|Year : 2013 | Volume
| Issue : 4 | Page : 176-180
Experience with homoeopathy in a case of large urethral calculus
Soma Sharma1, Gyandas G Wadhwani2
1 Homoeopathic Practitioner, New Delhi, India
2 Chief Medical Officer (Homoeopathy), Directorate of ISM and Homoeopathy, Government of NCT of Delhi, India
|Date of Submission||15-Apr-2013|
|Date of Acceptance||28-Oct-2013|
|Date of Web Publication||26-Dec-2013|
Gyandas G Wadhwani
101, Sidhartha Enclave, New Delhi - 110 014
Source of Support: None, Conflict of Interest: None
Calculus in the male urethra is a rare clinical presentation and case reports of urethral calculi in the medical literature are likewise scant. We report a case of a 33-year-old male who presented at Delhi Govt Homoeopathic Dispensary at Aali Village with intense pain and scanty urination. Ultrasonography confirmed the diagnosis of urethral calculus in prostatic part of urethra. On the basis of keynotes, Lyssin prescribed in LM potencies improved urinary flow immediately and provided pain relief, which were objectively assessed as per pre-defined scales, and the 11 mm calculus was expelled in 8 days. No complication was observed during the following 6 months with after expulsion of a large calculus.
Keywords: Homoeopathy, Keynote prescribing, Lyssin, Urethral calculus
|How to cite this article:|
Sharma S, Wadhwani GG. Experience with homoeopathy in a case of large urethral calculus. Indian J Res Homoeopathy 2013;7:176-80
|How to cite this URL:|
Sharma S, Wadhwani GG. Experience with homoeopathy in a case of large urethral calculus. Indian J Res Homoeopathy [serial online] 2013 [cited 2019 Sep 24];7:176-80. Available from: http://www.ijrh.org/text.asp?2013/7/4/176/123377
| Introduction|| |
Urethral calculi are a rare occurrence in the industrialised world, accounting for 0.3-2% of all urinary tract stones. ,, Their occurrence is almost exclusively in men, in whom the urethra is longer and more tortuous (hence predisposed to stagnation and infection), although few cases in women and children have also been reported in literature. ,,, Urethral calculi are preponderantly found in the prostatic urethra just proximal to the narrow membranous portion. Primary urethral calculi can form in situ secondary to urethral pathology (viz. strictures, diverticula, foreign bodies). , The secondary urethral calculi originate from the kidneys or the bladder  and are more common. 
Most primary urethral calculi in the developed world contain Calcium oxalate or phosphate, have no nucleus and are of uniform structure. In developing countries, where bladder calculi are far more common, urethral stones are predominantly composed of struvite or uric acid. ,,
The clinical presentation includes irritative and obstructive urinary symptoms, as well as severe pain, which may be localised or referred to the perineum. In order to cause obstruction, the stones generally have to be larger than 1 cm in diameter.  The most common presentation of an impacted urethral calculus is acute urinary retention. , Failure to recognise and to remove an obstructing urethral stone can lead to a host of complications, such as post-obstructive renal failure, long-term urethral damage, urethrocutaneous fistulas, incontinence and impotence.  Investigations should include routine blood tests, urinalysis, urine culture and imaging studies - plain radiography, penile ultrasonography and computed tomography (CT) abdomen.
The objectives of treatment are to provide pain relief, relieve the urinary obstruction, expulsion/removal of stone without damaging the urethra and avoid any possible complication for which allopathic doctors often prescribe analgesics and anti-emetics. In larger calculi, Extracorporeal Shock Wave Lithotripsy (ESWL) and transurethral litholapaxy are treatments of choice.
There has not been any published case study or research paper on urethral calculus in homoeopathic literature so far.
A patient presented at Delhi Government primary health centre with clinical features suggestive of urolithiasis after undergoing conventional treatment without relief. He was advised to undergo sonography and prescribed the indicated homoeopathic remedy on the basis of keynotes as required. During first follow-up, 4 days later, he presented with sonography reports, which revealed a large uretheral calculus. The relief reported by the patient in obstructive and painful symptomatology and previously published case study  of expulsion of a large urinary calculi in homoeopathic journal helped in deciding to continue the treatment.
| Case Report|| |
A 33-year-old wheatish complexioned male of average height and built presented on 13 July 2012 at Delhi Government Homoeopathic Dispensary, Aali Village, with severe burning pain in urethral region since past 20 days.
