Volume 9, Number 4 | Winter 2014

Japanese Acupuncture - Current Research
Japanese Traditional Medicine Text (14) –Department of Urology

improvement of their symptoms and, following
urodynamic study, showed a significant increase inmaximum bladder capacity2). With regard to theHisashi Honjo

reliability of this research, it was not stated that the

Lecturersubjects were “randomly” assigned to test groups so

Faculty of Acupuncture and Moxibustion

the evidence cannot be considered to be of a highMeiji University of Integrative Medicine

level. On the other hand, St36 was established as thecontrol test point and was expected to produce

The positive effects of acupuncture for Urologicalconditions have been reported in international
journalssinceacupuncture

the

and

late

1980s.The

moxibustion

effectsoftreatment,inparticular acupuncture effects, have been known formany precisians in urology more than 20 years.
Bladder and urethra, as it is called the lower urinary
tract,

functionsareobviously

controlledbyautonomic and somatic nervous systems as research
has revealed1). Neuromodulation is an easy tounderstand mechanism of acupuncture treatments
as the therapeutic procedure for the lower urinary
tract symptoms (LUTS). Further, as a supplemental
treatment for refractory enuresis or incontinence(mainly side effects of drug therapy) there are highexpectations for the effectiveness of acupuncture
treatment. Actually, although there have been
numerous reports of acupuncture treatment being
used successfully for refractory enuresis, urinary
incontinence and urinary tract conditions, theusefulness of acupuncture should not be limited tothese conditions. This section outlines for indications
and effects of acupuncture treatment for domestic

distinctly different clinical effects, because it is in adifferent anatomical location, this may be considereda relevant research hypothesis. In contrast, Philip etal. collected 20 subjects complaining of urinary
frequency, urinary urgency and urge incontinence
and treated them with acupuncture. Treatmentareas included the low back, low abdomen and thelower medial leg and utilized K23, BL28, BL32, GV4,CV4 and CV6. It was reported that 77% of thesubjects stated that their symptoms had improved
and of those subjects it was found that their bladdercapacity had also increased3). This study does not
qualify as "integrated" because a control group was
not established, however, as with Chang et al.’sreport, objective improvement in bladder capacity
was confirmed among those subjects who reported
subjective improvement of their symptoms.
Further, at the beginning of 2000, several reports
were published whose titles did not include the term
“acupuncture”,

but

stimulation”

treat

to

used

“electro-acupunctureurinaryfrequency

andincontinence4-6). Up until recently, skin surface
electrodes known as “transcutaneous electricaland international research in the field of Urology.

nerve stimulation” or TENS have been used,

1. Clinical studies abroad

usefulness of electrical stimulation of the medial

The first International journal to publish researchon the effects of acupuncture for LUTS was in 1988.
Chang et al. reported on the effects of acupuncture
for urinary frequency and urgency in 52 women. The
subjects were divided into two groups: one group wastreated at Sp6 (medial lower leg) and the other at St
36 (lateral lower leg, below the knee). Results

however,

here

the

reportedonlower leg after using a needle electrode intended tostimulate the tibial nerve. The affected area is on thelower medial leg in areas almost equivalent totreating Sp6 and K3 with electro-acupuncture.
These reports implicitly indicated the usefulness ofeven low-frequency electrical stimulation using
acupuncture in clinical research.

showed 85% of women treated at Sp6 reported

2

researchers

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 9, Number 4 | Winter 2014

Klingleret al. investigated the effects of acupuncture

stimulation while creating no side effects can beat points near Sp6 on the lower medial leg in 15

useful in children.

subjects with frequent urination and urinary

This research points to a changed environment

urgency. The opposite pole plate was attached to asurrounding the lower urinary tract symptoms. In

needle below and posterior to the medial malleolus

2002, effective acupuncture treatment for lower(approximately K3), so stimulation would be appliedurinary tract symptoms was reported. The syndrome

to the posterior tibial nerve (20Hz, 30 minutes).

includes a constellation of symptoms with or without

Treatments were conducted 4 times per week for aurge

total of 12 treatments before results were confirmed.

urination or accompanied by frequent urge to

After urodynamic testing, it was found that onset ofurinate at night that has become referred to as

urination was easier, the urge to urinate was"overactive bladder" (OAB), a concept addressed bynormalized and bladder capacity was significantly

the International Continence Society (ICS).Until

increased. In conclusion, 47% of the subjects

recently, invasive inspection protocols had been used

reportedincontinence,usuallyincludingfrequent

had

completely

to diagnose such symptoms but these methods havereportedsignificant

changed significantly7). According to this new

improvement4). Vandonincket al. conducted a 12-

symptom syndrome, overactive bladder has been

week study using electro-acupuncture once a weekreported with an estimated prevalence of 16% in(20Hz, 30 minutes) near the posterior tibial nerve on

