This document provides information on the anal region (guda) including its anatomy, measurements, blood supply, relations, and diseases like piles (hemorrhoids) and fistula-in-ano. It describes the components and measurements of the guda, the classification and management of piles and fistula-in-ano according to Ayurveda and modern medicine. Clinical features, examination, and investigations for piles and fistula-in-ano are also summarized.

2.  Pranaytana
 Karmendriya
 Bahirmukha Srotsa
 Sadhya Pranhara Marma
 Utpatti :- Prasada bhag of Rakta & Kapha
digested by Pitta along with active
participation of Vayu
 Derived from Matruj bhava
 Site :- Sthulantrapratibaddha

3. Components :-
 Sira :- Eight siras in Shroni
connected with Linga & Guda
 Dhamani :- Two
 Asthi :- One Gudasthi
 Sandhi :- Samudge
 Peshi :- Three

4. Guda as a Marma :-
 Nivesha bheda :- Mamsa marma,
Dhamani marma
 Vyapad bheda :- Sadha Pranhartwa
 Samkhya bheda :- Eka(one)
 Mana bheda :- Panitala Pranana
 Anga bheda :- Kostha marma,
Udara marma

5. Measurements of Guda :-
Four & Half (4.5) angula in length
Gudavali :- Three
1. Pravahini- bears the stool down
2. Visarjani- relaxes the colon &
evacuates the faeces
3. Samvarani- covers the anus &
opens during defecation

7. Anatomic or embriological - 2 cm long
extending from anal verge to dentate line
Surgical or functional - 4 cm
male - 4.6 cm female - 3.7 cm
Relations of Anal canal :-
Posteriorly – coccyx
Anteriorly – perineal boby, urethra,
vaginal wall
Laterally - ischium & ischiorectal fossa

8. Dentate line :-
At midpoint of anal canal- undulating
demarcation approx 2 cm from anal verge
also known as anal transitional zone
Columns of Morgagni :-
Longitudinal folds above Dentate line (6-14)
Anal Glands :- average 6 (3-10)
Anal Sphincter :- External & Internal sphincter
separated by conjoint longitudinal muscle

9. Blood Supply :- 3 main arteries
1. Superior haemorrhoidal artery
2. Middle haemorrhoidal artery
3. Inferior haemorrhoidal artery
Venous Drainage :-
1. Superior haemorrhoidal plexus
2. Inferior haemorrhoidal plexus
drains into middle & inferior
haemorrhoidal vein

10. Nerve Supply :-
Internal anal sphincter by Sympathetic(L-5) &
Parasympathetic (S-2, S-3, S-4)
External anal sphincter by pudendal nerve(S-
2, S-3) & perineal branch of S-4

11. Ano rectal spaces :-
Perianal space Presacral space
Intersphincteric space Submucous space
Ischiorectal space Deep postanal space
Supralevator space Rectovesical space

12. Nirukti :-
“Arivat pranan Srnatiti arsha”
Kills the person like enemy
like a projection, deep rootedness,
relation with marmas(vital points),
long standing nature & complications
Synonyms :-
Durnam, Gudaja, Gudakila

13. Nidana (Aetiology) :-
 Intake of incompetible diet
 Constipation & straining
 Sitting for long time on hard seats
 Horse riding
 Abdominal tumours
 Diarrohoea, excess ama
 Overexertion, excess sex
 Pregnancy, abortion, miscarriage
 Trauma by rough objects
 Suppression or forced release of
gas, urine or feces

14. Samprapti (pathoganesis):-
 Simultaneous vitation of
tridoshas reaches Guda
by principal veins
 Weakens the skin(twak),
muscles(mamsa) &
fat(meda) i.e. the
sphincter
 Protrusion of vascular
bed
Protrusion of Internal
& External
Haemorrhoids

15. Bheda (Classification) :-
1. According to origin –
i. Sahaja ii. Janmottar
2. According to bleeding nature –
i. Shushka ii. Sravi
3. According to dosha –
i. Vataja ii. Pittaja
iii. Shleshmaja iv. Raktaja
v. Sannipatika vi. Sahaja

