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In this section I will discuss urinary symptoms such as frequency, dysuria (pain on passing water), and urgency (being unable to hold on to water), urge incontinence (inability to ‘hold on’), over-active bladder and interstitial cystitis and how they may be treated by acupuncture.
Definition of Interstitial Cystitis / Painful Bladder syndrome
Interstitial cystitis (IC) is a condition that results in recurring discomfort or pain in the bladder and the surrounding pelvic region. The symptoms vary from case to case and even in the same individual. People may experience mild discomfort, pressure, tenderness, or intense pain in the bladder and pelvic area. Symptoms may include an urgent need to urinate, a frequent need to urinate, or a combination of these symptoms. Pain may change in intensity as the bladder fills with urine or as it empties. Women’s symptoms often get worse during menstruation.
From the National Kidney and Urological Diseases information Clearing house (part of the US government National Institute of Health)
Bladder problems are often complex, long-lasting and can have a devastating effect on the sufferers’ quality of life. They are very common, and affect between 15 and 20% of women aged 20-29 (bladder over-activity) and a smaller percentage suffer with ‘painful bladder syndrome’.
The most frequent symptoms are pain (either in the bladder, over the lower abdomen, or on passing water (know as micturition), frequency (as the term suggest passing water more frequently than normal) and nocturia (getting up at night to pass water). There are frequently other symptoms such as pain during intercourse and longstanding pelvic pain.
The diagnosis of this sort of problem is often confusing- many terms are used to describe the symptoms and may be grouped together as a ‘syndrome’. Two people may have very similar symptoms but may well have been given two different diagnoses.
Common diagnoses
- Chronic pelvic pain
- Dysuria
- Dysparaeunia (painful intercourse)
- Interstitial Cystitis
- Chronic Pelvic Pain syndrome
- Overactive Bladder
- Bladder Hypersensitivity
- Urethral syndrome
- Myofascial pain syndrome of the pelvic floor
- Proctalgia
- Proctalgia fugax
And in men;
- Chronic prostatitis
- Prostatodynia
- Orchialgia
A number of treatments are used, often with disappointing results. These include long-term antibiotics, alpha blockers, antimuscarinics, tricyclic antidepressants, sacral neruostimulation, urethral dilatation, anticholinergics and anti-anxiety drugs such as diazepam. As these drugs frequently cause side-effects such as dry mouth, constipation and sedation, as few as 1 in 5 sufferers are still taking the medication at 6 months. (see Burgio et al JAMA 1998)
As the symptoms are often long-lasting (chronic) there is a high degree of associated depression, fatigue and anxiety. There is also a strong correlation with other conditions such as chronic fatigue syndrome, irritable bowel syndrome and fibromyalgia suggesting there may be a common causal link.
Acupuncture and the bladder- treatment of interstitial cystitis (Painful Bladder syndrome or PBS) and other functional bladder conditions.
Investigation, by a consultant urologist or gynaecologist is important to exclude any underlying pathology. Such investigation should exclude structural abnormalities of the urinary tract which may have been undiagnosed since birth, malignant tumours of the urinary or gynaecological systems (kidney, ureter, bladder, genitalia etc) or other significant diseases. Such investigation should also exclude chronic bacterial infections of the bladder or prostate, and chronic sexually transmitted diseases such as Chlamydia. If any of these pathological conditions are present, conventional medicine will usually offer significant improvement or in many cases a cure from the underlying disease process.
Many conditions however, would be described as ‘functional’ rather than ‘pathological’.
Generally speaking, modern medicine is very adept at treating pathological conditions, where a significant structural abnormality exists (caused by a disease process). However, when a functional abnormality exists (i.e. when an organ or a system is not functioning 100% but there is no ‘disease’ underlying it), conventional medicine is less adept. Treatments for functional disorders are rarely specifically targeted at the underlying dysfunction, so there may be unwanted adverse effects from the treatment.
A number of studies have now been completed, examining the effects of acupuncture on bladder pain and dysfunction. (This is often named interstitial cystitis or overactive bladder and is a general descriptive term covering a wide range of bladder problems which also includes urge incontinence).
Much of the treatment for bladder problems in the past has focussed on the anatomical structure and function of the bladder, however there is now an evolving and growing body of work that clearly demonstrates that this is only part of the story.
Studies using functional MRI (fMRI) which examine brain activity, have specifically studied bladder problems. It is now clear that the role of the brain in the role of bladder dysfunction has been somewhat underestimated.
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Responses to bladder filling (main effects, thresholded at P = 0.05) rendered on standard brain surface (red = activation, blue = deactivation). A. Normal subjects; blue arrow: right insula and adjacent regions; black arrow: inferior parietal region. B. Urge-incontinent subjects; blue arrow: insula and frontotemporal; black arrow: parietal; white arrow: medial orbitofrontal; yellow arrow: anterior cingulate (ACG).
Taken from Neuroimage. 2008 February 15; 39(4): 1647–1653.
Abnormal Connections in the Supraspinal Bladder Control Network in Women with Urge Urinary Incontinence
Stasa D. Tadic, Derek Griffiths, Werner Schaefer, and Neil M. Resnick |
The images in A are from normal subjects obtained during a period with full bladder and strong bladder sensation while repeatedly infusing and withdrawing a small amount of liquid in and out of the bladder (study undertaken in Pittsburgh USA- for the reference see images). The red areas indicate activation of nerves, and the blue areas, deactivation.
