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Pilonidal Sinus is a common problem affecting mainly young people and more
often males. The causes have been debated but most doctors nowadays believe
that it is an acquired problem resulting from a combination of a gland
deterioration, foreign body (hair) entrapment and infection.
The location is invariably in the natal cleft (the cleavage between the two
buttocks). A pilonidal cyst is always in the midline although the sinus or sinuses
may be ending on either buttock. It is important to distinguish between a
pilonidal sinus and a peri-anal fistula, the latter lies lower and closer to the
anus and has a very different pathology and management.
The symptoms are pain, swelling, discharge of pus or bloody fluid and if left
untreated a serious abscess can occur. The abscess should preferably be
drained surgically because antibiotics have only a limited and temporary effect.
At the acute infection stage usually only a drainage of the abscess is performed
and excision of the pilonidal cyst/sinus is done at a later stage.
Excision of the pilonidal sinus is performed under a general anaesthetic and is
technically straight forward. A number of options are available:
a. excision and primary closure of the skin
b. excision leaving the skin open (secondary closure)
c. excision with partial closure of the skin
d. excision with creation of a skin flap to cover the defect
Excision with primary closure of the skin has the advantage of fast healing and
early recovery. However it often fails. This is because healing depends on a
number of factors:
a. Any wound in order to heal has to remain still for several days. This is
practically impossible with a pilonidal sinus because it lies between the buttocks
and is affected by any movement during sitting, walking etc.
b. Healing is inhibited by infection, and the anus with billions of bacteria lies
only a few centimetres away and is impossible to sterilise. Therefore
contamination of the wound by anal bacteria often occurs.
c. Healing is inhibited by tissue tension, and the position of the wound after
a pilonidal sinus operation subjects it to tension with each movement.
d. Healing is inhibited by foreign bodies. Hairs from the wound edge can
grow into the wound and cause infection and delayed healing. Hairy males have
a higher incidence of recurrence.
For all the above reasons, closing the wound primarily many times does not work
and the result is wound breakdown. In that case the wound is left to heal, a
process which can take several weeks, depending on the size of the wound and
other factors.
The complications after surgery can be:
a. bleeding
b. infection
c. wound breakdown
d. delayed healing
e. development of granulation tissue
f. recurrence
In some cases a second or a third operation is required, either to re-excise a
recurrent sinus or remove infected granulation tissue. The complication of
delayed healing can be particularly annoying for the patient.
After surgery the patient finds sitting uncomfortable and those who work in
offices need more time off work than people who work manually. If a wound has
been left open for secondary closure considerable nursing wound care is
required the first week, although after that the wound gradually improves and the
patient can have only salt baths and application of dry gauze.
Creation of a surgical “flap” (Karydakis or Z flap) is used to cover defects
which have failed to heal after pilonidal sinus surgery. Those flaps need an area
free of infection in order to succeed and require the patient to stay in hospital for
longer. They are useful in complex cases but are not applied as first line
treatment for small sinuses.
In summary the pilonidal sinus is a “simple” problem which however can create a
considerable amount of irritation and suffering. It always settles in the end but
patience may be required!
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Pilonidal Sinus