Treatment of levator ani syndrome with cyclobenzaprine

To report a case of levator ani syndrome (LAS) that was successfully treated with cyclobenzaprine.

A 26-year-old male presented with a 3-week history of severe, intermittent, aching anorectal pain that would last for 30-60 minutes per episode and occurred between 1 and 3 times per day. The pain was aggravated by squatting, with no alleviating factors. Physical examination revealed no prostate tenderness, lesions, hemorrhoids, or fissures and rectal tone was intact. The patient had moderate posterior rectal tenderness. After a standard workup, he was diagnosed with LAS and treated with oral cyclobenzaprine 5 mg 3 times daily for 7 days. The patient experienced resolution of his symptoms after 3 days of treatment and remained symptom-free 6 months after completion of therapy. The only reported adverse effect was mild drowsiness, which resolved after discontinuation of the cyclobenzaprine.

A review of the literature via StatRef (April 1965-December 2011), Ovid (April 1965-December 2011), and MEDLINE (April 1965-December 2011) reveals that existing treatment options for LAS have been limited to levator massage, sitz baths, nonsteroidal antiinflammatory drugs, diazepam, biofeed-back, botulinum toxin, steroid injections, and electrogalvanic stimulation, all of which offer minimal support. Cyclobenzaprine is a muscle relaxant; however, its mechanism of action is unclear. It is thought to influence the α and γ motor neurons in the central nervous system, which leads to the attenuation of muscle spasm. To our knowledge, cyclobenzaprine has not been reported as a treatment for LAS. In our patient, however, the clinical efficacy of cyclobenzaprine was clearly apparent.

Cyclobenzaprine effectively treated our patient's LAS. Given that cyclobenzaprine is safe, inexpensive, and shown to be effective in our case study, we believe it warrants further investigation as a first-line treatment option for LAS.