Geo Espinosa, ND, LAc, CNS
Doctors do not know the exact cause of nonbacterial chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). Affecting the majority of men with prostatitis, CP/CPPS is frustrating for patients and physicians alike. However, we are learning that the diagnosis and treatment of this condition should involve a multimodal, whole-body approach, as opposed to addressing it simply as a prostate disorder. It is increasingly clear that in order to treat prostatitis effectively, we must find and treat the underlying cause of the symptoms, and not just treat the symptoms themselves.
The NPAT Protocol
The majority of CP/CPPS cases (90-95%) stem from problems that take place elsewhere in the body. There are a variety of triggers for CP/CPPS, including chronic stress, inflammation, chronic tension disorders, food intolerances, and pelvic floor disorders. For this reason, I would like to present a protocol that encompasses these possible causes into a holistic approach to diagnosing and treating the condition: The NPAT Protocol.
NPAT stands for the following:
- Naturopathic Medicine (hydrotherapy and nutrition, eg, elimination diets and wheat-free diets)
- Phytotherapy (pollen and quercetin, together with probiotics)
- Alternative Treatments (eg, acupuncture, prostate massage, pelvic rehabilitation and therapy)
- Total body (exercise, chronic stress management, lifestyle)
Using the NPAT Protocol, every patient participates in an individualized diagnostic and treatment program that completely focuses on his unique symptoms. Physicians using the NPAT Protocol recognize that symptoms of CP/CPPS, such as pain and chronic pelvic discomfort, are grounded in a man’s diet, nutrition, lifestyle, exercise, and personal response to stress, all of which originate outside of the prostate. In fact, diet is one of the most important elements in a whole-body approach. Because certain foods can trigger allergic or other reactions that contribute to inflammation and pelvic tension, eliminating these problem foods is an important step in treatment.
There are also foods that can specifically exacerbate CP/CPPS symptoms. Many prostatitis patients find relief when they avoid spicy foods (eg, hot peppers), acidic foods, alcohol, wheat, gluten, and caffeine. As bowel health and prostatitis appear to be intimately connected, taking probiotics can help restore the correct balance of gut microflora. This is especially important if the patient has taken antibiotics, which are commonly prescribed for prostatitis.
It is estimated that about 50% of CP/CPPS cases are related to stress- or tension-related pelvic floor disorders.1 This tension in the pelvic floor muscles can be due to psychological problems (such as stress, anxiety, or other emotional imbalances) neuromuscular tension, immune disorders, or food allergies and intolerances. Traditional therapies (antibiotics, 5-alpha reductase inhibitors, alpha blockers) are unsuccessful at treating this tension; however, many natural and alternative treatments aimed at treating the physical and psychological source of the tension often result in success.
Treatments for pelvic tension might include acupuncture, biofeedback, pelvic rehabilitation and physiotherapy, trigger-point release, prostate massage, and/or exercise. An important component of treating pelvic tension is addressing the underlying psychological factors that cause or accompany the tension, such as stress, anxiety, and emotions. A typical treatment might also include dietary changes, including elimination diets and supplements. If the patient is overweight, weight loss is also strongly recommended.
The NPAT Protocol has elements in common with the UPOINT system (described below), in that it helps doctors and patients identify symptoms and problem areas and then employ treatments that specifically target those areas. However, NPAT involves more than just treating symptoms; it provides a broader and individualized look at a man’s entire lifestyle. I have found this multimodal, natural treatment approach to prostatitis to successfully provide relief where traditional treatments generally fail.
The UPOINT System
The UPOINT System is used by doctors to facilitate more effective treatment decisions for patients with CPPS. UPOINT stands for the following 6 domains:
- Urinary
- Psychosocial
- Organ-specific
- Infection
- Neurologic/Systemic
- Tenderness
Identifying problem areas related to symptoms, and then targeting treatments that have been proven to be effective for those problems, helps patients avoid other treatments that are not only unnecessary, but also ineffective.
When evaluating a patient with CP/CPPS, both NPAT and UPOINT can assist in narrowing down the symptoms and their causes. Both methods allow physicians to develop an individualized treatment program with multiple treatments that have been proven to work for the patient’s specific symptoms. NPAT, however, takes diagnosis and treatment to the next level by identifying the cause of those symptoms and guiding the patient to make lifestyle changes that prevent recurrence of symptoms.
Using Supplements for Prostatitis
Both NPAT and UPOINT (organ-specific domain) employ the use of well-researched supplements. Phytotherapy, specifically, is one of the main naturopathic treatments for CP/CPPS. Some of the most researched Tier-1 phytotherapy supplements that have anti-inflammatory effects and promote pelvic health, include quercetin, pollen, and turmeric/curcumin, especially in combination with each other. Quercetin and pollen extracts are recommended as treatment for men whose UPOINT Domains indicate organ-specific prostatitis symptoms and/or pelvic spasm. These natural therapies have been well-validated in studies.
