|Year : 2021 | Volume
| Issue : 1 | Page : 19-23
Lower urinary tract symptoms complicated with obstructive uropathy and urosepsis managed through ayurveda
Nasreen Hanifa Barbhuiya, K Aishwarya, Rahul Sherkhane, Vyasadeva Mahanta, Sanjay Kumar Gupta
Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi, India
|Date of Submission||27-Aug-2020|
|Date of Decision||05-Oct-2020|
|Date of Acceptance||02-Nov-2020|
|Date of Web Publication||26-Mar-2021|
Nasreen Hanifa Barbhuiya
PG Scholar, Department of Shalya Tantra, All India Institute of Ayurveda, New Delhi
Source of Support: None, Conflict of Interest: None
Introduction: Lower urinary tract symptoms (LUTS) are highly prevalent in men and the incidence increases with aging. The pathophysiology of LUTS is multifactorial and is characterized by voiding and storage symptoms. Acharya Sushruta described 12 types of Mutraghata along with its management in the form of single drug or compound formulations. Clinical Finding & Diagnosis: This is a case of LUTS secondary to benign prostatic hyperplasia; the patient was a known case of urosepsis, obstructive uropathy, and presented with LUTS with a Foley urethral catheter in situ for refractory urinary retention. Interventions: Despite the poor prognosis of the complicated LUTS, conservative treatment was given as per the management principles of urinary disorders in Ayurveda which showed a great potential in the management of complicated LUTS. Conclusion: The bothersome urinary symptoms of the patient were improved along with improvement in the quality of life and better compliance was observed by the patient.
Keywords: Benign prostatic hyperplasia, bladder outlet obstruction, lower urinary tract symptoms, Mutraghata, prostate, uropathy, urosepsis
|How to cite this article:|
Barbhuiya NH, Aishwarya K, Sherkhane R, Mahanta V, Gupta SK. Lower urinary tract symptoms complicated with obstructive uropathy and urosepsis managed through ayurveda. J Ayurveda 2021;15:19-23
|How to cite this URL:|
Barbhuiya NH, Aishwarya K, Sherkhane R, Mahanta V, Gupta SK. Lower urinary tract symptoms complicated with obstructive uropathy and urosepsis managed through ayurveda. J Ayurveda [serial online] 2021 [cited 2021 Apr 13];15:19-23. Available from: http://www.journayu.in/text.asp?2021/15/1/19/311913
| Introduction|| |
Benign prostatic hyperplasia (BPH) is the most common cause reported for lower urinary tract symptoms (LUTS) by direct bladder outlet obstruction from enlarged tissue (static component) and increased smooth muscle tone and resistance within the enlarged gland (dynamic component). Fourteen percent of men with LUTS, clinical progression in terms of acute urinary retention (AUR), urinary incontinence, renal insufficiency, or recurrent urinary tract infection (UTI) were observed over a period of 5 years. The risk of LUTS also increases in patients with metabolic syndrome, defined as the co-occurrence of at least three of five conditions comprising obesity, increased blood pressure (hypertension), high fasting glucose, high triglycerides, and abnormal cholesterol levels.
LUTS secondary to urinary retention requires consultation to the emergency department and BPH is the most common cause of urinary retention in men. Urinary retention can be acute or chronic. The risk of recurrent AUR secondary to BPH was cited as 56% to 64% within 1 week of the first episode and 76% to 83% later on. Urinary retention is highly associated with significant anxiety, discomfort, and inconvenience. Although catheterization provides immediate relief of the acute event, many men will ultimately have failure of a trial without catheter. The catheter is inconvenient, restricts daily activities, and is a potential source of infection. Intermittent catheterization also leads to poor quality of life due to the requirement of evacuating the bladder at regular intervals. Therefore, treatment should be focused to prevent urinary retention, especially in men with high-risk comorbidities.
Earlier prostate was considered the core of progression of LUTS; therefore, management is aimed either through a surgical approach, e.g., open prostatectomy, transurethral resection of the prostate (TURP), cryotherapy, etc., or by conservative treatment using drugs (e.g., hormonal therapy, alpha-blockers such as tamsulosin and alfuzosin) in the conventional system of medicine. But nowadays, bladder dysfunction is also an emerging cause of LUTS, thus management is focused on improvement in bladder function. Patients with LUTS who experience frequent, recurrent, and symptomatic UTI are considered for long-term suppressive antimicrobial treatment after urine culture analysis. However, there is no definitive regimen (dose and duration) or preferred antibiotic, therefore individual hospital guidelines are followed.
