Pilonidal Cyst Removal, Recovery, and Recurrence

A pilonidal cyst is a cyst or abscess (boil) located near the intergluteal cleft, otherwise known as the groove between the buttocks. Treatment usually requires having a pilonidal cyst removed surgically.

Pilonidal surgery is a minor procedure typically performed by a colorectal surgeon who removes the cyst and any surrounding infection. While a cystectomy, or cyst removal, is usually effective, there is a high rate of recurrence.

This article explains what a pilonidal cyst is, the benefits of surgery, expected outcomes, and ways to reduce the risk of recurrence.

What Is a Pilonidal Cyst?

Pilonidal cysts develop near the crease between the buttocks, known as the intergluteal cleft. An impacted or ingrown hair follicle, along with debris like dead skin cells and dirt, become enclosed in a pocket that forms a cyst.1

The ingrown hair often continues to grow under the skin, irritating the cyst and leading to an infection, which is known as a pilonidal abscess or boil. The abscess fills with foul-smelling pus.

How to Tell if an Abscess Needs Medical Attention

The pain of an infected pilonidal cyst is often excruciating. It feels as if you were to press your tailbone up against the sharp corner of a table and hold it there.

After the abscess drains of pus, which may happen if it erupts on its own or with medical treatment, many patients develop a pilonidal sinus.2 The sinus is a cavity below the skin that connects to the surface through your pores. With a pilonidal sinus, the infection spreads from the cyst into the sinus tract and, over time, may lead to recurring infections that become increasingly severe and painful.

Signs of a pilonidal sinus include:

• Severe pain near the tailbone
• Tenderness in the lower back
• Swelling in the area
• Foul-smelling drainage
• Fever

Risk Factors

Pilonidal cystspilonidal cysts

Risk factors for developing pilonidal cysts include having thick, wiry hair on the lower back, sitting for long periods of time, and friction, such as a belt rubbing against the skin. During World War II, these cysts were so common among GIs driving Jeeps that pilonidal disease was referred to as "Jeep seat."3

Diagnosis

An infected pilonidal cyst is diagnosed by a visual examination by a primary care healthcare provider, dermatologist, ER healthcare provider, or colorectal surgeon. Ultrasound also may be used to determine the scope of the infection. Once the infection is identified,

First-Line Non-Surgical Treatments

Surgery is not usually the first treatment option your healthcare provider will recommend for a pilonidal cyst. In fact, it will likely only be considered if other treatments have not worked.

The typical first-line treatment is to lance the boil. This can be done in your healthcare provider's office or emergency room using local anesthesia. Once the area is numb, the healthcare provider will make an incision into the abscess to drain the pus.

Lancing may work to remove the initial infection, but pilonidal cysts can be complex, and they frequently return and worsen over time.2

Antibiotics are not usually prescribed for pilonidal infections unless an accompanying skin infection (i.e., cellulitis) is present.

The next level of treatment is incision and drainage. This is also done using local anesthesia and may be performed in the healthcare provider's office, an outpatient surgical center, or an emergency room setting.4

This procedure involves unroofing (splitting open) the cyst, curetting (scraping out) the base, and marsupialization (suturing the edges). The wound is left open to drain.1 This, too, is usually a temporary fix, and the pilonidal sinus cavity experiences recurrent infections.

If the cyst does not heal after draining or you continue to have problems, a pilonidal cyst surgery may be needed to surgically remove the cyst and surrounding tissue.

Purpose of Pilonidal Cyst Surgery

While pilonidal cysts can go away without surgery, most cases require minor surgery to remove a pilonidal cyst or to clear out the infection and treat a pilonidal cyst.5 It's usually an outpatient procedure, meaning you go home the same day.

Possible Risks

Pilonidal cyst surgeryPossible risks

• Bleeding
• Infection
• Lengthy healing time
• Recurring pilonidal cysts

What Does Pus From a Surgical Wound Mean?

How to Prepare

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What to Bring

Pilonidal cyst surgeryovernight

Don't forget to bring your insurance documents, identification, and any additional paperwork your surgeon requires on the day of the procedure.

What to Wear

It is recommended to wear something comfortable that is easy to change out of. You will be in a hospital gown for the procedure. Do not wear any jewelry, and leave anything of value at home.

Food and Drink

Your healthcare provider will instruct you on whether you will need to stop eating and drinking before the procedure. If you are going under general anesthesia, it is typically recommended to not consume anything in the eight hours before the procedure.

Medications

Your healthcare provider will advise you on whether you need to make any alterations to your current medications. Certain drugs can interfere with medical procedures and should not be taken prior to any surgery. In particular, blood thinners may cause problems with blood clotting during surgery.

