A Critical Review on Nidana of Mootrashmari with Special Reference to Urolithiasis

Introduction

Mutraroga has been prevalent since the vedic period, and our ancient physicians had detailed knowledge about its etiopathogenesis and management. Basti, which is one among the trimarma, is the main seat of urinary disorder.⁴ Acharya Charaka has described that the basic pathology of the disease lies in the vitiation of doshas and accumulation of malas (body’s waste products), leading to changes in smell and color, and suppression or excessive elimation of malas. In another context, Charaka has mentioned that due to sexual intercourse, fluid and food intake during mootra vegadharana (micturition), and injury to the Mutravaha srotas (urinary system), the mutravaha srotas function is impaired, resulting in excessive voiding, dribbling, and painful micturition.⁵ Acharya Sushruta has described the pathology of mutrarogas on the basis of Shatkriyakala concept, wherein the vitiated doshas in the Sthansamraya stage reach basti and manifest as Prameha, Ashmari, and Mutraghata. ^6,7

Acharya Charaka has considered Ashmari as a type of Mootrakrichra (Ashmarijanya mootrakrichra). Therefore, the nidanas for mootrakrichra can also be considered as the nidanas for ashmari also.⁸ Teekshna aushadha sevana, ruksha madyapana, anupamatsya sevana, adhyashana, ajeerna bhojana, ativyayama, and ashwayana are the nidanas for mootrakrichra.⁹ Acharya Sushruta gives two main nidanas for Ashmari – Asamshodhana Sheelata and Apathya sevana, which includes samashana, adhyashana, sheeta ahara sevana, snigdha, guru, madhura ahara sevana, maithuna vighata, and divaswapna.¹⁰ Vagbhata in Astanga Hridaya has stressed the importance of mootra vegavarodha as one of the main nidana.¹¹ Hareeta gives importance to pitru matruja dosha and vegavarodha.¹²

All the above nidanas can be grouped into:

• Doshaja nidana
• Beeja doshaja
• Khavaigunya kara nidana
• Anya nidana.

Doshaja Nidana

(a) Kapha Prakopaka Nidana

All the Acharyas agree that the main dosha involved in the formation of Ashmari is Kapha. Nidanas such as anupamatsyasevana, ajeerna, samashana, adhyashana, and snigdha guru madhura ahara sevana are some of the aharaja nidana, and divaswapna is the viharaja nidana.¹³

Kapha is the dominant dosha of anupa desha (marshy land) and creatures of such regions are maha abhishyandi by nature. These are responsible for excessive kledatva in dosha, dhatus, mala, and srotas, producing favorable conditions in the body for various diseases. Mutra being the drava constituent of sara-kitta vibhajana, it can cause the excess of kledatva to be imparted to mutra, thereby allowing the vitiated doshas to be lodged in it, giving rise to ashmari. Improper dietetic habits lead to the production of Ama in the body, leading to srotoavarodha, which may contribute to the manifestation of Ashmari. Indulging in food intake before the earlier ingested food is digested increases kapha which attains aparipakwa avastha, which may later result in ashmari. Indulgence in these ahara dravya may not produce vitiation of dosha immediately but continous indulgence may vitiate the dosha in the long term, resulting in Ashmari. Divaswapna is the viharaja kapha prakopaka nidana but causation of ashmari by indulging in divaswapna alone cannot be justified. However, if the person is predisposed to other nidanas and if he further indulges in divaswapna, then there may be chances of ashmari utpatti.

(b) Vata Prakopaka Nidana

Nidanas such as maithuna vighata, ativyayama, ashwayana, and mootra vegadharana can be taken as viharaja vata prakopaka nidana, and rooksha madya sevana is the aharaja nidana.¹⁴ Ativyayama causes vata prakopa, and increased perspiration leads to a more concentrated urine. Rooksha guna of vata increases upon indulgence in ativyayama, leading to shoshana of kapha; thereby, facilitating the formation of ashmari. Maithuna vighata does cause vata prakopa, but it is the main caustive factor of Shukrashmari wherein maithuna vighata (abstinence) or Ati maithuna (excessive indulgence) leads to the formation of Shukrashmari. Excessive driving or riding of vehicles or horse leads to fatigue, vitiating vata dosha. Furthermore, in the present era, due to constant stress, strain, and having to travel long distances to reach the destination, everybody is used to suppression of the natural urge of micturition, leading to conditions such as Ashmari. This may aggravate the symptoms such as pain produced by Ashmari by displacing or compressing the already formed Ashmari. Mootra vegadharana, which is one of the most important nidana for the formation of Ashmari, causes Apanavata prakopa and also simultaneously results in stasis of mutra, causing excess of kleda to stay in one place which attributes to the aggregation of kapha dosha finally resulting in Ashmari.

As Vatakara nidana causes the shosha of drava bhaga of shareera, concentration of urine is increased, leading to the aggregation of different solutes present in the urine, resulting in Ashmari formation.

Beeja Doshaja

Beeja dosha signifies the inborn error in beeja and beejabhagavayavas of matru and pitru. Doshas already existing in the beeja and beejabhagavayavas of matru and pitru bring about the inheritance of dosha in the offspring, resulting in the disease.¹⁵ Ashmari may not be an exception to this as the beejabhagavayava of mutravaha srotas may develop a tendency for the formation of ashmari.

