Effect of Murivenna Ointment in the Management of Parikarthika (Acute Fissure in Ano) – A Pilot Study

Parikarthika (Fissure in ano) is one of the most painful condition which is occurring in the ano rectal region. Due to irregular food habits and modern life styles of peoples in the present era has also added to the increase in the rate of incidence of fissure in ano. The aim of the present pilot study was to assess the effectiveness of Murivenna ointment in the management of Parikarthika. This study was conducted in 22 patients diagnosed as acute fissure in ano. Patients Murivenna ointment was applied locally with digitally in fissure bed (Parikartika) of all 22 patients. All patients were advised to follow this twice daily after sitz bath for 4 weeks or till healing of fissure bed whichever is earlier. Adjuvant drug Triphalachurnam 5 gm orally at bedtime with lukewarm water was prescribed daily to all patients with constipation. There was significant relief in symptoms like pain in ano and bleeding per rectum in all patients after 30 days of treatment. The anal sphincter tonicity became normal in 21 patients (95.45%) after 30 days of treatment. Ulcer in ano was completely healed in 19 patients (86.36%) after 30 days of treatment. There was no reoccurrence in all patients after 30 days of follow up. The irritable symptoms like pain and bleeding per rectum were effectively relieved within 14 days of treatment in all patients. It is one of the effective treatments in the management of fissure in ano as it relieved the cardinal symptoms of fissure in ano such as cutting pain and burning pain. Short Research Article Sreerag and Dhule; JPRI, 33(39A): 156-161, 2021; Article no.JPRI.71540 157


INTRODUCTION
Fissure in ano is one of the most common painful disease which is occurring in the ano rectal region. It affects a great majority of population and occurs at any age irrespective of gender. The term fissure itself denotes a split or crack. It has been described as an acute superficial break in the continuity of the anal canal [1]. The cutting pain and burning pain are the cardinal symptoms of fissure in ano. In Ayurvedic science it is known as Parikartika which refers to a condition in which patient experiences a sensation of pain as if the anal canal is being cut around with scissors [1].
The causative factors of Parilarthika is described in different context of Ayurvedic classics as a Upadrava(complication). This includes complications due to various procedures such as Vamana-Virechana-Vyapad [2], Basti Vyapad [3] and Basti Netra Vyapad [4] and also due to various complications which arise from the diseases such as Vataja Athisara [5]. Kashyapa also mentioned about this disease that it is most prevalently affected in Garbhini (gravid women) [6]. Apana Vayu which is one type of Vata Dosha is concerned with the expulsion of Sakrit (faeces) and Mutra (urine). The vitiation of Apana Vayu cause to occur abnormal functions like passage of hard and loose stools etc. The Vrana (wound) which is developed in Parikartika is mostly due to Nija (Self causative factors) in origin like hard stool passage, intermittent passing of loose stool etc. So Apana Vayu vitiation can be considered as a chief causative factor for the manifestation of Parikarthika.
Due to the similarity in the classical signs and symptoms Parikarthika can be correlated as fissure in ano in modern science. A fresh cut linear ulcer is developed either at anterior or posterior part of anal canal. Its management is more difficult due to its recurrence nature. Fissure in ano has been classified into acute and chronic on the basis of clinical symptoms. Whether it acute or chronic it makes the patient suffer from excruciating pain and bleeding during and after defecation. The patho-physiology is based on high anal sphincter pressure. Management is generally aimed towards the healing of ulcer along with reduction of anal sphincter pressure. There are many management protocols for fissure-in-ano in modern science as well as in Ayurvedic science. Modern management includes medical manipulation of the internal sphincter and softening of stool in case associated with constipation. Ointments containing Diltiazem Hydrochloride 2% Gel, glyceryl trinitrate (GTN), 2% lignocaine ointment or 2% hydrocortisone cream are commonly used in the management of fissure in ano. Ayurvedic management includes Avagaha Swedana(medicated luke warm water sitz bath), Snehavasthi (Oil enema therapy) and Lepanam(medicated ointments).In Parikarthika a fresh cut linear ulcer is developed either at anterior or posterior part of anal canal and patients demand urgent relief from burning pain. So that Parikarthika can be considered as Sadya Vrana [7]. The cutting pain and burning pain are the cardinal symptoms of Parikarthika. Hence, we can understand that there is involvement of Vata and Pitta Dosha. Hence the drugs which are either Vata or Pitta Dosha Shamakaand Vranaropana properties are found to be very effective in the management of Parikarthika. Jatyadi Ghruta, Yastimadhu Ghruta, Kasisadi Taila, Vranaropaka Taila are used which are proven effective in healing of fissure in ano [8].
Murivenna is a medicated oil which is prepared with eight medicinal plants -Karanja, Kumari, Tamboola, Sigru, Paribhadra, Palandu, Vasuka and Satavari [9]. It is widely used in the conditions like contusions, fresh wounds, ano-rectal diseases and even for fractures [9]. Due to its Vata Dosha Shamaka and Vranaropana properties, Murivenna will be very effective in the management of Parikarthika. Oil enema and Pichu with Murivenna are widely practicing by Ayurvedic practitioners in Parikarthika. Even though these procedures are widely performing there are some practical difficulties which are experienced by the patients during and after the application. Oil enema in less than 15 ml quantity should follow for more than 2 to 3 weeks up to the healing of fissure-in-ano wound. So, most of the practitioners train the patients to carry out the procedure themselves at home. However, the patients experience difficulty in administration of oil enema by themselves. Pain aggravation was also one of the problem due to improper insertion of enema nostril towards anal canal. Moreover, lot of patients hesitate to follow this due to fear. Due to this most of the patients are withholding the treatment during its course period. So, there is need to find out alternative form of this Murivenna oil which should be easily applicable and equally effective and should be acceptable by the patients to overcome above said practical difficulties. Thus, the idea behind the preparation of ointment form of Murivenna was formulated. Application of Ointment is quite easy than oil and it can be applied in any time even during working hours. It is also being a cost-effective therapy.

