Archive - Sex & Ejaculation After Biopsy, Digital Rectal Exam (DRE) & Gleason Score

Questions & Answers

My pathology report after my prostatectomy showed a Gleason score of 3+4=7, with a tertiary 5. My doctor said the tertiary 5 may increase my chance of tumor recurrence. Can you explain what this means?

A tertiary Gleason pattern refers to a very minor component, i.e., just a “smidge” of that type of cancer. Therefore, the predominant pattern of cancer in your prostate was the less aggressive pattern 3. The majority pattern is called the “primary” pattern. The “secondary” pattern was the intermediately aggressive pattern 4. The “tertiary” pattern, which by definition can comprise no more than 5% of the cancer, was the most aggressive pattern 5. The tertiary Gleason 5 pattern does carry a higher risk for recurrence than if there were only patterns 3 and 4 present, but not as much as if the primary or secondary patterns had been pattern 5.

Does a needle biopsy of the prostate spread cancer cells?

There is no clinical evidence suggesting that needle biopsy compromises the chances for cure. First, the needle is designed so that it enters the prostate as a solid piece of metal; once in the prostate it opens up and “bites off” a sliver of prostate tissue and then closes and comes out again as a solid piece of metal. All of this takes place in a fraction of a second. There is no evidence that tumor cells “track” along the path of the needle. Also, there are countless patients who have been cured of prostate cancer after having had many needle biopsies.

How long after a prostate biopsy can you expect to still have blood in your semen?

It is not rare for a man to still have blood in his semen as long as two or three months after a prostatic biopsy.

Relating to one of your other questions – blood in semen after prostatic biopsy, which you say may last for 2-3 mos – does it help to clear it any better/faster by increasing the frequency of ejaculation, or does further aggravating the prostate in such a way delay healing?

There is no solid data on this issue. After a week or so after the biopsy, I believe that more frequent ejaculation would help clear the semen. If the blood becomes more bright red (rather than rust colored or brown), it may indicate that the situation is being aggravated.

My biopsy states: “One of the cores shows perineural invasion by tumor glands.” Does this mean the cancer has spread from the prostate gland or am I still a candidate for nerve-sparing surgery?

This does not necessarily mean that you are not a candidate for nerve-sparing surgery. It does indicate an increased risk (but by no means a certainty) that the cancer has spread beyond the capsule of the prostate, which would make it more likely that it might not be possible to spare both nerves. There are other questions on the website discussing perineural invasion. Please refer to those questions.

Is a transrectal prostrate biopsy done with a local anaesthetic and with an ultrasound?

Not always, but, in my opinion, it should be. With local anesthesia, it is virtually painless and with ultrasound guidance it is more accurate.

I was biopsied and diagnosed with PCa with a Gleason score of 8. Being that the more aggressive cancer cells with a score this high tend to metastasize easier, would the biopsy procedure itself, opening veins, etc. be a cause for further spreading of the cancer?

The short answer is “not to our knowledge.”

Can I be with my husband during his prostate needle biopsy?

It would, of course, depend upon the doctor’s preferences, but I have had spouses present during biopsy procedures.

Are biopsy samples ever mixed up? And is a second biopsy reviewed by a different pathology lab advisable if a man thinks that might have happened?

It is very unlikely that the biopsy cores were mixed up, but there are ways to check to be certain. The biopsy could be tissue typed to see if it matches your tissue – for a cost. I do not think another biopsy would be advisableToo many biopsies can cause scarring around the prostate gland that can make nerve-sparing surgery more difficult.

I have had biopsies three times with each one turning out negative. My PSA went from 5 to 7 to 13.5 and now it is at 11.5. My doctor wants to do exploratory surgery. I am wondering if this is really necessary. Would you recommend that I get more testing done at well-known places? Fortunately, my health plan will cover this. If so, what should I request from these clinics that my own urologist has not already done?

I’m not certain what he meant by exploratory surgery. Sometimes, performing multiple biopsies under anesthesia can help find cancers that were missed by out-patient office biopsies. Please see other Q&A about high PSA and multiple negative biopsies. The key is to have the prostate gland sampled thoughtout – especially the anterior region, which is often missed on office biopsies.

I am 52, PSA 3.2, Gleason 3+3=6. But the path report found cancer cells in 7 of 8 cores. Does this indicate wide-spread cancer and what is the best treatment?

Not necessarily. The relatively low PSA and Gleason grade are countervailing favorable features. You might have diffuse cancer in your prostate gland that still has not escaped. In general, if you are healthy, and all other tests suggest that the cancer has not spread, I would say that radical prostatectomy is the most effective treatment for you.

How long after a biopsy do you have to wait before you can have intercourse?

You should wait a week to minimize bleeding.

I am 54 and my regular doctor detected a nodule on my prostrate and sent me to a urologist about two years ago. He is montioring my PSA which has been below 1.0. Last year, it jumped to 1.3 but fell a few months later to .8 and he still did not recommend biopsy. Yesterday, I learned that my 52 year old younger brother was diagnosed with prostate cancer. My father also has prostate cancer that was diagnosed late; he is 80 and is treated with hormones and is doing well. Should I have a biopsy? And what does that PSA count and the nodule mean? Anything else you would recommend?

