Clinical UM Guideline


Subject: Transrectal Ultrasonography
Guideline #:  CG-MED-45 Publish Date:    06/06/2018
Status: Reviewed Last Review Date:    05/03/2018


This document addresses the use of transrectal ultrasonography in the diagnosis, staging, and management of conditions involving the prostate, rectum, and surrounding tissues.

Note: Please see the following related document for additional information:

Clinical Indications

Medically Necessary:

Transrectal ultrasonography (TRUS) is considered medically necessary for any of the following indications:

  1. To guide prostate biopsy when prostate cancer is suspected based on abnormal digital rectal examination (DRE) or prostate-specific antigen (PSA) level greater than 3.0 ng/ml or medical history; or
  2. To guide application of cryotherapy or brachytherapy for treatment of prostate cancer; or
  3. To evaluate and stage prostate cancer or rectal cancer; or
  4. To evaluate and guide treatment for any of the following:
    1. Anal, rectal, or peri-rectal abscess, tumors, fistula, or anal sphincter dysfunction; or
    2. Azoospermia, hematospermia (hemospermia), or male infertility; or
    3. Benign prostatic hyperplasia (BPH), prostate abscess, prostatic calculi, or prostatitis; or
    4. Pelvic masses, pelvic inflammatory conditions, or rectovaginal endometriosis; or
    5. Suspected congenital anomalies of the prostate, rectum, or surrounding tissue.

Not Medically Necessary:

Transrectal ultrasonography (TRUS) is considered not medically necessary when criteria are not met and for all other indications, including but not limited to use as a primary screening test for prostate cancer.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Ultrasound, transrectal



ICD-10 Diagnosis



Malignant neoplasm of rectosigmoid junction


Malignant neoplasm of rectum


Malignant neoplasm of anus and anal canal


Malignant neoplasm of prostate


Malignant carcinoid tumor of the rectum


Malignant neoplasm of pelvis


Secondary malignant neoplasm of large intestine and rectum


Secondary malignant neoplasm of genital organs


Carcinoma in situ of rectosigmoid junction, rectum, anus and anal canal


Carcinoma in situ of prostate


Benign neoplasm of rectosigmoid junction, rectum, anus and anal canal


Benign neoplasm of prostate


Benign carcinoid tumor of the rectum


Neoplasm of uncertain behavior of rectum


Neoplasm of uncertain behavior of other specified digestive organs


Neoplasm of uncertain behavior of prostate


Neoplasm of unspecified behavior of digestive system


Neoplasm of unspecified behavior of other genitourinary organs


Fissure and fistula of anal and rectal regions


Abscess of anal and rectal regions


Other diseases of anus and rectum


Benign prostatic hyperplasia


Inflammatory diseases of prostate


Other and unspecified disorders of prostate


Male infertility


Inflammatory diseases of female pelvic organs


Endometriosis of rectovaginal septum and vagina


Fistula of vagina to large intestine


Congenital absence, atresia and stenosis of large intestine


Other congenital malformations of intestine


Congenital rectovaginal fistula


Other congenital malformations of vas deferens, epididymis, seminal vesicles and prostate


Fecal incontinence


Intra-abdominal and pelvic swelling, mass and lump


Other specified symptoms and signs involving the digestive system and abdomen




Elevated prostate specific antigen (PSA)


Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus


Personal history of malignant neoplasm of prostate


Personal history of prostatic dysplasia

Discussion/General Information

Transrectal ultrasonography (TRUS), also called endorectal ultrasound (ERUS), is an imaging procedure used in the diagnosis, staging, and management of conditions involving the prostate, rectum, and surrounding tissues. TRUS has both diagnostic and therapeutic indications. The brief outpatient procedure involves the use of a small lubricated probe inserted into the rectum that sends out high-energy sound waves. These sound waves bounce off internal tissues or organs, making echoes that form a picture of body tissue called a sonogram. While the probe may be temporarily uncomfortable, TRUS is essentially a painless procedure.

