From the Guidelines
The workup for levator ani syndrome should begin with a thorough medical history and physical examination, including a digital rectal examination to assess for tenderness in the levator ani muscle, as this is a key feature of the syndrome 1. The diagnosis of levator ani syndrome is often one of exclusion, and a comprehensive workup is necessary to rule out other conditions that may be causing the patient's symptoms.
- A digital rectal examination is essential to evaluate for tenderness in the levator ani muscle, particularly on the left side, which is a characteristic finding of the syndrome 1.
- Laboratory tests, such as a complete blood cell count, may be performed to rule out other conditions, such as hypothyroidism or colon cancer, although their diagnostic utility and cost-effectiveness have not been rigorously evaluated 1.
- A structural evaluation of the colon, such as colonoscopy or flexible sigmoidoscopy, 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 1.
- The patient should also be instructed to integrate the expulsionary forces by requesting that they “expel my finger” during the digital rectal examination, which can help to evaluate pelvic floor function 1.
- An examination to evaluate for a rectocele or consideration of gynecologic consultation may also be necessary to rule out other pelvic floor disorders 1.
From the Research
Workup for Levator Ani Syndrome
The workup for levator ani syndrome involves a combination of clinical history, physical examination, and exclusion of organic disease that can produce recurrent or chronic proctalgia 2. The diagnosis is suggested primarily by the clinical history and physical examination, including digital rectal examination and vaginal examination to elicit pain in the levator ani muscles.
Diagnostic Criteria
The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings 3.
Laboratory Investigations
Laboratory investigations, including a full blood count and C reactive protein, may be performed to rule out other causes of pain, but are often within normal range in patients with levator ani syndrome 2. Further investigation with imaging studies such as transabdominal ultrasound scan, CT of the abdomen and pelvis, and MRI of the lumbar spine may also be unremarkable 2.
Physical Examination
Physical examination, including digital rectal examination and vaginal examination, is essential to elicit pain in the levator ani muscles and to rule out other causes of pain 2, 4. Palpation of the levator ani muscles may elicit pain, indicating pelvic floor dysfunction 2.
Electromyography
Electromyography of the levator ani and external anal sphincter muscles may be performed to assess muscular recruitment and to detect any abnormalities in motor unit function 5. Interference pattern analysis may be used to measure muscular recruitment and to detect any changes in motor unit function 5.
Key Points
- The diagnosis of levator ani syndrome is suggested primarily by the clinical history and physical examination 2.
- Laboratory investigations and imaging studies may be performed to rule out other causes of pain, but are often within normal range in patients with levator ani syndrome 2.
- Physical examination, including digital rectal examination and vaginal examination, is essential to elicit pain in the levator ani muscles and to rule out other causes of pain 2, 4.
- Electromyography of the levator ani and external anal sphincter muscles may be performed to assess muscular recruitment and to detect any abnormalities in motor unit function 5.