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

Sung S-H, et al., J Altern Complement Integr Med 2020, 6: 090 DOI: 10.24966/ACIM-7562/100090 HSOA Journal of Alternative, Complementary & Integrative Medicine

Research Article

(54.5%) and PC6 (54.5%), were frequently used acupuncture point Interventions of Traditional in acupuncture treatment. Conclusion: TKM treatment such as acupuncture, moxibustion, Korean Medicine for Chronic herbal medicine seems to be an effective treatment in patients with CPP. High-quality RCT is needed in order to make decisions on Pelvic Pain: A Literature whether TM treatments should be used for treating CPP. Keywords: Case studies; Chronic Pelvic Pain; Literature Review; Review of Case Studies Traditional Korean Medicine

Soo-Hyun Sung1, Angela-Dong-Min Sung1, Ji-Hye Yeon2, Jang- Kyung Park3, Won-Choon Jung4, Tae-Young Jung5 and Jong- Introduction 4 Hyun Park * Chronic Pelvic Pain (CPP) refers to a condition in which local 1Deptment of Traditional Korean Medicine Policy, National Development Insti- bodily pain, of which the cause cannot be identified, non-periodically tute for Korean Medicine, Korea continues at the pelvis, frontal abdominal wall, lumbar, hip for more than six months [1,2]. CPP can be caused by infection, inflammation, 2Sonamoo Traditional Korean Medicine Clinic, Korea neuropathic pain, fibromyalgia, myoma uteri, endometriosis, prostati- 3Deptment of Korean OB & GY, School of Korean Medicine, Pusan National tis, or unknown causes [3]. University, Korea Ahangari conducted a systematic literature review on the preva- 4Deptment of Pathology, College of Korean Medicine, Dae-Gu Haany Univer- sity, Korea lence 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 5Deptment of Diagnostics, College of Korean Medicine, Dae-Gu Haany Univer- prevalence of CPP among women was between 6% and 27%. Roberts sity, Korea 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]. Abstract In the textbooks of Oriental medicines, CPP falls into the category of dysmenorrhea (經水行後作痛), pain due to qi stagnation for a long Objectives: The aim of this study is to review case studies on in- time(氣滯卽將行而痛), Pain before and after mestruation (經來後 terventions of Traditional Korean Medicine (TKM) for Chronic Pelvic 作痛少腹痛 Pain (CPP). ) and lower abdominal pain ( ) and is closely related to the factors of internal medicine, OBGY, urology, musculoskeletal system Methods: We searched eleven electronic databases for relevant and psychiatric/neural factors [6-8]. Six evils (六淫), seven passions ( studies up to Apr 2018. Case studies of Case studies of TKM treat- 七情), foods (飮食), the tirednesss (勞倦), injuries (外傷), insect bite ments for CPP were included and analyzed. (蟲獸傷) or the insufficiency in essence 精( ), qi (氣), or blood (血) Results: 12 case studies were included and total number of patients may result in the pain by disturbing the flow of energy and blood (氣 of the experimental group was 91 cases. A total of 9 intervention 血) in organs or the Gyeongrak of the body [9]. The treatment is op- methods were used, of which acupuncture was of the highest num- timized according to the symptoms of the patients. The key treatment ber, used in 11 studies (91.7%), followed by herb medicine in 10 stud- elements are composed of acupuncture, moxibustion, or Traditional ies (83.3%), moxibustion in 8 studies (66.7%), pharmacopuncture in Medicine (TM), considering the medical history, mental elements and 3 studies (25.0%) and steam therapy in 2 (16.7%). SP6 (90.9%), LI4 living environment of the patient [2].