The burning pain in urethra was present during micturition only. Along with this he also had progressively increasing scanty, frequent and ineffectual urination with constant urging to urinate along with increasing weakness over past 20 days. On the day of consultation, he reported that he had passed urine nearly 18-20 times with intense burning pain and passage of very few drops only. Analgesics and antibiotics taken so far had provided little relief. There was no past or family history of calculi.
Since childhood, he also had a tendency for sneezing and running nose with acrid nasal discharge and acrid lachrymation with every change of season. He normally recovered from these episodes without medication in about 3 days.
Measles: Early childhood.
Injury to left great toe in accident (for which he received 12 stitches): 4-5 years back.
Fracture of lower part of ulna: A year back.
Dog bite: About 5-7 times since childhood; no vaccination.
Married for 18 years; has two children.
Addictions/Habits: Smoking 1-2 cigarettes/day and alcohol consumption occasionally (1-2drinks in 1 or 2 months).
Education: Primary school.
Appetite: Three meals a day, has irregular meal timings (as he is a driver by profession), can tolerate hunger.
Thirst: 3-4 litres of water daily deliberately increased to 8 litres since past 15 days or so.
Desire: Extra salt in his food +++; spicy food (green chillies) ++; fish++; 7-8 cups of tea daily.
Perspiration: Profuse (even in air conditioner) more on face and neck, offensive.
Sleep: 8 hours, on back (mostly) or left lateral side; in absolute dark.
Thermal reaction: Hot +++; being in sun for long caused intense uneasiness with a desire to stay away from direct sunlight +++.
Life and Circumstances
He belonged to a poor family and has been working as a driver with a family since past 16 years. Apart from regular life problems and struggle he did not report any other major trouble. Being extremely fond of dogs, he played and fed street dogs and hence was bitten a few times.
| Methodology Followed for Outcome Assessment, Selection of Medicine and Dosage|| |
His primary complaints of pain and reduced urinary output were objectively followed up using the following scales:
Patient was asked to rate his severity of pain on the Numerical Rating Scale (NRS) [Figure 1]:
His urinary output was judged according to the following self designed Urinary Output Scale (UOS):
The most striking (characteristic) features of the case, apart from the pathognomonic features, were: Personal history of dog bite 6-7 times and intolerance of heat, especially sunlight, which are the keynote features of Lyssin. Since he also had a marked craving for salt, the rubric, "Stomach, desires, salt things", in Kent's Repertory was referred, which also revealed Lyssin in ++ grade.  Since Lyssin is not mentioned under the rubric for urethral calculi or colic in any repertory we referred the Materia Medica of Nosodes by H C Allen, which mentioned the following symptoms:
Urine scanty, no albumin (symptom no. 11).
Urging to urinate after a slight accumulation (symptom no. 13).
Tickling burning in urethra near orifice after urinating (symptom no. 15).
If he passes but a little quantity of urine his sense of weakness is increased; weakness after urinating as if he passed his strength away (symptom no. 19).
Appetite, Thirst, Desires, Aversions
Excessive desire for salt (symptom no. 15).
Temperature and Weather
Extreme sensibility to cold or least variation in temperature of air (symptom no. 11).
Unbearableness of heat of sun (symptom no. 12).
History of dog bite  (Dr. Lippe cured an important case guided by a symptom produced only from bites, Dr. Knerr made some provings, on a woman bitten by dog).
Since the pain was acute and demanded instant relief, the LM potency scale was selected about which Hahnemann has mentioned in Organon,  '…the preparations thus produced, I have found after many laborious experiments and counter-experiments, to be the most powerful and at the same time mildest in action, i.e., as the most perfected…'. He also explains further, '…Thus in chronic diseases, every correctly chosen homoeopathic medicine, even those whose action is of long duration, may be repeated daily for months with ever increasing success…'.
