Prameha: Nidana, Lakshana, Samprapti, Oushadhi, Chikitsa (Treatment)

Prameha often interpreted as diabetes mellitus in modern medicine, is a group of urinary disorders described in Ayurveda that result in frequent and too much urination.

In Ayurveda, Prameha is considered one of the eight significant and serious disorders (Astamahagad) due to its complications.

Passing urine very often and too much is the main characteristic of the Prameha.

Ayurveda describes twenty types of Prameha. Each of these is described with specific causes, symptoms, and dosha imbalance.

Ayurvedic treatment of Prameha is specific to the nature of the patient (Prakriti) and dosha imbalance (Vikriti). Such as, an obese diabetic (Sthoola Pramehi) is given Shodhana (cleansing eg. panchakarma) treatment while a lean diabetic is given Santarpan (nourishing) treatment.

Moreover, healthy dietary practices and activities are recommended to prevent the severity of the disease.

In this article, I will explore the symptoms, types, causes, and treatment options for Prameha, shedding light on this ancient yet enduring health concern.

Understanding Prameha in Ayurveda

Understanding the different types of Prameha is essential for appropriate diagnosis and timely treatment.

What is Prameha in Ayurveda?

Prameha, as described in Ayurveda, is a group of urinary disorders characterized by excessive urination and an abnormal constitution of the urine.

It is caused by an imbalance in the Tridosha (Vata, Pitta, and Kapha) due to diet and habits that continuously aggravate the doshas.

This imbalance leads to a variety of symptoms, including polyuria (Prabhuta Mutrata), increased thirst (Pipasa Aadhikya), yellowish-white (Pandu Varna) or white urine, and a feeling of sweetness in the mouth and body (Mukha Sharira Madhurya).

Difference between Prameha and Madhumeha

Prameha meaning

Prameha comes from the Sanskrit root “Mih-Secane,” which means “to flow.” It is originally mentioned in the Atharva Veda as Asrava, which is understood as ad Mutrasrava (excess urination)¹Rajasekharan, S., & Raju, G. S. (1982). Certain concepts of “prameha” (diabetes) in ayurveda (Indian system of medicine) with special reference to the relationship between ancient Indian and modern thoughts. Ancient science of life, 2(1), 17–22..

In Ayurveda, Prameha is defined as “Prakarshane Meheti”. That is excessive and frequent urination.

There are 20 types of Prameha (urinary disorders) described in Ayurveda.

What is Madhumeha?

Madhumeha also called Ojo Meha is composed of two words Madu and Meha where Madhu means honey. That is, the one who urinates excessively and frequently, similar to the color and odor resembling honey.

Madhumeha is one of the twenty types of Prameha (urinary disorders) which is closely related to diabetes mellitus in modern medicine²Murthy, A. R., & Singh, R. H. (1989). Concept of prameha/madhumeha (contradictions and compromises). Ancient science of life, 9(2), 71–79..

According to Charak Samhita, The properties of Vata and Ojas are opposite to each other. When the Vata Dosha is aggravated, it destroys the properties of Ojas through its roughness (Ruksha), Cold (sheeta), and moving (chala) properties.

The Diminished Ojas is excreted out through the urinary tract. Therefore, the urine is excessive, honey-like, and pale yellow-white (Pandu).

According to Vagbhata, all Prameha, if left untreated will develop into the more serious and incurable condition called Madhumeha (diabetes mellitus). This condition is subject to the continuous practice of factors aggravating Vata Dosha and ignoring its initial stage.

Prameha Nidana (Causes)

According to Sushruta, Prameha is caused by a combination of genetic predisposition (Sahaja) and lifestyle factors (Apathya Nimittaja).

