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A Blend of Incontinence and Lower Back Pain.

 

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, lower sleep scores, and a higher probability of depression.

Badlani et al. (2009) note that incontinence sufferers report more physical discomfort, are more worried about their health, are more troubled and more frequently hindered in their social activities when compared with individuals who do not suffer from incontinence.

The Clinical Guideline for Lower Back Pain, published in 2009 by the National Institute of Clinical Excellence, recommends prescription of 10 Acupuncture treatments over a period of 12 weeks for the management of persistent non-specific lower back pain.
About the patient
The patient discussed in this case study is male, 76 years old and presented himself with lower back pain, pins and needles in his right and left foot and urinary incontinence in the first consultation on the 5th of September 2013. He limped into the clinic without an appointment, having difficulties standing upright because of his severe back pain.

The patient is of South Indian origin, a proud man, married and has undertaken manual work for most of his life. He was employed as a handy man until the age of 70, and still likes to help his grandson repair his car, though he tends to develop after these projects another bout of back pain. He comes across as a kind man struggling with the effects of aging.

The patient’s illness history in chronological order:

Back pain

His back pain started around 12 years ago.

2003 Knee Replacement

He had a total knee replacement on his right side in 2003 which does not appear to have left him with any detrimental effect.

2008 Prostate Gland Removal and resulting Urinary Incontinence

In the summer 2008, the patient had his prostate gland removed. Since then he has been suffering from urinary incontinence which affects his mood severely. It is not known whether this incontinence is due to a functional or structural problem.

The patient has a high urinary frequency, urge incontinence and enuresis. Sometimes he is incontinent without urge. The patient’s GP manages the condition with the drug Detrunorm (15mg daily), a drug indicated for Overactive Bladder Syndrome. His incontinence has not improved as a result of this treatment. The patient complains that the incontinence deeply affects his quality of life and is desperate to manage the condition effectively. Once on the way to the clinic he experienced an episode of incontinence whilst getting out of the tube, and told me later that he considered jumping in front of the next train which indicates how severely he feels this affects his pride.

2009 Back Pain – Surgery

The patient’s back pain started around 12 years ago. In April 2009 he had bilateral L4/L5 porthole decompression surgery for lumbar canal stenosis. He described his pain to a doctor prior to the surgery as bilateral leg “heaviness” which seemed resolved after the operation, but he was left with sensory changes affecting his feet. The patient considers the deterioration of sensation in the feet to be an effect of the decompression surgery, though an examiner later stated that this appears to be in a non dermatomal pattern.

2012 Back Pain – Second Onset

After his 2009 surgery, the patient’s back pain was alleviated until the 3 July 2012, when he fell down the escalator in Kings Cross station. The patient remembers a twisting sensation, which resulted in an onset of acute lower back pain and subsequently pain down the side of his left leg.

The pain was so severe that he needed medical attention. In August 2012 the patient had an MRI scan of the affected area which showed evidence for multilevel degenerative changes in the lower leg. His physician at the time reported that there appeared to be more space for the nerve roots at the level of the patient’s previous decompression surgery (L4/L5), although he noted there was evidence of predominantly left sided lateral recess stenosis which could have been impinging on L3/L4.

In October 2012 the patient saw another back specialist. This physician noted at the time that the worst symptoms were that of the left side hip and thigh pain (6/10 on the scale). The lower back pain was also deemed to be significant (6/10) in this examination. The patient could at the time manage to walk about a quarter of a mile but only with fairly severe pain in his lower back and left leg.

The patient had then a further caudal epidural injection and left sided CT guided nerve root injection. He is taking the drug Piroxicam to manage the pain.
2012 High Blood Pressure

The physician who administered the caudal epidural injection referred the patient to a cardiologist as a result of the patient’s high blood pressure. (15.5.13: BP 132/108 HR: 84). The patient denied exertional chest pain or angina.

The patient manages his high blood pressure with Amlodipine (5mg) and Bisoprol (1.25), and he takes Simvastatin (20mg) for his cholesterol levels.

