6 Inquiry of urination and defecation
Defecation, though directly governed by the large intestine, is closely related to the functions of the spleen and the stomach to digest, transport and transform, the functions of the liver to convey and disperse, the functions of mingmen (vital gate) to warm and the functions of the lung to cleanse and descend. Urination, though directly governed by the bladder, is in close relation with
the function of the kidney to transform qi, the functions of the spleen to transport, transform and distribute, the functions of the lung to cleanse and descend as well as the functions of the triple energizer to regulate water passage. So the inquiry of urination and defecation not only is a way to directly understand the digestive function of the body and metabolism of fluid, but also is an important evidence to determine whether the disease is cold or heat and asthenia or sthenia.
Inquiry of urination and defecation includes the nature, colour, odor, time, quantity, frequency, sensation and the accompanied symptoms of urination and defecation. The following is detailed discussion on the nature, frequency and quantity of urine and stool as well as the sensation in urination and defecation.
1.3.3.6.1 Defecation
Normally a person defecates once a day and the stool is marked by normal shape, no dryness; proper dampness, smooth discharge, yellow colour without pus, mucus and indigested food.
Abnormal frequency of defecation:
Constipation: Constipation means difficulty in defecation or prolonged defecation or even no defecation in several days due to dry feces. Constipation is usually caused by retention of heat in the intestines, or consumption of body fluid, or insufficiency of yin blood which fails to moisten the intestines and causes excessive dryness in the intestines. Sometimes constipation also results from failure of asthenic qi to propel, or from obstruction of the intestines due to cold coagulation due to yang asthenia. Constipation, accompanied by abdominal fullness, distending pain and unpalpable pain, fever and yellowish dry fur, is due to heat retention in the intestines which prevents qi in the fu organ to flow; constipation, accompanied by cold pain in the abdomen, cold extremities, pale tongue with whitish fur and deep and slow pulse, is due to failure of asthenic yang to transport and internal exuberance of yin cold which stagnate the intestinal qi; constipation, accompanied by shortness of breath, spiritual lassitude, pale tongue and weak pulse, is usually due to qi asthenia; constipation, accompanied by pale complexion, lips and tongue, dizziness and palpitation, is usually due to blood asthenia; constipation, accompanied by dry mouth, red cheeks and reddish tongue with scanty fur, is usually due to consumption of body fluid resulting from yin asthenia.
Diarrhea: Diarrhea refers to loose, water-like and frequent discharge of stool, usually due to improper diet, exogenous pathogenic factors, insufficiency of yangqi in the body and emotional disorders which lead to failure of the spleen to transform and failure of the small intestine to separate lucidity from turbidity, resulting in direct downward flow of water and failure of the large intestine to transmit. Generally speaking, acute diarrhea in new disease is usually of sthenia syndrome; slow diarrhea in prolonged disease is often asthenia syndrome. Diarrhea, marked by fulminant discharge, yellowish chyle, abdominal pain and 'scorching heat sensation of the anus, is usually due to internal accumulation of damp heat in the intestines; clear loose stool mingled with water and feces, accompanied by abdominal pain, borborygmus and whitish greasy tongue fur, is caused by internal invasion of cold dampness Which encumbers the spleen yang to separate lucidity from turbidity; diarrhea following abdominal pain, marked by putrid and foul odor like decayed eggs, alleviation of pain after diarrhea and acid regurgitation is usually due to retention of food which damages the spleen and stomach and leads to failure of the intestines to transmit; loose stool following dry feces, accompanied by abdominal distension, reduced appetite, worsened distension after meal and lassitude, is often caused by asthenia of splenic qi and failure of the spleen to transport and transform; diarrhea following abdominal pain before dawn, marked by loose stool with indigested food, is called morning diarrhea, usually resulting from decline of fire in mingmen (vital gate) and internal accumulation of yin cold and damp turbidity; diarrhea following abdominal pain and often worsened by emotional upsets is frequently caused by
imbalance between the liver and the spleen.
