BHAGANDARA

 Bhagandara is acommon disease occurring in the ano-rectal region. Acharya

Sushruta, the father of surgery has included this disease as one among the
Ashtamahagada .this can be correlated to fistula in ano.

classical categorization

 Susrutha samhita : deatiled description in nidana sthana and chikitsa sthana

as separate chapters.

 Charaka samhita : little description of bhagandara in sotha chikitsa chapter

of chikitsa sthana

 Ashtanga hridaya : detailed description in separate chapters. Add 3 more

varieties to susrutha.

etymology

 The word bhagandara derived from two words ,

* Bhaga.

* Dharana.

o The word bhaga means vagina , MN used word bhaga for bhaga , guda
and vasthi.
o The word dharana means splitting or discontinuty with severe pain.

Definition

 भगगु दबस्तिप्रदे शदारणाच्च भगन्दरा इत्यु च्यन्ते I (SU NI )

 The word “ Bhaga “ means the pubic region, and “dhara” means tear.

Bhagandara means the tear at the bhaga, guda and vasthi pradesa.

 ते तु भगगु दबस्तिप्रदे शदारणाच्च ‘भगन्दरा ‘ इत्यु च्यन्ते I

अभिन्नाः पिडकाः, भिन्नस्तु भगन्दरा II (Su.Ni.4/2)

According to susrutha, in un suppurated stage it is known as pidaka, while in the

stage of suppuration it is known as bhagandara.

 According to madhava nidana,

“ गु दस्य द्वयन्गु ले क्षे तर् े पार्श्वतः पिडकार्तिक् रुत् I

भिन्न भगन्तरो ज्ने य स च पन्चविधो मतः II”

When a painful blister that occurs within a distance of two inches surrounding the
anus gets burst, it is to be known as bhagandara.

Nidana

हस्त्यश्वपृ ष्ठगमनकठिनोत्कटकासनै :।
अर्शोनिदानाभिहतै रपरै श्चनिषे वितै :।।
अनिष्टा अदृष्टापाकेन सद्यो वा साधु गर्हणै : (A.H.U.28/4)

 Riding on elephant, horse etc for a long period .

 Sitting on hard seats, ones own heel.

 Indulging in unsuitable activities enumerated as the cases of arsas.

 Maturing of sinful acts of previous lives.

Purvaroopa

 ते षां तु पूर्वरूपाणि- कटीकपालवे दना कण्डूर्दाह शोफश्च गु दस्य भवति।

(su.s.ni.4/4)
 *Pain over the low back and pelvic bones.

*Itching

*burning sensation

*swelling around anus.

Samprapthi

प्राये ण पिडिकापूर्वो यो अन्गु लो हि अन्गु ले अपि वा

पायोर्व्रणोःअन्तर्बाह्यो वा दुष्टास्रुन्माम्सगो भवे त् बस्तिमूतर् शयाभ्यासगतत्वत्स्यन्दनत्
II (A.H.U.28/6)

Nidana

Dosha – dhatu dushti

Sthana samsraya in guda

Pidaka within 1 to 2 angula from guda

( continue to follow nidanas )

Paka occurs

Bhagandara

Types

 Susrutha : 5 types sathaponaka

Ushtragreeva
Parisravi
Sambukavartha
Unmargi

 Vagbhata, M. N : 8 types they include,

Parikshepi
Rju
Arsobhagandara
Sataponaka bhagandara

 According to Susruthacharya ,

* It occurs due to apathyasevana and other vata prakopa nidanas.

