Breaking the Cycle of Recurrence: An Integrative Approach to Chronic Fistula-in-Ano Management

Recurrent fistula-in-ano presents a significant clinical challenge due to high morbidity and the risks associated with repeated surgical interventions. This report details an N-of-1 observation of a patient with a Grade 3 fistula-in-ano who experienced a symptomatic recurrence one year post-fistulotomy. In a resource-constrained setting, management was achieved through a multimodal Supported Self-Management (SSM) framework, integrating topical phytotherapy via Neem (Azadirachta indica) sitz baths with systemic interventions, including mechanical offloading, optimized hydration, and dietary fiber intake. The protocol involved 15-minute immersions in a Neem-leaf decoction, with frequency titrated between three and two times daily based on pain, edema, and scar integrity. Following the intervention, all clinical manifestations—including persistent pruritus, abscess formation, and hemopurulent discharge—completely resolved. These findings suggest that Neem-based bioactive compounds may function as a biological tissue conditioner, enhancing scar elasticity and mitigating mechanical triggers in ways traditional saline baths do not. While this case offers a viable, low-cost model for enhancing health equity in developing economies, structured clinical trials are necessary to quantify the efficacy and long-term safety of this integrative approach.