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Improvement
In Excretory Function In
A Female With Neurogenic Bowel And Bladder
Michael P. Acord, MD
ABSTRACT
Background Acupuncture is used in many conditions to provide
relief from symptoms and to increase patient function.
Objective To describe the use of acupuncture in a patient with neurogenic
bowel and bladder of unknown etiology.
Design, Setting, and Patient A 59-year-old woman with neurogenic
bowel and bladder requested acupuncture to improve her symptoms and
general functioning.
Intervention Points were selected bilaterally from Yang Ming-Tai
Yin in an n, n+1 arrangement (LI 4, ST 36, SP 3, SP 6, and LU 7); adjunctive
points also were needled.
Main Outcome Measure Bowel and bladder function improvement.
Results After the 1st treament, the patient reported noticeable
improvement. By the 5th treatment, bowel and bladder function were at
their premorbid level.
Conclusion Acupuncture demonstrated efficacy in the treatment
of this patient with neurogenic bowel and bladder.
KEY WORDS
Neurogenic Bowel, Neurogenic Bladder, Acupuncture
CASE REPORT
The patient, a 59-year-old female, was first seen in 1995 for complaints
of right upper limb pain and dysfunction, secondary to posttraumatic
reflex sympathetic dystrophy, beginning with a fall approximately 1
year prior to presentation. Vascular symptoms were managed with intermittent
stellate ganglion blocks, performed by an anesthesiologist trained in
pain management. The patient continued to complain of pain, described
as aching and burning, interfering with movement and activities of daily
living, involving the entire right upper limb and aggravated by motion.
At the time
of referral, physical examination revealed swelling, hypersensitivity
to touch, and an approximate 50% reduction of voluntary motion in all
joints of the limb, with 70% reduction in internal and external rotation
at the shoulder. Cervical x-rays demonstrated age-consistent degenerative
changes; a cervical magnetic resonance imaging (MRI) scan
demonstrated slight narrowing of the C5-C6 disk space, with minimal
compromise of the neural foramen at that level on the right. Electromyography
findings were consistent with mild, recent denervation of the right
C5 nerve root, and nerve conduction studies revealed only a minimal
slowing of the median velocity at the wrist. Results of routine laboratory
studies were normal. Secondary myofascial pain syndrome was diagnosed.
Physical therapy began, with goals of pain reduction and improved function.
This approach, along with medication changes and adjustments, intermittent
trigger point injections, psychiatric support, and transcutaneous electrical
nerve stimulation (TENS), resulted in a degree of symptom stabilization
of approximately 1 year. The patient was able to resume some of her
pre-injury activities. A significant degree of muscular pain and dysfunction
continued.
In early 2000, she reported difficulty controlling both bowel and bladder,
which symptomatically increased. Mid-year, the patient reported 5-7
small, involuntary bowel movements per day, frequently diarrheal, along
with several small, loose, semi-voluntary bowel movements following
straining at stool. In addition, she reported frequent urinary leakage,
both day and night, often without awareness of it. She was unable to
empty her bladder completely without the use of sitz bath several times
daily.
Physical examination
continued to demonstrate muscular difficulties, along with moderate
bilateral ankle edema and mild lumbar paraspinal muscle spasm. Repeat
cervical, thoracic, and lumbar magnetic resonance imaging (MRI) revealed
only minimal central canal stenosis; bilateral lower extremity electromyogram
results were normal, as were routine laboratory values. Renal ultrasound
scan findings were unremarkable, as were results of barium enema and
routine colonoscopy.
TREATMENT
A working diagnosis was made of neurogenic bowel and bladder of unknown
etiology, and the patient was referred to both a urologist and a neuro-urologist.
The diagnosis was confirmed, and a program of fluid restriction, oxybutynin,
and intermittent self-catheterization was initiated.
In March 2001,
the patient requested acupuncture to improve her overall symptoms and
function; initially, she was scheduled for 4 weekly treatments. Based
on the organs involved within the subcircuit, and manifesting as diarrhea
(SP, LI), prior and present muscular pain (SP), and edema (SP, LU),
points were selected bilaterally from Yang Ming-Tai Yin, representing
a simple n, n+1 arrangement, with n=2 (LI 4, ST 36, SP 3, SP 6, and
LU 7). The +1 needle was placed on the Yin side because of the chronicity
of the complaints.1
Adjunctival
points chosen were KI 3 and KI 7 to tonify general Kidney function,
exert influences on the lower orifices, and simultaneously influence
the spinal cord (through its association with Marrow). Liver function
was aided by LR 2 (influencing the Sinews involved in the myofascial
pain symptoms and paravertebral muscle spasm); CV 5 was chosen because
of its influence on the Lower Heater. All points, except CV 5, were
chosen bilaterally.2 Stainless steel needles (0.25 x 50 mm, Tak Ki;
Lhasa Medical, Accord, Mass) were placed with the aid of guide tubes
and left in neutral position for 20 minutes without stimulation. Patient
consent was obtained
RESULTS
After the 1st treatment, the patient reported significant improvement,
with normalizing bowel function although some minimal leakage continued.
The initial regimen was repeated.
After the 2nd
treatment, she reported continued improvement in bowel function and
no further need to self-catheterize. Oxybutynin was discontinued. No
improvement in myofascial symptoms or lumbar spasm occurred. The initial
regimen was again repeated.
At the 4th treatment,
the patient reported minor bladder leakage and some reduction in lumbar
spasms. Initial points were again used.
By the 5th treatment,
the patient reported bowel and bladder function both at their premorbid
level. The focus of treatment was changed from Yang Ming-Tai Yin (concentrating
on bowel and bladder) to Shao Yang-Zue Yin (concentrating on movement
and muscle function [Sinews]). Points were selected bilaterally, representing
a simple n, n+1 pattern, with n=1 (TE 5, LR 3, LR 8). Again, because
of the chronic nature of the complaints, the treatment was weighted
toward the Yin side. The patient was needled for 20 minutes with no
stimulation.
At the 6th visit,
the patient reported reduction in lumbar spasm and the treatment was
repeated. At present, treatment continues.
CONCLUSION
Acupuncture demonstrates efficacy in the treatment of neurogenic bowel
and bladder.
REFERENCES
-
Helms
JM. Acupuncture Energetics: A Clinical Approach for Physicians.
Berkeley, Calif: Medical Acupuncture Publishers; 1995.
-
Maciocia
G. The Foundations of Chinese Medicine. Edinburgh, Scotland: Churchill
Livingstone; 1989.
AUTHOR INFORMATION
Dr Michael P. Acord is Chief of Physical Medicine and Rehabilitation
at the Kaiser Foundation Hospital in Harbor City, California, and is
a Fellow of the American Academy of Physical Medicine and Rehabilitation,
and American Academy of Medical Acupuncture (AAMA). Dr Acord specializes
in the diagnosis and management of musculoskeletal pain and dysfunction.
Michael P. Acord, MD, AB, MA, FAAPM&R, FAAMA
Chief of Service, Dept of Physical Medicine and Rehabilitation
Kaiser Foundation Hospital
25825 So Vermont Ave
Harbor City, CA 90710
Phone: 310-517-2932 • Fax: 310-517-2902 • E-mail: Michael.P.Acord@kp.org
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