**4.3 Pain control**

Only 11% of urologists in US used local anesthesia to reduce pain during trus biopsy in 2002 (Davis et al. 2002). At the time, a strong appeal from one of the most distinguished opinion leaders favored local anesthesia (Soloway, 2003). Thereafter, guidelines (AUA, EAU, NCCN) all recommended or even mandated (AUA) local pain medication use during this procedure. Intrarectal application of eutectic cream or lidocaine jelly may decrease pain as some anesthetic agent may reach site of pain with diffusion, but it is variable and is considered not adequate. Pain during transrectal prostate biopsy is caused by two sources. First source of pain is probe insertion and presence and movement of probe in the anal

canal during biopsy. This can be ameliorated with slow and gentle dilation and local lidocaine jelly or EMLA cream, but other measures for relaxation of sphincter were also used with success and are available – local glyceryl trinitrate oinment or spray or local 2% diltiazem or 0,2% - 0,5% nifedipine oinment. Using gylceryl trinitrate oinment, headache was noted as side effect in 10% of patients – dose was 2 mg (McCabe et al., 2007). It remains open, whether lower dose of spray (0,4 mg/activation) would reach same effect with less side effects.

Second source of pain during trus biopsy is related to nerves in prostate capsule and neurovascular bundles. After a lot of research (for example (Scattoni et al., 2010)) it seems accepted injection of 2x 5 ml (each side) of 1% lidocaine most appropriately reduces pain. Site of injection may be at the base (basolateral periprostatic nerve plexus area, described also as prostate-vesicular junction injections) or at the apex. Debate where to inject sill continues. Quality control suggested for standard technique of periprostatic block, observation of hypoechoic nodule ("wheal") formation on the site of injection is needed. It was shown least pain (best effect) was observed, when hypoechoic nodule formed after injection on both sides (Obek et al., 2006). Regarding injectable agents, for potential lidocaine allergic patients, tramadol has significant local anesthetic properties and is universally available and it has also been studied in this setting (Seckiner et al., 2011).

Addition of oral medication, either for sedation or for additional pain relief may be also helpful in selected patients.
