What is the initial approach to treating Levator ani syndrome?

Treatment of Levator Ani Syndrome

Biofeedback therapy is the first-line treatment for levator ani syndrome, particularly in patients who demonstrate tenderness on digital rectal examination.

Diagnosis and Clinical Presentation

Levator ani syndrome (LAS) is characterized by:

• Chronic or recurrent episodes of anorectal pain
• Pain typically lasting longer than 20 minutes
• Pain exacerbated by sitting
• Absence of structural or inflammatory causes

The diagnosis is primarily clinical and requires:

• Focused medical history to exclude other causes of anorectal pain
• Digital rectal examination to assess for tenderness along the puborectalis muscle 1
• Evaluation of pelvic floor motion during simulated evacuation 1

Treatment Algorithm

First-line Treatment:

1. Biofeedback therapy - Most effective treatment with 87% of patients reporting adequate relief in those with tenderness on examination 2
   • Teaches pelvic floor relaxation techniques
   • Significantly reduces pain days per month (from 14.7 to 3.3)
   • Reduces pain intensity (from 6.8 to 1.8 on a 0-10 scale)
   • Benefits maintained for at least 12 months

Second-line Treatment:

1. Electrogalvanic stimulation (EGS) - Moderately effective with 45% of patients reporting adequate relief 2
   • Reduces pain days per month (from 14.7 to 8.9)
   • Reduces pain intensity (from 6.8 to 4.7 on a 0-10 scale)

Third-line Treatment:

1. Digital massage of levator muscles - Less effective with only 22% of patients reporting adequate relief 2
   • Minimal reduction in pain days or intensity

Adjunctive Treatments:

1. Pharmacological options 3:

   • Amitriptyline (typically starting at 10-25mg daily)
   • Non-steroidal anti-inflammatory drugs
   • Gabapentin
   • Diazepam

2. Other supportive measures:

   • Sitz baths
   • Pelvic floor physiotherapy 3

Important Clinical Considerations

1. Patient selection is crucial: Only patients with tenderness on rectal examination benefit from these treatments 2

   • Patients without tenderness (classified as "possible LAS") showed no significant improvement with any treatment modality

2. Mechanism of action: Biofeedback and EGS improve symptoms by:

   • Increasing the ability to relax pelvic floor muscles
   • Improving evacuation
   • Reducing urge and pain thresholds 2

3. Botulinum toxin is not recommended: A randomized controlled trial showed no improvement in pain scores or physiological parameters compared to placebo 4

4. Diagnostic exclusion: Before diagnosing LAS, exclude:

   • Anorectal abscess
   • Inflammatory bowel disease
   • Anal fissure
   • Rectal prolapse
   • Colorectal malignancy

Follow-up and Prognosis

• Patients should be reassessed after completing the initial treatment course
• Biofeedback benefits have been shown to persist for at least 12 months 2
• Some patients may require maintenance therapy
• For refractory cases, consider multidisciplinary pain management

Levator ani syndrome can be a challenging condition to treat, but with proper patient selection and appropriate application of biofeedback therapy, most patients can experience significant relief of symptoms.