Pelvic plexus block is more effective than conventional periprostatic block for controlling pain during transrectal ultrasound (TRUS)-guided prostate biopsy, according to a new study.

In a prospective, double-blind study, Tarun Jindal, MD, of Apollo Gleneagles Hospital in West Bengal, India, and collaborators randomly assigned 139 men undergoing TRUS-guided biopsy into 1 of 3 groups.

One group included 47 patients who received intrarectal local anesthesia (IRLA) with 10 mL 2% lidocaine jelly along with pelvic plexus block (PPB) with 2.5 mL 2% lidocaine injection. A second group consisted of 46 patients who received IRLA with perprostatic nerve block (PNB). The third group included 46 patients who received only IRLA without any type of nerve block. Patients rated their level of pain from 0 to 10 (worst pain) on a visual analogue scale (VAS) during the biopsy procedure and 30 minutes after the procedure.

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The mean pain score during biopsy was significantly lower in the PPB group compared with the PNB group (2.91 vs. 4.0), the investigators reported online ahead of print in BJU International. Both the PPB and PNB groups reported significantly lower pain scores than the group with no nerve block, which reported a mean score of 5.4. The researchers found no significant difference in mean pain scores among the 3 groups 30 minutes after the procedure.

Dr. Jindal’s group noted that PNB is considered the gold standard for lessening pain from biopsy needle insertion, but the method has not been found to be completely satisfactory. In PNB, lidocaine is instilled bilaterally at the junction between the bladder, prostate, and seminal vesicle with the aim of blocking the posterolateral neurovascular bundle carrying the main serve supply to the prostate. 

The problem is that a few superolateral and anterior fibers that escape. “This may be the possible reason why apical biopsies have been reported to be more painful than biopsy from other areas of the prostate,” the authors wrote. In PPB, lidocaine is injected bilaterally directly into the pelvic plexus, thereby blocking all nerve fibers and thus having a theoretical advantage over PNB.