The Aging Male
ISSN: 1368-5538 (Print) 1473-0790 (Online) Journal homepage: http://www.tandfonline.com/loi/itam20
Association of auricular reflective points and the status of lower urinary tract symptoms in aging males Lorna KP Suen, Chao Hsing Yeh, Wing Ki Lee, Wai Leung Chu, June FY Loo & Wai Huen Tam To cite this article: Lorna KP Suen, Chao Hsing Yeh, Wing Ki Lee, Wai Leung Chu, June FY Loo & Wai Huen Tam (2015) Association of auricular reflective points and the status of lower urinary tract symptoms in aging males, The Aging Male, 18:3, 149-156, DOI: 10.3109/13685538.2015.1027679 To link to this article: http://dx.doi.org/10.3109/13685538.2015.1027679
Published online: 01 Jun 2015.
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Date: 05 November 2015, At: 23:06
http://informahealthcare.com/tam ISSN: 1368-5538 (print), 1473-0790 (electronic) Aging Male, 2015; 18(3): 149–156 ! 2015 Informa UK Ltd. DOI: 10.3109/13685538.2015.1027679
ORIGINAL ARTICLE
Association of auricular reflective points and the status of lower urinary tract symptoms in aging males Downloaded by [Texas A & M International University] at 23:06 05 November 2015
Lorna KP Suen1, Chao Hsing Yeh2, Wing Ki Lee3, Wai Leung Chu4, June FY Loo5, and Wai Huen Tam6 1
School of Nursing, The Hong Kong Polytechnic University, Hong Kong, P.R. China, 2School of Nursing, University of Pittsburgh, Pittsburgh, USA, Bamboos Professional Nursing Service Limited, Hong Kong, P.R. China, 4Yan Chai Hospital, Hong Kong, P.R. China, 5Caritas Chan Chun Ha Hostel, Hong Kong, P.R. China, and 6Christian Family Service Centre, Hong Kong, P.R. China
3
Abstract
Keywords
Objective: This study aimed to investigate the association between auricular reflective points and the status of lower urinary tract symptoms (LUTS) among Chinese aging males. Methods: A total of 113 male participants, with 69 having LUTS (LUTS+ve) and 44 having no LUTS (LUTSve), were recruited for this case–control study. Ear diagnosis was conducted in three ways: inspection, electrical skin resistance measurement, and tenderness testing. Results: Quality of life was lower among the LUTS+ve cases than among the LUTSve cases. The tenderness and electrical conductivity of a number of auricular points, including the ‘‘angle of superior concha’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, the ‘‘urethra’’, and the ‘‘internal genitals’’ were associated with LUTS in the Chinese aging males. In terms of electrical conductivity, the ‘‘angle of superior concha’’ on both ears exhibited the highest sensitivity among the other auricular points under testing. This auricular point also demonstrated considerable sensitivity, specificity, and positive/negative predictive values for both ears during the tenderness testing. Conclusions: Auricular diagnosis has a pre-diagnostic value and could be considered as a screening method for the aging population with relatively high LUTS risk.
Aging, auricular diagnosis, elders, lower urinary tract symptoms, males
Introduction The prevalence of lower urinary tract symptoms (LUTS) is considerably high among aging males. Historically known as prostatism, LUTS refers to a set of symptoms resulting from the compression or obstruction of the urethra and irritating voiding disturbances [1]. Aging has been considered a major risk factor for LUTS, with men over 60 years of age experiencing two-fold the odds of moderate or severe LUTS compared with men younger than 40 years [1]. LUTS is a collective term that refers to storage symptoms related to the bladder, voiding symptoms related to the outlet, post-micturition symptoms, or a combination of the three symptoms that affect the lower urinary tract. The characteristics of storage include urinary frequency, urgency, nocturia and urge incontinence; voiding symptoms include slow stream, splitting or spraying, intermittency, hesitancy, straining, incomplete emptying and terminal dribble; and postmicturition symptoms include dribbling and feeling of incomplete emptying [2]. Even though LUTS may manifest
Address for correspondence: Lorna KP Suen, School of Nursing, The Hong Kong Polytechnic University, HungHom, Hong Kong. E-mail: [email protected]
History Received 3 February 2015 Revised 4 March 2015 Accepted 6 March 2015 Published online 1 June 2015
in people with detrusor muscle weakness, overactive bladder, prostatitis, urinary tract infection, low testosterone, or prostatic cancer [3–5], its principal underlying cause is benign prostatic hyperplasia (BPH) of the prostate gland [6]. Existing Western diagnostic methods for LUTS begin with a thorough and focused acquisition of the patient’s medical history, followed by a physical examination, which includes a digital rectal examination, uroflowmetry, urine analysis, prostate specific antigen, urinary cytology, ultrasound, imaging, cystoscopy, urodynamic pressure flow study, and a measurement of post-void residual volume [7,8]. Generally, these diagnostic methods for LUTS are time consuming, invasive and costly [8]. Although LUTS is mostly not a life-threatening condition, its prevalence and severity in aging males can be progressive [9]. More important, LUTS is associated with serious medical morbidities, such as an increased risk of falls, an increased risk of depression and a diminished quality of life (QoL) [9]. The considerable negative impact of LUTS on QoL can be significant and has been well documented [1,4,8,10–12]. As the population ages, the incidence and prevalence of LUTS increase rapidly. LUTS and its morbidities contribute to heightened annual health care expenses. Therefore, simple, non-invasive and inexpensive methods for the early screening
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of LUTS and for identifying the LUTS status of the public are necessary. Auricular diagnosis, using the reactive ear points to identify body pathology may be used as a complementary approach for screening LUTS condition. The ear was first reported in the earliest Chinese medical book Yellow Emperor’s Classics of Internal Medicine, which was published more than 2000 years ago. The book states that the ear is related to all parts of the human body [13]. The Chinese Association of Acupuncture and Moxibustion was entrusted by the World Health Organization (WHO) to standardize the auricular acupoint locations so as to facilitate the exchange of ideas in research and practice [13]. The first document was accomplished in 1992 (GB/T 13734-1992) but was published in 1993 [14]. The latest nomenclature and location of auricular points announced by the China Standardization Organizing Committee in 2008 (GB/T 137342008) is more comprehensive in that it has added further elements about the anatomical classification of the different parts of the auricle and included the comments of different authors on the location of each point. Auricular signs, which are distributed as the projection of an inverted fetal homunculus that refers to the associated organs of the body, have been reported in previous studies to be associated with body functions. Such attributes may include variations in shape, color, size, and sensation; appearance of papules, creases, and edema; and increased tenderness or decreased electrical conductivity [15–18]. From the perspectives of traditional Chinese medicine (TCM), abnormal hair growth on the ear is a sign of hormonal changes accompanying the decline in kidney-qi (energy flow of the kidneys) [16]. In a recent study conducted on auricular diagnosis and coronary heart disease (CHD) [19], the participants with CHD exhibited earlobe crease; the same was not observed among the participants without CHD. The ‘‘heart’’ zone of the CHD cases significantly showed higher conductivity and tenderness in both ears compared with that of the controls. For example, BPH is considered to be caused by deficiency of the kidney-qi and the accumulation of heat and dampness in the ‘‘lower jiao’’ (pelvic cavity). Severe tenderness or nodular scleroma on the ‘‘angle of superior concha’’ and the ‘‘urethra’’ is reportedly associated with the hyperplasia of the prostate [13]. Given that auricular diagnosis is an objective, painless and non-invasive method that provides rapid access to information, the association between auricular signals and LUTS is further investigated in the present study through a systematic method involving inspection, electrical skin resistance measurement and tenderness testing. Such an investigation would help extrapolate the research findings to the aging male population for purposes of early LUTS screening, through which further diagnosis and treatment could be given. Aim and objectives This study aims to investigate the association between auricular reflective points and the status of LUTS among Chinese aging males. The objectives of this study include the following: (1) To determine whether significant differences exist in the skin surface change of specific auricular points in aging males with and without LUTS; (2) To ascertain whether significant differences exist in the electrical skin resistance on
Aging Male, 2015; 18(3): 149–156
Figure 1. Selected auricular acupoints associated with lower urinary tract symptoms.
specific auricular points in aging males with and without LUTS; (3) To identify whether significant differences exist in the tenderness in the specific auricular points in aging males with and without LUTS. The six specific auricular points included in this study are the ‘‘angle of superior concha’’, the ‘‘internal genitals’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, and the ‘‘urethra.’’ The location of these specific auricular points in the Chinese Standard Ear-Acupoint Chart is displayed in Figure 1. The ‘‘angle of superior concha’’ is also known as the ‘‘prostate’’ and has high predictive value in cases with BPH [20]; the rest of the acupoints are related to the urinary tract system. Point selection was studied through a consultation with a registered TCM practitioner.
