Tuni Pratituni – meaning, symptoms, management, probable modern correlation

Article by Dr Raghuram Y.S. MD (Ay) & Dr Manasa S, B.A.M.S

Context and Reference

Tuni and Pratituni are two painful conditions explained in the context of ‘Vata Vyadhi Nidanam’ chapter of Madhava Nidana treatise. This explains that they both are types of vata vyadhi, special disorders caused by severe aggravation of only vata. These two conditions have been very briefly explained and the references of these conditions are taken from chapter 1 of Nidana Sthana section of Sushruta Samhita treatise i.e. ‘Vata Vyadhi Nidanam’. Master Sushruta has explained the treatment for these conditions in Sushruta Samhita Chikitsa Sthana, Chapter 5 i.e. ‘Mahavatavyadhi Chikitsa’. So, the context of the explanations of these conditions gives a clarity that they are considered as vata vyadhis and are also treated on the lines of vata vyadhi treatment.

Tuni Pratituni: Symptoms

अधो या वेदनां याति वcÉÉåïमूत्राशयोत्थिता ।।
भिन्दतीव गुदोपस्थं सा तूनीत्यभिधीयते ।।८६ ।।
गुदोपस्थोत्थिता सैव प्रतिलोमविसर्पिणी ।।
वेगैः पक्वाशयं याति प्रतितूनीति सा स्मृता ।।८७ ।। Su.Ni.Ch 1 / Vata Vyadhi Nidanam

Tuni – The aggravated vata gets localized in the purisha ashaya – the seat of faeces or large intestine and mutra ashaya – seat of urine or urinary bladder. By doing so, the vata, while moving downwards from these seats, gives rise to cutting pain in the rectum and penis. This condition is called Tuni.

Pratituni – The same type of pain (cutting pain) which begins in the rectum and penis, moves upwards, reaches pakvashaya – large intestines / colon in bouts. This condition is called Pratituni.

Going deeper with this explanation,

Tuni and Pratituni clearly look like severely painful conditions, wherein the pain is travelling in opposite directions.

Tuni has 2 courses. It follows one or both the courses as given below –

a.    The aggravated vata moves downwards from upper part of large intestine along the colon, towards rectum and causes pain in the rectum

b.   The aggravated vata moves downwards from urinary bladder / kidney along the urinary tract (passage), reaches the penis and causes pain therein

Pratituni also has 2 courses but in the reverse direction. It follows one or both the courses as given below –

a.    The aggravated vata moves upwards from the rectum towards the upper part of the large intestine / colon and causes pain therein

b.   The aggravated vata moves upwards from the penis towards the urinary bladder and causes pain therein

In the verses, pakvashaya has been mentioned but mutrashaya has not been mentioned in the context of pratituni. But we can infer its involvement in accordance with the pattern of pain occurring in tuni.

The pain caused in tuni and pratituni need not be occurring at the end points i.e. rectum or penis in one case and large intestine and urinary bladder in the other case. In fact, it can be inferred that the pain in tuni or pratituni may occur throughout the length of the pathway or channels in which the aggravated vata moves, in bouts, like colic.

We need to see that the entire pathway in which vata moves upwards or downwards and causes pain are hollow organs.

Master Vagbhata’s View

पक्वाशयाद्गदोपस्थं वायुस्तीव्ररुजः प्रयान् ।
तूनी, प्रतूनी तु भवेत्स एवातो विपर्यये ॥ ६२|| As.Hr.Ni.Sth.11

The aggravated vata produces severe pain as it travels from pakvashaya i.e. large intestine to the guda i.e. rectum and upastha i.e. penis. This condition is called Tuni.

When a similar type of pain travels in a reverse direction i.e. upwards from the rectum and penis to the large intestine it is called as Pratituni i.e. Tuni moving in the opposite direction.

One thing that we need to see is that the explanation is almost similar to that of Master Sushruta but Master Vagbhata misses the mention of mutrashaya. The same was done by Master Sushruta in the explanation of Pratituni.

Summary and Collective inference

Summing up Sushruta and Vagbhata references, we can draw some inferences.

Aggravated vata causes both conditions, tuni and pratituni. The nature of pain depends on the direction in which the aggravated vata moves. It moves downwards in tuni and upwards in pratituni. 

The organs involved in the causation of tuni and pratituni are – large intestine, urinary bladder / kidney, rectum and penis. In women, the vulva / vagina is involved.

Urinary bladder (Sushruta) can be involved in tuni and can transmit pain to the penis or vulva. It is a variant of Tuni. Urinary bladder may or may not be involved in pratituni. As per Vagbhata it is not at all involved. The involvement if any may be because they are the structures very closely related in the lower abdomen and pelvis and located in the Apana Vata zone. Apana vata controls these structures and their functions.

