Anal Fistula: Ayurvedic Concept, Types, Treatment

Article by Dr Raghuram Y.S. MD (Ay) and Dr Manasa B.A.M.S
Anal fistula has been compared to a condition called ‘Bhagandara’ explained in Ayurveda due to resemblance in clinical picture.

Painful blisters (boils, eruptions) occurring all around the guda (anal region) encroaching an area of 2 angulas, when break open are called as Bhagandara. They are of 5 types.

Thus Bhagandara means – painful blisters which open up, occur around the anal opening and encroach around an area of 2 angula dimension all around the guda.

Table of Contents

Sanskrit verse

The disease which causes painful and draining openings in and around guda (anal region), vasti (urinary bladder) and bhaga (pubic region, perineum, vaginal region, genital area) is called Bhagandara. When this blister remains unripe it is called Pidaka, when the same gets ripened it will be called Bhagandara.

Types of Bhagandara

Bhagandara is of 5 types. They are as below mentioned –

Shataponaka Bhagandhara

Vataja or Shataponaka Bhagandara
Causes – Excessive consumption of Kashaya (food predominant in astringent taste) and Rukhsa (dry) foods

Pathogenesis – The Vata aggravated due to the above said causative factors will cause a pidaka or blister in the anal region. This pidaka when neglected gets ripened (suppurated). This is called Vataja Bhagandara

Symptoms –

Pakwa Pidaka – ripened blister
Daruna Ruja – severe pain
Bhinna aruna phena vahini – when the blister opens it presents aruna (reddish yellow) and phena (froathy) discharges
Aneka vrana – many openings
Mutra-pureesha-retasaam aagame – discharge of urine, stools and semen through multiple orifices of the fistula

Ushtragreeva Bhagandhara

Paittika (Ushtragreeva) BhagandaraCauses – Excessive consumption of Pitta aggravating foods and lifestyle practices

Pathogenesis – The Pitta aggravated due to the above said causes a red coloured blister near the anal region. This is called Pittaja or Paittika Bhagandara.

Symptoms –
Ashupaki – the lesions get ripened quickly
Ushna sraava – hot discharges
Puti srava – foul smelling discharges
Ushtra shiro gharam – shape of the blister resembles the neck of a camel
Read related: Anal Fistula: 25 Diet And Lifestyle Tips To Avoid Repeated Infection

Prisravi Bhagandara

Kaphaja (Parisraavina) Bhagandara
Causes – Excessive consumption of Kapha aggravating foods and lifestyle practices
Pathogenesis – The kapha aggravated due to the above said causes a blister in the anal region. This is called Kaphaja Bhagandara.
Symptoms –

Kanduyana – itching
Ghana sravee – dense discharges (thick)
Kathina – hard in consistency
Manda vedana – mild pain
Shweta avabhasa – white coloured

This is called Parisraavi Bhagandara because the thick discharges keep flowing from the blisters.

Shambukavarta Bhagandara

Sannipataja (Shambukavarta) Bhagandara
Causes – consumption of food and activities which aggravate all the 3 doshas
Pathogenesis – All the 3 doshas aggravated due to the consumption of above said causes will cause blisters in the anal region. This is called Sannipataja Bhagandara.
Symptoms –

Bahu varna srava – discharges of various colours
Bahu rujaa – various types of pain
Bahu sraavaa – severe discharges in large quantity
Gostana upama – appears like a rudder of a cow
Shambuka avarta iva – the shape of blister in the form of rudder of a cow, gets converted into the shape of shambuka avarta, the curls of conch or shape of a whirl)

Agantuja Bhagandara

Agantujam (Unmargini) Bhagandara
Causes – Injuries occurring in the anal region

Pathogenesis – When the anal region gets injured from any sharp instrument, a sinus is formed. When this sinus is neglected, it gets infested with worms and microorganisms. The microorganisms further go deep inside by drilling the pathway of the sinus and contaminate the tissues. Blisters are formed around the anal region and the worms cause many openings in the lesion. Due to the inward or upward movement of the germs, this Bhagandara is called Unmargini Bhagandara.

Some authors have also called this condition as ‘Arsho-Bhagandara’. There is a possibility that on getting ripened or suppurated, the arsha (pile mass) can transform into Bhagandara, thus the name.
Read related: Anal Fistula Symptoms, Types, Differential Diagnosis, Treatment

Prognosis of Bhagandara

All the bhagandaras are painful and troublesome in nature. The Tridoshaja (Sannipataja, Shambukavarta) and Kshataja (Agantuja, Unmargini) types of Bhagandara are said to be incurable.

The Bhagandara from which there is discharge of urine, stools, semen and flatus (fart) is said to be incurable and life-threatening.

