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Local Anaesthetic for Transrectal Ultrasound-Guided Prostate Biopsy: A Prospective, Randomized, Double Blind, Placebo-Controlled Study
European Urology
European Urology 43 (2003) 441–443
Local Anaesthetic forTransrectal Ultrasound-Guided Prostate Biopsy: A Prospective, Randomized, Double Blind, Placebo-Controlled Study S.K. Addla*, A.A.B. Adeyoju, G.D. Wemyss-Holden, D. Neilson Department of Urology, Blackburn Royal Infirmary, Blackburn BB2 3LR, UK Accepted 3 March 2003
Abstract Objective: To evaluate the efficacy of local anaesthetic (LA) infiltration in decreasing the discomfort experienced by patients undergoing transrectal ultrasound (TRUS)-guided biopsy of prostate. Patients and methods: 98 patients were randomized to receive 3 3 ml of 1% lidocaine (n ¼ 55) or saline (n ¼ 43). The injection sites were basolaterally on each side to infiltrate the neuro-vascular bundle and one at the apex. Generally 12 systematic random biopsies were performed after which patients were asked to grade the pain of the whole procedure using a visual analogue scale ranging from 0 to 10. Results:The LA group had a significantly lower pain score compared with placebo. The mean pain scores were 3.0 and 4.3 ( p < 0:001), respectively. Using an unpaired t-test, the difference between means was 1.96 to 0.51 with 95% confidence interval. There were no significant problems associated with the infiltration of either saline or LA. Conclusion: Local anaesthesia for TRUS biopsy is simple and well tolerated. It significantly reduces the pain associated with the procedure. We recommend its usage as a part of standard TRUS biopsy of the prostate. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Local anaesthetic; Transrectal ultrasound; Prostate biopsy; Pain 1. Introduction Transrectal ultrasound (TRUS)-guided biopsy was introduced by Torp-Pedersen et al. [1] in 1989 and has since become the standard method used to diagnose prostatic carcinoma. The discomfort associated with the procedure was recognised by Collins et al. [2] who found that 60–80% of patients experienced mild to moderate pain. In a study by Irani et al. [3] 6% of patients judged that the procedure was so uncomfortable that it should have been performed under a general anaesthetic. Our department recently changed from a 6-biopsy to a 12-biopsy technique and increased discomfort was noted. A review of previous publications on various methods of pain relief [4–9] revealed several shortcom*
Corresponding author. Present address: 98, Lavington Avenue, Cheadle, Cheshire SK8 2HH, UK. Tel. þ44-161-491-3813; Fax: þ44-161-419-5699. E-mail address: [email protected] (S.K. Addla).
ings (Table 1) particularly the lack of good randomised, double blind, placebo-controlled studies with adequate numbers.
2. Patients and methods The local ethical committee approved the trial. 126 new patients presenting over a 12-month period (December 2000–December 2001) were considered for the study. Prescriptions were requested on a named patient basis at the beginning of each TRUS biopsy list. 28 patients were not included for the reasons given in Table 2, leaving 98 for further investigation. All patients had the study explained in a verbal and written form. Consent was obtained from those that wished to continue. Antibiotic prophylaxis was 160 mg of gentamicin given intravenously then a three-day course of oral ciprofloxacin 500 mg twice daily. The TRUS was performed in the left lateral decubitus position using a Kretz-Technik Combison 310.A, 7.5 MHz probe (KretzTechnik, Austria). The patient’s age, PSA, prostate volume and any complications associated with the procedure were recorded. Randomisation tables were supplied by medical statistics and the injections were supplied on a named patient basis by the pharmacy
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00104-0
442
S.K. Addla et al. / European Urology 43 (2003) 441–443
Table 1 Comparison of studies regarding use of LA for TRUS-guided biopsy of prostate Authors [reference]
LA (lidocaine)
Technique
Control
Double blind
N
S.D.
