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Pilonidal Cyst and Sinus Treatment & Management

  • Author: Alex Koyfman, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
 
Updated: Mar 23, 2016
 

Emergency Department Care

Patients with pilonidal disease without abscess or other significant symptoms should be discharged from the ED with reassurance and instructions to return if signs of an abscess develop. Patients should maintain adequate hygiene of the area and closely observe for infection. Current literature review by this author failed to note an indication for surgical intervention at this stage.[12] However, if clinical signs of a pilonidal abscess are noted, primary incision and drainage should be performed in the ED for symptomatic relief, as follows:[2, 13, 14]

  • Place the patient in the prone position as comfortably as possible and have him or her undress adequately to expose the region is question. Rarely, a patient may require a small amount of sedative to tolerate the procedure, though reassurance by medical personnel is usually adequate.
  • Using sterile technique and instrumentation, prepare the region for incision with povidone-iodine (Betadine) or other suitable skin cleansing agent. Local anesthetic should be infiltrated generously with a small-gauge needle along the planned incision site (use of local vasoconstrictor such as epinephrine is acceptable).
  • The primary incision is longitudinal and should be made off the midline into skin, subsequently carrying it down to the level of subcutaneous tissue to open up the abscess cavity. As much purulent drainage and debris should be removed from the site as possible; blunt dissection may assist with this process as the patient can tolerate.
  • Once the space is evacuated adequately, ribbon wound packing should be placed to occupy the space and allow further passive drainage. The space should not be packed tightly, and there is no known advantage to using medicated ribbon gauze. Cover dressing can be with 4 X 4 gauze or an ABD pad secured with surgical tape. The patient may require brief amounts of nonopioid analgesia post procedure.[8]
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Consultations

A surgical consultation is only needed if the diagnosis and management are unclear from the patient presentation. The presence of chronic disease with recurrent painful episodes may warrant surgical consultation for surgical excision of all sinus tracts. If there is a question of whether a true pilonidal abscess has formed, ultrasound can be used to identify the abscess prior to definitive incision and drainage. The practice of exploratory needle aspiration in these instances seems to have gone by the wayside.

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Contributor Information and Disclosures
Author

Alex Koyfman, MD Assistant Professor, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital

Alex Koyfman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Brit J Long, MD Chief Resident, Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium

Brit J Long, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Emergency Medicine Residents' Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital

Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, South Carolina Medical Association, Columbia Medical Society, South Carolina College of Emergency Physicians, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Chief Editor for Medscape.

Chief Editor

Gil Z Shlamovitz, MD, FACEP Associate Professor of Clinical Emergency Medicine, Keck School of Medicine of the University of Southern California; Chief Medical Information Officer, Keck Medicine of USC

Gil Z Shlamovitz, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association

Disclosure: Nothing to disclose.

Additional Contributors

Jerry R Balentine, DO, FACEP, FACOEP Vice President, Medical Affairs and Global Health, New York Institute of Technology; Professor of Emergency Medicine, New York Institute of Technology College of Osteopathic Medicine

Jerry R Balentine, DO, FACEP, FACOEP is a member of the following medical societies: American College of Emergency Physicians, New York Academy of Medicine, American College of Osteopathic Emergency Physicians, American Association for Physician Leadership, American Osteopathic Association

Disclosure: Nothing to disclose.

Michael D Lanigan, MD Attending Physician, Department of Emergency Medicine, Administrative Section, State University of New York Downstate Medical Center

Michael D Lanigan, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Robert Ringelheim, MD, Mark A Silverberg, MD, and Norma Jean Johnson-Villanueva, MD, to the development and writing of this article.

References
  1. Hull TL, Wu J. Pilonidal disease. Surg Clin North Am. 2002 Dec. 82(6):1169-85. [Medline].

  2. Gul VO, Destek S, Ozer S, Etkin E, Ahioglu S, Ince M, et al. Minimally Invasive Surgical Approach to Complicated Recurrent Pilonidal Sinus. Case Rep Surg. 2015. 2015:759316. [Medline].

  3. da Silva JH. Pilonidal cyst: cause and treatment. Dis Colon Rectum. 2000 Aug. 43(8):1146-56. [Medline].

  4. Miller D, Harding K. Pilonidal Sinus Disease. Dec 2003. World Wide Wounds. Available at http://www.worldwidewounds.com/2003/december/Miller/Pilonidal-Sinus.html.

  5. Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg. 2011 Mar. 24 (1):46-53. [Medline].

  6. Ghnnam WM, Hafez DM. Laser hair removal as adjunct to surgery for pilonidal sinus: our initial experience. J Cutan Aesthet Surg. 2011 Sep. 4(3):192-5. [Medline]. [Full Text].

  7. Caestecker J, Mann BD, Castellanos AE, Straus J. Pilonidal Disease. Medscape Reference from WebMD. Last updated Jan 22, 2009. [Full Text].

  8. Burnstein M. Managing anorectal emergencies. Can Fam Physician. 1993 Aug. 39:1782-5. [Medline].

  9. von Laffert M, Stadie V, Ulrich J, Marsch WC, Wohlrab J. Morphology of pilonidal sinus disease: some evidence of its being a unilocalized type of hidradenitis suppurativa. Dermatology. 2011. 223(4):349-55. [Medline].

  10. Feigen GM, Gordon RB. Pilonidal disease simulating rectal abscess and fistula. AMA Arch Surg. 1956 Aug. 73(2):258-60. [Medline].

  11. Hoffman NN, Hoffman GH, Firoozmand E, Capiendo LM. Pilonidal Disease: Subtle, Not So Subtle and Stubborn. Los Angeles Colon and Rectal Surgical Associates. Available at https://www.lacolon.com/documents/Pilonidal%20Disease.pdf.

  12. Doll D, Friederichs J, Boulesteix AL, Dusel W, Fend F, Petersen S. Surgery for asymptomatic pilonidal sinus disease. Int J Colorectal Dis. 2008 Sep. 23(9):839-44. [Medline].

  13. Nguyen AL, Pronk AA, Furnée EJ, Pronk A, Davids PH, Smakman N. Local administration of gentamicin collagen sponge in surgical excision of sacrococcygeal pilonidal sinus disease: a systematic review and meta-analysis of the literature. Tech Coloproctol. 2015 Nov 6. [Medline].

  14. Sevinç B, Karahan Ö, Okuş A, Ay S, Aksoy N, Şimşek G. Randomized prospective comparison of midline and off-midline closure techniques in pilonidal sinus surgery. Surgery. 2015 Oct 31. [Medline].

  15. McCallum I, King PM, Bruce J. Healing by primary versus secondary intention after surgical treatment for pilonidal sinus. Cochrane Database Syst Rev. 2007 Oct 17. CD006213. [Medline].

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