EFFECT OF ANANDA YOGA IN THE MANAGEMENT OF ...

EFFECT OF ANANDA YOGA IN THE MANAGEMENT OF MUTRASHMARI

By

NAVEEN BASAVARAJ SAJJAN

Dissertation Submitted to the

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA.

In partial fulfilment of the requirements for the degree of

AYURVEDA VACHASPATI (M.S. AYURVEDA)

In

SHALYA TANTRA

Under the guidance of

Dr. P. HEMANTHA KUMAR M.S. (Ayu) (IMS, BHU), Ph.D.

Professor and HOD

DEPARTMENT OF POST GRADUATE STUDIES IN SHALYA TANTRA

S.D.M. COLLEGE OF AYURVEDA AND HOSPITAL

HASSAN – 573201

2009

DDEEPPAARRTTMMEENNTT OOFF PPOOSSTT GGRRAADDUUAATTEE SSTTUUDDIIEESS IINN

SSHHAALLYYAA TTAANNTTRRAA

SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN – 573 201

(Affiliated to RGUHS, Bangalore, Karnataka)

CCeerrttiiffiiccaattee This is to certify that the thesis entitled “Effect of Ananda

Yoga in the management of Mutrashmari” is the record of research work

conducted by Naveen Basavaraj Sajjan under my direct supervision and

guidance as a partial fulfilment for the award of the degree of Ayurveda

Vachaspati (Master of Surgery) in Shalya Tantra.

The candidate has fulfilled all the requirement of ordinances

laid down in the prospectus of Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka for the award of Degree of Doctor of M.S (Ayurveda)

in Shalya Tantra.

We are fully satisfied with his work and recommend this thesis

to be submitted for adjudication.

Date: Place: Hassan

Guide Co Guide Dr. P. Hemantha Kumar Dr. Gopikrishna B.J. M.S. (Ayu) (IMS, BHU), Ph.D. M.S. (Ayu) Professor and HOD Asst. Professor P. G. Studies in Shalya Tantra P.G. Studies in Shalya Tantra S D M College of Ayurveda, S D M College of Ayurveda and Hospital. and Hospital. Hassan. 573 201 Hassan. 573 201

DDEEPPAARRTTMMEENNTT OOFF PPOOSSTT GGRRAADDUUAATTEE SSTTUUDDIIEESS IINN SSHHAALLYYAA TTAANNTTRRAA

SHRI DHARMASTHALA MANJUNATHESHWARA COLLEGE OF AYURVEDA AND HOSPITAL, HASSAN – 573 201

(Affiliated to RGUHS, Bangalore, Karnataka)

EENNDDOORRSSEEMMEENNTT BBYY TTHHEE HH OO DD ;; PPRRIINNCCIIPPAALL // HHEEAADD OOFF TTHHEE IINNSSTTIITTUUTTIIOONN

This is to certify that the dissertation entitled “Effect of

Ananda Yoga in the management of Mutrashmari” is a bonafide

research work done by Naveen Basavaraj Sajjan under the guidance

of Dr. P. Hemantha Kumar M.S. (Ayu) (IMS, BHU), Ph.D., Professor and HOD,

Department of Post Graduate Studies In Shalya Tantra, S.D.M.

College of Ayurveda and Hospital, Hassan - 573201.

Dr. P. Hemantha Kumar Dr. Prasanna N. Rao

M.S. (Ayu) (IMS, BHU) , Ph.D. M.S. (Ayu) (IMS, BHU) , Ph.D. Professor & HOD Principal P G Studies in Shalya Tantra, S D M College of Ayurveda S D M College of Ayurveda & Hospital. & Hospital. Hassan. Hassan.

RRAAJJIIVV GGAANNDDHHII UUNNIIVVEERRSSIITTYY OOFF HHEEAALLTTHH SSCCIIEENNCCEESS,,

BBAANNGGAALLOORREE,, KKAARRNNAATTAAKKAA

DDEECCLLAARRAATTIIOONN BBYY TTHHEE CCAANNDDIIDDAATTEE

I hereby declare that this dissertation / thesis entitled “Effect of

Ananda Yoga in the management of Mutrashmari” is a bonafide and

genuine research work carried out by me under the guidance of

Dr. P. Hemantha Kumar M.S. (Ayu) (IMS, BHU) Ph.D. Professor and HOD,

Department of Post Graduate Studies In Shalya Tantra, S. D. M. College

of Ayurveda and Hospital, Hassan – 573 201.

Date : Signature of the candidate

Place : Hassan Naveen Basavaraj Sajjan

CCOOPPYYRRIIGGHHTT

I hereby declare that the Rajiv Gandhi University of Health

Sciences, Karnataka shall have the rights to preserve, use and disseminate

this dissertation / thesis in print or electronic format for academic /

research purpose.

Date : Signature of the candidate Place : Hassan Naveen Basavaraj Sajjan

© Rajiv Gandhi University of Health Sciences, Karnataka.

AACCKKNNOOWWLLEEDDGGEEMMEENNTT I offer my prayers to Lord Vigneshwara, Shri Manjunatha Swamy for showering blessings

and empowering me to do this work without any impediments and enabled me to be what I

am today. It is because of God’s grace only the work could be completed as per my

expectations.

It is an inexplicable to offer my sincere & respectful regards to the persons whom I

admire the most, my beloved father Shri. Basavaraja G, mother Smt. Suvarnamma T.V

who’s Blessings, affection and inspiration reflected in me in the present position.

I pay my respectful salutation to his holiness Pujya Padmabhushana Dr. Shri D.

Veerendra Heggadeji, founder of this institution for his blessings, which made me complete

my thesis without hurdles.

It gives me immense pleasure to offer profound gratitude to my beloved Principal

Prof. Dr. Prasanna Narasimha Rao for all his guidance & co-operation in this work as

well as throughout. I remain indebted to him, who is the great source of inspiration for me,

for his parentally concern and constant encouragement.

I am extremely thankful to my guide and HOD Dr. P. Hemantha Kumar, Dept. of

P.G. studies in Shalya Tantra, S.D.M.C.A, Hassan and my co-guide Dr. Gopikrishna B.J.

Asst. Prof. and Consultant Surgeon. I will be ever grateful for there invaluable guidance,

support, Love & thought provoking ideas in every stage this work.

It is a great pleasure for me to express deep gratitude, to my highly respected and

revered preceptor Prof. Gurdip Singh who gave me Constructive suggestions, confidence,

guidance and cooperation in this work.

I extend heartfelt gratitude to my beloved teachers Dr. Avnish Patak,

Asst.Professor, Dr. Pravesh Mishra, Lecturer, Dr.Mahesh.E.S Lecturer Department of

P.G. Studies in Shalyatantra, for their care, affection and guidance.

I am very much thankful to Dr. Girish K.J and Dr. Prakash Hegade for their kind

support and providing materials and technical support to complete my thesis.

Words fall short to express my gratitude to my beloved Brother Basantha Kumar ,

Sister in law Vidya T.V, my sister Thriveni G. B. & Brother in law Girish Kumar

without whom; it would not have been possible for me to complete this work.

I am very much thankful to my seniors Ashok, Nataraj, Prasanna joshi, Pradeep

Shindhe, Pallavi hegade, Manoj Sinha, Mahesh, Tanuja, Pradeepa, my classmates Deepak,

Abhinandan, Abhjith, Vedavyas, Anitha, Sachin, Shivakumar, juniors Ramya, Praveen,

Sudarshan, Maheshwar, Varun, Brijesh, keertiprakash, Setukrishna, Pankaj & others for

their love, affection & co-operation in completion of my thesis work.

I am thankful to all my teachers, peer research scholars, non-teaching staff and

hospital staff for their affection, timely help and co-operation throughout my research.

The co-operation shown by my patients, the foundation bricks of this work is not

at all forgettable as they followed up throughout the work.

The memories filled with gratefulness will always linger in my heart forever about

all of them that have helped me either directly / indirectly in my research.

Dr. Naveen Basavaraj Sajjan

ABBREVIATIONS 1. A.San. - Astanga Sangraha

2. A.Hr. - Astanga Hridayam

3. Ayu. Sha. - Ayurveda Shareera Rachana

4. B.P. Pu. - Bhavaprakasha Purvarda

5. Chi. - Chikitsasthana

6. Cha. - Charaka samhita

7. D.G. - Dravya Guna

8. H.S - Harita Samhita

9. M.Ni. - Madhava Nidana

10. Ni - Nidanasthana

11. Sha. Pra. - Sharangadhara Prathama Khanda

12. Su. - Sushruta Samhita

13. Su (Dalhana) - Dalhana Tika on Sushruta Samhita

14. Sha - Shareera

15. Si. - Siddi Sthana

16. Ut. - Uttara Sthana

17. Vi. - Vimana Sthana

18. Y - Yavaksharadi Yoga

19. A - Ananda Yoga

20. Y.R. - Yogarathnakara

21. B.R - Bhaishajya Ratnavali

SYMBOLS USED

BT - Before treatment AT - After treatment P - Probability

S.D. - Standard deviation S.E. - Standard error

t - t test > - More than < - Less than % - Percentage

0,1,2,3 - Grades of severity

CONTENTS

Page No.

01. Introduction 01 -04

02. Review of Literature :

Review of Shareera Rachana and Kriya 05 - 13

Review of Anatomy and Physiology 14 - 29

Review of Mutrashmari 30 - 41

Review of Urolithiasis 42 - 59

Drug Review 60 - 76

03. Methodology 77 - 83

04. Observation 84 - 97

05. Results 98 - 107

06. Discussion 108 -117

08. Case Study 118 -123

07. Summary and Conclusion 124 -126

08. List of References 127 -131

09. Bibliography 132 -135

10. Annexure 136 -140

ABSTRACT

Background:

In current surgical practice we are facing problems in treating

Mutrashmari disease effectively even with all modernized facilities, and are

insufficient to reduce the prevalence of Mutrashmari and health care cost. In

Modern era it can be compared to Urolithiasis.

Objectives:

1. To evaluate the effect of “Ananda Yoga” in the management of

Mutrashmari”

2. To evaluate the effect of Ananda Yoga and Yavaksharadi Yoga in the

Management of Mutrashmari.

3. To evaluate the pH of Urine.

4. To see whether the drug is having Lithotripsic or Diuretic Action

Methods:

30 diagnosed cases of Mutrashmari are selected for study and recorded

through Proforma designed in to two groups of comparative study.

Results:

In this series of 30 patients of Ashmari, both Ananda Yoga provided

60% complete remission and Yavaksharadi Yoga provided 33.3% patients.

Further in Ananda Yoga, 13.33% patients remained unchanged while in

Yavaksharadi group 13.33% patients remained unchanged.

Interpretation:

The Ananda Yoga drug is having the property of Chedana, Bhedana,

Lekhana, Tridoshahara, Mutrala, Mutrakruchrahara, Anulomana, Krimigna

which helps significantly in Ashmari treatment.

Conclusion:

On the basis of the results of this study it can be concluded that Ananda

Yoga provided comparatively better relief to the patients of Ashmari

particularly in reduction of pain, haematuria, Mutradharasangha,

Bastigouravata, frequency of micturition and expulsion as well as descending

the stones. Therefore Ananda Yoga is better than control drug Yavaksharadi

Yoga in providing the relief to the patients of Mutrashmari.

Key words:

1. Mutrashmari 2. Urolithiasis 3. Ananda Yoga 4. Yavaksharadi Yoga

LIST OF THE TABLES

TABLE

NO. CONTENTS OF THE TABLES

PG.NO

1. Relations of the Kidney 16

2. Site of Re-absorption in Kidney 22

3. Showing Nidanas according to different Acharyas 32

4. Showing the Samprapti Ghataka 34

5. Shows the Urolithiasis precipitating foods 44

6 Showing on the basis of composition of Calculi 47

7. Showing Age-wise distribution 84

8. Showing sex-wise distribution 84

9 Showing Habitat-wise Distribution 85

10 Showing Occupation-wise Distribution 85

11 Showing distribution of patients as per Religion 86

12 Showing distribution of patients as per Socioeconomic status 86

13 Showing distribution of patients as per Habits 88

14 Showing distributions of patients as per Diet 88

15 Showing distribution of patients as per Family history 89

16 Showing distribution of patients as per Prakruthi 89

17 Showing distribution of patients as per presenting complaints 90

18 Showing distribution of patients as per Degree of pain abdomen 92

19 Showing distribution of patients as per Character of pain 92

20 Showing distribution of patients as per Associated symptom 93

21 Showing distribution of patients as per Side of the stone 93

22 Showing distribution of patients as per Bheda of Ashmari 94

23 Showing distribution of patients as per Site of the stone 94

24 Showing distribution of patients as per Size of the stone 96

25 Showing distribution of patients as per H/O Previous complaints 96

26 Showing distribution of patients as per PH of urine 97

27 Showing response pain abdomen- Group Y 98

28 Showing relief for the Burning micturition- GroupY 99

29 Showing relief for the haematuria- GroupY 99

30 Showing response on frequency of micturition- GroupY 99

31 Showing response on Mutradhaarasangha- Group Y 100

32 Showing response on Bastigouravata- Group Y 100

33 Showing response on number of stones- GroupY 101

34 Showing response Size of the calculi- GroupY 101

35 Showing response on Descent / Expulsion of calculi (on their site) – GroupY

101

36 Showing response pain abdomen- Group A 102

37 Showing relief for the Burning micturition- Group A 102

38 Showing relief for the haematuria- Group A 103

39 Showing response on frequency of micturition- Group A 103

40 Showing response on Mutradharasangha- Group A 104

41 Showing response on Bastigouravata- Group A 104

42 Showing response on number of stones- Group A 105

43 Showing response Size of the calculi- Group A 105

44 Showing response on Descent / Expulsion of calculi (on their site) - Group A

105

45 Overall effect of Yavaksharadi yoga Group 106

46 Overall effect of Ananda yoga Group 106

List of Figures

Sl.No Figures Pages

1 Anatomy of Urinary System 14

2 Types of Urinary Calculus 51

3 Ananda Yoga 75

4 Yavaksharadi Yoga 76

5 Case study 1 118

6 Case study 2 121

LIST OF THE GRAPHS

1 Showing Age-wise distribution 87

2 Showing sex-wise distribution 87

3 Showing Habitat-wise Distribution 87

4 Showing Occupation-wise Distribution 87

5 Showing distribution of patients as per Religion 87

6 Showing distribution of patients as per Socioeconomic status 87

7 Showing distribution of patients as per Habits 91

8 Showing distributions of patients as per Diet 91

9 Showing distribution of patients as per Family history 91

10 Showing distribution of patients as per Prakriti 91

11 Showing distribution of patients as per presenting complaints 91

12 Showing distribution of patients as per Degree of pain abdomen 95

13 Showing distribution of patients as per Character of pain 95

14 Showing distribution of patients as per Associated symptoms 95

15 Showing distribution of patients as per Side of the stone 95

16 Showing distribution of patients as per Ashmari Bheda 95

17 Showing distribution of patients as per Site of the stone 95

18 Showing distribution of patients as per Size of the stone 97

19 Showing distribution of patients as per H/O Previous complaints

97

20 Showing distribution of patients as per PH of urine 97

21 Overall effect of both the Groups 107

Introduction…

Effect of Ananda Yoga in the Management of Mutrashmari 1

INTRODUCTION

Ashmari comprises of two words, i.e. ‘Ashma’ and ‘Ari’. Where

Ashma means a stone and Ari means enemy. Ashmari is a disease in which

there is formation of stone, resulting into severe pain as given by enemy. Hence

it might have been considered as one among the ‘Ashtamahagada’. It occurs

commonly in the Mutravahasrotas and described its Nidana, Purvaroopa,

Roopa, Chikitsa (Oushadha and Shastra Karmas) and Upadravas.

The earliest reference of Ashmari with detailed description is available

only in Ayurvedic texts. Sushruta (800-1000 B.C.) has given elaborate

description of Ashmari in his treatise.

Among all the pains, abdominal pain will drag not only patient’s

attention but also the curiosity of the surgeon. Renal stones are one among the

cause for pain abdomen and it is estimated that each individual will have a

chance of 1% to suffer from Urolithiasis in their lifetime. It affects up to 5% of

the population. Males are more frequently affected than the females and their

ratio is 3:1. Hence, it is the need of the hour to understand the disease and to

find a best solution that not only treats the condition but also prevents the

disease at primary and secondary levels.

Urinary stones have afflicted human kind since antiquity with the

earliest recorded example being bladder and kidney stones detected in Egyptian

Mummies dated to 3500 B.C.

The word urolithiasis can be splitted as Uro-lithiasis, which means a

condition due to the stone in the urinary tract. The cause for the formation of

stone is due to the factors like concentrated urine, deficient of stone inhibitor

substance like mucopolysaccharides, citrate etc. However the role of heredity,

geographical condition, dietic factors have their key role to play.

Introduction…


The patient of this disease will have the symptoms like pain abdomen,

burning micturition, etc. and is confirmed by investigations like – USG and X-

ray (KUB) etc.

To manage the condition, the available effective procedures are removal

of stone by increasing the pressure of urine output or extracorporeal shock

wave lithotripsy or surgery (surgical intervention), while using analgesics, anti

spasmodic etc, and provide symptomatic relief.

However these therapies are curative treatment of Urolithiasis but

cannot avoid the pathogenesis behind the formation of stone. So recurrence of

stone even after removal is becoming a great problem and constant efforts are

being made to evolve an effective treatment as well as prevention of recurrence

of the disease.

In Ayurvedic classics, Mutrashmari having the symptoms of blood

stained urine, pain on micturition, excruciating pain over Nabhi and Vasti is

described, which goes in accordance with the symptoms of Urolithiasis.

Sushruta while dealing with the management mentions that prior of

undertaking surgery drugs such as Gritha, Kshara should be tried depending on

the intensity of the condition.

In Ayurveda numbers of drugs are mentioned to treat different types of

Ashmari. Among them the ‘Ananda Yoga, which is mentioned in Bhaishajya

Ratnavali is selected for the study. It contains Apamarga Panchanga, Tilanala

Panchanga, Palasha Kanda, Kadali Kanda and Amalaki Churna.

This compound drug is advised in Churna form to be taken along with

Gomutra Arka as Anupana. The drug is having Vedana Shamaka, Mutrala and

Ashmari Bhedhana actions.

Hence the clinical study was undertaken to evaluate the efficacy of

Ananda Yoga over the subjective and objective parameters of Ashmari.

Introduction…


This present dissertation is broadly divided under the headings of

1. Conceptual study

2. Clinical study

The conceptual study includes review of literature with respect to

Mutrashmari, Urolithiasis and Ananda Yoga.

In the chapter of disease review, various topics like Nirukti, Rachana

and Kriya of Mutravaha Srotas, Nidana Panchaka of Ashmari etc. of

Mutrashmari has been dealt with giving special important to its clinical

applicability. Simultaneously the importance has also been given to modern

literature and correlating wherever required.

In clinical study, the materials and methods had been explained along

with drug review and various parameters for selection and assessments.

In observation part, the results that are observed have been explained

with relevant tables, pictorial graphs and statistical parameters wherever

required.

In discussion chapter, interpretations are made on literary work and also

on various results.

At the end of this study some of the conclusions are drawn keeping in

view of results and discussion.

Objectives…


OBJECTIVES OF THE STUDY

Mutrashmari disease is a commonest burning problem, which is

increasing in today’s population. The disease is given prevalence by etiological

pathogenesis and its symptoms.

For any scientific trial, a proper design is required so as to assess the

efficacy of the therapy in term to meet the objectives. Here the drug “Ananda

Yoga” is selected keeping in view of each ingredient present in it. The main

objectives of the study are -

• To evaluate the effect of Ananda Yoga in the management of

Mutrashmari.

• Comparative study between Yavakharadi Yoga and Ananda Yoga

• To evaluate the pH of Urine.

• To see whether the drug is having Lithotripsic or Diuretic Action

Shareera Rachana and Kriya...


SHAREERA RACHANA OF MUTRAVAHA SROTAS

Scattered information regarding Urinary system is available while

dealing the diseases like Prameha, Mutrakruchra, Mutraghata and Ashmari.

Body is composed of Dosha, Dhatu, and Mala. These Malas are

produced as result of digestion and metabolism of food, and these should be

eliminated from the body through their respective channels among these Mutra

is one of the Drava Mala, for the production and excretion of Mutra specialized

system is present in our body that is called as “Mutravaha Srotas.”

