A pilonidal sinus, also known as a coccyx fistula, is a common but often underestimated condition that occurs in the coccyx region. It mainly affects young adults, particularly men, and can cause significant discomfort such as pain, swelling or persistent pus discharge. Many patients wonder whether surgery is really necessary and what risks are associated with the condition. This article provides a comprehensive overview of the development, diagnosis and modern treatment options for pilonidal sinus, supplemented by the latest scientific findings.
What is a pilonidal sinus?
Pilonidal sinus is a chronic inflammation of the skin and subcutaneous tissue in the area of the gluteal fold. It is characterized by a cavity created by ingrown hairs, dirt particles and dead skin cells. This cavity can become a fistula, which becomes inflamed and triggers a permanent inflammatory reaction. The term “pilonidal” comes from Latin and means “nest of hair” – an apt reference to the central role of hair in the development of this disease.
Epidemiology and risk factors
- Age and gender: The disease is most common in young adults between the ages of 15 and 30 and affects men about twice as often as women.
- Hair growth: Dense hair growth in the buttock region favors the penetration of hair into the skin and the formation of fistulas.
- Mechanical stress: Prolonged sitting, especially among office workers, truck drivers and students, and repetitive mechanical friction increase the risk.
- Hygiene and skin condition: A moist, poorly ventilated buttock crease, combined with inadequate cleaning, promotes the accumulation of hair and dirt.
- Overweight: Increased pressure and increased sweating in the coccyx region can promote the development of a pilonidal sinus.
- Genetic factors: Studies indicate that familial clusters occur, suggesting a genetic predisposition.
Development and pathophysiology
The development of a pilonidal sinus usually begins with ingrown hairs. These penetrate the skin and are perceived by the body as a foreign body, which leads to an inflammatory reaction. As the condition progresses, a cavity (sinus) develops in which hair debris, dead skin cells and bacteria accumulate. If the condition remains untreated, the cavity can enlarge, fistula tracts can form and recurrent infections and abscesses can occur. An acute abscess can cause severe pain and fever and often requires rapid surgical relief.
Symptoms and clinical manifestations
The symptoms of pilonidal sinus range from mild to severe and depend on the stage of the disease:
- Early stage: No or only minor symptoms. Those affected may notice a small, painless cavity or slight redness in the gluteal fold.
- Chronic inflammation: Recurrent discharge of pus or blood from the fistula openings, accompanied by itching, pain or skin irritation.
- Acute abscess: Sudden, severe pain, swelling, redness and occasionally fever indicate an advanced infection. In these cases, rapid surgical intervention is required to control the infection.
Diagnosis
The diagnosis of a pilonidal sinus is usually made on the basis of a thorough medical history and physical examination.
- Medical history: Patients often report recurring discharge, pain and swelling in the breech region. Questions about occupational activity (e.g. prolonged sitting), hair growth and family history are helpful.
- Clinical examination: The doctor inspects the gluteal fold for visible fistula openings, swelling, redness and discharge of secretions.
- Imaging: In complex or recurrent cases, imaging techniques such as ultrasound or MRI can be helpful to visualize the extent of the fistula tract and facilitate the planning of a surgical procedure.
Treatment options: Conservative or surgical?
The treatment of a pilonidal sinus depends on the severity and the individual needs of the patient. The aim is to control the inflammation, remove the fistula and prevent recurrences.
Conservative measures
- Hair removal: Regular shaving or the use of laser technologies can reduce the risk of new inflammation.
- Hygiene measures: Thorough cleaning and drying of the gluteal fold is essential to avoid the accumulation of hair and dirt.
- Antibiotics: For mild infections, antibiotics can help in the short term, but do not eliminate the underlying fistula.
Incision and drainage
- In the case of an acute abscess, rapid surgical relief is required.
- The aim is to drain pus and relieve acute symptoms.
- Restriction: The fistula remains, and without further measures there is a high risk of relapse.
Surgical removal
- Open wound healing: The fistula is completely removed and the wound is left open to heal from the inside out.
- Advantages: Low risk of relapse (approx. 10 %).
- Disadvantages: Longer healing time (4-8 weeks), complex wound care.
- Primary wound closure: The wound is closed immediately after removal of the fistula.
- Advantages: Shorter healing time (2-3 weeks).
- Disadvantages: Higher risk of relapse (up to 20 %).
- Minimally invasive procedure (e.g. pit picking): Only the affected fistula openings and ducts are removed.
- Advantages: Gentle, fast recovery.
- Disadvantages: Not suitable for extensive fistulas.
Long-term prognosis and relapse rates
- The relapse rate depends heavily on the chosen treatment method.
- According to a meta-analysis in Diseases of the Colon & Rectum (2017), the recurrence rate with open wound healing is less than 10 %, while it is up to 20 % with primary wound closure.
- Compliance with post-operative hygiene measures and regular check-ups are crucial to prevent relapses.
Complications of untreated pilonidal sinus
- Chronic, recurring abscesses and fistulas.
- Spread of deep fistula tracts into the surrounding tissue.
- In very rare cases, chronic inflammation can lead to malignant changes (squamous cell carcinoma).
Conclusion
Pilonidal sinus is a common condition that can cause significant discomfort without proper treatment. While conservative measures can be helpful in the early stages, most patients require surgical removal to permanently eliminate the fistula. Today, modern minimally invasive techniques offer a quick and gentle solution, although the choice of method should be made on an individual basis.
Wiener Ziel – Your experts for pilonidal sinus
If you suffer from a pilonidal sinus, experienced specialists are available at Ziel in Vienna to offer you precise diagnostics and modern treatment methods. Our aim is to offer you an effective and long-term solution – for your health and quality of life.
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