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R E S E A R C H A R T I C L E Open Access
The role of flower pollen extract in
managing patients affected by chronic
prostatitis/chronic pelvic pain syndrome: a
comprehensive analysis of all published
clinical trials
Tommaso Cai
1*
, Paolo Verze
2
, Roberto La Rocca
2
, Umberto Anceschi
1
, Cosimo De Nunzio
3
and Vincenzo Mirone
2
Abstract
Background: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is still a challenge to manage for all
physicians. We feel that a summary of the current literature and a systematic review to evaluate the therapeutic
efficacy of flower pollen extract would be helpful for physicians who are considering a phytotherapeutic approach
to treating patients with CP/CPPS.
Methods: A comprehensive search of the PubMed and Embase databases up to June 2016 was performed. This
comprehensive analysis included both pre-clinical and clinical trials on the role of flower pollen extract in CP/CPPS
patients. Moreover, a meta-analysis of available randomized controlled trials (RCTs) was performed. The NIH Chronic
Prostatitis Symptom Index (NIH-CPSI) and Quality of Life related questionnaires (QoL) were the most commonly
used tools to evaluate the therapeutic efficacy of pollen extract.
Results: Pre-clinical studies demonstrated the anti-inflammatory and anti-proliferative role of pollen extract. 6
clinical, non-controlled studies including 206 patients, and 4 RCTs including 384 patients were conducted. The
mean response rate in non-controlled studies was 83.6% (62.2%-96.0%). The meta-analysis revealed that flower
pollen extract could significantly improve patients’quality of life [OR 0.52 (0.34-.0.81); p= 0.02]. No significant
adverse events were reported.
Conclusion: Most of these studies presented encouraging results in terms of variations in NIH-CPSI and QoL scores.
These studies suggest that the use of flower pollen extract for the management of CP/CPPS patients is beneficial.
Future publications of robust evidence from additional RCTs and longer-term follow-up would provide more
support encouraging the use of flower pollen extracts for CP/CPPS patients.
Keywords: Chronic pelvic pain syndrome, Inflammatory chronic pelvic pain syndrome, Prostatitis syndrome,
Chronic prostatitis symptom index, Pollen extract
* Correspondence: ktommy@libero.it
1
Department of Urology, Santa Chiara Regional Hospital, Trento, Italy
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Cai et al. BMC Urology (2017) 17:32
DOI 10.1186/s12894-017-0223-5
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Chronic prostatitis has been described as one of the
most common illnesses in men aged <50 year [1] with
differing clinical presentations [2]. According to the clas-
sification of the National Institute of Health (NIH) [3],
class III chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS) is the most frequent category [4]. Symptoms
such as pelvic pain, painful voiding and ejaculation and
disturbed sexual functioning are common, often result-
ing in a significant impact on quality of life [5]. Recently,
it has been established that the annual cost of a patient
affected by prostatitis exceeds that of a patient with type
1 diabetes and that his quality of life is analogous to a
patient with a heart attack or acute Crohn's disease [5].
Available therapies for CP/CPPS are not highly effective
and require further in-depth analysis and consideration
of such alternate strategies [6]. The traditional treatment
of CP/CPPS is known as the “three A’s”: antibiotics, anti-
inflammatory medications, and alpha blockers. The use
of antibiotics remains controversial, especially due to the
fact that bacteria cannot be isolated from the urogenital
samples of CP/CPPS patients [7]. On the other hand,
even if anti-inflammatory medications, aspirin or other
NSAIDs such as ibuprofen can decrease pain, they can
only be taken for a limited period of time due to their
high prevalence of drug-related adverse effects. In other
words, the standard treatment for CP/CPPS has not yet
been definitively established [7]. In this scenario, even if
phytotherapeutics seems to be an interesting option be-
cause of their generally low side effects, demonstrated
efficacy, and high treatment compliance by patients, few
compounds have been subject to scientific scrutiny and
prospective controlled clinical trials [8, 9].
Over the last few years, interest in the use of flower
pollen extract in the management of CP/CPPS has in-
creased. Several clinical experiments show that flower
pollen extract preparations may allow for a durable and
marked symptom reduction in young men with CP/CPPS
with improvement in semen quality and a significant re-
duction in the National Institutes of Health-Chronic Pros-
tatitis Symptom Index (NIH-CPSI) score [10–13]. The
most common pollen extracts used in clinical trials is
Graminex® (Graminex® LLC, 95 Midland Road, Saginaw,
MI 48638) that is a mixture of standardized extracts of rye
grass pollen (Secale cereal), corn pollen (Zea mays), and
timothy pollen (Phleum pretense). However, up to the
present no comprehensive analysis of the current litera-
ture has been made so as to evaluate the tolerability and
clinical efficacy of flower pollen extract in the manage-
ment of patients affected by CP/CPPS.
