In order to explore the effect of electroacupuncture (EA) for chronic bowel and bladder dysfunction after traumatic spinal cord injury, 14 patients were treated with electroacupuncture once a day, five times a week for the first four weeks, and once every other day, three times a week for the following four weeks. The patients were then followed up for six months. After treatment, four (4/14, 28.57%) patients resumed normal voiding; six (6/14, 42.86%) resumed normal voiding for no less than half of all micturition behaviors; four (4/14, 28.57%) required supplementary urination methods for higher than half of all micturition behaviors. These effects persisted during followup. Mean postvoid RUV decreased by
Traumatic spinal cord injury (SCI) is an accidental disaster, causing unexpected suffering physically, emotionally, and costly to patients [
Acupuncture is a therapy that is commonly utilized by the Chinese people for the management of bowel and bladder dysfunction. Documentation of acupuncture use for bowel and bladder symptoms dates back to thousands of years ago in the ancient medical monograph Huang Di Nei Jin (Yellow Emperor’s Inner Canon). Propositions of therapeutic effects of acupuncture in neurogenic bowel and bladder dysfunctions are supported by modern research studies. Compared with urinary catheterization or use of medications, Cheng et al. [
This was a prospective consecutive case series study performed at the Acupuncture Department of Guang An Men Hospital, China Academy of Chinese Medical Sciences. The hospital ethics committee approved this treatment protocol, and all patients signed informed consent before study participation. Acupuncture procedures were implemented by senior acupuncturists at the department with more than 20 years’ clinical experiences. Data management and analysis were performed by graduates who were blinded to the treatment procedures.
For inclusion, the participants had to fulfill the following criteria: (1) simultaneous bladder and bowel dysfunctions caused by traumatic SCI of or above Level L1; (2) no history of sphincter injury or surgery of the urinary tract, gastrointestinal tract, or anus; (3) SCI history for no less than six months and onset of bowel and bladder symptoms after SCI; (4) they must be at least 18 years old; (5) cardiac, hepatic, and renal functions as well as coagulative functions are normal or near normal; (6) no cognitive or mental disorders.
Huatuo brand needles (size 0.45 mm × 125 mm and 0.30 mm × 75 mm, manufactured by Suzhou Medical Appliance, Suzhou, Jiangsu, China) together with GB6805-2 Electro-Acu Stimulators (Medical Supply & Equipment Co., Ltd., Shanghai, China) were used. The parameters of electric stimulation were set as the follows: continuous wave with electric current frequency of 20 Hz and intensity between 3 and 10 mA according to patients’ tolerance. Based on the clinical experiences and anatomical knowledge (direct stimulation of S2-S3) of the acupuncturists, bilateral BL32, BL33, and BL35 were used.
Acupoints were selected and localized according to the WHO Standardized Acupuncture Points Location [
Bladder functions including postvoid residual urine volume (RUV), weekly urinary incontinence frequency, and additional conservative interventions (if any) were measured and documented at baseline, after treatment, and during followup. With reference to the International Lower Urinary Tract Function Basic Spinal Cord Injury Data Set [
With reference to the International Bowel Function Basic Spinal Cord Injury Data Set [
Adverse events which may include hematoma, fainting, and unbearable pain and others were documented during study.
Statistical analysis was performed with the SPSS software package (Version 17.0) for Windows XP. Quantitative data of postvoid RUV and weekly urinary incontinence frequency were expressed with mean ± standard deviations (SD). Paired samples
As presented in Figure
Flow chart of study participation.
Of these 14 patients, nine were male and five were female; eight had motor vehicle accident, five were injured from falling, and one was injured by gun shot. The mean age of these participants was 34 years old with a range from 21 to 57 years old. The mean disease course was 16.3 months with a range from six months to nine years. In these 14 patients, two patients’ injuries were at the cervical level, two at the upper thoracic level, four at the lower thoracic level, and six at the lumbar level. According to American Spinal Cord Injury Association (ASIA) Impairment Scale (AIS) classification [
Demographic information and changes of urination and defecation after electroacupuncture treatment.