Methods Settings and participants A total of 113 male participants from five elderly centers in Hong Kong were recruited for this case–control study. The group of participants comprised of 69 male individuals with LUTS (LUTS+ve) and 44 controls (LUTSve). The LUTS+ve cases included those who were verified to have LUTS based on an International Prostate Symptom Score (IPSS) of 8 or above (moderately symptomatic) and a maximum urinary flow rate (Qmax) 515 mL/s, as measured by a uroflowmeter (Model: FloPoint Elite Uroflow System, Bothell, USA) [21,22]. The controls included those who were verified to not have LUTS, as determined using the criteria mentioned above. Only the subjects who were aged 60 years or above during the study period and those who did not meet any of the exclusion criteria were invited to participate in the study.
DOI: 10.3109/13685538.2015.1027679
The exclusion criteria were as follows: clients who (1) were anticipating to receive or had undergone minimal invasive therapies (such as transurethral microwave heat treatments and stent insertion) or surgical interventions of any kind (such as transurethral resection of the prostate and transurethral laser vaporization/coagulation) in the past three months; (2) were currently undergoing pharmacotherapy for BPH; (3) had prostate cancer history; (4) had damaged kidney functions; (5) were mentally incapable of evaluating his LUTS; or (6) had infections that might affect the shape of the ears.
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Data collection The medical history of each participant was taken, and a health assessment was performed. The health assessment covered the duration of LUTS, the number of comorbid illnesses, the IPSS, and the Qmax. Ear diagnosis was conducted by using three methods, namely, inspection, electrical detection and tenderness testing. The researcher involved in the auricular examination was blinded to the grouping of the subjects. (a) Visual inspection: Both auricles were observed for auricular signals, such as discoloration and/or the presence of nodular scleroma, on the specific auricular points. (b) Electrical skin resistance measurement: An electrical acupoint detector (Pointer PlusÔ) [23] was used to measure auricular electrical resistance in the specific auricular points. An individual threshold was set for each subject before the ear acupoints were assessed using ‘‘shenmen’’ acupoint as a reference. The threshold was set by placing an acupoint detector on the ‘‘shenmen’’ and increasing detection sensitivity until the sound, lights, or visual meter on the equipment indicated high electrical conductance. The sensitivity was then reduced slightly until the ‘‘shenmen’’ point was only barely picked up [13,24]. If the acupoints under testing indicated a higher conductivity compared with the ‘‘Shenmen’’ (reference point), the results was taken as ‘‘positive’’; and vice versa. During the testing, the skills were closely observed. For example, the detector can easily miss a reactive ear point when moved too quickly, and applying excessive pressure with the detector may create a false positive result because of the increased electrical contact with the skin. Ear cleaning prior to the testing was not allowed. If the examination were to be conducted in cold weather, the client would rest for at least 10 min in room temperature before the procedure. (c) Tenderness testing: A pressure algometer (force gauge) with a unit range of 0–500 g was used to apply force in this region, again with the ‘‘shenmen’’ as reference. The researcher recorded the observed value (g) once the subject started to feel a tender sensation after the application of the pointer of the device on the acupoints under testing. If the acupoints under testing indicated a lower tolerance in tenderness when compared with the ‘‘Shenmen’’ (reference point), the results was taken as ‘‘positive’’; and vice versa. There might be situation when the reading of the acupoint under testing was identical (i.e. equal) with the ‘‘Shenmen’’ point.
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The research assistant (RA) involved in this project received formal training about the project, the use of equipment for measurement, and the conduct of the auricular examination. The formal training was given by the first author who holds a Certificate in Auriculotherapy from the Auriculotherapy Certification Institute, Inc., USA. Return demonstration from the RA was required to ensure his understanding of the execution of the auricular examination. Both the RA and the first author of this project were involved in the assessment of auricular diagnosis. To establish the reliability of the auricular examinations, an inter-observer agreement between the first author and the RA was recorded for 10 cases and the inter-observer agreement was 90%. When discrepancies in the assessment of the two raters emerged, a consensus was sought after discussion. To avoid observer bias, the raters were blinded to the grouping of the subjects. Measures (a) IPSS – Hong Kong Chinese Version 2: The IPSS was originally developed by the American Urological Association and was adopted by the WHO in 1993 [25]. The instrument consists of seven Likert-scale questions [with scores ranging from 0 (‘‘not at all’’) to 5 (‘‘almost always’’)] related to LUTS, which result in a total score ranging from 0 to 35. Three questions involve filling problems (daytime frequency and nocturnal urgency), and four questions assess voiding problems (emptying, intermittency, weak stream, and straining). The instrument also includes one question that evaluates the impact of urinary symptoms on QoL, with the score ranging from 0 (‘‘delighted’’) to 6 (‘‘terrible’’). This question helps in assessing the severity of LUTS. The IPSS (Hong Kong Chinese version 2) has been recently validated and found to be a valid, reliable and sensitive measure for assessing Chinese populations with LUTS (Cronbach’s alpha coefficient ¼ 0.71, ICC of the symptom questions ¼ 0.80, ICC of the QoL ¼ 0.70) [26]. (b) The participants were asked to urinate into a special funnel connected to a portable uroflowmeter (Model: FloPoint Elite Uroflow System), which then measured the Qmax per second and evaluated the severity of urinary obstruction. The device was calibrated before use. To ensure that the participants had a full bladder prior to the testing, they were reminded to drink more water and not to void before going to the center. Voids of less than 150 mL were repeated to increase the validity of the findings [27]. Data analyses Chi-square test was used to determine the association between LUTS status and the presence or absence of auricular signals. However Fisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom [28]. The sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) of the acupoints under testing were computed. A multivariate logistic regression analysis was conducted to examine whether the LUTS status of the subjects was associated with a number of auricular
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signals, problem duration and number of comorbid illnesses. Analyses were conducted using SPSS version 21.0 (Armonk, NY: IBM Corp.); or the R Foundation for Statistical Computing (3.0.2 for Windows) was used if Fisher’s exact test was performed. A p value of 50.05 was considered statistically significant.
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Ethical considerations Ethical approval from the university with which the first author is affiliated was sought. Written informed consent was obtained from all the participants. The purpose and procedures of the study were explained verbally and in writing to the participants. Participation in the study was voluntary, and all participants were assured of their right to refuse or withdraw from the study at any time. Personal information and data remained confidential and anonymous.
Results Demographic characteristic and LUTS conditions of the participants A total of 113 male participants from five elderly centers in Hong Kong were evaluated. The mean ages were 74.36 years (S.D. ¼ 7.59) for the LUTS+ve group (n ¼ 69) and 70.93 years for the LUTSve group (n ¼ 44). No significant differences were observed in the presence of comorbid illnesses in the two groups. The mean IPSS score of the participants from the LUTS+ve group and the LUTSve group were 14.64 (S.D. ¼ 5.93) and 3.09 (S.D. ¼ 2.84), respectively. We noted statistically significant differences in each domain of the IPSS scale between the two groups in terms of the symptoms related to LUTS, including incomplete emptying (p50.001), frequency (p50.001), intermittency (p50.001), urgency (p50.001), weak stream (p50.001), straining (p50.001), and nocturia (p50.001). The mean Qmax values of the participants from the LUTS+ve group and the LUTSve group were 8.40 mL/s (S.D. ¼ 3.45) and 17.94 mL/s (S.D. ¼ 14.77), respectively, with the former group reporting a significantly low QoL (Table 1). Association of specific acupoints and LUTS status The auricular signals that were observed on the participants from the LUTS+ve group were compared with those on the participants from the LUTSve group using the three methods of ear diagnosis. The six specific acupoints under testing were the ‘‘angle of superior concha’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, the ‘‘urethra’’, and the ‘‘internal genitalis.’’ (a) Visual inspection: Generally, no significant differences were observed in the discoloration and the presence of nodular scleroma in the specific acupoints of the LUTS+ve and LUTSve groups. (b) Electrical skin resistance measurement: Nearly all the specific acupoints on the participants from the LUTS+ve group (except the ‘‘urethra’’ on both ears and the ‘‘ureter’’ on the left ears) indicated a significantly higher conductivity compared with those on the participants from the LUTSve group (Table 2). (c) Tenderness testing: Unlike those from the LUTSve group, the participants from the LUTS+ve group
Aging Male, 2015; 18(3): 149–156
experienced significant tenderness on almost all the specific acupoints, except on the ‘‘angle of superior concha’’ and the ‘‘urinary bladder’’ on the right ears (Table 2).
