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Levator Ani Syndrome

Levator Ani Syndrome, pelvic pain, pelvic floor dysfunction, pudendal neuralgia, pain with sitting, causes of rectal pain

Levator Ani Syndrome is a rare but exquisitely painful condition characterized by intermittent burning pain and the feeling of an incomplete bowel movement in the rectum and perineal region.  While the exact cause of levator ani syndrome is largely unknown, the pain is believed to be the result of spasm in the levator ani muscle, itself, and/or inflammation of the acrus tendon.  The overall incidence is relatively low, however it does seem to affect the female gender slight more – it is  estimated that roughly 7.4% of women in the general population have levator ani syndrome as compared to 5.4% of men.[1]

Due to the rarity of it, there is very little research on the condition and relatively little is known about it.  Fortunately, at the Ainsworth Institute of Pain Management, our physicians are experts in treating all types of pelvic pain, and can offer a variety of treatments, many of which are not available anywhere else in New York City.

Levator Ani Syndrome goes by many names: Levator spasmPuborectalis syndromeChronic proctalgiaPiriformis syndromePelvic tension myalgiaLevator syndrome, and Proctodynia

What is Levator Ani Syndrome?

levator ani syndrome, pain with sitting, pelvic painLevator ani syndrome is considered a subtype of a larger class of pain  known as “pelvic pain.”  Generally speaking, pelvic pain as a whole is considered a neuropathic condition – meaning the pain is caused by nerve damage which causes pain in the associated area.  Levator ani syndrome, on the other hand, is a combination of neuropathic and muscular which makes it much harder to tease out from other types of pain.  It is not clear if the muscle dysfunction is what led to nerve damage or the other way around.  Either way, one cannot effective treat levator ani syndrome without treating both pathologies.

It is estimated that 33-39% of woman will experience pelvic pain at least one point in their lives with as many as 20% of these cases progressing to Chronic Pelvic Pain (CPP). It is also estimated that up to 5% of the general population of women will experience CPP – that estimate rises to 20% in those with a previous diagnosis of pelvic inflammatory disease (PID). [2]  Of the various conditions that cause pelvic pain, levator ani sydrome is one of the least common, overall.[3][4]  Despite its overall rarity, it can affect as many as 7.4% of woman, and 5.4% of men.  While it is not entirely understood as to why women seems to be more susceptible to it, the obvious differences in the content of the pelvis between men and women is thought to play a role.  In men, the organ and the pelvic floor are never meant to move.  Women, the other hand, have evolved to possess a dynamic pelvic region and pelvic floor to accommodate a baby during pregnancy and musculature that can shift during the process of child birth.  It is believed that the relative lack of rigidity may play a role such that the area may be more predisposed to movement and change which leads to spasming and dysfunction.

The Pelvic Floor - A Closer Look

The pelvis is a complex circuit consisting of interweaving muscles and intertwining nerves that all sit together in a tight, compact space.  It is this complexity that makes diagnosis pelvic pain so challenging – there are dozens of potential pain generators literally stack on top of one and other, positioned a mere inch or two from each other.  As such it is extremely difficult to tell the difference between pain coming from an organ versus a muscle or a branch of a nerve.  The pelvic floor is perhaps the most complicated region within the pelvis.  The musculature of the pelvic floor carries an incredible burden on a daily basis – not only is it tasked with supporting all of the organs of the pelvis, but the contents of the abdomen as well.  As such, these muscles need to maintain enough tension to hold up all of these structures simultaneous, but not contract so much that they cause compression of blood vessels and nerves that are coursing through them. 

The muscle in the pelvic floor push and pull against one and other to create a perfect synergy that is maintained on a subconscious level that we do not even have to think about, much less worry about. The sympathetic nervous system keeps the muscles in the pelvic floor in perfect balance without our knowledge by regulating tension and blood flow on a constant basis. So if the sympathetic nervous system is thrown into disarray, the pelvic floor is going be one of the first victims.

Levator Ani Syndrome, pelvic pain, pelvic floor dysfunction, pudendal neuralgia, pain with sitting, causes of rectal pain


Looking at the muscles of the pelvic floor, the levator ani is a relatively small player on a large team.  Its role is simple – provide support to hold up the pelvic organs.  The levator ani is not single muscle but rather a name given to a group of 3 muscles that a situated on either side of the pelvic floor:

  • Pubococcygeus
  • Iliococcygeus
  • Puborectalis

Collectively, this group of muscles comprise the main source of support for the organs and viscera of the pelvic.  In addition, it contracts during orgasm.  The levator ani receives blood from the inferior gluteal artery and is innervated by several different nerves:

  • Levator ani nerve
  • Inferior rectal nerve from the pudendal nerve
  • Coccygeal plexus
  • S3 and S4 nerve roots
What are the Symptoms?

