Karnini Yonivyapad (Cervical Erosion): A Review

Health status of women is essential for healthy society. In today's fast and competitive world, there is change in the lifestyle of women which leads to their physical and mental stress, women mostly get affected by this environment and are prone to gynaecological problems. Common health problem or gynaecological problem in women is white discharge, foul smell discharge, itching at vulvar region, burning micturition. Cervical erosion is a condition seen in the age group of 20-40 years with more of Kapha dominance. Kandu, Yoni Srava and other features of Kapha Pittadushti are seen in cervical erosion. It is seen as red circular granular surface surrounding the cervical os bathed in discharges. On the study of etiological factors, sign and symptoms the disease is found to be caused by Kapha – Pittadosha Prokopa affecting Yoni and Garbhasayamukha leading to Samprapti which manifests as cervical erosion. Based on symptomatology, cervical erosion can be correlated with Karnini Yonivyapad. Karnini is an abnormal proliferation of cervical epithelium which may produce abnormal discharge, alter the vaginal pH and cervical mucus plug. Chikitsa of Karnini Yonivyapad is Yoni Prakshalana,Yoni Pichu Dharana, Yoni Varti Dharana, Agni Karma and Kshara Karma. Kaphahara line of treatment should be done. Diet also plays an important role in cervical erosion so proper Pathya Apathtya are to be followed.


INTRODUCTION
Due to straining during labour in the absence of labour pains means Akalavahana, the Vayu obstructed by fetus, with holding Kapha and getting mixed with Rakta produces Karnika in Yoni, which obstructs the passage of Raja. Due to presence of Karnika this condition is termed as Karnini. A different type of pathogenesis of Karnini is that vitiated Kapha along with Rakta produces Karnika in the Yoni [1][2][3][4]. Due to premature ejaculation of fluid by women brought about by untimely straining leads to vitiation of Vata, aggravated Vata with holding Kapha and Rakta produces 'Karnika' on 'Garbhashaya Dwaramukha' which obstructs the passage of Raja. Karnika can be correlated to the erosion on cervix which may be slightly raised above the level of squamous epithelium of vaginal portion of the cervix and granular in appearance and when touched gives a grating sensation. Cervical erosion refers to denudation of superficial epithelium and it is described as the "interplay between two epithelia" [5][6][7]. It is the development of a reddened area on the portio vaginalis around the external os of the cervix. The squamous covering of the vaginal part of the cervix is replaced by columnar epithelium, which is continuous with that lining of the endocervix. Erosion is never ulcerated unless or until it is malignant [8][9][10]. Cervical erosion is the replacement of squamous epithelium of the ectocervix by the columnar epithelium of the endocervix which is more prone to infection. Due to this the chances of infection increases which plays important role in increases the chances of malignancy.

INCIDENCE
The incidence of cervical erosion is between 50-85% in females of child bearing age.

TYPES
Cervical erosion is of two types: Congenital, Acquired

Congenital Cervical Erosion
At birth 1/3 rd of all female new born the columnar epithelium of the endocervix extends beyond the external os and covers the portio-vaginalis of the cervix due to influence of maternal estrogen. As the estrogen level in neonate falls, the condition reverts and erosion disappears. This condition persists only a few days after birth until the level of oestrogen from mother falls and congenital erosion heals spontaneously.
Simple flat erosion: During early stage of established cervicitis desquamation and shedding out of the epithelium around the external os occurs due to loosing of the epithelium presenting as red glistening area which is flat erosion. It is with smooth surface and a very few glands open on its surface. Microscopically it shows the tissue beneath the raw area that are infiltrated with round and plasma cells [11][12][13].
ii. Papillary erosion: Due to proliferation of cervical erosion it gets folded and forms papillary projections on granulation tissue base of chronic cervicitis. The papillary effect is mainly the result of local proliferation which can be easily infected.
iii. Follicular/Cystic erosion: During its healing stage the endocervicitis and chronic discharge subsides, the squamous epithelium regrows towards the external os replacing the columnar epithelium which heals and disappears. As the mouth of the glands may be blocked may produce retention cyst like elevations on the surface of the portio vaginalis and these are called Nabothian follicles [14][15][16].

Fig. 1. Chronic cervicitis, with cervical erosion
During pelvic examination an area on the cervix appears raw red and inflamed.

Karnini Yoni Vyapad
The word Karnini refers to the seed capsule of the lotus flower. The minute protuberance at the Garbhasaya Dwara due to morbidity of the Pitta and Rakta resembling the Padma Karnika or pericarp of the lotus is known as Karnini Yoni Vyapad.
An elevated lesion at the Garbhasaya Greeva characterises the Karnini Yonivyapad. The lesion is said to simulate the pericarp of lotus flower in appearance.
Karnini can be compared with cervical erosion. In cervical erosion the cervix becomes somewhat hypertrophied, congested and covered with small red projection resembling sprouts this erosion is often associated with nabothian cysts which are small pea sized smooth nodular structures, thus due to presence of small sprouts the cervix assumes the shape of barbed wire or small brush and when associated with nabothian cysts then assumes to the pericarp of lotus.  [17]. Excessive coitus done by a woman having Sushka body or else a weak woman or at an early age with a man having big sized penis is also responsible for Yonivyapad due to vitiation of Vata.
[18] Accepting the abnormalities of Artava and Bija as well as Daiva as causative factors, the abnormal diet, having coitus in abnormal body postures, excessive coitus and use of any foreign body or substance for sexual pleasure are also responsible for the disease of reproductive tract i.e. Yonivyapad [19].

