Scientific Basis for Ayurvedic Therapies -36

Scientific Basis for

Ayurvedic Therapies 

edited by

Brahmasree Lakshmi Chandra Mishra

57. Seth, S.D., Maulik, M., Katiyar, C.K., and Maulik, S.K., Role of Lipistat in protection against

isoproterenol induced myocardial necrosis in rats: a biochemical and histopathological study,

Indian J. Physiol. Pharmacol., 42, 101, 1998.

58. Arpaia, M.R., Ferrone, R., Amitrano, M., Nappo, C., Leonardo, G., and del Guercio, R., Effects

of Centella asiatica extract on mucopolysaccharide metabolism in subjects with varicose veins,

Int. J. Clin. Pharmacol. Res., 10, 229, 1990.

59. Incandela, L., Cesarone, M.R., Cacchio, M., De Sanctis, M.T., Santavenere, C., D'Auro, M.G.,

Bucci, M., and Belcaro, G., Total triterpenic fraction of Centella asiatica in chronic venous

insufficiency and in high-perfusion microangiopathy, Angiology, 52(Suppl. 2), S9, 2001.

60. Shoji, N., Umeyama, A., Saito, N., Takemoto, T., Kajiwara, A., and Ohizumi, Dehydropipernonaline,

an amide possessing coronary vasodilating activity,isolated from Piper longum

L., J. Pharm. Sci., 75, 1188, 1986.

61. Senthil Kumar, S.H., Anandan, R., Devaki, T., and Santhosh Kumar, M., Cardioprotective

effects of Picrorrhiza kurroa against isoproterenol-induced myocardial stress in rats, Fitoterapia,

72, 402, 2001.

62. Singh, R.B., Niaz, M.A., and Ghosh, S., Hypolipidemic and antioxidant effects of Commiphora

mukul as an adjunct to dietary therapy in patients with hypercholesterolemia, Cardiovasc. Drugs

Ther., 8, 659, 1994.

63. Arora, R.B., Das, D., Kapoor, S.C., and Sharma, R.C., Effect of some fractions of Commiphora

mukul on various serum lipid levels in hypercholesterolemic chicks and their effectiveness in

myocardial infarction in rats, Indian J. Exp. Biol., 11, 166, 1973.

31

Urolithiasis (Mutrashmari)

Venigalla Sridevi, I. Rajya Lakshmi, and I. Sanjeeva Rao

31.1 Introduction

Formation of stones in the urinary tract is a global phenomenon and is described in ancient

Ayurvedic scriptures as

mutraashamari.

It is said to be one of the eight most troublesome

diseases (

mahaorgas

).

1

Ayurvedic texts have classified the stones according to

dosic

profiles,

namely,

vata-

,

pitta-

, or

kapha

-related and others. Here we have to interpret that the very

mention of

dosic

involvement is indicative of the biochemical influences in the formation of

stones.

The formation of a stone (calculus) can be at any level in the urinary system. These

stones are most frequently formed in the kidney, but they pass farther down the urinary

tract toward the bladder. They are intensely painful as they pass along the ureters and

out through the urethra.

There are useful management and herbal treatments for urolithiasis that have been

currently investigated extensively. The main aim of this chapter is to summarize the

management of urolithiasis with herbs, herbal formulations, and dietary and lifestyle

inventions; to understand the Ayurvedic concept of urolithiasis; and to explore the scientific

basis of Ayurvedic therapies.

31.2 Epidemiology

The overall probability of forming stones varies in different parts of the world. The risk

of developing urolithiasis in normal adults appears to be lower in Asia (1 to 5%) than in

Europe (5 to 9%) and in North America (12% in Canada, 13% in the U.S.). The highest

risk was reported in Saudi Arabia (20.1%).

2

The compositions of stones and their location

in the urinary tract, bladder, or kidneys may also significantly differ in different countries.

Moreover, in the same region, the clinical and metabolic patterns of stone disease can

change over time. In India, bladder stones accounted for 30% of all urinary stones in 1965,

but their prevalence had dropped to 5% in 1985. Concurrently, the chemical composition

of stones in the upper urinary tract changed; the prevalence of calcium oxalate stones rose

from 26 to 82%, and the prevalance of struvite stones fell from 20 to 5%.

3

In Japan, bladder

stones decreased from 50 to 5% from 1950 to 1985.

4

In Portugal, over a 20-year period, the

prevalence of calcium stones rose from 64 to 82%, struvite stones decreased from 14 to

3%, and uric acid stones decreased from 19 to 12%.

5

31.3 Definition

Urolithiasis is defined as a stone or stonelike hard substance formed in the urinary tract.

