Urinary Problems, Overactive Bladder Syndromes and Stress Incontinence

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Urinary symptoms have always been a prevalent problem for women, a cause of embarrassment, and often a health problem that women have decided to just live with. Many men too have problems of urgency, frequency, urinary difficulty, and nocturia, often associated with prostate growth (hypertrophy), but also with other causes that are poorly understood (see the section on male urinary difficulties below). Standard medicine has failed to properly address this widespread health issue, and only in recent years has the complex pathology of syndromes of overactive bladder, and other urinary difficulties, been realistically addressed with comprehensive study. Complementary and Integrative Medicine (CIM/TCM) presents an array of treatments that can be invaluable to correct these difficult to treat multifactorial problems holistically, finally engaging the patient proactively in a step-by-step protocol to fix the problem, not just decrease a symptom temporarily. It is universally agreed that loss of urinary control in an individual without a serious neurological disorder is still not understood, but that an array of health factors may contribute, including aging, hormonal imbalance and deficiency, poor tissue health around the bladder, myofascial pelvic floor dysfunction, pressure from chronic inflammation and swelling, constipation, gastrointestinal disorders, or obesity, and problems with both the autonomic and central nervous system. These health problems in relatively healthy patient must be individually assessed, and a persistent and holistic individualized therapeutic protocol initiated, which is proactive and includes therapeutic activities performed by the patient, both to strengthen and pelvic muscles, and to learn how to consciously control what is normally involuntary. 

In 2002, doctors at the University of Pennsylvania published research on the incidence and prevalence of overactive bladder in the medical journal Current Urological Reports (Dec 2002;3(6):434-8), and stated: "This symptom syndrome (Overactive Bladder / OAB), is highly prevalent worldwide and significantly impairs the quality of life of those who suffer from it. Accurate epidemiological incidence and prevalence studies of OAB have been hampered in the past by, among other issues, a generalized lack of agreement regarding definition of the disorder, and consequently, accurate case finding. This obstacle resulted in considerably wide estimates in the reported incidence and prevalence of OAB in the literature." A 2009 study of prevalence of OAB by Sahlgrenska Academy at Gothenburg University in Sweden found that an estimated 20 percent of women over age 20 were experiencing, or had experienced, overactive bladder syndromes, with remission rate of only 43 percent (Eur Urol. 2009 Apr;55(4):783-91). A 2000 study of prevalence of OAB found that various scientific studies presented a range of prevalence from 3 to 43 percent of the female population. These authors (Milsom I, Stewart W, Thuroff J) reported that urinary urgency and frequency were more commonly reported to physicians than urge incontinence, and were particularly prevalent in women aged 35 to 55. Neurogenic Bladder is a syndrome that may involve an underactive bladder with a loss of control of emptying properly, causing pressure on the urinary sphincter and both urinary leakage, discomfort and sudden urgency. In Neurogenic Bladder the detrusor muscles may become underactive or overactive, depending on the site of nerve injury or dysfunction, though, and obviously this may be part of an Overactive Bladder syndrome. As with many difficult pathologies, a one-size-fits-all diagnostic description is not realistic, and hence a broader set of treatment protocols must be utilized in an holistic and individualized manner. Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) provides adjunct treatment that fulfills these needs.

Almost all women with urinary symptoms of frequency, urgency, and incontinence wait until the problems are severe and chronic to report them to their medical doctors. Almost all of these women are given a diagnosis of "Overactive Bladder", yet this is not a diagnosis, but merely a symptom syndrome. This means that their symptoms of urinary frequency, urgency and/or urge incontinence, are part of a syndrome of health dysfunction that is often slowly developing. These patients are usually frustrated because they want to know what the actual diagnosis is. They already know that they have these symptoms. Standard medicine almost always fails to educate the patient to the researched facts concerning the underlying factors and health problems that need to be addressed to stop this syndrome of symptoms. Research in recent years has revealed that most of these patients have a neurogenic bladder syndrome related to the muscles of the pelvic floor, as well as chronic low-grade microbial infections, and a disorder related to neurohormonal regulation of growth factors, inflammatory mediators, and tissue maintenance. Often, these factors are grouped into a pelvic pain syndrome (see the article entitled Piriformis Syndrome, Pelvic Pain Syndromes, and other complex low back and body pain on this website). Often, women with a pelvic floor myofascial syndrome that is contributing to urinary problems do not complain of significant pain, or may complain of referred pain that they do not clearly associate with the pelvic floor muscles and fascia. Both men and women with urinary dysfunction related to pelvic floor syndromes that do not experience direct pelvic pain of significance dismiss this as a cause of their urinary symptom syndrome, but this is often a mistake.

In recent years that subject of urinary dysfunction has finally become a prevalent issue, but still we see mainly a confusing array of different diagnoses, but no clear explanation for the causes and corrections. Urinary incontinence is now acknowledged as a problem affecting a significant percentage of women age 40-64, and is characterized as either a stress incontinence, occurring during exertion or sneezing, and attributed to weak muscles of the pelvic floor, or as an urge incontinence, with pelvic floor muscles contracted and putting pressure on the bladder at inconvenient times. The former is treated with kegel exercises and use of a pad in the underwear, and the latter is associated with diabetes and obesity, and often women are told there is nothing they can do about this problem other than losing weight and treating diabetes. Experts now agree that most women with episodes of incontinence experience a mix of these two syndromes, called a complex syndrome. What is overlooked is that a number of factors contribute to these problems and understanding of these factors in an individualized manner is needed to design a proper treatment protocol. Obviously, most women need to improve the function of pelvic floor muscles, and if needed clear chronic inflammatory conditions or other health problems, and short courses of acupuncture stimulation, deep soft tissue physiotherapy, and herbal and nutrient medicine provide a valuable array of treatments to address a host of issues. Neuromuscular reeducation in this protocol provides guidance for the patient to exert better control over the muscles and bladder, and neurogenic concerns can be addressed with this protocol as well. In 2013, a meta-review of studies of acupuncture stimulation alone to treat urinary incontinence, by experts at the Kyung Hee University School of Medicine, in Seoul, South Korea, showed that a number of small randomized controlled human clinical trials supported this therapy, but the small size and quality of the trials showed that larger and better designed trials were needed. Of course, with a symptom that is so varied and complex, this will be hard to achieve, and in clinical practice, combining therapies into a more thorough and holistic protocol is often needed, not just a simplified short course of acupuncture stimulation. 

Lack of a clear diagnostic explanation and the complexity of the multifactorial underlying causes in most cases of chronic urinary dysfunction make treatment a problem, both for the patients and their physicians. Patients and physicians need to understand the importance of a holistic integrated medical approach to treatment of these problems. Standard medicine still simply treats with a single pharmaceutical, usually an anticholinergic muscarinic inhibitor, which merely, and temporarily in most cases, decreases the symptoms by blocking the integral nerve excitation. The body adapts to these medications by growing more muscarinic receptors, though, and the essential health problems are not addressed. Side effects become an issue over time. In January of 2014, experts in this field from the University of Montreal, in Canada, and the Swiss Federal Institute of Technology, Zurich, Switzerland, Dr. Chantal Dumoulin and Dr. Eling D. deBruin, along with Valerie Elliott, a professor of physiology and rehabilitation at the University of Montreal, released the findings of a study that demonstrated significant improvements in the symptoms of overactive bladder and stress incontinence with the application of dance combined with virtual gaming that was designed to improve the health of the pelvic floor muscles. Such research proves that improvement in pelvic floor myofascial function is integral to the treatment protocol, and should be at the heart of a comprehensive holistic treatment strategy for these problems. Complementary Medicine, especially in the form of acupuncture combined with herbal and nutrient medicine, and even physiotherapies of myofascial release and neuromuscular reeducation, provide a comprehensive treatment strategy that can be integrated into this patient centered proactive protocol to achieve better results, and to finally cure this syndrome of urinary dysfunctions.

The biggest obstacle to actually resolving a syndrome of Overactive Bladder and Pelvic Syndromes is the realization that a more comprehensive step-by-step treatment protocol is needed, and that there may not be a quick and easy fix. Short courses of acupuncture and physiotherapy, with myofascial release and neuromuscular retraining, a series of herbal formulas that address various underlying problems, simple hormonal restoration with the hormone Vitamin D and bioidentical hormonal creams, improved therapeutic activities and weight loss all may be combined into a comprehensive package of care whose only side effect is better overall health. This article, and the research cited and linked at the end can convince you of the need for this strategy, which needs to be individualized.