As per the definition of Srotas (Sravanat Srotamsi) any tubular structure

which permits the liquid media for Sravana (mobility) is considered as a

Srotas. So these can be correlated to all the micro and macro structures

including the intercellular connectors. Thus on this view, with reference to

Mutravahana whatever tubular structures which come in formation secretion

and excretion can be termed as Mutravaha Srotas.

Mutravaha Srotas:

Acharya Sushruta describes the Mutravaha Srotas as a paired structure

with Basti and Medra as their Mula.1

Acharya Charaka and Vagbhata2 mentioned Basti and Vankshana as

their Mula.3

Mutravaha Srotas means the system, which is responsible for Utpatti

and Visarjana of Mutra. In Ayurvedic classics, there is no exact reference

regarding the detailed description of the Urinary system. Hence by taking the

help of contemporary science, anatomical description of Urinary system is co-

related with Mutravaha Srotas.

The structures related to Mutravaha Srotas are:

• Vrikka (Kidney)

• Gavini (Ureter)

• Mutravaha Dhamani, Sira and Nadi (Renal vessels)

• Basti and Bastisira (Bladder)

• Mutrapraseka (Urethra)



Vrikka:

Almost all the Samhitakaras have used the terms ‘Vukka’ and ‘Vrikka’

in the form of singular and plural.

Derivation:

Vukka and Vrikka terms are derived from the Dhatu ‘Vukkadanae’

which means ‘to take’ or ‘derive from’

The word Vrikka is derived from the Dhatu ‘Vrush Varshati’ which

literally means ‘to rain’.

Anatomy:

Charaka, Sushruta and Vagbhata have shown Vrikka’s relation to the

Medovaha Srotas as its Mula.4

Site:

They are classified under the Koshthanga and Pratyangas.5 All the

Acharyas has stated its position in the Koshta i.e. the trunk. The position of the

Vrikka in the either side of the Koshta is said to be the back part of the

abdomen (lumbar region).

Shape:

They are round in shape and composed of Mamsa.6

Number:

Vrikkas are two in number.

The words used by different Acharyas about Vrikka are

• The “Mutravaha Srotamsi” of Charaka,

• The “Sukshmamukha Sahasra” of Sushruta,7 And “Mutravaha

Nadis” of Vagbhata may have close proximity with the basic

units of the Kidneys i.e., the Nephrons.



Embryological Origin:

Vrikka are Matruja Avayava and derived from the Prasadabaga of

Raktha and Meda. 8 Sharangadhara described the function of the Vrikka as it

nourishes Jatharastha Meda. 9

Acharya Vagbhata while describing the Samprapti of various

Mutraghatarogas and Prameha mentions that, many Mutravaha Nadis through

their innumerable tiny opening fills the Basti. Sushruta also confirms the

existence of the Mutravaha Nadis with their innumerable and invisible

openings.10 The writers of 20th century like Dr. Ghanekar and Acharya

Gananathsen have identified Vrikka as the Kidneys.11

On the basis of above statements it can be concluded that Vrikka are two

round shaped bodies, composed of Rakta, Mamsa and Meda, situated in the

lumbar region on either side. This conclusion specifically points towards the

Kidneys only.

Therefore for the purpose of our study we will treat the term Vrikka as a

synonym for the Kidney.

Gavini:

In Atharvaveda, we find clear reference of Gavini as two Nalikas,

BASTI AND BASTISIRAS:

Synonyms:

Basti, Bastiputaka, Mutradhara, Bastisira, Bastisirasha, Bastibila,

Bastimukha and Bastidvara may be used as synonyms.12 The Bastisira and

Bastidvara are other terms used in connection with the Basti in various texts.

The term Basti Sheersha has been used as a synonym to the Bastisira. While

the terms Bastibila, Bastimukha and Bastidvara have been used as synonyms13.

These are not different organs but in fact they are different parts of the Basti

itself. Bastisira represents the upper end of the fundus of Bladder, while

Bastidvara indicates the lower opening i.e. the internal urethral orifice13.



Embryological Origin:

According to Charaka Basti is maternal contribution.14

According to Sushruta it is derived from the essence of Rakta and Kapha

supported by Pitta in which Vayu also enters.15

Number:

Acharyas have enumerated Basti under the Koshthanga and ‘Eka

Vachana’ has been used to indicate it as a single organ.16

Site:

According to Charaka, Basti is located between the Sthulaguda,

Mushkasevani, Shukravaha Nadis and Mutravaha Nadis17.

According to Sushruta Basti is surrounded by Nabhi, Prushta, Kati,

Mushka, Guda, Vankshana and Shepha. It is made up of thin skin (Tanu Twak)

having an opening, which is facing downwards.

Further, he elaborates that Basti, Bastisira, Paurushavrishana and Guda

all are interrelated and situated in the Pelvic cavity.18 Its position in females is

said to be nearer to Garbhashaya. Vagbhata states its location is inside the Kati.

According to Sharangadhara and Bhavamishra are little bit more specific

and mentioned that it is located below Pakvashaya.19

Shape:

According to Sushruta Basti is compared with the shape of the

‘Alaboo’.20 According to Vaghbhata its shape is Dhanurvakra i.e. bent like a

bow.

It is having one opening downwards21 and is composed of Alpa Mamsa

and Rakta21.

According to Adhamalla he compares the shape of Basti to ‘Charma

Khalwatvakar’ i.e. Bag of Leather.22

Acharya Gananathsen has given an elaborate description of the Rachana

Shareera of the Basti and considered it as Urinary Bladder with the help of

available recent knowledge.



Medra:

According to Dalhana the Medra (urethra) is the name of

“Mutrapraseka”. It takes its origin from the lower end of Bladder.

Mutravaha Nadi, Dhamani and Sira:

The term’s Nadi, Dhamani and Sira have not been used specifically in

Ayurvedic literature. The same term at different places conveys different

meaning.

Mutravaha Nadi:

Acharya Sushruta states that as many rivers unite to fill the ocean, in the

same way Basti is filled with Mutra through many Nadi’s, which are present in

Pakvashaya.23

Vagbhata, states that; Mutra through thousands of openings in the

Mutravaha Nadis continuously fills up the Basti.24

Charaka describes the location of Basti between the structures -

Sthulaguda, Sevani, Mushka, Shukravaha Nadis and Mutravaha Nadi’s.25

Mutravaha Dhamani:

Acharya Sushruta in his description of the Adhogami Dhamanis, which

carries Vata, Mutra, Purisha, Shukra, Artava etc. downwards.26

Acharya Vagbhata is of same opinion and adds that (All the ten)

Adhogami Dhamanis divide in the Pakvashaya into three branches, out of these

two are concerned with transportation of Mutra.27

Bhavamishra also express similar view but according to him, they are

responsible for the Dharana and Chalana of Mutra.28

According to Dalhana there are two main Mutravaha Dhamanis, which

are divided into innumerable branches29 and finally goes to Basti.



Mutravaha Sira:

Bhavamishra states that the ‘Jala Bhaga’ of the Drava Mala is

transported by Siras from the Grahani to the Basti. Here it is converted into

Mutra.30 .

Sharangadhara opines that the watery portion of the Mala of the digested

food is carried to the Basti by the Siras and then it is called as the ‘Mutra’. 31

With above references few conclusions can be drawn as -

• The direct relation between the Pakvashaya and Basti through Mutravaha

Nadi’s, Dhamanis and Sira’s depends largely on assumptions.

• Charaka’s description of Mutravaha Nadi’s seems to indicate the Gavini.

Sushruta and Vagbhata while using the same term seem to indicate the

Glomerular capillaries especially in the light of Dalhana’s description.

• Sushruta and Vagbhata while describing the Mutravaha Dhamanis must be

pointing towards the renal arteries, which are two in number. These carry

the essentials for the formation of Mutra to the Kidneys.

• The Mutravaha Siras as described by Bhavamishra and Sharangadhara

might be pointing to the blood vessels carrying the essentials for the

formation of Mutra.



SHAREERA KRIYA OF MUTRAVAHA SROTAS

Various Acharyas have described the concept of urine formation in

different ways. They consider the Mutra as a Mala, which is absorbed in the

Pakvashaya.

Sushruta’s Concept:

About urine formation the Mutravaha Nadis related to Pakvashaya

constantly replenish the Basti, like river carries water from different regions to

ocean. These Nadi’s divides into innumerable branches and are not visible. The

Mutra drained from interiors of Amashaya and Pakvashaya enters Basti both in

wakening and even in state of sleep. It is a continuous process like a new pot

immersed up to its neck in water, gets filled by water through its lateral pores32.

According to Acharya Sushruta the Pachakapitta residing between

Amashaya and Pakvashaya is responsible for the digestion of four kinds of

food and separation of the Rasa, Mutra and Pureesha33.

Dalhana’s Concept:

While elaborating the function of Adhogami Dhamani, says that they go

to Pittashaya and separates Mutra, Purisha and Sweda from the digested part of

food34.

Bhavamishra and Sharangadhara Concept:

The ‘Sarabhaga’ of digested food is known as the ‘Rasa’ and the

‘Sararahitha bhaga’ (liquid) that goes to Basti is called ‘Dravamala’.

The Mutra Nirmana Prakriya is completed in three stages:

1. The Drava Mala Avastha

2. Sakleda Avastha

3. Mutra Avastha



1. Drava Mala Avastha:

This is an initial stage. The Prasada Rahitha Dravamsha absorbed in the

Pakvashaya after the digestion of the food is known as the ‘Drava Mala’35.

Acharya Dalhana’s views are very important in this context. According

to him the process of Digestion of the food, which takes place in 3 phases is

denoted as Amavasta, Pachyamanavasta and Pakvavasta. In the third stage, the

digested food gets assimilated and undigested food material bifurcates into

Ghanabaga and Udakabhaga. This Udakabhaga is nothing but Upadana of

Mutra.

According to Sushruta the Pakvashaya does the absorption of Dravamsha

from Ahara Kitta with the help of Vayu. Thus the first stage of Mutra Nirmana

Prakriya is completed here i.e. absorption of Mutra Upadana i.e. Dravamala.

This also establishes that Pakvashaya is indirectly related to the Mutra

formation.36

2. Sakleda Avastha:

The Dravamala absorbed from the Pakvashaya is circulated through out

the body along with Saara Rasa. They perform the functions of Poshana,

Tarpana and Vardhana of various Dhatus and Malas.

The Kriyas of Abhivahana, Pachana, Grahana and Visarjana are

performed in all the Srotamsi. According to the quotation ‘Paripakvashaya

Dhatvaha Mala’ the Paripakva Dhatus are converted into the Malas. These

Malas are again brought back in to the Siras from the Srotas and circulated in

the body.

The Drava Dravya which contains the Drava Mala and Dhatu Mala

formed by Pachana Kriya in various Srotas is in dissolved form and is known

as the Kleda. As the Malas are dissolved in Kleda in this Avastha, it is known

as the Sakleda Avastha. The circulating fluid from which the Mutra is formed

is said to be of 10 Anjali.



3. Mutra Avastha:

The Upadana Bhuta Dravya in the Dravamala remains in this Avastha

till the Vivechana Karma is done by the Vrikkas.

After the Kriyas of Vivechana, Munchana, etc. the separated part is

termed as the Mutra. This is the third stage or the Mutra Avastha. Although this

stage is not very well described in ancient texts, Acharya Gananathsen has

elaborated it very clearly.

Hemadri the commentator of Ashtangahridaya quotes on “Mutrasya

Kleda Vahanam”, according to him ‘Kleda Vahanam’ means Kledasya

Bahirgamanam (Kleda is excretory part of Sakleda Drava Dravya). Thus the

Mala brought to the Vrikkas by the Vrikkiya Dhamanis is excreted out of the

body. This Kriya along with the Vivechana is performed in the Mutra

Nirmapaka Yantra.

So the Mutra Nirmapaka Yantras can be treated as the basic functional

units of the Vrikkas37.

Thus it can be stated that Vivechana of Drava Dravya in the Sakleda

Avastha takes place in Mutra Nirmapaka Yantra.

Anatomy and Physiology...


ANATOMY AND PHYSIOLOGY OF ‘URINARY SYSTEM 38, 39, 40

The urinary organs are two kidneys, urinary bladder, ureters & urethra -

kidneys producing urine, two ureters conveying it to the bladder for temporary

storage and the urethra by which the bladder empties. The female urethra is

purely in function while the male one carries out both urinary as well as

reproductive functions.

KIDNEY

Introduction

The kidneys excrete the final products of metabolic activities and excess

water. Both of these actions are essential for the control of concentration of

various substances in the body fluids e.g. maintaining electrolyte and water

balance approximately constant in tissue fluids.

They also have endocrine functions, producing and releasing

erythropoietin, which affects blood formation, renin that influences blood

pressure, hydroxycholecalciferol involved in the control of calcium metabolism

and a derivative of Vitamin D.

Anatomy

Kidneys are reddish brown in colour.

And bean shaped, they are situated posterior

behind the peritoneum on each side of vertebral

column surrounded by adipose tissue.

Fig - 1



Site:

Superiorly the upper borders of 12th thoracic vertebra and inferiorly with

the 3rd lumbar vertebra. The right kidney is slightly inferior, due to liver on this

side. The left kidney is little longer and narrower and lies nearer to the median

plane.

Size:

Each kidney is about 11 cms in length, 6 cms in breadth and 3 cms in

Antero-posterior dimension.

Weight:

Adult male – 150gms

Adult female – 135gms.

Parts:

The kidney has two surfaces, two borders and two poles

The ventral surface of each kidney is convex and faces anterior and

slightly lateral.

The dorsal surface of each kidney is directed posterior and medial.

The lateral border is convex and directed towards the posterio-lateral

wall of the abdomen.

The medial border is concave in the center and convex towards their

extremity. Its center part has a deep longitudinal fissure named as hilum which

transmits the vessels, nerves and ureter.



Relations:

Common to both kidneys:

a) The upper pole of each kidney is related to suprarenal gland.

b) Posterior relations

The diaphragm, medial and lateral arcuate ligaments, psoas

major, quadratus lumborum, transverse abdominis, sub costal vessels

and sub costal, iliohypogastric and ilioinguinal nerves.

Other relations of the kidney:

Table-1

Relations of Kidneys

Right Kidney Left Kidney

Anterior Relations:

• Right suprarenal gland

• Liver

• Second part of duodenum

• Hepatic flexure of colon

• Small intestine

• Left supra renal gland

• Spleen

• Stomach

• Pancreas

• Splenic vessels

• Splenic flexure & descending

colon

• Jejunum

Lateral relations:

• Right lobe of liver

• Hepatic flexure of colon

• Spleen

• Descending colon



General renal structure:

Renal Fascia:

The kidney and adipose capsule together are enclosed in a specialized

lamination of the sub serous fascia, called the renal fascia.

Fixation of the Kidney:

The kidneys are rigidly fixed to the abdominal wall, and they are held in

position by the renal fascia, large renal arteries and veins.

The cortex and renal pyramids constitute the parenchyma of the kidney.

It is the functional portion of the kidney. Structurally parenchyma consists of

about one million microscopic units called Nephrons.

Renal Histology:

The Kidney is composed of many torturous closely packed uriniferous

tubules bound by a little connective tissue in which the blood vessels, in

lymphatics and nerves.

Each tubule consists of two distinct parts

• Nephrons

• Collecting tubules

Nephron:

These are functional and structural units of the kidney. They filter blood

by allowing certain selected substances to pass into kidneys. As the filtered

liquid moves through the Nephrons, certain wastes and excess substances are

added to it and certain useful substances are removed from it as a result urine is

formed.

Essentially it consists of two portions

• Renal tubule

• Glomerulus (tuft of capillaries)



The renal tubule begins as a double walled epithelial cup known as

‘Bowman’s capsule’ lying in the cortex of the kidney and surrounded by renal

capsule.

The visceral layer of the Glomerular capsule and the endothelium of the

Glomerulus form an endothelial capsular membrane.

It consists of following parts.

• Endothelium of the Glomerulus.

• Basement membrane of Glomerulus.

• Epithelium of visceral layer of Bowman’s capsule.

The endothelial capsular membrane filters water and small solutes from

blood plasma. Large molecules such as proteins do not pass through it.

The water and solutes that are filtered out of blood pass into capsular

space between the visceral and parietal layers of the Bowman’s capsule and

into the renal tubule.

Renal Tubule:

It consists:

• Bowman’s capsule

• Proximal convoluted tubule

• Descending limb of loop of Henle

• The ‘U’ turn

• Ascending limb of loop of Henle

• Distal convoluted tubule

• Connecting tubule

• Collecting duct

The Glomerular capsule opens into the first section of renal tubule called

the proximal convoluted tubule, which also lies in the cortex. Its walls consist

of cuboidal epithelium with microvilli. These increase the surface area same as

in the intestines for re-absorption and secretion.



Juxtaglomerular Apparatus:

The smooth muscle fibers of the tunica media, adjacent to the afferent

arteriole are modified in several ways. Their nuclei are round instead of long,

and their cytoplasm contains granules instead of myofibrils. Such modified

muscle fibers are called ‘Juxtaglomerular cells’. The cells of the distal

convoluted tubule adjacent to the afferent and efferent arterioles are

considerably narrower and taller than the other cells. Collectively these cells

are known as ‘macula densa’. Together with the modified cells of the afferent

arteriole, they constitute ‘Juxtaglomerular apparatus’, which help in regulating

the renal blood pressure.

Arterial supply:

The right and left renal arteries transport about ¼ or 26% of the cardiac

output to the kidney approximately 1200 ml of blood passes through the kidney

every minute.

Before or immediately after entering hilum the renal artery divides into a

large anterior branch and a small posterior branch from these branches five

segmental arteries originate, each supplying a particular segment of kidneys.

Each segmental artery divides into several branches that enter parenchyma,

they are called as inter lobar arteries. Inter lobar arteries that arch between

medulla and cortex is called as arcuate arteries. These further divide to form

interlobular arteries and afferent arteriole.

Venous supply:

The peritubular capillaries re-unite to form peritubular venules and then

inter lobular veins. The bloods then drains through arcuate veins to interlobular

veins running between the pyramid and then the segmental veins and leave the

kidney through a single renal vein that exists at the hilus.

Nerve supply:

The nerve supply to kidney is derived form the renal plexus of the

sympathetic division of autonomous nervous system. Nerve from the plexus



accompanies the renal arteries and their branched ends are distributed to the

vessels. As nerves are vasomotor they regulate the circulation of blood in

kidney by regulating the diameter of arterioles.

Physiology:

The metabolism of nutrients results in production of wastes by body

cells, such as carbondioxide, water and heat. The protein catabolism produces

toxic nitrogenous wastes such as ammonia and much less toxic urea. In

addition many of the essential ions such as sodium, chloride, sulphate,

phosphate and the hydrogen ion tend to accumulate in the access of the body’s

needs. The basic work of kidneys is done by the nephrons, the other parts are

primary passage ways and storage areas.

Functions of kidney:

• It excretes various nitrogenous waste products, especially sulphur (end

products of protein metabolism)

• It helps to maintain the normal hydrogen-ion concentration of body fluids and

electrolytes.

• It helps to maintain water balance of the body ( by plasma volume)

• It helps to maintain the optimum concentration of certain constituents of blood.

• It eliminates various drugs and toxic substances from the body.

• It manufactures certain new substances – Ammonia, Hippuricacid & inorganic

phosphates. (Ammonia helps in preserving acid-base equilibrium)

• It helps in maintaining osmotic pressure in blood & tissue.

• It helps in regulation of blood pressure.

• It helps in regulation of erythropoiesis through the formation of erythropoietin.

• 10. They play an important role in Vitamin D metabolism.



Formation of urine: The formation of urine takes place under three processes

They are as follows:

• Filtration – At the Glomerular level

• Selective reabsorption – Along the renal tubule

• Secretions – By cells of tubules into this filtrate

Glomerular filtration:

It is passage of water containing various dissolved small molecules from

blood to urinary space in Bowman’s capsule. Large molecules such as plasma,

protein, polysaccharides and lipids are largely retained in blood through

selective permeability of Glomerular basement membrane.

Selective reabsorption:

The tubular cells of kidney selectively reabsorb the substances present

in the Glomerular filtrate, according to the needs of the body. Hence, the

tubular reabsorption is called as the selective reabsorption.

When the Glomerular filtrate passes through the tubular portion of

nephron, both quantitative and qualitative changes occur.

The tubular epithelial cells reabsorb large quantity of water (more than

99%), electrolytes and other substances. The substances, which are reabsorbed,

pass into the interstitial fluid of renal medulla and from here the substances

move into the blood through peritubular capillaries. As the substances are taken

back into the blood, this entire process is tubular reabsorption.