The definition is consistent with current knowledge of urolithiasis — the accretion of hard,

solid, nonmetallic minerals in the urinary tract consisting of a nucleus of organic material

around which urinary salts are deposited in concentric layers.

31.4 Clinical Description

A renal calculus is similar to that of the kadamba flower. It is three-layered, resembles a

stone, and is either hard or smooth in texture.

6

The prodromal signs and symptoms

described in Ayurvedic texts consist of severe pain around or near the urinary bladder

region, suprapubic region, internal urethral orifice, testicles, and in the penis. Common

symptoms include distension of urinary bladder, fever, anorexia, dense and turbid urine,

dysuria, fatigue, and odor of urine resembling the smell of a sheep.

15,16

The major clinical features described are pain in the umbilical and suprapubic regions

and in the penis; obstructed urinary flow; split voiding of urine; hematuria; honey colored

or yellowish red urine, turbid urine; sandlike particles passing along with urine; pain

aggravated by jumping, swimming, riding a horse or camel, climbing in upward direction;

and polyurea.

17–19

All these clinical features are very much similar to those currently known. In conventional

medicine, clinical features of stones vary according to their size, shape, and location

of the stone and the nature of underlying condition. The most common complaint is

intermittent dull pain in the loin or back increased by movement. Proteins, red cells, or

leucocytes may appear in the urine.

31.4.1 Clinical Features According to the Location of the Calculi

31.4.1.1 Renal Calculus

Pain is characterized by a fixed dull ache in the angle between the lower border of the last

rib and lateral border of sacro spinalis. Pain is also felt anteriorly in the corresponding

hypochondriac region. Pain worsens with movement like running, jumping, and climbing

up stairs and eases with rest. Sudden gripping pain is felt in the loin and tends to radiate

toward the groin. Patients may experience fitful sleep because of pain. Pain may be associated

with hematuria and may be complained of either during or after an attack.

31.4.1.2 Ureteric Calculus

Ureteric colic starts as soon as the stone enters into the pelviureteric junction and recurs

at shorter or longer intervals as long as the stone remains in the ureter. Ureteric colic

ceases when the stone is ejected into the bladder or impacted in the ureter. When the stone

is present in the upper one third of the ureter, pain starts in the loin or near the renal

angle and gradually radiates to the groin. Pain is gripping and starts suddenly. The patient

experiences fitful sleep because of pain, which is often associated with hematuria and may

be complained of either during or after an attack. When the stone is at a lower level, pain

commences rather anteriorly just above the iliac crest and is referred along the two

branches of the genitofemoral nerve to the testis in males, labia majora females, and

anteromedial aspect of the thigh in both sexes. When the stones enter into the intramural

part of the ureter in males, pain is referred to the tip of the penis, and the patient complains

of strangury.

When the stone is impacted, colic ceases; a dull ache arises according to the site of

impaction. Such pain varies in intensity, and it increases with exercise and is relieved by rest.

31.4.1.3 Vesical Calculus

With increased frequency of micturition, pain is often referred to the tip of penis or the

labia majora and becomes aggravated by running and jolting. Children may scream and

pull the prepuce for pain after micturition and experience hematuria at end of the micturition.

31.5 Etiology

In Ayurveda the causes of urinary calculi are mainly nonadoption of the purificatory

measures such as emesis, purgation, and medicated enemas in order to eliminate the

vitiated

dosas

(toxic materials

)

and practice of unhealthy diets and lifestyles. These factors

are responsible for the formation of calculi.

7–10

They are primarily classified into two

categories: unhealthy diet or excessive physical activity.

In conventional medicine, there are three primary factors considered responsible for

stone formation. They are the supersaturation of stone-forming compounds in urine, the

presence of chemical or physical stimuli in urine that promote stone formation, and the

inadequate amount of compounds in urine that inhibit stone formation (e.g., magnesium,

citrate).

Categories of specific risk factors for stone formation are listed below.

11

1. Diet associated with stone formation — Vitamin A deficiency; a high-oxalate diet

rich in purine levels; a diet high in protein from animal sources, glucose, or

sucrose; etc.

2. Medication associated with stone formation — Calcium supplements, vitamin D

supplements, ascorbic acid in megadoses (4 g/day), sulfonamides, triamterene,

indinavir, etc.

3. Diseases associated with stone formation — Hyperparathyroidism, renal tubular

acidosis (complete or partial), jejunoileal bypass, Crohn’s disease, intestinal resection,

malabsorptive conditions, sarcoidosis, hyperthyroidism, etc.

