Pilonidal Sinus

What Is Pilonidal Sinus?

Pilonidal sinus is a channel that forms at the junction of the buttocks in the coccyx area, where hair and skin debris accumulate. The disease is explained by two main mechanisms:

1. Congenital weakness theory: An inherent weakness of the skin structure in the area
2. Acquired theory: Hairs that pierce the skin and create a foreign body reaction

The second view is more widely accepted today. Hairs penetrating the skin create a tunnel that expands and becomes inflamed over time.

Types of Pilonidal Sinus

Pilonidal sinus is classified differently based on the clinical presentation:

Asymptomatic Pilonidal Sinus

Appears as a small hole or depression on the tailbone and causes no complaints. Active treatment may not be required at this stage.

Acute Pilonidal Abscess

Develops due to sudden inflammation of the sinus. There is severe pain, swelling, redness, and warmth in the area. Requires emergency drainage.

Chronic Pilonidal Sinus

Manifests with recurrent inflammation attacks, continuous discharge, and mild pain. Surgical treatment is usually required.

Complex (Recurrent) Pilonidal Disease

An advanced-stage disease that recurs despite previous surgeries or has multiple channels.

Risk Factors

Factors facilitating the development of pilonidal sinus:

• Male gender: 3-4 times more common than in women
• Young age: Most commonly seen between 15-35 years of age
• Excessive hair growth, especially hard and dark-colored hair
• Excess weight and obesity: Increases moisture and friction in the area
• Prolonged sitting: Drivers, office workers, students
• Family history: Genetic predisposition may exist
• Tight and narrow clothing
• Excessive sweating
• Inadequate hygiene
• Recurrent trauma to the area

Symptoms of Pilonidal Sinus

Symptoms vary depending on the stage of the disease:

Early Stage Symptoms

• A small hole or depression on the tailbone
• Mild itching or discomfort
• Occasional wetness in the area
• Small lumps under the skin

Acute Abscess Symptoms

• Severe, throbbing pain in the area
• Significant swelling and redness
• Sensation of warmth
• Fever and chills
• Pain that increases when walking and sitting
• In some cases, spontaneous pus discharge

Chronic Sinus Symptoms

• Continuous or intermittent discharge (pus, blood, or clear fluid)
• Mild pain and discomfort
• Foul odor
• Skin irritation
• Recurrent inflammation attacks

Diagnostic Methods

Physical Examination

The foundation of diagnosis. The tailbone area is visually inspected. Typically observed findings:

• One or more "pits" (holes)
• Discharge or pus
• Swelling, redness (in acute stage)
• Scar tissue (in recurrent cases)

Additional Examinations

Imaging methods may help in complex cases:

• Soft tissue ultrasound: To evaluate the depth and extension of the sinus
• MRI: In complex or recurrent cases
• Fistulography: In long sinus tracts

Pilonidal Sinus Treatment

Treatment is determined according to the stage of the disease, the complexity of the sinus, and the patient's condition.

Treatment of Acute Abscess: Drainage

In case of acute pilonidal abscess, drainage of the abscess is required first:

• A small incision is made under local anesthesia
• Pus and inflamed tissue are cleaned
• The wound is left open for secondary healing
• Antibiotic therapy is added in some cases

Drainage resolves the acute condition but is not a definitive treatment; the sinus often persists and may become inflamed again.

Definitive Treatment: Surgical Methods

The definitive treatment for chronic or recurrent pilonidal sinus is surgical. Several surgical options exist:

Classic Excision and Open Healing

The entire sinus tract is excised and the wound is left open for secondary healing.

Advantages:

• Low recurrence rate
• Simple technique

Disadvantages:

• Long healing time (6-12 weeks)
• Daily dressing required
• Long-term work loss

Excision and Primary Closure

The sinus is removed and the skin is directly sutured to close it.

Advantages:

• Fast recovery

Disadvantages:

• High recurrence rate
• Risk of wound dehiscence

Limberg Flap (Most Commonly Preferred Method)

After excision of the sinus, closure is made with a rhomboid-shaped flap prepared from the surrounding tissue. Advantages:

• The wound is shifted off the midline (hair pressure is reduced)
• The natal cleft is flattened
• Low recurrence rate (2-5%)
• Fast recovery (2-3 weeks)
• Good cosmetic outcome

Karydakis Flap

Similar to the Limberg flap, based on the principle of moving the wound line away from the midline. Can be performed under local anesthesia.

Pit Picking (Bascom Technique)

A minimally invasive method. Only the pit (hole) portions are removed, preserving the surrounding tissue.

Advantages:

• Can be performed under local anesthesia
• Fast recovery (1-2 weeks)
• Little pain
• Early return to work

Disadvantages:

• Not suitable in complex cases
• Moderate recurrence rate

EPSiT (Endoscopic Pilonidal Sinus Treatment)

Treatment is performed from inside the sinus with an endoscope. One of the newest minimally invasive methods.

Advantages:

• Smallest incision
• Very fast recovery
• Little pain
• High patient satisfaction

Laser Treatment (SiLaT - Sinus Laser Treatment)

A laser fiber is placed inside the sinus and the tissue is destroyed with its energy.

Advantages:

• Minimally invasive
• Short recovery
• Can be performed under local anesthesia
• Low complications

Phenol Application

Phenol is injected into the sinus to seal the channel. Can be effective in selected cases.

Post-Operative Process

Healing time varies depending on the selected technique:

• Minimally invasive methods (EPSiT, laser, pit picking): 1-3 weeks
• Flap techniques (Limberg, Karydakis): 2-4 weeks
• Open excision: 6-12 weeks

Important points after surgery:

• Attention should be paid to wound cleanliness
• Regular dressing changes should be made
• Prolonged sitting in the area should be avoided
• Tight and narrow clothing should be avoided
• Hair cleaning in the area should be done (laser epilation recommended)
• Bath time is determined according to physician recommendation
• Sports and heavy lifting are restricted for 3-4 weeks

Recurrence of Pilonidal Sinus

Pilonidal sinus is a disease that can recur despite surgical treatment. Recurrence rates:

• Classic excision and primary closure: 15-30%
• Open excision: 5-15%
• Limberg flap: 2-5%
• EPSiT, laser, pit picking: 5-15% (in selected patients)

To prevent recurrence:

• Continuous hair removal in the area (especially laser epilation)
• Weight control
• Good hygiene
• Avoiding prolonged sitting
• Wound follow-up
• Avoiding tight clothing

Laser Epilation and Pilonidal Sinus

Permanent hair removal in the area significantly reduces the risk of recurrence both before and after surgery. Laser epilation is:

• The gold standard adjuvant treatment in recurrent cases
• Can be started 4-6 weeks after surgery
• 6-8 sessions are recommended
• The most effective method for long-term protection