EP328 - Botulinum Toxin for Chronic Pelvic Pain: Short-Term Relief in Refractory Levator Ani Syndrome

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Purpose/Background: Levator ani syndrome (LAS) is a diagnosis of exclusion, characterized by non-specific symptoms such as anal and rectal pain, levator muscle spasms, and constipation. LAS significantly impacts quality of life and is difficult to diagnose and treat. While botulinum toxin (Botox) injections have been safely used to manage LAS, their efficacy is uncertain. We present two cases of suspected LAS treated with Botox injections into the internal anal sphincter and levator muscles, resulting in short-term symptom relief.

Methods/Interventions: • Patient 1: A 42-year-old female with history of an anal fissure presents with chronic constipation, anorectal pain and spasms suggestive of LAS. Despite conservative treatments (dietary changes, pelvic floor physical therapy, stool softeners, laxatives, and muscle relaxants), her symptoms persisted. Following a recurrent fissure after fissurectomy, she underwent Botox injections in the operating room: the intersphincteric groove was identified and internal anal sphincter was identified by palpation (similar to closed partial internal sphincterotomy), 100 units of Botox was then injected into the internal anal sphincter. The left levator was then identified and isolated between the index finger (internal) and thumb (external) and 50 units of botox was injected, this was repeated for the right side (total of 100 units into levators).

• Patient 2: A 68-year-old female presents with several years of anal pain, constipation, and recurrent fecal impaction, often exacerbated by stress. Conservative management including dietary modifications, bowel regimens, and pelvic floor physical therapy was unsuccessful. An anorectal exam revealed increased sphincter tone. She underwent examination under anesthesia (EUA), fecal disimpaction, and Botox injections following the same protocol as Patient 1.

Results/Outcomes: • Patient 1: Following the initial Botox injection, the patient showed significant improvement in constipation and pain, with the anal fissure healing within two months. Her bowel regimen was reduced, and her quality of life improved. Six months later, her symptoms recurred, and a pre talk exam showed no evidence of an anal fissure. She received a second Botox injection in the operating room by the same protocol as above, leading to symptom resolution at her three-month follow-up.

• Patient 2: After Botox treatment, the patient reported improvement in anal pain, spasms, and constipation but remained dependent on an aggressive bowel regimen. Four months later, her symptoms recurred along with fecal impaction, requiring another disimpaction and Botox injection (as above). At two-month follow-up, she experienced symptom relief but continued laxative use.

Conclusion/Discussion: Botox injections appear to be a safe option for treating LAS, providing short-term symptom relief. Both patients in this report experienced symptom recurrence after 4-6 months, which is consistent with typical Botox duration. In these cases, Botox was injected into both the internal anal sphincter and levator muscles, addressing anal fissures (Patient 1) and increased sphincter tone (Patient 2). This dual-targeted approach may enhance treatment outcomes. While Botox offers temporary relief for refractory LAS cases, further research is needed to assess optimal dosing, time to re-injection, and long-term effects. In-office Botox administration could also provide a cost-effective alternative, potentially minimizing anesthesia-related risks associated with operating room procedures.