The mechanisms involved in the tubular reabsorption are of two types

• Active reabsorption

• Passive reabsorption

Active reabsorption:

Active reabsorption is the movement of molecules against the

electrochemical gradient. This needs liberation of energy (ATP).



Passive reabsorption:

In this process, the molecules move along the electrochemical gradient.

This process does not need energy.

Site of reabsorption

Table-2

Site of Re-absorptions in Kidney

Proximal convoluted tubule Henle’s loop

Distal convoluted tubule

Active

Glucose, calcium, sodium, potassium, Aminoacids, Phosphates, Uric acids, Bicarbonates

Sodium

Bicarbonates, Sodium

Passive Water & Urea Chloride Water

Tubular Secretion:

Although selective reabsorption is main function of renal tubules, also

secrete some substances. Tubular secretion is an active process carried out by

the tubular epithelial cells. Various ethereal sulphates, steroids and other

glucoronides, 5-hydroxyindole acetic acid, which are normally produced in the

body, are secreted by the tubules. Certain substances like diphenol red, diodrast

(diodone),

Paraaminohippuric acid, penicillin, potassium, amino derivatives and hydrogen

ions etc., are also secreted by the tubules.

Thus by the process of Glomerular filtration, selective reabsorption and

tubular secretion, urine is formed in the nephron.

Counter current mechanism and ADH also concentrate it. Finally it

passes through ureter into the urinary bladder and is stored there until it is

voided out.



Concentration of Urine:

The formation of dilute or concentrated urine depends upon two factors

• Medullary gradient

• ADH mechanism

Medullary Gradient:

This is developed by the three factors

• Reabsorption of sodium from ascending segment into medullary interstitium

• Reabsorption of sodium from collecting duct into medullary interstitium

• Diffusion of urea from the collecting duct into medullary interstitium.

ADH mechanism:

Anti diuretic hormone combines with V2 receptors in the tubular

epithelium and activates adenyl cyclase to produce cyclic AMP. This cyclic

AMP increases the permeability of the tubules for water.

Mechanism of urine concentration:

When the Glomerular filtrate passes through renal tubule, its osmolarity

is altered in different segments.

Bowman’s capsule: It has the same osmolarity (300 milli osmoles/litre) of

plasma as it contains all substances of plasma except proteins.

Proximal convoluted tubule:

When the filtrate passes through proximal convoluted tubule there is

active reabsorption of sodium and chloride followed by reabsorption of water.

So the osmolarity of fluid remains the same.

Descending segment:

When the fluid passes from proximal convoluted tubule into the thick

descending segments, by the process of osmosis, water gets reabsorbed into

outer medullary interstitium. So the fluid inside the segment becomes slightly

hypertonic and the osmolarity is 450-600 milli osmoles/litre.



Descending segment of Henle’s loop:

This segment is so permeable to water hence more water is reabsorbed.

So in the short loops of cortical nephrons, the osmolarity at the hairpin bend of

the loop becomes 600milli osmoles/litre and in the long loops of

juxtamedullary nephrons, at the hairpin bend, the osmolarity is 1200 milli

osmoles/litre.

Thin Ascending Segment of Henle’s Loop:

When the ascending segment of Henle’s loop ascends upwards through

the medullary region, osmolarity is gradually decreases to 400 milli

osmoles/litre, due to concentration gradient.

Thick Ascending Segment of Henle’s Loop:

This segment is impermeable to water. But there is active reabsorption

of sodium and chloride from this reabsorption, osmolarity of fluid decreases

between 150 to 200 milli osmoles/litre.

Distal Convoluted Tubule and Collecting Duct:

These two segments are totally impermeable to water but permeable to

solutes, so sodium and chlorides are reabsorbed. Therefore at the end of distal

convoluted tubule the osmolarity is 100 milli osmoles/litre. The osmolarity of

urine leaving collecting duct is as low as 60 milli osmoles/litre. In this way

diluted urine is formed.



URETER

Anatomy

Once urine is formed by the nephrons and drains into

Collecting ducts

Papillary ducts

Calyces

Renal pelvis

Ureters

This is carried by peristalsis in the urinary bladder.

Structure: The body has two ureters each is an extension of the pelvis of

kidney. It passes downwards behind the peritoneum and then medially and

forwards below the peritoneum to enter the bladder at the superior lateral angle

of its base as ureters descend their thick walls increase in diameter but at their

widest point they measure less than 1.7 cm.Three coats, which forms the walls

of the Ureter are –

1. The inner coat or mucosa:

Mucous secreted by mucosa prevents cells from contact of urine.

2. The middle coat or muscularis:

It is composed of inner longitudinal and outer circular layers of smooth

muscles. At proximal end some longitudinal fibers are also present on outer

side. Peristalsis is the main function of muscularis.



3. The external or fibrous coat:

Extensions of fibrous coat anchor ureter in place.

Blood supply:

The arteries supplying the ureter are branches of renal, testicular,

internal iliac & inferior vesical arteries

Nerve supply:

The sympathetic nerves are derived from T10 to L1 and parasympathetic

by S2 to S4 nerves, they reach the ureter through the renal, aortic and

hypogastric plexus.

Physiology

The principal function of ureter is to carry urine from renal pelvis to

bladder. Peristaltic movements primarily carry it, but hydrostatic pressure and

gravity also contribute. Rate of peristaltic wave from kidney to Ureter is about

1-5/mm depending upon amount of urine formed.

URINARY BLADDER

Urinary bladder is a muscular membranous sac that acts as reservoir for

the urine. Its size, position and relation vary according to the amount of fluid it

contains (normal bladder capacity 300 to 500 ml). The position of the bladder

varies with the condition of the rectum, being pushed upward and forward

when the rectum is distended.

Interior of the bladder:

In an empty bladder, the greater part of the mucosa shows irregular folds

due to its loose attachment to the muscular coat. Small triangular area over the

lower part of the base of the bladder is termed as “trigone” of the bladder.

Structure:

The bladder is composed of four coats - serous, muscular, submucous and

mucous.



Serous coat: Formed by peritoneum covers only superior surface.

Muscular coat: Consists of three layers of smooth muscular fibers, an external

layer, middle layer and an internal layer. External layer is named as detrusor

urinae muscle.

Submucous coat: is formed of dense connective tissue and joins mucosa to

muscularis.

Mucous coat: it contains transitional epithelium, which can stretch while

bladder is filled.

Blood supply:

The arteries supplying the bladder are the superior, middle and inferior

vesicle arteries, derived from internal ileac artery and in females, uterine and

vaginal arteries.

The veins form a complicated plexus on the inferior surface and fundus

near the prostate; they end in the internal iliac vein.

Lymphatic drainage:

Most of the lymphatics terminate in the external iliac nodes. Few

vessels may pass to the internal iliac or to the lateral aortic nodes.

Nerve supply:

The nerves of the bladder are

Fine medullated fibers from the third and fourth sacral nerves

Non-medullated fibers from the hypogastric plexus.

Physiology

Urine is expelled from urinary bladder by an act called micturition. This

response is brought by combination of voluntary and involuntary nerve

impulses. Average capacity of the bladder is 300 to 500 ml. When the amount

of urine exceeds 200 – 400 ml, bladder wall transmits impulse to lower portion

of spinal cord. This causes desire to pass urine.



Parasympathetic impulse from spinal cord to bladder and internal

sphincter causes contraction of detrusor muscle and relaxation of sphincter,

thus urination takes place.

Although emptying of the bladder is controlled by reflex, it may be

initiated voluntarily and stopped at will, because of cerebral control of external

sphincters.

URETHRA

The urethra is a small tube extending from the internal urethral orifice in

the urinary bladder to the external urethral orifice.

In females, it lies directly posterior to the symphysis pubis and is

embedded in the anterior wall of vagina. The external urethral orifice lies

between clitoris and vaginal opening. Its diameter is about 6mm and length

approximately 3.8 cm.

In males, urethra measures 18-20 cm in length immediately below the

urinary bladder.

Structure:

The urethra is composed of three layers in females.

• Mucosa – continues externally with that of vulva.

• Spongy layer – contains plexus of veins.

• Muscular layer – continues with that of bladder and consists

of circular fibers of smooth muscles.

Male urethra consists of two layers

• Inner mucosa – continues with that of bladder.

• Outer submucosa – connects urethra to structures through which

it passes.



Blood supply & Nerve supply:

Females –

Arteries are derived from the inferior vesicle and internal pudendal

arteries. Veins drain into the vesicle and vaginal veins. Nerves are from the

pelvic and pudendal nerve.

Males –

The urethral artery a branch of internal pudendal artery in the perineum

supplies the membranous and penile urethra. Veins of the urethra and corpus

spongiosum drain into the deep vein of the penis and pudendal plexus.

Physiology

It serves as a pass way for discharging urine from the body. Male

urethra also serves as a duct, through which reproductive fluid is discharged

from the body.

Mutrashmari Review….


MUTRASHMARI

Historical Review

Vedic period:

We find very few references regarding Ashmari in Rigveda and

Yajurveda, the oldest literatures available (Rigveda-10-163-3, Y Veda-19-85).

But in Atharvaveda we find references regarding Ashmari in relation with

Mutravarodha (AV/Pr Khanda / Pr Anuvaka / Pr Sukta / 1-9).

The documentation about Ashmari Roga can be found in Atharvaveda

1/3/6, 7, 8, 9.

Samhita Period:

Detailed description regarding etio-pathogenisis, classification, clinical

features, prognosis and treatment are found in several classical texts viz.,

Sushruta Samhita, Charaka Samhita and Ashtanga Hridaya etc. Bhela and

Harita have also devoted separate chapter for Ashmari, where Harita says

Ashmari may be hereditary.

Most of the other texts such as Sharangadhara Samhita, Yogaratnakara,

Chakradatta, Madhavanidana, Gadanigraha, and Bhavaprakasha have also

explained details of Ashmari.

Anthropologic history provides evidence that urinary stone disease

existed as long as 7000 years ago and perhaps more.

Riches (1968) refer to that formation of stone in the pelvis (bladder) of

an Egyptian skeleton estimated to be 7000 years old.

Urinary System: The scattered information regarding urinary system is

available in Sushruta which has been mentioned while dealing the diseases like

Prameha, Mutrakruchra, Mutraghatha & Ashmari. The diseases pertaining to

this system have been classified as Mutra Apravruti and Mutra Atipravruti

Vyadhis.



Ashmari as a Maharoga:41

The Maharogas are difficult to cure due to their Ashraya in Marma

Sthana, involvement of Bahu Dosha etc. They are 8 in number and are

explained in all Brihatrayees. Sushruta and Vagbhata considered Ashmari

under Mahagada. They are Vatavyadhi, Prameha, Kusta, Arsha, Bhagandara,

Ashmari, Mudagarbha and Udara Roga.

Ashmari is considered as Maharoga because,

• This disease is Tri Doshaja in origin

• It is Marmashrayee.

• Basti is Vyakta Sthana of Ashmari and Basti is also a Pranayatana.

• It is a fatal disease, as it needs surgical intervention.

• On prognosis, the disease becomes Kruchra-Sadhya.

Utpatti:

As per Shabdatra Kaushujbha the term Ashmari is derived from the root

“Ashu” (Sanghata) as Dhatu and manin as “Krit” Prathyaya, when said as

Strilinga it becomes “Ashmari”.

Ashmanam-rahi dadati ya (Amarakosha)

Ashmanam+Ra+Ka+Goraditwae Daiae (Shabdakalpadruma)

The word Ashmari is derived from the root Ashman & Ra is suffixed by

Ka & Goraditvat daiae.

Ashma – Ashman means stone, Rahi - ready, favorable or to give.

Nirukti:

Which resembles to stone is called as ‘Ashmari’.

The Ashmari refers to a stone / gravel..42



Ashmari is the stone formed in the Srotas especially in the Mutramarga.

Sushruta calls it is a dreadful disease similar to Antaka, which is as the

fatal as the god of death himself. Madhavakara also of same opinion.43

Hetu:

Various causative factors that lead to the formation of the Mutrashmari

have been discussed in various Ayurvedic texts.

According to Sushruta Samhita, children are more prone to suffer from

this disease, because of structural difference between adults and children.

Table-3

Nidana of Mutrashmari44

Nidana Cha. Sam. Sus. Sam Yog. Rtn. Ck. Gad. Nig

Asamsodana - + + - -

Adhyasana + + + + -

Sheetha Ahara + + + + -

Medo Ahara - + + + -

Guru Ahara - + + + -

Madura Ahara - + + + -

Ati Vyayama + + + + +

Teekshna Oushdi + + + + +

Ashwayana + + + + +

Teekshna Madhyasevana + + + + +

Anoopa Mamsa Sevana + + + + +

Divaswapna - + + + +



Harita has given some slightly different causes for the formation of

Ashmari. According to this text, Ashmari can occur due to Vegavarodha (when

intercourse is done along with suppressing the urge of urine), Apathyasevana,

Matruja or Pitruja Dosha (heriditary) 45.Nidana described by the various texts

has been presented in Table-3.

Samprapti:

According to Sushruta, in Ashamsodana sheela & Apathyakari persons

the Prakupita Kapha and Mutra combine to stay in the Basti to form the

Ashmari.46

This process is further explained and cleared by giving following examples -

• The crystal clear water, when stored in a new earthen pot, after some

time mud sediments at the bottom of the pot. Similarly when urine stays

in the bladder for some time, the stone formation is initiated.

• In the process of formation of hails by the action of Vayu & Agni of

Vidyuth in the sky, Similarly Ashmari also forms by the action of Agni

(i.e. Pitta & Vayu) on the urine including Prakupita Kapha in the Basti.47

• According to Charaka Samhita, by the action of Ruksha Guna of Vata

against Shukra or Pitta or Kapha along with Mutra, the Ashmari are

formed in the Basti.

• As the bile hardens in the Gallbladder of the cow to form the

‘Gorochana’, similar process takes place in the Basti in the formation of

the Mutrashmari.48

• The vitiated Vayu obstructs the outlet of Basti and dries up the Mutra in

association with Pitta or Kapha or Shukra to form the Ashmari

gradually.

• The pathophysiology is supported mainly by Kapha, is explained with

the similies of formation of pebbles in Gorochana and sedimentation of

silt even by the clean water, which remain stagnant for longer period.49



SAMPRAPTHI GHATAKAS

Table-4

Samprapti Ghataka of Mutrashmari

Dosha Tri Dosha

Dushya Mutra

Agni Jataragnimandya

Ama Jataragnimandyajanya ama

Srotas Mutravaha Srotas

Udbhava Sthana Amashaya and Pakvashaya

Sanchara Sthana Siras, Amashayapakvashayagat

ha Mutravahasrotas

Adhistana Mutravaha Srotas and Basti

Vyaktha Sthana Mutravaha Srotas and Basti

Dustiprakara Sanga

Rogamarga Madhyama

Vyadhi Swabhava Chirakari

Sadhyasadhyatha Kruchrasadhya, Shasthrasadhya



Purvaroopa:

Premonitory signs and symptoms, which appear in the stage of

Doshadushya Sammurchana and Sthana Samshrayavastha, suggest the probable

disease of the future. In our classics Purvaroopas explained under two headings

namely Samanya Purvaroopa and Vishista Purvaroopa, Mutrashmari disease as

per available references Purvaroopas mentioned do persist during the stage of

manifestation and later attain the state of Samanyalakshana50 The Purvaroopas,

which appear in the lakshanas according to various Acharyas are as follows

• Basthipeeda - Explained as basthivedana

• Shepavedana - Explained as mehaneshuvedana

• Asannadeshashoola

Mushkavedhana

• Availa muthra - Explained as athiyavilamuthra

After summarizing the various texts, the Purvaroopas are compiled here

under the same heading as explained.

Samanya Purvaroopa:51

These are the predisposing symptoms exhibited in common despite of

their individual varieties.

The Samanya Purvaroopas are-

• Jvara

• Aruchi

• Avasada

• Bastagandha Mutratha

• Agamana of basti

Vishista purvaroopa:

These are the purvaroopa, which present and exhibit the properties of

respective Dosha. These Vishista Purvaroopas can be classified according to

the Dosha involved.

Explained in terms of seevanivedana



Lakshana:

Lakshanas are exhibited particularly in Vyakthavastha. The Lakshanas

may differ or show the combined symptoms as the disease progress. It is not

necessary that all the Lakshanas must be present in a particular type of

Mutrashmari as it may differ according to the Dosha involved. These

Lakshanas as per our classics are mentioned as Samanya Lakshanas and

Vishistha Lakshanas.

Samnaya Lakshana: 52

Mahathivedana

• SarudhiraMutrata

• Vedana in Nabhi Pradesha, Basthi Pradesha, Sevani Pradesha, Mehana

Pradesha and even in other regions.

• Mootradharasangha

• Mootravikirana

All these symptoms may increase on riding, fasting, and taking long

journey on camel or horse or by any means. According to Vagbhata and

Bhavamishra 53the person passes urine of colour resembling Gomedhaka or

reddish. Even according to Charaka, the person may pass blood mixed urine.54

Vishistha Lakshana:

As said earlier Vishistha lakshanas are presented after the complete

manifestation of disease. This is characterized by the individual Dosha

involved. These depend on the Nidana for which a particular Dosha gets

vitiated and leads to that type of Mutrashmari.

These include

1. Vataja Ashmari Lakshana 3. Sleshmaja Ashmari Lakshana

2. Pittaja Ashmari Lakshana 4. Shukraja Ashmari Lakshana



Vataja Ashmari Lakshana:

The clinical symptoms presented by a person who is suffering from

Vataja Ashmari will have,

• Mootra Pratigatat Teevravedana (Very severe pain during micturition)

• Dantan Khadayati (Clenches his teeth)

• Nabhim Peedayati (Pain at the umbilical region)

• Medram Mridnati (Touches his scrotal region)

• Payum Prushati (Touches his perineal regions)

• Vishardhate (Shouts loudly)

• Vidahate (Feels burning sensation all over the body)

• Passes Vata, Mutra and Purisha with high difficulty

The Vataja Ashmari will posses the following qualities: 55

Colour - Shyavavarna

Surface - Parusha & Kara

Edges - Vishama

Resembles - Kadamba Pushpa Kantaka.

Pittaj Ashmari Lakshana: The person suffering from Pittaja Ashmari will

present with the following signs and symptoms.

• Chooshana,

• Dahana, different types of burning sensations.

• Pachana.

• Symptoms of ‘UshnaVata’ will be seen.

The Pittaja Ashmari will posses the following characters

Colour - Raktavarna or Peetavarna or Krishnavarna or

Madhuvarna

Resembles - Ballataka Asthi.56



Shleshmaja Ashmari Lakshana :

The person suffering from Shleshmaja Ashmari will present with

following signs and symptoms.

• Biddyathe

• Nisthyudyathe

• Basti Gurutha

• Sheetata

The Kaphaja Ashmari will posses the following characteristic

Colour - Shwetha or Madhukapushpavarna

Size - Mahath

Surface - Snigdha

Resembles - Kukkutanda57

Shukraja Ashmari Lakshana:

In Ayurvedic classics the Ashmari formed due to Shukra in association

with Mootra and Tridosha, produce the disease Shukrashmari. But at the same

time it is said that children won’t suffer from Shukrashmari as Shukra is not

secreted and hence there is no formation of Ashmari in relation with Shukra in

the Basti. Thus the persons who suffer from the same will have the following

characteristic.

• Mutrakruchra (Difficulty in micturition)

• Pain in the Basti Pradesha

• Vrushanayoho Shopha (Swelling in the testicular region )58

Upadrava: 59

• Sharkara

• Bhasmakya

• Sikatameha

• Mutraghata and Bhadda Mutrata



• Prashoonatha of Nabhi and Vrishana

• Jeevaruja ( S S Su 33/12, S S Ut Ta 59/14, S S Ni 3/13)

• Dourbalya, Angasada, Aruchi and Trishna

• Karshya, Kukshishoola, and Panduta

• Vamana

• UshnaVata. ( S S Ni 3/17, M Ni 32/16)

Sadhya-Asadhyata:

The disease Mutrashmari is a Daruna Vyadhi as explained by our

ancient Acharyas. As per Sushruta the recent formed stones (Taruna) can be

managed by conservative or palliative methods where in the well-developed

(Pravrudda) Ashmari, which has already progressed, can be treated by surgical

intervention60. But as with the consideration of Basti, being Marma,

Pranayathana and seat for Tridoshas the disease Mutrashmari is generally

considered as asadhya which is directly pointed by quoting Mutrashmari as one

in Ashta Mahagada.

