Biofeedback and other Therapies for the Treatment of Urinary ...

Urinary IncontinenceReviewBiofeedback and other Therapiesfor the Treatment of Urinary Incontinencein the ElderlyE. Paul Cherniack, MDAbstractAlternative therapies hold potential promisefor the treatment of urinary incontinence inthe elderly. Assessment and comparisons ofthe efficacies of such therapies have beenhindered by a lack of standardized definitionsof urinary incontinence in the study populations,lack of standardization of treatment protocols,inadequate sample sizes, and lack of blindingand appropriate controls. Biofeedback hasbeen the most extensively studied therapy andmay provide appropriate adjunctive or primarytherapy for select individuals. Other potentialtherapies, such as acupuncture, hypnosis, andherbal therapies, have not been sufficientlyexamined to make definitive recommendations.(Altern Med Rev 2006;11(3):224-231)IntroductionThe treatment of urinary incontinence (UI)in elderly individuals is a significant challenge. UI isa multifactorial syndrome caused by normal age-relatedchanges and pathology in the urinary tract. Approximately15-30 percent of adults over age 65 areaffected, experiencing loss of health and quality oflife. Women are twice as frequently affected as menuntil age 80, after which the prevalence is equal. 1Pathophysiology of UINormal continence is maintained by nervoussystem control of the detrusor muscle surroundingthe bladder, the muscles surrounding the urethralsphincter, and the muscles of the lower abdomen andpelvic floor. 1,2 Urination occurs when parasympatheticnerves from the sacral spine S2 to S4 contract thedetrusor muscle, while sympathetic nerves from T11to L2 relax the urethral sphincter. 1 The spinal neuronsare under the control of the brain – parietal lobes andthalamus – and receive afferent impulses from bladderreceptors, the frontal lobes, and basal ganglia toprevent leakage. The pons synthesizes afferent signalsand provides efferent regulation of the detrusorand sphincter muscles. 1Classification of Urinary IncontinenceUI has been classified into three subtypesbased on symptoms and pathologic mechanisms –urge incontinence (UR), stress incontinence (SI), andoverflow incontinence (OI). Mixed incontinence canoccur when a patient exhibits features of two differentforms simultaneously; the combination of SI andUR has been reported. 3Urge IncontinenceThe most common form of incontinence isUR, characterized by a sudden urge and loss of urinewith polyuria. 1 UR usually occurs when the detrusormuscle becomes disinhibited as the result of centralnervous system disease, such as Alzheimer’s dementia,stroke, or Parkinson’s disease. 1 Denervation ofbladder smooth wall muscle from increased intravesicularpressure with bladder outlet obstruction canalso result in UR. 3 Two other theories explaining URinclude increased sensitivity to the neurotransmitteracetylcholine by bladder smooth muscle receptorsand abnormal leakage of neurotransmitter by efferentfibers that innervate bladder smooth muscle. 3E. Paul Cherniack, MD – Division of Geriatrics and Gerontology, LeonardM. Miller School of Medicine, University of Miami and the Miami VAHealth Care System.Correspondence address: Room 1D200, Miami VA Medical Center, 1201NW 16 St, Miami, FL 33125Email: evan.cherniack@med.va.govPage 224 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

ReviewUrinary IncontinenceStress IncontinenceConventional Treatments for StressSI is the second-most frequent form of incontinencein women. 1 SI results when laxity in theConventional treatments for SI include pel-Incontinencemuscles of the pelvic floor, loss of urinary sphincterfunction, or urethral closure fails to prevent urine two studies, the combination of exercise and educavicfloor muscle exercises and reparative surgery. Infrom leaking from the bladder. 1 Childbirth-related tion about the function and anatomy of the urinarytrauma is a common cause of pelvic muscle injury tract decreased incontinence by 88 6 and 94 7 percent,that ultimately predisposes to SI. 2 SI can also occur respectively. However, two other studies found no additionalbenefit from the combination after surgery. 8,9in men who have had prostate surgery. 