Ayurveda Treatment Methods

A Guide Line To Ayurveda Treatments & Principles

 BHAGANDARA (FISTULA-IN-ANO)  Treatment Protocol by Ayush

 

 

INTRODUCTION

Bhagandara is a Marmaasrita Vyadhi which affects Bhaga, Guda & Basti, characterized by the tract formation, tearing & multiple openings in the perineal region (Bhaga Pradesha) around anus & urethra, through which discharge of pus, urine, feces, semen, flatus etc. may occurs. It is a disease of Madhyama Rogamarga which lists under Ashta Mahagada. It is a Krichrasadhya Vyadhi. According to Dosha predominance, 8 types of Bhagandara are described by different Acharyas. It can be compared to Fistula-in-ano in terms of Modern Science.

Case Definition:

One or more than one external opening present anywhere around the anus i.e. in peri-anal area as an elevation of granulation tissue with discharge of pus and associated with pain and itching.

Various Presentations:

Due to predominance of particular Dosha, various kinds of presentations my found. Types described by Sushruta Acharya are as follows:

 

Table 15.1: Types of Bhagandara with their characteristics

 

 

Features

Shataponaka

Ushtragriva

Parisravi

Shambuk-avarta

Unmargi

Dosha predominance

Vatika

Paittika

Kaphaja

Sannipatika

Agantuja

Possible Modern Correlation

Multiple fistulas

-

-

Horse shoe fistula

-

Structural change

Multiple small, tiny openings

Initially red coloured thin boil followed by quick suppuration.

Initially whitish, long standing boil developed in hard, smooth fistula

Initially a big boil

Ulceration converts into Kotha and finally developed as Fistula

Discharge

Profound, clean frothy discharge

Foul smelling, hot discharge.

Continuous sticky and whitish discharge

Discharge of various colours

-

Associated

symptoms

Cutting or pricking type pain.

Severe burning.

severe itching

Pricking pain, burning and itching together.

Krimi (micro organism)

 

 

Three more types are mentioned by Vagbhata Acharya which comes under Dosha Samsargaja variety.

Table 15.2: Another classification of Bhagandara based on Dosha Samsarga

 

Features

Parikshepi

Riju

Arsho

Doshik

predominance

Vata Pittaja

Vata Kaphaja

Kapha Pittaja

Structural change

Circular fistula around anus

Straight fistula Tear in rectum

Swelling, later developed as fistula

Discharge

-

-

Continuous discharge

Associated

Symptoms

-

-

Severe itching & burning

 

 

Differential Diagnosis:

  • Arsha (Haemorrhoids)
  • Gudabhramsha (Rectal prolapse)
  • Parikartika (Fissure-in-ano)
  • Ano-rectal carcinoma
  • Ano-rectal abscess
  • Diverticular Disease
  • Herpes Simplex
  • Inflammatory Bowel Disease
  • Pilonidal Cyst and Sinus
  • Proctitis

LEVEL 1: AT SOLO AYURVEDA PHYSICIAN’S CLINIC / PHC

Clinical Diagnosis: On the basis of history and clinical presentation, patient can be diagnosed provisionally as case of Bhagandara.

 

Examination: Following examinations will help in the confirmation of diagnosis.

Hard stool mass with line of pus/ blood on the direction of fistulous tract opening

  1. Palpation: One can feel indurated tract, fresh discharge of pus on palpation and mild tenderness.
  2. Digital Examination (Per-rectal): It can reveal internal opening palpable as a nodule, which can be in the straight line to the external opening or at 6 o’clock in lithotomy position and about middle of the anal canal.

Treatment: In the initial stage when the patient is having mild features of Bhagandara, along with diet restriction, two or more of following drugs may be given.

 

 

Table 15.3: Medicines at level 1 for Bhagandara

 

Drugs

Dosage form

Dose

Time of administration

Duration

Anupana

Haritaki Churna1

Churna

2-4 gm

Empty stomach /

at bed time or early morning

2-3 weeks

Luke warm water

Triphala Churna2

Churna

2-4

gm

Empty stomach /

at bed time or early morning

1-2 weeks

Luke warm water

Draksha3

Dried fruit

10-20 gm

Empty stomach /

at bed time or early morning

1-2 weeks

Luke warm water

Aragvadha4

Churna

2-4 gm

Empty stomach /

at bed time or early morning

1-2 weeks

Luke warm water

Castor oil5

Oil

10-20 ml

Empty stomach /

at bed time or early morning

1-2 weeks

Luke warm water

Avipattikara Churna6

Churna

5-10 gm

Empty stomach /

at bed time or early morning

2-5 days

Water

Abhayarishta7

Arishta

10-20 ml

After meals /

twice a day

1-2 weeks

Equal quantity of water

Thriphala Guggulu8

Vati

500 mg (2 Vati)

After meals /

thrice a day

1-2 weeks

Luke warm water

Surana Vataka9

Vataka

500 mg

After meals /

twice a day

1-2 weeks

Luke warm water

 

 

Local or External Application:

v Ushnodaka Avagaha (Hot sitz bath) with 100 ml of Panchavalkala Kwatha or Triphala Kwatha10 twice a day

v Jatyadi Taila11, 5-10 ml P/R, twice a day, after Ushnodaka Avagaha

Pathya-Apathya (Diet and life style):

Do’s -

  • Ahara: Green gram, fruits like Draksha, orange juice, sweet lemon juice, musk melon, salads prepared

from cabbage, cucumber, carrot and spinach, green leafy vegetables, Surana, Patola, gourd, intake of sufficient quantity of warm water.

  • Vihara: Regular exercises like walking, jogging, outdoor games, following daily & seasonal regimen properly.

