MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

Some of us got used to the idea that acupuncture might be effective for pain. But could it work for infections? Unlikely! Well, let’s not rely on gut feelings; let’s have a fair and critical look at the evidence.

This systematic review assessed the evidence for acupuncture for uncomplicated recurrent urinary tract infections (rUTI) women. Five randomised controlled trials (RCTs) evaluating the effects of acupuncture and related therapies for prophylaxis or treatment of uncomplicated rUTI in women were included. The methodological quality of the studies and the strength of the evidence were low to moderate. The chance of achieving a composite cure with acupuncture therapies was greater than that with antibiotics (three studies, 170 participants, RR 1.92, 95% CI 1.31‐2.81, I2 = 38%). The risk of UTI recurrence was lower with acupuncture than with no treatment (two studies, 135 participants, RR 0.39, 95% CI 0.26–0.58, I2 = 0%) and sham acupuncture (one study, 53 participants, RR 0.45, 95% CI 0.22–0.92).

The authors concluded that acupuncture showed promising results compared to no treatment and sham acupuncture in reducing recurrence, based on low to moderate certainty evidence. Low certainty evidence found acupuncture increased the chance of achieving a composite cure compared to antibiotics. Findings from this review should be interpreted with caution, taking into consideration the biases identified and small sample size of the included trials. Included studies suggest acupuncture has a good safety profile for women with UTI, and may be considered as a therapeutic option in the treatment and prevention of rUTI in women, particularly those who are unresponsive to, or intolerant of, antibiotics. Rigorously designed research is needed to inform clinical decisionmaking about the use of acupuncture for women with UTIs.

The authors of this review are affiliated to the Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangdong Provincial Academy of Chinese Medical Sciences and The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China and the China-Australia International Research Centre for Chinese Medicine, School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia. The review was funded by the China-Australia International Research Centre for Chinese Medicine (CAIRCCM) (International Cooperation Project, Grant Number 2012DFA31760), and the National Natural Science Foundation of China (NSFC) (Grant Number 81873261). In view of these facts, it is strange, I think, that the authors declared no conflicts of interest.

The 5 primary studies included in this review are the following:

    1. Alraek T, Soedal LI, Fagerheim SU, Digranes A, Baerheim A. Acupuncture treatment in the
      prevention of uncomplicated recurrent lower urinary tract infections in adult women. American journal of
      public health. 2002;92(10):1609-11.
    2. Aune A, Alraek T, LiHua H, Baerheim A. Acupuncture in the prophylaxis of recurrent lower urinary
      tract infection in adult women. Scandinavian journal of primary health care. 1998;16(1):37-9.
    3. Hong JY, Li F, Liang XQ, Hou Z. [Efficacy observation on female chronic pyelonephritis treated with
      abdominal cluster-needling therapy]. Zhongguo zhen jiu = Chinese acupuncture & moxibustion.
      2013;33(4):303-5.
    4. Yu SM, Guo DD. Moxibustion combined with antibiotics was used to treat 30 cases of chronic
      urinary tract infection in adult women. Shandong Journal of Traditional Chinese Medicine.
      2010;29(09):621-2.
    5. Liu JL, Luo Q, Liu XH, Lin L. Observation on the clinical effect of external treatment of strong renal
      moxibustion on recurrent urinary tract infection. China Modern Doctor. 2018;56(29):116-8.

As always, it is worth checking these studies for reliability.

In the trial by Alraek et al patients were randomised patients to receive either acupuncture or no treatment. Is anyone surprised that the former group fared better than the latter? (I am not!)

The trial by Aune et al is the only study that attempted to control for placebo effects by using a sham control group. This is what they used as a sham treatment: Sham acupuncture was given using six needles superficially inserted in the calves, thighs or abdomen outside known acupuncture points or meridians. Needles were not manipulated in the sham group. Sham controls have the purpose of rendering patients unaware whether they receive the real or the sham treatment. The method used here cannot achieve this aim; patients were easily able to determine that they were in the control group.