Among normal subjects, many regions involved in bladder control were effectively connected and the authors interpreted this as suggesting mainly inhibitory connections i.e. there is a strong central suppression of the feelings to pass urine.
The images in B are from subjects with urge incontinence (unable to hold on to water). Among urge-incontinent subjects, the effective connectivity was shifted to a different part of the brain and the authors suggested this was consistent with excitation (recruitment) of accessory pathways in an attempt to maintain bladder control.
In other words, those with normal bladder function send strong inhibitory stimuli to the bladder, whilst those with urge incontinence tend towards a more excited rather than suppressed state.
In a normally functioning individual, the brain will regularly send impulses down the spinal cord to cause an inhibition of bladder emptying i.e. it is the action of inhibitory nerves that enables bladder emptying to occur at long intervals. (For an excellent short animationb of this see the link below http://www.nlm.nih.gov/medlineplus/ency/anatomyvideos/000009.htm )
If, for whatever reason, these central (ie deriving from the brain) signals are lost or weaker than normal, then inhibition of bladder emptying is also impaired, so the individual feels the urge to empty the bladder too frequently.
Several studies have now been completed that have demonstrated, very successfully, that it is possible to treat such symptoms with acupuncture. It is believed that acupuncture acts by re-training the brain to start sending out the inhibitory signals once again, thus regaining control.
A paper presented at the American Urological Association’s annual meeting in 2009 by Felicity Reeves, Chris Chapple and Mike Pullman from Sheffield, demonstrated that in a series of 15 patients who had failed to respond to conventional therapy, all of these patients had improvement of symptoms, whilst 86% also achieved improvements in their quality of life when treated with a course of acupuncture (using a combination of manually stimulated acupuncture points).
A much larger, and well controlled study, published in April 2010 in the Journal of Urology, by Peters and others, (Vol 183,1438-1443, April 2010) undertook a multicentre, controlled study, comparing ‘percutaneous tibial nerve stimulation’ with a ‘sham’ treatment. This was equivalent to electro-acupuncture- a needle was inserted and then electrically stimulated on a point near to the tibial nerve (a nerve on the lower leg adjacent to a number of frequently used acupuncture points).
The results from the study were quite spectacular- over 58% of patients reported moderately or markedly improved bladder symptom scores (showing highly statistical significance over sham treatment)- The patients enrolled in the study were a difficult group of patients- they had over 10 bladder voids per day, failed ‘conservative treatment’ (meaning anti-muscarinic or other such treatments). The average duration of symptoms prior to enrolment in the study was over 10 years in both groups.
The symptoms that improved, included frequency, night time voiding, urinary urge incontinence and voids with severe urgency. They did not report any serious adverse effects.
Bearing in mind that the study above used only a single treatment point (using a pair of needles), it would bode very well, if further assessment of the patient revealed active myofascial trigger points in structures also known to be implicated in aggravating symptoms of the bladder.
Myofascial trigger points and bladder symptoms
Muscles in the abdomen, pelvis, thighs and lower back have all been implicated in causing, aggravating or perpetuating bladder dysfunction. A thourough examination of these muscles often reveals trigger points, that once deactivated by dry needling or other manual therapy, will lead to improvement of symptoms. Listed below are the muscle groups most frequently affected. |
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Pyramidalis
This is a small muscle that lies just above the pubic bone and helps tighten the linea alba- the thin central tendon that runs up the centre of the abdominal wall. Trigger points in this muscle may develop through injury, scars (such as caesarean section) or in association with other muscle groups. Symptoms may be simply pain in the lower abdomen, but this may also aggravate urinary symptoms.The oblique abdominal muscles may sometimes also cause testicular pain in men, as may the gluteus maximus muscle. |
Trigger points in the vastus medialis are also very
common indeed and often cause the knee to “give
way” or buckle. The pain is usually felt as a severe
ache over the inner part of the knee spreading upwards
in the inner thigh.
| Scar Pain |
Myofascial trigger points commonly occur in scars. Such scars could be from trauma, surgical procedure or minor- seemingly insignificant injuries. Tenderness in the scar (especially when squeezed) is often associated with other urinary symptoms, particularly pain. Scars respond very well to simple dry needling, combined with simple massage by the patient. Referred pain is less common, however, so called ‘autonomic’ symptoms (basically dysfunction of nerves) are often associated with trigger points in scars in the abdominal wall. This includes cramping pain, frequency and urge incontinence.
Pelvic muscles implicated in bladder dysfunction
Muscles of the pelvic floor- specifically the urinary and anal sphincters and their associated muscles, iliococcygeus, obturator internus and the intrapelvic part of piriformis, and the bulbospongiosus and ischiocavernosus muscles can all be implicated in urinary symptoms. These are discussed in more detail here .
Treatment of chronic urinary symptoms with acupuncture- what is involved?
From studies (including those listed above) it would appear the best method for treating urinary symptoms would be with a course of treatment.
My chosen protocol is to initially assess by means of a bladder questionnaire, and full physical examination to exclude other associated abdominal or pelvic trigger points. If other such trigger points exist, these would be treated by simple needling. I would then treat once per week for 6 (ideally) consecutive weeks, and then review after a further 6 weeks. Treatment points would be a combination of points based on symptoms and findings during examination.
Occasionally, a second course of treatment is required if response is sub-optimal, however this would not be considered if negligible response was gained from the first course of treatment.
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