A Pilonidal sinus also called Pilonidal cyst, Pilonidal abcess or Sacrococcygeal fistula is a cyst ( small sac ) or tunnel in the skin. It develops over the tailbone at the top of the cleft of the buttocks. The cyst usually contains hair and skin debris. More than one cyst may develop and these are linked by tunnels under the skin.
Causes Of Pilonidal sinus
More common in males
People who sit for long hours at a stretch eg. Drivers
Thick body hair especially those that are coarse and curly
Previous injury in the area
Family history of Pilonidal sinus
Having a deep cleft between buttocks
History of previous Pilonidal cyst
Symptoms Of Pilonidal sinus
Recurring episodes of pain or swelling in the area of the tailbone.
Yellowish pus-like or bloody discharge from the tailbone area which may be foul smelling
Painful lump under the skin in that area
Certain activities like riding a bicycle, doing sit-ups may be very uncomfortable.
Diagnosis Of Pilonidal Sinus
A history of your symptoms followed by a visual examination of the tailbone area is enough to diagnose a Pilonidal sinus.
No treatment is necessary in case of a Pilonidal sinus that lies dormant, which means it is not infected. In this silent phase, certain precautions are advised which may abate the chances of infection and thereby, the need for a surgery.
Following care should be taken :
Keep the area as clean and dry as possible.
Avoid sitting in one place for too long, avoid driving for long hours.
Remove hair from the area using a razor or hair removal cream. You could see a dermatologist ( skin specialist ) and consider permanent hair removal with Laser.
If there is pain or discharge from the Pilonidal sinus, it spells infection and surgery is likely to be needed.
LEARN MORE ABOUT YOUR TREATMENT
I. WIDE EXCISION OF PILONIDAL SINUS
In this procedure the surgeon does a wide bore local excision of the skin containing the sinus tract. The resulting cavity is left open to heal and fill in naturally from the bottom upwards. The wound is kept covered with a dressing.
The disadvantage of wide excision is that the wound size is large and healing may take upto 3 months. The dressing needs to be changed daily making it a tedious process. However the procedure is safe with a recurrence rate of 10-15%.
II. LASER PILONIDOPLASTY ( LPP )
This is a minimally invasive procedure done using the Leonardo laser. This laser was first introduced in India by Dr. Ashwin Porwal at Healing Hands Clinic. In LPP, a small cut is made on the skin and all the pus is drained out. The entire sinus tract is then sealed with the laser fibre.
Advantages of LHP
Patient is discharged within 24 hours and can return to routine work by the 5th day.
Wound healing occurs in about 6-8 weeks and thus recovery is much faster as compared to conventional Wide excision.
Recurrence rate is negligible.
III. EXCISION WITH PRIMARY CLOSURE
In this procedure, the abscess and sinus are surgically removed and the wound is closed with stitches/sutures. The stitch line is preferably off the midline, where the tension is less and chances of healing are better. The advantage of this technique is that the healing is faster and takes about 4-6 weeks. The main drawback is that the infection rate is almost 20-25%. In case of such an infection a revision procedure is done and the wound is left for open healing anyways.
In Z-plasty after removing the abscess and sinus, the surgeon loosens triangular flaps on each side of the midline to fill the cavity, with points of flap towards the head and foot. While closing the surgeon crosses the pointed flaps to cross the midline in a horizontal direction, thus converting an N-shaped incision to a Z-shaped closure. Z-plasty is not a preferred choice of treatment because :
The chances of recurrence are very high.
Flap necrosis may occur in which case the dead portion of the flap also has to be removed.
The post-operative pain and discomfort is very high.
V. CLEFT LIFT / MODIFIED KARYADAKIS / CLEFT CLOSURE
In this procedure the surgeon removes all the area of disease and makes sure the wound is healthy. The resultant defect, a football shaped 'ellipse' or cavity, lies parallel to the midline but to one side. The edges of the skin are then freed up a little and the wound is closed with multi-layered stitches. In cleft lift, the actual shape of the cleft is changed to be more shallow and allow for better healing. By almost flattening the cleft, the gathering of loose hair is less likely, and the less deep cleft does not favour the growth of anaerobic bacteria.
VI. LIMBERG FLAP / GLUTEAL FLAP
This procedure is done in patients who have extensive Pilonidal disease or who have disease affecting both sides of the buttock. The surgeon removes an oblong shaped plug containing the abscess, skin and fat, thus creating a cavity. To fill the cavity, a flap of skin and thick fat is mobilised from the buttock beside and below the cavity. The flap is swung into the centre and the edges are sutured.
NOTE : The flap procedures are quite invasive and patients are hospitalised for a couple of days afterwards. The post-operative recovery time is also quite long. These surgeries remove a large amount of tissue, which destabilises the area and leave few options to the patient if they fail.
Pilonidal sinus can be a tricky condition. It is of utmost importance that you understand it well, as self care is an important aspect, especially if you have been operated upon. Following are answers to a few questions that may arise in your mind before you decide to undergo a surgery. These are general guidelines and any final decision about your health lies with your surgeon.
What do I feel during the surgery ?
Most of the surgeries for Pilonidal sinus are done under General anaesthesia. So apart from a pin-prick there is not much you will feel. After that it's just like going into deep sleep.
How do I feel immediately after the surgery?
Soon after your operation you may feel some discomfort and pain as the effect of the anaesthetic medicine wears off. However, painkillers should solve your problem. You can start having sips of water after a couple of hours, and an hour thereafter, a regular full diet can be started
When can I get back to my routine activities?
You can start walking the same day. There need not be any change in your toilet patterns. You will probably need time off work, although this depends on how you are feeling and the type of work you do. After a laser surgery you can join office work from 3rd day. If you have undergone a flap surgery or have stitches, you can join office after 2 weeks. In any case, strenuous work should be avoided for the first 2 weeksYou can start mild to moderate exercise as soon as you feel able to. However, if you have stitches, you will have to avoid activities that disrupt the stitches for upto 4 weeks
How do I ensure appropriate wound care?
Whichever the type of operation you have ( open/close ), it is extremely important to keep the site of wound clean. We will direct you on how to do this, which may include the following guidelines:
Have a bath at least once a day if you have an open wound. If your wound is closed with stitches, avoid a bath as you may be advised to keep it dry for the first few days.
When washing an open wound, do not use soap as it may irritate the skin. Use plain water instead
Use a soft cloth/towel to dry the area. Gently dab to dry, do not rub.
Do not put talcum powder.
Wear loose fitting cotton underwear.
Eat high-fibre foods to soften your stools, so you don't have to strain during defection, which may cause unnecessary straining in the wound area.
When should I seek help?
Following your operation you may need help if you have :
Excessive pain, not relieved by painkillers.
The wound area becomes red, swollen.
Fever > 38 C ( 100.4 F )
Blood, pus or fluid leaking from the wound..
Foul odour from the wound.
What is the role of permanent hair removal in preventing recurrence?
As the cause of Pilonidal sinus is excessive thick hair that breaks and gets embedded into the skin, the problem of recurrence is always looming large. The recurrence can be prevented to a large extent by using temporary methods like razors, hair removal creams etc. However, it is extremely bothersome for the patients to do this regularly, that too at a rather inaccessible area of the body. Thus, permanent hair reduction with Lasers ( Diode, Nd-YAG ) is advised to reduce hair growth and hair thickness in the area.
Pilonidal Sinus Treated with Laser Pilonidoplasty by Dr Ashwin Porwal