Europe and 12% in Japan. Here, clinical studies on

35 subjects complaining of urinary urgency andthe effect of acupuncture treatment for overactive

incontinence. Seventy percent of the subjects

bladder are reported.

confirmed their incidence of incontinence had been

Emmons et al. treated 85 overactive bladder patients

reduced by more than half and 46% reported

who complained of urinary incontinence. The

complete disappearance of their incontinence5). The

patients were divided by into two groups by

above integrated reports on both urinary frequency

treatment objective. The first was an acupuncture

and incontinence suggest the usefulness of thetreatment group aiming to treat their OAB

posterior

symptoms with Sp6, UB40, UB38 and CV4. The

theirdisappeared

andtibialsymptoms
20%

nerve

stimulation

for

these

conditions.

second group, considered the placebo group, aimed toSimilarly, Hoebeke et al. treated 32 school age

promotechildren (average age 12) who’s symptoms of urinary

utilized GB31, St36, UB12 and CV12. The frequency

urgency, frequency and enuresis were found to beof urinary incontinence in the treatment group

resistant to standard medical treatments. They

decreases by 59%and by 40% in the placebo trial

reported that stimulation to the posterior tibial

group. Both of these results are significant and there

nerve (20HZ, 30 minutes) once a week for 12 weeks

was no significant difference between the two groups.

eliminated the sensation of urinary urgency in 25%

It was reported that the frequency of urinaryof the subjects and improved the symptom in 36%.

urgency decreased significantly and the overall

Further, it was reported that 17% of subjects withamount of urine increased significantly only in theenuresis experienced complete elimination of theacupuncture trial group8). This RCT paper provided

symptom and 52% confirmed their symptom had

high level evidence and so is of great international

improved6). This study treats patients with ansignificance as a published journal article inintegrated research approach, and further shows

Obstetrics and Gynecology while examining thethateffect of acupuncture treatment for overactiveatherapyusing

posteriortibialnerve

relaxation

throughacupuncture

andbladder.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

3

Volume 9, Number 4 | Winter 2014

On the other hand, acupuncture treatment for lower

the effects of acupuncture for chronic prostate

urinary tract symptoms has been adapted for

inflammation resulting in chronic pelvic pain

enuresis in children, and it usefulness has been

syndrome. They randomly divided 39 patients into

reported in the scientific literature. Björkström et al.

three groups for their RCT study. All subjects

treated 24 school age children (average age 10 years)

received life style coaching and were instructed inwith electro acupuncture (2Hz or 15Hz) on the lower

appropriate exercises as the basis for long-term

medial leg, foot and lower abdomen (Sp6, UB60, LV3change. The first group received electro-acupuncture,

and CV3 or K3, GB34, ST44 and CV4). It was

the second group received sham acupuncture and thereported that six months following the cessation of

third group received no extra stimulation and served

the treatment sessions, 46% of the subjects

as the control. After the six-week observation period,

confirmed

improved9).

the acupuncture electrical stimulation group was

Additionally, it was reported that among the subjects

compared to the other two groups, they reported

who had felt their enuresis improved, also statedsignificant (p<0.001) improvement of subjectivethat it was easier to wake up to go to the bathroom

symptoms. On the effect of acupuncture treatment

at night than it had been previously. Consequently,

for intractable chronic prostate inflammation andit was concluded that acupuncture was not only

chronic pelvic pain syndrome, this research inuseful for enuresis but is also expected to help theurology, because this RCT based evidence wassubject awaken to urinate without wetting the bed.

gleaned from a high level project, it has greatThis research is an integrated compilation of caseacademic significance.

studies, however, as a useful mechanism of effective

A urinary stone (colic) attack is cited as one of theacupuncture treatment for nocturnal enuresis it

most violent types of pain experienced in urology.

represents significant research. By the way, reports

However, the effectiveness of acupuncture as aof acupuncture treatment of urological conditions

treatment has been reported. Lee et al. randomly

are not only relevant for enuresis, urinary frequency

divided 38 male patients with colic attacks into to an

and incontinence.

acupuncture treatment or a drug administration

There are of course more painful urological disordersgroup. The acupuncture group subjects were treatedsuch as chronic prostatitis and urinary calculi. The

with points on their upper and lower back: UB21, 22,effectiveness of acupuncture as a treatment for such

