Acupuncture and Voiding Problems
By Christer P.O. Carlsson MD, PhD
Several, mostly uncontrolled, clinical studies have examined acupuncture and voiding disorders. Small, uncontrolled trials of acupuncture have claimed a benefit in voiding symptoms among patients with idiopathic bladder instability,1 symptoms and cystometric capacity in spinal-cord-injured patients with detrusor hyperreflexia and urinary incontinence,2 and bed wetting in children.3
Only two controlled trials were identified. A randomized, controlled study in 39 subjects, ages 18-75, with previously untreated "irritative bladder symptoms," found that superficial acupuncture was as effective as anticholinergic therapy.4 The frequency of side effects was much higher in the group treated with anticholinergics. It is unfortunate that there were no clear diagnoses indicated.
A randomized, placebo-controlled, single-blind study in 20 patients with nocturia (17 females, ages 65-96) in two geriatric hospitals compared acupuncture to placebo control (mock-transcutaneous electrical nerve stimulation [TENS], which is a TENS unit with no electrical output).5 Subjects received 10 treatments over two weeks; acupuncture, compared to control, significantly improved nocturia. The mean number of voids in three nights decreased from 6.3 to 4.2 in the treated group at the end of the study (P = 0.004, 95% confidence interval -1.0 to -3.0). Significant improvement was noted by the end of the first week (P = 0.008). The placebo group experienced no change over the course of the study. No follow-up was conducted.
Urinary incontinence is more common in women than men, and affects 38% of community-dwelling women older than age 60. In addition to being a major social problem, health care costs due to incontinence are estimated to be $16 billion a year.6 This author and colleagues recently conducted an uncontrolled study to examine whether acupuncture affects urge and mixed-type incontinence in older women.6
All women who were treated by a specialized incontinence team during a three-year period and who regarded their symptoms as not satisfactorily relieved by standard treatment (bladder and pelvic-floor muscle training and drug therapy) were invited to participate. Fifteen women (average age 76.4, average duration of incontinence 3.7 years) with urge or mixed-type incontinence accepted.
Twelve sessions of acupuncture were performed twice weekly, for 25 minutes, over six weeks. The number of traditional acupuncture points used was gradually increased from four to 14. The following points were used bilaterally: six sacral (BL31, BL32, and BL33), two thoraco-lumbar (BL23), four in the lower legs (SP6, KI3) and two near the elbows (LI11). Practitioners attempted to elicit the de qi feeling (a characteristic feeling of numbness, soreness or slight pain, that spreads around a correctly located acupuncture needle).
Outcome measures were taken at baseline, study end, and one and three months after the study ended. Patients completed a structured questionnaire that subjectively assessed different aspects of urgency, leakage, and frequency of voiding, and a validated quality-of-life assessment that included questions about the influence of urinary incontinence on daily life. An overall global outcome was assessed after the last treatment and at follow-up; patients were asked to score their condition as symptom-free, much improved, slightly better, unchanged, or worse.
Objective measurements utilized an Inco-test, a 48-hour, two-part test that consists of the patient’s record of voiding frequency and the amount of urine passed and measurements of the amount of leakage by weighing incontinence pads.7 Although there was no significant improvement in amount of leakage immediately after the study ended, leakage was improved significantly one month and three months after treatment ended (both P < 0.03).
Compared to baseline, there were significant improvements in scores. Twelve of the 15 women considered themselves improved at the end of the study; eight considered themselves much improved even three months after treatments were finished.
This uncontrolled study suggested significant, lasting improvements in older women who were dissatisfied with other treatments for long-term incontinence.
