Understanding prostate health
Prostate disorders beg greater attention and understanding given they affect such a large percentage of the male population; more than one in three of all men over 50 will have some symptoms of prostate enlargement (1), 15% of men of all ages will experience acute inflammation of the prostate at some point in their lives (with 2-10% suffering from chronic inflammation of the prostate) (2) and prostate cancer is currently the most common form of cancer in men (3). Given the nature of the symptoms involved, prostate disease can have many detrimental effects – both physical and psychological – on those affected, with a huge impact on quality of life.
The prostate is a small gland located around the base of the urethra (the tube via which urine is excreted) in men that secretes seminal fluid. The primary prostate conditions are:
Prostatitis (chiefly: acute bacterial, chronic bacterial and chronic non-bacterial prostatitis): inflammation of the prostate gland
Benign Prostatic Hyperplasia (BPH): non-cancerous enlargement of the prostate gland
Prostate Cancer: cancer of the prostate gland (1)
Of these disorders, chronic non-bacterial prostatitis (often known as Chronic Pelvic Pain Syndrome (CPPS)) is the most common prostate condition in men under 50 and BPH the most common for those over 50 and the most common prostate disorder, overall. Of all the prostate diseases, they are also the least understood by allopathic medicine, where no exact causes are known. CPPS and BPH present challenges to modern medicine, where treatment is largely aimed at symptom control and recovery is often slow. (1,4)
While TCM does not have specific disease categories for CPPS and BPH, it has used herbal medicine to treat their associated symptoms for millennia. Prior to the introduction of conventional medicine in China, the Chinese relied exclusively on TCM to treat BPH for more than 3,000 years. (5) And, while more good quality research is needed, some recent research studies for TCM for BPH and CPPS have yielded promising results. (5-9)
How does TCM view prostate health?
In TCM, we divide the internal organs into three regions (jiaos); the upper, middle and lower jiaos. While the prostate gland is not specifically recognised in classical Chinese medicine, the genitourinary system as a whole lies in the domain of the lower jiao which is governed by the Kidneys and Liver. As such, prostate conditions are often understood in terms of an imbalance with one of these organ systems – in particular, the Kidneys.
‘Shen zhu yi shen zhi shui; The kidneys govern the water of the entire body’ (10 p78)
‘Shen zhu kai he; The Kidneys govern opening and closing’ (10 p81)
TCM, where the energies of opposing but mutually engendering yin and yang are central, sees male conditions as typically (but not always) yang in nature. It holds that the Kidneys belong to the Water element and are fundamental to fluid physiology.
It is the warming, vitalising energy of Kidney yang that enables both the creation and excretion of urine. The ‘opening and closing’ of the lower ‘gates’ (urethra/ spermatic duct and anus) is also overseen by the Kidneys. Where Kidney qi is weakened, this function is impaired, allowing leakage from the ‘gates’ (ie. incontinence, spermatorrhea etc). There may also be insufficient yang energy to drive urination, resulting in difficult urination and a weak flow.
Stress, anger, frustration and repressed emotions disrupt the circulation of Liver qi in TCM. This may then transfer to the Liver meridian which passes through the lower jiao. The Bladder, also in the lower jiao can be impacted and Bladder qi may become disrupted, resulting in urinary dysfunction.
Qi moves Blood and prolonged impairment of Bladder qi can also lead to Blood stagnation in the lower jiao. This is another common, potentially serious, clinical presentation in prostate disorders. Stones (bladder or kidney) and prostate cancer often present with patterns of disharmony involving blood stagnation.
In addition to chronic qi stagnation, blood stagnation in the prostate may also arise from trauma, surgery, infections, urinary tract stones or as the result of pathogenic factors – the ‘six excesses’, wind, cold, dampness, heat, dryness and fire. In cases of prostate disorders, we are typically looking at heat and, in particular, damp heat.
Damp heat in the lower jiao can be externally contracted, as in the case of infections, or internally generated. Internal damp heat can come from numerous sources (eg. prolonged yin deficiency, heat or damp stagnation) but is often the result of diets high in spicy, fatty foods and alcohol. This creates damp heat in the middle jiao (the digestive organs of Spleen and Stomach) which, as dampness is heavy in nature, then ‘sinks’ to the lower jiao where it may affect the prostate.
