The first part of the article discussed the ethical and legal aspects in using the points Huiyin Ren-1 and Changqiang Du-1 suggesting the classical texts to be re-examined from a modern point of view and expressing the significance of understanding the potential to harm our patients and the regulation of our role as practitioners:
“Our success as practitioners is based on our knowledge and skill, but cannot be separate from the need to create a compassionate and safe environment for our patients to heal. I therefore believe we should deepen our understanding of the potential harm of these points and the understanding of the benefit of alternative points available to us”.
In this part, Hila Yaffe and I (Orit) will present our findings in modern and ancient texts about these points and other equally effective as well as safe and well-tolerated options.
Clinical Indications of Huiyin Ren-1 and Changqiang Du-1:
According to Deadman, P., Al-Khafaji, M. & Baker, K. (1998). A Manual of Acupuncture
Huiyin Ren -1:
Regulates genito-urinary and anal regions, including difficult urination and defecation, enuresis, seminal emission, impotence, genital diseases, sweating of the genitals, pain of the head of the penis, cold sensation of the head of the penis, swelling of the testicles, swelling and pain of the vagina, prolapse of the rectum, haemorrhoids, pain of the anus and urethra, sensation of heat in the urethra, itching and pain of the perineum, shan disorder.
Treats gynecological disorders, including amenorrhoea, irregular menstruation, uterine prolapse.
Calms the spirit, mania-depression
Promotes resuscitation and revives from drowning
Treats hemorrhoids, difficult defecation, cold or damp diarrhoea, blood in the stool, prolapse of the rectum.
Benefits the two lower yin, treats painful urinary dysfunction, difficult urination, retention of urine, dark urine, sexual taxation, seminal emission due to fear and fright.
Activates the channel and alleviates pain of the lumbar region, heavy sensation of the sacrum, heaviness of the head, shaking of the head, stiffness of the spine, pain of the Heart.
Calms the spirit, treats mania, fright epilepsy, upward staring eyes, mad walking, tetany, clonic spasm.
Acupuncture points should be understood both as tools for practitioners to use, as well as tools for patients to use on themselves for self-treatment and preservation. The indications of these points should be viewed from both perspectives separately.
From the perspective of self-treatment, most of the indications listed above can be realized through self-practice of qi gong and tantric exercises. The practitioner’s role is to inform the patient of these points and their potential benefit and to guide them on how to learn the self-practice techniques that could be relevant to their condition.
From the perspective of utilizing them in acupuncture treatment, we would like to examine their practical necessity. We can distinguish between general indications such as calming the spirit and local indications linked to the points’ location. Regarding general indications, there are numerous options of points in the body to treat the disorders linked to these point functions, which do not involve exposing the patient. Considering the inconvenience and emotional risk involved in this intimate exposure, we believe the various alternatives should be the preferred choice.
According to our understanding, the main reason practitioners choose to use these points in treatment is not for their general systemic indications, but rather for their local indications. This will therefore be the main focus of this article:
We will present 2 basic concepts in Chinese medicine to establish that even for the treatment of local disorders of the perineal area, they can be replaced with numerous points. We will provide a list of alternative points that are indicative for treating this area, that we have personally found to be clinically efficient.
We will also make the argument that based on the approach that we treat our patients with consideration to the whole person as opposed to an isolated symptom, it is our responsibility to the patient to consider other options before referring to these 2 points. A basic question at the core of the practice of acupuncture and relevant to our case, is:
Among the hundreds of acupuncture points in the body, how do you choose the specific ones to treat a specific patient?
We will address this question with 2 main considerations:
1. Local acupuncture vs. distant acupuncture:
Acupuncture as we all know is based on the meridian theory, which maintains the concept that stimulating an acupuncture point in one area of the body can stimulate a response in a distant organ or region. This is why we can successfully treat diseases of internal organs by stimulating external superficial acupuncture points.
Syndromes of pain are also treated efficiently with distant acupuncture. Examples of this are endless. The acupuncture point located in the hand known as Hegu Li-4 is a well-known remedy for headaches, while this same point located closer to the metacarpal joint of the thumb and the index finger (also known as Linggu 22.05 in Master Tung acupuncture) is an excellent point to alleviate lower back pain, as well as point that corresponds to the genital area.