The last three trials are all not Medline-listed studies authored by Chinese investigators published in inaccessible journals in Chinese. We know that such studies invariably report positive outcomes which are often fabricated and thus have a reliability close to zero. But even if we ignore these facts for a moment, from what I see in the results table of the review, these studies are invalid. All three are equivalence trials of acupuncture versus antibiotics; with a sample size of merely around 30, they must be woefully underpowered and thus unable to generate a reliable result.

The authors of this review claim that the risk of bias of trials was generally high or unclear. This is an understatement to put it mildly. In fact, the quality of the studies was mostly dismal.

In view of all this, I take the liberty to re-formulate the conclusions drawn by the review authors as follows:

Due to the lack of reliable RCTs, the effectiveness of acupuncture as a treatment or prevention of rUTIs remains unproven. Due to the implausibility of the therapy, its effectiveness seems highly unlikely.

PS

The BJOG should never have published such a deeply misleading paper.

16 Responses to Acupuncture for recurrent urinary tract infections? No, I don’t think so!

  • The authors conclude with: “Tweetable abstract This review found that acupuncture may improve treatment and prevent recurrence of urinary tract infection in women.”

    This is frankly delusional. As per usual acupuncture afficionados manage to turn an absence of evidence into imagined proof that their fictional therapy somehow works even in the most implausible situations. It is preposterous to suggest treating women with UTIs by sticking them with needles while allowing infections to run rampant. What happens when some of these poor women develop complications from their untreated infections? What if some of them are pregnant? Isn’t it unethical to treat a bacterial UTI with an imaginary remedy of no proven value?

    AFAIK TCM doesn’t subscribe to the germ theory – does that absolve one from having to treat UTIs rationally?

  • It seems obvious that acupuncture (and other reflexive therapies, of which acupuncture is one) would be unlikely to affect the outcome of an established infection. Studies using subjects in that condition are likely to resemble these.

    However, in the early stage of an infection the story might be different. I’ll try to make this short.

    Biology is essentially the result of interaction of charged chemical species. Which is, of course, built upon the dffects of quantum interactions which I am unable to address. However, staying out of that realm, consider the fact that charged moities create the outcomes of health and disease. It is at that level that reflexive therapies can have an effect.

    The proven electrical milieu in which tissues and organisms grow has been demonstrated. It’s quite possible that infections begin with a disturbance of that milieu with results that allow “invading” infective entities to gain a foothold. If infection begins in that manner, it’s possible that reflexive therapies which themselves create alterations of the electrical characteristics of target areas might possibly offset the effects of the would-be “invaders”.

    I realize this might seem too far outside the box for some, but anyone in that group should read Beissner, et al: “Fogotten Features of Head Zones and Their Relation to Diagnostically Relevant Acupuncture Points”. Perhaps the size of the box can be expanded: they discuss published findings of Sir Henry Head.
    If his observations are accepted as valid, questions arise about mechanisms: how can this be? For myself, the next step was Bjorn Nordenstrom’s investigation and findings regarding aspects of electrical aspects of healthy and diseased tissue. There is a PDF version of his first book available online. I suggest ignoring the cancer-treatment aspects and read his comments on electrical properties of tissues. That’s where mechanisms that can explain Head’s observations start to appear. Don’t expect an easy journey, but I suggest that it’s worth the effort to make.

    • this looks like a house of cards built of weird assumptions to me

    • @ Raymond Barnum
      this is all wild speculation with absolutely no proof – like all things aucupuncture.
      There is no evidence for the existence of Qi either – or meridians – or acupuncture points – yet we are supposed just to “believe” in them – why?
      Why should we just believe in this magical invocation of “quantum” whatever because it sounds sciency when all they are trying to do is marry up ancient voodoo with the sub-atomic world by using clever words they don’t really understand just to make it sound good? It isn’t any more believable.

      Why should we just accept his observations as valid? And even you want to cherry pick as you recommend ignoring his references to cancer! Since acupuncture relies on the TCM schema of things which as we know bears no relation to reality – it bears no relationship to anatomy, physiology or biochemistry and has no knowledge of germ theory, inflammation, degeneration or any of the other disease processes – it is difficult to see how useful it can be in interpreting anything much.

