The diagnosis of pilonidal disease (pilonidal cysts), and other conditions
The symptoms of pilonidal disease can very very greatly from one person to another. But, I will describe the basic symptoms below. Note: there are links to some graphic photos of this condition. Only click on these if you want to see how this looks:
- Chronic discomfort in the buttock crease area
- Acute Pain with a lump (pilonidal abscess)
The visible signs are:
- A very deep crease in the buttocks
- Enlarged pores or open areas in the midline of the crease, possibly with hairs entering them (see image)
- Bleeding or drainage
- Sinus tract openings on the skin (see image)
- Darkening of the skin on each side of the buttock crease
- A painful, red lump adjacent to the buttock crease, or reddening of the skin in that area.
- Note: these signs may not be visible unless the buttocks are spread apart to visualize the base of the cleft. Sometimes, a cursory external examination will look quite normal!
There are a few other conditions that can be confused with pilonidal disease. Usually, with some basic knowledge of these conditions, and a visual inspection of the buttock crease and perianal area, the diagnosis is usually clear. Here are some of the other conditions that should be considered:
Anal Fistula. This is manifested by a small opening on the skin near the anal opening. It is usually more anterior (forward) than pilonidal sinus tracts – but there is an area of overlap where either could exist. The definition of a “fistula” is an abnormal passage between a hollow or tubular organ and the body surface. These fistulas come from a plugged anal gland, which causes an infection to develop in the peri-anal area. This may initially present as a painful lump or “boil” on the buttock which drains a lot at first, but then continues to intermittently drain over the succeeding weeks or months. This is because an abnormal connection between the rectum and the skin has developed. This requires surgery to correct – but it is not the same surgery as needed for pilonidal disease.
Perirectal Abscess. This presents as a painful lump or boil. This can be similar to a pilonidal abscess – but the location is usually different. A pilonidal abscess is usually higher up within the buttock crease, or off to one side of that crease. A perirectal abscess is usually right next to the anus, or on one of the butt cheeks. Either of these needs the same initial treatment – which is drainage (“lancing”) and possibly antibiotics. You can read more about pilonidal abscess on the FAQ page.
Hidradenitis Suppurativa. This is a disease of the skin which occurs most frequently in the armpits and groin creases. The symptoms from this are repeated skin abscesses (pockets of infection) in those areas. It is possible to get this in the buttock crease or right next to the anus. Here is more about HS.
Anal Fissure. This should not be confused with pilonidal disease, but I mention it here because its name is similar to Anal Fistula. An Anal Fissure is a tear in the lining of the anal canal, usually caused by a hard bowel movement. It causes sharp pain in the anus with bowel movements, and usually some small amount of bleeding with bowel movements. Most of the time these heal by themselves – but if the symptoms persist for more than a month – surgery may be needed.
Hemorrhoids. This is a problem that is adjacent to, or within, the anus – not up in the gluteal crease. It can present with a lump next to the anus, that can be uncomfortable; particularly with bowel movements. There may be some bleeding associated with it. Although it is possible for a hemorrhoid to become secondarily infected, this is unusual, and antibiotics are not usually indicated. Most of the time the acute symptoms of pain with a hemorrhoid will resolve with stool softeners, sitz baths, and time (usually 2-3 weeks). If symptoms are particularly severe, a surgeon may recommend that the hemorrhoid be drained or removed – but usually it is safer to let the acute swelling resolve before performing any surgery.