Complementary Therapies in Medicine (2011) 19, 27—31

avai lab le at www.sc iencedi rec t .com

journa l homepage: www.e lsev ierhea l th .com/ journa ls /c t im

Acupuncture in urological practice—–A surveyof urologists in England

Heidi Tempesta,∗, John Reynarda, Richard J. Bryanta,b,Freddie C. Hamdya,b, Stéphane Larréa,b

a Urology Department, Churchill Hospital, Old Rd, Headington, OX3 7LJ Oxford, UKb Nuffield Department of Surgery, University of Oxford, Oxford, UKAvailable online 3 December 2010

KEYWORDSAcupuncture;Urology;Questionnaire;Medical practice

SummaryObjective: To determine the feasibility of obtaining cooperation from urologists in carrying outlarge-scale studies on the efficacy of acupuncture for the treatment of urological conditions,based on urologists’ general views and knowledge of acupuncture.Methods: A questionnaire was distributed to 145 urologists within three training deanerieswithin England.Results: A response rate of 70% (n = 102) was achieved. The majority of urologists rated theirknowledge of acupuncture as low (46%, n = 46) and their general attitude towards acupuncturewas neutral (54%, n = 55). The majority of responding urologists (95%) thought that acupuncturemay be of value in urological conditions, and acupuncture was suggested to patients by 30 urol-ogists (29%). The urologists most likely to suggest acupuncture to their patients were typicallyover 40 years of age, more experienced, not in a training post, and since starting their urologicalcareer had changed their attitude towards acupuncture. In a multivariate analysis, a changeof view regarding the efficacy of acupuncture was found to be the only variable significantlyassociated with a recommendation of acupuncture to patients.

Conclusions: Although overall knowledge about acupuncture was poor, most responding urol-ogists thought acupuncture may be useful for urological conditions. Those who had changedtheir views were most likely to suggest acupuncture to their patients. Acupuncture for urolog-ical conditions warrants further investigation and, as this study has shown high interest within

argets re

the urological community l© 2010 Elsevier Ltd. All righ

There is a growing interest in complementary medicine,especially acupuncture, within both Western society andthe Western medical profession. This increased interest may

Abbreviation: OR, odds ratio.∗ Corresponding author. Tel.: +44 01865741841;

fax: +44 01865226086.E-mail address: htempest@hotmail.com (H. Tempest).

rctAcvuNo

0965-2299/$ — see front matter © 2010 Elsevier Ltd. All rights reserved.doi:10.1016/j.ctim.2010.10.001

clinical trials involving multicentres may be feasible.served.

eflect increasing frustration with the poor efficacy of manyonventional treatments for a range of conditions. Acupunc-ure is believed to have originated in China during the Stonege,1 and is typically used to treat symptomatic chronic

onditions, especially pain, that are often resistant to con-entional therapies. One example of its more widespreadse in various clinical conditions is its advocation by theational Institute for Clinical Excellence as a treatmentption for back pain.2 Nevertheless, acupuncture remains

2 H. Tempest et al.

awe

lfasttaAtftowtfstaaacc

iKtttacAofoombc

tacdsutwprf

M

Aods

Acupuncture in Urology Questionnaire

1. Sex M/F

2. Age

3. Years of experience in Urology

4. Grade

5. How would you rate your knowledge of acupuncture

1 2 3 4 5

Low high

6. What is your general attitude towards acupuncture?

1 2 3 4 5

very negative neutral very positive

7. Do you think acupuncture may help in any urological conditions ? Y/N

1 2 3 4 5

Very unlikely maybe very likely

If so which ones ?

8. Have you ever suggested acupuncture to a patient?Y/N

9. Have your views towards acupuncture changed since you started your career?

Alot more positive/ more positive/ no change/ more neg ative/ Alot more negative

10. Has anything changed your views?

Fr

fatGsS(fPucdurhoeacrupa(

8

highly controversial treatment option, particularly as noell-defined conventional pathophysiological mechanism toxplain its efficacy has been identified.