      • Actually, the point is to establish that acupuncture can work through processes based on the discoveries of ‘western’ science, and not on the mythology of TCM. (Apologies to those who have spent much time, effort and money to learn TCM)

        Opinions are fine, but informed opinions are better. The challenge is to set aside preconceptions long enough to allow in new information. That’s a difficult task: been there, done that.

        An easy way to start, re: Nordenstrom, is with this video produced by 60 Minutes around 1988.
        I don’t believe they did a follow-up, despite their intention stated at the end of the video.
        He did, in fact, go to China and received great credit for his efforts which resulted in favorable outcomes in thousands of cases. Here’s the link to a site that currently has the video:

        https://www.youtube.com/watch?v=XKXH_4PNPcQ

        If that piques interest, a PDF version of his first book can be found online. If unable to locate it, post a response here and I’ll find and relay a link to that.

        • “the point is to establish that acupuncture can work through processes based on the discoveries of ‘western’ science”
          that’s not how science procedes. first, we need to know THAT it worls; subsequently, we might try to find out HOW it works.

        • 1988? That’s forever in research years.

          “I don’t believe they did a follow-up”

          Can’t imagine why. Especially given the knowledge that modern acupuncture is a Maoist invention, and nothing says “intellectual integrity” like the party of “Great Leap Forward” and “Cultural Revolution”. At some point you have to admit prior plausibility looks absolutely terrible, never mind that the best scientific research done since then shows efficacy consistent with placebo, even as the best marketing research shows it profitable as ever. Multiple threads of evidence all pointing to it being just another sack of crap in a giant field already full of them.

          (And let’s not even mention traditional pre-Mao acupuncture, which was just Galenic-style bloodletting; a “treatment” so actively harmful it made even useless homeopathy look good in comparison.)

        • @ Ray Barnum

          Nordenstrom seems to have been big on opinions (whether they were informed is a matter of conjecture.) he is somewhat thin on facts and actual experimental evidence however. Anyone can come up with opinions – what matters is whether they are backed up by evidence.

          There is another big problem that you are missing however in attempting to link “ancient Chinese” acupuncture
          techniques with modern medicine and science. Acupuncture as we know it today is neither ancient nor most likely even Chinese. Original ‘acupuncture’ needles resembles curettes used for bloodletting and scooping out and it was not possible to manufacture the kind of fine steel needles currently used until the beginning of the 20th century!
          https://sciencebasedmedicine.org/puncturing-the-acupuncture-myth/

          It was in fact Chairman Mao who popularised TCM including acupuncture with barefoot doctors for the masses because there were nowhere near enough Western trained doctors to treat China’s vast population.
          He then decided to capitalize on the idea to export it to the West as well
          Mao and his party faithful of course never used it themselves preferring Western conventional medicine.

          It is interesting isn’t it that we only have alternative theories in medicine and not in engineering or aeronautics for example. Would you fly in an airplane designed by an alternative aircraft designer? Or drive on a bridge designed by an alternative engineer? Or drive a car with alternative safety standards?

          Reading this stuff it is “tooth fairy science” – they measure the electrical potentials of different spots on the human skin and then claim this changes when they insert acupuncture needles. They then interpret these changes to be meaningful. All of this is without determining if the electrical potentials in themselves are meaningful in the first place or if changes in them have any meaning in themselves. It is about as meaningful as Astrology or Numerology.

    • “Which is, of course, built upon the dffects of quantum interactions”

      Ray, no, it is not. From where do you pluck this arrant nonsense?

    • Mr Barnum,

      That is a far-fetched hypothesis, but before throwing it out I would like to ask whether you have any experimental evidence to support it. By this I mean proper experimental evidence, designed, as all scientific experiments are, to attempt to disprove the hypothesis under investigation.

  • It appears that I have stumbled into a Citadel of Certainty.
    There is no need to disprove a hypothesis if it is rejected out of hand.
    Or to investigate further once the answer is “known”.
    Were conflicting investigations and reports created by imbeciles?
    Is that why their work should be ignored?

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