Chinese Herbal Formulas for Prostate Health By Jake Schmalzriedt, DOM

The prostate gland is part of the male reproductive system. It is (finasteride and dutasteride), alpha blockers, and surgery. approximately the size of a walnut that surrounds the urethra, just below the urinary bladder. The main function of the prostate Prostate Cancer is to secrete prostatic fluid during ejaculation to provide better Prostate cancer is a malignant tumor that begins development sperm motility and protection for the sperm during ejaculation. in the prostate gland. This is often a slow growth tumor. Prostate cancer is the most common cancer affecting older Disorders that Affect the Prostate men. According to the American Cancer Society, in 2014, there The principle and most common disorders that affect the will be an estimated 233,000 new cases of prostate cancer, and prostate include: prostatitis, benign prostate hypertrophy (BPH), 29,480 deaths due to prostate cancer. For a sense of perspective, and prostate cancer. in 2014, breast cancer will have an estimated 235,030 new cases, and 40,430 deaths. There are usually no signs and Prostatitis symptoms of early prostate cancer. As the disease progresses, Prostatitis is characterized as swelling and inflammation of the the signs and symptoms may include: difficult urination, prostate gland. This inflammation puts pressure on the urethra, frequent urination, difficulty starting and stopping urination, decreasing the bladder’s ability to empty. The main types of weak flow, painful urination, and blood in urine. Advanced prostatitis include acute prostatitis, chronic bacterial prostatitis, prostate cancer often metastasizes to and chronic non-bacterial prostatitis. other areas of the body, especially the The first two are relatively uncommon bones and the lymph nodes. Prostate and are usually caused by bacterial cancer risk factors include: family infections mimicking the signs and history, increasing age (with 97% symptoms of a urinary tract infection. of cases diagnosed at age 50 and Western medical treatment usually older), and African ancestry. African- consists of a course of antibiotics. Americans are more than twice as The most common form of prostatitis likely to develop prostate cancer and is chronic non-bacterial prostatitis, are more likely to die from it than also known as chronic pelvic pain whites. Prostate cancer is identified syndrome. This makes up roughly by signs and symptoms, a physical 90% of all prostatitis cases. Chronic rectal exam, prostate specific antigen non-bacterial prostatitis often occurs (PSA), urinalysis Engrailed-2 (EN2), in younger men, with the average and biopsy. Testing for early prostate age around 30. The main and distinguishing symptom is cancer is recommended for men starting at age 50. Men with painful urination. Other symptoms commonly present may high risk factors should start as early as age 40. Western medical include difficult urination, pelvic pain, low back pain, pain treatment options for prostate cancer consist of chemotherapy, upon ejaculation, perineum and testicular pain, fatigue, and hormone therapy, radiation, and surgery. flu-like symptoms. There are a variety of different western treatment options including physical therapy and lifestyle The Prostate and Oriental Medicine changes, western medications like alpha blockers, non-steroidal There is no specific reference to the prostate gland in any of the anti-inflammatory drugs (NSAID’s), antibiotics, and surgery. classic texts. In the Ling Shu (The Spiritual Pivot) the term bao Chronic bacterial prostatitis and chronic non-bacterial prostatitis is used to refer to a structure in the lower abdomen. In women it share similar signs and symptoms. The difference in diagnosis is the uterus, in men it is considered the “room of jing” and it is between these two conditions is whether or not bacterial assumed that this structure is the prostate. infection is present. The prostate has all the characteristics of an extraordinary Benign Prostate Hyperplasia organ. Extraordinary organs are defined as being hollow similar Prostate gland enlargement, also known as benign prostatic to fu organs, storing jing similar to zang organs, and while not hyperplasia (BPH) or prostatic hypertrophy, is common in a specific characteristic of extraordinary organs, there is often older men and increases in occurrence with age. Prostate gland a strong connection with the kidney. The prostate has the yin growth occurs throughout