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Top Non-Surgical Fistula Treatment You Should Know About

Top Non-Surgical Fistula Treatments You Should Know About

Introduction

Fistula are abnormal connections between organs or vessels, often arising from infections, inflammation, or trauma. The most common type is the anal fistula, which forms between the anal canal and the skin around the anus. Fistula can cause significant discomfort and complications, making effective treatment essential. While surgery is often recommended for many cases, there are several non-surgical treatments that can be highly effective. Here’s a comprehensive look at some of the top non-surgical fistula treatments you should know about, including insights from the best fistula treatment in Delhi.

Understanding Fistula

A fistula is a passage or connection that forms between two areas that are not normally connected. In the case of anal fistula, they develop as a result of an infection in the anal glands that creates an abscess. Once the abscess drains, a fistula can form, leading to persistent symptoms such as pain, discharge, and irritation. Addressing these symptoms effectively often involves non-surgical approaches that focus on managing the condition and promoting healing.

Non-Surgical Treatments for Fistula

1. Fistula Treatment Without Surgery

For many patients, non-surgical methods can provide relief and manage symptoms effectively. Here are some top non-surgical treatments:

Fistula Seton Placement
A seton is a thread placed through the fistula tract to keep it open and allow continuous drainage. This method helps in managing the infection and promoting healing by preventing further buildup of pus. It is considered one of the best treatments for fistula without resorting to invasive surgery.

Fibrin Glue Injection
Fibrin glue is a type of adhesive that can seal the fistula tract. It is injected into the fistula to close it and promote healing. This treatment is minimally invasive and suitable for certain types of fistulas. It offers a non-surgical alternative for those seeking less invasive options.

Plug Procedures
Fistula plugs are biocompatible materials that are inserted into the fistula tract to block and close it. This method can be effective for certain types of anal fistulas and provides a non-surgical option that helps in the healing process.

2. Anal Fistula Treatment

Anal fistulas can be particularly challenging to manage. Non-surgical treatments include:

Antibiotics and Antiseptics
In some cases, antibiotics may be prescribed to control infection and reduce inflammation. Antiseptic solutions can also help in cleaning the area and preventing further complications.

Sitz Baths
Warm sitz baths can provide relief by reducing pain and promoting healing. Soaking the affected area in warm water helps to relax the muscles and improve blood flow, which can aid in the healing process.

Dietary Adjustments
A diet rich in fiber helps to prevent constipation and ease bowel movements, reducing strain on the anal area and preventing further irritation of the fistula.

3. Fistula Ayurvedic Treatment

Ayurveda offers various natural remedies that can complement traditional treatments. Some common Ayurvedic approaches include:

Herbal Remedies
Herbs such as Triphala, Turmeric, and Aloe Vera are known for their anti-inflammatory and healing properties. These can be used in various forms, such as topical applications or oral supplements, to support the healing of fistulas.

Dietary Recommendations
Ayurvedic dietary guidelines emphasize consuming foods that balance the body’s doshas and support digestive health. This includes foods rich in fiber, fruits, and vegetables, which can help in managing symptoms and promoting overall well-being.

Panchakarma Therapy
Panchakarma is a detoxification process in Ayurveda that involves various treatments to cleanse the body. It can be beneficial for individuals with chronic fistulas by reducing toxins and promoting healing.

Choosing the Best Doctor for Fistula Treatment in Delhi

When seeking non-surgical treatment for fistulas, consulting with an experienced specialist is crucial. The best doctor for fistula treatment in Delhi will have extensive experience in managing fistula conditions and will provide personalized care based on your specific needs.

Fistula Specialist Doctor in Delhi

A fistula specialist doctor in Delhi has the expertise required to offer both non-surgical and surgical treatment options. They can evaluate your condition and recommend the most effective non-surgical treatments, such as those mentioned above.

Fistula Disease Treatment: Finding the Right Approach

Selecting the right treatment for fistula disease requires a thorough understanding of the condition and available options. Non-surgical methods can be highly effective, particularly when tailored to the specific type and severity of the fistula. Consulting with a knowledgeable fistula specialist doctor in Delhi can help in developing a treatment plan that aligns with your health needs and lifestyle.

