Background: Prostate biopsy, while essential, often causes discomfort that can affect patient experience and adherence to follow-up procedures. Objective: This study aimed to identify factors associated with pain during fusion prostate biopsy to optimize the experience of prostate cancer diagnosis and monitoring. The primary goal was to assess the relationship between pain during viscous lidocaine (lido) instillation and periprostatic nerve block with the overall pain experienced by patients undergoing prostate biopsy. Methods: We queried our database for patients who underwent transrectal magnetic resonance imaging-ultrasound fusion prostate biopsy from March 2020 to July 2023 and had complete pain scores (1–10) recorded during lido instillation, periprostatic nerve block, biopsy, and overall. Results: A total of 779 patients were included. The mean pain scores during lido instillation, periprostatic block, biopsy, and overall were 0.11, 2.8, 3.5, and 3.6, respectively. Multivariable analysis revealed that patients with a pain score during lido instillation of >2 (odds ratio [OR] = 10.28; p=0.027) patients with periprostatic block of >2 (OR = 7.49; p<0.001), black patients (OR = 2.838; p<0.001), and patients on active surveillance (OR = 1.648; p=0.003) were more likely to experience the upper quartile (UQ) of overall pain. Men with abnormal digital rectal examination (DRE) findings were less likely to develop the UQ of overall pain than men with normal DRE findings (OR: 0.586; p=0.004). This finding suggests that digital rectal examination during the initial clinic visit can help identify patients who may benefit from sedation during prostate biopsy, potentially improving patient comfort and procedural experience. Conclusion: This finding suggests that digital rectal examination during the initial clinic visit can help identify patients who may benefit from sedation during prostate biopsy, potentially improving patient comfort and procedural experience.