An Overview of Levator Ani Syndrome

Levator ani syndrome (LAS) is a pelvic floor disorder that causes chronic rectal or vaginal pain. LAS pain is typically dull but long-lasting and felt deep inside your pelvis. The pain is due to spasms of the levator ani muscles, which are near the anus, and occurs frequently or even constantly.

Levator ani syndrome is more common in people assigned female at birth. It affects an estimated 7.4% of natal females and 5.7% of natal males. While there are strategies to help relieve symptoms, only around a third of those with this chronic (persistent) condition seek medical care.

This article explains the symptoms, causes, diagnosis, and treatment of levator ani syndrome as well as the medical conditions that mimic the signs and symptoms of LAS.

What Is Levator Ani Syndrome?

Levator ani syndrome is a type of non-relaxing pelvic floor dysfunction. The pelvic floor is a dome-shaped group of muscles that support the organs in the pelvis and lower abdomen. 

The levator ani is a symmetrical set of three, deep pelvic-floor muscles: the iliococcygeus, pubococcygeus, and puborectalis. These muscles surround the rectum, urethra, and vagina.

The levator ani muscles are used to coordinate urination and bowel movements. You hold your bladder or stool by engaging the levator ani muscles. You relax these muscles to urinate or defecate.

Sometimes, these muscles remain contracted and tense, also known as hypertonic. When this happens, the muscles are unable to relax, causing levator ani syndrome.

Levator Ani Syndrome Symptoms

Levator ani syndrome, formerly known as chronic proctalgia, causes chronic pain in the upper part of the rectum or vagina.

The pain can be constant or comes in waves and is described by some as a dull ache, a burning sensation, or a feeling of rectal pressure, though it is not usually related to bowel movements. It can also be felt deep in the vagina. The pain generally worsens with sitting and eases when standing up or lying down.

In addition to pain, other symptoms are possible, including:

• Painful or difficult bowel movements
• Frequent bowel movements
• Urinary urgency (the sensation you have to pee all the time)
• Loss of bowel or bladder control
• Painful sexual intercourse
• Sexual dysfunction

Causes and Risk Factors

The cause of levator ani syndrome is not clear. The pain is due to spasms of the levator ani muscles, in particular, the puborectalis, a sling-like muscle that wraps around the lower rectum.

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.

Diagnosis

Levator ani syndrome is largely based on an exclusion of all other causes.

In addition to reviewing your medical history, your healthcare provider will need to do a physical exam. This includes a rectal exam and pelvic exam, which is likely to cause some pain and tenderness. Your pelvic floor muscles may also spasm during the exam.

When diagnosing the condition, your healthcare provider will look for the following criteria:

• A history of chronic or recurrent rectal or vaginal pain that lasts for at least 30 minutes
• Tenderness of the puborectalis muscle when touched
• At least six months of symptoms, three of which must be consecutive
• No identifiable cause or explanation

There are no blood tests and imaging tests that can diagnose LAS, although they may help rule out other causes.

Differential Diagnoses

Conditions in the differential diagnosis (used to differentiate LAS from all other causes) include:

• Anorectal abscess (a pus-filled cavity in the anus or rectum)
• Anorectal fissure (a tear or crack in the anus or rectum)
• Coccygodynia (tailbone pain)
• Crohn's disease (a type of IBD)
• Prostatitis (inflammation of the prostate)
• Thrombosed hemorrhoid (a blood clot in a hemorrhoid)
  
• Ulcerative colitis (another type of IBD)
• Prostate cancer
• Colon cancer

Levator Ani Syndrome Treatment

There are a few treatment options for levator ani syndrome, including at-home treatments, prescription medication, and interventional procedures.

Most of the recommended treatments can provide temporary relief, but they have not been proven to be effective in all people.

Home Remedies and Lifestyle Changes

At-home treatments that can help ease the pain and discomfort of levator ani syndrome include:

• Apply a moist heating pad or ice pack to your lower back or buttocks
• Avoid prolonged sitting—get up and walk around at least once every hour
• Prevent constipation by maintaining a diet that is moderate in fiber and staying hydrated
• Take a sitz bath or soak in a warm bath
• Take an over-the-counter pain reliever, such as Advil (ibuprofen), Aleve (naproxen), or Tylenol (acetaminophen)
• Try to use the bathroom or pass gas
• Use a seat cushion

There are also exercises you can do at home that can help ease rectal pain. Try the following:

• Pelvis squat stretch: Squat down by lowering your hips straight down from a standing position, bending your knees toward your ears, and relaxing your lower back down between your legs.
• Butterfly stretch: Sit on the floor with the soles of your feet touching and your knees spread out to each side.
  
• Belly breathing: Lie on your back and breathe deeply into your diaphragm.

Medical Treatments

Some of the medical options commonly used to relieve LAS pain include:

• Pelvic floor exercises from a physical therapist to engage and relax the levator ani muscles
• Therapeutic massage by a qualified pelvic floor physical therapist
• Electrogalvanic stimulation, in which a rectal probe delivers a gentle electrical current to relax rectal muscles
• Botox (botulinum A), delivered by injection to reduce muscle spasms
  
• Biofeedback therapy which uses equipment to give feedback on muscle activation and relaxation during pelvic floor exercises

Your healthcare provider may also prescribe medications to relieve levator ani syndrome pain. These may include:

• Elavil (amitriptyline), a tricyclic antidepressant that also relieves pain
• Flexeril (cyclobenzaprine), a prescription muscle relaxant
• Neurontin (gabapentin), an anti-seizure medicine that relieves nerve pain
• Valium (diazepam), an anti-anxiety medicine that relaxes muscles

Alternative Therapies

There has been at least one case study that shows traditional therapies such as herbal medicine and acupuncture may relieve symptoms of LAS. The research is not conclusive, though. Discuss alternative therapies with your healthcare provider to weigh the potential benefits and risks.

Summary 

Levator ani syndrome is a pelvic-floor disorder that causes pain deep inside the rectum or vagina. It occurs when the levator ani muscles are unable to relax, causing painful muscle spasms. 

LAS is diagnosed based on physical symptoms and ruling out other potential causes of pain. Symptoms must last at least 30 minutes and recur over six months before levator ani syndrome is diagnosed. 

Symptoms may be relieved with home remedies, including OTC pain relievers, sitz baths, and exercise. Pelvic floor physical therapy is usually helpful and may include exercises, biofeedback, and massage treatments. Prescription muscle relaxers, tricyclic antidepressants, and anti-seizure medicines may also bring relief.