4 The incidenceof SI following prostate surgery varies widely fromSuccess rates of surgical treatments for incontinencefollowing prostatectomy vary widely. In0.3-65.6 percent, possibly due to differences in surgicaltechnique. 5a series of small studies – less than 50 patients perstudy – continence was restored in 36-95 percent ofOverflow Incontinencesubjects. 10-15OI is the second-most common form of incontinencein men. 1 It usually results when the outflowfrom the bladder is blocked by structures distalConventional Treatments for OverflowIncontinenceto the bladder (in men usually an enlarged prostate). 1OI is typically treated with medication or surgery.Urinary pressure builds in the bladder until it exceedsthe ability of the musculature surrounding the bladder1 In published trials of the treatments for symptomaticrelief of benign prostatic hypertrophy, theto maintain continence, causing leakage. 1incidence of OI has been rather low – less than oneevent per patient per year – making evaluation of suchConventional Treatmenttreatments difficult. In these trials, neither surgery norConventional treatments consist of behavioraltherapy, exercises to strengthen the pelvic floormedication decreased the incidence of OI. 16,17muscles, medications, or surgery. 1Alternative TreatmentsSince no conventional therapy is completelyConventional Treatments for Urgeefficacious and older individuals may be unwillingIncontinenceor unable to undergo surgical treatment, alternativeUR is treated either by behavioral therapy treatments may potentially be used as primary or adjunctivetherapy to reduce the number of episodes ofor medication. Behavioral therapies, although nota cure, can decrease the incidence of incontinence. UI. While conventional non-surgical treatments canTherapies may include habit training consisting of eitherscheduled voiding based on a person’s usual toi-Assessment and comparison of the efficaciesbe efficacious, the cure rate is less than 50 percent. 18leting schedule (which can result in at least a 25-percentdecrease in episodes of incontinence) or specific hindered by lack of a standardized definition of UIof alternative therapies in different studies have beeninterval toileting schedules every 2-3 hours (which in the subject populations, lack of standardization ofcan reduce episodes by as much as 80 percent). 1treatments and treatment protocols, inadequate samplesizes, and lack of blinding and appropriate con-The most effective medications, includingoxybutinin and tolterodine, inhibit bladder muscle trols.contractions, reduce episodes of incontinence by approximately70 percent, and have a cure rate of about20 percent. 1Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 225Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Urinary IncontinenceReviewBiofeedback and Pelvic Exercise forUrinary IncontinenceBiofeedback is the most extensively studiedunconventional therapy for UI. In the application ofbiofeedback to treat UI, surface or internal electrodescreate visual or auditory signals when pelvic musclesare contracted. Using these signals, subjects can learnto augment or reduce muscle contractions voluntarilythrough muscle exercises to maintain continence. Thetechniques used in the various studies differ in regardto location of the electrodes (intravesicular, anal, orurethral sphincter), type of signal, (auditory or visual),and duration of training. 19Biofeedback/Pelvic Floor Exercises for UrgeIncontinenceBoth controlled and uncontrolled trials havecompared pelvic exercises with and without biofeedbackin limited numbers of subjects with UR; noresults of placebo-controlled trials have been published.In a small study, biofeedback reduced urinaryincontinence symptom scores and improved bladdermuscle pressure in 10 subjects, ages 24-53. 20 In a secondstudy, women (ages 16-65 years; mean age 41)were administered biofeedback for an average of fivesessions with an 87-percent cure rate. 21,22Wang et al compared biofeedback-assistedpelvic floor muscle exercises to either pelvic floormuscle exercise alone or exercise aided by electricalstimulation of the pelvic floor musculature via an intravaginalelectrode in 103 women (ages 15-71 years)for 12 weeks. 