Sinus pilonidalis – coccyx fistula / coccyx ulceration

Symptoms of a coccyx fistula

Do you always have severe pain at the transition from the buttocks to the back?
Does an unnatural swelling appear over the coccyx in a short time with severe redness, overheating and pain, perhaps also with fever and chills?
Or has a painful area slowly developed that is getting bigger, red, painful and feels like there is something soft or liquid under the skin?
Is that why you can no longer sit without pain?
Has the bump on the tailbone opened and discharged pus? Or is there just one or more small, point-like openings in the skin that weep and from which a cloudy liquid escapes?
Is there a foul-smelling, putrid secretion that is extremely unpleasant and annoying, especially in company?
Sometimes the clothing is smeared with pus or blood in this painful area?
Are you suddenly unable to lie or sit properly within a few days because the coccyx region hurts directly or in the surrounding area when pressure is applied?
Or is there perhaps no swelling, reddening, or overheating at all, but blood, purulent fluid or pus is repeatedly emptied from a punctiform fistula opening in surges or constantly? Does this only cause a feeling of pressure instead of pain, which is sometimes more and sometimes less?
Have you ever had a coccyx fistula diagnosed or operated on?
Has another pus cavity (abscess) developed over the coccyx?

Registration at our doctor’s office

If you suffer from one or more of these conditions, professional assessment from an experienced surgeon is always recommended.
You can easily, quickly and confidentially arrange an appointment in our doctor’s office .
Of course, we treat privately insured patients, but as a surgical doctor’s office with statutory health insurance, we can of course also offer our expertise to people with statutory health insurance.

* by phone
* directly online in the appointment calendar on our website or
* by email

Initial consultation

At the first appointment, it is important that you can describe your symptoms in detail and calmly: how they affect you in everyday life, how long the problems have been occurring, how they could be influenced and how the entire course has developed over time.

Dealing with coccyx fistulas is not always easy for patients, shame, embarrassment and insecurity often accompany the disease. Many patients are reluctant to talk about the rather intimate problem with others, sometimes even relatives, and also try to hide the condition as much as possible.
Since we know this, we treat the wishes of these mostly young patients even more than usual with the greatest discretion and prudence.

It is important that sufficient time is devoted to the complaints at this stage, as even seemingly unimportant details can be crucial clues.
Targeted questions by the experienced surgeon often give a good first indication of the cause of the symptoms.

Coccyx fistulas are acquired pathological changes in the buttock fold above the coccyx that, under certain conditions, are more likely to occur in some people than in others. These so-called risk factors are male gender, rather thick hair, deep buttock folds, overweight, increased sweating, unusual strain, prolonged sitting and a rather young age between 20 and 40 years.

But the initial consultation is more than just listing complaints by type, severity, time of occurrence and ways to influence them. The initial consultation must always provide space for a professional acquaintance with the person who trustingly goes into treatment.

Different people may objectively have the same complaints, but they are perceived individually. What is unbearable for one person may just be annoying for another. The assessment by the surgeon must also take this fact into account, and this is only possible if the initial consultation is not limited exclusively to the objective complaints, but focuses on the person as an individual with their own assessment of their physical problem.

Physical examination

In addition to describing the history of the symptoms, the physical examination is one of the main pillars for finding a diagnosis.
Of course, it is important to you that the physical examination is also in the hands of a surgeon with many years of clinical, technical and operational experience in order to avoid misinterpretations. After all, it should be routine and discreet and quickly lead to a reliable result.

The chronic form of the pilonidal fistula (pilonidal sinus) manifests itself as a constantly or periodically suppurating or weeping small skin opening (fistula opening), which represents the exit of a duct from the depths of the underlying tissue. There may also be multiple passage openings. If there are several fistula openings in the skin, the associated passages can end independently of one another in the depths or also converge like a foxhole in tissue cavities.
In its acute form, there is a more or less severe inflammatory reaction, usually above the upper buttock fold, with a painful accumulation of pus in the depths, causing swelling, redness and overheating of the area.
The precise and expert examination is crucial for the choice of the most promising form of treatment.
The sonographic interpretation of the upper buttock fold requires a lot of experience, but can be decisive for the diagnosis if the clinical findings are not clear. In addition, it can also depend on the sonographic finding which is the most promising form of therapy. In very rare cases, an MRI examination is required to decide on therapy.

In our doctor’s office we offer you the ideal combination of experienced examiners and modern technical equipment.

Diagnosis and explanation

The diagnosis results from the history, the physical examination and the technical examination (sonography).
I would then like to explain to you exactly what it means to have a coccyx fistula (pilonidal sinus).

