Fistula Treatment

Fistula-in-ano is well known for its high rate of recurrence so the best Fistula-in-Ano treatment would be only which assures NO RECURRENCE without any other complication.

Fistula-in-Ano is an infected tunnel between the skin and the anus with two openings. Its primary opening lie inside the anal canal which might be closed sometime due to an attempt of the body to heal it. Whereas the secondary opening lies on the skin in the area around the anal opening.

Most anal fistulas are the result of infection in anal glands which spreads to the skin.

Symptoms include a nodular swelling or an opening in the area near the anal opening. There is intermittent pus discharge from this swelling or opening. Once the pus has been discharged; the patient feels that he is alright as there is no swelling or pain after pus discharge. Soon pus starts accumulating there and the patient experiences swelling and pain.

Bowel movement may aggravate the pain especially if the stool is hard. This cycle of recurrent swelling and pain followed by pus discharge and pain subsidence continues to increase the severity of the problem.

Why Ayurvedic/ Ksharsutra treatment is the best Fistula-in-Ano Treatment

Many treatment modalities are available to treat Fistula with varying rates of success. So a Fistula patient finds it very difficult to decide which treatment to adopt. Here we are listing a few advantages of Ksharsutra treatment so that you can make an informed decision

Keeping all the above observations in mind; one can conclude that Ksharsutra treatment is the best treatment for Fistula-in-Ano available to date. So a patient suffering from Fistula-in-Ano should opt for Ksharsutra Treatment for complete recovery.

What is Ksharsutra/ Best Fistula-in-Ano Treatment?

What is Ksharsutra

In word Ksharsutra- Kshar stands for a specialized ayurvedic medicines prepared from the ashes of Apamarga/ Yava/ Til Naal etc. which is alkaline in nature and sutra stands for a thread. So Ksharsutra is a medicated thread. Here thread in itself has no role in treatment it only works as the vehicle for the application of medicine at a desired site.

Ksharsutra preparation

Ksharsutra is prepared by coating a linen thread with latex of Snuhi (Euphorbia neriifolia Linn), Apamarga Kshar (Kshar prepared from Apamarga – Achyranthes aspera) and Haridra (Curcuma longa). In total 21 coating of these medicines are done one by one on the thread. Afterward, ultraviolet radiations are used to sterilize the prepared Ksharsutra.

Ksharsutra Treatment procedure:

Before starting Ksharsutra treatment all routine checkups are done. During checkup; a Ksharsutra expert gives special emphasis on the simultaneous possibility of other diseases like Diabetes/ Tuberculosis/ Ulcerative colitis/ Hypertension etc. Then comes the proper defining of the fistulous tract with special reference to its length, depth, and branching pattern. In majority of cases; probing by a soft malleable metallic probe is enough to get all these details. If the fistula is deep enough to be properly defined by manual probing or branching pattern of the fistula is in doubt; a Ksharsutra expert advises going for an MRI Fistulogram/ Ultrasound.

Once the Ksharsutra expert has defined the fistula tract properly by probing; he inserts Ksharsutra in the fistula tract through the external opening which comes out from the Anal opening. Then the expert puts a knot on both the ends of Ksharsutra. Medicines present on Ksharsutra debride the Fistula tract and induce healing. This medicine works for 5-7 days so after every week/ 10 days time interval; old Ksharsutra is replaced by a new one. Number of Ksharsutra changes required for complete healing of fistula depends on length, depth and branching pattern of fistula tract.

It is a common practice to measure the length of ksharsutra at every ksharsutra change sitting to assess the progress of treatment. It is observed that the Fistula heals @ 0.5 to 1 cm per ksharsutra change sitting. So a fistula tract of 3 cm length may require 4-6 Ksharsutra change sittings at a week or 10-day time interval.

Causes of Fistula-in-Ano

There are many glands inside the anus which secrete very small quantities of fluid. The exact function of these glands in human beings is still uncertain. When something clogs the opening of any of these glands; it will result in the accumulation of fluid leading to infection and abscess formation namely perianal abscess. When this perianal abscess is not treated properly; it results in further spread of the pus and accumulated fluid; which finally bursts through an opening in the skin near the opening for stool passage. Here one thing needs to be made clear that all perianal abscesses do not turn in Fistula-in-Ano. It is only when the abscess is not treated in time and properly; it turns to be Fistula-in-Ano.

