A pilonidal cyst is a pocket filled with fluid that also contains body hairs found at the natal cleft just right below the coccyx. It could either be symptomatic presenting with pain due to infection or an inflammation or asymptomatic. It most commonly occurs in men of the Caucasian race.
Other risk factors include deep natal clefts seen in obese people or people with big buttocks, very hairy people are predisposed as well as a positive family history of pilonidal disease is a contributory factor.
It comes about when an ingrown hair through an enlarged hair follicle stimulates an immune response that leads to inflammation around the area especially when pressure or trauma is applied, a cyst is then formed.
Intense pain, lower back swelling, reddening of the affected region are some of the inflammatory signs associated with the pilonidal cyst. If severe, leaking pus can be seen from the affected site, this is usually due to trauma to the area. With any infection comes fever but it is very uncommon in this case.
Asymptomatic cases generally require no immediate treatment because the quality of life is not affected. Symptomatic cases, however, need urgent management due to the intense dysfunctional pain and swelling around the affected region.
Surgery is recommended for these symptomatic cases for faster symptomatic relief and easier management. There are two ways in which surgery can be applied; incision and drainage and pilonidal cystectomy. Surgery is required because once a cyst has become infected it will not be responsive to any antibiotics. The cyst is removed if the infection has been recurring.
Incision and drainage is the procedure of choice for a first-time pilonidal cyst. It is a very simple procedure that can be done in an outpatient setting with very few complications. The length of the procedure is short if compared to cystectomy; it takes a short time for the wound to heal. However, the recurrence rates have been reported to be high with this procedure, thus a pilonidal cystectomy is advised. The patient is counseled about the procedure before it is carried out. The affected area is sterilized, and a local anesthetic is administered around the region (lidocaine is the preferred choice). An incision is made on the cyst and drainage ensues. The wound is thoroughly washed with antiseptic and packed with gauze and covered with a sterile dressing. The patient is put on antibiotics to prevent or manage infection and painkillers for the pain. The wound remains covered for at least 2 days after which the dressing can be removed. Healing generally takes about two weeks, depending on the extent of infection and size of the cyst. Complications of incision and drainage may include wound infection, poor wound healing (especially in diabetics) and cyst recurrence.
Pilonidal cystectomy is the preferred choice for recurrent infected pilonidal cysts or chronic pilonidal disease. It is under general or local anesthesia as an outpatient procedure. It involves complete removal of the cyst with or without the surrounding skin, and is highly dependent on whether the cyst is infected or not. If the cyst is not infected, an incision on the skin is made, the cyst is removed and the incision is stitched into place. If infected, the incision is made, and the cyst together with a part of the surrounding tissue is removed. The wound is then packed with sterile gauze and left open for continuous drainage of the fluids that collect after surgery.
Some of the risks of this procedure may include infection, bleeding at the site, cyst recurrence if it was not fully removed. If the wound was not fully packed with gauze, the wound tends to heal superficially and this might lead to the formation of an abscess.
The stitches are to be removed in two weeks, meanwhile; the patient is put on antibiotics and painkillers and can be discharged from the hospital on the same day or in two days depending on the procedure. The wound takes a minimum of 8 weeks to fully heal to as close as 6 months. The patient is discharged and advised on good wound care to minimize the risk of infection.
The wound heals and forms a scar that fades off with time. Patients can go back to work or their usual activities in about 2 weeks. A diet rich in fiber is advised as constipation is a common occurrence during recovery usually because of the pain medication. Regular showers are advised to keep the wound clean. High success rates have been recorded with this procedure.