Acupuncture In Unexplained Urinary Retention And Sluggish Bowel

Muzaffar K. Awan, MD ABSTRACT Background Auricular therapy is used in many conditions to provide relief from symptoms and to increase patient function. Objective To describe the use of auricular acupuncture in a patient with urinary retention and sluggish bowel of unknown etiology. Design, Setting, and Patient A 39-year-old woman with urinary retention of 3 weeks duration requested acupuncture to relieve her bladder retention and restore voiding. Intervention The patient's only treatment consisted of a 40-minute auricular acupuncture session. Left ear points selected were: thoracic, lumbar, and sacral vertebrae, urethra, urinary bladder, kidney, smooth muscle, cerebral cortex, and 3 parts of the trunk. Right ear points selected were: 2nd urethra, pelvic plexus, ureter, inferior mesenteric sympathetic ganglion, Shenmen, liver, and brain. Main Outcome Measure Restoration of bladder and bowel function, including elimination of the need for self-catheterization. Results Within an hour after treatment, the patient reported elimination of urinary retention and restoration of normal voiding function. By the 3rd day after treatment, bowel and bladder functions were at their premorbid level. This patient was followed up for 12 weeks without any relapse. Conclusion Auricular acupuncture was effective in the treatment of this patient with unexplained urinary retention and sluggish bowel function. KEY WORDS Urinary Retention, Sluggish Bowel, Acupuncture, Auricular Acupuncture, Auricular Medicine INTRODUCTION Urinary retention in young, healthy individuals is uncommon, but if left untreated, can eventually lead to pathological changes1 in the genitourinary system, and anxiety and frustration in a patient who has to daily self-catheterize. The use of medical acupuncture for treatment of urinary retention is not well documented in the literature. We report a case of an otherwise healthy patient experiencing new-onset urinary retention and sluggish bowels who was treated with acupuncture. Case Report A 39-year-old white woman developed sudden and unexplained urinary retention and sluggish bowel movements 3 weeks prior to presentation. Her complaints included mild thoracic-lumbar pain and stiffness for 2 months, along with numbness in the vaginal and rectal areas, left posterior thigh, and lateral sole of her left foot. She was initially evaluated at a local emergency department and had seen a urologist. She had been prescribed trimethoprim-sulfamethoxazole, but had to discontinue due to allergic reaction. The patient underwent radiography and ultrasonography of the pelvis and kidneys; results were unremarkable. Electromyographic and nerve conduction studies of the lumbosacral region and lower extremities performed by a neurologist also did not reveal unusual findings. Magnetic resonance imaging of the lumbosacral spine revealed mild disk degeneration with posterior annular tearing at the L5-S1 level without associated focal disk herniation or nerve root impingement. For more than 3 weeks, she had been unable to void her bladder except by self-catheterizations 2-4 times daily, and had occasionally used laxatives to evacuate her sluggish bowel. Figure 1. Auricular Acupuncture Points for Urinary Retention and Sluggish Bowels2

A. Right ear points included: 1. Urethra (2nd) 2. Pelvic plexus 3. Ureter 4. Inferior mesenteric sympathetic ganglion 5. Shenmen 6. Liver 7. Brain

B. Left ear points included: 1. Thoracic, Lumbar, and Sacral Vertebrae 2. Urethra (1st) 3. Urinary bladder 4. Kidney 5. Smooth muscle tone control 6. Cerebral cortex 7. 3 Parts of the trunk

METHODS Auricular Acupuncture Treatment After obtaining patient consent, the patient's only treatment consisted of a 40-minute auricular acupuncture session. In the 1st half of the session, 7 needles (Seirin J-type No. 3, 0.20 x 30 mm, with tube; Seirin Company, Tokyo, Japan) were placed in the right ear at selected points 1-7 (urethra, pelvic plexus, ureter, inferior mesenteric sympathetic ganglion, Shenmen, liver, and brain) as shown in Figure 1A. In the 2nd half of the session, points 1-7 (thoracic, lumbar, and sacral vertebrae, urethra, urinary bladder, kidney, smooth muscle, cerebral cortex, and 3 parts of the trunk) were needled in the left ear (Figure 1B). RESULTS The patient responded within 1 hour of her acupuncture treatment and confirmed regulation of her bladder control. She returned for follow-up 3 days later and reported ongoing regulation of her bladder and bowel functions. No treatment was necessary on the follow-up visit. This patient was followed up for 12 weeks without any relapse. DISCUSSION This clinical report was challenging and unusual in its presentation because no anatomical or physiological explanation could be determined. Perhaps certain mechanisms3 are involved in some cases, not unlike this one, in which a pathophysiology cannot be established by routine diagnostic methods.

