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What is pilonidal sinus?

A pilonidal sinus is an abnormality in the natal cleft area just above the buttocks. Loose hairs fall off the neck or back and collect in the natal cleft. The hairs can cause small holes to form in the skin or can get into existing holes - called pilonidal sinus.

As the hairs carry infection, the holes can become infected. This causes a pilonidal abscess to form or a discharge that is released through a tunnel (sinus) out onto the skin.

Almost all patients present with either recurrent pain or a recurrent pus-like discharge from just above the buttocks.

The condition usually affects young adults, occurring in 1 in 100 young men and 1 in 400 women.

Are there any alternative to surgery for Pilonidal sinus?

If a pilonidal abscess has not formed and you have not had any discharge from the sinus for a while, then there is not an immediate need to have the operation.

An occasional discharge can be treated with antibiotics. However, infection is likely to come back and surgery is normally advised.

If you leave things as they are, the trouble will remain. It may get better on its own by the time you are 40 years or so. Burning the deeper tissue with a phenol treatment is an alternative, but is does not lead to better healing than an operation.

What are the benefits of surgery?

Surgery is the most dependable way to remove the pilonidal sinus.

Once the area has fully healed, the infection and any discharge should not come back.

What does the Pilonidal Sinus operation involve?

If you have a pilonidal abscess, the normal operation is simply to cut into it and let the pus out. Once all the inflammation has settled down, a second operation can remove the sinus.

Shaving: the area will be shaved for your just before your operation (there is no need to do this yourself).

Surgery: Pilonidal sinuses can be treated in several different ways, all of which remove the ‘pits’ in which hairs get stuck and cause infection. To remove the sinus the operation is performed under a general anaesthetic. The surgeon will remove the sinus and infected tissues, sometimes over a large area.

At the end of the operation, the surgeon will decide whether to close the wound with stitches or leave it open. Occasionally, if the sinus is very small, it can be completely removed and the skin closed with stitches (sutures, which are later removed). If it is closed with stitches, a small tube (drain) is usually placed in the wound for a day or two. Produces 70% healing at 2 weeks – 20% develop wound infection.

More often, it is necessary to leave an open wound; the edges of the wound might be partly closed with an absorbable stitch. If it is left open, the surgeon will place a pack in the wound. Produces 70-90% healing at 70 days – 5-15% recurrences rate.

Special dressings are not normally required, but a gauze pad will help to protect clothing from any discharge.

Other procedures may be carried out in rare cases. These include:

1. Excision of pits, removal of hair and brushing of tracts– Produces 80-90% healing in small and selected cases.

2. Phenol injections- produces 60-70% healing in very mild cases

3. Skin flap procedures (e.g. Karydakis procedure). Failure rates as low as 5% have been reported.

What can I do to help make the operation a success?

Lifestyle changes: 

If you smoke, try to stop smoking now. There is strong evidence that stopping smoking several weeks or more before a general anaesthetic reduces your chances of getting complications. If your are overweight, loosing weight will reduce your chances of developing complications.

Medication

You should continue your medication unless you are instructed otherwise.

If you are on warfarin or aspirin, you will need to stop taking it before the operation. Make sure your surgeon is aware you are on these drugs and follow the advice about stopping it.

Plan for your care and recovery after the operation, especially if you are to have general anesthesia. Allow for time to rest and try to find people to help you with your day-today duties.

Follow any instructions your doctor may give you. If you are to have general anesthesia, eat a light meal, such as soup or salad, the night before the procedure. Do not eat or drink anything after midnight and the morning before the procedure. Do not even drink coffee , tea, or water. No special preparation is needed for local anesthesia.

What risks or complications can occur?

Most operations are successful ‘with few complications”. However, every procedure has risks and potential complications. Those most relevant to this operation are listed below. Please discuss them with your doctor if there is anything you do not understand.

General complications of any operation

Pain: which occurs with every operation. Efforts will be made to minimize the pain. A local anaesthetic may be injected into the skin and local nerves to ease the pain for several hours after the operation. You will be given medication to control the pain and it is important that you take it as instructed so you can move about freely.

