The coccyx (tailbone) is a small bone at the base of the spine. It consists of three to five vertebral bodies that may be joined together. Coccygeal area pain (pain at the tailbone or the nearby area) can have many causes. Often, the problem comes from structures near the coccyx rather than the coccyx itself.
It is unknown exactly how many people experience coccygeal area pain, but it is much less common than low back pain.
Causes of Coccygeal Pain
Coccygeal area pain may come from problems in:
The coccyx itself
Nearby structures
The most common coccyx disorders that cause coccydynia are musculoskeletal and may be traumatic or nontraumatic. These include:
Hypermobility
Bone spurs
Dislocations
Fractures and other injuries
Pain from one area of the coccyx can spread to nearby areas. Symptoms in one region can also trigger or worsen problems in another. For example, coccyx pain can cause muscle guarding and spasm in the pelvic floor, leading to pelvic floor myofascial pain. In the opposite direction, tight or painful pelvic floor muscles that attach to the coccyx can cause coccyx pain.
Other nearby conditions that can cause coccygeal area pain include:
Ischial bursitis
Perianal or perirectal abscess
Perineural cysts of the sacrum, such as Tarlov cysts
Piriformis muscle pain (where the piriformis muscle irritates the sciatic nerve and causes pain in the buttock, hip, or upper leg
Pudendal nerve pain (pain in the nerve that supplies sensation to the anus, genitals, and perineum [area between the genitals and anus])
Retrorectal tumors (a growth located behind the rectum in front of the coccyx; most are benign [for example, retrorectal hamartoma])
Sacroiliac joint (joint where the lower spine and pelvis meet) pain
Colorectal cancers rarely cause coccygeal area pain unless they invade nearby bone.
Evaluation of Coccygeal Area Pain
Examination by a doctor
Testing based on the suspected diagnosis (x-rays, MRI, CT, colonoscopy, sigmoidoscopy, or proctoscopy)
Pain in the coccyx (coccygeal) can be challenging to diagnose because it may be caused by conditions affecting different organ systems. As a result, the evaluation may involve different specialists (for example, orthopedists, gastroenterologists, gynecologists) before the cause is identified.
To help identify the cause of coccygeal area pain, doctors ask about the location of the pain, when it started, whether it followed an injury, how long it has been present, and whether it has changed over time. They may ask the person to point to the area where the pain is most severe and describe factors that make it better or worse, particularly with sitting, certain activities, or during a bowel movement. Doctors also ask about other symptoms, such as whether there is an area of warmth, swelling, or drainage (eg, with pus or blood), or if there is blood on the toilet paper or in the toilet bowl with a bowel movement.
Doctors may also ask about a person's sexual history, including about recent receptive anal sex. They will also look for symptoms that could indicate a nerve disorder that could cause numbness, weakness, tingling, and trouble controlling the bladder or bowels.
Physical examination
The doctor will inspect the person's skin for lumps, redness, warmth, fistulas (abnormal openings or tunnels that can develop between the anus or rectum and the skin), or drainage. They will then do a more detailed examination to pinpoint the source of pain and determine whether it is coming from the coccyx or from nearby structures.
If touching the coccyx from the outside does not reproduce the pain, an internal examination may be needed. A digital rectal examination may be done to check for hemorrhoids, bleeding, and tenderness, or other abnormalities. If neither an external nor internal physical examination causes tenderness when pressure is applied to the coccyx, the coccyx itself is unlikely to be the main source of the person’s pain.
The doctor may also perform a neurologic examination of the perineum and lower extremities to check for sensation, strength, and reflexes.
Red flags
The following findings are especially concerning:
Neurologic symptoms
Physical symptoms, such as unexplained weight loss, fatigue, fever, and lymph node swelling
Constant, chronic pain that doesn't have a cause
Drainage with pus
Rectal mass
Rectal bleeding or pain with bowel movements
Testing
Imaging tests are not always needed for coccygeal area pain. However, if symptoms last longer than 2 weeks or follow a significant injury, doctors may take x-rays with the person sitting and standing to look for abnormalities of the coccyx.
If the symptoms persist and the cause remains unclear, magnetic resonance imaging (MRI) of the pelvis may be done. MRI can show both bone and soft tissues and may help identify problems such as inflammation, infection, tumors, or other masses. Computed tomography (CT) may also be used, but MRI provides more detailed images of soft tissues and does not expose the person to ionizing radiation.
If a disorder of the anus is suspected, procedures such as colonoscopy, sigmoidoscopy, or proctoscopy may be done to look for abnormalities such as masses, ulcers, or sources of bleeding.
Blood tests are usually not needed unless infection is suspected. In that case, doctors may order a complete blood count, tests for inflammation, and tests for sexually transmitted infections. Urine tests are also sometimes done.
Treatment of Coccygeal Area Pain
Oral pain relievers and use of cushions
Injections of anesthetics and steroids
Pelvic floor physical therapy for some musculoskeletal causes
Rarely, surgical removal of the coccyx (coccygectomy)
Treatment depends on the cause of the coccyx pain. Pain originating from the coccyx is often treated initially with oral pain relievers and cushions that reduce pressure on the area while sitting. If these measures do not provide adequate relief, injections of local anesthetics and steroids (also sometimes called glucocorticoids or corticosteroids) may be used.
Musculoskeletal disorders that can cause pain in the coccygeal area, such as sacroiliac joint dysfunction, piriformis syndrome, pelvic floor pain, and ischial bursitis, are often treated with pelvic floor physical therapy and, in some cases, injections of local anesthetics and steroids.
If the pain is caused by a disorder of the digestive, reproductive tract, or another organ system, treatment is directed at the underlying condition and may involve a specialist such as a gastroenterologist, a gynecologists, or a colorectal surgeon.
In rare cases, surgical removal of the coccyx (coccygectomy) may be considered.
Prompt diagnosis and treatment are important to help prevent persistent pain and reduce the risk of developing a chronic pain syndrome.
Key Points
Coccygeal area pain can be caused by disorders of many different organ systems.
Evaluation and treatment may require teamwork among specialists in musculoskeletal medicine, pain management, colorectal disorders, and pelvic floor physical therapy.
Coccyx disorders are treated with oral pain medicine and cushions to reduce pressure while sitting.
Other treatments may include injections of local anesthetics and steroids.
In rare cases, doctors will perform surgical amputation of the coccyx (coccygectomy).
A common complication is chronic pain syndrome, which may be avoided with timely evaluation and treatment.
