Dysuria is painful urination due to impedance of flow in the urethra, and is often characterized by frequency and urgency, yet dribbling of urine. Sometimes there is spasm in the lower abdomen, which may extend to the upper abdomen or flank. Typically, the pain of dysuria is prickling or burning in quality.
According to variations in etiology and clinical characters dysuria may be classified into six groups: Heat-dysuria, Qi-dysuria, chyle-dysuria, stone-dysuria, blood-dysuria, and overstrain-dysuria.
Etiology and Pathology
Dysuria results from disorder of the transformation of kidney and urinary bladder Qi. The condition is located in the bladder and the kidney, but also bears a relationship to the spleen and the liver. In the initial stages it is mainly a condition of strength, due to the accumulation of Dampness and Heat in the lower-jiao, which impairs bladder-Qi transformation. If it persists, it may turn into one of deficiency, or a mingling of strength and deficiency.
Dampness-Heat in Urinary Bladder. Dampness and Heat attack the urinary bladder through several mechanisms. Contamination or inadequate hygiene of the meatus may lead to these Pathogenic Evils invading the bladder. Overindulgence in fats, sweets or alcohol may result in the impairment of spleen and stomach functions, conducing to the rise of endogenous Dampness and Heat, which can move downward into the bladder. Strong Heart-Fire can move into the small intestine, and thence flow into the bladder. All these can impair bladder-Qi transformation and the passage of water.
If the urine is scorching hot and its passage causes prickling pain, it is Heat-dysuria. If Dampness-Heat accumulation is longstanding, the impurities in the urine may condense and form grains of sand or stone. This is stone-dysuria. If strong Heat injures the blood vessels and induces blood to move wildly or erratically, blood may overflow into urine. This is blood-dysuria. If Dampness and Heat attack downward, they can easily impair bladder-Qi transformation. This in turn impairs the bladder’s ability to separate the clear from the turgid. Milky urine may result. This is chyle-dysuria.
Insufficiency of Spleen and Kidney. Several mechanisms lead to the insufficiency of the spleen and the kidney, including Dampness-Heat consuming genuine Qi, senescence, weakening by prolonged illness, excessive physical strain and excessive sexual indulgence. Protracted dysuria resistant to treatment may also injure the spleen and the kidney. Spleen insufficiency allows middle-jiao-Qi to sink. Sinking of middle-jiao-Qi leads to Qi-dysuria. If spleen-Qi fails to control blood movement, blood may overflow into urine and lead to blood-dysuria. Kidney insufficiency allows lower-jiao-Qi to leak. This leakage may lead to continual dribbling of urine. An insufficient kidney fails to prevent nutritive substances from leaking, so that the urine becomes creamy and turbid. This is chyle-dysuria. Deficiency of kidney-Yin may give rise to Fire, which burns and injures the blood channels and produces blood-dysuria. If excessive physical strain induces dribbling of urine, it is overstrain-dysuria.
Stagnation of Liver-Qi. Stagnation or trapping of liver-Qi by any cause may give rise to Fire. Fire attacking the lower-jiao impairs bladder-Qi transformation, which in turn leads to distention of the lower abdomen and dribbling dysuria. This is the strength-type of Qi-dysuria.
Clinical Manifestation
Dysuria is painful urination that is usually dribbling. Characteristically, there often are frequency, urgency, and a sensation of impeded urine flow or burning in the urethra. There is a desire to urinate but difficulty in doing so. There may be spasm or pain in the lower abdomen, which sometimes extends or radiates to the upper abdomen or the flanks.
Each of the six main types of dysuria has unique features in addition to these common features. Heat-dysuria typically begins abruptly, and the pain is burning in quality. The urine is dark and hot, and fever is common. Qi-dysuria often presents with lower abdominal fullness and pain, especially distention in the lower abdomen. Urination is difficult with pain and dribbling. This is often exacerbated by emotional distress. In stone-dysuria the patient often discharges sand grains or stones in the urine. Often, urination is interrupted and the urethral pain is excruciating. There may be colicky pain in the flanks and abdomen. In blood-dysuria the urine may be deep red or bloody with clots. The dysuria is burning in quality and urine flow is impeded. In chyle-dysuria typically the urine is turgid like rice-water or greasy and creamy. In overstrain-dysuria urination is dribbling, and there often is recurrent lumbago precipitated by excessive physical exertion.
