EVERYTHING YOU EVER WANTED TO KNOW ABOUT CHRONIC PROSTATITIS
“A CRITICAL UPDATE ON PROSTATITIS AS A CAUSE OF PROSTATE CANCER”
NIH Classification of Prostatitis
THE CLINICAL PRESENTATION
SIGNS & SYMPTOMS ASSOCIATED WITH CHRONIC PROSTATITIS
THE ETIOLOGY (CAUSE) OF PROSTATITIS
CHRONIC NON-BACTERIAL PROSTATITIS OPTIONS
PROSTATE SPECIFIC ANTIGEN (PSA) AND PROSTATITIS
THE LINK BETWEEN CHRONIC PROSTATITIS AND PROSTATE CANCER
THE PROSTATE BIOPSY REVOLVING DOOR
“NATURAL THERAPIES” FOR PROSTATE DISEASE
Why Peenuts® Qualifies to Be Your Prostate Nutritional Formula
Herbal Prostate Nutrition & Health
With patents in numerous countries, Peenuts continues to deliver results. Introduced in 1997, Peenuts, a synergistic blend of Anti-inflammatories, Immune-Boosters, Herbs, Vitamins, Minerals & Anti-Oxidants, was intended for men with Prostatitis. In a randomized, double blind, placebo controlled study performed in 1997, Peenuts® demonstrated improved ability to decrease the signs and symptoms associated with an enlarged prostate or prostatitis. MORE INFO -->
Chronic prostatitis (inflammation or infection of the prostate) is common to virtually all adult men. Not surprisingly, Prostatitis is associated with virtually all cases of prostate cancer and present in nearly every prostate biopsy, regardless of other findings. (FN) According to Drs. Krieger and Berger, Urologists at the University of Washington, in Seattle, “All men either have prostatitis or will get prostatitis in their lifetime.” Prostatitis has received some unexpected, but welcomed, publicity with the movie, “The Green Mile”, starring Tom Hanks as the Prison Warden as well as the revelation that the now deposed former leader from Iraq, Saddam Hussein had an attack of prostatitis while incarcerated. Interestingly, and notwithstanding the above comment, prostatitis has been termed the “trucker’s disease”, based on the fact that truck drivers sit on their backsides, (better stated, prostates), all day, while driving a truck. While I can’t change the historical reference, truckers manifest the signs and symptoms of prostatitis by virtue of sitting all day long, driving mile after mile. The sitting position does not create the disease, but rather allows the disease to be readily identified clinically. Just for the record, all men are equally likely to contract prostatitis regardless of job description.
Chronic prostatitis may not cause significant symptoms in many men, but in others it can be a devastating disease that severely affects the quality of life of those afflicted. For many Professionals, prostatitis is difficult to diagnose and even more difficult to treat. A wide variety of therapies are available but few actually work in more than a small percentage of cases. While none of the standard treatments available is able to improve the health and wellness of the prostate long-term, a proven approach, with a patented formula, may be your best first step. We'll review the current knowledge about chronic prostatitis, your treatment options, and the science linking an inflammatory disease to prostate cancer.
All men are born with a prostate that grows and enlarges throughout life based on various forms of stimuli. The prostate gland (in health) is a spongy, walnut sized, mucus-producing organ that lies just below the urinary bladder and superior to the rectal wall. The prostate surrounds the urethra, a channel through the prostate, which carries urine from the bladder to the outside. The most significant growth of the prostate, associated with an increase in the number of cells (hyperplasia), begins in the early to mid 40s and is believed to be related to Dihydrotestosterone production. Inflammation or growth of the prostate commonly causes difficulties in urination that should be addressed at the earliest sign. The only known function of the prostate is to produce a secretion that nourishes and protects the sperm during reproduction. It has no other known purpose.
Prostatitis is defined as inflammation or infection of the prostate. Simplistically, prostatitis can be divided into two groups; bacterial and non-bacterial. Bacterial may be divided into acute and chronic while non-bacterial prostatitis is generally recognized as chronic. The National Institute of Health developed and accepted the latest definition of prostatitis primarily guided by the presence of chronic pelvic pain associated with the more traditional acute and chronic clinical presentation. While I refer you to the formal paradigm presented by the NIH for a complete understanding, the most common presentation is Type IIIA or non-bacterial, inflammatory prostatitis. While prostatitis may be acute, (associated with systemic findings of fever, chills and rigors (shakes), most cases of prostatitis are chronic and tend to be incurable, with relatively frequent recurrences despite optimal traditional treatment. Unfortunately, traditional therapy involves the use of antibiotics, which are effective in less than 5% of cases, as a remedy for non-bacterial prostatitis, although, antibiotics may improve symptoms temporarily secondary to an anti-inflammatory mechanism.
I. Acute bacterial prostatitis: acute infection of the prostate
II. Chronic bacterial prostatitis; recurrent infection
III. Chronic abacterial prostatitis; chronic pelvic pain syndrome (CPPS) – no demonstrable infection
IIIA. Inflammatory CPPS: WBCs in semen/EPS/voided bladder urine (VB3)
IIIB. Non-inflammatory CPPS: no WBCs in semen/EPS/VB3s
IV. Asymptomatic inflammatory prostatitis: no subjective symptoms; detected either by prostate biopsy or presence of WBCs in prostatic secretions during evaluation for other disorders
THE CLINICAL PRESENTATION:
Symptoms of prostatitis (also common to EP or enlarged prostate) are the number one reason that men seek the advice of their primary care physician or Urologist. The most significant symptom of chronic prostatitis is pelvic pain, followed by various voiding symptoms, impotence and/or infertility. Referred pain from prostatitis is commonly located in the groin, testicles, lower back, penis, circumferentially around the rectum, the perineum and/or in the suprapubic area above the bladder. Additionally, pain is not uncommonly associated with ejaculation. Typical urinary symptoms produced by prostatitis include getting up at night to void (Nocturia), frequency of urination, urgency of urination, incomplete voiding, decreased force of the urinary stream, intermittency of the stream and a need to push or strain to void.
