Bhagandara/Fistula in Ano treatment in Ayurveda

 

Bhagandara

Introduction:

Bhagandara is laceration of anal region (fistula). According to Sus`hruta it is one of the Mahaavyaadhi.

Nirukti:

o Te Tu Bhaga Guda Basti Prades`ha Daaran`aat Cha Bhagandaraa Iti Uchyante |

o Bhagam Parisamantaat Cha Gudam Bastim Tathaa Eva Cha |

o Bhagam Daarayati Tasmaat Tat Dnyeyo Bhagandarah || M. N. 46/1 Madhukos`ha

 

Whenever an Pid`akaa (abscess) formed at the sites like perineal region (Bhaga), anal region (Guda) and bladder region (Basti) bursts out after suppuration, it causes tearing of the skin making an opening on the surface of skin, this is called as Bhagandara.

 

Manifestation of Bhagandara:

Due to Krimi, Asthi, Kshan`ana, Vyavaaya, Pravaahan`a, Utkat`akaasana, there is manifestation of abscess (Pid`akaa) with excessive pain (Bhris`ha Arti) at the anal region. This Pid`akaa gets suppurated and bursts out, which leads to Bhagandara. After suppuration, the Pid`akaa is called as Bhaagandaree Pid`akaa.

 

Types:

There are 5 types of Bhagandara according to Sus`hrita.

1. S`hataponaka
2. Usht`ragreeva
3. Parisraavee
4. S`hambookaavarta
5. Unmaargee

 

Doshabhedena:

1. Vaataja
2. Pittaja
3. Kaphaja
4. Vaatapittaja
5. Vaatakaphaja
6. Kaphapittaja
7. Saannipaatika
8. Aagantu

 

If the Pid`akaa is not treated at proper time, this leads to formation of Bhagandara. Bhaga, Basti and Guda, these areas get lacerated. There is secretion of Vaata, Mootra, S`hukra in succession.

 

Sampraapti:

S`hataponaka:

S`hataponaka Chaalanikaa, Sahasra Dhaaraa Iti Anye |

S`hataponakavad Anekamukhaakaara Bhagandarah | M. N. 46/2 Madhukos`ha

 

1. In a person who is consuming unwholesome diet, aggravated Vaayu residing at the periphery of anal region 2 to 3 Angula in length, vitiates Rakta and Maamsa. It causes Arun`a Varn`ee Pid`akaa of (reddish colour).
2. Due to this Pid`akaa, a person suffers from pain. If this is not treated then it gets suppurated.
3. As it is near the urinary bladder, it gets vitiated (Praklinna).
4. This Pid`akaa may have hundreds of (many) small openings.
5. These openings discharge with continuous frothy secretions.
6. At the site of Vran`a, there are different types of pain like Taad`ana, Bhedana, Chhedana, Todana.
7. Ultimately, the anal region gets lacerated. At this stage also if at all it remains untreated, then Vaata, Pureesha, Retas may get secreted through these openings.
8. This type of Bhagandara is called as S`hataponaka.

Usht`ragreeva:

Atra Pid`akaavasthaagatagalavaktratvena Usht`ragreevaakaaratvam, Tena Usht`ragreeva Samdnyaa | M. N. 46/3, 4 Madhukos`ha

 

1. Aggravated Pitta is carried towards the anal region by Vaayu.
2. It gets resided around the anal region in the periphery.
3. It manifests with a Pid`akaa which is red colored, thin, elevated and resembles to Usht`ragreevaa. (neck of the camel)
4. It causes different types of pains. It remains untreated, it gets suppurated.
5. There is a burning sensation as if the wound is being burnt by fire or alkali (Agni and Kshaara)
6. There is discharge having the foul smell and hot property.
7. Then also, if remains untreated, it may secrete Vaata, Mootra, Pureesha and Retas.
8. This type of Bhagandara is called as Usht`ragreevaa.

 

Parisraavee:

Ghanasraava Yogaat Parisraavee | M. N. 46/5 Madhukos`ha

 

1. Aggravated Kapha is carried by the Vaayu towards anal region.
2. It gets resided around the anal region in the periphery.
3. It manifests with a Pid`akaa which is white (S`hukla), Sthira, Kan`d`oomatee (with itching).
4. It remains untreated, it gets suppurated.
5. The wound becomes hard (Kat`hina) and Samrambhee, more with itching.
6. It discharges with the sticky secretions (Pichchhila).
7. Then also, if remains untreated, it may secrete Vaata, Mootra, Pureesha and Retas.
8. This type of Bhagandara is called as Parisraavee.

