Pelvic Pain in Women

Localized provoked vulvodynia, also called vestibulodynia, is a neurological condition that causes pain or discomfort in a specific area of the vulva (external part of the female genitals) when it’s touched or pressed. This can happen during activities like inserting a tampon, having a gynecological exam, sitting for long periods, or wearing tight clothes. For some people, even light touch, like the feeling of clothing against the area, can be very uncomfortable.

The pain is often described as burning, stinging, or raw, and it might last for hours after the area is touched. Some people also experience sharp, stabbing, or jolting pain, or a feeling of pressure in the area. Sitting down can make the pain worse, and the condition can have a big impact on daily life, making it hard to use tampons, have sex, or feel comfortable during routine activities.

1. Do you experience pain, burning, or discomfort in a specific area of the vulva when it is touched or pressed (e.g., during activities like tampon insertion, intercourse, or pelvic exams)? – Yes / No

2. Is the pain you feel usually triggered by touch or pressure, rather than occurring spontaneously without contact? – Yes / No

3. Does the pain or discomfort linger for some time after the area has been touched or irritated? – Yes / No

4. Have you ruled out infections, skin conditions, or visible injuries as a cause of this pain through medical evaluation? – Yes / No

5. Does the pain interfere with daily activities or cause emotional distress? – Yes / No

Answering “Yes” to most of these questions, could suggest symptoms consistent with localized provoked vulvodynia. It should be followed up by a thorough evaluation and personalized care.

Localized provoked vulvodynia (LPV) is a classic nerve entrapment syndrome that typically develops during puberty. As the pelvic structures and genital organs mature, an entrapment of one of the nerves to the vulvar region can develop. Alternatively, a nerve entrapment can develop after trauma to the area. There does not need to be major trauma such as a pelvic fracture from an auto accident. Even minor, repetitive trauma to the pelvis, such as during certain sports, can cause an entrapment syndrome.

Primary vulvodynia typically starts earlier in life and is caused by nerve entrapment alone, which is severe enough to trigger symptoms. On the other hand, secondary vulvodynia develops when other conditions begin to irritate an already entrapped nerve, causing symptoms to appear later. Understanding these differences can help guide treatment and management strategies.

The first step in diagnosing localized provoked vulvodynia is to have a pelvic examination with your gynecologist. During this exam, the doctor gently touches the vaginal vestibule (the sensitive area around the opening of the vagina) using a cotton-tipped swab to check for pain. Your gynecologist will also look for other potential conditions that might worsen the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your gynecologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

Nerve-related pain in the vulva can be worsened by several factors, including hormonal changes and coexisting conditions like allergies, chronic infections, interstitial cystitis (bladder pain syndrome), irritable bowel syndrome (IBS), endometriosis, and conditions affecting the nervous system (dysautonomia). These issues can irritate the nerves further, leading to increased pain.

• Follicular Phase (Pre-Ovulation): Rising estrogen levels may reduce pain sensitivity and inflammation.
• Luteal Phase (Post-Ovulation): Increased progesterone can heighten pain perception and contribute to vestibular tissue swelling.
• Menstruation: Some women experience flare-ups due to prostaglandin release, which can increase nerve sensitivity and pelvic discomfort.

If your symptoms worsen during specific phases, tracking cycles and adjusting treatment strategies may help. Hormonal therapy (oral medications, patches, suppositories, creams, etc.) can help alleviate symptoms but typically does not address the underlying cause of LPV.

Possible Effects of Pregnancy on LPV:

• Hormonal Influence: Increased estrogen and progesterone levels may reduce pain sensitivity, but in some cases, hormonal fluctuations can exacerbate symptoms.
• Pelvic Pressure: As the uterus expands, pressure on nerves and tissues may contribute to discomfort.
• Changes in Sexual Function: Some women report improved sexual comfort, while others experience heightened pain due to increased blood flow, vascular congestion, and tissue sensitivity.
• Postpartum Considerations: After childbirth, hormonal shifts, vaginal trauma, or breastfeeding-related estrogen decline may trigger vestibular pain recurrence.

If LPV symptoms worsen during pregnancy, focusing on exercise, good posture, ergonomics, and pelvic floor therapy can help alleviate vascular congestion and decrease nerve hypersensitivity.

