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JoVE Journal Medicine

Medicine

Acupoint Catgut Embedding for Treatment of Chronic Pelvic Pain due to the Sequelae of Pelvic Inflammatory Disease

Published: May 3, 2024 doi: 10.3791/66438
1, 1, 1, 1, 1, 1
1Hospital of Chengdu University of Traditional Chinese Medicine

Abstract

Chronic pelvic pain caused by the sequelae of inflammatory pelvic disease is a common clinical condition of pelvic pain in women. At present, the main challenges in its treatment are the limited effectiveness of pain relief and the frequent recurrence of symptoms, which significantly impact patients' quality of life and impose a considerable psychological burden on them. It is a clinically challenging disease. After summarizing years of treatment experience, the author's team discovered that acupoint catgut embedding demonstrated notable clinical efficacy in managing chronic pelvic pain stemming from pelvic inflammatory disease sequelae. Compared to existing Western medicine treatment methods, acupoint catgut embedding offers advantages such as a good analgesic effect, lower recurrence rate, economic benefits, and a relatively straightforward procedure. This article provides a comprehensive guide on embedding absorbable catgut into patients' acupoints for the treatment of chronic pelvic pain in females resulting from the sequelae of pelvic inflammatory disease.

Introduction

Chronic pelvic pain (CPP) refers to pelvic pain that persists for over 6 months, is non-periodic, and is unresponsive to non-opioid drugs. The latest research shows that the global incidence rate of CPP is ~5%-26%1. Sequential pelvic inflammatory disease (SPID) is one of the main conditions causing CPP, accounting for 23%-30% of all cases of chronic pelvic pain in females2. Due to the limited efficacy of existing analgesics in alleviating this pain, over 50% of CPP patients may seek non-pharmacological treatment3. Currently, the main non-pharmacological treatments include pelvic floor physical therapy, psychological therapy, neuroregulation, and dietotherapy. However, they also have limitations, such as suboptimal pain relief and difficulties in achieving long-term control. Most SPID women with CPP experience anxiety, depression, and decreased quality of life due to recurrent pain4. Therefore, finding an effective treatment method that can alleviate patients' pain symptoms has become a pressing clinical concern.

Acupuncture and moxibustion, two of the main external therapeutic methods in traditional Chinese medicine, have shown good efficacy in treating pain-related conditions and have been widely used in clinical practice, especially in the relief of chronic pain, where their effectiveness surpasses other non-pharmacological treatments for CPP5,6. In a cross-sectional study on the treatment of CPP with traditional Chinese medicine, 7.63% of chronic pain patients were chosen to receive acupuncture and moxibustion treatment, resulting in excellent therapeutic outcomes7. The acupoint catgut embedding introduced in this article is an extension and development of acupuncture and moxibustion. It refers to a traditional Chinese medicine external treatment technique that uses specially designed disposable medical devices to implant absorbable catgut into corresponding acupoints, providing prolonged and continuous acupoint stimulation to achieve analgesic effect. The author's team has employed this technology to treat recurrent and incurable pelvic pain in women caused by SPID, yielding positive outcomes. It can be utilized either as a standalone treatment or as an important component of a comprehensive traditional Chinese medicine treatment plan or a combination of traditional Chinese and Western medicine. This article takes the most common traditional Chinese medicine syndrome (dampness heat stasis type) patients with SPID as an example to provide a detailed demonstration of the procedures for acupoint catgut embedding.

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Protocol

All procedures of this study were conducted in accordance with clinical trial registration and have been approved by the Ethics Committee of the Affiliated Hospital of Chengdu University of Traditional Chinese Medicine (Filing No. 2021KL-004). All patients in this study provided informed consent to the investigators' use of data, images, and related video filming during the trial.

