Minimal research in CAM and overactive bladder (OAB) has been accomplished, but dietary changes including reduction in fluid intake, caffeine, alcohol and acidic foods alone with weight reduction, smoking cessation, and bladder retraining have been of some benefit [1]. Low levels of physical activity and obesity may be an emerging risk factor for OAB and may exacerbate symptoms [2].

Arguably, a modified form of CAM derived from conventional medicine principles applied to acupuncture is percutaneous tibial nerve stimulation (PTNS). Apart from cost issues, it could be argued that PTNS is as effective as pharmacologic therapy with a better side effect profile based on past and recent results from clinical trials [3–5].

Similar issues abound for patients concerned about urinary incontinence from urge to stress and mixed in terms of lifestyle factors, especially obesity and worsening of symptoms, but weight loss could provide significant reduction in symptoms, as exemplified by already completed randomized trials. One randomized weight-loss trial (n = 226 with intervention and n = 112 in control, mean age 53 years and BMI of 36 ± 6) resulted in significant greater loss of weekly stress incontinence episodes (65 % vs. 47 %, p < 0.001) at 12 months and greater percentage of women experiencing more than 70 % improvement in urge incontinence episodes at 18 months [6]. Mean weight loss was 8.0 kg over the entire study.

One of the more novel and exciting areas of incontinence improvement has to be the reduction in the risk of side effects from prostate cancer and other treatments with lifestyle changes. For example, core or abdominal strength training exercise two sessions a week (60 min per session) can result in significant improvement in continence rates and quality of life post-prostatectomy compared to Kegel exercises alone [7]. In a unique prostate cancer radiation series of 440 men given a questionnaire found significantly lower rectal symptom scores (p < 0.001), better erectile function (p < 0.001), and urinary function (p < 0.01) in nonsmoking men who were physically active and had a lower body mass index [8].

Minimal research in pediatric urology and CAM has been accomplished. For example, there is limited evidence for the effectiveness on acupuncture for nocturnal enuresis in children [9, 10]. This is not necessarily a negative finding because it is my belief that pediatric urologic research should first focus on lifestyle changes compared to exotic tablets or herbal products. For example, the high rate of dysfunctional voiding, especially nocturnal enuresis in obese children, and a lower rate of treatment response are concerning [11]. Hypertension, diabetes, and obesity appear to be associated with a higher risk of stone disease [12, 13].

Preventing recurrent urinary tract infections (UTIs) in children with cranberry juice has mixed results [14–16], but I am concerned about the caloric contribution and compliance of these beverages in the age of an obesity epidemic [17]. Overall, the sum of the evidence has resulted in discouraging the use of this beverage to prevent UTI [16]. Dietary supplements of cranberry concentrate appear to have similar data to juice and contribute little to no calories, but a definitive pediatric clinical trial is needed with a high proanthocyanidin (PAC and PAC-A) concentrations, and oxalate contributions from supplements need to be reported [18]. For example, in a successful and more recent pediatric UTI trial, the juice utilized had a total PAC concentration of 37 % [15]. A total of 12 out of 40 participants did not complete the study (six in each group). It would be prudent to report weight or waist changes in future clinical trials.

Probiotic dietary supplements are needed in more urologic clinical trials in pediatric patients. There is the suggestion of certain populations of children, including those with persistent primary vesicoureteral reflux (VUR), benefiting with a Lactobacillus acidophilus (10⁸ CFU.g 1 g twice a day) and showing similar effects to antibiotics (trimethoprim/sulfamethoxazole) in larger clinical studies (n = 120) [19, 20]. This data with probiotics needs to continue to mature, but it is a potentially critical development because antibiotic resistance is an ongoing issue in children with UTI [21], and, interestingly, the benefit of probiotics for antibiotic-associated side effects such as diarrhea is becoming well recognized in conventional medicine [22]. It is also of interest that few dietary studies in pediatric urology have been completed, especially in regard to conditions to UTI. It would seem logical to promote a heart-healthy diet and lifestyle in children to encourage overall health and to reduce the risk of blood sugar changes or weight that could increase the risk of urologic issues.

If Peyronie’s disease (PD) has an inflammatory component and there are acute, early chronic phases, then the potential for a CAM option to be utilized early with some conventional therapy is practical and logical, especially if “first do no harm” is the approach here. For example, vitamin E supplements have been used with mixed success [23], and some would argue similar to placebo effects or discouraged use from reputable experts [24], but the recent finding of an increased risk of prostate cancer in just a few years of ingesting this supplement from the SELECT is concerning enough [25, 26]. It is for this reason the future of vitamin supplements in PD should be discouraged. Some clinicians have used topical vitamin E cream and perhaps this makes more sense and might be far less concerning, but it does need some clinical controlled testing outside of the office, and the real concern of allergic reactions or contact dermatitis from these topicals is rare in general skin use but should be addressed [27, 28].