Aim of the present review
Herein we aim to analyse all published data on flower
pollen extract’s role in the management of patients
affected by CP/CPPS both in a pre-clinical and clinical
setting, with particular attention given to the random-
ized clinical trials. Moreover, we aim to analyse all pub-
lished studies in order to identify all clinical, laboratory
and instrumental characteristics that are able to predict
patients’clinical response to the treatment.
Research questions
We put forth two research queries:
1. Is flower pollen extract able to obtain significant
pre-clinical data in order to justify its clinical use in
the management of patients affected by CP/CPPS?
2. Is flower pollen extract able to improve overall and
disease-specific quality of life of patients affected by
CP/CPPS?
Methods
Types of studies
We have included pre-clinical studies regarding the ef-
fects of flower pollen extracts as a background and nar-
rative review. Moreover, we have included clinical trials,
randomized controlled trials, cohort, and case-control
studies for our systematic review and meta-analysis. Edi-
torials, commentaries, and review articles were used only
for the background and the narrative review.
Outcome measures
The primary outcome of the study was the improvement
of disease-related quality of life in terms of clinical re-
sponse to the treatment as defined by the investigators.
Clinical response to the treatment was generally evalu-
ated in terms of NIH-CPSI and SF-36 questionnaires.
Moreover, the improvement of symptoms [urinary and
sexual symptoms, in terms of the International Prostatic
Symptoms Score (IPSS)] and other questionnaires were
also considered as outcome measures, if used by the
investigators.
Risk of bias assessment
The risk of bias was performed by using the Newcastle-
Ottawa Scale for risk of bias assessment [14].
Search strategy and research methods
We performed a search of literature up to June 2016
using the Medline computerized database of the US
National Library of Medicine. The Google Scholar data-
base was used, too. The Medline search was carried-out
using Medical Subject Headings and free text terms as
follows: ‘pollen extract’,or“flower pollen extract”and
‘prostate’(exploded) were combined with the terms:
‘treatment’and ‘therapy’. Abstracts were not considered
when full articles focusing on the same studies were
available. Due to the limited number of pre-clinical
Cai et al. BMC Urology (2017) 17:32 Page 2 of 8
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studies published, we also included all non-English lan-
guage papers as well. In cases of non-English language
papers, the paper was included if the abstract was
written in English and informative. Overlapping ex-
periments have not been included because they were
considered redundant. We considered as background
information and as a comparative paper the latest re-
view about the role of flower pollen extract in CP/
CPPS patients by Wagenlehner FM published in 2011
[15]. From an initial literature search with pollen ex-
tract and prostatitis, a total of 23 extended papers
were screened and 15 were selected and included in
the present review. Finally, 10 clinical trials and 5
pre-clinical studies were analysed and are discussed in
this review (Fig. 1). The Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) and
Meta-analyses of Observational studies in Epidemi-
ology (MOOSE) guidelines for the reporting of this
present study was used in order to perform an accur-
ate research check-list and report [16, 17]. The meta-
analysis was performed using Review Manager 5.3
(Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014) software. The inverse
variance technique for the meta-analysis of the hazard
ratios has been used. Due to the fact that the studies’
heterogeneity cannot be explained, a random-effects
model has been employed which in fact involves an
assumption that the effects being estimated in the dif-
ferent studies are not identical.
Review methodology
Two authors performed the study selection independently
(TC and PV). All disagreements were resolved by the se-
nior author (VM). Titles and abstracts were used to screen
for initial study inclusion. Full-text review was used where
abstracts were insufficient to determine if the study met
Fig. 1 The figure shows the study flow chart in line with the PRISMA statement (http://www.prisma-statement.org/)
Cai et al. BMC Urology (2017) 17:32 Page 3 of 8
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inclusion or exclusion criteria. Two authors (TC and PV)
independently performed all data abstraction including
evaluation of study characteristics, risk of bias, and out-
come measures with independent verification performed
by the senior author (VM). The limited number of the
studies collected did not require any other authors.
