Prostate Biopsy: What to Expect Before, During and After the Procedure

By Mr Neil Haldar, Consultant Urological Surgeon

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In brief

A prostate biopsy is the standard test used to confirm most diagnoses of prostate cancer. It involves taking small tissue samples from the prostate to examine under a microscope.

Most men being investigated for possible prostate cancer now have a multiparametric MRI scan before a biopsy is considered. The MRI can identify suspicious areas and help the urologist decide whether a biopsy is necessary and, if so, where to take samples.

Prostate biopsies are increasingly performed through the skin of the perineum rather than through the rectum. This is known as a transperineal prostate biopsy and has a substantially lower risk of infection than the traditional transrectal approach.

A raised PSA does not automatically mean that a biopsy is required. The decision should take into account the PSA level and trend, prostate size, PSA density, MRI findings, examination findings, family history, general health, and personal preferences.

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What is a prostate biopsy?

A prostate biopsy is a procedure in which a number of very small tissue samples are taken from the prostate gland. These samples are known as biopsy cores.

The cores are sent to a specialist pathologist, who examines them under a microscope to determine whether prostate cancer is present. If cancer is identified, the pathologist will also assess how abnormal the cells appear and how much cancer is present in the samples.

A biopsy can therefore provide important information about:

• whether prostate cancer is present;
• the Grade Group and Gleason score;
• how many samples contain cancer;
• how much cancer is present within each sample;
• whether particular microscopic patterns are present.

A biopsy does not, however, examine every part of the prostate. It cannot by itself show the complete distribution or exact extent of cancer throughout the gland.

The results must therefore be considered alongside the PSA, MRI scan, clinical examination and other relevant information. In some men, further scans may also be needed to determine whether cancer has spread outside the prostate.

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Why might a prostate biopsy be recommended?

A prostate biopsy is not usually the first investigation performed when prostate cancer is suspected.

The decision is normally made after an overall assessment of a man’s risk. No single PSA value or MRI finding automatically determines whether every man should have a biopsy.

The most common reasons for recommending a biopsy include the following.

A raised or rising PSA

Prostate-specific antigen, or PSA, is a protein produced by prostate tissue. A small amount normally enters the bloodstream and can be measured with a blood test.

A raised PSA can be associated with prostate cancer, but it is not specific to cancer. PSA can also be increased by:

• benign enlargement of the prostate;
• inflammation of the prostate;
• a urinary infection;
• recent ejaculation;
• recent catheterisation or instrumentation;
• urinary retention;
• recent procedures involving the prostate.

For this reason, an unexpectedly raised PSA may sometimes be repeated before further investigation is arranged.

PSA interpretation also depends on factors such as age, prostate size, previous PSA results, and MRI findings.

PSA density

PSA density compares PSA levels with prostate volume.

It is calculated by dividing the PSA by the prostate volume, which can usually be estimated from an MRI or ultrasound scan. This helps distinguish between a PSA that may be explained by a large benign prostate and one that is disproportionately high for the size of the gland.

PSA density is particularly useful when the MRI is normal or only mildly suspicious. A reassuring MRI combined with a low PSA density may allow some men to avoid or defer biopsy. A higher PSA density may increase concern even when the MRI does not show an obvious lesion.

PSA density is only one part of the assessment and should not be interpreted in isolation.

An abnormal prostate examination

During a digital rectal examination, the urologist feels the back surface of the prostate through the rectal wall.

A hard area, nodule, marked asymmetry or other abnormality may increase suspicion of prostate cancer. An abnormal examination may justify further investigation even if the PSA is not markedly raised.

Many prostate cancers cannot be felt on examination, however, so a normal examination does not exclude cancer.

A suspicious MRI scan

Multiparametric MRI has become central to the modern assessment of men with suspected prostate cancer.

MRI findings are commonly graded on a five-point Likert or PI-RADS scale. A score of 1 or 2 is generally considered reassuring, while a score of 4 or 5 indicates a higher probability of clinically significant prostate cancer. A score of 3 is uncertain and must be interpreted alongside PSA density and other risk factors.

An MRI can help answer two important questions:

1. Is a biopsy likely to be necessary?
2. If a biopsy is performed, which areas should be targeted?

Monitoring known prostate cancer

Some men with low-risk or selected favourable intermediate-risk prostate cancer choose active surveillance rather than immediate treatment.

