TOPIC
“Efficacy of Apamarga Paniya Kshara in the
Management of Mootrashmari”
Dr. Bharat M. Rokade (Asso. Proff.) Bharati Vidyapeeth
College of Ayurved Pune
Dr. Yogesh R. Badwe
(Asso. Proff.) Bharati Vidyapeeth College of Ayurved Pune
INTRODUCTION
Since ancient
times the problem of 'Mootrashmari' (Urinary calculus) is known to
mankind as one among the most troublesome obstructive urological disorders. It
is considered as "Mahagada" in Ayurvedic Classics. Detailed
description regarding etiopathogenesis, signs and symptoms and management of the disease can be seen in ‘Sushrut
Samhita’.
Approximately 2% of
population experiences the disease in lifetime. It is more commonly seen in
males than females, with peak incidence in second and third decades of life. The formation of stone is due to the
factors like concentrated urine, deficiency of stone inhibitor substances like
mucopolysaccharides, citrates etc. However hereditary and dietary factors like
imbalance of electrolytes such as Calcium, Phosphates, Oxalate, Magnesium,
abnormal metabolism, deficiency of vitamin A etc. have major role in formation
of calculus.
The conventional system of modern
medicine offers numerous treatment modalities through both medicinal and
surgical procedures for the management of urinary calculus. The modalities like
extra corporeal Shock Wave Lithotripsy (ESWL), Percutaneous Nephrolithotomy
(PCNL), URS and Laser etc. having their own merits and demerits and certain
limitations. These procedures reduce the rate of open surgery in urolithiasis.
All these surgical procedures are indicated in large size calculus with
obstructive uropathy.
Hence it is the need of society to
find out an alternative which should be cost-effective, easily available and
with minimum adverse effects with lesser chances of recurrence for the management.
It is also necessary to treat the early detection of calculus and calculus of
small size.
While going through different
Ayurvedic literature we come across Apamarga Paneeya kshara used in Mootrashmari.
As the drug is easily available and can be given on O.P.D. basis Apamarga
Paneeya kshar is one of the useful treatments fulfilling all the norms of ideal
treatment in Mootrashmari. Hence we have decided to work on the burning medical
issue of the society.
AIMS AND
OBJECTIVES
1) Efficacy of Paniya Kshar to reduce the
size of calculus.
2) Efficacy of paniya kshara
in expulsion of calculus as well as to reduce sign and symptoms.
MATERIALS & METHODS
The clinical research study was
designed as follows -
1.Clinical Trial :
A clinical randomized trial was
conducted in 25 patients
2. Selection of Patients :
Patients registered in hospital either
in OPD or IPD was selected for study.
Written informed consent was taken from every
patient.
Proper case history was taken and special case
record form was prepared.
Inclusion
Criteria :
Ø Uncomplicated Patients having renal / ureteric/
Bladder calculi upto 8mm in size will be selected randomly.
Ø Age between 15yrs to 55 yrs.
Exclusion Criteria :
Ø Age below 15 yrs and Above 55 yrs.
Ø Calculus more than 8 mm in size.
Ø Deranged Kidney Functions.
Ø Other complications related to kidneys /ureter /bladder
Investigations :
Ultrasonography :
Abdomen
and pelvis before and after treatment.
X- Ray KUB:
If
Necessary
According to selection criteria, 25
patients were selected for clinical trial.
3. Method of
administration of drug :
1)
Route
of administration - Oral
2)
Dose
- 15 ml twice / day
3)
Anupan - Lukewarm water
4)
Sevan
Kala - Apan Kala (Before both meals)
5)
Duration - maximum given for 10 days.
Follow up study –
Thorough clinical assessment was
done before subjecting patient for clinical trial detailed assessment of the
patient, using various clinical parameters, on 1st, 5th, 10th
& 15th day respectively.
4. Clinical Parameters for the
Assessment of results :
Subjective Parameters
1. Pain in abdomen
2. Burning micturation
3. Frequency of micturation
4. Any associate symptoms.
Objective Parameters
1) Size of calculus.
2) Site of calculus.
Analysis of Subjective Parameters:
1) Pain in abdomen :
0 - No pain at all.
1 - Pain (mild) but not
disturbing the routine life.
2 - Pain causing disturbance
in daily routine life.
3 - Severe pain. (patient
rolls on bed in agony)
2) Burning micturation :
0 - Absent.
1 - Burning only while micturition.
2 - Burning persist for longer time after
micturition.
3 - Continuous burning sensation.
3) Frequency of micturation:
0 - 5-7 times per day.
1 - 7-10 times per day.
2 -10-13 times per day.
3 - More than 13 times per day.
4) Associate symptoms (like hematuria,fever, nausea,
vomiting, painfull micturition)
0 - No any associate symptomrmal.
1 - Present only one associate symptom.
2 - Present two associate symptoms.
3 -present more than two associate symptoms.
