# Prostate biopsy: transperineal or transrectal route, antibiotic prophylaxis and aftercare

Source: https://onco.cc/protocols/prostate-biopsy-route-and-antibiotic-prophylaxis/  
OnCo record `prostate-biopsy-route-and-antibiotic-prophylaxis` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

If an MRI suggests prostate cancer, needle samples are taken. The European urology guideline now recommends going through the skin between the scrotum and the back passage (transperineal) rather than through the back passage, because infections are rarer, and says most men having it this way need no antibiotics. Blood in urine and semen afterwards is common; fever or shivering needs urgent help.

## Summary

Biopsy follows a multiparametric MRI in suspected clinically localised prostate cancer and is offered when the MRI score is 3 or more (NICE NG131 1.2.2 to 1.2.4 [2019]). The EAU 2026 guideline recommends the transperineal route (Strong), with surgical disinfection of the perineal skin (Strong), and omitting antibiotic prophylaxis for transperineal biopsy in men without risk factors for infection such as diabetes or a history of urinary retention (Weak). Where transrectal biopsy is done, it recommends povidone-iodine rectal cleansing (Strong) and either targeted prophylaxis from a rectal swab or stool culture or augmented prophylaxis with two or more antibiotic classes (Strong), and avoiding fluoroquinolones (Strong, because of European restrictions). Both routes can be done under local anaesthetic; a periprostatic block is the standard for transrectal biopsy.

The evidence: EAU pooled eight randomised trials (1,596 men) with more infections after transrectal biopsy (48 of 789 against 22 of 807, RR 2.48); a review of 165 studies gave sepsis rates of 0.1% transperineal and 0.9% transrectal. Two later trials found no significant difference against transrectal biopsy with targeted or standard prophylaxis (PREVENT: 0 against 4 infections in 658 men, p = 0.059; ProBE-PC: 2.7% against 2.6%). TRANSLATE (1,126 men, 10 UK hospitals) found more grade group 2 or higher cancer with local anaesthetic transperineal biopsy (60% against 54%) and 2 against 9 admissions for infection, at the cost of more immediate pain and embarrassment (38% against 27%). A 2026 meta-analysis of 10 trials (4,188 biopsies) found lower odds of admission for infection with transperineal biopsy (OR 0.23) and no difference with or without antibiotics for transperineal biopsy. NICE (2019) found no evidence to separate the two routes and says "prostate biopsy" throughout; it advises against mapping transperineal template biopsy as an initial test. Low-dose aspirin is not an absolute contraindication (EAU).

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: prostate biopsy; transperineal biopsy; LATP; local anaesthetic transperineal biopsy; TRUS biopsy; transrectal ultrasound-guided biopsy; antibiotics before prostate biopsy; MRI-targeted prostate biopsy; post-biopsy sepsis

## Connected records

- cancers: [Prostate cancer](https://onco.cc/cancers/prostate/)
- technologies: [Freehand transperineal prostate biopsy devices (PrecisionPoint and others)](https://onco.cc/technologies/transperineal-prostate-biopsy-devices/), [MRI](https://onco.cc/technologies/mri/), [Ultrasound](https://onco.cc/technologies/ultrasound/)
- institutions: [National Institute for Health and Care Excellence](https://onco.cc/institutions/nice/)
- terms: [Biopsy](https://onco.cc/terms/biopsy/), [Template mapping biopsy (transperineal template prostate mapping)](https://onco.cc/terms/template-mapping-biopsy/)

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