The Functional Medicine Approach to Prostatitis

on December 6, 2017 by Chris Kresser

The incidence of prostatitis, a painful, psychologically distressing condition in which the prostate gland becomes swollen and inflamed, is rising rapidly among men of all ages. (1) The conventional medical approach to prostatitis focuses primarily on symptom management, utilizes drugs with serious adverse effects, and does little to address the underlying causes of this condition. Fortunately, Functional Medicine offers an innovative, multifaceted approach to prostatitis that addresses the root causes of this condition and offers hope for a full recovery. Read on to learn about the underlying causes of prostatitis and why Functional Medicine is the best approach for treating this difficult condition.

What is prostatitis?

Prostatitis is an inflammation of the prostate gland associated with urinary symptoms, sexual dysfunction, and chronic pain in the pelvic region. Acute bacterial prostatitis and chronic bacterial prostatitis, which comprise 5 to 10 percent of prostatitis cases, are caused by bacteria that enter the urethra or bladder and infect the prostate. (2) The remaining 90 to 95 percent of prostatitis cases do not show signs of obvious infection and are referred to as “chronic prostatitis” (CP) or “chronic pelvic pain syndrome” (CPPS).

CP/CPPS is notorious for being the most difficult type of prostatitis to live with. Its impact on quality of life is comparable to that of myocardial infarction, angina, and Crohn’s disease. (3) CP/CPPS is a syndrome with a wide array of physical and psychological symptoms including pelvic pain, straining during urination, frequent urination, painful ejaculation, erectile dysfunction, and infertility. It is also linked to several comorbid disorders, including irritable bowel syndrome, depression, and anxiety. CP/CPPS currently affects 10 to 15 percent of men and significantly reduces quality of life. (4) Due to its complex nature, CP/CPPS is difficult to treat and often doesn’t respond to conventional medical interventions.

How the seminal microbiome can affect the prostate.

The conventional approach to prostatitis is focused on “symptom management” and does little to address the underlying causes of prostatitis. To make matters worse, many of the pharmaceutical drugs prescribed for prostatitis are associated with serious adverse effects. Men with prostatitis often endure repeated rounds of fluoroquinolone antibiotics, which are known to cause microbiome disruption, irregular heartbeat, nerve damage, and ruptured tendons. Another common class of drugs prescribed for prostatitis, 5-alpha reductase inhibitors, is associated with a devastating condition called “post-finasteride syndrome,” named after the 5-alpha reductase drug finasteride. Post-finasteride syndrome causes adverse effects that may persist for years after stopping the drug, including low libido, erectile dysfunction, depression, suicidal ideation, anxiety, panic attacks, penile shrinkage, gynecomastia, muscle atrophy, cognitive impairment, insomnia, severely dry skin, and tinnitus. (5, 6) Clearly, the conventional medical approach to prostatitis leaves much to be desired.

The underlying causes of prostatitis

While a single infectious agent such as E. coli is typically the cause of acute and chronic bacterial prostatitis, the etiology of CP/CPPS is far more complex. A growing body of scientific literature indicates that a handful of underlying factors contribute to the pathology of CP/CPPS. However, identification and modulation of these factors hold significant promise in the treatment of prostatitis.

Disrupted gut microbiome

Our medical system has long viewed the male reproductive tract as being physically distinct from the gut. However, emerging research indicates that the gut microbiome and reproductive tract are closely linked in terms of health and that bacterial imbalances in the gut may increase the risk of prostatitis. CP/CPPS is associated with an increased risk of irritable bowel syndrome (IBS), and men with CP/CPPS have been found to harbor a less diverse gut microbiota compared to healthy controls, including significantly decreased levels of Prevotella, a bacterium that mitigates inflammation. (7, 8) Decreased Prevotella may promote a proinflammatory state that ultimately impacts the prostate. Alterations in the gut microbiome are also associated with changes in pain perception, and researchers suspect that the altered microbiota of men with prostatitis may exacerbate pelvic pain through crosstalk between visceral sensory pathways.

Disrupted urinary and seminal microbiomes

In addition to a disrupted gut microbiome, men with prostatitis also demonstrate alterations in their urinary and seminal microbiomes. Urine samples from men with CP/CPPS harbor increased Burkholderia cenocepacia, an opportunistic pathogen that is resistant to many antibiotics. (9) Semen samples from men with prostatitis have significantly lower levels of Lactobacilli and higher levels of Proteobacteria compared to samples from healthy men. Lactobacilli are known to exert anti-inflammatory effects in the female reproductive tract, and researchers believe they may play a similar protective role in the male reproductive tract. Proteobacteria, on the other hand, are common urinary tract pathogens. (10) Together, these findings suggest that dysbiosis of the male reproductive and urinary tracts promote the pathogenesis of prostatitis. The fact that many patients with CP/CPPS have been treated with multiple (and often unnecessary) rounds of antibiotics is concerning, since antibiotics may further disrupt the gut, urinary, and seminal microbiota and increase the risk of recurrent prostate problems.

