This document presents the case of a 35-year-old male street vendor presenting with a 15-year history of pain and foul-smelling discharge from the low back region between the buttocks. On examination, multiple interconnected sinus tracts were found in the natal cleft with tufts of hair and blood-mixed pus discharge. The patient was diagnosed with a pilonidal sinus. He underwent primary threading followed by weekly Apamarga kshara sutra ligations, which resulted in the gradual healing of the sinus tracts over 6 weeks of treatment. Follow up was advised every two weeks for 6 months to monitor for recurrence.

1. 1
WELCOME

2. CASE PRESENTATION
2
DR NEHARU MANDOLI
BAMS, MS, FRHS, D,Pharma
Surgeon, Proctologist
Assisstant professor
Dept of PG studies in Shalyatantra
Shri Kalabyraveshwara Swamy Ayurvedic Medical
College and Hospital, Vijayanagar, Bangalore 104

3. ATURA PARICHAYA:
Name- Mr. XYZ
Age/Sex – 35 years/ male
Occupation – Street Vendor
Religion – Muslim
Marital status – Married
Address – Shyamanna garden, Bangalore
DOC – 01/04/2015
OPD No – C 8896
Source of data- Patient
Socio economic status – Lower economic status
Education – 7th standard
CASE TAKEN ON- 13/05/2015
3

4. PRADHANA VEDANA:
Pain and foul smelling discharge from low back region
between the buttocks since 15 years.
4

5. ANUBANDHA VEDANA
• Nothing significant

6. 6
VEDANA VRUTTANTA:
• The patient was apparently normal before15 years. Then gradually he noticed
mild swelling at natal cleft with intermittent dull aching pain which was there
for 6 days . Later he noticed foul smelling pus discharge associated with mild
itching in that area . He used to feel discomfort in this region during sitting and
bending. He neglected it even though it used to interfere with his daily
activities.
Whenever there was little injury to the area, pain and bleeding was noticed for
which he consulted a local physician to get rid of pain.

7. • Two years before again he noticed mild swelling at right side of natal cleft with
intermittent dull aching pain which was there for one week followed by foul
smelling pus discharge. Symptoms used to aggravate by travelling on his bike
and profuse sweating. when the pain and foul smelling blood mixed pus
discharge increased considerably, the local physician advised him to consult at
higher center. So he approached Shalyatantra OPD in SKAMCH & RC.

8. 8
PURVA VYADHI VRUTTANTA:
No H/O any other illness.

9. KAUTUMBIKA VRUTTANTA:
No H/O of similar complaints in the family .
9

10. 10
VRUTTI VRUTTANTA:
Working as a Street Vendor, he pushes heavy cart from morning 9am
to 6 pm.
Travelling on his bike for 05-08 kms daily

11. VAYAKTIKA VRUTTANTA:
• Diet – Mixed
• Sleep – Undisturbed
• Bowel – 1 – 2 times per day,
• Micturition – 3-4 times per day.
• Habit - tea twice a day.
• Addiction - Nil
11

12. SAMANYA PAREEKSHA:
 Built Moderately.
 Nourishment- Moderately nourished
 Pallor – Absent
 Edema - Absent
 Cyanosis - Absent
 Clubbing - Absent
 Icterus - Absent
 Lymphadenopathy - Absent
12

13. • B.P - 110/80 mm of Hg
• Pulse- 74/min, regular
• R.R - 19/min, regular
• Temperature - Afebrile
• Wt- 72kgs
• Ht- 166 cms

14. ASHTASTHANA PAREEKSHA:
1. नाडी - 74/min
2. मूत्र - 3-4 times per day
3. मल – 1-2 times per day
4. जिह्व - Alipta
5. शब्द – Prakrutha
6. स्पशश – Prakruta
7. दृक् - Prakrutha
8. आकृ ति - Madhyama
14

