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Levator Ani Syndrome
Symptoms And Treatment

What is Levator Ani syndrome? LAS, sometimes known as ani levator syndrome or levator spasm syndrome is a form of pelvic and anal pain.

The symptoms are classically a triad of rectal spasm, rectal pain and a feeling of fullness in the pelvis and rectum.

It’s thought to emanate from the levator ani muscles that make up the pelvic floor giving rise to pain.

It differs from proctalgia fugax in several ways. In LAS, symptoms are constant or frequent with a prolonged period of pain.

With proctalgia fugax, the symptoms are usually short lived and can be very sharp, painful rectal and anal pain episodes.

On this page, I am going to discuss more about this condition, including treatment for symptoms.

What Is Levator Ani Syndrome?

As mentioned, levator syndrome symptoms are a combination of rectal spasm, pain and fullness.

It affects approximately 6% of the population and is more common in women than men.

Levator ani symptoms are commonly, although not exclusively, associated with IBS or the Irritable Bowel Syndrome.

The pain symptoms can be very disabling and sufferers with the condition often don’t know where to go or who to talk to, perceived as an embarrassing disorder and not one commonly known or talked about.

How Is Levator Ani Diagnosed?

There is no one single test that diagnoses ani levator syndrome.

It is the recognition of levator ani symptoms and exclusion of other causes of recto anal pain such as hemorrhoids, anal fissures, proctitis, coccydynia (coccyx pain), prostatitis (inflamed prostate in men) and many more that clinches the diagnosis.

PR or per rectal examination in levator spasm syndrome using a glove and finger usually elicits tenderness in or pain when pressure is placed on the levator ani muscles.

What Causes Levator Ani Symptoms?

No one knows the cause of ani levator syndrome. It is thought to be a spasm of the pelvic floor muscles although this hasn't been confirmed by anorectal studies.

As mentioned, it is associated with the Irritable Bowel Syndrome and may be associated with previous pelvic trauma. This might be the reason why symptoms are more common in childbearing women.

Treatment Of Levator Ani Syndrome

There is no one effective treatment for ani levator syndrome.

There have been many treatments and these can be split into conservative treatments, drug treatments, biofeedback, EGS or electrogalvanic studies and hypnotherapy.

Conservative Treatment For Ani Levator Syndrome

Conservative treatment for levator ani syndrome includes taking regular exercise, maintaining a high fiber diet with good fluid intake.

Regular hot baths may help although none of this is evidenced based.

Performing digital massage every two or three weeks with the use of a gloved finger well lubricated with a lubricant jelly may also help symptoms.

Levator ani syndrome exercises in the form of pelvic floor exercises or Kegel exercises may help.

In a women, the insertion of a finger into the vagina and then trying to squeeze the muscles against this or the use of vaginal inserts such as Kegel weights or balls can provide some help for symptoms.

In men, stopping passing urine mid flow, clenching the anal muscles (you will know when this is effective as the penis moves inwards and the testes rise) will produce similar results.

The Kegel exercises should be performed for 10 seconds or so at least 3 times a day.

Drug Treatment For Ani Levator Syndrome

Clonidine– An alpha-2-agonist used to lower blood pressure, has an effect on relaxing the pelvic floor muscles and improving blood flow and reducing levator ani pain.

Amitriptyline- A tricyclic antidepressant has pain relieving properties. Some people with levator spasm syndrome can’t tolerate the drug due to the side effects of dry mouth, blurred vision, urine retention and drowsiness.

SSRI Drugs- The more modern antidepressants such as Fluoxetine may help some sufferers with more tolerable side effects than Amitriptyline.

Nitrates- Nitrates such as Isosorbide Mononitrate and dinitrate act to relax the pelvic musculature and may help levator ani symptoms. There main side effect is to lower blood pressure causing dizziness and also headache. The headache tends to improve over time with use.

Calcium Antagonists- Again, these drugs such as Amlodipine and Diltiazem act as a muscle relaxant easing symptoms.

They are used in hypertension to lower blood pressure. As a result, side effects such as dizziness, headache, leg swelling and constipation can occur.

Benzodiazepines- Drugs such as Diazepam rectally can help to relax the pelvic floor. However, they should be avoided in long term use due to potential dependence.

They can also cause drowsiness so caution should be exercised with driving and operating machinery.

Analgesics- General painkillers such as Paracetamol, anti-inflammatories such as Ibuprofen and Diclofenac, codeine and opiates can be used to reduce pain.

Laxatives- Laxatives to reduce straining may help some sufferers

Botox- Botox injected into the Levator Ani muscle may provide symptomatic relief in some sufferers of levator ani syndrome, but is usually time limited.

Steroid- Steroid injection with Triamcinolone steroid into the muscle mixed with a local anaesthetic can be an effective way of helping the symptoms.

Hypnotherapy

Hypnotherapy has been used with some success in levator ani pain.

Biofeedback

Biofeedback is a method of re-teaching the process of defecation. First the sufferer is shown how to bear down as if they are opening their bowels by holding their breath and moving their diaphragm downwards.

They are then connected to a portable biofeedback device and are taught to relax the pelvic floor muscles whilst bearing down. This can be done in several sessions and is quite an effective way in dealing with Levator Ani Syndrome.

Electrogalvanic studies (EGS)

EGS is a method of applying high voltage EGS to the pelvic floor via an anal probe.

This has provided conflicting results, but may be of benefit as a treatment for Levator Ani in some sufferers.

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Levator Ani References

1. Gastroenterology. 2010 Apr;138(4):1321-9. Epub 2010 Jan 4.

Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome.

Chiarioni G, Nardo A, Vantini I, Romito A, Whitehead WE.

Division of Gastroenterology, University of Verona at Verona, Italy.chiarioni@tin.it

2. Recenti Prog Med. 2011 May;102(5):196-201. doi: 10.1701/659.7668.[Treatment of levator ani syndrome: update and
future developments.]

3. Ailiment Pharmacol Ther. 2009 May 1;29(9):985-91. Epub 2009 Feb 13.Clinical trial: effects of botulinum toxin on Levator ani syndrome-a double-blind, placebo-controlled study.Rao SS, Paulson J, Mata M, Zimmerman B.

4. Dis Colon Rectum. 2000 Sep;43(9):1288-91.Transanally injected triamcinolone acetonide in levator syndrome.Kang YS, Jeong SY, Cho HJ, Kim DS, Lee DH, Kim TS.Daehang Clinic, Seoul, Korea.

5. Dis Colon Rectum. 1997 Feb;40(2):187-9.Biofeedback is effective treatment for levator ani syndrome.Heah SM, Ho YH, Tan M, Leong AF.Department of Colorectal Surgery, Singapore General Hospital.

6. Dis Colon Rectum. 1987 Aug;30(8):584-7.Treatment of levator syndrome using high-voltage electrogalvanic stimulation.Billingham RP, Isler JT, Friend WG, Hostetler J.

7. Dis Colon Rectum. 1985 Jun;28(6):406-8.Levator syndrome. A treatment that works.Nicosia JF, Abcarian H.