13.3 Clinical Presentation
How does one recognize pilonidal disease? Look for pits. These pits represent primary and secondary openings of the pilonidal sinus. The primary opening(s) is usually located at the base of the natal cleft, roughly 5 cm above the anus, and is the opening through which hair may be observed to protrude (Fig. 13.3). There is a subcutaneous tract that forms from this primary opening, creating a sinus. The sinus(es) can vary in length and number. The pit may form tracts that create a secondary opening off the midline. These secondary openings are where spontaneous drainage or incision and drainage of an abscess occur. The pilonidal tract along with its two openings, the primary and secondary sinuses, can be visualized on the sketch in Fig. 13.2. Patients can have a single or multiple secondary openings, depending on the chronicity and complexity of the disease.
Patients can present with either an acute pilonidal abscess, a single chronic draining sinus, or a complex or recurrent pilonidal sinus [3] which are treated in different ways as will be discussed later. A pilonidal abscess usually presents as a tender, fluctuant mass with overlying cellulitis (Fig. 13.4) as opposed to a chronic draining sinus, which shows no signs of infection. A chronic sinus presents with a primary pit located in the natal cleft often with possible hair sticking out of it’s opening (Fig. 13.3).
Fig. 13.4
Pilonidal abscess
Complex and recurrent pilonidal sinuses are usually the result of persistent sinuses or multiple abscess drainages that may have more than one opening to the skin. It is important to keep in mind that other diseases such as anorectal cryptoglandular abscesses, hidradenitis, and fistulas secondary to complex presentations of Crohn’s disease can present similarly to pilonidal disease and need to be ruled out as possible differential diagnoses [8, 9]. Although pilonidal disease is not life threatening, it can be debilitating for the patient and poorly impact their quality of life. Regardless of the presentation of pilonidal disease, the ultimate goal for treatment is to decrease morbidity for the patient and to allow for quick recovery and return to daily activities.
13.4 Management of Pilonidal Abscesses
13.4.1 Case 1
A 24-year-old man presents to the emergency room complaining of “pain over their tailbone.” This is the first time he has ever felt such pain. He recalls falling on his tailbone during his speed skating practice roughly 2 weeks ago. He also mentions that he had a fever yesterday with some chills over the last 2 days. He first noticed a “lump” about a week ago but came in today to see you because he felt that it increased in size and the pain was keeping him up at night. He denies any other lower gastrointestinal symptoms or abdominal pain.
On exam, he is afebrile and his vital signs are all within normal limits. Abdominal and digital rectal exam are unremarkable. You notice an inflamed, erythematous lump at the natal cleft with no spontaneous discharge (Fig. 13.5). It is very tender and fluctuant.
Fig. 13.5
Pilonidal abscess (from Slater [9] with permission)
This is a typical presentation of a pilonidal abscess. Just as in any other clinical presentation of an abscess, this patient presents with the universal signs of erythema, pain, and cellulitis. In the case of a pilonidal abscess, the technique used to drain the abscess is important (Fig. 13.6).
Fig. 13.6
Technique for shaving (adapted from Papaconstantinou and Thomas [3], with permission)
When a patient presents with a pilonidal abscess, it is usually located lateral to the midline despite the initial sinuses being located in the midline, along the gluteal cleft. Studies have shown that the best way to drain the abscess is to make the incision off the midline [2] because this leads to better healing. A midline wound is under constant traction and vacuum forces that allow surrounding hair and bacteria to enter the wound impair wound healing [10], whereas an off-midline incision may be less likely to create this traction force. The incision is ideally made about 1 cm lateral to the midline and deepened all the way down into the cavity, to ensure that the abscess cavity is opened and pus and any other material, such as hair, can be evacuated [3] (Fig. 13.7).
Fig. 13.7
Sketch of proper incision technique for incision and drainage of a pilonidal abscess (adapted from Papaconstantinou and Thomas [3], with permission)
Once this is completed, the incision is converted to a cruciate or elliptical incision to ensure the skin and subcutaneous tissues overlying the abscess cavity do not close prematurely and lead to a recurrence of the abscess. The cavity is then copiously irrigated. A randomized control trial assessed the benefit of performing a curettage at the time of incision and drainage, and the authors found that there was a significant difference in healing at 10 weeks after the procedure and lower recurrence rates observed with curettage [11]. This is due to removal of all inflammatory debris that may impair healing and removal of all epithelialized surfaces to encourage quicker wound healing. As such, once the cavity is irrigated, a gentle curettage should be performed, followed by a light packing of the cavity (Fig. 13.8).
Fig. 13.8
Packing post incision and drainage
The act of packing a wound and removing the packing for cleansing at least once daily promotes healing; however, it can be quite painful and bothersome for the patient, which may lead to poor posttreatment compliance to wound care. For this reason some surgeons advocate that the packing be removed the following day by the patient and the cavity be washed with soap and water, preferably two to three times a day to accelerate healing [2, 3] and to help keep the area clean. If the wound is packed daily, it should be lightly packed with saline gauze to allow a good balance between keeping the wound dry and promoting the formation of granulation tissue to ensure proper healing. Any hypertrophic granulations tissue should be cauterized with silver nitrate as this will allow for adequate epithelialization to occur [2].