CONCLUSION Auricular acupuncture was effective in the treatment of bladder and bowel dysfunction. These results suggest the need for further studies of auricular acupuncture in the treatment of genitourinary and bowel dysfunctions. REFERENCES

1. Schimmel HW, Penzer V. Functional Medicine: The Origin and Treatment of Chronic 2. 3.
Diseases. 2nd ed. New York, NY: Thieme Medical Publishers; 1997. Pesikov Y, Rybalko S. Auricular Acupuncture: Clinical Atlas. Donetsk, Ukraine: Three Dragons Press; 1994. Whatmore GB, Kohli DR. The Physiopathology and Treatment of Functional Disorders. New York, NY: Grune & Stratton; 1974.

AUTHOR INFORMATION Dr Muzaffar K. Awan is Medical Director of the Allen Park Health Center in Allen Park, Michigan. Dr Awan is a specialist in Musculoskeletal Pain Management, Medical Acupuncture, and Physical Rehabilitation, as well as being a Primary Care physician. Muzaffar K. Awan, MD, PT* 7105 Allen Rd Allen Park, MI 48101 Phone: 313-381-1809 Fax: 313-381-0721 E-mail: mkawan@aol.com *Correspondence and reprint requests

Clinical Observation Thirty-six Cases of Urinary Retention Treated by Acupuncture Zhang Dongshu College of Acupuncture and Massage, Guangzhou TCM University, Guangzhou 510405, China Available online 18 June 2008. Objective To observe the clinical therapeutic effects of acupuncture on urinary retention. Methods 36 cases of urinary retention were treated by acupuncture at the following points: 1) Qugu (CV 2), Zhongji (CV 3) Guanyuan (CV 4), Sanyinjiao (SP 6) and Yinlingquan (SP 9); 2) Shenshu (BL 23), Pangguangshu (BL 28), Ciliao (BL 32) and Weiyang (BL 39). Results 30 cases were cured, 4 cases improved and 2 cases failed, with a curative rate of 83.33% and a total effective rate of 94.44%.

Conclusions Acupuncture is affirmatively effective in treating urinary retention. Acupuncture For The Treatment Of Chronic Postoperative Urinary Retention
Tony V. Lu, MD Mary Pat Fitzgerald, MD ABSTRACT Background The Kidney-Bladder Distinct Meridians have been used for disorders of the kidney and bladder of a dense and material nature, such as urinary tract infection, cystitis, pyelonephritis, incontinence, urethritis, and nephrolithiasis. No studies report the use of this meridian couplet for postoperative chronic urinary retention. Objective To illustrate the use of KI-BL Distinct Meridians in the treatment of chronic postoperative urinary retention. Design, Setting, and Patient A case report of a 36-year-old multiparous patient with new onset of urinary retention following a total abdominal hysterectomy. The patient was instructed in selfcatheterization and asked to check post-void residual volumes. A 3-day diary revealed post-void residual urine volumes of 75-225 mL (normal range <100 mL). This case occurred in the Midwest in July 2002. Intervention The Yin and Yang access points KI 10 and BL 40 were piqured bilaterally; BL 10, BL 23 (the Shu point of the kidney), and BL 28 (the Shu point of the bladder) also were piqured bilaterally. Electrical stimulation at 4 Hz was applied between the crossed handles of the inferior needles (negative pole) and BL 23 for 15 minutes, followed by BL 28 for 15 minutes (positive pole). Treatments lasted 20 minutes and continued weekly for 6 weeks. Main Outcome Measure To cease self-catheterization. Results At the patient's 3rd visit, she reported that catheterized post-void urine volumes were almost zero. Self-catheterization was discontinued by the 4th visit. However, the patient needed maintenance treatment every 3-4 weeks to sustain the result. Conclusion This case suggests that the KI-BL Distinct Meridian couplet is a promising therapeutic modality for the treatment of chronic urinary retention following total abdominal hysterectomy. KEY WORDS Acupuncture, Urinary Retention, Sacral Neuromodulation, Self-Catheterization INTRODUCTION rinary retention, a partial or total inability to void, occurs after general surgery in 7%-25% of patients.1 Despite its prevalence, the exact pathophysiology of chronic urinary retention is unclear. It is a significant medical problem because elevated urine volumes retained in the bladder act as a focus for recurrent urinary tract infections (UTIs), can cause urinary frequency, urgency, and incontinence, and place the patient at risk for secondary infection of the upper renal tracts. Current theories concerning the pathophysiology of postoperative urinary retention include the effects of periurethral and perivesical edema,2,3 inhibition of detrusor contractility,2 failure of the external urethral sphincter to relax,1,4-6 outlet obstruction due to bladder neck elevation following surgery for stress urinary incontinence,7,8 partial sensory and motor paralysis of the urinary bladder leading to autonomic dysfunction,2 pelvic floor muscle dysfunction, and detrusor sphincter dyssynergia.9 Although transient postoperative urinary retention is common with no intervention required except bladder drainage, there are few effective allopathic treatment options available for cases of persistent postoperative retention. Patients unwilling to accept a trial of sacral root neuromodulation10 may need to resort to intermittent selfcatheterization for symptom control because no effective pharmacological therapy exists. Although self-catheterization is not uncomfortable, it is inconvenient and carries a risk of recurrent UTI. A review of the literature on acupuncture for the treatment of urinary retention revealed various approaches from Traditional Chinese Medicine to classical French Meridian styles of acupuncture.11-

