AC501: Special Topics in Acupuncture Week 2 Enuresis and Incontinence 2 â— â— â— Deï¬nition: â— Loss of control of urination Enuresis: involuntary discharge of urine. Lack of awareness Incontinence: inability to control the voiding of urine. With awareness Less severe: â—‹ â—‹ Enuresis and Incontinence â— Urgency Difï¬culty holding urine VS. Lin Syndrome: â—‹ â—‹ Pain Difï¬culty 3 Incontinence differentiated â— Urge Incontinence: â—‹ Leakage immediately on perceiving the urge to urinate â— Stress Incontinence: â—‹ Increased intra-abdominal pressure due to sneezing, coughing, or jumping 4 Possible Biomedical Causes â— â— â— â— â— â— â— â— â— Cystitis Prostatitis Pregnancy Diabetes Diuretics Essential enuresis Hypothyroidism Stress Trauma â— â— â— â— â— â— â— â— Multiple sclerosis Irritable bladder Bladder stones/tumors Neurogenic disease Parkinson’s disease Post-surgery Interstitial cystitis Postmenopausal atrophic changes in the bladder and urethral wall 5 Organs: Enuresis and Incontinence â— Lungs â—‹ â—‹ â— Spleen â—‹ â— Raises Qi Kidneys â—‹ â—‹ â—‹ â— Govern Qi Provide Qi to Urinary Bladder to control urine Balance of Kidney Yin/Yang influence urination Kidney Yang provides Qi to Urinary Bladder to control and transform urine Kidney Qi controls the two lower oriï¬ces (urethra in this case) Liver â—‹ Liver controls the smooth flow of Qi throughout the body 6 Etiology & Pathology: Enuresis/Incontinence â— Kidney Deï¬ciency: â—‹ â—‹ â— â– Old age â– Excessive sexual activity â– Weak constitution (Jing Xu) â– Pregnancy / childbirth Yang / Qi Deï¬ciency â– Chronic Illness â– Excessive lifting or standing â– Excessive exposure to Cold Yin Deï¬ciency â– Febrile disease â– Overwork under stress â– Insufï¬cient sleep â– Drug use Shock: Heart, Kidney or Liver â— Spleen Qi Deï¬ciency: â—‹ â—‹ â— Lung Qi Deï¬ciency: â—‹ â—‹ â—‹ â— Failure to govern Qi Chronic cough Exacerbated by cough or sneeze Damp Heat accumulation: â—‹ â—‹ â—‹ â—‹ â— Failure to transport - sink to Lower Jiao Failure to Raise Qi - sink to Lower Jiao Poor hygiene Sexual contact Poor diet Any prolonged Heat Liver Qi Stagnation / Liver Fire: â—‹ â—‹ Stress / stagnant emotions Blood stasis due to pelvic surgery 7 Diagnostic Differentiation â— Color of urine â—‹ â—‹ â— Concentrated and dark - Damp Heat or Yin Deï¬ciency Pale or normal - Liver Qi Stagnation, Spleen and/or Lung or Kidney Qi or Yang Deï¬ciency â— Common patterns: â—‹ â—‹ Aggravated by: â—‹ â—‹ â—‹ â—‹ Stress - Liver Qi Stagnation Cold - Kidney Deï¬ciency Cough or sneeze - Lung Qi Deï¬ciency Fatigue - Deï¬ciency pattern â—‹ â—‹ Frequent urination - Kidney Deï¬ciency, Spleen and Lung deï¬ciency, Liver Qi Stagnation, Damp Heat Incontinence - Kidney Deï¬ciency, Lung and Spleen Deï¬ciency, Damp Heat Nocturia - Kidney deï¬ciency Nocturnal enuresis - Kidney deï¬ciency, Liver Qi Stagnation with Heat or Fire 8 Lung Qi Deï¬ciency Symptoms: Frequent urge with inability to contain. Slight incontinence often on coughing or sneezing. Dribbling. Tiredness. Weak voice, slight sweating, shortness of breath Tongue: Pale â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Weak â—‹ Treatment principle: Warm and tonify Lung Qi UB13, Du12, Du20, LU7, Ren6, UB23, UB28, UB53 Bu Zhong Yi Qi Tang â– Tonify