Active surveillance involves carefully monitoring the cancer using PSA tests, clinical review, MRI and, in some cases, repeat biopsy. A repeat biopsy may be advised to confirm that the cancer has not become more extensive or aggressive.

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The role of MRI before prostate biopsy

One of the most important changes in prostate cancer diagnosis has been the introduction of MRI before biopsy.

In the past, prostate biopsies were usually performed without knowing whether there was a specific abnormal area within the gland. Samples were taken systematically from different parts of the prostate in the hope that any cancer would be detected.

MRI now allows clinicians to identify suspicious areas before biopsy.

This has several potential advantages:

• suspicious lesions can be sampled directly;
• clinically significant cancers are more likely to be detected;
• fewer insignificant low-grade cancers may be diagnosed;
• some men with reassuring scans can avoid an immediate biopsy;
• the location and size of a lesion can help plan the procedure;
• MRI findings can contribute to decisions about treatment if cancer is found.

MRI is not perfect. Some clinically significant prostate cancers are not clearly visible on a scan. A reassuring MRI therefore reduces the probability of important cancer but does not reduce it to zero.

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Can a biopsy be avoided if the MRI is normal?

Some men with a normal or low-scoring MRI can safely avoid or defer an immediate biopsy.

This decision should not be based on the MRI result alone. The urologist will also consider:

• the PSA level and trend;
• PSA density;
• prostate examination;
• family history;
• previous biopsy results;
• general health and life expectancy;
• the level of residual clinical concern;
• the man’s preferences regarding uncertainty and further testing.

A man with a reassuring MRI, low PSA density and no other concerning features may reasonably choose continued PSA monitoring.

A biopsy may still be recommended despite a normal MRI if the PSA density is high, the prostate feels abnormal or the overall level of suspicion remains significant.

When a biopsy is deferred, there should normally be a clear monitoring plan. This may include repeat PSA testing, clinical review and further MRI if the PSA changes.

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What is a transperineal prostate biopsy?

A transperineal biopsy is performed by passing the biopsy needle through the skin between the scrotum and the anus. This area is known as the perineum.

An ultrasound probe is placed in the rectum to provide a live image of the prostate. The ultrasound guides the procedure, but the biopsy needle passes through the disinfected perineal skin rather than the bowel wall.

The principal advantage is a much lower risk of infection. The needle does not pass through the rectum and is therefore far less likely to carry bowel bacteria into the prostate or bloodstream.

Transperineal biopsy also allows good access to the front, apex and other areas of the prostate that may be more difficult to sample adequately through the rectal route.

Historically, transperineal biopsies were usually performed under general anaesthetic. Advances in equipment and local-anaesthetic techniques mean that they can now commonly be performed as an outpatient procedure under local anaesthetic.

For these reasons, the transperineal approach has become the preferred biopsy route in many UK centres.

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What is a transrectal prostate biopsy?

A transrectal ultrasound-guided biopsy, often called a TRUS biopsy, is performed by passing the biopsy needle through the rectal wall into the prostate.

An ultrasound probe is placed in the rectum to show the prostate and guide the sampling. Traditionally, approximately 10 to 12 samples were taken in a systematic pattern.

The transrectal approach is relatively quick and can be performed under local anaesthetic. It was the standard biopsy technique for many years and remains in use in some settings.

Its main disadvantage is the risk of infection. Because the biopsy needle passes through the rectal wall, it can carry bowel bacteria into the prostate, urinary tract or bloodstream. This can occasionally lead to serious infection or sepsis.

The increasing prevalence of antibiotic-resistant bacteria has been an important reason for the move towards transperineal biopsy.

A transrectal biopsy may still be appropriate in selected circumstances, depending on local expertise, available equipment and individual patient factors.

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What is the difference between targeted and systematic biopsy?

The route used to reach the prostate and the method used to select the biopsy sites are separate decisions.

A biopsy may include targeted samples, systematic samples or a combination of both.

Targeted biopsy

A targeted biopsy takes samples directly from an abnormality identified on MRI.

Targeting may use one of several techniques.

MRI-ultrasound fusion

Specialist software combines the previously acquired MRI images with the live ultrasound image used during the biopsy. The suspicious lesion can then be displayed on the ultrasound screen and targeted more precisely.