4. Anatomical abnormalities associated with stone formation — Tubular ectasia

(MSK), pelviureteral junction obstruction, calix diverticulum or calyceal cyst, ureteral

stricture, vesicoureteral reflux, horseshoe kidney, etc.

The additional risk factors include habitually low urine volume, high urine excretion

of calcium, uric acid and oxalate, low urine pH (uric acid and cystine are less soluble in

acid urine), and high urine pH (struvite and calcium phosphate are less soluble in alkaline

urine). Some of the biochemical processes not only become relevant here, but also lay the

basis for the drug therapy.

The stone is the outcome of accretion of inorganic material around an organic nidus not

soluble in its own solution

.

Urine that is an end-point excreta, in a liquid form, represents

the biochemical status of a person’s metabolism. For example, in normal urine, nephrocalcin

is an acidic glycoprotein, rich in

°

-carboxy glutamic acid, which inhibits calcium

oxalate crystal growth. The nephrocalcin present in the organic matrix of calcium oxalate

kidney stones resembles the nephrocalcin present in the urine of the patient from whom

the stone was removed, but it differs from the nephrocalcin in normal urine. The stone’s

former nephrocalcin lacks ‘

°

’-carboxy glutamic acid, which reduces to air-water interfacial

films that are less stable than those formed by nephrocalcin from normal urine. It is safe

to presume that the alteration of the biochemical quality of urine can help in the prevention

of stone formation. The biochemical quality of urine can change with the quality and

quantity of fluid inputs, the type of diets, and the constitutional factors. This in turn can

play a great role in the formation or nonformation of stones in the urine. Ayurveda suggests

a number of herbs and herbal preparations for stone breakdown. It is possible that the

therapeutic agents are capable of altering the chemical composition of the urine and its pH.

31.6 Pathology

In Ayurveda, the concept of renal calculi pathogenesis is indicated as when the

kapha

dosa

is vitiated because of the etiological factors,

kapha

reaches to the urinary system and, with

the help of

vata

and

pitta

dosas

, dries up and forms the calculus.

12

There is another similar

opinion regarding the pathogenesis of urolithiasis.

13

Urinary concretions may vary greatly in size. There may be particles like sand anywhere

in the urinary tract or large stones in the bladder. Staghorn calculi fill the whole pelvis

and branch into the calyces and are usually associated with pyelonephritis. Deposits may

also be present throughout the renal parenchyma, giving rise to nephrocalcinosis.

14

31.7 Classification of Renal Calculi

Ayurvedic texts have described four types of urinary calculi:

sleshmaashmari, pittaashmari

,

vataashmari,

and

sukraashmari.

20

1.

Sleshmaashmari

— In

sleshmaashmari

, stones are white, unctuous, and as big as a

hen’s egg. They produce symptoms such as dysuria, cutting, incising, pricking

pain, heaviness, and a cold sensation over area the bladder region.

2.

Pittaashmari

— In

pittaashmari

, stones are reddish, yellowish, and blackish and

resemble the color of honey. They produce a sucking type of pain, burning sensation,

a warm feeling over the bladder region, and

ushnavata

.

3.

Vataashmari

— In

vataashmari

, stones are dusty in color, hard, irregular, rough and

nodular or spiny like the kadamba flower. Patients experience severe pain (and

may scream); pull out the prepuce; and have difficulty when passing flatus, urine,

and stools.

4.

Sukraashmari

—

Sukraashmari

occurs in adults only. It is due to suppression of

ejaculation for months or years and frequent coitus or coitus interruption. The

semen to be ejaculated will be obstructed, condensed, and brought in-between

the scrotum and penis (prostatic part of the urethra) by

vata

. This causes dysuria,

scrotal swelling, and lower abdominal pain. The special characteristic of

sukraashmari

is that handling can dissolve it.

In conventional medicine, urinary calculi are classified according to their chemical

components. Examples include uric acid and urates, calcium oxalates calcium and ammonio-

magnesium phosphate (Struvite),

cystine, combinations of the preceding items, and

drugs or their metabolites (e.g., phenytoin, triamterene). Descriptions of these components

are highlighted below.

1. The uric acid stone is moderately hard and brown. It is usually multiple, typically

faceted, occurs in acid urine, and shows concentric rings on the cut surface. The

uric acid usually combines with urates and sometimes with oxalates to form

opaque stones.

2. The oxalate stone is the most common form of calculus and consists of calcium

oxalate. It is extremely hard and the surface is rough and sometimes spiny

(mulberry calculus). It causes marked irritation due to rough surface and

becomes dark in color due to bloodstains. The outer layers often contain urates,

which are usually a single crystal, and give an exceptionally good shadow on

radiography.

