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23 Chronic Anal Pain
367
Fig. 23.8 Retrorectal tumor
helpful to avoid any accompanying skin breakdown and irritation that can be a source of constant irritation.
Prostatitis
Pain in the anterior rectum in the region of the prostate may
be from infl ammatory, neurological, or bacterial origin and
may be acute or chronic. This may be associated with urinary
symptoms and/or sexual dysfunction. This may lead to pelvic fl oor pain as well. Pain with palpation of the prostate is
often diagnostic in the setting of normal anal and rectal tissues. A combination of alpha-blockers and antibiotics is generally used by urologists to treat the condition, to whom
referral is recommended [ 4 ]. Patients sometimes say it feels
like a dull ache in the pelvis or as if they are sitting on a
saddle. The bacteriology will differ depending on the age
group, with sexually transmitted organisms such as chlamydia predominating in younger men, while multiple bacteria including gram-negative rods are more common in older
men. In either case, often a prolonged course of antibiotics is
required to completely clear the infection and avoid chronic
prostatitis that is hallmarked by chronic pain but minimal
objective evidence of prostatic infl ammation.
Constipation
Sometimes patients associate anorectal pain with large and/
or dry bowel movements (dyschezia). Anal fi ssures are commonly associated with this symptom and should be sought,
but overdistension of the sphincter mechanism alone, without the presence of a fi ssure, may be an issue for some.
Attention to improving bowel consistency with bulk laxatives and/or osmotic laxatives may give effective long-term
relief. Regardless of whether or not a fi ssure is seen,
Fig. 23.9 Proctitis
hypertonicity of the sphincter can often be felt on exam, and
treatment is the same, regardless.
Gynecological Sources
Gynecologic causes of pelvic pain, such as endometriosis,
enterocele, rectocele, ovarian diseases, ectopic pregnancies,
or fallopian tube abnormalities, typically do not cause anal
pain. Rather, they result in deep-seated abdominal or pelvic
pain, constipation, or defecation outlet dysfunction. Though
they may be broadly included in the discussion of the differential diagnosis of anal pain, the reader is referred to one
of several available gynecological textbooks where they are
best addressed.
Proctitis/Pouchitis
Proctitis is infl ammation of the rectum secondary to infections, postradiation, diversion, chemical irritation (corrosive
or disinfectants), or infl ammatory bowel diseases. Proctitis is
usually associated with rectal bleeding, and diagnosis is generally readily made using offi ce sigmoidoscopy (Fig. 23.9 ).
By contrast, pouchitis occurs in 30–50 % of patients undergoing a restorative ileal pouch-anal anastomosis following
total proctocolectomy for chronic ulcerative colitis
(Fig.
23.10 ) [ 5 ]. Typically bacterial overgrowth in the pouch
results in an infl ammatory response. Infl ammation can also
occur in the remnant mucosa of the anus (i.e., “cuffi tis”).
Pouchitis and proctitis may be associated tenesmus, or with
painful sensations in the pelvis, and is classically associated
with a sharp rise in the number of bowel movements each
368
R.P. Billingham and A.L. Bastawrous
Fig. 23.10 Pouchitis (With permission from Science SourceÆ, registered trademark of Photo Researchers, Inc. Images and Text. Copyright
© 2013 Photo Researchers, Inc. All Rights Reserved)
day. It is our experience that some patients develop pouchitis
from overcompensating with antidiarrheals, in an effort to
diminish the frequency of bowel movements below about
3/ day.
Treatment of pouchitis is generally with antibiotics (metronidazole or ciprofl oxacin are the most commonly used).
Probiotics are sometimes used in an effort to prevent pouchitis, but there are very limited data on the effi cacy of this practice. Other more recalcitrant bouts of pouchitis require
steroids, chronic cyclical courses of antibiotics, or even
immunosuppressants or diversion. Proctitis is best managed
by addressing the cause and may include anti-infl ammatory
agents or antibiotics as indicated given the underlying etiology. Proctitis resulting from radiation therapy is addressed in
the section below.
