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Introduction

Mutrashmari is a disease of the urinary tract that causes significant discomfort, particularly during micturition(1). Charaka described Ashmari in the context of Mutrakrichra and stated that excessive physical exertion, intake of strong and irritant drugs (Tikshna Aushadhi), riding fast-moving vehicles or animals, excessive consumption of dry wine, intake of meat from aquatic animals, overeating, and eating before digestion of the previous meal (Adhyashana) contribute to the development of eight varieties of Mutrakrichra and ultimately Ashmari.

According to Sushruta, individuals who neglect purification therapies (Samshodhana) and indulge in unwholesome dietary habits are more prone to develop Ashmari(2). Ayurvedic management broadly includes two approaches(3): Samanya Chikitsa (general treatment), which provides symptomatic relief, and Vishesha Chikitsa (specific treatment), which is planned based on the type of disease, involved Doshas, and status of Dhatus. Nidana Parivarjana (avoidance of causative factors) remains the cornerstone of prevention. Since Ashmari is predominantly Kapha-related, Kapha-aggravating factors should be avoided and Kapha-pacifying therapies should be adopted.

The principal modalities of treatment include:

Aushadhi Chikitsa

Basti Chikitsa

Kshara Chikitsa

Shastra Chikitsa

Surgery is considered the last resort and is advised only when conservative measures fail or when life is threatened. And this surgery should be carried out by a well knowledged and expertise person in the respective field.(4) Shastra Karma is indicated when calculi are not amenable to treatment with Ghrita, Kshara, decoctions, milk preparations, and Uttar Basti.

Aim and Objectives

To review the management of Mutrashmari as described in Ayurvedic classical texts.

To analyze the surgical management of Mutrashmari according to Acharya Sushruta.

Materials and Methods

A comprehensive review of classical Ayurvedic texts and published national and international research articles related to Mutrashmari was conducted.

Management of Ashmari

Ashmari is considered a grave and potentially fatal disease; hence early diagnosis and management are essential. Sushruta emphasizes treatment during the Purvarupa (prodromal) stage. Medications vary according to the type of Ashmari.

Aushadhi Chikitsa

Vataja Ashmari(5):

Drugs such as Pashanabheda, Vasuka, Gajapippali, Changeri, Shatavari, Yava, Kulattha, Bera, Nirmali, Gokshura, Brihati, Kantakari, and Shyonaka are used. Ghrita prepared with these drugs along with Ushakadi group effectively disintegrates calculi caused by aggravated Vata.

Pittaja Ashmari(6):

Kusha, Kasha, Ikshumoola, Pashanabheda, Shatavari, Vidarikanda, Brihati, Gokshura, Patala, along with additives like Shilajatu, Madhuka, Indivara seeds, Trapusa, and Ervaruka are used in Ghrita preparations to dissolve Pitta-induced calculi.

Kaphaja Ashmari(7):

Varunadi Gana, Guggulu, Ela, Kushta, Devadaru, Haridra, Maricha, and Dhanya processed in goat’s milk Ghrita with Ushaka drugs are administered to reduce Kapha-induced stones.

Basti Chikitsa

Sushruta recommends Uttara Basti using decoctions of latex-producing plants to flush out calculi and accumulated blood from the bladder.

Kshara Chikitsa

Kshara prepared from drugs like Apamarga, Tila, Kadali, Palasha, and Yava is administered, often with sheep’s urine, for dissolving urinary gravel. Paneeya Kshara possesses properties such as Chedana, Bhedana, Lekhana, Shodhana, Ropana, and Vilayana, facilitating stone disintegration and expulsion.

Shastra Chikitsa (Surgical Management)(8)

Purva Karma

The patient undergoes Snehana, Dosha elimination, mild fasting, massage, sedation, and psychological reassurance.

Positioning

The patient is placed supine with pelvis elevated, thighs flexed and tied.

Pre-operative Manipulation

The stone is manipulated digitally through the rectum and abdominal pressure to localize it near the perineum.

Pradhana Karma

An incision is made lateral to the perineal raphe and the stone is removed using forceps, ensuring complete removal. Special precautions are taken in females to avoid uterine injury and in males to prevent trigonal damage.

Paschat Karma (Post-operative Care)(9):

Paschat Karma plays a vital role in ensuring proper wound healing, prevention of infection, maintenance of urinary tract patency, and restoration of normal physiological functions after surgical removal of Ashmari. Immediately after surgery, the patient is advised Avagaha Sweda (hot water sitz bath) to prevent accumulation of blood in the urinary bladder, reduce pain and inflammation, relieve muscular spasm, and promote circulation. If blood or clots accumulate in the bladder, irrigation with decoction of latex-yielding plants is recommended to cleanse the bladder effectively.

Proper wound care (Vrana Chikitsa) is essential. The surgical wound is cleaned regularly and dressed with Madhu (honey) and Ghrita (ghee) because of their Shodhana (cleansing), Ropana (healing), and antimicrobial properties. Herbal decoctions are used for washing the wound to maintain asepsis. Local application of medicinal pastes and medicated oils supports granulation and tissue regeneration. In cases of urinary fistula, cauterization therapy is advised.

