Mutra

Urine (mutra) is an essential metabolic waste product (mala). It excretes excess water (udaka), moisture (kleda) and other non-usable waste products from the body (SAT-B.460).

Etymology and derivation

Urine is known by the Sanskrit word ‘mutra’. It is derived from the word root “mutr-prasrave” that means to piss, to lose water etc. It is also known by the synonyms 'prasrava' and 'drava mala'.

Formation of urine

The waste products of digestion of food get diluted in water in the intestine. After absorption, products are circulated for filtration and metabolic transformation to form urine which goes through ureter to urinary bladder and then excreted through urethra.[Sha.Sa.Purva khanda 4] The urinary system consists of the kidneys, ureters, urinary bladder and urethra.

Normal composition of urine

The urine is composed of various nitrogen-based products formed during cellular metabolism and other electrolytes.

The properties and composition of urine is as described below.

Property and composition	Normal range in humans
Volume	0.8–2 L
pH	4.5–8.0
Specific gravity (SG)	1.002–1.030 g/ml (all)
Osmolality	150–1150 mOsm/kg (>1)
Urea (CH4N2O)	10–35 g/d (all)
Uric Acid (C5H4N4O3)	<750 mg/d (>16)
Creatinine (C4H7N3O)	Males: 955–2936 mg/d Females: 601–1689 mg/d (18–83)
Citrate (C6H5O73−)	221–1191 mg/d (20–40)
Sodium (Na+)	41–227 mmol/d (all)
Potassium (K+)	17–77 mmol/d (all)
Ammonium (NH4+)	15–56 mmol/d (18–77)
Calcium (Ca2+)	Males:<250 mg/d Females:<200 mg/d (18–77)
Magnesium (Mg2+)	51–269 mg/d (18–83)
Chloride (Cl−)	40–224 mmol/d (all)
Oxalate (C2O42−)	0.11–0.46 mmol/d (all)
Sulphate (SO42−)	7–47 mmol/d (all)
Phosphate (PO42−)	20–50 mmol/d (>18)

Quantity

The total quantity of mutra is four anjali (personified measurement unit). [Cha.Sa.Sharira Sthana 7/15] In normal human being, 800 ml to 2 litres of urine is excreted per day.

Functions

Urine carries following functions:

1.Separation and excretion of excess moisture from the body

2.Filling the urinary bladder or maintaining fluid volume in bladder.[Su. Sa. Sutra Sthana 15/5], [A.Hr. Sutra Sthana 11/5]

The overall function of urinary system is to filter approximately 200 liters of fluid a day from blood. It excretes toxins, metabolic waste products, and excess ions through urine.Essential substances in the blood are reabsorbed.Apart from this, plasma osmolarity and acid-base metabolism is regulated.

Channels carrying urine (mutravaha srotas)

The channels carrying urine originate from pelvic region including kidneys and the urinary bladder (basti and vankshana).[Cha.Sa.Vimana Sthana 5/8] It involves the urinary system.

Causes of vitiation

The channels carrying urine are affected due to following causes:

• Drinking water, eating food or coitus while having the urge of micturition

• Long time and frequent suppression of urge of micturition

• Especially in persons suffering from wasting and trauma.[Cha.Sa.Vimana Sthana5/20]

• Retention of urine is observed on suppression of urge to ejaculate [Cha.Sa.Sutra Sthana 7/10]

Etiology of dysuria (painful/difficult micturition)

• Excessive physical exertion

• Drugs having excessive sharp (tikshna) effect (adverse effects of toxic drugs)

• Un-unctous or excess dry food (that requires more fluid for digestion)

• Habitual intake of alcohol

• Riding on a fast-moving vehicle

• Excessive consumption of the meat of marshy animals and fish

• Intake of food before the previous meal is digested and chronic indigestion

These are causes of eight type of dysuria (mutrakricchra).[Cha.Sa.Chikitsa Sthana26/32-33]

=Abnormal states

The increase or decrease in quality and/or quantity of urine can lead to various abnormal conditions.

The states can be assessed by following clinical features.

