The Treatment Of Interstitial Cystitis By Acupuncture

What is interstitial cystitis?
Interstitial cystitis (IC) is defined as “a chronic non-bacterial inflammatory, haemorragic disease of the bladder wall”. It occurs mainly in women (90% of cases) and is rarer in men (10% of cases) in whom it may be misdiagnosed as prostatitis. IC is also found in children, although according to the official criteria the diagnosis may not be confirmed until the age of 18. It is estimated that the incidence of IC in the US female population is 67 per 100,000 1*, whilst a Finnish study* 2 estimated an incidence of 450 per 100,000 women.
Epidemiological studies indicate that it takes on average five to seven years to obtain an accurate diagnosis of IC and that IC patients score worse on quality of life measures than dialysis patients with end stage renal disease (US Interstitial Cystitis Association)3*. IC patients can experience severe pelvic pain and the need to urinate as often as every 10 to 15 minutes during both the both day and night.  Some are housebound, and many are unable to work or care for their families.  The intractable pain of IC can even cause people to commit suicide.


Symptoms
The symptoms of IC include
• pain which is stabbing in the more acute phase and dull and aching when less acute and after treatment for acute symptoms
• the pain tends to worsen as the bladder fills, although pain is not always relieved after urination
• pain is worse with pressure or touch.
• pain may extend to the lower abdomen, pelvic floor, lower back (in the region between Sanjiaoshu BL-22 and Dachangshu BL-25), external genitalia, groin or thighs
• in women there may be vestibular ulceration
• in men the pain may occur in the penis and testicles
• urinary urgency, the feeling of which may remain after urination
• urinary frequency - from every three minutes up to half an hour
• emotional distress
• there may be blood and pus in the urine detected by urine analysis

Western medicine
Causes of IC
Following considerable research it is now thought that IC is a multi-factorial syndrome characterised by an inflammatory response of the bladder wall that may be based on a number of factors including: mechanical (such as injury to the lumbar spine), allergic, immunological, neurovascular, bacterial or viral and environmental.

History
The name ‘interstitial cystitis’ was first used by AJ Skene in “Diseases of the Bladder and Urethra in Women” published in 1897, but early knowledge of the disease is more commonly linked to Guy Hunner, a Boston surgeon who described this inflammatory bladder disorder in 1914. Hunner discovered that patients presenting themselves with the above symptoms had a very sensitive bladder lining. Although there were no visible signs on the mucosa of the bladder, he found that when he touched the bladder wall it immediately began to bleed profusely. He also observed inflammation and ulceration in the bladder mucosa which came to be known as Hunnner’s ulcer.
The treatment he chose for his patients was silver nitrate bladder instillations that usually had no more than a temporary effect.

Investigations and diagnosis
Diagnosis of IC is often a long and complex process and involves exclusion of other bladder disorders which may give rise to similar symptoms. In some cases IC may be diagnosed even though pain is absent from the presentation.
Diagnosis is made by medical history, urinalysis, cystoscopy, urodynamics and biopsy.
Unfortunately intrusive methods of diagnosis can exaggerate the symptoms of IC and cause burning in the bladder and urethra for several weeks. A bladder biopsy can cause bleeding until the lining of the bladder has fully recovered.

Treatment by Western medicine

Oral medication
Antihistamines – e.g. Cimetidine and Ranitidine
Antispasmodics
Sodium pentosanpolysulfate (Elmiron)
Analgesics
Sulphasalazine
Steroids
Tricyclic antidepressants


Bladder instillations
Medication is applied directly to the bladder and is directly absorbed by the lining of the bladder into the bloodstream. The disadvantages are that the patient has to be catheterised, hence there is a risk of infection occurring and further trauma to the neck of the bladder, and that this is a painful procedure.
Drugs used for bladder instillation include:
Dimethyl sulfoxide (DMSO)
Heparin
Oxybutynin chloride
Disodium cromoglycate
Silver nitrate
Chlorpactin

Other intravesical therapies
Subtrigonal injections such as Marcain
Laser therapy - mostly for IC patients with Hunner’s ulcer
Bladder hydrodistention

Nervous stimulation -TENS
Many IC patients in different countries use TENS (Transcutaneous Electrical Nerve Stimulation) as a form of pain control. Mild electric stimulation is generated by a small portable TENS unit which stimulates nerve fibres to block the pain signals transmitted to the brain (the Gate-Control theory). TENS is also believed to increase endorphins, the body’s own natural pain-killing chemicals.

Stoller Afferent Nerve Stimulation
This treatment works by sending a mild electric current through a very fine needle inserted near a nerve bundle just above the ankle. This stimulation is then carried to sacral nerves that control the bladder, bowel and pelvic organs.

