What are the treatment options for coccygodynia?

Treatment Options for Coccygodynia

The treatment of coccygodynia should follow a stepwise approach, beginning with conservative measures and progressing to more invasive interventions only for refractory cases. The management strategy should prioritize pain relief and improved quality of life.

Conservative Management (First-Line)

• Rest and activity modification including reduced sitting time and use of specialized cushions (donut or wedge-shaped) to relieve pressure on the coccyx 1
• Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line pharmacological treatment in the acute phase 2
• Physical therapy including manual therapy techniques such as massage and stretching of the levator ani muscle and mobilization of the coccyx 1, 3
• Postural adjustments to reduce pressure on the coccyx during sitting 3

Interventional Procedures (Second-Line)

For patients who fail to respond to conservative measures after 8-12 weeks:

• Local injections of anesthetic agents and corticosteroids into painful structures (sacrococcygeal joint, intercoccygeal joints, or Walther's ganglion) 1, 2

  • These injections can both diagnose and treat coccygeal pain
  • Typically performed under fluoroscopic guidance

• Ganglion impar block can provide dramatic pain relief in patients with idiopathic coccygodynia 4

  • Can be performed using either trans-sacrococcygeal joint or intra-coccygeal joint approach under fluoroscopic guidance
  • Has shown complete pain relief (NRS=0) in some patients with sustained results for up to one year 4

• Other interventional options include:

  • Radiofrequency ablation of coccygeal discs and Walther's ganglion 1
  • Caudal epidural blocks 5
  • Pulse radiofrequency treatment 5

Surgical Management (Third-Line)

• Coccygectomy (partial or total removal of the coccyx) should be reserved for patients with refractory pain who have failed both conservative and interventional treatments 1, 3
  • Best results are seen in patients with specific pathological findings:
    • Abnormal mobility of the coccyx (hypermobility, subluxation)
    • Presence of bony spicules 3
  • Success rates vary, with moderate long-term outcomes 2
  • Should be approached with caution due to potential for major complications 2, 5

Diagnostic Considerations

• Dynamic lateral radiographs in standing and sitting positions are recommended to identify abnormal coccyx mobility, which is found in approximately 70% of patients with coccygodynia 1
• Manual examination of the coccyx should be performed to reproduce the pain 2
• Extracoccygeal causes should be excluded, including:
  • Pilonidal cyst, perianal abscess, hemorrhoids
  • Diseases of pelvic organs
  • Disorders of lumbosacral spine and sacroiliac joints
  • Tumors or infections 1

Treatment Algorithm

1. Initial approach (0-8 weeks): Conservative management with NSAIDs, cushioning, physical therapy, and postural adjustments
2. Persistent pain (8-12 weeks): Consider local injections or ganglion impar block
3. Refractory pain (>3 months): Consider additional interventional procedures
4. Severe, persistent pain with documented pathology: Consider coccygectomy only after failure of all other approaches and with evidence of abnormal mobility or spicule formation 3, 5

The treatment of coccygodynia requires patience and a methodical approach, as most patients will respond to conservative measures when given adequate time and proper implementation 1, 3.