Chronic Prostatitis & Pain: Getting to the Root and Resolving It
Eric Yarnell, ND, RH(AHG)
“Chronic prostatitis” is a common but under-recognized, poorly researched entity that addresses a spectrum of disease in men. It includes interstitial cystitis (IC), a condition formerly believed to occur largely in women until men were actually inspected and found to have it at similar rates; chronic pelvic floor hypertonicity; and non-inflammatory and neuropathic chronic pain syndromes affecting the pelvis and prostate.1,2 The incidence of chronic prostatitis is approximately equal to that of type 2 diabetes mellitus and ischemic heart disease in men over the age of 30 years, and yet it remains little discussed and in the shadows.3 This article will attempt to shed some light on it after 20 years of clinical experience treating over 150 chronic prostatitis and IC patients.
Forms of Chronic Prostatitis
First, the mostly worthless National Institute of Diabetes and Digestive and Kidney Diseases categories for prostatitis should be jettisoned. Yes, acute prostatitis and chronic prostatitis are different; they got that right. But beyond that, its categorizations (bacterial, non-bacterial inflammatory, and non-inflammatory) are not particularly helpful, as they don’t tell us anything about etiology. Many patients who have bacteria in their urine or semen samples are not cured by antibiotic prescriptions; consequently, even the apparently obvious category of chronic bacterial prostatitis is mostly unhelpful.4,5 Also note that there is some evidence that antibiotics can actually cause prostatitis (not because they are breeding resistant flora but because they are damaging normal urethral and gut flora), also that it is simply a total myth that when antibiotics don’t work that well, it’s because they can’t penetrate into the prostate (some don’t, but those that do are the ones that are used in treatment, such as fluoroquinolones).6-8
A more helpful categorization, which is becoming a bit more common, is the UPOINT system (see Table 1).9 This system benefits from moving away from the largely discredited theory that chronic prostatitis is mostly due to bacterial infection, and toward more individualized, symptom-based treatment. However, it still fails to identify and address the causes of chronic prostatitis in most cases. Here, a 2-fold naturopathic model based on etiology will be presented as an alternative for directing treatment that is focused on cure and not just symptom management. The UPOINT system is a better tool for selecting symptom-relieving therapies, but should not be the sole basis for therapy.
Table 1. UPOINT Chronic Prostatitis Phenotyping System10 – Naturopathic Interpretation
|Phenotype||NIH-CPSI Result||Other Major Features||Post-DRE UA/EPS Results||Suggested Symptom-relieving Treatments|
|Urological||u>4||LUTS; PVR often >100 mL; prostate feels enlarged||All negative||Spasmolytics, hot sitz baths; avoid diuretics|
|Psycho-social||u<4||Anxiety, depression, non-tender prostate on DRE||All negative||Nervines, counseling, stress reduction/coping, constitutional hydrotherapy|
|Organ-specific||p>5||Pelvic pain, pain on urination and/or ejaculation, prostate tender and soft on palpation||WBC and/or bacteria present||Inflammation modulators, analgesics, vulneraries, demulcents, cold sitz baths|
|Infection||p>5||(Same as for organ-specific)||WBC and bacteria present||Antimicrobials, immune stimulants; otherwise same as for organ-specific|
|Neurological||q>5||Dyspepsia, IBS||All negative||Adaptogens, nervines, bitters and/or carminatives, contrast sitz baths|
|Trigger point||p>5||Perineal pain, trigger points, pelvic pain, pelvic neuropathies, tenderness on pelvic floor palpation||All negative||Skeletal muscle relaxants, pelvic floor physical therapy, hot sitz baths, magnesium; avoid prolonged sitting and Kegel exercises|
Color coding groups relatively similar types together, or highlights very different types.