Here are some factors that make a person more prone to Fistula-in-Ano:

Symptoms of Fistula-in-Ano

Types of Fistula-in-Ano:

According to the relation of Fistula tract with sphincter muscles Fistula-in-Ano is of following types:

As the name tells; this fistula tract lies in the space between internal and external sphincter muscles. In this type of fistula; the external opening is usually very close to the mouth of the anus.

This tract also begins in the space between the internal and external sphincter muscles or the space behind the anus. But it pierces the external sphincter muscle to open up externally. Usually, the external opening lies about 3-5 cm from the mouth of anus. In some cases; it can pierce on both sides with visible external openings on both sides of the anus (called a horseshoe-shaped fistula).

The tract begins in the space between the internal and external sphincter muscles but instead of piercing the external sphincter, it turns upward to reach above the puborectalis muscle, then extends downward to open an inch or two away from the anus.

The tract begins very high at the rectum or sigmoid colon and extends downward, passing through the levator ani muscle opens around the anus. These fistulas usually result from an appendiceal abscess, diverticular abscess, or Crohn’s disease.

When Fistula tract has crossed 30-50% of external sphincter, has multiple branches and recurrent in nature.

When both the openings are insides the anus; the fistula is usually Submucosal

Best Treatments for Fistula-in-Ano:

Before discussing about the best treatment for Fistula-in-Ano; we wish to make one thing clear that oral medicines could not treat Fistula-in-Ano; Allopathic/ Homeopathic/ Ayurvedic whatever it may be. Understanding this fact; doctors have tried different treatments to treat Fistula-in-Ano with different success rates. Some of these treatment options are:

Treatment for Fistula without surgery:

All of these treatment procedures bear a high rate of recurrence. In about 15-25% or more cases, recurrence is reported in all of these treatment options. That means one or more patients among every 4 patients suffer from a recurrence of Fistula after any of these treatments. Partial or complete stool incontinence may also be there depending on the severity of damage to sphincter muscles.

Ksharsutra/ Best Treatment for Fistula-in-Ano:

This is an Ayurvedic treatment for Fistula-in-Ano as advised by Acharya Sushruta. In this treatment; a Ksharsutra expert places a medicated thread namely Ksharsutra in the Fistula tract and replaces it with a new one at a week or 10-day interval till the fistula heals completely. This is an OPD procedure and usually patient doesn’t require any hospitalization or bed rest. The patient can continue his normal routine activities as usual during treatment.

Complications like stool incontinence or recurrence of Fistula-in-Ano are not seen in Ksharsutra treatment for Fistula-in-Ano. So one can say Ksharsutra treatment is the best treatment available till date for Fistula-in-Ano.

Home remedies for Fistula-in-Ano:

FAQs about Fistula-in-Ano

A fistula is an abnormal connection in the form of a tunnel-like structure that connects two body parts. When this connection is found near the anus; it is termed as Fistula-in-Ano. In Fistula-in-Ano; this tunnel-like structure has its internal opening in the anal canal while an external opening on the skin in the area surrounding the anus.

No; fistula can not be treated by a specific diet and/ or by some Yogasanas.

Fistula can not be treated by oral medicines only – Homeopathic/ Allopathic or Ayurvedic; whatever it may be.

There are many reasons which make surgery a bad choice for Fistula-in-Ano. Most important among these are the complications like a recurrence of Fistula (in about 15-25% of cases fistula recurs after surgery even after being done by the best surgeon and by the latest treatment like VAAFT/ Laser etc.) after surgery and stool incontinence – inability to hold stool (partial or complete stool incontinence is reported in many cases after surgery for fistula depending on the severity of damage to the sphincter muscles.)

Yes; the claim “Ksharsutra treatment is better than surgery in patients suffering from Fistula-in-Ano” has been scientifically validated. In 1991; clinical trials were conducted by the Indian Council of Medical Research (ICMR) at premier institutes of medical science including AIIMS New Delhi; and PGI Chandigarh. In these trials, it was concluded that Ksharsutra treatment is more convenient and more effective than surgery in patients suffering from Fistula-in-Ano. *
*Indian Council of Medical Research. Multicentric randomized controlled clinical trial of Kshaarasootra (Ayurvedic medicated thread) in the management of fistula-in-ano. Indian J Med Res 1991;94:177–85.

The location of the external opening of the fistula has nothing to do with the severity of Fistula-in-Ano. It only tells about the location of the external opening nothing else.

