MUTRASHMARI – URINARY CALCULI

Urinary calculi or Urolithiasis is a condition where urinary stones are formed or located anywhere in the urinary system. It consists of aggregates of crystals containing small amounts of protein and glycoprotein. Different types vary in frequency around the world, probably as a consequence of dietary and environmental factors, but genetic factors may also contribute. Ayurveda describes urinary calculi as Mutrashmari

Ashmari means stone and mutra (urine) denotes mutravaha srotas. Mutrashmari is calculi in the urinary tract. Mutrashmari (urinary stones) is one among the Ashtamahagada (eight fatal conditions) and is Kaphapradhan Tridoshaja Vyadhi (kapha dosha predominant tridosha involved disease), which is correlated with Urolithiasis. ”. It is the formation of stony concretions in the bladder and urinary system. It is the common diseases of Mutravaha strotas (urinary tract) that occur due to disequilibrium between stone inhibiting and promoting factors in the urinary system.

It is considered difficult to cure because of its Marma Ashrayatwa due to involvement of Basti, which is one of the Tri Marma (three vital parts), being the Vyakta Sthana. It is Kapha predominance Tridoshaja Vyadhi. India has high incidence of calculi especially in Gujarat, Rajasthan, Haryana and eastern parts of Uttar Pradesh, as such this area is known as the “stone belt area. Urinary calculi affect all ages and both sexes but it is two to three times more common in men. Urolithiasis affects 12% of the population at some stage of their lifetime. Obstruction of the flow of urine, which leads to pathological changes in the urinary tract and the kidney, is known as obstructive uropathy. Mutrashmari is one of the causes for the obstruction of urine flow.

NIDANA / CAUSES

• Apathya ahara Indulgence of unwholesome foods harmful to urinary tract. Diet rich in animal protein, oxalate, vitamin C, sodium chloride > 4 gram per day and refined carbohydrates
• Consumption of food containing milk and milk products mixed with sugar, eating vegetables containing minerals
• Exposure to heat
• Low fluid intake
• Low fiber intake
• Sedentary occupation and lifestyle
• Dehydration from geographical and tropical climate
• Urinary tract infections
• Certain sulpha group of drugs, loop diuretic (long term abuse) , vitamin C,
• Non elimination of vitiated doshas from the body through ritu shodhana (seasonal regimen and panchakarma )
• Working in dry places
• Over exertion
• Suppression of natural urges

PREDISPOSING FACTORS

Environmental and Dietary Causes

• Low urine volume
• Diet: high protein, high sodium, low calcium
• High sodium excretion
• High oxalate excretion
• High urate excretion
• Low citrate excretion

Acquired causes

• Hypercalcaemia of any cause
• Ileal disease
• Renal tubular acidosis Type 1

Congenital and Inherited causes

• Familial hypercalcinuria
• Cystinuria
• Medullary sponge kidney
• Hyperoxularia

SAMPRAPTI/ PATHOGENESIS OF CALCULI FORMATION

Mutrashmari is a kapha dosha dominant tridoshaja disorder occurring in any part of the urinary tract. The disease process can be explained in the following sequence according to Ayurveda

• When vata dosha in aggravated state settles down in vasti pradesha (urinary bladder) by virtue of its ruksha guna (dry quality), dries up the locally available mutra(urine) , sukra(semen) and pitta to convert them into sharkara or gravels.
• Kapha dosha by its guru (heavy), Sandra (thick), snigdha (unctuous), pichila (slimy) gunas  (attributes) and alepana karma binding mechanism , binds those gravels together to make a soft stone like structure
• Pitta dosha by its paka karma completes the calculi formation

CHEMICAL COMPOSITION OF URINARY STONES

Major crystalline substances identified in renal stones could be categorized into six groups

• Calcium oxalates – when urine is acidic or alkaline
• Calcium phosphates – when urine is acidic or alkaline
• Bacterial induced magnesium ammonium phosphate(struvite)– infections in the kidney
• Uric acid and other metabolites of purine metabolism- when urine is persistently acidic
• Cystine – rare genetic disorder
• Others eg. drugs and matrix

Majority of stones are admixture of two or more of the above said components. These inorganic compounds are associated with 2-3% of macromolecular matrix. Out of this uric acid, xanthine and triamterene containing stones are radiotranslucent, calcium oxalate monohydrate and calcium phosphate stones are most radio-opaque, whereas cystine and struvite are less dense giving ground glass appearance.

