History

Fact Explanation
Painful swelling A pilonidal cyst, also referred to as a pilonidal abscess, pilonidal sinus or sacrococcygeal fistula, is a cyst or abscess near or on the natal cleft of the buttocks that often contains hair and skin debris. The exact cause of a pilonidal sinus is unclear, although it is thought to be caused by loose hair piercing the skin which may trigger an inflammatory response to form an abscess. Patients usually presents with an swelling in the cleft of the buttocks. The swelling is painful, tender, warm and reddish. Though the usual site is the skin of the natal clefts, cleft between the fingers, axilla, at the umbilicus, in the perineum or the sole of the foot as well as on the amputation stumps may also be affected. [1,2,3,4]
Discharge Spontaneous drainage might have occurred prior to presentation. The discharge is foul smelling and purulent in color. A pilonidal cyst/ abscess is usually painful, but with draining, the patient might not feel pain. [2,3,4,5]
Past history of similar events Pilonidal abscesses are usually recurrent. The patient may mention that a similar lesion occurred in that area before. [1,4,5]
At risk population Usually the young adult males are affected. It is more common among the dark haired individuals. They are an occupational disease in barbers, in whom sinuses occur in the clefts between the fingers. Individuals with coarse, curly or crinkly hair, obesity, family predisposition, poor hygiene and prolonged sitting or buttock friction causing increased sweating are predisposing. [2,3,4,5]
Commonly observed among young adults It occurs after puberty, since during that period the pilosebaceous gland affected by sex hormones influence growth of healthy body hair. The disease is rare in after 40 years.
References
  1. VARNALIDIS I, IOANNIDIS O, PARASKEVAS G, PAPAPOSTOLOU D, MALAKOZIS SG, GATZOS S, TSIGKRIKI L, NTOUMPARA M, PAPADOPOULOU A, MAKRANTONAKIS A, MAKRANTONAKIS N. Pilonidal sinus: a comparative study of treatment methods. J Med Life [online] 2014 Mar 15, 7(1):27-30 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24653753
  2. KHANNA A, ROMBEAU JL. Pilonidal disease. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):46-53 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272823
  3. KITCHEN P. Pilonidal sinus - management in the primary care setting. Aust Fam Physician [online] 2010 Jun, 39(6):372-5 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20628674
  4. GORDON P, GRANT L, IRWIN T. Recurrent pilonidal sepsis. Ulster Med J [online] 2014 Jan, 83(1):10-2 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757262
  5. ONDER A, GIRGIN S, KAPAN M, TOKER M, ARIKANOGLU Z, PALANCI Y, BAC B. Pilonidal sinus disease: risk factors for postoperative complications and recurrence. Int Surg [online] 2012 Jul-Sep, 97(3):224-9 [viewed 07 August 2014] Available from: doi:10.9738/CC86.1

Examination

Fact Explanation
Abscess Patient usually present with a painful typical abscess with redness, local tenderness, warmth, and fluctuance with or without an induration. There may be tufted loose hair projecting out of it. [1,2,3]
Discharge Material from the cyst may drain through the pilonidal sinus. It is usually purulent with or without streaks of blood. [2,3,4]
Sinus tract A sinus tract, or small channel, that originates from the abscess/cyst may open to the surface of the skin. at the natal cleft. Usually there is only one one sinus opening. But there may be two at times. [3,4,5]
Surgical incisions near-by As these abscesses are usually recurring, the natal cleft area may have healed surgical incisions indicating past surgical interventions to similar episodes. [1,2]
References
  1. ONDER A, GIRGIN S, KAPAN M, TOKER M, ARIKANOGLU Z, PALANCI Y, BAC B. Pilonidal sinus disease: risk factors for postoperative complications and recurrence. Int Surg [online] 2012 Jul-Sep, 97(3):224-9 [viewed 07 August 2014] Available from: doi:10.9738/CC86.1
  2. GORDON P, GRANT L, IRWIN T. Recurrent pilonidal sepsis. Ulster Med J [online] 2014 Jan, 83(1):10-2 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757262
  3. KHANNA A, ROMBEAU JL. Pilonidal disease. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):46-53 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272823
  4. VARNALIDIS I, IOANNIDIS O, PARASKEVAS G, PAPAPOSTOLOU D, MALAKOZIS SG, GATZOS S, TSIGKRIKI L, NTOUMPARA M, PAPADOPOULOU A, MAKRANTONAKIS A, MAKRANTONAKIS N. Pilonidal sinus: a comparative study of treatment methods. J Med Life [online] 2014 Mar 15, 7(1):27-30 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24653753
  5. KITCHEN P. Pilonidal sinus - management in the primary care setting. Aust Fam Physician [online] 2010 Jun, 39(6):372-5 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20628674

