Coccygeal cyst is a condition that mainly affects young men in a ratio of 3:1 compared to women. It is more common in the white race. Symptoms rarely appear before 15 or after 40 years of age. Other factors associated with the appearance of coccygeal cyst are obesity, hyperhidrosis and local injuries (figure 1). The etiology appears to be acquired and has to do with the encapsulation of hairs within the skin of the sacrococcygeal region. The acquired theory was explained in detail by Bascom, who described the whole process in several stages, starting from the distension of the hair follicle and ending in the formation of a chronic abscess and fistulas (figure 2). The coccygeal cyst may not present any symptoms for years. Other times, it is characterized by pain, tenderness to palpation, a floating mass in the sacrococcygeal region, cellulitis of the surrounding tissues, and fever. In 50% of cases, it presents with the appearance of a sacrococcygeal abscess, while in other cases the patient complains of multiple episodes of inflammation.
Other diseases that mimic the coccygeal cyst to a varying degree and should be excluded are hidradenitis, perianal fistula, perianal abscess, Crohn’s disease, sacral osteomyelitis, etc. Treatment depends on the clinical picture with which the coccygeal cyst presents. In the case of an abscess, opening and drainage are required. These patients progress to chronic coccygeal cyst in 40-60%. Therefore, usually, after the initial treatment with opening the abscess, the patient is recommended a more radical form of treatment. There are various non-surgical treatment methods that have been described in the literature.
One of these is the injection of phenol into the fistulas of the cyst, which causes an inflammatory reaction and destruction of the granulation tissue of the cyst. This is a painful method, which according to various studies achieves a cure rate of 60-95%. Another method is the injection of fibrin glue into the fistulas, but without significant success. Finally, some small series of patients are described in the literature, who were successfully treated with local laser hair removal. Various techniques have been described in surgical methods. One of these is the simple incision of the cyst and its fistulas, the scraping of the cyst wall and the suturing of the remaining tissue to the skin (marsupination), or the cauterization of the remaining tissue. This is a technique with high recurrence rates, exceeding 20% (image 3 and 4).
Another technique is the excision of the coccygeal cyst, which is followed either by keeping the wound open (open method and healing by secondary intention), or by fixation of the skin and subcutaneous fat to the presacral fascia (semi-closed method or Mc Fee technique), or by primary closure of the wound. In any case, extensive excisions of healthy tissue that reach the sacrum should be avoided, because they increase morbidity, create problems in healing, while they do not offer anything additional in the final treatment. However, even with excision, the recurrence rates are high (20-38%) (image 5).
In neglected cases with large cysts, multiple fistulas and continuous recurrences, special excision techniques are applied with subsequent application of myodermal or skin flaps. Recurrence rates range from 2-11%, but have high morbidity and require long hospitalization (image 6).
Postoperative wound care is very important in coccygeal cyst and includes weekly local shaving of the area and daily diligent wound care (washing, antiseptic with Betadine, changing dressings). It is confirmed that neglecting proper postoperative care nullifies any good results that surgical treatment may have.
Finally, in rare cases of long-standing and neglected coccygeal cysts, cancer may coexist, which in 14% of cases will have spread to the regional lymph nodes. The treatment of these cases is with wide local excision, accompanied by some form of flap coverage. The recurrence rate is high (38%), but can be reduced by adding radiotherapy to the treatment regimen.
In conclusion, the coccygeal cyst is a condition that significantly affects the patient’s daily life. Prudent treatment according to the case and good postoperative care are required in order to achieve the maximum possible result. My personal experience has led me to the conclusion that the best results result from a careful excision, without unnecessary removal of surrounding healthy tissues, combined with diligent postoperative care.
