Background <p>To explore the possible impact of real-time ultrasound screen visualization on pain perception, anxiety levels, and overall patient experience during transperineal prostate biopsy (TPBx) performed under local anesthesia.</p> Materials and methods <p>The prospective observational study was conducted at two medical centers. Patients were allocated into two groups: a control group (<i>n</i> = 59), which did not receive visual feedback, and a display group (<i>n</i> = 63), which observed the ultrasound screen with concurrent procedural explanations. Pain was assessed using the Visual Analog Scale (VAS), while anxiety levels were measured with the Spielberger State-Trait Anxiety Inventory (STAI) and Beck Anxiety Inventory (BAI). Patient satisfaction and willingness to undergo repeat biopsies were also evaluated.</p> Results <p>A total of 122 patients were included. The display group reported significantly lower overall procedural pain (VAS: 2.46 ± 1.28 vs. 3.08 ± 1.49, <i>p</i> = 0.005) and reduced post-procedure anxiety (STAI-1: 44.6 ± 8.8 vs. 49.5 ± 9.2, <i>p</i> = 0.001). Additionally, patient satisfaction scores were significantly higher in the display group (8.00 [6–9] vs. 5.00 [4–7], <i>p</i> &lt; 0.001), along with an increased willingness to undergo repeat biopsy (8.00 [4–10] vs. 5.00 [2–8], <i>p</i> = 0.002).</p> Conclusion <p>Real-time ultrasound screen viewing during TPBx under local anesthesia was associated with statistically significant reductions in pain and anxiety scores. However, considering the study’s non-randomized design and the modest magnitude of VAS change, the clinical relevance of this difference should be interpreted with caution. This simple and low-cost approach may help improve patient comfort and procedural compliance, but further randomized studies are needed to confirm its effectiveness.</p>