Cognitive targeting

The urologist reviews the MRI and uses their understanding of the lesion’s position to target the same location using live ultrasound. This is sometimes described as cognitive fusion.

In-bore MRI biopsy

The biopsy is performed while the patient is inside the MRI scanner. This technique can provide direct visualisation of the target but is less widely available and is generally reserved for selected cases.

Systematic biopsy

A systematic biopsy samples a number of predetermined areas throughout the prostate. This provides broader coverage of the gland and may identify significant cancer that is not clearly visible on MRI.

Regional or perilesional sampling

Some clinicians take additional samples from the tissue immediately around an MRI-visible lesion. This may detect cancer extending beyond the precise boundary shown on the scan while avoiding an unnecessarily extensive systematic biopsy.

Which approach is best?

In men having their first biopsy, targeted samples are often combined with systematic or regional samples. This is because clinically significant cancer can occasionally be found outside the MRI-visible target.

The best sampling strategy depends on:

• whether this is the first or a repeat biopsy;
• the MRI appearance;
• the size and location of the lesion;
• prostate volume;
• PSA density;
• previous biopsy findings;
• the individual level of cancer risk.

Taking more samples may increase the chance of detecting significant cancer, but it can also increase discomfort and the diagnosis of small low-grade cancers that may never cause harm. The biopsy plan should therefore be tailored to the individual man rather than applied as a rigid formula.

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How should I prepare for a prostate biopsy?

Your biopsy team should provide written instructions before the procedure. These may vary slightly between hospitals.

Blood-thinning medication

Tell the team if you take any medication that affects blood clotting, including anticoagulants or antiplatelet drugs.

Examples include warfarin, apixaban, rivaroxaban, edoxaban, dabigatran, clopidogrel and aspirin.

Some medicines may need to be stopped temporarily or adjusted. Others may be continued.

Do not stop any prescribed blood-thinning medication unless you have received specific instructions from the biopsy team or the clinician responsible for prescribing it.

Stopping some of these medicines without appropriate advice can increase the risk of a stroke, blood clot or other serious complication.

Antibiotics

Antibiotic practice varies by biopsy route, local policy, and individual risk factors.

Antibiotics are normally required for a transrectal biopsy because the needle passes through the bowel wall.

The infection risk after a transperineal biopsy is much lower. Some centres use a single preventive dose, while others may not routinely use antibiotics in low-risk patients.

Urine testing

A urine sample may be checked before the procedure. A biopsy may need to be delayed if there is evidence of a urinary infection.

Tell the team if you develop:

• burning when passing urine;
• cloudy or offensive-smelling urine;
• fever;
• worsening urinary symptoms;
• a recent diagnosis of urinary infection.

Eating and drinking

For a biopsy under local anaesthetic, patients can often eat and drink normally. If sedation or general anaesthetic is planned, fasting instructions will be provided.

Follow your hospital’s instructions, as requirements vary.

Enema

An enema may sometimes be requested before a transrectal biopsy. It is less commonly required for a transperineal procedure.

Transport home

Ask whether you can drive after the procedure.

Driving may not be permitted if you have received sedation or general anaesthetic. Even after a local-anaesthetic biopsy, some men prefer to arrange transport because of discomfort or anxiety.

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What happens on the day of the biopsy?

The precise process depends on whether the biopsy is transperineal or transrectal and whether it is performed under local or general anaesthetic.

For a typical local-anaesthetic transperineal biopsy, the following steps are common.

Initial checks

A member of the clinical team will confirm:

• your identity;
• the reason for the biopsy;
• your medication;
• any allergies;
• whether you have symptoms of infection;
• whether you have followed the blood-thinner instructions;
• that you understand the procedure and have given consent.

You should have an opportunity to ask questions before the biopsy begins.

Positioning

You will usually lie on your back with your legs supported. For some biopsy techniques, you may lie on your side.

The perineal skin is cleaned with antiseptic solution.

Local anaesthetic

Local anaesthetic is injected into the skin and deeper tissues. The injections may sting briefly.

Further anaesthetic is then used to numb the tissues around the prostate. The aim is to make the sampling tolerable, although you may still feel pressure, movement or brief sharp sensations.

Tell the team if you experience significant pain. The team can often give additional local anaesthetic.

Ultrasound guidance

A lubricated ultrasound probe is gently inserted into the rectum. This provides a live image of the prostate.

