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Levator Ani Syndrome

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Symptoms and Treatment for Levator Ani Syndrome (spasm) using THE WISE-ANDERSON PROTOCOL

The following symptoms are most often identified with Levator Ani Syndrome. Below this list we discuss our treatment for these symptoms and also provide a more comprehensive and detailed list and description of the symptoms of Levator Ani Syndrome and other pelvic floor muscle pain.

Levator Ani Symptoms

    • Discomfort or relief after a bowel movement is common
    • The rectal pain is typically a constant or intermittent vague, dull ache, or pressure sensation high in the rectum and/or in the anal sphincter as well.
    • Pain is often worse with sitting and better with standing or lying down although some patients symptoms are aggravated with standing
    • When the doctor presses inside the sphincter or above, the muscles pressed on can be exquisitely painful
    • Pain typically occurs more on one side, or exclusively on one side
    • Temporary relief can occur in a hot bath
    • No disease can be found with conventional medical testing and the doctor typically has little to offer other than pain medications which offer little
    • The general prevalence of levator ani syndrome is approximately 6%.
    • About half of those suffering from this condition are aged 30-60 years
    • more common in women than in men
    • a small minority of patients with this condition see a doctor for this disorder
    • A significant number of people with this kind of rectal pain miss work or school
    • Depression, anxiety, and a severe reduction in the quality of life is common.
    • There is no conventional medical treatment that reliably resolves this condition
    • Patients with levator ani syndrome appear to have a general tendency to anxiety
    • As we discuss in our book and in the articles we have published, these painful muscles are the result of years of chronic tension of these muscles and at the point of pain, the patient cannot voluntarily relax these muscles
    • When pressures inside the pelvis are measured with manometry, the pressures inside the internal anal sphincter are often elevated
    • Pain may be aggravated by sitting, bowel movements, sexual activity and stress.

Levator ani syndrome is BUT one of a number of terms for chronic anorectal pain

In the 1850s a doctor first described a patient having the symptoms of levator ani syndrome. In the 1930s, the term levator ani syndrome was used to describe a disorder that involved pain in the rectal area with no evidence of pathology by a colorectal surgeon named George Thiele, who wrote the classic article on this condition in 1937. He reported that studies that he and his colleagues participated in showed a majority of the patients felt relief through the massage of the levator muscles which were painful and often in spasm.

Simply put, levator ani syndrome (sometimes called levator syndrome, levator spasm, pelvic floor dysfunction, chronic proctalgia, puborectalis syndrome, piriformis syndrome, or chronic proctalgia) is experienced as rectal pain.

Both men and women can suffer from this kind of pain, on either an intermittent or constant basis. This diagnosis is an imprecise one because the diagnosis implies that the problematic pain is found in the levator ani muscle which is found up inside the pelvic floor. In fact, what is called levator ani syndrome, in our view, is more properly called pelvic floor dysfunction, chronic proctalgia, or simply chronic pelvic pain syndrome because in this condition, many of the muscles of the pelvic floor can be painful and not just the levator muscle. Levator ani syndrome typically refers to pain that is experienced in the posterior or back part of the pelvis as opposed to patients with pelvic pain who experience more anterior symptoms like supra pubic and genital pain, although those diagnosed with levator ani syndrome sometimes complain of these anterior symptoms as well.

Relieving Levator Ani Syndrome With The Wise-Anderson Protocol

Over the last 21 years, we have helped a large number of patients who were previously diagnosed with levator ani syndrome. The following are some key points from our experience and understanding of what is referred to as levator ani syndrome:

  • In our 2009 Journal of Urology trigger point study, the relationship between levator ani pain and trigger points was documented.
  • In our 2009 Journal of Urology trigger point study, we document that trigger points in the levator ani and other pelvic muscles can refer pain to different places in the body.
  • Pain from levator ani syndrome in selected patients, even when it lasts for years, can reduce and sometimes resolve with proper treatment involved in reducing or release painful trigger points in the levator muscles.
  • A major focus of the Wise-Anderson Protocol is helping to relieve pain in the levator ani muscle.
  • The Wise-Anderson Protocol trains patients to release trigger points in the levator ani and other pelvic muscles and to relax the muscles related to levator ani pain.
  • In our 2011 study published in the Clinical Journal of Pain, we document that after 6 months, patients who did our protocol reduced the sensitivity of their trigger points from 7.5 to 4, a significant reduction in such sensitivity.
  • Our protocol is aimed at reducing or resolving pain in the levator and other muscles in the pelvic floor through internal trigger point release with our newly FDA approved Internal Trigger Point Wand and through the reduction of nervous arousal that we believe originally caused the contraction of the levator ani and other muscles of the pelvic floor.

