Acupuncture for Urinary Incontinence in Women
Acupuncture for Urinary Incontinence in Women
By Christine Dehlendorf and Nassim Assefi, MD
Urinary incontinence afflicts 17-55% of older women and 12-42% of middle age women,1 causing a significant deterioration of quality of life, including emotional disturbances, social isolation,2 and increased risk of placement in long-term care facilities.3 It also presents a major cost burden to the U.S. health care system, estimated in the range of $26.3 billion for both direct and indirect costs.4
Although conventional treatments often are effective, they fail a significant number of women. Many therapies are associated with unacceptable side effects, and pelvic floor exercises are dependent on patient motivation and ability to contract the muscle groups voluntarily. Furthermore, conservative treatment has decreased effectiveness with increasing age.5
Acupuncture has long been used to treat disorders of the urinary tract and increasingly is being investigated as both an adjunctive and first-line therapy for all three types of incontinence in women.
Description
Genuine stress incontinence (GSI) describes an involuntary loss of urine during physical exertion, whereas urge incontinence (UI) is an irritative bladder syndrome that is associated with dysuria, frequency, and urgency. Mixed incontinence, any combination of the preceding two types, is the third major form of incontinence in women.
Conventional Treatment
Conventional treatment for GSI consists of pelvic floor exercises with or without biofeedback, hormone replacement therapy, surgery, and the use of devices such as vaginal cones. UI generally is treated with bladder re-training with or without medication. Newer approaches to the treatment of both types of incontinence include transcutaneous electrical stimulation,6,7 as well as direct neuromodulation of the sacral nerve roots.8
Mechanism of Action
The understanding of the physiologic basis of acupuncture in urinary conditions remains rudimentary. In GSI, acupuncture has been suggested to have a role in afferent nerve stimulation, producing reflex contraction of the muscles contributing to urethral closure.9,10 A second proposed mechanism is that of improved vascularization to the pelvic floor, resulting in improved competence of the urethral sphincter mechanism.9 Controlled studies have shown an increase in urethral pressure following acupuncture.10,11
With respect to UI, one proposed mechanism relates to acupuncture’s effect in increasing cerebrospinal fluid levels of endogenous opiates.12,13 Enkephalins have been shown to inhibit in vitro detrusor muscle contraction,14 and the pontine micturition center is under tonic inhibition by enkephalins.15 Furthermore, intravenous naloxone has been associated with decreased bladder capacity, compliance, and stability, as well as decreased urethral closure pressure in urodynamic studies.16 A second hypothesis suggests that acupuncture may function in a manner similar to electrical stimulation, which in- fluences neuronal pathways for detrusor inhibition.17 Finally, the periurethral muscle contractions associated with acupuncture itself could contribute to reflex inhibition of the detrusor muscle.18
Clinical Trials
Literature searches of Pubmed, Cochrane registry, Biosis, CINAHL, and AMED, with key words "urine," "urinary," "incontinence," and "acupuncture," supplemented by hand-searched citations, revealed nine relevant studies.
For UI, there were two randomized controlled trials (RCTs) of acupuncture, three non-controlled studies, and two poorly designed studies that provided some support for the use of acupuncture.
For GSI alone, two studies were found. One abstract reported a study of 17 women with GSI, showing significant improvement in subjective quality-of-life variables up to six months after treatment, but no improvement in bladder capacity or leakage.19 One randomized controlled study of 60 women with stress incontinence showed improvement in maximal pressure of the urethra and urethral length, but not in the 2-second flow rate of urine.10 (See Table, below.)
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Table |
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Results of clinical trials of acupuncture and urinary incontinence |
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| Study | Design | Incontinence | Patients | Objective Results | Subjective Results |
| Bergström et al9 | Prospective, no control | Urge and mixed | 15 | + | + |
| Huitian et al10 | RCT vs. placebo | Stress | 60 | +/- | N/A |
| Chang17 | RCT vs. placebo | Urge | 52 | +/- | + |
| Preiner et al19 | Prospective, no control | Stress | 17 | - | + |
| Kelleher et al21 | RCT vs. medication | Urge | 39 | +/- | +/- |
| Philp et al22 | Prospective, no control | Urge | 16 | +/- | + |
| Pigne et al23 | Prospective, no control | Urge | 16 | + | N/A |
In 1988, Chang conducted a RCT of 52 female outpatients without urinary tract infections who complained of frequency, urgency, and dysuria.17 The study group received one acupuncture treatment at a point traditionally used in the treatment of urinary tract disorders, Spleen 6 (Sp6), while the control group received treatment at a point generally used for the treatment of gastrointestinal disease, Stomach 36 (St36).