In Ayurveda, various urinary disorders are well explained along with their etiopathogenesis, clinical features, pharmacological treatment, as well as surgical approach. The symptomatology of Mutrakruchra and Mutraghata coincides with the symptoms of LUTS. Mutrakruchra is characterized by severe pain in passing urine, whereas Mutraghata has been defined as a syndrome of obstructive urinary pathology due to the deranged function of Vata Dosha. Twelve types of Mutraghata are described by Acharya Sushruta. In Mutraghata, there is total suppression or intermittent flow of urine during urination and reflects the symptoms of retention of urine, incomplete voiding, dribbling, hesitancy, weak stream, increased frequency, nocturia, etc., Sushruta has given various regimens consisting of Kashaya (decoction), Kalka (paste), Ghrita (medicated ghee), Kshara (alkalizers), etc., to combat this condition. Various single drug and compound formulations having the property of pacification of Vata, Vatanulomana, anti-inflammatory, scraping, and therapeutic procedures such as Matrabasti and Uttarabasti are recommended to normalize the function of the urinary system.
In this case report, on the basis of the Ayurvedic principle, the treatment regimen was opted which would provide symptomatic relief. The commonly used drugs were selected which will act on bladder function, combat recurrent UTI, and will relieve bothersome urinary symptoms. Complete recovery is uncommon, so the goal of the treatment remains the management of its effects and to facilitate the evacuation of the bladder in a timely manner. The criteria of assessment of treatment outcome were as per the International Prostate Symptom Score (IPSS) [Annexure 1], quality of life due to urinary symptoms [Annexure 2], and uroflowmetry. The IPSS is a short validated questionnaire which can document the baseline severity of LUTS and is used to monitor the impact of therapy.
| Case Report|| |
A 60-year-old male bought on a wheelchair by his family members to the Shalya Outpatient Department (OPD), All India Institute of Ayurveda, New Delhi, with a complaint of intermittent retention of urine for the last 6 months. He was also suffering from anorexia, shortness of breath, and generalized weakness for 1 month. The patient had a history of recurrent fever, urgency, hesitancy, and burning sensation during micturition for the last 6 months, and for that, he consulted a general physician nearby his residence and after treatment, he got improved symptomatically for some days. He was diagnosed with recurrent UTI by another doctor and for which, he took the course of antibiotic therapy, but significant relief was not obtained. In the meanwhile, his symptoms got worsen. The patient had a history of frequent catheterization on account of refractory urine retention. The patient was a known case of diabetes mellitus for the last 6 months and for that he took medicine regularly. The patient had a history of hospitalization for obstructive uropathy with urosepsis and for which, he was in the intensive care unit for 10 days. During hospitalization on investigation, blood and urine culture revealed Escherichia coli infection, and pyuria was detected on urine analysis. Further, high-resolution computed tomography revealed pulmonary edema and effusion. Ultrasonography whole abdomen revealed prostatomegaly (65 g) with chronic cystitis. The bladder wall was irregular and thickened (~15.1 mm). Uroflowmetry report revealed poor flow rate with significant Post Void Residual Urine (PVR >100 ml). He was also treated with blood transfusion for anemia during hospitalization. After 10 days, the patient was discharged from the hospital with indwelling catheter and consulted to our OPD for further management.
On physical examinations, the patient was stable and the catheter in situ was present with moderate volume, firm prostate, borders of which were not identified in digital rectal examination. There were no abnormalities found on other systemic examinations. Routine laboratory reports were within normal ranges except enlarged prostate gland. The patient was taking regular conventional medicines for diabetes mellitus, hypertension, and coronary artery disease. We continued ongoing all that medications as such (tablet Cetil 500 mg, tablet Dytor 10 mg, tablet Ecosprin, tablet Razel 20 mg, tablet Flavedon MR 35, injection Lantus 10 units, injection Apidra S/C, and tablet Trajenta 5 mg).
After a thorough clinical examination from the Ayurveda perspective, the symptoms were resembling with clinical features of Mutraghata; frequent catheterization in view of urine retention resulted in urine infections, unable to completely empty the bladder, and the stagnant urine acted as a growth medium for bacteria thus developed urosepsis and obstructive uropathy.
Considering the patient, age, comorbidity, socioeconomic background, patient preferences, and clinical presentation of the patient, an Ayurvedic drug regimen was initiated consisting of Chandraprabha Vati (2 tablets twice a day after meal), Gokshuradi Guggulu (1 tablet thrice a day after meal), Varunadi Kwath (40 ml twice a day after meal), Trinapanchmula Kwath (40 ml twice a day after meal), and Punarnavasava (10 ml twice a day with equal water after meal). Regular assessment and follow-up was done on every 15th day. Healthy diet and lifestyle instructions were reinforced. The patient was counseled regarding the importance of follow-up and maintenance with special emphasis on motivation and was followed for the next 4 months.