Prostate Cancer

Prostate cancer is the most common cancer found in North American men other than skin cancer and is the second leading cause of male cancer death. The National Cancer Institute (NCI, 2017) estimates new cases and disease-related deaths from prostate cancer in the United States in 2017 to be 161,360 and 26,730, respectively. Imaging procedures suggested as possible screening modalities for prostate cancer include ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI). Each modality has relative merits and disadvantages for distinguishing different features of prostate cancer. Ultrasound has been examined by several investigators in observational settings (Waterhouse, 1989). The sensitivity of TRUS in these settings ranged from 71% to 92% for prostate cancer and 60% to 85% for subclinical disease. Specificity values ranged from 49% to 79%, and positive predictive values in the 30% range have been reported. The sensitivity and positive predictive value for ultrasound as a single test may be better than for rectal examination. The rate of cancer is extremely low among ultrasound-positive men for whom rectal and PSA examinations are normal (Cooner, 1988). According to the NCI prostate cancer screening PDQ® (2017):

Any potential benefits derived from screening asymptomatic men need to be weighed against the harms of screening and diagnostic procedures and treatments for prostate cancer. These harms are particularly burdensome to individuals with false-positive screening results and those who are unnecessarily treated because of overdiagnosis.

The gold standard in the diagnosis of prostate cancer is a prostate biopsy. Contemporary prostate biopsy relies on spring-loaded biopsy devices that are either digitally guided or guided via ultrasound. TRUS guidance is the most frequently used method of directing prostate needle biopsy because the yield of biopsy may be improved; however, ultrasound is operator dependent and does not assess lymph node size (NCI, 2017; Renfer, 1995).

The American College of Radiology (ACR) Appropriateness Criteria® for pretreatment detection, staging, and surveillance of prostate cancer (ACR, 2016c) recommends a TRUS-guided systematic needle biopsy of the prostate gland as the standard procedure for the diagnosis of prostate cancer. For monitoring of lower-risk prostate cancer, the ACR criteria states “serial TRUS-guided systemic remains a standard component of active surveillance regimens.” An ACR Appropriateness Criteria for post-treatment follow-up of prostate cancer (ACR, 2017) states:

Biopsy proof of recurrence is standard practice, and can be performed as TRUS-guided biopsy or MRI-targeted biopsy of a lesion identified by a diagnostic MRI…The yield for detecting local recurrent tumor with TRUS with needle biopsy rises significantly with serum PSA levels.

The AUA, American Society for Radiation Oncology (ASTRO), and Society for Urologic Oncology (SUO) (2017) have published a guideline with treatment approached and clinical care options for clinically localized prostate cancer. The recommended approach for active surveillance of clinically localized prostate cancer includes “…accurate disease staging including systematic biopsy with ultrasound or MRI-guided imaging (Clinical Principle).” Current consensus supports “…a 10- to 12-core extended biopsy scheme, with additional cores from areas suspected by DRE, transrectal ultrasonography (TRUS), or MRI.”

The National Comprehensive Cancer Network® (NCCN) Clinical Practice Guideline (CPG) for management of early detection of prostate cancer (NCCN, V1.2018) recommends that systematic prostate biopsy (extended-pattern biopsy of 12 cores) under TRUS guidance should be considered as initial biopsy for men (for those aged 45 to 75 years) with “a serum PSA level > 3.0 ng/mL” (Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate). This level of PSA correlates with the risk of prostate cancer reported in the Prostate Cancer Prevention Trial (PCPT) results (Thompson, 2006) in which 15% of men with a PSA level of ≤ 4.0 ng/mL, approximately 30% to 35% of men with serum PSA between 4 to 10 ng/mL were found to have cancer, and PSA levels of > 10 ng/mL conferred a greater than 67% likelihood of biopsy-detectable prostate cancer. The NCCN CPG considered randomized controlled trials using PSA thresholds to prompt a biopsy, noting PSA cut points for biopsy varied between centers and trials over time, stating:

Although a serum PSA of 2.5 ng/mL has been used by many, a level of 3 ng/mL is supported by the trials and would more robustly limit the risk of overdetection. However, some panel members did not recommend limiting the option of biopsy to pre-specified PSA thresholds, noting that there are many other factors (eg, age, race, family history, PSA kinetics) that should also inform the decision to perform biopsy (NCCN, V1.2018).

For management of benign biopsy results, the guideline recommends “repeat prostate biopsy, based on risk.” For management of high-grade prostatic intraepithelial neoplasia (HGPIN) biopsy (focal) results, the guideline recommends follow-up with: 1) PSA and DRE at 6-24 month intervals; and, 2) repeat TRUS-guided prostate biopsy based on risk, considering “ is well known that a negative biopsy does not preclude a diagnosis of prostate cancer on subsequent biopsy” (both 2A recommendation). Current tools to calculate risk combine factors including age, family history, race, DRE and PSA (that is, medical history) to aid in the decision of whom to biopsy. The guideline also recommends a repeat extended pattern rebiopsy (12 cores) within 6 months with increased sampling of the affected site and adjacent areas for individuals with: 1) initial atypia (suspicious for cancer); and, for 2) multifocal HGPIN (> 2 sites) (2A recommendation).