SIGNS & SYMPTOMS ASSOCIATED WITH CHRONIC PROSTATITIS:
Perineal Discomfort/Pain Inguinal Discomfort/Pain Lethargy
Penile Discomfort/Pain Ejaculatory Discomfort/Pain Epididymal/Testicular Swelling
Burning on Urination Hematuria (Microscopic) Scrotal Discomfort/Pain (Including testicular)
Blood in the ejaculate Voiding Symptoms Dysuria (Pain/Stinging on Urination)
PSA ≥ 1 Irritability Decreased Sexual Performance/Impotency
Depression Hematuria (Gross)
Prostatitis is a troubling disease that remains a health risk to most of the adult male population for far longer than is necessary. Frequently, men don’t realize they have prostatitis, requiring a Prostate Specific Antigen (PSA) blood test to be performed to prove it. A PSA of ≥ 1 ng/ml indicates prostatitis, based on research presented at the NIH in 2000. Historically, men under 50 years old, with voiding symptoms or pelvic pain, had prostatitis until proven otherwise. Men over 50 years old, with the same symptoms, were assumed to have had an enlarged prostate (EP). A study presented at the NIH in 1999 has shown that most men with voiding symptoms, regardless of age, actually had prostatitis when properly tested. In a trial of 235 consecutive men who exhibited even mild voiding symptoms, greater than 80% were found to have chronic prostatitis, regardless of their age based on an evaluation of the expressed prostatic secretion (EPS).
Prostatitis has been termed "the waste basket of clinical ignorance" by prominent Stanford University Urologist Dr. Thomas Stamey because of the difficulty it presents in diagnosis and treatment. Prostatitis is usually identified or suggested by the symptoms it produces and the findings of a sore or tender prostate when a digital rectal examination is performed. Prostate Specific Antigen (PSA), a blood test designed to identify patients at risk for prostate cancer, will also be increased in most cases of prostatitis. The presence of a specific urinary tract infection, together with pelvic pain, fever, chills, rigors, voiding symptoms and a sore or tender prostate on rectal examination, will identify the 5% of patients with acute bacterial prostatitis, a true infection. Chronic bacterial prostatitis is also quite uncommon, but devoid of the acute symptoms including fever. While it would not be surprising to identify men with chronic prostatitis who have no symptoms at all, the PSA provides a virtual 100% sensitivity to predict the diagnosis when the PSA number is ≥ 1.0 ng/ml.
While obtaining an EPS requires some knowledge and skill on the part of the Care provider, for the most part the frequency of performing this procedure is critical to the ability to obtain representative results for the condition for which you seek assistance. In other words, do not expect a Urologist or Primary Care Physician to perform this test with any degree of accuracy or skill if they rarely perform it. If you have concerns about prostatitis, you must go to a physician who is understands the importance of the EPS and understands how to get the specimen to be evaluated. Unfortunately, most Urologists do not understand the disease or the diagnostic principles with significant clarity to assist you. When patients ask me how to find a doctor who performs the EPS procedure, I suggest they call the office and ask if the doctor(s) perform the test. If the receptionist hesitates with the response, they likely do not. The prostatic secretion (fluid) is obtained by gentle to moderate massage of the prostate during the digital rectal examination (DRE). When the secretion is examined under the microscope, a finding of ≥ 10 white blood cells per microscopic field (400X) is considered definitive proof of inflammation or prostatitis. Additionally, a histological examination of a prostate biopsy (a tissue sample) can also show definitive signs of inflammation and diagnose prostatitis. Unfortunately, inflammation tends to be under diagnosed when prostate biopsy specimens are reviewed by the Pathologist, based on its presence in virtually every tissue sample. Ultrasonographically, the presence of cysts (fluid filled spaces or sacs) and calcium deposits herald the diagnosis of prostatitis as well. Despite the fact that examination of the prostatic fluid or EPS makes the definitive diagnosis, the rare family physician and fewer than 20% of all Urologists perform it because of difficulty in obtaining a proper sample, lack of interest, test complexity, lack of time, inadequate testing equipment, uncertainty of treatment or a lack of knowledge. In the busy world of a medical practice, uncertainty of treatment and a lack of time are likely the two most common reasons physicians prefer not to deal with this disease.
Based on challenges inherent with obtaining an accurate EPS, many physicians (including Urologists) have resorted to an evaluation of the post massage urine (VB-3) for the diagnosis of prostatitis. This concept has been popularized by Curtis Nickel, M.D. (Chairman of the NIH Prostatitis Collaborative) and others as an acceptable diagnostic alternative to the EPS. In an effort to validate the post massage urine as a surrogate diagnostic marker, a direct comparison of EPS and VB-3 was performed on 49 men believed to have prostatitis based on any degree of urinary symptoms and PSA (Reference the EPS/VB-3 Comparative Study at the end of this chapter). In this study comparison, all 49 men had prostatitis based on a diagnostic EPS with a median white blood cell count of 145 WBCs/HPF (High Power Field) or (400X). The post massage urine (VB-3) performed immediately following the collection of the EPS noted a non-diagnostic median white blood cell count of 5-6 white blood cells/HPF. Using ≥ 10 WBCs, as diagnostic for prostatitis, the VB-3 (post massage urine) missed 61% of patients with prostatitis. In other words, a test that was heralded as an acceptable alternative for the EPS missed almost two thirds of patients with the disease that it was intending to discover.
For this reason, patients and physicians are discouraged from using the VB-3 (post massage urine) as a definitive screening test for prostatitis. To restate, there are too many false negatives to suggest that this test has any redeeming diagnostic clinical value. On the other hand, if the pre-massage urine (a typical urinalysis) is compared to the post massage urine quantitatively for white blood cells, there is value to the test technique from a relative point of view. In my opinion, any increase in the number of white blood cells per high power field from one specimen to another will identify prostatitis patients definitively when the PSA is ≥ 1.0 ng/ml. Unfortunately, the mere diagnosis does not provide an adequate and dependable marker for follow up based on variability of massage technique from one office visit to another. Acceptance and clinical application of flawed test procedures by physicians merely underscores the ignorance and confusion that trickles down to the suffering patient. With a clear understanding of the above, patients empowered with this knowledge will be able to take a more active role in treatment decisions with their physician while ultimately improving their outcome. While nearly everyone recognizes that medicine is an inexact science, physicians are obligated to separate fact from fiction. In other words, if a test fails significantly to identify the disease it is intended to find and cannot be reliably repeated, we should not use the test. Failure to understand this principle from a professional point of view merely widens the chasm of ignorance between the educated and the under-educated masses allowing confusion to remain rampant.