Be candid about your use of any recreational drugs, marijuana, alcohol, and nicotine, as these may affect your response to sedation.6

Don't assume that your entire surgical team knows what medications you are taking. Repeat it to them on the day of your procedure so they are aware of what you have been on and how much time has passed since you last took it.

Things to Tell Your Surgeon Before You Have Surgery

What to Expect on the Day of Surgery

A day or two before your scheduled pilonidal cyst surgery, you will be notified when to arrive at the facility to check in. The procedure itself should take about 45 minutes.

Before the Procedure

After you check in on the day of your procedure, you'll be taken to a room to change and have a brief exam. You will review your medical history with a nurse, answer questions about the last time you ate or drank, and have your vitals checked.

From there, you will be brought into the procedure room set up with a surgical table, medical equipment, and computers. You will lie face down on the table and the surgical team will prepare the skin on your lower back for surgery by shaving and disinfecting it.

The anesthesiologist will connect you to an IV to give you medicine to relax. If you are having general anesthesia, you will be asleep for the procedure. Some patients instead opt for regional anesthesia, such as an epidural or spinal block, which numbs the area while keeping you awake and alert.

During the Procedure

Once the anesthesia has taken effect, the surgeon will use a scalpel to cut and excise the cyst and sinus, including the skin, pores, underlying tissue, and hair follicles surrounding the infection.2

The area will be suctioned to remove pus and cleaned with saline. Any remaining inflamed tissue will be removed and the area will be cleaned again until no sign of infection remains.2

Depending on how much tissue was excavated, the wound may be left open to keep watch for infection. If a lot of tissue has been removed, the wound may be packed with gauze. In addition, a drainage tube may be left in to help fluid continue to drain and prevent reinfection.1

If the wound is large, your healthcare provider may need to close it up with stitches. In some cases, skin flaps may need to be created in order to close the wound. There is a greater risk of recurring infection if the wound is closed after surgery.1

After the Procedure

Immediately following the removal of the cyst, you will be taken to the recovery room and monitored as the sedation wears off. Once you are steady on your feet, you will be discharged with instructions for caring for the incision, bathing, and making a follow-up appointment.

Recovery

The timeline for healing after pilonidal cyst surgery varies based on how the surgery was performed. If your wound was stitched closed, complete healing usually takes four weeks, while wounds left open to drain can take months to completely heal.7

Most people can return to work in two to four weeks after surgery. However, it is advised to avoid strenuous exercise and activity until the area is completely healed. You will likely need several follow-up appointments.

Do not drive the first 24 hours after surgery and while you are taking narcotic medication. In general, you can drive once you feel comfortable sitting in the driver's seat and using the brake and gas pedal. The timeline for this varies depending on your individual circumstances.8

Recurrence

Unfortunately, pilonidal cysts can return after surgery. Between 13.8% and 32% of pilonidal cysts recur within five years of pilonidal cyst surgery.

Healing

The first few days after pilonidal cyst surgery can be uncomfortable. Since the wound is by your tailbone, it may be difficult to sit or find a comfortable position. Sitting on a soft pillow or donut seat may bring relief.9

Over-the-counter pain relievers like Tylenol (acetaminophen) should help ease the discomfort. If not, your healthcare provider may prescribe pain medicine to take on a short-term basis.7

It is very important to keep the wound clean and dry until the skin is fully healed. Your healthcare provider will give you instructions on how to care for the wound, including changing the packing and dressing, and bathing. Pat the area dry after showers, but avoid taking baths until the wound is healed over.

How to Care For Your Incision After Surgery

Lifestyle Adjustments

Once the site is healed, it is important to keep the skin in the buttocks crease clean and free from hair. Young men may need to shave, wax, or use hair removal cream every two to three weeks until the hair shafts begin to soften and thin out around age 30.2

If you prefer a more permanent solution, laser hair removal or electrolysis may be a better option. A small study of 60 patients found post-surgical laser hair removal significantly reduces the risk of recurring pilonidal disease. Further research has shown that laser treatments to control hair growth are more effective than repeated surgical treatments.10

People who have jobs that require sitting for long periods of time, such as truck drivers, are at increased risk of recurrence. If you have a desk job, consider switching to a standing desk or setting an alarm to stand up and stretch your legs several times throughout your shift. Concentrating on correct posture when sitting can also help you manage the pain.11

Possible Future Surgeries

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Summary

Pilonidal cysts are painful cysts near the tailbone that easily become infected. Left untreated, they can turn into an abscess (a swollen pocket of infection). You may need pilonidal cyst surgery to prevent these complications. Keep in mind that the cyst can return after surgery. Weigh the pros and cons of treatment with your healthcare provider.

11 Sources

By Naveed Saleh, MD, MS
Naveed Saleh, MD, MS, is a medical writer and editor covering new treatments and trending health news.