 

S`hambookaavarta:

Poorn`a Nadyaavarta S`hambookaavartaakaaren`a Avagatvaad Avagaad`ha Vedanaa Bhavanti | S. Ni. 4/8 D`alhan`a

 

S`hambookaavartavad Aavartam Vedanaa Doshagati Vis`heshaad Bhavanti Iti S`hambookaavartah | M. N. 46/6

 

1. Aggravated Pitta and Kapha are carried towards the anal region by Vaayu.
2. They cause a Pid`akaa similar in size of thumb of foot.
3. This Pid`akaa gets manifested with the symptoms by all the three Dosha.
4. It causes different types of pain like Toda, Daaha, Kan`d`oo etc.
5. The wound secretes different types of secretions in color.
6. The pains in this type of Bhagandara are as severe as the whirlpool of the fully flooded river.
7. Therefore, it is called as S`hambookaavarta.

 

Unmaargee:

Unmaargen`a Vikrita Gati Maargen`a Pureeshaadigamanaat Unmaargee Samdnyaa | M. N. 46/7 Madhukos`ha

 

1. When a stupefied person consumes meat with bones, then this Asthi (bone) passes with the stools which causes tear in the anal region and causes putrefaction in the wound.
2. In this vitiated wound where Maamsa is putrefied with Rakta and pus, maggots (Krimi) are formed. They eat the region causing tears.
3. Through this wound created by Krimi, Vaata, Mootra and Pureesha, Retas are secreted.
4. This type of Bhagandara is called as Unmaargee.

 

Parikshepee:

This Bhagandara is manifested around the anus like a trench round a town or fort.

This is caused due to Vaata and Pitta.

 

Riju:

This type of Bhagandara is caused due to Vaata and Kapha.

This Bhagandara tears anus in a straight direction towards anus.

 

Ars`hobhagandara:

There is S`hotha at the root of the Ars`ha. There is Kan`d`oo and Daaha. Here, Kapha and Pitta gets aggravated. This S`hotha bursts out causing wetness at the root of the Ars`ha. This is called Ars`hobhagandara.

Difference between Pid`akaa and Bhaagandaree Pid`akaa:

Pid`akaa	Bhaagandaree Pid`akaa
Alpa Vedanaa Pid`akaa	With severe Vedanaa (Rug Aad`hya)
S`hotha pacifies earlier	S`hotha does not pacifies easily
Not so close to the anal region	They are near to anal region around anus of 2 to 3 Angula in diameter
Not so deeply rooted	Deeply rooted (Good`hamoolaa) with inflammation. It vitiates after healing also.

Vaataja Pit`ikaa:

It is S`hyaava, Arun`a in color.

There is Toda, Bheda, Sphuran`a and Rujaa.

 

Pittaja Pit`ikaa:

This is thin Pit`ikaa elevated like Usht`ragreeva.

There is redness at the site (Raaga). Temperature is elevated at the site (Ushmaad`hyaa).

Other signs are Jvara and Dhoomaayana.

 

Kaphaja Pit`ikaa:

Sthira (stable not increasing or decreasing in size)

Snigdha

Deeply rooted (Mahaamoola)

Whitish in color (Paan`d`u)

 

Vaata Pittaja Pit`ikaa:

Paan`d`ura

Dark brown in color (Kinchid S`hyaava)

It does not suppurate easily (Krichchhrapaaki).

Sarva Doshajaa Pit`ikaa:

It resembles to the shape and size of thumb of foot.

It manifests with different pains.

There is S`hoola, Arochaka, Trishn`aa, Daaha, Jvara, Chhardi.

All these types of Pit`ikaa get suppurated if remain untreated.

 

Correlation of types of Pit`ikaa and Bhagandara:

Type of Pit`ikaa	Type of Bhagandara
Vaataja Pit`ikaa	S`hataponaka
Pittaja Pit`ikaa	Usht`ragreeva
Kaphaja Pit`ikaa	Parisraavee
Vaatapittaja Pit`ikaa	Parikshepee
Vaatakaphaja Pit`ikaa	Riju
Kaphapittaja Pit`ikaa	Ars`hobhagandara
Sarva Doshaja	S`hambookaavarta
Aagantu (Kshataja Unmaargee)	Kshataja

 

Asaadhya Criteria:

1. Vaata Sraavee Bhagandara
2. Mootra Sraavee Bhagandara
3. Pureesha Sraavee Bhagandara

 

