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Pilonidal Cysts:  What You Should Know!

A pilonidal cyst is a sac under the skin at the base of the spine located in the opening between the buttocks muscles. Learn what it is and how to treat it!

By: Randy Herring

    Note: The information on this page is for educational purposes. It is the opinion of doctors and professionals and is presented to inform you about pilonidal cyst and surgical conditions. It is not meant to contradict or replace any information you may receive from your personal physician and should not be used to make decisions about pilonidal surgical treatment. Commentaries by post-op patients reflect individual experiences and not meant to be used to replace medical advice or recommendations.

What You Should Know!

A pilonidal (PIE-low-NI-dal) cyst is a sac under the skin at the base of the spine located in the opening between the buttocks muscles. It looks like a small hole, often with a few hairs coming out. A pilonidal cyst is a minor abnormality that occurs during fetal development. Infection is usually caused by staphylococcal bacteria. If infected you may need an antibiotic to fight the infection. Your doctor may have to open the cyst to drain the pus, and may need to remove the cyst surgically. See below.


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Pilonidal disease has a male predominance and usually affects patients from the mid-teens into the thirties. In the U.S. pilonidal disease affects 26 cases per 100,000 inhabitants and occurs 2.2 times more often in men than women. This seemingly minor disease process has physicians baffled, as demonstrated by the multiple theories of its etiology and management found in the current literature.

The term pilonidal (pilus-hair, nidal-nest) was coined by Hodges in 1880. As the name suggests, pilonidal disease consists of a hair-containing sinus or abscess in the saccrococcygeal area. For a time, the entity was referred to as Jeep rider's disease. It hospitalized over 80,000 U.S. army soldiers during WWII, accounting for 4.2 million sick days. Much of the information we have about the disease comes from the military.

Medical Treatment

After the infection is cleared, a day surgery procedure to remove the cyst is performed. The cyst may be a simple abscess or may be draining from sinus tracts that need to be closed. The process of raising the borders of the emptied cyst and stitching them to form a pouch is called marsupialization.

The interior of the pouch then empties the collection of pus and gradually closes. Several weeks of packing the pouch with gauze is needed to collect the pus while the pouch closes. There are several treatments for pilonidal sinus, and some controversy over which is the best; none is well studied:

  • Closed technique of Lord and Millar: core out the affected midline epithelial follicles and then brush the track weekly until closure to remove hairs. Healing takes an average of 42 days. Injecting the track with phenol instead of brushing gives similar results. Done under local.
  • Open up the track and let it heal by secondary intention. Healing takes an average of 43 days. Average healing time is similar when cauterization with heat, silver nitrate, or freezing is added. Done under local.
  • Wide and deep excision to the sacrum: done if one believes that the sinus is congenital. Average healing time is 73 days if the wound is left open, and 27 days if it is partially closed
  • Excision with primary closure: requires general anesthesia. Healing occurred in 2 weeks in 90% of patients; the rest had been reopened and heal by secondary intention.

Recurrence rates:

    1. Higher for closed techniques than for open.
    2. Rate for wide and deep excision similar to that for opening the track.
    3. 13% for opening the track.
    4. 18% for excision and primary closure with a midline scar.
    5. 10% if the primary closure scar is displaced.

Personal Experience

Surgical Treatment and Post-Op Recovery - Symptoms and side effects of this disease and post-op treatment will vary from one individual to another. Modifying diet and using a laxative & pain reliever should not be used to replace medical advice or recommendations for another individual. Warning: Consult with your physician first before making any modifications in your post-op treatment previously prescribed.

Week 1:

  • My surgical treatment consisted of a "wide and deep excision" (a tad bit larger than a golf ball) and left open to heal from the inside out - leaving to my wife the aid of packing the pouch with gauze twice a day for a month. I was discharged from the recovery room at the hospital 1 1\2 hours after surgery (it is usually 3 hours).
  • Two tablets of Hydrocodone/APAP5 500mg were taken every 4 hours or "as needed for pain." Hydrocodone is a Class III controlled substance classification. It has an abuse potential but less than Schedules I & II. To wait until "as needed for pain" is not a pleasant option so I took it as directed. Side effects I experienced from taking hydrocodone (good and bad):

    • Because it is a narcotic analgestic combination used to relieve moderate to severe pain including codeine it makes you high and drowsy (good).
    • It helps you to relax, remain calm and take it easy. So don't fight the effect of the drowsiness. Rest is important to the healing process. Take advantage of it (good).
    • It causes constipation (bad). I had no bowel movement for 48 hours and that concerned me. (I admittedly was scared to "squat down" due to the thought of re-opening the wound and splitting it!) My doctor recommended I take a laxative. Six hours later it "spilled" relief - and again the next day! After two days I discontinued the laxative due to the following two reasons:

        1. The amount of fluid expulsion, i.e., diarrhea! This raised my fear of infecting the wound from the diarrhea splashing back up (bad)! Seeing my doctor on June 1 he advised me to stop taking the laxative and start relying on my body to get me through this. (The body knows how to take care of itself... It really does.) He told me not to worry.

