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[Scriptural Principles]
The Sanjiao (Triple Burner) is the official responsible for dredging waterways, through which water passages emerge. ○ The Bladder is the official of the Zhou Du (State Capital), where body fluids are stored; only through Qi transformation can they be excreted. ○ When the Bladder functions poorly, it is called Long (urinary retention); when it lacks restraint, it is called Yiniao (urinary incontinence). ○ If urine flows incessantly from the Shuiquan point, it indicates that the Bladder fails to store fluids. ○ Those suffering from Long urinate dozens of times a day, which signifies deficiency. ○ The Du Mai (Governing Vessel) originates from the center below the lower abdomen; in women, it enters and connects to the Ting Kong (near the urethral opening); diseases here manifest as Long, hemorrhoids, and urinary incontinence. ○ In Pao Bi (Bladder Bi syndrome), pressing the interior of the lower abdomen at the Bladder location causes pain, feeling as if scalded by hot water, with difficult and scanty urination. ○ In Pi Bi (Spleen Bi syndrome), one startles during sleep, drinks excessively, and urinates frequently. ○ Insufficiency of Middle Qi leads to abnormalities in urination and defecation. (From *Suwen*)

The Sanjiao is governed by the Foot Shaoyin (Kidney) and Foot Taiyang (Bladder) meridians; excess manifests as Bi Long (obstructive urinary retention), while deficiency manifests as Yiniao (urinary incontinence). (From *Lingshu*)

[Philosophical Discourses]
Xiaobianmi (Minor Urinary Constipation): Complete inability to urinate, with fullness in the lower abdomen, caused by dryness of the Bladder. Xiaobiaoshao (Scanty Urine): Urine is excreted but in small amounts, due to insufficient body fluids. Xiaobiaonan (Difficult Urination): Urine comes out drop by drop with difficulty, without pain in the glans. Xiaobiaolinli (Dribbling Urination): Urine drips drop by drop, sometimes accompanied by pain. (From *Yijie Bianzheng*)

Bi (Obstruction) refers to the complete inability to urinate, blocked and unpassable; Long (Retention) refers to physical weakness and insufficient Qi, with urine dripping drop by drop, or being difficult and painful, occurring dozens or even hundreds of times a day, commonly known as Lin disease (strangury). Bi is an acute condition; Long is a chronic condition. Yiniao (Urinary Incontinence) refers to urinating in one's sleep, realizing it only upon waking; Jinb (Incontinence) refers to frequent urination without day or night restraint. (From *Chishui Xuanzhu*)

Heat in urination causes obstruction; cold causes loss of control. Severe heat leads to complete blockage; mild heat leads to difficulty and only scanty output. (From *Renzhai Zhizhi*)

There are cases of Heart-Kidney non-interaction, with Yin and Yang not communicating, leading to internal closure and external rejection; there are cases of Heat binding in the Lower Jiao, blocking the interior of the Pao and causing stagnation of the Qi pathway; there are cases of latent Heat in the Lung, failing to generate Water and thus failing to execute Qi transformation; there are cases of Damp-Heat in the Spleen meridian, with stagnant Clear Qi and failure of Turbid Qi to descend; there are cases of Phlegm-Saliva obstruction, blocking the Qi pathway; there are cases of prolonged illness with excessive sweating, depleting body fluids; there are cases of Liver meridian anger, causing Qi closure and blockage; there are cases of Spleen deficiency and Qi weakness, leading to improper regulation. (From *Zhengzhi Huibu*)

The symptom of inability to urinate is either Cold binding in the Bladder or Heat forcing the Bladder; differentiation relies entirely on the lower abdomen: if urination is obstructed and painful, it is Heat; if not painful, it is Cold. (From *Jiren Bian*)

If there is Qi in the Small Intestine, the urine feels distended; if there is Blood, urination is difficult/astringent; if there is Heat, urination is painful. All these conditions contraindicate the use of tonifying herbs, because tonifying Qi worsens distension, tonifying Blood worsens astringency, and tonifying Heat worsens the heat. (From *Yitong*)

