Pilonidal Sinus (Tailbone Cyst)?

Immediate help by the experts

Dr. Bernhard Hofer and his teamspecialize in the treatment of Pilonidal Sinus (Sinus Pilonidalis), a chronic inflammation in the area of the glutealfold. We offer you

  • Experienced consultant surgeons
  • Detailed information about the surgery and other options
  • Careful Pit Picking Procedure
  • Modern laser technology
  • No hospital stay
  • Painless operation under local anaesthesia without general anaesthesia
  • A short absence from work
  • Rapid return to physical and sports activity

Diagnosis Pilonidal Sinus - Everything you need to know

Dr. Bernhard W. Hofer, senior physician of the Pilonidalsinus Center
Bernhard W. Hofer, M.D., Practice Owner
5/5

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In young adults, pilonidal sinus is a common disease. For some patients, going to the doctor feels uncomfortable or embarrassing. There is no need for this. Get active and trust our experience from over 4000 operations. With the most state-of-the-art technology and a well elaborated approach, we will find the right solution for you to heal your pilonidal sinus. Then a long journey is also worth the effort.

What is a Pilonidal Sinus - Tailbone Cyst?

Schematic drawing of a coccyx
1 secondary opening, 2 primary opening ("pit"), 3 hair tufts in primary opening, 4 anal fistula, 5 anal canal, 5 rectum, 7 coccyx (os sacrum), 8 subcutaneous tissue

The clinical picture was first discovered in 1833 by Mayo described. Fistula (lat. fistula = tube, pipe) is the name given to a tubular duct as a result of chronic inflammation. The term sinus pilonidalis ( pilonidalsinus, pilonidal cyst, "coccyx cyst", "sacraldermoid", "dermoid cyst") was coined by Hodge 1880 (lat. pilus = hair and nidus = nest).

These fistulas are only found in the gluteal fold. They can be chronic (= Pilonidal Sinus) or acute (= coccyx abscess). Ingrown or spiked hair leads to a state of irritation as a foreign body. A protective wall of scar tissue forms, the fistula capsule (foreign body granuloma).

A stable layer of collagenous connective tissue, the fascia, protects the gluteus and coccyx bone.

The rectum and sphincter are never involved.

Pilonidal Sinus: 5 typical symptoms

Midline pits

Small dots or Openings in the center line prove the diagnosis of Pilonidal Sinus.

These so-called pits can be overlooked. They also occur remote from the obvious fistula opening ("pimple") or swelling.

Occasionally, loose hair can be pulled out. Other pits contain a pasty secretion of horn scales, similar to a "blackhead".

In our Picture gallery you can see how a Pilonidal Sinus can look like.

Pain, Induration

The most common symptom is a pain or foreign body sensation when sitting .

This is particularly noticeable on an unupholstered chair (school, lecture hall, further education, beer garden bench).

You can also feel the hardening during athletic exercises (sit-ups, bench press).

In the case of inflammatory episodes or pilonidal abscess, it can become so painful that you can no longer sit.

Lump, asymmetry

Not always in the pilonidal sinus there is a clearly visible fistula opening.

The only sign may then be an asymmetry of the gluteal fold or a visible bump on the buttocks.

The fistula capsule can be felt as a hardening, it sometimes feels like bone or cartilage.

When comparing the sides left - right you will find the difference - bone would always be symmetrical!

 
 

Blood, pus, fluid

Some patients notice dampness, stains in the laundry, or unpleasant odors.

Bleeding occasionally suggests blood in the stool. They originate from the granulation tissue lining the fistula, which contains many, delicate blood vessels and can bleed easily.

These bleedings are not dangerous. They are a sign of the body's efforts to heal the wound. Building materials for healing are transported in the bloodstream.

Fever, feeling ill

In pilonidal abscess, redness is often found beyond the borders of the Pilonidal Sinus .

Most often, the abscess eventually bursts by itself . Otherwise, there may be a feeling of illness and fever. Then abscess cleavage is urgently needed.

Blood poisoning" (sepsis) is possible, but extremely rare.

Opening the abscess brings immediate relief. Antibiotics reduce inflammatory co-reaction of the surrounding area.

During the ultrasound examination, we can see the extent of the fistula cavity and possible branching. We can measure the fistula and get a three-dimensional idea for surgical planning. On our site Images you can see photos and corresponding ultrasound images of different coccygeal fistulas.

The high sensitivity of magnetic resonance imaging (MRI) is useful when the patient has symptoms but clinical examination and ultrasound cannot detect a clear fistula.

The pilonidal sinus is a simple disease.

1992 George E. Karydakis, Greek surgeon and founder of asymmetric wound closure during surgery at Pilonidal Sinus, Anz Journal of Surgery, 62(5), 385-389.

To which doctor at Pilonidal Sinus?

Why does one need a specialist for a simple illness?

The coccyx fistula is a disease of the skin. Consequently, the dermatologist would be responsible. However, the first contact person is usually the family doctor. He will refer the patient to a surgeon.

About 50,000 patients are operated on a pilonidal sinus per year in Germany. In other words, each surgeon treats an average of only 1.4 Pilonidal Sinus patients per year. With this number of cases it will be difficult to gain experience.

Pilonidal Sinus - OP: What is the problem?

The supposedly small intervention can have unexpectedly large consequences.

  • Long healing period with sick leave
  • Extensive and painful wound treatment,
  • frequent wound healing disorders
  • high relapse rate of up to 57 %(Deutsches Ärzteblatt 2019)
  • scarring 
  • Repeated hospital stays
  • Loss of income and career interruption 
  • Restrictions in sports fitness, weight gain
  • Restrictions of body feeling and sexuality
The healing of a coccyx fistula gives you back physical well-being!

Good decisions are based on experience.