1. Preparation before operation

  1. Set the inclusion criteria as follows: include patients meeting the diagnostic criteria for pelvic inflammatory disease in Western medicine8,9 and the dampness heat stasis syndrome type in traditional Chinese medicine10, aged 20-25 years old.
  2. Set the following exclusion criteria: other causes of pelvic pain or lower abdominal pain; pregnancy, lactation, or preparing for pregnancy within the past 6 months; severe conditions affecting the heart, liver, kidneys, and hematopoietic system that make treatment intolerable; inability or unwillingness to cooperate; individuals prone to allergies or keloid formation; history of similar medication or physical treatments within the last month.
  3. Get the following materials ready: sterile gloves, disposable catgut embedding needles, disposable thread embedding kit (treatment tray, sterile gauze, sterile cotton swab, iodophor cotton swab, tweezers, "0" catgut, medical patches; Figure 1).
  4. Ask the patient to lie on her back, relax, and fully expose the abdomen and lower limbs.
  5. Check the skin condition of the target acupoint location and proceed with the procedure if there are no abnormalities.
    NOTE: Patients with infection, ulceration, or scars on the skin at the acupoint should not undergo the embedding. Patients should not have the procedure right away if they are extremely hungry, fatigued, or under significant mental stress. Avoid performing the procedure on a menstruating patient.
  6. Have the physician perform routine hand disinfection and wear sterile gloves.
  7. Check whether the core of the disposable thread embedding needle and the needle tube match smoothly (Figure 2A).
  8. Holding tweezers in the right hand, place the catgut into the needle tube (Figure 2B).
    NOTE: The catgut needs to be completely inserted into the needle tube.

2. Operating steps

  1. Select the following acupoints (international code): Zhongji (RN3), Guanyuan (RN4), Qihai (RN6), Guilai (ST29), Zigong (EX-CA1), Xueha (SP10), Zusanl (ST36), Yinlingquan (SP9), and Sanyinjiao (SP6; Figure 3).
  2. Needle insertion
    1. Tighten the skin of the needle insertion site with the left hand, and pinch the needle tube with the thumb, index, and middle fingers of the right hand.
    2. Quickly insert the needle downwards at a 90° angle to the skin (Figure 2C,D).
    3. When the patient experiences getting qi (needle sensation) such as soreness, numbness, and bloating, stop inserting the needle, push the needle core, and withdraw the needle tube, leaving the catgut in the qi-receiving area.
  3. Needle extraction: Press the skin of the acupoint with the left hand and pull out the needle core and barrel with the right hand.
    NOTE: The catgut thread must be fully intradermal and should not be left subcutaneous or exposed outside the hypodermic.
  4. Compress the needle hole with a sterilized dry cotton ball for 30 s and apply a medical application to the needle hole for 2 days.

3. Precautions after embedding the catgut

  1. Ensure that the embedded site does not come into contact with water within the first 48 h.
  2. Advise the patient to avoid strenuous physical activities, especially around the area where the thread was embedded, for 7 days following the procedure.

4. Adverse reactions and management

  1. Patient discomfort
    1. Pain
      1. Advise patients that pain is a common adverse reaction11 and that their pain will mostly disappear after 5-7 days.
      2. Use fine thread-embedding needles and catgut bodies during the procedure.
      3. Consider preoperative oral analgesics for patients who are sensitive to pain and have no known contraindications11; If necessary, administer local anesthesia with lidocaine before embedding the catgut12.
    2. Needle-related fainting
      NOTE: This refers to the sudden occurrence of dizziness, blurred vision, palpitations, nausea, and even syncope during the acupoint catgut-embedding treatment.
      1. If the patient faints, immediately stop the catgut embedding and observe the patient's vital signs. For milder cases, ask the patient to lie down for a while and receive warm water or a sugary drink. In cases where there is no alleviation of the symptoms, employ modern first-aid measures.
    3. Bleeding or local hematoma
      1. If postoperative bleeding occurs at the embedding site, apply gentle pressure with a dry cotton swab at the local site to stop it.
      2. If a hematoma forms, apply a cold compress within 24 h, followed by warm compresses after 24 h to promote hematoma absorption.
        NOTE: If the bleeding persists or is substantial, it may indicate vascular damage, necessitating surgical intervention.
  2. Catgut body rejection reaction
    1. Fever
      NOTE: Any fever generally disappears within 1 week.
      1. Instruct the patients to drink plenty of water. Treat continuous fever with physical cooling or oral antipyretic medications.
      2. When prolonged high fever occurs, ensure prompt cooling and removal of the embedded catgut by a surgical specialist.
    2. Allergic reactions
      1. Look for allergic symptoms such as local redness, rash, and itching; provide antihistamine drugs (such as chlorpheniramine maleate, cetirizine, loratadine) or corticosteroids (such as dexamethasone) for allergy management, and if necessary, remove the embedded catgut from the body.
    3. Nodules or masses
      1. Small nodules usually resolve on their own. For localized firm masses, employ methods like moxibustion and acupoint injections13.
    4. Thread overflow
      1. Manage thread overflow by trimming or extracting the extruded catgut and then re-embedding it.
    5. Infection
      1. During the first 5 days after catgut embedding, there may be varying degrees of inflammation at the local site. If there is excessive discharge at the embedding site or signs of purulent changes, treat with antibiotics for infection control. If necessary, seek surgical intervention.