In TCM, BPH and CPPS fall in to the following disease categories: lin zheng; painful urination syndrome, niao zhuo; cloudy urination, long bi; difficult urination, yi niao; frequent urination and incontinence, niao xue; haematuria, yang wei; impotence and fu tong; abdominal pain. The predominating symptom determines the category and the accompanying symptoms indicate the specific pattern. (10-15)
(note: ‘frequent’ urination is defined differently between men and women as women have larger bladders than men. Frequent urination may be considered as more than 3 times a day for women and more than 5-6 times a day for men) (14)
Understanding the root
Common underlying TCM patterns for prostate disorders, therefore, include:
Kidney deficiency: Constitutionally weak Kidney energy, aging, prolonged illness, excessive sexual activity, overwork, drug abuse
Liver qi stagnation: Stress, anger, frustration and repressed emotions
Blood stagnation: trauma, surgery, infections, urinary tract stones, chronic qi stagnation, heat or damp heat
Damp heat: Infections, damp and ‘heating’ diet, alcohol, yin deficiency, damp stagnation, heat (10-15)
Signs and symptoms
Benign Prostatic Hyperplasia (BPH):
- frequent or urgent need to urinate
- increased frequency of urination at night (nocturia)
- difficulty starting urination
- weak urine stream or a stream that stops and starts
- dribbling at the end of urination
- inability to completely empty the bladder
- pain during or after urination or ejaculation
Chronic Pelvic Pain Syndrome (CPPS) (chronic non-bacterial prostatitis):
Prostatitis symptoms are defined as chronic if they persist for longer than 3 months.
- perineal and genital pain that can be unrelenting
- possible pain in lower back and rectum
- frequent or urgent need to urinate
- increased nocturia
- difficulty urinating
- pain during or after urination
- pain during ejaculation
- blood in urine
- sexual dysfunction (1,2,4)
Common TCM patterns for BPH/ CPPS:
This provides a general, non-exhaustive, overview of TCM patterns for BPH and CPPS. In clinical practise, there is often an overlap of patterns and not all symptoms listed will be present in all cases. For instance, BPH may not present with any pain.
Heat Patterns
Damp heat (BPH/ CPPS):
- pain: occurs during urination, burning in nature, worse for pressure
- frequency: frequent, urgent
- flow: can feel incomplete
- colour: dark, cloudy (greater opacity indicates more dampness), pink/ red/ purplish red and possible clots where blood is present
- amount: concentrated
- other: smelly
- accompanying symptoms: possible nausea, poor appetite, loose stools, low-grade fever (especially in the afternoon)
- tongue: greasy coat
- pulse: rapid
Heart fire (CPPS): as per damp heat, but the urine is not typically cloudy and is accompanied by significant emotional upset (typically anxiety or worry), often with insomnia and heart palpitations. If there is blood present, the urine will be fresh red in colour. The tongue will be red with a very red tip (in TCM, the tongue tip corresponds to the Heart) and may have ulcers (an expression of the significant heat in the body). Rapid radial pulse.
Liver fire (CPPS): as per Heart fire, but the predominating emotions here are anger, frustration and resentment, with angry outbursts. Symptoms are encouraged by excessive consumption of alcohol and spicy foods. The eyes, governed by the Liver in TCM, may also be red and sore and the tongue sides, rather than the tip, will be red as these areas pertain to the Liver. There may also be a predisposition to rashes in the groin region. Again, the radial pulse will be rapid, but it will also feel ‘wiry’, like a guitar string.