Results
Pre-clinical evidence
Our literature search identified 5 pre-clinical studies
(Table 1). Three “in vitro models”[18–20] and three ani-
mal models [12, 21, 22] were used. All the studies dem-
onstrated/confirmed that pollen extracts show two
important pharmacological effects: anti-inflammatory
and anti-proliferative. Loschen et al. demonstrated that
rye pollen is able to inhibit the synthesis of prostaglan-
din and leukotriene performing an anticongestive and
anti-inflammatory effect on the prostate tissue [20]. An-
other aspect to take into account is the possible effect of
pollen extract on other tissues that differ from those of
prostate glands. In fact, Wagenlehner highlighted an-
other pharmacological effect of pollen extract that
can be considered as a therapeutic mechanism of this
compound: its effect on smooth muscles [15]. In
conformity with Wagenlehner [15], Nagashima
demonstrated in an animal model that consecutive
administration of flower pollen extracts increased
significantly maximum pressure during micturition to
promote micturition reflex [22].
Anti-inflammatory effect
It was concluded that pollen extracts are able to inhibit
prostaglandin and leukotriene synthesis and this effect is
comparable to that of diclofenac and indomethacin and
approximately 10 times higher than that of aspirin [20].
Anti-proliferative effects
Several animal models showed that pollen extract has a
possible effect on the prostate via the androgen metabol-
ism [21]. Talpur and co-workers demonstrated that pollen
extract decreased the size of the prostate in androgen-
induced prostatic enlargement in rats [21]. The effect of
pollen extract on prostate enlargement is due to the fact
that a fraction of this compound is a powerful mitogenic
inhibitor of fibroblastic and epithelial proliferation [15].
Moreover, Kamijo and co-workers found that pollen ex-
tract protects acinar epithelial cells and inhibits stromal
proliferation in association with enhanced apoptosis [12].
Finally, several in vitro studies demonstrated that pollen
extract is able to inhibit prostate cancer cell growth, as
found by Habib [18]. This effect is even more pronounced
in hormone-independent models, suggesting that there
might be a place for pollen extract in the control of abnor-
mal growth of hormone-insensitive cells [18].
Clinical evidence and meta-analysis
We identified 10 clinical studies (Table 2) and selected 6
clinical non randomized trials [10, 11, 23–26] and 4
RCTs [13, 27–29]. All trials demonstrated that pollen ex-
tracts significantly improved total symptoms, pain, and
QoL in patients with inflammatory CP/CPPS without se-
vere side-effects. Cai et al. used Graminex® (Graminex®
LLC, 95 Midland Road, Saginaw, MI 48638) in associ-
ation with B vitamins for the treatment of inflammatory
and non-inflammatory CP/CPPS [11, 27]. Wagenlehner
used Cernilton for the treatment of inflammatory CP/
CPPS [13], while Elist used Prostat/Poltit that contains
Table 1 Summary of all pre-clinical studies
Author, year [reference] Study type Model Compound used Main study finding
Habib FK, 1990 [18] In vitro study Human prostate
cancer cell line
pollen extract - pollen extract is able to inhibit
the prostate cancer cell growth
(hormone-independent model)
Habib FK, 1995 [19] In vitro study Human prostate
cancer cell line (DU145)
pollen extract - pollen extract V-7 fraction is able
to inhibit the prostate cancer cell
growth
Kamijo T, 2001 [12] Animal model Rats pollen extract - pollen extract protects acinar
epithelial cells and inhibits stromal
proliferation in association with
enhanced apoptosis
Loschen G, 1991 [20] In vitro study Microsomes (RBL-1 cells) pollen extract - pollen extract shows an
anti-inflammatory and
anti-proliferative therapeutic effect
Talpur N, 2003 [21] Animal model Rats pollen extract vs serenoa repens - pollen extract is able to influence
prostatic hyperplasia via effects on
androgen metabolism
Nagashima A, 1998 [22] Animal model Rats pollen extract - pollen extract increases the maximum
pressure during urination to promote
the urination reflex
Cai et al. BMC Urology (2017) 17:32 Page 4 of 8
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74 mg of highly defined extract of pollen from selected
Graminae species [28]. Finally, Iwamura used an associ-
ation of Cernitin T60 and Cernitin GBX [29].
Non-RCTs
As reported in Table 2, 6 clinical, non randomized trials
including 206 patients were selected. The mean response
rate in non-controlled studies was 83.6% (62.2%-96.0%).