For individuals diagnosed with cancer on prostate biopsy, the NCCN CPG for prostate cancer (treatment) (V2.2018) does not recommend routine repeat biopsy, except in special circumstances, such as the suspicion that the individual harbors more aggressive cancer than was evident on the initial biopsy and the individual is otherwise a candidate for active surveillance. TRUS is also used to guide transrectal biopsies for staging for candidates for local therapy and for those individuals with biochemical PSA persistence/recurrence or positive DRE after radical prostatectomy or post-irradiation recurrence.

An American Urological Association (AUA) clinical guideline (Carter, 2013) states that early detection of prostate cancer is driven by PSA-based screening followed by TRUS biopsy for diagnostic confirmation; however, PSA testing can generate a significant number of false positive results due to low specificity. The AUA references the use of a 3.0 ng/mL cut off point as used in the multicenter European Randomized Study of Screening for Prostate Cancer (ERSPC), estimating that PSA screening at this level will correctly predict the presence of prostate cancer in about 1 of every 2 (TRUS) biopsies (Schroder, 2009). The guideline recognizes PSA testing as the primary screening test to assist in informed decision-making concerning the need for a (TRUS) prostate biopsy or repeat biopsy. The AUA further recommends that for men ages 70 to 75 with a PSA of < 3.0 ng/mL, further screening may not be needed, based on the estimated lifetime probability of prostate cancer-related death at 7%, with the frequency increasing with age, as reported in an observational study by Schaeffer and colleagues (2009).

Transperineal prostate brachytherapy is considered a treatment option for clinically localized prostate cancer. TRUS is used as an effective guide prior to brachytherapy to determine the number of needles and corresponding radioactive seeds, the isotope, and the isotope strength for the procedure and during the procedure to execute the placement of the radioactive seeds into the prostate (Davis, 2012).

The peer-reviewed medical literature does not support the use of TRUS alone as a screening tool for prostate cancer because of its low sensitivity and positive predictive value. An American College of Preventive Medicine (ACPM) (Lim, 2008) position statement states:

The principal screening tests for the detection of asymptomatic prostate cancer are the DRE and serum PSA levels. Transrectal ultrasound (TRUS) is no longer considered a first-line screening test for prostate cancer but does play a role in the investigation of patients with abnormal DRE or PSA when guided biopsies are required.

Rectal Cancer

In 2017, the NCI estimates 135,430 new cases and 50,260 deaths from colorectal (combined) cancer in the United States. Pretreatment local staging evaluation for rectal cancer is mainly accomplished through physical examination, endoscopy, CT scans, MRI, and TRUS.

An update to the ACR Appropriateness Criteria for pretreatment staging of colorectal cancer, states that imaging modalities including TRUS, CT, and MRI have all been extensively evaluated in the initial staging of colorectal cancer (ACR, 2016b). TRUS has been the gold standard for T-stage evaluation of rectal cancer with substantive evidence to support its use:

TRUS enables one to distinguish layers of the rectal wall and provides high accuracy in detecting and characterizing tumors within the superficial layers of the rectal wall. Reported accuracies range between 80% and 97% for T-stage determination (Yimei, 2012). The T-stage accuracy for TRUS (84.6%) is far superior to that of CT (70.5%) (Ju, 2009). Although TRUS performs better than MRI for T-1 tumors, similar for T2-3, it may be less accurate in characterizing locally advanced tumors (T4) with a tendency to understage (Fernandez-Esparrach, 2011).

In one systematic review, the accuracy of TRUS was greatest (95%) in distinguishing whether a tumor was confined to the rectal wall or invaded through it (tumor grades T1-T2 versus T3 or greater). TRUS has also been associated with overstaging of rectal cancer and is not fully accurate in differentiating T2 from T3 lesions (ACR, 2016b).

