Optimising treatment for sacrococcygeal pilonidal sinus disease

Abstract

Sacrococcygeal pilonidal sinus disease (SPSD) is a common disease and a surgical procedure is often prescribed for treatment. Excision techniques are most commonly applied, but a ‘gold standard’ treatment does not exist. Minimally invasive techniques are being applied more frequently, and these techniques are being investigated for safety and efficacy.

As mentioned above, radical excision is still the most frequently applied treatment. The main disadvantage of radical excision is that surgical site infection is reported in up to 24%. The effect of local intra-operative administration of a gentamicin collagen sponge after excision of SPSD was assessed. In this systematic review, a trend towards a reduced incidence of surgical site infections was found.

In addition to a high risk of surgical site infection, high recurrence rates have been reported after surgical treatment of SPSD. All available literature regarding the effect of hair removal on the recurrence rate of SPSD after surgical treatment has been summarised. Patients should be discouraged to shave the gluteal cleft and instead be advised to use laser hair removal as a means of preventing recurrence. However, this advice should be interpreted with caution because of the methodological low quality of the included studies.

The outcomes of a randomised controlled trial (RCT) comparing the phenolisation technique with radical excision in patients with primary SPSD are described, focusing on time to return to normal daily activities. A significant reduction in time until return to daily activities was found; 5.2 days after phenolisation versus. 14.5 days after radical excision. The long-term results of the randomised trial revealed no significant differences in recurrence rate and quality of life after a follow-up of four years (2.6% versus 5.6%, p = 0.604). Hence, we propose that phenolisation should be considered as first treatment option for primary SPSD.

Phenolisation in patients with recurrent SPSD was performed in a prospective cohort study focusing on short-term results (3 months of follow-up). A mean of five days of loss of normal daily activities after phenolisation was found in 57 patients with recurrent SPSD. This is similar to the data on patients treated with phenolisation for primary SPSD. However, long-term results, especially with regard to recurrence rate, should be assessed before a final determination on the most effective treatment for patients with recurrent SPSD can be justified.

SPSD mainly occurs in the young, male working population and we hypothesised that SPSD might have a negative impact on sexual functioning. In a prospective study the influence of SPSD on sexual function in male patients was reported. Treatment of SPSD apparently had more impact on sexual embarrassment, since the sub-scale focusing on sexual embarrassment decreased at six weeks postoperatively and this persisted twelve weeks after surgery, indicating a better sexual function. The results of this study could aid in preoperative counselling of patients who are preparing for treatment for SPSD.

Finally, a treatment protocol of SPSD is recommended in this thesis based on the covered studies and available literature.