23 There was a significant improvementin symptom score in biofeedback-assisted pelvic floorexercises above that achieved by pelvic floor muscleexercises alone; however, the cure rate was not significantlydifferent among the three groups. Althoughindividuals in the electrical-stimulation group experiencedthe most improvement, the subjects in thisgroup were significantly younger than women in theother two groups.In a second study, 30 of 70 women who failedmedication as therapy for UR were offered either biofeedbackor pelvic floor muscle exercises. 24 Biofeedbackrecipients exhibited greater bladder detrusormuscle pressures, although there was no differencein cure rate.Biofeedback for Stress IncontinenceBiofeedback has also been used alone or incombination with conventional therapy to treat stressincontinence. Although the pelvic muscle exercisesthat are the mainstay of conventional therapy for SIbear the name of Dr. Arnold Kegel (Kegel exercises), 19Kegel did not develop these exercises, but invented abiofeedback device to use with the exercises. 19 Usinghis device, he reported to have eradicated symptomsin 93 percent of incontinent individuals. 19Pages et al performed a randomized, controlled,four-week trial on 40 women (ages not reported)with SI. They compared biofeedback andphysical therapy followed by two weeks of home exercises.The physical therapy group received 20 onehoursessions of practice in pelvic muscle exerciseswith education on the anatomy and function of thebladder. Subjects who received biofeedback experienceddecreased urinary frequency and subjectiveimprovement on symptom scores. 25In a controlled investigation, 130 women(mean age 60) were randomized to receive biofeedback,pelvic floor muscle exercises, or no treatmentfor six months. Compared to the control group, bothinterventional arms experienced equal statisticallysignificant reductions in episodes of incontinence. 26Thirty-five women (ages 31-69 years; meanage 50) were randomized to utilize pelvic floor muscleexercises with or without home biofeedback. After12 weeks, the biofeedback group obtained significantimprovement on a self-reported questionnaire scaleof urinary leakage. 27In several small, uncontrolled studies involving28-60 women, subjects observed both symptomreduction and improved contractility of pelvic floormusculature. 28-30Not all studies have noted positive results. Ina randomized study, 103 women (ages 30-70; meanage 46.6) received pelvic floor muscle training withor without biofeedback. 31 No differences were notedbetween groups in any of the measures studied.In another study, 44 subjects were randomizedto receive six treatments of pelvic floor exerciseswith or without biofeedback. Both groups improved,but no statistically significant differences were notedbetween the groups at the end of the trial. 32Page 226 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

ReviewUrinary IncontinenceAlthough a systematic review concludedthere is no benefit to adding biofeedback to pelvicfloor muscle exercises, 33 a meta-analysis of the samedata noted a “trend” in favor of adding biofeedback toexercise; the pooled results almost reached statisticalsignificance. 34Biofeedback has been evaluated as a treatmentfor patients who develop post-surgical SI. Studiesadding biofeedback to pelvic floor muscle exerciseshave reached different conclusions as to whether biofeedbackconfers an additional advantage. 1,35-43 In oneinvestigation, 50 post-prostatectomy subjects (meanage 65) were randomized to receive biofeedback-assistedpelvic floor muscle exercises and educationfor three months or to a control group who receivedno post-surgical intervention. 35 Biofeedback-trainedsubjects experienced a 26-percent greater continencerate at three months and 14 percent at one year. 35In two studies, individuals who utilized biofeedbackregained continence sooner after prostatectomy,although the overall rate of continence wasunchanged. 36,37 Biofeedback yielded continence ratesof close to 80 percent in two other uncontrolled trialsafter prostatectomy. 38,39 Two investigations, however,did not find added benefit to the use of biofeedbackafter prostate surgery. 