MUTRAGHATA

The Vrikkas are the Koshtangas situated on the either side of the vertebral column Ch. Sha. 7/10; A. Hr. Sha. 3/12; Jejjata Su.Ni.9/8) Dalhana speaks that they are ball-shaped, compact and dense, covered by fleshy masses and lie in the Kukshi region (Dalhana on Su. Sha. 4/331). It could be well assumed that the description of Dalhana indicate towards the Kidneys. Throughout the centuries, many texts have been lost to us may be those texts dealing with the Anatomical description are unavailable today. So there is room for controversy in identifying an Anatomically correct description of the entire Urinary tract in the existing Ayurvedic classics. The term Mutraghata comprises two words viz. Mutra and Aghata, which stands for low urinary output either by retention, absoulute or relative anuria or oliguria. DEFINITION: Acharya Dalhana defines Mutraghata as, Mutraghatena mutravarodhah i.e. a Clinical entity of Mutravaha srotas where in the obstruction to the flow of urine is the pahognomic sign, but further states that some experts ascribe the term Dushti to Aghata as Mutrashukra, Mutrasada, UshnaVata types are not characterized by Mutravarodha. [Dalhana Su.U. 58/1] According to Chakrapani, Mutraghatena Mutram shoshyate pratihanyate va i.e. a condition characterized by Drying up or Retention of urine is Mutraghata [Ch.Chi 26/44]. Acharya Vijayarakshita in his commentary states that,

Mutraghata tu vibhandho balavan, kricchratvamalpamiti i.e. a condition with violent obstruction but with little difficulty in micturition is Mutraghata. [Ma.Ni. 31/11]. According to Sir Monier Williams, The swelling of the abdomen in consequence of Retention of Urine is called asMutraghata . [Sanskrit English Dictionary] The mechanical obstruction to the outflow of urine may be located in the lower tract, or in the upper tract alone and on one or both the sides; sometimes the obstruction may be complete or partial, temporary or intermittent. A complete obstruction of the lower tract results in a complete retention but complete obstruction is rare as compared to the partial types of obstruction. Many partial types slowly progress to a more or less complete block but during this time, there also has been a gradually developing decompensation in the emptying ability of the bladder in cases of lower tract obstruction, and in the secreting of the kidneys in the obstruction of lower and upper tracts.
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The block increases more and more complete, as the function of the bladder and kidneys becomes more and more inefficient.

In all the obstructions of the lower tract the effect of backpressure will be felt in the upper tract sooner or later, but the changes of back pressure from Obstruction in the lower tract may be very unequal on the two sides of the upper tract. Changes in lower tract are basically vesicle where as those in upper tract are Uretero-renal.

NIDANA: Ancient Acharyas have not mentioned any specific causative factors for Mutraghata, but those factors which are responsible for Mutrakricchra can be taken into account 2

[ref. Acharya Gangadhara Ch.Chi. 26/32].

Acharya Charaka has mentioned these factors as, Vyayamateekshnoushadha rookshamadhyaprasanga nitya drutaprishta- yaanaat anupa matsya adhyashanat ajeernat. [Ch.Chi.26/32]. Viz. 1. Ativyayama excessive exercise 2. Teekshna aushadha drugs of strong potency 3. Rukshamadhya prasanga excessive indulgence in dry alcohol 4. Nityadrata prishtayanat riding on the back of fast moving animals regularly/Bike ride 5. Anupamatsya ingestion of flesh of wet land creatures 6. Adhyashana eating before digestion of previous meal 7. Ajernat indigestion. In addition to the above factors, the aetiology of Mutra vaha srotodushti is also to be taken into consideration, which is described by Acharya Charaka in Vimana Sthana as below, Mutritodaka bhakshya stree sevanat mutranigrahat mutravahini dushyanti ksheenasyabhikshatasya cha .. [Ch. Vi. 5/20] Viz. 1. Mutritodaka bhakshya stree sevanat indulging in sex or drinking or eating under the urge of micturition. 2. Mutranigrahat 3. Ksheena 4. Abhikshat suppression of the urge of micturition emaciated person trauma to urinary passage

Each of the above enumerated Nidana are discussed below separately in relation to their role towards the manifestation of Mutraghata. 3

