Chapter  9     Bladder and Urinary track issues

9.1       Interstitial cystitis

9.1.1    A 43 year old female had complaint of having “interstitial Cystitis.” The pain was centered at the bladder. In the good days, the pain was at 2-3 level in the scale of 0-to 10.  In the bad days, it was 9-10. The pain felt like rubbing alcohol on a wound, it’s sharp and burning.  It started gradually about 5 years ago. The pain never went away. One doctor diagnosed her condition as Interstitial Cystitis due to Hunter’s Ulcer inside the bladder. She was prescribed drugs: Elmiron,  Mobic twice a day, Pyridium 1 three times a day and Atarax one a day for a while now. The medicine did not seem to have any effect and she decided to wean herself off recently by reducing the medicine intake, which did not seem to make any difference in pain. In those years since the pain started, when the pain became intolerable, she would visit her doctor and have a procedure done. That happened about twice a year. The doctor pumped air into her bladder to stretch the her bladder( refer to the following). Although it is painful, sometimes it gave her some relieve afterwards, other times, no effect what- so- ever. Then she had to have another procedure within a few months.

“Bladder Distention from http://kidney.niddk.nih.gov/kudiseases/pubs/interstitialcystitis/

Many people with IC/PBS have noted an improvement in symptoms after a bladder distention has been done to diagnose the condition. In many cases, the procedure is used as both a diagnostic test and initial therapy. Researchers are not sure why distention helps, but  some believe it may increase capacity and interfere with pain signals transmitted by nerves in the bladder. Symptoms may temporarily worsen 4 to 48 hours after distention, but should return to predistention levels or improve within 2 to 4 weeks.

She was advised to pay attention on food intake, avoiding things like tomatoes, citrus. Although she did not experience any problem with food, she did minimize its intake. She has no problem initiating urination. The pain came after urination, so she drank plenty of water, 24-36 ounces per day.

Other history includes a herniated disc at  L3-L5 six years ago.  For which, she had disc-ectomy on the left of her spine between L3-L5. The operation did not resolve the back pain completely. She thought there was a connection between her bladder problem and her back but the doctor dismissed the connection.

Other features include: cold hand and feet, standing in the cool place for a while and her feet would go cold and numb.  Her hands ran cold in the cold weather, in severe condition, they turned icy cold, white and painful. Her pulse was a little fast, 85-90. In TCM term, she was Yang deficiency.

She also experienced tightness in the neck, worse on the right. She had it adjusted by chiropractors when it became too tense and uncomfortable. The result never seemed to last for long. Occasionally, she would have episode of migraine headache. Her bladder problem did not seem to be related to her menses at all.

Diagnosis and Analysis:

This is an interesting case because it is an IC, interstitial cystitis–like problem, because IC is diagnosed based on elimination of other pathological causes for bladder problem. She does not have other problems around the low abdominal area.  What is unique about this case as compared to other IC cases is that the patient has no food allergy issue.  No standard bladder sensitivity to food items. She could practically eat anything and nothing seemed to bother her. In other word, her problem was not rests on interstitial tissues of the ladder as would be for classical IC. As for the Hunter’s ulcer, she probably has that since childhood without any pain. So how did it cause problem all of a sudden much later in life without provocation (except back surgery)? One other point, if it were caused by Ulceration, the last thing that one would do is to stretch the bladder through compressed air.

It is quite clear from TCM perspective that her problem came from low back. The Bladder meridian goes through the back along the spine, where she had disc herniation. That back pain caused Qi of the urinary bladder to become congested which frequently resulted in pain.  Unfortunately the operation of disc hernia was not very successful. Her back pain continued after surgery of the back. In addition, the new pain with “bladder problem " was actually the result of back surgery.

What is also interesting about her medical treatment is that her doctor decided to stretch the bladder to relieve her pain which sometimes did relieve pain but other times achieved nothing. Such treatment should have been contra indicated if indeed her IC were caused by ulceration, the last thing the doctor should do is to aggressively stretch the bladder, because it could aggravate “ulceration” and make her pain intensify.  Therefore, the result does cast a doubt about the ulcer as the pathological factor.

