Exploration of urinary incontinence and its treatment in Chinese and Western medicine.
Urinary incontinence, though not life-threatening, is a big burden to the affected individuals and their families. According to research by Stewart, et al. (2003) urinary incontinence is associated with poorer quality of life and sleep scores, and a higher probability of depression.
Incontinence sufferers reported more physical discomfort, were more worried about their health and were more troubled and more frequently hindered in their social activities compared to individuals who did not suffer from incontinence. (Badlani, et al., 2009)
In the context of its extreme commonality, urinary incontinence is therefore a highly attractive area of research for both Western medical practitioners and TCM practitioners alike. Interestingly, Western and TCM treatment approaches in respect to urinary incontinence share some similarities in their focus on spinal cord nerve innervations.
Nevertheless, research is stymied by a lack of studies with sufficiently large sample sizes. Much of the research has focused on small-size trials. Complicating matters further, TCM practitioners argue that the randomized control trials (RCT) which form the backbone of research into the effectiveness of medical treatment fail to properly assess TCM treatments.
Incontinence is a condition that would benefit from treatment from multiple angles. Research into incontinence treatment through acupuncture demonstrates a low to medium effect. These trials deserve greater interest from the medical community and should give TCM practitioners the confidence necessary to treat and support patients with this problem. In addition, TCM practitioners can and should be able to guide patients who would benefit from further treatment through their GP, as well as advising on self-treatment options.
The International Continence Society (ICS) defines urinary incontinence as involuntary loss of urine that is objectively demonstrable and is a social or hygienical problem. (Abrams et al., 1988)
Broadly speaking, bladder problems can be divided into three areas: problems of storing urine, problems of emptying urine and problems that occur after voiding. (Abrams, et al., 2002)
Overactive Bladder Syndrome (OAB) describes problems of storing and emptying urine. OAB is sometimes referred to by doctors using the terms irritable or unstable bladder or detrusor over-activity. The syndrome is characterized by urinary urgency, nocturia and a high frequency of voluntary of involuntary urination.
In many cases, patients report feeling their bladder squeeze as if full, but do not pass urine when they go to the loo. This condition is common in patients with diabetes, the elderly, patients with co-morbidities that affect the nervous system, and men with prostate problems. The symptoms include a strong urge to go to the loo (referred to in the literature as Urgency), occasional Urinary Urgency Incontinence (UUI – a sudden urge to go the loo shortly before the incontinence), a high frequency of needing to empty the bladder, in the range of more than 8 times per day and the need to use the loo at night (Nocturia).
The OAB syndrome is divided into OAB wet (occasional incontinence) and OAB dry. The impact of OAB on patients‘ quality of life is commonly reported to be higher than in Stress Incontinence and patients are therefore more likely to seek treatment, Badlani, et al. noted in their 2009 book.
Stress Incontinence is a type of incontinence, which is characterized by sudden involuntary leakages during activities like coughing, sneezing, laughing, or exercise.
Stress incontinence usually occurs when the muscles in the pelvic floor or sphincter have been damaged or weakened through childbirth, surgery or simply age-related muscle atrophy.
The most intense form of stress incontinence results in urine escaping during low-impact, everyday activities like walking or carrying things. Such patients have no urge to pass urine and therefore are often unconscious of the urine escaping until too late. This is most common in women during and after menopause.
Stress incontinence in women is related to a weakness of the connective tissue in the area around the bladder. This weakness leads to the detrusor weakness. There is no imperative urge.
Male Stress Incontinence is a condition which occurs, in the vast majority of cases, as a result of a radical prostatectomy. Most patients suffer from some kind of incontinence after this type of surgery. This is often not a structural problem and therefore the prognosis for this condition is good when treated. Because of the rapid aging of the population in Europe we can expect more prostatectomies in the future and therefore an increase in the prevalence of male stress incontinence.
Overflow Incontinence occurs when small amounts of urine leak from a full bladder. A common cause is an enlarged prostate is blocking the urethra. This type of incontinence is can also be caused by diabetes or spinal cord injury.