Radiation
Radiation effects in the perianal area are occasionally painful
and must be distinguished from pruritus ani, from dermatoses such as lichen sclerosus et atrophicus, and from Bowen’s
or Paget’s diseases. Since the radiation to this area is usually
given for anal or distal rectal, vulvar, and prostatic malignancies, the differential diagnosis should include a careful search
for recurrence of these cancers. The radiation effects that
cause pain include anoderm thinning, proctitis, sphincter
injury, and stenosis. It is our practice to fi rst attempt sucralfate suppositories (these can be made by compounding pharmacies). If bleeding persists, then dilute 10 % formalin
placed topically. For more resistant sources of bleeding, laser
therapy or argon beam coagulation are occasionally needed
to destroy the damaged tissue (Fig. 23.11 ) [ 6 ].
Fig. 23.11 Radiation proctitis
Anorectal Stricture
Rectal and anal strictures can cause pain during defecation
but are unlikely to be obscure sources of chronic anal pain,
due to their easy detection by physical examination, and their
association with defecation. The pain is usually related to
tearing of narrowed anal canal anoderm or scar. While it is
important to rule out any associated malignancy, treatment of
benign strictures typically includes dilation and anoplasty.
Anal Cancer
When symptomatic, anal cancer is usually readily diagnosed
by offi ce examination. Anal canal cancers are generally
associated with more pain than those that are located only on
the perianal skin. Related conditions, such as Bowen’s or
Paget’s disease, may also be considered but are generally
associated with more itching and irritation than pain. With
anal cancer, pain is usually related to associated ulceration
and sphincter irritation/spasm related to infi ltration
(Fig. 23.12 ) [ 7 ]. Though beyond the scope of this chapter,
management of anal cancer includes proper staging and typically multimodality chemoradiation therapy, though surgical
resection may be indicated for very small early lesions and in
the palliative setting.
Foreign Bodies
Sometimes, due to embarrassment on the part of the patient,
a complaint of “chronic anorectal pain” will be the ostensible
reason for a visit to the colon and rectal surgeon for a patient
23 Chronic Anal Pain
369
Fig. 23.12 Anal cancer
Fig. 23.14 Rectal prolapse
Rectal Prolapse
While classically not associated with acute sharp pain,
patients with moderate degrees of rectal prolapse may note
pain during and after defecation. Additionally, acute pain can
occur with incarceration of the prolapsed rectum (Fig. 23.14 )
[ 9 ]. In the chronic setting, once the prolapsed rectum has been
reduced, either spontaneously or manually, there may be minimal or no evidence of it on static examination in the prone
jackknife or left lateral position. If the clinician is considering
this in the differential diagnosis, a “toilet test” (with either
simple straining or following enema administration) or video
defecogram may be helpful in demonstrating this pathology.
Fig. 23.13 Rectal foreign body
with a retained foreign body. Even if digital and anoscopic
examinations are negative, rigid sigmoidoscopy and, if
needed, a plain radiograph of the abdomen and pelvis are
simple means to confi rm or exclude this diagnosis from the
differential. While this is never, by defi nition, chronic, the
insult may have occurred a few days prior to presentation.
The trauma with the insertion and (often) repeated attempts
to remove it may result in further damage than initially suspected (Fig.
23.13 ) [ 8 ]. Management includes removal either
in the outpatient or operating room settings, along with
exclusion of an associated bowel perforation. Typically adequate sedation including an anorectal block is required for
successful removal in the emergency department or clinic
environment.
Neurogenic Pain
While uncommon, disorders of the distal lumbar and sacral
sensory nerves, whether from pressure or other entrapment,
may give a key to ruptured discs, tumors, or congenital bony
abnormalities. A neurologic exam looking for signs of weakness, sensory changes, or refl ex abnormalities may be helpful in diagnosis. Radiological workup may include
cross-sectional or MR imaging with appropriate referral as
indicated.
