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;
• Chronic or recurrent rectal pain or aching
• Episodes last 20 minutes or longer
• Other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess, fissure, haemorrhoids, 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 pubo-rectalis 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 generally 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
    • many patients fail to respond to treatment - surgical treatment of this condition should be avoided

Reference:

1. Carrington E et al. Proctalgia Syndromes: Update in Diagnosis and Management. Curr Gastroenterol Rep. 2020 Jun 9;22(7):35.