Introduction

Anorectal abscesses are a common surgical condition, categorized into five distinct types based on their anatomical location: perianal (60%), ischiorectal (30%), intersphincteric (5%), supralevator (4%), and submucosal (1%).^[1] These abscesses typically originate from infections of the crypto glandular epithelium lining the anal canal. In the case of an ischiorectal abscess, as observed in our patient, pathogenic microorganisms may breach the internal anal sphincter via the crypts of Morgagni, subsequently spreading into the intersphincteric and ischiorectal spaces.^[2]

An ischiorectal abscess is characterized by the accumulation of pus in the ischiorectal fossa, commonly resulting from an obstructed and infected anal crypt gland. Clinically, patients often present with deep-seated perianal pain, buttock swelling, and systemic symptoms such as fever and malaise. If left untreated, complications may arise, including fistula-in-ano formation or systemic infections such as septicaemia.^[3] Prompt surgical drainage remains the cornerstone of effective management. From an epidemiological perspective, anorectal abscesses have a prevalence of 8 to 23 cases per 100,000 population, with a higher incidence in males than females. They can occur in all age groups, with a peak incidence between 20 and 40 years.^[4] Ischiorectal abscesses specifically account for approximately 20% to 22.7% of all anorectal abscesses.^[5]

Post-drainage management is crucial for facilitating healing and reducing the risk of recurrence or complications. Conservative management typically includes daily wound cleansing, dressing, analgesics, and systemic antibiotics. However, inadequate post-operative care may result in persistent infection, leading to fistula formation, recurrent abscesses, or even life-threatening systemic infections like septicaemia.^[6] Recurrence rates for ischiorectal abscesses remain high, ranging from 26% to 69% annually, highlighting the challenges in long-term management.^[7]

In Ayurveda, this clinical condition is aligned with Gudavidradhi, a type of deep-seated inflammatory swelling in the anal region. Delayed wound healing, referred to as Dushta Vrana, can occur due to various aetiologies, including infection, improper post-operative care, and systemic imbalances.^[8]

Patient’s History
History of Present illness

Onset - Before 7-8 days,
Duration - since last 5-6 days,
Progress - Gradual

Past History

No history of similar episode
No any comorbidities
No h/o past surgery

Family History - Mother - NAD, Father - NAD,

Personal History

Diet: Mixed
Sleep: Normal
Appetite: Adequate
Bowel: 1-2times/day
No history of any addiction.

Local Examination
Local Examination at Perianal Region

Inspection

• Ischiorectal abscess of right gluteal region approx. 2 cm away from anal verge.
• Edema at right Ischiorectal abscess +++
• Ischiorectal abscess of left gluteal region approx. 3 cm away from anal verge.
• Edema at left Ischiorectal abscess +++

Palpation

• Tenderness (at B/L ischiorectal abscess) +++
• Fluctuation tests positive (at B/L ischiorectal abscess)
• Pus discharge from left ischiorectal abscess ++
• No pus discharge from right ischiorectal abscess.

P/R done with lox 2%
No spasm
P/S done with lox 2%
NAD

Investigations

Imaging Test

MRI was advised for the patient; however, due to lack of cooperation, MRI imaging could not be performed, and therefore no MRI evidence of the ischiorectal abscess is available.

Post-Op management

• Done by Nimba- Patol- Erandmool Kwath Vrana Dhavan.
• Topical application of Yashtimadhu Lajjalu Tail dressing for 4 weeks.

The line of treatment was adopted, shown in Table 4.

Table 4: Post-operative Line of treatment

Image 1: Day 0 - Before I & D (left sided perianal abscess)

Image 2: Day 0 - Before I & D (Right sided perianal abscess)

Image 7: Yahtimadhu-Lajjalu Tail:

Image 8: Yashtimadhu-Lajjalu Tail dressing:

Figure 1: of right & left ischiorectal abscess & post-op dressing with Ayurvedic Approach:

Follow Up Images:

Figure 2: Follow up after 1 week (Healthy Granulation tissue)

Figure 3: Follow up after 2 weeks (collapse of cavity)

Result

The wound in this case was successfully managed using an Ayurvedic protocol involving meticulous wound care combined with herbal formulations. Specifically, Nimb Patol Erandmool Kwath was utilized for wound cleansing (Vrana Dhavan), owing to its established anti-inflammatory, antioxidant, antimicrobial, and cleansing properties. This was followed by the topical application of Yashtimadhu-Lajjalu Taila to promote wound healing.

