Anal Fistula is a medical condition in which the infected gland inside the anus opens around the anal skin connecting through a canal. This usually happens when the glands inside the anus get blocked and get infected. The infected gland leads to the formation of an abscess and results in an anal fistula. Fistula treatment in Ayurveda includes the usage of ayurvedic medicines along with correcting the diet and lifestyle.
The incidence of a fistula-in-ano or anal fistula developing from an anal abscess ranges from 26% to 38%. One study showed that the prevalence of fistula-in-ano is 8.6 cases per 100,000 population. In men, the prevalence is 12.3 cases per 100,000 population, and in women, it is 5.6 cases per 100,000 population. The male-to-female ratio is 1:8:1. and the mean patient age is 38.3 years.1 Fistula-in-ano is described as “Bhagandara” in Ayurveda. According to Sushrutha, “The Father of Surgery”, Bhagandara is one among the “Ashtamahagada” (ashta means eight; mahagada– that which is difficult to treat).2
An anal fistula is a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus. It is a result of an infection near the anus causing a collection of pus in the nearby tissue. Anal fistulae commonly occur in people with a history of anal abscesses. They can form when anal abscesses do not heal properly.
Anal fistulae originate from the anal glands, which are located between the internal and external anal sphincter and drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually extend to the skin surface. The tract formed by this process is a fistula.
Anal fistula generally does not harm, but can be very painful, and can be irritating because of the drainage of pus. Recurrent abscesses may lead to significant short-term morbidity from pain, and create a starting point for systemic infection.
Treatment, in the form of surgery, is considered essential to allow drainage and prevent infection. Repair of the fistula itself is considered an elective procedure that many patients opt for due to discomfort and inconvenience associated with an actively draining fistula viz. fistulotomy, seton techniques, advanced flap procedure, LIFT procedure, etc.3
Signs and symptoms of anal fistula4
- Frequent anal abscesses
- Pain and swelling around the anus
- Bloody or foul-smelling discharge (pus) from an opening around the anus
- Pruritus ani – itching around the anus from drainage
- Tenderness around the anus
- Unpleasant odor from the discharge of the opening
- Thick discharge which keeps the area wet
- Pain with bowel movements
- Bleeding at the opening
- Fever, chills, and a general feeling of fatigue
Causes of anal fistula4
- The most common cause – Anal abscess
- Rarely due to conditions like tuberculosis, sexually transmitted diseases, Crohn’s disease or ulcerative colitis, diverticulitis
Types anal fistula
- Extrasphincteric fistulae: begin at the rectum or sigmoid colon and proceed downward opening into the skin surrounding the anus.3
- Supraspincteric fistulae: begin between the internal and external sphincter muscles, proceed downward and open an inch or more away from the anus.3
- Transphincteric fistulae: begin between the internal and external sphincter muscles or behind the anus opening an inch or more away from the anus taking a ‘U’ shape and form multiple external openings.3
- Interspincteric fistulae: begin between the internal and external sphincter muscles, pass through the internal sphincter muscle and open very close to the anus.3
- Submucosal fistulae: pass superficially beneath the submucosa.3
Tests advised in anal fistula
- Physical and rectal examination to look for signs of oozing fluid or bleeding
- Fistula probe, is an instrument specially designed to be inserted through a fistula
- A proctoscopy, where a special telescope with a light on the end is used to look inside the anus
- Flexible sigmoidoscopy, a procedure to rule out other disorders such as ulcerative colitis and Crohn’s disease
- An ultrasound, CT scan, or MRI scan to get a better view of the fistula tract, providing detailed images of the sphincter muscle and other structures of the pelvic floor
- Fistulography is an X-ray of the fistula
- Sometimes, the surgeon will need to examine the patient in the operating room (called exam under anesthesia) to diagnose the fistula
Anal fistula – An Ayurvedic View
A disease or condition causing severe referred pain to Bhaga (perineum), Guda (anus), and Basti (pelvis) is called Bhagandara. An abscess initially not treated turns into a narrow tunnel-like structure with discharge from the track.
As per Sushrutha, one who is indulged in mithya aahara-vihara (improper food habits and sedentary lifestyle), vata dosha in the body gets aggravated and accumulates in the anal canal. This aggravation in turn vitiates mamsa and rakta dhatu (muscle and blood) and gives rise to pitika (boil/abscess). This, when left untreated a tunnel or track-like structure is formed with discharge oozing out of it which is Bhagandara.
