Uttarbasti in Various Gynecological Disorders

Uttarbasti is an essential and unique Ayurvedic procedure, which is descriptively defined in Ayurvedic classics. Uttarbasti is mentioned for the Genitourinary problems for both males and females. The manner was selected as a method of drug administration in case of infertility due to the tubal aspect of the present study. Hence, its elaborative classical description alongside with interpretation of present-day tools is related to Uttarbasti is described here.

There are two routes for the administration of Basti described in classics, viz. Basti (through anal canal) & Uttara Basti (through urogenital tract). The Basti Yantra is also used to inject medicines through the urinary and vaginal passage, for which the term Uttara Basti is given. The Uttara Basti deals with both males and females. But the following discussion is carried out taking females in view only, as required here.

CLASSICAL UTTARBASTI:

Uttarbasti as a Vishesa Chikitsa:

विधिमुत्तरबस्त्यन्तंकुर्यादार्तवशुद्धये ||

Acharya Sushruta has mentioned that after applying five Shodhana Karma, Uttara Basti should be given repeatedly for Artava Shuddhi. Acharya Charaka has also advised in Siddhisthana: ‘The woman, who is not able to conceive (due to Vata Dosha) should be treated by Basti because Basti is the best Chikitsa for this type of woman’

Definition:

There are three reasons behind this terminology –

• It is administered after Niruhabasti (Niruhat Uttarena)
• Niruhat Uttaro Yasmat Tasmat Uttarsamgyakah)
• It is administered in the superior organ (upper passage)
• Uttarena Va Margena Deeyat),(Uttarmarga deeyamantaya)
• It is superior as it does Snehanam like Anuvasanabasti and Shodhana like Niruhabasti. (Shreshtthagunatva)

Indications of Uttarbasti

• For conception (GarbhamYonih Tada)
• To pacify Vata (JiteVayuh)
• For urinary bladder disease (Bastijeshu Vikareshu)
• Diseases caused by prolapse (Yonivibhramshajeshu Cha)
• Severe Pelvic pain (Yonishuleshu Tivreshu)
• Gynecological disorders (Yonivyapada, Yonivyadhim)
• Menometrorrhagia (Asrigdara)
• Retention of urine (AprasravatiMutre, Mutraghata)
• Incontinence of urine (BindumBindumSravatyapi)
• Menstrual disorders (DushtamShonitam)
• Menorrhagia (Pushpodrekam)
• Pathological amenorrhoea(TasyaNasham)
• Dysmenorrhoea (Kashtam)
• Urinary diseases (Mutradosham)
• Retention of the placenta (SamsathatimApara)
• Urinary calculi (SharkaraAshamarim Cha)
• Groin pain (Vamkshana Shula)
• For all reproductive tract disorders (RogeshuNarinam Yoni Garbhashayeshu Cha)

Contraindications –

• Not described in classics
• The only contraindication given in classics is the genital tract in girls (Balanam Apatya Marge Na Diyat Iva

Time of administration

Uttarabasti should be given in Ritukala (just after a menstrual period) after purifying the body with two or three Asthapana Basti because Garbhashaya (Garbhashaiya or Yoni)[xiv] is prepared to soak up Sneha this time. Acharya Charaka & Vagbhata have given very correct rationalization for the choice of appropriate time by saying that all through menstruation, vaginal and uterine orifices open (Apaavrita yoni), so medicine is taken in a higher way.

Dose

Dose of Snehana type of Uttarabasti[xv][xvi]

Acharya Sushruta has given the quantity of Snehana (oleaginous) type of Uttarabasti for the urinary tract as one Prasrita (palm of an outstretched hand and hollowed it as to hold liquid, stuffed up to the Svangulimula i.e., the base of fingers). For cleansing (Vishodhana) of the uterus, it is doubled i.e., two Prasrita. Acharya has given this dose for extreme illness and strong patients (Paramvarga) and has left the decision of fixing individual doses on the knowledge of Shalya Chikitsaka (BuddhiVikalpitam). While commenting on the same, Acharya Dalhana again clarifies that the volume can also be half or less (as decided by the physician at his discretion), depending on the strength of the disease or the capacity of the patient. Acharya Chakrapani has followed Sushruta and repeated the same.¹²

Acharya Sharangadhara[xviii] and Bhava Mishra[xix] have considered this dose as:

• In adult women: two Pala (96 ml) in the genital tract & one Pala (48 ml) in the urinary tract
• In premature girls: two Karsha (24 ml)

Acharya Vagbhata has mentioned it as:

• For adult women: one Prakumcha (Pala=48gms)
• For girls: 1 Shukti (24 gms)

The aforementioned Matra is Madhyama as per Acharya Vagbhata. It should be increased gradually by half & one Karsha in the second & third Uttarabasti respectively.

