Acupuncture for Recurrent Uncomplicated Urinary Tract Infection in Women

Abstract

Background:

Urinary tract infection (UTI) is the most common bacterial infection in women, with 50%–60% having at least one episode of infection at some point of their lives. Recurrences are common (66%); Escherichia coli is the most common causative organism. Uncomplicated UTI, which is the focus of this article, responds well to short courses of antibiotics, but, after repeated use, emergence of antibiotic resistance is a major issue.

Objective:

The aim of this article is to discuss the development of a system of acupuncture that covers all aspects of UTI, including control of symptoms and prevention of recurrence.

Methods:

This article discusses the following: (1) a combination of points to control symptoms in all cases of UTI; and (2) a combination of points to address the possible Disharmony patterns that predispose patients to UTIs and thus reduce or prevent the chances of recurrence. The use of Extra Meridian Yin Qiao Mai (Yin Heel Vessel), which has the potential to treat symptoms of UTI and and neutralize the Disharmonies effectively—thus reducing chances of recurrence—is explained. Points with immune-stimulating functions that are used to combat infection are also covered.

Conclusions:

Use of the combination of points for symptom control; and selective use of points according to Disharmony patterns for each particular patient; and supportive use of Extra Meridian Yin Qiao Mai, which has beneficial effects on all aspects of UTI, can treat most patients with UTI effectively. In addition, control of symptoms and prevention of recurrence can be acheived.

Introduction

Urinary tract infection is more common in women (84%) and is the most common bacterial infection in the ambulatory care setting in the United States, accounting for 8.6 million visits in 2007.¹ 50%–60% of adult women experience a UTI during their lives. ^2,3 In young women, there are 0.5 episodes of acute cystitis per person, per year;⁴ in postmenopausal, women the number is 0.07 episodes per person per year.⁵

Recurrent UTI is defined as 2 uncomplicated UTIs in 6 months or ≥3 positive cultures within the preceding 12 months.^6,7 When the same organism is responsible for the subsequent infection, this situation is considered to be a relapse. When the subsequent infection is caused by a different organism or by the same organism after a negative culture, or if there are ≥2 weeks between infections, this situation is considered to be a reinfection.⁸ Reinfection is more common than relapse (66%).⁹ When the initial infection is caused by E. coli—the most frequent organism found in UTIs—there is a higher risk of reinfection in the first 6 months after the first infection.¹⁰

UTIs occurring in healthy premenopausal nonpregnant women with no urinary tract abnormalities is classified as uncomplicated; all other UTIs are classified as complicated; asymptomatic bacteriuria is not usually treated.

Conventional Biomedical View of UTI

Causes

The urinary tract from the kidneys to the urethra is normally sterile. Infection is initiated when pathogens from the bowel or vagina (as a result of sexual activity) colonize the urethral mucosa and ascend to the bladder or up to the kidneys.

Risk factors for recurrent UTI include sexual intercourse, previous UTIs, a new sexual partner, use of spermicides, and a family history of UTIs in a first-degree female relative.^4,11

Polymorphisms in the interleukin 8–specific receptor gene CXC RI are associated with increased susceptibility to pyelonephritis.¹² Estrogen loss at menopause predisposes patients to UTIs.

Symptoms

Classic symptoms include urinary frequency, dysuria, suprapubic pain, and, in some cases hematuria. Symptoms after intercourse, absence of nocturia, a past history of UTIs, and prompt resolution of symptoms after antibiotics usually differentiate UTI from herpes simplex infection, bacterial vaginosis, chlamydia, candidiasis, and gonorrhea. The main negative predictors are persistence of symptoms after an infection is treated and the presence of nocturia.⁶ Fever, chills, flank pain, costovertebral angle tenderness, nausea, or vomiting will indicate the possibility of pyelonephritis; vaginal irritation and discharge will often point to vaginitis.

Microbiology

From 75% to 95% of UTIs are caused by E. coli. Other causative organisms include Staphylococcus saprophyticus, Enterococcus faecalis, Group B Streptococcus, Klebsiella pneumoniae, and Proteus mirabilis. Infections by unusual organisms are usually associated with structural abnormalities or renal calculi.

Investigations

Most women with recurrent UTIs will not need extensive investigations.^9,13 The presence of a prolapsed uterus should be excluded, and an examination should be done to evaluate each patient's urogenital anatomy and estrogenization of her vagina. Diabetes screening and measurement of postvoidal residual volumes are important.

Assessment of pyuria and bacteriuria can be done using dipsticks, which have a sensitivity of 72% and a specificity of 82%.¹⁴ A urine culture is also performed to confirm the presence of bacteriuria and microbial susceptibility; but treatment can be started before the results are available, based on symptoms and signs.

