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The use of acupuncture in the treatment of erectile dysfunction
HG Kho
1
*, CGJ Sweep
2
, X Chen
3
, PRI Rabsztyn
2
and EJH Meuleman
2
1
Institute of Anesthesiology, University Hospital Nijmegen;
2
Department of Chemical Endocrinology, University Hospital
Nijmegen;
3
Department of Anaesthesia of Renji hospital, Shanghai, China; and
4
Department of Urology, University
Hospital Nijmegen, The Netherlands
The ef®cacy of acupuncture as a mono-therapy was evaluated in a pilot study of 16 patients
suffering from erectile dysfunction (ED). In nine patients no organic co-morbidity was
encountered. In a period of four weeks, acupuncture treatment was performed twice a week for
a total of eight sessions. Each treatment session consisted of puncture of the same eight acupoints,
four of which were connected to a Swiss made constant current Doltron ESA 600 stimulator. Low
frequency electrical stimulation (5 Hz and 10 mA) was applied to these four acupoints, whereas no
stimulation was applied to the other four points. After 30 min, the electrical stimulation was
terminated and all needles removed. Blood samples were drawn according to a ®xed time
schedule, to study the pro®le of a number of stress hormones, for example, adrenocorticotropic
hormone, antidiuretic hormone and cortisol, the gonadotrophines follicle stimulating hormone
and leutinizing hormone, and the sex steroid testosterone and its binding globulin, within the
treatment period. Based on a diary of both patient and partner, and an interview one month after
the end of treatment, the changes of sexual activity were evaluated over a period of 12 weeks,
starting from the four weeks prior to the treatment, the four weeks during the treatment period and
the four weeks after the treatment. An improvement of the quality of erection was experienced by
15% of patients, while 31% reported an increase in their sexual activity. No changes in the pro®les
of hormones were detected. The use of acupuncture as a mono-therapeutic modality in ED, did not
in¯uence the pro®le of the stress and sex hormones, but did improve the quality of erection and
restored the sexual activity with an overall effect of 39%. No de®nite conclusions can be drawn
from this pilot study. A controlled and blinded study including more patients will be needed before
any de®nitive conclusion can be reached.
Keywords: erectile dysfunction; acupuncture; hormones
Introduction
Nowadays more patients are seeking help for sexual
dysfunction (SDS). This suggests that the incidence
of SDS is increasing and=or that sexual issues are
more easily discussed.
1
In recent years, several
therapeutic modalities for patients suffering from
erectile dysfunction (ED) have become available.
The treatment for psychogenic ED is sex-therapy.
For organic ED, which accounts for more than 50%
of cases, the clinical guideline panel of the Amer-
ican Urological Association recommends three
alternatives, that is, vacuum constriction devices,
injection of vasoactive drugs and=or implantation of
a penile prosthesis. The majority of patients dis-
continue non-surgical treatment because of sexuo-
logical and relational determinants or
dissatisfaction with the method. The long-term
success rates of these therapies are disappointing.
2
Other treatments, including oral drugs, are in the
experimental stage.
3
Therefore, an ideal solution for
ED has not yet been achieved.
Traditional medicine (TM) as an alternative
approach to the modern health care system is
increasing in popularity. Each year, fully one third
of all US residents seek service from TM for
disorders which may not respond to modern
medicine.
4
In 1991, the WHO adopted resolution
WHA44.34. It urged member states to intensify
cooperation between TM and modern health care,
especially concerning the effectiveness and safety of
approved treatment methods of TM. The aim of this
resolution was to reduce the national budget of
drugs.
5
Acupuncture has been practised for many cen-
turies and is one of the most important branches of
traditional Chinese medicine (TCM). Modern med-
icine understands the Yin ± Yang balance because in
a healthy body as an equilibrium of the autonomic
nervous system (ANS) i.e. sympathetic and para-
sympathetic nervous systems. Based on the homeo-
static in¯uence of the ANS, acupuncture may have a
*Correspondence: Dr HG Kho, University Hospital Nijmegen,
PO Box 9101, 6500 HB Nijmegen, The Netherlands.
