Case Report
Coccydynia Related to the Use of a Contraceptive Vaginal Ring
Coccigodinia relacionada con uso de anillo vaginal anticonceptivo
Patricia Tejón
, Miguel Angel Belmonte, Juan José Lerma, Antonio Lozano
Corresponding author
Sección de Reumatología, Hospital Universitario General de Castellón, Castellón de la Plana, Castellón, Spain
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This complaint is formed mainly by women of 20 to 50 years. In clinical terms, it is characterized by a sharp pain when a person who is sitting stands up. Physical examination usually comes across a point of selective pain in response to pressure on the tailbone. The most common cause is trauma.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 34-year-old woman who was referred to rheumatology for the study of coccydynia that had begun 3 months before. She mentioned pain upon sitting down and with certain postures. She reported no previous trauma; she works in an office. In the examination, there was discreet discomfort in response to pressure on the tailbone. We recommended that she avoid sitting on hard seats and the use of an inflatable rubber ring for at least 2 months. As the symptoms persisted, she was referred to the rehabilitation unit, where she underwent up to 6 local injections with poor results.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient became a user of the Nuvaring<span class="elsevierStyleSup">®</span>, a flexible contraceptive vaginal ring (ethynyl estradiol 0.12<span class="elsevierStyleHsp" style=""></span>mg, etonogestrel 0.015<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h), 2 months before the onset of her pain. She mentioned feeling better when the ring was removed during menstruation and that the pain returned when it was put in again. Thus, her gynecologist ultimately decided against that contraceptive system. Once the device was removed, the patient noted a rapid relief in the coccydynia. Six months later, she came to the rheumatology department and reported no recurrence of the pain in her tailbone.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">We should know our bone, nerve and muscle anatomy, as each element can be the source of coccygeal pain. Certain anatomic factors of the coccyx and the formation of bone spicules have been related to a greater predisposition to pain. A very frequent cause of coccydynia is an unstable coccyx due to hypermobility, and it can even become dislocated. Muscle spasms or contractures of the pelvic floor muscles can provoke myofascial pain. In these cases, it is possible to identify points or bands as tense zones that correspond to the contracted fibers. Pudendal nerve neuropathy is presented as a perineal and/or pelvic neuropathy pain, which can accompany urinary, anal and even sexual dysfunction.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> One little known aspect is the fact that the sacral sympathetic chain ganglia converge at the sacral level into a single ganglion, the so-called ganglion impar or (ganglion of Walther), which is located in front of the sacrococcygeal symphysis, between the sacrum and the posterior wall of the rectum, and contributes to the innervation of pelvic and genital organs, as well as those of the perianal region. The irritation of this ganglion may also be the cause of the sacrococcygeal dysfunctional pain. The differential diagnosis should include infections and tumors of the perianal region or pelvic inflammatory disease.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> Cases related to calcifications,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> glomus tumor<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> or hemangiomas have been reported.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Thus, coccydynia can have many causes and, therefore, what is needed is an etiological study to deal with the most appropriate therapy. In our patient, the ancillary tests requested were a radiography and abdominal ultrasound, with normal results. The pain had a clear relationship to the presence of the contraceptive vaginal ring, appearing when the latter was used and remitting on a couple of occasions when the device was removed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A causal hypothesis is that the pain affects the coccyx. It has been reported in pelvic diseases, transmitted via the hypogastric plexus. The inferior third of the vagina is the only region with somatic innervation. The remainder of the vagina is insensitive to touch, and receives innervation from the uterovaginal plexus, which originates in the inferior hypogastric plexus, and is the region where the contraceptive ring should be placed.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Another possibility could be the indirect irritation of the ganglion impar; this ganglion is classically identified as the cause of the sympathetic afferent of the pelvic organs, including the region that is distal from the vagina; however, some authors associate it with nociceptive pathways, although this concept has not remained clear. The compression of this ganglion has been reported in patients with anterior dislocation of the coccyx. It could be irritated by the vaginal ring, if we take into account the proximity of the vaginal fornix to the rectum and the fact that this ganglion has a variable size and location.