# Undiagnosed Sacrococcygeal Fistulas: A Case Report

## TL;DR

A 74-year-old man with a long-standing sacrococcygeal fistula sought treatment after symptoms worsened, highlighting the impact of delayed care due to embarrassment.

## Contribution

This case emphasizes the role of patient behavior and embarrassment in delaying treatment for chronic fistulas.

## Key findings

- The patient's long-standing sacrococcygeal fistula was undiagnosed for over fifty years due to lack of significant symptoms and embarrassment.
- Antibiotic therapy was initiated, but a non-invasive approach was chosen after a targeted workup proved non-definitive.
- The patient's decision to avoid surgery highlights the importance of autonomy in medical decision-making.

## Abstract

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.