Acupuncture in the Prophylaxis of Recurrent Lower Urinary Tract

ORIGINAL PAPER Acupuncture in the prophylaxis of recurrent lower urinary tract infection in adult women Audun Aune1, Terje Alraek2, Huo LiHua1 and Anders Baerheim2 1 Bryggen Medisinske Senter, 2Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway. Received October 1996. Accepted February 1997. Scand J Prim Health Care 1998;16:37–39. ISSN 0281-3432 Objecti7e – To evaluate the effect of acupuncture in the prevention of recurrent lower urinary tract infection (UTI) in adult women. Design – A controlled clinical trial with three arms: an acupuncture group, a sham-acupuncture group, and an untreated control group. Patients were followed for 6 months. Setting – An acupuncture clinic in Bergen, Norway. Subjects – Sixty-seven adult women with a history of recurrent lower UTI. Main outcome measures – Acute lower UTIs during the 6-month observation period. Results – Eighty-five percent were free of lower UTI during the 6-month observation period in the acupuncture group, compared with 58% in the sham group (p B0.05), and 36% in the control group (p B 0.01). There were half as many episodes of lower UTI per person-half-year in the acupuncture group as in the sham group, and a third as many as in the control group (p B0.05). Conclusion – Acupuncture seems a worthwhile alternative in the prevention of recurring lower UTI in women. Key words: acupuncture, urinary tract infection, prophylaxis. Anders Baerheim, MD, Department of Public Health and Primary Health Care, Ulriksdal 8C, N-5009 Bergen, Norway. Lower urinary tract infection (UTI) in adult women is a frequent disorder, and as many as 3% of the adult female population may experience three or more episodes of lower UTI during a 12-month period (1). Women with recurrent lower UTI may need prophylactic antibacterial treatment. Long-term antibacterial treatment can, however, lead to unintended increased bacterial resistance, which is a medical problem of increasing concern. It is therefore relevant to apply non-medical prophylaxis when this is available. Acupuncture has traditionally been used in the treatment and prevention of many clinical conditions, and it incorporates tradition-based systems for preventing urological problems. There is, however, little scientific documentation on the clinical use of these systems (2). The aim of this study was to evaluate the effect of acupuncture in the prevention of recurrent lower UTI in adult women. MATERIAL AND METHODS A total of 86 non-pregnant women, aged 18 – 60 years, were evaluated for inclusion during 12 months from February 1994, after advertising in local newspapers. For inclusion, they should have had three or more episodes of distal urinary symptoms during the previous 12 months, of which at least two should have been diagnosed and treated as a lower UTI. The subjects should have sterile urine at inclusion, and no antibiotics should have been taken during the previous 3 weeks. Subjects were excluded if they were pregnant, used a diaphragm, or had any complicating illness (e.g. diabetes, cancer, obstruction of the urinary tract). Patients who became pregnant, or were put on prophylactic antibacterial treatment during the study period, were included for analysis with data collected until that time. Of the 86 non-pregnant women, 11 failed to obtain sterile urine, and two were known to have obstructive anomalies in their urinary tract. Of the 73 women included, five failed to attend after treatment, and one moved out of the area during the treatment. Two women became pregnant during the observation period and these were included in the calculations with the weeks of observation before detection of the pregnancy. After inclusion, the 67 remaining women were randomized to three groups in blocks of five: acupuncture treatment, sham acupuncture treatment, or no treatment, in the ratio of 2:2:1. Patients were blinded to whether they were given real or sham acupuncture. The acupuncture treatment was given for 20 minutes twice weekly for 4 weeks. Steel needles were inserted to the correct depth, the qi sensation was obtained, and needles were manipulated further by hand in rotating and stabbing movements. The main points were Ren-3, Ub-23, and Ub-28 on the lower Scand J Prim Health Care 1998; 16 38 A. Aune et al. Table I. Age, previous UTIs and UTIs during a 6-month observation period after treatment (after inclusion for the untreated