Colovaginal Fistula

Pilonidal disease is an acquired inflammatory condition of the natal cleft caused by penetration of loose hair through vulnerable midline skin, producing pits, sinus tracts and recurrent abscesses.

It primarily affects young adults.

Deep natal cleft anatomy, friction, hair burden and prolonged sitting contribute to recurrence.

Chronic disease presents with one or more midline pits and intermittent bloody or purulent discharge.

There may be lateral secondary openings from chronic branching sinus tracts.

An acutely tender fluctuant swelling represents pilonidal abscess.

The pits should be clearly distinguished from perianal fistula openings. Pilonidal disease generally lies cephalad within the natal cleft and does not communicate with the anal canal.

Diagnosis is clinical.

Routine imaging is unnecessary.

MRI is reserved for highly atypical disease or concern for fistula, osteomyelitis or another diagnosis.

Remove loose hair from the natal cleft and keep the cleft clean and dry.

Limited chronic disease can be treated with pit excision, trephination or other minimally invasive approaches.

For more extensive chronic disease requiring excision, avoid routine primary closure directly in the deep midline cleft because wound breakdown and recurrence are higher.

When primary closure is chosen, move the scar off the midline and flatten the cleft.

Useful operations include:

• Karydakis flap
• Bascom cleft lift
• Limberg flap

The cleft lift is particularly useful for complex, recurrent or previously nonhealing disease and achieves high healing rates in experienced hands.

Do not perform increasingly wide tissue excision simply because disease has recurred. Correcting deep cleft anatomy and placing the wound away from the midline is often more important than the absolute amount of tissue removed.