1. Urolithiasis refers to the formation of stones in the urinary tract, which can occur anywhere from the kidneys to the urethra. The document discusses the clinical approach to urolithiasis with a focus on etiology, pathogenesis, clinical features, investigations, medical and surgical management based on Ayurveda and modern medicine. 2. Evaluation involves history, physical exam, lab tests of urine and blood, and imaging modalities like ultrasound, CT, IVU. Management depends on stone size, location and includes conservative measures, medical expulsive therapy, extracorporeal shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, and

1. 1

2. CLINICALCLINICAL
APPROACH TOAPPROACH TO
MOOTRASHMAMOOTRASHMA
RI WITHRI WITH
SPECIALSPECIAL
REFERENCEREFERENCE
TOTO
UROLITHIASISUROLITHIASIS
Dr. Arpitha H.R
IInd yr P.G scholar,
Dept., of P.G Studies in
Shalyatantra,
SKAMCH&RC

3. OverviewOverview
Introduction
Nidana and Samprapthi
Poorvaroopa
Saamanya and vishesha lakshana
Types of kidney stones
Clinical features based on location of calculi
Patient evaluation
Laboratory investigation
Radiological / diagnostic imaging
Approach consideration for management
Chikitsa
Pathyaapathya
Discussion & Conclusion 3

4. INTRODUCTION
🚹🚹🚹: �
Incidence peak @ 3rd and 4th
decade of life.
4
DUSHCHIKITSY
A

5. DEFINITION
“”
(Ayurvedic
shabdhakosha)
Urolithiasis (from Greek oûron-
urine and lithos-stone) is the
condition where urinary stones
are located anywhere in the
urinary tract.
5

6. ACHARYA
SUSHRUTA


6
ACHARY
A HARITA




ACHARYA
VAGBHATA


7. Hyperexcretion
of relatively
insoluble urinary
constituents
Altered
urinary
crystalloids
& colloids
Physical
changes
in the urine
Prolonged
immobilisation
Urinary stasis
Urinary infection
Hyper
parathyroidism
Vitamin A
deficiency
Etiopathogenic factors
7

8. 8

9. PATHOGENESIS
9

10. 10

11. •
•
•
•
•
•
•
•
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(/,)
11

12. • in , ,, ,
•
• ()
• ()
• (,
)
•
•
• , ,
(/)
12

13. NATURE OF
CALCULUS
( ),
(
)
( )
(
)
,
13

14. NATURE OF
CALCULUS
(
)
( )
( )
(
)
14

15. NATURE OF
CALCULUS
,
( ),
(
)
(
)
, ,
, ,
15

17. ----------
-
-
17

18. • In order of prevalence
• Calcium Oxalate 75%
• Calcium Phosphate
• Struvite (magnesium ammonium phosphate)
15%
• Uric Acid 5%
• Cystine 2%
• Rare varieties : xanthine, indigo
18
Chemical Types

19. CLASSIFICATION
PRIMARY
• oxalate calculus (calcium
oxalate)
• uric acid & urate calculi
• cystine calculi
• xanthine calculi
• indigo calculi
SECONDARY
• phosphate calculus
(calcium or triple
phosphate)
• mixed stones
19

20. Chemical
types of
stone
Appearance Nature PH On
radiation
Symptoms
Calcium
oxalate
(Mulberry
stone )
White
(brown)
Irregular
having
Sharp
projections
Single,
extremely
hard
Acidic Radio
opaque
Produce
haematuria
very early,
resulting in
deposition
of blood
over the
stone giving
a dark
colour to
the stone.
Calcium
phosphate
Round,
dirty white
to yellow in
colour
Smooth Alkaline Radio
opaque
Minimum
symptoms
Recurrent
UTI
Haematuria20

21. Chemical
types of
stone
Appearance Nature PH On
radiation
Symptoms
Mg
Ammonium
PO4 /
Struvite
Large.
If it
enlarges
rapidly,
filling renal
calyces
taking their
shape ->
staghorn
calculus
Slowly
Growing.
Alkaline Radio
opaque
Associated
with
chronic UTI
haematuria
21

