What are the treatment options for coccydynia?

Treatment Options for Coccydynia

Conservative management should be the first-line approach for coccydynia, with surgical intervention reserved only for patients who fail multiple conservative treatments over at least 6 months. 1, 2, 3, 4

Initial Assessment and Conservative Management

First-Line Treatments

• NSAIDs: Begin with oral non-steroidal anti-inflammatory drugs for pain control 1, 4
• Ergonomic modifications:
  • Coccyx cushion with a cutout/recess to reduce pressure on the tailbone 3, 4
  • Posture correction when sitting
  • Avoid prolonged sitting when possible

Second-Line Conservative Treatments

• Local injections: Corticosteroid with local anesthetic directly to the painful area 1, 5

  • May require repeat injections over time
  • Particularly effective for Type I coccydynia (normal coccyx configuration) 5
  • Success rate varies but provides significant pain relief in most patients

• Physical therapy interventions:

  • Pelvic floor rehabilitation 3
  • Manual manipulation and massage of coccyx region 2, 3
  • Levator ani muscle stretching and massage 2
  • Strengthening exercises for pelvic floor 4

Advanced Interventional Options

For patients with persistent symptoms despite initial conservative management:

• Ganglion impar block: Targets the ganglion impar at the anterior surface of the sacrococcygeal junction 2
• Pulsed radiofrequency ablation: Emerging technique for pain management 2
• Transcutaneous electrical nerve stimulation (TENS) 3
• Extracorporeal shock wave therapy 2
• Caudal epidural blocks 2

Surgical Management

Reserved for patients with debilitating pain who have failed conservative and interventional treatments for at least 6 months:

• Coccygectomy (surgical removal of the coccyx) 1, 2, 5, 4
  • Success rates of 80-90% in appropriately selected patients 4
  • More effective for patients with:
    • History of trauma 5
    • Type II, III, and IV coccyx configurations (based on Postacchini classification) 5
  • Potential complications:
    • Wound infection (reported in up to 27% of cases) 1
    • Wound dehiscence 1
    • Most infections resolve with irrigation, debridement, and oral antibiotics 1

Treatment Algorithm Based on Patient Classification

1. All patients: Begin with NSAIDs and coccyx cushion
2. If no improvement after 4-6 weeks: Add local steroid/anesthetic injections
3. If temporary relief with injections: Consider repeat injections as needed
4. If minimal or no relief with injections:
   • Try physical therapy interventions
   • Consider advanced interventional techniques
5. If persistent debilitating pain after 6+ months of conservative treatment:
   • Evaluate for surgical candidacy based on:
     • Response to injections (temporary relief suggests better surgical outcomes)
     • Radiographic findings (Type II-IV configurations respond better to surgery)
     • History of trauma (better surgical outcomes)

Important Considerations

• Conservative treatment is successful in approximately 90% of cases 3
• Many cases resolve without medical intervention 3
• Female gender and obesity are risk factors for developing coccydynia 3
• Dynamic lateral radiographs in both standing and sitting positions are the gold standard for imaging 4
• A multidisciplinary approach yields the best outcomes for refractory cases 3
• Patients should be warned about the relatively high infection rate (up to 27%) if surgery is considered 1