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If there is redness, swelling or tenderness in the region of the sacral bone or the buttocks, if bloody or purulent discharge is seen on the toilet paper or underwear, you have to consider having a "coccygeal", pilonidal "cyst" or fistula. Treatment of pilonidal disease should be done by a specialist. Only thorough examination by an experienced surgeon allows adequate therapy with an acceptable downtime.

What is a Pilonidal Sinus ("Pilonidal Cyst")

Hair follicle (left), dilated hair follicle and pilonidal sinus (right)

Pilonidal sinuses are foreign-body sinuses in which the foreign body is hair (Lord, Millar 1964). It is not precisely known how these hairs enter the subcutaneous tissue.  The combination of the presence of a foreign body and the bacteria of the natal cleft causes local inflammation. Inflammation causes tissue destruction and development of a cavity or a tubular duct. "Strong" types of tissue like the fascia of muscles and bones or bone itself form a barrier against this spread of inflammation, as does the scar capsule the body forms to seperate the foreign body from healthy tissue. The sacral bone and the sphincter muscle are almost never involved in Pilonidal fistula. Rarely an anal fistula can be misdiagnosed a Pilonidal fistula and vice versa. 

How can hair enter the subcutaneous tissue and cause pilonidal sinus formation? 

Typical Pilonidal Sinus with "pits"" (the black dots) and an external fistula opening (the "pimple")

We believe there are three possible explanations for hair entering a pilonidal sinus: 

1. The formation of a new hair by the germinal follicle is disturbed. Keratin, the protein hair is made of, accumulates without structure within the hair follicle. The follicle is stretched, the external opening widens, the "pit" is born.

2. Growth of the hair is normal, but it is pushed back into the follicle, breaks and stabs into the basal cell layer, causing local inflammation and tissue distruction.

3. In some instances we observed orderly hair growth within a tubular fistula tract, which might be the result of a disturbance of (fetal? stem cell movements?) development.

The enlarged hair follicle appears as black "dots" or tiny openings in the midline. Peter Lord, a British surgeon, described the widened hair follicle as the origin of pilonidal sinuses and named it the "pit". John Bascom, pioneer of minimal invasive pilonidal surgery in the USA, popularized the term in the 80's.

If there is evidence of "pits" in the midline of the natal cleft, the diagnosis of Pilonidal Sinus is proven.

Which symtoms are caused by Pilonidal Sinus?

There is an acute form of Pilonidal Sinus (Pilonidal Cyst) which causes swellling, tenderness and even severe pain sometimes within days. It can be triggered by trauma or periods of long sitting. The typical finding on examination is a reddening of the skin and a palpable induration or mass, sometimes central, more often lateral to the natal cleft. The causative hair follicle often is not visible at that stage because of edema of the surrounding tissue.


The chronic form causes tenderness when sitting on hard surfaces, discharge of fluid, blood or pus at a varying extent and sometimes an unpleasant smell. Sometimes an obvious external fistula opening can be seen ("pimple"). Evidence of little openings or dark spots in the midline, representing enlarged hair follicles, proves the diagnoses of pilonidal sinus.

Why a Pilonidal Center? Why search for a specialist in treating pilonidal fistula?

The prevalence of Pilonidal Sinus among young adults is high - in Germany about 20.000 Patients are operated on a sinus. After the conventional wide excision leaving the wound open ("butcher's method") time to heal not rarely exceeds several months to years. Sometimes the wound does not heal at all and patients are advised to undergo even more "radical" surgery.


Having a large wound sitting is difficult and frequent appointments for wound care are time consuming. Completing school or university can be delayed, the start into a professional career is at risk. Athletes cannot afford to or do not want to pause training.


Since 2001 we have specialized in treatment of Pilonidal Sinus. Only  a few surgeons in Europe can rely on the experience of over 1200 surgical procedures, with pit picking, minimal fistulectomy and Laser treatment as the most frequently applied modalities.  Founded in 2013, Surgeons of the Pilonidal Center in Munich have continously developed minimal invasive surgery for Pilonidal Sinus. Knowing the numerous pitfalls of procedures, experience with difficult cases and having the right equipment for every situation is the basis of successful surgery.


Our patients are able to return to work and physical activity usually within a few days after the operation. Pilonidal Surgery is possible under local anaesthesia without pain


Postoperative care after Pit Picking is easy. Patients take a shower once or twice a day and use soft dressings or a pad in the underwear until secretion (moisture) of the wound subsides. It is allowed to take a bath or go swimming from the second day after surgery. 

Dr. Hofer Facharzt für Chirurgie, Viszeralchirurgie, Proktologie und Spezialist für Steißbeinfisteln in München Dr. Bernhard Hofer, Chirurg und Proktologe. Leitender Arzt des Behandlungszentrums für Steißbeinfisteln.

2044 Patienten

mit Steißbeinfistel haben die Behandlung in unserer Praxis gewählt (Stand 11.04.17).

European Pilonidal Center

Zentrum zur Behandlung der Steißbeinfistel

Dr. B. Hofer

Brienner Str. 13

80333 München



Allgemeine Chirurgen
in München auf jameda

Warum ein "Zentrum" zur Behandlung der Steißbeinfistel?

In Deutschland werden im Jahr etwa 20.000 Patienten an einer Steißbeinfistel operiert.

Die herkömmliche Therapie der Steißbeinfistel ("Metzger-Methode") führt nicht selten zu einem Monate bis Jahre langen Krankenstand.

Die meisten Patienten sind im jungen Erwachsenenalter, so daß Schule, Ausbildung, Studium und Start ins Berufsleben leiden können. Auch (Leistungs-) Sportler können und wollen sich eine Trainingspause nicht leisten.

Seit 2001 haben wir uns als einer der wenigen Ärzte in Europa auf die Behandlung des Sinus pilonidalis spezialisiert und in über 1200 Operationen seit Gründung der Praxis in München 2013 die Technik des Pit Picking weiterentwickelt. Nach Pit Picking, Laser-OP (FiLaC) und minimal tubulärer Exzision (Fistulektomie) wird Arbeits- und Sportfähigkeit wenige Tage nach einer Operation erreicht. Die Rate primärer Heilung liegt über 90 %.

Die OP des Pilonidalsinus ist schmerzfrei in örtlicher Betäubung möglich.

Die Nachbehandlung nach Pit Picking - OP ist einfach, Duschen, Baden und Schwimmen sind ohne Einschränkung möglich ab dem zweiten Tag nach der OP.

Dr. Hofer Spezialist für Steißbeinfisteln in München Dr. Hofer, Facharzt für Viszeralchirurgie und Proktologie
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