16. Etymology :-
Haima = blood,
rhoos = following
Piles = Pila = ball like
Definition :-
 varicosities of superior &
inferior haemorrhoidal
plexus
 dilatation of internal
rectal plexus

17. Aetiology :-
 Habitual straining
 Hereditary causes
 Diet & constipation
 Chronic diarrhoea
 Infection of lower intestine
 Bad hygiene
 Raised intra abdominal pressure (pregnancy)
 Rectal carcinoma, BEP, Urethral stricture,
pelvic tumour, portal hypertension

18. Classification :-
1. Internal haemorrhoids
2. External haemorrhoids
3. Interno-external
haemorrhoids
According to position –
Primary – 3,7,11 O’clock
Secondary – 1,5,9 O’clock

20. Clinical features :-
 Bleeding – bright red &
occurs during
defecation as early
symptom
 Prolapse – discomfort
& heaviness in rectum
 Discharge – mucoid
discharge, pruritis ani
 Pain – by thrombosis
or fissure in ano

21. Examination :-
 Inspection – mass seen after straining
 Digital Exam. - not palpable unless thrombosed
 Proctoscopy – bluish mucosal bridges in classical
3,7,11 O’clock position
 Sigmoidoscopy – to exclude higher lesions
 Barium enema – for colonic pathology

22. Complication :-
 Bleeding – Anaemia
 Thrombosis
 Strangulation
 Gangrene
 Fibrosis
 Suppuration

23. Management :-
Four basics of Arsha Chikitsa
 Bheshaja – medicinal treatment
 Kshara – caustic application for soft, deeply
situated, extensive & projecting pile mass
 Agnikarma – cauterization for rough, firm,
thick & hard pile mass
 Shastrakarma – surgical management for
narrow pedicle, projecting & moist piles

24. Line of treatment :-
 Nidan parivarjanam
 Vatanulomana
 Agnibalvriddhi
 Anupanoushadhadravyam

25. Kshara karma :-
1.Pratisarniya kshara-
 Proper bowel clearance
 Snehana, Swedana
 Light meal previously
 Lithotomy position
 Exposure of pile mass by
proctoscope
 Clean pile mass
 Cover surrounding area with
cotton or gauze

26.  Apply Kshara with shalala or cotton swab
 Cover it for 100 matra (60 sec.)
 Continue still samyak dagdha lakshana
 After getting pakwa jambuphal varna remove
it & wash with dhanyamla/dadhimastu
 Apply Yashtimadhu-ghee
 Give avagaha sweda (Sitz bath)
 Proper rest, hygiene & bowel clearance
(more beneficial in 2nd & 3rd degree piles)

27. 2. Kshara sutra application-
 Local anaesthesia with xylocaine 2%
with adrenaline
 Identify & catch pile mass by forcep
 Ligate ksharsutra through the
pedicle of pile mass
 Pile mass becomes gangrenous &
falls down in 2-4 days
 It gives putrid odour & offencive
oozing

28. Shastra karma :-
kshar sutra or a plain thread may be ligated
at pedicle & pile mass can be excised out with
proper post operative management
Jalouka Avacharana (Leech therapy) :-
 Vagbhata advises for non bleeding,elevated &
hard pile mass repeatedly
 Proper rest & Gophana bandh (t-bandage) to
prevent further bleeding

29. Modern treatment :-
 Conservative management
 Sclerotherapy
 Rubber band ligation
 Infra red coagulation
 Cryodestruction
 Laser therapy
 Surgical excision- Haemorrhoidectomy
 Stapled haemorrhoidopexy
 DGHAL – Doppler guided haemorrhoidal artery
ligation

30. Sclerotherapy
Rubber
band
ligation

31. Infra red coagulation
Cryodestruction
DGHAL
Laser therapy

32. Haemorrhoids :-
 Indicated for 3rd & 4th
degree prolapsed,
thrombosed haemorrhoids
& External haemorrhoids
 V-shape incission
 Separation of
haemorrhoidal plexus
 Transfixation at the base of
haemorrhoid
 Removal of entire
haemorrhoidal plexus
Haemorrhoidectomy

