Epithelial pilonidal disease (ECD) is a congenital anomaly that is a pathology of soft tissues. A subcutaneous canal with one or more exits to the surface is formed above the buttocks. In medicine, this phenomenon is also known as a cyst or fistula of the coccyx and pilonidal sinus. A coccyx cyst does not pose a threat to the patient’s life, but causes numerous inconveniences in the form of repeated suppuration and inflammation, the formation of pyoderma of the intergluteal fold, and others.
The disease affects men and women under 30 years of age, and in most cases it is asymptomatic.
What does the epithelial coccygeal duct look like?
The pilonidal cone is a narrow canal in the subcutaneous tissue, the walls of which are lined with epithelium consisting of many sebaceous glands, hair follicles and sweat glands, as well as connective fibers. It is not connected with the sacrococcygeal region, but is closed blindly in the subcutaneous tissue. Systematically, accumulated waste products of the epithelium are released from the stomata, which open at one or several points.
Photos of the epithelial coccygeal tract in a hidden form do not give an idea of the scale of the problem, since pathological changes are not visible on the skin of the sacrococcygeal region.
In some cases, when an infection penetrates inside the epithelial coccygeal duct or its external openings are blocked, inflammation begins inside the formation with the formation of an abscess. It is at such moments that ECX is often detected.
A rapidly increasing abscess, which can spontaneously open, is evidence of a coccygeal cyst, and after opening, a deep fistula is formed.
Recurrence of ECX after surgery
Recurrent development of ECC after a previous operation can occur on average after 1-2 years. Relapse may be associated with insufficient volume of the previous operation, imperfect surgeon technique, or impaired wound healing in the postoperative period. In this case, patients are also indicated for repeated surgery, which is more difficult due to the presence of scar changes in the intergluteal region. This also helps to increase the wound healing time and worsen the cosmetic effect. To reduce the risk of relapse after the initial operation, it is recommended to carefully observe the rules of personal hygiene and care for the postoperative wound; shaving of the sacrococcygeal area is recommended for 3 months after the operation. The patient must also limit physical activity for 2 months after the procedure, and after some operations it is also necessary to limit sitting for 2 weeks after surgery.
Causes of pathology
The main causes of coccyx cysts are still unknown. It has been established that this pathology appears at the stage of intrauterine development, when a space lined with epithelial tissue forms between the buttocks in the fold. The reasons for its appearance are unknown, and there are no statistics on the number of children born with ECC.
According to experts, the causes of epithelial coccygeal duct in the fetus in 99% of cases are associated with a hereditary factor. If one of the parents has been diagnosed with this disease, the risk of its detection in children increases several times.
Also, the formation of a coccygeal cyst can occur in an adult, but there are specific reasons for this:
- Bruise of soft tissues in the coccyx area or other injury, as a result of which a purulent focus is formed in the form of a narrow tube under the skin. After the pus comes out and the external opening heals, the cavity remains and periodically becomes inflamed.
- Inflammation and suppuration of the skin in the intergluteal fold (boils), resulting from clogged pores, inflammation of acne and insufficient hygiene.
- Thick hair in the area of the coccyx and sacrum, especially if there are ingrown hairs. In such situations, inflammation of the soft tissues may occur with the formation of a fistula.
The same factors influence the condition of a congenital coccygeal cyst. As a result of a bruise, hair, epithelium, and bacteria entering the external opening, inflammation and exudate occur.
Inflammatory and purulent processes in the pilonidal cone often begin in people leading a sedentary lifestyle. Insufficient blood circulation and stagnant processes in the soft tissues of the sacrococcygeal region contribute to the manifestation of pathology.
The main problem of early detection of pilonidal cyst is its hidden course. Until inflammation begins with the release of exudate and the formation of an abscess, a person is unaware of its presence.
Symptoms
Most often, patients complain of the following symptoms:
- Pain in the coccyx area. As a rule, pain increases significantly with physical activity.
- There is compaction in the area of the intergluteal fold, and there is a sensation of a foreign body in this area.
- Swelling and hyperemia of the skin just below the sacrum
- Discharge of white, yellow, or clear fluid from the inflamed area.
