Treatment of Coccydynia
Conservative management should be the first-line approach for coccydynia, with 90% of cases responding successfully to non-surgical interventions including NSAIDs, physical therapy, cushioned seating, and manual manipulation. 1
Initial Conservative Management
Begin with these evidence-based interventions:
- NSAIDs as first-line pharmacologic therapy, with addition of acetaminophen or small doses of narcotics if NSAIDs alone are insufficient 2
- Specialized coccyx cushions (donut-shaped or wedge cushions) to reduce pressure during sitting 3, 1
- Physical therapy and manual manipulation, including massage and stretching of the levator ani muscle and mobilization of the coccyx 3, 4
- Pelvic floor rehabilitation for refractory cases 1
- Ergonomic modifications to reduce sitting time and optimize posture 1
The majority of coccydynia cases resolve without medical treatment, though conservative therapy significantly improves outcomes in symptomatic patients 1.
Diagnostic Considerations
Confirm coccygeal origin of pain through:
- Dynamic radiographs (lateral X-rays in standing and sitting positions) to assess abnormal coccyx mobility, which is present in 70% of coccydynia patients 3
- Diagnostic injections of local anesthetic into the sacrococcygeal disc, first intercoccygeal disc, Walther's ganglion, or muscle attachments to confirm coccygeal pain source 3
- Advanced imaging (MRI or CT) when plain radiographs are inconclusive but clinical suspicion remains high 5
Abnormal mobility (hypermobility, anterior/posterior subluxation) is the most common pathological finding and can result from trauma or chronic overload 3.
Interventional Therapies for Refractory Cases
When conservative management fails after 3 treatment sessions, consider:
- Local injections of corticosteroids and local anesthetics into painful structures 3, 4, 6
- Radiofrequency ablation of coccygeal discs and Walther's ganglion 3, 6
- Ganglion impar block 6
- Intrarectal massage and manipulation 6
- Extracorporeal shock wave therapy 6
- Transcutaneous electrical nerve stimulation (TENS) 1
Note that the patient with nontraumatic onset in one case series had only temporary relief from conservative therapy and injections, ultimately requiring surgical intervention 4.
Surgical Management
Coccygectomy (partial or total) is indicated for:
- Refractory cases failing conservative and interventional therapies 3, 1, 6
- Patients with abnormal coccyx mobility and bony spicules, who respond best to surgical treatment 3
- Debilitating pain significantly impacting quality of life 6
Coccygectomy demonstrates high success rates for pain reduction in appropriately selected patients, though it should be reserved for cases unresponsive to all other interventions 5, 6. Emerging surgical techniques require further research before their efficacy can be established 1.
Clinical Pitfalls
Important considerations:
- 30% of coccydynia cases are idiopathic with no identifiable cause 3
- Exclude extracoccygeal sources including pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ disease, lumbosacral spine disorders, sacroiliac joint dysfunction, and piriformis syndrome 3
- Obesity and female gender are associated with increased risk 1
- Multidisciplinary approach combining physical therapy, ergonomic adaptations, medications, injections, and possibly psychotherapy provides the greatest success for refractory cases 1