Prameha Nidana Shloka

आस्यासुखं स्वप्नसुखं दधीनि ग्राम्यौदकानूपरसाः पयांसि|
नवान्नपानं गुडवैकृतं च प्रमेहहेतुः कफकृच्च सर्वम्|| (च.चि.6/4)

āsyāsukhaṃ svapnasukhaṃ dadhīni grāmyaudakānūparasāḥ payāṃsi|
navānnapānaṃ guḍavaikṛtaṃ ca pramehahetuḥ kaphakṛcca sarvam|| (ca.ci.6/4)

Contributing factors to Prameha include:

• Ashyasukham: Lack of physical activity and poor dietary practices.
• Swapna Sukham: Prolonged sleeping specifically during the day.
• Dadhi: Excessive consumption of Curd.
• Gramya Oudak Aanup Mamsa: Overconsumption of meats sourced from domestic, aquatic, and marshland animals.
• Payamsi: Excessive intake of Milk and its derivatives.
• Nava Anna Pana: Overindulgence in the consumption of fresh grains and freshwater during the rainy season.
• Vaikruta Guda: Excessive consumption of Jaggery or cane sugar.
• All substances increasing Kapha Dosha.

Besides these, Avyayama (sedentary lifestyle), Divaswapna (daytime sleep), and Bija Dosha (Hereditary defects) all contribute to Prameha disease.

Due to the above factors, Kapha dosha is aggravated which further depletes the Meda Dhatu, Mamsa Dhatu, and Kleda. Then reaches the bladder through the urinary channels, contaminates the urine, and causes Prameha Roga.

Prameha Types in Ayurveda

There are 20 types of Prameha. Ayurveda classifies Prameha into two major categories, which can be further divided into subtypes:

According to cause

As per Sushruta Samhita, there are two types of Prameha.

1. Sahaja Prameha (Congenital Diabetes)
2. Apathya Nimittaja Prameha (Acquired Diabetes)

Here Shaja (Congenital) is correlated with type 1 diabetes while Apathyanimittaja (Acquired Diabetes) is correlated with type 2 diabetes³Sharma H, Chandola HM. Prameha in Ayurveda: correlation with obesity, metabolic syndrome, and diabetes mellitus. Part 1-etiology, classification, and pathogenesis. J Altern Complement Med. 2011 Jun;17(6):491-6. doi: 10.1089/acm.2010.0396. Erratum in: J Altern Complement Med. 2011 Jul;17(7):661. PMID: 21649515..

According to therapeutic Importance

As per Charak Samhita, it is categorized into two types.

1. Sthoola Pramehi (Obese diabetic)
2. Krusha Pramehi (Lean diabetic)

According to Vagbhatta

1. Dhatu Kshaya Janya (Due to depletion of Dhatu)
2. Dosha Avruta Janya

According to Dosha Involvement

1. Vataja (4 subtypes)
2. Pittaja (6 subtypes)
3. Kaphaja (10 subtypes)

According to Bhel Samhita

1. Prakritija (Congenital)
2. Svakrutija (Acquired)

Prameha Symptoms (Lakshana)

The primary characteristics of all types of Prameha include excessive and frequent urination.

However, the specific symptoms can vary depending on the subtype and the dosha predominance.

Common Signs and symptoms of Prameha include:

• Prabhuta Mutrata (Polyuria): Frequent and excessive urination.
• Avila Mutrata: Turbidity of urine.
• Akasmat Mutra Nirgama (Nocturnal enuresis): bedwetting in children.
• Trishna Adhikya (Polydipsia): Excessive thirst
• Daurbalya: Fatigue and Weakness
• Vibandha: Constipation and heaviness of the body.
• Kshudha Adhikya: Intense desire for food
• Pandu Varna Mutra: Yellowish-white urine
• Shwet Mutra: White urine
• Mukha Sharira Madhurya: Sensation of sweetness in the body and oral cavity.

Sahaja Prameha Symptoms (Congenital Diabetes)

• Krushta: Weak and emaciated
• Rookshta: Lack of bodily moisture.
• Pipasayukta: Excessive thirst.
• Parisaranashila: Desire to move around.
• Alpabhojana: Consumes a reduced amount of food.