Treatment

Several studies have confirmed the effectiveness of 3-day regimens of trimethoprim, (300 mg once per day) trimethoprim sulfamethoxalole (160/800 mg b.i.d.), or fluoroquinolones as empirical therapy.¹⁵ This is most appropriate for nonpregnant women with uncomplicated UTI. Nitrofurantoin is safe and effective and should be given for 7 days (100 mg b.i.d.). A single dose of fosfomycin is also effective (3 g). Fluoroquinolones can be used as first-line treatment if typical therapy is not tolerated or ineffective. Nitrofurantoin, ampicillin, and cephalosporins are safe in pregnancy.¹⁶

Prevention

Spermicides containing contraceptive agents should be avoided and other methods used to prevent conception. A Cochrane review of 19 trials involving 1120 patients showed that the antibiotics are effective for reducing recurrences of UTI.¹⁷

Prophylaxis (nonpregnant women) may be continuous or postcoital. For continuous prophylaxis TMP-SMX (40/200 mg at bedtime) or nitrofurantion (50–100 mg at bedtime) or cephalexin (250 mg at bedtime) can be used for a period of 6 months.¹⁸ For postcoital prophylaxis, the same medications are used as a single dose after intercourse. This method has the advantage of fewer side-effects and less chance of antibiotic resistance. Locally applied vaginal estrogens are effective for reducing recurrent UTI in postmenopausal women.¹⁹

A Cochrane review of 10 studies with a total number of 1049 subjects showed that cranberry (Vaccinium macrocarpon) juice reduced recurrences of UTI.²⁰ Cranberries prevent adhesion of bacteria (especially E. coli) to uroepithelial cells, and may prevent acute cystitis in women.

In pregnant women, continuous (6–12 months) prophylaxis can be used; agents of choice are nitrofurantoin 50 mg and cephalexin 250 mg, either of which are taken in a single dose per day. Manufacturer's precautions should be consulted.

Acupuncture for UTIs

Two studies demonstrated that acupuncture could play a significant role in preventing recurrent UTIs.^21,22 Acupuncture has been observed to reduce infection rate by >50% in 6 months following treatment.

Chinese Medicine Causes of Disease

Chinese Medicine lists various causes of disease—a weak constitution; overwork; lack of exercise; excessive sexual activity; errors in diet; trauma; disorders as a result of treatment (side-effects and incorrect treatment); emotional factors (often described as internal factors); and external factors, such as Heat, Cold, Wind, Dampness, and Dryness. Of these, in UTIs, the relevant factors are Dampness and Heat, because, according to Chinese Medicine, this disorder is a combination of Dampness and Heat that is termed Damp Heat.

Dampness as a condition in Chinese medicine is described as sticky, heavy, dirty, and difficult to get rid of; it slows things down and causes repeated attacks. Climate dampness refers to damp weather, living in a damp house, wearing wet clothing, sitting on damp ground, etc. Dampness can settle in any part of the body and produce various symptoms—epigastric pain, a “sticky” taste, abdominal fullness and indigestion (Stomach and Spleen), hypochondrial fullness and pain (Liver and Gallbladder), painful urination, cloudy urine (Urinary Bladder and Kidneys), loose stools and mucus (Intestines), oozing eczema, vesicles (Skin), a white and sticky vaginal discharge, and swollen joints.

When a patient has Dampness, there is retention of fluid; thus, the pulse feels as if it is beating through a medium of liquid (which makes it feel soggy), with indistinct margins, and this pulse slips under the fingers—this is known as a slippery pulse. Fitting with the general nature of Dampness, the Tongue has a sticky, thick, and dirty coating. Heat is generally manifested as a feeling of heat, a red face, thirst, mental restlessness, a red Tongue, and a rapid pulse. Other symptoms will depend on the organs involved. The Spleen controls movements of fluids in the body. If the Spleen's function is impaired, fluid transport will be affected adversely, and fluids may accumulate in the form of Dampness, Phlegm or edema.

Because of this situation, in any case of Dampness, the Spleen must always be treated. Heat denotes excess Yang. It can affect any organ and can be from external sources, such as exposure to hot weather. However, in clinical practice, the most relevant form of Heat is internal Heat, which results from emotional factors and/or consumption of Heat-producing items, such as alcohol, greasy foods, and hot spicy foods.

Anger affects the Liver, joy affects the Heart, pensiveness affects the Spleen, worry affects the Lungs, and fear affects the Kidneys—but they all affect the Heart.²³

The Kidney is the root of all organs and, in any chronic condition, there will be Kidney Deficiency.

These facts have to be considered when selecting points; if any Disharmony is missed, one may not succeed in preventing recurrences of problems, which is the main focus of acupuncture treatment.