Conclusion

Managing a fistula effectively involves understanding the available treatment options and working with an experienced specialist. Non-surgical treatments such as seton placement, fibrin glue injections, and fistula plugs offer viable alternatives to traditional surgery, particularly for those seeking less invasive solutions. Ayurvedic treatments also provide a complementary approach to managing symptoms and promoting healing.

For the best fistula treatment in Delhi, consider consulting with a leading specialist who can offer comprehensive care and personalized treatment plans. Whether you’re exploring non-surgical options or seeking expert advice, the right treatment can significantly improve your quality of life and lead to successful healing.

If you are seeking effective treatment for fistula, consider consulting Dr. S.K. Singh at Sushruta Ano-Rectal Institute, renowned for his expertise in both non-surgical and comprehensive fistula care.

Read More: Home Remedies for Fissures: What Really Works?

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The Ultimate Guide for Pilonidal Sinus Treatment Without Surgery

The Ultimate Guide for Pilonidal Sinus Treatment Without Surgery

Understanding Pilonidal Sinus

Pilonidal sinus is a condition where a small, infected cavity forms near the tailbone, often filled with hair and debris. While surgery and laser are usually recommended by the doctors for treating this problem. However, these are not the good choices for treating Pilonidal Sinus as the chances for recurrences are pretty high. Pilonidal Sinus can be treated without surgery in Ayurveda by using Ksharsutra therapy. Ksharsutra is a para surgical treatment and usually does not require any bed rest or hospitalization. The chances of recurrences of the disease with this treatment are comparatively very very low as compared to conventional surgeries and laser. The facilities of the Graded Ksharsutra is available in India only at Sushruta Anorectal Institute, the best pilonidal sinus hospital in Delhi.

Pilonidal Sinus

A pilonidal sinus is typically located at the top of the buttock cleft and can cause significant discomfort and pain. The condition arises when hair and debris become trapped in a small pit or cavity in the skin, leading to infection and inflammation. Common symptoms include pain, swelling, redness, and discharge of pus or blood.

For those seeking pilonidal sinus non-surgical treatment, several holistic and medical approaches can provide relief and potentially prevent the need for surgical intervention.

1. Maintain Proper Hygiene

Maintaining good hygiene is crucial for managing and treating pilonidal sinus without surgery. Keeping the affected area clean and free from infection is the first step in sinus treatment.

  • Clean the Area Regularly: Use mild, non-irritating soap and water to gently cleanse the affected area daily. Avoid using harsh soaps or scrubs that could exacerbate irritation.
  • Keep the Area Dry: After washing, ensure the area is thoroughly dried to prevent moisture buildup, which can worsen symptoms.

Proper hygiene helps reduce the risk of infection and can aid in the healing process, contributing to pilonidal sinus pain relief.

2. Use Warm Compresses

Applying warm compresses to the affected area can provide significant relief and assist in managing pilonidal sinus without resorting to surgery. The warmth helps to increase blood flow, reduce inflammation, and promote drainage of any accumulated pus.

  • How to Apply: Soak a clean cloth in warm water and apply it to the affected area for 10-15 minutes, several times a day. Ensure the compress is not too hot to avoid burning the skin.

Warm compresses are a simple yet effective way to relieve pain and promote healing by reducing inflammation and facilitating the natural drainage of the sinus.

3. Adopt a High-Fiber Diet

fiber food

Diet plays an important role in overall health, including the management of pilonidal sinus. A high-fiber diet helps maintain regular bowel movements, reducing strain and pressure on the affected area.

  • Fiber-Rich Foods:Fiber-Rich Foods: Include fruits, vegetables, whole grains, and legumes in your diet. These foods help soften stools, making bowel movements easier and less painful.

Maintaining a diet rich in fiber can prevent constipation and reduce the strain on the area affected by the pilonidal sinus, contributing to sinus treatment and overall comfort.

4. Consider Lifestyle Adjustments

Certain lifestyle changes can significantly impact the management of pilonidal sinus and contribute to sinus pain relief.

  • Avoid Prolonged Sitting: If possible, reduce the amount of time spent sitting, as prolonged pressure on the affected area can worsen symptoms. Use cushioning or ergonomic seating if sitting for extended periods is unavoidable.
  • Wear Comfortable Clothing: Choose loose-fitting clothing made from breathable fabrics to minimize irritation and allow the affected area to heal.

Making these adjustments can reduce pressure and irritation, supporting the healing process and helping to manage symptoms without surgery.

