Electroacupuncture neurostimulation for treatment of chronic voiding dysfunction ???????????? ????

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Electroacupuncture neurostimulation for treatment
of chronic voiding dysfunction????????????????

• Prof. Wang Siyou
• Shanghai Research Institute of Acupuncture and
  Meridian

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Stress Urinary Incontinence??????
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• Urinary incontinence can be classified under 7
  types in Western medicine
• ?????????7????

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• Stress urinary incontinence (SUI)
• ??????
• Urge urinary incontinence (UUI)
• ??????
• Unconscious urinary incontinence
• ???????
• Continuous urinary incontinence
• ??????

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• Nocturnal enuresis
• ????
• Postvoid dribble
• ?????
• Overflow urinary incontinence
• ??????

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• Stress urinary incontinence (SUI) is defined as
  an involuntary leakage of urine from the urethral
  meatus at a sudden increase in intra-abdominal
  pressure (eg coughing, sneezing, laughing,
  running or strenuous activities) without
  simultaneous detrusor contraction.
• ?????????????????,??????(??????????????????)??????
  ?????,?????????????

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• It often happens in multiparous and
  postmenopausal women.
• It comes under the category of enuresis in TCM.
• ??????????????
• ?????????

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Stress Urinary Incontinence
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Overactive bladder Urge incontinence
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• Etiology
• The possible causes of stress urinary
  incontinence (SUI) are (1) childbirth and
  puerperal injury, and dystocia, especially
  forceps delivery (2) changes in the urethra and
  periurethral tissues, eg atrophy of pelvic floor
  tissues due to postmenopausal changes in sex
  hormones
• ?.   ??
• ????????(1)???????,?????????(2)???????????,?????
  ???????????

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• Etiology
• (3) history of vaginal, urethral or prostatic
  surgery (4) perineal or urethral injury (5)
  pelvic tumescence resulting in a high
  intra-abdominal pressure and a lower position of
  bladder neck. More than one cause may coexist.
• (3)????????????(4)????????(5)??????????,????????
  ?????????????

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• Pathogenesis
• The above etiologies produce the abnormalities of
  (vesical neck and urethra) sphincters, that is,
  urethral hypermobility or/and intrinsic sphincter
  deficiency (intrinsic malfunction of the urethral
  sphincter itself) to result in SUI.
• ?. ????
• ???????(??????)?????????????/????????(???????????
  ???,???????????),?????????

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• Pathogenesis
• In the former, a weakness of pelvic floor support
  causes the hypermobility and descent of the
  vesical neck and proximal urethra during an
  increase in intra-abdominal pressure and thereby
  unequal transmission of abdominal pressure to the
  bladder and urethra (vesicourethral pressure
  transmission ratio decreases) when vesical
  pressure exceeds urethral pressure, incontinence
  ensues .
• ????????????????????????????????????????,?????????
  ????,????????????,????????

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Subtypes of stress incontinence??????????
????

• There are 2 possible reasons for urodynamic
  stress incontinence????????????2?????
• Hypermobility ?????
• (weakness of bladder support) (???????? )
• Intrinsic sphincter deficiency
• ?????????
• (ISD - weakness of urethral sphincter)
  (ISD-???????)
• Video or extra tests (UPP, VLPP) help to make
  this distinction???????????( ??????
  UPP,????????VLPP)?????

??
????
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Stress Urinary Incontinence
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Stress Incontinence VLPPRest Straining
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Simple Tests

• Q Tip Test
• Test for mobility
• gt30 degree
• Simple CMG
• Urethral catheter
• Manometer or
• Toomey Syringe

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• Clinical manifestations
• 1.  Symptom
• Involuntary loss of urine during coughing,
  sneezing, laughing, running or physical exertion
  such as sport activities and sudden changes of
  position.
• ?. ????
• 1.  ??
• ??????????????????????????????????????????

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• Clinical manifestations
• 2.  Signs
• The observation of loss of urine from the urethra
  during coughing, sneezing, or physical exertion.
• Positive Marshell (bladder base elevation) test.
• Positive pad test.
• A vaginal examination shows cystocele, enterocele
  or rectocele.
• 2.  ??
• ??????????????????????????(????)??????????????????
  ??????????

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• Video-urodynamics
• 1. Urethral hypermobility
• The vesical neck is closed at rest (no increase
  in intra-abdominal pressure). During stress (an
  increase in intra-abdominal pressure), the
  vesical neck and proximal urethra open and
  descend.
• ?. ???????
• 1. ???????
• ??(?????)?,???????(????)?,??????????????