*Corresponding author: Jong-Hyun Park, Deptment of Diagnostics, College Western medicine treats this disease with paracetamol, NSAIDs, of Korean Medicine, Dae-Gu Haany University, #1, Hannydaero, Gyeongsan, antidepressants, anticonvulsants, gabapentin, or nerve blocks [3]. In Gyeongsangbuk-do, 712-715, Korea, Tel: +82 538191827; Fax: +82 538191850; the case of paracetamol, while the medicine is effective in the alle- E-mail : [email protected] viation of fever or pain, if the medicine hits the spot, there is no evi- Citation: Sung S-H, Sung A-D-M, Yeon J-H, Park J-K, Jung W-C (2020) Inter- dence to support the use of this medicine on CPP [3]. As for NSAIDs, ventions of Traditional Korean Medicine for Chronic Pelvic Pain: A Literature they are effective when the disease is related to pain, inflammation or Review of Case Studies. J Altern Complement Integr Med 6: 090. peripheral nervous system and therefore used to treat ordinary CPP. Received: February 13, 2020; Accepted: February 24, 2020; Published: Febru- However, these medicines are known for severe side effects [3]. An- ary 28, 2020 tidepressants, anticonvulsants, or gabapentin are effective in neuro- Copyright: © 2020 Sung S-H, et al. This is an open-access article distributed pathic pain. However, there is no effect on CPP with other causes [3]. under the terms of the Creative Commons Attribution License, which permits un- Nerve blocks are effective in treating CPP. However, the diagnosis restricted use, distribution, and reproduction in any medium, provided the original and treatment using this method must be given by a trained expert, author and source are credited. and there is a chance of side effects, as well [3]. Citation: Sung S-H, Sung A-D-M, Yeon J-H, Park J-K, Jung W-C (2020) Interventions of Traditional Korean Medicine for Chronic Pelvic Pain: A Literature Review of Case Studies. J Altern Complement Integr Med 6: 090.

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Sung conducted a meta-analysis and systematic review on the ef- Also, there were no limitations with regard to the intervention meth- fect of acupuncture treatment on female CPP patients [10]. Carinci ods used on the control groups in controlled studies or randomized conducted a systematic literature review on the effect of alternative and controlled studies. treatments, including acupuncture, herbal medicine, mind/body med- Exclusion criteria icine and massage therapy [11]. However, there has not been a study that summarized the overall trends in the treatment of CPP, covering Reviews, experimental studies, surveys, or other studies that were Traditional Korean Treatment (TKM) (e.g., acupuncture, electroacu- not clinical trials were not included in our analyses. Clinical studies puncture, pharmacopuncture, moxibustion, herb medicine, cupping, that were not conducted upon the patients of CPP were also excluded. chuna and qigong). Also, studies based on western medicine, surgeries or clinical studies that were not case studies were also excluded. Therefore, the researchers gathered and analyzed the case studies on the TKM treatment of CPP. The purpose of this study is to provide Study selection and data extraction a guideline for the TM of CPP that could be utilized in clinical contexts. The researchers check the titles and abstracts of the studies in the search results to identify the studies that satisfied the inclusion cri- Method teria. The analyses were conducted after extracting the information such as the author, year, diagnosis name, number of patients, treat- Data sources and searches ment period, treatment, traditional Korean medicine pattern, out- As for the English databases, the researchers searched Pubmed, come, and results. Medline, EMBASE, the Cochrane Central Register of Controlled Results Trials (CENTRAL) and CINAHL Plus, totaling to five websites. As for the Korean databases, the researchers searched the Korea Institute Study selection and description of Science and Technology Information (KISTI), Korean Traditional Our search generated a total of 82 potentially relevant studies, fi- Knowledge Portal, KoreaMed, Oriental Medicine Advanced Search- nally, 12 case studies (English databases: n = 1; Korean databases: ing Integrated System (OASIS), Research Information Service Sys- n=11) met our inclusion criteria (Figure 1). tem (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)”.

keyword chronic pelvic pain OR chronic pelycalgia OR chronic pain of pelvic OR #1. chronic pelvic ache acupuncture OR electroacupuncture OR pharmacopuncture OR moxibus- #2. tion OR herb medicine OR herb OR cupping OR korean medicine OR oriental medicine OR chuna OR qigong #3. case studies OR case series OR case report #4. #1 AND #2 AND #3 Table 1: Search Strategy for Databates. Figure 1: Flowchart of Study Selection Process. CPP: Chronic Pelvic Pain; RCTs: Randomized Clinical Trials, TKM: Traditional Korean Medicine. Inclusion criteria

In this study, the studies on TKM treatment (e.g., acupuncture, 12 case studies on CPP can be summarized in terms of their au- electroacupuncture, herb medicine, pharmacopuncture, cupping, thors, year, diagnosis name, the number of patients, treatment period, moxibustion and chuna etc.) upon patients of CPP were included. treatment, traditional Korean medicine pattern, outcomes and results There were no limitations in the genders or ages of the patients. as shown in table 2 (A & B).

