Clinical Diseases Responding Specifically To Traditional Chinese Medicine：Chronic Prostatitis

3. Traditional Chinese Medicine (TCM)-Dominated Treatment

3.1 CP Patients Who Cannot Tolerate or Are Unwilling to Accept Adverse Reactions of Western Medications

Common Western medications for CP treatment include α-blockers, nonsteroidal anti-inflammatory drugs (NSAIDs), antibiotics, muscarinic receptor blockers, β3 receptor agonists, antidepressants, and anti-anxiety medications [11]. However, these drugs may cause adverse reactions, such as:

α-blockers: Dizziness, orthostatic hypotension, retrograde ejaculation.

NSAIDs: Gastrointestinal reactions (e.g., abdominal discomfort, nausea, vomiting), central nervous system symptoms (e.g., headache, dizziness), skin reactions (e.g., rash), hematologic complications (e.g., aplastic anemia).

Antibiotics: Gastrointestinal reactions (e.g., nausea, vomiting, abdominal pain, diarrhea), central nervous system symptoms (e.g., insomnia, dizziness, headache).

Muscarinic receptor blockers and β3 receptor agonists: Prolonged QT interval, increased sweating, dry mouth.

Antidepressants and anti-anxiety drugs: Urinary retention, increased intraocular pressure, dry mouth, constipation, tachycardia.

Patients with the following conditions should cautiously consider Western medications to avoid adverse effects that may worsen their underlying diseases:

Patients with gastrointestinal diseases such as gastritis or peptic ulcers.

Patients with cardiovascular diseases such as hypertension or coronary artery disease.

Patients with a history of psychiatric disorders or epilepsy.

Patients with benign prostatic hyperplasia (BPH).

Patients with glaucoma.

Patients with diabetes.

Patients who are allergic to antibiotics or show poor response to antibiotic treatment.

Patients who refuse long-term use of α-blockers or cannot tolerate the adverse effects of α-blockers.

In addition to the above cases, CP patients who cannot tolerate or are unwilling to accept the potential adverse reactions of Western medications are suitable candidates for TCM-dominated therapy.

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3.2 Non-Inflammatory CP/CPPS Patients

According to the National Institutes of Health (NIH) classification, CP/CPPS can be divided into inflammatory and non-inflammatory types based on laboratory findings of white blood cell levels in prostatic fluid, semen, or post-prostatic massage urine.

For inflammatory CP/CPPS, Western medicine typically uses NSAIDs for symptomatic relief and empirical antibiotics to improve clinical symptoms. However, these treatments are not recommended for non-inflammatory CP/CPPS patients [12].

Unlike Western medicine, which lacks treatment options when no pathogens are identified, TCM focuses on symptom-based pattern differentiation and treatment. TCM recognizes damp heat, blood stasis, and kidney deficiency as the primary pathological factors in CP. These factors often interact, leading to persistent and difficult-to-resolve symptoms. Treatment should address the key pathological mechanisms of dampness, heat, cold, stasis, stagnation, and deficiency. Principles such as clearing heat, tonifying the kidney, soothing the liver, resolving blood stasis, and eliminating turbidity are applied along with dietary and lifestyle adjustments to improve the overall condition of the patient. This approach integrates clinical experience with individualized patient care [13].

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3.3 CP Patients with Predominant Pain Symptoms

The primary clinical symptoms of CP can be categorized into four types: pelvic pain, lower urinary tract symptoms (LUTS), psychological symptoms, and sexual dysfunction. Among these, pelvic pain significantly impacts patients' quality of life, including perineal pain, testicular pain, penile pain, pain during ejaculation, pain while urinating, and tenderness in pelvic or abdominal muscles.

Clinical studies have shown that certain drugs fail to penetrate the blood-prostate barrier effectively, resulting in suboptimal efficacy [14]. Additionally, some pain medications, such as opioids, carry risks of addiction and significant adverse effects, making them unsuitable for early-stage patients.

For CP patients with predominant pain symptoms, TCM is an effective treatment alternative. TCM believes that "pain results from obstruction" and attributes localized pain to blocked meridians and blood flow. Pain-related CP subtypes in TCM include qi stagnation and blood stasis, liver qi stagnation, and damp heat stagnation. Treatment aims to unblock the meridians and promote the flow of qi and blood, focusing on soothing the liver, regulating qi, and invigorating blood circulation.

