Philip A.M. Rogers MRCVS

AP and the Urogenital / Adrenal System


Caione_P; Nappo S; Capozza N; Minni B; Ferro F (1994) Primary enuresis in children. Which treatment today? Minerva-Pediatr Oct 46(10):437-443. Dept di Chirurgia, Ospedale Pediatrico Bambino Gesu-Roma. Enuresis is a problem that paediatric urologists are often called to treat. It affects 15-30% of school-age children. In 85% of affected children bedwetting is monosymptomatic, not accompanied by other voiding disorders or daytime incontinence. Treatment of choice is still highly controversial, as the physiopathology is not yet fully understood and the pathogenesis is multifactorial: genetic and psychological factors, sleep disorders, urinary reservoir abnormalities, urine production disorders can all play a part. Behavioural treatments (psychotherapy, bladder training and biofeedback, electric alarm) and pharmacological therapy (tricyclic antidepressants, anticholinergics, DDAVP) have been used with variable results. In our experience (54 enuretic children) DDAVP proved to be effective in reducing the number of wet nights/wk in 79% of cases. AP, which we have been using for many years, also gave good results in 55% of treated patients. Long term success of DDAVP and AP was respectively 50 and 40%. We discuss the probable pathophysiology and present our own results and those reported in the literature. An accurate diagnostic selection of patients and a better understanding of physiopathology are the basis of effective treatment of enuresis.

Capozza_N; Creti C; De Gennaro M; Minni B; Caione P (1991) The treatment of nocturnal enuresis: A comparative study between desmopressin and AP used alone or in combination. Minerva Pediatrica Sep 43(9):577-582. In Italian. From Mar to Sep 1989, 40 children suffering from primary nocturnal enuresis, aged between 5 and 14 yr, were included in a study to assess the comparative therapeutical efficacy of DDAVP and AP. Children were assigned to 4 treatment groups (n=10/group): A=DDAVP; B=AP; C=DDAVP + AP and; D=Placebo (untreated control). The trial design included 3 periods: observation (2 wk), treatment (8 wk) and follow-up (4 wk). 19 children completed the study. When used separately, DDAVP and AP were highly effective treatments, as expressed by % of dry nights. However, the combined treatment of DDAVP + AP was best as regards the % of dry nights at the end of treatment and as regards the stability of results after the end of the study. Detailed analysis of correlations between type of treatment and urinary osmolarity is given.

Chang_PL; Wu CJ; Huang MH (1993) Long-term outcome of AP in women with frequency, urgency and dysuria. AJCM 21(3-4):231-236. Dept of Surgery, Chang Gung Memorial Hospital, Chang Gung Med Coll, Taipei, Taiwan, ROC. Urodynamic measurements including cystometry, anal sphincter electromyography, urethral pressure profilometry and uroflowmetry were carried out on 21 female patients before AP and at 1 and 3 yr during follow-up. Follow-up ranged from 60-72 (mean 66) mo. Differences in urodynamic measurements before AP and at the 1- or 3- yr follow-up were not significant. During follow-up, AP at SP06 was performed in patients who had recurrence of symptoms of frequency, urgency and dysuria. Mean number of AP treatments was 4.8 (range 2-8). 8 patients decreased their AP treatments after 30 mo, but this was not statistically significant. The long-term outcome of AP at SP06 for women with frequency, urgency and dysuria was positive, but that the effect was temporary and repeated AP was necessary to maintain beneficial effects.

Chen_Z; Chen L (1991) The treatment of enuresis with scalp AP. JTCM Mar 11(1):29-30. Linhai City Hospital of TCM, Zhejiang Province, PRC.

Geirsson_G; Wang YH; Lindström S; Fall M (1993) Traditional AP and electrostimulation of the posterior tibial nerve: A trial in chronic interstitial cystitis. Scand J Urol Nephrol 27(1):67-70. Dept of Surgery, Sahlgrenska sjukhuset, Univ of Göteborg, Sweden. A prospective study on the symptomatic effect of traditional Chinese AP treatment and transcutaneous nerve stimulation (TENS) of the tibial nerve in patients with interstitial cystitis is presented. There was no difference in voiding frequency, mean voided volume, maximal voided volume or visual analogue scale symptom scores before or after treatment with either TENS or AP. Only one patient became improved both subjectively and objectively after AP for a short period of time. Even though the present material involves a small group of patients, it seems that the 2 methods, as applied in this study, have a very limited effect in patients with interstitial cystitis.

