Biopsy of the prostate

If any of the initial tests (rectal examination, PSA) show the possibility of cancer, the urologist may recommend a biopsy, in which a sample of tissue is taken from the prostate to be examined through a microscope. The biopsy is usually done through the back passage (rectum). It is usually done in the urology out-patient department. The procedure itself takes about 5-10 minutes.

During a trans-rectal ultrasound (TRUS) guided biopsy an ultrasound scanner is used to guide the placement of a needle. The needle is then passed through the wall of the rectum to take the sample of prostate tissue. Some men we talked to had wanted to see the process on screen, but had not been able to do so. It is usual to take approximately ten to twelve biopsy samples at any one time. Because there is a chance of infection, men are routinely given an antibiotic before the procedure.

Had biopsies on two different occasions. He describes how they were done and what they were like.

Age at interview 60

Gender Male

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The, the biopsy, the first time I had it I didn’t find it, it’s a little uncomfortable, a little bit invasive, but I didn’t find it too bad. I couldn’t say it was painful, it’s just something again that you’re not used to, but the second time was a little more painful, probably because I knew what was coming and with the first biopsy I had they couldn’t find any problem, but the second biopsy obviously they were, there was a problem there, and they had to perhaps, or in my terms dig a little deeper to find what it was so that was a little more uncomfortable. But I can’t say it was really painful. I think a lot of it is actually in your head that someone is doing something that you don’t know about, you’ve never had done before.

And the biopsy is done through the back passage?

That’s right yeah.

Can you explain what you’re asked to do or?

Well you just lie in, is it the prone position when you bring your, no not the, when you bring your knees up? You lie on your side, on the couch and bring your knees up and probably face the wall or something like that and so everything is carried on behind you, as it would be [laughs], and that’s basically all you know about it.

And then the ultrasound could you say a little bit about that?

Well that’s all done at the same time. The ultrasound is done first, that’s a probe that goes in, obviously does the ultrasound and the actual biopsy is part, is a thing within the ultrasound instrument.

So you just feel a sharp prick or something?

That’s it yeah, yeah basically that’s it. The ultrasound is not a problem, but the actual biopsy thing I had twelve taken each time so I did find it, the first 6 or 7 not too bad but after that you were I suppose tensing yourself up knowing what’s coming and I did find not the first time, not the first biopsy, but the second biopsy I did find a little, a little painful.

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Says that the biopsy ‘wasn’t that bad and that he would have liked to have seen the ultrasound…

Age at interview 69

Gender Male

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Can you say a little bit more in detail about the biopsy for men who might be worried about it?

Oh I see oh well yes this is the least pleasant of the things that happened to me but I’d never had any pain or anything like that throughout any of the procedures that happened in the next few months. This was the first time, as I say, all the women present said, ‘Well weve been interfered with since we were teenagers, it’s about time you men had, you know suffered the same fate. And they stick a thing, it’s just like a, just like a large finger up your bum. It was an enormous finger as far as I was concerned and then they put a needle through the wall of your rectum into the prostate and they take, under guidance from an ultrasound cinema screen, you know television screen, they carefully select places that look dodgy. And I think six out of ten or nine out of, or five out of ten or something like that of these turned out to be cancerous and they take a samples. Having taken them through the wall of the rectum they obviously can introduce dirt into your system and therefore they stuff you full of antibiotics, a huge injection and all this sort of stuff which is not something that that one wishes to do voluntarily really, you know we try and avoid antibiotics if we can. But that was probably the worst procedure I had throughout the whole of the exercise, but it wasn’t that bad, for heavens sakes it wasn’t that bad at all.

So did you have any local anaesthetic for that?

Oh yes, yes they gave a local anaesthetic yeah, yeah. You couldn’t see the screen, that’s the only thing that they could improve, put the screen so you could see it but yes local anaesthetic certainly.

So you’d liked to be able to see what was going on the screen?

It would be nice, it would be nice, for an engineer it would be nice.

Did you have any side-effects of the biopsy?

I don’t think so no. A bit tender and that sort of thing but not no, no nothing serious at all.

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The men we talked to had very variable experiences. Some had been worried about the procedure, anticipating pain, particularly if waiting for a second biopsy. One man said he was ‘frightened to death’ and another man described the tense atmosphere in the waiting room.

