Case 5 Anovaginal Fistula: A case presentation and Ayurvedic Approach

• Admin worker – sits for long periods
• Married 7 years
• Moved to Aust 7 years ago (before this history of anaemia).
• In last 2 years had tinnitis. Ignored for a while. Then visited GP after some hearing loss.
• 2018 Bartholian cyst. Had incision and drained. Returned later on. Surgery undertaken where specialist noticed the fistula tunnel. Only half fistulotomy done (vaginal side), so not to cut into sphincter muscles.
• Colonoscopy done. Ulcers in sm. and lge. intestine. Indicated Crohn’s disease. Currently referred to gastroenterologist.
• No rectal bleeding.
• Vertigo attacks (4 in last 3 years). Head spinning and vomiting. Eventual stomach ulcer from vomiting.
• First onset of Vertigo GP thought only food poisoning.
• Stemitil only medication that worked to alleviate.
• Lost 11 kg in 2020. Much of this was deliberate. Recent 3kg weight loss appears to be attributed to diet recommended by another Ayurvedic physician (not eating enough???).
• Had depression 2019 (diagnosed??) visited hypnotherapist on India at time. Working on herself to improve from this.
• Used to be vegetarian. Now back on meat.
• Menses regular. Since this year period pain with more constipation during ovulation.
• Previous PCOS diagnosis
• Never been pregnant
• Never been on pill
• Scared of having sex – pain -pain is on entry, not when penis fully inserted.
• Wants to conceive one day
• Gets racy heartbeat every now and then.

Past Medical History

• No hospitalisations

Surgical History

• Half fistulotomy. See above

Medications

• None at present.

Family History

• Cholesterol father and recent sugar issues
• Thyroid mother

Social History

• Smoker 2 x day started last year Cannabis
• Alcohol stopped 18 months ago. Before this 1 x beer week (4-5 years)

Physical Examination

Nadi Pariksha (Pulse Examination)

• Not on client notes

Mutra Pariksha (Examination of Urine)

• NAD

Mala Pariksha (Stool Examination)

• Constipated

Jihwa Pariksha (Tongue Examination)

• Coated

Shabda Pariksha (Voice Examination)

• NAD

Sparsha Pariksha (Touch Examination)

• NAD

Drik Pariksha (Eye Examination)

• NAD

Akrti Pariksha (Physical Appearance Examination)

• NAD

Akruti (volume and tension of pulse)

• Not on client notes

Abdominal examination: Possible faeces blocked up in intestine in right hypochondriac region. Client advised to check this following day after next passing of stools. If still there after this, then need to go to GP ASAP to arrange ultrasound.

• Ensure to get colonoscopy done with specialist to confirm conventional diagnosis.

Prakruthi:VP

Vikruthi:VP

Agni:Imbalanced/Vishama

Sub dosha Vata (Prana, Udana, Samana, Vyana, Apana):

• Apana vata (constipation, fistula, IBS)
• Prana vayu (tinnitus, vertigo, depression)
• Samana vayu (constipation)
• Vyana vayu (joint pain in wrist)

Sub dosha Pitta (Sadhaka, Alochaka, Pachaka, Bhrajaka, Ranjaka):

• Bhrajaka pitta (ulcers)
• Sadhaka pitta (depression)

Sub dosha Kapha (Tarpaka, Bodhaka, Kledaka, Sleshaka, Avalambaka):

• Sleshaka kapha (joint pain in wrist)
• Tarpaka Kapha (Vertigo)

Dhatus (Rasa, Rakta, Mamsa, Meda, Asti, Majja, Shukra):

• Rasa kshaya (dizziness, tachycardia)
• Rakta vruddhi (vertigo)
• Majja kshaya (dizziness)
• Majja dushti (dizziness)
• Shukra kshaya (dizziness)
• Artava kshaya (desire for marijuana)
• Purisha vruddhi (constipation)
• Purisha dushti (constipation, fistula)

Srotas (Annavaha {Digestive}, Pranavaha {Respiratory}, Udakavaha {Fluid}, Rasavaha, Raktavaha, Mamsavaha, Asthivaha, Majjavaha, Sukravaha, Swedavaha, Purishsvaha, Mutravaha, Manovavaha, Arthavavaha {Menstruation}, Stanyavaha {Lactation}): 

• Annavaha sroto dushti (constipation, potential Crohn’s disease)
• Rasa vaha sroto dushti (sensitivity to sound, palpitations)
• Purisha vaha sroto dushti (constipation, fistula)
• Mamsavaha sroto dushti (abscesses)

Prana, Tejas, Ojas:

• Ojas kshaya (chronic vata disorders, palpitations)
• Tejo vruddhi (ulcers)
• Prana Kshaya (depression)
• Prana vruddhi (dizziness, conditions of excess vata)
• Majja vaha sroto dushti (pain in wrist, dizziness)
• Pathway (Internal, external, middle): Internal and middle
• Kriyakala (Accumulation (Sanchaya); Aggravation (Prakopa); Overflow (Prasara); Relocation (Sthyana Samsraya); Manifestation (Vyakti);  Complications (Bheda): Manifestation
• Dosha gati (Direction): Adho downward vata, urdhava vata, Adho pitta.
• Purvaroopa (Prodormal Signs and symptoms): Tinnitus, constipation, cyst, ulceration, palpitations, vertigo, cyst.
• Roopa (Disease Manifest Signs and symptoms): Anovaginal fistula, depression.
• Ayurvedic Pathogenesis:  This is actually got two directions

Inappropriate Vata aggravating lifestyle & food habits including potentially eating too fast and without proper chewing of food have led to Apana Vata aggravation in the anal canal causing chronic constipation. Pitta aggravating diet and lifetstyle factors have then more recently led to vitiation of Pitta leading to Brahma (vertigo), and Pana Vaya which has led to tinnitus. This has then further led to depression.  Further, the aggravation of Apana Vayu has led to vitiatation the muscle & blood, giving rise to a Bartolian cyst, which has progressed to complications of leading to an anovaginal fistula. Inappropraite diet and lifestyle habilts have also led to to poor agnia nd the development of ama in the colon whcihh has also ledto the development of ulvers in the intestine.

Anovaginal fistula: Anal fissures are an acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of the anal canal. It causes severe pain, sometimes with bleeding, particularly with defecation. Thought to result from laceration by a hard or large stool, or frequent loose bowel movements. Fissures may cause internal sphincter spasming, thus decreasing the blood supply and worsening the chronic nature of the condition.

Tinnitus: Tinnitus is a person hearing noise or ringing in the ears, and affects about 15 to 20 percent of people. Tinnitus isn’t a condition within itself, rather it is a symptom of an underlying condition, which could include age-related hearing loss, ear injury or a disporder of the circulatory system.

Intestinal ulceration: It is not known why the ulcers in the large intestine and colon occur, but it is thought that continued inflammation through bacteria in the colon, as well as genetic factors that affect the immune system. Normally the immune system can suppress the inflammation, however in some cases this is not achieved, resulting in ulcers of the large intestine. One of the first diagnostic signs of Crohn’s disease is ulceration of the large intestine and colon.

Vertigo: Vertigo is a form of dizziness where one feels that they are spinning, or that the world is spinning around hen, especially that they change position. The condition is often the result of an inner ear problem, such as paroxysmal positional vertigo, which happens when calcium particles clump together in the inner ear. Vertigo can also be caused by Meniere’s disease which leads tp tinnitus and subsequent hearing loss, swelling or infection of the inner ear, and vestibular neuronitis and labyrinthitis.

Depression: Depression is associated with the lowering of a persona’ mood for a period of two weeks or more. Here, one may feel tired, sick and run down, have sleep issues, overwhelmed, disappointed, miserable, irritable, sad, and lose interest in life. One may prefer to stay home, not get work done, withdraw from friends of family, not enjoy social activities and be unable to concentrate. It can be caused by stress, life events, genetic history, medical illnesses, drug and alcohol abuse, trauma, and a number of other factors.

Constipation: Constipation is referred to as the passing of hard, dry stools that may be infrequent or difficult to pass. Common causes include changes in routine, not enough daily fibre intake, lack of exercise and decreased fluid intake. https://www.jeevahealth.com.au/ayurvedic-glossary/constipation-gut-health-ayurvedic-management/

Ayurvedic herbs:

Its been advised that fistula is a surgical conditions that needs surgery as per Ayurvedic Medicine, however the herbs may be used to reduce the inflammation.

Ayurvedic herbs:

Its been advised that fistula is a surgical conditions that needs surgery as per Ayurvedic Medicine, however the herbs may be used to reduce the inflammation.

