Levator ani

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Levator ani
Gray404.png
Left Levator ani seen from within.
Gray1079.png
Coronal section through the anal canal. B. Cavity of urinary bladder V.D. Ductus deferens. S.V. Seminal vesicle. R. Second part of rectum. A.C. Anal canal. L.A. Levator ani. I.S. Sphincter ani internus. E.S. Sphinear ani externus.
Details
Latin Musculus levator ani
Inner surface of the side of the lesser pelvis
Inner surface of coccyx, levator ani of opposite side, and into structures that penetrate it.
Inferior gluteal artery

pubococcygeus and iliococcygeus:


puborectalis:

Actions Supports the viscera in pelvic cavity
Identifiers
Gray's p.422
Dorlands
/Elsevier
m_22/12549567
TA A04.5.04.002
FMA FMA:19087
Anatomical terms of muscle

The levator ani is a broad, thin muscle, situated on the side of the pelvis.

It is attached to the inner surface of the side of the lesser pelvis, and unites with its fellow of the opposite side to form the greater part of the pelvic floor.

It supports the viscera in pelvic cavity, and surrounds the various structures that pass through it.

In combination with the coccygeus muscle, it forms the pelvic floor also called the pelvic diaphragm.

Structure[edit]

The levator ani is divided into three parts:

Origin and insertion[edit]

The levator ani arises, in front, from the posterior surface of the superior ramus of the pubis lateral to the symphysis; behind, from the inner surface of the spine of the ischium; and between these two points, from the obturator fascia.

Posteriorly, this fascial origin corresponds, more or less closely, with the tendinous arch of the pelvic fascia, but in front, the muscle arises from the fascia at a varying distance above the arch, in some cases reaching nearly as high as the canal for the obturator vessels and nerve.

The fibers pass downward and backward to the middle line of the floor of the pelvis; the most posterior are inserted into the side of the last two segments of the coccyx; those placed more anteriorly unite with the muscle of the opposite side, in a median fibrous raphé (anococcygeal raphé), which extends between the coccyx and the margin of the anus.

The middle fibers are inserted into the side of the rectum, blending with the fibers of the Sphincter muscles; lastly, the anterior fibers descend upon the side of the prostate to unite beneath it with the muscle of the opposite side, joining with the fibers of the sphincter ani externus and transversus perinei, at the central tendinous point of the perineum.

The anterior portion is occasionally separated from the rest of the muscle by connective tissue.

From this circumstance, as well as from its peculiar relation with the prostate, which it supports as in a sling, it has been described as a distinct muscle, under the name of levator prostatæ.

In the female the anterior fibers of the levator ani descend upon the side of the vagina.

Innervation[edit]

The levator ani muscles are mostly innervated by the pudendal nerve, perineal nerve and inferior rectal nerve in concert.[3]

Variation[edit]

In addition, sacral spinal nerves (S3, S4) innervate the muscles directly as well (in ~70%[3] of people). Sometimes (in ~40%[3] of people) the inferior rectal nerve innervates the levator ani muscles independently of the pudendal nerve.

Function[edit]

The levator ani muscles, in quadruped animals with tails, are responsible for moving the tail around in the act of "wagging." These muscles are not as strong in their human equivalents, as tail-wagging is more demanding than the support function that the muscles serve in humans.[4]

Clinical signifiance[edit]

Levator ani syndrome[edit]

Levator ani syndrome (also called levator spasm, puborectalis syndrome, chronic proctalgia, piriformis syndrome, pelvic tension myalgia, levator syndrome, and proctodynia) is episodic rectal pain, caused by spasm of the levator ani muscle.[5][6] The etiology is unknown, however it has been suggested that inflammation of the arcus tendon is the possible cause of levator ani syndrome[7]

Symptoms include a dull ache to the left 2 inches above the Anus or higher in the rectum and a feeling of constant rectal pressure or burning. The pain may also be felt in the low pelvis or perineum.[citation needed]

The discomfort may be relieved by walking or pelvic tightening exercises similar to Kegel exercises. Other treatments include massage of the muscle, warm baths, muscle relaxant medications, therapeutic ultrasound and biofeedback. Electrical stimulation of the levator ani muscle has been used to try to break the spastic cycle. Injection of botulinum toxin A has also been used.

Variants of levator ani syndrome include proctalgia fugax (fleeting pain in the rectum) and coccydynia (pain in the coccygeal region). Proctalgia fugax and levator ani syndrome have not been found to be of psychosomatic origin, although stressful events may trigger attacks.[5] Patients with levator ani syndrome also have "significant elevations on the hypochondriasis, depression, and hysteria scales of the Minnesota Multiphasic Personality Inventory," which is also the case in general among chronic pain sufferers.[6]

Additional images[edit]

See also[edit]

This article uses anatomical terminology; for an overview, see anatomical terminology.

References[edit]

This article incorporates text from a public domain edition of Gray's Anatomy.

  1. ^ Essential Clinical Anatomy. K.L. Moore & A.M. Agur. Lippincott, 2nd ed. 2002. Page 217
  2. ^ Wallner C, Maas C, Dabhoiwala N, Lamers W, Deruiter M (2006). "Evidence for the innervation of the puborectalis muscle by the levator ani nerve". Neurogastroenterol Motil 18 (12): 1121–1122. doi:10.1111/j.1365-2982.2006.00846.x. PMID 17109696. 
  3. ^ a b c Grigorescu BA, Lazarou G, Olson TR et al. (2008). "Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles". Int Urogynecol J Pelvic Floor Dysfunct 19 (1): 107–116. doi:10.1007/s00192-007-0395-8. PMID 17565421. 
  4. ^ Sloan, Ethel (2001, p. 53). Biology of Women, Wisconsin: CENGAGE Delmar Learning. ISBN 0-7668-1142-5 (excerpt available here)
  5. ^ a b Giulio Aniello Santoro; Andrzej Paweł Wieczorek; Clive I. Bartram (27 October 2010). Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management. Springer. p. 601. ISBN 978-88-470-1542-5. 
  6. ^ a b Bharucha AE, Trabuco E (September 2008). "Functional and chronic anorectal and pelvic pain disorders". Gastroenterology Clinics of North America 37 (3): 685–96, ix. doi:10.1016/j.gtc.2008.06.002. PMC 2676775. PMID 18794003. 
  7. ^ Park DH, Yoon SG, Kim KU, et al. (May 2005). "Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome". International Journal of Colorectal Disease 20 (3): 272–6. doi:10.1007/s00384-004-0662-9. PMID 15526112. 

External links[edit]