Stagnation Patterns
Liver qi stagnation (BPH/ CPPS):
- pain: occurs during urination, worse for pressure and stress, better after urination, lower abdominal pain and distension
- frequency: frequent, urgent
- flow: difficult, incomplete
- colour: normal
- amount: normal
- accompanying symptoms: chest oppression, frequent sighing, irritability, depression, fatigue (better for exercise)
- tongue: normal or slightly dark
- pulse: wiry
Blood stagnation (BPH/ CPPS):
- pain: occurs during urination, fixed, sharp, stabbing in nature, can be intense, worse for pressure
- flow: difficult, thin stream
- frequency:
- colour: possibly dark, purple (if bleeding present)
- amount: normal
- other: possibly containing small dark blood clots
- accompanying symptoms: spider veins on abdomen/ inner ankle/ knees, dark complexion and lips, darkness under the eyes
- tongue: purple
- pulse: wiry
Deficiency patterns
Kidney yang deficiency (BPH/CPPS):
- flow: difficult, weak, incomplete, broken, dribbling after, incontinence
- frequency: frequent desire to urinate but may be difficulty in starting, nocturia
- colour: clear
- amount: copious or scanty
- other: urge to urinate can be worse when cold
- accompanying symptoms: propensity to feeling cold, oedema (swelling), fatigue, weak low back and knees, possible impotence
- tongue: pale, wet, swollen
- pulse: deep, weak, slow
Kidney yin xu (BPH/ CPPS):
- pain: burning
- flow: incontinence
- frequency: frequent
- colour: yellow
- amount: scanty
- accompanying symptoms: thirst, insomnia, dizziness, night sweats, constipation, weak low back and knees, possible impotence
- tongue: red, dry
- pulse: rapid, thin (11-14)
Herbal solutions
Chinese herbal medicine tends not to use herbs individually but in synergistic formulae. It is important to consult a qualified TCM practitioner as they must be carefully prescribed and modified to match the individual’s presenting symptoms, environment and constitution.
In the case of prostate complaints, particularly those involving signs of blood stagnation or bleeding, referral for screening is important. The use of TCM for prostate cancer should be done alongside conventional medical treatment with qualified practitioners. Additionally, where there is severe infection (damp heat), antibiotics are advised. These will quickly clear the heat and can then be followed by TCM herbs to remove the remaining dampness. Inability to urinate at all is always a medical emergency. (11,12)
TCM herbs for prostate health
Herbs that drain damp heat
hua shi (Talcum): another important herb for this purpose. However, mineral herbs such as talcum are not currently allowed in herbal medicine prescriptions in the UK, so alternatives must be used.
qu mai (Dianthus superbus, aerial parts of fringed pink Dianthus): another bitter, cold herb that clears heat, drains dampness and unblocks painful urinary dysfunction. Especially useful for bloody painful urination and damp heat in the lower jiao.
Herbs that drain fire
zhi zi (Gardenia jasminoides, Gardenia fruit): an especially cold, bitter herb, zhi zi is eminently useful in cases of urinary dysfunction due to excessive heat owing to its ability to strongly clear heat/ damp-heat, cool the blood and stop bleeding.
dan zhu ye (Lophatherum gracile, Lophatherum stem and leaves): similar in function to zhi zi, this herb is especially indicated in cases of scanty, painful urination from damp-heat accompanied by irritability and thirst.
Herbs that stop bleeding
san qi fen (Panax notoginseng, powdered Notoginseng root): Concurrently stops bleeding of all kinds and clears blood stagnation. Hence, it can stop bleeding without creating blood stasis, making it one of the most important haemostatic (stop bleeding) herbs in TCM. It is also very useful for prostate disorders such as CPPS as it reduces swelling and alleviates pain.
zi zhu (Callicarpa pedunculata, Callicarpa leaf): another common haemostatic herb, zi zhu is specifically indicated for blood in the urine.
Herbs that stabilise and bind
shan zhu yu (Cornus officinalis, Chinese dogwood berries): astrong astringent herb and popular choice for the treatment of very frequent urination, spermatorrhea (involuntary ejaculation), nocturia and nocturnal emission (ejaculation during sleep). It is sour, warm, tonifies the Kidneys and “binds up essence” (15 p377) (where semen is seen as an outer manifestation of essence).
wu wei zi (Schisandra chinensis, Schisandra fruit): likewise, “secures below” (16), in cases of Kidney deficiency spermatorrhea and frequent urination. It also calms the shen (mind/ spirit) and is, therefore, useful in cases of frequent urination from yin deficiency with concurrent insomnia and palpitations.
