Pilonidal

Cysts/Sinus
Presented by:
Ms. Prajita Puri
Roll no. 29
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B.Sc. Nursing Programme

 SPECIFICS OBJECTIVES:
At the end of this presentation the student will be able to:
- review anatomy
- define pilonidal sinus/cysts.
- mention epidemiology of pilonidal sinus/cysts
- enlist etiology and risk factors of pilonidal sinus/cysts.
- describe pathophysiology of pilonidal sinus/cysts

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 CONTD…
₋ enlist clinical manifestations of pilonidal sinus/cysts
₋ explain medical diagnosis and treatment.
₋ discuss nursing managements.
₋ enlist its differential diagnosis.
₋ enlist its complications.

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• Anatomy
• Introduction
• Epidemiology
• Etiology and risk factors
• Pathophysiology
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• Clinical manifestations
• Diagnostic measures
• Treatment & its management.
• Nursing management
• Differential diagnosis
• Complications
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Anatomy
…

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 Anatomy
• Intergluteal cleft: A groove between the buttocks that extends from just
below the sacrum to the perineum.
Level of
iliac crests
Intergluteal
cleft
Hip (H)
region
Buttock (B)
Greater
trochanter
Ischial
tuberosity
Gluteal fold
Thigh (T)
• Anchoring of the deep layers of skin overlying the coccyx to the
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anococcygeal raphe
Introducti
on

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 WHAT IS PILONIDAL SINUS??

• A pilonidal sinus or sacrococcygeal fistula is a “SMALL

HOLE” or “TUNNEL” in the skin that usually develops in the
natal cleft of the buttocks where the buttocks separates.
PILONODAL= NEST OF HAIR
• It is also called as ‘Jeep Disease’ as the condition was
common in jeep drivers during WWII.

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... CONTD…
• It is found in the inter-gluteal cleft on the posterior surface
of the lower sacrum.
• A pilonidal cyst usually contains hair, dirt, and debris. It
can cause severe pain and can often become infected. 

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Epidemiol
ogy

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 EPIDEMOLOGY

•  Incidence : 26 per 100,000

• Mean age: 19 years for women and 21 years for
men (more common in younger men)
• Sex: M/F ratio – 2:1 to 4:1
• Equal incidence of acute : chronic

@Medscape
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Etiology & Risk
factors

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 ETIOLOGY
The exact cause of this condition isn’t known, but its cause
is believed to be a combination of:
• changing hormones (because it occurs after puberty),
• hair growth,
• obesity and
• friction from clothes or from spending a long time
sitting.
• Activities that cause friction, like sitting, can force the
hair growing in the area to burrow back under the skin.
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... RISK FACTORS
• Age between15 to 35years
• Prolonged sitting like driver, IT professionals,
students, bankers, etc.
• Overweight
• Excessive and thick hair
• Local trauma or irritation
• Sedentary lifestyle
• Deep natal cleft
• Family history 1/5/21 15
Pathophysiology

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 PATHOPHYSIOLOGY
• While sitting the buttocks move & some hair are broken off by
1 friction

• Broken hair collects in the Natal Cleft at the midline.

2

• Some of these hair penetrate the soft &moistened skin at the region
3 or may enter in the open mouth of any sweat gland.

• This region is usually warm, moist and most of time it is covered.

All theses factors helps in promoting the growth of bacteria and the
4 cavity inside gets infected very easily. 1/5/21 17
 • Infection leads to the formation of an Abscess (Pus Formation)
5

• Abscess causes Pain, Swelling & Tenderness of the area

6
• As the overlying skin at this region is thick, the abscess does not
burst easily and the pus keeps on travelling under the skin
producing branching tracts beneath the skin in midline or on one
7 or both sides.

• Later it bursts producing often multiple sinus opening in or

around the midline.
8 1/5/21 18
 • After spontaneous discharge of pus, Pain, Swelling &
Tenderness temporarily subsides for some days.
9

• After some days the infection repeats itself & the problem
comes again
10

• The problem of pain & discharge keeps on coming again

& again at regular intervals until the main cavity (root)
11 containing hair is treated.

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Clinical
Manifestations

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 CLINICAL MANIFESTATIONS
The symptoms experienced by someone with a pilonidal sinus include the
following:
• Pain when sitting or standing
• Swelling of the cyst
• Redness, sore skin around the area
• Pus or blood draining from the abscess, causing a foul odor
• Formation of more than one sinus tract, or holes in the skin
• May also experience a low grade fever, but this less common.
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CONTD…

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...
CONTD…
Clinical presentations of pilonidal sinus have three disease ‘stages’:
• Asymptomatic — an initial stage pilonidal sinus may be discovered by the
patient themselves or on routine medical examination
• Acute — this will present as a painful, swollen area with a sacrococcygeal
abscess, which may have purulent exudate. There may also be cellulitis over
the natal cleft. Patients will be referred for an emergency incision and
drainage procedure.
• Chronic — this will manifest as recurrent infections in the sacrococcygeal
area. The outward skin will be unbroken and oral antibiotics should be
prescribed.
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Diagnostic
Measures

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 DIAGNOSTIC MEASURES
•  It is a clinical diagnosis best elicited by history and physical examination
findings.
• Very extensive sinus formation and fistulation may be assessed by MRI
scanning of the natal cleft and buttocks.
• No specific laboratory studies or tests are needed to diagnose pilonidal
disease and its sequelae or differentiate it from other disease entities.
• Swabs may be taken to determine the type of bacteria responsible for the
infection.

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Treatment and
Management

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Management and Treatment

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Asymptomatic Management includes;
•Treatment is not needed if there are no signs of
infection.
•A "watch and wait" approach will be recommended.