Numerous urological conditions can be difficult and chal-enging to treat symptomatically.3 The use of acupunctureor urological conditions was reviewed by Ripoll and Bunn,4

nd since then there have only been a limited number oftudies investigating its use. These mainly focus on func-ional disorders such as chronic pelvic pain,5,6 lower urinaryract symptoms,7,8 or, more recently, hot flushes followingndrogen deprivation therapy for prostate cancer.9,10

cupuncture treatments have been reported to improvehese conditions. Although promising, especially afterailure of conventional treatment options, the majority ofhese studies are observational or contained small numbersf patients, and few of the studies are randomised.4 Largerell-powered studies with multicentre involvement are

herefore needed to investigate the efficacy of acupunctureor the treatment of urological conditions. The feasibility ofuch studies largely depends on the willingness of urologistso participate, and this may be influenced by their interestnd beliefs regarding the potential efficacy of acupunctures a treatment modality for urological conditions. Without

strong and widespread interest within the urologicalommunity for acupuncture, such studies may have littlehance of success.

To date, and to our knowledge, there has been no specificnvestigation either of the views of urologists in the Unitedingdom towards acupuncture or of their attitudes towardshis unconventional treatment option for urological condi-ions. Much of the published literature has concentrated onhe use of acupuncture in general practice, where as manys 83% of practitioners believe that acupuncture might belinically useful and may recommend it to their patients.11

study of Norwegian doctors showed that they would rec-mmend acupuncture to 38% of their patients sufferingrom migraine.12 With regard to surgeons, the only studyf acupuncture reported to date demonstrated that 63%f surveyed neurosurgeons believed that complementaryedicine may have a potential role in patient managementut it did not elaborate fully if they recommend it in theirlinical practice.13

The principal objective of this study was to investigatehe views of urologists in England towards acupuncturend to ascertain their beliefs about its use for urologicalonditions. We investigated whether sufficient urologistsemonstrate an interest in acupuncture as a preliminarytep such that future larger studies on acupuncture forrological conditions might be feasible. We also aim to even-ually identify a profile of urologists or their clinical centres,hich may be more likely to recommend acupuncture toatients, such that these urologists could potentially beequested to become co-investigators and recruiting centresor future large-scale randomised clinical trials.

ethods

questionnaire (Fig. 1) was designed to investigate thepinion of urologists practising in three English trainingeaneries. These deaneries were chosen as they coveredeveral regions and the authors had professional contacts

R

Wh

Thank you for your time in answering these questions

igure 1 Questionnaire used to assess urologists viewsegarding acupuncture.

or most of them facilitating identification of the urologistsnd a high response rate. The three deaneries (and hospi-als therein) were Oxford (Churchill (Oxford), Northamptoneneral, Royal Berkshire (Reading) and Wycombe), Wes-ex (Royal Bournemouth, Salisbury District, Winchester,outhampton, Queen Alexandra (Portsmouth), St RichardsChichester)) and Eastern (Addenbrookes (Cambridge), Nor-olk and Norwich, Luton and Dunstable, Bedford, Ipswich,eterborough and West Suffolk (Bury St Edmunds)). Therologists working at these hospitals were identified byontacting the deaneries and hospitals. The urologists asefined for the purposes of this study were either qualifiedrologists or urology trainees. There were no exclusion crite-ia within this group. All the urologists, who worked in theospitals within these training deaneries, were contactedver a 3-month period, either directly or by telephone or-mail. The urologists included consultants, staff grades,ssociate specialists and trainees, and all were asked toomplete a questionnaire (Fig. 1) evaluating their viewsegarding acupuncture and its use in urology. A profile ofrologists more likely to have suggested acupuncture to theiratients was identified using logistic regression. Statisticalnalyses were conducted using Stat View 5.0 for WindowsSAS Institute, Cary, NC, USA).

esults

e identified 145 urologists working within the designatedospitals. These included 86 consultants, 13 staff grades

Acupuncture in urological practice—–A survey of urologists in Eng

46

27

1711

04 5

55

29

93

9

54

30

6

0

10

20

30

40

50

60

1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Num

ber o

f Uro

logi

sts

Knowledge A�tude Helpfulnes

Figure 2 Histograms representing the number of urolo-gists giving each score (1—5) regarding knowledge about

lkthrmhwi(aTv(v9‘ubarac(r

duw6

D

Tiipti

pmedical students in universities in the UK. Specialised train-

acupuncture, attitude towards acupuncture and usefulness ofacupuncture.