life. This growth puts pressure on the characteristic of storing jing. The prostate produces and stores urethra and bladder, inhibiting or blocking urine flow. Voiding prostatic fluid which is part of the male reproduction system. issues become the chief complaint, with signs and symptoms Semen is considered a manifestation of jing, but is not the consisting of frequent and urgent urination, difficulty starting only aspect of the male reproductive system that should be urination, weak urine stream, dribbling, and painful urination. considered jing, the prostate and seminal vesicle should be as Diagnosis is done by digital rectal exam, PSA test to rule out well. The organ is hollow and yang in nature, and the prostate cancer, urinalysis, post-void residual urine test, urine flow has a close connection with the kidney. Additionally it is analysis, and cystoscopy. Western medical treatment consists considered the room of jing (bao), the male equivalent of the of lifestyle changes, western medications like androgens uterus, which is an extraordinary organ. The prostate produces

©Herbal Medicine Press, 2014 2 Chinese Herbal Formulas for Prostate Health prostatic fluid that is both yin and yang in nature, which Primary organ involvements for prostate disorders include: nourishes the semen (yin) and it protects semen (yang). In the urinary bladder with its direct relation, the kidney with Chinese medicine, disease categorization of prostate issues its ability to regulate qi and govern water metabolism, the is defined by the main symptom. It usually falls under these spleen with its transportation and transformation function, categories: painful urination (niao tong), obstructed urination and the liver with its ability to regulate the flow of qi. There (xiao bian bu tong or long bi), and difficult urination (xiao are three main mechanisms that affect the prostate: (1) spleen bian bu li). It may also be characterized as a lin (painful and kidney deficiency; (2) lower burner damp-heat; and (3) urination) syndrome—especially if the key symptoms are qi, blood, and phlegm stagnation. The spleen and kidney more irritative in nature—with symptoms like urinary deficiency is often a qi or yang deficiency, but can present as urgency or frequency. a kidney yin deficiency as well. This is seen as the inability to properly move qi and discharge urine due to lack of force Key Symptoms Definition and Differentiation and/or the inability to upbear and contain urine within the Painful urination Pain is the chief and main complaint; bladder resulting in leakage, dribbling, and incontinence. niao tong however signs and symptoms from other Damp-heat pours down and collects in the lower burner. This categories are often present. damp-heat obstructs qi movement, causing urinary frequency, Obstructed urination Impeded passage resulting in difficulty pain, burning, and urgency. Qi stagnation, blood stasis, and xiao bian bu tong or expelling urine, manifesting as dribbling phlegm accumulation—or a combination of the three—cause long bi urine, blocked urine flow, weak stream, or bladder obstruction, exacerbating voiding issues. urinary hesitancy. The bladder is full, but Common Oriental Medicine Patterns and Formulas unable to be emptied. Pain may be present, but obstruction is the chief complaint. This OM diagnosis, tongue, and pulse of patients with prostate is also termed dribbling urinary block. issues vary greatly. Thus, it is important to follow the presenting pattern when treating prostate issues. It is also rare Difficult urination Urine is difficult to expel but urination is xiao bian bu li not necessarily painful; there is reduced that presentation will fall under just one category. Usually volume, often accompanied by edema. it is a combination of multiple patterns simultaneously. The principle patterns include: Painful urination Characterized by urinary urgency, frequent syndrome urination, and painful urination. This is also Lower Burner Damp-Heat lin zheng termed urinary strangury. Painful urination Lower burner damp-heat is almost always involved. It is is broken down into several subcategories the primary pattern for bacterial prostatitis, but is usually in Chinese medicine. The predominant present in chronic prostatitis and BPH as well. Damp-heat subcategories when dealing with pros- usually arises from an improper diet (overconsumption of tate issues are: heat strangury (re lin), qi fatty greasy foods, alcohol, coffee, and sugar), or due to strangury (qi