Piles, Fistula in ano, Fissure in ano, Abscess in ano-rectal region are the common diseases that occur in ano rectal area. This slide show is specially useful for Doctors who want to learn ano-rectal diseases, their diagnosis and their treatment

1. HISTORY TAKING, EXAMINATION,
SYMPTOMATOLOGY AND AYURVEDA TREATMENT IN
ANO-RECTAL PATIENTS
By: Dr. Naveen Chauhan
BAMS, CCYP, ROTP, CRAV (Kshara sutra)
Consultant Ayurveda Proctologist
Brahm Healthcare, Ghaziabad
www.ayurvedapilescure.com
www.brahmayurved.com

2. GENERAL BIO DATA OF PATIENT
 Patient Name
 Age
 Gender
 Address with contact numbers
 Occupation
 Marital status

3. CHIEF COMPLAINTS WITH DURATION
 Encourage the patient to speak
 Oldest complaint should be noted first
(Chronological order)
 Example:
 Bleeding during defecation
 Pain during and after defecation
 Constipation
 Anal itching and so on……

4. HISTORY OF PRESENT ILLNESS
 The events must be listened and recorded in
patient’s own language like a story.

5. HISTORY OF PAST ILLNESS
 Past disease like Diabetes, IHD, TB, HTN, Asthma,
Jaundice etc.
 Any hospitalization or surgery in past
 History of trauma or accident if any

6. FAMILY HISTORY
 Ask if any member of family ever suffered from
similar problem

7. DRUG AND TREATMENT HISTORY
 Any kind of medication in past or present
 Write generic names of drugs with dosage

8. SOCIAL HISTORY
 Smoking (with amount per day)
 Alcohol (with amount per day)
 Any other addiction
 Food habits
 Socio-economic status

9. EXAMINATION OF PATIENT
 GENERAL EXAMINATIN
 TRIVIDH PAREEKSHA
 SHADVIDH PAREEKSHA
 ASTAVIDHA PAREEKSHA
 SYSTEMIC EXAMINATION
 LOCAL EXAMINATION (Sthanic pareeksha)

10. EXAMINATION OF PATIENT
 Must be with oral or written consent
 If male doctor is examining a female patient, female
doctor or hospital staff must be present

11. EXAMINATION OF PATIENT: GENERAL
EXAMINATION
General examination includes;
 G/C
 Gait
 Build
 Height, weight, BMI
 Pulse
 R/R
 Temperature
 BP
 Pallor
 Jaundice
 Cynosis
 Tongue
 Lymph nodes
 Any notable swelling

12. EXAMINATION AYURVEDA: TRIVIDH PAREEKSHA
 Aaptopdesh
 Pratyaksh
 Anumaan
 Darshan
 Sparshan
 Prashna

13. ASHTASTHANA PAREEKSHA (EIGHTFOLD
EXAMINATION)
 Nadi-Pulse
 Moothram-Urine
 Malam -Faecal matter
 Jihwa- Tongue-taste
 Sabdam -Voice and speech of the patient
 Sparsham-Touch, skin and tactile sense
 Drik -Eyes and vision
 Akrithi- General body build, eg: lean, muscular, etc.

14. DASAVIDHA PAREEKSHA (TENFOLD
EXAMINATION)
 Prakrithi- The natural Thridosha constitution of the body
 Vayas -Age of the patient.
 Dooshyam- Regarding the structural and functional
abnormalities of the body
 Desham -Geographical situation of the place where patient
lives (eg: marshy)
 Balam -Physical strength
 Kalam- The season and climatic conditions
 Analam -The digestive system of the patient
 Satvam- Psychological strength of the patient
 Sathmyam- General and personal habits of the patient e.g.:
smoking, hard working, day sleeping etc.
 Aharam- Nature of food (e.g. vegetarian or non-vegetarian)

15. SYSTEMIC EXAMINATION
 CNS
 RESPIRATORY SYSTEM
 CVS
 GIT (PER ABDOMEN, BOWEL SOUNDS)
 UROGENITAL SYSTEM
 LOCOMOTORY SYSTEM AND SO ON

16. LOCAL EXAMINATION
POSTION OF PATIENT
It may be carried out in;
 Lithotomy
 Knee abdomen or
 Left lateral (Sim’s) positions
 Knee elbow position

17. LITHOTOMY POSITION
 Patient lies in supine position with buttock at the
lower break of the table.
 The legs are flexed in and hips abducted (30
degrees)
 The knees are bent 70 to 90 degrees.
 The lower legs are supported on padded leg shells..

