A case of urinary difficulty

September 11, 2000

I've got a case I need some help with.

29 year old physical therapist, female.

1. Chief Complaint: urinary difficulty

4 years ago while she was abroad she got a bad uti that wasn't adequately treated. Several weeks later she came home and was treated for 1 more month on antibiotics before urinalysis showed the infection to be gone. Even though the infection was gone the symptoms peristed. She has been treated by a homeopath, another practitioner of Chinese medicine, biofeedback, and western medicine to no avail.

Her current symtoms, pretty much unchanged over the last 4 years are as follows: slowed stream which is worse after intercourse, in the morning, and when she feels stressed out; incomplete voiding; a stinging sensation in her urethra upon emptying her bladder which is relieved as her bladder fills; the same stinging sensation of and on throughout the morning; occasional cloudiness of the urine but no abnormal colors or odors; a burning sensation when she hasn't drunk enough fluids; needs to urinate very 2 hours; and severe urgency when she drinks too much. Any one of these symptoms will occasionally disappear for a day for no apparent reason.

2. Biomedical diagnosis: Her first urologist diagnosed her with interstitial cystitis even though her cystoscopies showed no inflammation. Her current urologist has diagnosed her with a urethral stricture which he has tried to treated with various drugs and multiple series of urethral dilations which have provided little relief. A Rimso procedure also provided no relied. The only med she is on now is Elmiron which helps to minimize the burning.

3.Relevant medical history: Diagnosis and successful treatment of chlymidia right after the uti was brought under control.

Car accident, 6 years ago, which she feels was the beginning of her overall health problems.

GB removed 3 years ago.

4. Questioning/A systems review

Digestion: reflux, burping, tiredness after eating, bowel movements 3x/day tending to be loose sometimes with foul odor

Ears, Nose and Throat: Occasional tinnitus. Nosebleeds of profuse bright red blood which were daily until she started using a saline nasal spray, now they only happen when she leans over for a long time or when she sneezes. She feels that her sinuses are dry. Also, hayfever in the autumn. Hoarse dry itchy throat in the morning probably from relfux. Small nodules on vocal cords which inhibits her singing. Constant phlegm in the throat.

Sleep: Nocturia 2-3x/week. Sleeps 7-8 hours/night.

Heart: mitral valve prolapse, palpitations with exercise

Musculoskeletal: Low back pain (since the car accident) worse from prolonged standing and fatigue. Paresthesias in toes in the morning. Bruxism.

GYN: 30-40 day cycle since menarche. 7 days of bleeding- moderate quantity, tend to run dark with medium sized clots. Mild/moderate groin pain on the 1st and 2nd days. PMS starts 1week before with breast tenderness, acne and moodiness. History of birth control pill use. Painful intercourse.

Lifestyle: Exercises 1 hour everyday-yoga, weights, running. Eats a spleen friendly diet.

General: runs cool, feet tend to be cold; considers herself "uptight"; is very active and finds that she can be restless

5. Pulse: thin and wiry in every position, all the time

General palpation: very tight paraspinals along the entire back; cold soft lower abdomen

6. Tongue: Dusky overall with a mildly red tip with irritated red swollen papilla in the very back. Slightly swollen. A thin central depression in the anterior 2/3rds including the tip. Coat is usually tofuy in the back and thin white otherwise with possible peeled pathches in the center or the back half. Sublingual veins are thin and dark.

General Observation: a short, thin, "fit" looking; pale face with pale malar flush

7.Patterns: Dampheat, and blood stasis in the lower jiao. Liver depression qi stagnation. K/Lung yin xu with vacuity heat. (K yang xu)

Treatment Principles:Clear heat and disinhibit dampness. Quicken the blood, transform stasis. Course the Liver and rectify the qi. Enrich the Kidneys and moisten the Lungs. Downbear heat. Disinhibit urination.

8.I've seen her 8 times. This is the most recent formula that I have given her; her formulas haven't changed much in the last 6 weeks or so because initially she seemed to be responding and I thought that it was a matter of time. But positive changes have become intermittent and she feels like she is back to square 1 urinary wise. However, her periods have been less painful, she has almost no clotting and almost no PMS, and her low back and jaw are feeling better.

I initially tried to put stronger damp disinhibiting herbs like zhu ling and hua shi but she started getting constipated so I opted for the likes of che qian zi and ze xie. She seemed to make progress when I added mu gua and zi cao individually to her formula.

I give the herbs in granules but dosages reflect what she would be getting if she were taking 1 packet of raw herbs over 2 days.

zi cao, 12

sheng di, 12

han lian cao, 12

huang bai, 12

yi yi ren, 12

che qian zi, 9

ze xie, 12

cang zhu, 9

niu xi, 15

tao ren, 9

bai shao, 12

gan cao, 8

xiang fu, 9

wu yao, 9

mu gua, 9

gui zhi, 6

bai zhu, 9

fu ling, 9

9. Other treatments: I have been performing acupuncture. She has started regularly doing castor oil packs on her lower abdomen in the last week.

How do you prioritize such a diagnosis when almost every aspect seems like it could be a major player in the chief complaint? I don't know what to do with the fact that she runs cool and has cold feet and a consistently cold lower abdomen when most of the other signs and symptoms seem to point to heat. I have gingerly put in some gui zhi. Should I be adding a yang tonic or 2? What do you all make of this case?

Thanks for your help.

Kristin Wisgirda, MTOM, Lic.Ac.