Interesth in and use of complementary and alternative therapies, especially nutraceuticals, is high in prostate disease. These therapies have shown potential in benign prostatic hyperplasia (BPH), prostatitis, and prostate cancer. Some have produced results equal to or better than pharmaceuticals currently prescribed for BPH. In category III prostatitis, some nutraceuticals may offer relief to patients who get little from standard therapy. Because it is becoming apparent that inflammation may play a role in the progression of BPH and development of prostate cancer, nutraceuticals, which commonly have anti-inflammatory properties, may play a role. These therapies have also shown potential in prostate cancer treatment and prevention, especially those that also reduce cardiovascular events or risk. Nevertheless, uses of some nutraceuticals in prostate disease have had less desirable consequences, showing lack of efficacy, adulteration, and/or severe side effects or drug interactions. By ensuring that these therapies undergo careful study for effectiveness, quality, and safety, urologists can look forward to adding them to their evidence-based armamentarium for prostate disease.
Phytotherapies have shown the greatest potential in category III prostatitis, termed CP/CPPS, which is the most common of the clinical prostatitis syndromes. The symptoms may be similar to those experienced by patients with chronic bacterial prostatitis (category II) but without infection and probably with more pain and discomfort (certainly with more durable and sustained discomfort). The etiology is unknown, but there are many theories, including persistent, occult prostate infection or inflammation, possibly as a response to infection or a dysregulated immune response or a true autoimmune disease. All the symptoms of CP/CPPS, however, can be caused by pelvic muscle spasm and can be extrinsic to prostate tissue. In some patients who underwent radical prostatectomy for CP/CPPS or prostate cancer, CP/CPPS symptoms did not resolve. In these cases, disease may never have been in the prostate or, because of long-term prostatic inflammation and pain, an autonomous neuromuscular condition developed.
Even though the term prostatitis is often applied to category III, there is often no evidence of inflammation. Only about 50% of symptomatic patients have leukocytes in expressed prostatic secretions (EPS),55,56 and only about 33% have any apparent inflammation in biopsy specimens, with only 5% having moderate to severe inflammation.57 Leukocytes, however, are not the only indicators of inflammation in EPS and seminal fluid. Various investigators have found evidence of elevated oxidative stress58,59 and elevated levels of certain cytokines and chemokines that are inflammatory mediators in EPS and semen of men with category III prostatitis.60
Interestingly, some of these cytokines are blocked directly by quinolone and macrolide antibiotics, which may account for the reduction in symptoms with antibiotics even when patients have no proven infection. Typically, symptoms return within a day or 2 of stopping the antibiotics, which is not characteristic of infection because bacteria remain suppressed for weeks after antibiotic therapy is stopped.
Many phytotherapies have antioxidant and anti-inflammatory characteristics, and it might be by these mechanisms that these compounds produce their clinically beneficial effects. The best-studied phytotherapies in this category are quercetin, rye and other pollen preparations, and saw palmetto.