Missed Diagnosis for 1 Month: How a Hidden Fistula Caused Lower Back Pain

Lower back pain is one of the most common complaints in OPD - what happens when it doesn’t behave like “typical” back pain?

One of my patients lived with unexplained lower back pain for 1 full month. He consulted multiple doctors, including an orthopedic specialist, yet no clear diagnosis was made. What finally explained the pain was something far more hidden: an intersphincteric fistula-in-ano presenting in an unusual way.

Patient’s Story

Last week, a 38-year-old male patient came to my OPD with complaints of lower back pain for one month. He had consulted multiple doctors, including an orthopedic surgeon, but no diagnosis was made.

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.

Clinical Examination

On examination near the tailbone, there was tenderness and tenseness extending toward the anal region. At first, we suspected a pilonidal sinus, but there were no external pits seen.

Further examination revealed key perianal findings:

• Tenderness at the 5 o’clock position (about 7-8 cm from the anal verge)
• On applying gentle pressure -> pus discharge from an internal opening at the 6 o’clock position

Diagnosis

Based on clinical findings, I suspected fistula-in-ano.

Steps taken to confirm:

• Digital Rectal Examination (DRE) -> confirmed the internal opening at 6 o’clock
• MRI fistulogram advised to confirm the tract and plan surgery accurately

MRI Confirmation

MRI fistulogram showing intersphincteric fistulous tract.

Final Diagnosis

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

Treatment Plan

I explained to the patient that surgery is the only definitive treatment for a fistula tract.

We planned a fistulotomy with careful sphincter preservation.

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Surgery

Performed complete fistulotomy with careful preservation of the sphincter to address the full tract.

Recovery

• Patient operated yesterday
• Discharged next day
• Pain score: 2-3/10
• Walking, sitting, and passing motion comfortably

Outcome

• Complete tract addressed
• Minimal chances of recurrence

Watch Video Explanation

Conclusion

This case highlights how a fistula can present in unusual ways, including persistent lower back pain. Early diagnosis and proper surgical management can lead to excellent recovery and a clear resolution of the underlying tract.

Call To Action

अगर आपको ऐसे symptoms हैं, delay मत कीजिए.