Proctology

Pilonidal Sinus Disease

Pilonidal Sinus Disease

The pilonidal sinus disease is the epithelial dip in the form of a narrow channel located under the skin sacrococcygeal region and opens the skin by one or more point openings (primary) strictly in the midline between the buttocks.

Pilonidal sinus has a length of 2— 3 cm, ends in the subcutaneous tissue blindly with itself coccyx is not connected. The epithelium lining the course, contains hair follicles, sweat and sebaceous glands surrounded by connective tissue fibers.

Causes

Pilonidal sinus disease — a congenital disease caused by a defect in the development of the caudal end of the embryo, resulting in under the skin buttock cords stays the course, lined with epithelium. This anomaly occurs quite frequently. Many foreign experts, who call the course hair cyst, I think the reason for the formation of its irregular growth of hair that in the presence of deep buttock cords and abundant hair leads to ingrown (immersion) hair in the skin and cyst.

Symptoms

Complaints of pain in the sacrum, discharge of pus or ichor appear in case of development of inflammation. Sometimes patients associate onset with an injury sacrococcygeal region. Uncomplicated pilonidal sinus disease does not usually cause a man any trouble.

The presence of pilonidal sinus disease has no significant impact on child development in the first years of life does not provide clinical manifestations (asymptomatic period). The clinical manifestation of the disease starts with the onset of puberty. During this period, in the lumen of the epithelial turn start to grow hair, accumulate the products of the sebaceous and sweat glands. The proximity of the anus determines the abundance of microflora on the skin of the sacrococcygeal region and in the progress. In those cases where the primary holes of stroke do not provide sufficient drainage, inflammation develops, which may go to surrounding tissue. The development of inflammation contribute to the injury, abundant scalp skin sacrococcygeal region, to hygiene.

If the epithelial the course of inflammation, there is pain in the sacrum and the coccyx, there is discharge from the primary holes move. When distributing inflammation to the surrounding tissue the pain becomes strong enough, there are seal and flushing of the skin. Most often, this inflammation is lateral to the buttock cords. Local changes may be accompanied by fever. Thus, there is an acute inflammation of the epithelial pilonidal sinus, in which there are 2 stages:

  • infiltrative:
  • abecedarian.

If at this stage the patient does not go to the doctor after the spontaneous opening of the abscess is improving and even the disappearance of external signs of inflammation, but perhaps the formation of secondary purulent fistula draining an inflammatory lesion in the epithelial the course. In that case, if the patient went to the doctor in the period of acute inflammation, but he for some reason was not performed radical surgery, and only opening the abscess, the cure also comes to develop chronic inflammation progress with the formation of infiltrates, fistulas, recurrent abscesses.

Thus, if one occurred inflammation of the epithelial pilonidal sinus self-held, even in the absence of pain and discharge from the primary holes of the stroke, the patient cannot be considered as fully recovered as it remains the focus of inflammation.

Classification and types

1) epithelial coccygeal course of uncomplicated (without clinical manifestations);

2) acute inflammation of the epithelial pilonidal sinus:

— infiltrative stage

— abscess formation;

3) chronic inflammation of the epithelial pilonidal sinus:

— infiltrative stage

— recurrent abscess,

— purulent fistula;

4) remission of the inflammation of the epithelial pilonidal sinus.

Complications

Inflammatory changes in the epithelial the course and the surrounding tissue during prolonged refusal to radiologicaly can lead to the formation of multiple secondary fistula opening far enough from the Sacro – kopchikova region: in the skin of the perineum, on the scrotum, groin folds and even on the anterior abdominal wall. The presence of secondary fistula with purulent secretions sometimes leads to the development of pyoderma. It is especially difficult to treat patients with the fistulous form of pyoderma, when the whole skin of the perineum and sacrococcygeal region represents the system epitelizirutmi moves that grow hair, are products of the sebaceous glands and pus. It is necessary to excise the affected skin over a large area, or to achieve a cure is impossible.

Described cases of developing squamous cell carcinoma with long-term existence of the inflammatory process in epithelial coccygeal course and surrounding tissue.

Diagnostics

Diagnosis of uncomplicated pilonidal sinus disease special difficulties is not. The presence of primary holes in mezhyagodichnoy the crease is a pathognomonic sign. The appearance of inflammation in the Sacro-coccygeal region, the formation of fistula on the site of the abscess having primary holes along the mid-line crease mezhyagodichnoy makes diagnosis complicated by epithelial progress is undeniable.