* The vitiated vata localised in about 1-2 angulas around the anus. This vata
vitiates the mamsa and sonitha and leads to formation of a pidaka.
* pidaka : aruna varna ( light red colour )
accompanied with pricking and other pains.
if not treated this pidaka undergoes paka and leads to the formation of
sataponaka bhagandara.
 The word sataponaka means a sieve with minute pores.
 As the vrana situated near to the moothrasaya , it becomes moistened
greately through the minute pores.
 This exudates through this pores.
* discharge : exudates in large quantity.
clear and frothy exudate.
* character of pain : ulcer feels as being hit,split,torn, and pricked by needles.
Sometimes rectum becomes torn.
 if neglected then vata,muthra ,pureesha and semen starts coming through
these holes.

o अरुणवर्णपिडक तोतादि वेदनाविेशेष्ः शतपोनकवदणुमुखैश्छिद्रै्रापूर्यते

o अस्रमच्छ्ं फे् नानुद्धमधिकमास्रावम् स्रवन्ति
o व्रणाश्च तड्य़ते भिद्यते छिद्यते सूचिभिरिव निस्तुद्यते

 According to AH
* Pidaka : syava aruna varna
with toda , bheda and spurana type of pain
* the vrana having minute openings.
“…………………………..तत्र वातजा ।
चीयते अणुमुखैश्छिद्रै:शतपोनकवत्क्रमात्
अच्छं स्रवद्भिरास्रावमजस्रं फे नसंयुतम् ।।
शतपोनकसंज्ञो अयम्” (A.H.u 28/12)
  Watering can perenium / fistula

Watering-can perineum is the result of multiple fistulae extending from the

urethra to open within the perineum. 

 Multiple fistula

A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation

tissue and that connects a primary opening inside the anal canal to a secondary
opening in the perianal skin; secondary tracts may be multiple and can extend
from the same primary opening.

Ustragriva bhagandara

 According to Susruta
* the pitha aggrivated and pushed down by vata and located in gudapradesa.
* Pidaka: rakthavarna ( red colour )
thanvi ( small )
uchritha (elevated )
ustragrivakaram ( camel’s neck )
Associated with burning type of pain.
 If not treated the pidaka undergoes paka and forms Ustragriva bhagandara.
* Pain: burning sensation in the ulcer as though touched by agni or kshara .
*Exudation: Durgandha ( bad smell )
Ushnam ( warm )
 If neglected vata , muthra , pureesha and rethas also comeout through it.
 According to AH ,
“……………………उष्ट्रग्रीवस्तु पित्तज:”I
(A.H.u.28/12)
 AH extra mentions ushma, jwara and dhoomayana in pidaka lakshana.
Parisravi bhagandara

 According to susrutha ,
* The sleshma gets aggrevated and pushed down by vata and located in the
guda pradesa.
* Pidaka : sukla ( white )
sthira ( static)
kandumati ( with itching)
associated with kandu type of pain.
* If not treated the pidaka undergoes paka and forms parisravi bhagandara.
The vrana of parisravi bhagandara is ,
- katina (hard)
- samrambhi(swollen)
- With itching
*discharge : Pichila( slimy)
Ajasra srava ( large quantity , continuous)

* If neglected vata , muthra , pureesha and rethas also comeout through it.

o शुक्लावभासाम् स्थिराम् कण्डू मतीम् पिडकाम्

कण्डु आदि वेदनाविशेष्ः व्रणश्च कडिनः संरम्भी कण्डू प्रायः पिच्छिलमास्रावम् स्रवति
o According to AH,
बहुपिच्छापरिस्रावी परिस्रावी कफोद्भव:”।
(A.H.u28/13)
*AH extra mentions snighda , mahamoola and pandu in pidaka lakshana.

Sambukavartha bhagandara

 According to susrutha ,
* It is the tridoshaja type of bhagandara.
* the word sambukavartha means the ridges of a conch shell.
* Vata getting aggrevated , combining with aggrevated pitta and kapha and
moving downwards and localised in the guda region.
 *Pidaka : with size of big toe having features of all doshas.different types
of pain .

If not treated the pidaka undergoes paka and forms sambukavarta bhagandara.
* discharge : with different colours.
* produces pain which resembles sambookavartha.
 पादान्गुष्डाग्रप्रमाणाः सर्वलिन्गा पिडक
तोददाहकण्डु आदि वेदनाविशेषः
व्रणश्च नानाविदवर्णमास्रावम् स्रवति

Unmargi bhagandara

o The mooda person who being greedy of meat , if consumes meat along
with bone pieces and with foregin body.
o hard stools.

Pushed down by the apana vayu

moving in an improper way and produce kshata in guda.

