The epithelial coccygeal passage is a narrow canal in which the sebaceous glands, hair follicles are located and which are lined with epithelium. On the skin, it opens with several primary holes in the area of the intergluteal fold. Their number can range from one to several. This pathology has many synonyms: pilonidal, epithelial, hair cyst, epithelial immersion, sacrococcygeal fistula, posterior navel.
The concept
The epithelial coccygeal passage ends blindly in the subcutaneous tissue. On the skin there are primary holes that appear when a pathology occurs.
Their blockage and mechanical injuries lead to the fact that the contents are delayed in the lumen of the course, which causes inflammatory processes. As a result of this, the course expands, its wall collapses, and fatty tissue is involved in the process. The resulting abscess can reach large sizes, after which it breaks through the epithelium, forming the external opening of the purulent fistula, related to the secondary.
This pathology is congenital. However, patients may not suspect their presence of such a disease for a long time. In the so-called cold period, the symptoms of the disease do not appear, or anal itching, epithelial humidity in the intergluteal zone, small purulent discharge above the rectal opening may be present.
ICD epithelial coccygeal passage
The International Classification of Diseases (ICD) is the basic document in medicine used as the main statistical classification base. Under WHO leadership, it is reviewed once every ten years. In this system, diseases are indicated by Latin letters and numbers. This innovation was made after the adoption of the Tenth Revision (ICD-10). The epithelial coccygeal passage is present in this system along with other pathologies.
The ICD-10 classification is based on a three-digit code that encodes mortality data provided by WHO by various countries. In our country, its use is mandatory in forensic psychiatric examinations and in clinical psychiatry.
The ICD-10 code for the epithelial coccygeal passage is L05.0 in the case of an abscess. Pathology belongs to the XII class "Diseases of the skin and subcutaneous tissue." In the absence of an abscess, the ICD code of the epithelial coccygeal passage is L05.9.
Classification
There is no generally accepted division of the disease by any criteria today. The same processes lead to various surgical interventions. This contributes to confusion in assessing the results of treatment and leads to not always justified actions of the doctor.
At present, the classification of the epithelial coccygeal passage proposed in 1988 by the SSC Coloprotectology is considered the most complete. According to her, the disease is divided into the following forms:
- uncomplicated;
- acute inflammation, characterized by the presence of infiltration and abscesses;
- chronic inflammation, in which the same phenomena are observed, mainly recurring, and purulent fistula;
- remission.
Thus, this classification is not related to the epithelial-coccygeal passage code.
Diagnostics
In most cases, the diagnosis of epithelial coccygeal passage is based on:
- history taking;
- examination of the patient;
- digital research of the rectum.
In the first case, the factors of the occurrence of the ailment, impaired functions of the pelvic organs, which history of injuries of the sacrococcygeal region, the duration and nature of the complaints, are revealed.
Examination of the patient is performed when he is in the knee-elbow position or lying on his stomach. The doctor assesses the condition of the buttock epithelium, sacrococcygeal region, perianal zone, the number and location of holes characteristic of this pathology. During the examination of the anus and perineum, concomitant ailments are revealed: prolapse of the rectum, fistula, hemorrhoids, anal fissure. During palpation, it is determined whether there is a cicatricial and inflammatory process of the sacrococcygeal zone.
With a digital study of the rectum, the state of the last region, as well as the location of the organo-crypts, is assessed.
Also, the doctor may prescribe additional studies:
- Sigmoidoscopy. In this case, the mucous membrane of the distal sigmoid and rectum is examined. In the first, the presence of inflammatory dynamics is noted. An assessment is also made of the nature of the vascular pattern.
- Fistulography. It is carried out in difficult cases for differential diagnosis.
- Ultrasound of the sacrococcygeal zone. Using this study, the depth of the location of the focus from the integument of the skin, the degree of involvement in the inflammation of the subcutaneous fatty tissue, surrounding tissues, the presence of additional moves, the structure and size of the pathology, and its localization are determined.
Clinical picture
Depending on it, there are complicated by purulent process and uncomplicated epithelial coccygeal passage.
In the first case, the pathology can be in acute or chronic form, as well as remission. If the waste products are delayed in the course, then the appearance of a painless infiltrate, which has clear contours, which interferes with movement.
If he becomes infected, acute inflammation develops, accompanied by pain syndromes. The skin above the infiltrate becomes hyperemic and swollen. An increase in body temperature is noted.
In chronic inflammatory processes, the general condition of a person remains stable, a small purulent discharge is noted from the openings of the course, hyperemia and edema are not observed. Around the secondary of them, cicatricial tissue dynamics occurs. Some of the secondary holes heal, while others continue to function. If remission is observed over a long time interval, they are closed with scars. When you press the stroke, the primary holes do not produce any discharge.
An abscess in the coccyx can be opened by doctors or by itself. At the same time, wound closure without fistula formation is noted, pain syndromes disappear, external signs of the inflammatory process disappear. However, the focus of a chronic infection goes into a sleeping state and can lead to exacerbations with the formation of recurrent abscesses, fistulas and phlegmon. They can come and after a few months, and after a certain number of years.
Between them, the patient continues to be disturbed by discharge from the primary holes, discomfort or dull pain in the coccyx, which occurs, as a rule, when sitting.
Photos of the epithelial coccygeal passage are not very attractive.