• Dose for Niruha Uttarbasti

If cleansing is needed by Uttarabasti:

• For the genital tract reproductive age group of women (Nullipara or parous) – 2 Prasrita
• For a urinary tract of reproductive age and girls of less than 12 years – 1 Prasrita

Duration: 

At night, a total of 2, 3, or 4 Basti should be given and the procedure should be continued for three nights gradual increase in the quantity of oleaginous substance.

Interval

After giving rest for 3 days (Trayahmeva Cha Vishramya), the procedure was repeated for another 3 days.

• Method of Uttarbasti

Yantra (Instruments): Pushpanetra & Bastiputaka

• Pushpa Netra:

The Netra or nozzle of Uttarbasti is termed as Pushpanetra;

In a nutshell, the parameters of Pushpanetra can be summarized as follows:

• Should be made of silver, gold, brass, bell metal, tin, or lead
• It must be smooth, tapering like a cow’s tail

Age	Passage	Length	Circumference of nozzle	Size of lumen
Girl	Urinary	10 fingers	The flower stalk of Malati	Size of a mustard seed
Adult women	Urinary	10 fingers	Size of the urethral meatus	Size of Mudga seed
Adult women	Vaginal	10 fingers	Index finger	Size of Mudga seed

Uttarbasti Putaka

• Not mentioned specifically in classics

• Can be made on the same pattern as mentioned for Guda (anal) Basti, but smaller in dose /quantum.Uttarbasti putaka should be made from a soft material, like the skin of an animal, and in case they are unavailable skin of birds, one-fourth portion of a leather bag or any other soft leather can be used.
• Position (Sthiti)

The woman should be placed in a supine position with flexed thighs and elevated knees (Uttanaya Shayanaya Samyak Samkochya Sakthini UrdhvajanveStriyeDadyatUttanaye

• Procedure (Vidhi)

The nozzle should be inserted in the urinary or vaginal passage slowly with steady hands, following the direction of passage.

• Pratyavartana (Returning)
• Pratyavartana of Snehana is considered essential for Uttarabasti.
• Acharya Charaka has mentioned the administration of PippalyadiVarti (suppositories) if Basti does not return.[xxxiv]
• Acharya Dalhana has given a very specific description of the Pratyavartana of Sneha. These measures are –Yoni Varti, GudaVarti, Sphika – Tadana & Eshana etc.[xxxv]

UTTARBASTI IN PRACTICE

Nowadays, Uttarabasti referred to as classic is being practiced after making several modifications. Everything has been extensively modified from its indications to contraindications, instruments to the method and only Snehana type of Uttarabasti is in practice.

• Method
• Poorva Karma
• The patient is asked to evacuate the bladder & rectum.
• Yoni Prakshalana – by some Kwatha of antiseptic property
• Snehana (Abhyanga) of the local abdomen, back, thigh, and legs
• Svedana especially Nadi Sveda on the back and lower abdomen
  
  Pradhana Karma

The instruments used for the Uttarabasti are Posterior Vaginal Speculum, Anterior Vaginal Wall retractor, Allis’ forceps & Uttarabasti cannula fitted with a disposable syringe. Uttarbasti is done under perfect aseptic precautions. It can be given intravaginally or intrauterine. In Intrauterine Uttarbasti– The genital parts are prepared and the medicine should be autoclaved or heated and cooled at room temperature. The drug can be instilled when slightly warm but not beyond 95°F.

The routine disposable syringe is used and not more than 5 cc of medicine (usually Snehadravya) is used in one sitting. Rubin’s cannula, Uttarbasti canula, IUI canula, or butterfly needle with the needle cut off and only the tube is used. The patient is taken in a dorsal lithotomy position, and cleaned with the antiseptic solution. Expose the cervix by instruments (By Speculum). Before inserting the medicine, one should ensure that there are no air bubbles in the syringe or the tube, and then the medicated oil is gradually pushed in, while the anterior lip of the cervix is held with Allis’ forceps and the patient is kept in head low position.

