Introduction: Transrectal ultrasound-guided prostate biopsy (TRUS-PB) is the standard diagnostic procedure for prostate cancer but is frequently associated with patient discomfort. Adequate and balanced anesthesia is essential, especially with extended core biopsy protocols. While caudal block (CB) provides effective analgesia and sphincter relaxation, it may be associated with transient motor weakness. Combined intrarectal lidocaine gel with periprostatic nerve block (cGPNB) has been proposed as an alternative balanced anesthetic technique; however, comparative data remain limited. Our Objectives were to compare the analgesic efficacy, patient tolerability, and subjective preference of cGPNB versus CB during all stages of TRUS-guided prostate biopsy in a single-center setting. Methods: This prospective randomized study was conducted at the Department of Urology, Shyam Shah Medical College, Rewa, between October 2022 and October 2024. One hundred patients undergoing TRUS-guided prostate biopsy were randomized into two groups: Group A received combined intrarectal lidocaine gel with periprostatic nerve block (n=50), and Group B received caudal block (n=50). Pain was assessed using the Numerical Rating Scale (NRS) during anesthetic administration; TRUS probe insertion, biopsy needle puncture, and one hour post-procedure. Patient tolerability, willingness for repeat biopsy, and procedure-related complications were recorded. Results: Baseline demographic and clinical parameters were comparable between groups. Both techniques provided effective analgesia during biopsy needle puncture and post-procedure periods, with no statistically significant difference in overall pain scores. CB was associated with significantly less pain during probe insertion; however, transient lower limb weakness was observed in a subset of CB patients. Patient willingness for repeat biopsy and overall tolerability were high in both groups, with a trend favoring cGPNB. Conclusion: Combined intrarectal lidocaine gel with periprostatic nerve block provides effective, balanced analgesia throughout TRUS-guided prostate biopsy and is a well-tolerated alternative to caudal block, without associated motor impairment.