1. Cao Min Department of Emergency Longhua Hospital Affiliated to SHUTCM
URINE RETENTION
Cao Min
Department of Emergency
Longhua Hospital Affiliated to SHUTCM

2. DEFINITION
Urine retention is caused by inability of the kidneys and urinary bladder to transform Qi. It is mainly marked by small amount of urine, difficult urination or even complete retention of urine.

3. Long means scanty urine volume, poor urinary stream with intermittent flow (dripping), which belongs to a mild case.
Bi refers to a severe case, which means anuresis, an inability to urinate.

4. Relative Diseases in Western Medicine
Nervous Anuria
Spasm of Sphincter Vesicae
Lithiasis
Tumors, Trauma, and Narrowness of the Urinary Tracts
Senile Prostatic Proliferation

5. ETIOLOGY & PATHOGENESIS
“小便不通，由肾与膀胱俱有热故也。”
——《诸病源候论·小便病诸候》
Damp-heat accumulating in the urinary bladder
Unresolved damp-heat in the middle jiao may flow downwards to the urinary bladder. Or the heat in the kidney may transmit into the urinary bladder, and then the heat may accumulate with water, leading to the damp-heat stagnating at urinary bladder. As a result, the damp-heat may impair the qi transformation of the bladder, leading to difficulty passing urine and urine retention.

6. ETIOLOGY & PATHOGENESIS
Exuberance of lung-heat
The lung is known as the source of upper water. Exuberance heat in the lung may impair the descending of lung-qi, causing failure of lung-qi to transport water to the urinary bladder and subsequent urine retention. Or excessive heat may directly transmit downwards to the urinary bladder. Finally, both upper jiao and lower jiao are blocked by the heat, and thus causing urine retention.

7. ETIOLOGY & PATHOGENESIS
“中气不足，溲便为之变”
——《灵枢·口问》
Inability of the splenic Qi to ascend
Overstrain, an improper diet, or weak constitution due to a prolonged disease will cause the splenic deficiency, which will further cause the inability of the clear qi to ascend and the inability of the turbid yin to descend. The turbid yin, including the metabolized fluids, cannot be eliminated smoothly. Thus, dysuria will follow up.

8. ETIOLOGY & PATHOGENESIS
“无阳则阴无以生”
“无阴则阳无以化”
Kidney-yang deficiency
A weak constitution due to an elderly age, or a prolonged disease will lead to renal Yang deficiency and the decline of life gate fire. As a word saying, “If there is no Yang, there is no birth of Yin”. As a result, the urinary bladder loses its function of qi transformation, which will further cause the inability of the turbidity to descend, leading to urine retention. As we know, if there is no Yin, there is no transformation of Yang. Retention of heat in the lower jiao may consume Yin fluid, and cause renal Yin deficiency, further causing anuria.

9. ETIOLOGY & PATHOGENESIS
“肝足厥阴之脉，……是主肝所生病者。……遗溺闭癃”
——《灵枢·经脉》
Liver qi stagnation
Emotional disturbance may cause liver qi stagnation, which will impair the ability of the triple jiao to transport water and transform qi. The water passage will be blocked and urine retention will be formed. In addition, the liver channel goes through the external genitals and enters the lower abdomen. As a result, liver qi stagnation may affect the urinary bladder along the path of the channel. This is another cause for urine retention.

10. ETIOLOGY & PATHOGENESIS
“或以败精，或以槁血，阻塞水道而不通也。“
——《景岳全书·癃闭》
Blockage of the urinary tracts
Blood stasis, stale essence, masses or stones will block the urinary tracts, leading to difficult urination and urine retention.

11. Above all, the pathogenic region of urine retention is urinary bladder
Above all, the pathogenic region of urine retention is urinary bladder. The disease is also closely associated with the triple jiao, lung, spleen and kidney.
Urine retention is primarily caused by disordered qi transformation of the urinary bladder. It can be differentiated into excess and deficiency. Excessive syndromes are caused by damp-heat in the urinary bladder, Exuberance of lung-heat, Liver qi stagnation and Blockage of the urinary tracts. Deficient syndromes are caused by Inability of the splenic Qi to ascend and Renal deficiency.

