Incontinence: urinary (2019)

Overview

Key points

• Urinary incontinence has a significant negative impact on quality of life
• The evidence for acupuncture in the treatment of urinary incontinence is promising with reductions in episodes of incontinence and other symptoms observed in people with overactive bladder, stress incontinence, mixed urinary incontinence, or bed wetting
• Acupuncture has a favourable side effect profile in the majority of studies
• Further well-designed studies are required to make definite conclusions regarding the effectiveness of acupuncture in the management of urinary incontinence

Background

Overactive bladder (OAB) is characterised by urgency incontinence and increased urinary frequency during the day and night, and has a significant impact on a person’s quality of life. [Yuan 2015; Zhao 2018] Medication, such as tolterodine, is the first line treatment for OB [Forde 2016; Yuan 2015]. Acupuncture is a viable option for people with OAB who want to avoid more invasive options, such as sacral neuromodulation, where medication proves ineffective. [Forde 2016]

Many women suffer from stress urinary incontinence (SUI), which impacts on quality of life and psychological wellbeing. [Lui 2017] The effectiveness of current treatments for SIU is limited by poor compliance and side effects, so it is worthwhile investigating the potential of acupuncture to treat SIU. [Lui 2017; Liu 2019]

Acupuncture has also been studied for the management of nocturnal enuresis (bed wetting), alone and in combination with medication, and the results are promising. [Yang 2015]

Overactive bladder

A systematic review of studies investigating acupuncture for the treatment of OAB concluded that electroacupuncture is more effective than sham electroacupuncture in improving 24-hour nocturia episodes (going to the toilet at night). It may also reduce the number of micturition (going to the toilet) and incontinence episodes. Electroacupuncture, in combination with the medication tolterodine, relieved symptoms associated with OAB and improved quality of life. Acupuncture was considered safe, with a very small number of people reporting mild, transient side effects. The authors called for further well-designed studies in order to draw definite conclusions. [Zhao 2018]

A literature review suggested that acupuncture may have similar benefits to antimuscarinic medication, such as tolterodine, in the management of OAB with a more favourable side effect profile.[Forde 2016] In a study comparing acupuncture with tolterodine in women with OAB, acupuncture had similar effects to the drug in improving symptoms such as urinary frequency, episodes of incontinence and volume  voided.[Yuan 2015] A small crossover study showed that moxibustion in combination with behavioural training decreased daytime voiding episodes and increased voiding volume compared with behavioural training alone. [Lee 2018]

A systematic review by the Society of Gynecological Surgeons found that acupuncture may improve urodynamic testing parameters and quality of life in OAB. [Olivera 2018] Some side effects of acupuncture for OAB were reported, but they bear little resemblance to those in the two source papers cited [Emmons 2005, Engberg 2009], which noted mainly minor bleeding and bruising, rated as ‘insignificant’.

Stress urinary incontinence (SUI)

In a Cochrane review of non-pharmacological methods for treating SUI, one eligible study comparing acupuncture with midodrine showed that more women improved with acupuncture, although cure rates were low in both groups and not statistically different. Adverse events were only experienced in the midodrine group. [Wang 2013]

A recent study published in the Journal of the American Medical Association revealed that electroacupuncture significantly reduced urine leakage in women compared with sham acupuncture. The multicentre RCT compared electroacupuncture with sham acupuncture in 504 women with SUI. At week 6, urine leakage was 8.2 g in the electroacupuncture group compared with 16.8 g in the sham electroacupuncture group. A significantly higher proportion of the electroacupuncture group showed at least 50% reduction in mean number of 72-hour incontinence episodes compared with sham electroacupuncture, with the benefits persisting up to 24 weeks after treatment. [Liu 2017]

Mixed urinary incontinence (MUI)

A large RCT published in 2019 concluded that, in women with moderate-to-severe MUI, electroacupuncture was not inferior to standard treatment of pelvic floor muscle training (PRMT) in combination with the antimuscarinic agent, solifenacin. Between weeks 1 and 12, there was a 38% reduction from baseline in mean 72-hour urinary incontinence episode frequency (IEF) in the electroacupuncture group and a 36% reduction in the PFMT-solifenacin group. The positive effects could persist up to 24 weeks after treatment. Mild bruising was infrequently observed in the electroacupuncture group. Digestive system diseases were reported by 28% of the PFMT-solifenacin group and 1.6% of the electroacupuncture group. [Liu 2019]

A much smaller study found no significant difference in outcomes between electroacupuncture and tolterodine in combination or electroacupuncture alone in the treatment of MUI. Both groups improved incontinence severity and quality of life, with >50% reduction in episodes of incontinence apparent in 76% in the combination group and 59% in the group receiving electroacupuncture alone.

Post-stroke urinary incontinence

Urinary incontinence affects up to 60% of people hospitalised after a stroke. A systematic review to assess the effects of interventions for treating urinary incontinence at least one-month post-stroke suggested that acupuncture may increase the number of continent people. [Thomas 2019]

Nocturnal enuresis (bed wetting)

Nocturnal enuresis is a common problem that affects children and can extend into adulthood. [Moursy 2014] An overview of systematic reviews of studies in children concluded that the evidence for acupuncture in the treatment of nocturnal enuresis is promising, with significant reductions in the number of wet nights experienced. [Yang 2015]

In patients with resistant monosymptomatic nocturnal enuresis, laser acupuncture in combination with desmopressin resulted in a higher cure rate than with either treatment as monotherapy. Bladder capacity was increased in patients receiving acupuncture, either alone or in combination with desmopressin. [Moursy 2014]

There is also evidence that acupuncture and laser acupuncture is more effective at reducing enuresis and relapse rates compared to sham procedures, although further well-designed studies are required to confirm these findings. [Kiddoo 2015]