Effect of Acupuncture for Mixed Urinary Incontinence in Women: A Systematic Review

Mixed urinary incontinence represents a significant challenge in the lives of many women, combining symptoms of two distinct types of incontinence: stress incontinence, which occurs during physical exertion such as coughing or sneezing, and urge incontinence, characterized by involuntary loss of urine associated with a strong sudden urge to urinate. This problem affects millions of women worldwide, with prevalence rates varying widely between different countries and populations. What makes mixed urinary incontinence particularly problematic is that it can be more bothersome and negatively impact quality of life more than either of the types alone. Conventional treatment options face important limitations, as many therapies are effective only for one of the components of the condition, leaving patients with partial symptom relief.

Current treatment of mixed urinary incontinence follows a stepwise approach, starting with pelvic floor exercises as first-line treatment, followed by antimuscarinic medications or other drugs as a second option. However, these medications often address only the urgency component, while pelvic floor exercises focus mainly on the stress component. In addition, the medications can cause significant side effects such as dry mouth and constipation, leading to poor treatment adherence. Surgery is reserved only for cases in which the stress component is predominant and other treatments have failed, but it can paradoxically worsen urgency symptoms.

This complexity in the management of mixed incontinence has led researchers and clinicians to seek therapeutic alternatives that can address both components simultaneously.

This study represents the first systematic review specifically dedicated to evaluating the efficacy and safety of acupuncture for women with mixed urinary incontinence. The researchers conducted a comprehensive search in ten scientific databases, including PubMed, Web of Science, Embase, and other Chinese and international sources, looking for randomized controlled studies that investigated any type of acupuncture compared with other interventions or controls. The methodology rigorously followed the guidelines of the Cochrane Handbook for Systematic Reviews, and the protocol was registered in advance with PROSPERO. Two independent reviewers selected the studies and extracted the data, using specific criteria that included adult women with a diagnosis of mixed urinary incontinence, comparing acupuncture with conventional treatments, surgery, sham acupuncture, or no treatment.

Risk of bias was systematically assessed using standardized tools, and the results were analyzed both quantitatively and qualitatively.

The analysis identified only three randomized controlled studies that met the inclusion criteria, involving a total of 591 women. The study by Liu and colleagues was the largest, with 497 participants, comparing electroacupuncture with a combination of pelvic floor exercises and solifenacin. This study demonstrated that electroacupuncture was non-inferior to combined conventional treatment in reducing the number of incontinence episodes, urgency, and nocturia, as well as the amount of urinary leakage, with benefits sustained at 12-, 24-, and 36-week assessments. The Zhan study, involving 60 participants, showed that electroacupuncture significantly reduced more urinary leakage compared with tolterodine after 8 weeks of treatment.

The third study, conducted by Solberg and colleagues with 34 participants, compared manual acupuncture with pelvic floor exercises and a control group, although it was limited by a high dropout rate. All three studies reported significant improvements in participants' quality of life, measured by the ICIQ-SF questionnaire, with reductions above the minimum considered clinically important.

For patients suffering from mixed urinary incontinence, these results suggest that acupuncture may represent a promising therapeutic option, especially considering its favorable safety profile compared with conventional medications. Liu's study demonstrated that adverse events related to electroacupuncture were rare, occurring in only 4% of participants and consisting mainly of small subcutaneous hematomas that did not require treatment. In contrast, more than a third of participants in the group that received medication experienced side effects, mainly dry mouth, which frequently leads to treatment discontinuation. For health professionals, these findings suggest that acupuncture could be considered as a valid alternative, especially for patients who do not tolerate medications or prefer non-pharmacological approaches.

The ability of acupuncture to potentially address both components of mixed incontinence simultaneously represents an important theoretical advantage over conventional treatments that typically focus on only one aspect of the condition.

However, it is important to recognize the significant limitations of this evidence. The very small number of available studies, just three, substantially limits the robustness of the conclusions. In addition, there was considerable variation between the studies in terms of methodology, acupuncture treatment regimens, points used, frequency and duration of treatments, making it difficult to determine the most effective protocol. Risk of bias varied between studies, with particular concerns about blinding of participants and assessors, which is admittedly challenging in acupuncture studies.

Two of the three studies had relatively small samples, and one had a dropout rate higher than 40%, compromising the reliability of the results. None of the studies used sham acupuncture as a control, preventing determination of the specific effect of acupuncture versus placebo effects. The heterogeneity between studies made it impossible to perform a meta-analysis, limiting the ability to provide precise estimates of effect size.

Although the initial results are encouraging and suggest that acupuncture may offer benefits for women with mixed urinary incontinence, especially in terms of reducing urinary leakage and improving quality of life, more high-quality evidence is needed before definitive recommendations can be made. Future research should include studies with larger samples, more rigorous methodology including controls with sham acupuncture, standardization of treatment protocols, and long-term follow-up to evaluate the durability of benefits. The low incidence of adverse effects is promising and suggests that acupuncture may be a safe option to explore in discussions between patients and health professionals, particularly when conventional treatments are not well tolerated or do not provide adequate symptom relief.