In prostatitis, any combination of pelvic and urinary symptoms are possible, individually or concomitantly as well as the common presentation of an individual (with a PSA blood test result of ≥ 1.0 ng/ml), who is without pain, discomfort or urinary problems, yet still has prostatitis, based on an abnormal examination of the prostatic fluid or EPS. In other words, it is not unusual to have prostatitis without signs and symptoms common to the disease. Our data shows conclusively that the PSA blood test is the most convenient marker to identify the presence of prostatitis. Furthermore, our research demonstrates the Sensitivity and Specificity of PSA as a diagnostic tool to be 100% when the PSA is ≥ 1.0 ng/ml.
THE ETIOLOGY (CAUSE) OF PROSTATITIS:
- Viruses - Idiopathic (Unknown) Factors
- Bacteria, Nanobacterium, Mycoplasma, Chlamydia - Stress and Psychological Factors
- Yeast - Immune System Related Disease (Including AutoImmune Diseases)
- Dietary Factors - Social, Genetic or Environmental factors
- Crystal Deposition and Biofilms - Any Combination of the Above
Treatment of prostatitis has been anything but a sure proposition. According to noted prostatitis expert Dr. Curtis Nickel of Kingston, Ontario and the NIH, "there is widespread frustration, discomfort, and lack of knowledge in both primary care physicians and urologists' ability to manage prostatitis”.
Those patients who truly have an identifiable bacterial infection of the prostate will certainly benefit from antibiotics. These may need to be continued for 2-6 weeks and, in rare cases, long-term or indefinite antibiotic suppression therapy may be necessary. We don't have any data that looks at recurrent disease over many years, but, it is believed by this author that bacterial prostatitis may transition to non-bacterial prostatitis. Campbell's Urology, the Urologist's most authoritative reference text, identifies only about 5% of all patients with prostatitis as having a bacterial component, which can be "cured", at least in the short term, by antibiotics. In other words, 95% of men with prostatitis have little hope for a cure with antibiotics alone since they don't actually have any identifiable bacterial infection. I encourage men to request a culture & sensitivity (proving bacterial prostatitis) of either the urine or EPS, before consenting to the use of antibiotics. While antibiotics are over used, if your doctor insists on an initial trial of antibiotics, despite your concerns, it may be most prudent to follow his instruction as he likely has your best interests in mind. Repeated trials of antibiotics are discouraged based on concern for suppression of the immune system and the possibility that a super-resistant organism may result, not to mention the needless expense.
In the treatment of prostatitis, physicians have traditionally recommended everything from doing nothing to multiple and extended courses of antibiotics, synthetic drugs and lifestyle changes. It is not unusual to hear a doctor tell his/her patient that he needs to learn to live with it; referencing prostatitis. Among the various treatment options; alpha blockers (Hytrin®, Cardura®, Flomax® and Uroxatrol®) are designed to relax the muscle tension at the junction of the prostate and bladder neck region (like a hammock) to improve urinary flow. This class of drug does tend to improve voiding difficulties by relaxing tension at the bladder neck region (space between the prostate and the bladder); but are expensive, need to be taken indefinitely, may have significant side effects and don't cure the underlying problem or prevent prostate growth.
Finasteride (Proscar®) or Dutasteride (Avodart®), synthetic drugs that block the conversion of Testosterone to Dihydrotestosterone, can shrink prostate tissue but there is no proof it helps in the treatment of prostatitis as defined by decreasing white blood cells found in the prostate secretion. Allopurinol, a drug which reduces uric acid levels in the body, has been used to treat prostatitis, based on the theory that uric acid crystals may form in the prostate secondary to refluxing urine and cause inflammation. Most clinicians who have tried Allopurinol for prostatitis report disappointing results from this therapy. Anti-inflammatory agents (Motrin® or Advil®) and hot sitz baths have been helpful in treating the discomfort caused by prostatitis in many patients, but neither of these treatments actually cures the disease and the benefits wear off rapidly. Irritative voiding symptoms may be relieved by a myriad of bladder relaxing agents such as oxybutynin (Ditropan®), while anti-depressants such as amitriptyline (Elavil®) have been helpful in various chronic pain conditions such as prostatitis associated with depression. Nanobacterium (one hundredth the size of an E. Coli bacterium) has been postulated as a cause of prostate stone formation. Unfortunately, there is no definitive data to suggest that this microbe is problematic, much less a concern for prostatitis evolution. Biofeedback, behavioral therapy, referral to a pain clinic, and/or psychological treatment has been recommended for patients with prostatitis and occasionally offers some relief to selected individuals. For the most part, current treatment methods for prostatitis are generally rather disappointing.
Prostatic massage plus antibiotics deserves further review. Proponents of prostate massage (championed in the Philippines) have little reproducible data to support their enthusiasm. My personal experience with prostate massage demonstrates only temporary results with transient prostate size reduction and relief from congestion. Unfortunately, long term benefit for the resolution of prostatitis based on prostate massage (as measured by EPS), over time, is unrealistic and is not likely to occur. Other drawbacks include intense discomfort/pain at the time of massage, the need for accurate cultures of the prostatic fluid and a dependence on antibiotics to ultimately affect the cure.
