European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 35–38

Contents lists available at ScienceDirect

European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full length article

Acupuncture for the treatment of post-partum urinary retention

Roy Lauterbacha,* , Cara Ferrer Sokolovskia , Jenia Rozenberga , Amir Weissmanb
a
Department of Obstetrics & Gynecology, Rambam Health Care Campus Israel
b
Lin Medical Center, Clalit Health Services Israel

A R T I C L E I N F O A B S T R A C T

Article history: Study objectives: The aims of the present study were to evaluate acupuncture as an alternative treatment
Received 26 October 2017 to an indwelling catheter for women with postpartum urinary retention, and to evaluate the accuracy of
Received in revised form 21 January 2018 sonographic estimation of bladder volume by portable bedside equipment in women postpartum.
Accepted 24 January 2018
Study background: Post-partum urinary retention is a common obstetric complication. The accepted
Available online xxx
method for diagnosing post void residual bladder volume is by ultrasound or catheterization. However,
the accuracy of bedside sonographic evaluation of bladder volume in women postpartum is controversial
Keywords:
due to anatomical and technical issues. The traditional treatment of urinary retention is catheterization
Urinary retention
Residual bladder volume
for variable lengths of time. Acupuncture, while an accepted treatment method for urinary retention in
Acupuncture traditional societies in the Far East, has not been proven scientifically to resolve the problem. Therefore,
Catheterization the aims of our study were to evaluate acupuncture as an alternative treatment to catheterization for
urinary retention, and to evaluate the accuracy of sonographic estimation of bladder volume by portable
bedside ultrasound in women postpartum.
Materials and methods: The study was a prospective randomized case-controlled trial conducted in 55
women post-partum with urinary retention. All patients underwent a pre and post treatment
sonographic evaluation of bladder volume. Women with urinary retention were given the choice of
treatment by acupuncture or catheterization. Acupuncture was performed by an experienced
acupuncturist licensed in Traditional Chinese Medicine and point selection was based on Meridian
theory and clinical experience.
Results: In the acupuncture group, 23 women (92%) achieved spontaneous micturition within one hour
following treatment. Bedside sonographic evaluation of bladder volume showed excellent correlation to
actual volume as measured by catheterization (r2 = 0.988).
Conclusion: Acupuncture proved to be an excellent alternative to catheterization in treatment of women
with postpartum urinary retention.
© 2018 Elsevier B.V. All rights reserved.

Introduction retention is described as “the inability to void spontaneously

Post-partum urinary retention (PUR) is a common condition
defined as the inability to void after delivery. This inability may be
symptomatic (overt) or asymptomatic (covert). The incidence of
this disturbing condition has been reported to be 1.7–17.9% [1,2].
This large variance has been accounted for the various definitions
for PUR and the different methodologies that have been used. Of
the women with PUR about 5% may suffer significant and longer
lasting dysfunction [3]. Traditionally, post-partum urinary
* Corresponding author at: Department of Obstetrics and Gynecology, Rambam
Health Care Campus, Haifa, Israel.
E-mail address: r_lauterbach@rambam.health.gov.il (R. Lauterbach).
within 6 h after vaginal delivery or 6 h after removal of an
indwelling bladder catheter after cesarean section, requiring
catheterization” [4].
Post-void residual volume (PVR) is defined as the volume of
remaining fluid in the bladder immediately following micturition
completion. Although there is great variance in the determination
of significant residual urine, the most accepted threshold for a post
void residual bladder volume is 150 ml after spontaneous
micturition, verified by ultrasound or catheterization [5–7].
Another difficulty with estimating urinary volume is that there
is much controversy on the accuracy of ultrasound bladder volume
estimation and its usefulness in cases of urinary retention,
especially postpartum, where the normal anatomy of the bladder
may be distorted by the enlarged uterus. However, most recent

