History and Physical Examination

Although pilonidal disease may manifest as an abscess, a pilonidal sinus, a recurrent or chronic pilonidal sinus, or a perianal pilonidal sinus, the most common manifestation of pilonidal disease is a painful, fluctuant mass in the sacrococcygeal region.

Initially, 50% of patients first present with a pilonidal abscess that is cephalad to the hair follicle and sinus infection. Pain and purulent discharge from the sinus tract are present 70-80% of the time and are the two most frequently described symptoms. In the early stages preceding the development of an abscess, only a cellulitis or folliculitis is present. The abscess is formed when a folliculitis expands into the subcutaneous tissue or when a preexisting foreign body granuloma becomes infected.

The diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, which can be palpated as an area of deep induration beneath the skin in the sacral region. These tracts most commonly run in the cephalad direction. When the tract runs in the caudal direction, perianal sepsis may be present.

The distinctions among pilonidal disease, fistula-in-ano, and hidradenitis can be difficult to discern. In the differential diagnosis, also include skin furuncle, syphilitic granuloma, tubercular granuloma, and osteomyelitis of the underlying sacrum with a draining sinus.

Recurrent pilonidal disease is most often observed after incision and drainage of a pilonidal abscess. In this setting, the pilonidal sinus has not been excised and remains after the abscess cavity heals, only to precipitate a recurrence. After surgical excision, the hair follicle has been removed and is no longer the precipitating cause of the chronic pilonidal sinus. Instead, the base of the unhealed surgical wound is believed to become filled with granulation tissue, hair, and skin debris, which is a nidus for the ongoing foreign body reaction that causes the chronic disease.

Endoanal pilonidal sinus is a rare variety of pilonidal disease that affects the perianal skin directly or may occur circumferentially around the anus, involving the skin of the anal verge.^[9] Three causes of perianal pilonidal disease have been described, as follows:

First, the pilonidal sinus may tract down caudally, creating a perianal fissure or fistula communicating with the anal canal
Second, hair may enter the healing wound of a surgically managed fistula-in-ano
Third, hair may be propelled, penetrating the normal anoderm and producing a similar foreign body reaction, which is usually observed in the sacrococcygeal region

