Pilonidal sinus: All you need to know

Leading consultant laparoscopic colorectal and general surgeon Mr Anwar Ahmad discusses pilonidal sinus including symptoms, treatment and diagnosis, in this informative article. 

What is pilonidal sinus?

Pilonidal sinus is a condition where a pit, or hole, forms between the buttock cleft. This area is also sometimes called the gluteal cleft. This word 'pilonidal' originates from the Latin word 'pilus' which comes from the term 'hair'. That may suggest the cause of this condition, which is often thought due to hair present in the gluteal cleft area and causing irritation around the skin.  

What are the symptoms of pilonidal sinus?

Pilonidal sinus can present sometimes as an abscess. Patients will notice a swelling and pain between the gluteal cleft and it's one of the presentations of pilonidal sinus. That needs to be drained if it's an abscess. 

Other occasions, patients will notice that there's some discharge around that area which again, can be one of the presentations of pilonidal sinus. Sometimes, it's a sinus opening where they don't notice much discharge, but they've noticed that if they have some irritation around that area.  

What causes pilonidal sinus?

It's commonly believed that it's because of hair causing irritation of the skin, and some trauma in that area. The presence of loose hair can cause a formation of these pits. It's a very commonly accepted theory, but there are patients who don't have a lot of hair around that area but will still develop pilonidal sinus. It's very commonly seen in late teenagers and young adults. This remains to be proven, but it's commonly accepted that the cause is the presence of hair around that area. 

How is a pilonidal sinus diagnosed?

Diagnosis of pilonidal sinus depends on a good history taken from the patient, and examination by the clinician. Pilonidal sinus diagnosis doesn't, or very rarely, requires any imaging. A good history and examination by the clinician are often enough to establish a diagnosis. 

How is a pilonidal sinus treated?

Pilonidal sinus can be managed non-surgically or surgically. A non-surgical approach would be to keep the area clean, to ensure good hygiene of the area which often isn't very easy considering the area is a difficult area to look after. Coming to the surgical options, there are a number of surgical options. 

The ideal procedure for pilonidal sinus surgery would be something that would ensure the condition is completely cured. There's no recurrence, it's cost effective, it's less painful and the patient can get back to work more quickly. 

Unfortunately, none of the available surgical procedures will be able to satisfy all of these criteria. So, it's a bit of give and take, and depending upon how severe the disease is, the clinician may go for various treatment options.

In general, the options are either to:

• Completely excise the pilonidal sinus and leave it open as a wound to heal from inside-out. 
• The other option is to excise the sinus and close it. 

There are various procedures which have been named, but for the sake of simplicity I won't go into the names of those procedures. 

There are options of making flaps, and more recent techniques of using either laser or endoscopic pilonidal sinus surgery to treat the tract without causing a bigger defect or a wound. These new techniques are minimally invasive and have become more popular over the last few years. There's a very obvious and clear reason for that; 

• patients have less pain and; 
• get back to work much quicker. 

Therefore, they prefer this. And I've said before, this is a condition which affects teenagers and adults, and affects their working life and therefore, their preferred options are least invasive.

I'd divide the surgical options into: 

• Most invasive, and;
• least invasive. 

The invasive options include:

• The Karydakis procedure;
• The Bascom procedure, where we excise the sinus and then close the defect. 

The other options could be making flaps, which are again, a bit more extensive. A patient could be off work for longer, and in comparison, the minimally invasive techniques are:

• laser, or;
• endoscopic pilonidal sinus surgery, where we burn the inside of the track without causing a big scar. 

There's been some studies which have shown that these are, as expected, more popular among patients. Long-term results of some studies have shown that recurrence isn't as bad as expected. So, these options, either laser or endoscopic pilonidal sinus surgery, which is sometimes called EPSiT. 

These are options that should be considered with careful consideration because it also depends upon the extent of the condition; if you have side tracks of the sinus which aren't dealt with, then you'll definitely get a recurrence. Therefore, it's important to choose the right treatment for the right type of condition. 

How can I prevent pilonidal sinus? 

Pilonidal sinus is something that's difficult regarding prevention. It's a very difficult area to look after, because we all have to sit on our buttocks and therefore there'll be some trauma to that area. There have been theories that it's more common in barbers, or people who sit like lorry drivers who sit for a long time. So, ideally speaking, we could say:

• make sure you're not sitting in the same position for too long. Obviously that depends upon your work;
• to ensure that the area is clean, and; 
• to have good hygiene around that area, which at times can be difficult, especially during summer. 

It isn't the easiest of things to ensure that you don't get pilonidal sinus, but there's a tendency for patients who have lots of hair, are sweatier and should probably keep a closer eye on good hygiene around that area. 

If you require pilonidal sinus treatment and want to arrange a consultation with Mr Ahmad, you can do so via his Top Doctors profile.