A graded dietary regimen (Ahara Krama) is followed to maintain digestive strength, purify urine and blood, and support tissue repair. Initially, light warm gruels with Ghrita are given, followed by milk with jaggery and small quantities of well-cooked rice. Later, strengthening foods such as citrus fruits and light meat soups are introduced. Adequate fluid intake is encouraged while avoiding heavy, oily, and Kapha-aggravating foods.

After initial healing, mild Swedana therapy using warm oils or liquids is advised to relieve stiffness, improve circulation, and enhance tissue flexibility. Gradual rehabilitation is recommended with progressive return to daily activities while avoiding excessive exertion. Sexual activity and strenuous exercise are strictly prohibited for one year to prevent wound disruption, urinary fistula formation, recurrence of stone, and pelvic strain. Continuous monitoring and adherence to Pathya Ahara and Vihara are emphasized for complete recovery and long-term prevention of Mutrashmari.

Precautions(10)

During surgical management of Mutrashmari, extreme caution must be exercised to avoid injury to vital anatomical structures such as the urinary passages, urinary bladder, trigone (Mutrapraseka), urethra, seminal ducts, testicular channels, vagina, perineal raphe, and rectum. Any accidental injury to these structures may lead to serious consequences including urinary leakage, infection, infertility, sexual dysfunction, chronic pain, or even death. Proper patient positioning, adequate exposure, careful incision placement, and gentle manipulation of the stone are essential to minimize tissue trauma. The stone should be removed intact, as even a small residual fragment can act as a nidus for recurrence. Strict aseptic precautions must be maintained throughout the procedure to prevent post-operative infection and sepsis. Continuous monitoring of the patient’s vital signs is necessary to detect early signs of shock or complications.

Contraindications(11)

Surgical intervention is contraindicated when the patient exhibits signs of severe weakness, collapse, unconsciousness, or shock, such as protrusion of the eyes, loss of responsiveness, drooping of the head, or extreme exhaustion, as described by Acharya Sushruta. In such conditions, the patient may not tolerate surgical stress, and operative intervention may prove fatal. Surgery should be deferred until the patient is stabilized and fit for anesthesia and operative procedures. Additionally, when the stone is small and amenable to medical management, surgical treatment should be avoided.

Complications

Several complications may arise during or after surgery. Incomplete removal of the calculus may lead to persistence of symptoms and recurrence of stone formation. Operative shock can occur due to pain, blood loss, or trauma. Urinary fistula may develop if the bladder wall or urethra is injured, resulting in continuous leakage of urine and delayed wound healing. Infection, hemorrhage, delayed wound healing, and injury to adjacent organs are other possible complications. In females, improper incision may increase the risk of vesicovaginal fistula, while in males, damage to the trigone or seminal pathways can lead to urinary incontinence or infertility. Therefore, precise surgical technique, careful patient selection, and proper post-operative care are essential to minimize complications and ensure favorable outcomes.

Pathya-Apathya(12)

Therapies such as Basti, Vamana, Virechana, Langhana, and Avagaha Sweda are beneficial. Proper dietary and lifestyle modifications are essential for recovery and prevention.

Discussion

The superiority of Ayurvedic explanation of this disease can be observed relating to the specificity of symptoms mentioned for each variety of Ashmari. Importance of medical and surgical management of this disease is not to be overlooked because, the principles of management designed by different Ayurvedic authorities, are not only selective but also effective. If the calculi are not amenable to treatment with ghritas, alkalies, decoctions, milk preparations and bladder washes, surgery is the ultimate treatment. Even with expert surgeons success is uncertain, in these cases, operation should be considered last of all.[13] When death is inevitable with non-operative treatment and a doubt (in the inevitability of death) is raised by surgery, it should be carried out by the well meaning persons after taking the consent of the authorities. The disease is still an unsolved problem for the physicians and surgeons. The etiopathogenesis of this disease includes many multidirectional problems requiring multidirectional treatment. There are altered biochemical, physico chemical picture originating from metabolic or environmental disturbances requiring medical as well as surgical management to cure. Both the methods of treatment are complementary to each other. Dramatic surgical removal procedure is available but there is continuing need for medical diagnosis and prevention[14,15]. Medical treatment is more superiorly placed over surgery because of the need of prevention of recurrence, prophylaxis (mediating through biochemical and physico- chemical pathways), reduction of colic pain and spontaneous passage of stone, reduced chance of stone removal, prevention of complications, easy availability of drug with low cost and obviously less or nontoxic[15].

Conclusion

Basti (urinary bladder) is the seat of urinary diseases including stone (Ashmari). Ashmari is formed by condensation of Kapha with the impact of Pitta and Vayu. Though now a day’s modern non-surgical management is available yet surgery is still widely practiced. Ayurvedic medical management includes internal and local therapy (Uttar Basti) by some drug decoctions. Ayurvedic surgical treatment for many diseases is mentioned in Sushruta Samhita. Scientific procedure of surgery indicates deep knowledge of Anatomy and physiology of system to Acharyas.