Abstract

Abstract

Complex trans-sphincteric fistulas with multidrug-resistant infection pose high recurrence risks and challenge sphincter preservation. While MRI fistulogram and pus culture-sensitivity guide targeted treatment and Ayurvedic Kshar Sutra ligation—a minimally invasive sphincter-sparing technique—remains under-utilized in modern protocols. A 35-year-old male with a recurrent fistula-in-ano with pus discharge from perianal region and failed private-hospital treatment underwent MRI fistulogram (trans-sphincteric track, intersphincteric abscess extending to scrotal root) and pus culture, isolating a multidrug-resistant organism sensitive only to higher antibiotics. Patient undergone partial fistulectomy surgery with Apamarga Ksharsutra ligation followed by targeted antibiotics were started. Weekly thread changes and modern wound assessment were performed. Significant clinical improvement occurred; the fistula track epithelialized completely within 8 weeks, with symptom resolution and no continence impairment. Antibiotics alone had previously failed; MRI and culture-directed therapy provided diagnostic clarity and effective planning. Integrating MRI fistulogram and pus culture-sensitivity testing with Apamarga Kshar Sutra ligation offers a reproducible integrative protocol for complex fistulas in controlling resistant infection, preserving sphincter function, and reducing recurrence. Broader studies can standardize this Ayurveda–modern approach. This case highlights the potential of combining modern diagnostics with traditional Ayurvedic techniques for effective management of complex fistula-in-ano. The use of Kshar Sutra ligation, guided by MRI and Pus C/S test, provides a promising approach for treating complex fistulas, especially in recurrent cases.