EVERY YEAR, MILLIONS of men and women visit urologists and primary care physicians for the symptoms caused by either prostatitis in men or the urethral syndrome in women. These visits result in billions of health care dollars being spent annually.
A study by the U.S. National Center for Health Statistics suggests that 25% of visits by men to urologists are for prostatitis [1]. It has been estimated that 50% of all males experience symptoms of prostatitis during their lifetime [2]. Prostatitis is the most common urological diagnosis in men younger than 50 and is the third most common urological diagnosis in those older than 50 (after benign prostatic hyperplasia and prostate cancer). It appears that prostatitis affects men of all ages [3]. Similarly, 50% of adult females have an attack of urinary symptoms at sometime in their lives. About half of their episodes of dysuria and frequency will be caused by the urethral syndrome [4].
The clinical presentation of both prostatitis and the urethral syndrome are very similar. The symptoms include nocturia and irritative voiding complaints such as frequency, dysuria, urgency, and urgency incontinence. Lower abdominal pain, lower back pain, genital pain and pain associated with intercourse can often be associated with these syndromes. Some instances of microscopic hematuria, terminal or initial hematuria, post-void dribble, hesitancy, feeling of incomplete emptying and interrupted stream are also associated with this complex of symptoms.
Prostatitis has been grouped into different categories as defined by Drach et al. [5] These include acute bacterial prostatitis, chronic bacterial prostatitis, nonbacterial prostatitis, and prostatodynia. Acute prostatitis is usually evident on clinical grounds and is relatively easy to treat. In contrast, chronic prostatitis, nonbacterial prostatitis, and prostatodynia are difficult to treat and the etiology has never been clearly determined.
The urethral syndrome (also known as urethral stenosis) commonly presents with voiding difficulties, perineal and lower abdominal discomfort, or painful sexual encounters. The diagnosis is made when voiding symptoms are present without any demonstration of an infectious process. A true mechanical obstruction is rarely demonstrated [6]. According to Bodner, “there is no reason to assume that a similar entity does not incur in men, possibly as prostatodynia” [7].
An inexpensive and simple dietary approach is presented for the treatment of prostatitis and the urethral syndrome. This approach has been demonstrated to be highly effective, involves no medication, and has prevented surgical procedures and manipulations. The treatment protocol is through a dietary method whereby the patients abstain from consuming caffeine, alcohol and hot, spicy foods.
The results of this dietary regime suggest that the long sought etiology for chronic prostatitis, nonbacterial prostatitis, prostatodynia, and the urethral syndrome is an “allergic type” reaction leading to inflammation of the prostate in men and of the urethra in women. It appears that the inflammatory process is secondary to caffeine, alcohol, and hot, spicy foods.
It is now proposed that with proper dietary changes, patients can be cured of their symptoms caused by prostatitis and the urethral syndrome. No other method or treatments are required.
Materials and Methods
Patients were selected for this study from a community urology practice when they presented with chronic clinical symptoms that suggested either chronic prostatitis in men or the urethral syndrome in women. This covers a period from 1978 to 1999. Two thousand three hundred and eighty five patients (ranging in age from 18 to 83) were treated. One thousand seven hundred and ten men were treated for what was classified as either chronic prostatitis, nonbacterial prostatitis or prostatodynia. In this study these three entities are all defined simply as chronic prostatitis. Six hundred seventy five women were treated for the urethral syndrome. Patients were entered into the study if they had at least two symptoms associated with either chronic prostatitis or the urethral syndrome. The symptoms included dysuria, frequency, nocturia, urgency, urgency incontinence, post void dribble, feeling of incomplete emptying, perineal discomfort, lower abdominal discomfort, testicular pain, sexual discomfort, and microscopic hematuria. Two associated symptoms existed in 25% of men and 23% of women. In 75% of men there were at least 3 to 5 symptoms coexisting at the time of diagnosis. In 77% of women, there were at least 3 to 5 coexisting symptoms at the time of diagnosis. The study population included only patients who were reevaluated after 12 weeks.
All patients were treated with a dietary approach only. No patients in the study group received antibiotics in either a short or prolonged course. None were treated with medications such as alpha-blockers, 5-alpha reductase inhibitors, or phenazopyridine. No women had urethral dilations. Only patients with a negative urine culture were entered into the study. A positive urine culture excluded the diagnosis of prostatitis or urethral syndrome. A positive urine culture was defined as greater than 104 organisms. All patients had relevant physical exams. Men had genitalia and rectal exams and women had pelvic exams. Cultures of prostate expressions were never performed, and targeted lab tests for STDs were rarely done and only if the patent specifically requested one.
