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. [8] 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.
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. [6] Loose hair may be seen projecting from the site. [5, 9]
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.
Complications
Recurrence of the abscess is by far the most common complication. Most literature reviewed quote a rate between 40% and 50%, although 58% will heal primarily by 5 weeks.
Primary incision and drainage seems to clearly be the primary mode of treatment; for recurrent disease presentations, a multitude of surgical techniques, from incision and curettage and marsupialization to wide excision with flap procedures, have been described throughout the years. A continuum seems to exist, from fairly simple to more complex procedures that should be offered to patients as needed given their particular needs; obviously, the surgeon's own training and experience will factor into the operative decision. [2, 4]
A Cochrane Database of Systematic Reviews article published in 2007 showed no significant difference in outcomes between techniques involving primary closure versus healing by secondary intention, though the review did recommend off-line closure when primary closure is performed. [10] A series of treatments of the local region with phenol have also been described, with a low incidence of recurrence reported. [2]
Wound infection after primary incision and drainage is rare but described. At least one article suggests broad-spectrum antibiotics should be administered given the possibility of both aerobic and anaerobic infection at the incision site. [5]
Squamous cell carcinoma after recurrence of pilonidal disease has been described; it is rare in incidence but, when diagnosed, requires en bloc surgical resection and appropriate oncologic care with local radiation and possibly chemotherapy. [2]
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Pilonidal cyst.
