Xu Lei (徐蕾), Ding Min (丁敏), Feng Hua (馮驊), Lin Tian-yun (林天云)

Wuxi Hospital of Traditional Chinese Medicine, Jiangsu Province, Wuxi 214001, China

Abstract Objective: To observe the clinical efficacy of deep electroacupuncture (EA) at Baliao points in treating stress urinary incontinence (SUI).Methods: A total of 60 female patients with SUI were divided into two groups according to the order of consultation,with 30 cases in each group. The control group was treated with pelvic floor muscle training. The treatment group was treated with deep EA at Baliao points [Shangliao (BL 31), Ciliao (BL 32), Zhongliao (BL 33) and Xialiao (BL 34)].Results: The total effective rate was 93.3% in the treatment group, versus 33.3% in the control group, and the total effective rate of the treatment group was significantly higher than that of the control group (P＜0.05). After treatment,the scores of international consultation on incontinence questionnaire-short form (ICIQ-SF) and the volume of urinary leakage in both groups were lower than those before treatment (all P＜0.05), and the ICIQ-SF score and the volume of urinary leakage in the treatment group were lower than those in the control group (both P＜0.05).Conclusion: Deep EA at Baliao points with long needles can improve the clinical symptoms in female patients with SUI,and it has a better curative effect than pelvic floor muscle training.

Keywords: Acupuncture Therapy; Electroacupuncture; Acupuncture-moxibustion Therapy; Urinary Incontinence, Stress;Points, Baliao; Women

Stress urinary incontinence (SUI) refers to unintentional leakage of urine caused by a sudden increase in abdominal pressure such as coughing,sneezing, laughing, exercising or changing posture. The International Continence Society (ICS) defines it as a social and health issue. Currently, there are different reports on the prevalence of SUI, mainly because most patients consider urinary incontinence as embarrassment. According to statistics, 10%-80% of women have symptoms of urinary incontinence, and 3% to 10% have severe incontinence[1]. SUI is commonly seen at clinic, can seriously affecting the quality of life(QOL) and social activities of patients. The main causes of SUI include pregnancy, childbirth, and pelvic surgery that result in the damage of pelvic floor tissue, as well as atrophy of urethral and periurethral tissues and decrease or loss of support due to the decrease in estrogen level in elderly women[2]. The occurrence of SUI is related to the types of childbirth, the times of childbirth, body mass index (BMI) and age.

Current SUI treatment methods can be divided into surgical treatment and conservative treatment. Surgical treatment may cause complications such as bladder perforation, hemorrhage in retropubic space, dysuria,foreign body reaction, delayed healing of incision,intestinal perforation and infection. The long-term effect requires further observation. There are various conservative treatment methods, but there is no consensus so far. In this study, we applied deep electroacupuncture (EA) at Baliao points in treating SUI.

1 Clinical Materials

1.1 Diagnostic criteria

This study referred to the diagnostic criteria of SUI in the latest 2017 edition of the SUI guidelines developed by the Gynecologic Pelvic Floor Group of the Obstetrics and Gynecology Branch of Chinese Medical Association:involuntary release of urine as a result of an increase of abdominal pressure caused by action, such as laughing,coughing, sneezing or walking; positive Marshall-Marchetti test.

1.2 Inclusion criteria

Those who met the above diagnostic criteria of SUI;aged between 25 and 80 years; had no Chinese or Western medical therapy in the past 3 months; agreed to participate in this clinical trial and signed informed consent.

1.3 Exclusion criteria

Those with neurogenic incontinence, psychogenic incontinence, impulsive incontinence, and incontinence due to urethral sphincter insufficiency or ectopic ureter that required surgery; combined with severe primary diseases of cardiocerebrovascular system, liver, kidney or hematopoietic system; patients with mental disease;diabetes mellitus; combined with severe urinary tract infection, or combined with uterine prolapse degree Ⅰor above.

1.4 Elimination and shedding criteria

Those who didn’t follow the required treatment;dropped out during the treatment; unable to assess the effect, or with incomplete data that affected efficacy evaluation.