If fusion targeting is being used, the MRI information is combined with the ultrasound image to locate the suspicious area.

Taking the samples

A biopsy needle takes thin cylinders of tissue from the prostate. Each sample is only a small amount of tissue.

The biopsy device makes a clicking sound as it takes each core. You may feel a brief sting, tap or pressure.

The doctor takes targeted samples from MRI abnormalities. Additional systematic or regional samples may then be taken from other parts of the gland.

How long does it take?

Sampling commonly takes about 20 to 45 minutes, although this varies with the technique, prostate size, number of samples, and complexity of the MRI targets.

Additional time is needed for preparation and observation afterwards.

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Is a prostate biopsy painful?

Most men describe a local-anaesthetic prostate biopsy as uncomfortable rather than severely painful.

The local-anaesthetic injections may cause a brief stinging sensation. The ultrasound probe can create pressure in the rectum, and each biopsy sample may feel like a quick click, tap, or sting.

Individual experiences vary. Factors such as anxiety, prostate size, the number of samples and the position of the target can influence discomfort.

Tell the clinical team if the procedure becomes painful. The team can often administer more local anaesthetic, or pause the procedure.

Men who are particularly anxious, have previously found biopsy difficult or require a more extensive procedure may sometimes be offered sedation or general anaesthetic.

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What happens immediately afterwards?

After the biopsy, you will normally be observed for a period before going home.

The team may check that you:

• feel well;
• are not experiencing significant bleeding;
• can pass urine;
• understand the aftercare instructions;
• know whom to contact if a problem develops.

Most men who have a local-anaesthetic biopsy go home the same day.

You may experience mild aching or bruising in the perineum. Simple pain relief is usually sufficient, but follow your clinical team’s advice.

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Recovery after a prostate biopsy

Recovery is usually relatively quick, although some effects can continue for several weeks.

Returning to work

Many men can return to desk-based work within a day or two. More time may be needed if your job is physically demanding or if you have had sedation or general anaesthetic.

Exercise

It is usually sensible to avoid strenuous exercise, heavy lifting and cycling for a short period after the biopsy. Follow the specific advice given by your hospital.

Driving

Do not drive if you have had sedation or general anaesthetic until the advised restriction period has passed.

After local anaesthetic alone, you should only drive when you feel comfortable, can perform an emergency stop and are not affected by pain or medication.

Sexual activity

Blood in the semen is common after prostate biopsy and may persist intermittently for several weeks.

This is usually harmless, although the colour can appear alarming. Semen may initially look bright red and later become brown or rust-coloured as older blood clears.

Your clinical team may advise avoiding ejaculation for a short period immediately after the procedure.

Fluids

Drinking a reasonable amount of water after the biopsy may help maintain urine flow. You don’t need to drink excessive fluids unless specifically advised.

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What side effects are normal after a prostate biopsy?

Several temporary effects are common.

Blood in the urine

A small amount of blood in the urine is common after biopsy. It may appear intermittently and should gradually settle.

Blood in the semen

Blood in the semen is extremely common and can continue for several weeks. It is not usually dangerous and generally resolves without treatment.

Blood from the rectum

Minor rectal bleeding can occur, particularly after a transrectal biopsy or from the ultrasound probe. It should normally be limited and short-lived.

Perineal bruising or discomfort

Men undergoing transperineal biopsy may notice tenderness, bruising or swelling in the skin between the scrotum and anus.

Temporary urinary symptoms

The prostate can become temporarily swollen or irritated. This may cause:

• increased urinary frequency;
• urgency;
• mild burning;
• a slower urinary stream;
• difficulty starting urination.

These symptoms usually improve as the swelling settles.

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What are the possible complications?

Prostate biopsy is generally safe, but no invasive procedure is completely risk-free.

Infection

Infection is the most important concern after a transrectal biopsy because the needle passes through the bowel wall.

Possible infections include:

• urinary tract infection;
• infection within the prostate;
• bloodstream infection;
• sepsis.

The infection risk is substantially lower with the transperineal route because the biopsy needle does not pass through the rectum.

A low risk does not mean no risk. Any man who becomes feverish, shivery or acutely unwell after a biopsy needs urgent medical assessment.

Urinary retention

Swelling or bleeding within the prostate can occasionally prevent a man from passing urine.

This is more likely in men with a very large prostate or significant urinary symptoms before the procedure. You may need a temporary urinary catheter.

