Anorectal: Pilonidal Cysts

Pilonidal Cysts

Basics

  • Skin & Subcutaneous Inflammatory Condition of the Gluteal Cleft
    • Collection of Hair & Skin Debris
  • An Acquired Condition (Not Congenital)
  • No Epithelial Lining (Not a True Cyst)
  • Presentations:
    • Acute Cellulitis or Abscess
    • Chronic Smoldering Disease

Risk Factors

  • Young (Teens-20’s)
  • Deep Gluteal Cleft – Facilitates Hair Entrapment
  • Obesity
  • Males
  • Hirsute Body (Thick/Stiff Body Hairy)
  • Caucasian
  • Prolonged Sitting (> 6 Hours)

Classification

  • Tezel Classification
    • Type I: Asymptomatic Sinus
    • Type II: Acute Abscess
    • Type III: Chronic Symptomatic Disease, Limited to the Navicular Area
    • Type IV: Chronic Symptomatic Disease, Extending Beyond the Navicular Area
    • Type V: Recurrent Disease
  • Many Other Classifications Have Been Described

Diagnosis

  • Dx: Physical Exam
    • Classic Midline Pits in the Nadal Cleft
    • Shed Hairs Protruding from Pits
    • Draining Sinuses
    • Tender Cellulitis or Abscess if Acute
  • MRI if Osteomyelitis Suspected

Pilonidal Cyst 1

Pilonidal Cysts – Treatment

Acute Disease

  • Primary Treatment: Incision & Drainage
    • Incision Lateral to the Cleft Off Midline – Improved Healing
    • 60% Chance of Successful Healing
  • Include Antibiotics if Diabetic, Immunocompromised or Other Signs of Systemic Infection

Chronic Disease

  • Early Disease:
    • Non-Operative: Hair Removal #1 & Hygiene
    • Operative: Midline Excision of Pit & Sinus Tract
  • Advanced Disease: Flap Closure

Surgical Excision Considerations

  • Options for Wound Closure:
    • Primary Repair
      • Fast Healing
      • Higher Recurrence
    • Secondary Intention
      • Longer Healing (Months) – Not Typically Preferred
      • Lower Recurrence
    • Marsupialization – Suture Skin Margins to Presacral Fascia at the Edges
      • Decreases Healing Time of Secondary Intention
      • Better Recurrence Risk than Primary Closure
  • Postoperative Wound Breakdown
    • Small Wound: Daily Packing Changes
    • Large Wound: Rotational Flap or Skin Graft

Limberg Flap for Pilonidal Disease 2

References

  1. Giggs Hammouri. Wikimedia Commons. (License: CC BY-3.0)
  2. Bali İ, Aziret M, Sözen S, Emir S, Erdem H, Çetinkünar S, İrkörücü O. Effectiveness of Limberg and Karydakis flap in recurrent pilonidal sinus disease. Clinics (Sao Paulo). 2015 May;70(5):350-5. (License: CC BY-NC-3.0)