The presence of epithelial-coccygeal cysts and tracts significantly reduces the patient’s quality of life, so they require mandatory treatment. Unfortunately, today the only effective method of eliminating pathology is surgical intervention.
Classification of coccygeal cyst
The epithelial coccygeal tract does not have a complex classification. Proctologists distinguish two types of pathology:
- uncomplicated, occurring without clinical manifestations;
- complicated, with the formation of exudate, abscess and/or fistulas.
In a complicated course, the disease occurs in two stages. At the first stage, which is called infiltrative, sweat and fat secretions, ichor and exudate accumulate in the cyst cavity. The skin over the cyst turns red and swells. The photo below is an example of what such inflammation may look like.
At the second stage, which is called abscess formation, the formation of one or more abscesses occurs, which open out.
In rare cases, pus leaks into the soft tissue. In this case, new foci or tracts form, and the disease takes on a chronic form.
In a chronic course, the epithelial coccygeal tract occurs in three stages:
- infiltrative;
- recurrent abscess;
- stage of purulent fistula.
After an exacerbation, remission occurs, the duration of which varies depending on many factors. The only way to permanently get rid of chronic inflammation of the epithelial coccygeal duct is surgical intervention.
Delicate and complex problem
Coccyx cyst (epithelial coccygeal duct) is one of the most delicate and complex health problems.
Those who have dealt with her understand what we are talking about. Coccyx cyst occurs in both men and women. According to statistics, the stronger sex suffers three times more often. The delicacy lies in the localization of the pathological focus. The formation is located in a fairly intimate place (the area of the coccyx, sacrum and intergluteal fold) not far from the anus. Not everyone will easily want to share this with others, even with relatives and loved ones. Not everyone is ready to immediately show the sore spot, discuss their complaints and discomfort, even with doctors. When an epithelial cyst of the coccyx becomes complicated (abscess formation, suppuration, relapse), a person in most cases is deprived of the opportunity to maintain his usual lifestyle and quality of life. Irritating pain, excruciating discomfort, serous or purulent discharge, an unpleasant odor appear, laundry gets dirty, and additional hygiene procedures become necessary. Often it is simply impossible to sit normally. And this is not the whole list of inconveniences.
Many in this situation are forced to give up their usual activities, sports, and even intimate life. All this is depressing. Adding to the delicacy is that a coccyx cyst clinically manifests itself more often in adolescence or puberty. Teenagers are known to be especially sensitive to such problems, although they will try their best not to show it. Wise advice, understanding, help and timely consultation from a surgeon are especially important for them.
The complexity of this pathology lies in the fact that very often there are relapses (repeats) after improper preparation for surgery, an insufficiently radical operation (incomplete removal of cysts, fistulas and leaks), inattentive management in the postoperative period, failure to follow doctor’s recommendations, ignoring basic hygienic procedures and other reasons. Some people have to undergo surgery for coccyx cysts not once, not twice, but multiple times. You won’t believe it, but there are still people who suffer all their lives due to relapses. This reduces the quality of life and is certainly a tragedy. It shouldn't be like this!!!
It is necessary to initially take this disease and the initial operation very seriously. Agree, no one wants to have multiple surgeries. However, repeated surgical intervention should be taken no less seriously, and perhaps more seriously, if the clinical situation has recurred. It is very important to prevent chronicity and continuation of the sluggish process. A coccyx cyst is not a very common and not at all an ordinary problem. The choice of clinic and doctor is extremely important to minimize the risk of relapse. Consultation and surgery with a qualified surgeon who has experience in treating this pathology is necessary.
How does ECC manifest - signs and symptoms
The main sign of exacerbation of a coccyx cyst is throbbing or aching pain in the sacrum or coccyx, accompanied by exudate from the opened holes. Inflammation occurs in the area:
- redness;
- tissue compaction;
- one or more abscesses along the course of the cyst.
With proper therapy, the suppurating epithelial coccygeal duct opens up on its own. If this does not happen, the doctor (proctologist or surgeon) decides to incise the skin over the source of suppuration. After cleansing the EC cavity, a temporary improvement occurs and the symptoms subside. The photo below shows a surgically opened abscess that formed above the epithelial coccygeal duct.