ATIVYAYAMA: This means over exertion of the body and the ill effects of it are mentioned as Shrama (exertion), Klama (exhaustion), Kshaya (consumption), Trishna (thirst) Raktapitta (bleeding disorder), Pratamaka (dyspnoea), Kasa (cough), Jwara (fever) and Chhardi (vomiting) [Ch. Su. 7/33]; And is described that it brings a violent end to the body (Ch. Su. 7/35). Thus it is clear that Ativyayama leads to extreme vitiation of Vata and other Doshas & thus could serve as causative factor for the onset of Mutraghata. TEEKSHNA AUSHADHA: Teekshna means sharp or acute and Aushadha means drug. Hence, the excessive intake of the drugs having sharp potency will definitely lead to Vata vitiation. RUKSHA MADYA PRASANGA: Bhavaprakasha has elaborated on this term as Ruksheti Madya Visheshanam and Prasanga Satatam Seva [Bh.Pr.Ut. 35/1] Thus continuous use of excess quantity of Ruksha [dry] variety of Madya [alcohol] leads to Mutraghata. In western medical science too, it has been reported to cause Haematuria and micturition syncope (Frenchs index). As Madya is having opposite qualities of Ojas, it causes destruction of Ojas. Thus Oja-kshaya again leads to Vata vitiation thus providing a base of causation of Mutraghata.

NITYA DRUTA PRISHTAYANAT: Excessive riding or driving of vehicles, horses etc. lead to fatigue and exertion thus vitiates Vatadosha. Furthermore, it can be understood that in the present era of mechanical life style, due to constant stress, strain and having to ride long distances to reach the destinations, everybody is in the habit of suppression of natural urge of micturition and therefore the conditions such as Mutraghata can be manifested. ADHYASHANA AND AJEERNA: Improper dietetic habits lead to the production of Ama in the body thus lead to Sroto Avarodha, which is one of the main causes for Vata vitiation. This may contribute to manifestation of Mutraghata. ANUPA MATSYA: Kapha is the dominant Dosha of Anupa Desha and creatures of such land are Maha-abhishyandi by nature (Su.Su. 36/49; 46/124). Maha-abhishyandi Ahara is responsible for excessive Kledatva in Dosha, Dhatu, Mala and Srotas, thus producing favourable conditions in the body for various diseases. Mutra being the watery constituent of Sara kitta Vibhajana, it can be thought that excess of Kledatva is imparted to Mutra and there by allowing the vitiated Doshas to be lodged in it and thus gains access to Mutrashaya, giving rise to various conditions of Mutraghata. KSHEENA: An emaciated person is more prone for Mutraghata, as it is one of the cause of Mutravaha Srotodushti. Also Rukshasya Klantadeshasya has been a causative factor of Mutrakshaya, type of Mutraghata.

Here, it is worth to note the symptoms of Ksheena person as put forth by Charaka in Kshataksheena chapter viz., Sarakta Mutrata (Haematuria), Parshvaprishta Katigraha (stiffness of loins, back and waist regions) [Ch. Chi. 11/13].

Thus, an emaciated person is more likely to be a sufferer of Mutraghata and related complaints.

ABHIKSHATA: A person suffering with injury to the organs of Mutravaha Srotas no doubt will suffer from Mutraghata and related complaints. This can be substantiated by Sushrutas verse Mutravahedve, Tayormulam Vasti Medhram Cha, Tatra Viddhasya Anaddha Vastitaa Mutra-nirodhah Stabdha-medhrata. Cha [Su.Sha.10/12]

There are two Srotases, carrying urine. Their origin is from urinary bladder and penis.

Any injury to them will give rise to bladder distension, urine retention and stiffness of penis.

Tatra mutravahacchedan --- mutrapoorna basteh!.

(Su. Chi. 7/36)

- Vasti is enumerated under Sadhyopranahara Marma and therefore in operative procedure of Ashmari, the following structures are to be protected:- Mutravaha Shukravaha Mushkasroto Mutrapraseka Sevani Yoni Vastinashtou Pariharet. (Su. Chi.7/36).

- Injury to Mutravaha Srotas leads to death or retention of urine in the bladder. Thus it is obvious that any sort of injury will lead to retention of urine or Haematuria and may even be fatal. MUTRAVEGA NIGRAHA / MUTRA VEGARODHA This is one of the prime factor mentioned in the causation of Mutraghata.

First it is to be understood that Apana Vata, being seated in pelvic region must be functioning normally for evacuation of urine; any impairment in its function such as Pratiloma - gati, leads to various affliction of Mutravaha Srotas such as Mutraghata, Ashmari, Prameha etc. Marute pragune bastou mutram samyak pravartate vikara vividhanshchapi pratilome bhavanti hi Mutraghatah pramehashcha shukradoshastathaiva cha mutradoshascha ye kechid Vastireva bhavanti hi ( Su.Ni. 3/27,28). Also, the Laxanas of suppression of Mutraghata have been mentioned by

Sushruta under the Laxanas of Mutrodavarta viz., Mutrasya vege abhihate narastu kricchrena mutram kurute alpam alpam medhre gude vankshna Vasti mushka nabhi pradeshesvathapi murdhni anaddha Vastischa bhavanti tivrah shoolascha shoolairiva bhinnamurteh. ( Su. Utt.55/9-10). Thus scanty micturition with increased frequency and distention of the bladder along with pain in the penis, rectum , groin, bladder and umbilical regions are caused due to voluntary suppression of the urge of micturition. Here Vata is the root factor in the manifestation of all the varieties of Mutraghata i.e. Sarveshu mutraghateshu yatha Vatah karanam. (Da. On Su. Utt. 58/27). And it is Vata which is responsible for the onset of urge of micturition. The involvement of Vata in Mutraghata can be further substantiated by the following conditions as described by Acharya CharakaTatra koshtashrite dushte nigraho mutra varchasau (Ch. Chi. 28/24) Vata provoked in Koshta produces Nighrahana (retention) of urine and faeces.

