CASE REPORT
Effectiveness of Electroacupuncture for Management of Young Patients with Overactive Bladder at 1-Year Follow-Up
Newanda Johni Muchtar, MD,
1Dwi Rachma Helianthi, MD,
1and Irma Nareswari, MD
1ABSTRACT
Background:
Overactive bladder (OAB) is defined as urgency (a sudden compelling desire to pass urine with or without urge incontinence) usually associated with frequency and nocturia. OAB is a chronic condition that affects quality of life (QoL) significantly in patients. Acupuncture can help in the treatment of OAB for patients who cannot take certain medications.
Case:
A 32-year-old a female patient was diagnosed with OAB. She came to the department of medical acupuncture with a chief complaint of frequent urination for 15 years. Urinalysis test results were normal.
Before acupuncture, a bladder ultrasound (US) showed a postvoid residual volume (PVR) of 53 mL, and a uroflowmetry test showed a maximum flow rate of 20.6 mL/s, with an average flow rate of 12.1 mL/s and a voided volume of 71 mL. Her OAB Symptom Score (OABSS) was 13 and the King’s Health Questionnaire result was (KHQ) was 87. She was treated with electroacupuncture (EA).
Results:
After 12 EA sessions, 3 times per week, this patient’s bladder US showed a PVR of 3 mL; a uroflowmetry test showed a maximum flow rate of 30.5 mL/s, with an average flow rate of 15.3 mL/s and a voided volume of 120 mL. Her OABSS score was 7. Her KHQ score was 0.
Conclusions:
OAB can be treated with EA to improve QoL, as seen by this patient’s decreasing OABSS and KHQ scores, reduced PVR, and increase the voided volume.
Keywords:Overactive bladder, bladder hyperactivity, incontinence, nocturia, acupuncture, electroacupuncture
INTRODUCTION
O
veractive bladder (OAB) is defined by the Inter- national Continence Society (ICS) as urgency (a sud- den urge to urinate with or without incontinence) usually associated with a high frequency (more than 8 times in 24 hours), and nocturia. The term OAB can be used if there is no proven infection.1Seventeen percent of American men and women suffer from OAB Syndrome, and women, about half of these patients also experience urinary incontinence.2 In addition to placing a financial burden on the health sys- tem, OAB causes a significant decrease in quality of life (QoL) in patients. OAB affects mental health, work pro- ductivity, and sexual health.3OAB is a common and significant chronic condition faced by women and men, and women with OAB have a higher incidence of urinary incontinence. The prevalence of OAB in adults varies from 5.2% to 22% and increases with age. Due to low self-confidence and shame, some patients suffer qui- etly and feel shame. Many feel that OAB is part of the aging process, so that the true prevalence is more than that which is reported. OAB symptoms have a negative influence on QoL that affects health, increases social isolation, and increases such morbidities as falls and fractures. OAB has a large in- fluence on the social burden of the health system in various countries. The total cost of diagnosis and treatment of OAB in 2000 was estimated at $12.6 billion U.S. dollars, which can be compared to the costs for osteoporosis and breast cancer.4 Department of Medical Acupuncture, Faculty of Medicine, Universitas Indonesia, Jakarta, Daerah Khusus Ibukota Jakarta, Indonesia.
MEDICAL ACUPUNCTURE Volume 33, Number 2, 2021
#Mary Ann Liebert, Inc.
DOI: 10.1089/acu.2020.1462
169
Therapeutic options for OAB include lifestyle modifica- tion, behavioral therapy, pharmacologic therapy, neuromo- dulation, botulinum toxin therapy, and surgical intervention.5 The OAB Symptom Score (OABSS) is a tool to measure the symptoms of OAB that includes 4 symptoms: (1) day- time frequency (value 0–2); (2) nocturia (value 0–3); (3) urgency (value 0–5); and urge incontinence (encouragement 0–5). Total values, using this instrument represent OAB symptoms at a single assessment with scores from 0 to 15, with larger values indicating an increase in symptom se- verity. The King’s Health Questionnaire (KHQ) is a tool for assessing QoL that consists of 9 parts: (1) general health perception; (2) influence on life; (3) role constraints; (4) physical limitations; (5) social barriers; (6) personal rela- tionships; (7) emotions; (8) sleep/energy; and (8) measure- ment of the severity of incontinence. The score for each domain ranges from 0 to100, with 0 showing the best results and 100 showing the worst results. The total KHQ is rated on a scale from 0 (best) to 100 (worst). The main outputs assessed are the differences between the OABSS and KHQ from their initial results to the final results after treatment.6 This case report presents is about a female patient who had OAB for 15 years, which decreased her QoL. She was treated with electroacupuncture (EA) with a very minimal points used to ensure her comfort during the sessions.
