What are the treatment options for coccygodynia?

Coccygodynia Treatment

Conservative management with NSAIDs, physical therapy, seat cushioning, and coccygeal manipulation should be the initial approach for coccygodynia, as approximately 90% of patients achieve satisfactory results without surgery. 1, 2, 3

Initial Conservative Management

The first-line treatment strategy includes multiple modalities used concurrently:

• NSAIDs with or without acetaminophen form the pharmacologic foundation, with small doses of narcotics added if NSAIDs alone are insufficient 1
• Decreased sitting time and seat cushioning (specifically coccyx cushions with cutouts) reduce direct pressure on the painful area 2, 4
• Physical therapy interventions including coccygeal massage, stretching of the levator ani muscle, and postural adjustments address muscular components 2, 4, 5
• Manual manipulation of the coccyx can be performed bimanually to address abnormal mobility 2, 6

The majority of patients (approximately 90%) respond adequately to these conservative measures and do not require escalation of care 3.

Interventional Procedures for Refractory Cases

When conservative therapy fails after an adequate trial (typically several weeks to months), interventional techniques provide the next tier of management:

• Local injection of corticosteroids and local anesthetics into painful structures (sacrococcygeal disc, intercoccygeal disc, Walther's ganglion, or muscle attachments) serves both diagnostic and therapeutic purposes 2, 5
• Ganglion impar block (GIB) demonstrates substantial efficacy, with mean VAS scores improving from 7.83 at baseline to 3.11 short-term, 3.55 intermediate-term, and 4.71 long-term, with an 86% success rate 3
• Radiofrequency ablation (RFA) of the ganglion impar shows similar effectiveness, with mean VAS improving from 6.92 to 4.25 short-term and 4.04 long-term, with an 86% success rate and no reported complications 3
• Extracorporeal shock wave therapy represents an emerging non-invasive option for patients who have failed initial conservative measures 5

Both GIB and RFA demonstrate failure rates of approximately 14%, with GIB having a 2.88% complication rate versus 0% for RFA 3.

Surgical Management: Coccygectomy

Coccygectomy should be reserved for patients who fail both conservative and interventional therapies, particularly those with documented abnormal coccygeal mobility (hypermobility, subluxation, or luxation) or bony spicule formation on dynamic radiographs. 2, 6, 4

Patient Selection for Surgery

The ideal surgical candidates demonstrate:

• Abnormal coccygeal mobility documented on dynamic lateral radiographs (standing versus sitting positions), present in 70% of coccygodynia patients 2
• Bony spicules or exostoses visible on imaging 2, 4
• Failure of at least 6 months of conservative and interventional therapies 6, 4, 5
• Positive response to diagnostic local anesthetic injections confirming coccygeal origin of pain 2

Surgical Outcomes and Complications

• All patients in one case series showed improvement following coccygectomy after failing conservative management 6
• Wound infection represents the most common complication, occurring in approximately 12.5% of cases (1 of 8 patients in one series) 6
• Delayed wound healing may occur due to the anatomical location and difficulty keeping the surgical site clean 6

Patients with documented instability and spicule formation respond best to surgical treatment 2, 4.

Diagnostic Considerations

Before initiating treatment, confirm the coccygeal origin of pain and exclude alternative diagnoses:

• Dynamic radiographs (lateral views in standing and sitting positions) identify abnormal mobility in 70% of cases 2
• Diagnostic injections with local anesthetic into suspected pain generators confirm coccygeal etiology 2
• Exclude extracoccygeal causes including pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ pathology, lumbosacral spine disorders, sacroiliac joint dysfunction, and piriformis syndrome 2

Approximately 30% of cases remain idiopathic despite thorough evaluation 2.

Treatment Algorithm

1. Initial phase (0-3 months): NSAIDs, activity modification, seat cushioning, physical therapy with manual techniques 1, 2, 4
2. Refractory phase (3-6 months): Add local corticosteroid injections or ganglion impar blocks 2, 3, 5
3. Persistent symptoms (6+ months): Consider RFA of ganglion impar for longer-lasting relief 3, 5
4. Surgical consideration (after 6-12 months): Coccygectomy for patients with documented instability or spicules who have failed all conservative and interventional measures 2, 6, 4

Common pitfall: Proceeding to coccygectomy without adequate trial of conservative and interventional therapies, or operating on patients without documented coccygeal pathology (instability or spicules), as these patients have poorer surgical outcomes 4.