or associate specialists and 46 trainees. A completed ques-tionnaire was obtained in 102/145 cases, giving a responserate of 70%. These were 41 from the Eastern deanery, 39from the Oxford deanery and 22 from the Wessex deanery.Of the 43 non-responders, 10 were due to incorrect e-mailaddress or phone number, leading to an adjusted responserate of 76%, if this group is not included. The response ratewas higher from trainees (93%) compared with non-trainees(60%) (p < 0.001). The male to female ratio was 10:1 (4:1 fortrainees and 58:1 for non-trainees). The overall mean age(range) was 40 years (29—66) whilst the mean (range) agewas 33 years (29—41) for trainees and 46 years (36—66) fornon-trainees.

Results concerning knowledge, attitude and usefulness ofacupuncture are outlined in Fig. 2. The majority of urologistsrated their knowledge of acupuncture as low (n = 46, 46%)and their general attitude towards acupuncture as neutral(n = 55, 54%). Nevertheless, 95 (95%) urologists thought thatacupuncture may be a useful treatment modality for urolog-ical conditions, including chronic pain, overactive bladder,prostatitis and hot flushes. At least one urological condi-tion was mentioned as being treatable through acupunctureby 78 urologists (76%), with pain being the most frequentlyquoted of these (n = 76, 75%).

Acupuncture was suggested as a therapeutic optionfor patients by 30 urologists (29%). This was significantlymore frequent among non-trainees (42%) than trainees

(12%) (p < 0.001). Univariate analysis demonstrated that thechance of acupuncture being suggested as a treatmentoption for patients was significantly higher if the urologistwas of a higher age (>40 years), had more years of uro-

iAis

Table 1 Univariate analysis indicating the odds ratio (OR) of haviinterval.

OR 9

Sex: male 0.818 0Age: >40 4.126 1Experience: >10 years 3.417 1Status: non-training 5.59 1Knowledge: score >3 5.098 1Attitude: score >3 4.818 1Helpful: score >3 5.588 2Views changed: yes 21.429 5

OR: odds ratio.

land 29

ogical experience, was of non-trainee status, had greaternowledge of acupuncture, had a greater positive attitudeowards acupuncture, had a greater belief in its possibleelpfulness, and if the urologist had changed their opinionegarding acupuncture during their career (Table 1). In theultivariate analysis, the only variable associated with a

igher probability of suggesting acupuncture to a patientas when the urologist had changed their opinion regard-

ng acupuncture during their career (odds ratio (OR): 10.42.5—42.4), p = 0.001). This group of urologists representslmost half (n = 48, 48%) of the responders in this study.rainees (n = 15, 35%) were less likely to have changed theiriews regarding acupuncture compared with non-traineesn = 33, 57%) (p = 0.03). Of those who had changed theiriew, the change was always either ‘‘more positive’’ (n = 45,3%) or ‘‘a lot more positive’’ (n = 15, 7%), and was never‘negative’’ or ‘‘a lot more negative.’’ Within the group ofrologists, who had changed their views regarding the possi-le efficacy of acupuncture, 27 (56%) suggested acupunctures a treatment to their patients, although 3 out of 53espondents (6%), who had not changed their views hadlso suggested acupuncture. Reasons identified as factorsausing a change of view included feedback from patientsn = 16), reading literature/media (n = 4) and personal expe-ience (n = 1).

There was no significant difference among the threeeaneries for all data analysed except for the number ofrologists, who had their view changed about acupuncture,hich was higher (p = 0.025) in the Eastern group (n = 25,3%) compared with the others (n = 23, 38%).

iscussion

his study demonstrates that despite most urologists hav-ng poor knowledge about acupuncture, many believe thatt may play a role in the urological management of someatients. Half of the urologists in this study had changedheir views regarding the effectiveness of acupuncture and,n general, this was in a positive manner.

