fistula in ano is a hollow inflammatory tract which has an external or secondary opening in the perianal skin and an internal or primary opening in the anal canal or rectum. The Secondary tracts may be multiple and from the same primary opening. The fistula tract is lined by unhealthy granulation tissue and fibrous tissue. It usually results from an ano-rectal abscess which burst spontaneously. Ancient Ayurveda surgeon Susruta has described five types of Bhagandara where Bagbhata added another three and made it eight. They have been classified according to the vitiation of the three doshas and the shape & site of the track of the fistula.
An ano-rectal abscess may produce a tract, the orifice of which has the appearance of a fistula but it does not communicate with the canal, called Sinus.
The prevalence rate fistula in ano is 8.6 cases per 100,000 population. The prevalence in men is 12.3 cases per 100,000 population. In women, it is 5.6 cases per 100,000 population.
Types of Fustula:
Low level or anal:
it opens into the canal bellow the anorectal junction.
High level or anal:
it opens into the anal canal at or above the anorectal junction.
Parks classification system
The Parks classification system defines 4 types of fistula-in-ano that result from cryptoglandular infections.
Intersphincteric, Transsphincteric, Suprasphincteric, Extrasphincteric
What are the Causes:
a) Perianal abscess
Fistula-in-ano is nearly always caused by a previous anorectal abscess. Anal canal glands situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces. Following surgical or spontaneous drainage in the perianal skin, occasionally a granulation tissue lined tract is left behind. Multiple series have shown that the formation of a fistula tract following anorectal abscess occurs in 7-40% of cases.
b) Ulcerative colitis
c) Crohn’s disease
e) Colloid carcinoma of the rectum
A) Past history of perianal abscess
B) Persistent seropurulent discharge
C) If orifice is occluded pain increases until the discharge erupts.
What is Ksharsutra?
The Ksharsutra is a type of thread / medicated seton prepared by coating the thread with the Kshara (the ash obtained by the burning of various herbs) like Apamarga kshar, Arka kshar etc and Snuhi kshira. Apart from this, natural antibiotic like haridra powder, guggulu, etc are also used to make Ksharasutra. The thread is then sterilized by UV light. 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 the healing. The process of healing starts from deeper tissues & travels towards 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.
The Ksharsutra is passed through the track usually under local anesthesia and the two ends of the thread are tied forming a loop. The drugs coated on the thread are continually released throughout the length of the track there by cutting, curetting, draining cleansing and healing the track. The thread works for almost seven days. Then, A new thread should be inserted replacing the old one with the same procedure. The changing of the thread is a simple OPD procedure taking about 1 to 2 minutes and requires no anesthesia. It may take one month to cut the tract and heal up.
Benefits of the ksharsutra
The Ksharsutra procedure is performed under local anesthesia a
• The procedure does not require hospitalization for more than 4 to 5 hours.
• The patient requires minimal bed rest & can resume his / her daily routine within 12 to 24 hours.
• It gives freedom from pain full dressings.
• The drugs coated on the Kshar-Sutra are slowly and gradually released into the track and the wound, leaving no pockets overseen. These pockets are drained out by the action of the drugs.
• The recurrence rate is less than 2% after Ksharsutra ligation procedure. 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.
• The sphincteric muscles are not dissected and hence the possibility of incontinence is ruled out.
Disadvantages of Ksharsutra
The gradual cutting of the track takes a very long time.
Sometimes, the thread has to be changed more than three times.
Do’s: Diet and habits
a) Strictly follow instructions given by the doctor.
b) Keep ano- rectal part clean and dry.
c) Consume lot of liquids.
d) Butter milk is very useful in these conditions.
Eat fruits and plenty of vegetable especially cucumber, radish, cabbage, carrot, green leafy vegetables, etc.
a) Avoid constipation and straining in the toilet.
b) Avoid chilly, spicy, non-vegetarian and other heavy food items.
c) Avoid sitting, standing and walking for long duration
Patent Drugs for FIstula in ano:
Dose: Adult: 2 tablets three times a day. Children: Half of the adult dose.