Herbs that tonify the yang
yi zhi ren (Alpinia oxyphylla, black cardamon): a yang tonic with astringent properties indicated for yang deficient urinary symptoms such as frequent, copious urination, incontinence and dribbling of urine.
Herbs that Warm the Interior and Dispel Cold
rou gui (Cinnamomum cassia, Cinnamon bark):a 2013 meta-analysis of clinical trials for TCM herbs used in the treatment of BPH found rou gui was the most frequently used herb in all of the studies. As rou gui is a powerful yang tonic, this reflects the prevalence of yang deficient presentations in cases of BPH. (5) Along with its stimulant and astringent properties, rou gui is also an analgesic and useful in cases of pain deriving from cold.
Herbs that ‘soften hardness’
zhe bei mu (Fritillaria thunbergii, Fritillaria bulb) and xuan shen (Scrophularia ningpoensis, Scrophularia) “soften hardness and disperse swelling” (11 p451) – in this case, the enlarged prostate gland – and are added to formulae addressing the underlying causes of BPH.
Herbs used in cases of prostate cancer
“According to in vitro and in vivo studies, TCM might be beneficial for prostate cancer patients by inhibiting the invasion of cancer cells, inducing apoptosis [cell death; in this case, cancer cells], suppressing prostate cancer-dependent angiogenesis, and down-regulating human androgen receptors.” (7)
ling zhi (Ganoderma lucidum, Reishi mushroom) and huang qin (Radix Scutellariae, Scute) have anti-inflammatory, possible anti-cancer properties and show promise for the treatment of prostate cancer (8,17). The result of a retrospective study of prostate cancer patients in Taiwan – where more than 50% of prostate cancer patients used TCM alongside conventional medicine over a six-year period – suggested that complementary TCM may be associated with reduced risk of death in metastatic prostate cancer patients. (7)
TCM formulas for prostate health
Ba Zheng San (Eight-Herb Powder for Rectification): a very popular eight-herb formula used in cases of damp heat painful urinary dysfunction with urinary difficulty to clear heat and dampness and, thus, ‘rectify’ the lower jiao.
hua shi, qu mai, bian xu (Polygonum aviculare, Polygonum)– clear damp heat, promote urination, zhi zi – drains heat via the urine, da huang (Rheum palmatum, Rhubarb) – drains heat via the stool, deng xin cao (Juncus effuses, Juncus) – an envoy herb to guide heat downwards, gan cao (Glycyrrhiza uralensis, Licorice root) – eases abdominal pain and harmonises the functions of the other herbs.
Dang Gui Bei Mu Ku Shen Wan (Chinese Angelica, Fritillaria and Flavescent Sophora Pill): a classical formula used widely in modern TCM practise for a range of prostate disorders including CPPS, BPH, and prostate cancer. It clears heat, drains dampness, relieves stagnation and nourishes Blood. Experimental studies suggest it may have anti-inflammatory, antibacterial, antioxidative, sex hormone regulating and immunomodulating properties, but more high-quality research is needed. (6)
dang gui (Angelica sinensis radix, Angelica root), zhe bei mu, ku shen (Sophorae Flavescentis Radix, Sophora root) and hua shi
Jin Gui Shen Qi Tang (Kidney Qi Pill from the Golden Cabinet): a popular, well-balanced formula for strengthening the Kidney yin, essence and, in particular, yang used in cases of urinary difficulty, oedema, copious urination and incontinence due to Kidney weakness. Because this formula addresses the underlying cause of the associated urinary problems, and because Kidney energy is not readily replenished, treatment may take some time.
shu di huang (Rehmannia glutinosa, Rehmannia) – tonifies Kidneys, yin and Blood, shan zhu yu, shan yao (Dioscorea opposita, Wild yam) – tonify essence and Blood via supporting the Liver and Spleen, respectively, fu zi (Aconitum carmichaeli, processed Aconite), gui zhi (Cinnamomum cassia, Cinnamon twigs) – warm and revive yang, promote water metabolism, ze xie (Alisma orientale, Alisma tuber), fu ling (Poria cocos, Poria root), mu dan pi (Paeonia suffruticosa, cortex of tree Peony root) – clear heat and damp and regulate the Kidneys, Liver and Spleen.