Once the speculum is withdrawn the patient may be asked to lie in the left lateral position for 15-20 mins and then shifted toward. The patient is kept in a head-low position for at least 2 hours for better absorption of the drug from the vagina and to prevent any vasovagal shock.

• Pashchata Karma
• Complete rest in head low position for at least 2 hours.
• Abdominal hot fomentation with hot water bag.
• Light diet.

• Indications

• Yoni Shula
• UdavartaYonivyapada
• Rajodosha
• Asrigdara
• Vandhyatwa
• Artavadosha
• Premature ovarian failure
• Yonivyapada
• Tubal Block
• Gulma
• Granthi, Arbuda

2.3. Contraindications

Contraindications being considered these days can be divided into two categories –

• Absolute contraindications: Pregnancy and in-situ contraceptive device
• Relative contraindications: vaginitis, cervicitis, endometritis, endometriosis, and carcinoma.

2.4. Period of Uttarabasti

The best period is from the 6th to 12th day post menstruation, as it will lead to a well-formed Bija and facilitate conception.

PROBABLE MODE OF ACTION OF UTTAR BASTI

The mode of action of Uttarabasti lies not only in the Pradhana Karma but also in its Poorva Karma-

• Mode of action of Poorva Karma in Uttar Basti:
• Though, in classics have not specifically emphasized much upon Snehana and Svedana before Uttarbasti, but this method looks to be genuine and appropriate.
• Uttarbasti deals generally with the Apana Vayu, as the close by situated organs are its seat. Snehana and Swedana before Utttarbasti do its Anulomana and thus, Uttarbasti becomes more efficacious.
• Besides this, chances of any type of complication are also less, if Vatanulomana is done before the procedure.
• Besides, Snehana and Swedana (just before Uttarabasti) relax the abdominal muscles. Good relaxation is very important for Uttarbasti, so that uterus does not get irritated by the instillation of medicine from outside. If it is not relaxed adequately, it may contract at once and may not retain any of the medicine.
• Snehana and Svedana (before Uttarbasti) also lessen the ache all through and after the procedure.
• Yoni Prakshalana carried out before Uttarabasti with Kwatha of antiseptic property nullifies the possibility of any kind of infection as a complication.

Mode of action of Pradhana Karma in Uttarabasti:

The mode of action of Uttarabasti can be understood in two ways –

• Local effect of Uttarbasti
• The effect of Uttaabasti will depend on various things; like method, instrument, drug used etc. If the medicine is put in the cervical canal, it may act more on the cervical factors. For the factors like cervical stenosis, a Katu – Ushna Taila based medication is more useful, while for increasing the secretion of mucous from cervical glands, a nutritive like Madhura-Sheeta Ghrita-based medicine will be more efficacious.
• In the same way, drug selection for ovulatory and tubal factors will be different from each other. On the ovary, the effect of the drug will be after absorption and then by promoting the Hypothalamo-Pituitary-Ovarian axis, while in the tubal block, Uttarabasti acts locally. In ovulation, a drug with Snehana property can be good while for tubal block, a drug with Lekhana Karma will be better.
•  The advantage of intrauterine instillation of oil is proved in modern science also as it is said that approximately 30% of the patients who have normal hysterosalpingography, conceive over the following 6 months and it is thought to be a characteristic of only oil-based contrast medium.
• Apart from this, Uttarabasti may also stimulate certain receptors in the endometrium, leading to the correction of all the physiological processes of the reproductive system. It may also help in the rejuvenation of endometrium.