Infection

Cases of acute and chronic bacterial prostatitis are caused by bacteria such as E. coli, Klebsiella, Pseudomonas, and Staphylococcus aureus. Conversely, the symptoms of CP/CPPS are not attributed to an active infection. However, researchers suspect that previous infection with a bacterium or virus may serve as an initial stimulus for CP/CPPS. Previous infection may alter inflammatory and neurological pathways and increase proinflammatory cytokine levels and pain perception, ultimately causing symptoms of CP/CPPS. Bacterial biofilms have also been detected in men with CP/CPPS, suggesting that this condition may result from a long-standing infection. (11, 12)

HPA axis dysfunction and low testosterone

The HPA axis facilitates communication between the central nervous system and endocrine system and is responsible for regulating the body’s response to stress. Altered levels of adrenocortical hormones have been detected in men with CP/CPPS, indicating that HPA axis impairment and a dysfunctional stress response influence the progression of prostatitis. Furthermore, CP/CPPS is associated with previously undiagnosed anxiety disorder, suggesting that stress may trigger prostatitis. (13, 14)

A dysfunctional HPA axis also influences circulating levels of steroid hormones, such as testosterone. Men with CP/CPPS have demonstrated significantly lower levels of total testosterone compared to controls, suggesting that low testosterone may play a role in the development of prostatitis. (15)

Environmental toxins

Environmental toxin exposure may promote prostatitis by disrupting the endocrine system, altering prostate gene expression, and promoting inflammation.

The pesticides chlorpyrifos, fonofos, and phorate, commonly used in agricultural and residential settings, inhibit the cytochrome P450 enzymes CYP1A2 and CYP3A4, which are responsible for metabolizing estrogen. Exposure to these pesticides may elevate estrogen levels in the body and promote prostate pathologies such as prostatitis. (16, 17) Vinclozolin, a fungicide applied to fruits, vegetables, and turf on golf courses, has been found to alter prostate gene expression and induce prostatitis. (18, 19) Finally, the notorious endocrine-disrupting chemical (EDC) bisphenol-A (BPA) has detrimental epigenetic effects on the prostate and may play a role in the development of prostatitis. (20)

Inflammation and oxidative stress

Elevated levels of proinflammatory cytokines have been detected in prostatic secretions of men with CP/CPPS, suggesting that active inflammation, in the absence of an infectious stimulus, plays a role in prostatitis. (21) Proinflammatory conditions in the prostate induce oxidative stress, which may contribute to the development of prostatitis symptoms such as pelvic pain and infertility. (22)

Autoimmunity

A disrupted tolerance of prostate antigens has been detected in patients with CP/CPPS, suggesting that autoimmunity triggers prostatitis in some men. (23) The autoimmune attack on the prostate causes immune cells to infiltrate the gland and produce lesions, resulting in prostate inflammation.

The functional approach to prostatitis

The functional approach to prostatitis aims to treat the many underlying causes of this disease, rather than simply managing symptoms. The primary goals of the functional approach are to restore health to the gut, seminal, and urinary microbiomes, balance the HPA axis, reduce toxic exposures and inflammation, and decrease stress.

Balance the microbiota

Dysbiosis of the gut and male reproductive tract influence the health of the prostate, and modulation of these microbial communities is a crucial component of the functional approach to treating prostatitis. Research suggests that probiotics and other nutraceuticals that modulate the microbiota may be useful in the treatment of prostatitis. A clinical trial found that the probiotic VSL#3, plus the antibiotic rifaximin, improves the health of the gastrointestinal microbiota and inhibits the progression of prostatitis in men with concurrent prostatitis and IBS. This finding suggests that oral probiotics may also have beneficial effects on the urinary and seminal microbiomes. (24) Quercetin, a bioflavonoid found in many fruits and vegetables, modulates the gut microbiota and reduces inflammation, reducing pain and urinary symptoms in men with CP/CPPS. (25, 26)

Levels of the anti-inflammatory bacterium Prevotella are low in the gut microbiota of patients with prostatitis. However, a diet high in vegetables and fiber increases Prevotella and should be recommended to patients with prostatitis. Prostatitis patients should also be screened for food sensitivities because certain foods and beverages, including spicy foods, coffee, and alcohol, have been found to exacerbate symptoms. (27)

Phytotherapy

Saw palmetto is a small palm tree native to the southeastern United States. Its fruit is a popular herbal therapy for male health issues such as prostatic hyperplasia, chronic pelvic pain, low libido, and hair loss. A combination of saw palmetto, selenium, and lycopene has been found effective for relieving symptoms of CP/CPPS, including elevated white blood cell counts and trouble with urine voiding. (28) Another natural product, rye pollen extract, has anti-inflammatory properties and reduces pain and biomarkers of seminal oxidative stress in men with prostatitis. (29)

A novel Chinese herbal formula called WSY-1075 has also been found effective for the treatment of CP/CPPS. The formula contains anti-inflammatory and antimicrobial herbs and animal ingredients, including Japanese cornel, Angelica root, goji berry, deer antler velvet, red ginseng, and cinnamon bark. (30)

Reduce exposure to toxins

Given the impact of environmental toxins on the prostate, patients with prostatitis should be encouraged to avoid pesticide and EDC exposures as much as possible. Practitioners should recommend the consumption of organic foods, which are devoid of the pesticides and fungicides that have been found to provoke prostate inflammation. Patients should also be encouraged to avoid BPA-containing plastic water bottles and food storage containers and use glass or stainless-steel containers instead.

Mind-body therapies

Stress may both initiate and perpetuate CP/CPPS, and therapies designed to modulate the stress response have been found effective for the treatment of this condition.

Pelvic floor biofeedback is a form of “muscular re-education” that teaches men how to relax their pelvic floor muscles, thus helping to correct the pelvic floor dysfunction and pelvic pain characteristic of prostatitis. Pelvic floor biofeedback has been found to result in a significant improvement in pain scores and urinary symptoms among men with CP/CPPS, with no side effects. (31, 32)

Acupuncture is another useful modality for reducing stress, pain, and urinary symptoms in men with CP/CPPS. It has been found more effective than ibuprofen, Flomax, and levofloxacin for reducing pelvic pain and urinary voiding symptoms in men with CP/CPPS. (33)

Now I want to hear from you. Have you ever used a functional approach to treating prostatitis in your practice? What treatments have you found to be the most beneficial? Let me know in the comments below.

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