The Third International Consultation on Incontinence (2004) generated a comprehensive report on the overall prevalence of incontinence among adult women and adult men in the general population. The epidemiology committee of the Consultation cited a median prevalence range of 20% to 30% for young women, 30% to 40% for women in the middle age group and 30% to 50% in elderly women. Among men, prevalence rates from 3% to 39% have been cited, with increasing rates as the study population ages. (Badlani, et al., 2009)
Establishing the prevalence of Urinary Urgency is difficult because the feeling of urgency is subjective and the amount of bother felt varies, with some individuals viewing UU as normal. (Abrams, et al., 2002)
The related symptoms of Urge Urinary Incontinence (UUI) have been easier to track. A study by Stewart, et al. (2003) suggests that prevalence of UU increases with age and shows similar prevalence overall in men and women (16% vs. 16.9%) whereas UUI is more common in women than in men.
The aetiologies of urinary urge and the related condition of UUI are not entirely clear.
The apparently simple repertoire of bladder function responsible for the storage and periodic elimination of urine is controlled by a complex neural system that involves three sets of peripheral nerves (the T11-L2 originating sympathetic hypogastric nerves, the S2-S4 originating parasympathetic pelvic nerves and the sacral somatic pudendal nerves), the sacral spinal cord and the higher brain centers located in the brain stem (Badlani, et al., 2009).
Age-associated changes that increase the prevalence of UU include decreased bladder capacity, delay in the signal to void, increased post-void residual, increased night time voiding and atrophic muscle and skin changes, Melillo noted in a 1995 report.
Symptoms of UU may also be related to increased bacteruria, which is itself associated with increased alkalinity and decreased autonomic nervous system responsiveness, dysregulation of urine volume control, and a general decrease in mobility related to loss of muscle strengths and joint disease. (Hazzard, et al., 2003)
Pregnancy, substance abuse, nerve injury, smoking (and persistent coughs, a consequence thereof), obesity, pharmacological side effects and prostate problems are common precursors of the condition.
UI explained in Chinese medical terms.
In Chinese medicine, the vast majority of urinary incontinence cases are of the deficiency type, according to Maciocia (1994). The natural decline of Qi occurring with ageing may cause incontinence in old people, which is due to declining Kidney-, Lung- and Spleen-Qi.
The Spleen controls the muscles, and therefore has an effect in controlling the detrusor muscle. If their Spleen becomes weak, elderly patient may suffer from water in the legs, varicose veins and incontinence. (Personal conversation with M. Logue, November 2013)
Excessive sexual activity weakens Kidney-Yang and may lead to inability of the Kidneys to control fluids and therefore slight incontinence, according to Maciocia.
The Lungs, one of the organs involved in fluid metabolism, also have an energetic connection to the Bladder, Maclean & Lyttleton (1998) wrote. Lung-Qi descends and takes a portion of the fluid (sent up by the Spleen) to the Kidneys for reprocessing and sends a portion to the skin as sweat. If one pathway is unavailable (for example when the pores are shut during cold weather), fluids will increase along the other. This can be seen in the simple observation that most people tend to urinate more frequently in cold weather.
Urinary frequency can be due to the irritating effects of Heat- or Liver-Qi stagnation on the Bladder, or from failure of Yang to be fully within Yin; that is, the essential Yang Urine concentrating function that continues at night (Yin) to allow unbroken sleep. Nocturia is mostly associated with weak Kidney Yang. (Maclean & Lyttleton, 1998)
Urinary incontinence and nocturnal enuresis have similar mechanisms. As with high frequency and nocturia, they may be associated with weakness of the Yang in transforming fluids, but with the additional feature of weakness of the lower Yin (in this case the urethra which is unable to hold urine in). Deficiency of either the Kidney or Spleen may contribute to this mechanism as the Kidney controls the lower Yin orifices and the Spleen controls both the quality of muscle tone and the lifting of organs against gravity. (Maclean & Lyttleton, 1998)
Urinary incontinence treatment paradigms in Western medicine.
Common treatments for urinary urgency are predominantly nonsurgical, and involve a combination of behavioral techniques, pelvic muscle strengthening, and pharmacologic treatment with anticholinergic medications. (Wyman, 2003)
Behavioral modifications, including fluid and dietary changes, scheduled voiding and bladder retraining, pelvic floor muscle strengthening and voiding diaries to monitor effectiveness are safe, effective first-line treatments for symptoms related to urinary urgency in any age group. (Fantl, et al., 1996)
Pelvic floor exercises can lead to a big improvement in the early stages of urinary urgency and UUI if the condition was originally induced by a weakening of the pelvic floor muscles. Regular exercise of this muscle group can lead over a number of months to a reconditioning of the pelvic floor and to an improvement of the symptomatic.