Frequent administration of divided doses is also mentioned by Hahnemann, 'Made in 40, 30, 20, 15 or 8 tablespoonfuls of water with the addition of some alcohol…solution of the medicinal globule (and it is rarely necessary to use more than one globule) or a thoroughly potentized medicine in a large quantity of water can be obviated by making a solution in only 7-8 tablespoonfuls of the water and after thorough succussion of the vial take from it 1 tablespoonful and put it in a glass of water (containing about 7-8 spoonfuls), this stirred thoroughly and then give a dose to the patient…'. 
As a keynote prescription the patient was given Lyssin LM1 (one globule was dissolved in 100 ml of water and 40 drops of alcohol were added, as directed in Organon of Medicine). The patient was directed to strike the bottle 10 times (holding bottle in dominating hand and striking it against palm of the other hand) and dissolve 1 teaspoonful (tsp) of the medicine in 4 tsp of water; from this mixture he was directed to take 1 tsp every 2-3 hours.
| Investigations|| |
He was advised to go for ultrasonography of lower abdomen, which revealed a large calculus of 8 mm in prostatic part of urethra [Figure 2].
| Follow Up|| |
17 July 2012
Urine flow markedly improved but pain persisted; no nausea or vomiting; water intake good; appetite good; no fever.
He was told to continue with the same medicine.
19 July 2012
Urine flow further improved; pain and discomfort decreased.
He was prescribed Lyssin LM 2; (prepared and administered as before).
21 July 2012
He reported that he has passed a stone in morning. When measured, it was found to be of 11 mm. No pain or discomfort; urine flow good [Figure 3].
Date-wise follow up of the patient as per NRS and UOS was [Table 1]:
The quick relief in pain and improved outflow of urine soon after the remedy was administered, bolstered our confidence in the choice of remedy, which led to complete recovery, that is the 11 mm stone (ultrasound mentioned 8 mm) was expelled within 8 days.
| Discussion|| |
For the homoeopathic physician, the remedy that matches the entire patho-bio-graphy of the person presenting with calculus not only relieves the spasm that occasions the pain but also has a tendency to prevent the formation of more stones. As James Tyler Kent advised, "You cannot promise there will be no more colic if you fit only the condition. So long as stones are there, they may be passed. The constitutional remedy is the best thing for the patient." 
The most commonly used homoeopathic repertory by James Tyler Kent mentions the following three rubrics for calculi: Urinary organs, bladder, calculi; urine, sediment, renal calculi and urine, sediment, sand, gravel (small calculi).  There is no specific mention of urethral calculus in this repertory. None of the other repertories available so far have any rubric for urethral calculus. The closest rubric found for this condition is generals, stones in organs, formation of, in "The Essential Synthesis". 
This case reiterates fundamental teaching of homoeopathy, 'prescribing for the patient, not his disease/diagnosis' as per the directions in 2 nd footnote to aphorism 81 in Organon of Medicine. 
Drawing an analogy between medicine and music, prescribing on the characteristics was termed by Henry Newell Guernsey, Adolph von Lippe, Henry Clay Allen, etc., as keynote prescribing. There is only one keynote to any piece of music, however, complicated, and that note governs all the others in the various parts, no matter how many variations, trills accompaniments, etc., In both the patient and remedy to be selected, there is and must be a peculiar combination of symptoms, a characteristic or keynote. Strike that and all the others are easily touched, attuned or sounded.  In this case we could verify the logic and practical application of this methodology.
Failure to grasp the true spirit behind the methodology, whose usage can be seen in the clinical cases of James Tyler Kent, though he cautioned against their misuse,  and dwindling study of homoeopathic philosophy and textbooks of Materia Medica has resulted in statements such as, "….Keynote prescribing as an empirical approach leading to cognitive bias in prescribing". 
The case was followed up for another 6 months to rule out any complication like urethral stricture due to passage of a large urethral calculus or relapse.
| Conclusion|| |
A rare clinical presentation of large urethral calculus, normally considered to be within the domain of surgery, was suitably managed with homoeopathic treatment alone without any relapse or complications. The indicated homoeopathic medicine, selected on the basis of keynote prescribing, provided immediate pain relief when analgesics had failed, restored urinary flow and helped in expulsion of 11 mm urethral calculus.