The sensitivity of TRUS is limited in the detection of lymph node involvement to mesorectal nodes in the vicinity of the tumor. Sensitivity ranges from 45%-74% (Lin, 2011; Ravizza, 2011) and overall accuracy ranges from 62%-83% (Low, 2008). TRUS, however, has not been shown to be predictive of the histology of the visualized lymph nodes (Li, 2015). The ACR criteria states:

Many lymph nodes measuring < 5 millimeters in diameter have associated micrometastases, and some early-stage T1 and T2 tumors are likely to have lymph node micrometastases missed by TRUS. Lymph nodes along the superior rectal vessels and outside the mesorectal fascia along the internal iliac and obturator nodal stations also cannot be assessed with TRUS. TRUS similarly is limited in evaluating lateral lymph nodes.

The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for the treatment of rectal cancer (Monson, 2013) recommend that clinical staging of primary rectal tumors be performed by ERUS or dedicated high resolution rectal MRI. ERUS may be better for distinguishing between T1 and T2 tumors; although, ERUS is less accurate in the assessment of large bulky lesions (T4 stage accuracy of 44-50%) and can pose difficulties in evaluating stenotic lesions.

For the surveillance of individuals after curative resection with anastomosis for rectal cancer, the ASCRS practice guidelines (Steele, 2015) recommend proctosigmoidoscopy, with or without ERUS, “every 6 to 12 months for 3 to 5 years for those undergoing low anterior resection, and every 6 months for 3 to 5 years for those with a higher risk of local recurrence.” Surveillance of rectal cancer using ERUS may be more sensitive in detecting locoregional recurrence, although the impact on overall survival is unknown. For surveillance of individuals who have undergone transanal local excision of rectal cancer, proctosigmoidoscopy, with or without ERUS, is recommended every 6 months for 3 to 5 years.

Other Indications

TRUS is a clinically useful tool for evaluation of other conditions involving the prostate, rectum, and surrounding tissues and has been used in the evaluation of congenital anomalies. The procedure can be performed quickly and is well-tolerated by individuals with no exposure to radiation. TRUS can identify structural abnormalities of the prostate gland, seminal vesicles, and spermatic cord, and guide biopsies if suspicious abnormalities are identified in those organs. Additional uses of TRUS include assessment of the prostate gland and prostate volume before medical management or minimally invasive surgical procedures for BPH (for example, transurethral microwave thermotherapy [TUMT]) (Wasserman, 2006), and, to evaluate other conditions of the prostate including symptoms of prostatitis, suspected abscess, or prostatic calculi. An AUA guideline on the management of BPH (2014) states “TRUS has been used to determine prostate volume in men with BPH. Therapy for lower urinary tract symptoms due to BPH have shown the most efficacy when the prostate is assessed by PSA levels, TRUS, or on DRE.”

In evaluation of infertility, the male partner is involved in approximately one-third of the cases. TRUS, with or without seminal vesicle aspiration and seminal vesiculography, is considered as an initial minimally invasive diagnostic test to identify ejaculatory duct obstruction in azoospermic men with low ejaculate volumes and bilateral palpable vasa (Abdulwahed, 2013; ASRM, 2012; AUA, 2011; Chen, 2014; Gangel, 2002). In men with ejaculatory duct obstruction demonstrated by TRUS, the findings may direct testis biopsy if needed to confirm normal spermatogenesis. TRUS is also used to rule out seminal vesicular cysts, müllerian cysts, or utricular cysts.

Hematospermia (hemospermia), defined as blood in the semen, is a common condition that is infrequently associated with significant pathology. Hematospermia may be the result of calcifications or calculi in the prostate, ejaculatory ducts, or seminal vesicles, an infection (prostatitis), benign prostatic hyperplasia, prostate cancer, prostatic cysts, conditions of the urethra (urethritis and other lesions), congenital and acquired seminal vesicle lesions, systemic disorders, or trauma. TRUS is considered the imaging procedure of choice for evaluation of men with persistent hematospermia (lasting more than 1 month) to distinguish idiopathic from secondary hematospermia when the bleeding cause is known or suspected (for example, bladder, prostate or systemic malignant pathology) and an accurate diagnosis dictates the extent of further evaluation and treatment of the condition. TRUS is sensitive for detecting a variety of abnormalities that may involve the prostate gland and seminal tract in the setting of hematospermia, reportedly demonstrating abnormalities in 82% to 95% of men with hematospermia. (ACR, 2016a; Manohar, 2008; Yagci, 2004; Zhao, 2012). Xing and colleagues (2012) reported on a prospective trial of 106 subjects with persistent hematospermia and found the diagnostic accuracy of TRUS and transurethral seminal vesiculoscopy was 45.3% and 74.5%, respectively, although the diagnostic accuracy was higher when both modalities were combined.  

