Pilonidal sinus, pilonidal sinus, "sacral dermoid", "pilonidal cyst".

Coccygeal fistula (pilonidal sinus)

Here you will find the information that will help you decide on the best therapy.

Emergency? Severe pain?

You want to know more? Here you will find the concentrated knowledge on coccygeal fistula:

A little-known clinical picture

Coccygeal fistula - What to do?

People don't like to talk about health complaints when they affect sensitive areas such as the gluteal fold (rima ani) or coccyx. But especially if you notice pain, hardening, blood or pus or other, unusual symptoms in these parts of the body, you should confide in an experienced proctologist.

With these non-specific symptoms, one often thinks of a bruise, increased sweating or an uncomfortable bicycle saddle as the cause. In the following, you will learn which signs indicate a coccygeal fistula - also called pilonidal sinus - and what the causes are.

Since the foundation of our practice in Munich, our specialists Dr Hofer and colleagues have treated over 4500 patients with sinus pilonidalis.

Based on the revolutionary idea of pit picking by Lord and Bascom, we have been developing our sinusectomy and laser ablation technique since 2004.

With this experience, we have an optimal therapy concept for almost every form of coccygeal fistula.

Diagram of the development of coccygeal fistula
1 normal hair root, 2 broken hair in the hair root, 3 beginning inflammation, 4 and 5 "pits" of different calibre, 6 secondary opening, 7 broken hair in intact skin

What is a fistula?

A fistula is a tubular duct formed as a result of chronic inflammation. There are fistulas in the area of the buttock fold as a result of penetrated hair(coccyx fistula), at the anus starting from the anal glands (analfistula) and in acne inversa (armpits, groin, buttock fold, anal region), a disease that occurs almost exclusively in smokers as a result of a pathologically altered immune reaction.

Do I have a coccygeal fistula?

The 6-point checklist for easy self-diagnosis

If you have these symptoms, you should think of a coccygeal fistula:

  • Palpable induration or visible "bump" over the coccyx
  • pain or feeling of pressure while sitting
  • "Pimple" or "boil on the buttocks" on the side of the buttock crease that does not want to heal

These complaints indicate an abscess (accumulation of pus):

  • Visible redness
  • Rapidly increasing swelling

This practically proves the diagnosis of coccygeal fistula:

  • Small openings or black dots in the centre line ("pits")

Cause and origin

How a coccygeal fistula develops

The Latin term "hair pit" (from Latin pilus 'hair' and nidus 'nest') best describes the problem. A pilonidal sinus is a collection of impaled or ingrown h airs in an encapsulated cavity that leads to inflammation of the soft tissues in the area of the buttock fold.

Hairs can break off in the hair root and penetrate the subcutaneous tissue through the movements of sitting and walking. According to recent studies, hairs from the head or back are also a possible source. Sometimes hair malformation occurs and keratin is deposited in the hair root.

The opening widens and becomes visible, sometimes only as a small black dot. These openings are called "pit" or "porus" and form an entry port for bacteria.

The pilonidal sinus has nothing to do with the coccyx itself ("coccygeal fistula") or a developmental malformation ("dermoid cyst, sacral dermoid"). ... more on this topic

Who helps?

To which doctor for coccygeal fistula?

A coccygeal fistula is a disease of the skin and skin appendages (the hair roots). The dermatologist will nevertheless refer you to the surgeon in most cases. Although surgery for a coccygeal fistula is performed at least 40,000 times a year in Germany, it is still a rare procedure in relation to the total population.

So you will only find a fistula surgeon experienced in minimally invasive techniques in specialised centres. You should see an expert because complications and recurrences are common.

Don't be afraid to ask your doctor which surgical technique he uses, what alternatives he sees and how often he performs the procedure per year.

In addition, the question of whether you need inpatient treatment in hospital and general anaesthesia is justified according to the expected healing time and the personal success rate of a surgeon.

Coccygeal fistula with 2 ports of entry
Coccygeal fistula with 2 entry ports (red arrows) and a secondary opening (green arrow)
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SURGERY FOR COCCYGEAL FISTULA
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TREATMENT CASES
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YEARS OF PIT PICKING EXPERIENCE
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YEARS OF LASER EXPERIENCE

Take the initiative now

Non-binding request to Dr. Hofer

Gain time to think ...

Coccygeal fistula - treatment without surgery

The first two questions after a diagnosis of coccygeal fistula is always: "Does the fistula need surgery? Isn't there a treatment option without surgery?".  