33. Stapled haemorrhoidopexy

34. Nirukti :-
“Bhagavaddaryed yasmat tasmat jneya
bhagandara”
 Bhaga = Guhyamushkamadhyasthanam
i.e. wide perinium
Darana = tear/damage
 Deterioration of guda, mushka & related
structures

35. Aetiology :-
Outcome of bhagandara pidka
 Faulty dietary habits
 Faulty bowel habits
 Straining during defecation
 Improper sitting habits
 Excessive riding
 Trauma

36. Purvarupa :-
 Pain at kati kapala (pelvic region)
 Itching
 Burning sensation around guda
 Swelling around guda
 Formation of Bhagandara pidaka
Rupa :-
Discharging vrana around guda with previous
history of Bhagandara pidaka

37. Classification :- according to Sushruta
 Shatponak – vataja
 Ustragreeva - pittaja
 Parisravi – kaphaja
 Shambukavarta – tridoshaja
 Unmargi – agantuja
Vagbhata further added
 Parikshepi – vatapittaja
 Arshobhagandara – pittakaphaja
 Riju - kaphavataja

38. Definition :-
 Fistula is an abnormal communication
between any two epithelial lined surfaces.
 Pipe like structure
 Fistula in ano is track lined by granulation
tissue, which connects deeply in the anal
canal or rectum & superficially on the skin
around anus.

39. Aetiology :-
 Sequel of anorectal abscess
 Chronic fissure in ano
 Trauma at anus
 Tuberculosis
 Anal carcinoma
 Pilonidal sinus
 Chron’s disease
 Ulcerative colitis
 Actinomycosis

40. Pathogenesis :-
 Anal gland infection
 Abscess formation
 Recurrent suppuration &
healing
 Fibrous track lined by
granulation tissue
 Fistula in ano

41. Classification :-
Anatomical basis –
1) High anal fistula –
Internal opening above
ano rectal ring
2) Low anal fistula -
Internal opening below
ano rectal ring

42. Standard classification –
 Sub cutaneous
 Sub mucous
 Low anal
 High anal
 Pelvi rectal

43. Park’s classification –
 Intersphincteric
 Trans-sphincteric
 Suprasphincteric
 Extrasphincteric

44. Intersphincteric fistula –
 Simple low track
 High blind track
 High track with rectal opening
 Rectal opening without a perineal opening
 Extrarectal extension
Trans-sphincteric – Uncomplicated, High blind
Suprasphincteric - Uncomplicated, High blind
Extrasphincteric – secondary to anal fistula,
trauma, anorectal disease, pelvic inflammation

46. Clinical features :-
 Single or multiple
external openings
 Persistent
mucopurulent
discharge
 Cutting, throbbing,
pricking pain
 Soreness & itching of
perianal skin

47. Examination of patient :-
 Number of openings – single/multiple
 Position – anteriorly/posteriorly & O’clock
 Colour of opening – pink/red nodule
 Colour of perianal skin – red, moist, thickened
 Any previous scar – H/O fistula or abscess
 Discharge – serous/purulent/blood
 Presence of sentinel tag – fissure fistula

48. Palpation :-
Digital palpation –
 In simple (low anal/subcutaneous) – track felt
as rod of induration extending from external
opening to anal verge.
 Horseshoe fistula - usually impalpable
Per rectal Exam. –
 seropurulent pus in gloved finger
 Internal opening can be felt as a dimple
 An area of induration is felt

49. Probing :-
It provides knowledge regarding
 Track – complete or not
 Extent of the track
 Direction of the track
 Position of internal opening
 Branching of track
 Relation with sphincter muscles, anorectal
ring, levator muscles & neighboring bones
Proctoscopy :- Internal opening might seen

50. Goodsall’s Rule :-
 It relates location of
internal opening to
the external opening
 Whether the track
opens radially or will
curve posteriorly &
open in the midline

51. Investigations :-
 Blood – Hb, TLC, DLC, ESR, CT, BT, BSL(F&PP),
BU, Serum creatinine, HIV, HBsAg
 Urine – routine & microscopic
 Stool – ova, cyst, occult blood
 Pus – culture & sensitivity
 Biopsy – from floor of fistula

