Evaluation of the Levator Ani And Pelvic Wall Muscles in Levator Ani Syndro m e M a rg a ret Hull Marlene M. Cort o n h ronic pelvic pain is a C h ronic pelvic pain is a difficult pro blem to evaluate and treat. debilitating condition K n ow l e d ge of the pelvic floor and pelvic wall mu s cles may enable the that affects many wo- p rovider to identify levator ani spasm syndro m e, a possible cause of men. The location of ch ronic pelvic pain. Cpain may be vague and diff i c u l t for patients to define, or it may © 2009 Society of Urologic Nurses and Associates include specific symptoms of U rologic Nurs i n g, p p . 2 2 5 - 2 3 2 . d y s p a r eunia, irritative voiding symptoms, low back and buttock Key Wo rd s : Levator ani, pelvic wall muscles, chronic pelvic pain, pain, constipation, vaginal and levator ani spasm syndrome. vulvar pain, and low abdominal pain (Lilius & Valtonen, 1973). C h ronic pelvic pain is defined as O b j e c t i v e s the complaint of pain in the lower abdomen and pelvic floor 1 . Explain chronic pelvic pain. muscles for greater than 6 months 2 . Discuss the examination process for properly diagnosing chron- and affects approximately 15% to ic pelvic pain. 20% of women 18 to 50 years of age (Jamieson & Steege, 1996; 3. Identify treatment modalities for chronic pelvic pain. Mathias, Kuppermann, Liberm a n , Lipschutz, & Steege, 1996). Patients may present for evalua- multiple times with many pro- Background tion and treatment of these com- viders before the patient re c e i v e s To d a y ’s re s e a rche rs and clini- plaints, only to be told there is a re f e rra l for a definitive diagno- cians refer to this condition as nothing physically wrong with sis. levator ani spasm/syndro m e them. This scenario may occur T h e re can be many causes of (LAS) (Hoffman, 2008; Smith, c h ronic pelvic pain, including 1959). It was first described by gynecologic sources (such as Simpson in 1859 and later by endometriosis), gastro e n t e ro l o g i c Thiele (1963), although these M a rgaret Hull, M S N , W H N P - B C , is a s o u rces (irritable bowel syn- re s e a rchers called it, somewhat Urogynecology Nurse Pra c t i t i o n e r, the d rome), urologic sources (intersti- i n a c c u r a t e l y, coccygodynia (Grant Center for Pelvic Health, St. Thomas Health tial cystitis), and musculoskeletal & Salvati, 1975). Thiele (1963) S e r v i c e s, Franklin, T N . s o u rces (sacroiliac joint dysfunc- made significant contributions to tion). This discussion will Marlene M. C o rt o n , M D, is an Associate f u rther understanding the syn- P r o fe s s o r, University of Texas Southwe s t e rn a d d r ess the specific cause of d r ome by noting that patients Medical Center, Dallas, T X . c h ronic pelvic pain attributed to who had levator spasm often dysfunction of the levator ani and complained of low back and but- N o t e : The authors reported no actual or other pelvic wall muscles. potential conflict of interest in relation to this tock pain, which are common c o n t i nuing nursing education art i c l e. Dysfunction occurring fro m complaints of people who have spasm of these muscles may N o t e : O b j e c t i ves and CNE Evaluation Fo rm coccygodynia. appear on page 232. result in significant chronic pain Even though similarities exist for the patient. between LAS and coccygodynia, UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 225 i m p o rtant diff e rences exist to Figure 1. separate them. For example, L evator Ani and Pelvic Wall Muscl e s early re s e a rch ers noticed that patients with levator ani spasm could not describe any traumatic or triggering event; unlike coccy- godynia, the symptoms of levator spasm may worsen during peri- ods of stress that led observers in the past to question a re l a t i o n s h i p between the syndrome and psy- chiatric disorders (Grant & Salvati, 1975). Furthermore, patients with spasm may experi- ence rectal pain when the levator ani muscles are palpated, but the pain may not be re p ro d u c i b l e when applying pre s s u r e or mov- ing the coccyx, as is seen