Senile lower urinary tract symptoms [LUTS] management through Ayurveda: A case series

Abstract

Lower urinary tract symptoms (LUTS) refer to a range of symptoms of anatomical and physiological variations of the bladder and urethra in women and also the prostate in men. This involves storage and voiding related pathologies and clinically present with urgency, nocturia, weak stream of urine, incomplete emptying of the bladder, dysuria, hesitancy, frequency, intermittency, etc. Medical and surgical management based upon core pathogeneses is under practice successfully but post-operative complications and high chances of post-operative urethral stricture are also on account. No gold standard management has been validated yet for the management of LUTS in contemporary Ayurveda clinical practice. This study refers to the Ayurvedic management of 10 clinical cases of LUTS through the 21-day protocol of 60 ml Bala Taila Matra Basti, and internal medicines like Haritaki (T. chebula Retz.) powder, Kanchanar Guggul and Varunadi Kwatha for 30 days and their assessment through uroflowmetry, and IPSS Score before and after the treatment. Remarkable improvement was observed in relieving the IPSS (26.97%) symptoms and post-voided residual urine volume (PVRV) (39.54%). Improvement in increasing average flow rate (Qavg), (41%), Maximum flow rate (Qmax.) (43.51%), and total voided volume (53.57%) were also observed in this study. Anulomana (promoting Normal motion of Vata) and Mootrala (diuresis) were the two clinical principles that helped to manage LUTS. Improved Peak flow (Qmax.), Average volume (Qavg.) and total voided volume are the key indicators of improved micturition function. Ayurveda management with Bala Taila Matra Basti can be considered for the management of LUTS.

1. Introduction

Lower urinary tract symptoms (LUTS) (2024 ICD-10-CM Diagnosis Code R39.8) refer to a range of symptoms that are discomforting in day-to-day routine life, especially voiding experiences. Anatomically it may involve bladder outlet, bladder muscles, urethra, urethral orifice (and the prostate in men). LUTS can affect both men and women and can significantly impact the quality of life. The clinical picture of LUTS involves difficulties at different stages of Micturition including storage, voiding, post voiding, and other generalized symptoms [Table 1]. A range of clinical conditions that represent LUTS as identical clinical pictures; are benign and malignant prostatomegaly, urethral stricture, bladder outlet obstruction, Neurogenic bladder, hypertrophy of bladder muscles, detrusor inactivity, etc. Contemporary management of LUTS includes surgical, para-surgical, and some office procedures like urethral dilatation, calibration, Kegel exercise, and medical management. Repeated Catheterization, whether indwelling or intermittent, transurethral, or supra-pubic, has its own set of complications. These invasive procedures have the potential to develop long-term complications such as recurrent LUTS, urosepsis, septicaemia, and stone formations [1].

Table 1.

Storage and voiding related symptoms of Lower urinary Tract Symptoms.

1. Storage Symptoms (related to urine storage in the bladder) • Increased Frequency: Needing to urinate more often than usual during the day. • Nocturia: Waking up at night to urinate. • Urgency: A sudden and strong need to urinate, which can be difficult to delay. • Incontinence: Leakage of urine, which may occur with urgency (urge incontinence) or physical activity (stress incontinence).

2. Voiding Symptoms (related to the flow of urine) • Hesitancy: Difficulty in starting the flow of urine. • Weak Stream: A weaker than normal urine stream. • Straining: The need to strain or push to start or maintain urination. • Intermittency: The urine stream stops and starts during voiding. • Incomplete Emptying: A feeling that the bladder is not completely emptied after urination.

Senile Age group people are bound to meet with degenerative changes in their anatomy and physiology. In concern to Urinary system, they tend to meet with altered experiences of voiding and storage capacity of urinary bladder. According to an American Urology Association report, Benign Prostatic Hyperplasia (BPH) prevalence increases from 8% in men aged 31-40 years to 40-50% in men aged 51-60 years and more than 80% in men over 80 years [2]. Medical management of BPH and BNO (Bladder neck obstruction) with alpha-blockers are equally effective but have the risk of developing orthostatic hypotension, dizziness, asthma, headache, nasal congestion, and retrograde ejaculation [3].