What exactly are the anatomical changes in your body?
How and why did these develop?
How severe is this illness?
What stage is it?
Will the changes change in the future?
What effects can be expected on other areas of life?
Are further investigations necessary?
Are the changes harmless or dangerous?

Ultimately, you should be able to recognize which anatomical change causes your symptoms in which way mechanically and how your change should be evaluated individually in comparison to most other patients in the eyes of an experienced surgeon.

Your referring family doctor automatically receives a detailed report of findings and recommendations from us, so that a professional flow of information is guaranteed.

Treatment options

There are several ways to treat coccyx fistulas.
Basically, it is unfortunately the case that coccyx fistulas are very stubborn, which means that the symptoms reappear after a certain time, even if a short-term improvement could be achieved with non-surgical (conservative) measures, because the pathological changes do not heal, but persist throughout life.
A cure, i.e. a treatment that leads to the permanent disappearance of the disease, is unfortunately only possible with surgery.
Treatment depends on the severity of the disease.
As long as there is no larger accumulation of pus (coccyx abscess), the inflammation can initially be improved.
Externally, moist compresses and regular disinfection of the gluteal fold help to reduce the infiltration of additional germs through the open pores. Antibiotics are given internally. In many cases it is possible to calm the situation down. After that, the surgery required for healing can be performed.
If the first examination already shows an acute inflammatory reaction with a large accumulation of pus on the coccyx (coccyx abscess), surgical treatment is necessary immediately.

In our doctor’s office , a comparatively gentle treatment, which we use extremely successfully and which in every respect is not restrictive for the patient, is carried out, which avoids the problems of conventional treatment.

At this point, most patients receive surgical treatment under general anesthesia, in which the pus cavity is radically excised. The crater above the coccyx created by the excision, which sometimes extends to the bony coccyx, is left open and then slowly heals over about 3 months from below to skin level. The patients are unable to work for up to 1.5 months and daily complex hygienic wound treatments and bandages are necessary for the entire healing period. Even in the case of healing without setbacks due to wound infections, in about 10% of cases there are new coccyx fistulas (recurrences) and in these cases a new major operation is necessary in every third patient.

In our procedure, the acutely inflamed accumulation of pus on the coccyx is treated under local anesthesia in such a way that the dangerous, severe inflammation can subside quickly. This is followed by plastic surgery, in which the skin is closed at the end of the operation. In this way, a beautiful cosmetic result and a comparatively very high and lasting probability of healing are achieved.
This patient-friendly operation to permanently eliminate a pilonidal sinus disease is called “Karydakis operation” (or modified by Bascom).

There are numerous other treatment options, both under local anesthesia in so-called semi-surgical (minimally invasive) procedures and under general anesthesia as plastic surgeries.
The semi-operative procedures include, for example

phenol instillation
Pit picking

These procedures – if they are approved in Germany – are justified in individual cases, but like the other surgical treatments, they are associated with different lengths of treatment periods and healing probabilities (so-called recurrence rates), so that they are not routinely used in our doctor’s office . The sustained good result of your treatment is primarily important to us, not the procedure leading to it, so that we can recommend the right method for you on the basis of experience from hundreds of treatments.

All surgical procedures used in our doctor’s office have been scientifically well examined and have proven themselves hundreds of thousands of times in terms of tolerability during and after the operation as well as the success of the treatment in patients.
Many different factors influence which of the treatment options is the right one for you. Which method is recommended for you depends, for example, on which anatomical changes are present, whether there are concomitant diseases, which anesthesia is possible or how old you are.
Of course, just as important for whether a procedure is more suitable or not are the circumstances related to you as a person, your genetic predisposition, your living conditions, your level of activity, your hobbies and your job.
It is particularly important to me that you work with me to find the most suitable procedure for you from the various good options for treating a pilonidal fistula, by allowing your personal circumstances to flow in and allowing us to use our professional experience.
We take as much time for this as it takes, because this not only corresponds to modern interaction between doctor and patient, but also primarily determines the success of the therapy.

Planning and preparation of the surgery

Operating with minimal bleeding is part of reducing surgical risks. One of the prerequisites for this is good blood clotting. Many patients take blood-thinning medications, including aspirin (ASA), Marcumar, Xarelto, Plavix, and others. If possible, these drugs must be discontinued in good time before the procedure. Whether this is possible can sometimes only be determined by consulting the doctor who prescribed the medication, such as your family doctor, angiologist, cardiologist or neurologist.

