Pilonidal Sinus?

Immediate medical care by specialists

Dr. Bernhard Hofer and his team havespecialized in the treatment of Pilonidal Sinus (Sinus Pilonidalis). We offer you

Diagnosis coccyx fistula - All important facts

Dr. Bernhard W. Hofer, senior physician of the Pilonidalsinus Center
Dr. Bernhard W. Hofer, senior physician of the Pilonidalsinus Center

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Pilonidal Sinus is a common disease among young adults. For some patients, going to the doctor is uncomfortable or embarrassing. There is no reason for this. Get active and trust our experience from over 4000 operations. With the latest technology and a well thought-out concept we will find the right way to cure the Pilonidal Sinus for you too. Then even a long journey is worthwhile.

What is a Pilonidal Sinus - pilonidal sinus?

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 described 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") comes from Hodge 1880 (lat. pilus = hair and nidus = nest).

These fistulas are only found in the gluteal fold. It can be chronic (= Pilonidal Sinus) or acute (= coccyx abscess). Ingrown or impaled hairs lead 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 bones.

The rectum and sphincter are never affected.

Pilonidal Sinus: 5 typical symptoms

Openings in the center line (pits)

If small black dots or openings of variable size, the "pits", are found in the midline, the diagnosis is proven. Sometimes you have to look very closely to find them. It is not uncommon for the pits to be located at some distance from the obvious (secondary) fistula opening ("pimple") or swelling.

Loose hair can be pulled out of some pits. Others contain a pasty secretion of horn scales, similar to a "blackhead".

It's different with you? In our Picture gallery you will find numerous examples of different forms of Pilonidal Sinus and the causal pits.

pain, palpable hardening

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).

The hardened region of the fistula can also be felt during sports exercises (sit-ups, bench presses).

In the case of inflammatory flares or pilonidal abscesses, it can become so painful within a short time that you can no longer sit.

These complaints lead many patients to the doctor.

Visible bump or asymmetry of the intergluteal fold

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 - bones would always be symmetrical!


issue of blood, pus or clear secretion

Some patients only notice moisture, stains in the laundry or an unpleasant smell.

Bleeding occasionally makes one think of blood in the stool and leads to the gastroenterologist. They originate from the granulation tissue lining the fistula, which contains many delicate blood vessels and can bleed to a not inconsiderable extent just by touch.

These bleedings are not dangerous. They are actually a sign of the body's efforts to heal the wound. Healing requires building materials that are transported by blood.

The granulation tissue therefore consists to a large extent of blood vessels.


redness, overheating, feeling ill or fever

In pilonidal abscesses there is usually a clearly visible redness that goes far beyond the limits of the underlying Pilonidal Sinus one. Usually the abscess bursts open by itself at some point.

If this is not done, general symptoms of illness and fever may rarely occur. In such cases, abscess splitting is urgently required.

The possibility of "blood poisoning" (sepsis) cannot be excluded in principle, but it is extremely rare. In 28 years of my work in surgery, I have never Pilonidal Sinus experienced a case of threatening sepsis. 

The opening of the abscess brings immediate pain relief. Occasionally antibiotics may be useful to treat the inflammatory involvement of the surrounding tissue.

During the ultrasound examination, the doctor can see and measure the extent of the fistula cavity and possible branching. On our site pictures you will (soon again) see numerous photos and associated ultrasound images of the different types of a Pilonidal Sinus.

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 surgeryPilonidal 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 point of contact 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 on average only 1.4 Pilonidal Sinus patients per year. It is difficult to gain experience with this number of cases.

Pilonidal Sinus - OP: What's 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

This must be prevented. I have been specializing in the treatment of the pilonidal sinus since 2004. With me you benefit from the experience of over 3600 Pilonidal Sinusoperations.

We operate on an outpatient basis without hospitalisation. We operate painlessly under local anesthesia or tumescent anesthesia. This means you do not need a general anaesthetic.

Statue newly exposed
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 modern pilonidal surgery, Eugene/Oregon U.S.A., 1925 - 2013

We are the experts for coccyx fistula


Surgery for coccyx fistula (as of 01.10.20)


Treatment cases for coccyx fistula (status 30.03.20)


Experience in laser therapy and laser surgery since 2012

Private and statutory insurances

Full approval for outpatient operations

Pit Picking Operation - The gentle alternative

According to the current state of science, a cure 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 the Pilonidal Sinushairs are 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 the Pilonidal Sinus, BRIT. J. SURG, 1965, Vol. 52

Surgical techniques for Pilonidal Sinus

Excision with open wound treatment ("Butcher method")

Cutting of conventional, whetstone shaped cuttings

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

When the diagnosis of pilonidal sinus disease became increasingly common at the beginning of the last century, among soldiers in the First World War ("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) has become accepted worldwide. Although this theory has been around since Patey is regarded as refuted, most surgeons still stick to this outdated therapy concept.

Cutting out with closure of the wound by the patient's own tissue (flap plastic)

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

Why don't you sew up the wound?

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

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 Operation, Laser - OP (SiLaC®), Sinusectomy, Endoscopy (EPSiT)
laser epilation
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 healing process and avoid relapses
Aftercare through telemedicine
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.

Pit picking under the guidance of Dr Bascom
With this little parcel from Pit Picking pioneer John U. Bascom M.D., the history of today's Pilonidal Sinus Center in Munich began.
Pit Picking Bascom redrawn
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 to heal someone Pilonidal Sinus differently.

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 one Pilonidal Sinus of them.

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).