A transrectal Ultrasound uses sound waves to create an image of the inside the body. It is often used to examine the male pelvic organs. The most common use of ultrasound is to view the prostate gland and screen for prostate cancer.

It is 5-15 minutes outpatient procedure. A small lubricated probe is placed into the rectum this releases sound waves, which creates echoes as they enter the prostate. The echoes that bounce back are sent to the computer which translates the patterns of echoes into a picture of prostate. TRUS is a painless procedure. It is used to feel some tumors in the prostate gland that cannot be detected by DRE. In addition it also helps the doctor to estimate the size of the prostate gland and get a better idea of the PSA density, which helps distinguish BPH from prostate cancer.

Preparation for TRUS:

Prior to TRUS the patient may be asked to have an enema to remove feces and gas from the rectum that might impede the progress of the rectal probe.

TRUS Technique:

The patient traditionally lies on his left side, which is considered a more relaxing position as well allows the easy insertion of the rectal probe. After the probe is inserted into the rectum, the tester adjusts the console on the ultrasound machine to a baseline for the echoes of the normal prostate tissues, which will serve as a standard by which other tissues will be classified. Imaging is usually begun at the base of the bladder and then the probe is rotated to provide a full picture of the prostate.

The rectal probe that sends sound waves to the prostate gland helps bounce back echoes from both normal and abnormal tissues that are relayed on the computer.

  • Isoechoic areas, which represent normal tissue echo the same amount of sound waves as they received.
  • Hypo echoic areas sent back lesser echoes than they have received, indicating the presence of cancer.
  • Hyper echoic areas sent back significantly more echoes than they received indicating the presence of prostatic calcifications or tiny stones in the prostate. They are harmless unless infected.
  • PSA DENSITY, the blood PSA level divided by the size of the prostate as determined by TRUS helps in distinguishing between BPH and prostate cancer.

Prostate- Specific Antigen (PSA) is a protein produced in the cells of the prostate gland. The PSA test measures the level of PSA in the blood. PSA produced in the body can be used to detect disease. That is why it is sometimes called biological maker or tumor mark.

It is normal for men to have low PSA in their blood; however prostate cancer or benign conditions can increase the level of PSA in the blood. The most frequent benign prostate condition is Prostatitis inflammation of the prostate and benign prostate hyperplasia (BPH) – enlargement of prostate.

Why is PSA test performed?

The use of PSA test help doctors detect prostate cancer in men of 50years and above of age who have no symptoms? However a single elevated PSA does not confirm prostate cancer.

Men who are receiving hormone treatment for prostate cancer may have low PSA level during treatment.

For whom the PSA test may be recommended?

Doctors advise PSA test for men above 50. However the benefits and risks of the screening test are discussed first by the doctor with the patient.

How are PSA test results reported?

PSA test results are reported as nanograms per milliliter (ng/mL) of blood. There is no specific normal or abnormal PSA level. Patients have been detected with prostate cancer even with PSA level as low as 4.0ng/mL PSA level increases with age. Continuous increase in PSA level is an indication of prostate cancer.

What if screening test results show elevated PSA level? :

If screening test results show elevated PSA levels, doctors recommend repeated PSA level test and DRE to confirm prostate cancer.

What if the PSA level keeps rising during treatment for prostate cancer?

If the rise in PSA levels is accompanied with abnormal DRE results doctors recommend further treatment. Only a rise in PSA levels while a treatment is not something abnormal.

Limitation of PSA level test:

PSA level test can detect small tumor. But this does not reduce the man’s chance of dying from cancer. The test does not help fast growing aggressive cancer that has already spread in other parts of the body. False positive test results occur when PSA level is elevated but no cancer is detected. The test therefore faces controversy.

The prostate biopsy is taking tissue samples from the prostate gland and examining it under the microscope for cell differentiation. Cancerous cells are shaped and arranged differently than healthy cells. The more differentiated the cancerous cells are from the healthy cells the more aggressive the cancer .If no cancerous cells are reveal through the biopsy, it means either the patient does not have cancer or the biopsy missed the tumor. 75% of men report negative primary biopsy report.

Before the Prostate biopsy:

Before undergoing biopsy the patient has to take antibiotics to reduce the risk of infection after prostate biopsy. He should also stop taking anti-inflammatory drugs such as aspirin or ibuprofen that may increase the risk of bleeding after biopsy. Finally the doctor may also order an enema before biopsy to remove feces and gas from the rectum that may complicate the process of transrectal biopsy.

Types of Prostate biopsies:

There are three types of prostate biopsies – transrectal, transurethral and transperineal. The transrectal biopsy is guided by transrectal ultrasound through the anus into rectum. The transurethral biopsy is performed with a lighted cytoscope up through the urethra so that the doctor can look directly at the prostate gland. The transperineal biopsy collects the tissue through a small incision in the perineum.

Transrectal Prostate Biopsy

In this biopsy the patient may experience a small amount of bleeding from the rectum after the biopsy. The process uses spring loaded needles to collect the sample tissues.

Transperineal Prostate Biopsy:

Patients opting to undergo the transperineal biopsy may be put under general anesthesia if they wish to be unconscious during biopsy. The patient may experience some tenderness and blood in the semen for one or two months after biopsy.

Transurethral Prostate Biopsy:

In this kind of biopsy the cytoscope is inserted into the urethra. Local anesthesia is given to numb the area. Doctors look directly at the prostate through the cytoscope and insert a cutting loop to extract tissue.

Side effects of Prostate Biopsy:

Though minimal pain is associated with prostate biopsy, men may experience blood in their urine and semen after the test.  Soreness and groggy feeling may also be experienced, for which the patient may need an attendant to be driven home. Repeated test has to be conducted if the tumor is small.

Doctors use the Digital Rectal exam as a relatively simple test to check the prostate. As prostate in an internal organ, it’s not possible for the doctor to see it from outside. It lies in front of the rectum and the doctors can see it by inserting a gloved finger into the rectum.

Who should get a Digital Rectal Exam?

For most men at an average risk screening is started at the age of 50. However men with a family history of prostate cancer can start their test at an early age say from the age of 40, with the schedule of follow up test to be decided individually.

What happens during Digital Rectal Exam?

The doctor inserts a gloved finger into the rectum and feels the prostate for hard, lumpy or abnormal areas. The test takes only a few minutes.

The patient feels slight discomfort during the test, with no significant pain and damage to the prostate.

What happens after the Digital Rectal Exam?

The patient may go about with his normal activities. Only if any kind of lump or abnormality is detected during the examination, or if the patient’s PSA level is elevated, he may be asked to go for an Ultrasound guided Biopsy.

The ‘Digital Rectal Exam’ is an examination of the lower rectum. The doctors first examine the outside of the anus for ‘hemorrhoids or fissures’. Inside the rectum a latex glove and lubricated finger is inserted.

The patient is asked to relax himself by taking deep breath during the insertion of the finger into the rectum by the doctor.

Why the test is performed? :

The test is performed by doctors not only to test any kind of abnormalities in the prostate gland but also to make sure that nothing is blocking the rectum before inserting any instrument; if at all surgery is required to remove the prostate cancer cells.

Results of the test:

A normal result means the doctor has not detected any problem during the test. An abnormal result may be due to:

  • A prostate problem such as prostate enlargement or prostate cancer.
  • Bleeding in gastrointestinal tract.
  • Tumor of rectum
  • Other problems within the rectum.

This is first preliminary test for prostate cancer, but before the test doctors always discuss the benefit and risk factors.