in those with coccygodynia (Smith, 1959; Wright, 1969). As seen in early discussions, S o u rc e : R e p rinted with permission from Marie Sena, University of Tex a s this debate over what constitutes S o u t h we s t e r n Medical Center. LAS and coccygodynia is some- what nebulous, with much con- t roversy surrounding the defini- A n a t o m y evacuation (voiding, defecation, tion. Much of the confusion con- One of the muscle layers in and during parturition) (Cort o n , tinues to this day with disagre e- the pelvic floor is collectively 2 0 0 8 ) . ment over the evaluation and known as the pelvic diaphragm. The most commonly re c o g- diagnosis of LAS. There f o re, the This diaphragm consists of the nized components of the levator objectives of this discussion are levator ani and coccygeus mus- ani muscles are the pubococ- to provide a detailed description cles along with their superior cygeus, puborectalis, and iliococ- of the levator ani muscles and to and inferior layers of fasciae (see cygeus muscles. The pubococ- p res ent a thorough system of F i g u re 1). cygeus muscle arises from the examination of these muscles. The levator ani is a very pubic bone and inserts at the Discussion will also include a i m p o rtant muscle complex in the anococcygeal body forming a description and examination of pelvic floor and re p resents a crit- sling around the urethra, vagina, the pelvic wall muscles, which ical component of pelvic org a n and rectum. According to include the piriformis and obtu- s u p p o r t. The normal levators Delancey and Ashton-Miller rator internus muscles. While maintain a constant state of re s t- (2007), this muscle elevates the these muscles do not comprise ing contraction, maintained by vagina, perineal body, and anus. the levator ani complex, and the action of Type I (slow twitch) Spasm from this muscle can cre- t h e r e f o re, are not included as fibers that predominate in this ate low abdominal pain, back p a rt of the diagnosis of LAS, dys- muscle. This baseline activity of pain, and insertional dyspare u- function of them may impact the the levators keeps the uro g e n i t a l nia, as well as pain with re p e t i t i v e levator ani muscles, which may hiatus narrowed and draws the penile movement and thru s t i n g g r eatly affect patients with distal parts of the urethra, vagina, (see Table 1). The pubore c t a l i s c h r onic pelvic pain. Finally, and rectum toward the pubic also arises on either side f rom the some basic therapeutic measure s bones. Type II (fast twitch) mus- pubic bone and forms a U-shaped will be described. While not cle fibers allow for involuntary sling behind the anorectal junc- meant to be a complete listing of reflex muscle contraction elicited tion. The action of the pubore c- techniques and treatments for by sudden increases in abdomi- talis draws the anorectal junction LAS, this information will fur- nal pre s s u re. The levators can t o w a rd the pubis contributing to ther aide the provider in under- also be voluntarily contracted, as the anorectal angle (Cort o n , standing how some techniques with Kegel exercises and sudden 2008). Spasm of this muscle may may help relax the muscles and i n c reases in abdominal pre s s u re . result in chronic constipation as alleviate the patient’s pain. Relaxation of these muscles the anorectal canal re m a i n s occurs only briefly and interm i t- angulated, prohibiting the re l a x- tently during the processes of ation needed for proper evacua- 226 UROLOGIC NURSING / July-August 2009 / Volume 29 Number 4 Ta ble 1. al surface of the sacrum and par- such as from an episiotomy. Symptoms of LAS and Pe l v i c tially fills the postero l a t e r a l F u rt h e rm o re, the examiner assess- Wall Muscle Spasm pelvic walls. It exits the pelvis es skin integrity by looking for t h rough the greater sciatic fora- any atrophic or dermatologic Pubococcygeus: Dyspareunia, men, attaches to the gre a t e r changes that may contribute to the lower abdominal pain, low back pain t r ochanter of the femur, and p a t i e n t ’s discomfort.