February 05, 2012
Acupuncture has traditionally been utilized to treat a variety of urinary bladder dysfunctions and symptoms.
Research studies have suggested that acupuncture may be effective in treating chronic prostatitis and chronic pelvic pain syndrome, preventing recurrent urinary tract infections, and relieving recurrent cystitis and overactive bladder. The exact mechanisms by which acupuncture works for certain individuals with urinary symptoms are unknown. However, it has been suggested that acupuncture elicits autonomic responses that exert a modulation effect on the nerves that control bladder function. In addition, acupuncture has been shown to positively influence the immune system and psycho-emotional status, and these effects may also benefit certain individuals with urinary symptoms. Here, I primarily discuss how acupuncture works in the management of overactive bladder symptoms.
What Is Overactive Bladder?
According to the International Continence Society, overactive bladder is a condition characterized by urinary urgency, with or without urgency incontinence, usually with urinary frequency and nocturia. A diagnosis of overactive bladder is made based on the patient’s symptoms and is appropriate in the absence of a proven infection or other obvious pathology. Overactive bladder is caused by the bladder muscles’ contracting before the bladder is full.
Symptoms of overactive bladder and explanation of terms:
• Urinary urgency: The sudden, strong need to urinate immediately.
• Urge incontinence: Leakage or gushing of urine that follows a sudden, strong urge.
• Urinary frequency: Bothersome, frequent urination occurring eight or more times a day or two or more times at night.
• Nocturia: Awaking at night to urinate.
Rationale of Acupuncture Treatment for Overactive Bladder
Acupuncture has been used to treat urological conditions for thousands of years, particularly in East Asian countries. In the West, the usage of acupuncture has greatly increased over the last 40 years. In the majority of cases, acupuncture has been used as an alternative or complementary treatment.
In recent years, however, acupuncture has also been used by urologists as a primary treatment for overactive bladder. Not many people, including general healthcare practitioners, are aware of this fact. Even patients who are receiving the treatment may not know that they are receiving acupuncture. This is because most of the time the therapy is not referred to as acupuncture; instead, it is introduced in different terms, such as “percutaneous posterior tibial nerve stimulation” or “Stoller afferent nerve stimulation,” which is one of the neuromodulation techniques.
Types of Neuromodulation Techniques
A neuromodulation technique is a procedure that can modulate the neural functioning of the urinary bladder in an attempt to positively influence urinary control.
One of the earliest neuromodulation studies was conducted nearly 50 years ago. Since then, a variety of methods for electrically stimulating the bladder, sacral roots, and pudendal nerves has emerged, with varying success. Most of these treatments have failed to gain widespread acceptance due to poor results, technical problems, high costs, or low patient compliance due to the discomfort of treatment procedures.[3, 4] For example, a neuromodulation therapy called sacral neuromodulation (SNM or InterStim therapy) involves the surgical implantation of an electrostimulator adjacent to the sacral or the pudendal nerves, bladder wall, or urethra. Another form of neuromodulation therapy called anogenital electrical stimulation involves no surgical procedure; however, the method requires the insertion of plugs equipped with electrodes into the anal canal or vagina. Then the highest needed intensity of stimulation is applied in order to obtain sufficient therapeutic benefit.
Percutaneous posterior tibial nerve stimulation (PTNS, also referred as Stoller afferent nerve stimulation) is considered one of the most promising methods of neuromodulation for the treatment of overactive bladder.
History of Percutaneous Posterior Tibial Nerve Stimulation and Its Relation to Acupuncture
The posterior tibial nerve is a mixed nerve, containing both motor and sensory nerve fibers. PTNS involves inserting a fine-gauge needle just above the ankle (at the site of the posterior tibial nerve). The inserted needle is attached to an electric stimulator; the tibial nerve then carries electrical signals in an afferent direction to the sacral spine. The procedure typically lasts 30 minutes and is administered weekly over a period of 12 weeks.
The “needle” used in PTNS is actually a 36-gauge acupuncture needle inserted by using a specially designed guiding tube. The guiding tube was invented by a blind Japanese acupuncturist, Waichi Sugiyama, in the 17th century; it is currently used by the majority of acupuncturists worldwide.
It is reasonable to consider the PTNS technique is a variation of the electroacupuncture technique commonly used by acupuncturists, not only because of the needling materials used in PTNS but also because its concept was derived from the practice of acupuncture. The stimulation site used in PTNS is the SP6 acupuncture point. This well-known acupuncture point has been traditionally used to treat a wide variety of urological conditions.
