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Acupuncture Treatment For
Interstitial Cystitis: A Case Report
Paula M. Lyons, MD
ABSTRACT
Background Interstitial cystitis (IC) is a chronic relapsing disease of the urinary bladder. Symptoms include severe chronic pelvic pain, urinary frequency, urgency, and nocturia. No single treatment modality provides complete relief to all patients, and the condition may relapse after periods of remission.
Objective To describe the adjunctive use of acupuncture in a young woman with IC who had been treated previously with most of the available conventional modalities.
Design, Setting, and Patient Single case report of a 31-year-old woman diagnosed as having IC for at least 5 years.
Intervention Acupuncture treatment, including Back Shu points for Kidney and Bladder, were stimulated each time, along with other Shu points according to tenderness. Chong Mo and Tai Yin meridians were alternated and coupled with Yang Ming. The patient was also encouraged to adopt lifestyle modifications.
Main Outcome Measures Relief of pelvic pain, vaginal pain, daytime urinary frequency, urgency, nocturia, and frequency of narcotic analgesic use.
Results The patient reported rapid improvement in voiding symptoms after the 1st treatment. Pain levels rapidly diminished, permitting
reduction in use of 1 of the detrusor stabilizer medications and most narcotic analgesics. Energy levels, emotional symptoms, constipation, and sexual symptoms were also improved over the course of treatment. The only adverse acupuncture effect this patient experienced was occasional bruising.
Conclusion Acupuncture treatment enabled this patient with IC to reduce her medication use and experience an enhanced quality of life.
KEY WORDS
Interstitial Cystitis, Acupuncture, Alternative Therapies, Pain, Urgency
INTRODUCTION
nterstitial cystitis (IC) is a chronic, relapsing disease of the urinary bladder that manifests with urinary frequency, urgency, nocturia, and pelvic pain.1 The diagnosis is often delayed for years while patient are treated for recurrent urinary tract infections, chronic pelvic pain syndromes, chronic prostatitis, and, sometimes, psychological disorders. No single treatment modality provides complete relief to all patients, and the condition may relapse after periods of remission. The following case report describes a patient with IC who requested acupuncture as an adjunctive therapy.
CASE REPORT
A 31-year-old woman requested acupuncture for chronic pelvic pain caused by IC and complicated by irritable bowel syndrome; both conditions had been diagnosed approximately 5 years previously. She experienced the pain across the entire pelvis, usually symmetrically, sometimes extending into the mid-abdomen when she was constipated; it was markedly worse before and during menses. Urinary frequency averaged 10 voids daily and nocturia 3-4 times nightly. She was often constipated and used a laxative 1-2 times weekly after 3-4 days without a bowel movement. Her vaginal pain was diagnosed as "vestibulitis;" numerous examinations failed to find an etiology. Her symptoms precluded most sexual activity. The patient's average daily pain score was 5/10; on most days, it rose as high as 8/10. She was treated with numerous pain control regimens, including fentanyl transdermal patches, at which time her narcotic medication would be used. She regularly saw a urologist, gastroenterologist, gynecologist, and allergist.
Upon presentation, the patient was taking polyethylene glycol laxative, hydrocodone/acetaminophen (7.5/500 when necessary, averaging 12 per week), or tramadol for less severe pain. She had previously tried oral pentosan polysulfate, a medicine for IC, but indicated that it was ineffective. On several occasions in the past, she had undergone cystoscopic hydrodistension and taken other intravesical medications. She had some pain improvement over the previous 6 months that she attributed to the antidepressant citalopram; she discontinued the drug because of a 16-lb weight gain. The patient recognized a worsening in energy level, constipation, insomnia, depressed mood, and pelvic pain since discontinuing the antidepressant. Her past medical history included allergic rhinitis and asthma since childhood. Daily cetirizine, fluticasone, and as-needed guaifenesin, pseudoephedrine, and albuterol controlled these symptoms. She had experienced dysmenorrhea since a teenager; this somewhat improved with oral contraceptive use. She had no history of surgeries, pregnancies, or major injuries.