40,41 Differences in biofeedbacktraining techniques, devices, and subject populationsmight have accounted for the variation in results.Overall, two comprehensive reviews concludedthe preponderance of evidence suggests theremight be benefit to the addition of biofeedback to pelvicfloor muscle exercises for SI. 2,44 In one, the combinedrelative risk of SI in biofeedback-assisted exercisewas 0.74 (95% confidence interval 0.60-0.93)compared to no treatment. 44Biofeedback for Mixed UIBiofeedback has been utilized for individualswho exhibit features of both SI and UR – termedmixed UI. In several small, uncontrolled trials, lastingfrom six weeks to 26 months and involving primarilymiddle-aged or elderly women, improvementin symptom scores of episodes of incontinence andurgency ranged from 36-75 percent. 45-49One investigation added biofeedback to othertreatments to reduce urge or mixed incontinence ina primarily elderly population. One hundred ninetysevenpatients (ages 55-92) were randomly assignedto utilize biofeedback-assisted pelvic floor muscleexercises, medication, or a placebo. 50,51 Subjects whoperformed the pelvic floor muscle exercises had twosessions to learn how to perform them. Biofeedbackwas added to the protocol for those subjects who exhibitedless than 50-percent reduction in frequencyof incontinence with exercise alone. Those subjectstrained in combination exercise and biofeedback reducedepisodes of incontinence from 15 to two episodesa week, medication-treated subjects decreasedincontinent episodes from 15 to three episodes aweek, and placebo recipients lowered episodes from15 to 10 episodes a week after two months. 50 Biofeedback-treatedsubjects also reduced episodes ofnocturia from 1.9 to 1.4 episodes a night, which wasstatistically significant and not matched in the othergroups. 51Biofeedback ConclusionsA number of problems exist in the quality ofthe evidence on the use of biofeedback as a treatmentfor incontinence: (1) there is no standardization ofbiofeedback devices or subject training used in differentinvestigations; (2) the nature of the treatmentmakes blinding difficult, if not impossible; (3) manyof the studies include a small number of subjects; (4)varying inclusion criteria are used to define incontinence;and (5) different instruments are used to assessthe efficacy of treatment on outcomes.Other important issues must be considered ina feasibility assessment of biofeedback for the elderly.Although many studies include older subjects, fewtrials have been performed exclusively on the elderly.It is not clear how easily elderly patients, many whomight have sensory or cognitive impairment, can betrained to use a biofeedback device. Other concernsinclude determining the optimal biofeedback deviceor training method and assessing the cost of such adevice.Miscellaneous Therapies: Hypnosis,Acupuncture, and Botanical MedicineHypnosis was the subject of one uncontrolledtrial to treat UR. 52 The subjects had 12 sessions overone month, followed by audio-taped sessions at homefor six months. Fifty-eight percent of 50 subjects whoreceived hypnosis experienced symptom improve-Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 227Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Urinary IncontinenceReviewTable 1. Potential Application of Alternative Therapies in the Treatmentof Urinary IncontinenceTherapyBiofeedbackAcupunctureHypnosisChinese herbsSerenoa repensPygeum africanumHerbal combinationsSt. John’s WortCuban Royal PalmYoga*Randomized controlled trialsUR√√√SI√√√√√Potential Uses in UIOI√√√√Mixed√RCTs*√√√√ment, and incontinence resolved in 41 percent of subjects.Six of the symptom-free patients relapsed, andfive had complete resolution of incontinent episodesafter additional treatment.Acupuncture has been studied as a treatmentfor SI or UR in several small trials. 53-56 In one study,13 subjects with UI due to chronic spinal cord injuriesreceived four acupuncture treatments. Incontinencewas completely eliminated in two patients andreduced to 50 percent or less compared to baseline inanother six patients. 53In a placebo-controlled, one-month trial of85 elderly women, 14-percent more subjects in theacupuncture-treated group experienced reduction inurinary incontinence compared to those in the placebogroup, who received acupuncture at sham points. 54In one small uncontrolled investigation, 11 subjects(mean age 71) had individualized treatments of acupuncturebetween four and12 times. Nine subjects experiencedcomplete resolutionof incontinent episodes. 