Abbreviations: DRE = digital rectal exam; EPS = expressed prostatic secretions; IBS = irritable bowel syndrome; IC = interstitial cystitis; LUTS = lower urinary tract symptoms (eg, frequency, urgency, nocturia); NIH=CPSI = National Institutes of Health Chronic Prostatitis Symptom Index (p = pain domain, q = quality of life domain, u = urinary domain); PVR = post-void residual; UA = urinalysis; WBC = white blood cells
Note that the UPOINT system uses the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) – a freely-available clinical questionnaire easily located with a quick Google search. It is recommended that every patient suspected of having chronic prostatitis be given this questionnaire and that its results be used to help guide therapy as well as assess progress by re-administering it every 3-6 months. There are 3 domains of problems assessed by this questionnaire: pain, quality of life, and urinary symptoms. These are crucial to UPOINT categorization and helpful in determining symptomatic treatments, but not usually helpful in determining the cause of the problem.
It is also crucial to perform a proper digital rectal exam (DRE) to assess men with chronic prostatitis. Even if the patient has recently had a DRE, it is well worth doing your own, as they are usually too brutal (ie, performed in such a way that the patient’s possible muscle tightness is exaggerated, giving false positives) and/or are not very thorough or specific. It is important to have the patient side-lying for the exam, as this relaxes the muscles in their legs and pelvic floor and makes for a more accurate and less intrusive exam. Go slowly and talk the patient through the procedure. When your finger is only about 1 digit into the anus, palpate the lateral walls, as this is the only way to directly assess the pelvic floor in men. If this triggers their pain symptoms or causes a burning sensation (not just pressure or discomfort), then it is much more likely that pelvic floor hypertonicity is a cause of all their problems. Most urologists are not trained to perform this exam. Proceed to palpating the prostate, again inquiring about pain or burning (not just pressure or a feeling of needing to urinate) and assessing softness. Often there is coexisting benign prostatic hypertrophy (BPH), which can lead to a urological phenotype of the disease. Don’t be surprised though if you find nothing amiss; this is by far the most common result of the exam. After the exam, collect an initial (not mid-stream) urine specimen, to assess whether any WBC and/or bacteria were mobilized by the exam.
One final side note: chronic prostatitis is not more common in gay or bisexual men or in men who are more sexually active.11 And there is really no difference in results on prostate exam in men who receive anal sex compared to those who don’t. It just doesn’t seem to affect what is going on at all, as far as I or any researchers have been able to tell. This is yet another nail in the coffin of the infectious etiology theory of most cases of chronic prostatitis.
Leaking Mucous Membranes
The most common cause of chronic prostatitis can ultimately be traced backed to increased intestinal permeability, which causes increased permeability of the urothelium. This seems to have been the problem in about 75% of my patients. There is ample evidence of increased urothelial permeability as a pathologic factor in chronic prostatitis and IC, including the finding that prostate stones are made of urine elements; studies in which carbon particle instillations in the bladder result in carbon particle distribution throughout the prostate tissue; significantly higher uric acid concentrations in the prostates of men with chronic prostatitis compared to healthy controls; and that the potassium sensitivity test, which causes severe pain in IC patients, causes no problem in people without this condition.12-15 Once the urothelium is hyperpermeable, even normally benign substances like potassium and uric acid can pass into the prostate tissue and bladder wall, triggering inflammation and unmyelinated C fibers and thus neuropathic pain.
What has not been studied is why the urothelium becomes hyperpermeable. So the rest of this is purely theoretical, based on clinical experience with patient after patient, which has consistently (though not 100%) shown that in most cases the problem originates in the gut. Basically, leaky gut allows non- or partially-digested food and/or gut flora molecules to cross the basement membrane and be seen by the gut-associated immune cells. These immune cells are then triggered and migrate elsewhere in the body, stirring up other reactions. In the case of chronic prostatitis and IC, they migrate to the urothelium; however, in other people, they cause migraines, GERD, cholecystitis, rheumatoid arthritis, or various other syndromes. This started out as a basic translation of our naturopathic theory into the realm of chronic prostatitis, which no one taught me could be anything other than an infection – the conventional party-line in the 1990s. But I found giving a bunch of antimicrobial supplements as hopeless as the antibiotic treatments, though at least almost entirely without the adverse effects of antibiotics. Eventually, I noticed that at least some men with chronic prostatitis had other manifestations of food reactions and leaky gut – conditions I had been taught about. As a result, I started having men do elimination/challenge diets, and patients began coming back reporting that they were completely cured, much to everyone’s astonishment.
