The Tigers - Painting Corridor of the Pilonidal Sinus Centre
(Donation of Prof. Dr. med. med. habil. Bernd Steckmeier)
Pictures of coccyx fistulas
Classification of the pilonidal sinus and clinical images
On this page we show you with pictures from clinical practice what coccyx fistulas can look like. Coccyx fistulas can develop very differently. For this reason, patients and doctors are often uncertain about the diagnosis. By comparing your own fistula with the findings shown here, you can assess whether you have a large or small fistula, an early stage or a chronically scarred situation. Classification in our classification system simplifies the decision for the best surgical method.
You will also learn what other causes of inflammation in the coccyx region can occur. Finally, we show you some pictures of the healing process. Some before-and-after pictures illustrate what the result of an operation can look like.
In this context, we would like to point out that every therapy has an individual course and that the concrete result of a treatment can never be promised.
Coccyx fistula - Pictures
Pilonidal Sinus: Images before OP
In football there are standard situations. In medicine we use classifications. Such a classification system makes it easier to decide on the best form of therapy. Our "Munich" classification is based on many years of experience with the most diverse forms of Pilonidal Sinus and takes into account the specific "pitfalls" in treatment.
Forms of the Pilonidal Sinus
Acute pilonidal sinus: Pilonidal abscess
The pilonidal abscess - when an unbearable pain develops within a few days
This often Pilonidal Sinus exists long before it becomes noticeable through an abscess. The abscess often develops after sitting for a long time, for example during a long-haul flight or the weeks of exam preparation. The pus accumulates in the fistula cavity, causing pain, sometimes a visible bump and reddening of the skin. Such an abscess often develops quickly within a few days.
Sometimes even the doctor does not see much at first glance. If there is severe pain in the gluteal region - this also applies to the anal region, by the way - you still have to think of an abscess. Indications of this can be an asymmetry of the gluteal fold or a conspicuous smooth skin over the abscess. The patient can give the decisive indication of where the pain is located. During a careful (!) palpation you can feel a bulging elastic hardening. If the abscess is about to burst, a soft zone in the otherwise hardened area can be palpated.
Images of coccyx abscesses
Clinical picture
Sonographic image (ultrasound)
Pilonidal abscess: treatment
In the acute situation, the rule is to treat only the inflammation first. SurgerPilonidal Sinusy is best performed after 1 - 2 weeks when the inflammation has subsided. This recommendation is also found in the current guideline 2020.
Ultrasound and palpation findings help to find a favourable site for opening the abscess. Local anaesthesia of the skin above the abscess is usually possible despite the inflammation. Icing spray is not sufficient to eliminate pain (and with CFCs it harms the climate, including that between doctor and patient). After drainage the pain is quickly forgotten.
If the findings are less pronounced, antibiotic treatment may be sufficient in individual cases.
If, as in the pictures, a strongly reddened bump is visible, the diagnosis is simple. But sometimes only a slight asymmetry of the gluteal fold is noticeable, or the abscess can only be detected by palpation and ultrasound.
Any very painful condition above the coccyx is suspected of being a pilonidal abscess!
Chronic pilonidal sinus: primary pilonidal fistula
With the types I - III of our classification no operation has taken place yet.
Type I A: Short-distance fistula ≤ 2 cm and a maximum of 3 primary openings (pits)
The small, uncomplicated Pilonidal Sinus
The small fistula under 2 cm length and with a maximum of 3 pits is sometimes not to be found at first sight.
Once the painful point is known, the diagnosis Pilonidal Sinus can usually be made with ultrasound.
Treatment of the 1st choice: Sinusectomy
Complete, economical triggering with the radio frequency scalpel or the blue 470 nm laser
Alternative: Classic Pit Picking
Pit picking and cleaning of the fistula cavity from hair and skin scales (debridement)
Type I B: Long fistula > 2 cm and a maximum of 3 primary openings (pits)
The long, simple Pilonidal Sinus
We see this type of fistula most frequently in our practice.
An expansion of 10 cm and longer is possible. Causal pits are often far down in the gluteal fold and can only be detected after shaving and viewing with magnifying glasses.