There is only one drug available that is indicated for stress incontinence, Duloxetine (since 2004 available in Europe). It is used as an antidepressant but has of an impact on the detrusor muscle.
Duloxetine, as an SSRI, comes with an array of side effects due to its systemic effect on the body. In a trial comparing Duloxetine with a placebo, the discontinuation rate for adverse events was 4% for placebo and 24% for Duloxetine. Nausea was the most common reason for discontinuation. (Dmochowski, et al., 2003)
Anticholinergic medications can also be used to treat urinary incontinence. These are indicated in overactive bladder syndrome and treatment with these drugs are usually combined with an intense “toilet training” (going to the toilet at set times to desensitize the bladder).
Although use of anticholinergic medication is discouraged in older adults, even without treatment for UU, many are on multiple, commonly used medications with potent anticholinergic effects such as sleep aids and sedatives, antipsychotics, antidepressants, decongestants and antihistamines, and treatments for Parkinson’s Disease, Reuben, et al. noted in a 2004 editorial.
Despite its shortcomings, medication helps in the context of incontinence, though medical practitioners should be aware that comorbid conditions in the elderly tend to make polypharmacy more common. This situation puts older adults at risk of a prescribing cascade, whereby side effects of prescribed medications are mistaken for new illnesses and treated with additional prescriptions (Rochon & Gurwitz, 2003).
There are surgical treatments and invasive as well as superficial electrical devices available for the treatment. The use of electrical devices for the treatment of bladder dysfunction was reviewed in 2004 but came to the result that there are hardly any high-quality RCTs using placebo (Van Balken et al., 2004).
Western medical treatment techniques like sacral nerve stimulation are indicated in severe cases of UUI. These techniques involve implanting an electric pacemaker which stimulates the sacral nerve using a needle and electric current. The needle is inserted via the 3rd sacral foramen or the acupuncture point BL33 Zhongliao which regulates the lower Jiao and has an impact on urination and defecation.
Acupuncture treatment for incontinence.
Despite public interest in the subject, complementary therapies that may help avoid unnecessary pharmacologic therapies are understudied. (Flaherty, et al., 2001; Solomon, et al., 2004)
RCTs for acupuncture treatments are difficult to finance as well as to design, Flower wrote in a 2012 commentary. They require not just highly selected, homogenous, and frequently atypical sample population, but they tend to distort important aspects of the actual treatment that can be delivered, Flower notes. Treatment in an RCT should ideally be standardized in constituents, dosage, and over time. This is to ensure blinding, to keep a simple relationship between the intervention and the observed effect of this intervention, and to exclude the messy, impractical (and expensive) business of having someone individualize a treatment.
Acupuncture trials have to be standardized to become comparable and to come to measurable results that are acceptable to the wider medical community. Despite the difficulty of designing acupuncture trials, there was a relatively impressive amount (for acupuncture) of trial data available in the incontinence indication.
The acupuncture points referred to in most studies in the indication are selected in the traditional way but their mechanism may be understood with reference to the autonomic and somatic nerve innervation to the bladder. (Paik et al., 2013)
The points BL31, BL32 and BL33 are most commonly used in acupuncture to treat incontinence, Paik et al note. These are located above the first, second and third sacral foramina which lie over the first, second and third sacral nerve roots, respectively. These points are frequently used, due to the fact that they correspond with the segmental innervation of the parasympathetic nerve supply to the bladder.
The acupuncture points that are known to affect the micturition center and parasympathetic innervation to the urinary system include BL22, BL28 and several points on one of the eight extra meridians in the lower abdomen (Paik et al).
In Korean medicine, acupuncture points SP6, ST36 and KI3, all located on the legs, are also considered to assist bladder function by invigorating energy. This corresponds with TCM. Furthermore, Paik et al note, these acupuncture points correspond to skin dermatomes from L4 to S2 innervation, which means that stimulation of these points may influence bladder function. Similarly RN3, RN4 and RN6 correspond to the skin dermatomes of T11 and L1. (Paik et al.)