Standard medicine has opted for a surgical implantation of transvaginal mesh support in many cases of OAB that have proceeded to stress urinary incontinence, as well as the chronic use of muscarinic antagonists. U.S. FDA warnings in 2008 and 2011 stressed that serious and common complications of these mesh support devices are reported, and that patients were not properly warned of the risks and permanent nature of the device, or the fact that future surgeries are often needed to correct the complications that eventually occur. The serious adverse events associated include urinary incontinence, pelvic pain, pain during intercourse, erosion of tissues in the bladder and vagina, chronic infection, perforation of the blood vessels with systemic chronic infection, bowel incontinence, and of course increased risks for chronic inflammatory disease, cancer etc. The quality of life is often affected negatively with this treatment, although the immediate effects may seem positive in correction of the stress incontinency. The FDA urged surgeons and physicians to discuss non-surgical options for this problem. These warnings are cited with links below in additional information. In clinical trials of standard muscarinic peripheral nerve antagonists, such as Sanctura (Trospium chloride), Ditropan (Oxybutynin), Enablex (Darifenacin), Detrol (Tolterodine), and Propiverine, side effects of dry mouth, constipation, dry eyes, and gastrointestinal dysfunction resulting in abdominal discomfort, flatulence, and nausea were experienced by 3-4 times the number of patients as those taking a placebo pill. Warnings of potential kidney and liver impairment, as well as anticholinergic effects on the central nervous system resulting in somnolence, dizziness and confusion have also been noted. While muscarinic antagonists have been generally regarded as safe and effective in decreasing urinary incontinence, a 2011 meta-review of studies noted that real-life compliance in long-term use is low, with discontinuation rates of up to 50 percent at 6 months due to adverse effects (Scandinavian Journal of Urology and Nephrology 2010; vol.44(3): 138-146). One area of non-surgical treatment involves the integration of the treatments in Complementary Medicine described in this article, and early intervention may help avoid dependence on pharmacological therapy, as well provide benefits to decrease the adverse side effects if these drugs are needed.

Since 2002, a number of strategies have been implemented in standard medicine to address proper treatment of overactive bladder syndromes (OAB), but without much success. Treatment strategies in standard medicine have depended upon allopathic pharmaceutical remedies, and surgery, targeting just a particular factor in a syndrome involving multiple underlying health problems that act synergistically to perpetuate the symptoms of urinary urgency, frequency, and urge incontinence. The primary problem is the failure to address the whole picture, or adopt a comprehensive holistic protocol. Simply blocking the function of the peripheral nervous system does not restore health, or address the underlying health problems. A comprehensive and holistic protocol, and early treatment intervention, is the key to success and improved quality of life.

A number of health problems frequently are associated with OAB, or are comorbid, including falls and fractures, urinary tract infections, skin infections, sleep disturbances, ADHD, anxiety, and depression. These comorbid conditions have elucidated the complex physiological pathology of most syndromes of overactive bladder, with both a central nervous and hormonal component, and a local array of tissue problems, not confined to the urinary bladder alone. Since the muscles surrounding the bladder are what initiates contraction of the organ, here is where the focus of the problem usually occurs, unless an acute bladder infection is evident. Central nervous system controls are another area of focus, as the control of bladder function and urination is both voluntary and involuntary, and involves an array of neural pathways in the brain. The main control area of the urination (micturation) lies in the pons of the reticular formation, in the brainstem, just below the hypothalamus, but control may be modulated by the basal ganglia and frontal lobes. What this means is that alternations in any of these areas, central or local, may result in dysfunction. The brain, the thoracolumbar spine, the nerves under the sacrum, the pelvic floor muscles, and stimulation of inflammatory cytokines and prostaglandins, adrenal hormones, nerve growth factors, and neurohormonal and inflammatory tissue receptors may be involved in this syndrome of dysfunction. By understanding this array of problems, the patient and their team of physicians may provide an array of therapies to correct the potential health problems and restore healthy function.

Research in recent years has identified a considerable overlap in the pathologies of Overactive Bladder Syndrome, Interstitial Cystitis, Vulvodynia and Painful Bladder Syndromes, and Endometriosis. Many women are diagnosed with a combination of these health problems. This is because these pathologies have complex underlying health dysfunctions that are alike, and multifactorial. While focus in standard medicine is to choose just one of these confusing symptom presentations, and focus on just one allopathic strategy to relieve symptoms, these chronic health syndromes related to urinary problems demand a holistic approach to treatment and restoration of health. Often, the patient must educate oneself to the variety of underlying health problems and devise this holistic strategy. A knowledgeable Complementary Medicine physician, especially a practitioner of Traditional Chinese Medicine, such as a Licensed Acupuncturist and herbalist, may be the physician that can help achieve the clearing of a number of underlying or contributing health factors that would restore normal healthy homeostasis and an end to these symptoms. In addition, a growing body of research has demonstrated that bladder pain syndrome and interstitial cystitis is associated with an array of both physical and psychological disorders, including anxiety disorder, showing that this complex array of chronic dysfunctions is truly affecting not only the local tissues, but the central nervous system as well in many cases. Overactive bladder may be secondary to menopause, Parkinsonism, Multiple Sclerosis, Lumbosacral disc pathology, and other nerve disorders, and CIM/TCM may help with any of these health problems in the same course of therapy that addresses the symptoms of urinary urgency and incontinence.

Pathophysiology of the Syndromes of Overactive Bladder Dysfunction

Almost all research models for overactive bladder, which include interstitial cystitis (low-grade inflammation of the deep bladder wall), neuropathic disorders, urinary tract obstruction, bladder instability, and diabetes, share the common feature of nerve excitability of the pelvic floor muscles and nerves of the bladder and ureter. This neurological problem must be corrected by functional restoration, not just the chemical block of the peripheral nerve receptors. There are many and varied underlying factors that may affect the nervous system control of various tissues, the muscles that control the bladder function, the sphincters that control holding and voiding, and the autonomic function and balance of the sympathetic and parasympathetic systems. Since these neurogenic (arising from or generated by the nervous system) problems may occur in the brain, the spinal cord, the nerve roots from the tenth thoracic to the fourth sacral (T10-S4), the peripheral pathway through the pelvic girdle and between or through muscles, or even in the autonomic pathway from the brain through the peripheral plexus, to really treat this problem effectively we need an accurate diagnosis and description of the underlying factors that are affecting the nervous system. Instead, as with many difficult health problems, standard medicine seems to want to dumb down this problem, describing the urinary symptoms as over or under, with overactive bladder being one thing and underactive bladder being a Neurogenic Bladder. This is untrue and not really helpful, although it makes prescribing medication and surgical procedures easier to deal with.

The detrusor muscle is the pelvic floor muscle that contracts when urinating to propel urine. Normally, this pelvic floor muscle is relaxed, but in almost all cases of OAB this muscle remains contracted, usually limiting the amount of urine able to be comfortably held in the bladder. The detrusor muscle encompasses the bladder completely, and its fibers arise in the prostate of males, and in the pelvic floor musculature, near the pubis, in both sexes (musculi pubovesicales). Studies have demonstrated that blood flow to the detrusor muscle (ischemia) occurs with bladder decompensation (reduced ability to completely empty due to nerve degeneration) over time. The innervation of the detrusor muscle arises from the spine between the T10 (tenth thoracic vertebra) and L2 (second lumbar) for the sympathetic nerve responses, and the S2-4 (second to fourth sacral) for the parasympathetic. The parasympathetic control of the detrusor muscle is what stimulates the contraction, and also releases the smooth muscle of the urethra. The sympathetic control of the detrusor muscle relaxes the muscular contraction and stimulates the urethra. Dysfunction may arise from either of these autonomic systems. The sympathetic innervation acts via the hypogastric and adrenergic nerves, so that problems of adrenergic receptors, or problems associated with the hypogastric nerve (T10-L2 spinal roots) may affect the control of detrusor muscle relaxation. In addition, the filling and voiding of the bladder is controlled not by the detrusor muscle alone, but by a combined action of the pelvic floor muscles and the detrusor. This is why problems of the bladder and urination control are almost always associated with problems of the pelvic floor and detrusor, especially chronic myofascial pathologies.