Workup

Hodges RM. Pilonidal sinus. Boston Med Surg J. 1880. 103:485-586.
Doll D, Friederichs J, Dettmann H, Boulesteix AL, Duesel W, Petersen S. Time and rate of sinus formation in pilonidal sinus disease. Int J Colorectal Dis. 2008 Apr. 23 (4):359-64. [QxMD MEDLINE Link].
Corman ML, Nicholls RJ, Fazio VW, Bergamaschi R. Corman's Colon and Rectal Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2012. 195-203.
Akinci OF, Kurt M, Terzi A, Atak I, Subasi IE, Akbilgic O. Natal cleft deeper in patients with pilonidal sinus: implications for choice of surgical procedure. Dis Colon Rectum. 2009 May. 52 (5):1000-2. [QxMD MEDLINE Link].
Clothier PR, Haywood IR. The natural history of the post anal (pilonidal) sinus. Ann R Coll Surg Engl. 1984 May. 66 (3):201-3. [QxMD MEDLINE Link]. [Full Text].
Spivak H, Brooks VL, Nussbaum M, Friedman I. Treatment of chronic pilonidal disease. Dis Colon Rectum. 1996 Oct. 39 (10):1136-9. [QxMD MEDLINE Link].
Akinci OF, Bozer M, Uzunköy A, Düzgün SA, Coşkun A. Incidence and aetiological factors in pilonidal sinus among Turkish soldiers. Eur J Surg. 1999 Apr. 165 (4):339-42. [QxMD MEDLINE Link].
Orland PJ, Rhei E, Brolin RE, et al. Comparison of open versus closed excision of chronic pilonidal sinus. Contemp Surg. 1992. 41:13-8.
Taylor BA, Hughes LE. Circumferential perianal pilonidal sinuses. Dis Colon Rectum. 1984 Feb. 27 (2):120-2. [QxMD MEDLINE Link].
Keighley MRB. Anorectal disorders. Fischer J, Ellison EC, Upchurch GR Jr, Galandiuk S, Gould JC, Klimberg VS, et al, eds. Fischer's Mastery of Surgery. 7th ed. Philadelphia: Wolters Kluwer; 2019. Vol 2: Chap 164.
Velitchkov N, Djedjev M, Kirov G, Losanoff J, Kjossev K, Losanoff H. Toxic shock syndrome and necrotizing fasciitis complicating neglected sacrococcygeal pilonidal sinus disease: report of a case. Dis Colon Rectum. 1997 Nov. 40 (11):1386-90. [QxMD MEDLINE Link].
Kulaylat MN, Gong M, Doerr RJ. Multimodality treatment of squamous cell carcinoma complicating pilonidal disease. Am Surg. 1996 Nov. 62(11):922-9. [QxMD MEDLINE Link].
Senapati A. Pilonidal sinus. Sagar P, Hill AG, Knowles CH, Post S, Bemelman WA, Roberts PL, et al, eds. Keighley and Williams' Surgery of the Anus, Rectum, and Colon. 4th ed. Boca Raton, FL: CRC Press; 2019. Vol 1: 229-38.
Liyanage A, Woods Y, Javed MA, Deftly C, Shaban H, Kalaiselvan R, et al. Laser depilation as adjuvant therapy in prevention of recurrence of pilonidal sinus disease: initial experience of a district general hospital in the UK. Ann R Coll Surg Engl. 2020 Nov. 102 (9):685-688. [QxMD MEDLINE Link]. [Full Text].
Stansby G, Greatorex R. Phenol treatment of pilonidal sinuses of the natal cleft. Br J Surg. 1989 Jul. 76 (7):729-30. [QxMD MEDLINE Link].
Dag A, Colak T, Turkmenoglu O, Sozutek A, Gundogdu R. Phenol procedure for pilonidal sinus disease and risk factors for treatment failure. Surgery. 2012 Jan. 151 (1):113-7. [QxMD MEDLINE Link].
Calikoglu I, Gulpinar K, Oztuna D, Elhan AH, Dogru O, Akyol C, et al. Phenol Injection Versus Excision With Open Healing in Pilonidal Disease: A Prospective Randomized Trial. Dis Colon Rectum. 2017 Feb. 60 (2):161-169. [QxMD MEDLINE Link].
Lund JN, Leveson SH. Fibrin glue in the treatment of pilonidal sinus: results of a pilot study. Dis Colon Rectum. 2005 May. 48 (5):1094-6. [QxMD MEDLINE Link].
Lund J, Tou S, Doleman B, Williams JP. Fibrin glue for pilonidal sinus disease. Cochrane Database Syst Rev. 2017 Jan 13. 1:CD011923. [QxMD MEDLINE Link].
Win M, Went TR, Ruo SW, Kannan A, Dominic JL, Sultan W, et al. A Systematic Review of Fibrin Glue as an Ideal Treatment for the Pilonidal Disease. Cureus. 2021 Aug. 13 (8):e16831. [QxMD MEDLINE Link]. [Full Text].
Gupta PJ. Radiofrequency sinus excision: better alternative to marsupialization technique in sacrococcygeal pilonidal sinus disease. J Natl Med Assoc. 2005 Jul. 97 (7):998-1002. [QxMD MEDLINE Link].
Dessily M, Charara F, Ralea S, Allé JL. Pilonidal sinus destruction with a radial laser probe: technique and first Belgian experience. Acta Chir Belg. 2017 Jun. 117 (3):164-168. [QxMD MEDLINE Link].
Zimmerman CE. Outpatient excision and primary closure of pilonidal cysts and sinuses. Am J Surg. 1978 Nov. 136 (5):640-2. [QxMD MEDLINE Link].
Søndenaa K, Nesvik I, Andersen E, Søreide JA. Recurrent pilonidal sinus after excision with closed or open treatment: final result of a randomised trial. Eur J Surg. 1996 Mar. 162 (3):237-40. [QxMD MEDLINE Link].
Allen-Mersh TG. Pilonidal sinus: finding the right track for treatment. Br J Surg. 1990 Feb. 77 (2):123-32. [QxMD MEDLINE Link].