Significant bleeding

Minor bleeding is common. Heavy or persistent bleeding is uncommon.

Rarely, a patient may require further assessment, catheterisation, medication or another procedure to control bleeding.

Allergic or medication-related complications

Some men may react to antibiotics, local anaesthetic, or other medication used during the procedure.

Tell the team about all allergies and previous medication reactions.

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When should I seek urgent medical help?

Contact your biopsy team, NHS 111 or an urgent medical service if you develop:

• a fever;
• shaking chills or rigors;
• feeling suddenly or severely unwell;
• worsening pain;
• an inability to pass urine;
• heavy bleeding;
• repeated passage of large blood clots;
• dizziness, faintness or marked weakness;
• persistent vomiting;
• confusion or breathlessness.

Sepsis can initially resemble flu. Do not wait for symptoms to become severe if you feel acutely unwell after a biopsy.

If you cannot pass urine or believe you may have sepsis, urgent assessment is required.

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How are the biopsy samples examined?

A specialist pathologist processes each biopsy core in a pathology laboratory and examines it under a microscope.

The report will address several questions.

Is cancer present?

The first question is whether any of the samples contain prostate cancer.

The pathologist may occasionally identify other findings, such as inflammation, benign enlargement or atypical cells that are suspicious but not sufficient to make a definite diagnosis.

What is the Gleason score?

The Gleason score describes the microscopic pattern of prostate cancer.

The pathologist identifies the two most important patterns and assigns each a number. These are added together to produce the Gleason score.

For example:

• Gleason 3 + 3 = 6;
• Gleason 3 + 4 = 7;
• Gleason 4 + 3 = 7;
• Gleason 4 + 4 = 8.

Although both 3 + 4 and 4 + 3 produce a total score of 7, they are not equivalent. A 4 + 3 cancer contains more higher-grade pattern 4 and generally behaves more aggressively than a 3 + 4 cancer.

What is the Grade Group?

Grade Groups provide a simpler way of communicating the likely biological behaviour of the cancer.

• Grade Group 1: Gleason 3 + 3
• Grade Group 2: Gleason 3 + 4
• Grade Group 3: Gleason 4 + 3
• Grade Group 4: Gleason score 8
• Grade Group 5: Gleason scores 9 or 10

Grade Group 1 is the least aggressive category. Grade Group 5 is the most aggressive.

Grade Group matters, but it is not the only factor used to recommend treatment or active surveillance.

How much cancer is present?

The report may describe:

• the number of positive cores;
• the total number of cores taken;
• the length of cancer within each core;
• the percentage of each core involved;
• whether the cancer was found in targeted or systematic samples;
• the amount of higher-grade pattern 4.

This helps the clinical team estimate disease volume and significance.

Are there any additional microscopic features?

The pathologist may report specific features such as cribriform or intraductal cancer. These patterns can be important because they may influence prognosis and management.

Such terminology can be difficult to interpret without context. The report should be explained during the follow-up consultation rather than read in isolation.

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What happens when the results are available?

The results should be discussed at a follow-up appointment with a urologist or specialist member of the prostate cancer team.

The biopsy findings are interpreted alongside:

• the PSA;
• PSA density;
• MRI findings;
• prostate examination;
• age and general health;
• urinary and sexual function;
• the amount and distribution of cancer;
• personal priorities and preferences.

In many hospitals, prostate cancer cases are reviewed by a multidisciplinary team. This may include urologists, radiologists, pathologists, oncologists and specialist nurses.

The team considers the biopsy and scan findings before recommending appropriate options.

A diagnosis of prostate cancer does not automatically mean that immediate treatment is required. Some cancers can be safely monitored, while others are more likely to benefit from surgery, radiotherapy, hormone treatment or a combination of treatments.

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What if the biopsy is negative?

A negative biopsy is reassuring, but it does not always exclude prostate cancer completely.

A biopsy examines only small samples of the prostate. A small tumour can occasionally be missed, particularly if it was not visible on MRI or was located in an area that was difficult to sample.

The next step depends on the level of residual suspicion.

Options may include:

• returning to routine PSA monitoring;
• repeating the PSA after an agreed interval;
• reviewing the MRI images;
• repeating the MRI;
• using additional risk assessment;
• performing a repeat targeted or systematic biopsy.