First Patient(s), Intervention Traditional Kore- Outcome Treatment author, number of cases an (Chinese) measure- Main Result period Year Acupuncture Herbal medicine moxibustion Etc. medicine pattern ments

Volume 6 • Issue 1 • 100090 J Altern Complement Integr Med ISSN: 2470-7562, Open Access Journal DOI: 10.24966/ACIM-7562/100090 Citation: Sung S-H, Sung A-D-M, Yeon J-H, Park J-K, Jung W-C (2020) Interventions of Traditional Korean Medicine for Chronic Pelvic Pain: A Literature Review of Case Studies. J Altern Complement Integr Med 6: 090.

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ST36, LR3, SP4, SP6, HT7, HT8, CPP patient with SP2, LR2, 1. Suggestive 1. Qi stagna- 1. Seonghyang- chronic pelvic LR1, SP1, therapy tion-blood Kang jeonggi-san CV12, CV4, inflammatory 13 days CV13, CV12, 2. Relaxation stasis 1. VAS 1. Improved [12] 2. Gamisoyo- BL23 BL17 disease, CV10, ST25, therapy 2. Liver-spleen san-gami n=1 LI11, LI4, 3. Retention enema disharmony EX-HN5, ST8, BL2, GV20 CPP patient after Rim treated with West- 1. Pharmacopunc- 1. TER 5 weeks - - - n.r. 1. Improved [13] ern medication and ture for CPP surgery, n=56 CPP patient with LI4, LR3, 1. Saenghwa-tang Yi [14] 4 weeks CV4, CV12 - 1. Blood-stasis 1. VAS 1. Improved ovarian cyst, n=1 PC6, SP6 2. Banchong-san SP6, SP9, 1. Banchong- ST36, LI4, san-gami LR3, CV2, 2. Gwi- 1. VAS CV3, CV4, bi-tang+Gyoae- CPP patient with 1. Deficiency and 2. 1. Improved Yu [15] 7 weeks ST28, KI19, samul CV3 CV4 - adenomyosis, n=1 cold Symptom 2. Improved BL31, BL32, -tang changes BL33, BL34, 3. Gwibitang GB30, BL40, 4. Yikwiseung- LI4 yang-tang GV20, PC6, 1. CPP patient with 1. Improved Youn 2 weeks to KI6, SP9, 1. Indong- CV6, CV4, NIH-CPSI chronic prostatitis, - n.r. 2. Improved [16] 8 weeks SP6, ST25, soyeom-bang CV12 2. IPSS n=15 3. Improved CV4, CV2 3. EPS KI7, SP10, SP6, SP9, 1. Yin deficiency CPP patient with CV3, PC6, LI11, Ohlsen 1. Paljung-san of the 1. chronic prostatitis, 8 weeks LI12, - - 1. Improved [17] 2. Ilguan-jeon liver and kidney NIH-CPSI n=1 ST36, BL18, 2. Qi stagnation BL23, BL28 LR5 1. CPP patient with 1. Improved NIH-CPSI Lee [18] chronic prostatitis, 4 weeks Ouch point - CV4, CV2 - n.r. 2. Improved 2. IPSS n=1 3. Improved 3. VAS (2 cases-endometriosis) 1. Banchong- san-gami 2. Yijinsamul- tang-gami (1 cases-ovarian (2 cases) cyst) (2 cases) 1. Qi stagnation 1. Banchong- CV3, CV4, 2. Yin and blood CPP patient with san-gami GB41, SI3, CV8, CV12, (2 cases) deficiency endometriosis(2 2. Yikwiseung- BL66, SI2, SP6 - (1 cases) cases) yang-tang Kim 6 days to SP6, SP8, (1 cases) (1 cases) 1. Cold hernia or ovarian cyst(1 (3 cases-adeno- 1. VAS 1. Improved [19] 20 days SP9, CV6, CV4, CV12 - 2. Qi deficiency case)or adenomyo- myosis) CV4, CV8, (3 cases) (3 cases) (3 cases) sis(3 cases), 1. Banchong- CV3 CV3, CV4, 1. Steam therapy 1. Qi stagnation n=6 san-gami CV6, CV12, 2. blood stasis and 2. Pal- ST25, SP6 deficiency mul-tang+Gangh- 3. Qi deficiency wang-san 3. Gunggwijohyeo- reum-gami 4. Yijinsamul- tang-gami 5. Bojungikgi- tang-gami LI4, PC6, LI11, LR3, CPP patient with 1. Small intersine 1. NRS Kim SP6, ST36, 1. Simmido- 1. Pharmacopunc- 1. Improved chronic prostatitis, 6 weeks - excess heat syn- 2. [20] CV13, CV12, jeok-san ture 2. Improved n=1 drome NIH-CPSI CV10, CV24, GV20