23, 24, 25, 50, 51, 52, You Gan (extra point) as welldiseases has been studied and reported.

as 4-5 points on the hand were selected, needled and

The effectiveness of acupuncture has been reported

retained for about 1 minute. In the acupuncture

for pelvic pain syndrome due to non-bacterialgroup, after an average of 3 minutes treatment, an

prostatitis classified under chronic prostatitis. Chen

analgesic effect was observed and 86.4 % of subjects

et al. confirmed significant reduction of symptoms

reported their pain was completely relieved. For thefollowing

6

subjects in the analgesic group, 62.5% reported

weeks10). Two protocols were utilized. The first wascomplete pain relief, however only after an average

CV4, CV3 and 腸遺穴 (extra point) (M ─CA ─ 17) atof 15 minutes had elapsed12). This study reported the

5 Hz, for 20 minutes. The second set included UB35

effectiveness of acupuncture for urinary calculi colic

and UB53 (20 Hz, 20 minutes). This research was an

attack using RCT evidence level methods, for the

integrated review of case studies, however it hasapplication of acupuncture this should be considered

deep clinical significance regarding the usefulness of

meaningful research.

their

symptoms

bi-weekly

hadelectro-acupunctureforacupuncture therapy for treating chronic pelvic pain
syndrome. On the other hand, Lee et al. investigated

4

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 9, Number 4 | Winter 2014

2 Current status of and prospects for clinical studies

61% reported their incontinence was reduced by half

in Japanand following urodynamic study, a significant

In Japan, there have not been many reports ofincreaseacupuncture and moxibustion therapy in the field ofconfirmed(p<0.01)14). From these results, sacralurology. Until now, most research has focused on theacupuncture treatment was hypothesized to likely

perspective of impact on or changes in symptoms andinhibit over active bladder function. Further, it has

bladder function. The effects of acupuncture therapy

been suggested that sacral acupuncture treatment

for overactive bladder, urinary frequency andfor the patients with bladder hyperactivity caused byurinary incontinence have been primary. One ofchronic spinal cord injuries would likely be useful.

these reports, for subjects complaining of urinary

Incidentally, among the subjects who reported

incontinence and urgency, 11 patients with detrusor

acupuncture was effective for their symptoms after 4

hyperreflexia

astreatments, urodynamic study conducted one monthdemonstrated by urodynamic study, underwent

later, confirmed 6 people continued to showsacral acupuncture treatment and these effects wereincreased urine capacity greater than prior to

examined13).

treatments. These results suggest that treatment

The acupuncture treatment focused on the sacrum

effects continued for more than one month without

involving bi-lateral insertion at the 3rd sacralanyforamendisposablesuggested that monthly maintenance acupuncture

acupuncture needle (0.3 mm in diameter, 60 mm intherapy would be beneficial, because bladder

length). Stimulation was obtained by inserting thecapacity began to decrease slightly after just one

needle into the sacral periosteal edge directedweek cessation of the treatments. One point worth

toward the head to a depth of 60mm until a dull,

noting in the present study is that these results wereheavy sensation (dull pain) was achieved. One

the due to a combination of acupuncture andtreatment consisted of thrusting stimulation fromanticholinergic treatment. Four of 13 subjects who

this location, continued to a depth of 5 mm for 10

were taking anticholinergic agents (Oxybutynin

minutes. Following the treatment, 82% of thehydrochloride) found drug therapy by itself did not

subjects

hadproduce a desired effect, also increasing amount of

disappeared or their urinary urgency had improved.

the drug led to unpleasant side effects in these

Urodynamic study was performed before and after

refractory

the acupuncture treatment. Prior to the treatmentincontinence

maximum urine capacity was 142.5 ± 62.9 mL but

pharmacotherapy by anticholinergic agents wereafter the treatment it became 250.0 ± to 100.4 ml, amore effective than the patients without thesignificant increase ( p<0.01 ).55% of patients withpharmacotherapy. Therefore, it suggests that theoveractive bladder reported their symptoms had

usefulness of a combination therapy utilizing

disappeared. From the observed improvement ofacupuncture and the pharmacotherapy among theurinary urgency or incontinence with acupuncture

patients with bladder hyperactivity.

treatment for overactive bladder, it should be

Besides overactive bladder, we have also reported onsuggested that sacral acupuncture is a usefulthe effects of acupuncture on enuresis. We treated 15

alternative

children (average age 10 years), these subjects also

(detrusor(UB33),

reported

or

using

their

overactivity),stainlessincontinencecomplement

tostandardinfurtherurine

capacity

acupuncture

cases.

treatments.