52. Radiological examination :-
 Fistulogram
 Trans Rectal Ultra Sonography
 Magnetic Resonance Imaging
 Colonoscopy
 Histopathological Examination
Differential diagnosis :-
 Urethral fistula in males
 Chronic infected Bertholin’s gland in females

53. Modern management :-
 Fistulotomy –
opening the fistulous
track
 Fistulectomy –
excission of fistulous
track
 Use of seton

54. Ayurvedic management :-
Medicinal – two stages
 During the stage of bhagandara pidaka, to avoid
suppuration – Shaman chikitsa
 Wound care after surgical excission of track
Surgical procedure –
 Pt. laid in lithotomy position
 Internal opening located by Eshani yantra(probe)
 Chedana i.e. excission of complete track

55. Para Surgical Measures :-
 Agni karma
 Raktamokshana - jalouka
 Ksharkarma -
1. External application (Pratisarniya kshara)
2. Kshara varti & ksharatail pichu
3. Ksharsutra

56. Kshara sutra karma :-
Purva karma - Laxative
Part preparation
Inj. T.T. 0.5cc IM
Pradhan karma – lithotomy position
 Probing through external opening towards internal
opening & manipulated to come outside anal canal
 Plain thread placed in the eye of probe & probe pulled
out to position the thread in the track
 Two enda of the thread tied loosely
 After 3 days tread is replaced by Ksharsutra

57. Kshara sutra karma :-

58. Change of Ksharsutra –
 On weekly intervals
 Rail-road technique
 New KS tied to lateral side of knot
 Thread is cut between knot & clipped by artery
forcep on medial side
 Artery forcep gently pulled out & old thread
comes out leaving the new KS in the track
 Old tread cut off & its length noted
 New KS is knoted

59. Paschat karma –
 Sitz’s bath in luke warm water medicated with
triphala choorna/haridra twice daily
 Jatyadi ghritam/ Roaniya ghritam packing for
wound healing
 Antibiotics if necessary
 Analgesics if necessary
 Vitamin C & B-complex to enhance wound
healing

60.  Kshara is one of the anushstra described by
Sushruta
 Two types as per administration
1. Paniya – Internal medication
2. Pratisaraniya – External application
 ‘Ksaranat ksananat va ksara’(Su. Su.3/11)
 Material which destroys or cleans
excessive/morbid doshas
 Caustic materials obtained from ashes after
distillation & mostly alkaline in nature

61. Preparation of Kshara :-
Drugs used – Apamarga, Arka, Kadali, Palasha etc.
According to tikshnata – 3 types
1. Mridu – Bhasmikarana (Ash formation)
Ash-Water dissolution (1:6)
Filtration (21 times)
Sedimentation
Distillation (boiling ksharjala)
Collection of dry kshara
2. Madhyam – Extra powders of Katasarkara,
Bhasma sharkara, Ksheerapaka, Shankhanabhi
are added to boiling Ksharajala

62. 3. Tikshna – similar to madhyam kshara but
addition of drugs like Chitraka, danti, vacha etc.
Preparation of apamarga kshara
(Caustic preparation of Achiranthus aspera)

63. Preparation of Ksharasutra :-
 Thread – Linen no. 20
Ingredients No. of coatings
Snuhi ksheer 11
Snuhi ksheer +
Apamarga kshar
07
Snuhi ksheer +
Haridra churna
03
Total 21

64. Collection of
Snuhiksheer
(Latex of
Euphorbia
neripholia)
Coating of
Snuhiksheer
& Apamarga
Kshara
Coating of
Haridra
(Cucurma
longa)
Preparation of Ksharsutra

65. Other Ksharsutras in use :-
 Gomutra ksharasutra
 Udumbara ksharasutra
 Guggulu ksharasutra
 Karaveera ksharasutra
 Erandakarkati ksheera sutra
The credit of making the Ksharasutra
practically in use goes to Prof. P.J.Deshpande
& his coworkers. They rediscovered &
standardized this Ksharasutra in present era