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CV12, ST25, CV4, CV3, 1. Qi stagnation CV12, ST25, Kim CPP patient with EX-CA1, 1. Jogyeongjongok- 2. Deficiency of qi 1. TSD 1. Improved 21 weeks CV3 - [21] endometriosis, n=1 LI4, LR3, tang-gami and blood 2. EHP-5 2. Improved PC6, TE5, 3. Blood stasis ST36, SP6 CV3, CV4, CV6, CV12, 1. Samultang-gag- SP6, SP7, 1. Urine am CV12, CV4, 1. Improved Park CPP patient with SP9, LR1, 1. Cupping 1. Blood deficiency test 20 days 2. Banchong- ST25 2. Improved [22] hematuria, n=1 LR2, PC6, 2. Steam therapy 2. Blood heat 2. HGS san-gagam 3. Improved ouch point, 3. NRS yeong-gol, dae-baeg CPP patient with 76 days to LU8, KI7, 1. Sibimijihwang- 1. Pharmacopunc- 1. Kidney defi- 1. Yu [23] chronic prostatitis, - 1. Improved 184 days SP3, KI3 tang-gagam ture ciency NIH-CPSI n=6 Table 2A: Characteristics of Published Case Studies of Chronic Pelvic Pain.

which was the highest in number; (90.9%), LI4 (合谷) and PC6 (內 Intervention Number of Papers N (%) 關), respectively being used in 6 studies (54.5%); CV3 (中極), CV4 ( Acupuncture 11 (91.7) 關元), LR3 (太衝), SP9 (陵泉) and ST36 (足三里), respectively be- Herbal Medicine 10 (83.3) ing used in 5 studies (45.5%); and CV12 中脘) being used in 4 studies Moxibustion 8 (66.7) (46.4%) (Table 3). Ouch points (阿是穴) were not considered as an Pharmacopuncture 3 (25.0) acupuncture point. Steam Therapy 2 (16.7)

Table 2B: Interventions Reported in Case Studies of Chronic Pelvic Pain. Acupuncture Point Chinese Name Number of Papers n(%) SP6 三陰交 10 (90.9) As for the number of case studies on CPP, the first was published LI4 合谷 6 (54.5) in 2001, while 2015 saw the largest number of publications, which PC6 內關 6 (54.5) was 3. A total of 12 case studies were published, with the total number CV3 中極 5 (45.5) of patients being 91 (Figure 2). CV4 關元 5 (45.5) LR3 太衝 5 (45.5) SP9 陰陵泉 5 (45.5) ST36 足三里 5 (45.5) CV12 中脘 4 (36.4) 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 fo- cusing on the diseases that were mentioned in two or more studies. Kim used the same acupuncture points for the patients of CPP with

