Foye: I think that the biggest problem is that the vast majority of physicians unfortunately have a huge blind spot when it comes to understanding coccyx [tailbone] pain. We learned almost nothing about the coccyx in medical school. This leads to four main problems.
Dela Rosa: Your book Tailbone Pain Relief Now! describes the many reasons why people end up with tailbone pain. Are there 1 or 2 causes of tailbone pain that are more common than others?
Foye: Great question! By far the most common cause coccyx pain is when there is an unstable joint between the bones of the coccyx. Many medical textbooks and websites incorrectly state that the coccyx is a single fused bone. But that is rarely true. In the vast majority of humans, there are 3 to 5 individual coccygeal bones, with variability in whether there is fusion between any of those bones. Most people have at least a few coccygeal joints. And most people with coccyx pain have joint hypermobility (excessive movement) as the source of their pain.
The second most common cause of coccyx pain is a "bone spur"; extending from the lowest tip of the coccyx. When this happens at the bottom of the coccyx, there is thickening of the bone that projects backwards, often coming to a sharp focal point. It’s almost like a tiny icicle made of bone. This bone spur pinches the skin between the spur and the chair where the patient sits, and especially when they sit leaning partly backwards.
Dela Rosa: Thank you for clarifying the common causes of tailbone pain. In your book, you detail some of the seat cushions and medications that may help. People ask about injections for pain. As a pain management doctor, would injections be helpful for these causes and if so, could you describe how and what kind?
Foye: Sure it's a great question. Medications by mouth have a couple of big problems with them, which is why a lot of times medication given focally by a small local injection could be superior.
When medications are given by mouth, number one they go through multiple places throughout the body. If you're taking medication by mouth, they can cause side effects in the stomach, the intestines, the liver, and the kidneys, so the side effects can be quite limiting.
The second problem with medications by mouth is that because the medicine travels throughout the entire body, it gets diluted out. So only a minuscule amount of the medication actually makes it to the tailbone where the patient needs it the most. Many of these patients do respond to medication given locally at the site. Typically, that's done under fluoroscopic guidance. Fluoroscopy is like x-ray up on a computer screen, and using fluoroscopy we can target a specific location at the tailbone. I'm generally opposed to blind injections, which is where injections are done without any image guidance because 1) you can't guarantee where the medication is going to go and whether it's actually given at a place where it's going to be helpful, and 2) you also can get into problems if it's given in the wrong place - it can cause side effects.
So back to your question, which was about the diagnoses like hypermobility or a bone spur... Absolutely those can respond very, very well to placing medication locally at the spot under image guidance. Often that's a combination of steroid which helps to fight inflammation, and also local anesthetic which can be given as a nerve block and can be very helpful when there's hyperactivity or hyperirritability of the nerves.
Dela Rosa: How is the x-ray your center performs different than how many other facilities perform the test?
Foye: Here at the Coccyx Pain Center, the biggest difference is that we take coccyx x-rays while the patient is sitting down, since that is when tailbone pain hurts the most. I have trained the radiology technicians here regarding how to properly perform this technique, which was first developed in France. Very few places in the United States have ever heard of this approach and even fewer are experienced at doing these x-rays properly. We have evaluated and treated thousands of patients with tailbone pain, many of whom fly in from around the country and internationally. And it is extremely common that patients had previous imaging studies that were read as being normal. But then they come here and our seated x-rays show that when the person sits down and leans backwards (putting their body weight onto the coccyx) they often have very dramatic dislocations or other abnormalities that would be completely undetected if the x-rays had not been done while the patient was sitting. It is a huge relief for patients to finally have an answer as to what is causing their pain. Then, when we have identified a specific cause for their pain, we can provide treatments for that specific cause, which is much more likely to be helpful than generic treatments done blindly without a diagnosis.
Foye: A lot of this goes back to and starts with the general lack of awareness that physicians, radiologists and radiology technicians have about tailbone pain. Frequently, they lump it all in with low back pain. Lumbosacral pain is thousands of times more common than tailbone pain. A lot of the automatic checkoff boxes that people have on their radiology x-ray or MRI forms will have a box to check off for lumbar spine or lumbosacral spine, but they will not have a box to check off for the coccyx or tailbone just because it is thousands of times less common. So what happens is that the primary care doctor, or the orthopedic surgeon, or the pain management doctor, will check off the box and order lumbar or lumbosacral x-rays or MRI, and then that doesn't even include the tailbone at all.
