Pilonidal Disease: Can I Avoid Surgery?

Will this go away by itself? Is it manageable with non-surgical care?

This is a commonly asked question. Although I am a surgeon, I realize that surgery is not for everyone, and nobody is really excited about having an operation if there is another option. Drainage of a painful, infected, abscess (lancing, I&D) is often an emergency and is very obviously necessary, other operations are elective – meaning that a patient has a chance to think about it, weigh the pros and cons, and decide if that is the route they want to proceed.

The decision is easy if the pilonidal disease is painful, embarrassing, disruptive and depressing, and it’s clearly time to do something about it. On the other hand, for other patients surgery is not really the route they want to go. There can be various reasons for this:

  • The symptoms aren’t that bad.
  • Their philosophy that surgery is only a last resort.
  • Financial considerations.
  • Concern regarding the cosmetic change.
  • General fear of surgery and hospitals.
  • Lack of a qualified specialist nearby.

These are all reasons to step back and see if there is a non-surgical approach that will work. It is a rare situation in which pilonidal disease becomes life-threatening. For various reasons, there isn’t very robust data regarding the recurrence rate of pilonidal problems. So, I can’t really tell you that if you had one abscess, what the chances are that you will have another. In a specific situation, if I can evaluate the anatomy, I may be able to predict whether future problems are expected or not. But, if you are not seeing a pilonidal specialist, it will be hard for you to come to any conclusion on your own.

These are situations where future problems are very likely:

  • Multiple, enlarged midline pores or actual open wounds.
  • A very deep gluteal cleft. Sometimes this is apparent, because it takes some strength to spread the buttocks apart to see the base. Or, in other situations, the crease seems to open up easily when prone, but folds when standing. Brownish discoloration (hyperpigmentation) of the skin on either side of the cleft is a clue that this is a problem.
  • Multiple abscesses.
  • The presence of a sinus.

Sometimes after an abscess has been drained, there are no visible abnormalities. This is the kind of situation where it is not clear how much a problem it will be in the future. This web page discusses that situation.

But, if you are dealing with any of the situations described above, it is possible to get along without surgery, but the pilonidal disease is going to be an intermittent long term problem and, contrary to some rumors, will not just disappear after age 40.

Diligent attempts at hygiene, antiseptics, dressings and at times antibiotics may help minimize symptoms, but most likely won’t completely eradicate the problem. A discussion of home remedies can be found here. However, if a patient’s issue is that surgery is not feasible now because of finances or other obligations, some of these home remedies may make delay less painful.

In general my recommendation is that the best approach is to proceed with surgery at some point, and the sooner this is treated, the sooner patients can get on with their lives. I believe the cleft-lift operation by an experienced pilonidal surgeon is the best combination of high success rate coupled with ease of recovery. Contact us if this is something you would like to explore.

Pain after Pilonidal Surgery

Strategies to evaluate and treat pain after surgery

One of the more common questions I receive is how to deal with chronic pain after pilonidal surgery. Fortunately, these have not been patients on whom I have performed a cleft-lift, but rather other patients coming to me seeking solutions. However, it is possible for a patient to have a cleft lift and some time afterwards develop pain that seems similar to the pain that they had with pilonidal disease – raising the question about what exactly is happening.  Although there isn’t always an obvious answer or a simple solution, I thought I’d share my observations on how to deal with this.

Pain developing months after a cleft lift is not a common occurrence. Having a cleft lift does not absolutely guarantee that a patient will ultimately be pain free, but in a recent article I wrote, 500 cleft lift patients were surveyed. Of the 500, only two said that they had some minor discomfort with sitting at two months post-op, so chronic, residual pain was not common at all in this group of patients. You can read about it by following this link.

What is the type of pain?

When dealing with “pain” it is important to differentiate the different kinds of pain, and there are several significant questions that have to be answered in order to start narrowing it down.

  • When did the pain start in relationship to the previous surgery? Did something else set it off, like a fall?
  • Is the pain deep inside, or on the skin?
  • Is the pain an ache, stinging, burning, throbbing, etc?
  • Does it hurt all the time? Just when sitting? With certain activities? At night?
  • Is it “pain” that occurs spontaneously, or “tenderness” that only hurts when touched?
  • Exactly where is the pain? In the gluteal crease? Next to the anus? Near the hip? Radiating down the leg? Low back?
  • Does it occur with bowel movements? And persist afterwards?

What can you see?

  • It is important to know if there are any physical findings that might help explain it. A rash? A raised scar? Any openings, drainage or bleeding? Any swelling or visible asymmetry?
  • If there are physical findings, where exactly are they? Are they in the gluteal crease?
  • Is there bleeding with bowel movements? Constipation? Any lumps around the anus?

