Overactive Bladder: a TCM Perspective
I hear it often from my patients: ‘sometimes I pee a little when I laugh,’ ‘I wouldn’t dare try to do jumping jacks or it would be a mess,’ and ‘I just know that I have to use the bathroom before I leave to go anywhere, or I might pee my pants.’ Overactive bladder, leakage and incontinence are not anything new, but in my practice, I have gotten the impression that patients think that having these conditions are just part of getting older, from giving birth or prostate enlargement, and it is something with which you just must live. Treatments for overactive bladder (OAB) leave a lot to be desired; patients do not want to undergo invasive surgery, and medications have high rates of undesirable side effects, which leave most patients thinking there is not a viable treatment option, and that urinary leakage is just something they will have to tolerate. While Kegel exercises may provide some relief and help for many patients, not everyone notices a difference with doing them, which presses the point home again that OAB is just something to be lived with, untreated.
Common symptoms of overactive bladder include:
- urinary frequency, with or without volume of urine output
- excessive nighttime urination
- urine leakage or incontinence
- weak flow of urine
- discomfort while urinating
- patient may or may not have a specific physical trigger, such as giving birth or an enlarged prostate
Overactive bladder (OAB) is a condition that affects adults and children worldwide and can be caused by various underlying factors or traumas like childbirth, prostate enlargement, poor pelvic floor muscle control, bladder prolapse, and more. It is obvious that this condition can create a significant psychological burden on patients and symptoms range from urinary urgency to incontinence. While this condition can be incredibly bothersome, surgery often seems a drastic approach and medications may have limited results and side effects. Acupuncture is an incredibly effective treatment for OAB, working better than most pharmaceutical medications and with fewer adverse effects. It is so effective in fact, that medical doctors may use acupuncture and electrostimulation in order to address the tibial nerve and improve its functionality, which addresses the innervation of the bladder and helps with OAB. They call it Percutaneous Tibial Nerve Stimulation (PTNS).
The tibial nerve innervates the sacral plexus at the base of the spine, which controls the bladder and pelvic floor and is responsible for its function. This nerve runs down the medial side of the leg along the Spleen and Kidney channels into the foot. PTNS utilizes acupuncture and electro-stimulation to stimulate the nerve and sacral plexus, and this electro-stimulation of the nerve helps to correct the misinformation travelling between the brain and bladder; thus, decreasing overactive bladder symptoms and episodes. Studies on PTNS have shown improvement in bladder symptoms of over 50% improvement and up to 80% improvement in quality-of-life studies and this therapy is also minimally invasive and does not pose traditional risks or side effects associated with medications and surgeries. The acupuncture points used are SP-6 or a choice of Kidney 2, 3 or 5 depending on the sensitivity of the patient. For a full discussion of the PTNS, see the side box below.
The rate of adverse events for typical treatments of overactive bladder such as Botox, beta-3 adrenergic agonists, and anticholinergic medications range from 9.7 - 63%, which include constipation, dry mouth, impaired urination, and urinary tract infections. The high rate of adverse events with these standard medications is considered a likely reason there is a high rate of discontinuance of therapy after one year. In addition to offering acupuncture treatment and PTNS for our patients struggling with OAB, herbs can be another adjunctive option to help curb symptoms and treat the root of the issue.
TCM Differential Diagnosis for Urinary Urgency and Frequency
Lin 淋 syndrome is one of Chinese medicine’s specific ways of looking at bladder issues. There are five types of Lin syndrome - Qi, Blood, Damp, Stone, and Fatigue Lin. For urinary frequency, leakage, and incontinence, Fatigue Lin is the most appropriate diagnosis in addition to a root diagnosis. Typical symptoms of Fatigue Lin are:
- incomplete urination that stops and starts
- frequent urges to urinate
- symptoms that are exacerbated by excess activity or exertion
- may affect men with enlarged prostate or women, particularly with some type of bladder prolapse
- Tongue: pale, swollen, greasy coat
- Pulse: thin, weak
Fatigue Lin is thought to be caused by a Spleen and/or Kidney deficiency. Our treatment principle is to build and raise Qi and tonify the Spleen.
Preferred herbal treatments are:
Gui Pi Tang - while not specifically indicated for the treatment of urinary frequency, Gui Pi Tang accesses the fundamental imbalance that can lead to Fatigue Lin. It augments the Qi, nourishes Blood, and tonifies the Spleen and Heart. This formula would be most appropriate with a patient with additional symptoms of the Spleen not holding - prolapse of bladder / uterus, leukorrhea, frequent urination, incontinence, leakage with fatigue, and depression or anxiety.