The next problem then is that the study gets done and the patient is told that there's nothing wrong, and that there's no explanation for their pain when really the images did not even include the symptomatic area, or worse yet, it shows an incidental finding of the lumbar spine that may not be causing any symptoms at all. But now they start down the treatment path of epidural injections, and even spine surgery and other things for a part of the body that wasn't even causing the problem. So basically back to your question about what the patient can do: 1) look at the orders, look at the x-ray or MRI orders, make sure that the ordering physician has specifically explicitly requested imaging of the coccyx, and 2) when you go into the radiology center, make a point of talking to the radiology technician and being crystal clear with them that this is not your lumbar spine, that this is not up in the small of your back at the belt line, that the pain is specifically down at the coccyx, and make sure that the radiology technician is going to include that part of the anatomy within the study. It really does require a certain amount of self-advocacy by the patient unfortunately to fight this uphill battle against the ignorance that's out there.
Dela Rosa: I'm just curious, have people come to you from outside of the US? Or are you mostly seeing people domestically?
Foye: Most of my patients travel in from out-of-state and about a third of my patients fly in. It's maybe 5% or less that are international. Within the last six to 12 months, I've had patients from Japan, Sweden, Africa, the UK, New Zealand, and I think two from Australia. Which really just gets back to that there's this unmet need out there and patients who are not able to find local clinicians who will either take them seriously or that know the appropriate testing and treatments to provide.
Dela Rosa: How do you work with pelvic floor physical therapists in the treatment of tailbone pain?
Foye: As a physician specializing in Physical Medicine and Rehabilitation (PM&R), I'm a strong advocate for the role of physical therapists in treating patients who are suffering from painful musculoskeletal conditions. Historically, a big problem was that very few physical therapists were comfortable or experienced in treating pelvic floor problems. Fortunately, that has been improving in recent years.
The pelvic floor is often described as being like a muscular sling, or hammock, which supports and holds up the pelvic organs. The back end of that sling has attachments to the coccyx. Pelvic floor physical therapists and I often collaborate on figuring out the "chicken and the egg" phenomenon. By that I mean that we assess whether a patient is having tailbone pain due to pulling and tugging onto the tailbone caused by tightness and spasms of the muscles that attach to the coccyx. Or, sometimes it could be just the reverse: a painful condition at the coccyx itself might be causing reactive muscle spasm and guarding of the pelvic floor. If evaluation and treatment at one location is not providing adequate relief, then it often makes sense to collaborate and to consult each other, to help the patients find the answers and relief that they deserve.
Question from Don:
“I am 32 years old and have no difficulty with sex. I do find that it is hard for me to pee after ejaculation. Is this normal? And should I be forcing out pee after sex?”
Answer from Becca:
“What you are describing is very normal. The muscles of your pelvic floor that allow you to maintain an erection and expel semen during ejaculation are in a shortened position during sex. These same muscles must be completely relaxed and elongated to allow urine to exit the urethra. Asking your body to pee immediately after having sex is like decelerating a car from 90 mph to a full stop. The pelvic floor muscles are too revved up after climax to stretch and relax. Instead of ‘forcing out pee after sex’, try sitting on the toilet and taking some deep breaths. This will allow whatever is within the bladder to naturally come out of your penis. And if you do not have the urge to pee after sex, you needn’t try this at all.”
Question from Gary:
“I am 53 years old and in pretty good shape. I have diabetes and my erections are not as strong as they used to be. My doctor has tried to give me Cialis; it works only some of the time, and it is very expensive. Are there any tips that you could offer as a pelvic floor physical therapist to improve my erections?”
Answer from Becca:
“Erectile dysfunction and diabetes are often linked. This is because having high blood sugar in the body alters circulation of blood and leads to nerve damage over time. The good news is that this type of erectile dysfunction can be reversed with good lifestyle choices. Maintaining a good diet for stable blood sugar, regular exercise and stress reduction can all help to improve your sexual response. From a physical therapy perspective, we can teach you how to isolate and contract your pelvic floor muscles during sex (also known as Kegel exercises), and improve your core strength. This will allow for increased rigidity of erections. You are one of so many men with exactly the same problem; there is help in pelvic floor physical therapy for a better sex life.”
Question from Pedro:
“I am 28 and began having groin pain over one year ago. I have penile pain along my shaft and up towards the tip, both during and after sex. It helps when I masturbate versus have sex with someone else, because I can avoid the tip of my penis and ejaculate with much less pain. I am not having sex with anyone at the moment, but I am worried because I used to get morning erections and now I don’t. Is this normal? I can’t exactly ask my friends.”