In advance, the family doctor should prepare a current laboratory with blood count, liver values, inflammation values ​​and coagulation.
In the case of certain previous illnesses, clarifying examinations such as an X-ray of the lungs or functional tests of the lungs and heart are also important in order to be able to assess the risk of anesthesia.

Please bring all the papers and reports you have about yourself with you, that is

medical letters
findings reports
allergy passport
X-ray passport
blood group card
List of medications, especially insulin regimens for diabetics and anti-Parkinson medication for M.Parkinson.

The preparation for the operation includes an informative briefing on the type and scope of the planned intervention, which also addresses the possible complications and risks. This briefing gives you the opportunity to ask any questions you have about the surgery.

Which procedure is used in your case and for what reasons?
What exactly is done during this operation?
What type of anesthetic is used for the operation?
How long does this operation take?
What are the risks of this operation?
How long may you need to stay in the hospital?
What scars will be left from the surgery?
What complaints can be expected in the future?
How likely is it that the hernia will come back?

The interview is based on a standardized information sheet, which also serves as a legally relevant document.

Dealing with uncertainty, anxiety and nervousness

Of course, the informational discussion must also take into account aspects that go beyond the factual facts.
Many people experience dread at the thought of having an operation, and we know how regularly modern medicine ignores this fact, despite the importance it plays. Especially if you have never had an operation before, you may feel uncertain and nervous before the procedure.
By addressing and discussing these concerns in a targeted manner, in addition to the extensive factual information, a prepared and confident mind is ultimately created, so that you can then give yourself comprehensive confidence in the surgical treatment.
For us, you as a person are the focus of our activities and our actions are geared towards ensuring that you also feel optimally cared for emotionally.

Performing the surgery

The surgical procedures are carried out on an ambulant basis in modern operating theaters with experienced and highly specialized staff, depending on need and possibility.
The operation as a decisive focus in the treatment process is carried out exclusively by myself.
This is the only way to ensure that all factors that were important in the examination, in the preliminary discussions and in the informational discussion are known to the surgeon first-hand and can be taken into account during the procedure.
Likewise, an optimal and individual follow-up treatment can only take place if the conditions during the operation are known as precisely as possible.

A surgical intervention is always teamwork, the anaesthetist, anesthetic nurse, instrument nurse, surgical assistant and surgical assistant work closely with the surgeon and thus contribute to a patient-friendly, safe, uncomplicated and perfect operation. It is therefore very important to me, for my patients and myself, that the procedures take place in an ideal environment in this regard.

The Karydakis operation is a plastic surgery procedure.
The pilonidal sinus is excised and a slightly flatter gluteal groove is created by shifting the skin and fatty tissue of the buttocks. The resulting scar is slightly to the side of the gluteal furrow.
The procedure is performed under general anesthesia and takes about 45 minutes.
The best treatment results are achieved with subsequent bed rest as part of hospital treatment for about four days. During this time, the wound is sucked out through a drainage system.


As soon as you wake up after the procedure, you will be pain-free in the surgical area. This is due to the fact that, regardless of the procedure performed, you have been injected with a local anesthetic in the operated area, the effects of which last beyond the time of the procedure. Involuntary reactions of the body, which otherwise occur with pain, do not occur and also contribute to your well-being.
Aches and pains that occur over the next few days are usually so minor that painkillers are often not needed at all. If you do, you will be immediately provided with mild to moderate painkillers, which you should take as needed.
Lying in bed is not necessary; instead, exercise is even recommended to avoid thrombosis.
In the next few days, the closed and sutured wound and its surroundings are cleaned and kept germ-free by daily showering and treatment with a disinfectant. Special bandages are not required.
Prolonged sitting should be avoided in the first two weeks. Sitting on hard surfaces should be avoided in the first four weeks after the operation.
After four weeks, most patients are symptom-free. Permanent healing is possible in 95% of the patients treated in this way.

The sutures are removed after about twelve days.
With a waterproof plaster on the wound, you can shower at any time after the drainage has been removed. You should wait approx. 14 days before the procedure before taking a full bath and going to the sauna until the wound has healed.

In any case, you will receive a detailed memo on which all recommendations for behavior and information on follow-up treatment can be read.

In acute emergencies, you can of course reach me personally at any time by telephone.

Controll visit in our doctor’s office

After discharge and in the case of ambulant operations, a check-up visit to the surgical doctor’s office follows after the operation.
The clinical and sonographic findings are checked after the operation and the surgical wound is also assessed.
All appointments will of course be given to you in writing as a reminder.

After completion of the treatment, your family doctor will receive a detailed report on the entire process, including the operation performed, the recommended follow-up treatment and medication.