How to identify the causes and what to do if pain in the coccyx area

Despite the fact that coccyx refers to a vestigial organ of the body (i.e. In the course of evolution have lost their significance) and its owner, he brings a lot. Why is this and what disease can cause pain in the coccyx area, consider further.

Why can hurt tailbone

The Coccyx is a bone, or rather a few bones (4-5), tightly connected, spliced between a cartilage – synchondrosis (see figure below). The coccyx is associated with the movable sacrum through the Sacro-coccygeal articulation (shown only one surface in the form of an oval top). It during childbirth, the coccyx is able to deviate, thereby facilitating the passage of baby through the birth canal. Also important are front, back and Sacro-coccygeal ligaments.

The Coccyx is one of the points of attachment of muscles of the pelvic floor: the muscle that lifts the anus and coccygeal muscle (see figure below).

Important in the development of pain in the coccyx area is the so-called coccygeal plexus.

Coccygeal plexus is located at the anterior surface of the tendon of the coccygeal muscle and sacrospinous ligament. From him depart the following branches: to the PC muscle and the muscle lifting the anus, anococcygeal nerves – Innervate the skin from coccyx to anus (see figure below).

As can be understood from the description above, all pathology is associated with involvement of the pelvic floor muscles (inflammation, tension), skin the perianal area can cause due to the innervation of the pain in the coccyx.

Pain in the coccyx area can be divided into primary and secondary. Primary pain (kokcigodiniâ true) are less common than the secondary, called secondary coccygodynia, pseudococcidae and anorectal pain. Approximate percentage of primary/secondary coccygodynia 30/70 from all patients seeking medical help with this problem.

The Primary pain in the coccyx area due to his injuries, inflammatory and degenerative diseases of the Sacro-coccygeal articulation, tumors of the coccyx. The first two reasons appear more often in women.

Secondary due to diseases of other organs located near anatomically. To the organs, the pathology of which can cause pseudococcidae include the rectum, uterus, bladder, and surrounding these bodies tissue and skin (see table below).

pelvic Organ	Diseases having as one of the symptoms of anorectal pain	the Pathogenesis of pain
Degenerative-inflammatory diseases of the spine	degenerative disc disease of the lumbar and sacral spine, sciatica, herniated lumbar MTD	Pinched, and the inflammatory process in the area of exit of the nerve roots
Neurological diseases	neuritis of the sciatic nerve
diseases of the rectum	Frequent constipation and diarrhea. Anal fissures	Damage to the lining of the anus and its involvement in the inflammatory process
	Hemorrhoids in the acute stage. Proctitis	inflammation of the hemorrhoid and the rectal wall
	acute and chronic Paraproctitis	Inflammation in the tissue surrounding the rectum
Gynecological diseases	Prolonged labor, hemorrhage in the parametrium. Parameters (especially side and rear)	an Inflammatory process in the tissue surrounding the uterus
Urologic diseases	dysfunction of urination, painful ejaculation (urethra and the rectal area radiating to coccyx), impaired erectile function. Prostatitis (more acute)	an Inflammatory process in the prostate gland
Surgical diseases	Previously transferred surgery on the pelvic organs and the rectum (adhesive disease)	Formation in the healing process of dense connective tissue adhesions that may affect coccygeal plexus
Anomalies	Epithelial coccygeal course	Inflammatoryprocess in Kista

Next leading causes of pain in the coccyx area, discussed in more detail.

Injury

The Main mechanism of injury of the coccyx is a strong fall on the buttocks, for example, when slipping on ice, skating, dance steps, women can tears and ruptures in the sacral-coccygeal articulation in the process of childbirth.

This may develop bruises of the tailbone and soft tissues around, subluxations and dislocations of the Sacro-coccygeal articulation, at least Pereloma-dislocations and rarely closed fractures coccyx bone. Pereloma-dislocations and closed fractures (with displacement of fragments or not) most often occur in older people due to changes in bone density with age.

Patients with injuries to the sacrococcygeal region initially complain of constant severe acute pain in the coccyx for about 5-7 days, then pain decreases: pain persists when sitting, decreasing dramatically when standing up from a seated position, pain when walking, abates somewhat.

Perhaps the appearance of pain during defecation, particularly if there is constipation. This is happening due to tension of the pelvic floor muscles, displacement of the coccyx and, as a result of excessive stress involving nerves and ligaments.

within 1-3 months after injury, a period of the normal condition of the patient, and years later reappears kokcigodiniâ. At this stage pain is associated with degenerative processes in the coccyx area with involvement in the pathological process of the nerves coccygeal plexus (coccygeal neuralgia).

In the first picture the arrow shows rupture of the Sacro-coccygeal articulation, the second is the gap between the segments of the coccyx on the third of a fracture of the fifth sacral vertebra. Below is a CT scan of the dislocation (1) and subluxation (2) the Sacro-coccygeal articulation. As can be seen from these figures, the dislocation is characterized by the violation of congruency of the articular surfaces, and when subluxation of the articular surfaces remain in slight contact.

