ABSTRACT

Perianal pilonidal fistula can sometimes be mistaken as perianal fistula of cryptoglandular origin. Careful physical examination of the natal cleft and the anal canal is the mainstay of the correct diagnosis. The treatment of the disease is surgical. In this article, we report the management of a young male patient with perianal pilonidal fistula originating from the natal cleft.

Introduction

Pilonidal disease is generally located in the natal cleft but its secondary tracts can sometimes have their opening in the perianal region. They have no connection with the anal canal. Pilonidal pits can be detected at the midline of the buttocks. Sometimes this may be confused with perianal fistula of cryptoglandular origin. Most of the time, careful physical examination under good lighting is enough for the correct differential diagnosis.

Case Report

A 22-year-old male patient was complaining about discomfort from his bottom for two years. He had also experienced purulent discharge from a hole near his anus from time to time. Physical examination in the lithotomy position revealed a fistula opening at the 7 o’clock position, 3 cm from the anus, and a midline pit orifice located in the natal cleft (Figure 1). After it was determined that there was no fistula connection with the anal canal, fistulectomy and primary suturing was performed under spinal anesthesia (Figure 2, 3, 4). He was discharged the next day and the wound healed without any complication in the subsequent three weeks. The patient provided written consent for publication.

Figure 1

Figure 2

Figure 3

Figure 4

Discussion

Pilonidal disease is a problem of the natal cleft in human beings. Secondary tracts of the disease can sometimes have their opening in the perianal area. Notaras observed that the direction of natal cleft sinus tracts usually extend in a cephalad direction (93%) while only 7% of cases progress caudally.¹ Contrary to the literature, we have experience of many cases of pilonidal disease with caudal extension around the anus (secondary perianal pilonidal disease), as in this case.

Primary perianal pilonidal disease invading the anal canal can also be encountered, but it is very rare. There are only a few cases reported in the literature.^2-4 The disease can be confused with a perianal fistula of cyrptoglandular origin. If the distinction cannot be made between pilonidal disease and a perianal fistula, magnetic resonance imaging would be helpful.^5,6 Correct diagnosis, and thus optimal management plan for the disease, must be established before surgery. Examination under anesthesia would also be useful for this purpose.

The treatment of secondary perianal pilonidal fistula with midline pits is surgical. Lay open or fistulectomy and primary suturing is the treatment of choice. Marsupialization can be performed as a less invasive technique.⁷ Open excision or various flap techniques have also been used for treatment.^8,9 Invasive procedures are not suitable because of the proximity of the disease to the anal canal. Furthermore, wound breakdown after flap coverage of the defect can occur before complete wound healing has taken place, then subsequent wound infection and discharge may ensue. These complications may lead to high recurrence rates.¹⁰ The authors believe that wide skin excision is not necessary since the skin is not involved with this condition. The simpler the treatment, the better the results!

Secondary perianal pilonidal disease is not a rare disease. Perianal fistula of cryptoglandular origin should be excluded in the differential diagnosis.

Ethics

Informed Consent: The patient provided written consent for publication.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: G.N., M.B., H.O.İ., Concept: G.N., M.B., Design: G.N., M.B., Data Collection or Processing: G.N., M.B., H.O.İ., Analysis or Interpretation: G.N., M.B., H.O.İ., Literature Search: G.N., M.B., H.O.İ., Writing: G.N., M.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.