https://doi.org/10.1016/j.ejogrb.2018.01.029
0301-2115/© 2018 Elsevier B.V. All rights reserved.
36 R. Lauterbach et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 35–38
studies report good correlation with bedside portable ultrasound
equipment compared to urine volume as determined by catheteri-
zation [8–10].
Risk factors for post-partum urinary retention include nulli-
parity, prolonged labor (especially in the setting of a prolonged
second stage), assisted/instrumental delivery, perineal injury,
tissue edema, cesarean section and regional analgesia [11,6].
Urinary retention may also result from nerve injury during delivery
[12]. However, many women with post-partum voiding difficulties
may have no apparent risk factors.
When postpartum urinary retention results, an indwelling
catheter is usually utilized and maintained for 24–72 h. If
symptoms persist, catheterization for a week or longer may be
recommended [6]. Others advocate intermittent catheterization as
it may decrease the probability of urinary infection [13,14].
Acupuncture has been used as an alternative treatment for
urinary retention in several Chinese medical centers with reports
of spontaneous restoration of micturition in all treated patients
[15,16]. Though results seem to be quite promising, none of the
studies published to date, performed PVR measurements whether
by catheterization or sonographic evaluation, they used diverse
treatment protocols and no post treatment follow-up has been
reported.
The aims of the present study were therefore: a) to evaluate
acupuncture as an alternative treatment to an indwelling catheter
for women with postpartum urinary retention, and 2) to evaluate
the accuracy of sonographic estimation of bladder volume by
portable bedside equipment in women postpartum.
Methods and materials
Population selection
The study is a prospective randomized case-controlled trial
conducted between January 2016 and March 2017. The study
protocol was approved by the local Ethics Committee (RMB-0590-
15) and all women participating signed an informed consent. Our
policy is that women who cannot void within four hours after
spontaneous delivery have a Foley catheter inserted for 24 h. For
women who have undergone cesarean section and have a Foley
catheter, our policy is to remove it within 8–12 h upon patient
ambulation. These women who cannot void spontaneously within
4 h, have the Foley catheter reinserted. Patients after vaginal
delivery or cesarean section who could not void within four hours
following delivery or the removal of the catheter were selected for
the study. During the study period fifty-five subjects had PVR of
over 150 ml by sonographic evaluation. Twenty five women were
willing to undergo acupuncture treatment, and thus comprised the
study group, while 30 did not want to undergo acupuncture
treatment, and thus comprised the control group. These women
were treated by catheterization. The 55 patients that comprised
the study and control groups were selected from partituents with a
PVR of 0.5–1 l. The reason for this selection was that patients with a
PVR of over 1 l were in high risk for bladder damage and would not
benefit from any prolongation of the time interval until catheteri-
zation
Time interval selection
According to previous studies regarding postpartum urinary
retention, the accepted interval between delivery or catheter
removal and micturition is 4–6 h [2,4,6]. The selection of the four
hour marker was based in this study on the expected time required
for study explanation and informed consent retrieval, sonographic
PVR evaluation and the acupuncture treatment, all of which took
between 45 and 60 min, therefore reaching the accepted six-hour
limit. Additionally, patients in the study group were given an extra
60 min to void after the end of acupuncture and before treatment
failure was asserted. Thus, a maximum time frame of six hours
postpartum or post catheter removal was maintained for all
subjects.
Sonographic evaluation and catheterization
All patients enrolled for the study underwent a pre-treatment
ultrasound to measure bladder volume. Subjects with a PVR of
more than 150 ml were included in the study. Subjects who
achieved micturition post treatment had a second ultrasound
performed in order to determine the residual volume. Treatment
success was considered as a PVR of less than 150 ml post treatment.
Subjects who continued to experience micturition difficulties one
hour after the completion of the treatment, had a second
ultrasound performed in order to assess again the PVR, and then
underwent bladder catheterization. This allowed the validation of
the ultrasonographical accuracy of the estimated bladder volume
vs. the actual volume.
Ultrasound evaluation
We used the CUBEscan BioCon 700 (Mcube Technology Co, Ltd,
Korea) portable ultrasound in the present study. The ultrasound
transducer head was placed suprapubically with the patient in
supine position and the bladder image was obtained. Bladder
volume was automatically calculated from the acquired image.
Three readings were acquired from each woman consecutively and
if the readings were within 15%, the average of the three readings
was calculated.
Acupuncture treatment
All treatments were performed by an experienced acupunctur-
ist licensed in Traditional Chinese Medicine (TCM). Acupuncture
point selection was based on TCM, Meridian theory, and clinical
experience. Acupuncture points included: BL-28 (Pangguangshu)-
the back transporting points of the bladder, known to be
responsible for bladder and micturition regulation, located mid-
laterally at the level of the second posterior sacral foramen; BL-32
(Ciliao)-known for bladder channel obstruction removal and
micturition promotion, located in the mid second posterior sacral
foramen; LU-7 (Lieque)-known for bladder blood supply regula-
tion, located at the radial aspect of the forearm, in the cleft
between the tendons of the brachioradialis and abductor pollicis
longus; KI-6 (Zhaohai)- known for bladder blood supply regula-
tion, located below the prominence of the medial malleolus; GV-20
(Baihui)-known for promotion of clear qi ascending and impure qi
descending, located at the midline vertex; HT-7 (Shenmen)-known
for calming the spirit, located at the radial side of the wrist joint at
the level of the flexor carpi ulnaris; SP-6 (Sanyinjiao)-known for
three leg yin channels qi regulation and water passage in addition
to pain management.
Five to seven acupuncture points were selected for each
treatment after diagnosis by the experienced licensed acupunc-
turist. Patients underwent acupuncture treatment either in the
decubitus or supine position. The acupuncture points were
punctured 0.5–2 cm deep depending on the point selected, and
moderate stimulation was applied. The needles were retained for
20–30 min after achieving de-Qi and were manipulated once every
3–5 min. Dong bang spring handle sterilized acupuncture needles
were used (0.16\15 mm 0.20\30 mm 0.25\30 mm 0.25\40 mm in
diameter). Sham needles were not used during the study for ethical
reasons.
 R. Lauterbach et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 35–38 37