13 We report the use of the Kidney-Bladder Distinct Meridian system for successful treatment of postoperative urinary retention. Case Report In July 2002, a Midwestern 36-year-old multiparous woman was referred from her primary care physician to the urogynecology clinic for assistance with urinary retention of 6 months' duration following a total abdominal hysterectomy, which was performed for symptomatic uterine fibroids. During the 1st month following surgery, the patient noted new onset of urinary urgency, frequency, and a sense of incomplete emptying of her bladder. By 6 months after surgery, her condition had progressed to a complete inability to void spontaneously. In addition, the patient noted the onset of a bilateral dull pain in the area of her kidneys. She did not feel the urge to void except when her bladder was extremely full, at which point the patient experienced urge and stress incontinence. Her bowel habits were normal; there were no symptoms of pelvic organ prolapse reported. She was taking no medications. Her urinalysis and culture were negative for infection on multiple occasions. Cystoscopy, intravenous pyelography, and filling-phase urodynamics were performed at another center approximately 3 months after surgery, and those findings were reported as normal except for a simple right ureterocele seen on cystoscopy and intravenous pyelography. METHODS We performed a physical examination 6 months after the patient's surgery that revealed intact pelvic screening reflexes and post-void residual urine volumes of 60 mL and 200 mL on 2 separate occasions (normal <100 mL). There were no abnormalities on gynecologic examina-tion. The patient was instructed in self-catheterization and asked to check post-void residual volumes after each void. A 3-day diary revealed voided urine volumes of 175-750 mL with post-void residual urine volumes of 75-225 mL (normal range <100 mL). Multichannel urodynamic testing was carried out with concomitant needle electromyographic (EMG) surveillance of urethral sphincter activity. Filling-phase testing demonstrated a 1st urge to void at 560 mL (normal range, 150-250 mL) and a maximum cystometric capacity of 1080 mL (normal range, 500-600 mL). No incontinence was demonstrated. During attempts to void, the patient was observed to be passing urine primarily by Valsalva maneuver, with a supplemental small detrusor contraction of 8 cm H2O, and only intermittent quieting of the urethral sphincter was demonstrated on EMG. Urethral sphincter-needle EMG during the fill and emptying phases of the urodynamic study demonstrated complex repetitive discharges at rest, during bladder fill, and during attempts to void. Patient consent was obtained. Acupuncture Treatment After obtaining patient consent, the Kidney-Bladder Distinct Meridians were chosen to treat this patient because the current theories concerning the pathophysiology of postoperative urinary retention revolve around the dysfunction of specific anatomical parts of the urinary bladder, and the process had gone beyond the premorbid stage. She was placed in a prone position on the treatment table. The Yin and Yang access points KI 10 and BL 40 were piqured bilaterally with Seirin acupuncture needles (J type, No 5, 0.25 x 50 mm; Seirin, Tokyo, Japan). The superior return point, BL 10, and the focusing points, BL 23 (the Shu point of the kidney) and BL 28 (the Shu point of the bladder) were piqured bilaterally (DBC Spring Handle acupuncture needles, 0.18 x 30 mm, Lhasa Medical Supplies Inc., Accord, Mass). No attempt was made to elicit the traditional De Qi sensation. Electrical stimulation (IC 1107, asymmetric biphasic square waveform pattern, 70 ms pulse width, OMS Medical Supplies, Braintree, Mass) at 4 Hz was applied between the crossed handles of the inferior needles (negative pole) and BL 23 for 15 minutes, followed by BL 28 for 15 minutes (positive pole). Treatments lasted 20 minutes and continued weekly for 6 weeks. RESULTS The patient noted some improvement by the 2nd treatment, and at the time of her 3rd visit, reported that catheterized post-void urine volumes were almost zero. Self-catheterization was discontinued by the time of the 4th visit. The beneficial effect continued during subsequent visits. Moreover, the patient noted that the best result could be achieved with treatment at 3-week intervals, and the beneficial effect could be continued with maintenance treatments every 3-4 weeks. This beneficial effect was still present 18 months later. There were no adverse effects attributable to the KI-BL Distinct Meridian therapy at any time during or after the