Infection: in the surgical wound, which may need treatment with antibiotics and usually settles after a few days.

Blood clots in the legs (thrombosis), which can occasionally move through the bloodstream to the lungs , causing breathing difficulties (embolus). You will be encouraged to get out of bed soon after the operation.

General complications of this operation

Bleeding-which can occur either during or after surgery. The risk increases if the wound is left open. If the wound was closed with stitches, bleeding can result in a lump caused by a blood clot (haematoma), risk 3 in 50.

Unsightly scarring of the skin, it is common for the shape of the natal cleft to be deliberately changed, to help prevent the problem coming back.

A small percentage of people have an inherited tendency to scars that are unusually red and raised.

Specific complications of this operation

Partial breakdown of the wound, which is quite common if it is closed with stitches. The risk increases if there is an infection at the time of surgery that leads to the wound being infected (risk 1 in 4). The wound may then need to be packed until it has healed.

Slow healing, which can sometimes occur if the wound is packed. Healing usually takes about eight weeks but can take much longer (risk 3 in 100).

Recurrence of the pilonidal sinus: It is important to keep the area free from hairs and as clean as possible to reduce this risk (risk 1 in 9).

Numbness around the wound, which is quite common, but is not a major problem. (risk 1 in 9).

How soon will I recover?

In hospital

Within one to two hours of your operation, you will be encouraged to get up and walk around. Occasionally you will be allowed home from hospital on the same day, though more usually the following day. When you are ready to leave the hospital the nurses will talk to you about your home arrangements so that a proper time for you to leave hospital can be arranged. You will be given an appointment so that your care is followed up. You will be given instructions about any follow up and, if you have stitches, when they will be removed.

If you are worried about anything, whether in hospital or at home, ask a member of the healthcare team. They should be able to reassure you or identify and treat any complications. You will be given some painkillers to be taken my mouth as required. A small amount of bleeding or discharge is expected. You should be able to resume normal daily activities rapidly. Provided you feel comfortable, you may lift things, drive and go back to work. You should, however, avoid contact sports or other activities that might disrupt the stitches during the first two to four weeks.

Return to normal activities

Once at home you should rest for the first few days, walking as you feel comfortable.

Try to avoid sitting on the wound.

Do not drive until you are comfortable and confident about controlling your vehicle in an emergency and always check with your insurance company first.

You should be able to return to work after two to three weeks. However, if your wound was packed you will need to have regular time off to have the packing changed.

Will I feel any pain?

Local anaesthetic will wear off after an hour or two, so the wound gradually gets uncomfortable. Take paikillers early to control any pain. Feeling in the wound may come back quicker after a general anaesthetic so that you should be ready to take painkillers inside an hour. The wound should be just about pain-free within a day or so.

If there is any bleeding, add extra dressings and lie on them. If the bleeding is troublesome, you will need to go back to the doctor.

If your wound is packed, soak in a bath of warm water without salt for 30 minutes, and pull out all the dressings. A new dressing will be placed over the wound. It often helps to be held in place by underwear. There may be a bloody discharge for a day or two, but the discharge may then become yellow.

Washing

You can wash the wound area as soon as the dressing has been removed. Soap and warm tap water are entirely adequate. Salted water is not necessary. You can shower or bathe as often as you want. At home, if the wound has been sutured closed, then you should keep it dry for at least five days to minimize the risk of infection getting inside. In order to prevent recurrence of the sinus, the area around the wound should be kept free of hairs by weekly shaving. If the wound was closed with stitches, it will need to be checked and the stitches removed after several days.

At the Out Patient Clinic

The wound will be inspected and the surrounding skin shaved for you, if required.

To prevent the condition coming back, you should attend the Doctor’s Clinic as required until the wound has healed.

The future

Once the wound has fully healed, the infection should not come back. However, it is important to keep the area free from hairs and as possible to reduce the risk. If you do not, the risk of the pilonidal sinus recurring can be 10% - 20%.