A guide to the causes of chronic prostatitis with solutions

I am post-doctoral scientist working in autoimmunity in the UK and have recovered from likely autoimmune prostatitis, now it is in remission, but I still need to avoid certain things. I wanted to make a thread that has a lot of information in one place from this forum and from papers written in a fairly scientific way for people to get help from. Many people are confused about what to do if the antibiotics do not work and the urologist cannot help.

This is not supposed to be a substitute for professional medical advice. If you decide to try supplements it is best to inform your doctor, and any information here is for educational purposes only.

1. Bacteria

Prostatitis may be caused by infection usually by intercourse with variety of bacteria. The best course of action is usually to find an urologist who does one of the following; the expressed prostatitic excretion test (EPS) (Ref1), semen analysis, or the four glass test. Since prostate infection occurs inside the prostate, urine analysis has limited use so it is best to test material from the source of the potential infection. These tests can identify candidate strains the infection is caused by, and then the appropriate antibiotics can be used. I will avoid a discussion of which antibiotics are best, that is really up to the urologist. Note, it may be a good idea to try a course of antibiotics regardless of whether you get a test or not.

If an infection is proving very hard to get rid of, there is a doctor in New York, Dr. Attila Toth, who does intra prostate injections. There is also another urologist Dr. Duke Bahn, based in Ventura, California, who will do these. There is some scientific support for this method working, although it isn't widely accepted (Ref4). Some users have reported benefit from these injections in combination with follow up antibiotics (viewtopic.php?f=2&t=1267), but reports are mixed.

Prostate massage is often used in combination with antibiotics or alone, and there is some support of this again in the literature (Ref5). It seems worth a try. There is a user on this forum, ihateprostatitis, who has been cured through this method (viewtopic.php?t=197). Some urologists will offer this as part of a treatment package.

2. Muscle/fascia tension/pelvic alignment issues

It is apparent that many cases of nonbacterial prostatitis may be related to muscle or fascia tensions around the prostate region (Ref2). In these cases a specialised physiotherapist may be able to suggest exercises and provide myofascial release techniques to treat and sometimes cure these issues. There have been a variety of posters on the forum who have found relief through this kind of approach e.g. UKSufferer (viewtopic.php?f=2&t=494&start=25). There is the book, headache in the pelvis, which is probably worth a read. Additionally, mindfulness based approaches and or CBT may help reduce related stress that either causes the problem, or makes it worse. Finally, pelvic alignment may be responsible for some types of prostatitis, e.g. David88 (viewtopic.php?f=2&t=385). A chiropractor may be worth a visit. Magnesium is known to help relax muscles and is a common and safe supplement.

3. Related digestive problems, supplements, and lifestyle changes

It seems many of us suffer digestive issues that in many cases are related to the prostatitis in more complex cases. Leaky gut, small intestine overgrowth (SIBO), and general gut dysbiosis (e.g. IBS) are all serious problems and are related to autoimmune problems, normal medical doctors sometimes ignore these problems or give poor quality advice. There is a poster on this forum bill_johnstl who has found prostatitis relief through treating his diagnosed SIBO through treatment with Rifaximin, an antibiotic (viewtopic.php?f=2&t=1011). There is a paper that supports this treatment approach (Ref3). You could consult with a sensible naturopath or Western herbalist for testing and treatment. Note: Bad gut health is related to a lot of other problems like Rheumatoid arthritis so it is really worth sorting out sooner rather than later.

Definitely, diet plays a big role in treating prostatitis and related gut problems. Aim towards a plant-based diet without processed foods, refined sugar, white bread, etc. Chilli peppers, tomatoes, alcohol, and caffeine are big prostatitis triggers in many of us. There are also reports that gluten sensitivity may underlie some cases of prostatitis, so an elimination diet is an option. Reducing or eliminating diary, grains, sugars, and processed foods in the diet may help resolve gut issues. I partially agree with the Paleo diet, but it is pretty extreme and consumption of red meat is linked to inflammation and cancer (Ref14). I found red meat made my inflammation worse. There is also the keto diet which is along similar lines. With every diet, the individual will have to work on modifying it for their own body until they find everything is working better. Sugar is related to increased inflammation so please try and reduce that along with overeating which is bad for gut issues and associated problems.

Many autoimmune diseases you don't want to get (e.g. MS) may be related to vitamin D deficiency/ lack of sunlight (Ref6). Vitamin D is deficient in most people so it is worth supplementing with unless you are out in the open sun a lot. A multivitamin with vitamin D may be beneficial.

