Interventions of Traditional Korean Medicine for Chronic Pelvic Pain: A Literature Review of Case Studies

Chronic Pelvic Pain (CPP) refers to a condition in which local bodily pain, of which the cause cannot be identified, non-periodically continues at the pelvis, frontal abdominal wall, lumbar, hip for more than six months [1,2]. CPP can be caused by infection, inflammation, neuropathic pain, fibromyalgia, myoma uteri, endometriosis, prostatitis, or unknown causes [3]. 

Ahangari conducted a systematic literature review on the prevalence of CPP among women [4]. With seven articles out of the 140 articles published on CPP from 2005 till 2012, it was reported that the prevalence of CPP among women was between 6% and 27%. Roberts reported in his cohort study on 2,115 American men between 40 and 79 that about 9% of the patients were diagnosed with prostatitis/CCP by a doctor [5]. 

In the textbooks of Oriental medicines, CPP falls into the category of dysmenorrhea (??????), pain due to qi stagnation for a long time(??? ????), Pain before and after mestruation (?????) and lower abdominal pain (???) and is closely related to the factors of internal medicine, OBGY, urology, musculoskeletal system and psychiatric/neural factors [6-8]. Six evils (??), seven passions (??), foods (??), the tirednesss (??), injuries (??), insect bite (???) or the insufficiency in essence (?), qi (?), or blood (?) may result in the pain by disturbing the flow of energy and blood (??) in organs or the Gyeongrak of the body [9]. The treatment is optimized according to the symptoms of the patients. The key treatment elements are composed of acupuncture, moxibustion, or Traditional Medicine (TM), considering the medical history, mental elements and living environment of the patient [2]. 

Western medicine treats this disease with paracetamol, NSAIDs, antidepressants, anticonvulsants, gabapentin, or nerve blocks [3]. In the case of paracetamol, while the medicine is effective in the alleviation of fever or pain, if the medicine hits the spot, there is no evidence to support the use of this medicine on CPP [3]. As for NSAIDs, they are effective when the disease is related to pain, inflammation or peripheral nervous system and therefore used to treat ordinary CPP. However, these medicines are known for severe side effects [3]. Antidepressants, anticonvulsants, or gabapentin are effective in neuropathic pain. However, there is no effect on CPP with other causes [3]. Nerve blocks are effective in treating CPP. However, the diagnosis and treatment using this method must be given by a trained expert, and there is a chance of side effects, as well [3]. 

Sung conducted a meta-analysis and systematic review on the effect of acupuncture treatment on female CPP patients [10]. Carinci conducted a systematic literature review on the effect of alternative treatments, including acupuncture, herbal medicine, mind/body medicine and massage therapy [11]. However, there has not been a study that summarized the overall trends in the treatment of CPP, covering Traditional Korean Treatment (TKM) (e.g., acupuncture, electroacupuncture, pharmacopuncture, moxibustion, herb medicine, cupping, chuna and qigong). 

Therefore, the researchers gathered and analyzed the case studies on the TKM treatment of CPP. The purpose of this study is to provide a guideline for the TM of CPP that could be utilized in clinical contexts.

Data Sources and Searches

As for the English databases, the researchers searched Pubmed, Medline, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL Plus, totaling to five websites. As for the Korean databases, the researchers searched the Korea Institute of Science and Technology Information (KISTI), Korean Traditional Knowledge Portal, KoreaMed, Oriental Medicine Advanced Searching Integrated System (OASIS), Research Information Service System (RISS) and National Library of Korea, totaling to six websites. The searches were all conducted in April 2018 and there were no limitations in the periods and languages. 

The search keyword was “chronic pelvic pain OR chronic pelycalgia OR chronic pain of pelvic OR chronic pelvic ache” AND “acupuncture OR electroacupuncture OR pharmacopuncture OR moxibustion OR herb medicine OR herb OR cupping OR Korean medicine OR oriental medicine OR chuna OR qigong” AND “clinical Studies OR case studies OR case series OR case report OR case controlled trial OR randomized controlled trial OR cohort studies (Table 1)”.

Table 1: Search Strategy for Databates.

Inclusion criteria

In this study, the studies on TKM treatment (e.g., acupuncture, electroacupuncture, herb medicine, pharmacopuncture, cupping, moxibustion and chuna etc.) upon patients of CPP were included. There were no limitations in the genders or ages of the patients. Also, there were no limitations with regard to the intervention methods used on the control groups in controlled studies or randomized and controlled studies.