Dampness and Heat frequently combine together to form Damp Heat. If a person is stuck in a room on a hot humid day with no air conditioning, that person experiences Damp Heat. Symptoms will vary according to the organ involved; a classical example will be swollen, painful, and warm joints—the swelling is Dampness, and the pain and warmth are caused by Heat. Germs love Dampness; it is an ideal breeding ground for them.

A UTI is Damp Heat in the Urinary Bladder—the infection can extend to the Kidneys. Dampness predisposes a patient to infection; Heat is its manifestation. Difficult urination is Dampness, burning, dark urine, and Blood in urine, all of which result from Heat. The patient's pulse will be slippery and rapid. The patient's Tongue will have the thick dirty coating of Dampness, and the Heat will toast it to a brownish yellow—all of this is manifested at the root of the Tongue where the Bladder is represented.

In almost all cases of Damp Heat in the Bladder, there is the pattern of Spleen Deficiency and Kidney Deficiency. Dampness arises from Deficient Qi of the Spleen and Kidneys, which leads to Stagnation of Qi; when this Stagnation is prolonged, it produces heat.²⁴

Treatment

Table 1 lists the syndromes, signs and symptoms, pulse and Tongue characteristics, and the points used to address UTIs. The points include:

Table 1.

Urinary Tract Infections (UTIs)

Syndromes	Signs and symptoms	Pulse	Tongue	Points used
Damp Heat in Urinary Bladder (all cases of UTI)	Urgency, frequency of urination with burning, hypogastric fullness, fever, hematuria & turbid urine possible	Slippery & rapid	Thick, with yellow coating at the root, sticky	SP 9, ST 28 & CV 9 to resolve Dampness; CV 3 & BL 28 (Front Mu and Back Shu Points for Bladder); & BL 22 to Open Triple Energizer; all points are reduced
Kidney Qi Deficiency	Tiredness, low-back pain, weak knees, dribbling of urine, enuresis, deafness & premature ejaculation	Deep, weak in rear position	Pale	BL 23 (Back Shu point of Kidneys), KI 3, GV 4 (tonifies the Kidney), CV 4 (tonifies Qi); GV 20 (raises Qi), CV 6 (tonifies Qi), BL 32 (firms Qi in genitourinary organs); all points are reinforced
Spleen Qi Deficiency	Tiredness, loose stools, weakness of extremities, & tendency to obesity abdominal distension after eating	Empty	Pale	SP 6, ST 36, CV 12, & SP 3 (to tonify Spleen); BL 20 & BL 21 (Back Shu points of Spleen & Stomach to tonify Spleen); All points are reinforced

Note: SP 6, LI 11, & GV 14 are immune-stimulating & can be reinforced in all cases as specific points for addressing infection.

• BL 23 and BL 28 (back transporting points of the Kidney and Urinary Bladder, respectively)

• CV 3 (the front collecting point of the Urinary Bladder and the point of intersection of three leg Yin channels with the Conception Vessel)

• SP 6 (another point of intersection of leg Yin channels)

• SP 9 (resolves Dampness in the pelvis)

• BL 22 (opens water passages),

• BL 63 (stops pain on urination)

• BL 66 (clears Heat from the Bladder)

• ST 28 (resolves Dampness in the Urinary Bladder)

• LR 8 (reduces Heat in the Urinary Bladder; the Liver channel traverses the urogenital area and LR 8 is the Sea point of Liver channel)

• Ear points (Classic Chinese approach), including the Urethra, Sub Cortex, Neurogate, and Sympathetic points.

Needle daily, using 0.5-inch 28-gauge needles. Retain the needles for 30 minutes at all points, with 5–10 treatments constituting one course.

A Western approach (by the late Paul Nogier, MD, 1908–1996) to acupuncture includes the following main points: Kidney; Kidney E; Ureter C; Ureter E; Bladder; Urethra C; Urethra E; Shen Men, and Occiput. Supplementary points in this approach include: Adrenal Gland C; Adrenal Gland E; Sympathetic Automomic Point; and Point Zero.

Chinese medicine holds that, because the Kidneys' main function is storing the Essence, and, given that the Essence cannot be in Excess, Kidney has no Excess patterns—it has only Deficiency patterns. So BL 23 (back transporting point) is always reinforced. Damp Heat in the Bladder/Kidney (pyelonephritis) is an exception to that general rule. Being an Excess condition, in this situation, BL 23 is reduced until Damp Heat settles.

While the abovementioned points are the ones commonly recommended in most textbooks, the current author finds the use of Extra Meridian Yin Qiao very useful in all painful urination syndromes—not only with respect to efficacy, but also for reducing the number of points used. The “Golden Mirror of Medicine” mentions burning urine in its long list of symptoms related to Yin Qiao. The method of stimulation is needling the KI 6 (Opening point), then LU 7 (Coupled point), and then BL 1 (Exit point), in that order—bilateral stimulation is applied, using a reducing method. Additional stimulation of CV 2, CV 3, and CV 4 by a reduction method will add to the effect. The Conception Vessel is the coupled partner of Yin Qiao, and the abovementioned points are in close proximity to the Urinary Bladder. If required, other points listed before from the generally recommended points can be added.