This kshata leads to sloughing of mamsa accompanied with flowing of pus

and blood .

development of krimi and they eat away the guda in different places.

Causes tears in the sides of guda

From these tears the vata , muthra , pureesha and rethas also comeout .
  According to AH ,
“अस्थिलेशो अभ्यवहृतो मांसगृद्ध्या यदा गुदम् ।।
क्षिणोति तिर्यङ्निर्गच्छन्नुन्मार्गं क्षततो गति:।
स्यात्ततः पूयदीर्णायां मांसकोथेन तत्र च ।।
जायन्ते कृ मयस्तस्य खादन्त: परितो गुदम्।
विदारयन्ति न चिरादुन्मार्गी क्षतजश्च स:” ।।
(A.H.u.28/20)

Parikshepi bhagandara

 It is mentioned by AH ,
* this type is of vatapitta origin.
* it forms a circular fistula around the anus like the moat ( pit ) around the
fort.
* pitaka : syava , tamra
with daha and osha
severe pain.
 It is characterised by peculiar parigha akara – circular trench.
““वातपित्तात्परिक्षे पी परिक्षिप्य गु दं गति: ।
जायते परितस्तत्र प्रकारपरिखे व च”।।
(A.H.u.28/14)
 HORSE SHOE FISTULA
Type of anal fistula where the tract extends around both sides of the body and
has external openings on both sides of the anus.

Riju bhagandara

 It is mentioned by AH ,
* vata kapha origin.
* forms a straight fistula
* causing a tear in the rectum.
 “ऋजुर्वातकफादृज्व्या गुदो गत्याS त्र दीर्यते “।
(A.H.u 28/15)
Arso bhagandara
  It is mentioned by AH ,
* Kapha pitta origin.
* kapha and pitta invading the previously existing haemorrhoids .
* produce swelling , itching and burning
sensation.
* it become ripen and forms a fistula by softening the roots of the
pilemass.
* begins to exudates continously throgh gati.
 “कफपित्ते तु पूर्वोत्थं दुर्नामाश्रित्य कु प्यत:।।
अर्शोमूले तत: शोफ: कण्डू दाहदिमान् भवेत्।
स शीघ्रं पक्वभिन्नो अस्य क्ले दयन्मूलमर्शस:।।
स्रवत्यजस्रं गतिभिरयमर्शो भगन्दर:”।
(A.H.u.28/16)

TYPES OF ANAL FISTULA

Park ‘s classification of ano rectal fistula.

( Surgical classification)

Intersphincteric fistula – Grade 1

Transphincteric fistula – Grade 2
Suprasphincteric fistula- Grade 3
Extrasphincteric fistula- Grade 4

 intersphincteric fistula : Through the dentate line to the anal verge

tracking along the intersphincteric plane ending in peri anal skin.
 transsphincteric fistula: Through external sphincter into the ischio rectal
fossa, encompassing a portion of internal and external sphincters, ending in
the skin.
 suprasphincteric fistula: Through the anal crypt and encircling the entire
sphincter ending in ischio rectal fossa.
 extrasphincteric fistula: Starting high in anal canal enclosing the entire anal
sphincter and ending in skin.
St.JamesUniversityHospitalclassification.
( Radiological classification )
Based on land marks on the axial plane and incorporates abscesses and secondary
extensions to the grading system.
 Grade 1 : simple linear intersphincteric fistula.
 Grade 2 : Intersphincteric fistula with abscess or secondary tract .
 Grade 3 : Transphincteric fistula
 Grade 4 : Transphincteric fistula with abscess or secondary tract within the
ischio rectal fossa.
 Grade 5 : Fistula with supra levator and trans levator extension.
Other types of fistula in ano
 Recto vaginal fistula
 Recto vesical fistula
 Radiation associated fistula
 High fistula
 Horse shoe fistula
 Fistula connected with anal fissure
 Fistula in Crohn’s disease, tuberculosis and colloid CA.

Prognosis
 According to Susruthacharya ,
* all types of bhagandara are dreadfull ( ghora)
And difficult to cure ( dukha sadhya ) .
* sambukavartha and unmargi bhagandara are asadhya in nature.

