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Open Access Full Text Article                                                        Review Article

Non-Pharmacological Management of Heamorrhoids (Bawāsīr) in Unani System of Medicine: A Systemic Review

*Fakhara Khan ¹, Tafseer Ali ², Mohd Tarique ³, Shamama Usmani ⁴

1-PG Scholar, Department of Jarahat, Faculty of Unani Medicine, AKTC, AMU, Aligarh 

2-Professor, Department of Jarahat, Faculty of Unani Medicine, AKTC, AMU, Aligarh, 

3-Assistant Professor, Department of Jarahat, Faculty of Unani Medicine, AKTC, AMU, Aligarh, 

4-JRF, Department of Ilaj-Bit-Tadbeer, Faculty of Unani Medicine, AKTC, AMU, Aligarh 

 

 

1. Introduction:

Haemorrhoids are dilated veins located within the anal canal in the sub-epithelial region, formed by the radicles of the superior, middle, and inferior rectal veins.¹ The term "haemorrhoids" is derived from the Greek words “heama” (blood) and “rhoos” (flowing). Around 460 BC, this term was originally used by Buqrat (Hippocrates) to describe the flow of blood from the veins around the anus. During the period of John of Arderne (1307–1392 AD), in his 1370 treatise, he noted that common people referred to them as "piles," which comes from the Latin word "pila," meaning a ball, the nobility called them haemorrhoids, and in French they were referred to as "figs" (from "figer," meaning to clot ^2–4  In Unani medicine, which has roots in Greco-Arabic traditions, haemorrhoids are indeed referred to as " Bawāsῑr". The term " Bawāsῑr " is derived from the Arabic word "baasoor", which means a wart or a polyp-like swelling.⁵ According to Hippocrates (Buqrat), Bawāsῑr refers to the varicosities of the internal mucous membrane of the rectum, wherein the veins become swollen, like varicose veins in the lower limbs. He suggested that haemorrhoids may confer protection against various systemic diseases such as liver disease and portal hypertension, and he advocated for their ligation. ^6,7 

Many other Unani physicians have documented in their texts that haemorrhoids develop due to stagnant and thickened blood (Sawdāwῑ and viscous blood), often caused by constipation. Ancient authors like Zakariya Razi, Ibn-e-Zuhar, and Ibn-e-Sina mentioned in their writings that surgery should be considered as a last resort, as without addressing the underlying cause, haemorrhoids may recur at a different location.^8,9

The precise understanding of how haemorrhoids develop remains unclear. For many years, it was believed they were simply varicose veins of the anal plexus, but this view is now outdated, as haemorrhoids and anorectal varices are recognized as distinct conditions. Haemorrhoids and anorectal varices are now recognized as separate conditions, highlighting the complexity of their pathogenesis. The exact cause of haemorrhoids remains multifactorial, with various theories proposed to explain their development.^10–12

The link between haemorrhoids and factors such as straining and irregular bowel habits, as described by Hyams and Philpott (1970), provides further evidence for this theory. Irregular bowel habits, which often result in hard, bulky stools, can lead to straining that displaces the cushions from their position in the anal canal.¹³ Additionally, Burkitt (1972) suggested that anal compliance, influenced by diet and stool consistency, may play a role in the development of haemorrhoids and their geographical distribution.^14,15

When the anal canal becomes narrow and rigid, the cushions are more likely to be pushed out during bowel movements, which may explain the effectiveness of forcible anal dilation in haemorrhoid treatment, as observed by Sames (1972). This theory underscores the interplay between anatomy, bowel habits, and diet in the pathogenesis of haemorrhoids.¹⁶ 

Ibn Lūqa states that people who use castor oil excessively often get piles. Native people who live in damp, humid climates with high humidity levels are more likely to have it. People utilize excessive amounts of milk, curd, dry fruits, and dry fish. People who are melancholic are more likely to accumulate piles. In a same vein, people with Sawdāwῑ Maraz are more likely to develop Bawāsῑr^4,5

Jurjani believed that Sawdāwῑ blood is the source of the illness. He offered two explanations for the reason it happened: 

1. Heated and highly acidic temperament; foods and medications that cause blood to burn or become acrid. 
2. Blood that is too viscous is produced by consuming too much Sawdāwῑ food. Additional factors include long-term illness, walking too much, sitting too much, using too much castor oil, and eating too many dried fruits.¹⁷ 

Azam Khan claims that Sawdāwῑ Dam, which originates from two reasons is the cause of Bawāsῑr. 

1. Blood oxidation from overindulging in spicy foods and drugs, or the amalgamation of Safrā Hādd Muḥtariq (acute burnt bile) in the blood, which leads to the development of Khūnῑ Bawāsῑr. 
2. When melancholic bile-producing foods are consumed in excess, Sawdāwῑ Khūn is produced, which causes Bawāsῑr.⁵

The most common cause of piles is Mādda Sawdā’ or Sawdawῑ Khūn and rarely Mādda Balghamῑ. Unani scholars identify the primary cause of Bawāsῑr as Khilt-i-Sawdā’ (abnormal black bile), which arises from the excessive intake of foods that generate black bile, such as spices, brinjal, cabbage, cauliflower, and certain meats. Additional contributing factors include living in humid conditions, overconsumption of dates, fish, and milk, a sedentary lifestyle, prolonged sitting, increased alcohol consumption, and the misuse of laxatives.

2. Methodology

A systematic literature search was conducted to gather relevant information on haemorrhoids, lifestyle disorders, and dietotherapy. The search strategy involved using specific keywords such as haemorrhoids, piles, lifestyle disorders, dietary management, Unani medicine, and traditional healing practices. The databases PubMed, Medline, and the Cochrane Library were searched to identify peer-reviewed articles, clinical trials, and systematic reviews related to the topic. Additionally, Unani medicine sources and ancient texts were reviewed to explore traditional perspectives on the management and treatment of haemorrhoids. Classical Unani texts and manuscripts were examined for insights into diet-based interventions and holistic approaches to treating haemorrhoids in traditional medicine. The data extracted were categorized based on aetiology, pathophysiology, dietary interventions, and Unani treatment principles to ensure a comprehensive understanding of the subject.

3. Discussion

Haemorrhoids are a widespread medical condition; studies suggest that approximately 50% of the population will experience symptomatic haemorrhoid disease at some point in their lives. The peak incidence of symptomatic haemorrhoids occurs between the ages of 45 and 65 years. Of these, approximately one-third seek surgical intervention. The condition affects individuals of all ages and both genders. While the exact prevalence in developing countries remains uncertain, there is evidence to suggest an increasing incidence, likely linked to the adoption of westernized lifestyles. This highlights the need for greater awareness, prevention, and management strategies tailored to diverse populations.

Non-pharmacological management of haemorrhoids focuses on lifestyle modifications and physical interventions to alleviate symptoms and prevent recurrence. By integrating modern medical understanding with Unani therapeutic strategies, this approach highlights the significance of traditional medicine in addressing haemorrhoids. Key strategies include dietary changes, such as increasing fibre intake to prevent constipation, ensuring adequate hydration, and promoting regular bowel movements. In Unani system of medicine, ‘Ilāj-bit-Tadbīr (Regimenal Therapy) which includes Riyāḍat (Exercises) regular physical activity, hydrotherapy like Ābzan (Sitz bath), Hammām (Turkish bath) etc and proper hygiene practices are effective and plays a role in managing the symptoms like soothing irritation and reducing inflammation. Additionally, avoiding prolonged sitting or standing, especially on hard surfaces, can alleviate pressure on the anal area. These approaches, when combined, offer a holistic and effective treatment plan for managing haemorrhoids, particularly in mild to moderate cases, and can complement medical treatments for more severe conditions. 

Haemorrhoids can be aggravated by constipation and straining during bowel movements. A diet focused on improving digestion and preventing constipation is key. Below are non-pharmacological recommendations for managing and alleviating haemorrhoid symptoms:

‘Ilāj bi’l Taghdhiya (Dietary management)

Dietary recommendations: ^18–21

Fiber softens stools and facilitates easy bowel movements, reducing strain and irritation.

• Fruits: Apples, pears (with skin), bananas, berries, oranges, and prunes.
• Vegetables: Broccoli, carrots, spinach, kale, zucchini, and sweet potatoes.
• Whole Grains: Oats, brown rice, whole-grain bread, barley, and quinoa.
• Legumes: Lentils, chickpeas, black beans, and kidney beans.
• Nuts and Seeds: Almonds, chia seeds, and flaxseeds (in moderation).
• Aghziya Latīfa Martūba- refers to foods that are gentle, moist, and nourishing. These types of foods are considered beneficial for individuals with digestive issues or those recovering from illness, as they help soothe the stomach, provide nourishment, and maintain hydration.