After opening, the remission stage begins, and then, if an operation to excise the cyst was not performed, the process is repeated.
In the case of chronic inflammation of the ECC, the likelihood of developing pyoderma is high. This condition is characterized by the formation of an extensive network of subcutaneous passages, sweat and fat secretions, pus and hair. Only surgical intervention can help in this situation.
Indications and contraindications for surgery about surgery
It is recommended to carry out surgery in the presence of epithelial-coccygeal cysts and tracts as soon as the disease is discovered. It is worth noting that excision of a coccyx cyst is carried out exclusively during a period of stable remission, when the inflammatory process in the area of the tract is reduced or completely eliminated. In order to eliminate the inflammatory process, non-steroidal anti-inflammatory drugs or other medications may be prescribed.
Let's consider a number of contraindications for which surgical intervention is not performed:
- Presence of cancer.
- Blood diseases.
- The presence of acute inflammatory processes in the body.
- Serious pathologies of blood vessels or heart.
- History of renal and liver failure.
Women are not recommended to have coccyx cyst excision during menstruation. Please take this into account when planning your operation.
Diagnostic methods
The diagnosis of a pilonidal cyst in most cases occurs after the onset of the inflammatory process, since in its absence the disease is asymptomatic. When unpleasant symptoms of EC suppuration appear, ulcers and fistulas form, the diagnosis becomes undeniable.
If the fistulous form of the coccyx cyst has begun, a detailed examination is carried out in order to exclude other pathologies:
- rectal fistula;
- meningocele;
- presacral teratoma;
- osteomyelitis and others.
The diagnosis is carried out by a proctologist. To begin with, a digital examination of the rectum is carried out for changes in the Morganian crypts and the internal opening of the fistulous tract. The sacral and coccygeal vertebrae are also palpated. With the epithelial coccygeal course there are no changes in them.
To exclude rectal disease, an instrumental examination is performed:
- sigmoidoscopy;
- irrigoscopy or colonoscopy (in the presence of alarming symptoms);
- fistulography;
- radiography of the sacrococcygeal region;
- Ultrasound of the pelvic organs.
The listed instrumental diagnostic methods are used only if there are doubts regarding the nature of inflammation in the area of the coccyx and sacrum.
Rehabilitation period
After the operation, there will be a rehabilitation period from 3 weeks to several months (depending on the complexity and scope of the intervention). This time is necessary for the wound to heal properly and for the inflammation in the area of intervention to completely disappear. For several days after surgery, a drain will be installed in the area of the postoperative wound to ensure the drainage of accumulated fluid. It is also necessary to limit physical activity to 21 days.
Modern minimally invasive technologies make it possible to reduce the period of hospitalization and complete the remaining period of rehabilitation at home. Before you leave the hospital, your doctor will tell you in detail how your recovery period will go and prescribe appropriate therapy. If complications occur or your condition worsens during the rehabilitation period, you must immediately contact your doctor or make an appointment for a consultation.
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Treatment of epithelial coccygeal duct
You should not delay treatment of the epithelial coccygeal duct, especially if its inflammation has begun. In this case, a conservative method or surgery is used. The first is significantly inferior in effectiveness to surgical intervention, but it is indispensable in preparation for it and during recovery after surgery.
Conservative treatment
Drug treatment is used at the stage of acute exacerbation and involves the use of several groups of drugs:
- broad-spectrum antibiotics or drugs against the identified type of microorganisms;
- anti-inflammatory drugs;
- analgesics.
Antibiotics are often given orally. Anti-inflammatory and painkillers are prescribed both in tablet form and in external form. Ointments and gels, when applied directly to the site of inflammation, help to quickly eliminate symptoms and alleviate the course of the disease before the planned procedure of opening the abscess or excision of the epithelial tracts.
Drug treatment without surgery is ineffective and often leads to re-inflammation, especially if it was done independently without consulting a doctor.
Important! Heating an inflamed pilonidal cyst is strictly prohibited. This can cause pus to spread into surrounding tissues.
