Treatment of levator ani syndrome: update and future developments

Abstract

Chronic proctalgia is defined by chronic or recurrent episodes of rectal pain or aching lasting at least 20 minutes in the absence of structural or systemic disease explanation for the pain syndrome. Digital rectal examination distinguishes between levator ani syndrome where the patient reports tenderness on palpation of the pubo-rectalis muscle and unspecified functional anorectal pain where no pain can be elicited. There is no consensus on its etiology, but chronic tension of the pelvic floor muscles is the most common view. Diagnosis is focused on excluding organic diseases potentially responsible for the pain. A number of small sized, non-controlled trials have evaluated different treatments for chronic proctalgia with frustrating results for both patients and physicians. A recent well designed, prospective, randomized, controlled trial has evaluated the three most commonly prescribed treatments to relax pelvic floor muscles in chronic proctalgia: biofeedback, electrogalvanic stimulations and digital massage of the levator ani. The study has provided unequivocal evidence that biofeedback is effective treatment for chronic proctalgia, but its efficacy is limited to levator ani syndrome. In these patients a paradoxical contraction of the pelvic floor muscles on attempted defecation has been documented in most cases and its therapeutic reversal do correlate with clinical benefit. Similar data have been also reported in constipation secondary to obstructed defecation. Electrogalvanic stimulation is somewhat effective and may be considered where high biofeedback expertise is not available. No treatment has been proven effective in unspecified functional anorectal pain where analgesic and antidepressant drugs retain a role in the absence of randomized, controlled trials.