Coccyx pain

Coccyx Pain (Coccydynia)

Introduction

Coccyx pain, also known as coccydynia or tailbone pain, is pain localized to the coccyx (terminal vertebral segments). It is more common in women (due to pelvic anatomy and childbirth) and can be acute (following trauma) or chronic (lasting >2 months).

Although not life-threatening, it can be debilitating, interfering with sitting, standing, bowel movements, and sexual activity.

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Anatomy of the Coccyx

• The coccyx is the terminal portion of the vertebral column, composed of 3–5 fused vertebrae.

• It articulates with the sacrum via the sacrococcygeal joint.

• Surrounded by ligaments, pelvic floor muscles, and gluteal attachments.

• Pain arises from joint instability, fracture, or soft-tissue inflammation.

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Causes of Coccyx Pain

1. Trauma

• Direct fall on buttocks.

• Childbirth injury.

• Sports injury.

• Repetitive microtrauma (cycling, rowing).

2. Idiopathic (no clear cause)

• Often chronic, sometimes due to joint hypermobility.

3. Musculoskeletal & Degenerative

• Sacrococcygeal arthritis.

• Hypermobility of coccygeal joint.

• Malalignment.

4. Soft Tissue Conditions

• Pilonidal cyst or abscess near coccyx.

• Bursitis, fibrosis.

5. Neoplastic / Infective (rare but serious)

• Primary bone tumors (chordoma).

• Metastasis (prostate, breast).

• Infections (osteomyelitis, tuberculosis).

6. Referred Pain

• From lumbar spine, sacroiliac joint, pelvic organs (gynecological, rectal disease).

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Clinical Features

• Localized pain over tailbone, often sharp/stabbing.

• Worse when:

  • Sitting on hard surfaces.

  • Rising from sitting.

  • Leaning back while sitting.

• Relieved by standing or leaning forward.

• Associated features:

  • Swelling, tenderness on palpation.

  • Pain during defecation or sexual intercourse (dyspareunia).

  • Chronic cases: depression, poor quality of life.

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Diagnostic Approach

1. History

• Recent trauma, childbirth, prolonged sitting.

• Onset, duration, severity.

• Associated bowel, urinary, gynecological symptoms.

• Red flags: weight loss, fever, night pain.

2. Examination

• Local tenderness over coccyx.

• Rectal exam: check coccygeal mobility, rule out masses.

• Neurological exam to rule out lumbar/sacral pathology.

3. Investigations

• X-ray (sitting and standing): Dislocation, fracture, hypermobility.

• MRI: Rule out tumor, infection, disc pathology.

• CT scan: For bony detail if fracture suspected.

• Ultrasound: To exclude pilonidal cyst or abscess.

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Management and Treatment

Treatment is usually conservative, but tailored to cause and severity.

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A. Conservative Measures (First-line)

• Cushions: “Donut” or wedge cushions to relieve pressure.

• Posture correction: Leaning forward when sitting.

• Activity modification: Avoid prolonged sitting, cycling.

• Heat or ice packs: Local relief.

• Physical therapy: Stretching, pelvic floor therapy, massage.

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B. Pharmacological Treatment

1. Analgesics

• Paracetamol (acetaminophen): 500–1000 mg orally every 6–8 h (max 4 g/day).

• NSAIDs (first-line):

  • Ibuprofen 400 mg orally every 6–8 h (max 2400 mg/day).

  • Naproxen 250–500 mg orally twice daily.

• Topical NSAIDs: Diclofenac gel applied 3–4 times daily.

2. Muscle Relaxants

• Cyclobenzaprine 5–10 mg orally at bedtime (short-term use).

• Tizanidine 2–4 mg orally every 6–8 h.

3. Neuropathic Pain (chronic cases)

• Amitriptyline 10–25 mg orally at night.

• Gabapentin 300 mg orally at night, titrate up to 900–1800 mg/day.

4. Stool Softeners (if painful defecation)

• Docusate sodium 100 mg orally once or twice daily.

• Lactulose 15–30 mL orally daily.

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C. Interventional Therapy

1. Local Injections

• Corticosteroid injections into sacrococcygeal joint:

  • Triamcinolone 20–40 mg with local anesthetic (lidocaine).

  • Provides temporary relief in chronic cases.

2. Nerve Blocks

• Ganglion impar block (via coccygeal nerve plexus):

  • Local anesthetic ± steroid, significant pain relief in refractory cases.

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D. Surgical Options (last resort)

• Coccygectomy (removal of coccyx):

  • Reserved for chronic disabling pain unresponsive to ≥6–12 months of conservative therapy.

  • Complications: infection, poor wound healing, persistent pain.

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Complications

• Chronic pain syndrome.

• Depression, reduced quality of life.

• Constipation due to painful defecation.

• Rare: malignant causes if missed (chordoma, metastasis).

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Prognosis

• Most cases improve with conservative therapy within weeks to months.

• Chronic coccydynia may persist in ~10–20% and require advanced interventions.

• Surgical outcomes vary but can be effective in carefully selected cases.

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Patient Education

• Use cushions when sitting, avoid hard surfaces.

• Maintain healthy posture, avoid prolonged sitting.

• Exercise regularly (low-impact, e.g., swimming, walking).

• Manage constipation with fluids, fiber, stool softeners.

• Seek urgent medical attention if pain is associated with fever, weight loss, or neurological symptoms.