CASE
A 32-year-old female patient came to the Cipto Man- gunkusumo Hospital—in Jakarta, Daerah Khusus Ibukota Jakarta, Indonesia—to the hospital’s acupuncture clinic on January 18, 2018 due to sudden urges to urinate that were usually associated with her high frequency of*12 times in 24 hours. She also had urination while asleep at least 3 times per night that would awaken her from her sleep. She had this problem for 15 years (Table 1).
During this time, the patient used sanitary pads several times daily because small amounts of her urine would often get on her clothing (Table 1). She experienced a feeling of wanting to urinate. Her defecation was smooth and could be detained. She was able to urinate normally and had no complaints about that ability. At the urology clinic of the Cipto Mangunkusumo Hospital, this patient had a Bladder ultrasound (US) and uroflowmetry testing; she was then diagnosed with having OAB (Table 1).
There was no history of past illnesses, such as allergies, diabetes, neurologic diseases, kidney disease, recurrent urinary-tract infections, and ‘‘sandy’’ urine; and there was no family history of similar disorders. She had abdominal surgery for appendicitis in 2010. She was gravida 3, para 3, alive 0, with 1 normal delivery 2 caesarian sections. There was no history of antimuscarinic use. This patient did not get enough sleep because of the frequent urination waking
Table1. Evaluations of the Patient at Different Timepoints
Mo & yr of visit Results & symptoms reported January 2018 OABSS score: 13
KHQ score: 87 Uroflowmetry results
Maximum flow rate: 20.6 mL/s Average flow rate: 12.1 mL/s Voided volume: 71 mL Bladder US results PVR: 53 mL
Average urination in 24 hr: 12·/d, including 3 nocturia episodes Sanitary pads used: 3·/d February 2018 OABSS score: 17
KHQ score: 0
Average urination in 24 hr: 6·/d, including 1 nocturia episode Sanitary pads used: 0
March 2018 OABSS score: 0
KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
April 2018 OABSS score: 0
KHQ score: 0 Uroflowmetry results
Maximum Flow Rate: 30.5 mL/s Average Flow Rate: 15.3 mL/s Voided volume: 116 mL Bladder US results PVR: 3 mL
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 3·/day
May 2018 OABSS score: 0
KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
August 2018 OABSS score: 0 KHQ score: 0
Average urination in 24 hr: 7·/d, including 0 nocturia episodes Sanitary pads used: 0
September 2018 OABSS score: 0 KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
October 2018 OABSS score: 0 KHQ score: 0
Average urination in 24 hr: 6·/d.
including 0 nocturia episodes Sanitary pads used: 0
(continued)
her, and her quality of sleep was disturbed; this had a neg- ative effect on her ability to interact with her environment and have a social life. A physical examination revealed no abnormalities and her overall laboratory results were within normal limits Table 2.
Prior to initiating EA therapy this patient signed informed consent. Asepsis and antisepsis were carried out then acu- puncture was performed at the bilateral BL 33 Zhongliao and BL 35Huiyangacupoints (Fig. 1), using 0.25·40–mm stainless-steel filiform disposable needles. The connecting cable from the electrostimulator with a brand SDZ V was connected to the acupuncture needle. This was activated by a continuous wave, at a low intensity set to a comfortable level for the patient, with a frequency of 50 Hz for 30 minutes at BL 33 and BL 35. The patient was scheduled for this therapy 3 times per week. During the course of therapy, the patient did not experience pain; she was also given a bladder diary to record her reactions to the treatment. US and uroflowmetry tests were done prior to the EA therapy and after the EA therapy were completed.
