A A M J Anveshana Ayurveda Medical Journal

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1 A A M J Anveshana Ayurveda Medical Journal ISSN: Research Article A clinical study on the efficacy of Viṣādi Vaṭi in the management of Mūtrāśmarī w.s.r. to Urolithiasis Gujar Rakeshkumar 1 Masalekar Srinivas 2 A b s t r a c t Background and objectives: Mūtrāśmarī or urinary stone is the most painful & common disease of the urinary system. Despite having various treatment modalities in case of Mūtrāśmarī, even today many lacunas still exist. To try & overcome the lacunas, this study namely A clinical study on the efficacy of Viṣādi Vaṭi in the management of Mūtrāśmarī w.s.r. Urolithiasis was been taken up. In this study, an effort is made to find out the significance of Viṣādi Vaṭi in the management of Mūtrāśmarī. Materials and Methods: The study was conducted in the OPD and IPD of S.J.I.I.M. Hospital Bengaluru. 20 cases of Mūtrāśmarī were selected from the OPD and IPD of the aforesaid institution and randomly treated with Viṣādi Vaṭi. Results: The treatment modality of Viṣādi Vaṭi is efficacious in treating Mūtrāśmarī. Key words: Mūtrāśmarī, Urolithiasis, Viṣādi Vaṭi. 1 PG Scholar, 2 Assistant Professor, Dept of Shalya Tantra, Govt Ayurveda Medical College, Bengaluru, India. CORRESPONDING AUTHOR Dr. Gujar Rakeshkumar PG Scholar, Department of Shalya Tantra, Govt Ayurveda Medical College, Bengaluru, (India). rakeshkumarsgujar@gmail.com sue4/aamj_1482_1488.pdf AAMJ / Vol. 3 / Issue 4 / July August 2017

2 INTRODUCTION The earliest reference about Aśmarī is available in Atharvaveda (1st khanda, 3 rd sukta, 6-9 shlokas). Aśmarī is described by authors of Bruhatrayees and later period treatises. Acharya Sushruta, the father of surgery has systematically described Mūtrāśmarī in detail with its aetiology, classifications, symptomatology, pathology, complications and management. It is included as one among Aṣṭamahāgada [i] and calls it as Antakapratima which means swarūpa of Yama. Acharya Charaka explained it as a type of Mūtrāghāta [ii]. Madhavakra also mentioned Aśmarī as Yamopama - The God of death which reflects Aśmarī s fatal nature. Mūtrāśmarī or urinary stone is the most painful & common disease of the urinary system. It is the third most common affliction of the urinary tract, exceeded only by UTI and BPH [iii]. Acharya Sushruta has described various medicines as well as surgery for treatment of Mūtrashamari. Medicinal treatment has been advised to be undertaken in the early stage of the disease. Surgery is indicated along with a note of caution regarding its complication and doubt of success 4. Sushruta has advised that surgery to be done only on failure of conservaṭive treatment and when death becomes inevitable if not operated. The process of urinary stone formation as described by Sushruta is that, in Asaṁśōdhanaśīla persons, one who does not follow Śōdhana(purification) treatment and who is Apathyakāri (uses unwholesome items), Ślēṣma Dōṣa gets aggravated, and saturates the urine in system. This saturated urine (Ślēṣma Yukta Mūtra) is the material (cementing substance) which leads to urinary stone formation. Through urine, different stone forming Dōṣas like Vāta, Pitta & Kapha come from the system and along with the cementing substances they form urinary stone of particular dōṣa involved. Modern science also emphasizes on involvement of various factors like heredity, age, sex, metabolic disorders, sedentary life style, hydration status, mineral content of water, nutritional deficiency etc., for urinary stone formation. Urolithiasis typically occurs in middle age which is the most productive years of life. It causes severe pain leading to loss of working time, medical expenses, need for hospitalization as well as it is an infrequent cause of renal failure and death [v]. About 15% of men and 5% of women develop renal calculi at some stage. If one has developed kidney stones in the past, is likely to have a 70% chance of formation of new stones in the