However, if the inspection of sacrococcygeal region there are signs confirming the presence of epithelial stroke, you need to hold finger examination of the rectum and anal canal to exclude other diseases in this region. When digital examination should pay attention to changes in the field morganeve crypts, mindful of the fact that the internal opening of the fistula of the rectum is located in one of the crypts. Definitely need to be palpated through the posterior wall of the rectum sacral and coccygeal vertebrae, there should not be changes.

In order to exclude diseases of the colon in all patients proctosigmoidoscopy is performed, and in the presence of alarming symptoms — colono – or barium enema, but the latest research has to resort rare, since most patients seeking about pilonidal sinus disease, very young.

The introduction of dye into the fistula orifice with a diagnostic purpose, as a rule, is not carried out. Fistulografiya used only in difficult cases, if necessary, with the differential diagnosis.

Differential diagnosis. To differentiate the presence of epithelial pilonidal sinus is sometimes necessary from the following diseases:

  1. fistula of the rectum;
  2. coccygeal cyst;
  3. posterior meningocele;
  4. presanella teratoma;
  5. osteomyelitis.

They hiss differential diagnosis between rectal and complicated coccygeal course performed on the basis of the finger study of the rectum, sensing the coloration sinus tracts and fistulography. In the presence of a fistula of the rectum and a careful study reveals the internal opening of the fistula in the area of morganeve crypts, the probe goes through the fistulous course not to the coccyx, and anal canal; the paint is introduced through the outer opening, penetrates into the lumen of the intestine, staining of the affected passageways. Fistulografiya serves as another confirmation of a connection with the intestine.

Coccygeal epidermoid cyst located in the sacrococcygeal region, palpated under the skin and if there is no inflammation, movable and painless. These cysts may suppurate and then it seems that it is the epithelial course. But coccygeal cysts unlike the latter do not have primary holes.

Rear meningocele is also on the middle line in mezhyagodichnoy crease, has the appearance of an oval elevation, the skin over it is not changed, the touch is togolaises education, almost motionless. No primary holes, as epithelial stroke, no. With careful questioning revealed violations of functions of pelvic organs (typically, enuresis). Requires radiography of the sacrum and coccyx, further evaluation and treatment from neurosurgeons.

Presacral teratomas can have so-called embryonic progress, opening on the skin near the anus in the form of epitelizirutmi funnel, sometimes very similar to the primary hole pilonidal sinus. Hole embryonic stroke most often, located behind the anus in the midline. Themselves teratomas can also be the cause of purulent fistulas sacrococcygeal region. Presacral teratomas are located between the rear wall of the rectum and the anterior surface of the sacrum that can be set by digital examination through the anus. When it is determined tumor formation tugolesskiy or solid consistency on the anterior wall of the sacrum, while the epithelial coccygeal passage located under the skin on the posterior surface of the sacrum and coccyx. Ultrasound, and in the presence of a fistula and fistulografiya will allow you to establish the correct diagnosis.

Osteomyelitis of the sacrum and coccyx, too, can give fistula on the skin of the sacrococcygeal region and perineum. In the presence of osteomyelitis palpation of the sacrum and coccyx through the anus helps to establish the presence of cestovatele, vbuhanie in the lumen of the intestine, pathological mobility of bones. If you suspect osteomyelitis requires radiography of the pelvis and ultrasonography, with presence of fistula x-ray must be supplemented by fistulography.

Treatment

Treatment of pilonidal sinus disease surgery alone. You must remove the main source of inflammation — epithelial channel with all the primary holes, and if I had any inflammation, and tissue changes around stroke and secondary fistulas.

The question of the timing and methods of operation most convenient to consider, using the above clinical classification.

1. Pilonidal sinus disease is uncomplicated, i.e., when there is a move from the primary holes, but there was no inflammatory complications, it is best to operate in a planned manner. The operation in this case is the painting progress through the primary holes (usually methylene blue that has not gone unnoticed some of the primary hole), and cutting slits bordering strips of skin buttock cords with all the opening there of primary holes and be fiber, which is very course. All this is dissected as a single unit to the fascia covering the coccyx. The operation in this stage is advantageous for several reasons: in the epithelial the course and the surrounding tissue, no inflammation; microbial flora in the course and on the skin non-aggressive; the wound after excision of uncomplicated stroke is not extensive, and this means that there is no great tension of the tissue after the incisions. Thus, after excision of uncomplicated pilonidal sinus disease the wound can be closed tightly. Most often used the so-called return seams Donati. This method of wound closure when properly executed provides good hemostasis and complete contact of all layers of the wound. But when suturing Donati is a feature in the postoperative management: the patient should be on bed rest for 5-6 days to when walking does not increase the load on the joints. Seams in favorable cases, can put on 10-12-th day after surgery. Relative contraindications to the use of the deaf-joint after excision of uncomplicated pilonidal sinus can be a obesity of the patient, the abundance of subcutaneous tissue that leads to the formation of deep wounds after excision of the turn. But this situation is not often as uncomplicated stroke is diagnosed primarily in adolescence and early adulthood, when adipose tissue is not so pronounced.

