constipationA recent study in the Journal of General Internal Medicine evaluated a treatment for constipation. It tested whether training patients to massage the perineum (the area between the vagina or scrotum and the anus) would improve their reported bowel function and quality of life at 4 weeks after training. They found that it did. It’s a simple, innocuous treatment that may be worth trying, but why, oh why, did they have to call it “acupressure”? That irritated me. Should it have? Why should it matter? Isn’t a rose by any other name still a rose? Is this a meaningless semantic quibble and hypersensitivity on my part, or am I right to see it as yet another example of quackademia’s attempts to infiltrate science-based medicine? I’ll explain my thinking and let you decide for yourself.

Why perineal pressure?

Constipation is a common complaint that is usually treated with increased dietary fiber and fluids, exercise, stool softeners, and laxatives. There were no previous studies of perineal massage for constipation. Where did the idea of treating constipation with perineal pressure come from? The authors explain that perineal massage is recommended in pregnancy to prevent lacerations and decrease the need for episiotomy. True, but irrelevant. They explain that patients with rectocele or descending perineum syndrome have used perineal or transvaginal pressure to support the weakened rectal wall and aid in defecation. Also true, but irrelevant for most patients with constipation. They cited a study showing that perineal pressure increases rectal muscle tone by 52%, but the clinical relevance of that finding is not clear. They cited other research suggesting that perineal pressure might break up hard stools, relax the anal sphincter, stimulate sacral nerves, and treat hemorrhoids. But none of the studies they cited called it “acupressure.”

How the study was done

The study was randomized with a treatment group and a control group but no blinding. The 100 participants met the Rome III criteria for functional constipation. Both groups received educational materials about constipation and conventional treatment options. The self-acupressure group also received 3-5 minutes of oral instruction with the aid of a plastic anatomical model and were given handouts with written sex-specific instructions. The handout for women explains:

With two extended fingers (middle and index), you should press on your perineum, pushing toward the back of your body on the skin roughly half way between your vagina and anus. When you sense that you are just about to defecate, your fingers should be able to feel underneath your perineum the stool inside you pushing against your sphincter…you should push on your perineum in repeated pulses. Imagine that you are using your fingers to break up and guide the stool downward inside you. By pushing several times on the skin, you can manually break up the stool before it passes through the sphincter. You should relax your sphincter only when the stool above it is sufficiently soft to pass through.

Subjects filled out questionnaires at the beginning of the study and again after one month. The questionnaires asked about various subjective factors such as ease of defecation, feeling of incomplete bowel evacuation, hemorrhoid symptoms, physical and psychosocial discomfort, worries, satisfaction, quality of life, etc. Eight patients were lost to follow-up and one decided not to practice self-acupressure after instruction, so 91 subjects completed the study.

Study results

It worked! Outcomes for the treatment group were better than for the control group. There were statistically significant differences in 13 out of the 18 primary and secondary outcomes. Patients in the treatment group reported using the technique 3.6 times a week, and 82% said they intended to continue using it.

Limitations of the study

The authors themselves point out several limitations of the study. The sample size was modest, the randomization left the two groups poorly balanced with regard to gender and baseline scores, and the study was not blinded. Outcomes were not measured objectively but only by subjective patient self-report. A placebo effect and a Hawthorne observer effect may well have influenced results.

There was no comparison with other manual techniques. I wondered if it might be more effective for women to insert a finger in the vagina. Or for either sex to use a lubricated glove or finger cot and insert a finger in the rectum to disimpact the stool directly and stimulate defecation. For that matter, if they’re going to call it acupressure, why didn’t they compare it to stimulation of other acupoints elsewhere on the body that have traditionally been used to treat constipation? (I suspect they knew that would be fruitless.)

Recommendation

In their conclusion, the authors say, “Clinicians should consider incorporating education in perineal self-acupressure as a treatment for constipation, along with conventional interventions such as increased exercise and dietary fiber intake.” The advice to consider trying perineal massage is reasonable, and I have no quarrel with that. My only objection is to calling it acupressure.

What is acupressure?

Acupressure is a variant of acupuncture. Like acupuncture, it is based on the concept that life energy (qi) flows through meridians and obstructions to the flow can be treated by stimulating acupoints. There is no credible evidence that qi, obstructions, meridians, or acupoints even exist. One self-styled world expert on acupressure therapy recommends that constipation be treated, not by pressure on the perineum, but by pressure at acupressure point CV6 on the abdomen just below the belly button. Other online acupressure advice generally involves points on the hand, with either steady pressure or light repetitive tapping. One acupuncture website lists a whole slew of acupuncture points for constipation, the particular combination varying according to whether the patient has hot constipation, cold constipation, qi constipation, qi deficient constipation, wind constipation, food constipation, blood deficient constipation, or yin deficient constipation.

There is indeed an acupoint on the perineum, the Ren 1 point. It is said to nourish Kidney Yin and resolve Damp-Heat, and is used for constipation, dysuria, incontinence of feces and urine, hemorrhoids, rectal prolapse, spermatorrhea, impotence, pruritus vulva, loss of consciousness, asphyxiation from drowning, and manic psychosis. When I read that, my imagination ran wild. I couldn’t help envisioning an acupuncturist responding to a drowning emergency by pulling off the victim’s swim trunks and sticking needles in his bottom. Or trying to do that to a psychotic patient in the throes of a manic episode. Could be interesting…

Why did the study call it “acupressure” rather than massage?

I was curious enough to write the lead author and ask him. He replied that they could just as well have called it massage. (So why didn’t they?) He said acupressure was part of the Rome criteria for diagnosis of constipation, but the Rome criteria don’t mention acu- anything. They only include “Manual maneuvers to facilitate at least 25% of defecations (e.g., digital evacuation, support of the pelvic floor)”.

I exchanged several e-mails with the author in an attempt to understand his reasoning. He directed me to the website for the Center for East West Medicine. When I searched that site for constipation, I found only a reference to the Large Intestine 6 (He Gu) point on the hand. That point is recommended for headaches and jaw pain in addition to constipation, general pain, and delayed labor. They say it must never be used during pregnancy because it may induce labor; I wouldn’t worry about that.

The author is an MD, JD, and MTOM (Master of Traditional Oriental Medicine) who uses what he calls a “holistic paradigm” to make traditional Chinese medicine diagnoses and treat patients on that basis. He said the study provided a technique that would integrate well with conventional medicine. I think that provides a crucial clue to understanding what is going on here.

Conclusion

The study suggests that perineal pressure or massage might be a useful addition to conventional treatment of constipation. We don’t usually go by the results of a single study that has not been replicated, but in this case the treatment is harmless and not unreasonable to try. I only wish they had called it “perineal pressure” instead of “acupressure.” I think the use of the word “acupressure” constitutes a deliberate attempt to promote belief in fanciful alternative medicine concepts and to infiltrate them into mainstream medicine. In my opinion it is a prime example of the so-called “integrative” approach to medicine that science-based medicine so rightfully deplores and that Mark Crislip has compared to mixing cow pies with apple pies.

 

 

Posted by Harriet Hall

Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.