Overview
Definition:
Levator ani syndrome is a chronic pain condition characterized by pain in the anorectal area due to spasm or dysfunction of the levator ani muscle group
It is a common cause of functional anorectal pain and is often intermittent, though it can become constant
The pain is typically described as a dull ache, pressure, or a feeling of fullness in the rectum.
Epidemiology:
The exact incidence and prevalence are difficult to determine due to varied diagnostic criteria and patient reporting
However, it is estimated to affect a significant portion of the population experiencing chronic pelvic pain
It is more commonly reported in women than men, but can occur in both sexes
Age of onset is variable, often occurring in young to middle-aged adults.
Clinical Significance:
Levator ani syndrome can significantly impact a patient's quality of life, leading to discomfort, pain with sitting, bowel movements, and sexual activity
Accurate diagnosis and appropriate management are crucial to alleviate suffering and prevent chronicity
For surgical trainees, understanding the spectrum of surgical options and their indications is vital for comprehensive patient care in proctology and colorectal surgery.
Clinical Presentation
Symptoms:
Pain is the hallmark symptom: typically a deep, aching, or throbbing pain in the rectum or anus
Pain is often worse when sitting and relieved by standing or lying down
Symptoms may be intermittent or constant
A feeling of rectal fullness or a sensation of incomplete defecation can also occur
Pain may be exacerbated by prolonged sitting, stress, or certain bowel movements
Sexual activity can be painful.
Signs:
Physical examination may reveal tenderness on digital rectal examination (DRE) in the region of the levator ani muscles
Palpation of the levator muscles may elicit spasm or pain, which can be temporarily relieved by counter-pressure
There are usually no gross abnormalities of the anus or rectum on external inspection or anoscopy
The patient may appear uncomfortable when sitting during the examination.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on characteristic symptoms and exclusion of other causes of anorectal pain
The Rome IV criteria for functional anorectal disorders include: "(1) Recurrent episodes of anal or rectal pain, lasting at least 30 minutes during sitting, for at least 3 of the last 12 months
(2) Tenderness of the levator ani muscles during rectal examination
(3) Pain relieved by expulsion of flatus or stool." Exclusion of organic causes is critical.
Diagnostic Approach
History Taking:
A detailed history is paramount
Inquire about the character, location, duration, frequency, and aggravating/relieving factors of the pain
Ask about any associated symptoms such as constipation, diarrhea, dyschezia, or fecal incontinence
Assess for previous anorectal procedures or trauma
Evaluate psychological factors like stress, anxiety, or depression
Red flags include rectal bleeding, weight loss, change in bowel habits suggestive of malignancy, and fever.
Physical Examination:
A thorough physical examination includes inspection of the perianal region, digital rectal examination (DRE) to assess for tenderness, masses, sphincter tone, and to identify levator spasm
Anoscopy and, if indicated, rigid sigmoidoscopy should be performed to rule out intraluminal pathology
In women, a bimanual pelvic examination may be considered to assess for gynecological causes of pelvic pain.
Investigations:
Generally, investigations are aimed at excluding other conditions
Anorectal manometry can document levator spasm and assess sphincter function
Pelvic MRI may be useful to rule out structural abnormalities, although it is not typically required for diagnosis
Laboratory tests are usually not indicated unless infection or inflammatory conditions are suspected.
Differential Diagnosis:
Conditions to consider include: Proctalgia fugax (brief, severe rectal pain), Coccydynia (tailbone pain), Anal fissure, Anal fistula, Perianal abscess, Proctitis, Irritable bowel syndrome (IBS), Pudendal neuralgia, Interstitial cystitis, Endometriosis, and musculoskeletal causes of pelvic pain.
Management
Initial Management:
Conservative management is the first line of treatment and includes reassurance, patient education, and lifestyle modifications
This may involve advice on posture, avoiding prolonged sitting, and stress management techniques
Warm sitz baths can provide symptomatic relief.
Medical Management:
Pharmacological treatments include: Muscle relaxants such as cyclobenzaprine or baclofen
Neuropathic pain agents like gabapentin or pregabalin
Non-steroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief
Topical anesthetics or nitrates can sometimes be used
Botulinum toxin injections into the levator muscles have also shown promise in refractory cases.
Surgical Management:
Surgical options are reserved for patients who fail to respond to conservative and medical management, particularly those with significant, persistent levator spasm and tenderness
The primary surgical procedure is a **levatorplasty** or **levator tenotomy**
This involves surgically releasing the spasm by dividing the puborectalis muscle, either partially or completely
Indications include chronic, debilitating pain refractory to non-surgical treatment and confirmed levator spasm on examination.
Supportive Care:
Psychological support and referral to pain management specialists or pelvic floor physical therapists are often beneficial
Physical therapy may involve biofeedback, stretching exercises, and manual therapy to address muscle dysfunction
Long-term management may require a multidisciplinary approach.
Complications
Early Complications:
Bleeding from the surgical site
Infection of the surgical wound
Pain at the incision site
Urinary retention
Transient fecal incontinence or urgency in some cases.
Late Complications:
Recurrence of pain if the levator spasm is not fully addressed or if other contributing factors are not managed
Persistent changes in bowel function
Sexual dysfunction may persist or develop
Formation of scar tissue potentially leading to increased pain.
Prevention Strategies:
Thorough preoperative assessment to confirm diagnosis and exclude other pathologies
Meticulous surgical technique to minimize trauma and ensure appropriate division of muscle fibers
Careful postoperative pain management
Comprehensive rehabilitation program including physical therapy.
Prognosis
Factors Affecting Prognosis:
Severity and chronicity of symptoms
Presence of comorbidities
Patient's psychological status and adherence to treatment
Success of surgical technique
Response to conservative and medical management prior to surgery.
Outcomes:
Surgical outcomes vary
Many patients experience significant pain relief and improvement in quality of life following levatorplasty
However, a subset of patients may have only partial improvement or a recurrence of symptoms
The success rate is generally higher when the diagnosis is accurate and surgical intervention is performed by experienced surgeons.
Follow Up:
Postoperative follow-up typically involves regular clinic visits to monitor pain levels, bowel function, and wound healing
Physical therapy is often a crucial component of long-term management and follow-up
Patients may require long-term management strategies, including ongoing pelvic floor exercises and psychological support.
Key Points
Exam Focus:
Levator ani syndrome is a diagnosis of exclusion
Digital rectal examination is key to diagnosis, revealing tenderness and spasm
Surgical management (levatorplasty/tenotomy) is a last resort for refractory cases
Differentiate from proctalgia fugax and coccydynia
Understand the Rome IV criteria.
Clinical Pearls:
Emphasize the importance of a thorough history and physical exam, particularly the DRE, to identify levator spasm
Consider a trial of conservative and medical management before surgical referral
Multidisciplinary approach including physical therapy and pain management is often essential for optimal outcomes.
Common Mistakes:
Misdiagnosing levator ani syndrome as other anorectal pathologies like fissures or fistulas without proper investigation
Proceeding to surgery without exhausting conservative measures
Inadequate physical examination focusing only on the anal canal lumen and not the levator muscles themselves
Failing to consider psychological factors that may exacerbate or maintain pain.