future. In modern medicine, the treatment modalities of urinary stones depend upon size, position of calculi etc. Nonsurgical management includes flush therapy, medical expulsive therapy using alpha-antagonists or calcium- channel blockers, ESWL & Dormia basket procedure. Operative treatment includes advanced techniques like PCNL, Ureteroscopy, Pyelolithotomy, Nephrolithotomy, Partial Nephrectomy, Nephrectomy,Nephrostomy etc. However, all these medications and procedures are expensive, involve invasive therapies, needs hospitalization, in most of the cases, recurrence rate is high & have one or the other drawbacks. Keeping in view of the lacunas in the treatment modalities presently available, there is a need for safe, cost effective and simple method of management of Urolithiasis. The present study was planned to find out an effective treatment by Ayurvedic approach. In Ayurvedic management, use of various ghruta, kṣāra, kaṣāya, kṣīra and uttarabasti are described as main line of treatment. If the disease does not get alleviated, shastrakarma is ultimate treatment. Viṣādi vaṭi, mentioned in Basavarajeeyam, Aśmarī chikitsa, chapter-9, shloka-263,264 is described to be more effective in the treatment of Mūtrāśmarī. Contents of Viṣādi vaṭi are; Vatsanabha, Pāṣāṇabheda, Yavakṣāra, Saindhava lavaṇa and Gōmūtra. Vatsanaabha is said to be vātakaphāmayāhāra, śōthāhāra, vedanapaha, jwarāhāra and yogavāhī. Pāṣāṇabheda is said to be ashmaghna, bastiśōdhana, bhedana and śūlāhāra. Yava kṣāra is said to have bhedana, lekhana, mūtrala and vātaślēṣmaja śūlāhāra. Saindhava lavaṇa is said to have dīpana, pāchana and tridōṣāhāra properties. Gōmūtra have śūlaghna, bastirogāhāra, śōthaghna and kṣāra guṇa. So this study was taken up to explore the efficacy of Viṣādi vaṭi in the management of Mūtrāśmarī which can overcome the above said lacunas. The results obtained by the present study was analysed. METHODOLOGY The clinical study on management of Mūtrāśmarī with Viṣādi Vaṭi was conducted at SJIIM hospital -Government Ayurvedic Medical College, Bengaluru. Source of Data: The patients with classical features of Mūtrāśmarī which can be co-related with Urolithiasis were selected from SJIIM Hospital, Bengaluru. AAMJ / Vol. 3 / Issue 4 / July August

3 Method of Collection of Data: A total of 20 patients with classical features of Mūtrāśmarī, having features namely unilateral or bilateral pain in the Renal angle, pain in lumbar region, radiating pain from loin to groin, pain in scrotum and inner aspect of thigh, dysuria, haematuria and presence of Calculi confirmed by Ultra Sonogram of abdomen and pelvis were be selected for the study. Inclusion Criteria: Patient complaining of unilateral or bilateral pain in the renal angle, pain in lumbar region and radiating pain from loin to groin, pain in scrotum and inner aspect of thigh or pain in at least any one or more of above said sites. With or without dysuria. With or without micro haematuria. Patient with solitary or multiple stones. The cases of Renal calculi that have not been lead to retention of urine. Unilateral or bilateral Calculi present anywhere in urinary tract measuring up to 9mm size confirmed by USG abdomen and pelvis. Patient not having impacted calculi in ureter /ureter s causing unbearable pain. Exclusion Criteria: Patient with retention of urine due to any other pathology. Patient with other systemic disorder. Presence of calculi during pregnancy and lactation. Pānīya kṣāra and Vatsanabha sevana anarha patients. Stag horn calculi. Materials Used: Capsules containing 250mg of Viṣādi vaṭi in sufficient number. Tandulodaka in sufficient quantity. Study Design: A total of 20 patients with features of Mūtrāśmarī were selected randomly for the study. Treatment Procedure and Observations: Procedure of Treatment Patients in this group were advised 250mg of Viṣādi vaṭi capsule orally with tandulodaka twice daily, once after breakfast in the morning and once after dinner in night, every day for 21 days. Observations were