He tried to dispel another man’s fears while waiting to see the urologist in the out-patient clinic

Age at interview 69

Gender Male

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They just told me it was crucial, they told me it was very important that I had to get a biopsy.

Right.

And they says an enlarged prostate when they come back positive it doesn’t necessarily mean to say you have cancer, you know, they says it’s just one of these parts of the body, he says most people your age at some time or another have prostate trouble you know, I was aware of that, I’ve been aware of that for quite a number of years so [clears throat] I had to wait, I actually told them if they thought it was important I would go private, I would pay for a private consultation because sometimes in this neck of the woods you wait a year before I see specialists, no but he says the PSA the department of Urology were quite speedy, you didn’t have to wait for months.

Good. How long did you have to wait?

Two weeks I think it was, two weeks or three weeks and I were in the [hospital] and I met about another fifty men sitting waiting for the same thing you know and there was a bit of tension, [ee] there wasnae that much conversation and that, there was one gentleman in particular he was frightened, and a older man than me and he was pretty tall and I got just spent the morning trying to pacify him and tell him it would go okay.

It’s what?

I told him, I says, ‘It’s only a formality’

Oh a formality.

I says, ‘You, you never count your chickens. I says, ‘You’ve just to take it a bit in your stride, to see you don’t know to-to hear the-the biopsy. You know, however [clears throat] I got a biopsy.

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Men described vividly what having a biopsy felt like. One man, for example, said it was like ‘a paper clip going into you’, another likened it to a ‘huge wasp or bee sting’. The sound of the biopsy was like ‘a gun going off’ or ‘an air rifle firing’ or ‘a clicking noise’. Some said that the procedure was undignified and uncomfortable but not painful. A few mentioned being given a local anaesthetic. Local anaesthetic is now routinely given during the procedure.

The biopsy was all over in a few minutes and didn’t hurt.

Age at interview 71

Gender Male

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Can you say a little bit more about the biopsy for men who might be wondering what’s going to happen?

Well, I went into this little room and you have to pull, put your trousers down and lay on the couch and then theres like a little prong that they put up your rectum and it takes little pieces of I suppose the prostate for analysis and they put a lot of cream up there and it’s, it’s just a little, it doesn’t hurt at all it’s just uncomfortable. And, it took about, he said, ‘You’ll hear 3 little clicks and then it’ll be all over, 2 so it went up there as I said just like now and it went click, click, click and out it came and he said ‘That’s it Mr, [own name] you can, and it’s all finished. And then you go and clean yourself up and it was all over in a matter of minutes. And it didn’t hurt at all really, just uncomfortable, no pain.

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Says that the biopsy was uncomfortable but didn’t hurt.

Age at interview 65

Gender Male

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Can you explain in some detail what it’s like to have a biopsy?

Yes well that’s what I was just coming to yes it [laughs] it’s, it didn’t hurt, I mean it was uncomfortable, I mean you have to lay there, I mean it was all done properly and you put a gown on and you lay there and the nurse like talked to you about things which you want to talk about like holidays or whatever it was. And then you had like this, they greased up, like a, well I take, I take it was a, like a clipper sort of affair or something which they take, they only take like little clips out. And then they just inserted that and then…

In the back passage?

Yeah in the back passage and then they actually took, I think it was 12 they took and I mean to explain what it felt like it, it was alright in the back passage because you know you could, you could stand that alright but it was like as though they was firing, every time they done it, it was like a paper clip going into you, as though they was firing a paper clip in. So anyway that is what I had done, I had 12 and after that it was, you know it’s quite alright. I mean I’ve talked to other people who’s had it and like they all said it’s nothing really to worry about, it’s a bit uncomfortable but I mean that is all.

Did you have any side effects after that?

No, no, no they say that you, you could turn round and pass a bit of blood or something like that but no I had nothing at all, no pains, no nothing and everything was fine.

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He was given an oral painkiller and a local anaesthetic – the biopsy wasn’t painful.

Age at interview 57

Gender Male

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Yes, I couldn’t stop laughing during the biopsy, I didn’t find it painful. I went to a local private hospital. People were very, very good. I wanted to see what the doctor was using for the biopsy. He wouldn’t let me look at it, which I thought was quite funny. They were very, very professional; they were very, very good. One of the samples taken, they took 10 samples, the first 5 I really didn’t feel anything I had, I was given an oral pain killer, I was given a local anaesthetic, they rubbed a liquid on, and I had an injection. The first 5 samples, there were no problems with at all, I really just felt, not even a pin prick. The 5th, 6th sample was a little sharp, as if you’d caught yourself on a drawing pin, the rest was no problem at all. They were super people, it just wasn’t a problem.