1.5 Statistical methods

The SPSS version 15.0 software was used for statistical analysis of data. Measurement data were expressed as mean ± standard deviation (x ±s).Independent sample t-test or non-parameter test was applied to the comparison between groups. Paired sample t-test was applied to the comparison of intra-group data. Rank-sum test was applied to the comparison of ranked data. The comparison of rate was processed by Chi-square test. P＜0.05 indicated a statistically significant difference.

1.6 General data

A total of 60 cases were enrolled from the Acupuncture Clinic of Wuxi Hospital of Traditional Chinese Medicine, Jiangsu Province between September 2018 and April 2019. All patients were divided into two groups according to the visiting sequence, with 30 cases in each group. There was no dropout case in either group during the treatment.There were no statistically significant differences in age,duration of disease, BMI and parturition times between the two groups (all P＞0.05), indicating that the two groups were comparable (Table 1).

Table 1. Comparison of general data between the two groups

2 Treatment Methods

2.1 Control group

The control group was treated with pelvic floor muscle training. Contracted the external genitalia and anus for 3 s, relaxed for 3 s, contracted again, and repeated in order. The training was practiced for 3 sets of 10 min every day, for a total of 30 min.

2.2 Treatment group

Acupoints: Xialiao (BL 34), Zhongliao (BL 33), Ciliao(BL 32) and Shangliao (BL 31).

Methods: The patient took a prone position. The physician sought the points from bottom to top. First,the physician touched the protuberant sacral horn of the tip of sacral hiatus, and the depression near the lateral sacral horn was the location of Xialiao (BL 34).Took the line connecting the posterior superior sacral spine and posterior median line as the side, made a triangle downward, and the depression at the top angle was the location of Zhongliao (BL 33). The midpoint of the line between the sacral hiatus and the posterior superior sacral spine was the location of Ciliao (BL 32).The location of Shangliao (BL 31) was about 2 cm above Ciliao (BL 32), at the outward depression. After routine disinfection, the physician punctured the acupoints with disposable acupuncture needles of 0.35 mm in diameter and 75 mm in length. Xialiao (BL 34) was punctured perpendicularly; Zhongliao (BL 33) was punctured in obliquely at an angle of 70° to the plane of sacrum; Ciliao (BL 32) was punctured obliquely at an angle of 50° to the plane of sacrum; and Shangliao(BL 31) was punctured obliquely at an angle of 30° to the plane of sacrum. The feeling of soreness and distension would generate at the local part or spread to the perineum. The lifting-thrusting and twirling reinforcing manipulation was performed. And then a Hwato brand SDZ-ⅡB EA apparatus (Suzhou Medical Appliance Factory, China) was connected, with sparse-dense wave, and 2 Hz/15 Hz frequency. The intensity was decided by patient tolerance, and the stimulation lasted for 30 min (Figure 1). The treatment was performed once a day on Monday, Wednesday and Friday, that was 3 times a week, with an interval on Saturday and Sunday. The treatment lasted for 2 months as one treatment course.

3 Observation of Curative Efficacy

3.1 Observation items

3.1.1 International consultation on incontinence questionnaire-short form (ICIQ-SF)

ICIQ-SF was used to evaluate the frequency of urinary leakage, the volume of urinary leakage and the influence of urinary incontinence on patients with SUI.The higher the score, the more frequent the urinary leakage, the greater the volume of the urine leakage,and the worse the condition.

3.1.2 Pad test

After the patient's bladder was emptied, a urine pad was used (or used a sanitary napkin instead), and the urine leakage was observed for 1 h. The patient was asked to drink 500 mL water within 15 min, followed by a 30-minute walk, and finally performed the ICSprescribed movements (quickly walked for 3 min, went up and down stairs for 1 min, run in place for 1 min, sat down and stood up 10 times, and coughed 12 times) for 15 min. Finally, the urine pad was removed and weighed.

3.2 Criteria of curative efficacy

Cured: Urinary incontinence completely disappeared.No urine leakage during sports and coughing or laughing.

Improved: Urinary incontinence symptoms were improved or subjective symptoms were relieved, with a decrease of urine leakage in pad test.

Invalid: No changes in the symptoms after treatment or even went worse.

