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Coccygodynia and Proctalgia Fugax Problem

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Coccygodynia and Proctalgia Fugax Problem Clinical notes eliminated pilonidal disease as an inpatient hospital Coccygodynia and proctalgia fugax problem. However, if hospitalization is desired, the length of stay will be shorter and the patient will be LESTER I. TAVEL, D.O., DR.P.H., FAOCPR, HAP able to return to work earlier. This procedure has Houston, Texas been used on poorly healing or delayed healing wounds after complete surgical excision in the Coccygodynia is a syndrome associated with pain in operating room, with good results. the coccygeal region. The pain may occur at the I believe that this is a simple, logical approach to coccyx and its articulation with the sacrum, or, occa- correspond with most writers on this subject.8 sionally, as reflex pain in the sacroiliac articulation, down the back of the thigh, or in the levator ani or supragluteal muscles. 1. Aird, I.: Pilonidal sinus of the axilla. Brit Med J 1:902-3, 26 Apr 52 Coccygodynia is encountered most often in per- 2. Hardaway, R.M.: Pilonidal sinus of the umbilicus. US Air Force Med J sons 20 to 40 years old. Because of pelvic structure, 10:88-9, Jan 59 3. Patcy, D.H., and Scarff, R.W.: Pilonidal sinus in a barbers hand with childbearing, constipation, and the disturbances observations on postanal pilonidal sinus. Lancet 2:13-4, 3 Jul 48 often associated with the menopause, women are its 4. Patey, D.H., and Scarff, R.W.: Pathology of postanal pilonidal sinus: Its most frequent victims. Thin persons are more likely bearing on treatment. Lancet 2:484-6, 5 Oct 46 to suffer it because they lack a protective cushion of 5. Hardaway, R.M.: Pilonidal cyst—neither pilonidal nor cyst. AMA Arch Surg 76:143-7, Jan 58 fat. 6. Brearley. R.: Pilonidal sinus: A new theory of origin. Brit J Surg 43:62-8, 1955 Etiology 7. Abramson, D.J.: A simple marsupialization technic for treatment of pilonidal sinus: Long-term follow up. Ann Surg 151:261-7, Feb 60 The cause of coccygodynia may be any of several 8. Rickles, J.A.: Ambulatory surgical management of pilonidal sinus. Am factors. Pathologic processes of the anus and. Surg 40:237-40, Apr 74 perianal area often produce spasm of the coccygeus, piriformis, or levator ani muscles, thereby causing Submitted for publication in May 1975. Updating, as necessary, pain in the coccygeal region. In fact, Thiele 2 found has been done by the author. anal infection to be the most common cause in 324 This paper was presented at the 27th annual convention of the patients. Retrorectal abscess, infected pilonidal cyst, Western States Osteopathic Society of Proctology, held in Scotts- dale, Arizona, April 20-23, 1975. posterior anal fissure, anal ulcer, thrombotic or ul- cerated hemorrhoids, papillitis, cryptitis,. or fistula Dr. Wadle, who is in private practice in Union, New Jersey, serves may be etiologic in coccygodynia. as chairman of the Department of Proctology, Memorial General Duncan, 3 in a study of 262 patients who com- Hospital, Union, New Jersey. He is president-elect of the Ameri- can Osteopathic College of Proctology. plained of pain in the region of the coccyx, found a Dr. Wadle, 1020 Galloping Hill Road, Union, New Jersey 07083. history of a fall, usually in the sitting position, in 89 percent of the cases. Although fracture and disloca- tion could be the cause, numerous minor injuries to the coccyx are more likely. For example, the person who drives a truck with poor springs over rough roads and streets suffers repeated minor trauma. In women the wide pelvic outlet does not protect the coccyx; when she rides in automobiles over the same type of streets, trauma to the exposed coccyx is re- ceived. Infective processes such as arthritis, osteomyelitis, and tuberculosis can, but rarely do, cause such pain. 1068/96 Clinical notes Referred pain from a spinal cord tumor, multiple cygodynia such as that caused by anal or rectal dis- sclerosis, tabes dorsalis, or other organic or radicular orders can best be diagnosed by inspection, palpa- lesions may be noted; however, these are not the tion, and instrumentation of the anorectum. The common etiologic factors. presence of urinary tract symptoms, of course, de- There is a small group in whom the etiologic fac- mands urologic study or consultation. tor is primarily psychogenic. These include cases of Differential diagnosis is often difficult and some- hysteria, neurasthenia, and psychosis. times a neurologic consultation is advisable. Her- niated intervertebral discs should be considered, Pathology particularly in those patients with pain radiating The pathologic features of coccygodynia involve in- down the thigh. These cases should have orthopedic flammatory reaction of the nerves of the coccygeal or neurosurgical consultation. One should be