一 一人小便不通，目突脐胀，膝以上坚硬，皮肤欲裂，饮食不下。东垣与以淡渗之药，无效。精
思半夜，始悟其故，夫膀胱为津液之府，必得气化乃出，无阴则阳无以化，淡渗气薄，皆阳药也，孤阳无
阴，欲化得乎？以滋肾丸群阴之剂投之，即愈。
二 一老人患小便不利，因服分利之药太过，遂致秘塞，点滴不出。丹溪曰∶此因胃气下陷，用
补中益气汤，一剂而通。因先多用利药，损其肾气，遂至通后遗尿，一夜不止。急补其肾然后已。凡医
之治是症者，未有不用泄利之药，谁能顾其肾气之虚哉？特表着之，以为世鉴。
小便不禁，内经有责之膀胱，〔宜分寒热。〕责之肾者，〔分水衰火衰〕有责之肺，〔分气盛气
虚。〕责之肝者。〔分实火虚火〕按赵氏云∶天暖衣浓则多汗，天寒衣薄则多溺，多溺者寒也。至于不
禁，虚寒之甚。又戴氏云∶睡。着遗尿者，此系下元冷所致。又言∶遗尿此属于虚，所以婴儿脬气
不固，老人下元不足，多有此症。河间独以为旋溺遗失，此系热症。《明医杂着》亦云∶因肾水不足，膀
胱火邪妄动，水不得宁，故不能禁，而小便频数也。老人每多患此。当补阴〔地、冬、龟甲。〕泻
火〔知、柏、白薇。〕为主，佐以收涩〔萸肉、牡蛎。〕引导之剂，〔猪胆鸡肠。〕毋用温药。诸说
不一。惟晚村则言∶多溺不禁，有热有寒，临症细审，不可执一。旨哉斯言。
固脬丸〔自制，亦可煎汤〕经曰∶膀胱不约为遗溺。又曰∶水泉不止者，是膀胱不藏也。宜此固之。
熟地 枸杞〔补肾益阴。〕山萸 五味〔酸以收之〕。龙骨 牡蛎〔涩以固之，〕覆盆
子续断〔益肾脏，缩小便。〕鸡肠〔专治溺数不禁遗尿。 存性〕猪脬〔咸寒引导入脬。挟
寒宜用羊肠。〕可加紫河车、〔嘉言云∶取以脬补脬，而助膀胱之化原，只宜入丸药。〕人参、柏
仁〔仲淳云∶小便不禁，属气血虚。〕挟热加知、柏、二冬、白薇
〔益阴除热。〕挟寒加破故纸，益智仁〔暖下焦，缩小便。糯米糊为丸，桐子大，空心白汤下。〕
此方补肾益阴敛涩，以助其封藏，固其脬气为主，当因症寒热，而随宜加减之。
左归丸饮〔见虚劳。〕
宜参固脬丸诸药加之。
此方因肾水衰而火迫，遗失不禁者用之。
八味丸〔见不能食。〕
宜去泽泻〔嫌其渗泄。〕加收涩引导诸药，及鹿茸、鹿角胶〔鹿角补督脉，经言∶督脉生
病为遗溺，故也。〕
此方因真火衰而阳虚失禁，遗尿旋溺者用之。
竹叶石膏汤〔见伤寒。〕治肺热，溺数不禁。〔经言∶肺气盛则小便数。盖气有余便是火，火
热入肺，高原之水，为炎威所逼，病趋而下，故溺数甚则不禁。〕
宜加芦根、生地、知柏、白薇。
此方清其肺热，固为先务，然除下焦热药，如知柏、生地之属，亦不可少。
生脉散〔见中暑。〕治肺气虚，溺数不禁。〔东垣云∶小便频数，肺气虚也，宜安卧养气，
禁劳役，以参补之，不愈，当责之肾。〕
宜加黄 、覆盆，续断、鸡肠，或合补中益气汤加益智仁。
此方一补一清，一敛肺气，虚而有热者甚宜。按薛氏云∶若系脾肺虚，宜补中益气汤加益智之类。
加味逍遥散〔见虚劳。〕治肝经热甚，阴茎失职，溺数不禁，虚火加二冬、白薇，实火加胆
草、黄连，〔猪胆汁
炒。〕俱加鸡肠。
此方宜分别虚火实火，加减用之。
遗尿若见诸绝症，不治。
1. A patient presented with urinary retention, protruding eyes, umbilical distension, hardness above the knees, skin tight as if about to split, and inability to eat. Li Dongyuan prescribed diaphoretic and leeching drugs (drugs that promote urination through mild diuresis), but without effect. After deep reflection until midnight, I finally understood the cause: The Bladder is the mansion of body fluids (Jinye), which must be excreted only after Qi transformation. Without Yin, Yang cannot transform; diaphoretic and leeching drugs are thin in Qi and belong to Yang medicines. Isolated Yang without Yin cannot achieve transformation. Therefore, I administered Zishen Wan (Nourishing Kidney Pill), a formula composed of Yin-nourishing herbs, and the patient recovered immediately.