Although the Bladder is called the organ of body fluids, regarding the reception and storage of fluids, there is a "Pao" (bladder sac) located within the Bladder. Thus, *Neijing* states: "Heat shifts from the Pao to the Bladder." It also states: "The Pao of the Bladder is thin and moist." *Leizan* states: "The Bladder is the chamber of the Pao." The Pao resides within the Bladder, having an upper opening but no lower opening. When fluids fill the Pao, they cannot exit spontaneously; they must rely on Qi transformation to gradually infiltrate outside the Pao, accumulating in the empty space below the Pao, thereby forming urine to exit via the anterior yin. If there were no empty space below the Pao, how could urine be expelled immediately upon reaching the toilet? It is precisely because urine accumulates in this empty space until it cannot hold more, causing urgency, and when urgent, it is expelled immediately upon reaching the toilet. (Li Dongyuan)

Qi is the mother of Water; only through the Qi transformation of the Taiyang meridian can bladder urine be excreted. This shows that water pathways rely on formless Qi transformation, not solely on the有形 (form) of the Zhou Du (Bladder). However, Water is Yin, and Qi is Yang. Qi is the root of Yang, and Fire is the manifestation of Yang. Therefore, excess Qi becomes Zhuang Huo (Fierce Fire) and turns into pathogenic Heat. When Fierce Fire ascends to the Sanjiao, it damages the Qi of the Taiyang; when pathogenic Heat descends into the Bladder, it dries up the fluids of the Zhou Du. When Fire prevails, Water is deficient; this is natural law. The Water and Fire of the Five Zang organs all originate from Qi; thus, Shao Huo (Mild Fire) generates Qi, and Qi becomes Water. When Water Essence spreads throughout, descending to the Bladder, a clear source yields clean flow. If Fierce Fire consumes Qi, the source of transformation loses its support, leading to Long/Bi (retention/obstruction), Linse (strangury/difficulty), Gaolin (gurry strangury), bean-water urine, stones, and pus-blood, causing obstruction of the water pathways. Ultimately, this is due to a turbid source of transformation, not a failure of the Duodu (Sanjiao). Using formulas like Bazheng San, Zhouche Wan, Yugong San, or Junchuan San would exhaust the Yin deficiency of the Five Zang and cut off the Qi transformation of the Taiyang. (Ke Yunbo)

*Neijing* states: "The Bladder is the official of the Zhou Du; Qi transformation allows it to exit." It also states: "Regulate the water pathways, transporting downward to the Bladder." Generally, among substances transformed in the human body, urine is the most abundant, as it is formed by the fermentation of damp-evaporated Qi. What exits the Large Intestine is merely food residue, not a product of transformation. As for Kidney essence, Liver tears, Lung mucus, and Heart sweat, they are discharged according to specific stimuli, not through Qi transformation. Therefore, transformation products belong uniquely to bladder urine. I have often observed deeply that the Bladder, besides transforming harmonious Qi into urine, also transforms pathogenic Qi into urine. When pathogenic Qi is heavy, urination becomes difficult; when pathogenic Qi subsides, urination gradually clears. Among all organs in the body, none can expel pathogenic Qi better than the Bladder. When Bladder water is excreted, Spleen Earth becomes solid; when Spleen Earth is solid, Lung Metal becomes clear and Heart Fire descends, allowing the whole body to regulate itself. Thus, in health preservation, strengthening the Spleen is the pivot; in treating disease, draining the Bladder is the pivot.

Long Bi (Retention and Obstruction)
There are three types of difficult urination, which cannot be generalized. First, if body fluids leak preferentially into the intestines and stomach, causing diarrhea and scanty, difficult urination, treatment should focus on separating and draining. Second, if Heat combats the Lower Jiao, preventing fluid movement, treatment with渗泄 (percolating and draining) will cure it. Third, if Spleen-Stomach Qi is stagnant, unable to regulate water pathways and transport them downward to the Bladder for transformation, treatment should follow the Qi mechanism to allow transformation and excretion. (Luo Qianfu)