Cai and co-workers in a non-randomized clinical study re-
ported a clinical response rate of 90%, demonstrating that
pollen extract in association with vitamins significantly
improved total symptoms, pain, and QoL in patients with
non-inflammatory CP/CPPS without severe side effects
[11]. The same results, in terms of clinical efficacy, were
reported by Rugendorff [10] and Buck [23] in two non-
randomized trials which reported a clinical response rate
of 62.2% and 86.6%, respectively. Moreover, three studies
by Japanese researchers demonstrated a high clinical re-
sponse rate to pollen extract treatment in patients with
both class IIIa and class IIIb CP/CPPS [24–26].
Table 2 Summary of all clinical studies
Author, year
[reference]
Study design Patients number
(response rate)
Controls Number
(response rate)
Comparator Outcomes measured
Buck AC. 1989 [23] Prospective trial
(phase II)
15 (86.6) - - - pollen extract effective in the
treatment of chronic prostatitis
and prostatodynia.
Cai T. 2013 [11] Prospective trial
(phase II)
20 (90.0) - - - pollen extract significantly
improved total symptoms, pain,
and QoL in patients with
non-inflammatory CP/CPPS
without severe side effects.
Cai T, 2014 [27] Randomized
controlled trial
41 (75.6) 46 (41.3) ibuprofen - pollen extract significantly
improved quality of life of
patients when compared with
those treated with ibuprofen
(treatment difference in the
NIH-CPSI pain domain,
-2.14 ± 0.51, P < 0.001;
QoL scores, P = 0.002).
Elist J. 2006 [28] Randomized
controlled trial
30 (73.3) 28 (64.2) Placebo - pollen extract is superior to
placebo in providing
symptomatic relief in men
with chronic nonbacterial
prostatitis/chronic pelvic pain
syndrome.
Iwamura H, 2015 [29] Randomized placebo-
controlled trial
50 (78.1) 50 (88.2) Eviprostat
(phytotherapeutic
agent)
- pollen extract significantly
reduced the symptoms of
category III CP/CPPS without
any adverse events, in terms
of NIH-CPSI, IPSS, and QoL.
Jodai A, 1988 [24] Prospective trial
(phase II)
32 (75.0) - - - pollen extract significantly
reduced the symptoms in
75.0% of all treated patients.
Monden K. 2002 [25] Prospective trial
(phase II)
24 (91.6) - - - pollen extract significantly
reduced the symptoms of
chronic prostatitis group
Rugendorff EW. 1993 [10] Prospective trial
(phase II)
90 (62.2) - - - pollen extract significantly
reduced the symptoms of
category III CP/CPPS without
any adverse events, in terms
of urinary symptoms and QoL.
Suzuki T. 1992 [26] Prospective trial
(phase II)
25 (96.0) - - - pollen extract significantly
reduced the symptoms of
prostatitis patients without
any adverse events.
Wagenlehner FM. 2009 [13] Randomized
controlled trial
70 (70.6) 69 (49.3) Placebo - pollen extract significantly
improved total symptoms,
pain, and QoL in patients with
inflammatory CP/CPPS without
severe side-effects.
Cai et al. BMC Urology (2017) 17:32 Page 5 of 8
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RCTs and meta-analysis
The mean response rate in RCTs was 74.4% (70.6%-
78.1%). The latest RCT carried out by Iwamura and co-
workers demonstrated a response rate of 78.1% in 50
patients affected by CP/CPPS after 8 weeks of treatment
[29]. The authors defined the clinical response as a de-
crease in the NIH-CPSI total score by at least 25% [29].
They did not observe severe adverse events in any pa-
tients in their study [29]. On the other hand, Cai and
co-workers, in a cohort of patients randomized to pollen
extract or ibuprofen, reported a response rate of 75.6%
in the flower pollen extract group [27]. Both class IIIa
and class IIIb CP/CPPS patients were enrolled and,
moreover, it was reported that adverse events were less
frequent in the pollen extract group than in the ibupro-
fen group [27]. In the largest study, Wagenlehner and
co-workers demonstrated a clinical response rate of
70.6% [13] in 139 patients affected by inflammatory CP/
CPPS and treated for 12 weeks with flower pollen ex-
tract. They concluded that the beneficial effect continued
to improve after 12 weeks’treatment showing that pollen
extract can be recommended for patients with inflamma-
tory CP-CPPS for long-term treatment [13]. In 2006 Elist,
by carrying out a double-blind study which included 60
patients with class IIIa or class IIIb CP/CPPS who were
treated with flower pollen extract for 6 months, reported
an overall clinical response of 73% [28]. All these 4 RCTs
were used for the/included in our meta-analysis. We in-
cluded 384 patients from 4 studies. The meta-analysis re-
vealed that flower pollen extract could significantly
improve patients’quality of life [OR 0.52 (0.34-.0.81); p=
0.02]. Figure 2 shows the forest plot of the effect of pollen
extract on CP/CPPS patients in terms of clinical response
rate, as defined by the investigators.
