Excision of Pilonidal Sinus

This leaflet explains what a pilonidal sinus is and how it is treated.

What is a Pilonidal sinus?

A pilonidal sinus is a small hole or tunnel on the skin at the top of the buttocks (the cleft). In some people dents (small depressions) in the skin develop naturally in this area.

Pilonidal sinus form in these dents in the skin, often around a hair follicle (the tiny holes in the skin that hair grow out of).

It is unclear what causes a pilonidal sinus, but it may be caused by ingrown hairs, or when dents in the skin get blocked with bits of hair and skin.

Pressure or friction to the skin may also be a factor. The sinus can then become infected. It does not always cause symptoms and only requires treatment if it becomes infected. It often begins as a tiny area of inflammation in the base of the area from which hair grows.

Who gets Pilonidal sinus?

Pilonidal sinus are most common in young adults and are rarely seen in children. They happen slightly more often in men than women and seem to occur more often in people with a lot of body hair.

What causes a pilonidal sinus?

This is a skin problem caused by hair between the buttocks that have been pushed inwards (ingrown hairs). Pilonidal means “nest of hairs” and hair follicles can often be found in the cyst.

Contributing factors can be:

• Obesity.
• Sitting for long periods of time.
• Lots of hair surrounding the area.
• Excessive sweating.
• Poor hygiene.

Symptoms of a pilonidal sinus.

• Bleeding.
• Redness.
• Pain.
• Swelling.
• Inflammation.
• Discharge (pus) often smells.
• Formation of more than one sinus tract or holes in the skin.
• Tenderness to touch.
• Temperature.

How will the operation benefit me?

You have been advised that you need surgery to treat your pilonidal sinus. The aim of this operation is to treat the pilonidal sinus by removing or draining it.

Are there any risks or possible complications?

These risks are applicable to any minor or major surgery:

• Risks associated with general anaesthetic – Your anaesthetist (a doctor with special training in anaesthetics) will discuss this with you. 

• Deep Vein Thrombosis – DVT (blood clots in the leg veins) or Pulmonary Embolism – PE (blood clots in the lungs) Sometimes a clot forms in the deep veins of the leg after an operation. This can cause the leg to swell and become painful. If the blood clot in the vein becomes dislodged (moves) it can travel to the lung and cause a PE. A DVT or PE can be due to the effects of the surgery or reduced activity during your recovery.
  
  All adult patients will have their risk of developing a blood clot assessed within 12 hours of admission. Patients who are being admitted for planned surgery may have their risk assessed at a pre-assessment visit.
  
  The nurse or doctor who carries out the risk assessment will discuss your risk factors with you and advise on treatment to reduce your risk. 
  
• Infection – Signs of an infection include generally feeling unwell, with a temperature or a very smelly discharge from your rectum that is not faecal. This can be treated with a course of antibiotics and you may need a longer stay in hospital.   

• Pain – You may experience pain following your operation in which you will be given pain relief to take on discharge. Local anaesthetic may be given at the time of the operation to help for the first few hours following your operation. 

• Recurrence (happening again) – If this happens you may need further treatment or another operation. 

• Wound Healing – this may be a prolonged process and take time to heal.

What will happen at the Pre-assessment Clinic?

Unless you have already attended after your outpatient appointment, you will be invited to attend the pre-assessment clinic around 2 weeks before your operation.

You will be asked about your general health. Your blood pressure, pulse and weight will be checked. Please remember to bring a fresh sample of your urine with you and all tablets, medicines, inhalers and creams that you are using.

Your nurse will tell you if you need to stop taking any of these before your operation. Samples of your blood will be taken and you may be sent for an X-ray and ECG (heart tracing).

Acute Symptoms

Antibiotics may be given if you show signs of an infection before surgery. Antibiotics treat a wide range of bacteria and help to give relief from infection and discomfort. Painkillers and inflammatory medications can be taken to help reduce pain.

