Pilonidal Cyst and Sinus Clinical Presentation

Updated: Mar 16, 2017
  • Author: Alex Koyfman, MD; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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Presentation

History

Pilonidal disease can present in a couple of different disease states and may be asymptomatic, but the most common form seen in the ED is a painful, swollen lesion in the sacrococcygeal region about 4-5 cm posterior to the anal orifice. At times, spontaneous drainage may have occurred prior to presentation to the clinician. Patients may present with intermittent swelling and drainage, including purulent, mucoid, or bloody fluid from the area. Chronic pilonidal disease often manifests as recurrent or persistent drainage and pain.

Occasionally, a history of trauma is recalled, and the patient may state that a similar lesion occurred in that area before, for which the patient may have had a primary incision and drainage or other definitive care prior to this presentation. [7] Given most patients are young and healthy, other comorbidities are not common, and review of systems is often negative, including fever and chills.

There is no known preponderance of this disease in smokers or alcohol or drug abusers.

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Physical

Usually, the patient is afebrile and nontoxic. Local examination may show a relatively unremarkable sinus tract in the sacrococcygeal region, but, usually at ED presentation, the patient has typical findings of an abscess, including redness, warmth, local tenderness, and fluctuance with or without induration. A tender mass with sinus drainage may be present. [5] Loose hair may be seen projecting from the site. [8, 4]

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Causes

Pilonidal disease is acquired, not congenital, and involves loose hair and skin and perineal flora.

Risk factors for pilonidal disease include male gender, hirsute individuals, Caucasians, sitting occupations, existence of a deep natal cleft, and presence of hair within the natal cleft. Family history is seen in 38% of patients with pilonidal disease. Obesity is a risk factor for recurrent disease.

The most commonly reported bacteria cultured from pilonidal abscesses differ by author. In one study, anaerobic cocci were present 77% of the time; aerobic, 4%; and mixed aerobic and anaerobic, 17%. Other studies quote Staphylococcus aureus, an aerobe, as being the most common bacterial pathogen.

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