Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

new diagnosis: acute or chronic disease

1st line – lifestyle measures

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ACUTE
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new diagnosis: acute or chronic disease
1st line – 

lifestyle measures

Rest is recommended.

Adjustments in seating with U-shaped cushions can relieve pressure on the coccyx.

Additional measures include sitz baths, pelvic floor physiotherapy, and chiropractic manipulation.[1][28][29]​​ These measures may relax the pelvic floor musculature and decrease pain and tenderness, although the precise mechanism is unknown.

Plus – non-steroidal anti-inflammatory drug (NSAID)

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ACUTE
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new diagnosis: acute or chronic disease
Plus – 

non-steroidal anti-inflammatory drug (NSAID)

Treatment recommended for ALL patients in selected patient group

Most patients are prescribed an NSAID as required for a period of up to 8 weeks to relieve pain and inflammation, except in those with contra-indications to their use.[27]​ NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation), and should be used at the lowest effective dose for the shortest effective treatment course.

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) three times daily when required

OR

naproxen: 500 mg orally initially, followed by 250 mg every 6-8 hours when required, maximum 1250 mg/day

Consider – stool softener

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ACUTE
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new diagnosis: acute or chronic disease
Consider – 

stool softener

Additional treatment recommended for SOME patients in selected patient group

In patients who give a history of pain with defecation, a stool softener is prescribed for a period of 8 weeks in order to decrease the pain and effort required in defecation.[27]

Primary options

docusate sodium: 50-500 mg/day orally given in 2-4 divided doses when required

OR

lactulose: 15-60 mL/day orally given in 1-2 divided doses

symptoms ≥2 months and failed acute management

1st line – corticosteroid plus local anaesthetic injection

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ACUTE
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symptoms ≥2 months and failed acute management
1st line – 

corticosteroid plus local anaesthetic injection

First-line treatment is monthly corticosteroid plus local anaesthetic injections given on an as-required basis.

They may be given alone or in combination with invasive manipulation (i.e., transrectal flexion and extension) under general anaesthesia, the latter being considered more successful.[30]

The corticosteroid plus local anaesthetic should either be injected into the soft tissues around the sides and tip of the coccyx (using methylprednisolone) or the sacrococcygeal (SC) junction and dorsal periosteum of the coccyx (using triamcinolone).[31]

However, percutaneous SC junction injection is sometimes recommended if local injection and/or manipulation fails, and may be accomplished fluoroscopically or with digital rectal localisation of the SC junction.[31][32]

Primary options

methylprednisolone acetate: 40 mg given by injection once monthly into the soft tissues around the sides and tip of the coccyx

and

bupivacaine: (0.25%) 10 mL given by injection once monthly into the soft tissues around the sides and tip of the coccyx

OR

triamcinolone acetonide: 80 mg given by injection once monthly into the sacrococcygeal junction and dorsal periosteum of the coccyx

and

lidocaine: (1%) 2 mL given by injection once monthly into the sacrococcygeal junction and dorsal periosteum of the coccyx

Consider – invasive manipulation and massage

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ACUTE
|
symptoms ≥2 months and failed acute management
Consider – 

invasive manipulation and massage

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid injection may be given in combination with invasive manipulation (i.e., transrectal flexion and extension) under general anaesthesia, which is considered more successful than corticosteroid injection alone.[30]

2nd line – corticosteroid plus local anaesthetic injection + physiotherapy

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ACUTE
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symptoms ≥2 months and failed acute management
2nd line – 

corticosteroid plus local anaesthetic injection + physiotherapy

If corticosteroid plus local anaesthetic injections have no effect after two successive monthly injections, physiotherapy combined with corticosteroid injection is an effective second-line option.

Physiotherapy measures include transrectal pelvic floor massage and coccygeal mobilisation.[30][33][34][35]

Primary options

methylprednisolone acetate: 40 mg given by injection once monthly into the soft tissues around the sides and tip of the coccyx

and

bupivacaine: (0.25%) 10 mL given by injection once monthly into the soft tissues around the sides and tip of the coccyx

OR

triamcinolone acetonide: 80 mg given by injection once monthly into the sacrococcygeal junction and dorsal periosteum of the coccyx

and

lidocaine: (1%) 2 mL given by injection once monthly into the sacrococcygeal junction and dorsal periosteum of the coccyx

3rd line – ganglion impar injection

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ACUTE
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symptoms ≥2 months and failed acute management
3rd line – 

ganglion impar injection

Injection of the ganglion with a local anaesthetic (e.g., lidocaine, bupivacaine) under fluoroscopic guidance has been used to successfully treat coccygodynia. One systematic review concluded that the injections have a >85% success rate for pain control. The average percent improvement score was 60% at 1 month, 55% at 3 months, and 40% at 6 months.[36] Repeat injections may be required. Injections should always be performed with image guidance to avoid complications from intravascular injection.[37]​​

4th line – surgery

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ACUTE
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symptoms ≥2 months and failed acute management
4th line – 

surgery

Patients with chronic coccygodynia, in whom a 3 to 6 month period of conservative management has failed, may be referred to a spine surgeon for coccygectomy.

Surgical series have reported success rates ranging from 60% to 91% after coccygectomy.[27]

Coccygectomy is more successful in cases of traumatic and post-partum coccygodynia than in idiopathic coccygodynia (75% success versus 58% success).[14]

Confining coccygectomy to patients with radiographic instability on dynamic x-rays can result in good or excellent outcomes in 92% of cases.[21]

Residual coccygeal fragments or a prominent sacral edge in a thin patient may lead to poor outcomes and necessitate reoperation for redo coccygectomy, or rongeuring of the edge of the sacrum.

Rectal hernia is a rare complication after coccygectomy.[38][39]

Sacral rhizotomy (sectioning the S4 and S5 nerve roots) might be considered for patients with pain strictly localised to the coccygeal region, following failed coccygectomy; however, sacral rhizotomy does not currently play a major role in treatment.[40]

Plus – prophylactic antibiotic therapy + drainage

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ACUTE
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symptoms ≥2 months and failed acute management
Plus – 

prophylactic antibiotic therapy + drainage

Treatment recommended for ALL patients in selected patient group

Wound infection is the most common complication after surgery, with rates ranging from 2% to 22%.[27]

The use of a drain along with post-operative antibiotics may reduce the incidence of post-operative wound problems including infection.

Antibiotics should be continued for 72 hours after surgery.

Primary options

cefazolin: 1000 mg intravenously every 8 hours

and

metronidazole: 500 mg intravenously every 8 hours

and

gentamicin: 2 mg/kg intravenously every 8 hours

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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