LEVATOR ANI SYNDROME

BHAVANI.V
T0521004
ANATOMY OF LEVATOR ANI MUSCLE
 Levator ani muscle is the largest component of the pelvic floor. It is a
broad muscular sheet that attaches to the bodies of the pubic bones
anteriorly, ischial spines posteriorly and to a thickened fascia of the 
obturator internus muscle.[1] The levator ani muscle provides support to
the pelvic visceral structures and play an important role in urinary
voiding, defecation and sexual function. It consists of three parts:
puborectalis, pubococcygeus and iliococcygeus muscle .
STRUCTURE :
 Puborectalis is a thick narrow, medial part of the levator ani. It forms a U-
shaped muscular sling around and behind the rectum, just cephalad to the
external sphincter.
 Pubococygeus, also known as pubovisceral is the wider but thinner
intermediate part of the levator ani. Within the pubovisceral muscle are
parts that attach to the perineal body (puboperineal), a part that inserts into
the anal canal (puboanal), and pubovaginal which inserts into the vaginal
wall.
 Iliococcygeus is a thin sheet of muscle that traverses the pelvic canal from
the tendinous arch of the levator ani to the midline iliococcygeal raphe
where it joins with the muscle of the other side and connects with the
superior surface of the sacrum and coccyx.
FUNCTION :

 The major function of Levator ani is to provide support to the pelvic

viscera and also resist increses in intra-abdomial pressure.
 Puborectalis muscle acts in association with the internal and external
anal sphincter during the process of defecation
 Pubococcygeus muscle supports the vagina and prostrate in females
and males, respectively. It aids ejaculation and assists in proper
positioning of the fetus head.
 Iliococcygeus which meets the fibers from the opposite side at the
midline raphe provides a secure anchoring for the pelvic floor.
• 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.
• (Grant SR, Salvati EP, Rubin RJ. Levator syndrome: ananalys of 316
cases. Dis Colon Rectum 1975;18:161–3.)
• It is estimatedTrusted Source to affect 7.4 percent of women and 5.7
percent of men in the general population. Over half of all those with
symptoms of levator ani syndrome are 30-60 years of age .
• Pelvic floor muscles that are too tight can lead to nonrelaxing pelvic
floor dysfunction. This can cause problems with storing or emptying
bowels, as well as pelvic pain, painful intercourse, or erectile
dysfunction.
CAUSES :
• In levator ani syndrome, the levator ani muscles of the pelvic floor are
short, contracted, and weak.
• This contracted state does not allow for the levator muscles to support its
surrounding structures and leads to a decrease in blood blow to the area.
• After several months, this decrease in blood flow leads to an acidic
environment which stimulates an inflammatory cascade.
• The inflammatory cascade causes an “inflammatory” soup in the pelvis
and surrounding area, in addition to inflammation around the nerves. This
cascade is ultimately what leads to the pain symptoms 
• Poor posture while sitting at a computer keyboard or while watching
television also has been implicated as a predisposing factor to the
development of myofascial pain syndrome.
• Previous injuries may result in abnormal muscle function and predispose
to the subsequent development of myofascial pain syndrome.
CLINICAL FEATURES :
 The symptoms of levator ani syndrome can be both acute or chronic and can
include:
 Excessive discomfort or relief after a bowel movement
 Pain that is aggravated by sexual activity or stress
 Pelvic pain
 Rectal pain or anal pain, especially when sitting or during a bowel movement
 Burning sensation in the rectum or perineal area
 Intermittent spasms in the pelvic floor muscles
 Tenesmus, a feeling of incomplete defecation
 Pain that radiates out to the thighs and buttocks

 Lying down often relieves the pain. Some patients describe the pain as a
sensation of a “golfball in my rectum”. Sometimes patients with levator ani
syndrome can also have referred pain patterns in the lower abdomen. They can
also have anterior pelvic floor muscle dysfunction symptoms such as genital
pain. Others describe it as a rectal burning and some feel an achy discomfort .
 A variant of levator ani syndrome is called proctalgia fugax, and it is
characterized by severe, episodic pain that is felt especially in the
rectum and anus. Proctalgia fugax is usually caused when there is
extreme cramping of the pubococcygeal section of the levator ani
muscles. For reasons that are still unclear, this anorectal pain usually
occurs in the middle of the night, waking the patient with a levator
spasm. For persistent or chronic proctalgia, sometimes botulinum
toxin injections are used for treatment.
• Patients with levator ani syndrome exhibit a trigger point along the
rectum or perineum Taut bands of muscle fibers often are identified
when myofascial trigger points are palpated. Despite this consistent
physical finding in patients who have myofascial pain syndrome, the
pathophysiology of the myofascial trigger point remains elusive, it is
the thought that trigger points are the result of microtrauma to
theaffected muscle.
• The levator ani muscle seems to be particularly susceptible to stress-
induced myofascial pain syndrome.
• Stiffness and fatigue often coexist with the pain of myofascial pain
syndrome, increasing the functional disability associated with this
disease and complicating its treatment.
• Myofascial pain syndrome may occur as a primary disease state or
may occur in conjunction with other painful conditions, including
radiculopathy and chronic regional pain syndromes.
• Local point of exquisite tenderness in affected muscle. Mechanical
stimulation of the trigger point by palpation or stretching produces
not only intense local pain but also referred pain.
• In addition to this local and referred pain, an involuntary
withdrawal of the stimulated muscle, termed a jump sign, may occur.
The jump sign also is characteristic of myofascial pain syndrome.
DIAGNOSIS :

• A sigmoidoscopy. This is an examination with a camera on a longer

tube, which can pass further up inside your gut.
 An ultrasound scan
 An MRI scan
 Anorectal manometry. This is a test used to measure the pressure of
anal muscle contractions.
 Rectal examination