Clinical studies have demonstrated that Qianliexin capsules [15] and Qianlie'an suppositories [16] are effective in alleviating pain in the lower abdomen and surrounding areas. Acupuncture targeting the bladder meridian (foot Taiyang), spleen meridian (foot Taiyin), and conception vessel (Ren meridian) has been shown to significantly reduce pain and NIH Chronic Prostatitis Symptom Index (CPSI) scores [17]. TCM's advantage lies in its ability to tailor treatment to the patient's constitution and symptoms, addressing the core pathological factors of blood stasis and qi stagnation to achieve pain relief.

3.4 CP Patients with Predominant Lower Urinary Tract Symptoms (LUTS)

CP patients often present with varying degrees of LUTS, including storage-phase symptoms (e.g., urgency, frequency, nocturia, urgency incontinence), voiding-phase symptoms (e.g., delayed urination, weak stream, difficulty voiding), and post-voiding symptoms (e.g., incomplete emptying, dribbling).

Western medicine commonly uses α-blockers to improve LUTS, but some patients experience insufficient efficacy or intolerable side effects such as dizziness, orthostatic hypotension, or retrograde ejaculation [18]. Therefore, TCM may be a preferable treatment option for CP patients with predominant LUTS.

In TCM, LUTS corresponds to conditions such as "long bi" (urinary obstruction) and "jing zhuo" (seminal turbidity). The pathology is located in the bladder and involves the spleen, lungs, kidneys, and triple burner, with bladder qi transformation dysfunction as the underlying mechanism [19].

Key TCM patterns for LUTS in CP include damp heat descending, damp heat stagnation, kidney yang deficiency, and kidney yin deficiency. Treatment principles involve clearing heat and dampness, eliminating turbidity, warming the kidney, and promoting qi transformation and blood flow [20-21].

Studies have shown that:

Longqing tablets can alleviate clinical symptoms such as urethral burning, urinary frequency, urgency, and pain [22].

Ningmitai capsules are effective for symptoms such as urinary hesitancy and painful urination [23].

Shumitong capsules improve symptoms such as difficulty voiding, low urine output, and incomplete emptying [24].

TCM emphasizes a holistic view of the urinary system, treating LUTS comprehensively and systematically. This approach significantly alleviates overall symptoms, improves voiding difficulties, reduces pain and discomfort, and enhances quality of life.

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3.5 CP Patients with Mild Anxiety and Depression

Anxiety and depression not only affect the mental health of CP patients but also influence their treatment compliance, thereby impacting treatment efficacy and prognosis [25]. The reasons why CP patients are prone to anxiety and depression include:

Chronic and Recurring Nature of the Disease: CP often has a long course with persistent symptoms, difficult recovery, and frequent relapses. Suboptimal treatment outcomes and prolonged therapies impose mental and financial burdens, fostering pessimistic and anxious emotions.

Lack of Proper Understanding of the Disease: Patients may have misconceptions about their condition, often exacerbated by misleading information from some institutions, leading to exaggerated and distorted perceptions of their illness, which intensifies anxiety and depression.

Cultural Stigma Around the Disease: The private nature of CP symptoms makes some patients hesitant to discuss their condition, especially in the context of traditional cultural norms. Over time, sexual dysfunctions such as erectile dysfunction (ED) or premature ejaculation (PE) may develop, further aggravating their mental distress.

CP and anxiety/depression are interrelated, influencing each other in a cause-and-effect cycle. To achieve better clinical outcomes, it is crucial to address the mental health of patients while treating CP. Western medicine typically treats such patients with psychiatric medications and psychological interventions. However, psychiatric drugs often have significant side effects, and the effectiveness of psychological interventions varies greatly among individuals and is not always feasible. Many patients in China are resistant to psychiatric drugs and lack access to multidisciplinary care involving psychiatrists, resulting in suboptimal outcomes.

Thus, for CP patients with mild anxiety and depression, TCM is recommended as the primary treatment approach.

