Objective To assess the value of multi-modal image-guided transrectal ultrasonography in the diagnosis of prostatic nodules in elderly patients.Methods Sixty-four elderly patients suspected of prostate cancer (PCA) were enrolled from December 2015 to December 2016.Sixty-four patients with 72 nodules underwent transrectal ultrasound (TRUS),contrast-enhanced transrectal ultrasound (CETRUS) and transrectal real-time tissue elastography (TRTE).A combination of systematic biopsy and suspicious sitetargeted biopsy was conducted.The accuracies of different detection methods for prostate cancer were assessed against the gold standard of histological examination of prostate biopsy samples.Results Among the 72 nodules,31 were prostatic hyperplasia,5 were chronic prostatitis,35 were prostatic cancer,and one was prostatic lymphoma.There were significant differences in enhancement strength,enhancement time fast-in and degree of elasticity on TRTE and CETRUS between the malignant and benign groups (x2 =28.794,10.889,52.898;P =0.000,0.001,0.000,respectively).When the 35 PCA nodules were divided into two subgroups based on the Gleason score,there were statistically significant differences in enhancement strength,homogeneity of enhancement,and enhancement time fast-in and fast-out between them (x2=6.073,12.315,4.717,18.093;P =0.048,0.001,0.030,0.000,respectively).The combination of CETRUS and TRTE in diagnosing prostate nodules produced a sensitivity of 83.3 ％,a specificity of 86.1 ％,an accuracy of 84.7 ％,a positive predictive value of 85.7％,and a negative predictive rate of 83.8％,better than either method alone.Conclusions Multi-modal image-guided transrectal ultrasonography has an advantage in providing information on the perfusion and elasticity of prostate nodules in the elderly patients and thus has important clinical value for the diagnosis of prostate nodules.