So, what could be causing it?

It would be difficult in a short post to go through an “if this, then that” algorithm, so this may require you be evaluated by a physician, but here are some reasons for chronic pain:

  • If there are any openings, drainage, or bleeding in the gluteal crease, then you may have recurrent pilonidal disease.
  • Although patients with pilonidal disease usually blame any discomfort in that area to pilonidal problems, orthopedic issues can give pain in that area. Possibilities include sacroiliitis, lumbar disk problems, or coccydynia. Sacroiliitis is one of the more common causes of this problem, and here is a link discussing this in more detail.
  • If the scar is thickened and raised, it could mean that you have developed a keloid (hypertrophic) scar, and that can be painful.
  • If it is less than 6 months from your surgery, it still can be related to the surgery itself. Things are still healing and sutures are still in the process of dissolving.
  • If you had a lot of pain before or immediately after surgery, it is possible to develop a chronic pain syndrome, where it keeps hurting even though things have healed. Names for this are causalgia, reflex sympathetic dystrophy, complex regional pain syndrome (CRPS), or reflex neurovascular dystrophy. This is real pain that occurs as an aberrant response to previous pain. This is an unusual location to have this, it is more commonly associated with the arms and legs.
  • If you had excisional surgery, where a fair amount of tissue was removed, there may not be much padding between the coccyx and skin, and it may be uncomfortable with sitting. Using a pillow or coccyx cushion may help. When I perform a cleft-lift, I add additional padding over the coccyx which prevents this kind of pain.
  • Spasm of the gluteal or pelvic muscles can cause pain, but muscle spasm is usually caused by some other factor that is the source of the irritation or pain, and the muscle spasm is secondary. So, although muscle spasm may be present, one has to look for the cause.
  • If there is bleeding or pain with bowel movements, or a lump on the anus, it could be an anal fissure, anal fistula, perirectal abscess or hemorrhoid. This page describes some of the other things that can be causing a problem.
  • You may have noticed that I haven’t included “scar tissue” or “nerve regeneration” as a cause for chronic pain. I do not believe that the scar tissue caused by normal healing causes pain.

How to deal with the pain?

  • If there are findings to suggest recurrent pilonidal disease, then a cleft-lift or revision of a cleft-lift is the best approach.
  • If it seems to be related to a hypertrophic scar (keloid), then this should be addressed by your surgeon or a plastic surgeon. Plastic surgeons are usually the most qualified to treat keloid scars. Over the counter hydrocortisone gel may help with the discomfort.
  • If it is related to position and activity, an orthopedic cause should be evaluated. Your primary care physician or an orthopedic surgeon can help you evaluate this. Anti-inflammatory medications, rest, and heat, may help.
  • If you have a rash, the rash may be causing the discomfort. Keeping the area as clean and dry as possible may help. Anti-fungal or steroid applications may help, but seeing a physician for a diagnosis will help guide therapy.
  • If you think it may be due to a chronic pain syndrome, seeing a physician at a “pain clinic” may be the best solution. They will help figure out what is happening, and suggest treatments.

I don’t think it is any of these things, what should I do?

If there are no physical findings, and this just seems to be some prolonged, but mild discomfort or tenderness in the surgical area, here are some strategies you can consider:

  • Anti-inflammatory medications like ibuprofen or naproxen. Or, consider prescription Celebrex or over-the-counter Kaprex if you have a sensitive stomach.
  • Acetaminophen
  • Ted’s Pain Cream. This has resveratrol, and has been successful in stopping post-op discomfort.
  • Acupuncture
  • CBD products, either topical or oral

In summary, pain is not normal, and there is usually a diagnosis and a solution. I recommend that you don’t give up and consider seeing the various physicians discussed above in order to resolve the pain.

Does Pilonidal Disease Go Away After Age 40?

Can I just wait, and it will disappear?

Although it is unusual to start getting new pilonidal disease after age 40, preexisting pilonidal problems often will not go away if they have been untreated.  The reason it is rare for pilonidal disease to start as one gets older, is that the gluteal cleft naturally opens up and widens as we age, and the cleft is less deep, and sharp. However, lingering sinus tracts and cysts may still be present and cause problems. So, if you have an untreated sinus tract or cyst, it will not suddenly disappear with age, and may be a problem at any time, even after age 40.

Trauma to the gluteal area may cause it to suddenly act up after years of being asymptomatic. Also, especially in women, starting a new habit of wearing tight stretch pants, can deepen the gluteal crease and start new pilonidal disease even after age 40.

We have seen patients as old as 70 with pilonidal disease that continues to be symptomatic.

So, although it is true that pilonidal disease becomes less and less of a problem as one ages, it is not something that you can rely on to make your pilonidal problems disappear.