Neural modulation/neurostimulation
This therapy involves electrostimulation of the sacral nerve.

Surgical removal of the bladder/urinary stoma (urostomy)
In some IC patients surgical removal of the bladder and a urostomy (artificial opening in the urinary tract) seems the only option. However this is not something to be taken lightly, as surgery may lead to other complications such as phantom pain - even when the diseased bladder has gone, pain may still continue to be felt due to the development of new pain nerves in the pelvis as a result of the severe pain in the bladder caused by IC.

Bladder augmentation
This is a procedure where the patient’s own bladder is enlarged through the addition of a piece of the patient’s small intestine. Some patients may subsequently be unable to void and need to use a catheter in order to empty the bladder. It is sometimes chosen as a temporary measure before taking the step to complete bladder removal.

Despite extensive research and clinical studies, no possibility has been found of curing this disease. Treatment is highly individual and no medication or treatment exists that is effective in all IC patients.


IC and other diseases
Certain facts are known about IC which give rise to the suspicion that it could be an autoimmune disease:
• IC is frequently associated with arthritis, systemic lupus erythematosus (SLE), thyroid disorders and Sjogren’s syndrome
• IC occurs 10 times more frequently in women than in men (autoimmune diseases disproportionately affect women)
• No micro-organism or other cause has been found in IC
• IC is often accompanied by:
Joint pain
Muscle pain
Chronic fatigue
Gastrointestinal disorders
Medicine intolerance
Allergies (including food)
Migraine
Dry mouth
Dry, irritated eyes
Itchy, sensitive skin / skin disorders
Vulvodynia
Non-bacterial prostatitis
Eating disorders
Depression

Chinese medicine

Pattern differentiation
From the perspective of Chinese medicine, IC is a shi (excess) pattern mixed with severe underlying deficiency. Commonly encountered patterns include:

Deficiency of Kidney and Spleen qi
Aetiology and pathology
• prolonged illness
• repeated attacks of bacterial cystitis which were not treated effectively
• prolonged and repeated medication to treat IC further damages the qi of the Spleen and the Kidney
• sequelae of traumatic injuries such as accidents to the lumbar spine, epidurals and difficult instrumental deliveries.
The function of the Bladder depends on the warming function of Kidney yang which, in turn, is supported by the yang qi of the Spleen. Weakness of the Kidney yang and decline of mingmen fire, therefore lead to impairment of Bladder qi in storing urine and urination.

Stagnation of Liver qi and Liver stagnant fire
Aetiology and pathology
• emotional upset such as prolonged frustration, anger, hysteria or clinical depression
The Liver governs the free flow of qi and if the Liver becomes depressed the qi stagnates leading to impairment of the qi hua (qi transformation) function of the Bladder and hence pain.
The Liver channel travels to the pelvis and encircles the external genitalia, hence stagnation and obstruction of Liver qi leads to conditions such as vulvodynia and, if damp-heat is also present, to pruritis of the urethra.
If stagnant Liver qi transforms to heat, it may descend to the lower jiao along the Liver channel and impair the function of the Bladder and pelvic floor.

Blood stasis in the lower jiao
Aetiology and pathology
• difficult labour and childbirth or traumatic injury
• prolonged stagnation of Liver qi or damp-heat
Blood stasis is usually associated with piercing or stabbing pain, especially on urination.

Deficiency of zheng (anti-pathogenic) qi
Aetiology and pathology
• deficiency of the Spleen and Stomach as a result of poor or irregular diet.
• difficult pregnancy and childbirth
• prolonged illness such as post-viral syndrome, myalgic encephalomyelitis (M.E.) etc.

Accumulation and sinking of damp-heat
Aetiology and pathology
• deficiency of Spleen qi impairs the transformation of clear and turbid fluid and results in accumulation of dampness, which over time transforms into damp-heat.
• excessive consumption of spicy, greasy food and alcohol
• repeated attacks of bacterial cystitis which have been ineffectively treated
• invasion of damp cold which transforms into damp heat
• invasion of exogeneous dampness (which transforms internally to damp-heat) or exogenous damp-heat
Damp-heat obstructs the network of blood vessels of the Bladder, impairing the flow of the qi and blood and leading to painful urination. In the author’s experience, damp-heat in the lower jiao is the main cause of persistent pain and urinary difficulty (frequent, urgent, burning, scanty and painful urination) in IC.
If heat injures the network of blood vessels lining the Bladder it can result in reckless movement of blood causing the blood to extravasate and giving rise to urinary bleeding.

Deficiency of yin
Aetiology and pathology
• prolonged damp-heat consumes Bladder yin.
• prolonged illness damages Kidney yin
Yin deficiency may be seen on cystoscopy as a reduction in the size of the bladder. As a result, the bladder walls react and show extreme sensitivity to the presence of small amounts of urine leading to urinary frequency which is not relieved after voiding.
Prolonged damp-heat and consequent consumption of yin can lead to the development of Hunner’s ulcers.

