Editors

MattiV.Kairaluoma

Syndroma Pelvis Spastica

The pain may be paroxysmal and even arouse the patient at night. The duration of an attack varies from a couple of minutes to a couple of hours. Such episodic pain is also called proctalgia fugax.
Another type of pain is precipitated by prolonged sitting. This more continuous pain is called coccygodynia.
The third group of pain is continuous neuralgia-type pain in the anus (idiopathic proctalgia). It most commonly occurs in elderly women without any pathological findings.

A spasm of the levator muscle is considered the cause of the pain. The site of the pain reflects the localization of the spastic portion of the muscle.
May be associated with surgical operations in the pelvic floor area or with inflammation, endometriosis or rectal intussusception in the lesser pelvis.
Psychogenic factors often play a role.

Possible aetiological factors are assessed.
Investigations in the primary care:
- thorough clinical examination (location of the pain, tender spots, tenderness of the coccyx etc.)
- gynaecological examination (endometriosis)
- EMG of the pelvic floor (may be performed by a physiotherapist; excessive muscle tension or anismus)
- colonoscopy (tumour or inflammation in the colon)
Investigations in specialized care (rarely needed, only in troublesome cases):
- defecography or magnetic defecography (rectal intussusception; to be suspected if the pain is associated with defecation difficulties or faecal incontinence)
- MRI if necessary (cyst in the spinal nerve root canal, schwannoma etc.).
Often no clear cause for the symptom is found and the patient can be reassured of the benign nature of the symptom.
NSAIDs and spasmolytes may be effective in some cases.
If needed, proctalgia fugax can be treated with topical nitrate ointment Anal Fissure or with an oral calcium channel blocker.
Excessive tension of the pelvic floor muscles or anismus can be treated with electrical stimulation combined with biofeedback. If the patient benefits from the treatment it can be continued with a device intended for home use 1.
Trigger points identified in the levator muscle can be treated with injections containing local anaesthetic and corticosteroid.
In especially troublesome cases, sacral nerve stimulation can be tried 2.

Salvati EP. The levator syndrome and its variant. Gastroenterol Clin North Am 1987 Mar;16(1):71-8. [PubMed]
Aboseif S, Tamaddon K, Chalfin S, Freedman S, Kaptein J. Sacral neuromodulation as an effective treatment for refractory pelvic floor dysfunction. Urology 2002 Jul;60(1):52-6. [PubMed]