ACKNOWLEDGEMENT

I would like to express my sincere and heartfelt thanks to my respected teacher and guide, Dr.T.Abdu Rahiman, Principal Government Homoeopathic Medical College, Calicut for the valuable guidance and encouragement given to me throughout my postgraduate course and necessary direction in the preparation of this thesis.

I am grateful to Dr.Sreedharan Unni.T.M.B.B.S, M.S, Mch, Malabar Hospital and urology centre, Calicut, for his valuable suggestions in the conduction of this study particularly regarding diagnosis and follow up.

I sincerely thank P.I.Narayan, Professor(Retd), Department of Biochemistry, Medical College, Kozhikode, for his valuable guidance and suggestion in the analysis of this work..

I extend my gratitude to Dr. Annie Pushpam, H.O.D. of Pathology,G.H.M.C, Calicut, for giving me permission to conduct urine culture in the pathology lab.

I acknowledge my sincere thanks to the staff in clinical laboratory and to other staff members of the college and hospital.

I owe my unlimited indebt ness to all the patients involved in the study for without whose cooperation, this study would not have been possible.

I extend my thanks to Padmakumar, Anish & Dr.Sanilkumar, whose cooperation and timely help eased my work.

Finally to my husband Dr. Riyas.Y, who helped me in my study and gave necessary encouragement and help throughout the preparation of this research.

ABSTRACT

Twenty cases of cystitis, in female patients under the age group 15-50 years were included in the study. Statistical evaluation of pre and post treatment scores showed that the Homoeopathic medicines prescribed according to the individual peculiarities of the patient was found to be more effective in the treatment of cystitis. 

CONTENTS

  LIST OF TABLES 

 LIST OF FIGURES

Homoeopathy differs with regular medicine in its interpretation and application of several fundamental principles of science. It is these differences of interpretation and the practice growing out of them which gave homoeopathy its individuality and continues its existence as a distinct school of medicine¹.

          Disease is always primarily a morbid dynamical or functional disturbance of the vital principle; and upon this is reared the entire edifice of therapeutic medication governed by the law of similia as a selective principle.¹

Cystitis is the most common urinary tract infection among women during the reproductive years². The vast majority of acute symptomatic involve young women. It was reported that an annual incidence of 0.5 – 0.7 infections per year occur in this group³.  Cystitis is common among women between 20 and 50 years of age⁴.

          Cystitis in adult women is of concern mainly because they cause discomfort, minor morbidity, time lost from work and substantial health care cost³.

          Because of the risk of the infection spreading to the kidneys (complicated UTI) and due to the high complication rate in the elderly population, prompt treatment is almost always recommended⁵.

          Since homoeopathic treatment has found to be effective in managing cystitis cases, and a scientific study on this subject is not known to be conducted, an attempt is made to evaluate the effectiveness of homoeopathic medicines with appropriate statistical analysis. Analysis is based on Paired  t test with the level of significance, P<.01 0r P <.05. The method of approach is a clinical study without the use of control.

AIM AND OBJECTIVE OF THE STUDY

          To assess the efficacy of homoeopathic treatment in the management of cystitis affecting females of the age group 15 – 50 years.

          Cystitis is an infection of the bladder, but the term is often used indiscriminately and covers a range of infections and irritations in the lower urinary system⁹.

3.1. ANATOMY OF URINARY ORGANS

The urinary organs comprise the kidneys, which secrete the urine, the ureters, or ducts which convey urine to the urinary bladder, where it is for a time retained, and the urethra through which it is discharged from the body⁶.

Kidney:

The kidneys are situated in the posterior part of the abdomen one on either side of the vertebral column, behind the peritoneum, and surrounded by a mass of fat and loose areolar tissue⁶.