Surgery
The type of surgical intervention for this diagnosis is chosen based on the patient’s condition. In the absence of signs of inflammation, the epithelial coccygeal duct is excised after staining its cavities with a solution of methylene blue. With this manipulation, it is possible to identify all the primary openings of the pilonidal cyst. Next, a strip of skin with subcutaneous tissue in which the tract is located is excised.
Removal of uncomplicated ECC has many advantages:
- the risk of postoperative tissue infection tends to zero, since there are no pathogenic microflora in them;
- the wound area is smaller;
- the stitch heals faster.
Recovery after surgery lasts about a month. The sutures are removed on days 10-12, and until this time the patient is advised to be careful when walking for the first week. The consequences of the operation are visible in the photo below.
In the first days after the intervention, bed rest should be observed so that the load on the sutures is minimal.
The operation to remove the suppurating epithelial coccygeal tract is performed somewhat differently. It is prescribed only after the inflammatory process has been stopped and the purulent cavity has been opened and cleaned. The process of eliminating pathology takes place in two stages:
- The abscess is opened and drained. It is washed every day for 4-5 days and water-soluble ointments are introduced into the cavity.
- A radical excision of the epithelial coccygeal duct is performed.
Recovery after surgery in this case lasts longer, but the risk of relapse becomes zero.
In the chronic course of the disease, surgery is performed in the stage of remission or infiltration as planned. In this case, a radical removal of the epithelial coccygeal tract, secondary fistulas and primary openings is immediately performed.
The most difficult procedure is considered to be one in which the fistulous form of ECC is removed with the spread of inflammation to the soft tissue around the passages. In this case, the wound surface is too large, which does not allow sutures due to excessive tissue tension.
After surgery, the patient should visit the doctor periodically. Until the postoperative wound is completely healed, it is recommended to remove hair near the seam and maintain hygiene of the coccyx and sacrum, wear clothes made of soft fabrics, preferably without seams at the back.
Complications after surgery performed in coloproctology departments occur much less frequently than those performed in general surgical hospitals.
The prognosis after surgery is favorable at any stage and form of pathology. Patients completely get rid of unpleasant symptoms and manifestations of the disease.
Preparation
Before surgery, preparation is necessary. First of all, you should undergo a preoperative examination, which includes a number of laboratory and instrumental diagnostics. This is necessary in order to exclude contraindications, as well as to identify the features of the pathological process.
Typically the list of studies includes:
- Taking a general blood and urine test.
- Blood test for clotting.
- Blood for HIV, hepatitis and syphilis.
- Electrocardiogram.
- Fluorography.
- Ultrasound examination or magnetic resonance imaging of the coccyx area.
- Consultation with a therapist, and, if necessary, consultation with specialists. As a rule, this is required in the presence of chronic diseases.
Please pay attention to some preparation features:
- If the operation is performed under general anesthesia, the patient must refuse to eat at least 7-8 hours before surgery.
- On the eve of the study, it is necessary to cleanse the intestines. As a rule, manipulation is carried out with the help of laxatives or special drugs designed to cleanse the intestines.
- If there is excess vegetation in the tailbone area, it must be removed.
- Hygiene procedures should also be carried out before the operation.
Possible complications
In the absence of therapy, the epithelial coccygeal tract is complicated by extensive inflammation and suppuration of the soft tissues in the area of the sacrum and coccyx. In this case, fistulas are formed that open in the perineum, in the inguinal folds, between the buttocks, and sometimes on the genitals.
Another common complication of ECX is pyoderma with the addition of a bacterial or coccal infection (pictured below).
This disease requires gradual excision of the affected areas. All this takes the patient out of his usual routine for a long time.
Symptoms
A coccyx cyst does not have any signs as such until the active phase of development begins. But it can still be detected even in the latent stage - approximately at a distance of 8-10 mm from the anus there is a tiny hole between the two buttocks. Pathology can develop over years without manifesting itself in any way.
Photo of coccygeal cyst
Typically, patients come to the doctor with already advanced cysts, which are more difficult and complex to treat than those that are in the initial stages of development. The fact is that at first the cyst does not bother the patient at all. And only with exacerbation and obvious symptoms does he come to the doctor with complaints.