22. Chemical
types of
stone
Appearance Nature PH On radiation
Uric acid Multiple,
small,
hexagonal,
faceted, yellow
or red brown
coloured
Moderate
hardness, soft
and friable
Acidic
5.5
Radio lucent
Cystine Pink or yellow
coloured,
multiple
Soft Acidic Faint radio
opaque
22

23. • Stone history
• Present and past medical history
• Medical treatment and surgical history
• Family history
• Lifestyle/occupation
• Diet/fluids
• Period of prolong illness with immobilization.
PATIENT EVALUATION

24. PATIENT EVALUATION
On taking the history of any pain, consider the
Site
Onset
Character
Radiation
Alleviating factors
Timing
Exacerbating factors and
Symptoms associated with the pain
24

25. CLINICAL FEATURES DEPENDING UPON
LOCATION OF THE CALCULI
SIGNS
• murphy’s kidney punch
test demonstrates renal
angle tenderness
SYMPTOMS
• Fixed dull ache in the
flanks and
hypochandriac region.
It gets worse on
movement particularly
on climbing stairs,
running , jolting.
• Haematuria
25
RENAL
CALCULI

26. SIGNS SYMPTOMS
26
URETERIC
CALCULUS
Patient is
usually in
agony, tossing
over bed,
tenderness on
deep palpation
over the part
where calculus
lies
Hypertension
Tachycardia
 Pattern of severe exerbation on a
background of continuing pain.
Abrupt, severe, Intermittant colicky
pain in the flank and ipsilateral
lower abdomen pain with radiation
to the groin, external genitalia and
the medial surface of the thigh
Intense nausea, with or without
vomiting
 Haematuria

27.  Mild-to-severe sudden gripping pain is felt in the
loin
Pain starts in the loin or near the renal angle and
gradually radiates to the groin.
pain tends to radiate to the lateral flank and
abdominal region
pain tends to radiate into the groin or testicle in the
male or labia majora in the female and to the antero-
medial aspect of the thigh.
cause irritative voiding symptoms mimicking
cystitis, such as urinary frequency, urgency,
UPPER (1/3rd
)
URETERIC
CALCULUS
MID
URETERIC
CALCULUS
DISTAL
URETERIC
CALCULUS
URETERO VESICULAR
JUNCTION
CALCULUS
URETERO PELVIC
JUNCTION
CALCULUS
27

28. VESICAL CALCULUS
SIGNS SYMPTOMS
28
Giant calculi
can be felt
suprapubically,
Moderate sized
stone may be
palpable on
rectal/vaginal
examination
May be asymptomatic.
Increased frequency of micturition
Sensation of incomplete bladder emptying
Pain and discomfort at the end of micturition,
Rarely positional urinary retention (obstruction
precipitated by standing, relieved by
recumbency)
Interruption of the urinary stream
Referred pain to the tip of the penis/labia majora,
rarely to the perineum or suprapubic region.
Pain worsens on jumping and jolting
Terminal haematuria
Acute retention of urine.

29. • obstructed flow, dribbling of urine,
increased frequency , dysuria, nocturia,
pyuria and in rare haematuria.
• Male –radiating pain in glans penis.
• Female –dyspareunia
29
URETHRAL
CALCULI

30. •
•
•
•
30

31. Differential diagnosis
• cholecystitis
• ruptured ectopic gestation
• appendicitis
• diverticulitis
• Acute salphingitis
• cholelithiasis
31

32. LABORATORY INVESTIGATIONS
• Blood : ESR, serum calcium, phosphate, creatinine,
blood urea, uric acid, PTH level
• Urine analysis: calcium, urate, cystine, PH, specific
gravity
• Urine C/S -to identify
the organism involved
32

33. DIAGNOSTIC TESTS RATIONALE OF TESTING
• PLAIN X-RAY, KUB
• ULTRASOUND ABDOMEN
AND PELVIS
• to locate radio opaque stones
• to identify radiolucent stones
& changes in renal
parenchyma, hydronephrosis33
shows multiple stones in the right kidney.
B/L large renal stones
& right ureteral stone.