In TCM, anxiety and depression are categorized under "yu syndrome" (stagnation), with the pathological focus on the liver and heart. The core mechanisms involve liver qi stagnation and unrest of the mind. Treatment principles include soothing the liver, regulating qi, and calming the mind [26]. Expert consensus and guidelines recommend Wuling capsules for CP patients with anxiety and depression, as they help alleviate mental distress, improve quality of life, and enhance treatment outcomes [27-28]. TCM emphasizes the role of emotions in the progression of diseases, supported by theories such as the "seven emotions" and "five spirits and organs." TCM also incorporates lifestyle adjustments, dietary recommendations, and traditional exercises such as Baduanjin and Tai Chi, which have been shown to improve mild anxiety and depression [29].

Overall, TCM offers a holistic approach to treating CP patients with mild anxiety and depression, demonstrating advantages that make it suitable for clinical application.

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3.6 CP Patients with Abnormal Semen Liquefaction

Abnormal semen liquefaction refers to a condition where semen fails to liquefy within 60 minutes at room temperature. This condition restricts sperm motility, negatively affecting fertilization and leading to male infertility. Studies show that CP patients have a higher prevalence of abnormal semen liquefaction compared to the general population [30]. This is attributed to reduced proteolytic enzyme activity in prostatic fluid, which impairs fibrinolysis in semen, resulting in liquefaction abnormalities [31].

Although abnormal semen liquefaction does not significantly affect the progression or treatment of CP, it greatly heightens anxiety and depression due to infertility, which can further impact treatment efficacy and prognosis. Therefore, for CP patients with abnormal semen liquefaction, it is essential to address this issue alongside CP treatment.

Currently, Western medicine lacks a consensus on the pathogenesis of abnormal semen liquefaction. Clinical treatments primarily include:

Antibiotics: For patients with reproductive tract infections.

Testosterone supplementation: For patients with testosterone deficiency.

Intrauterine insemination (IUI): To bypass the negative impact of abnormal semen liquefaction on conception.

However, these approaches often have limitations, such as uncertain efficacy, unsuitability for long-term use, low success rates, and high costs [32].

In TCM, abnormal semen liquefaction corresponds to conditions such as "jing han" (cold semen) and "jing re" (hot semen). The underlying causes and mechanisms include kidney yin deficiency, kidney yang deficiency, damp heat descending, and phlegm-stasis obstruction [33]. TCM treatment emphasizes differentiating between cold, heat, deficiency, and excess to restore semen liquefaction by supporting normal physiological processes and eliminating pathogenic factors.

For inflammatory CP patients with abnormal semen liquefaction, a combination of TCM and antibiotics is recommended for integrated treatment [34]. See Table 2 for details.

Table 2 Clinical advantages of traditional Chinese medicine in the treatment of CP

No.	Advantages	Explanation of TCM Treatment Advantages
1	Improvement of Lower Urinary Tract Symptoms	TCM can alleviate symptoms such as urgency, frequency, incomplete urination, and weak urine stream, avoiding the side effects of α-blockers.
2	Improvement of Pain Symptoms	TCM can reduce pain in the perineum, pelvic area, or lower abdomen and improve the efficacy of pain-related symptoms without relying on painkillers.
3	Improvement of Anxiety and Depression Symptoms	TCM can relieve anxiety and depression, soothe the liver, and calm the mind, avoiding the side effects of psychotropic medications.
4	Improvement of Sexual Dysfunction Symptoms	For patients with sexual dysfunction, TCM can enhance libido and sexual function without the side effects of Western medications like PDE5 inhibitors.
5	Overall Symptom Improvement	TCM provides a comprehensive approach to CP by addressing pain, urination issues, sexual dysfunction, and emotional states, improving

