3 rd International Conference and Exhibition on Traditional

3 rd International Conference and Exhibition on Traditional & Alternative Medicine August 03 -05, 2015 Birmingham, UK In Association with Presented By Name: Dr. Prathamesh V. Karpe Country: INDIA BAMS, MS (shalyatantra)

The concept of Urolithiasis in Ayurveda By Dr. Prathamesh V. Karpe BAMS, MS (shalyatantra) Consulting surgeon and Lecturer in Dept of shalyatantra Gomantak Ayurveda mahavidyalaya & Research centre, Shiroda Goa- India

“Stones are precious but not in the body”

What is Urolothiasis �It is commonly known as kidney stone or urinary stone �In sanskrit it is known as “Ashmari” �In India, the “stone belt” occupies some parts of Maharashtra, Gujarat, Punjab, Haryana, Delhi and Rajasthan

तलयत मशमन य नत तसम तत शमर व द / (tulyataamshmana yaanti tasmaatashmari vidu) Ashmari or calculus looks like small gravels/stones hence they are termed as ashmari

What are its causes 1. ततर सश धनश लसय पथयक र ण परकप त शलषम मतरसमपरकत sनपरव शय बसत मशमर जनयत // )स. न . ४( 2. व श षयद बसत गत सशकर मतर सप तत पवन कफ़ व / यद तद sशमरयपज यत त करमण प ततषव व र चन ग // )च. च . ३६( Due to improper purification of the body and by following the improper diet and lifestyle, kapha dosha gets vitiated in the urine and reaches in the basti to form ashmari. According to charakacharya- the shukra dhatu in the basti gets dried up along with Pitta or Kapha dosha by Vata

Pathogenesis- samprapti 1. एवमव परवशन व / मतरयकत करत sशमर म व त प तत कफ़ sप उपसनह त परव शय // Vata-Pitta-kapha dosha enters into basti like how mutra enters into basti from Pakwashaya and with Upasneha nyaya Ashamari is formed in Basti.

1. अपस सवचछ सवप यथ न ष कत स नव घट / क ल नतरण पक सय दशमर समभवसतथ // )स. न . २४ -२६( When clear water is placed in a new mud pot, after sometimes some particles precipitates into the water, similarly in the basti ashmari develops- this explains the stagnation of the urine in the bladder due to bladder outlet obstruction like BPH etc can form calculus in the bladder.

�सहनतयप यथ द वय म रत sगन शरच वदयत तवददबल स बसत सथमषम स न ल / / सहनत It explains the crystallization process- when dry air along with the static electricity in the clouds forms the crystalls of water present in the cloud, similarly ashmari develops.

Purvaroopa त स परवरप ण - बसत प ड र चक मतरकरचछ बसत श र मषकशफ़स वदन जवर करचछ वस द बसतगनध तव मतरसयत // Pain and discomfort in the bladder, urethra, testicles/external genital organs. Anorexia, dysuria, fever, debility, smell of goat’s urine. Colour of urine appears like that of individual doshas and pain accordingly. urine appears non-clear, increased specific gravity.

Types 1. 2. 3. 4. Kaphaja Vataja Pittaja shukraja

Samanya lakshana �Pain in the umbilicus, bladder, perineum, external genitals eithr in any one of them while passing urine. �Obstruction to the urine stream �Hematuria �Urine appears clear as Gomeda or some crystals can be seen in urine. �Discomfort or pain while performing the activities like running, swimming, hanging, swimming, riding on back of horse, camel.

Vataja Ashmari �Vata and kapha dosha after combining together obstructs the urine and causes pain as a result person bites his teeth, presses navel, external genitals, anus and shouts due to pain. �Has to pass urine after putting force. �The ashmari formed is Shyava, hard, irregular, rough, it contains thorny structures like of kadamba Pushpa.

Pittaja Ashmari �Kapha dosha along with Pitta dosha attends compactness and obstructs the urine and produces discomfort like burning sensation in the basti-medhra, feeling of hot air coming out of bladder. �Ashmari appears like red, yellow, dark in colour and appears like seed of Bhallataka

Kaphaja ashmari �The Kapha dosha attends compactness and increases in size and obstructs the urine and produces features like tearing type of pain in bladder, heaviness in the bladder and feeling of cold. �Ashmari appears like hen’s egg, pale-white colour, unctous to touch, large in size and like madhuka flower.

kukkutanda Madhuka pushpa

Shukrashmari �Causes = shukraveghdharan or excessive coitus. �The vitiated vata causes vimargagaman of shukra into medhra or vrushana and after drying it up forms the shukrashmari. �The resultant ashmari obstructs flow of urine and causes dysuria, pain in bladder and external genitals, oedema in legs. �On pressing the ashmari it gets broken into pieces easily.

