Levator ani syndrome

Levator ani syndrome is episodic rectal dull aching pain caused by spasm of the levator ani muscle. Levator ani syndrome is a functional disorder in which recurrent or persistent distressing pain, pressure or discomfort is felt in the region of rectum, sacrum and coccyx that may be associated with the presence of pain in the gluteal region and thighs ¹. Levator ani syndrome pain is worse by sitting for long periods and disappears on standing, walking or lying down ². Often no organic pathology is detected clinically.

Levator ani syndrome typically causes a dull aching pain or discomfort of the anus, that lasts more than 20 minutes, and frequently hours to days.

Levator ani syndrome more often affects women than men, usually younger than 45 years of age ³ and is thought to result from spasm of the upper most layer of the anal sphincter (puborectalis muscle).

Levator syndrome diagnosis is suggested mainly by the history, clinical examination, and the exclusion of other disorders that can produce recurrent or chronic proctalgia.

The diagnosis of levator ani syndrome is considered ‘highly likely’ if symptom criteria are satisfied and traction on the puborectalis muscle reveals tight levator ani muscles with focal tenderness or pain.

Examination of the anus is usually unremarkable with only palpable tenderness of the levator ani muscles, signifying puborectalis spasm. Anal manometry typically shows increased anal pressures.

The diagnosis is ‘possible’ if symptoms occur in the absence of physical findings.

No single treatment is successful for all patients with levator ani syndrome. The aim of treatment is to reduce anal canal or levator ani tension. Digital massage, sitz bath, muscle relaxants, electrogalvanic stimulation and biofeedback are the treatment modalities most frequently described in the literature.

Hot Sitz baths (100.4 °F or 38 ° C) have been shown to be of some use, on their own, as well as in combination with massage and muscle relaxants (diazepam) ¹.

Digital massage of the muscle ², electrogalvanic stimulation by a rectal probe and biofeedback regimes utilizing pressure-measuring probes have variable success ⁴.

Figure 1. Pelvic floor female

Levator ani syndrome causes

The exact cause of levator ani syndrome is unknown, but is thought to result from spasm of the levator ani muscles. Thiele ⁵ perceived the relationship between spasm of the levator ani muscles and pain in the anal area, but used the term ‘coccygodynia’ (even through he noted that the pain was not in
the coccyx but in the muscles which partially inserted into the coccyx). The term ‘levator spasm syndrome’ was first described by Smith ⁶ in 1959. Thereafter, the most commonly proposed mechanism of levator ani syndrome was the spasm of the levator ani muscles ⁷. The symptoms of levator ani syndrome may be precipitated by stress, trauma from sitting for long periods of time (e.g., long distance travel), childbirth, various surgical procedures (e.g., herniated lumbar disc, low anterior resection, hysterectomy), sexual intercourse and defecation ⁸. A US national householder survey ⁹ of functional gastrointestinal disorders published in 1993 showed the prevalence of levator ani syndrome in the general population was 6.0% and more common in women. More than half of affected patients are aged 30–60 years with prevalence declining after the age of 45 years. Only 29% of sufferers consult a physician ¹⁰.

Levator ani syndrome symptoms

Levator ani syndrome is characterized by recurrent dull aching pain, pressure or discomfort in the region of the rectum, sacrum, and coccyx. The pain typically gets worse on sitting and resolves by standing or lying down. The symptoms of levator syndrome may also be increased by trauma, stress, long distance travels, parturition, surgical procedures (e.g. low anterior resection, hysterectomy), sexual intercourse and defecation.

Levator ani syndrome diagnosis

The diagnosis of levator ani syndrome is suggested primarily by the clinical history, physical examination, and the exclusion of other disorders that can produce recurrent or chronic proctalgia. A
multinational committee on functional anorectal disorders defined the Rome II criteria for diagnosis of levator ani syndrome in a consensus document on functional gastrointestinal disorders in
1999 (see below) ¹⁰.

Rome II diagnostic criteria for levator ani syndrome ¹⁰:

• At least 12 weeks, which need not be consecutive, in the preceding 12 months of:
  • chronic or recurrent rectal pain or aching
  • episodes last 20 minutes or longer, and
  • other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess, fissure, hemorrhoids, prostatitis, and solitary rectal ulcer have been excluded

An important clinical finding is palpable tenderness of overly contracted levator ani muscles as the examining finger moves from the coccyx posteriorly to the pubis anteriorly ⁸. A diagnosis of levator ani syndrome is ‘highly likely’ if symptom criteria are satisfied and posterior traction on the puborectalis reveals tight levator ani muscles and tenderness or pain; whereas the diagnosis is considered ‘possible’ if symptoms occur in the absence of physical findings ¹⁰. Often the tenderness is asymmetric and more common on the left side of the levator ani muscles ¹.

Levator ani syndrome treatment

No single treatment is successful for all patients with levator ani syndrome. The aim of treatment is to reduce anal canal or levator ani tension. First line treatment is reassurance that attacks are benign and do not indicate cancer or other serious organic disease. A range of treatments have been reported to be effective in the treatment of levator ani syndrome including digital massage, sitz baths, muscle relaxants, electrogalvanic stimulation and biofeedback. None of these treatments have been evaluated with controlled trials.

According to a review article by Salvati ², digital massage of the levator ani muscles, from anterior to posterior, in a firm manner to tolerance at 3–4 week intervals will alleviate symptoms. The affected side if unilateral, or both if bilateral, should be massaged up to 50 times depending on the patient’s tolerance. The most frequent reason for inadequate massage is failure to reach high enough in the rectum to palpate the levator ².

In a cohort study of 57 subjects (31 patients and 26 controls), sitz baths of 104 °F or 40 ° C were found to reduce anal canal pressures in both patients with anorectal problems and in the controls ¹¹. The efficacy of sitz baths in levator ani syndrome is uncertain, but they have no harmful effect.

In a case series of 316 patients with levator ani syndrome, digital massage of the levator ani muscles in conjunction with sitz baths and diazepam, was reported to bring good or moderate pain relief in 87% patients ¹. However, the addictive potential of diazepam decreased the enthusiasm of the clinicians to use it to treat chronic levator ani syndrome.

Since intermittent levator ani muscles spasm is the most likely cause of levator ani syndrome, electrogalvanic stimulation was first described by Sohn et al ¹² in 1982. The mechanism for pain relief was the induction of spasmodic muscle fasciculation and fatigue in levator ani syndrome patients by repeated application of a direct electrical current through an intra-anal probe. In this series, the use of high voltage electrogalvanic stimulation of the levator ani muscles produced complete or partial pain relief in 90% of patients ¹². Thereafter, three case series ¹³, ¹⁴, ¹⁵ and one cohort study ¹⁶ have shown that electrogalvanic stimulation could attain satisfactory pain control in 40–91% of patients suffering from levator ani syndrome. None of these studies were controlled. In addition, no follow up was mentioned, except in one study by Hull et al ¹⁶ mean follow up 28 month.

Biofeedback was a treatment modality introduced by some clinicians to train the minds of patients with levator ani syndrome to relax their levator ani muscles, thereby breaking the spastic cycle. Three cohort studies have shown that biofeedback could achieve pain relief or improvement in 34.7% (follow up period not mentioned) ¹⁷, 42.9% (mean follow up 15 months) ¹⁸ and 87.5% (mean follow up 12.8 months) ¹⁹ of patients with levator ani syndrome. Again, none of these studies were controlled. No undesirable side effects of electrogalvanic stimulation and biofeedback have been reported in the literature.