2012/2013 Cataract Surgery

Cataract surgery left eye: June 2012, right eye June 13.

2013 Gout Attack

During the period in which I was treating him, mid-October, 2013, the patient experienced a gout attack in his big toe and second toe. This is likely to be a result of insufficient fluid intake, as the patient hadn’t been drinking enough to manage his incontinence condition.
Energetic Effects of the medications

Piroxicam
Piroxicam (Non steroid anti-inflammatory drug) use can result in gastrointestinal toxicity, tinnitus, dizziness, headache, rash, and pruritus. Approximately 30% of all patients receiving daily doses of 20 mg of piroxicam experience side effects. Piroxicam is heat inducing and injures Spleen and Stomach.
Simvastatin
Simvastatin may cause side effects like stomach pain, constipation, nausea, headache, memory loss or forgetfulness or confusion. Simvastatin injures Spleen and Stomach.

Amlodipine
Adverse side effects of the use of amlodipine may be: Very often: peripheral edema in 8.3% of users, fatigue in 4.5% of users Often: dizziness; palpitations; muscle-, stomach- or headache; dyspepsia; or nausea.
Amlodipine seems to injure Kidney Yang and the Spleen/Stomach.

Detrunorm
Detrunorm comes with side effects like dry mouth, blurred vision, constipation, fatigue, headache, nausea and vomiting, dizziness and many others. This drug is an anticholinergic muscle relaxant. It works by relaxing the involuntary muscle, called the detrusor muscle, which is found in the wall of the bladder. Detrunorm is drying in nature.

 

Family history
There is no history of either smoking or heart disease in patient’s family.
Lifestyle

The patient is a proud family man. He has never smoked and enjoys working with his hands. Throughout his life he has kept active and had a very physical working life. He drinks a small amount of alcohol once per week.
The patient likes to have 3 meals per day and eats porridge for breakfast, very spicy curries with rice for lunch and a light dinner in the evening. He avoids drinking liquids to reduce the likelihood of incontinence.
Pulse
The patient’s pulse at first presentation was very rapid at 89 BpM. It felt very full and wiry on the left side indicating a lot excess of the heart and excess and stagnation of the liver. His right sided pulse was much weaker and softer, indicating a deficiency of Qi, tiredness and pain.

Tongue
The patient’s tongue is dark red, no coating, dark on the sides (Liver position) and has a crack at the tip of the tongue (heart crack).

 

Other symptoms at first presentation
Pain at the back of the patient’s right arm, his nose feels stuffy and wet in the mornings and his feet wake him up tingling at 4:30/5 am in the morning. He has lymph oedema in his legs as well as varicose veins.

Identification of Patterns and Diagnoses

腎氣虛 – Kidney Qi deficiency

Symptoms indicating this pattern are the presenting 腰背痛, lower back pain and the 尿失禁, urinary incontinence. The 水腫, oedema are as well related to the deficiency in the Kidney.

The Kidney Qi deficiency leads to empty heat rising most prominently visible in the tingling and “prickling” sensation in the patient’s feet which wake him up at 4:30am/ 5:00am in the morning. This time is in the Circadian clock related to the Lung and therefore the weakest time of the Kidney.

肝鬱氣滯 – Liver Qi Stagnation

The early onset of the back pain was most likely an effect of the stagnation of Qi and Blood in the lower back, facilitated by the deficiency of the Kidney. The patient is irritable and emotional, his pulse is rapid and wiry which indicates heat and Liver Qi Stagnation. The 血壓高, high blood pressure, is most likely an effect of Liver Yang rising.

熱 – Heat

The patient shows signs of full as well as empty heat. The tongue is dark red but has no coating. The heat generated by the stagnation of Qi injured the Yin leading to the rising of empty heat. The patient regularly eats very spicy food and that might have – consumed on a daily basis – aggravated the condition.