In 1982, McGuire et al.  stimulated acupuncture points near the posterior tibial nerve (SP6 acupuncture point) with TENS and obtained good symptomatic results among patients diagnosed with detrusor (urinary bladder muscle) instability, intestinal cystitis, and neurological conditions. In 1987, Stoller  reported “prompt relief of unstable bladder” with acupuncture stimulation on the SP6 point on monkeys. With repeated treatments on the SP6 acupuncture point, progressively longer periods of bladder stability were noted. In 1988, Chang  reported results using acupuncture, showing statistically significant changes in the urinary parameters (maximum cystometric capacity and maximum flow rate) in a group of 26 women immediately after a 30-minute treatment. Acupuncture was administered on the SP6 point, which is located near the ankle over the posterior tibial nerve. In 1999, Stoller  reported the outcomes of their study using posterior tibial nerve stimulation (electroacupuncture on the SP6 point). Patients were having pelvic-floor dysfunction with symptoms such as urinary urge, incontinence, and/or pelvic pain. Stoller described an 81% clinical success rate in 90 patients after a mean follow-up of 5.1 years. Despite these promising results from administering acupuncture on the SP6 point, the therapy was not commonly used in urological practice. However, an FDA-approved electric stimulator (PercSANS™) became available commercially in February 2000 and has been used by a growing number of urology clinics.
An increasing number of research papers have been published on PTNS treatment. Most of these papers show good results for various urinary symptoms; however, the success rates were not as high as Stoller had initially reported. It should be noted that although pioneers of PTNS obtained the idea from traditional acupuncture practice [6, 7, 10], research papers on PTNS and its promotional materials rarely mentioned the word “acupuncture” once the commercial version of the PTNS unit was introduced. Nevertheless, urology specialists have recommended that PTNS is useful for treating refractory urinary urge incontinence and should at least be considered as a therapeutic alternative before resorting to an aggressive surgery. PTNS is contraindicated for patients wearing pacemakers or defibrillators. It is also not recommended for patients with coagulopathy (a tendency toward bleeding) or neuropathy, or for pregnant women.
Acupuncture Treatment for Urological Problems
It is important to note that PTNS (or electroacupuncture on SP6) is only one element of acupuncture treatment for urological problems. A wide variety of acupuncture points and stimulation methods are available to influence urological function.
Kitaoji et al. examined the efficacy of acupuncture on 11 overactive-bladder patients. Acupuncture needles were inserted at the BL33 points (bilateral), and the needles were manually stimulated for 10 minutes. After 4 to 12 acupuncture sessions, 7 patients experienced a complete or partial control of urinary-urge incontinence. Acupuncture significantly increased their maximum bladder capacity and bladder compliance. It should be noted that the BL33 point used in this study is traditionally used for various urological conditions. It is located at the S3 sacral nerve root, which governs detrusor muscle contractions. The S3 nerve has therefore been frequently targeted in various forms of neuromodulation treatments. Other acupuncture studies [13-16] have shown improvements in subjective and/or objective parameters in overactive-bladder patients through the use of a variety of acupuncture points (e.g., LI11, ST36, BL23, BL28, BL31, BL32, BL39, KI3, GV4, CV3, CV4, CV6).
Unlike neuromodulation techniques, most of which attempt to stimulate only one point or area of the body, acupuncture traditionally utilizes a much wider variety of points across the body (see Table 1a & 1b). Interestingly, most of the acupuncture points traditionally used to treat urinary incontinence are located within the nerve segments or dermatomes targeted by neuromodulation methods. Most of the aforementioned neuromodulation methods attempt to influence detrusor muscle functions by stimulating the root or dermatomes of S2-S4 or the tibial nerve, which contains sensory-motor nerve fibers originating from spinal roots L4 through S3 (See Fig. 1 and Fig. 2).
Table 1a. Prescriptions of Acupuncture Points for Urinary Incontinence Described in Acupuncture Textbooks and Chinese Medicine Classics
It should be noted that traditional acupuncturists administer treatment on an individual basis, using combinations of the above-mentioned points. In addition, many traditionally trained acupuncturists not only utilize the points related to urinary organs but also use points to address the patient’s underlying physical and/or emotional imbalances. This approach could be highly important, especially when considering that a previous PTNS study has strongly suggested that the success of PTNS treatment depends upon the patient’s emotional state.
Figure 1: Locations of Acupuncture Points Used for Urinary Incontinence in Relation to Anterior Dermatomes
Figure 2: Locations of Acupuncture Points Used for Urinary Incontinence in Relation to Posterior Dermatomes
An overactive bladder can considerably impair a patient’s quality of life. The International Consultation on Incontinence guidelines state that when the first-line approach, including medications, behavioral therapy, and lifestyle modifications, is not fully satisfactory or fails after 8 to 12 weeks, alternative therapies should be sought out.
Acupuncture can be a reasonable treatment option to consider before proceeding to more aggressive conventional treatments. It may be also suitable for patients who did not respond to previous drug treatments.
Consumers who wish to try acupuncture should look for a qualified practitioner in their region. It is best to look for a practitioner who has been formally trained in traditional acupuncture and also has sufficient knowledge of overactive bladder and urinary-bladder physiology.
Tim H. Tanaka, PhD. is a Japanese licensed acupuncturist, certified herbalist, and board-certified biofeedback therapist.
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