Disturbance of the spirit (shen)
Emotional distress may be a consequence of pain, or the cause of pain. On the one hand, prolonged or excruciating pain may injure the spirit. On the other hand excessive anger, hysteria, depression, grief, fear or phobias can transform into fire (especially when their expression is repressed) and damage the function of the zangfu, especially the Heart and spirit. This may be further complicated by heat derived from excessive consumption of spicy food, smoking and alcohol. Heart fire can transmit into its interiorly-exteriorly paired Small Intestine, and from there to the Bladder (paired with taiyang Bladder channel according to six channel theory).
As a result of this mutual relationship between pain and the spirit, emotional and physical pain in IC patients becomes one component and at times it is very difficult for the practitioner to separate and to differentiate, especially when the disease has become long term. I therefore believe that the treatment of IC patients must be multi-dimensional

Principles of treatment
Treatment combines selecting points to directly treat the pain of IC, with treatment directed at underlying patterns of disharmony.

To relieve pain
Points are selected from among:
• Hegu L.I.-4 combined with Kunlun BL-60
• Changqiang DU-1 for perineal pain and pain in the lower back
• Ciliao BL-32 and/or Xialiao BL-34
• Sanjiaoshu BL-22, Shenshu BL-23, Dachangshu BL-25, especially in cases with lumbar pain
• Zhongfeng LIV-4 for pain of the urethra
• Shuiquan KID-5 for pain and burning of urination
• Jinmen BL-63, xi-cleft point of the Bladder channel, for very acute painful attacks

To treat underlying patterns
• Sanyinjiao SP-6 and Zusanli ST-36 to tonify qi and blood and strengthen the Spleen
• Yinlingquan SP-9 to resolve dampness, relieve dysuria and alleviate pain in the external genitals
• Xuehai SP-10 to control reckless movement of hot blood and treat haematuria
• Taichong LIV-3 to smooth the Liver qi and resolve stagnation
• Ququan LIV-8 to clear heat and damp-heat from the Liver channel in the genital region and alleviate the pain of vulvodynia
• Taixi KID-3 to tonify Kidney qi, Kidney yin and Kidney yang
• Shenshu BL-23 to tonify Kidney qi, Kidney yin and Kidney yang
• Jinggu BL-64, the yuan-source point of the Bladder channel, to tonify the Bladder
• Zhongji REN-3 combined with Pangguangshu BL-28 to rectify the qi of the Bladder and lower abdomen, and alleviate pain
• Baihui DU-20, Neiguan P-6 and Gongsun SP-4 to calm the mind and pacify the spirit

Method
Local , proximal and distal points are combined, with about 10-15 needles used at each treatment session. Even technique is normally applied, although strong reducing technique may be used in cases with acute pain.
The overall length of the treatment depends on a number of factors including the patient’s constitution, the duration of the condition, other systems being affected (for example the Stomach and Spleen where there is IBS, the reproductive system where there is polycystic ovarian syndrome, endometriosis, thrush etc.), and the degree of emotional disturbance.

Observations
From my clinical experience, acupuncture is definitely effective in treating interstitial cystitis. In an informal study of eighteen female IC patients carried out at my clinic, there was an 81% improvement in physical symptoms, and a 90 % improvement in emotional wellbeing. It should be noted however that IC can be difficult to treat and may require prolonged treatment. This is especially the case when IC is complicated with other diseases such as polycysctic ovarian syndrome, endometriosis, IBS, chronic fatigue etc.



Notes
1. The Journal of Urology, Vol. 161(2) February 1999 pp 549-552.
2. (The Journal of Urology 2002 Jul;168(1):139-43)

3. A survey carried out by the UK’s Interstitial Cystitis Support Group, responded to by 736 members, it was found that the age at first symptoms ranged from four to eighty-two years, and that the duration of symptoms before diagnosis ranged from 1 month to 60 years. A majority had undergone pelvic/abdominal surgery –the majority of these prior to the onset of symptoms. Urinary frequency was the most common main symptom, followed by nocturia, urgency and pain. The most common secondary medical condition was back pain, followed by arthritis, IBS, bacterial cystitis, thrush and sinusitis. The most common accompanying ‘general problem’ was fatigue, followed by depression, insomnia, difficulty in undertaking everyday tasks, and impaired concentration (21% had had to give up work). Nearly 80% said their symptoms caused difficulty in travelling, whilst over 50% reported difficulty in just leaving the house. Over 50% reported that IC had affected their sex life. The most common factor aggravating pain was stress (nearly 60%), followed by travel, anxiety and sexual intercourse.