Huang Qi Jian Zhong Tang - this formula tonifies the Spleen and Stomach, replenishes Qi, harmonizes the interior, and stops pain for Stomach Qi deficiency, Spleen Yang deficiency, and deficiency Cold in the Middle Jiao. It would be appropriate for frequent urination with GI involvement and coldness.
Spleen and Kidney Qi Deficiency
This pattern bridges closely with Fatigue Lin but we would see a more apparent pattern of the differential diagnosis in the general presentation of the patient; specifically with the addition of gastrointestinal symptoms, coldness and the typical pain in low back and knees associated with Kidney patterns.
- frequent urination and nocturia
- copious clear urine
- abdominal distention, GI upset, loose stools
- coldness in the limbs
- pain in low back and/ or knees
- Tongue: pale with teeth marks
- Pulse: deep, weak, tight
The treatment principle is to strengthen the Spleen and tonify the Kidneys.
The preferred herbal treatment is Bao Yuan Tang which tonifies the Qi and warms Yang. This formula may take several months to see a beneficial effect.
Lung and Spleen Qi Deficiency
Another pattern that can be found with Fatigue Lin, or as a precursor to Fatigue Lin syndrome, is Lung & Spleen Qi deficiency. The differentiating factor will be the involvement of the lung as we see with either cough, asthma, chest oppression or phlegm production. In this pattern there will also be more symptoms of the Spleen not holding with organ prolapse.
- frequent, copious clear urine or,
- incontinence with enuresis
- worse with exertion, fatigue, or sneezing / coughing / jumping
- chronic cough with white phlegm
- soft, low weak voice
- possible facial edema / puffiness
- organ prolapse - uterus, bladder
- general fatigue
- cold body
- loose stool
- Tongue: pale, white coat
- Pulse: thready, weak
The treatment principle is to tonify Spleen, benefit Lungs, aid the ascent of Yang and warm and transform Phlegm-dampness.
The preferred formula is Bu Zhong Yi Qi Tang to tonify the Middle Jiao, benefit and regulate Qi, raise Yang, and raise prolapsed organs.
Liver Qi Stagnation
Liver Qi Stagnation will be the diagnosis that should be considered when emotions and stress are a primary link with urinary symptoms. We may also see a bit less of the copious urine output and more tension and stagnation with urination. Within the patient there may be emotional symptoms or physical symptoms with diverse types of body pain and stiffness.
- urinary frequency that is exacerbated by stress or emotional upset
- incomplete or hesitant urination, difficulty to start the flow
- tightness or fullness in the abdomen or chest and flanks
- frequent sighing
- fatigue that improves with exercise
- emotional irregularity or outbursts, frequent anger, melancholy, or repressed emotion
- menstrual dysregulation - PMS, painful periods, irregular menstruation
- Tongue: pink or dark, slightly enlarged, thin white coat, may be slimy
- Pulse: wiry
Treatment principles are to soothe the Liver, regulate Qi and clear stagnation, resolve Dampness, and disinhibit urination. There are two appropriate formulas:
Chai Hu Shu Gan Tang - spreads Liver Qi, promotes Qi circulations, harmonizes Blood, and alleviates pain. This formula is appropriate when there is a GI involvement in the Wood overacting on Earth pattern. The modification of Ze Xie (9g), Hua Shi (18g), Che Qian Zi (12g) and Yu Jin (9g) is specific to frequent urination. (Note: all dosages of herbs are for whole, bulk herbs which are intended for use in a decoction.)
Xiao Yao San - pacifies the Liver, harmonizes Liver and Spleen, strengthens the Spleen and tonifies Blood. This formula will be a more appropriate option when the patient has some deficiency qualities in their presentation. For frequent urination, remove Sheng Jiang and replace with Pao Jiang (6g), add Wu Yao, Mu Xiang, and Qing Pi, each 6g.
Helping patients navigate overactive bladder, regardless of the cause, can be a difficult, slow-moving process. It is imperative that both the patient and practitioner are committed to long term strategy, treatment, and lifestyle modifications. Whether you are employing acupuncture, PTNS treatment, and/or herbal treatments, this is a process that may take months to see significant changes. Tracking symptoms like frequency of urinary urges, nocturia events, incontinence and leakage events can be helpful signposts to understand what changes are occurring since this will be very subjective to the patient. Some patients respond immediately to PTNS treatment while others take longer or may not respond at all. Getting to the root diagnosis in the non-responders can be a very helpful way to provide some relief or change in the system. Many patients, despite not having significant improvements, may also experience shifts in their quality of life or experience of their overactive bladder just by receiving treatment and herbs. It is important to validate this response as a practitioner. Not all changes will be what the patient or practitioner are expecting or wanting, yet they can be profound improvements despite the original problem remaining. A shift in how the patient reacts and responds to their OAB can make a massive difference in their life, regardless of the physical changes that may or may not take place.
