Overactive bladder and nocturia

The International Continence Society defines overactive bladder (OAB) as urinary urgency, usually with frequent urination and nocturia, with or without leakage, and with no infection or other obvious cause, the definition the 2024 AUA/SUFU guideline adopts. Nocturia is waking one or more times in the night to pass urine, in the words of the NOCTURNAL trial below. The trials for these conditions test two related methods: acupuncture and electroacupuncture, and percutaneous tibial nerve stimulation (PTNS), in which a fine needle near the ankle carries a current to the tibial nerve. Leakage on coughing or lifting, and the trials of electroacupuncture over the sacrum for it, are covered in Urinary incontinence; this page reports on urgency, frequency and night-time voiding.

The Cochrane review of acupuncture

The 2022 Cochrane review by Hargreaves and colleagues searched English and Chinese databases to May 2022 and included 15 studies with 1,395 adults: 14 randomised trials and one quasi-randomised. All raised some concerns about bias, and participants were blinded to their group in only 20% of them. GRADE, the scale Cochrane uses to rate confidence in a result from high to very low, rated the comparisons separately.

Nocturia against sham came from one small study, with very low certainty. No study reported a major adverse event, and the authors note that the trials were too small to detect rare ones. They concluded that it is uncertain whether acupuncture differs from sham, and that their findings must stay tentative until larger trials with comparable outcomes report. Sham acupuncture sets out the kinds of control these trials use.

Later reviews of acupuncture

A 2022 review by Lee and colleagues at Kyung Hee University in Seoul searched English, Korean and Chinese databases and included 30 randomised trials, 25 of them run in China. Seven compared acupuncture with sham. Against sham, it reported OAB symptom scores 1.13 points lower and fewer voids a day, and no difference in incontinence; against drugs, similar symptom scores with fewer adverse events (risk ratio 0.38). It rated the evidence mostly low or very low, for risk of bias and small samples.

A 2025 umbrella review by Ma and colleagues assessed seven systematic reviews, searched to February 2024. On AMSTAR 2, a checklist for how a review was conducted, it rated six critically low and one low. Of 34 outcomes it graded, one was moderate certainty, five low and 28 very low.

How PTNS relates to needling at the ankle

A 2017 review of PTNS by de Wall and Heesakkers at Radboud University in Nijmegen states that the technique derives from acupuncture and was first described in the early 1980s, and that Stoller and colleagues developed it, first in monkeys and then in people. A 34-gauge needle goes in about three finger breadths above the inner ankle bone, between the back edge of the tibia and the soleus muscle, with its tip close to the posterior tibial nerve. A stimulator delivers 20 Hz, usually for 30 minutes a session over 12 sessions. The authors place SP06 (Sanyinjiao) on the inner lower leg about four finger breadths above the same bone, and write that electroacupuncture at similar settings resembles PTNS; the difference they name is that PTNS targets a nerve where acupuncture describes a channel. A 2025 trial by Tan and colleagues at Xiyuan Hospital in Beijing describes the tibial nerve as running beneath SP06 and chose that point to stimulate it. The European Association of Urology (EAU) states that the stimulus reaches the spinal centre that controls voiding through the second to fourth sacral nerve roots.

Cochrane’s 2016 review of electrical stimulation with non-implanted electrodes, by Stewart and colleagues, counts PTNS among those methods, alongside vaginal and anal probes. Searched to December 2015, it included 63 trials with 4,424 people. Moderate-quality evidence showed more people reporting improvement with electrical stimulation than with sham (risk ratio 2.26; 677 people) or with drugs (1.20; 439 people). There was too little evidence to say which kind of stimulation worked best or whether benefits lasted after treatment stopped.

The PTNS trials

The SUmiT trial, reported in 2010 by Peters and colleagues, randomised 220 adults with OAB to 12 weekly sessions of PTNS or a sham, double-blind. At 13 weeks, 54.5% of the PTNS group rated their bladder symptoms moderately or markedly improved, against 20.9% of the sham group. Voiding diaries showed fewer voids, fewer night-time voids, fewer urgent voids and fewer urge incontinence episodes with PTNS. No serious adverse event related to the device was reported. Of the people who responded, 50 entered the STEP study, which continued treatment at about one session a month: 29 completed three years, night-time voids fell from a median of 2.7 to 1.7, and a statistical model estimated that 77% kept their improvement.