Symptoms of decrease of urine(mutra kshaya)*	Symptoms of increase in urine(mutra vriddhi)**
Dysuria	Increased quantity of urine
Discoloration of urine	Increased frequency of micturition
Excessive thirst	Pain in lower abdomen (hypogastrium)
Dryness of mouth	Abdominal distension
Pain in lower abdomen	Not being satisfied on micturition (feeling of incomplete voiding) or urge of frequent micturition
Deceased frequency and amount of urine	--
Hematuria	--

• *[Cha Sa. Sutra Sthana 17/70], [Su. Sa. Sutra Sthana 15/11], [A. Hr. Sutra Sthana 11/22]

• **[Su. Sa. Sutra Sthana 15/15], [A. Hr. Sutra Sthana 11/13]

Clinical features of affected urinary system:

The symptoms of the affliction of channels carrying urine include excessive excretion, excessive obstruction or suppression of urine, vitiated, diminished or frequent voiding of thick urine with pain.[Cha.Sa.Vimana Sthana 5/8]

Clinical features of suppression of urge of micturition: Suppression of the urge of micturition causes pain in the bladder and phallus, dysuria, headache, bending of the body and distension of the lower abdomen.[Cha.Sa.Sutra Sthana7/6]

Urine Examination (mutra pareeksha)

Hippocrates (400 BC), in his text De Urinis Theophilus, mentioned the use of urine to interpret human body functioning, urine was mainly used as a means for prognosis and prediction of outcomes of illness. Theophilus (700 AD) treated uroscopy in a sophisticated objective manner, and contributed to the birth of medieval medical studies.

The routine urine examination (urinalysis) is a useful tool for determining the health status as well as many diseases especially related to urinary system.

The examination includes following:

a) Physical examination: in terms of volume, colour, appearance, odour, specific gravity.

b) Chemical examination: pH, sugar, protein, ketone bodies, bilirubin, urobilinogen, occult blood, nitrates, ascorbic acid

c) Microscopic examination: White blood cells, epithelial cell, red blood cells, casts, crystals, bacteria, yeasts, non-bacterial organisms.

d) Bacterial screening –Gram staining, colony count.

Ayurvedic perspective of urine examination

Ayurvedic text describe detailed methodology for collection, examination and interpretation of the results. This was used to diagnose the disease condition based on urine examination.Some of the practices, which are rarely practiced and seem obsolete, are given below. These can be researched further for better understanding of the pathological changes through urine examination.

Method of collection of samples:

The sample of first urine early in the morning shall be collected. While collecting, the first stream of urine should be discarded and collect the subsequent flow in a clean glass vessel.[Y. R. mutra pariksha /2-3]

Physical characters of urine and predominance of dosha

Dosha predominance	Characteristic features*
Vata	Pale white in color
Kapha	frothy
Pitta	Reddish in color
Sannipata	Bluish/blackish in color

• *[Y. R. mutra pariksha /4]

Method of examination of urine – oil-drop method (taila bindu pariksha)

Oil drop method was widely practiced for diagnosis and prognosis of disease conditions. Researches are being conducted to study application of this test in current times.The physician should drop one or two drops of sesame oil (tila taila) into the sample of urine collected.

Observations and interpretations

Changes in the character of urine	Shape of oil drop	Interpretation of dosha predominance
Bluish discoloration, free from oily appearance	Resembling snake (sarpa)	Vata
Yellowish and slightly reddish, looks like oil	Resembling umbrella(chhatra)	Pitta
Cloudy, oily, looks like puddle water	Resembling a pearl(mukta)	Kapha
Oily, hot, red color	resembling blood	Rakta

• [Y. R. mutra pariksha /8]

Disease wise interpretation*

Characteristic feature of urine Disease Resembles rice water Indigestion(ajeerna) Smoky appearance, excessive quantity Acute stage of fever Reddish yellow Chronic stage of fever Smoky, watery, hot Vata-pitta predominant fever More whitish, with bubbles Vata-kapha predominant fever Polluted appearance, mixed with blood Kapha-pitta predominant fever Mixed shades of different colors Sannipata type of fever

• [Y. R. mutra pariksha /9-10]