Examples of Aghziya Latīfa Martūba might include:

1. Soups and broths: Easily digestible and provide both moisture and nutrition.
2. Yogurt: Moist, cooling, and often considered a beneficial food for gut health.
3. Fresh fruits and vegetables: Such as watermelon, cucumbers, and oranges, which have high water content.
4. Smoothies or fruit juices: Blended drinks that are easy to consume and provide hydration along with essential nutrients
5. Hydration: Adequate hydration is crucial for softening stools and preventing constipation, which can worsen haemorrhoids. Drinking 8-10 glasses of water daily and consuming hydrating foods like fruits and soups help maintain digestive health and prevent straining during bowel movements. This reduces pressure on the anal region and helps prevent haemorrhoid flare-ups.^23,24 

Examples of Zūd Hazm Aghziya:

1. Rice: Particularly white rice, which is simple to digest.
2. Yogurt: Contains probiotics that aid digestion and are gentle on the stomach.
3. Cooked vegetables: Such as carrots, zucchini, and spinach, which are soft and easy to digest.
4. Bananas: Known for their ease of digestion and soothing properties.^19,23

Dietary restrictions: 

Examples of Aghziya Ghalīza:

• Red meats: Such as beef, lamb, or mutton, which are high in protein and fat.
• Fried foods: Including deep-fried snacks and dishes that are rich in oil.
• Cheese: Particularly full-fat varieties, which are rich and difficult to digest.
• Nuts and seeds: While nutritious, they can be dense and harder to break down for some individuals.
• Refined sugars and pastries: High-sugar, processed foods that can be heavy on the digestive system.¹⁹
• Aghziya Muwallid-i Sawdā (Black bile producing foods)-refers to foods that are thought to increase the production of black bile (Sawdā) in the body. In Unani medicine system, black bile is considered one of the four bodily humors, and its excess is believed to contribute to conditions like melancholy, irritability, digestive issues, and other imbalances.

Foods that are considered Aghziya Muwallid-i Sawdā typically include:

1. Red meats: Particularly beef, lamb, and mutton, which are heavy and rich in proteins and fats, believed to stimulate the production of black bile.
2. Fried and oily foods: Foods that are greasy, deep-fried, or rich in unhealthy fats may contribute to the formation of black bile.
3. Spicy foods: Foods that are excessively hot or spicy, such as chili peppers, garlic, and strong spices, are believed to aggravate the production of black bile.
4. Caffeine: Overconsumption of caffeinated beverages like coffee and strong tea is thought to have a stimulating effect on black bile production.
5. Alcohol: Drinking alcohol, especially in large amounts, is also believed to contribute to the excess of black bile.
6. Processed and sugary foods: Refined sugars, pastries, and processed foods that are rich in unhealthy fats and sugars can also be linked to the creation of black bile.^5,19,25 

‘Ilāj bi’l-Tadbīr (Regimenal therapy):

5. Ḍimād (Poultice)^19, 26
6. Local application of bone marrow.
7. Local application of following formulation for analgesia: Nākhūna (Pod of Trigonella uncata, Boiss.), Khatmī (Althaea officanalis, Linn.), Afyūn (Dried latex of Papaver somniferum, Linn.), Za‘farān (Crocus sativus, Linn.)
8. Local application of paste containing egg yolk, barley flour and Roghan-i Gul is very effective in Bawāsīr Dāmiya (bleeding piles).
9. Local application of a paste containing egg yolk and Roghan-i Gul.
10. Local application of old olive oil.
11. Ābzan (Sitz bath): ^27–29
12. Post-i Anār (Fruit rind of Punica granatum, Linn.), Māzū (Quercus infectoria, Oliv.), Zar-i Ward (Stamens of Rosa damascena, Mill.), Gulnār (Flower of Punica granatum Linn.)
13. Ābzan (Sitz bath) with the decoction of Khatmī (Althaea officinalis, Linn.), Khubbāzī (Malva sylvestris, Linn.) and Banafsha (Viola odorata, Linn.).
14. Ābzan (Sitz bath) with the decoction of Masūr (Lens esculenta, Moench.), Post-i Anār (Fruit rind of Punica granatum, Linn.), Māzū (Quercus infectoria, Oliv.) and Zar-i Ward (Stamen of Rosa damascena, Mill.)
15. Ta‘līq al-‘Alaq (Leech Therapy) Leeches are directly applied over the haemorrhoidal swellings or adjacent to them due to which the morbid matter lodged in the haemorrhoidal plexus directly expel out from the affected area.³⁰
16. Riyāḍat (Exercise) ³¹ 

Exercise plays a significant role in both preventing and managing haemorrhoids by promoting overall digestive and circulatory health. Engaging in regular physical activity offers the following benefits for individuals with or at risk of haemorrhoids:

Improves Digestion and Prevents Constipation:

Exercise helps stimulate bowel movements and promotes a healthy digestive system, reducing the risk of constipation, which is a primary factor in the development of haemorrhoids.

 

Enhances Blood Circulation:

Physical activity improves blood flow, reducing pressure and pooling in the rectal and anal veins, which can alleviate or prevent the development of haemorrhoids.

Reduces Straining:

By preventing constipation and promoting softer stools, exercise minimizes the straining required during bowel movements, lowering the risk of haemorrhoid flare-ups.

