Urinary Strangury (Lín Zhèng)

Characterized by discomfort during urination with symptoms of urgency, increased frequency, oliguria, and painful, difficult urination. Additional symptoms may include fever and lower abdominal spasms or pain radiating to the lower back during urination. Note: pain is not always experienced with urinary strangury.

Relevant Biomedical Diseases

-Acute or chronic UTI to (cystitis, urethritis)
-Prostatitis
-Urinary renal calculi
-Neoplasms of the bladder, prostate, and urethra
-Chyluria

Etiology and Pathology

Urinary strangury can be categorized according to six types depending on pathogenesis and clinical manifestations:
Heat strangury (rè lín): Damp-Heat
Stone strangury (shí lín): urinary calculi
Qi strangury (qì lín): Qi stagnation or Qi vacuity
Blood strangury (xuè lín): hematuria
Cloudy strangury (gāo lín): Dampness
Taxation strangury (láo lín): difficult urination with dribbling

Exogenous Damp-Heat invades the Urinary Bladder via the Tai Yang (BL) channel, the leg Yin channels, or the local luo/collaterals of the genitourinary system.
Diet of greasy, spicy foods and alcohol can generate Damp-Heat in the Middle Jiao that, over time, will pour down into the Urinary Bladder.

Complications of Damp-Heat:
-Long-term Damp-Heat in the Lower Jiao may condense fluids and create urinary stones.
-Heat or Damp-Heat may injure the collaterals causing reckless movement of Blood.
-Damp-Heat may disturb the Urinary Bladder’s ability to separate to clear from the turbid, causing cloudy urine.

Emotions: long-standing frustration, anger and irritability will stagnate Liver Qi. Over time, this will generate Heat and Fire that will disrupt the Qi transformation function of the Urinary Bladder.

Chronic urinary strangury, aging, constitutional vacuity, taxation fatigue, or excessive sexual activity deplete the Spleen and Kidneys. This may result in Spleen Qi sinking, decline in the Kidney Qi and failure to secure Essence, or Yin vacuity with empty Heat. Any of these pathologies may result in urinary strangury.

Main Organs Involved in Urinary Strangury (Lín Zhèng)

-Urinary Bladder
-Kidneys
-Spleen
-Liver
-Lungs
-Heart/Small Intestine

Identification of Repletion vs. Vacuity

Repletion
Vacuity
Acute
Damp-Heat, Qi stagnation, urinary stones may be present
Sharp, burning pain common when voiding
Urine may be dark, turbid or red
Chronic
Spleen Qi vacuity, Kidney Qi or Yin vacuity common
Slight burning or no pain when voiding; dribbling more common
Urine is light in color or clear

Differential Diagnosis of Similar Disorders

-Oliguria-anuria: Characterized by difficultly urinating with less than normal urine volume or no urination at all. By comparison, urinary strangury often (though not always) presents with pain when voiding and the daily volume of urine output is adequate.
-Hematuria: Blood in the urine is a common symptom for both hematuria and Blood strangury. However, pain during urination is absent with hematuria and is always present with Blood strangury.
-Turbid Urination: Both Turbid Urination and Cloudy strangury manifest a milky appearance of the urine. To differentiate, pain is often a major symptom of Cloudy strangury but is absent with Turbid Urination.

TCM Pattern Differentiation

Heat Strangury

Signs: frequent, urgent, painful, difficult urination with dark, scanty urine
Symptoms: burning sensation and sharp pain of the urethra, lower abdominal pain that may radiate to the lower back during urination; possibly with chills, fever, bitter taste in the mouth, lower back pain, constipation, nausea or vomiting
Tongue: red with yellow, greasy coat
Pulse: rapid and slippery
Treatment Principle: Clear Heat, drain Dampness, free and promote urination
Herbal Treatment: Ba Zheng San (Eight Corrections Powder)
[Mu tong ( 9g), Che Qian Zi (12g), Bian Xu (9g), Qu Mai (9g), Hua Shi (15g), Deng Xin Cao (3g), Shu Da Huang (9g), Shan Zhi Zi (9g), Zhi Gan Cao (6g.)]

