Coccygodynia

COCCYGODYNIA, coccygodynia (coccygeal pain), spontaneously occurring (mainly in women) dull, often very intense pains in the region of the coccyx. According to modern concepts, coccygodynia (like pain in the sacrum) is more of a symptom than a disease, since it is of various origins and is observed in diverse lesions of the female reproductive sphere and adjacent organs (ovaries, uterus, vagina, external genitalia, rectum, pelvic bones, etc.). A distinction is made between coccygodynia of functional and organic origin. In the absence of organic damage, coccygodynia is considered a neuralgia of the coccygeal plexus. As a referred symptom in diseases of the female reproductive organs, coccygodynia, in view of its inconstancy and variety in the localization of pain, was attributed by some to the realm of hysterical phenomena. Organic coccygodynia has in its etiology trauma [childbirth, especially with forceps, in cases of narrow pelvises or accompanied by a pathological mechanism of the passage of the fetal head, falls, horseback riding, or pathological processes in the bones of the coccyx and surrounding tissues (caries, osteomalacia, periostitis, etc.)]. The pathological-anatomical substrate for pain sensations in such cases are ruptures of ligaments, painful displacements, dislocations, and ankylosis of the coccygeal bones (Luschka), edema, hematomas, periostitis, and other changes in the region of the coccyx and sacrum. It is possible that coccygeal pain, analogous to sacral pain, sometimes has as its cause inflammatory changes (myositis, edema) in the muscles of this region (m. coccygeus, ischio-coccygeus, levator, sphincter ani, gluteus, etc.). The pain in coccygodynia is dull, unnerving (Scanzoni compares it to a toothache), in the coccyx or buttocks, manifesting intensely during walking, rising quickly, sitting down, defecation, coitus, and sometimes making it impossible even to sit (patients sit on one buttock). Examination (index finger in the rectum, thumb on the dorsal surface of the coccyx or sacrum) in the neuralgic form of coccygodynia does not reveal palpable changes and confirms only increased tenderness upon pressure on the coccyx. In organic coccygodynia, one can note displacements, changes in the mobility of the coccygeal bones, tumors, or localized edematous areas on the coccyx or to the side of it. Sometimes the pain resolves spontaneously (resorption of postpartum hematomas and healing of other injuries during childbirth); but in the majority of cases, it is prolonged, persistent, upsets the nervous system and the general condition of the patients, responds poorly to treatment, and produces relapses. In treatment, it is necessary to conform to the etiology. In neuralgic forms, one begins with anti-inflammatory and resolving agents (application of Tinctura Jodi, heat in the form of compresses, sitz baths, attention to easy bowel movements), uses painkillers [morphine, cocaine, belladonna in suppositories or injections (atropine)], recommends rest (prolonged lying down with the goal of immobilizing the coccyx), counter-irritants, and local bloodletting (leeches). In more persistent cases, good results have been seen from faradization (Seligmuller—a metal electrode in the vagina, against the cervix of the uterus, a soft one externally on the painful areas of the coccyx; Graefe—electrodes to the sacrum and coccyx, 3–8 sessions with progressive strengthening of the current) and massage (Rose—from the side of the rectum). If these manipulations fail, surgical intervention remains: with the goal of freeing the painful coccygeal bones from movements, traction, etc., the attachments of the muscles to the coccyx are severed subcutaneously with a tenotome. If this operation also does not yield comforting results, then it remains to resort to the removal of the coccyx (a median longitudinal incision of the skin over the coccyx, separation of the muscles, grasping of the bones with strong bone-holding forceps, and their removal with rotating movements; bleeding is stopped with sutures).