Answer from Becca:
“This is a multi-pronged question, so I want to be careful that I address each part of it. First, a great place for you to start if you have penile pain would be to go to a physician. There may be an infection under your foreskin (known as Balanitis), certain cancers or scar tissue development within the penis (also named Peyronie’s disease. You may have seen commercials on television about this diagnosis). Once your physician has ruled out any medical cause for the pain in your penis, a pelvic floor physical therapist can assess the musculature of your pelvis to determine if there are any imbalances or muscle tension that may be driving your pain.
“Second, having pain in the penis is one of the symptoms of Chronic Male Pelvic Pain Syndrome. That is not to say you have this diagnosis, Pedro. But this description of your problem is more common than you know. In pelvic floor physical therapy, we treat many men with penile, testicular, perineal and rectal pain. The causation of this pain is often tight musculature in the saddle area. Relaxation of these muscles can do wonders, but it is often difficult for guys to learn how to relax this region of the body without some guidance.
“Thirdly, many men with such symptoms tend to prefer masturbation to sex with a partner, especially when they are having a flare-up of pain. This is because, just as you mentioned, only you know what hurts and how to avoid pain during sex. Your partner will have a more challenging time working around your specific pain. That said, once your symptoms are decreasing in severity, the reintroduction of sex with a partner can be a creative and exciting learning curve. Physical therapists can help with this area of problem-solving with both partners.
“Lastly, morning erections are the body’s natural response from overflow of the parasympathetic nerves in your spine. In other words, the nerves are sending calming signals to the pelvis during sleep. This explains why having erections in the middle of the night or first thing in the morning is not a result of having erotic dreams or a person feeling aroused, per se; rather, the body is in a calm state and the testicles and penis become engorged with blood during sleep. Your lack of morning erections is consistent with your penile pain. This is because your pelvis is not relaxing appropriately during the sleep cycle to facilitate those erections. Many men with pelvic pain find that their morning erections return once their symptoms of pain are better managed. This is a good sign that the muscles of the pelvis are relaxing and allowing the return of painfree arousal and improved sex.”
A lot of people ask us about the practice of physiatry. Some people know how it's pain management, but they don't really know how it's different than seeing their gynecologist or their urologist in the way they would treat their pelvic pain. So, can you give me a general overview to describe physiatry and how it treats pelvic pain differently than their gynecologist or their urologist.
Dr. Shrikande: Sure, thank you so much for having me, Michelle, this is great. For a physiatrist treating pelvic pain, we help the other doctors treat the muscles, the nerves, and the joints of the pelvis in a non-operative approach.
Michelle: How would that be different--can you give me examples of treatments that people may not see with their doctor that they're already seeing?
Dr. Shrikande: Essentially, we want to look at it from more of a sports medicine approach, seeing if the pelvic pain is coming from the pelvic floor musculature. Are the muscles in spasm and potentially irritating the nerves of the pelvis, causing some pain? So that's where we would come in when we're evaluating patients. Is there a pelvic floor muscle spasm, which we call pelvic floor hypertonia and can cause pain in patients. And we're really trying to evaluate why this is happening and is there anything from the sports medicine standpoint where we can identify a cause and help to find a proper diagnosis and treatment.
Michelle: I was lucky enough to be able to shadow you for an afternoon and I noticed that while you were treating patients, you were interested in not just recognizing that there was spasm, but like you said, what else could be contributing to it. So what other things do you look for that could be contributing to pelvic spasm?
Dr. Shrikande: From the musculoskeletal or the sports medicine standpoint, you want to see if there's anything going on in the lumbar spine that can cause pelvic floor dysfunction. Or is there anything going on in the sacroiliac joint? Or you want to consider the hips--are the hips working, functioning well? And is there any underlying pathology in the hips as well as what we call the pubic symphysis, which is the joint in the anterior aspect of the pelvis. In addition, is there anything going on from the other specialties as well that could be causing this secondary guarding of the pelvic floor muscles? So is there a gynecological reason if it's a female, or urological reason if you're male or female, or maybe from the GI system, etc? But you really want to say, 'Is there anything else going on here that's causing these muscles to go into this guarding state where it's really not letting go very well?'
Michelle: This is interesting because so many of my patients say they've gotten a diagnosis of pelvic spasm, but they didn't really get checked out. As a physiatrist, you are doing a pelvic exam?
Dr. Shrikande: When you see us, we would do a full exam--again looking at your back, your hips, etc--but we do end the exam evaluating your pelvic floor both externally and internally. So we do an internal exam. I always tell our patients that we're not gynecologists, so we're really looking at the muscles and distribution of the nerves internally. But we would do an internal exam and it does not require a speculum. It would be similar to an internal exam of a pelvic floor physical therapist--we really look at the tone of the muscles, the strength, and the lift of the pelvic floor, and follow the nerve distribution internally to see if there's any increased sensitivity or pain internally.
