If you need a prostate biopsy, your specialist may use either a transperineal or transrectal approach. The main difference is how the biopsy needle reaches your prostate: through the skin of your perineum with a transperineal biopsy, or through the wall of your rectum with a transrectal biopsy.
Both approaches can detect prostate cancer effectively, particularly when MRI findings are used to guide sampling. However, the transperineal approach is increasingly used because the needle avoids the rectal wall, which lowers the risk of infection.
What Is a Transperineal Prostate Biopsy?
If you have a transperineal prostate biopsy, your doctor takes small tissue samples through the skin between your scrotum and anus, known as the perineum. An ultrasound probe is usually placed in your rectum to provide clear images of your prostate.
The biopsy needle itself does not pass through your rectal wall. Instead, your specialist uses the ultrasound images to guide the needle through the perineal skin and collect tissue samples from the prostate.
How Does a Prostate Biopsy Fit Into the UK Diagnostic Pathway?
If prostate cancer is suspected, your specialist will usually consider several factors before recommending a biopsy. These may include your PSA result, examination findings, medical history and a multiparametric MRI scan.
NICE recommends multiparametric MRI as the first-line investigation for people with suspected clinically localised prostate cancer. MRI can identify areas that may need targeted sampling and can also help your specialist decide whether a biopsy is necessary. Your individual biopsy recommendation will depend on your MRI findings and other clinical risk factors.
What Is a Transrectal Prostate Biopsy?
If you have a transrectal prostate biopsy, your doctor places an ultrasound probe in your rectum to see your prostate and guide the procedure. The biopsy needle then passes through the rectal wall before entering the prostate to collect tissue samples.
This differs from a transperineal biopsy, where the needle passes through the skin of your perineum instead. Your specialist will consider your individual circumstances when deciding which approach is most suitable for you.
Which Biopsy Has the Lower Infection Risk?
If you have a transperineal prostate biopsy, the biopsy needle does not pass through the rectal wall, so there is less exposure to bacteria from the rectum. This gives the transperineal approach a lower risk of infection compared with a transrectal biopsy.
Reducing the risk of infection is one of the main advantages of the transperineal approach. Your specialist will still explain the possible risks and aftercare you should follow after the procedure.
How Big Is the Difference in Infection Risk?
In the final published results of the PREVENT randomised trial, there were no Grade 2 or higher biopsy-related infections among 372 men who underwent transperineal biopsy without prophylactic antibiotics, compared with six infections (1.6%) among 370 men who underwent transrectal biopsy with targeted antibiotic prophylaxis.
Infection rates can vary between studies and clinical settings, particularly according to the antibiotic and infection-prevention strategies used for transrectal biopsy. The risk you face in clinical practice can vary depending on your health, the biopsy technique used and your hospital’s infection-control and antibiotic policies. Your specialist can explain the risks that apply to you.
Why Can Transrectal Biopsy Cause Infection?
If you have a transrectal prostate biopsy, the needle passes through the rectal wall before entering your prostate. Because bacteria naturally live in the rectum, bacteria can occasionally enter the prostate or urinary tract during the procedure and cause an infection.
Serious infection, including sepsis, is uncommon but possible. Compared with transperineal biopsy, this higher infection risk is an important reason the transperineal approach is increasingly used.
Are Antibiotics Needed?
If you have a transrectal prostate biopsy, antibiotic prophylaxis is generally used to reduce the risk of infection because the needle passes through the rectal wall. With a transperineal biopsy, routine prophylactic antibiotics may not be required in some protocols, particularly for patients at lower infection risk, although practice varies between centres and according to individual circumstances.
Your hospital’s policy may differ depending on your circumstances and the biopsy technique being used. Follow the instructions given by your clinical team and take any prescribed antibiotics exactly as directed.
How Do the Two Biopsy Approaches Compare for Cancer Detection?
Both approaches can detect clinically significant prostate cancer effectively. Some trials have found similar detection rates, while the large UK TRANSLATE trial found a modest but statistically significant increase in the detection of Grade Group 2 or higher prostate cancer, generally regarded as clinically significant disease, with local-anaesthetic transperineal biopsy.
The likelihood of detecting clinically significant cancer in an individual patient still depends on factors such as MRI findings, lesion location, targeting technique and sampling strategy.
- PREVENT Found Similar Detection: In the PREVENT trial, Grade Group 2 or higher prostate cancer was detected in 55% of men having a transperineal biopsy and 52% having a transrectal biopsy. This difference was not statistically significant.
- MRI Findings Matter: The results of your prostate MRI can help your healthcare professional identify areas that may need targeted biopsy.
- Targeting Technique Matters: How accurately the biopsy targets suspicious areas can affect whether clinically significant cancer is detected.