Carnitine (acetyl esters) dietary supplements may be able to reduce calcium levels inside endothelial cells, which are found in the penis and elsewhere [29, 30]. This may cause a reduction in fibroblasts and collagen production, which can reduce the risk of plaques or fibrosis. There have been randomized trials of this supplement—for example, acetyl-l-carnitine, 1,000 mg twice a day, compared with 20 mg twice a day of prescription tamoxifen [29]. After 3 months, acetyl-l-carnitine was more effective in reducing pain and curvature and slowing the progression of PD and was better tolerated, but not in reducing plaque size (both significantly accomplished this). This is another example of the need to use the supplement as early as possible (early chronic phase or earlier) in PD with conventional treatment because otherwise the supplement is expected to accomplish an unrealistic outcome.

However, there is a suggestion that propionyl-l-carnitine is more active than acetyl-l-carnitine and l-carnitine [30]. A total of 60 patients with advanced PD were placed in one of two studies—2,000 mg per day for 3 months and verapamil injections (10 mg weekly for 10 weeks) compared to verapamil plus tamoxifen (40 mg per day). The reduction in pain was similar, but a significant reduction in penile curvature, plaque size, need for surgery, and disease progression and increased IIEF occurred in the carnitine group. The group taking tamoxifen instead of the supplement did not experience these benefits. There was also a hint in a second smaller study of resistant PD that the combination of verapamil and carnitine could be beneficial. Yet, despite these positive studies, it has become difficult for some clinicians to promote this instead of vitamin E. This is slightly perplexing since there have been no side effects over that of placebo and perhaps because there has been one study that failed over placebo at 2,000 mg of propionyl-l-carnitine [31]. In all fairness, this should not completely remove the preliminary results with other studies that showed some benefit and good safety.

A total of 300 mg of coenzyme Q10 (CoQ10) per day for 6 months worked significantly better than placebo at reducing plaque size, penile curvature, pain, and improved sexual function and slowed the progression or stabilized this disease in approximately 85 % of the men with early chronic PD within approximately 24 weeks [32]. CoQ10 is a fat-soluble supplement, so it should be taken with food, but keep in mind that it can reduce the effect of the blood thinner warfarin, but at the same time it could enhance the effect of the blood thinner clopidogrel [33]. This is one large study, but it was of interest, and since this supplement has a good safety record, overall, it may be worth a recommendation, and perhaps the same mechanism of action whereby blood pressure has been reduced in some clinical trials of hypertensive patients [33] offers the same mechanism of action on those with PD at the microvascular level. CoQ10 could be used in PD whenever the health care professional desires to use vitamin E dietary supplements with conventional therapy, but these dietary supplements are not low cost, and comparative pricing should still allow for good quality control on this product. Another trial by the same research team using omega-3 fatty acid supplements for PD found no benefit [34].

l-arginine research in PD has not matured yet, but there is a hint of efficacy in a study (n = 74) utilizing 1,000 mg twice a day of l-arginine along with conventional treatment [35]. l-arginine could increase nitric oxide (NO) and increasing perfusion could allow for an anti-fibrosis effect and could reduce the development of scars and improve healing of wounds [36]. Laboratory studies for some time have suggested that it can prevent inflammation and fibrosis in the liver, kidney, lung, and cardiovascular system. Perhaps the other true benefit for l-arginine might just be an improvement in erectile function in those with PD. Please read the erectile dysfunction chapter of this book because there is plenty of information as to why l-citrulline could be a more ideal and safer dietary supplement compared to l-arginine for NO production. Thus, using 1,500 mg of l-citrulline daily or 2,000 mg of l-arginine daily could be a viable option for PD and is arguable that the one I find has some of the most potential for future research, especially in combination with other therapies [35–37].

Other areas of interest have not been impressive, for example, a topical magnesium sulfate, which could theoretically function as a less potent calcium channel blocker, worked no better compared to a topical placebo [38].

Few studies have researched the potential for cranberry supplements to be a large source of oxalate. One of the classically small but urologic impactful studies to show the importance of CAM research of any size was published back in 2001 [18]. A total of five subjects utilized cranberry supplements at the recommended daily dosage on the label for 7 days, and then urinary oxalate levels increased significantly (p = 0.01) by an average of over 43 %. If over 10 % consistent increases as noted by these authors can cause calcium and oxalate to bind and crystallize or form a stone, then this is concerning. The average normal intake of oxalate from the diet is about 150 mg per day, but two cranberry tablets from this study could be expected to contain over 350 mg of oxalate per day. Another problem with many cranberry concentrate supplements is that they can contain a good amount or at least some plain vitamin C (known oxalate-increasing compound). Otherwise, it would appear today that for adults inquiring about cranberry juice to prevent recurrent UTIs, a good quality-controlled cranberry supplement is more sensible for adults compared to juice. These pills do not appear to add to the obesity epidemic in terms of caloric contribution (100–150 cal per 8 oz of juice vs. little to no calories with pills) [17] and have worked as well thus far as the juice option for the prevention of UTIs [16]. Also, the impact of cranberry juice for UTIs is being questioned now with added clinical trials, and the compliance rates of drinking cranberry juice daily for months in some trials have been poor. If someone has a high risk for oxalate stone and UTI recurrence, then again some idea of the contribution of the amount of oxalate from the supplement would be of assistance in deciding if the benefit was worth the risk.