Differential Diagnosis for Patient with Pain and Tenderness in Pubic Area

Single Most Likely Diagnosis

• Pilonidal Sinus or Cyst: The presence of a firm, tender mass in the pubic area with mild pus discharge and the finding of granular tissue upon incision under local anesthesia strongly suggests a pilonidal sinus or cyst. These are typically found near the tailbone (coccyx) but can occur in the pubic area, presenting with similar symptoms.

Other Likely Diagnoses

• Infected Sebaceous Cyst: An infected sebaceous cyst in the pubic area could present with pain, tenderness, and pus discharge. The presence of granular tissue could be consistent with the body's response to an infected cyst.
• Furuncle or Carbuncle: A furuncle (boil) or carbuncle (cluster of boils) in the pubic area could cause similar symptoms, including pain, tenderness, and pus discharge. However, the absence of significant pus upon incision might make this less likely.
• Hidradenitis Suppurativa: This chronic skin condition can cause painful, inflamed bumps in areas of the body with apocrine glands, such as the pubic area. It could present with similar symptoms, including discharge and granular tissue upon incision.

Do Not Miss Diagnoses

• Necrotizing Fasciitis: Although rare, necrotizing fasciitis is a life-threatening condition that requires immediate attention. It can present with pain, tenderness, and swelling, and the presence of granular tissue could be indicative of tissue necrosis. The absence of significant pus and the presence of granular tissue upon incision could be misleading, making this a "do not miss" diagnosis.
• Fournier's Gangrene: This is another severe and potentially life-threatening condition involving necrotizing fasciitis of the genital or perineal area. It presents with severe pain, swelling, and sometimes a foul odor, which might not be immediately apparent in the provided scenario.

Rare Diagnoses

• Tubercular Abscess: Although rare in many parts of the world, a tubercular abscess could present with chronic discharge and granular tissue. This would be more likely in individuals with a history of tuberculosis or those immunocompromised.
• Actinomycosis: This rare bacterial infection can cause abscesses and sinus tracts, presenting with chronic discharge and granular tissue upon examination. It's more common in individuals with poor dental hygiene or who have recently had abdominal surgery.

The next line of management would depend on the confirmed diagnosis but could include antibiotics for infected sebaceous cysts, furuncles, or carbuncles, and surgical debridement or drainage for pilonidal sinus, hidradenitis suppurativa, or necrotizing fasciitis. For conditions like necrotizing fasciitis or Fournier's gangrene, immediate surgical intervention and broad-spectrum antibiotics are crucial.