Clinical Experience of Dr. Guo Yaxiong, Chief Physician, in the Treatment of Pediatric Enuresis

: Based on many years of clinical experience, Dr. Guo Yaxiong, Chief Physician, believes that the basic pathogenesis of the disease is bladder disorder, which is located in the bladder and is closely related to the lung, spleen and kidney, and involves the heart and liver. Although the clinical evidence is mainly asthenia syndrome, also visible such as dampness and heat in the liver meridian and mixed evidence of deficiency and reality such as breakdown of the normal physiological coordination between the heart and the kidney can be seen. Treatment is based on open the inhibited lung-energy, strengthening the spleen and warming the kidneys, and at the same time, family care and psychological intervention should be paid attention to.


Introduction
Pediatric enuresis (NE) is a common pediatric condition in which children ≥5 years of age urinate involuntarily at least twice a week for more than 3 months, often urinating spontaneously during sleep [1]. It is commonly known as "bedwetting", and in Chinese medicine, it is known as "urinary loss", "incontinence" and so on. According to research, the prevalence of enuresis among children and adolescents aged 5 to 18 in China is 4.8% [2]. If left untreated, about 1%-2% of affected children will developlifelong enuresis [3]. Enuresis can be relieved with age and physical improvement, but the condition is recurrent and persistent, and children are prone to guilt, low selfesteem, anxiety, fear, depression and other negative emotions, or even withdrawal social behavior, which has a serious impact on the physical and mental health of the child [4]. In recent years, parents of children and pediatric clinicians are also paying more and more attention to this disease.
Dr. Guo Yaxiong, a chief physician, has been mainly engaged in clinical, teaching and scientific research work for more than 30 years, and was selected as ne of the "Third Batch of National Outstanding Clinical Talents in Chinese Medicine" in 2012. He has achieved remarkable clinical results in treating this disease. I have the honor to stuy with my mentor, Dr. Guo Yaxiong, and I have benefited greatly from his clinical experience ind the treatment of pediatric enuresis.

Etiology and pathogenesis
The pathogenesis of enuresis in children is unclear in modern medicine; nocturnal polyuria and abnormal vesicourethral function and abnormal arousal function are currently considered to be the main pathogenesis of NE. Mind and sleep abnormalities are still controversial and it is thought that these factors are likely to be a complication of NE [5]. There is a genetic predisposition. Treatment is based on basic therapy (educational encouragement, behavioral training), alarm therapy, and pharmacotherapy. Common medications are divided into three categories: ADH/AVP analogs, anticholinergics, and tricyclic antidepressants, but there are limitations in terms of adverse effects, the uncertain clinical efficacy of some medications and high family economic conditions for treatment [6]. Concomitant other disorders: if there are complications such as urinary tract infection, sleep dyspnea, and constipation [7], eliminating the causative factors may alleviate or cure NE. ICCS recommends basic therapy as first-line treatment, and interventions are based on behavioral training and lack effective treatment. Chinese medicine has a profound understanding of enuresis, with outstanding efficacy and a low recurrence rate in treating according to syndrome differentiation NE.
The Zang-fu Qi and Liquids of the Suwen [8] say that "The bladder does not restrain the urine and develops into enuresis", suggesting that the basic pathogenesis of NE is "The bladder is not constrained". Neijing Suwen [8] says: "Drinking into the stomach, overflowing essence, upward transmission to the spleen, spleen Qi dispersing essence, upward return to the lungs, through the water channel, downward transmission to the bladder. The lung controls respiration, and drops raw water to the bladder, the lung being the upper source of fluids, good at regulating the water channels and regulating the flow and distribution of water throughout the body. The lung is good at regulating the movement of water and fluid throughout the body. When the lung is in order, the upper source is cleared, the turbid fluid is transferred to the bladder, the waterway is controlled, and the bladder is contracted; in children, "asthenia susceptibility of the lung " and is easily attacked by external evil, the disorder of mother-organ involving its child-organ, resulting in kidney deficiency and lack of power to fix the urine, and the bladder is not opened and closed and urination occurs. In children, the spleen is often deficient and its function transportation is not yet complete. The spleen is in the middle-Jiao and the Gas goes up and down the hub. The kidney is the water organ, Water under the source, the main division and regulation of the water metabolism of the whole body, the kidney is the master of the closed collection, the division of the opening and closing, the kidney and the bladder, the kidney yang warming qi and the kidney qi fixed to control the opening and closing of the bladder, the bladder opening and closing in moderation, the urine out in moderation; children "kidney often hypoplasia", the kidney Qi is not fixed, the closed collection is out of order, the bladder is out of order, or at night the yin Qi is in full bloom, Yang Qi is weak, kidney Yang is weak, the bladder is not warm, the Qi is not able to control the watercourse, and the bladder is out of order, the water moves down, and urine comes out. Therefore, the lungs, spleen and kidneys play a key role in the production and excretion of urine. Children are infantile Yin and Yang bodies, the internal organs are delicate, the form of Qi is not yet full, and one organ is easily transmitted to other organs by evil. The liver is the master of draining and regulating Qi, which can help the spleen to transport and transform, the lungs to distribute, and the kidneys to gasify water and liquid. In children, "the liver being liable to excess ". If the liver is depressed and the Qi is stagnant, the function of draining is lost, and the pivot is unfavorable, then the function of regulating the Qi is out of order and the Qi stagnates and water stops. The liver meridian goes around the yin apparatus to the small abdomen, and if the emotions are not comfortable, the depression turns into fire and forces the bladder downward, or if the evil of damp-heat accumulates in the liver meridian, damp-heat injects downward and moves heat to the bladder and morbidity. The heart harbors the spirit, which governs all vital activities. The heart sends the ruling fire, and the kidney harbors the phaser fire. When the fire of the ruler crosses over, the mind is not in charge, the mind has no master, the night dreams are confused, the mind cannot wake up, the phase fire should be in the lower part of the body, and urine is lost. In conclusion, the basic pathogenesis of NE is loss of bladder contract, the location of the disease is in the bladder, and is closely related to the lung, spleen and kidney, involving the heart and liver. The disease is mostly seen with asthenia syndrome, or with actual evidence such as damp-heat in the liver meridian, or with the syndrome of intermingled deficiency and excesses such as breakdown of the normal physiological coordination between the heart and the kidney.

