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Fistula & Fissure - Ayurveda Treatment
WHAT IS AN ANAL FISTULA?
Anal fistula, or fistula-in-ano, is an abnormal connection or channel like structure, between the surface of the anal canal and the exterior perianal skin.
Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.
Ancient Ayurveda surgeon, Susruta has described five types of Bhagandara(Sataponak, Ustragriwa, Parisrabi, Sambukawarta, Unmargi). They have been classified according to the vitiation of the three doshas and the shape & site of the fistula tract.
CAUSES OF FISTULA?
Anal fistulas commonly occur due to an anal abscess.
An abscess is a collection of pus and infected fluid. An anal abscess usually develops after a small gland, just inside the anus, becomes infected with bacteria.
A fistula may occur if an abscess has not completely healed, or if the infected fluid has not been entirely drained away.
An anal fistula may also develop as a result of:
- a growth or ulcer (painful sore)
- a complication from surgery
- a congenital abnormality (a health problem that you were born with)
Anal fistulae are also a common complication of conditions that result in inflammation of the intestines. Some of these conditions include:
- Irritable bowel syndrome (IBS): a chronic (long-term) disorder that affects the digestive system, causing abdominal pain, diarrhoea and constipation.
- Diverticulitis: the formation of small pouches that stick out of the side of the large intestine (colon), which become infected and inflamed.
- Ulcerative colitis: a chronic condition that causes the colon to become inflamed and can cause ulcers to form on the lining of the colon.
- Crohn's disease: a chronic condition that causes inflammation of the lining of the digestive system.
SYMPTOMS OF FISTULA
Anal fistulae can present with many different symptoms such as:
- Discharge - either bloody or purulent
- Pruritus ani– itching around the anus
- Systemic symptoms if abscess becomes infected
DIAGNOSIS OF FISTULA
Diagnosis is by examination, either in an outpatient setting or under anaesthesia. The examination can be an Anoscopy.
- The opening of the fistula onto the skin may be seen
- The area may be painful on examination
- There may be redness
- A discharge may be seen
- It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula
AYURVEDA TREATMENT OF FISTULA
Kshara Sutra is utilized in the treatment of fistula in Ayurveda.
Kshara Sutra is a seton thread medicated with organic alkalis,such as Apamargakshara(Achyranthesaspera), Arkakshara(Caltropisgigantea) or Snuhikshara (Euphorbia lingularia). The alkali is repeatedly coated on the seton thread 15 – 21 times. Apart from this, natural antibiotic like haridra powder, guggulu, etc are also used to make Ksharasutra. The mechanical action of the threads and the chemical action of the drugs coated , collectively do the work of cutting, curetting, draining, and cleaning the fistulous track, thus promoting healing of the track/ wound. This also acts both as the antiseptic and fibrotic agent to induce healing. The process of healing starts from deeper tissues and moves towards the periphery. This can be applied and changed periodically till the thread cuts the fistulous tract. Since the sphincter heals by fibrosis, there is no incontinence.
Under local anaesthesia, the kshara sutra is inserted into the tract and the two ends of the thread are tied forming a loop. The alkalis coated on the thread are continuously released throughout the length of the track there by cutting, curetting, draining cleansing and healing the track. This therapeutic action of the thread lasts for seven days. The old thread is then replaced with a new thread following the same procedure. Depending on the length of the tract and the extent of damage, the kshara sutra may be changed up to 5 times. The changing of the thread is a simple procedure taking about 1 to 2 minutes and requires no anaesthesia.
BENEFITS OF KSHARA SUTRA
- The procedure does not require hospitalization for more than 4 to 5 hours
- The patient requires minimal bed rest and can resume daily activities within 12 – 24 hours
- No painful dressings required
- The drugs coated on the Kshar-Sutra are slowly and gradually released into the track and the wound, leaving no abscess overseen. These abscess are drained out by the action of the drugs.
- The sphincteric muscles are not dissected and hence the possibility of incontinence is ruled out.
COMPLICATIONS OF FISTULA
Depending on the effectiveness of the treatment, fistula may result in infection or incontinence of stools.
RECURRENCE OF FISTULA
The reoccurrence rate of fistula treated with kshara sutra ligation procedure is less than 2%. This is because the medicines on the thread gradually and continually curate the payogenic membrane and fibrous tissue in the track and thus leave no pus pockets undrained.
In some cases, the fistula can reoccur despite having surgery. After having a fistulotomy, the reoccurrence rate rises to 21%. After an advancement flap procedure, the reoccurrence rate may be as high as 36%.
What is a fissure?
An anal fissure is a small tear in the skin that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. An anal fissure typically causes pain and bleeding with bowel movements.
Anal fissures most often affect people in middle age, but fissures also are the most common cause of rectal bleeding in infants. Most anal fissures heal within a few weeks with treatment for constipation, but some fissures may become chronic
COMMON CAUSES OF ANAL FISSURES
Anal fissures can be caused by trauma to the anus and anal canal. The cause of the trauma can be one or more of the following:
- Chronic constipation
- Straining to have a bowel movement, especially if the stool is large, hard, and/or dry
- Prolonged diarrhea
- Anal stretching
- Insertion of foreign objects into the anus
Other causes of anal fissures (other than trauma) include:
- Longstanding poor bowel habits
- Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)
- Scarring in the anorectal area
- Presence of an underlying medical problem: such as Crohn’s disease and ulcerative colitis; anal cancer; leukemia; infectious diseases (such as tuberculosis); and sexually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)
- Decreased blood flow to the anorectal area
SYMPTOMS OF ANAL FISSURE
Signs and symptoms include:
- Pain during, and even hours after, a bowel movement
- Blood on the outside surface of the stool
- Blood on toilet
- A visible crack or tear in the anus or anal canal
- Burning and itch that may be painful
- Discomfort when urinating, frequent urination, or inability to urinate
- Foul-smelling discharge
RISK FACTORS FOR ANAL FISSURES
Factors that may increase your risk of developing an anal fissure include:
- Infancy. Many infants experience an anal fissure during their first year of life, although experts aren't sure of the reason.
- Aging. Older adults may develop an anal fissure partly because of slowed circulation, resulting in decreased blood flow to the rectal area.
- Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.
- Childbirth. Anal fissures are more common in women after they give birth.
- Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing
PREVENTION OF ANAL FISSURES
For fissures in adults:
- Keep the anorectal area dry
- Wipe the area with soft materials, a moistened cloth, or cotton pad; avoid rough and scented toilet paper
- Promptly treat all occurrences of constipation and diarrhea
- Avoid irritating the rectum
AYURVEDA TREATMENT FOR ANAL FISSURES
Ayurveda advises internal medication as well as topical ointment application in the treatment of anal fissures. To avoid further irritation to the damaged tissue, medicines which soften the stools and promote healing of the tissues are utilized. Ointments which are natural anti-bacterial and anti-septic are used for topical application.
COMPLICATIONS OF ANAL FISSURES
Complications of anal fissure can include:
- Anal fissure that fails to heal. An anal fissure that doesn't heal can become chronic, meaning it lasts for more than six weeks.
- Anal fissure that recurs. If you've experienced anal fissure once, you have an increased risk of another anal fissure.
- A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter). This makes it more difficult for your anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medications or surgery to reduce the pain and repair or remove the fissure.