How should I evaluate and manage a 63-year-old woman with a 5-year history of chronic coccygeal pain that worsens with defecation?

Evaluation and Management of Chronic Coccygeal Pain Associated with Defecation

Initial Diagnostic Approach

Begin with dynamic lateral radiographs of the coccyx in both standing and sitting positions to identify abnormal coccygeal mobility, which is the most common pathological finding (present in 70% of coccygodynia cases). 1

Key Clinical Features to Assess

• Pain characteristics: Confirm that pain is localized to the midline below the sacrum and above the anus, worsens with prolonged sitting or transitions from sitting to standing, and specifically intensifies during bowel movements 2
• Trauma history: Document any remote or recent falls, childbirth trauma, or chronic mechanical stress (obesity, prolonged sitting, cycling, rowing) 1, 3
• Physical examination: Perform direct palpation of the coccyx both externally and via rectal examination to reproduce the pain and assess for focal tenderness, abnormal mobility, or bony spicules 4, 2

Essential Diagnostic Studies

• Dynamic radiographs (lateral views in standing and sitting) are the primary imaging modality to detect coccygeal hypermobility, subluxation, luxation, or spicule formation 1, 3
• If plain films are inconclusive but clinical suspicion remains high, obtain MRI or CT to identify subtle fractures, disc degeneration at sacrococcygeal or intercoccygeal segments, or other structural abnormalities not visible on plain radiographs 5
• Rule out extracoccygeal causes: Exclude pilonidal cyst, perianal abscess, hemorrhoids, pelvic organ pathology, lumbosacral spine disorders, sacroiliac joint dysfunction, and piriformis syndrome through appropriate examination and imaging 1, 4

Conservative Management (First-Line Treatment)

Conservative therapy achieves satisfactory results in the majority of patients and should be exhausted before considering surgery. 1

Multimodal Conservative Approach

• Mechanical modifications: Use a coccyx cushion (donut or wedge-shaped) to reduce direct pressure during sitting; limit prolonged sitting and avoid activities that aggravate symptoms 3, 2
• Pharmacologic therapy: Initiate NSAIDs for pain control in the acute phase 4
• Manual therapy: Perform coccygeal massage and stretching of the levator ani muscle; manual mobilization of the coccyx can address mechanical dysfunction 1, 4
• Pelvic floor physical therapy: Address associated pelvic floor muscle dysfunction and teach stretching exercises 2

Interventional Conservative Options

• Local injection therapy: Inject local anesthetic combined with corticosteroid into the painful sacrococcygeal or intercoccygeal disc, Walther's ganglion, or muscle attachments around the coccyx (Level 2C+ evidence) 1, 4
• Diagnostic and therapeutic value: These injections can confirm coccygeal origin of pain and provide prolonged relief 1
• Alternative interventions: Radiofrequency ablation of coccygeal discs and Walther's ganglion may be considered, though evidence is limited and should be performed only under study conditions 1, 4

Surgical Management (Reserved for Refractory Cases)

Coccygectomy (partial or total) is indicated only after failure of comprehensive conservative therapy, particularly in patients with documented abnormal coccygeal mobility or spicule formation who demonstrate the best surgical outcomes. 1, 3

Surgical Considerations and Cautions

• Patient selection is critical: Reserve surgery for patients with radiographic evidence of advanced coccygeal instability (subluxation, hypermobility) or spicule formation 3
• Coccygectomy is generally not recommended due to long-term moderate results and risk of major complications, including wound infection, delayed healing, and persistent pain 4
• Expected outcomes: When appropriately selected, surgical patients may experience significant pain reduction, but this should be considered a last resort after 6-12 months of failed conservative management 1, 3

Critical Pitfalls to Avoid

• Do not assume coccygeal origin without confirmation: In patients whose pain is NOT provoked by prolonged sitting or manual examination, consider neurological causes such as lumbar disc herniation rather than true coccygodynia 4
• Do not overlook idiopathic cases: Approximately 30% of coccygodynia cases have no identifiable structural cause; these patients may still respond to conservative management 1
• Do not rush to surgery: The 5-year history in this patient does not automatically indicate surgical candidacy—many patients with chronic symptoms respond to appropriately applied conservative measures 1, 4
• Address bowel-related exacerbation: The specific association with bowel movements may indicate pelvic floor dysfunction or straining during defecation; optimize bowel habits with adequate hydration, fiber, and stool softeners to reduce mechanical stress on the coccyx 1

Recommended Management Algorithm for This Patient

1. Obtain dynamic lateral radiographs to document coccygeal mobility and structural abnormalities 1, 3
2. If radiographs are negative but clinical suspicion is high, proceed to MRI or CT 5
3. Initiate conservative therapy: Coccyx cushion, NSAIDs, pelvic floor physical therapy, and manual therapy for 8-12 weeks 4, 3, 2
4. If inadequate response, perform diagnostic/therapeutic injection of local anesthetic and corticosteroid into the sacrococcygeal junction or intercoccygeal disc 1, 4
5. Consider coccygectomy only if: Conservative measures fail after 6-12 months AND radiographic evidence of abnormal mobility or spicule formation is present 1, 3