5. Observation indicators

  1. Clinical efficacy evaluation14
    1. Define recovery as the improvement of all related symptoms and signs such as pelvic pain, with a score decrease of ≥95%.
    2. Define a significant effect as 70% ≤ score reduction < 95%.
    3. Consider the treatment to be effective if 30% ≤ score reduction < 70%.
    4. Consider the treatment to be invalid if the score reduction is <30%.
  2. Use the simplified McGill Pain Scale (SF-MPQ)15 to evaluate pain emotions and severity before and after treatment, with higher scores indicating more severe pain.
  3. Use the Traditional Chinese Medicine Damp Heat Stasis Syndrome Scale to score Traditional Chinese Medicine Syndrome16. The higher the score, the more severe the symptoms.
  4. Evaluate abdominal tenderness or rebound pain, uterine tenderness, neck elevation and swing pain, and accessory tenderness before and after treatment using the Pelvic Physical Signs Scale17. The higher the score, the more severe the pelvic pain.
  5. Use the World Health Organization quality of life (WHOQOL) - BREF scale18 to rate the quality of survival of the patients, and count the domain scores positively, meaning that the higher the score, the better the quality of life.

6. Statistical analysis

  1. Express measurement data conforming to a normal distribution as mean ± standard deviation (SD).
  2. Use an independent samples t-test for group comparisons and a paired samples t-test for comparisons before and after treatment.
  3. Express data not conforming to a normal distribution as M (25%,75%).
  4. Conduct group comparisons using the rank-sum test and comparisons before and after treatment using the paired rank-sum test.
  5. Express counts or ordinal data as component ratios.
  6. Perform group comparisons using Fisher's exact probability method or the Chi-square test.
  7. Use a paired-design t-test for pre and post control. Perform bilateral hypothesis testing to α= 0.05; consider P < 0.05 to be statistically significant.

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Representative Results

In this clinical study, a total of 88 participants were initially enrolled, with 8 cases dropping out (4 from the treatment group and 4 from the other one). The remaining 80 participants were divided using a random number table into the treatment and control groups, with 40 participants in each group. The course of treatment included catgut embedding once every 10 days, avoiding menstrual periods, for a continuous duration of 3 months. The patients in the treatment group also took a dose of Traditional Chinese Medicine daily, with discontinuation during the menstrual period, for a consecutive 3-month period.The oral Chinese herbal medicine used was a modified formula of Si Ni Si Miao Shi Xiao San, which included the following ingredients: Vinegar Beichaihu 10 g, red peony 15 g, bran fried orange shell 15 g, bran fried Atractylodes macrocephala 10 g, Chuan Niu Xi 15 g, Coix seed 30 g, salt Huangbai 10 g, fried Wulingzhi 15 g, raw dandelion 20 g, honeysuckle vine 20 g, dandelion 15 g, licorice 6 g, prepared as a decoction and taken once daily, divided into three doses. The control group was treated only with traditional Chinese medicine, and the selection of formulae, additions and subtractions, and the course of treatment were kept the same as that of the treatment group.

