A pilonidal cyst is a fairly common, probably congenital abnormality located in the midline superficial to the coccyx or the lower sacrum. It is clinically identified by the opening of a sinus tract. This opening may exhibit a small tuft of hair and be surrounded by a halo of erythema. Although pilonidal cysts are generally asymptomatic except perhaps for slight drainage, abscess formation and secondary sinus tracts may complicate the picture.
An anorectal fistula is an inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface (as shown here) or into another viscus. An abscess usually antedates such a fistula. Look for the fistulous opening or openings anywhere in the skin around the anus.
An anal fissure is a very painful oval ulceration of the anal canal, found most commonly in the midline posteriorly, less commonly in the midline anteriorly. Its long axis lies longitudinally. Inspection may show a swollen "sentinel" skin tag just below it, and gentle separation of the anal margins may reveal the lower edge of the fissure. The sphincter is spastic; the examination painful. Local anesthesia may be required.
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