Exclusion criteria

Reviews, experimental studies, surveys, or other studies that were not clinical trials were not included in our analyses. Clinical studies that were not conducted upon the patients of CPP were also excluded. Also, studies based on western medicine, surgeries or clinical studies that were not case studies were also excluded.

Study selection and data extraction

The researchers check the titles and abstracts of the studies in the search results to identify the studies that satisfied the inclusion criteria. The analyses were conducted after extracting the information such as the author, year, diagnosis name, number of patients, treatment period, treatment, traditional Korean medicine pattern, outcome, and results.

Study selection and description

Our search generated a total of 82 potentially relevant studies, finally, 12 case studies (English databases: n = 1; Korean databases: n=11) met our inclusion criteria (Figure 1).

Figure 1: Flowchart of Study Selection Process. CPP: Chronic Pelvic Pain; RCTs: Randomized Clinical Trials, TKM: Traditional Korean Medicine.

12 case studies on CPP can be summarized in terms of their authors, year, diagnosis name, the number of patients, treatment period, treatment, traditional Korean medicine pattern, outcomes and results as shown in table 2 (A & B). 

Table 2A: Characteristics of Published Case Studies of Chronic Pelvic Pain.

Table 2B: Interventions Reported in Case Studies of Chronic Pelvic Pain.

The number of studies and patients by years

As for the number of case studies on CPP, the first was published in 2001, while 2015 saw the largest number of publications, which was 3. A total of 12 case studies were published, with the total number of patients being 91 (Figure 2).

Figure 2: Studies and Case of Cases Studies of Chronic Pelvic Pain by Years.

Categorization by the intervention methods

A total of 12 case studies on CPP used a total of 9 intervention methods. There were 4 intervention methods that were used in two or more studies, of which acupuncture was of the highest number, used in 11 studies (91.7%), followed by herb medicine in 10 studies (83.3%), moxibustion in 8 studies (66.7%), pharmacopuncture in 3 studies (25.0%), and steam therapy in 2 (16.7%).

Categorization by acupuncture points

Among the 12 case studies, 11 used a total of 58 different acupuncture points. Of these, nine acupuncture points that were used in 4 or more studies. These were, respectively; SP6 (???), being used in 10, which was the highest in number; (90.9%), LI4 (??) and PC6 (??), respectively being used in 6 studies (54.5%); CV3 (??), CV4 (??), LR3 (??), SP9 (??) and ST36 (???), respectively being used in 5 studies (45.5%); and CV12 ??) being used in 4 studies (46.4%) (Table 3). Ouch points (???) were not considered as an acupuncture point.

Table 3: Acupuncture Point of Case Studies of Chronic Pelvic Pain.

The classification of the acupuncture point by diseases: Table 4 shows the results of the classification of the acupuncture points used in 11 out of 12 case studies of CPP. The classification was made focusing on the diseases that were mentioned in two or more studies. Kim used the same acupuncture points for the patients of CPP with three different diseases [19].

Table 4: Acupuncture Point of Case Studies according to Patient’s Diseases.

Classification by the herb medicines

Of the 12 case studies, 10 used a total of 17 different herb medicines. 

Classification of the herb medicines by diseases: Table 5 shows the result of the classification of the herb medicines used in 10 studies out of the total 12 case studies by their diseases.

Table 5: Herbal Medicine of Case Studies according to Patient’s Diseases.

Classification of the herb medicines by traditional Korean medicine patterns: Table 6 shows the classification result of the herb medicines used in 10 out of 12 case studies of CPP by their traditional Korean medicine patterns.

Table 6: Traditional Korean Medicine Pattern of Case Studies of Chronic Pelvic Pain.

Classification by moxibustion points

Of the 12 case studies of CPP involving TKM treatments, 8 studies used a total of 10 moxibustion points. A total of five moxibustion points were used in more than two studies; CV4 (??) was used in 7 studies (87.5%), making it the largest in number; CV12 (??) in 6 studies (75.0%); CV3 (??) and ST25 (??) in 3 studies respectively (37.5%); and CV6 (??) was used in 2 studies (25.0%) (Table 7).

Table 7: Moxibustion Point of Case Studies of Chronic Pelvic Pain.

Classification by outcome

A total of 11 outcomes were used in the 12 case studies of CPP. Four outcomes were used in more than one study. NIH-CPSI (National Institutes of Health Chronic Prostatitis Symptom Index) and VAS (Visual Analogue Scale) were used in 5 studies (41.7%), which was the largest in number; IPSS (International Prostate Symptom Score) and NRS (Numerical Rating Scale) were used in 2 studies (16.7%) (Table 8).