It is a fact that all Fistulas originate from inside of Anus so theoretically internal opening should always be there in fistula-in-Ano. But when the fistula has burst and pus is drained; the healing process will start. As a result; there is a possibility that the internal opening will close and if an MRI is done at this stage; it will be difficult to locate the internal opening of the Fistula tract.

Yes; Fistula-in-Ano where internal opening could not be located; can be treated effectively by Ksharsutra treatment.

Usually Fistula does not progress to Cancer. In very rare cases; Fistula can progress to Cancer.

Ksharsutra comprises two words namely Kshar (Specialized Ayurvedic medicine prepared from ashes of certain plants which are alkaline in nature) & Sutra (thread) so Ksharsutra is a specialized medicated thread having Kshar as medicine in it. In Ksharsutra Treatment for Fistula-in-Ano; your proctologist will ligate this medicated thread in the fistula tract.

A standardized Ksharsutra contains three medicines namely Apamarga Kshar (Specialized Alkaline medicine prepared from Achyranthus aspera), Snuhi Ksheer (Latex of Euphorbia nerrifolia), and Haridra (Curcuma longa). First 11 coatings of Snuhi Ksheer are applied; then 7 coatings of Snuhi Ksheer & Apamarga Kshar and lastly 3 coatings of Snuhi Ksheer & Haridra are applied. In this way; there are a total of 21 coatings of medicines in a standardized Ksharsutra. The next coating is done only when the previous one has dried up.

In last; this Ksharsutra is sterilized by ultraviolet radiation. Nowadays; Ksharsutra is prepared in specially manufactured Ksharsutra cabinets which have an arrangement for Ksharsutra hanging, source of heat, source of Ultraviolet radiations, etc.

Acharya Charaka has only mentioned the Ksharsutra treatment for fistula-in-ano while Acharya Sushruta has given detailed description of the Ksharsutra treatment. He mentioned Ksharsutra in the context of Nadi Vrana (Sinuses); Hemorrhoids and Fistula-in-Ano in 500 BC.

While Acharya Chakradatta detailed the method of Ksharsutra preparation. Due to certain reasons (not relevant to discuss here) we did not get every detail about Ksharsutra preparation here also. So, Dr. Deshpande from Banaras Hindu University (BHU) did extensive research on Ksharsutra preparation. This is because of the efforts of Dr. Deshpande that there is standardized method of Ksharsutra preparation which is also approved by Central Council for Research in Ayurvedic Sciences (CCRAS).

First of all, your proctologist will define the fistula tract with the help of a soft malleable probe from the external opening of the fistula tract with special reference to depth direction & branching pattern of the Fistula tract. If he is unable to define the fistula tract properly; he may advise you to go for an MRI Fistulogram. Once the Fistula tract has been defined precisely; he will ligate the Ksharsutra in the tract. For ligation of the Ksharsutra; he will attach the Ksharsutra to one end (with eye on its tip) of the probe. As he will withdraw the probe from the internal opening; Ksharsutra will be placed in the fistula tract. Medicine present in the Ksharsutra debrides the fistula tract and induces healing. This medicine works for 5-10 days’ time period so your proctologist will advise to get old Ksharsutra replaced by a new one at an interval of a week or 10 days until fistula heals completely.

The time required for complete healing of the Fistula will depend on the length, depth, and branching pattern of your Fistula. It is observed that the Fistula heals @ 0.5 to 1 cm per Ksharsutra change sitting. That is to say for complete healing of a 3 cm long Fistula tract; you may require 4-6 Ksharsutra change sittings at weekly intervals.

While describing Ksharsutra treatment; Acharya Sushruta says:

कृशदुर्बलभीरूणां नाड़ी मर्माश्रिता च या |
क्षारसूत्रेण तां छिन्दयात् न तु शस्त्रेण बुद्धिमान् ||

i.e. An intelligent surgeon prefers Ksharsutra treatment over any surgical intervention to treat a patient suffering from a Fistula/ sinus or other similar problem who is emaciated/ weak/ fearful/ timid/ whose fistula or sinus is in a vulnerable area.
सुश्रुत संहिता चि. स्था . 17/29 (Sushruta Samhita Chi. Stha. 17/29)

That is to say, Ksharsutra treatment is equally effective in treating Fistula-in-Ano in patients suffering from Sinus or Fistula where surgery is contraindicated otherwise. So as such, there are no contraindications for Ksharsutra Treatment in treating Fistula-in-Ano.

