Introduction

The Benign Prostatic Hyperplasia (BPH) is one of the commonest problems amongst obstructive uropathies affecting a large population of the elderly community (Abrams & Griffiths, 1979; Darson et al., 2017). Although this disorder is almost universal among aging men, its etiopathogenesis is poorly understood. Consequently, no constant, reliable medical therapy without complication is acceptable so far, and surgery is the only remedy with a lot of complication (Chopra, 1970). In ayurvedic system of medicine vatastheela, a types of mutraghata (obstructive urogpathies) closely resembles with Benign Prostatic Hyperplasia on the basis of clinical feature and is supposed to be a result of vitiation of Apana vayu (a type of vata dosha) and the Vasti Chikitsa is considered as the treatment par excellence for vatika disease (Chikitsasthana, 1979; Sutrasthana, 1984).

The present clinical study is a comprehensive evaluation of Vasti Chikitsa on Beingn Prostatic Hyperplasia by using the ultrasonographic technique and response of Vasti Chikitsa is assessed in terms of prostatic size (weight) along with the amount of residual urine before and after the treatment in addition to clinical observations and laboratory findings.

Materials and Methods

The present study was conducted on 75 patients of BPH, presenting with or without indwelling catheter along with different symptoms of prostatism, in the Department of Shalya-Shalakya, S.S. Hospital, BHU, Varanasi. The patients were selected by clinical examination of urine with culture study along with other investigations.

Grading of the enlargement of prostat

Grade I : Weight of prostate was upto 29 gms.

Grade II : Weight of prostate was in the range of 30-59 gms.

Grade III : Weight of prostate was in the range of 60-89 gms.

Grade IV : Weight of prostate was more than 90 gms.

Method of Treatment

The patients were treated with Ayurvedic modalities as following and results are assessed after 21 days of treatment.

Preparation of Patients

Shatasakara Churna or Triphala Churna3-6 gms HS for 3-5 days in normotensive and hypertensive patients, respectively before starting the therapy.

Samsodhana Chikitsa

• Abhyanga (massage) on the suprapubic and lumbosacral region with Narayana taila for 15-20 minutes daily before giving vasti.

• Nadi-Sweda (Steam fomentation) following Abhyanga on the same region with the stream of Dashmoola kwatha for 10-15 minutes before application of vasti.

• Vasti (Retention Enema)

• Anuvasana Vasti : Narayana taila (50 ml) on alternate days.

• Niruha Vasti : Narayana taila (20ml) + Dashmoola Kwatha (150 ml) on alternate days.

Samshamana Chikitsa

• Varuna Kwatha : 50 ml, twice daily orally.

• Sudha Kupeelu - 125 mg with honey followed by a cup of milk twice daily orally to normotensive patients.

Follow-up

All patients were asked to attend the hospital at monthly intervals initially and than at an interval of three months. Clinical examinations and laboratory investigations were performed during the follow-up period. During the follow-up period, patients were given Varuna-Kawtha 50 ml twice in a day. Follow-up assessment of patients was done from six months to two years and an even more.

Results and Discussion

To start with blood urea and serum creatinine level was normal in 53% and 87% cases, respectively. The per cent of patients having a normal level of urea and creatinine was increased to 76% and 93% after treatment, respectively. Similarity after treatment, the number of patients having albumin, pus cells, RBC crystals and epithelial cells were decreased. Before treatment, the bacteria was observed in 44% of patients, and after the treatment, the number of patients with bacteria was decreased to 7% only.

Ultrasonographic study

Changes in Weight of Prostate: The size of the prostate was determined, and weight was calculated. Comparative study of before treatment and after treatment value of prostatic weight revealed a reduction in size (weight) of the prostate after the therapy). The reduction in weight of the prostate was not uniform. In a few cases, an increase in weight was also observed. For the convenience of analysis, the changes in weight were assessed in three categories viz. significant reduction, insignificant reduction and increase in weight. After therapy, when the reduction in weight was more than 10 gms it was termed as Significant Reduction and when the reduction in weight was less than 10 gms, it was considered as Insignificant Reduction while increase in the weight of prostate irrespective of degree of advancement in weight, in few cases, were regarded as Increase in weight.

The number of patients having a significant, insignificant reduction and increase in weight varied from grade to grade (Table 1). After treatment, out of 75 patients, 70.67% of patients showed a significant reduction in weight of the prostate and in 12% patients there was an insignificant reduction of weight while in 17.33% patients weight was increased.

