How Do You Treat Nocturnal Enuresis in the Adult Patient in Your Practice?

Nocturnal enuresis (NE) is defined as an involuntary discharge of urine during night sleep in patients 5 years or older. The prevalence is estimated at 5%–10% in children who are 7 years' old. In up to 1%–2% of these children, the NE persists into adulthood. ¹ In adults, NE may actually affect 2%–6% of the population. ² Some risk factors for NE in adult males are obesity, neurogenic disorders, excessive urine production, and bladder storage and emptying dysfunctions. ³

The pathophysiology of NE involves hormonal abnormalities, sleep disorders, and psychologic disorders. ⁴ NE includes nocturnal polyuria, with urine production exceeding bladder capacity, absence of a circadian rhythm in arginine vasopressin hormone, and abnormal bladder capacity. ⁵

First-line treatment for NE, regardless of etiology, is behavioral and lifestyle changes. The approach should also, in second-line treatment, control other systemic and urinary diseases that contribute to NE, and, in third-line treatment, medications. Due to the lack of studies in adults, clinical management of NE in adults is commonly based on data on this disease in children. ² In addition, there are no articles in the literature addressing treatment of NE in adults with acupuncture.

Acupuncture is used for treatment as a primary therapy in some Eastern countries and has been introduced as a complementary treatment in Western medicine. Furthermore, acupuncture rarely has adverse effects.^6,7 Its positive effects include reducing the number of enuresis episodes, increasing storage capacity of the bladder, making it easier for patients to awaken from sleep to void, and suppressing uninhibited bladder contractions in patients with detrusor overactivity. The cure rate is 76%–98%.

These positive effects of acupuncture on NE are due to the response of the spinal micturition centers and parasympathetic innervation of the urinary tract, modulating brain function via the descending serotonergic system. This occurs when using acupuncture points—such as BL-23, BL-28, and BL-32; as well as CV-3, CV-4, CV-6, and CV-12—in areas of innervation near spinal sacral segments S-2 through to S-4. Scalp acupoints DU-20 and DU-14 modulate brain function via the inner temporal, thalamencephalon, and prefrontal cortical systems. Moreover, BL-20, BL-13, SP-6, ST-36, KI-3, and LU-9 are used in Traditional Chinese Medicine (TCM) to normalize bladder function, through invigorating Spleen, vital energy, and Blood. ⁶

Acupuncture and laser acupuncture reduce enuresis and relapse rates more effectively than sham procedures, although the evidence is weak due to errors or lack of information about study designs. ⁸ In 2017, Alsharnoubi et al. concluded that there was a statistically significant higher cure rate in children who received laser acupuncture (73.3%), compared to a group who received treatment with desmopressin alone (20%) or both interventions (13.3%). ⁷ The acupuncture points used for that study were CV-2, CV-3, and CV-4; BL-23, BL-28, and BL-32; and SP-6 bilaterally. ⁷ In a 2022 systematic review and meta-analysis, Ton et al. found that the most-used acupoints for treating NE with laser acupuncture were ST-36, CV-3, CV-4, BL-23, BL-28, BL-32, SP-6, and KI-3. These researchers found that groups receiving laser acupuncture had significant improvements, compared with control groups; however the evidence in these studies was of low quality. ⁹

In our experience, the best options to treat NE with acupuncture may involve using scalp acupuncture with Wen's technique or systemic points described by TCM. In Wen's scalp acupuncture, areas of the scalp that are effective for controlling NE require special needling that crosses the sensory and motor areas. Those areas correspond to TCM's BL meridian. Another useful area is the Inferior Jiao area, located in the same place as ST-8. ¹⁰ For TCM acupuncture, we use points from the CV meridian; 2 useful points are CV-4 (Guanyuan; Mo point of the SI meridian; also the connection point of CV and the 3 Yin meridians of the Foot) and CV-3 (Zhongji; Mo point of the Bladder; also the connection point of CV and the 3 Yin meridians of the Foot).