• Avoid tight or constrictive clothing that can increase pressure on the affected nerve.
• Use adequate lubricants during intercourse to help prevent further trauma to the area.
• Discontinue any irritants, which may include avoiding certain dyes or materials in clothing, changing personal care products, and modifying your diet.
• Adjust your exercise regimen and seating position to avoid putting pressure on the affected nerves.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or vaginal suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can release tension on the affected nerve and alleviate nerve irritation.
• Pudendal nerve blocks: To decrease pain and relieve pressure on the affected nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

• Vestibulectomy with vaginal advancement involves the removal of the vaginal vestibule, including the hymenal ring, followed by vaginal advancement.
• Modified vestibulectomy involves removal of only the superficial painful tissue without vaginal advancement.

Surgery can sometimes provide relief, but it comes with risks, including the possibility of developing a condition called deafferentation syndrome. This syndrome may lead to more widespread vaginal pain, which is why surgery is only considered carefully and on a case-by-case basis.

Generalized vulvodynia (GV) is a different condition from localized provoked vulvodynia. In GV, pain in the vulva (external part of the female genitals) happens spontaneously, without needing to be triggered by touch or pressure, and it can be constant. Activities like sitting for a long time, wearing tight clothes, or having sexual intercourse can make the pain worse, but the discomfort is there even without any added pressure.

The pain may affect only one part of the vulva, multiple spots on both sides of the vulva, or even extend to the entire area between the vagina and anus (the perineum). It’s often described as burning, stinging, or raw, and touching the area can make the pain worse for hours. Some women also describe sharp, stabbing, or jolting sensations, or a feeling of pressure. GV can have a big impact on daily life, making it hard to use tampons, have sex, or even go about routine activities comfortably.

PGAD can be related to the same neurological conditions that cause GV, but with PGAD, pain is not as prominent. Usually there is also hormonal dysregulation coupled with venous congestion, pelvic floor dysfunction, and medication side effects. As with other forms of GV, treatment focuses on addressing the underlying causes.

The first step in diagnosing generalized vulvodynia (GV) is to have a pelvic examination with your gynecologist. During this exam, your gynecologist will also look for potential conditions that might be causing GV and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound or other imaging to identify any nerve-related issues. Combining the findings from your gynecologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your neurological symptoms effectively.

• Do not put ice on the vulva or perineum (the area between the vagina and anus) unless directed to do so by a physician.
• Avoid tight or constrictive clothing that can put excessive pressure on the affected area.
• Avoid any perfumes, dyes, or other irritating chemicals that can come in contact with the affected area. This includes not only soaps and other products that are applied directly to the vulva but also personal care products like tampons, pads, cleaning wipes, and even toilet paper. These products can be used, simply choose those products that have the least potential irritants as possible.
• Use adequate lubricants during intercourse to help avoid trauma to the area. Remember to choose a lubricant that does not contain perfumes, dyes, or other irritating chemicals.
• Discontinue any personal products (such as underarm deodorants, etc.) or foods that may cause irritation elsewhere in the body. This may include diet modification to avoid foods that can trigger flare ups.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or vaginal suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can release tension on the affected nerves and alleviate nerve irritation.
• Pudendal nerve blocks and sympathetic nerve blocks: To decrease pain and alleviate irritated nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

Surgery – because it permanently alters the vaginal anatomy, this is reserved for cases in which nothing else helps and the affected area is clearly defined to allow for proper surgical removal. Surgical options include:

• Vestibulectomy with vaginal advancement involves the removal of the vaginal vestibule, including the hymenal ring, followed by vaginal advancement.
• Modified vestibulectomy involves removal of only the superficial painful tissue without vaginal advancement.

Surgery can provide relief only if there is a well-defined area that is the source of the pain, but it comes with risks, including the possibility of developing a condition called deafferentation syndrome. This syndrome may lead to more widespread vaginal pain, which is why surgery is only considered carefully and on a case-by-case basis.

• Bladder lining problems: Damage to the protective layer of the bladder can lead to irritation from urine. Even previous infections may increase risk
• Nerve dysfunction: Problems affecting the autonomic nerves can cause pain and urgency.
• Autoimmune conditions: Various autoimmune disorders can involve the bladder in addition to other organs of the body.
• Other: Both genetics and allergies can contribute to developing interstitial cystitis.