lin), and taxation strangury an external pathogenic invasion. The damp-heat inhibits (lao lin). qi transformation in the lower burner and presents with •Re lin or heat lin manifests as lower signs and symptoms that include frequent urgent urination, burner damp-heat: dark yellow, cloudy burning pain upon urination, scanty turbid, dark yellow urine, urine, frequent urination, burning sensa- dribbling urination, low back pain, rapid slippery pulse, and tion, pain with urination, strong odor a red tongue with a sticky, yellow coat at the root. Formulas • Qi lin is further subdivided into excess to look at for this pattern are Polyporus and Dianthus and deficient conditions: Formula (Zhu Ling Qu Mai Tang) or Dianthus Formula (Ba Zheng San, KPC 0080A). If there is more liver involvement, ~Qi stagnation lin manifests as difficult with indications like bitter taste, fullness in the chest and urination, dribbling, urgency, with low hypochondrium, and irritability, Gentiana Drain Fire abdominal pressure pain upon voiding, and is usually due to a liver qi stagna- Formula (Long Dan Xie Gan Tang) may be a better choice. tion Lower burner damp-heat often presents in conjunction with qi and blood stagnation in chronic conditions. ~Qi deficientlin manifests as difficult urination, dribbling, weak stream, Qi Stagnation heavy sensation in the lower abdomen, The liver’s inability to freely course the qi is responsible pain that usually comes after voiding, for qi stagnation. This stagnation is primarily due to and is usually due to a spleen and kid- prologned emotional states like depression, irritability, or ney qi deficiency. anger, but also can be due to damp-heat invasion that turns • Lao lin or taxation lin manifests as dif- chronic, or to other conditions like traumas, surgeries, ficult urination, dribbling, occuring with poor diet, drugs, and western pharmaceuticals. Signs and fatigue symptoms of liver qi stagnation pertinent to prostate issues are obstructed urination, dribbling, urinary hesitancy, low abdominal distention or discomfort, and a wiry pulse. The Chinese Herbal Formulas for Prostate Health 3 signs and symptoms will be worse with emotional stress or Transforming Formula (Xia Ku Hua Tan Pian) treats instability. Formulas to consider for treating qi stagnation are phlegm accumulation, along with qi stagnation and blood Bupleurum and Tang Kuei Formula (Xiao Yao San) or Free stasis. and Easy Wanderer Plus Formula (Jia Wei Xiao Yao San). Spleen Qi Deficiency Blood Stasis Spleen qi deficiency is a pattern that is usually present in One current school of thought holds that the enlargement of some form, though it is often not the primary pattern. Spleen the prostate is always due to blood stasis, though the stasis deficiency is due to a poor diet, excessive work or mental may be accompanied with numerous other presentations activity, over-worrying, or chronic illness, which inhibit the like yang deficiency, qi deficiency, phlegm accumulation, transportation and transformation functions of the spleen or damp-heat. This idea defines the enlarged prostate as an and over time, cause stagnation and damp-heat in the lower accumulation with a fixed location and as such, falls under the burner. Signs and symptoms of spleen deficiency include categorization of blood stasis. This blood stasis is confirmed fatigue, diarrhea or loose stools, cold abdomen, lack of upon digital examination of the hard prostate. Blood stasis appetite, pale tongue with thin, white coat, and a weak or manifests as partially or completely obstructed urinary flow, empty pulse. thin stream, dribbling, lower abdominal pain, a choppy, Kidney Deficiency deep pulse; and the tongue will be purple or dusky with When looking at prostate issues, kidney deficiency is a very engorged, sublingual veins. Formulas that can be effective common pattern diagnosis. Aging is a primary cause of for blood stasis in the lower burner are Cinnamon and prostate problems due to the decline of kidney function. The Poria Formula (Gui Zhi Fu Ling Wan), a classical formula deficiency can present as kidney qi, kidney yang, or kidney to move and transform blood stasis in the lower burner. yin deficiency. Stasis-Transforming Formula (Dan Shen Hua Yu Pian) is a modern formula that also focuses on moving blood in the Kidney qi or yang deficiency may be due to chronic illness, lower burner. Another classical formula that addresses blood aging, inherited deficiencies, excessive sexual activity, or stasis in the lower