Ashmari is considered as asadhya if it is associated with Upadravas like

Nabhishotha,Vrishana Shotha, Baddha Mutra, presence of Sikata and Sharkara

in Mutra, which may result in immediate death61.

Chikitsa:

After knowing the Bala of roga as well as Rogi, the line of treatment can

be selected. The principles adopted in the treatment of Mutrashmari are listed

below.

Sushruta says that these Snehadi karmas are to be adopted in only

purvarupavastha only and medicinal treatment to be adopted in initial stage, but

when it is progressed only surgical treatment to be adopted62.

According to Charaka, the Chikitsa principles of Kaphaja and Vataja

Mutrakruchra are to be adopted in the management of Mutrashmari.63

Chakrapani opines that both the measures have to be combined in the

management.



Vagbhata, opines that principles of treatment used for Sannipataja

Mutraghatha is utilized, based on the predominance of Dosha64.

Shamana Karma:

This line of treatment has to be followed along with Nidana

Parivarjana, particularly after Shodhana therapy.

The administered drug must posses Bhedhana, Ashmarighna properties

to disintegrate the formed stone. It also should have the Mutra Virechaneeya

properties to expel the stone out.

Apart from all these, Charakacharya mentions some regimen to follow

for the expulsion like raiding on camel or horse or doing vigorous exercise on

taking Madhyapana etc. these all aim at the function of Apanavata which helps

to expel the Mutra, there by expelling the Ashmari present in it.

Shodhana Karma:

It is imperative to the principles, to adopt the Snehadi karmas in the

Purvaroopa stage of Ashmari. Snehadi is interpreted as Sneha, Sweda and

Vamanadi by Arunadatta, and the commentator of Ashtangahridaya. As

Ashmari is a Tridoshaja Vyadhi whatever Shodhana therapy is advised in

Mutrakruchra is to be adopted according to the Doshic predominance. e.g. In

Vatajashmari, the therapy advised in Vatajamootrakrichra is to be adopted,

where in Abhyanga by Vatahara Tailas, Niruha basti, Uttara basti, Upanaha,

Parisheka to katipradesha, with Vatahara Tailas or Kvathas are carried out.65

Management of Ashmari with Shodhana therapy in the stage of

Purvaroopa helps in checking the manifestation and aggravation of disease

during the Doshadushya Sammurchana stage itself. Hence the Shodhana

Chikitsa is beneficial by the process of elimination of morbid Doshas. Once

Ashmari is formed and hardened the related Doshic nature in it also changes.

There is no positive effect of Shodhana on Ashmari, which is already formed,

even if the Doshas are brought to the Koshta and efforts are made to expel

them out.



Shastra Karma:

As per Sushruta the line of surgical treatment must be employed

in the Ashmari of Pravruddavastha, and if all the measures previously

mentioned gets

failed. 66

Sushruta was the first person to mention the surgical management in the

context of Mutrashmari where he has elaborately

dealt with the consequences and complications faced after surgery. Emphasised

regarding the pre-operative, operative and the post-operative procedures with

actual techniques and instruments. Indications, contraindications and the

complications are also been dealt in Chikitsa Sthana 7th chapter of Sushruta

Samhita.

Pathyaapathya: 67

Pathya:

Shashtikashali, Rakthashali, Yava, Kulatta, Purana Kushmanda Phala,

Ardraka, Gokshura, Pashanabheda, Yavashooka, Renuka, Shyamaka, Varuna,

Krounchamamsa Rasa and Vari.

Apathyas:

Shushka, Rooksha Pistanna Sevana, Virudda Bhojana, Karjura, Shaluka,

Kapitta, Jambu, Divaswapna, Vegadharana, Ativyayama and Atimithuna. All

the Ahara Viharas which aggrevates Kapha and Vata can be considered as

Apathya.

Urolithiasis Review….


MODERN REVIEW – UROLITHIASIS68, 69, 70

Anthropologic history provides evidence that urinary stone disease

existed as long as 7000 years ago and perhaps more.

Riches (1968) refer to that formation of stone in the pelvis (bladder) of

an Egyptian skeleton estimated to be 7000 years old.

Urinary stone or calculus or lithiasis is one of the most common diseases

of the urinary tract. It occurs more frequently in men than in women. Urinary

calculus is a stone like body composed of urinary salts bound together by a

colloid matrix of organic materials. The organic matrix is a mixture of muco-

proteins and muco-polysaccharides. It consists of a nucleus around which

concentric layers of urinary salts are deposited.

ETIOLOGY

The causes of renal stone formation are not fully understood but in most

cases multiple factors are involved. An adequate stone analysis is the key to an

understanding of pathogenic mechanisms involved.

The electrolytes are held in a super-saturated solution absorbed to the

colloid particles. If the colloids are reduced or the electrolytes increased,

crystallization will occur. Crystallization is not necessarily followed by

calculus formation. A crystal grows up to calculus only if it is held up and it

may be held up in the lowest calyx (from which drainage is not very

satisfactory) or in any part of pelvis below the ureteric outlet. By keeping this

idea it seems to be two main elements in stone formation.

• Disturbance in crystalloid colloid ratio

• Imperfect drainage

Other theories in relation to etiology are

• Metabolic abnormalities, anatomical abnormalities, infection and

dietic factors.

To understand the etiology of Urolithiasis, various theory have put

forwarded such causes are summarized below under various headings.



I. Cause related to metabolic abnormality

A. Hyper excretion of insoluble urinary constituents

a. Oxalate - hyper oxaluric states are

1. Primary Hyperoxaluria due to enzymes deficiencies:

Type I ketaglutarate glyxylate carboligiasse deficiency

Type II D glyceric dehydrogenase deficiency.

b. Calcium

Sarcoidosis and Hypervitaminosis D

c. Uric acid

Gout, after chemotherapy

Dehydration and ulcerative colitis

d. Cystinuria Mendelian recessive defect (congenital)

e. Physical changes in urine

• Urinary pH

• Colloid content

• Decreased concentration of colloids

• Urinary magnesium/calcium ratio

B. Altered urinary crystalloid and colloid

C. Decreased urinary output of citrate

II. Causes related to dietetic abnormalities

• Vitamin A deficiency

• Excess amount of oxalate (rich oxalate contained diet)

• Rich calcium diet



Table- 5

Urolithiasis Precipitating Foods:

Calcium Phosphates Oxalates Purines

Leafy

vegetables

Milk & milk

products

Sesame seeds

Ragi

Whole cereals

Legumes

Nuts & oil

seeds

Meat, fish,

eggs and milk

Leafy

vegetables

Beetroots

Tea, cocoa

Rhubarb

Sesame seed

Raw

plantain

Meat, fish

Animal

tissue &

organs

III. Causes related to endocrine gland abnormalities

1. Hyper parathyroidism

• Primary

• Secondary

• Tertiary

2. Parathyroidectomy

IV. Causes related anatomical deformity

• Urinary infection

• Others - Prolonged immobilization, Urinary stasis, Drug induced,

Steroids and Idiopathic.

PATHOLOGY 71

Urinary concentration vary greatly in size. There may be particles like

sand anywhere in the urinary tract, or large round stones in the bladder.

Deposits of calcium may be present throughout the renal parenchyma, giving

rise to nephrocalcinosis. This is liable to occur in-patients with chronic

pyelonephritis, renal tubular acidosis, hyperparathyroidism, vitamin D

intoxication and healed renal tuberculosis.



So to understand this concept or pathology, various theories are

compiled here, they are as follows:

• Saturation

• Super saturation/crystallization

• Crystal nucleus

• Crystal growth

• Crystal aggregation

Saturation:

When crystals begin to form, we say that the solution has become

saturated with the substances. There is specific limit to amount of solids that

can be held in solution. When this limit is exceeded, crystals must form

crystallization of a single substance, such as cystine or uric acid will occur,

when enough of the substance is added to water at given pH and temperature to

saturate the solution. When two or more substances are combined to form the

crystal as in the case with table salt (sodium chloride) or calcium oxalate, the

level of saturation is governed by the product of the concentrations of the two

(or more) substances.

Saturation and solubility products are easy to dissolve in water, but urine

is a much more complex solution. In urine, concentration of a substance reach

when the point at which saturation would occur in water, crystallization does

not occur as expected. Urine has ability to hold more solute in solution than

pure water. Although all elements and molecules in urine are suspended in

water, the mixture of many electrically active ions in urine causes interaction,

which changes the solubility of their elements. In addition many organic

chemicals and molecules such as urea, uric acid, citrate and the complex

mucoproteins of the urine all mutually affect the solubility of other substances.

For example, citrate is known to combine with calcium to form a

soluble complex. It therefore prevents some calcium from combining with

oxalate or phosphate a becoming crystalline. Many researchers have reported

that deficiency in urinary citrate is one of many factors found in urine stone



formation. It is however important to stress that the presence of such a large

number of ionically active substances does change the solubility of any given

element or substance in urine.

Super saturation:

If a given amount of calcium and oxalate that would crystallize, when

placed in a solution of water at a given pH and temperature is placed in urine, it

will be held in solution. If the amount of calcium and oxalate is increased

progressively in the same volume of urine, at constant pH and temperature, the

calcium and oxalate will stay in solution even though the solubility product has

been exceeded. In doing this we are actually creating super saturation is called

the metastable region. The area of super saturation between the solubility

product and spontaneous urinary crystallization is the metastable region of a

given substance. This means that although urine contains multiple and complex

solubilizing factors for that particular crystal, the amount of substance in urine

may eventually become so great that it is capable of crystallizing in spite of the

solubilizers and inhibitors that are present.

Crystal nucleation:

Nucleation of crystals occurs when active ions and molecules in a

solution no longer flow randomly in a completely dissociated fashion but

cluster together closely enough to form the earliest crystal structure that will

not dissolve. No matter what type of nucleation is probably most likely to

occurs, it requires energy to ‘push’ the crystal nucleus together, the energy

required for nucleation is higher than that required for simple crystal growth,

and is provided when the amount of super saturation is high enough to cause

nucleation.

Crystal growth:

Once nucleation has occurred in the complete solution known as urine,

certain nuclei may continue to grow if the urine remains super saturated.

These particles must float freely in urine and should serve as nuclei for

further growth or aggregation of crystals. Therefore nuclei or larger growing



crystals may aggregate to form large crystal masses. These become large

enough to become lodged in a given position in the urinary tract. It is likely that

both processes are important in the creation of urinary calculi.

Matrix:

Extensive research showed that, matrix as derivative of several of these

mucoproteins of urine. Matrix content of a given stone varies but most solid

urinary calculi have a matrix content of about 3% by weight. Matrix may

inhibit crystal growth, interfere with crystal aggregation and even enhance

stone growth.

To summarise

• Renal function must be adequate for the excretion of excess amounts of

crystallizable substances.

• The kidney must be able to adjust the pH, excretion to confirm to that

required to crystallize the substance.

• Crystal mass must reside in the urinary system for a time sufficient to allow

growth on aggregation of crystal to a size large enough to obstruct the

urinary passage through which it is passing.

Table-6

Showing on the basis of composition of Calculi:

Site Composition Incidence

Renal calculi

Ureteric calculi

Vesical calculi

Calcium oxalate

Calcium phosphate

Urate stones

Triple phosphate

Cystine calculi

Xanthine calculi

70 %

70 %

5 – 10 %

15 – 20 %

1 – 5 %

Rare



TYPES OF RENAL CALCULUS:72, 73

Basically the Renal stones can be divided into two major groups.

• Primary stones

• Secondary stones.

Primary stones:

Primary stones are those, which appear in apparently healthy Urinary

tract without any antecedent inflammation. These stones are usually formed in

acid urine and usually consist of calcium oxalate, uricacid, urates, cystine,

xanthine or calcium carbonate.

A. Calcium Oxalate Calculus:

This type of stone is usually single and is extremely hard. It is dark in

colour due to staining with altered blood precipitated on its surface. It is spiky

that means it is covered by sharp projections, which cause bleeding due to

injury to the adjacent tissues. This stone is popularly known as Mulberry stone.

On section it shows wavy concentric laminae that mean it is formed by

deposition of layers of calcium oxalate on a nidus.

The peculiarities of this stone are-

• It is often impacted in the ureter.

• It causes bleeding due to its rough surface.

• There may be deposits of secondary phosphate on its surface caused by

infection leading to formation of mixed stone.

• Due to high calcium content it casts an exceptionally good shadow

radiological (radio-opaque). The rough surface may also be evident in

x-ray.

B) Uric Acid and Urate Calculus

Pure uric acid calculi are rare and are not visible in x-ray (Radioluscent).

The majority contains urates and enough calcium oxalate to render such calculi

radio-opaque. These stones usually occur in multiples and so are typically



faceted. The stone are of moderate hardness. Their color varies from yellow to

dark brown.

On section the stones display wavy concentric markings. The surfaces of

these stones are usually smooth. These stones usually occur in Acid urine.

In children stones of ammonium & sodium urate are sometimes found.

These stones are yellow, soft and friable. But unfortunately if these do not

contain some impurities like calcium oxalate, they do not become radio-

opaque, so may not be visible on straight x-ray.

C. Cystine Calculus:

These stones usually appear in patients with cystinuria. Such cystinuria

sometimes occurs in young girls. Cystine is an amino acid rich in sulphur,

Cystine calculi usually occurs in multiple. These calculi are soft and yellow or

pink in color. When these are exposed outside, they gradually change to green.

Pure cystine calculi are radioillucent, but as they contain sulphur they are

usually radio-opaque. Such stones also occur in acid urine.

D. Xanthine calculus:

These are extremely rare. These are smooth, round & brick red in color.

On cut surface it shows lamellar appearance.

SECONDARY STONES:

These are formed as result of inflammation. The urine is usually

Alkaline, as urea splitting organisms are most often the causative organisms.

Majority of Secondary stones are Phosphate and Mixed stones.

A. Phosphate Calculus:

Majority of these stones are composed of calcium phosphate, though a

few are composed of ammonium magnesium phosphate, known as triple

phosphate’. Such calculus is usually smooth, soft & friable. It is usually dirty

white in color.



This type of calculus usually occurs in infected urine and so is a

secondary calculus. Urine is often alkaline. Such stone enlarges rapidly and

gradually fills up pelvis and renal calyces to take up the shape of stag horn

calculus. As this stone gives little symptoms due to its smooth surface, it

enlarges rapidly. Triple phosphate usually results from liberation of ammonium

carbonate from urea brought about by urea splitting organisms. While majority

of such stones are made up of calcium phosphate, a few are made up of mixture

of calcium phosphate & triple phosphate. On cut section it shows laminated

appearance as the crystalloids are deposited in layers. These stones are usually

radio-opaque as these contain calcium. But it is also due to its large size rather

than density that it is radio opaque.

B. Mixed Calculus:

Phosphate stone may occur as covering of a primary stone. Such stones

are known as ‘Mixed stones’. The primary stone is often the calcium oxalate

stone. When the urine becomes infected deposits of phosphate occur on the

rough surface of calcium oxalate stones. Such stones also occur in alkaline

urine.



Fig - 2

Calcium Oxalate Calculus Uric Acid and Urate Calculus

Cystine Calculus Xanthine calculus Phosphate

Calculus

Mixed Calculus



CLINICAL FEATURES74, 75, 76

Clinical feature changes depending upon the site and size of the calculi.

I. Renal calculus

Symptoms:

• Extreme, sharp pain in the back or side that will not go away

• Blood in the urine

• Nausea and vomiting

• Cloudy or odorous urine

• Frequent urination

• A burning feeling while patient urinates

• Fever and chills

Signs:

• Tenderness - This is mostly present at the renal angle posteriorly.

• Muscle rigidity - This is found only in cases with acute infection.

• Swelling - When there is hydronephrosis, Pyelonephritis, associated

with renal calculus then swelling may be palpated in the flank.

II. Ureteral calculus

Symptoms:

• Radiating, colicky, agonising pain

• Rather constant ache in the costovertebral area and flank.

• Nausea and vomiting may be associated.

• Blood mixed urine

• Urgency and frequency

• Chills

Signs:

Patient is usually in agony, pacing the floor rather than lying quietly in bed.

• The skin is cold and clammy and there may be other signs of mild shock.

• Marked tenderness in the costovertebral angle and flank

• On percussion posteriorly causes severe pain



• The abdomen is distended, tympanitic and quiet on auscultation

III. Vesicular calculus:

Symptoms:

• Increased frequency

• Pain and discomfort at the end of micturition

• Haematuria – terminal haematuria

• Dysuria

• Acute retention of urine.

Signs:

• Only giant calculi can be felt suprapubically.

• The bladder may be visible, palpable or persuable. (If there is a great deal of

residual urine.)

• Rectal examination – Relaxed anal sphincter (neurogenic bladder) or an

enlarged or hard (cancerous) prostate. Cystocele may be noted.

IV. Urethral calculus:

Symptoms:

In males – Patient may experience a sudden stoppage of urine while

urination and thereby unable to empty the bladder. Dribbling also occurs. Pain

due to the stone in urethra may be rather severe and may radiate to the glans

penis.

In females – The symptoms of urethral diverticulum with or without

calculus

Are those of infection of lower urinary tract including frequency, dysuria,

nocturia, Pyuria and in rare haematuria, dyspaerunia is a prominent symptom,

occasional discharge of pus through urethra may occur.



COMPLICATIONS77

Complication of urolithiasis depends on the size and position of the

stone. The development of secondary pathologic changes in the urinary tract is

also depending on the same factor.

Renal calculus:

• Obstruction: Partial obstruction leads to hydro nephrosis. Complete

obstruction leads to destruction of kidney.

• Infection: Infection leads to pyelitis, pyelonephritis, pyonephric abscess etc.

• Parenchymal ischaemia may be caused by local pressure due to stone.

• Epithelioma (Malignancy of epidermoid): due to presence in the lining

epithelium of the renal pelvis.

Ureteral stones:

• Obstruction

• Ulceration

• Diverticulum in the wall of the Ureter

INVESTIGATION 78

Renal calculi:

Blood examination: This is to be done for urea, creatinine, uric acid, total

count, serum calcium and phosphate.

Urine analysis:

Physical examination:

This is to be done for gross haematuria, smoky appearance or

opalescence.

Chemical examination:

Should be done for protein cystine and for pH values.



Microscopic examination:

Microscopy of urine should be done for the presence of RBC, pus cells,

epithelial cells, and for the presence of any casts and crystals.

Bacterial examination:

This is highly important including cultural and sensitivity tests. If the pH

increases, the urea splitting organisms present.

Radiography:

A. Plain X – ray (KUB)

An X- ray of kidney, ureter and bladder region is to be taken after

thorough bowel preparation and is watched for any opacities.

At least 90% of renal stones are radio opaque and are easily visible in

X-ray film unless they are very small or overlie bones. A staghorn calculus can

be easily diagnosed and there is no confusion with other radio opaque shadows.

Calcium oxalate calculi are most radio opaque than carbonate phosphate, urate

and uric acid. In that order cystine calculi are sometimes said to be non-opaque

but them infact giving a good shadow. All infective calculi are radio opaque, in

cases of pyuria a negative X-ray excludes stones almost certainly.

B. Intra venous urogram (IVU) or intravenous pyelography:

A laxative is usually given before the IVU and patient is advised not to

drink for 6 – 8 hours before the study. It is necessary to accurately localize the

calcified shadow in relation to the kidney. It also reveals the function of other

Kidney of the stone is non-opaque excretory urograph will show filling defect.

Ultrasonography:

This is useful to distinguish between opaque and non opaque stones.

This is cheap, painless procedure. The size, shape and number of the stones in

kidney, thickness of the cortex of the kidney, presence of cysts can be

estimated any obstruction in the hydronephrosis.



Computed tomography:

This is particularly useful in the diagnosis of non-opaque stones. It also

reveals about any fluid collections, demonstration of pelvicalyceal system and

ureter, any renal masses and cysts.

Renal scan:

If excretory urogram shows poor renal functions isotope studies may

indicate further about renal function. Such findings may different isotopes the

need for nephrectomy rather than nephrolithotomy.

Instrumental examination

Cystoscopy:

Cystoscopy is useful in diagnosis of the ureteral stricture. It can also be

used for diagnosis of obstruction due to stone formation.