Physical examination revealed a tired-looking young woman. Her tongue was pale, had a thin clear coating, and teeth marks were apparent. She did not appear overweight. The radial pulse in the left rear position was weaker than in all other positions. Abdominal palpation revealed moderate tenderness in the periumbilical region and marked tenderness in the suprapubic area across the entire lower abdomen. Front Mu points for Large Intestine, Triple Energizer, Small Intestine, and Bladder (ST 25, CV 5, CV 4, and CV 3) were tender to palpation. On the back, there was tenderness of the paraspinous muscles corresponding to the Back Shu points from BL 18 to BL 28. No pedal edema or varicosity was noted. Her skin was mildly dry, and her hair and nails were normal.
TREATMENT
Patient consent was obtained; the first 10 acupuncture treatments, performed weekly, are summarized in Table 1. Lifestyle change recommendations included increasing water intake while reducing caffeinated soft drinks, taking a daily fiber supplement, and following a regular exercise program. Ear tacks at the satiety point were placed weekly for appetite suppression per the patient's request. A 7th regular visit was scheduled, but treatment was modified after a back strain.
After that, the patient was treated every 2 weeks with few exceptions. The Back Shu points for Kidney and Bladder were stimulated each time, along with other Shu points according to tenderness.
Chong Mo and Tai Yin meridians were alternated and coupled with Yang Ming, always with the needle balance toward the Yin side of the circuit. Abdominal focus points were chosen by degree of tenderness, and included some combination of Ren 3, 4, 7, 12, SP 12 or ST 30, ST 25, KI 11 or KI 12. Manual stimulation, electrical stimulation, and Mylar "space blanket" were used for most treatments. Moxibustion was performed only periodically.
RESULTS
Treatment results were gratifying and prompt. Urinary frequency/ urgency improved for 4 days after the 1st treatment; by the 3rd treatment, bladder symptoms were gone except for nocturia. Pelvic pain was largely relieved, including the vulvo-vestibular pain. The patient was able to resume sexual intercourse without pain. Constipation was improved but not entirely regulated. The treatment type was alt-ered in hope of increasing improvement with a dense Kidney organ tonification input. After the Kidney Distinct Meridian input on 2 occasions, the patient asked to return to the original treatment type; she reported that it had afforded better pain and bladder symptom relief as well as mood elevation, energy recovery, and clearer thinking. By the 4th week, she was using tramadol on average only twice a week, and no longer required hydrocodone/acetaminophen. The low back strain and sciatica proved to be a setback requiring narcotic medications and muscle relaxants for almost 10 days; intense coughing increased abdominal pressure and pain. Prompt relief resulted afer resuming treatment.
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Table 1. Acupuncture Protocol for Management of Interstitial Cystitis
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Chronology of Treatments
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Back Shu Points†
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Channel Input
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Local *Focus Points
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1
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BL 18, 20, 23, 25, 28
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Chong Mo‡
Yang Ming§
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ST 25, SP 12, CV 3, CV 4
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2
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BL 18, 20, 23, 25, 28
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Chong Mo
Yang Ming
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ST 25, CV 3, CV 4, ST 30
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3
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BL 18, 20, 23, 25, 28
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Chong Mo
Yang Ming
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ST 25, CV 3, CV 4, ST 30
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4,5
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BL 23, 25, 28
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Kidney Distinct
Meridian ||
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CV 3, CV 4, CV 7, ST 25
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6
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BL 18, 20, 23, 25, 28
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Chong Mo
Yang Ming
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ST 25, CV 3, CV 4, ST 30
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7
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Lumbar PENS T12 through S3
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Bladder
tendinomuscular¶
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BL 40, 53, GB 30 for acute low back pain and sciatica
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8
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BL 18, 20, 23, 25, 28 plus local back tender points
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Chong Mo Yang Ming
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ST 25, CV 3, CV 4, CV 12, CV 7, ST 30
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9
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#
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Auricular needles Shen Men, Lung, Kidney
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None
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10
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BL 18, 20, 23, 28 plus local back tender points
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Chong Mo Yang Ming
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ST 25, CV 3, CV 4, CV 7, ST 30, GB 30
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* All needles were manually tonified. Moxibustion was used variably.