5. Consult a Specialist

For persistent or severe cases of pilonidal sinus, consulting a specialist is crucial. The best pilonidal sinus doctor in Delhi can provide expert advice on non-surgical treatment options and tailor a treatment plan to your needs.

  • Pilonidal Sinus Non-Surgical Treatment: Graded Ksharsutra is a treatment of choice for treating Pilonidal Sinus at Sushruta Anorectal Institite.
  • Personalized Care: A specialist can provide a comprehensive evaluation and recommend the most effective non-surgical treatments based on the severity of your condition.

Dr. S.K. Singh at Sushruta Ano-Rectal Institute is renowned for his expertise in non-surgical treatments for pilonidal sinus. As a leading pilonidal sinus doctor in Delhi, Dr. Singh offers a range of advanced non-invasive treatments designed to provide effective relief and support healing.

Conclusion

Managing pilonidal sinus without surgery involves a combination of proper hygiene, lifestyle adjustments, dietary changes, and targeted treatments. By adopting these holistic approaches, you can alleviate pain, reduce inflammation, and promote healing effectively. Consulting with a specialist like Dr. S.K. Singh at Sushruta Ano-Rectal Institute ensures that you receive the most appropriate non-surgical treatments tailored to your condition. Combining these methods with professional medical care can lead to significant improvement and relief from pilonidal sinus symptoms.

Read More: Top Holistic Approaches to Treating Anal Fissures

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Top Holistic Approaches to Treating Anal Fissures

Top Holistic Approaches to Treating Anal Fissures

Introduction

Anal fissures, characterized by small tears in the lining of the anal canal, can cause significant pain and discomfort. While various medical treatments are available, holistic approaches offer natural, effective solutions that complement traditional care methods. Adopting holistic strategies can help manage symptoms, alleviate pain, and promote faster healing. Here, we explore some of the most effective holistic approaches for treating anal fissures.

fissure

1. Enhance Your Diet with Fiber

Dietary changes are one of the most impactful ways to address anal fissures holistically. A high-fiber diet is crucial in treating anal fissures because fiber helps soften the stool and reduces the strain during bowel movements. This is essential for both preventing and relieving fissure pain.

fiber foods

High-fiber foods include fruits like apples, pears, and berries, vegetables such as spinach, carrots, and broccoli, and whole grains like oats, quinoa, and brown rice. Legumes, including beans, lentils, and chickpeas, are also excellent sources of fiber. Incorporating these foods into your daily diet can help maintain regular bowel movements and reduce the discomfort associated with anal fissures.

Fiber helps improve stool consistency, making bowel movements less painful and preventing further irritation of the fissure. By easing the passage of stool, you can significantly reduce the strain and pain that exacerbates fissures.

2. Stay Hydrated

glass of water

Proper hydration plays a vital role in managing and healing anal fissures. Drinking sufficient water is essential for maintaining stool softness and preventing constipation, which can worsen fissure pain.

Aim to drink at least 8-10 glasses of water daily. Staying hydrated helps keep your digestive system functioning smoothly, making bowel movements easier and less painful. Water works in tandem with a high-fiber diet to ensure that your stool remains soft and manageable, thus providing effective anal fissure relief.

In addition to water, you might also consider herbal teas such as chamomile or peppermint, which can aid digestion and offer soothing effects. However, avoid caffeinated or alcoholic beverages, as they can contribute to dehydration.

3. Practice Sitz Baths

Sitz baths are a simple yet highly effective holistic treatment for anal fissures. This method involves soaking the affected area in warm water to alleviate pain and promote healing.

Fill a bathtub or a specialized sitz bath basin with warm water and soak the anal area for 10-15 minutes several times a day. The warmth helps relax the anal sphincter muscle, which can reduce pain and increase blood flow to the fissure, promoting healing.

Adding Epsom salts or baking soda to the bathwater can enhance the soothing effects. Epsom salts have anti-inflammatory properties that can help reduce swelling and discomfort, while baking soda can help neutralize irritants and provide additional relief.

Sitz baths are especially beneficial after bowel movements to help cleanse the area and reduce post-bowel movement pain. Regular use of sitz baths is a cornerstone of treating anal fissure discomfort and facilitating recovery.

