Expert Consensus On Clinical Diseases Responding Specifically To Traditional Chinese Medicine：Chronic Prostatitis

[Abstract] 

Chronic prostatitis is a common and frequently occurring disease in male clinics. Due to the diverse symptoms, complex causes, unclear mechanisms, and recurrent attacks of chronic prostatitis, Western medicine often faces the problem of limited treatment methods and poor treatment effects. To fully leverage the unique advantages of traditional Chinese medicine in the treatment of chronic prostatitis, the Chinese Society of Traditional Chinese Medicine has organized experts in the fields of traditional Chinese medicine, urology, and related pharmacy to conduct in-depth discussions on the progress of modern medicine in chronic prostatitis, various theories on the etiology, pathogenesis, and treatment of traditional Chinese medicine, entry points with various interdisciplinary fields, the role and advantages of traditional Chinese medicine in the full process management of chronic prostatitis, and research on the mechanisms related to chronic prostatitis. After discussion among the attending experts, it is believed that chronic prostatitis is one of the advantageous diseases in traditional Chinese medicine. Traditional Chinese medicine can effectively improve the clinical syndromes of chronic prostatitis, including urinary tract, social psychology, organ specificity, infection, nervous system, pain and discomfort, sexual dysfunction, etc., and improve the quality of life. For CP patients who cannot tolerate adverse reactions to Western medicine or may not accept adverse reactions that may occur with Western medicine; Noninflammatory CP/CPPS patients; CP patients with pain symptoms as the main symptom; CP patients with predominantly urinary tract symptoms; CP patients with comorbid anxiety and depression; CP patients with abnormal semen liquefaction can all be treated with traditional Chinese medicine as the main approach. At present, the optimal diagnosis and treatment strategy for chronic prostatitis has not yet been formed, and in-depth research is needed from different perspectives such as clinical epidemiology,evidence-based medicine, and molecular biology. Chinese and Western medicine should integrate the advantages of both, and based on mutual reference, clarify the positioning and advantages of traditional Chinese medicine intervention, in order to improve the diagnosis and treatment level of chronic prostatitis in China. 

Keywords： Chronic prostatitis; Dominant diseases of traditional Chinese medicine; Expert guidance and suggestions; Integrated traditional Chinese and Western medicine

TCM HERBAL FORMULATION FOR CHRONIC PROSTATITIS (CP)- CLICK FOR MORE DETAILS 

Chronic prostatitis (CP) is a common and frequently occurring disease in the field of men's medicine. It is a clinical syndrome characterized by pain in the bladder reproductive area and urination irritation symptoms[1]. Epidemiological surveys show that approximately 50% of men will be affected by prostatitis at some point in their lives[2]. Although CP is not a disease that directly threatens life, its prolonged course and repeated attacks seriously affect the patient's physical and mental health and quality of life. Due to the diverse clinical manifestations of CP, the complex and unclear specific etiology, and pathological mechanisms, Western medicine has no satisfactory treatment measures for CP, especially type III prostatitis (CP/CPPS), and lacks effective drug treatment methods proven by evidence-based medicine[3]. Traditional Chinese medicine, based on the holistic concept, treats the liver, spleen, kidney, and bladder, and comprehensively treats pathological factors such as damp-heat, qi stagnation, blood stasis, and deficiency of vital energy. It can effectively improve clinical symptoms and improve the patient's quality of life. It is one of the main measures for the clinical treatment of CP[4].

To further explore the advantages of TCM in treating CP, the Chinese Association of Traditional Chinese Medicine invited 20 experts from Zhuhai Hospital of Guangdong Provincial Hospital of Traditional Chinese Medicine, the Fifth Affiliated Hospital of Sun Yat-sen University, Dongzhimen Hospital of Beijing University of Chinese Medicine, Peking University First Hospital, Jinan University, First Affiliated Hospital of Anhui Medical University, First Affiliated Hospital of Wenzhou Medical University, First Affiliated Hospital of Guangzhou University of Chinese Medicine, First Affiliated Hospital of Yunnan University of Traditional Chinese Medicine, Shenzhen Hospital of Traditional Chinese Medicine, Zhejiang Provincial Hospital of Integrated Traditional Chinese and Western Medicine, Xiamen Hospital of Traditional Chinese Medicine and other hospitals. Based on adhering to the coordinated development of traditional Chinese and Western medicine, the experts conducted heated and in-depth discussions and repeatedly deliberated and argued about the advantages, optimal solutions, expectations, and suggestions of the integrated traditional Chinese and Western medicine treatment of chronic prostatitis, and formed the following basic consensus for reference by clinical physicians.