Infectious Causes of Anal Pain (Table 23.2 )
Gonorrhea
One of the many manifestations of gonorrhea can be anal
pain. According to Gottesman and Gandhi, 50 % of males
and 95 % of females are asymptomatic [
10 ]. When symp-
toms do occur, they are usually attributable to proctitis, with
370
Table 23.2 Infectious causes of anal pain
Disease Pathogen Characteristics
Gonorrhea
Chlamydia
LGV
Syphilis
HSV HSV 2, HSV 1 less common Vesicles open, forming shallow ulcers that coalesce into multiple grouped lesions with
Chancroid
Granuloma
inguinale
Adapted from Gottesman and Gandhi [
Neisseria gonorrhoeae , gram (−)
diplococcus in pairs and clusters
Chlamydia trachomatis , obligate
intracellular bacterium
Chlamydia trachomatis , serovars
L1, L2, L3
Treponema pallidum
Haemophilus ducreyi , gram (−) rod
Calymmatobacterium granulomatis
10 ]
Pruritus, tenesmus, bloody mucopurulent discharge, proctitis
Tenesmus, discharge, mild proctitis
Small shallow ulcers with rapid spontaneous healing
Chancre, small clean-based eccentric ulcer, smooth fi rm borders with rolled edges
erythematous base, single lesions/fi ssure can occur
Sharply circumscribed or irregular ulcer with ragged edges, no induration, gray/yellow
exudates at base, multiple
Extensive, progressive, granulation-like tissue, rolled edges
R.P. Billingham and A.L. Bastawrous
tenesmus, but occasionally severe anal pain is experienced
(though the anal canal is usually not involved). Culture from
within the rectum is generally reliable, but anal lubricants
sometimes have antibacterial properties that may give a
false-negative culture. For this reason, swabs can also be sent
for DNA probe testing, using specialized specimen containers. Treatment typically includes oral cephalosporins or fl uoroquinolones, and patients should be also treated for
concomitant chlamydia and evaluated for other sexually
transmitted diseases including HIV.
Herpes Simplex, Genitalis, and Zoster
Herpes simplex, including herpes zoster, is a common cause of
perianal ulcers and pain. Inguinal lymphadenopathy, and even
radiculopathy in the lumbosacral distribution, may also be
present as a result of this virus. The perianal lesions may begin
as pain alone, progressing to vesicles that rupture, causing shallow ulcers that take about 3 weeks to resolve spontaneously.
Herpes can also affect the anal canal and rectal mucosa in some
cases, with friability and ulcerations seen on anoscopy or sigmoidoscopy. Recurrences are common, at highly variable
intervals, because of persistence of the viral genome in the ganglia of the sensory nerves supplying the anal and perianal area.
HSV may also be associated with radiculopathy in the lumbosacral distribution, which can affect bladder function, cause
impotence, and cause pain in the cutaneous distribution of
these nerves, namely, the buttocks and thighs. Radiculopathic
symptoms may still be present after disappearance of the cutaneous ulcerations. Treatment with oral acyclovir can often
shorten the duration of symptoms by several days, but the drug
does not prevent recurrence (Fig. 23.15 ) [ 10 ].
Syphilis
Anal ulcers can be quite painful, mimicking the pain of anal
fi ssure. However, such ulcers typically are not in the midline
and may be multiple. In contrast, genital ulcers, or chancres,
Fig. 23.15 Perianal herpes (With permission from Gottesman and
Gandhi [
10 ]. © Elsevier 2012)
are typically not painful (Fig. 23.16 ). Treatment is usually
successful with a single muscular injection of penicillin
when detected in the early stages.