Received 29 January 1998; accepted in revised form
1 October 1998.
International Journal of Impotence Research (1999) 11, 41±46
ß 1999 Stockton Press All rights reserved 0955
-
9930/99 $12.00
http://www.stockton
-
press.co.uk/ijir
positive in¯uence on the pathophysiology of ED.
Several studies indicate a high success rate after
TCM treatment, including acupuncture, in patients
suffering from psychogenic ED.
6 ± 10
Increasing evi-
dence demonstrates that a number of neuropeptides
are involved in the mechanisms of pain relief after
acupuncture.
11
Neuropeptides have also been re-
cognized as important substrates in the central
control of male sexual behaviour.
12 ± 14
This present
study was designed to evaluate the effect of acu-
puncture as a mono-therapy in patients with ED.
The results are discussed against the background of
literature data of the well-known therapies of ED. In
addition, the pro®les of a stress and pituitary and
gonadal sex hormones were studied within the
treatment sessions.
Patients and methods
The protocol was approved by the hospital Ethics
Committee. Between September 1995 and March
1996, 16 consecutive patients suffering from ED
were included in the study.
Inclusion criteria
To enter the study: written informed consent; age
between 18 and 75 y, Diagnostic and Statistic
Manual of mental disorders (DSM-III-R) diagnosis
of ED,
15
inability to obtain or maintain erection
suf®cient for penetration including intravaginal
orgasm in more than 50% of coitus attempts;
complaints not exclusively related to depression, a
positive erectile response following administration
of 0.5 ml of Androskat
R
(7.5 mg of papaverine and
0.25 mg of phentolamine) intracavernously;
15
a
stable sexual relationship that has been sexually
functional within this relationship; patient and
partner willing and able to have intercourse at least
three times a month during the study period. In this
study, the de®nitions are con®ned to partner-related
sexual activity.
Exclusion criteria
The only exclusion criterium was if the patient did
not ful®l the inclusion criteria.
Study design
At the ®rst visit all patients included in the study
underwent an extensive sexual history and medical
examination, including Penile Pharmaco Duplex
Ultrasonography. After informed consent was ob-
tained from the patient and partner, they were
instructed to ®ll in diaries, with the patient on a
daily basis and his partner on weekly basis con-
tinuously for a period of 12 weeks, starting from four
weeks prior to the treatment. This diary contained
questions on the frequency of sexual intercourse and
the quality of erection during intercourse according
to a four point scale. A month after the end of the
study period a ®nal interview was arranged for all
patients, in which attention was focused on items as
sexual fantasy, libido, sexual arousal, penile erec-
tion, orgasm and ejaculation.
Acupuncture treatment procedure
Following the `run-in' period of four weeks, acu-
puncture treatment was performed twice a week
over a period of four weeks for a total of eight
sessions. Each treatment session consisted of punc-
ture of the same eight acupoints (Guanyuan, Bahui,
left and right Sanyinjiao, Taixi and Shenmen). The
correct placement of the needle was con®rmed by
the characteristic but subjective needle sensation
`deqi'. It is described as a sudden feeling of
numbness, soreness, distension or heaviness in the
deep tissue experienced when the inserted needle
has reached a certain depth. Four of the inserted
needles at the acupoints Guanyuan, Bahui and left
and right Sanyinjiao were connected to a Swiss
made constant current Doltron ESA 600 stimulator.
Table 1 Location of acupoints used in the study
Acupoint Anatomical location
Guanyuan
a
(ren 4) Three cuns below the umbilicus, in the midline
Bahui
a
(du 20) Seven cuns above the posterior hairline, midway on a line connecting the apex of
both ears.
Sanyinjiao
a,b
(spleen 6) Three cuns above the tip of the medial malleolus just posterior to tibial border
Taixi
b
(kidney 3) Midway between the tip of medial malleolus and tendo calcaneus
Shenmen
b
(heart 7) On the ulnar side of the wrist, on the posterior border of the pisiform bone, in the
depression at the radial side of the tendon of musculus ¯exor carpi ulnaris
cun the distance between two creases marking the joints of the distal and the middle phalanges of the middle ®nger.
a
Indicates the electrical stimulated acupoint.
b
Indicates the symmetrical location of the points, and at the right and left side of the body resp.