Improved

among

the

was

rates

patients

of

also

It

was

urinary

using

the

pharmacotherapy.

received the sacral area acupuncture treatment

Similarly, 13 spinal cord injury patients with urinary

mentioned

incontinence were treated with sacral acupuncture.

Treatment results were evaluated after UB33 wasabove

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

foroveractive

bladder15).

5Volume 9, Number 4 | Winter 2014needled once a week for 4 weeks. The children in theutilized the International Prostate Symptom Score

study reported that rather than feeling pain at the(IPSS),

insertion site, there was a feeling of heaviness orenlargement and diminished bladder capacity as

dullness.

discontinued

subject criteria. Twenty-four subjects with an IPSS

treatment because they could not put up with such agreater than 8 and bladder capacity less than 30ml

sensation and no especially harmful side effects were

were accepted into the study. According to the results

observed. Urinary records were evaluated based on

obtained, it was reported that following sacral

the effects of 1 acupuncture treatment per week andacupuncture, IPSS improved significantly (p<0.001)

how this influenced urinary frequency at night.

and the parameter of maximum urinary flow andFollowing one month of Acupuncture treatments, 6

averagesubjects (40%) reported decreased urinary frequency

significantly16). As the mechanism of action in thisat night, and following 2 months of treatment, 7

study, following sacral acupuncture, the results

subjects

showed increased urine flow rate and decreased

None

(47%)

of

the

reportedpatients

theirenuresis

hadasubjective

flow

rate

measure(p<0.05)ofalso

prostate

improved

disappeared. In this study, only the subjects in theurethralacupuncture

experienced

acupuncture on urinary tract function suggest thatsignificantly greater nocturnal bladder capacity. One

this type of treatment not only impacts bladder

hypothesis about enuresis is that if the childfunction but also that of the lower urinary tract.

becomes cold while sleeping, his bladder may

In addition, we present international and domestic

contract, thereby reducing bladder capacity andevidence on the usefulness of acupuncture treatment

retention. Acupuncture is thought to counteract thisfor chronic pelvic pain syndrome17). This study

contraction, allowing the subject to maintain or

recruited 10 patients with non-inflammatory chronic

improve

pelvictheirtreatment

bladder

group

capacity,effectively

resistance.

pain

The

syndrome

results

associated

of

with

sacralpelviceliminating or reducing enuresis. Also, following

congestion syndrome. Prior to receiving acupuncture,acupuncture treatment, the subjects who reported

8 of these subjects had received pharmaceuticalmore than 50% improvement in the number times

therapy but found their symptoms unchanged as athey went to the bathroom at night were placed inresult. The Acupuncture treatment was similar to

the “effective” group. In contrast, those subjects who

previous reports, sacral acupuncture once a week forreported less than 50% improvement were placed in

4 sessions, then the patients were given the NIH

an “ineffective” group. Nocturnal bladder capacity

chronic pelvic pain symptom index (NIH-CPSI),

increased significantly in the "effective" group, andwhich is a measure of subjective symptoms. Before

showed no significant change in the "ineffective"

and after acupuncture treatment, findings from MRgroup. Additionally, it was found that most of thevenouschildren in the “effective” group were over the age ofultrasonography of pelvic vein stasis were evaluated.

10 and most of the children in the “ineffective” group

Results showed that NIH-CPSI findings for levels of

were under 10 years. From the above results, it ispain and discomfort following acupuncture were

thought that the effectiveness of acupuncture forsignificantly reduced (p<0.05) and QOL items werereducing or eliminating enuresis by increasing

significantly

bladder capacity is more significant in older children

following acupuncture treatment, it was confirmed(over 10 years).

that pelvic vein congestion and stasis was eliminated

Next, acupuncture has also been found effective forand subjective symptoms indexes were improved. On

treating enlargement of the prostate gland, a very

the other hand, these results indicated the relevanceangiography

improvedcommon complaint in geriatric men. Kitakoji et al.

6

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

and(p<0.01).

trans-rectal

Additionally,Volume 9, Number 4 | Winter 2014of this study and point to the validity of the reported

References

effectiveness18).