Abnormal texture of stool: Besides dryness and looseness, the texture of stool is also marked by indigested food, looseness complicated by dryness, feces with pus and blood and hematochezia, etc. Stool with indigested food is usually due to asthenia cold in the spleen and stomach or kidney asthenia and decline of fire in the vital gate. Occasional dry and loose stool is called looseness complicated by dryness usually caused by liver depression and spleen asthenia as well as imbalance between the liver and the spleen; loose stool following dry feces in defecation is often due to weakness of the spleen and the stomach; stool mingled with pus, blood and mucus is known as pus and blood stool, usually seen in dysentery due to accumulation of damp heat in the intestines which damages the meridians and coagulates qi and blood into pus blood; blood in stool is known as hematochezia which is divided into distal bleeding marked by bleeding following stool with purplish blood and proximal bleeding marked by bleeding preceding stool with fresh blood; loose stool with black colour like pitch is usually due to damage of the stomach collateral and retention of blood stasis.
Abnormal sensation in defecation: Scorching sensation of anus is often caused by downward migration of damp heat or invasion of stagnant heat in the large intestine into the rectum, usually seen in diarrhea due to heat or dysentery due to damp heat. Abdominal pain with frequent desire to defecate, prolapsing sensation of the anus and obstructive defecation is called tenesmus, often caused by internal retention of damp heat and obstruction of intestinal qi seen in dysentery. Difficult and astringent sensation in defecation accompanied by abdominal pain, distension and frequent flatus is caused by liver qi attacking the spleen and obstruction of intestinal qi; incontinence of stool is usually due to asthenia of the spleen and the kidney failing to control the anus, often seen in patients with weakness due to prolonged illness and senility or chronic diarrhea. Fulminant diarrhea in new disease or spontaneous defecation with coma is also due to failure of the anus to control, but is not necessarily caused by weakness of the spleen and kidney. Prolapsing sensation of the anus or even prolapse of the anus is known as qi prolapse of the anus which often occurs after overstrain or becomes worsened after defecation, usually due to prolapse of the gastrosplenic qi and seen in patients with chronic diarrhea or prolonged dysentery.
1.3.3.6.2 Urination
Normally a person urinates 3 - 5 times in the daytime and 0 - 1 time in the night, and the volume of urine discharged in a day and a night is 1,200 - 2,000 ml. The frequency and volume of urine are affected by such factors like drinking of water, body temperature, sweating and age.
Urine is transformed from body fluid. The inquiry of urine is helpful for understanding the conditions of body fluid and qi transforming functions of the concerned viscera.
Abnormal volume of urine: Clear and profuse urine is usually due to asthenic cold syndrome. Profuse urine is also an important evidence in diagnosing other diseases, such as polyuria in diabetes marked by emaciation, polydipsia and polyphagia. Reduced urine is often caused by exuberant heat consuming body fluid, or sweating, vomiting and diarrhea which over consume body fluid and weakens the transformation source. Polyuria may also be caused by dysfunction of the lung, spleen and kidney as well as improper transformation of qi.
Abnormal frequency of urine:Frequent urination means increased times of urination and frequent desire to urinate. Frequent urination marked by brownish scanty and urgent urine is usually due to damp heat in the lower energizer and failure of the bladder to transform qi; frequent urination with profuse discharge, clear colour and aggravation in the night is due to asthenic cold in the lower energizer resulting from insufficiency of the kidney yang, weakness of kidney qi and failure of the bladder to control. Obstructive urination with dripping discharge is known as retention of urine; blockage of urine is called obstruction in urination; the conditions of both are collectively called retention of urine. The retention of urine due to downward migration of damp heat or blood stasis and obstruction by calculus is of sthenia syndrome; while retention of urine due to insufficiency of kidney yang, improper transformation of qi or insufficiency of kidney yin and deficiency of body fluid is of asthenia syndrome.
Abnormal sensation in urination: Obstructive urination with pain, often accompanied by urgency and scorching heat, is often due to accumulation of damp heat in the bladder and improper function of the bladder to transform qi, usually seen in stranguria. Dripping urination is usually due to asthenia of kidney qi and failure of the kidney to manage closure and opening, often seen in old and weak patients with prolonged illness. Inability to control urine and spontaneous discharge of urine is called incontinence of urine, usually due to insufficiency of kidney qi and weakness of kidney function. If coma is accompanied by incontinence of urine, it is a critical pathological condition. Spontaneous urination during sleep is called enuresis, usually caused by insufficiency of kidney qi and failure of the bladder to control urine.