Acupuncture in the treatment of erectile dysfunction
HG Kho
et al
42
Low frequency electrical stimulation (5 Hz and up to
10 mA) was applied to these four acupoints. No
stimulation was applied to the other four points.
The anatomical location of the acupoints is depicted
in Table 1. After 30 min, the electrical stimulation
was terminated and all needles removed.
Measurement of hormones
Venous blood was collected in pre-chilled K3-EDTA
tubes between 2 pm and 4 pm following the sche-
dule presented in Table 2.
Samples were then centrifuged for 10 min at
1500 g (4
C) within one hour. The plasma obtained
was aliquoted in polystyrene tubes containing
250 KIU=ml of plasma Trasylol
R
(aprotonine, Bayer),
frozen and stored at 7 20
C until measurement.
This was carried out within two months.
Adrenocorticotropic hormone (ACTH) in plasma
was measured by an immunoradiometric assay
(IRMA) based on two polyclonal antibodies (Euro-
Diagnostics, Arnhem, The Netherlands). The catch-
ing antibody is directed against the C-terminal part
of the ACTH molecule, and coupled via a sheep
anti-rabbit antibody to a polystyrene tube. The
detecting antibody is directed against the N-terminal
part of ACTH and radioiodinated. Standard curves
were prepared by spiking ACTH-free plasma with
ACTH (1 ± 39) (MRC 74=555). The assay was per-
formed as follows. Two hundred microliters of
sample standard (0 ± 220 pmol=l) was added to the
coated tubes and subsequently iodinated ACTH
antiserum (250 dpm=200 ml) was added. The mixture
was incubated for 24 h at room temperature. The
supernatant was decanted and the tubes washed two
times with 0.9% NaCl. Radioactivity in the tubes
was counted using an automatic gamma-counter
(1470 Wizard
TM
Wallac). The sensitivity of the assay
was 0.5 pmol=l, and the within- and between-assay
coef®cients of variation of the IRMA procedure were
4.4% and 7.2% respectively. All sample measure-
ments were duplicated. The IRMA speci®cally
detects ACTH (1 ± 39). Crossreactivity with ACTH
(1 ± 24), CLIP and beta-endorphin was < 0.1%.
Table 3 shows the characteristics of the assay
methods for the anti-diuretic hormone (ADH),
cortisol, follicle stimulating hormone (FSH), lutei-
nizing hormone (LH), prolactin (PRL), sex-hormone
binding globulin (SHBG) and testosterone.
Data evaluation
Variables measured at admission or before the ®rst
treatment were used as control. Data are presented
as mean s.e.m. and analyzed by repeated measure-
ment analysis of variance (SPSS, Statistical analysis
package, version 6.1.3, SPSS Benelux Bv Gorinch-
em, The Netherlands). P < 0.05 was the threshold of
signi®cance.
Results
Sixteen patients entered the study. For three of them
the study could not be ®nished. After the ®rst
treatment session, two patients decided not to
continue the therapy and one patient could not ®ll
the diary due to the absence of a partner shortly after
he entered the study. The data of these patients were
excluded. Table 4 shows the clinical data of the 13
patients completing the study. In four patients, an
organic factor contributing to the ED was present,
the remaining nine patients were classi®ed as
psychogenic ED.