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† Electrical stimulation at 2-4 Hz for Shu Points (10-12 minutes) and lumbar percutaneous electrical nerve stimulation (PENS) (20 minutes).
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‡ Chong Mo: SP 4, KI 3, PC 6 with 4-Hz stimulation between SP 4 and Conception Vessel focus points.
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§ Yang Ming: LI 4, 10, or 11 with ST 36, 39, or 40 depending on point sensitivity.
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|| Kidney Distinct Meridian: KI 10, BL 40, and BL 10.
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¶ Bladder tendinomuscular points BL 67, SI 18.
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# Scheduled visit for follow-up, but patient unable to lie on treatment table due to acute respiratory tract infection.
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The patient was anxious about lengthening the interval between acupuncture visits beyond 2 weeks. However, despite 2 respiratory tract infections and a bout of sciatica in 7 months, the patient reported feeling her best in 6 years, the longest interval without cystoscopic intervention since her diagnosis.
At the time of this writing, the patient was using a combination of bladder medications with occasional tramadol for the IC symptoms.
She exercises several days per week, continues consuming a healthy diet (despite no measurable weight loss), and has resumed sexual activity. The only adverse acupuncture effect this patient experienced was occasional bruising. Withdrawal from long-term narcotic pain medications presented no problems.
DISCUSSION
Interstitial cystitis is a chronic relapsing disease of the urinary bladder. Symptoms include urinary urgency or frequency, nocturia, dysuria, and pelvic pain. Patients often present with only 1 symptom, others with many.1 Secondary symptoms include sleep deprivation from the nocturia, depression, and sexual dysfunction. Interstitial cystitis was once believed to be a rare disease in women only, usually in postmenopausal years. Actually, it occurs in men and children and women of all ages, and is more prevalent than previously thought.2 Ongoing controversy exists regarding diagnostic criteria; the actual prevalence of IC is not known.3
Diagnosis of IC requires exclusion of urinary tract infection and malignancy. Interstitial cystitis should be considered in the differential diagnosis of patients with a clinical diagnosis of cystitis whose condition is unresponsive to antibiotics, or in patients who have persistently negative urine bacterial cultures. Likewise, a male patient with a clinical diagnosis of prostatitis or benign prostatic hyperplasia, whose symptoms fail to respond to conventional treatment, should be evaluated for IC. The National Institutes of Health – National Institute of Diabetes and Digestive and Kidney Diseases (NIH-NIDDK) adopted diagnostic criteria in the 1980s. These in- clude cystoscopic findings of ulcers and glomerulations in the bladder, and a reduced bladder capacity upon hydrodistension under anesthesia. However, bladder biopsy is not required for diagnosis, and approximately 10% of IC patients have no Hunner's ulcers or glomerulations on cystoscopic examination.4
Treatments available for IC include oral medication, intravesicular treatments, and physical modalities. Standard 1st-line treatment is hydrodistension of the urinary bladder under anesthesia. Intravesicular installation of dimethyl sulfoxide, lidocaine, pentosan polysulfate, or heparin can augment the distension procedure results. Medications include tricyclic antidepressants, antihistamines (hydroxyzine, particularly), detrusor muscle stabilizers (such as oxybutynin), pentosan polysulfate, and analgesics.5 These treatments alone or in combination provide 30%-70% of patients with symptom improvement, in some cases complete and durable remission; in others, improvement is noted only during active treatment periods.