Involvement of pakvashaya – colon is mandatory in both these conditions and so is the rectum and penis or vulva.

Since the pain moves in upward or downward directions (in pratituni and tuni respectively) along with movement of vata, the structures coming in the pathway are also involved. So, the urethra and the majority of the colon above the level of rectum shall be considered.

The purishavaha and mutravaha srotas are involved in these conditions.

The srotodushti (mode of contamination of channels / ducts) is in the form of

–        sanga – impaction or obstruction caused by fart or faeces (in colon) or stones or foreign bodies (in urinary tract)
–        sira granthi – cysts or tumours or space occupying lesions in or around the structures involved, imparting pressure on them
–        vimargagamana – reverse or retrograde movement of vata – limited to pratituni

The possible different patterns of pain included in tuni and pratituni are –

Tuni –

–        large intestine to rectum
–        large intestine to penis / vulva
–        urinary bladder to penis
–        urinary bladder to the region of rectum

Pratituni –

–        rectum to large intestine
–        penis to region of large intestine
–        penis to urinary bladder
–        rectum to urinary bladder

Tuni and Pratituni: Treatment

General line of treatment

Nidana Parivarjana

Keeping away the causative factors responsible for aggravation of vata and also causation of disease should be avoided.

Hetu Viparita and Vyadhi Viparita Chikitsa

The treatments and medicines which are planned should be antagonistic to the cause of the disease and disease itself. The underlying disease if causal should be dealt with. The sroto dushti should be analysed and treatment planned accordingly.

Dealing with vata

Anti-vata strategy needs to be implemented in terms of food and lifestyle practices and also habits and behaviours. Medicines and therapies to combat vata shall be planned and implemented.

Panchakarma therapies

Vasti and Virechana are the main therapies for tuni and pratituni. Gudavarti – suppositories and Uttara Vasti – enema into urinary passage should also be considered as and when needed.

External therapies

Abhyanga – herbal oil massage, Swedana – sudation / fomentation, Avagaha – tub bath sudation, Lepa – anointment / application of medicinal pastes prepared with vata mitigating herbs and dhara – streaming or showering hot / warm liquids like decoction or milk should be considered to combat vata and also to treat the conditions.

Specific line of treatment

तूनीप्रतून्योःस्नेहलवणमुष्णोदकेनपाययेत्,पिप्पल्यादिचूर्णवा,हिङ्गुयवक्षारप्रगाढंवासर्पिः,बस्तिभिश्चैनमुपक्रमेत्। Su Chi 5/26 Mahavatavyadhi Chikitsa

In both tuni and pratituni, Master Sushruta advocates the below mentioned remedies.

Hot / warm water added with sneha – oil and lavana – siandhava lavana or rock salt should be given to drink.

Powder of herbs of Pippalyadi Gana group mixed in hot or warm water shall be given to drink.

Large quantities of powder of Hingu – asafetida and Yava kshara – alkali of the whole plant should be given mixed in ghee.

Vasti – medicated enemas are helpful in combating pain and dosha (vata).

Kulattha Yusha – soup prepared from horse gram is also beneficial in the treatment of tuni and pratituni.

Other considerations

Vata Vyadhi Chikitsa – Tuni and Pratituni shall be treated on the lines and principles of vata vyadhi chikitsa – treatment of vata vyadhi.

Udavarta Chikitsa – Treatment as prescribed for abnormal upward movement of vata and diseases caused by the same – especially in pratituni.

Gudagata Vata Chikitsa – Treatment as prescribed for aggravated vata localized in the rectum – especially in pratituni.

Mutrashmari and Mutrakrichra Chikitsa – Treatment as prescribed for urinary calculus and dysuria – especially in tuni.

Vibandha, Anaha, Adhmana Chikitsa – Treatment as prescribed for constipation, platulence and distension of abdomen – especially in tuni.

Shula Chikitsa – Treatment as prescribed for abdominal colic.

Beneficial formulations

–        Gandharvahastadi Kashayam
–        Brihatyadi Kashayam
–        Gokshuradi Guggulu
–        Gandharvahastadi Eranda Tailam
–        Vayu Gulika

Modern Correlation

Tuni – This condition can be correlated with

–        abdominal colic
–        acute or chronic constipation
–        flatulent dyspepsia
–        gaseous distension of abdomen
–        urinary bladder stone / cystic calculi
–        urinary bladder pain
–        renal calculi

Pratituni – This condition can be correlated with

–        proctalgia / rectum pain
–        urethral calculi
–        balanitis / urethritis
–        vaginitis / vulvitis
–        urinary bladder pain / calculi