Graho vinmutraVatanam .gudasthite anile

(Ch.Chi. 28/26)

Vata situated in Guda produces Graha of Mutra, Purisha and Vata etc. Mutrapravrittiradhmanam bastau mutravrite anile (Ch.Chi.28/60)

when Vata gets Avrita by Mutra, it causes Mutra-apravritti and Adhmana in Vasti.
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Acharya Sushruta states:Pakvashayasto .. kricchramutra purishatvam anaham .. (Su.Ni.1/23-24)

Vata vitiated in Pakvashya, produces Antrakujana, Nabhi - Shula, Mutrakrichhra, Anaha etc. Ayurved believes that Vata is the factor responsible for movement and as seen above, its functioning has been correlated with that of the nervous system. Therefore it could be possible that a vitiated rather than deranged functioning of Apana Vayu may bring about neural transmission of the bladder. This is just a speculation and therefore we could probably say that Mutravegarodha or voluntary suppression of the urge of micturition for longer period may be even upto many years, will cause changes in the functioning of bladder and therefore leading to various disorders. SAMPRAPTI (AETIO-PATHOGENSIS OF MUTRAGHATA) : Acharya Sushruta states the importance of Pratiloma Vata in the Vasti- Rogas such as Mutraghata, Prameha, Shukra Dosha and Mutradosha i.e. Marute pragune bastau .. vikara vivdanschapi pratilome bhavantihi (Su.Ni.3/27-28) Acharya Vagbhata states Adhomukho api I parshwebhyah puryate sukshmaihi syandamanairanaratam II yaistaireva pravishyenam doshah kurvanti vimshatim I Mutraghatan pramehanscha kricchran marmasamashrayan II (A. Hr.Ni.9/2-3).

The commentator Arunadatta raises a doubt that, if Vasti were to be facing downwards with a single outlet, then how do the Doshas enter to produce Mutraghata ?

The clarification is that even though the Vasti facing downwards, minute vessels fill the bladder from the sides and these are the routes for the entry of Doshas, to produce Mutraghata.

Acharya Dalhana quotes that Vata is the main factor in the pathogenesis of Mutraghata i.e. Sarvesham Mutraghatanam vayureva prayashah karanam (Da. on Su. Utt. 58/6)

Acharya Charaka states that when Amavisha gets localized in the urine it leads to Mutra Rogas i.e..mutrarognscha mutrastham. (Ch.Chi.15/49)

SHATAKRIYAKALA: Shatakriyakala explains the pathogenesis of a disease in stages right from the incubation period to the complete manifestation and later consequences there of. SANCHAYA: This is the initial accumulation of a Dosha due to individual vitiating factors. Mutravegarodha has been mentioned as one of the prime Nidana in almost all the types of Mutraghata. The Apana Vayu being vitiated by indulging in the afore mentioned Nidanas starts accumulating in its own places- the Kati, Vasti, Pakwashaya and Medhra . Along with this the bodily Vayu is vitiated by Vatakara ahara and Vihara. In this stage, the individual experiences occasional discomfort in the act of micturition, which seems to be tolerable and he neglects it. There may be feeling of Adhmana and Atopa in Vata Pradesha along with a very mild discomfort in passage of urine.

In this stage, the person presents with vague symptomatology and the physician has to be clear enough to elicit the history and symptoms to prevent further vitiation.

If not, the symptom will not seem to be those of the Mutravaha Srotas and treatment can be missed altogether.

PRAKOPA: If a person neglects above stage and, passes into this stage, there will be further vitiation of Vata, due to the indulgence in the above said Nidanas. This vitiation occurs in all the Vata stanas and lead to hampering of the functioning of both Pitta and Kapha in terms of Vishamagni which lays the foundations for the production of Ama. Here, again the symptomatology experienced may not be directly related to Mutravaha Srotas but rather to those of initial Ama formation i.e. Amlika, Pipasa etc. and further Adhmana and Atopa. Therefore, again the possibility of not arriving at a diagnosis of the Mutravaha Srotas. Only an experienced physician can foretell the consequences.

