PILONIDAL SINUS DISEASE
Description
🔹 Definition:
#Pilonidal sinus disease (PSD) is a persistent infection of the skin and subcutaneous tissues that usually affects the sacrococcygeal region in the natal cleft, which is the space between the buttocks.
#It involves a tiny, hair-and debris-filled, epithelialized tract or cyst that can cause infection, abscess formation, and persistent discharge.
🔹Epidemiology:
•Age: Young adults (15–40 years old) are frequently affected.
•Sex: Approximately two to four times as many men as women are impacted.
• Occupation: Those who spend a lot of time sitting down, like drivers, office workers, and students, are more vulnerable.
•Incidence: around 26 out of 100,000 people.
•Peak: late teens to the thirties.
🔹 Causes and Etiology:
• Unlike what was once believed, pilonidal sinus illness is acquired rather than congenital.
#The primary mechanism :
• The theory of hair penetration: Because of friction, pressure, or trauma, loose hair pieces pierce the skin in the birth cleft.
• The sinus tract may get infected as a result of the body mounting a foreign body reaction.
# Contributing elements:
1. A deep natal cleft causes more friction and hair growth.
2. Body hair that is coarse, particularly in the sacrococcygeal area.
3. Bacterial colonization is made possible by poor hygiene.
4. Extended periods of sitting can lead to stress and injury.
5. Obesity causes a deeper cleft and more perspiration.
6. Localized perspiration and maceration compromise the integrity of the skin.
7. Possible genetic predisposition based on family history.
🔹Pathophysiology:
1. Hair shafts pierce the natal cleft's skin.
2. Inflammation and abscess formation are the body's reactions. 3. The abscess either drains on its own or by a surgical incision.
4. Multiple holes in the sinus tract are caused by chronic inflammation. 5. The sinuses may occasionally release blood or pus.
🔹Clinical Characteristics:
A. Acute Abscess of the Pilonida :
• A painful enlargement of the sacrococcygeal area.
• A delicate, variable mass that is frequently lateral to the midline.
• There may be purulent discharge, fever, and redness.
•Bending or sitting makes pain worse.
B. Persistent Sinus Pilonida :
• Continuous or sporadic serosanguinous or pus discharge from a sinus aperture.
• The newborn cleft contains several midline pits or holes.
• Localized discomfort, itching, or bad smell.
•Recurrent abscess development events.
🔹Differential Diagnosis:
•Fistula-in-ano or perianal abscess. • Suppurative hiprodenitis.
• A dermoid cyst.
• Boiled furunculosis.
• A cyst of epidermis.
• Rare cases of sacral osteomyelitis.
🔹 Investigations :
#Usually clinical diagnosis, however investigations may support evaluation or rule out other illnesses. 1. Clinical examination: hair, sinus passages, midline pits, and discharge.
2. Ultrasound: identifies sinus tracts and abscess cavities.
3. MRI: shows the extent of the tracts (in complex/recurrent situations).
4. Discharge culture: for antibiotic sensitivity.
🔹 Treatment:
A. Non-surgical and conservative: •Maintain local hygiene (regular washing, hair removal) for tiny acute abscesses or those that are asymptomatic.
• Hair removal by shaving or laser to stop recurrence.
• Only use antibiotics (such as co-amoxiclav) if cellulitis is present. •Sitting baths are comfortable.
B. Management via Surgery:
1. Drainage and Incision (I&D):
• For an acute abscess.
•Easy pus drainage; dirt and hair are eliminated.
•Offers respite, although chronic diseases might not be cured. •Definitive surgery might be needed later.
2. Excision Techniques (for recurring or chronic diseases):
•Excision accompanied with Secondary Healing -
~The entire sinus is removed and allowed to granulate and recover. ~Long recovery period (6–10 weeks), but low recurrence.
•Excision with Midline Primary Closure:
~The wound mostly closed over the midline. quicker recovery but a greater chance of recurrence.
• Off-Midline Closure (Karydakis/Bascom procedure):
~To flatten the cleft, the sinus is removed and the wound is closed off midline.
~Better cosmesis, less recurrence, and quicker recovery.
• Flap procedures (Limberg/Z-plasty):
~Rotational or rhomboid flaps are utilized to flatten clefts and close defects.
~Good results when used for extensive or recurrent diseases.
🔹 Postoperative Care :
•After surgery, make sure the region is dry and clean.
• Regular hair removal (laser or shaving).