Endometriosis is a condition in which tissue similar to that normally lining the uterus is found outside the uterus, usually on the ovaries, fallopian tubes, and other pelvic structures, and affects 10% to 15% of women of reproductive age. TRUS has been used for assessing the extent of endometriosis and is accurate in the diagnosis and management of endometriosis in the rectovaginal septum (Nisenblat, 2016). The sensitivity and specificity of preoperative imaging with TRUS in defining the extent of endometrial lesions and predicting rectovaginal septum or rectosigmoid infiltration has been confirmed in prospective and retrospective case series (Abrão, 2004; Delpy, 2005; Doniec, 2003; Fedele, 1998; Kruse, 2012; Ribeiro, 2008).

TRUS and TRUS-guided transrectal biopsy have been used with or without other imaging modalities including pelvic or transvaginal ultrasonography to evaluate the extension of gynecologic-related pelvic masses, including cervical, retroperitoneal, ovarian, or uterine masses, into surrounding tissues and to guide further treatment (such as drainage of deep pelvic and perirectal abscesses) (Giede, 2004; Lorentzen, 2011; Nielsen, 2004; Zaritzky, 1979). When transvaginal scanning is not feasible or contraindicated, TRUS has been used as an alternative to transvaginal ultrasonography to evaluate conditions of the female pelvis (Fleischer, 1995; Timor-Tritsch, 2003). For women with endometrial cancer in the presence of atrophic or post-radiation vaginal stenosis, TRUS has been used to define the extent of the cancer and guide fine-needle aspiration biopsy of recurrent tumors (Squaillaci, 1988).

Structural abnormalities of the anal sphincter, the rectal wall, and the puborectalis muscle can be identified in detail with TRUS. TRUS has been used as an alternative to MRI evaluation of anal, rectal, and perianal abscesses and fistulas, and benign tumors. The majority of TRUS studies have focused on individuals without Crohn's disease. The rigid nature of the TRUS probe, however, may prevent good acoustic coupling higher in the rectum, preventing the interpretation of higher fistula tracks in the evaluation of these conditions in individuals with or without Crohn’s disease. For management of severe Crohn’s disease, an American College of Gastroenterology (ACG) (Lichtenstein, 2009) practice guideline recommends evaluation of an abdominal mass/abscesses or perianal complications with serial imaging, including endoscopic ultrasonography, CT, or MRI, prior to consideration of surgical intervention.

TRUS is also useful for establishing a diagnosis in individuals in whom a medical history or manometric findings suggest sphincter dysfunction or occult sphincter injury, and is currently the simplest, most reliable, and least invasive test for defining anatomic defects in the external and internal anal sphincters. For persons with suspected fecal incontinence, an ACG practice guideline (Rao, 2004) recommends imaging with endosonography to assess and define structural defects of the external and internal anal sphincter muscle for the presence of scarring, loss of muscle tissue, and other local pathology.

An American Institute of Ultrasound in Medicine (AIUM, 2012) Practice Guideline for the Performance of an Ultrasound Examination in the Practice of Urology (developed in collaboration with the AUA) states the indications for the transrectal approach to ultrasound of the prostate include, but are not limited to:

  1. guidance for biopsy in the presence of abnormal DRE examination findings or an elevated PSA level;
  2. assessment of gland and prostate volume before medical, surgical, or radiation therapy;
  3. symptoms of prostatitis with a suspected abscess;
  4. assessment of congenital anomalies;
  5. infertility; and
  6. hematospermia.

Biopsy: The removal of a sample of tissue for examination under a microscope for diagnostic purposes.

Digital rectal examination (DRE): An examination of the lower rectum where the medical practitioner uses a gloved, lubricated finger to check for abnormalities of the prostate.

Prostate: A walnut-shaped gland in men that extends around the urethra at the neck of the urinary bladder and supplies fluid that goes into semen.

Prostate-specific antigen (PSA): A blood test that measures the amount of a specific prostate-related protein in blood, used to screen for prostate cancer and other conditions. A high PSA level in the blood has been linked to having prostate cancer as well as several other benign prostate conditions.

Transrectal ultrasound (TRUS): A procedure in which sound waves produced by a probe inserted into the rectum bounce off internal tissues or organs and make echoes to form a picture of body tissue called a sonogram.


