 test is not (as far as I am aware) commercially available, and there are questions about its value.

    You also ought to be able to get your insurance company to pay for the catheters. Try contacting the office of your state commissioner for health insurance. The fact that there is no diagnosis of the problem doesn’t mean that there isn’t a clinical need. The problem is simple: inability to normally express urine. Tell your primary care physician that you need help appealing this decision.

  5. Regardless, this is a valuable post for men just having a biopsy….

    Three weeks ago I had a 12-core biopsy that unfortunately (fortunately?) was 5-core-positive for prostate cancer (Gleason 6). Last week I developed urination frequency problems following the biopsy and I am hopeful that this is a transient matter as a result of the biopsy. This article seems to point in that direction and, for that, this article is very useful to men. Though my urologist explained the possible complications of bleeding, I don’t remember him telling me about frequency issues with urination. This article helps in that regard and hopefully men having this procedure will be informed of this. Thanks for posting this … and I would have the biopsy again or, otherwise, how would I know and seek further treatment. This article does not dissuade me one bit from that.

  6. I had a 10-core prostate biopsy with spinal pain medicine 1.5 years ago which was negative, and I continue to experience complete erectile dysfunction. I am only 58 years old and used to love sex with my wife, but the ED has caused us to have intimacy issues, and we may separate. Now I wish I had just died from prostate cancer.

    The uologist who performed the biopsy reminded me that I read and signed the release that had side effects listed, but he does not see any possible treatment to repair the damage done to my nerves during the procedure.

  7. Dear John:

    I think you need to go see a urologist who specializes in sexual function issues. While you may not be able to recover the ability to have spontaneous erections, there are almost certainly things that could be done to allow you to recover sexual functionality.

  8. Hi John:

    I feel the same way and I thought I was alone in this. If you enjoy sex with your wife, becoming sexually dysfunctional is like a death blow that lingers for ever. Like you, I should never have had a prostate biopsy and wouldn’t be bothered if it was the cause of my death. Studies reveal that a large number of men die from other causes and never knew they had prostate cancer. With a 20% rate of detection, prostate biopsies are a medieval procedure and more like a fishing expedition. Making me miserable because you are looking for a disease that I don’t even have makes no sense to me. I can’t roll back the clock, but other men should be cautioned. There are other more targeted procedures that may not have such devastation consequences on your quality of life. What I am going through now is not living. I am 63 years old and retired but I can’t do the things I wanted to retire early to do. Most of the enjoyment in life revolves around loving and being loved. Without it, nothing matters, not even life.

    I am sorry that you are going through a separation from the love of your life because some doctor was not sensitive enough to properly advice you. Right now, my marriage does not look too good either, but I am hoping something will come along and save it. God bless you.

  9. Had a 12-point biopsy a week ago and since have had three catheters inserted as, after removal of first two, urine build-up was excessive and very painful (going to toilet every 7 min and little coming out).

    Wondering now how long before swelling subsides enough to not have a catheter. Doing my head in at the moment as catheterizing is not pleasant and getting more painful with each one (albeit the relief as urine pours out is instant).

    Now kind of wish I’d skipped the biopsy as MRI showed no cancer and have had regular PSA tests. (The last one was 1.7). The biopsy was an added precaution.

    My problem is just enlargement of my prostate that is squeezing the urethra and making urination slow to difficult. On Duodart for past 6 months and that has helped — now looking at “rebore” or Urolift so I can get off Duodart.

  10. Dear Ian:

    Alas, I am in no position to be able to tell you exactly why: (a) your urologist didn’t just do the “rebore” as opposed to giving you what sounds like a not particularly necessary biopsy or (b) how long it will be before your prostate inflammation dies back down for you to avoid catheterization. However, there are drugs other than Duodart (e.g., tamulosin/Flomax) that might help in the short term. You are going to need to discuss that with your urologist … if you are still on speaking terms with him (or her).

  11. My next appointment is to discuss rebore or Urolift as I’d rather not spend the rest of my life on Duodart, and yes, still talking to urologist. In the end, I take responsibility for what happens — just need to consider more carefully what I decide. His aide did say about 1 in 30 to 40 patients suffer my problem. I think he may have been a little over-cautious as a previous (very recent) local patient (known to me), died of prostate cancer and the family told me they thought in that case he wasn’t thorough enough. (I only have their side of the story.) Hopefully time will see me come good — just don’t want another catheter inserted!!

  12. It is the rush to biopsies that is the problem with the present diagnostic protocols. Most high PSAs are associated with prostate enlargement. In fact, that is why the detection rate through biopsies is less than 20% across such tests. Doctors should begin treating patients for enlargement first before proceeding to do biopsies. But the perverse incentives are driving medical decisions these days and doctors are reluctant to recommend active surveillance even after a first biopsy is negative.

    High PSA is never a reliable indicator of prostate cancer, even though this tends to be the rationale for doing biopsies. My last visit to a urologist made me a skeptic. He asked leading questions like “What supplements are you taking?” When I mentioned saw palmetto, he decided to double my PSA measurements to justify a repeat biopsy. I asked for a scientific basis to artificially elevate my PSA results, and he said because the saw palmetto suppresses my normal PSA. Incredulous, I am thinking, isn’t that a good thing? Needless to say, I never saw him again. There may be ethical doctors out there, but unfortunately, I keep running into doctors who think the race on Wall Street applies equally to them.

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