1 Modern medical knowledge of CP is in a stage of continuous exploration and updating

The etiology of CP is very complex, and the pathogenesis has not yet been fully elucidated. Most scholars believe that CP is mainly related to many factors such as pathogen infection, urinary dysfunction, neuroendocrine factors, oxidative stress, pelvic-related diseases, mental and psychological factors, abnormal immune response, and bad living habits [5]. As the understanding of CP gradually deepens, some experts have proposed to replace the name of "chronic prostatitis" with "prostatic pelvic syndrome" [6] to reduce the excessive attention of andrologists and patients to prostate "inflammation", which is more in line with the cognition of many scholars that "chronic prostatitis is a clinical syndrome". Some scholars have also proposed the POINTS classification system for the clinical treatment of CP [7]. It can more comprehensively reflect the clinical manifestations of CP, thereby more accurately guiding clinical physicians to carry out targeted comprehensive treatment for different patients. The UPOINT classification system includes 7 independent factors, namely urinary symptoms, psychosocial symptoms, organ-specific symptoms, infection symptoms, neurogenic/systemic symptoms, tenderness of muscles, and sexual dysfunction.

At present, the effect of a single Western medicine treatment for CP is not very ideal, and physical therapy has gradually entered the field of vision of researchers. In the physical treatment of CP, the commonly used methods mainly include prostate massage, biofeedback therapy, magnetic therapy, ultrasound and shock wave therapy, heat therapy, acupuncture therapy, and electrophysiological therapy. These physical therapies can directly or indirectly achieve clinical effects by improving local blood circulation in the prostate, promoting the dissipation of inflammation, and relieving muscle tension [8]. See Table 1.

Table 1 POINTS classification system

2 Treatments led by Western medicine

Western medicine treatment has advantages in the following situations, and Western medicine can be given priority for leading treatment: ① For CP patients with moderate/severe anxiety and depression, the drugs that can be selected mainly include selective serotonin reuptake inhibitors (SSRI), 5- Serotonin-norepinephrine reuptake inhibitor (duloxil statin, etc.), tricyclic antidepressants (amitriptyline), etc. Antidepressants and anxiolytics can not only improve the psychological symptoms of CP patients but also relieve physical symptoms such as pain [9]. ② For CP patients with erectile dysfunction (ED), such patients have high expectations for sexual life. Using phosphodiesterase 5 inhibitors (PDE5I) for the first visit can improve the patient's self-confidence. PDE5I is the first-line drug used in the clinical treatment of ED, and commonly used drugs include sildenafil, tadalafil, vardenafil, etc. ③ For CP patients with premature ejaculation (PE), most of these patients have varying degrees of anxiety, depression, tension, pessimism, and other emotions. SSRIs can not only significantly improve the symptoms of premature ejaculation, but also relieve patients' anxiety, depression, tension, and other symptoms [ 10]. SSRI drugs include two categories: on-demand treatment drugs dapoxetine and regular treatment drugs such as citalopram, paroxetine, sertraline, etc. Different SSRI drugs can be selected according to the patient's condition. ④Patients with type II prostatitis whose pathogenic infection can be confirmed through laboratory examination can be treated with sensitive antibiotics based on the bacterial culture results. Antibiotics can have a certain improvement effect on patients' urinary symptoms, pain, and quality of life scores, but only if they are used rationally based on the results of pathogen detection, bacterial culture, and drug susceptibility testing, with full consideration of disease characteristics and drug interactions/contraindications, etc., to avoid abuse.

3 Treatment dominated by TCM

3.1 CP patients who cannot tolerate adverse reactions of Western medicine or cannot accept possible adverse reactions of Western medicine Common Western medicines used to treat CP in clinical practice include α-receptor blockers, nonsteroidal anti-inflammatory drugs, antibiotics, M-receptor blockers and β3-receptor agonists, antidepressants and antianxiety drugs, etc.

[11]. α-receptor blockers may cause dizziness, orthostatic hypotension, and retrograde ejaculation; nonsteroidal anti-inflammatory drugs may cause gastrointestinal reactions such as upper abdominal discomfort, nausea, and vomiting, central nervous system symptoms such as forehead headache and dizziness, skin reactions such as rash, and blood system reactions such as aplastic anemia; antibiotics may cause gastrointestinal reactions such as nausea and vomiting, abdominal pain and diarrhea, and central nervous system symptoms such as insomnia, dizziness, and headache; M-receptor blockers and β3-receptor agonists may cause QT interval prolongation, increased sweating and dry mouth; antidepressants and antianxiety drugs may cause urinary retention, increased intraocular pressure, dry mouth, constipation, and tachycardia.