The earlier OrBIT trial, reported in 2009 by the same group, randomised 100 adults to 12 weeks of PTNS or extended-release tolterodine, an antimuscarinic bladder drug, at 4 mg a day. Of the participants, 79.5% with PTNS and 54.8% with tolterodine rated themselves cured or improved. Frequency, urge incontinence, urgency and night-time voids improved by similar amounts in both groups. The trial had no sham arm.

Acupuncture and electroacupuncture trials

A 2020 trial in Hong Kong by Lin and colleagues randomised 100 people with OAB to 16 sessions over eight weeks of acupuncture at BL32 (Ciliao), BL23 (Shenshu), SP06, KD03 (Taixi), BL39 (Weiyang), BL28 (Pangguangshu) and CV04 (Guanyuan), or to blunt sham needles that retracted into the handle at the same points. Both groups improved from baseline, and the improvement lasted three months. The groups did not differ in urge incontinence or daytime frequency; night-time frequency fell more with real acupuncture, after adjusting for a higher starting level in that group. The authors wrote that the trial could not establish a specific effect of acupuncture.

A 2025 trial by Noh and colleagues in South Korea compared two frequencies of electroacupuncture, 2 Hz and 16 Hz, with manual acupuncture in 147 postmenopausal women, twice a week for six weeks at CV03 (Zhongji), CV04, GV20 (Baihui), KD03 and SP06. Voids per 24 hours, the primary outcome, did not differ between the three groups, and neither did night-time voids. In Tan’s trial, 68 women had electroacupuncture at BL33 (Zhongliao) and SP06 three times a week for four weeks, or tolterodine. Symptom scores did not differ at four weeks, and more of the electroacupuncture group were rated as responding (88.6% against 48.5%). Electroacupuncture describes the method.

Nocturia after prostate cancer

The NOCTURNAL trial, a pilot reported in JAMA Oncology in 2025 by Liou and colleagues at Memorial Sloan Kettering Cancer Center in New York, randomised 60 men treated for prostate cancer, who woke two or more times a night to urinate, two to one to acupuncture or a waiting list with usual care. The acupuncture group had 10 weekly sessions at points including BL23, BL28, BL31 (Shangliao), BL33, BL35 (Huiyang), BL40 (Weizhong), KD03, KD07 (Fuliu) and SP06, with current between points on the lower back and sacrum. At week 10, nocturia fell by 1.08 episodes a night with acupuncture and rose by 0.05 on the waiting list, a difference of 1.13; at week 14 the difference was 0.85. The authors list as limitations the small sample, one month of follow-up after treatment, a single site, and no placebo control or masking.

What guidelines say

The AUA/SUFU guideline of the American Urological Association and the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction, published online in April 2024, says clinicians should offer sacral neuromodulation, PTNS or botulinum toxin injection into the bladder when drugs or behavioural therapy have not worked or were not tolerated (a moderate recommendation, evidence grade A). It lists acupuncture among minimally invasive therapies, which clinicians may offer to people unable or unwilling to have behavioural, non-invasive or drug treatment. Its discussion cites a meta-analysis that found acupuncture’s evidence uncertain against sham or no treatment and similar to drugs on low-certainty evidence.

NICE guideline NG123, on incontinence in women, says not to offer transcutaneous tibial nerve stimulation for OAB, and not to offer PTNS unless a local multidisciplinary team has reviewed the case, medication has not worked adequately, and the woman does not want botulinum toxin or sacral nerve stimulation. It also says not to recommend complementary therapies for incontinence or OAB, without naming acupuncture. The EAU guideline on female lower urinary tract symptoms, in its 2026 edition, gives a strong recommendation to offer tibial nerve stimulation for OAB and urge incontinence, and a weak one to consider acupuncture for OAB symptoms. Clinical guidelines compares how other bodies treat acupuncture.

What the reviews could not settle

For acupuncture, the two reviews that pooled sham comparisons reached different readings: very uncertain in Cochrane’s, favourable in Lee’s, and both drew on fewer than ten sham-controlled trials. The comparisons with drugs were not blinded. NOCTURNAL, the one trial above built around nocturia, compared acupuncture with a waiting list and ran at one site. For PTNS, the sham-controlled evidence rests on SUmiT, and its longer follow-up kept only people who had responded. The reviews above report PTNS and acupuncture separately, so none compares a needle placed at the tibial nerve with one placed at SP06. Cochrane’s review of electrical stimulation predates the trials published since 2016.

AcuiQ’s overactive bladder, nocturia, urge incontinence and frequent urination pages list the protocols individual studies prescribed, each with its citation.