[30] Pilonodal Sinus

Question 1

What is pilonodal sinus disease?

Answer 1

A disease of the anorectal region characterised by formation of a sinus in the cleft of the buttocks

Question 2

Who does pilonodal sinus disease most commonly affect?

Answer 2

Males aged 15-30years, with coarse, dark body hair

Question 3

What is the most widely accepted theory for pilonodal sinus disease development?

Answer 3

A hair follicle in the intergluteal cleft becomes infected or inflamed. This inflammation obstructs the opening of the follicle, which extends inwards, forming a ‘pit’. A foreign-body type reaction may then lead to the formation of a cavity, connected to the surface of the skin by an epithelialised sinus tract

Question 4

What behaviour is pilonodal sinus disease classically associated with?

Answer 4

Sitting for prolonged periods, e.g. lorry and taxi drivers

Question 5

What are the risk factors for pilonodal sinus disease?

Answer 5

Increased sweating
Prolonged sitting
Buttock friction
Obesity
Poor hygeine
Local trauma

Question 6

When does pilosinus disease typically not occur?

Answer 6

After 45 years of age

Question 7

How does pilonodal sinus disease most commonly present?

Answer 7

As an intermittent red, painful, and swollen mass in the sacrococcygeal region. There is commonly discharge from the sinus, and there may be systemic features of infection

Question 8

What is the main distinguishing feature of a pilonodal sinus from other anorectal conditions, such as anal fistulae?

Answer 8

It opens up into the skin, but does not continue into the anal canal like a fistula

Question 9

How is it determined that an opening in the skin doesn’t extent into the anal canal?

Answer 9

Rigid sigmoidoscopy in clinic

Question 10

How can extensive pilonodal sinus formation and fistulisation be assessed?

Answer 10

By MRI scanning of the natal cleft and buttocks

Question 11

Why is surgery not always required for pilonodal sinuses?

Answer 11

Because pilonodal sinus disease eases with age

Question 12

What is involved in the conservative treatment of a pilonodal sinus?

Answer 12

Shaving the affected region
Plucking the sinus free of any hair that is embedded
Washing out of accessing sinuses

Question 13

What can be used in septic episodes in pilonodal sinus disease?

Answer 13

Antibiotics

Question 14

What is required for any pilonodal abscesses?

Answer 14

Surgical drainage

Question 15

What is the exact surgical management of a pilonodal sinus dependant on?

Answer 15

Wether the disease is acute or chronic

Question 16

What does surgical management involve in acute pilonodal sinus disease?

Answer 16

Drainage and washout of any abscess that is present

Question 17

What is the limitation of surgical intervention in pilonodal sinus disease?

Answer 17

It can be difficult to remove the sinus in the same operation as it is drained and washed out , and so most patients will require further surgery

Question 18

How is chronic pilonodal sinus disease treated?

Answer 18

With the removal of the pilonodal sinus tract

Question 19

What are the main methods of removal of the pilonodal sinus tract?

Answer 19

Excising the tract and laying open the wound, allowing closure by secondary intention
Excising the tract followed by primary closure of the wound

Question 20

What is the advantage of exising the pilonodal tract and laying open the wound, allowing closure by secondary intention?

Answer 20

Low rates of recurrence

Question 21

What is the disadvantage of exising the pilonodal tract and laying open the wound, allowing closure by secondary intention?

Answer 21

Can take a long time to heal

Increased risk of infection

Question 22

What is the disadvantage of exising the pilonodal tract followed by primary closure of the wound?

Answer 22

Higher rates of recurrence

Patients may require reconstructive surgery due to tissue loss from this operation