publication on mootrashmari

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 1^st, 5^th, 10^th & 15^th 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.

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.