Chronic Prostatitis

What is Chronic Prostatitis?

Chronic prostatitis is a group of conditions with long-lasting prostate-area pain, and the most common form is chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS).^[1] CP/CPPS means pelvic pain or discomfort for at least 3 months, often with urinary symptoms, and it is diagnosed when tests do not find another cause.^[2]

Prostatitis as a whole is estimated to affect about 9.3% of men in their lifetime.^[2]

Common symptoms

The main symptom is pain or discomfort in the pelvic area, which can include the perineum, the testicles, the penis and the lower abdomen.^[2] Urinary symptoms such as frequency are common.^[2]

Sexual problems are also common. A meta-analysis of 24 studies found sexual dysfunction in about 6 in 10 men with CP/CPPS, including erectile dysfunction in about 3 in 10 and premature ejaculation in about 4 in 10.^[3]

Causes and risk factors

The cause of CP/CPPS is not well understood, and it is a heterogeneous condition in which different men have different contributing factors.^[4] Bacterial prostatitis, by contrast, is an infection of the prostate that is treated with antibiotics.^{[1, 2]}

Possible contributors include pelvic floor muscle tension, nerve sensitivity, inflammation and psychological stress.^{[4, 5]} This is why a doctor tests for infection and other causes first.

How it is diagnosed and treated conventionally

CP/CPPS is a diagnosis of exclusion with no standardized treatment.^[1] A physician takes a history, does a physical exam and checks urine for infection, and other causes such as cancer, blockage or retention are ruled out.^[2]

Alpha-blockers are the usual first-line medicine for CP/CPPS with urinary symptoms. Other medicines, including anti-inflammatory drugs, pregabalin and pollen extract, give modest benefit over placebo.^[2] Pelvic floor physical therapy, cognitive behavioral therapy and other approaches are also used, and specialists often combine them according to the man's symptom pattern.^[4]

Why Chronic Prostatitis calls for a whole-person approach

Chronic prostatitis is a heterogeneous syndrome, and no single therapy works for everyone.^[4] A system called UPOINT sorts patients into six domains (urinary, psychosocial, organ-specific, infection, neurologic or systemic, and tenderness of muscles), and therapy guided by it led to symptom improvement in about three quarters or more of patients in three studies.^[4]

Care that looks at several factors at once is therefore a reasonable addition to the treatment your urologist directs.

Pelvic floor muscle tension

Tight pelvic floor muscles can cause pelvic pain, urinary and sexual symptoms.^[5] A systematic review of pelvic floor physical therapy found it seemed beneficial in chronic prostatitis and pelvic pain syndromes, although most studies were small and at risk of bias.^[5]

Inflammation and the immune system

Inflammation and immune function have been proposed as part of CP/CPPS.^[6] A small study of 12 men looked at immune cell changes with acupuncture, but its authors said the specific effect remained unclear.^[6]

Stress, mood and the nervous system

Psychosocial stress is one of the six UPOINT domains, and nerve-related and systemic factors are another.^[4] Cognitive behavior therapy is one of the approaches used in multimodal treatment plans.^[4]

Urinary symptoms

Frequency and other urinary symptoms are a main reason for treatment, and alpha-blockers are used for them.^[2] Studies of acupuncture have measured urinary scores and flow rates as well as pain.^{[7, 8]}

Sexual health

Sexual problems affect many men with CP/CPPS and add to stress.^[3] They should be discussed with your physician, who can look for other causes.

Acupuncture for Chronic Prostatitis

What the research shows

Research suggests acupuncture can reduce symptoms of CP/CPPS in the short term. A Cochrane review of 38 non-drug trials found that, in the short term, acupuncture reduced symptom scores compared with sham (3 studies, 204 men, high-quality evidence) and compared with standard medical therapy (moderate quality).^[9]

A multicenter sham-controlled trial of 440 men in China gave 20 sessions over 8 weeks. At week 8, about 61% of men in the acupuncture group had a clinically important improvement, compared with about 37% with sham, and the difference was still present at week 32. No serious adverse events occurred.^[10] A smaller sham-controlled trial of 68 men found a symptom score difference of about 6 points at week 8 and benefit through week 32.^[11] A trial of 100 men with category IIIB CP/CPPS reported that 92% of the acupuncture group and 48% of the sham group were responders 8 weeks after treatment.^[12]

Meta-analyses agree. One of 10 high-quality trials (798 patients) found acupuncture better than sham acupuncture or Western medicine for pain, symptom score and quality of life, with mild adverse effects.^[7] A review of 17 trials, mostly against medication rather than sham, found electroacupuncture beneficial, rating the evidence as medium quality.^[8] Moxibustion, a warming technique, was also found promising in a review of 8 trials, but the authors called for better studies.^[13]

Limits remain. Most trials are from China, treatment has been short-term, and one trial noted that sham acupuncture might have some physiologic effect.^[10] A broader meta-analysis found a significant placebo effect across CP/CPPS outcomes.^[14]

How acupuncture may work

How acupuncture helps CP/CPPS is not known. Researchers have looked at the immune system, and in a small study of 12 men acupuncture changed natural killer cell levels compared with sham, although the authors said its specific effect remained unclear.^[6] This is a proposed explanation from a very small study, not a settled fact.