A major textbook²⁵ recommends moxa for addressing urinary infection. This needs clarification, because UTI is an Excess condition, and, if moxa stimulation is used at the time of infection, this treatment would increase inflammation. Any moxa heating, if used, should be strictly limited to the period when the infection has subsided completely; at that time, moxa can be used to stimulate Deficient Spleen and Kidney.

Discussion

Acupuncture, because of its immune-enhancing effects abolishes the relapsing character of urinary infections, so that a chronic course can often be avoided.²⁵ The focus is not only on immune-enhancing but also on correction of basic Disharmony that predisposes patients to infection.

The late Rudolf Virchow, MD (1821–1902), the father of cellular pathology said: “If I could live my life over again, I would devote it to proving that germs seek their natural habitat—diseased tissues—rather than causing disease.”²⁶ So, when it is said that E. coli has caused bladder disease, it is “putting the cart before the horse.”

To understand this concept, it is necessary to do some “unlearning” on our part of with respect to what we were taught in medical schools. It is quite clear that the symptoms of urinary infection are caused by pathogenic microorganisms, but the microorganisms are there because of predisposing factors that had produced the unhealthy tissue prior to the manifestation of symptoms. Those factors in this situation are Dampness and Heat combining to form Damp Heat in the Urinary Bladder and that, in turn, is the result of Spleen and Kidney Deficiency. The points mentioned in the treatment section address all these Disharmonies.

A living body functions as a single unit, and each organ has its effect on other organs, and, in resistant cases, one has to look for other possible hidden Disharmonies.

Lung Qi descends to communicate with the Kidneys and Urinary Bladder. (This fact has major implications for treating Bronchial Asthma). A deficient Lung Qi, especially in old people, can cause retention of urine and infection. The Liver channel flows through the genitalia and urethra. Stagnation of Liver Qi can affect the Bladder, predisposing a patient to develop a urinary infection. Use of LR 8 has already been mentioned; additional Liver points may be needed in resistant cases. Resistant cases—whether they are urinary infections or any other illnesses—indicate that something, somewhere along the line has been missed. It could be a sad experience some time before, or it could be some other emotional trauma (as stated before, every emotional insult injures the Heart causing Heart Fire). Qi circulation occurs as follows:

• The first circulation starts from the Lung channel.

• This connects to the Large Intestine channel in the hand.

• Qi flows from the hand to the head along the Large Intestine channel.

• This connects to the Stomach channel.

• Then Qi descends along the Stomach channel to the foot, where it meets the Spleen channel.

• Qi then rises along the Spleen channel back to the Lung channel, completing the first circulation.

There are two Yin–Yang relationships here: Lung–Large Intestine and Spleen–Stomach. There are also two axis relationships; Large Intestine–Stomach and Lung–Spleen.

Similar relationships exist in the second circulation involving the Heart, Small Intestine, Urinary Bladder, and Kidney; and in the third circulation, involving the Pericardium, Triple Energizer, Gallbladder, and Liver. With respect to the second circulation, if there is an emotional trauma, Heart Qi is affected; this disruption will extend to Small Intestine channel (a Yin–Yang relationship) and then go along the Small Intestine channel to the Urinary Bladder channel (an axis relationship). This is the basis of including HT 8 and SI 2 in patients with recurrent UTIs when emotional trauma is a causative factor. This is similar to ST 38 being used for shoulder pain along the LI channel; the Stomach and Large Intestine channels are axis-related. H8 and SI 2 are the Spring points that are indicated for addressing burning sensations and Heat. It has been suggested that emotional trauma precipitates urinary infection.²⁷

Excessive consumption of greasy foods, sweets, and dairy products can cause Dampness. Spicy foods and alcohol may generate Heat. Attention to these facts will often help in resolving resistant cases.

If there are associated abnormalities in the urinary tract predisposing a patient to a urinary infection (complicated UTI), those factors would need attention. The current author uses antibiotics in all cases of infections; acupuncture is used to eliminate recurrences.

Conclusions

More than 50% of adult women will have at least one episode of UTI in their lifetime. Most acute infections respond well to antibiotics, but recurrence and subsequent multiple courses of antibiotics with the attendant risks of antibiotic resistance are major problems. Studies have shown that acupuncture is effective for reducing recurrent urinary infections by >50%. Using a holistic approach to correct associated Disharmonies will often enhance the results. Behavioral counseling especially useful in relation to sexual practices, and use of biological mediators, such as cranberry juice, topical estrogen, etc., can be useful adjuvants.

Footnotes

Disclosure Statement

There are no financial interests related to this article.

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