There are various operations which can be done to cure this problem.

Your surgeon will be able discuss the pros and cons of each operation and recommend the most suited for your diagnosis.

Wide excision and healing by secondary intent

Wide excision involves excision of (cutting out) the sinus but also excision of a wide margin of skin which surrounds the sinus. The wound is not closed but left open to heal by natural healing processes.

This usually requires regular dressing changes where the wound is packed with a dressing called sobasan or aquacel. Until the wound heals fully.

The advantage of this method is that all inflamed tissue is removed and the chance of the condition recurring is low, however the wound healing process can take a few months to heal fully.

Excision and primary closure

This means taking out the section of skin which contains the sinus.

This is done by cutting out an ellipse (oval shaped) flap of skin either side of the sinus, which takes out the sinus. The two sides of the ellipse are then sutured (stitched) together.

The advantage for this is that, if successful, the wound heals quickly. However the risk of recurrence or of developing a wound infection after the operation is higher than the above procedure. You will need your stitches removing around day 10 to 12.

What do I need to do before the operation?

Routine blood tests may have been done in pre-assessment, but if not they will be done before your operation.

You will be given some anti-embolism stockings “TED stockings” to wear before, during and after the operation. This is to help prevent blood clots forming in your legs.

We often give you flowtron boots to wear, which are applied on the lower legs in surgery to help stimulate the flow of blood through the deep veins. These will be removed when you are awake and you can mobilise again safely.

Why am I asked not to eat or drink before my operation?

Your nurse will tell you when you must stop eating or drinking before your procedure. This is very important. You must follow the instructions. Nothing means nothing at all (including water and chewing gum).

This is because when you are unconscious, if your stomach contains food or drink you may be sick and it could get into your lungs, affect your breathing and cause an infection. If you forget and do eat or drink anything you must tell your doctor or nurse, as your procedure may need to be postponed for your safety.

What will happen during my operation?

Your theatre nurse will check your details again before taking you into the anaesthetic room.

A warm air blanket or jacket may be used to raise your temperature.

In the anaesthetic room you will meet your anaesthetist again; a cannula (fine needle) will be placed in the back of your hand or arm so we can administer medication. Sometimes, when drugs are injected they may feel cold and sting a little.

An intravenous drip may be attached to your cannula. Your blood pressure will be measured. Your pulse will be taken, and the amount of oxygen in your blood will be measured by attaching a special clip to your finger. This should not hurt.

Your heart rate will be monitored by placing sticky pads on your chest. These are attached to some leads to show a tracing of your heart on a monitor. This is routine and nothing to worry about.

The operation will be carried out under a general anaesthetic (a state of carefully controlled and supervised unconsciousness that means you are unable to feel any pain) or spinal anaesthetic (which may mean you are awake or asleep). Your anaesthetist will explain this in more detail before the surgery.

What will happen after the operation?

You will be taken to the recovery room. Specially trained nursing staff will look after you until you are ready to return to your ward.

If at any time you are in pain or feel sick, please let one of your nurses know and they will give you medication to help relieve it.

You will have an intravenous drip in your hand or arm through which you will receive fluids to prevent you from dehydrating until you are able to eat and drink normally again.

Patients are encouraged to keep mobile within their ability after the procedure.

What to expect after the operation?

You are likely to experience some discomfort following this procedure when the local anaesthetic wears off. The discomfort will get better, but may take a few weeks to resolve completely.

Analgesia and laxatives will be prescribed for you to take home.

We advise you to keep the area hair free around the wound as this will reduce the risk of recurring and will help with the healing process. You are advised to keep the area shaved if possible.

For the next few weeks, to try and help with the healing process try to avoid putting pressure on your wound, please follow these instructions:

• No strenuous activity.
• No lifting items overs approx. 10lbs (5kg) such as children or heavy bags of shopping.
• No exercise beyond a gentle walk.
• Keep the area clean and dry.
• Do not apply any creams or ointments, unless they have been prescribed by your surgeon.
• Keep the wound area hair free.