Predictive power of various acupoints on the risk of LUTS (a) Electrical skin resistance measurement: The electrical conductivity of the ‘‘angle of superior concha’’ on the right ears of the participants exhibited the highest sensitivity of 0.74 and an NPP value of 0.58. The ‘‘kidney’’ had the highest specificity of 0.68 and a PPV value of 0.76. The ‘‘angle of superior concha’’ on the left ear indicated the highest sensitivity (0.70), PPV (0.73), and NPV (0.55) (b) Tenderness testing: The ‘‘angle of superior concha’’ demonstrated considerable sensitivity, specificity, PPV, and NPC on both ears during the tenderness testing (Table 3). Multivariate analysis Multivariate logistic regression analysis was conducted to examine the association of the LUTS status of the subjects with a number of auricular signals after controlling for the significant risk factors (age, comorbid illness, discoloration, electrical conductivity and tenderness of a number of auricular signals on the left and right ears). Backward stepwise logistic regression was employed, and the auricular signals that demonstrated statistical significance (using p50.05 for entry and p40.10 for removal) were retained in the final model (Table 4). The overall multivariate model was significant (X2 ¼ 26.906, p50.001) and correctly classified in 74.1% of the subjects. The result of the Hosmer–Lemeshow test indicated that the model effectively fitted the data (p ¼ 0.088). In the final model, four independent variables made a statistically significant contribution at the 5% level. The strong predictors in descending order were the presence of tenderness in the ‘‘angle of superior concha’’ (left) (adjusted OR ¼ 3.174, 95% CI ¼ 1.211–8.319), the presence of electrical conductivity in the ‘‘angle of superior concha’’ (left) (adjusted OR ¼ 3.029, 95% CI ¼ 1.107–8.288), and the electrical conductivity in the ‘‘kidney’’ (right) (adjusted OR ¼ 2.719, 95% CI ¼ 1.045–7.077) after adjustment of age. This result indicated that the respondents who reported the presence of tenderness or electricity conductivity in the ‘‘angle of superior concha’’ (left) were around three times more likely to have LUTS than those who did not. In addition, the respondents who reported the presence of electrical conductivity in the ‘‘kidney’’ (right) were 2.7 times more likely to have LUTS than those who did not. The odd ratio of age (adjusted OR ¼ 1.102, 95% CI ¼ 1.028–1.181) indicated that the likelihood of having LUTS increased 1.1 times (or 10.2%) for every one year of age increase.
Discussion This study adopted a systematic and scientific approach using visual inspection, electrical skin resistance measurement, and
Association of auricular reflective points and LUTS
DOI: 10.3109/13685538.2015.1027679
Table 1. Socio-demographic data and LUTS-related conditions of participants.
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Age (years)
LUTS +ve (n ¼ 69)
LUTS –ve (n ¼ 44)
Test statistics
74.36 (7.59)
70.93 (6.43)
Mann–Whitney U-test p50.05* X2 ¼ 0.84 df ¼ 1 p40.05
Comorbid Illness No Yes
20 49
12 32
International Prostate Symptoms Score (IPSS) Incomplete emptying 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
19 12 7 6 3 22
34 5 0 2 2 1
p50.001*
Frequency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
13 8 2 10 5 31
38 4 0 1 1 0
p50.001*
Intermittency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always Urgency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
40 10 7 5 7 18
40 6 0 0 0 2
p50.001*
39 8 3 3 2 14
36 3 1 0 1 3
p50.001*
Weak stream 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
34 7 5 3 4 16
38 3 2 0 0 1
p50.001*
Straining 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
48 7 4 4 1 5
43 1 0 0 0 0
p50.001*
Nocturia 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
2 6 25 18 14 4
10 21 7 4 2 0
p50.001*
Overall IPSS score (cases were 8 or above) Maximum urinary flow rate (Qmax) (cases were 515 mL/second) Quality of life (7 levels) 0 ¼ Delighted 1 ¼ Pleased 2 ¼ Mostly satisfied 3 ¼ Mixed 4 ¼ Mostly dissatisfied 5 ¼ Unhappy 6 ¼ Terrible
14.64 (5.93)
3.09 (2.84)
p50.001*
8.40 (3.45)
17.94 (14.77)
p50.001*
0 3 10 30 16 7 3
6 3 24 9 2 0 0
p50.001*
Fisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom. *Statistically significant.
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Aging Male, 2015; 18(3): 149–156
Table 2. Auricular signals between cases and controls assessed by electrical skin resistance measurement (conductivity) and tenderness testing.
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Test statistics (chi-square test or Fisher’s LUTS +ve LUTS –ve exact test)y (n ¼ 69) (n ¼ 44) Electrical skin resistance measurement (conductivity) Right ear Angle of superior concha positive 18 25 negative 51 19 Urinary bladder positive 20 22 negative 49 22 Ureter positive 23 24 negative 46 20 Kidney positive 24 30 negative 45 14 Urethra positive 28 24 negative 41 20 Internal genitalis positive 28 28 negative 41 16 Left ear Angle of superior concha positive 21 26 negative 48 18 Urinary bladder positive 25 25 negative 44 19 Ureter positive 30 27 negative 39 17 Kidney positive 26 26 negative 43 18 Urethra positive 26 24 negative 43 20 Internal genitalis positive 26 28 negative 43 16 Tenderness testing Right ear Angle of superior concha positive negative Equal Urinary bladder positive negative Equal Ureter positive negative Equal Kidney positive negative Equal Urethra positive negative Equal Internal genitalis positive negative Equal
p50.01* p50.05* p50.05* p50.001* p>0.05 p50.05*
p50.01* p50.05*
Table 2. Continued
Test statistics (chi-square test or Fisher’s LUTS +ve LUTS –ve exact test)y (n ¼ 69) (n ¼ 44) Left ear Angle of superior concha positive negative Equal Urinary bladder positive negative Equal Ureter positive negative Equal Kidney positive negative Equal Urethra positive negative Equal Internal genitalis positive negative Equal
28 38 3
26 16 2
p50.001*
29 23 7
22 19 3
p50.05*
34 31 4
20 19 5
p50.05*
34 32 3
19 20 5
p50.05*
38 31 0
15 24 5
p50.001*
31 35 3
19 22 3
p50.001*
*Statistically significant. yFisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom.
p>0.05 p50.05* p>0.05 p50.05*
33 32 4
30 11 3
p>0.05
34 31 4
25 14 5
p>0.05
32 34 3
22 19 3
p50.01*
35 27 7
21 22 1
p50.001*
35 30 4
22 19 3
p50.05*
36 30 3
17 25 2
p50.001*
(continued )
tenderness testing to investigate auricular signals and their relationship with LUTS status. French physician Dr Paul Nogier [29] hypothesized that the human body can be projected into the auricle just as it can be projected into the brain cortex. This idea accords with the following ancient Chinese medical text (‘‘Lingshu Jing’’, also known as ‘‘Divine Pivot’’): ‘‘the ears are the confluence of the channels.’’ From the perspective of TCM, this text implies that the ears are related to the internal organs through the channels and collaterals and that they are directly or indirectly related to the 12 main pairs of meridians (channels) that run through the human body [30]. Participants from the LUTS+ve group, especially those with moderate to severe LUTS, experienced a lower QoL compared with those from the LUTSve group. This result concurs with those of other studies on LUTS and QoL, which found that LUTS can significantly lower QoL in aging men [1, 4, 7, 9–11] and that it is particularly associated with poor sleep quality [10]. The participants of the present study mentioned that when outside their homes, they must constantly and repeatedly look for washrooms. This condition had made them reluctant to go out, which they would only do when necessary. Waking up frequently during the night to urinate or waking up in the early morning and not being able to fall back to sleep after urination was continually reported by many of the participants. These issues reduce QoL drastically. Therefore, an early diagnosis would benefit patients with LUTS, as they could be given early treatment to improve their QoL. The participants from the LUTS+ve
Association of auricular reflective points and LUTS
DOI: 10.3109/13685538.2015.1027679
Table 3. Predictive power of various acupoints on the risk of LUTS assessed by electrical skin resistance measurement (conductivity) and tenderness testing.