Sitting triggers or makes symptoms worse

Sitting typically triggers symptoms or makes symptoms worse for patients diagnosed with levator ani syndrome. For those with intermittent pain, pain can be set off by sitting, standing, or lying down. Some patients also complain of constipation, post bowel movement pain or relief, tailbone pain and/or low back pain. It is estimated that more of these patients are women, and that this condition seems to affect people at midlife.

When a digital-rectal examination is performed, pain is elicited by pressing on a small area within the levator ani muscle as well as other internal muscles. The tissue feels like a tight band. Often, though not always, the tenderness is more on one side.

Urinary frequency and urgency are uncommon, but possible, with levator ani syndrome

Levator ani syndrome is infrequently associated with urinary symptoms and/or pain during or after sex although these symptoms can co-exist with a diagnosis of levator ani syndrome. While proctologists/colorectal surgeons (doctors who specialize in disorders of the colon and rectum) naturally tend to see patients with levator ani syndrome, gastrointestinal doctors, urologists, gynecologists and physical therapists also see such patients and give these symptoms different names, which can be confusing for the patient.

Different names are given to muscle based pelvic pain including the name levator ani syndrome

Because of the lack of communication between different specialties of medicine and the current state of physician training, muscle based pelvic pain, whether felt in the back or front of the pelvic floor, is diagnosed as a number of supposedly different conditions among different types of physicians, including levator ani syndrome in men and women, prostatitis (in men), pelvic floor dysfunction in men and women, chronic pelvic pain syndrome in men and women, and coccydynia in men and women, among other diagnostic categories. The different names given to the condition substantially identical to what is considered levator ani syndrome can include:

  • levator spasm
  • pelvic floor dysfunction,
  • chronic proctalgia,
  • puborectalis syndrome
  • piriformis syndrome
  • chronic proctalgia
  • prostatitis
  • chronic anorectal pain
  • coccydynia
  • coccygodynia

All of these different diagnoses has, obviously, led to much confusion among patients and doctors. Our research is based on our treatment of muscle based pelvic pain conditions regardless of the name of the disorder. Our understanding is that all of these diagnoses possess the same root cause.

How We Can Help

Our 6-day clinic has been successful in training a large majority of patients to use the Wise-Anderson Protocol to reduce pelvic floor tenderness by repetitively releasing the spasm, trigger points and restriction in the levator ani muscle and other muscles of the pelvic floor numerous times per week, using the Internal Trigger Point Wand that we have developed.

While the conventional treatment rarely contains a comprehensive protocol to reduce anxiety and the upregulated nervous system, the Wise-Anderson Protocol trains patients in regular relaxation of the pelvic muscles and the reduction of nervous system arousal using Paradoxical Relaxation, which is a central part of the treatment that is done. Training patients in physiotherapy self-treatment and pelvic floor relaxation is the central goal of the 6 day clinic. Our goal in training patients to do self-treatment is to help them become free of the need for further professional help.

6-Day Treatment Clinic for Levator Ani Syndrome and Related Conditions

About the Wise-Anderson (Stanford protocol) Clinics for Levator ani Syndrome

The Wise-Anderson Protocol (popularly called the Stanford Protocol on the internet) is a pioneering treatment first developed and used in the Department of Urology at Stanford University and later in comprehensive 6 day immersion clinics in which patients are trained in self-treatment in all of the physical, psychological and behavioral parts of the method. Our team originally developed the Wise-Anderson Protocol (Stanford Protocol) and has treated pelvic pain patients for over 21 years using the protocol. In the latest published research, it was shown to help a majority of patients who attended the 6-day immersion clinic. Below we will refer to Levator Ani Syndrome as simply pelvic pain.