A more recent cohort study ²⁰ compared the outcomes of two treatment modalities: local injection therapy of a mixture of triamcinolone acetonide and lidocaine into the maximal tender point of the arcus tendon in the levator ani muscles, and electrogalvanic stimulation therapy. Patients in the local injection group showed better results in pain score at the 1 month, 3 months and 6 months follow up. There were no statistically significant differences in pain score between the two therapy groups at 12 months follow up ²⁰. The better short term result of the local injection therapy suggested that inflammation of the arcus tendons of the levator ani muscles (tendinitis hypothesis) might also have a role in the cause of levator ani syndrome. The authors pointed out that since there was a low subjective response of patients for complete pain relief in both treatment groups, this study could not positively conclude that the tendinitis hypothesis is the more reliable pathophysiology of levator ani syndrome ²⁰.

A case series ²¹ reported that surgical division of the puborectalis muscle resulted in a high incidence of incontinence for liquid or gas, and therefore this surgical treatment should not be recommended due to such an undesirable side effect.

References

1. Grant SR, Salvati EP, Rubin RJ. Levator syndrome: an analysis of 316 cases. Dis Colon Rectum 1975;18:161–3.
2. Salvati EP. The levator syndrome and its variant. Gastroenterol Clin North Am 1987;16:71–8.
3. Hull TL. Unexplained anal/rectal pain. In: Cameron JL, editor. Current surgical therapy. 7th edn. St. Louis: Mosby, 2001;307–9.
4. Wald A. Anorectal and Pelvic Pain in Women. J Clin Gastroenterol 2001; 33(4): 283-28
5. Thiele GH. Coccygodynia: cause and treatment. Dis Colon Rectum 1963;6:422–6.
6. Smith WT. Levator spasm syndrome. Minn Med 1959;42:1076–9.
7. Reilly WT, Pemberton JH. Levator spasm and pelvic pain. Perspect Colon Rectal Surg 1994;1–5.
8. Wald A. Functional anorectal and pelvic pain. Gastroenterol Clin North Am 2001;30:243–51.
9. Drossman DA, Li Z, Andruzzi E, et al. US house-holder survey of functional gastrointestinal disorders: Prevalence, sociodemography and health impact. Dig Dis Sci 1993;38:1569–80.
10. Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SSC. Functional disorders of the anus and rectum. Gut 1999;45(Suppl 2):55–9.
11. Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles. Dis Colon Rectum. 1986 Apr;29(4):248-51. DOI:10.1007/bf02553028
12. Sohn N, Weinstein MA, Robbins RD. The levator syn-drome and its treatment with high voltage electrogalvanic stimulations. Am J Surg 1982;144:580–2.
13. Nicosia JF, Abcarian H. Levator syndrome: a treatment that works. Dis Colon Rectum 1985;28:406–8.
14. Oliver GC, Rubin RJ, Salvati EP, et al. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum 1985;28:662–3.
15. Billingham RP, Isler JT, Friend WG, Hostetler J. Treatment of levator syndrome using high voltage electrogalvanic stimulation. Dis Colon Rectum 1987;30:584–7.
16. Hull TL, Milsom JW, Church J, Oakley J, Lavery I, Fazio V. Electrogalvanic stimulation for levator syndrome: how effective is it in the long term? Dis Colon Rectum 1993;36:731–3.
17. Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD. Biofeedback for intractable rectal pain: outcome and predictors of success. Dis Colon Rectum 1997;40:190–6.
18. Ger GC, Wexner SD, Jorge JMN, et al. Evaluation and treatment of chronic intractable rectal pain: a frustrating endeavour. Dis Colon Rectum 1993;36:139–45.
19. Heah S-M, Ho Y-H, Tan M, Leong AFPK. Biofeedback is effective treatment for levator ani syndrome. Dis Colon Rectum 1997;40:187–9.
20. Park D-H, Yoon S-G, Kim KU, et al. Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome. Int J Colorectal Dis 2005;20:272–6.
21. Barnes PRH, Hawley PR, Preston DM, Lennard-Jones JE. Experience of posterior division of the puborectalis muscle in the management of chronic constipation. Br J Surg 1985;72:475–7.