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Positive Negative Sensitivity Specificity predictive predictive value (%) value (%) (%) (%) Electrical skin resistance measurement (conductivity) Right ear Angle of superior concha 0.74 0.57 0.73 Urinary bladder 0.71 0.50 0.69 Ureter 0.67 0.55 0.70 Kidney 0.65 0.68 0.76 Urethra 0.59 0.55 0.67 Internal genitalis 0.59 0.64 0.72 Left ear Angle of superior concha 0.70 0.59 0.73 Urinary bladder 0.64 0.57 0.70 Ureter 0.57 0.61 0.70 Kidney 0.62 0.59 0.70 Urethra 0.62 0.55 0.68 Internal genitalis 0.62 0.64 0.73 Tenderness testing Right ear Angle of superior concha 0.49 0.73 0.74 Urinary bladder 0.48 0.64 0.69 Ureter 0.52 0.54 0.64 Kidney 0.52 0.49 0.55 Urethra 0.46 0.54 0.61 Internal genitalis 0.45 0.40 0.55 Left ear Angle of superior concha 0.58 0.62 0.70 Urinary bladder 0.44 0.54 0.55 Ureter 0.48 0.51 0.62 Kidney 0.48 0.49 0.62 Urethra 0.45 0.38 0.56 Internal genitalis 0.53 0.46 0.61
0.58 0.52 0.51 0.56 0.46 0.50 0.55 0.50 0.47 0.50 0.48 0.40 0.48 0.42 0.41 0.46 0.39 0.32 0.48 0.43 0.37 0.36 0.28 0.38
Figures in bold indicate the highest among the acupoints under testing on each side of ear. Sensitivity (true positive) ¼ number of true positives/number of true positives + number of false negatives. Specificity (true negative) ¼ number of true negatives/number of true negatives + number of false positives. Positive predictive value ¼ number of true positives/number of true positives + number of false positives. Negative predictive value ¼ number of true negatives/number of true negatives + number of false negatives.
Table 4. Multivariate analyses.
Variable
Adjusted Odds ratios
95% CI
p value of Wald statistic
Tenderness of ‘‘Angle of superior concha’’ (Left)y Present Absent
3.174 1.000
1.211–8.319
0.019*
Electrical conductivity of ‘‘Angle of superior concha’’ (Left)y Present Absent
3.029 1.000
1.107–8.288
0.031*
Electrical conductivity of ‘‘Kidney’’ (Right) y Present Absent Age
2.719 1.000 1.102
1.045–7.077
0.040*
1.028–1.181
0.006*
CI ¼ confidence interval. *Statistically significant; yCompared with reference point ‘‘Shenmen’’.
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group were generally older than those from the LUTS–ve group. In the former, the likelihood of having LUTS increased 1.1 times (or 10.2%) for every one year of age increase, as shown in the multivariate analysis. This finding also accords with a previous study that found that the prevalence of LUTS increases as men age, given that aging was observed to be a major risk factor for LUTS [1]. The visual inspection of the acupoints under testing may not be a reliable measure for detecting LUTS status, at least in this study. Meanwhile, nearly all specific acupoints on the participants from the LUTS+ve group indicated a significantly higher conductivity than those on the participants from the LUTSve group. The electrical resistance in corresponding auricular points reportedly decreases when a disease or disorder is present in the body. From a physiological perspective, the changes in electrical resistance in auricular points can be the result of a change in electrical resistance in underlying cell membranes, in which the signal is transmitted to the central nervous system through the meridians and then to the corresponding auricular points, after which electrical resistance changes [31]. Unlike those from the LUTSve group, the participants from the LUTS+ve group experienced significant tenderness on almost all specific acupoints in both ears as detected by the pressure algometer. The degree of tenderness was usually related to the severity of the condition, that is, a highly sensitive point equates to a highly severe disorder [15,32]. Oleson [33] demonstrated in an animal experiment that the skin acupoints on dogs show significantly higher concentrations of substance P compared with the acupoints of the controls. Substance P is a spinal neurotransmitter found in afferent C-fibers involved in pain transmission. Therefore, an increase in substance P decreases the pain threshold and causes the auricular points to become tender when touched. For the predictive power of various acupoints on the risk of LUTS, the ‘‘angle of superior concha’’ appeared to have considerable sensitivity, specificity, PPV and NPV when compared with the other selected points in both ears. This result can be explained by the fact that this acupoint is known as the ‘‘prostate’’ of the human body [18]. The findings of this study enhance our understanding of the association between specific auricular reflective signs and the status of LUTS in the male population. They also add to our knowledge of the integrated approach to combining Chinese and Western models of care for diagnosing people with LUTS. Even though the principal underlying cause of LUTS is BPH of the prostate gland [5], this condition may be associated with much severe conditions, such as prostatitis, urinary tract infection, or prostatic cancer [3,4]. Given that auricular diagnosis is speculated to have a pre-diagnostic value and is important in the secondary level of prevention, further diagnosis and early treatment could be given. As the ear is a valuable tool for revealing constitutional predispositions, auricular diagnosis can be used as a simple, effective, and inexpensive complementary approach for aging males who may be vulnerable to LUTS. Limitations of this study Although the association between the selected acupoints under testing and LUTS status was suggested in this study, the
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mechanisms leading to the time of onset of auricular signals remains unknown. A prospective cohort study should be conducted in the future to follow-up on the cases with LUTS detected at an early stage. Such study could be performed to identify changes in the auricular signals that may have appeared during disease progression. The present study was conducted on a relatively small sample. Therefore, further investigations could be performed with a large sample to validate the use of auricular signs as predictors that assist in the detection of LUTS status. Our work was based on Chinese men, and the auricular signals may be governed by ethnic differences. Thus, additional research is required before the results can be extrapolated to other ethnic groups.
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Conclusion People with LUTS have a relatively lower QoL compared with those who do not have this condition. The results of this study suggest that electrical conductivity and tenderness of a number of auricular points, including the ‘‘angle of superior concha’’, the ‘‘internal genitals’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, and the ‘‘urethra’’, are associated with LUTS condition in Chinese aging males. Auricular diagnosis could be considered as a screening method for the aging population with a relatively high LUTS risk. Through this approach, early diagnosis and appropriate treatment can be given for people with this condition.
Acknowledgements We thank Mr. Dino Wong (Registered TCM practitioner of Hong Kong) for his valuable advice on the selection of acupoints. We also extend our appreciation to the subjects for their participation in and support for this study.
Declaration of interest The authors have declared that no conflict of interest exists. This project was supported by the Division of Transitional, Supportive, and Palliative care (TSP), School of Nursing, The Hong Kong Polytechnic University.
References 1. Gao Y, Wang M, Zhang H, et al. Are metabolic syndrome and its components associated with lower urinary tract symptoms? Results from a Chinese male population survey. Urology 2012;79:194–201. 2. Oelke M, Burger M, Castro-diaz D, et al. Diagnosis and medical treatment of lower urinary tract symptoms in adult men: applying specialist guidelines in clinical practice. Brit J Urol Int 2012;110: 710–18. 3. Ford AP, Gever JR, Nunn PA, et al. Purinoceptors as therapeutic targets for lower urinary tract dysfunction. Brit J Pharmacol 2006; 147:S132–43. 4. Nickel JC. Lower urinary tract symptoms associated with prostatitis. Can Urol Asso J 2012;6:S133. 5. Lunenfeld B, Mskhalaya G, Zitzmann M, et al. Recommendations on the diagnosis, treatment and monitoring of hypogonadism in men. Aging Male 2015;18(1):5–15. 6. Abrams P. New words for old: lower urinary tract symptoms for prostatism. BMJ 1994;308:929. 7. Priest R, Garzotto M, Kaufman J. Benign prostatic hyperplasia: a brief overview of pathogenesis, diagnosis, and therapy. Tech Vascular & Interv Radiol 2012;15:261–4.