Desgrandchamps et al. [4] Issa et al. [8] Alavi et al. [6] Nash et al. [5] Seymour et al. [7] Tavern et al. [9] Lynn et al. [12]
15 ml 2% gel 10 ml 2% gel 10 ml 1% injection 5 ml 1% injection 10 ml 1% injection 10 ml 1% injection 10 ml 1% injection 2% lidocaine gel
Intrarectal Intrarectal 5 ml on each side basolateral 5 ml basolateral on one side 5 ml on either side of apex Single injection at apex Periprostatic Intrarectal
Placebo–trans-sonic gel No placebo control 10 ml 2% lidocaine intrarectal Placebo–saline No placebo control No placebo control Placebo–10 ml normal saline Placebo–plain gel
Yes No No Yes No No No No
56 25 75 34 84 100 30 27
No Yes Yes Yes Yes Yes Yes No
N: number of patients in study group; S.D.: significant difference in pain scores.
department. 55 patients received 9 ml of 1% lidocaine hydrochloride (Phoenix Pharma Ltd., UK) and 43 received normal saline. Infiltration was performed using a 22-gauge spinal needle through the biopsy guide. 3 ml was injected on each side basolaterally between the seminal vesicles and the lateral margin of the prostate. A further 3 ml was injected at the apex between Denonvillier’s fascia and the prostatic capsule. The position of the needle was confirmed by the lack of resistance while injecting and by visual confirmation of fluid infiltrating the desired region on ultrasound scanning. Following this, prostate measurements were taken which took 3–5 minutes before proceeding with the biopsies. Generally, 12 systematic random biopsies were taken with an 18-gauge needle and a Pro-mag 2.2 biopsy gun (Mana-tech Ltd., UK). Immediately following the procedure patients were asked to grade the pain they experienced using the 11-point Wayne State University visual analogue scale (VAS) [10] rating it from 0 (no discomfort) to 10 (the most severe pain ever experienced). The results were analysed using an unpaired t-test after which the investigators were unblinded as to which group was the LA and which was the placebo.
3. Results Of the 98 patients that were recruited, 55 received the LA and 43 the placebo. This inequality was because the other 28 patients, for whom the injections were prepared but not used (Table 2), were not evenly split between the two groups. The groups were otherwise evenly matched with respect to age, prostate volume and PSA as shown in Table 3. The LA group had significantly lower VAS pain scores compared to the placebo arm of the study (Fig. 1) with mean pain scores of 3.0 and 4.3, respec-
tively ( p < 0:001). 84% of the patients in LA group and 54% of patients in Placebo group had VAS pain scores >5. Using an unpaired t-test, the difference between means was 1.96 to 0.51 with 95% confidence interval. The median pain scores were 3 and 4 for LA and Placebo group, respectively. One patient in the LA group was admitted later the same day with collapse and bradycardia that was thought to be vasovagal in origin and so unrelated to the lidocaine. Table 3 Patient demographics Variables
LA group
Placebo group
Number of patients Average age in years (range) PSA (median) Calculated volume (ml) Average number of biopsies taken Clinically abnormal prostate, n (%) Malignant histologically, n (%)
55 67.6 (47–89) 9.8 56.3 12 21 (38) 27 (49)
43 67.0 (43–82) 8.2 54.4 11.9 15 (34) 20 (46)
Both the groups were well matched with respect to age, PSA and prostate volume. Similar percentage of patients in each group had a clinically abnormal and histologically proven malignant prostate.
Table 2 Details of 28 patients not entered into the study Reason for non-inclusion
Number
Patients declined study Refused TRUS biopsy Not suitable due to comprehension problem Biopsy not performed Other
14 5 4 2 3
Fig. 1. Comparison of visual analogue pain scores for patients in LA (grey bars) and Placebo group (pink bars). Pain scores recorded by patients in the LA group were significantly lower.
