Chronic, Non-bacterial Prostatitis
Geo Espinosa, ND, LAc, CNS
Prostatitis is a condition in which the prostate gland becomes inflamed. It can be caused by a bacterial infection, decreased immune function, or a reduction in muscle-related function. Prostatitis is a term that describes a group of disorders that have related symptoms.
Prevalence of Prostatitis
According to the Professional Guide to Diseases, 9th edition,1 as many as 35% of men older than 50 years of age have chronic prostatitis and about 50% of males will be diagnosed with prostatitis at some point during their lives. This high number of men with the condition results in an estimated 2 million outpatient visits per year made by men seeking treatment for prostatitis.2 According to one large community-based study, symptoms of chronic prostatitis show a prevalence of 9.7% among men 20 years of age and older.3 Interestingly, inflammatory infiltrate has also been detected in up to 100% of biopsy specimens from men with benign prostatic hypertrophy (BPH), suggesting a possible role for prostatitis in the pathogenesis of BPH.4
Types of Prostatitis
As defined by the National Institutes of Health (NIH), there are 4 types of prostatitis.5 Even though these different types share some similarities, they also have some differences.
Acute bacterial prostatitis (category 1): Acute bacterial prostatitis is the least common and most serious type of prostatitis. The usual course of treatment is antibiotics.
Chronic bacterial prostatitis (category 2): Chronic bacterial prostatitis can last for months and is associated with long-term complications also caused by bacterial infection. Long-term antibiotics is the typical course of treatment.
Chronic nonbacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) (category 3): This form of prostatitis is the most common and is the main focus of this article. For diagnosis, symptoms must be present for at least 3 months, and they tend to come and go. Like chronic bacterial prostatitis, experts do not know why men get this form of the disease. Some men have symptom relief without treatment while others require a variety of treatment options. In some cases, symptoms become unbearable and require surgery.
Asymptomatic inflammatory prostatitis (category 4): Men who have this form of prostatitis typically have an elevated prostate-specific antigen (PSA) level and an inflamed prostate, but they don’t have the classic symptoms of prostatitis. The standard treatment is a course of antibiotics, after which the PSA levels usually return to normal within 4 to 6 weeks.
Symptoms of CP/CPPS
- Symptoms of chronic, nonbacterial prostatitis are similar to those of acute and chronic bacterial prostatitis. The symptoms tend to fluctuate and can include:
- Blood in the urine or semen
- A strong urge to urinate
- Difficulty starting the urinary stream
- A weak urinary stream once it starts
- Frequent nighttime urination
- Pain and/or burning during urination
- Pain in the genital and pelvic area
- Pain when ejaculating
- Although CP/CPPS is a non-definitive diagnosis, a combination of urinary dysfunction and pelvic pain has to be present for CP/CPPS to be ruled in.
- For some men, symptoms of
- CP/CPPS improve over time without treatment. Others have chronic symptoms for a lifetime.
Health care providers can use the following tools for diagnosing prostatitis:
Chronic Prostatitis Symptom Index, developed by the NIH (NIH-CPSI) – This questionnaire takes 5 minutes to fill out and explores the 3 most important domains of a patient’s experience: pain (location, frequency, and severity), voiding symptoms (obstructive and irritative), and, importantly, impact on quality of life
Digital rectal examination (DRE) – The prostate may be tender, causing pain on exam
Urinalysis and urine culture to rule out infections
Physical exam of the pelvic muscles
Note: PSA testing is not of value and should not be performed, as it will likely be falsely elevated.
Why Conventional Medicine Fails in Treating CP/CPPS
Chronic prostatitis (CP/CPPS) is the most difficult type of prostatitis to treat and these are the patients who have often failed to respond to conventional treatments. For CP/CPPS, most doctors prescribe a list of medications, from long-term antibiotics (which do not work because CPPS is not caused by bacteria) to BPH medications or other drugs to treat the symptoms of chronic prostatitis. Unwanted side effects from conventional treatments may include gastrointestinal and sexual dysfunction.
The reason these treatments don’t work is that CP/CPPS requires a whole-patient approach where the treatment begins outside the prostate. The naturopathic medical model is specifically applicable with this patient population.
The naturopathic approach to treating CP/CPPS involves evaluating the patient’s dietary and lifestyle factors, including food intolerances, gastrointestinal health, trigger points in the pelvic area, hydration, supplements, intake of healthy fats, exercise, and stressors.
Food Allergies and Comorbidities
A whole-person-centered approach, including diet, supplements, and lifestyle choices, can help support the patient’s overall health. Many men with prostatitis also have other medical problems, such as irritable bowel syndrome (IBS) and fibromyalgia. Many patients who have IBS have increased intestinal permeability, or “leaky gut,” which may be caused by intolerance to certain foods or ingredients.