One very important point for the promotion of healing and prevention of recurrent disease is to ensure that hair surrounding the diseased area is shaved regularly. There should be a close follow-up, with visits scheduled every 2 weeks in order to ensure that the wound is healing well and there are no signs of recurrence [3, 11].
Although this patient presented with a history of fever and chills, incision and drainage of the abscess is sufficient to treat the infection. The role of post-drainage antibiotics has been reviewed, and there is no strong evidence to consider treating patients after drainage with antibiotics as such treatment has not been shown to improve the risk of wound complications and healing rates [11]. The only patients for whom post-drainage antibiotics may be considered are those who are immunocompromised, have any prosthetic implants, are known diabetics, or have significant cellulitis [11].
Most pilonidal abscesses heal very well following incision and drainage [11]; however, some may require further incision and drainages or debridement because of the excess in granulation tissue that forms in the wound. All pilonidal sinuses, if symptomatic, will need further elective management for eradication.
13.5 Management of a Pilonidal Sinus
13.5.1 Case 2
The same 24-year-old patient, who presented with a pilonidal abscess earlier, now comes to your office, 3 months after having his abscess drained in the emergency room. He is feeling well and his wound has healed. He comes to see you because he is complaining of staining his undergarments regularly with light colored yellow fluid. On further examination, you notice that he has multiple pits in the natal cleft, with a secondary opening off the midline where his abscess was drained. There is no sign of recurrent abscess and there is no induration or tenderness on exam. You notice small little hair shafts sticking out of the pits and secondary opening (Fig. 13.9). How would you treat this young man?
Fig. 13.9
Numerous non-inflamed midline pits, the primary source of the disease (small arrow). Hairs extrude from the secondary sinus (large arrow) (adapted from Nivatvongs [2], with permission)
13.5.2 Nonoperative Approaches
There is a role for nonoperative management following an initial episode of uncomplicated pilonidal disease. Thus, this patient may be offered conservative treatment. An important component of the nonoperative approach for the treatment of pilonidal disease is shaving and hygiene around the diseased area (see Fig. 13.1). This simple act in addition to a limited lateral incision for drainage of the index abscess has been shown to decrease the number of hospital admission days, decrease the number of surgical procedures and is associated with an earlier return to work when compared to more invasive surgical techniques [11]. This conservative, noninvasive practice of meticulous hair control and perineal hygiene has been used for quite some time. In a study with military personnel in the mid-twentieth century, Armstrong and Barcia retrospectively reviewed outcomes of patients that were treated with a variety of surgical approaches and compared their outcomes to a prospective cohort of 101 patients who were solely treated using a conservative, nonoperative approach consisting of shaving 5 cm around the diseased area. In this pilot study, no patients who had undergone conservative treatment had any evidence of unhealed wounds and all were able to continue serving in the army during their treatment [12]. Their data strongly suggested that conservative treatment was superior to excisional therapies although they did not control for the different operative approaches. This approach however was not as effective in patients suffering from recurrent disease after having undergone an excisional procedure [12]. The most recent 2013 practice parameters developed by the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons suggest that gluteal shaving should be used as a primary and/or adjunct treatment measure for acute and chronic pilonidal disease. Although there is no ideal extent of shaving that has been determined in the literature, the common recommendation is roughly a 4–5 cm area be shaved around the pits in the gluteal cleft [3]. In our practice, we advise patients to remove their hair from the lower back to the lower thighs, including the perineal area. We have found that in hirsute individuals, surrounding hairs easily travel into the cleft from more distant areas. Moreover, it is important to continue regular hair removal in the postoperative period if a patient has undergone a surgical procedure. The length of time and frequency of shaving however are not clear, so it is currently recommended to do so until the wound is healed [10]. It is very important to avoid leaving any little hairs behind as even one single hair shaft can lead to impaired healing and possible recurrence. The majority of surgeons advise their patients to continue keeping the area around the healed wound bare of any hair in order to prevent recurrence. There is controversy around the topic of shaving with studies actually showing that shaving is harmful and leads to higher recurrence rates in patients operatively treated for pilonidal disease. One reason for this is that possible microtrauma that results secondary to the blades [13]. For now, the idea of hair removal is compelling and there are promising studies looking at other methods of hair removal such as laser. In one study of 14 patients with recurrent disease, all patients reported improvement in their disease, with only 4 diagnosed with recurrent disease. One important disadvantage was the pain associated with the laser procedure [14]. Despite these findings, there is still insufficient evidence for this technique to be generally used. In our practice, we recommend clipping, depilation creams, or waxing, rather than shaving, to avoid the microtrauma caused by the razor blade.
