What is a Pilonidal Cyst?
A pilonidal cyst is a cavity filled with hair follicles and fluid which can become infected. The cysts are typically asymptomatic and usually present as an abscess at or around the tailbone. The abscess causes swelling, pain or discomfort to the patient. While symptoms may go away on their own, most pilonidal cyst infections recur and need to be treated by a professional, often through a pilonidal cyst drainage and then an outpatient surgery. Sometimes the cyst abscesses drain spontaneously. If drainage persists this indicates a sinus tract has formed under the skin.
What Causes Pilonidal Cysts?
Despite being a common condition, experts are still unsure of what exactly causes a pilonidal cyst. Although theories of congenital origin were popular in the past, generally an acquired etiology is more accepted at present. Three popular theories maintain that either:
1. A small pit develops secondary to subcutaneous rupture of a follicle in the natal cleft, into which stray hairs may collect.
2. Stray hair strands after a haircut burrow into the skin at the level of the natal cleft secondary to their natural unidirectional scaled surface and the propensity of hair to collect in this region. Once a single hair has started the process, others follow.
3. Deep trauma to the fascial tissue surrounding the tailbone which leads to blood and fluid in this area. When the blood and fluid are reabsorbed a negative pressure cavity forms which pulls tissue and eventually hair into the area. During World War II it was called “Jeep’s disease” as many of the young jeep drivers were afflicted with this problem. The young men and women were bouncing around on the tailbone all day as they rode in the jeep. The etiology of pilonidal disease remains controversial, and may in fact be a combination of factors.
In any case, a subcutaneous cavity or sinus is created, not uncommonly with a surprisingly large amount of hair present in the space. This may smolder for months or years before becoming an infected abscess.
Symptoms of Pilonidal Cysts
Common symptoms of pilonidal cysts include:
- Pain
- Swelling
- Redness around the swollen area
- Spontaneous drainage of the abscess
- Chronic drainage from a secondary opening in the skin
Pilonidal cysts can be different sizes, ranging from a small, not very noticeable dimple, to a large painful bulge. Non-infected cysts almost never bother the patient as they are small and do not create symptoms.
The most common symptom leading to the diagnosis is an abscess causing pain and swelling, which causes the patient to eventually seek care.
Differential Diagnosis of Pilonidal Cysts
There are several conditions that cause the same or similar symptoms as pilonidal cysts, including:
- Fistula-in-ano
- Furuncle (deep hair infection)
- Hidradenitis suppurativa
How are Pilonidal Cysts diagnosed?
Pilonidal cysts are diagnosed by the symptoms and the visualization on examination by a physician.
Once your doctor has identified the cyst, they will make a recommendation on the course of treatment that is best suited for your situation.
Can You Drain a Pilonidal Cyst Abscess Yourself?
A pilonidal cyst abscess drainage treatment should only be conducted by a health professional, such as a proctologist. Attempting to drain or pop the pilonidal cyst abscess on your own at home may cause further complications and even worsen the infection that might need surgery.
Your proctologist will be able to safely drain the pilonidal cyst abscess with minimal discomfort to you, ensuring that the cyst heals properly.
How are Pilonidal Cysts Treated
Office Procedures – Pilonidal Cyst Drainage
Office procedures for a pilonidal cyst abscess include incision and drainage. In the acute abscess phase this is the first line of therapy. Pilonidal cyst abscess drainage is a simple procedure that can be done in the office with minimal discomfort.
While the drainage of a pilonidal cyst abscess will not cure the disease, it will remove the infection making the definitive surgery easier to perform. If the abscess is too big, the incision and drainage may need to be performed as an outpatient.
Outpatient Surgery
Pilonidal cyst only – Surgically removing the pilonidal cyst.- In my opinion, this is the best cure for a pilonidal cyst. This is done as an outpatient procedure. When I do surgery patients have a twilight anesthesia with an anesthesiologist, and I inject the area with local analgesia to make it numb. A small incision is created to remove the cyst and offending pilonidal pits.
I will close the deeper portion and keep the wound open to prevent recurrence. I keep the wound open to allow for secondary intention healing. When the wound is left open it will need to be packed 2 times a day, so having someone reliable that can do a dressing change is important. It takes 8-10 weeks for the wound to heal though the recovery from the pain is only 7 days.
Pilonidal Cyst with Sinus Tract – Surgically removing the pilonidal cyst and unroofing the sinus tract. The same procedure for the pilonidal cyst is performed and after the cyst is excised I place a probe into the outer sinus tract opening into the area of excision and unroof the tunnel. This also heals as an open wound.
Another option is excising the sinus and unroofing any offending pilonidal pits. The deep wound will be brought together to decrease the depth of the cavity. The wound is left open and will need to be packed two times a day for 6-8 weeks. Wound care is the most important part of healing and someone is necessary to change the dressing.
Sometimes a deep tissue flap is necessary to heal the area, but this is often reserved for recurrence of the cyst.
Finally, there is the option of debriding the cyst cavity and applying phenol into the area. Studies show this works but recurrences can happen from 5% – 38% of the time. The procedure is done in the outpatient setting under twilight anesthesia along with local analgesia. It may need to be repeated if the first application doesn’t work.
Pilonidal Cyst Surgery Risks
There are inherent risks to having pilonidal cyst surgery. Though the complications are not frequent they can occur. The risks to the surgery include but are not limited to:
- Death
- Bleeding
- Infection
- Abscess
- Recurrence of the pilonidal cyst
- Stroke
- Heart attack,
- Blood clots in the legs that can dislodge and go to the lungs
- Anesthesia complications.
Pilonidal Cyst Surgery Recovery
When I perform surgery for a pilonidal cyst I inform my patients to take a week off work. The pain should be gone in a week and patients usually get back to work by then. It could take up to 10 days but for the majority of patients a week is all that is needed. I prescribe pain pills which usually aren’t necessary after the 3rd day. Patients can switch to the anti-inflammatory medicines like Motrin or Aleve.
Since I leave the wound open it takes about 8-12 weeks for the wound to completely heal. The wound needs to be packed 2 times a day for the full 8-12 weeks to keep it from closing too prematurely which leads to a non-healing wound with swelling and drainage just like the pilonidal cyst. I typically have a family member come in for the recovery period to teach him/her how to pack the wound. Again, the pain will be gone in a week but the wound won’t heal for 8-12 weeks.
After the pain has resolved there is no restriction on non contact activity. Patients can work out, swim, hike, etc. after a week. Contact activity such as grappling or sports which require hitting and tackling should be postponed for 2 weeks. I follow the patients in the office for the duration of the healing process and until the wound is completely healed. If you have symptoms of a pilonidal cyst see your proctologist for an evaluation and treatment. You are worthy.