18. LITHOTOMY POSITION

19. LITHOTOMY POSITION

20. KNEE ABDOMEN POSITION
 Patient lie in supine position
 Hip joints flexed to maximum to touch chest
 Hips are at the edge of table
 Similar to Pawanmuktaasana

21. KNEE ABDOMEN POSITION

22. SUSHRUT’S POSITION FOR ASHMARI AAHRAN
AND ARSHAS
 Similar to Knee abdomen position
 Reference: Su. Chi. Chapter 6 and 7

23. LEFT LATERAL OR SIM’S POSITION
•Can be conveniently used for rectal
examination and diagnostic procedures
•Flex hips and knees and position the
buttocks at the edge of the couch.

24. KNEE ELBOW POSITION
 Suitable in physically fit patient
 Ideal for examination of prostate and pilonidal sinus

25. LOCAL EXAMINATION :
 INSPECTION:
 Appropriate positioning of the patient over the
examination table

26. LOCAL EXAMINATION
 Good source of light is needed and it should be
preferably behind the doctor

27. LOCAL EXAMINATION: INSPECTION
 Entire perineum must be inspected thoroughly and
carefully

28. LOCAL EXAMINATION: INSPECTION
 Observe any scar of previous surgery if present

29. LOCAL EXAMINATION: INSPECTION
 Look for any swelling or any opening with or without
discharge in perianal region

30. LOCAL EXAMINATION: INSPECTION
 Note the colour, nature and consistency of
discharge if any. Colour may be yellowish, reddish,
nature may be purulent, bloody, consistency may
be watery or thick

31. LOCAL EXAMINATION: INSPECTION
 Note the o’clock position of the swelling, scar or
external opening and its approximate distance from
anal verge in cms.

32. LOCAL EXAMINATION: INSPECTION
 Gently seprate the gluteal folds to expose the anal
verge
 Look for any ulcer or crack or Fissure. Note it’s
O’clock position
 Observe any external growth or lump or skin tag at
anal verge
 Look for any bleeding or discharge from anus
 Look for any prolapse of some lump or mucosa etc.
from anus

33. LOCAL EXAMINATION: INSPECTION

34. LOCAL EXAMINATION: PALPATION
 Palpate the perianal area thoroughly but gently
 Feel the temperature of perianal region and hips
 If there is swelling, the area covered by the swelling
should be measured by scale

35. LOCAL EXAMINATION : PALPATION, P/R
EXAMINATION
 Digital examination:
 Also known as per rectal examination or P/R
 Essential part in every rectal case
 Must be done gently and with maintaining privacy
and dignity of patient

36. DIGITAL EXAMINATON: NEED
 To find out the underlying pathology i.e. to reach the
diagnosis of the disease e.g. the cause of rectal
bleeding
 Also done in urinary problems to palpate prostate in
males
 To diagnose the gynecological diseases in females
 Sometimes to get the stool samples for pathological
tests

37. DIGITAL EXAMINATION: CONTRAINDICATIONS
 Must be avoided if;
 Patient is not comfortable
 Pain is there like in Anal fissure or external
thrombosed piles

38. DIGITAL RECTAL EXAMINATION (P/R)
 Appropriate position: Lithotomy, Knee abdomen or
Sim’s

39. DIGITAL RECTAL EXAMINATION
 Always wear a mask as a rule

40. DIGITAL RECTAL EXAMINATION
 Use an examination glove or finger stall

41. DIGITAL RECTAL EXAMINATION (P/R)
 Use appropriate lubricating agent like Lignocaine
2% gelly

42. DIGITAL RECTAL EXAMINATION (P/R)
 Ayurveda alternatives as lubricating agents Jatyadi
oil or Goghrit or Aloe vera gel