Other possible nonoperative treatments that can be used for chronic pilonidal sinuses include the use of phenols or fibrin glues to attempt to occlude the tract. Small series have reported up to 95 % success rate with phenol injections combined with proper hygiene and excellent hair removal of the surrounding area [11]. Another study by Dogru et al. in 2004 showed that crystallized phenol placed into a wound resulted in low recurrence rates at 8-month follow-up [15]. The crystals were applied in the wound after careful removal of all remaining hair or debris, allowed to liquefy at body temperature, and then expressed out of the wound after a 2 min period. This noninvasive technique appears promising however availability of these crystals may be an issue [2]. A review in 2009 concluded that phenol injections were appropriate for patients with 1–3 sinus tracts with good overall success rates, up to 97 %, with quicker return to work despite longer healing times, up to 1 month. Despite this, the current evidence is weak and more studies are needed to assess long-term outcomes [16].
Fibrin glue also appears to be promising in a variety of settings such as application after the curettage of the sinus tracts or in the bed of the excised tract prior to primary closure [11]. Most studies looking at fibrin glue are small series; however, success rates reported are quite high, up to 100 % in some, with minimal recurrence and good tolerance by the patients [11, 17, 18]. One retrospective review with 93 patients treated with fibrin glue over a 5-year period found high levels of patient satisfaction as well as rapid return to normal activities [18]. Lastly, similar to the treatment of an acute pilonidal abscess where antibiotics are not recommended, the use of oral or intravenous antibiotics for chronic disease has not been found to have any benefit for the patient. In both the pre- and postoperative settings, antibiotics have not shown any significant benefit for wound healing or prevention of complications when compared to patients not receiving them [19]. In addition, the evidence for use of topical antibiotics such as gentamicin-impregnated sponges is conflicting. Some studies have found a positive association between topical antibiotics and healing, while other studies showed no benefit. It remains unclear whether topical antibiotics in the treatment of chronic or complicated pilonidal disease have any advantages and more studies are looking into this matter. In summary, at this time, antibiotics should only be used as adjuncts in patients with severe cellulitis from an abscess or any underlying systemic illness or immunocompromised patients [11].
13.5.3 Operative Approaches
When the nonoperative approach fails, it is best to proceed to surgery. If a patient suffers from chronic, recurrent, or complex pilonidal disease, the surgeon must decide whether to proceed with an excisional approach with primary closure of the defect or excision with secondary healing of the wound. There is no strong evidence proving one approach is superior to the other, and in the end, it comes down to surgeon experience and comfort level in performing the procedure. In other words, there is no ideal treatment modality that has proven to be strongly superior to other approaches. There are a few differences in outcomes of these two approaches (which will be reviewed later); however, the main goal of treatment for pilonidal disease is one that allows the patients a quick return to their daily activities, has a low recurrence rate, minimizes pain, requires limited wound care, and is cost-effective [8]. Keeping all of this in mind, this allows the surgeon to tailor the best approach for each patient.
Operative approaches for pilonidal disease can be classified by wound closure as follows: primary closure or open (secondary) wound closure techniques. A Cochrane review in 2009 looked at the healing rates of primary versus secondary closure in the surgical treatment of a pilonidal sinus. Their primary outcomes were time to healing, infection, and recurrence rates. Overall, there were benefits to either approach such that patients who had primary closure of their wounds showed more rapid healing and quicker return to work, whereas those with open healing wounds had lower recurrences. The good news is that both approaches showed no difference in infection and complication rates as well as length of stay after the procedure [20].
The open wound approaches include traditional wide excision with packing of the wound, the use of vacuum-assisted closure (VAC) therapy, or marsupialization of the sinus tract, whereas primary closure approaches include a variety of flap procedures with midline or off-midline closure of the wound. All these approaches will be covered in the following sections.
There are several ways one can approach treating pilonidal disease. The open wound approaches have been used for years and are still very successful at treating pilonidal disease because they are simple to perform and many surgeons feel comfortable with this technique. They have also been found to have lower recurrence rates compared to primary closure [20]. The primary flap closure techniques are mostly reserved for the more complex cases, including patients who have failed prior treatment or who persistently have recurrence of their disease, despite having undergone surgical management. There is minimal prospective evidence that compares excision with secondary healing versus excision and primary closure. There is an older randomized control trial that found midline excision with primary closure to show no clear benefit over the secondary healing technique and had a tendency toward higher recurrence rates [21]. In this case, the patient had a recurrence following an excision with primary midline closure. A reasonable approach at this point would be to offer him excision of the sinus tracts with an open wound healing by secondary intention. Several open techniques exist and will be described below.
13.5.4 Case 3
A 27-year-old male presents to your office 6 months after having undergone a resection and primary midline closure of a pilonidal sinus. On his initial follow-up visits after surgery, he was doing well and the wound was healing nicely. He is now complaining that the sinus and discharge has come back. It is not that painful but he regularly has discharge and it is uncomfortable to sit. He also mentioned that his girlfriend noticed some hair sticking out of the sinus tract. He denies any other symptoms. You recall having offered him resection and primary closure because he works as a security guard and really wanted to get back to work as quickly as possible.
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