So today, unless the patients present with a hypertonic pelvic floor picture, I usually explain the whole leaky urothelium/gut theory to them, and then recommend an elimination/challenge diet. I did initially try using the serum RAST IgG4 and IgE antibody testing; however, this consistently delivered results that were either false positives (patients didn’t get better eliminating the foods indicated and didn’t react when reintroducing them) or false negatives (foods that were supposedly OK, but which clearly improved their situation when eliminated and could flare symptoms reliably when re-challenged). So now I just go straight to elimination/challenge as the foundational element of treatment. I also experimented with gut healing supplements, but have rarely found this to work as long as the patient is continuing to eat the triggers. You can access the handout I use to guide elimination/challenge diets at: http://student-doctor.dryarnell.com, along with many other free materials.
If food triggers are found and can be eliminated, then I usually also have patients start taking aloe gel, 1-2 oz BID; glutamine, 2-3 g per meal; and N-acetylglucosamine (NAG), 700 mg BID. These are to both heal any remnant intestinal permeability defects and, in the case of NAG, to help repair the urothelial leaks. NAG has not apparently been studied in humans, but has been found helpful for cats with IC.16 A related combination of chondroitin sulfate, 37.5 mg; glucosamine sulfate, 30 mg; sodium hyaluronate, 3 mg; quercetin. 37.5 mg; and rutin, 5 mg (all amounts are per cap, and are obviously pretty low) – at a dose of 4-6 caps per day – has been shown to reduce symptoms of IC in 2 clinical trials.17,18 These agents can take 6 months to work, particularly NAG, so give them plenty of time.
Pelvic Floor Hypertonicity
Another 10% of my patients have had pelvic floor hypertonicity. This is ironic, as many men with chronic prostatitis are recommended to do Kegel exercises, which further tonifies their hypertonic muscles and makes things worse. The exact origin of this syndrome is unclear, but sometimes it seems that men clench these muscles as a response to stress. It is also common that they sit too much, but sitting is so common that I also see it in a lot of men who don’t have pelvic floor hypertonicity. The DRE approach to diagnosing this is described above. If this test is negative, I discard this theory and move on to the leaky urothelium/gut theory and work that angle. If that doesn’t work, or if they later tell me they notice their symptoms are worse from prolonged sitting, then I will revisit this theory.
It’s a little sad to admit, but I always hope this is what a chronic prostatitis patient is suffering from, as it is much easier to treat and cure than the leaky urothelium/gut problem. In most cases I’ve seen, the patient only has to do hot sitz baths once a night for 10-15 min, take magnesium, 200 mg (elemental) BID, and take Pedicularis or Piper methysticum (discussed below), and the problem completely resolves. If not, then I send him to a physical therapist specialized in pelvic floor problems, which almost always does the trick.
Sometimes patients are just too symptomatic to wait for elimination-challenge to work, or simply aren’t ready to do elimination-challenge. In these patients, I will use the UPOINT system to guide therapy, as I said, but there are 5 herbs and 2 constituents that I use more than anything else by far. Pedicularis bracteosa (towering lousewort) has become my main go-to pelvic anodyne that is also a nervine and a smooth- and skeletal muscle relaxer. This covers basically all phenotypes of chronic prostatitis and IC in one way or another. This wonderful plant is native to the mountains of the western United States. Pedicularis racemosa (lousewort, parrot’s beak) and P groenlandica (elephant head) also work; and at least the former is somewhat more common than the other species, but P bracteosa tastes better. The aerial parts of all 3 are used. It is crucial that they are harvested away from poisonous plants (often they are found growing right next to Veratrum, Senecio, Lupinus, and Arnica), as they are hemiparasitic and will take up constituents from whatever they are growing near.19 This fact can be used to our advantage, in that when they are growing near Valeriana sitchensis (Pacific valerian), they get even more potent. As tea, they are actually quite delicious, but a little too diuretic for the average chronic prostatitis patient. Consequently, fresh plant tincture is preferred, and using a 1:2-1:3 w:v (weight:volume) extract, 1-3 mL up to QID, usually significantly helps the pain.