Structure:

The kidney is invested by a fibrous tunic, which forms a smooth, firm covering to the organ. Beneath this coat, a thin wide-meshed network of unstirred muscular fiber forms an incomplete covering. If a vertical section of the kidney is made from a convex to its concave border, it will be seen that the hilum expands into a central cavity, the renal sinus. This contains the upper part of the renal pelvis and the calyces, surrounded by some fat in which are embedded the branches of the renal vessels and nerves. The renal calyces forms seven to thirteen in number are cup-shaped tubes, each of which embraces one or more of the renal papillae- they unite to form two or three short tubes, and these in turn join to form a funnel shaped sac, the renal pelvis. The renal pelvis, wide above and narrow below where it joins the ureter, is partly outside the renal sinus. The renal calyces and pelvis form the upper expanded end of the excretory duct of the kidney⁶.

The ureters:-

The ureters are the two tubes which convey the urine from the kidneys to the urinary bladder. The ureter proper measures 25 to 30 cm in length, and is a thick walled narrow cylindrical tube which is directly continuous near the lower end of kidney with the tapering extremity of the renal pelvis. It runs downwards medial-ward in front of the psoas major and entering the pelvic cavity finally opens into the fundus of the bladder, at the lateral angles of the trigone. When the bladder is distended the openings of the ureters are about 5 cm apart, but when it is empty and contracted, the distance between them is diminished by one half. Owing to their oblique course through the coats of the bladder, the upper and lower walls of the terminal portions of the ureters become closely applied to each other when the viscous is distended, and acting as valve, prevent regurgitation of urine from the bladder⁶.

              In female, the ureter forms as it lies in relation to the wall of the pelvis the posterior boundary of a shallow depression named the ovarian fossa, in which the ovary is situated. It then runs medial-ward and forward on the lateral aspect of the cervix uteri and upper part of the vagina to reach the fundus of the bladder. In this part of its course, it is accompanied for about 2.5cm by the uterine artery, which then crosses in front of the ureter and ascends between the two layers of the broad ligament. The ureter is distant about 2 cm from the side of the cervix of the uterus⁶.

Urinary bladder:-

              The urinary bladder is a musculo-membranous sac as a reservoir for the urine⁶. In the adult, the empty bladder lies in the pelvic minor, posterior to the pubic bones, from which it is separated by the retro-pubic space. An empty bladder lies almost entirely in the pelvis. It is located in the antero-inferior part of the pelvis minor, inferior to the peritoneum. It rests on the pelvic floor posterior to the symphysis pubis, as it fills it ascends into the abdomen. A full bladder may reach the level of the umbilicus⁷.

The female bladder:-

              In the female, the bladder is in relation behind with the uterus and the upper part of the vagina. It is separated from the anterior surface of the body of the uterus by the vesico-uterine excavation, but below the level of this excavation it is connected to the front of the cervix uteri and the upper part of the anterior wall of the vagina by areolar tissue. When the bladder is empty, the uterus rests upon its superior surface. The female bladder is said by some to be more capacious than that of the male, but probably the opposite is the case⁶.

Structure of the urinary bladder:-

              The wall of the bladder is composed chiefly of smooth muscles, called detrusor muscle. It consists of three layers running in many directions. These are external and internal layers of longitudinal fibers and a middle layer of circular fibers. Towards the neck of the bladder, these muscle fibers form the involuntary internal sphincter of the urinary bladder. Some of these fibers run radially and assist in the opening of the internal urethral orifice⁷.

Interior of the bladder:-

              The mucus membrane lining the bladder is over the greater part of the viscous, loosely attached to the muscular coat and appears wrinkled or folded when the bladder is contracted in the distended condition of the bladder, the folds are effaced. Over a small triangular area, termed the trigonum vesicae, immediately above and behind the internal orifice of the urethra, the mucous membrane is firmly bound to the muscular coat, and is always smooth. The anterior angle of the trigonum vesicae is formed by the internal orifice of the urethra, its postero- lateral angles by the orifices of the ureters. Stretching behind the latter openings is a slightly curved ridge, the torus uretericus, forming the base of the trigone and produced by an under lying bundle of non striped muscular fibers. The lateral part of this ridge extend beyond the openings of the ureters, and are named the plicae uretericae. They are produced by the terminal portions of the ureters as they traverse obliquely the bladder wall⁶.