Of course, nerve signals of the bladder itself may play a significant role in the abnormal reactions of urgency and frequency of urination, as well as deficient control of the muscles and sphincters. Neurogenic Bladder is a term that is non-specific, just like the term Overactive Bladder Syndrome, and encompasses any type of nervous system dysfunction, central or peripheral. Nerves in the bladder wall include stretch sensitive nerve endings, triggered by bladder fullness and filling. It is believed, though, that the sensation of urgency is triggered by local distortions in the bladder wall, caused by contractions of the surrounding muscles of the pelvic floor. Urgency may also result from a lowered threshold of signal necessary to trigger these bladder nerves, or spontaneous firing elicited from irritation, as with interstitial cystitis. Alterations of these nerves may be related to excess of nerve growth factor (NGF), in conjunction with inflammatory cytokines, which is seen in studies of certain types of OAB. Excess NGF is also found to contribute to excess or unstable detrusor muscle contraction. Chemical blockade of NGF results in lowered reflex activity, decreased growth factors in the spinal cord, and decreased growth of dorsal root ganglion (DRG) neurons of the vertebral area. It appears that both neural growth factor excess and myofascial syndromes of pelvic floor muscles are integral to the pathology, and that chronic low-grade inflammation with excesses of certain types of inflammatory cytokines are probably involved as well. Over time, poor health of the bladder wall may lead to degeneration of the peripheral nerves, and restoration of healthy bladder tissues may be needed to fully correct the problem. Integration of a number of treatment protocols is clearly needed.

Nerve growth factor (NGF) is a small protein that is important for growth, maintenance, and survival of nerve cells (neurons). Neurons are very long cells, and a single neuron may stretch from the spinal cord to the bladder of muscles of the pelvic floor. Nerve growth factors are critical for the survival and maintenance of the sympathetic and sensory nerves. The sympathetic innervation of the bladder occurs in the lower thoracic and upper lumbar nerve roots, and sensory nerves are, of course, very integral to the feedback control of the bladder. Nerve growth factor reduces neuronal degeneration in the brain, promotes myelin repair, and promotes peripheral nerve regeneration as well. Since NGF suppresses inflammation, it is found to be in excess in inflammatory diseases. Both excess and deficiency of NGF are found to be pathological causes or contributors to a variety of diseases, including anorexia, bulimia, depression, dementia and Alzheimer's, as well as atherosclerosis, obesity, diabetes type 2, metabolic syndrome, rheumatoid arthritis, active lupus, and multiple sclerosis. Since NGF serves as an antioxidant as well, excess NGF may also be related to chronic oxidant stress. In some gynecological diseases, elevated NGF is believed to result from excess prostaglandin type 2, a pro-inflammatory immune modulator. Excess of NGF is thought to contribute to perception of pain and increased inflammation in endometriosis. Circulating nerve growth factors are elevated in patients with allergic diseases. In some studies, nerve growth factor was 4 times higher in the spinal fluid of fibromyalgia patients than in normal subjects. Nerve growth factor may increase the production of substance P nerves, increasing the person's pain sensitivity. We see the many possible contributors to excess NGF in overactive bladder syndromes, especially with chronic inflammation, low-grade microbial infections, and myositis (chronic muscular inflammation).

Nerve growth factor (NGF) is produced by several cells, including mast cells of the immune system, and the name nerve growth factor many be a misnomer, underestimating the role of this regulatory protein in non-nerve tissues and cells. NGF is now considered an important molecule in the field of neurohormonal immunology, or the crosstalk of immune modulators, hormones and neurotransmitters on cell receptors. Many experts now believe that the immune, endocrine and nervous systems represent a single integrated defense system, and an imbalance of any of these three components reflects on regulation of the other two. An excess of NGF in overactive bladder syndromes may thus involve larger dysfunctions, and the implication is that a more holistic approach should be utilized to resolve this syndrome. Certainly, decreasing the activity of immune mast cells by clearing chronic infection and inflammation seems the most direct way to decrease excess levels of NGF.

The adrenal system also plays an important role in the regulation of urination. As the bladder fills, the sympathetic nervous system inhibits the detrusor muscle contractions by relaxing the muscle via beta adrenergic receptors, while the coordinated parasympathetic responses of bladder contraction are inhibited via the alpha adrenergic receptors. Chronic adrenal stress may upset the balance of alpha and beta adrenergic receptors. These receptors are activated by catecholamines such as adrenaline (norepinephrine) and dopamine, and an imbalance of expression of the receptors is seen in cardiac pathologies as well as overactive bladder syndromes.

Stress Urinary Incontinence is often part of the syndrome for women with bladder dysfunction as well, and this too is still poorly understood. In 2015, a study of the pathophysiology of stress urinary incontinency was conducted at the China Medical University School of Medicine, in Tachung, Taiwan, and may have been the first study that measured the problems of steroid hormone imbalance causing poor tissue maintenance of the bladder and urethra. This study found that relative deficiency of Estrogen receptor alpha resulted in poor expression of 5 regulatory proteins on the membrane involved in muscle contraction, development and regulation, as well as immune maintenance of tissues (PMID: 25577129). Estrogen receptor alpha (ER-alpha) is generally located on the outside of the cell membrane, while estrogen receptor beta on the inside, and a relative imbalance has been associated with breast cancer and other pathologies, mainly related to regulation of cell apoptosis, or programmed cell death, which if delayed leads to more mutations and a greater risk of cancer. The estrogen receptor alpha was discovered in 1958, and the estrogen receptor beta not till 1996. There are 3 types of estrogen, estradiol, estrone and the most abundant form estriol, and the estradiol binds to the alpha and beta receptors equally, while estrone selectively binds to the alpha receptor, and estriol to the beta receptors, as does genistein. Estrogen receptor alpha deficiency is linked to increased expression of androgens, and a relative excess of estrogens over progesterone could create an underexpression of the estrogen receptor alpha, especially if synthetic estradiol is taken, explaining the adverse health outcomes with use of synthetic unopposed estradiol sulphate in hormone replacement therapy. Such hormonal imbalance explains the enormous number of women with problems related to relative deficiencies of expression of the alpha receptor, as well as the hormonal imbalances seen in OAB syndromes, but medical journals are loathe to publish many of the studies exploring such holistic imbalance. Inherited genetic traits do not explain the many women with an imbalance of the estrogen receptor types alpha and beta, and it is obvious that these imbalances are acquired with aging and with related health problems. While hormonal balancing in CIM/TCM practice may not immediately reverse the tissue problems related to stress urinary incontinence and OAB, the long term benefits are evident, and including hormonal balancing in the holistic treatment protocol is essential.

In Complementary and Integrative Medicine, especially Traditional Chinese Medicine (CIM/TCM), the holistic treatment protocol would thus incorporate treatment of the lower spine and sacrum, myofascial release and neuromuscular reeducation of the pelvic floor muscles, and clearing of chronic inflammation and normalizing of immune responses in the pelvic and bladder tissues, as well as hormonal balancing when needed, utilizing bioidentical topical hormonal creams and herbal and nutrient medicines. Treatment could also address the central nervous system, aiding brain function and health, and perhaps decreasing learned responses in chronic cases. Restoration of the tissues of the bladder wall and nerve regeneration, increased blood flow, and a regaining of the control of bladder reflex is the goal in holistic medicine, not just a blocking of the peripheral nerve signals with muscarinic inhibitors. The pathology of overactive bladder syndromes are complex, and to actually restore homeostatic function, a persistent and more thorough treatment protocol is necessary. Short courses of frequent acupuncture and electroacupuncture stimulation with soft tissue physiotherapy (Tuina), with more persistent step-by-step treatment with herbal and nutrient medicine provide the holistic protocol that is needed to finally reverse this complex syndrome of dysfunction and degeneration, restoring related systems and regaining a broad measure of health. The only side effects to this course of treatment would be better overall health and quality of life. The time to response and resolution of OAB would vary considerably between individuals, depending on the complexity of the health problems underlying the syndrome and the length of time that it has been developing.