What treatment involves

Treatment uses fine, sterile, single-use needles placed at points on the lower abdomen, lower back, sacrum and legs, usually left in place for about 20 to 40 minutes. The largest trial gave 20 sessions over 8 weeks.^[10] We reassess after a short course of visits.

Serious problems from acupuncture are rare. In prospective studies, about 9 in 100 patients had a minor reaction such as brief bleeding, soreness or bruising, and serious events occurred in about 1 in 10,000 patients.^[15] Tell the practitioner first if you have a bleeding disorder, take blood thinners, or have a pacemaker (relevant to electroacupuncture).

Ayurvedic medicine for Chronic Prostatitis

The Ayurvedic view

Ayurveda has no single classical name for chronic prostatitis. Practitioners may describe long-lasting pelvic pain with urinary difficulty as a disturbance of Vata, the principle said to govern movement and the pelvic region, sometimes with Pitta or Kapha. These are traditional categories for choosing treatment, not biomedical diagnoses.

Therapies that may be used

Care is chosen for the individual and traditionally combines:

• Diet and daily routine, with regular meals, fluids and sleep, and attention to sitting habits
• Warm oil massage of the lower back and legs
• Warm sitz-style baths and local heat
• Herbs prescribed individually by a qualified practitioner

Panchakarma procedures are not appropriate during acute illness or frailty, and not while an infection is being evaluated or treated.

What the research shows

We found no clinical trials of Ayurvedic treatment for chronic prostatitis in PubMed. Without trials, no claim of benefit can be made, and specialists note that no therapy for CP/CPPS has level 1 evidence to guide care.^[4] General self-care measures such as lifestyle changes and physical activity have been studied in CP/CPPS, but the Cochrane review rated that evidence as very low to low quality.^[9]

Herbal medicine for Chronic Prostatitis

Herbs and formulas that have been studied

Chinese patent medicines and plant-derived products have been studied for chronic prostatitis. These include Ningmitai capsule, a Chinese formula, plant flavonoids, and grass pollen extract.^{[16, 17, 18]}

What the research shows

The evidence is limited. A meta-analysis of 30 trials with 6,185 patients found Ningmitai capsule improved response rates in chronic prostatitis, especially when combined with other drugs; used alone, the pooled difference was not significant. The authors noted a need for higher-quality, blinded trials.^[16]

A meta-analysis of 11 trials with 975 men found plant flavonoids improved response rates and symptom scores, with minor adverse effects. Results differed by type of prostatitis, and in CP/CPPS overall the response-rate difference was not significant, though it was in placebo-controlled trials.^[17] An umbrella review concluded that evidence supports grass pollen extract for chronic prostatitis, and the JAMA review reports a modest benefit of pollen extract over placebo.^{[2, 18]}

Safety and herb-drug interactions

Herbs are active substances and can interact with medicines. A literature review, mostly of case reports, found enhanced warfarin effect or bleeding with herbs such as dan shen (Salvia miltiorrhiza), garlic and ginkgo, and bleeding when ginkgo was combined with aspirin.^[19] People taking blood thinners, alpha-blockers or other long-term medicines need a practitioner's review before using herbs.

In one study, about one fifth of Ayurvedic products bought online contained detectable lead, mercury or arsenic.^[20] Herbs should come from tested sources and be prescribed individually. Tell us if you have liver or kidney disease, are allergic to pollen, or have surgery planned.

Translating traditional medicine into modern biological language

The links drawn here are interpretation, not equivalence. Chinese medicine often describes chronic prostatitis as damp-heat, qi and blood stasis, or kidney deficiency, depending on the person. Researchers instead study pelvic muscle tension, nerve sensitization, inflammation and immune signaling.^{[4, 6]}

Ayurveda's Vata imbalance describes pain and movement problems in the pelvis, which loosely parallels the nerve and muscle-tension features seen in CP/CPPS.^[5] No study has shown that a dosha or a TCM pattern corresponds to a specific biological process.

How this care fits with your medical care

Integrative care for chronic prostatitis is complementary. Keep your urologist or physician, and do not stop or change prescribed medicines without your prescriber. We do not diagnose the cause of pelvic pain or urinary symptoms, and a physician should first rule out infection, cancer, obstruction and other causes.^[2]

Please bring your diagnosis, urine and prostate test results, a list of medicines and supplements, and notes on any pelvic floor therapy.

When to seek urgent medical care

Fever, chills and painful urination can signal acute bacterial prostatitis, which is treated with antibiotics.^[2] Some other symptoms also need prompt evaluation.

• Fever or chills with pelvic pain or burning with urination
• Being unable to pass urine, or a very weak stream with a swollen lower abdomen
• Blood in the urine or semen
• Severe or rapidly worsening pelvic or testicular pain
• Pain and swelling in the scrotum, which can be an emergency
• Back pain with leg weakness or numbness, or loss of bowel control

If any of these occur, call 911 or go to the nearest emergency department.