Ashmari in children �Due to kapha avastha more chances of forming ashmari �Occurs in those children who follows life style and diet which increases and vitiates kapha �Ashmari can be of any 3 doshas �Due to thin bladder wall and under developing basti, ashmari is small in size and can be easily removed with instruments �Due to non development of shukra dhatu, there are no chances of forming shukrashmari

chikitsa �Newly formed ashmari can be treated with medicines �Chronic- surgical removal

Medicinal treatment �Vataja ashmaripashanbheda, vasuka, shatavari, gokshura, bhruhati, kantakari etc drugs should be used in form of kshaar, yavagu, kwatha, milk, food etc. �Pittaja- kusha-kasha-sara-gundra-itkatamorata(sugarcane root), pashanbhedh, vidaarivarahkandashaalimoola, gokshura, shyonaka, punarnava, shirisha, lo tus seed, evaru(cucumber) etc

�Kaphaja ashmari- varunadi gana, guggulu, ela, kushtha, devdaru, haridra, maricha, chitraka etc drugs in form of kshar, peya, kshira, yavagu, kwatha. �Kshara prepared from tila, apamarga, kadali, palasha and yava kalka with sheep’s urine prevents sharkara formation

�Use of Ghrita, Kshara, kashaya, kshira and Uttarbasti are advised. �If no relief with above medications then surgical extraction of calculus should be performed.

Surgical extraction �Purvakarma- consent from the king, snehan-swedanvaman-virechana, food should be given to the patient. �Mangala-swastik vachan �Collection all required instruments and medicines required during surgery

Pradhana karma �This technique is Perineal Vesicolithotomy �Position is lithotomy postion, head resting in lap of attendant �Sneh is applied on nabhi and pressure massaging in done on left lateral region till ashmari decends into Basti. �Lubricated middle and index finger is inserted into anal canal of the patient. �Calculus is then pushed with those fingers in upward direction towards in between guda and external genital. Ashmari can be seen as nodule

�While performing this procedure if patient becomes unconscious or goes into shock, in such condition procedure should be hold and extraction shouldn’t be done. �Site of incision- vama. Parshwa (left lateral) 1 yava(grain) distance from the sevani(perineal raphe). Incision should be adequate to remove stone �While extracting the calculus, it should be brought out without crushing it. Otherwise it can cause recurrence. �Instrument used is अगरवकर आह रण यनतर (curved forcep)

�In case of female – uterus should be protected, incision should not be too deep otherwise it causes vrana through which urine oozes out. �Avoid damaging important structures like mutravaha, shukravaha, mutrapraseka, sevani, yoni, guda, basti.

� Damage to 1. Mutravaha srotas and Basti-death due to extavasation of urine 2. Shukravaha srotas-death or infertility 3. Mushkasrot- dhwajabhanga (erectile dysfunction) 4. Mutraprasek- vesical fistula urine discharge 5. Sevni and yoni- severe pain 6. Guda and basti- death

Paschat karma �Patient should be kept in hot water tub, this prevents collection of blood in bladder. �If blood gets collected in bladder then Uttarbasti of kshirvruksha kwatha should be administered, it removes the collected blood out of bladder (bladder wash) �For mutramargavishodhana – rice mixed with jaggery should be given. �After removing from tub, apply honey+ghrita on the incision wound

�For diuresis- trunapanchamoola, gokshura etc drugs in the form of yavagu is given 2 -3 times a day. �For rakta-mutra shodhan and vrana kledanarthajaggery mixed milk along with cooked rice is given in small quantity for 10 days. �After 10 days- sour fruit like dadima and jangala mamsa rasa is given. �Carefully snehan and drava swedan is performed. �Clean wound with kshiravruksha decoction. �Apply lepa of rodhra, madhuka, manjishtha, prapaundarika kalka

�If urine doesn’t come through its normal route and comes out from incision site (vrana), then it should be thermally cauterized ( agnikarma). �After urine comes out via normal route, uttarbasti, anuvasan and niruha basti are given prepared from kakolyadi gana or Kshiravrukshadi gana.