H . ducreyi (Chancroid)
Infection with this gram-negative coccobacillus results in
genital and perianal ulcers, usually multiple and painful,
occasionally associated with abscesses. Gram stain and culture on a chocolate agar are used for diagnosis. It is typically
treated with azithromycin and a third-generation
cephalosporin.
Chlamydia (LGV)
Lymphogranuloma venereum (LGV) results from infection
with Chlamydia trachomatis . Following anorectal infection, a
proctocolitis ensues where ulcers are usually not found in the
anal canal but in the rectum. Rectal swabs for gram stain and
culture are often unreliable. Sending such swabs for NAAT
testing, in an appropriate specimen container, is more reliable.
23 Chronic Anal Pain
371
Fig. 23.16 Anal chancre from syphilis
Fig. 23.17 Lymphogranuloma venereum (With permission from Dr.
Pravin J. Gupta.
http://drpravingupta.com/ )
Gottesman and Gandhi point out that if a rectal gram stain
shows polymorphonuclear leukocytes in the absence of visible gonococci, this constitutes presumptive evidence of
Chlamydia (Fig. 23.17 ) [ 10 ]. Common treatment regimens
include tetracycline, doxycycline, or erythromycin.
Chronic Anal Pain
Key Concept : Chronic anal pain can result from a variety of
sources that include pelvic fl oor pathology and are oftentimes diffi cult to diagnose and less responsive to treatment .
Multidisciplinary nonoperative therapies including biofeedback and stimulation are often useful to alleviate symptoms .
Chronic anal pain syndromes are those which are often
more diffi cult to diagnose and treat and include levator syndrome, coccygodynia (which may often be a manifestation
of levator syndrome), pudendal neuralgia, infectious diseases such as herpes zoster or syphilis, neurogenic pain, or
other pain of unknown etiology.
Levator Spasm
Levator syndrome (also known as tension myalgia of the pelvic fl oor, proctalgia fugax, piriformis syndrome, puborectalis syndrome, or coccygodynia) is a vague, crampy
intermittent pain around the lower rectal area. It defi es localization, will sometimes develop after prolonged sitting,
sometimes awaken patients at night, and is typically unpredictable in its frequency and intensity. It has been described
as similar symptoms as urgency to have a bowel movement.
The pain may last 10 min to an hour and resolves spontaneously (a variant of this pain, called “proctalgia fugax,” is
characterized by sudden sharp spasms in the anal muscle
area, often lasting only a few seconds and disappearing).
Interestingly, bowel movements tend to make this pain better
(as opposed to the causes of acute pain listed above). A
related diagnosis to levator ani syndrome is non-relaxing
puborectalis. Patients may sometimes feel pain but mostly
complain of constipation and inability to empty the rectum.
This is also sometimes referred to as “anismus.”
Diagnostic criteria for levator syndrome, as outlined by
Wald in 1991 [ 11 ], are (1) chronic or recurrent episodes of
rectal area pain or aching, (2) lasting 20 min or longer, (3)
occurring for at least 3 months, and (4) in the absence of
other causes. The diagnosis is “highly likely” if, on digital
rectal examination, posterior traction on the levator muscle,
particularly near its attachment to the coccyx, reproduces the
discomfort or reveals “contracted levator muscles.” The
diagnosis can be made when the pain is reproduced with palpation of a lateral muscle cord, which is a portion of the levator ani in spasm. Even without this specifi c fi nding, the
diagnosis is still “possible” if the symptoms meet the criteria
listed above. A complete anorectal examination is necessary
to look for, and exclude, other possible causes. Other tests,
which may be appropriate in certain patients, include colonoscopy, CT, GI contrast studies, and sometimes even diagnostic laparoscopy. But typically, history and physical
examination are suffi cient.
Wexner and Jagelman [ 12 ] reported on a series of 19
patients with intractable pelvic pain. Paradoxical puborectalis contraction was frequently found, more often with EMG
than on videodefecography. Grimaud et al. [
13 ] noted that
anal canal resting pressure was signifi cantly higher than in
controls and that half of such patients showed that the
puborectalis muscle failed to relax on videodefecography.
