From the Guidelines
Diagnosing levator ani syndrome requires a thorough digital rectal examination to assess for acute localized tenderness to palpation along the puborectalis muscle, which is a key feature of the condition. The diagnostic steps for levator ani syndrome involve a systematic approach, starting with a medical history and physical examination.
- A digital rectal examination should be performed to evaluate for tenderness in the levator ani muscle, particularly on the left side, as pain reproduction during this examination is considered diagnostic 1.
- The examination should also include an assessment of the puborectalis muscle, which should contract during squeeze, and the patient should be instructed to integrate the expulsionary forces by expelling the examiner's finger 1.
- Additional steps include ruling out other conditions through laboratory tests, such as a complete blood cell count, although the diagnostic utility of metabolic tests like thyroid-stimulating hormone, serum glucose, creatinine, and calcium has not been rigorously evaluated and is probably low 1.
- A structural evaluation of the colon may be appropriate in certain circumstances, especially if the patient has alarm symptoms or has abrupt onset of constipation or is older than 50 years and has not undergone previous screenings for colorectal cancer, and can include colonoscopy, computed tomographic colonography, or flexible sigmoidoscopy and barium enema 1.
- The patient's medications can be adjusted when possible to avoid those with constipating effects, and a trial of fiber and/or over-the-counter laxatives can be instituted 1.
From the Research
Diagnostic Steps for Levator Ani Syndrome
To diagnose levator ani syndrome, the following steps can be taken:
- A thorough medical history should be obtained to identify symptoms of chronic or recurrent rectal pain or aching lasting at least 20 minutes in the absence of structural or systemic disease explanation for the pain syndrome 2.
- A digital rectal examination should be performed to check for tenderness on palpation of the pubo-rectalis muscle, which is a characteristic feature of levator ani syndrome 3, 2.
- The Rome IV diagnostic criteria can be used to diagnose functional anorectal pain syndromes, including levator ani syndrome, based on symptom duration and digital rectal examination findings 4.
- Other diagnostic tests, such as imaging studies, may be necessary to rule out other causes of rectal pain, such as structural or systemic diseases 2.
Key Diagnostic Features
Some key features to look for when diagnosing levator ani syndrome include:
- Tenderness on palpation of the pubo-rectalis muscle during digital rectal examination 3, 2.
- Chronic or recurrent rectal pain or aching lasting at least 20 minutes in the absence of structural or systemic disease explanation for the pain syndrome 2.
- Paradoxical contraction of the pelvic floor muscles on attempted defecation, which can be documented using biofeedback or other diagnostic tests 3, 2.
Importance of Accurate Diagnosis
Accurate diagnosis of levator ani syndrome is important because it can help guide treatment and improve patient outcomes. Biofeedback, for example, has been shown to be an effective treatment for levator ani syndrome, but its efficacy is limited to patients with tenderness on rectal examination 3, 2.