Dr. John Krieger, noted Urologist at the University of Washington and member of the Prostatitis Collaborative at the NIH, appropriately points out the following multiple factors preclude accuracy of the culture technique involving urine, semen or prostatic secretion for diagnosing or treating prostatitis:
1. The presence of inhibitory substances
2. The unknown effects of many previous courses of antibiotics
3. The fact that most bacteria from the prostate do not readily grow on conventional culture media
4. The high number of uncharacterized bacteria that infect human prostate tissue
5. The difficulty in obtaining a pure specimen from the prostate which has not been contaminated by possible infectious organisms of the urethra or urinary passage
6. The fact that most cases of prostatitis are not infections in the first place
CHRONIC NON-BACTERIAL PROSTATITIS OPTIONS:
PRODUCT OR PROCEDURE Effects on LUTS (lower urinary tract symptoms) /Voiding symptoms EFFECTS ON PSA EFFECTS ON EPS ABILITY TO CURE IMPROVED SEXUAL PERFORMANCE
Antibiotics Possible Yes No No No
Avodart/Proscar Yes Yes No No No
Alpha - Blockade (Hytrin, Cardura, Flomax and Uroxatral) Yes No No No No; also causes retrograde ejaculation commonly
PEENUTS® (all natural Patented formula) Yes Yes Yes Yes Yes; secondary to prostatitis resolution
Surgery Yes Yes Possible Possible No
Chronic Prostatitis is non-bacterial in ≥ 95% of all cases
PROSTATE SPECIFIC ANTIGEN (PSA) AND PROSTATITIS:
Prostate Specific Antigen (PSA), referenced earlier, was originally designed as a blood test for prostate cancer surveillance. Historically, PSA blood levels of 0-4 were designated as "normal", but this range was arbitrarily selected and never meant to become gospel for normalcy; therefore, does not necessarily indicate a healthy prostate. Prostatitis represents the number one reason that PSA elevates. Additionally, we know that up to 30% of all prostate cancers occur in patients with PSA levels less than 4 ng/ml. Since prostate cancer obviously cannot be considered normal, this suggests that the original "normal" PSA range of 0-4 ng/ml is much too high. It's been suggested that any PSA level greater than or equal to one ng/ml indicates an unhealthy prostate, with active prostatitis, as confirmed by an NIH presentation in 2000 (R. Wheeler). Data from Johns Hopkins corroborates the importance of PSA to prostate cancer. Based on the Baltimore Longitudinal Data, Ballentine Carter and colleagues confirmed a 3-4 fold increased incidence of prostate cancer development in men aged 40-60, when the PSA level was in excess of 0.6-0.7 ng/ml. Peter Gann and colleagues have shown through their research that a PSA between 2.0-4.0 ng/ml is associated with a 5-9 times increased incidence of an aggressive cancer within the subsequent 10 years. This is sobering data that predicts disease even when men choose to be unknowing and/or ignorant regarding prostate disease markers rather than choosing a proactive or preventative course of action.
As noted earlier, it's well known that prostatitis increases the PSA level. In fact, it is much more likely that any unexplained increase in PSA level is due to prostatitis than to BPH or prostate cancer. A few Urologists currently treat their high PSA levels in patients with 4-6 weeks of antibiotics and repeat the PSA level before recommending a biopsy when the DRE (digital rectal exam) findings are non-diagnostic. In this scenario, only if the second PSA level remains elevated will a biopsy be ordered. I would, likewise, recommend this clinical approach for all patients, but instead of antibiotics (unless a bacterial infection is isolated); I would recommend the patented prostatitis formula, Peenuts®. A minimum of 3-6 months on this nutritional formula would be required to adequately make an impact on a disease that may be worsening at the time the patient is evaluated.
I believe that a significant percentage of any elevation in PSA level in the blood (associated with a normal digital prostate examination) should be considered prostatitis until proven otherwise. This is based on the fact that 70-80% of all biopsies are negative when an elevated PSA is encountered. While prostate cancer is certainly a concern and should be considered carefully and appropriately, prostatitis is much more likely from a statistical point of view. PSA can serve as a very useful marker or indicator of the degree of prostatic inflammation present and help determine the effectiveness of prostatitis therapy through comparative testing.
THE LINK BETWEEN CHRONIC PROSTATITIS AND PROSTATE CANCER:
Virtually all men will develop prostatitis at some point in their adult lifetime. This has been shown in several studies including one done in 1979 by Drs. Kohnen and Drach who found 98.1% of 162 prostates removed surgically had evidence of inflammation (prostatitis). Dr. Timothy Moon, Urologist at the University of Wisconsin, and many others, report that virtually 100% of the biopsy and surgical prostate specimens they examine show evidence of prostatitis.
We also know that all men eventually get prostate cancer if they live long enough. In 2004, according to the American Cancer Society (ACS), 32,000 men died from prostate cancer; while over 232,000 new cases were diagnosed. Prostate cancer is the most common malignancy to affect men and the second leading cause of cancer death in men (lung cancer is first). In the United States, one in four men who undergo prostate biopsy will be found to have prostate cancer, but all of them will have prostatitis. These findings have led Dr. Timothy Moon and others to suggest that prostate cancer is always associated with prostatitis.
Young men in their thirties typically are quite prone to prostatitis and are not generally thought to be at risk for prostate cancer. But a study from Memorial Sloan-Kettering Cancer Center, in New York, found that 30% of 525 American men aged 30-39 actually had microscopic prostate cancer. Is it postulated then that chronic prostatitis may increase the risk for and/or promote the growth of prostate cancer? There is evidence that suggests this may be so. The importance of this data is confirmed by the Detroit Autopsy Study, which corroborated that 30% of 30 year old men had prostatitis and prostate cancer (Weil Sakr).
It is well known that chronic inflammation of several other organs is associated with various cancers. Examples include but are not limited to: the inflammation of the lower esophagus (Barrett's esophagitis) which leads to esophageal cancer, hepatitis that may eventually become hepatic cancer and ulcerative colitis which often develops into colon cancer. Since chronic inflammation causes cancer in other organs, it is not unreasonable to suggest that chronic prostate inflammation (prostatitis), if left unattended, may ultimately lead to prostate cancer. This concept has been demonstrated more clearly by the American Association of Cancer Research (AACR) and corroborated by David Bostwick, M.D., world renowned Pathologist. Specifically, the AACR has shown that prostatitis (an inflammatory disease) represents cellular oxidative stress resulting in cellular dysplasia, proliferative inflammatory atrophy, subsequent cellular mutation associated with changes in DNA (Deoxyribonucleic Acid), prostatic intraepithelial neoplasia (PIN), and ultimately prostate cancer.
Prostate cancer is always found together with prostatitis and all men will probably get both diseases if they live long enough. Both prostate cancer and prostatitis raise Prostate Specific Antigen (PSA) levels and occur most often in men in their 60s. Both conditions are currently at epidemic, if not pandemic, levels. While prostate cancer and chronic prostatitis are clearly associated, further research and epidemiologic studies are required to add additional clarity to the exact nature of the relationship.
Based upon the now well recognized association between Prostatitis and Prostate Cancer, prostatitis resolution is a key component to Chronic Disease Management (CDM). CDM is a competing option to more traditional therapies that allows men to live with their cancer, while preventing Impotency, Incontinence, and a failure to cure. Living with prostate cancer is realistic and is analogous to living with Arthritis or Diabetes. Living with prostate cancer becomes more attractive when it is realized that successful intervention for cure (replete with the negative side effects) adds only 3 years to the life expectancy of a man in his 50s, 1.5 years to a man in his 60s and 0.4 years to a man in his 70s. This data comes from the elegant work of Michael Barry and colleagues at Harvard. For many prostate cancer patients, the risk of treatment failure is often too big of a gamble to take. Thus, as the male becomes better informed through prediction nomograms (models) and up-to-date treatment outcome data, an attempt at formal therapy may lose some of its luster, as quality of life takes center stage and becomes the dominant issue for our remaining years.
