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PROSTATE ULTRASOUND/BIOPSY INSTRUCTIONS
The following information is provided by Urology Specialists, P.C. to help you prepare for your prostate ultrasound and biopsy. Please read and sign these forms and bring them to your appointment. There will be a $50 administrative fee for any biopsy that is cancelled or rescheduled, if 24 hour
notice is not given.

In preparation for your biopsy:
1. You will need to purchase two (2) Fleet enemas from a pharmacy.
2. Use one Fleet enema the evening before your scheduled procedure.
3. Have a clear liquid* meal the evening before the procedure.
4. Use the second Fleet enema the morning of the procedure, before leaving for the office.
5. You ARE able to have solid foods the day of the procedure.
6. Fill your antibiotic prescription and take as follows:
One Cipro and one Bactrim in the morning and one Bactrim in the evening
the day before the procedure.
One Cipro and one Bactrim in the morning and one Bactrim in the evening
the day of the procedure.
One Cipro and one Bactrim in the morning and one Bactrim in the evening
the day after the procedure.
*CLEAR LIQUIDS include broth, bouillon, coffee or tea without cream or milk,Jell-O, popsicles, fruit juices, water, sports drinks, and clear carbonated beverages --- anything you can see through.
*******************************IMPORTANT**************************************
STOP
taking any aspirin, aspirin containing products, ibuprofen (Motrin, Advil, Nuprin), Vitamin E,
fish oil, garlic, glucosamine/chondroitin (Osteo-Biflex),or any blood thinning medications (Coumadin,
Lovenox, Plavix, Ticlid) 10 days before the procedure.
**********************************************************************************.
********************Please notify us if you are taking Coumadin*************************
Stop your __________________________________on________________________
Date_____________________________Time________________________________ Location: Liberty Office/ Liberty Hospital/ North Kansas City Hospital Your biopsy will be performed either in the hospital or in our office at our Liberty office location: Liberty Hospital, Medical Plaza East Building, 2529 Glenn Hendren Dr., Suite 202 ***Please contact our office one week following the procedure to obtain your test results*** Liberty Office: 816-781-8400
What to expect after your prostate biopsy:
It is normal to feel some rectal discomfort following the procedure. Some patients have found it helpful to soak in a warm tub of water (sitz bath) for approximately 20 minutes to help relieve this discomfort. If you would like to take a pain reliever, start with a regular or extra strength Tylenol. AVOID aspirin or aspirin-like products (ibupforen, Excedrin, Aleve, Motrin, Nuprin, etc.) as these products will prolong the healing process and may result in bleeding from the biopsy site.
You may experience some blood in your urine, stool or semen for the next several days after the biopsy. This is NORMAL after your prostate biopsy and should stop on its own. If you feel there is excessive bleeding or prolonged bleeding (blood in the stool/urine after 2 weeks from your biopsy) please contact our office and speak to one of our health care professionals.
If you develop a fever (temperature over 101°F) or chills after your procedure, please contact our office immediately.
I have read these instructions, understand them, and have no further questions.
Patient’s signature_______________________________________________ Witness_______________________________________________________

Source: http://www.urologyspecialistskc.com/sites/default/files/pdf/prostate_ultrasound_9.10.pdf

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CARONDELET HEALTH NETWORK A MEMBER OF ASCENSION HEALTH F AC S I M I L E T R AN S M I T T A L S H E E T DATE: TO: ROBIN MARCELLO/ERIKA GONZALEZ/LISA P R IO R A U T H O R IZ A T I O N : The authorization team is available to assist with getting most Would you like the authorization team to obtain prior Authorization? CONFIDENTIALITY STATEMENT The information contained in this

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