Key Points of Analysis
Types of Dysuria. The following are diagnostic symptoms. Heat-dysuria: burning sensation with prickling pain on urination. Stone-dysuria: sand grains or stones in the urine. Blood-dysuria: blood in the urine. Qi-dysuria: lower abdominal distention and dribbling urination. Chyle-dysuria: urine like rice-water or cream. Overstrain-dysuria: recurrent dribbling precipitated by physical overstrain.
Deficiency versus Strength. In the early stages, dysuria is mostly a condition of strength. Strength-type dysuria is mainly caused by Dampness-Heat, stones or Qi stagnation. Characteristic symptoms include burning or prickling dysuria or sand grains, stones or blood in the urine, lower abdominal spasm or fullness, a yellow greasy tongue coating and a slippery, rapid and forceful pulse. Persistent dysuria with frequent recurrence or injured genuine Qi is a condition of deficiency. Deficiency-type dysuria is mainly due to insufficiency of the spleen and kidney or deficiency of Qi and Yin. Characteristic symptoms include dribbling of urine, a pale tongue with thin coating and a threadlike and feeble pulse. Sometimes deficiency and strength are intermixed. This may result from either superimposed exogenous pathogenic evil upon a deficiency state or persistent strength causing injury to genuine Qi.
Herbal Treatment
Heat-Dysuria
Main Symptoms. Burning and prickling dysuria, urinary frequency, scanty dark urine and lower abdominal spasm or flank pain with guarding; or, chills and fever, bitter taste and nausea or constipation. The tongue coating is yellow and greasy. The pulse is soft and rapid or slippery and rapid.
Therapeutic Principle. Cool Heat, eliminate Dampness and relieve dysuria.
Treatment. Ba Zheng San (Eight-Herb Rectification Powder).
For constipation and abdominal distention, use a larger amount of dahuang and add zhishi (Citrus aurantium) to relax the bowels and purge Heat.
For chills and fever and bitter taste, add Xiao Chaihu Tang to harmonize Shaoyang.
Stone-Dysuria
Main Symptoms. Sand or stone in the urine; impeded urination or abrupt interruptions in urination; urethral constriction and pain; colicky lower abdominal or flank pain; and blood in the urine. The tongue is red, with thin yellow coating, and the pulse is taut or intermittent and rapid.
Therapeutic Principle. Cool Heat, eliminate Dampness, eliminate stones and relieve dysuria.
Treatment. Augmented Shiwei San (Pyrrosia Powder). Shiwei San has the following composition: shiwei (Pyrrosia petiolosa) 30 g, dongkuizi (Malvia verticillata) 12 g, qumai (Dianthus superbus) 10 g, huashi (talcum) 12 g, and cheqianzi (Plan-tago) 15 g. The augmented formula is especially efficacious for promoting urination and relieving dysuria, and is designed for stone-dysuria. It may be augmented with jinqiancao (Glechoma), haijinsha (Lygodium) and jineijin (Gallus gallus domesti-cus) to dissolve solids and remove stones.
For severe flank and abdominal colic, add baishaoyao (Paeonia) and raw gancao (Glycyrrhiza) to relieve colic and pain.
For blood in the urine, add xiaoji (Cephalanoplos), shengdihuang (Rehmannia) and oujie (Nelumbo nucifera) to cool blood and stop bleeding.
If stone-dysuria persists and consumes Qi and Yin, manifested by lusterless complexion, lassitude, weakness, a pale tongue and a threadlike and feeble pulse, there is now deficiency in addition to strength. Use Ba Zhen Tang augmented with haijinsha (Lygodium) and huashi (talcum).
For dull pain in the flanks and abdomen, hotness in the palms and soles, a red tongue with little coating and a threadlike and rapid pulse, use Liu Wei Dihuang Wan together with Shiwei San.
Qi-Dysuria (Deficiency-Type)
Main Symptoms. Lower abdominal distention with downward pressure; incomplete urination with dribbling; pale complexion; a pale tongue; and a depletive, threadlike and forceless pulse.
Therapeutic Principle. Nourish the middle-jiao and augment Qi.
Treatment. Bu Zhong Yi Qi Tang (Middle-Restoring and Qi-Augmenting Decoction).
If there is deficiency of kidney-Qi as well as spleen-Qi, add duzhong (Eucommia) and niuxi (Achyranthes).
Qi-Dysuria (Strength-Type)
Main Symptoms. Impeded urination with dribbling of urine; lower abdomen distention and pain; thin white tongue coating; and a deep and feeble pulse.