For 12 weeks, the patients were treated with a strict diet that demanded total abstinence from caffeine, alcohol, and hot, spicy foods. They were carefully instructed to avoid these food items and to maintain 100% compliance, as even a slight deviation could prevent resolution of their symptoms. At the end of 12 weeks, if their individual symptoms had not disappeared, then the approach was not considered to be successful.
Results
Clinical Data
Table 1 summarizes the presenting symptoms for both men and women. Both sexes demonstrated very similar symptoms. The most common individual symptoms in men were frequency (31%), followed by nocturia (25%), dysuria/discomfort (14%), urgency (13%), testicular pain/penile pain (12%), microscopic hematuria (11%), hesitancy/interrupted stream (7%), pain with ejaculation (4%), post-void dribble (4%) and hematospermia (3%). The most common individual symptoms in women with urethral syndrome paralleled that of men with prostatitis. Frequency (34%), was followed by nocturia (23%), urgency (21%), dysuria (19%), urgency incontinence (10%), microscopic hematuria (10%), suprapubic/perineal discomfort (8%), and feeling of incomplete emptying (8%).
;)
TABLE 1: Prevalence of urinary symptoms in men and women
Treatment and Outcome
There was an 87% success rate in men and an 89% success rate in women after 12 weeks of dietary treatment only. Success is defined as at least an 80% improvement in each and every symptom at reevaluation 12 weeks after the start of the dietary restrictions. Success was based solely on the patients’ self-reevaluation of their symptoms from clinical reassessments at follow-up visits. Only if there was not complete success were the traditional urological methods employed—antibiotics, cystoscopy, alpha-blockers, antihistamines, etc.
Discussion
The treatment of prostatitis and urethral syndrome are very frustrating to both the patient and their urologist. Urologists are embarrassed about their management of prostatitis. Many urologists freely acknowledge that they would be happy to never see another patient with prostatitis in their office again. Many ignore the real issue, dispensing their “antibiotic of the month” [8].
The standard treatment for men with chronic prostatitis continues to be with antibiotics. Unfortunately, the success of antibiotics in this clinical situation appears no better than if antibiotics are not used [9]. Antibiotics appear to relieve symptoms in 35% of patients and provide a cure in 28%. Similar results were found when no antibiotics were used. There is also no evidence to suggest that prolonged courses of antibiotics were beneficial. Searches for other less common organisms were just as unsuccessful. No valid evidence was found to implicate Chlamydia trachomatis, Ureaplasma urealyticum, Staphylococci, Streptococci, Bacteroides fragilis or Clostridium perfringens [10].
Finding the proper treatment for urethral syndrome has been just as difficult. No specific organism has ever been found and specific mechanical obstructions have never been validated. Many women have undergone urethral dilation but its true value has never been proven. Chronic antibiotic administration, biofeedback techniques, skeletal muscle relaxants, and psychological counseling have also been advocated [6].
In searching for a more effective therapy, a dietary approach that eliminates caffeine, alcohol, and hot, spicy foods was used. One thousand seven hundred and ten men and 675 women have been treated accordingly. This dietary approach has been extremely successful in eliminating symptoms associated with prostatitis and the urethral syndrome, resulting in an 87% success rate in men and an 89% success rate in women. Success means that after 12 weeks of dietary restriction, there was an elimination of each individual symptom that patients presented with. Their symptoms included frequency, dysuria, urgency, urgency incontinence, nocturia, hesitancy, interrupted stream, feeling of incomplete emptying, lower abdominal discomfort, genital discomfort, and pain associated with intercourse.
The achievements of this dietary treatment are based on the removal of irritants or possible “allergens” to the urinary tract. Allergy as a possible cause of lower urinary tract symptoms has been considered in the past. Between 1960 and 1970, Powell et al. treated more than 900 patients who were complaining of urinary tract symptoms and were placed on dietary restrictions and antihistamines [11]. They found that 75% of these patients were relieved of their symptoms. They concluded that citrus fruits, pepper, condiments, nuts, cocoa, and tomatoes were the most common offending foods. They felt that in many cases of relapse the patients had gone back to eating “forbidden foods.” Therefore, they concluded that the avoidance of allergens through careful attention to diet brought about an improvement in conditions.
In a review of clinical prostatitis by Roberts et al., he specifically suggested the avoidance of spicy foods, excessive caffeine, or alcoholic drinks. These have been associated with a worsening of symptoms for men with prostatitis. They suggested that men who notice an association are counseled to reduce their intake [12].
In the present study group, the etiology appears to be an “allergic-like” reaction to caffeine, alcohol, and hot, spicy foods. These substances appear to cause inflammation in the prostate and the urethra. The results from the elimination of the irritants have been sustainable as long as the patients have been committed to staying away from these inflammatory agents on a continuing basis.