burner is Fennel Seed and Corydalis over-exposure to cold. Signs and symptoms can present Combination (Shao Fu Zhu Yu Tang, KPC 0750). This as frequent, urgent urination, incontinence, nocturia, clear formula is best if there is cold in the lower burner as well as urine, dribbling urine, weak, forceless stream, weak pulse, a stasis. As most prostate issues occur in older populations it is sinking or down-bearing sensation around the perineum, and important to monitor and be careful not to damage the upright a pale, swollen tongue with a thin, white coat. Low back pain, qi when using blood movers. cold and pain in the lower abdomen, fatigue, diarrhea, and edema may also be present. Essential Yang Formula (Jia Another school of thought that I am including under this Jian Jin Gui Shen Qi Wan) is a modification of the classical title is the idea of stasis of jing. It is included here because Rehmannia Eight Formula (Jin Gui Shen Qi Wan) for urinary clinically these two patterns (blood stasis and jing stasis) difficulties due to kidney yang deficiency, and is the basis or are difficult to distinguish. As described above, the term bao starting point for many prostate formulations. If you work refers to the room of jing and is associated with the structure with granules, a common addition to Jin Gui Shen Qi Wan is in the lower abdomen that is thought to be the prostate. Jing Achyranthes Root (niu xi) with Asian Plantain Seed (che qian emerges from the lower abdomen, specifically the bao, and is zi). Spleen and kidney yang deficiency are often seen together circulated throughout the body via the sanjiao. As one ages, in many chronic prostate cases and are often the underlying the kidneys become deficient and unable to push the jing root cause. Sea of Qi Formula (Qi Hai Yao Fang) is an up into the sanjiao for circulation. This causes a congealing excellent formula to treat spleen and kidney yang deficiency. or stasis of jing in the lower abdomen. Thus, the prostate, being part of the male reproductive system can considered Kidney yin deficiency often arises due to overwork, high jing, and the enlargement and hardening of the prostate can stress, febrile disease, poor sleep, excessive sexual activity, be considered stasis of jing. The signs and symptoms of or drugs. Signs and symptoms of kidney yin deficiency jing stasis mimic that of blood stasis—presenting as sharp, are frequent, scanty urination, yellow urine, nocturia, stabbing pain in the low back, low abdomen, and testicles, dribbling urine, thin stream, urinary difficulties worse with urinary difficulty and obstructed flow—and the treatment with overstraining, thin, rapid pulse, red, peeled tongue— for these two patterns is similar. accompanied by general yin deficient signs and symptoms like five palm heat, malar flush, tidal fever, insomnia, Phlegm Accumulation restlessness, and night sweats. Formulas to consider are: Phlegm accumulation is often due to an impairment of Rehmannia Six Formula (Liu Wei Di Huang Wan) or True fluid metabolism, which is the result of the spleen and Yin Formula (Zou Gui Jia Er Zhi Wan). If accompanied kidney’s inability to regulate fluid metabolism. The urinary by deficientcy heat, use Rehmannia and Scrophularia difficulties will present similar to that of blood stasis with Formula (Zhi Bai Di Huang Wan). This condition is obstructed flow. Phlegm accumulation will often manifest commonly seen in conjunction with spleen qi deficiency, simultaneously with qi stagnation and/or blood stasis. Phlegm 4 Chinese Herbal Formulas for Prostate Health and may be combined with an appropriate qi tonic like Six elevated PSA levels and prostate cancer, combine this formula Gentlemen Formula (Liu Jun Zi Tang). with Five Mushroom Formula (Wu Gu Fang) or Astragalus and Ligustrum Formula (Huang Qi Dong Qing Pian) to Two Modern Formulas for Complex Patterns stimulate and support immune system function. As previously mentioned, it is rare to find someone dealing with prostate issues who falls under a single pattern. Usually it Treatment Course is some combination of spleen qi deficiency, kidney deficiency, Herbal treatments for acute prostatitis or exasperations of qi stagnation, blood stasis, and phlegm accumulation. The chronic conditions usually resolve quickly, within one to two following two formulas were developed to address several weeks, with symptom relief after a couple of days. Herbal of the common patterns that often present together in the treatments for chronic prostatitis