The most common pollen extract substances are Cernitin GBX and Cernitin T60. The proposed mechanisms of action are as follows: anti-inflammatory [10], smooth muscle relaxation [11, 12], interference with prostatic androgen metabolism [13], and inhibition of prostatic stromal proliferation [14]. Prospective noncomparative studies have shown that pollen extracts may have benefits in patients with CP/CPPS. A recent RCT has shown that compared to placebo, Cernitin GBX + Cernitin T60 provides significant improvement in NIH-CPSI scores [3]. In this study, two capsules of 60 mg Cernitin T60 and 3 mg Cernitin GBX were administered three times a day for 12 weeks. The accompanying urethral stricture and bladder neck sclerosis are associated with less favorable outcomes [2]. Finally, Cai et al., by using a phase III RCT, showed that a complex with pollen extract in association with vitamins significantly improved total symptoms, pain, and quality of life compared with ibuprofen in patients with CP/CPPS, without severe side effects [15].

Saw palmetto is a palmlike tree that has fruits (berries) rich in fatty acids and phytosterols. The extract of the berries is very popular as an alternative treatment for benign prostate hyperplasia (BPH). Although the mechanism of action of saw palmetto is not clear, it is thought that it has anti-inflammatory, antiandrogenic, and proapoptotic effects. Despite the popularity of saw palmetto among patients with BPH, an RCT published in 2011 and a Cochrane review published in 2009 have shown that it does not improve lower urinary tract symptoms in patients with BPH [16, 17].

In the only RCT conducted in patients with CP/CPPS, saw palmetto (325 mg per day) was compared with finasteride (5 mg per day) [4]. The improvement in NIH-CPSI total score and subdomains of pain was similar with both saw palmetto and finasteride. However, with finasteride, the treatment effect was seen to continue up to 12 months, while with saw palmetto, it deteriorated after the 3rd month. Currently, there are no placebo-controlled studies for saw palmetto. Nevertheless, with the RCT conducted, there seems to be benefit for patients and further studies may be warranted.

The three best-studied phytotherapeutics in CP/CPPS, as mentioned above, are quercetin, pollen extracts, and saw palmetto. Among these, the methodologically most robust and satisfying study with the lowest risk of bias was done for pollen extracts by Wagenlehner et al. [3]. The results obtained from these studies have been summarized in Table 8.1. A similar improvement in NIH-CPSI score can be seen with all substances. The duration of improvement in symptoms for saw palmetto did not go beyond 3 months, while for pollen extracts, it was not measured after 3 months and with quercetin, it is not clear. A similar improvement in IPSS scores was seen with pollen extracts and saw palmetto. Finally, a decrease in WBC count in expressed prostatic secretion with quercetin and pollen extract was reported. Well safety and tolerability levels were reported for all substances.