- Sampling Areas Matter: The parts of your prostate that are sampled can also influence the likelihood of finding cancer.
Your urologist will consider your MRI results, clinical findings and individual circumstances when deciding which biopsy approach is most appropriate for you.
Can Transperineal Biopsy Reach More of the Prostate?
If you have a transperineal biopsy, this approach can provide particularly useful access to areas such as the front (anterior) and lower (apical) parts of your prostate. These regions may sometimes be more difficult to sample adequately using a transrectal approach.
This may be particularly useful if your MRI shows a suspicious area towards the front of your prostate. Your specialist will use your MRI findings to decide which areas need to be sampled.
Can Both Techniques Target MRI Abnormalities?
If your MRI shows a suspicious area, either a transperineal or transrectal biopsy can be used to target it. Your specialist can use the MRI findings to guide the biopsy needle towards the area that needs closer examination.
MRI-targeted samples may also be combined with systematic samples from other areas of your prostate. This can provide a broader assessment when your specialist believes additional sampling would be useful.
What Side Effects Can Follow Transperineal Biopsy?
After a transperineal prostate biopsy, you may notice some blood in your urine or semen, along with temporary soreness or bruising around your perineum. You may also find that your urinary flow is temporarily weaker because of swelling following the biopsy.
The duration of bleeding varies between patients. Blood in your urine usually settles sooner, while your semen may remain pink, red or brown for several weeks and occasionally longer. Your biopsy team should explain what is expected and when persistent or heavy bleeding needs medical assessment.
Infection can still occur, but it is uncommon with the transperineal approach. If you develop a fever, shivering, worsening pain or feel significantly unwell, contact your healthcare team urgently.
Which Type of Anaesthetic Is Used?
If you have a prostate biopsy, both transperineal and transrectal techniques can be performed under local anaesthetic. A transperineal biopsy can often be completed as an outpatient procedure without needing a general anaesthetic.
In some circumstances, your specialist may recommend spinal or general anaesthesia instead. The most suitable option will depend on your individual circumstances, the biopsy planned and your ability to tolerate the procedure comfortably.
Clinical Tip
If you take an anticoagulant or antiplatelet medicine, such as warfarin, apixaban, rivaroxaban or clopidogrel, make sure your biopsy team knows. Some medicines may need to be temporarily adjusted around the procedure, but you should not stop or restart prescribed blood-thinning treatment unless your clinical team has told you exactly when to do so.
Is One Technique More Painful?
Both transperineal and transrectal biopsies can cause temporary discomfort. Evidence suggests that transperineal biopsy may be slightly more uncomfortable during the procedure for some patients, although local anaesthetic is used to reduce pain and the experience varies between individuals.
The amount of discomfort can depend on the anaesthetic technique, the number of samples taken and your individual sensitivity. If you feel significant pain during the procedure, tell your clinical team so they can take steps to keep you comfortable.
What Side Effects Can Follow Transrectal Biopsy?
After a transrectal prostate biopsy, you may notice some blood in your urine or semen. You may also experience rectal bleeding because the biopsy needle passes through the wall of your rectum.
Minor rectal bleeding usually settles, but you should seek medical advice if bleeding becomes heavy, persists or is accompanied by feeling significantly unwell.
Infection is another possible complication, as the needle passes through an area where bacteria naturally live. Contact your healthcare team urgently if you develop a fever, shivering, worsening pain or feel significantly unwell after the biopsy.
Can Either Biopsy Cause Urinary Retention?
Yes. If you have a prostate biopsy, temporary swelling of the prostate can sometimes make it difficult to pass urine, regardless of whether the biopsy is transperineal or transrectal.
Rates of urinary retention can vary between studies and according to the biopsy technique and sampling strategy used. In the PREVENT trial, urinary retention requiring medical intervention was uncommon with both biopsy approaches.
When Should You Seek Urgent Medical Help?
After a prostate biopsy, contact your biopsy team urgently or call NHS 111 if you develop worsening pain, burning when passing urine or other symptoms that may suggest an infection and you are not severely unwell.
Go to A&E urgently if you suddenly cannot pass urine, have heavy bleeding or pass large blood clots, develop a very high or very low temperature, feel hot or cold and shivery, or become rapidly or severely unwell. Call 999 or go to A&E immediately if you think you may have sepsis, particularly if you are breathing very fast or having difficulty breathing, become confused or develop slurred speech, or have blue, pale, grey or blotchy skin, lips or tongue. Sepsis does not always cause every typical symptom, so seek immediate medical help if you feel seriously unwell and think something is seriously wrong.
Why Is Transperineal Biopsy Increasingly Preferred?