Apathya Nimittaja Prameha Symptoms (Acquired Diabetes)

• Sthoolta: Obsessed
• Atibhojana: Engages in excessive food consumption
• Shnigdha: Unctuous body
• Shaiyashana: Inactive lifestyle
• Svapnashila: Overwhelming drowsiness

Apart from these, further dosha imbalance leads to more complex conditions which may include the following symptoms.

• Unintended Weight Loss Fatigue and Weakness.
• Visual Disturbances: Blurred vision
• Impaired Wound Healing: Slow-healing wounds and increased susceptibility to infections.

Prameha Purvarupa (Prodromal Signs & symptoms)

• Swedo: Excessive perspiration.
• Shayasana Svapnasukhe: Desire to sit and sleep.
• Jatilibhavam Kesheshu: Matting of hairs.
• Sheetapriyatvam: The desire for cold liquids.
• Anga Gandha: The foul odor of the body.
• Karpadayo Suptata: (Neuropathic Sensations): Numbness in the extremities.
• Mukha Talu Kantha Shosha: Dry mouth (Xerostomia), throat, palate.
• Paridaha: Burning sensation in the body.
• Madhurya Ashyata: Sweet taste of mouth.
• Pipasa Aadihikya (Polydipsia): Excessive thirst
• Tandra Sad: Persistent drowsiness and somnolence throughout the day.
• Excess of waste in eyes, ears, tongue, and teeth.
• Keshnakha Ativriddhi: Excessive growth in hair and nails.
• Karpada Daha: Burning sensation in hands, feet, and soles.
• Alashya (Lithargy)
• Flies and Ants get attracted to the body and urine.

Prameha Samprapti

Samprapti refers to the process of the complete manifestation of the disease.

According to Charak Samhita, due to overindulgence of the causative factors, Kapha dosha is aggravated which further vitiates the Meda Dhatu, Mamsa Dhatu, and Kleda. Then reaches the bladder through the urinary channels, contaminates the urine, and causes Prameharoga.

Kaphaja Prameha Samprapti:

Caused primarily by an imbalance in the Kapha dosha. Aggravated Kapha vitiates Meda Dhatu, Mamsa Dhatu, and Kleda situated in the bladder (basti), giving rise to various types of Kapha-dominant disorders.

Kaphaja Prameha is classified into ten subtypes.

Kaphaja Prameha Symptoms

Pittaja Prameha Samprapti

It is caused by an imbalance in the Pitta Dosha. Excessive consumption of hot, spicy, salty acidic, and alkaline foods frequent consumption of foods, excessive exposure to sunlight or heat, overwork, anger, and incompatible foods all result in aggravation of pitta which leads to depletion and contamination of Dhatus.

Symptoms include such as burning sensation, and yellowish urine.

Pittaja Prameha is categorized into six subtypes.

Pittaja Prameha Symptoms

Vataja Prameha Samprapti

It is primarily caused by an imbalance in Vata dosha. Excessive consumption of dry, bitter, pungent, and astringent foods.

Consumption of foods having Cold potency, excessive fasting, and physical exertion, over-practicing Vamana, Virechana, Asthapana Basti, and Nasya, suppression of natural urges, and staying up all night.

All these factors result in Vata aggravation leading to symptoms like weakness, fatigue, dry mouth, constipation, etc. This type of Prameha is considered incurable.

Vataja Prameha is classified into four subtypes.

Vataja Prameha Symptoms

Kshayaja Prameha:

This type is associated with wasting diseases and prolonged illnesses, leading to symptoms like weight loss, fatigue, and weakness.

Prameha Samprapti Ghataka (Elements of Pathogenesis)

Components that are involved in the pathogenesis of the Prameha are as follows.

Prameha Dushya (vitiated factors)

Dushya refers to the components of the body that are spoiled by the vitiated Tridosha.

There are ten Dushya (Dhatu vitiated) spoiled by the influence of aggravated dosha which are as follows.

Meda, Rakta (blood), Shukra, Ambu (Kleda), Vasa (fats), Lasika (lymphatics), Majja (marrow), Rasa, Ojas, Mamsa.

