Prostatitis- Part IV of a VI Part Article

(2/17/06)- About 2.5 million American males take the herbal supplement saw palmetto for their enlarged prostate problem. A recent study concluded that the supplement was no more helpful in alleviating the problem than was a placebo. The multistudy analysis was performed by the Cochrane Collaboration, a nonprofit group that specializes in reviewing medical literature. Stephen Bent, professor of medicine at the University of California, San Francisco, was the main author of the study.

The study involved 225 men over the age of 49 with moderate to severe benign prostate hyperplasia (BPH), who were randomly assigned to either the saw palmetto or a placebo group. Those who received the saw palmetto received a capsule dosage of 180 mgs, twice a day. The patients did not know which group they had been assigned to.

Saw palmetto is an extract from the berry of the American dwarf palm tree, common in Florida and the southeastern part of this country. The National Institutes of Health sponsored the study. It is estimated that more than half of all Americans over 29 years of age suffers from BPH.

There are two drugs that have been approved by the FDA to treat BPH-finasteride and terzosin-but they both cost triple the cost of saw palmetto, which sells for about $5 to $15 for a month's supply of the supplement.

Saw palmetto is the third-highest-selling herbal supplement in the U.S. with annual sales of about $100 million to $120 million. Garlic, which is used for high cholesterol levels, and echinacea, which is used to treat cold symptoms are the leading herbal supplement sellers in this country are the number one and number two selling herbal supplements in this country according to the American Botanical Council, an educational organization focusing on the science-based use of herbs..

Patients took the capsules for a year. Symptoms were assessed through a questionnaire and by measuring of the size of the prostate gland and the volume of urine left, as well as other tests. The study found no significant difference between the placebo and the saw palmetto group.

A prior study analysis of 21 trials involving over 3,000 men found that the saw palmetto did provide "mild to moderate improvement" in symptoms with fewer adverse events than finasteride.

Please see our article: "Latest Research Questions the Effectiveness of Herbal Supplements."


Prostatitis, according to The Merck Manual is defined as "an acute infection of the prostate gland characterized by chills, high fever, urinary frequency and urgency, perineal and low back pain, varying degrees of symptoms of obstruction to voiding, dysuria or burning urination, nocturia, sometimes gross hematuria, and often arthralgia and myalgia." Prostatitis is considered one of the most common outpatient diagnoses in an urologist's practice.

A reading of the literature on this subject suggests that there was some controversy as to the definition and relevant classification system for the various forms of prostatitis. A uniformly accepted classification system leads to appropriate evaluation strategies and treatment guidelines. The National Institute of Health within which is the National Institute of Diabetic and Digestive and Kidney Disease (NIH-NIDDK) attempted to correct this issue by convening a symposium of experts to develop guidelines for the diagnosis and classification along with treatment guidelines. The North American and International urology community has now accepted the results of the classification system and has started using it in clinical practice.

The NIH system makes a few changes to the previous system and adds a new classification (category IV). It defines four categories of the disorder in which patients may fall. Category I is similar to acute prostatitis, category II is similar to chronic bacterial prostatitis, category III is similar to chronic nonbacterial prostatitis and prostatodynuria, category IV includes those patients with asymptomatic inflammatory prostatitis (AIP). Category III is further divided into two subclasses: category IIIA or inflammatory chronic prostatitis/chronic pelvic pain syndrome indicated by a significant number of leucocytes in the prostate specific specimen; category IIIB or non inflammatory chronic prostatitis/chronic pelvic pain syndrome in which there are no significant leucocytes in the prostate specific specimen.

Characterization of different categories

Category I is characterized by an acute infection of the lower urinary tract, including the prostate gland. Symptoms include fever, local pelvic/perineal pain, irritative and obstructive voiding symptoms and other generalized symptoms of acute infection. A physician's evaluation should include a history and physical examination including digital rectal examination, but does not have to include a digital massage. To confirm the diagnosis, the physician will take a urine specimen to culture uropathogenic bacterium. Other testing to be done would include a bladder scan to tell whether the patient is in acute urinary retention indicative of need for lower urinary tract drainage. The physician would also have to rule out the existence of prostate abscess.