Age-associated depletion in tissue anatomy and physiology has been considered as ‘Jara (Aging)’ in Ayurveda. Sharangadhara quoted decade-wise benchmarks for body physiology and maturity of systems [4]. Udavarta (∼misdirected Vata), Vega Avarodha (∼Multiple episodes of suppressing natural urges), Jara Janya Vata Vriddhi (Vata vitiation due to old age), Dhatukshaya (∼depletion of body anatomy and physiology) and adopting Vata provoking diet and lifestyle, contribute to Vata vitiation and ultimately to alteration in Apana physiology (a form of Vata responsible for pelvic physiology and excretory functions and motions in the body) [5,6]. Disturbed Apana Vata physiology, plays a role in development of alteration in the storage and voiding-related changes of the lower urinary tract, and result in senile dysuria.

In Ayurveda, Obstructive uropathies have been defined under the title of Mutraghata. (Dalhana: Mutrasya Avarodha—restricted urine outflow) and dysuria has been described under the title of Mutrakrucchra (Dukhen Mutra Pravrutti) by Sushruta [7,8]. However, no direct classical reference to senile dysuria has been discussed in the classical texts of Ayurveda, but references to Lower urinary tract symptoms have been narrated with clinical conditions and their management [Table 2].

Table 2.

Clinical conditions and possible correlations with Mutraghata.

Sr no.	Mutraghata	Possible correlations
1.	Vatakundalika	Spasmodic painful dysuria with cystourethritis
2.	Ashthila	Benign prostatic enlargement
3.	Vatabasti	Bladder neck obstruction with retention of urine
4.	Mutratita	Fibrous prostate with cystitis
5.	Mutrajathara	Bladder outlet obstruction with lower abdominal distension
6.	Mutrotsanga	Stricture urethra, with or without infection
7.	Mutrakshaya	Oliguria
8.	Mutragranthi	Enlarged prostate or tumour base of the bladder
9.	Mutrashukra	Spermaturia
10.	Ushnavata	Acute cysto-urethritis, e.g.? Gonorrhoeal
11.	Paitika Mutraukasada	Chyluria
12.	Kaphaja Mutrauksada	Phosphaturia

Uroflowmetry is the non-invasive assessment of the free flow of urine voided per unit time, measured in millilitres per second (ml/s) [9]. (Q_max) for men complaining of lower urinary tract symptoms (LUTS). The present study is an observational outcome of 10 cases of LUTS treated with Bala Taila Matra Basti and adjuvant medicines.

2. Case series

2.1. Patient information

10 male cases (Age: average 69.3 years) having more than 4 weeks of history of weak urine stream, incomplete bladder emptying, nocturia, dysuria, urgency, hesitancy, and intermittency were selected for the study irrespective of their demographic data. None of the patients were having T2DM, Hypertension or any other comorbidities. None of the patients were having positive symptoms of Sama Dosha. Patients were analysed based on IPSS Score, Ultrasonogram, and Uroflowmetry before and after the treatment. For the Uroflowmetry test, well-hydrated patients, comfortably feeling urinary urges were encouraged to urinate without applying force or manipulation in the funnel-shaped urinal collection pot of the uroflow meter. The device remains connected to a computerized system to produce a graphical presentation of urine flow. The Y-axis of the graph shows the volumetric measurement of the urine flow and the X-axis represents the time taken for the voided volume. From the presentation of Uroflowmetry, Average Urine Flow Rate (Q_avg), Maximum Urine Flow Rate (Q_max), and Total Voided Volume were considered for the assessment of the treatment. An ultrasonogram was taken with a full bladder and after voiding. Both the observations were recorded. All the cases were checked for S. PSA (Serum Prostate Specific Antigen) and were reported with controlled S. PSA levels. 7 cases were having benign prostatomegaly conditions of varied grades and 3 cases were having chronic obstructive bladder changes, due to detrusor hypertrophy.

2.2. Therapeutic intervention

For the management of clinical condition, patients were prescribed Bala Taila Matra Basti of 60 ml in evening time just after the evening meal (7-8 pm) for 21 days, especially considering Vata pacification timing. Patients were also given Varunadi Kwatha 40 ml twice a day empty stomach, Tab. Kanchanar Guggul (500 mg each) 2 tablets thrice a day (i.e., total 3 gm of Kanchanar Guggul/Day) by crushing with warm water after meal. Haritaki (T. chebula Retz.) Powder 6 gms with warm water at bed time for consecutive 30 days [Table 3]. The same diagnostic investigations and assessment evaluations were carried out once again at the end of 30 days of treatment. The medicines used in this study, were procured from IMPCL.

Table 3.

Cases Timeline.