To diagnose the nature of the injury, you must seek medical care to the traumatologist-the orthopedist in the first day or two from the time of injury.

During palpation the doctor there is tenderness to direct pressure on the coccyx, and lateral pressure (near the tailbone), necessarily carried out rectal examination to identify tenderness of the surface of the coccyx facing to the rectum, its mobility and availability of crepitate as a sign of fracture. Rectal examination allows assessment of the degree of tension of the pelvic floor muscles (very common symptom).

After inspection, typically performed with x-rays of the coccyx area, but due to its insufficient information content (the coccyx is surrounded by a large amount of soft tissue that hamper the visualization of fractures and dislocations in this zone), may need CT.

Tactics of the injury of the coccyx vary from patient to patient, the duration of trauma, of comorbidities.

The Main directions of treatment are presented in the table below.

Nature of injury	Statute of limitations	Conservative treatment	surgical treatment
Bruised tailbone and soft tissues around	Any	Analgesics, anti-inflammatory drugs, physiotherapy, when expressed pain syndrome hydrocortisone and novocaine blockade	Not shown
Subluxation and dislocation of coccyx	Fresh	Reposition	Not done
Subluxation and dislocation of coccyx	Old	the Reduction is not performed, analgesics and anti-inflammatory drugs, physiotherapy, hydrocortisone and novocaine blockade	When expressed pain syndrome can be performed resection of coccyx
Pereloma-sprain of coccyx	Fresh	Reposition and splinting, bed rest, anti-inflammatory drugs, vitamin D in combination with CA, rehabilitation (massage or physical therapy)	In the absence of reposition of bone fragments, damage to their internal organs, the absence of accretion of fragments
Pereloma-sprain of coccyx	Old	anti-Inflammatory therapy, analgesia, procaine blockade, the introduction of corticosteroids in the area of articulation	When expressed pain syndrome can be performed resection of coccyx
Closed fracture of coccyx, without offset / with offset	Fresh	Splinting, bed rest,anti-inflammatory drugs, vitamin D in combination with CA, rehabilitation (massage or physical therapy)	Conducted in the absence of the repositioning of bone fragments, damage their internal organs, the absence of accretion of fragments

Osteoarthritis of the sacrococcygeal joint

In the normal structure of the coccyx is that the Sacro-coccygeal joint has a small amount of movement, so with age (after 30 years) it can ossify. Also ossify the gaps between the segments of the coccyx. Thus, the process of ossification is not pathological, but the important point is how it is happening, and get involved in this process sacrococcygeal ligament and the sacrococcygeal plexus.

If there is their injury, develop intense pain (kokcigodiniâ). Most often, the process of ossification-calcification cause just above the injury.

The Treatment of pain in the coccyx (coccygodynia) with a history of trauma, osteoarthrosis of the Sacro-coccygeal articulation are presented in the table below.

therapies	Options	Efficiency
Conservative medical	NSAIDs + muscle relaxants, when expressed psychogenic – antidepressants and tranquilizers	50%
Conservative physiotherapy	Darsonval, mud treatment, ozonation, UHF-therapy, etc.
Novocaine blockade, blockade with corticosteroids	Aminev, procaine, lidocaine, hydrocortisone, kenalog	80%
surgical treatment	Resection of the coccyx (coccygectomy)	90%

Neoplasms

The Most common neoplasms of the sacrum and coccyx is a teratoma, dermoid cyst sacrococcygeal Department, chordoma.

Chordoma is a benign tumor, the localization of which in the base of the coccyx can occur up to 40%, while the tumor itself to is not common (about 1%). Some authors attribute it to malignant.

Among the main clinical manifestations – pain, sometimes very pronounced (the lack of sleep the patient, the inability to lie on his back), which is associated with lesions of the sacral nerve roots. Give pain in the perineum, legs, genitals. With the large size of the tumor may impair the function of the pelvic organs and impaired sensation in the perianal region.

Teratoma and dermoid cyst are congenital abnormalities. The teratoid tumors often found in children, dermoid cysts in adults. It is also a rare disease – approximately 1% of all tumors of the spine. Pain for a long period of time can be a mild, nagging, often the first symptom detected during the inspection, is swelling at the site of tumor growth. The skin may have an extended vascular network.

When it detects a vascular mesh on the sacrum of the child is necessary to consult a doctor! TOOOhese tumors are Initially benign but can be malignant.

Instrumental diagnosis includes:

1. Inspection.
2. Digital examination of the rectum.
3. ultrasound of the pelvic organs.
4. CT.
5. MRI (especially important for teratoma formation and dermoid cysts).