Michelle: Wonderful, we have such a growing population of men coming to see us for pelvic pain as well. And they're always curious how your exam would be different or how you would be able to help them because they're hearing that a lot of these treatments are for women. Would they be able to access you and what would you be able to offer them?
Dr. Shrikande: We see a lot of men here at Pelvic Rehabilitation Medicine, about equal amounts of men and women. From the muscle, nerve and joint standpoint, the anatomy is actually the same. For us, evaluating men and women, it is a similar approach. For the men, we do look at your lumbar spine, hips, and abdomen, any concern for underlying hernias that could have been missed. But then we do an internal pelvic floor exam as well--it would be internal rectally, also evaluating the muscle's tone and lift and any nerve tenderness internally. With men it would be a similar approach trying to see if there is any possible underlying cause for pelvic floor guarding. And then it's a full body treatment approach where we really can--we call it down-regulate--or calm down the nerves, of both the central and peripheral nervous system and increase blood flow to your muscles, and get the muscles longer and stronger to rehabilitate the pelvic floor.
Michelle: Many of our patients have been seeing multiple providers. And I noticed that in your practice, you seem to be a gateway to many of the other providers, sort of--coordinating care. Is that part of your model of care and how would you say your practice runs differently than other practices that treat pelvic pain?
Dr. Shrikande: Definitely. We see ourselves as the quarterback here, because as rehabilitation doctors, we really are trained from the beginning to look at the whole body and the interplay between multiple organ systems. So quite often, we are talking to a patient, and in our minds, thinking if there's any other specialist that we would need to bring into the picture to help us get this patient better. We work closely with specialists who are excellent in treating the pelvic pain from their angle. But we do see ourselves as the quarterback kind of sending as needed, as well as working closely with pelvic floor physical therapy, to figure out how to get our patients better and what other specialty is needed to calm down their muscles and their nerves.
Michelle: Some of our patients have been getting injections for their pelvic floor and they've been given an option for steroid. I know that you have other options, and also, can you touch upon the imaging that you use to guide you through the injections--if injections are necessary.
Dr. Shrikande: The way we do our injections, or treatments as we like to say…everything is external, nothing is internal. So it's all external, along the sling of the pelvic floor, and they're ultrasound guided. Patients call them their butt injections, that's kind of what it feels like--it's not internal, it's external. The idea behind the guidance is like internal eyes so you can see where you're going. And in addition, it allows us to do a hydrodissection technique, where we can really open up the fascial planes and create space where there is restriction, particularly where the nerves want to flow. What we're using to supplement for a steroid, is something called Traumeel, which is a homeopathic medicine, so it's derived from plants. The main ingredient is arnica--a lot of people have heard of arnica cream like topical arnica--but this is an injectable form of arnica and in combination with echinacea. So it's a nice way to promote healing in addition to decreasing inflammation, which is why we love it. I really used it more in my plastic surgery rotation. Post-operatively we would give it out after a surgery so that patients wouldn't become as bruised and swollen. It would decrease inflammation and promote a faster healing topically. So that's where the idea kind of came from.
Michelle: I know that one of the positions that you hold is that you're the Chair of the Medical Education Committee for the International Pelvic Pain Society. How do you feel that the position helps to shape what you do in your practice and helps shape how pelvic medicine is moving for the future?
Dr. Shrikande: We're actually lucky enough to be surrounded by amazing, intelligent, pelvic health practitioners who constantly push me to really think about things and learn more. The mission of what we do is educate the future of pelvic health from the medical practitioner standpoint--from both the residency program and urology, as well as gynecology and physiatry and any pelvic floor physical therapist who's had training there--just to try and increase awareness for the people who are training, that the pelvic floor itself is its own distinct entity. And although it does not show up in imaging, we really should not ignore it, particularly when the workup is normal and the patient symptoms persist. So we're really trying to raise awareness and at an earlier stage in physician's medical careers, in hopes of getting all our patients recognition earlier and treatment earlier. Because we really believe that is the key--early recognition and early treatment, to squashing it early and getting patients better.
Michelle: What's the range of people that you see in terms of how long patients have had pelvic pain for prior to seeing you? Is there a range?
Dr. Shrikande: It's getting better by the day. But still at this point, the average is six months to 25/30 years worth of symptoms. Even six months is rarest. It's really along the lines of 1.5 years to 25 years.
Michelle: Hmm, yeah. So, both of us are working on that.
Dr. Shrikande: We have to work together.