These points may be stimulated with needles or moxibustion. They may be combined with SP-6 (Sanyinjiao; the connection point of the 3 Yin meridians of the Foot). The 3 Yin meridians of the Foot cross the Pelvis. SP-6 is a very good tonifying point, either with needles, or moxibustion, or a combination of both, as it can be done in CV-3 and CV-4. BL-23 (Shenshu; the Back Shu point of the Kidney) can be stimulated with needling, moxibustion, or both. Other useful points are LI-4 (Hegu), LR-3 (Taichong), ST-36 (Zusanli) and SP-9 (Yinling Quan). Those points can treat Deficiency of the Inferior Jiao, Deficiency of Qi from Pi and Fei, or Heat of the Liver. ¹¹

Yolanda Maria Garcia, MD, PhD,^1,2

Amanda Victória Casagrande, MD,^1,2

and Gabriela Rodrigues dos Santos, MD²

¹Centro de Acupuntura, Clinics Hospital

São Paulo, Brazil

²São Paulo University Medical School

São Paulo, Brazil

Address correspondence to:

Yolanda Maria Garcia, MD, PhD

R. Teodoro Sampaio, 352 Room 57

São Paulo, 05406-000

Brazil

E-mail: yolanda@usp.br

Nocturnal enuresis (NE) as defined by the International Continence Society is involuntary voiding during sleep. ¹ This condition is a physiologic finding in children younger than 5 years' old; however, it is considered to be abnormal in adults. ² Patients whose symptoms reemerge following resolution of enuresis in childhood are considered to have recurrent NE. However, patients who develop symptoms of NE without any related previous medical history of the condition are considered to have secondary adult-onset NE. ³

In 2020, Song et al. showed that the prevalence of NE was >50% in the general population of patients age 65 and older. ⁴ Comparatively, the prevalence of primary persistent NE and recurrent NE is ∼1%–2.5%. ⁵ Patients with NE should not be neglected, as it has a considerable negative impact on an individual's quality of life, self-esteem, mental health, and family relationships. ⁶

The etiology and pathogenesis of NE is multifactorial, and some of the commonly implicated causes include nocturnal diuresis that overwhelms an individual's functional bladder capacity, nocturnal detrusor overactivity, nocturnal polyuria, sleep disorders, smoking, obesity, hypertension, and a sedentary lifestyle. ⁷ In Traditional Chinese Medicine, production and excretion of urine are associated with functions of the Lungs, Kidneys, Spleen, and Urinary Bladder, and NE is considered to be a problem involving fluids in the body. If Kidney Qi is insufficient, it will be unable to maintain the function of the Bladder to hold urine; thus, enuresis occurs. ⁸

Clinically, moxibustion shares its theoretical background with traditional acupuncture but has its own clinical advantages related to thermal stimulation of acupuncture points, as well as herbal and aromatic effects. Moxibustion therapy is considered to be particularly supportive for overall body energy and is widely applied to support Bladder control and supplement the body's energy. ⁹

We select the Back-Shu points as the principal points, with moxibustion methods to strengthen the Kidney and reinforce Qi. BL-23 (Shenshu), BL-28 (Pangguangshu), and BL-20 (Pishu), as well as CV-3 (Zhongji), CV-6 (Qihai), and LR-3 (Taichong) are used to support the Lower Burner and reinforce Qi. Back Shu points are where Qi of the respective Zang-fu organs are infused. These points are located on each side of the vertebral column, in close proximity to the spinal ganglia and their respective Zang-fu organs. These points are where Qi of the respective Zang-fu organs are infused, where pathogenic factors can lodge, causing diseases of either the Zang-fu organs or of the body's surface.

A typical case example in my clinic involved a 32-year-old female patient who initially had bedwetting between 1:00 am and 3:00 am every night, but had since developed wide variations in frequency. Sometimes—especially during the past 2 years—she could remain dry for ∼2 months and then her bedwetting would occur at a greater frequency, when she was under stress or feeling unhappy about something. She had no history of diabetes or other chronic medical conditions, nor was she taking any medications that could plausibly have caused her urologic symptoms.

This patient received 30 minutes of moxibustion, 3 times per week, for 8 weeks. After 4 weeks, she reported an improvement, with more-limited night-time urination and a stronger urine flow during the daytime. After 8 weeks, the patient did not experience enuresis. We also educated her to apply daily self-moxibustion therapy at home at the following acupuncture points: CV-3, ST-36 (Zusanli), and LR-3. This patient did not experience any adverse events as a result of this moxibustion self-therapy.

Address correspondence to:

Yun Jin Kim, PhD

School of Traditional Chinese Medicine

Xiamen University Malaysia

Jalan Sunsuria, Bandar Sunsuria

Sepang, 43900 Selangor

Malaysia

E-mail: yjkim@xmu.edu.my