Piper methysticum (kava) root is also very helpful for chronic pelvic pain. Re-read any of the old Eclectic textbooks, particularly Ellingwood’s materia medica, and you will find authors talking about kava primarily as a pelvic anodyne and not as an anxiolytic (though it is both). The very awful taste of kava, combined with the fact that it is inevitably coming from very far away (unless you happen to be so lucky as to live in Hawai’i or another Pacific island), led me to try towering lousewort originally, as well as the recommendation of the herbalist Howie Brounstein. I had a few patients on herbal formulas containing kava switch to towering lousewort, and all felt it worked better and was more palatable. I rarely have to use kava anymore, though since it is readily available in capsules, I will sometimes use it when tinctures are too expensive for patients. I will not even stoop to addressing the nonsensical theory that this herb is hepatotoxic in the ways we use it in medicine today.
When inflammation seems to be a major problem, I use quercetin, bromelain, Eryngium yuccafolium (rattlesnake master) root, and/or Chamaerion angustifolium (aka Epilobium angustifolium) (fireweed) aerial tops. Quercetin is the rare natural product that has actually been studied in clinical trials in men with chronic prostatitis and shown to be helpful.20 I recommend a dose of 1 g TID. Bromelain (at a potency of 3200 mcu/g or 2400 gdu/g), 1 g TID away from food, is a great accompaniment to quercetin.
Rattlesnake master is native to the Great Plains and into the South. Its leaves do look somewhat like yucca, but it is not related; in fact, it is in the Apiaceae family. It has a very resinous root that is quite specific for reducing inflammation in pelvic organs. There is no modern research on this herb, but empirically it is fantastic. I use a 1:3 w:v fresh-root tincture, and dose it at 1-2 mL TID. Firewood is found in the Pacific Northwest and is a more gentle pelvic inflammation modulator. It has been studied more for BPH and prostate cancer in the test tube. Clinically, I dose the 1:2-1:3 fresh tincture at 3-5 mL TID.
Finally, I cannot recommend Fouquieria splendens (ocotillo) bark highly enough. This really does seem to help with chronic prostatitis, and whether it is because it is a “pelvic lymphagogue,” as the theory goes, or because it drives other herbs to the pelvis, I do not know. When I leave it out of pelvic formulas, I am almost always somewhat disappointed in the results. Just 5-10 gtt TID are required in a formula to get its synergistic effects.
It is important, if possible, to stop even these agents for pain relief in an elimination-challenge situation. Otherwise, challenge-triggered symptoms will be masked and the diet will give false-negative information. However, often I find the herbs can stabilize a patient and lower their symptom burden to the point where they can face the elimination-challenge diet, partly, perhaps, because they gain some confidence that these crazy-sounding natural approaches really do have something to offer.
Using the appropriate testing approach, seeing through the problems with the old way of thinking about chronic prostatitis, and relentlessly asking “why” chronic prostatitis/IC happens, are all crucial to an effective approach to patients with these conditions. By trying to address these causes, rather than just endlessly suppressing symptoms, we can achieve total cure in a substantial portion of patients. In others, we can substitute natural medicines that are far safer and may provide more relief. It is time that more natural practitioners learned how to help men (and women with IC, for that matter) more effectively so that they will have one less excuse to not go to the doctor.
- Forrest JB, Schmit S. Interstitial cystitis, chronic nonbacterial prostatitis and chronic pelvic pain syndrome in men: a common and frequently identical clinical entity. J Urol. 2004;172(6 Pt 2):2561-2562.
- Wise D, Anderson R. A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes. 6th ed. Occidental, CA: National Center for Pelvic Pain; 2012.
- Roberts RO, Lieber MM, Rhodes T, et al. Prevalence of a physician-assigned diagnosis of prostatitis. Urology. 1998;51(4):578-584.
- Schaeffer AJ, National Institute of Diabetes and Digestive and Kidney Diseases of the US National Institutes of Health. NIDDK-sponsored chronic prostatitis collaborative research network (CPCRN) 5-year data and treatment guidelines for bacterial prostatitis. Int J Antimicrob Agents. 2004;24 Suppl 1:S49-S52.
