Pilonidal Cyst (Sinus Pilonidalis)

The term coccyx fistula is misleading. It is purely a skin disease without any involvement of the bones. Pilonidal sinus occurs mainly in young men. The condition is probably caused by hairs kinking and slowly drilling into the skin between the buttocks.

A (fistulous) tract forms around these hairs, which can lead to chronic inflammation. In the acute stage, an accumulation of pus (abscess) occurs, which either bursts spontaneously or has to be opened surgically.

The accumulation of pus always requires surgical treatment, so antibiotics should not be prescribed. 

However, pus formation does not always have to be present. The resulting duct (fistula, porus) usually remains open and “sucks” in new hair, so that the disease continues to progress.

The word pilonidal sinus is made up of the Latin words “pilus” for hair and “nidus” for nest, which translates as hair nest. 

The disease has typical symptoms and skin changes. It is a visual diagnosis in the hands of the specialist. In rare cases, an ultrasound can supplement an examination; further imaging is not necessary except in the case of recurrences. 

• Openings in the midline (pits): These are found in the midline of the gluteal fold at intervals of a few millimeters. In some cases, hair or hair cell material can be pulled out. Pus appears in the case of infection.
• Pain or feeling of pressure: The chronic inflammation causes scar material to form or, in acute cases, pus. Both lead to swelling, which causes pressure or pain on a hard surface.
• Secretion: discharge of pus in the case of abscesses and orange-colored secretion in the case of chronic irritation.
• Displacement of the butt crease: In the case of larger findings, the buttocks may shift due to the swelling

• The asymptomatic form, which is an incidental finding and causes no symptoms. No treatment is necessary, but can develop into the acute or chronic form.
• The acutely inflamed form with pain, swelling and pus. No antibiotics, immediate treatment with lateral incision and drainage of the pus. Surgery may be planned after several weeks.
• The chronic form with mild symptoms such as a feeling of pressure and fluid secretion. Surgery is always advisable as there is no spontaneous healing. Surgical procedure according to findings.

The sinus usually contains cell debris (detritus), hair and scarred tissue (fistula cavity). These are signs of a chronic reaction of the body to the hair in the subcutaneous fatty tissue, which it regards as a foreign body and attempts to remove or seal off by means of an inflammatory reaction (foreign body granuloma). As there is no spontaneous healing, the body is only partially successful in this endeavor.

The accumulation of pus always involves surgical treatment, so antibiotics should not be prescribed. However, pus formation does not always have to be present. The resulting duct (fistula, porus) usually remains open and “sucks” in new hair, so that the disease continues to progress. This explains why soldiers are often affected, where the disease is best described: long periods of marching in unhygienic conditions encourage the hair to burrow into the skin.

In Germany, 48 out of every 100,000 inhabitants (2012) suffer from coccyx fistula, with an increasing trend. The risk factors for the disease are sometimes very controversially discussed. The following, for example, are of greater significance in the development of the disease

• Increased hairiness in the buttock region with strong, longer hair. Most of our patients showed this finding. However, there are also women with the disease who have very little hair and often have a light skin type.
• Young men between the ages of 20 and 40. This group is affected more than twice as often as women.
• Heredity: Children of a parent with pilonidal sinus have an increased risk of developing the disease
• Sedentary work: There are several speculations about this, which could also explain the increase in the disease, as most people have sedentary jobs.
• Hormonal in women with an elevated serum prolactin level
• Lack of hygiene: Is not currently a risk factor, but in our own experience, it favors the development and recurrence of the disease after operations.
• Smoking: Also not a proven risk factor, but we know that nicotine reduces microcirculation and leads to poorer wound healing, so it is better to leave it out.

The only proven prophylaxis is regular anal hygiene and refraining from smoking.

There is no scientific proof of the effectiveness of hair removal in the affected buttock area using laser (epilation), but where there are no hair cells, no hair can grow in. Therefore, the costs are not covered by statutory health insurance. Hair removal by shaving should be avoided, as the disease is more likely to recur (recurrence).

If you have short hair, it is advisable to rinse the anal region thoroughly with water after a visit to the hairdresser, as hair from the neck can accumulate here and migrate into the anal fold.

It does not always have to be a pilonidal sinus, even if this is the most common disease in the gluteal fold. 

Acne inversa (hidradenitis suppurativa) should also be considered as a differential diagnosis. This is a skin disease of the sebaceous glands and hair root glands, which leads to small but painful inflammations and has a tendency to form extensive small ducts (fistulas) in a chronic course.

An Anal Fistula must always be ruled out in the case of findings near the sphincter muscle. These originate in the anal canal (rectum) and require a completely different surgical strategy.

Often, however, only the uppermost layer of skin (epidermis) is affected. These are often small tears (rhagades) or the development of Psoriasis, both of which are not treated surgically.

Treatment of a pilonidal sinus is always surgical and antibiotic therapy is not indicated. A simple sentence that actually explains everything. However, when patients are sent to a surgeon or a neighboring hospital by their family doctor, a large excision is usually recommended, which is better known to patients as the “butcher method”. The shock is profound.

This is a simple, inexpensive and quick operation with a low recurrence rate, which any surgeon can perform and which is still recommended in the guidelines. 

The only problem is the long wound healing time, which is given as 6 weeks (as I used to do), after which the wound is closed. Unfortunately, this is not the case and we have many patients in our practice after external surgery who still have an open wound after 6-12 months with understandable physical and psychological problems for the (often young) patients.

We have therefore thought about what alternatives there are and specialized in minimally invasive therapy procedures in the treatment of the pilonidal sinus 10 years ago. 

Minimally invasive procedures are operations that do not involve cutting out a large amount of tissue and can be performed under outpatient conditions. 

Due to the small wounds, these operations are associated with less pain, faster wound healing and significantly shorter absence from work or school.

You are welcome to book an appointment with our doctors. 

We look forward to hearing from you.

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