Levator Ani Syndrome

levator - ani - charlie - horseLevator Ani Syndrome has been described as “a chronic charlie-horse up inside the pelvis” but it is also known by a few other names; rectal spasm, levator spasm, puborectalis syndrome, chronic proctalgia, proctodynia, coccygodynia, pyriformis syndrome, proctalgia fugax, chronic anal pain syndrome and pelvic tension myalgia. Levator Ani Syndrome consists of pain, pressure, and discomfort in the region of the rectum, sacrum, and coccyx, which appears to be aggravated by sitting.

The levator ani is a broad, thin muscle inside the pelvis that tightens and relaxes to aid in a number of bodily functions, including bowel movements.

Studies dictate that more than 50% of affected people are aged 30-60 years, and it is more common in women than in men.

Symptoms of Levator Ani Syndrome

Patients usually present to a doctor or therapist with chronic or recurrent rectal pain or aching. The pain is often described as a vague, dull ache, or pressure sensation high in the rectum. Attacks often occur suddenly at night, waking patients from sleep.  In some cases, attacks may occur when the patient is straining to produce or after a bowel movement. For those with intermittent pain, pain can be set off by sitting, standing, or lying down. Some patients also complain of constipation, post bowel movement pain or relief, tailbone and/or low back pain.

Pelvic floor muscle spasms can also cause tightness, burning, and a sensation that the rectum is full. Sometimes the pelvic muscle spasm is caused by a trapped nerve or ligament, or some sort of adhesion or restriction in the pelvis. Again, it may be aggravated by sitting, bowel movements, sexual activity and stress.

After a brief palpation of the posterior and lateral pelvis the therapist will identify any spasms (spasm of a portion of the levator ani is often detected as a palpable band resembling a guitar string within the muscle or focal trigger points) in the levator ani, pubococcygeus, iliococcygeus, and puborectalis muscles. Upon physical examination the therapist may find an overly contracted levator ani muscles and some pelvic floor tenderness. Tenderness is often asymmetric and more frequently affects the left than the right side. Rectal examination reveals a tender levator muscle, which when digitally pressed, reproduces the patient’s discomfort. I know you may be baulking at the idea of a rectal exam. But it really does help with the diagnosis and treatment of trigger points.

Pelvic floor muscle spasms often begin when you have a build-up of stool. But once your rectum goes into spasm, it then prevents the stool from coming out. So then you need to defecate → pressure causes spasm → you can’t go → there is a build up of feces → then you really have to go → but this increased pressure causes stronger spasm, and you are in this painful loop. The way to break this cycle is for the rectum and/or anus to relax, so that you can have a bowel movement without straining too much. 

Let’s look at some treatment methods

Apply a Hot Castor Oil Pack to Rectal Muscles

Apply cold-pressed castor oil with your fingers in a horseshoe shape from the base of your right sitz bone, up to your tailbone, across your sacrum and then down to the bottom of your left sitz bone.

Place a piece of 100% cotton or flannel over the skin where you applied the castor oil. Add more castor oil to saturate the cloth, then apply a layer of plastic (to prevent the castor oil from leaking out). Lie down in your bed on top of an old towel with a heating pad or hot water bottle directly under the area you applied the castor oil. Try this for 20-30 minutes.

Take A Hot Magnesium Bath

Magnesium is nature’s muscle relaxant. I like to take Magnesium before bed to relax my muscles.

Fill your bathtub with hot water and then add 2 ounces ofmagnesium bath - pelvic pain magnesium oil (or one ounce of magnesium oil and 1 cup of epsom salts). Do this nightly for 20-30 minutes. Play relaxing music, and focus on relaxing your abdominal and pelvic floor muscles. We sometimes do not realize that we are clenching these muscles.

Herbal Muscle Relaxants

You could try herbal muscle relaxants and anti-spasmodic’s.  Some people have found relief using cramp bark and black haw. These herbs are said to relax cramping in all smooth muscles, including levator ani muscles and the rectum. They are typically used to relax the uterus. (I have never used this, so can’t say for sure)

magnesium for constipationYou could try a stool softener/bulking agent like pysllium, flax or chia seeds once a day during treatment to help keep stool soft and reduce stress/irritation on the rectum. However, sometimes these can actually cause problems in some people. Most people don’t drink enough water, so that can make fiber actually bulk up and clog the colon. (I find my nightly regiment of 500mg of magnesium oxide helps me to relax and have an easier BM in the morning)

Prevent Constipation

You really must not get constipated. I have a whole page devoted to relieving constipation.

Research on Levator Ani Syndrome

There has been much research done on using high-voltage pulsed electrogalvanic stimulation (HVPGS) to help relieve symptoms of Levator Ani Syndrome. Here are the results. (Complete Article)

Sohn et al (1982) reported that HVPGS is effective in treating patients with LS.  Eighty patients participated in the study.  Treatment duration was 1 hour per day, 3 times over a period of 3 to 10 days.  Of the 72 patients evaluated, 90 % had excellent (total relief of pain and no recurrence of levator spasm during the course of follow up) or good (with complete resolution of pain but with recurrence of levator spasm at a markedly reduced frequency during the course of follow-up) results.  Nicosia and Abcarian (1985) treated 45 patients with LS using HVPGS.  Treatment time was 15 to 30 mins administered every other day for an average of 5 treatments.  Excellent (complete pain relief) or good (relief was followed by recurrence of pain that responded completely to additional treatment) results were observed in 91 % of patients.  (Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high-voltage electrogalvanic stimulation. Am J Surg. 1982;144(5):580-582.)

Oliver et al (1985) also employed HVPGS to treat 102 patients with LS.  Patients had tried and failed conservative treatments before being included in this study.  All treatments were 60 mins in duration, and a total of 3 treatments were provided within a 10-day period.  Follow-ups consisted of 1 post-treatment office visit to the attending surgeon or by telephone interviews if the patient failed to return for follow-up examination.  Of the 90 patients with correct diagnoses, 77 % were relieved or improved after treatment. (Oliver GC, Rubin RJ, Salvati EP, Eisenstat TE. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum. 1985;28(9):662-663)

Morris and Newton (1987) reported their findings of 28 patients with LS treated with HVPGS.  The number of treatments ranged from 3 to 10 with each session lasting for 60 mins.  Overall, 75 % patients reported complete or partial relief of pain/symptoms following HVPGS treatment. (Morris L, Newton RA. Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome. Phys Ther. 1987;67(10):1522-1525.) 

In the study by Billingham et al (1987) 20 patients received an average of 5.6 treatment sessions of HVPGS treatment. Immediately after the first course of treatment, 65 % of patients achieved excellent or good results.  Several months after completion of therapy, results were classified as excellent in 4 (20 %) patients, good in 4 (20 %), fair in 6 (30 %), and poor in 6 (30 %).  The authors concluded that although the long-term results of HVPGS are not as successful as the short-term results, this modality is still a valuable adjunct in the management of patients with LS. (Billingham RP, Isler JT, Friend WG, Hostetler J. Treatment of levator syndrome using high-voltage electrogalvanic stimulation. Dis Colon Rectum. 1987;30(8):584-587.)

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