Electroacupuncture neurostimulation for treatment of chronic voiding dysfunction

Electroacupuncture neurostimulation for treatment of chronic voiding dysfunction 电针神经刺激疗法治疗慢性 排尿障碍 Prof. Wang Siyou Shanghai Research Institute of Acupuncture and Meridian

Stress Urinary Incontinence 压力性尿失禁

• Urinary incontinence can be classified under 7 types in Western medicine • 尿失禁在西医可分为 7种类型。

• • Stress urinary incontinence (SUI) 压力性尿失禁 Urge urinary incontinence (UUI) 急迫性尿失禁 Unconscious urinary incontinence 无意识性尿失禁 Continuous urinary incontinence 持续性尿失禁

• • • Nocturnal enuresis 夜间遗尿 Postvoid dribble 排尿后滴尿 Overflow urinary incontinence 充盈性尿失禁

• 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. • 压力性尿失禁是指平时无尿失禁状态下， 当腹压骤增时（如咳嗽、打喷嚏、大笑、 奔跑、剧烈活动）尿液不自主从尿道口 流出，同时不伴有膀胱逼尿肌收缩。

• It often happens in multiparous and postmenopausal women. • It comes under the category of enuresis in TCM. • 临床多见于中年已生育的妇女。 • 属中医学遗尿范畴。

Stress Urinary Incontinence

Overactive bladder & Urge incontinence

• 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; • 一. 病因 • 可能的发病原因有：（1）分娩及分娩损伤， 难产、产钳操作尤甚；（2）尿道及尿道周围 组织改变，如绝经后性激素改变致盆底组织萎 缩；

• Etiology • (3) history of vaginal, urethral or prostatic surgery; (4) perineal or urethral injury; (5) pelvic tumescence resulting in a high intraabdominal pressure and a lower position of bladder neck. More than one cause may coexist. • （3）阴道、尿道及前列腺手术史；（4） 会阴部及尿道损伤；（5）盆腔内肿物致 腹压增高，膀胱颈位置降低。一个或多 个病因可同时存在。

• 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. • 二. 发病机理 • 上述原因可引起（膀胱颈和尿道）括约肌异常： 尿道活动度增大或/和括约肌内在缺陷（尿道括 约肌本身的内在机能异常，近端尿道失去括约 肌作用），导致压力性尿失禁。

• 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. • 前者是由于盆底支持组织松弛引起膀胱颈部和 近端尿道在腹压增加时活动度增大、向下移位， 导致膀胱尿道压力传递比降低，膀胱内压暂时 高于尿道内压，于是发生尿失禁。

Subtypes of stress incontinence 压力性尿失禁的亚分类 腹压升高 There are 2 possible reasons for urodynamic stress incontinence: 尿流动力学压力性尿失禁的2个可能原因 • “Hypermobility” “过度移动症 ” (weakness of bladder support) （薄弱的膀胱支持力 ） 漏尿 • “Intrinsic sphincter deficiency” “固有括约肌功能障碍” (“ISD” - weakness of urethral sphincter) (“ISD”－尿道括约肌力弱) Video or extra tests (UPP, VLPP) help to make this distinction 影像技术及其他辅助检查（ 尿道压力描计 UPP，屏气时漏尿点压力VLPP）有助于区 分 尿道 无力

Stress Urinary Incontinence

Stress Incontinence: VLPP Rest & Straining

Simple Tests • Q Tip Test – Test for mobility – >30 degree • Simple CMG – Urethral catheter – Manometer or – Toomey Syringe

• 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. • 三. 临床表现 • 1. 症状 • 咳嗽、打喷嚏、大笑、奔跑或体育活动、突然 改变体位等身体用力时尿液不自主从尿道口流 出。

• 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. 体征 • 咳嗽、打喷嚏或身体用力时观察到尿液从尿道 口流出。指压（尿道抬举）试验阳性。护垫试 验阳性。阴道检查可见膀胱、肠、直肠膨出。

• 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. • 四. 影象尿动力检查 • 1. 尿道活动度增大 静止（无腹压增加）时，膀胱颈关闭；应 力（腹压增加）时，膀胱颈和近端尿道开 放和下移。

• Video-urodynamics • 2. Intrinsic sphincter deficiency • The vesical neck and proximal urethra are open at rest in the absence of detrusor contraction. • 2. 括约肌内在缺陷 静止、无逼尿肌收缩时，膀胱颈（和近端 尿道）开放。

Hypermobility (type II incontinence) 过度移动症（II型尿失禁） 正常 • Easily defined on videourodynamics 通过影像尿流动力学很容易确 定 – but Q-tip test or simple observation will help 但 Q-tip 试验及简单的观察有助于 诊断 Hypermobility 过度移动症 (on cough or Valsalva, or permanent descent) （咳嗽，Valsalva，或者持续下降）

LPP measurement 漏尿点压力测量 Strain: leaks at 165 cm H 2 O 用力屏气: 在 165 cm H 2 O时 漏尿 （活动过度） (hypermobility)

• Hypermobility with leakage (on cough) 活动过度 伴漏尿（ 在咳嗽时）

LPP measurement 漏尿点压力测量 Initial pves 初始膀胱压 Strain: leaks at 45 cm H 2 O 用力屏气: 在 45 cm H 2 O时 漏尿 Stop fill at 200 ml 在 200 ml时 停止充盈 Start filling 开始充盈 (no hypermobility, ISD) （无过度移动症，固有括 约肌功能障碍）

• • • 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. 五. 诊断 根据： 1. 压力性尿失禁症状（病史）。 2. 应力试验阳性（咳嗽或用力腹压增高时有漏 尿）和指压试验阳性或护垫试验阳性。