Don’ts –

  • Ahara: Heavy food articles and preparations, green peas, black eyed beans, yellow gram, raw vegetables

 

and salads, refined foods such as white flour, cabbage, cauliflower, brinjal, peas, potatoes

  • Vihara: Jobs involving sedentary activities, continuous standing, or sitting for long durations on hard seats, continuous bicycle, bike or horse riding etc.

Referral Criteria:

  • Cases not responding to above therapy.
  • Development of complications
  • Fistula-in-ano cases associated with one or more of the following conditions:
  1. Pregnancy
  2. Uncontrolled Tuberculosis
  3. Uncontrolled Hypertension
  4. Uncontrolled Diabetes mellitus

LEVEL 2: CHC’S OR SMALL HOSPITALS WITH BASIC FACILITIES

Clinical Diagnosis: Same as level 1 for fresh cases reporting directly. A patient presenting in an advance stage of Fistula-in-ano would have Doshika Lakshanas of Bhagandara and after examining the case thoroughly, the selection of drugs may be done.

Investigations:

1) Digital Examination

2) Proctoscopy

3) Fistulogram

4) Trans-rectal Ultrasonography

Treatment: In addition to the management mentioned in Level 1, few of the following drugs may be added as per the requirement and status of the patient. Patient should be kept under observation while prescribing these kinds of medicines.

 

Table 15.4: Medicines at level 2 for Bhagandara

 

Drugs

Dosage form

Dose

Time of administration

Duration

Anupana

Guggulu Panchapala Ch.

Churna

2-4 gm

Empty stomach /

at bed time or early morning

2-3 weeks

Madhu

Yogaraja Churna*

Churna

2-4 gm

Empty stomach /

at bed time or early morning

2-3 weeks

Madhu

Arogyvardhini Vati12

Vati

1-2 Vati

Empty stomach /

at bed time or early morning

1-2 weeks

Luke

warm water

Arshakuthara Rasa13

Vati

1-2 Vati

Empty stomach /

at bed time or early morning

1-2 weeks

Luke

warm water

 

Drakshasava14

Asava

20-40 ml

After meal /

twice a day

1-2 weeks

Equal quantity of water

Kumaryasava15

Asava

20-40 ml

After meal /

twice a day

1-2 weeks

Equal quantity of water

Phalatrikadi Kwatha16

Kwatha

20-40 ml

Empty stomach / twice a day

1-2 weeks

-

Erandamula Kwatha

Kwatha

20-40 ml

Empty stomach / twice a day

1-2 weeks

-

Trayodashanga Guggulu17

Vati

2-3 Vati

After meal /

thrice a day

2-3 weeks

Luke warm water

Shodashanaga Guggulu

Vati

2-3 Vati

After meal /

thrice a day

2-3 weeks

Luke warm water

Kaishore Guggulu18

Vati

2-3 Vati

After meal /

thrice a day

2-3 weeks

Luke warm water

Saptavimshati Guggulu19*

Vati

2-3 Vati

After meal /

thrice a day

2-3 weeks

Luke warm water

 

 

 

*Contraindicated in Pitta Rakta predominance

 

Pathya - Apathya (Diet and life style education): Same as Level -1

Referral Criteria:

  1. Cases not responding to above therapy
  2. Cases needing surgical intervention (Shastra Karma / Ksharasutra Chikitsa)
  3. Associated with diseases like Osteomy­elitis, chronic or acute Ulcerative Colitis, Crohn’s disease etc.

LEVEL 3: AYURVEDA HOSPITALS AT INSTITUTIONAL LEVEL OR DISTRICT

HOSPITAL / INTEGRATED AYURVEDIC HOSPITALS

Clinical Diagnosis: Same as level 1 for a fresh case reporting directly

 

Investigations: Same as level 2

Treatment: At this level, the following treatment options may be applied in addition to treatment option available at level 1 and 2.

In addition to the treatment prescribed in level-1 and 2, following procedures can be done

  1. Classical Vamana Karma
  2. Classical Virechana Karma

Management for Pakwa Bhagandara Pidika:

Shastra Karma: After proper Snehana and Swedana, Pakwa Pidika should be incised and drained from most prominent and dependent part. After that packing should be done with sterilized dressing materials and bandage it properly. From next day onwards, dressing should be changed daily with appropriate

 

 

Shodhana materials. After complete Shodhana of Vrana, Ropana Karma should be done with appropriate drugs.

Management for established cases of Bhagandara:

  • Shastra Karma
  • Ksharasutra Chikitsa: Ksharasutra can be prepared with Haridra20, Snuhiksheera21, Arkaksheera22 etc.

Pathya - Apathya (Diet and life style education): Same as level 1

Note: Treatment of Parikartika can also be applied in the management of Bhagandara.

REFERENCES

 

 

  1. Anonymous, The Ayurvedic Pharmacopoeia of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 Vol.1 (31).
  2. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (7:15).
  3. Anonymous, The Ayurvedic Pharmacopoeia of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 Vol 3 (21).
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  5. Anonymous, The Ayurvedic Pharmacopoeia of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 Vol 3 (23).
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  9. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (12:34).
  10. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (7:15).
  11. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (8:17).
  12. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (20: 4).
  13. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 2 (16 : 2).
  14. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 2 (1 : 1).
  15. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1, (36).
  16. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 2, (4 : 16).
  17. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1, (5 : 4).
  18. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (5: 2).

 

 

  1. Anonymous, The Ayurvedic Formulary of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 (5: 11).
  2. Anonymous, The Ayurvedic Pharmacopoeia of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 Volume 1 (30).
  3. Anonymous, The Ayurvedic Pharmacopoeia of India, Ministry of Health and Family Welfare, Govt. of India, Part 1 Volume 1 (63).
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