made before treatment, on 8 th day, 15 th day, and 22 st day of treatment and changes in the clinical features were recorded in the proforma of case sheet prepared for the study. In the cases where, the patients inform about the expulsion of calculi while passing urine along with total relief of symptoms, were advised USG abdomen and pelvis. The cases which were showing expelled calculi from the urinary tract, the treatment was stopped on the same day and same were recorded in case sheet. Observations for Recurrences: In cases where calculi were totally expelled during the study period, a duration of 3 months was fixed to observe for possible recurrence and the patients were advised to report immediately in case of occurrence of the symptoms or otherwise, once a month during observation period. In such cases the recurrence, presence of urinary calculi was confirmed by USG abdomen and pelvis and same were recorded in the case sheet. Note: The patients who had complications like uncontrolled pain, excessive haematuria and retention of urine during the treatment were referred to higher medical centres for further management and such cases were deleted from the study. Pathya Āhāra: The patients of both the groups were advised to drink plenty of salt free water / fluids not less than 5 liters altogether per day & consume more of yava, godhuma, shastikashaali, horse gram, Banana, Pineapple, Bittergourd as food. Apathya: Āhāra: Excessive intake of guru, snigdhaāhāra, anupamamsa, matsya, calcium rich dairy products, non-vegetarian food, tomato, Spinach, Ragi, Brinjal, Cauliflower, Cashew nut and excess of salt. Vihāra: Advised not to suppress the urge of micturition, excessive exercise and exposure to hot climate. Investigations: 1. USG - Abdomen and Pelvis- done before and after treatment. 2. Urine tests for presence of RBCs Assessment Criteria: Subjective Parameter Pain: Pain refers to: pain of any degree & type, occurring at any site/sites of urinary system. Grade (0) - Absence of pain (No pain). Grade (1) - Pain Present but does not disturb day to day activity (Mild pain). AAMJ / Vol. 3 / Issue 4 / July August

4 Grade (2) - Pain Present which disturbs routine work (Moderate Pain). Dysuria: Grade (0) - Absence of pain during micturition. Grade (1) - Pain during micturition and tolerable. Grade (2) - Severe pain during micturition and intolerable. Objective parameter: Size of the calculi: Change in size of calculi as seen in USG Abdomen and pelvis in each patient where there are multiple calculi. No response - No reduction in size of calculi. Mild response - Reduction in size of calculi up to 25% and below. Moderate response- Reduction in size of calculi above26-50%. Good response- Reduction in size of calculi above 51-75%. Excellent response- Reduction in size of calculi above 76%. Descent of the calculi - as seen in USG Abdomen and pelvis. Grade 0 completely expelled calculi. Grade 1 descent of calculi to any of lower site of urinary tract irrespective of its original site. Grade 2 no descent. Micro-Haematuria as observed in urine microscopic examination. Grade (0) - Absence of RBCs in urine. Grade (1) - Presence of RBCs in urine. Overall assessment of the treatment: Poor response - up to 25% and below reduction in over all signs and symptoms Mild response - above 26 to 50% reduction in over all signs and symptoms Moderate response - above 51 to 75% reduction in over all signs and symptoms Excellent response - above 76% reduction in over all signs and symptoms. RESULTS Table No.1: Effects of Viṣādi Vaṭi on Pain PAIN Mean score % of reduction Diff Diff S.D of mean S.E of mean t Value p Value Remarks Day <0.001 HS Day <0.001 HS Day <0.001 HS Effects of Viṣādi vaṭi on pain in Mūtrāśmarī: Statistical analysis with respect to pain showed that the mean score was 1.7 before the treatment and the same was reduced to 0.35 after the treatment with 79.4% improvement which is statistically highly significant. (P<0.001). Table No.2: Effects of Viṣādi Vaṭi on Tenderness: TENDERNESS Mean score % of reduction S.D of mean Diff S.E of mean Diff t Value p Value Remarks Day <0.001 HS Day <0.001 HS Day <0.001 HS Effects of Viṣādi vaṭi on Tenderness in mūtrāśmarī: Statistical analysis with respect to pain showed that the mean score was 1.5 before the treatment and the same was reduced to 0.3 after the treatment with 80% improvement which is statistically highly significant. (P<0.001). Table no.3: Effects of Viṣādi vaṭi on dysuria in mūtrāśmarī: DYSURIA Mean score % of reduction S.D of mean Diff S.E of mean Diff t Value p Value Remarks Day <0.001 HS Day <0.001 HS Day <0.001 HS AAMJ / Vol. 3 / Issue 4 / July August

5 Effects of Viṣādi Vaṭi On Dysuria in Group A: Statistical analysis with respect to pain showed that the mean score was 1.3 before the treatment and was reduced to 1.1after the treatment with 84.61% improvement which is statistically highly significant. (P<0.001). Table No.4: Effects of Viṣādii Vaṭi on Size of Calculi: Mean SIZE OF CAL- % of reduction Diff Diff Value Value marks S.D of mean S.E of mean t p Re- score CULI GROUP B <0.001 HS Effects of Viṣādi Vaṭi on Size of Calculi in Group B: Statistical analysis with respect to pain showed that the mean score was 3 before the treatment and the same was reduced to 1.15 after the treatment with 61.66% DESCENT OF CALCULI Table No.6: Effects of Viṣādi Vaṭi in descent of Calculi: Mean score % of reduction mean Diff Diff Value marks S.D of S.E of mean t Re- p Value <0.001 HS Statistical analysis with respect to Descent of Caculi showed that the mean score was 2before the treatment and the same was reduced to 0.8 after the treatment with 60% improvement which is statistically highly significant. (P<0.001). Effects of Viṣādi Vaṭi in Micro Hematuria: Statistical analysis with respect to MICRO HEMATURIA showed that the mean score was 0.6 before the treatment and was reduced to 0.2 after the treatment with Assessment of Total Effect of Therapy Table No.7. Class Effect of Treatment Grading No of patients % of patients Up to 25% Poor Response % Moderate Response % Good Response % Excellent response Chart No.1: Effect of Treatment PRECENTAGE OF IMPROVEMENT IN GRADINGS Poor Response Moderate Response Good Response Excellent response Viṣādi vaṭi showed excellent response in 65%, moderate improvement in 15 %, Good response in 20% and poor response in 0% of patients. DISCUSSION The present clinical study was aimed at evaluation of efficacy of Viṣādi vaṭi with Tandulodaka as Anupana in the management of Mūtrāśmarī. After 21days of treatment, over all response of the drug on signs and symptoms were collectively presented here in a nutshell. Viṣādi vaṭi showed marked response in 50%, moderate improvement in 25 %, mild response in 20% and poor response in 5% of patients. Spontaneous passage is very likely when the stone is in the ureter and less than 4mm. A stone more than 4mm and located in renal calyces is very unlikely to pass spontaneously. But in the present study 85.25% of the calculi were more than 5mm and 90% were in Renals. The biggest stone eliminated was 9mm. Follow up Study: The patients were advised to review once in a month after completion of treatment for next 3 months. No recurrence was reported by the patients within this period. They were instructed to drink sufficient quantity of water and dietary regimen throughout study period. No adverse effect was noticed during study period with Viṣādi vaṭi on Aśmarī. It was observed during the study that, there was no alteration in the readings of serum calcium and serum uric acid levels before treatment and after treatment. AAMJ / Vol. 3 / Issue 4 / July August

