TCVM Research Update: The TCVM Approach to Chronic Urinary Tract Inflammation in Small Animals

DEFINING CHRONIC UTI

Biomedically, chronic UTI is defined here as a recurrent or persistent bacterial infection of the urinary bladder in the absence of neoplasia, urolithiasis, concurrent disease, and/or structural and functional abnormalities of the bladder. It can also include sterile inflammation of the urinary tract and absence of a documented bacterial infection. The clinical signs include dysuria, stranguria, pollakiuria, hematuria, pyuria, crystalluria, foul-smelling urine, urine dribbling and pain. Cystitis is the term used to describe bladder diseases that result in inflammation.

THE CHINESE MEDICINE APPROACH

In Chinese Medicine, a disease is not traced back to a single cause, but rather to a combination of body signs and symptoms that are carefully analysed to determine a pattern. The ability to recognize patterns of illness is fundamental to the practice of Chinese Medicine. Two animals may have the same disease according to Western medicine, but the pattern of signs and symptoms can be different in each individual, therefore requiring a different treatment strategy.

Chinese Medicine defines urinary tract infection as Lin Zheng (dysuria syndrome) and many patterns exist; the form described here is commonly referred to as Urinary Bladder Damp Heat. The primary pathogenic factor seen in chronic UTI is Damp Heat, which affects the lower Jiao and can be generated from multiple causes that include inappropriate diet, obesity, and underlying Zang-Fu organ dysfunction which facilitate exogenous pathogen (bacterial) invasion of the bladder.²

Multiple overlapping patterns are often responsible for the chronic nature of the disease, which will vary depending on the individual animal. The most common pattern seen in longstanding infections of the urinary bladder in the dog and cat is dual deficiency of the Kidney and Spleen. Chinese Medicine is often effective at treating and resolving chronic UTI because it can accurately identify the underlying patterns of disease responsible for its development and recurrence.

A Chinese medicine treatment plan may include the use of herbal medicine, acupuncture, food therapy, and conventional medications as needed for an integrative approach. Antibiotics are energetically cold and bitter and effectively clear Heat. However, chronic use of antibiotics easily injures the Spleen, causes Liver Qi stagnation, and negatively impacts the normal bacterial flora of the gastrointestinal and urinary tracts. Acute UTI often becomes chronic because residual Damp is not cleared and/or continues to be produced. The use of cold, bitter herbal medications should be undertaken carefully in weak patients. This is especially true if the animal is already on long-term antibiotic therapy and a prescription diet.

TCVM ETIOLOGY AND PATHOPHYSIOLOGY

Conventional Western medicine attributes acute and chronic urinary tract infection to invasion of bacteria in the urinary bladder. In acute uncomplicated UTI, a single course of antibiotics is usually sufficient to resolve the infection. However, because conventional treatment is unable to recognize other contributing disease factors responsible for the development of chronic UTI, it is typically restricted to chronic antibiotic therapy. Low dose chronic antibiotic therapy is often prescribed for the life of the animal, with an increased potential for the development of antimicrobial resistance and superinfection over time.

In Chinese medicine, chronic UTI is considered multifactorial in nature and develops from exogenous and endogenous causes. The basic pathophysiology revolves around the presence of Damp Heat. This can result from the invasion of exogenous Damp Heat pathogens (bacteria), or be generated internally from Zang Fu organ dysfunction. Damp Heat obstructs the normal Qi activity of the urinary bladder, resulting in stranguria, pollakiuria, pyuria, and pain. Damp Heat can transform into Fire and damage the blood vessels of the bladder, causing hematuria, and long-term Damp Heat can congeal into crystals and stones.

If the condition is not appropriately treated during the acute phase, it then becomes chronic. It should be noted that a documented bacterial infection is not necessary to make a diagnosis of Urinary Bladder Damp Heat; some animals exhibit classic signs of cystitis and have sterile urine on laboratory evaluation.

Chronic UTI typically develops from an underlying dysfunction of the internal organs in conjunction with bacterial infection, so a mixture of both excess and deficiency is typically seen at presentation. The recognition and appropriate treatment of these underlying patterns, in addition to the treatment of bacterial infection, is essential to prevent continued development or persistence of Damp Heat, and recurrence of the disease.

In TCVM, lower urinary tract diseases associated with cystitis can be divided into four common patterns:

• Damp Heat (Re-Lin and Stone Lin syndromes)
• Heat (Blood Lin Syndrome )
• Liver Qi Stagnation (Qi Lin Syndrome)
• Kidney Deficiency ( Lao Lin Syndrome)

These patterns commonly develop in animals that are pure-bred; have Kidney Jing deficiency; are old; have chronic illness; are overbed or given a species-inappropriate diet; are not regularly exercised (weakens the Spleen); are kept isolated for long periods (stress-induced); or are confined indoors or in conditions that necessitate holding their urine for prolonged periods. The process of normal urination flushes out ascending bacteria and debris within the urinary tract. Any situation that prevents regular micturition and the healthy flow of urine can weaken the kidney and bladder and facilitate the development of UTI.

Dampness and Heat are the two primary pathogens associated with cystitis. Liver Qi Stagnation and Kidney Deficiency are also important factors. These patients are often cats that are very stressed and irritated by different situations and have recurrent episodes of FIC during stressful times. Recent literature has described FIC as an imbalance in the neuroendocrine system, in which excitatory sympathetic nervous system outflow is not controlled by the cortisol. This results in increased permeability of the bladder wall.

We can summarise the TCVM treatment of the major patterns involved in lower urinary tract disease as described in the table below:

Chinese herbal medicine in combination with biomedical treatment of urolithiasis provide benefits of low-cost, non-invasiveness, and minimal side effects. The results of this study, encourage and support a larger randomised controlled study, that could provide evidence based support for this integrated treatment as a reliable alternative for patients with urolithiasis.³

CONCLUSION

Cystitis is a very common problem in clinical veterinary practice. A number of different patterns of imbalance can develop and lead to the clinical signs of cystitis.

Conventional medicine can be effective at quickly resolving the signs, but when cystitis becomes chronic and recurrent, TCVM can be used to effectively resolve these imbalances. In some cases, a combination of conventional medicine and TCVM is needed to resolve or control the condition.