2. An elderly man suffered from difficult urination. Because he had taken too many diuretic drugs, his urine became completely blocked, with not a single drop coming out. Zhu Danxi said: This is due to the sinking of Stomach Qi. Use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction); one dose will restore flow. However, because he had previously used too many draining drugs, damaging Kidney Qi, he experienced enuresis (involuntary urination) after the blockage was relieved, lasting all night. Urgent tonification of the Kidney stopped it. Physicians treating this condition almost always use draining and leeching drugs; who can attend to the deficiency of Kidney Qi? I record this specifically as a warning for future generations.
Urinary incontinence is attributed to the Bladder in the *Neijing* [Internal Classic], [distinguishing between Cold and Heat patterns]. It is attributed to the Kidney [distinguishing between Water Deficiency and Fire Deficiency]; to the Lung [distinguishing between Qi Excess and Qi Deficiency]; and to the Liver [distinguishing between Excess Fire and Deficient Fire]. According to Zhao Shi: When the weather is warm and clothing is thick, there is much sweating; when cold and clothing is thin, there is much urination. Much urination indicates Cold. As for incontinence, it indicates extreme Deficient-Cold. Dai Shi also stated: Enuresis during sleep is caused by coldness in the Lower Yuan (Lower Origin). He further said: Enuresis belongs to Deficiency. Thus, infants often have insecure Bladder Qi, and the elderly often suffer from insufficient Lower Yuan, both presenting this symptom. Liu Hejian alone believed that involuntary loss of urine is a Heat pattern. *Mingyi Zazhu* also states: Due to insufficiency of Kidney Water, pathological Fire in the Bladder moves recklessly, causing the water to be unsettled, thus unable to be controlled, resulting in frequent urination. This is common in the elderly. Treatment should focus on nourishing Yin [Shudi, Tandong, Guijia] and purging Fire [Zhimu, Huangbai, Baiwei], assisted by astringents [Yurou, Muli] and guiding agents [Zhudan, Jichang]. Do not use Warm medicines. Various theories differ. Only Wancun stated: Frequent urination with incontinence can be either Heat or Cold; careful examination at the bedside is required, and one must not adhere rigidly to one view. These words are profound.
