Nephrolithiasis, or kidney stone disease, is caused by an accumulation of mineral and acid salts that form crystals in the urine inside the kidney or urinary tract. Common causes include low urine volume, hypercalciuria, and hyperoxaluria. Symptoms include pain in the lumbar region, flank, or groin and hematuria. Diagnosis is typically made using ultrasound, CT scan, or X-ray. Treatment depends on the size of the stone but may include increased fluid intake, pain medications, shockwave lithotripsy, or surgery.

1. Nephrolithiasis - Ashmari

2. Etiology
1. Low urine volume
2. Hypercalciuria
3. Hyperoxalouria
4. Hyperuricosuria
5. Low fluid intake
6. Fluids such as apple juice, grape fruit, sodas increases the risk
7. High NaCl intake
8. High protein intake
9. Low calcium intake
10. H/o prior kidney stone
11. Hyperoxalouria (enteric hyperoxaluria, short bowel syndrome)
12. Type I Renal Tubular Necrosis
Patients may be occassionally diagnosed on radiology of abdomen done for
other cause.

3. pathophysiology
Normally soluble solutes (e.g-calcium)
supersaturates in the urine(site like end of
collecting ducts)crystallization
occurscrystal aggregatesbecomes large in
shape and sizeanchoring of crystals occurs
at epithelial cell injury site caused by crystal
itself or by infection– acting as Nodus(charged
particle)attracts unsoluble solutes towards
it calculi formation

4. Types
1. Calcium oxalate (more common)
2. Calcium phosphate (less common)
3. Uric acid, struvite (Mg, Ammonium
Phosphate)
4. Cystine stones
5. Combination of different stones can exist in
single stone

7. Clinical features
• Pain in the lumbar region (kidney stones), Renal
Punch test postive
• Pain radiating from Loin to Groin (ureteric stone)
• Pain onset when stone descends in the ureter
• Spasmodic pain occuring in waves or paroxysm,
mostly at night
• Nausea and vommitting
• Hematuria- microscopic or gross or absent

8. Investigation
• Urine routine and Microscopic- shows crystalls
• USG abdomen & Pelvis
• Xray KUB
• IVP
• Non contrast enhanced CT/MRI

9. Treatment
• Acute colic-IV hydration
• Nonnarcotic analgesics (eg, Acetomenophen)
• PO/IV narcotic analgesics (eg, codeine, butorphanol, morphine sulfate,
oxycodone/APAP, hydrocodone/APAP, meperidine, nalbuphine)
• NSAIDS (eg, ketorolac, ketorolac intranasal, ibuprofen)
• Uricosuric agents (eg, allopurinol)
• Antiemetics (eg, metoclopramide)
• Antidiuretics (eg-desmopressin acetate)
• Antibiotics (eg, ampicillin, gentamicin, ticarcillin/clavulanic acid,
ciprofloxacin, levofloxacin, ofloxacin)
• Alkalinizing agents (eg, potassium citrate, sodium bicarbonate): For uric
acid and cysteine calculi
• Corticosteroids (eg, prednisone, prednisolone)
• Calcium channel blockers (eg, nifedipine)
• Alpha blockers (eg, tamsulosin, terazosin)

10. Surgery
• Stones that are 7 mm and larger are unlikely to
pass spontaneously and require some type of
surgical procedure, such as the following:
Stent placement
Percutaneous nephrostomy
Extracorporeal shockwave lithotripsy(ESWL)
Ureteroscopy
Percutaneous nephrostolithotomy (PCNL)
Open nephrostomy

15. Ashmari- ayurvediya concept
1. तत्र संशोधनशीलस्यापथ्यकारिणः प्रकु पपतःश्लेष्मा
मूत्रसम्प्प्रुक्तोsनुप्रपिश्य बस्स्तमश्मिी जनयतत// (सु.तन.४)
2. पिशोषयेद् बस्स्तगतं सशुक्रं मूत्रं सपपत्तं पिनं कफ़ं िा/
यदा तदाsश्मयुुपजायते तु क्रमेण पपत्तेस्ष्िि िोचना गोः//
(च.चच.३६)
Due to improper purification of the body and by following the
Apathya, kapha dosha gets vitiated in the urine and reaches in
the basti to form ashmari.
According to charakacharya- the shukra dhatu in the basti gets
dried up along with Pitta or Kapha dosha by Vata forms
Ashmari like how Gorochana forms in Gallbladder of cow.