The Link between Prostatitis and Infertility: The inflammatory process of prostatitis has been shown to affect sperm quality primarily by decreasing motility of the sperm. Couples who are trying to conceive a child should look at the very real possibility of prostatitis treatment as the most cost effective, best “first step” to improving sperm quality. While the identification of ≥ 10 white blood cells in the prostate secretion is sine qua non for the diagnosis of prostatitis, the presence of any white blood cells in a sperm sample (ejaculate) would also herald the presence of the disease in most cases. Additionally, my clinical acumen suggests that a PSA blood test result of ≥ 0.5 ng/ml may also be associated commonly with prostatitis and decreased fertility. (Please review data regarding my patented natural remedy Peenuts® for resolution of signs and symptoms consistent with prostatitis)
Present research dollars in prostatitis are so few, that at our present pace generations will come and go with countless innocent men suffering and possibly dying needlessly before the true answers are known. A reflection for the paucity of academic support to prostatitis research is noted with the 1998 National Convention of the American Urological Association, (attended by American and International Urology experts). Specifically, while 51% of all the papers and studies presented involved prostate cancer, only 3% addressed prostatitis. While a few studies relevant to antibiotics as a treatment for bacterial prostatitis are underway (funded largely by a pharmaceutical industry that manufactures the antibiotics), there is virtually no other significant research currently being done in the United States on this disease. Clearly, there is no disease topic more worthy of research than the number one health risk that men face. Whether we are speaking about prostatitis, enlarged prostate (EP) or prostate cancer; these diseases are individually and collectively epidemic while individually and collectively equally germane to male health and wellness.
To state further, practically every man alive has prostatitis, making it one of the world's most common diseases, if not the most common. Diagnosis is difficult and current treatments are frequently inadequate. The association between prostatitis and prostate cancer is irrefutable. With all this in mind, it is particularly disturbing that prostatitis research has been so seriously under-funded for years. Leroy Nyberg, M.D., Head of Urology Research for the National Institutes of Health (NIH) has stated: "It's amazing to me that we can't reliably treat the majority of men with prostatitis". The NIH has organized a research arm that expects to bring a fresh look to chronic prostatitis, but the results of this research are not expected for several years, if then. Today, chronic prostatitis for many represents an enigma, but clearly qualifies as the single most under diagnosed, misunderstood and inappropriately treated medical disease in the world.
In an effort to demonstrate the impact of prostatitis resolution to the evolution of prostate cancer, I have proposed the “ProCap” (Prostate Cancer Prevention) Trial. This is a randomized, double blind, placebo controlled, age matched study that is intended to prove the patented Peenuts® prostatitis formula can prevent prostate cancer by resolving prostatitis. This study, intended to underscore the importance of inflammation resolution to an avoidance of prostate cancer, is the most ambitious effort to date to establish validation for prostate nutrition in men’s health. As noted earlier in this article, the American Association of Cancer Research, Pathologist, David Bostwick, M.D. and others have shown that prostatitis evolves to prostate cancer. While this study seeks funding, the concept grew out of clinically significant results from a Prospective Prostate Cancer Study that showed benefit of diet and nutrition on men with moderately well differentiated prostate cancer (Gleason 5/6). Specifically, 90% of men enrolled in the study (n=20), noted suppression of their PSA (the marker of disease activity) over a surveillance period in excess of 30 months. The remaining 10% noted stable disease. While the study findings suggest that 50-60% of all prostate cancer cases (consistent with a Gleason scores of 5 or 6) are being over treated with traditional treatments, the Prospective Study was a designed effort to prove that prostatitis resolution (partial or complete) with the Peenuts® formula would have an impact on prostate cancer. In this study, the improvement in the white blood cell count associated with the EPS (a biological representation for prostatitis resolution) was noted to be 73% which mirrors the 66% reduction in white cells (based on previous clinical research) presented to the US Patent & Trademark Office regarding the patent application which was granted in 2001.
THE PROSTATE BIOPSY REVOLVING DOOR:
The inability to maintain a normal PSA (less than 1.0 ng/ml ideally) will put you in a unique group of men asked to consider a biopsy of the prostate. Men unique to this group who fail to stabilize the PSA (preferably less than 4.0 ng/ml) will become the hunted. Once the biopsy scheduling (merry-go-round) begins, it is difficult to prevent subsequent biopsies, as anxiety is what drives the process in the absence of a cancerous result. As doctors, it is important to find disease, seemingly at any cost, in men who will benefit the most from our therapies. If your PSA is high (≥ 4.0 ng/ml), your prostate will become the target of a biopsy needle with virtually any Urologist you meet.
While I might be an exception to the traditional Urologist, there are basic principles that need to be applied when a clinical scenario presents itself as consistent with prostate cancer. In my clinical practice, men with a non-cancerous digital prostate examination can defer the biopsy when prostatitis is identified and the preferred recommended treatment course is followed. Obviously, the Peenuts® prostate nutritional formula is an integral part of the program. The inability to resolve the degree of disease as determined by a normalized PSA will put us back at square one where the biopsy makes most sense.
A classic example of a patient's experience in the traditional doctor’s office involves a 65-year-old man from Lubbock, Texas who had noted a PSA of 18 ng/ml. His Urologist appropriately offered and performed an ultrasound examination and prostate biopsy. The biopsy result noted chronic prostatitis with no evidence of cancer. Antibiotics were ordered despite the lack of a positive culture and sensitivity, with no other therapy considered. Remember that less than 5% of cases of prostatitis are actually caused by bacteria; potentially curable with antibiotics. His PSA was repeated after 6 months and found to be unchanged. The patient underwent a second prostate biopsy, at the doctor’s insistence, which again showed only chronic prostatitis. When the patient asked his doctor what he could do, the urologist offered to repeat the PSA in another 6 months and consider an additional biopsy at that time. This is a clinical scenario that is all too common across the United States daily whereby men are given no alternative in an attempt to avoid a future biopsy. I believe, as physicians, we must become better educated regarding relevant scientific concepts that may radically change the diagnostic or treatment course of any patient. Far too many men are asked to return to the biopsy arena over and over, without a well thought out, patient-friendly strategy or “master plan”. In this case, the patient was aware enough to research prostatitis on the Internet. Eventually, he discovered a nutritional product that improved his urinary symptoms substantially and reduced his PSA by almost half, in only 3 months. This was accomplished by merely using an advanced nutritional therapy for the prostate called Peenuts®, which he was able to purchase without a prescription! While this patient’s response was outstanding, not all patients respond identically. The use of the Peenuts® formula is not intended to replace the advice of your doctor but your thoughts (as the patient), will play a role in the physician’s decision.