Category II patients have a history of recurrent urinary tract infections. Physicians have found that many of the individuals with this diagnosis respond well to antibiotic treatment and remain well between infections. But others continue to have varying degrees of pelvic and perineal discomfort associated with irritation and obstructive voiding symptoms. A physician will conduct a focused physical examination including a prostate examination followed by a prostate massage. Prior to a prostate massage, initial strain urine and a mid strain urine is collected. Where possible, an expressed prostatic secretion and a t least a post prostatic massage urine specimen should be collected for microscopy and culture.

Category III patient's assessment includes three levels: mandatory assessments, recommended assessments, and optional assessments. Mandatory for category III patients is a history, and physical examination including a digital rectal examination. Recommended are a lower urinary tract localization test, a symptom inventory or index, a flow rate, a residual urine determination and urine cytology. Optimal assessment should include a semen analysis and culture, urethral swab for culture, pressure flow studies, video urodynamics (including flow-EMG), cystoscopy, TRUS, pelvic imagery (ultrasound, CT scan or MRI), and Prostate Specific Antigen test. (Note: TRUS of the prostate is helpful in determining prostate size, shape and architecture but in most cases is unhelpful in determining the etiology, pathogenesis or for determining effective treatment modalities. TRUS can identify potential treatable prostate abscesses or cysts, seminal vescular abnormalities and ejaculatory duct abnormalities.)

Explanation of terms used above

1. Bladder outlet obstruction: involves symptoms of urinary hesitancy, diminished force and caliber of the stream, and postvoid dribbling. Benign prostatic hyperplasia (BPH) is the most common cause of bladder outlet obstruction in men over 50 years of age.
2. Diminished functional bladder capacity: results from symptoms of urinary frequency, urgency, and nocturia.
3. Irritative bladder symptoms: urinary frequency, urgency and nocturia. This condition is seen with cystitis, prostatitis, bladder stones, and bladder carcinoma.
4. Digital rectal examination: permits the examination of the lateral lobes of the prostate and the posterior lobe, adjacent to the apex. The size of the prostate gland as estimated by rectal examination is not directly related to the degree of urinary obstruction. This exam determines the consistency of the prostate gland. You may feel the urge to void during this examination.

Several new promising therapies are emerging for the treatment of BPH. At a meeting of the American Urological Association in San Francisco researchers at the University of Pittsburgh used injections of botulinum toxin-the Botex used in cosmetic procedures- to temporaryily reduce prostate tissue. Another new promising therapy involves the injection of ethanol into the prostate. Another group of researchers is working on the usage of high-intensity ultrasound and light waves to shrink the prostate. These new therapies involve relief from the symptoms of BPH, but they are not cures for the problem.

The most common way to treat BPH up to now includes the usage of two types of drugs. Alpaq-blockers such as Saanofi-Synthelabo Inc.'s Uroxatral and Boehringer Ingelheim Pharmaceuticals" Flomax relax the muscles of the prostate to allow regular flow of urine. The other type of medication, which inhibit the enzyme 5 alpha-reductase, such as Merck's Proscar and Propetia, shrink the prostate by interfering with hormones that cause it to enlarge

See our earlier articles on:

Prostate Cancer-Part I
Predicting Survival After Prostate Cancer -Part II
Prostate Specific Antigen (PSA) -Part III
Prostate Specific Antigen- Part IIIa
Prostate Cancer-Colon Cancer- An Overview - Part V
New Drugs in the Battle Against Prostate Cancer -Part VI

Also please see: Justice Ruth Bader Ginsburg and Colon Cancer


Allan Rubin and Harold Rubin, MS, ABD, CRC, Guest Lecturer
updated February 17, 2006

To e-mail: or

Return to Home