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Introduction

Ayurveda is an ancient medical and health care system which not only manages chronic diseases but maintain the health of the healthy human beings10.

Acharya Charaka has explained Mutrashmari in the context of Trimarmiya Adhyaya. In Charaka Samhita, the formation of Mutrashmari has been explained that, the vitiated Vata dosha dries up the Shukra dhatu, Mutra, Pitta and Kapha dosha and forms Ashmari11. The Mutravaha srotas gets blocked with the stones and crystals causing severe abdominal pain  and difficulty in micturation.

Ashmari is one among disease included under Ashtamahagada i.e, difficult to cure.

Urolithiasis is a condition that occurs when the stones exit the renal pelvis and move into the remainder of the urinary collecting system, which includes the ureters, bladder, and urethra12. Global incidence is rising with over 106 million new cases in 2021 marking 27% increase since 2000. The female and men ratio is 1:2 with peak incidence occurring in age group of 50-7013.

 There are four types of stones –calcium stones, uric acid stones, struvite stones, cystine stones. The causative factors includes low water intake, high salt or protein diet, recurrent urinary tract infections, family history and metabolic disorders.

 Modern treatment and surgical management includes Extracorporeal lithotripsy, Percutaneous nephrolithotomy, Ureteroscopy.14

Medical management includes Oral Alpha- adrenergic blocker which relax ureteral muscle and shown to reduce time to stone passage and the need for surgical removal. Pain relief medications and antibiotics in presence of infection. Ibuprofen, Acetaminophen and Naproxen to relieve pain.  Sodium bicarbonate or Sodium citrate makes urine less acidic, Thiazide diuretics and Phosphorus prevents calcium forming stones.15

Case study

A 35 years old female patient visited OPD with the complaints of severe abdominal pain at bilateral flanks region since 15 days associated with pain and difficulty in micturition. One day she noticed sudden severe pain in abdomen associated with nausea and irregular periods with interval of 3-4 months. The nature of pain is colicky and radiates to lower abdomen.

 She consulted to a physician and got temporary symptomatic relief with oral medications, and was advised Ultrasonography of abdomen and pelvis. The USG report of abdomen and pelvis suggestive of 2 calculi in the Right kidney measuring 3.9 mm calculus in upper pole calyx, 4.5 mm calculus in mid pole calyx, left kidney- 3.7 mm calculus in mid pole calyx. No evidence of hydronephrosis. The patient was also detected with polycystic ovarian disease in bilateral ovaries.

Past History–No history of DM, HTN, Thyroid or any other systemic illness.

Family history – Not significant

Personal History

Diet- Mixed

Appetite – Reduced

Bladder- increased frequency with burning micturition

Sleep – disturbed

Menstrual history- irregular 3-4 months

Painful and scanty bleeding

Obstetrical history- P1 L1 A0 D0

General Examination

Built- Moderate

Nourishment – Moderate

Pulse- 78 bpm, regular

BP- 110/80 mmHg

Temperature- 98.4 F

Respiratory rate- 20 cycles/min

Height – 153 cm

Weight – 50kg

BMI- 21.4 kg/m2

Tongue- coated

Pallor- absent

Icterus/ Cyanosis/ Clubbing/ Edema/ Lymphadenopathy -Absent

Systemic examination

CVS- S1 S2 Normal

CNS - Concious, well oriented

RS – Normal vesicular breathing no added sounds

P/A – soft, tenderness + Right and Left lumbar  region

Ashtavidhapariksha

Nadi- Vata-pitta

Mala- Samyak

Mutra- Sadaha,  Muhur Muhur  pravritti

Jivha- Alpalipta

Shabda- Prakrut

Sparsha- Anushna

Druk- Prakrut

Akruti- Madhyama

Samprapti of Mutrashmari16

                           Nidana- Asamshodhana and Apathya Sevana

                                 Kapha dosha Prakopa

Vitiation of Kapha, Vata, Pitta dosha and Shukra dhatu

              Sthanasamshraya of dosha in Basti pradesha

                    Mutrashmari Samprapti Ghataka

Dosha- Kapha

Dushya- Vata, Pitta, Mutra and Shukra

Agni- Jataragni, Dhatwagni

Adhishthana- Basti pradesha

Srotas- Mutravaha Srotas

Srotodushti prakara- Sanga

Vyadhi swabhava- Chirakari

Sadhya Asadhyata- Kruchra sadhya

Materials and Methods

Intervention from 5th Feb to March 5th 2022

1. Varunadi Kashaya 17 15 ml BD A/F with warm water
2. Tab Chandraprabha vati 18 2 tab BD A/F with warm water 
3. Tab Gokshuradi guggulu19 2 tab BD B/F with warm water