To Treat this pathology is possible only operatively, this entails the removal of the tumor with resection of the coccyx, when possible malignancy chemotherapy.

Neurological diseases with anorectal pain syndrome

degenerative disc disease of the lumbar and sacral spine, sciatica, lumbar hernia MTD Department.

These pathologies can cause pain in the buttocks (usually on one side), the tailbone, the sacrum due to the fact that these areas receive innervation from the lumbosacral spine (L4-L5-S1).

Pain in the coccyx region in the back pain, generally shooting. Additional symptoms may include pain along the sciatic nerve (posterior surface of the leg to foot). The process often one-sided, sometimes there is an alternation, i.e. The pain left goes to right leg.

Upon examination by a neurologist can be marked by the following symptoms (see table below).

kill Zone	Symptomatology
L4	L4 Paresthesia, paresis of the quadriceps femoris, anterior tibial muscles, the reduced knee reflex
L5	Paresthesia, paresis, atrophy of the long extensor of the thumb, short extensor of the foot, absence of posterior tibial reflex
S1	Paresthesia, paresis of the triceps muscle of Shin, the lack of reflex with the Achilles tendon.

Described in the table refers to symptoms of radicular syndromes.

Principles of treatment of osteochondrosis and hernia of the intervertebral disc following:

1. Conservative drug treatment of drugs NSAIDs, especially highly selective, in combination with muscle relaxants, vitamins, drugs that improve blood circulation.
2. Novocaine blockade.
3. Physiotherapy: electrophoresis,magnetotherapy.
4. minimally Invasive surgery: microdiscectomy, and endoscopic laser nucleotomy, decompression of the disks, ablative, etc.
5. the Fusion with the implant and discectomy with the formation of fixed joints between two vertebrae (the method is rooted in the past).

Pathology of the rectum

Anal fissure

Under anal fissure proctologists in practice refers to damage to the lining of the anus under the influence of excessive mechanical forces straining (see figure below). After damage occurs infection the cracks, then the process occurs as the wound. Anal fissures are often combined with hemorrhoids.

The Main complaints made by the patient – pain in the rectum (sometimes felt as pain in the tailbone), especially aggravated by bowel movement or the urge to defecate. When interviewed, the patient may describe periodic appearance in fresh Kale (scarlet red) blood in small amounts like drops and clots. Diagnosis to be confirmed by a doctor-proctologist on the basis of the conducted inspection, digital rectal examination of the rectum, anoscopy or viewed in a mirror.

Treatment includes the conservative management of the patient, his or her diet with a high content of fiber, drinking plenty of water, prevention of constipation, washing the genitalia and the anus after each trip to the toilet. Locally assigned ointment or suppositories with the content of the SCS ("Posterize"), with analgesic and wound-healing effect ("relief advance"). When the chronicity of the process with severe pain and spasm of the sphincter is sometimes used surgical treatment.

Hemorrhoids, the acute stage

Another disease that can lead to the syndrome of pain in the coccyx area, is hemorrhoids.

The flow hemorrhoids can be acute or chronic. A more detailed classification is presented in the table below. Here we are interested in to a greater extent acute hemorrhoids, accompanied by thrombosis of the hemorrhoidal veins, as other forms are not accompanied by pain.

Treatment of acute hemorrhoids involves and conservative tactics, and surgery.

The Methods of surgical intervention depend on the stage of the disease:

1. Infrared photocoagulation, sclerotherapy.
2. Adds a method for the ligation, the combination with sclerotherapy photocoagulation.
3. Transanal resection, hemorrhoidectomy.
4. Hemorrhoidectomy.

Abscess

Paraproctitis (acute and chronic) of the disease is accompanied by purulent inflammation in the tissue surrounding the rectum.

Around the rectum in normal there are several fiber spaces (see figure below): iliac-rectal, pelvic-rectal and behind-rectal. In addition, there is still submucous space, directly under the mucous membrane of the rectum and skin near the anus.

Infection (most commonly Staphylococcus, Streptococcus, E. Coli, less other flora) due to additional etiological factors are able to penetrate into these fiber spaces and run them in the process of inflammation with the formation of abscesses (abscess).

Concomitant etiological factors are:

1. Worsening of hemorrhoids, the lack of adequate treatment.
2. Frequent or prolonged constipation.
3. Long-existing anal fissure.
4. Inflammation of anal glands and crypts.
5. pelvic Injury.
6. Neoplastic process with a decay in the rectum.

Symptoms of acute paraproctitis depending on localizations presented in the table below.