濕熱 – Damp Heat

The Gout attack the patient suffered just before the 7th treatment was an effect of the damp heat accumulating in the Lower Jiao. The damp heat is visible in the yellow tinge in his eyes and irritates the Bladder increasing the urge.

脾胃氣虛 – Spleen Qi deficiency

The Spleen does not fulfil its function of transforming and transporting fluids properly, adding to the dampness and to the oedema in the legs. The 靜脈曲張, varicose veins are another manifestation of the inability of the Spleen to hold the Blood in the Vessels. If the Spleen is weak, it will fail to distribute fluids. Those will accumulate in the Lower Jiao being another cause of incontinence and frequent urination.

Minor Patterns
The high blood pressure and his emotional agitation on one side and the oedema in his legs, the incontinence and the lower back pain on the other, lead me to diagnose a condition with excess above and deficiency below.

The Heart crack in the tongue might be a result of his Heart being affected by the rising heat or a constitutional indicator for his Heart being easily affected by the rising heat.

Aetiology
The patient has spent a great deal of his life carrying out physical work in both outdoor and indoor environments. It’s very possible that his prolonged exposure to the cold could have aggravated the conditions he presents. It’s likely that the patient has undertaken an abnormally large amount of lifting and standing activities, both of which are common precursors of Kidney deficiency. Moreover, the patient is a strong candidate for overwork which commonly affects the Spleen and Kidney. In addition to this, the aging process typically results in a natural decline of Qi and Essence, compounding deficiency syndromes. His general constitution might have led to the presenting condition of excess above and deficiency below.

The back pain, most likely a stagnation of Qi or Blood, was resolved by the surgery the patient underwent in 2009, but the condition that gave rise originally to the stagnation of Qi and Blood in the lower back does not seem to have been resolved. This stagnation, which started 12 years ago in the lumbar area, might have shifted to another place in the Lower Jiao, first affecting the prostate gland, and after its removal, moving on to the Bladder. This stagnation of Liver Qi irritating the Bladder may have led to his urinary urgency, the enuresis, and the patient’s agitation.

The Gout attack the patient suffered in 2013 was likely a result of damp heat affecting the Liver, Stomach and Spleen Channel in his feet. The damp heat is most likely a result of his weak Spleen Qi resulting in dampness. Kidney Yang is the facilitator of Spleen Yang; in this circumstance the Kidney Yang does not warm the Spleen, and as a result the Spleen fails to perform its function correctly, which leads to the rise of Dampness. Deficiency heat rising and heat rising as a result of Liver Qi stagnation in combination with eating hot and spicy foods on a daily basis may have led in the overall combination to the onset of Damp Heat.

The damp heat apparent during the Gout attack was most likely already earlier irritating the Bladder, increasing the urinary urge.

The “prickling” and numb sensation in the feet is a result of empty heat rising which is likely to be an effect of the deficiency of Kidney Yin and Liver Yin.

Pathology
Liver Qi Stagnation leads to the Stagnation of Qi and Blood in the lower back, inducing back pain. The Liver Qi Stagnation gave rise to heat agitating the heart. This Stagnation moved after the surgery further in the Lower Jiao affecting the prostate gland which had to be removed too.

The weakness of Spleen Qi leads to the raise of Dampness sinking into the Lower Jiao mixing with Heat and becoming Damp Heat. The Damp Heat irritates the Bladder.

The Spleen fails to hold the Blood in the Vessels, leading to varicose veins.
The Kidney deficiency leads to oedema, adds to the weakness of the lower back and the difficulty of holding the urine.

The Water element fails to control the Fire and leads to high blood pressure and the condition of excess above and deficiency below. The Heart is stirred up by the rising Yang of the Liver, which is not controlled by the Kidney. Another aspect adding to the high blood pressure might be the damp/phlegm obstruction that evolved through the deficiency of the Spleen.