In a study using manual therapy of pelvic floor myofascial trigger points, Weiss treated 42 patients with urgency-frequency syndrome with or without pain, and 10 patients with IC.6 He reported that 7 of the 10 IC patients had moderate to marked improvement, but long-term follow-up data were not provided. Fall's Swedish study reported use of transcutaneous electrical nerve stimulation (TENS) of sacral nerve roots in 23 IC patients.7 It was reported that 18 patients had pain reduction, 8 patients had normalized urinary frequency, and 4 women who used TENS for 7 years or longer became asymptomatic and resolved their bladder lesions. Fall also studied complete transurethral resection of visible lesions as a measure for histopathologic diagnosis and definitive treatment. Reportedly, 21 of 30 women had improvement. In a 1994 study, Fall again showed TENS effective in producing long-term remission of IC, with overall better results in classic IC than in the non-ulcer subtype of IC.8
Maher et al reported the use of percutaneous electrical nerve stimulation (PENS) of the sacral nerve roots at S3 in 15 women with IC whose symptoms were unresponsive to standard oral or intravesicular therapy.9 Results included increase in void volumes, reduction in daytime frequency and nocturia, and improvement on urinary bladder pain scores. This favorable response occurred in 11 women (73%) who had the temporary stimulating electrode replaced by a permanently implanted electrode and neuromodulator unit.
Geirsson et al compared patient-applied TENS of the posterior tibial nerve at the ankle and traditional acupuncture.10 Those authors reported no improvement of voiding frequency, volume, or symptom scores in either treatment group. The acupuncture points used were CV 6, SP 6, and SP 9. All were tonified manually for 10 treatments over 5 weeks.
CONCLUSION
Most patients with IC are treated with a combination of modalities, and all patients should be offered referral to a support group. The Interstitial Cystitis Association of America provides a support link to patients throughout the United States. The psychological, physical, and socioeconomic toll taken by this disease is surprisingly large. There are also still some clinicians who believe the once-commonplace myth that IC is a psychosomatic condition.2
In the case I reported, the patient obtained substantial improvement in pain, voiding patterns, and quality of life through treatment with medical acupuncture as an adjunct to medication therapy. Many IC patients could benefit from a therapeutic trial of acupuncture. This treatment could be studied prospectively, using the patient as his/her own control, and comparing before/after treatment pain scales, voiding diaries, and medication counts.
ACKNOWLEDGEMENT
Thanks to Dr Jeffrey Meffert for sharing his computer savvy, medical publishing, and editing experience.
REFERENCES
- Driscoll A, Teichman JM. How do patients with interstitial cystitis present? J Urol. 2001;166:2118-2120.
- Ratner V. Current controversies that adversely affect interstitial cystitis patients. Urology. 2001;57:89-94.
- Kusek JW, Nyberg LM. The epidemiology of interstitial cystitis: is it time to expand our definition? Urology. 2001;57(6 suppl 1):95-99.
- Sant GR, Hanno PM. Interstitial cystitis: current issues and controversies in diagnosis. Urology. 2001;57(6 suppl 1):82-88.
- Metts JF. Interstitial cystitis: urgency and frequency syndrome. Am Fam Physician. 2001;64:1199-1206.
- Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166:2226-2231.
- Fall M. Conservative management of chronic interstitial cystitis: transcutaneous electrical nerve stimulation and transurethral resection. J Urol. 1985;133:774-778.
- Fall M, Lindstrom S. Transcutaneous electrical nerve stimulation in classic and nonulcer interstitial cystitis. Urol Clin North Am. 1994;21:131-139.
- Maher CF, Carey MP, Dwyer PL, Schluter PL. Percutaneous sacral nerve root neuromodulation for intractable interstitial cystitis. J Urol. 2001; 165:884-886.
- Geirsson G, Wang YH, Lindstrom S, Fall M. Traditional acupuncture and electrical stimulation of the posterior tibial nerve: a trial in chronic interstitial cystitis. Scand J Urol Nephrol. 1993;27:67-70.
AUTHOR INFORMATION
Dr Paula M. Lyons' specialty is Family Practice. Dr Lyons is in private practice in San Antonio, Texas, and is Clinical Assistant Professor in the Department of Family and Community Medicine, University of Texas Health Science Center, San Antonio, Texas.
Paula M. Lyons, MD*
105 Cas Hills
San Antonio, TX 78213
Phone: 210-341-5588 • Fax: 210-348-8428 • E-mail: paulalyons@grandecom.net
*Send all correspondence and reprint requests to Dr Lyons at the above address.
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