Therefore, the following patients need to be cautious in accepting Western medicine treatment and try to avoid possible adverse reactions that may aggravate the condition of their underlying diseases. ① Patients with digestive system diseases such as gastritis and gastric ulcers; ② Patients with cardiovascular diseases such as hypertension and coronary heart disease; ③ Patients with a history of mental illness or epilepsy; ④ Patients with prostatic hyperplasia; ⑤ Patients with glaucoma; ⑥ Patients with diabetes; ⑦ Patients who are allergic to antibiotics or have poor antibiotic efficacy; ⑧ Patients who refuse to take α-receptor blockers for a long time or cannot tolerate the adverse reactions of α-receptor blockers. In addition to the above-mentioned cases, other types of CP patients who cannot tolerate or tolerate the possible adverse reactions of Western medicine are all suitable for receiving TCM-dominated treatment.

3.2 Non-inflammatory CP/CPPS patients

According to the NIH classification standard, CP/CPPS can be divided into inflammatory and non-inflammatory types by laboratory testing of whether the white blood cell level in prostate massage fluid, semen, or urine after prostate massage is elevated. For patients with inflammatory CP/CPPS, Western medicine can use non-steroidal anti-inflammatory drugs for symptomatic treatment and empirical antibiotics to improve clinical symptoms; for patients with non-inflammatory CP/CPPS, the above two types of drugs are not recommended for treatment [12]. Compared with Western medicine, which loses its treatment means due to the inability to find the pathogen, the advantage of TCM in treating non-inflammatory CP/CPPS is that it can be treated based on syndrome differentiation according to the patient's clinical symptoms. With the deepening of TCM's understanding of chronic prostatitis, damp-heat, blood stasis, and kidney deficiency are considered to be the three main causes of prostatitis. The internal accumulation of damp-heat, internal obstruction of blood stasis and kidney deficiency often cause each other, making the disease lingering and difficult to cure. Therefore, in treatment, the key pathogenesis of the six evils of dampness, heat, cold, blood stasis, depression and deficiency should be clarified, and the treatment principles of clearing, tonifying the kidney, soothing the liver, removing blood stasis and removing turbidity should be formulated. In combination with diet, daily life and daily care, the overall condition of the patient can be comprehensively improved to achieve a high degree of integration of the doctor's clinical experience and the patient's individualized treatment [13].

3.3 CP patients with pain symptoms 

The main clinical symptoms of CP can be divided into four categories: pelvic pain symptoms, lower urinary tract symptoms, mental and psychological symptoms and sexual dysfunction symptoms. Among them, the pelvic pain symptoms that most affect the quality of life of patients are pelvic pain symptoms, which include perineal pain, testicular pain, penile pain, ejaculation pain, urination pain, abdominal/pelvic muscle tenderness, etc. Clinically, it has been found that some drugs are difficult to penetrate the blood-prostate barrier and their actual efficacy is not ideal[14]. Some analgesics, such as opioids, are addictive and have many adverse reactions. They are not recommended for early-stage patients. Therefore, CP patients with pain symptoms can choose TCM as the main treatment. TCM believes that "pain occurs when there is no smooth flow of qi and blood". Local pain symptoms occur when the qi and blood in the meridians are not smooth. In the TCM syndrome differentiation of CP, the main manifestations of pain include qi stagnation and blood stasis syndrome, liver qi stagnation syndrome, and damp-heat stasis syndrome. Therefore, to relieve the pelvic pain symptoms of CP patients, the qi and blood in the meridians of the painful area should be unblocked. The treatment should focus on soothing the liver and regulating qi, and promoting blood circulation, and removing blood stasis. Clinical studies have shown that Qianliexin Capsules[15] and Qianliexin Suppositories[16] have good efficacy in improving pain symptoms in the lower abdomen and surrounding areas. Acupuncture of the foot-taiyang bladder meridian, foot-trying spleen meridian, and conception meridian can significantly improve a patient's pain symptoms and reduce NIH-CPSI scores[17]. The advantage of TCM in treating CP pain symptoms lies in combining the patient's constitution and other symptoms, and conducting individualized intervention treatment based on the two core pathological elements of blood stasis and qi stagnation to achieve the therapeutic effect of "no pain if the flow is unobstructed".