Fred A. Marx, Monroe Louisiana, USA
Techniques In Coloproctology Vol.4 - No.1 - 1996
UCP News - Official Journal of UCP Club
The Italian Association of Coloproctology Units
Coccydynia/Levator Syndrome is a more common cause of rectal pain than realized and the diagnosis often missed. A therapeutic test for diagnosis and treatment of this condition is presented.
Coccydinia/Levator Syndrome, is a common, frequently missed, cause of rectal pain. The complaint is one of a vague ache high in the rectum, varying from acute to chronic, and may radiate to suprapubic area, perineum, buttocks and legs (1), thus mimicking back, pelvic and urologic disease. It is tempting to suggest that, in the vast majority of instances, it is due to prolonged sitting on a soft seat with pressure applied directly to the coccyx.
The diagnosis requires a high index of suspicion and should be entertained whenever rectal pain is not associated with positive physical findings. Detailed history directed toward seating habits will lead to the suspicion.
A therapeutic test often provides proof of the diagnosis as well as relief from pain especially when coupled with instructions to avoid sitting with pressure on the coccyx. This test consists of the injection of a local anesthetic agent mixed with a depository steroid. If the complaint is present before the injection and absent within a few minutes afterwards, the diagnosis of coccydynia is confirmed.
A mixture is prepared of 4ml 1% lidocaine, 4ml 0.5% bupivacaine and 100 mg prednisone in a 10ml syringe with a 23 ga, 1 in needle.
The patient is placed in the right lateral position and the index finger of the physician's left hand is inserted into the rectum and advanced to the level of the sacrococcygeal junction. Between the internal finger and external thumb the configuration of the coccyx is easily determined and the rectal finger monitors the procedure.
The needle is inserted over the sacrococccygeal junction which is entered if possible and injected with 1-2ml of the suspesion. Then the needle is "walked around" the edge of the entire coccyx, injecting small amounts of the mixture into the pericoccygeal soft tissue as it progresses. The area is massaged from within and without. Injection is also applied to spastic Levators when present.
Within a period of minutes evaluation by the patient is requested. Coccydynia/Levator syndrome is relieved right away. Failure to gain relief demands further investigation.
This test is inexpensive, reliable, minimally painful, without complications and should be performed when a vague rectal pain is not explained by physical findings.
1. Beck DE, Wexner SD. Fundamentals of Anorectal Surgery. 1992; 218-20.
Correspondance: Fred A. Marx M.D.
417 Wood Street
Monroe, Louisiana 71201