Sr no.	Day	Management
1.	Day 0	Consultation, Investigations, Consent, Treatment Plan
2.	Day 1 to 21	60 ml Bala Taila Matrabasti just after evening meal
3.	Day 1 to 30	Tab. Kanchanar Guggul (500 mg each) 2tablets thrice a day by chewing or crushing with luke warm water after meal
		Haritaki (T. chebula Retz.) powder 6 gm once at bed time with luke warm water
		Varunadi Kwatha 40 ml twice a day empty stomach

2.3. Follow up outcomes

All the 10 cases tolerated Basti well. In initial 5-7 days it was observed that, the Basti was retaining for 2-3 h in night, later on it was absorbed well and retaining for 6-8 h. All the 10 cases (Age: ∼69.3 Years) received remarkable improvement in relief and the assessment parameters i.e., Post voided residual volume (PVRV) (39.54%), international prostate symptom score (IPSS) (26.97%), Uroflowmetry parameters like Q_Max. (43.51%), Q_Avg. (41%), and Total Voided Volume (53.57%) [Table 4]. After treatment, all the patients were followed up for 1 year on monthly once OPD visit basis. No cases were found with any exaggerations in symptoms. 3 cases were reported with chronic obstructive bladder changes and it was found unchanged after the therapy.

Table 4.

Central Table with assessment of cases Before and After the treatment.

Cases	Age	LUTs Profile Diagnosis	IPSS		PVRV (ml)		Uroflowmetry
							Total vol.in ml.		Avg flow (QAvg.) (ml/s)		Max flow (QMax.) (ml/s)
			Before	After			Before	After	Before	After	Before	After
Case 1	79	BPH	23	16	80	65	101.3	154.9	2.8	6	4.7	9.3
Case 2	53	Chronic obstructive bladder hypertrophy	27	21	95	55	159.4	276.4	4.3	4.6	6.6	9.5
Case 3	72	Chronic obstructive bladder hypertrophy	25	18	80	40	104.5	135.3	6.6	7.2	10.6	13.9
Case 4	76	BPH	16	13	75	30	147.3	174.8	9.2	12.3	11.3	17.2
Case 5	74	BPH	28	17	110	75	102.6	182.5	3.3	7.2	6.6	9.2
Case 6	62	BPH	28	20	70	40	103.7	146.2	2.3	4.8	5.7	8.6
Case 7	61	BPH	24	16	90	40	108.4	141.6	4.4	7	7.2	11.7
Case 8	60	Chronic obstructive bladder hypertrophy	21	16	80	45	140.2	281.6	7.8	9.6	12.6	17.3
Case 9	80	BPH	26	21	110	80	124.9	177.3	4.7	6.4	9.6	12.7
Case 10	76	BPH	23	18	95	65	131.5	208.9	6.3	7.8	9.9	12.3
Avg	69.3	24.1	17.6	88.5	53.5		122.38	187.95	5.17	7.29	8.48	12.17

*ml-millilitre, *ml/s-millilitre/second, IPSS- International Prostate Severity Score.

3. Discussion

Aging seems to develop tissue morbidity in an equally proportional way and inversely proportionate to generalized body immunity. Urinary Bladder and detrusor muscle activity are expressed by volumetric assessment of urinary outflow per second. Bladder wall calcification, followed by Bladder muscle hypertrophy is the cause of reduction in bladder muscle flexibility and physiology. The maximum capacity of bladder storage remains between 300 and 600 ml in young adult males and 300-500 ml in young adult females. For females of 14-45 years 18 ml/s is a normal maximum urine flow rate whereas for aging females of 46-65 years, 15 ml/s has been considered the maximum urine flow rate. For males aged between 14 and 45 years 21 ml/s is considered a normal maximum urine flow rate whereas for aging males of 46-65 years, 12 ml/s has been considered maximum [10].

During LUTS these parameters are deranged and patients suffer with weak stream of urine due to compromised detrusor function. LUTS can significantly impact the quality of life due to storage and voiding-related discomforts presenting with uncontrolled frequent urge to urinate, prolonged and strainful urination, urgency, soiling of underclothes due to dribbling of urine, disturbed sleep, hesitancy, and incomplete bladder emptying even after frequent urination. While suppressing the urinary urge, due to continuous bladder filling, the bladder detrusor muscle gets distended. Over-stretching of the detrusor muscle result in reduced functionality and detrusor hypotrophy in later age [11]. This leads to bladder wall distention and obstructed urine outflow.

