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)
Leave plastic waterproof dressing on for 1 week
If steristrips used – they can be left on for a further week.
If non-dissovable sutures used – they need to be removed usually in 1 weeks time, may be left in longer in certain areas where there is higher risk of the wound pulling apart(eg lower legs, back), can be removed earlier from face(eg 5 days postop)
Answers to FAQ:
1. Showering – you can shower anytime if waterproof dressing is on. If there is no dressing eg sutures on the scalp – best to keep that area dry for 1-2 days.
2. Bleeding – If a cyst/lipoma has been excised, the residual cavity will initially fill with blood-stained fluid(haemoserous fluid – this can have the colour of red wine). This can sometimes leak out from the wound. So be careful if you lie on the wound – it might be a good idea to have a towel under to soak any discharge. If there is a lot of thick red blood or pain from a hard swelling under the wound – you must contact me again.
3. Pain – The wound can be sore eg like any cut. The local anaesthetic usually lasts for a couple of hours. Paracetamol is usually all that is needed after that. If still in pain , consider adding something stronger like Ibuprofen(please from that there is no contraindication). If the pain is severe or the wound becomes painful after a few days (and there is surrounding skin redness) – please contact me
4. Work – most patients can go back to work the next day. But it is important to keep the surgical area clean.
5. Swimming – best not to swim in a public swimming pool until the wound is fully healed. After the sutures are removed, one should wait a few more days until the stitch holes are fully sealed over. (same applies to water sports eg in the Murray – best not to let the unhealed wound get into contact with water)
To prevent wound breaking open/scar getting wider after the sutures have been removed: sometimes it might be neccessary to reinforce the healing scar with Steristrips or even simple Bandaid. Also you should apply more sunscreen to the scar especially in the first 12 months to avoid the scar getting sunburnt.
LP Cheah
Surgeon
MelbourneSurgery.com
As a general surgeon, I am always wary of operating on someone who is taking aspirin or clopidogrel.
This reason for this is the increased risk of bleeding. Studies have shown patients on aspirin have an increased risk of bleeding( X1.5 times). For patients on both aspirin AND clopidogrel, the increased risks of bleeding is 50%. On the other hand(this point is often quoted by the cardiologists), there is no increase in the severity of bleeding complications(except for brain and prostate surgery) and no increase in the risks of dying from surgery(except for brain surgery)
On the other hand, stopping aspirin or clopidogrel during the time of surgery would increase the riks of getting a heart attack and even dying threefold. The risks here would be greater for someone with a coronary stent in. There are basically 2 types – the bare stents and the drug-eluting stents. Even with being on aspirin and clopidogrel, there is always a risk of occlusion of the stents. Cardiologists vary in the advice on the duration one needs to take the aspirin and clopidogrel.
It is best if you are on aspirin or clopidogrel, that you discuss this with your general practitioner first. Your family doctor is the one who is fully aware of what advice the cardiologist has given. If there is any doubt, discuss this further with your cardiologist.