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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.
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).
Why: The MRI shows where to aim the needle and lets some men with a reassuring scan avoid a biopsy.
“Offer multiparametric MRI-influenced prostate biopsy to people whose Likert score is 3 or more.”
NICE 2021 · [2019]
Why: Most men get some bleeding afterwards and knowing what is normal makes it easier to spot what is not.
“The most serious is sepsis, which develops in a bit fewer than 1 out of 100 people.”
NICE 2021 · [2019]
Why: Going through skin that can be cleaned, rather than through the bowel, leads to fewer infections.
“Perform prostate biopsy using the transperineal approach due to the low risk of infectious complications and better antibiotic stewardship.”
Why: Numbing the area makes the procedure tolerable as a clinic appointment.
“Local anaesthesia can also be used effectively for MRI-targeted and systematic transperineal biopsy”
European Association of Urology (EAU) 2026 · Summary of evidence (no strength rating)
Why: Clean skin keeps skin bacteria from being carried in by the needle.
“Use routine surgical disinfection of the perineal skin for transperineal biopsy.”
Why: Trials and reviews found infection rates just as low without them, and unnecessary antibiotics breed resistant bacteria.
“Omit perioperative antibiotic prophylaxis in transperineal biopsy in patients without risk factors for infectious complications.”
Why: Reducing the bacteria in the bowel lowers the chance the needle carries them into the prostate.
“Use rectal cleansing with povidone-iodine prior to transrectal prostate biopsy.”
Why: Bowel bacteria are often resistant to the old standard antibiotic, and choosing by culture or covering more widely prevents more infections.
“First option: Targeted prophylaxis based on rectal swab or stool culture. Second option: Augmented prophylaxis (using two or more different classes of antibiotics).”
Why: Knowing where each sample came from tells the team where the cancer is and how much there is.
“Ensure that prostate core biopsies from different sites are submitted separately for processing and pathology reporting.”
Why: Aspirin on its own does not rule out a biopsy; stronger blood thinners need an individual plan.
“Low-dose aspirin is not an absolute contra-indication”
European Association of Urology (EAU) 2026 · Text statement (no strength rating)
Why: Bleeding is expected and settles; infection and urinary retention are the after-effects that need treatment quickly.
“90 out of 100 people have blood in their semen; in 60 of them, it will last for at least 2 weeks; 25 will consider it a moderate or serious problem.”
NICE 2021 · [2019]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Transperineal biopsy under local anaesthetic, with surgical skin disinfection and without routine antibiotics in men without risk factors (EAU 2026: route Strong, skin disinfection Strong, omitting antibiotics Weak). The route recommendation rests on fewer infections in pooled randomised trials and large cohorts, a higher detection of significant cancer in TRANSLATE, and antibiotic stewardship; EAU notes the certainty for the infection benefit is low but rates it strong for its clinical significance. Where transrectal biopsy is used, povidone-iodine rectal cleansing and targeted or augmented prophylaxis without fluoroquinolones (EAU Strong). NICE NG131 (2019) does not choose a route: its committee found no evidence to separate them, and it predates PREVENT, ProBE-PC and TRANSLATE. The two later trials comparing transperineal biopsy with transrectal biopsy under antibiotics did not show a significant difference in infection, so the size of the advantage over well-protected transrectal biopsy is uncertain.
European Association of Urology (EAU) 2026 · NICE 2021 · Lancet Oncology 2025 · Hu et al., European Urology 2024 · European Urology Focus 2026
Where it differs: Rectal culture screening for fluoroquinolone-resistant bacteria and antibiotics chosen from the culture, then transrectal biopsy, instead of transperineal biopsy without antibiotics.
Evidence: PREVENT (658 men): 4 infections (1.4%) after transrectal biopsy with targeted prophylaxis against none after transperineal biopsy, p = 0.059; cancer detection similar (53% against 50%). The authors say it achieves similar infection rates but needs rectal cultures and careful antibiotic selection.
Hu et al., European Urology 2024 · European Association of Urology (EAU) 2026
Where it differs: NICE NG131 refers to "prostate biopsy" throughout and recommends against mapping transperineal template biopsy as part of an initial assessment unless in a trial (1.2.5 [2019]); it does not recommend one route of non-mapping biopsy over the other, and its box 1 harms figures come from transrectal biopsy in PROMIS and ProtecT.
Evidence: The 2019 committee found no evidence to separate transperineal (non-mapping) and transrectal biopsy and made a research recommendation on the transperineal route.
Where it differs: Many centres still give a single antibiotic dose before transperineal biopsy.
Evidence: EAU summarises meta-analyses of non-randomised cohorts and two randomised trials showing comparable infection rates with and without prophylaxis (for example 1.35% of 29,880 with against 1.22% of 4,772 without); the 2026 meta-analysis of randomised trials found no significant difference. EAU keeps prophylaxis for men with risk factors such as diabetes or a history of urinary retention.
European Association of Urology (EAU) 2026 · European Urology Focus 2026
Where it differs: The United States guideline was amended in 2025 to 2026 with revised statements on biopsy technique. Its statements could not be read for this page.
Evidence: Only the abstract was reachable; it reports revised strength of evidence on biopsy techniques without stating them.
American Urological Association and Society of Urologic Oncology (Journal of Urology) 2026
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Transperineal route “Although data showing the lower risk of infection via the transperineal approach is low in certainty, its statistical and clinical significance warrants its strong rating.” | Strong | European Association of Urology (EAU) 2026 |
| Omit antibiotics for transperineal biopsy in men without risk factors | Weak | European Association of Urology (EAU) 2026 |
| Surgical disinfection of perineal skin | Strong | European Association of Urology (EAU) 2026 |
| Povidone-iodine rectal cleansing before transrectal biopsy | Strong | European Association of Urology (EAU) 2026 |
| Targeted or augmented antibiotic prophylaxis for transrectal biopsy | Strong | European Association of Urology (EAU) 2026 |
| Avoid fluoroquinolones for prostate biopsy “A ‘Strong’ rating is given for avoiding fluoroquinolones in prostate biopsy due to its legal implications in Europe.” | Strong | European Association of Urology (EAU) 2026 |
| Offer MRI-influenced biopsy when the Likert score is 3 or more | [2019] | NICE 2021 |
| Do not offer mapping transperineal template biopsy at initial assessment, unless in a trial “Do not offer mapping transperineal template biopsy as part of an initial assessment, unless as part of a clinical trial.” | [2019] | NICE 2021 |
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