During this study, two cases of gastrointestinal reactions, both in the control group, presented as diarrhea, possibly related to the consumption of Chinese herbal medicine. Due to the weakness of the spleen and stomach in these two patients, we added Sharen 4 g and Shanyao 20 g to strengthen the spleen and stop diarrhea. After modifying the herbal medicine for these patients, the gastrointestinal reactions subsided. In the treatment group, two cases experienced mild redness and slight discomfort at the acupoint point where the catgut was embedded. This was attributed to the rejection of the catgut material. Patients were advised to apply daily alcohol compresses to the affected areas. In one case, the redness disappeared after 3 days, while in the other case, it resolved after 7 days. Importantly, no severe adverse reactions were observed.

Chronic pelvic pain caused by SPID causes distress for women; We found that compared to using traditional Chinese medicine decoction alone, the combination of acupoint thread embedding can improve the total effective rate of clinical treatment (95% vs 85%, P = 0.031, < 0.05, Table 1). To further evaluate the efficacy, we also scored the pain level, traditional Chinese medicine syndrome, and pelvic signs of patients at different time points (before treatment, 4th, 8th, and 12th weeks of treatment). The results showed that the SF-MPQ score, traditional Chinese medicine syndrome score, and pelvic sign score of the treatment group were significantly reduced compared to the control group (P < 0.05, Table 2, Table 3, and Table 4). In addition, our study also showed that the quality of life of the two groups of patients improved compared to before treatment, and the treatment group was better than the control group (P < 0.05, Table 5).

Figure 1
Figure 1: Item preparation. (A) Adhesive bandage. (B) "0" Catgut. (C) Disposable buried needle. (D) Tweezers. (E) Surgical tray. (F) Iodophor cotton swab. (G) Sterile gauze. (H) Sterile cotton swab. (I) Tweezers. (J) Sterile gloves. Please click here to view a larger version of this figure.

Figure 2
Figure 2: The burying needle and its insertion after placing the catgut. (A) Burying needle. (B) Placing disposable catgut into the syringe. (C,D) Schematic diagram of needle insertion. Please click here to view a larger version of this figure.

Figure 3
Figure 3: Diagram of the distribution of acupoints. (a) Qihai (RN6): On the anterior midline, 1.5 cun below the umbilicus. (b) Guanyuan (RN4): On the anterior midline, 3 cun below the umbilicus. (c) Zhongji (RN3): On the anterior midline, 4 cun below the umbilicus. (d) Guilai (ST29):4 cun below the umbilicus, 2 cun apart from the front midline.(e) Zigong (EX-CA1): 4 cun below the umbilicus, 3 cun apart from the front midline. (f) Xuehai (SP10): 2 cun above the medial end of the patellar floor, at the protrusion of the medial femoral muscle. (g) Zusanli (ST36): On the anterolateral side of the calf, 3 cun below the Dubi (Flexion of the knee, at the knee, in the lateral depression of the patella and patellar ligament.), one transverse finger (middle finger) from the anterior tibial ridge. (h) Yinlingquan (SP9): In the depression between the medial condylar edge of the tibia and the medial edge of the tibia on the inner side of the calf. (i) Sanyinjiao (SP6): Posterior to the mesial border of the tibia and 3 cun above the tip of the medial malleolus. Cun19 is a special unit of measurement in Chinese medicine theory; it is usually equal to the length of the distal interphalangeal joint and the length of the proximal interphalangeal joint of the index finger; according to the literature, 1 inch is ~2.0-2.2 cm long. Please click here to view a larger version of this figure.

Group n Heal Significant effect Effective Invalid Total efficiency F P
Treatment group 40 11 (27.5) 18 (45.0) 9 (22.5) 2 (5.0) 38 (95.0) 8.8 0
Control group 40 5 (12.5) 11 (27.5) 18 (45.0) 6 (15.0) 34 (85.0)

Table 1: Comparison of clinical efficacy between two groups after treatment [n (%)].