 According to AH ,
 * first 6 types are difficult to cure.
* nichaya and kshataja type are incurable.
* fistula located in pravahini vali or in sevani are incurable.
Differential diagnosis
 According to Susruthacharya ,
* the pidaka of bhagandara should be differentiated from other type of pidaka
by certain features . Which include,
> the pidakas with alpa ruk , swelling and dissappeared quickly should
be understood as different from bhagandara pidaka.
> the pidakas situated in the area of two angulas around anus , deep
rooted, accompanied with pain and fever is considered as bhagandara pidaka.
Differential diagnosis of fistula in ano
* Anal carcinoma
* Ano rectal abscess
* Constipation
* Diverticular disease
* herpes simplex
*inflammatory bowel disease
*pilonidal cyst and sinus
* proctitis.
Investigations
 According to AH and Susruthacharya the bhagandara should be examined
with the help of a bhagandara yanthra to find out whether it is arvachina
/parachina , antharmukha / bahirmukha.
 an eshani is used to find out the course of fistulous tract.
 Exam under anesthesia ( EUA):
* Through anoscopy or proctoscopy.
* To access the internal opening and occult abscess.
* Injection of hydrogen peroxide and povidine iodine allows to visualise
bubbles at internal opening.
 Endo anal ultrasound.
 MRI : It is the gold standard for find out the fistulous tract
 CT scan
 Fistulography : Special X ray technique after injecting contrast dye
into the tract.

CHIKITSA
 The treatment of bhagandara ,
* Samanya chikitsa
* Visesha chikitsa
 Samanya chikitsa
* Pidakavastha
* Pakwavastha

Treatment for pidaka

 According to Su ,
* eleven upakramas mentioned in shadupakrama starting from apatharpana
to vireka.
* local – alepa , parisheka , vimlapana , upanaha.
 * general – apatarpana, abhyanga, swedana,pachana, visravana , snehana,
sodhana.

 According to AH,
* sodhana therapies.
* asrik sruthi ( blood letting )
*seka etc.
Treatment for pakwavastha
 For pakwa bhagandara treatment surgical methods are adopted .
for every surgical procedure ,
> Purva karma
> Pradana karma
> Paschat karma
PURVA KARMA
 According to Su ,
* snehana
* Avagaha swedana
* Made to lie on a sayya .
* Position should be done like that of arsas.
( anus facing towards sun , the waist should be raised a little by cloths
or blanket )
* Patient should be firmly fixed by cloths.
 AH also mentioned snehana and avagaha swedana as poorva karma.
PRADHANA KARMA
 EXAMINATION
 The tract is examined to find out whether the bhagandara is ,
* Prachina ( opening outward / blind external)
* Avachina( opening inward / blind internal )
 According to AH the bhagandara should be examined using a bhagandara
yantra. It is examined to find out whether it is ,
* arvachina or parachina(nearer or farther)
* antharmukha or bahirmukha.
 According to Su,
* in antharmukha bhagandara the opening is searched using eshani while the
patient is straining, after the orifice is obtained it is cut using a sharp instrument.if
it is not possible it should be touched by agni or kshara.
 According to AH,
* Same as Susrutha .
* Ushtra griva bhagandara should be treated with kshara only.
VISESHA CHIKITSA
o sataponaka bhagandara
o According to Su ,
* the physician should make a wound in the middle of one of the
fistula and after it has healed the remaining ones should be treated.
* When many fistulae are inter connected they should be cut opened
at many places.
* if they are not interconnected if the physician make many
cuttings it will create a wide wound leads to tearing of guda.
it will lead to ,
- feces and urine come out through this sinuses.
- aggrevated vata leads to atopa and guda soola.
 * the incisions,
Ardhalangalaka , langalaka , sarvatobhadra , gothirthaka.
* all the orifices which are exudating should be touched by agni.
* Sathaponaka is difficult to cure in bhiru persons.
 ushtragriva bhagandara
According to Susruthacharya ,

* eshana of the tract should be done followed by chedana . Kshara should

be applied.