Prameha Sadhya Asadhyata (Curablity and incurability)

• Kaphaja Prameha are Curable (Sadhya) Pittaja Prameha are manageable (Yapya) and Vataja Prameha are considered incurable (Asadhya).
• As per Sushruta Samhita, Prameha, when accompanied by complications like Pidaka, is deemed incurable.

Kaphaj Prameha (Sadhya)

Kaphaj Prameha can be effectively treated, because of the treatment compatibility for dosha and Dushya. Here dosha and Dushya exhibit similar qualities hence the treatment approach is the same for both the Dosha and Dushya ‘Samakriyatvata’.

Pittaja Prameha (Yapya)

Pittaja Prameha, on the other hand, can only be managed to alleviate symptoms (Yapya), because of treatment incompatibility for Dosha and Dushya ‘Vishamkriyatvat’.

It requires continuous treatment. The condition remains controlled as long as treatment continues and the patient adopts a favorable diet and habits.

Ceasing treatment and indulging in causative factors can lead to disease relapse.

Vataja Prameha (Asadhya)

In the case of Vataja Prameha, the condition is considered incurable due to both the incompatibility of therapies and the severe depletion of vital components like Vasa, Majja, Lasika, and Oja. Which leads to dreadful complications ‘Mahatyatvat’.

Depletion of Vasa (fats), Majja (marrow), Lasika (lymphatics), and Ojas occurs only in the Vata types, not in the Pitta and Kapha types.

Rapid depletion of the Vital elements makes it difficult for medication to recover the disease effectively.

Incurablity of the Hereditary Diabetes (Sahaja Prameha)

According to Acharya Charaka, Congenital (Sahaja) and Prameha manifested due to Bija Dosha (Hereditary causes) are considered incurable.

Similarly, Kulaja Prameha (Familial Diabetes) is also considered incurable.

Prameha Upadrava (Complications)

Upadrava refers to complications that arise as a result of the progression of the disease. If Prameha is neglected, it becomes difficult to manage and results in various complications.

As per Charaka Samhita general complications (Upadrava) of Prameha are as follows.

Trishna (thirst), Atisara (diarrhea), Jvara (fever), Daha (burning sensation), Daurbalya (generalized weakness), Arochaka (anorexia), Avipaka (indigestion), Puti Mamsa (carbuncles), Alji and Vidridhi.

Prameha Chikitsa: Prameha Treatment in Ayurveda

Ayurvedic line of treatment for Prameha (Prameha Chikitsa) focuses on restoring the balance of the doshas and addressing the root cause of the condition.

It includes the examination of patient (Rogi Pariksha) and disease (Roga Pariksha). Considering, the patient’s body type (Prakriti), dosha dominance (Vikriti), and Dushya (Vitiated factors).

Furthermore, Avoiding etiological factors (Nidana Parivarjana), dietary and lifestyle modifications play an important role in the management of the disease.

Prameha Chikitsa Sutra (line of treatment)

स्थूलः प्रमेही बलवानिहैकः कृशस्तथैकः परिदुर्बलश्च|
सम्बृंहणं तत्र कृशस्य कार्यं संशोधनं दोषबलाधिकस्य||१५||

sthūlaḥ pramehī balavānihaikaḥ kṛśastathaikaḥ paridurbalaśca|
sambṛṃhaṇaṃ tatra kṛśasya kāryaṃ saṃśodhanaṃ doṣabalādhikasya||15||

As per Charaka Samhita, There are two types of Pramehi (diabetics).

1. Obese diabetics (Sthoola Pramehi)
2. and lean diabetics (Krusha Pramehi)

Hence, the line of treatment is specific to their body type.

Obese diabetics (Sthoola Pramehi) are given Shodhana treatment while lean diabetics (Krusha Pramehi) are given Brimhana (Nourishing) and Shamana (palliative) treatment.

Obese diabetics often have Kapha and pitta dominance and lean diabetics (weak and emaciated) have Strong Vata dominancy.

