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New Treatments for Levator Ani Syndrome and Proctalgia Fugax

Proctalgia, or perirectal pain, was first described in the 19th century. Three terms are used to classify proctalgia: levator ani (or levator spasm) syndrome, proctalgia fugax, and coccygodynia. Levator ani syndrome refers to chronic or recurrent rectal pain or aching, with episodes lasting 20 minutes or longer in the absence of organic disease that could account for the pain levator ani syndrome, anal pain, rectal pain, proctalgia fugax, proctalgea. Proctalgia fugax connotes anal or rectal pain, lasting for seconds to minutes.

Coccygodynia usually describes tenderness of the tip of the coccyx and is synonymous with levator ani syndrome. Both levator ani syndrome and proctalgia fugax are common disorders. It is estimated that 6% of the United States population suffers from levator ani syndrome, while 8% have proctalgia fugax. Proctalgia fugax was at one time thought to be a disorder of perfectionistic young men. It is now apparent that both proctalgia fugax and levator ani syndrome occur slightly more often in women. Both are more common in patients under age 45; psychological factors

Cause and Pathophysiology

Levator Ani Syndrome

Thiele generally is acknowledged as the first to recognize the relationship between levator ani muscle spasm and chronic intermittent rectal pain. The levator ani consists of pain in the pelvis.

Proctalgia Fugax

The cause of proctalgia fugax is not known, but current theories favor rectal muscle spasm. Anal manometric studies have demonstrated that patients with proctalgia fugax have normal anorectal muscle function at rest, but develop anal smooth muscle dysfunction.

Proctalgia fugax may be associated with functional gastrointestinal disorders. Abdominal pain and distension, frequent loose stools, and a sensation of incomplete evacuation.

Treatment and Patient Education

Management of levator ani syndrome and proctalgia fugax is controversial. No single treatment has been unusually successful in all patients. Patients with levator ani syndrome and proctalgia fugax should be reassured that their painful attacks are benign and often diminish over time.

Levator Ani Syndrome

For patients with levator ani syndrome, initial conservative treatment with hot baths, nonsteroidal anti-inflammatory drugs, muscle relaxants, or levator muscle massage is recommended. Levator muscle massage consists of high, deep, digital pressure over the puborectalis portion of the levator floor. This procedure is repeated every 2 to 3 weeks for two to three courses. One-half to two-thirds of levator ani syndrome sufferers improve.

In the 1980s, several researchers tried electrogalvanic stimulation of the levator muscle. Early studies reported a 90% success rate, but subsequent investigations demonstrated a long-term failure rate of 32% to 60%. More recently, researchers using EMG-based biofeedback have shown improvement in pain in some studies.

Proctalgia Fugax

Recommendations for treatment of proctalgia fugax are limited to anecdotal reports and a single randomized controlled trial. Fortunately for most patients, the attacks are brief and infrequent. For patients with frequent attacks, physical modalities such as hot packs or direct anal pressure.

Diltiazem has helped at least two patients, and oral clonidine provided relief for another. A recent, randomized, controlled trial of albuterol in 18 patients with proctalgia fugax showed significant reduction in duration of pain compared with placebo. Although intriguing, the authors could not commit to recommending albuterol for proctalgia fugax.