Few other causes to mention are krimi bhakshana (infected by micro-organism), trina- asthi kshanana (due to injury or trauma), pravahan (straining while defecation), utkataasana (sitting in a squatting posture for a long time), horse riding which in present days can be correlated to excess riding can lead to Bhagandara, as described by Charaka.2
Types of Bhagandara as per Sushrutha are five in number.2
- Shataponaka: Bhagandara (fistula) is the one having multiple openings
- Ushtragreeva : curved fistula resembling the neck of the camel
- Parisraavi: Fistula with big cavity and profuse discharge
- Shambukavart: Fistula resembling the horseshoe
- Unmaargi : Fistula due to trauma
Fistula Treatment in Ayurveda2
Fistula Treatment in Ayurveda will be discussed below as per different classics.
- Non-suppurative stage – treatment measures of vrana chikitsa (wound management) such as apatarpana (light diet) and virechana (purgation) have to be followed.
- Suppurative stage – Snehana (oleation) and Avagaha swedana (sudation of immersing the part in medicated liquid in the tub) of the perianal region.
If the pitika (abscess) does not resolve, then exploration of the tract (fistulotomy) is to be done followed by Kshara application (medicated caustic paste) or Agnikarma (cauterization) should be done in the explored bed of uthe lcer. Postoperatively, irrigation of medicated oils (Yashtimadhu taila or Anu taila) over the ulcerative lesions and Sitz bath is advised for the patient.
In conditions where it is chronic, recurrent episodes, the tract is partially fibrosed and is not patent, or patients who are unwilling for surgery, irrigation of the tract with medicated oils (Bhagandara nashana taila) is advised.
Charaka opines the treatment for the non-suppurative stage of fistula as mentioned above by Sushrutha and says to do raktamokshana (bloodletting) to prevent suppuration followed by Vata patradi lepa (medical paste poultice application) over the affected site.
In the suppurative stage, fistulotomy is done and then Kshara application or Agnikarma is to be performed.
Chakradatta, advises lepa or paste applications in the suppurative stage such as Rasanjanadi lepa or Kushtadi lepa; and also application of Snuhi dugdhadi varti.
Vagbhata advises Vamana (emesis), Virechana (purgation) ,and Raktamokshana (bloodletting) therapies when the abscess is in nthe on-suppurative phase. Once the abscess suppurates, incision and drainage (bhedana karma) followed by Kshaara application and Agnikarma procedures.
Ksharasutra ligation for fistula ablation is explained by Vagbhata in the context of “Parikshepi Bhagandara” (high anal complex fistula) and is the direct reference available.
Common Ayurvedic medicines used in treating Fistula
Ayurvedic medicines for anal fistula includes various preparations like decoctions, tablets, herbal jams, external applications, medicated ghee, etc…Few commonly used ayurvedic medicines are
- Triphala Guggulu
- Kaishora Guggulu
- Arogyavardhini vati
- Chandraprabha Vati
- Gokshuradi Guggulu
- Triphala choorna
- Hingwashtaka choorna
- Jatyadi taila for application
Diet and Lifestyle in Anal Fistula
Green gram, leafy vegetables, wheat, an old variety of rice, red variety of rice, fiber-rich diet viz. radish, tubers like carrot, adequate drinking of water is a healthy diet in fistulous conditions.
Sitz bath, proper hygiene of anal region, proper bowel habits, avoiding excess sitting or standing for long periods, avoiding excess riding.
Home remedies for Anal Fistula
- Cloves: – Prepare clove water by boiling a few cloves in water and consume
- Add a pinch of clove powder in black or green tea and drink5
- Turmeric milk: Boil milk and add a pinch of turmeric powder to it (honey can also be added)5
- Oregano leaves oil: Mix the oil in lukewarm water and drink5
- Tea tree oil: Mix a few drops of tea tree oil with either coconut oil or olive oil. Dip the cotton pad in the oil and dab over the affected area and leave it for 30-40 minutes and then wash5
When to see a doctor
Consult a doctor if you have persistent symptoms of anal fistula and the discharge is profuse.
Fistula-in-ano is the most common perianal regional condition due to unresolved anal abscess formation affecting a large population due to unhealthy diet, and irregular bowel habits. Ayurveda has a unique procedure of Ksharasutra ligation, along with Kshaara application, and Agnikarma procedures. Fistulotomy is advised when the abscess does not resolve and the fistulous tract is formed with profuse discharge.
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- https:// emedicine.medscape.com/article/190234-overview
- https:// www.researchgate.net/publication/314168513