Levator syndrome, also known as levator ani syndrome, is a form of chronic proctalgia (the medical term for rectal pain). It is defined as a chronic or recurrent, dull, aching pain or feeling of pressure located high in the rectum that lasts for hours or days at a time. The condition is caused by a spasm or chronic tension in the levator ani muscles, which are a major part of the pelvic floor.

To understand this, it is essential to picture the pelvic floor. The pelvic floor is a complex “hammock” or “sling” of muscles that stretches from the pubic bone in the front to the tailbone in the back. This muscular sling has several vital jobs: it supports the pelvic organs (the bladder, rectum, and uterus or prostate), and it plays a key role in maintaining bowel and bladder control. The levator ani muscle group is the largest and most important part of this sling.

A helpful analogy is to think about a tension headache. When you are under stress or have poor posture, you might unconsciously clench the muscles in your neck and shoulders. Over time, this chronic tension can lead to a persistent, dull, aching headache. Levator ani syndrome is essentially a “tension headache of the pelvis.” For various reasons, the levator ani muscles become chronically tight and develop spasms. It is this constant, involuntary muscle tension that creates the vague, deep, and nagging ache that patients feel high in the rectum.

It is important to differentiate levator syndrome from a related condition called proctalgia fugax. While both are caused by pelvic muscle spasms, proctalgia fugax causes brief, fleeting, but often excruciatingly sharp and severe episodes of rectal pain that last for only a few seconds to minutes. In contrast, the pain of levator syndrome is a dull, constant ache that can persist for many hours or even days.

In my experience, this condition is often underdiagnosed or confused with other anorectal problems. Patients are relieved to learn it’s a muscle issue, not something more serious like cancer or infection.

The exact cause of why the levator ani muscles become chronically tense and spastic is often unknown. It is considered a functional pain disorder, which means that there is no visible structural problem such as a tumor, hemorrhoid, or infection that is causing the pain. The problem is the function of the muscles themselves.

While the specific cause is often idiopathic, several factors are thought to contribute to or initiate the development of the muscle spasm in some individuals. These can include:

• Pelvic floor injury during childbirth.
• Pelvic surgery.
• Chronic constipation and straining.
• A history of lower back problems or sciatica.
• Stress and anxiety leading to unconscious pelvic muscle clenching.

I often see levator syndrome in people who spend long hours sitting or dealing with high stress levels. The pelvic floor muscles respond to tension just like neck or back muscles, they tighten and ache.

Levator syndrome can develop gradually or appear suddenly. It is not contagious and is not a sign of a more serious underlying disease like cancer.

While it can affect anyone, some groups are at a higher risk.

• Gender: The condition is diagnosed more frequently in women than in men, possibly due to the stress placed on the pelvic floor during pregnancy and childbirth.
• Age: It most commonly affects people between the ages of 30 and 60.
• Associated Conditions: There appears to be an overlap with other chronic pain and functional disorders, such as fibromyalgia, irritable bowel syndrome (IBS), and chronic lower back pain.

Many of my patients can’t pinpoint a cause. I explain it like this: just as stress can trigger a tension headache, it can also cause rectal muscles to tighten and levator syndrome is the result.

The hallmark symptom of levator syndrome is the specific character and location of the pain. The symptoms are often chronic, having been present for many months or years before a diagnosis is made.

The key signs and symptoms include the following:

• A vague, dull ache or a feeling of pressure high up in the rectum.
• The pain is often described as feeling like “sitting on a golf ball” or a ball in the rectum.
• The pain is chronic and can be present for many hours, days, or even longer periods.
• The ache is often made worse by prolonged sitting and may be temporarily relieved by walking, standing, or lying down.
• The pain is typically located more on the left side than the right.
• The pain is usually not directly associated with the act of having a bowel movement, although it can be aggravated by it.

In some individuals, the chronic muscle tension can also lead to a feeling of incomplete evacuation after a bowel movement or contribute to urinary symptoms like frequency or hesitancy.

Patients often describe the pain as a “deep cramp” that comes out of nowhere. When symptoms are recurrent, it can create real anxiety, even though there’s no structural damage.

There is no single test for levator syndrome. Diagnosis is typically based on patient history and physical exam after ruling out other conditions. The diagnostic process, usually performed by a colorectal surgeon or a gastroenterologist, involves two main components:

1. Ruling Out Other Conditions

Your doctor will take a detailed history and perform exams and tests to make sure your pain is not being caused by another condition, such as:

• Hemorrhoids or anal fissures
• A perianal abscess or fistula
• Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
• Prostatitis in men
• Endometriosis in women
• A tumor or cancer

This workup may include a physical exam, anoscopy, and sometimes a flexible sigmoidoscopy or colonoscopy. It is the normal results of these tests that point toward a functional pain disorder.