Qian Lie Xian Wan (Prostate Gland Pills): patent herbal pill taken alongside traditional TCM formulas that address the underlying cause of BPH. Reduces pain, swelling and inflammation of the prostate by clearing damp heat, invigorating qi and Blood and dissipating masses.
dang gui, bai shao (Paeonia lactiflora, white Peony root), huang bai (Phellodendron amurense, Phellodendron bark), ze xie, chai hu (Bupleurum chinense, Bupleurum), huai niu xi (Achyranthes bidentata, Achyranthes root), san leng (Sparganium stoloniferum, Scirpus rhizome), gan cao(11,12,15-19)
(Note: patent TCM pills are not currently allowed in the UK)
Holistic solutions
- As in allopathic medicine, diet and maintaining a healthy weight is very important in the prevention and management of prostate disorders. Limit caffeine, alcohol, fizzy drinks and artificial sweeteners as these can irritate the bladder and worsen urinary symptoms. Avoid spicy, rich, fatty foods in cases of damp heat. A fibre-rich diet can help ease prostate pain exacerbated by constipation.
- Damp heat painful urination – at the onset, drink plenty of water. May also be useful to drink a decoction of chi xiao dou (adzuki beans) boiled for 30 mins. (11)
- Barley water or alfalfa tea – urinary alkalysing agents to reduce discomfort. (11)
- Bladder training (progressively extending periods between voiding) and pelvic floor exercises may be useful for leakage and incontinence
- Nocturia – consume less fluids in the evening
- Liver qi stagnation, Liver fire, Heart fire – counselling or psychotherapy may be necessary to achieve lasting results
- Keep active, particularly in cases of stagnation. Cycling and other activities that put pressure on the groin area may worsen pain.
- Kidney deficiency – avoid sex and masturbation during the early stages of treatment as these can further deplete an already taxed Kidney system and exacerbate symptoms. (This may be contrary to recommendations given to ejaculate more frequently to relieve pressure on the prostate).
- Pain – warm baths, relaxation techniques and using a cushion when sitting may help
- Acupuncture may be beneficial and bring symptomatic relief in cases of
- BPH (20,21)and CPPS (22); “Compared with conventional Western medicine, acupuncture may be more effective in decreasing the total NIH-CPSI score [National Institute of Health – Chronic Prostatitis Score Index], especially in terms of pain relief”. (22) (Note: The NIH-CPSI is a commonly used questionnaire for the assessment of symptom severity in CPPS) (1,11)
References
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- Knott L. Prostatitis: Types, Diagnosis, and Treatment. Updated October 13, 2021. Accessed March 1, 2022. https://patient.info/doctor/prostatitis.
- Prostate Cancer Incidence Statistics. Cancer Research UK. Updated September 20, 2021. Accessed March 1, 2022. https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence.
- Prostate Problems. NIH. Updated March 20, 2016. Accessed March 1, 2022. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems?utm_source=copy&utm_medium=sharing+button&utm_content=%2Fhealth-information%2Furologic-diseases%2Fprostate-problems
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- Li H, Hung A, Yang AWH. A Classic Herbal Formula Danggui Beimu Kushen Wan for Chronic Prostatitis: From Traditional Knowledge to Scientific Exploration. Evid Based Complement Alternat Med. 2018;2018:1612948. Published 2018 Nov 13. doi:10.1155/2018/1612948
- Liu JM, Lin PH, Hsu RJ, et al. Complementary traditional Chinese medicine therapy improves survival in patients with metastatic prostate cancer. Medicine (Baltimore). 2016;95(31):e4475. doi:10.1097/MD.0000000000004475
- Wang X et al. ‘Chinese Medicines in the Treatment of Prostate Cancer: From Formulas to Extracts and Compounds’. Nutrients. 2018;10(3):283. Published 2018 Feb 28. doi:10.3390/nu10030283
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