A Potential Role of Central Nervous System Neurodegeneration as the cause or major contributor to Overactive Bladder Disease and chronic urinary dysfunction

There is compelling evidence that neurodegenerative disorder in the brain could manifest primarily as Overactive Bladder Syndrome independent of dementias, such as Parkinson's and Alzheimer's diseases. White Matter Disease (WMD) and Small-vessel Disease of the brain are being investigated more seriously in 2013 to see if improved health of the brain could cure or improve many of these cases of Overactive Bladder Syndrome and urge incontinence. These problems are multifactorial, and difficult to treat, but CNS neurodegeneration may play a significant role, and prevention of CNS neurodegeneration, as well as restoration of brain health, could thus be of great benefit to counter this growing health problem. Studies of aging patients with White Matter Disease have shown that incidence of nocturia were seen in up to 90 percent of subjects, and urge incontinence was seen in about 40 percent. All of these health issues must be assessed individually to be addressed in a thorough and holistic manner, and a patient who brings understanding and a proactive approach to therapy is essential to success. Complex health problems require persistent solving of diagnostic puzzles and a step-by-step approach that addresses any and all health concerns.

White Matter Disease (WMD) has been described in the past as multiple cerebral infarctions (obstruction of the blood flow) of the white matter in the brain, and was considered a rare condition until recently, when improved technology with MRI and other means have allowed much greater analysis of structural brain health. Today, large studies reveal that the incidence of White Matter Disease of moderate intensity is about 10 percent of the population over age 55, and primarily involves hardening of the small blood vessels in the brain and gradual restriction of blood nutrients to the white matter, or myelinated support tissues (neuroglia). The usual symptom manifestations of WMD are grouped into vascular dementia, vascular parkinsonism, or vascular incontinence, with vascular incontinence most prevalent. Risk for WMD is heightened with atherosclerotic risk factors, such as dyslipidemia, diabetes, Metabolic Syndrome, hypertension, obesity, cigarette smoking, carotid plague, and various genetic and epigenetic morphisms. The frontal cortex is believed to be the area most involved in urinary dysfunction, as well as the prefrontal cortex, linked to the hypothalamic centers. Support for brain health is very important to decrease the incidence of WMD, and standard medicine has no real treatment to restore health to brain tissues.

The treatment considerations in Complementary and Integrative Medicine (CIM/TCM) in this regard include improved vascular health and maintenance, improved brain health and function, antioxidant therapies, and clearing of advanced glycation endproducts (AGEs). Anticholinesterase inhibitors in herbal medicine could potentially alleviate some of the unwanted hyperactivity of signals creating symptoms as well. While some of these therapies may not produce a dramatic and immediate relief of symptoms of urinary dysfunction, patient understanding and evaluation will show the value of such therapeutic protocols when applicable to the individual health and history. In recent years, the opportunity to study a broad section of the population with new imaging tools has revealed that White Matter Disease is responsible for about a fifth of all strokes worldwide, more than doubles the risk of stroke, and is a factor in up to 45 percent of all cases of Alzheimer's Disease, so this potential contributor to OAB is not uncommon. Since WMD is a gradually progressive disease, prevention and restorative treatment is important, and a sensible analysis would see the need to integrate Complementary Medicine to achieve these goals whenever WMD is suspected. Waiting until this health problem becomes severe is a ticket for failure.To see more information on the options in restorative medicine concerning brain health, go to the article on this website entitled Brain Health and Function. There is no magic herb or supplement that simply achieves this goal for everyone, but a persistent and habitual preventive medicine routine, incorporating Traditional Chinese Medicine (TCM) with short courses of acupuncture and sensible guided use of the many herbal and nutrient medicines, individually prescribed in a step-by-step process of preventive and restorative care by a professional CIM physician, or Licensed Acupuncturist and herbalist, can have an enormous impact on future health with aging. While this holistic approach may be daunting, the patient needs to understand that the only side effects from this treatment protocol in CIM/TCM is better overall health and vitality. Each patient may approach this broad array of treatment protocols with the time and intensity that they desire, or that fits individual needs and lifestyles.

Treatment Protocol for Overactive Bladder Syndromes and Proof of Effect

Acupuncture treatment alone, in standardized clinical trials conducted in the United States, has shown remarkable success in treatment of stress incontinence and Overactive Bladder Syndrome (see study links below). Due to the complexity of the pathology, though, a more thorough and individualized treatment protocol is recommended in the clinic. By addressing the array of potential underlying factors contributing to these problems in an individualized manner with an holistic approach, success in therapy is more assured for these difficult to treat problems of urinary dysfunction. Addressing myofascial problems of the pelvic floor with physiotherapy, clearing of low-grade interstitial inflammation and infection with herbal and nutrient medicine, and restoring biochemical and neurological function with nutrient therapy and acupuncture may all play important roles in the overall treatment protocol. For more difficult and chronic health problems patient understanding and persistence may be the key to success.

Standard medicine has provided very little treatment for these conditions of urinary dysfunction, with most women utilizing an anticholinergic muscarinic inhibitor of peripheral nerve signals to decrease nocturia and urgency, but few women prescribed the more effective treatments offered at specialized clinics, with electrical stimulation, biofeedback, and instruction in pelvic floor muscle exercise and neuromuscular reeducation. Prescription of the antidepressant Duloxetine (Cymbalta) has had negative evaluations, with the Cochrane Systematic Reviews and the Minnesota Evidence-based Practice Center of the U.S. government stating in 2005 and 2008 that Cymbalta performed no better than placebo. On the other hand, this same University of Minnesota systematic review stated that with stress incontinence, that weight loss would improve symptoms in perhaps over 90 percent of patients, and that pelvic floor neuromuscular reeducation plus bladder training relieved stress incontinence in 13 percent of patients studied in all competent RCTs. These same studies showed that the favored anticholinergic muscarinic inhibitor, Detrol (Tolterodine), alleviated symptoms of stress incontinence in only 18 percent of patients, and came with considerable adverse effects. A more holistic and thorough treatment strategy just may improve the health to the point where the problem is resolved without need for chronic treatment with drugs, or the herbal and nutrient, acupuncture, physiotherapy and home therapies. The goal in CIM/TCM is always to restore the patient and not create a dependence on therapy.

Studies in China demonstrate remarkable success with electroacupuncture in rehabilitation of the pelvic floor muscles and urinary dysfunction (see study links below), and acupuncture treatment affords the patient the treatment of the whole body, with point prescription addressing the brain, spine, immune system, autonomic nervous system, endocrine system, and the pelvic floor and bladder. More and more studies are proving the benefits of various herbal chemicals and nutrient medicines, and some of these studies are linked below in additional information. A safe and effective balancing of the cholinergeric system may be achieved with various herbs and nutrient medicines combined with acupuncture, perhaps using the acetylcholinesterase inhibiting Huperzine A and CDP choline. Few studies have been performed showing direct anticholinergic activity of herbal chemicals, but Guettarda speciosa from South America, and the Chinese herbal chemicals baicalin (Huang qin), anisodamine (San long zhi), and isovoacristine are proven as such, and the chemical curcumin is shown to have a close synergistic interaction with the cholinergic system (PMID: 26019804), as well as the herb Houttynia (Yu xing cao). Of course, traditional herbs to treat urinary leakage and incontinence, usually Yang tonics that both clear tissue inflammation and restore function, may be utilized. 

A few randomized controlled human clinical trials of common Chinese herbal formulas have shown mild benefit (Bai wei Di huang Wan), and a broad survey of herbal use worldwide to treat OAB, by the Weill Cornell Medical College in New York and the New York Presbyterian Hospital found that common medications used (muscarinic inhibitors) produced a high rate of undesirable side effects. Consequently, the U.S. CDC reported in 2002 that 74.6 percent of patients consequently used some form of Complementary and Integrative Medicine (CIM/TCM), while the World Health Organization estimated that 80 percent of the world population used some form of herbal medicine for these health problems (PMID: 24223020). It would perhaps be best to utilize a professional herbalist in the form of a Licensed Acupuncturist and herbalist, and assured professional products, rather than self prescribing and purchasing herbs off the shelf and the internet that are heavily advertised but come with little or no regulation and quality assurance in the United States. The usual problem with utilization of CIM/TCM care involves a lack of understanding of the full treatment protocol, and consequently a lack of persistence with therapy. Expectations that a quick fix should result from just treatment with needle stimulation performed once a week, or once every two weeks, are not realistic, and a more intensive and thorough individualized protocol is usually needed. Short courses of frequent acupuncture and electroacupuncture, with a persistent stress reduction and use of daily kegel exercises, and a step-by-step protocol with herbal and nutrient medicine will work, if given the chance. Patients can show that research studies provided in Additional Information to their Licensed Acupuncturist and herbalist to improve the protocol. 