3.3 Results

3.3.1 Comparison of clinical efficacy

The total effective rate was 33.3% in the control group and 93.3% in the treatment group. The difference between the two groups was statistically significant(P＜0.05), indicating that the efficacy of the treatment group was superior to that of the control group(Table 2).

Table2. Comparison of clinical efficacy between the two groups (case)

3.3.2 Comparison of ICIQ-SF score

After treatment, the ICIQ-SF scores in both groups decreased (both P＜0.05), and the score in the treatment group was lower than that in the control group (P＜0.05), indicating that the improvement of symptoms in the treatment group was superior to that in the control group (Table 3).

3.3.3 Comparison of pad test results

After treatment, the volume of urine leakage in 1 h of both groups reduced (both P＜0.05), and the volume of urine leakage of the treatment group was less than that of the control group (P＜0.05), indicating that the improvement of urine leakage in the treatment group was superior to that in the control group (Table 4).

Table 3. Comparison of ICIQ-SF score between the two groups ( x±s, point)

Figure 1. EA treatment

Table 4. Comparison of the volume of urine leakage in 1-hour pad test between the two groups (x ±s, g)

4 Discussion

The commonly used acupoints in acupuncture treatment of SUI are Guanyuan (CV 4), Zhongji (CV 3),Sanyinjiao (SP 6), Shenshu (BL 23) and Zusanli (ST 36) in order, while using Baliao points accounts for less than 50%[3]. From 2001 to 2013, there had been a noticeable increase in the use of Baliao points. In many literatures,although there were various treatment methods,including EA[4], moxibustion[5], combination of acupuncture and medicine[6], acupoint application[7]and catgut embedding[8], the treatment regimen and acupuncture manipulations were not unified[9]. After 2013, the treatment methods mostly focused on acupuncture at Baliao points combined with pelvic floor muscle training[10-11].

The range of indications of Baliao points is wide,including: urinary incontinence, urinary retention and voiding dysfunction[12-13]; menstrual disorders,gynecological miscellaneous diseases, assisting reproduction and postoperative analgesia[14-15];prostatic diseases and male sexual dysfunction[16-17];lumbago, sacroiliac joint disease, heel pain and soft tissue injury[18-19]; constipation, fecal leakage,bearing-down sensation of anus and anorectal neurosis[20-21]. From the clinical application literatures from ancient times to present, it can be seen that Baliao points are effective in treating SUI.

The anatomical positions of Baliao points are closely associated with their therapeutic effect. Baliao points include Shangliao (BL 31), Ciliao (BL 32), Zhongliao(BL 33) and Xialiao (BL 34, and are located in the nerve distribution region of S2-S4. EA at Baliao points can stimulate S2-S4nerve roots, passively cause rhythmic contraction and relaxation of detrusor and urethral sphincter, which is conducive to the formation of micturition reflex, and improve bladder compliance and stability[22]. Thus, acupuncture at Baliao points to a certain depth can directly stimulate the sacral nerves,thereby enhancing the above effects. And adding EA can directly stimulate pudendal nerve and induce rhythmic contraction of pelvic floor muscle, thereby enhancing the strength of pelvic floor muscle and improving the ability in controlling urination.

This study indicated that EA at Baliao points could significantly improve the clinical efficacy, and reduce the 1-hour urine leakage and the frequency of urinary leakage. It has the advantages of quick effect, slight side effect, low cost and easy operation, and is more easily accepted by patients, with a broad application prospect.

Conflict of Interest

The authors declare that there is no conflict of interest in this article.

Acknowledgments

This work was supported by 2018 Project of Science and Technology Bureau of Wuxi (無錫市科技局2018 項(xiàng)目,No. WX18IIAN036); Medical Innovative Teambuilding Project of Wuxi Municipal Commission of Health and Family Planning (無錫市衛(wèi)計(jì)委醫(yī)學(xué)創(chuàng)新團(tuán)隊(duì)建設(shè)項(xiàng)目,No. CXTDJS006).

Statement of Informed Consent

Informed consent was obtained from all individual participants.

Received: 1 July 2019/Accepted: 15 August 2019