Levator ani syndrome is a condition affecting the pelvic floor and causing pain in the rectal and perineal areas. 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.
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. Researchers think that the condition affects 6 in 100 people. Certain surgical procedures, such as those to treat and diagnose endometriosis, can increase the risk of developing levator ani syndrome.
Types of Levator Ani Syndrome
Levator Ani Syndrome is typically classified into two main types based on the predominant symptoms and clinical presentation:
Levator Ani Muscle Tension Type
This type of Levator Ani Syndrome is characterized by chronic or recurrent pain or discomfort in the pelvic region, particularly in the area of the levator ani muscles. Individuals with this type of syndrome often experience a sensation of tightness, pressure, or aching in the pelvic area. The pain may worsen with prolonged sitting, exercise, or during bowel movements. Muscle tenderness and increased muscle tone in the levator ani muscles may be observed during a physical examination.
Levator Ani Spasm Type
This type of Levator Ani Syndrome is characterized by episodes of sudden, severe, and involuntary muscle spasms in the levator ani muscles. Individuals may experience intense rectal or pelvic pain, which can be intermittent or persistent. The spasms may be triggered by specific activities or situations, such as sitting for prolonged periods, stress, or bowel movements. During a physical examination, the levator ani muscles may feel tense and exhibit increased muscle activity.
It is estimated that 33-39% of woman will experience pelvic pain at least one point in their lives with as many as 20% of these cases progressing to Chronic Pelvic Pain (CPP). It is also estimated that up to 5% of the general population of women will experience CPP – that estimate rises to 20% in those with a previous diagnosis of pelvic inflammatory disease (PID). Of the various conditions that cause pelvic pain, levator ani sydrome is one of the least common, overall. Despite its overall rarity, it can affect as many as 7.4% of woman, and 5.4% of men. While it is not entirely understood as to why women seems to be more susceptible to it, the obvious differences in the content of the pelvis between men and women is thought to play a role.
In men, the organ and the pelvic floor are never meant to move. Women, the other hand, have evolved to possess a dynamic pelvic region and pelvic floor to accommodate a baby during pregnancy and musculature that can shift during the process of child birth. It is believed that the relative lack of rigidity may play a role such that the area may be more predisposed to movement and change which leads to spasming and dysfunction.
Symptoms of Levator Ani Syndrome
The most notable symptom is a muscle spasm of the pelvic floor musculature. Symptoms of levator ani syndrome also include:
- 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 intensified during or after intercourse
- Pain that radiates out to the thighs and buttocks
Causes of Levator Ani Syndrome
The cause of levator ani syndrome is not clear. The pain is due to spasms of the puborectalis muscle, part of the pelvic floor muscles. This sling-like muscle wraps around the lower rectum and plays an important role in controlling bowel movements.
Dysfunction of the puborectalis muscle is associated with certain medical conditions, such as:
- Childbirth:You may be at higher risk for developing LAS after vaginal childbirth, particularly if you had a large incision or vaginal tears.
- Surgery or trauma: If you experience trauma or have surgery around the spine, anus, or rectum, you may be predisposed to LAS.
- Muscle dysfunction: Dyssynergic defecation is a condition in which the pelvic floor muscles do not function as they should, causing chronic constipation.
- Bowel diseases: Conditions characterized by irritation or inflammation near the rectum, such as irritable bowel syndrome (IBS) and inflammatory bowel disease (IBD), can increase your risk of LAS.
Trigger points of Levator Ani Syndrome
The exact cause of Levator Ani Syndrome is not fully understood, but several risk factors have been identified that may increase the likelihood of developing the condition. These risk factors include:
- Chronic pelvic pain increases the risk of developing Levator Ani Syndrome.
- Previous pelvic trauma or injury, such as childbirth trauma or pelvic surgery, can contribute to the condition.
- Psychological factors like stress, anxiety, and depression may play a role in the development of Levator Ani Syndrome.
- Engaging in activities that involve repetitive straining, like heavy lifting or chronic constipation, can strain the pelvic floor muscles and increase the risk.
- Muscle imbalances or weakness in the pelvic floor muscles can contribute to Levator Ani Syndrome.
- Sexual dysfunction, such as pain during intercourse, is associated with a higher risk.
- Inflammation or infection in the pelvic region, such as pelvic inflammatory disease (PID) or prostatitis, can contribute to the condition.
The complications of Levator Ani Syndrome can include:
- Decreased quality of life: Chronic pelvic pain and discomfort can significantly impact a person’s quality of life, affecting daily activities, work, relationships, and overall well-being.
- Sexual dysfunction: Levator Ani Syndrome can cause pain or discomfort during sexual intercourse, leading to sexual dysfunction and difficulties in intimate relationships.
- Psychological impact: Living with chronic pain can lead to psychological distress, including anxiety, depression, and increased stress levels.
- Sleep disturbances: The constant pain and discomfort associated with Levator Ani Syndrome can interfere with sleep patterns, resulting in sleep disturbances and fatigue.
- Negative impact on bowel function: Levator Ani Syndrome may cause alterations in bowel function, such as constipation or difficulty with bowel movements.
- Reduced physical activity: The pain and discomfort experienced with Levator Ani Syndrome can limit physical activity and exercise, potentially leading to physical deconditioning and further loss of muscle strength.
