Acupuncture For Bladder
Dysfunctions In Multiple Sclerosis
Jan M. Keppel Hesselink, MD
D. J. Kopsky, MD
A 38-year-old woman with multiple sclerosis (MS) and severe chronic nocturia was unable to sleep due to the necessity to urinate 10-15 times per night. She received 1 acupuncture treatment each week using electroacupuncture on SP 4 and 6 during 30-minute sessions at a frequency of 15 Hz. After several sessions, the nocturia was reduced to twice a night. In a number of treatment sessions, we demonstrated a causal relation between this therapy and its effect. A 54-year old man with MS experienced bladder dysfunction. After several partly successful treatment cycles in our clinic, we provided him with transcutaneous electrical nerve stimulation (TENS) to stimulate the Spleen points every day on his own in between weekly electroacupuncture sessions. The patient became free of bladder symptoms.
Nocturia, Multiple Sclerosis, Bladder Dysfunction, Electroacupuncture, Segmental Acupuncture, TENS
In our Institute of Neuroacupuncture in Soest, the Netherlands, we regularly treat patients with urogenital complaints such as incontinence and nocturia, many of whom have multiple sclerosis (MS). Because electroacupuncture can enhance the effects of needling, we use electroacupuncture bilaterally on SP 6 and 4. In treating MS patients for bladder problems, we follow a Western medical approach of segmental acupuncture.
The following case reports demonstrate the efficacy of treating bladder problems using simple acupuncture points and electroacupuncture in a challenge-rechallenge paradigm. This paradigm helps to define causal relationships between symptoms and treatment. If a symptom disappears during treatment and reappears after stopping treatment, and again disappears after reinstalling treatment, a causal relation between treatment and improvement of symptoms is highly likely.
Nocturia, excessive urination at night, is a common symptom in MS due to bladder instability and overactivity. Animal experiments have demonstrated that segmental acupuncture can decrease urinary bladder activity.1
The effects obtained most probably were induced via stimulation of dermatomes related to the nerves innervating the bladder; thus, this treatment could also be seen as a variety of segmental acupuncture.
Bladder symptoms such as urinary incontinence caused by detrusor hyperreflexia in patients with chronic spinal cord injuries seem to be successfully treated by acupuncture on the skin of the 3rd posterior sacral foramina (bilateral BL 33, Zhongliao points).2 Maximum cystometric bladder capacity increased significantly during this treatment. A pilot trial reported by an independent group also documented efficacy from this bladder point.3 Patients with spinal cord injury and neurogenic bladder disturbances also seem to benefit from electroacupuncture at points Chung Chi (CV 3), Kuan Yuan (CV 4), and bilateral Tzu Liao (BL 32).4
Percutaneous tibial nerve stimulation is introduced by urologists in the Netherlands for a variety of bladder dysfunctions and incontinence.5-7 This treatment consists of introducing needles in SP 4 and 6 and applying electrostimulation. The success of this approach has been replicated by a group of urologists in France.8
Both patients described below had a reflex pattern characteristic for MS (asymmetric hyperreflexia), and weakness of the legs and arms with signs of spasticity. The woman had slight paresis of the distal muscle groups in the arms and legs, especially at the right side. The man had signs and symptoms of ataxia related to cerebellum dysfunctions and sensory dysfunctions in the legs.
The patients had been treated with various conventional medical treatment without success. The woman consumed cranberry capsules to avoid recurrent bladder infections. Neither had been treated with interferon or other immunotherapy.
The patients were treated with acupuncture once a week. Needles (JW 0.22 x 25 mm, single use, sterile needles) were left in place for 30 minutes each session. Needles were inserted 0.5 cun bilaterally in SP 4 (Gongsun) and 6 (San Yin Jiao). Electroacupuncture was performed using an AS Super Han Electrostimulator (Schwa-Medico GmbH, Export Dept, Ehringshausen,Germany). The TENS (Primo) was manufactured by Klinerva. Electroacupuncture was applied at 15 Hz and the intensity was just under the individual pain threshold.
A 38-year-old woman presented with relapsing-remitting MS accompanied by many different motor and sensory symptoms, fatigue, nocturia, and sleep disturbances. Due to frequent nocturnal urination, up to 15 times each night, her sleep was severely disturbed and she experienced chronic fatigue. Treatment sessions of electroacupuncture at SP 4 and 6 were highly effective; stopping treatment resulted in rebound nocturia. Challenge-rechallenge resulted in a predictable pattern of increasing and decreasing the symptoms. Each acupuncture treatment in which we omitted this specific treatment resulted in increased bladder symptoms. During a holiday period, the patient's symptoms also increased dramatically. Thus, a clear causal relation between the treatment and the results emerged.