care- plexus; of the levator ani, coccygeus, piriformis, ful in making the diagnosis of psychogenic coc- gluteus maximus, and sphincter muscles; and of the cygodynia until all possible organic sources have sacrosciatic ligaments. There is also a proliferation been eliminated. of fibrous connective tissue around the coccyx. Management Diagnosis Treatment, of course, varies with the etiology. Gen- There are two kinds of symptoms. The first, a erally, while the diagnosis is being made, an chronic ache around the coccyx, is precipitated or analgesic such as acetylsalicylic acid 31/2 grains, aggravated by sitting or riding. The second type is acetophenetidin 2 1/2 grains, and caffeine citrate 1/2 spasmodic pain, which often starts during sleep, be- grain alone or in combination with codeine may be comes excruciating, and then gradually subsides. given for relief of pain. Hot sitz baths, diathermy, or This second type is often called "proctalgia fugax," a infrared lamp often help in mild cases. term coined by Thaysen 4 meaning a fleeting rectal Constipation must be corrected when pressure pain. Whether this is a true coccygodynia is still from a fecal mass is the cause of pain. Removal of controversial. fecal impactions will often give relief. In some The diagnosis of coccygodynia should be consid- women a perineorraphy may be necessary to al- ered when coccygeal pain has followed trauma to leviate a rectocele and eliminate constipation. Too the coccyx. Inspection and palpation may reveal a often the patient who is constipated fails to drink posterior projection of the coccyx as well as spasm of sufficient water and should be advised to drink at the muscles of the coccyx. A bimanual digital exami- least two glasses of water during each meal. Eating nation should be conducted by placing one hand sufficient bulk foods should also be encouraged. over the coccyx with the examining finger of the The correction of anorectal disease will often re- other hand in the rectum. In true coccygodynia, sult in complete cessation of symptoms. pressing posteriorly with that finger will cause pain In the treatment of proctalgia fugax, the patient is when the coccyx is moved in either direction or given a soluble tablet of 1/100 or 1/200 grain of when pressure is applied to the musculature on nitroglycerin to place under the tongue and repeat if either side of the coccyx. Limitation of motion .in necessary. 5 An enema of baking soda using 1 dram inward rotation of the thigh when fully extended to 8 ounces of warm water will often relieve the pain. indicates spasm of the piriformis muscle. Other antispasmodics are often employed to al- Roentgen examination is employed to determine leviate pain. whether there is any pathologic alteration of bone. Conservative treatment for coccygodynia is the Roentgen evidence is often not demonstrable, how- wisest and offers a greater likelihood of relief than ever, because the injury is more to the ligaments or radical treatment. Osteopathic manipulative muscles attached to the coccyx. Referred coc- therapy is the treatment of choice in the majority of 1069/98 instances; it is the most simple of all treatments. The incision is extended below and behind the Massage is performed through the rectum with the coccyx to the sacrococcygeal articulation. The ar- index finger on the coccyx and the thumb on the ticulation is then divided with a scalpel, freeing the outside. The coccyx is then moved backward and coccyx. The open wound is closed in layers with the forward; often one will feel the coccyx slip back into use of plain no. 00 or suture the surgeon desires. The place during this manipulation. Then the muscula- skin is closed with interrupted silk sutures. ture is massaged from the midline laterally first on Postoperative care consists of 2 to 5 days bed rest. one side and then on the other, advancing from the Mineral oil is given night and morning. On the third tip of the coccyx to massage the levator ani, coc- postoperative day an 8-ounce enema of warm min- cygeus, and piriformis muscles. The entire proce- eral or olive oil is ordered. Sutures are removed on dure should not take more than 2 or 3 minutes. The the fifth to seventh postoperative day. treatment should be given once or twice weekly for 3 to 4 weeks and will bring relief in about 75 percent of Summary the cases. True coccygodynia is more commonly found in If results are not satisfactory, I then send my pa- women and thin persons. The pain may result from tients to the radiologist for x-ray treatments consist- anal infection, but the most common etiologic factor ing of 125r over the coccyx once weekly for 4 to 6 appears to be repeated trauma to the coccyx. Con- weeks. The next step, if relief is not obtained, is the servative treatment consisting of osteopathic man- injection of an anesthetic agent around the coccyx.
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