Electrical Stimulation
Other forms of afferent nerve stimulation techniques (e.g., intravesical or nerve root stimulation and TENS) have been used to treat voiding disorders.8,9 TENS applied over the suprapubic area, over the sacral dermatomes, or over quadriceps and hamstring muscles have all shown some positive effects.10,11 The success rate for different kinds of electrical stimulation in the treatment of urinary incontinence varies from 45% to 91%. All studies seem to agree that about one-third of all patients will have good long-term results with repeated stimulation. One review reports that 20% of patients became dry and 37% were significantly improved.9
Mechanism of Action
Mechanisms of action for acupuncture probably involve different somato-autonomous reflexes. In anesthetized animals, somatic afferent stimulation (particularly on the perineal area) induces changes in bladder function and sphincter activity, both excitatory and in-hibitory, as a consequence of reflex changes in the para-sympathetic efferent activity.12,13 These responses are strongly segmentally organized. Periurethral electromy-ography (EMG) showed excitation when acupuncture-like stimulation was done rostrally on the body or on the hind limbs. A reduction of EMG was seen if the dorsal or ventral sacrococcygeal muscles were stimulated.14
Three of the acupoints used (BL31, BL32, and BL33) are located just above the sacral foramina and thus over the S1, S2, and S3 roots. Also, the acupoints on the legs (KI3 and SP6) have innervation from the S1-S2 area. This means that segmental influences are neuroanatomically possible. Interactions with the muscle innervation of the pelvic floor and urethral sphincters are possible.
Conclusion
Acupuncture, as well as other forms of sensory stimulation, may have a clinically relevant effect in the treatment of incontinence and does not worsen the condition. Adequately powered controlled trials should be done, and if beneficial effects are confirmed, the technique can be incorporated into a multimodal program of incontinence management.
Dr. Carlsson is Consultant, Pain Specialist, Physical Medicine Unit, Department of Rehabilitation, Lund University Hospital, Lund, Sweden.
References
1. Philp T, et al, Acupuncture in the treatment of bladder instability. Br J Urol 1988;61:490-493.
2. Honjo H, et al. Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Urol Int 2000; 65:190-195.
3. Björkström G, et al. Electro-acupuncture in the treatment of children with monosymptomatic nocturnal enuresis. Scand J Urol Nephrol 2000;34:21-26.
4. Kelleher CJ, et al. Acupuncture and the treatment of irritative bladder symptoms. Acup Med 1994;12:9-12.
5. Ellis N, et al. The effect of acupuncture on nocturnal urinary frequency and incontinence in the elderly. Complement Medical Res 1990;4:16-17.
6. Burgio KL, et al. Behavioral vs drug treatment for urge urinary incontinence in older women: A randomized controlled trial. JAMA 1998;280:1995-2000.
7. Siltberg H, et al. Pad weighing tests: The best way to quantify urine loss in patients with incontinence. Acta Obstet Gynecol Scand Suppl 1997;166:28-32.
8. Hasan ST, Neal DE. Neuromodulation in bladder dysfunction. Curr Opin Obstet Gynecol 1998;10:395-399.
9. Appell RA. Electrical stimulation for the treatment of urinary incontinence. Urology 1998;51(2A suppl): 24-26.
10. Fall M, Lindström S. Transcutaneous electrical nerve stimulation in classic and nonulcer interstitial cystitis. Urol Clin North Am 1994;21:131-139.
11. Nakamura M, et al. Bladder inhibition by electrical stimulation of the perianal skin. Urol Int 1986;41: 62-63.
12. Sato A, et al. Changes in vesical function produced by cutaneous stimulation in rats. Brain Res 1975;94: 465-474.
13. Sato A, et al. Reviews of Physiology Biochemistry and Pharmacology 130. The Impact of Somatosensory Input on Autonomis Functions. Berlin, Heidelberg: Springer-Verlag; 1997.
14. Morrison JF, et al. Long-lasting facilitation and depression of periurethral skeletal muscle following acupuncture-like stimulation in anesthetized rats. Neurosci Res 1995;23:159-169.
Carlsson CPO. Acupuncture and voiding problems. Altern Ther Women's Health 2002;4:2123You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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