Generally, poor knowledge about acupuncture is unsur-rising given that acupuncture is not routinely taught to

ng is available from institutions such as the British Medicalcupuncture Society (a registered charity); however, this

s only within fee-paying courses. Interestingly, it has beenhown that when a medical course includes some tuition on

ng suggested acupuncture to a patient with a 95% confidence

5% inf. 95% sup. p-Value

.191 3.511 0.7871

.604 10.617 0.0033

.327 8.796 0.0109

.92 16.13 0.0016

.366 19.021 0.0153

.941 11.958 0.0007

.226 14.03 0.0002

.856 78.411 <0.0001

3

citag

iuswihdttbtume

Evwbtdr

tpamaomtfsmcieartisfatv

iuaoue

ad

wotdt

mskwtagpttuaef

qikibu

acepdfitaasu

C

N

A

Tt

R

0

omplementary therapies, doctor’s views become more pos-tive towards such treatments.14 It has also been shown thathe majority of doctors and medical students believe thatlternative therapies should be taught during their under-raduate medical degree course.15

Whilst the overall interest in acupuncture by respondentsn this study was neutral, 95% of urologists believed in aseful potential role of acupuncture in the management ofome urological conditions, suggesting that most urologistsould be keen on referring patients to acupuncture clin-

cs. In practice, however, only around one-third of urologistsave suggested it to their patients. The exact reasons for theiscrepancy between urologists’ beliefs regarding acupunc-ure, and the frequency with which they recommend thisreatment, are unknown but may potentially be explainedy the fact that the majority of patients may be successfullyreated by conventional medicine. It is also possible thatrologists may have reservations about suggesting a treat-ent with minimal high-quality research and little scientific

vidence.The study results presented herein apply only to the three

nglish deaneries investigated, and may not represent theiews of other urologists in the United Kingdom or else-here. That said, we did not observe significant differencesetween deaneries, making geographical location unlikelyo result in differences of opinion between regions. We alsoid not investigate any ethnical or economic backgrounds ofespondents that may have had an effect on views.

More experienced urologists, who had completed theirraining, were more likely to suggest acupuncture to theiratients. This was, however, not statistically significant inmultivariate analysis, suggesting that years of experienceay be a confounding factor. More experienced urologists

re more likely to have seen the same patients on manyccasions, especially in the outpatient setting, and theyay realise the limits that conventional medicine can offer

heir patients. Curative treatment of chronic prostatitis,or example, may not be realistic in some patients, leavingymptom management to be the only route to an improve-ent in quality of life. The current treatment strategies for

hronic prostatitis including antibiotics, �-blockers, anti-nflammatory agents and other medical agents are notffective for many patients3; therefore, they may be offeredlternative treatments, such as acupuncture, after pooresults of standard treatments or to avoid more invasivereatments. Intriguingly, the use of acupuncture has resultedn good results for patients with this condition.5,6 Our resultshowed that good feedback from patients was the reasonor 16 urologists to have changed their views concerningcupuncture. This highlights the fact that patient satisfac-ion with acupuncture has a significant impact on a doctor’siews and prescribing practice.

These results suggest that younger urologists are lessnterested and more sceptical about acupuncture than olderrologists. This may be for reasons similar to those describedbove, but may also be explained by the rising developmentf evidence-based practice in current medical teaching,16

nderpinned by the need for large randomised trials tostablish the role of acupuncture in urological practice.

Acupuncture clinics are sometimes available as part ofchronic pain management service offered by anaesthetic

epartments in hospitals; however, this is an unusual feature

H. Tempest et al.

ithin the National Health Service. This may explain whynly a third of the urologists in this study suggest acupunc-ure to their patients, and why trainees are less likely toiscuss this treatment modality during patient consulta-ions.

Most urologists believe acupuncture may play a role in theanagement of urological conditions, some having already

uggested it to their patients. Urologists declaring the mostnowledge and positive attitudes regarding acupunctureere also most likely to find this treatment helpful for

heir patients. Urologists, who changed their views aboutcupuncture, were unsurprisingly more likely to have sug-ested the treatment to their patients. The most powerfulredictor for an urologist to recommend acupuncture washem ‘‘having changed their views,’’ and this increasedhe chance of this treatment being offered 21-fold. Manyrologists tend to develop more favourable views towardscupuncture later in their career, which may reflect thexisting limited efficacy of conventional treatment optionsor some chronic conditions, in particular.