Modern research has supported this theory, one study for example demonstrated with fMRI that stimulation of an acupuncture point in the leg can activate the region in the brain associated with the eyes. (Jian Kong, Ted Kaptchuk, et al. Functional neuroanatomical investigation of vision-related acupuncture point specificity – A multisession fMRI study. Human Brain Mapping, 2009 30(1): 38-46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4009985/)
When treating a disease with a local manifestation, practitioners must take into account the pros and cons of using local points or distant points or both. There is no definite right or wrong answer, and as we will see in the next point of discussion, there are additional factors to be taken into consideration when deciding on the appropriate treatment.
Specifically, when treating a disorder related to the genitals, such as vulvodynia and vaginismus there are additional considerations for treatment that must not be ignored: the increased physical and emotional sensitivity of the area due to the disorder itself as well as invasive examinations and treatments most women have undergone, the intimate exposure involved in treating this area locally, and the possibility of unintentionally giving rise to trauma associated with sexual experiences. Since we have established that it is possible to treat local diseases using distant points, it is our recommendation that in the treatment of the genital and anal areas distant points should have priority over local points.
In order to enable acupuncturists to choose appropriate treatment options, we are providing a list of distal points that are related to creating a response in the genital area. (Appendix A)
2. Treating the Root vs. the Branch:
Chinese medicine views symptoms as a manifestation of imbalance. When the body is balanced and regulated, then the natural processes of healing and maintaining health can be realized. The aim of treatment, therefore, is to address the systemic factors involved in enabling and maintaining a specific state of disease.
This systemic complexity of disease is clearly understood through the modern conceptions of pain. Pain is initially a simple and straightforward mechanism: the purpose of pain is to serve as a warning to damage or potential damage to tissue in the body. However, clinical experience and research have proven pain to be more complex. If it was just a simple warning mechanism, then there should be a correlation between pain location and degree, and between tissue damage. Surprisingly, the clinical reality is that this correlation does not exist, especially in the case of chronic pain. This is due to the fact that pain is a sensation that is transmitted from the brain. The brain receives extensive amounts of signals and information through the nervous system and responds to this information. The response is not based solely on the information coming directly through the local nervous system but is also largely affected by a combination of behavioral patterns, previous memories, and experiences as well as the overall physical and emotional state of the body.
It is clear that pain is not just a symptom of a local disorder but rather a manifestation of complex systemic imbalance. Chinese medicine has long ago recognized this complexity and has always sought to identify and correct the root of a disease. Various diagnostic models have been developed throughout the history of Chinese medicine, in order to enable identification of the imbalance and the proper strategy to regulate it.
This is also evident in the systemic function attributed to many acupuncture points, allowing the acupuncturist to effectively choose acupuncture points for treating the root while combining them with points to treat the manifestation, also known as “branch” of the disease. The importance of this systemic approach towards disease is stated clearly in the ancient classical medical text Huang Di Nei Jing:
Su wen: ch 65: 標本病傳論 - On the Treatise of Disease Transmission of Manifestation and Root
“Those who know the manifestation (biao) and root (ben), are able to correctly treat a great variety [of diseases]. Being unaware of manifestation and root, is called careless practice.”
Choosing an acupuncture point should therefore not be based solely on local symptoms, but rather on differential diagnosis which aims to understand the symptom in reference to the function of the body as a whole. The above quote for the Nei Jing warns us of the unintentional damage we might cause when attempting to treat a disease without considering its relation to all aspects affecting the patient, referring to it as careless or reckless practice.
It is not in the scope of this article to discuss the differential diagnosis of disorders of the genitalia and anal regions. We have collected a list of recommended articles in Appendix B.
A few more things regarding Vulvodynia
One of the modern indications of Huiyin Ren-1 is for the treatment of Vulvodynia, chronic vulvar pain without an identified cause.
There are many possible scenarios of vulvodynia according to Chinese medicine, but since pain is always associated with stasis of the free flow of qi, and since all Liver channels reach the genitals, we can assume that any vulvar pain is related to stasis in the free flow of Liver qi, therefore, the main aspect of the treatment strategy is to harmonize the liver. It is well known that there is no need to needle the genitals in order to have an effect on liver function.