Clinical Observations

1. Granulation Tissue Formation:

Healthy granulation tissue began forming within a few days of initiating treatment, indicating active tissue repair and regeneration.

2. Wound Size and Depth Reduction:

A progressive reduction in wound size and depth was observed over a period of four weeks.

The patient also exhibited improved mobility and was able to resume daily activities without any post-treatment complications.

Discussion

In present case, patient was diagnosed with bilateral ischiorectal abscesses without any interconnecting tract between them. Bilateral abscess formation, though not uncommon, may evolve into horseshoe-shaped abscesses, which pose a greater therapeutic challenge due to their deep anatomical extension, higher recurrence rate, and risk of fistula-in-ano development.^[11] The objective of this study was to evaluate role of Ayurvedic interventions in managing postoperative complications associated with bilateral ischiorectal abscess, in line with principles described in classical Ayurvedic texts. Anorectal abscesses are primarily classified into five types: perianal (60%), ischio-rectal (30%), intersphincteric (5%), supralevator (4%), and submucosal (1%).^[12] These infections originate in anal cryptoglandular epithelium, sprea-ding along anatomical fascial planes. In ischiorectal abscesses, pathogenic organisms breach internal anal sphincter and propagate through ischiorectal fossa, a space composed of loose connective tissue, allowing extensive infection spread.^[13]

The standard modern medical approach involves incision and drainage under anaesthesia followed by healing by secondary intention. Antibiotic therapy is typically reserved for patients with systemic signs of infection or underlying immunosuppression.^[14] However, such wounds often exhibit delayed healing and recurrence. Thus, integrative approaches that enhance granulation, reduce microbial burden, and modulate local immunity are desirable.

In Ayurvedic pathology, the condition is closely related to Antarbahya Vidradhi, with Guda Vidradhi described as an internal variety. Classical management involves Bhedana (incision) and Visravana (drainage) followed by wound care with herbal formulations possessing Shodhana (cleansing) and Ropana (healing) properties.^[15]

In this case, treatment was executed in phased manner:

During the Pachyamanavastha (immature stage), the patient was managed conservatively with antibiotics and Magnesium sulfate dressing to reduce local inflammation and induration.

Notably, no adverse events such as hypersensitivity, irritation, or delayed healing were observed throughout the postoperative period, highlighting the biocompatibility and therapeutic efficacy of Ayurvedic formulations when used in a structured, evidence-informed manner.

Conclusion

The successful management of ischiorectal abscess through integrated Ayurvedic interventions highlights the potential of classical wound care principles described in ancient texts like the Sushruta Samhita and Charaka Samhita. While modern surgical drainage addresses the acute suppurative pathology, the postoperative wound remains vulnerable to delayed healing and chronic complications. In such scenarios, Ayurvedic management serves as a complementary strategy, offering holistic wound care by promoting Shodhana (cleansing), Ropana (healing), and Dhatu Poshana (tissue nourishment). In this case, postoperative use of Nimba-Patol-Erandmool Kwatha for Vrana Dhavana and local application of Yashtimadhu-Lajjalu Tail provided favourable outcomes in terms of wound contraction, granulation tissue formation, and prevention of infection recurrence—without any adverse effects. These formulations, supported by both Ayurvedic textual evidence and modern pharmacological validation, offer a safe and effective approach for wound management, especially in high-risk or recurrent abscess.

This case supports the view of Sushruta who emphasized that "Shuddha Vrana (clean wound) heals spontaneously with proper treatment, just as a well-watered seed grows by itself" (Su. Chi. 1/71). Furthermore, the pharmacodynamic actions described under Tikta-Kashaya Rasa, Ushna-Virya, and Lekhana-Ropana Guna contributed significantly to the healing cascade. These interventions, grounded in Tridosha balancing and tissue-level rejuvenation, reflect the unique strength of Ayurveda in surgical convalescence. Thus, structured integration of Ayurvedic principles in post-surgical wound care can provide enhanced healing outcomes, reduce complications, and potentially minimize the recurrence of conditions like fistula-in-ano or chronic sinuses. Further randomized controlled trials and pharmacological studies are warranted to explore these results on a larger scale.