From TCM perspective, it does offer a clue about the true pathology: by stretching the bladder, the Qi stagnation that caused the bladder problem, if done properly, was being improved. However, because the procedure can be very uncomfortable, it causes pain and pain invariable causes Qi stagnation and render the procedure ineffective. This explains why the procedure only works sometimes.

Treatment:     The goal for treating her “IC” is to remove the stagnation of Qi at her bladder. This can be achieved by addressing her back pain by acupuncture (refer to acupuncture for L-B protocol) and the bladder itself.  Both are easily achieved. As the result, her pain was significantly reduced after 6 visits.

9.1.2  A lady in her late 50’s was diagnosed as having IC. She had two grown up children and couple grand kids. About 10 years ago she started to develop this painful bladder/ burning urethra problems. There was a constant pain and ach in her low abdominal-bladder/urethra area, in TCM the Lower Jiao.  Needless to say she had to run to the bathroom constantly. Some doctors suggested that she had interstitial cystitis, while some other doctors did not agree. One doctor operated on her for “endometriosis” seven thousand dollars later, pain as usual. It did not help a bit. Her body was on the thin side, had problem sleeping as the result of incessant pain. Her low back was always achy as well.  She had a good marriage but intercourse had been excruciating painful.

She reported to have severe food allergic issue-tomato was on the top of the no-no list. Being an Italian descendant, that had been a major sacrifice in life.  There were many other items forbidden as well- anything that was acidic seemed to bring up intense pain in the bladder. She came to believe that her body being too acidic was part of her suffering. (I don’t agree with such line of thought. Refer to articles in my blog.)

Treatment:

First, I used points which calm her mind and body. Relax her neck and shoulder using the N-S protocol stated above, which happens often to people with chronic pain. I also applied IR heat over her low abdomen. This was quite pleasant for her. I then applied acupuncture using empirical point group –one third down from the perineum on the mid-line along the inner thigh with electro-stimulation in a mix mode.

Such treatment reduced her pain significantly; she could have more rest at night. In the second treatment, I added the Ci Liao points over sacral area  - also with electro acupuncture, because she reported that back achiness did not improve from last treatment. It had been preventing her from sleeping on her back. To my surprise, this pair of needle totally suppressed her “spasm urethra” pain.

She was treated once a week. Initially, the effect of treatment would last for a few days.  After a month time, she pretty much had minimal achiness throughout the week. She was very happy. However, one day she came in and I knew her problem had came back just by looking at her gait. It turned out that she had intercourse over the previous weekend which set off all the previous pain. I told her not to worry because this was to be expected.

She continued to make progress. In three months, she actually could start to enjoy sex rather than just endure shear pain after the act. Discomfort after sex became minimal and brief in duration.

Analysis:

As with other patients who suffered from interstitial cystitis, her pain was very sensitive to food intake. Before her first visit, she discovered that if she ate potassium carbonate, which is an alkaline chemical as supplement, her pain would be reduced a little. This seemed to confirm her suspicion that her acidic body was part of the culprit of her problem. There was one glitch to this therapy. She soon experienced palpitation and tachycardia, which is not pleasant. So she replaced it with sodium carbonate. If her theory had been right, she should also have similar pain relieve.  To her surprise, it did nothing for reducing the pain.

What she did not realize is that the potassium did not work the way she thought. It is NOT that alkalinity helped her pain; otherwise, sodium from table salt would have worked. Potassium is a highly regulated substance in the blood stream. Elevated potassium level in blood excites the heat rate. As a matter of fact, in open heart surgery procedure, surgeons routinely inject potassium into the blood to cause heart organ to beat so fast that it spasms and eventually stops. In her case, potassium caused her heart rate to increase which improved her circulation. As is true for most cases involving pain issue, increased circulation reduced her pain. (Cold also reduces pain sensation but through a totally different mechanism. Have possible long term side effect, if used for a long time. More on this topic later.)

9.1.3    A 54 year old lady complaint of both hip pains, worst on the right. She also had constant pain, in her shoulder, neck and low back. Frequently, she felt knifing, burning sensation at her low back. Her low abdomen was always tender, worst on the right side. Urination was painful so was sexual encounter even though she had good marriage. Over the last five years, she had several surgeries–two bone spurs surgery, bone fusion L4-L5 and S1. Nothing worked.

