〔Abstract〕 Objective The purpose of this study is to evaluate the false positive rate of 4,5 points lesions in the prostate imaging report and data system. Methods A retrospective analysis of 163 patients undergoing prostate MRI examination at Shenzhen second people’s hospital from September 2015 to May 2019, MRI ultrasound fusion targeted biopsy was performed on 168 lesions, and radiologists retrospectively adopted PI-RADS v2.1 for identifi cation and evaluation. In PI–RADS 4 and 5 lesions, the incidence of clinically signifi cant prostate cancer (defi ned as Gleason score ≥ 7) was determined. The clinical data fi rst compared categorical variables by t-test, and compared continuous variables by Fisher's exact test. Multivariate logistic regression models are used to determine factors related to benign pathological results. Results Among 36 PI–RADS 4-point lesions assessed by mpMRI cognitive fusion biopsy,80.55 % (29/36) were prostate cancer, and 19.45 % (7/36) were benign lesions; among 132 PI–RADS 5-point lesions,93.94 % (124/132) were prostate cancer, and 6.06 % (8/132) were benign lesions. In general, PI–RADS 4-point lesions showed 61.11 % (22/36) as clinically signifi cant prostate cancer; PI–RADS 5-point lesions showed 87.88 % (116/132) as clinically signifi cant prostate cancer. In addition, there are no clinically meaningful prostate cancers elsewhere in these 15 benign lesions. In univariate analysis, compared with PI–RADS 4 and 5 with malignant pathological results, PI–RADS 4 and 5 with benign pathological results were signifi cantly related to lower PSA density (P = 0.002). In the multivariate analysis, the factor associated with benign characteristics is the lower PSA density (OR = 0.016; P = 0.005). Fifteen lesions with benign pathological results were re-examined again, 53.33 % (8/15) pathologies were stromal benign prostatic hyperplasia, and 46.67 % (7/15) pathologies were infl ammation. Conclusion PI–RADS types 4 and 5 with benign pathological results occur very low. Our results suggest that clinical parameters (PSA density) may help clinical decision-making, and consider including them in future PI–RADS scores.