34. DIAGNOSTIC TESTS RATIONALE OF
TESTING
• CT
• INTRAVENOUS PYELOGRAM
• to identify small missed
stones in ureter
• to detect radiolucent
stones, anatomical
anomalies in the
urinary tract and
hydronephrosis
34

35. (/)
35

36. (/)
36

37. ( . / )
37

38. pashanabheda, vasuka,
vashira, ashmantaka ,
shatavari, gokshura,
brihati, kantakari,
gunja, shyonaka,
varuna, yava, kulattha,
kola, kataka, ushakadi
gana saadhitha gritha/
kshara/ yavagu/
yoosha/kashaya/
ksheera/bhojana
kusha, kasha,
ikshumoola,
pashanabheda,
shatavari, vidarikanda,
root of shali dhanya,
dhanyaka, gokshura,
shyonaka, patala, patha,
punarnava, shireesha
saadhitha gritha/ kshara/
yavagu/yoosha/
kashaya/ksheera/
bhojana
varunadigana,
guggulu, ela,
kushta,
devadaru,
haridra,
maricha,
chitraka,
ooshakadi gana
siddha
ajasarpi
/kshara
/yavagu /yoosha/
kashaya
/ksheera/bhojana
38

39. • - ()
• - ()
• - ()
• (.)
• (.)
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• ()
• ()
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40. • + / ()
• + ()
• + + ()
• (. )
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• (. )
• (. )
• (.)
• (. )
40

41. • (.)
• (. . )
• (. )
• (. )
• (.)
• (../)
41

42. • + (.)
• (.)
• + (.)
• + (.)
• + (.)
• + (.)
• + + (.)
• + + ()
• + - ()
42

43. Patala, tila, apamarga, kadali, palasha, yava, karaveera, moolaka,
varunadi gana, ooshakadi gana, kutaja, snuhi, vasa, arka.
S(.)
• (.../-)
• + + (.)
• + (.)
• + (.) 43

44. 44
PUNARNAVA
MOOLA SIDDHA
KSHEERA
TRIPHALA
SIDDHA
KSHEERA

45. (/)
45

46. 46

47. Consent before surgery
(/)
47

48. POSITION :
PER RECTAL APPROACH: ,
48

49. •
()
• / / ,
()
49

50. •
• () –
Wound care :
Diet: -x 3 days
• - () x 10 days
•
• /
•
•
• / 50

51. INDICATIONS FOR
ACTIVE STONE REMOVAL
• Stones with diameter exceeding 6-7 mm.
• Persistent pain despite adequate medication
• Persistent obstruction with risk of impaired renal
function
• Stone with urinary tract infection
• Risk of pyonephrosis or urosepsis
• Bilateral obstruction.
• Obstructing calculus in a solitary functioning kidney
51

52. SPONTANEOUS RATE OF STONE PASSAGE BASED
ON SIZE ANDLOCATION OF STONE
STONE SIZE (MM) STONES PASSED(%)
 1 87
 2-4 76
 5-7 60
 7-9 48
 >9 25
STONE LOCATION STONES PASSED(%)
 PROXIMAL URETER 48
 MIDURETER 60
 DISTAL URETER 75
 URETEROVESICAL JUNCTION 79
52
Approach Considerations

53. UROLITHIASIS MANAGEMENT
CONSERVATIVE
• Hydration
• Analgesia
• Treat the underlying cause
FACILITATING STONE PASSAGE
• Antispasmodic
• Calcium channel blockers
• Lithotripsy
• Laparoscopic removal
OPEN SURGERY
53

54. 54

55. FLUSHTHERAPY
• Mainly for lower ureteric stones
• Intravenous fluids about 1.5-2 litres
• Inj frusemide 60-80 mg IV
• Usually given for 3-5days
55

56. EXTRACORPOREAL SHOCKWAVE
LITHOTRIPSY
56

noninvasive technique

For stones that are < 2.5cm
lodged in

upper or middle calyx

upper ureter
Calculi in the upper urinary tract are
reduced to fragments, which pass
spontaneously from the collecting
system and bladder in most patients.

