levator ani syndrome

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) 4).

Digital massage of the muscle 5), electrogalvanic stimulation by a rectal probe and biofeedback regimes utilizing pressure-measuring probes have variable success 6).

Figure 1. Pelvic floor female

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 7) 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 8) in 1959. Thereafter, the most commonly proposed mechanism of levator ani syndrome was the spasm of the levator ani muscles 9). 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 10). A US national householder survey 11) 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 12).

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) 13).

Rome II diagnostic criteria for levator ani syndrome 14):

  • 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 15). 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 16). Often the tenderness is asymmetric and more common on the left side of the levator ani muscles 17).

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 18), 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 19).

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 20). 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 21). 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 22) 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 23). Thereafter, three case series 24), 25), 26) and one cohort study 27) 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 28) 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) 29), 42.9% (mean follow up 15 months) 30) and 87.5% (mean follow up 12.8 months) 31) 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 32) 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 33). 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 34).

A case series 35) 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.

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