Levator Ani Syndrome Presenting with Vaginal Pain

Abstract

Levator ani syndrome (LAS), also known as levator ani spasm, puborectalis syndrome, chronic proctalgia, pyriformis syndrome and pelvic tension myalgia, produces chronic anal pain. The levator ani muscle is susceptible to the development of myofascial pain syndrome, and trigger points may be elicited on physical examination. The pathophysiology remains to be fully delineated. The diagnosis of LAS is suggested primarily by the clinical history, physical examination and the exclusion of organic disease that can produce recurrent or chronic proctalgia. Digital massage, sitz bath, electrogalvanic stimulation and biofeedback are the treatment modalities most frequently described in the literature. Pharmacological management includes non-steroidal anti-inflammatory medications, diazepam, amitriptyline, gabapentin and botulinum toxin. The evaluation of these patients can be challenging due to a diversity of causative factors. The authors present the case of a nulliparous woman in her mid-30s presenting with acute onset of lower abdominal and rectal pain radiating to her vagina. There was no history of trauma, inflammatory bowel disease, anal fissure or altered bowel habit. Each pain episode lasted longer than 20 min and was exacerbated by sitting. Neurological examination showed no evidence of neurological dysfunction. Rectal examination was unremarkable. During vaginal examination, palpation of the levator ani muscles elicited pain indicating pelvic floor dysfunction. Laboratory investigations including a full blood count and C reactive protein were within normal range. Further investigation with a transabdominal ultrasound scan, CT of the abdomen and pelvis and MRI of the lumbar spine were unremarkable. She commenced treatment with amitriptyline 20 mg once daily. She was referred for pelvic floor physiotherapy. Functional pain syndromes, such as LAS, should be regarded as diagnoses of exclusion and considered only after a thorough evaluation has been performed to rule out structural causes of pain. Knowledge of the pelvic floor and pelvic wall muscles may enable the physician to identify LAS, a possible cause of chronic pelvic pain.

Keywords: Emergency medicine; Obstetrics and gynaecology; Surgery.

Figure 1

CT of the abdomen and pelvis with contrast. The copper intrauterine device (IUD) was correctly sited. There was no acute intra-abdominal pathology evident.

Figure 2

MRI of the lumbar spine, T1 and T2-weighted sagittal images. The lumbosacral spine was unremarkable. There was no other imaging abnormality which might explain the patient’s symptoms.

Figure 3

Further review of her CT of the abdomen and pelvis showed a normal levator ani muscle group.

Figure 4

Her CT of the abdomen and pelvis confirmed a normal levator ani muscle group.

Figure 5

A vaginal examination should be performed systematically (figure created by LD).