3. The phosphatic stone consists of calcium phosphate and triple phosphates (ammonio-

magnesium phosphate). It is white, smooth, chalky, and is easily broken up;

occurs in alkaline urine; and is easily distinguishable from other types. It often

fills the renal calyces taking on their shape such as stag horn calculus. In alkaline

urine it grows rapidly because it is smooth; a phosphatic calculus gives rise to

few symptoms until it attains a large size. Deposits of phosphates are often formed

on the surface of uric acid and oxalate stone due to changes in chemical characteristics

of the urine as a result of infection.

4. The uric acid and oxalates stones occur away from gross infection in the renal

pelvis and sometimes in the bladder as primary stones. The phosphatic stones

that form as a result of infection usually in the bladder, but sometimes in the renal

pelvis, are known as secondary stones.

5. Cystine calculi are

hexagonal, white, translucent, and occur in acid urine. They are

soft like bees wax, pink or yellow when first removed, and change color to a greenish

hue on exposure to air and light. They are radio-opaque due to the sulfur atom.

6. Xanthene calculi

are extremely rare. They are smooth, round, brick red, and show

lamella structure.

It should be noted that with the Ayurvedic description of urinary stones,

sleshmaashmari

can be correlated with the phosphatic stone and

pittaashmari

can be correlated with urate

stones,

vataashmari

can be correlated with oxalate stones, and

sukraashmari

can be correlated

with spermolith or seminal concretions of conventional medicine.

31.8 Diagnosis

After taking a detailed history, diagnosis is made on the basis of laboratory investigations

and diagnostic imaging for mere confirmation.

31.8.1 Laboratory Investigations

The routine laboratory investigation includes examination of the urinary sediment and a

dipstick test for red cells, white cells, nitrate, pH of the urine, and measurement of serum

creatinine. In patients with fever, an analysis of C-reactive protein, a white blood cell

count, and a urine culture are carried out. In cases of vomiting, serum sodium and serum

potassium should be measured. To exclude metabolic risk factors, it is important to

measure the serum calcium and serum urate.

31.8.2 Diagnostic Imaging

Routine examination involves a plain film of kidneys, ureters, and bladder plus an ultrasound

examination or an excretory pyelography (urography). The latter examination must

not be carried out in patients with an allergy to contrast media, serum creatinine (>200

m

mol/l), or treatment with metformine and myelomatosis. Other special examinations

that can be useful in diagnosis are spiral (helical) unenhanced computered tomography

(CT), retrograde and antegrade pyelography, and scintigraphy. Because of the risk of

impaired renal function due to lactic acidosis, the antidiabetic drug metformine should

be stopped 2 to 3 days before administration of iodine containing contrast medium. Spiral

(helical) CT is a new noninvasive technique that might be considered in case iodine

containing contrast medium cannot be administered.

21

Health conditions frequently associated with stone formation are as follows

22

:

1. Obstruction and infection of urinary tract

2. Climate or occupation giving rise to high concentration of constituent materials

in the urine and reduced urine volume

3. Hypercalciuria

4. Hyperoxaluria

5. Inherited disorders (e.g., cystinuria, xanthinuria, gout)

31.9 Prognosis

From an Ayurvedic perspective, except for

sukraashmari

or

seminal

concretions, the other

three types are manageable by surgery. If the renal calculus is associated with swelling in

the scrotum and umbilical region, retention of urine with severe pain, and passing of urine

with fine particles, the condition is said to be incurable.

23

In conventional medicine,

prognosis of renal calculi is generally good. Occasionally, death or significant morbidity

occurs, but most of the patients recover.

31.10 Treatment

The management of urolithiasis in Ayurveda basically includes herbal formulas, alkaline

liquid, and surgical procedures. Newly formed calculi can be cured by herbal formulas,

but chronic calculi has to be treated surgically. Oiling, induced sweating, medicated emesis,

purgation and enemas should be given in the prodromal state of the disease only in order

to cure it completely.

24

31.10.1 Type of Management

31.10.1.1 Shamana Therapy

Palliative treatment includes administration of herbal drugs and herbal formulas orally.

The palliative drugs used to treat renal calculi are analgesic, diuretic, and linthnotriptic

agent and are able to balance

vata

.

Preparations of

varuna, gokshura, pashana bheda, shilajitu,

ela, veerataru, brihati, kantakari, yava kshara, kushmanda, trapusa, hazrul yahud bhasma,

etc. are

commonly used in renal calculi.

31.10.1.2 Shodhana Therapy

Cleansing treatment includes

prepanchkarma

procedures such as external and internal

oleation and induced sweating, and

panchakarma

procedures, such as medicated emesis,

purgation, and enemas. Most of the Ayurvedic classics recommend medicated enemas

for the treatment of urolithiasis.

