Undiagnosed Sacrococcygeal Fistulas: A Case Report

The clinical presentation of fistulas can include persistent drainage, pain or swelling. In the perianal, gluteal and sacrococcygeal areas, differential diagnosis may include perianal fistula, malignancy, inflammatory bowel disease or pilonidal disease. Lack of treatment can lead to disease progression. Patient appraisal of symptoms plays an important role in clinical outcomes, a role possibly shared with the shame of exposing symptoms. A behavior of avoidance and withholding of information can directly impact clinical outcomes by not seeking medical help and delays in treatment. This case describes a 74-year-old man who, during a routine visit, reports complaints of purulent drainage in the sacrococcygeal region. This complaint was more than fifty years old and had been undervalued until now, according to the patient, because it lacked significant symptoms and the embarrassment of exposing the condition. The symptoms worsened in the previous two weeks, leading him to report the complaints. On physical examination, extensive fistulous disease in the sacrococcygeal region with purulent discharge was observed. Antibiotic therapy was started (amoxicillin and clavulanic acid - 875 mg plus 125 mg every 12 hours), given the worsening of symptoms described. The patient was referred to a surgical consultation where antibiotic therapy with metronidazole (500 mg every 12 hours) was added, and a targeted workup was performed but proved non-definitive. After considering the risks and benefits of an intervention, the patient opted for a non-invasive expectant attitude, preserving his autonomy in medical decisions.