Levator Ani Syndrome: The Literal Pain in the Butt

Levator Ani Syndrome is a deep, dull, aching pressure that can be felt in the rectum or the sacrum and coccyx and can spread throughout the pelvic floor. It can last for long periods of time and has been described as rectal pain, pressure, or overwhelming tension. It can be chronic in nature, or it can be recurrent. And by all accounts, it is quite literally, a significant pain in the butt!

The prevalence of levator ani syndrome is quite likely underreported due to the individuals not seeking support based on the nature of their symptoms. But if you look for your medical advice on TikTok…the information is abundant! Everyone is talking about it! It is not necessarily correct…but it is abundant!

The triggers for LAS  may include prolonged sitting, heavy lifting, chronic constipation (straining), incomplete bowel emptying, stress and anxiety, childbirth trauma, prolonged driving or cycling, and some people report a correlation with menstruation. Many people who suffer report that their pain subsides with standing, walking, side-lying or child’s pose, the application of heat, and using a doughnut cushion when sitting.

The role of the pelvic floor muscles in levator ani syndrome are evident when we look at the provoking factors and the mitigating factors. The puborectalis, the pubococcygeus and the iliococcygeus are the group of muscles that play a central role in LAS. These muscles are often found to be tight or overactive creating chronic spasm and tension and qualifying LAS as a muscle-based pelvic floor disorder. Understanding this helps to both explain symptoms to those suffering, and to develop a treatment plan aimed at eliminating pain.

The role of the levator ani muscles includes supporting the pelvic organs, assisting with both urinary and fecal continence, as well as allowing for defecation. They also work with the deep muscles of the core to support good posture and strong body movements and play a role in both male and female orgasms. If these muscles are in a state of overactivity or tension, there are a number of potential physical functions being impacted.

This tension may also interact with other systems in the body. The sensitization of the nearby nervous system will greatly contribute to pain perception. Not to mention the stress and anxiety, which will directly impact pelvic floor tension and in turn perpetuate the pain cycle.

So how do we determine if levator ani syndrome is the cause of your rectal pain? There are no diagnostic tests or imaging to support a diagnosis so we must focus on history, a physical examination, and we must exclude any other potential perpetuating factors that may be causing the rectal pain. The history will focus on your pain descriptors, aggravating factors, alleviating factors, and your bowel and bladder habits. The physical exam will include ensuring that there are no other physical explanations for your pain. We will rule out hemorrhoids and fissures, rectal prolapsing, and any other sinister causes. We will palpate the pelvic floor muscles, and if tolerated, we will perform an internal rectal exam to assess for tenderness and/or tightness/spasms. Levator ani syndrome is in fact, a diagnosis of exclusion and the determination of causal criteria. It this assessment that allows us to conclude LAS and develop a treatment plan that will best support your healing and start you on your journey to being pain-free.

Pelvic physiotherapy is a first line of defence for LAS because the cause of the syndrome is pelvic floor muscle dysfunction, primarily muscle tightness and spasm. We begin with pelvic floor muscle relaxation which will highlight deep breathing, PFM lengthening through stretching, myofascial release, muscle tender point release, massage, and mobilizations. Pelvic physiotherapists may use biofeedback training to provide auditory and visual cues to assist patients in learning to relax their muscles, particularly during lengthy sitting and bowel movements. This modality can also help with coordination and timing of muscle activity as well as allow patients to connect with muscles that are unfamiliar. Our goal is to ensure that pelvic floor muscle activity is harmonious, and that the pelvic floor muscles are working with the core muscles to create overall pelvic health and stability.

Education is a large part of treatment and will include an analysis of current lifestyle and potentially offer modifications that will help to reduce pain and maintain homeostasis to avoid a reoccurrence. Your pelvic physiotherapist will provide postural education and may review your workspace setup with you to ensure that you are avoiding potential triggers. We provide guidance on toileting, bowel habits and encourage proper hydration and good fiber choices. We also provide stress management strategies to assist with obtaining and maintaining a relaxed pelvic floor.

So…if you are experiencing rectal pain, and TikTok is not telling you to see a pelvic physiotherapist, this is your sign! Please do not live with pain! Seek out a pelvic physiotherapist who will help you live a much more comfortable life.

Keri Martin is a Pelvic Floor Physiotherapist and owner of A Body in Motion Rehabilitation.  She discovered her passion for Pelvic Physiotherapy in 2013 and has continued to further her education in the areas of sexual pain, incontinence, special topics in women’s health including endometriosis, infertility and post-hysterectomy treatment, gastrointestinal disorders, and oncology. Keri enjoys her work with children with paediatric incontinence, her pre-natal and post-natal clientele as well as men and women suffering with pelvic pain as a result of bladder or bowel difficulties, interstitial cystitis and prostatitis. She boasts a strong commitment to educating and empowering people to find their ultimate pelvic health.