Levator Ani Syndrome
"Based on the advice of Dr. Rodney Anderson at Stanford, I now routinely palpate the pelvic floor muscles before palpating the prostate. In some patients, the muscles are readily appreciated to be in spasm and pressure on them reproduces their pain. Dr. Anderson has stated, and I agree, that some patients who improve with "prostatic" massage are actually getting better because the have levator muscle spasm and the massage helps relieve that. I have also had success with Neurontin and Elavil in these patients." Dr Daniel Shoskes, August 1999
the Second International Prostatitis Collaborative Network Workshop
the University of Washington made a presentation which concluded
that "Men with chronic prostatitis/chronic pelvic pain syndrome
(CP/CPPS) have more abnormal pelvic floor and abdominal muscular
pathologic findings as compared with a group of men without pain."
Although we know that CP/CPPS is associated with dysfunctional pelvic muscles, it is more difficult to prove that this is the cause of the painful syndrome. Are some cases of CP/CPPS actually "levator ani syndrome" (see the musculature of the area), or is the chronic tension or spasm of the levator ani only a secondary condition caused by pain in the prostate area? This question is still open to debate.
Confusing matters further, nerves in the area
may themselves be causing pain. Aberrant nerves may therefore be causing
muscle spasms. Significantly, both neurogenic pain and LAS respond to
electrical stimulation. So, is it nerves or muscles, or both, or neither
- questions still to be answered.
No one treatment will work for every sufferer of levator ani syndrome. Urologist Dr. Shoskes has found that for his patients whose levator ani muscles are in spasm, medications such as Elavil, Flexeril, and Neurontin help to break the spasm. Massage of the levator ani may help, and biofeedback works well in many cases (read about this here). Also, some studies suggest that electrogalvanic stimulation of the levator ani by means of an intra-anal probe helps. Finally, injections of botulinum toxin type A may provide relief.
The most recent work in this area is being done at Stanford by Dr
David Wise and his team. Dr Wise claims to have cured himself
after 22 years of CP/CPPS using his relaxation techniques.
More on Levator Ani Syndrome and Related Conditions
ANORECTAL PAIN AND IRRITATION
Anal Fissure, Levator Syndrome, Proctalgia Fugax, and Pruritis Ani
Primary Care; Clinics in Office Practice
Volume 26 o Number 1 o March 1999
Chris Vincent MD
Department of Family Medicine, Swedish Family Practice Residency,
University of Washington School of Medicine, Seattle, Washington
PERIRECTAL PAIN SYNDROMES: LEVATOR ANI SYNDROME AND PROCTALGIA FUGAX
Definition and Epidemiology
Proctalgia, or perirectal pain, was first described in the 19th century. Three terms are used to classify proctalgia: levator ani (or levator spasm) syndrome, proctalgia fugax, and coccygodynia. Levator ani syndrome refers to chronic or recurrent rectal pain or aching, with episodes lasting 20 minutes or longer in the absence of organic disease that could account for the pain. Proctalgia fugax connotes anal or rectal pain, lasting for seconds to minutes and then disappearing for days to months, in the absence of organic disease to account for these symptoms. Coccygodynia usually describes tenderness of the tip of the coccyx and is synonymous with levator ani syndrome. Unfortunately, the three terms have been used interchangeably in the literature, making precise recommendations for treatment difficult.
Both levator ani syndrome and proctalgia fugax are common disorders. It is estimated that 6% of the United States population suffers from levator ani syndrome, while 8% have proctalgia fugax. Proctalgia fugax was at one time thought to be a disorder of perfectionistic young men. It is now apparent that both proctalgia fugax and levator ani syndrome occur slightly more often in women. Both are more common in patients under age 45; psychological factors are not always present (see below).
Cause and Pathophysiology
Levator Ani Syndrome
Thiele generally is acknowledged as the first to recognize the relationship between levator ani muscle spasm and chronic intermittent rectal pain. The levator ani consists of three muscles: the ileococcygeus the puborectalis, and pubococcygeus. These three surround the anus to form a muscular sling that supports the rectum. The muscle is palpated easily during a digital rectal examination. Chronic tension of the levator muscle is thought to cause the pain that characterizes levator ani syndrome.
