Levator ani syndrome

• levator ani syndrome (also called levator spasm, puborectalis syndrome, chronic proctalgia, pyriformis syndrome, and pelvic tension myalgia)
  • pain - often described as a dull, vague ache or pressure sensation high in the rectum, often worse with sitting or lying down, which lasts for hours to days
  • prevalence of symptoms compatible with levator ani syndrome in the general population is 6.6%
    • the condition is more common in women
    • more than 50% of affected patients are aged 30-60 years, and prevalence tends to decline after age
  • aetiology is unknown
  • diagnostic criteria(1) Chronic or recurrent rectal pain or aching; (2) Episodes last 20 minutes or longer; and (3) Other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess, fissure, hemorrhoids, prostatitis, and solitary rectal ulcer have been excluded
    • at least 12 weeks, which need not be consecutive, in the preceding 12 months of:
  • clinical evaluation
    • diagnosis of levator ani syndrome is made on the basis of symptoms alone and exclusion of other causes of rectal pain
      • however if posterior traction on the puborectalis reveals tight levator ani muscles and tenderness or pain then this is suggestive of levator ani syndrome
        • tenderness may be predominantly left-sided, and massage of this muscle will usually elicit the characteristic rectal discomfort
        • clinical evaluation will generallly include sigmoidoscopy and appropriate imaging studies such as ultrasound, or pelvic CT to exclude alternative diseases
  • treatment
    • a variety of treatments directed at reducing tension in the levator ani muscles have been described:
      • digital massage of the levator ani muscles
      • Sitz baths
      • muscle relaxants such as diazepam
      • electrogalvanic stimulation
      • and biofeedback training
    • however none of the treatment studies included a control group, and patient selection criteria varied (1)
      • many patients fail to respond to treatment. Surgical treatment of this condition should be avoided

Reference:

1. Whitehead WE et al.Functional disorders of the anus and rectum. Gut. 1999 Sep;45 Suppl 2:II55-9.