经义
胞移热于膀胱，则癃、溺血。○悲哀太甚，则胞络绝，胞络绝则阳气内动，发为心下崩，数溲血也。（《素问》）
哲言
溺血所出之由有三，从溺孔出者二，从精孔出者一。（张景岳）
溺血全无疼痛，血从精窍而出，非若血淋茎痛血从溺窍而出也。（《证治汇补》）
溺血者，盖心主血与小肠合，血之流行，周遍经络，循环脏腑，若热聚于膀胱，血渗入脬，故从小便而出
也。（钱仲阳）
《经》云∶悲哀太甚，则胞络绝，阳气内动，发为心下崩，数溲血也。又云∶胞移热于膀胱，则癃、溺血。
是溺血未有不本于热者。陈无择以为心肾气结所致，不思血虽主于心，其四脏孰无血以为养？所尿之血，岂拘
于心肾气结者哉？推之五脏，凡有损伤妄行之血，皆得如心下崩者，渗于胞中；五脏之热，皆得如膀胱之移热者，
传于下焦。何以言之？肺金者，肾水之母，恃之通调水道，下输膀胱者也。肺有损伤，妄行之血若气逆上者，
既为呕血矣，气不逆上，如之何不从水道下降入于胞中耶？其热亦直抵肾与膀胱可知也。脾土者，胜水之贼邪
也。水精不布，则壅成湿热，陷下伤于水道，肾与膀胱俱受其害，害则阴络伤，伤则血散入胞中矣。肝属阳，
主生化，主疏泄，主藏血；肾属阴，血闭藏而不固，必渗入胞中，正与《内经》所谓肝伤血枯，时时前后血者
类也。大抵溲血、淋血、便血三者，虽前后阴所出之窍有不同，然于受病则一，故治分标本亦一也。维引导佐
使，各走其乡者，少异耳。（《证治准绳》）
大便下血不死；小便下血多死；年过七旬，服药无效。（许宣治）
补编
溺孔之血，其来近者，出自膀胱，其证溺时必孔道涩痛，小水热赤不利。此多以酒色欲念，致动下焦之火
而然。常见相火妄动，逆而不通者，微则淋浊，甚则见血。《经》曰∶胞移热于膀胱，则癃、溺血。治宜清利
膀胱之火。○溺孔之血，其来远者，出自小肠，其证溺孔不痛，血随溺出，或痛隐于脐腹，或热见于脏腑。盖
小肠与心为表里，此丙火气化之原，清浊所由分也。无论焦心劳力，浓味酒浆，而上中二焦之火，凡从清道
以降者，必皆由小肠以达膀胱，治须随证察因，以清脏腑致火之原。○精道之血，必自精宫血海而出于命门。
盖肾者主水，受五脏六腑之精而藏之。凡劳伤五脏，或五志之火，致令冲任动血者，多从精道而出。何以辨之？
但辨在小肠者，必从溺孔出；病在命门者，必从精孔出。凡于小腹下，精泄处，觉酸痛而出者，即是命门之病。
治法与水道不同，盖水道之血宜利，精道之血不宜利；涩痛不通者宜利，血滑不痛者不宜利也。（张景岳）
尿血，虚者居多，有火亦能作痛，当与血淋同治。清之不愈，专究乎虚，上则主于心脾，下则从乎肝肾，
久则主于八脉。（《临证指南》）
溺血治法∶暴病实火，宜甘寒清火；房劳虚损，宜滋阴补肾；病久中枯，非清心静养不可治也。（《证治汇补》）
肾阴亏损，下焦结热，血随溺出，用六味汤加牛膝以镇阳。○溺血日久，屡用清利药不效，补中益气汤加
车前良验。（《见闻录》）
脉候
溲血形脱，脉小劲者逆也，脉搏者亦逆也。（《证治准绳》）
选案
予治一人溺血，二、三年一发，服补中益气汤加黄柏、山栀，数剂而止。又治一人尿血成条，药皆不应而逝。（许宣治）
内弟顾元叔溺血，溺孔疼痛，周身麻木，头旋眼黑，手足心经脉绌急酸麻，脉弦细数，两尺搏坚。与
生料六味汤加牛膝、门冬，服之辄效，但不时举发，复以六味汤合生脉散，用河车熬膏丸服而痊。○一商夏月过
饮烧酒，溺血，服益元散、六味汤，均不效。予用导赤散，三啜而愈。○宋孝先年七十余，溺血点滴涩痛，诸药
不效，云是壮岁鳏居，绝欲太早之故。令以绿豆，水浸捣汁，微温，日服一碗而愈。煮熟即不应。（《张氏医通》）
【经文释义】
胞宫（此处指代下焦相关脏腑或组织）的热邪转移至膀胱，就会导致小便不通（癃闭）和尿血。○极度悲哀会损伤胞络，胞络受损则阳气在内躁动，引发心下部出血（心下崩），表现为频繁排出带血的尿液。（出自《素问》）
【哲人言论】
尿血产生的原因有三种：从尿道口排出的有两种情况，从精道排出的有一种情况。（张景岳）
尿血完全没有疼痛感，血液是从精窍排出的；这与血淋不同，血淋会有茎中疼痛，血液是从溺窍（尿道）排出的。（《证治汇补》）
所谓尿血，是因为心主血脉并与小肠相表里，血液在经络中流行，循环于脏腑之间。如果热邪聚集在膀胱，血液渗入膀胱（脬），就会随小便排出。（钱仲阳）
《内经》说：“极度悲哀会损伤胞络，胞络受损则阳气在内躁动，引发心下部出血，表现为频繁排出带血的尿液。”又说：“胞宫的热邪转移至膀胱，就会导致小便不通和尿血。”
由此可见，尿血没有不是由热邪引起的。陈无择认为是心肾之气郁结所致，但他没考虑到，虽然血主要由心所主，但其他四脏哪一脏没有血来滋养呢？从小便排出的血，难道仅限于心肾气结的情况吗？推及五脏，凡是因损伤导致妄行外溢的血液，都能像“心下崩”那样，渗入膀胱；五脏的热邪，也能像膀胱移热那样，传变到下焦。为什么这么说呢？肺属金，是肾水之母，依赖肺的通调水道功能，将津液向下输送到膀胱。如果肺受到损伤，妄行之血若随气逆上，就会成为呕血；如果气不逆上，怎么会不从水道下降进入膀胱呢？其热邪也会直接抵达肾与膀胱，这是显而易见的。脾属土，是克制水的邪气。如果水精不能布散，就会壅滞形成湿热，下陷损伤水道，肾与膀胱都会受害，受害则阴络受伤，受伤则血液散入膀胱。肝属阳，主管生化、疏泄和藏血；肾属阴，如果血闭藏而不固，必然渗入膀胱，这正是《内经》所说的肝伤导致血枯，时常前后二阴出血的情况类似。大抵来说，尿血、淋血、便血这三种病，虽然从前阴和后阴排出的孔窍不同，但它们受病的机理是一样的，所以治疗时区分标本的原则也是一样的。只是在引导药物归经的佐使药选择上，各自走向不同的部位略有差异罢了。（《证治准绳》）
大便下血不一定致死；小便下血大多致死；年龄超过七十岁，服药无效的更难治愈。（许宣治）
【补编】
从尿道口排出的血，来源较近的，出自膀胱，症状是小便时尿道涩痛，小便短少、色黄赤且排尿不畅。这多是因为酒色过度或欲念妄动，导致下焦火旺所致。常见相火妄动，气机逆乱而不通畅的，轻微的表现是淋浊，严重的则见尿血。《内经》说：“胞宫的热邪转移至膀胱，就会导致小便不通和尿血。”治疗应当清利膀胱的火邪。○从尿道口排出的血，来源较远的，出自小肠，症状是尿道口不痛，血液随小便排出，或者脐腹部有隐痛，或者脏腑有热象。因为小肠与心相表里，这是丙火气化之源，也是清浊分化的关键所在。无论是用心过度、劳累，还是食用浓味厚腻食物、饮酒，导致上焦和中焦的火邪，凡是从清道（呼吸道/消化道等清气通道）下降的，必定都经过小肠到达膀胱，治疗必须根据证候考察病因，以清除脏腑产生火邪的根本。○从精道排出的血，必定自精宫、血海出于命门。因为肾主水，接受并储藏五脏六腑的精气。凡是劳伤五脏，或五志化火，导致冲任脉动血的情况，多从精道排出。如何辨别呢？只要辨别出在小肠病变的，必定从尿道口排出；病在命门的，必定从精窍排出。凡是在小腹下方，精液排泄处，感觉酸痛而排出血的，就是命门的病。治疗方法与水道（泌尿系统）不同，大概水道的尿血适宜通利，精道的尿血不宜通利；涩痛不通的适宜通利，滑泄不痛的就不宜通利。（张景岳）
尿血，虚证居多，有火邪也能引起疼痛，应当与血淋同治。如果清热利尿无效，专门探究虚损的原因，上部主要责之心脾，下部主要责之肝肾，病程久者主要涉及奇经八脉。（《临证指南医案》）
