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Updated: Dec 16 2021

Pilonidal Cyst

  • Snapshot
    • A 17-year-old male presents with lower back pain. He reports that the pain worsens when he sits or bends forward. Medical history is significant for metabolic syndrome. He is a high school student who spends hours playing online computer games. On physical exam, there is a tender and fluctuant mass that is erythematous. There is also purulent discharge from a sinus tract.
  • Introduction
    • Clinical definition
      • skin and subcutaneous tissue infection occurring in the sacrococcygeal region leading to an acute or chronic abscess
  • Epidemiology
    • Incidence
      • approximately 70,000 cases per year
    • Demographics
      • 15-30 years of age
    • Location
      • gluteal cleft
    • Risk factors
      • increased hair
      • poor hygiene
      • prolonged sitting
      • skin pits
      • trauma or irritation of the region
      • obesity
      • family history
  • EitIoLOGY
    • Pathophysiology
      • pathoanatomy
        • unclear
        • possibly due to stretching the natal cleft which damages the hair follicles and creates a pore "pit"
          • pore serves as an environment for hair to become embedded
          • hair is drawn deeper into the pore, resulting in a foreign body reaction and creating a subcutaneous cavity
  • Presentation
    • Symptoms
      • asymptomatic
      • intergluteal region pain while the patient is
        • sitting or partaking in activities that stretch the natal cleft (e.g., bending)
      • swelling
      • drainage that can be mucoid, bloody, or purulent
      • fever
      • malaise
    • Physical exam
      • pores found in the midline of the natal cleft
      • painless sinus opening
      • tender mass or sinus with fluid drainage
      • mass may be fluctuant and erythematous
  • Studies
    • Diagnostic criteria
      • clinical diagnosis
  • Differential
    • Perianal abscess
    • Hidradenitis suppurativa
    • Anorectal fistula
    • Folliculitis
    • Perianal furuncle and carbuncle
    • Perianal complications from Crohn's disease
  • Treatment
    • Operative
      • incision and drainage
        • indication
          • considered first-line for acute pilonidal cyst
      • surgical excision of the sinus tract
        • indication
          • chronic or persistent pilonidal cyst
  • Complications
    • Cellulitis
    • Abscess
    • Squamous cell carcinoma
      • this is rare
  • Prognosis
    • Approximately 50% of patients with acute pilonidal cyst may develop a chronic pilonidal cyst
    • Approximately 20% of cases treated with initial surgery have recurrence of the disease
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