LAUSR

Levator spasm is a condition characterized by constant or frequent anal pain that is typically dull in nature. This is due either to paradoxical contraction of the puborectalis at the anorectal junction during defecation, or the failure of muscular relaxation [1]. Symptoms typically occur more than 6 months prior to diagnosis, with episodes lasting for longer than 20 min at a time, on a background of persistent rectal pain. The pain is reproduced by posterior palpation of the puborectalis during a digital rectal examination [2]. This condition must be differentiated from proctalgia fugax, which is sudden, severe pain in the anal area that lasts for seconds to minutes and then disappears between attacks [2]. When examining a patient, the thickest fibers of the pubococcygeus are located inferomedially. These fibers are called “puborectalis muscle fibers”. Patients with levator spasm typically have concomitant psychological issues that may have triggered the condition, making this a difficult condition to treat, not infrequently challenging the doctor–patient relationship. The poor management of levator spasm is partially reflected by the numerous names given to this condition including: anismus, levator ani syndrome, paradoxical contraction of puborectalis, chronic proctalgia, pelvic tension myalgia, and piriformis syndrome. The goal of therapy is to relax the muscular spasm. Injection of botulinum toxin A (Botox® Allergan) has been described as a treatment for levator spasm [3], and it must be noted that contraindications include local infection, hypersensitivity to botox, and a concomitant neuromuscular disorder. After initial success using transanal injections of Botox, we have refined our technique and now deliver the injections via a transperineal approach. The procedure is performed in a lithotomy position under general, or monitored anesthesia care (MAC) anesthesia. The patient is prepped and draped in the standard fashion. We commence the procedure by performing a pudendal nerve block, injecting 5 ml of local anaesthetic near each ischial tuberosity and 10 ml into the levators via the transperineal route. The use of local anaesthetic blockade is synergistic in the relief of symptoms, as there is a delay of 1 week in the onset of action of Botox. Recently, we have commenced using a bupivacaine liposome injectable suspension (Exparel® Pacira) for longer lasting pain relief. At our institution, we use 200 units of Botox, diluted in 6 ml of saline (3 ml in each vial) and loaded in 6 tuberculin syringes, each with a 23 gauge, 1.5 inch needle (Fig. 1). To commence procedure: