Complex fistula-in-ano with scrotal extension: A rare case managed using the minimally invasive Interception of fistulous tract with application of Ksharasutra technique

Fistula-in-ano with extension to the scrotum represents a rare and complex variant of anorectal fistulous disease. Its management is particularly challenging due to the close proximity of the fistulous tract to vital anatomical structures, as well as its atypically long course. Moreover, traditional surgical treatments may carry risks such as injury to the sphincter muscles, slow wound healing, and postoperative complications. However, the Interception of Fistulous Tract with Application of Ksharasutra (IFTAK) technique offers a minimally invasive, sphincter-sparing alternative for managing such conditions. A 34-year-old male presented with a four-year history of intermittent purulent discharge from the scrotal region, associated with mild pain. The patient had previously undergone two surgical interventions for the same condition. Magnetic resonance imaging showed a right inguinoscrotal sinus tract opening on the scrotal skin with extension up to the left pectineus muscle (~3.8 cm) and a few small secondary branches, without abscess or deep pelvic spread. However, on clinical examination and probing, an internal opening was felt at the 12 o’clock position. The case was managed using the IFTAK technique, which involved strategic interception of the fistulous tract approximately 2 cm above the anal verge. A Ksharasutra (~medicated seton) was applied to the proximal segment of the tract, while the distal segment was left to heal by secondary intention. Postoperatively, adjunctive Ayurveda measures, including herbal sitz baths and local medicated dressings, were administered to facilitate healing. The patient experienced complete symptom relief within eight weeks, and the tract was healed progressively without complications or recurrence over a six-month follow-up. The sphincter function was preserved, with minimal postoperative morbidity. This case highlights the clinical utility of the IFTAK technique in managing complex fistulas. Its minimally invasive nature, sphincter preservation, and incorporation of Ayurveda principles offer a promising alternative to conventional methods. However, further studies are recommended to validate its efficacy on a larger scale.