Prognosis

• Prognosis of disease as per mode of spread of oil in urine* Observation Interpretation Oil spreads quickly over the surface of urine The disease is curable/ manageable Oil does not spread Disease is difficult to be treated or cured Oil sinks and touches the bottom of the vessel Disease is incurable

• [Y. R. mutra pariksha /5-6]

• Prediction about good and bad prognosis of the disease as per direction of spread* Direction of spread of oil drop Prognosis East Patient get relief through proper treatment South Patient will suffer from fever and gradually recovers North Patient will be definitely cured and become healthy West Patent will attain happy and healthy life North –east(ishanya) Patient will die within a period of 1 month South-East (agneya)/ South-West (Nairutya )/ North-West(vayavya)/oil drop gets split Patient is bound to die

• [Y. R. mutra pariksha /11-17]

• Prognosis as per the shape of oil drop in urine* Good Prognosis Bad Prognosis Swan Tortoise Lotus Buffalo Elephant Honey-bee Umbrella Headless human body House Any instrument used in surgery Any part of body

• [Y. R. mutra pariksha /15-18]

Role of urine in etiopahogenesis and clinical features of diseases

• Suppression of urge of micturition is a causative factor for endogenous generalized edema (shopha)[Cha.Sa. Sutra Sthana 18/6], abdominal lump (gulma)[ Cha. Sa. Nidana Sthana 3/6], progressive wasting disease(shosha)[ Cha. Sa. Nidana Sthana 6/6]. • Suppression of the urge of micturition is one of six types of udavarta (disease due to reverse movement of vata) [ Cha. Sa. Sutra Sthana 20/ 3] • Obstinate Urinary Disorders including diabetes (prameha) is characterized by excessive quantity of urine with altered characteristics. Excess fluid content of the body (kleda), vitiated kapha and fat (medas) enter the kidney (vrikka) and urinary bladder (basti). These factors vitiate urine (mutra) and increase its turbidity and frequency. The different morbid conditions are named after characteristic changes in urine due to vitiated dosha. [Cha. Sa. Nidana Sthana 4/9] • Dysuria (mutrakrichchra) There are eight types of presentations of difficulty in micturition as per the causative factors. [ Cha. Sa. Nidana Sthana 4/33-44] Type Clinical Signs/ Symptoms Vata predominant Severe pain in groins, urinary bladder and genitals, increased frequency and scanty urine Pitta predominant Yellowish or reddish discoloration, haematuria with pain, burning sensation; urine passes frequently and with difficulty Kapha predominant Heaviness and oedema in urinary bladder and phallus, slimy urine Sannipatika (tridosha) type Mixed symptoms, difficult to cure Due to urinary calculus • pain in urinary bladder and perineum, phallus and hypogastric region • Urine is passed in divided streams • Because of pain; the patient squeezes the phallus and frequently voids stool and urine. • haematuria Due to gravels • the small fragments (gravels) get passed along with the urine Due to obstruction by semen • pain in the groin, urinary bladder, and phallus • swollen, stiff and intensely painful testicles Due to trauma (kshataja) • severe pain and heaviness in the region of bladder • distention of abdomen

Other urinary disorders (mutra dosha) [Cha. Sa. Siddhi Sthana 9/25-26] • Dense urine (mutraukasada) • Acute abdominal condition due to accumulation of urine in abdominal cavity (mutrajathara) • Dysuria (mutrakrichchra) • Residual urination (mutrotsanga) • Suppression of urine formation (mutrasamkshaya) • Delayed micturition (mutratita) • Hard globular swelling like tumor (vatashthila) • Vata influence on bladder(vatabasti) • Vata-pitta vitiation of urine/burning micturition (ushnavata) • Scanty and painful flow of urine (vatakundalika ) • Cyst at the neck of bladder (granthi) • Feces coming through urine (vid vighata) • Circular distension of bladder (bastikundala)

Above listed disorders are observed in current clinical practices.