Table 2 Clinical advantages of traditional Chinese medicine in treatment of CP

No.	Discussion Points	Details
1	TCM as a Comprehensive Advantage in Treating CP	CP is a disease where TCM demonstrates significant overall advantages in male health. Its effectiveness warrants further exploration and discussion.
2	Focus on TCM Advantage Scenarios	Six scenarios suitable for TCM treatment are summarized, focusing on TCM's advantages in specific areas, phases, and patient groups.
3	Current TCM Treatment Methods	TCM treatments include herbal decoctions, patent medicines, external treatments, and combined internal-external therapies.
4	Efficacy of Herbal Medicines and Plant Extracts	Properly prescribed herbal decoctions and patent medicines can alleviate both physical and mental symptoms. Plant-based treatments such as saw palmetto extract have shown clinical efficacy and require more high-quality research.
5	TCM External Treatments	External treatments include suppository rectal administration, acupuncture, acupoint application, moxibustion, massage, herbal retention enemas, and sitz baths. Suppositories and acupuncture have the most research, but others need exploration.
6	Advantages of TCM External Treatments	External treatments bypass the liver's first-pass effect and penetrate the prostate capsule effectively, offering fast results, fewer side effects, better patient experience, and high compliance.
7	Future Research Directions	Conduct high-quality randomized controlled trials (RCTs) and real-world studies (RWS) to provide stronger evidence for TCM treatments and include economic evaluations to enhance recognition of TCM's clinical advantages in treating CP.

4 Discussion

As a disease where Traditional Chinese Medicine (TCM) demonstrates significant advantages in the field of andrology, chronic prostatitis (CP) warrants in-depth exploration and research. This article summarizes six scenarios where TCM treatment is particularly suitable, focusing on its advantages in specific treatment stages, areas, and patient populations. The summarized TCM treatment strategies aim to provide valuable reference points for andrology practitioners.

Currently, TCM treatments for CP primarily include oral herbal decoctions or patent medications, external therapies, and combined internal-external therapies. When prescribed based on proper pattern differentiation, herbal decoctions or patent medicines can achieve favorable outcomes, alleviating both physical and psychological symptoms. Additionally, plant-based formulations, such as saw palmetto extract, have demonstrated promising clinical efficacy in CP treatment [35]. Further high-quality clinical studies are needed to provide robust evidence-based support for these therapies.

TCM external therapies include rectal administration of suppositories, acupuncture, acupoint application, moxibustion, massage, herbal retention enemas, and sitz baths [36]. Among these, rectal suppositories and acupuncture have been extensively studied, while other external therapies remain underexplored and require further investigation into their mechanisms of action.

Due to the unique anatomical and physiological features of the prostate, many oral medications struggle to reach the affected area effectively, limiting their therapeutic impact. In contrast, TCM external therapies bypass the liver's first-pass effect and achieve better penetration of the prostate capsule, offering advantages such as rapid onset of action, minimal side effects, improved patient experience, and higher compliance. However, the current level of evidence supporting these therapies is low, with limited clinical studies, making the need for high-quality randomized controlled trials (RCTs) and real-world studies (RWS) critical to provide higher-level evidence for TCM treatments.

Moreover, there is a lack of health economics evaluations of TCM treatments for CP. This gap affects public perception and recognition from Western medicine practitioners regarding the clinical advantages of TCM in CP treatment. Filling this void should be a priority in future research to better demonstrate the cost-effectiveness and overall value of TCM in the management of CP.

Table 3 Points of unmet clinical needs in CP

No.	Clinical Challenges in Treating CP	Solutions Offered by TCM
1	Oral medications often fail to effectively reach the prostate due to its unique anatomical location and physiological features.	TCM external therapies bypass the liver's first-pass effect, directly targeting the prostate capsule for better efficacy.
2	Many oral medications have adverse effects, such as gastrointestinal discomfort, dizziness, and tolerance issues.	TCM therapies, including herbal decoctions and patent medicines, are generally well-tolerated with fewer side effects.
3	Conventional therapies often fail to address both physical symptoms (e.g., pain, urination issues) and psychological symptoms (e.g., anxiety, depression).	TCM adopts a holistic approach, addressing physical and mental health comprehensively for better outcomes.
4	Limited evidence for the mechanisms and efficacy of external therapies like herbal retention enemas, sitz baths, and moxibustion.	Further research into these therapies is needed to explore their mechanisms and confirm their efficacy.
5	Lack of high-quality clinical research and randomized controlled trials (RCTs) to support TCM efficacy for CP.	Conduct high-quality RCTs and real-world studies (RWS) to provide robust evidence for TCM treatments.
6	Limited health economics evaluations of TCM for CP, affecting its recognition and acceptance among Western medicine practitioners and the public.	Conduct cost-effectiveness studies to demonstrate the economic and clinical value of TCM in CP treatment.