Spleen Qi, Raise Qi (+ Mu Li, Gan Jiang, Yi Zhi Ren, Wu Wei Zi) â– Warming astringents 9 Spleen Qi Deï¬ciency Symptoms: Frequent urge with inability to contain. Slight incontinence. Loose stool, poor appetite. Tongue: Pale â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Weak Treatment principle: Tonify and raise Spleen Qi UB20, ST36, Ren12, Du20, Ren6, UB23, UB28, UB53 â—‹ Bu Zhong Yi Qi Tang â– Tonify Spleen Qi, Raise Qi (+ Mu Li, Gan Jiang, Yi Zhi Ren, Wu Wei Zi) â– Warming astringents 10 Kidney Qi/Yang Deï¬ciency Symptoms: Frequent urination, nocturia, slight dribbling, nocturnal enuresis in children, incontinence in old people, pale urine, exhaustion, dizziness, tinnitus, weak and sore lower back and knees, feeling of cold. Tongue: Pale and wet â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Weak and Deep Treatment principle: Tonify and warm Kidneys UB23, Du4, K7, Ren6, Ren4, Du20, UB28, UB53, UB32, SP6, HT7, Yin Tang. â—‹ Jin Gui Shen Qi Wan â– Tonify and warm Kidney Yang + Suo Quan Wan â– Astringents 11 Kidney Yin Deï¬ciency Symptoms: Urinary incontinence, scanty urine, dribbling after urination, dark urine. Dry throat, dizziness, tinnitus, nightsweats, insomnia. Tongue: Less coat, red body â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Floating, Empty Treatment principle: Tonify the Kidneys, Nourish Yin Ren4, K3, SP6, UB23, UB28, LU7, K6 â—‹ Sang Piao Xiao San â– Astringe urine, Nourish Yin, calm Shen Zhi Bai Di Huang Wan â– Nourish Yin, Clear Deï¬cient Heat 12 Liver Qi Stagnation / Fire Symptoms: Urinary frequency aggravated by stress, teeth grinding, fullness in lower abdomen, irritability, hypochondrial pain. Thirst, bitter taste. Nocturnal enuresis in children, restless sleep, nightmares, waking up crying. Tongue: Qi stagnation - normal or dusky, Fire red with redder sides, yellow coat â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Wiry. Rapid Treatment principles: Move and spread Liver Qi. Drain Fire, Calm Shen, Settle Hun. LV2, HT7, SP6, YinTang, UB28. â—‹ Xiao Yao San â– Harmonize Liver and Spleen, nourish Blood Long Dan Xie Gan Tang â– Sedate Liver Fire, Clear Damp Heat from the Liver / Gallbladder 13 Heart Fire Symptoms: Nocturnal enuresis, nervous child, palpitations, thirst, insomnia, crying at night Tongue: Red, redder tip with red papules. Thick yellow coat Pulse: Overflowing in left Cun. Rapid Treatment principle: Drain Heart Fire, Calm Shen â— Acupuncture: â—‹ HT8, Ren14, SP6, K3 â— Formula: â—‹ Dao Chi San â– Drains Heart Fire through the urination 14 Damp Heat in the Urinary Bladder Symptoms: Nocturnal enuresis or incontinence, difï¬cult urination, burning urination â— Acupuncture: â—‹ SP9, SP6, Ren9, ST28, UB22, Ren3, UB28, UB32 Tongue: Greasy yellow coat Pulse: Slippery, rapid Treatment principle: Clear Heat, Resolve Dampness, Promote the Bladder’s Qi transformation â— Formula: â—‹ Ba Zheng San â– Clears Damp Heat from the UB 15 Appendix: Hematuria â— Characterization â— â— The presence of frank or occult blood in the urine without pain Classiï¬ed into prerenal, renal and postrenal depending on the location of the cause Cause must always be found refer to urologist 16 17 18 Urinary Retention: Long Bi 19 â— Long: Difï¬cult urination â—‹ Deï¬nition: Long Bi â—‹ â— Reduced volume of urine with difï¬culty in voiding the bladder Difï¬culty in starting urination or a weak and broken stream and a feeling of incomplete voiding Bi: Urinary retention â—‹ â—‹ â—‹ Severe difï¬culty urinating even though the bladder is full No urine at all or only a few drops *Medical emergency 20 Possible Biomedical Causes â— â— â— â— â— â— Urinary tract infection Tumors of the bladder, prostate or kidneys Urethral scarring Prostatic hypertrophy Pressure from gynecological tumors, ie. ï¬broids Obstruction by urinary calculi â— â— â— â— â— â— â— Transverse myelitis Multiple sclerosis Extreme cold Alcohol Fecal impaction Foreign body Anticholinergic drugs 21 Organs: Urinary Retention Similar to Lin Syndromes as retention is common to most Lin syndromes â— Urinary Bladder - Stores/excretes urine. Qi transformation â— Spleen - transform/transport fluid. Formation of Dampness â— Kidneys - Yin/Yang regulate amount of urine excreted. Qi controls lower oriï¬ce â— Lungs - Qi provides strength for urination, propulsion of Qi â— Liver - Regulate the smooth flow of Qi â— San Jiao - Regulate water passages 22 Etiology & Pathology: Urinary Retention â— Damp Heat obstruction â—‹ â—‹ â— Lung Qi obstruction / Lung Heat â—‹ â—‹ â— External pathogen, ie sexual activity â– Localised, no systemic DH sxn Internally generated â– Any source of internal Heat â– More systemic sxn of Heat/Damp Spleen Qi sinking preventing turbid Qi from descending â—‹ â—‹ â—‹ â— Emotional Qi blockage Creating Heat and/or Dampness Stasis due to physical obstruction â– Ie. tumor, stone, surgery â– Mutual exchange of Blood/Body Fluid Over work, excessive mental activity Irregular / poor diet (cold raw foods) Prolonged illness Kidney Deï¬ciency Not descending to Kidney and UB Usually due to invasion of Wind/Heat Liver Qi Stagnation / Blood Stasis â—‹ â—‹ â—‹ â— â—‹ â—‹ â– Old age â– Excessive sexual activity â– Frequent pregnancies Yang Xu -> Damp obstruction â– Chronic illness â– Overexposure to cold â– Excessive lifting / standing Yin Xu -> burn fluids â– Febrile disease â– Overwork w/ stress â– Insufï¬cient sleep â– Drug use 23 Primary differentiation is between Excess and Deï¬ciency 24 Dampness or Damp Heat Symptoms: Urinary retention, scanty urination, dysuria, dark urination, fullness in the hypogastrium â— Acupuncture: â—‹ SP9, SP6, Ren3, ST28, Ren9, UB22, UB39 Tongue: Greasy yellow coat, thicker at root Pulse: Slippery, Rapid Treatment principle: Resolve Dampness, clear Heat, promote urination â— Formula: â—‹ Ba Zheng San â– Clear Damp Heat in the UB 25 Lung Qi obstruction, Lung Heat Symptoms: Acute urinary retention, dysuria, feeling of heat, thirst, breathlessness, cough â— Acupuncture: â—‹ LU5, LI11, LU7, UB39 Tongue: Red, yellow coat Pulse: Overflowing, Rapid Treatment principle: Clear Lung Heat, open Water passages, promote urination â— Formula: â—‹ Qing Fei Yin â– Clear Heat in the Lungs, dissipate Phlegm 26 Liver Qi Stagnation Symptoms: Urinary retention, dysuria. Distention in hypogastrium, irritability, abdominal distention, premenstrual breast distention â— Acupuncture: â—‹ Tongue: slightly Red on sides. (Can be dusky) LV3, GB34, Ren3, UB63, UB39 Pulse: Wiry Treatment principle: Soothe Liver, move