Food sensitivity tests, such as antibody or cytotoxic assays, may be helpful in determining the culprit food. Such tests are more accurate for detecting food sensitivities than standard allergy tests such as radioallergosorbent (RAST) skin testing. Men who can identify those substances to which they are hypersensitive or allergic may be able to significantly reduce their prostatitis symptoms via elimination of allergenic foods.
An elimination diet is a less expensive alternative to the lab testing. This involves removing certain foods or ingredients from the diet that one suspects are causing allergic reactions while keeping a food/symptom diary and watching for changes in symptoms.
Omega-3 Fatty Acids
Omega-3 fatty acids, such as EPA and DHA in fish oil, can be useful due to their anti-inflammatory properties. Omega-3 fats calm the inflammatory response and prevent tissue damage and swelling that lead to pain and illness, as in prostatitis.
Green Tea Catechins
Catechins in green tea can destroy certain bacteria and viruses and help manage prostatitis, as well as enhance the immune system and combat several forms of cancer, including prostate cancer. Although there are several different kinds of catechins, the most powerful is epigallocatechin gallate (EGCG).
In a rat model of chronic bacterial prostatitis, the animals were given placebo, catechins, the antibiotic ciprofloxacin, or catechins plus ciprofloxacin.6 The catechins group, alone, showed modest improvements in inflammation and bacterial growth compared with the placebo group, but the combination of catechins and ciprofloxacin demonstrated significant improvements when compared with placebo.
In a more recent study, researchers used rat models of chronic prostatitis and found that nanocatechins (catechins that have been altered using nanotechnology) had more effective anti-inflammatory and antimicrobial effects on rat chronic prostatitis than “normal” catechins because the body was able to absorb them more effectively.7
One caution about green tea is to watch the caffeine content. Caffeine is a diuretic and can stimulate the bladder, causing an urgent need to urinate. On average, 1 cup of green tea contains 25 mg of caffeine, while black tea contains nearly twice as much. Thus, when shopping for green tea, choose decaffeinated.
Nutraceuticals to Consider
I use a unique combination of nutrients for my CP/CPPS patients that includes the following:
- Beta-sitosterol is a cholesterol-like substance derived from plants (phytosterol) that can be used to manage symptoms associated with prostatitis, such as urinary frequency, urinary urgency, and flow problems.8
- Cranberry contains phytonutrients called proanthocyanidins (PACs), and more specifically A-type PACs, which are not found in other berries. A-type PACs help prevent bacteria from attaching themselves to the walls of the urinary tract, which in turn helps prevent the development of urinary tract infections. This quality makes cranberry helpful in managing the health of men with pelvic discomfort, which can include urinary urgency, urinary flow problems, and urinary frequency.9
- Diindolylmethane (DIM) is a phytonutrient from cruciferous vegetables that is released in the body when gastric acid from the digestive process acts on indole-3-carbinol, the precursor of DIM. Research shows that DIM has the ability to promote and support healthy metabolism of estrogen and related hormones by enhancing the liver’s ability to metabolize estrogen to a weaker compound called 2-hydroxyestrone.10 This weaker estrogen helps protect prostate tissue from inflammation and cancer. DIM may also improve prostate function.11
- Green tea contains potent antioxidants known as catechins, which have an ability to support prostate health, as was demonstrated in several animal studies, mentioned earlier.6,7
- Pollen extracts have anti-inflammatory properties, a feature that has proven beneficial in helping patients with prostatitis. For example, 70 men who had CP/CPPS were given a pollen extract, while 69 men with the same condition received a placebo. After 12 weeks, the men who took the pollen extract reported significant improvements in their symptoms and quality of life compared to placebo, and had no severe side effects.12
- Pygeum is a derivative from the Pygeum africanum tree whose long history of use as a folk cure for bladder problems has been joined by its use in managing prostatitis. Studies indicate that pygeum contains several compounds that make it a good candidate for prostatitis patients.13
- Quercetin is a phytonutrient that reportedly “provides significant symptomatic improvement” in men who have CP/CPPS.14 Other studies have also uncovered quercetin’s anti-inflammatory and antioxidant properties.15
- Serenoa repens (saw palmetto) has been used for centuries to manage prostate and urinary tract problems, a tradition that continues today. For men who have prostatitis, saw palmetto may offer relief from symptoms when combined with other ingredients.16
- Urtica dioica (stinging nettle) root has anti-inflammatory and diuretic properties, which make it a good candidate for management of urinary tract and prostate health.17
- Curcuma longa (turmeric) is a perennial plant with anti-inflammatory properties. The active ingredient in turmeric is curcumin, which has been shown to effectively manage chronic nonbacterial prostatitis.18
- Vitamin D has been shown to be helpful in relieving symptoms of another prostate condition, BPH, which suggests the vitamin may be useful in managing prostatitis as well.19
- Vitamin E comprises a group of 8 chemically-related substances called tocopherols and tocotrienols. The anti-inflammatory abilities of one of the substances, gamma-tocopherol, may prove helpful in men who suffer
- from prostatitis.20
- Zinc is a mineral found in large concentrations in the prostate gland. Researchers have found lower concentrations of zinc in men who have prostatitis than in healthy controls, indicating that zinc supplements may be recommended for men with prostatitis.21
- Probiotics should be considered as long-term therapy. A recent report from South Central University in China suggested that probiotics’ health benefits may make them a good treatment option for men who have chronic prostatitis.22,23 The authors hypothesize that urethral bacteria may be a primary cause of chronic prostatitis and that widespread use of antibiotics may be contributing to the risk of developing this disease. As a result, they believe probiotics could be a viable treatment for chronic prostatitis. However, no clinical work has been done thus far to support this idea.
