One of the most common questions I am asked, is what a patient should do when they have evidence of pilonidal disease, but minimal symptoms. In these cases patients notice enlarged midline pores (often referred to as “pits”), with or without drainage, and with or without occasional discomfort in the area. I would consider this minimal disease.
There are also patients who have had a single abscess drained, and are now asymptomatic. The drain site has healed, but there are a few midline pores remaining. I would also consider this minimal disease. Studies suggest that 50% of patients with a single abscess will go on to have further problems.
This is contrasted with patients who have intermittent pain and drainage from a spot off to the side of the gluteal cleft, who have repeated abscesses, who have open draining wounds in the midline, or have wounds from surgery that will not heal. These patients absolutely need surgical treatment, and are not the topic of this discussion.
It is impossible to know which patients with minimal disease will go on to have further problems. There is no good, long term, statistical study of the incidence of problems in these patients, but my feeling from dealing with this disease process over the last 35 years, is that most of these patient will eventually have progression of their disease, and have to deal with this.
The kind of problems that can develop vary, but are usually a variation of the ones listed to the right:
It is a very rare situation where any of these become life threatening, but they can make a person’s life miserable. It is certainly possible to wait and consider surgery once these problems occur – but constant discomfort and fear of recurrent symptoms can weigh heavily on a person. Also, these flareups or abscesses seem to develop at the worst possible times, such as on vacation, before and exam, when starting a new job, etc. Even if a patient can manage these symptoms with home remedies, it is basically turning a treatable problem into a chronic disease.
One thing that I have learned over my many years in surgical practice, is that every patient has a different approach to problems like this. Some jump at surgery at the first suggestion and want to be proactive in preventing any future problems; others want to wait and see what kind of problems they have before committing to an operation; and others put surgery off to an extreme degree and wait until their problem has turned their lives upside-down and made the surgery more difficult. You have to decide which kind of person you are, and go with what seems right to you.
My personal philosophy is that I’m here to help in whatever capacity my patients want. I think it is very reasonable to wait and see if the midline pores cause a problem, but I am also glad to be proactive with surgery to prevent future issues. I think it makes sense to have surgery before there are multiple sinus tract openings, wounds close to the anus, or the pilonidal disease has become an overriding issue in one’s life. My experience has taught me that in my hands, the cleft-lift is the best operation and that’s why it is my operation of choice. The recovery from the cleft-lift is easier than most of the operations you may have heard about, and the recurrence rate is very low, but it does change the appearance of the cleft and leaves a scar. I suggest that you read about this operation, and consider it if you decide that you want surgery.
We routinely take care of patients with pilonidal cysts, non-healing pilonidal wounds, and pilonidal abscesses with great success in the pediatric, teen, and adult age groups.