        2. Nutrients were being destroyed (bad) in my body necessary to maintain an adequate daily dietary allowance, to help heal the surgical wound, and also to maintain lean body mass (LBM), i.e., protein (I have enjoyed weight training for over 20 years.) To compensate for this problem I included supplementing my diet with a protein supplement that helped supply over 1,000 calories (500 per serving taken twice per day) to make sure my body was receiving a fair (or the least amount of) allowance of nutrients and protein necessary that it had not been getting through food due to the laxative. A dietary protein supplement is easy to digest, is absorbed more readily in the body, and expelled through the urine. Choosing constipation (the body knows how to care for itself in times like these) over the laxative thus causing diarrhea and modifying my diet by adding a dietary liquid protein supplement is at least more preserving and healing for the purpose.

    • Four days after my surgery my pain was worsening. The 1000mg of hydrocodone dosage every 4 hours ceased to be effective for relieving pain or making my body drowsy so I could rest or sleep. My body seemed to have built up a tolerance level of or adapted to the dosage (very bad). The next day I mistakenly increased the dosage. MORE IS NOT BETTER. Not only did it not help to relieve the pain but also it made me nauseated around 4am. On my post-op follow-up, five days after surgery, my pain was intolerable. Changing the gauze didn't "feel" pleasant! My doctor prescribed a stronger pain reliever (see Week 2).
    • I have only been able to stand, lie on either side or stomach or sit at my desk at the computer remaining in an upright and forward position. I have not been able to sit on the sofa, chair, relax with my family or play baseball or basketball with my two boys. And driving is literally a "pain in the butt!" while I'm trying to relieve the pressure points of pain! One important thing that I have learned about all this, however, is proper posture and how often most of us slouch and literally sit on our tail bones most of the day! As a matter of fact, just for the stats every day positions slouching in a chair hits the top of the chart at 275%. Sitting upright is 140%, standing erect is 100%, lying on our side is 75% and lying down on our back hits the bottom of the chart at 25%.
    • Little every day things has made me become irritable due to the increasing pain with little effect from the hydrocodone and not being able to sit down comfortably and with my family!
Week 2:

  • During my post-op follow-up mentioned above my doctor prescribed a stronger pain reliever to take. It was Roxicet5-325mg (one taken once every 3 hours). Like hydrocodone it is a narcotic analgestic combination used to relieve moderate to severe pain. But unlike hydrocodone it is a Class II controlled substance classification. It has a high abuse potential but less than a Schedule I. My doctor suggested I could take a shower (finally!) and get the wound wet. (Before I was taking occasional "spit baths".) My doctor also told me the pain would subside this week - and that was the best news! In the evening I was still in a lot of pain (even taking the Roxicet) and went to bed that way.
  • The next morning I felt like a new person. For the first time in a week I had bowel movement and with normal stools. I also took a shower. I didn't feel any pain taking a shower, except for what I had already been feeling before where the open wound was. My pain was still there but not as much. I think I was developing a tolerance to the pain (why fight it right?). Both driving and normal everyday walking continued to be a "pain in the butt!" My appetite is coming back and I began drinking less of the dietary liquid protein supplement.
  • The following day I had three bowel movements with perfect stool texture. I have no constipation side effect with taking the Roxicet. Increased the dosage of Roxicet and taking them until gone (in a couple of days) - 1 1/2 tablets of 488mg every 3 hours to control or subdue the pain. This dosage seems to work fine. My appetite comes and goes when the pain becomes more or less intense on days. However, the pain clearly seems to be dissipating on a daily basis. I have not been able to sit yet since the operation. My wife (whose been changing my gauze twice daily) says the wound is healing and looks much better.

Week 3:

  • I am no longer taking either the hydrocodone or roxicet pain pills. My wound is healing as scheduled and I feel much better. Sitting down has become more tolerable but not yet normal to support my whole body weight while sitting in a reclined or slouched position in a vehicle, recliner or sofa. My two young boys have joined into helping change my gauze (removing only). I decided to look at my "wide and deep excision" with a mirror since I was feeling up to it. It was disgusting. It's what I expected I guess for what a "wide" excision would consist of. Just looking forward to it closing in the next few weeks ahead! Will begin working out again at the gym today after a 2-3 week layoff.

Week 8:

  • My wound is completely healed.

Resources

Information on compiled excerpts above on what pilonidal is, it's history and treatment is derived from the following resources below by individuals, organizations, institutions and internet sites:

http://www.pedisurg.com/PtEduc/Pilonidal_Cyst.htm
http://www.emedicine.com/emerg/topic771.htm

Hoping my story can help you can get through your pilonidal experience!

Thanks,

Pilonidal Cysts:  What You Should Know!

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