All Bhagandaras are said to be Krichrasadhya (difficult to treat or cure). Below mentioned conditions of Bhagandara are said to be incurable –

Tridoshaja Bhagandara
Agantuja Bhagandara
Bhagandara occurring in the Pravahini layer of guda or anus
Bhagandara occurring in the sevani (perineum)
Shataponaka Bhagandara occurring in timid and delicate people
Bhagandara occurring in people suffering from lung and intestinal tuberculosis

Bhagandara Chikitsa

Treatment of Anal Fistula on the lines of Bhagandara Chikitsa (Treatment of Bhagandara)
Rakta Mokshana – Bloodletting should be the first stage of the treatment and should be done immediately after a pidaka is formed (blister). When Raktamokshana is done and the contaminated blood and other regional contaminants are expelled, the pidakas do not become ripened and do not progress towards formation of fistula. The patient should also be made to sit in a tub filled in cold water. With these measures, the blister will be cured. Raktamokshana is also a useful treatment even after formation of Bhagandara and should be skilfully done. Raktamokshana not only removes the contaminants from the ano-rectal region, it prevents suppuration, formation of sinus tracts and fistula and avoids formation of germs and subsequent infection by cleansing the area. The blood becomes purified and the symptoms like pain etc will be reduced.

Agni Karma (fire cauterization) – The Pidakas occurring in the anal region should be burnt using swarna shalakas (golden rods prepared to conduct cauterization). The burns caused due to Agni karma shall be later treated on the lines of treating agnivrana i.e. burns or burnt wounds.

Apakwa Pitika Chikitsa

Apakwa pitika chikitsa (treating unripe or unopened blister) –

Apakwa pitaka should be treated by administering apatarpana (langhana or fasting) and Virechana (therapeutic purgation). After successfully administering apatarpana and virechana, other treatments shall be done.

Sushruta further emphasises that all the 12 methods starting with Apatarpana and ending with Virechana as explained in Shashti Upakrama (60 minor treatments) shall be followed in apakwa pitika bhagandara. They are as below mentioned –

Apatarpana – starvation
Alepa – anointment of medicinal pastes
Parisheka – stream pouring of medications
Abhyanga – massage
Sweda – fomentation or sudation (sweat inducing treatments)
Vimlapana – gentle pressing / cleansing measures
Upanaha – poultices
Paachana – causing maturity in suppuration (helping the pus to form properly so as to drain it out)
Visraavana – drainage
Sneha – inducing oiliness or unctuousness
Vamana – therapeutic emesis
Virechana – therapeutic purgation

Medicines for Pitaka from Sahasrayoga text book
1.Tiktaka Ghrita
2. Maha tiktaka Ghrita
3. Eladi thaila

Pakwa Pidika Chikitsa

Pakwa of Bhinna Pidaka or Pakwa Pidaka (ripened) –
The Pakwa Pidaka (ripened blister) should be subjected to Patana (excision and drainage of contaminated fluids), Kshara Karma (alkali cauterization) and Agni Karma (fire cauterization). After administering them chronologically and successfully, the burns caused by them should be treated on the terms of Vrana Chikitsa (treating wounds or burns).

Firstly the patients should be administered with snehana (oleation) followed by Avagaha sweda (tub bath fomentation). Later the patient should be made to lay in the arsha chikitsa vidhi or the position in which treatment is conducted for patients of haemorrhoids (lithotomy position). Later the paraacheena or bahirmukha bhagandara (fistula with external opening) and arvacheena or antarmukha bhagandara (fistula with internal opening) should be thoroughly examined. Eshanee yantra (probe) should be inserted into the tract and the tract is elevated. Following this the whole tract is cut open using a sharp sterile instrument.

Later after thorough examination and excision of fistula, Kshara karma (alkaline cauterization) or agni karma (fire cauterization) shall be done.

Treatment approach towards individual types of Bhagandara

Shataponaka Bhagandara Chikitsa

Shataponaka Bhagandara (multiple fistula) –

In this the wise physician should cause vrana (wounds or cuts) in between the fistulas. Once the wounds get healed, the fistulae should be treated on the general lines (as explained above). The sravamargas (oozing points or openings through which oozing occurs) should be burnt all around with the help of agni (fire cauterization).
This type of fistula in which there are multiple tracts becomes difficult to treat in patients who are delicate and panic. In these people instead of agnikarma, swedana (sudation) should be conducted immediately to stop discharges and to control pain.
Nadi Sweda or tubular fomentation is an ideal choice in these types of bhagandara. In this the decoction prepared using swedana dravyas (herbs used to produce fomentation), krushara (gruel), payasa (sweet milk based drink), meat of animals and birds living in desert, marshy lands and in water, eranda (castor plant) and dashamula (10 roots) should be boiled in an earthen vessel with concealed opening. A tube connected to the neck of the pot is used for fomentation. The steam coming out of the tube is used for swedana.
Alternatively, decoction made up of tila (sesame), eranda (castor plant), masha (black gram), yava (barley), godhuma (wheat), sarshapa (mustard), lavana (salts) and amla dravya (sour tasted medicaments) shall be used for swedana.
After swedana kushtadi churna powder shall be given.
This is followed by parisheka or sprinkling of mridvikadi taila (medicated oil) over the afflicted parts.
To pacify the pain, oil processed with vata alleviating herbs is used for parisheka.