尿血的治疗方法：急性病实火，适宜用甘寒药物清火；房劳导致的虚损，适宜滋阴补肾；病程长久身体衰败，非清心静养不可治愈。（《证治汇补》）
肾阴亏损，下焦结聚热邪，血液随小便排出，使用六味地黄汤加牛膝以镇潜浮阳。○尿血日久，多次使用清热利湿药无效，使用补中益气汤加车前子效果良好。（《见闻录》）
【脉候】
出现尿血且形体消瘦脱失，脉象小而劲急的是逆证，脉搏急促有力的也是逆证。（《证治准绳》）
【选案】
我治疗一个人尿血，每两三年发作一次，服用补中益气汤加黄柏、山栀，几剂药后停止。又治疗一个人尿血呈条状，用药均无效而去世。（许宣治）
内弟顾元叔患尿血，尿道疼痛，全身麻木，头晕眼花，手足心经脉拘急酸麻，脉弦细数，两尺脉搏动坚实。给予生料六味地黄汤加牛膝、麦冬，服用后立刻见效，但病情不时复发，后来再用六味地黄汤合生脉散，用紫河车熬膏制成丸药服用而痊愈。○一位商人在夏天过量饮用烧酒后尿血，服用益元散、六味地黄汤，均无效。我用导赤散，喝三次就痊愈了。○宋孝先年过七十，尿血点滴且涩痛，各种药物无效，说是壮年守寡，过早断绝性欲的缘故。让他用绿豆，用水浸泡捣汁，微温，每天服用一碗而痊愈。煮熟了就无效。（《张氏医通》）
[Scriptural Interpretation]
When heat from the Bao (uterus/lower jiao organs) shifts to the Bladder, it results in strangury (difficulty in urination) and hematuria. ○ Excessive grief severs the Bao Collaterals; when the Bao Collaterals are severed, Yang Qi moves internally, causing "collapse below the heart" (upper abdominal bleeding), manifesting as frequent passage of bloody urine. (From *Su Wen*)
[Philosophical Remarks]
There are three origins for hematuria: two types exit from the urinary meatus, and one type exits from the seminal meatus. (Zhang Jingyue)
Hematuria is completely painless, with blood exiting from the seminal orifice; this differs from blood strangury, which involves pain in the glans penis and blood exiting from the urinary orifice. (*Zhengzhi Huibu*)
Regarding hematuria, since the Heart governs Blood and has an interior-exterior relationship with the Small Intestine, blood circulates through the collaterals and viscera. If heat gathers in the Bladder, blood infiltrates the bladder sac and is thus discharged via urination. (Qian Zhongyang)
The Classics state: "Excessive grief severs the Bao Collaterals; when the Bao Collaterals are severed, Yang Qi moves internally, causing 'collapse below the heart,' manifesting as frequent passage of bloody urine." It also states: "When heat from the Bao shifts to the Bladder, it results in strangury and hematuria."
Thus, hematuria invariably originates from heat. Chen Wuyue attributed it to the binding of Heart and Kidney Qi, failing to consider that although the Heart governs Blood, do not the other four Zang organs also possess blood for nourishment? Is the blood passed in urine restricted only to cases of Heart-Kidney Qi binding? Extending this to all five Zang organs, any blood that flows recklessly due to injury can infiltrate the Bao like "collapse below the heart"; heat from any Zang organ can transmit to the Lower Jiao like heat shifting to the Bladder. Why? The Lung (Metal) is the mother of Kidney (Water), relying on its function of diffusing and descending water passages to transport fluids downward to the Bladder. If the Lung is injured, reckless blood rising with rebellious Qi becomes hematemesis; if Qi does not rebel upward, how would it not descend via the water passages into the Bao? Its heat would naturally reach the Kidneys and Bladder. Spleen (Earth) is the controlling factor of Water. If water essence fails to distribute, it stagnates into damp-heat, sinking to damage the water passages, harming both the Kidneys and Bladder; when harmed, the