Strengthens Muscles:

Certain exercises, such as Kegel exercises, strengthen the pelvic floor and anal sphincter muscles, improving support and reducing the likelihood of hemorrhoidal issues.

Reduces Weight:

Regular physical activity aids in weight management. Excess weight, particularly around the abdomen, increases pressure on the pelvic and anal regions, contributing to haemorrhoid development.

Stress Relief:

Exercise reduces stress, which can indirectly improve bowel habits by minimizing stress-induced constipation.

Recommended Exercises for Haemorrhoids:^32,33 

• Walking: Gentle walking improves blood flow and promotes digestion.
• Yoga: Certain poses, like the child’s pose or squatting pose, can help improve circulation in the anal region.
• Swimming: A low-impact exercise that enhances blood flow and reduces pressure on the pelvic area.
• Kegel Exercises: Strengthen the pelvic floor muscles, providing better support to the rectal area.

Exercises to Avoid:

• Activities that involve heavy lifting or high strain, as they can increase abdominal pressure and worsen haemorrhoids.
• Long periods of sitting or cycling, as these can exert pressure on the anal area.
• Tahaffuz (Prevention/Precaution): ^19,34 
• Muwallid-i Sawdā Tadābīr- Tadābīr refers to strategies or measures in Unani medicine to prevent or manage the excessive production of Sawdā (black bile) to be avoided. These measures aim to balance the humors in the body and mitigate the harmful effects of an overproduction of black bile, which can lead to conditions such as melancholy, digestive issues, and skin disorders. 
• Tadābīr for Muwallid-i Sawdā:
  1. Avoid prolonged fasting or irregular eating habits, as they can disrupt digestion and increase Sawdā.
  2. Ensure adequate sleep and avoid overexertion.

 

1. Emotional and Mental Well-being (Tadbir-e-Nafsani): Practice relaxation techniques and maintain a balanced emotional state to reduce melancholy associated with excess Sawdā.
2. Elimination Therapies (Tanqiya): Unani therapies such as Fasd-i Sāfin (Bloodletting through saphenous vein) or Hijāma (Cupping) on hip may be used to remove excess black bile from the body. 
3. Purgation (Ishaal): Use of mild laxatives to cleanse the body of excess Sawdā.
4. Gradual Increase in Fiber: Increase fiber intake slowly to avoid bloating and gas.
5. Meal Timing: Establish a regular eating schedule to promote consistent digestion.

4. Conclusion

The strategies for managing Muwallid-i Sawdā focus on maintaining a balance in the body's humors through dietary changes, physical activity, emotional balance, and Unani therapeutic interventions. These measures collectively help in preventing and alleviating conditions associated with excess black bile. Prevention not only minimizes discomfort but also reduces the need for invasive interventions. Many patients can effectively manage their symptoms through dietary adjustments and lifestyle modifications. Ensuring a balanced diet rich in fibre, adequate hydration, and regular physical activity can help maintain optimal bowel health and prevent constipation, which is a major contributing factor in the development and worsening of haemorrhoids. Avoidance of constipation is crucial, as it minimizes straining during bowel movements, reducing pressure on the anal veins and preventing the recurrence of hemorrhoidal symptoms. Incorporating simple practices, such as avoiding prolonged sitting, practicing good toilet habits, and maintaining a healthy weight, can significantly improve the condition and enhance the quality of life for individuals suffering from haemorrhoids. In addition to these measures, the Unani system of medicine offers highly beneficial non-surgical techniques, such as Fasd (venesection), Hijāma (cupping therapy) and Ta‘līq al-‘Alaq (leech therapy). These therapies aim to balance the body’s humors, reduce inflammation, and promote the healing of hemorrhoidal tissues. These treatments are natural, cost-effective, and have been shown to provide significant relief without the complications often associated with surgical interventions. 

Furthermore, Unani medicine emphasizes the use of herbal remedies, and these formulations are designed to improve digestion, prevent constipation, and reduce inflammation, supporting both prevention and treatment. The holistic approach of Unani medicine not only addresses the symptoms but also targets the root causes, ensuring long-term relief. In conclusion, haemorrhoids can be managed and treated effectively with a combination of preventive measures, lifestyle modifications, and natural therapies. The non-surgical techniques and medicinal formulations of Unani medicine provide a promising and economical alternative for patients, making it a comprehensive and patient-friendly approach to managing this common condition. 

Conflicts of Interest: Nil

Ethical Approval: Not applicable.

Consent for Publication: Not applicable.

Human and Animal Ethical Right: Not applicable.

Availability of Data and Materials: The data supporting this study’s findings will be available in the cited references.

Funding: The research received no external funding. 

Author Contribution: All authors have equal contribution in the preparation of manuscript and compilation.

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