Saindhavadi taila niruha vasti

25

and

vrushadi asthapana

vasti

26

are generally used in renal calculi. The idea here is that transmucosal fluxes are

encouraged away from the kidney for removal of unwanted metabolites, thereby reducing

the ionic load on the kidney filtration system. This may be considered as a type of

dialysis procedure.

31.10.1.3 Alkali Therapy

Most of the alkaline materials (

kshara

) act as diuretics, lithotriptic, alkalizer, and antispasmodic

agents. These pharmacological activities are shown to be effective in the management

of different symptoms of urolithiasis. Examples include

palasa kshara, yava kshara,

and

mulaka kshara.

31.10.2 Medical Management

27

31.10.2.1 Vataashmari Treatment

A decoction is made for the following drugs:

pashana bheda, vasuka, ashmantaka, satavari,

gokshura, brihati, kantakari, bhramhi, artagala, usira, kubjaka, vrukshadani, bhalluka,

and

varuna,

and

fruits of

saka, yava, kulutha, kola,

and

kataka

. To this

ushakadi

group of drugs,

kalka

(paste)

is added and thus ghrita is prepared. This preparation immediately destroys vatashmari.

Kshara (alkali), gruels, soups, decoctions, milk preparations, and food prepared from

this vata-allaying group of substances should be administered.

31.10.2.2 Pittaashmari Treatment

A decoction is made for the following drugs: kusa, kasa, sara, morata, pasana bheda, satavari,

pashana bheda, vidari, varahi, shalimula, trikantaka, bhalluka, patala, patha, kuruntika, punarnava,

and shirisha. Ghritha has to be prepared by using the above drugs’ decoctions to which

silajit, madhuka, seeds of indivara and trapusa, and seeds of eravaruka are added.

A list of commonly used formulations is in Table 31.1.

Alkalis, gruels, soups, decoctions, milk, and foods prepared from these pitta-allaying

groups of substances should be administered.

31.10.2.3 Sleshmashmari Treatment

Drugs of this decoction include varunadi gana, guggulu, ela, harenuka, kushta, and drugs of

bhdraadi gana, maricha, chitraka, and devadaru. The decoction, added with paste of the

ushakadi group of drugs, has to be taken along with dehydrated butter. This preparation

provides relief from sleshmaashmari.

Alkalies, gruels, soups, decoctions, milk preparations, and food prepared from these

kapha-balancing groups of substances should be administered. Karpasa flowers, ankola,

nirmali, saka, and indivara fruits powder have to be taken internally with water and

TABLE 31.1

Some of Important Formulations Mentioned in Ayurvedic Texts

No. Medicine

Doses, Vehicle, and

Duration Referencea Manufacturer

1 Gokshuradi guggulu 3 g/day with pashana bheda

kwatha

AF Sec. 5:3 Amrita, Arkashala,

Baidyanath, Indian

Medical Practitioner's

Co-operative Pharmacy

& Stores, Kerala

Ayurvedic Pharmacy

Ltd., Sandu, Zandu

2 Ashmari hara

kashaya churna

48 g/day AF Sec. 4:3 —

3 Varuna kwatha

churna

48 g/day AF Sec. 4:22 —

4 Trikantaka ghritha 12 g/day with warm water

or warm milk

AF Sec. 6:15 Kottakal

5 Vatsyamayantaka

ghritha

12 g/day with warm milk AF Sec. 6:40 Arya Vaidya Pharma,

Kottakal

6 Mulaka kshara 1 g/day with water AF Sec. 10:10 Dindayal, Prabhat

7 Yava kshara 1/2 –1 g/day with water Dindayal, Prabhat

8 Palasha kshara 1/2 –1 g/day with water AF Sec. 10:9 —

9 Chandra prabha vati 250–500 mg two times/day

with water, milk, or

ginger powder

AF Sec. 12:10 Arya Vaidya Pharma,

Dabur, Dindayal,

Dhootpapeshwar,

Nagarjuna, etc.

10 Sweta Parpati 725 mg–1.25 g two times/

day with coconut water or

cold water

AF Sec. 12:2 —

11 Hazrul yahud

bhsama

500 mg–1 g two times/day

with ashmari hara kashaya

AF Sec. 14:4 —

12 Trivikrama ras 250 mg two times/day

with beejapuraka nimba

mooola twak and water

AF Sec. 16:24 Bhuvaneshwari

13 Sukramatraka vati

500 mg with juice of

pomagranate, goat’s milk,

or water

AF Sec. 12:29 —

14 Vishnu Tailam Internal and external

application

AF Sec. 8:15 —

15 Brihat Saindhavadya

Tailam

External application AF Sec. 8:40 —

aAll references are from The Ayurvedic Formulary of India (AF), a Government of India Publication.

jaggery; this mixture quickly reduces blood sugar levels. Gokshura, talamuli, ajamoda,

roots of kadamba, and adraka are taken with wine or hot water to remove calculi. Gokshura

seeds powder with honey should be taken with milk for 1 week to disintegrate the

calculi.