Subjectively, 22 patients (84.6%) in the treatment group reported improvement, compared to six (23.1%) in the control group. In the treatment group, the maximum cystometric capacity increased (P < 0.01) and the peak urinary flow rate decreased (P < 0.02) significantly 30 minutes after acupuncture, while no changes were found in the control group. In addition, six of the eight patients in the treatment group with unstable detrusors achieved stability, compared to one of six in the control group. There were no changes in first sensation to void, residual urine, maximum urethral closure pressure, or voided volume.
A subsequent paper published by Chang and colleagues in 1993 reported the long-term follow-up data (average 66.2 months) for this same study group.20 Although the study population showed continued symptomatic improvement with repeated acupuncture treatments, when urodynamic studies were performed one week after the most recent treatment, no long-term improvement was found.
The second RCT randomized 20 women with irritative bladder symptoms to receive acupuncture and 19 women to receive conventional pharmacologic therapy with oxybutynin.21 Following six weekly treatments at multiple acupuncture points, the subjective measures of urgency and frequency were significantly improved in both groups and nocturia was improved in the acupuncture group, but there was no significant improvement in UI in either group. Objectively, significant improvement was found in both groups in detrusor pressure rise on filling. A significant improvement also was seen in the acupuncture group in bladder capacity, but not in the other group. No changes were seen in flow rate, residuals, first sensation, or voiding pressure for either group. The medication group also reported more side effects than the acupuncture group. Three months following the treatment, eight of the 18 women who received acupuncture and were available for follow-up remained symptom-free, with four more continuing to experience partial relief. Seven of the 19 oxybutynin-treated patients were symptom-free.
Three non-controlled studies also addressed the use of acupuncture in UI, including mixed incontinence. A recently published pilot study investigated UI symptoms in 15 elderly women who had failed conventional treatment.9 Quality-of-life measures, subjective urge to void, and objective leakage tests were significantly improved up to three months following acupuncture treatment. Another non-controlled study of 16 patients with UI showed symptomatic improvement in 11 patients, with no consistent change in bladder filling curves.22 Finally, one study of 16 patients with UI that was published only as an abstract found improvement in frequency of micturition, leakage, first desire to void, bladder capacity and compliance, and detrusor instability.23
Methodologic Challenges
There are numerous challenges in interpreting acupuncture studies. These include specifying the acupuncture treatment plan (i.e., the number of points stimulated, the type of acupuncture used, and the frequency and duration of treatment), identifying appropriate controls (e.g., acupuncture at presumed non-therapeutic points, non-invasive acupuncture, and mock electro-stimulation units), correlating diagnoses between traditional Chinese medicine and allopathic medicine, and the blinding of patients to the intervention.24
In addition, measurement of treatment outcomes is complicated by the time-consuming and potentially invasive nature of objective measures in studies of incontinence. Furthermore, objective measures in UI do not always correlate with patient symptoms.25
Adverse Effects
A review of the global acupuncture literature from 1981 to 1994 attempted to identify the adverse effects of acupuncture, and found 193 adverse events with three deaths.26 The largest risk with acupuncture is infection, including 100 reported cases of hepatitis B/C/non- A-non-B. In all of these cases, the sterilization of needles was inadequate. One case of HIV infection also has been reported, and is presumed to be due to lack of sterilization. Sterilization of needles is not thought to be an issue in the United States where the use of disposable sterile needles is required by the Food and Drug Administration.
Sepsis and endocarditis are reported rarely, as well as one case of death secondary to an asthma attack. Finally, pneumothorax is reported to be the dominant mechanical injury, and is more common in those with pre-existing chronic obstructive pulmonary disease.
With respect to acupuncture for incontinence, only one of the above studies reported side effects.21 Of the 20 women receiving acupuncture, two complained of discomfort upon insertion of the needles, three noted feeling lightheaded following treatment, four patients reported headache, and four patients experienced drowsiness. Some patients may have experienced multiple side effects.
Conclusion
Reasonable data support a physiologic mechanism for the use of acupuncture for both GSI and UI. However, high-quality clinical trials are scarce. No RCT of acupuncture for GSI was identified. One randomized, placebo-controlled trial of acupuncture for UI showed subjective efficacy, with some objective benefit, and another RCT found some increased subjective and objective efficacy of acupuncture treatment for the same symptoms when compared to standard pharmacologic therapy. Non-controlled reports support the effectiveness of acupuncture in urge and mixed incontinence.
Recommendation
Acupuncture appears to be a promising option for urge incontinence. However, the frequency and duration of treatment, the acupuncture points to use, and potential interactions with pharmacologic therapies have not been elucidated. There are insufficient data to recommend the use of acupuncture in the treatment of genuine stress incontinence.