From Orit’s experience with hundreds of women who suffered from vulvodynia, distal points are well tolerated and very effective.
For some women with vulvodynia, emotional exposure can be hard enough and along with physical exposure, the risk of harming our patients increases. As mentioned earlier, the majority of women arriving at the clinic already went through too much of this exposure with invasive examinations and treatments, which have probably increased the stress and therefore the pain.
Avoiding genital acupuncture can turn our clinic into their safe place, where they can stay dressed and covered, forget about their vulva and nonetheless heal.
Under what conditions should these points be used?
If the practitioner does decide to use these points, it should be the last resort before choosing a more radical treatment method such as surgery.
We highly recommend to resort to these points only after all the following has been done:
Different acupuncture strategies have been used with no sufficient improvement
Herbal treatment was added along with lifestyle and diet changes
Other methods other than Chinese medicine were researched and tested
The practitioner discussed it with other colleagues or referred to them
Once all of the above were thoroughly examined the option of using these points can be suggested beginning with teaching the patient how to locate it and massage it or supply them with a magnet/seed for local use (Teaching can be done with pictures or on a pelvic floor model).
When the therapist can honestly say that they have tried everything, needling these points should be done following the instructions in the first part of this article.
Examples of articles and research about non-invasive acupuncture treatments for genital and anal region disorders:
Vulvodynia: Chinese medicine articles:
Orit Zilberman, The Treatment of Vulvodynia with Acupuncture and Chinese Herbal Medicine. Journal of Chinese Medicine, Number 109, October 2015.
Lee Hullender Rubin, The Comprehensive Treatment of Provoked, Localised Vulvodynia with Acupuncture and Associated Modalities. Journal of Chinese Medicine, Number 120 June 2019.
Research and pilot studies:
University of Ilinois at Chicago, Double-blind phase 2 RCT: Effect of Acupuncture on Patient Vulvodynia Outcomes, (research in progress) https://ichgcp.net/clinical-trials-registry/NCT03364127 https://vulvodyniastudy.uic.edu/
L. Hullender Rubin et al. Acupuncture Augmentation of Lidocaine for Provoked, Localized Vulvodynia: A Feasibility and Acceptability Study. Journal of Lower Genital Tract Disease, October 2019
Schlaeger JM et al. Acupuncture for the Treatment of Vulvodynia: a Randomized Wait-List Controlled Pilot Study. J Sex Med 2015.
Curran S et al. The ACTIVE Study: Acupuncture Treatment in Provoked Vestibulodynia. J Sex med, 2010
Danielsson I et al. Acupuncture for the Treatment of Vulvar Vestibulitis: a Pilot Study. Acta Obset Gynecology Scandinavia. 2001.
Powell J, Wojnarowska F. Acupuncture for Vulvodynia. JRSM 1999.
Ana-Carolina Beth, Effective One-Point, One-Minute Hemorrhoid Treatment, Acupuncture Today, February 2012 https://acupuncturetoday.com/mpacms/at/article.php?id=32524
Xue-Mei Bian et al, Moxibustion Therapy at CV4 Prevents Postoperative Dysuria after Procedure for Prolapse and Hemorrhoids, Evidence-Based Complementary and Alternative Medicine, 2013 https://www.hindawi.com/journals/ecam/2013/756095/
Libido and Sexual dysfunction
Susan H. Oakley et al, Acupuncture in Premenopausal Women With Hypoactive Sexual Desire Disorder: A Prospective Cohort Pilot Study, SexMed, 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005297/
Baljit Khamba et al, Efficacy of acupuncture treatment of sexual dysfunction secondary to antidepressants, J Altern Complement Med, November 2013. https://pubmed.ncbi.nlm.nih.gov/23790229/
Li, Yangfeng et al, Acupuncture for erectile dysfunction in post-stroke patients - study protocol clinical trial, Medicine April 2020 https://journals.lww.com/md-journal/fulltext/2020/04100/acupuncture_for_erectile_dysfunction_in.37.aspx