Group N Observation time node
Before Week 4 Week 8 Week 12 t P
Treatment group 40 25.63±6.52 17.15±3.09*# 10.18±2.75*# 4.53±2.73*# 16.87 <0.001
Control group 40 25.70±6.01 19.15±4.73* 14.33±2.91* 9.76±5.14* 13.74 <0.001
t 0.959 -2.301 -6.894 12.947
P 0.4 0.024 <0.001 <0.001

Table 2: Comparison of SF-MPQ scores between two groups of treatment at different observation points (scores, x¯ ± s). *Compared to before treatment; #Compared with the control group.

Group N Observation time node
Before Week 4 Week 8 Week 12 t P
Treatment group 40 14.45±4.55 8.10±1.82*# 6.08±2.18*# 3.68±2.30*# 11.5 <0.001
Control group 40 14.40±4.58 9.63±1.96* 7.83±2.75* 5.60±2.80* 9.45 <0.001
t 0.01 -3.606 -3.153 3.274
P 0.961 0.001 <0.002 <0.001

Table 3: Comparison of Traditional Chinese Medicine Syndrome Scores between both treatment groups at each observation node (Score, x¯ ± s). *Compared to before treatment; # compared with the control group.

Group N Observation time node
Before Week 4 Week 8 Week 12 Z P
Treatment group 40 7.00 (4.25,10.00) 4.00 (3.00,4.00)*# 3.00 (2.00,4.00)*# 2.00 (2.00,3.00)*# -5.4 <0.001
Control group 40 5.50 (4.00,8.00) 5.00 (4.00,6.00)* 4.00 (3.00,4.00)* 3.00 (2.00,4.00)* 5.05 <0.001
Z -1.588 -3.141 -2.002 -2.215
P 0.112 0.002 0.045 0.027

Table 4: Comparison of pelvic physical sign scores between two groups of treatment at different observation points [M (25%, 75%)]. *Compared to before treatment, #compared with the control group.

Dimension Group Before treatment After treatment Z P
Physiological field Treatment group 20.00 (19.00,21.75) 23.00 (22.00,23.00) -3.1 0.002
Control group 21.00 (19.00,22.50) 22.00 (21.00,23.00)
psychological domain Treatment group 18.50 (18.00,19.00) 21.00 (19.50,22.00) -3.4 0.001
Control group 18.00 (18.00,19.00) 19.00 (19.00,21.00)
Social relations field Treatment group 9.50 (9.00,11.00) 11.00 (11.00,12.00) -3.6 <0.001
Control group 10.00 (9.00,10.00) 10.00 (10.00,11.00)
Environmental field Treatment group 24.00 (24.00,29.00) 26.50 (24.00,29.75) -2.1 0.033
Control group 24.00 (23.00,25.00) 25.00 (24.00,26.75)

Table 5: Comparison of The World Health Organization quality of life (WHOQOL) - BREF18 scores between two groups before and after treatment [M (25%, 75%)].

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Discussion

There is no record of chronic pelvic pain in ancient Chinese medicine books, and according to its symptom characteristics, it can be mutually referenced with diseases such as "abdominal pain," "women's abdominal pain," and "menstrual abdominal pain." According to traditional Chinese medicine theory, when the blood vessels are open, improper care may lead to the invasion of pathogenic factors, such as dampness and evil heat, which can stagnate in the uterus and its channels, leading to a struggle between pathogenic factors and healthy energies, manifesting as pelvic inflammatory diseases. If pelvic inflammatory disease is untreated or not properly treated, the condition may persist and develop into the sequelae of pelvic inflammatory diseases. The core pathogenesis of sequelae of pelvic inflammatory disease is blood stasis, which obstructs the uterus and blood vessels. Damp heat stasis syndrome is a common type of syndrome. It is often caused by the lingering evil of dampness and heat in the later stage of pelvic inflammatory disease or by dysfunction of visceral function. Dampness and heat are endogenous, blocking qi and blood. The intersection of dampness and heat with blood stasis causes lingering and difficulty in healing, so chronic pelvic pain persists.

