A randomised controlled trial comparing use of lignocaine periprostatic nerve block alone and combined with diclofenac suppository for patients undergoing transrectal ultrasound (TRUS)‐guided prostate biopsy

Abstract

ObjectiveTo examine whether or not the combination of diclofenac suppository with peri-prostatic nerve block (PPNB) was effective in reducing the degree of pain experienced during transrectal ultrasound (TRUS)-guided prostate biopsy in a randomised single-blind placebo-controlled trial. Patients and MethodsIn all, 96 patients having a planned TRUS-guided prostate biopsy were randomised into one of the following arms on a 1:1 basis: 10 mL 1% lignocaine PPNB and placebo suppository (control) or 10 mL 1% lignocaine PPNB and 100 mg diclofenac suppository (treatment). Pain scores were recorded using the Numerical Rating Scale for pain (0-10) at the following time-points: (i) introduction of probe, (ii) during biopsy, (iii) 1 h after biopsy, (iv) later that evening (≈6 h after biopsy) and (v) 1 day after biopsy. Patients were asked about their preferred method for pain control if a repeat TRUS-guided prostate biopsy was required: local anaesthetic (LA) again or intravenous sedation. ResultsThere were no significant differences in age (P = 0.653) or PSA level (P = 0.584) between either study arm. The differences in pain scores between the control and treatment groups were not significant at Time 1 (probe insertion; P = 0.299), Time 2 (biopsy; P = 0.983), Time 4 (evening after; P = 0.231) and Time 5 (1 day after biopsy; P = 0.384). At Time 3 (1 h after biopsy), the control pain scale scores were statistically significantly higher than the treatment pain scale scores (P = 0.044). There was no difference between treatment (87%) and control (80%) groups as to whether they would prefer to repeat the biopsy under LA (P = 0.373). ConclusionThe use of a diclofenac suppository with PPNB did not show any clinically meaningful effect in decreasing pain or improving tolerability of TRUS-guided prostate biopsy and is not recommended. PPNB TRUS-guided biopsy is extremely well tolerated, with >80% of patients electing for subsequent LA biopsy if required.

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“…Conversely, in our study, prostate volume did not effect VAS scores in both groups. In the prostate biopsy, various other analgesia methods were investigated using intravenous conscious sedation (fentanyl and midazolam), nitrous oxide inhalation, oral analgesia (paracetamol/codeine), intrarectal diclofenac and 40% dimethyl sulfoxide [22,23]. Obek et al showed a meaningful reduced level of pain with local lidocaine gel application before PPNB whereas tradamol and periprostatic blockage had similar effects [24].…”

Comparing use of lidocaine periprostatic nerve block and diclofenac suppository alone for patients undergoing transrectal ultrasound guided prostate biopsy

“…For prostate cancer diagnosis, the current standard method is taking a core biopsy from prostate tissue by transrectal ultrasound guidance. During this procedure, which can be very painful, many topical analgesics, such as lignocaine gel, glyceryl trinitrate and analgesia methods, such as an eutectic mixture of local anaesthetics (EMLA) cream, intravenous or inhalation anaesthesia, periprostatic nerve block, and oral or intrarectal analgesics are used [ 4 , 5 ].…”

Addition of intrarectal local analgesia to periprostatic nerve block improves pain control for transrectal ultrasonography‐guided prostate biopsy: A systematic review and meta‐analysis

“…For VAS of both probe manipulation and needle biopsy pain, the analyses showed only slight changes in the precision of the effect estimate with sequential exclusion of each study from the analysis. Exclusion of two retrospective studies 12,25 and four abstracts 19,20,23,24 resulted in a slightly decreased WMD of −2.12 (95% CI −2.98 to −1.44, P < 0.001) for probe manipulation pain and −0.56 (95% CI −0.82 to −0.40, P < 0.001) for needle biopsy pain compared with the original effects.…”

“…Six studies used lidocaine gel 4,10-14 for IRLA, six used lidocaine-prilocaine cream, [15][16][17][18][19][20] three used GTN ointment [21][22][23] and three used a diclofenac suppository. 6,24,25 PPNB was accomplished by a 22-G needle under ultrasound guidance into the neurovascular bundle at the base of the prostate, just lateral to the junction between the prostate and seminal vesicle bilaterally in all, but not specified in three studies.…”

“…Ultrasound probe-related pain was assessed in 12 studies involving 1391 patients. 10,12,13,15,16,[18][19][20][21][23][24][25] In general, IRLA + PPNB modalities significantly reduced the probe manipulation pain (WMD −2.06, 95% CI −2.77 to −1.35, P < 0.001; Fig. 3).…”