Analysis of objective parameters :
1. Size of Ashmari :
0 -No
Calculus
1 -Tiny
Renal Concreations
2 -Calculus
Upto 4mm of Size
3 -Calculus
5-8 Mm of Size
2. Site of calculus
1Ra-Right kidney upper pole, 1La-Left kidney upper pole
1Rb-Right kidney middle pole, 1Lb-Left kidney middle pole
1Rc-Right kidney lower pole, 1Lc-Left kidney lower pole
2Ra-Right upper ureter, 2La-Left upper ureter
2Rb-Ri ght middle ureter, 2Lb-Left
middle ureter
2Rc-Right lower ureter, 2Lc-Left lower ureter
3-Bladder calculi
OBSERVATION
& RESULTS
ABDOMINAL PAIN
|
|
B.T.
|
A.T.
|
t-cal
|
t-value
|
p-value
|
|
Mean
|
2.4
|
0.4
|
11.44
|
2.14
|
0.000086
|
|
S.D.
|
0.48
|
0.48
|
Since p-value is
less than 0.05 indicate there is significant reduction in abdominal pain after
treatment
Burning
micturation
|
|
B.T.
|
A.T.
|
t-cal
|
t-value
|
p-value
|
|
Mean
|
1.53
|
0.33
|
7.5
|
2.14
|
0.00016
|
|
S.D.
|
0.72
|
0.47
|
Since p-value is less than 0.05 we reject Ho i.e there is
significant reduction in burning micturation after treatment
Frequency of micturation :
|
|
B.T.
|
A.T.
|
t-cal
|
t-value
|
p-value
|
|
Mean
|
1.10
|
0.93
|
8.33
|
2.14
|
0.044
|
|
S.D.
|
0.57
|
0.45
|
Since p value is less than 0.05 but there is slightly
difference in frequency of micturation before and after treatment with
satisfactory voiding and increased urine output
Expulsion of
calculus according to site
|
Site of calculus
|
Before treatment
|
After treatment
|
Expulsion
|
|
Renal
|
23
|
08
|
15
|
|
Upper ureter
|
00
|
00
|
00
|
|
Mid ureter
|
05
|
00
|
05
|
|
Lower ureter
|
05
|
02
|
03
|
|
Bladder
|
00
|
00
|
00
|
|
Total
|
33
|
11
|
22
|
Total percentage of
calculus expulsion is 66.66 % and that too more in ureteric calculi than renal
calculus.
Distribution of patients according to
size of calculus
Size of Ashmari
At the end of
treatment there was significant reduction in size of calculus and 6 patients
were free of calculus.
DISCUSSION
Probable
mode of action:
v On analysis of the subjective and objective
parameters, Apamarga paniya kshara is found effective to minimize the symptoms
of Mootrashmari. Here an attempt is made to produce a probable hypothesis
regarding the action of Apamarga paniya kshara.
v Kapha and Vata always play a major role in
urolithiasis. As Apamarga paniya ksharaa is Kaphavataghna in its Doshaghnata,
it is helpful for Shaman of associated Doshas taking part in etiopathogenesis
of Mootrashmari.
v Ruksha, Laghu, Tikshna, Shighragami properties of
Apamarga paniya kshara reduces the chances of nidus formation as well as
reduces the growth of stone by inhibiting the binding property of Kaphadosha.
v Apamarga paniya ksharaa have mootrala effect there-by
increasing intra-luminal pressure. Because of this pressure, calculus is
expelled quickly as a whole from urinary system. As earlier
stated, hyper-concentration of the urine results into formation of
urolithiasis. Apamarga paniya kshara's Diuretic activities either promote or
increase the amount of urine excretion and helps in preventing the
hyper-concentration of urine as well as further complications.
v Chemically Apamarga paniya ksharaa is potassium carbonate which increases
the concentration of potassium in intra cellular fluid there by enhances
osmotic activity which tends to force water and electrolyte into extra cellular
fluid and the colloidal osmotic pressure of the plasma proteins which draw
water back in the vessels. It helps in its diuretic activity without depleting
serum potassium level which is a common demerit of other diuretic drugs.
v Apamarga paniya ksharaa removes obstruction from
urinary tract by flushing the urine by its Sarak property.They increase
peristaltic movements of smooth muscles in urinary system and in turn help in
expulsion of urinary calculus.
v Active ingredient of Apamarga seeds is saponine acts
as a diuretic so it increases intrluminal pressure & flow of urine in
ureter and helps to wash out calculus.
v As Acyranthine one of the principal constituent of
Apamarga paniya kshara is anti-inflammatory in nature it reduces pain in
abdomen associated with calculus
v The pH of Paneeya Apamarga paniya kshara is 10.63.
This alkaline nature of the drug reduces acidic condition of the urine, which
is one of the main causes of calculus formation. The normalization of pH of
urinary passage helps to dislodge the lithus.
v Apamarga paniya kshara reduces burning micturition,
pain in abdomen associated with calculus by maintaining urine pH and
anti-inflammatory action.
v Thus action of Paneeya Apamarga paniya ksharaa may
ultimately result
in painless expulsion of mootrashmari by relaxation of smooth muscles.
in painless expulsion of mootrashmari by relaxation of smooth muscles.
v Ashmari is a disease of mootravaha strotas which is
under influence of Apana-vayu. So Paneeya Apamarga paniya kshara is given in
apana-kala i.e. before meal to enhance the action of drug.
CONCLUSION
Ø
Apamarga paniya
kshara also possesses Mootral property i.e. diuretic action which is helpful
for expulsion of calculi.
Ø
During the study,
there were no adverse effects or complications and the treatment was well
tolerated by all the patients.
From the study, it can
be concluded that administration of Apamarga paniya kshara can be effective
treatment method for mootrashmari which may overcome the surgical intervention
by easy, comparatively cheap and painless expulsion of ashmari.