Symptoms of a Levator Ani Syndrome include:

  Dull aching or burning pain typically located slightly to the left of the anus, 2 inches above it, or even higher up in the rectum
  Intermittent episodes of pain lasting 30 minutes or longer
 Pain that is worse with sitting for extended periods of time as well as with bowel movements and stress
 Pain with intercourse or painful ejaculation
  Palpation of the levator ani muscles causes pain

What are the Causes?

As mentioned above, the exact cause of Levator Ani Syndrome is unknown.  Spasming of the levator ani muscles and/or inflammation of the arcus tendon are known to cause the pain the episodes of pain, itself, but why these 2 occurs happen in the first place is a mystery.[5]  Childbirth and surgery are suspected to be potential causes or at the very least precipitating factors that may make one more likely to develop it.

While levator ani syndrome is not considered to me a psychosomatic condition, it can be made worse with stress and anxiety.[6]  Levator ani syndrome has been associated with a high incidence of hypochondriasis, depression, hysteria, perseveration and catastophization.[7]

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How is it Diagnosed?

Levator ani syndrome is considered a “diagnosis of exclusion” meaning that it is only considered after more obvious, more common and testable conditions are ruled out.  Routine imaging like MRI and CT scan are relatively pointless for this condition except for the purpose of ruling out other causes of rectal pain.  There are no tests or specific types of exam that are particularly useful for making a diagnosis of levator ani syndrome – not even nerve blocks serve a real role.  A diagnosis is essentially made based on the presentation and pattern of the signs and symptoms.  To make a diagnosis one must have all 3 of the following:
Pain that comes and goes (pain that is constant and unrelenting is not levator ani syndrome)
Episodes of pain that last at least 30 minutes
Pain with posterior traction of the puborectalis muscle
No sensations of numbness or tingling

What are my Treatment Options?

Treatments for Pelvic PainIn most cases, those suffering from Pelvic Pain or Chronic Pelvic Pain are already under the care of either a OB/GYN or Urologist – typically, patients will consult with Pain Management Physician several months to year the onset of the pain and after other several treatment options fail.[8]  The first step in finding the right treatment for Levator Ani Syndrome is finding the right Pain Management Physician.  It is important to not only seek out someone board certified in pain management but someone with a substantial amount of experience in pelvic pain.  There are a number of self proclaimed “pelvic pain rehabilitation experts” who have no formal training in diagnosing pelvic pain, much less treating it.

The diagnosis and management of all Pelvic Pain requires a good integration and knowledge of all pelvic organ systems and other systems including musculoskeletal, neurologic, and psychiatric. A significant number of patients with Pelvic Pain may have a variety of associated problems including bladder or bowel dysfunction, sexual dysfunction, and other systemic or constitutional symptoms. Other associated problems, such as depression, anxiety, and drug addiction, may also coexist.  Once a diagnosis of Levator Ani Syndrome has been established (which is the hard part), the most important next step is to seek evidence-based care and avoid treatments that sound good.

Is a Sympathetic “Reset” Right for You?

Find a REAL Pelvic Pain Expert

pelvic specialist

Pelvic pain treatment requires a specialist with experience and precision.  At the Ainsworth Institute of Pain Management, we offer some of the most modern and cutting edge treatments for chronic pelvic pain.  Our very own Dr. Hunter is widely considered one of the WORLD’S experts in pelvic pain with a number of publications on the topic to his credit.

When looking for a specialist to treat pelvic pain, the doctor should be boarded in either pain management, gynecology or urology – make sure to ask what they are boarded in and what formal training they have in the field.  Don’t accept any substitutes.  There are a number of unscrupulous physicians out there who market themselves a “pelvic pain specialists” who have no training in pain, no training in women’s health, no training in pelvic pain…basically someone who has no business treating patients with pelvic pain.  If the person says they worked with someone or worked in a women’s health department and that’s the only experience they have, WALK AWAY

When looking for a physical therapist that specializes in pelvic floor therapy, find out how many active patients the therapists has, what exercises he/she offers and what doctor’s he/she works with in the community.  There are very few out there with the qualifications and experience so make sure to find the right one.

Hydrodissection: Science or Science Fiction

Pelvic pain is one of THE most difficult pain syndromes to treat – anyone who says any different is trying to sell something…and therein lies the problem.  There are a number of physicians marketing themselves as “Pelvic Pain Specialists” who have no business treating anyone with pelvic pain but unfortunately patients don’t know the difference until it is too late.  They know that patients with pelvic pain are so desperate that they will try anything new or different for the small hope of finding any shred of pain relief.

Evidence-Based Treatment Options

The most important first step in treating levator ani syndrome is to focus on relaxation – something as simple as taking a relaxing walk can effectively relieve muscle tension in the pelvic floor.  Massage, biofeedback, ultrasound and warm baths are also effective means of decreasing the pain. 