group) for 67 women receiving acupuncture, sham acupuncture or no treatment as prophylaxis for recurrent lower UTI. Acupuncture Number of patients Age (mean years) UTI last 5 years, mean no. Number of patients with no UTI during the registration period UTIs during observation period, no. Mean observation period in weeks Incidence rate 95% confidence interval 27 35.2 14.7 23 7 24.1 0.28 0.07 – 0.49 Sham acupuncture 26 33.1 14.8 15*1 15 25.6 0.59 0.29 – 0.88 No treatment 14 37.3 14.3 5** 10 22.8 0.82*2 0.31 – 1.32 Incidence rate =x/nt where x=number of lower UTI episodes observed, n = number of patients in the group, and t = length of observational period in half years. *1 pB0.05 versus the acupuncture group, Fisher’s exact test. *2 pB0.05 versus the acupuncture group, see text. ** pB0.01 versus the acupuncture group, Fisher’s exact test. abdomen or back, and K-3, Sp-6, Sp-9, Liv-2 or Liv-3 on the lower extremities. According to his/her best judgement, the acupuncturist chose a combination of these acupuncture points, and eventually some other points, individually for each patient. Sham acupuncture was given using six needles superficially inserted in the calves, thighs or abdomen outside known acupuncture points or meridians. Needles were not manipulated in the sham group. The subjects were followed monthly for 6 months. The medical history was checked at each follow-up, and side-effects were noted. Samples for bacteriological examination were collected from clean-voided urine using a dip-slide (Uricult®). The specimens were examined at the Department of Microbiology and Immunology, the Gade Institute, University of Bergen, using standard techniques. The subjects were asked to seek medical aid if they developed acute distal urinary symptoms. They were provided with a pre-addressed dip-slide and a registration form on which the treating physician should note the symptoms and the result of urinalysis. Distal urinary symptoms were defined as dysuria, urinary frequency, and/or suprapubic discomfort. An acute lower UTI was defined as acute distal urinary symptoms and bacteriuria (105 or more colony-forming units per ml (cfu/ml) of uropathogens, or any amount of Staphylococcus saprophyticus). Leucocyturia was defined as five or more leucocytes per high-power field by microscopy of urine sediment, or 1+ or more on the leucocyte esterase field on a urinary strip. The study was approved by the regional committee of medical research ethics. Statistics Differences between groups were evaluated using the Fisher exact test. The incidence of lower UTI in the Scand J Prim Health Care 1998; 16 observation period is given as incidence rates (IR= number of episodes per person and 6 months) with 95% confidence intervals. Comparison between incidence rates was made using incidence rate ratios (IRR, e.g.= IRa/IRs with 95% confidence intervals. IRR has the default value of 1.0 under H0. RESULTS As Table I indicates, there were half as many episodes of lower UTI per person-half-year in the acupuncture group as in the sham group (IRR= 0.47, 0.19–1.16), and a third as many as in the control group (IRR=0.38, 0.13–0.90, pB 0.05). Likewise, 85% of the acupuncture group were free of lower UTI during the 6-month observation period, compared with 58% of the sham group (pB 0.05 vs. the acupuncture group) and 36% of the control group (pB 0.01 vs. the acupuncture group). Several episodes of acute distal urinary symptoms were noted, in which bacterial culture either was not obtained, or was negative. Seventeen of these episodes occurred in the acupuncture group, 25 in the sham group, and ten in the control group. Few side effects were noted (Table II), and all were experienced as undramatic by the patient. Among the 32 episodes of lower UTI, there were 19 cases of Escherichia coli, one Klebsiella, five Staphylococcus saprophyticus, and five enterococci. Two samples showed simultaneous growth of two different uropathogens. DISCUSSION Acupuncture was highly effective in reducing the reinfection rate among the cystitis-prone women in our study. Lower urinary tract infection in adult women Table II. Side effects among women receiving acupuncture or sham acupuncture in the prophylaxis of recurrent lower urinary tract infection. Acupuncture (n= 27) Dizziness after treatment Pain during treatment More frequent menstruation Less frequent menstruation Less climacteric discomfort Gastroenteral discomfort Feeling warm in legs Total 