Mutraghata (∼Obstructive uropathies) have been considered as a clinical condition arising as an advanced condition of Udavarta. Also, it has been mentioned among three major vital organ-related physiological disturbances in Ayurveda and has been recommended to be managed with Basti Chikitsa (∼Therapeutic enema) with a view to Vata pacification [12]. Bala Taila has Vata pacifying properties. The base ingredient Atibala (Abutilon indicum (L) Sweet.) has been considered as an important and essential herb for Vaya-Sthapana (∼Anti-aging Therapy) [13]. Bala Taila is a medicated oil formulated from A. indicum Linn. and sesame seed oil. Sesame seed oil (SSO) has natural lignan-like antioxidants (sesamin, sesamolin and their derived products, sesamol and sesaminol, respectively) giving the oil superior stability and beneficial physiological effects. These are inhibitors of both 5-α reductase and α blockers activity [14]. Thus it prevents the conversion of testosterone into Dihydrotestosterone (DHT: a more potent form of androgen) and ultimately prevent further growth of the prostate. Hence, it relieves BPH signs and symptoms and ultimately limits the size of the prostate gland [15].

Kanchnar Guggul is a compound Ayurvedic formulation listed in the Ayurvedic formulary of India and the Ayurvedic Pharmacopoeia of India. [16] Kanchnar (Bauhinia veriegata Linn.) and Guggul (Commiphora mukul (stock) Hook.) are chief ingredients that possess anti-proliferative action along with properties like Deepana, Pachana, Vata-Kaphashamaka, Shothahara, Lekhana, and Bhedi, which help to get rid of the cardinal symptoms of minor tumours and nodular growths [17]. Guggul contains oleo-resins which have a potent anti-inflammatory (Shothhara) effect [18]. Kanchanar Guggul's anti-proliferative properties have helped in improving the voiding experience by reducing nodular growth of prostate and bladder detrusor hypertrophy and calcification. Guggulsterone (an isolate) of Guggul, works as the bioactive constituent and is responsible for Guggul's therapeutic effects. Guggulsterone has been found to inhibit the activation of nuclear factor-kappaB; which provides a molecular basis for its therapeutic potential in treating inflammatory conditions [19]. The prostate gland has Oestrogen alpha (Associated with prostatic hyperplasia) and Oestrogen beta receptors (inhibiting excessive cell proliferation). By aging testosterone surge reduces and the expression of oestrogen behaves like a high concentration of oestrogen in compare to testosterone. A high concentration of oestrogen tends to induce a level of 5-DHT which triggers the pathophysiology of prostatomegaly. Thus, a reduction in 5 DHT concentration helps in reducing prostate growth. Kanchanar Guggul helps in reducing 5 DHT levels and ultimately prostate growth. Ascorbic acid of Kanchanar Guggul provides smooth muscle relaxant effects in the prostate and bladder neck, improving the superior urethral orifice's function and ultimately improving the urine outflow [20].

Sushruta has recommended Varunadi Kwatha for the management of nodular growths and swellings [21]. Varuna (Crateva nurvala Buch-Ham.) is one of the major ingredients of Varunadi Kwatha containing Lupeol which possesses analgesic, and anti-inflammatory activity. Moreover, Varuna bark has been reported for its protective action against androgen-induced oxidative injury in the prostate [22]. Anulomana properties of Haritaki (T. chebula Retz.) helps in pacification of Vata motion and have been recorded reducing fecal transit time. This ensures Vata pacification and correction at Pakwashaya level, which is considered as a main residing location for Vata Dosha [23].

3.1. Limitations of the study

Though the interventions were observed benefitting to the patients, but the sample size was less, it is insufficient for reporting statistical significance and accurate predictions. Hence, conclusive claims cannot be submitted. Matra Basti helps in establishing Vata Anulomana action but, its interference with hormonal surge cannot be claimed with this. Bladder distention, and chronic obstructive bladder wall due to detrusor muscle hypertrophy may require additional management for a satisfactory outcome.

4. Conclusion

By Vatanuloman role of Matra Basti and Shothahara properties of adjuvant medicaments have a satisfying role in the clinical management of LUTS without any untoward adverse events and drug reactions. Administration of procedure with sterile precautions by trained medical and paramedical staff promote positive outcomes of therapy.

Declaration of patients' consent

Informed written consents for the treatment as well as scientific publication were taken prior to the management. All the patients were convinced with the information and the details that their confidentiality of identity will not be declared.

Declaration of author contribution

Clinical contrive, case assessments, manuscript drafting, language correction, editing, referencing etc. done by author herself.

Declaration of generative AI in scientific writing

None.

Sources of funding

None.

Declaration of competing interest

Nil.