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• Video-urodynamics
• 2. Intrinsic sphincter deficiency
• The vesical neck and proximal urethra are open at
  rest in the absence of detrusor contraction.
• 2. ???????
• ??????????,???(?????)???

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Hypermobility (type II incontinence)?????(II????)
??

• Easily defined on videourodynamics??????????????
• but Q-tip test or simple observation will help?
  Q-tip ?????????????

Hypermobility????? (on cough or Valsalva, or
permanent descent)(??,Valsalva,??????)
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LPP measurement???????
Strain leaks at 165 cm H2O????? 165 cm H2O???
(????)(hypermobility)
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• Hyper-mobility with leakage (on cough)
• ???????(????)

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LPP measurement???????
Strain leaks at 45 cm H2O????? 45 cm H2O???
Initial pves?????
Stop fill at 200 ml? 200 ml?????
Start filling????
(no hypermobility, ISD)(??????,?????????)
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• Dagnosis
• Based on
• The symptom (history) of stress incotinence
• Positive stress test (loss of urine during
  coughing or physical exertion) and Marshell test
  or pad test.
• ?. ??
• ??
• 1. ????????(??)?
• 2. ??????(?????????????)???????????????

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• Dagnosis
• Based on
• The results of imaging urodynamic examination
  urethral hypermobility or/and intrinsic sphincter
  deficiency no involuntary detrusor contraction.
• 3. ?????????????????/???????????????????

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• Treatment
• 1. Western conservative treatment
• Conservative treatment can be applied to mild and
  moderate SUI.
• Its advantages are safety, micro invasion, and
  much lower incidence and less severity of
  complications compared with surgical treatment.
• ?. ????
• 1. ??????
• ???????????????????,????????,????????????????????

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• 1. Western conservative treatment
• Conservative treatment mainly includes pelvic
  floor muscle exercises (PFME), electrical
  stimulation (ES), various vaginal and urethral
  devices and medication.
• PFME and transvaginal or trans-anal ES (TES) are
  the two most commonly used forms of conservative
  treatment for SUI.
• ??????????????????????????????????????????????????
  (????????)????????????

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• 1. Western conservative treatment
• PFME can build up the structural support of the
  pelvis, improve neuromuscular function, prevent
  the proximal urethra and bladder base from
  descending during a rise in abdominal pressure
  and increase urethral pressure.
• ?????????????????,????????,???????????????????????
  ??????

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• 1. Western conservative treatment
• Its shortcomings are many patients difficulty
  identifying and isolating their PFM and inability
  to perform PFME effectively lack of long-term
  patient compliance.
• ?????????????????????

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• 1. Western conservative treatment
• TES is passive PFME that produces PFM
  contractions and has good patient compliance.
• Its shortcoming is that it applies vaginal or
  anal surface electrode and induces PFM
  contractions by indirect nerve stimulation, so
  its effect is not as good as that of PFME which
  is done correctly.
• ??????????????????,??????????????????,??????,????
  ???????? ?

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• 2. Acupuncture treatment
• Acupuncture of traditional Chinese medicine can
  also be applied to mild and moderate stress
  incontinence. Its advantages are safety,
  convenience, and no side effects and
  complications.
• 2. ??????
• ??????????????????????,???????????????????

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• 2. Acupuncture treatment
• 1) Therapeutic principle
• According to TCM theory, it is caused by
  deficiency of kidney qi and failure of the
  bladder in restraining the urine discharge, so
  the therapeutic principle is reinforcing kidney
  qi and improving vesical restraining function.
• 1) ????
• ????,??????????,??????,???????????,?????

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• 2) Point selection
• The Back-Shu and Front-Mu points of the kidney
  and bladder are selected as the main acupoints.
  The acupoints often selected are Shenshu (B 23),
  Pangguangshu (B 28), Zhongji (Ren 3), Guanyuan
  (Ren 4), Mingmen (Du 4), Huiyang (B 35),
  Sanyinjiao (Sp 6) and Zusanli (S 36).
• 2) ????
• ???????????????
• ???????,???,??,??,??,??,???,????