372
R.P. Billingham and A.L. Bastawrous
Epidemiology
Thompson, in a series from the UK, (1981) [
14 ], reported
that 14 % of patients surveyed had such symptoms within the
past 12 months; of these, 17 % of women reported this, while
only 9 % of men did so. Wald [ 11 ] found that 6–7 % of the
general population reported these symptoms but observed
that only about 30 % ever consulted a physician about this
problem. He also mentions that there appears to be no relationship between this syndrome and irritable bowel
syndrome.
Management
One important step, after making the diagnosis, is reassurance of the patient that the condition, while annoying in various degrees, is not serious or life-threatening. Often such
assurance assuages the anxiety, which usually accompanies
this condition, and which may magnify the symptoms.
Pharmacologic therapy, using anxiolytics or “muscle relaxants,” is rarely helpful, either in treating individual episodes
(which typically resolve before any oral medication could
become effective) or in preventing the development of pain.
Furthermore, the side effects of these medications are
signifi cant.
Vigorous digital massage of the muscle by the physician,
in an offi ce setting, was described by Thiele, but the muscle is
generally too tender and painful, in this venue, to permit
effectiveness [ 15 ]. Therefore, generally the fi rst line of
therapy is “electrogalvanic stimulation” (EGS; Fig. 23.18 ), a
physical therapy technique used by therapists for many other
skeletal muscular complaints. This was fi rst reported by Sohn
in 1982 [ 16 ]. EGS requires an intra-anal probe, a dedicated
and interested physical therapist, and is commonly administered for 20–30 min at a session, for three sessions a week for
2 weeks. Salvati reported that 77 % of 90 patients so treated
were relieved or improved [ 17 ]. In our own series, 60 % had
good to excellent response, but over the longer term, only
25 % remained free of symptoms [ 18 ]. Hull’s experience was
that, of 52 patients, symptoms were relieved in only 19 %,
partially relieved in 24 %, and 57 % of patients reported no
relief [ 19 ]. Ger and Wexner found that 38 % of their patients
reported good to excellent results [ 20 ].
For those for whom electrogalvanic stimulation is not
available or is not effective, biofeedback has been recommended as another effective treatment. Grimaud reported a
series in which all of his patients experienced relief after 8
weeks of once-weekly sessions, with only one relapsing
patient after 2 months [ 13 ].
Other therapies with which success has been reported
(often anecdotally) include acupuncture, injection of local
anesthetic +/− steroids, levator massage under anesthesia
(with or without the injection of botulinum toxin), inhalation
of salbutamol (a beta-adrenergic), or even surgical division
of the puborectalis muscle.
Fig. 23.18 Electrogalvanic stimulation (EGS) generator with anal
probes
Coccygodynia
Coccygodynia, originally described by Simpson in 1859, is,
in our experience, nearly always related to, and caused by,
traction on the coccygeal periosteum by the tense levator
muscle. Some have reported coccygeal hypermobility or
“luxation” based on physical and radiologic exams and have
recommended treatment with manipulation, injection, cryoanalgesia of posterior rami of lower sacral nerve roots (if the
patient has responded to injection of these roots with a test
dose of local anesthesia), or rarely, coccygectomy.
Pudendal Neuralgia
The sensory nerve from the anal canal and perianal area is the
inferior rectal and perineal branches of the pudendal nerve
[ 21 ]. Pudendal neuralgia, fi rst described in 1988 by Amarenco
et al. [ 22 , 23 ], is an uncommon condition characterized by
burning, pinching, or twisting sensations in the territory of the
pudendal nerve, usually exacerbated by the sitting position
and relieved by standing, and may be either unilateral or bilateral. This may be perceived in the perineum, vulvar, or anorectal areas. It is caused by compression of pudendal nerve
within Alcock’s canal at the border by the ischium and the
obturator internus muscle. The pudendal nerve is a mixed
sensory and motor nerve, arising from S2–S4. It supplies anal
and urethral sphincters, pelvic fl oor muscles, and is a sensory
nerve for the anal, perineal, and genital areas. It traverses the
pelvic cavity, gluteal region, and perineum, where it divides
to become the perineal nerve and the dorsal nerve of the penis
or clitoris. The two most likely sites of compression are at the
ischial spine in gluteal region or within the pudendal canal.