55 Inanother uncontrolled series,20 individuals were given individualizedtherapy accordingto the principles of traditionalChinese medicine; 5677 percent had resolution ofincontinence.In an uncontrolledtrial, 23 subjects were given7.5 g three times daily of aChinese herbal formula (buzhongyiqitang)consisting ofginseng, Astragalus, Atractylodisalbae, Codonopsis,Glycyrrhiza, Angelica, Citrusreticulatae, Cimicifuga,Bupleurum, Zingiberis recens,and Ziziphus jujuba.Eighteen subjects (78%)experienced decreased frequencyof incontinent episodes.57 Several herbal therapieshave been tested to determineif they amelioratethe symptoms of benignprostatic hypertrophy, the most common cause of OI,although none has been specifically tested as a treatmentfor OI. 58-78 Botanicals studied for BPH includeSerenoa repens (saw palmetto), 61,62,64,66-73,77 Pygeumafricanum, 74,78 and Urtica dioica (stinging nettle). 76,78ConclusionsAlternative medicine holds promise for thetreatment of UI. Biofeedback has been the mostfrequently utilized and integrated into experimentalregimens. Biofeedback might be an appropriatetherapy for middle-aged or elderly women with stressincontinence wishing to avoid surgery and for whompelvic-floor muscle exercise alone does not providecomplete relief. Biofeedback should also be consideredafter prostate surgery in men who experience incontinence,despite exercise, and who wish to avoidPage 228 Alternative Medicine Review u Volume 11, Number 3 u 2006Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

ReviewUrinary Incontinenceadditional surgery. Other potential treatments, suchas acupuncture, hypnosis, and botanical medicine requirefurther research to determine effectiveness forUI.Further research may identify other alternativetreatments that alleviate symptoms of UI. Forexample, St. John’s wort has been found in rats toinhibit contraction of the bladder, implying a possiblerole in treatment of UR; 79 a fruit extract of the Cubanroyal palm, Roystonea regia, inhibited testosteroneinducedprostate enlargement in rodents; 80 and yogahas been suggested as a means to improve pelvic floormusculature to alleviate SI, although no clinical trialshave been published. 81Table 1 provides a summary of potential alternativetherapies. More methodologically rigorousstudies are indicated in order to determine safety andefficacy of these treatments for UI, particularly in theelderly population.References1. DeBeau CE. Urinary incontinence. In: Pompei P,Murphy JB, eds. Geriatric Review Syllabus. 6th ed.Oxford, UK: Blackwell; 2006:184-195.2. Norton P, Brubaker L. Urinary incontinence inwomen. Lancet 2006;367:57-67.3. Wein AJ, Rackley RR. Overactive bladder: a betterunderstanding of pathophysiology, diagnosis, andmanagement. J Urol 2006;175:S5-S10.4. Johnson TM 2nd, Ouslander JG. Urinaryincontinence in the older man. Med Clin North Am1999;83:1247-1266.5. Alivizatos G, Skolarikos A. Incontinenceand erectile dysfunction following radicalprostatectomy: a review. ScientificWorldJournal2005;5:747-758.6. Cornel EB, de Wit R, Witjes JA. Evaluation ofearly pelvic floor physiotherapy on the durationand degree of urinary incontinence after radicalretropubic prostatectomy in a non-teachinghospital. World J Urol 2005;23:353-355.7. Filocamo MT, Li Marzi V, Del Popolo G, et al.Effectiveness of early pelvic floor rehabilitationtreatment for post-prostatectomy incontinence. EurUrol 2005;48:734-738.8. Pannek J, Konig JE. Clinical usefulness of pelvicfloor reeducation for men undergoing radicalprostatectomy. Urol Int 2005;74:38-43.9. Stern JA, Clemens JQ, Tiplitsky SI, et al. Longtermresults of the bulbourethral sling procedure. JUrol 2005;173:1654-1656.10. Moore KN, Griffiths D, Hughton A. Urinaryincontinence after radical prostatectomy: arandomized controlled trial comparing pelvicmuscle exercises with or without electricalstimulation. BJU Int 1999;83:57-65.11. Hubner WA, Schlarp OM. Treatment ofincontinence after prostatectomy using a newminimally invasive device: adjustable continencetherapy. BJU Int 2005;96:587-594.12. Castle EP, Andrews PE, Itano N, et al. The malesling for post-prostatectomy incontinence: meanfollowup of 18 months. J Urol 2005;173:1657-1660.13. Gnessin E, Livne