- Social and emotional effects: Coping with chronic pain can lead to social isolation, reduced participation in social activities, and emotional challenges.
Diagnosis of Levator Ani Syndrome
Diagnosing Levator Ani Syndrome involves a comprehensive evaluation by a healthcare professional, typically a gastroenterologist or a pelvic pain specialist. The diagnostic process may include the following steps:
- Medical history: Your doctor will begin by asking about your symptoms, including the location, duration, and intensity of your pelvic pain or discomfort. They may also inquire about any relevant medical conditions, surgeries, or trauma that could contribute to your symptoms.
- Physical examination: A physical examination may be performed to assess the pelvic area. The doctor may palpate the pelvic floor muscles and surrounding structures to check for tenderness, muscle spasms, or abnormalities.
- Digital rectal examination (DRE): During a DRE, the doctor inserts a lubricated, gloved finger into the rectum to examine the rectal muscles and assess for any abnormalities or tenderness.
- Diagnostic tests: Additional tests may be recommended to rule out other possible causes of your symptoms and to confirm the diagnosis of Levator Ani Syndrome. These tests may include:
- Anorectal manometry: This test measures the pressure and function of the muscles in the rectum and anus. It can help assess the coordination and relaxation of the pelvic floor muscles.
- Endoanal or endorectal ultrasound: This imaging test uses a small probe inserted into the anus or rectum to create detailed images of the pelvic floor muscles and surrounding structures. It can help detect any abnormalities or structural issues.
- Magnetic resonance imaging (MRI): An MRI scan may be recommended to evaluate the pelvic region in more detail and to rule out other potential causes of your symptoms.
- Diagnostic criteria: Levator Ani Syndrome is typically diagnosed based on a set of diagnostic criteria, which may include chronic or recurrent pelvic pain lasting for at least three months, tenderness or spasm in the levator ani muscles, and the absence of any other identifiable structural or inflammatory causes.
It’s important to discuss your symptoms and concerns with a healthcare professional who can guide you through the diagnostic process.
The treatment for Levator Ani Syndrome typically involves a combination of conservative measures and medical interventions. Here are some common approaches:
Pelvic floor physical therapy: Physical therapy, specifically tailored for the pelvic floor muscles, can help relax and strengthen the muscles, improve blood flow, and reduce pain. A pelvic floor physical therapist can teach you exercises, stretches, and relaxation techniques to alleviate muscle tension and improve your symptoms.
Biofeedback therapy: This therapy involves using sensors to measure muscle activity in the pelvic floor. By providing visual or auditory feedback, biofeedback can help you learn to relax and control your pelvic floor muscles more effectively, reducing pain and tension.
Muscle relaxants: Your doctor may prescribe muscle relaxants to help reduce muscle spasms and alleviate pain in the pelvic region.
Pain relievers: Over-the-counter or prescription pain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can help manage pain associated with Levator Ani Syndrome.
Nerve medications: Certain medications, such as anticonvulsants or tricyclic antidepressants, can help alleviate nerve-related pain and reduce muscle tension.
Other Treatment Options
In addition to physical therapies and medications, there are a few other treatment options that may be considered:
Trigger point injections: In some cases, your healthcare provider may recommend injecting a local anesthetic or corticosteroid into specific trigger points in the pelvic floor muscles to relieve pain and reduce muscle tension.
Nerve blocks: Nerve blocks involve injecting an anesthetic or medication near the nerves that are responsible for transmitting pain signals from the pelvic region. This procedure can provide temporary relief from pain and help identify the source of the pain.
Stress management and relaxation techniques: Managing stress and practicing relaxation techniques such as deep breathing exercises, meditation, or yoga can help reduce muscle tension and alleviate symptoms.
Dietary modifications: Some individuals with Levator Ani Syndrome find relief by making dietary changes. Avoiding certain foods or drinks that may irritate the bladder or bowel, such as caffeine, spicy foods, or alcohol, can help reduce symptoms.
It’s important to consult with a healthcare professional, such as a gastroenterologist or a pelvic pain specialist, for an accurate diagnosis and personalized treatment plan based on your specific symptoms and medical history.
Home remedies and relief
Home remedies include:
- Sitz baths: Soaking the anal region in warm water, known as a sitz bath, can provide relief from episodes of anal spasms.
- Non-steroidal anti-inflammatory medication (NSAIDs): Taking an over-the-counter pain reliever may help to reduce discomfort.
- Sitting on a pillow: Some people report that sitting on a donut-shaped pillow reduces the pressure on the anus, which may alleviate symptoms.
- Gas or bowel movement: Episodes of levator ani spasms may be relieved by passing gas or by a bowel movement.
Prevention of Levator Ani Syndrome
To help prevent Levator Ani Syndrome, you can follow these simple steps:
- Stay active and exercise regularly to keep your pelvic floor muscles strong and flexible.
- Eat a balanced diet and drink plenty of water to maintain healthy bowel movements and prevent straining.
- Manage stress levels and practice relaxation techniques to reduce muscle tension in the pelvic area.
- Practice good posture when sitting and use ergonomic seating if possible. Avoid prolonged sitting and take breaks to move around.
- Use proper lifting techniques to avoid putting excessive strain on your pelvic floor muscles.
- If you experience chronic pelvic pain, seek early medical attention to address the issue and prevent the condition from worsening.