Background: A significant proportion of men undergoing transrectal ultrasound guided prostate biopsy report pain during the procedure. The aim of this study was to determine and compare the efficacy of intrarectal lidocaine gel and oral tramadol in achieving pain relief during transrectal ultrasound-guided prostate biopsy. Patients and methods: A total of 107 patients scheduled for transrectal prostate biopsy were randomly assigned to two groups. Group 1 (tramadol group) received 100 mg of tramadol administered orally as well as intrarectal instillation of 20mls of KY jelly (placebo lidocaine gel) before the procedure. Group 2 (lidocaine group) received 100 mg of vitamin C (placebo tramadol) with intrarectal instillation of 20 mls of 2% lidocaine gel prior to the procedure. The severity of pain experienced during the procedure was assessed using the numerical rating score (NRS). Results: The mean pain scores for the tramadol and lidocaine groups during ultrasound probe insertion were 3.1±2.2 and 3.9±2.1 respectively. The mean pain scores for both groups during biopsy needle insertion were 3.9 ± 2.3 and 4.2 ± 1.9 for the tramadol and lidocaine groups respectively. The differences in mean pain scores between the groups during ultrasound probe insertion was statistically significant (p=0.004). On the contrary, a statistically insignificant difference in mean pain scores was observed between both groups during biopsy needle insertion (p=0.366). Conclusion: Oral tramadol offers significantly better pain relief during rectal ultrasound probe insertion when compared with intrarectal lidocaine gel. However, no significant difference in pain relief was found with the use of oral tramadol nor intrarectal lidocaine gel during needle insertion in biopsy of the prostate