Figure 2: Studies and Case of Cases Studies of Chronic Pelvic Pain by Years. three different diseases [19]. Classification by the herb medicines Categorization by the intervention methods Of the 12 case studies, 10 used a total of 17 different herb medicines. A total of 12 case studies on CPP used a total of 9 intervention Classification of the herb medicines by diseases: Table 5 shows the methods. There were 4 intervention methods that were used in two result of the classification of the herb medicines used in 10 studies out or more studies, of which acupuncture was of the highest number, of the total 12 case studies by their diseases. used in 11 studies (91.7%), followed by herb medicine in 10 studies Classification of the herb medicines by traditional Korean medi- (83.3%), moxibustion in 8 studies (66.7%), pharmacopuncture in 3 cine patterns: Table 6 shows the classification result of the herb med- studies (25.0%), and steam therapy in 2 (16.7%). icines used in 10 out of 12 case studies of CPP by their traditional Categorization by acupuncture points Korean medicine patterns. Among the 12 case studies, 11 used a total of 58 different acupunc- Classification by moxibustion points ture points. Of these, nine acupuncture points that were used in 4 or Of the 12 case studies of CPP involving TKM treatments, 8 stud- more studies. These were, respectively; SP6 (三陰交), being used in 10, ies used a total of 10 moxibustion points. A total of five moxibustion

• Page 5 of 8 • points were used in more than two studies; CV4 (關元) was used in Institutes of Health Chronic Prostatitis Symptom Index) and VAS 7 studies (87.5%), making it the largest in number; CV12 (中脘) in 6 (Visual Analogue Scale) were used in 5 studies (41.7%), which was studies (75.0%); CV3 (中極) and ST25 (天樞) in 3 studies respective- the largest in number; IPSS (International Prostate Symptom Score) ly (37.5%); and CV6 (氣海) was used in 2 studies (25.0%) (Table 7). and NRS (Numerical Rating Scale) were used in 2 studies (16.7%) (Table 8).