S.K. Addla et al. / European Urology 43 (2003) 441–443
4. Discussion To be effective, local anaesthesia should block all possible routes of painful stimuli. One region requiring blockade is the prostatic capsule that has a rich autonomic innervation conveying visceral pain to the spinal cord via fibres that run with the vascular pedicles basolaterally [11]. LA infiltration of the neurovascular bundles bilaterally should therefore be effective and has been used in some studies [5,6] as well as forming part of the technique that we have used. Though there is a theoretical risk of vascular injury with this site of infiltration, we have not seen any in our experience and to our knowledge none have so far been reported in the literature. Biopsies of the basal and mid zones of the prostate tend to involve puncture of the rectal mucosa that has no innervation for sharp stimuli. We noted clinically that the apical biopsies were often the most painful and hence why we added an ’apical’ infiltration site. Seymour et al. [7] and Schostak et al. [13] have shown that with apical infiltration alone, good pain control could be achieved. However, infiltration of LA in the apical region is more likely to puncture anorectal mucosa around the dentate line where somatic innervation is involved, and may also transgress the external sphincter which is innervated by perineal branch of the pudendal nerve. Previous studies have used different techniques that might not be expected to give adequate anaesthetic blockade. Issa et al. [8] for example gave intrarectal lidocaine gel which, in spite of a good absorptive surface of the rectum would be unlikely to have had any effect on the important areas. Lynn et al. [12] compared LA to lidocaine gel and showed that LA was
443
significantly better but there was no mention of technique of infiltration and the numbers were small. Others have infiltrated the neurovascular bundles but have omitted the apical injection [5,6]. Seymour et al. [7] infiltrated around the apex but did not block the neurovascular bundles. It is unclear whether the apical injection anaesthetises just the peri-apical capsule or whether the external sphincter and/or mucosa below the dentate line are also blocked. Other deficiencies in the previous studies include a lack of a Placebo group and/or small numbers and are detailed in Table 2. There was no increased fibrosis or difficulty with dissection noted at radical prostatectomy operation due to the infiltration of LA or saline. No significant difference was noted in post operative continence or impotency rates (personal communication from GDWH who performed all the radical prostatectomies). Our study combined a more complete blockade, with placebo control with larger number of patients than any other trial. LA infiltration significantly reduces the pain associated with TRUS guided prostate biopsy. With many departments shifting from 6 to 12 biopsies as a routine we recommend usage of LA as a standard part of the procedure. The technique and the amount of LA infiltration, which has varied between the studies, could be of interest for future research.
Acknowledgements We wish to thank Ruth Townson and the staff of the Pharmacy department at Blackburn Royal Infirmary for preparing the injections. The funding for the study was provided by Department of Urology, Blackburn.
References [1] Torp-Pedersen S, Lee F, Littrup PJ. Trans-rectal biopsy of the prostate guided with transrectal US: longitudinal and multiplanar scanning. Radiology 1989;170:23. [2] Collins GN, Lloyd SN, Hehir M, McKalvie GB. Multiple transrectal ultrasound-guided prostatic biopsies: true morbidity and patient acceptance. Br J Urol 1993;71:460–3. [3] Irani J, Fournier F, Bon D, Gremmo E, Dore B, Aubert J. Patient tolerance of transrectal ultrasound-guided biopsy of the prostate. Br J Urol 1997;79:608–10. [4] Desgrandchamps F, Meria P, Irani J, Desgrippes A, Teillac P, Le Duc A. The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography-guided biopsy of the prostate: a prospective randomised placebo-controlled study. BJU Int 1999;83:1007–9. [5] Nash PA, Bruce JE, Indudhara R, Shinohara K. Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 1996;155:607–9. [6] Alavi AS, Soloway MS, Vaidya A, Lynne CM, Gheiler EL. Local anaesthesia for ultrasound guided prostate biopsy: a prospective randomised trial comparing 2 methods. J Urol 2001;166:1343–5.
[7] Seymour H, Perry MJA, Lee-Elliot C, Dundas D, Patel U. Pain after transrectal ultrasonography-guided prostate biopsy: the advantages of periprostatic local anaesthesia. BJU Int 2001;88:540–4. [8] Issa MM, Bux S, Chun T, Petros JA, Labadia AJ, Anastasia K, et al. A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: the Emory University experience. J Urol 2000;164:397. [9] Tavern G, Maffezzini M, Benetti A, Seveso M, Giusti G, Graziotti P. A single injection of lidocaine as local anaesthesia for ultrasound guided needle biopsy the prostate. J Urol 2002;167(1):222–3. [10] Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175. [11] Hollabough Jr RS, Dmochowski RR, Steiner MS. Neuroanatomy of male rhabdosphincter. Urology 1997;49:426. [12] Lynn NNK, Collins GN, Brown SCW, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002;90:424–6. [13] Schostak M, Christoph F, Muller M, Heicappell R, Goessl G, Staehler M, Miller K. Optimizing local anesthesia during 10-core biopsy of the prostate. Urology 2002;60(2):253–7.
