ABSTRACT
Pilonidal sinus, also known as “jeep bottom,” is common among people who sit a lot, such as cab drivers. It mostly affects men and young adults and is associated with thick hair. Surgical techniques are available for treatment, but the condition has a relatively high recurrence rate. The Kshara Sutra method described in the Sushruta Samhita offers a minimally invasive treatment option. Pilonidal disease is estimated to affect about 26 out of every 100,000 persons, with around 0.7% of people affected. This study focuses on the diagnosis and treatment of patients who have Naadi Vrana (Pilonidal Sinus) using Udumber Ksheer Sutra. The Kshara Sutra is a minimally invasive, cost-effective technique with a low recurrence rate for treating pilonidal sinus. Udumber Ksheer Sutra management has also proven to be beneficial as a curative therapy for the pilonidal sinus.
KEYWORDS: Naadi Vrana (pilonidal sinus), Standard Kshar Sutra, Udumber Ksheer Sutra
INTRODUCTION
The Sushruta Samhita details various Shastra and Anushastra Karma. Anushastra Karma treats Naadi Vrana, a type of sinus categorized into eight types: Vaatik, Paitik, Kaphaj, Vata-Pitaj, Pitta-Kaphaj, Kapha-Vaataj, Sannipatik, and Aagantuja. Naadi Vrana refers to a blind tunnel lined with granulation tissue extending from an epithelial surface to surrounding tissues.[1] According to Mayo’s 1883 theory, pilonidal sinuses arise from insufficient separation of mesoderm and ectoderm layers during development, mainly affecting hairy males before puberty or after age 40, with a male-to-female ratio of 3:1 to 4:1.[2] Pilonidal sinuses, accounting for 15% of anal suppurations, significantly impact health and productivity.[3] These sinuses are lined with squamous epithelium and contain hair nests and granulation tissue, forming deep cavities where abscesses may develop.[4]
Naadi Vrana is comparable to pilonidal sinus, also known as the “jeep bottom” due to its prevalence among jeep drivers.[5] A pilonidal sinus is a painful, odorous cyst that often affects men and young people, particularly those with sedentary jobs, with an incidence rate of 0.7% (26 out of 100,000 people). Surgical treatments include open excision or closed techniques like the Karydakis procedure, Bascom technique, and “Z” plasty. However, recurrence and slow wound healing are possible. The Kshar Sutra treatment, having a longer recovery time, is safe and causes less discomfort than standard surgery.[6,7]
PATIENT INFORMATION
A 29-year-old hirsute male patient attended the OPD of Shalya Tantra at Mahatma Gandhi Ayurved Hospital and Research Centre, Wardha, with a complaint of trouble sitting down and could not do without cursing for 12 days.
Past history
The patient experienced serous discharge, throbbing pain, itching, and discomfort in the lower back and natal cleft 12 days ago. He had a previous abscess in the gluteal cleft and is now recovering with antibiotics and anti-inflammatory medication. There is no history of painful defecation, rectal bleeding, mucus, or anal discharge, and no chronic conditions like diabetes or hypertension.
All routine blood investigations were normal, ESR was 35 mm/1st hour, B.T. was 2 min 15 sec, and C.T. was 3 min 55 sec.
Family history
Not relevant
CLINICAL FINDINGS
General examination
Pulse – 76/min
BP – 130/80 mmHg
RR – 18/min
Temperature – 98.8 F
Local examination
In prone posture
Inspection – Mid-gluteal cleft opening with a fair amount of hair around
Palpation – At the sinus orifice, a cord-like indurated structure, a slight degree of discomfort, and a watery discharge. During probing in the mid-gluteal cleft, a tract of about 7 cm was discovered.
ASSESSMENT CRITERIA
□ Objective Parameters:
Cutting rate per week[8]
Unit cutting rate per week
Table 1.