PRASARA: In this stage there will be the spread of the vitiated Doshas from their locations to other sites and therefore a mixed symptomatology may be found. The process of Ama formation already set in is further carried on. As it is already known that the Mutra is result of Sara-Kitta Vibhajana of Ahara, which is a combined effort of Tridoshas with Agni. The Mutranirmanaprakriya (formation of urine) has been nicely presented in Sushruta Samhita. The Dhamanis are classified into Urdhwa, Adhah, and Tiryak traversing. It has been explained that there are two Adhogami Dhamanis, which carry Mutra from the Antras to be expelled out. (Su.Sha. 9/7).

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But Acharya Dalhana comments that it is not the Mutra that is carried out but rather the Toya, which is the product of Ahara Vivechana. This Toya is further converted into Mutra (Bhavishyato mutrasya karanabhutam) by the time it enters the Vasti (Tadevodakam Vastivivarapraptam mutramityucchyate) and it is Toya part of Kitta, which is carried by the above said two downward traversing Dhamanis (Da. Su. Sha. 9/7).

Thus this process of Sara-Kitta Vivechana is hampered and the Doshas gain the access to the Mutravaha Dhamani and start spreading. And also due to Ama there exist Sroto Avarodha, which further vitiates the Vata, which lead to Vimarga Gamana and Atopa due to the blockage in its course through the channels.

And there will be the manifestation of the Laxanas due to Ama such as Avipaka, Paridaha, Arochaka, Agnisada etc. In this stage, the Laxanas related to Mutra may be more pronounced than the previous stages, with increased difficulty in micturition. But, again there is no evidence which exists to pinpoint a diagnosis.

STHANA SAMSHRAYA: In this stage, the premonitory features of a disease are manifested and in this stage only the vitiation of Dhatus starts. The vitiated Doshas along with Ama traversing through the Sukshma Siras, Dhamanis get lodged in Vasti and forms a base for the complete manifestation of Mutraghata. The terminologies like Chidravaigunya and Mutra Srotonirodha used in the types of Mutraghata further substantiate the lodging of Ama in Vasti to manifest Mutraghata. Acharya Charaka states that Ama attaining its seat in Vasti causes Vasti Rogas (Ch. Chi. 15). As mentioned in the literary contrive, a doubt is raised in Astanga Hridaya in Mutraghata Nidana as to how the Doshas reach the Vasti?

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It is said that it is through the Sukshma Siras pouring in to Vasti from the sides and thus the entered Doshas produce various Vasti Rogas. Further, Acharya Dalhana clarifies that fact that all the varieties are not purely of Mutraghata but the conditions like Mutroukasada, Ushna Vata and Mutra Shukra are Mutradoshas as there is no Aghata in these conditions.

Thus, Vasti is the Sthana for the Sthana Samshraya of Doshas. In this stage, the premonitory symptoms are manifested. As there are thirteen varieties of Mutraghata, no set of Purvarupa is described. But it can be evaluated that the obstruction to the flow of urine is more pronounced and occurs more often than the previous stages. The symptoms of Vasti Adhmana and Vasti Shula are also experienced in a greater degree. Mutra Vivarnata too is noticed occasionally. It is the expert physician, who recognizes the seat of the disease as Vasti and labels a person suffering from afore mentioned symptoms to be proceeding towards either of the variety of Mutraghata.

This can be further supported if a careful analysis and proper investigations are carried out.

VYAKTI: This is a stage, where complete manifestation of a disease sets in. each and every symptom of individual variety of Mutraghata is identified in this stage. BHEDA: If the disease is miss-diagnosed and miss-managed or properly not treated in the various stages, they proceed towards complications and involvement of other bodily systems thereby complicating the management, probably due to extensive damage sustained or irreversible structural changes having taken place, on account of the negligence of early diagnosis and prompt treatment. In Mutraghata, there may be Acute obstruction or Chronic obstruction followed by Incontinence, Haematuria, Diverticulaformation, Ureteral Dialation and Ascending Hydronephrosis there by leading to fatal outcome.

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SAMPRAPTI GHATAKA: Dosha Vata (Apana) predominant Tridoshas Dushya Rasa, Rakta, Kleda, Sveda, Mutra Agni Jatharagni Mandya Udbhava Sthana Koshta Adhishtana Vasti Srotas Mutravaha Stotodushti Prakara Sanga, Vimarga Gamana, Siraja Granthi. Roga Marga Madhyama

PROGNOSIS OF VARIOUS TYPES OF MUTRAGHATA: Vatakundalika Ashteela VataVasti Mutrateeta Mutra jathara Mutrasanga Mutrakshaya Mutragranthi Mutrashukra Ushna Vata Mutroukasada Vidvighata Vasti Kundalika - difficult to cure --

difficult to cure. -

curable with great difficulty serious -

dreadful condition with accompaniment colic, cardiac

failure, fainting, dyspnoea due to displacement of bladder. CLASSIFICATION: The types of Mutraghata as per the view of different Acharyas is given below13