Peer Reviewed Publications:

  1. Abdulwahed SR, Mohamed EE, Taha EA, et al. Sensitivity and specificity of ultrasonography in predicting etiology of azoospermia. Urology. 2013; 81(5):967-971.
  2. Abrão MS, Neme RM, Averbach M, et al. Rectal endoscopic ultrasound with a radial probe in the assessment of rectovaginal endometriosis. J Am Assoc Gynecol Laparosc. 2004; 11(1):50-54.
  3. Chen X, Wang H, Wu RP, et al. The performance of transrectal ultrasound in the diagnosis of seminal vesicle defects: a comparison with magnetic resonance imaging. Asian J Androl. 2014; 16(6):907-911.
  4. Delpy R, Barthet M, Gasmi M, et al. Value of endorectal ultrasonography for diagnosing rectovaginal septal endometriosis infiltrating the rectum. Endoscopy. 2005; 37(4):357-361.
  5. Doniec JM, Kahlke V, Peetz F, et al. Rectal endometriosis: high sensitivity and specificity of endorectal ultrasound with an impact for the operative management. Dis Colon Rectum. 2003; 46(12):1667-1673.
  6. Donnelly BJ, Saliken JC, Ernst DS, et al. Role of transrectal ultrasound guided salvage cryosurgery for recurrent prostate carcinoma after radiotherapy. Prostate Cancer Prostatic Dis. 2005; 8(3):235-242.
  7. Doornebosch PG, Bronkhorst PJ, Hop WC, et al. The role of endorectal ultrasound in therapeutic decision-making for local vs. transabdominal resection of rectal tumors. Dis Colon Rectum. 2008; 51(1):38-42.
  8. Fedele L, Bianchi S, Portuese A, et al. Transrectal ultrasonography in the assessment of rectovaginal endometriosis. Obstet Gynecol. 1998; 91(3):444-448.
  9. Fernandez-Esparrach G, Ayuso-Colella JR, Sendino O, et al. EUS and magnetic resonance imaging in the staging of rectal cancer: a prospective and comparative study. Gastrointest Endosc. 2011; 74(2):347-354.
  10. Fleischer AC, Burnett LS, Jones HW 3rd, Cullinan JA. Transrectal and transperineal sonography during guided intrauterine procedures. J Ultrasound Med. 1995; 14(2):135-138.
  11. Giede C, Toi A, Chapman W, Rosen B. The use of transrectal ultrasound to biopsy pelvic masses in women. Gynecol Oncol. 2004; 95(3):552-556.
  12. Ju H, Xu D, Li D, et al. Comparison between endoluminal ultrasonography and spiral computerized tomography for the preoperative local staging of rectal carcinoma. Biosci Trends. 2009; 3(2):73-76.
  13. Kruse C, Seyer-Hansen M, Forman A. Diagnosis and treatment of rectovaginal endometriosis: an overview. Acta Obstet Gynecol Scand. 2012; 91(6):648-657.
  14. Li XT, Sun YS, Tang L, et al. Evaluating local lymph node metastasis with magnetic resonance imaging, endoluminal ultrasound and computed tomography in rectal cancer: a meta-analysis. Colorectal Dis. 2015; 17(6):129-135.
  15. Lin S, Luo G, Gao X, et al. Application of endoscopic sonography in preoperative staging of rectal cancer: six-year experience. J Ultrasound Med. 2011; 30(8): 1051-1057.
  16. Lorentzen T, Nolsoe C, Skjoldbye B. Ultrasound-guided drainage of deep pelvic abscesses: experience with 33 cases. Ultrasound Med Biol. 2011; 37(5):723-728.
  17. Low G, Tho LM, Leen E, et al. The role of imaging in the pre-operative staging and post-operative follow-up of rectal cancer. Surgeon. 2008; 6(4):222-231.