• Screening laboratory tests, consisting of complete blood count,

erythrocyte sedimentation rate, antinuclear antibody testing, and
automated blood chemistry testing, should be performed to rule out
occult inflammatory arthritis, infection, and tumor.
Rome II criteria for levator ani syndrome
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 ischaemia, inflammatory bowel
disease, cryptitis, intramuscular abscess, fissure, haemorrhoids,
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.
• A diagnosis of LAS 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.
• Often the tenderness is asymmetric and more common on the left
side of the levator ani muscles
RISK FACTOR

 Medical history: You may be at higher risk for developing levator

ani syndrome after vaginal childbirth, particularly if you had a large
incision or vaginal tears. Surgery or trauma involving the spine,
anus, or pelvic area may also predispose you to the condition.
 Muscle dysfunction: Dyssynergic defecation is a condition in
which the pelvic floor muscles, including the puborectalis muscle,
do not function as they should. It may play a role in the
development of the syndrome.
 Inflammatory disease: Conditions characterized by irritation or
inflammation near the anal area, such as 
irritable bowel syndrome (IBS), inflammatory bowel disease (IBD),
chronic constipation, and infections, can increase your risk of
developing this condition
TREATMENT
• Levator ani pain syndrome is best treated with a multimodality
approach.
• Physical therapy, including correction of functional abnormalities
(e.g., poor posture, improper chair or computer height) and use of
heat modalities and deep sedative massage, combined with
nonsteroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle
relaxants is a reasonable starting point.
• If these treatments fail to provide rapid symptomatic relief, local
trigger point injection of local anesthetic and steroid into the
myofascial trigger point area is a reasonable next step.
• Underlying diffuse muscle pain, sleep disturbance, and depression
are best treated with a tricyclic antidepressant compound, such as
nortriptyline, which can be started at a single bedtime dose of 25
mg.
 Flexeril (cyclobenzaprine): Flexeril is a prescription muscle
relaxant that may relieve temporarily relieve symptoms for some
people who have LAS.
• When performing trigger point injections, careful preparation of the
patient before trigger point injection helps optimize results.
• Trigger point injections are directed at the primary trigger point,
rather than in the area of referred pain..
• It should be explained to the patient that the goal of trigger point
injection is to block the trigger of the persistent pain and, it is hoped,
provide longlasting relief.
 High-voltage pulsed galvanic stimulation (HVPGS) has also been
used in the treatment of this condition, and is not associated with
any adverse side effects. 
 It should be noted that HVPGS is generally not employed to treat
patients while they are experiencing symptoms since the attacks
usually last only for seconds to minutes. 
 Instead, this technology is often used as a prophylactic means to
reduce the incidence of attacks. 
 The patient is usually placed in the left lateral decubitus position
and a sterile probe is inserted into the anus.
  The negative electrode is used and the stimulator is set with a pulse
frequency of 80 to 120 cycles per second.
 The voltage (intensity) is started at 0, progressively raised to a
threshold of patient discomfort, and then is decreased to a level that
the patient finds comfortable.
   As the patient's tolerance increases, the voltage can be gradually
increased to 250 to 350 Volts. 
 Each treatment session usually lasts between 15 to 60 mins (Oliver
et al, 1985; Morris and Newton, 1987).
   Several studies have reported short-term success rates that ranged
from 65 to 91 % (Sohn et al, 1982; Nicosia and Abcarian, 1985;
Oliver et al, 1985; Morris and Newton, 1987; Billingham et al,
1987).
 Sohn et al (1982) reported that HVPGS is effective in treating
patients with LS. 
 Eighty patients participated in the study.  Treatment duration was 1
hour per day, 3 times over a period of 3 to 10 days.  Of the 72
patients evaluated, 90 % had excellent (total relief of pain and no
recurrence of levator spasm during the course of follow up) or
good (with complete resolution of pain but with recurrence of
levator spasm at a markedly reduced frequency during the course
of follow-up) results. 
 Nicosia and Abcarian (1985) treated 45 patients with LS using
HVPGS.  Treatment time was 15 to 30 mins administered every
other day for an average of 5 treatments.  Excellent (complete pain
relief) or good (relief was followed by recurrence of pain that
responded completely to additional treatment) results were
observed in 91 % of patients.
• Biofeedback was a treatment modality introduced by some
clinicians to train the minds of patients with LAS to relax their
levator ani muscles, thereby breaking thespastic 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 LAS.
• Again, none of these studies were controlled. No undesirable side
effects of electrogalvanic stimulation and biofeedback have been
reported in the literature.
(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).
DIGITAL MASSAGE
According to a review article by Salvati, 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.
(Salvati EP. The levator syndrome and its variant.Gastroenterol Clin
North Am 1987;16:71–8).
In a case series of 316 patients with LAS, 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.
However, the addictive potential of diazepam decreased the
enthusiasm of the clinicians to use it to treat chronic LAS .
In a cohort study of 57 subjects (31 patients and 26 controls), sitz
baths of 400C were found to reduce anal canal pressures in both
patients with anorectal problems and in the controls.
The efficacy of sitz baths in LAS is uncertain, but they have no
harmful effect.
(Grant SR, Salvati EP, Rubin RJ. Levator syndrome: an
analysis of 316 cases. Dis Colon Rectum 1975;18:161–3)
• A more recent cohort study 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.
• 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 aetiology of
LAS
• 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 LAS.
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.
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.
EXERCISES :
 Deep squats
 Happy child
 Legs on wall
 Kegels exercises
Digital massage, sitz baths, muscle relaxants, electrogalvanic
stimulation and biofeedback have all been reported to be effective in
treating LAS and cause no harm.