eSurgery

This is written with the aim of helping my medical students and doctors in training go through my thought process in the outpatient clinic. This list is not meant to be all comprehensive but rather a practical guide in coming to a diagnosis quickly.

1. Ask the patient how long this pain has been there for – acute ie recent onset – most likely abscess or chronic(?coccydynia) or intermittent(recurrent pilonidal abscess)
2. Examine the patient: Look at the lump ?red, swollen, discharging pus, tender(abscess); any pits/sinus in the midline in the natal cleft(pilonidal sinus)
3. If no pits/sinus openings and the red tender lump is away from the midline – think of other differentials: fat necrosis(has the patient been sitting a lot eg cycling long distances), abscess arising from folliculitis. If the abscess is near the anus low in the natal cleft – then consider a perianal abscess.
4. Always keep at the back of the mind other differentials which are much rarer but as a specialist one has to be aware of:
(i) Skin cancer in the area – BCC, SCC, melanoma
(ii) Other types of soft tissue tumour and sacral tumours
(iii) Dermatitis – ?chronically scratching the area
5. Less commonly – infected/inflammed sebaeceous cyst can also occur there

Management:
If pilonidal sinus abscess – I would do a small operation to drain the abscess through the pits/sinus by making a small incision around the sinus opening, putting in an artery to remove the hair and drain the pus, swiping the cavity with Betadiene soaked gauze. This can be done with LA infiltration around the area if the patient is tolerant or in theatre under Local anaesthesia & sedation in lateral position(easier for the anaesthetist and safer). I would normally treat with oral antibiotics for a week. Review again next week. (In the long term, if recurrent infections, to consider operation with lower recurrence rate namely Modified Karydakis surgery)