Comparative study of Bhagandara

	Bhagandara	S`hataponaka	Usht`ragreeva	Parisraavee	S`hambookaavarta	Kshataja (S`halya nimittaja)
Rogamaarga	Madhyama
Svabhaava	Mahaavyaadhi Ghora
Avayava	Guda Bhaga Basti
Krichchhra	Kasht`asaadhya	Sukumaara Bheeru
Asaadhya***	Sevanee Praapta Bhagandara Valee Praapta Bhagandara			Asaadhya		Asaadhya
Dosha		Vaata Prakopa	Pitta Prakopa	Kapha Prakopa	Vaata Prakopa Pitta Prakopa Kapha Prakopa
Dhaatu		Maamsa Dusht`i Rakta Dusht`i	Maamsa Dusht`i Rakta Dusht`i	Maamsa Dusht`i Rakta Dusht`i	Maamsa Dusht`i Rakta Dusht`i
Srotas		Maamsavaha Raktavaha Pureeshavaha	Maamsavaha Raktavaha	Maamsavaha Raktavaha	Maamsavaha Raktavaha
Avayava	Guda Bhaga Basti

 

 

 

*** As per Vaagbhat`a, Saannipaatika and Aagantu (Kshataja) are Asaadhya.

 

 

 

 

 

BhagandaraChikitsaa

Reference:

C.Chi.12, S.Chi.8, A.H.U.28, N.R. Bhagandara

Introduction:

Bhagandara is anal fistula. Generally, while treating Bhagandara, principles to treat Vran`a should also be applied.

 

Chikitsaa

Prior to manifestation of Bhagandara, BhagandariPit`ikaa appears. It is necessary to avoid suppuration in the Pit`ikaa. For this purpose, RaktaSraava andSeka could be done. Then also, if the Pit`ikaa gets suppurated, then Snehana, Svedana, AvagaahaSveda should be done.

Bhagandara should be treated with following modalities:

1. Virechana
2. Eshan`a(to know the direction of the Bhagandara tract using probe)
3. Paat`ana

When Bhagandara becomes clean (free from vitiated Dosha) with above four Chikitsaa Karma, it is to be burnt / cauterized by using oil i.e. TailaDaaha

Ks`haarasootra should be used in Bhagandara management.

When the tract of Bhagandara is split open with the Kshaara, it should be treated like a Vran`a.

If BhaagandareePid`akaa is Apakva (not perforated and without suppuration), then it is to be treated with the procedures in following order

1. Apatarpan`a
2. Aalepa
3. Parisheka
4. Abhyanga
5. Sveda
6. Vimlaapana
7. Upanaaha
8. Paachana
9. Visraavan`a
10. Snehana
11. Vamana
12. Virechana

 

S`hataponaka Chikitsaa

If BhaagandareePid`akaa is Pakva i. e. spontaneously perforated and with suppuration, it should be treated in the following manner

o Snehana

o Avagaaha Sveda

Bhagandara should be examined with the procedure same as that of Ars`ha

Bhagandara may be having opening internally or externally.

Using probe (Eshan`aa), its direction should be defined and in that direction, incision to be made.

This is to be done for both the types of Bhagandara having opening internally or externally.

After that, Agni Karma or Ks`haara Karma is to be done.

This is the general treatment for all the types of Bhagandara.

If the Bhagandara tract is incised more than once it may lead to widening the anus and even urine and stools may pass through it. Repeated incisions vitiateVaayu which causes GudaS`hoola (pain in ano rectal region), Aat`opa (gurgling in the abdomen). Hence it is advisable to avoid repeated surgery.

If anal perforation or laceration occurs, it may lead to death. (Guda is a Praan`aayatana and SadyahPraan`aharaMarma)

In S`hataponaka, the incision should be

o Ardhalaangalaka plough like

o Laangalaka

o Sarvatobhadra – military array

o Goteerthaka it suggests flexibility of the incision. Multiple and flowing incisions can be taken, It resembles the external genitalia of a cow / oblong or it could resemble the pug marks of a cow at their drinking place.

After that, Agnikarma / cauterization should be done.

S`hataponaka is difficult to cure in Sukumaara and Bheeru persons.

After the S`hastrakarma, following is the advised regime

1. SvedanaBy using Kris`haraa, Paayasa, made from Graamya, Aanoopa, Audaka, VishkiraMaamsa; Kvaatha of Vrikshaadanee, Eran`d`a, Bilva should be used for Naad`eeSveda.
2. After the Svedana, Kusht`ha, Lavan`a, Vachaa, Hingu, AjamodaaChoorn`ashould be given internally with Ghee or Maardveeka or AmlaDravya; depending upon the Dosha and Avasthaa.
3. Parisheka should be done with MadhukaTaila.

