Management of Recurrent Fistula-in-Ano with Apamarga Ksharsutra Therapy: An Ayurvedic Case Report

Background: Fistula-in-ano is a chronic anorectal condition with a high risk of recurrence after conventional surgical procedures. Ayurveda describes this condition as Bhagandara, categorized under Aṣṭa Mahāgada because of its complexity and tendency to recur. Case Presentation: A 20-year-old male presented with perianal pain, boil formation, and pus discharge for one month, with a history of fistulotomy performed twice, first in February 2025 and again in May 2025. MRI pelvis revealed a recurrent low intersphincteric fistula with a single internal opening. The patient was treated with Apāmārga Kṣārasūtra ligation together with internal Ayurvedic medicines and local Pañcavalkala decoction sitz bath. Intervention and Outcome: Gradual cutting and healing of the fistulous tract occurred with marked reduction in pain and discharge. Complete healing was achieved without sphincter damage, and no recurrence was observed during the available one-month follow-up period. Conclusion: Apāmārga Kṣārasūtra therapy provided a minimally invasive, sphincter-preserving approach in this recurrent cryptoglandular fistula-in-ano. The case also emphasizes that precise identification of the internal opening, secondary extensions, sepsis, and abscess is essential because failure to define or adequately treat these factors can contribute to non-healing or recurrence. Keywords: Fistula-in-ano, Bhagandara, Ksharsutra, MRI pelvis, recurrent fistula, Apamarga, case report