Ushtragreeva Bhagandara Chikitsa

Ushtragreeva Bhagandara –

In this type of bhagandara, eshana or probing of the tract is done using probes. Later the tract is cut open with sterile sharp instruments and applied with kshara (alkalis).
Later paste of tila (sesame) mixed with ghee should be applied.
Following this dressing should be done with bandage.
Afterwards, parisheka (sprinkling or showering) of the afflicted area should be done with ghrita (ghee).
On the 3^rd day, the wise physician should remove the bandage and cleanse the wounds with teh medicines which alleviate pitta and tapa (temperature or heat).
After vrana shuddhi (cleansing of wound), ropana (medicines promoting healing) should be done.

Parisravi Bhagandara Chikitsa

Parisravi Bhagandara

The srava margas (tracts from which discharges are seen or openings through which oozing occurs) shall be cut open with sharp surgical instruments.
Following this kshara karma (alkali cauterization) or agni karma (fire cauterization) should be done. Following this seka or sprinkling should be done over the anal orifice using sukhoshna taila (lukewarm oil).
Pralepa (anointment) and or upanaha (poultice) should be applied using kshara (alkalis) and go mutra (urine of cow).
Parisheka (sprinkling or spraying or showering) of afflicted area should be done by using decoctions prepared with vamaka dravyas (emetic herbs).
By these procedures when teh discharges reduce and the pain also reduces, the bhagandara should be probed with eshana yantras or probes. Following this they should be cut open with the help of sterile surgical instruments. Following this the site should be cauterized with the help of kshara or agni.
Following this Mridu shodhana (mild cleansing) should be done followed by teekshna virechana (strong purgation).
Varti – wicks made by smearing paste of Aragwadha (Cassia fistula), Haridra (turmeric), Tagara (Valeriana wallichii), ghee and honey over a thick thread should be inserted into the fistula tracts for quick healing.

Agantuka Bhagandara Chikitsa

Agantuka Bhagandara –

In this the tract of Bhagandara should be split open with the help of sharp surgical instrument and later be burnt properly using shalaka yantra or tapta shalaka (instruments used for cauterization). The foreign material is removed from within the vrana (wound or tract). Later krimi nashaka chikitsa is done (medicines to destroy microbes and worms, like antibiotics).

Medicines for Bhagandara From Sahasra Yoga Text Book
Arsohara Kashaya
Tiktaka Ghrita
Mahatiktaka Ghrita
Pancha Tikta Guggulu Ghrita
Trikatwadi Choorna
Yogaraja Choorna
Guggulu Panchapala Choorna
Narasimha Choorna
Dasamoolarishta
Lohasava
Kautajadi Guda
Brihat Madhusnuhi Rasayana
Amruta Guggulu
Bhagandarahara Lepa
Neelakantha Rasa

Panchakarma treatment

Role of Panchakarma in the treatment of Anal Fistula (Bhagandara)
As explained above the below mentioned Panchakarma measures are useful in combating anal fistula vis-a-vis bhagandara in an effective way. Different Pancha karma measures shall be used at different stages of the disease for effective cleansing and healing and also for disease modulation. They shall be skilfully merged with good disease modifying medicines, diet and Rasayanas (immune-modulators).

Raktamokshana – Bloodletting is the first and most important measure to remove contaminated blood from the fistula tract.

Virechana – Therapeutic purgation is used in the Apakwa or unripe stage of the disease in combination with Langhana or lighting measures. Virechana also expels the morbidity and disease causing doshas from the system. Thus it acts like a cleansing measure apart from bringing about the ripeness of the wound or fistula tract. Virechana is also disease modifying.

Arsha Chikitsa

Treating Fistula-in-ano on the lines of Arsha Chikitsa (treatment of Piles)
Fistula-in-ano and piles have been treated on similar lines in Ayurveda. Medicines and treatments advised in Arsha chikitsa (treatment of piles of haemorrhoids) are highly effective in treating and curing fistula and other ano-rectal diseases effectively. They are also considered to be inter-related diseases. We can also find that the Agantuja type of Bhagandara has been named as Arsho-Bhagandara.

Pathya apathya – Yogaratnakara

Wholesome herbs, diet and habits

Rice, green gram, rice-gruel, meat of animals of desert-like land, pointed gourd, drumstick, thorn-apple, tender radish, sesame oil, mustard oil, bitter herbs, ghee, honey etc.

Unwholesome herbs, diet and habits

Exercise, sexual intercourse, riding on horse etc. animals, heavy to digest food substances etc.

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