Abstract
Coccydynia is a common syndrome characterized by pain localized to the tailbone that radiates into the lower sacrum and perineum. Coccydynia affects female patients more frequently than male patients. It occurs most commonly after direct trauma from a kick or a fall directly onto the coccyx. Coccydynia can also occur after a difficult vaginal delivery. The pain of coccydynia is thought to be the result of strain of the sacrococcygeal ligament or, occasionally, fracture of the coccyx. Less commonly, arthritis of the sacrococcygeal joint can cause coccydynia. A recent clinical report attributed the onset of coccydynia to use of an intravaginal contraceptive ring.
On physical examination, patients exhibit point tenderness over the coccyx; the pain increases with movement of the coccyx. Movement of the coccyx may also cause sharp paresthesias into the rectum, which patients find quite distressing. On rectal examination, the levator ani, piriformis, and coccygeus muscles may feel indurated, and palpation of these muscles may induce severe spasm. Sitting exacerbates the pain of coccydynia, and patients often attempt to sit on one buttock to avoid pressure on the coccyx
Keywords
coccydymia, pelvic pain, coccyx, sacrococcygeal ligament, diagnostic sonography, ganglion of Walther, ganglio impar, ultrasound guided injection, proctalgia fugax, caudal epidural block
ICD-10 CODE M53.3
Keywords
coccydymia, pelvic pain, coccyx, sacrococcygeal ligament, diagnostic sonography, ganglion of Walther, ganglio impar, ultrasound guided injection, proctalgia fugax, caudal epidural block
ICD-10 CODE M53.3
The Clinical Syndrome
Coccydynia is a common syndrome characterized by pain localized to the tailbone that radiates into the lower sacrum and perineum. Coccydynia affects female patients more frequently than male patients. It occurs most commonly after direct trauma from a kick or a fall directly onto the coccyx. Coccydynia can also occur after a difficult vaginal delivery. The pain of coccydynia is thought to be the result of strain of the sacrococcygeal ligament or, occasionally, fracture of the coccyx. Less commonly, arthritis of the sacrococcygeal joint can cause coccydynia. A recent clinical report attributed the onset of coccydynia to use of an intravaginal contraceptive ring.
Signs and Symptoms
On physical examination, patients exhibit point tenderness over the coccyx; the pain increases with movement of the coccyx. Movement of the coccyx may also cause sharp paresthesias into the rectum, which patients find quite distressing. On rectal examination, the levator ani, piriformis, and coccygeus muscles may feel indurated, and palpation of these muscles may induce severe spasm. Sitting exacerbates the pain of coccydynia, and patients often attempt to sit on one buttock to avoid pressure on the coccyx ( Fig. 97.1 ).
Testing
Plain radiography is indicated in all patients who present with pain thought to be emanating from the coccyx, to rule out occult bony disease and tumor. Based on the patient’s clinical presentation, additional testing may be warranted, including a complete blood count, prostate-specific antigen level, erythrocyte sedimentation rate, and antinuclear antibody testing. Magnetic resonance and ultrasound imaging of the pelvis, including the sacrococcygeal joint and ligament, are indicated if occult mass or tumor is suspected ( Fig. 97.2 ). Radionuclide bone scanning may be useful to exclude stress fractures not visible on plain radiographs. The injection technique described later serves as both a diagnostic and a therapeutic maneuver.
Differential Diagnosis
Primary disease of the rectum and anus is occasionally confused with the pain of coccydynia. Primary tumors or metastatic lesions of the sacrum or coccyx may also manifest as coccydynia ( Fig. 97.3 ). Proctalgia fugax can be distinguished from coccydynia because movement of the coccyx does not reproduce the pain. Insufficiency fractures of the pelvis or sacrum and disorders of the sacroiliac joints may on occasion mimic coccydynia.
