STOOLS AND URINE

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Chapter 31

imageSTOOLS AND URINE

HOW WE ASK

When asking about urination and defecation it is important to be specific: asking “Are your bowels regular?” may elicit a positive response when the patient means that he or she evacuates the bowels once every 3 days regularly. Similarly, if we ask whether the urination is “frequent” (by which we mean “too frequent”) the patient might answer affirmatively when it is normal. We should therefore ask precisely how many times patients evacuate their bowels and how many times they urinate in a day (bearing in mind seasonal variations, as urination is generally less frequent in summertime).

As for urination, we should also bear in mind differences between men and women as women have a large bladder and need to urinate less frequently than men. An added difficulty in most Western countries is that many people force themselves to drink a lot of water in the mistaken belief that it flushes the kidneys; this means that the urination will be much more frequent than normal and that the colour of the urine will be paler, making diagnosing from urination more difficult.

STOOLS

Observation, Chapter 20; Hearing and Smelling, Chapter 54; Symptoms and Signs, Chapter 72

When asking about stools we should ask about the following aspects systematically:

The bowel movement is an important indicator of the state of the digestive system and specifically of the Large Intestine and Stomach. These two organs are connected within the Bright-Yang system and their pathology is often interconnected. For example, Heat in the Stomach is easily transmitted to the Large Intestine; Stomach-Qi failing to descend may cause constipation, etc. However, other organs also play a role in defecation and especially the Liver, which should assist defecation with its free flow of Qi, the Kidneys, which control the two lower Yin orifices (i.e. the urethra and anus), and the Spleen, which controls the transportation of Qi.

The normal bowel movement should occur at least once a day. The stools should be formed, and not too hard, not dry, and without excessive smell. Evacuation should be easy and effortless.

The Large Intestine, Small Intestine, Stomach, Spleen, Liver, Kidneys and Triple Burner all affect defecation.

Frequency

A normal bowel movement is once or twice a day. Any evacuation that occurs with less frequency than this constitutes constipation. A bowel movement (which may or may not be loose) occurring more than three times a day is considered to be too frequent.

Constipation is the most common disturbance of frequency of evacuation but its clinical significance cannot be separated from the consistency of the stools. Constipation indicates not only the infrequent passage of stools, but also excessive dryness of the stools or difficulty and straining in passing stools.

Acute constipation with thirst and yellow tongue coating indicates acute Heat in the Stomach and Intestines.

Chronic constipation in old people or women may be due to Blood or Kidney deficiency; in this case the stools would be slightly dry and there would be other signs of Blood or Kidney deficiency.

If the stools are bitty, small and difficult to pass, this indicates Liver-Qi stagnation or Heat in the Intestines (if they are also dry); when it is due to Liver-Qi stagnation, it often alternates with diarrhoea or loose stools as so often happens in irritable bowel syndrome.

Constipation with dry stools indicates Heat in the Large Intestine or Yin deficiency and Dryness of the Stomach, Intestines or Kidneys. If there is difficulty in evacuation but the stools are not dry, this indicates Liver-Qi stagnation.

Constipation with abdominal pain that is relieved by the bowel movement indicates retention of food or Dampness in the Intestines; constipation with abdominal pain and distension that is not relieved by the bowel movement indicates Liver-Qi stagnation. Constipation with abdominal pain and a pronounced feeling of cold indicates Cold in the Intestines.

Spleen-Qi deficiency normally causes loose stools but in a few cases a severe Spleen-Qi deficiency may cause constipation because the deficient Spleen-Qi fails to move and transport. Constipation may also be caused by a so-called “shut-down” of the Qi mechanism; this happens when there is an impairment of the ascending and descending of Qi in the digestive system, which may be seen, for example, after surgery.

Alternation of constipation and loose stools indicates stagnant Liver-Qi invading the Spleen.

If the stools are not loose but very frequent and the person cannot hold them easily, this indicates deficiency of the Central Qi, that is, the Qi of Stomach and Spleen; it also indicates sinking of Spleen-Qi.

Box 31.1 summarizes patterns underlying constipation and increased frequency.

BOX 31.1   CONSTIPATION

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