12. CLINICAL MANIFESTATION
small amount of urine
difficult urination
even complete retention of urine

13. LABORATORY EXAMINATION
Routine urine test, prostatic fluid, blood routine, free prostate specific antigen, some related tumor markers, and renal function examination
Tests of renal functions
Ultrasonic examination
X-ray examination of abdomen
Cystoscopy
Pelvic CT scan

14. Diagnostic Basis
Urine retention can appear suddenly or gradually worsening. It is characterized by difficulty passing urine, poor urinary stream with intermittent flow or anuresis.
Distention of the bladder can be felt upon palpation. In severe cases, patients may also present with edema, dizziness or panting.
Urine retention is more commonly seen in the elderly males, women after childbirth, patients after abdominal surgery or those with edema, lin syndrome or diabetes.
Physical examination, ultrasonography and urine flow tests can help to evaluate the condition.

15. Differential Diagnosis Stranguria 淋证
Both of them are located in urinary bladder. Both have small amount of urine and difficult urination. Stranguria is marked by frequent, short, dripping and painful urination, and the total amount of urine per day is normal. Urine retention doesn’t have painful urination. In a severe case of urine retention, anuria will appear. In addition, the total amount of urine per day is less than normal as for a case of urine retention. Normally, urine retention is much more severe than stranguria, and the prognosis of the former is worse.

16. Differential Diagnosis Obstruction and Rejection 关格
Both have urine retention. Obstruction and rejection is marked by urine retention and vomiting. Obstruction and rejection is called as Guan Ge in Chinese. Guan refers to urine retention and Ge means vomiting. Guan Ge is the later period developed from urine retention or edema, which is severe and complicated. Urine retention may complicate with the syndrome of water storage in urinary bladder, which is relatively mild than Guan Ge.

17. Differential Diagnosis Edema 水肿
Both have small amount of urine and difficult urination. Edema is marked by hesitancy in passing urine, scanty volume, edema in the face, eyelids and extremities or pleural effusion and ascites, without water retention in the urinary bladder. Urine retention doesn’t have edema. Edema and urine retention are closely related, because the prolonged edema may develop into urine retention and even Guan Ge; while the prolonged urine retention may cause edema.

18. Differential Diagnosis Ascites 臌胀
Both have small amount of urine. Sometimes, urine retention may show drum-like abdominal distention. However, ascites is marked by a drum-like abdomen, a dark yellow discoloring complexion and exposed distending veins. Ascites may show scanty urine, but seldom anuria. Urine retention shows scanty urine or even anuria. Some patients appear a drum-like abdominal distention, which is limited at the lower abdomen, without exposed distending veins. The course of ascites is long, while the course of urine retention is short.

19. Emergency Treatment Hot compress
The region for hot compress is the suprapubic bladder region and perineum. It is suitable for the urine retention which lasts for a short time. There may be a good efficacy for those patients with unserious bladder filling. Bath in hot water is also useful. If the patient has a feeling of urination when staying in hot water, he/she can just urinate in the water. We do not suggest the patient to urinate outside the hot water, because he/she may lose the desire to urinate.

20. Emergency Treatment Massages
Massage the midpoint between the umbilicus and the pubic symphysis mildly in clockwise direction. Then increase pressure gradually. Use the thumb to press Guan Yuan point for about 1 minute, and use palm to press the urinary bladder mildly to help urination. Avoid excess force so as to prevent the rupture of bladder.

21. Emergency Treatment Umbilical compress
Stir-fry 250g salt. Put the hot salt into a pocket and then iron the umbilical abdomen. Repeat the above operation if the salt becomes cold. Or mash up a single head garlic together with 3 Fructus Gardeniae and small amount of salt, and spread them on a piece of paper, then stick to the umbilicus.

22. Emergency Treatment Indwelling catheter
Catheterization generally should be performed under sterile conditions. After catheter insertion, release the urine in several times. Do not release more than 500ml for the first time. Then, let out the rest 1-2 hours later until exhausted. This is mainly because the bladder pressure will decrease rapidly if release excessive urine, which may induce rupture of blood vessels, causing bleeding or a sudden shock.

23. Emergency Treatment Bladder puncture and drainage
suprapubic cystostomy
Hemodialysis

25. TREATMENT ACCORDING TO DIFFERENT SYNDROMES
“腑以通为用”
Treatment should focus on dredging since fu-organs work better when being free. The specific methods should vary according to deficiency and excess. In a excess case, dispersing dampness-heat and stagnant blood and promoting the smooth circulation of qi should be applied to free the water passages. In the case of deficiency, replenishing the spleen and kidneys to strengthen qi transformation should be adopted to normalize qi activities and promote spontaneous urination.