Medicines present in Ksharsutra are alkali in nature so you might experience some burning sensation or irritation during Ksharsutra treatment for Fistula-in-Ano. You may perceive these sensations as pain. This pain can be managed by a Sitz bath (Warm water tub bath); application of some anesthetic gel like lignocaine gel etc. or painkiller medicine.

As said above; your Ksharsutra specialist will define the fistula tract precisely before putting the Ksharsutra in the tract. If by chance; some part of tract is not covered by the Ksharsutra; the medicine released from the Ksharsutra will take care of that part as it spreads all around the tract wherever it finds the passage. If the uncovered part of the tract is small; it will be debrided completely by the Ksharsutra already placed. 

If by chance; the uncovered Fistula tract is big enough to be debrided completely; then the medicine of Ksharsutra will open up this part through some other external opening where the Ksharsutra expert can put another Ksharsutra.

So, it is the debriding action of Ksharsutra medicine and the time; you give in Ksharsutra treatment that assures complete healing of Fistula-in-Ano without any recurrence.

The healing rate of the Fistula might differ between two persons. Even the same person may notice the different rates of healing at two different times. This difference is because of the different consistency of the intervening tissues. When the involved part is softer like fatty tissue; healing will be fast while harder muscular tissue will take more time for healing.

Comparison of Surgery for Fistula-in-Ano Ksharsutra Treatment for Fistula-in-Ano

Surgery for Fistula-in-Ano Ksharsutra treatment for Fistula-in-Ano
1.   In all types of surgeries for Fistula-in-Ano; recurrence of the fistula after treatment (in approx. 15-25% of cases recurrence of the fistula is reported after surgery) is the main complication. 1. Predictably; Ksharsutra treatment involves ZERO recurrence.
2.  Partial or complete stool incontinence is reported in Surgery for fistula-in-Ano. 2.   Patients taking Ksharsutra treatment do not complain of stool incontinence.
3.  Surgery requires spinal or general anesthesia so obviously there will be anaesthesia-related complications in surgery for Fistula-in-Ano like headache, light-headedness, temporary loss of memory, lower backache, retention of urine, etc. 3.   Usually, a Ksharsutra expert gives local anesthesia while doing Ksharsutra treatment for Fistula-in-Ano; which is the safest form of giving anesthesia.
4. Surgery involves cutting of fresh tissue so there might be plenty of bleeding in surgery for Fistula-in-Ano. 4. There is no fresh tissue injury in Ksharsutra treatment for Fistula-in-Ano so chances of too much bleeding are minimal in Ksharsutra treatment for Fistula-in-Ano.
5.   Surgery involves dressing of wound for a long time period so your surgeon may advise you long stay in hospital and/ bed rest at home. 5. Ksharsutra treatment for Fistula-in-Ano is a daycare procedure and you can return home the same day after taking a few hours of rest. Usually, there is no need for hospitalization or bed rest in Ksharsutra treatment for Fistula-in-Ano.
6. It takes a lot of time for a patient to return to his normal daily routine after surgery for Fistula-in-Ano. 6. In Ksharsutra treatment for Fistula-in-Ano; the patient can continue his normal routine activities from the very 1st day of Ksharsutra treatment.
7. Financial burden is too much in Surgery for Fistula-in-Ano. 7. Ksharsutra treatment for Fistula-in-Ano is more economical. The patient needs to pay a lesser amount and that too at weekly intervals over a long span of time.

So, we can conclude that Ksharsutra treatment for Fistula-in-Ano is better than any kind of surgery for Fistula-in-Ano.

Ksharsutra works on fistula-in-Ano by its debriding action on the Fistula tract. This action is equally effective in recurrent Fistula-in-Ano also. So Ksharsutra Treatment has got same success rate in treating recurrent Fistula-in-Ano also.

Ksharsutra treatment for Fistula-in-Ano works on the principle of debriding the tract, cutting the intervening tissue followed by healing. Here cutting of intervening tissue differs from the cutting of tissue in surgery in the sense that it is not in one shot but a slow process i.e., only a few fibers are cut in a time (which is followed by the reunion of these fibers) not the whole sphincter. This gives a chance to the sphincter muscle to remain patent. It is supported by the sphincter exercise which we use to advise to the patients. 

This is the reason; patients taking Ksharsutra treatment for Fistula-in-Ano do not complain of stool incontinence.

  • Ensure normal regular bowel movement
  • Maintain local hygiene
  • Take a sitz bath (warm water tub bath) at least twice daily and after every bowel movement.
  • Be active as much as possible
  • 3-4 Km. daily walk – It will help in pain management as well as speed up the healing process.

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