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8. Urology Care Foundation. Management of benign prostatic hyperplasia (BPH); 2011. Available from: http://www.urologyhealth. org/urology/index.cfm?article=144 [last accessed 27 Jan 2015]. 9. Parsons JK. Benign prostatic hyperplasia and male lower urinary tract symptoms: epidemiology and risk factors. Curr Bladder Dys Rep 2010;5:212–18. 10. Wong S, Hong A, Leung J, et al. Lower urinary tract symptoms and depressive symptoms in elderly men. J Affect Dis 2006;96: 83–8. 11. Coyne KS, Sexton CC, Irwin DE, et al. The impact of overactive bladder, incontinence and other lower urinary tract symptoms on quality of life, work productivity, sexuality and emotional wellbeing in men and women: results from the EPIC study. Brit J Urol Int 2008;101:1388–95. 12. Speakman MJ, Kirby RS, Joyce A, et al. Guideline for the primary care management of male lower urinary tract symptoms. Brit J Urol Int 2004;93:985–90. 13. Feng CX, Bai XH, Du Y. Chinese auricular therapy [ ]. Beijing: Scientific and Technical Documents Publishing House; 1994. (Chinese-English edition). 14. Nomenclature and location of auricular points (GB/T 13734-2008), China Standardization Organizing Committee. Beijing: China Zhijian Publishing House and Standards Press of China; 2008. 15. Oleson T. Auriculotherapy manual. 4th ed. Edinburgh: Churchill Livingstone Elsevier; 2014. 16. Abbate S. Chinese auricular acupuncture. Boca Raton: CRC Press; 2004. 17. Yeh CH, Huang LC. Comprehensive and systematic auricular diagnosis protocol. Med Acup 2013;25:423–35. 18. Romoli M. Auricular acupuncture diagnosis. Edinburgh: Churchill Livingstone Elsevier, 2010. 19. Suen LKP, Lau YK, Ma HC, et al. Predictive value of auricular diagnosis on coronary heart disease. EB-CAM; 2012 doi:10.1155/ 2012/706249. 20. Wang ZH, Zeng Q, Wang SX, Lin MH, Wang K. The application of angle of superior concha in clinical diagnosis. Chin Acup & Moxi 1999;11:673–4. 21. Roberts RO, Lieber MM, Jacobson DJ, et al. Limitations of using outcomes in the placebo arm of a clinical trial of benign prostatic hyperplasia to quantify those in the community. Mayo Clin Proceed 2005;80:759–64. 22. Roehrborn CG. BPH progression: concept and key learning from MTOPS, ALTESS, COMBAT, and ALF-ONE. Brit J Urol Int 2008; 3:17–21. 23. Pointer PlusÔ (EC Certificate Registration Number: DD600751270001). Hong Kong: Tens Plus Industrial Company. 24. Huang LC. Auricular diagnosis and treatment. Beijing: Scientific Technology Publisher; 1995 [in Chinese]. 25. O’Leary MP. Validity of the ‘‘bother score’’ in the evaluation and treatment of symptomatic benign prostatic hyperplasia. Rev Urol 2005;7:1–10. 26. Choi EPH, Lam CLK, Chin WY. Validation of the International Prostate Symptom score in Chinese males and females with lower urinary tract symptoms. Health Qual Life Out 2014;12:1. 27. The Flopoint Clinical Application Guide. Verathon Medical. Bothell, WA: Verathon; 2007. 28. Fisher’s exact test. Wikipedia – the Free Encylopedia. http:// en.wikipedia.org/wiki/Fisher’s_exact_test [last accessed 1 Feb 2015]. 29. Ischenko AN, Kozlova VP, Shev’yev PP. Auricular diagnostics used in the system of screening surveys. Med Prog Thro Tech 1991;17: 29–32. 30. Suen LKP, Wong TKS, Leung AWN. Is there a place for auricular therapy in the realm of nursing? Comple Ther Nurs Midwifery 2001;7:132–9. 31. Wang L. Auricular acupuncture – diagnostic therapy. Beijing, China: Science and Technology; 2000. 32. Yuan LR. A brief introduction to ear diagnosis. Euro J Oriental Med 1997;2:34–7. 33. Oleson T. Electrophysiological research on the differential localization of auricular acupuncture points. Med Acup Online J 1999;11 (14 pages).
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Association of auricular reflective points and the status of lower urinary tract symptoms in aging males Lorna KP Suen, Chao Hsing Yeh, Wing Ki Lee, Wai Leung Chu, June FY Loo & Wai Huen Tam To cite this article: Lorna KP Suen, Chao Hsing Yeh, Wing Ki Lee, Wai Leung Chu, June FY Loo & Wai Huen Tam (2015) Association of auricular reflective points and the status of lower urinary tract symptoms in aging males, The Aging Male, 18:3, 149-156, DOI: 10.3109/13685538.2015.1027679 To link to this article: http://dx.doi.org/10.3109/13685538.2015.1027679
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Date: 05 November 2015, At: 23:06
http://informahealthcare.com/tam ISSN: 1368-5538 (print), 1473-0790 (electronic) Aging Male, 2015; 18(3): 149–156 ! 2015 Informa UK Ltd. DOI: 10.3109/13685538.2015.1027679
ORIGINAL ARTICLE
Association of auricular reflective points and the status of lower urinary tract symptoms in aging males Downloaded by [Texas A & M International University] at 23:06 05 November 2015
Lorna KP Suen1, Chao Hsing Yeh2, Wing Ki Lee3, Wai Leung Chu4, June FY Loo5, and Wai Huen Tam6 1
School of Nursing, The Hong Kong Polytechnic University, Hong Kong, P.R. China, 2School of Nursing, University of Pittsburgh, Pittsburgh, USA, Bamboos Professional Nursing Service Limited, Hong Kong, P.R. China, 4Yan Chai Hospital, Hong Kong, P.R. China, 5Caritas Chan Chun Ha Hostel, Hong Kong, P.R. China, and 6Christian Family Service Centre, Hong Kong, P.R. China
3
Abstract
Keywords
Objective: This study aimed to investigate the association between auricular reflective points and the status of lower urinary tract symptoms (LUTS) among Chinese aging males. Methods: A total of 113 male participants, with 69 having LUTS (LUTS+ve) and 44 having no LUTS (LUTSve), were recruited for this case–control study. Ear diagnosis was conducted in three ways: inspection, electrical skin resistance measurement, and tenderness testing. Results: Quality of life was lower among the LUTS+ve cases than among the LUTSve cases. The tenderness and electrical conductivity of a number of auricular points, including the ‘‘angle of superior concha’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, the ‘‘urethra’’, and the ‘‘internal genitals’’ were associated with LUTS in the Chinese aging males. In terms of electrical conductivity, the ‘‘angle of superior concha’’ on both ears exhibited the highest sensitivity among the other auricular points under testing. This auricular point also demonstrated considerable sensitivity, specificity, and positive/negative predictive values for both ears during the tenderness testing. Conclusions: Auricular diagnosis has a pre-diagnostic value and could be considered as a screening method for the aging population with relatively high LUTS risk.
Aging, auricular diagnosis, elders, lower urinary tract symptoms, males
Introduction The prevalence of lower urinary tract symptoms (LUTS) is considerably high among aging males. Historically known as prostatism, LUTS refers to a set of symptoms resulting from the compression or obstruction of the urethra and irritating voiding disturbances [1]. Aging has been considered a major risk factor for LUTS, with men over 60 years of age experiencing two-fold the odds of moderate or severe LUTS compared with men younger than 40 years [1]. LUTS is a collective term that refers to storage symptoms related to the bladder, voiding symptoms related to the outlet, post-micturition symptoms, or a combination of the three symptoms that affect the lower urinary tract. The characteristics of storage include urinary frequency, urgency, nocturia and urge incontinence; voiding symptoms include slow stream, splitting or spraying, intermittency, hesitancy, straining, incomplete emptying and terminal dribble; and postmicturition symptoms include dribbling and feeling of incomplete emptying [2]. Even though LUTS may manifest
Address for correspondence: Lorna KP Suen, School of Nursing, The Hong Kong Polytechnic University, HungHom, Hong Kong. E-mail: [email protected]
History Received 3 February 2015 Revised 4 March 2015 Accepted 6 March 2015 Published online 1 June 2015
in people with detrusor muscle weakness, overactive bladder, prostatitis, urinary tract infection, low testosterone, or prostatic cancer [3–5], its principal underlying cause is benign prostatic hyperplasia (BPH) of the prostate gland [6]. Existing Western diagnostic methods for LUTS begin with a thorough and focused acquisition of the patient’s medical history, followed by a physical examination, which includes a digital rectal examination, uroflowmetry, urine analysis, prostate specific antigen, urinary cytology, ultrasound, imaging, cystoscopy, urodynamic pressure flow study, and a measurement of post-void residual volume [7,8]. Generally, these diagnostic methods for LUTS are time consuming, invasive and costly [8]. Although LUTS is mostly not a life-threatening condition, its prevalence and severity in aging males can be progressive [9]. More important, LUTS is associated with serious medical morbidities, such as an increased risk of falls, an increased risk of depression and a diminished quality of life (QoL) [9]. The considerable negative impact of LUTS on QoL can be significant and has been well documented [1,4,8,10–12]. As the population ages, the incidence and prevalence of LUTS increase rapidly. LUTS and its morbidities contribute to heightened annual health care expenses. Therefore, simple, non-invasive and inexpensive methods for the early screening
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of LUTS and for identifying the LUTS status of the public are necessary. Auricular diagnosis, using the reactive ear points to identify body pathology may be used as a complementary approach for screening LUTS condition. The ear was first reported in the earliest Chinese medical book Yellow Emperor’s Classics of Internal Medicine, which was published more than 2000 years ago. The book states that the ear is related to all parts of the human body [13]. The Chinese Association of Acupuncture and Moxibustion was entrusted by the World Health Organization (WHO) to standardize the auricular acupoint locations so as to facilitate the exchange of ideas in research and practice [13]. The first document was accomplished in 1992 (GB/T 13734-1992) but was published in 1993 [14]. The latest nomenclature and location of auricular points announced by the China Standardization Organizing Committee in 2008 (GB/T 137342008) is more comprehensive in that it has added further elements about the anatomical classification of the different parts of the auricle and included the comments of different authors on the location of each point. Auricular signs, which are distributed as the projection of an inverted fetal homunculus that refers to the associated organs of the body, have been reported in previous studies to be associated with body functions. Such attributes may include variations in shape, color, size, and sensation; appearance of papules, creases, and edema; and increased tenderness or decreased electrical conductivity [15–18]. From the perspectives of traditional Chinese medicine (TCM), abnormal hair growth on the ear is a sign of hormonal changes accompanying the decline in kidney-qi (energy flow of the kidneys) [16]. In a recent study conducted on auricular diagnosis and coronary heart disease (CHD) [19], the participants with CHD exhibited earlobe crease; the same was not observed among the participants without CHD. The ‘‘heart’’ zone of the CHD cases significantly showed higher conductivity and tenderness in both ears compared with that of the controls. For example, BPH is considered to be caused by deficiency of the kidney-qi and the accumulation of heat and dampness in the ‘‘lower jiao’’ (pelvic cavity). Severe tenderness or nodular scleroma on the ‘‘angle of superior concha’’ and the ‘‘urethra’’ is reportedly associated with the hyperplasia of the prostate [13]. Given that auricular diagnosis is an objective, painless and non-invasive method that provides rapid access to information, the association between auricular signals and LUTS is further investigated in the present study through a systematic method involving inspection, electrical skin resistance measurement and tenderness testing. Such an investigation would help extrapolate the research findings to the aging male population for purposes of early LUTS screening, through which further diagnosis and treatment could be given. Aim and objectives This study aims to investigate the association between auricular reflective points and the status of LUTS among Chinese aging males. The objectives of this study include the following: (1) To determine whether significant differences exist in the skin surface change of specific auricular points in aging males with and without LUTS; (2) To ascertain whether significant differences exist in the electrical skin resistance on
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Figure 1. Selected auricular acupoints associated with lower urinary tract symptoms.