If symptoms are consistent with this diagnosis and
other examinations and studies are negative, perineal
electrophysiologic examination (looking for neurogenic
23 Chronic Anal Pain
373
long periods;
Pain after sitting for
Mass identified on ORE
after a bowel
Itching or pain worse
on palpation
at coccyx and levator
muscles with tightness
tenderness reproduced
Anal ulcers,
HIV+, History
Rectal
Anal
margin
Anal
Retro
rectal
changes consistent
movement; visible skin
Levator syndrome
Culture
of SOTs
Biopsy
Excise
Biopsy
MRI,CT
Pruritis ani
with chronic irritation
Biofedback
Biopsy
Treat as
Colon
Tattoo
oscopy
Resect
and wipes
Stop anal preps
stimulation
Electrogalvanic
Physical therapy
appropriate
Rectal
JSor MRI
Sitz baths
& decreased water
Dry stools with fiber
Reassurance
necessary
Stool culture, if
Use cotton to wipe
barriers
Use of moisture
trauma
& mechanical
Minimize chemical
History and physical exam suggest diagnosis
without a bowel
movement, fever;
physical exam with
Pain worsening, even
minimal bleeding,
bowel movement,
Sharp pain with each
swelling, visible
Pain of short duration,
Anal pain
information needed
indicate diagnosis or more
History and physical exam do not
MRI
See Table 2
the anus
erythema,swelling,
often after a bout of
thrombosis
Perianal abscess
tenderness around
hard stools
Anal fissure
Acutely thrombosed
external hemorrhoid
CT
Ultrasound
drainage
Incision and
Sitz baths
Fiber supplement
Excise
Video
defecography
Nitroglycerine or
Expecteant
observation
Culture
internal
nifedipine
Partial lateral
Biopsy
injection
sphincterotomy
Botulinum toxin
Fig. 23.19 Algorithm for the workup and treatment of anal pain
374
R.P. Billingham and A.L. Bastawrous
muscles within the pelvic fl oor or prolonged pudendal nerve
terminal motor latency) is often helpful in confi rming the diagnosis. The likely sites of nerve compression can be identifi ed
on CT, and one can do a diagnostic CT-guided nerve block
using local anesthetic, with or without long-acting steroids, to
see whether the pain is relieved. If pain is indeed relieved and
returns, additional injection via the peridural route or surgical
decompression can be considered [
22 – 24 ]. Mauillion reported
a series of 12 patients with such decompression: 4 patients had
their pain totally relieved and 3 were partially improved.
Results did not depend on electrophysiologic data but were better if they had complete disappearance of pain for 2 weeks after
each of two nerve blocks and worse if patients were taking
antidepressants [ 25 ]. Other authors reporting limited success
with injection and/or decompression include Amarenco [ 26 ],
Shafi k [ 27 ], Bautrant [ 28 ], and Vancaille [ 29 ].
Summary Pearls
Anal pain is one of the most common complaints that brings a
patient to seek the services of a colorectal surgeon.
Distinguishing acute from chronic pain, obtaining a thorough
history, and performing a detailed anorectal examination with
anoscopy and proctoscopy are the initial steps in diagnosis.
