E-ISSN:2456-3110

Case Report

Urolithiasis

Journal of Ayurveda and Integrated Medical Sciences

2024 Volume 9 Number 7 JULY
Publisherwww.maharshicharaka.in

Avapeedaka Snehapana: A Novel Therapeutic Protocol in the management of Mutrashmari (Urolithiasis) - A Case Report

Harshitha H S1*, Sanjay KMD2, Mythrey RC3
DOI:10.21760/jaims.9.7.52

1* Harshitha H S, Post Graduate Scholar, Dept of PG Studies in Kayachikitsa, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.

2 Kumar M D Sanjay, Post Graduate Scholar, Dept of PG Studies in Kayachikitsa, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.

3 Mythrey RC, Professor and Head, Dept of PG Studies in Kayachikitsa, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.

Mutrashmari (~renal stone) is characterized by formation of Ashma (~stone-like substance) in Mutravaha Srotas (~urinary system). Due to similarities in clinical manifestations Mutrashmari can be correlated to Urolithiasis. Urolithiasis is characterized by the formation of solid masses or calculi within the urinary system. Increasingly prevalent worldwide, its prevalence in India mirrors global trends, at around 12%. Men are affected more than women with male to female ratio of 3:1. Chronic and recurrent nature underscores its significant impact on healthcare emphasizing the need for effective management strategies. Avapeedaka Snehapana is one such novel therapeutic protocol, where Sneha (~medicated ghee) is administered before and after digestion of meal, commonly indicated in Adhonabhigata Vikaras (~diseases manifesting below umbilicus) specific to Mutravaha Sroto Dushti (~Urinary system disorders). In this case report, a male patient of age 65 years diagnosed with Urolithiasis since 1 year visited Out Patient Department (OPD) with symptoms of pain in left flank region, associated with burning micturition. Ultrasonography report revealed a 7 mm calculus located at upper pole of left kidney. Patient was administered Avapeedaka Snehapana with Vastyamayantaka Grutha. Patient exhibited remarkably positive outcomes, with symptoms completely resolved and Ultrasonography report confirming absence of calculi post-treatment.

Keywords: Avapeedaka Snehapana, Mutrashmari, Renal Calculi, Urolithiasis, Vastyamayantaka Grutha

Corresponding Author How to Cite this Article To Browse
Harshitha H S, Post Graduate Scholar, Dept of PG Studies in Kayachikitsa, Government Ayurveda Medical College and Hospital, Mysuru, Karnataka, India.
Email: 		Harshitha H S, Sanjay KMD, Mythrey RC, Avapeedaka Snehapana: A Novel Therapeutic Protocol in the management of Mutrashmari (Urolithiasis) - A Case Report. J Ayu Int Med Sci. 2024;9(7):328-334.
Available From
https://jaims.in/jaims/article/view/3308

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2024-05-14 2024-05-25 2024-06-05 2024-06-15 2024-06-25
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
None Nil Yes 12.32

© 2024by Harshitha H S, Sanjay KMD, Mythrey RCand Published by Maharshi Charaka Ayurveda Organization. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Sanjay KMD et al. Avapeedaka Snehapana in the management of Mutrashmari

Introduction

Avapeedaka Snehapana is a unique form of Snehpana (~drinking medicated ghee), administered in Yojana Dwaya pattern at Hrisva Matra (~minimal dose) before and Uttama Matra (~higher dose) after digestion of food respectively.[1]

This treatment modality is specifically indicated in Adhonabhigata Vikaras, predominantly in Mutravahasroto Dushti.[2]

In Sushrutha Samhitha, Mutrashmari is classified among the Ashtamahagada and is mentioned as Atanka Pratima as it causes intolerable pain.[3]

Lakshanas (~symptoms) being Mahati Vedana (~renal colicky pain), Sarudhira Mutrata (~haematuria), Vedana in Nabhi and Basti Pradesha (~abdominal pain), Mutradhara Sanga (~obstruction in urine flow), Mutradaha (~burning micturition) and Mutrakrichra (~difficulty in urination).[4]

Due to Similarities in clinical manifestations Mutrashmari can be correlated to Urolithiasis. Urolithiasis is the condition where urinary stones are formed and located anywhere in the urinary system having symptoms like dull aching pain in the loins accompanied with or without haematuria, altered frequency of micturition, difficulty in passing urine. Urinary stones frequently occur worldwide with prevalence rate of 1-5% in Asia, 12% in India.[5]

Demographic statistics also underline increasing prevalence of urolithiasis in geriatric patients with 19.1% in men aged 65 years and above.[6]

Contemporary treatment for urolithiasis typically begins with flush therapy for stones up to 5mm, while larger stones often necessitate advanced procedures such as ESWL (Extracorporeal Shock Wave Lithotripsy), or operative interventions like PCNL (Percutaneous Nephrolithotomy), Pyelolithotomy, Nephrolithotomy, or Nephrectomy.[7]

Operative procedures for renal calculi are not cost-effective and carry inherent risks. Additionally, surgical interventions may not be recommended for patients in the geriatric age group due to increased vulnerability to potential complications. According to Sushrutha Samhitha, Snehapana is the first choice of treatment protocol for Mutrashmari.[8]

Here Avapeedaka Snehapana does Peedana of the Dosha,[9] and with property of Srustha Vinmutrata it helps pushing down the calculi.