31.10.2.4 Sukraashmari Treatment

If seminal concretions or fine particles spontaneously come in the urethra, they should be

removed by the badisha instrument (a hook). After the wound is healed, the patient is

advised not to undertake any physical activity, such as horse riding.

31.10.2.5 Alkali Treatment28

In Ayurvedic texts, it is advocated that a formulation with medicated ghrita and kshara is

made from the drugs mentioned above.

Kshara (alkali) prepared from pastes of tila, apamarga, kadali, palasa, and yava administered

as a drink quickly relieves the symptoms. Kshara prepared from patala and karavera can

also be effective.

Patients suffering from pain should be given milk processed with the above drugs or

triphala groups or with punarnava as a drink. The drugs of the veerataru group can be

administered by all modes.

31.10.2.6 Surgical Treatment

The surgical procedure (shastra karma) depicted in the classical texts may be presented as

follows.29

First, the patient should be cleansed of the vitiated dosas. Then the patient, who is strong

enough and is not nervous, should be laid flat with the upper part of his body resting on

the lap of another person sitting on a knee-high plank facing east; the patient’s waist

should be raised by cushions and his knees and ankles flexed and tied together by straps

(lithotomy position). After massaging the left side of the well-oiled umbilical region,

pressure should be applied first below the navel until the stone comes down. Introduce

the lubricated index and middle fingers into the rectum below the perineal raphe. Thereafter,

with manipulation and force bring the stone down between the rectum and the

penis. Keeping the bladder tense and distended so as to obliterate the folds, the stone is

pressed hard by fingers so that it becomes prominent like a tumor.39

An incision of about the size of the stone is then made just a few millimeters away

from the perineal raphe on the left side. Some surgeons prefer the incision on the right

side for the sake of technical convenience. Precautions should be taken so that the stone

does not get broken or crushed. Even a small particle left behind can increase in size.

The stone is then removed with an agravaktra instrument (small-tipped forceps, like

mosquito forceps).

In females, as the uterus is situated very near the urinary bladder posteriorly, the incision

should be directed upward. An incision in the bladder made at one place for the removal

of a stone heals well. After removal of the stone, the patient is put in a tub of hot water

and sedated to avoid any blood filling the urinary bladder. If the bladder does fill with

blood, it is irrigated through a catheter with the decoction of the latex trees.

The decoction of the latex trees administered as an irrigating fluid through a catheter

also removes the stones and the blood from the bladder.

31.10.3 Postoperative Management

To purify the urinary tract after an operation, the patient is given sufficient jaggery-based

preparations. The patient is taken out of the tub, and honey and ghee are applied to the

wound. The patient is given warm gruel processed with urine-purifying substances twice

daily for 3 nights. After 3 nights, milk with treacle and small quantities of well-cooked

rice is given to eat for 10 nights. After 10 nights, the patient is given sudation therapy

either by oils or by liquids. The wound is washed with the decoction of latex trees.

The paste of lodhra, madhuka, manjista, and prapaundrika is applied to the wound. An oil

or ghrita prepared from same substances along with haridra should also be anointed over

the wound.

In case blood coagulates, it should be managed by bladder washes. If urine does not

come out from its natural passage even after 7 nights, the wounds should be treated by

heat treatment (cautery) according to the described method. When urine starts flowing

along its natural passage, the patient should be treated by bladder washes, enemas of

medicated decoctions, and medicated oils and given preparations made of jaggery to eat.

31.10.4 Management of Urolithiasis in Modern Medicine

The immediate treatment of loin pain or renal colic is bedrest and application of warmth

to the site of pain. Pain relief can be achieved by administering the following agents:

Diclophenac sodium, Indomethacin, Hydromorphone (Hydrochloride+atropin sulfate

[Dilaudid-Atropin®]), Methamizol, Penta-zocin, and Tramadol. Treatment is started with

an NSAID and changed to an alternative drug if the pain persists. Hydromorphone and

other opiates without simultaneous administration of atropine should be avoided. Diclophenac

sodium affects glomerular filtration rate in patients with reduced renal function

but not in patients with normal renal function.30 When pain relief cannot be achieved by

medical means, drainage by stenting or percutaneous nephrostomy or by stone removal

is performed.