Differential BlockFor many patients with pelvic pain, the pain came out of nowhere and there is no known cause.  Imaging is normal…diagnostic tests are normal…no one has been able to figure out what is causing the pain or where it is coming from.  A differential block is power diagnostic tool for determining what part of the nervous system is responsible for sending the pain signals and in turn which treatment would be most appropriate.

Muscle Relaxers Muscle relaxers may be effective for decreasing tension in the pelvic floor however there are specific criteria with which this class of medications should be used. Baclofen and tizanidine are effective and proven muscle relaxers that work directly on the central nervous system and have been shown to cause muscle relaxation in even the most difficult to treat conditions like cerebral palsy.

Valium suppositories have not been shown to be effective for levator ani syndrome and can be dangerous long term due to the higher risk of addiction associated with absorption of the medication in the lower digestive tract.  Benzodiazepines in general are very addictive and have not been shown to be effective for this condition.

Cannibus (aka Medical Marijuana) – Cannibus has shown to be extremely effective in reducing muscle-related tension and relaxing muscles.  Medical marijuana is a personalized treatment whereby the pharmacist will interview you to discuss your pain and your medical history to create the proper blend and ratio to suit you, individually. It is a safe medical option with a low side effect profile.

Chemodenervation (aka Botox) – Botox is well known for its cosmetic uses, but what many people do not know is that this special medication has a number of medical uses that includes treating spasticity, headaches, eye twitches and pelvic floor dysfunction.  In the case of a spasming levator ani muscle, Botulinum toxin A can be injected in small, dilute concentrations to relax the muscle and limit its ability to contract.  This premise is the same as trigger point injection.

IV Infusion Therapy – A simple procedure commonly performed in the office. Your doctor will administer a small IV catheter, and then infuse special medications intravenously in an attempt to halt the pain process.

Superior Hypogastric Plexus Block – This procedure is used as both a diagnostic and therapeutic tool for tricking the sympathetic nervous system into cycling down, which in turn will allow the muscles of the pelvic floor to relax. Under radiographic guidance, a thin needle is inserted through the skin and advanced toward the L5 vertebra – the location of the superior hypogastric plaexus. A blockade of the superior hypogastric plexus has been reported to decrease pelvic pain by 70%.[9]Pelvic Pain New York City

Ganglion of Impar Block – Like the Superior Hypogastric Block, this procedure can also be used for both diagnostic and therapeutic purposes. This procedure is performed under radiographic guidance with the target being a small area directly in front of the coccyx (tailbone). This injection is extremely effective in treating pain originating from the cervix, colon, bladder, rectum and endometrium. Studies have reported 70-100% pain relief from this procedure.[10]

Sympathetic “Reset” When the sympathetic nervous system becomes involved in your pain, it becomes exponentially harder to treat and may explain why your pain has stopped responding to conventional treatment options.  Resetting or rebooting the sympathetic nervous system is an old fashioned technique used for treating Complex Regional Pain Syndrome (CRPS) in the arms and legs whereby a small amount of local anesthetic is injected onto a specific part of the sympathetic nervous system to temporarily turn it off and give it the opportunity to recalibrate itself at a normal level.[9]  Applying this age old concept to pelvic pain by adding growth factors from Amniotic Tissue, we are able to trick your Sympathetic Nervous System into slowing back down to a normal level.

Inferior Hypogastric Block – Similar to the Superior Hypogastric Plexus Block and the Impar blocks, this can be diagnostic and therapeutic. This procedure is typically considered when more lower and external pelvic pain and if the treating the impar is ineffective

Hypogastric Nerve Block – This is an unconventional block that not many are trained to perform due to the skill involved to reach this nerve selectively, while leaving other structures unharmed.  The hypogastric nerve connects the superior and inferior hypogastric plexuses which make it an excellent target for treating neuropathic pain.

Peripheral Nerve Block – A peripheral nerve block can be extremely effective way of treating many types pain, however not so much in levator ani syndrome.  Many physicians will tout the idea of doing a series of nerve blocks, combined with trigger point injections and something called “hydrodissection.”  Unfortunately, the nerves involved in levator ani syndrome are much too small to target individually, much less “dissect” away from the adjacent tissue to decompress them.  A nerve block may be effective insofar as blocking the pain but will not truly address the underlying cause.  There are an abundance of nerves providing innervation to the pelvic region and its organs – any of which can be targeted and blocked with a small amount of local anesthetic to provide dramatic pain relief. Many of these injections can be performed under ultrasound guidance.  Choosing the right one is based on the presentation of the pain.pudendal nerve

  • Pudendal Nerve Block
  • Genitofemoral Nerve Block
  • Obterator Nerve Block
  • Coccygeal Nerve Block
  • Inferior Rectal Nerve Block

Neurolysis & Ablation – In many cases an injection will provide relief, but this is only a temporary solution. In cases such as these, neurolysis or neuroablation can be utilized to provide longer relief. There are several different techniques available:

  • Radiofrequency Ablation (RFA) – Radio waves are applied to a nerve, subsequently stunning it and preventing from transmitting pain.
  • Chemodenervation – Small amounts of either alcohol or phenol are injected, thus blocking the nerve’s ability to transmit a signal.

