Classification

Anal abscesses are categorized based on their location relative to structures surrounding the anus and rectum:

• Perianal: The most common type.
• Ischioanal
• Intersphincteric
• Supralevator: The rarest type.

A horseshoe abscess is when an abscess spreads partially circumferentially around the anus and rectum.

Fistulas are classified by their relationship to parts of the anal sphincter complex:

• Intersphincteric: The most common type.
• Transphincteric
• Suprasphincteric
• Extrasphincteric: The rarest type.

Symptoms

Common symptoms include anorectal pain, swelling, redness of the skin, and fever. Occasionally, patients may experience rectal bleeding and difficulty urinating. Those with fistulas often have a history of previously drained anal abscesses, anorectal pain, drainage from the perianal skin, and perianal itching.

Diagnostic Studies

Most anal abscesses and fistulas are diagnosed and managed based on clinical findings. Additional studies, such as traditional two-dimensional and three-dimensional endoanal ultrasound, can help diagnose a deep perirectal abscess, identify a horseshoe extension, and delineate the fistula tract. A pelvic MRI is highly accurate, up to 90%, for mapping the fistula tract and identifying internal openings.

Treatment of Anal Abscess

The primary treatment for an abscess is surgical drainage. An incision is made near the anus to drain the infection, which can be done in a doctor’s office with local anesthesia or in an operating room under deeper anesthesia. Hospitalization may be required for patients prone to significant infections, such as diabetics or those with decreased immunity.

After an abscess has been drained, a tunnel (fistula) may persist in up to 50% of cases, leading to recurrent abscesses if not properly treated.

Treatment of Anal Fistula

Currently, there is no medical treatment for anal fistulas; surgery is almost always necessary. If the fistula involves minimal sphincter muscle, a fistulotomy may be performed, which involves unroofing the tract and creating a groove that will heal from the inside out.

For high complex fistulas, modern surgical options include:

• Coreout fistulectomy with primary repair
• Fibrin glue
• Endorectal advancement flap
• VAAFT (Video-assisted anal fistula treatment)
• LIFT (Ligation of intersphincteric fistula tract)

However, these surgeries can have a recurrence rate of up to 50%.

Ksharasutra Treatment

Ksharasutra Therapy is an Ayurvedic parasurgical technique described by the great Indian surgeon Sushruta. It involves the use of a medicated thread (Ksharasutra) which cuts through the fistulous tract and allows for simultaneous cutting and healing.

The Ksharasutra thread:

• Prevents the fistulous cavity from closing prematurely.
• Ensures continuous drainage of pus.
• Chemically curettes the tract, preventing bacteria from multiplying.

While effective, Ksharasutra treatment has a longer duration due to the slow cutting and healing process.

Modified Ksharasutra Techniques:

• Fistulotomy + Ksharakarma: Unroofing the tract to the internal opening and applying herbal caustic material.
• Partial Fistulotomy + Ksharasutra: Deroofing the tract up to the sphincter complex and applying Ksharasutra.
• IFTAK (Interception of fistulous tract and application of Ksharasutra): Intercepting the proximal part of the tract and applying Ksharasutra from the site of interception to the infected anal crypt.

Indications

• High transphincteric fistula
• Horseshoe type fistula
• Complex fistulas with extension to the scrotum, gluteus, thigh, and abdomen
• Intersphincteric fistula with supralevator extension
• Blind internal fistulas with post-anal abscess

By combining ancient Ayurvedic techniques with modern surgical methods, we aim to provide effective and holistic treatment for complex ano-rectal conditions.