During finals week of my sophomore year at NYU — you know, the time when you sit amongst the quiet stacks of books in the library for hours on end in the most uncomfortable desk chair — I started to literally feel a “pain in my ass”. It took me a few days to ascertain if it was coming from my actual asshole or a region in close proximity. After my go-to pain reliever, Advil, did nothing to minimize any pain and I started to develop more symptoms — a fever and localized swelling — I realized that it was from an infection in the area around my tailbone. Fuck, what a burden! I did some Googling (after all, who doesn’t?) and realized it was indeed a pilonidal cyst. Yet, I must admit — I did need some assistance on the actual pronunciation of my new found friend. I subsequently took all the advice of warm baths and cushioning my seats, and managed to get an appointment with Dr. Goldstein for an evaluation. He confirmed Google’s diagnosis and, before I knew, it was all drained. That itself hurt just as much as the pilonidal cyst itself, but my symptoms abated almost immediately and I was finally able to study and pass all my exams. Once things settled down, unfortunately, it became a chronic issue associated with persisting drainage, so Dr. Goldstein decided to perform a surgical procedure for excision of the entire cyst, tract, and all that came with it. While this may seem daunting, the procedure was straightforward and healed normally. Per Dr. Goldstein’s suggestion, I got laser hair removal, which has so far prevented any recurrence and now I am back to those fucking hard chairs studying for my doctorate. Now I come prepared with a cushion, though.
What is a pilonidal cyst and what are its causes?
A pilonidal cyst is a hair follicle gone awry. Dr. Goldstein equates this to a pimple in a bad spot—the spot being one’s tailbone. Being at the top of one’s butt crack, with its hair and deep creases, there is localized friction from normal daily activities, like sitting and walking, which makes for a bad combination. This, in turn, causes a hair follicle to become ingrown, instead of growing out normally. The follicle tracks its way into the depths of the skin crease, which causes a localized infection, abscess, or both. Talk about a literal pain in the ass! And one doesn’t necessarily have to have a hairy ass for this to occur, though an abundance of hair is a major predisposing factor. Another cause can be that one has coarse hair that just so happens to be in the perfect spot that leads to this bothersome condition.
What are the symptoms of a pilonidal cyst?
Most people gradually feel pain and pressure over the tailbone and don’t really know what to make of it. This is especially true since it typically occurs more often during the teen to early adulthood years, so many individuals aren’t familiar with pilonidal cysts and are embarrassed to bring it to someone’s attention.
What is pilonidal cyst treatment?
If caught early, pilonidal cyst treatment starts with simple techniques. Warm baths or warm compresses can decrease the localized infection. A one-time occurrence, followed by preventative measures, like laser hair removal in the patch of one’s butt-crease and padding on hard seating, may be just what is needed to decrease recurrence.
Pilonidal cyst drainage is imperative for the initial treatment of an abscess. The key is to make sure you see a specialist who focuses on the appropriate placement of the incision. Strategic placement not only will lead to the immediate resolution, but also will allow for the minimization of the amount of tissue needed for the subsequent surgical excision. One will feel so much relief with this drainage and then, of course, the addition of antibiotics. Of note: local anesthesia in the region has limited efficacy due to the localized inflamed tissues. You will get some pain control, but it will still hurt like a MF — there’s no sugarcoating it. The best thing to do is buckle down and allow the drainage to occur. You will feel improved beyond belief once the contents have been expelled. The drainage cavity is irrigated and then packed. One is advised to take baths later that evening and then daily to assist in improvement. With the antibiotics and the local cleaning routine, all should improve within a few days. The usual protocol is to schedule a follow-up appointment about two weeks post-incision and drainage, and then plan for the future subsequent excision. This usually is warranted as the above drainage just takes care of the abscess, but fails to remove the actual pilonidal hair follicle, which is the cause of the issue at hand.
This leads us to the surgical discussion of pilonidal cyst removal. If one has the follicle (a dimple or pimple on the crease) and a tract/abscess that is constantly draining secretions, then something needs to be done surgically. A lot of people see dermatologists as the first line of evaluation and treatment, yet from Dr. Goldstein’s experience, most do not go deep enough on their excisions to remove the entire cyst. Also, most chronic cysts need both local anesthesia and sedation for complete excision because the pimple that one sees is just the tip of the iceberg—the full pilonidal cyst is quite large. Dr. Goldstein usually informs his clients that the incisions themselves can be quite large—larger than one may think.
If one Googles ‘pilonidal cyst removal’ they will see pretty horrific excisions and some surgeons still feel the need to cut out this tissue and then leave it open for what’s called secondary closure. However, the reality is that with appropriate surgical techniques, offset to the midline incision and tissue transfer or excision with a rotational flap, one should achieve appropriate removal and closure as a one-stage procedure. This is why it’s imperative one sees a surgeon who performs a lot of these each year with full knowledge of the most up-to-date removal techniques.
Now, because it’s natural for this cyst to be chronically infected, there is a chance of a post-operative infection after excision. Most surgeons not only give antibiotics in the operating room and irrigate the wound with antibiotic solution, but also give pills post-operatively to decrease the chance of reinfection. That said, with the usual offset to midline incision, you may get central wound opening that clearly is a preferred outcome versus leaving the entire wound open. Dr. Goldstein usually discusses with his clients that he would rather have a small opening that will heal quickly with in-office tactics, than have one’s entire excised cyst cavity left open. For the most part, these heal quite well and rather easily, with the post operative pain being no different than the pain experienced when it was present.
After a successful complete excision, the wound is evaluated a week or so post-surgery and the staples are removed partially or fully at that time, if appropriate. Initially, one will be gentle with pressure-causing maneuvers so as to not separate the closure. Due to this particular region of the body, it can indeed still occur. Once everything has healed, in order to prevent recurrence, most clients get laser hair removal in the patch of the ass crack. This, along with proper pressure reducing mechanisms, allow for decreased recurrences of this pain in the ass, also know as a pilonidal cyst.