Bergstroem lead a trial in 1999 (published 2000) which combined conservative and pharmacological treatment for urinary stress incontinence. This trial did not result in sufficiently positive outcomes. She simultaneously conducted a study that combined pharmacological treatment and acupuncture, which resulted in significant improvement in leakage frequency, leakage amount, and the patient’s quality of life. The study demonstrated that the improvements that patients experienced were maintained even after three months post treatment.
Bergstroem, et al. chose the point prescription not just in the Chinese medical context but also according to the segmental innervation of the bladder. This is common practice in the trials done to test the efficacy in the treatment of incontinence.
Bergstroem’s point protocol BL23, BL31, BL32, BL33, SP6 and KI3 is appropriate from a Western medical as well as from a Chinese medical perspective. The points SP6 and KI3 have innervation from L5-S2. BL23 is related to T11 which is the efferent as well as the afferent innervation of the Bladder T11-L2 (sympathetic) and S2-S4 (parasympathetic). The innervations of the muscle sphincters in the perineum are also related to the S2-S4.
The study demonstrated significant improvement even though the group of patients did not reach a statistically relevant sample size.
Results of other Reviews.
There are a number of interesting systematic reviews evaluating acupuncture trials done for the indication.
Paik, et al. (2013) came to the result that the selected RCTs failed to demonstrate any statistically significant improvements in urinary incontinence, although acupuncture or acupressure did exhibit favorable effects on overactive bladder symptoms and quality of life in comparison with other conventional therapies.
A systematic review by O’Dell & McGee (2006) compared five studies using acupuncture as a treatment of urinary urgency and related symptoms in women above 50 years of age. None of the studies had a sufficient sample size to rule out placebo effect as the modality of efficacy, O’Dell & McGee argue.
The systematic review found that protocols varied related to the numbers of needles used, rotation versus non-rotation of needles, and number of visits. All five studies included stimulation of acupuncture needle to point SP6 in the treatment arm as originally suggested by Chang (1988), and significant differences were seen after four to six treatments in three of the studies (Bergstroem, et al., 2000; Emmons & Otto, 2005; Kelleher, et al., 1994).
Both subjective and objective improvements were reported. All studies reported significant improvement of subjective measures such as Quality of Life (QOL) and symptom distress. (O’Dell & McGee, 2006). However, no cumulative effect was noted and intermittent treatments were suggested as necessary to maintain symptom relief over time. (Chang, et al., 1993)
No serious adverse effects were reported from these acupuncture treatments.
Overall effectiveness and conclusion.
Acupuncture can treat the condition but in too many cases neither Western nor Chinese medicine can get a patient suffering from urinary incontinence dry again.
This is a serious shortcoming, given the extreme commonality of the condition, and the very high impact urinary incontinence has on a patient’s life. Thus far, studies into the effectiveness of TCM treatments have suffered from low sample sizes and the difficulty of reproducing TCM results within the context of an RCT.
Despite this, TCM practitioners ought not to feel discouraged. Studies show we can improve the urge, which has a very big impact on the patient’s comfort levels. We can teach pelvic floor exercises, recommend the writing of a bladder diary for 48 hours (which can help patients and fellow physicians to better understand the patient’s incontinence patterns). We can also encourage our parents not to reduce their water intake (as many choose to do, to the detriment of their health), while suggesting that they give up coffee, alcohol, and black or rosehip tea, whose diuretic effects worsen the symptoms of some patients (Badlani, et al. 2009).
Finally, we can also reduce the impact of the condition, particularly among elderly patients, with some words of encouragement. As people age, their propensity to suffer from urinary incontinence increases. Sadly, fear and embarrassment can discourage them from leaving their home, limiting their social interaction. Over the course of treatment it is surely worth reminding them in particular that taking a second pair of trousers when going out can be a very effective, confidence-boosting palliative.
Abrams, P., Blaivas, J., Stanton, S. & JT, A., 1988. The standardisation of terminology of lower urinary tract function.. Scandinavian Journal of Urology and Nephrology, Issue 114, pp. 5-9.
Abrams, P. et al., 2002. The standardization of terminology in lower urinary tract function: Report from the Standardization Sub-commitee of the International Continence Society. Neurology & Urodynamics, Issue 21, pp. 167-178.