Thus, the mode of action of Uttarbasti can be understood in the following ways –

• Intravaginal Uttarbasti helps in removing infections. (If given with antiseptic drugs)
• Intra-vaginal Uttarabasti may also facilitate the absorption of the drug, as the posterior fornix has a very rich blood supply and it may also act as a reservoir of the drug (when the patient is lying down in head low position after Uttarabasti).
• Intra-cervical Uttarbasti with oil-based drug helps to remove cervical stenosis and restore the function of the cervix in conception and helps to treat dysmenorrhoea caused by stenosis.
• In cervical Uttarbasti Bhrimhana drugs may stimulate the secretion of cervical mucous leading to an ascent of sperms in the uterine cavity.
• Intrauterine Uttarbasti with Ghrita-based Snehana & Brimhana drugs helps in the rejuvenation of endometrium, especially where apart from regular ovulation, poor endometrium is causing infertility or scanty menstruation.
• In cases of menorrhagia due to endometrial hyperplasia, intra-uterine Uttarabasti with Lekhana Dravyas may help.
• For tubal factors of infertility, a high intra-uterine Uttarabasti with Lekhana & Ropana Dravyas acts in two ways. Lekhana Dravyas removes the blockage of the tubal lumen by directly acting on obstruction mechanically and Ropana Dravyas restores the normal function of tubal cilia by stimulating it. As endometrial covering is continuous in the tubes too, its scraping and regeneration also leads to normalization of tubal functions.
• Systemic effect of Uttarbasti after absorption: –
• Ayurveda had a very clear approach between oral and parenteral routes of drug administration from the very beginning. Thus, Acharyas have described the administration of drugs from almost all the open organs and have considered the Basti (rectal administration) the most efficacious.
• On the same pattern, Uttarbasti can also act after getting absorbed from rich blood circulation of uterus and posterior fornix. Then, it may act on whole body system and can act as a parenteral route.
• The systemic effect of Uttarbasti can also be understood with the help of the system biology concept. System biology is the latest concept emerging and getting accepted in modern science. This concept believes in a holistic approach similar to as advocated in Ayurveda from the very beginning. It considers the need for a standard shift of modern science from reductionist to holistic. It believes that all bodily systems and organs are interconnected at the molecular level. This concept is the first step of modern science towards the concept of Mahabhuta and Tridosha. Ayurveda also considers whole the body as one unit on the Mahabhautic level. Still, Tridosha and Mahabhuta are something broader, but more abstract than molecules, which will be explored in modern science too in the coming future. It is now clear that ‘whatever may the effect Uttarbasti drugs have on the physiology of the reproductive system, it will involve the physiological functions and corrections of other systems.
• Thus, Uttarbasti can be taken as a parenteral route of administration for reproductive diseases, as it can act, locally as well as systemically.

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References

1. Prof. P. V. Tiwari, AyurvediyaPrasuti-Tantra&Stri-Roga, Vol. 2, 2nd edition, ChaukhambaOrientalia, Varanasi, Reprint 2016, Pg 479
2. Vaidya JadavjiTrikamji Acharya editor- SushrutaSamhita with the Nibandhasangraha Commentary of Sri Dalhanacharya, Chaukhambha Sanskrit Sansthan Varanasi, Reprint 2013, Sharirsthana 2/12, pg-345
3. Vaidya YadavjiTrikamji  Acharya editor-CharakaSamhita of Agnivesha with Ayurvedadeepikavyakhya by Chakrapanidatta, ed. ChaukhambhaSurbharatiPrakashan, Varanasi, 2019, Siddhi sthana, 1/34, pg-683
4. Dr. Shivprasad Sharma editor-Astangasamgraha of Vagbhat or VrddhaVagbhat with Sashilekha Sanskrit Commentary by Indu, Prologue by Prof. JyotirMitra, Chaukhamba Sanskrit Series Office, Varanasi, 2016, Sutrasthana 28/10, pg-213
5. Pandit Sri Bramha Shankar Mishra, Bhavaprakasha, ‘Vidyotini’ commentary, Vol-1, Chaukhamba Sanskrit Bhavan, edition 12^th, Reprint 2016, Purvakhanda, Panchakarmavidhi 5/172, pg-1026
6. Ibid-4, A. S. Su. 28/10, pg-213
7. Ibid-3, Ch. Si. 9/50, pg-720
8. Ibid-3, Ch. Si. 9/62-64, pg-720-721
9. Ibid-2, Su. Chi. 37/125 – 126, pg-539
10. Ibid-4, A. S. Su. 28/55, pg-221
11. Ibid-3Ch. Si. 9/66, pg-721
12. Ibid-4, A. S. Su. 28/58, pg-222
13. Ibid-2, Su. Chi. 37/116, pg-538
14. Ibid-4, A. S. Su. 28/59, pg-222
15. Alper M M, Gareus P R, Spence J E, Quaringtom A M, Pregnancy rate after HSG in oil and water-based contrast media, ObstetGynael, 1986, 68: 6 -9
16. System Biology, The Wikipedia, the free encyclopedia, www.systems.biology.org (cited on date 2/3/2013)

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