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Detrusor Sphincter Dyssynergia: A Case Study in Integrated Care and Management Anthony G Bailes AOMA Graduate School of Integrative Medicine

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Detrusor Sphincter Dyssynergia (DSD) Bladder Sphincter Dyssynergia Voiding dysfunction symptoms related to both the storage and emptying phases of the micturition cycle Storage dysfunction Emptying dysfunction

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DSD Detrusor muscle The detrusor muscle remains relaxed to allow the bladder to store urine Contracts during urination to release urine External sphincter muscle of urethra Efferent muscle Receives innervation form the pudendal nerve

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Voiding Dysfunction Storage Dysfunction Frequency Urgency Urge incontinence Dysuria Pain Emptying Dysfunction Hesitancy Straining Difficulty initiating Diminished stream Incomplete voiding Urinary retention

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Patient Information Demographic Information 60 years old Female Caucasian Social History Lives alone Unmarried No tobacco No ETOH No recreational drugs Limited social interaction No spiritual/religious affiliation

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Medications/Supplements Insulin Aspirin prn Magnesium glycinate 300mg QD Multivitamins Allergies Sulfas Floroquinolone (Cipro) Dietary Habits Gluten free Low sugar Includes animal proteins Exercise Walking to tolerance Physical therapy

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Medical Hx Contracted Hep C in 1982 form surgical blood transfusion Was not diagnosed until 2008 Treated with Copegus (ribavirin) and Alinia (nitazoxanide) Treated for 1 yr w/resolution of sustained virologic response Diagnosed Type I Diabetes in 2009 Thought to be a result of undiagnosed/untreated Hep C Managed w/insulin

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Surgical Hx 1982: T8 to S1 fusion to correct scoliosis February 2014: T8 to S1 fusion to correct long standing complications from 1982 surgery December 2013, presented in ER with complaints of severe pain Internal hemorrhaging, spontaneous cerebrospinal fluid leak, and atrial fibrillation Resulted in 10 hospitalization During corrective surgery, the pudendal and hypogastric afferent nerves around the bladder were damaged, resulting in DSD

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May 5, 2014 Initial office visit Vitals within normal ranges CC: urinary difficulty with dribbling, urgency, and retention Urgency up to 20 times daily, difficulty initiating urination, interrupted urine flow, and inability to void completely Recurrent urinary tract infections UTIs Self-cath three times daily Secondary complaint: Depression Tegretol 200mg BID and Prozac 20 mg QD Self-discontinued Prozac and Tegretol after 1 month, citing the inability to function Tertiary Complaint: R sided sciatic pattern pain rating 8/10 Confirmed with seated straight leg raise

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DDX: Qi blockage in Bladder Channel and Organ TX: Unblock channel and organ Qi Points: SP 6, 9; Ren 2, 3, 4; ST 36; Yintang, Kidney Gate; BL 23, 27, 28, 39, 52; (R) GB 30, 42; (R) BL 60, 61, 63; (Bilateral) Ashi around PSIS (4 needles) and Ashi lateral hip (1 needle); All points with strong manual manipulation. Herbs: (patent unspecified) Shao Yao Gan Cao Tang; 2 pills TID

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June 3, 2014 June 13, 2014 June 16, 2014 August 5, 2014 Follow Up Visits No significant changes other than reduction in sciatic pain to manageable levels. Initial tx resulted in full bladder evacuation for 1 day, but returned to old pattern. During this period, patient had multiple UTIs and was dx w/Kidney infection. Antibiotics resolved infection and patient began prophylactic Hiprex (methenamine hippurate) to manage UTIs No remarkable changes to DSD

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August 12, 2014 DSD symptoms still persisting Outside research found study on pudendal nerve stimulation for DSD and voiding disorders Percutaneous Tibial Nerve Stimulation (PTNS) protocol 12 treatments and reevaluate

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Points: BL 14, 15, 18, 23, 28, 40, 65; PTNS Protocol Herbs: (patents) Plum Flower Ba Zheng San 8 pills TID; Plum Flower Jia Wei Xiao Yao San 8 pills TID Notes: Patient was instructed to take herbs concurrently with antibiotics. **PTNS Protocol: Electro acupuncture at SP 5 to SP 6 bilaterally. Stimulated with continuous wave at 20 Hz for 30 minutes (Agr, E. (2013). Percutaneous tibial nerve stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: A systematic review. BMC Urology, 13, 61-61.)

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PTNS Protocol Agr, E. (2013). Percutaneous tibial nerve stimulation (PTNS) efficacy in the treatment of lower urinary tract dysfunctions: A systematic review. BMC Urology, 13, 61-61. 2013 Italy PTNS was found to be effective in 37-100% of patients with overactive bladder syndrome (OAB) 41-100% of patients with non-obstructive urinary retention (NOUR) 100% of patients with chronic pelvic pain/painful bladder syndrome (CPP/PBS), dysfunctional voiding and patients with neurogenic pathologies No major complications have been reported

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PTNS Protocol Stimulating the tibial nerve by means of a 34 gauge needle electrode 45 cm cephalad to the medial malleolus Continuous wave at frequency of 20 Hz Stimulation sessions last for 30 minutes Once a week for 1012 weeks Mechanism of action still remains unclear

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August 14, 2014 Patient reports more complete evacuation after last treatment. Easier to initiate urination. Patient reports increased energy, improved bowel movements, and increased appetite. Patient reports numbness in vaginal wall.

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Points: BL 14, 18, 23, 24, 25, 26, 40, 65; Four Gates; KD 7; Jiaji L2 through S1; PTNS Protocol Herbs: (patents) Plum Flower Ba Zheng San 8 pills 5X a day; Plum Flower Zhi Bai Di Huang Wan 8 pills TID

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August 19, 2014 Patient reports she has been evacuating bladder 100%, verified by urologist with imaging. Urologist dismissed patient and has taken her off self-catheterization. No UTI for first time in 7 months. Numbness in R lower leg, R anterior upper leg, pelvic floor, and vaginal wall. Although mood has improved, patient is still worried that results are only temporary and is feeling emotional.

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Points: BL 13, 23, 24, 25, 26, 40; GB 41; Four Gates; Jiaji L4 through S4; (R) PTNS Protocol Herbs: Continue current Plum Flower Ba Zheng San 8 pills TID; Plum Flower Jia Wei Xiao Yao San 8 pills TID

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August 21, 2014 dx with Interstitial Cystitis August 28, 2014 September 1, 2014 IC controlled with dietary changes September 4, 2014 September 9, 2014 IC resolved, but new dx of UTI. Antibiotics prescribed September 15, 2014 September 23, 2014 IC resolved September 29, 2014 October 7, 2014 UTI cleared

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October 21, 2014 No UTIs since early September Bladder function maintaining normal with complete evacuation Emotions stabilized Patient wishes to consider support for increasing libido and addressing mild vaginal dryness No other complaints Patient will schedule follow up treatments as needed

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Thank You ???s