Okay. Did you have any side effects as a result of the biopsy?

I passed blood through urine the next day, and that was it, just once, absolutely simple as anything, gave me no fears at all.

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Pain is a complex experience, which is difficult to measure. Men’s discomfort may vary according to the number of samples taken. In Britain, prostate biopsies can sometimes be performed without pain relief (analgesia) or sedation. However, over the past five years there has been a growing awareness of the need to use some form of anaesthetic when taking a prostate biopsy, and most urologists now use a local anaesthetic, such as lignocaine, which is injected around the prostate through the rectal wall. A pain relieving gas, such as nitrous oxide (Entonox) may also be used if required. Additionally, some urologists offer glyceryl trinitrate paste for men with very ‘tight backsides’ who find insertion of the transrectal probe uncomfortable.

He wasn’t offered an anaesthetic but thought other men might consider it if faced with a biopsy.

Age at interview 62

Gender Male

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Yes I mean basically I was asked to lie on a couch, to draw my legs almost up to my neck and then the doctor goes in via the rectum in order to feel and examine number 1. And that in itself is not exactly joyful but then.

In order to examine the prostate?

In order to examine the prostate and then obviously accesses via the same route in order to take the samples which sounded a little bit, when it happened they are obviously inserting, and even to this day I never asked what it was [laughs] presumably a machine of some sort and it sounded a bit like a gun going off every time they took one and they moved it slightly, there was just this clicking noise and he said ‘That’s one more done, and then obviously was moving round and taking more than one sample. And whilst I say it was not a pleasant experience I mean to be fair I keep using the analogy but going to the dentist isn’t always the most pleasant, you get on and do it because that’s part of, part of the process. So I mean I wouldn’t be totally negative about it. To be fair, they did say this will be uncomfortable, and they did say you know it might be slightly painful but well do everything we can to kind of ease that. I have heard of some men who since have explained to me that they did have an anaesthetic in some shape or form. I wasn’t offered that and if I’m being asked I don’t think it’s particularly, you know if I was doing it again I wouldn’t particularly say I wanted one. Presumably it was a local anaesthetic they had. But I have heard of some men who offered it and who did have it. I think in most cases it was because they’d had something similar before, knew what it was like and therefore were ready and questioned it. So I guess from an awareness point of view it’s something to think about but I certainly wasn’t offered it and yes if it happened again I’m not sure that I would be particularly saying I wanted one from that perspective.

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In contrast to the men who experienced very little pain, a few men said they had found the biopsy extremely painful. A man who had a biopsy several years ago (in 1996) found the procedure very painful.

He was told that the biopsy would be uncomfortable but he found it very painful and wouldn’t let…

Age at interview 70

Gender Male

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So when I went back now to have the, the biopsy [laughs] that was painful. However, but he explained to me what was, how it’s going to be and I went and I lie down on the bed and the doctor, he explained to me that I would hear like a little ‘Pouf going off, ‘But it’s not painful and it’s nothing, it, it’s just discomfort.

That’s what he said?

That’s what he said. But to me, when he started it wasn’t discomfort, but it was painful. On the outset he said they wanted eight samples. So I said, ‘OK. But when he started, and when he reached, he got his six samples, I said, ‘Hang on a minute doctor’, I said, ‘I want to go to the toilet. Because I couldn’t stand that any more. But when I go to the toilet I was passing blood, you know, I see the, set of blood. So I got some paper, the tissue paper and pat myself with it. And when I went back in he said, ‘Right, two more pieces. I said, ‘No you ain’t. I said. ‘You’ve got six pieces of samples, whatever tests you’re going to run, that’s enough. I said, ‘Theres no way I’m going back on that table for you. And he started arguing with me. I says, ‘You can talk until doomsday, I’m not going back there.

Because it was so painful?

Because it was so painful.

And how did you feel after the biopsy?

I was in, I was in some pain. Because imagine you’ve got like a claw, snipping these bits of flesh from you, it leaves you sore inside.

Right.

Inside sore. And the, the blood, I was passing blood for about a day and a half or so. And in the meantime it was uncomfortable.