•Avoid applying pressure or sitting for extended periods of time.
• Promote early walking.
• Frequent changes of attire.
🔹 Problems:
• Recurrence (up to 20–30% if not properly treated).
• Infection or dehiscence of the wound.
• Prolonged sinus development.
• Uncommon: Squamous cell carcinoma in sinuses that have not been treated for a long time.
🔹 Prognosis:
•The cure rate surpasses 90% with appropriate surgical care. •Recurrence primarily brought on by deep clefts, inadequate hair removal, or inadequate wound care.
🔹 Prevention:
• Keep yourself clean.
• The sacrococcygeal area's hair is regularly removed.
• Steer clear of extended sitting.
• Maintain a clean and dry natal cleft area.
• If you are fat, lose weight.
🔹Case Report:
• Patient information: man, age 22
• The main complaints are anal verge pain and pus discharge. Fever that comes and goes for two years
• Results of the local examination: Two external apertures on either end of the scar, approximately 9 cm from the anal margin, and a scar measuring 4 cm at 5 o'clock •Inquiries:
~Regular inquiries: within typical bounds
~Intraoperative observations: #External entrance used for dye test #Dye traced to natal cleft rather than anal canal → Diagnosis: proven to be the pilonidal sinus (PNS), not fistula-in-ano
• Surgical procedure :
~Elliptical incision over the natal cleft up to the pre-sacral fascia; complete excision of the sinus with removal of the hair tuft; and secondary intention healing of the wound
~Apamarg Ksharasutra was used to treat the residual tract (about 9 cm) from the base of the natal cleft to the external aperture.
~Ksharavarti (alkali suppositories) was used to treat the ramifications and communication tracts. •Postoperative care:
~Unremarkable recuperation
~On a daycare basis. Ksharasutra was changed every four days.
~The procedure lasted until the tract was completely cut.
• Outcome:
~After four weeks, the patient fully recovered.
Protocol
🔹 Nursing Management:
A) Issues Nurses Face:
• Difficulty controlling discomfort when moving and clothing.
• The danger of infection and foul-smelling discharge.
• Wounds that heal slowly, particularly following extensive excision.
• It is necessary to change clothes frequently.
• It can be difficult to maintain hygiene in the natal cleft area.
• Disregard for hair removal and hygiene recommendations.
• Anxiety or embarrassment because of the wound's position.
• Limited movement as a result of surgery site pain.
• It is challenging to educate patients about recurrence prevention and hygiene.
• Disease recurrence in the event of insufficient care and follow-up.
B) Nursing Management Prior to Surgery:
•Evaluate pain, discharge, and infection symptoms.
• Preserve local cleanliness by using an antiseptic solution to clean the region.
• To avoid micro-injury, clip your hair instead of shaving it.
• Describe the condition, the process, and the expectations following surgery.
• Promote a diet rich in fluids and high in protein.
• Administer analgesics and antibiotics as directed.
• Offer psychological support and reassurance.
C) Nursing Management Following Surgery:
#Pain Management:
• Give analgesics as directed.
• Promote the prone or side-lying position.
• Instruct students in deep breathing and relaxation methods.
#Wound Care:
• Apply dressings in an aseptic manner.
•Examine for signs of infection, such as redness, swelling, discharge, or odor.
• Extract any loose hair from the wound.
• If a drain is present, maintain adequate drainage.
#Infection Control:
•Hand washing should be done thoroughly both before and after dressing.
• Give antibiotics as directed.
• Teach them how to maintain the space dry and clean.
#Mobility:
• Promote slow mobilization.
• Steer clear of pressure on the wound or extended sitting.
• If sitting is required, use a ring pillow or soft cushion.
#Hygiene and Hair Removal:
• Give instructions on how to clean and dry the natal cleft every day.
• Frequent hair removal, ideally with a laser or clip.
• Steer clear of tight apparel.
#Nutrition:
• Promote foods heavy in iron, protein, and vitamin C.
• Retain adequate hydration.
#Psychological Support:
• Offer confidentiality while receiving care.
• Provide emotional support and reassurance.
• Permit emotional and anxious expressions.
#Health Education / Recurrence Prevention:
•Maintain personal hygiene and cleanliness.
• Consistent hair removal in the sacrococcygeal area.
• Steer clear of perspiration and extended sitting.
• Promote physical exercise and weight control.
• Emphasize the value of routine follow-up appointments.
Notes
https://doi.org/10.4103/0974-7788.72492