Ureteric & Vesical calculi:

• Examination of blood

• Urine analysis

• Straight X-ray of KUB region

• Excretory urography

• Cystoscopy

Urethral calculi:

• Cystoscopic examination

• Roentgenography



MANAGEMENT

The diagnostic and treatment of urinary stone disease has 3 goals;

• Symptomatic relief for the patient

• Preservation of renal function and elimination of a source for infection or

bleeding.

• Management thus depends on the anatomy and symptoms of the patient, the

degree of obstruction and function in the involved renal unit, the presence

of infection or gross haematuria, size and composition of stone.

Specific treatment for kidney stones will be determined based on

• Patient age, overall health, and medical history

• Extent of the disease

• Patient’s tolerance for specific medications, procedures, or therapies

• Expectations for the course of the disease

Kidney stones may be treated with various techniques. If they get lodged

in the renal pelvis or get so big that they cannot possibly go down the ureter,

then they have to be removed.

• Management of acute symptoms produced by a stone impacted in the pelvi-

ureteric junction or passing down the ureter is very urgent.

• The pain of ureteric colic is severe. Hospital admission, bed rest, oral fluid

and intramuscular injections of pethidine, morphine and anti spasmodics

etc. All urine is collected and sieved to retrieve a calculus that may be

voided.

Revolution in the Treatment of Stones:

The technological revolution over the last decade has enabled as an

outpatient procedure or with minimal hospital stay.

• Extracorporeal shock wave lithotripsy.

• Surgical intervention (PUNL, URS etc)

• Flush out therapy



Anticipating modern lithotripsy, the Egyptians used gum to attach a

diamond to the tip of a hollow reed, inserted it into the bladder through urethra

and the patient then walked, allowing the diamond to fragment the more fragile

bladder stone.

Surgical Procedures 79

Indications:

• When it is sure that stone can not be naturally eliminated

• Causing obstructive uropathy

• In progressive renal damage

• Patient with severe continuous pain.

Shock waves or extracorporeal shock wave lithotripsy (ESWL):

Use of a machine to send shock waves directly to the kidney so that the

stone is broken into smaller fragments that will pass through the urinary

system. There are two types of shock wave machines, with the first machine,

the patient sits in a tub of water, with the other, the patient lies on a table.

Ureteroscope:

A long wire with a camera attached and it is inserted into the patient's

urethra and passed up through the bladder to the ureter where the stone is

located. A dormia basket is used to obtain the stone and remove it.

Tunnel surgery (Also called percutaneous nephrolithotomy):

A small cut is made in the patient's back and a narrow tunnel is made

through the skin to the stone inside the kidney. The surgeon can remove the

stone through this tunnel.



Flush out therapy:

If the stone size is small (3-4 mm) by flush out therapy only we can

expel the stone. It is of two types, oral hydrotherapy and intravenous

hydrotherapy .

• Pyelolithotomy

Removal of stone through an incision on the pelvis of the kidney

• Nephrolithotomy

Removal of stone through renal parenchyma.

• Pyelonephrolithotomy

Removal of the stone through both the pelvis of the kidney and through the

renal parenchyma.

• Nephrostomy

Simple drainage of kidney with removal of calculi.

• Nephrectomy

Removal of whole kidney, etc

Drug Review….


DRUG REVIEW

The drug we have chosen for the study was the ‘Ananda Yoga’. This drug

has been described in the Ashmari Chikitsa Prakarana of Bhaishajya Ratnavali.

It comprises of Tila Panchanga, Apamarga Panchanga, Kadali Kanda, Palasha

Kanda and Amalaki. The other drug used in this study was Yavaksharadi

Yoga. The details of each of these drugs are as follow:

ANANDA YOGA

The ingredients of Ananda Yoga are Tila Panchanga, Apamarga

Panchanga, Kadali Kanda, Palasha Kanda and Amalaki. Each of these drugs is

being described in detail under the separate headings.

TILA1, 2, 3, 4

Botanical name - Seasmum indicum

Family - Pedaliacae

Vernacular name:

Hindi - Til

Bengal - Sanki Til

Gujarat - Tal

Telugu - Gubbulu

Kannada - Ellu, Achchellu

English - Sesamum

Synonyms: Homadhanyam, Pavithra, Pitrutarpana, Paapaghna, Putradhanya,

Jatril and Vanobhav.

Vargeekarana:

Charaka - Swedopagna, Purreshavisarjaneeya

Introduction: It is annual herb growing upto 1 m bearing white or light pink

coloured flowers. It is mainly cultivated in temporal regions of India. There are

Drug Review….


two varieties such as Shweta and Krishna Tila. Flowers tender, ciliated, bluish,

whitish, brown or yellowish. Its flowering seasons are October and November

and fruits in December and Januvary. It is distributed all over India.

Properties:

Rasa - Madhura, Kashaya, Tikta

Guna - Guru, Snigda, Tiksna

Virya - Ushna

Vipaka - Madhura

Doshagnata - Kapha, Pitta.

Karma:

Tridoshahara, Mootrajanana, Snehana, Vedanasthapana, Sandhaaneeya,

Vranashodhana, Yogavahi, Vedanasthapana, Vajikarana, Sandhaaneeya,

Shulaprashamana, Deepana, Graahi, Balya and Vranaropana.

Indication: Ashmari, Arshas, Mootraavarodha, Raktasrava, Prameha,

Vatashoola, Amavata, Atisara and Netraroga.

Parts used: Beeja, Taila, Patra, Moola.

Dosage: Beeja Churna-3-6 gms, Taila 10-20 ml.

Formulations: Tila Prayoga, Tiladi Gutika and Tilastaka.

Chemical composition: Neutral lipids, glycolipids and phospholipids,

Seasamose, Seasomolin, Seasomolinal, Seasomol and Pinoresinol.

Pharmacological activities: Antioxidant, Cholesterolemic, hepatoprotective,

antitumour, free radical scavenging activity.

Drug Review….


APAMARGA 5, 6, 7

Botanical name - Acahyranthus aspera

Family - Amaranthaceae

Vernacular names:

Hindi - Chirachinta

English - Pricky chaff flower

Bengal - Apang

Malayalam - Katalati

Telugu - Uttareni

Tamil - Nayurvi

Kannada - Uttarani

Synonyms:

Kapi Pippali, Pratyak Pushpi, Shikhari, Kinithi, Adhahashalya, Markata Pippali

and Kubja

Vargeekarana:

Charaka - Shirovirechanopaga, Krimigna, Vamanopaga

Sushruta - Arkadi

Vagbhata - Arkadi

Introduction: In Rugveda we don’t find the reference about Apamarga. It is

claimed to remove the excessive water from the body on administration.

Botanical description: An aromatic slender climber. Stems-creeping, jointed,

Leaves- 5-9 cm* 3-5 cm, subacute, entire, glabrous cordate at the base.

Flowers-in pendulate spikes, straight; male larger and slender; female 1.3-2.5

cm* 4-5 cm diameter.

Distribution: All over India.

Drug Review….


Varieties:

Sweta Apamarga

Rakta Apamarga

Chemical composition: Ecdysone, ecdysterone, inokosterone, oleoanolic acid

and glycoside from roots. Saponin A and B from seeds, Saponins C and D from

fruit, achyranthine and beaine from the whole plant.

Properties;

Rasa - Katu, Tikta

Virya - Ushna (ardra sita)

Vipaka - Katu

Guna - Laghu, Rooksha, Tikshna

Doshaghnata - Kaphavatashamaka, Kaphapittasamshodhana.

Karma:

Deepana, Pachana, Vrisya, Rasayana, Mutrala, Mutramalanashaka,

Ashmarihara, Krimighna, Sanghrahi, Raktashodahka and Vardhaka,

Shothahara, Kandugna and Arshoghna.

Indication:

Udara Roga, Shoola, Arsha, Krimi, Ashmari, Amavata, Gandamala, Pandu,

Kasa,Shwasa, Hikka, Basti Shotha, Vrikka Shotha.

Parta used: Mula, Tandula, Patra, Panchanga.

Dosage:Kshara 0.5-2 gms, 10-20 ml swarasa.

Pharmacology: Diuretic, lithotripsic, spasmolytic, antimicrobial, antifungal,

antiimplantation, purgative, vasodialater.

Drug Review….


KADALI8,9,10

Botanical name - Musa paradisiaca

Family - Musaceae

Classical name - Kadali

Sanskrit name - Kadali, Mocha, Rambhaa, Anshumati, Ambusara,

Varana, Phala, Mochaphala, Drighapatrika,

Palasika, Bruhatpushpa, Mutkatarasa.

Regional name:

Hindi - Kela

English - Banana

Tamil, - Vashap Pasham

Telugu - Ariti

Bengali - Kela

Gujarati - Kela

Kannada - Bale, Balenaru, Balehannu.

Gana:

Caraka - Katukaskandha, Shvasahara, Shirovirechana.

Susrutha – Amradi.

Description: A stout, stoloniferous, perineal herb, 2-8 m tall, leaves ablong,

suddenly ternicute at both ends, acuminate or emarginated, petioles on long

sheaths forming pseudostems. Flowers unisexual, in a cymose inflorescence,

subtended by a large bract, brownish red, truncate at base. Fruits oblong to

fusiform, generally 15-25 cm long, fleshy.

Distribution: It is extensively cultivated in throught India

Chemical composition: Cyclocholeston, triterpinoid, cychlotriterpinoid,

carbohydrates, minerals and Vitamins.

Drug Review….


Types:

Kashta Kadali.

Girikadali.

Suvarna Kadali.

Properties:

Rasa - Madhura, Kashaya

Guna - Guru, Snigdha, Sheeta

Virya - Sheeta

Vipaka - Madhura

Doshakarma - Pittahara and Kaphakara

Karma: Doshaprashamana, Ashmarighna, Vrushya, Shukrala, Sangrahi,

Brumhana, Hrudhya, Trishnanigraha. Mutrajanana, Balya.

Indications: Ashmari, Mutrakrichra, Varna, Apasmara, Daha, Udararoga,

Shwasa, Kasa, Kshaya, Kshata, Madhumeha.Grahani.

Parts used: Moola, Patra, Kanda, Pushpa and Phala.

Dose: 10-20 ml Swarasa, 10-20 gm Churna.

Pharmacological activities: Antihyperglycaemic, antiulcerogenic,

hypotensive, diuretic, expectorant.

Drug Review….


PALASHA11,12,13

Botanical name - Butea monospora

Family - Febaceae

Classical name - Palasha

Sanskrit name - Kimshuka, Ksharashreshta, Rakta Pushpa,

Samvidara, Vatapotha, Bramha Vruksha and

Brmhopanethra.

Regional name:

Hindi - Dhaka

English - Flame of the forest tree

Tamil - Paras

Telugu - Moduga Chettu

Bengali - Palasha

Gujarati - Khakaro

Kannada - Muttuga

Gana:

Charaka - Nyagrodadi.

Susrutha - Nyagrodadi, Mushkakadi and Avashtambakadi.

Description: A decodious tree growing upto 15 m height and 1.5-1.8 m in

girth, trunk is crooked. Bark is light brown or bluish grey, yielding a rubber red

vitreous gum. Leaves are trifoliate, large, unequal, 10.2-20.4 cm. Flowers in

racomones, brilliant orange-red, 3.8-8.1 cm long. Fruits are pods, silvery-white,

Distribution: It is extensively cultivated in throught India

Chemical composition: Butin, isocorcopsin, butein, coreopsin, palsitrin,

leucocyanidin, procyanidin and palmitic acid.

Drug Review….


Types:

Lata Palasha

Rakta Palasha

Shweta Plasha

Neela Plasha

Peeta Palsha

Properties:

Rasa - Katu, Tikta and Kashaya

Guna - Laghu, Snigdha.

Virya - Ushna

Vipaka - Katu

Doshakarma - Vatakaphahara.

Karma: Mutrala, Ashmarighna, Shothahara, Vedanasthapana, Lekhana,

Yakruduttejaka, Sthambaka, Grahi, Pramehagna, Raktashodhaka, Krimigna

and Deepana.

Indications: Ashmari, Mutrakrichra, Mutravarodha, Arsha, Agnimandhya,

Grahani, Krumi and Raktapitta.

Parts used: Twak, Pushpa, Niryasa and Beeja.

Dose: 50-100 ml Twak kwatha, 3-6 gm PushpaChurna, 1-3 gm Niryasa and 3-6

gm Beeja Churna.

Pharmacological activities: Diuretic, lithotripsic, antihelmenthic,

antiimplantation, antihepatotoxic, anitispasmodic.

Drug Review….


AMALAKI14,15,16

Botanical name : Phyllanthus emblica Linn., Emblica officinalis Gaertn.

Family : Euphorbiaceae

Kula : Eranda kula

Gana:

Charaka – Jwaraghna, Kasaghna, Virechanopaga, Kushtaghna,Vayaha sthapana

Sushruta – Aamalakyaadi, Parushakaadi, Triphala

Vagbhata – Parushakaadi

Vernacular names:

Sanskrit – Aamalaki, Dhaatree

Kannada – Nellikayi

English – Emblica myrabalan, Indian gooseberry

Hindi – Amlica, Aamalak, Aawvlaa

Malayalam – Nellimaram, Nellikka

Telugu – Usirikaaya, Aamalakamu

Distribution: Wild / cultivated throughout tropical India. Wild distribution is

in deciduous forests and on hill slopes up to 200m.

Botanical description:

A small to medium sized deciduous tree, 8 – 18 mt in height with thin light

gray bark exfoliating in small thin irregular flakes. Leaves simple, very many,

subsessile, closely set along the branchlets, distichous, light green having the

appearance of pinnate leaves. Flowers greenish yellow, in axillary fascicles,

unisexual, males numerous on short slendour pedicles, females few, subsessile,

ovary 3 celled. Fruits globose, fleshy, pale yellow with six obscure vertical

furrows enclosing 6 trigonous seeds in 2 seeded 3 crustaceous cocci. Flowers in

February – May and Fruits in October – April

Parts used: Fruit pulp / Fruit rind, Root bark, Bark, Leaves, Seed.

Drug Review….


Properties:

Rasa – Amla Pradhana Vilavana Pancharasa

Guna – Guru, Ruksha, Sheeta

Veerya – Sheeta

Vipaka – Madhura

Doshaghnataa – Pittapradhana Tridosha Shamaka

Rogaghnataa – Netraroga, Pittajavikara, Yakrutvikara, Shwasa,

Meha,Twakvikara.

Karma – Daaha Prashamana, Chakshushya, Pramehaghna, Rasayana,

Vayahsthaapana.

Physical constituents:

Dry mature fruit contains –

Foreign matter (seed & coat) – not less than 3%

Total ash – not more than 7%

Acid insoluble ash – not more than 2%

Alcohol soluble extractive – not less than 40%

Water soluble extractive – not less than 50%

Chemical constituents:

Good source of vitamin C (fresh fruit), Carotene, nicotinic acid,

riboflavin, D – glucose, D – Fructose, myoinositol and a pectin with D-

galacturonic acid, D-arabinosyl, D-xylosyl, L-rhamnosyl, D- glucosyl, D-

mannosyl, and D-galactosyl residues. Embicol, mucic, Indole acetic acid and 4

other auxins, two growth inhibiters- R1 and R2

Pharmacological activities:

Spasmolytic, hypo-lipidemic, anti-microbial, anti-oxidant, immuno-

modulator and adrenergic potentiating

Drug Review….


GOMUTRA17

Rasa : Katu, Tikta, Kashaya, Lavana (Anurasa)

Guna : Tikshna, Ushna, Laghu

Virya : Ushna

Vipaka : Katu

Doshghanta : Kaphavata Shamaka

Action and Uses:

Deepana, Lekhana, Pachana, Anulomana, Malashodhaka and Amapachana. It

is also used in Virechana and Basti.

Chemical Composition:

“Gomutra Mahaushadhi” written by Rajvaidya Revashankar Sharma and the

Indian agriculture research institute, New Delhi have described chemical

constitution of Gomutra as following.

Nitrogen (N2) - Lactose (C6H12O6)

Sulpher (S) - Water (H2O)

Copper (Cu) - Iron (Fe)

Urea [CO(NH2)2] - UricAcid

Phosphate (P) - Sodium (Na)

Manganese (Mn) - Carbolic Acid

Calcium (Ca) - Salt (NaCl)

Vit. A,B,C,D,E

Central institute of Medicinal and Aromatic plants, Central Scientific and

Industrial Research (CSIR), Go-Vigyan Anusandhan Kendra, Nagpur have

reported that cow urine distillate is having bioenhancing activity, anti microbial

effect, anti fungal agents, anti infective agents and anti cancer agent etc.

properties. It also reduces the cost of treatment and the side effects due to

toxicity.

Drug Review….


YAVAKSHARADI YOGA

Yavaksharadi Yoga consists of Yavakshara and Gokshura. It has been

indicated in Mutrashmari by Yogaratnakara. The details of these two drugs are

as follow:

‘Yavaksharadi Yoga’ contents are Kshara of Yava (Hordeum vulagare)

and choorna of Gokshura (Tribulus terresteris). Yavakshara is prepared as

explained in classics.

GOKSHURA18

Gokshura is one of the safest, easily available, non-toxic and non-

controversial plant and is found listed among medicinal plants. Many ancient

and modern scientists have discribed its many beneficial effects on human life.

The therapeutic properties of Gokshura have been discussed in detail by almost

all Ayurvedic Samahitakaras.

Gana – Mootravirechaneeya, Shothahara,

Krumighna, Vatashmari Bedhana.

Kula – Gokshura kula

Family – Zygophyllaceae

Botonical Name – Tribulus terrestris

Synonyms :

Gokshura : Spines of Gokshura fruit causes injury to cow’s hoof.

Swadu Kantaka : Spiny fruits are having Madhura Rasa.

Trikantaka : There are three Kantakas.

Vana Shringataka : Gokshura fruits resemble to fruits of Shringataka.

Chandramukha : Stems and leaves resemble to black gram plant.

Ikshu Gandhika : Plant juice odour smells like sugar cane juice.

Drug Review….


Names in different languages:

Kannada - Neggilu

Hindi - Gokharee

Bengali - Gokharee

Marathi - Sarate

Gujarathi - Nahna, Gokharu

Punjabi - Bhakhada

Tamil - Neroonjaji

Telugu - Pannera mullu

Malayalam - Jneringire

English - Small calotrops

Distribution : Found in all over India.

Description :

This is an annual herb or rarely perennial, greyish white or rusty brown,

prostate herb with many slender spreading branches, one to two feet or more in

length and about 0.05 inch in thickness.

Leaves are opposite, obruptly pinnate with persistent, lanceolate acute

stipules, leaflets 3 to 6 or more pairs, almost sessile or with short petiole,

oblong, round, flowers pseudo axillary or leaf opposed, solitary regular,

bisexual bright yellow or rarely white faintly scented. Sepals 5, free, lanceolate,

petals 5, free spreading about equaling the sepals or longer, rounded shortly

clawed imbricate and fugacious stamens ten inserted at base of disc. Ovary

sessile, style short, pyramidal stigma 5 ribbed or 5 to 12 stigmatic lobes.

Fruit is stalked, greyish spiny trabeculate, 5 ribbed, more or less

spherical with the base and upper flattened and covered with a matting of short

stiff or pubescent hair.

Drug Review….


Type:

Other type is Bruhatgokshura. It belongs to pedaliaceae family (Tila

kula). Its fruits are bigger than Gokshura fruits. It grows in costal area.

Useful parts: Root and fruit

Value of pH: 8.6

Chemical composition:

Fruit contains fixed oil, essential oil, resin, nitrate and alkaloid.

Guna :

Rasa - Madhura

Guna - Guru, Snigdha

Vipaka - Madhura

Veerya - Sheetha

Doshagnata - Pitta Vataghna

Karma - Vrushya, Deepaka, Pusthikara, Mutrala

Uses - Prameha, Shwasa, Kasa, Arsha, Hridroga,

Mutrakrichchra. Mutrashmari.

YAVA

Family - Gramineae.

Botonical name - Hordeum vulgarae

Regional Names:

Hindi - Jow

Tamil - Barliyarasi

Telugu - Barlibiyan

Kannada - Jave Godhi

English - Wheat

Drug Review….


Description: It is a stiff shrub ranging upto a year of life span, grows from 3 –

4 feet leaves are venated (Rekhakara), broad, Patrakosha are soft, membranous.

Fruit – Round, 3/8th inch long, both ends of fruit are sharp, soft glabrous and

the fruit is thickened at the middle. It has a very good reference in Rigveda,

wherein from those times it was used for holy purpose like Homa etc.

Type: In India there are 24 varities.