The etiology is easily identifi ed in the vast majority of cases
within minutes on the fi rst visit. Once acute treatable causes of
pain are ruled out you may be left with a diagnosis of levator
syndrome, coccygodynia, or pudendal neuralgia. These diagnoses can be debilitating for patients. Nonsurgical treatments
are most effective, but there are times where both physician
and patient may feel frustrated. Resist the urge to order nonuseful and unnecessary tests. Also be aware that systemic
pharmacologic therapy is usually not effective. It is often
important to work with urologists and gynecologists to help
the patient through the diagnosis and treatment. Figure 23.19
shows an algorithm for the workup and treatment of anal pain.
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Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
Herand Abcarian and Guy Robert Orangio
2 4
Key Points
• Reconstruction of a complex perineal wound often
requires a multidisciplinary team—enlist their input
early and use their expertise.
• Flaps are very useful, especially in younger patients
with pilonidal disease who do not have time or the
support for chronic wound care and in large perineal defects.
• Healing by secondary intention still has a role in the
place of chronic pilonidal wounds.
• The underlying disease process often governs the
approach to large perineal wounds.
• Both nonoperative and operative approaches are
needed for chronic open perineal wounds. Do not
just rush back to surgery.
Surgical Management of Complex or Recurrent Pilonidal Sinus
Pilonidal sinus is an acquired disease, seen in the second
decade of life with almost 4 to 1 greater ratio of men to
women [
1833, as a “hair-containing sinus” [
duced the term “pilonidal” which means “hair nest” [ 3 ].
1 ]. Herbert Mayo fi rst described this disease in
2 ]. In 1880 Hodges intro-
Karydakis suggested that the disease is caused by loose hair
becoming inserted into the skin, which leads to chronic
infl ammation and infection [ 4 ].
Patients with chronic pilonidal disease, complicated pilonidal sinus with multiple sinus tracts, and partially drained
abscess cavities or recurrent pilonidal disease require surgical
management. Midline pilonidal excision en bloc of the cyst
and the sinus tracts is the most common operation performed.
Excision down to the presacral fascia should be performed
with complete excision of the cystic component of the pilonidal disease. The controversy is how to manage the postexcision wound in patients with complex pilonidal disease.
Most of these patients have failed conservative measures and
surgical treatment. In this setting, excision of the pilonidal
disease is combined with fl ap closure and modifi cation of the
midline gluteal cleft. There are multiple fl aps utilized: rhomboid fl aps, Z-plasty, the Karydakis procedure, the Bascom
cleft lift procedure, V–Y-plasty, gluteus maximus myocutaneous fl aps, and skin grafting. The major disadvantages to
the fl ap procedures are longer operative times, greater blood
loss, and complications related directly to the fl aps including
infection, loss of fl ap, and scarring.
Pilonidal Cystectomy Combined with Fasciocutaneous Advancement Flap
Key Concept : Excision of a pilonidal cyst is bound to leave
wound issues and often a disgruntled patient . Be familiar
H. Abcarian , MD FACS
Division of Colon and Rectal Surgery,
Department of Surgery , University of Illinois at Chicago,
John H. Stroger Hospital of Cook County , 840 S. Wood Street,
MC 958, 518 E CSB , Chicago , IL 60612 , USA
e-mail: abcarian@uic.edu
G. R. Orangio , MD, FACS, FASCRS (
Division of Colon and Rectal Surgery, Department of Surgery ,
Louisiana State University Health Science Center,
LSU School of Medicine , 1542 Tulane Ave, Room 734 ,
New Orleans , LA 70112 , USA
e-mail: guyhd1950@gmail.com
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_24, © Springer Science+Business Media New York 2014
*)
with the various fl aps that are available for these complex
wounds , as well as their intrinsic outcomes and challenges .
Historically the advancing fl ap was performed by Dr.
Karydakis in Athens, Greece, in 1965. In 1992, he reported
his results in 7,471 patients treated from 1966 to 1990, with
over a 95 % follow-up ranging from 2 to 20 years. He had a
The online version of this chapter (doi: 10.1007/978-1-4614-9022-
) contains supplementary material, which is available to
7_24
authorized users.
377