RESULTS
Before acupuncture, this patient’s bladder US showed a postvoid residual volume (PVR) of 53 mL, and her uro- flowmetry test showed a maximum flow rate: 20.6 mL/s, an average flow rate of 12.1 mL/s, and a voided volume of 71 mL.
After 12 sessions, the bladder US showed a PVR of 3 mL, and the uroflowmetry test showed a maximum flow rate of 30.5 mL/s, an average flow rate of 15.3 mL/s, and a voided volume of 120 mL. (Fig. 2). By the end of the sessions, the patient’s complaints had resolved completely and she was
very satisfied with the results. Furthermore, her QoL im- proved and her sleep was no longer compromised. As of January 2019, this patients’ complaints had not recurred. .
DISCUSSION
This was a report on EA for treating a patient who had OAB. This 32-year-old woman stated that she had been having frequent urination for 15 years. She said that the frequent urination was accompanied by an unbearable and immediate feeling of needing to void. She also had frequent urination at night so that her sleep was also disturbed. She had consulted the urology department, was diagnosed with OAB after being assessed on the basis of her history, OABSS assessment, uroflowmetry results, and a bladder US by an urologist.
The bladder US showed a PVR volume of 53 mL. PVR was the initial evaluation—the volume of urine residue in the bladder that was obtained immediately after the patient Table1. (Continued)
Mo & yr of visit Results & symptoms reported November 2018 OABSS score: 0
KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
December 2018 OABSS score: 0 KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
January 2019 OABSS score: 0 KHQ score: 0
Average urination in 24 hr: 6·/d, including 0 nocturia episodes Sanitary pads used: 0
mo, month; yr, year; OABSS, Overactive Bladder Symptom Score; KHQ, King’s Health Questionnaire; US, ultrasound; s, second; hr, hours; d, day.
Table2. The Patient’s Laboratory Test Results Laboratory tests Results Units Reference values
Complete peripheral blood
Hb 12.3 g/dL 12.0–14.0
Hematocrit 37.4 % 37.0–43.0
Erythrocytes 4.72 ·106/lL 4.00–5.00
MCV/VER 79.2 fL 82.0–92.0
MCH/HER 26.1 Pg 27.0–31.0
MCHC/KHER 32.9 g/dL 32.0–36.0
Platelet count 295 103/lL 150–400
Leukocytes count 6.77 103/lL 5.00–10.00 Complete urine
Color Yellow – Yellow
Clarity Clear – Clear
Sediments
Leukocytes 5–6 /LPB 0–5
Erythrocytes 1–2 /LPB 0–2
Cylinder Negative /LPK 0–2
Epithelial cells +3 – +1
Crystal Negative – Negative
Bacteria Negative – Negative
Specific gravity ‡1.030 – 1.005–1.030
pH 6.0 – 4.5–8.0
Albumin Negative – Negative
Glucose Negative – Negative
Ketone Negative – Negative
Blood/Hb Negative – Negative
Bilirubin Negative – Negative
Urobilinogen 3.2 lmol/L 3.2–16.0
Nitrite Negative – Negative
Leukocyte esterase Negative – Negative MCV/VER, mean corpuscular volume; MCH/HER, mean corpuscular hemoglobin; MCHC/KHER, mean corpuscular hemoglobin concentration;
Hb, hemoglobin; LPB, large viewing area; LPK, small field of view.
EA FOR MANAGING OVERACTIVE BLADDER 171
FIG. 1. Locations of the BL 33 and BL 35 acupoints on a 32-year-old female with overactive bladder.
FIG. 2. Bladder ultrasound images showing postvoid residual volume before (above) and after (below) 12 sessions of electro- acupuncture.
172
voided. Normally, this residual urine volume is very small.
In adults, the normal PVR value is<25 mL.
This patient did not have diabetes mellitus nor any history of spinal-cord trauma. It can be concluded that this patient’s OAB could have been caused by lower urinary-tract abnor- malities, namely bladder contractility and sphincter weakness.