4. Apply Natural Topical Remedies

Topical treatments can provide localized relief and support the healing process of anal fissures. Natural remedies offer soothing and anti-inflammatory properties that can help alleviate pain and irritation.

Aloe vera gel is known for its soothing properties and can be applied directly to the affected area to reduce inflammation and promote healing. Witch hazel is another natural remedy with anti-inflammatory and astringent properties that can help reduce swelling and discomfort. Coconut oil has moisturizing and healing properties that can soothe the anal area and aid in the healing of fissures.

When applying these remedies, ensure that the area is clean and dry. Gently apply the natural treatment with clean hands or a cotton swab to avoid further irritation. These topical treatments can be used in conjunction with other holistic methods to enhance anal fissure pain relief.

5. Maintain Proper Anal Hygiene

Good hygiene is crucial for preventing infection and reducing irritation in the anal area. Keeping the area clean and free from irritants helps support the healing process and prevents further complications.

After each bowel movement, gently cleanse the anal area with mild, unscented soap and water. Avoid using harsh soaps, wipes with alcohol or fragrance, or scrubbing the area vigorously, as these can cause additional irritation and worsen symptoms.

Pat the area dry with a soft towel rather than rubbing, and consider using a gentle, hypoallergenic moisturizer if dryness or itching occurs. Maintaining proper hygiene helps prevent infection and supports anal fissure relief.

6. Seek Professional Medical Advice

While holistic approaches can significantly aid in managing anal fissures, professional medical advice is often necessary for comprehensive treatment. Consulting a specialist can provide tailored care and ensure that you receive the most effective treatment for your condition.

If holistic methods are not providing sufficient relief, it is advisable to seek the expertise of a fissure doctor in Delhi. Dr. S.K. Singh at Sushruta Ano-Rectal Institute is renowned for his expertise in treating anal fissures with non-surgical methods. As one of the leading fissure specialists in Delhi, Dr. Singh offers a range of effective treatments designed to complement holistic strategies and address more severe or persistent cases.

Dr. Singh’s approach focuses on personalized care that integrates holistic methods with advanced non-invasive treatments. His expertise ensures that patients receive the best fissure treatment in Delhi, tailored to their specific needs.

Conclusion

Holistic approaches to treating anal fissures offer a natural and effective way to manage pain and support healing. By incorporating a high-fiber diet, staying hydrated, practicing sitz baths, applying natural topical remedies, and maintaining proper hygiene, you can address both the symptoms and underlying causes of anal fissures. Consulting a specialist like Dr. S.K. Singh at Sushruta Ano-Rectal Institute can further enhance your treatment plan, providing you with comprehensive care and the best fissure treatment in Delhi. Combining these holistic methods with professional medical guidance can lead to significant relief and a faster recovery from anal fissures.

Read More: How to Heal a Fissure Fast With 6 Tips?

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What are the Non-Surgical Procedures for Pilonidal Sinus Disease?

What are the Non-Surgical Procedures for Pilonidal Sinus Disease?

Introduction

Pilonidal sinus disease (PSD) is a condition that can significantly impact a person’s quality of life. Traditionally, surgical intervention has been the go-to treatment. However, for those looking for less invasive options, non-surgical treatments can be effective and offer promising results. This blog explores various non-surgical procedures for pilonidal sinus disease, highlighting the expertise of Dr. S.K. Singh at Sushruta Ano-Rectal Institute, renowned for offering some of the best pilonidal sinus treatment options without surgery.

fissure

Understanding Pilonidal Sinus Disease

Pilonidal sinus disease involves the formation of a small, infected cavity or sinus at the base of the spine, often filled with hair and debris. This condition is more common in young adults and can cause discomfort, pain, and recurrent infections. While surgery is a common treatment, many individuals prefer to explore non-surgical methods.