Symptoms of Karnini Yonivyapad
The disease is the resultant of localized vitiation of Vata and Kapha in the region of Yoni, so the symptoms produced due to these Doshas will be found in this disease.
Acharya sushruta has clearly mentioned that the 'Shleshmala' features will also be found associated in 'Karnini Yonivyapad

Symptoms due to Vitiation of Vata
Pain in lower abdomen III.
Aayasa i.e. sickness feeling are also found in this disease

Yoni Prakshalana
It is a procedure in which the discharges of Yoni is washed out using the Kwatha prepared out of respective drugs for Doshas.

 Yoni Prakshalana should be done with
Nyagrodhadi Kwatha mixed with Ghrita, milk, and sugar.  Aragwadhadi Kashaya is also effective in Kaphaja Yonivyapad for Prakshalana.  Kasisa, Triphala, Kankshi, Amra, Jamb Beeja, Dhataki with honey is useful in Kaphaja Yonivyapad for Prakshalana.  The action of these drugs which are used have Shulaghna, Sravaghna and Dourgandhyahara properties.

Yoni Pichu
Yoni Pichu means packing the vagina with tampon (gauze strip, cotton wool). Yoni Pichu which is routinely practiced is Taila Pichu.
Yoni Pichu is the application of sterile swab soaked in medicated oil or decoction etc. in the vagina. Yoni Pichu means packing the vagina with cotton wool). Yoni Pichu which is routinely practiced is Taila Pichu.

Fig.2. Flow chart of Samprapti (pathogenesis) of Karnini yonivyapad
Yoni Pichu is the application of sterile swab soaked in medicated oil or decoction etc. in the Yoni Pichu with Jataydi Taila: which is having the properties of healing, pain relief, reduces burning sensation, especially in Pitta Dosha.

Yoni Varti (pessary):
Varti is long in size and can be used effectively in infections and dealing with their recurrence. Eg: Pessary prepared with powdered Yava (barley) and Masa (a type of bean) is used in Kaphaja Yonivyapad.

Agni Karma / electro-cauterization
Electrocautery is the burning of diseased tissue by a red hot electric cautery. The basic principle behind the application of Agni karma heat rate of the material used.

cauterization
Electrocautery is the burning of diseased tissue by a red hot electric cautery. The basic principle behind the application of Agni karma is the latent heat rate of the material used.

Fig.2. Flow chart of Samprapti (pathogenesis) of Karnini yonivyapad
Superficial cauterization can be done without anaesthesia as an outdoor procedure, if extensive area to be cauterized it can be done under general anaesthesia.
The heat transferred acts by removing the obstruction in the Srotas and increases the blood circulation to the affected site, hence the cellular activity and metabolism increases.
In Dagdha vrana, rakta agitated by fire and gets aggrevated. Pitta dosha also get aggrevated due to similar properties in virya and rasa. Jatyaadi Taila, Haridra, Daruharidra, Nimba Patra, and Jati Patra present in it have antibacterial, antifungal and anti-inflammatory effects. Kasisa (copper sulphate) is highly toxic to microbes even at low concentrations. Haridra also showed analgesic properties thus working on pain induced by inflammation. Highly significant effects were obtained on cervical tenderness (75 % relief) and they can be understood by anti-inflammatory and analgesic effect of the contents of the drugs used in the therapy [20][21][22][23]. Researches showed that Manjishta when applied externally increases peripheral circulation and detoxifies blood thus it reduced hyperaemia of the local cervical tissue. Reduction in dischargesnoer vagina by the grahi and astrigant property of lodhra. Results: Highly significant results (p<0.0001) were obtained on amount of discharges (75%), color of erosion (72%) and cervical tenderness (72%). Area covered by erosion decreased (68%) significantly after treatment. Overall effect of the therapy includes marked improved in 50 % of the patients.

Conclusion:
The therapy proved to be an effective measure in the management of cervical erosion. ii. Jasmine

DISCUSSION
In Ayurvedic classics, all gynecological disorders including cervical erosion come under Yonivyapad. Yonivyapad which are caused by Kapha or Vata-Kaphaja Dosha's are main causative factors of Swetapradara. Treatment of Karnini Yonivyapad is mainly based on the use of drugs which are having predominance of Kashaya Rasa and Kapha-Shamaka property and anti-inflammatory action also. Therefore, the drugs of Katu, Tikshana & Kashaya Rasa dominance are mainly used locally as well as internally.

CONCLUSION
Karnini Yonivyapad can be put parallel to Cervical Erosion in modern medicine on the basis of different signs & symptoms. By improving the general health of women and increasing personal hygiene, we can prevent the incidence of cervical erosion. Sthanika Chikitsa also play important role to prevent the incidence and to treat this condition. Anti-inflammatory drugs also have important role in treatment of Karnini Yonivyapad. Agnikarma with Tamra shalaka also gives a good result in cervical erosion as the procedure is done at the most affected area and the reoccurance of the cervical erosion is impossible. It also helps to cure the secondary infection as Tamra ions(copper ions) have antimicrobial properties.