Coccyx pain (Coccygodynia)
Coccyx pain (tailbone pain) can frustrate patients and significantly impair quality of life, but relief is possible. Currently, the term coccydynia is used somewhat more commonly than coccygodynia. The two terms are interchangeable and indicate pain localized to the coccyx. Neither term specifies the underlying etiology. Coccyx pain can occur from local trauma or a tumor, but most cases have no identifiable cause.
Patients with coccyx pain often report that their physicians minimize, dismiss, or belittle their symptoms. Tailbone pain is often relatively severe and persistent, causing significant compromise of the patient's ability to perform or endure various activities. Physicians who understand coccydynia and the available treatment options can provide a great service to this otherwise neglected patient population.
History
The history obtained from a patient with coccydynia involves details regarding the coccydynia itself and other underlying conditions that may refer pain to the coccyx region.
Localization of pain - The patient should be asked to indicate or point to the painful site or sites.
Severity of coccyx pain - The patient should be asked to rate the level of coccygeal pain (0-10 scale) when it is at its best and at its worst and to indicate overall pain severity.
Duration and onset date of coccydynia - The patient should be asked whether any identifiable traumatic incident, recent or remote, occurred.
Exacerbating factors - The patient should be asked whether there is pain associated with, for example, prolonged sitting or sitting on hard versus soft surfaces, as well as with sexual intercourse, standing up after sitting, or bowel movements.
Sitting tolerance - The patient should be asked to quantify how many minutes of sitting can be tolerated before the pain mandates changing position.
Other elements of the patient's history that should be obtained include the following:
Cushions tried - Such as donut cushions, which have a circular hole in the middle, or wedge cushions, which have a triangular wedge cut out posteriorly
Oral medications tried and response to these Interventional pain management procedures and response to these - Such as caudal or other epidurals, local anesthetic blocks, and steroid injections, as well as whether these were administered blindly or guided fluoroscopically
Gastrointestinal (GI) symptoms - Constipation; diarrhea; bright-red blood per rectum; melena (black, tarry stool); and fecal
incontinence GI workup - Such as GI consult, colonoscopy, or rectal exam
Urinary symptoms - For instance, urinary incontinence, or dysuria
Urinary diagnostic workup - Such as urology consult or urinalysis
Female intrapelvic history - Such as uterine fibroids or ovarian cysts
Female obstetric history - Childbirth, vaginal or cesarean delivery, and any associated difficulties at the time
Female menopausal status - Premenopausal, perimenopausal, or postmenopausal
Lower limb neurologic symptoms - Such as radicular pain or lower limb numbness or weakness
Concomitant ischial bursitis - Such as unilateral or bilateral ischial buttock pain due to leaning to either side to avoid sitting with pressure on the midline/coccyx region
Body weight - Such as any significant increase or decrease in body weight preceding the onset of the symptoms.
History of cancer - Especially colon, prostate, ovarian, cervical, testicular, or other intrapelvic malignancies.
Risk factors for cancer - Blood per rectum, abnormal vaginal bleeding, unexplained weight loss, fevers, or chills
Physical
Palpation
Sacrococcygeal palpation involves identifying and exerting pressure onto the sacrococcygeal junction and the coccyx, noting whether the presenting symptoms localize well to that site (ie, exquisite tenderness at the coccyx and/or sacrococcygeal junction, with only mild or absent tenderness at adjacent structures).
Some clinicians palpate the coccyx via an internal/external approach by using a gloved hand with 1 or 2 fingers placed inside the rectum (anterior to the coccyx) and another 1 or 2 fingers palpating externally (posterior to the coccyx). In this way, some clinicians also attempt to assess for increased or decreased sacrococcygeal mobility. Patients with severe coccydynia may have difficulty tolerating this examination.
Palpation of other (noncoccygeal) lumbosacral structures is important to help rule out pain generators from the ischial bursae, sacroiliac joints, lumbosacral facet joints, and lumbosacral or gluteal muscles.
Neurologic examination - Strength, sensation, and muscle-stretch reflexes can be assessed throughout the bilateral lower limbs to assess for any lumbosacral radiculopathy.
Lumbosacral range of motion - This can be assessed in multiple planes, including documentation of pain with these motions, particularly if the presenting symptoms are reproduced.
GI and gynecologic physical examination - Depending on the patient's history and the clinician's expertise, abdominal and gynecologic physical examinations may be performed. Manual digital rectal examination can assess for hemorrhoids or other intrarectal masses.
Causes
Some causes of coccyx pain include trauma, fractures, dislocations, and malignancies (either primary or metastatic).
Sources of trauma include childbirth, falls, and prolonged sitting.
Tailbone pain may begin after certain medical procedures, such as colonoscopy.3
Some cases of coccydynia are idiopathic, without any identified etiology.
Other Problems to Be Considered
Coccygeal fracture
Sacrococcygeal dislocation
Intracoccygeal dislocation (dislocation of one coccygeal segment from another)
Intrapelvic malignancy and/or metastatic lesions
Ischial bursitis
Sacroiliac joint pain
Ovarian cyst
Fibroid uterus
Pilonidal cyst