Types of Patient’s Diseases Acupuncture Number of Papers Chinese Name (Number of Case Studies) Point n(%) PC6 內關 3 (60.0) Traditional Korean Medicine Pattern Herbal Medicine SP6 三陰交 3 (60.0) Qi Stagnation and Blood Stasis (氣滯 Seonghyangjeonggi-san (星香正氣散) GV20 百會 2 (40.0) Chronic Prostatitis 血瘀) (n=5) KI7 復溜 2 (40.0) Saenghwa-tang (生化湯) LI11 曲池 2 (40.0) Blood Stasis Banchong-san (蟠葱散) Blood Stasis (血瘀) SP9 陰陵泉 2 (40.0) Symptom Jogyeongjongoktang-gami (調經種 ST36 足三里 2 (40.0) (瘀滯症) 玉湯-加味) CV3 中極 2 (100.0) Ilguan-jeon (一貫煎) Endometriosis (n=2) CV4 關元 2 (100.0) Qi Stagnation Banchongsan-gami (蟠葱散-加味) (氣滯) SP6 三陰交 2 (100.0) Jogyeongjongoktang-gami (調經種玉湯-加味) CV3 中極 2 (100.0) Adenomyosis Banchongsan-gami (蟠葱散-加味) CV4 關元 2 (100.0) (n=2) Gwibi-tang+Gyoaesamul-tang (歸脾湯 SP6 三陰交 2 (100.0) Deficiency Cold +膠艾四物湯) (虛寒) Ovarian Cyst SP6 三陰交 2 (100.0) Gwibitang (歸脾湯) (n=2) Yikwiseungyang-tang (益胃升陽湯) Table 4: Acupuncture Point of Case Studies according to Patient’s Diseases. Liver-Kidney Yin Defi- Paljung-san (八正散) ciency (肝腎陰虛) Sibimijihwangtang-gagam (十二味地 Deficiency Kidney Deficiency 黃湯-加減) Symptom (腎虛) (虛症) Yikwiseungyang-tang (益胃升陽湯) Types of Pa- Qi Deficiency (氣虛), tient’s Diseases Number of Bojungikgitang-gami (補中益氣湯- Indongsoyeom-bang (忍冬消炎方) Blood Deficiency ( (Number of Papers n(%) 加味) 血虛), Case Studies) Qi and Blood Deficien- Samultang-gagam (四物湯-加減) Paljung-san (八正散) 1 (25.0) cy (氣血虛) Jogyeongjongoktang-gami (調經種 Chronic Pros- 玉湯-加味) tatitis Ilguan-jeon (一貫煎) 1 (25.0) (n=4) Simmidojeok-san (十味導赤散) 1 (25.0) Yin Blood Deficiency ( Yijinsamultang-gami (二陳四物湯- 陰血虛) 加味) Sibimijihwangtang-gagam (十二味地黃湯-加減) 1 (25.0) Small Intestinal Excess Simmidojeok-san (十味導赤散) Jogyeongjongoktang-gami (調經種玉湯-加味) 1 (50.0) Heat Heat (小腸實熱) Endometriosis Symptom Banchongsan-gami (蟠葱散-加味) 1 (50.0) Blood Heat (n=2) (熱症) 蟠葱散-加減血熱 Banchongsan-gagam ( ) Yijinsamultang-gami (二陳四物湯-加味) 1 (50.0) ( ) 加味逍遙散-加 Banchongsan-gami (蟠葱散-加味) 2 (100.0) Liver-Spleen Dishar- Gamisoyosan-gami ( mony (肝脾不和) 味) Gwibi-tang+Gyoaesamul-tang (歸脾湯+膠艾四 1 (50.0) Cold Lower Abdominal 物湯) Banchongsan-gami (蟠葱散-加味) Etc. Colic (寒疝) Gwibitang (歸脾湯) 1 (50.0) Blood Stasis + Blood Adenomyosis Gunggwijohyeoreum-gami (芎歸調 Yikwiseungyang-tang (益胃升陽湯) 1 (50.0) Deficiency (血瘀 + 血飮-加味 (n=2) 血虛 ) Palmul-tang+Ganghwang-san (八物湯+薑黃散) 1 (50.0) ) Gunggwijohyeoreum-gami (芎歸調血飮-加味) 1 (50.0) Table 6: Traditional Korean Medicine Pattern of Case Studies of Chronic Pelvic Pain. Yijinsamultang-gami (二陳四物湯-加味) 1 (50.0) Bojungikgitang-gami (補中益氣湯-加味) 1 (50.0) Saenghwa-tang (生化湯) 1 (50.0)