Therapeutic Principle. Normalize Qi movement and promote urination.
Treatment. Chenxiang San (Aquilaria Powder). It has the following composition: chenxiang (Aquilaria) 3 g, chenpi (Citrus tangerina) 10 g, danggui (Angelica) 12 g, baishaoyao (Paeonia) 15 g, shiwei (Pyrrosia petiolosa) 30 g, huashi (talcum) 10 g, dongkuizi (Malvia verticillata) 10 g, wangbuliuxing (Vaccaria segetalis) 10 g, and gancao (Glycyrrhiza) 6 g.
If liver-Qi stagnation is especially severe, manifested by unbearable distention and fullness in the lower abdomen, add Qingpi (Citrus tangerina), wuyao (Lindera) and xiaohuixiang (Foeniculum vulgare) to regulate Qi and relieve stagnation.
Blood-Dysuria (Deficiency-Type)
Main Symptoms. Light red urine; mild dysuria; aching weakness of the waist and knees; lassitude and weakness. The tongue is pale red, and the pulse threadlike and rapid.
Therapeutic Principle. Nourish Yin, clear Heat, restore the deficient and stop bleeding.
Treatment. Zhi Bai Dihuang Wan (Anemarrhena-Phellodendron-Rehmannia Pill).
To enhance the ability to restore and stop bleeding, add moliancao (Eclipta), ejiao (Equus asinus) and xiaoji (Cephalanoplos).
If Yin deficiency is complicated by Dampness-Heat, add zhuling (Polyporus) and fuling (Poria).
Blood-Dysuria (Strength-Type)
Main Symptoms. Burning prickling dysuria, dark red urine or urine containing blood clots, and lower abdominal fullness and pain; or, restlessness. The tongue coating is yellow, and the pulse slippery and rapid.
Therapeutic Principle. Clear Heat, relieve dysuria, cool blood and stop bleeding.
Treatment. Xiaoji Yin Zi (Thistle Decoction).
If there is much blood in the urine with severe pain, add powdered sanQi (Panax pseudoginseng), powdered huashi (talcum) and baimaogen (Imperata) to relieve blood stasis and stop bleeding.
Chyle-Dysuria (Deficiency-Type)
Main Symptoms. Persistent and recurrent but mild dysuria, rice-water or creamy urine, emaciation, lassitude and aching weakness in the waist and knees. The tongue is pale with greasy coating, and the pulse is deep and feeble.
Therapeutic Principle. Restore what is deficient and astringe what leaks.
Treatment. Gao Lin Tang (Chyle-Dysuria Decoction). It has the following composition: dangshen (Codonopsis) 10 g, shanyao (Dioscorea) 15 g, shengdihuang (Rehmannia) 10 g, Qianshi (Euryale ferox) 12 g, longgu (fossil bone) 30 g, muli (Ostrea) 30 g, and baishaoyao (Paeonia) 10 g.
If deficient middle-jiao-Qi sinks, use Bu Zhong Yi Qi Tang in combination with Gao Lin Tang.
Chyle-Dysuria (Strength-Type)
Main Symptoms. The urine is like rice-water, and if left standing for a while there are thorn-like sediments and a floating layer of cream or fat globules. Sometimes the urine contains blood. Impeded urine flow with burning urethral pain; a red tongue with yellow and greasy coating; and a soft and rapid pulse.
Therapeutic Principle. Cool Heat, separate the clear from the turbid and eliminate turbid Dampness.
Treatment. Beixie Fen Qing Yin (Dioscorea Clear-Separating Drink). It has the following composition: beixie (Dioscorea hypoglauca) 24 g, cheqianzi (Plantago) 10 g, fuling (Poria) 15 g, shichangpu (Acorus) 10 g, baizhu (Atractylodes) 10 g, lianzixin (Nelumbo) 12 g, danshen (Salvia) 12 g, andhuangbai (Phellodendron) 6g.
If there is lower abdominal fullness with impeded urine flow, add wuyao (Lindera) and Qingpi (Citrus tangerina).
Overstrain-Dysuria
Main Symptoms. Persistent but intermittent dribbling of urine, precipitated by physical strain; mild dysuria; lassitude; weakness; and aching weakness of the waist and knees. The tongue is pale, and the pulse is depletive and feeble.
Therapeutic Principle. Strengthen the spleen and nourish the kidney.