1st choice: sinusectomy
With this type of fistula, the fistula tube can be released through small incisions and the overlying skin can be protected. Result: smaller scars and faster healing
Alternative: Pit Picking and SiLaC
For fistulas longer than 4 - 5 cm, the use of the radially emitting laser probe (SiLaC / FiLaC®) be a gentle alternative to sclerosing the fistula with shorter convalescence and a somewhat lower success rate of 75 - 80 %.
Type II A: Long-distance fistula > 2 cm and and ≥ 4 primary openings (pits)
The long, complex Pilonidal Sinus
On average 4 - 5 cm long, these fistulas sometimes have very numerous or closely adjacent pits (> 10). This is often the case in patients pre-operated with Limberg Plasty. Pits on the side of the midline (off-midline pits) make one think of an acne inversa.
1st choice: sinusectomy
Since these fistulas are often very scarred, often only sinusectomy offers optimal chances of healing. Access is a small incision at the upper end of the fistula. The pits can be punched out with 2 - 3 mm or vaporized with laser. The stability of the gluteal fold is maintained.
Alternative: Pit Picking and SiLaC
Type II B: Long-distance fistula with blind sac over the lower spine
The flat, large-volume Pilonidal Sinus
Externally, the extent of this fistula species is often not recognizable. The diagnosis with ultrasound is Pilonidal Sinustherefore particularly important for type II B. With good planning, unpleasant surprises during the procedure can be avoided.
Alternative: none
Type III: Secondary fistula after sacral pits
The fistula resulting from a congenital retraction of the skin above the tip of the coccyx
About 5% of all newborns have a small indentation of the skin above the tip of the coccyx (sacral dimple). In less than 0.1 % of these children this is significant. However, the
later impaling of hair is favoured. These fistulas have nothing to do with the spinal column or spinal cord either. They often move downwards towards the anus and are confused with anal fistulas.
1. sinusectomy
Since these fistulas are often very scarred with a palpable hardened strand and retraction of the skin, often only sinusectomy offers good chances of healing.
2nd Pit Picking and SiLaC
Cleansing and laser treatment may be sufficient if hair and fistula capsule have not yet grown together too much.
.
Chronic pilonidal sinus: relapsing or recurrent fistula
The true recurrence, i.e. the renewed development of a pilonidal sinus from the pit to a fully developed fistula, is possible but rare. Type I - III therefore plays no major role in recurrence.
In group IV fistulas, either the wound has never completely healed or pain or opening has reappeared after supposed healing. The germ cell for these recurring symptoms is often hair that has already been embedded during the course of wound healing.
Type IVa: Tubular pseudo-recurrence
If hairs are sprouting from the base of the surgical scar...
This type of fistula can occur after all types of previous surgery. The cause is almost always the impaling of hair at the lower pole of the scar. This entrance gate hidden in the depth of the gluteal fold is often overlooked. The diagnosis of a relapse is not made until the fistula tract has worked its way upwards and blood or pus has been secreted again.
1.cleaning of the corridor and laser - sclerotherapy
The entry port is usually a funnel-shaped retraction, much less often single hair roots. This funnel is cut out sparingly. The actual fistula passage can usually be treated well by cleaning and sclerotherapy with laser or radiofrequency. With this type of fistula, permanent hair removal by laser in the area of the entrance port should be performed without fail.
2nd sinusectomy
If a fistula tract limited by hard scar tissue has developed again, occasionally the peeling out of this tract from the existing openings may be the best treatment method.
3. cutting and Karydakis plastic
If the above methods do not lead to success, the asymmetrical excision with closure by flap plastic surgery may be used as an exception.
Type IVb: spindle-shaped or oval pseudo-relapse
If loose hair or textile particles prevent healing...
This form of fistula occurs mainly after the whetstone shaped, radical excision with open wound treatment. The cause is the ingrowth of hairs from the area surrounding the wound. The mechanical stimulus prevents permanent healing. Usually the wound closes temporarily, but ruptures again at every opportunity. Physical protection cannot change this.
1.cleaning of the corridor and laser - sclerotherapy
The entry port is usually a funnel-shaped retraction, much less often single hair roots. This funnel is cut out sparingly. The actual fistula passage can usually be treated well by cleaning and sclerotherapy with laser or radiofrequency. With this type of fistula, permanent hair removal by laser in the area of the entrance port should be performed without fail.