Case History

It is a single case study and the informed consent of the patient is taken in his own language. The demographic details and complaints of the patient are tabulated in Table no.1 & 2 respectively.

Table 1: Demographic details

1.NameXYZ
2.SexMale
3.Age65 years
4.OccupationFarmer
5.AddressNanjungudu taluk, Mysuru.
6.Marital statusMarried
7.EducationNo formal education received
8.Socioeconomic statusLower
9.OPD registration number3331
10.IPD registration number132
OPD – Out Patient Department
IPD – In Patient Department

Table 2: Chief complaints with duration

SNComplaintsDuration
1.Abdominal pain radiating from left loin to groin region.1 year
Aggravated since 2 months
2.Burning micturition2 months
3.Difficulty in urination2 months

History of Present Illness

A 65 year old male patient, with no known comorbidities was relatively healthy 1 year ago, then he experienced mild intermittent pricking pain at the left flank region for 3 months, followed by two months of colicky abdominal pain radiating from the left loin to the groin.

Upon consulting at regional hospital, he was diagnosed with a stone in the left kidney and was prescribed oral medications, which provided mild relief for around 6 months, after which symptoms aggravated, associated with difficulty in urination (intermittent urinary stream often with pain) and burning micturition since past 2 months; following it he consulted district hospital and was advised for surgical intervention, which patient denied. Hence, seeking relief he approached the Outpatient department of Kayachikitsa at Government Ayurveda medical college and hospital, Mysore.


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Past history

Not known of comorbidities. Known case of recurrent renal calculi since 1 year.

Medication history

Had taken medications for renal calculi previously – details not known.

Personal history

Diet: Vegetarian, spicy and salty food, Ruksha Ahara Sevana.

Lifestyle: Inadequate water intake.

Sleep: Disturbed due to pain.

Habits: Chronic cigarette smoking since 30 years, have stopped since 1 year.

Family History: Not significant.

Examination History / Clinical Findings

Briefly mentioned in Table 3 and Table 4.

Table 3: General physical and systemic examination.

1.General appearance and condition§ Conscious and well oriented§ Moderately distressed due to pain
2.Body built and nutritional status§ Ectomorphic and Asthenic body type.
§ Height – 178cm Weight – 65kg
§ BMI – 20.1 kg/m2 (Normal)
3.Per Abdomen§ Tender at Left lumbar quadrant on palpation.
§ Left Renal angle - tenderness ++ upon percussion.
§ No distension & organomegaly.
4.Other systemic examinationNormal
Vitals -
1.Pulse76 bpm
2.Blood pressure120/80 mm of Hg
3.TemperatureAfebrile

Table 4: Ashta Vidha Pariksha

1.NadiVatakapha Pradhana, Niyamita
2.MalaVibandha (Hard stools once in 1 or 2 days)
3.MutraSadaha, Mutrakrichrata.
Prakruta Varna & Gandha
4.JihwaAliptata
5.ShabdaSpashta
6.SparshaSamasheetoshna
7.DrikPrakrutha
8.AakrutiLeena

Timeline

Table 5: Time line of the case.

DateClinical FindingIntervention
January 2023Intermittent mild pricking pain at left flank region.No intervention seeked.
April 2023Colicky abdominal pain radiating from loin to groin.Consulted regional hospital – prescribed oral medications (details not known).
October 2023Above symptoms aggravated associated with intermittent urinary stream with pain and burning micturitionConsulted regional hospital – prescribed oral medications (details not known).
Symptoms reduced considerably.
25th January 2024§ Abdominal pain radiating from loin to groin.
§ Intermittent urinary stream with pain.
§ Burning micturition.
§ USG Abdomen – Left kidney calculus measuring 7 mm in upper pole.		§ Approached Kayachikitsa OPD.
§ Advised Deepana Pachana with Chitrakadi Vati 250mg 1-1-1 before food for 6 days.
Advised for admission on 1st February 2024.
1st February 2024Earlier symptoms of pain, burning micturition and difficulty persists.Avapeedaka Snehapana with Vastyamayantaka Grutha for 4 days under admission. Followed by Pathya.
8th February 2024First Follow up
§ No Abdominal pain radiating from loin to groin.
§ Burning micturition reduced considerably.
§ Slow initiation of micturition persists.
§ USG Abdomen - No evidence of Kidney stone.		Pathya Sevana.