Conservative treatment
It is mainly used in chronic forms. In addition, it is used to prepare for surgery for epithelial coccygeal passage.
Therapy includes the following activities:
- diathermy and cryotherapy - destruction of fistulous epithelium by exposure to high or low temperatures, respectively;
- hyperbaric oxygenation - oxygen is supplied to the tissue under pressure, which helps to restore the affected areas;
- shaving every week, capturing the intergluteal fold from the lower back to the anal canal with a width of 2 cm;
- hygiene, including frequent washing and drying of the intergluteal zone.
Surgical intervention
The main treatment for epithelial coccygeal passage is surgery. In an immediate manner, it is carried out with an acute form of inflammation. If a chronic form is present, then the operation for epithelial coccygeal passage is carried out as planned.
The type of surgery is determined by the following factors:
- the prevalence of the process;
- his stage;
- clinical picture.
During its execution, the main source of inflammation is removed - the course with primary and secondary holes, surrounding tissues changed as a result of pathology.
With any type of surgery, the patient is placed on his stomach, his legs are slightly spread to gain access to the intergluteal fold.
Today, the following forms of surgical intervention are used:
- sinusectomy - subcutaneous excision of the epithelial coccygeal passage;
- open operations;
- excision with suturing the wound tightly;
- Marsupialization - opening a cyst with the removal of its contents and suturing into the external wound of the edges of its wall;
- excision with plastic displaced flaps.
Excision with dull wound closure
It is used for uncomplicated moves. Methylene blue is introduced into the primary holes to detect leaks and taps. The strokes are excised with two excision sections as a single block with the intergluteal fold epithelium with subcutaneous tissue, which contains the passages, with all available openings, to the sacrococcygeal fascia.
The following contraindications are characteristic for this type of operation:
- the presence of infiltrates in the intergluteal zone;
- previous operations with cicatricial deformity of this area.
Positive results after surgery are observed in 58-88% of cases. However, complications can reach 31%.
Marsupialization
It is performed in acute form at the stage of infiltrate.
The initial excision is performed similarly to the previously described. Subsequently, it is carried out along the back wall of the stroke, affecting the upper sections of the side walls. Then the epithelial edges of the incision are stitched in a checkerboard pattern to the surface of the coccyx and sacrum. After 10-12 days, the stitches are removed.
Positive results are characteristic in more than 93% of patients.
Open operations
They are performed in acute inflammation in the abscess stage. Such operations are carried out in two stages. At the first, the abscess cavity is punctured at the point of greatest fluctuation, the contents are pumped out with a syringe. It is opened using a longitudinal incision.
After removal of acute inflammation, in the second stage, a gentle excision of the branches and the coccygeal passage itself surrounding the fiber is performed, the wound is conducted in an open way.
Positive results, including satisfactory, are observed in 79-87% of patients.
Wound repair
It is carried out with recurrent pathologies or advanced forms, in which there are many fistulous streaks on the buttocks.
When using this method of surgical intervention, the passages are excised with branches, external fistulous openings, surrounding tissues, skin, infiltrates and cavities to the sacral fascia as a single unit.
Cutting out of skin-fat flaps is carried out separately, mainly at an angle of 60 degrees to the main wound defect, since it ensures their good blood supply with good mobility. Flaps are made to the maximum thickness so that they contain all the subcutaneous tissue.
Positive results were observed in more than 84% of patients.
Sinusectomy
It is carried out in remission of the inflammatory process, its chronic form in the stage of purulent fistula and uncomplicated course.
It is excised from primary to secondary openings under the skin. Staining is carried out with methylene blue. Through the holes after excision, a button-shaped probe is carried out and a stroke is excised on it using electrocoagulation. The wounds that form are not sutured.
A positive result is delayed, observed in 93% of cases.
Further management
After surgery for epithelial coccygeal passage patients carry out:
- Daily wound dressings using the following drugs: “Povidone iodine”, “Iodopyron”, “Betadine”, hydrogen peroxide, “Dioxidine”, “Chlorhexidine”.
- Everyday ultraviolet irradiation and microwave therapy.
- The use of ointments for faster tissue repair ("Methyluracil"), which have anti-inflammatory and antimicrobial properties ("Fusimet", "Levosin", "Levomekol").
Complications of untimely treatment
In this case, the inflammatory process can cover the entire sacrococcygeal zone, which can lead to the formation of multiple secondary fistulas located in the perineum, inguinal folds, scrotum. Pyoderma and fungal diseases can be added to them.
It will take a long outpatient treatment, excision of a larger surface of the skin, the operation in several stages.
Forecast and Prevention
Full recovery can occur at any stage of treatment.
For the prevention of acute inflammation, it is necessary to carry out general strengthening measures:
- treat concomitant proctological ailments in time;
- eliminate constipation and diarrhea;
- treat atherosclerosis and diabetes;
- prevent or fight infections in time;
- strengthen immunity;
- observe personal hygiene, especially in the intergluteal area.
Finally
The epithelial coccygeal passage is a congenital soft tissue defect in the tissue area of the sacrococcygeal region. Mostly it manifests itself in young people 15-30 years of age. The treatment is mainly surgical, radical. In normal cases, surgical intervention by patients is easily tolerated. The prognosis of the disease is favorable. With untimely treatment, secondary fistulas can develop at a sufficiently large distance from the intergluteal space.