43. DIGITAL RECTAL EXAMINATION
 How it is performed?
 Index finger of working hand after proper lubrication is
gently inserted inside the anus NOT straight way but in a
way that pulp of finger gets inserted at anus first
 Lubricate the examining index finger with suitable water-
soluble gel and press the finger against the posterior
anal margin (6 o'clock according to convention).The
finger should slip easily into the anal canal, and the
finger tip is directed posteriorly following the sacral
curve.
 At this point, if appropriate, the anal tone can be
checked by asking patients to squeeze the finger with
their anal muscles.

44. DIGITAL RECTAL EXAMINATION

45. DIGITAL RECTAL EXAMINATION
 The finger is then moved through 180°, feeling the walls of the rectum.
With the finger then rotated in the 12 o'clock position, helped usually by
the examiner bending knees in a half crouched position and pronating
the examining wrist, the anterior wall can be palpated. Rotation facilitates
further examination of the opposing the walls of the rectum. In men, the
prostate will be felt anteriorly. In women, the cervix and a retroverted
uterus may be felt with the tip of the finger. It is important to feel the walls
of the rectum throughout the 360°. Small rectal wall lesions may be
missed if this is not done carefully.
 Examination of the prostate gland (felt anteriorly):
 Normal size is 3.5 cm wide, protruding about 1 cm into the lumen of the
rectum.
 Consistency: it is normally rubbery and firm with a smooth surface and a
palpable sulcus between right and left lobes.
 There should not be any tenderness.
 There should be no nodularity.
 Massage of the prostate may enable prostatic fluid to be examined at the
urethral meatus.
 On removal of the examining finger check the tip of the glove (for stool,
blood).

46. DIGITAL RECTAL EXAMINATION
 Cleaning the anus by a sterile swab
 Findings must be noted properly and carefully
 Patient is to be told that examination is over and
thanked

47. PROCTOSCOPY
 Gives direct visualization of anal canal and partially
of rectum too.

48. PROCTOSCOPY
 Appropriate postion and Light

49. PROCTOSCOPY
 Adequate preparation has to be done either by
giving a suitable laxative one night before or by
giving proctoclysis enema 2 hours before the
procedure

50. PROCTOSCOPY : CONTRAINDICATIONS
 Painful anal conditions like Anal fissure,
Thrombosed external hemorrhoids
 Patient is not co-operative

51. PROCTOSCOPY
 Proctoscope of suitable size should be gently
inserted inside the anus after proper lubrication by
Lignocaine 2% jelly
 The obturator is withdrawn and proctoscope is
pulled slowely outside with simultaneous focussing
the light inside its lumen

52. PROCTOSCOPY
 Careful observations should be done. Internal piles
with or without ulcerations or bleeding can be easily
diagnosed by proctoscopy
 Sometimes internal opening of Fistula in ano can
be visualized through proctoscope

53. CONCLUSION OF EXAMINATION
 After proctostopy the anal area must be cleaned by
sterile swab and patient must be informed that
examination is over
 Findings must be noted carefully

54. ANO-RECTAL DISEASES
 Piles or Hemorrhoids (Arshas)
 Fissure in ano (Parikartika)
 Fistula in ano (Bhagandar)
 Abscess in ano rectal region (Vidradhi)
 Polyps
 Pilonidal sinus (naadivrana) – Not truly a disease of
ano rectum but included due to similar symptoms.
 Cancer

55. PATIENT’S COMMON COMPLAINTS
(SYMPTOMS AND THEIR ANALYSIS)
 Bleeding during and/or after defecation
 Pain
 Discharge of pus like material
 Itching
 Anal irritation
 Constipation
 Diarrhoea
Associated symptoms:
 Anaemia
 Anxiety
 Depression

56. SYMPTOM: BLEEDING P/R
Questions to be asked during history
1. Do you remember the date when bleeding
occurred first time? i.e. Approximate duration of
bleeding.