2. The Physical Examination

The key to a positive diagnosis of levator syndrome lies in the physical examination.

• A doctor will perform a digital rectal exam.
• During the exam, the doctor will gently press on the levator ani muscles inside the rectum.
• The diagnosis is strongly supported, and often confirmed, when firm pressure on the levator ani muscle (particularly the puborectalis part on the left side) reproduces the patient’s exact, familiar pain.
• This finding of a tight, tender levator muscle in the absence of any other pathology is the cornerstone of the diagnosis.

A careful rectal exam can confirm muscle tenderness, which is key. I also spend time reassuring patients that we’re not missing something more serious, it’s part of building trust and relieving fear.

There is no cure, but treatment focuses on relieving symptoms and relaxing the pelvic floor muscles. This often requires a combination of therapies and a commitment to self-care.

1. Pelvic Floor Physical Therapy

This is now considered the cornerstone and most effective treatment for levator ani syndrome. A physical therapist who has specialized training in pelvic floor rehabilitation should perform it. The goal is to teach the patient how to relax the chronically tense muscles.

• Digital Massage and Myofascial Release: A trained therapist can perform gentle internal and external massage to release tight trigger points in the levator ani muscles.
• Biofeedback: This technique uses special sensors to give you real-time feedback on a screen, helping you to “see” your muscle activity. This allows you to learn how to consciously relax and release the tension in your pelvic floor muscles.
• Stretching and Relaxation Exercises: The therapist will teach you specific exercises and stretches to help lengthen and relax the pelvic floor and surrounding hip and back muscles.

2. Home Care and Lifestyle Measures

These are simple, accessible strategies that can provide significant relief.

• Sitz Baths: Soaking in a tub of warm water for 15-20 minutes, two to three times a day, can be very effective at relaxing the pelvic muscles and relieving the aching pain.
• Cushions: Using a doughnut-shaped or coccyx “cut-out” cushion can help to relieve direct pressure on the tailbone and pelvic floor when sitting for long periods.
• Dietary Fiber and Stool Softeners: If constipation and straining are a contributing factor, increasing dietary fiber and using a gentle stool softener can help to reduce stress on the pelvic floor during bowel movements.
• Stress Management: Techniques like deep breathing, meditation, or yoga can help to reduce overall stress and the unconscious muscle clenching that can accompany it.

3. Medications

Medications can be a helpful adjunct to other therapies.

• Muscle Relaxants: Low doses of skeletal muscle relaxants, such as cyclobenzaprine, may be prescribed.
• Nerve Pain Medications: Low doses of certain medications typically used for nerve pain, such as tricyclic antidepressants (like amitriptyline) or anti-seizure medications (like gabapentin), can help to modulate the pain signals.

4. Other Interventions

For severe or refractory cases that do not respond to other treatments, a specialist may consider:

• Therapeutic Massage: A physician can perform digital massage of the levator ani muscle in the office.
• Botulinum Toxin (Botox) Injections: Injections of Botox into the spastic muscle can sometimes be used to temporarily paralyze the spasm and break the pain cycle.

The biggest breakthrough I’ve seen is pelvic floor physiotherapy. Once patients learn to relax those muscles often with breathing and posture work, the pain becomes manageable or disappears entirely.

Levator ani syndrome is a common, real, and often frustrating cause of chronic rectal pain due to a spasm of the pelvic floor muscles. It is a benign condition that arises not from a dangerous disease, but from a persistent, involuntary spasm of the pelvic floor muscles. The journey to diagnosis often involves ruling out other conditions, but the validation of finally having a name for the pain can be the first step toward healing. I always tell patients, levator syndrome can be stubborn, but it’s manageable. With the right approach, especially physiotherapy and stress reduction, you can get your life back.

American Society of Colon and Rectal Surgeons (ASCRS). (2020). Proctalgia Fugax and Levator Ani Syndrome. Retrieved from https://fascrs.org/patients/diseases-and-conditions/a-z/proctalgia-fugax-and-levator-ani-syndrome

International Foundation for Gastrointestinal Disorders (IFFGD). (2021). Levator Ani Syndrome. Retrieved from https://iffgd.org/other-disorders/levator-ani-syndrome/

The Merck Manual Professional Version. (2023). Levator Syndrome. Retrieved from https://www.merckmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/levator-syndrome