TYPES

There are four types of Mutrashmari

Vataja mutrashmari

Pittaja mutrashmari

Kaphaja mutrashmari

Sukraja mutrashmari

PURVARUPA/ PREMONITARY SYMPTOMS

• Admana / Bloating
• Vedana (pain) and discomfort in the bladder, urethra, testicles, external genital oragans.
• Mutra krichhata/ Dysuria
• Jvara /Fever
• Aruchi/ Anorexia
• Debility
• Urine smell resembles like goat’s urine
• Colour of urine appears that of individual dosha and pain accordingly
• Urine appears non-clear and of increased specific gravity

COMMON LOCATIONS WHERE STONES GET DISLODGED

• Junction between renal pelvis and ureter
• Crossing of the ureter over iliac blood vessels
• Entrance of ureter into bladder

CLINICAL MANIFESTATION

Onset of the disease occurs in three stages

• Severe pain in the kukshi (abdomen), kati (flanks,back) regions
• Burning urination, followed by
• Obstruction of urinary flow

Patients with urinary calculi may report:

• Pain
• Infection
• Heamaturia
• Remain asymptomatic
• Classical renal colic- acute onset of severe flank pain radiating to groin, scrotal or labial areas, gross or microscopic hematuria, nausea and vomiting
• Stag horn calculi is relatively asymptomatic

GENERAL SIGNS AND SYMPTOMS

• Pain in umbilicus (nabhi), ureters (sevani), bladder (vasti), headache (siras-ruk)
• Obstructed flow of urine
• Urine resembling cow urine
• Irritation in the urinary system
• Blood stained urine with pain

Vataja Mutrashmari

• Severe pain
• Dysuria
• Difficulty in movement or expulsion of urine (mutra), stool (purisha)
• Ashmari shape is that of kadamba pushpa irregular surface
• Resembles uric acid stone
• Retention of urine
• Increased frequency of urine

Pittaja Mutrashmari

• Burning sensation
• Feeling of hot air coming out of bladder
• Inflammation in lower abdomen and bladder
• Blood – stained urine
• Ashmari shape resembles seed of bhallataka (marking nut)
• Resembles calcium oxalate, uric acid and cystine stone

Kaphaja mutrashmari

• Pain in the bladder region like that of needle pricks(suchibhairava)
• Heaviness in the bladder
• Feeling cold
• Ashmari– shape resembles egg shape
• Resembles to calcium phosphate stones

Sukraja mutrashmari

• Due to suppression of semen
• Dysuria
• Pain in the bladder, external genitals
• Edema in legs
• White and soft stone
• Resembles to calcium phosphate stones

UPADRAVA/ COMPLICATIONS

• Weakness
• Heaviness of body
• Emaciation
• Pain in abdomen
• Anorexia
• Anemia
• Gonorrhea
• Polydipsia
• Vomiting
• Acute renal failure
• Recurrent or persistent urinary tract infections

MANAGEMENT

Management of urinary stones consists of diet and drugs designed to reduce the risk factors of stone production. It is indicated in all stone-formers specially for preventing recurrence after stone is passed or removed by surgery. The most vital modification in diet is adequate fluid intake through-out the day to produce a minimum of 2 litres of urine. There should be adequate calcium intake so that the oxalate in the diet is chelated and not absorbed.

Reduction of salt intake to less than 4gram per day is recommended. Among fluids, grape fruit juice, alcoholic beverages and beer should be avoided due to its high purine content which promotes stone formation. High fiber diet and potassium is helpful.

YOGASANAS

• Paschimottasana- Seated Forward Bend
• Dhanurasana- Bow Pose
• Pavanamuktasana – Wind Relieving Pose
• Uttapadasana – Raised leg pose

TREATMENT

• Nidana parivarjana : avoiding the causative factors
• Ahara and Vihara : eating balanced diet maintaining hydration and good lifestyle
• Surgery : in acute cases surgery is required

Samshodhana therapy

Snehana (oleation)

Svedana (sudation)

Virechana (medicated purgation)

Vasti (medicated enema)

Uttaravasti (medicated enema)