Anybody with inflammatory conditions, unless eating a lot of oily fish (salmon and tuna for example) should consider supplementing with Omega3 (Ref7). Omega3 often comes packaged with omega6 which is pro-inflammatory, so don't get this. Pure omega3 is the best with a combined amount of EPA plus DHA of 1000mg, clinical trials of omega3 usually use this high dose form.

Urologists will normally encourage ejaculation (Ref17), although it is clear from this forum that some individuals will benefit from this and others it will just make the pain worse. Additionally, completely avoid any activities that put a lot of pressure on the prostate region like cycling.

4. Prostatitis specific supplements

There are a variety of prostatitis specific supplements available online. Two with scientific credibility for prostatitis are Quercetin (Ref8) and Cernilton/Graminex (rye grass pollen extract) (Ref9), both of which have been demonstrated to help patients in double-blind placebo controlled studies. Dr. Daniel Shoskes headed the Quercetin trial and then was involved in creating a Quercetin containing product called ProstaQ which is sold by Farrlabs. These are probably worth a try as they contain natural anti-inflammatories probably better for you then NSAIDs.

5. Other supplements

There are also various supplements and herbs for reducing inflammation, immune stimulation, relaxing tense muscles, and reducing neuropathic pain around that haven't been tested for prostatitis, but may be helpful and have differing degrees of scientific support. Check Examine for fairly unbias information.

To stimulate the immune system to fight infections, herbalists sometimes use astragalus, reishi, and echinacea. For inflammation, common herbs are turmeric and boswellia. The adaptogens from Ayurveda and TCM are herbs that relax the nervous system and may also reduce inflammation, common options include; ashwagandha, reishi, gotu kola, holy basil, panax ginseng, astragalus, and cordyceps.

6. Pain clinics

Drugs like Lyrica (Ref10) and amitriptyline can be effective in treating chronic pelvic pain and additionally may help related sleep problems. NSAIDs like naproxen reduce the inflammation, although will likely cause problems in the long term. Ibuprofen is a bit safer.

7. Other options

Working with a traditional Chinese (or Indian or Western) herbalist could help (Ref20) (viewtopic.php?f=2&t=1322). Another option is homeopathy (Ref18) (viewtopic.php?f=2&t=1878).

I believe the answers are out there... try to remain optimistic.

Remember many cases of chronic prostatitis will resolve or get better on their own, but it may take some time. I waited one year and I was improved a great deal.

Good luck.