Types Vatakundalika Ashteela Vata Vasti Mutrateeta Mutrajathara Mutrotsanga Mutrakshaya Mutragranthi (Raktagranthi) Mutrashukra (mutrakricchra) Pittaja mutroukasada Kaphaja mutroukasada Mutroukasada Vidvighata Vasti kundalika

Su + + + + + + + + + + + + -

Cha + + + + + + + + + + + +

Va + + + + + + + + + + + +

Dosha Vata Vata Vata Vata Vata Vata Vata Pitta VataPitta,Rakta Vata Vata,Pitta Vata,kapha Vata,Kapha Vata Vata

Thus, Mutrashukra of Sushruta is described as Mutrakricchra by Charaka. Mutroukasada is divided into Pittaja and Kaphaja types by Sushruta whereas Charaka dealt it under one heading i.e. Mutroukasada. Vidvighata and Vastikundala types are not described by Acharya Sushruta. If these types of Mutraghata can be classified into three categories as projected below, then we may be in a position to understand the varieties more clearly and it will help us to analyze a patient presenting with related complaints A. Vatakundalika, Vata Vasti and Mutrajathara can be grouped under Neurogenic disturbances of bladder. B. Ashteela, Mutragranthi, Mutrotsanga and Vastikundalika can be grouped under Organic disturbances, where the symptoms of retention of urine, increased frequency of micturition, distension of abdomen and mass felt per rectum are due to a growth either in the bladder, urethra, prostate or other growths.

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C. Mutrateeta, Mutrakshaya, Ushna Vata, Mutroukasada, Vidvighata and mutrashukra can be grouped under category Others, where the disturbance in urinary function is either due to physiologic reasons or injury etc. We can analyze the various varieties of Mutraghata under the three categories and possible explanation on modern lines is presented, which is completely based on thorough discussions. Though the classification may not be complete but it may prove to be an aid in approaching a case of Mutraghata with varied symptomatology and to plan the treatment accordingly. A table is presented here on the lines of modern symptomatology, to identify the various types. Types Vatakundalika Vata Vasti Vasti kundalika Mutra jathara Mutra granthi Mutrotsanga Ashteela Mutrateeta Mutrakshaya UshnaVata Mutroukasada Vidvighata Mutrashukra A Retention of urine B Increased frequency C Dysuria D Dribbling Micturition E Haematuria F Oliguria G Constipation H Granthi A + + + + + + + + B + + + + C + + + + + + + + + + D + + + E + + + F + + G + + + + H + + I + + J + + + K + + + + + L + + -

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I Abdominal distension J Pain in Abdomen K Discoloured urine L Faecum through urine

VATA KUNDALIKA [Ref : Su.Ut.58/5-6, Ch.Si.9/39,40, A.Hr.Ni.9/25] Nidana: Rukshannapana (Ingestion of un-unctuous substance) Vega Vidharana (Suppression of the natural urges) Sampapti: Vayurantramashritah, gatisangadudavrittah Aavidhya mutram bhramati Vayurbhagna vyaviddha kundali Mutram charati sangrihya vigunah kundali kritah i.e., owing to clogging in the urinary passages, the Vata is turned upwards and thus its motion, becoming broken or vitiated, it assumes either a crooked or circumgyratory motion in the bladder as well as in the urinary channels and vitiates the urinary function. Laxanas: Srijedalpam alpam shanaih shanaih (scanty and dribbling micturition with increased frequency) Sarujaska (painful micturition) Samstambha bhanga gaurava veshtana (rigidity, breaking pain, heaviness, girdle pain) Teervaruja (severe colic) Vitsanga (retention of faeces)

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Commentary (Teeka) : Here Stambha is explained as Vasti Kathinyam Alpam Alpam indicates Stokam Stokam; i.e. in obstructed jets with increased frequency (Arunadatta A. Hr. Ni. 9/25). VATA VASTI ( Ref. Su. Ut. 58/9-10, Ch. Si. 9/37, A. Hr. Ni. 9/ 20-22) Nidana: Mutravegadharana (suppression of the urge of micturition). Samprapti: Nirunaddhi mukham tasya basterVastigato anilah i.e. the Vata gets provoked owing to suppression of its action and causes obstruction to the bladder outlet. Laxana: Mutrasanga (retention of urine) Vasti kukshi nipiditah (pain in bladder and loin region) Kandu (itching sensation in the bladder region) MUTRAJATHARA (Ref. Su. Ut. 58/13-4, Ch. Si. 9/29-30, A.Hr. Ni. 9/27,26) Nidana: Mutrasya vihate vege (voluntary suppression of the desire of micturition) Samprapti: Apanah kupito vayurudaram purayedbhrisham (i.e. in consequence of suppression of the urge of urination, the Vayu gets aggravated and causes painful distention of abdomen) Laxana: Nabhera dhostadhmanam janaye tteevra vedanam adha hsroto nirodhanam (distension below the umbilical level resulting into indefinite pain accompanied by retention of urine and faeces). Apakti (indigestion) The Laxanas mentioned in these varieties seem to simulate with the conditions of bladder due to neurogenic disturbances. Therefore a brief review of this aspect is presented here:VASTIKUNDALIKA (Ch. Si. 9/44-46)