After treatment was completed, two patients had
a better erection (15%) and four patients had an
Table 2 Time schedule for drawing blood samples
Code Time Description
T1 30 min Before the ®rst acupuncture treatment
T2 30 min Before the third acupuncture treatment
T3 30 min Before the ®fth acupuncture treatment
T4 30 min Before the seventh acupuncture treatment
T5 30 min After the last (eight) acupuncture treatment
Table 3 The assay methods for determinants of hormones, their intra- and interassay coef®cients of variation (%), sensitivity (sens), the
reference values (ref) in the non-stressed state, units and literature (lit)
Variable Method Intra Inter Sens Ref Unit Lit
ACTH IRMA 3.6 8.3 0.8 1.3 ± 9.2 pmol.l
71
text
ADH RIA < 8.0 < 8.0 0.8 1.2 ± 3.7 pmol.l
71
16
Cortisol RIA 5.0 5.8 0.005 0.19 ± 0.55 (8 am) mmol.l
71
17
0.06 ± 0.38 (5 pm) mmol.l
71
17
FSH IRMA 3.6 8.2 0.6 2.0 ± 7.5 IU.l
71
18
LH IRMA 5.5 7.6 0.5 1.8 ± 9.5 IU.l
71
18
Prolactine IRMA 3.6 5.7 20 100 ± 700 mIU.l
71
18
SHBG IRMA 2.9 4.6 0.5 30 ± 90 nmol.l
71
16
Testosterone RIA 5.6 5.8 0.04 11 ± 45 nmol.l
71
16
Acupuncture in the treatment of erectile dysfunction
HG Kho
et al
43
increase in sexual activity (31%). The ®nal inter-
view also revealed that ®ve patients, two months
after the ®rst treatment, still experienced improve-
ment of their sex life in terms of activity and global
quality of erection (39%). The overall improvement
rate was 54% (7 out of 13 patients). None of the
partners, however, reported any difference. Table 5
shows the results of the measurement of plasma
levels of the pituitary hormones ACTH, ADH, FSH,
LH and PRL and the steroid hormones cortisol and
testosterone as well as SHBG.
No signi®cant changes in the levels of these
hormones during and after the treatment sessions
were detected.
Discussion
Clinic
The present pilot study was conducted to determine
the effect of acupuncture as a mono-therapy in
patients suffering from ED. The results show that it
has an effect in 54% of patients. It is remarkable that
none of the partners reported any improvement of
erection or activity. Presumably, partners were less
focused on performance related sexual domains such
as erection and activity. Moreover, they may not have
been involved suf®ciently in the study. Though
limited to a small number of patients, our study was
unable to con®rm the reported high success rate of
acupuncture treatment in ED of at least 70% in other
studies.
6 ± 9
A number of factors are thought to have
affected the results. Firstly, the choice of acupoints
used in our study was identical in each treatment
session and for all patients, rather than an individual
approach as reported by others. After all, TCM
considers a patient in his totality with a wide
aetiological spectrum, and takes into account that
illness, health and disease are brought about by
imbalance in human beings. According to TCM, ED
is caused by a strengthened inhibition to erection in
the cerebral cortex or a functional disorder of the
spinal cord. The disease is related to such organs as
the kidney, heart, spleen and liver. The majority of ED
may result from insuf®ciency of kidney energy Qi
(functional activities of the kidney) and of roaring ®re
at the vital portal caused by emission, spermatorrhea,
excessive worries or from injured kidney Qi due to
sudden panic weakness of the genitalia but the
downward ¯ow of damp and heat.
19
TCM treats the
body, mind and social relationship, and determines
Table 4 Outcome of 13 included patients: diary, interview and partner's diary
Patient Interview partner
Interview
Pt Age Aetiology Erection Activity Patient Erection Activity
1 43 psychogenic un Increased un un un
2 46 DM type 1 un un un un un
3 47 psychogenic un un Improved un un
4 47 psychogenic un un Improved un un
5 48 psychogenic un un un un un
6 53 psychogenic un un un un un
7 53 psychogenic Improved Increased un un un
8 53 Med un Increased Improved un un
9 54 psychogenic un un un un un
10 59 HT,
a
Med
b
un un un un un
11 61 psychogenic Improved Increased Improved un un
12 62 psychogenic un un Improved un un
13 65 Art,
c
HT, Med un un un un un
a
Hypertension.
b
Medication with impact on erectile function.
c
Arteriogenic factor as demonstrated by duplexscanning.
un unchanged.