15. DASHAVIDHA PAREEKSHA:
1. 1) प्रक्रु ति – Vatha kaphaja
2. 2) ववक्रु ति – Madhyama
3. 3) सार – Madhyama
4. 4) संहनन - Madhyama
5. 5) सात्म्य – Pravara
6. 6) प्रमाण - Madhyama
7. 7) सत्मव - Madhyama
8. 8) आहारशजति :Abyavaharana shakti - Madhyama,
9. Jarana shakti - Madhyama
10.9) व्यायाम शजति - Madhyama
11.10) वय - Madhyama
15

16. SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM
• Inspection: Bilaterally symmetrical.
• Palpation: Trachea-centrally placed
• Percussion: Resonant sound heard except the area of
cardiac dullness.
• Auscultation : Normal vesicular breath sounds.
CARDIOVASCULAR SYSTEM
• S1 S2 heard,
• No Murmurs.
16

17. GASTRO INTESTINAL SYSTEM
• ABDOMEN
Inspection – Umbilicus is centrally placed
• Palpation – Tenderness absent
• Percussion – Tympanic sound heard
• Auscultation – Bowel sounds (++)
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18. ANO RECTAL EXAMINATION:
INSPECTION –
• No signs of inflammation around the anus
• No external pile mass or sentinel pile mass
• No external opening in the peri-anal region
PALPATION –
No tenderness in the perianal region.
DIGITAL EXAMINATION
Sphinchter tone- normal
No spinchter spasm
18

19. P2
S1
S2
S3
S4
P1
Anus
Imaginary vertical line
NATAL CLEFT
INSPECTION
1) Number of sinus
6 Sinuses
2) Position of sinus
2 Primary openings in the midline of
natal cleft just above the buttocks.
4 Secondary openings seen right
laterally.
3) Opening of the sinus
Presence of tuft of hairs seen
Margin – normal.
STHANIKA PAREEKSHA:

20. 4) Discharge
Pus discharge present
5) Surrounding Skin
Inflammation - present.
Scars – Absent
7) Smell
Foul smelling discharge.
20

21. PALPATION:
1. Tenderness Present
2. Mobility Present
3. Lump Absent in the surrounding area
21

22. SINUS PROBING:
• Position: Knee elbow position
• Painting done with Betadine solution.
• Xylocaine gel applied on the probe and around the sinus.
• Probe was introduced in the primary sinus in the middle line.
• Then probe was introduced from primary sinus in to the secondary sinus.
Findings:
1. Two primary sinuses were inter connected with a depth of 2cms directed
downwards.
2. The secondary sinuses right laterally were connected to the primary sinuses
and inter connected with each other.
3. There was blood mixed pus and hair on withdrawal of the probe.
22
Knee elbow position

23. FINDINGS ON PROBING:
P2
S1
S2
S3
S4
P1
P = Primary sinus
S = Secondary sinus
P1- P2 interconnected
P1- S1interconnected
P2-S4 interconnected
S1-S2interconnected
S3-S4interconnected Anus
Imaginary vertical line

24. PRAYOGASHALA PAREEKSHA:
11/04/2015
• Haemoglobin – 15.9 Gms%
• RBS- 118 mg/dl
• HIV 1 & 2 – Non reactive
• HBsAg – Non reactive
24

25. NIDANA PANCHAKA:
तनदान
• Ati sweda
• Ashuchitwa
• Ati roma
• Ati Yaana
• Bhaara harana
पूवशरूप
• Ruja and kandu
रूप
• Ruja
• Rakta mishrita durgandhayukta puya srava
25

26. SAMPRAPTI:
Due to Ati sweda, ashuchitwa, ati roma, ati yaana, bhaara harana
Tridosh vikriti
Sopha
Pakwa sopha & prachura puya srava
Incomplete drainage of puya
Puya abyantaram pravishyati
Atimatra gamanat
Nadi vrana 26

27. SAMPRAPTI GHATAKA:
दोष tridosha
दूष्य Twak, Rakta, mamsa
अजनन Rasa, Rakta and Mamsa
dhatwagni
स्रोिस् Rasavaha, Raktavaha,
Mamsavaha,
स्रोिोदुजष्ि Sanga,vimarga gamana
व्यतिस्थान Kati pradesha
अधिष्ठान Twak, Mamsa
रोगमागश Bahya
साध्यासाध्यि Kashta sadhya
27