specific auricular points in aging males with and without LUTS; (3) To identify whether significant differences exist in the tenderness in the specific auricular points in aging males with and without LUTS. The six specific auricular points included in this study are the ‘‘angle of superior concha’’, the ‘‘internal genitals’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, and the ‘‘urethra.’’ The location of these specific auricular points in the Chinese Standard Ear-Acupoint Chart is displayed in Figure 1. The ‘‘angle of superior concha’’ is also known as the ‘‘prostate’’ and has high predictive value in cases with BPH [20]; the rest of the acupoints are related to the urinary tract system. Point selection was studied through a consultation with a registered TCM practitioner.
Methods Settings and participants A total of 113 male participants from five elderly centers in Hong Kong were recruited for this case–control study. The group of participants comprised of 69 male individuals with LUTS (LUTS+ve) and 44 controls (LUTSve). The LUTS+ve cases included those who were verified to have LUTS based on an International Prostate Symptom Score (IPSS) of 8 or above (moderately symptomatic) and a maximum urinary flow rate (Qmax) 515 mL/s, as measured by a uroflowmeter (Model: FloPoint Elite Uroflow System, Bothell, USA) [21,22]. The controls included those who were verified to not have LUTS, as determined using the criteria mentioned above. Only the subjects who were aged 60 years or above during the study period and those who did not meet any of the exclusion criteria were invited to participate in the study.
DOI: 10.3109/13685538.2015.1027679
The exclusion criteria were as follows: clients who (1) were anticipating to receive or had undergone minimal invasive therapies (such as transurethral microwave heat treatments and stent insertion) or surgical interventions of any kind (such as transurethral resection of the prostate and transurethral laser vaporization/coagulation) in the past three months; (2) were currently undergoing pharmacotherapy for BPH; (3) had prostate cancer history; (4) had damaged kidney functions; (5) were mentally incapable of evaluating his LUTS; or (6) had infections that might affect the shape of the ears.
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Data collection The medical history of each participant was taken, and a health assessment was performed. The health assessment covered the duration of LUTS, the number of comorbid illnesses, the IPSS, and the Qmax. Ear diagnosis was conducted by using three methods, namely, inspection, electrical detection and tenderness testing. The researcher involved in the auricular examination was blinded to the grouping of the subjects. (a) Visual inspection: Both auricles were observed for auricular signals, such as discoloration and/or the presence of nodular scleroma, on the specific auricular points. (b) Electrical skin resistance measurement: An electrical acupoint detector (Pointer PlusÔ) [23] was used to measure auricular electrical resistance in the specific auricular points. An individual threshold was set for each subject before the ear acupoints were assessed using ‘‘shenmen’’ acupoint as a reference. The threshold was set by placing an acupoint detector on the ‘‘shenmen’’ and increasing detection sensitivity until the sound, lights, or visual meter on the equipment indicated high electrical conductance. The sensitivity was then reduced slightly until the ‘‘shenmen’’ point was only barely picked up [13,24]. If the acupoints under testing indicated a higher conductivity compared with the ‘‘Shenmen’’ (reference point), the results was taken as ‘‘positive’’; and vice versa. During the testing, the skills were closely observed. For example, the detector can easily miss a reactive ear point when moved too quickly, and applying excessive pressure with the detector may create a false positive result because of the increased electrical contact with the skin. Ear cleaning prior to the testing was not allowed. If the examination were to be conducted in cold weather, the client would rest for at least 10 min in room temperature before the procedure. (c) Tenderness testing: A pressure algometer (force gauge) with a unit range of 0–500 g was used to apply force in this region, again with the ‘‘shenmen’’ as reference. The researcher recorded the observed value (g) once the subject started to feel a tender sensation after the application of the pointer of the device on the acupoints under testing. If the acupoints under testing indicated a lower tolerance in tenderness when compared with the ‘‘Shenmen’’ (reference point), the results was taken as ‘‘positive’’; and vice versa. There might be situation when the reading of the acupoint under testing was identical (i.e. equal) with the ‘‘Shenmen’’ point.
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The research assistant (RA) involved in this project received formal training about the project, the use of equipment for measurement, and the conduct of the auricular examination. The formal training was given by the first author who holds a Certificate in Auriculotherapy from the Auriculotherapy Certification Institute, Inc., USA. Return demonstration from the RA was required to ensure his understanding of the execution of the auricular examination. Both the RA and the first author of this project were involved in the assessment of auricular diagnosis. To establish the reliability of the auricular examinations, an inter-observer agreement between the first author and the RA was recorded for 10 cases and the inter-observer agreement was 90%. When discrepancies in the assessment of the two raters emerged, a consensus was sought after discussion. To avoid observer bias, the raters were blinded to the grouping of the subjects. Measures (a) IPSS – Hong Kong Chinese Version 2: The IPSS was originally developed by the American Urological Association and was adopted by the WHO in 1993 [25]. The instrument consists of seven Likert-scale questions [with scores ranging from 0 (‘‘not at all’’) to 5 (‘‘almost always’’)] related to LUTS, which result in a total score ranging from 0 to 35. Three questions involve filling problems (daytime frequency and nocturnal urgency), and four questions assess voiding problems (emptying, intermittency, weak stream, and straining). The instrument also includes one question that evaluates the impact of urinary symptoms on QoL, with the score ranging from 0 (‘‘delighted’’) to 6 (‘‘terrible’’). This question helps in assessing the severity of LUTS. The IPSS (Hong Kong Chinese version 2) has been recently validated and found to be a valid, reliable and sensitive measure for assessing Chinese populations with LUTS (Cronbach’s alpha coefficient ¼ 0.71, ICC of the symptom questions ¼ 0.80, ICC of the QoL ¼ 0.70) [26]. (b) The participants were asked to urinate into a special funnel connected to a portable uroflowmeter (Model: FloPoint Elite Uroflow System), which then measured the Qmax per second and evaluated the severity of urinary obstruction. The device was calibrated before use. To ensure that the participants had a full bladder prior to the testing, they were reminded to drink more water and not to void before going to the center. Voids of less than 150 mL were repeated to increase the validity of the findings [27]. Data analyses Chi-square test was used to determine the association between LUTS status and the presence or absence of auricular signals. However Fisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom [28]. The sensitivity, specificity, positive predictive values (PPVs) and negative predictive values (NPVs) of the acupoints under testing were computed. A multivariate logistic regression analysis was conducted to examine whether the LUTS status of the subjects was associated with a number of auricular
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signals, problem duration and number of comorbid illnesses. Analyses were conducted using SPSS version 21.0 (Armonk, NY: IBM Corp.); or the R Foundation for Statistical Computing (3.0.2 for Windows) was used if Fisher’s exact test was performed. A p value of 50.05 was considered statistically significant.