66. Probable mode of action :-
 Ingredients of plant ashes are Sodium
carbonate, Potassium carbonate, Calcium
oxide, Magnesium oxide, silica etc.
 Ayurveda – Ksharan property, Shodhana
(cleansing, antimicrobial), Ropana (healing)
 Action of pratisaraniya kshara may be –
Dehydration action
Dissolving property of albumin
Saponification of fat
Anti infective action

67. Nirukti :-
 Pari = Sarvato Bhavaha i.e. all around
 Kartika = sharp shooting pain
 Cutting pain all around anus
 Solitary rectal ulcer, Fissure in ano &
Laceration all come under Parikartika

68. Nidana :-
1. Vyadhi Nimittaja (Diseased) –
Udavarta Arsha
Purishavritta vata Vatik Grahani
Vatik Atisara Jirna Jwara
Disease of Garbhini
2. Vaidya Nimittaja -
Vasti Vyapada Virechana Vyapada
Vasti Netra Vyapada Excess Yapana Vasti

69. Rupa :-
‘Tivrasula sapicchasram karoti parikartikam’
Severe pain with bloody mucous discharge
Bheda (Types):-
Kasyapa has classified the disease
Dosha involved Related symptoms
Vata Parikartanam (Cutting pain)
Pitta Daha, Asra-srava (Bleeding)
Kapha Piccha-srava (Mucous discharge)

70. Samprapti :-
 Formation of Fissure in ano is vyakta avastha
 Abhighata i.e. direct trauma by hard stool
 Kshataj vrana or Guda vidarana & later
becomes Dushta vrana
 Due to Purisavrta vata malasuskata
 Vitiated vata localized in twak makes it Ruksa
& shows tendency to crack
 Later on associated with rakta & forms ulcer
 Affects mamsa dhatu & forms knotty swelling
or tags & causes pain

71. Definition :- Tears or split in the anoderm just
distal to the dentate line
Epidemiology :-
 Occurs at any age, but usually seen in
younger & middle-aged adults
 Posterior midline fissure common in both
sexes, but anterior midline commonly
affected women
 Fissure in lateral position – Chron’s disease,
Tuberculosis, syphilis, HIV/AIDS, carcinoma
 Also due to long standing loose stools

72. Aetio-pathogenesis :-
 Local trauma usually by hard stool to the
anoderm
 Overstretching & tearing of the squamous
epithelium of anal canal
 Reflex sphincter spasm
 Some pts. Report episode of diarrhoea
 Anal infection

73. Classification :-
Acute – mere crack in the epithelial surface,
severe pain & spasm
Chronic – 6 to 8 weeks history
- Presence of visible transverse internal anal
sphincter (IAS) fibers
- Chronic granulation tissue at its base
- Indurate edge,
- Sentinel pile
- Hypertrophic anal papilla

74. Signs & Symptoms :-
 Pain – sharp, tearing, starts with defecation &
persists several hours
 Bleeding – streaking of red blood on motion
 Discharge & Prurities – soilage of under
clothes, increase moisture of peri-anal skin
with pruritis around anus
 Lower end of the fissure can be seen
 Sentinel tag present in some cases

75. Management :-
A) Charaka -
 Sama dosha – langhan, pachan,rooksha usna-
laghu-bhojana
 Amajirna anubandha – kshara, amla, madhu
 Durbala – vrimhana with madhura rasa
 Vata predominance – dadimadi ghrita
 Milk should be used regularly
 Piccha Vasti - madhura,, kashaya rasa & sita
(sushruta- yashtimadhu, krishna til kalka with
madhu & ghrita)
 Sneha vasti – prepared with yashtimadhu
(Vagbhata - pippallyadianuvasanam)

76. B) Kashypa Samhita :-
 Lehana yoga – cold milk medicated with
madhur group drugs;sarkara, madhu taila;
yashtimadhu phanita
 Yusha for Vatika – Brihati, Bilva, Anantmul
 Yusha for paittika – Madhuyashti, Hanspatti,
Dhaniya, Madhu etc.
 Yusha for Kaphaja – Kateri, Gokshura, Pippli &
salt