Non-Surgical Treatments for Pilonidal Sinus Disease

  1. Medication and Topical Treatments
    Medications are often the first line of defense against pilonidal sinus disease. Antibiotics can help manage bacterial infections, while topical treatments can soothe irritated skin and reduce inflammation. Over-the-counter antiseptics and creams may also aid in keeping the area clean and free from infection.
  2. Laser Therapy
    Laser therapy is a modern approach that targets the pilonidal sinus with concentrated light beams. This treatment helps to reduce the size of the sinus, eliminate hair and debris, and minimize discomfort. It is a non-invasive option that promotes faster healing and reduces the likelihood of recurrence.
  3. Sitz Baths
    Regular sitz baths can provide significant relief for individuals suffering from pilonidal sinus disease. Soaking in warm water helps to reduce inflammation, cleanse the affected area, and ease pain. This simple yet effective method can complement other non-surgical treatments.
  4. Hair Removal Treatments
    Since pilonidal sinus disease is often exacerbated by hair growth, effective hair removal is crucial. Methods such as laser hair removal or electrolysis can permanently eliminate hair from the affected area, reducing the risk of recurrence and promoting healing.
  5. Lifestyle and Hygiene Adjustments
    Maintaining proper hygiene and making certain lifestyle changes can play a significant role in managing pilonidal sinus disease. Regular cleaning of the area, wearing loose-fitting clothing, and avoiding prolonged sitting can help prevent irritation and infection.

Why Choose Non-Surgical Treatments?

Non-surgical treatments for pilonidal sinus disease offer several advantages over traditional surgical options. Pilonidal sinus non-surgical treatment is less invasive, involves fewer risks, and often has shorter recovery times. For many individuals, this approach provides effective pilonidal sinus treatment without surgery, managing symptoms and improving quality of life without the need for extensive procedures.

Dr. S.K. Singh: Expert in Non-Surgical Pilonidal Sinus Treatment

When it comes to pilonidal sinus non-surgical treatment, Dr. S.K. Singh at Sushruta Ano-Rectal Institute is recognized as one of the best pilonidal sinus doctors in Delhi. His expertise in offering innovative, non-surgical treatments provides patients with effective options that align with their needs and preferences.

Dr. Singh’s approach to pilonidal sinus treatment without surgery is both comprehensive and patient-centered. He utilizes a range of non-invasive techniques tailored to individual cases, ensuring the best possible outcomes for his patients. His clinic, Sushruta Ano-Rectal Institute, is renowned for its commitment to providing the pilonidal sinus best treatment options, focusing on both immediate relief and long-term management.

Conclusion

Exploring non-surgical procedures for pilonidal sinus disease can be an excellent choice for individuals seeking less invasive treatment options. With methods ranging from medication and laser therapy to lifestyle adjustments, there are various ways to manage and alleviate symptoms effectively. Dr. S.K. Singh at Sushruta Ano-Rectal Institute stands out as a leading expert in this field, offering top-notch non-surgical treatments that cater to the unique needs of each patient.

If you’re struggling with pilonidal sinus disease and considering non-surgical options, consulting with the best pilonidal sinus doctor in Delhi could be your first step toward effective treatment and improved well-being. For personalized care and cutting-edge solutions, Dr. Singh’s expertise in pilonidal sinus treatment without surgery can provide you with the relief you need.

Feel free to reach out to Sushruta Ano-Rectal Institute to learn more about how non-surgical treatments can help you overcome pilonidal sinus disease and regain a better quality of life.

Read More: The Benefits of Fiber-Rich Diets in Anal Fissure Treatment

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How to Handle Recurring Anal Fissures: Treatment Insights

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How to Handle Recurring Anal Fissures: Treatment Insights

Recurring anal fissures can be a distressing and painful condition, often leading individuals to seek effective treatments. Understanding the causes, symptoms, and treatment options for recurring anal fissures is crucial for managing these conditions effectively. In this comprehensive guide, we’ll explore how to handle recurring anal fissures, highlighting the expertise of Dr. S.K. Singh at Sushruta Ano-Rectal Institute, renowned as the best fissure doctor in Delhi.

Understanding Anal Fissures

Anal fissures are small tears in the lining of the anus, often caused by passing hard or large stools. They can lead to severe pain, bleeding, and discomfort during bowel movements. While many fissures heal with simple self-care, others may become chronic or recurrent, requiring medical intervention.

Symptoms of Anal Fissures

  • Pain during and after bowel movements: This is usually severe and can last several minutes to hours.
  • Bleeding: Noticeable bright red blood on the stool or toilet paper
  • Itching or irritation around the anus: Persistent discomfort.
  • Visible crack or tear: An observable fissure in the skin around the anus.
  • Spasms: Tightening of the anal sphincter muscles.

Causes of Recurring Anal Fissures

Several factors can play a role in the recurrence of anal fissures:

Chronic Constipation: Straining during bowel movements can exacerbate or lead to fissures.