The Actual Clinical Treatment Protocol with CIM/TCM Care

Knowledgeable physicians in Traditional Chinese Medicine (TCM) should utilize a more comprehensive, step-by-step protocol to fully address the needs for both symptom relief and healthy regeneration of pelvic floor and bladder tissues than acupuncture alone, as well as restoration of autonomic and central nervous system function. A short course of acupuncture and electroacupuncture may be combined with instruction in neuromuscular reeducation and pelvic floor myofascial release techniques, which involve contract and release techniques with breathing reflex, similar to Kegel exercises, which should also be performed at home. In addition, herbal formulas may be utilized to achieve a number of treatment goals, including clearing of chronic low-grade microbial infections and chronic inflammation, increased circulation, and tissue growth support. Pelvic floor myofascial syndromes may be associated with a broader syndrome of musculoskeletal repetitive and postural strain, such as piriformis syndrome, which may be cleared with more traditional myofascial release and correction of postural mechanics. In addition, comorbid conditions that may be contributing may be addressed in therapy, and healthy function of the brain and restoration of the autonomic nervous system achieved with a combination of acupuncture, electroacupuncture, herbal and nutrient medicine. To see some of the many studies now available confirming efficacy of herbal medicine in this regard, go to the section of this article entitled Additional Information.

Kegel Exercises, just one small part of the whole treatment protocol, are methods of neuromuscular reeducation that need patient understanding and focus. The pelvic flood muscles involved must be identified with conscious intent, usually achieved by feeling what muscles are involved in stopping the urination midstream. The exercises can be performed in any position, lying down, sitting on the toilet, or squatting are usually recommended. To start, identify the muscles with your conscious mind and tighten them for 5 seconds, then relax them fully for 5 seconds, repeating this 4-5 times. To improve the reflex, taking a deep breath in through the nose during the muscle contraction, and then a relaxing sigh outbreath from the mouth during muscle relaxation will greatly improve the retraining of your nervous system. Work up to contracting the muscles for at least 10 seconds, and relaxing them completely for 10 seconds. Both conscious contracting and relaxing are important to achieve real neuromuscular reeducation. The method of contraction often is described as imagining that you are picking up a marble and holding it with the vaginal muscles, as well as holding or stopping the urine stream. Various exercise devices, some of them with vibrators, are also available for the more adventurous, but not necessary for success. The key to success with neuromuscular reeducation exercises is mental focus on the muscle function.

In all cases, the knowledge and experience of the TCM physician is important when treating more complex pathologies, and articles such as this can be a resource for all TCM physicians. In difficult and chronic cases, persistence may be the key, as both neurodegeneration of the peripheral nerves in the bladder wall and autonomic dysfunction of the central nervous system may be involved. Giving up too easily in treatment, or expecting a quick cure to a difficult health problem is not sensible, but an individually tailored and persistent course of treatment, with just short repeated courses of acupuncture and the right individualized prescription of professional herbal and nutrient medicines, as well as help with pelvic floor myofascial syndromes when necessary, presents patients with an affordable and manageable treatment routine, whose only side effect is better overall health. When utilizing acupuncture and electroacupuncture for this problem, short courses of frequent stimulation are much more effective, and can be used with 2-3 treatments per week for a few weeks, with breaks between these courses of treatment that meet the needs of each patient as far as their schedule, coverage and monetary considerations. Studied and proven protocols include a 20 Hz stimulation at the sacral points UB31 and 34, and 100 Hz stimulation at the points affecting the hypogastric innervation, either at the T10 and L2 jaiji, or at UB21 and 23. In all cases, a more complete needling protocol is individualized to the patient needs and type, and a course of herbal and nutrient medicine, and physiotherapy may be included in the same treatment course.

Studies that emphasize the importance of weight loss and treatment of generalized anxiety and depressive disorders in treating overactive bladder syndromes and stress incontinence also emphasize the need for a holistic strategy. Obviously, in a pathology that becomes so complicated, simple solutions may not achieve enough success, and a more thorough strategy in the treatment protocol is recommended. Complementary Medicine, in the form of Traditional Chinese Medicine, or acupuncture, herbal and nutrient medicine, may provide such a holistic strategy. Improvements in overweight and obesity cases point out the need to achieve a better overall health and homeostasis to stop the array of metabolic dysfunctions contributing to these urinary syndromes. Treatment of anxiety and depressive disorders with Complementary Medicine also emphasizes restoration of neurohormonal health, improving the central control of urinary function, as well as the hormonal imbalances that may be contributing to autonomic dysfunction and adrenal stress, which are at the heart of the pathology in OAB syndromes. Stimulation and modulation of the nerve plexuses and autonomic nervous system, clearing of low-grade interstitial infections, clearing of excess oxidant stress, clearing of fibrin formations in the bladder wall, and pelvic myofascial release are all effective protocols that may be incorporated in the treatment model in TCM. The benefits from a conservative comprehensive therapy in TCM are many. Repeated short course of acupuncture and herbal medicine may be utilized with pelvic floor neuromuscular retraining, weight loss, treatment of mood disorders, and general improvement in overall health, especially hormonal health.

Male Urinary Dysfunction

Almost all men will have some problems in their life with a weaker urinary stream, starting urination, urinary dribbling, urgency, frequency, and nocturia, and a majority of aging men will experience prostate pathology, such as enlarged prostate (hypertrophy) and chronic prostatitis. Other common causes of male urinary dysfunction include side effects of drugs (decongestants, cold remedies, antidepressants, and anticholinergic drugs, sometimes prescribed for male incontinence), postoperative adverse effects, scar tissue, urinary tract infections, and nervous system disorders. Most men will not need direct therapies to treat these issues, but for those with more severe and persistent problems of urinary dysfunction, a comprehensive treatment strategy is important. Understanding the problem rather than ignoring it is the key issue, and integrating Complementary Medicine may help immensely to achieve an individualized step-by-step restorative protocol.

Urinary dysfunction and stress incontinence in men occurs due to a variety of coordinated factors, as in female syndromes. These include pelvic floor muscle pathology, overactive bladder syndromes, and nerve degeneration due to chronic inflammation. A comprehensive treatment protocol for men is similar to that described above for women. Comorbid conditions include stroke, diabetes, Parkinson's Disease, and Multiple Sclerosis. Benign Prostate Hypertrophy (BPH) may exhibit both symptoms of urinary difficulty and hesitation, as well as urgency, leaking, dribbling, frequent urination, urge incontinence, and nocturia, but these symptoms may be caused by an array of factors other than BPH, and diagnostic assessment is often unclear. These conditions may be resolved with a comprehensive individualized treatment protocol in Complementary Medicine, and treatment should be started early in the course of symptoms if possible. Of course, a thorough diagnostic workup with a Urologist is important, and the results of tests and reports should be brought to the Licensed Acupuncturist to create the best and most efficient treatment protocol.

In 2006, the Feinberg School of Medicine at Northwestern University in Chicago, Illinois, a prestigious medical school, reviewed all clinical data on prostatitis in the United States and determined that 90-95 percent of cases of chronic prostatitis actually involve Pelvic Pain Syndrome (PMID: 16409145). This was then classified as non-bacterial prostatitis (see the article on this website entitled Piriformis Syndrome, Pelvic Pain Syndromes, and other complex low back and body pain). The diagnosis and treatment with standard medicine for this condition is unclear and offers little chance of success, often treating with such problematic pharmaceuticals as alpha receptor blockers (alpha adrenergic receptor antagonists). These drugs are prescribed for a variety of conditions, including hypertension of autonomic origin, autoimmune diseases, autonomic vascular diseases such as Renaud's phenomenon, and some anxiety disorders. A number of herbs contain chemicals that are alpha receptor blockers as well. For example, once popular herb, Yohimbine, is a selective alpha receptor blocker. Standard medical guidelines suggest that these drugs should only be used for benign prostatic hyperplasia with moderate to severe symptoms, though, and the side effects tend to create noncompliance in a large percentage of patients. In other words, standard medicine has little to offer the patient with Pelvic Pain Syndrome causing prostate problems. On the other hand, Complementary Medicine and the knowledgeable Licensed Acupuncturist has an array of therapeutic tools to treat this problem thoroughly, systematically and holistically. Often, symptoms of urinary dysfunction are caused by the combination of chronic prostatitis and pelvic pain syndrome.