She was always constipated since childhood and had been regularly taking Aloe Vera and acidophilus to help bowel movement. She could only eat small portion at one time otherwise she would have severe abdominal pain. She is 5’6 95 lbs, prefer warm food, and love ginger soup, having cold hands and feet. Have difficulty keep body warm in the winter in Southern California.

She was diagnosed as having “interstitial cystitis” recently and her doctor recommended putting cortisone suppository in the bladder. She did not agree to it. She was on many courses of antibiotics. HRT (prempro patch), ibuprofen. Cranactin, organic Cranberry juice. She also took antacids and sleeping pill frequently.

Analysis and treatment:

Her condition is complex. At the bottom of the problem is this condition that in TCM called Yang deficient. Because of that, her body was incapable to repair itself resulting in all kind of problems. Aloe Vera which she used frequently for constipation also added her Yang deficient problem because it is a very “cold “ food in TCM. She easily qualifies as a patient of fibromyalgia.  The most important step to treat her is to tontify Yang. There are several TCM herbal formulas for this purpose. I put her on a formula made by Evergreen called Vitality for several months. It helped her to feel warmer especially during the cold of the winter(  in California, winter can be very cold.). Gradually her condition started to improve. She still had some painful issues because all the surgery done and yang deficiency issue but much easier to live with. She would come in for treatment from time to time.

9.2       Vaginal pain (vulvodynia)

Vagina is a complex organ, it contains several parts. It is often difficult to clearly pin point which part of the vagina is at fault. Most frequently, it is the inflammation of urinary track like bladder or urethra (UTI) that is the cause of pain. UTI causes severe pain both in urination and intercourse.  

One female patient in her mid 30’s with vaginal pain went to see four doctors and came up with four different diagnosis: hormonal deficiency, infection, dryness, inflammation.  Nothing worked.  I used electro acupuncture  at  points, one each leg, on the inner thigh, mid line, down about  three fingers width from Perineum. 30 minutes interval two times a week. This is an extra acupuncture point on the Liver channel which according to TCM encircles the vaginal area. The problem disappeared within a month. It was a case with minor inflammation of one spot of labiaminora that created a QI stagnation at the whole area. Soon she was pregnant which made her very happy.

This point that I used lies on the liver meridian. In TCM, Liver(Lv) meridian surround genitalia.  Other points on the liver meridian, Lv 3 in particular, is also good choice but not as effective in electro acupuncture because of the electro conduction issues. In electro acupuncture, the electrical current has to travel from one pole to the other. The longer the distance between the points used, the higher the voltage needed to get the same current flow.

9.3       Painful urination

This happens frequently with many women, very painful, hurting like being knifed. One potential problem is the infection in urinary tract which is called UTI in medical terms that involves overgrowth of pathogenic bacteria, mostly E. coli, in and around the urinary track.  In such situation, antibiotics work well.  Alternative, Chinese patent herbal formula can be used, frequently either Ba Zheng San or Long Dan Xie Gan wan are prescribed.

Frequently, bacterial is not the culprit. “Honeymoon” UTI frequently do not involve bacterial infection.  These problems could come from emotional triggered issues  as well as physiological. Because urinary track runs next to vagina, any gynecological issues would be affecting the urinary function as well.

In treating these problems, either moving Qi and Blood or smooth Qi will do. Acupuncture sometimes coupled with electric stimulation –electro acupuncture and or moxibustion offers good results.

53 year old female had a painful urination one day after visiting OB/GYN for a routine Pap smear. She went to Urgent care and was diagnosed as having UTI which she had once about 6 months ago.  The urine did not appear to be different from normal but the doctor maintained that it’s positive for white cells. The doctor prescribed her 10 days antibiotics, which gave her dry mouth. Next day, it did seemed to have helped somewhat. Although the urine appeared to be clear light yellow, she was told that it still has some blood and white cells.  Next day, she felt uncomfortable tension in the low abdomen.

The patient had been married for 10 years to the current husband. The husband has no interest in sex so she had not been  intimate  for many years. She appeared to be on the upper range of normal weight.