 

Usht`ragreevaChikitsaa

Usht`ragreevaBhagandara is to be incised first, after probing.

Kshaara is applied.

Agni Karma is contraindicated.

Paste of Tila and Ghee is to be applied on the wound.

GhritaParisheka also can be done.

Then it is to be bandaged Gophan`aaBandha for three days.

After Vran`a S`hodhana, the wound is to be applied with healing agents.

Ropan`aKriyaa – After removal of bandage and examination of the wound.

The Antarmukha type of Bhagandara should be incised with a S`hastra after probing.

The BahirmukhaBhagandara, should be treated with Ks`haara Karma only.

 

ParisraaveeBhagandaraChikitsaa

Utkartana (incised) of the passage with secretions should be done.

Kshaara Karma or Agnikarma should be done.

Followed by An`utailaParisheka

Upanaaha, Pradeha with Mootra and Kshaara should be used.

Parisheka could also be done with VaamakaAushadha.

Probing should be done (Eshan`a), and Chhedana should be done of the Bhagandara in various ways

1. Kharjoorapatraka
2. Chandraardha
3. Chandrachakra
4. Soocheemukha
5. Avaanmukha

After the incision, Kshaara / Chemical cauterization, Teekshn`aS`hodhana should be done.

Bhagandara in the children, which may be having opening towards inner or outer side (Antarmukhee or BahirmukheeBhagandara), is not to be treated with

1. Virechana
2. Agni Karma
3. S`hastra Karma
4. Kshaara Karma which should not be excessively mild or strong should be used in children.

KshaaraSootra could be applied even in children according to Vaagbhat`a.

 

AagantuBhagandaraChikitsaa

AagantuBhagandara is to be incised.

Agni Karma should be done by using Jaambavausht`haS`halaakaa.

If there is any incumbent S`halya (foreign body), it is to be removed.

KrimighnaChikitsaa should be done.

 

KshatajaBhagandaraChikitsaa

This is Pratyaakhyaaya.

It should be treated with the knowledge that it is incurable.

Foreign body if present should be removed first.

KrimighnaChikitsaa is advised by Vaagbhat`a.

Pin`d`a and Naad`eeSveda should administered after Snehana, especially when there is pain, to relieve local pain.

 

AavasthikaChikitsaa

Ars`hoBhagandaraChikitsaa

In the Ars`hoBhagandara, Ars`ha should be treated first.

 

S`hastrakarmaChikitsaa (after incision of Bhagandara)

• After S`hastrakarma, to reduce pain, following Chikitsaa Karma should be performed.

An`utailaParisheka – by

Sneha Parisheka

BaashpaSveda

Avagaahana

• All the Bhagandara should be treated with Agnikarma, cauterization of the Bhagandara tract renders the wound clean and prevents its recurrence.
• Kosht`ha S`huddhi of the patient is always the first step of treatment.

 

Precautions

Following things should be avoided for one year after Bhagandara is treated successfully

1. Vyaayaama
2. Maithuna
3. Kopa
4. Prisht`hayaana traveling on back of fast moving vehicles
5. Guru Bhojana
6. MadyaPaana
7. Ajeern`a
8. Asaatmya
9. Saahasa

Pathya –

Rasa – Amla Tikta

Gun`a / Karma – Deepana

Dhaanya – S`haalee, Kulattha

S`haaka – Vetaagra, Pat`ola, S`higruphala, Jalapippalee, Moolaka

S`himbee – Kulattha, Mudga

Maamsa – JaangalaMaamsarasa

Dugdha – Ghrita

Drava – Tila Taila, Sarshapa Taila

Kritaanna – Vilepee, Madhu, Suraa, Sauveeraka, Jambooka Maamsajanita Padaartha

Other – Lepa, Langhana, S`hodhana, Raktamokshan`a (In Apakvaavasthaa)

Apathya –

Rasa – Amla, Madhura

Gun`a / karma – Guru

Maamsa – Aanoopa Maamsa

Dugdha – Dugdha, Dadhi

Kritaanna – S`higrujanya Padaartha

Other – Vyaayaama, Maithuna, Kopa, Prisht`hayaana, Madyapaana, Ajeern`a, Asaatmya, Atisaahasa