Sub-analysis on the basis of CP/CPPS type (class III a or b)
The analysis of the 4 RCT studies did not permit us to
clearly identify which CP/CPPS sub-type was the best
candidate to treat with the pollen extract. In this sense,
the CP/CPPS class type is not able to predict patients’
clinical response to the treatment. Only one out of four
studies enrolled inflammatory CP/CPPS (class A) [13],
while the other three studies enrolled both class III a
and b [27–29]. Cai and co-workers enrolled 25 patients
with inflammatory CP/CPPS (type IIIa) and 62 type IIIb
[27]. They found that in the pollen extract group pa-
tients affected by type IIIb CP/CPPS showed higher QoL
results and a lower pain level following treatment in
terms of the NIH-CPSI score (the NIH-CPSI score was
24.8 ± 1.8 at the enrolment versus 11.7 ± 1.7 at the
follow-up visit; P < 0.001) when compared with type IIIa
CP/CPPS patients [27]. Iwamura and co-workers en-
rolled 20 participents with class IIIa and 19 with class
IIIb, without any reference to the difference between the
two groups [29]. Finally, Elist did not report the results
stratified by the CP/CPPS class [28]. In the two studies
in which in which a data stratification according to class
IIIa or b, 84 class A CP/CPPS and 30 class b had been
treated with pollen extracts, while 80 class A CP/CPPS
and 32 class b were considered as controls. The lack of
data did not allow a significant analysis.
Risk of bias assessment
The 4 RCTs included showed few risk of bias. Three
studies contained both class IIIa and IIIb CP/CPPS pa-
tients, thus introducing the risk of a selection bias.
Moreover, the RCT by Elist showed an important risk of
a selection bias due to the fact that in this study patients
between 20 and 60 years were included.
Discussion
Main findings
Pollen extract is a mixture of natural components, such
as amino acids, carbohydrates, lipids, vitamins, phytos-
terols and minerals that have been introduced in uro-
logical practice for the treatment of CP/CPPS patients
[15]. In this review and meta-analysis of 4 RCTs with
low-to-moderate risk of bias, we found that the use of
flower pollen extracts in the management of CP/CPPS
patients is associated with a high rate of clinical re-
sponse without any significant adverse events. Moreover,
we found that in both class IIIa and class IIIb the use of
pollen extract is able to obtain significant improvements
in a patients’QoL. These findings allow us to discuss
Fig. 2 The figure shows forest plot of the effect of pollen extract on CP/CPPS patients in terms of clinical response rate
Cai et al. BMC Urology (2017) 17:32 Page 6 of 8
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several beneficial aspects of the role of pollen extract in
the management of CP/CPPS patients. Firstly, upon con-
sideration of the high clinical response rate of all in-
cluded papers it was found that the mean response rate
was high in both non-controlled [83.6% (62.2%-96.0%)]
and in RCTs studies [74.4% (70.6%-78.1%)]. In analysing
the reported encouraging results in terms of variations
in NIH-CPSI and QoL scores, the following consider-
ations should be taken into account:
- the proven anti-inflammatory, anti-proliferative effect
of pollen extract
- the low rate of adverse events
All pre-clinical studies demonstrated that pollen ex-
tracts show an important anti-inflammatory effect due
to the inhibition of prostaglandin and leukotriene syn-
thesis [20]. Moreover, the dose-dependent, anti-
inflammatory action of pollen extract in nonbacterial
prostatitis in rats leading to decreased levels of
interleukin-1b, interleukin-6 and a tumour necrosis fac-
tor, decreases glandular inflammation [15] has been
demonstrated. The anti-inflammatory effect of pollen ex-
tract is approximately 10 times higher than that of as-
pirin [20] and did not lead to significant adverse events.
This aspect is very important to highlight, due to the
fact that the low prevalence of adverse effects correlates
with a high patient compliance rate to the treatment.