77. Standard Ayurvedic :-
 Vatanulomana
 Vedana shamana & Shothahara drvya (kaishor
guggulu, triphala guggulu)
 Ushna avagahan – triphala kashaya
 Local application –Jatyadi ghrita
 Pippalyadi anuvasan Vasti (30-60 ml 7 days)
 Anal dilatation
 Sphincterotomy
 Excision of senitenal tag

78. Modern management :-
Conservative –
 Warm sitz bath
 Oral analgesics
 Laxatives
 Loal anaesthetic application – Lignocaine 2%
 Loal application of nitroglycerine or isosorbid
dinitrate
 Injection of botulinum toxin

79. Surgical treatment :-
 Anal dilatation
 Excision of anal fissure with skin grafting
 Internal sphincterotomy
 Posterior sphincterotomy
 Fissurectomy with tag excision

80.  Displacement of Guda from its normal site
 Kshrudra roga – Sushruta
Nidana :-
“Pravahanatisarabhyam nirgacchati gudam
bahih l ruksadurbaladehasya gudabhramsam
tamadiset ll su. ni. 13/61”
 Excess straining during defecation
 Loose motions
 Excess cough
 Urinary flow obstruction
 Haemorrhoids

81. Lakshana :-
“Nirgacchati gudam bahi”
 Protrusion of guda(Rectum) outside the anal
opening

82. Theories :-
Theory of Sliding hernia-
 Alexis Moschowitz (1912)- Rectal prolapse is
caused by a sliding herniation of the pouch of
Douglas through the pelvic floor fascia into the
anterior aspect of the rectum through the weak
pelvic floor muscle.
Intussusception Theory –
 Broden & Snellman(1968)- Initial step in the
genesis of prolapse is circumferential
intussuception of the rectum

83. Types :-
Partial prolapse –
 Protrusion of mucous membrane alone
 1.25 to 3.75 cm. outside the anal verge
 Occurs in children(1-3yrs) & elderly people
 Only mucosa & submucosa will be palpable
Complete prolapse –
 Protrusion of all layers of rectal wall
 More than 3.75 cm. in length
 Uncommon in children, more common in elderly,
female to male ratio is 6:1
 Entire bowel can be palpated

85. Aetiopathogenesis :-
Infants –
 Direct downword course of rectum, due to
undeveloped sacral curve
 Reduced anal musculature torn & diminished
support of mucosal lining
Children –
 Excessive straining, diarrhoea, wooping cough
 Loss of weight & reuced fat in ischio rectal fossa
 Fibro cystic disease, neurological deficit
 Maldevelopment of pelvis

86. Adults –
 Associated with 3rd degree haemorrhoids
 Atonicity of spincter mechanism
 Torn perineum in female
 Straining due to urethral obstruction in male
 Following surgery for fistula in ano, fissure in
ano or haemorrhoidectomy

87. Complete prolapse –
 Bowel habit – difficulty in defication
 Laxity of anal spincter
 Lack of rectal fixation – weak pelvic muscles
 Rectal intusucception -6 to 8 cm above anus
 Sliding hernia
 Disordered function of pelvic musculature

88. Clinical features :-
 Mass or large lump through anus to push
back in after defecation
 Fecal incontinence , difficulty in bowel
regulation, discomfort, sensation of
incomplete evacuation, & tenesmus
 Sensation of Chronic moisture & Mucous
drainage in perineal area
 Chronic prolapsed rectal mucosa permanently
extruded and ulcerated, leading to mucous
discharge & bleeding

89. Examination :-
Inspection –
 Visible prolapsed mass
 Patulous anus with lax mucosa at anal orifice
 Prolapsed mucous membrane is pink coloured
Palpation –
 Reduced sphincter tone
 Increased size of anal orifice
 Reduced contractile power of anal musculature
 Protrusion of mass occurs while straining

90. Management :-
Ayurvedic –
 After snehana & swedana the protruded guda
is gradually pushed back to its naormal
position. Then gophana bandh having
opening in center is applied.
 Medication – Panchaksheeri kashaya,
Abhayarishtam, Mushika taila, Changeryadi
ghrita, Chavyadi ghrita, Pippalyadi anuvasan
vasthi, Ghrita with Madhur & amla rasa drugs