Statistical analysis

Continuous data were analyzed using one-way anova or the

Student's t-test. Proportions were compared using the chi 2-test.
Correlations between sonographic bladder volume and actual
bladder volume as measured by were determined using the
Pearson correlation coefficient. Linear regression analyses were
performed to evaluate the association between estimated and
actual bladder volumes. The accuracy of sonographic bladder
volume estimation compared to actual volume was assessed also
by the Bland-Altman test. The Bland-Altman test is a method of
comparing the agreement of two methods of measurements – a
new method compared to a “gold standard” or an established
method. In our study the aim was to compare the agreement
between the sonographic estimation of bladder volume and the
actual volume as determined by catheterization. The Bland-Altman
method calculates the mean difference between the two measure-
ments (the “bias”), standard deviation, and 95% limits of the mean
difference (1.96 standard deviations from the mean). It is expected
that the 95% limits include 95% of differences between the two
measurement methods. A P-value of <0.05 was considered
statistically significant.
Fig. 1. Estimated bladder volume by ultrasound vs. actual volume by catheteriza-
Results tion (cc). Superimposed is a regression line with a 95% confidence interval.

Among the 5626 deliveries during the study period, there were to maintain spontaneous micturition until discharge. Sonographic
684 women with postpartum urinary retention (12.2%). Of the 684 PVR evaluation that was performed for all patients in both the
patients with postpartum urinary retention 246 women (36%) had study and control groups before discharge showed PVR of less than
a PVR of over 1 l, 212 women (31%) had a PVR of 0.5–1 l and 148 50 ml.
(21.7%) had a PVR of 0.15–0.5 l. Demographic and obstetric data of The estimated sonographic bladder volume compared to the
the study and control groups are given in Table 1. No statistically actual volume as determined by catheterization is presented in
significant differences were noted between the groups. Fig. 1 with a regression line superimposed. There was an excellent
All patients in the control group except one (96%) resumed agreement between the two methods with an r2 of 0.988. In Fig. 2
spontaneous micturition after removal of the Foley catheter. The we present the Bland-Altman plot that shows the agreement
patient who did not resume spontaneous micturition had previous between sonographic and actual bladder volumes in each patient.
urinary retention issues due to a previous car accident. The patient The bias was 4.9 cc, the standard deviation was 20.8 cc, and the
resumed spontaneous micturition after an additional prolonged limits of agreement were 36–46 cc with 95% confidence intervals
10 day catheterization period. of 2.8–2.7 cc.
Of the patients in the study group, all patients except two (92%),
resumed spontaneous micturition during the allocated 1 h period
after the acupuncture treatment session. Of the patients who did
not resume spontaneous micturition within one hour, one had
previous urinary retention problems; possibly on account of
urinary tract changes due to previous multiple urinary tract
insults. She was therefore treated by prolonged 10 day catheteri-
zation period, after which she resumed spontaneous micturition.
The second patient had massive edema postpartum because of a
traumatic vacuum extraction and she resumed spontaneous
micturition after a 3 day catheterization period.
None of the patients that resumed spontaneous micturition in
the acupuncture group required any further intervention in order

Table 1
Demographic and obstetric data.

