The Nuances of Pilonidal Abscess Drainage

An accumulation of pus under the gluteal skin is a common way that pilonidal patients experience severe symptoms and present for medical treatment. This pus accumulation defines the typical “pilonidal abscess”. It is accompanied by redness and swelling of the overlying skin, in addition to severe pain and sometimes fever.

Often, a nonspecialist surgeon or a nonsurgeon practitioner is tasked with incising and draining this abscess, and here, an unwanted deviation from necessary provider experience and therefore desired outcomes are introduced. We offer the following guidelines to patients in need of abscess drainage, so that they are better informed and equipped to self-advocate before and after” this procedure.

1. The abscess drainage is much,much easier for the patient when some form of pain reliever or sedation is administered sufficiently before the injection of local anesthetic (numbing medication). This is standard when the patient is drained by a surgeon in an operating room setting, so this can always be requested or even demanded in the emergency room setting. Alternatively,the patient can reach out to a specialized center such as PTCNJ from the outset of such symptoms.
2. The drainage incision should be a fairly liberal transverse cut well off of the midline towards the side of, and not within, the cleft. This affords patients with mild disease a better chance of healing the cut and avoiding the development of a chronically draining sinus tract. It may be the difference between the patient needing a formal cleft-lift versus being adequately managed by lifestyle modification
   alone. The incision should be generous enough so that repeat packing is not beneficial or required. At PTCNJ, we use packing initially mostly to stop bleeding, but instruct patients to remove and discard it in the first shower the day after the procedure; repeat packing is not required. If the incision is too short or if the cavity is not adequately dissected and explored, persistent or repeat abscess can be seen, so having the procedure performed by an experienced provider or a pilonidal specialist is of great importance.
3. The pus that is drained should be sampled and sent to the laboratory for the purpose of culture, in which the organism is identified and optimal antibiotic is determined. A patient should always be given a broad-spectrum antibiotic to initially take with the possibility that it may need changing pending culture results.
4. One advantage of abscess drainage at PTCNJ is that we can usually do it in combination with a minimally invasive treatment such as Gips procedure and/ or laser pilonidoplasty. We have also found that patients with acute abscess can skip the drainage step and go right to cleft-lift with the same operative success and healing time!