28. VYAVACHEDAKA NIDANA:
INCLUDED EXCLUDED
OSTEOMYLITIS OF
COCCYX:
• Tract at midline of
natal cleft just above
the buttocks.
• pain
• Pus discharge
• Sinus is mobile
• No sequestrum on
probe
FISTULA IN ANO: • Opening with pain
and discharge at just
above the buttocks.
• No internal opening
felt on P/R
examination

29. PILONIDAL SINUS:
INCLUDED AND
DIAGNOSED
• Tract at midline of natal cleft just
above the buttocks with
secondary sinus openings at right
laterally.
• With pain and
• foul discharge
• O/E tuft of hair at opening of the
sinus

30. INCLUDED EXCLUDED
UNMARGI
BHAGANDHARA:
• Due to Shalya
• H/O Kshata
• Presence of pidaka
with puya rudhira
srava
• Asthi Shalya at nadi
• No vata mutra
purisha srava
KAPHAJA VIDRADHI: • H/O Shotha
• Sheeta
• Chirottana prapak
• Sakandu
• H/O Kshata
• Absence of baala
• Na nadivat bahati

31. SHALYAJA NADIVRANA:
INCLUDED AND DIAGNOSED
• Rakta mishrita Puya srava
• Sahasa saruja sa nityam
• Sankandu
• Presence of baala as a
shalya
• H/O Kshata
• Nadivat bahati

32. VYADHI VINISHCHAYA:
• SHALYAJA NADI VRANA
• PILONIDAL SINUS
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33. CHIKITSA :
01/04/2015
Primary threading was done
under Aseptic precaution
Orally
1. Triphala Guggulu 2-0-2 for 1month
2. Gandhaka rasayana 2-0-2
with milk after food
4/04/2015
• Apamarga kshara sutra ligation
under Aseptic precaution P2
S1
S2
S3
S4
P1
Anus
Imaginary vertical line
Kshara sutra

34. • Regular Shaving of the area
• Maintain hygiene
• Rest
• Avoid -Bike riding During treatment
-Strenuous work
• Changing Apamarga kshara sutra once a week.

35. PATHYA:
• More of vegetables
• Laghu ahara
• Liquids
APATHYA:
• Spicy, oily, deep
fried
• Non veg food

36. 01/04/2015 1. Primary threading under
aseptic precaution
2. Triphala Guggulu 2-0-2
3. Gandhaka rasayana 2-0-2
Tuft of hair seen
Burning pain with blood
mixed pus discharge.
04/04/2015 Apamarga kshara sutra ligation
under Aseptic precaution.
Tuft of hair less than
previously seen
Burning pain with pus
discharge noticed
08/04/2015 c/o pain and discharge from tract.
Pus discharge was cleaned
and advise to continue same
Tuft of hair seen
DATE TREATMENT OUTCOME

37. 11/04/2015 Apamarga kshara sutra changed
under Aseptic precaution
Tuft of hair not seen
Burning pain with mild
pus discharge noticed.
18/04/2015 Apamarga kshara sutra changed
under Aseptic precaution
P1 and P2 Primary tracts
Were opened
Mild burning pain and
pus discharge reduced
29/04/2015 Apamarga kshara sutra changed
under Aseptic precaution
Mild Burning pain with
pus discharge
DATE TREATMENT OUTCOME

38. 06/05/2015 Apamarga kshara sutra
changed under Aseptic
precaution
Mild burning pain and pus
discharge absent
13/05/2015 Apamarga kshara sutra
changed under Aseptic
precaution
Burning pain with
pus discharge absent
20/05/2015 Dressing with Jatyadi taila S3-S4 S1 and S2 tracts were
opened
pain and pus discharge
absent
DATE TREATMENT OUTCOME

39. COURSE OF HEALING:
39
11/04/15

40. 18/04/2015

41. 13/05/2015

42. 20/052015

43. FOLLOW UP:
• Regular Shaving of the area
• maintain hygiene
• Rest,
• Avoid -Bike riding
-Strenuous work
• Once in every two weeksto observe healed tract for any recurrence
till 6 months.

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