16. 1. एिमेि प्रिेशेन िातः पपत्तः कफ़ोsपप िा/ मुत्रयुक्त उपस्नेहात्
प्रपिश्य कु रुतेsश्मिीम्//
2. अप्सु स्िच्छास्िपप यथा तनपषक्तासु निे घटे/ कालान्तिेण
पंकः स्यादश्मिीसम्प्भिस्तथा//
3. संहन््यपो यथा ददव्या मारुतोsस्ननश्र्च िैद्युतः/ तव्दद्बलासं
बस्स्तस्थमूष्मा संहस्न्त सातनलः/
(सु.तन.२४-२६)
Vata-Pitta-kapha dosha enters into basti like how mutra enters
into basti from Pakwashaya and with Upasneha nyaya
Ashamari is formed in Basti.
When clear water is placed in a new mud pot, after sometimes
some particles precipitates into the water, similarly in the
basti ashmari develops- this explains the stagnation of the
urine in the bladder due to bladder outlet obstruction like
BPH etc can form calculus in the bladder.

17. • Third shloka explains the crystallization
process- when dry air along with the static
electricity in the clouds forms the crystalls of
water present in the cloud, similarly ashmari
develops.

20. Purvaroopa
तासां पूिुरुपाणण- बस्स्तपपडािोचकौ मुत्रक्रु च्छं
बस्स्तशशिोमुष्कशेफ़सां िेदना ज्ििः क्रु च्छािसादौ
बस्तगस्न्ध्िं मूत्रस्येतत //
Pain and discomfort in the bladder,
urethra,testicles/external genital organs.
Anorexia, dysuria, fever, debility, smell of goat’s urine.
Colour of urine appears like that of individual doshas
and pain accordingly.
urine appears non-clear, increased specific gravity.

21. Types
1. Kaphaja
2. Vataja
3. Pittaja
4. shukraja

22. Samanya lakshana
• Pain in the umbilicus,bladder, perineum, external
genitals eithr in any one of them while passing
urine.
• Obstruction to the urine stream
• Hematuria
• Urine appears clear as Gomeda or some crystals
can be seen in urine.
• Discomfort or pain while performing the activities
like running, swimming, hanging,
swimming,riding on back of horse,camel.

23. Vataja Ashmari
• Vata and kapha dosha after combining together
obstructs the urine and causes pain as a result
person bites his teeth, presses navel, external
genitals,anus and shouts due to pain.
• Has to pass urine after putting force.
• The ashmari formed is Shyava, hard, irregular,rough,
it contains thorny structures like of kadamba Pushpa.

24. Pittaja Ashmari
• Kapha dosha along with Pitta dosha attends
compactness and obstructs the urine and produces
discomfort like burning sensation in the basti-
medhra, feeling of hot air coming out of bladder.
• Ashmari appears like red,yellow, dark in colour and
appears like seed of Bhallataka

25. Kaphaja ashmari
• The Kapha dosha attends compactness and increases
in size and obstructs the urine and produces features
like tearing type of pain in bladder, heaviness in the
bladder and feeling of cold.
• Ashmari appears like hen’s egg, pale-white colour,
unctous to touch, large in size and like madhuka
flower.

26. Madhuka pushpa
kukkutanda

27. Shukrashmari
• Causes = shukraveghdharan or excessive
coitus.
• The vitiated vata causes vimargagaman of
shukra into medhra or vrushana and after
drying it up forms the shukrashmari.
• The resultant ashmari obstructs flow of urine
and causes dysuria, pain in bladder and
external genitals, oedema in legs.
• On pressing the ashmari it gets broken into
pieces easily.