The Wise-Anderson Protocol trains patients who suffer from pelvic pain in a method whose aim is to enable them to rehabilitate their chronically contracted and spastic muscles of the pelvic floor and to relax the nervous system that feeds the pelvic tension and perpetuates chronic pelvic pain. The immersion clinics are offered privately to eligible patients in a monthly 6-day immersion formats and are held in Santa Rosa, California.

The clinic is limited to 14 patients who learn the protocol in private and group sessions. The aim of these clinics is to train patients in how to reduce or resolve their pelvic pain and related symptoms without the need for ongoing professional assistance.

In the past there has been no solution.

Chronic pelvic pain syndromes have been a puzzle to the best medical minds for a century. Antibiotics, anti-inflammatories, prostate massage, and surgical procedures, which form the backbone of traditional treatments, have been of little use in dealing with these debilitating afflictions. Most patients with pelvic pain fade into the background, stop going to the doctors and suffer silently. Some undergo heroic procedures and surgeries that only complicate their condition.

New treatment that rehabilitates the pelvic muscles.

In A Headache in the Pelvis, we describe a new treatment protocol developed over a period of 8 years at Stanford University’s Department of Urology that has stepped out of the box of conventional medical treatment. This treatment comprehends the nature of pelvic pain, which is typically a condition of ongoing spasm and contraction in the muscles of the pelvis that can cause havoc with urination, defecation, ejaculation, sitting, and other basic kinds of functions. This involves a treatment that has been successful in substantially reducing or resolving the symptoms of pain and dysfunction in a select group of men and women with chronic pelvic pain syndromes. This protocol is based on a new understanding that chronic pelvic pain syndrome is not caused by prostate, bladder, or other organ pathology but instead by chronically contracted pelvic floor related muscles that can cause a variety of difficult symptoms that few can understand unless they have actually experienced it. The Wise-Anderson Protocol (Stanford Protocol) is an inter-disciplinary treatment. It addresses the physical and behavioral and psychological dimensions of this psycho-physical problem.

The Content of the clinics

  • Individual medical evaluations are done with physicians associated with our clinics prior to the intensive program, at which time the nature of the condition of the participants will be evaluated and the appropriateness of the treatment protocol determined.
  • Participants undergo a specific form of physiotherapy training consisting of pelvic floor related Trigger Point Release developed for chronic pelvic pain syndromes and physiotherapy self-treatment instruction on a daily basis.
  • Participants are trained to use an FDA approved Internal Trigger Point Wand that that allows the patient to safely and effectively loosen the pelvis in a way that has only been available through competent, professional treatment.
  • Training in Paradoxical Relaxation of the pelvis. A year-long plus, 60 lesson (40 hour) audio course in Paradoxical Relaxation is an integral part of the instruction during the clinic and is geared toward training participants to use the recorded lessons of the course at home. Specific cognitive strategies for reducing the impact of frequent negative/catastrophic thinking that accompanies chronic pelvic pain syndromes are part of the curriculum.
  • The main goals of the Wise-Anderson Protocol are to train participants to self-administer the physiotherapy and behavioral components of treatment at home on a regular basis. Patients receive a map of their trigger points and areas of restriction. Pelvic floor physiotherapy is done in conjunction with regular paradoxical relaxation.

Our patients are typically people who have had pain and dysfunction for years, have seen numerous doctors, and have unsuccessfully used the conventional treatments. We have established these monthly 6 day clinics to allow us to treat in a 6 day period patients who live far away. We believe that they are the most effective and comprehensive form of the treatment available, as described in our book, A Headache in the Pelvis. Perhaps the greatest suffering for patients with pelvic pain is the sense of helplessness that they feel in the presence of their chronic pelvic pain and dysfunction. The aim of the Wise-Anderson Protocol is to empower patients to help resolve their own symptoms through their own skillful efforts.

When we are successful in helping people with this problem, our help is in the form of giving patients the tools to reduce or stop their symptoms. When participants comply with the home practice portion of the protocol, many experience windows of symptom reduction or resolution. Stable reduction or resolution of symptoms in patients who do respond to our protocol (we do not help everyone) can take months to a few years and in many individuals who respond to our treatment, improvement tends to continue over time with the use of the protocol. These clinics train participants to do self-treatment at home. They are done in a small group and consist of approximately 20-30 hours of treatment over the period of 6 days.

