What is a Pilonidal Sinus & how does it occur?

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The natal cleft is a region of the body that is located between the buttocks in the lower back and extends towards the anus. Hair can fall into this region or grow inwards into the skin of this region. The movement of the buttocks can cause further penetration of this deeper into the skin especially where there maybe small pits or dimples in to the skin. Bacteria can be carried with this hair and result in infections forming of this area under the skin and result in pilonidal abscesses (collection of pus under the skin in this area).

 

Deep infections of the skin that fill with pus mixed with blood will naturally form a tract to the surface to expel the collection which is called a pilonidal sinus. With more complex disease over time, there maybe multiple tracts formed of area which may require more complex treatment. Symptoms result in recurrent infections requiring antibiotics, recurrent pain that relieves after discharge, recurrent discharge from a small sinus opening and larger collections requiring an incision and drainage of the abscess.

 

This condition mostly occurs in young men (1 in 100) and is less common in females. It is thought that hormones is a risk factor for the formation of some pilonidal sinuses.

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What treatment is available?

 

General Advice

 

• Depleting the natal cleft of hair: Regularly removing hair from the natal cleft with waxing or hair depleting creams will reduce the risks of hair penetrating the skin and causing infections.

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• Keeping the area clean: Regularly cleaning the pilonidal area and patting dry can keep the area clean reduce risks of infections.

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• Antibiotics: When there are signs of infection with pain, redness, swelling and little discharge, antibiotics can help.  This is extremely important to help keep your stools soft. Fibre and bran intake alone will constipate without adequate fluid intake.

 

 

Alternatives to an Operation

 

Under local anaesthetic:

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• Abscesses may be drained if small (incision and drainage and left open with packing until healed).

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• The Sinus tracts can also be brushed from within under local anaesthetic to destroy the tract and allowing healing or be filled with fibrin glue or phenol that has a similar effect.

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What happens without an operation?

 

The pilonidal disease will continue to recure and may over time become larger, cause more complex sinus tracts and sometimes cause generalised sepsis (infection spreading to the blood and rest of the body). An operation at a later time can be more extensive and have higher potential complication rates.

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What does an Operation Involve?

 

Sometimes your specialist may suggest an operation. This is usually done under a general anaesthesia (where you are asleep) but the best options will be discussed with the anaesthetist.  Depending on the extent of the pilonidal disease, there are different operations that are available. Each patient is individual and therefore assessment and treatments will vary depending on each patient. Some are outlined below:

 

• Wide excision:  If the pilonidal area is infected of unhealthy at the time of the operation, the area is excised under a general anaesthetic and left open with packing of material that will need to be regularly changed. This reduces the recurrence rate allowing infected fluids to drain and healing to occur from the deeper surfaces working its way more superficially until healed.

 

• Excision and Primary Closure: The pilonidal sinus, midline pits/dimples and unhealthy-looking tissue is removed. An unmined flap is created and the skin is closed ‘off-centre’ to reduce recurrence rates. As the skin is closed, there is a high infection rate after this operation and wound breakdown that will require packing. Drains may be inserted to prevent collections from forming under the skin.

 

 

• Excision and Skin Flap Reconstruction: If there is a wider and more extensive disease of the pilonidal area, a wider excision and a skin flap is created to fill the defect. Drains will be inserted to prevent collections from forming under the skin.

 

• EPSiT (Endoscopic Pilonidal Sinus Treatment): This is a procedure with approximately an 80% success rate with some cases. An endoscope (telescope) is inserted into the sinus tract once asleep under a general anaesthetic. The tract is then destroyed with cauterisation then brushed. Hair is also removed from this site. This can avoid a major operation.

 

 

Before the operation ensure you tell your specialist and anaesthetist about all medication you take. You will usually also have a pre-assessment appointment to ensure you are optimised before your surgery.

 

General recommendations for all operation is to reduce or stop smoking as this decreases complications of wound infections, breakdown, chest infections and longer term health problems. Regularly exercising even leading up to your operation has shown to improve on outcomes post-operatively by leading to better ‘pre-habilitation’.

 

On the day operation day.  The procedure is usually done as a day case procedure and therefore be admitted and discharged from the hospital on the same day. After the anaesthetic, you will be given local anaesthetic to help with any pain post-operatively and may be given antibiotics.

 

 

Potential Complications

 

Complications can be both general for any operation and specific for the particular procedure.

Complications are rare but all of the potential ones are listed below.  Your specialist will be able to go over specific ones with you.

 

General Complications:

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• Pain: Local anaesthetics at the time of the operation will be given and you should take regular pain killers after the procedure.

• Bleeding: Bleeding can happen during or after the operation and is more common if the wound is left open. If closed, then a lump can form under the skin (haematoma) with a risk of around 3 in 50 people. This may require draining if infected.  

• Infections: This usually causes a high temperature, and possible pus from the operation site.

• Blood clots in the legs or lungs: Keeping mobile is important to prevent this along with the use of TED stockings.

 

Specific Complications:

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• Partial Wound Breakdown: This is relatively common if the wound is closed with stitches and higher in around 50% (1 in 2 people) if infected at the time. The wound will then need to be packed.

• Slow healing: If the wound is packed then healing can take up to 8 weeks and sometimes longer.

• Numbness: One in 9 people can develop numbness of this area which may start to resolve over time.

• Recurrence: This can be reduced by using the recommendations above under general advice for management of pilonidal sinuses. Recurrence is around 1 in 9 people.

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Recovery from the Operation

 

Following the operation, you will be wake up in recovery and usually go home the same day. You will require a responsible adult to be with you at home for the first 24hours and have access to a telephone in case you help or advice is required. It is important to continue to take regular pain killers. You may also be given antibiotics following your operation.

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Activities following surgery

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For the first 24 hours following a general anaesthetic or sedation, do not drive, operative machinery, carryout dangerous activities, drink alcohol or sign legal paperwork. You can usually start driving once you can control and make an emergency stop. Ensure you are comfortable to drive before starting.  It is important to be mobile to avoid blood clots and may need to wear stockings to prevent these. Depending on the procedure and on the type of work you do, you can usually return within 3-6 weeks. You may require some time off for packing/dressing changes if the wound is open or partially open.

Regular exercise once your wound has healed will help you to return to normal activities.

 

You will usually have a follow-up after you operation between 4-12 weeks depending on the operation carried out.