Table 8: Outcome Measure of Case Studies of Chronic Pelvic Pain.

For this study, a total of 11 databases were used to understand the trend of the case studies regarding TKM treatments on CPP, in order to gather and analyze the related study articles. Case studies are studies that explain the cases in clinical practices. They are highly relevant to the clinical contexts and form new research questions [24,25]. Case studies also contribute to establishing the support for TM in the medical clinics or at home and the designing of randomized controlled trials, which are used as the key supporting materials for the recognition of such treatments by the national institutions. Therefore, when a TM for CPP is selected, or when a randomized and controlled study is designed, the findings of this study should be considered.

In the 12 case studies on CPP that were finally included in this study, a total of 9 treatments were used. Four treatments were used in more than one study, namely acupuncture in 11 studies (91.7%), herb medicine in 10 (83.3%), moxibustion in 8 (66.7%), and pharmacopuncture in 3 (25.0%). More than half of the studies were using acupuncture, herb medicine, and moxibustion. And, in most of the studies, the results were improved. Therefore, as the TM for CPP patients, acupuncture, herb medicine and moxibustion should be considered as the primary options.

The pharmacopuncture used in 3 studies is a new form of acupuncture therapy that injects herbal extracts into acupoints [26]. Pharmacopuncture is based on the theory of TKM, and is practiced in TKM clinics [27]. Today, pharmacopuncture is covered by automobile insurances in South Korea. And, many TKM clinics use this method frequently, among other treatment options [28]. A future clinical study is mandated to verify the effectiveness of pharmacopuncture in CPP, by integrating pharmacopuncture, which is frequently used in the clinical treatment of CPP and the acupuncture points that were proven to be effective in this study.

The result of the classification of the acupuncture points used in 11 studies out of the 12 case studies showed that patients with CPP and accompanying chronic prostatitis were acupunctured at PC6, SP6, GV20, KI7, LI11, SP9 and ST36, while the patients with CPP and accompanying endometriosis were treated at CV3, CV4, and SP6. The patients with CPP and accompanying adenomyosis were treated at CV3, CV4 and SP6, while those with ccc and accompanying ovarian cyst were acupunctured at SP6. Chronic prostatitis is a disease found among men, while endometriosis, adenomyosis, and ovarian cyst are diseases that affect women. It is recommended to consider the sex and accompanying diseases when selecting the acupuncture points for treating CPP.

In TKM, CPP is known to be related to the liver meridian (??), kidney meridian (??), bladder meridian (???), conception vessel (??), and governor vessel (??) [2]. The acupuncture points used in case studies can be classified by their meridians into spleen meridian(??), stomach meridian(??), liver meridian(??), kidney meridian(??), large intestine meridian(???), pericardium meridian(???), conception vessel(??) and governor vessel(??). The number of available clinical studies is too small to make recommendations on the selection of meridians rather than specific acupuncture points, which mandates future clinical studies and scientific analyses.

In this study, a total of 17 herb medicines were used in 10 case studies, and these were classified based on their traditional Korean medicine patterns and diseases. Herb medicines have been used for thousands of years to treat a number of diseases, as one of the preferred forms of TM [29,30]. They are used as prescription types, mixing more than one medicinal material based on TM texts in South Korea, China, Taiwan and Japan [31]. However, as the number of prescriptions identified in this study was vast, it is necessary to gather more clinical data to make recommendations on the prescriptions based on the diseases of the CPP patients and traditional Korean medicine patterns.

In western medicine, there is no treatment of CPP unless the cause of the pain is identified. However, in TM, the meridians and traditional Korean medicine patterns can be used to apply acupuncture, moxibustion, and cupping to patients. The implication of this study is that the clinical ground for TM of CPP and it is the hope of the researcher that this study can be used as the support for making recommendations of traditional treatments as a part of the treatment guidelines for CPP.

TKM treatment such as acupuncture, moxibustion, herbal medicine seems to be an effective treatment in patients with CPP. However, the number of case studies found in this study was not sufficient, while the evidence level was also too low, to make recommendations on TM treatment for CPP. Future studies of High-quality RCT are needed in order to make decisions on whether TM treatments should be used for treating CPP.

This work was supported by the Policy Support Project for the Development of Traditional Korean Medicine funded by the Ministry of Health and Welfare.

The authors declare that there are no conflicts of interest regarding the publication of this paper.