Below we provide an exhaustive, comprehensive list of symptoms we have seen in the pelvic pain patients that come to our clinics related to the diagnosis of Levator Ani Syndrome.

A Comprehensive List of Levator Ani Related Symptoms Treated by the Wise-Anderson Protocol

Below is an exhaustive list of symptoms of muscle based pelvic pain related to the diagnosis of Levator Ani Syndrome.  Most patients have from several to many of the symptoms.  Rarely do patients experience all of the symptoms.

Perineal pain

  • Perineum is one of the most common sites of pelvic pain, is intimate, can hurt 24/7 and can be very distressing
  • The perineum is the place where most muscles of the pelvic floor attach and therefore has many sources of referred pain and can be on one side or another
  • Perineum is often the site of bicycle riding pain
  • Perineum pain can be made worse by sitting or standing
  • In a 2009 Stanford study of our work published in the Journal of Urology, it was documented that 79% of subjects complained of pain in the perineum
  • In our 2009 study we documented key abdominal and pelvic muscles that all refer pain to the perineum (rectus abdominus, adductor magnus, and coccygeus)
  • The perineum and the anal sphincter are parts of the body where the patients feel the feeling of “sitting on a golf ball”
  • Chronic perineal pain is intimate pain and can be very distressing

Dyspareunia (pain with sexual activity in women)

  • Sexual activity can be painful either during or afterward
  • Pain is felt on the outside of the vagina, inside or both
  • Pelvic examination in which trigger points are palpated can often recreate symptoms of pain during sex

Sitting pain

  • Sitting can trigger or exacerbate discomfort/pain/symptoms
  • Sitting is one of the great sufferings and scares in pelvic pain and makes all aspects of normal life difficult
  • Sitting pain makes one acutely aware of how sitting is the center of social and work life
  • Sitting pain usually starts out milder in the morning but after sitting through the day, there is increased discomfort that can last into the night
  • Patients often look for the padded seats in a restaurant because sitting is so uncomfortable
  • Sitting pain can make it miserable to sit with friends or family and socialize
  • Difficult to fly or drive for any distance without pain
  • Sometimes patients have to go on disability because they can’t work because their job is a sitting job
  • Sitting pain is one of the symptoms that raises the fear that you might not be able to work or function
  • Most patients endure sitting pain and deal with the increase of pain during the day

Genital pain

  • Women can have pain inside the vagina, on one side or another is common
  • In women, sometimes vulvar pain accompanies pelvic pain
  • We have found that in muscle based pelvic pain, genital pain usually referred from the anterior levator ani muscle of the pelvic floor

Coccyx (tailbone) pain or coccygodynia/coccydynia

  • Tailbone pain is common
  • It is typically referred pain from the pelvic floor or muscles attached to the tailbone and not from the tailbone itself
  • Many patients` we have seen who had their tailbones removed typically felt no relief
  • Coccyx pain is often related to post bowel movement pain

Low back pain (on one side or both)

  • Low back pain is common and often confuses patients and practitioners because the symptoms are referred from the muscles of the pelvic floor, not the low back
  • Discomfort can be on one side or another or migrate from one side to another

Ct Scan, MRI’s, Xray, and other tests fail to detect anything problematic in those with muscle based pelvic pain

  • What is disconcerting to many patients with chronic pelvic pain syndromes is that the conventional medical testing including imaging, blood and urine tests fail to document any abnormalities or point in any therapeutic direction.  Conventional medical treatment including antibiotics, alpha blockers, anti-inflammatories, analgesics and all surgeries and procedures tend to fail in helping symptoms as well