In Addition, Ayurvedic Herbs For The Following Include: 

Anovaginal Fistulas (Bhagandara):

• Vata Pitta Balancing: Aloe vera juice, Triphala
• Vata Kapha Balancing: Turmeric, Cinnamon  Ashwganda, Guggulu, Triphala
• Pitta Vata Balancing: Turmeric – not in excess,  Guduchi, Aloe vera juice, Licorice, Triphala
• Pitta Kapha Balancing: Turmeric – not in excess, Chitraka, Triphala, Kanchanara
• Kapha Vata Balancing: Turmeric, Cinnamon, Guggulu, Triphala
• Kapha Pitta Balancing: Turmeric, Kutaja, Chitraka, Kanchanara, Triphala
• Jatyadhi ghee (external application) – heals external wounds including anal wounds. Soothes anal sphincter and increases speeds of healing process.
• Nirgundi oil (external application) – analgesic

Vertigo (Brahma):

• Vata Pitta Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, licorice,
• Vata Kapha Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, vacha, ginger, sarpaganda
• Pitta Vata Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, licorice,
• Pitta Kapha Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, gingo biloba,
• Kapha Vata Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, vacha, ginger, gingko biloba, sarpaganda
• Kapha Pitta Balancing: Brahmi, guduchi, sariva, coriander, shankapushpi, shilajat, gingko biloba,

Tinnitus (Kananada):

• Vata Pitta Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi, licorice
• Vata Kapha Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi, rasna, fenugreek, vacha
• Pitta Vata Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi, locorice
• Pitta Kapha Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi
• Kapha Vata Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi, rasna, fenugreek, vacha
• Kapha Pitta Balancing: Guduchi, Bala, Sariva, amalaka, gokshura, jatamansi

Intestinal Ulceration/Chron’s (Grahani):

• Vata Pitta Balancing: Shatavari, Bilwa, Turmeric, Aloe vera juice, Licorice
• Vata Kapha Balancing: Turmeric, Cinnamon, Ashwaganda
• Pitta Vata Balancing: Turmeric – not in excess, Guduchi,  Aloe vera juice, Licorice
• Pitta Kapha Balancing: Turmeric – not in excess, Aloe vera juice, Daruharidra, Musta
• Kapha Vata Balancing: Turmeric, Cimnnamon
• Kapha Pitta Balancing: Turmeric, Musta, Kutaja

Depression(Unmada):

• Vata Pitta Balancing: Shatavari, Turmeric, Licorice, Brahmi, Haritaki, Licorice, Jatamamsi, Mandukaparni, Ginseng, Shatavari
• Vata Kapha Balancing: Turmeric, Ashwaganda, Brahmi,  Jatamamsi, Guduchi, Ashwaganda, Shankapushpi, Bhringaraja, Tulsi,
• Pitta Vata Balancing: Turmeric – not in excess , Guduchi, Licorice, Brahmi, Licorice, Jatamamsi, Mandukaparni, Ginseng, Shatavari
• Pitta Kapha Balancing: Turmeric – not in excess, Brahmi, Haritaki, St John’s Wort, Jatamamsi,
• Kapha Vata Balancing: Turmeric, Brahmi, Ashwaganda, Bhringaraja, Guduchi, Tulsi, Jatamamsi, Jyostismathi,
• Kapha Pitta Balancing: Turmeric, Brahmi, Shankapushpi, St John’s Wort, Jatamamsi,

Constipation (Vibhanda):

• Vata Pitta Balancing: Triphala, katuka, psyllium, dashamoola, Castor oil, flax, licorice
• Vata Kapha Balancing: Triphala, katuka, psyllium, dashamoola, flax, vasa,
• Pitta Vata Balancing: Triphala, katuka, psyllium, dashamoola, castor oil, vasa, licorice
• Pitta Kapha Balancing: Triphala, katuka, psyllium, dashamoola, dandelion root,
• Kapha Vata Balancing: Triphala, katuka, psyllium, dashamoola,
• Kapha Pitta Balancing: Triphala, katuka, psyllium, dashamoola, dandelion root,

Bhagandara/Anal Fistula:

• Avoidance of causative factor, Diet and lifestyle changes, Increase Agni, abhyanga, avagaha sweda, dhumapana, Ayurvedic herbs, Kshara sutra.
• Eleven Measures are described in Dvivraniyeadhyaye for   management: Aptarpana, Alepa,  Parisheka, Abhyanga, Swedana, Vimlapana, Upnaha, Pachana, Vishravana, Snehana, Vamanaand Virechana.
• The current gold standard for the treatment of the condition is Kshar Sutra treatment (medicated caustic thread) – a minimal invasive Ayurvedic Parasurgical procedure. It is not Available in Australia. Patients need to go to an experienced Ayurvedic physician in India for treatment.

Vertigo/Tinnitus/ Intestinal Ulceration/Depression/Constipation treatment options for this patient:

• Avoidance or eradication of causative factors and increase Ojas.
• Increase Mandagni and remove ama.
• Vata and Pitta pacifying herbs, lifestyle and dietary advice for the physical body, prana and senses balancing on a subtle level and meditation and mantra on a mind level.
• Abhyanga, shirodara, shirobasti, basto, Navara khizi, nasya, karana purnana, kalawa and gandush.
• Yoga, exercise, mantra, counselling, pranayama.