There are three approaches to treating constipation/obstruction: 1. Lung dryness fails to generate Water, so use the sweet and bland properties of Fu Ling (Poria) and Ze Xie (Alisma) to drain the Lung and generate Water; 2. Spleen dampness fails to ascend Jing Essence, so use the bitter and warm property of Bai Zhu (Atractylodes Macrocephala) to dry the Spleen and ascend Jing Essence; 3. The Bladder lacks Yang and cannot transform Qi, so use the acrid and hot property of Rou Gui (Cinnamon Bark) to warm the Bladder and transform Qi. This makes the water pathways smooth: upward it stops thirst, middle it removes dampness, and downward it drains pathogenic Heat. For True Yin deficiency, Liuwei Dihuang Tang (Six-Ingredient Rehmannia Pill) is needed to tonify Kidney Water; for True Yang deficiency, Bawei Wan (Eight-Ingredient Pill) is needed to tonify Kidney Fire. For Zhuanbao (displaced bladder) with asthma and urgency threatening death, regardless of gender, pregnancy, or postpartum status, urgently decoct Bawei Wan ingredients; delay means no rescue. Some doubt the acrid-hot nature of Gui Zhi (Cinnamon Twig) and Fu Zi (Aconite) and dare not use them lightly. Do they not know that Kidney Qi deficiency and cold resemble frozen water; heat makes it flow. Besides these, what else can reach the Bladder directly to melt snow and bring spring water? (Chen Laizhang)

Heat in the Upper Jiao Qi level causes obstruction and thirst; this is latent Heat in the Lung failing to generate Water, cutting off the Bladder's transformation source. Use bland-draining herbs to drain Fire, clear Metal, and nourish the Water source. Heat in the Lower Jiao Blood level causes obstruction without thirst; this is insufficiency of True Water, leaving the Bladder dry. Without Yin, Yang cannot transform. Use bitter-cold herbs to nourish the Yin of the Kidney and Bladder, allowing Yang to transform naturally and urination to clear. (Li Dongyuan)

For all Long/Bi syndromes, there are four causes, and distinguishing excess from deficiency is paramount. One cause is Fire-Evil aggregating in the Small Intestine and Bladder, where water springs are dried up and the Qi gate is heat-blocked. Another cause is Heat residing in the Liver and Kidneys, where stale semen or dried blood blocks the water pathways. These are not cases of absolute lack of water, but rather blockage. Since the etiology is excess, it can be cleared or drained; these are mild forms of Long/Bi. Only Qi Blockade is a critical condition. Qi Blockade has two meanings: Qi Excess Blockage and Qi Deficiency Blockage. The Bladder is the organ storing Water, but water enters via Qi transforming into Water, so Qi produces Water; water exits via Water reaching Qi, so Water produces Urine. *Neijing* states: "Qi transformation allows it to exit." There must be transformation-in before there is transformation-out; without transformation-out, there is no transformation-in. Thus, both entry and exit depend on Qi transformation. This follows the *Neijing*'s meaning of Qi transformation, not just referring to the act of exiting. Therefore, Water contains Qi, so Qi is Water; Qi contains Water, so Water is Qi. For cases of Qi Deficiency Blockage, there is inevitably depletion of True Yang at the lower extremities, rootlessness of the Yuan Sea, non-interaction of Water and Fire, and Yin-Yang obstruction. Thus, Qi remains Qi and does not transform Water; Water remains Water and accumulates without moving. If Qi does not transform Water, the Water Organ may become depleted; if Water accumulates without moving, it may rot and corrupt. If Qi cannot transform, can forced drainage work? If there is no Yang in Yin, can bitter-cold herbs be used without harm? As for Qi Excess Blockage, it is merely strong Liver Qi reversing and obstructing the Bladder; breaking the Qi, unblocking stagnation, or lifting sinking obstruction will remove the blockage. Treating excess is easy, but treating deficiency requires mastering Qi transformation, which is difficult. (*Jingyue Quanshu*)