Value of pH: 9.6

Chemical composition:

Ardratha - 13.5 %

Protein - 11.5 %

Carbohydrate - 69.3 %

Sootra - 3.9 %

Khanija Padartha - 1.5 %

Calcium - 0.03 %

Phosphorous - 0.23 %

Loha - 3.8 %

Guna Karma:

Rasa - Madhura, Kashaya

Guna - Laghu, Rooksha

Veerya - Ushna

Vipaka - Madhura

Doshakarma - Kapha Shamaka,

Karma - Mootrala, Mootrakruchrahara,

Uses : Used as Ahaareeya Dravya

Drug Review….


Ananda Yoga

Tila Apamarga

Kadali Palasha

Amalaki Gomutra

Fig – 4

Drug Review….


Yavaksharadi Yoga

Yava Gokshura

Fig – 4

Clinical Study….


CLINICAL STUDY

Ashmari is one of the most common disorder of the Mutravaha Srotas. It

is one among the Asta-Mahagada. In modern science the disease can be

correlated with Urolithiasis.

The incidence of calculi varies as per geographical distribution, sex and

age group. The highest incidence of calculi occurs in between the age group of

30 to 50 yrs, male and female ratio is 3:1.

Ashmari description is available in all classical textbooks of Ayurveda.

Much medicinal Yoga has been told in the classics, which are cost effective

and also told to be very potent in treating Ashmari.

Acharya Sushrutha says that before going for surgical procedures one

should try to manage with oral medications like Ghrita, Taila and Kshara etc.

In this modern era many treatment modalities like Open surgery,

Cystolithotomy, Nephrolithotomy, Ureterolithotomy, Dormia basket are

available. All procedures are very costly and these facilities available in urban

areas only. For that reason, constant efforts are being made to evaluate an

effective treatment as well as prevention of recurrence of calculus.

Since there is need to evaluate an alternative, safe effective therapy for

the Mutrashmari, reachable for people of all economic class. In Bhaishajya

Ratnavali told that Ananda yoga is one of the good medicine for the treatment

of Mutrashmari. It contains Tila Panchanga, Apamarga panchanga, Kadali

Kanda, Palasha Kanda and Amalaki in equal quantity. All these drugs are

having Mutrala, Ashmari Bhedana properties.

Clinical Study….


MATERIALS AND METHODS

Source of data:

Patients of Mutrashmari were selected from the out patient and in patient

Department of P.G. Studies Shalyatantra, S. D. M. College of Ayurveda and

Hospital, Hassan.

Diagnostic criteria:

• As per the classical signs and symptoms of Ashmari like Sarudiramutrata,

Mahativedana, Vedana in Nabhi Pradesha, Basti Pradesha, Seevani

Pradesha, Mehana Pradesha and Mootradharasanga

• As per the Laboratory, Radiological and Sonological investigations.

Inclusion criteria:

• Patients with complaints of Samanya Lakshanas of Ashmari are included.

• Patients of have calculus below 20 mm of size.

• Patients of Urolithiasis confirmed by any of the diagnostic criteria.

• The patients between the age group of 16-60yrs will be selected irrespective

of Sex, Occupation, Race and Socioeconomic status.

Exclusion criteria:

• Patients who were suffering with severe systemic disorders like Renal

failure, Tuberculosis, Congenital Disorders of urinary system and

Neoplasms.

• Patients with Hyperparathyroidism.

• Patient with acute urinary obstruction.

• Patients who were contraindication for Paneeya Kshara.

Clinical Study….


Groups of the Treatment:

Selected patients were randomly divided into two groups, each group

consisting of 15 patients.

Yavaksharadi Yoga (Control Group, Group Y): The patients in this group

were treated with Yavaksharadi yoga.

Yavaksharadi Yoga was given in the dose of 6 gm thrice a day before food

with water for 21 days.

Yavakshara and Gokshura Choorna were taken in the proportion of 1:5.

Ingredients:

• Yavakshara

• Gokshura

Ananda Yoga (Study Group, Group A): The patients of this group were

treated with Ananda Yoga & was given to the patient for 21 days in a dose of

250mg – 500mg (2-4 Ratti), 3 times a day with Gomutra Arka.

Ingredients:

• Tila Panchanga

• Apamarga Panchanga

• Kadali Kanda

• Palasha Kanda

• Amalaki

Method of preparation of Ananda Yoga:

Take Equal parts of Tila Panchanga, Apamarga Panchanga, Kadali Kanda,

Palasha Kanda and Amalaki. Dissolve them together in water measuring 6

Parts. Strain the preparation for 21 times through a thick piece of cloth and

keep the preparation undisturbed for three hours. Subsequently, obtain the

upper layers of water of the preparation and store it in a pan. Cook it on a slow

heat. When the water content is evaporated, dry the silt under sun. Preserve the

Clinical Study….


same in glass bottle or air tight container. It should be given along with Urine

of Sheep.

Because of scarcity of Avi Mutra, the Gomutra Arka is used as Anupana.

Duration: Duration of the drug administration in both the groups was 21 days.

Assessment criteria:

Assessment was made on the basis of subjective and objective

parameters before and after treatment.

Subjective:

• Pain

• Frequency of micturition

• Burning micturition

• Haematuria

• Mootrdharasangha

• Bastigouravata

Objective:

According to Radiological / Sonological findings.

• Size of the stone

• Site of the stone

• Dislodging of the stone

• Expelling of the stone

Scoring Pattern of Subjective criteria:

1) Pain abdomen:

• Absence of pain abdomen Grade 0 (no pain)

• Present but does not disturbs routine Grade 1 (mild pain)

• Present, which disturbs routine Grade 2(moderate pain)

• Patient rolls on bed due to pain Grade 3 (severe pain)

Clinical Study….


2) Frequency of micturition:

Frequency was counted only when patient passes normal flow of

urine/urination.

3) Haematuria:

• Absence of haematuria Grade 0

• Presence of Microscopic haematuria Grade 1

• Presence of Macroscopic haematuria Grade 2

4) Burning micturation:

• Absence of Burning micturation. Grade 0

• Presence of Burning micturation. Grade 1

5) Mootradharasangha:

• None Grade 0

• Occasionally Grade 1

• Mild Grade 2

• Moderate Grade 3

• Severe Grade 4

6) Bastigouravata:

• None Grade 0

• Occasionally Grade 1

• Mild Grade 2

• Moderate Grade 3

• Severe Grade 4

Clinical Study….


Objective criteria:

• Size of the stone

• Site of the stone

• Number of stone

All these criteria were assessed by Radiological / Sonological findings.

Laboratory investigations:

1. Urine analysis:

Physical – Color

Ph

Specific Gravity

Sugar.

Microscopic – RBC

Casts & Crystals

Epithelial and Pus cells

Urine for Culture and Sensitivity. (If Necessary)

2. Blood examination:

Hemoglobin

Blood urea

Serum Creatinine

Serum Calcium

Serum Uric Acid.

3. Radiological investigation:

Plain X – ray KUB, IVP (If Necessary).

4. Ultrasonography:

KUB.

5. Analysis of Stone [was carried out where ever needed].

Clinical Study….


Overall Effect: Overall effects of the therapies were assessed as follows:

Complete Remission: 100% relief with expulsion of the stone or number of

stone observed in X Ray/Sonography.

Marked Improvement: 75 to 99% relief in signs and symptoms.

Moderate Improvement: 50 to 74% improvement in signs and symptoms.

Mild Improvement: Less than 26 to 50% improvement in signs and

symptoms.

Unchanged: < 25% improvement in signs and symptoms.

Observation and Results….


OBSERVATIONS AND RESULTS

Thirty patients of Mutrashmari (Urolithiasis) were selected for this dissertation

work. These patients were divided into two group viz. Yavaksharadi Yoga Group

(Group Y) and Ananda Yoga group (Group A). Each group comprised of 15

patients. All the selected patients were thoroughly examined and diagnosed based

on exclusive and inclusive criteria. The assignment showed the following statistics

which is presented in tables and graphs with brief description:

Age: Out of 30 patients 40% patients belonged to the age group of 15-30 yrs,

33.34% belonged to 31-45 yrs and 26.66% patients belonged to 46-60 years of age

group (Table-7, Graph no. 1).

Table-7

Showing Age-wise Distribution of 30 Patients of Mutrashmari

Age groups Group Y % Group A % Total %

15 to 30 6 40 6 40 12 40

31 to 45 3 20 7 46.66 10 33.34

46 to 60 6 40 2 13.33 08 26.66

Sex:

Among the 30 patients for the study, 80% were male and 20% were females

(Table-8, Graph no. 2).

Table-8

Showing sex-wise Distribution of 30 Patients of Mutrashmari

Sex Group Y % Group A % Total %

Female 03 20 03 20 06 20

Male 12 80 12 80 24 80



Habitat:

Out of 30 patients of this series, maximum patients 63.34% were from rural

area and 36.66% patients were from urban area (Table-9, Graph no.3).

Table No-9

Showing Habitat-wise Distribution of 30 Patients of Mutrashmari

Habitat Group Y % Group A % Total %

Rural 10 66.66 09 59.94 19 63.34

Urban 05 33.33 06 39.96 11 36.66

Occupation:

Study reviles that out of 30 patients 33.33% were agriculturists, 13.33%

were housewives, 23.33% were government servants, 10% were coolie and

students, 6.66% were buisinessmen and 3.35% were driver. (Table-10, Graph

no.4).

Table no. 10

Showing Occupation-wise Distribution of 30 Patients of Mutra Ashmari

Occupation Group Y % Group A % No. of patients %

Agriculture 05 33.33 05 33.33 10 33.33

House wife 02 13.33 02 13.33 04 13.33

Govt.Servant 04 26.66 03 20 07 23.33

Business 00 00 02 13.33 02 6.66

Cooli 02 13.33 01 6.66 03 10

Driver 00 00 01 6.66 01 3.35

Hotel worker 00 00 00 00 00 00

Student 02 13.33 01 6.66 03 10



Religion:

Religion wise distribution showed that out of 30 patients, 96.66% were

Hindu, 3.34% were Muslim. (Table-11, Graph no.5)

Table no 11

Showing distribution of patients as per Religion of 30 Patients of Mutrashmari

Religion Group Y % Group A % Total %

Hindu 15 100% 14 93.33 29 96.66

Muslim 00 00 01 6.66 01 3.34

Socioeconomic status:

Analysis of socio-economic status of 30 cases of Mutrashmari showed that

majority of patients 50% belonged to lower middle class whereas 20% patients

were found in poor and upper middl and 10% patients were reported having good

class socio-economic status. (Table - 12, Graph - 6)

Table no 12

Showing distribution of patients as per Socioeconomic status of 30 Patients of

Mutrashmari

Socioeconomic

status

Group Y % Group A % Total %

Good 02 13.32 01 6.66 03 10

UMC 01 6.66 05 33.33 06 20

LMC 08 53.28 07 46.62 15 50

Poor 04 26.64 02 13.32 06 20



0

5

10

15

20

25

30

35

40

Age Wise Distribution

Graph 1

15 to 30 31 to 45 46 to 60

0

10

20

30

40

50

60

70

80

Sex Wise Distribution

Graph 2

Male Female 3-D Column 3

0

10

20

30

40

50

60

70

Habit Wise Disrribution

Graph 3

Rural Urban

0

5

10

15

20

25

30

35

Occupation Wise Distribution

Graph 4

Agriculture House Wife Gov. ServantBuisness Coolie DriverStudent

0102030405060708090

100

Religion Wise Distribution

Graph 5

Hindu Muslim

05

101520253035404550

Socio-Economic Status

Graph 6

Good UMC LMC Poor



Habit:

Habit wise distribution shows that among 30 patients, 43.29% had no

habits, 9.99% patient had only smoking habit, 13.38% were only alcohol drinkers

and 33.34% were having both habit of smoking as well as drinking. (Table-13,

Graph no.7)

Table no 13

Showing distribution of patients as per Habits of 30 Patients of Mutrashmari

Habits Group Y % Group A % No. of patients %

No habits 07 46.62 05 33.3 13 43.29

Smoking 02 13.32 01 6.66 03 9.99

Alcohol 02 13.32 02 13.32 04 13.38

Both Alcohol

& Smoking

04 26.64 06 39.96 10 33.34

Diet:

Diet wise distribution shows that among 30 patients, 23.34% were

vegetarian, 76.33% were mixed dietary habit. (Table-14, Graph no.8)

Table no.14

Showing distributions of patients as per Nature of food intake of 30 Patients of

Mutrashmari

Ahara Group Y % Group A % No. of patients %

Vegetarian 03 19.98 04 26.66 07 23.34

Mixed 12 79.92 11 73.33 23 76.66



Family history:

Family history wise distribution shows that among 30 patients, 10% were

present, 90% were absent. (Table-15, Graph no.9)

Table no. 15

Showing distribution of patients as per Family history of 30 Patients of Mutrashmari

Family history Group Y % Group A % Total %

Present 01 6.66 02 13.33 03 10

Absent 14 93.24 13 86.66 27 90

Prakruthi:

Prakruti wise distribution has shown that out of 30 patients, 50% were of

Vatapittaja Prakruti, 16.66% were of VataKaphaja Prakruti, 30% were of

Kaphavataja, and 3.34% were of Kaphapittaja Prakruthi (Table-16) (Graph-10).

Table no. 16

Showing distribution of patients as per Prakruthi of 30 Patients of Mutrashmari

Prakruthi Group Y % Group A % No. of patients %

Vatapittaja 08 53.33 07 46.66 15 50

Vatakaphaja 02 13.33 03 20 05 16.66

Kaphavataja 05 33.33 04 26.66 09 30

Kaphapittaja 00 00 01 6.66 01 3.34



Presenting Complaints:

Among the 30 patients taken for the study, all the patients 100%

complained of pain in abdomen, 73.26% complained of Frequency of micturition

and 79.92% complained of burning micturition, 19.98% complained of

haematuria, 23.33% complained of Mutradhara Sangha and 16.66% complained of

Bastigouravata. (Table-17, Graph no.11)

Table no. 17

Showing distribution of patients as per presenting complaints of 30 Patients of

Mutrashmari

Symptoms Group

Y

% Group A % No. of

patients

%

Pain abdomen 15 100% 15 100 30 100

Frequency of

micturition >5 Times

11 73.26% 11 73.26 22 73.26

Burning micturition 13 86.58% 11 73.26 24 79.92

Haematuria 03 19.98% 03 19.98% 06 19.98

Mootradhara Sangha 03 19.98% 04 26.66 07 23.33

Bastigoravata 02 13.33 03 10 05 16.66



0

10

20

30

40

50

Habit Wise Distribution

Graph 7

No habitsSmokingAlcoholBoth Alcohol & Smoking

0

10

20

30

40

50

60

70

80

Diet Wise Distribution

Graph 8

Veg Mixed

0102030405060708090

Family Histroy WiseDisrribution

Graph 9

Present Absent

05

101520253035404550

Prakruti Wise Distribution

Graph 10

Vatapittaja Vatakaphaja

Kaphavataja Kaphapittaja

0

20

40

60

80

100

Lakshana Wise Distribution

Graph 11Pain abdomen

Frequency ofmicturition >5TimesBurningmicturition

Haematuria

MootradharaSangha

Bastigoravata



Degree of Pain Abdomen:

10% patients suffered from mild form of abdominal pain, 56.66% from

moderate and 33.34% from severe form of abdominal pain (Table-18) (Graph-

12).

Table no. 18

Showing distribution of patients as per Degree of pain abdomen of 30 Patients

of Mutrashmari

Degree of

pain

Group Y % Group A % No.of

patients

%

Mild 02 13.34 01 6.66 03 10

Moderate 09 60 08 53.34 17 56.66

Severe 04 26.66 06 40 10 33.34

Character of pain:

Character of pain showed that among 30 patients, 16.66% had constant pain

in abdomen, 10% had Intermittent and 73.34% had radiating and colicky type of

pain. (Table-19, Graph no.13).

Table no. 19

Showing distribution of patients as per Character of pain of 30 Patients of

Mutrashmari

Character of

pain

Group Y % Group A % No. of patients %

Constant 03 19.98 02 13.32 05 16.66

Intermittent 02 13.32 01 6.66 03 10

Radiating &

Colicky

10 66.6 12 79.92 22 73.34



Associated symptoms:

Associated symptoms showed that among 30 patients, 13.34% had no

symptom , 50 % complained of vomiting and 36.66% complained of nausea.

(Table-20, Graph no.14)

Table no. 20

Showing distribution of patients as per Associated symptom of 30 Patients of

Mutrashmari

Associated

symptoms


No 02 13.32 02 13.32 04 13.34

Nausea 07 46.62 04 26.64 11 36.66

Vomiting 06 39.96 09 59.94 15 50

Side of the stone:

Study reviles showed that among 30 patients, 83.34% had unilateral stone

and 16.66% had bilateral stone. (Table-21, Graph no.15)

Table no 21

Showing distribution of patients as per Side of the stone of 30 Patients of

Mutrashmari

Side of the stone Group Y % Group A % Total %

Unilateral 13 86.66 12 79.92 25 83.34

Bilateral 02 26.34 03 19.98 07 16.66



Ashmari bheda:

Among 30 patients, 76.66% of patients had Vataja type of stone, 13.34%

had Pittaja type of stone, and 10% had Kaphaja type of stone.

Table no 22

Showing distribution of patients as per Ashmari bheda of 30 Patients of

Mutrashmari

Ashmari

Bheda


Vataja 11 73.34 12 80 23 76.66

Pittaja 03 20 01 6.66 04 13.34

Kaphaja 01 6.66 02 13.33 03 10

Site of the stone:

Distribution as per site showed that among 30 patients, 43.34% had renal

calculi, 46.66% had Ureteric Calculi and 10% of patients had both renal and

Ureteric calculi. (Table-23,Graph-17)

Table no 23

Showing distribution of patients as per site of the stone of 30 Patients of

Mutrashmari

Site of the stone Group Y % Group A % Total Percentage

Renal 06 33.33 07 46.66 13 43.34

Ureteric 08 53.33 06 33.33 14 46.66

Both 01 6.66 02 13.33 03 10

Urethra 00 00 00 00 00 00



0

10

20

30

40

50

60

Degree of Pain WiseDistribution

Graph 12

Mild Moderate Severe

0

10

20

30

40

50

60

70

80

Character of Pain WiseDistribution

Graph 13

Constant Intermittent Radiating & Colicky

05

101520253035404550

Ass. Symptom WiseDisrribution

Graph 14

No Nausea Vomiting

0102030405060708090

Side of Stone WiseDistribution

Graph 15

Unilateral Bilateral

01020304050607080

Ashamari Bheda WiseDistribution

Graph 16

Vataja Pittaja Kaphaja

05

101520253035404550

Site of Stone WiseDistribution

Graph 17

Renal Ureteric Both Urethra



Size of the stone:

Among 30 patients, 39.96% of patients had 1 - 5 mm of stone, 73.26% had

6 – 10 mm of stone, and 19.98% had 11-15 mm of stone and in 9.99% had >

15mm. (Table-24,Graph-18)

Table no 24

Showing distribution of patients as per Size of the stone of 30 Patients of

Mutrashmari

Size of the stone Group Y % Group A % Total Percentage

1-5mm 06 39.96 06 39.96 12 39.96

6-10mm 10 66.6 12 79.92 22 73.26

11-15mm 03 19.98 03 19.98 06 19.98

>15mm 02 13.32 01 6.66 03 9.99

H/O Previous complaints:

Among the 30 patients only 16.65% of patient had history of previous

Complaints of stone. (Table-25, Graph no.19)

Table no 25

Showing distribution of patients as per H/O Previous complaints of 30 Patients

of Mutrashmari

H/O Previous

complaints

Group Y % Group A % Total %

Absent 12 79.92 13 86.58 25 83.35

Present 03 19.98 02 13.32 05 16.65



pH of Urine:

Among the 30 patients only 33.34 % of patient had urine pH of 5, 30% of

patient had urine pH 6 and 36.66% of patient had urine pH 7. (Table-26, Graph

no.20)

Table no 26

Showing distribution of patients as per Urine PH of 30 Patients of Mutrashmari

Urine pH Group Y % Group A % Total %

5 03 19.98 07 46.62 10 33.34

6 07 46.62 02 13.32 09 30

7 05 33.3 06 39.96 11 36.66

01020304050607080

Size of Stone WiseDistribution

Graph 18

1-5mm 6-10mm 11-15mm >15mm

0102030405060708090

H/O Previous ComplaintWise Distribution

Graph 19

Absent Present

0

5

10

15

20

25

30

35

40

pH Disrribution of Urine

Graph 20

5 6 7



EFFECT OF THE THERAPY

Thirty Patients of Mutrashmari were studied in this study by randomly dividing

them into two groups, viz. Yavaksharadi Yoga (Group Y) and Ananda Yoga

(Group A). The results obtained in both the groups are being described under the

separate headings.

