What are the treatment options for a patient with levator ani syndrome?

Treatment for Levator Ani Syndrome

Biofeedback therapy is the most effective first-line treatment for levator ani syndrome, achieving adequate symptom relief in 87% of patients with confirmed diagnosis, and should be initiated after confirming tenderness on digital rectal examination of the puborectalis muscle. 1

Diagnostic Confirmation Required Before Treatment

• Acute localized tenderness to palpation along the puborectalis muscle during digital rectal examination is the key diagnostic feature that distinguishes true levator ani syndrome from other causes of chronic anorectal pain 2
• Only patients with tenderness on traction of the levator muscles ("highly likely" diagnosis) benefit from treatment; those without this finding ("possible" diagnosis) do not respond to any intervention 1
• The digital examination should be performed with the patient in the left lateral position, assessing for tenderness during palpation of the puborectalis muscle above the internal sphincter 2

First-Line Treatment: Biofeedback Therapy

Biofeedback is superior to all other treatment modalities and should be the initial therapeutic approach. 1

Treatment Protocol and Expected Outcomes

• Biofeedback programs should include 9 sessions using electronic and mechanical devices to teach pelvic floor muscle relaxation (not strengthening, as this is a spasm disorder) 1
• Treatment focuses on improving the ability to relax pelvic floor muscles and reducing pain thresholds 1
• 87% of patients with confirmed levator ani syndrome achieve adequate relief with biofeedback, compared to 45% with electrogalvanic stimulation and only 22% with massage 1
• Pain days per month decrease from 14.7 at baseline to 3.3 after biofeedback treatment 1
• Pain intensity drops from 6.8/10 to 1.8/10 on a 0-10 scale 1
• Improvements are maintained for at least 12 months after treatment completion 1

Mechanism of Action

• Biofeedback works by increasing the ability to relax pelvic floor muscles, improving balloon evacuation, and reducing urge and pain thresholds 1
• The pathophysiology is similar to dyssynergic defecation, involving paradoxical muscle contraction 1

Second-Line Treatment: Electrogalvanic Stimulation (EGS)

If biofeedback is unavailable or only partially effective, high-voltage electrogalvanic stimulation is the next best option. 1, 3

EGS Treatment Protocol

• High voltage electrogalvanic stimulation delivered via an intra-anal probe at 150-400 volts (based on patient tolerance) 3
• Use negative electrodes at 80 cycles per second for 20 minutes every other day 3
• An average of 5 treatments is needed for complete pain relief 3
• Achieves adequate relief in 45% of patients with confirmed levator ani syndrome 1
• Over 90% effectiveness reported in some studies, with excellent results (total pain relief) in 80% of patients 3

Alternative Pharmacologic Approach: Cyclobenzaprine

For patients who cannot access biofeedback or EGS, cyclobenzaprine 5 mg three times daily for 7 days represents a reasonable pharmacologic option. 4

Cyclobenzaprine Details

• Works by influencing α and γ motor neurons in the central nervous system to attenuate muscle spasm 4
• In case reports, symptom resolution occurred after 3 days of treatment with sustained relief at 6 months 4
• Main adverse effect is mild drowsiness, which resolves after discontinuation 4
• This is an off-label use but warrants consideration given its safety profile, low cost, and demonstrated efficacy 4

Adjunctive Physical Therapy Approach

Combining massage of the coccygeus muscle with treatment of associated pelvic joint disorders can cure or alleviate symptoms in 72% of cases at 12 months. 5

Physical Therapy Protocol

• Massages performed with patient lying on the left side 5
• Physical treatment of pelvic joint disorders given at the end of each massage session 5
• Only 1-2 sessions are typically necessary 5
• 69% of patients are symptom-free at 6 months, with 62% remaining symptom-free at 12 months 5

Treatment Algorithm

1. Confirm diagnosis with digital rectal examination demonstrating tenderness on palpation of the puborectalis muscle 2, 1
2. Initiate biofeedback therapy (9 sessions) as first-line treatment 1
3. If biofeedback unavailable or only partially effective, proceed to high-voltage electrogalvanic stimulation (average 5 treatments) 1, 3
4. Consider cyclobenzaprine 5 mg three times daily for 7 days if device-based therapies are inaccessible 4
5. Add physical therapy with coccygeus massage and pelvic joint treatment (1-2 sessions) as adjunctive therapy 5

Critical Pitfalls to Avoid

• Do not treat patients without confirmed tenderness on rectal examination—they will not respond to any intervention 1
• Traditional treatments like sitz baths, NSAIDs, and diazepam offer minimal benefit and should not be relied upon 4
• Levator massage alone has poor efficacy (22% adequate relief) compared to biofeedback 1
• Do not confuse levator ani syndrome with fecal incontinence or defecatory disorders—the treatment approaches are fundamentally different 2