Will I be able to open my bowels?

This operation should have no cause of concerns or affect your bowels. Just make sure the area is clean if it is close to the wound site.

Avoid constipation or straining on the toilet.

How long will I be in hospital for?

Every patient is different and recovers at different speeds. This can normally be done as a day case procedure. If you have any medical conditions that need to be monitored post operatively then you might be asked to stay in hospital for 24 hours of observation.

It is important to try and be mobile as soon as you feel safe to do so and hygiene is important to try and prevent any infection. You are able to take a shower the day after the procedure.

Will I have any sutures (stitches) to be removed?

You will be given advice after the operation and instructions to follow if you require any sutures to be removed. 

How long will I need to be off work?

This may depend upon the type of work you do. You should ask your Doctor or GP for advice.Your consultant will send a discharge letter to help advise your GP.

If you are taking any medication that makes you drowsy, you must not drive or operate machinery.  

You should try to avoid any lifting that may require straining. Most patients require 2 weeks off work, however every patient is different. You should only do what you feel able to do and give your body time to heal. 

If you require a ‘Fit note’ for work please let a member of staff know before you are discharged from hospital. 

What to look out for on discharge?

When you go home, if you notice any of the following symptoms;

• Signs of infection
• Redness.
• Swelling.
• Pain.
• Heat.
• High temperature.
• Bleeding from the wound site.
• Pus or an unpleasant smell coming from the wound site.

or have any worries about the wound within 7 days after your surgery, contact the Surgical Decisions Unit.

If it has been more than 7 days since your surgery contact your GP if any of these symptoms occur or you are worried about the wound.

How can I help myself?

You will probably be more comfortable wearing loose fitting cotton underwear.

It is helpful to increase the amount of fibre in your diet. This is best done gradually as a sudden as a sudden increase can cause abdominal discomfort and wind. Below are a few examples of the foods you could introduce into your diet:

• Wholemeal bread, pasta and rice.
• Beans.
• Lentils.
• Vegetables and fruit.
• Nuts.
• Seeds.
• High fibre cereals.

When can I drive again?

You can drive two weeks after the operation, however, if you do not feel ready to drive then wait until it is safe to carry out an emergency stop.

You should check with your insurance company as policies may vary with individual companies.

When can I play sport again?

You should not go swimming until the area has healed and only do light sport activities. This will prevent the wound re-opening in the healing process.

Will I have a follow up appointment?

You will have a follow up appointment after the operation to check the wound and healing process.

When you are discharged we will discuss this with you. It is generally different for each patient.

If you haven’t received an appointment please call the outpatient department or the ward which you were discharged from, they will be able to check this for you.

Outpatient Department: 01642 383838.

Contact Numbers

If you have any worries or concerns during the first 24 hours following your discharge from hospital, please phone the ward to which you were admitted.

After 24 hours; please seek advice from your GP.

North Tees and Hartlepool NHS Foundation Trust

University Hospital of North Tees

Ward 28

Telephone: 01642 382828

24 hours a day, 7 days a week.

Ward 31

Telephone: 01642 382831

24 Hours a day, 7 days a week.

Day Case Unit

Telephone: 01642 624168

Monday to Friday 8am to 5pm.

Specialist Colorectal Nurses

Telephone: 01642 624399

Monday to Friday 9am to 4.30pm.

Hospital of Hartlepool

Ward 9

Telephone: 01429 382809

24 hours, 7 days a week.

Day Case Unit

Telephone: 01429 522949

Monday to Friday 8am to 5pm

Non-urgent messages can be left on the answering machine.

For Urgent advice within 1 week of discharge, please contact:

Surgical Decision Unit

24 hours a day, 7 days a week

01642 617617 – ask for switchboard to connect the SDU coordinator on extension 46430 or via Vocera.

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