In my clinical study, I made no attempt to find a physiological reason that caffeine, alcohol, or hot, spicy foods should cause these symptoms. The approach to cure these problems came from listening to my patients initially explaining their self-observations that many times their own symptoms were effected when they were consuming these products. The use of an “allergic-like” reaction was simply used to help patients understand that their prostate or their urethra was “allergic” to these products and therefore they must avoid them or face continued suffering.
In order to achieve a high success rate, adequate time must be spent with each patient to thoroughly educate them regarding the above irritants. Patients are generally not aware of the specific contents of what they eat or drink. It is important to discuss the different products containing caffeine as most people think that caffeine is only synonymous with coffee. Caffeine is not only found in coffee, but is also in tea, decaffeinated coffee, decaffeinated teas, cola drinks, some non-cola drinks, and in all forms of chocolate (Table 2). Caffeine free herbal teas or grain beverages such as Postum are acceptable drinks. Alcohol means all forms of alcohol including beer and wine (Table 3). Hot, spicy foods include salsa, hot peppers, hot mustards, horseradish, chili, Tabasco, hot sauce, and pepperoni (Table 4). It is not necessary for the patient to be on a bland diet. Mild spices such as salt, black pepper, onion, salad dressing, or ketchup are not involved in the process and it is acceptable for the patient to consume these mild spices.
TABLE 2: Common beverages, foods and medications containing caffeine
TABLE 3: Alcoholic beverages
TABLE 4: Hot, spicy foods
I recognize important limitations in this study. The patients for this study presented to my community based urology practice. There was no attempt at randomization and no attempt to control for placebo effect. They were selected purely from clinical symptoms that suggested either chronic prostatitis or urethral syndrome. Many had been on antibiotics or antispasmodics from previous urologists or had undergone previous procedures, but once they presented to my practice, they were all placed on dietary restrictions only.
Why certain patients fail on this program is not truly understood. It certainly is not easy for some patients to follow a strict program that requires 100% compliance. This could easily be an explanation for some nonresponders. Cystoscopy in some nonresponders found urethral strictures in some men. Transurethral resection of the prostate has occasionally found pockets of chronic prostatic abscesses that were unroofed by the surgery. No true case of interstitial cystitis was ever found by cystoscopy in any woman.
Conclusion
Prostatitis and urethral syndrome are a major health care problem. Quality-of-life studies for patients with prostatitis equate the impact to be similar to patients suffering myocardial infarction, angina, or Crohn’s disease.
The results of this study suggest that diet alone can eliminate the pain and suffering caused by prostatitis and the urethral syndrome. Caffeine, alcohol, and hot, spicy foods appear to cause an “allergic-like” reaction leading to inflammation of the prostate and the urethra. Millions of patients might benefit and billions of dollars might be saved with this new simple approach. These dietary irritants appear to represent the long sought explanation for the most common problem in all of urology.
REFERENCES
1. National Center for Health Statistics. Office visits for male genitourinary conditions. National Ambulatory Medical Care Survey: United States 1977, Hyattsville, Maryland.
2. Stamey TA. Pathogenesis and treatment of urinary tract infection. Baltimore, Williams & Wilkins, 1980. pp 212–223.
3. Nickel JC, Downey J, Hunter D, et al. Prevalence of prostatitis-like symptoms in a population based study using the national institute of health chronic prostatitis symptom index. Journal of Urology 2001;842–845.
4. Hamilton-Miller JMT. The urethral syndrome and its management. Journal of Antimicrobial Chemotherapy 1994; 33:63–73.
5. Drach GW, Fair WR, Meares EM, et al. Classification of benign disease associated with prostatic pain, prostatitis or prostatodynia. Journal of Urology 1978; 120( 2):266–271.
6. Chancellor M, Blaivas J. Unstable bladder and anatomic defects. In: Buchsbaum H, Schmidt J, eds. Gynecologic and Obstetric Urology. Philadelphia: WB Saunders Co., 1993, pp 371–395.
7. Bodner D. The urethral syndrome. Urological Clinics of North America 1998; 15( 4):699–704.
8. Nickel JC. Prostatitis - myths and realities. Urology 1998; 51:362–366.
9. De La Rosette JJ, Hubregtse MR, Meuleman EJ, et al. Diagnosis and treatment of 409 patients with prostatitis syndrome. Urology 1993; 4( 4):301–307.
10. Shortliffe LD, Sellers R, Schachter J. The characterization of non-bacterial prostatitis: search for an etiology. Journal of Urology 1992; 148:1461–1466.
11. Powell NB, Powell EB, Thomas OC, et al. Allergy of the lower urinary tract. Journal of Urology 1972; 107:631–634.
12. Roberts RO, Lieber MM, Bostwick DG, et al. A review of clinical and pathological prostatitis syndromes. Urology 1997; 49( 6):809–821.