Differential Diagnoses

Fact Explanation
Anal fistula Anal fistula, or fistula-in-ano, is an abnormal connection between the epithelialised surface of the anal canal and (usually) the perianal skin. Anal fistulae can present with many different symptoms such as pain, discharge and Pruritus ani. [1]
Anal fissure An anal fissure (fissure-in-ano) is a small, oval shaped tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. The typical symptoms of an anal fissure include severe pain during, and especially after, a bowel movement, lasting from several minutes to a few hours. Patients may also notice bright red blood from the anus that can be seen on the toilet paper or on the stool. [2]
Hidradenitis Suppurativa is a skin disease characterized by clusters of chronic abscesses, epidermoid cysts, sebaceous cysts, pilonidal cyst or multi localised infections that most commonly affects areas bearing apocrine sweat glands, such as the underarms, under the breasts, inner thighs, groin and buttocks. [3]
Perirectal Abscess It is an abscess adjacent to the anus, arises from an infection at one of the anal sinuses. Pain in the perianal area is the most common symptom of an anorectal abscess. The pain may be dull, aching, or throbbing. It is worst when the person sits down and right before a bowel movement. After the individual has a bowel movement, the pain usually lessens. Other signs and symptoms of anorectal abscess include constipation, drainage from the rectum, fever and chills, or a palpable mass near the anus. The condition invariably becomes extremely painful, and usually worsens over the course of just a few days. [1]
References
  1. ABCARIAN H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):14-21 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272819
  2. ZAGHIYAN KN, FLESHNER P. Anal fissure. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):22-30 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272820
  3. FERNANDES NC, FRANCO CP, LIMA CM. Hidradenitis suppurativa: retrospective study of 20 cases. An Bras Dermatol [online] 2013 May-Jun, 88(3):480-1 [viewed 07 August 2014] Available from: doi:10.1590/abd1806-4841.20131637

Management - General Measures

Fact Explanation
Prevention It is essential to educate the patients regarding prevention as pilonidal sinus tends to recur. Good hygiene in the sacrococcygeal area is critical. That area should be kept clean and dry. Shaving or using depilatory creams to keep the area free of hair is helpful. Electrolysis or laser hair removal in this area may be another option. Prolonged sitting or excessive repetitive pressure to the area of the coccyx should be avoided. Weight loss in obese individuals may also help decrease the likelihood of recurrence. [1,2,3]
References
  1. GORDON P, GRANT L, IRWIN T. Recurrent pilonidal sepsis. Ulster Med J [online] 2014 Jan, 83(1):10-2 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757262
  2. KITCHEN P. Pilonidal sinus - management in the primary care setting. Aust Fam Physician [online] 2010 Jun, 39(6):372-5 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20628674
  3. KHANNA A, ROMBEAU JL. Pilonidal disease. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):46-53 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272823

Management - Specific Treatments

Fact Explanation
Watchful waiting An asymptomatic pilonidal cyst doesn't require any treatment. The patient should be advised to keep the area clean and free of hair by shaving or using a hair removal agent every 2–3 weeks. The cyst may resolve itself. [1,2,3,4]
Primary incision and drainage If a pilonidal sinus becomes infected, it should be treated as soon as possible, as it is likely to get worse. Persistent and inflamed cysts (acute pilonidal abscess) are incised and drained out to reduce inflammation and pain. This intervention and can not reduce the recurrence rate. Rarely, a patient may require sedation but a reassurance by medical personnel is considered adequate for the procedure[1,2,3]
Excision of sinus or cysts For those individuals with recurrent, complicated, or chronic pilonidal disease, more invasive surgery may be necessary. This reduces the rate of recurrence to about 15%. Persistent, complex or recurrent pilonidal sinus disease must be treated surgically. Procedures vary from taking the roof off the sinuses to wide and deep excision. [1,3,4]
Phenol injections Phenol injection is a simple procedure requiring only a short hospital stay.Ideally, the injection should be done at a quiescent/ chronic phase and a pre-injection course of an appropriate antibiotic may be useful in some cases. [2,4,5]
Wound care and follow up Aftercare will consist of simple analgesics and diligent wound care. Once packing is removed sitz baths or cleansing the wound with warm shower water should be done 2-3 times per day and a clean dressing is applied.This should be continued until the primarily closure of the abscess cavity occurs. Keeping the wound area clean and removing any hair from around the sacrococcygeal area can help to prevent recurrence. [1,2,3,4,6]
References
  1. ONDER A, GIRGIN S, KAPAN M, TOKER M, ARIKANOGLU Z, PALANCI Y, BAC B. Pilonidal sinus disease: risk factors for postoperative complications and recurrence. Int Surg [online] 2012 Jul-Sep, 97(3):224-9 [viewed 07 August 2014] Available from: doi:10.9738/CC86.1
  2. GORDON P, GRANT L, IRWIN T. Recurrent pilonidal sepsis. Ulster Med J [online] 2014 Jan, 83(1):10-2 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24757262
  3. VARNALIDIS I, IOANNIDIS O, PARASKEVAS G, PAPAPOSTOLOU D, MALAKOZIS SG, GATZOS S, TSIGKRIKI L, NTOUMPARA M, PAPADOPOULOU A, MAKRANTONAKIS A, MAKRANTONAKIS N. Pilonidal sinus: a comparative study of treatment methods. J Med Life [online] 2014 Mar 15, 7(1):27-30 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24653753
  4. KHANNA A, ROMBEAU JL. Pilonidal disease. Clin Colon Rectal Surg [online] 2011 Mar, 24(1):46-53 [viewed 07 August 2014] Available from: doi:10.1055/s-0031-1272823
  5. KELLY SB, GRAHAM WJ. Treatment of pilonidal sinus by phenol injection. Ulster Med J [online] 1989 Apr, 58(1):56-59 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2448552
  6. KITCHEN P. Pilonidal sinus - management in the primary care setting. Aust Fam Physician [online] 2010 Jun, 39(6):372-5 [viewed 07 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20628674