All men with urinary symptoms should insist on a thorough diagnostic evaluation, ruling out more serious concerns, such as prostate or colorectal cancers, and then proceeding to a serious investigation of benign prostate hypertrophy, chronic prostatitis, and the associated pelvic pain syndromes. Even if pelvic or low back pain is not a serious symptom, myofascial pathology of the pelvic musculature may be a root cause of the problem. The pelvic floor muscles involve 8-12 muscles that wrap around the internal organs of the pelvis, controlling functions of the bladder and sexual organs, as well as the anus and rectum. These muscles are innervated at the problematic lumbosacral area, where many men and women develop degeneration and chronic neural pathologies. Impingement or irritation of the lumbosacral nerve roots may impact firing and function of the pelvic muscles. Physical examination of pelvic trigger points is problematic, as they are inside the pelvic bone, and direct trigger point myofascial release is thus also problematic. Medical doctors could examine myofascial trigger points during prostate exams if they were trained in this area, but they seldom receive such training. Treatments thus involve isometric relaxation techniques, neuromuscular reeducation, correction of postural mechanics, electrical stimulation via acupuncture, and treatment of contributing problems, such as the accessible myofascial pathologies of the gluteal, piriformis, tensor fascia latae, iliopsoas, and quadratus lumborus muscles. Restoration of healthy tissues of the lumbosacral spine may also be very important in treatment. Self massage is recommended, using a stripping, or longitudinal, massage of the fibers between the anus and the scrotum, and trying to relax the area by initiating a bearing down (as in a bowel movement) while relaxing the area with mental focus. Such massage has been utilized successfully to clear prostate inflammation and hypertrophy for decades. A Licensed Acupuncturist that is trained in phyisotherapies (Tui na) could provide such comprehensive treatment protocol and instruction, as well as herbal and nutrient therapies.

The experts on myofascial pathologies include the renowned Dr. Janet Travell and Dr. David Simons, who wrote the first extensive clinical texts on myofascial syndromes and trigger point analysis. These experts state that pelvic floor trigger points are potentially activated by falls, auto accidents, surgery in the pelvic region, and repetitive postural strain, often from prolonged sitting at work with a slumped posture, or on a hard chair. They state that nutritional inadequacies may also be a significant contributing factor, focusing on Vitamins B1 (benfotiamine or thiamin), B6 (P5P), B12, folic acid (5MTHF), Vitamin C, calcium, iron, and potassium. Benfotiamine delivers an essential thiamin metabolite to aid cellular energy via ADP, and reduce advanced glycation endproduct accumulation that results in muscle collagens stiffening and reducing function. P5P is a pyroxidine phosphate deficient in most myofascial pathologies, and crucial to many enzymatic activities. B12 and 5MTHF folate aid both nerve firing and function, as well as detoxification via the glutathione metabolism. Vitamin C is integral to tissue repair and maintenance. Potassium and calcium metabolism is integral to muscle firing, and a calcium and magnesium aspartate is the correct supplement for this use. Of course, chronic inflammatory pathologies, such as prostatitis or inflammatory bowel syndromes, may also contribute to pelvic floor irritation. Chronic hemmorrhoids may also contribute to these pelvic floor muscular pathologies. By addressing this array of potential contributors to pelvic floor muscle pathologies, and taking a comprehensive and holistic approach to treatment, these various health problems and urinary symptoms are more likely to be resolved. Simply taking an alpha adrenergic antagonist, or muscarinic inhibitor, the standard therapy, provides only a partial reduction in symptoms. Integrating Complementary Medicine helps to resolve the problems.