Another equally riveting case involved a 75 year old male who had experienced five previous biopsies (all negative) associated with a PSA of 22.6 ng/ml. Using only Avodart® (Dutasteride) and the Peenuts® prostate nutritional formula, his PSA dropped to 7.88 ng/ml by the end of 11 months and 5.1 ng/ml at 24 months. Without the presence of prostate cancer, Avodart® would have been expected to cut the PSA in half or to 11.3 ng/ml. The improvement to 5.1 ng/ml is exceptional and validates further the benefit of the Peenuts® nutritional formula related to the resolution of prostatitis. Furthermore, his EPS decreased from 400 WBCs to 130 WBCs in only 9 months. While this approach likely shows the benefit of Avodart® and Peenuts® in combination, the need for additional biopsies is now gone as the patient’s prostate health status has improved markedly. While further studies with this treatment protocol are encouraged, the expectation remains high that similar results will be forthcoming.
“NATURAL THERAPIES” FOR PROSTATE DISEASE:
THE ROLE OF NUTRITIONAL THERAPIES FOR PROSTATITIS, BPH AND PROSTATE CANCER
The 5 Keys to Systemic Health include: Proper Diet, Appropriate Nutrition, Adequate Exercise, Stress Reduction, and Education. Not surprisingly, these same categories are equally important to prostate health. Regarding the diet, I recommend a modified Mediterranean Cuisine. Specifically, this diet is devoid of saturated fats associated with red meat and dairy products. Nutritionally, I recommend the scientifically validated natural product called Peenuts®, taken at 2-3 capsules per day with meals. Additionally, I recommend Omega-3 fatty acids, based on scientific data that supports the inhibition of known prostate cancer cell lines. This activity takes place with the daily supplement of Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA) in an appropriate dose. The need for daily exercise cannot be understated based on enhancement of the immune system and cardiovascular benefit. Stress reduction is critical to the avoidance of many illnesses while assisting a strong immune system. Last, but not least, education will empower the patient to make improved decisions regarding disease prevention and/or treatment. An extended commentary on the diet will be forth-coming in my up coming book, entitled, “Men at Risk: A Rush to Judgement”.
Beyond the 5 Keys to systemic and prostate health, natural remedies for prostate related disease are centuries old. The ancient Chinese, for example, used a combination of Amino Acids, including Glutamic Acid, Alanine and Glycine successfully, for prostate maladies. It is not surprising that various remedies used today contain some combination of these beneficial Amino Acids.
Saw Palmetto (Serenoa repens, Dwarf Palm), indigenous to Florida valued for its Beta-Sitosterol content, has been revered by some and reviled by others.
Unfortunately, when the data is reviewed, Saw Palmetto does not demonstrate adequate clinical efficacy, in men with prostate related symptoms. In a randomized, placebo controlled, double blind study, sponsored by the NIH, Saw Palmetto did not perform clinically any better than a sugar pill (placebo) at one year (N=225 men). Men were evaluated using the American Urology Association Symptom Index (AUASI), as the primary study outcome in men with moderate to severe symptoms.
Additionally, maximal urine flow, post void residual, prostate size and other health-related issues were assessed.
To state further, while I personally believe that Saw Palmetto has synergistic benefit when added to other ingredients, it may mask disease recognition, when used alone, by improving slightly the only signal (sign or symptom) a man may have, that a problem exists. Specifically, men commonly look to Saw Palmetto when there is any sign of urinary difficulty. As many men “self-treat the symptoms”, any mild improvement (placebo or real) will commonly delay a doctor visit, but more importantly, miss an opportunity to assess prostate health, through a Prostate Specific Antigen (PSA) blood test. The need for a PSA at the time men have urinary symptoms cannot be understated, as prostate disease is the #1 health risk that men face. This should not turn into an opportunity lost. The PSA test will serve as your baseline from which to compare others. An additional reason to get a PSA beginning at age 30-35 is based on the fact that it is not uncommon for men to have prostate disease in an absence of any voiding symptoms. (To order a PSA “Diagnostic Home Kit”, please contact our office (toll free) at 1-877-766-8400.
While I endorse natural remedies for prostate disease that can be validated, independent of generic ingredient claims, men should choose a product or formula that works versus prostatitis primarily. While 50% of 50 year old men will have prostate enlargement, virtually all men, at this age, also have prostatitis as noted through an evaluation of voiding symptoms and EPS (expressed prostatic secretion). Specifically, data presented at the NIH in 1999 showed that 81% of men less than 50 years old, with any level of urinating symptoms, had prostatitis (n=83), while 88% of men aged 50 or older had prostatitis (n=152), as judged by the EPS.
Because prostate enlargement begins in most men by their mid-forties, it would appear likely that multiple disease processes play a role in a male of this age. Despite the controversy, there are few, if any, dependable, disease-altering natural remedies for prostate enlargement.
Much of the older historical data suggests a role for Saw Palmetto (Beta-Sitosterol) as a product that blocks the conversion of testosterone to Dihydrotestosterone (DHT). If this were true, the PSA blood test would be altered (cut in half) by using Saw Palmetto. This does not occur, as independent studies performed by Marks & Gerber showed no effect of Saw Palmetto on PSA, at six and twelve months, respectively. If men are interested in shrinking the prostate size, I would refer them to an FDA approved product called Avodart® (Dutasteride). This product blocks the enzyme 5-Alpha Reductase, causing the prostate to shrink in size by 20-30%. Men are encouraged to ask their doctors about this option and should remember to multiply the PSA result by two, to provide an accurate number.