Huang_X (1991) Treatment of urinary retention with AP and moxibustion. JTCM Sep 11(3):187-188. People's Hospital of Ji'an District, Jiangxi Province, PRC.

Kachan_AT; Trubin MIu; Skoromets AA; Shmushkevich AI (1993) AP reflexotherapy of neurogenic bladder dysfunction in children with enuresis. Zh Nevropatol Psikhiatr Im S S Korsakova 93(5):40-42. Urodynamics of the lower urinary tract were evaluated in 25 children treated for enuresis (16 with unstable bladder). 12 children with detrusor hyperreflexia comprised the largest group. AP helped 17/25 cases. A follow-up showed its detrusor-stabilizing effects in patients with neurogenic bladder dysfunctions. The success of AP depended on the patients' mental and emotional status, concurrent abnormalities and accuracy in observing the practitioner's recommendations. The mechanisms of therapeutic effects of AP are discussed.

Kitakoji_H; Terasaki T; Honjo H; Odahara Y; Ukimura O; Kojima M; Watanabe H (1995) Effect of AP on the overactive bladder. Nippon Hinyokika Gakkai Zasshi Oct 86(10):1514-1519. Dept of Channels and AP points, Mejii Coll of Oriental Med, Japan. We examined the effect of AP for the overactive bladder. 11 patients (9 males, 2 females; aged 51-82 (mean 71 yr)) with the overactive bladder were treated with AP. 9 had urge-incontinence and 2 had urgency. Before AP, all patients had uninhibited contraction. A disposable needle (0.3 mm in diameter, 60 mm in length) was inserted to a depth of 50-60 mm into BL33 bilaterally and was rotated manually for 10 min. Treatment was given 4-12 (mean 7) times. Urge incontinence was controlled completely in 5/9 and partially in 2/9 patients. In 2 patients who complained urgency, complete response was obtained after treatment. Uninhibited contraction disappeared in 6 patients after treatment. AP increased maximum bladder capacity and bladder compliance significantly. AP at BL33 controlled overactive bladder effectively.

Minni_B; Capozza N; Creti G; De Gennaro M; Caione P; Bischko J (1990) BL instability and enuresis treated by AP and electro-therapeutics: early urodynamic observations. AETRIJ 15(1):19-25. Dept of Paediatric Urol, Ospedale Bambino Ges×, Vatican Hospital Rome, Italy. The authors report the results of a study on 20 children suffering from a particular type of enuresis, associated with bladder instability, characterized by uninhibited contractions of the detrusor muscle. The children selected showed symptoms of enuresis, frequency, urinary urgency and a positive urodynamic test. This test was performed on 11 patients before and after AP. In 16/20 children, the authors observed a net increase in the intensity and frequency of uninhibited bladder contractions 30 min after AP. At 60 min the contractions decreased and at 24 h they had practically disappeared. Clinically, enuresis was eliminated gradually in 11 cases and other 7 cases improved. AP suppressed uninhibited bladder contractions, even though the therapeutic mechanism has yet to be clarified.