57. SYMPTOM: BLEEDING P/R
 What is the colour of blood that comes?
Piles bleeding is bright red colored with fresh blood
coming during and after defecation.

58. BLEEDING P/R
 Is bleeding painless or with pain?

59. BLEEDING P/R
1. How much is the amount of bleeding? Is it;
 As drops?
 As streak over hard stool?
 Or as splash inside the toilet pan? (Large quantity)

60. SYMPTOM : PAIN
 Pain also troubles a patient quite frequently and
often he/she looks for an expert’s consultation
Questions to be asked?
Site, severity, duration, relief

61. PAIN
 Is pain mild, moderate or severe?

62. PAIN
 Is pain present at anus or nearby it (perianal
region)?

63. PAIN
 Does pain has relation with defaecation?
 Is present at the time of defaecation or at other
times too?

64. PAIN
 How pain gets relieved?
By some medicine or by Sitz bath or by fomentation
etc.

65. SYMPTOM ANALYSIS: PAIN
Conditions to be considered in Acute pain:
 Anal fissure or Fissure in ano
 Thrombosed external piles
 Boil or Abscess in ano rectal region
 Cryptitis

66. SYMPTOM ANALYSIS: PAIN
Conditions to be considered in Chronic pain:
 Perianal abscess
 Fistula in ano
 Carcinoma anal canal
 Carcinoma rectum

67. SYMPTOM: PROLAPSE OF MASS
While straining during defecation, a patient may feel
something coming out from anus.
Questions to ask?
1. Does the mass is felt coming out during straining
in segments or unsegmented?
2. How much straining leads to prolapse? Mild
coughing or excess straining?
3. Is spontaneous reduction present or needs
manual intervention for reducing it back?

68. SYMPTOM ANALYSIS: PROLAPSE
 Prolapse of mass is the peculiar symptom of piles and
based on this feature piles have been classified as
Grade 1, 2, 3 or 4
 Grade 1 or 1st degree piles – only bleeding no prolapse
 Grade 2 or 2nd degree piles – Bleeding off and on,
prolapse on straining, spontaneous reduction present
when strain removed
 Grade 3 or 3rd degree piles – Bleeding off and on,
prolapse on straining, don’t get reduce when strain is
removed, finger support needed for reduction
 Grade 4 or 4th degree piles – Always out

69. SYMPTOM ANALYSIS: PROLAPSE

70. DISEASE WISE SYMPTOMS
Piles/Hemorrhoids :
 Bleeding during and/or after defecation
 As drops sometimes as splash in pan (more in
quantity)
 Prolapse of some mass
 Generally painless bleeding if there is no other
associated disease

71. PILES/ HEMORRHOIDS

72. PILES/HEMORRHOIDS LINE OF TREATMENT
 Grade 1 or 1st degree hemorrhoids : Medicinal
management
Ayurveda rakt stambhak aushadhis like; Naagkeshar,
Sphutika, kaharwa, Aristak, Rasanjan, Bol etc.
Many combinations are available in market
Locally acting vran-ropak creams and oils like Jatyadi
oil, kaasisadi oil etc.
Treatment of constipation includes diet management
and use of laxatives

73. PILES/HEMORRHOIDS LINE OF TREATMENT
 Grade 2 or 2nd degree hemorrhoids :
Ayurveda rakt stambhak aushadhis like; Naagkeshar,
Sphutika, kaharwa, Aristak, Rasanjan, Bol etc.
Many combinations are available in market in tablets
and capsules form
Locally acting vran-ropak creams and oils like Jatyadi
oil, kaasisadi oil etc.
Treatment of constipation includes diet management
and use of laxatives

74. PILES/HEMORRHOIDS LINE OF TREATMENT
 Grade 2 or 2nd degree and 3rd degree hemorrhoids :
When to refer the patient to surgery department?
If patient is not responding to medicine, his bleeding not
stopped or in spite of taking medicines, he is having
episodes of bleeding.
If patient is anxious and got fed up of taking medicines
and wants permanent cure.
If prolapsed pile mass is/are large and making patient
uncomfortable frequently

75. PILES/HEMORRHOIDS LINE OF TREATMENT
 Grade 2 or 2nd degree hemorrhoids and 3rd degree
hemorrhoids often need surgery:
Ayurveda Surgical approach : Kshara sutra
ligation procedure
There are many methods of surgery and kshara sutra is
one of them with some advantages.

