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
- Palpation: One can feel indurated tract, fresh discharge of pus on palpation and mild tenderness.
- 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:
- Pregnancy
- Uncontrolled Tuberculosis
- Uncontrolled Hypertension
- 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:
- Cases not responding to above therapy
- Cases needing surgical intervention (Shastra Karma / Ksharasutra Chikitsa)
- 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
- Classical Vamana Karma
- 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.
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