No. | Gender (F/M) | Age (years) | Courses (months) | Injured level | AISA classification | Urination form | Defecation form | ||||
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Baseline | after treatment | After followup | Baseline | after treatment | After followup | ||||||
1 | F | 21 | 8 | T11 | A | Intermittent catheterization | Normal voiding | Normal voiding | Suppositories | Suppositories | Suppositories |
2 | F | 36 | 6 | L1 | A | Intermittent catheterization | Normal voiding | Normal voiding | Suppositories + perianal stimulation | Suppositories + perianal stimulation | Suppositories + perianal stimulation |
3 | M | 48 | 6 | L1 | B | Intermittent catheterization | Normal voiding | Normal voiding | Suppositories | Normal defecation | Normal defecation |
4 | M | 25 | 12 | L1 | B | Intermittent catheterization | Partially normal voiding + pushing the bladder | Partially normal voiding + pushing the bladder | Suppositories + assisted by hands | Partially normal defecation + suppositories | Partially normal defecation + suppositories |
5 | F | 22 | 11 | C5 | C | Intermittent catheterization | Partially normal voiding + intermittent catheterization | Partially normal voiding + intermittent catheterization | Suppositories + laxative | Partially normal defecation + suppositories | Partially normal defecation + suppositories |
6 | M | 27 | 6 | L1 | C | Pushing the bladder | Partially normal voiding + pushing the bladder | Partially normal voiding + pushing the bladder | Suppositories | Normal defecation | Normal defecation |
7 | M | 27 | 9 | L1 | B | Intermittent catheterization | Partially normal voiding + intermittent catheterization + pushing the bladder | Partially normal voiding + pushing the bladder | Suppositories | Suppositories | Suppositories |
8 | M | 48 | 6 | T10 | B | Intermittent catheterization | Normal voiding | Normal voiding | Suppositories + laxative | Normal defecation | Normal defecation |
9 | F | 43 | 14 | T9 | A | Pushing the bladder | Pushing the bladder | Pushing the bladder | Suppositories | Suppositories |
Suppositories |
10 | M | 38 | 14 | C5 | B | Intermittent catheterization | Partially normal voiding + intermittent catheterization | Partially normal voiding + intermittent catheterization | Suppositories | Suppositories |
Suppositories |
11 | M | 36 | 15 | T3 | C | Intermittent catheterization | Intermittent catheterization | Intermittent catheterization | Suppositories + laxative | Suppositories + laxative | Suppositories + laxative |
12 | F | 26 | 7 | T6 | A | Pushing the bladder + intermittent catheterization | Pushing the bladder + intermittent catheterization | Pushing the bladder + intermittent catheterization | Suppositories | Suppositories | Suppositories |
13 | M | 57 | 108 | L1 | B | Intermittent catheterization | Partially normal voiding + pushing the bladder | Partially normal voiding + pushing the bladder | Suppositories + laxative | Partially normal defecation + suppositories | Partially normal defecation + suppositories |
14 | M | 26 | 6 | T12 | A | Intermittent catheterization | Pushing the bladder + intermittent catheterization | Intermittent catheterization | Suppositories | Normal defecation | Normal defecation |
Before treatment, all 14 patients had no normal voiding ability and required assisted therapies (intermittent catheterization or abdominal push) to empty the bladder. After eight-week treatment, four (4/14, 28.57%) patients resumed normal voiding (Group A); six (6/14, 42.86%) resumed normal voiding for no less than half of all micturition behaviors (Group B); four (4/14, 28.57%) required assistive urination therapies for higher than half of all micturition behaviors (Group C). In the six patients of Group B, three patients required bladder emptying via abdominal push, two required intermittent catheterization, and one required both. Similar results were found during followup (Table
Mean postvoid RUV for these 14 patients decreased by 190.29 ± 101.87 mL after treatment, from 262.43 ± 131.50 mL at baseline to 72.14 ± 83.59 mL (
Mean postvoid RUV.
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Baseline (A) | After treatment (B) | Followup (C) | Difference |
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AB | AC | BC | AB | AC | BC | AB | AC | BC | ||||
14 (total) |
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6.989 | 6.633 | 1.207 | 0.000 | 0.000 | >0.05 |
4 (group A) |
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3.498 | 3.571 | 1.000 | 0.040 | 0.038 | >0.05 |
6 (group B) |
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3.878 | 3.961 | 1.000 | 0.012 | 0.011 | >0.05 |
4 (group C) |
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3.934 | 2.698 | 0.302 | 0.029 | >0.05 | >0.05 |
Histogram of mean postvoid RUV. Group A refers to patients who had normal voiding all the time; Group B refers to patients with normal voiding frequency no less than half of all micturition; Group C refers to patients who require assistive urination help with a frequency higher than half of all micturition.