Yeah.

But it had to be done, so it had to be done. When I went back to the hospital I saw a different consultant and he told me well the prostate gland is cancerous.

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A man diagnosed in 2005 said he had received an information sheet from the hospital which said that some men find the biopsy a ‘little unpleasant’, but he found it very painful and needed ‘gas and air’ (Entonox). An elderly man was told that he wouldn’t feel pain but he recalled that he ‘broke out in a bad sweat’. He recalled that the doctor told him that the local anaesthetic hadn’t had time to work.

He found the biopsy very painful and needed ‘gas and air’ (Entonox).

Age at interview 52

Gender Male

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The biopsy, I went to the local hospital to have. And I was very, very nervous before I went there, because I’d heard already that it was unpleasant. And, and, and it didn’t disappoint me. It was unpleasant. It was done under, with just some GTN cream and, and some gas and air. And it was very painful, or very painful for me for the ten, fifteen minutes, twenty minutes that the biopsy was taking place. However I must admit that even though it was painful that twenty minutes, two hours later I was fine. I was very shaken up to start with, but two hours later when I got back home I was fine.

So they, did they use a little bit of local anaesthetic? You mentioned a cream?

They used some GTN, glyceryl trinitrate cream, which they applied rectally, and gave me some antibiotics when I had it. But to be fair that, that didn’t, that didn’t ease, ease the procedure. Then they gave me some standard gas and air, which I could take while I was having the procedure. Which I did take. However the procedure I found very very unpleasant.

Do you know how many samples of tissue they took?

I think it was either six or eight. I, I could have told you at the time because it seemed to be very vivid. But I think my minds blocked it out since then.

Did they tell you to expect that sort of level of discomfort?

Perhaps they didn’t warn me as much as that, you know, as, as much as I thought it was going to be. But from what I understand of talking to other people, it, it just depends on different people as to how painful they find it. I found it particularly painful.

The biopsy was worse than the operation [laugh]. The biopsy was more painful than the operation.

Well, you’re the first person that’s told me you had gas and air during the biopsy. Was that easy, was that on hand, or did you have to ask for that?

I said, ‘What op?’ Well, I said, ‘What painkilling can I have?’ And they said, ‘Well, you can have this gas and air. So I said, ‘Right. Get the mask here. Let’s get that mask in my face.

Did that make you feel a bit queasy afterwards or not?

No, not really.

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Thinks he had the biopsy before the local anaesthetic had time to work.

Age at interview 69

Gender Male

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What was it like having a biopsy?

I felt it very discomforting, the they said you don’t feel any pain I think it was five snips or something they take off the prostate and I felt every one, I felt every one, I had the specialist that done it actually says to me, ‘You’re awful lean looking. And I told him, I says, ‘Well I’ve lost two and a half stone. I says, ‘I’ve just had my wife. I had the trauma of my wife dying on me, I said I lost quite a bit of weight, which I did do, you know?

[Mmm].

I says it’s maybe that, but they apologised for, because I felt it and they said they hadnae give the-the anaesthetic time to work.

Did they give you some local anaesthetic?

Oh aye-aye-aye-aye-aye-aye, they were very good actually, I’ve no complaints about them you know?

[Mmm].

And-and they says well it might be a bit too soon and I had, I think they still had two cuts to take and I told them I was sweating, I broke out in a bad sweat and that you know and they put this thing on my finger for the pulse rate and all this bather and…

But they had they had something on your finger to measure the pulse rate?

Oh aye-aye-aye-aye-aye but I told them to go ahead, I said, ‘Just go ahead and take them.

Because, but it was hurting you?

Aye it did hurt, it did hurt,

[Mmm].

But I mean it was over and then after that I, it’s vague now, but you get a cup of tea and you sit for a while and then you go and pass urine.

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After the biopsy some men said that they felt a bit sore. One man said that he looked pale and felt as though he’d been ‘though a bit of an experience’ but went back to work that afternoon. Another man said he felt ‘shaken’, but two hours later felt fine. Some men passed blood in their urine or sperm for few days. Others had discomfort or slight bleeding when they opened their bowels. It is normal to see some blood in the stools or urine for up to two weeks.