Transperineal biopsy is increasingly used and may be preferred in many centres because it has a lower infection risk while providing effective detection of clinically significant prostate cancer. It can also provide useful access to anterior areas of the prostate and can often be performed under local anaesthetic.
| Feature | Transperineal Biopsy | Transrectal Biopsy |
| Needle route | Through the skin of the perineum | Through the rectal wall |
| Infection risk | Lower because the biopsy needle avoids the rectum | Higher because the needle crosses the rectal wall |
| Antibiotics | Routine prophylactic antibiotics may not be required in some protocols; practice varies by centre and individual infection risk | Prophylactic antibiotics are generally used |
| MRI targeting | Can target suspicious MRI abnormalities | Can target suspicious MRI abnormalities |
| Prostate access | Particularly useful for anterior and apical areas | Effective sampling, although some anterior areas may be more difficult to reach |
| Anaesthetic | Often performed under local anaesthetic | Can also be performed under local anaesthetic |
| Procedural discomfort | May cause slightly greater immediate discomfort for some patients | Can also cause temporary discomfort; individual experience varies |
| Common after-effects | Blood in urine or semen and temporary perineal soreness or bruising | Blood in urine or semen and possible rectal bleeding |
| Cancer detection | Effective; detection depends on MRI findings, targeting and sampling | Effective; detection depends on MRI findings, targeting and sampling |
What Does NICE Say About Transperineal Biopsy?
NICE HealthTech guidance HTG680 recommends local-anaesthetic transperineal prostate biopsy using the PrecisionPoint freehand needle-positioning device as an option for diagnosing prostate cancer. NICE also recommends the EZU-PA3U device, Trinity Perine Grid and UA1232 puncture attachment as options, although there is less evidence for these devices than for PrecisionPoint.
If you are considering specialist prostate biopsy services in London, you can discuss whether a transperineal approach is suitable for your MRI findings and individual circumstances. Your specialist can explain the benefits, risks and available biopsy techniques before you decide.
Is Recovery Different?
Recovery after either a transperineal or transrectal prostate biopsy is usually relatively quick, and you can often go home on the same day. Both approaches can cause temporary bleeding or discomfort; transperineal biopsy may also cause soreness or bruising around the perineum, while transrectal biopsy can cause rectal bleeding.
The overall recovery time is often similar between the two approaches. The more important difference is their complication profiles, particularly the lower infection risk associated with the transperineal approach.
Does Transrectal Biopsy Still Have a Role?
Yes. If you need a prostate biopsy, a transrectal approach remains an established option and can detect clinically significant prostate cancer. However, it carries a higher risk of infection because the needle passes through the rectal wall.
Many centres are therefore moving towards transperineal biopsy where appropriate. Your urologist will consider your MRI findings, clinical circumstances and the facilities available when recommending the most suitable approach.
Frequently Asked Questions
1. What is the difference between transperineal and transrectal prostate biopsy?
The main difference is where the biopsy needle enters the body. A transperineal biopsy passes through the skin between your scrotum and anus, while a transrectal biopsy passes through the rectal wall to reach the prostate.
2. Which prostate biopsy has a lower infection risk?
Transperineal biopsy has a lower infection risk because the needle does not pass through the rectum, where bacteria naturally live. This is one of the main reasons the transperineal approach is increasingly preferred.
3. Is a transperineal biopsy more accurate than a transrectal biopsy?
The evidence does not show that one approach is always more accurate in every situation. The PREVENT randomised trial found similar detection of Grade Group 2 or higher prostate cancer with the two biopsy routes, while the 2025 UK TRANSLATE trial found a modestly higher detection rate for Grade Group 2 or higher cancer with local-anaesthetic transperineal biopsy. MRI findings, lesion location, targeting and the sampling strategy can all affect whether clinically significant cancer is detected.
4. Can both types of biopsy use MRI targeting?
Yes. MRI findings can guide either a transperineal or transrectal biopsy towards suspicious areas of the prostate. Your specialist may also combine targeted and systematic samples when appropriate.
5. Can a transperineal biopsy reach the whole prostate?
A transperineal biopsy can provide broad access to different parts of the prostate, including the anterior and apical regions, which may sometimes be more difficult to sample adequately through the transrectal route. This can be particularly useful when MRI identifies a suspicious area towards the front of the gland. However, as with any biopsy technique, sampling does not guarantee that every area of the prostate will be tested.
6. Is a transperineal biopsy more painful?
Both biopsy techniques can cause temporary discomfort. Evidence suggests that transperineal biopsy may be slightly more uncomfortable during the procedure for some patients, although local anaesthetic is used to reduce pain. Your experience can also depend on the anaesthetic technique, the number of samples taken and your individual sensitivity.