• Nerve entrapment: The pudendal nerve can become compressed or trapped due to anatomical structures or scar tissue.
• Prolonged sitting: Sitting for extended periods, especially on hard surfaces, can put pressure on the nerve.
• Trauma or injury: Pelvic fractures, childbirth, or surgical procedures can lead to nerve damage.
• Repetitive activities: Activities like cycling, squatting, or horseback riding can irritate the nerve over time.
• Infections or tumors: These can compress or irritate the nerve.

Nerve-related pain can be worsened by several factors, including hormonal changes, diabetes, hypothyroidism, obesity, chronic infections, interstitial cystitis (bladder pain syndrome), irritable bowel syndrome (IBS), endometriosis, post-surgical scarring, and pelvic trauma or injury. These issues can irritate the nerves further, leading to increased pain.

The first step in diagnosing pudendal neuralgia is to have a pelvic examination with your gynecologist. Your gynecologist will look for other potential conditions that might be causing the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your gynecologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Avoid prolonged sitting. Using a cushion with a cutout or sitting on a soft surface can help reduce pressure on the nerve.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can irritate the pudendal nerve. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting pressure on the pudendal nerve.
• Use good posture. Maintaining proper posture can reduce strain on the pelvic area and help alleviate nerve irritation.
• Pelvic floor relaxation exercises. Learning techniques to relax the pelvic floor muscles, such as diaphragmatic breathing or gentle stretches, can ease tension and reduce pain.
• Stress management. Stress can exacerbate pain, so incorporating relaxation techniques can be beneficial.
• Dietary adjustments. If constipation is a concern, eating a fiber-rich diet and staying hydrated can help reduce strain during bowel movements, which may relieve pressure on the pudendal nerve.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can release tension on the affected nerve and alleviate nerve irritation.
• Pudendal nerve blocks: To decrease pain and relieve pressure on the affected nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

Decompression of the pudendal nerve may be necessary to alleviate the pain. Unlike the surgery for vulvodynia, however, this surgery typically does not alter the anatomy of the vagina. It is a much more extensive neurological surgery that is typically done once the area of pudendal nerve entrapment is identified with imaging (such as an MRI or ultrasound) and nerve blocks.

• Bladder lining problems: Damage to the protective layer of the bladder can lead to irritation from urine. Even previous infections may increase risk.
• Nerve dysfunction: Problems affecting the autonomic nerves can cause pain and urgency.
• Autoimmune conditions: Various autoimmune disorders can involve the bladder in addition to other organs of the body.
• Other: Both genetics and allergies can contribute to developing interstitial cystitis.

• Urinalysis: To rule out infections or other abnormalities.
• Cystoscopy: To inspect the inside of the bladder using a tiny camera.
• Urodynamics: To check bladder capacity and how your bladder fills, stores, and empties urine.
• Ultrasound: To inspect the structure of the bladder.
• CT of the abdomen and pelvis: To inspect the pelvic organs.

Your urologist or gynecologist will also look for other potential conditions that might be causing or worsening the pain and treatment them first. If this doesn’t offer enough relief, or if they feel your pain may be related to a neurological condition, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your urologist’s or gynecologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Avoid trigger foods: Common irritants include caffeine, alcohol, spicy foods, acidic fruits (like oranges), tomatoes, and artificial sweeteners.
• Experiment with eliminating irritants: Identify which specific foods, and even personal care products like soaps, underarm deodorants, etc., worsen your symptoms and gradually remove them.
• Stay hydrated: Drinking enough water can help dilute urine and reduce irritation.
• Timed voiding: Try scheduling bathroom breaks rather than going only when you feel the urge. This can help train your bladder.
• Avoid holding urine too long: This can increase discomfort.
• Stress management: Stress can exacerbate pain, so incorporating relaxation techniques can be beneficial.
• Opt for gentle activities: Walking, swimming, or other low-impact exercises can improve overall health without stressing the pelvic region.
• Use adequate lubricants during intercourse: This helps avoid trauma to the area. Remember to choose a lubricant that does not contain perfumes, dyes, or other irritating chemicals.
• Pelvic floor exercises: As recommended by your doctor or physical therapist, these can improve bladder control.
• Warm compresses: Applying heat to the lower abdomen can help ease bladder pain.
• Wear loose clothing: Tight waistbands or restrictive clothes can increase discomfort.