Chronic Diarrhea: Frequent loose stools can irritate and inflame the anal lining.

Inflammatory Bowel Diseases: Conditions such as Crohn’s disease can contribute to fissure development.

Previous Anal Surgeries or Injuries: Past surgeries or injuries in the anal region may increase the risk of recurrence.

Inadequate Blood Flow: Poor circulation in the anorectal area can hinder healing and contribute to recurrent fissures.

 

Effective Treatments for Recurring Anal Fissures

Managing recurring anal fissures requires a comprehensive approach that combines lifestyle changes, medical treatments, and, in some cases, surgical intervention.

1. Dietary Adjustments

To treat and prevent anal fissures, adjusting your diet is essential. These changes can help soften stool and minimize strain during bowel movements:

  • Boost Fiber Consumption: Add more fruits, vegetables, whole grains, and legumes to your meals.
  • Stay Hydrated: Ensure you drink sufficient water throughout the day.
  • Limit Processed Foods: Cut down on refined sugars and processed items to support digestive health.

2. Proper Bowel Habits

  • Avoid Straining: Don’t push hard during bowel movements.
  • Regular Schedule: Try to have bowel movements at the same time each day.
  • Clean Gently: Use soft toilet paper or wipes and avoid harsh soaps.

3. Topical Treatments

Topical medications can help relieve pain and promote healing.

  • Numbing Creams: Such as lidocaine to reduce pain.
  • Hydrocortisone Creams: To reduce inflammation.
  • Nitroglycerin Ointment: Enhances blood circulation to support healing and alleviate symptoms.

4. Medications

  • Calcium Channel Blockers: Such as nifedipine or diltiazem, to relax the sphincter muscle.
  • Botox Injections: To temporarily paralyze the sphincter muscle, allowing the fissure to heal.

5. Sitz Baths

Taking warm sitz baths multiple times a day, particularly after bowel movements, can help relax the anal sphincter, improve blood circulation, and alleviate discomfort.

Why Choose Dr. S.K. Singh and Sushruta Anorectal Institute?

Expertise and Experience

Dr. S.K. Singh is a leading fissure doctor in Delhi, known for his expertise in managing and treating anal fissures and other anorectal conditions. With years of experience and a patient-centered approach, he ensures comprehensive care tailored to each individual’s needs, offering the best fissure treatment in Delhi.

Comprehensive Care

At Sushruta Ano-Rectal Institute, patients receive holistic care that combines the best of modern medicine and traditional practices. From dietary advice to advanced surgical treatments, Dr. S.K. Singh and his team provide a full spectrum of services aimed at achieving the best possible outcomes.

State-of-the-Art Facility

Sushruta Ano-Rectal Institute is equipped with the latest medical technology, ensuring that patients receive cutting-edge treatments in a comfortable and supportive environment. The clinic’s commitment to excellence makes it a top choice for those seeking treatment for recurring anal fissures.

Conclusion

Managing recurring anal fissures requires a comprehensive approach that addresses both symptoms and underlying causes. From dietary changes and proper bowel habits to topical treatments and potential surgical interventions, there are various strategies to consider.

For those seeking expert care, Dr. S.K. Singh at Sushruta Ano-Rectal Institute offers unparalleled expertise and a patient-centered approach, making him the best fissure doctor in Delhi. By combining modern medical techniques with a holistic approach, Dr. S.K. Singh provides effective solutions for managing and preventing recurring anal fissures.

If you are experiencing symptoms of recurring anal fissures, don’t hesitate to seek professional help. Visit Sushruta Ano-Rectal Institute and consult with Dr. S.K. Singh, a leading fissure specialist in Delhi, to explore the best treatment options tailored to your needs. Your journey to recovery and relief from recurring anal fissures starts with expert care and comprehensive treatment at Sushruta Ano-Rectal Institute.

Read More : 10 Reasons Why You Should Not Choose Laser Treatment for Piles?

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Disclaimer: Individual results may vary. The statements on this website and all affiliates have not been evaluated by the FDA. Advice on treatment or care of an individual patient should be obtained through consultation with a physician.

*Multicentric Randomized controlled clinical trial of Ksharsutra (Ayurvedic medicated thread) in the management of Fistula-in-Ano; Indian J Med Res (B) 94, June 1991, pp 177-185

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