  18. Manohar T, Ganpule A, Desai M. Transrectal ultrasound- and fluoroscopic-assisted transurethral incision of ejaculatory ducts: a problem-solving approach to nonmalignant hematospermia due to ejaculatory duct obstruction. J Endourol. 2008; 22(7):1531-1535.
  19. Nielsen MB, Torp-Pedersen S. Sonographically guided transrectal or transvaginal one-step catheter placement in deep pelvic and perirectal abscesses. AJR Am J Roentgenol. 2004; 183(4):1035-1036.
  20. Ravizza D, Tamayo D, Fiori G, et al. Linear array ultrasonography to stage rectal neoplasias suitable for local treatment. Dig Liver Dis. 2011; 43(8):636-641.
  21. Renfer LG, Schow D, Thompson IM, et al. Is ultrasound guidance necessary for transrectal prostate biopsy? J Urol. 1995; 154 (4):1390-1391.
  22. Ribeiro HS, Ribeiro PA, Rossini L, et al. Double-contrast barium enema and transrectal endoscopic ultrasonography in the diagnosis of intestinal deeply infiltrating endometriosis. J Minim Invasive Gynecol. 2008; 15(3):315-320.
  23. Schaeffer EM, Carter HB, Kettermann A, et al. Prostate specific antigen testing among the elderly--when to stop? J Urol. 2009; 181(4):1606-1614; discussion 1613-1614.
  24. Schroder FH, Hugosson J, Roobol MJ, et al.; ERSPC Investigators. Screening and prostate-cancer mortality in a randomized European study. N Engl J Med. 2009; 360(13):1320-1328.
  25. Squillaci E, Salzani MC, Grandinetti ML, et al. Recurrence of ovarian and uterine neoplasms: diagnosis with transrectal US. Radiology. 1988; 169(2):355-358.
  26. Thompson IM, Ankerst DP, Chi C, et al. Assessing prostate cancer risk: results from the Prostate Cancer Prevention Trial. J Natl Cancer Inst. 2006; 98(8):529-534.
  27. Timor-Tritsch IE, Monteagudo A, Rebarber A, et al. Transrectal scanning: an alternative when transvaginal scanning is not feasible.  Ultrasound Obstet Gynecol. 2003; 21(5):473-479.
  28. Ukimura O, de Castro Abreu AL, Gill IS, et al. Image visibility of cancer to enhance targeting precision and spatial mapping biopsy for focal therapy of prostate cancer. BJU Int. 2013; 111(8):E354-E364.
  29. Wasserman NF. Benign prostatic hyperplasia: a review and ultrasound classification. Radiol Clin North Am. 2006; 44(5):689-710, viii.
  30. Waterhouse RL, Resnick MI. The use of transrectal prostatic ultrasonography in the evaluation of patients with prostatic carcinoma. J Urol. 1989; 141(2): 233-239.
  31. Xing C, Zhou X, Xin L, et al. Prospective trial comparing transrectal ultrasonography and transurethral seminal vesiculoscopy for persistent hematospermia. Int J Urol. 2012; 19(5):437-442.
  32. Yagci C, Kupeli S, Tok C, et al. Efficacy of transrectal ultrasonography in the evaluation of hematospermia. Clin Imaging. 2004; 28(4):286-290.
  33. Yimei J, Ren Z, Lux X, Huan Z. A comparison between the reference values of MRI and EUS and their usefulness to surgeons in rectal cancer. Eur Rev Med Pharmacol Sci. 2012; 16(15):2069-2077.
  34. Zaritzky D, Blake D, Willard J, Resnick M. Transrectal ultrasonography in the evaluation of cervical carcinoma. Obstet Gynecol. 1979; 53(1):105-108.
  35. Zhao H, Luo J, Wang D, et al. The value of transrectal ultrasound in the diagnosis of hematospermia in a large cohort of patients. J Androl. 2012; 33(5):897-903.