28. Ashmari in children
• Due to kapha avastha more chances of
forming ashmari
• Occurs in those children who follows life style
and diet which increases and vitiates kapha
• Ashmari can be of any 3 doshas
• Due to thin bladder wall and under developing
basti, ashmari is small in size and can be easily
removed with instruments
• Due to non development of shukra dhatu,
there are no chances of forming shukrashmari

29. chikitsa
• Newly formed ashmari can be treated with
medicines
• Chronic- surgical removal

30. Medicinal treatment
• Vataja ashmari-
pashanbheda,vasuka,shatavari,gokshura,bhru
hati, kantakari etc drugs should be used in
form of kshaar, yavagu,kwatha,milk,food etc.
• Pittaja- kusha-kasha-sara-gundra-itkata-
morata(sugarcane root),pashanbhedh,vidaari-
varahkanda-
shaalimoola,gokshura,shyonaka,punarnava,shi
risha,lotus seed, evaru(cucumber) etc

31. • Kaphaja ashmari- varunadi
gana,guggulu,ela,kushtha,
devdaru,haridra,maricha,chitraka etc drugs in
form of kshar, peya,kshira,yavagu,kwatha.
• Kshara prepared from
tila,apamarga,kadali,palasha and yava kalka
with sheep’s urine prevents sharkara
formation

32. • Use of Ghrita, Kshara,kashaya, kshira and
Uttarbasti are advised.
• If no relief with above medications then
surgical extraction of calculus should be
performed.

33. Surgical extraction
• Purvakarma- consent from the king, snehan-
swedan-vaman-virechana, food should be
given to the patient.
• Mangala-swastik vachan
• Collection all required instruments and
medicines required during surgery

34. Pradhana karma
• This technique is Perineal Vesicolithotomy
• Position is lithotomy postion, head resting in lap
of attendant
• Sneh is applied on nabhi and pressure massaging
in done on left lateral region till ashmari decends
into Basti.
• Lubricated middle and index finger is inserted
into anal canal of the patient.
• Calculus is then pushed with those fingers in
upward direction towards in between guda and
external genital. Ashmari can be seen as nodule

35. • While performing this procedure if patient becomes
unconscious or goes into shock, in such condition
procedure should be hold and extraction shouldn’t
be done.
• Site of incision- vamaParshwa (left lateral) 1
yava(grain) distance from the sevani(perineal raphe).
Incision should be adequate to remove stone
• While extracting the calculus, it should be brought
out without crushing it. Otherwise it can cause
recurrence.
• Instrument used is अग्रिक्र आहािण यन्त्र (curved
forcep)

39. • In case of female – uterus should be
protected,incision shouldnot be too deep
otherwise it causes vrana through which urine
oozes out.
• Avoid damaging important structures like
mutravaha,shukravaha,mutrapraseka,sevani,y
oni,guda,basti.

40. • Damage to-
1. Mutravaha srotas and Basti-death due to
extavasation of urine
2. Shukravaha srotas-death or infertility
3. Mushkasrot- dhwajabhanga (erectile
dysfunction)
4. Mutraprasek- vesical fistula urine discharge
5. Sevni and yoni- severe pain
6. Guda and basti- death

41. Paschat karma
• Patient should be kept in hot water tub, this
prevents collection of blood in bladder.
• If blood gets collected in bladder then
Uttarbasti of kshirvruksha kwatha should be
administered, it removes the collected blood
out of bladder (bladder wash)
• For mutramargavishodhana – rice mixed with
jaggery should be given.
• After removing from tub, apply honey+ghrita
on the incision wound

42. • For diuresis- trunapanchamoola,gokshura etc
drugs in the form of yavagu is given 2-3 times a
day.
• For rakta-mutra shodhan and vrana kledanartha-
jaggery mixed milk along with cooked rice is given
in small quantity for 10 days.
• After 10 days- sour fruit like dadima and jangala
mamsa rasa is given.
• Carefully snehan and drava swedan is performed.
• Clean wound with kshiravruksha decoction.
• Apply lepa of
rodhra,madhuka,manjishtha,prapaundarika kalka

43. • If urine doesn’t come through its normal route
and comes out from incision site (vrana), then
it should be thermally cauterized ( agnikarma).
• After urine comes out via normal route,
uttarbasti, anuvasan and niruha basti are
given prepared from kakolyadi gana or
Kshiravrukshadi gana.

44. • Obstructed shukrashmari or sharkara should be
removed with badisha yantra
• Avoid coitus, horse-elephant-camel ride climbing
mountain, riding chariots, swimming, heavy to digest
food for 1 year after healing of the wound.