14.  COCCYX FİSTULA

Definition

The coccyx fistula or Pilonidal Cyst (It is a combination of two Latin words, pilus, meaning hair and nidal, meaning nest) is a tubular tract, which is usually at the beginning and centrically between the buttocks and penetrates into the depth up to the sacral bone.  In this fistula there are often one or more hair.  The fistula can show itself as symptom-free, exhibit a chronic inflammation or have burning sensation and pus.  One or more several openings can be seen from outside, whereby one or more fistula tracts can be present. 

Causes

Although the exact cause is not sufficiently clarified, one theory is that it proceeds from an acquired illness.  There are also theories that the fistula causes from a cyst, which exists from birth, but these were not widely accepted.

The cause is more likely to be due to repeated shearing stress by the buttocks in the natal cleft. A rubbing movement of the buttocks presses broken off hair and pushes the top into the skin.  The horn sheds of the hair function as barbed hooks, whereby the hair penetrates ever more deeply.

There it has the effect like a foreign substance, so the tissue begins to change in a so-called granuloma.  This tissue cannot any longer heal by itself (asymptomatic status), but may have burning sensation (acute or chronic status).

Increasing in hair quantity, being overweight, excessive sweetening, sitting of long durations and lack of hygiene are favoring factors. 

Symptoms

During Asymptomatic stage patience does not experience any symptoms. There may be only a few fistula openings, which are often coincidentally discovered.  With the acute inflammation a swelling with turning red and violent pain occurs, whereby pus forms.

In the chronic condition secretions show up, which can be festering or aqueous, but only cause slight pain.

If this secretion stopped then acute inflammation with pus formation occurs.  In lengthy chronic cases, 0,1 % of the malicious degenerations were seen. 

Treatment

There are conservative treatments of the coccyx fistula with phenol or silver nitrate solutions, but these show unsatisfactory results and have a high toxicity.

Therefore the treatment should take place with the help of a surgical interference. There are different surgical techniques.  These are as following: leaving the wound uncovered after surgery, an immediate sewing or plastic covering methods.

In case of an abscess formation this must be first relieved and often the fistula has to be removed in a second operation.  It is important that all fistula tracks are removed during the operation.

In the Proktoklinik  a new and, minimal-pain procedure takes place: called the minimal invasive fistulectomy with laser obliteration.

This technique is in particularly suitable for single or double fistula tracts.  Under local anesthesia a special head milling cutter removes the fistula tract from the inside and the tract becomes smaller with the help of the ELVeS  laser.  This technique helps body converting the fistula into a scar tissue without causing any open wounds so wound is completely closed within a few weeks. It does not require any other after-surgery treatments except regular follow-ups with wound. 

In case of branched fistula tracts or acute inflammations a surgical operation has to be needed, which is followed by an open wound treatment.

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