Management of urinary disorders

Management of increased state

• Increased state of urine is treated by removing the cause by either cleansing (shodhana) procedures or medicines to facilitate the natural excretion. [Su. Sa. Sutra Sthana 15/17] • In diseases due to suppression of urge of micturition, the treatment includes fomentation, sitz bath, massage, administration of ghee in large doses in divided form before and after meals (avapeedaka sneha), three types of therapeutic enema (basti) with oil, decoction and instillation of medicine through urinary orifice(uttara basti) [Cha. Sa. Sutra Sthana 7/9]

Management of decreased state

• Consumption of substances having the nature of increasing or promoting the formation of sufficient quantity of urine. [Su. Sa. Sutra Sthana 15/11] • Sugar cane juice, varuni type of wine, thin gruel (manda), liquid food articles and substances having sweet (madhura), salty (lavana) and sour (amla) tastes and moist in nature are administered. [Cha. Sa. Sharira Sthana 6/11]

Treatment of dysuria (mutra krichra)

In all types of dysuria, vata pacifying therapies are administered at first and then other dosha are considered. [Cha. Sa. Chikitsa Sthana 26/58]. In case of dysuria caused by calculus, the measures for breaking and flushing out the calculus are administered. Surgical intervention is advised if medical treatment fails. [Cha. Sa. Chikitsa Sthana 26/59-68].

= Contraindicated diet and lifestyle

Lifestyle: Avoid exercise, suppression of natural urges, coitus , exposure to strong wind, strong rays of the Sun Diet: Avoid dry and ununctuous food, pastries, herbs like Phoenix dactylifera (kharjura), Feronia linonia (Linn.) (kapittha), Syzygium cumini(jambu), Nelumbo nucifera Gaertn (bis) and food with astringent taste. [Cha. Sa. Chikitsa Sthana 26/76]

Herbs acting on urinary disorders

• Saccharum Officinarum Linn.(ikshu) is considered as the best medicine for promoting the formation of urine. • Tribulus terrestris (gokshura) is considered as the best drug for treating dysuria. [Cha. Sa. Sutra Sthana 25/40] The group of drugs acting on urine as described in Charak Samhita [ Cha. Sa. Sutra Sthana 4/13-15] Action Medicines [latin name remaining] Anti-diuretics (mutra samgrahaniya) Syzygium cumini(jambu), Mangifera indica Linn.(amra), Ficus lacor Buch.(plaksha), Ficus benghalensis Linn.(vata), Albizzia lebbeck(kapitana), Ficus racemosa(udumbara), Ficus religiosa (ashwattha), Semecarpus anacardium (bhallataka), Bauhinia racemosa(ashmantaka), Acacia catechu Willd (somavalka) Urinary depigmenters (mutra virajaniya) Flowers of different kinds of water lilies and lotus like Nelumbo nucifera (padma), Nymphaea stellata Willd.(utpala), , Nymphaea pubescens (kumuda), White Ginger Lily (saugandhika) etc. Glycyrrhiza glabra Linn. (madhuka), Callicarpa macrophylla (priyangu) and Woodfordia fruticosa (L.) Kurz.(dhataki) Diuretics (mutrala) Roots of Dendrophthoe falcate Linn(vrukshadani), Tribulus terrestris (shwadanshtra), Indigofera enneaphylla Linn(vasuka), Gynandropis gynandra (vashira), Bergenia lingulata(pashanabheda), Desmostachya bipinnata (darbha & kusha), Saccharum spontaneum Linn(kasha), Saccharum sara(gundra),

The following groups of herbs (gana) are also used in treatment. • Veeratarvadi gana[ Su. Sa. Sutra Sthana 38/13] • Bruhatyadi gana[ Su. Sa. Sutra Sthana 38/32] • Ushakadi gana [ Su. Sa. Sutra Sthana 38/38] • Parushakadi gana [Su. Sa. Sutra Sthana 38/44] • Trunapanchamula [Su. Sa. Sutra Sthana 38/76]