6 It was found during the study, that urine volume was increased in patients treated with Viṣādi vaṭi yoga. It shows Diuretic properties of the medicine. Probable Mode of Action of Viṣādi Vaṭi: Mūtrāśmarī is said to be tridōṣaja vyādhi, still kapha plays a major role in the formation of the stone. Kledaka kapha and guru snigdha āhāra guṇa form the basis for Aśmarī formation. Rūkṣaguṇa of Apānavāta and uṣṇa guṇa of pitta hardens the kapha which acts as nidus, upon which aggregation of dōṣa takes place and finally results in Aśmarī. Therefore, the management should be vilayana or lysis of the nidus, vāta and pitta are to be brought back to normalcy, Āvilathva or unwanted saturation of urine to be decreased and excretion of unwanted deposition of solutes. Overall the treatment for urinary calculi should include antispasmodic, analgesic, antimicrobial, diuretic, analgasic, lithotriptic, anti-microbial and normalisation of crystal collide ratio. Samprāpti vighatana at the level of formation of calculi become the main goal of treatment. The ingredients of Viṣādii vaṭi possess properties like bedana, vilayana, kṣaraṇa, lekhana, krimihara and vedanastapaka, which try to reverse the samprāpti of Aśmarī. This helps in reduction, elimination and non-recurrence of aśmarī in the long run. The chemical constituents of vatsanabha analgesic and diuretic activity which supports the current study for its excellent response. The concept of bile clearance by healthy liver which supports the vatsnabha as yakrut uttejaka and thus helping in reducing the urolithiasis. Pāṣāṇabheda is known for its lithotripsic activity because of its chemical constituents and classical reference the making the viṣādi vaṭi more efficient. Yava kṣāra is having the bhedhana and lekhana properties and have lithotripsic activity. Gomuti used as bhavana dravya, helps in reducing the stone formation by its rūkṣa, bhedhana and lekhana guṇa which directly acts on Kapha dōṣa. Tandulodaka used as anupāna for the current study which has the sthambaka properties helps in controlling the haematuria. Thus synergetic activity of ingredients of viṣādii vaṭi with above properties have the efficiency in reducing the features of calculi. CONCLUSION Following conclusions were drawn from the present clinical study with treatment and observations. 20 patients of Mūtrāśmarī included in this study were treated with Viṣādi Vaṭi. In the present study it was observed that Mūtrāśmarī was common in the age group of years, Males were more affected than females, Occupation wise it was more common in Employees, more in middle class and was more in people with mixed dietary habits who had a habit of less water intake, irregular dietary habits with much intake of animal protein. Urinary calculi is a disease which give rise to large number of symptoms and Prominent being pain and it is expressed in various manner like dull, colicky and radiating in different sites. Viṣādi Vaṭi has shown significant result in all subjective and objective criteria. During the observational period no recurrence of calculi was observed. The preparation of Viṣādi Vaṭi is simple, palatable, easy for administration, free from side effects and therapeutic efficacy is good. So, it can be adopted as a remedy for treatment of Mūtrāśmarī. ΛΛΛΛ AAMJ / Vol. 3 / Issue 4 / July August

7 REFERENCES i. Sushruta, Sushruta Samhitaa Sootrasthaana 33/4, Page 144, with Nibandhasamgraha commentary of Shri Dalhanaachaarya, edited by Vaidya Yaadavaji Trikamji Āchaarya Chaukhamba Surbhaarati Prakaashana, Vaaraanasi, reprint edition ii. Agnivesha, Charaka & Dridabala, Charaka Samhitaa Chikitsaa Sthaana 26/36, page-599, with Aayurveda Deepikaa commentary of Chakrapani edited by Vaidya Yadavaji Trikamji Ācharya, Chaukhamba Surbhaarati Prakaashana, Vaaraanasi, reprint edition iii. iv. homepage.vghtpe.gov.tw/ Shao-Chuan Wang et.al., Correlation between urinary tract pure stone composition and stone morphology on plain abdominal film, J Chin Med Assoc 2004;67: v. McDonald MW, Stoller ML, Urinary stone disease: a practical guide to metabolic evaluation, 1997 May;52(5):38-40 Source of Support: Nil. Conflict of Interest: None declared How to cite this article: Rakesh & Srinivas : A clinical study on the efficacy of Viṣādi Vaṭi in the management of Mūtrāśmarī w.s.r. to Urolithiasis. AAMJ 2017; 4: ΛΛΛΛ AAMJ / Vol. 3 / Issue 4 / July August