- Nickel JC, Downey J, Johnston B, et al. Predictors of patient response to antibiotic therapy for the chronic prostatitis/chronic pelvic pain syndrome: a prospective multicenter clinical trial. J Urol. 2001;165(5):1539-1544.
- 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.
- Bergman B, Wedrén H, Holm SE. Long-term antibiotic treatment of chronic bacterial prostatitis. Effect on bacterial flora. Br J Urol. 1989;63(5):503-507.
- Larsen EH, Grasser TC, Dorflinger T, et al. The concentration of various quinolone derivatives in the human prostate. In: Weidner W, Brunner H, Krause W, Rothauge CF, eds. Therapy of Prostatitis. Munich, Germany: M Zuckschwerdt Verlag;1986.
- Shoskes DA, Nickel JC, Rackley RR, Pontari MA. Clinical phenotyping in chronic prostatitis/chronic pelvic pain syndrome and interstitial cystitis: A management strategy for urologic chronic pelvic pain syndromes. Prostate Cancer Prostatic Dis. 2009;12(2):177-183.
- Yarnell E. Natural Approach to Urology and Men’s Health, 2nd ed. Wenatchee, WA: Wild Brilliance Press; 2016.
- Breyer BN, Vittinghoff E, Van Den Eeden SK, et al. Effect of sexually transmitted infections, lifetime sexual partner count, and recreational drug use on lower urinary tract symptoms in men who have sex with men. Urology. 2012;79(1):188-193.
- Torres Ramirez C, Aguilar Ruiz J, Zuluaga Gomez A, et al. A crystallographic study of prostatic calculi. J Urol. 1980;124(6):840-843.
- Kirby RS, Lowe D, Bultitude MI, Shuttleworth KE. Intra-prostatic urinary reflux: an aetiological factor in abacterial prostatitis. Br J Urol. 1982;54(6):729-731.
- Hou BS, Xia XY, Pan LJ, et al. Determination of uric acid in the expressed prostatic secretion of chronic prostatitis patients and its clinical significance. Zhonghua Nan Ke Xue. 2008;14(3):245-247. [Article in Chinese]
- Parsons CL, Greenberger M, Gabal L, et al. The role of urinary potassium in the pathogenesis and diagnosis of interstitial cystitis. J Urol. 1998;159(6):1862-1867.
- Panchaphanpong J, Asawakarn T, Pusoonthornthum R. Effects of oral administration of N-acetyl-d-glucosamine on plasma and urine concentrations of glycosaminoglycans in cats with idiopathic cystitis. Am J Vet Res. 2011;72(6):843-850.
- Theoharides TC, Sant GR. A pilot open label study of Cystoprotek in interstitial cystitis. Int J Immunopathol Pharmacol. 2005;18(1):183-188.
- Theoharides TC, Kempuraj D, Vakali S, Sant GR. Treatment of refractory interstitial cystitis/painful bladder syndrome with CystoProtek–an oral multi-agent natural supplement. Can J Urol. 2008;15(6):4410-4414.
- Schneider MJ, Stermitz FR. Update of host plant alkaloids by root parasitic Pedicularis Phytochemistry. 1990;29(6):1811-1814.
- Shoskes DA, Nickel JC. Quercetin for chronic prostatitis/chronic pelvic pain syndrome. Urol Clin North Am. 2011;38(3):279-284.
Eric Yarnell, ND, RH (AHG), a 1996 Bastyr graduate, is a full professor in the department of botanical medicine at Bastyr University. Dr Yarnell is the former chair of Botanical Medicine at SCNM and former editor of the Journal of Naturopathic Medicine. He is the CMO at Northwest Naturopathic Urology and has been focused on men’s health, urology, and nephrology for 15 of his 20 years in practice. He is also Chief Creativity Officer at Wild Brilliance Press, and president of Heron Botanicals. He has authored numerous textbooks, including Natural Approach to Urology and Men’s Health, Natural Approach to Gastroenterology, and Clinical Botanical Medicine, and he is the 2014 recipient of the AANP’s Vis Award.