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Ethical considerations Ethical approval from the university with which the first author is affiliated was sought. Written informed consent was obtained from all the participants. The purpose and procedures of the study were explained verbally and in writing to the participants. Participation in the study was voluntary, and all participants were assured of their right to refuse or withdraw from the study at any time. Personal information and data remained confidential and anonymous.
Results Demographic characteristic and LUTS conditions of the participants A total of 113 male participants from five elderly centers in Hong Kong were evaluated. The mean ages were 74.36 years (S.D. ¼ 7.59) for the LUTS+ve group (n ¼ 69) and 70.93 years for the LUTSve group (n ¼ 44). No significant differences were observed in the presence of comorbid illnesses in the two groups. The mean IPSS score of the participants from the LUTS+ve group and the LUTSve group were 14.64 (S.D. ¼ 5.93) and 3.09 (S.D. ¼ 2.84), respectively. We noted statistically significant differences in each domain of the IPSS scale between the two groups in terms of the symptoms related to LUTS, including incomplete emptying (p50.001), frequency (p50.001), intermittency (p50.001), urgency (p50.001), weak stream (p50.001), straining (p50.001), and nocturia (p50.001). The mean Qmax values of the participants from the LUTS+ve group and the LUTSve group were 8.40 mL/s (S.D. ¼ 3.45) and 17.94 mL/s (S.D. ¼ 14.77), respectively, with the former group reporting a significantly low QoL (Table 1). Association of specific acupoints and LUTS status The auricular signals that were observed on the participants from the LUTS+ve group were compared with those on the participants from the LUTSve group using the three methods of ear diagnosis. The six specific acupoints under testing were the ‘‘angle of superior concha’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, the ‘‘urethra’’, and the ‘‘internal genitalis.’’ (a) Visual inspection: Generally, no significant differences were observed in the discoloration and the presence of nodular scleroma in the specific acupoints of the LUTS+ve and LUTSve groups. (b) Electrical skin resistance measurement: Nearly all the specific acupoints on the participants from the LUTS+ve group (except the ‘‘urethra’’ on both ears and the ‘‘ureter’’ on the left ears) indicated a significantly higher conductivity compared with those on the participants from the LUTSve group (Table 2). (c) Tenderness testing: Unlike those from the LUTSve group, the participants from the LUTS+ve group
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experienced significant tenderness on almost all the specific acupoints, except on the ‘‘angle of superior concha’’ and the ‘‘urinary bladder’’ on the right ears (Table 2).
Predictive power of various acupoints on the risk of LUTS (a) Electrical skin resistance measurement: The electrical conductivity of the ‘‘angle of superior concha’’ on the right ears of the participants exhibited the highest sensitivity of 0.74 and an NPP value of 0.58. The ‘‘kidney’’ had the highest specificity of 0.68 and a PPV value of 0.76. The ‘‘angle of superior concha’’ on the left ear indicated the highest sensitivity (0.70), PPV (0.73), and NPV (0.55) (b) Tenderness testing: The ‘‘angle of superior concha’’ demonstrated considerable sensitivity, specificity, PPV, and NPC on both ears during the tenderness testing (Table 3). Multivariate analysis Multivariate logistic regression analysis was conducted to examine the association of the LUTS status of the subjects with a number of auricular signals after controlling for the significant risk factors (age, comorbid illness, discoloration, electrical conductivity and tenderness of a number of auricular signals on the left and right ears). Backward stepwise logistic regression was employed, and the auricular signals that demonstrated statistical significance (using p50.05 for entry and p40.10 for removal) were retained in the final model (Table 4). The overall multivariate model was significant (X2 ¼ 26.906, p50.001) and correctly classified in 74.1% of the subjects. The result of the Hosmer–Lemeshow test indicated that the model effectively fitted the data (p ¼ 0.088). In the final model, four independent variables made a statistically significant contribution at the 5% level. The strong predictors in descending order were the presence of tenderness in the ‘‘angle of superior concha’’ (left) (adjusted OR ¼ 3.174, 95% CI ¼ 1.211–8.319), the presence of electrical conductivity in the ‘‘angle of superior concha’’ (left) (adjusted OR ¼ 3.029, 95% CI ¼ 1.107–8.288), and the electrical conductivity in the ‘‘kidney’’ (right) (adjusted OR ¼ 2.719, 95% CI ¼ 1.045–7.077) after adjustment of age. This result indicated that the respondents who reported the presence of tenderness or electricity conductivity in the ‘‘angle of superior concha’’ (left) were around three times more likely to have LUTS than those who did not. In addition, the respondents who reported the presence of electrical conductivity in the ‘‘kidney’’ (right) were 2.7 times more likely to have LUTS than those who did not. The odd ratio of age (adjusted OR ¼ 1.102, 95% CI ¼ 1.028–1.181) indicated that the likelihood of having LUTS increased 1.1 times (or 10.2%) for every one year of age increase.
Discussion This study adopted a systematic and scientific approach using visual inspection, electrical skin resistance measurement, and
Association of auricular reflective points and LUTS
DOI: 10.3109/13685538.2015.1027679
Table 1. Socio-demographic data and LUTS-related conditions of participants.
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Age (years)
LUTS +ve (n ¼ 69)
LUTS –ve (n ¼ 44)
Test statistics
74.36 (7.59)
70.93 (6.43)
Mann–Whitney U-test p50.05* X2 ¼ 0.84 df ¼ 1 p40.05
Comorbid Illness No Yes
20 49
12 32
International Prostate Symptoms Score (IPSS) Incomplete emptying 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
19 12 7 6 3 22
34 5 0 2 2 1
p50.001*
Frequency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
13 8 2 10 5 31
38 4 0 1 1 0
p50.001*
Intermittency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always Urgency 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
40 10 7 5 7 18
40 6 0 0 0 2
p50.001*
39 8 3 3 2 14
36 3 1 0 1 3
p50.001*
Weak stream 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
34 7 5 3 4 16
38 3 2 0 0 1
p50.001*
Straining 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
48 7 4 4 1 5
43 1 0 0 0 0
p50.001*
Nocturia 0 ¼ Not at all 1 ¼ Less than 1 time in 5 2 ¼ Less than half the time 3 ¼ About half the time 4 ¼ More than half the time 5 ¼ Almost always
2 6 25 18 14 4
10 21 7 4 2 0
p50.001*
Overall IPSS score (cases were 8 or above) Maximum urinary flow rate (Qmax) (cases were 515 mL/second) Quality of life (7 levels) 0 ¼ Delighted 1 ¼ Pleased 2 ¼ Mostly satisfied 3 ¼ Mixed 4 ¼ Mostly dissatisfied 5 ¼ Unhappy 6 ¼ Terrible
14.64 (5.93)
3.09 (2.84)
p50.001*
8.40 (3.45)
17.94 (14.77)
p50.001*
0 3 10 30 16 7 3
6 3 24 9 2 0 0
p50.001*
Fisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom. *Statistically significant.
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Table 2. Auricular signals between cases and controls assessed by electrical skin resistance measurement (conductivity) and tenderness testing.
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Test statistics (chi-square test or Fisher’s LUTS +ve LUTS –ve exact test)y (n ¼ 69) (n ¼ 44) Electrical skin resistance measurement (conductivity) Right ear Angle of superior concha positive 18 25 negative 51 19 Urinary bladder positive 20 22 negative 49 22 Ureter positive 23 24 negative 46 20 Kidney positive 24 30 negative 45 14 Urethra positive 28 24 negative 41 20 Internal genitalis positive 28 28 negative 41 16 Left ear Angle of superior concha positive 21 26 negative 48 18 Urinary bladder positive 25 25 negative 44 19 Ureter positive 30 27 negative 39 17 Kidney positive 26 26 negative 43 18 Urethra positive 26 24 negative 43 20 Internal genitalis positive 26 28 negative 43 16 Tenderness testing Right ear Angle of superior concha positive negative Equal Urinary bladder positive negative Equal Ureter positive negative Equal Kidney positive negative Equal Urethra positive negative Equal Internal genitalis positive negative Equal
p50.01* p50.05* p50.05* p50.001* p>0.05 p50.05*
p50.01* p50.05*
Table 2. Continued
Test statistics (chi-square test or Fisher’s LUTS +ve LUTS –ve exact test)y (n ¼ 69) (n ¼ 44) Left ear Angle of superior concha positive negative Equal Urinary bladder positive negative Equal Ureter positive negative Equal Kidney positive negative Equal Urethra positive negative Equal Internal genitalis positive negative Equal
28 38 3
26 16 2
p50.001*
29 23 7
22 19 3
p50.05*
34 31 4
20 19 5
p50.05*
34 32 3
19 20 5
p50.05*
38 31 0
15 24 5
p50.001*
31 35 3
19 22 3
p50.001*
*Statistically significant. yFisher’s exact test was used if the expected values in any of the cells of a contingency table are below 5, or below 10 when there is only one degree of freedom.