Morrison_JF; Sato A; Sato Y; Suzuki A (1995) Long-lasting facilitation and depression of periurethral skeletal muscle after AP-like stimulation in anaesthetized rats. Neurosci Res Sep 23(2):159-169. Dept of Physiology, Univ of Leeds, UK. The effects of AP-like stimulation on the tone of the partially filled bladder and on the periurethral electromyogram (EMG) were examined in urethane-anaesthetized rats. AP-like stimuli usually were applied to the skin and underlying muscles (or other structures), either separately or together, for a period of 1 min; the effects were studied in spinal cord intact and in spinalized animals. Maps have been constructed showing the effects of AP-like stimulation at different sites on the body surface and of similar stimulation applied to individual muscles, the urethra and the testis. AP-like stimuli applied to the skin and underlying structures in the rostral half of the body and the hindpaw, testis or urethra, usually excited periurethral EMG activity. Depression of EMG activity was seen mainly during stimulation of structures close to the urethra, but not opposed to it. When AP-like stimuli were applied only to structures beneath the skin, depression of EMG activity usually occurred. AP-like stimulation of the bulbocavernosus, which partly overlies the proximal urethra produced depression of EMG activity in 50% of trials, but the incidence of similar effects from the more distant pubococcygeus, or the dorsal or ventral sacrococcygeal muscles was circa 90-100%. AP-like stimulation for 1 min produced either excitation or depression of periurethral EMG activity lasting circa 5 or 6 min, depending on the site of insertion and rotation of the AP needles. Excitation of short duration (<3 min) was consistently observed from areas of the body distant to the bladder, e.g. the nose, forepaw, forelimb, chest, abdominal wall and hindpaw. Longer lasting excitation of EMG activity was often seen from the penile urethra, perineal area and hindlimb. Depression of EMG activity with a duration of >3 min was consistently seen from the muscles at the base of the tail (sacrococcygeus) and perineal area (pubococcygeus and bulbocavernosus). The bladder was partially filled in these experiments, so that micturition contractions were never seen; AP-like stimulation of the perineal area induced some increase in bladder tone in 40% of trials. In spinalized animals, the pattern of activity induced by AP-like stimulation was similar to that seen in spinal cord intact animals and the durations of the effects were not significantly different in these two groups. The distribution of sites from which AP-like stimuli can influence the activity of the lower urinary tract is discussed.

Roje-Starcevic_M (1990) The treatment of nocturnal enuresis by AP. Neurologija 39(3):179-184. Univ Hospital, Zagreb. The etiology of enuresis is not fully known. It is assumed that it may be a psychosomatic disorder caused by psychological and urological predispositions, combined with unfavourable environmental factors. 37 patients of both sexes (mean age 8 yr), who had not improved after psychotherapy, were treated by AP. Statistical decrease of enuresis was evident (2.9) during the 6-mo observation period after AP treatment. AP offers a new possibility to treat patients with enuresis.

Sato_A2; Sato Y; Suzuki A (1992) Mechanism of reflex inhibition of micturition contractions of the urinary bladder elicited by AP-like stimulation in anaesthetized rats. Neurosci Res Nov 15(3):189-198. Dept of ANS, Tokyo Metropolitan Inst of Gerontology, Japan. The effects of AP-like stimulation of various segmental areas on the rhythmic micturition contractions (RMCs) of the urinary bladder were examined in anaesthetized rats. The urinary bladder was cannulated via the urethra and expanded by infusing saline until the urinary bladder produced micturition contractions rhythmically as a consequence of the rhythmic burst discharges of the vesical pelvic efferent nerves. An AP needle, having a diameter of either 160 or 340 um, was inserted to a depth of circa 4-5 mm into the skin and underlying muscles at various segmental areas, rostrally from the face then caudally to the hindlimb. Once being inserted, the needle was twisted left and right with the fingers circa once/s for 60 s.
1. AP-like stimulation of the perineal area inhibited both the RMCs and the rhythmic burst discharges of vesical pelvic efferent nerves without any significant changes in the hypogastric efferent nerve activity. By contrast, stimulation applied to the face, neck, forelimb, chest, abdomen, back, and hindlimb areas was ineffective.
2. After surgically separating the perineal skin from the underlying muscles with the main cutaneous nerve branches intact, stimulation of either the perineal skin or the perineal muscles inhibited the RMCs. Stimulation of the perineal muscles produced a stronger inhibition of the RMCs than that of the perineal skin.
3. Stimulation of the perineal area increased afferent nerve activity, either recorded from the pudendal nerve branches innervating the perineal skin or underlying muscles, or recorded from the pelvic nerve branches innervating the perineal muscles.
4. ิhe stimulation-induced inhibition of the RMCs was abolished after surgically severing both pudendal and pelvic nerve branches that innervated the perineal skin and underlying muscles.
5. The inhibition of the RMCs after AP-like stimulation of the perineal area is a reflex response characterized by segmental organization. The afferent arcs of the reflex are both pelvic and pudendal nerve branches innervating the perineal skin and underlying muscles, while the efferent arcs are pelvic nerve branches innervating the urinary bladder.