76. PILES/HEMORRHOIDS LINE OF TREATMENT
KSHAR SUTRA LIGATION

77. PILES/HEMORRHOIDS LINE OF TREATMENT
KSHAR SUTRA LIGATION
 It takes about 7 to 10 days to shed off the ligated
hemorrhoids
 Daily dressing and gudpooran with jatyadi oil is
done
 Sitz bath and NSAIDs are advised for post
operative pain
 Patient cures completely in about 15-20 days after
the procedure

78. FISSURE IN ANO SYMPTOMS
 Pain during and after defaecation: Severe cutting or
throbbing type pain. Leads to a lot of discomfort
and patient fears to go to toilet. Pain persists even
hours after defecation.
 Bleeding in small amounts as streak over hard
stools, sometimes as drops
 Burning sensation
 Spasm of anal sphincter
 constipation

79. FISSURE IN ANO

80. FISSURE IN ANO
AYURVEDIC TREATMENT APPROACH
The aims of treatment are;
 To relieve pain
 To reduce the spasm of sphincter
 To remove the causative factors mainly
Constipation
 To heal the fissure wound

81. AYURVEDIC TREATMENTS
For Pain: Anti-inflammatory drugs
 Guggulu preparations like Trifala guggulu, Shigru
guggulu, Saptvinshati guggulu

82. AYURVEDIC TREATMENTS:
 Sitz bath (kati snan): Soaking anal region in tub
filled with lukewarm water or decoction of Ayurvedic
herbs like; Trifala kwath or Panchvalkala kwath
 It acts as WONDER REMEDY and helps in
relieving the pain and spasm

83. AYURVEDIC TREATMENTS:
 Vasti of Healing oils like; Anu tail, Panchaguna tail,
Jatyadi tail, Prabhakar tail etc.
 Vasti of yastimadhu kwath, ghrita etc.
 Ointments for local application

84. AYURVEDIC TREATMENTS
For Constipation: Bowel regulators and laxatives like;
 Haritaki Churna
 Trifala Churna
 Panchasakar Churna
 Isabgol Husk
 Erand tailam
 Jiva Mukti powder

85. AYURVEDIC TREATMENTS
Finger dilation of anal canal; GANESH KRIYA
 Indicated when sphincter got relaxed just after having
a Sitz bath
 A condom/glove is used to cover the index finger, it is
lubricated using any healing oil then the finger is
rotated clockwise and anticlockwise

86. AYURVEDIC TREATMENTS
To heal Fissure all these treatments work collectively
i.e. :
 Anti-inflammatory drugs
 Bowel regulators
 Sitz bath
 Finger dilation (Ganesh kriya)
 Locally acting healing oils and ointments

87. AYURVEDIC TREATMENTS : SURGICAL
APPROACH
When to refer a Fissure patient to surgery?
 If patient is not responding to medicines.
 If fissure is chronic and accompanied with a
sentinel tag
Ask him/her if there is some hanging mass of skin at
anus margin ?
 If fissure is infected, indicated by pus discharge
with pain

88. KSHARA SUTRA TREATMENT IN CHRONIC
FISSURE WITH SENTINEL TAG
The sentinel tag(s) is/are ligated tightly by kshara
sutra under local, spinal or general anaesthesia. It
is followed by Manual Forceful Dilation of anal
canal up to six fingers (Lord’s procedure). There
after Jatyadi oil is instilled per rectally and aseptic
dressing applied using T-Bandage (Gofana
Bandaha of Sushruta).