Badlani, G., Davila, G., Michel, M. & de la Rosette, J., 2009. Continence, Current Concepts and Treatment Strategies. 1st ed. London: Springer.
Bergstroem, K., Carlsson, C., Lindholm, C. & Widengren, R., 2000. Improvement of urge- and mixed-type incontinence after acupuncture treatment in elderly women – a pilot study. Journal of the Autonomic Nervous System, Volume 79, pp. 173-180.
Chang, P., 1988. Urodynamic studies in acupuncture for women with frequency, urgency and dysuria. Journal of Urology, Issue 140, pp. 563-566.
Chang, P., Wu, C. & MH, H., 1993. Long term outcomes of acupuncture in women with freuquency, urgency and dysuria. American Journal of Chinese Medicine , Issue 21, pp. 231-236.
Deadman, P., Al-Khafaji, M. & Baker, K., 2007. A Manual of Acupuncture. 2nd ed. Hove: Journal of Chinese Medicine Publications.
Dmochowski, R. et al., 2003. Duloxetine versus placebo for the treatment of North American women with stress urinary incontinence. Journal of Urology, IV(170), pp. 1259-63.
Emmons, S. & Otto, L., 2005. Acupuncture for Overactive Bladder. Obstretics and Gynecology, 106(1), pp. 138-43.
Fantl, J. et al., 1996. Urinary incontinence in adults: Acute and chronic management. Rockville: US Department of Health and Human Services.
Flaherty, J. et al., 2001. Use of alternative therapies in older outpatients in the United States and Japan: Prevalence, reporting patterns, and perceived effectiveness.. Journal of Gerontology A: Biological Sciences and Medical Sciences., Issue 56A, pp. M650-55.
Flower, A., 2012. Becoming a stakeholder: Herbal medicine, vampires and the research process. Journal of herbal medicine, Issue 2, pp. 23-25.
Hazzard, W. et al., 2003. Principles of geriatric medicine and gerontology. New York: McGraw-Hill.
Kelleher, C. et al., 1994. Acupuncture and the treatment of irritative bladder symptoms. Acupuncture in Medicine, I(12), pp. 9-12.
Maciocia, G., 1994. The Practice of Chinese Medicine: The Treatment of Diseases with Acupuncture and Chinese Herbs. 1st ed. s.l.:Churchill Livingstone.
Maclean, W. & Lyttleton, J., 1998. Clinical Handbook of Internal Medicine. The Treatment of Diesease with Traditiona Chinese Medicine. 1 ed. Sidney: University of Western Sidney.
Mani, L. et al., 2010. Neurotrophins and Acupuncture. Autonomic Neuroscience: Basic and Clinical Journal, Issue 157, pp. 9-17.
Melillo, K., 1995. Asymptomatic bacteriuria in older adults: When is it necessary to screen and treat?. Nurse Practicioner, Issue 20, pp. 50-66.
Milsom, I., Fall, M. & Ekelund, P., 1992. Urinikontinens – en kostnad-skraevande folksjukdom.. Laekartidningen, Issue 89, pp. 1772-4.
O’Dell, K. & McGee, S., 2006. Acupuncture for urinary urgency in women over 50: What is the evidence?. Urologic Nursing, XXVI(1).
Paik, S. et al., 2013. Acupuncture for the the treatment of urinary incontinence: A review of randomized controlled trials. Experimental and therapeutic medicine, Issue 6, pp. 773-780.
Reuben, D. et al., 2004. Geriatrics at your fingertips. New York: American Geriatric Society.
Rochon, P. & Gurwitz, J., 2003. Medication use. New York: Mc Graw-Hill.
Solomon, D., LoCicero, J. & Rosenthal, R., 2004. New frontiers in geriatrics research. New York: American Geriatrics Society, pp. 269-302.
Stewart, W. et al., 2003. Prevalence and burden of overactive bladder in the United States. World Journal of Urology , Issue 20, pp. 327-336.
Van Balken, M., Vergunst, H. & Bemelmans, B., 2004. The use of electrical devices for the treatment of bladder dysfunction: a review of methods. Journal of Urology, III(172), pp. 846-51.
Wyman, J., 2003. Treatment of urinary incontinence in men and older women: The evidence shows the efficacy of a variety of techniques.. American Journal of Nursing, Issue 103, pp. 26-35.