European Urology 43 (2003) 441–443
Local Anaesthetic forTransrectal Ultrasound-Guided Prostate Biopsy: A Prospective, Randomized, Double Blind, Placebo-Controlled Study S.K. Addla*, A.A.B. Adeyoju, G.D. Wemyss-Holden, D. Neilson Department of Urology, Blackburn Royal Infirmary, Blackburn BB2 3LR, UK Accepted 3 March 2003
Abstract Objective: To evaluate the efficacy of local anaesthetic (LA) infiltration in decreasing the discomfort experienced by patients undergoing transrectal ultrasound (TRUS)-guided biopsy of prostate. Patients and methods: 98 patients were randomized to receive 3 3 ml of 1% lidocaine (n ¼ 55) or saline (n ¼ 43). The injection sites were basolaterally on each side to infiltrate the neuro-vascular bundle and one at the apex. Generally 12 systematic random biopsies were performed after which patients were asked to grade the pain of the whole procedure using a visual analogue scale ranging from 0 to 10. Results:The LA group had a significantly lower pain score compared with placebo. The mean pain scores were 3.0 and 4.3 ( p < 0:001), respectively. Using an unpaired t-test, the difference between means was 1.96 to 0.51 with 95% confidence interval. There were no significant problems associated with the infiltration of either saline or LA. Conclusion: Local anaesthesia for TRUS biopsy is simple and well tolerated. It significantly reduces the pain associated with the procedure. We recommend its usage as a part of standard TRUS biopsy of the prostate. # 2003 Elsevier Science B.V. All rights reserved. Keywords: Local anaesthetic; Transrectal ultrasound; Prostate biopsy; Pain 1. Introduction Transrectal ultrasound (TRUS)-guided biopsy was introduced by Torp-Pedersen et al. [1] in 1989 and has since become the standard method used to diagnose prostatic carcinoma. The discomfort associated with the procedure was recognised by Collins et al. [2] who found that 60–80% of patients experienced mild to moderate pain. In a study by Irani et al. [3] 6% of patients judged that the procedure was so uncomfortable that it should have been performed under a general anaesthetic. Our department recently changed from a 6-biopsy to a 12-biopsy technique and increased discomfort was noted. A review of previous publications on various methods of pain relief [4–9] revealed several shortcom*
Corresponding author. Present address: 98, Lavington Avenue, Cheadle, Cheshire SK8 2HH, UK. Tel. þ44-161-491-3813; Fax: þ44-161-419-5699. E-mail address: [email protected] (S.K. Addla).
ings (Table 1) particularly the lack of good randomised, double blind, placebo-controlled studies with adequate numbers.
2. Patients and methods The local ethical committee approved the trial. 126 new patients presenting over a 12-month period (December 2000–December 2001) were considered for the study. Prescriptions were requested on a named patient basis at the beginning of each TRUS biopsy list. 28 patients were not included for the reasons given in Table 2, leaving 98 for further investigation. All patients had the study explained in a verbal and written form. Consent was obtained from those that wished to continue. Antibiotic prophylaxis was 160 mg of gentamicin given intravenously then a three-day course of oral ciprofloxacin 500 mg twice daily. The TRUS was performed in the left lateral decubitus position using a Kretz-Technik Combison 310.A, 7.5 MHz probe (KretzTechnik, Austria). The patient’s age, PSA, prostate volume and any complications associated with the procedure were recorded. Randomisation tables were supplied by medical statistics and the injections were supplied on a named patient basis by the pharmacy
0302-2838/03/$ – see front matter # 2003 Elsevier Science B.V. All rights reserved. doi:10.1016/S0302-2838(03)00104-0
442
S.K. Addla et al. / European Urology 43 (2003) 441–443
Table 1 Comparison of studies regarding use of LA for TRUS-guided biopsy of prostate Authors [reference]
LA (lidocaine)
Technique
Control
Double blind
N
S.D.
Desgrandchamps et al. [4] Issa et al. [8] Alavi et al. [6] Nash et al. [5] Seymour et al. [7] Tavern et al. [9] Lynn et al. [12]
15 ml 2% gel 10 ml 2% gel 10 ml 1% injection 5 ml 1% injection 10 ml 1% injection 10 ml 1% injection 10 ml 1% injection 2% lidocaine gel
Intrarectal Intrarectal 5 ml on each side basolateral 5 ml basolateral on one side 5 ml on either side of apex Single injection at apex Periprostatic Intrarectal
Placebo–trans-sonic gel No placebo control 10 ml 2% lidocaine intrarectal Placebo–saline No placebo control No placebo control Placebo–10 ml normal saline Placebo–plain gel
Yes No No Yes No No No No
56 25 75 34 84 100 30 27
No Yes Yes Yes Yes Yes Yes No
N: number of patients in study group; S.D.: significant difference in pain scores.