S2 Dorsal Root Ganglion Block – The hard part of treating pelvic pain is finding which nerve or nerves is/are either the cause of the pain or is/are responsible for transmitting the pain signals.  The S2 level is unique in that it captures all but 1 of the pelvic nerves thus making it an excellent target for hard to treat pelvic pain.Pelvic Pain New York City Pudendal Neuralgia

Spinal Cord Stimulation – This is a regularly performed procedure utilizing technology similar to that of cardiac pacemakers. This method involves placing small electrodes into the epidural space near the spinal cord. These electrodes produce a small electrical current over the spinal cord that your brain will interpret as a gentle massage or feeling of “champagne bubbles.” In the case of pelvic pain, the leads are placed over the sacral nerve roots, or in the thoracic region.[11-12]

DRG Stimulation for Chronic Pelvic Pain Pudendal NeuralgiaDRG StimulationA variant of Spinal Cord Stimulation but way more effective.  This procedure involves placing leads a fraction of the size of traditional stimulator leads directly over the nerve levels that are transmitting the pain.  Our very own doctor discovered the use of DRG Stimulation for the use of pelvic pain by using unique lead combinations that isolate discomfort in the pelvic region.[12]

Intrathecal Pumps – This is a method whereby a small catheter is placed in the subarachnoid space and minuscule amounts of medication are delivered directly to the spinal cord and the rest of the CNS. This enables your physician to provide the same medications but at a fraction of the dose due to the proximity to the spinal cord.  More importantly, our doctors have been putting a revolutionary drug inside the pumps called ziconotide and are reported amazing successes!

The Ainsworth Institute is Here to Help
Our doctors at the Ainsworth Institute of Pain Management are experiences in managing and treating Levator Ani Syndrome. Dramatic improvements are possible with the right treatment. The sooner treatment is started, the better the chances of success. Call and schedule an appointment now with one of our board-certified pain management experts.


[1] Bharucha AE, Trabuco E. Functional and chronic anorectal and pelvic pain disorders. Gastroenterol Clin North Am. 2008;37(3):685-ix. doi:10.1016/j.gtc.2008.06.002
[2] Ryder RM: Chronic pelvic pain. Am Fam Physician. 196; 54:2225-2232.
[3] Zondervan KT, Yudkin PL, Vessey MP, et al. The community prevalence of chronic pelvic pain in women and associated illness behavior. Br J Gen Pract. 2001;51: 541-547.
[4] Fall M, Baranowski AP, Elneil S, et al. Guidelines on chronic pelvic pain. In: EAU Guidelines. Edition presented at the 23rd EAU Annual Congress, Milan, 2008.
[5] Park DH, Yoon SG, Kim KU, Hwang DY, Kim HS, Lee JK, Kim KY. Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome. Int J Colorectal Dis. 2005 May;20(3):272-6. doi: 10.1007/s00384-004-0662-9. Epub 2004 Oct 30. PMID: 15526112.
[6] Giulio Aniello Santoro; Andrzej Paweł Wieczorek; Clive I. Bartram (27 October 2010). Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management. Springer. p. 601.
[7] Bharucha AE, Trabuco E. Functional and chronic anorectal and pelvic pain disorders. Gastroenterol Clin North Am. 2008 Sep;37(3):685-96, ix. doi: 10.1016/j.gtc.2008.06.002. PMID: 18794003; PMCID: PMC2676775.
[8] Hunter C, Stovall B, Chen G, Carlson J, Levy R. Anatomy, Pathophysiology and Interventional Therapies for Chronic Pelvic Pain: A Review. Pain Physician. 2018; 21:147-167
[9] Benzon, Honorio. Essentials of Pain Medicine. Philadelphia: Saunders Elsevier, 2011. Print
[10] De Leon Casasola OA, Kent E, Lema MJ: Neurolytic superior hypogastric plexus block for chronic pelvic pain associated with cancer. Pain. 1993; 54:145-151.
[11] Hunter C, Davé N, Diwan S, Deer T. Neuromodulation of Pelvic Visceral Pain: A Review of the Literature and Case Series of Potential Novel Targets for Treatment. Pain Practice 2013;13(1):3-17.
[12] Hunter C, Yang A. Dorsal Root Ganglion Stimulation for Chronic Pelvic Pain: A Case Series and Technical Report on a Novel Lead Configuration. Neuromodulation. 2018 Aug 1. doi: 10.1111/ner.12801.