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• 2) Point selection
• The kidney is exteriorly-interiorly related to
  the bladder, so the Back-Shu points of the kidney
  and bladder are applied. Zhongji (Ren 3) is the
  Front-Mu points of the bladder. The combined use
  of the above three acupoints contributes to
  reinforce kidney qi and improve vesical
  restraining function.
• ???????,???????????????????????????????,?????

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• 2) Point selection
• Guanyuan (Ren 4) and Mingmen (Du 4) are the
  sources of primordial qi and acupuncture of them
  can tonify primordial yang (kidney-yang). Huiyang
  (B 35) is the acupoint of the foot-taiyang
  meridian and acupuincture of it can invigorate
  the meridional qi of the bladder.
• ??????????,?????????????????,???????????

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• 2) Point selection
• Sanyinjiao (Sp 6) is the crossing point of the
  three foot-yin meridians and acupuncture of it
  can regulate the qi of the three foot-yin
  meridians. Zusanli (S 36) belongs to the yangming
  meridian, which is full of qi and blood, and
  acupuncture of it can tonify qi to stop
  incontinence.
• ???????????,??????????????????,???????,????????

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• 3) Shortcoming
• Because it uses a general method of acupuncture,
  it is difficult for conventional acupuncture,
  like electrical nerve stimulation, to improve the
  ability in controlling urination by exciting the
  pudendal nerve, inducing the rhythmic contraction
  of the pelvic floor muscles and increasing their
  strength.
• 3) ????
• ?????????,???????????????????????????????,????????
  ????????

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• 3. Electroacupuncture pudendal nerve stimulation
• By combining the advantages of PFME and TES and
  incorporating the technique of deep insertion of
  long needles, we developed electracupuncture
  pudendal nerve stimulation ( Four sacral points
  electracupuncture therapy), which is a
  combination of traditional Chinese and Western
  medicine.
• 3. ??????????
• ??PFME ? TES??????,??????????,??????(??????)??????
  ????(???????)?

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• 3. Electrical pudendal nerve stimulation
• In this therapy, four sacral specific points are
  acupunctured by a special needling method (the
  needle tip in a specific direction) and
  electrified
• 3. ??????????
• ????????????????????(???????)??????

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• 3. Electrical pudendal nerve stimulation
• to improve the ability in controlling urination
  by exciting the pudendal nerve and inducing the
  rhythmic contraction of the pelvic floor muscles
  (including the urethral sphincter ) to strength
  the muscles, restore the normal positions of
  bladder neck and proximal urethra and increase
  urethral closure pressure.
• ??????????????(???????)?????,??????????,??????????
  ??????,???????????????

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Four sacral points???

• Location of four sacral points and acupuncture
  methods
• 1) The two upper points located by the two edges
  of the sacrum on a level with the fourth sacral
  foramina
• ???????
• 1)??????????,??4??????(??)?

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Four sacral points???

• Location of four sacral points and acupuncture
  methods
• 1) The two upper points use a long needle of 4
  cun (100mm) puncture perpendicularly 33.5 cun
  in depth make the needling sensation reach the
  urethra or anus.
• ??4?????,?????3-3.5?,??????????

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Four sacral points???

• Location of four sacral points and acupuncture
  methods
• 2) The two lower points 0.5 cun bilateral to the
  tip of the coccyx use a long needle of 4 or 5
  cun (100 or 125mm)
• 2)?????
• ????0.5?(??),??4??5???,

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Four sacral points???

• Location of four sacral points and acupuncture
  methods
• 2) The two lower points puncture obliquely
  (laterally) towards the ischiorectal fossa, 34.5
  cun in depth make the needling sensation reach
  the urethra.
• ???(?????)??,3-4.5??,???????

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• Electrical pudendal nerve stimulation
• After the needling sensation referred to the
  above regions was produced, a G6805-2
  Multi-Purpose Health Device was connected with
  the inserted needles used as electrodes. The
  device was set to produce an electrical
  stimulation at a frequency of 2.5 Hz (150
  times/min) and an intensity as high as the
  patient could tolerate without discomfort. The
  electroacupuncture was set for 60 minutes each
  time.
• 3. ??????????
• ?????????G6805????????????,???2.5Hz
  (150?/?),?????????????,????60???

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• Electrical pudendal nerve stimulation
• Strong rhythmic and cephalad contraction of the
  pelvic floor muscles around the urethra must be
  kept during the electroacupuncture.
• The treatment was given once every other day. The
  treatment course was based on the patients
  condition.
• ??????????????????????(????)????????
• ????1?,??????????

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Thanks