Spyridakis M, Christodoulidis G, Chatzitheofilou C, Symeonidis D, Tepetes K. The role of the platelet-rich plasma in accelerating the wound-healing process and recovery in patients being operated for pilonidal sinus disease: preliminary results. World J Surg. 2009 Aug. 33 (8):1764-9. [QxMD MEDLINE Link].
Khodakaram K, Stark J, Höglund I, Andersson RE. Minimal Excision and Primary Suture is a Cost-Efficient Definitive Treatment for Pilonidal Disease with Low Morbidity: A Population-Based Interventional and a Cross-Sectional Cohort Study. World J Surg. 2017 May. 41 (5):1295-1302. [QxMD MEDLINE Link].
Solla JA, Rothenberger DA. Chronic pilonidal disease. An assessment of 150 cases. Dis Colon Rectum. 1990 Sep. 33 (9):758-61. [QxMD MEDLINE Link].
Bascom J. Pilonidal disease: origin from follicles of hairs and results of follicle removal as treatment. Surgery. 1980 May. 87 (5):567-72. [QxMD MEDLINE Link].
Edwards MH. Pilonidal sinus: a 5-year appraisal of the Millar-Lord treatment. Br J Surg. 1977 Dec. 64 (12):867-8. [QxMD MEDLINE Link].
Bascom J. Pilonidal disease: long-term results of follicle removal. Dis Colon Rectum. 1983 Dec. 26 (12):800-7. [QxMD MEDLINE Link].
Theodoropoulos GE, Vlahos K, Lazaris AC, Tahteris E, Panoussopoulos D. Modified Bascom's asymmetric midgluteal cleft closure technique for recurrent pilonidal disease: early experience in a military hospital. Dis Colon Rectum. 2003 Sep. 46 (9):1286-91. [QxMD MEDLINE Link].
Ersoy E, Devay AO, Aktimur R, Doganay B, Ozdoğan M, Gündoğdu RH. Comparison of the short-term results after Limberg and Karydakis procedures for pilonidal disease: randomized prospective analysis of 100 patients. Colorectal Dis. 2009 Sep. 11 (7):705-10. [QxMD MEDLINE Link].
Kulacoglu H. Choosing the correct side for Karydakis flap. Colorectal Dis. 2008 Nov. 10 (9):949-50. [QxMD MEDLINE Link].
Farringer JL Jr, Pickens DR Jr. Pilonidal cyst: an operative approach. Am J Surg. 1978 Feb. 135 (2):262-4. [QxMD MEDLINE Link].
Abu Galala KH, Salam IM, Abu Samaan KR, El Ashaal YI, Chandran VP, Sabastian M, et al. Treatment of pilonidal sinus by primary closure with a transposed rhomboid flap compared with deep suturing: a prospective randomised clinical trial. Eur J Surg. 1999 May. 165 (5):468-72. [QxMD MEDLINE Link].
Mahdy T. Surgical treatment of the pilonidal disease: primary closure or flap reconstruction after excision. Dis Colon Rectum. 2008 Dec. 51 (12):1816-22. [QxMD MEDLINE Link].
Başterzi Y, Canbaz H, Aksoy A, Sar A, Türkmenoğlu MO, Cağlkülekçi M. Reconstruction of extensive pilonidal sinus defects with the use of S-GAP flaps. Ann Plast Surg. 2008 Aug. 61 (2):197-200. [QxMD MEDLINE Link].
Kaya B, Eris C, Atalay S, Bat O, Bulut NE, Mantoglu B, et al. Modified Limberg transposition flap in the treatment of pilonidal sinus disease. Tech Coloproctol. 2012 Feb. 16 (1):55-9. [QxMD MEDLINE Link].
Kirkil C, Böyük A, Bülbüller N, Aygen E, Karabulut K, Coşkun S. The effects of drainage on the rates of early wound complications and recurrences after Limberg flap reconstruction in patients with pilonidal disease. Tech Coloproctol. 2011 Dec. 15 (4):425-9. [QxMD MEDLINE Link].
[Guideline] Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR, Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons' Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis Colon Rectum. 2019 Feb. 62 (2):146-157. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

of 0

Author

M Chance Spalding, DO, PhD Resident Physician, Department of General Surgery, Doctors Hospital, OhioHealth

Disclosure: Nothing to disclose.

Coauthor(s)

Jason P Straus, MD Staff Physician, Department of Surgery, Wright State University School of Medicine

Jason P Straus, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons

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.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Andres E Castellanos, MD Assistant Professor, Associate Surgical Residency Program Director, Department of Surgery, Drexel University College of Medicine

Andres E Castellanos, MD is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

James de Caestecker, DO Instructor, Department of Surgery, MCP Hahnemann University

James de Caestecker, DO is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Barry D Mann, MD Program Director, Associate Professor, Department of Surgery, Division of General Surgery, MCP Hahnemann University

Barry D Mann, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Education, American College of Surgeons, American Society of Bariatric Physicians, Association for Surgical Education, Society for Surgery of the Alimentary Tract, and Society of Surgical Oncology

Disclosure: Nothing to disclose.

Pilonidal Disease Clinical Presentation

History and Physical Examination

References

Tables

Contributor Information and Disclosures

What would you like to print?