The organ governing the Five Fluids is the Kidney. When Kidney Qi is deficient and disturbed, it lacks strength to transform fluids, allowing Evil Fire to attack, resulting in scanty, difficult urination. Although superficial Heat arises from the Bladder, the root deficiency/excess lies in the Kidney. Tonify the Kidney to benefit deficiency, and warm to transform Qi; then the Kidney source is nourished, and urination becomes free, verifying the recovery of Kidney Qi. ○ Although water seeps into the Bladder, separation is performed by the Small Intestine. Heat in the Small Intestine can shift to the Bladder. The Small Intestine is the Fire Organ, rooted in the Heart. If Heart Qi is unblocked, Small Intestine Fire descends naturally, leaving no Heat to shift; the source clarifies, and the flow clears. (Cheng Jiaoqian)

Yin Deficiency causing short, difficult, obstructed urination: do not see apparent excess signs and use diuretics. This is due to weakness of the Original Yin Qi in the Lower Jiao, unable to transport and transform. Greatly tonify Original Yin, and urination will naturally clear. Cases of Qi Deficiency with Phlegm obstructing the Middle Jiao, Qi stagnation in the Lower Jiao, or Damp-Heat are not included here. (Luo Chicheng)

Use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction); add Xu Duan (or Niu Xi/Achyranthes) for difficult urination. Use Liujun Dihuang Wan (Six-Ingredient Rehmannia Pill); add Che Qian Zi (Plantago Seed) for difficult urination. (Zhou Shenzhai)

The Bladder is the official of the Zhou Du, storing fluids; Qi transformation allows them to exit. What is Qi transformation? Body fluids are transformed by Qi. Food enters the Stomach, overflowing with Essence-Qi, transported upward to the Spleen. The Spleen disperses Essence, sending it upward to the Lung. The Lung regulates water pathways, transporting downward to the Bladder. Water Essence spreads everywhere, running through the Five Meridians. It is like steaming food: soup vapor rises to steam the pot, creating liquid that drips down. This is the Spleen Qi steaming the Lung lobes, enabling regulation of water pathways and transport to the Bladder. Therefore, for obstruction of urination due to Qi Deficiency and water depletion, using diuretics worsens it. One must use a large dose of Ren Shen (Ginseng) with a little Sheng Ma (Cimicifuga); then Yang rises and Yin descends, earth qi becomes clouds, heaven rain falls, and natural clearance occurs. ○ Danxi said: Obstruction of urination can be due to Qi Deficiency, Blood Deficiency, Excess Heat, or Phlegm-Qi blockage. All should be treated with vomiting to lift Qi; when Qi rises, Water descends. Qi carries Water. For Qi Deficiency, use Ren Shen, Bai Zhu, Sheng Ma, etc., take first, then induce vomiting; for Blood Deficiency, use Siwu Tang or Xionggui Tang, take first, then induce vomiting; for much Phlegm, use Erchen Tang, take first, then induce vomiting; for Phlegm-Qi blockage, use Erchen Tang plus Xiang Fu (Cyperus) and Mu Tong (Akebia), take first, then induce vomiting. Someone asked: What is the rationale for using vomiting to clear urination? Answer: To utilize Qi transformation. (*Zhengzhi Zhunsheng*)

*Neijing* says: "Extreme Yin deficiency cuts off Heaven Qi; extreme Yang excess leaves Earth Qi insufficient." Kidney and Liver are below, representing Earth Dao; Heart and Lung are above, representing Heaven Dao; Spleen and Stomach are central, the division of Qi intersection. Thus, if Heaven Yang is cut off and cannot settle in Earth, white dew does not fall; if Yang above does not interact with Yin below, Yin below has nothing to transform, how can water pathways exit? This is Qi transformation of the Upper Jiao. Zhang Zhongjing said: "When Wei Qi circulates, urination is unobstructed." He also said: "Spleen disease causes obstruction of the nine orifices." This is Qi transformation of the Middle Jiao. Li Dongyuan said: "Yin deficiency below and Yang excess above cause Kidney Qi failure to transform; one must promote Yang and lift it, then Yin can be balanced." Thus, Danxi said: "I use vomiting to clear urination, like a dripping vessel; if the upper orifice is closed, the lower orifice cannot open itself; only when the upper orifice opens does water flow from the lower." However, lifting is only suitable for drops that do not pass; for difficult, scanty, or painful dribbling, it is not appropriate. From *Neijing* and various discourses, none do not emphasize Qi transformation. Not examining this, but turning to draining agents for merit, shows much ignorance of measure. (*Zhangshi Yitong*)