Therapeutic use of urine

Urine is a product of animal origin (jangama dravya) used in therapeutics. [Cha. Sa. Sutra Sthana 1/68-69] Eight types of urines are described for medicinal uses such as: urine of ewe, she-goat, cow, she-buffalo, elephant, she-camel, mare and she-donkey. [Cha.Sa.Sutra Sthana 1/93] These are used in the preparation of evacuation enema(basti), purgatives(virechana), poultice (upanaha), affusion (parisheka) and in antidote (agada) preparations. It is indicated in afflictions such as retention of faeces, urine and flatulence (anaha), generalized enlargement of abdomen (udara roga), abdominal lumps (gulma), piles, dermatosis (kushtha) and leukoderma. [Cha. Sa. Sutra Sthana 1/95-96] Urines possess activity as digestive stimulants, antidotes to poison and vermicides. These are excellent in the treatment of anemia(pandu). [Cha. Sa. Sutra Sthana 1/97] Oral administration of urine pacifies kapha, regulates peristaltic movement of vata and evacuates morbid pitta through lower channels. [Cha. Sa.Sutra Sthana 1/98-99]

Current Researches

• Urine is a very useful and widely used bio fluid for research purpose in metabolomics. An online database containing the complete set of 2651 confirmed human urine metabolite species, their structures (3079 in total), concentrations, related literature references and links to their known disease associations are freely available now. • Now a days, artificial urine is prepared as similar to the chemical composition of human urine and has been used with many advantages for research and educational purpose. • In the field of research in Ayurveda, many studies are being conducted to standardize the techniques and various parameters of oil drop examination (Taila bindu pareeksha) of urine to extend it in terms of modern parameters and make use of it as a cost-effective method for diagnostic and prognostic aspects. • It is being studied and used in clinical practice in the prognostic aspects of various disorders including malignancy. • The mechanism of urine formation in the intestine and its connection with the renal system may provide substantial solutions in management of chronic kidney diseases. A recent experimental study conducted on rats with impaired renal function (induced by intragastric administration of adenine), has proven that intestinal tract had excretory function compensative for renal function. A study showed good improvement in microalbuminuria in diabetic patients after therapeutic enema (basti) with ayurvedic formulation of Tribulus terrestris (gokshura) and Borrhavia diffusa (punarnava). Another study showed significant improvement in cases of chronic renal failure. The relation of gut and kidneys can be explored more to find better management solutions for kidney diseases.

