Pilonidal Sinus pictures

Pilonidal Sinus pictures

This is what a Pilonidal Sinus looks like

The diagnosis Pilonidal Sinus covers a spectrum from barely visible, enlarged hair roots (pits) in the early stages to cartilage-like hardened, finger-thick fistula ducts.

The images are arranged according to our "Munich" classification and are provided with a recommendation for the surgical technique.

Furthermore you see Pictures of other inflammatory diseaseswhich occur in the coccyx area and can be confused with a Pilonidal Sinus

Finally we show you some Images of the healing process. Before and after images can give an impression of what the result of an operation may look like.

Coccyx fistula - Pictures

Acute pilonidal sinus: Images of pilonidal abscess

The pilonidal abscess - when an unbearable pain develops within a few days

The Pilonidal Sinus exists long before it becomes conspicuous by an abscess. Triggers of an abscess are prolonged sitting, e.g. during a long-haul flight or in preparation for an examination. Rapidly increasing pain, a visible bump or redness always makes one think of an abscess. 

Sometimes even the doctor does not see much at first glance. If there is severe pain in the buttocks area, one must still think of an abscess. Indications of this can be an asymmetry of the gluteal fold or a striking smooth skin over the abscess. The patient can give the decisive hint 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 can be felt centrally in the bulge.

The ultrasound examination shows a round or oval cross-sectional accumulation of fluid and can prove the abscess in unclear cases.

Clinical picture

Sonographic image (ultrasound)

Pilonidal abscess2 Ultrasound image
Small, spherical pilonidal abscess
6 cm abscess ultrasound image
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.

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

Scheme Type I a Fistula
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

Scheme Pilonidal Sinus Type IIB new 2020
Schematic drawing Pilonidal Sinus type II A

With an average length of 4 - 5 cm, these fistulas also have numerous or closely adjacent pits. This is often the case in patients who have been pre-operated on with Limberg Plastics. 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 through a small incision at the upper end of the fistula or the narrow excision of the "pimple". 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

Laser sclerotherapy can be a sensible alternative for long, slender fistula ducts. 


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

Scheme Pilonidal Sinus Type III new 2020
Schematic drawing Pilonidal Sinus type III

5 % of all newborns have a retraction of the skin above the tip of the coccyx (sacral dimple). OnlyKucera, Wilson). When extended to the anal region they can be confused with anal fistulas.

1. sinusectomy

Since these fistulas are often very scarred with a palpable hardened strand and retraction of the skin, only sinusectomy offers good chances of healing.

We would advise against radical surgery or FiLaC/SiLaC for these fistulas.

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...

Scheme Pilonidal Sinus Type IV new 2020
Schematic drawing Pilonidal Sinus type IV A

This form of fistula can occur after all types of previous surgery. The cause is almost always the ingrowth of hair from the lower pole of the wound. Only later does an opening reappear on the upper edge, when the inflammation has worked its way under the scar. 

1st laser sclerotherapy (SiLaC): In the early stages, scraping out the fistula tract and laser sclerotherapy may be sufficient. In this situation, laser epilation is an essential part of the treatment concept.

2nd sinusectomy

In many cases, the removal of the fistula tract through the existing openings with radiofrequency scalpel or laser is a goal-oriented treatment.

3. cutting and Karydakis plastic

Alternatively we recommend the asymmetrical closure according to Karydakis.

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 spindle-shaped excision with open wound treatment. The cause is the ingrowth of hairs from the area surrounding the wound. The mechanical irritation prevents permanent healing. Usually the wound closes again and again, but ruptures at every opportunity. Physical protection cannot change this.

1. sparingly peeling off the hypergranulations ("wild meat"), taking the trapped hair with the Dios Blue Laser Close shaving in the post-treatment and laser epilation ensure the treatment result.

2. excision and Karydakis plastic

Alternatively we recommend the asymmetrical closure according to Karydakis.

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 26 years, no previous surgery, type I A fistula

Pilonidal Sinus Type I A
Pilonidal Sinus Type I A, deep, solitary pit, 2 cm long, scarred fistula. Sinusectomy performed.
Pilonidal Sinus Type I A, smooth, stable scar

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
IMG 20200703 WA0002

Patient 26 years old, type I B fistula with 2 pits, first presentation with abscess

Acute pilonidal abscess, severe pain for 2 days
After the inflammation has subsided
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

Patient 38 years, longstanding known fistula type II A

Picture of a long existing Pilonidal Sinus
Pilonidal Sinus Type II A, numerous openings, strong scarring after years of progression
Picture of a healed Pilonidal Sinus
Healing result after sinusectomy and 3 x laser epilation

Patient 23 years old, type IV B fistula, first presentation with non-healing wound

Type IV B praeop
Purulent, non-healing wound after conventional radical surgery
Type IV B postop
Stably healed condition after fistulectomy and 6 x laser treatment

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 tear or a cut. It always affects only the most superficial layer of the skin, the epidermis.

In patients who have already undergone surgery using the "Metzger" method, the cause is probably a lack of stability of an inelastic scar in the face of 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 limited 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.

Infected atheroma of the coccyx
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.

Acne inversa 1
Severe acne inversa Hurley III with pronounced scarring and numerous lateral openings
Mixed form of a coccyx fistula with acne inversa
Mixture of a Pilonidal Sinus with the acne inversa (note lateral "off midline" pits, scarring)

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 %.

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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