Qi Deficiency causing obstruction of urination: *Neijing* says: "The Bladder stores fluids; Qi transformation allows exit." Qi Deficiency means inability to transform, hence obstruction. Blood Deficiency causing obstruction: Blood belongs to body fluids; Blood Deficiency means dry fluids and unfavorable urinary pathways, hence obstruction. This differs from Phlegm-Qi blockage in the Lower Jiao in terms of deficiency/excess. Danxi used vomiting in all cases, treating the branch in emergencies. However, Qi and Blood Deficiency are fundamentally deficient; deficiency must be tonified. Using Ren Shen, Bai Zhu, Siwu to regulate True Qi and then vomiting can indeed clear urine, but can a few moments of swallowing these tonics truly replenish fundamental deficiency? I fear the root cause remains, and relapse will occur soon. My opinion is that if there is true Qi and Blood Deficiency, one must use Qi-tonifying and Blood-nourishing herbs to make Qi vigorous for transformation and Blood generated for moisture, so urination clears naturally, without needing induced vomiting. If vomiting is truly indicated, vomit first, wait for urination to clear, then continue with tonics to achieve recovery, unlike Phlegm-Qi blockage which resolves with vomiting alone. This reveals the incomplete aspect of Danxi's theory, which I hereby highlight. (*Yixue Tongzhi*)

Incontinence and Frequency
*Lingshu* states: The collateral name of Hand Taiyin is Lieque; its disease, when deficient, leads to lack and frequent urinary incontinence. The Lung is the Upper Jiao, regulating water pathways and transporting to the Bladder. The Kidney connects upward to the Lung; the two organs are mother and son. Mother deficiency leads to son deficiency. Dongyuan said: Urinary incontinence is Lung Metal deficiency. Tonify with Ren Shen and Huang Qi; if not cured, blame the Kidney. *Neijing* states: "Bladder lack of restraint causes incontinence." Zhongjing said: "Lower Jiao failing to return causes urinary leakage." The Lower Jiao is at the upper opening of the Bladder, responsible for separating clear and turbid. If the Lower Jiao fails to return, this region cannot restrain urine, causing incontinence. Generally, warm weather and thick clothes cause sweating; cold weather and thin clothes cause urination. As for incontinence, it is severe deficiency-cold; only Bawei Wan (Eight-Ingredient Pill) is effective. Tusizi Wan, Lurong San, and Erqi Wan are also selectable. (*Zhao Shi Yiguan*)

Frequent urination is simply inner Qi failing to hold; frequent yet scanty, due to deficiency of the Five Fluids flowing downward. This is a disease of internal deprivation of Jing Essence, body fluids, and blood vessels. Do not say that because drops are few, it doesn't constitute a leak in the Zang-Fu; the responsibility lies not only in the Jade Gate (Kidney). Directly use Shiquan Dabu Tang (Ten Substance Great Tonifying Decoction) to tonify Qi and restore Spirit, restore Spirit and nourish Essence. Indeed, knowing that repairing the earth with turtle legs requires smelting stones to repair heaven. (Cheng Jiaoqian)

Human urine relies on the transmission of Heart and Kidney Qi. The Heart and Small Intestine are exterior-interior; the Kidney and Bladder are exterior-interior. If Heart and Kidney Qi decline and Yang mechanisms fail to operate, transmission becomes irregular, leading to incontinence. Treatment should warm and tonify the Lower Origin, clear the Heart, and reduce desires. (Xue Lizhai)

Note: Yiniao means loss. Losing in sleep and realizing upon waking is common in children, rare in adults. Children have weak Yang Qi, lacking restraint, active with wandering Hun (Ethereal Soul), hence frequent nocturnal enuresis. Ancient formulas mostly use warming herbs, intending to warm and nourish Yang Qi. I have seen several people aged twenty or thirty still suffering from continuous enuresis, who later had no children. Is this truly not due to Lower Origin deficiency-cold? (Sun Yikui)

