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Practice Practice Pointer

Diagnosis and management of sacrococcygeal pilonidal disease in primary care

BMJ 2023; 382 doi: (Published 11 September 2023) Cite this as: BMJ 2023;382:e071511
  1. Hamish Walker, ST4 general surgery,
  2. Osama Hamid, ST2 general surgery,
  3. Jozel Ramirez, ST2 general surgery,
  4. Damian Glancy, consultant colorectal surgeon
  1. Gloucestershire Royal Hospitals NHS Foundation Trust, Gloucestershire, UK
  1. Correspondence to H Walker Hamish.walker2{at}

What you need to know

  • Refer urgently patients with an acute abscess for incision and drainage

  • Refer patients with chronic symptomatic disease for specialist input, which could include non-surgical, minimally invasive, or surgical management

  • Assess pain in symptomatic disease and offer analgesia as required

A 25 year old man who works as a driver of heavy goods vehicles complains of pain and swelling in the natal cleft over the past few months. On examination, inflammation is evidentin the sacrococcygeal region, with visible pits and discharging sinuses.

Sacrococcygeal pilonidal disease is an inflammatory condition of the skin and subcutaneous tissues of the natal cleft, often presenting as a spectrum ranging from asymptomatic pits to painful large abscesses. The term “pilonidal” is derived from the Latin “nest of hairs,” referencing the accepted pathophysiology of loose hair burrowing into normal skin, and causing a foreign body reaction. Sacrococcygeal pilonidal disease primarily affects young adults of working age. Patients usually have few comorbidities.

In this article, we outline approaches to assessment of sacrococcygeal pilonidal disease, alleviation of symptoms, and guidance on referral.

How does it present?

Sacrococcygeal pilonidal disease can arise in one of three forms1:

  • Acutely as an abscess (fig 1)

  • Chronically as a sinus (an abnormal epithelialised connection with the skin surface) (fig 2)

  • As complex disease characterised by chronic or recurrent abscesses with extensive, branching sinus tracts.

Fig 1

Acute sacrococcygeal pilonidal abscess

Fig 2

Visible granuloma from sacrococcygeal pilonidal sinus disease (black arrow). Patient had a concurrent acute abscess (white arrow)

The affected area is above the anus and superficial to the coccyx under the skin of the sacrococcygeal region. Diagnosis is usually by clinical examination and further investigation is rarely warranted. On examination, a cyst or sinus is usually found 4-10 cm above the anus in the midline. Whether acute or chronic, the sinus is frequently accompanied …

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