57. 57

58. URETEROSCOPY
58

Ureteroscopic manipulation of a
stone is a commonly applied
method of stone removal

Flexible ureteroscopy allows
tackling of even lower calyceal
stones

Stones are retrieved using a stone
basket

59. 59

60. PERCUTANEOUS
NEPHROLITHOTOMY
60
•
For stones >2.5cm
•
Multiple stones
•
Stones not responding for ESWL

61. 61

62. 62
(A) Pyelolithotomy,
(B) Extended
pyelolithotomy,
(C) Nephro-
pyelolithotomy
(D) Nephrolithotomy
(E) Partial nephrectomy
Open Surgical Procedures

63. APPROACH FOR REMOVAL OF URETERIC
STONES
Indications:
• size of the stone more than
5 to 8 mm
• IVU showing deterioration
of function
• co-existing infection
• if stone is impacted in the
ureter with persistent
symptoms
63

64. RUTU
ANUSAARA
SHODHANA
BASTHI
VIRECHANA
VAMANA
LANGHANA
AVAGAAHA
SWEDANA
VIHARA
AHARA
VAARI
SEVANA
PURANASHA
LI
 YAVA
 KULATTHA
MUDGA
GODHUMA
KUSHMANDA
ARDRAKA
GOKSHURA
64

65. 65
SHUSHKA
RUKSHA
LAVANA
VIDAHI
,VISHTAMBI
PISHTANNA
KHARJURA
SHAALUKA
KAPITTHA
JAMBU
BISA
KASHAYA RASA
ATHI VYAYAMA
ATHI ADHWA
VEGADHARANA
ATHI ATAPA
SEVANA
ATHI VYAVAYA
AHARA VIHARA

66. flush! forced water intake after strenuous exercise, if perspires.
Take fluids in evening to guarantee a high urine flow during the night
prevent solute overload by low oxalate, salt, purine containing food and
moderate Ca intake
replace “solubilizers” i.e... citrate
manipulate pH in case of uric acid and cystine
Encourage a diet low in sugar & animal proteins – refined carbohydrates
appear to lead to hypercalciuria and urolithiasis; animal proteins increase
urine excretion of calcium, uric acid & oxalate
66
PROPHYLAXIS OF CALCULI
Urinary supersaturation of salts occurs in concentrated urine
Atleast drink 3 lits to avoid stone formation
PREVENT SUPERSATURATION

67. DISCUSSION
The term basti mentioned in samprapthi cannot be taken only with
reference to urinary bladder, but contextually refers to the entire
urinary system.
Mutra vegadharana is one of the most important causative factors for
the formation of ashmari. this causes aggravation of apana vata and
ghanatva of kleda finally resulting in ashmari.
The mode in which the withholding the urge of micturition operates
as a causative factor of ashmari can be classified under these
headings.
1.firstly it may allow time for precipitation of crystals from normally
supersaturated urine,
2.may result in the growth of the size of the crystal which already
exists.
67

68. Ushnagamana is one of the aggravating factors which causes
increased perspiration leads to increased concentration of
urine. It is noted that more incidences of calculi are found
in people who are exposed to high temperature and those
who perspire a lot.
68
As clear water kept in a new pitcher gets muddy in due course
of time, similarly ashmari forms in Basti. Experimentations
have also shown that the formation of a stone is similar to
the development of a crystalline mass in vitro.

69. The investigations identifies causes that may contribute to
stone formation
Urinalysis: volume, calcium, oxalates and cystine levels
Urine pH > 8 suggests urinary tract infection (Mg amm.
PO4)
• The specific cause mentioned in harita samhita for the
formation of ashmari is pitrumatrika dosha suggesting the
hereditary susceptibility of an individual to the disease.
• Analysis of family members with and without stones
demonstrates that the trait of hypercalciuria (i.e. elevated
urinary calcium concentrations) is passed from generation
to generation.
69

70. 70
Acharya Sushruta,has described widely and
comprehensively about Mutrashmari along with its
classification, symptomatology, etiology,
pathology, complications and its management. This
is the proof for the depth of knowledge of the
Acharyas on the subject of urinary disorders as a
whole.

71. CONCLUSION
• Ashmari is a highly prevalent condition with a
high recurrence rate and it has a large impact on
the quality of life.
• Since ashmari has been considered a grave
disease, it is necessary to diagnose and treat the
disease at the earliest.
• Prevention of recurrence is possible only when
the cause is established.
“
71

72. 72