Qi, eliminate stagnation, open the Water passages, promote urination â— Formula: â—‹ Chen Xiang San â– Move Qi, eliminate stagnation 27 Blood Stasis Symptoms: Urinary retention, dysuria, stabbing hypogastric pain â— Acupuncture: â—‹ Tongue: Purple Pulse: Wiry, Firm, or Choppy Treatment principle: Invigorate Blood, eliminate stasis, open the Water passages, promote urination LV3, GB34, Ren3, UB63, UB39, SP10, SP4, P6 â— Formula: â—‹ â—‹ Dai Di Dang Wan â– Invigorate Blood, eliminate Stasis + Open Water passages herbs 28 Spleen Qi Sinking Symptoms: Chronic urinary retention, dysuria, tiredness, loose stools, poor appetite, pale urine, desire to lie down. â— Acupuncture: Tongue: Pale â— Formula: Pulse: Weak Treatment principle: Tonify and raise Spleen Qi, raise clear Qi, make turbid Qi descend, open the Water passages, promote urination â—‹ â—‹ â—‹ Ren12, ST36, SP6, UB20, Ren3, Ren6, Du20, UB22 Bu Zhong Yi Qi Tang â– Tonify Spleen, Raise Qi + Chun Ze Tang â– Tonify Qi, promote urination 29 Kidney Yang Deï¬ciency Symptoms: Urinary retention, dysuria, dribbling urine, pale urine, nocturia, lower back and knee ache, dizziness, tinnitus, coldness. â— Acupuncture: â—‹ UB23, K7, K3, Ren4, Ren3, UB39, UB22 Tongue: Pale Pulse: Deep, Weak Treatment principle: Tonify and Warm Kidney Yang, open the Water passages, promote urination â— Formula: â—‹ Shen Qi Wan â– Warm and tonify Kidney Yang 30 Kidney Yin Deï¬ciency Symptoms: Urinary retention, dysuria, scanty concentrated yellow urine. Irritability, night sweats, dry mouth/throat, sore and weak low back and knees, tinnitus. Tongue: Red, dry with little coat â— Acupuncture: â—‹ â— Formula: â—‹ Pulse: Thready, Rapid Treatment principle: Nourish Kidney Yin, open Water passages, promote urination UB23, Ren3, Ren6, Ren4, HT5, K3, K6, LU7, SP6 â—‹ Liu Wei Di Huang Wan â– Nourish Kidney Yin + Zhu Ling Tang â– Eliminate Damp, promote urination, clear Heat, nourish Yin 31 Interstitial Cystitis 32 Deï¬nition: Interstitial Cystitis Painful Bladder Syndrome (PBS) â— A condition of recurrent discomfort or pain in the bladder and pelvic region â— Presents similarly to a bacterial infection but tests reveal no organism 33 Diagnostic differentiation â— Mixture of 3 Lin syndromes: â—‹ Heat Lin â—‹ Cloudy Lin â—‹ Lao Lin â— Pathological patterns: â—‹ Spleen Qi and Kidney Yang deï¬ciency â—‹ Sinking Qi of Spleen or Kidney â—‹ Heat (Excess, Deï¬cient, Yin Fire) â—‹ Dampness â—‹ Qi stagnation â—‹ Blood stasis 34 Clinical manifestations: Interstitial Cystitis â— â— â— â— â— â— â— â— â— Mild discomfort: Qi stagnation or Heat Pressure / heaviness: Dampness Tenderness: Damp or Qi stagnation Intense pain: Damp / Qi stagnation with blood stasis Urgency / frequency: Qi sinking Irritated bladder wall: Heat Glomerulations: Heat Hunner’s ulcers: Heat Nocturia: Kidney Yang deï¬ciency 35 Spleen Qi and Kidney Yang Xu with Yin Fire Symptoms: frequent urgent urination, sl incontinence, sl burning or no pain. Irritation on bladder wall: glomerulation, Hunner’s ulcers. Worse when tired, loose stool, desire to lie down. Low back ache dizziness, tinnitus, cold with hot face. Tongue: Pale Pulse: Deep, Weak Treatment principle: Tonify Spleen, tonify / warm Kidney Yang, tonify Yuan Qi, subdue Yin Fire â— Acupuncture: â—‹ Ren4, Ren3, UB23, K3, LU7, K6, ST36, SP6, Ren12, UB20, SJ5, P7, UB63 â— Formula: â—‹ Bu Zhong Yi Qi Tong mod. â– + warm Yang â– + Yuan Qi â– +Yin Fire 36 Spleen Qi and Kidney Yang Xu w/Dampness Symptoms: Frequent urgent urination, sl burning or no pain, fullness in the hypogastrium. Dysuria, irritated bladder wall: glomerulations, Hunner’s ulcerations. Loose stools, fatigue, abdominal fullness. Lower backache, dizziness, tinnitus. â— Acupuncture: Tongue: Pale with thick greasy coat. â— Formula: Pulse: Soft Treatment principles: Tonify Spleen Qi and Kidney Yang, resolve Dampness â—‹ â—‹ Ren12, ST36, SP6, UB20, UB23, K3, Ren4, UB63, Ren3, SP9, ST28 Jin Gui Shen Qi Wan mod. â– + tonify Spleen â– + resolve Dampness 37 Spleen Qi + Kidney Yang Xu w/ Qi Stag. Symptoms: Frequent urgent urination, sl burning or no pain, hypogastric distention. Dysuria, irritated bladder wall: glomerulations, Hunner’s ulcerations. Worse with stress, irritability, abdominal distention. Loose stool, fatigue. Lower backache, dizziness, tinnitus. Tongue: Slightly red on the sides Pulse: Wiry. Weak in Chi positions Treatment principles: Tonify Spleen Qi and Kidney Yang, move Qi, soothe Liver, eliminate stagnation, calm Shen â— Acupuncture: â—‹ Ren12, ST36, SP6, UB20, UB23, K3, Ren4, UB63, Ren3, Ren6, LV3, GB34 â— Formula: â—‹ Chen Xiang San mod. â– +Tonify Spleen â– +Tonify Kidney Yang 38 Spleen Qi + Kidney Yang Xu w/ Blood Stasis Symptoms: Frequent urgent urination, intense hypogastric pain. Hematuria, irritated bladder wall: glomerulations, Hunner’s ulcerations. Abdominal distention and pain, irritability. Loose stool, fatigue. Lower backache, dizziness, tinnitus. â— Acupuncture: Tongue: Purple â— Formula: Pulse: Firm or Choppy Treatment principles: Tonify Spleen Qi and Kidney Yang, invigorate Blood and eliminate stasis â—‹ â—‹ Ren12, ST36, SP6, UB20, UB23, K3, Ren4, UB63, Ren3, Ren6, LV3, GB34, SP10 Cheng Xiang San mod. â– + tonify Spleen & Kidney â– + invigorate Blood 39 Kidney Yin Xu with Deï¬ciency Heat Symptoms: Frequent urgent urination, sl burning or no pain. Dysuria, irritated bladder wall: glomerulations, Hunner’s ulcerations. Fatigue, lower backache, dizziness, tinnitus. Night sweats, 5 Ht heat, feeling hot in the evening â— Acupuncture: â—‹ â— Formula: â—‹ Tongue: Red with little/no coat Pulse: Floating-Empty, Rapid K3, Ren4, SP6, Ren3, UB63, LU7, K6, K2 â—‹ Zhi Bai Di Huang Wan â– Nourish Kidney/Liver Yin, clear Deï¬cient Heat + clear Heat from UB Treatment principles: Nourish Kidney Yin, clear Deï¬ciency Heat 40 Acupoint Review 41 Urinary Bladder Dysfunction Point Review â— â— â— â— â— â— Ren3 UB28 UB53 UB32 UB63 HT5 42 45 46 47 48 Water Metabolism Dysfunction Point Review â— â— â— â— â— â— â— LU7 K7 SP9 Ren9 ST28 UB22 UB39 49 50 51 52 53 55 56 Tonify Deï¬ciency Point Review â— â— â— â— â— â— â— â— â— â— â— â— UB13 Du12 UB20 Ren12 ST36 UB23 Du4 Ren4 K3 K6 Ren6 SP6 57 58 59 60 61 62 63 64 65 66 67 68 69 Regulate Qi Point Review â— â— â— â— Du20 Ren6 LV3 GB34 70 71 72 73 Clear Heat Point Review â— â— â— â— â— â— â— â— â— LV2 SP6 HT8 Ren14 LU5 LI11 K2 SJ5 P7 74 75 76 77 78 79 80 81 82 Calm Shen Point Review â— â— â— â— HT7 Yin Tang Du20 SP6 83 84 85 Invigorate Blood â— â— â— SP10 P6 SP4 Point Review 86 87 88 89