department. 55 patients received 9 ml of 1% lidocaine hydrochloride (Phoenix Pharma Ltd., UK) and 43 received normal saline. Infiltration was performed using a 22-gauge spinal needle through the biopsy guide. 3 ml was injected on each side basolaterally between the seminal vesicles and the lateral margin of the prostate. A further 3 ml was injected at the apex between Denonvillier’s fascia and the prostatic capsule. The position of the needle was confirmed by the lack of resistance while injecting and by visual confirmation of fluid infiltrating the desired region on ultrasound scanning. Following this, prostate measurements were taken which took 3–5 minutes before proceeding with the biopsies. Generally, 12 systematic random biopsies were taken with an 18-gauge needle and a Pro-mag 2.2 biopsy gun (Mana-tech Ltd., UK). Immediately following the procedure patients were asked to grade the pain they experienced using the 11-point Wayne State University visual analogue scale (VAS) [10] rating it from 0 (no discomfort) to 10 (the most severe pain ever experienced). The results were analysed using an unpaired t-test after which the investigators were unblinded as to which group was the LA and which was the placebo.
3. Results Of the 98 patients that were recruited, 55 received the LA and 43 the placebo. This inequality was because the other 28 patients, for whom the injections were prepared but not used (Table 2), were not evenly split between the two groups. The groups were otherwise evenly matched with respect to age, prostate volume and PSA as shown in Table 3. The LA group had significantly lower VAS pain scores compared to the placebo arm of the study (Fig. 1) with mean pain scores of 3.0 and 4.3, respec-
tively ( p < 0:001). 84% of the patients in LA group and 54% of patients in Placebo group had VAS pain scores >5. Using an unpaired t-test, the difference between means was 1.96 to 0.51 with 95% confidence interval. The median pain scores were 3 and 4 for LA and Placebo group, respectively. One patient in the LA group was admitted later the same day with collapse and bradycardia that was thought to be vasovagal in origin and so unrelated to the lidocaine. Table 3 Patient demographics Variables
LA group
Placebo group
Number of patients Average age in years (range) PSA (median) Calculated volume (ml) Average number of biopsies taken Clinically abnormal prostate, n (%) Malignant histologically, n (%)
55 67.6 (47–89) 9.8 56.3 12 21 (38) 27 (49)
43 67.0 (43–82) 8.2 54.4 11.9 15 (34) 20 (46)
Both the groups were well matched with respect to age, PSA and prostate volume. Similar percentage of patients in each group had a clinically abnormal and histologically proven malignant prostate.
Table 2 Details of 28 patients not entered into the study Reason for non-inclusion
Number
Patients declined study Refused TRUS biopsy Not suitable due to comprehension problem Biopsy not performed Other
14 5 4 2 3
Fig. 1. Comparison of visual analogue pain scores for patients in LA (grey bars) and Placebo group (pink bars). Pain scores recorded by patients in the LA group were significantly lower.
