Introduction
Bhagandara (fistula-in-ano) is a chronic anorectal disorder characterized by an abnormal communication between the anal canal and the perianal skin. It is described by Sushruta as one of the Ashtamahagada (eight difficult-to-treat diseases) owing to its recurrent nature and therapeutic challenges. Conventional surgical procedures such as fistulotomy and fistulectomy are effective but may be associated with recurrence, prolonged wound healing, and occasional impairment of anal continence. Ksharasutra therapy, a unique Ayurvedic para-surgical procedure, has emerged as a minimally invasive and sphincter-preserving treatment for Bhagandara with proven clinical efficacy.1
Overview of ksharasutra therapy
Ksharasutra is a medicated surgical thread prepared by repeated coatings of Snuhi (Euphorbia neriifolia) latex, Apamarga Kshara (Achyranthes aspera), and Haridra (Curcuma longa) powder. The combined action of these ingredients facilitates gradual excision of the fistulous tract while simultaneously promoting healing. Snuhi latex acts as an adhesive and chemical debriding agent, Apamarga Kshara provides alkaline cauterization and tissue dissolution, whereas Haridra contributes antimicrobial, anti-inflammatory, and wound-healing properties.2
Practical procedure
Successful Ksharasutra therapy begins with thorough clinical evaluation. Digital rectal examination, proctoscopy, and imaging techniques such as MRI fistulography help identify the internal opening, external opening, and course of the fistulous tract. Proper assessment is essential for planning treatment and estimating healing duration.
The procedure is generally performed under local or spinal anesthesia. A malleable probe is gently introduced through the external opening and guided along the fistulous tract until it emerges through the internal opening. The Ksharasutra is then tied to the probe and threaded through the tract, creating a medicated loop. Once secured, the thread remains in place and exerts continuous therapeutic action.
A distinctive feature of Ksharasutra therapy is the weekly replacement of the thread. During each sitting, the old thread is replaced with a freshly prepared medicated Ksharasutra. This process ensures sustained chemical cauterization, drainage, debridement, and gradual cutting of the tract. Simultaneously, healthy granulation tissue forms behind the advancing thread, resulting in healing from within.
Post-procedure care
Postoperative management plays a crucial role in treatment success. Patients are advised to maintain local hygiene through regular warm sitz baths, consume a high-fiber diet, ensure adequate hydration, and avoid constipation. Routine follow-up visits are essential for thread replacement and monitoring of healing progress. Most patients can continue normal daily activities during the treatment period, making Ksharasutra a convenient outpatient procedure.3
Clinical significance
Numerous clinical studies have demonstrated favorable outcomes with Ksharasutra therapy in both primary and recurrent fistula-in-ano. The treatment achieves simultaneous cutting and healing of the tract, minimizes damage to the anal sphincter, and significantly reduces recurrence rates. The antimicrobial and anti-inflammatory actions of Haridra, combined with the cauterizing effect of Apamarga Kshara, help control infection and promote rapid wound healing.
Conclusion
Ksharasutra therapy represents a scientifically validated Ayurvedic approach for the management of Bhagandara. By combining mechanical, chemical, and biological actions, the medicated thread facilitates gradual tract excision, infection control, and tissue regeneration. Its minimally invasive nature, low recurrence rate, and sphincter-preserving advantages continue to make it a valuable therapeutic option in contemporary anorectal practice.
Reference:
- Khade, DR & Patil, Manoj. (2025). The Role of Ksharasutra in the Management of Fistula-In-Ano: A Case Study. International Journal of Pharmaceutical Research and Applications. 10. 644-645. 10.35629/4494-1004644645. https://www.researchgate.net/publication/394582560
- Pandey AK, Katkar S, R S, et al. IFTAK (Interception of Fistulous Tract with Application of Ksharasutra) technique: a minimally invasive solution for recurrent fistula-in-ano-a case series analysis. Int J Colorectal Dis. 2025;40(1):155. Published 2025 Jul 11. doi:10.1007/s00384-025-04900-2 https://pmc.ncbi.nlm.nih.gov/articles/PMC12254057/
- Hariprasad CP, Kumar A, Kumar M, et al. The efficacy of Ksharsutra, Fistulectomy and Ligation of Intersphincteric Fistula Tract (LIFT) procedure in management of Fistula in ano a prospective observational study. BMC Surg. 2023;23(1):70. Published 2023 Mar 29. doi:10.1186/s12893-023-01969-w https://pmc.ncbi.nlm.nih.gov/articles/PMC10061687/