What are the potential causes and management options for pain during intercourse in a patient with a history of recurrent falls on the coccyx (tailbone)?

Pain During Intercourse Following Recurrent Coccyx Falls

In a patient with recurrent tailbone trauma, pain during intercourse is most likely caused by coccydynia with associated pelvic floor muscle dysfunction, and should be managed with a combination of pelvic floor physical therapy, cushioning strategies, and potentially local corticosteroid injections if conservative measures fail. 1, 2

Primary Mechanism of Pain

The coccyx serves as a critical weight-bearing structure and insertion site for multiple pelvic floor muscles, ligaments, and tendons. 2 Recurrent falls directly traumatize this structure, leading to:

• Coccygeal instability or fracture: Abnormal mobility between coccygeal segments is the most common finding in symptomatic coccydynia, visible on dynamic standing and seated radiographs. 3
• Pelvic floor muscle tension and spasm: The levator ani and other pelvic floor muscles attach to the coccyx, and trauma causes secondary myalgia and dysfunction. 4, 3
• Direct mechanical pain during intercourse: The coccyx is positioned immediately posterior to the vaginal canal, making it susceptible to pressure and movement during penetrative intercourse, particularly in positions that cause posterior vaginal wall pressure. 1, 4

Coccygeal fracture-dislocation specifically can result in introital dyspareunia (pain at the vaginal opening) and tension myalgia of the pelvic floor. 4

Diagnostic Evaluation

Physical examination should focus on:

• Focal tenderness during direct palpation of the coccyx, performed rectally or externally. 1, 3
• Assessment for crepitus or abnormal mobility of coccygeal segments. 4
• Single-digit vaginal examination to identify tender, hypertonic pelvic floor muscles (particularly levator ani). 5, 3
• Sequential pressure testing with cotton swab around the introitus to map pain distribution. 5

Imaging studies:

• Dynamic radiographs (standing and seated views) are the most accurate diagnostic test, revealing abnormal coccygeal mobility in most symptomatic patients. 3
• MRI or bone scan may show inflammation and edema but are less accurate than dynamic radiography for identifying the structural cause. 3
• Plain radiographs can identify fracture-dislocation between coccygeal segments if present. 4

Treatment Algorithm

First-line conservative management (successful in 90% of cases): 2

1. Ergonomic modifications: Use of a doughnut-shaped cushion or wedge cushion to eliminate direct pressure on the coccyx while sitting. 1, 2, 4

2. Pelvic floor physical therapy: This is essential for addressing secondary muscle dysfunction and should include manual manipulation, massage, and stretching of the levator ani muscle. 1, 2, 3 This directly addresses the pelvic floor tension that contributes to dyspareunia. 5

3. Positional modifications during intercourse: Avoid positions that place posterior pressure on the vaginal wall and coccyx. 4

4. Topical and oral analgesics: NSAIDs and topical analgesics can reduce inflammation. 1, 5

5. Local heat application: Provides symptomatic relief. 4

Second-line interventions for refractory cases:

• Local corticosteroid and anesthetic injection: Injection into the painful coccygeal segment is indicated for patients with severe pain who fail initial conservative measures. 3 This should target the specific segment showing abnormal mobility on dynamic radiographs. 3

• Transcutaneous electrical nerve stimulation (TENS): May provide additional pain relief. 2

• Cognitive behavioral therapy: Particularly important given the impact on sexual function, relationship distress, and quality of life associated with dyspareunia. 5, 2

Surgical consideration (rare):

• Coccygectomy is reserved only for cases where nonsurgical treatment fails, which is infrequent. 2, 3 Best results occur in carefully selected patients with radiographically demonstrated abnormalities of coccygeal mobility. 3

Critical Pitfalls to Avoid

• Do not dismiss the complaint as purely psychological: Coccydynia following trauma has a clear structural basis, and dyspareunia is a recognized complication of coccygeal injury. 4
• Do not delay pelvic floor physical therapy: This addresses both the coccyx pain and the secondary pelvic floor dysfunction that directly causes dyspareunia. 5, 2, 3
• Do not proceed to surgery without adequate trial of conservative therapy: A multidisciplinary approach with physical therapy, ergonomic adaptations, medications, and injections should be exhausted first. 2
• Do not overlook the psychosexual impact: Women with sexual pain are at increased risk of sexual dysfunction, relationship distress, diminished quality of life, anxiety, and depression, requiring comprehensive support. 5

Expected Timeline

Conservative treatment typically shows considerable improvement within 4-8 weeks. 4 Many cases resolve without medical treatment, but those with persistent symptoms require the structured approach outlined above. 2