Ayurvedic Diet for this client:

• Client needs to be on a Pitta Vata balancing/pacifying diet.
• See the general diet chart at the end of this advice form – taking onto consideration any contraindicated food that is listed here.
• In general, you need to eat on time, keep eating healthy food, eat warm food, wholefoods, cooked food, steamed veggies, boiled eggs or whites, lamb bone broth, goat bone broth, soaked almonds, soaked walnuts. Keep aggravating spices to a minimum and do not over-spice meals. Keep food combinations and preparation methods simple and nutritious. Add lots of buttermilk to you diet and use ghee in your cooking.
• Pomegranate – 1 per day (or pomegranate juice)
• Coconut water 200-300ml per day
• Use ghee in cooking.
• Upon waking: Drink a glass of warm water with aloe vera juice, or lemon, fenugreek and fresh ginger.
• (Allow 6 hours between meals and snack 3 hours after a meal).
• Few times per week it is recommended that you eat meat (chicken, lamb)
• Breakfast: Continue with current breakfast but add in oats, soaked almonds and chia seeds.
• Lunch: Stop fruit or fruit juice. Eat chapati with curry and some rice and buttermilk.
• 4pm: Fruit juice with apple, pear, ginger, and some carrot or beetroot.
• Dinner: Kitchari or soup.
• Avoid: Cold foods, raw foods, leftover foods (24 hours), frozen foods, cold water, processed and packaged foods, soft drinks, alcohol, coffee, wine, high fat foods, greasy foods, potatoes.
• Water Intake: Drink warm water during the day. This will also help to keep system clear of toxins and help avoid constipation.
• Use all of the five senses at mealtimes. Create a ritual of eating to bring back the sacredness of eating.
• Eat in a pleasant environment. Eat seated. No TV, no electronic devices.
• Eat slowly, eat with respect/reverence for what you are eating, chew thoroughly. Savour the food. This helps prevent overeating and helps to retrain the brains wrings in relationship to food.
• Creating a loving relationship with food is very important. Eating meditations can be of great benefit.

Ayurvedic Lifestyle advice for this client:

• Regular daily routines are essential – and stick to them.
• Daily exercise is important (yoga, swimming, walking, tai chi etc.)
• Develop practices that centre around self-care and self-love.
• Yoga, meditation, pranayama and chanting are highly beneficial activities.
• Mandala colouring can be of great benefit for stress and anxiety.
• Positive affirmations and gratitude journaling can be beneficial.
• Aim to establish a more solid support system for yourself.
• Work on your social life and spend time around nurturing and supportive people who foster healthy relationships.
• Limit screen time on electronic devices and establish a regular sleeping pattern.
• Listen to music, meditate, practice yoga, talk walks in nature.
• Work on your sleep patterns. Aim to be in bed by 10pm and wake by 6am to 6.30 am.
• Try to avoid the use of electronic devices after 6-7pm in the evening and allow time to wind down and relax.
• Decrease or try to eliminate addictions over time

Review: 4 Weeks

Note: It is always advised to continue any and all prescribed conventional medicine as advised by one’s healthcare practitioner. Should one use Ayurvedic herbs alongside conventional medicines, be sure to consult with your GP and/or medical specialist and your qualified Ayurvedic practitioner about any possible drug interactions and potential side effects.

• Vata Pitta Food Chart
• Use This Chart As A Guide.

Please Be Sure To Avoid Foods That You Are Aware Of That Aggravate Your Condition(S). Please Also Refer To The Specific Diet Advice In The Above Sections.

Use mostly cooked vegetables. Use bitter vegetables in small amounts.

Try to eat in season with fresh produce and eat local produce whenever possible.

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Use mostly sweet fruits, with a small amount of sour ones.

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Since most grains are available all year round, grains are categorised by season for the dual types.

Winter/Spring

Spring/Summer

Autumn

Major (These are the foods to have the most often)

Legumes, Beans, And Soybean Derivatives:

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Major (These are the foods to have the in moderation)

All other nuts can be used occasionally.

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Moderate (These are the foods you can have in moderation)

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

Seldom (These are the foods you have on occasion)

Major (These are the foods to have the most often)

Moderate (These are the foods you can have in moderation)

The information provided in this article is for strictly for educational purpose only: prepared by the clinical ayurvedic students at the Jeeva Health, under the supervision of Mr Kumar – Principle Ayurvedic Practitioner. For professional help kindly contact, us at 0399399474