Khavaigunya Kara Nidana

As mootrakrichra and ashmari are complementary to one another, repeated attacks of mootra krichra will create a favorable platform for the formation of ashmari and vice versa. Mootrashthila may again lead to stasis of mutra, further bringing about khavaigunya.

ANYA NIDANA

(a) Teekshna Oushadha Sevana

Nidana of Mootra krichra as told by Charaka can be interpreted as “all the medicines taken orally are excreted by the mutra”. Therefore, teekshna oushada sevana by its teekshna guna will definitely lead to vata vitiation or irritate the mootravaha srotas, thus initiating the formation of Ashmari.

(b) Asamshodhana sheelata

It has been recommended for people with bahudoshavastha to get periodic shodhana done for a healthy living. When this shodhana is not done, and the person continues to indulge in apathya ahara-viharas, the doshas go on attaining sanchaya and predispose him to ashmari formation. By undergoing periodic shodhana, even if the person indulges in apathya ahara occasionally, there will not be excessive collection of doshas.

Analogous Study of Nidana

About 20% of calcium oxalate stone formation are hyperuricosuric, primarily because of an excessive intake of purine from meat, fish, and poultry,¹⁶ which are snigdha, guru, and madhura, and have high protein and fat content, constituting kaphaja ahara. Protein ingestion increases endogenous acid production and secretion. Acidosis inhibits calcium resorption in the distal nephron, thereby increasing urinary calcium excretion, decreasing urinary citrate excretion, and indirectly causing calcium oxalate crystallization.¹⁷

Food substances which have katu, tikta, and kashaya rasa like tomato and spinach ultimately result in shoshana karma, causing increased concentration of urine and leading to aggregation of different solutes present in the urine and formation of Mootrashmari eventually. The foods rich in oxalate and calcium are not easily broken down if they are consumed in excessive amounts. The extra nutrients accumulate in the body and possibly lead to the formation of kidney stones.

Hot climate usually exposes people to more ultraviolet rays, increasing vitamin D3 production. Increased calcium and oxalate excretion has been correlated with increased exposure time to sunlight.¹⁸ Hence, we commonly see more incidence of Ashmari in agriculturists and coolies who are exposed to high temperatures and wind, and perspire a lot.

Stone formation requires supersaturated urine. Supersaturation depends on urinary pH, ionic strength, and solute concentration.¹⁹ Mootra vegadharana, which is one of the most important nidanas for the formation of ashmari, causes apanavata prakopa and also results in stasis of urine, leading to supersaturation of solutes and resulting in ashmari.

In case of Ashmari, beeja dusti of matru and pitru is considered as utpadaka hetu. This aspect can be correlated to the hereditary aspect of renal stones described in modern literature. Idiopathic hypercalciuria is a hereditary condition which can lead to urolithiasis. Familial renal tubular acidosis is associated with nephrolithiasis and nephrocalcinosis in almost 70% of the patients. Cystinuria is a homozygous recessive disease, and the genes that cause it have been cloned. Similarly, xanthinuria and dihydroxyadeninuria are rare hereditary disorders that cause renal stones.²⁰

Teekshna oushadha sevana in the form of ashuddha manashila, ashuddha vanga, and ashuddha loha can produce ashmari. It can be compared to the long-term use of magnesium trisilicate in the treatment of peptic ulcer, which causes silicate stone formation. Acetazolamide causes hypercalciuria and decreases the urinary magnesium/calcium ratio, which is associated with the increased incidence of stone formation. Thiazides, which have a tremendous influence in preventing the recurrence of stone formation, increase the ratio. The antihypertensive medication triamterene is a component of several other medications, including dyazide, and has been frequently associated with urinary calculi.²¹

Khavaigunyakara nidana can be considered as any congenital anomaly of the urinary system, like ureteropelvic junction obstruction or horseshoe kidney, or acquired conditions such as benign prostatic hypertrophy and urethral stricture, which lead to urinary stasis and stone formation. Infections favor the formation of urinary calculi. Both clinical and experimental stone formations are common when urine is infected with urea-splitting Streptococci and Staphylocci, especially Proteus species. An infection causes an increase in the concentration of crystalloids, which may produce stones under certain circumstances.

Conclusion

Vitiated kapha dosha is the Samavayee karana for the production of Ashmari. This kapha in association with vata gives rise to the Shoshana of such mala found in the urine, leading to Sanghata and Ashmari. All these can be described as Vishoshana, which brings about the concentration and supersaturation of urine that serves as nidus for crystal aggregation. The continued presence of Ashmari causes the mootravaha sroto dushti, later producing vyadhi lakshana. The symptomatology of Ashmari and urolithiasis are very much similar; however, the pathogenesis explained in Ayurveda and modern medicine varies due to ideological differences. Beeja dusti (beeja bhaga avayava dusti) seems to play an important role in the causation of Ashmari. Hence, this may be considered as Utpadaka nidana. Asamshodhana sheelata, Apathya sevana, and mootravegavidharana precipitate its occurrence and hence, may be termed as Vyanjaka nidana.

Conflicts of interest

Declared.