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Levator Ani Syndrome is a muscle-based pelvic pain due to chronically contracted pelvic muscles. It has many names and can be associated with pelvic floor muscle dysfunction, chronic proctalgia fugax, or chronic pelvic pain syndrome. Levator Ani Syndrome typically describes pain in the rectum or the bottom and back of the pelvis.
The levator ani muscles are a sling or muscles that go from the pubic symphysis in the front of the body to the coccyx in the back. Directly they hold up the bladder, prostate (in men), and uterus and vagina (in women) as well as the descending rectum. Because the pain occurring in the rectal muscle can feel like a spasm this condition can sometimes be called Levator Spasm Syndrome. These spasms are episodic, usually, last no longer than 20 minutes and often unrelated to a bowel movement.
They can feel different for every patient. Common symptoms associated with pelvic floor muscle spasm are a pain with intercourse or post-intercourse soreness, urinary urgency/frequency/incomplete emptying/urge incontinence, bowel constipation/pain with bowel movements/sensation of rectal fullness/rectal burning. Or the symptoms could be vaguer such as sensations of “flicker” or “vibration” in perineum, vagina or rectum.
The symptoms of levator ani syndrome can be both acute or chronic and can include:
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.
There is an absence of visible symptoms when tests are conducted. This can be frustrating to both patients and medical practitioners and can delay a diagnosis and treatment plan. There is tenderness to palpation of the anal sphincter and above pelvic floor muscles.
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 described above and lack of muscle coordination for the pelvic floor muscles in levator ani syndrome.
There are both local and systemic factors that contribute to causing the symptoms of levator ani syndrome. Locally, unconscious tensing of the pelvic floor muscles from stress and anxiety, contribute to the symptoms. Often this is combined with certain “triggers” or risk factors. Additionally, contributing factors include chronic constipation or loose stools, poor toileting habits usually started as a young child, a history of hemorrhoids or an anal fissure, a history of colorectal or gynecological surgery. Systemically, a genetically wired nervous system with a “dial” or “amplifier” that is turned up or “hyperexcitable” predisposes patients to potentially suffering from levator ani syndrome.
Treatment for levator ani syndrome involves retraining both the pelvic muscles and the nervous system. Firstly, conservative treatment involves pelvic floor physical therapy with biofeedback along with daily relaxation techniques. This treatment will calm the area and reduce nervous system arousal. If the patient doesn’t respond to this conservative treatment, we have created a second line treatment option to help break up tension in the contracted pelvic floor muscles. This helps to lengthen and strengthen the muscles as well as improve blood flow. This option is non-surgical and minimally invasive. It addresses the nerve inflammation that occurs with chronically contracted pelvic floor muscles. We ask patients to continue pelvic floor physical therapy and daily relaxation techniques during our treatment.
The prognosis depends on the underlying cause as well as the duration of symptoms. However, yes it can go away and patients can get better.