PTNS Treatment Protocol
A typical treatment protocol for PTNS therapy is twelve consecutive 30-minute treatments given 1-3 times per week. There are also medical devices developed that do not require needling of both points and are implanted into the patient permanently for cases that require more consistent management. The following protocol is an effective way to administer a PTNS treatment to acupuncture patients using TCM terminology and point locations. PTNS is an approved medical treatment for overactive bladder in the US under CPT code 64566 or can be billed as Acupuncture with Electro-Stimulation CPT 97813 / 97814; it is also approved for fecal incontinence in Europe.
After a routine evaluation and intake with diagnosis, treat the patient for underlying constitutional imbalances and add on PTNS treatment with acupuncture treatment. Alternatively, PTNS may be performed without an adjunct acupuncture treatment and may be applied in private or a community style session.
The negative lead is placed on a needle 1 cun below Spleen 6 to the depth of 2cm and the positive lead on the foot or ankle, approximately Kidney 2, 3 or 5 depending on the sensitivity of the patient. The patient may also put the legs in a ‘butterfly’ position with the knees abducted and flexed. Slowly turn on the electro-stimulation device with the current level set at 0.5–9 mA and 20 Hz, the patient should feel mild tapping then more significant tapping or buzzing in the areas of the needles and ideally a sensation that runs down the medial leg and into the big toe. They may also experience fanning of the toes or extension of the big toe. Increase the amplitude of the current until the patient feels a slight discomfort or there is a physical response, such as a fanning of the toes, then turn the machine down slightly until that discomfort diminishes to a tolerable state. If there is still discomfort after the current level has been adjusted, it may be alleviated by adjusting needle depth and placement. Leave the patient to rest with the current for 30 minutes and then remove needles.
Adverse Events and Contraindications
Adverse events with PTNS treatment are no greater than typical adverse events associated with acupuncture and electro-acupuncture. Adverse events are reported as mild, transient, and uncommon at 1-2%, including bruising or bleeding at the needle site, tingling and mild pain.
Contraindications for PTNS treatment are identical to those with electro-acupuncture, and PTNS should not be used on patients with a history of epilepsy or seizures, severe heart disease, strokes, or on patients with pacemakers. If a patient has a difficult time tolerating needling, then adjustments should be made and then consideration of discontinuance of treatment if no alleviation of discomfort during treatment can be found.
- de Wall, L. L., & Heesakkers, J. P. (2017). “Effectiveness of percutaneous tibial nerve stimulation in the treatment of overactive bladder syndrome.” Research and reports in urology, 9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5565382/
- Staskin, D. R., Peters, K. M., MacDiarmid, S., Shore, N., & de Groat, W. C. (2012). “Percutaneous tibial nerve stimulation: a clinically and cost-effective addition to the overactive bladder algorithm of care.” Current Urology Reports, 13(5).
- Polyuria (Frequent Urination, Overactive Bladder), American Dragon, https://www.americandragon.com/conditions/Polyuria.html
About the Author
Dr. Kim Peirano, DACM, L.Ac. is a practicing Acupuncturist and Transformational Coach in San Rafael, CA. She is a published author, speaker, and intuitive healer. Dr. Kim’s treatments and offerings aim to access the deep inner workings of the mind-body-spirit connection to help her patients unlock the root cause of disharmony. Dr. Kim is the Founder and CEO of The Integrative Healing Institute, a non-profit education and research institution with a mission to help educate practitioners and the general public of the connection of the spirit - mind - body in healthcare. In private practice she treats patients for trauma, major life changes and spiritual growth as well as pain management and sports medicine. As a transformational coach her work centers around helping her clients develop self-awareness, confidence, and the ability to transform their problems into opportunities. Her healing approach is to unblock misalignment in the body-mind-spirit so that her patients can experience a deeper level and layer of their most authentic self - free of pain, stress, tension and full of confidence and vitality. For more information on her practice, offerings and to receive free meditations, healing images and more, please visit: https://www.lionsheartwellness.com/ or https://www.theintegrativehealinginstitute.com/.