From the Research
Imaging is generally not necessary to rule out pilonidal disease in a patient with coccydynia who has no visible pilonidal clefts or pits. The diagnosis of pilonidal disease is typically clinical, based on the presence of characteristic findings such as midline pits, sinus tracts, or abscess formation in the sacrococcygeal region 1. When these clinical signs are absent, other causes of coccydynia should be considered first, such as trauma, coccygeal instability, or referred pain from lumbar pathology. If clinical suspicion remains high despite normal examination, an MRI would be the preferred imaging modality as it can detect occult pilonidal sinuses, inflammatory changes, or abscesses not apparent on physical examination 2. However, this would be uncommon, and a thorough history and physical examination, including digital rectal examination to assess for coccygeal tenderness or mobility, should guide the diagnostic approach. Some key points to consider in the management of coccydynia include:
- Conservative management with NSAIDs, cushioning, and physical therapy is reasonable to try initially while monitoring for the development of more specific symptoms or signs of pilonidal disease 3
- The current evidence supporting different treatment options for pilonidal disease is limited by study quality, with inconsistent characterization of disease severity and use of variable definitions and reporting of treatment-associated outcomes across studies 1
- MRI can offer valuable information about the extent of sepsis associated with pilonidal sinus disease, particularly in cases with involvement of critical anatomical structures such as the coccyx and anal triangle 2
- A recent review of the management of pilonidal disease highlights the need for standardization of definitions used to characterize pilonidal disease and its outcomes to develop evidence-based treatment algorithms 1.