Pain in the enthesis of levator ani muscle: A novel source of chronic pelvic pain

Abstract

Background: Managing chronic pelvic pain (CPP) remains a challenge due to its diverse range of causes. A newly identified anatomical entity known as the enthesis of the levator ani muscle (LAM) and its associated disorders might play a role. This paper describes a novel insight into CPP’s origin, aiming to improve accurate diagnosis and treatment. Methods: Data were collected from medical records (paper or electronic) retrospectively. The study included 112 patients meeting the criteria, divided into chronic pelvic pain (CPP) and non-CPP groups. Clinical symptoms, including location of LAM enthesis, referred pain from pain in LAM enthesis, and related lower urinary tract symptoms (LUTSs) were discussed. To identify differences in symptoms between the groups, a chi-squared test and descriptive analyses were conducted. Results: Bimanual examination revealed tender sites in the attachment of the LAM to the pubic bone. LAM enthesis pain presumably caused referred pain in at least 10 areas, primarily in the lower abdominal quadrate (40.2% to 47.3%) followed by the inguinal area (8.9% to 15.1%). Multiple LUTSs were observed, including urinary frequency (72.3%), urgency (42.9%), nocturia (53.6%), residual urine sensation (64.3%), urinary incontinence (30.3%), painful bladder (34.8%), and weak urine stream (47.9%). Patients in the CPP groups experienced significant residual urine sensation (53.6%) and bearing-down sensation (42%) compared to the non-CPP group. Conclusion: Pain in LAM enthesis is a novel cause of pelvic pain and LUTSs that warrants attention for the evaluation and management of CPP.