The empty heat pattern visible in the “prickling” sensation in the balls of the feet seems to be related to the deficiency of Kidney Yin and Liver Yin. Liver Yin is very closely related to Blood. Blood is based on Gu Qi which is generated by the Spleen. If the Spleen isn’t warmed and nourished well, the Spleen fails to make and raise the Gu Qi to the heart where it becomes Blood.

incontinenceTreatment Principle

Move Qi, drain damp, drain heat, nourish Yin, nourish Spleen, and nourish Kidney.

 

Treatment plan

During the first treatments I had to concentrate on the acute pain with which the patient came into the clinic and had to learn to make him comfortable. The target was therefore to treat mostly the manifestation of the presenting condition and to calm the patient’s Shen.

With the knowledge of how to put the patient in a comfortable position and with reduced symptoms of back pain, I could concentrate on the urge incontinence and the feet. As part of my treatment plan I choose to divide the urge from the stress incontinence. In western medicine, the urge is seen more as a neurological issue than as a muscular problem of the perineum. I would like to allow space to the assumption that stress incontinence is a result of deficiency of the Spleen and Kidney, whereas urge incontinence is more closely related to a problem in Kidney and Liver. Urge incontinence has measurably a far higher emotional impact on the patients quality of life.

When the patient came in for the 7th treatment with an acute Gout attack in his toe, my main objective was to make him comfortable and give him a little bit of a break from the pain while snoring away on the couch. The treatment principle in this treatment was to move Qi and resolve Damp Heat.

 

Points

Key Points in the overall treatments were:

SI3+ BL62, the opening and closing points of the governor vessel

BL23 Back Shu point tonifying the Kidney, Kidney Yang and Yin, firming Kidney Qi and regulating the water passage.

BL28 Back Shu point to regulate the Bladder, to clear damp heat and to dispel stagnation from the lower Jiao

BL20 Back Shu point to tonify the Spleen Qi and Yang, to resolve Dampness, supporting the Spleens in its functions of raising Qi and holding Blood.

BL54 benefits the lumbar region, activates the Channel and alleviates pain. Moreover this point is indicated in regulating urination.

SP6 is not just via skin dermasomes connected to the bladder. It is the meeting point of Spleen, Liver and Kidney Channels, it resolves Dampness, harmonizes the Liver, invigorates Blood, harmonizes the Lower Jiao including urination and calms the Shen.

SP9 is one of the mayor points indicated for Dampness. As noted in the “Ode of the Essentials of Understanding” this point opens and moves the Water passages. A point that I particularly choose to deal with the swellings in the lower legs.

DU4 is very sensitive in the patient. It is exactly at the area where the L4/L5 porthole surgery took place. The point regulates the governing vessel, tonifies the Kidneys and benefits, as a local point, the lumbar spine

BL32 is the most commonly used of the eight baliao points. It regulates the lower Jiao and facilitates urination and defecation. It benefits the lumbar region as well as the legs.

KI3 lies as well as SP6 on the same skin dermasome as the Bladder. It nourishes the Kidney, clears deficiency heat and tonifies Kidney Yang. Moreover it has a strengthening effect on the lumbar spine.

SP3 is one hand an important local point for the “prickling” and numb sensation in the balls of the feet, at the same time it is a strong point in resolving Dampness and Damp-Heat. It has overall Qi regulating properties.

KI2 is another local for the “prickling”. Adding to that it clears deficiency heat, regulates the kidneys and regulates the lower Jiao.

BL40 benefits the Bladder as well as the lumbar region.

BL58 is a point used for conditions characterized by fullness above and deficiency below.

 

Life Style Advice

The patient had the very bad habit of reducing his water intake to manage his incontinence episodes, a behaviour which led ultimately to the gout attack. His GP was strongly advising him to drink 5 large glasses of water a day and I echoed that with the addition of “not cold water”.

It was difficult. Overall the patient heard from me: Drink water, stop assisting your grandson repairing the car, you can advise but not assist, don’t eat extremely spicy curries and relax and smile. After the Gout attack I presented the patient with a table outlining dietary considerations for a purine low diet. The patient seemed to appreciate this advices and I’ve since heard this is on display on the family’s fridge door.

