Friday, August 10, 2007
Pile O' Problems
Many years ago, a friend of mine told a story that, at the time, I thought was hilarious. He'd been hospitalized -- I forget why -- and his roommate was a fellow young man who'd undergone surgery for a pilonidal cyst. The operation had involved the placing of wires, which had been tied down over buttons (the technique -- not always involving buttons and wires -- is called "marsupialization," although I didn't know it at the time.) One evening the man felt a pop and pain. He called the nurse who, after having a look, placed an urgent call for the man's surgeon. On arrival, the doctor (resident? the man's actual surgeon?) felt it necessary rapidly to dig in to retrieve the wire, and did so with a clamp, without any attempt at anesthesia. My friend was horrified by the screams of his roommate, and began yelling at the doctor and nurse to do something. "Knock him out, knock him out," he demanded. (In telling the story, he described his own drugged state, painting a bizarre picture of confusion, paranoia, and semi-stupor. And I'd be pretty sure prodigious profanity of Shakespearean quality was involved.) Seeing no attempt on anyone's part to reduce the pain of his neighbor, he finally starting throwing things at the man's head, trying in his own way to knock him out. First some books, then the phone, and finally an IV bottle. (I must interject that my friend happened to be one of the funniest people on Earth, and could have elicited helpless laughter in the reading of a water-meter. Plus, this being a long time ago, I can't say with certainty that the mood was not enhanced in any way.)
Well, it was funny back then. Now, it's a pretty horrible story on many levels. Forgetting about the brutality of the surgeon and the indelicate approach to the initial problem, it does illustrate one thing: pilonidal disease can be a bitch. If people were cars, along with the anus the tailbone area would be subject to recall and redesign. (Maybe this time it could be intelligent?)
"Pilo" means hair. "Nidus" derives from the Latin word for nest, and generally means the area in which a thing forms. In essence, pilonidal disease arises from the fact that some people have little dimples -- deep and narrow pits, really -- over their tailbones. Not always a problem, they can be a starting place for infection in many owners thereof -- particularly hairy people. Those pits are an indrawing of skin, along with the usual players in the skin: bugs, hair, etc. Although people of any body habitus can have problems, big hairy guys are the poster-children of the disease. It's a gigantic case of ingrown hair; and once infected, it's impossible permanently to eradicate it without some sort of surgery. Sometimes the amount of hair in there can be truly stupefying. Trust me, you don't wanna know. Tempting as it might be, had I a picture, I'd not link it. And that's saying something, as many readers know. But not all pilonidal infections have hair in them.
It's a surgical truism: when there are lots of widely varying operations to accomplish a thing, the perfect one remains undiscovered. And so it is with pilonidal disease. In part, that derives from the fact that it manifests itself in myriad ways. The rest is due to the fact that if you were to compile a list of ideal conditions to promote post-operative healing, the tail bone area is the antithesis, right down the line. Dark, moist, self-contaminating (being discreet here), and subject to tension which tries to pull an incision apart.
About the only straightforward decision is when a patient shows up miserable with a big pilonidal abscess. You drain the damn thing, and the patient will be immediately grateful (once again, the ancient and honorable and most basic tool of the surgeon: draining pus. Break out the air-freshener, Trish. I stunk up another exam room.) Other than that, who knows? Antibiotics alone for a little mild discomfort? Only remove the dimples? Simple excision of the "cyst?" (Cyst, by the way, is something of a misnomer, strictly speaking. It's a collection of infected gunk. "Cyst" implies an obstructed and filled-up gland, which is not what pilonidal disease is.) Leave open? Close?
It's my experience that once you get to the point of an abscess that needs draining, you'll need some sort of surgical eradication or it will be a recurring problem. And it can be worse than an abscess: infection can track impressively under the skin, making a tunnel and popping up nearly anywhere else in the area (a pilonidal sinus.) If it surfaces vertically in the midline, you may get away with a fairly simple operation. The more off to the side, and the more tracks, the more likely it is you'll need some sort of complicated operation, widely to excise the area with creation of flaps to bring it all together again. When it's uncomplicated disease, as with an abscess having been drained, once it's healed a fairly small operation to excise the dimple and the formerly infected tissues underneath, with simple closure may do the trick. But slow healing, with an open wound requiring regular cleansing and shaving of the area, is a pretty common sequence of events.
All in all, an annoying and frustrating array of approaches for what seems a simple problem. We can transplant livers; we haven't figured out the best care for a tiny hole by the tailbone. My advice: if you're hairy and have a dimple "down there" but haven't yet had problems, keep the area shaved (it requires a sympathetic significant other) or invest in a depilatory creme. If you're a peach-skinned person, keep the area clean and dry (no powders) and your fingers crossed.
[Some time ago, a reader asked me about pilonidal disease, so this has been sitting around for a while. You'd be right in thinking I'm cleaning out the attic...]