The patient had many grown up children. The last pregnancy was 15 years ago, delivered with c-section which led to a 6 inches horizontal scar, 3-4 inches below umbilicus. The scar is slightly tender to pressure at the left corner.

Her tongue looks normal light red with thin white coating and the pulse is slightly tight. The patient complained about being tired.

Diagnosis and treatment:

Most likely the patient had no UTI.  As with many patients who went through surgery, her surgical scar did not heal well that caused Qi and Blood stagnation according to TCM, Her low abdomen from time to time gave her trouble because of that. Her current pain was mostly triggered by Gynecological examine.

Treatment: The goal of treatment is to reduce the QI and Blood stagnation at the scar; this is achieved by using electro acupuncture coupled with moxibustion on and around the scars, particularly on the tender area. After the treatment, the pressure disappeared.

9.4       Frequent urination

These days, we are bombarded with commercial about “over active “ bladder. Medically, it is the symptom of frequent urination.  The bladder is not overly active, just a frequent urge to pee. People don’t have “overactive” nose when they are having running nose. It is a neurological event. Anything that irritates the bladder nerve and some surrounding nerves would cause such issues. These include excessive water intake, pregnancy. Infection or inflammation of bladder, vagina and urinary tracks as well as  prostate disorders all can irritate bladder. Look at such list, it is easy to understand why female are more prone to such problem.

Finding out the true cause will help selection of effective treatment. Infection can be handled mostly through antibiotics or through herbs useage. Usage of antibiotics often resulted in yeast infection, therefore, many people would take cranberry juice concurrently or instead of antibiotics.  In TCM, the commonly used herbal formula for such problem is called Long Dan Xie Gan Wan which clears heat toxin through urination or Ba Zheng San which reduces infection in the UTI.

IF no infection is involved, acupuncture would be very effective in treating frequent urination issue because it can smooth the overactive nerve or excess Qi. Ren 2, Ren 3 are very popular choice. My favorite is St 28 with electro acupuncture. Better yet, St 28 and the empirical points on the inner thighs on the Liver meridian. The results are quite good. Most of such patients have lower Jiao Qi deficiency or blood stagnation. So, use warm therapy concurrently is highly desirable.

Many pregnant women have urinary issues such as urge to pee frequently or difficult to urinate. Using St 28 would be difficult, but along the Lv channel in the upper inner thigh can be used.

Prostate problem easily cause frequent urination. Prostate related frequent urination which is not caused by infection( relative rare event for men) is quite unique. It is due to restrict urine flow, which can be resulted from incomplete empty of bladder each peeing. So the urge to go becomes a constant occurrence. 

9.5       Prostate issues

9.5.1    Prostate enlargement-frequent urination and dysuria

The true issue about prostate enlargement is the difficulty in urination and the resulting urgency and frequency of urination. It bothers many elderly men.

It is kind of curious to think that as men ages, everything in the body shrinks, including the bones. One exception is that the many male’s prostate gland grow bigger. It appears even more strange to realize that the only function for prostate is to increase the liquid volume (not sperm) to assist ejaculation. What is the Mother Nature trying to tell us with “enlarged “prostate? Knowing that more and more percentage of sperm are not viable as men ages anyway. Bigger testicles may help. Bigger prostate would not make any difference. It does not make sense. Furthermore, when a man can’t pee, there is no desire nor ability for sex.

I believe the problem is not about the size of the prostate organ that is causing the problem.  Remember, the urethra runs through the center of the prostate gland. Enlargement of prostate has little effect on the urethra.  The true culprit is the stiffness of the musculature of the urethra and the gland.  As with any other muscles in the body, they become stiffer, less elastic with age. Therefore, it becomes more and more difficult to move urine through the duct. The discomfort that is associated with the pressure further stiffens the duct. Therefore, soften these tissues and the urination problem would go away. 

I have a 75 year old patient who has had frequent pain and discomfort at the low abdominal area,  with elevated PSA. His sleep was disturbed because of the need to visit bathroom.  Using the points prescription in above section for frequent urination plus heat lamp over low abdominal area weekly. Everything began to work fine. Slept through the night. Currently, if he skipped the treatment for more than two weeks, the problem would start to creep back.