The medical therapy depends on the type of stone produced. The therapeutic agents

that are generally used in renal calculi are alkalinizing agents (sodium citrate and citric

acid, sodium citrate, and potassium citrate mixture), diuretics (hydrochlorothiazide),

chelating agents (cellulose sodium phosphate), and Xanthine oxidase inhibitors (Allopurinol).

31.11 Prevention

Ayurvedic texts provide detailed information regarding the dietary habits and lifestyles

that are to be adopted in renal calculi. It is advised to take whole rice, wheat, barley, horse

gram, green gram, matured pumpkin, varuna, ginger, gokshura and amaranthus, flesh of

birds residing on dry soil or barren land, and measures such as medicated enemas, emesis,

purgation, fasting or light diet, and sudation. The intake of sour, dry, and heavy foods,

food substances that cause indigestion, and unwholesome food items should be

avoided.31,32

In conventional medicine, the dietary habits are not much emphasized, but in some

conditions some general advice is given. In idiopathic calcium nephrocalcinosis, patients

are advised to maintain adequate fluid intake to produce at least 2 l/day of urine, maintain

adequate calcium intake (at least recommended daily allowances) from food sources, cut

down intake of animal protein, cut sodium intake 4 g/day (170 meq), cut sucrose intake,

increase dietary K intake, avoid grapefruit juice, and avoid unnecessary vitamin C. Coffee,

tea, and alcoholic beverages should neither be avoided nor encouraged.33

31.12 Scientific Basis for the Use of Ayurvedic Drugs in Urolithiasis

31.12.1 Clinical Studies

1. In one study34 with 30 cases of nephrouretero lithiasis, 17 cases were given 1 g of

swetaparpati with 50 ml of kuluttha kwatha three times/day for 1 month. Marked

improvement was noticed in different symptoms and pathological findings after

the course of the therapy. Radiological investigations revealed expulsions of ureteric

calculi were much more than those of renal calculi.

2. In another study,35 50 patients with urolithiasis (24 patients with renal calculus

and 26 patients with ureteric calculus) were given palasa kshara in the dose of 1 g

three times/day for 30 days. On the basis of radiological findings, the drug is said

to be more effective in the expulsion of ureteric calculi as compared with renal

calculi.

3. In one clinical study36 consisting 30 urolithiasis patients (14 patients with renal

calculi and 16 patients with ureteric calculi), 1 g of sveta parpati with 50 ml of

pasanabheda and gokshuru kwatha was given three times/day for 3 weeks. The study

indicated significant effect in majority of the cases. The x-ray findings indicated

the clearance of the stone. Some of the stones had also passed through urine during

the course of treatment.

4. A study37 was conducted with 71 patients suffering from urolithiasis (ashmari)

who were diagnosed by kidney, ureter, and bladder intravenous pyelography

(KUB, IVP). They were treated with juice of the core of the pseudostem of Musa

paradisiaca Linn. and Musa sapientum Linn. A significant segment of them passed

out calculi of varying size after consuming the drugs for 2 weeks. The recurrence

of stone formation was also prevented by the treatment. The author concludes

that the plant material is quite effective in curing urolithiasis, especially of the

calcium oxalate variety.

5. Of a total 110 cases, 30 cases were included in group A-1 and treated with sveta

parpati, pasanabheda, and gokshuru; 30 cases were included in group A-2 and treated

with sveta parpati and kulutha kwatha; and 50 cases were included in group B and

treated with palasa-ksara. On the basis of the radiological evidence and clinical

pathological criteria, it was concluded that the drug combinations in groups A-1

and A-2 had very good lithotriptic, diuretic, alkaliser, coagulant, and vata shamaka

properties. The drug combination in group A-2 showed better lithotriptic action

than that in group A-1. The drugs in group B have diuretic, linthnotriptic, and

alkalizer properties and also have an antispasmodic effect. The radiological findings

indicate that almost all the three therapies proved more effective in the

expulsion of ureteric calculi as compared with the nephrotic calculi.38

6. One hundred cases of nephroureterolithiasis were treated with Cystone tablets

(Himalaya Drug Company) in four different combinations (plenty of fluids by

mouth, forced diuresis, antispasmodics, and antispasmodic-forced diuresis) for 1

year. The therapy with Cystone tablets and fluids given orally gave 76% positive

results. The therapy with Cystone tablets combined with forced diuresis revealed

80% positive results, whereas antispasmodics combined with fluids given orally

showed 20% positive results. Therapies with antispasmodics in combination with

forced diuresis showed 28% positive results. The study indicates that forced diuresis

alone is not as effective as the therapy with Cystone tablets alone in the

treatment of nephroureterolithiasis. The mechanism action of Cystone could be

attributed to any of its pharmacologic agents: diuretic, spasmolytic action, effect

on crystalloid and colloid balance, and disintegrating action on the binding mucin.