Chris

Ref1. Schaeffer, A. J., Knauss, J. S., Landis, J. R., Propert, K. J., Alexander, R. B., Litwin, M. S., ... & Shoskes, D. A. (2002). Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study. The Journal of urology, 168(3), 1048-1053.
Ref2. Anderson, R. U., Wise, D., Sawyer, T., Glowe, P., & Orenberg, E. K. (2011). 6-day intensive treatment protocol for refractory chronic prostatitis/chronic pelvic pain syndrome using myofascial release and paradoxical relaxation training. The Journal of urology, 185(4), 1294-1299.
Ref3. Weinstock, L. B., Geng, B., & Brandes, S. B. (2011). Chronic prostatitis and small intestinal bacterial overgrowth: effect of rifaximin. Canadian Journal of Urology, 18(4), 5826.
Ref4. Yamamoto, M., Hibi, H., Satoshi, K., & Miyake, K. (1996). Chronic bacterial prostatitis treated with intraprostatic injection of antibiotics. Scandinavian journal of urology and nephrology, 30(3), 199-202.
Ref5. Shoskes, D. A., & Zeitlin, S. I. (1999). Use of prostatic massage in combination with antibiotics in the treatment of chronic prostatitis. Prostate Cancer & Prostatic Diseases, 2(3).
Ref6. Baeke, F., Takiishi, T., Korf, H., Gysemans, C., & Mathieu, C. (2010). Vitamin D: modulator of the immune system. Current opinion in pharmacology, 10(4), 482-496.
Ref7. Simopoulos, A. P. (2002). Omega-3 fatty acids in inflammation and autoimmune diseases. Journal of the American College of Nutrition, 21(6), 495-505.
Ref8. Shoskes, D. A., Zeitlin, S. I., Shahed, A., & Rajfer, J. (1999). Quercetin in men with category III chronic prostatitis: a preliminary prospective, double-blind, placebo-controlled trial. Urology, 54(6), 960-963.
Ref9. Wagenlehner, F. M., Schneider, H., Ludwig, M., Schnitker, J., Brähler, E., & Weidner, W. (2009). A pollen extract (Cernilton) in patients with inflammatory chronic prostatitis–chronic pelvic pain syndrome: a multicentre, randomised, prospective, double-blind, placebo-controlled phase 3 study. European urology, 56(3), 544-551.
Ref10. Pontari, M. A., Krieger, J. N., Litwin, M. S., White, P. C., Anderson, R. U., McNaughton-Collins, M., ... & Zeitlin, S. (2010). Pregabalin for the treatment of men with chronic prostatitis/chronic pelvic pain syndrome: a randomized controlled trial. Archives of internal medicine, 170(17), 1586-1593.
Ref11. Irwin, M., McClintick, J., Costlow, C., Fortner, M., White, J., & Gillin, J. C. (1996). Partial night sleep deprivation reduces natural killer and cellular immune responses in humans. The FASEB journal, 10(5), 643-653.
Ref12. Branco, J., Atalaia, A., & Paiva, T. (1994). Sleep cycles and alpha-delta sleep in fibromyalgia syndrome. The Journal of rheumatology, 21(6), 1113-1117.
Ref13. Vicari, E., La Vignera, S., Castiglione, R., Condorelli, R. A., Vicari, L. O., & Calogero, A. E. (2014). Chronic bacterial prostatitis and irritable bowel syndrome: effectiveness of treatment with rifaximin followed by the probiotic VSL# 3. Asian journal of andrology, 16(5), 735.
Ref14. Azadbakht, L., & Esmaillzadeh, A. (2009). Red meat intake is associated with metabolic syndrome and the plasma C-reactive protein concentration in women. The Journal of nutrition, 139(2), 335-339.
Ref15. Esposito, K., Marfella, R., Ciotola, M., Di Palo, C., Giugliano, F., Giugliano, G., ... & Giugliano, D. (2004). Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomized trial. Jama, 292(12), 1440-1446.
Ref16. Birrell, M. A., McCluskie, K., Wong, S., Donnelly, L. E., Barnes, P. J., & Belvisi, M. G. (2005). Resveratrol, an extract of red wine, inhibits lipopolysaccharide induced airway neutrophilia and inflammatory mediators through an NF-κB-independent mechanism. The FASEB journal, 19(7), 840-841.
Ref17. YAVAŞÇAOĞLU, Į., OKTAY, B., ŞIMŞEK, Ü., & ÖZYURT, M. (1999). Role of ejaculation in the treatment of chronic non‐bacterial prostatitis. International Journal of Urology, 6(3), 130-134.
Ref18. Linde, K., Clausius, N., Ramirez, G., Melchart, D., Eitel, F., Hedges, L. V., & Jonas, W. B. (1997). Are the clinical effects of homoeopathy placebo effects? A meta-analysis of placebo-controlled trials. The Lancet, 350(9081), 834-843.
Ref19. Rutten, A. L. B., & Stolper, C. F. (2008). The 2005 meta-analysis of homeopathy: the importance of post-publication data. Homeopathy, 97(4), 169-177.
Chicago
Ref20. Chen, R., & Nickel, J. C. (2003). Acupuncture ameliorates symptoms in men with chronic prostatitis/chronic pelvic pain syndrome. Urology, 61(6), 1156-1159.
Ref21. Joseph, S., Sabulal, B., George, V., Smina, T. P., & Janardhanan, K. K. (2009). Antioxidative and antiinflammatory activities of the chloroform extract of Ganoderma lucidum found in South India. Scientia Pharmaceutica, 77(1), 111-122.
Ref22. Kimmatkar, N., et al. "Efficacy and tolerability of Boswellia serrata extract in treatment of osteoarthritis of knee–a randomized double blind placebo controlled trial." Phytomedicine 10.1 (2003): 3-7.
Ref23. Riehemann, Kristina, Bert Behnke, and Klaus Schulze-Osthoff. "Plant extracts from stinging nettle (Urtica dioica), an antirheumatic remedy, inhibit the proinflammatory transcription factor NF-κB." FEBS letters 442.1 (1999): 89-94.
Ref24. Chandran, Binu, and Ajay Goel. "A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis." Phytotherapy research 26.11 (2012): 1719-1725.
Ref25. Schwalfenberg, Gerry K. "The alkaline diet: is there evidence that an alkaline pH diet benefits health?." Journal of Environmental and Public Health 2012 (2011).