Treatment at various stages of the disease

• During the purvarupa (premonitory stage) : sneha(oleation), sveda(sudation), vamana (medicated emesis )and adhika ambupna (increased intake of water), avagaha sveda( sudation)
• Rupavastha (manifested stage): Virechana (medicated purgation) with Tilvaka ghruta; Uttara vasti with ashmari bhedana (lithotripsic) drug decoctions like Varuna, Gokshura, Pashana Bhedi and Shatavari Taila.
• By these measures – the urinary pathway purification takes place and the apana vata movements are stimulated

Other medicines

• Chandanasava : 30 ml thrice daily after food
• Usheerasava: 30 ml thrice daily after food
• Punarnavasava: 30 ml thrice daily after food

Specific Treatment

Vataja mutrashmari

• Give medicated ghee followed by Niruha basti (medicated basti)and Anuvasana basti (medicated basti)
• Sahacharadi taila– 20 to 40 drops
• Bolbadha rasa – 250 mg thrice daily
• Punarnavadi kashaya and Varunadi kashaya in equal parts; 30 ml thrice daily
• Drugs : Pashanabheda, Vasuka, Shatavari, Gokshura , Bruhati and Kantakari in the form of kshara (alkali), yavagu (gruel),   kwatha (decoction) and milk

Pittaja mutrashmari

• Give medicated ghee from Trinapanchamuladi ; dose 2 gram thrice daily
• Chandraprabha vati : 1 to 2 tablet (500mg); twice daily
• Avipattikara churna: 1 to 3 grams; twice daily
• Punarnavashtaka kwatha; 30 ml thrice daily with Chandrakala rasa 125 mg
• Karpasamuladi yoga : decoction 30 ml thrice daily
• Shatavaryadi yoga : decoction 30 ml thrice daily

 Kaphaja mutashmari

• Shwadamshtrakadi kwatha; 15 ml thrice daily
• Veerataradi gana kwatha; 15 ml thrice daily
• Usheeradi gana kwatha ; 15 ml thrice daily
• Varunadi Gana, Ela, Guggulu, Kushta, Devadaru, Haridra, Maricha,Chitraka etc. drugs in the form of kshara (alkali), peya (gruel), ksheera (milk), yavagu (thick gruel) and kwatha (decoction)
• Gokshuradi guggulu : 1 to 3 gram twice daily with Pashanabheda decoction
• Triphala guggulu : 1 to 2 tablets; twice daily with lukewarm water
• Trikantakadi guggulu : 1 to 2 tablets; twice daily with lukewarm water

 Sukraja asmari

• Chandraprabha vati :1 to 2 tablet (500mg); twice daily
• Pashanabhedi chura : 1 to 3gram twice daily
• Dasamularishta : 30 ml thrice daily after food
• Varuna-sigru-kulatha kwatha : 30 ml thrice daily before food
• Jatamamsi hima kashaya

 Rasoushadhis

Shilajatu vati : 1 to 2 tablets (125 mg) twice daily

Chandraprabha vati: 1 to 2 tablet (500mg); twice daily

Trivikrama rasa: 125 mg twice daily

Yashada bhasma: 250 mg, twice daily with honey

Godanti bhasma: 250 mg, twice daily with ghee

Jaharamohar pishti:1 to 2 tablet (125 mg); twice daily with honey

PATHYA – Dos

Ideal diet

• Mushrooms
• Germinated beans
• Pulses
• Wheat
• Bajra
• Green peas
• Bittergourd
• Sugar
• Jams
• Green chillies
• Papaya
• Mango
• Apple
• Wheat bran
• Bengal gram flour
• Fig
• Grapes
• Musk melon
• Old rice
• Green gram soup
• Buttermilk
• Ash gourd
• gooseberry
• Drinking good amount of water throughout the day
• Warm water
• Coconut water

APATHYA- Don’ts

• Milk and milk derivatives
• Vanaspathi ghee
• Tea, coffee
• Eggs
• Green vegetable
• Non vegetarian foods having bones
• Crabs
• Dry foods
• Grained flour
• Heavy exercises
• Suppressing urge to urinate thus leading to retention of urine
• Exposure to breeze
• Exposure to sun
• Excessive sexual indulgence
• Kapitta / Wood apple
• Jambu/ Malabar plum
• Bisa/ Lotus rhizome or stem
• Excess of astringent foods
• Sedentary lifestyle
• Chilled water intake
• Excess intake of salty foods