Research by Liu et al., in 2017, on using BL 33 and BL 35 for patients with urinary incontinence found that BL 33 can affect the sacral nerves III and BL 35 can affect the pu- dendal nerves.8BL 33 is located in the sacral region, in the third posterior sacral foramen (S-3). The detrusor muscle is conserved by the sacral nerves that run from segments S-2, S-3, and S-4 in the spinal cord, whereas most nerve fibers are located in S-3, so that stimulation in this region results in contraction of the bladder wall and causes bladder empty- ing. Using high-frequency EA in this situation at 50 Hz might increase the maximum urethral closure pressure. EA in the lumbosacral might cause contraction in the muscles and cause the pelvic floor muscles to react. EA in BL 33 and BL 35 encourages reinnervation and reinforcement of the pelvic floor muscles. In addition, the literature states that stimulating the sacral nerves can induce sphincter relaxa- tion. Electrical stimulation in this sacral region is generally performed on the foramen S-3.8
EA on BL 33 with deep pricking can increase bladder capacity and suppress excessive activity of the bladder.
When pricking in BL 33, the tip of the needle touches the third sacral nerve root. Therefore, the mechanism underly- ing EA and pricking in BL 33 can be similar to stimulation of the sacral nerves. Both stimulate somatic afferents in the pudendal nerve to produce an inhibitory effect.9
In previous studies, it was noted that pricking BL 33 reduced the intercontraction interval (which indicates the interval between contractions), shortened the vesical me- chanical time and basal pressure, and increased maximum detrusor pressure. These results showed that EA on BL 33 with deep pricking can reduce the excessive activity of the bladder effectively, thereby reducing the urination fre- quency. Pricking in BL 33 reduced urinary rhythmic con- tractions and rhythmic eruptions that released the pelvic efferent nerve, without altering hypogastric efferent-nerve activity significantly. These findings indicated that rhythmic urinary contractions after acupuncture were characterized by segmental organization. The main nerve segment con- trolling S-1–S-4. BL 33 is in the anterior branch pathway of the second sacral nerve; therefore, deep EA in BL 33 stimulated the second sacral nerve directly.10
The effect of acupuncture on bladder activity was sig- nificantly shortened when c-aminobutyric acid (GABA) antagonists were administered prior to the acupuncture stimulus, suggesting that acupuncture could work through mediating the GABA-receptor system. The point stimula- tion used in that study was BL 33.11
Acupuncture points in the sacral area can stimulate so- matic nerves, autonomic nerves. and central nervous uri-
nation processes, with acupuncture points BL 33 and BL 35 producing endorphins and serotonin, which affect the cen- tral nerve that results in bladder-muscle relaxation and ex- ternal sphincter muscle contractions.12
BL 33 is segmentally conserved by the 3rd sacral nerve of the spinal medulla. The segmental sacral nerve is the center of the ictus in the spinal cord region. Three nerve branches synergistically supply the bladder muscle wall (detrusor muscle), pelvic floor muscles, and the urethral sphincter, so the 3 nerves are related directly to urinary complaints. In addition to the peripheral nervous system S-2–S-4, the spinal-cord nerve segments T-10–T-11 and L-1–L-2 are also associated with urination. Urination is influenced by pelvic floor muscles that are innervated by innervation of the pu- dendal nerve originating from the spinal cord S-2–S-4.
Thus, BL 33 and BL 35 can have segmental effects on the bladder directly by inhibiting parasympathetic nerves, stimulating sympathetic nerves, and stimulating the external sphincter, resulting in relaxation of the detrusor muscles, internal-sphincter contractions, and external sphincter con- tractions. EA can stimulate S-3 through BL 33 and the pu- dendal nerve through BL 35 in the lumbosacral region.
Thus, EA can facilitate rehabilitation and strengthening of pelvic floor muscles, decreasing symptoms of OAB.13
CONCLUSIONS
In this patient the OAB was treated with acupuncture and improved her QoL, as seen by decreasing OABSS and KHQ scores, as well as reducing her PVR, and increasing the voided volume. However, more studies are required to af- firm these reaction factors.
AUTHOR DISCLOSURE STATEMENT No financial conflicts of interest exist.
FUNDING INFORMATION No funding was received for this study.
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Address correspondence to:
Newanda Johni Muchtar, MD Department of Medical Acupuncture Faculty of Medicine Universitas Indonesia Jl. Pangeran Diponegoro No.71 RW.5 Kenari, Kec. Senen Kota Jakarta Pusat Jakarta 10430 Daerah Khusus Ibukota Jakarta Indonesia E-mail:[email protected]