With your family history and the presence of a nodule in your prostate, I would recommend a biopsy. The chances of finding cancer are lower if the PSA is low, but there are some cancers (and some patients) that do not produce high PSA levels.

Are there any negatives to having numerous prostate biopsy procedures?

Too many biopsy procedures can cause scarring around the prostate gland that can make nerve-sparing surgery more difficult.

What number of biopsies do you recommend so a patient can still be a candidate for nerve sparing surgery?.

It is important that the urologist take enough biopsies to ensure thorough sampling of the prostate. Obviously biopsies can cause inflammation, bleeding and scarring that can make nerve-sparing surgery more difficult to perform, but it is necessary to establish the diagnosis of cancer first.

My father has prostate cancer age 66 he has been told it is outside the prostate. His Gleason score is between 4-5. An MRI shows it not to be in the bone, but he has been told surgery is not possible and to go for radiation treatments. Should he seek another opinion? Is the score 4-5 bad?

Gleason 4+5 is an aggressive tumor that usually has spread beyond the prostate gland at the time of diagnosis and often is best treated with hormonal therapy.

My husband had his prostate removed a few months ago. The biopsy indicated perineural involment. The Gleason score is 6 and tumor designated as pT2+. The seminal vesicles and lymph nodes are not involved. I am not clear re: the perineural involvement and where it is located in relation to the prostate gland. His PSA after 1 month was 0. However, we were told there is a 30% it could return.

There are several Q&A on my website explaining the significance of “perineural invasion.” Please read them for more details. The bottom line is that it is not an independent risk factor for tumor recurrence if the tumor was confined within the prostate gland and the other tumor features (Gleason grade, PSA, etc. were favorable).

I am 57 years old. My recent PSA was 7 up from 5 six months ago. I expect my urologist will recommend a biopsy. I also have colitis. I am concerned about having to stop my colitis medication (six Colozal capsules per day) prior to the biopsy.

The biopsy could be done without stopping the medication. There would be an increased risk for bleeding, but it would not be prohibitively high.

I am a 46 year old white/hispanic male. I recently had two PSA’s and they both were 8. I had read that there was a 25% chance of cancer for men with this elevated PSA level. I had a digital rectal exam and the doctor said my prostate felt normal but that he was going to send me for a biopsy. Since the DRE came up normal have my odds of having cancer dropped below 25% or is that still the odds? Secondly, if I do have cancer, are the odds that it has spread beyond my prostate lower since my DRE came back normal?

Actually, the odds are closer to 35% to 40% that cancer will be found with 12-core needle biopsy. It is still lower than it would be if the DRE were suspicious for cancer. Also, the chances that the cancer has spread beyond the prostate is also lower if the DRE is normal.

My urologist suggests a biopsy, but I am worried about its side effects, especially the possibility of causing metastases. I read there is a 3.0 Telsa magnet MRI that may detect very small tumors. Can this be an alternative to biopsy?

The powerful magnets may allow MRI scans to detect small areas of prostate cancer, but these scans are far from perfect and are not an adequate substitute for a biopsy. Furthermore, there is no evidence that biopsies cause metastases.

Regarding a post radical prostatectomy report, what do the following mean?

  1. Tertiary pattern 5
  2. MX
  3. RO

  1. In the Gleason scoring system, the majority Gleason pattern is called the primary pattern. The minority pattern is called the secondary pattern. If there is another pattern that makes up only a “smidge” (less than 5% of the cancer), it is called the tertiary pattern. A tertiary pattern 5 would mean that there is just a “smidge” of the most aggressive Gleason pattern present.
  2. The “M” category relates to whether or not distant metastases are present. If the bone scan and CT scan show no evidence of metastases, the M category is “M0.” If the scans show that metastases are present, the M category is “M1.” If the pathologist does not know the results of the scans, it is called “MX,” i.e. they don’t know whether or not metastases are present.
  3. The “R” category refers to the surgical margin; if there is cancer at the margins, it is called “R1.” If all of the margins are clear, it is called “R0.”

I am 50 years old and my PSA has been 0.4 on my last 2 tests. However, my doctor says that my prostate is firm on one side and my PCA3 was 51.1. What does this suggest?

Although there is a strong correlation between the PSA level and prostate cancer, it is possible for men with a very low PSA to have prostate cancer. In general, a biopsy is recommended in men who have a firm region in the prostate, and the PCA3 of 51.1 (normal is less than 30) is also an indication for a biopsy.

Which test is more accurate after a positive biopsy—MRI or PET Scan?

The MRI, by far. In general, glucose based PET scans are not useful in prostate cancer. However, the biopsy procedure can also create artifacts that make MRI scans inaccurate as well.