Diagnostic Assessment

At the first visit, routine investigations including complete blood count, random blood sugar, liver function tests and renal function tests were done which were within normal limits. The clinical findings (including burning, increased frequency of micturition and intermittent urine stream with pain) and Ultrasonography (USG) abdomen & pelvis confirmed the diagnosis of Mutrashmari (~Urolithisasis).

Therapeutic Intervention

Poorva Karma (~preparatory procedure) -

Deepana Pachana with Chitrakadi Vati 250mg 1-1-1 before food for 6 days.


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Pradhana Karma (~main therapeutic procedure):

After attaining Jeerna Ahara Lakshana on Day 0 - Hrisva Matra (~minimal dose) (30ml) of Vastyamayantaka Grutha[10] was given in Kshudhita Avastha (~hunger) and Ananna Kala (~empty stomach with hunger), Grutha Jeerna Kala (time taken for digestion of ghee) was observed, depending on this Uttama Matra (~high dose) for Day 1 was calculated. As per Vakhya Pradeepika Teeka of Astanga Hrudaya, the obtained dose was divided into 1/3rd and 2/3rd. 1/3rd is Prakbhakta Sneha (~intake of Grutha morning in empty stomach) i.e., Hrisva Matra and 2/3rd is Ahara Jeernantika Sneha (~intake of Grutha after digestion of meal) i.e., Uttama Matra.[11] Intake of Ushna Jala was advised. This protocol was continued till Vyadhi Shaman Lakshanas were attained and Lakshanas like Snehodhwega and Adhastasnehadarshana were observed. The above protocol has been illustrated in Table 6.

Table 6: Avapeedaka Snehapana protocol - Yojanadwaya pattern

Day 001/02/2024Day 102/02/24Day 303/02/2024Day 404/02/2024
Pragbhaktika Snehamatra / time of administration30mL @ 8 am
(Hrusiyasi Matra)		50mL@ 8 am60mL @ 8am60mL@ 8am
Sneha Jirnakala12:30 am2:30 pm3:30pm3:30pm
Ahara Sevan Kala12:45pm3:00pm4:00pm4:00pm
Ahara Jirna Kala5:00pm9:00pm8:00pm8:30pm
Jeernantika Snehamatra/time of administration-100mL@ 9:30pm100mL@
9:00pm		100mL@ 9:00pm
Sneha Jirna Kala-4:30am5:00am5:30am

Paschat Karma (~post therapy procedure)

Patient was advised for Pathya Sevana (~diet) and follow up was done.

Observations and Results

Assessment was done based on USG findings and clinical symptoms and signs. USG findings revealed no stone during the first follow up. Patient showed absence of pain and significant relief in symptoms of Mutra Daha, Mutra Krichrata. These observations infer that Avapeedaka Snehapana with Vastyamayanataka Grutha, successfully managed the condition of Mutrashmari (urolithiasis).

Figure 1: USG Report - Before Treatment (AvapeedakaSnehapana).
jaims_3308_01.JPG

Figure 2: USG Report - After Treatment. (First Follow-up).
jaims_3308_02.JPG

Discussion

Snehapana always stood as the mainstay therapeutic approach in the management of various diseases.


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Therapeutically, lipids are used in various forms and modes, lipids when used in form of oral ingestion is termed as Snehapana and it is most effective of all other modes of application of Sneha (lipids).[12] Avapeedaka Snehapana is considered as Pittanilamayagna.

It is not aimed for Dosha Utkleshana or Shodhana rather it is classified under Shamana Snehapana, also being classified under Uttama Matra Snehapana, it helps in Sheeghra Shamana of Vikaras, and it is Sarvamarganusari acting on all Rogamargas viz. Shakha, Sandhi, Marma and Koshta. It also acts as Punarnavakari - which refers to renewal or restoration.

It is Balya to Shareera, Indriya and Chetas.[13] Ashmari is one among Mutravegavarodhajanya Vikara and is a Kaphaja Vikara associated with Apana and Vyana Vata Dushti. Yojanadwaya pattern of Avapeedaka Snehapana is intended to correct this Dushti.

Kaala plays a crucial role in this situation, Sneha which is administered as Pragbhakta does Anulomana and Shamana of Apana Vata and Sneha which is administered as Aharajeernanthika avastha acts on Vyana vayu, which is Sarva Dehachari, thus doing Shamana of Vyadhi. Hence, Avapeedaka Snehapana brings Kledana to Mutravahasrotas and does Anulomana of Vata.