Good work. Great summary. Sensible. Rational. Comprehensive. Actionable. Thanks for preparing this post synthesizing all you have learned and sharing it with us.

My hypothesis is completely different as I believe that CPPS is caused by a microbial (fungal?) overgrowth that involves the gut. This overgrowth somehow affects neighboring muscles causing the chronic tension. It can also reach and cause inflammation in neighboring tissues and organs. Burning urination, burning ejaculation and rectal burning can be present. Many other symptoms can appear which are either caused by the fungi theselves (fungal skin lesions), fungal toxic metabolites (brain fog, anxiety, depression) or nutrient deficiencies due to malabsorption/depletion.

I don't have any evidence to support my hypothesis. I am talking out of my hat.

And then, you are recovering while I am struggling. I always recommend to learn from those that recover.

I wanted to ask you about your diet. In particular, are you using any probiotic food?

Loved this. It was very helpful, and I liked it overall. the part that gets to me though fully is the part of sugar reduction. I know for me, and a lot of other people that's going to be hard. Sugar is practically in everything I eat and drink, and I know I'm quite addicted to it. But anything to help deal with the pain and get me on a road to recovery.

Thank you so much for this chris85. This is great!

Yes thanks, this is summarising everything I have learnt during the past 1 year from reading. I just eat yoghurt every day, I don't know if that helps or not.

I left out prostatitis being caused by non bacterial species like fungi because I am not aware of any studies where they have found this or reports in forums, but it is definitely a possibility.

OK I did find a paper where they focus on fungal infections causing prostatitis. They do say it is much less common.

Wise, G. J., & Shteynshlyuger, A. (2006). How to diagnose and treat fungal infections in chronic prostatitis. Current urology reports, 7(4), 320-328.

This is interesting; they have found the gut microbiome differs between patients with CPP and controls. So our theory that the gut could cause some of these problems might be true.

Shoskes, D. A., Wang, H., Polackwich, A. S., Tucky, B., Altemus, J., & Eng, C. (2016). Analysis of Gut Microbiome Reveals Significant Differences Between Men with Chronic Prostatitis/Chronic Pelvic Pain Syndrome and Controls. The Journal of urology.

The questions being, what were the causes of the differences in the gut microbiomes of the cpp sufferers vs those of the controls. There are any number of reasons why the differences could've come into play, most of which could also be theoretical. We have some ideas, but nothing substantiated. A gastroenterologist recently told me the gut microbiome is poorly understood. We do know antibiotics change the floral landscape, there are probably several other things that do as well.

It'd be interesting to see CDSA test results of CPP sufferers compared those those of the controls. I'm wondering if that, or something similar was used in this study.

I think the dysbiosis occurs because of bad diet, stress, and lack of exposure to pathogens which changes the microbiome and is related to leaky gut, then once this is dysfunctional it can mess up the immune system and possibly levels of serotonin & other neurotransmitters. Then once this 'dysbiosis' happens, which probably has many different manifestations this can lead to problems like prostatitis and fibromyalgia. That is just a theory.

Diet seems to be a huge factor. It may not specifically be just the foods we eat, but what's added to, and on them. The mechanics of how we eat may also play a role. We do know that pesticides, artificial sweeteners, antibiotics, and added hormones are undesirable in the foods we eat, or should be eating.

I once read an article stating that drinking liquids while eating a meal can lead to improper digestion due to a change that occurs in stomach acid levels. It went on to say that the change wouldn't normally occur in the presence of food by itself.

I think there are definitely instances where some of us have a few things going on, and when combined cause the symptoms we all seem to battle against. It's frustrating. I do think that if we were to eliminate all the potential causes we can think of, we might make great progress.

I found a paper about the success rate of fluconazole as a second-line treatment after antibiotics. I could search for it if you were interested. I were not interested about fluconazole as I never read a success story with it in the forums.

The fungal idea is highly speculative. I'd like to find a way to prove it or disprove it. If the cpps trigger foods were the same as those for fungal problems, it would be a hint. Dairy, gluten, vinegar, ... Apparently fungal problems are also worsened by ketogenic diets.