Dr. Dehlendorf is a fourth-year medical student and Dr. Assefi is Attending (Clinician-Teacher), Departments of Medicine and Obstetrics/Gynecology, Complementary and Alternative Medicine Liaison, School of Medicine, University of Washington in Seattle.
References
1. Thom D. Variation in estimates of urinary incontinence prevalence in the community: Effects of differences in definition, population characteristics, and study type. J Am Geriatr Soc 1998;46:473-480.
2. Grimby A, et al. The influence of urinary incontinence on the quality of life of elderly women. Age Ageing 1993;22:82-89.
3. Thom DH, et al. Medically recognized urinary incontinence and risk of hospitalization, nursing home admission and mortality. Age Ageing 1997;26:367-374.
4. Wagner TH, Hu TH. Economic costs of urinary incontinence in 1995. Urology 1998;51:355-361.
5. Susset J, et al. A predictive score index for the outcome of associated biofeedback and vaginal electrical stimulation in the treatment of female incontinence. J Urol 1995;153:1461-1466.
6. Yasuda K, Yamanishi T. Critical evaluation of electro-stimulation for management of female urinary incontinence. Curr Opin Obstet Gynecol 1999;11:503-507.
7. Yamanishi T, et al. Randomized, double-blind study of electrical stimulation for urinary incontinence due to detrusor overactivity. Urology 2000;55:353-357.
8. Hasan ST, Neal DE. Neuromodulation in bladder dysfunction. Curr Opin Obstet Gynecol 1998;10: 395-399.
9. Bergström K, et al. Improvement of urge- and mixed incontinence after acupuncture treatment among elderly women—a pilot study. J Auton Nerv Syst 2000; 79:173-180.
10. Huitian Z, et al. Flow dynamics of urine in female patients with stress urinary incontinence treated by acupuncture and moxibustion. Int J Clin Acupuncture 1992;3:243-247.
11. Kubista E, et al. Electro-acupuncture’s influence on the closure mechanism of the female urethra in incontinence. Am J Chin Med 1976;4:177-181.
12. Clement-Jones V, et al. Acupuncture in heroin addicts: Changes in met-enkephalin and beta-endorphin in blood and cerebrospinal fluid. Lancet 1979;2:380-382.
13. Clement-Jones V, et al. Increased B-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain. Lancet 1980; 2:946-948.
14. Klarskov P. Enkephalin inhibits presynaptically the contractility of urinary tract smooth muscle. Br J Urol 1987;59:31-35.
15. Chai TC, Steers WD. Neurophysiology of micturition and continence in women. Int Urogynecol J Pelvic Floor Dysfunct 1997;8:85-97.
16. Murray KH, Feneley RC. Endorphins—a role in lower urinary tract function? The effect of opioid blockade on the detrusor and urethral sphincter mechanisms. Br J Urol 1982;54:638-640.
17. Chang PL. Urodynamic studies in acupuncture for women with frequency, urgency and dysuria. J Urol 1988;140:563-566.
18. Brubaker L. Electrical stimulation in overactive bladder. Urology 2000;55(5A Suppl):17-23.
19. Preiner J, et al. Acupuncture for female stress urinary incontinence: SEAPI, AUAQOL and video-urodynamic assessment. J Urol 2001;165(5 Suppl):76-77.
20. Chang PL, et al. Long-term outcome of acupuncture in women with frequency, urgency and dysuria. Am J Chin Med 1999;21:231-236.
21. Kelleher CJ, et al. Acupuncture and the treatment of irritative bladder symptoms. Acupuncture Med 1994; 12:9-12.
22. Philp T, et al. Acupuncture in the treatment of bladder instability. Br J Urol 1988;61:490-493.
23. Pigne A, et al. Acupuncture and the unstable bladder. Abstracts from the 15th Annual Meeting of the International Continence Society; 1985:186-187.
24. Staebler FE, et al. Why research into traditional Chinese acupuncture has proved difficult. Strategies of the Council for Acupuncture, UK, to overcome the problem. Complement Ther Med 1994;2:86-92.
25. Frazer MI, et al. The severity of urinary incontinence in women: Comparison of subjective and objective tests. Br J Urol 1989;63:14-15.
26. Norheim AJ. Adverse effects of acupuncture: A study of the literature for the years 1981-1994. J Altern Complement Med 1996;2:291-297.
Dehlendorf C, Assefi N. Acupuncture for urinary incontinence in women. 2002;5:46-49.Subscribe Now for Access
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