1) Ford

AP,

Gever

JR,

Nunn

PA,

et

al.:

Concerning the usefulness of Japanese acupuncture

Purinoceptors as therapeutic targets for lower

treatment in urology and its mechanism of action as

urinary tract dysfunction. Br J Pharmacol 147

reported so far, because many of these papers are(suppl 2): S132─S143, 2006

compilations of case studies from Japan, although

2) Chang PL: Urodynamic studies in acupuncture

they may be integrated in theory, it cannot be said

for women with frequency, urgency and dysuria.

there is a high level of evidence. For these reasons,

J Urol 140: 563─566, 1988

therefore, under the present situation, descriptions

3) Philp T, Shah PJ, Worth PH: Acupuncture in theof acupuncture as seen in typical clinical practicetreatment of bladder instability. Br J Urol 61:

cannot be equated with standard guidelines for490─493, 1988

lower urinary tract symptoms in the "over active4) Klingler HC, Pycha A, Schmidbauer J, et al.: Use

bladder treatment guidelines",19).

of peripheral neuromodulation of the S3 region

This concludes our personal research as well as aforsurveyurodynamic ─ based study. Urology 56: 766─771,

ofrelevant

researchonacupuncture

treatment for Urological conditions. As for domestic

treatmentofdetrusoroveractivity:

a

2000

or international clinical reporting of acupuncture5) Vandoninck V, Van Balken MR, Finazzi Agró E,

treatment for lower urinary tract symptoms andet al.: Posterior tibial nerve stimulation in the

success of treatment, acupuncture treatment should

treatment of urge incontinence. Neurourol

be considered one useful treatment option. However,

Urodyn 22: 17─23, 2003

many questions still remain about the detailed6) Hoebeke P, Renson C, Petillon L, et al.:mechanism of acupuncture treatment, so without

Percutaneous electrical nerve stimulation inreports of the usefulness of acupuncture performed

children with therapy resistant nonneuropathic

using large-scale randomized controlled trials in

bladder sphincter dysfunction: a pilot study. J

clinical research that yield convincing evidence, it is

Urol 168: 2605─2608, 2002

hard to say there is enough evidence. In the future,7) Abrams P, Cardozo L, Fall M, et al.: The

our greatest efforts should be organized toward

standardization of terminology of lower urinary

elucidating the mechanism and usefulness oftract function: report from the Standardisationacupuncture, integrating the evidence as recognizedSub ─ committee of the International Continencein urology and other fields and transmitting thisSociety. Neurourol Urodyn 21: 167─178, 2002

information to the medical establishment.

8) Emmons SL, Otto L: Acupuncture for overactive
bladder: a randomized controlled trial. Obstet
Gynecol 106: 138─143, 2005
9) Björkström G, Hellström AL, Andersson S:
Electro ─ acupuncture in the treatment ofchildrenwithmonosymptomatic

nocturnal

enuresis. Scand J Urol Nephrol 34: 21─26, 2000
10) Chen R, Nickel JC: Acupuncture ameliorates
symptoms in men with chronic prostatitis /chronic pelvic pain syndrome. Urology 61:1156─1159, 2003

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

7

Volume 9, Number 4 | Winter 201411) Lee SH, Lee BC: Electroacupuncture relieves
pain in men with chronic prostatitis / chronic
pelvic pain syndrome: three ─ arm randomized
trial. Urology 73: 1036─1041, 200912) Lee YH, Lee WC, Chen MT, et al.: Acupuncturein the treatment of renal colic. J Urol 147: 16─18,
199213) Kitakoji Hiroshi, Terasaki Toyohiro, Honjo
Hisashi, et al.: A study on the usefulness ofacupuncture treatment for overactive bladder.
Japanese Journal of Urology 86:1514─1519,
1995
14) Honjo

H,

Naya

Acupunctureon

Y,Ukimuraclinical

O,

et

al.:

symptoms

andurodynamic measurements in spinal ─ cord
injured patients with detrusor hyperreflexia.
Urol Int 65: 190─195, 2000
15) Honjo H, Kawauchi A, Ukimura O, et al.:Treatmentofmonosymptomatic

nocturnal

enuresis by acupuncture: A preliminary study.
Int J Urol 9: 672─676, 200216) Kitakoji

Hiroshi:

Effectsofacupuncture

treatment for first stage enlarged prostate.
Bulletin of Meiji University of Oriental Medicine
24: 25─32, 199917) Honjo H, Kamoi K, Naya Y, et al : Effects ofacupuncture for chronic pelvic pain syndrome
with intrapelvic venous congestion: preliminary
results. Int J Urol 11: 607─612, 2004
18) Tugcu V, Tas S, Eren G, et al : Effectiveness ofacupuncture in patients with category IIIB
chronic pelvic pain syndrome: a report of 97
patients. Pain Med 11: 518─523, 201019) Committee of edited guidelines for overactive
bladderonJapanese

Continence

Society:guidelines for treatment of over active bladder,Blackwell Publishing Inc. Tokyo, 2005

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The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)