89. Kshar sutra in anal fissure

91. MANUAL ANAL DILATION : GANESH KRIYA
(LORD’S PROCEDURE)

92. AGNIKARMA CHIKITSA: EXCISION OF TAGS BY
FIRE
In this procedure the tags are excised using
Agniyantra (Thrmocautery). This is a blood less
procedure which can be comfortably used to excise
the tags in one sitting. Thus the Fissure gets healed
in about 07 to 10 days.

93. FISSURE IN ANO : KSHAR SUTRA TREATMENT
Q. How much will it take to heal a chronic fissure by
kshar sutra or Agnikarma treatments?
Answer: To heal completely it takes about 15 to 20
days.
Q. Will there be pain after treatment?
Answers: There can be mild to moderate pain
especially if there is constipation during post
operative period. But it’s managaeble by medicines
and sitz bath.

94. DISEASE WISE SYMPTOMS
Fistula in ano (Bhagandar) :
 Boil or cystic swelling in perianal region
 Purulent discharge
 Itching in anal or perianal region
 Pain off and on

95. DISEASE WISE SYMPTOMS
Fistula in ano (Bhagandar) :

96. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
Fistula in ano is a 100% surgically curable disease
Medicines (Whether Ayurveda or Allopathic or any other
pathy) can only relieve some symptoms but can NOT
cure the disease

97. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
Q. - When to refer a Fistula patient to Ayurveda
surgery department?
Answer: To avoid defame, you must refer a fistula
patient once you get the above discussed
symptoms of boil, purulent discharge and so on.

98. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
How kshara sutra threading procedure is done in
Fistula in ano?
Under suitable anaesthesia probing is done and the track
is threaded loosely by kshar sutra.
Unhealthy granulation tissue or fibrosed tissue is excised
off by cautery or using knife/scissiors.

99. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
How kshara sutra threading procedure is done in
Fistula in ano?

100. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
How kshara sutra threading procedure is done in
Fistula in ano?

101. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
How kshara sutra threading procedure is done in
Fistula in ano?
Weekly follow up: Kshar sutra is changed on weekly
basis by rail road technique. New thread is tied at old
thread lateral to the knot and the old thread is pulled
from anal end.
https://www.youtube.com/watch?v=DM-CqtW_-OA
The only video of kshar sutra change on youtube is
uploaded by me about 7 years ago.

102. FISTULA IN ANO
AYURVEDIC TREATMENT APPROACH
Q. How much time will it take for complete cure by
kshara sutra threading procedure in Fistula in ano?
Answer: This can NOT be predicted by without
examination and/or investigations.
Duration of treatment depends on many factors like;
 Length and depth of track
 Previous surgery
 Individual healing capacity
 Associated disease like DM

103. DISEASE WISE SYMPTOMS
Pilonidal sinus (Naadivrana) :
 Boil or cystic swelling in natal cleft at the end of
tailbone
 Purulent discharge off and on
 Itching around affected region
 Pain off and on

104. PILONIDAL SINUS

105. PILONIDAL SINUS
AYURVEDIC TREATMENT APPROACH
Like Fistula in ano, pilonidal sinus is also a 100%
surgically curable disease
Medicines (Whether Ayurveda or Allopathic or any other
pathy) can only relieve some symptoms but can NOT
cure the disease

106. PILONIDAL SINUS
AYURVEDIC TREATMENT APPROACH
When to refer a Pilonidal sinus patient to
Ayurveda surgery department?
Answer: To avoid defame, you must refer a
pilonidal sinus patient once you get the
above discussed symptoms of boil, purulent
discharge and so on.

107. PILONIDAL SINUS
AYURVEDIC TREATMENT APPROACH
How kshara sutra threading procedure is done in
Pilonidal sinus?
Under suitable anaesthesia, the track is probed.
Unhealthy tissue is excised off and the track is loosely
threaded by kshar sutra.

108. PILONIDAL SINUS : STEPS OF KSHAR SUTRA
THREADING

109. PILONIDAL SINUS: STEPS OF THREADING