�Obstructed shukrashmari or sharkara should be removed with badisha yantra �Avoid coitus, horse-elephant-camel ride, climbing mountain, riding chariots, swimming, heavy to digest food for 1 year after healing of the wound.

Commonly used medicines in treatment of Ashmari 1. Eranda 2. Kantakari 3. Gokshura 4. Ikshumoola 5. Apamarga 6. Shatavari 7. Brihati 8. Yava 9. kulattha Above all drugs with sweet curd helps in breaking of Vataja ashmari

�Kusha �Kasha �Shara �Pashanbheda �Darbha �Vidarikanda �Varahikanda �Shalimoola �Gokshura �Patha �Punarnava �Shirisha Above drugs either in decoction of medicated ghee helps in breaking the pittaja ashmari

Treatment of kaphaja ashmari �Drugs from Viratarvadi gana �Varunadi gana �Mushakadi gana The medicated ghee prepeared with either one of the group along with guggulu, maricha, kushta, chitrak. Also various types of kshar (alkalies), kshira(medicated milk), yavagu(gruels) are used in the treatment.

Formulations used 1. 2. 3. 4. 5. 6. 7. Suvarnarajvangeshwar rasa Gokshuradi guggulu Badarashma pishti Sangehyahud bhasma Yavak kshar Apamarga kshar Shwetaparpati

Panchakarma �Before starting any formulations first purification of the body should be performed depending on doshic dominances �Vaman (kapha dominant) �Virechana (pitta dominant) �Niruha Basti (vata dominant)

To do- pathya Ø What to eat? �Yava �Kulattha �Purana shali �Purana kushmaand phala �Shighru Things to do �Avagaha sweda �Seasonal purification-vaman, virechan, basti

not to do �Holding of natural urges like urine/faecal �Foods which causes indigestion- acidic in nature �Stale food �Aerated drinks �Incompatible food �Dry food

Case presentation A male 48 years old came to the shalya OPD of the GAM&RC Goa with recurrent pain in lower abdomen shifting to the groin along with burning micturation and nausea. He is Truck driver by profession. He was diagnosed with bilateral renal calculus at J&K by private GP and was referred to urologist for sugrical treatment. He was not having any history of other major illness.

O/e all vitals were stable. Nadi parikshan- Vata kapha Prakruti- Kaphapradhan pittanubandi Eyes-NAD Tongue- saam (coated) Mala- constipated Mutra- burning micturation Akruti- thin Srotas- annavaha sroto and mutravaha srotodushti

USG abdomen on 19/2/14 showed 7 calculi in the left kidney, two in the middle calyx 3 mm & 2 nd 4 mm, Three in the inferior calyx- 1 st 3 mm, 2 nd 4 mm & 3 rd 4. 3 mm and two in the superior calyx 1 st is 5 mm and 2 nd 6 mm in size. Six calculi in right kidney. Two in middle calyx- 6. 5 mm and 4 mm in size Two in the inferior calyx- 5. 7 mm and 5 mm in size

�Kidney function test was normal �Urine analysis revealed oxalate crystals along with increased pus cells and cast cells �Ayurvediya diagnosis- Mutrashmari- Vata-kaphaja

Treatment 1) Ama pachan 2) Agni dipana 3) Vata-anuloman 4) Ashmari bhedan 5) Mutra virechana

�Drugs used 1) Combination of gokshura+erandamoola+pashanbheda+punarnava+s hatavari+chitraka+haritaki in the decoction form 40 ml two times a day before meals 2) Yavakshar 200 mg along with above decoction 3) Gandharva haritaki 2 gm at night time with hot water 4)Pathya was advised

Post treatment USG Date- 24/9/2014 Left kidney shows 5 mm calculus in the middlecalyx & 3 mm calculus in inferior calyx and 2. 5 mm in superior calyx Right kidney shows 4 mm calculus in the middle calyx & 2 mm calculus in inferior calyx and 5 mm in superior calyx

Thank you

Meet the eminent gathering once again at Traditional Medicine-2016 London, UK October 03 -05, 2016 Traditional Medicine-2016 Website: http: //traditionalmedicine. conferenceseries. com/