The Tigers - Painting Corridor of the Pilonidal Sinus Centre 

Pilonidal Sinus pictures

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)

Small, spherical pilonidal abscess
6 cm abscess in the ultrasound image

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

Schematic drawing Pilonidal Sinus type I A

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

Pilonidal Sinus Pictures: Scheme Type I B Fistula
Schematic drawing Pilonidal Sinus type I B

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

Schematic drawing Pilonidal Sinus type II A

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

Picture of one Pilonidal Sinus with a big blind bag
Schematic drawing Pilonidal Sinus type IIB

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.

1st choice: laser sinusectomy, if necessary endoscopically assisted
Many surgeons are convinced that such a fistula can only be treated radically. We disagree. With the Dios Blue laser, endoscopic visualization and experience, the Distance via lateral accesses of about 1 - 2 cm.

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

Schematic drawing Pilonidal Sinus type III

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.

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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...

Schematic drawing Pilonidal Sinus type IV A

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...

Schematic drawing Pilonidal Sinus type IV B
Schematic drawing Pilonidal Sinus type IV B

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

Pilonidal Sinus with numerous primary openings
Type II A fistula, before surgery
Picture after Pit Picking Operation
Fistula removed during pit picking surgery

Type I B Fistula with 2 pits, first presentation with abscess

Acute pilonidal abscess, severe pain for 2 days
Inflammation-free condition 2 weeks after abscess puncture
Picture of the course of treatment Situation after pit picking and sinusectomy
Wounds after pit picking and sinusectomy
Picture of the removed fistula
Picture of the removed fistula. In the lower left corner of the picture a small fragment was left, which was removed as a second fragment. Clearly visible the enclosed hairs

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.

Pronounced inflammation in atheroma

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

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Under Construction

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(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