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Levator Ani Syndrome

by Tamer Seckin, MD | Posted on February 15, 2021

Introduction

Levator ani syndrome is a condition affecting the pelvic floor and causing pain in the rectal and perineal areas. 

What is the pelvic floor? If you think of the pelvis as a bowl, the pelvic floor is the “bottom of the bowl”, where a sling of muscles helps to elevate and provide a muscular function to the organs in the pelvis. The role of the pelvic floor muscles is to support the pelvic organs such as the bladder, uterus, and rectum (1)

About the levator ani

The levator ani is the largest component of the pelvic floor muscles. It provides support to the vagina, uterus, and rectum. It connects from the front, at the pubic bone, and at the back, at the tailbone.  In levator ani syndrome, the pelvic muscles are chronically contracted (2).

Levator Ani Syndrome, what does it have to do with Endometriosis pain?

How common is levator ani syndrome?

Levator ani syndrome is thought to affect 6 in 100 people. Certain surgical procedures, such as those that are implemented for treatment and diagnosis of endometriosis, can increase the risk of developing levator ani syndrome (3).

Causes

What causes levator ani syndrome?

It is not clear what causes levator ani syndrome in the general population. However, some factors may contribute to the development of the condition such as the prolonged holding of urine or stool, continued intercourse even if it is painful, childbirth, and injury to the pelvic floor from surgery or trauma (3).

Because the levator ani muscles are chronically contracted, there is a decrease in blood flow to the pelvic area. With time, this decreased blood flow can stimulate inflammation and cause pain.

Relationship between endometriosis and levator ani syndrome

Although the exact cause is not known, endometriosis can increase the risk of levator ani syndrome. Because the endometrial tissue is inflamed, women with endometriosis experience severe pelvic pain. This can cause the pelvic floor muscles, including the levator ani to contract.

Certain surgical procedures to treat endometriosis, such as hysterectomy and low anterior resection of the rectum may increase the risk of developing levator ani syndrome (3).

Symptoms

What are the symptoms of levator ani syndrome? 

The symptoms of levator ani syndrome include pain in the rectum when: sitting, after a bowel movement, urination, or sexual intercourse. Other symptoms may include bloating, urinary incontinence, and urgency.

Diagnosis

How do doctors diagnose levator ani syndrome?

For doctors to diagnose levator ani syndrome, there are certain criteria that must be met. These are (1) chronic or recurring rectal pain lasting at least 30 minutes,(2)  tenderness in the puborectalis muscle (part of the levator ani group of muscles), (3) at least six months of symptoms with at least three of them being consecutive, and (4) no other identifiable cause of the pain (4).

The puborectalis muscle is the muscle that wraps around the rectum and the pubic bone. Doctors will examine this as part of a physical exam to see if it is tender. They will also look at your medical history and ask you to describe your symptoms.

Treatment

What are the treatment options?

There is no single treatment that can be successful for all patients with levator ani syndrome.

The first thing that patients can do to relieve the pain is to use sitz baths (sitting in shallow warm water).

Lifestyle changes can also help with the symptoms of the syndrome. For example, a diet that contains a moderate amount of fiber can help with regular bowel movements and avoid constipation or diarrhea. It is also important to stay active and avoid prolonged periods of sitting. Daily relaxation techniques such as yoga and meditation can also help.

Pelvic floor physical therapy is another approach that can reduce the symptoms of levator ani syndrome. It involves a qualified physical therapist teaching the patient pelvic floor exercises where they contract and relax their pelvic floor muscles. Techniques such as biofeedback and digitally massaging the levator ani muscle can also be used. In biofeedback, a probe is inserted into the patient’s vagina to monitor the working of the pelvic floor muscles including the levator ani. Finally, electro galvanic stimulation where a rectal probe sends electric pulses to the muscle can help reduce the pain in some cases (5). 

To temporarily relieve the symptoms of levator ani syndrome, some doctors may prescribe muscle relaxants such as Flexeril (cyclobenzaprine).

References

  1. Anatomy, Abdomen and Pelvis, Levator Ani Muscle, NCBI US National Library of Medicine National Institutes of Health
  2. What is pelvic floor dysfunction?, Cleveland Clinic
  3. Levator ani syndrome, Ching Luen Ng MBBS, FRACGP, FHKCFP
  4. Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice, NCBI US National Library of Medicine National Institutes of Health
  5. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome, Giuseppe Chiarioni, MD, Adriana Nardo, MD, Italo Vantini, MD, Antonella Romito, RN, and William E. Whitehead, PhD

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