A. C. Buck, R. W. M. Rees, L. Ebeling
The treatment of chronic, relapsing nonbacterial prostatitis presents a formidable challenge to the clinician. It is also well recognized that other conditions, such as pelvic floor myalgia, prostatodynia, adductor muscle strain and chronic traumatic osteitis pubis, may give rise to symptoms of dysuria, perineal, groin, testicular and suprapubic pain that mimic inflammatory disease in the prostate (3,13,15). It is, therefore, important to differentiate such conditions from chronic prostatic inflammation on the basis of objective morphological, biochemical, radiological, urodynamic and microbiological criteria.
To achieve a cure in these patients is extremely difficult. The response to antibiotics, a-adrenergic blockage, non-steroidal anti-inflammatory drugs and other empirical manoeuvres is either ineffective or, at best, variable (10, 11). The pollen extract Cernitin (A. B. Cernelle, Sweden) has been used in the treatment of chronic prostatitis for nearly 30 years with favourable results (1,4,5,14). The aim of this study was to evaluate the efficacy of Cernitin in the treatment of patients with chronic non-bacterial prostatitis and prostatodynia.
Patients and Methods
Fifteen patients, ranging in age from 23 to 63 years (mean 42.9±SD 11.1) and with a clinical diagnosis of chronic relapsing non-bacterial prostatitis or prostatodynia, were entered into an open trial to study the effect of Cernitin. Twelve patients had previously been treated with 1 or more courses of antibiotics for varying periods of time, 4 had been treated with an alpha-adrenergic blocker, 1 had undergone a transurethral resection of the prostate and 1 an epididymectomy without relief of symptoms. At the time that the patients were commenced on Cernitin they had suffered from their symptoms for periods ranging from 5 months to 7 years (mean 3.3±SD 2.2). Their clinical presentation was as follows: 13 complained of irritative urinary symptoms, mainly dysuria (13) and frequency (6). All complained of pain or discomfort, either persistent or intermittent, localized to the testis (7), groin (4), perineum (5), suprapubic area (1) urethra / penis (3) or on ejaculation (2) (Table 1).
The diagnosis of chronic prostatitis or prostatodynia was made on the basis of the segmented urine sample method of Meares and Stamey (1968). No significant bacteriuria was present in any of the patients, nor were pathogenic organisms, including Chlamydia trachomatis, cultured from the EPS (expressed prostatic secretion). In 5 patients the pH of the prostatic fluid was alkaline (pH 7.0-8.0) with >10 leucocytes and fat laden macrophages /high power field on microscopy. In 8 patients the characteristics of the EPS were normal (pH < 6.5; pus cells < 10 / HPF) and in 2 cases no fluid could be obtained by massage for examination. The patients were commenced on Cernitin 2 tablets twice daily and assessed clinically at monthly intervals.
The duration of treatment with Cernitin varied from 1 to 18 months. Seven patients became symptom-free, 6 were significantly improved and continue to take Cernitin regularly, and 2 failed to respond. Most patients (11) did not begin to show any improvement in signs or symptoms until 3 months after starting treatment (See Table 1 below). Only 1 patient, with a 12-month history of right testicular pain and urinary frequency, who had received 3 courses of antibiotics, with sterile urine and an EPS pH of 6.8 with < 5 leucocytes/HPF, was completely relieved of symptoms after 1 month's treatment with Cernitin. A second patient with a 5-month history of dysuria, frequency, back ache and sterile urine, but an EPS pH of 8 and > 20 pus cells/ HPF, was partially relieved of symptoms at 2 months and the pH of the EPS fell to 7.8, < 10 pus cells / HPF.
Two patients had a recurrence of symptoms after cessation of treatment. A 36 year old man had a 2-year history of intermittent dysuria, left groin and testicular discomfort and an EPS pH of 8 with masses of pus cells /HPF on microscopy; he had been treated with several courses of antibiotics (minocycline, doxycycline, trimethoprim) without relief of symptoms or a change in the alkalinity or leucocytosis of the EPS. After 3 months' treatment with Cernitin the symptoms were completely relieved and the pH of the EPS fell to 7.1 with < 5 pus cells / HPF. On discontinuing treatment the symptoms recurred, with a return to leucocytosis and an alkaline shift in the pH of the EPS. After recommencing Cernitin the signs and symptoms again reverted to normal.
Cernitin is an extract of various pollens from different plants. The active ingredients are a water-soluble (T/60) and fat-soluble (GBX) fraction. The water-soluble fraction attenuated the inflammatory response in experimental animals (7). The acetone-soluble fraction was found to consist of 3ß-sterols with a similarity on UV absorption spectra to oestrone and stigmasterol (9). More recently, in vitro studies have shown that GBX inhibits cyclo-oxygenase and lipoxygenase enzyme in the eicosanoid cascade, blocking both leukotriene and prostaglandin synthesis (Loschen, personal communication). Cernitin was shown to reduce significantly the size of the ventral and dorsal prostate in the rat and to inhibit testosterone- induced prostatic hypertrophy in the castrated animal (7). Kimura et al. (1986) observed that T60 and GBX produced relaxation of the smooth muscle of the mouse and pig urethra and increased the contraction of the bladder muscle.
Although the precise mode of action of Cernitin on the inflammatory process in the prostate is not known, it has been shown to be effective in the treatment of chronic abacterial prostatitis (5,12). In this study, Cernitin was found to relieve completely the symptoms of prostatitis in 7/15 patients and a further 6 were markedly improved. All patients had previously received several courses of antibiotics, analgesics and muscle relaxants and some were given adrenergic blockade, without effective or lasting relief of symptoms. It is of interest that the effect of the pollen extract was mainly observed after 3 months or more of treatment. Most patients have opted to continue with treatment and no adverse side effects have been reported. The in vitro experiments suggest that it could be either a potent cyclo-oxygenase and lipoxygenase inhibitor or a smooth muscle relaxant. These actions could explain its anti-inflammatory effect in abacterial prostatitis and symptomatic relief in prostatodynia, a condition in which an increase in the maximum urethral closure pressure and spasm of the external sphincter mechanism has been observed in association with a diminished urine flow rate (2,10). Conversely, it may affect metabolic processes within the prostatic cell (Habib, personal communication). Further clinical and laboratory studies are necessary to elucidate the exact mode of action of this compound.
Chronic abacterial prostatitis and prostatodynia are notoriously difficult both to diagnose and to treat. These patients tend to have received several courses of antibiotics, anti-inflammatory agents or adrenergic blockade and various other therapeutic manoeuvres with little success. The pollen extract, Cernitin, is reported to be effective in the treatment of this condition and we present the results of an open trial with Cernitin in a group of 15 patients with chronic prostatitis and prostatodynia. In 13 patients there was either complete and lasting relief of symptoms or a marked improvement; 2 patients failed to respond.
Cernitin was found to be effective in the treatment of chronic prostatitis and prostatodynia. Its precise mode of action is not known, although experimental studies suggest that it has anti-inflammatory and antiandrogenic properties.
* Published in Brit.J. Urol. 64 (1989) 496-499
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