Localization of abscess	General symptoms	Additional methods of instrumental diagnostics	treatment
Subcutaneous paraproctitis	Pain in the anal, pronounced swelling, redness and tenderness there that febrile temperature (above 38-39°C) and symptoms of intoxication	Inspection, digital examination of the rectum, ultrasonography of pelvic roentgenography of small pelvis organs, CT	Operational, opening and drainage of the lesion, antibiotic therapy
Submucous paraproctitis	Pain in the rectum, aggravated during defecation, painful defecation tenesmus, the appearance of pus and blood in the stool, sharp pain during digital examination of the rectum, febrility, symptoms of intoxication		Operational, opening and drainage of the lesion, excision of the anal crypts and glands, antibiotic therapy
Ishiorektalnuyu paraproctitis	Pain in the perineum radiating to the groin, febrility, symptoms of intoxication
Pelvic-rectal paraproctitis	Start blurred, there are only the symptoms of intoxication with hightemperature. Then may cause pain in the abdomen, appearance of blood and pus in the stool or from the vagina in women, febrility, symptoms of intoxication
Behind-rectal paraproctitis	Pain in the rectum, aggravated during defecation, painful defecation tenesmus, pain in the coccyx, febrility, symptoms of intoxication, when viewed from the changes of the skin near the tailbone (redness and swelling), pain with pressure, asymmetry of the buttocks

In chronic abscess of the phenomena of the General intoxication are less pronounced, the temperature rise above 39°C is not typical, in the area of the abscess formed a fistula, the skin around it swollen and has a purple-bluish color, of the fistula can be observed purulent or mucous-purulent content.

In Addition to the inspection and digital rectal examination of the rectum the investigation of the length and tortuosity of the fistulous canal by contrast radiography or CT, it is also possible ultrasound study (using probes). Tactics of treatment is the same – surgery with dissection and drainage of the abscess, in the scope of surgical intervention included excision of the fistulous.

Gynecological diseases with anorectal pain syndrome

Parameters

Inflammation of the tissue surrounding the uterus, may occur in the absence of treatment or inadequate treatment of adnexitis, endometritis, after a difficult birth with hemorrhage in the parametrium. Depending on the localization parameters can be front, rear and sides (see image below, yellow arrow marks the localization of the anterior and posterior parametritis).

Side parameters is more common, mainly due to the fact that infection of the fallopian tubes first enters the tissue located on either side of the uterus.

The Leading clinical symptoms parametritis of:

1. Severe fever (over 38°C) of the wrong type.
2. Pain in the abdomen, constant, not related to the position of the body, while the rear location of pronounced pain in the rectum and the coccyx.
3. Painful defecation and urination, urgency to defecate or urinate (depends on the localization process in front the process involves the bladder, at the back of the rectum).

The Diagnosis is confirmed by examination, finger examination of the rectum and vagina, ultrasound of the pelvic organs, puncture of posterior fornix of the vagina, cystoscopy and rectoscopy, CT (in complex cases).

Treatment of parametritis includes antibacterial, infusion therapy, bed rest, cold on the lower abdomen, when suppuration the opening of abscess and drainage of the pelvic cavity.

Prostatitis

In the development of pain syndrome of primary importance is acute prostatitis. Chronic inflammatory process in the prostate gland occurs mostly without pain.

Acute prostatitis occurs suddenly and is accompanied by pain in the perineum radiating to the groin, anal region, the region of the coccyx and sacrum. Also appears painful and frequent urination, fever and symptoms of General intoxication, violation of potency, pain during ejaculation in the course of the urethra, in the perineum and anorectal area.

Chronic prostatitis often manifest violation of urination (obstruction, involuntary urination during bowel movements), impaired ejaculation, absence of orgasm, at least a anorectal pain.

Diagnosis of prostatitis includes in addition to the inspection and digital rectal examination through the rectum the following methods:

1. OAM, urine culture microflora and sensitivity to AB. Of particular importance may be trehstakannaya test.
2. PAP smears from the urethra and study their STI.
3. blood testing for PCA (tumor markers for prostate cancer).
4. examination of the ejaculate.
5. ultrasound of the prostate.
6. Biopsy of prostate tissue (suspected c-r cancer).
7. CT scan of the pelvis for the differential diagnosis of complex cases.

Therapy of prostatitis can be categorized as follows:

1. Antibacterial treatment, especially for STIs.
2. Physiotherapy (electrophoresis, magnetic therapy, etc.) and massage of the prostate.
3. Immunomodulating therapy.
4. Restoring regular sex life.

the Algorithm for diagnosis for pain in tailbone

In connection with the above abnormalities for all patients with pain in the coccyx area and unaware of their reason, should be diagnosed by the following algorithm.

1. if the patient Recalls any trauma to the coccyx area?
2. If not, first delete pseudococcidae.
   • medical Consultation.
   • pelvic exam in women.
   • Examination of the urologist in men.
   • Consultation of Coloproctology.
3. a consultation with a neurologist and a traumatologist-orthopedist.

x-rays of the coccyx area; when poor visualization, when indicated (suspected tumor) – CT, MRI of the pelvis and tailbone.