Case examples
Chen, female, 6 years and 4 months old, parents complained that the child still has nocturnal enuresis after the age of 5, about 1-2 times/night, occasionally bedwetting during lunch break, no urinary frequency and urgency, no abdominal pain, normal body temperature, obese body shape, easy to catch a cold, fatigue, cold hands and feet, sweating, deep sleep, not easy to wake up, sleepy and talk at night, eat less, no swelling and oliguria, yellow and clear urine, dry stool, about 1 time/2-3 days. Tongue moss is pale white, and the pulse is sunken and thin. Auxiliary examinations: Complete urinary ultrasound, blood and urine routine, urine culture, lumbosacral spine nuclear magnetic examination are normal. Diagnosis: Paediatric enuresis, type of evidence: (deficiency of lung, spleen and kidney). Treatment: Open the inhibited lung-energy, strengthen the spleen, warm the kidneys and stop enuresis.
Dr. Guo Yaxiong, the chief physician, has treatment according to syndrome differentiation NE with special emphasis on the lung, spleen and kidney, considering account the heart and liver. The lack of warmth in the hands and feet and coldness in the limbs suggest a deficiency of kidney yang, a deficiency of yang Qi, a decrease in the warming function and therefore a lack of spirit, a white face and cold limbs, and a weak pulse; a deficiency in the spleen and stomach, a loss of nourishment, a deficiency in the spleen's power to consolidate and regulate, a lack of transformation of water and dampness, a loss of the spleen's power to transport and transform, and a loss of regulation of the stomach's intake, resulting in poor appetite; In the first prescription, ootheca mantidis, semen amomi amari and fructus psoraleae warm the spleen and kidney, Stop the enuresis. often with the addition of black shun slice and dried ginger to Strengthen the effect of replenishing fire and helping Yang, the yam enters the lung, spleen and kidney meridians and can benefit the lung, strengthen the spleen and nourish the essence to consolidate the kidney. The function of the semen amomi amari and yam is to shrink the urine and stop the loss of urine, Yang deficiency for a long time even and kidney yin, Radix Rehmanniae Praeparata and fructus corni to strengthen the power of nourishing yin and fixing essence to shrink urine, yin in seeking yang, nourishing yin to supplement yang. Therefore, with Astragalus, ginseng, Atractylodes cocos ling to strengthen the spleen and remove dampness, benefit the Qi and solid astringency, the combination of all the drugs, together with the lung, spleen and kidney, fixing the sperm and shrink urine function, the complementary benefits of both the sealing nature. The lung and spleen deficiency, the method to supplement their deficiencies, dampness and only the spleen and stomach harmonize, the middle Jiao is healthy, so that the earth can be cultivated to produce gold, the lung can be propagated. The pungent and dispersing ephedra, dispersing cold and promoting the lung and water, belongs to the lung and bladder meridian, leading the medicine to the meridian, with the function of "lifting the pot and uncovering the lid"; Cistanches almonds, warm the yang and moisten the bowels, Calamus awakens the mind and enlightens the mind, fructus corni dredges the liver and regulates the Qi, raising the clear yang. Licorice harmonizes all the medicines. The second visit: The child's enuresis decreased significantly from before, about 3-4 times a week, the volume of urine, decreased from before, and he woke up easily at night to urinate. The rest of the symptoms are better than before, with normal food and stool, a red tongue, white fur, and a strong pulse. Identify as heart-kidney non-interaction, clear the heart fire, traffic heart-kidney. Keep the above plus Wu Mei, Scutellaria, black shun piece, dry ginger reduction, so that both water and fire, to achieve Wu Mei pills to regulate the meaning of cold and heat. Add polygala rooti to tranquilize and calm the mind, awaken the brain and open the orifice. The evidence of spleen deficiency is particularly present, the rest is the same as before, followed by 14 doses. The third time to visit: the child has occasional enuresis, but the remaining symptoms have significantly improved, and the heat evidence has disappeared. After the follow-up visit, the parents said that the child did not suffer from enuresis after stopping the medicine. We treat both the symptoms and the root cause by regulating the activities of Qi, dispersing cold and warming yang, and at the same time taking into account the symptoms by Convergence bitter, relieving depression and clearing heat so that the three organs can be regulated together, and the flow of fluid can be restored so that the disease can be cured by itself.

Summary
The long-term enuresis can seriously affect the physical and mental health of the child. Dr. Guo Yaxiong, the chief physician, has achieved good clinical results with the treatment of opening the inhibited lung energy, strengthening the spleen and warming the kidney. In addition, Dr. Guo emphasizes the need for parents to show more concern for their children and teach them patiently, and advise them not to play too much and too tired. This disease has a long course of treatment and is prone to recurrence. Do not scold the child to help them grow up healthily and avoid any abnormalities in mood or behavior. Chinese medicine has a great advantage in the treatment of pediatric enuresis, and it is worth promoting because it is effective, has few side effects and has a low recurrence rate.