Yin collaterals are damaged, and blood scatters into the Bao. Liver belongs to Yang, governing transformation, production, free flow, and storing Blood; Kidney belongs to Yin. If Blood is stored but not secured, it inevitably infiltrates the Bao, similar to what the *Nei Jing* describes as Liver injury leading to blood depletion and frequent bleeding from both anterior and posterior orifices. Generally, hematuria, blood strangury, and hematochezia differ only in the orifices of discharge (anterior vs. posterior), but their pathogenesis is identical; thus, the principles of treating root and branch are the same. Differences lie only in the guiding herbs (assistant and envoy drugs) directing action to specific areas. (*Zhizhun Zhunsheng*)
Lower gastrointestinal bleeding is not necessarily fatal; lower urinary tract bleeding is often fatal; in patients over seventy, ineffective medication indicates a poor prognosis. (Xu Xuanzhi)
[Supplemental Compilation]
Blood from the urinary meatus originating nearby comes from the Bladder. Symptoms include painful, difficult urination with scanty, hot, red urine. This is mostly caused by excessive alcohol consumption, sexual indulgence, or lustful thoughts stirring up Fire in the Lower Jiao. Commonly, when Ministerial Fire moves recklessly and Qi rebels without flowing smoothly, mild cases present as turbid strangury, while severe cases present with visible blood. The Classics say: "When heat from the Bao shifts to the Bladder, it results in strangury and hematuria." Treatment should focus on clearing and draining Bladder Fire. ○ Blood from the urinary meatus originating distantly comes from the Small Intestine. Symptoms include painless urination with blood mixed in urine, or hidden pain in the umbilical/abdominal region, or heat sensations in the viscera. Since the Small Intestine and Heart have an interior-exterior relationship, this is the source of Bing Fire's qi transformation and the division of clear and turbid substances. Regardless of mental exertion, fatigue, rich flavors, or alcohol, Fire from the Upper and Middle Jiao descending via the clear pathways must pass through the Small Intestine to reach the Bladder. Treatment requires examining the syndrome and cause to clear the root of Fire generation in the viscera. ○ Blood from the seminal meatus originates from the Essence Palace and Sea of Blood at the Mingmen. The Kidney governs Water and stores the essence of all Zang and Fu organs. Cases where Five Zang organs are injured by labor, or Fire generated by Five Emotions causes Chong and Ren vessels to disturb Blood, usually bleed from the seminal meatus. How to differentiate? If the disease is in the Small Intestine, blood exits from the urinary meatus; if the disease is at Mingmen, blood exits from the seminal meatus. Pain and soreness felt at the lower abdomen near the seminal emission point indicate a Mingmen pathology. The treatment method differs from water pathway disorders: blood from the water pathway should be promoted/drainaged, whereas blood from the seminal pathway should not be drained; painful obstruction should be drained, while slippery non-painful discharge should not be drained. (Zhang Jingyue)