Hence, Kapha-dominant Prameha is treated with Vamana, Pitta-dominant is treated with Virechana, while Vata-dominant Prameha is treated with Brimhana (Nourishing) and Samshamana (palliative) treatment.

Panchakarma Treatment (Shodhana) in Obese Diabetics

Obese diabetics with strong dosha predominance are given Shodhana (cleansing eg. panchakarma) treatment.

Initially, Snehana serves as a Poorvakarma (preliminary therapy), where the patient receives either Triphala Ghrita or Pipali Ghrita. Subsequently, Shodhana (Panchakarma) is followed.

Following this, the patient undergoes Asthapana Basti, a medicated decoction enema, and is then provided with Santarpana, a nourishing diet.

Contraindications

• In Sthoola Pramehi (Obese diabetics), Aptarpana (depleting therapy) is contraindicated following Samsodhana. If Aptarpana is administered after Samsodhana, it may result in the aggravation of Vata, leading to depletion of Dhatu, bladder pain, and urinary retention (Mutra Graha).
• Swedana (Sudation therapy), a Poorvakarma (preparatory therapy) is contraindicated in Prameha.
• Anuvasana Basti (medicated oil enema) is contraindicated in Prameha due to it being a nourishing type of Basti (enema).

Brimhana & Sanshamana in lean diabetics (Krucha Pramehi)

As I previously mentioned, lean diabetics (those who are weak & emaciated) exhibit a strong dominance of Vata.

Hence, they are given Brimhana (Nourishing and rejuvenating therapy) followed by palliative (Sanshamana) medicines and diet.

• The patient should be administered Manthas, Kashayas (decoctions), Yava Churna (barley powder), and other light diets.
• Yava (barley), should be given with honey.
• Amalaki Swarasa should be given along with Haridra Churna (Turmeric powder) and Honey.
• According to Ashtanga Hridaya, in the case of Asadhya Prameha (Vata type), Shilajit is recommended to be administered along with a decoction of herbs from the Salsaradi-gana.

Remedy for all types of Prameha

• Phalatrikadi Kwath – The decoction of Triphala, Daruharidra (Berberis aristata), Indravaruni (Citrullus colocynthis), and Nagarmotha (Cyperus rotundus) mixed with the paste of turmeric and honey. Consuming this remedy aids in alleviating all types of Prameha (Sarvaprameha Hara).
• Palliative formulation – The Pramehi (diabetics) should drink the decoction of Daruharidra (Berberis aristata), Devdaru (Cedrus deodara), Triphala, Nagarmotha (Nagarmotha (Cyperus rotundus) daily in the morning and evening.

Prameha Oushadhi: Prameha Medicines in Ayurveda

Ayurvedic medicine for Prameha Includes:

Research and Clinical Studies

A report describes how they successfully treated a diabetic foot ulcer with osteomyelitis using Ayurvedic methods. They used leech therapy, cleaned the wound with Triphala decoction, gave Ayurvedic antidiabetic drugs, and dressed it with Jatyadi Taila. All these treatments together healed the ulcer and bone completely in less than three months⁴Bopparathi S, K V NR. Diabetic foot ulcer with osteomyelitis, successfully treated with the holistic approach of multiple ayurvedic treatment modalities – A case report. Int J Surg Case Rep. 2023 Jun;107:108315. doi: 10.1016/j.ijscr.2023.108315. Epub 2023 May 12. PMID: 37207585; PMCID: PMC10206147..

Chandraprabha Vati

An investigation into the Antidiabetic activity of Chandraprabha vati exhibited antihyperglycemic effects and positively influenced lipid profiles. This supports its effectiveness in managing hyperglycemia⁵Wanjari MM, Mishra S, Dey YN, Sharma D, Gaidhani SN, Jadhav AD. Antidiabetic activity of Chandraprabha vati – A classical Ayurvedic formulation. J Ayurveda Integr Med. 2016 Jul-Sep;7(3):144-150. doi: 10.1016/j.jaim.2016.08.010. Epub 2016 Sep 22. PMID: 27665674; PMCID: PMC5052381..