Quercetin
For example, the Cleveland Clinic provided evidence of the ability of quercetin to improve symptoms of prostatitis in a study of 100 men who were treated according to the UPOINT model. The patients had an average of 3 positive UPOINT domains, with “organ-specific” being the most common (70%). The researchers’ main goal was to achieve at least a 6-point decline in the Chronic Prostatitis Symptom Index (CPSI). They selected quercetin to treat men who were positive for the organ-specific category. Compared with other prostatitis treatments used, quercetin was associated with a greater decline in the CPSI.2
Another study, which was randomized, double-blind, and placebo-controlled, also showed positive results from quercetin. This study involved 28 men who had CP/CPPS and took either 500 mg of quercetin or placebo BID for one month. After one month, the International Prostate Symptom Score declined from 21.0 to 13.1 in the group that took quercetin, and from 20.2 to 18.8 in the group that took the placebo.3
Pollen
There are many studies examining pollen extracts for prostatitis. An early study of the pollen extract, cernilton, involved 90 men with CP/CPPS. Researchers divided the men into 2 groups: those who had no complicating factors (72 men) and those who had complicating factors (18 men). All the participants took cernilton TID for 6 months, and underwent testing (eg, digital rectal examination, uroflowmetry, bacterial studies) after 3 and 6 months of intervention. Of the men who did not have any complicating factors, 56 (78%) reported a favorable response to the pollen extract: 26 men (36%) experienced a complete elimination of symptoms, and 30 men (42%) experienced significant improvement, including an increase in urine flow rate. In the group of 18 men with complicating factors, only 1 patient reported a response. Overall, cernilton was well tolerated by 97% of the patients.4
Other Phytotherapeutic Agents
Another supplement combination that has produced impressive results consists of curcumin (from Curcuma longa), quercetin, stinging nettle (Urtica dioica), and saw palmetto (Serenoa repens). This supplement combination is also helpful for men with chronic bacterial prostatitis, which often does not respond to treatment with antibiotics.
A prospective and randomized study was conducted to determine the effect of these agents in combination with antibiotics in men with chronic bacterial prostatitis. The 143 men in the study were divided into 2 groups: Group A (106 men) received both the antibiotic (600 mg prulifloxacin daily) plus the 4 supplements for 14 days. Group B (37 men) received only the antibiotic. After 1 month, 89.6% of men in Group A were free of prostatitis symptoms, whereas only 27% of the men in Group B were symptom-free. Six months after the study ended, none of the men in Group A had a recurrence of symptoms, compared with 2 men in Group B. The authors of the study concluded that that the combination of quercetin, curcumin, stinging nettle, and saw palmetto can improve the clinical efficacy of prulifloxacin in men with chronic bacterial prostatitis.5 It is important to note that quercetin is contraindicated in combination with quinolone antibiotics because it can decrease the drugs’ effectiveness.
Conclusion
The best treatment program for chronic prostatitis involves a whole-body, multimodal approach that takes into account a patient’s diet, lifestyle, environment, and psychological health. The NPAT Protocol accomplishes this. Several natural agents, including quercetin, pollen extracts, curcumin, stinging nettle, and saw palmetto, have shown to be effective in studies for CP/CPPS.
Once the triggers of prostatitis symptoms are identified and treated, the patient should start experiencing relief. The healing process can take time, especially when dealing with pelvic tension and pain that is triggered by stress, anxiety, or other psychological factors, but patience and perseverance is the route to relief. Keep in mind that even if stress and anxiety are not the initial triggers of the patient’s prostatitis, these psychological factors can pose a barrier to treatment response in patients with long-term chronic pain conditions such as CP/CPPS. Consequently, treating the whole patient is key.
References:
- Shoskes DA, Berger R, Elmi A, et al. Muscle tenderness in men with chronic prostatitis/chronic pelvic pain syndrome: the chronic prostatitis cohort study. J Urol. 2008;179(2):556-560.
- Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. Urology. 2010;75(6):1249-1253.
- Shoskes DA, Zeitlin SI, Shahed A, Rajfer J. Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology. 1999;54(6):960-963.
- Rugendorff EW, Weidner W, Ebeling L, Buck AC. Results of treatment with pollen extract (Cernilton N) in chronic prostatitis and prostatodynia. Br J Urol. 1993;71(4):433-438.
- Cai T, Mazzoli S, Bechi A, et al. Serenoa repens associated with Urtica dioica (ProstaMEV) and curcumin and quercitin (FlogMEV) extracts are able to improve the efficacy of prulifloxacin in bacterial prostatitis patients: results from a prospective randomized study. Int J Antimicrob Agents. 2009;33(6):549-553.
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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. 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.