Of these 14 patients, seven patients (7/14, 50.00%) had various degrees of urinary incontinence. Five out of these seven patients were diagnosed as detrusor hyperreflexia through urodynamic study (UDS) before treatment; the remaining two patients lacked relevant examination. After treatment, the weekly urinary incontinence frequency for these seven patients reduced from 79.14 ± 64.80 times/week at baseline to 32.00 ± 20.94 times/week (
Before treatment, all 14 patients had constipation and required supplementary methods for defecation, and thus their symptoms were considered as complete constipation. After treatment, four (4/14, 28.57%) resumed normal bowel movements; five (5/14, 35.71%) regained partially normal bowel movements and reduced the dependence on supplementary defecation methods; five (5/14, 35.71%) had no change. In the five patients who regained partially normal bowel movements, one resumed the desire to defecate, one resumed anal reflex, and three regained the soft and smooth stool which was made of nuts-like hard lumps before. The effects of EA were maintained during followup (Table
No adverse effects were found. Five patients with residual sensory functions reported pain, sourness, numbness, and/or distension upon acupuncture procedures, which were well tolerated during treatment and disappeared after needle removal. Based on traditional Chinese medicine theories, these sensations are likely to be categorized into the De Qi sensations and are thus considered normal during acupuncture treatment [
Under physiological conditions, neurons are considered as permanent cells which remain in the G0 phase and lack proliferation. With spinal cord injury, sprouting and regeneration of the CNS tracts depend on the functions of glia cells due to the poor regenerative capacity of axons [
Improvements of bowel and bladder functions will reinforce patients’ confidence in recovery, encourage patient’s social interaction, and increase the quality of life and thus greatly decrease the incidence of SCI-associated complications and the development of other comorbidities [
Results of the present study indicate that EA at S2-3 and perianal region could improve patients’ voiding abilities. The results were consistent with our previous findings in which 10 out of 15 patients with cauda equina injury resumed voiding abilities and were urinary catheter-free after a similar EA treatment protocol [
Bladder functions can also be reflected by postvoid RUV. In the present study, postvoid RUV was measured using a cylinder via self-urethral catheterization after full urination. This technique theoretically provides reliable information regarding residue urine volume and thus the first impression of patients’ voiding function [
In conjuncture with evidence from the aforementioned research studies, we hypothesize that EA sacral nerve stimulation could modulate urinary functions in patients with SCI. Pelvic splanchnic nerves do not only provide parasympathetic innervations to the detrusor muscle responsible for involuntary bladder emptying, but also parasympathetic innervations to the sigmoid colon and rectum responsible for involuntary bowel movements. Somatic components of the pudendal nerve directly innervate the external urethral sphincter and the external anal sphincter via its branches of inferior anal nerves; normal functions of these sphincters serve as the foundation for normal bowel and bladder control. Both the pelvic splanchnic nerves and pudendal nerve arise from S2–S4; therefore, EA at S2-3 provides direct electric and mechanical stimulation to these nerves. Nonetheless, EA stimulation at S2-3 is nonselective which indicates two extremely opposite conditions. This could at least partially contribute to the interesting opposite phenomena (effects on neurogenic urinary retention and urinary incontinence) discovered with EA treatment at S2-3 [
Nonetheless, the present study is a case series study with a relative small sample size which indicates that results of the present study may not well represent the general response of patients with chronic bowel and bladder dysfunction caused by SCI. For example, in the present study, standard deviations of some quantitative measurements (such as postvoid RUV and the change of weekly urinary incontinence frequency after treatment) were bigger than its corresponding mean which indicates relative wide dispersions of values in the small sample and is unfavorable for the statistical analyses. Assessments of acupuncture effects in the present study mainly depend on patients’ reports which may be interfered with recall bias and patients’ believes and emotional status upon visits. To objectively evaluate EA effects on neurogenic bowel and bladder dysfunction, we may need to incorporate urodynamic measurements in future studies. Furthermore, assessment of bowel functions is limited to patient-reported bowel movement frequencies and supplementary defecation methods, information like average time required for defecation, frequency of defecation, and frequency of fecal incontinence is lacking.
In patients with chronic bowel and bladder dysfunction after SCI, EA may provide a valuable alternative tool in improving patients’ self-controlled bowel and bladder functions.
No competing financial interests exist.
This study was funded by 12th National Key Technology Support Program in China (no. 2012BAI24B01).