5 typical signs

Pilonidal Sinus Symptoms

Chronic fistula and acute abscess

How does a fistula at the coccyx manifest itself?

... and how does the doctor make the diagnosis

Midline pits

Primary fistula = starting point of the fistula

Small, black dots or Openings in the centre line prove the diagnosis of the Pilonidal Sinus. These so-called pits, also called porus, are easy to overlook. Sometimes you can only find them after shaving and under magnification.

Occasionally, loose or broken hairs can be pulled out. Other pits contain a thick secretion of horny scales, similar to a "blackhead".

The pits correspond to the starting point of the fistula and are the structure to be removed during pit picking.

Secondary fistula = end point of the fistula

The fistula can break through the skin in the middle or also on the side, in most patients for an unknown reason on the left side, and empty outwards. With such an open fistula on the coccyx, the patient usually has no pain. Not all fistulas work their way to the surface; many ends are also blind under the skin.

This opening looks similar to a "pimple" and is often the first and only symptom that the patient notices. A red, slightly bleeding tissue (granulation tissue, amateurishly called "wild flesh") seems to ooze out of the opening.

More often than one might think, medical measures also focus on this eye-catching finding and neglect the actual starting point of the problem.

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 especially noticeable when sitting on an unpadded chair (school, lecture hall, training course, beer garden bench). One suspects that it is due to the uncomfortable furniture.

A recent fall from the coccyx suggests a bruise or haematoma. More often than not, there is a temporal connection between the first complaints and a trauma.

You can also feel the hardening during sporting exercises (sit-ups, bench presses, floor gymnastics).

In inflammatory episodes or pilonidal abscesses, 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 is felt as a hardening, it feels like bone or cartilage in a chronic form that has existed for many years. If you compare the left and right sides, you can see the difference - bone would always be symmetrical!

So if you feel something but the doctor can't find anything, seek a second opinion if in doubt. Doctors who are rarely confronted with this problem sometimes do not know the discrete signs.


Blood, pus, fluid

Some patients notice dampness, stains in the laundry or unpleasant odour. The fistula secretion may be colourless and mistaken for profuse sweating.

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

Can general signs of illness such as fever or exhaustion be caused by a Pilonidal Sinus ? A severely inflamed Pilonidal Sinus is rarely the only possible cause. But it is quite unlikely that such an abscess on the coccyx is not mainly manifested by pain. After all, this region is very sensitive.

However, if an abscess persists for several days and is neither treated nor bursts open on its own, a bacterial infection with fever and blood poisoning cannot be completely dismissed. Such a complicated course is only seen in rare cases.

Patients often ask whether sinus pilonidalis, as a chronic inflammatory process, has consequences for general health. To my knowledge, there are no findings on this. But if you keep in mind that even gingivitis increases the risk of a heart attack, even a Pilonidal Sinus cannot be healthy in the long run.

Coccygeal fistulas are not associated with chronic bowel inflammation such as Crohn's disease.