* post operatively tila kalka with ghee is used for lepana and bandaged.

( dalhana mentioned gophanika bandha )

* bandage and dressing should be removed in the third day.

 parisravi bhagandara
o According to Susruthacharya,

* the physician should cut opened all the exudating channels followed by
cauterizing with kshara or huthahva ( fire heated rod)

* sechana of guda mandala should be done with sukhoshna anuthaila.

* upanaha and pradeha done using drugs added with urine and kshara.

* parisheka done with kashaya of vameneeya drugs.

* When the area becomes mridubhootha and the fistula is still having slight
exudation and pain then it should be probed again and cut opened.

* the incisions should be , kharjura pathraka , chandrartham, chandra chakra

, suchimukha , avangmukha.
 * After chedana dahana with agni or kshara should be done

 bhagandara in children

it should be treated with drugs which are mridu and tikshna.

* aragvadadi varthi

aragvada , nisa and kala choorna mixed with honey and ghee made to varthi
. This is benificial for vrana sodhana. And easily cures fistula.

 aganthu bhagandara

The tract should be cut opened and cauterisation done using jambavoshta or
taptha salaka.

* then do salyapanayana karma and krimighna treatment.

 tridoshaja bhagandara

* Prathyakheya chikitsa should be done.

 parikshepi bhagandara

* It should be treated as that of general method.

* In addition to it kshara suthra prayoga can be done.

 arso bhagandara

* In arso bhagandara treatment of arsas should be done first.

PASCHAT KARMA

Paschat karma includes all the measures which helps to attain the best results
of pradana karma .In sastra karma the paschat karma mainly aims to vrana
sodhana , ropana and pain releif .

 rujahara karma

* Parisheka with ushna anuthaila.

* Snehaabhyaktha guda of the patient should be fomented with nadisweda by
using vataghna oushada.
Ushnodaka avagaha .
* salvanopanaha and other type of upanaha kept inside the hide of either
kadali mriga , lopaka or priyaka should be applied on the painful part.
* Specifically in sathaponaka bhagandara swadana with krisara and anoopa
mamsa is indicated.
* nadi sweda with brihat panchamula kwatha and swedana with mridvika ,
kanji and souviraka are mentioned

 vrana sodhana karma

* jyothishmati thaila.
* trivrit , tila, nagadanti , manjishta macerated with milk and saindava for
utsadana.
* rasanjanadi prayoga.
* according to AH lepana with paste of bidalasthi macerated in thriphala
kashaya.
 vrana ropana karma
* Taila made of magadhi , madhuka , rodra etc.
 * Taila or gritha made with nyagrodadi gana.
* trivrithathi thailam
* visyantana taila
* According to AH, jyothishmati taila , madhukadi taila are mentioned.
* choorna prayoga includes vidangadi , amruthadi choorna of magadika etc ,
guggulu panchapala choorna
* The drugs of guggulu panchapala choorna along with sringavera choorna
and soaked in dasamoola kwatha is used.
* powder of uttama and khadira sara soaked in asana kwatha and mixed with
equal quantity of mahishakshi and makshika used in fistula.

PARASURGICAL METHODS

 rakthamokshana
* AH mentioned asruk sruthi in the context of pidaka chikitsa.
* SU mentions visravana in pidaka chikitsa.
* Sodhala in gadanigraha indicates rakthamokshana by jalouka in the
pidakavastha.

 agni karma
* This is mentioned in general treatment of pakwavastha after chedana.
* Different materials are used for agni karma mainly taptha salaka and
jambavoshta are used.
* agnikarma is contraindicated in ushtragriva bhagandara.
> agnikarma is also done in cases where surgical procedures cannot be done
due to deep rooted tract or fibrosed tract.
> it helps to cauterise the fibrosed tissue and arrest bleeding.

 kshara karma
* In bhagandara kshara can be used in two ways,
> Prathisaraneeya kshara after chedana.
> Kshara suthra prayoga.
* Prathisaraneeya kshara
> after chedana of the tract kshara applied and waited for 100 mathra .
After that wiped with amlarasa dravya.
* Ksharasuthra prayoga
> medicated thread used for bhagandara treatment.

kshara suthra prayoga

 INDICATION.

