FAQ about pilonidal cyst

In the case of pilonidal sinus, chronic inflammation occurs in the middle of the gluteal folds, as hair grows into the subcutaneous fatty tissue here, leading to an inflammatory reaction. If a lot of pus is formed, an acute inflammation occurs, which must be immediately treated surgically. 

The main symptom is pain in the coccyx area, especially when sitting or lying on the back. In addition, there are the signs of inflammation such as swelling, redness of the skin, pressure pain, overheating and leaking fluid (secretion). In addition to swelling, small holes, the so-called pits, are often visible.

It is not a life-threatening disease. The inflammation is localized to the center of the buttocks, there is also no blood poisoning (sepsis). Malignant degeneration is also very unlikely. However, a large scar plate can form, making sitting very difficult, so therapy should always be considered.

In most cases, the patient's description and the physician's look are sufficient for the assessment and diagnosis. In case of ambiguity, the skin can be examined with a type of magnifying glass (dermatoscope) according to pits. An ultrasound can assess the extent under the skin. A magnetic resonance imaging (MRI), on the other hand, is not necessary. 

A coccygeal fistula never heals on its own. There is only surgical therapy. If there are no complaints (symptomless), it is possible to wait. In the case of acute inflammation, the abscess must be opened, and in the case of chronic complaints, a minimally invasive procedure should always be considered first.

For small findings with pits, pit picking is the procedure of choice. In combination with longer fistula tracts, sinusectomy can be added. In the case of a very long and narrow fistula tract, laser treatment is an alternative.

Large scarred defects with pus accumulation should always be cut out classically (excision). In case of recurrent fistulas, plastic procedures can be applied.

Under local anesthesia, small visible fistula tracts (pits) with a skin margin of 3mm are punched out. The underlying fistula cavity is cleaned (debrided) and rinsed via a second access, leaving only very small wounds. The operation is performed on an outpatient basis under local anesthesia.

Often, an elongated induration with a lateral exit is seen next to the pits. This fistula must be completely excised in combination with the pit picking and is called a sinusectomy. This creates another defect of about 1-2cm. This procedure is also performed on an outpatient basis under local anesthesia.

Here, all tissue in the midline is removed extensively down to the periosteum and the wound heals over a longer period of 3-6 months.

The procedure can also be combined with suturing in the midline, but this is not recommended according to the guidelines because of a high risk of recurrence. Surgery is recommended under anesthesia and can be performed as an outpatient or inpatient procedure depending on the findings.

In these procedures, also described as "off-midline" excision, the tissue is removed and suture closure is combined with plastic surgery. The most common procedures are the Karydakis operation, the Limberg` plastic or the "cleft lift" procedure. It is important that the suture is lateral to the buttock midline. These operations are performed only in the hospital with a stay of 3-5 days. 

We use very fine needles for the operations under local anesthesia. Nevertheless, a burning pain and a feeling of pressure may occur for about 20 seconds.

After that, the region is anesthetized and only a feeling of pressure is felt. Before the operation, an ibuprofen tablet and an anesthetic ointment can be taken, so that the needle puncture is only slightly felt.

This depends on the findings. As a rule, a pit picking operation or sinusectomy performed on an outpatient basis takes about 10-20 minutes. Excision and laser surgery takes about 20-30 minutes and plastic surgery according to Karydakis 30-60 minutes.

The costs for a medical indication such as pilonidal cyst are covered in full by public and private health insurance companies. Since we are licensed by a public health insurer, there are no costs for patients with public health insurance. Laser treatment, on the other hand, is currently only covered by several company health insurance funds.  

With minimally invasive procedures such as pit picking, sinusectomy, or laser procedures, the wounds usually heal after 3-6 weeks. With excision, the healing time can be between 3-6 months, in some cases it does not heal at all. Then we speak of a new pilonidal cyst or recurrence. 

After surgery, the wound must initially be dressed daily. With our minimally invasive procedures, patients are usually off work for 1 to 2 weeks. In the case of excision, however, the inability to work can last up to 6 weeks.

After the operation, the pressure dressing remains on the wound until the next day. We make the first change of dressing, otherwise bleeding may occur. After that, the wounds must be washed out with water for 1-2 minutes twice a day and after defecation. Ointments or antibiotics are not necessary. As a dressing, only a compress is applied to the buttocks for 1-2 weeks, after which the wounds are usually dry. 

We will do the first two dressing changes. After that, you will need to see your primary care physician for routine checkups. However, such appointments are usually not necessary, as it takes time and patience for healing to occur.

In the literature, shaving the hair is not recommended, because in these patients the disease recurs more often. However, since we see hair in the wound already after 3 weeks, which leads to a wound healing disorder, we shave the wounds in the initial phase already for hygienic reasons.

Laser treatment for hair removal is not scientifically beneficial, but can of course be performed. The costs for this are not covered by health insurance.

If the wound is not closed after minimally invasive procedures after more than 8 weeks or after excisions after 3 months, please see us to rule out recurrence of the disease. Before we recommend another operation, we have the possibility to heal the wound with special ointments, shock wave treatment and autologous blood therapy (PRP). You should use this possibility. Wound cleansing (debridement) under local anesthesia can also trigger a new stimulus for wound closure. 

In the case of small wounds, normal movement is allowed already on the day after the operation. Prolonged sitting, such as at a desk, should not be done during the first 3 days. Sports without stressing the gluteal region, such as arm and shoulder exercises or push-ups, can be performed without problems after about 5 days. On the other hand, sedentary sports such as cycling or rowing should only be done when the wounds have healed completely.