After the biopsy he felt a bit sore when he opened his bowels and he passed blood in his urine…

Age at interview 72

Gender Male

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Whilst I was in hospital then they did, they asked, or they told me that it would be wise to have a biopsy. Small pieces, very minute pieces of the tumour taken away. The idea of it frightened me to death and then it was explained that it was not going to be painful, a little bit uncomfortable but certainly not painful, it wasn’t even necessary to give me an anaesthetic, but I did have to sign consent forms because I went into theatre. But the nurse was very supportive, the surgeon was very supportive, nothing to be frightened of and it was true. So it he took I think it was about seven samples, seven or nine samples by going in through the anus, into, into the prostate gland and removing tiny little pieces. And it was just as if a ballpoint pen had been pressed on my hand, it wasn’t even sharp, but there was a click each time it was done and then went back to the ward and recovered very quickly, nothing to worry about whatsoever. If I was told I as going to have it tomorrow it wouldn’t worry me at all, and far less, far less traumatic than going to the dentist.

Do you know if they used any local anaesthetic or anything?

No they didn’t use any anaesthetic at all, it wasn’t necessary.

And were there any side effects of the biopsy?

Noyes I was, just afterwards I passed blood in the urine for a short while, a few days and a little bit uncomfortable when I went to the toilet, when I passed stools, it was just that little bit sore. But after that no problems at all.

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More serious side effects can follow a biopsy. Occasionally men find it hard to pass urine. Infection may also occur in spite of prophylactic antibiotics. One man said he developed severe cystitis after his first biopsy.

He developed a bad urinary infection (cystitis) after the first biopsy, during which ten samples…

Age at interview 57

Gender Male

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I went for the biopsy, I had ten biopsies and basically what happens is they will give you a local anaesthetic, but it’s all, obviously they access your prostate through your back passage so you actually have a local anaesthetic injected up through there. They then put this bit of kit up inside you which grabs bits of your flesh, whatever. And I didn’t find it that unpleasant, I mean it certainly wasn’t pleasant, the whole thing is quite undignified and quite difficult but it wasn’t that unpleasant although obviously I did react to it because when I got home I was sort of pale and looked as if I’d been through a bit of an experience. But it was fine and later in the day I was fine and went back to work and what have you.

But at the time of having the, the biopsies the consultant said to me, ‘By the way, he said, ‘Obviously were going into your prostate and were taking samples from your prostate, it is going to have an impact on your insides and you may find that theres a little blood in your urine over the next little while. And I said, Well what do you call a little while?’ And he said, ‘Well may be a month, 6 weeks or so. And then that was that so off I went home and all the rest of it.

Went along for the results on the Friday and he explained that 9 of the biopsies were clear but one of them had very suspicious cells and the, the operative who was looking after this kit was saying, ‘We must do some more biopsies around that area. So he gave me a little rest and the following Monday, that is a fortnight after the first biopsies, I had another 12 biopsies. That obviously was quite difficult, and I know that, for instance in America, my brother-law is a surgeon in America, they would never give you 22 biopsies in your prostate in a matter of 2 weeks. But anyway I had, I had 12 biopsies done and went back for the results a few days later and he pronounced that they were clear. But by that time I was suffering from extremely bad cystitis which is an infection I’d got probably from the first biopsies. It took a little while for that to be sorted, in fact they thought that they might have to take me into hospital and put me on a drip because the cystitis was so very, very bad.

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This man went on to have another biopsy. In total 22 samples were taken over a two week period. Afterwards he passed blood in his sperm. Although it is normal for men to find blood in the semen for up to a month or two, he did not remember being warned that this might happen. His wife said that she wished someone had advised her husband to use a condom in order to ‘contain the drama’. They both said that the traumatic experience had affected their sexual relationship for months.

He suffered elements of ‘post traumatic stress’ for several weeks after he passed blood in his…

Age at interview 57

Gender Male

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But actually what I want to say about the biopsies is something which was very, very much more important to me and that was this, this remark about you may have some blood in your urine. Probably the most traumatic thing about the whole experience for me in terms of the PSA testing and the biopsies and visiting the consultant and all the discussions, quite apart from the difficulty with the, ‘Having sex in a coffin’ comment was the fact that I was not prepared for the effect of the biopsies on my sex life. And what I mean by that was the consultant said, ‘You may find that you pass a little bit of blood in your urine. In fact it isn’t blood in your urine which is the most significant thing it is the fact that when you have a sexual experience and you ejaculate it is a bit like the film ‘The Alien’ if you’re not expecting it. What happens is that you ejaculate what looks like very florescent strawberry jam. And I actually, according to my wife, was traumatised by this and subsequently suffered elements of post traumatic stress for several weeks.