p>0.05 p50.05* p>0.05 p50.05*
33 32 4
30 11 3
p>0.05
34 31 4
25 14 5
p>0.05
32 34 3
22 19 3
p50.01*
35 27 7
21 22 1
p50.001*
35 30 4
22 19 3
p50.05*
36 30 3
17 25 2
p50.001*
(continued )
tenderness testing to investigate auricular signals and their relationship with LUTS status. French physician Dr Paul Nogier [29] hypothesized that the human body can be projected into the auricle just as it can be projected into the brain cortex. This idea accords with the following ancient Chinese medical text (‘‘Lingshu Jing’’, also known as ‘‘Divine Pivot’’): ‘‘the ears are the confluence of the channels.’’ From the perspective of TCM, this text implies that the ears are related to the internal organs through the channels and collaterals and that they are directly or indirectly related to the 12 main pairs of meridians (channels) that run through the human body [30]. Participants from the LUTS+ve group, especially those with moderate to severe LUTS, experienced a lower QoL compared with those from the LUTSve group. This result concurs with those of other studies on LUTS and QoL, which found that LUTS can significantly lower QoL in aging men [1, 4, 7, 9–11] and that it is particularly associated with poor sleep quality [10]. The participants of the present study mentioned that when outside their homes, they must constantly and repeatedly look for washrooms. This condition had made them reluctant to go out, which they would only do when necessary. Waking up frequently during the night to urinate or waking up in the early morning and not being able to fall back to sleep after urination was continually reported by many of the participants. These issues reduce QoL drastically. Therefore, an early diagnosis would benefit patients with LUTS, as they could be given early treatment to improve their QoL. The participants from the LUTS+ve
Association of auricular reflective points and LUTS
DOI: 10.3109/13685538.2015.1027679
Table 3. Predictive power of various acupoints on the risk of LUTS assessed by electrical skin resistance measurement (conductivity) and tenderness testing.
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Positive Negative Sensitivity Specificity predictive predictive value (%) value (%) (%) (%) Electrical skin resistance measurement (conductivity) Right ear Angle of superior concha 0.74 0.57 0.73 Urinary bladder 0.71 0.50 0.69 Ureter 0.67 0.55 0.70 Kidney 0.65 0.68 0.76 Urethra 0.59 0.55 0.67 Internal genitalis 0.59 0.64 0.72 Left ear Angle of superior concha 0.70 0.59 0.73 Urinary bladder 0.64 0.57 0.70 Ureter 0.57 0.61 0.70 Kidney 0.62 0.59 0.70 Urethra 0.62 0.55 0.68 Internal genitalis 0.62 0.64 0.73 Tenderness testing Right ear Angle of superior concha 0.49 0.73 0.74 Urinary bladder 0.48 0.64 0.69 Ureter 0.52 0.54 0.64 Kidney 0.52 0.49 0.55 Urethra 0.46 0.54 0.61 Internal genitalis 0.45 0.40 0.55 Left ear Angle of superior concha 0.58 0.62 0.70 Urinary bladder 0.44 0.54 0.55 Ureter 0.48 0.51 0.62 Kidney 0.48 0.49 0.62 Urethra 0.45 0.38 0.56 Internal genitalis 0.53 0.46 0.61
0.58 0.52 0.51 0.56 0.46 0.50 0.55 0.50 0.47 0.50 0.48 0.40 0.48 0.42 0.41 0.46 0.39 0.32 0.48 0.43 0.37 0.36 0.28 0.38
Figures in bold indicate the highest among the acupoints under testing on each side of ear. Sensitivity (true positive) ¼ number of true positives/number of true positives + number of false negatives. Specificity (true negative) ¼ number of true negatives/number of true negatives + number of false positives. Positive predictive value ¼ number of true positives/number of true positives + number of false positives. Negative predictive value ¼ number of true negatives/number of true negatives + number of false negatives.
Table 4. Multivariate analyses.
Variable
Adjusted Odds ratios
95% CI
p value of Wald statistic
Tenderness of ‘‘Angle of superior concha’’ (Left)y Present Absent
3.174 1.000
1.211–8.319
0.019*
Electrical conductivity of ‘‘Angle of superior concha’’ (Left)y Present Absent
3.029 1.000
1.107–8.288
0.031*
Electrical conductivity of ‘‘Kidney’’ (Right) y Present Absent Age
2.719 1.000 1.102
1.045–7.077
0.040*
1.028–1.181
0.006*
CI ¼ confidence interval. *Statistically significant; yCompared with reference point ‘‘Shenmen’’.
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group were generally older than those from the LUTS–ve group. In the former, the likelihood of having LUTS increased 1.1 times (or 10.2%) for every one year of age increase, as shown in the multivariate analysis. This finding also accords with a previous study that found that the prevalence of LUTS increases as men age, given that aging was observed to be a major risk factor for LUTS [1]. The visual inspection of the acupoints under testing may not be a reliable measure for detecting LUTS status, at least in this study. Meanwhile, nearly all specific acupoints on the participants from the LUTS+ve group indicated a significantly higher conductivity than those on the participants from the LUTSve group. The electrical resistance in corresponding auricular points reportedly decreases when a disease or disorder is present in the body. From a physiological perspective, the changes in electrical resistance in auricular points can be the result of a change in electrical resistance in underlying cell membranes, in which the signal is transmitted to the central nervous system through the meridians and then to the corresponding auricular points, after which electrical resistance changes [31]. Unlike those from the LUTSve group, the participants from the LUTS+ve group experienced significant tenderness on almost all specific acupoints in both ears as detected by the pressure algometer. The degree of tenderness was usually related to the severity of the condition, that is, a highly sensitive point equates to a highly severe disorder [15,32]. Oleson [33] demonstrated in an animal experiment that the skin acupoints on dogs show significantly higher concentrations of substance P compared with the acupoints of the controls. Substance P is a spinal neurotransmitter found in afferent C-fibers involved in pain transmission. Therefore, an increase in substance P decreases the pain threshold and causes the auricular points to become tender when touched. For the predictive power of various acupoints on the risk of LUTS, the ‘‘angle of superior concha’’ appeared to have considerable sensitivity, specificity, PPV and NPV when compared with the other selected points in both ears. This result can be explained by the fact that this acupoint is known as the ‘‘prostate’’ of the human body [18]. The findings of this study enhance our understanding of the association between specific auricular reflective signs and the status of LUTS in the male population. They also add to our knowledge of the integrated approach to combining Chinese and Western models of care for diagnosing people with LUTS. Even though the principal underlying cause of LUTS is BPH of the prostate gland [5], this condition may be associated with much severe conditions, such as prostatitis, urinary tract infection, or prostatic cancer [3,4]. Given that auricular diagnosis is speculated to have a pre-diagnostic value and is important in the secondary level of prevention, further diagnosis and early treatment could be given. As the ear is a valuable tool for revealing constitutional predispositions, auricular diagnosis can be used as a simple, effective, and inexpensive complementary approach for aging males who may be vulnerable to LUTS. Limitations of this study Although the association between the selected acupoints under testing and LUTS status was suggested in this study, the
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mechanisms leading to the time of onset of auricular signals remains unknown. A prospective cohort study should be conducted in the future to follow-up on the cases with LUTS detected at an early stage. Such study could be performed to identify changes in the auricular signals that may have appeared during disease progression. The present study was conducted on a relatively small sample. Therefore, further investigations could be performed with a large sample to validate the use of auricular signs as predictors that assist in the detection of LUTS status. Our work was based on Chinese men, and the auricular signals may be governed by ethnic differences. Thus, additional research is required before the results can be extrapolated to other ethnic groups.
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Conclusion People with LUTS have a relatively lower QoL compared with those who do not have this condition. The results of this study suggest that electrical conductivity and tenderness of a number of auricular points, including the ‘‘angle of superior concha’’, the ‘‘internal genitals’’, the ‘‘urinary bladder’’, the ‘‘ureter’’, the ‘‘kidney’’, and the ‘‘urethra’’, are associated with LUTS condition in Chinese aging males. Auricular diagnosis could be considered as a screening method for the aging population with a relatively high LUTS risk. Through this approach, early diagnosis and appropriate treatment can be given for people with this condition.
Acknowledgements We thank Mr. Dino Wong (Registered TCM practitioner of Hong Kong) for his valuable advice on the selection of acupoints. We also extend our appreciation to the subjects for their participation in and support for this study.
Declaration of interest The authors have declared that no conflict of interest exists. This project was supported by the Division of Transitional, Supportive, and Palliative care (TSP), School of Nursing, The Hong Kong Polytechnic University.
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