Why Peenuts® Qualifies to Be Your Prostate Nutritional Formula
Peenuts® is a unique formula with a unique name. While the name suggests many things to many people, it is an acronym that stands for “Power to Empty Every Time while Never Urinating Too Soon”. It is also a name you will not likely forget. In effect, the name stands for normal bladder function and expected prostate health. Arguably, this formula is the most studied natural formula in the world. In a randomized, double blind, placebo controlled study performed in 1997, Peenuts® demonstrated improved ability to decrease the signs and symptoms associated with an enlarged prostate or prostatitis. The findings were statistically significant. More importantly, the findings were clinically significant; meaning…the patient was able to recognize the improvement. While all men in the study on Peenuts® improved their voiding symptoms, 69% of men improved either 6 or 7 out of 7 categories measured (Please refer to an IPSS-Index or AUA Symptom Index). In a follow up to the study, more than 300 men have been evaluated with similar results in the clinic setting. The average improvement in the urinary symptom score was 11 points. The PSA, “the barometer of prostate health” improved in all patients by an average of 49%, while the EPS, our most sensitive marker for prostatitis, noted a 66% reduction in white blood cells (consistent with a reduction in inflammation). There were no side effects or drug interactions noted during testing or clinical follow up.
Peenuts®, a complex, synergistic blend of natural ingredients, (comprised of antioxidants, anti-inflammatories, beta-sitosterols, and immune boosters), is patented to reduce the PSA (associated with inflammation), reduce urinary symptoms and reduce the white blood cell count in the EPS. The mechanism for PSA reduction is based on the formula’s effectiveness versus prostatitis as a cellular oxidative event while validated by a proven reduction in EPS as the diagnostic measure of inflammation. Men should exercise caution when comparing Saw Palmetto and Beta-Sitosterol related products (formulas) that speak to the intention to assist a healthy prostate and a prostatitis formula. Notwithstanding an apparent benefit from Beta-Sitosterol (the active ingredient in Saw Palmetto) on urinary symptoms (real or placebo effect), all prostate formulas are not created equal. In the process of application for European Patent recognition, I was asked by the European Patent Judges to compare the Peenuts® formula to a patented BPH formula. The intent of the study was to judge the benefit of both products regarding prostate inflammation (as judged by white blood cells in the EPS). To state further, the Patent Judges needed to see a difference in clinical outcome unique to the Peenuts® formula that was not seen with the previously patented BPH formula. After four months, of an open label study, a comparison of the EPS noted a 68.2% reduction in white blood cells with the Peenuts® formula while the BPH formula had no effect on the inflammation marker. While this study does not negate the benefit of the BPH formula to prostate health, it is doubtful; there is a benefit versus prostatitis. To reiterate, the only way to accurately assess inflammation of the prostate and the clinical benefit of the nutritional formula you currently use is to evaluate the Expressed Prostatic Secretion (EPS). Failure to do so creates more confusion while questioning the goal of your nutritional supplementation program.
Herbal Prostate Nutrition & Health
With patents in numerous countries, Peenuts continues to deliver results. Introduced in 1997, Peenuts, a synergistic blend of Anti-inflammatories, Immune-Boosters, Herbs, Vitamins, Minerals & Anti-Oxidants, was intended for men with Prostatitis. In a randomized, double blind, placebo controlled study performed in 1997, Peenuts® demonstrated improved ability to decrease the signs and symptoms associated with an enlarged prostate or prostatitis. MORE INFO -->
Ten or greater white blood cells in the prostate secretion, obtained at the time of prostate digital examination and massage, evaluated microscopically under 400 power, establishes the diagnosis of prostatitis.
In the event a vigorous prostate massage fails to yield an adequate specimen at the tip of the urethra, doctors are encouraged to use the patented dipstick technology on a post-massage urine specimen, to validate the disease process of prostatitis. While this methodology is not as accurate as the EPS, it will serve as an effective diagnostic indicator in the more severe cases of prostatitis.
Beyond Saw Palmetto, other sources of sterols (primarily Beta-sitosterols) include Pygeum Africanum (bark of the African Plum tree), pumpkin seed, sugar cane and nettle. None of these sterolic compounds have been validated to benefit men with prostatitis, as qualified by a numerical reduction in the white blood cell count, associated with the EPS. On the other hand, improvement in urinating symptoms has been reported. Nutritionally, zinc may play a role in the evolution of prostate cancer as most studies show prostate tissue levels of this mineral to be low or absent in prostatitis and prostate cancer. The exact relationship has yet to be scientifically elucidated.
Despite the historical data on the potential benefit of these ingredients, the majority of American doctors have shown a decided reluctance to embrace natural remedies for prostate health, without meaningful clinical trials with compelling data. The research of the late William Fair, M.D., Memorial Sloan-Kettering, Katz, Moyad, Lowe, Klotz, and others in the supplement arena continues to set the standard and challenge the industry to provide evidence-based facts. Despite the fact that the FDA has little control over natural products, no one benefits when false claims are made. It is for this reason that all nutritional products or formulas should welcome the constructive criticism of others, but on the other hand, medical journals and the media have an obligation to report on true breakthroughs of academic and clinical thought.
In regard to Prostate Cancer, Selenium supplementation, at 200 mcg daily, has been shown to decrease the incidence of Prostate Cancer by 66%, in a 10 year study. Likewise, Vitamin E, at 50 mg daily, was shown to decrease the incidence of Prostate Cancer by 32% (Alpha-Tocopherol/Beta-Carotene Study). It is interesting to note that the Vitamin E findings were demonstrated in a group of smokers. Notwithstanding the data, it is unknown what effect smoking has on the development of Prostate Cancer, independent of Vitamin E. The National Cancer Institute (NCI) intends to answer the questions related to the benefit of Selenium and Vitamin E in the evolution of Prostate Cancer, in a large scale 12 year study (start date in 2002). Dubbed, the SELECT Trial, patients will be randomized to Selenium 200 mcg, Vitamin E 400 mg, Selenium and Vitamin E in combination, and placebo taken on a daily basis.
Based on recent research, there is some concern for toxicity of Vitamin E in excess of 400 mg daily. How this will affect the outcome of the NCI study, as it is moving forward, is unknown, but individuals should be aware that 400 mg may be toxic to the heart in supplement form. Beyond the potential toxicity of Vitamin E, there is also concern for toxicity of other vitamins and minerals, including, but not limited to, Zinc, Calcium, Vitamin A, Vitamin D, Vitamin C and Vitamin B-6. When the dust settles on all the issues of toxicity, the most prevalent thought involves taking nutrients in appropriate doses, but more importantly, in moderation. Regardless of what anyone says, more is not better, when it comes to nutritional supplementation.