As Cystone contains no toxic ingredients, no side effects were observed even with

prolonged therapy for 6 months.39

31.12.2 Pharmacological Studies

31.12.2.1 Varuna (Cratevea nurvala)

1. The cytoprotective action of lupeol isolated from Crataeva nurvala stem bark

against free radical toxicity has been investigated in experimental urolithiasis. The

increase in lipid per oxidation and super oxide dismutase activity, associated with

decreased catalase activity and glutathione level, are the salient features observed

in tissues of stone-forming rats. Lupeol administration induced a remarkable

decrease in kidney oxalate level and also was effective in counteracting the freeradical

toxicity by bringing about a significant decrease in peroxidative levels and

an increase in antioxidant status. The antioxidant property of lupeol and its cytoprotective

action against free-radical toxicity has also been studied.40

2. The antiurolithiatic activity in the crude extract of C. nurvala has already been

examined. Further fractionation of this extract led to the isolation of the active

constituent lupeol (Lup 20(29)-en-3beta-ol). Antiurolithiatic activity of lupeol was

assessed in rats by observing the weight of the stone, biochemical analysis of

serum and urine, and histopathology of bladder and kidney. Lupeol not only

prevented the formation of vesicle calculi, but also reduced the size of the preformed

stones.41

3. Male albino rats (100 ~10 g) were fed daily with a 3% glycolic acid solution (1

g/kg) orally for 4 weeks. It caused the deposition of lithogenic constituents,

calcium and oxalate in kidneys, in significant amounts and induced hyperoxaluria,

hypercalciuria, and hypercrystalluria. Oral administration of ethanolic

extract of C. nurvala (stem bark) at the dose levels of 25, 50, and 100 mg/kg for

4 weeks showed 12 to 54% protection against the deposition of stone-forming

constituents in the kidney and against hyperoxaluria, hypercalciuria, and hypercrystalluria.

Similarly, lupeol, the active constituent of C. nurvala, was also found

to be active. At an oral dose of 10, 25, and 50 mg/kg for 4 weeks, it showed 24

to 63% activity. The increased urinary excretion of the crystalline constituents,

found in the stone-forming rats, was nearly normalized by lupeol treatment in

a dose-dependent manner.42

31.12.2.2 Gokshura (Tribulus terrestris)

An ethanolic extract of the fruits of T. terrestris showed significant dose-dependent protection

against urolithiasis induced by glass-bead implantation in albino rats. On subsequent

fractionation of the ethanol extract, maximum activity was localized in the 10%

aqueous methanol fraction. It provided significant protection against the deposition of

calculogenic material around the glass bead. It also protected leucocytosis and elevation

in serum urea levels. Further fractionation lead to decreased activity. This could be either

due to the loss of active compounds during fractionation or the antiurolithiatic activity of

T. terrestris being a combined effect of several constituents present in the methanolic

fraction.43

31.12.2.3 Pashanabheda (Bergenea ligulata)

Acetone extract of the root bark of B. ligulata has been subjected to preliminary pharmacological

investigations. Observations indicate that the extract contains components possessing

sedative action, potentates analgesia induced by a subanalgesic dose of morphine,

and anti-inflammatory activity comparable with that of aspirin. The extract was devoid

of possessing antilithiatic activity but exhibited a mild diuretic effect when tested on rats

and dogs.44

31.13 Discussion and Conclusions

The epidemiology shows that there is a wide variation in the occurrence of urolithiasis in

various countries. There are also many variations in the chemical composition of stones.

Basically, it is a physicochemical phenomena involving the nature of urine and the accretion

of minerals. It is interesting to note that the stone former’s nephrocalcin lacks °-

carboxy glutamic acid. This chapter provides a number of herbal treatments that provide

scope for research into their ability to alter the chemical composition of the urine, making

the stone vulnerable for dissolution. This is a very fruitful area for future research for

metabolic management of the patients, particularly after surgical removal of the stone.

31.14 Future Research Areas

Biochemical and biophysical characters of the body’s metabolism involving hydrokinetics

and dispersal of organic waste matter in urolithiasis is a potentially fruitful area. This may

give leads for phytotherapy intervention suited to rectify the aberration.

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Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to H H Maharshi ji,  Brahmasri Sreeman Lakshmi Chandra Mishra ji and other eminent medical scholars and doctors   for the collection)