All About Levator Ani Syndrome

Whether you’ve been diagnosed with levator ani syndrome or just googled “anal pain” and think this might be what's causing it, I’m so glad you're reading this. As a pelvic floor physical therapist who treats all kinds of pelvic symptoms, ranging from pain with sex to pubis symphysis dysfunction (aka ‘lightning crotch’), I know how hard it can be to deal with pain in this area of your body — and find useful information that goes beyond the basics.

First of all, I want to reassure you that having this type of 'functional anorectal pain' isn't at all unusual. Research has found that 1 in 10 people are living with anal or rectal pain that isn’t related to an injury or medical condition. Unfortunately, only one third of those individuals are likely to seek treatment (more on that later).

As unpleasant as it may be to tell a doctor that your butt hurts, ignoring anal pain is never a good idea. On the one hand, it can sometimes be a sign of a serious medical condition that requires immediate treatment. On the other, anorectal pain that isn't related to a serious condition can be successfully treated with pelvic floor PT. In either case, getting help sooner rather than later is the best thing to do for your health and wellbeing.

If you haven’t yet seen a doctor about your pain or are still considering your treatment options, below are some important things to know about levator ani syndrome. If you're having general anal pain and want an overview of possible causes, check out our guide here.

Where are the levator ani muscles located?

The levator ani is a group of 4 small muscles that are part of your pelvic floor: the puborectalis muscle, the pubococcygeus muscle, and the iliococcygeus muscle. These muscles surround the openings in your pelvic floor, including the urethra, vagina, and anus. You'll find them in the upper right hand corner of the diagram below:

In addition to your inner and outer anal sphincters, the levator ani muscles help to control fecal continence — aka your ability to hold in poop. Needless to say, they're pretty important to your day-to-day functioning.

What is levator ani syndrome and how is it diagnosed?

Levator ani syndrome (LAS) is a ‘functional anorectal pain syndrome,’ which means the problem is tied to how the muscle is working vs. being the result of an underlying medical condition or injury.

In order to be diagnosed with levator ani syndrome, all of the following have to be true:

1. All other tests and screens come back negative and your anatomy looks structurally normal. It’s likely to take many doctors and appointments before you’ll receive a LAS diagnosis. Your doctors will want to make sure they don't miss anything major because pain — especially the type that wakes you at night — suggests that other structures or organs could be involved. Testing is extensive in order to rule out any other source including potentially serious conditions.
2. You experience pain in or around the rectum that is not related to pooping. The pain may come and go but it will not be directly related to the urge to have a bowel movement, passing a bowel movement or being constipated.
3. There was no obvious initial injury or event that may have triggered the pain. For example, you didn’t have a fall, give birth to a baby, or get into a car accident before noticing the pain for the first time.
4. Your pain fits specific criteria that point to the levator ani muscles. If your pain is constant or chronic with moments of increased intensity, tends to feel worse as the day goes on, lasts for more than 30 minutes, and tenderness or pain is experienced when palpating the levator ani muscles, you may be experiencing levator ani syndrome (LAS). If that’s not your experience, you may be dealing with another type of functional anorectal pain syndrome.

How is levator ani syndrome treated?

Levator ani syndrome falls into the chronic pain category, which means that there are a number of different strategies available to help manage and reduce the pain. That said, no singular treatment is known to work for everyone with levator ani syndrome.

Part of the difficulty in finding a standardized treatment is likely due to a lack of understanding of what causes functional anorectal pain syndromes in the first place. The assumption is that the pain is tied to hypertonic or non-relaxing pelvic floor muscles leading to increased pelvic pain. In the case of LAS, the levator ani muscles are the ones that are overly tight.

For some, basic lifestyle changes like sleeping with a heating pad, daily sitz baths or using a coccyx pillow while seated may be enough to reduce their rectal pain. In other instances, pharmaceutical options and botox injections directed at muscle relaxation have proven effective. Massage to the pelvic floor muscles and electrogalvanic stimulation have also been helpful in some instances.

87% of those using biofeedback for chronic anorectal pain have found lasting relief.

But, hands down, the treatment that is known to have the most positive impact is a noninvasive therapy called “biofeedback.” 87% of those using biofeedback for chronic anorectal pain syndrome have found lasting relief from their symptoms.

What is biofeedback?

Biofeedback is a treatment strategy that aims to give a person greater awareness of their body's physiological functions with the goal of improving control over that function.

An easy way to use biofeedback is with diaphragmatic breathing. In fact, it’s so easy, you can do it right now: Begin by placing one hand on your chest and another on your abdomen. As you take a normal breath, watch as both hands gently rise and fall. To isolate your diaphragm, try to keep your hand on your chest perfectly still and only allow the hand on your abdomen to move with each inhalation and exhalation. Using your hands to become aware of this movement and then using your awareness to gain better control of your breathing is a form of biofeedback.

In the case of functional anorectal pain syndromes, especially levator ani syndrome, biofeedback is used to learn what a pelvic floor muscle contraction and relaxation feels like, to practice building control over these muscles, and to improve your ability to intentionally relax those muscles — which can reduce or eventually eliminate your pain.

Biofeedback can take on many different forms. If you’re working with a pelvic floor physical therapist, examples of biofeedback can include squeezing and releasing your pelvic floor muscles around a finger, contracting and relaxing your pelvic floor while wearing electrodes near your perineum and watching a number on a screen rise or fall, or relaxing your pelvic floor as you try to push a balloon out of your rectum as though passing a bowel movement.

Pelvic floor physical therapists are trained in providing biofeedback for the pelvic floor. When you work with a PT, they'll use the best strategy in your specific case to help improve your awareness and coordination of these muscles.

Why do some people avoid treatment for levator ani syndrome?

Just learning that you have "levator ani syndrome" typically requires blood work and STD screenings; scopes to assess your colon, rectum, and anus; imaging to visualize the structures surrounding your gastrointestinal, reproductive and urinary tracts; as well as visits to urologists, gynecologists, proctologists, pain specialists, and/or gastroenterologists.

The process can be incredibly exhausting and may be the main reason why a third of people with a diagnosis of functional anorectal pain syndrome do not seek treatment afterwards. By the time a person is told "we can find nothing wrong," they may want to take a break from all the doctor visits before seeing yet another medical provider for treatment.

They also may not know that any treatment exists. Doctors don’t always recommend treatment options since it is unclear what causes pain in the first place and no standard treatment works for every patient. Also, it can be difficult to confidently recommend treatment for something they do not fully understand. Primary care doctors do their best to support all aspects of the human body but if your condition is not harmful, dangerous, or an emergency, then some doctors may have trouble understanding how to help you.

Also, many doctors may have never even heard of pelvic floor physical therapy before or, if they have heard of it, they may not understand all of the areas that physical therapy can treat or how PT might help their patients with anorectal pain.

The pain can get better!

If you have been diagnosed with a functional anorectal pain syndrome like levator ani syndrome, book a visit with a physical therapist who specializes in treating the pelvic floor. We are equipped to support you by explaining what is happening in your body, providing treatment to help reduce your symptoms, teaching strategies to manage your pain, and providing guidance to reduce the risk of future exacerbations. With the right care, you can get relief from the pain.