The cause of proctalgia fugax is not known, but current theories favor rectal muscle spasm. Anal manometric studies have demonstrated that patients with proctalgia fugax have normal anorectal muscle function at rest, but develop anal smooth muscle dysfunction during a painful attack. Two families with hereditary proctalgia fugax have been studied. Members of both families had endosonographic evidence of thickened internal anal sphincter muscles. Anal manometry of affected persons showed increased resting pressure and prominent ultraslow wave pressure oscillations. The latter were thought to be caused by smooth muscle contractions of the internal anal sphincter, and peaks in pressure were associated with characteristic pain. Furthermore, drugs known to relax smooth muscles may have relieved attacks of proctalgia fugax.
Proctalgia fugax may be associated with functional gastrointestinal disorders. Abdominal pain and distension, frequent loose stools, and a sensation of incomplete evacuation after defecation have been noted more often in patients with proctalgia fugax. The significance of this remains a mystery.
An investigation of the psychological aspects of proctalgia fugax done in the 1960s found most sufferers to be anxious, tense, and perfectionistic. There was, however, no control group for the subjects. Current consensus does not support a psychosomatic origin for either proctalgia fugax or levator ani syndrome, although stressful events may trigger attacks.
Diagnosis and Clinical Features
Grant et al in an analysis of 316 cases observed that patients with levator ani syndrome complained of a vague, indefinite rectal discomfort or pain. The pain was felt high in the rectum and was sometimes associated with a sensation of pressure like a ball or other intrarectal object. Others note the pain may be aggravated by sitting or by the need to defecate, and relieved by walking or lying down.
By definition, the pain of proctalgia fugax is brief and self limited. Patients with proctalgia fugax complain of sudden onset of intense, sharp, stabbing or cramping pain in the anorectum. The pain occurs at any time of the day and typically awakens the sufferer from a sound sleep.
The physical examination of patients with levator ani syndrome and proctalgia fugax usually is unremarkable. In patients with levator ani syndrome, palpation of the levator muscle while performing a digital rectal examination usually reproduces their pain. Grant noted that in patients with levator ani syndrome, their levator muscle may be felt as a firm band beneath the examining finger as it is passed from a lateral to an anterior position within the rectum. He also observed these patients had tenderness of the levator muscle, and that in most it was unilateral and on the left, a finding confirmed by others.
There are no diagnostic studies to exclude or confirm levator ani syndrome or proctalgia fugax. The inexperienced practitioner should consider other causes of anorectal pain and obtain further investigations or consultations as appropriate. Other causes of anorectal pain are *
Anal fissure External hemorrhoids (thrombosed or infected) Fecal impaction or foreign body Myopathy (hereditary) Neoplasm (anorectal, ovarian, or prostatic) Perirectal abscess Prostatitis
Treatment and Patient Education
Management of levator ani syndrome and proctalgia fugax is controversial. No single treatment has been unusually successful in all patients. Patients with levator ani syndrome and proctalgia fugax should be reassured that their painful attacks are benign and often diminish over time.
Levator Ani Syndrome
For patients with levator ani syndrome, initial conservative treatment with hot baths, nonsteroidal anti-inflammatory drugs, muscle relaxants, or levator muscle massage is recommended. Levator muscle massage consists of high, deep, digital pressure over the puborectalis portion of the levator floor. This procedure is repeated every 2 to 3 weeks for two to three courses. One-half to two-thirds of levator ani syndrome sufferers improve with the above measures.
In the 1980s, several researchers tried electrogalvanic stimulation of the levator muscle. Early studies reporteda 90% success rate, but subsequent investigations demonstrated a long-term failure rate of 32% to 60%. More recently, researchers using EMG-based biofeedback have shown improvement in pain in some studies. The findings of these studies may be unreliable because of the small number of subjects, lack of controls, and high dropout rate.
Recommendations for treatment of proctalgia fugax are limited to anecdotal reports and a single randomized controlled trial. Fortunately for most patients, the attacks are brief and infrequent. For patients with frequent attacks, physical modalities such as hot packs or direct anal pressure with a finger or closed fist may alleviate the pain. Diltiazem has helped at least two patients, and oral clonidine provided relief for another. A recent, randomized, controlled trial of albuterol in 18 patients with proctalgia fugax showed significant reduction in duration of pain compared with placebo. Although intriguing, the authors could not commit to recommending albuterol for proctalgia fugax without further studies confirming efficacy. [extract]