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 Medical Management includes;
• Antibiotics for infection control.
• Pain killer to reduce pain.
• Antimicrobial ointment for dressing

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• Phenol injection
This is a closed technique under local anesthetic whereby injection of
phenol would be administered into the non-infected pilonidal sinus to
sclerose and close it.
The procedure is time consuming, needs frequent repetition, has a high
recurrence rate and has been largely replaced by operative techniques.

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a) Step 1: Local anesthetic (2% lidocaine solution) is applied.
b) Step 2: Hair is removed gently with a surgical clamp from the
pilonidal sinus pit.
c) Step 3: crystallized phenol is applied gently through the sinus
opening. 1/5/21 33

d) Postoperative view
 Surgical Management includes;
• Removal of whole pilonidal cysts.
• General anesthesia is required.
• 2-3 days of hospitalization is required.

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 CONTD
…
• Acute abscess
- Incision is performed lateral to midline
over area of maximum fluctuance
- Packing of the wound
- Marsupialization

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 CONTD
…
Chronic pilonidal sinus
•Surgical approaches:
-Excision
-Wound closure

(1)primary closure in midline/ off midline

›Z Plasty
›V-Y advancement flap
›rhomboid flap (Limberg)
(2) Reconstruction using flaps

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Z- Plasty

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V-Y advancement
flap

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Limberg Flap-Geometry

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Karydakis Procedure

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Nursing Management

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 NURSING ASSESSMENT
• History taking - to determine the presence and
characteristics of itching, burning, or pain.
• Questions relate to elimination patterns, diet history
(including fiber intake), the amount of exercise, activity
levels, and occupation (especially one that involves
prolonged sitting or standing).
• Inspection of the stool for blood or mucus and the perianal
area for hemorrhoids, fissures, irritation, or pus. 1/5/21 43
 NURSING DIAGNOSIS

• Acute pain related to irritation, pressure, and sensitivity in

the anorectal area from anorectal disease and sphincter
spasms after surgery.
• Constipation related to ignoring the urge to defecate because
of pain during elimination
• Anxiety related to impending surgery and embarrassment

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 NURSING GOAL

• Pain relief
• Adequate elimination patterns
• Reduction of anxiety

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 NURSING MANAGEMENT

• Pain relief
› Assess the intensity, duration , and location of pain in
order to determine if the inflammatory process worsens
or subside.

› Encouraging the patient to assume a comfortable

position. Flotation pads under the buttocks when sitting
help to decrease the pain, as may ice and analgesic
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ointments.
› Advising the patient’s party to provide warm compresses
which may promote circulation and soothe irritated
tissues.

› Advising to take sitz baths taken three or four times each

day which relieve soreness and pain by relaxing
sphincter spasm.
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• Adequate elimination patterns
› Encouraging to intake at least 2 L of water daily to provide
adequate hydration.

› Recommending high-fiber foods to promote bulk in the stool

and to make it easier to pass fecal matter through the
rectum. Bulk laxatives such as Metamucil and stool softeners
are administered as prescribed.
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› Encouraging patient to perform relaxation exercises before
defecating to relax the abdominal and perineal muscles,
which may be constricted or in spasm.

› Administering an analgesic before a bowel movement is

beneficial.

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• Reduction of anxiety
› Maintaining the patient’s privacy while providing care
and by limiting visitors, if the patient desires.

› Explain all the procedure to the patient and patient

party.

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› Encouraging the patient to use deep breathing
exercise.

› Soiled dressings are removed from the room promptly

to prevent unpleasant odors; room deodorizers may be
needed if dressings are foul smelling.

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Differential diagnosis and
Complications

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 DIFFERENTIAL DIAGNOSIS
• Anal Fistulas and Fissures
• Hidradenitis Suppurativa
• Perianal complications of Crohn’s disease
• Perirectal Abscess
• Skin abscess/ furuncle
• Folliculitis
• Osteomyelitis of Coccyx
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 COMPLICATIONS

- Infection.
- Haemorrhage.
- Prolonged healing.
- Wound break-down.
- Recurrence.

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summary !!

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 MCQS

Q. Pilonidal sinus is found in the ______________on the

posterior surface of the lower sacrum.
a) inter-gluteal cleft
b) natal cleft
c) cluneal cleft
d) All of the above

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 MCQS

Q. A small hole or tunnel in the skin that usually develops in

the buttocks where the buttocks separates.
a) Pilonidal Fistula
b) Anal Sinus
c) Sacrococcygeal fistula
d) All of the above

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 MCQS

Q. All these statements are true except……………..

a) Whole pilonidal cysts are removed during surgical
approach.
b) Pilonidal sinus can be completely treated by antibiotics.
c) Watch and wait approach is applied to asymptomatic
stage.
d) Pilonidal sinus cannot be controlled by antibiotics.

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 MCQS

Q. Surgical intervention is not recommended for………

a) Acute stage
b) Chronic stage
c) Asymptotic stage
d) None of the above

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 References;
• Brunner and Suddarths, Textbook of Medical Surgical
Nursing, 9th Ed. Pg; 1067 – 1069
• Smeltzer & Bare's Textbook of Medical-Surgical
Nursing, vol-1, 4th Ed. Pg; 1039-1037

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 Retrieved from
› https://www.nursingtimes.net/roles/practice-nurses/piloni
dal-sinus-08-04-2003
/
› https://www.omicsonline.org/india/pilonidal-cyst-peer-rev
iewed-pdf-ppt-articles
/
› https://onlinelibrary.wiley.com/doi/pdf/10.1002/tre.673

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