Follow-up and assessment outcomes
As per the IPSS, the parameters for assessment of subjective outcomes are incomplete emptying, urine frequency, intermittency, urgency, weak stream, straining, and nocturia. The score of incomplete emptying of the bladder in baseline was 5 which reduced to 3, 2, 2, and 0 at day 15th, 30th, 45th, and 60th, respectively. Urine frequency score was 0 on day 1st due to catheter in situ which dropped to 4, 2, 2, and 1 on day 15th, 30th, 45th, and 60th, respectively. Foley's catheter was removed after 7 days of initiating the medications. Urine frequency reduced gradually. Before treatment, the patient had recurrent urine retention; after treatment on day 60th, the patient had urine frequency of 4–5 times/day and 2–3 times at night. Intermittency was 2 at the time of the first visit which declined to 2, 1, 1, and 0 at 15 days interval of assessment. The score for the urgency of urine was assessed and found to be 1 before treatment which improved and changed to 2, 1, 0, and 0 on day 15th, 30th, 45th, and 60th respectively. Weak stream of urine score assessment was found 5 before treatment and dropped to 2, 1, 0, and 0 at 15 days interval of follow-up. Straining during micturition score was 5 which reduced to 2, 1, 1, and 0 at day 15th, 30th, 45th, and 60th, respectively. Burning micturition was also relieved gradually. Nocturia score was found to be 2 before treatment which improved and happened to be at a score of 2, 1, 1, and 1 at 15 days interval of assessment. The total IPSS 20 before treatment revealed severely symptomatic complicated BPH which happened to be at scores 17, 9, 7, and 2 at day 15th, 30th, 45th, and 60th, respectively.
Quality of life for urinary symptoms score before treatment was 6 (terrible) which improved and found to be 1 (pleased) on day 60th. Before treatment, uroflowmetry showed average flow rate of 5.6 ml/s which markedly improved and changed to 10.5 ml/s after treatment. Flow time was 0:40.5 and 0:23.6 min before and after treatment, respectively. Postvoid residual urine was significant before treatment (>100 ml) and markedly improved and dropped at 40 ml. Overall marked improvement was there and the patient observed satisfactory improvement in his quality of life.
| Discussion|| |
Increased prostate size is believed to contribute to LUTS because outward growth of the prostate is hypothesized to be limited due to lack of compliance of the fibromuscular band that encapsulates the human prostate. While age and genetic factors play a role in the development of LUTS, many modifiable variables contribute as well as factors that potentially may be altered in order to delay onset, prevent progression, or diminish symptoms. LUTS can have a significant impact on the quality of life due to increased frequency of urination, disturbed sleep, discomfort, and hampered daily activities. Catheterization, indwelling or intermittent, transurethral, or supra-pubic, has its own set of complications. These are invasive procedures having a potential of developing long-term complications such as recurrent LUTS, urosepsis, septicemia, and stone formations.
The current standard of pharmacological management for BPH-LUTS includes alpha-1 with or without 5-alpha reductase inhibitors (5-ARIs). Rates of discontinuation of alpha-blockers due to side effects range from 4% to 10%. Both ABs and 5-ARIs alone, or in combination, are somewhat satisfactory in alleviating LUTS symptoms, but they may lead to male sexual dysfunction. The progression of LUTS/BPH after discontinuing 5-ARI resulted in increase of TPV (total prostate volume) and occurrence of AUR leading to TURP.
As suggested in histological and immune-histochemical studies, supplementation of Chandraprabha Vati significantly restored the increased levels of the antimicrobial proteins, THP, and inflammatory markers in the kidneys of E. coli infected animals. It also contains Shilajatu which is a potent drug of choice for urinary disorders and useful in diabetes mellitus. Gokshuradi Guggulu is the commonly used medicine in diseases of urinary pathology. It is also indicated in diabetic patients. Gokshura is considered as the best single drug for the urinary disorder as per Ayurveda and is well known for its rejuvenating property. It contains diosgenin, which has antiproliferative activity that helps to relieve symptoms of BPH such as nocturia, increased frequency, and prostate enlargement. As per Ayurveda, Guggulu (Commiphora mukul) also act as Rasayana and it has Lekhana (scraping) effect also. It possesses phytochemical and pharmacological activities such as antiurolithic, immunomodulatory, antihypertensive, antihyperlipidemic, antidiabetic, antibacterial, and anti-inflammatory. Varunadi Kwath; Varuna acts as urinary antiseptic and anti-inflammatory. The ingredients of Varunadi Kwath possess properties such as Chedana, Bhedana, Lekhana, Tridoshghna, Mutrakrucchrahara, Anulomana, and Krimighna, which helps significantly in LUTS treatment. Trinapanchmula Kwath cleanses the urinary bladder and relieves pain and burning sensation during urination. Punarnavasava is used in all types of disorders with difficult prognosis. Punarnava contains diverse chemical compounds which have shown therapeutic activities, for example, anti-inflammation and immunomodulation.
In this patient, the combined drug therapy might have acted upon bladder function by increasing contractility and thus relieved voiding symptoms. The treatment offered reported here showed improvement in urine frequency and recurrent urine retention was relieved. The patient also had recurrent UTI which was successfully managed and there is no recurrence till date.
| Conclusion|| |
The study concluded that the Ayurvedic drug regimen showed promising may results, and the patient was totally satisfied with the treatment; he observed better compliance and symptomatic relief was satisfactory. To further prove the efficacy and to establish the drug regimen, well-designed and planned study on large sample size is required.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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