Study group (n = 25) Control group (n = 30)

Age 32  6 30  4
Parity 21 21
Delivery week 39.0  1.2 39.3  1.2
Vaginal delivery 5 7
Cesarean section 16 21
Instrumental delivery 3 3
Epidural analgesia 7 10
Spinal analgesia 19 16
Perineal tear 2 5 7
Fig. 2. Bland-Altman graph of the average of actual bladder volume and ultrasound
Bladder volume before treatment 778  76 (640–954) 788  192 (205–
estimated volume vs. the difference between the actual bladder volume and
1052)
ultrasound estimation. Superimposed are the mean and 1.96 standard deviations of
No statistical significance was found in any of the above variables. the calculations.
38 R. Lauterbach et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 223 (2018) 35–38
Discussion
The results of the present study suggests that: a) bedside
sonographic estimation of bladder volume with portable equip-
ment is reliable and can be safely utilized for women with
postpartum urinary retention, and b) that acupuncture can be an
excellent noninvasive option for women with postpartum urinary
retention as an alternative for an indwelling catheter.
Postpartum urinary retention is a common obstetric problem
with a reported incidence of, 1.7–17.9% [1,2] but can be as high as
24.1% following cesarean section [17,18]. If voiding dysfunction is
not promptly recognized, bladder over distension may eventually
lead to detrusor atony and prolonged voiding dysfunction [19]. The
management of postpartum urinary retention consists of support-
ive measures such as assisting the patient to walk to the toilet,
reduce swelling and edema (if present), controlling pain (particu-
larly if vaginal lacerations are present), etc. However, when these
measures fail, the prevailing method is an indwelling catheter
applied for variable lengths of time. With an indwelling catheter
there is obviously less patient satisfaction because of the
unpleasant procedure, embarrassment, and distressing feelings
when applied for prolonged periods. Ambulation may be difficult
and particularly to nursing mothers with a higher risk of acquiring
urinary tract infection.
There is very limited information on the usage of acupuncture
for the treatment of postpartum urinary retention [16]. The
sporadic and limited use of acupuncture stems from several
reasons – a) the lack of knowledge and awareness of this traditional
Chinese medicine treatment mode, and b) the lack of studies with
adequate methodological design to validate the hypothesis that
acupuncture may resolve postpartum urinary retention. In the
present study, by using rigorous methodology and validation
procedure, we show that acupuncture is successful in treating
postpartum urinary retention in 92% of the women, thus circum-
venting the need of an indwelling catheter with its drawbacks. Not
only there was an immediate subjective relief to all women, but we
were able to show objectively by using ultrasonography following
the procedure, that the residual bladder volume was indeed
insignificant.
The favorable result of the present study is aimed to increase
the awareness of midwives and obstetricians who treat women
after delivery for the existence of an excellent, short-term mode of
treatment for postpartum urinary retention with a very high
success rate and patient compliance. Although this was only a
preliminary study with a limited number of patients, it opens an
angle to the advantages of acupuncture in this setting. Larger
studies are certainly needed to examine this treatment method in
postpartum urinary retention as well as in other obstetric
complications. An open mind to alternative medicine was
advantageous in our case, and may be helpful in other fields as
well.
Limitation of the study
Although very encouraging, this was a small study with a
limited number of participants that was aimed at examining the
feasibility and success rate of acupuncture to treat postpartum
bladder dysfunction. Greater number of patients should be
recruited to validate our results. Another potential limitation is
the lack of applying sham points of acupuncture. However, we
thought using sham points was unethical and therefore these were
not used in the present study.
Conflicts of interest
The authors report no conflicts of interest relevant to this article
Authors’ contribution
A.W. C.F.S and R.L. conceived the idea of the study; R.L
performed the literature search; R.L., C.F.S and J.R. collected the
data and assessed the quality of data; A.W. performed statistical
analyses; A.W. and R.L. drafted the manuscript. All authors
reviewed and edited the final form of the manuscript and
approved it.
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