A repeat biopsy is not automatically necessary after every negative result.

It is more likely to be considered if:

• the PSA continues to rise;
• PSA density remains high;
• the MRI lesion remains suspicious;
• the prostate examination is abnormal;
• the original samples may not have adequately assessed the area of concern;
• the overall clinical suspicion remains significant.

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What if prostate cancer is found?

The appropriate next step depends on the type and extent of cancer rather than simply on whether cancer is present.

Some prostate cancers grow so slowly that they are unlikely to affect health or life expectancy. These may be suitable for active surveillance.

Other cancers have features suggesting that treatment should be considered.

Possible management options include:

• active surveillance;
• surgery to remove the prostate;
• external-beam radiotherapy;
• brachytherapy;
• hormone therapy;
• combinations of radiotherapy and hormone therapy;
• watchful waiting in selected men;
• treatment directed at advanced disease where appropriate.

The aim is not simply to treat every cancer that can be detected. It is to identify cancers that are likely to cause harm and recommend treatment when the expected benefits outweigh the side effects.

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Frequently asked questions

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Making the decision to have a prostate biopsy

Deciding whether to proceed with a biopsy involves balancing the value of obtaining a reliable diagnosis against the discomfort, uncertainty and small risk of complications.

Modern MRI-led pathways have made this decision more selective than it was in the past. The question is no longer simply whether the PSA is above a particular number.

A good biopsy decision should consider:

• the probability of clinically significant cancer;
• whether the result is likely to change management;
• the accuracy and limitations of the MRI;
• the risks of the procedure;
• the consequences of delaying diagnosis;
• age, health and life expectancy;
• the individual man’s attitude towards risk and uncertainty.

When I discuss biopsy with patients, I explain that the purpose is not to find every microscopic focus of prostate cancer. The aim is to identify cancers that are likely to matter while avoiding unnecessary investigation and treatment wherever it is safe to do so.

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Conclusion

Prostate biopsy remains a central part of diagnosing prostate cancer, but the way biopsies are planned and performed has changed considerably.

Multiparametric MRI identifies suspicious areas before the procedure and helps some men avoid an immediate biopsy. MRI-guided targeting improves assessment of clinically important lesions, while systematic or regional sampling can identify cancers not clearly visible on the scan.

The growing use of the transperineal approach has also made biopsy safer by greatly reducing the risk of introducing bowel bacteria into the prostate and bloodstream.

A biopsy should not be recommended solely because one PSA result is raised. The decision should reflect the PSA trend, PSA density, MRI appearance, clinical examination, previous results, general health and individual preferences.

For men facing this decision, a careful discussion with an experienced urologist can help establish whether a biopsy is necessary, which technique is most appropriate and how the result is likely to influence future care.

Concerned About a Raised PSA or Prostate Biopsy?

If you have been told that your PSA is raised, have had an abnormal prostate MRI, or have been advised to consider a prostate biopsy, I can review your results and discuss the next steps with you.

Not every raised PSA requires a biopsy. I assess the PSA trend, prostate size and PSA density, MRI findings, examination, family history and other individual risk factors before recommending further investigation.

Where a biopsy is appropriate, I can explain the advantages and limitations of the available techniques and ensure that the results are considered in the context of your overall prostate cancer risk.

I see private patients from Buckinghamshire, Berkshire, Oxfordshire, West Hertfordshire, North West London and further afield.

Learn More About the Rapid Access Elevated PSA Clinic

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Further Reading

NICE guidance on prostate cancer diagnosis and management

British Association of Urological Surgeons information on transperineal prostate biopsy

Prostate Cancer UK guide to prostate biopsy

About the author

Mr Neil Haldar is a Consultant Urological Surgeon with over 20 years of consultant experience. His practice includes prostate cancer diagnosis and treatment, robotic and minimally invasive surgery, general urology and paediatric urology.

He assesses men with raised PSA and suspected prostate cancer from across Buckinghamshire and the wider Thames Valley and North West London.

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Medical disclaimer

This article provides general information and does not replace individual medical advice. The most appropriate investigation and treatment will depend on personal circumstances, examination findings, test results and medical history.

Anyone considering or preparing for a prostate biopsy should follow the instructions provided by their own urology team. Urgent medical advice should be sought for fever, rigors, inability to pass urine, heavy bleeding or feeling acutely unwell after the procedure.