Stone Strangury

Signs: difficult urination with sand and stone; sudden interruption of micturition; dark yellow urine or possible hematuria in severe cases
Symptoms: cramping and colicky pain in lower abdomen/low back/perineum
Tongue: red with thin, yellow coating
Pulse: wiry and rapid
Treatment Principle: Clear Heat, drain Dampness, free and promote urination, eliminate stones
Herbal Treatment: Shi Wei San (Pyrrosia Powder)
[Shi Wei (9g.), Dong Kui Zi (9g.), Qu Mai (9g.), Hua Shi (15g.), Che Qian Zi (12g.)]
Modifications:
Stones: + Ji Nei Jin (15-30g. ), Jin Qian Cao (15-30g.), Hai Jin Sha (15g.)
Hematuria: + either Hu Po OR San Qi
Severe cramps: + Shao Yao Gan Cao Tang

Qi Strangury – Repletion Pattern

Signs: difficult urination, dripping urine with fullness and pain in the lateral aspect of the lower abdomen
Symptoms: fullness and distention in the chest and hypochondriac regions
Tongue: thin, white coating
Pulse: wiry
Treatment Principle: Rectify Qi, free and promote urination
Herbal Treatment: Chen Xiang San (Aquilaria Powder)
[Chen Xiang (1.5g), Chen Pi (9g.), Dang Gui (6g.), Bai Shao (9g.), Gan Cao (6g.), Shi Wei (9g.), Hua Shi (12g.), Dong Kui Zi (9g.), Wang Bu Liu Xing (9g.)]

Qi Strangury – Vacuity Pattern

Signs: difficult urination with frequent dribbling of clear urine, painful, heavy sensation in the lower abdomen
Symptoms: pale complexion, fatigue, loose stool
Tongue: pale
Pulse: weak, thready
Treatment Principle: Supplement the Spleen, boost the Qi
Herbal Treatment: Bu Zhong Yi Qi Tang (Supplement the Center Decoction)
[Huang Qi (15g), Ren Shen (9g), Bai Zhu (9g), Dang Gui (9g), Chen Pi (6g), Chai Hu (3g), Sheng Ma (3g), Zhi Gan Cao (6g)]

Blood Strangury – Repletion Pattern

Signs: frequent, urgent urination with sharp burning pain in the urethra; hematuria with dark red urine, blood-streaked urine or passage of blood clots with the urine
Symptoms: fullness and distending pain in the lower abdomen; irritability, restlessness
Tongue: read with yellow coating
Pulse: rapid, slippery, forceful
Treatment Principle: Clear Heat, free and promote urination, cool the Blood, stop bleeding
Herbal Treatment: Xiao Ji Yin Zi (Cephalanoplos Drink)
[Xiao Ji (15g), Sheng Di Huang (30g), Chao Pu Huang (9g), Ou Jie (9g), Dan Zhu Ye (9g), Mu Tong (6g), Hua Shi (15g), Zhi Zi (9g), Gan Cao (6g.), Dang Gui (9g.)]



Blood Strangury – Vacuity Pattern

Signs: long-standing hematuria with urine that is slightly red; mild or no pain or difficulty during urination
Symptoms: soreness and weakness of the lower back and knees, fatigue, 5-Center-Heat
Tongue: read with scanty coating
Pulse: thin and rapid
Treatment Principle: Nourish Yin, clear Heat, stop bleeding
Herbal Treatment: Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Pill)
[Shu Di Huang (24g.), Shan Zhu Yu (12g.), Shan Yao (12g.), Ze Xie (9g.), Mu Dan Pi (9g.), Fu Ling (9g.), Zhi Mu (9g.), Huang Bai (9g.)]