7. Do you need general anaesthetic for a transperineal biopsy?
Not necessarily. Many transperineal biopsies can be performed under local anaesthetic as an outpatient procedure. Spinal or general anaesthesia may be used in selected circumstances.
8. What are the common side effects of a transperineal biopsy?
You may experience blood in your urine or semen, temporary soreness or bruising around the perineum and some difficulty with urinary flow. Infection is possible but uncommon with the transperineal approach.
9. What are the risks of a transrectal biopsy?
Transrectal biopsy can cause bleeding, temporary discomfort and blood in the urine or semen. Because the needle passes through the rectal wall, there is also a greater risk of infection, including potentially serious infections.
10. Can a prostate biopsy miss cancer?
Yes. A biopsy takes tissue samples from selected areas rather than examining every part of the prostate microscopically, so a biopsy cannot completely exclude cancer in every situation. If your biopsy is negative but your PSA, MRI or other findings remain concerning, your specialist may recommend continued monitoring or further assessment.
Final Thoughts: Choosing Between Transperineal and Transrectal Prostate Biopsy
Both transperineal and transrectal prostate biopsies can provide the tissue needed to diagnose prostate cancer and assess its grade. Evidence shows that both approaches can detect clinically significant prostate cancer, although individual studies have reported somewhat different detection rates. Transperineal biopsy is increasingly used because it has a lower infection risk and can provide useful access to areas such as the anterior and apical prostate.
If you are considering a prostate biopsy in London or have been advised to undergo a biopsy after an abnormal PSA or MRI, you can contact Prostate Clinic London to discuss your assessment and biopsy options. Your specialist can review your results, explain whether a transperineal or transrectal approach may be appropriate for you, and help you understand the next steps in your care.
References:
- National Institute for Health and Care Excellence (NICE) (2019) Prostate cancer: diagnosis and management. NICE guideline NG131. Published 9 May 2019; last reviewed 13 August 2025. Available at: https://www.nice.org.uk/guidance/ng131
- National Institute for Health and Care Excellence (NICE) (2023) Transperineal biopsy for diagnosing prostate cancer. HealthTech guidance HTG680. Published 1 June 2023. Available at: https://www.nice.org.uk/guidance/htg680
- British Association of Urological Surgeons (2024) Transperineal ultrasound-guided biopsies of the prostate gland. Patient Information Leaflet O24/107. Published July 2024. Available at: https://www.baus.org.uk/patients/information_leaflets/112/transperineal_prostate_biopsies
- British Association of Urological Surgeons (2024) Transrectal ultrasound-guided biopsies of the prostate gland. Patient Information Leaflet O24/108. Published July 2024. Available at: https://www.baus.org.uk/patients/information_leaflets/
- Hu, J.C., Assel, M., Allaf, M.E. et al. (2024) ‘Transperineal vs transrectal prostate biopsy – The PREVENT randomized clinical trial’, JAMA Oncology, 10(11), pp. 1590–1593. Available at: https://pubmed.ncbi.nlm.nih.gov/39298143/
- Bryant, R.J., Marian, I.R., Williams, R. et al. and the TRANSLATE Trial Study Group (2025) ‘Local anaesthetic transperineal biopsy versus transrectal prostate biopsy in prostate cancer detection (TRANSLATE): a multicentre, randomised, controlled trial’, The Lancet Oncology, 26(5), pp. 583–595. Available at: https://www.sciencedirect.com/science/article/pii/S1470204525001007
- Du, J., Chen, S., Terris, M.K., Miyamoto, H., Yu, Y. and Ying, Q. (2025) ‘Comparison of prostate cancer detection rates and complications between transrectal ultrasound-guided transperineal and transrectal biopsies: a systematic review and meta-analysis’, Translational Andrology and Urology, 14(5), pp. 1418–1428. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC12170284/
- Najjar, S., Mirvald, C., Danilov, A., Labanaris, A., Vlaicu, A.G., Giurca, L., Sinescu, I. and Surcel, C. (2025) ‘Comparative analysis of diagnostic accuracy and complication rate of transperineal versus transrectal prostate biopsy in prostate cancer diagnosis’, Cancers, 17(6), article 1006. Available at: https://www.mdpi.com/2072-6694/17/6/1006
- Paesano, N., Picola, N., Muñoz-Rodríguez, J. et al. (2025) ‘Efficacy of prostate biopsies via transperineal and transrectal routes for significant prostate cancer detection: a multicenter paired-matched study’, Diagnostics, 15(3), article 288. Available at: https://www.mdpi.com/2075-4418/15/3/288
- NHS (2026) Sepsis. Page last reviewed 14 May 2026. Available at: https://www.nhs.uk/conditions/sepsis/