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Nidana: Drita (Excessive running) Adhvagamana (excessive way faring) Langhana (fasting) Ayasa (exertion) Abhigata (trauma) Prapeedanat (compression)

Samprapti: Svastanad Vastirudvrittah shulastishtati garbhavat (due to the above mentioned Nidanas, the bladder is displaced upwards and becoming enlarged and it appears like a gravid uterus). Laxana: Shula (colic) Spandana (throbbing) Daharti (burning pain) Bindum bindum sravatyapi (passes urine drop by drop) Peeditastu srijeddharam (when the bladder region is pressed the urine comes out in jets) This condition is characterized by rigidity (Stambha) and girdle pain and is termed as Vastikundala or circular distension of the bladder. Note: This condition appears similar to that of Vata Vasti type of Mutraghata as explained by Vagbhata (A. Hr. Ni. 9/20 22). In addition to this, Acharya Charaka has further explained the involvement of Pitta and Kapha in this disease. He says that when this condition is accompanied of urine, while when it is accompanied with morbid Kapha, there will be heaviness, swelling and unctuous,dense condition of the urine. Further, he states that, where the orifice of the bladder gets obstructedby Kapha and

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where there is provocation of Pitta too, there the prognosis is poor and if the orifice of the bladder is not displaced, then the condition is curable. MUTRA GRANTHI / RAKTA GRANTHI: (Su. Ut. 58/18-19; Ch. Si. 9/41; A. Hr. Ni. 9/31) Nidana: Raktam Vatakaphad dushtam (Rakta vitiated by Vata and Kapha) Samprapti: Abhyantare Vastimukhe mutramarga nirodhanah jayate sahasayasya granthihi i.e. abrupt or sudden manifestation of the Granthi in the interior side of the bladder which obstructs the flow of urine is called as Mutragranthi or Raktagranthi. Here, Rakta, Vata and Kapha are vitiated factors and are responsible for the onset of Raktagranthi according to Acharya Charaka. Acharya Sushruta doesnt mention the Doshic involvement but Dalhana specifies that Pitta is the responsible factor in the manifestation of Mutragranthi. Laxana: Vritta, Alpah, Sthira Granthih i.e. a round small and immobile Granthi in the interior side of the bladder. (Acharya Dalhana clarifies Abhyantare Vastimukhe as Vastidwarasyabhyantare iti) Vedanavan (continuous pain) Mutramarganirodhana (Retention of urine) Kricchrena srajenmutram (urine passed with difficulty & pain) Ashmari sama shoolam (pain similar to that experienced in Urolithiasis) VATASHTEELA / ASHTEELA (Su. Ut. 58/7-8; Ch.Si.9/36; A.Hr.Ni. 9/23-24) Nidana: Vayurantaramashritah i.e. vitiated Vata. Samprapti: Shakrinmargasya basteshcha ashteelavat ghanam granthim

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i.e. the vitiated Vata gets lodged between the bladder and rectum and produces the stony hard swelling. Laxana: Achala unnata granthih (singly immovable and elevated) Vinmutranila sanga (retention of urine, faeces and flatus) Vasti adhmana (distention of the urinary bladder) Vedana ca parabastou (excruciating pain in the bladder) MUTRASANGA ( Su. Ut. 58/15-16; Ch. Si. 9/33; A.Hr.Ni. 9/29-30) Nidana: Viguna anila (vitiated Vata) Khavaigunya (abnormality of the urinary outlet) Chidravaigunya (abnormality of urinary outlet) Samprapti: Bastou va api athava nale manou va yasya dehinah. i.e. in consequence of the Nidana, the urinary flow is obstructed at the level of either Vasti or Nala (urethra) or Mani (external urethral meatus). Laxana : Mutram pravrittam sajjet (obstructed flow of urine) Saraktam (with blood) Va Pravahatam (staining) Sthitva sravecchanaih (intermittent flow) Vicchinnatacchesha guru shephasah (dribbling of urine) Commentary (Teeka) - Acharya Dalhana explains the process of vitiation of Vata & the disease as follows a. The Viguna Anila i.e. Vimarga Gami Vata aggravated by its own factors lead to Margavarodha ( obstruction of the outlet ) or conversely Margavarodha ( obstruction of the outlet) may lead to aggravation of Vata.