1 0 2 0 0 2 3 8 Sham acupuncture (n =26) 0 1 0 1 1 2 2 7 39 Given a specific acupuncture effect, real acupuncture should be expected to be superior to sham acupuncture, and sham acupuncture, because of its placebo effect, superior to no treatment. Our data support this. The validity of our results is further supported by the use of a double-blinded result evaluation with regard to bacterial culture. The study otherwise mainly applied a single-blind design, since patients were not informed about the type of treatment they were receiving. It is however difficult to ensure that there was no non-verbal communication about treatment type between the acupuncturist and the patient, and patients receiving real acupuncture may have felt an increased anticipation of an effect. However, it seems unlikely that the patient’s anticipation alone could reduce the recurrence rate of an acute bacterial disease by 80%. The literature is sparse on acupuncture in the treatment or prevention of infectious diseases, and the few studies we found show conflicting results. Kuan et al. (3) found a short-lasting rise in immunoglobulins and leucocyte counts after needling mice at the St-25 point lateral to the umbilicus. The effect subsided within a few hours. Kho et al. (4), however, could not confirm this when treating human patients undergoing major abdominal surgery with acupuncture. Further, the protective role of the immune response to lower UTI seems controversial (5). Some studies have evaluated the effect of acupuncture on urodynamic parameters. Acupuncture-like stimulation of the pelvic floor in rats reduces rhythmic micturition contractions of the urinary bladder (6). The effect seems to be mediated both by a pelvic reflex arch via the pudendic nerve and parts of the sacral nerves and by more complex and less under- stood neural mechanisms (7). Similar urodynamic findings have been reported during acupuncture treatment of children with urinary bladder instability (8). Chang (2) found that stimulation of the acupuncture point Sp-6 at the ankle, but not of the St-36 at the proximal calves, increased maximum cystometric capacity, decreased peak urinary flow rate, and increased the intra-urethral pressure in the distal urethra in women with frequency, urgency, and dysuria. However, these effects may in sum lead to less frequent micturition, which in itself is a risk factor for UTI (9). Hence, the present study raises more questions than it answers, and further studies are needed to evaluate the more specific effects of acupuncture on the pathogenesis of lower UTI in women. Nevertheless, qualified acupuncture reduced the reinfection rate substantially among the cystitis-prone women in the study, and acupuncture may be considered as an alternative before putting these women on prolonged antibacterial treatment. ACKNOWLEDGEMENTS We thank the Norwegian Research Board for funding the study. REFERENCES 1. Walker M, Heady JA, Shaper AG. The prevalence of dysuria in women in London. J R Coll Gen Pract 1983;33:411 – 5. 2. Chang PL. Urodynamic studies in acupuncture for women with frequency, urgency and dysuria. J Urol 1988; 140:563 – 6. 3. Kuan TK, Lee SP, Lin JG, Shen M. The effect of needle stimulation of acupuncture loci Tienshu (St-25) ChungWan (CV-12) on the immune response in sensitized mice against experimental cholera. Am J Chin Med 1986;14:73– 83. 4. Kho HG, van Egmond J, Eijk RJ, Kapteyns WM. Lack of influence of acupuncture and transcutaneous stimulation on the immunoglobulin levels and leucocyte counts following upper-abdominal surgery. Eur J Anaesthesiol 1991;8:39 – 45. 5. Svanborg C. Resistance to urinary tract infection. N Engl J Med 1993;329:802 – 3. 6. Sato A, Sato Y, Suzuki A. Mechanism of the reflex inhibition of micturition contractions of the urinary bladder elicited by acupuncture-like stimulation in anaesthetized rats. Neurosci Res 1992;15:189 – 98. 7. Sato A, Sato Y, Schmidt RF. Reflex bladder activity induced by electrical stimulation of hind limb somatic afferents in the cat. J Auton Nerv Syst 1980;1:229 – 41. 8. Minni B, Capozza N, Creti G, De Gennaro M, Caione P, Bischko J. Bladder instability and enuresis treated by acupuncture and electro-therapeutics: early urodynamic observations. Acupunct Electrother Res 1990;15:19 – 25. 9. Nielsen AF, Walter S. Epidemiology of infrequent voiding and associated symptoms. Scand J Urol Nephrol Suppl 1994;157:49 – 53. Scand J Prim Health Care 1998; 16