Although the questionnaire in this study did not directlyuestion whether urologists would be willing to participaten acupuncture research, it has supplied the preliminarynowledge to future researchers that there is considerablenterest within the urological community about the possi-le positive effects of acupuncture in the management ofrological conditions.

In conclusion, this survey indicates that studies oncupuncture may be largely accepted among the urologi-al community and that cooperation from urologists may bexpected, such as mentioning the existence of a trial and theossibility of referring patients to an investigator for moreetails and inclusion. This study has also defined the pro-le of urologists more likely to have suggested acupunctureo their patients. This group of urologists may be suggesteds being the most appropriate for researchers to initiallypproach with regarding recruitment of patients for large-cale high-quality future clinical studies of acupuncture inrology.

ompeting interest

one.

cknowledgements

he authors are grateful to all the urologists who answeredhe questionnaire in this study.

eferences

1. Ernst E. Acupuncture—–a critical analysis. J Intern Med2006;259:125—37.

2. National Collaborating Centre for Primary Care. Low back pain:early management of persistent non-specific low back pain.

NICE Clin Guideline 2009:10.

3. Capodice JL, Bemis DL, Buttyan R, Kaplan SA, Katz AE.Complementary and alternative medicine for chronic prostati-tis/chronic pelvic pain syndrome. Evid Based ComplementAltern Med 2005;2:495—501.

Eng

Acupuncture in urological practice—–A survey of urologists in

4. Ripoll E, Bunn T. The role of acupuncture in the treatment ofurologic conditions. World J Urol 2002;20:315—8.

5. Tugcu V, Tas S, Eren G, Bedirhan B, Karadag S, Tasci A. Effec-tiveness of acupuncture in patients with category IIIB chronicpelvic pain syndrome: a report of 97 patients. Pain Med2010;11:518—23.

6. Lee SH, Lee BC. Electroacupuncture relieves pain in men withchronic prostatitis/chronic pelvic pain syndrome: three-armrandomized trial. Urology 2009;73:1036—41.

7. Li J, Han CH, Cheng XH, Zhu GX, Gong XH, Hou WG, et al. Obser-vation on therapeutic effects of elongated needle therapyon dysuria induced by benign prostatic hyperplasia. ZhongguoZhen Jiu 2008;28:707—9.

8. Kelleher C, Filshie J, Burton G, Khullar V, Cardozo L. Acupunc-ture and the treatment of irritative bladder symptoms.Acupunct Med 1994;12:9—10.

9. Beer TM, Benavides M, Emmons SL, Hayes M, Liu G, GarzottoM, et al. Acupuncture for hot flashes in patients with prostatecancer. Urology 2010.

10. Harding C, Harris A, Chadwick D. Auricular acupuncture: anovel treatment for vasomotor symptoms associated with

land 31

luteinizing-hormone releasing hormone agonist treatment forprostate cancer. BJU Int 2009;103:186—90.

11. Lipman L, Dale J, MacPherson H. Attitudes of GPs towards theprovision of acupuncture on the NHS. Complement Ther Med2003;11:110—4.

12. Norheim AJ, Fonnebo V. Doctors’ attitudes to acupuncture—–aNorwegian study. Soc Sci Med 1998;47:519—23.

13. Wu C, Weber W, Kozak L, Standish LJ, Ojemann JG, EllenbogenRG, et al. A survey of complementary and alternative medicine(CAM) awareness among neurosurgeons in Washington State. JAltern Complement Med 2009;15:551—5.

14. Hopper I, Cohen M. Complementary therapies and the medicalprofession: a study of medical students’ attitudes. Altern TherHealth Med 1998;4:68—73.

15. Perkin MR, Pearcy RM, Fraser JS. A comparison of the atti-tudes shown by general practitioners, hospital doctors and

medical students towards alternative medicine. J R Soc Med1994;87:523—5.

16. Walker PD, Dorsey SM. Creating an evidence-based culturewithin the schools of public health and medicine. Med Ref ServQ 2009;28:385—93.