Vasant Kusumakar Ras

A study on streptozotocin-induced diabetes retinopathy in rats was significantly prevented by the administration of Vasant Kusumakar Ras. The study suggests the potential therapeutic value of Vasant Kusumakar Ras in the management or prevention of complications related to diabetic retinopathy⁶Tamoli SM, Kohli KR, Kaikini AA, Muke SA, Shaikh AA, Sathaye S. Vasant Kusmakar Ras, an ayurvedic herbo-mineral formulation prevents the development of diabetic retinopathy in rats. J Ayurveda Integr Med. 2020 Jul-Sep;11(3):270-276. doi: 10.1016/j.jaim.2020.02.002. Epub 2020 Apr 17. PMID: 32312587; PMCID: PMC7527844..

Mustadi Kwatha

It is a formulation described in the Bhaishajya Ratnawali chapter Prameharoga Adhikara. A single case study explored the application of Mustadi Kwatha in managing Type II Diabetes Mellitus. The findings revealed a notable decrease in both fasting and post-prandial blood sugar levels⁷Dr. Akshay H. Malshikare, and Dr. Sharada Chikurte. “Management of Prameha With Mustadi Kwatha – A Case Study”. Journal of Ayurveda and Integrated Medical Sciences 3, no. 04 (August 31, 2018): 225-227. Accessed November 25, 2023. https://jaims.in/jaims/article/view/477.

Prameha diet kit according to Ayurveda

Lifestyle Modifications:

References

• 1
  Rajasekharan, S., & Raju, G. S. (1982). Certain concepts of “prameha” (diabetes) in ayurveda (Indian system of medicine) with special reference to the relationship between ancient Indian and modern thoughts. Ancient science of life, 2(1), 17–22.
• 2
  Murthy, A. R., & Singh, R. H. (1989). Concept of prameha/madhumeha (contradictions and compromises). Ancient science of life, 9(2), 71–79.
• 3
  Sharma H, Chandola HM. Prameha in Ayurveda: correlation with obesity, metabolic syndrome, and diabetes mellitus. Part 1-etiology, classification, and pathogenesis. J Altern Complement Med. 2011 Jun;17(6):491-6. doi: 10.1089/acm.2010.0396. Erratum in: J Altern Complement Med. 2011 Jul;17(7):661. PMID: 21649515.
• 4
  Bopparathi S, K V NR. Diabetic foot ulcer with osteomyelitis, successfully treated with the holistic approach of multiple ayurvedic treatment modalities – A case report. Int J Surg Case Rep. 2023 Jun;107:108315. doi: 10.1016/j.ijscr.2023.108315. Epub 2023 May 12. PMID: 37207585; PMCID: PMC10206147.
• 5
  Wanjari MM, Mishra S, Dey YN, Sharma D, Gaidhani SN, Jadhav AD. Antidiabetic activity of Chandraprabha vati – A classical Ayurvedic formulation. J Ayurveda Integr Med. 2016 Jul-Sep;7(3):144-150. doi: 10.1016/j.jaim.2016.08.010. Epub 2016 Sep 22. PMID: 27665674; PMCID: PMC5052381.
• 6
  Tamoli SM, Kohli KR, Kaikini AA, Muke SA, Shaikh AA, Sathaye S. Vasant Kusmakar Ras, an ayurvedic herbo-mineral formulation prevents the development of diabetic retinopathy in rats. J Ayurveda Integr Med. 2020 Jul-Sep;11(3):270-276. doi: 10.1016/j.jaim.2020.02.002. Epub 2020 Apr 17. PMID: 32312587; PMCID: PMC7527844.
• 7
  Dr. Akshay H. Malshikare, and Dr. Sharada Chikurte. “Management of Prameha With Mustadi Kwatha – A Case Study”. Journal of Ayurveda and Integrated Medical Sciences 3, no. 04 (August 31, 2018): 225-227. Accessed November 25, 2023. https://jaims.in/jaims/article/view/477