PM, Baniel J, Gillon G.Continence and quality of life assessment afterartificial urinary sphincter implantation. Isr MedAssoc J 2004;6:592-594.14. Jones JS, Vasavada SP, Abdelmalak JB, et al.Sling may hasten return of continence after radicalprostatectomy. Urology 2005;65:1163-1167.15. John H. Bulbourethral composite suspension: anew operative technique for post-prostatectomyincontinence. J Urol 2004;171:1866-1870.16. McConnell JD, Roehrborn CG, Bautista OM, et al.The long-term effect of doxazosin, finasteride, andcombination therapy on the clinical progressionof benign prostatic hyperplasia. N Eng J Med2003;349:2387-2398.17. Wasson JH, Reda DJ, Brusekwitz RC, et al. Acomparison of transurethral surgery with watchfulwaiting for moderate symptoms of benign prostatichyperplasia. The Veterans Affairs CooperativeStudy Group on Transurethral Resection of theProstate. N Engl J Med 1995;332:75-79.18. Weinberger MW, Goodman BM, Carnes M. Longtermefficacy of nonsurgical urinary incontinencetreatment in elderly women. J Gerontol A Biol SciMed Sci 1999;54:M117-M121.19. Doggweiler-Wiygul R, Sellhorn E. Role ofbehavioral changes and biofeedback in urology.World J Urol 2002;20:302-305.20. Holmes DM, Plevnik S, Stanton SL. Bladder neckelectrical conductivity in the treatment of detrusorinstability with biofeedback. Br J Obstet Gynaecol1989;96:821-826.21. Cardozo L, Stanton SL, Hafner J, Allan V.Biofeedback in the treatment of detrusor instability.Br J Urol 1978;50:250-254.22. Cardozo LD. Biofeedback in overactive bladder.Urology 2000;55:S24-S28.23. Wang AC, Wang YY, Chen MC. Single-blind,randomized trial of pelvic floor muscle training,biofeedback-assisted pelvic floor muscle training,and electrical stimulation in the management ofoveractive bladder. Urology 2004;63:61-66.Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 229Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005

Urinary IncontinenceReview24. Wang AC. Bladder-sphincter biofeedback astreatment of detrusor instability in women whofailed to respond to oxybutynin. Chang Gung MedJ 2000;23:590-599.25. Pages IH, Jahr S, Schaufele MK, Conradi E.Comparative analysis of biofeedback and physicaltherapy for treatment of urinary stress incontinencein women. Am J Phys Med Rehabil 2001;80:494-502.26. Burns PA, Pranikoff K, Nochajski TH, et al.A comparison of effectiveness of biofeedbackand pelvic muscle exercise treatment of stressincontinence in older community-dwelling women.J Gerontol 1993;48:M167-M174.27. Aukee P, Immonen P, Laaksonen D, et al. Theeffect of home biofeedback training on stressincontinence. Acta Obstet Gynecol Scand2004;83:973-977.28. Gordon D, Luxman D, Sarig Y, Groutz A.Pelvic floor exercise and biofeedback in womenwith urinary stress incontinence. Harefuah1999;136:593-596,660. [Article in Hebrew]29. Pena Outeirino JM, Leon Duenas E, RomeroGil JR, et al. 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ReviewUrinary Incontinence54. Emmons SL, Otto L. Acupuncture for overactivebladder: a randomized controlled trial. ObstetGynecol 2005;106:138-143.55. Kitakoji H, Terasaki T, Honjo H, et al. Effect ofacupuncture on the overactive bladder. NipponHinyokika Gakkai Zasshi 1995;86:1514-1519.[Article in Japanese]56. Philp T, Shah PJ, Worth PH. Acupuncture inthe treatment of bladder instability. Br J Urol1988;61:490-493.57. Murakami Y. Clinical effect of hotyuekkito(buzhongyiqitang) on symptoms due to renalptosis and stress incontinence. Hinyokika Kiyo1988;34:1841-1843. [Article in Japanese]58. Alsikafi NF, Gerber GS. The use of phytotherapyin the treatment of men with benign prostatichyperplasia. In: Cherniack EP, Cherniack NS,eds. Alternative Medicine for the Elderly. Berlin,Germany: Springer Verlag: 2003:399-410.59. Bracher F. Phytotherapy of benign prostatichyperplasia. Urologe A 1997;36:10-17. [Article inGerman]60. Madersbacher S, Schatzl G, Brossner C, DreikornK. Phytotherapy for BPS. 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Hatha yoga therapymanagement of urologic disorders. World J Urol2002;20:306-309.Alternative Medicine Review u Volume 11, Number 3 u 2006 Page 231Copyright © 2005 Thorne Research, Inc. All Rights Reserved. No Reprint Without Written Permission. Alternative Medicine Review Volume 10, Number 4 December 2005