Though Taila is considered as best medicine for Vata Shamana, using Taila is not appropriate because of it is Badda Shakrt (~constipated bowels) and Alpa Mutrata properties interferes with Anulomana of Vata.

Thus, Grutha having property of Srushta Vinmutra (increased urine output),[14] and as also mentioned by Acharya Charaka and Sushrutha in Chikitsa of Mutravahasroto Vikara, it can be an appropriate Sneha for performing Avapeedaka Snehapana.

Discussion on Vastyamayantaka Grutha

The main Doshas involved in formation of Ashmari are Vata and Kapha. The Tridosha Shamana properties of Vastyamayantaka Grutha is found to be effective in Samprapthi Vighatana of Ashmari. Vastyamayantaka Grutha mentioned in Sahasrayogam Grutha Prakarana has direct indication in Sarva Mutrakrichra Vikara, Sharkara, Ashmari and Vatapittasamutpanna Sarva Bastigata Gada.[10]

In Mutrashamri, herbs which are Mutravirechaniya (~diuretic), Ashmarighna (~Chedana, Bhedana and Lekhana properties - lithotriptic), Shophaghna (~anti-inflammatory) are need of hour.[15] Abundance of ingredients and above said properties in Vastyamayantaka Grutha made it appropriate for Snehapana , among which major ingredients are listed in Table 7.

Table 7: Vastyamayantaka Grutha - Dravyakarma, Phytoconstituents and its action.

DrugKarmaPhytoconstituentAction
Gokshura
Tribulus terrestris		Bastihodhana, Mutrala, Deepana, AshmarighnaFurosemide,
Campesterol,
Beta-sitosterol, Stigmasterol		Diuretic, Anti- urolithic activity, Analgesic, Anti-inflammatory, Antispasmodic
Pashanabedha
Bergenia ligulate		Ashmari Bhedana by Prabhava, MutrakricchraharaBergenin,
β-sitosterol,
Catechin-3 gallate
Paashanolactone		Diuretic, Anti- urolithic activity, Analgesic, Anti-inflammatory.
Varuna
Crateva nurvala		Ashmari Bhedana by Prabhava,
Mutrala		Lupeol,
Rutin,Varunol, Quercetin,
β-sitosterol		Lithotriptic, Anti-inflammatory Anti-pyretic, Analgesic.
Kushmanda
Benincasa hispida		Mutraghatahara, Mutrakruchrahara, Ashmarichedana, Vinmutra Glapanam, BastishuddikaraFlavonoids
Alkaloids
Tannins		Lipid lowering
Hypoglycemic
Diuretic
Ikshu
Saccharum officinarum Linn. 		Mutrala
Dahaprashamana
Trishna nigrahana		Sucrose
Glutamine
Riboflavin		Diuretic, Analgesic
Anti inflammatory
Narikela jala
Cocus nucifera		Basti shodhana
Mutrala		Flavonoids
Phenolic acids
Amino acid		Diuretic
Shatavari
Asparagus racemosa		Sarana
Vatanulomana
Shophajit		Saponins like Shatavarin I,II,III,IV
Steroidal saponins
Isoflavones		Diuretic
Punarnava Boerhavia diffusa LinnShophahara
mutrala		Punarnavoside, Borhaavone, Quercetin, Eupalitin, PunarnavineDiuretic
Anti-inflammatory
Antioxidant

Due to Samskarasya Anuvarthana and Snigdha Guna of Grutha, along with Tridoshahara properties of ingredients helps in Peedana of Dosha and Ashmari. Vrana Shodhana and Ropana properties will reduce Sarakta Mutrata and Mutradaha.


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Conclusion

Avapeedaka Snehapana stands as a Shreshta Chikitsa in Mutrashamri, by alleviating Vata Kapha Dushti and correcting Ashmari Janya Lakshanas like Shula, Mutradaha, Sarakta Mutarta, and Mutrakrichra by Peedana of Dosha and Ashmari. Vastyamayantaka Grutha has a pivotal role in disintegrating and eliminating kidney stones. This line of Ayurvedic intervention along with Pathya helps limiting the progression, recurrence and further complications of disease condition.

Declaration of patient consent

Authors certify that they have obtained patient consent, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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8. Acharya YT, editor. Susruta samhita of Susruta, Chikitsa sthana; Ashmari chikitsa: chapter 7, verse 4. Varanasi: Chaukhamba Orientalia; 2021. p. 435. reprint 2021.

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13. Parameshwari LH, Kulkarni V. A comparative clinical study to evaluate the efficacy of Avapeedaka Sneha Pana in fixed and increasing dose with Trinapanchamoola Ghrita in Mootrashmari (Urolithiasis). J Emerging Technologies Innovative Res. 2024 Jan;11(1):774.

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