91. Modern management :-
Partial prolapse –
 Conservative–
a) Digital reposition
b) Submucous
injection
 Operative –
a) Thierschs operation
b) Excission of mucosa

92. Modern management :-
Complete prolapse –
 Fixation operation-
a) Wells operation
b) Rectopexy operation
c) Rectal sling operation
 Resection operation –
a) Anterior resection of rectum
b) Perineal rectosigmoidoscopy
c) Operations on pelvic floor & Perineum

93.  First described by Hodges in 1880
 Sinus is a blind ending track usually lined by
granulation tissue that leads from an
epithelial surface into the surrounding tissue,
often into an abscess cavity
 Sinus may be congenital or acquired
 Pilonidal sinus is commonly seen at natal cleft
& generally contain hair
 Also known as ‘jeep disease’ since it was
common in jeep drivers during 2nd world war

94. Patho-anatomy :-
 Primary track – opening on skin & expanding
into a small terminal cavity
 Hairs – nearly all hairs lie loose but few are
still attached to the track wall
 Secondary tracks – connects the deep part of
primary track to the sinus opening lining
 Lining of track – granulation tissue
 Contents – hairs, epithelial scales & debris
 Microscopically – foreign body, giant cells,
aerobic & anaerobic organisms

95.  Age incidence – 20 to 30 yrs
 Gender incidence – more common in males
 Racial incidence – more in western countries
 More common in hairy people

96. Risk factors :-
 Obesity
 Sedentary occupation
 Positive family history
 Local irritation or trauma
 Increased sweating
 Poor personal hygine
 Abundant hairs in gluteal fold

97. Clinical features :-
 Acute abscess or chronic
draining sinus in the
sacrococcygeal area
 Pruritis
 Pain
 Tenderness
 Induration

98. Other sites of the disease :-
 Digital webs of hand & foot
 Axilla
 Umbilicus
 Perineum
 Amputation stump
 Supra pubic region

99. Differential diagnosis :-
 Hidraadenitis suppurativa
 Furunculosis Fistula in ano
 Osteomyelitis Crohn’s disease
 Actinomycosis Post anal skin dimples
Complications :-
 Abscess formation
 Recurrent inflammation
 Recurrence of sinus formation
 Squamous cell carcinoma

100. Modern management :-
A] Conservative management –
 Avoid long sitting & driving
 Depilation of hair
 Frequent sitz bath
 Keeping the area dry
 Injection of phenol

101. Modern management :-
B] Operative procedures –
 Eliptical excision
 Wide radical excision
 Excision & Healing by
granulation
 Excision & Marsupialization
 Excision & primary closure
 Closure by Z-plasty
 Myocutaneous Flap

102. Ayurvedic View :-
 Dushtsvrana – Shalyaja Nadivrana
 Shalya hidden in dhatus & not removed properly
result in Shalyaja Nadivrana
 Quickly formed sinus exuding warm liquid,
frothy, churned up, clear or blood stained
suddenly with pain - Shalyaja Nadivrana
 Prognosis is kashta sadhya
 In Shalyaja Nadivrana Sinus needs to be opened,
shalya removal & cleansing of track
 Management by bhedana, eshana & patana
 Medicine – Guggultiktakam kashayam
 Ksharsutra is described for nadivrana chikitsa

103. Surgical procedures for Shalyaja Nadivrana :-
 Chedana of the whole track
 Partial chedana of the track & Ksharsutra
application to the remaining track
 Ksharsutra application to complete track
 Ksharsutra application only to lateral tracks
 Ksharvarti application
 Chedana & ksharalepa application
 Cleaning wound with Triphala kwatha &
application of Jatyadi ghrita

104. Merits of Ksharasutra therapy :-
 Encourage healing from the base
 Least recurrence rate
 Simple procedure (OPD)
 Minimal invasive
 Minimal scar
 Cosmetic value
 Minimal work off days
 Cost effective

105. Dr. Yogesh S. Borase
M.S.(Shalyatantra)
Lecturer (Dept. of Shalyatantra)
Rural Institute of Ayurveda Research Center
& Hospital, Vidyagiri, Mayani.
Tal- Khatav, Dist- Satara (Maharashtra)