Nocturnal enuresis is blamed on Kidney Deficiency. Infants have unconsolidated Pao Qi; elders have insufficient Lower Origin, both often having this symptom. In infants, it is mostly accompanied by Heat; in elders, mostly by Cold. Treatment should use Da Tusizi Wan (Great Cuscuta Pill), taken with decoction of Pig Bladder. (*Yixue Liuyao*)

Excessive Heat lodging in the Foot Jueyin meridian, causing郁结 (stagnation) in the Ting Kong, leaves the Spirit without foundation, thus causing urinary loss and inability to restrain. (*Yuanbing Shi*)

Anyone suffering from Yin Deficiency disease with frequent urination does so because of hidden movement of Ministerial Fire. Do not mistake it for deficiency-cold and use Ren Shen, Huang Qi, Gui Zhi, or Fu Zi. Only greatly tonify True Yin, and urination will self-regulate. (Luo Chicheng)

Incontinence or frequency of urination was traditionally considered Cold in ancient formulas, treated with warming and astringent herbs. Little did they know that this syndrome is mostly Yin Deficiency with Heat. Because Fire-Evil moves recklessly, Water cannot rest, hence inability to restrain and frequency. Thus, elders often have frequency due to scanty Bladder Blood and predominant Yang Fire. Treatment should primarily nourish Kidney True Yin and replenish Bladder fluids, assisted by astringents, such as Liuwei Wan plus Maidong (Ophiopogon) and Wuweizi (Schisandra). Warming herbs should not be used. (Wang Jiezhai)

Note: Jiezhai's argument generally states that elders have exhausted Lower Origin and weak Qi unable to carry Water, hence frequency and incontinence. If, as Hejian and Jiezhai claim, Long/Bi is mainly Heat and incontinence is also Heat, there would be no deficiency-cold syndromes. Why do ancient texts mention warming/tonifying methods and *Neijing* mention cold/deficiency texts? It is better to consider frequent, clear, long urination as Cold, and frequent, yellow-red, difficult urination as Heat, combined with pulse examination (surging-rapid, forceful-forceless, slippery-slippery) for verification, avoiding error. ○ Jinb means lack of restraint, frequent urination without counting occurrences. Note: *Neijing* says: "If water springs do not stop, the Bladder fails to store." Syndromes include Damp-Heat and Lower Origin exhaustion. Frequent and scanty is Heat; frequent and abundant is Deficiency. Elders often have this due to weak Yang Qi unable to constrain. I have seen several people who died despite treatment, due to failure to nurture and dissipating Shen Qi. Ancients said obstruction is Heat, incontinence is Cold, due to weak Heart-Kidney Qi, cold Yang mechanisms, and irregular transmission. Method should be warming and tonifying, nurturing Shen, strengthening Kidney. When Shen is complete and Kidney solid, Bladder Qi is full, naturally able to constrain. (*Chishui Xuanzhu*)

Enuresis due to Upper Jiao Deficiency: Tonify Lung Qi. Due to Lower Jiao Deficiency: Secure the Bladder. Accompanied by Cold: Strengthen Mingmen Yang Qi, combined with astringents. Accompanied by Heat: Nourish Kidney and Bladder Yin-Blood, assisted by Fire-draining herbs. (*Zhengzhi Huibu*)

Yellow-Red Urine
Yellow-red urine has distinctions of Cold, Heat, Deficiency, and Excess. *Neijing* says: "All turbid body fluids belong to Heat." Treat with Huang Bo (Phellodendron) and Zhi Mu (Anemarrhena). This is a Heat syndrome. It also says: "Chi pulse is choppy, calves are cold, urine is red." Take Fuzi Sini Tang (Aconite Counterflow Decoction). This is a Cold syndrome. It also says: "Excess in the Foot Yangming Stomach meridian causes heat in the front of the body, hunger with good digestion, and yellow urine." Drain Stomach Fire. It also says: "Liver Heat disease presents with yellow urine first." Drain Liver Fire. This is an Excess syndrome. It also says: "Deficiency of Hand Taiyin Lung meridian Qi..."