Levator Ani Syndrome

Levator ani syndrome is a functional anorectal pain disorder with chronic or recurrent rectal pain from pelvic floor muscle tenderness (also unspecified functional anorectal pain).

• Prevalence is up to 6% of adults, more common in women, 30 to 60 years.
• Mechanism: levator ani and puborectalis spasm and hypertonicity, often with pelvic floor dyssynergia, trauma, childbirth, prior pelvic surgery, anxiety, and chronic stress.
• Rome IV criteria: chronic or recurrent rectal pain lasting 30 minutes or more, with tenderness on traction of puborectalis, symptoms for at least 6 months, onset at least 3 months before diagnosis.
• Associations: irritable bowel syndrome, depression, anxiety, interstitial cystitis, chronic prostatitis/pelvic pain syndrome, fibromyalgia.

• Dull ache, pressure or burning in the rectum or vagina, worse on sitting, relieved by standing or lying, lasting hours.
• Episodes may occur daily, with exacerbation after defecation or stress.
• Digital rectal examination reveals tenderness with posterior traction on the puborectalis, often left sided, with normal anal canal, no mass.
• Associated urinary symptoms, dyspareunia, constipation.

• Diagnosis by Rome IV criteria with exclusion of structural causes.
• Digital rectal examination for puborectalis tenderness, trigger points, anal fissure, abscess, mass, prostatitis.
• Investigations for red flags or atypical features: flexible sigmoidoscopy, MRI pelvis, anorectal manometry (paradoxical contraction), balloon expulsion test, defecography.
• Exclude coccygodynia, pudendal neuralgia, proctalgia fugax, endometriosis, prostatitis, anal fissure, ischiorectal abscess.

• Pelvic floor biofeedback therapy (6 to 8 sessions) is first line, giving improvement in about 60 to 80%, with relaxation training.
• Pelvic floor physiotherapy with digital massage of the levator ani, myofascial release, warm sitz baths, ischaemic compression.
• Muscle relaxants: diazepam 5 mg at night, or diazepam suppository 5 to 10 mg, baclofen 5 to 10 mg three times daily, cyclobenzaprine 5 to 10 mg at night.
• Topical diltiazem 2% or glyceryl trinitrate 0.2% for associated sphincter spasm.
• Neuropathic agents: amitriptyline 10 to 50 mg at night, gabapentin 300 mg titrated to 900 to 1800 mg daily.
• Botulinum toxin A 100 units into the puborectalis (benefit in about 50%, repeat after 3 to 6 months).
• Electrogalvanic stimulation, sacral neuromodulation, and trigger point injections of lidocaine for refractory cases.
• Cognitive behavioural therapy for associated stress and anxiety.