Other Natural Interventions
In one study, 89 men with CP/CPPS were randomly assigned to receive 20 sessions of real or sham acupuncture over 10 weeks. After the 10 weeks, 73% of the men who had received the real acupuncture experienced a 6-point or greater decline in their NIH-CPSI score, compared with only 47% in the sham group. The men who received the real treatment also were 2.4 times more likely to enjoy sustained relief than those in the sham group.24
- Prostate Massage
The small sacks inside the prostate gland can become blocked and accumulate prostatic fluids, which become a breeding ground for microbes that can cause more inflammation and prostatitis. The fluids cause the prostate to become enlarged, then irritate the nerves, and cause pain and tightness. Therapeutic prostate massage can milk out the accumulated fluids, open up the passages in the prostate, and allow the gland to shrink back to normal size.
Biofeedback can help men improve relaxation and proper use of pelvic floor muscles.25
In one randomized trial, researchers showed 18 months of aerobic exercise to be superior to light, non-aerobic exercise, for helping sedentary men suffering from category III prostatitis. The aerobic group practiced fast-paced walking at 70-80% of their maximum heart rate 3 times a week.26Physicians should discourage bicycle riding, as it’s my clinical experience that bicycle riding worsens pelvic symptoms in patients with CP /CPPS. Patients who have experienced at least a 50% improvement in symptoms may resume riding bicycles; however, they should be encouraged to purchase a prostate-friendly bicycle seat with a gap in the middle, to avoid impact to the perineal area.
- Trigger Point Release
Myofascial trigger point release with relaxation training is based on the idea that chronic pelvic pain may be the result of instinctively trying to protect the genitals and pelvic area from harm by contracting the pelvic muscles. This instinct causes some people to continuously tighten their pelvic floor muscles, which over time can cause chronic pain to set in. The combination of myofascial trigger point release and relaxation involves a series of exercises that desensitize the trigger points of the pelvic muscles.One of the most recent studies of this treatment approach involved 200 men who had suffered from type III prostatitis pain for an average of 4.8 years.27 The men participated in a series of 3 to 5-hour daily sessions that included pelvic floor exercises, self-treatment training, and paradoxical relaxation training for 6 days. The men were followed for a median of 6 months. Overall, 82% of the men reported an improvement in symptoms; 59% had a marked-to-moderate improvement, and 23% reported a slight improvement. Pain, urinary dysfunction, and quality of life showed significant improvements.
In closing, the successful treatment of CP/CPPS requires a multi-modality approach. In my clinical experience, short-term relief comes from some sort of physical therapy (ie, acupuncture, trigger-point release, etc) coupled with a strong anti-inflammatory lifestyle that includes the above-mentioned nutrients and stress management. Long-term benefits are acquired by healing the gastrointestinal system and the continuation of an anti-inflammatory lifestyle and the application of stress management techniques.
Geo Espinosa, ND, LAc, CNS is a renowned naturopathic urologist and a recognized authority in natural and complementary treatments for benign and malignant prostate conditions. Dr Geo is the founder and director of the Integrative Urology Center at New York University Langone Medical Center. He spent 5 years as a clinician, researcher, and director of clinical trials at the Center for Holistic Urology, Columbia University Medical Center, under Dr Aaron Katz. Dr Geo is the chief scientific officer of Prostate Research Labs, LLC, the formulator of ProstP10x and the cofounder and medical director of XY wellness, LLC. He is a prolific writer and a frequent contributor to medical journals, textbook chapters, and mainstream magazines. Dr Geo is the creator and blogger of his popular blog, DrGeo.com.
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Wagenlehner FM, Schneider H, Ludwig M, et al. A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis-chronic pelvic pain syndrome: a multicentre, randomized, prospective, double-blind placebo-controlled phase 3 study. Eur Urol. 2009;56(3):544-551.
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Liu L, Yang J, Lu F. Urethral dysbacteriosis as an underlying, primary cause of chronic prostatitis: potential implications for probiotic therapy. Med Hypotheses 2009;73(5):741-743.
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