Hematuria is mostly due to deficiency. Even with Fire, pain may occur, so it should be treated similarly to blood strangury. If clearing heat fails, investigate deficiency specifically: upper body issues relate primarily to Heart and Spleen, lower body to Liver and Kidney, and chronic cases involve the Eight Extraordinary Vessels. (*Linzheng Zhinan Yitan*)
Treatment methods for hematuria: Acute conditions with excess Fire require sweet-cold herbs to clear Fire; deficiency damage from sexual exhaustion requires nourishing Yin and tonifying Kidney; chronic conditions with central depletion require calming the Heart and restful cultivation to cure. (*Zhengzhi Huibu*)
Kidney Yin deficiency with heat accumulation in the Lower Jiao, causing blood to follow urine, is treated with Liuwei Dihuang Tang (Six-Ingredient Pill with Rehmannia) plus Niuxi (Achyranthes Root) to anchor Yang. ○ Chronic hematuria unresponsive to repeated clearing and draining medications responds well to Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Cheqianzi (Plantago Seed). (*Jianwen Lu*)
[Pulse Diagnosis]
In cases of hematuria with emaciation, a small and forceful pulse indicates an adverse prognosis; a rapid and surging pulse is also adverse. (*Zhizhun Zhunsheng*)
[Selected Cases]
I treated a patient with hematuria recurring every two to three years. After administering Buzhong Yiqi Tang added with Huangbai (Phellodendron Bark) and Shanzhi (Gardenia Fruit), the bleeding stopped after several doses. I also treated another patient whose urine contained blood clots; despite medication, he died. (Xu Xuanzhi)
My brother-in-law, Gu Yuanshu, suffered from hematuria with urinary pain, generalized numbness, dizziness, blurred vision, and cramping/soreness/numbness in the meridians of the hands and feet. His pulse was wiry, thin, and rapid, with firm pulses at both Chi positions. I prescribed Shengliao Liuwei Tang (Raw Ingredient Six-Ingredient Decoction) added with Niuxi (Achyranthes Root) and Dongchongxiacao (Ophiopogon Tuber). He responded immediately, but the condition recurred intermittently. Later, combining Liuwei Tang with Shengmai San (Generate the Pulse Powder), and using Heche (Placenta Hominis) boiled into a paste for pills, he recovered. ○ A merchant drank excessive distilled liquor in summer and developed hematuria. Yi Yuan San (Benefit Elemental Powder) and Liuwei Tang were ineffective. I used Daochi San (Direct Red Powder), and he was cured after three doses. ○ Song Xiaoxian, over seventy years old, had scanty, painful hematuria unresponsive to various medicines. He attributed it to celibacy starting too early in his youth. I instructed him to soak mung beans in water, crush them to extract juice, warm it slightly, and drink one bowl daily. He recovered; cooking the beans rendered them ineffective. (*Zhangshi Yitong*)