Effect of Yavaksharadi Yoga

15 patients of Mutrashmari were treated with Yavaksharadi Yoga

administered orally in the dose of 6 Gms three times a day for 21 days. Its effects

on the various signs and symptoms were as follow:

1) Effect of Yavaksharadi Yoga on Pain abdomen:

The drug showed significant relief of 30% in pain in 7 days. At 14th day the

quantum of relief further reduced to 58.57% and after completion of the treatment

it showed 68.57% reduction in the pain (Table-27).

Table-27

Effect of Yavaksharadi Yoga on Pain in Abdomen

Mean

Days N

BT AT% Of relief SD(±) SE(±) t P

7 days 15 2.3 1.6 30 % 0.48 0.11 3.2 <0.01

14 days 15 2.3 1.1 58.57 % 0.64 0.16 5.7 <0.001

21days 15 2.3 0.6 68.57 % 0.73 0.16 8.2 <0.001

2) Effect of Yavaksharadi Yoga on Burning Micturition:

The drug showed 16.38% relief in Burning Micturition after 7 days. At 14th

day further reduced to 63.53 % and after completion of the treatment it showed

94.30 % reduction Which is statistically highly significant (P<0.001) (Table-28).



Table-28

Effect of Yavaksharadi Yoga on Burning Micturition Mean

Days N BT AT % Of relief SD(±) SE(±) t P

7 days 13 1 0.81 16.38 % 0.37 0.10 1.4 >0.05

14 days 13 1 0.28 63.53 % 0.50 0.14 4.38 <0.001

21days 13 1 0.07 94.30 % 0.27 0.07 12 <0.001

3) Effect of Yavaksharadi Yoga on Haematuria:

The drug showed 30 % relief in Haematuria after 7 days. At 14th day further reduced to 50% and after completion of the treatment it showed 100 % reduction which is statistically significant (P- <0.05) (Table-29)

Table- 29 Effect of Yavaksharadi Yoga on Haematuria

Mean Days

N BT AT % Of relief SD(±) SE(±) T P

7 days 3 1.6 1.2 30 % 0.57 0.33 1 >0.05

14 days 3 1.6 0.9 50 % 0.57 0.33 2 >0.05

21days 3 1.6 0 100 % 0.57 0.33 5 <0.05

4) Effect of Yavaksharadi Yoga on Frequency of micturition:

The drug showed statistically significant increase in frequency of

micturition in 7 days by 18.07%. Which maintained even at 14th day it further

increased to 31.32 % and after completion of the treatment it increased to 31.32 %

(Table-30).

Table-30 Effect of Yavaksharadi Yoga on Frequency of micturition

Mean

Days N BT AT % SD(±) SE(±) T P

7 days 15 5.5 6.5 18.07 % 0.92 0.23 4.18 <0.001

14 days 15 5.5 7.2 31.32 % 1.38 0.35 4.84 <0.001

21days 15 5.5 7.2 31.32 % 1.43 0.37 4.66 <0.001



5) Effect of Yavaksharadi Yoga on Mutradharasangha:

The drug showed statistically significant reducing Mutradharasangha in 7

days by 16.07%, 33.32 % in 14 days and 82.17% after completion of the treatment

in 21 days. (Table-31)

Table-31

Effect of Yavaksharadi Yoga on Mutradharasangha

Mean

Days N BT AT % Of relief SD(±) SE(±) T P

7 days 03 0.4 0.3 16.07 % 0.93 0.04 4.84 <0.001

14 days 03 0.4 0.3 33.32 % 0.38 0.03 4.72 <0.001

21days 03 0.4 0.2 82.17 % 0.25 0.02 4.64 <0.001

6) Effect of Yavaksharadi Yoga Bastigouravata:

The drug showed statistically significant reducing Bastigouravata in 7 days

by 19.72%, 38.42 % in 14 days and 77.34% after completion of the treatment in

21 days. (Table-32)

Table-32

Effect of Yavaksharadi Yoga on Bastigouravata

Mean


7 days 02 0.3 0.1 19.72 % 0.28 0.04 4.74 <0.001

14 days 02 0.3 0.1 38.42 % 0.26 0.03 4.71 <0.001

21days 02 0.3 0.1 77.34 % 0.25 0.02 4.61 <0.001



7) Effect of Yavaksharadi Yoga on Number of Stones:

Before starting the treatment the mean number of stone was 1.4 per patient. After

the 21 days of treatment it significantly decreased to 1 per patient. (Table-33)

Table-33

Effect of Yavaksharadi Yoga on Number of Stones

Mean


21days 15 1.4 1 23.80 % 0.48 0.12 2.64 <0.02

8) Effect of Yavaksharadi Yoga on size of Stones:

After the treatment the stone size was reduced by 21% which is

stastistically insignificant (Table 34).

Table-34

Effect of Yavaksharadi Yoga on size of Stones

Mean


21days 21 8.6 6.85 21 % 5.0 1.2 1.4 >0.05

9) Response over descent/expulsion

Out of total 21 stones, 12 belonged to renal stone, 9 of ureteric stone.

Among 12 renal stones, 2 were expelled out and 1 descended down. Among 9

ureteric stone 3 were expelled out and 2 descended down. (Table-35)

Table - 35

Showing response on Descent / Expulsion of stones

Site of

stone

No.of

stones

Descent of

stone

% Expulsion

of stone

%

Renal 12 01 8.33% 02 16.66

Ureter 9 02 22.2% 03 33.33

T0tal 21 03 14.28% 05 23.8



Effect of Ananda Yoga:

15 patients of Mutrashmari were treated with Ananda Yoga administered

orally in the dose of 250-500 gm three times a day for 21 days along with Gomutra

Arka. Its effects on the various signs and symptoms were as follow: 1) Effect of Ananda Yoga on Pain abdomen:

The drug showed significant relief of 39.33 % in pain in 7 days. At 14th day

the quantum of relief further reduced to 68.77 % and after completion of the

treatment it showed 89.92 % reduction in the pain (Table-36).

Table-36

Effect of Ananda Yoga on Pain abdomen

Mean


7 days 15 2.4 1.6 39.33 % 0.41 0.10 7.4 <0.001

14days 15 2.4 1.2 68.77 % 0.45 0.11 10.71 <0.001

21days 15 2.4 0.4 89.92 % 0.67 0.18 8.66 <0.001

2) Effect of Ananda Yoga on Burning Micturition:

The drug showed 28.18% relief in Burning Micturition after 7 days. At 14th

day further reduced to 63.68 % and after completion of the treatment it showed

92.91 % reduction which is statistically highly significant (P<0.001) (Table-37).

Table-37

Effect of Ananda Yoga on Burning Micturition

Mean


7 days 11 1 0.81 28.18 % 0.4 0.12 1.4 >0.05

14days 11 1 0.36 63.68 % 0.5 0.15 4.1 <0.01

21days 11 1 0.09 92.91 % 0.3 0.09 10 <0.001



3) Effect of Ananda Yoga on Haematuria:

The drug showed 40 % relief in Haematuria after 7 days. At 14th day

further reduced to 60% and after completion of the treatment it showed 100 %

reduction which is statistically significant (P- <0.05) (Table-38).

Table-38

Effect of Ananda Yoga on Haematuria

Mean


7 days 03 1.6 1.3 40 % 0.67 0.43 1 >0.05

14 days 03 1.6 1 60 % 0.67 0.43 2 >0.05

21days 03 1.6 0 100 % 0.67 0.43 5 <0.05

4) Effect of Ananda Yoga on Frequency of micturition:

The drug showed statistically significant increase in frequency of

micturition in 7 days by 13.68%. Which maintained even at 14th day it further

increased to 26.64 % and after completion of the treatment it increased to 34.32 %

(Table-39).

Table-39

Effect of Ananda Yoga on Frequency of micturition

Mean

Days N BT AT % SD(±) SE(±) t P

7 days 15 4.8 5.8 13.68% 0.97 0.25 2.64 <0.02

14 days 15 4.8 6.9 26.64 % 0.45 0.11 10.71 <0.001

21days 15 4.8 7.0 34.32 % 0.72 0.18 7.13 <0.001



5) Effect of Ananda Yoga on Mutradharasangha:

The drug showed statistically significant reducing Mutradharasangha in 7

days by 19.07%, 38.32 % in 14 days and 86.74% after completion of the treatment

in 21 days. (Table-40)

Table-40

Effect of Ananda Yoga on Mutradharasangha

Mean


7 days 04 0.8 0.6 19.07 % 0.64 0.19 5.74 <0.001

14 days 04 0.8 0.5 38.32 % 0.58 0.17 5.72 <0.001

21days 04 0.8 0.4 86.74 % 0.54 0.15 5.24 <0.001

6) Effect of Ananda Yoga Bastigouravata:

The drug showed statistically significant reducing Bastigouravata in 7 days

by 21.62%, 48.52 % in 14 days and 87.24% after completion of the treatment in

21 days. (Table-41)

Table-41

Effect of Ananda Yoga on Bastigouravata

Mean


7 days 03 0.6 0.5 21.62 % 0.48 0.16 4.88 <0.001

14 days 03 0.6 0.5 48.52 % 0.45 0.15 4.86 <0.001

21days 03 0.6 0.4 87.24 % 0.41 0.13 4.83 <0.001

7) Effect of Ananda Yoga on Number of Stones:

Before starting the treatment the mean number of stone was 1.4/ patient.

After the 21 days of treatment it significantly decreased to 0.5/patient. (Table-42)



Table-42

Effect of Ananda Yoga on Number of Stones

Mean


21days 15 1.4 0.5 36.92% 0.5 0.18 2.9 <0.01

8) Effect of Ananda Yoga on size of Stones:

The drug showed significant reduction in the size of stones which is 38.46

% at the end of the treatment. (Table-43)

Table -43

Effect of Ananda Yoga on size of Stones

Mean


21days 22 7.9 5.2 38.46 % 3.89 0.78 2.52 <0.02

9) Response over descent / expulsion

Out of total 22 stones, 09 belonged to renal stone, 13 of ureteric stone. Among 09

renal stones, 4 were expelled whereas 03 descended down. Among 13 ureteric

stone 5 were expelled out and 3 descended down. (Table-44)

Table -44

Showing response on Descent / Expulsion of stones (On their site)

Site of

stone

No. of

stones

Descent of

stone

% Expulsion

of stone

%

Renal 09 02 22.22% 04 44.44

Ureter 13 03 23.07% 05 38.46

Urethra 00 00 00 00 00

Total 22 05 22.72% 09 40.90



Overall Effect of the Yavaksharadi Yoga:

Considering the overall response of the patients to the therapy with

Yavaksharadi Yoga showed that in these series 33.3% patients had complete

remission, no patients got marked improvement 6.7% patients showed moderate

improvement and 13.3% of the patients of this series remained unchanged (Table-

45).

Table-45

Yavaksharadi Yoga

Complete Remission 05 33.33%

Marked Improvement 00 00.00%

Moderate Improvement 01 6.7%

Mild Improvement 07 46.66%

Unchanged 02 13.33%.

Overall Effect of the Ananda Yoga:

Considering the overall response of the patients to the therapy with Ananda

Yoga showed that in these series 60% patients had complete remission, no patients

got marked improvement, 20% patients showed moderate improvement, 6.7%

patiemts showed mild improvement and 13.3% of the patients of this series

remained unchanged (Table-46).

Table-46

Ananda Yoga

Complete Remission 09 60%

Marked Improvement 00 00.00%

Moderate Improvement 03 20%

Mild Improvement 01 6.7%

Unchanged 02 13.33%



Overall Results of both the groups:

Overall Results of both the groups

0

20

40

60

80

100

Group Y Group A

Graph 19

Pain abdomen Burning micturition

Heamaturia Frequency of micturition

Mutradharasangha Bastigouravata

Number of stones Size of stone

Expulsion of stone

Follow up Study:

The patients were advised to attend the O.P.D at weekly interval for 3

months. No reccurence was reported by the patient’s upto the 3 months of the

follow up study.

Discussion….


DISCUSSION

Based on symptoms and other factors, the disease “Mutrashmari” is correlated

with Urolithiasis. Ashmari is considered as Maharoga because,

• This disease is Tridoshaja

• It is Marmashrayee.

• Basti is Vyakthasthana of Ashmari and Basti comes under Pranayatana.

• When it is a fatal disease, as it needs surgical intervention.

• On the basis of prognosis as this disease is Kruchchrasadhya Vyadhi.

Another observation showed that the males are the common victims than

females, as seen in the statistics. The reasons we can give may be due to:

• The dehydration rate is more in males, which lead to the concentration of

urine.

• Calcium and phosphate metabolism rate is high (as the muscles are vigorously

used)

• Regular changes in food habits.

These may contribute some factors which are responsible for the formation

of stones. Moreover the etiology as said in Sushruta Samhitha like Adhyashyana,

and Asamshodhana can be well interpreted in males who have the habits like

smoking, alcohol, non-veg, irregular timely food intake, and even the change of

type of food. All these contribute for the aggravation of Tridosha leading to the

Moothravaha Srothodusti causing Mutrashmari, when not eliminated by

Shodhana therapies.

In the present study, most of the patients were shown with the history

regular taking of Ragi and Matsya.

Discussion….


Ragi:

All the above Gunas are the Nidana as explained in Ayurvedic literature.

Nutritive value of Ragi contains 334mg/100gm of calcium, which is precipitating

factor for formation of calculus.

Anupa-Matsya:

Anupa-Matsya is said to be Aharaja Nidana for Ashmari.

These foodstuffs are rich in phosphates and purines, which helps in the formation

of phosphate stones.

The main diagnostic criteria are done on the basis of Lakshana. Ruja,

Varna, Samuthana, Sthana and Samsthana are had been used by our Acharyas to

differentiate the diseases for diagnosis.

Vatajashmari:

This variety can be compared with the oxalate type of stone.

Pittajashmari:

This is variety can be compared with the uric acid type of stone.

Kaphajashmari:

This variety can be compared with the phosphate type of stone.

Shukraja Ashmari:

Though this is bit difficult to find, it can be compared with seminal

concretions or the spermolith, which are of course not seen in ultrasonography or

X-ray but are very fragile in nature and can be crushed by fingers. Even the site of

pain also differs (mainly at the path of vas deference) and hence it is not included

in the present study.

Discussion….


Probable mode of action of Ananda Yoga:

Ananda Yoga composed of Tilanala, Apamarga, Kadali Kanda, Palasha

Kanda and Amalaki.

This compound is the combination of 5 drugs which having synergetic

action. All the drugs support or help each other for better combined effect.

Due to Teekshna Guna and Chedana, Bhedana and Lekhana properties

these drugs can easily breaks the stones or reduces the size of the stones and by

this the size of stones become small and can easily removed out.

Due to Sheeta Veerya and Madhura Vipaka of some drugs acts as a

Mutrala, while due to Katu Rasa these drugs have Marga Shodhaka and helps to

easy expulsion of the Ashmari.

Some of the patients came with associated complains of burning micturition

and haematuria and got good result by the treatment as some of these drugs having

Kashaya Rasa and Sheeta Veerya also having Sthambhaka and Mootra-Virajaniya

property thus it causes constriction in the bleeding capillaries.

It also has Ashmaribhedana, Tridosha Shamaka, Anulomana properties. It

acts as Kaphagna and Vataghna.

Vata and Kapha are the main responsible Doshas in the pathogenesis; it is

evident that this formulation is effective in Ashmari.

Apamarga having Teekshna Guna and Ashmari Bhedana property as well

as Palasha and Tila is best drug for Kaphaja Vyadhi. So these three drugs do the

Sampraptivighatana of Ashmari and thus in combination with Kadali and

Amalaki, this Choorna act as Ashmarihara.

The Yoga has Mutrala effect there by it will increase the intra luminal

pressure. Because of this pressure stone will be expelled as a whole from the

urinary system. It is due to Srustavinmutrakaraka and Anulomana property of the

drug.

Discussion….


Dose of drug: The drug was given 250-500 gm thrice a day considering severity

of the symptoms. But generally the Choorna Matra is Karsha Matra.

30 patients of Ashmari were studied in this series. Significant findings of

the patients of this series were as follow:

Age: Out of 30 patients 40% patients belonged to the age group of 15-30 yrs,

33.34% belonged to 31-45 yrs and 26.66% patients belonged to 46-60 years of age

group. This might be due to the stress work, irregular dietetics and habits,

orientations towards different food, lack of proper regimens in daily routines etc,

there by reducing the quantity of urine output in turn helping the formation of

stone.

Sex: Among the 30 patients for the study, 80% were male and 20% were females.

It was observed that men dominated in number than the female as said in the

standard data in modern literatures, it was found that a ratio of M: F was 3:1. This

can be once again justified with the above statement as males are prone for the

same.

Habitat: More number of patients treated for working in rural compared with

urban.

Occupation: Study reviles that out of 30 patients 33.33% were agriculturists,

13.33% were housewives, 23.33% were government servants, 10% were coolie

and students, 6.66% were buisinessmen and 3.35% were driver. Mutrashmari

mainly occurs in those who does work in hot sun, travels a lot, exertional

occupation leads to increased exposure to sun, increased perspiration leading to

more concentrated urine thereby leading to formation of Ashmari.

Nature of Food Intake: Out of 30 patients, 76.66% patients are non-vegetarians

and consuming more non-vegetarian food is one among the causes for urinary

calculus the intake of animal protein which is rich in calcium oxalates, phosphates

Discussion….


and purine is one. As in non-vegetarian there is a chance of more accumulation of

the above components in the body, they have a risk of developing the disease.

Prakruti: Prakruti wise distribution has shown that out of 30 patients, 50% were

of Vatapittaja Prakruti, 16.66% were of VataKaphaja Prakruti, 30% were of

Kaphavataja, and 3.34% were of Kaphapittaja Prakruthi. So the evidence is almost

same in all Prakruti persons.

Presenting Complaints: In this study clinical observation were found like Pain

abdomen, Burning micturition, Haematuria, Mutradhara Sangha, Bastigouravata

etc. But pain abdomen is the common symptom which is present in all the patients.

Ashmari Bheda: Based on Lakshana and possessing the qualities of the Vataja

Ashmari, it can be correlated as calcium oxalate type of stone. In this place their

main food habit is Ragi, which is rich in calcium. Vataja Ashmari is more in

number compared to Pittaja and Kaphaja Ashmari.

Site of Stone: Ureteric stones are more comparing to Renal and bladder stone.

Usually ureteric stones more pain full compares to renal stones and some time

renal stones are silent.

Side of Stone: Out of 30 patients, 76.59% patient stones are in one side of the

urinary tract unilateral and remaining 23.31% patient stones are bilateral. The

causes of stones are unilateral or bilateral it is very difficult to give definite

explanation.

Response on pain abdomen:

The Yavaksharadi Yoga group showed significant reduction in the

abdominal pain by 68.57%, whereas Ananda Yoga group showed significant

reduction in the abdominal pain by 89.92 % after 21 days of treatment.

Discussion….


Ananda Yoga group showed better improvement than Yavaksharadi Yoga

group in reducing abdominal pain as this compound having better analgesic,

antispasmodic and anti-inflammatory action.

Response on Burning Micturition:

The Yavaksharadi Yoga group showed significant reduction in the burning

micturition by 84.30 %, whereas Ananda Yoga group showed significant reduction

in the burning micturition by 92.91 % after 21 days of treatment.

Ananda Yoga group showed better improvement than Yavaksharadi Yoga

group in reducing burning micturition. This may be due to the reason that Ananda

Yoga contains more Kshara which is Daha Hara.

Response on Haematuria:

The Yavaksharadi Yoga group showed significant reduction in the

haematuria by 100 % where as Ananda Yoga group also showed significant

reduction in the Hematuria by 100 % after 21 days of treatment.

Thus Ananda Yoga group and Yavaksharadi Yoga group equally reduced

Haematuria as this compound having Mutravirajaniya property.

Response on Frequency of Micturition:

The Yavaksharadi Yoga group showed significant increase in the frequency

of micturition by 31.32 %, whereas Ananda Yoga group showed significant

increase in the frequency of micturition by 34.32% after 21 days of treatment.

Thus Ananda Yoga group showed better improvement than Yavaksharadi Yoga

group to increase frequency of micturition.

