What is levator syndrome in an adult patient, possibly with a history of pelvic surgery, childbirth, or other conditions affecting the pelvic floor?

What is Levator Syndrome?

Levator syndrome (also called levator ani syndrome or LAS) is a chronic functional anorectal pain disorder characterized by recurrent or chronic pain, pressure, or discomfort in the rectum and anus caused by spasm or tenderness of the levator ani muscles (specifically the puborectalis muscle), diagnosed by finding acute localized tenderness on digital rectal palpation of these muscles. 1

Clinical Presentation

Pain Characteristics:

• Severe, intermittent aching anorectal pain that typically lasts longer than 20 minutes per episode 2
• Pain may radiate to the vagina in women or present as lower abdominal and rectal pain 2
• Episodes occur between 1-3 times per day in typical cases 3
• Pain is exacerbated by sitting or squatting 2, 3
• No alleviating factors are typically identified 3

Diagnostic Criteria

Physical Examination Findings:

• The hallmark diagnostic feature is acute localized tenderness to palpation along the puborectalis muscle during digital rectal examination 1
• Tenderness is most commonly localized to the left anterior anal canal (71.2% of cases), followed by posterior location (25%), and right anterior (3.8%) 4
• Rectal tone is typically intact with no prostate tenderness, lesions, hemorrhoids, or fissures 3
• The puborectalis muscle should normally contract during squeeze maneuvers 1

Important Clinical Caveat:

• Only patients with demonstrable tenderness on rectal examination benefit from treatment—those with "possible" LAS without tenderness do not respond to therapy 5
• This is a diagnosis of exclusion requiring thorough evaluation to rule out structural causes including inflammatory bowel disease, anal fissure, recurrent pelvic cancer, and other organic pathology 2, 6

Pathophysiology

The levator ani muscle is susceptible to myofascial pain syndrome with trigger point development 2. The pathophysiology of LAS is similar to dyssynergic defecation, involving impaired ability to relax pelvic floor muscles 5. The exact mechanism remains incompletely understood but may involve tendinitis of pelvic floor musculature 4.

Associated Conditions and Risk Factors

Common Comorbidities:

• High rate of prior pelvic surgery, particularly hysterectomy 1
• May coexist with interstitial cystitis/bladder pain syndrome 1
• Associated with other chronic pain syndromes including fibromyalgia and irritable bowel syndrome 1

Pregnancy-Related Considerations:

• Levator ani muscle injury from vaginal birth increases risk of symptomatic prolapse and can lead to tissue laxity 1
• Forceps delivery is associated with greater maternal tissue damage despite being protective for the fetus 1

Treatment Approach

Most Effective Treatment:

• Biofeedback is the most effective treatment, providing adequate relief in 87% of patients with confirmed LAS (tenderness on examination) 5
• Pain days decreased from 14.7 to 3.3 per month after biofeedback 5
• Pain intensity decreased from 6.8 to 1.8 on a 0-10 scale 5
• Improvements are maintained for 12 months 5
• Biofeedback works by teaching pelvic floor relaxation, improving ability to evacuate, and reducing urge and pain thresholds 5

Alternative Effective Treatments:

• Electrogalvanic stimulation (EGS) is somewhat effective, providing adequate relief in 45% of patients 5, though long-term studies show only 19% complete symptom relief and 24% partial relief at 28 months mean follow-up 6
• Transanal injection of triamcinolone acetonide (40 mg) with lidocaine (1 ml of 2%) into the tenderest point is highly effective, with 71.8% of patients achieving pain-free or good response at 3 months and 76.6% at 6 months 4
• Injections can be repeated at two-week intervals up to three times if needed 4

Pharmacological Options:

• Cyclobenzaprine 5 mg three times daily for 7 days achieved complete symptom resolution in 3 days in a documented case, with sustained benefit at 6 months 3
• Amitriptyline 20 mg once daily is used for chronic management 2
• Other options include diazepam, gabapentin, and botulinum toxin 2

Adjunctive Therapies:

• Pelvic floor physiotherapy 2
• Digital massage of levator muscles (22% adequate relief) 5
• Sitz baths 2

Critical Pitfalls to Avoid

• Never diagnose LAS without demonstrable tenderness on digital rectal examination—patients without this finding will not respond to treatment 5
• Always exclude organic disease including recurrent pelvic cancer, anal fissure, and inflammatory bowel disease before diagnosing LAS 2, 6
• Standard laxative programs do not work for evacuatory disorders like LAS, and failure to recognize this is a frequent reason for therapeutic failure 1
• A normal digital rectal examination does not exclude pelvic floor dysfunction, but it does exclude LAS as the diagnosis 1