and BPH usually last from modern clinic: Prostate Formula (Qiang Lie Xian Fang) and two to six months, with the reduction of physical signs and Rabdosia Prostate Formula (Dong Ling Cao Fang). symptom usually coming after the first month. For patterns that present as kidney yang deficiency with References damp accumulation use Prostate Formula (Qiang Lie Xian Bensky, Dan, with Clavey, Steven and Stöger, Erich, Chinese Medicine Materia Medica, 3rd Edition, Eastland Press, 2004. Fang). This formula supplements the spleen and kidney yang, drains damp, and lightly moves blood. The formula takes a Chen, John K. and Chen Tina T. Chinese Medical Herbology and modification of Tokoro Combination (Bie Xie Fen Qing Yin, Pharmacology, City of Industry, CA, Art of Medicine Press, 2004. KPC 3320), a classical formula to drain dampness from the Chen, John K. and Chen Tina T. Chinese Herbal Formulas and lower burner, often due to yang deficiency, and adds to it the Applications, City of Industry, CA, Art of Medicine Press, 2009. chief herbs Chinese cuscuta seed (tu si zi) and ephemerantha Clavey, Steven, Fluid Physiology and Pathology in Traditional (yin yang huo) to supplement the kidney yang; codonopsis Chinese Medicine, Churchill Livingstone, 2003. root (dang shen) to tonify the spleen; and angelica sinensis Dharmananda, Subhuti, “Herbal Therapy for Benign Prostatic root (dang gui) to nourish and invigorate blood. The formula Hypertrophy,” Internet Journal of the Institute for Traditional also contains saw palmetto berry to benefit the prostate, reduce Medicine and Preventative Health Care, May 2002. inflammation, and to help guide the formula to the prostate. Ellis, Andrew, Notes From South Mountain: A Guide to Concentrated Indications for this formula include frequent urination, urgent herb granules, Berkeley, CA, New Moon Publishing, 2003. urination, dribbling urination, difficulty starting and stopping, Flaws, Bob and Sionneau, Philippe, The Treatment of Modern incontinence, nocturia, thin weak stream, a downbearing Western Medical Diseases with Chinese Medicine, Blue Poppy Press, sensation on the perineum or throbbing prostate, loss of libido, 2011. erectile dysfunction, and low back pain. Maciocia, Giovanni, “The Treatment of Male Problems in Chinese Medicine,” Maciociaonline.blogspot.com, June 2013. Rabdosia Prostate Formula (Dong Ling Cao Fang) treats prostate issues manifesting as damp-heat, blood stasis, Maclean, Will, and Lyttleton, Jane, Clinical Handbook of Internal Medicine: Vol 1-3, University of Western Sydney, 1998. and toxin accumulation in the lower burner. This formula was specifically designed to address and lower prostate MacPherson, Hugh, “The Treatment of Prostate Disorders,” Journal specific antigen (PSA) levels. PSA is a protein found in the of Chinese Medicine, January 1993. blood serum. Elevated PSA levels can be an indicator of Scott, John, Monda, Lorena, Heuertz, John. Clinical Guide to prostate cancer and PSA levels are often used to monitor the Commonly Used Chinese Herbal Formulas, 5th Edition, Placitas, progression of prostate cancer. A guideline for normal PSA NM, Herbal Medicine Press, 2009. levels are: 2.5ng/mL for men aged 40-49, 3.5ng/mL for men Volker, Scheid, with Bensky, Dan, Ellis Andrew, and Barolet, aged 50-59, 5.0ng/mL for men aged 60-69, and 6.5ng/mL Randall, Chinese Herbal Medicine: Formulas and Strategies, 2nd for men aged 70-79. There has been a lot of modern research Edition, Eastland Press, 2009. on rabdosia (dong ling cao), the chief herb in Rabdosia Wiseman, Nigel and Ye, Feng, A Practical Dictionary of Chinese Prostate Formula (Dong Ling Cao Fang), and its ability to Medicine, Paradigm Publications, Brookline MA, 1998. inhibit cancer cell growth and increase apoptosis of cancer cells. Modern research has also shown that hedyotis (bai hua she she cao), isatis leaf (da qing ye), scutellaria barbata (ban zhi lian), tree peony root bark (mu dan pi), paris rhizome (chong lou), Chinese licorice root (gan cao), zedoary rhizome (e zhu), ganoderma (ling zhi), and saw palmetto berry have anti-cancer and anti-tumor properties as well. While not the original intention, this formula has been shown to be clinically effective, and is currently more commonly prescribed by practitioners addressing other prostate issue like prostatitis and BPH. Rabdosia Prostate Formula (Dong Ling Cao Fang) can be effectively combined with other formulas to treat the constitutional pattern, but is often prescribed by itself. For