Cloudy Strangury – Repletion Pattern

Signs: cloudy, milky or creamy urine that may contain precipitate or blood clots; urethral pain and burning
Symptoms: abdominal pain and distention, thirst with no desire to drink
Tongue: red with yellow, greasy coating
Pulse: slippery and rapid
Treatment Principle: Clear Heat, drain Dampness
Herbal Treatment: Cheng Shi Bi Xie Fen Qin Yin (Cheng’s Fish Poison Yam Clear/Turbid Separation Beverage)
[Bi Xie (12g), Shi Chang Pu (6g.), Huang Bai (9g.), Che Qian Zi (12g.), Fu Ling (9g.), Bai Zhu (6g.), Lian Zi Xin (3g.), Dan Shen (9g.)]

Cloudy Strangury – Vacuity Pattern

Signs: chronic dribbling of cloudy or milky urine, mild or no pain with urination
Symptoms: emaciation, sore, weak low back and knees, dizziness, fatigue, tinnitus
Tongue: pale with greasy coating
Pulse: deep, weak
Treatment Principle: Supplement the Kidney, secure Essence
Herbal Treatment: Gao Lin Tang (Cloudy Strangury Decoction)
[Dang Shen (12g.), Shan Yao (30g.), Sheng Di Huang (9g.), Qian Shi (15g.), Duan Long Gu (30g.), Duan Mu Li (30g.), Bai Shao (9g.)]

Taxation Strangury

Signs: difficult urination with dribbling that occurs with or is exacerbated by exertion; repeat infections that do not respond well to treatment
Symptoms: fatigue, soreness and weakness of low back and knees
Tongue: pale
Pulse: deep and weak
Treatment Principle: Strengthen the Spleen, supplement the Kidney
Herbal Treatment: Wu Bi Shan Yao Wan (Matchless Dioscorea Pill)
[Shan Yao (30g), Fu Ling (15g), Ze Xie (9g), Shu Di Huang (12g), Shan Zhu Yu (12g), Ba Ji Tian (12g.), Tu Si Zi (9g.), Du Zhong (12g.), Niu Xi (9g.), Wu Wei Zi (6g.), Rou Cong Rong (15g.), Chi Shi Zhi (12g.)]



Acupuncture for Urinary Strangury

Primary Points: CV 3, SP 9, BL 28
Supplementary Points:
Heat: LI 4, TB 5
Stone: BL 39, KI 2
Repletion Qi: 4 Gates, BL 18, LV 14
Vacuity Qi: CV 4, CV 6, ST 36, BL 20
Repletion Blood: SP 10, SP 6
Vacuity Blood: SP10, SP 6, KI 3, BL17
Repletion Cloudy: ST 28, LV5
Vacuity Cloudy: BL23, GV4, CV6, KI3, GV20
Taxation: CV 6, ST 36, GV 20, GV 4, BL 20, BL 23

Clinical Tips for Treating Urinary Strangury

Use diaphoretics and tonics cautiously. In ancient Chinese medical documents, diaphoresis and tonification are contraindicated as treatment methods for urinary strangury. In the initial stage of urinary strangury, aversion to cold, fever and general body ache may be present. Because frequent urination and excessive Heat of urinary strangury can damage the Yin, using acrid and warm herbs to induce sweating and release the exterior will further damage the Yin and complicate the condition.

However, if urinary strangury is caused by exterior Wind-Heat or exterior Damp-Heat with manifestations of aversion to wind, fever, cough and sore throat, acrid and cool herbs to induce sweating and release the exterior may be used. Tonification is contraindicated for repletion urinary strangury. Tonification is appropriate and recommended for vacuity urinary strangury, including Spleen Qi vacuity, Spleen Qi sinking, and Kidneys failing to secure the Essence.

“Use the strategy of unblocking obstructions to promote elimination in unremitting draining syndromes.” Unremitting draining syndromes include intractable diarrhea, frequent urination and flooding and leaking syndrome caused by replete pathogenic influences. This treatment method is only applicable in repletion patterns, including repletion patterns of urinary strangury. By clearing Heat, draining Dampness, moving Qi and Blood and dissolving stones, replete pathogenic influences and the obstruction they cause in the urinary tract will be removed, thus freeing and promoting urination.

The most common cause of hematuria in men over the age of 50 is carcinoma of the bladder. Therefore, persistent hematuria should never be treated without a proper biomedical workup.