CPP, as a chronic, long-term, and persistent disease, has a complex etiology19. The causes of pain involve multiple mechanisms, including the nervous system, endocrine system, and immune system20,21,22,23,24. The effectiveness and safety of acupuncture and moxibustion in alleviating CPP pain have been confirmed by many clinical and experimental studies and shown excellent results in the treatment of chronic pain21,25,26. Previous studies have shown that acupuncture and moxibustion can improve the threshold of pain along the meridians of the body by regulating the secretion of central neurotransmitters, to achieve obvious and effective systemic analgesia5,27.

Acupoint thread embedding, as an extension and development of traditional acupuncture techniques, can result in a slow, soft, long-lasting, and benign "long-lasting needle sensation effect" on acupoints, which has a long-lasting analgesic effect28. At the same time, it can regulate the patient's immune function and cytokine levels, enhancing their disease resistance29, and its therapeutic effect is superior to simple acupuncture in treating chronic pain30. Some studies have indicated that the annual healthcare costs for each CCP patient range from $1,367 to $7,04331. Catgut embedding therapy offers a cost-effective solution with reliable effectiveness and a low recurrence rate. Compared with other non-pharmacological treatment methods, it reduces the medical cost of multiple treatments, thereby reducing the patient's economic burden. In addition, compared to traditional acupuncture methods, acupoint catgut embedding avoids the discomfort of repeated needling, enhancing patient compliance. The straightforward operation method and fewer adverse reactions make acupoint catgut embedding more clinically applicable compared to traditional acupuncture32.

During acupoint thread embedding, strict adherence to operational steps is crucial. Physicians are required to have a sense of sterility, and patients should also strictly follow the precautions after the operation (as discussed earlier) to avoid adverse reactions such as infection (adverse reactions and treatment have been discussed earlier); Secondly, the angle of needle insertion varies for different acupoints. For areas with rich muscles (such as the abdomen, buttocks, legs, etc.), direct needling (needle at 90 ° to the skin), oblique needling (needle at 45 ° to the skin), or flat needling (needle at 15 ° to the skin) for areas with shallow muscles (such as hands, feet, etc.). All acupoints in this study were treated with direct needling. Finally, acupoint thread embedding is an invasive procedure, and physicians should avoid blood vessels during the operation.

The literature on the selection pattern of acupuncture points for CPP indicated that Guanyuan, Sanyinjiao, Zhongji, Qihai, Zusanli, Guilai, Zigong, and Yinlingquan were the commonly used points for treatment, with a cumulative application frequency of 71.51%33. Other studies have shown that acupuncture on Guilai acupoints can improve the clinical symptoms and signs of CPP patients34. Acupuncture of Zhongji, Guanyuan, and Sanyinjiao reduced pain factors (COX-2, PGE2) and increased pain threshold in CPPS rats35,36.

This article only conducts clinical research on acupoint catgut embedding therapy for CPP caused by SPID. By integrating traditional Chinese medicine syndrome differentiation theory and expanding the use of acupoint thread embedding therapy for CPP caused by other diseases, there is potential to further enrich the treatment options for CPP, break through treatment bottlenecks, and improve the overall quality of life for CPP patients.

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Disclosures

The authors declare that they have no conflicts of interest.

Acknowledgments

The authors thank Dr. Wen Yi and other medical staff of the Department of Gynecology, Hospital of Chengdu University of Traditional Chinese Medicine for their help.

Materials

Name Company Catalog Number Comments
disposable catgut embedding needles Yangzhou Junbang Technology Development Co., Ltd 20212200112
disposable thread embedding kit Shangdong Weigao Ruixin Medical Technology Co.,Ltd. 20182140148
SPSS26.0  statistical analysis software 
sterile gloves Fitone Latex Products Co.,Ltd Guangdong. 20172140158

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Yang, W., Liu, H. l., Lu, S. s.,… More

Yang, W., Liu, H. l., Lu, S. s., Fan, P. x., Yi, W., Ji, X. l. Acupoint Catgut Embedding for Treatment of Chronic Pelvic Pain due to the Sequelae of Pelvic Inflammatory Disease. J. Vis. Exp. (207), e66438, doi:10.3791/66438 (2024).

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