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> In clinical practice, digital rectal examination is not usual, but it is clearly a maneuver indicated for a more complete study. This is the first report of a case of coccydynia related to a contraceptive vaginal ring.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical Disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres798113" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec796090" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres798112" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec796091" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-09-16" "fechaAceptado" => "2015-11-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec796090" "palabras" => array:2 [ 0 => "Coccydynia" 1 => "Contraceptive vaginal ring" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec796091" "palabras" => array:2 [ 0 => "Coccigodinia" 1 => "Anillo vaginal anticonceptivo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Coccydynia is a syndrome that rheumatologists encounter frequently in the form of tailbone pain, which is usually worse when sitting. Although the most common origin is trauma, there are several other possible causes of pain in the coccyx. We present an unusual case in which coccydynia developed shortly after the insertion of a contraceptive vaginal ring and remitted completely upon removal of this system.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La coccigodinia es un síndrome que se presenta con frecuencia en las consultas de Reumatología en forma de dolor en punta terminal del coxis, empeorando habitualmente al sentarse. Aunque la causa más frecuente es la postraumática local, existen diversas causas de dolor en el coxis. Presentamos un caso inhabitual en el que la coccigodinia comenzó poco después de instaurar un sistema de anticoncepción por anillo vaginal y remitió completamente al retirar este sistema.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Tejón P, Belmonte MA, Lerma JJ, Lozano A. Coccigodinia relacionada con uso de anillo vaginal anticonceptivo. Reumatol Clin. 2017;13:42–43.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L.S. Lirette" 1 => "G. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 19 | 32 |
| 2024 October | 141 | 69 | 210 |
| 2024 September | 158 | 53 | 211 |
| 2024 August | 146 | 74 | 220 |
| 2024 July | 135 | 75 | 210 |
| 2024 June | 99 | 82 | 181 |
| 2024 May | 118 | 88 | 206 |
| 2024 April | 99 | 64 | 163 |
| 2024 March | 111 | 81 | 192 |
| 2024 February | 86 | 71 | 157 |
| 2024 January | 107 | 72 | 179 |
| 2023 December | 91 | 68 | 159 |
| 2023 November | 90 | 66 | 156 |
| 2023 October | 102 | 61 | 163 |
| 2023 September | 99 | 72 | 171 |
| 2023 August | 71 | 62 | 133 |
| 2023 July | 104 | 64 | 168 |
| 2023 June | 80 | 64 | 144 |
| 2023 May | 103 | 70 | 173 |
| 2023 April | 79 | 57 | 136 |
| 2023 March | 93 | 81 | 174 |
| 2023 February | 96 | 79 | 175 |
| 2023 January | 91 | 66 | 157 |
| 2022 December | 105 | 100 | 205 |
| 2022 November | 101 | 62 | 163 |
| 2022 October | 97 | 32 | 129 |
| 2022 September | 71 | 49 | 120 |
| 2022 August | 89 | 52 | 141 |
| 2022 July | 69 | 54 | 123 |
| 2022 June | 62 | 39 | 101 |
| 2022 May | 81 | 72 | 153 |
| 2022 April | 89 | 73 | 162 |
| 2022 March | 92 | 64 | 156 |
| 2022 February | 78 | 35 | 113 |
| 2022 January | 104 | 57 | 161 |
| 2021 December | 73 | 38 | 111 |
| 2021 November | 57 | 60 | 117 |
| 2021 October | 84 | 59 | 143 |
| 2021 September | 62 | 56 | 118 |
| 2021 August | 45 | 50 | 95 |
| 2021 July | 50 | 31 | 81 |
| 2021 June | 49 | 40 | 89 |
| 2021 May | 80 | 41 | 121 |
| 2021 April | 141 | 73 | 214 |
| 2021 March | 113 | 64 | 177 |
| 2021 February | 52 | 27 | 79 |
| 2021 January | 64 | 16 | 80 |
| 2020 December | 51 | 29 | 80 |
| 2020 November | 121 | 25 | 146 |
| 2020 October | 89 | 18 | 107 |
| 2020 September | 61 | 35 | 96 |
| 2020 August | 57 | 23 | 80 |
| 2020 July | 30 | 28 | 58 |
| 2020 June | 41 | 35 | 76 |
| 2020 May | 41 | 27 | 68 |
| 2020 April | 37 | 17 | 54 |
| 2020 March | 16 | 5 | 21 |
| 2020 February | 1 | 0 | 1 |
| 2019 September | 2 | 0 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2018 May | 4 | 0 | 4 |
| 2018 April | 46 | 8 | 54 |
| 2018 March | 60 | 8 | 68 |
| 2018 February | 36 | 15 | 51 |
| 2018 January | 15 | 7 | 22 |
| 2017 December | 41 | 24 | 65 |
| 2017 November | 28 | 14 | 42 |
| 2017 October | 36 | 19 | 55 |
| 2017 September | 32 | 25 | 57 |
| 2017 August | 33 | 31 | 64 |
| 2017 July | 36 | 32 | 68 |
| 2017 June | 48 | 25 | 73 |
| 2017 May | 50 | 33 | 83 |
| 2017 April | 44 | 46 | 90 |
| 2017 March | 51 | 33 | 84 |
| 2017 February | 34 | 28 | 62 |
| 2017 January | 6 | 10 | 16 |
| 2016 December | 10 | 19 | 29 |
| 2016 November | 0 | 1 | 1 |
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