Levator Ani Syndrome

Levator Ani Syndrome is a chronic pelvic pain condition caused by muscle spasms in the pelvic floor.
It occurs when the levator ani muscles, which support the pelvic organs, become tense or overactive. This tension can lead to dull, aching pain in the rectum, pelvis, or lower back. The pain may worsen when sitting for long periods and improve when standing or lying down. Levator Ani Syndrome is not life-threatening but can significantly affect daily comfort. Diagnosis is usually made after ruling out other causes of pelvic or rectal pain.

The Levator Ani Syndrome is a functional disorder. It does not mean there is a dangerous underlying disease, but rather that the muscles of your pelvic floor are not functioning correctly. Specifically, the levator ani muscles, which form a critical sling at the base of your pelvis, have become chronically tight, spastic, and tender. The result is a persistent, dull ache that can make simple activities like sitting at a desk or driving a car an exhausting ordeal.

What Is the Levator Ani Muscle?

To understand the syndrome, we must first understand the anatomy. The pelvic floor is not a solid plate, but rather a complex, multi-layered hammock of muscles and connective tissues that stretches from your pubic bone in the front to your tailbone (coccyx) in the back. This “hammock” has several vital jobs. It provides essential support for your pelvic organs, including the bladder, rectum, and (in women) the uterus. It also plays a critical role in urinary and fecal continence, sexual function, and core stability.

The levator ani is the largest and most important muscle group in this pelvic sling. It is a broad, curved muscle that, as its name suggests, “levitates” or “lifts” the pelvic contents.

In a healthy state, this muscle is strong yet flexible. It can contract when needed (to hold urine or stool) and relax completely when not in use (to allow for urination or bowel movements). In Levator Ani Syndrome, this muscle loses its ability to relax. It becomes hypertonic, or chronically spastic. This constant, low-level clenching leads to the buildup of lactic acid, the formation of painful trigger points, and a reduction in blood flow. This is what causes the persistent, aching pain.

Levator ani syndrome symptoms

Levator ani syndrome symptoms typically involve chronic pelvic pain caused by spasms or tension in the pelvic floor muscles, especially the levator ani muscle group. These symptoms often come and go, and many people notice they worsen with stress, sitting, or bowel movements.

Common Levator Ani Syndrome Symptoms:

• Deep, aching pelvic pain: A persistent or intermittent ache felt high in the rectum or deep in the pelvis.
• Pain during or after sitting: Discomfort often improves when standing or lying down.
• Rectal pressure or fullness: Many describe it as a sensation of “a ball” or “pressure” inside the rectum.
• Sharp or spasmodic pain episodes: Muscle spasms can cause sudden, intense pain that lasts minutes to hours.
• Pain during or after bowel movements: Straining may trigger or worsen symptoms.
• Pain during intercourse (dyspareunia): Pelvic floor tension can cause discomfort for some individuals.
• Lower back or tailbone pain: Tight pelvic muscles may radiate pain to the lower back or coccyx.
• Difficulty relaxing pelvic muscles: Some people feel an inability to fully release or relax the pelvic floor.

Causes

It is not clear what causes levator ani syndrome in the general population. However, some factors may contribute to the development of the condition such as the prolonged holding of urine or stool, continued intercourse even if it is painful, childbirth, and injury to the pelvic floor from surgery or trauma.

Because the levator ani muscles are chronically contracted, there is a decrease in blood flow to the pelvic area. With time, this decreased blood flow can stimulate inflammation and cause pain.

Endometriosis and levator ani syndrome

Although the exact cause is not clear, endometriosis can increase the risk of levator ani syndrome. Because of inflammation, women with endometriosis experience severe pelvic pain. This can cause the pelvic floor muscles, including the levator ani to contract.

Certain surgical procedures to treat endometriosis, such as hysterectomy and low anterior resection of the rectum may also increase the risk of developing the condition.

Diagnosis

There are certain criteria for doctors to diagnose levator ani syndrome. These are:

• chronic or recurring rectal pain lasting at least 30 minutes
• tenderness in the puborectalis muscle (part of the levator ani group of muscles)
• at least six months of symptoms with at least three of them being consecutive
• no other identifiable cause of the pain.

The puborectalis muscle is the muscle that wraps around the rectum and the pubic bone. Doctors will examine this as part of a physical exam to see if it is tender. They will also look at your medical history and ask you to describe your symptoms.

Treatment options

There is no single treatment that can be successful for all patients with levator ani syndrome.

The first thing that patients can do to relieve the pain is to use sitz baths (sitting in shallow warm water).

Lifestyle changes can also alleviate the symptoms of the syndrome. For example, a diet that contains a moderate amount of fiber can help with regular bowel movements and avoid constipation or diarrhea. It is also important to stay active and avoid prolonged periods of sitting. Daily relaxation techniques such as yoga and meditation can also help.

Pelvic floor physical therapy is another approach that can reduce the symptoms of levator ani syndrome. It involves a qualified physical therapist teaching the patient pelvic floor exercises where they contract and relax their pelvic floor muscles. Techniques such as biofeedback and digitally massaging the levator ani muscle can also help. In biofeedback, a probe is inserted into the patient’s vagina to monitor the working of the pelvic floor muscles including the levator ani. Finally, electro galvanic stimulation where a rectal probe sends electric pulses to the muscle can help reduce the pain in some cases. 

To temporarily relieve the symptoms of levator ani syndrome, some doctors may prescribe muscle relaxants such as Flexeril (cyclobenzaprine).

What is the best muscle relaxant for levator ani syndrome?

There is no single best muscle relaxant for levator ani syndrome, but doctors commonly prescribe medications like diazepam or baclofen.

These muscle relaxants help reduce pelvic floor muscle spasms and relieve chronic pelvic pain. Diazepam may be used orally or as a vaginal or rectal suppository for targeted relief. Baclofen works by decreasing nerve signals that trigger muscle tightness. In some cases, cyclobenzaprine is also recommended for short-term symptom control. Medication is often combined with pelvic floor physical therapy for better results.

Author
Tamer Seckin, MD
Date: February 15, 2021

Dr. Seckin is an endometriosis specialist and women’s reproductive health advocate. He has been in private practice for over 30 years at Lenox Hill Hospital with a team of highly skilled personnel.

Dr. Seckin specializes in advanced laparoscopic procedures and is recognized for his expertise in complex cases of deep infiltrating endometriosis of the pelvis. He is particularly dedicated to performing fertility-preserving surgeries on cases involving the ovaries.

He has developed patented surgical techniques, most notably the “Aqua Blue Excision” technique for a better visualization of endometriosis lesions. His surgical techniques are based on precision and microsurgery, emphasizing organ and fertility preservation, and adhesion and pain prevention.

Dr. Seckin is considered a pioneer and advocate in the field of endometriosis.