treatment sessions. DISCUSSION Acupuncture texts are replete with references to its use for the treatment of urinary retention.11-13 An overview of the current indications for specific acupuncture points reveals 7 points on the Kidney channel, 4 points on the Bladder channel, and 4 points on the Spleen channel with traditional or current indications for this condition.14 In TCM, there are 6 major causes of the symptom of urinary retention or voiding difficulty.15 The appropriate diagnosis is made according to patient history and examination, with attention to the pulses and appearance of face and tongue according to usual practices. Treatment is then directed at the underlying cause. Xinnong notes, "After a surgical operation on the lower abdomen, the Qi of the Bladder Meridian is damaged and blood stasis occurs, so there appear dribbling urination, retention of urine, distension, and pain in the lower abdomen."13 That particular text recommends treatment of acute postoperative urinary retention by tonification of CV 3, SP 6, KI 5, and BL 28. There is no mention of the success rate of this treatment. According to Energetic Meridian acupuncture theory,11 chronic urinary retention can be a feature of patients of Shao Yin or Tai Yin structural biopsychotype. As a primary mode of treatment, acupuncture to the KI-BL Distinct Meridians is recommended. Other approaches include treatments along Shao Yin/Tai Yang or Tai Yin/Yang Ming axes. Most such treatments also include tonification of Kidney and Bladder points using either back Shu points or through incorporation of KI 3 into the design of the treatment circuit. For transient postoperative urinary retention, acupuncture of the Kidney-Bladder Distinct Meridians, with focusing points GV 4, BL 23, and BL 28, has been recommended.11 However, the success rate of this treatment is not known. Only 2 studies of the use of acupuncture for urinary retention are available in the English-language literature, and they document an almost 100% success rate for this modality of treatment. One review16 documents the outcome of 25 patients with urinary retention after gynecological surgery. Most patients received both medicinal herbs and bilateral tonification of SP 6 and SP 9. After treatment, all patients voided normally. Another review17 describes the treatment of 20 patients with chronic urinary retention. Patients received electroacupuncture at CV 2, CV 3, CV 4, and ST 36 or alternatively at BL 23, GV 4, and SP 6, along with moxa to the points. Eighteen of the 20 patients experienced resolution of their urinary retention. Because of the vague description of the patients involved in these 2 studies, evaluation is difficult in applying the study findings to other patients. The KI-BL Distinct Meridians diverge from their Principal Meridians in the popliteal fossa and proceed to their primary (Kidney) and coupled (Bladder) organs. The Distinct Meridian of the Kidney is described as joining the Extra Meridian Dai Mo that encircles the waist, ascending on the front of the body to the base of the tongue, and emerging with its coupled Bladder Distinct Meridian on the posterior side of the neck. In addition, the Kidney Distinct Meridians cross over the posterior midline Extra Meridian Du Mo at the level of the 7th thoracic vertebra. The Distinct Meridian of the Bladder travels along the anterior surface of the vertebral column and influences the cardiac region before joining the Bladder Principal Meridian on the posterior side of the neck. As a result, the KI-BL Meridian couplet can also influence the anterior surface of the sacrum and the vertebral column.11 In our patient, urodynamic testing indicated decreased afferent sensation during bladder filling (decreased urge to void and large maximum cystometric capacity). She also demonstrated incomplete relaxation of the urethral sphincter during attempts to void. Without repeat urodynamic testing to document normalization of bladder filling and emptying, the exact nature of the changes brought about by acupuncture remains unknown. Although the effects of acupuncture on incontinent patients have been studied during urodynamic testing,15 no such study has yet been documented among patients with urinary retention. This patient may have required ongoing treatment because she had surgically-induced structural alterations in nerve and muscle function that cannot be permanently redressed through the use of acupuncture. As with other chronic ailments, it is recommended that the patient undergo long-term treatment. The use of BL 23 and BL 28 as focusing points for the KI-BL Distinct Meridian treatment may incorporate elements of Ming Men treatment that this patient required. CONCLUSION

Few therapeutic options are available for chronic urinary retention, which can occur following abdominal and pelvic surgery. This case report suggests that acupuncture with the KI-BL Distinct Meridians was a useful therapeutic approach for this patient with urinary retention following total abdominal hysterectomy.