Since treatment, the patient has started regularly drinking 5 glasses of water a day. His wife – as she told me – cooks according to the purine low diet sheet, he took every week a second pair of trousers with him in a little bag. He didn’t start wearing incontinence pads (due to his pride), he did not start to help his wife around the house but kept climbing – at every given opportunity – into the bonnet of his grandsons car.

 

Progress and Outcome

I saw this patient for 10 sessions. Over this period his Mymop results evaluating the symptoms “Back Pain” and “Urination” in relation to the activity of walking.

1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th
MM4 3.6 3.5 3.5 2.5 3 1.4 2.5 3.25 1.5

The back pain improved over the course of the treatment and only flared up due to the patient’s over-exertion. Before the 5th treatment, the patient spent an afternoon working and repairing a car with his grandson, after which he reported his back pain was worse. At the last treatment he reported that the “water in the legs” problem was completely resolved, and noted an improvement in the back pain and the urinary urge. The stress incontinence remained unresolved after the treatment.

 

How did the treatment of this patient affect me?

I found it a pleasure to treat this older gentleman. He gave me some insight into the difficulties of the aging process on an emotional level, which is an area with which I had not previously had any real exposure to. I have grandparents with whom I am close, but our family dynamics preclude their being forthcoming with insight of this nature. This patient helped me to find a way to relate to him, and I learned how important it is to make the patient comfortable and how I could support him in being comfortable. In the age group of 70 and above it is much easier for me to assist and to ask directly how I can provide support. Treating this patient inspired me to do more research into geriatrics and familiarize myself with the challenges of aging and how I – as an Acupuncturist – can meet the needs of my elderly patients and improve their quality of life.

 

 

 

 

 

 

 

 

 

 

References

Badlani, G., Davila, G., Michel, M. & de la Rosette, J., 2009. Continence, Current Concepts and Treatment Strategies. 1st ed. London: Springer.

Deadman, P., Al-Khafaji, M. & Baker, K., 2007. A Manual of Acupuncture. 2nd ed. Hove: Journal of Chinese Medicine Publications.

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 Disease with Traditional Chinese Medicine. 1 ed. Sidney: University of Western Sidney.

Stewart, W. et al., 2003. Prevalence and burden of overactive bladder in the United States. World Journal of Urology , Issue 20, pp. 327-336.

Underwood, M., Watson, P., Buchanan E. et al., 2009. Low back pain, Early management of persistent non-specific low back pain. NICE clinical guideline, Issue 88. National Institute for Health Care Excellence.

 

 

 

 

 

 

 

 

Appendix

Liver Qi Stagnation +Stagnation of Qi and Blood in the lower back leading to back pain.

+leading to Liver infusing downwards – agitating the Bladder, leading to urinary urge

+leading to stagnation in the Lower Jiao – agitating the prostate

+failing to move Damp and Phlegm

+ leading to yellow eyes in combination with Damp Heat, generated by the overall pattern

Liver Yang rising + agitating the heart, leading to high blood pressure
Spleen Qi deficiency +failing to transform Damp and phlegm – leading to yellow eyes

+not holding the Blood in the Vessels – leading to varicose veins

+adding to water retention in the legs

+not nourishing the muscles – adding to feeling physically weak

Kidney deficiency of Yin and Yang +failing to govern the watermetabolism, leading to edema in the lowel legs

+not controlling the Heart – leading to high blood pressure and agitation

+not controlling the 2 lower orifices-leading to incontinence

+failing to provide the Yang to warm the Spleen, to supports its transforming and transporting function

+the lumbar region is the house of the kidney. If the Kidneys are weak, the lumbar regions is weak, leading to pain in the lower back.

+the Yin deficiency

Deficiency of Yin Leading to empty heat rising – a prickling and numb feeling in the feet, high blood pressure, the condition of excess above and deficiency below.

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