The levator ani complex is composed of the pubococcygeus, puborectalis, and iliococcygeus muscles.

The levator ani muscles are innervated by the pudendal nerve branches (perineal nerve and inferior rectal nerve) as well as sacral nerves S3 and/or S4.

In general, the levator ani complex is in a state of contraction, to support the abdominal and pelvic organs.

Gross continence is aided by a forward pull on the anorectal angle between the rectum and the anal canal. Relaxation allows straightening of the angle and facilitates defecation.

Levator ani syndrome results in symptoms of a chronic idiopathic deep aching pelvic pain, versus proctalgia fugax, which is described as a sharp “electrical shock” type pain.

Digital rectal examination can palpate the puborectalis sling that often feels firm or in spasm. Palpation in the area of the coccygeal attachment can reproduce the pain.

Botulinum toxin is one management option (along with biofeedback, electrogalvanic stimulation, physical therapy, and sacral nerve stimulation), which involves injection of the toxin with normal saline into the muscle.

Symptomatic relief rates are widely variable in the literature.

Dilute the Botox injection vials with 3-1/2 mL of normal saline in each vial and loaded in six tuberculin syringes (Fig. 53-1). Load the long-acting bupivacaine in a 10-mL syringe.

With the patient in the lithotomy position, clean the inside of the anal canal first with a gauze soaked in betadine solution and then clean the skin over the perineum up to the scrotum or the vagina anteriorly and the tailbone posteriorly. On the lateral side, the preparation should go beyond the ischial tuberosity.

Carry out an anal examination by placing a finger in the anal canal and sweep the anal canal for any abnormalities (Fig. 53-2A). Insert a Hill-Ferguson anal retractor and perform a visual examination, recording any findings or abnormalities (Fig. 53-2B).