• Medications: Oral and topical (such as creams or suppositories).
• Bladder Instillations: Medicines inserted directly into the bladder can sometimes provide better results.
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can release tension on the affected nerve and alleviate nerve irritation.
• Hypogastric plexus blocks: A type of sympathetic block used to decrease pain from pelvic organs, including the bladder.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain. There are three main types – transvaginal (which does not require an implanted device), sacral nerve stimulation, or spinal cord stimulation. Each method works differently depending on the symptoms being treated.

Typically, treating IC often requires a combination of treatments to improve quality of life. Regular follow-up visits are essential to adjust treatment plans as needed.

• Hydrodistension: Bladder stretching under anesthesia.
• Bladder augmentation (augmentation cystoplasty): To increase the size of the bladder. This is typically done to help patients who develop a small or spastic bladder that cannot hold a normal amount of urine, leading to frequent urination, urgency, or incontinence.
• Cystectomy: Surgery to remove or bypass damaged bladder tissues in extreme cases.

• Proctalgia fugax: This is characterized by sudden, brief spasms of the rectal muscles. The pain can be intense but typically resolves quickly.
• Levator ani syndrome: This involves persistent muscle spasms in the pelvic floor, leading to longer-lasting discomfort.

Rectal pain can arise from various causes, ranging from mild to serious. Some common causes include:

• Hemorrhoids: Swollen veins in the rectum or anus, often due to straining during bowel movements.
• Anal fissures: Small tears in the lining of the anus, typically caused by passing hard stools.
• Infections: Such as sexually transmitted infections or fungal infections.
• Inflammatory bowel diseases: Conditions like Crohn’s disease or ulcerative colitis.
• Trauma: From constipation, anal penetration, or other injuries.
• Abscesses or fistulas: Infected or abnormal channels near the rectum.
• Cancer: Rarely, rectal or anal cancer can cause pain.

• Sudden and Intense: It comes on abruptly and can feel sharp, stabbing, or like a cramp.
• Short-lived: Episodes usually last from a few seconds to a few minutes, though they may rarely persist longer.
• Localized: The pain is concentrated deep in the rectal area, without spreading to other parts of the body.
• Unpredictable: It often occurs without warning and may be triggered by stress, bowel movements, or no clear cause at all.

While the pain can be alarming due to its intensity, it typically resolves on its own without leaving lasting discomfort or damage.

Triggers:

• Bowel Movements: Straining during defecation or constipation can provoke spasms.
• Sexual Activity: Certain types of sexual activity may trigger episodes.
• Menstruation: Hormonal changes during the menstrual cycle can contribute to pelvic muscle spasms.
• Stress or Anxiety: Emotional stress is a known trigger for muscle spasms, including those in the pelvic region.
• Medical Procedures: Treatments like sclerotherapy for hemorrhoids or surgeries involving the pelvic area may lead to episodes.

These triggers vary from person to person, and not everyone with proctalgia fugax will experience pain due to all of these factors.

• Dull ache or pressure: The discomfort is often felt deep in the rectum, pelvis, or vagina and may feel like sitting on a ball.
• Persistent or intermittent: The pain can last for hours or occur sporadically, sometimes worsening throughout the day.
• Triggered by sitting: Sitting for extended periods often exacerbates the pain, while standing or lying down may provide relief.
• Radiating pain: In some cases, the pain may spread to the buttocks, tailbone, or upper thighs.
• Unrelated to bowel movements: Unlike other rectal pain conditions, levator ani syndrome pain is not typically associated with defecation.

This condition can significantly impact quality of life, but it is not life-threatening.

Triggers:

• Prolonged Sitting: Sitting for extended periods, such as during long car rides or desk work, can strain the pelvic floor muscles and trigger spasms.
• Stress: Emotional or physical stress can lead to muscle tension, including in the pelvic floor.
• Sexual Activity: Certain types of sexual activity may provoke muscle spasms in the pelvic region.
• Pelvic Trauma or Surgery: Previous injuries or surgeries in the pelvic area may predispose individuals to muscle spasms.
• Childbirth: Pelvic trauma or muscle strain during childbirth can lead to persistent muscle dysfunction.
• Heavy Lifting: Activities involving repetitive heavy lifting can strain the pelvic floor.