Information Resources / Additional Information and Links to Scientific Studies

  1. The National Institutes of Health Library of Medicine provides this explanation of the pathology of Overactive Bladder (OAB) syndromes, prepared in 2002 by Dr. William D. Speers of the University of Virginia. This points out that the central problems causing decreased bladder volume, urgency, frequency and stress incontinence lie with the pelvic floor muscles, especially the detrusor muscle that controls bladder function, and the nerves of these muscles. Peripheral nerve dysfunctions may be caused by a host of factors working together, both local and central, and these factors may all need to be addressed in diagnosis and treatment: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1476015/
  2. Injury to the nerves, tissues and bladder itself is often the cause of more serious cases of overactive bladder syndromes. Here, an article in the journal Nature describes how treatment for cervical cancer, with surgery, radiation or chemotherapy, often results in overactive bladder and neurogenic bladder syndromes, often not with immediate onset. A set of clear anatomical drawings help clarify the specific nerves and tissues involved, giving a clearer picture of the needs in restorative medicine: http://www.nature.com/nrurol/journal/v11/n2/full/nrurol.2013.323.html?message-global=remove
  3. The National Institutes of Health provides further discussion of the historical mistakes in understanding Stress Urinary Incontinence pathophysiology in this 2004 review, where pelvic floor muscles are integral, and serotonin is identified as a key neurotransmitter. A degeneration of the peripheral nerves in the tissues of the urethra and bladder are also noted as a significant component: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472864/
  4. The Rand Corporation, a nonprofit institution that creates health policy through research and analysis, focusing on evidence-based medicine, reported in 2007 that a significant overlapping of overactive bladder syndrome, interstitial cystitis, painful bladder syndrome, vulvodynia, and endometriosis is evident from a review of extensive medical research: http://www.ncbi.nlm.nih.gov/pubmed/17222607
  5. A 2002 study by experts at the University Medical Centre Utrecht, The Netherlands, found that prior history of a hysterectomy increased the chance of acquiring a syndrome of urinary incontinence by more than 30 percent. The procedure of hysterectomy was seen in about 25 percent of women over the age of 60, and excessive use of the hysterectomy to correct gynecological problems in the United States led to a very high history of hysterectomy, unfortunately. These experts doubted that hysterectomy directly caused urinary incontinence syndromes, but contributed to an array of health factors that cause these syndromes. It is obvious that a healthier approach in gynecology should be adopted whenever possible, restoring health and function with holistic medicine: http://onlinelibrary.wiley.com...http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.2002.01332.x/pdf
  6. Dr. Sonal Grover M.D., and research associates at Cornell University in New York, published a study of the role of inflammation in bladder dysfunction and interstitial cystitis in the medical journal Advanced Urology in 2011. Research has identified a host of chronic low-grade bacterial infections, medication side effects, autoimmune diseases, environmental chemicals, radiation, and inflammatory diseases associated with this type of inflammation. Nonpharmacological treatments commonly used in these syndromes include myofascial release, soft tissue massage therapies, pelvic floor rehabilitation training, dietary changes, and stress and anxiety reduction. A multimodal therapy protocol is recommended for syndromes where chronic inflammation has created injury to bladder mucosa, fibrosis, and neurogenic dysfunction: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3126088/
  7. In 2010, experts at the Karolinska Institute in Stockholm, Sweden noted that with rising incidence of antibiotic resistance we need to look for a more holistic and alternative solution to urinary tract infections and interstitial cystitis. They found that that the hormone Vitamin D, cholecalciferol, stimulates an endogenous antimicrobial chemical Cathelicidin in response to infection, and that when pathological bacteria growth increased, more Vitamin D and cathelicidin were produced. Many women are deficient in this hormone and it could be a valuable part of a more holistic protocol to decrease infections, even low-grade chronic infections, that contribute to overactive bladder and interstitial cystitis: http://www.ncbi.nlm.nih.gov/pubmed/21179490
  8. In 2015, these experts at the Karolinska Institute in Stockholm, Sweden noted that continuing research in prevention and treatment or urinary tract infections found that the hormones Vitamin D and estrogen were both useful in stimulating better endogenous anitmicrobial peptides. The use of liquid 5000 IU cholecalciferol as well as bioidentical estriol cream, and hormonal balancing, could play a significant role in the holistic treatment protocol for OAB. Estrogens are also integral to tissue maintenance, and the balance of estrogen, progesterone and other hormones are always important in the endocrine system, not just levels of specific steroid hormones: http://www.ncbi.nlm.nih.gov/pubmed/26828523
  9. The prestigious Johns Hopkins University School of Medicine wrote in 2002 that Chronic Pelvic Pain Syndromes were not being addressed diagnostically or in treatment for a majority of patients due to the lack of objective tests and lack of knowledge of the clinical characteristics by health providers. The treatment recommendations, though, are limited to symptomatic pain management in standard medicine: http://www.ncbi.nlm.nih.gov/pubmed/12474033
  10. The European Association of Urologists, with experts at 8 University Medical Schools, provided this 2015 updated guidelines for diagnosis of male urinary symptoms deemed non-neurological, in order to curb the increasing amount of unnecessary and invasive testing, and to provide sensible guidelines to target the key factors of many that may underlie this health problem. Patients too can pay attention to what tests are necessary for an individual condition, helping to avoid the stress of this sometimes complicated problem: http://www.ncbi.nlm.nih.gov/pubmed/25613154
  11. A 2008 randomized controlled study of urinary symptoms associated with benign prostate hypertrophy, by experts at the Kurume University School of Medicine, in Kurume, Japan, found that an extract of Reishi mushroom (Ganoderma lucidum or Ling zhi) provided significant improvement in symptom scores. Such herbal medicines can be combined to address an individualized case, and improved outcomes with addition of a short course of acupuncture can be achieved: http://www.ncbi.nlm.nih.gov/pubmed/18097503
  12. A 2015 meta-review of herbal medicine as an adjunct therapy for Benign Prostate Hypertrophy and related urinary symptoms, by experts at the Sapienza University of Rome Medical School, in Italy, shows that evidence is strong for phytomedicinals, with Serenoa repens (Saw palmetto), Pygeum africanum, and Urtica doica (Stinging nettle), which study has shown work via mechanisms of 5-alpha reductase inhibition (regulation of hormonal conversion in local tissues), alpha-andronergic inhibition, and DHT and estrogen receptor inhibition, with human RCTs showing efficacy for improving urinary function, and only very mild adverse effects in a few patients. Other herbs studied include Secale cereale (rye), Roystonea regia (palm) and Epilobium (evening primrose). The CAMUS trial of 2009 showed that dosage of saw palmetto was important, and that while long-term efficacy with use of low dose saw palmetto alone was not apparent, that the study design to disprove efficacy was manipulated in past study. Finally, standard medicine is admitting to such RCT design manipulation to discourage effective herbal care as an adjunct to standard therapy integrated into a holistic protocol: http://www.ncbi.nlm.nih.gov/pubmed/25703069
  13. A 2011 study of herbal chemicals compared to pharmaceuticals that show significant effects of 5-alpha reductase inhibition to resolve benign prostate hypertrophy and prevent prostate cancer, by the Institute of Computational Biology, in Bangalore, India, showed that the Chinese herbal chemicals Berberine and Monocaffeyltartaric acid show the highest affinity to hormonal receptor binding and should be used for chemopreventive integrated medicine. Berberine is found in the Chinese herb Coptis Chinensis (Huang lian), and has long been standardized in China, and is also found in other Chinese herbs. Monocaffeyltartaric acid is a flavonoid chemical in wild medicinal dandelion root, or Pu gong ying, which also contains luteolin and chrysoeriol, which are beneficial: http://www.ncbi.nlm.nih.gov/pubmed/22050680
  14. A multicenter study published in 2014 noted the success of a program of dance and virtual gaming technology designed to improve pelvic floor myofascial health and function to decrease the symptoms of overactive bladder and stress incontinency. This study, by experts at the University of Montreal and the Swiss Federal Institute of Technology, clearly shows the importance of restoring the pelvic floor myofascial health to correct these problems: http://www.sciencedaily.com/releases/2014/01/140114102457.htm
  15. A 2015 randomized controlled study at Trakya University Medical School, in Edime, Turkey, found that pelvic flood exercises performed during pregnancy and after birthing significantly improved long-term outcomes with prevention or resolution of overactive bladder syndrome and other urinary symptoms. These exercises are often quite easy to learn, beginning with Kegel exercises, where a contract and release method similar to holding one's urine is used, and proceeding to such exercises as deep squats with a mental focus on the contract and release of pelvic floor muscles: http://www.ncbi.nlm.nih.gov/pubmed/25648223
  16. Underlying health problems should be addressed to facilitate better tissue healing and pain reduction. This National Institute of Health study outlines how deficient estrogen syndromes increases pain perception and decreases tissue healing in women: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1808228/
  17. A meta-review of research concerning comorbid conditions seen with bladder pain syndrome and interstitial cystitis, by Taipei Medical University Hospital, showed that there is an association with anxiety disorder, chronic pelvic pain syndrome, irritable bowel syndrome, fibromyalgia and overactive bladder in epidemiological studies: http://www.ncbi.nlm.nih.gov/pubmed/24038135
  18. A meta-review of research concerning the potential role of the brain in overactive bladder syndrome was published in the medical journal International Journal of Urology in 2013, noting that these urinary problems often occur in types of stroke, and investigation into White Matter Disease, or focal neurodegeneration, and small-vessel vascular disease in the brain provides plausible explanations for a considerable number of patients with overactive bladder syndrome, especially with aging: http://onlinelibrary.wiley.com/doi/10.1111/iju.12288/pdf