To declare your prostate healthy, your PSA must be less than 1.0 ng/ml with a complete absence of urinary symptoms; To Check your PSA in the comfort of your home, call today for your PSA “Diagnostic Home Kit” – Toll Free: 1-877-766-8400. A PSA of ≥ 1 likely indicates an unhealthy prostate. It's obvious that the lower the PSA, the lower the risk of prostate cancer. Anything you can do to lower your PSA level will likely reduce your risk of eventually getting prostate cancer.
Keep track of your PSA level for your own records. The risk is too high if you do not! If your PSA is between 1.0-4 ng/ml, there is a 20-30% chance prostate cancer exists. Likewise, if your PSA is between 4.1-10 ng/ml, there is a 20-30% chance that prostate cancer is present. Given this data, the healthiest number for you is a PSA of less than one; remembering that prostate cancer has been reported with a PSA of less than one, as well, but the odds of not having cancer with such a low number are in your favor.
Have your PSA and digital rectal examination performed regularly, usually at least every year for men 30-35 or older. Men at greater than average risk for prostate cancer, such as Blacks and men with a positive family history of prostate cancer should be checked yearly starting at age 30. Men with known elevations in their PSA levels and those with inconclusive or "suspicious" previous biopsies may need to be checked more often.
Don't be afraid to ask questions of your physician or get a second opinion about your prostate health. A true professional will take the time to answer your questions and be open to suggestions about alternative therapies (after all, chances are the traditional therapies have not worked at this point, if you are reading this article).
Research from the American Association of Cancer Research (AACR) and others indicate the link between prostatitis and prostate cancer is real! Practically all men with prostatitis will eventually get prostate cancer (if we live long enough) as the diseases are commonly found together. Remember, understanding prostatitis is your best first step to helping yourself.
Learn all you can about prostatitis and treat it as aggressively and effectively as possible. Peenuts® may be your best first opportunity to establish and/or maintain prostate health and may delay or even prevent the development of prostate cancer. Validation will be identified by any combination of biologic disease marker improvement, as determined by a decrease in PSA, a decrease in EPS and/or a decrease in Urinary Symptoms.
Be aware that your physician may not be an expert on the treatment of prostatitis. Ask him about the various diagnostic tests and therapies available and which ones are appropriate for you.
For more information on Peenuts® and other nutritional products for the prostate, call Preferred Health Resources at 1-888-733-6887 or log onto the Peenuts® website at www.Peenuts.com. Also, check out the National Institutes of Health (NIH) Website (www.nih.gov) for more general information on prostatitis and prostate cancer research.
MEN WHO SHOULD CONSIDER PEENUTS® PROSTATE NUTRITION
*All Men with a Family History of Prostate Cancer, Regardless of Age, Have a 10% Increased Risk for Prostate Cancer
*Men with Known Prostatitis Regardless of Age; Prostatitis is Associated with All Cases of Prostate Cancer
*Men with Voiding Symptoms - Voiding Symptoms represent Prostatitis until Proven Otherwise. In a Study of 235 Consecutive Men, with Voiding Symptoms, More than 80% had Prostatitis, Regardless of Age. This is a Landmark Finding Not Seen Before in the Literature
*All Men with PSA Elevation ≥ 1 ng/ml; The Normal Range for PSA of 0-4 ng/ml is Incorrect; 0-4 ng/ml Cannot Be Normal when 30% of All Prostate Cancers are in This Range, A True Medical Oxymoron!
*All Men Who Have Undergone Prostate Biopsy Noting Negative Evidence of Prostate Cancer and a PSA ≥ 1 ng/ml
*All Men Younger than 30 who are Admittedly Proactive; One Capsule a Day May be Appropriate if Negative Symptoms and a PSA of < 1 ng/ml is Identified in Association with a Normal EPS
*All Men Who Have Failed to Be Cured by Traditional Antibiotic Therapy Who Note Continued Voiding Symptoms and/or a Rising PSA
*Men Who are Presently Taking Proscar (Finasteride) and are Not Comfortable with a Chemical that Works Minimally versus Urinary Symptoms (PLESS Study), yet Costs Significantly
*Men Who Take Alpha-Blockers such as Hytrin, Cardura, and Flomax; These Products Have Side Effects and Do Nothing to Improve the Health of the Prostate
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The widespread incidence of prostatitis is well known to urologists and other doctors, but its association with prostate cancer has previously been considered incidental. In this article, Dr. Wheeler has suggested that prostatitis may actually cause prostate cancer based on evidence supportive of inflammation leading to cancer consistent with a number of other organ cancers, the research of the American Association of Cancer Research, David Bostwick and others. While the association alone between these two conditions falls short of being considered definitive, it is certainly plausible and deserves more study. Even a limited causative link between prostatitis and prostate cancer would cause a dramatic change in our attitude and approach to prostatitis.
Currently, prostatitis therapy consists primarily of antibiotics, alpha blockers and other drugs. The article correctly points out that these remedies are often inadequate. Dr. Wheeler recommends considering nutritional agents in the absence of successful definitive therapy. Although nutritional therapy has been widely used and studied in Europe, it is not routinely recommended by many U.S. physicians for a number of reasons. Nutritional therapy is not taught in most U.S. medical schools and many American physicians are unfamiliar with the available scientific research on the subject. Published studies on nutritional therapy are criticized for using different preparations and dosages, having too small a sample size with limited numbers of participants, being of inadequate duration, and bias in the selection of patients to be tested. Commercially available nutritional therapies are usually not manufactured to a pharmaceutical grade standard, which means each bottle, even from the same company, may have different biological effects. There is no universally accepted dosing schedule for many of these natural remedies and their mechanism of action is often unknown. Further, no specific combination nutritional product for either prostatitis or symptoms of prostate enlargement has ever been properly tested in a well designed, scientific study.
Dr. Wheeler describes a study he performed at The Prostatitis & Prostate Cancer Center on a unique combination nutritional therapy called Peenuts®. He reports outstanding objective and clinical results, but the scientific details of his research need to be carefully reviewed and his findings duplicated by other medical experts. If further research indicates he has indeed found a safe and highly effective therapy for the signs and symptoms of prostatitis and prostate enlargement, this would be a major contribution to the health and well-being of American men while saving the health care system tens of millions of dollars. Further elaboration of the prostatitis to prostate cancer model would qualify as a major medical breakthrough. Minimally, Dr. Wheeler’s research offers a patented formula with little downside with a potentially tremendous upside for motivated men.