(Su.chi 17)
* Kshara suthra is indicated for emaciated , weak and coward persons. And if
the nadeevrana is located in marma sthana.
* AH mentioned it as ksharapeetha suthra.

o KSHARA SUTHRA
o भावितं रजनीचूर्णे स्नुहिक्षीरे पुनः पुनः ।
बन्धनात् सुदृढं सूत्रं भिनत्यर्शो भगन्दरम् ॥
 [C.D 58]
* Total number of coating – 21
* snuhi ksheera > 11 coating
* snuhi ksheera with kshara > 7 coating
*snuhinksheera with haridra choorna > 3 coating
o METHOD OF APPLICATION.

o COMPLICATIONS AND MANAGEMENT

The complications of bhagandara mentioned by Madhava nidana ,

वातमूत्रपुरीषाणि क्रिमियः शुक्रमेव च
भग्न्तरात् स्रवन्तस्तु नाशयन्ति तमादुराम् II (M.N.46/36)

* expulsion of vata , muthra , pureesha and krimi throgh the opening which
gradually destroy the person.

complications after operative procedures

 This include ,
* incontinence
* severe pain
* recurrence
* pain during defecation.
* constipation.
* bleeding
* itching around the anus and wound.
* scar formation.

o Management
*warm saline sitz bath
* internal analgesics.
* laxatives
* proper cleaning and dressing to avoid further
infection.
* internal medications.

o common medicines
* Guggulutikthakam kashayam
* Gandharvahasthadi kashayam
* Chiruvilwadi kashayam
* guggulu panchapala choornam
* brihat thriphala choornam
* kaisora guggulu
* kanchanara guggulu
 * jathyadi gritham
* murivenna
* thriphala choorna

TREATMENT OF FISTULA IN ANO

 Goals : Drain the local infection
Eradicate the fistula tract
Avoid recurrence while preserving the function
of sphincters.
 Surgical management : Fistulotomy
Fistulectomy
Seton technique
Advancement flaps and glues
LIFT procedure.
o Fistulotomy
o Lay open the tract, make incision over the entire lenth of the fistula using
probe as a guide.
o Contraindicated in intrasphincteric and transphincteric fistula with more than
30% of voluntary fibres included also in women with anteriorly placed
fistula.
o Fistulectomy
o Involves coring out of fistulous tract by diathermic cautery. Here the
fistulous tract is excised completely.
o Setons
o Non absorbable, non degradable, comfortable silk or linen ligatures.
o Kept for 3 months and replaced by rail road method.
o Types : 1. loose setons

2.Tight or cutting setons

o Loose setons : * For recurrent and post operative fistulas.

* For long term palliation to avoid septic and painful
exacerbations by effective drainage.
o Tight or cutting setons :
* cutting through enclosed muscle.
*Minimal sphincter dysfunction due to least scar formation.
*Used for staged fistulotomy.
 advancement flaps
o Endorectal advancement flaps : Coring out of the entire tract and closure of
the communication with the anal lumen with an adequately vascularised flap
consisting of mucosa and internal sphincter, sutured without tension to the
anoderm.
 Fibrin glues
o Fibrin glue is injected into the fistula to seal the tract. It is injected through
the opening of fistula and the opening is then stitched and closed.
 LIFTProcedure ( Ligation of intersphincteric fistula tract)
Steps of LIFT procedure.
o Incision at the intersphincteric groove
o Identification of the intersphincteric tract
o Ligation of the tract close to internal opening
o Removel of tract
o Scraping out all granulation tissue
o Suture the defect at the external sphincter muscle.

 Pathya and apathya

o PATHYA : Sali, visrama, mudga, vilepi, sigru, mulaka ,

 Thiktha varga, gritha, madhu.
o APATHYA : Vyayama, vyavaya, katu tikshna ushna ahara,
 Utkatikasana, kopa, vega virodha, ajeerna
 Sahasa karma.
o Patient should avoid the apathyas for 1 year.