              The orifices of the ureters are placed at the postero-lateral angles of the trigonum vesicae, and are usually slit like in form. In the contracted bladder, they are about 2.5cm apart and about the same distance from the internal urethral orifice, in the distended viscous these measurements may be increased to about 5 cm.

              The internal urethral orifice is placed at the apex of the trigonum vesicae, in the most dependent part of the bladder, and is somewhat crescentic in form;

              The bladder is composed of the four coats- serous, muscular, sub-mucous and mucous coats⁶.

The urethra:-

              The urethra conducts urine from the bladder to the outside⁶.

Female urethra:-

              The female urethra is a short muscular tube (about 4 cm long) lined by mucus membrane. It corresponds to the prostatic and membranous parts of the male urethra. The female urethra passes antero-inferiorly from the urinary bladder, posteriorly and then inferior to the symphysis pubis⁷.

              The external urethral orifice is located between the labia minora, just anterior to the vaginal orifice, and infero-posterior to the clitoris. The urethra, 5-6mm in diameter is closed except during micturition⁷.

              The urethra lies anterior to the vagina and is separated from it superiorly by a vesico-vaginal space. Inferiorly it is so intimately associated with the vagina that it appears to be embedded in it. The ureter passes with the vagina through the pelvic and uro-genital diaphragm, and the perineal membrane. The inferior end of the urethra is surrounded by the sphincter urethrae muscles and some of its fibers enclosed both the urethra and vagina⁷.

3.2. PHYSIOLOGY:

              Micturition is the process by which the urinary bladder empties when it becomes filled.

This involves two main steps:

1)    The bladder fills progressively until the tension in its walls rises above a threshold level, which then elicits the second step;

2) A nervous reflex called the micturition reflex occurs that empties the bladder, or if this fails, at least causes a conscious desire to urinate. Although the micturition reflex is an autonomous spinal reflex, it can also be inhibited or facilitated by centers in the cerebral cortex or brain stem.

INNERVATION OF THE BLADDER

              The principal nerve supply of the bladder is by way of the pelvic nerves, which connect with the spinal cord through the sacral plexus, mainly connecting the cord segments S2 and S3. Coursing through the pelvic nerves are both sensory nerve fibers and motor fibers. The sensory fibers detect the degree of stretch in the bladder wall. Stretch signals from the posterior urethra are especially strong and are mainly responsible for initiating the reflexes that cause bladder emptying.

              The motor nerves transmitted in the pelvic nerves are para-sympathetic fibers. These terminate on ganglion cells located in the wall of the bladder. Short postganglionic nerves then innervate the detrusor muscle.

              In addition to the pelvic nerves, two other types of innervations are important in bladder function. Most important are the skeletal motor fibers transmitted through the pudendal nerve to the external bladder sphincter. These are somatic nerve fibers that innervate and control the voluntary skeletal muscle of the sphincter. Also, the bladder receives sympathetic innervations from the sympathetic chain through the hypogastric nerves, connecting mainly the L2 segment of the spinal cord. These sympathetic fibers stimulate mainly the blood vessels and have little to do with bladder contraction. Some sensory nerve fibers also pass by way of the sympathetic nerves and may be important in the sensations of fullness and, in some instances, pain.

Transport of urine from the kidney through the ureters and into the bladder

              Urine that is expelled from the bladder has essentially the same composition as fluid flowing out of the collecting ducts, there are no significant changes in the composition of urine as it flows through the renal calyces and ureters to the bladder.

              Urine flowing from the collecting ducts into the renal calices stretches the calices and increases their inherent pace-maker activity, which in turn initiates peristaltic contractions t