A 54-year-old man with primary progressive MS presented with bladder dysfunction. Several times a day, the patient felt the urge to urinate, though no voiding occurred. At times when he succeeded in voiding, the force of the stream was decreased. Once a night, he had to void. Three days after the electroacupuncture treatment as described above, the bladder dysfunction symptoms normalized. After several electroacupuncture treatment cycles, we provided him with transcutaneous electrical nerve stimulation (TENS) in order to be able to stimulate the Spleen points every day on his own. Directly after, the symptoms further improved; nocturnal voiding vanished and the force of the urinary stream increased to normal.
Conventional medical management has no clear answer for treating nocturia. The urologists of the University of Nijmegen, the Netherlands, introduced electroacupuncture on SP 4 and 6 as percutaneous tibial nerve stimulation. The afferent nerves from the posterior tibial nerve communicate to the sacral center of micturition and this is the neurophysiological base of the percutaneous tibial nerve stimulation for the management of lower urinary tract dysfunction.
This form of electroacupuncture thus can be regarded as segmental acupuncture. This method is easy to apply using any electroacupuncture device when metal needles are inserted in SP 6 and 4. The original frequency was 20 Hz but in our clinic, we generated a higher response rate using slightly lower frequencies (10-15 Hz). Meanwhile, we have successfully treated various patients with MS and bladder dysfunctions using this treatment.
Bladder dysfunctions in MS are difficult to treat. The application of 10-15 Hz electroacupuncture on SP 4 and 6 seems to be a useful method to treat bladder dysfunctions. This treatment can be regarded as from segmental acupuncture, due to the fact that the posterior tibial nerve communicates to the sacral center of micturition. Effects are likely induced via stimulation of dermatomes related to the nerves innervating the bladder.
- Tanaka Y, Koyama Y, Jodo E, et al. Effects of acupuncture to the sacral segment on the bladder activity and electroencephalogram. Psychiatry Clin Neurosci. 2002;56(3):249-250.
- Honjo H, Naya Y, Ukimura O, Kojima M, Miki T. Acupuncture on clinical symptoms and urodynamic measurements in spinal-cord-injured patients with detrusor hyperreflexia. Urol Int. 2000;65(4):190-195.
- Honjo H, Kitakoji H, Kawakita K, et al. Acupuncture for urinary incontinence in patients with chronic spinal cord injury: a preliminary report. Nippon Hinyokika Gakkai Zasshi. 1998;89(7):665-669.
- Cheng PT, Wong MK, Chang PL. A therapeutic trial of acupuncture in neurogenic bladder of spinal cord injured patients—a preliminary report. Spinal Cord. 1998;36(7):476-480.
- van Balken MR, Vandoninck V, Messelink BJ, et al. Percutaneous tibial nerve stimulation as neuromodulative treatment of chronic pelvic pain. Eur Urol. 2003;43(2):158-163.
- Vandoninck V, van Balken MR, Finazzi Agro E, et al. Percutaneous tibial nerve stimulation in the treatment of overactive bladder: urodynamic data. Neurourol Urodyn. 2003;22(3):227-232.
- Vandoninck V, van Balken MR, Finazzi Agro E, et al. Posterior tibial nerve stimulation in the treatment of voiding dysfunction: urodynamic data. Neurourol Urodyn. 2004;23(3):246-251.
- Amarenco G, Ismael SS, Even-Schneider A, et al. Urodynamic effect of acute transcutaneous posterior tibial nerve stimulation in overactive bladder. J Urol. 2003;169(6):2210-2215.
Prof Dr Jan M. Keppel Hesselink specializes in Medical Biology, Neurology, Pharmacology, and Medical Acupuncture. Dr Keppel Hesselink holds a chair in Molecular Pharmacology at the University of Witten/Herdecke in Germany; is founder of the ORES Institute for Neuroacupuncture, Soest, the Netherlands; and chair of the Foundation IOCOB for Innovative Research and Education in Complementary Medicine.
Jan M. Keppel Hesselink, MD, PhD, MS, LAc*
Foundation for Research and Education in Complementary Medicine, IOCOB
3735 MV Bosch en Duin
E-mail: firstname.lastname@example.org • Website: www.iocob.nl
Dr David J. Kopsky is co-founder of the ORES Institute for Neuroacupuncture, Soest, the Netherlands, and Secretary of the Board of the Foundation IOCOB for Innovative Research and Education in Complementary Medicine.
David J. Kopsky, MD
E-mail: email@example.com • Website: www.ores.nl
*Correspondence and reprint requests