Response on Mutradharasangha:

The Yavaksharadi Yoga group showed significant reduction in

Mutradharasangha by 82.17 %, whereas Ananda Yoga group showed significant

reduction in Mutradharasangha by 86.74% after 21 days of treatment.

Discussion….


Thus Ananda Yoga group showed better improvement than Yavaksharadi

Yoga group in reduction of Mutradhara Sangha.

Response on Bastigouravata:

The Yavaksharadi Yoga group showed significant reduction in

Bastigouravata by 77.34 %, whereas Ananda Yoga group showed significant

reduction in Bastigouravata by 87.24% after 21 days of treatment.


Yoga group in reduction of Bastigouravata.

Response on number of stones:

The Yavaksharadi Yoga group showed significant decrease in the number

of stones by 23.80 % whereas Ananda Yoga group showed significant decrease in

the number of stones by 36.92 % after 21 days of treatment.

Thus Ananda Yoga group provided better improvement than Yavaksharadi

Yoga group to decrease in the number of stones.

Response on size of stones:

The Yavaksharadi Yoga group showed insignificant decrease in the size of

stones by 21 % where as Ananda Yoga group showed significant decrease in the

size of stones by 38.46% after 21 days of treatment.


group group to decrease size of stones.

Response on Descent/Expulsion of Stones:

The Yavaksharadi Yoga group significantly descends the stones by 14.28%

& expulses the stones by 23.80% whereas Ananda Yoga group significantly

descends the stones by 22.72% & expulses by 40.90% after 21 days of treatment.


Yoga group to expel the stones.

Discussion….


Overall effect Of Ananda Yoga:

Ananda Yoga showed complete remission in 60%, moderate

improvement in 20% & mild improvement in 6.7% of patients. Remaining 13.33%

showed no response to the treatment.

Overall effect Of Yavaksharadi Yoga:

Yavaksharadi Yoga showed complete remission in 33.3% patients,

moderate improvement in 6.7% patients and mild improvement in 46.7% of

patients. Remaining 13.33% showed no response to the treatment.

Significant Effects of Ananda Yoga:

Ananda Yoga showed significant reduction in Pain abdomen (89.92%),

Haematuria (100%), number of stone (36.92 %) and size (38.46%) of the stones.

In this group 60% patients got complete remission, 20% had moderate

improvement and 6.7% showed mild improvement.

Significant Effects of Yavaksharadi Yoga:

Yavaksharadi Yoga showed significant reduction in haematuria (100%) and

burning micturition (84.30 %) and significantly increased the frequency of

micturition (31.32 %). In this group 33.3% patients got complete remission, 6.7%

had moderate improvement, 46.33% showed mild improvement and 13.33%

patients remained unchanged.

Comparison of the Effects:

Ananda Yoga provided better relief in Pain, expelled more number of

stones, and reduced the size of the stones than that of Yavaksharadi Yoga.

Ananda Yoga provided better reduction in burning micturition and increase

in frequency of micturition. Both Yavaksharadi Yoga and Ananda yoga showed

complete reduction in Haematuria.

Discussion….


Considering the overall improvement provided by these showed that both

Ananda Yoga provided 60% complete remissiom and Yavaksharadi Yoga

provided 33.3% patients. Further in Ananda Yoga group 13.33% patients

remained unchanged while in Yavaksharadi Yoga group 13.33% patients remained

unchanged.

On the basis of the above comparison it can be said that improvement

provided by Ananda Yoga to the patients of Ashmari was better in comparison to

the Yavaksharadi Yoga.

Hence Ananda yoga may be recommended for the better management in

pain, haematuria, expulsion, descending and reducing the size of the stone as well

as for providing better overall effect to the patients of Mutrashmari.

Effect of Ashmarigna:

Ananda Yoga has Ashmaribhedana, Tridosha Shamaka, Anulomana

properties. It also increases the peristaltic movement of smooth muscles. All these

properties in terms help in reduction and expulsion of urinary stones.

The drugs are having the properties like Lekhana, Bhedana, Chedana and

Ashmarighna property acts over the compact molecules of the stones brings

weakness in their bondage. For the formation of stone, role of Kapha is very

essential as its basic quality is ‘Shlish Alinghane’. Here the Lekhana, Bhedana etc.

properties of the drug act over the compact molecules destructing their bondage. It

is having the properties of Bhedana, Mutrala, Mutrakruchraahara, Anulomana,

Shoolaprashamana and Krimigna property.

Discussion….


Difficulties:

Size of the stone –

• The size of the stone expelled was not measured and analyzed as patients were

not able to collect them, inspite of instruction.

Anupana –

• In clasics for Ananda yoga Avimutra is Anupana. The availability of Avimutra

is very difficulty in Hassan.

• While administering the Anupana of Gomutra Arka, some patients are refused

to take as Anupana.

Investigations –

The investigator had faced difficulty for the regular follow up of the

patients due to decrease in their complaints. Patient ignored regular follow up

dates.

Case Study….


Case Study

Case 1:

Mr. Basavaraju 21 year’s male, Hindu patient, farmer by occupation.

Resident of Hassan district, has attended to Shalya O.P.D SDM College of

ayurveda and hospital Hassan, with the complaints of pain abdomen, which is

severe in nature, since one week. He had associated features of nausea and

fever. Pain was Colicky Radiating in nature. Pain use to aggravate on

exercise/walking. There was no history of Hypertension, Diabetes mellitus and

long-term use of drugs he was mixed diet and prefers Madhura-snigdha Ahara

with Ragi & Fish as a prime food. His Prakruti was analyzed as Kaphavataja.

He belongs to Anupa-Sadharana Desha.

His pulse, Blood pressure and other general features were within normal

limits. On abdominal examination, there was tenderness in right lumbar region

and in renal angle. His USG report reveals a 6-mm sized left Renal stone. Urine

findings show the pH value as 6 and rest within normal limits. Depending on

the features it was diagnosed as Vataja Ashmari.

After administration of the Yavaksharadi Yoga in the 3rd week of the

treatment only stone was passed. The expelled stone is 4mm in size. He had

been advised to take 2 - 3 liters of water per day and instruction was given to

follow prescribed diet chart.

After one month, pain was absent. USG report shows the recent

expulsion of stone.

Expelled Stone Fig - 4

Case Study….


Case Study….


Case Study….


Case 2:

A male Kumar patient, aged 43 years, Resident from Hassan District,

was complaining of severe pain abdomen with radiating and colicky in nature

and burning micturation since 2 months. Patient was professionally an

Agriculturist and the pain use to aggravate with increased physical exercise and

subsides on taking rest and by applying pressure.

There is no history of long-term drug use, No history of Hypertension

and Diabetes mellitus. He used to take mixed diet and alcohol. His prakruti was

analyzed as Vata-Pittaja. He belongs to Anupa Sadharana Desha.

His pulse, Blood pressure and other general features were within normal

limits. On abdominal examination, there was tenderness in left and right

lumbar region and renal angle. His USG report reveals 8mm stone in left UV

Junction. All the urine and blood findings were in normal limits. It was

diagnosed as Vataja Ashmari.

After administration of the Ananda Yoga in the 3rd week of the

treatment stone was passed. He had been advised to take 2 - 3 liters of water

per day and instruction was given to follow prescribed diet chart.

Expelled Stones Fig – 5

Case Study….


Case Study….


Summary & Conclusion….


SUMMARY AND CONCLUSION

Ashmari comprises of two words, i.e. ‘Ashma’ and ‘Ari’. Where Ashma

means a stone and Ari means enemy. Ashmari is a disease in which there is

formation of stone, resulting into severe pain as given by enemy. Hence it

might have been considered as one among the ‘Ashtamahagada’.

Renal stones are one among the cause for pain abdomen and it is

estimated that each individual will have a chance of 1% to suffer from

Urolithiasis in their lifetime. It affects up to 5% of the population. Males are

more frequently affected than the females and their ratio is 3:1. Hence, it is the

need of the hour to understand the disease and to find a best solution that not

only treats the condition but also prevents the disease at primary and secondary

levels.

With this aim the present study entitled “Effect of Ananda Yoga in the

management of Mutrashmari” was carried out. The dissertation comprises of

five sections i.e. Introduction, Conceptual Review, Clinical Study, Discussion,

Summary and Conclusion.

Introduction is the preface of the dissertation. It gives the details of

dissertation, selection of the problem and drugs.

The conceptual study includes review of literature with respect to

Mutrashmari, Urolithiasis and Ananda Yoga. In the chapter of disease review,

various topics like Nirukti, Rachana and Kriya of Mutravaha Srotas, Nidana

Panchaka of Ashmari etc. of Mutrashmari has been dealt with giving special

important to its clinical applicability. Simultaneously the importance has also

been given to modern literature and correlating wherever required.

In the clinical study, the materials and methods have been explained

along with drug review and various parameters for selection and assessments.

The observations and results are statistically analyzed and presented in tabular

form along with brief description of each finding.



Logical interpretation of the results obtained, based on Ayurvedic

principles and at times supported by the modern knowledge are discussed in the

last part i.e. Discussion. The logical conclusions thus drawn were as follow:

1. In the present study 30 patients of Mutrashmari were studied; out of

which maximum belonged to 15-30 years (40%), male sex (80%),

agriculture occupation (33.33%), Hindu religion (96.66%), low socio

economic classes (50%), rural habitat (63.33%), mixed diet (76.66%)

and Vata-Pittaja Prakriti (50%).

2. Out of the 30 patients of Mutrashmari studied in this series, 15 patients

were treated with Ananda Yoga under group A and 15 patients were

treated Yavakshradi Yoga under group Y.

3. Effect of Ananda Yoga: Ananda yoga showed significant reduction in

pain abdomen (89.92%), haematuria (100%), number (36.92 %) & size

(38.46%) of the stones. Anada yoga provided complete remission to

60%, moderate improvement to20% & mild improvement to 6.7 % of

patients.

4. Effect of Yavakshradi Yoga: Yavaksharadi Yoga provided significant

reduction in haematuria (100%) and burning micturition (84.30 %) and

significantly increased the frequency of micturition (31.32 %).

Yavaksharadi Yoga showed complete remission in 33.33%, moderate

improvement in 6.66% and mild improvement in 46.66% of patients.

5. Comparison of the effects: Ananda Yoga showed better reduction in

pain, number & size of the stones as well explusion and descending of

the stones in comparison to Yavaksharadi Yoga. Both Yavaksharadi

Yoga & Ananda yoga showed complete reduction in haematuria.

Considering the overall improvement provided by these showed that

both Ananda Yoga provided 60% complete remissiom and

Yavaksharadi Yoga provided 33.3% patients. Further in Ananda Yoga



13.33% patients remained unchanged while in Yavaksharadi group

13.33% patients remained unchanged.

6. On the basis of the results of this study it can be concluded that Ananda

Yoga provided comparatively better relief to the patients of Ashmari

particularly in reduction of pain and expulsion as well as descending the

stones. Therefore Ananda Yoga is better than control drug Yavaksharadi

Yoga in providing the relief to the patients of Mutrashmari.

Recommendation for further studies:

• In this present study the duration of treatment was 3 weeks which was

insufficient to expel the stones. Hence it may require a longer time to get

the significant effect.

• The patients selected were having different types of Ashmari such as

Vataja, Pittaja and Kaphaja variety. Here suggestion is given for further

study to conduct on large number of patients concentrating on particular

type of stones with the same Yoga.

• Depending upon the stone analysis one has to identify the nature of the

different types of Ashmari like Vataja, Pittaja and Kaphaja.

References….


References

1. Sushruta Sharira 9/12

2. Ashtanga Sangraha Sharira shthana 6/26

3. Caraka Vimana Shthana 5/5


5. Ch.Sh 7/10-11/A.H.Sh 3/12


7. Su Ni 3/22

8. Su Sh 4/30

9. Sharangadhara Prathama Khanda 5/45

10. Su.Ni 3/21-22

11. Ayu.Sha.Vol 1 pp 249,

12. Ch. Si 9/4

13. Sushruta Nidana Sthana 3/19

14. Ch.Sh 3/6

15. Su.Sh 4/26

16. Su.Sh 5/57,6/31

17. Ch.Si 9/4

18. Su Ni 3/18-20

19. Bh.Pa.Pu 2/6, Sha.Pra 5/6,

20. Su.Ni3/19

21. A.S.Sh 7/19

22. Sha Pu 5/9

23. Su.Ni 3/21

References….


24. A.S.Ni 9/6

25. Ch.Si 9/4

26. Sushruta Sharira Sthana 9/7

27. A.S.Sha 6/36

28. Bh.P.Pu 3/364

29. Su.Ni 3/21-22 Dalhana

30. Bh.P.Pu 9/172

31. Sh.Pu 6/6

32. Su.Ni 3/21-24

33. Su.Su 21/10

34. Su Sha 9/7 Dalhana Tika

35. Sh.Sa .Pra 6/7

36. Su.Su 15/18

37. A.Hr.Su 11/5

38. Grays anatomy pp 1815-1843, Human Anatomy B.D. Chaurasia P.No 256

- 263, 304 - 310

39. Medical Physiology K. Sembulingam P. No 237 - 276

40. Concise Medical Physiology Chaudhari P. No 465 - 500

41. Su. Su 33/4-5

42. Monier and Williams

43. Su.Chi 7/3, M.Ni 32/1

44. Su. Ni 3/11,Ch.Chi 26/32

45. H.S 31/4

References….


46. Su Ni 3/4

47. Su Ni 3/25-26

48. Cha.Chi 26/36

49. A.S.Ni 9/11

50. M.Ni 1/5,6



53. A.H.NI 9/10

54. C.Chi 26/39





59. Sushruta Nidana Sthana 3/13,17

60. Sushruta Su 33/5, S.S.Chi 7/3

61. Sushruta Sutra Sthana 33/12

62. Su.Chi.7/3-4

63. Ch.Chi.26/59

64. A.H.Chi 11/15 ,

65. Ch.Chi.26/45 ,

66. S.S.Chi 7/27

67. (a) Ch.Chi.26/76,1/3 (b) B.R.36/70-72 (c) H.S.Tri.31/14-17

68. Harrisons PP 1569-1573, Baily and Love PP 1183-1190

69. Smith’s Urology P.No 291 - 316

70. S.Das P.No 1165 - 1185, 1208 - 1211

71. Robbins PP-984, Harrisons PP 1569-1573

References….


72. Bailey and Love PP 1183-1190, S.Das P.No 1167 - 1168

73. Harrisons PP 1569-1573, Smith’s Urology P.No 291 - 316

74. Harrisons PP 1569-1573

75. Bailey and Love PP 1183-1190

76. S.Das P.No 1168 - 1170, Smith’s Urology P.No 291 - 316

77. Harrisons PP 1569-1573, Bailey and Love PP 1183-1190

78. Bailey and Love PP 1164-1168, S.Das P.No 1134 - 1141

79. Bailey and Love PP 1185 - 1188, S.Das.

Drug review

Tila

1. D.G .V by Dr.J.L.N Shastry Vol 2 page 882

2. Indian medicinal plants- by K.R Kirtikar and B.D Basu vol 2 page- 983, 84

3. D.G .V by Dr. Privrut Sharma, Vol. 2 page no-120

4. Database on medicinal plants used in ayurveda vol 1 page no- 348, 49, 50

Apamarga

5. D.G .V by Dr.J.L.N Shastry Vol 2 page -542, 43, 44

6. D.G .V Part 2 by Dr. Privrut Sharma page no- 443-47

7. Database on medicinal plants used in ayurveda vol 3 page no- 472

Kadali

8. D.G .V Part 2 by Dr. Privrut Sharma page no-630

9. D.G .V by Dr.J.L.N Shastry Vol 2 page – 985, 86

10. Database on medicinal plants used in ayurveda vol 5 page no-391

Palasha

11. D.G .V Part 2 by Dr. Privrut Sharma page no-506, 07, 08, 09

12. D.G .V by Dr.J.L.N Shastry Vol 2 page -144, 45, 46, 47, 48

13. Database on medicinal plants used in Ayurveda vol 4 page no-281

References….


Amalaki

14. D.G .V Part 2 by Dr. Privrut Sharma page no-758, 59, 60.

15. D.G .V by Dr.J.L.N Shastry Vol 2 page -220, 21, 22, 23, 24.

16. Database on medicinal plants used in ayurveda vol 2 page no- 38

Gomutra

17. Central institute of Medicinal and Aromatic plants, Central Scientific and

Industrial Research (CSIR).

Yava & Gokshura - 16

1. Y.R. Ashmari Chikitsa Uttararda pp 72

2. D.G. – P.V. Sharma pp – 632

3. Su. Su. 11 / 12, 13 & 14

4. Keerthikar Basu – Vol. 4

Clinical study

1. Su.Chi 7/27

2. Bhaishajya Ratnavali, Ashmari Chikitsa Prakarana, 36th chapter. 21:22

3. Su Ni 3/7

4. Su.Su 11/9

5. Yogaratnakara Vidyotini Hindi Tika Uttarardha P.No 72

6. Sheshashaye B. (2002) – Clinical management of Mutrashmari

With Yavaksharadi Yoga

Bibliography….


Bibliography

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Bibliography….


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Annexure

Effect of ANADA YOGA in the management of MUTRASHMARI 136

DEPARTMENT OF POST - GRADUATE STUDIES IN SHALYA TANTRA

S.D.M COLLEGE OF AYURVEDA – HASSAN

CASE PROFORMA FOR CLINICAL STUDY

“EFFECT OF ANANDA YOGA IN THE MANAGEMENT OF MUTRASHMARI” Patients Name: Date: Age : Serial no: Sex : O P D No : Occupation : I P D No: Religion : D.O.A: Address : D O D: Socioeconomic status: Group: Clinical Features:

Pain in abdomen Frequency of Micturition Burning Micturition Haematuria Others Pain abdomen: Duration: Severity: Character: Constant / Intermittent / Colicky / Radiating / Dull Site: Rt, Lt Lumber / Perineal / Testicular / Groin / Thigh Mode of onset: Sudden / Recurrent / Gradual / Continous Micturition : Flow-Free / Obstructed / Incontinence Frequency-Day / Night Quantity in 24 hrs Character : Burning / Pricking / Others

Annexure


Hematuria : Nature- Constant / Intermittent / Beginning / Terminal / Mixed Others : Anaria / Polyuria / Oliguria / Nocturia / Dribbling / Pyuria Pain aggravating and Pain Relieving factors: Pain aggravates Pain Relieves Cough Rest Alcohol Applying Pressure Jerks Water intake Riding Others Exercise/Walking Others Associated Symptoms: Nausea/Vomiting Sweating Fever Constipation Others if any History of Present illness: History of Past illness : Urolithiasis Renal TB DM/HTN/IHD Hyperparathyroidism Gout Other Family history:

Annexure


Personal history: Appetite Habit - Alcohol Bowel Smoking Sleep Tea/Coffee Micturition Tobacco chewing Diet - Veg / Non Veg Gynec history: MC – Regular / Irregular Menopause / Menorrhagia / Leucorrhoea / Metrorrhagia General Examination: Prakruti Pulse BP Respiratory rate Temp

Pallor: Oedema: Icterus: Lymphadenopathy: Built / Weight

A. Systemic examination: C.N.S.: C.V.S.: R.S: G.I.T.: Locomotor system:

B. Local examination

Inspection: Palpation: Percussion: Auscultation: External Genitalia: Penis,Testis,Urethra,Epididymis,Spermatic cord

Annexure


P/R Examination - Prostatic enalargement Others Investigation: Blood – Hemoglobin Blood urea Sr Creatinine Sr Calcium Sr Uric acid Urine – Colour PH

Sp gravity Sugar Microscopic – RBC Casts & Crystals Epithelial & Pus cells Culture & Sensitivity [If necessary] X- Ray - Ultrasonography - Site Size Number Hydronephrosis Diagnosis: Renal Ureteric Vesicle Urethral

Annexure


Assessment Criteria

Subjective Criteria Sl.No C/F B.T I wk II wk III

wk IV wk

II mth

III mth

1 Pain abdomen

2 Burning Micturition

3 Haematuria

4 Frequency of Micturition

5 Mutradharasangha

6 Bastigouravata

Objective Criteria

S.No Stone Before treatment After treatment 1 Number 2 Site 3 Size

Signature of Scholar Signature of Co-guide Signature of Guide (Dr. Gopikrishna B.J) (Dr. P. Hemantha Kumar)

EFFECT OF ANANDA YOGA IN THE MANAGEMENT OF ...

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