• Dagnosis • Based on • The results of imaging urodynamic examination: urethral hypermobility or/and intrinsic sphincter deficiency ; no involuntary detrusor contraction. • 3. 影象尿动力检查结果：尿道活动度增大 或/和括约肌内在缺陷；无逼尿肌无抑制性 收缩。

• 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. • 六. 治疗方法 • 1. 西医保守治疗 • 对于轻、中度压力性尿失禁可采用保守 治疗，其优点是安全微创，并发症的发 生率和严重程度远低于手术治疗。

• 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. • 保守治疗主要包括盆底肌锻炼、电刺激、 各种阴道和尿道装置及药物治疗。其中 盆底肌锻炼和经阴道或肛门电刺激（被 动的盆底肌锻炼）是最常用的二种治疗 方法。

• 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. • 盆底肌锻炼具有增强盆底肌肉支持力量， 改善神经肌肉功能，阻止腹内压增高时 近端尿道和膀胱底部下降及增加尿道压 的作用。

• 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. • 缺点是：许多患者不能正确收缩盆底肌； 依从性差。

• 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. • 经阴道或肛门电刺激是被动的盆底肌锻 炼，有很好的依从性。缺点是：因使用 表面电极，作用是间接的，效果不及正 确的盆底肌锻炼 。

• 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. 中医针刺治疗 • 对于轻、中度压力性尿失禁也可采用中 医针刺治疗，其优点是安全、方便、无 副作用和并发症。

• 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 therapeutic principle is reinforcing kidney qi and improving vesical restraining function. • 1) 治疗原则 • 中医认为，尿失禁是由于肾气不足，膀 胱不固引起，因此治疗原则是补益肾气， 固脬止遗。

• 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) 穴位选择 • 主穴是肾和膀胱的背俞穴和募穴。 • 常用穴位有：肾俞，膀胱俞，中极，关 元，命门，会阳，三阴交，足三里。

• 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. • 肾和膀胱相表里，故选肾和膀胱的背俞 穴。中极是膀胱的募穴。三穴合用有助 于补益肾气，固脬止遗。

• 2) Point selection • Guanyuan (Ren 4) and Mingmen (Du 4) are the sources of primordial qi and acupuncture of them can tonify primordial yang (kidneyyang). Huiyang (B 35) is the acupoint of the foot-taiyang meridian and acupuincture of it can invigorate the meridional qi of the bladder. • 关元、命门是元气之源，针之能补肾益 元。会阳是足太阳经穴位，针之能振奋 膀胱之经气。

• 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. • 三阴交是足三阴经交会穴，针之能调节 足三阴经气。足三里属阳明经，阳明经 多气多血，针之能补气止遗。

• 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) 不足之处 • 因采用一般针刺方法，故难以象神经电刺激疗 法那样通过兴奋阴部神经诱发盆底肌节律性收 缩，增强盆底肌肉力量来改善控尿能力。

• 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. 电针阴部神经刺激疗法 • 综合PFME 和 TES二种疗法优点，融入针灸长 针深刺技术，我们发展成了(中西医结合的)电 针阴部神经刺激疗法（电针“骶四穴”疗法）。

• 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. 电针阴部神经刺激疗法 • 该疗法对骶部四个特定穴位采用特殊针 刺方法（针尖向特定方向）并加以电刺 激

• 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. • 能直接兴奋阴部神经诱发盆底肌（包括 尿道括约肌）节律性收缩，从而增强盆 底肌肉力量，恢复膀胱颈部和近端尿道 的正常位置，提高尿道关闭压来改善控 尿能力。

• 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; • 定位和针刺方法 • 1）上两针刺点：骶骨 边缘旁，平第 4骶后孔 水平处（双侧）。 Four sacral points 骶四穴

• Location of four sacral points and acupuncture methods • 1) The two upper points: use a long needle of 4 cun (100 mm); puncture perpendicularly 3~3. 5 cun in depth; make the needling sensation reach the urethra or anus. • 使用 4寸长针直刺，针 刺深度为 3 -3. 5寸，使 针感达尿道或肛门。 Four sacral points 骶四穴

• 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 125 mm); • 2）下两针刺点： • 尾骨旁开0. 5寸（双侧） ，使用 4寸或 5寸长针， Four sacral points 骶四穴

• Location of four sacral points and acupuncture methods • 2) The two lower points: puncture obliquely (laterally) towards the ischiorectal fossa, 3~4. 5 cun in depth; make the needling sensation reach the urethra. • 向外侧（坐骨直肠窝） 斜刺，3 -4. 5寸深，使 针感达尿道。 Four sacral points 骶四穴

• Electrical pudendal nerve stimulation • After the needling sensation referred to the above regions was produced, a G 6805 -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. 电针阴部神经刺激疗法 • 针感达特定部位后接G 6805Ⅱ治疗仪。电针采 用连续波，频率约 2. 5 Hz (150次/分），强刺激 以患者不感到难受为度，每次持续 60分钟。

• 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 patient’s condition. • 电针期间需保持盆底肌以尿道为中心有节律地 向上（头部方向）强烈收缩的感觉。 • 治疗隔日 1次，治疗次数视病情而定。

Accessories Pressure Measurement EMG Electrodes 1. DPT Pressure Transducer 1. Disposable Surface With extension line & flushing syringe 2. Disposable Anal and Vaginal 2. Abdominal Catheter 3. Reusable Anal Sphincter a. Opened end - F 8 b. Balloon With Abdominal catheter insertion lumen 2 b 2 a 1 1 3 2