Grading of subjective parameters
| Grade | Pain (visual analog scale) | Discharge | Tenderness | Induration |
|---|---|---|---|---|
| 0 | Not in pain | Absence of discharge | Absence of tenderness | Absence of an inflammatory response |
| 1 | Little pain (1–3) | Mild – if one gauze pad is soaked with discharge | Mild tenderness on firm pressure | Mild inflammatory response accompanied by cellular response and tissue edema |
| 2 | Modrate pain (4–7) | Moderate – if the discharge drenches two gauze pads | Moderate tenderness on gentle pressure | Moderate reaction involving the dermal reticular layer |
| 3 | Intense pain (8–10) | Profuse – if more than two gauze pads are soaked by the discharge | Severe patient denies touching | Severe – Subcutaneous tissue is involved in the reaction |
Diagnosis
Pilonidal sinus
THERAPEUTIC INTERVENTION
For First Five days
Triphala Guggulu 250 mg twice a day orally with lukewarm water after meals
Triphala Churna 5 gm orally Hs with lukewarm water
On Third day
Udumber Ksheer Sutra application under Local Anesthesia.
This was followed by weekly applications for up to 45 days.
Preparation of Udumber Ksheer Sutra
A slit incision was made across the stem of the Udumber (Ficus racemosa), and the Ksheer (latex) was extracted and collected in a sterile bottle. Daily, a sterile thread was coated with fresh Ksheer using sterile gauze and left to dry. This process was repeated for 11 days, disinfecting the thread with UV light while drying and storing it in a Kshar Sutra cabinet.
Procedure
After aseptic preparation, the patient was positioned prone, and Ksheer Sutra surgery was performed under local anesthesia. A probe was inserted into the pilonidal sinus tract and removed through an artificial opening. The Ksheer Sutra was threaded through the probe, and a tuft of hair and sero-purulent discharge were observed. The ends of the Ksheer Sutra were tied outside. The area was cleaned with saline and covered with a cotton pad. The surgery was successful, and the patient’s vital signs were normal.
Post-operative management
The patient was instructed to move around, apply warm fomentation twice daily, keep the surgical site clean and dry, and change the Ksheer Sutra weekly, measuring its length and method. This weekly change ensures effective drug delivery, maintains tract patency, and aids in draining infectious material for pilonidal sinus recovery. The local part was prepared each week.
FOLLOW-UP AND OUTCOME
The patient follows up every week. His discomfort decreased after 14 days. The tract was fully cut through by the 45th day, alleviating all symptoms like pain, discharge, induration, and thickness [Table 2].
Table 2.
Outcome
| Symptoms | Day 1st | Day 7th | Day 14th | Day 21th | Day 28th | Day 45th |
|---|---|---|---|---|---|---|
| Pain | 3 | 2 | 2 | 2 | 1 | 0 |
| Discharge | 2 | 2 | 2 | 1 | 0 | 0 |
| Lengths of tract | 7 cm | 6 cm | 4 cm | 2 cm | 1 cm | Cut through |
| Induration | 3 | 2 | 1 | 0 | 0 | 0 |
| Tenderness | 3 | 2 | 2 | 2 | 1 | 0 |
DISCUSSION
Hair is the primary cause of pilonidal sinus illness. In this instance, the patient has a deep natal cleft, is fat, and frequently rides his bike. Being overweight increases hair friction in the gluteal area. Excessive perspiration and inadequate anal hygiene post-urination contribute to the issue. Improper pus drainage and medications worsened Pakwasvastha’s condition. The treatment of the pilonidal sinus can be performed in a variety of ways. Kshara Sutra has more potential nowadays to cure pilonidal sinus. The Kshara Sutra’s melting and mitigating qualities progressively severed the pilonidal sinus tract from the inside and initiated healing simultaneously. This is because Udumbara demonstrates Pitta, Kapha, and Asrajita characteristics, meaning it drains Pitta and Kapha from the wound. The cleaning and wound healing are referred to as Vrana Shodhan Ropan. Due to its fast wound healing, analgesic, antimicrobial, antibacterial, antifungal, anti-inflammatory, and anti-diabetic qualities, Udumbara Ksheer was utilized in this condition to improve wound healing and cutting action. Additionally, it is widely accessible and abundant all-year round.
CONCLUSION
Modern surgical therapy for pilonidal sinus often fails, with recurrences common post-surgery. The Kshara Sutra is a minimally invasive, cost-effective technique that promotes good recovery and has a very low recurrence rate. Pilonidal sinus management using the Udumber Ksheer Sutra has been proven to be quite beneficial and may be utilized as a curative therapy in situations of pilonidal sinus.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We declare that the manuscript is original, has not been published before, and is not currently being considered for publication elsewhere.
Funding Statement
Nil.
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