Symptoms of a cyst in the active stage:
- increased body temperature, weakness, drowsiness;
- pain in the lower back when bending, moving and sitting, which becomes increasingly intense. With active suppuration, the pain becomes throbbing;
- redness and swelling in the area of pathology;
- feelings of discomfort;
- ingrown hair on the skin at the site of pathology;
- the appearance of purulent discharge in the last stage of development or mucous discharge in the primary stages.
These signs do not always appear together. In the early stages, a person may simply notice some discomfort when moving. But this should already serve as a signal to visit a doctor.
Prevention
The appearance of the epithelial coccygeal tract, or more precisely, its inflammation and suppuration, can be avoided by using simple preventive measures. Firstly, you should avoid injury and hypothermia of the sacrolumbar region. Secondly, you need to maintain hygiene: thoroughly wash the sacrum, coccyx and intergluteal fold daily, remove hair as it grows, especially if it is thick. Thirdly, there is no need to delay the operation, even if the pilonidal cone does not cause discomfort.
It is advisable to address the problem not to a surgeon, but to a proctologist. A doctor of this specialization is more competent in the treatment of the epithelial coccygeal duct, which allows you to get rid of the problem without the risk of complications. In conclusion, a video in which a coloproctologist at the Neo-Med clinic talks about the features of the epithelial coccygeal duct, diagnosis and treatment of the disease.
Who is at risk for developing ECC?
The disease occurs 4 times more often in men than women. ECC belongs to a group of rare diseases and is detected in only 26 out of 100,000 people. Mostly, young people of working age from 15 to 30 years old are affected. According to statistics, ECC most often occurs in Arabs and Caucasian peoples, less often in African Americans.
Risk factors for the development of ECC are:
- excess hair growth
- overweight
- insufficient attention to hygiene of the coccyx area
- passive lifestyle
- wearing tight and tight clothing (pants, skirts)
What operation is performed in case of an abscess (acute suppuration) of the EC?
In the event of an acute ECC abscess developing, in most cases, two sequential operations will be required. Treatment of a purulent focus of ECC should be carried out in a specialized coloproctology hospital. Its main goal is to ensure complete evacuation of purulent contents, stop inflammation in the surrounding soft tissues, and prevent further spread of the purulent process.
Important! Even such a simple step as opening an ECC abscess can significantly complicate the second (main) surgical intervention if simple rules are not followed.
The incision should be small and located as close as possible to the midline (intergluteal fold). During the second operation, the scar from the previous incision will need to be removed en bloc with the main volume of ECC tissue. The larger the primary scar, the more tissue will need to be removed during the second operation. At the same time, you should not make too small an incision, since the key to successful recovery is adequate drainage of the purulent-inflammatory focus (Fig. 8).
a)
b)
Figure 8. Stages of surgical treatment of ECX abscess:
a) local anesthesia
b) an incision above the place of greatest fluctuation and evacuation of purulent discharge with the collection of material to determine the microorganism that caused the inflammation.
Correctly performed opening of an abscess leads to the disappearance of pain, temperature and improvement of well-being. However, the final inflammatory processes (changes in the surrounding tissues) after the first stage of surgery (opening and draining the ECC abscess) usually subside within 1-2 weeks.
After successful completion of the first stage of surgical treatment, which will be accompanied by a decrease in the manifestations of acute inflammation and, in fact, is a “symptomatic operation”, it is no less important to carry out the second stage - a radical operation aimed at complete removal of the pilonidal cyst with the affected area of skin and subcutaneous fat. fiber and the subsequent plastic stage to achieve a good cosmetic result.
Important! In case of acute inflammation, two-stage treatment is the most effective and quickly leads to restoration of ability to work. Despite the improvement in the condition after opening and draining the ECC abscess, it is extremely necessary to perform a second radical operation, since each subsequent inflammation will involve an increasing amount of unchanged tissue in the process!
With a small size of the purulent focus and a high level of professionalism of the surgeon, one-stage radical treatment of acute ECC is sometimes possible.
Long-term inflammatory changes lead to persistent pain and long periods of disability, impaired quality of life, complications and relapses after the second stage of surgical treatment, and complicate radical surgery. It is optimal to perform a second (radical) operation 3-4 weeks after opening and draining the ECC abscess.