Keynote prescribing may appear novel, and even at first glance objectionable, prescription is based on a single symptom, but that is not what it is. The case reported here demonstrates this, and confirms the efficacy of keynote prescribing as a way to use Materia Medica guided by homoeopathic philosophy to add to our storehouse of evidence-based medicine, the need of the hour. 
| References|| |
|1.||Khai Linh VH, Segura JW. Chapter 84: Lower urinary tract calculi. In: Wein AJ, Kavoussi LR, Novick AC, et al. editors. Campbell's Urology. 9 th ed. St. Louis: Saunders Elsevier; 2007:2663-73. |
|2.||Gogus O, Isikay L, Yaman O, Sarica K, Bozlu M. An usually large anterior urethral stone. Br J Urol 1995;76:801-2. |
|3.||Verit A, Savas M, Ciftci H, Unal D, Yeni E, Kaya M. Outcomes of urethral calculi patients in an endemic region and an undiagnosed primary fossa navicularis calculus. Urol Res 2006;34:37-40. |
|4.||Hemal AK, Sharma SK. Male urethral calculi. Urol Int 1991;46:334-7. |
|5.||Durazi MH, Samiei MR. Ultrasonic fragmentation in the treatment of male urethral Calculi. Br J Urol 1988;62:443-4. |
|6.||Suzuki Y, Ishigooka M, Hayami S, Nakada T, Mitobe K. A case of primary giant calculus in female urethra. Int Urol Nephrol 1997;29:237-9. |
|7.||Thompson B, Hardwood Nuss AL. Urolithiasis in a child: An uncommon presentation of an uncommon disease. Ann Emerg Med 1995;25:837-40. |
|8.||Ginesin Y, Bolkier M, Nachmias J, Levin DR. Primary giant calculus in urethral diverticulum. Urol Int 1988;43:47-8. |
|9.||Kamal BA, Anikwe RM, Darawani H, Hashish M, Taha SA. Urethral calculi: Presentation and management. BJU Int 2004;93:549-52. |
|10.||Deodhar SD, Khope S. Giant prostatic urethral calculus. (A case report). J Postgrad Med 1983;29:49-50. |
|11.||Kaplan M, Atakan IH, Kaya E, Aktoz T, Inci O. Giant prostatic urethral calculus associated with urethrocutaneous fistula. Int J Urol 2006;13:643-4. |
|12.||Gupta AK, Gupta J, Siddiqui VA, Mishra A. A big urinary calculus expelled with homoeopathic medicine. IJRH 2008;2:50-5. |
|13.||Schmidt P. 'Kent's Final General Repertory of the Homoeopathic Materia Medica', published by National Homoeopathic Pharmacy, 2 nd ed. New Delhi; 1982. p. 486, 645 and 691. |
|14.||Allen HC. Materia Medica of the Nosodes with provings of the X-Ray, B. Reprint edition. New Delhi: Jain publishers (P) Ltd; 1998. p. 143, 171, 176 and 200. |
|15.||Hahnemann S. Organon of medicine, 5 th and 6 th ed. Delhi: B Jain Publishers (P) Ltd; 2009. p. 72; §248 and its footnote, pp. 127; footnote 7 to §270, pp. 137. |
|16.||Available from: http://www.homeoint.org/books3/kentwrit/writ28.htm [Last accessed on 2012 Dec 1]. |
|17.||Schroyens F. The essential synthesis. London: Homoeopathic Book publishers; 2007. p. 1942. |
|18.||Close S. The genius of h omoeopathy, Ch XI. Symptomatology. New Delhi: Pratap Medical Publishers Pvt Ltd. p. 160. |
|19.||Kent JT. The basis of future observations in the materia medica, or how to study the materia medica. J Homoeopath 1899;2:444f. |
|20.||Souter K. Heuristics and bias in homeopathy. Homeopathy 2006;95:237-44. |
|21.||Wadhwani GG. A case of parkinson-plus syndrome resolved using the 'lost art' of keynote prescribing. AJHM Summer 2012;105:70-5. |
[Figure 1], [Figure 2], [Figure 3]