And it was very, very difficult and it was very, very difficult because, mainly because I wasn’t prepared for it. If I’d been prepared for it I could have dealt with it, I wouldve expected it and I couldve dealt with it but it mean that we didn’t have full sex for about 6, 8 weeks, it meant that I was wearing a condom which I hadn’t worn since I was in my early twenties and basically I had a very, very difficult time which was quite shocking for me because I’m a very forthright confident person in my life, I’m a very, or always had been very confident in terms of my sexuality and I had some difficulty with that for some weeks and months after that and the whole thing seems rather bizarre to me because basically I went for a PSA because of my symptoms which were to do with restriction of urine flow.

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Regrets encouraging her husband (Interview 27) to have a PSA test. Also says her husbands…

Age at interview 54

Gender Female

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Right the two things that I feel now with the wisdom of hindsight. One, I would never have nagged my husband [laughs] to go for a PSA test, and I think that everything that happened after the PSA test had a slight air of panic and hysteria to it and so that I, I regret that, I regret that I was part of that. I didn’t appreciate how very hit and miss the PSA test was, so that’s the first thing. And the second thing to me was, and may be this is even more important is that it seems such a sin of omission on the part of the consultant, on any medical person, not to explain to a lay person what happens to you when you have 22 biopsies to your prostate and that you do ejaculate blood. And for a lay person, especially for a man I think who’s not used to bleeding, it had an incredible effect on my husband and, and it subsequently obviously had an effect on me because I love him very much and it took us about 18 months to get over that [coughs]. So I feel why on earth didn’t someone say something so simple as ‘put a condom on’, so the first time you ejaculate you are containing the drama as it were and also preparing. And so for me as the wife, I’ve been dealing with trauma, I’ve been dealing with my husband being sexually traumatised and so that I’ve had, a lot of; my regret is about is that; and I’m really glad about, I suppose about my job I’m a psychosexual therapist and I felt quite confident about us having a very good sexual relationship and being able to play my part in reassuring him but we should never have been put in that position. So that’s really what I want to say that if there are any medical people that are going to watch this, think, can you please think of what consequences are to people in their sexual relationships and, and the negative ripples that it sent out for us for months and months.

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One man had particular worries about the biopsy. His doctors put his mind at rest to some extent.

He was worried that the biopsy might allow cancerous cells to spread throughout his body.

Age at interview 72

Gender Male

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I made the point to a doctor later that if, as some of the diagrams show, cancer travels from the prostate through the blood system to other areas of the body, if you’re going to stab something which has a, a cancer e-, element inside it, which is then going to bleed fairly profusely at times [laugh], was that a way of spreading it around? And he said, ‘Yes, it’s something that one has to accept is a possibility. And the implications of that to me were, well, you know, if it’s the only way of finding whether you have a, you know, a cancer, I suppose that’s, you’ve got to accept.

Was there anything else that worried you about the biopsy?

I think that was the one which worried me most.

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He was concerned that the biopsy might have allowed cancerous cells to get into his sperm and…

Age at interview 72

Gender Male

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We were talking about the biopsy again, and you mentioned…

Yes.

…one other worry you had?

Yes.

Can you talk about that a bit?

Yes. It only occurred at the time I got the results from the biopsy, when having been expecting it to be benign, it, it turned out to be positive. And my wife and I had made love a couple of times during the interval between having the biopsy and the results. And it suddenly occurred to me after leaving the doctor who told me about this that I might in some way have contaminated my poor wife with semen which was, it had cancer cells involved. And so fortunately I was able to phone my GP, and spoke to his wife, who was also a doctor. And she put my mind at rest, because she said it could not contaminate a woman in any way, prostate cancer cells. Which was a great relief.

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If the results of the biopsy indicate prostate cancer is present the consultant will discuss treatment options (see ‘Choosing a treatment if prostate cancer is diagnosed’ and ‘Biopsy’ in our prostate cancer section). If, however, cancer is not diagnosed the consultant will probably suggest an MRI to see if a repeat biopsy is needed.

Last reviewed May 2016.
Last updated May 2016.