I am 58 years old and have undergone several urethroplasties for scar tissue in my urethra. My surgeon recommended an MRI scan of my pelvis to detect prostate cancer, as my elder brothers had prostate cancer. The MRI scan revealed a normal prostate size, diffuse T2 hypointense signal in the left peripheral zone having nonspecific appearance. The prostatic capsule is intact and the fat planes are well preserved. Seminal vesicles are normal. My PSA is 0.6. My surgeon has recommended prostate biopsy. Please advise if it is essential.

I would speculate that your urologist is concerned about your strong family history and the “hypointense” signal in the peripheral zone, which could be due to prostate cancer or to inflammation. Your PSA level is normal, but some prostate cancers do not produce much PSA, particularly the most aggressive high-grade prostate cancers. I would suggest that you have a discussion with him about why he recommends the biopsy.

Can I have a needle biopsy by being sedated instead of being awake?

Yes. About one-third of my patients have their needle biopsies performed under deep sedation in the operating room. The procedure is similar to a colonoscopy under sedation. In some cases, the biopsy procedure can be accomplished more completely and efficiently than if the patient is awake and not tolerating the manipulations well.

Can taking a biopsy leave scar tissue that can be mistaken later as a tumor?


How long should I wait after a prostate biopsy to have sex?

To avoid bleeding, it would be prudent to wait one week.

My last prostate biopsy was painful. Is this common? Also, after biopsy, I have difficultly having an erection and I have a double urine stream. Would another biopsy make these problems worse?

Biopsies can be painful if there is insufficient time for the numbing medicine to become effective. Also, biopsy can be performed under deep sedation but as an outpatient, usually in an operating room. It is common to have some urinary changes due to swelling of the prostate from the biopsy.

If prostate cancer in older men is more often the fast-growing type, do you recommend older men have a biopsy sooner?

In general, prostate cancer is more aggressive in older men. If a biopsy is indicated, sooner is better.

My prostate biopsy showed no cancer but there was high-grade PIN. What does this mean for me?

High-grade prostatic intraepithelial neoplasia (HGPIN) and atypical glands are sometimes precancerous changes, as about 25-30% of patients who have them may later be diagnosed with prostate cancer. Sometimes the conversion can take 10 years or more. My policy is to check the patient’s Prostate Health Index blood test (PHI) quarterly for the next year and then decide whether a follow-up biopsy is indicated to rule out the development of cancer.

The results of my prostate biopsy showed only inflammation in my prostate. Is there anything I should be doing to treat the chronic inflammation?

Prostatic inflammation is the most common cause of an elevated PSA. In the past, we treated patients with long-term antibiotic therapy; however, our infectious disease experts are concerned that this would lead to the intestines becoming colonized with bacteria that are resistant to multiple antibiotics. Accordingly, we now must rely on the patient’s immune system to deal with the prostate inflammation unless the patient is acutely ill with a high fever and/or a urinary tract infection.

Could you explain the old and new Gleason tumor grading systems and how they affect patient management options?

Here is the story on Gleason grading: in the 1960s, Dr. Donald Gleason introduced a grading system that included five patterns of cancerous cells, 1 through 5, with 1 being the least aggressive and 5 being the most aggressive. The first number is the “primary” or majority pattern and the second number is the “secondary” or minority pattern present in the biopsy specimen. Some patients have a “smidgen” (less than 5% of the cancer tissue) that is called the “tertiary” pattern as well. The primary and secondary pattern numbers were added together to give a Gleason Sum or Score that could range from 2 to 10. Over the decades, we learned that all Gleason scores of 3+3 or less behaved the same and were generally very mild (not aggressive).

About five years ago, an international group of pathologists modified and simplified the Gleason system into five different Gleason Grade Groups. Grade Group 1 is Gleason 6 or less; Grade Group 2 is Gleason 3+4; Grade Group 3 is 4+3; Grade Group 4 is 4+4; and Grade Group 5 is Gleason scores of 9 or 10.

The great majority of patients who are candidates for active surveillance patients will have Gleason 3+3=6 or less and therefore be Grade Group 1. A few with very small amounts of Gleason 3+4 (Grade Group 2) can also be potential candidates. Patients with more aggressive tumors require active treatment.

My biopsy revealed a Gleason grade 3+4=7 (Grade Group 2) prostate cancer. Could my MRI indicate any potentially higher grade cancer?

We cannot accurately determine from the MRI scan whether you have a higher grade prostate cancer. Your pathology results already show that your cancer is in the low end of the moderately aggressive category.

I just noticed on my final pathology report that it stated “Perineural Invasion: Present.” Is this common? How often do you see this versus not, and how does it affect long-term prognosis? I’m assuming this was in regard to prostate cancer that had invaded nerves inside the prostate, since it was organ confined.

“Perineural invasion” refers to tumor cells surrounding nerves on the inside of the prostate that regulate the amount of prostatic fluid secreted. It is always present if the pathologist looks through the entire prostatectomy specimen. However, if it is seen in the biopsy specimen, it is associated with an increased risk that the cancer has spread microscopically outside the prostate. However, it does not have the same adverse connotation in the prostatectomy specimen. All of these nerves have been removed with the removal of the prostate.

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