Table 5 Mean (s.e.m.) values of plasma peptide hormone levels at different time schedules
Hormones Unit T1 T2 T3 T4 T5
ACTH pmol.l
71
4.49 (0.75) 3.16 (0.35) 4.23 (0.55) 4.35 (0.61) 4.83 (0.66)
ADH pmol.l
71
1.27 (0.16) 1.41 (0.25) 1.53 (0.15) 1.54 (0.16) 1.83 (0.20)
Cortisol mmol.l
71
0.33 (0.02) 0.25 (0.02) 0.26 (0.03) 0.27 (0.02) 0.30 (0.03)
FSH IU.l
71
4.55 (0.45) 4.56 (0.43) 4.68 (0.46) 4.51 (0.53) 5.07 (0.60)
LH IU.l
71
3.40 (0.28) 3.18 (0.44) 3.33 (0.40) 3.01 (0.26) 3.32 (0.53)
Prolactine mIU.l
71
156 (15) 158 (150 154 (16) 182 (16) 167 (17)
SHBG nmol.l
71
30.8 (3.1) 31.8 (3.6) 32.8 (3.9) 31.4 (3.3) 33.7 (3.8)
Testosterone nmol.l
71
13.1 (1.4) 12.8 (1.6) 11.7 (1.0) 14.1 (1.8) 12.3 (1.6)
Acupuncture in the treatment of erectile dysfunction
HG Kho
et al
44
the choice of acupoints accordingly in every treat-
ment session.
Secondly, the present study evaluated the effect
of acupuncture performed as a mono-therapeutic
modality in ED patients. The high response by
others was in fact a result of the TCM approach in
which acupuncture was only a part of the treatment
procedures.
Thirdly, not all of the patients included in this
study suffered from psychogenic ED, whereas only
psychogenic ED has been included in other studies.
Four of them had ED due to organic disease; if they
are not taken into account, the overall effect of 63%
(5 out of 8) approached the success of other studies.
It is noteworthy that one patient labelled to have a
contributing organic factor reported increased sex-
ual activity and improvement of sexual quality
following treatment.
Fourthly, cultural background of the patient
populations. As acupuncture has been practised
for many centuries in China, the method has been
accepted as a treatment modality for different
complaints and disorders. This might have in¯u-
enced the higher response reported in the Chinese
studies on the one hand, and the moderate response
in this study.
Stress and sex hormones
It is widely accepted that a number of peripheral
hormones are also found in the central nervous
system and act there in the regulation of behavioural
processes,
14,20,21
including sexual behaviour. The
pituitary neuropeptide oxytocin for instance, is
thought to be important in a variety of positive
social behaviours, while vasopressin is associated
with enhanced arousal, attention and retrieval of
information.
22,23
In addition, a signi®cant increase
in the level of circulating, and thus pituitary-
derived, oxytocin has been reported to correlate
with multiorgasmic women.
14
In this study we
measured the activity of the pituitary-adrenal axis
(ACTH, ADH and cortisol levels) and that of the
pituitary-gonadal axis (LH, FSH and testosterone
levels) to evaluate whether there is any correlation
between these peripheral stress and sex hormones
with the changes in the patients' sexual behaviour
during the treatment course. The results show that
although the use of acupuncture was associated
with a moderate improvement of 54% clinically, no
correlation existed between the clinical sexual
performance and the pro®les of the peripheral
hormones during the treatment period. It should be
realised, however, that an action of neurohormones
on the central control of sexual behaviour is not
necessarily re¯ected in changes in the levels of the
corresponding circulating pituitary and gonadal sex
hormones. Moreover, the release of pain modulating
substances by acupuncture could inhibit the release
of sex behaviour affecting hormones.
12
Conclusion
This pilot study demonstrated a modulating positive
effect of acupuncture as a monotherapy on psycho-
genic and non-psychogenic ED, whereas no accom-
panying changes in circulating sex and stress
hormones are observed. A large control study is
needed before any de®nite conclusion can be made.
Acknowledgements
The study was made possible by a grant from the
Royal Dutch Academy of Sciences in view of a
bilateral exchange between Chinese and Dutch
scientists, and was supported by Schwa-Medico of
The Netherlands and Foundation for the scienti®c
study of Chinese medicine (SAPOC) of Nijmegen,
The Netherlands. We thank GJ Pesman for hormone
measurement, Caris CTM and WPJ Witjes for critical
comments and EN Robertson FRCA for correcting
the manuscript.
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