If you want to get rid of your coccygeal fistula, the only option is surgery. A pilonidal sinus is not a dangerous disease. Complications such as "blood poisoning" (sepsis) and the development of a malignant tumour are rare to extremely rare. The phase of development of a coccygeal fistula is probably a long time ago at the time of diagnosis. An increase in size can only be expected very slowly, if at all. But the symptoms of bleeding, secretion of pus, unpleasant odour and pain of varying severity do not have to be accepted in the long run. If there are no symptoms at all (asymptomatic form), you can also wait.

What significance do conservative treatment measures have then at all?

  • For the time being, a mild inflammatory surge can occasionally be caused by antibiotics, but the fistula does not disappear as a result.
  • So-called pull ointments may favour the spontaneous opening, the benefit of these preparations is limited.
  • Regular shaving and removal of visible, loose hair prevents the penetration of additional hair into the fistula canal and can reduce symptoms.
  • Furthermore, good hygiene is recommended with showering the gluteal folds once or twice a day, which reduces the bacterial density on the skin.
  • The same applies to the use of antiseptic ointments, for example Betaisodona.

With these tips, you can keep the level of inflammation as low as possible and gain time to plan an intervention that is ultimately always necessary at the most convenient time. It also creates optimal conditions for performing the operation. It is rarely necessary to cancel a holiday or postpone an examination because a pilonidal sinus has been diagnosed.

Keep your nerve, choose the smallest possible intervention!

Acute treatment for pilonidal abscesses

Acute inflammation is often the first sign of pilonidal sinus. It is often preceded by periods of prolonged sitting, such as during preparation for exams, urgent projects in the office or after a long-distance flight. A bruise during sports or a fall is also often mentioned as a possible trigger. The fistula tract fills with pus, the swelling increases rapidly within days and the pain can be unbearable. This is called a coccygeal abscess.

At this stage, treatment should be limited to removing the inflammation. This is best done by opening through a small incision under local anaesthesia.

The ultrasound examination helps to select the most suitable site. Afterwards, the patient is symptom-free within one to 2 days. The treatment of the fistula can be planned without time pressure. We advise against complete excision in the acute situation (in accordance with the guideline).

General symptoms of illness such as fever or even circulatory reactions in the context of "blood poisoning" (sepsis) are very rare.

In the early stages of inflammation or when surgical opening is not available, antibiotic therapy may also be sufficient. 

Acute pilonidal abscess. The causative pins cannot yet be delineated due to the swelling.
Acute pilonidal abscess. The causative pits cannot yet be delineated due to the swelling.

First think, then cut ...

Surgery for chronic pilonidal sinus

Radical surgery with open wound treatment

The clinical picture of pilonidal sinus was first described by Herbert Mayo in 1833 and was given its name by Hodges in 1880. Until the middle of the 20th century, the prevailing opinion was that pilonidal sinus was a congenital clinical picture. The large number of recurrences of the disease (relapse) after surgical removal led to the concept of "radical excision" (from the Latin radix = root) of ever greater extent.

It is now recognised that it is an acquired condition caused by hair. However, the majority of surgeons worldwide still believe that the best treatment is a large-scale excision, leaving a safe distance of healthy tissue down to the coccyx.

In this process, the surgical wound is left open. Gradually the wound is supposed to fill with scar tissue and thus healing is achieved. The healing process is long and prone to disturbances. We see quite a few patients who do not reach a stable state of healing even after months to years. Elaborate and sometimes painful wound treatments put a strain on the patient. Absences from school, training and work often impair professional development.

Simple closure by suturing in the midline is rarely successful. Wound healing disorders and infections are the rule rather than the exception, so that sutures have to be removed again prematurely or a scar that has just healed bursts open again.

We therefore advise against this procedure, which is also described in the Guideline Coccygeal Fistula recommended in the guideline on coccygeal fistula.

Radical surgery with plastic closure

Various techniques have therefore been developed to achieve a stable suture through a so-called plastic closure. By a Flap plastic closure is the closure of a defect with tissue taken from another part of the body, not the use of plastic. For coccygeal fistula, the Karydakis plastic, the cleft lift operation according to Bascom and the Limberg plastic are mainly used. Even these complex surgical techniques cannot guarantee a permanent cure and have their own specific complications.

Gentle surgical techniques: Pit picking and its variants

The pit-picking technique was developed by Peter Lord in London in 1965. However, it only became more widespread through John Bascom from Oregon, U.S.A. The basic principle consists of removing the entry ports (ingrown hair roots, "pits") and freeing the fistula tract from hair and inflammatory material. In this originally described technique, the fistula capsule is left in place. With this variant, healing rates of up to 70 % are achieved. To improve these results even further, methods have been developed to remove the fistula tract completely without making a large incision (synonyms: minimal tubular fistula excision, fistulectomy, sinusectomy), which increases the healing rates up to 90 %. Another approach is to burn out the fistula tract with a special laser probe. This principle, originally introduced for the treatment of anal fistulas, is called FiLaC (Fistula Laser Closure) or SiLaC® (Sinus Pilonidalis Treatment), up to 80 % of the fistulas treated in this way heal.