  19. A 2014 statement by the British Psychological Society noted that White Matter Disease (WMD), a slowly progressive neurodegenerative disease usually involving hardening of the small blood vessels in the brain, is a contributing factor is up to 45 percent of dementias, such as Alzheimer's diseases and parkinsonism, and is responsible for about a fifth of all strokes in the world, more than doubling the risk of stroke. The high association between Overactive Bladder Syndrome and WMD emphasizes the need to address brain and vascular health in this disease: http://www.sciencedaily.com/releases/2014/02/140224204806.htm
  20. A 2005 study at the Oregon Health and Science University, Department of Neurology, found that the herb Gotu kola (Centella asiatica), in alcohol tincture, may be useful for accelerating repair of damaged neurons: http://www.ncbi.nlm.nih.gov/pubmed/16105244
  21. A 2011 study at China Medical University in Taichung, Taiwan, found that an active component of many Chinese herbs, quercetin, has nerve growth-promoting effects that may speed the recovery of peripheral nerve degeneration, which is seen in overactive bladder syndromes. Quercetin is found in the Chinese herbs Luo bu ma, Sang ji sheng, Fan shi liu, Di er cao (St. John's wort), Man shan hong, and others: http://www.ncbi.nlm.nih.gov/pubmed/22183523
  22. A 2004 study at the University of Naples School of Medicine, in Naples, Italy, showed that an extract of the herb St. John's Wort, or Hypericum perforatum, inhibits hyperexcitation of the autonomic nervous system related to urinary contractility and urge incontinence: http://www.ncbi.nlm.nih.gov/pubmed/15245964
  23. A 2012 study at the Shanghai Research Institute of Acupuncture and Meridian, in China, found that electroacupuncture may improve the function of the pelvic floor muscles and improve symptoms of female stress incontinence: http://www.ncbi.nlm.nih.gov/pubmed/22417077
  24. A 2009 pilot study of acupuncture to treat stress incontinence in women at the University of Pittsburgh School of Nursing found that a 4 week course of standardized treatment resulted in a 67 percent reduction in accidents, while the sham acupuncture produced a 16 percent reduction, providing proof of efficacy: http://www.ncbi.nlm.nih.gov/pubmed/19920749
  25. A 2005 randomized, placebo-controlled trial of acupuncture to treat overactive bladder, at the Oregon Health and Science University Department of Obstetrics and Gynaecology, in Portland, Oregon, concluded that a 4 week standardized acupuncture treatment provided significant improvements in bladder capacity, urgency, frequency, and quality of life scores: http://www.ncbi.nlm.nih.gov/pubmed/15994629
  26. A 2013 randomized, placebo-controlled trial of acupuncture and moxibustion to treat interstitial cystitis that was chronic, or refractory, at the University of Miyazaki, Japan, found that this treatment was effective for 38 percent of patients, and that weekly treatments for 3 months provided sustained benefits for up to 48 months, and were able to discontinue hydrodistention therapy. Both moxa on needles and electroacupuncture was used on the points in the sacral foramen, UB32, 33, and 34: http://www.ncbi.nlm.nih.gov/pubmed/23719132
  27. A 2014 randomized, placebo-controlled trial of acupuncture for the treatment of overactive bladder syndrome, by experts at the Clinic of Urology in Ankara, Turkey, found that, compared to standard pharmacological therapy and no treatment, acupuncture was proven effective, and may be considered another viable treatment option for this difficult health problem. The study showed that neuron growth factor (NGF) was increased in the acupuncture group, and of 28 patients in the acupuncture group, only 8 did not achieve significant symptomatic improvement in the follow-up to the 4 week, and 8 treatment course of acupuncture: http://www.ncbi.nlm.nih.gov/pubmed/25033919
  28. A randomized controlled human clinical trial of electroacupuncture integrated into care for patients with urinary dysfunction after a spinal cord injury, at the Jiaxing University and Zhejiang University Schools of Medicine, in China, showed that integrating electrocupuncture with a short course once per day at just the Ba liao (8 sacral foramen) points, first obtaining de qi, or signs of stimulation, and then connecting the points UB31 and 34 bilaterally to electrical stimulation with a frequency of 20 Hz for 20 minutes, significantly improved urinary function when added to the standard catheterization required. Such study clearly demonstrates that acupuncture and electroacupuncture works: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694541/
  29. A 2016 meta-analysis of all published studies of acupuncture integrated into the treatment protocol for prostatitis and pelvic pain syndrome, at the National Yang-Ming University School of Medicine, in Taipei, Taiwan, found that this protocol is supported by evidence and actually performs better than standard treatment protocol: http://www.ncbi.nlm.nih.gov/pubmed/26741647
  30. A 2008 study at the Kurume University School of Medicine, in Japan, showed that the herbal medicine Ganoderma lucidum (Reishi mushroom or Ling zhi) as an alcohol tincture and provided a mild improvement in the International Prostate Symptom Score: http://www.ncbi.nlm.nih.gov/pubmed/18097503
  31. A 2008 study of stress urgency and incontinence and herbal therapy, at the Shiga University of Medical Science, in Otsu, Japan, found that the anti-cholinergic herb ephedra (Ma huang) supported urethral contraction to control stress incontinence with low dosage in a Chinese herbal formula (Kakkon-to). Other Chinese herbs have been shown to exhibit anti-muscarinic activity (Coptis, Goldenseal, Berberis, Mahonia, Zanthoxylum), and anticholinergic activity (Coptis, Berberis, horsechestnut, Artemesia, Black haw, Sang bai pi, and Jie geng), revealing just some of the potential for future studies of herbal chemistry to treat this condition. In addition, the Chinese herbal chemicals huperzine and vinco alkaloids are proven to provide significant anticholinergic effects, similar in studies to pharmacological anticholinergics: http:/www.ncbi.nlm.nih.gov/pubmed?term=urinary stress incontinence herb
  32. A 2008 study of the effects of ginsenosides in the Chinese herb ginseng, at the Fuzhou General Hospital Department of Obstetrics and Gynaecology, in Fuzhou, China, found that these herbal chemicals increased the growth rate of paraurethral cells in patients suffering from urinary stress incontinence, indicating a potential in the restoration of degenerated tissues in overactive bladder syndromes and urinary stress incontinence syndromes: http://www.ncbi.nlm.nih.gov/pubmed/19087567
  33. A 2002 study at the National Cheng Kung University College of Medicine, in Tainan City, Taiwan, showed that the common Chinese herbal formula Bai Wei di Huang Wan increased muscarinic receptor function and expression of M2 receptors in the bladder muscles of laboratory animals with induced diabetic neuropathy and loss of bladder control. The formula also lowered plasma glucose, helping to maintain the glucose metabolism in a healthy manner while also helping to treat OAB in diabetes: http://www.ncbi.nlm.nih.gov/pubmed/12213625
  34. A 2002 study at the University of Sheffield School of Medicine, in Sheffield, United Kingdom, explains how the poor expression of muscarinic receptor type 2 (M2) results in bladder dysfunction: http://www.ncbi.nlm.nih.gov/pubmed/12452898
  35. A 2013 study at the Korea University College of Medicine, Seoul, South Korea, found that CoQ10 (coenzyme Q10) significantly increased bladder capacity in chronic overactive bladder syndrome, increasing the contractile responses of the detrusor muscle around the bladder, in a study of laboratory animals with chronic bladder dysfunction induced by atherosclerotic ischemia. The detrusor muscle in pathologic subjects showed a high malondialdehyde accumulation, indicating that oxidant stress, or reactive oxygen species, and lipid peroxidation, contributed heavily to this dysfunction, as well as fibrotic changes of the bladder walls and degneration. CoQ10 is a potent ubiquitous cellular antioxidant and detoxifier that may help clear these problems: http://www.ncbi.nlm.nih.gov/pubmed/23306086
  36. A 2012 review of the common treatment for urinary stress incontinence in the elderly, insertion of a suburethral sling insertion or tension-free vaginal tape-obturator, by the Departments of Obstretrics and Gynaecology at Medway NHS Foundation in the UK, found that complications with these procedures occur and are poorly recognised and diagnosed, with groin pain occurring that may require surgical removal of retropubic slings and recurrent incontinence with further tissue and nerve damage. First trying more conservative treatment that includes acupuncture, electrical stimulation, myofascial release, neuromuscular reeducation, herbal and nutrient medicine may be the best choice for patients and their physicians: http://www.ncbi.nlm.nih.gov/pubmed/22752013
  37. A 2012 study by the Mercy Hospital for Women, in Heidelberg, Australia, followed 358 consecutive women receiving a midurethral sling surgical correction of stress incontinence, and found that after 50 months, nearly 28 percent experienced de novo urgency, and nearly 14 percent urgency and stress incontinence: http://www.ncbi.nlm.nih.gov/pubmed/22722646
  38. A 2008 FDA warning, or public health notification, of serious complications from the now common treatment for urinary stress incontinence, surgical transvaginal mesh support, reported that thousands of reports from manufacturers of serious complications and adverse events had been received by the U.S. Food and Drug Administration, and implied that physicians had not properly informed the patients of the risks of tissue erosion, infection, tissue damage, pain, pain during intercourse, tissue scarring, and narrowing of the vaginal wall, many of which need additional surgeries to correct, and that the surgical mesh is a permanent device: http://www.fda.gov/medicaldevices/safety/alertsandnotices/publichealthnotifications/ucm061976.htm
  39. A 2011 update of the 2008 FDA warnings of serious complications of transvaginal surgical mesh support to correct urinary urge incontinency stressed that the serious complications and adverse events were not a rare occurrence, with many thousands of reports of vaginal erosion, pain, infection, bleeding, pain during intercourse, organ perforation, and urinary incontinence caused by this common treatment of urninary incontincenc. The FDA stressed that surgeons and physicians should make sure that the patient is aware of non-surgical options for treatment: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm262435.htm
  40. A 2012 study of stress incontinence prophylactic surgery for women receiving laparoscopic sacrocolpopexy (for prolapse or post-hysterectomy care) recommended against this now common surgical protocol - University of Toronto: http://www.ncbi.nlm.nih.gov/pubmed/22742484
  41. A 2000 study by the University of Pittsburgh School of Medicine, U.S.A., found that anticholinergic and antimuscarinic agents used to treat overactive bladder syndrome are problematic with side effects, and that herbal capsaicin (vanilloid) therapy was proven in clinical studies to be effective - the initial irritating effects of capsaicin for many patients was problematic for a subset of patients, although quick adaptation to capsaicin occurs normally - products utilizing capsaicin were created to minimize the initial adverse reactions, such as Resinifiratoxin (RSX). Today, a number of topical and oral capsaicin products are available: http://www.ncbi.nlm.nih.gov/pubmed/10735579