26. Dampness-heat in the urinary bladder
Dribbling urinary stream or anuresis, extremely scanty urine volume with a burning sensation, fullness and distention of the lower abdomen, a bitter and sticky taste in the mouth, thirst with no desire to drink water and constipation.
Tongue: Red with a yellow, greasy coating.
Pulse: Rapid.
Method: Clear heat, resolve dampness and promote urination.
Prescription: Ba Zheng San

27. Exuberance of lung-heat
Dribbling urinary stream or hesitancy in passing urine, dry throat, thirst with desire to drink water, fast breathing, and cough.
Tongue: Thin and yellow.
Pulse: Rapid.
Method: Clear lung-heat and regulate water passage.
Prescription: Qing Fei Yin

28. Liver-qi stagnation
Sudden and complete urine retention or unsmooth urination, distention and fullness in the hypochondrium and abdomen, restlessness, irritability. .
Tongue: Red with a thin or thin-yellow coating.
Pulse: Wiry.
Method: Soothe the liver, move the qi and promote urination.
Prescription: Chen Xiang San

29. Blockage of the urinary tracts
Dripping of urine, or urinating a stream of thread-like urine, or even complete urine retention, distention, fullness and pain in the lower abdomen.
Tongue: Dark-purple tongue, or with purple spots.
Pulse: Choppy.
Method: Resolve stasis and regulate water passage.
Prescription: Modified Dai Di Dang Wan

30. Inability of the spleen qi to ascend
A down-bearing sensation of the lower abdomen, difficulty in passing urine even with the urge to urinate, or hesitancy in passing urine of a scanty volume, mental fatigue, a poor appetite, shortness of breath and a low voice.
Tongue: Pale with a thin coating.
Pulse: Thready and weak.
Method: Tonify spleen qi and promote urination.
Prescription: Bu Zhong Yi Qi Tang and Chun Ze Tang

31. Kidney yang deficiency
Anuresis, hesitancy or straining in passing urine, a bright, pale complexion, lassitude, cold intolerance, weakness and a cold feeling in the lumbar redion and knees.
Tongue: A pale tongue with a white coating.
Pulse: A deep, thread and weak pulse.
Method: Warm yang, supplement qi, tonify the kidney, and promote urination.
Prescription: Ji Sheng Shen Qi Wan

32. Summary chart on syndrome differentiation
and acupuncture treatment for urine retention
Syndromes
Acupuncture points
Damp-heat in the urinary bladder
BL 54 (秩边), SP 9 (阴陵泉),
RN 3 (中极), BL 28 (膀胱腧), BL 39 (委阳)
Exuberance of
lung-heat
BL 54 (秩边), RN 3 (中极),
BL 28 (膀胱腧), LU 7 (列缺), LU 5 (尺泽)
Liver-qi stagnation
BL 54 (秩边), SP 6 (三阴交), RN 3 (中极),
BL 28 (膀胱腧), LR 3 (太冲), LR 1 (大敦)
Urinary tract blockage
BL 54 (秩边), SP 9 (阴陵泉), SP 6 (三阴交),
RN 3 (中极), BL 28 (膀胱腧), BL 32 (次髎), RN 6 (气海)
Spleen-qi deficiency
BL 54 (秩边), RN 4 (关元), BL 20 (脾腧),
BL 22 (三焦腧), BL 23 (肾腧), RN 6 (气海), ST 36 (足三里)
Kidney-yang deficiency
BL 22 (三焦腧), BL 23 (肾腧), KI 3 (太溪), KI 7 (复溜)

33. Life Modification & Prevention
Maintain a peaceful mind and conduct appropriate physical exercise
Avoid holding the urine
Limit ingestion of sweet, oily food
Avoid sex over-indulgence

34. Case and Study Diagnosis: urine retention due to kidney qi deficiency.
A 70-year-old male received treatment after suffering from dripping of urination with difficult in passing urine, aversion to cold and loose stools.
The patient also presented with mental fatigue, lower back and knee soreness and a bright pale complexion.
Tongue coating: white.
Pulse: deep and thready.
Diagnosis: urine retention due to kidney qi deficiency.
Method: tonify kidney qi and warm kidney yang.

35. Formula:
茯苓（fu ling）12g 山茱萸（shan zhu yu）9g 山药（shan yao）12g
熟地黄（shu di huang）12g 泽泻（ze xie）9g 肉桂（rou gui）15g
附子（fu zi）4g 牡丹皮（mu dan pi）3g 车前子（che qian zi）9g
补骨脂（bu gu zhi）9g 牛膝（niu xi）4g
Acupoints:
Qi Hai, Shen Shu, Pi Shu, Guan Yuan, Ming Men, Zu San Li.
Reinforcing manipulation, moxibustion can be combined.