Moreover, several pre-clinical experiences demonstrated
that flower pollen extract is able to inhibit 5a-reductase
activity in the epithelium and stroma of the prostate in
vitro, inhibiting the formation of dihydrotestosterone
from testosterone [15]. This could be the reason for the
improvements in urinary symptoms reported by the pa-
tients. However, the inhibition of 5a-reductase activity
requires a long-term treatment as highlighted by several
authors [15]. Even if a placebo effect was generally re-
ported in patients treated with phytotherapeutic agents,
in the 4 RCTs, clinically significant improvements were
only observed in the pollen extract group and not in the
placebo group. Finally, while Wagenlehner and co-
workers found a decrease in leukocytes in post-prostate
massage urine samples in both patients and controls
[13], they did not find a significant difference between
the two groups in terms of leukocyte number and for
this reason leukocytes cannot be correlated with clinical
success [13]. This aspect supports the hypothesis that
the presence of inflammatory cells in the post-prostate
massage urine sample is not a laboratory characteristic
that is able to predict treatment response.
Strengths and limitations of the present study
In this review we excluded all studies on the effect of
pollen extract on patients affected by benign prostatic
hyperplasia or other urological diseases that can deter-
mine symptoms. Moreover, we excluded all studies in
which the dosage of the compound was indicated in the
publication. For this reason, despite the latest review by
Wagenlehner we have excluded the paper by Li [30]. On
the other hand, the most important limitation of this re-
view is the lack of a pharmacokinetic evaluation of
pollen extract. As highlighted by Wagenlehner, pharma-
cokinetic studies on the absorption, distribution, metab-
olism or excretion of the active components of flower
pollen extracts have not been performed [15]. This is
due to the fact that it is not known which compounds
are primarily responsible for clinical efficacy [15].
Clinical implications
It is well known that there is no standard treatment or
CP/CPPS to date. Amongst all the drugs and therapeutic
approaches suggested and used, phytotherapeutic agents
are those most widely prescribed in every day clinical
practice with variable success. However, their use has
only rarely been evaluated in suitable clinical trials. On
the other hand, pollen extract has been sufficiently eval-
uated in preclinical and clinical studies [10, 13, 15].
Herein, we report encouraging results in terms of varia-
tions in NIH-CPSI and QoL scores in patients treated
with pollen extracts indicating that the use of pollen ex-
tract appears to be safe and well tolerated by patients
and, for this reason, the compliance to the treatment is
high.
Conclusion
In conclusion, based upon our study analysis, pollen ex-
tracts appear to be clinically beneficial as indicated by
the significant improvements in terms of the NIH-CPSI
and QoL scores of patients diagnosed with CP/CPPS.
Moreover, this therapeutic approach has an excellent
safety profile with limited reported adverse effects. Fu-
ture publications containing robust evidence from add-
itional RCTs and longer-term follow-up would provide
doctors with more confidence regarding the use of
flower pollen extracts for their CP/CPPS patients.
Abbreviations
CP/CPPS: Chronic prostatitis/chronic pelvic pain syndrome; IPSS: International
prostatic symptoms score; NIH: National institutes of health; NIH-
CPSI: National institutes of health-chronic prostatitis symptom index;
NSAIDs: Non-steroidal anti-inflammatory drugs; QoL: Quality of life;
RCTs: Randomized clinical trials; SF-36: The short form (36) health survey
Acknowledgements
We are grateful to Juliet Ippolito for manuscript language revision.
Funding
None.
Availability of data and materials
Not applicable.
Cai et al. BMC Urology (2017) 17:32 Page 7 of 8
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Authors’contributions
Study conception and design: CT, MV. Acquisition, analysis and interpretation
of data: CT, AU, LRR, VP. Drafting of manuscript: Cai T. Critical revision and
supervisions: DNC, MV. All authors read and approved the final manuscript.
Competing interests
Tommaso Cai, Paolo Verze and Vincenzo Mirone are consultant for and have
received research support from IDIpharma.
Consent for publication
Not applicable.
Ethics approval and consent to participate
Not applicable.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Department of Urology, Santa Chiara Regional Hospital, Trento, Italy.
2
Department of Urology, University of Naples, Federico II, Naples, Italy.
3
Department of Urology, Ospedale Sant’Andrea, Sapienza University of Rome,
Rome, Italy.
Received: 25 February 2017 Accepted: 16 April 2017
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