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Introduction

Bhagandara[1] is one of the Ashtamahagadas[2] in Sushruta Samhita and classified as a chronic sinus tract near guda that discharges purulent material and resists spontaneous healing, closely matching modern fistula-in-ano,[3] it implies a chronic granulating tract connecting two epithelial lined surfaces. It may be mucosal or cutaneous and characterized by one or more small opening around anal verge. Most anal fistulas originate from intersphincteric abscesses caused by infected anal glands; these abscesses can extend upward, downward, medially, laterally, or circumferentially around the anorectum. Complex subtypes (high trans-sphincteric, suprasphincteric) carry recurrence rates up to 25–40% after fistulotomy and risk continence impairment. The challenge intensifies when multidrug-resistant organisms colonize the tract,[4] rendering antibiotics alone ineffective.

Modern management sets MRI fistulogram as the diagnostic benchmark: multiplanar T2-weighted and STIR sequences delineate primary tracks, secondary ramifications, and supralevator extensions, enabling Parks and St James’s grading. [5] Pus culture-sensitivity adds microbiologic direction in an era of rising antimicrobial resistance.[6] Yet operative choices—fistulotomy, LIFT, flaps—still trade cure against sphincter injury.

Acharya Sushruta recommended Ksharsutra therapy given the high recurrence after standard surgery; while he mentions Kshara from Kadali, Palasha, and others, Apamarga Kshara from Achyranthes aspera ash is considered the foremost.[7] Ayurveda addresses Bhagandara primarily through Ksharsutra ,[8] an Apamarga-based medicated Seton that combines slow mechanical division with controlled chemical cauterization, reporting minimal continence loss.[9] What remains underexplored is a structured protocol that priortised MRI and culture to guide patient selection, antibiotic adjuncts, and timely Kshar Sutra ligation.

We present a 37 years old male with a Parks grade-IV trans-sphincteric fistula and MDR colonization, treated with MRI- and culture-informed antibiotics followed by partial fistulectomy and standardized Apamarga Kshar Sutra. The tract epithelialized in 12 weeks, illustrating how integrative decision-making can link Sushruta’s Bhagandara principles to contemporary fistula care.

Chief Complaints

 This single case report was carried out in the Department of shalyatantra at Pakwasa Hospital Nagpur between October 2024 to February 2025. Patient gave history of boil at right perianal region 8-9 months ago and complaining intermittent pus discharge from anal and perianal region since last 8 months continuous pain. He had taken treatment from various medical practitioner, incision and drainage was done under local anaesthesia, but didn’t get relief and symptoms worsened. Then he came to Shalyatantra OPD of our institute and got admitted for further surgical and conservative management.

Discussion

Results and Discussion

In this case, the integration of MRI and pus culture-sensitivity guided antibiotics therapy and Apamarga Ksharsutra application along with adjunct Ayurvedic therapy proved beneficial in successfully managing a complex trans-sphincteric fistula with prior failed I & D.MRI-guided surgery was critical: T2/STIR sequences mapped the Grade IV trans-sphincteric track and its intersphincteric abscess, revealing ramifications that would have been missed clinically and enabling precise partial fistulectomy and safe Ksharsutra ligation. Pus culture-sensitivity proved equally important; MDR resistance to first-line drugs prompted escalation to Piperacillin-Tazobactam, avoiding blind antibiotic failure.[10-11] Apamarga Ksharsutra provided antibacterial effect [12] like, slow mechanical division with continuous chemical cauterization and medicated drainage, which minimized sphincter injury and likely lowered recurrence risk compared with conventional fistulotomy. Clinically, discharge resolved by days 10–11, granulation appeared and pain decreased by day 20, and the tract epithelialized at 12 weeks with continence preserved. The case supports culture guided therapy for faster healing, lower recurrence and better quality of life; comparative studies versus empirical care are warranted. Further research on well -designed studies comparing culture guided versus empirical management are needed to achieve faster wound healing [13] and avoiding recurrent [14-15] fistulas.

Conclusion

The present case highlights a successful integrative approach in the management of a recurrent, multidrug-resistant (MDR) Grade IV fistula-in-ano, demonstrating that the judicious combination of classical Ayurvedic principles with contemporary diagnostic and antimicrobial strategies can yield durable clinical outcomes. The use of MRI-guided anatomical mapping enabled precise delineation of the fistulous tract and its extensions, thereby facilitating accurate surgical planning. Culture-directed antibiotic therapy ensured targeted microbial control, particularly crucial in the setting of MDR infection, minimizing the risk of persistent sepsis and promoting optimal wound healing.

The incorporation of partial fistulectomy along with Apamarga Ksharsutra provided an effective sphincter-preserving intervention, aligning with the principles described in Sushruta’s management of Bhagandara. This approach not only aided in gradual chemical cauterization and debridement of the tract but also reduced the likelihood of recurrence by ensuring continuous drainage and healing from within. Importantly, preservation of sphincter integrity contributed to maintaining continence, thereby significantly improving the patient’s functional outcome and quality of life.

The favorable clinical response observed—characterized by sustained healing, absence of recurrence during follow-up, and symptomatic relief—suggests that this integrative protocol may serve as a viable and effective alternative to more invasive conventional procedures, particularly in complex and recurrent cases. Furthermore, it underscores the relevance of antibiotic stewardship when managing resistant infections alongside traditional therapies.

However, as this is a single case observation, the findings must be interpreted with caution. There remains a need for well-designed prospective studies and randomized controlled trials to systematically evaluate the efficacy, safety, recurrence rates, and patient-reported outcomes associated with this combined modality. Such evidence will be instrumental in validating this integrative approach as a standardized treatment strategy for complex fistula-in-ano in modern clinical practice.