Treatment. Wu Bi Shanyao Wan (Incomparable Dioscorea Pill). It has the following composition: shanyao (Dioscorea opposita) 30 g, fuling (Poria) 12 g, shudihuang (Rehmannia) 12 g, shanzhuyu (Cornus) 12 g, bijitian (Morinda) 10 g, duzhong (Eucommia) 10 g, niuxi (Achyranthes) 12 g, wuweizi (Schisandra) 10 g, roucongrong (Cistanche) 10 g, chishizhi (halloysite) 10 g, and zexie (Alisma) 10 g.
If the spleen is insufficient and Qi sinks, with the sensation of a full and drooping lower abdomen, remove niuxi and duzhong and add huangqi (Astragalus) and dangshen (Codonopsis) to augment Qi and raise Yang.
For kidney-Yin deficiency, use Zhi Bai Dihuang Wan in combination with Wu Bi Shanyao Wan.
For kidney-Yang deficiency, use You Gui Wan (kidney-Yang-Augmenting Pill) in combination with Wu Bi Shanyao Wan.
Acupuncture Treatment
Dampness-Heat in Urinary Bladder. Select the acupoints Pangguangshu (BL-28), Zhongji (CV-3), Yinlingquan (SP-9), Xingjian (LR-2) and Rangu (KI-2). Use filiform needles and apply the reducing method.
Insufficiency of Spleen and Kidney. Select the acupoints Pangguangshu (BL-28), Pishu (BL-20), Shenshu (BL-23), Guanyuan (CV-4) and Zusanli (ST-36). Use filiform needles and apply the reinforcing and reducing methods simultaneously. Moxibustion may also be applied.
Stagnation of Liver-Qi. Select the acupoints Pangguangshu (BL-28), Yanglin-gquan (GB-34), Xingjian (LR-2), Qimen (LR-14) and Zhigou (SJ-6). Use filiform needles and apply the reducing method.
Case Study
The patient was a 34-year old male who had chronic lumbar pain and impotence. A month prior to consultation, he noticed that his urine became turbid and creamy, with granular material in suspension. Urination was impeded, and was followed by urethral pain. He had discomfort in the lower abdomen, which radiated to the flanks. He had lassitude and fatigue through the day and mental clouding by twilight. Examination showed a red tongue with white and smooth coating. His pulse was taut and slippery, but intermittent and rapid.
Diagnosis. Dampness-Heat accumulating and gelling in the lower-jiao.
Therapeutic Principle. Cool Heat, eliminate Dampness, smooth urination and remove turbidity.
Treatment and Course. The prescribed formula had the following composition: tufuling (Smilax glabra) 30 g, beixie (Dioscorea hypoglauca) 25 g, zexie (Alisma) 25 g, shiwei (Pyrrosia petiolosa) 30 g, tusizi (Cuscuta) 20 g, lianxu (Nelumbo nucifera) 20 g, duzhong (Eucommia) 25 g, niuxi (Achyranthes) 25 g, jixueteng (Spatholobus suberectus) 30 g, dongkuizi (Malvia verticillata) 20 g, baimaogen (Imperata) 50 g, and wujiapi (Acanthopanax gracilistylus) 30 g.
After three doses the urine became less turbid. There were still granular material and the urethra still had pain. The same therapeutic principle was followed, but the formula was modified. It had the following composition: jinqiancao (Glechoma) 30g, haijinsha (Lygodium) 15 g, shiwei (Pyrrosia petiolosa) 25 g, baimaogen (Imperata) 50 g, tufuling (Smilax glabra) 30 g, zexie (Alisma) 25 g, beixie (Dioscorea hypoglauca) 20 g, lianxu (Nelumbo nucifera) 20 g, shayuanzi (Astragalus complanatus) 25 g, salt-treated buguzhi (Psoralea) 15 g, Sichuan xud-uan (Dipsacus) 20 g, and wujiapi (Acanthopanax gracilistylus) 25 g.
After three doses of the modified formula the urine cleared, with only occasional granules. The formula was continued with slight modification in amounts. After three doses, the urine became completely clear and urination was no longer painful. The only symptoms remaining were the aching weakness of the flank and knees and impotence, which he had had for a long time. He was further treated with formulas that nourish the kidney and invigorate Yang.
Note: The dosages of herbs prescribed in this case are relatively strong, which have to be modified in other cases according to the condition of the patients.