S.K. Addla et al. / European Urology 43 (2003) 441–443
4. Discussion To be effective, local anaesthesia should block all possible routes of painful stimuli. One region requiring blockade is the prostatic capsule that has a rich autonomic innervation conveying visceral pain to the spinal cord via fibres that run with the vascular pedicles basolaterally [11]. LA infiltration of the neurovascular bundles bilaterally should therefore be effective and has been used in some studies [5,6] as well as forming part of the technique that we have used. Though there is a theoretical risk of vascular injury with this site of infiltration, we have not seen any in our experience and to our knowledge none have so far been reported in the literature. Biopsies of the basal and mid zones of the prostate tend to involve puncture of the rectal mucosa that has no innervation for sharp stimuli. We noted clinically that the apical biopsies were often the most painful and hence why we added an ’apical’ infiltration site. Seymour et al. [7] and Schostak et al. [13] have shown that with apical infiltration alone, good pain control could be achieved. However, infiltration of LA in the apical region is more likely to puncture anorectal mucosa around the dentate line where somatic innervation is involved, and may also transgress the external sphincter which is innervated by perineal branch of the pudendal nerve. Previous studies have used different techniques that might not be expected to give adequate anaesthetic blockade. Issa et al. [8] for example gave intrarectal lidocaine gel which, in spite of a good absorptive surface of the rectum would be unlikely to have had any effect on the important areas. Lynn et al. [12] compared LA to lidocaine gel and showed that LA was
443
significantly better but there was no mention of technique of infiltration and the numbers were small. Others have infiltrated the neurovascular bundles but have omitted the apical injection [5,6]. Seymour et al. [7] infiltrated around the apex but did not block the neurovascular bundles. It is unclear whether the apical injection anaesthetises just the peri-apical capsule or whether the external sphincter and/or mucosa below the dentate line are also blocked. Other deficiencies in the previous studies include a lack of a Placebo group and/or small numbers and are detailed in Table 2. There was no increased fibrosis or difficulty with dissection noted at radical prostatectomy operation due to the infiltration of LA or saline. No significant difference was noted in post operative continence or impotency rates (personal communication from GDWH who performed all the radical prostatectomies). Our study combined a more complete blockade, with placebo control with larger number of patients than any other trial. LA infiltration significantly reduces the pain associated with TRUS guided prostate biopsy. With many departments shifting from 6 to 12 biopsies as a routine we recommend usage of LA as a standard part of the procedure. The technique and the amount of LA infiltration, which has varied between the studies, could be of interest for future research.
Acknowledgements We wish to thank Ruth Townson and the staff of the Pharmacy department at Blackburn Royal Infirmary for preparing the injections. The funding for the study was provided by Department of Urology, Blackburn.
References [1] Torp-Pedersen S, Lee F, Littrup PJ. Trans-rectal biopsy of the prostate guided with transrectal US: longitudinal and multiplanar scanning. Radiology 1989;170:23. [2] Collins GN, Lloyd SN, Hehir M, McKalvie GB. Multiple transrectal ultrasound-guided prostatic biopsies: true morbidity and patient acceptance. Br J Urol 1993;71:460–3. [3] Irani J, Fournier F, Bon D, Gremmo E, Dore B, Aubert J. Patient tolerance of transrectal ultrasound-guided biopsy of the prostate. Br J Urol 1997;79:608–10. [4] Desgrandchamps F, Meria P, Irani J, Desgrippes A, Teillac P, Le Duc A. The rectal administration of lidocaine gel and tolerance of transrectal ultrasonography-guided biopsy of the prostate: a prospective randomised placebo-controlled study. BJU Int 1999;83:1007–9. [5] Nash PA, Bruce JE, Indudhara R, Shinohara K. Transrectal ultrasound guided prostatic nerve blockade eases systematic needle biopsy of the prostate. J Urol 1996;155:607–9. [6] Alavi AS, Soloway MS, Vaidya A, Lynne CM, Gheiler EL. Local anaesthesia for ultrasound guided prostate biopsy: a prospective randomised trial comparing 2 methods. J Urol 2001;166:1343–5.
[7] Seymour H, Perry MJA, Lee-Elliot C, Dundas D, Patel U. Pain after transrectal ultrasonography-guided prostate biopsy: the advantages of periprostatic local anaesthesia. BJU Int 2001;88:540–4. [8] Issa MM, Bux S, Chun T, Petros JA, Labadia AJ, Anastasia K, et al. A randomized prospective trial of intrarectal lidocaine for pain control during transrectal prostate biopsy: the Emory University experience. J Urol 2000;164:397. [9] Tavern G, Maffezzini M, Benetti A, Seveso M, Giusti G, Graziotti P. A single injection of lidocaine as local anaesthesia for ultrasound guided needle biopsy the prostate. J Urol 2002;167(1):222–3. [10] Scott J, Huskisson EC. Graphic representation of pain. Pain 1976;2:175. [11] Hollabough Jr RS, Dmochowski RR, Steiner MS. Neuroanatomy of male rhabdosphincter. Urology 1997;49:426. [12] Lynn NNK, Collins GN, Brown SCW, O’Reilly PH. Periprostatic nerve block gives better analgesia for prostatic biopsy. BJU Int 2002;90:424–6. [13] Schostak M, Christoph F, Muller M, Heicappell R, Goessl G, Staehler M, Miller K. Optimizing local anesthesia during 10-core biopsy of the prostate. Urology 2002;60(2):253–7.