Method of Collection of Data
For the present Pilot study 22 patients of either sex were selected randomly from OPD and IPD of hospital Triveni Nursing Home, Thiruvananthapuram. The selected patients were treated with Murivenna ointment. All points of history taking, physical examination and lab investigation were noted in a special case proforma. Selected patients were noted before, during and after the proposed treatment and the changes in the parameters were documented in Case Proforma. Clinical study was conducted on diagnosed cases after obtaining voluntary informed consent.

Study Design
An observational non comparative pilot study.

Methods of Treatment
All selected patients were treated as out patients. Patients were treated with Murivenna Ointment.
Murivenna ointment was applied locally in fissure bed (Parikarthika) with digital was followed twice daily after sitz bath for 4 weeks or till healing of fissure bed whichever is earlier. Adjuvant drug Triphala Churnam 5 gm orally at bedtime with lukewarm water was prescribed daily to all patients with constipation.

Drug Preparation
Murivenna Ointment is a modified preparation without any direct classical references. Ointment form of Murivenna was prepared by adding melted Madhuchishta(bees wax) into oil Murivenna. The procedures were according to the rules of Malahara(Ointment) Kalpana [10]. 1:6 was the ratio followed for the preparation of the ointment. Small pieces form of Madhuchishta(Bees wax)was added slowly in the oil Murivenna which was boiled under mild intensity of fire. After complete dissolution of wax into oil, it was filtered properly by a clean cloth. The ointment was filled into the tubes [11].

Assessment Criteria
The signs and symptoms of Parikartika(Acute fissure-in-ano) are pain in ano, bleeding per rectum and constipation which were noted in the proforma during history taking. Assessment of the result was done on different criteria like Pain, bleeding per rectum, anal sphincter tonicity and ulcer in Ano.

RESULTS AND DISCUSSION
There was significant relief in symptom like pain in ano and bleeding per rectum in all patients after 30 days of treatment. The anal sphincter tonicity became normal in 21 patients (95.45%) after 30 days of treatment. Ulcer in ano was completely healed in 19 patients (86.36%) after 30 days of treatment. There was no reoccurrence in all patients after 30 days of follow up.
Murivenna is a traditional medicated oil which is prepared with eight medicinal plants -Karanja, Kumari, Tamboola, Sigru, Paribhadra, Palandu, Vasuka and Satavari. It is widely used in the conditions like contusions, fresh wounds, anorectal diseases and even for fractures [9]. Due to its Tridosha Dosha Shamaka, Shoola Prashamana, sophakara and Vranaropana properties, it is very effective in the management of Parikarthika. The base of oil Murivenna is coconut oil. This increases the permeability of skin and in turn increases the bioavailability of drugs [13]. Coconut oil is having Seetha Veerya (Cold in potency) which suddenly reduces inflammation [14]. Individual drugs of Murivenna having anti-inflammatory properties.
Antiinflammatory activity decreases wound exudate promotes analgesic effect and supports the process of wound healing. One research study also reported that Murivenna shows healing properties [14].
Madhuchishtha (Beeswax) plays an important role in traditional Indian medicine. The qualities bees wax are Mridu (soft), Snigdha (unctuous) and having the properties like Vrana Shodhana (cleansing the wound) and Vranaropana (healing the wound) [15]. Beeswax is used for the care of wounds from abrasion or even from burns with topical application [16]. It has been shown to be particularly effective in the treatment of heel cracking [17]. One study was conducted with the mixture of natural honey, olive oil and beeswax to analyse its effectiveness in the management of anal fissure. The results of the study demonstrated that patients with anal fissure showed significant reduction in pain, bleeding and itching after the treatment. The study was concluded that improvement for the anal fissure was due to the anti-inflammatory, antioxidant and healing properties of Bees wax [18]. Murivenna ointment was prepared by adding melted Madhuchishta(bees wax) into oil Murivenna. Both Murivenna and Bees Wax are having antiinflammatory and wound healing properties. Due to this Murivenna Ointment is a better therapeutic combination in the management of acute fissure in Ano.

CONCLUSION
Murivenna is a traditional medicated oil which is widely used in the conditions like contusions, fresh wounds, ano-rectal diseases and fractures. Murivenna ointment which was prepared with oil Murivenna and Bees wax are very effective medicine for the symptomatic relief in the management of acute fissure in ano. It is also having anti-inflammatory and wound healing properties. There is no need of hospital stay as this treatment is completely out patient-based system. The irritable symptoms like pain and bleeding per rectum were effectively relieved within 14 days of treatment in all patients. It is one of the effective treatment in the management of fissure in ano as it relieved the cardinal symptoms of fissure in ano such as cutting pain and burning pain. There was marked improvement noted in majority of patients in ulcer healing. Hence Murivenna ointment can be considered as better alternative for the symptomatic relief in the management of acute fissure in ano.

DISCLAIMER
The products used for this research are commonly and predominantly use products in our area of research and country. There is absolutely no conflict of interest between the authors and producers of the products because we do not intend to use these products as an avenue for any litigation but for the advancement of knowledge. Also, the research was not funded by the producing company rather it was funded by personal efforts of the authors.

CONSENT
As per international standard or university standard, patients' written consent has been collected and preserved by the author(s).

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).