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b. Sarakta has been analyzed as Samsakta meaning obstructed. c. Saruja is due to Ati Vata Prakopa , whereas Niruja due to HinaVata Prakopa. d. Even though Nala (urethra) signifies the Mani (ext. urethralmeatus) also, it is commented that more importance is stressedupon Mani region as the Utsanga of Mutra (obstruction of urine)(upward / reverse direction) is felt at that area. e. Arunadatta and Todaramalla in their commentary on AstangaHridaya have nicely analyzed the condition of Mutrasanga as below i. Yadakshiptam mutramalpam has been explained as kinchicchesari mutram tadhastou sthitamathara nale manikande va sthitam i.e. the obstructed flow resulting in residual urine may be situated either in the Vasti (urinary bladder), Nala (urethra) or the Manikanda (glans penis),depending upon; Chidravaigunya i.e. Mutradvara dosha. Here, the Mutradvara dosha may be considered as either theUreteral orifices or the Urethral orifice. ii. Furhter he quotes Tatra sthitva paschat anantaram, shanaih i.e. Mandam mandam kritva sravet, i.e. the residual urine then dribbles out in small jets frequently. iii. Mukta mutrasyah, Sheshatacchesah, Savicchinah ChitvaChitva Bhavati

Vayoschalatvena. Due to the Chalaguna of Vata, the urine flow is obstructed, small in jets and therefore thepatient has sense of incomplete emptying of the bladder and asa result of this, he experiences heavyness in the penis (Guru Sephas). This category of diseases, predominantly show obstructive as well as Irritative symptoms of the bladder due to an in growing Ganthi and therefore these symptomatologies of retention of urine, increased frequency of micturition, incontinence etc. are individually presented in order to understand the possibilities of the condition we may come across

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when presented with a patient of above complaints. Again this is just an attempt to analyze the varieties of Mutraghata for better understanding. MUTRATITA (Su.Ut.58/11-12; Ch. Si. 9/35; A.Hr.Ni. 9/20) Nidana: Vegam sandharya mutrasya (suppression of the natural urge of micturition) Laxana: Pravahato mandarujam (stream with mild pain) Alpam alpam (obstructed flow with little quantity) Punah punah (increased frequency) i.e., a person habituated to withholding to urge of micturition wanting to pass urine ( Sristamicchati) finds difficulty in starting the urine flow (Kanthancitsam pravartate) and experiences mild pain on straining and the flow is obstructed and frequency is increased due to the incomplete emptying. This variety can be very well understood by referring back to the Mutra vegavarodha part of this study. MUTRA-KSHAYA (Su. Ut. 58/17; Ch.Si.9/34; A.Hr.Ni.9/37) Nidana: Rukshasya klantadehasya Samprapti: Vastisthou pittamarutou mutrasanksayami. - i.e., even though a Ruksha person has no pitta aggravating factors, but still the involvement of the Pitta along withVata has been stressed upon. This leads to the drying up of the urine (Mutrashoshana Da.Su.Ut.58/17) Laxana: Sadaha (burning micturition) Savedana (painful micturition) Mutrakricchra (troublesome/small quantity of urine)

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Note: Acharya Charaka has not given the involvement of Pitta in this condition. The definition given by Chakrapani i.e. Pratihanyate shoshyate va seems to be applicable here and it could well define a case of Anuria. Hence, description of Anuria is being presented here. USHNA-VATA: (Su.Ut.58/22-23; Ch.Si.9/38; A.Hr..Ni 9/35-36) Nidana: Ati vyayama (excessive exercise) Ati adhvagamana (excessive walking) Ati atapasevana (wandering/sitting in sunlight) Samprapti: Pittam Vastim Prapyanilavritam Vastim medram gudam chaiva pradahan sravayedadhah. - Because of indulgence in causative factors, Vata accompanied with Pitta enters Vasti and causes burning pain in the Vasti, Medhra and Guda, and the person passes urine with difficulty. Laxana: Mutram haridram (haridra coloured urine) Saraktam (with blood or high red coloured urine) Raktamevava (only blood) Kricchrat pravartate (difficulty in micturition) Commentary (teeka) Acharya Dalhana clarifies the Laxana as follows (Su. Ut. 58/2223) Saraktam ishadraktavarnamishacchonitam va ; i.e., a high red coloured urine or bloody urine. Raktam va iti kevalam shonitam, atyanta raktavarna mutram iti; i.e., gross haematuria. As can be seen from the clarification of teeka, haematuria seems to be the prominent symptom. Hence, the description of haematuria is presented here. MUTROUKASADA: (Su. Ut. 58/24-26; Ch.si. 9/27-28; A.Hr.Ni. 9/38-39) 23