1.  Matrabasti- Sahacharadi taila 30ml night daily                                                                                                                                                                                                                
2. Churna combination- Parpati, pravala, shankha, Godanti, kukkutanda, Tamra bhasma- 1.5 gm each Musta, Avippatikara churna, Haritaki, yastimadhu, Musta, Gokshura, Punarnava, Pashanabheda, Amalaka churna ½ tsf twice a day with warm water B/F

2nd Follow up Medications March 10th to April 30th 2022

1. Varunadi Kashaya15 ml BD A/F with warm water
2. Tab Gokshuradi guggulu 2 tab BD A/F with warm water
3. Syp Kadalin 10 ml BD B/F with warm water
4. Tab Uricalli 1 tab BD B/F with warm water
5. Matrabasti- Sahacharadi taila 30ml night daily  

Results

Assessment of the patient was done with both radiological findings as well as clinical feature approximately after 3 months of oral medications. The Radiological assessment (USG Abdomen and Pelvis) suggestive of 2 calculi in the Right kidney measuring 3.9 mm calculus in upper pole calyx, 4.5 mm calculus in mid pole calyx, left kidney- 3.7 mm calculus in mid pole calyx. No evidence of hydronephrosis. During follow up the complaints of pain and burning micturition were reduced with prescribed treatment.  No, calculi were observed and the polycystic ovarian diseases was noted in the scan after 3 months of treatment.

Discussion

Urinary calculus is a stone-like body composed of urinary salts bound together by a colloid matrix of organic materials. It consists of a nucleus around which concentric layers of urinary salts are deposited20.

 Ureteric stones usually originate in the kidney. Gravity and peristalsis both contribute the spontaneous passage of stone into down the ureter. The probable pathological changes are obstruction (partial/complete), impaction, infection, ulceration.  

Patient usually present with pain abdomen, burning micturation, haematuria, increased frequency of micturation, nausea and vomiting.

Diagnosis of Urolithiasis is mainly based on Urine analysis, straight X-Ray of KUB region at least 90% of renal stones are radio-opaque and are easily visible unless they are very small or overlie bones. Ultrasonography of abdomen and pelvis is helpful to distinguish between opaque and non-opaque stones. Computed Tomography is particularly helpful in diagnosis of non-opaque stones21.

Treatment with drugs possessing Vatanulomaka, Tridosha Shamaka, Ashmari Bhedhana and Mootrala properties is needed in the management of the condition. The probable mode of action of each medication prescribed can be justified based on all the principles as follows.

Varunadi Kashaya acts as an excellent remedy to crush the calculi into minute particles which gets easy to wash out through urine out of the body due to its Kaphagna and Ashmarihara properties. 

Chandraprabha vati  indicated  in Ashmari and Mutra vikara, it is one of the herbo-mineral medicine possessing  the qualities of  Ashmarihara. The formulation contains Bhasma,  Lavana,  Kshara and drugs having the properties of Katu, Tiktka, Kashaya and Ushna Virya Dravya which does Lekhana and Bhedhana of Mutrashmari.

Gokshuradi guggulu is a potent medicine in the treatment of Mutrashmari and Mutravaha Srotovikara. The drug Gokshura possess properties diuretic, aphrodisiac, due to its Madhura Rasa, Madhura Vipaka and Sheeta Veerya which causes diueresis by increasing Kleda in the body.

Sahacharadi taila is used in the treatment of  Vata conditions. In the above case Sahacharadi taila Matra Basti was advised, which pacifies the Vata Dosha and relieves the symptoms of Pain.

Syp Kadalin contains Musa paradisiaca (banana) stem extract as the main ingredient used as the natural diuretic.

Tab Uricalli is the Ayurveda Proprietary formulation which posess diuretic, anti-inflammatory properties. It breaks down the stone flushes out and relieves the pain and burning sensation.

Conclusion

Renal stone present a challenging clinical problem, medical therapy with dietary measures can help to prevent recurrence and expulsion of small size (<10 mm) stones.

The above case of Mutashmari was well managed by Shamana Chikitsa within 3 months duration,  without recurrence of any symptoms.

The Medication selected in the above case possess the properties like Ashmarihara, Vata Anulomana, and Mutrala drugs. Matra basti was given to stabilize the Apana Vata – Vata Anulomana

Association of stone with infection is very common. In about 80% of cases there is infection of the urinary tract. The Churna combination of medicine has multiple effects like, reduces the infection, restores the urinary Ph and breaks the urinary calculi by its properties. The drugs possessing Ashmarighna, Anulomana, and Mutrala properties are selected.

The advantages and limitations of different modalities of medical therapy is necessary to provide correct treatment to the patient. Hence Shamana Chikitsa plays a crucial role in the management of Mutrashmari in the above case.