The differences between mean weight of prostate, before and after the treatment, were calculated in each category of each grade and then mean percentage of the significant reduction, insignificant reduction and increase in weight were calculated. Insignificant weight reduction category (>10gm) the mean percentage of reduction was maximum in 75% cases of grade II and was slightly higher than grade I (68.0%) and grade II (67%) (Table 2).

Changes in Residual Urine

The residual urine volume before after the treatment was estimated by ultrasonography. Before the treatment 8 (11%) patients were incapable of voiding the urine, the residual urine could not been estimated in these patients. Whereas, in (15%) patients, the residual urine, before and after the treatment was negligible. Thus, these patients were not included in the comparative study of residual urine. Effect of therapy on residual urine was variable in 46 (82%) patients, out of 56 of the residual urine was decreased while in 10 (18%) patients it was found also increased (Table 3).

After taking the difference between mean residual urine before and after the treatment, the mean percentage of changes in residual urine in each grade was calculated (Table 4). The maximum mean percentage of decrease was observed in 24 patients of grade II.

Objectively, results are assessed in terms of reduction in prostate weight (> 10 gm) only were regarded as Relieved while the patients having insignificant weight reduction and increase in weight were considered as Not Relieved while the patients having in significant weight reduction and increase in weight were considered as Not Relieved. Thus, the total number of relieved patients, out of 75 (100%) was 53 (69.33 %), and the non-relieved patients were 23 (30.66%), (Table 5).

In Ayurvedic system of medicine, Vasti Karma (retention enema) is the best and first line of treatment for Vatika disorders. Although the vasti medicaments may come out after some time of administration but its active components gests absorbed and circulated in the body through Srotas (Channels) with the help of apana, udana and vyana vayu in the same manner like the water sprinkled at the root of the tree reaches to all parts. So, per rectal administration, the medicaments are absorbed in the villi of the rectal mucosa and then through the external and internal haemorrhoidal vessels come into the systemic circulation.

Now it is well-established the fact that growth of the prostate gland is under the control of serum testosterone concentration (androgenic stimulation) (Thorpe & Neal, 2003). Moreover, reduction in prostatic size along with the regression of prostatic eipthelium has been reported after the treatment and Naferlin accetate, a LHRH against and androgen deprivation (Mcvary, 2011). So, it is possible that after administration of vasti (medicaments), the active components of vasti are absorbed and come into the systemic circulation and may have anti-androgenic activity so that no persistent androgenic stimulation is available to the prostate for its growth and consequently the prostate is regressed as evident from our observation of reduction in the size of prostate (Oelke et al., 2013).

The decrease in residual urine might be due to decrease in prostatic obstruction, but it is now established that the high residual urine volume is not caused by enlarged prostate itself, rather it is a sign of abnormality of bladder function. This view is consistent with that of Turner-Warwic et al. that residual urine is a sign of bladder failure, secondary to outlet obstruction leading to compensatory hypertrophy of detrusor muscle fibers of urinary bladder (Cindolo et al., 2014).

The decrease in residual urine volume by this unique ayurvedic therapy suggest revitalization of neuromuscular control of the urinary bladder. (Kumar, 1981) Probably, the application of vasti acts on urinary bladder wall and initiates the stretch reflex resulting in the contraction of hypertrophied muscle. On the other hand, the active components of medicaments are absorbed through rectal mucosa and might stimulate the sacral parasympathetic nerve endings to release more acetylcholine; by which sphincters get relaxed and smooth muscle of bladder contract with increased muscular tone and thus the amount of residual urine is reduced significantly (Gyaneshwar, 1991).

Besides the above, the oral medication used in this therapy also produces their effects on smooth muscle contraction. Kumar P et al. reported that Varuna is efficacious in neuro-muscular hypotonic and atonic conditions of the urinary bladder. Another drug, Shuddha kupilu churna is also a well-known convulsant in day-to-day practice and in therapeutic does it is used to improve the tonicity of smooth muscles including that of urinary bladder (Gupta, 1993; Kumar, 1981).

With the above consideration, it can be inferred that the employed non-surgical ayurvedic therapy-Vasti Karma is effective in the management of BPH as proved by a reduction in prostate size as well as a decrease in residual urine along with clinical improvement. Further scientific evaluations on this therapy are required to be carried out (Bhatt, 2003; Singh, 1997).

Conclusion

Basti therapy is useful in BPH with significant results, especially lateral lobe enlargement is more responsive without any adverse effect. This therapy needs to be evaluated on more recent parameters and on large sample size. Recently our department is the continuing effect of this treatment procedure on newer parameters like trans rectal ultrasonography, evaluation of hormones related to BPH and histology.