Pilonidal sinus

Question 1

What is a pilonidal sinus?

Answer 1

• Disease of intergluteal region
• Formation of sinus in the cleft of the buttocks
• Most common males 16-30yrs

Question 2

Theory of formation of pilonidal sinus

Answer 2

• Hair follicle in intergluteal cleft
• Becomes inflamed/infected
• = obstruction to opening of the follicle
• Follicle then extends inwards forming a pit instead
• Foreign body type reaction may then lead to formation of cavity connected to surface of skin via epithelialised sinus tract
• These fluid filled cavities will often discharge serous fluid and can periodically become acutely infected forming abscess

Question 3

RF for pilonidal sinus

Answer 3

• Caucasian male
• Coarse dark body hair
• Sit for prolonged periods eg lorry drivers or office workers

Others: increased sweating, buttock friction, poor hygiene

Question 4

Symptoms of pilonidal sinus

Answer 4

• Discharging and intermittently painful sinus in sacrococcygyeal region
• Discharge is episodic and serous - but can become bloody or purulent on occasion

Question 5

What is a pilonidal abscess?

Answer 5

• When pilonidal sinus becomes infected
• Presents as swollen and erythematous
• Fluctuant and tender mass
• Systemic features of infection

Question 6

Pilonidal disease vs perianal disease

Answer 6

• Pilonidal disease lying low can be difficult to distinguish between perianal fistula
• Protoscopy and MRI need to be used for assessment

Question 7

Investigations for pilonidal sinus

Answer 7

• Diagnosed and managed without investigations
• If extensive or complex - multi pit or previous surgery, can do MRI scarum to help operation planning

Question 8

Conservative treatment pilonidal sinus

Answer 8

• Removing hair of affected region - ideally with hair removal cream
• Keep area clean whenever possible

Question 9

Management pilonidal abscess

Answer 9

• Incision and drainage +/- washout +/- packing
• Elective surgery can then be performed at later date if patient remains symptomatic

Question 10

Elective surgical management pilonidal sinus

Answer 10

• Excision and laying open or excision and primary closure (Karydakis procedure) - uncomplicated simple disease
• Excision and advancement flaps (eg V-Y flap) or excision and rotational flaps (eg Limberg flap) - advanced disease
• Newer approaches are endoscopic pilonidal sinus treatment - cauterisation and cleaning