2. In acute inflammation of pilonidal sinus surgical treatment is definitely depending on the stage and prevalence of the inflammatory process:

a) in the stage of infiltration, if he does not go beyond the buttock cords located along the course, you can immediately perform radical surgery excision and primary stroke holes. But deaf seam in this situation is undesirable, as even excision within healthy tissue does not guarantee initial healing. If the infiltration extends to the surrounding tissue beyond the buttock cords, it is better to first implement conservative measures: after shave skin sacrococcygeal region — warm bath, daily shower; locally advanced dressings with ointments based on water-soluble (left-Shin, the throat pain); physiotherapy and after reduction of infiltration to perform radical surgery;

b) if an abscess is present you can immediately carry out a radical surgery to excise the move itself and the wall of the abscess. Most often this is done with a small size of the abscess (up to 3 cm in diameter). Wound not sutured, or sutured the wound edges to the bottom (like marsupialization). Extensive infected wound usually heals quite a long time, the scar turns rough. Therefore, many specialists prefer in acute inflammation of the epithelial pilonidal sinus to operate in two stages: first, open the abscess, saneroite (daily irrigation, the introduction into the cavity of the abscess ointments based on water-soluble) and after decrease inflammation is radical surgery. Delayed operation can be performed 4-5 days after the first stage, not the writing of the patient from the hospital.

The second phase of the operation is carried out in a planned manner and at a later date in 2-3 months. Deferred operation has the advantages of: is it more economical to excise the skin of the buttock cords, sutures so that the wound edges were as close together, but the bottom is well drained.

But the postponement of radical surgery for a few months also creates problems. So, if the patient after opening the abscess is discharged from the hospital and performs the recommendation to come through some time to complete the treatment, all is normal. Unfortunately, quite often patients for various reasons are not at the appointed time, the inflammation becomes chronic stage, the formation of new infiltrates and secondary fistulas. There are observations, when radical surgery was postponed for years and the result has been joined by pyoderma.

Given these circumstances, in specialized hospitals try to implement the second phase of the operation without the patient’s discharge from the hospital, shortening the interval between the stages due to the intensification of treatment of acute inflammation.

3. Stage of chronic inflammation of the epithelial pilonidal sinus performed planned radical surgery with excision of the stroke, the primary and secondary openings of the fistula, but in the absence of exacerbations of the inflammatory process. During exacerbation of inflammation, recurrence of the abscess often treatment is also divided into two stages. The principle remains the same: for the radical treatment necessary to excise himself of epithelial motion, all the primary holes, secondary holes and scars.

4. In remission, the inflammation of the epithelial pilonidal sinus is usually performed planned radical surgery with excision of the progress and Scar tissue.

It should be noted that in radical surgery for complicated pilonidal sinus disease has long been there are different approaches to the method of wound closure. There are advocates of Donati stitches in all stages of the disease. The experience of the specialized agencies shows that deaf seam safe only in uncomplicated move. If once inflamed, to the imposition of a deaf seam should be approached with caution. Installation of drains, flow-through washing does not always bring the desired result.

The prognosis of the radical treatment of epithelial pilonidal sinus at any stage of the disease is favorable, there comes a full recovery.

After the surgery the patient should be seen by a physician until complete recovery, periodically as the regrowth of hair along the edge of the wound to produce shaving or waxing them and do this until complete healing of the wound. Not recommended during the first 2-3 months after surgery to wear tight clothes made of thick fabric with a rough seam in order to avoid traumatizing postoperative scar. And of course, you need to observe hygiene: to wash regularly and wear clean clothes, preferably of cotton fiber.

Surgery for pilonidal sinus disease technically simple. But statistics show that when treating this category of patients in hospitals surgical profile of different complications occur in 30-40% of patients, which is ten times higher than in specialized departments. The study of this factor showed that for the treatment is simple, at first glance, the disease requires special knowledge. Therefore treatment of this group of patients should be carried out in coloproctol-cal offices where specialists know the anatomy of this region, the nature of the microbial flora, peculiarities of the clinical course of the disease.

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