All these variants of the pit-picking technique have their justification. We make the decision about the respective procedure on the one hand depending on the type and extent of the fistula. It also plays a role whether the preference of the patient is more on the fastest possible healing or more on the sustainability of the restoration.

If another operation has not led to success, the principles of pit-picking can also be applied in the relapse situation. In our practice, about 30% of patients with pilonidal sinus have already undergone conventional surgery one or more times. There is almost always a method of treatment that can avoid further downtime due to a painful wound.

Treatment procedure at the Pilonidal Sinus Centre Munich'
We perform almost all operations under local anaesthesia (local anaesthesia) and on an outpatient basis with little strain on the organism. With the use of diluted local anaesthetic (the tumescent anaesthetic known from aesthetic surgery), even major operations can be carried out completely painlessly and safely. The advantage of these anaesthetic methods is also that pain-free sitting on the drive home is possible even after the procedure. The local anaesthetic also has a germicidal (bactericidal) effect and thus helps to prevent infections.

We have summarised the exact treatment procedure for the removal of a pilonidal sinus in the Pilonidalsinus Zentrum München on the page Treatment procedure and the information sheet Outpatient surgery and treatment of a pilonidal sinus (pilonidal sinus).

All right?

FAQ - Frequently asked questions about surgery for coccygeal fistula

Provided the diagnosis is correct, treatment of coccygeal fistula is almost always possible with our minimally invasive methods. You are welcome to send me your history and picture documentation via the contact form, then we can say more about the individual case.

No, today we actually no longer see a reason for radical surgery in any case. We supplement the conventional pit-picking with a peeling out of the fistula capsule ("fistulectomy") or, less frequently, with a laser treatment ("FilaC") and are successful with this in about 90 % of cases, even if pit-picking operations have already taken place in the past.

Yes! Very often a recurrence of a coccygeal fistula (recurrence of a pilonidal sinus) is caused by hair roots that have grown in again or penetration of hair into the still sensitive scar. In the former case, pit-picking, in the latter, laser hair removal and release of invaded hairs leads to permanent healing. If this strategy is not applicable, we will advise you on the proven alternative of Karydakis or Cleft Lift surgery.

The operation itself is a benefit of the statutory health insurance. We are approved for treatment by all statutory health insurance funds. A number of health insurance companies have even concluded special care contracts with us for the treatment of coccygeal fistula. Many patients also choose a treatment for permanent hair removal as a preventive measure, which is not paid for by most health insurance companies and costs € 70 per treatment with us.

Depending on the complexity of the fistula and necessary consumables (laser probes), they invest between 600 and 1200 € for outpatient treatment under local anaesthesia.

More than 95 % of the procedures we perform are carried out under local anaesthesia without any problems or pain. The patient can return home after a short period of monitoring. If the patient has to travel a long way, it is possible to stay overnight in a hotel in Munich after the operation. If preferred, the operation can be performed under general anaesthesia in the Iatros Clinic. For an additional charge, an overnight stay in the Iatros Clinic is also possible. However, the laser for hair removal is not available at the clinic.

In this situation, we first carry out a pre-treatment with puncture of the abscess and/or antibiotics. The inflammation subsides and the actual fistula operation can take place about 1 - 2 weeks later.

Simply fill out the contact form above and upload 1 - 2 meaningful pictures of the findings. One of our doctors will then contact you and send you a proposed appointment. You are welcome to give us a time window for the desired appointment.

Yes, this is possible. If it is your express wish, you can waive your right to a cooling-off period and a second opinion, and the procedure can follow directly after the examination. Please inform us of this wish when making your appointment so that we can calculate sufficient time! This option is taken by the majority of patients. If you are not yet sure about your decision, we will be happy to arrange a second appointment for the treatment.

The duration of the inability to work depends very much on the type of surgery performed. After conventional radical surgery, it is not uncommon to have a large wound that makes sitting and walking very difficult. Frequent dressing changes and wound treatments are also usually necessary. In these cases, the patient may be unable to work for at least 4 weeks, but also up to months. This is the great advantage of the minimally invasive surgical technique. With us, hardly any patient is off sick for longer than 2 weeks. Any kind of physical activity is permitted again from the 2nd day after the operation.

Far far away, behind the word mountains, far from the countries Vokalia and Consonantia, there live the blind texts. Separated they live in Bookmarksgrove right at the coast

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DR. BERNHARD HOFER & COLLEAGUES

Specialists in surgery, proctology

Brienner Str. 13, D-80333 Munich, Germany

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