Ovarian Cyst Banchong-san (蟠葱散) 1 (50.0) (n=2) Banchong-san-gami (蟠葱散-加味) 1 (50.0) Moxibustion Point Chinese Name Number of Papers n(%) Yikwiseungyang-tang (益胃升陽湯) 1 (50.0) CV4 關元 7 (87.5) Table 5: Herbal Medicine of Case Studies according to Patient’s Diseases. CV12 中脘 6 (75.0) CV3 中極 3 (37.5) ST25 天樞 3 (37.5) Classification by outcome CV6 氣海 2 (25.0) A total of 11 outcomes were used in the 12 case studies of CPP. Table 7: Moxibustion Point of Case Studies of Chronic Pelvic Pain. Four outcomes were used in more than one study. NIH-CPSI (National

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meridian (脾經), stomach meridian (胃經), liver meridian (肝經), Outcome Measure Number of Papers n(%) kidney meridian (腎經), large intestine meridian (大腸經), pericardi- NIH-CPSI 5 (41.7) um meridian (心包經), conception vessel (任脈) and governor vessel VAS 5 (41.7) (督脈). The number of available clinical studies is too small to make IPSS 2 (16.7) recommendations on the selection of meridians rather than specific NRS 2 (16.7) acupuncture points, which mandates future clinical studies and sci- Table 8: Outcome Measure of Case Studies of Chronic Pelvic Pain. entific 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 Discussion medicine patterns and diseases. Herb medicines have been used for thousands of years to treat a number of diseases, as one of the pre- For this study, a total of 11 databases were used to understand the ferred forms of TM [29,30]. They are used as prescription types, mix- trend of the case studies regarding TKM treatments on CPP, in order ing more than one medicinal material based on TM texts in South to gather and analyze the related study articles. Case studies are stud- Korea, China, Taiwan and Japan [31]. However, as the number of ies that explain the cases in clinical practices. They are highly rele- prescriptions identified in this study was vast, it is necessary to gath- vant to the clinical contexts and form new research questions [24,25]. er more clinical data to make recommendations on the prescriptions Case studies also contribute to establishing the support for TM in based on the diseases of the CPP patients and traditional Korean med- the medical clinics or at home and the designing of randomized con- icine patterns. trolled trials, which are used as the key supporting materials for the recognition of such treatments by the national institutions. Therefore, In western medicine, there is no treatment of CPP unless the cause when a TM for CPP is selected, or when a randomized and controlled of the pain is identified. However, in TM, the meridians and tradition- study is designed, the findings of this study should be considered. al Korean medicine patterns can be used to apply acupuncture, moxibustion, and cupping to patients. The implication of this study is that In the 12 case studies on CPP that were finally included in this the clinical ground for TM of CPP and it is the hope of the researcher study, a total of 9 treatments were used. Four treatments were used that this study can be used as the support for making recommenda- in more than one study, namely acupuncture in 11 studies (91.7%), tions of traditional treatments as a part of the treatment guidelines for herb medicine in 10 (83.3%), moxibustion in 8 (66.7%), and phar- CPP. macopuncture in 3 (25.0%). More than half of the studies were using acupuncture, herb medicine, and moxibustion. And, in most of the Conclusion studies, the results were improved. Therefore, as the TM for CPP pa- TKM treatment such as acupuncture, moxibustion, herbal medi- tients, acupuncture, herb medicine and moxibustion should be consid- cine seems to be an effective treatment in patients with CPP. Howev- ered as the primary options. er, the number of case studies found in this study was not sufficient, The pharmacopuncture used in 3 studies is a new form of acupunc- while the evidence level was also too low, to make recommendations ture therapy that injects herbal extracts into acupoints [26]. Pharma- on TM treatment for CPP. Future studies of High-quality RCT are copuncture is based on the theory of TKM, and is practiced in TKM needed in order to make decisions on whether TM treatments should clinics [27]. Today, pharmacopuncture is covered by automobile in- be used for treating CPP. surances in South Korea. And, many TKM clinics use this method fre- Acknowledgment quently, among other treatment options [28]. A future clinical study is mandated to verify the effectiveness of pharmacopuncture in CPP, by This work was supported by the Policy Support Project for the integrating pharmacopuncture, which is frequently used in the clinical Development of Traditional Korean Medicine funded by the Ministry treatment of CPP and the acupuncture points that were proven to be of Health and Welfare. effective in this study. Conflicts of Interest The result of the classification of the acupuncture points used in 11 The authors declare that there are no conflicts of interest regarding studies out of the 12 case studies showed that patients with CPP and the publication of this paper. accompanying chronic prostatitis were acupunctured at PC6, SP6, GV20, KI7, LI11, SP9 and ST36, while the patients with CPP and ac- References companying endometriosis were treated at CV3, CV4, and SP6. The patients with CPP and accompanying adenomyosis were treated at 1. ACOG Committee on Practice Bulletins-Gynecology (2004) ACOG Prac- CV3, CV4 and SP6, while those with ccc and accompanying ovarian tice Bulletin No. 51. Chronic pelvic pain. Obstet Gynecol 103: 589-605. cyst were acupunctured at SP6. Chronic prostatitis is a disease found 2. Lee TK (1997) A literature review of chronic pelvic pain. J Korean Obstet among men, while endometriosis, adenomyosis, and ovarian cyst are Gynecol 10: 111-119. diseases that affect women. It is recommended to consider the sex 3. Fall M, Baranowski AP, Elneil S, Engeler D, Hughes J, et al. (2015) EAU and accompanying diseases when selecting the acupuncture points for guidelines on chronic pelvic pain. Eur Urol 57: 35-48. treating CPP. 4. Ahangari A (2014) Prevalence of chronic pelvic pain among women: an In TKM, CPP is known to be related to the liver meridian (肝 updated review. Pain Physician 17: 141-147. 經), kidney meridian (腎經), bladder meridian (膀胱經), conception 任脈督脈 5. Roberts RO, Lieber MM, Rhodes T, Girman CJ, Bostwick DG, et al. vessel ( ), and governor vessel ( ) [2]. The acupuncture points (1998) Prevalence of a physician-assigned diagnosis of prostatitis. Urol- used in case studies can be classified by their meridians into spleen ogy 51: 578-584.

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