Related theses works

1. Sharma Anilkumar(2001): Role of imaging techniques in the diagnosis of Mootrashmari (urolithiasis) and Shikhadi compound it its management, Department of Shalyatantra, IPGT&RA, Jamnagar. 2. 9. Kulkarni N H(2002) : A clinical study on the role of Devdarvyadi Kashaya and Dashamoola-Siddha-Taila Uttara-Basti in the management of Mootraghata w.s.r. to BPH, Department of Shalyatantra, IPGT&RA, Jamnagar. 3. Malhotra Dheeraj (2003) : Clinical evaluation of Gokshuradi Kalpa and Yoga-Basti in the management of Mootraghata (w.s.r. to B.P.H.), Department of Shalyatantra, IPGT&RA, Jamnagar. 4. Chovatia Shailesha N(2004) : Role of Nagaradi Kashaya in the management of Mootrashmari (urolithiasis), Department of Shalyatantra, IPGT&RA, Jamnagar. 5. Chirag Goradiya (2006) :An applied aspect of Trimarmiya Adhyaou (Charak Chikitsa 26 and Siddhi 9) wsr to Mutraukasada, Department of Basic principles, IPGT &RA, Jamnagar. 6. Gauri Gole(2006) : To Study the Efficacy of Bimbimula Syrup in the Management of Shayyamutra Enuresis, Department of Kaumarabhrutya, IPGT&RA, Jamnagar. 7. Pragya Pushpanjali(2010): A Clinical Study on the Effect of Brahmi Vati in the management of Shayyamutra (Enuresis), Department of Kaumarabhrutya, IPGT&RA, Jamnagar. 8. Neha Anilkumar Parmar(2013) : A comparative experimental study to evaluate Mutrala (diuretic) activity of Bilvamoola and Patra(Aegle marmelos Corr.), Department of Dravyaguna, IPGT &RA, Jamnagar. 9. Sheetal Kumar Solanki(2013) : A Comparative Clinical Evaluation of Ashmarihara Kwaatha & Palaasha Kshaara in the management of Mootraashmari (Urolithiasis), Department of Shalyatantra, IPGT&RA, Jamnagar. 10. Gajiram D Banothe(2015) : A Clinical Evaluation Of Kanchanar Guggulu And Bala Tail Matra Basti In The Management Of Mootraghata W.S.R. To BPH, Department of Shalyatantra, IPGT&RA, Jamnagar. 11. Bibhu Sankar Das(2015) : A Further Study Of Ashmarihara Kwath & Palasha Kshara In The Management Of Mootrashmari W.S.R. To Urolithiasis, Department of Shalyatantra, IPGT&RA, Jamnagar. 12. Chauhan Priyanka (2016): Role Of Ashmarihara Kwatha & Varuna-Shigru Kwatha In Management Of Mootrashmari W.S.R. To Urolithiasis, Department of Shalyatantra, IPGT&RA, Jamnagar. 13. Jay Vikram Upadhyay(2017): A Clinical Study About Evaluation Of The Efficacy Of Varunadi Kvatha In The Management Of Mutrasmari (Urinary Calculus).,Department of Kayachikitsa, JSAM Nadiad 14. Monika N Solanki(2018) : Efficacy of Shayyamutrahara Yoga and Medhya Rasayana in the management of Shayyamutra (Enuresis) - an open labelled, randomized, clinical trial, Department of Kaumarabhrutya, IPGT&RA, Jamnagar. 15. Bhagirath Sankaliya(2018) : Effect of Ushiradya Taila Matra Basti and Kanchanar Guggulu in the management of Mootraghata wsr to (Benign Prostatic Hyperplasia) An Open Labeled, Randomized, Comparative Clinical Trial, Department of Shalyatantra, IPGT&RA, Jamnagar. 16. Chirag Vaghasiya(2018) : A clinicocomparative study on Kushmand beej taila Uttar-basti and Matra-basti in the management of Mootraghata w.s.r to Benign prostatic hyperplasia, Department of Shalyatantra, IPGT&RA, Jamnagar. Theses related to Taila Bindu Pareeksha 17. Gohil M. N. (1978) - Ayurveda mein vikritivigyan ka swaroopa (Mootrapareeksha Antargata) – Dept. Of Basic Principles, I.P.G.T&R.A, Jamnagar. 18. Sharma.C (1983)–Mootra ki Tailabindu Pareeksha – Dept. of Rognidana, NIA, Jaipur 19. Ranade Rekha A. (1994) –Mootra chi Tailabindu Pareeksha: Ek taulnikaabhyasa.- Dept of Rognidana, Tilak Ayurved Mahavidyalaya, Pune 20. Asati G. G. (1998) – Vyadhi-Gyanartha Mootra Pareeksha Tailabindu Pareeksha Upayogita–Ek Adhyayana, Dept of Rognidana, Govt. Ayurvedic College, Nagpur 21. Sharma Ritu (2009) – A Preliminary Standardization of Tailabindu Pariksha., Dept of Kayachikitsa, BHU, Varanasi. 22. Muhamed Nazir K. K. (2015) – A clinical study on Tailabindu Pareeksha in Madhumeha (DM) - Dept of Rognidana, SDM Ayu. College, Hassan. 23. Mahesh Hirulal (2015) – Utility of Tailabindu Pareeksha in critically ill patients (Atyayika Rogi) – Dept. of Rognidana, SDM, Udupi . 24. Neha Tiwari (2017) – Dashwida Pariksha and Tailabindu Pariksha to evaluate the proneness, Disease status and prognosis in patients of Madhumeha w.s.r to Diabetes Mellitus, Dept. of Rognidana, R.G.Govt Post Graduate Ayurvedic College, Paprola, H.P 25. Singh Sarita (2018) – Urine examination by Tailabindu pariksha of pre-diabetes and Diabetes Mellitus conditions - An observational study. Dept. of Rognidana, Pt. K. L. Sharma Govt. Ayurveda Institute, Bhopal.

References