These triggers vary from person to person, and not everyone with levator ani syndrome will experience pain due to all of these factors.

The first step in diagnosing rectal pain is to have a thorough examination with your gastroenterologist or colorectal surgeon. Your doctor will look for other potential conditions that might be causing the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for further evaluation and care.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic or rectal exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your gastroenterologist or colorectal surgeon’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Avoid prolonged sitting. Using a cushion with a cutout or sitting on a soft surface can help reduce pressure on the affected area.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can make symptoms worse. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting too much pressure on the affected nerves.
• Use good posture. Maintaining proper posture can reduce strain on the pelvic area and help alleviate nerve irritation.
• Pelvic floor relaxation exercises. Learning techniques to relax the pelvic floor muscles, such as diaphragmatic breathing or gentle stretches, can ease tension and reduce pain.
• Stress management. Stress can exacerbate pain, so incorporating relaxation techniques can be beneficial.
• Dietary adjustments. If constipation is a concern, eating a fiber-rich diet and staying hydrated can help reduce strain during bowel movements.
• Heat therapy with warm baths or heating pads to relax muscles and alleviate pain can also be helpful at times.

Successful treatment usually consists of one or more of the following:

• Medications:Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can help alleviate muscle tension of the pelvic floor muscles and reduce pressure on the nerves in the rectal area.
• Trigger point injections of the pelvic floor muscles: To reduce muscles spasms and tight muscles. This is sometimes combined with Botox® or similar medications to provide longer lasting relief.
• Pudendal nerve blocks: To decrease pain and relieve pressure on the affected nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

Surgery is typically not used to treat rectal pain unless there is a specific condition causing the pain or there is a clearly defined nerve entrapment identified with imaging (such as an MRI or ultrasound) and nerve blocks.

Symptoms include:

• Pain or tenderness at the base of the spine (the tailbone), especially when sitting.
• Discomfort that worsens with prolonged sitting, especially on hard surfaces, or leaning backward.
• Pain during activities that put pressure on the coccyx, such as cycling.
• Sharp pain during movements like standing up from a seated position.
• Pain during bowel movements due to pressure on the coccyx.
• Pain during sexual activity may occur in some cases.
• In severe cases, pain may spread to nearby areas like the lower back or hips.

The top causes of coccydynia (tailbone pain) include:

• Trauma or injury: Falls or direct impact can bruise, dislocate, or fracture the coccyx (tailbone).
• Repetitive strain: Activities like cycling or rowing that involve prolonged pressure on the tailbone.
• Prolonged sitting: Sitting on hard or narrow surfaces for extended periods.
• Pregnancy and childbirth: Hormonal changes and pressure during delivery can strain or injure the coccyx.
• Poor posture: Slouching or improper alignment while sitting can strain the tailbone.
• Obesity: Excess weight can increase stress on the tailbone.
• Degenerative changes: Age-related wear and tear on the coccyx or surrounding structures.
• Infections or tumors: Rarely, nearby infections or tumors can cause tailbone pain.

Lifestyle changes can play a significant role in managing coccydynia (tailbone pain). Here are some helpful adjustments:

• Avoid prolonged sitting, especially on hard surfaces. Take frequent breaks to stand or walk during long sitting periods.
• Use a cushion with a cutout or sit on a soft surface to help reduce pressure on the affected area.
• Use good posture. Sit with proper alignment, avoiding slouching.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can make symptoms worse. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting too much pressure on the coccyx.
• Strengthen core muscles to support the spine and pelvis and focus on low-impact exercises like walking to avoid strain on the coccyx.
• Eat a high-fiber diet to prevent constipation and reduce strain during bowel movements.
• Maintain a healthy weight to reduce stress on the coccyx.
• Learn techniques to relax the pelvic floor muscles and reduce stress. Diaphragmatic breathing or gentle stretches can help ease tension and reduce pain.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can promote healing of the muscles, tendons, and ligaments around the coccyx.
• Injections along the sacrococcygeal ligaments and other soft tissue around the coccyx: To reduce inflammation and pain of the ligaments and tendons.
• Caudal epidural steroid injections: To reduce inflammation and pain at the coccyx.

Coccygectomy (removal of the coccyx), is considered only when all other treatments fail. This is a major surgery with a prolonged recovery time that is not always successful in controlling the pain.