Pilonidal disease can manifest itself in several ways. A patient can have a cyst, a sinus, an abscess, or a wound. These each have different types of discomfort, and there are different strategies to make things feel better. I’m going to discuss these types of pain in the tailbone area separately.
Note that if you perform an internet search for “tailbone pain” you will find many discussions about “coccydynia”. This is a more unusual diagnosis, and pilonidal disease should definitely be considered before deciding that it is “coccydynia”- even if a patient has had trauma to the area.
Pain from a pilonidal abscess
This is the most painful situation that patients encounter with pilonidal disease. In this situation a pilonidal cyst becomes infected, and a patient will notice increasing pain over the tailbone area, tenderness, and redness associated with a lump in the gluteal crease (butt crease). This can be directly in the midline, or off to the side. This usually becomes more severe as the days go by, until it is clear that there is something very wrong going on! This situation is discussed on this web page and the main message is that if it gets too severe the best way to alleviate the pain over the tailbone area is to have it drained (aka lanced, or an “I&D”). But, if you want to try things at home, taking oral analgesics and warm soaks may help. If the abscess is very close to the skin, the warm soaks may cause it to drain and provide relief.
Pain from a pilonidal sinus
A pilonidal sinus is a pilonidal cyst that has burrowed from a midline pore to a secondary opening. In other words, it is a small tunnel from one spot to another. These two spots can be as close as 1/4″ apart, or as far as several inches. Typically the fluid and bacteria in these tunnels builds up and causes pain over the tailbone, or in the butt crease. Eventually, the fluid starts draining through one or both of the openings, and the discomfort subsides. This may give the false impression that the problem is solved, but unfortunately these tend to cycle, and act up again in several weeks or months, and surgery is usually ultimately needed. But, while these are causing pain, taking over-the-counter analgesics along with warm soaks may help, and speed up the drainage process.
Pain from pilonidal cysts
A pilonidal cyst is a pocket of hair and skin debris under the skin, and it is always in the tailbone area, or butt crease, or slightly off to the side. A small one might be about the size of a pea, and a large one the size of a walnut. If it is not infected it may be unnoticed, unless pressure is put directly on it – like when doing sit-ups on a hard surface. Often when a patient develops a pilonidal abscess in retrospect they remember that they did have some minor discomfort in the tailbone area for quite some time. Aside from avoiding pressure or trauma to the tailbone area, there isn’t much to do for this – other than consider having surgery before other problems develop.
Pain from pilonidal wounds
There are situations, either before or after an operation, when there are openings in the gluteal crease that are large enough to be called “wounds”, rather than “pits” or “enlarged pores”. These can be as small as 1/4″ around, or significantly larger. Surprisingly, if these are not infected the discomfort may be minimal. Often, the surrounding skin irritation is more painful than the wound itself, and effort should be taken to protect the skin by tucking absorbent gauze in the crease next to the wound to allow air circulation, and absorb the irritating drainage quickly.
The ultimate solution?
All of these situations can be treated with surgery, and there are various surgical procedures available. In our clinic we perform the cleft lift procedure because of its quick recovery and high success rate. At what point a patient feels that they are ready for a surgical solution varies greatly, and the discussion on this web page may help.
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