Government Agency, Medical Society, and Other Authoritative Publications:

  1. American College of Radiology (ACR). ACR Appropriateness Criteria®. Hematospermia; 2016a. Available at: Accessed on March 9, 2018.
  2. American College of Radiology (ACR). ACR Appropriateness Criteria. Post-treatment follow-up of prostate cancer; 2017. Available at: Accessed on March 9, 2018. 
  3. American College of Radiology (ACR). ACR Appropriateness Criteria. Pretreatment staging colorectal cancer; 2016b. Available at: Accessed on March 9, 2018
  4. American College of Radiology (ACR). ACR Appropriateness Criteria. Prostate cancer - pretreatment detection, surveillance, and staging; 2016c. Available at: Accessed on March 9, 2018.
  5. American College of Radiology (ACR), American Institute of Ultrasound in Medicine (AIUM), Society of Radiologists in Ultrasound (SRU) practice parameter for the performance of ultrasound evaluation of the prostate (and surrounding structures). Revised 2015. Available at: Accessed on March 9, 2018.
  6. American Institute of Ultrasound in Medicine (AIUM), American Urological Association (AUA). AIUM practice guideline for the performance of an ultrasound examination in the practice of urology. J Ultrasound Med. 2012; 31(1):13.
  7. American Urological Association (AUA). Best Practice Statements and Clinical Guidelines. Available at: Accessed on March 9, 2018.
    • Best Practice Statement: The Evaluation of the Azoospermic Male (Reviewed and amended 2011).
    • Best Practice Statement: The Optimal Evaluation of the Infertile Male (Reviewed and validity confirmed 2011).
    • Clinical Guideline: Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline (2017).
    • Clinical Guideline: Management of Benign Prostatic Hyperplasia (BPH) (Reviewed and validity confirmed 2014).
  8. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA Guideline. J Urol. 2013; 190(2):419-426.
  9. Davis BJ, Horwitz EM, Lee WR, et al. American Brachytherapy Society consensus guidelines for transrectal ultrasound-guided permanent prostate brachytherapy. Brachytherapy. 2012; 11(1):6-19.
  10. Gangel EK. American Urological Association, Inc and American Society for Reproductive Medicine. AUA and ASRM produce recommendations for male infertility. Am Fam Physician. 2002; 65(12):2589-2590.
  11. Lichtenstein GR, Hanauer SB, Sandborn WJ. Practice Parameters Committee of the American College of Gastroenterology. Management of Crohn's disease in adults. Am J Gastroenterol. 2009; 104(2):465-483.
  12. Lim LS, Sherin K. ACPM Prevention Practice Committee. Screening for prostate cancer in U.S. men ACPM position statement on preventive practice. Am J Prev Med. 2008; 34(2):164-170.
  13. Monson JR, Weiser MR, Buie WD, et al. Standards Practice Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013; 56(5):535-550.
  14. NCCN Clinical Practice Guidelines in Oncology®. © 2017-2018 National Comprehensive Cancer Network, Inc. For additional information visit the NCCN website: Accessed on March 30, 2018.
    • Prostate Cancer. V2.2018. Updated March 8, 2018.
    • Prostate Cancer Early Detection. V1.2018. Updated March 12, 2018.
  15. Nisenblat V, Bossuyt PM, Farquhar C, et al. Imaging modalities for the non-invasive diagnosis of endometriosis. Cochrane Database Syst Rev. 2016;(2):CD009591.
  16. Practice Committee of American Society for Reproductive Medicine (ASRM). Diagnostic evaluation of the infertile male: a committee opinion. Fertil Steril. 2012; 98(2):294-301.
  17. Rao SS. Diagnosis and management of fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am J Gastroenterol. 2004; 99(8):1585-1604.
  18. Steele SR, Chang GJ, Hendren S, et al. Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. Practice guideline for the surveillance of patients after curative treatment of colon and rectal cancer. Dis Colon Rectum. 2015; 58(8):713-725.
Websites for Additional Information
  1. American Cancer Society (ACS). Available at: Accessed on March 9, 2018.
  2. National Cancer Institute (NCI). Available at: Accessed on March 9, 2018.
    • Colorectal Cancer Screening (PDQ). Last modified July 28, 2017.
    • Prostate Cancer Screening (PDQ). Last modified September 29, 2017.
    • Prostate Cancer Treatment (PDQ). Last modified January 19, 2018.

Transrectal Ultrasound

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.







Medical Policy & Technology Assessment Committee (MPTAC) review.



Hematology/Oncology Subcommittee review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated Discussion, References, and Websites for Additional Information sections.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated formatting in Clinical Indications section. Added “or” between criteria and alphabetized MN statements. Updated Discussion, References, and Websites for Additional Information sections.



Updated Coding section with 10/01/2016 ICD-10-CM diagnosis code changes.



MPTAC review.



Hematology/Oncology Subcommittee review. Updated Discussion/General Information, References, and Websites for Additional Information sections. Removed ICD-9 codes from Coding section.



MPTAC review.



Hematology/Oncology Subcommittee review. Format change and clarification to the Not Medically Necessary statement. Updated Description, Discussion, References, and Websites for Additional Information sections.



MPTAC review.



Hematology/Oncology Subcommittee review. Revised medically necessary criterion addressing the use of TRUS to guide prostate biopsy when prostate cancer is suspected by changing the required PSA level from >10 ng/ml to >3.0 ng/ml. Format change to Description. Updated Discussion, References, and Websites for Additional Information sections.



MPTAC review. Initial document development.