Definition: Mutrasya prasravanasya okam ashraya sthanam sidati iti . i.e., affliction of Ashraya sthana of Mutra (Vacaspatyam & Amarakosha) Nidana and Samprapti: Pittam kaphodvavapi va samhanyate anilena i.e., Pitta and Kapha combined together along with Vata enter the bladder and produce Mutroukasada. Laxana: Pittaja variety: Vishada mutra (clear urine) Pita mutra (yellowish urine) Sadaha (burning micturition) Bahala ( thick urine) Shuska Gorocana Sannibha (yellowish) Kaphaja variety: Picchila (slimy) Samhata (dense/cloudy urine) Shveta (white urine) Kricchrapravartana (burning micturition) Shankhachurna prapanduram (whitish discolouration) The main entity recognizable here is the passage of discoloured urine VIDVIGHATA (Ch. Si. 9/42-43; As. Hr. Ni. 9/33-34) NIDANA Ruksha Durbala- person who are emaciated & parched. SAMPRAPTI Vatenodavrittam shakridyada mutrasrotah prapadyet vitsamshritam tada 24

i.e. the morbid Vata enter into the urinary passage along with faeces and produces a condition characterized by foul smelling urine mixed with stools. LAXANA Acharya Vagbhata makes use of the terms- mutrasroto anuparyeti instead of mutrasrotah prapadyet of Charaka, which is commented upon by Todaramalla as Mutravaha srotovivaram prapnoti i.e. vitiated Vata along with the Shakrit ( faecal matter) enter the Mutravaha Srota Vivara ( urinary passage). The condition very aptly describes the entities wherein faeces is passed through urethra but again we have to recollect the conditions leading to thisMUTRASHUKRA (Su. Utt. 58/20-21, Ca,Si. 9/32: A.Hr. Ni. 9/32) Nidana Pratyupasthita mutrastu maithunam yo abhinandati ; i.e., performing coitus in the presence of natural urge of micturition. Samprapti Tasya mutrayutam retah sahasa sampravartate. Laxana Purastadvapi mutrasya pascat va api kadachana bhasmodaka pratikasham. Due to the aforesaid Nidana, the seminal fluid ejected by Vata will either precede or follow the urine stream, which is similar to Bhasmodaka (ash coloured). This seems to be the physiological disturbance of the sphincteric mechanism & therefore a brief review of the sphincteral region & the mechanism has been included here Throughout the most of the length of the prostatic urethra, the posterior wall possess a midline ridge, the urethral crest, which projects into the lumen causing it to appear crescent in transverse section. On each side of the crest, there is shallow depression called prostatic sinus, the floor of which has orifices of the prostatic ducts. About the middle of the length of the urethral crest, the verumontanum(colloculus- seminalis) forms an elevation, on which the ejaculatoryduct open. A distinct collar of circularly oriented nonstriated muscle occurs in the bladder neck, prostatic urethra, continues distally with themuscular components of the genital tract distally. This smooth muscleis supplied with

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a rich plexus of sympathetic nerve fibres, which onstimulation cause the sphincter to contract thereby prevent theretrograde ejaculation of semen in to the bladder. During seminalemission, the sympathetic nervous system too prevents coincidental contraction of detrusor smooth muscle.The epithelium lining of the prostatic urethra and the proximal part of the prostatic urethra is of typical urothelial type and is in continuity withthe lining of the bladder; it is also continuous with the ducts of theprostate and bulbo-urethral glands and with the linings of the seminal vesicles and ejaculatory ducts.At the time of seminal ejaculation, with a full bladder,when the external sphincter is completely open, the internal sphincter must function as voluntary muscle, otherwise there would be leakageof urine or passage of semen in to the bladder. Thus completes the classification of various types of Mutraghata and their near possible correlations to make the subjectmore vivid and understandable. As said earlier, this attempt is just toenhance our prospective viewing of Mutraghata but certainly a stepforward in helping us to approach a patient with varied symptomatology of the entity. PATHYA AND APATHYA: [ Bh. R. 35] Lastly, the most important and the most neglected aspect of the treatment is that of Pathya and Apathya. Dietetic control will give boost to the drugs administered and therefore enhance the results of the given drugs. Abhyanga, Snehana, Virechana Vasti Svedana Uttara Vasti are again descried to be Pathya indicating their importance. Purana Shali, Yava, Madya, Takra, Dugdha, Mashayusha, Kushmanda Phala, Patola, Talaphala etc. are all Pathya to the patients of Mutraghara; hence the food articles of above advised things will definitely be beneficial in alleviating the symptomatology of Mutraghata,atleast to a certain extent and mostly that of Vata vitiation. (Bh.R.35/50-52) Mutravegavarodha, Viruddhahara, Ativyayama, Ruksha Vidahi Annapana Ativyavaya, Vamana etc. are Apathya as they all lead to vitiation of Vata and results in further deterioration of the condition ofAghata or urine retention (Bh.R.35/53).

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