Gupao Wan (Secure the Bladder Pill) [Homemade, can also be decocted]. The *Classic* says: When the Bladder fails to constrain, enuresis occurs. It also says: Unceasing flow of water (continuous dribbling of urine) indicates the Bladder fails to store. This formula is suitable to secure it. Shudi (Prepared Rehmannia Root) and Gouqi (Goji Berry) [Tonify Kidney and benefit Yin]; Shanzhuyu (Cornus Fruit) and Wuweizi (Schisandra Fruit) [Sour flavor to astringe]; Longgu (Fossilized Bones) and Muli (Oyster Shell) [Astringent flavor to consolidate]; Fupenzi (Raspberry) and Xuduan (Dipsacus Root) [Benefit the Kidney and reduce urination]; Jichang (Chicken Intestine) [Specifically treats frequency and incontinence; keep charred]; Zhupao (Pig Bladder) [Salty and cold, guides medicine into the bladder. If accompanied by Cold, use Sheep Intestine]. Ziheche (Placenta) may be added [Jiayan said: Using the bladder to supplement the bladder assists the source of Bladder Qi transformation; suitable only for pills]. Renshen (Ginseng) and Bairen (Bai Zi Ren / Platycladi Seed) [Zhongchun said: Urinary incontinence belongs to Qi and Blood deficiency]. If accompanied by Heat, add Zhimu, Huangbai, Dongtian (Tian Dong), Dongmaitong (Mai Dong), and Baiwei [Nourish Yin and remove Heat]. If accompanied by Cold, add Poguzhi (Buguzhi / Psoralea Fruit) and Yizhiren (Alpinia Oxyphylla Fruit) [Warm the Lower Jiao and reduce urination]. Make pills with glutinous rice paste, size of paulownia seeds, taken on an empty stomach with plain boiled water. This formula tonifies the Kidney, benefits Yin, and astringes, helping its sealing and storing function, primarily securing Bladder Qi. Dosage should be adjusted according to the Cold or Heat nature of the symptoms.
Zuogui Wan Yin (Left Restoring Pill Decoction) [See Xu Lao chapter].
It is appropriate to add herbs from Gupao Wan to this formula.
This formula is used when Kidney Water declines and Fire presses, causing leakage and incontinence.
Ba Wei Wan (Eight-Ingredient Pill) [See Bu Neng Shi chapter].
Remove Zexie [due to its draining and leeching properties], and add various astringents and guiding agents, plus Lurong (Deer Antler Velvet) and Lu Jiao Jiao (Deer Antler Glue) [Deer Antler tonifies the Du Mai (Governing Vessel); the Classics state: Diseases of the Du Mai lead to enuresis, hence this combination].
This formula is used when True Fire declines and Yang Deficiency leads to incontinence and spontaneous urination.
Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) [See Shang Han chapter]. Treats Lung Heat, causing frequent urination and incontinence. [The Classics state: When Lung Qi is excessive, urination is frequent. Generally, excess Qi becomes Fire. When Heat-Fire enters the Lung, the water from the high source is forced by the blazing heat, and the pathology trends downward, so frequent urination becomes severe and uncontrollable].
Add Lugan (Reed Rhizome), Shengdi (Raw Rehmannia Root), Zhimu, Huangbai, and Baiwei.
Clearing Lung Heat is the primary task in this formula, yet herbs that clear Heat from the Lower Jiao, such as Zhimu, Huangbai, and Shengdi, are indispensable.
Shengmai San (Generate the Pulse Powder) [See Zhong Shu chapter]. Treats Lung Qi Deficiency, causing frequent urination and incontinence. [Dongyuan said: Frequent urination is due to Lung Qi Deficiency. One should rest quietly to nourish Qi, avoid overwork, and tonify with Renshen. If ineffective, blame the Kidney].
Add Huangqi (Astragalus), Fupenzi, Xuduan, and Jichang, or combine with Buzhong Yiqi Tang plus Yizhiren.
This formula combines tonification and clearing, and astringes Lung Qi; it is very suitable for Deficiency with Heat. According to Xue Shi: If it is Spleen and Lung Deficiency, use Buzhong Yiqi Tang plus Yizhiren, etc.
Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder) [See Xu Lao chapter]. Treats severe Heat in the Liver Meridian, dysfunction of the penis, frequent urination, and incontinence. For Deficient Fire, add Tian Dong and Mai Dong, Baiwei; for Excess Fire, add Danshen (Longdan Cao / Gentian Root) and Huanglian (Coptis Rhizome) [stir-fried with Pig Bile], all adding Jichang.
This formula should be modified based on whether the Fire is Deficient or Excess.
If enuresis presents with signs of terminal diseases, it is untreatable.