John U. Bascom M.D., pioneer of the modern operation of Pilonidal Sinus, Eugene/Oregon U.S.A., 1925 - 2013

We are the experts for coccyx fistula

4008

Surgery for coccyx fistula (as of 01.10.20)

6542

Treatment cases for coccyx fistula (status 30.03.20)

Laser

Experience in laser therapy and laser surgery since 2012

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Full approval for outpatient operations

Pit Picking Operation - The gentle alternative

According to the current state of science, a healing of Pilonidal Sinus is only possible through surgery. The decisive factors for the success or failure of an operation were already described in 1965 by the English surgeon Peter Lord.

  • The cause of Pilonidal Sinus is hair embedded in the subcutaneous tissue.
  • All penetrated hair must be completely removed.
  • All entry ports (pores, pits) for hair must be identified and eliminated.
  • These goals can usually be achieved by a comparatively simple, small operation

All fistulas will heal if they are not kept open. A pilonidal sinus is a foreign body - fistula, with hair being the foreign body. If the hair is removed, the fistula will heal

Peter H. Lord and Douglas M. Millar, founders of the pit picking operation for Pilonidal Sinus, BRIT. J. SURG., 1965, Vol. 52

Surgical techniques for Pilonidal Sinus

Wide excision and leaving the wound open ("Butcher method")

Cutting of conventional, whetstone shaped cuttings

The story of the operation of Pilonidal Sinus begins with an error.

At the beginning of the last century, when the diagnosis of the pilonidal sinus became increasingly common, including in soldiers in World War I ("Jeep's Disease"), one thought of the congenital disease of an embryonic malformation.

In other words, a relapse (recurrence) could not occur after complete removal. However, after recurrences were nevertheless observed, the extent of the operations was extended more and more.

This radical removal (Latin 'radix', root) became accepted worldwide. Although this theory has been Patey is regarded as refuted, most surgeons still stick to this outdated therapy concept.

Excision with closure of the wound by local tissue transfer (flap surgery)

Large-scale detachment of skin and subcutis from the underlying tissue, the so-called mobilization of the flap during Karydakis surgery

Why not close the wound by stitches?

With a simple suture in the midline, wound infections are common, the suture bursts open or must be reopened to control infection.

In addition, the suture leads to a slight inversion of the wound edges, which favours the re-growth of hair and thus the relapse (recurrence).

The constant movements while walking and sitting cause shearing forces in the area of the gluteal fold, which prevent a stable healing of a sutured wound.

For this reason, procedures have been developed to reduce the tension in the sutures by relocating the patient's own tissue (flap plasty) and to enable a laterally displaced (medically: lateralised) suture:

The alternatives to conventional surgery

Pit picking surgery, laser surgery (SiLaC®), sinusectomy, endoscopy (EPSiT)
Permanent hair removal by laser - the best prevention against Pilonidal Sinus

Less is more:

On the basis of the pit-picking technique developed in England and popularised in the USA, we have various variants of this gentle treatment available.

Pit picking refers to the selective removal of the affected hair roots as skin cylinders of 2-5 mm diameter and the cleaning of the fistula tract from deposited hair fragments.

The more perfectly this goal is achieved, the lower the risk of recurrence of fistula formation.

The decision for the best technology is made individually:  

  • Laser treatment of the fistula from the inside using a glass fibre probe(SiLaC®)
  • Precise peeling along the fistula capsule(sinusectomy or fistulectomy).
  • Videoendoscopic surgery (Endoscopic Pilonidal Sinus Therapy EPSiT) 

Aftercare after Pilonidal Sinus - Operation

Optimize the healing process and avoid relapses
Aftercare is possible in practice, by mail and video consultation

With us you will not be left alone after the operation.

Even the best operation does not guarantee a problem-free healing. In questions of post-operative treatment, we advise you already at the time of the operation.

Especially if you live further away, your relative can become your private wound specialist. We support you in this process through all common digital communication channels.

Our information brochure tells you what to expect during the course of the event.

During the follow-up appointment in the practice, your surgeon will personally ensure the optimal healing process, if necessary.

In our special wound and laser consultation your wound is professionally cared for by a trained and experienced therapist.

The success story of our practice

From the idea to an internationally renowned treatment centre for Pilonidal Sinus
Mail from Dr Bascom

It must have been around 2003. After successfully passing the specialist examination I was entitled to operate independently. The first operations waiting for a young surgeon are the supposedly simple ones - like the removal of a Pilonidal Sinus.

In specialist medical training, the complete excision of the fistula region down to the bone, which many patients now call the "Metzger method", was taught.

My friend and colleague Dr. K. had to undergo 9 months of painful wound treatment after such an operation on his own body.

October 13, 2004: With this package from Pit Picking pioneer John U. Bascom M.D. the history of today's Pilonidal Sinus Center in Munich began
First description of pit picking by Peter Lord 1965  Schematic drawing Pit Picking and Relief Cut (Redrawn according to Bascom, Rob & Smith's Surgery)
A revolutionary new method from England and the USA

"There must be another way," were his words that remained in my ear canal.

My research in the then just burgeoning Internet brought me to the method of Dr. John Bascom from the USA. The inventor was actually the British surgeon Dr. Peter Lord. Bascom's merit was to make the "pit picking" operation known worldwide.

Communication was still analogue back then. For this reason, a package with instructions, a video CD and self-drawn graphics provided the starting signal to try a different approach to healing a Pilonidal Sinus .

Despite an initial success rate of only about 50%, the patients were happy to have escaped the standard surgery. As a result, more and more inquiries came in.

Today we achieve healing rates of > 90 %. Currently, about 1000 patients per year visit our practice with a Pilonidal Sinus

We have learned from this that minimally invasive techniques are not only suitable for initial surgery. They can also take away the fear of relapse (recurrence).