By Dr. Kundan Kharde | MS General Surgery, FMAS | Proctologist & Laparoscopic Surgeon, Pune

Introduction

Lower back pain is one of the most common complaints seen in outpatient clinics. Most cases are attributed to musculoskeletal causes such as muscle strain, disc problems, or postural issues. However, not every case of lower back pain has a straightforward explanation.

In this article, I share a real clinical case where a patient suffered from persistent lower back pain for one full month, consulted multiple doctors including an orthopedic specialist, yet remained undiagnosed. The actual cause turned out to be something far more hidden — an intersphincteric fistula-in-ano presenting in an atypical manner.

This case serves as an important reminder for both patients and clinicians: when back pain doesn't follow the usual pattern, think beyond the spine.

The Patient's Story

A 38-year-old male patient visited my OPD complaining of lower back pain that had persisted for one month. He had already consulted multiple doctors, including an orthopedic surgeon, but no definitive diagnosis had been reached.

What made the case stand out was the persistence of symptoms and the fact that the pain didn't fit the usual pattern of musculoskeletal back pain. There was no history of trauma, no radiating pain down the legs, and no improvement with standard analgesics or physiotherapy.

Clinical Examination Findings

On careful clinical examination near the tailbone area, I found:

  • Tenderness and tenseness extending toward the anal region
  • Initially, we suspected a pilonidal sinus, but no external pits were seen

Further detailed perianal examination revealed critical findings:

  • Tenderness at the 5 o'clock position (approximately 7–8 cm from the anal verge)
  • On applying gentle pressure, pus discharge was noted from an internal opening at the 6 o'clock position

These findings pointed away from a musculoskeletal cause and toward a perianal pathology.

Diagnosis: Fistula-in-Ano

Based on the clinical findings, I suspected a fistula-in-ano. The following steps were taken to confirm the diagnosis:

  1. Digital Rectal Examination (DRE) — Confirmed the internal opening at the 6 o'clock position
  2. MRI Fistulogram — Advised to map the exact course of the tract and plan surgery accurately

The MRI confirmed the presence of an intersphincteric fistulous tract, leading to the final diagnosis:

Intersphincteric fistula-in-ano presenting atypically as lower back pain.

Why Was the Diagnosis Missed Initially?

Fistula-in-ano typically presents with perianal pain, swelling, or discharge. When the primary complaint is lower back pain — without obvious perianal symptoms — clinicians may not suspect a fistula at all.

Key reasons the diagnosis was delayed in this case:

  • The patient's chief complaint was back pain, which naturally directed evaluation toward orthopedic causes
  • There were no obvious external signs like a visible abscess or draining sinus
  • The fistula tract was intersphincteric, meaning it ran between the muscle layers and did not produce easily visible external findings
  • A thorough perianal examination was likely not performed during initial consultations

This highlights the importance of a comprehensive clinical examination, especially when standard treatments fail to provide relief.

Treatment: Fistulotomy with Sphincter Preservation

I explained to the patient that surgery is the only definitive treatment for a fistula tract. Medical management alone cannot cure a fistula because the tract is lined with epithelium and will not heal on its own.

The surgical plan included:

Complete fistulotomy — to lay open the entire tract

Careful sphincter preservation — to protect continence and ensure functional outcomes

For patients in Pune looking for expert fistula care, you can learn more about advanced treatment options at www.drkundankharde.com or visit Sharvari Hospital, Pune for consultation.

Post-Operative Recovery

The recovery was smooth and encouraging:

  • Patient was operated and discharged the next day
  • Pain score: 2–3 out of 10 (mild discomfort only)
  • Patient was walking, sitting, and passing motion comfortably within 24 hours
  • The complete fistula tract was addressed, ensuring minimal chances of recurrence

Key Takeaways for Patients

  1. Not all back pain is musculoskeletal. If your lower back pain is not responding to standard treatment, consider seeking evaluation from a surgeon — especially if the pain is near the tailbone.
  2. Fistula can present atypically. A fistula-in-ano doesn't always cause obvious perianal symptoms. In some cases, the predominant symptom may be pain in the lower back or near the coccyx.
  3. Early diagnosis matters. The sooner a fistula is diagnosed, the simpler the surgical management. Delayed diagnosis can lead to complex tracts and more involved surgery.
  4. Surgery is the definitive cure. Fistula tracts do not heal with antibiotics or ointments alone. A properly performed surgical procedure offers the best chance of complete resolution.
  5. Recovery is typically quick. Modern fistula surgery with sphincter-preserving techniques allows most patients to return to normal activities within 1–2 weeks.

Frequently Asked Questions

Can a fistula cause back pain?Yes. A fistula can sometimes cause atypical or referred pain, including discomfort around the tailbone and lower back, especially when the tract extends deeper between the muscle layers toward the anal region.

Is fistula surgery painful?Fistula surgery is performed under appropriate anesthesia. Post-operative pain is well managed with medications. Most patients experience only mild-to-moderate discomfort during the initial recovery period.

What is the recovery time after fistulotomy?Many patients can return to comfortable daily activities within 1–2 weeks. Complete wound healing may take several weeks depending on the size of the tract and quality of wound care.

How can I know if my back pain is caused by a fistula?If your lower back pain is near the tailbone, does not respond to orthopedic treatment, and is associated with any perianal discomfort, tenderness, or discharge, consult a proctologist for a thorough evaluation.

About the Author

Dr. Kundan Kharde is a senior proctologist and laparoscopic surgeon with over 17 years of experience in proctology and surgical care. He specializes in advanced laser treatments, VAAFT, and minimally invasive surgeries for conditions like fistula, piles, and fissure.

Website: www.drkundankharde.com, www.sharvarihospital.com

Hospital: Sharvari Hospital, Pune

Disclaimer: This article is for informational and educational purposes only and should not be considered a substitute for professional medical advice. Please consult a qualified healthcare provider for diagnosis and treatment.