The cooked tomatoes you reacted to were home cooked or store-bought? I learnt today that commercial cooked tomatoes are soaked in citric acid to preserve their shape. This citric acid is from fungal sources and may trigger fungal problems.

I will continue exploring the fungal possibility. I am not alone. See this story from prostatitis.org:

http://prostatitis.org/yeastessay.html


I recently came accross a paper that explained that PPIs have a deeper impact on the microbiome than antibiotics. I didn't read it.

Today I read this one:
Male Chronic Pelvic Pain; Smith, Christopher, Indian Journal of Urology. Pages 34-39. January 4th, 2016.
which is a brief overview of cpps.

Yes, PPI's decrease stomach acid, and can lead to SIBO, and malabsorption. Most don't realize that low levels of stomach acid can actually cause reflux due to the mechanics of digestion. When you stop taking a PPI, your body tends to rebound and reflux becomes worse. ACV is an option to try before going the PPI route.

Vinegar is a known trigger for those suffering from fungal problems. I'd be extremely careful with ACV. I read good things about raw ACV, but it wouldn't surprise me if it turns out to be bad for us. I use homemade beet kvass which is also full of enzymes, probiotics and stimulates stomach acid. I think that beet kvass is purely bacterial (no fungi if properly prepared in a fido jar) and therefore it should be safe for those of us with fungal problems, in theory. I noticed changes with it but I don't know if they are improvements or worsenings.

Wow, that's cool, thanks Jaumeb. I'll have to give that a try.

It happens with cooked tomatoes any kind, because they are pretty acidic I think. Also I have noticed my urination frequency is increased by vinegar and other acidic tasting foods so I am careful with these.

Inflamed, I've opened a new thread about probiotics.

Thanks. I see. It's true that tomatoes are naturally acidic. Then the acidity is the trigger as in GERD or IC. Really interesting.

I wonder if the rise in PH causes some kind of immune response. There's theories floating around on the net about people being too "acidic" but I don't really know how much weight I would give them.

I can't find anything on why acidic food trigger problems with IC or prostatitis. Mechanism seems unknown.

I think your right inflamed, it isn't just the foods we are eating, it is what they add to them too. Whatever it is something or a combination of things in this modern way of life is toxic to many people. I think many people in hunter gatherer communities do not suffer all these unusual health problems, especially at such a young age. However they die when being bitten by a poisonous beetle, so it does seem to come at a cost.

I wonder if anyone from Amish communities suffer with CP. They grow their own food, raise their own livestock, and are very physically active. That would be an interesting study actually.

I'm pretty sure that this kind of life is unhealthy. I'm also sure that all my health problems are caused by this civilization. Too much toxic stuff. If I could live with the indians I wouldn't think twice. I'm sure that my prostate problems would go away in a few months living among the Ainu, the Lakota, the Muskogee or any similar.

HI Chris,i beg to differ with you on your statement of chronic prostatitis resolving on it's own.I have had this condition for over 7 years and it's has not gone any where. Only when there is a better understanding and solution including a cure and not just give antibiotics to treat the symptoms it will get resolved.Also not running around the world for every one including the crack pots that say they and only they have the cure which is a lot of crock!. Like many on this site as well as thousands in the U.S and throughout the world who have had this for some time and i am sure for most it has not gone away with so called time just a way of selling hope and for me i like living in reality and not fantasy.Like many other Chronic conditions they do not just go away and give it time belief only when there is an actual cure like Polio does it go away.

Just sharing my honest opinion and not to offend.
Thanks,
Gary

In some cases it will resolve by itself, in some it doesn't. Depends what is causing it.

I had really severe symptoms one year ago it was hell, now it is a huge amount better. I have read of this kind of thing happening to other people. I'm sorry it hasn't happened to you.

Yes very true as some times people will feel better but that's some not a majority as nothing is 100%, it's either caused by infection/bacteria and it not means the it's non bacterial prostatitis and the prostate being inflamed which is most cases.Since there is no magic bullet to me and i sure to a lot means when someone feels better it's simply the symptoms have decreased and not because of anything magical happening that the medical field has done.
Again these are my opinion and my honest ones and only know what i have gone through and many who i have spoken to through the years.
If there is a better way of treating this i for one for surely be at the head of the line but don't think that's happening anytime soon as too much money to made by people having any chronic condition.

Sorry you went through H----ll but glad your feeling much better and that you for your good wishes.

Gary

Yes I agree. I'll change the wording in this post.