2nd sinusectomy
If a fistula tract limited by hard scar tissue has developed again, occasionally the peeling out of this tract from the existing openings may be the best treatment method.
3. cutting and Karydakis plastic
If the above methods do not lead to success, the asymmetrical excision with closure by flap plastic surgery may be used as an exception.
Pilonidal Sinus: Pictures of treatment processes
In the following we will put pictures of the course of a treatment. Basically, each "case" is an individual case, so that the procedure and treatment results cannot be transferred with certainty to future treatments. The pictures should demonstrate that very good treatment results are possible without radical surgery, but also show the limits of the possibilities.
Patient 30 years old, no previous surgery, type II A fistula
Type I B Fistula with 2 pits, first presentation with abscess
Inflammation above the coccyx, but no Pilonidal Sinus
Other causes of inflammation - contribution in progress
Rhagade of the Rima ani (butt fold)
Superficial tears
A raghade is a wound that looks like a superficial crack or cut. It always affects only the most superficial layer of the skin, the epidermis.
In patients who have already undergone an operation using the "Metzger" method, the cause is probably a lack
Stability of an inelastic scar against the strong shear forces.
But even in patients who have never been operated on before, such raghaden occur. The most common form of psoriasis is then a localised form of psoriasis.
Rhagades can lead to a usually low secretion of yellowish secretion (fibrin), so that one mistakenly suspects a suppurating fistula.
The treatment is conservative. In acute phases cortisone and antibacterial creams (e.g. Fucicort®) help.
Infected atheroma (groat pouch)
Inflamed sebaceous gland
An atheroma is a cystic accumulation of a pasty secretion. The cause is a clogged gland in the skin. It can remain asymptomatic for a long time, and then become inflamed for no apparent reason.
In these cases, the inflammatory reaction of the surrounding tissue often reaches a magnitude that is much larger than the cyst itself. A kind of pus pimple is sometimes found centrally in the "bulge". Typical pits in the midline are missing.
These cysts can also be removed through relatively small incisions, the probability of a relapse is lower than with the typical Pilonidal Sinus.
acne inversa
Complex fistulas as a result of an independent immune reaction
99% of all patients with acne inversa who have ever entered my practice are smokers. A cure for this systemic disease is only possible after giving up smoking. Surgery can only remove existing foci and relieve abscesses, but cannot prevent recurrences.
New treatment approaches are laser treatment, the LAIGHT therapy (https://www.laight.de/therapie), which was investigated in studies at the University of Mainz, and laser ablation.
anal fistula
Starting point in the anal canal
For fistula openings near the
Sometimes it is not possible
at first sight, a
Pilonidal Sinus from one
anal fistula
Mixed form of an Pilonidal Sinus acne inversa with acne inversa: branching, lateral fistula opening and severe scarring are indications of this fistula type
Economical, but complete excision
Acne inversa fistulas are, in contrast to the straight running fistulas, Pilonidal Sinus often complex, i.e. branched ("foxhole"). They are located so just below the skin level that it is usually not possible to protect the overlying skin during removal.
Abscess relief
In acutely inflamed, pus-filled fistulas, gentle relief is possible through puncture with a biopsy punch.
First choice: fistulectomy, preferably with laser
The fistula passage is best removed with the laser from the outer to the inner opening, precisely and under visual control with magnifying glasses. The tunnel becomes a shallow trench, which slowly fills with new tissue.
Healing rate: 90%.
Alternatives: LIFT, FiLAC, Fistula Plug, Advance Flap, OTSC-Clip ...
The number of possible alternatives alone shows that none of these methods is fully convincing.
These methods are used for significant sphincter muscle involvement of the fistula.
Healing rates: 20 to 60 %.
Under Construction
Under Construction
(https://www.darmsprechstunde.de/diagnosen/analfistel/)
to distinguish between the two. The real anal fistulas always have a starting point in the rectum, i.e. an internal fistula opening. This is why these fistulas contain intestinal bacteria rather than skin germs, and it is not uncommon for a history of pain to precede bowel movements. With rectal examination and ultrasound it can usually be clarified which type of fistula is present. Occasionally an MRI (magnetic resonance imaging) may be useful.
anal fistula, left transsphincteric, right highly transsphincteric to extrasphincteric