Discomfort or relief after a bowel movement

  • Relief after a bowel movement occurs when the tight pelvic muscles relax
  • Discomfort after a bowel movement can be particularly disconcerting when people have post bowel movement pain if the post bowel movement pain triggers symptoms more strongly for the rest of the day
  • Little is written about this symptom when it occurs in the absence of hemorrhoids or anal fissures, but in our experience it is common
  • The mechanism of defecation typically involves the filling up of the rectum with stool, which then sends a signal for the internal anal sphincter and puborectalis muscle to relax and triggers the experience of urgency to have a bowel movement
  • Once the stool passes through the relaxed anal sphincter and out of the body, the internal anal sphincter reflexively closes.
  • When someone has pelvic pain and exacerbation of symptoms after a bowel movement, we propose that the internal anal sphincter tends to ‘over close.’
  • That is, it tightens up more than it was tight before the bowel movement and sometimes appears to go into a kind of painful spasm
  • Post bowel movement pain appears to occur less frequently when someone is relaxed and not hurried, and whatever contributes to a more relaxed state during a visit to the bathroom may reduce this symptom
  • Resolving post bowel movement pain in our patients tends to occur as their entire chronic pelvic muscle tension releases

Symptoms can migrate or change location

  • It is not uncommon for symptoms to change location or ‘migrate’
  • Sometimes pain or sensation will appear in one part of the pelvis or abdomen and then the next day it is elsewhere

Heat (hot bath or shower, heating pad) helps temporarily

  • Hot water or heat often helps temporarily
  • Cold weather flares up symptoms in some patients

Benzodiazepines temporarily reduce symptoms when first used

  • The family of drugs called benzodiazepines can often relieve symptoms for a few hours and are helpful when used skillfully
  • Benzodiazepines are addictive and when used regularly for pelvic pain they can lose their effectiveness
  • Benzodiazepines typically make the user tired and should not be used when driving or having to be alert

Reduced libido (reduced interest in sex)

  • Reduced interest in sex is common with pelvic pain
  • In pelvic muscle related pelvic pain, there is typically no pathology of the physical structures involved in sexually activity
  • Our view is that reduced libido is a mix of anxiety, reduced self-esteem and pelvic pain which all mitigate against sexual arousal and sexual interest and resolution of pain and dysfunction of the pelvic muscles usually resolves reduced libido

Anxiety and catastrophic thinking

  • The most difficult part of pelvic pain tends to be the catastrophic thought that it will never go away
  • Most patients who have chronic pelvic pain are preoccupied with their pain
  • Anxiety and catastrophic thinking distracts patient’s attention away from life and paints an unacceptable picture of the  future


  • When one is in the throes of pelvic pain, the thought that it will never go away triggers depression in many patients
  • Where doctors cannot help and one sees no light at the end of the tunnel, depression and/or anxious depression is the rule rather than the exception
  • Depression involves the feeling of helplessness about doing anything about what feels critically wrong in one’s life

Social withdrawal and difficulty in intimate relations

  • Social withdrawal often stems from chronic pain and it distracts away from any enjoyment of the moment
  • There is a major toll that chronic pelvic pain takes on relationships on partners of those in pain
  • The difficult issues that arise from partners involve the problems that arise from the patient’s withdrawal from sex, withdrawal from going out and doing things with others, planning trips, parenting, socializing and doing the normal activities of partnership or marriage
  • Pelvic pain robs patients of the ability to be fully present in relationship with family and friends

Impairment of self-esteem

  • Self-esteem almost always goes down when one has pelvic pain
  • Men and women with chronic pelvic pain almost always worry that no one will want to be with them

Sleep disturbance

  • Sleep disturbance is common
  • Patients either wake up to urinate or because of pain and anxiety
  • We wrote a paper about precipitous rise in cortisol in the morning amongst pelvic pain patients

Stress increases pain

  • Ordinary stresses as well as extraordinary stress tend to increase symptoms
  • When stress has triggered pelvic pain, the stress tends to triggers the tension-anxiety-pain-protective guarding cycle that continues after the stress has gone
  • Helplessness and hopelessness is the real suffering with chronic pelvic pain
  • Helplessness comes from a patient’s inability to stop the pain/discomfort that is draining and scary
  • Hopelessness in pelvic pain patients arise when they can’t see anything on the horizon that might help them or change their circumstances for the better

Schedule of Clinics

2015 Clinic Schedule

January 15-20
February 19-24
April 9-14
May 28 – June 2
July 16-21
August 27 – September 1
October 1-6
November 5-10
December 10-15