Delivery related Coccydynia are thought to occur in around 1 to 4 % (Maigne

1
A Womans Tail and her Pelvic Floor Case Study of
the Involvement of Pelvic floor Muscles in
Chronic Coccydynia Shalini Wiseman (MISCP,POGP)
Jean Dennehy (MISCP,POGP)
Introduction Delivery related Coccydynia are
thought to occur in around 1 to 4
(MaigneTamalet, 1996 ), however other studies
have shown it to be as high as 14(Ryder I 2000
cited Wray et al 1991) . This is a case study of
a 34 year old woman who suffered coccyx trauma
during her first vaginal birth 4 years
previously. Treatment at that time consisted of
manual physiotherapy, osteopathy and local
anesthetic block at the pain clinic with minimal
result. MRI scan at that time showed bony
bruising but no fracture or obvious dislocation.
No manual therapy of the Pelvic Floor Muscles
was carried out postnatally. This case study
highlights the effectiveness of Pelvic Floor
Rehabilitation in the treatment of chronic coccyx
pain.
Pelvic floor muscle dysfunction and
Rehabilitation Pelvic floor muscle (PFM)
assessment was done at 12 weeks post partum as
per the Modified oxford grading system (MOGS),
(Laycock .J 1994) and along the Vertical and
Horizontal Clock (Haslem et al 2007) to assess
strength and muscle tone. Physiotherapy for
coccydynia involves manually working on tight,
painful muscular structures such as the
Coccygeus, Puborectalis, Illiococcyx ,
Ischiococcyx ,Obturator internus, Piriformis and
Gluteus medius muscles. Puborectalis was reviewed
vaginally and ano- rectally which resolved her
bowel symptoms completely. Persistent
dyspareunia with pain on sexual arousal was
assessed for pudendal nerve (PN) involvement .
The PN was palpated at the ischial spine and
alcocks canal . Nerve palpation revealed hyper
tonicity of the obturator internus muscles that
may have restricted the space in the alcocks
cannal. Soft tissue mobilization to decrease
obturator interni tightness bilaterally was done
for 10 15 minutes for 4 sessions. Connective
tissue work was also performed along the two
branches of the Pudendal nerve i.e. Posterior
rectal nerve and Perineal nerve. It is possible
that the trigger points resulted from those
muscles contracting in an attempt to stabilize
the traumatised pelvis/coccyx in absence of
strong core muscles. This lead to restricted
availability of space in the alcocks cannal
,impinging or entrapping the Pudendal nerve over
the years leading to pain along the nerve
distribution of the perineum , external anal
sphincter and the general myotome area
(Rosenbaum 2009 cited Filler et al 2009 Ramsden
et al 2003). Coccygeus muscle was released to
gain normal coccyxgeal mobility. The treatment
lasted over an hour each , for a period of 5
months and involved 2 physiotherapist.
Clinical Presentation Patient was referred with
coccyx/pelvic girdle pain post second delivery
via caesarean section with a 4 year history of
coccyx pain. Her symptoms was graded on the
Visual Analogue Scale (VAS) and Patient Specific
Functional Scale (PSFS) .See Table 1. Other
symptoms included pain on opening her bowels and
increased pain on sexual arousal. Patient was
examined spinally as per European Guidelines for
Pelvic Girdle Pain at 6 weeks postpartum. Right
up slip of the iliac crest with a right anterior
pubic symphysis and right side bent sacrum in
extension was corrected using Muscle Energy
Technique and myofascial trigger points was
released. The Patient required 4 sessions of 30
-45 minutes. Advice with regard coccyx pain
management and exercise was given. With manual
therapy treatment, pain reduced considerably in
sit to stand ,however the symptoms graded on PSFS
persisted. Ryder I 2000 cites Peytons (1998)
retrospective study of 180 obstetric related
Coccydynia showed

36 (n 64) Experience low back pain 20 (n 36) Pelvic pressure 11 (n20) Painful bowel movements or rectal spasm 7 (n13) Dyspareunia or painful intercourse

Table 1 Outcome measures Pre treatment Post manual therapy Post manual therapy and Pelvic floor rehabilitation
VAS 4/10 to 7/10 depending on activities 4/10 0/10
PSFS 1.Pain on sitting for longer than ½ hr 8/10 4/10 0/10
2.Intolerant to tight cloths 10/10 10/10 0/10
3. Pain during intercourse 8/10 8/10 0/10
Other symptoms 8/10 8/10 0/10
 
Conclusion Pre existing coccyx injury affects
its ability to flex and extend during birth .
Along with this, spasm of the muscles around the
coccyx can lead to pelvic floor dysfunction and
pudendal nerve symptoms.Pelvic floor assessment
should be a vital part in the treatment of
Chronic Coccydynia with normal coccyxgeal
mobility to rule out any associated anomalies of
mid pelvic floor muscles and pudendal nerve.
References Laycock J(1994)Clinical evaluation of
the pelvic floor .In Schussler B, Laycock J
,eds. Pelvic floor re-education. Vol
14.LondonSpringer Verlag 1994Pages 42
-8 Maigne j et al (1996) Standardized
Radiological protocol for the study of common
Coccydynia and characteristics of lesions
observed in sitting position, Spine 21(22)
Pages2588 -259 Ryder I, Alexander J (2000)
Coccydynia A woman's tail, Midwifery Vol. 16
Issue 2, Pages 155-160 Rosenbaum T.Y. 2009
Physical Therapy treatment of persistent genital
arousal disorder during pregnancy A case report,
Journal of Sexual Medicine 2009,10(1111),Pages j
1743 -6109
Contact Details Shalini Wiseman Senior.
Physiotherapist in Womens Health and Continence
Cork University Maternity Hospital Emailshalini.
wiseman_at_hse.ie