**2.3 Perineal pain syndromes**

Perineal pain syndromes are characterized by anorectal and perineal pain without anorectal or endopelvic organic disease which should be excluded. The most common perineal pain syndromes are levator ani syndrome, proctalgia fugax, and myofascial syndrome which are characterized by a chronic or recurrent anorectal and perineal pain. Etiology of these syndromes is usually idiopathic. However, they may relate to pelvic injury (fall, accident, and childbirth), surgical procedures (prostatectomy, hysterectomy, low anterior resection, spinal column, and anal fistulae), prolonged sitting in a car or train or hard surface, excessive physical activity, psychological stress, anxiety, and sexual abuse. Pathophysiology of levator ani syndrome is similar to that of dyssynergic defecation (incoordination between anorectum and pelvic floor muscles during defecation). The failure of relaxation of levator ani (puborectalis) or the external anal sphincter muscles or paradoxical contraction of them during straining to defecate was called spastic pelvic floor syndrome. Pathophysiology of proctalgia fugax has been associated with spasm of pelvic floor, abnormal contractions of internal anal sphincter, and hypertrophy of internal anal sphincter (inherited myopathy). Pathophysiology of myofascial syndrome relates to "trigger points" which are connected with the disturbance of the nerve endings and an abnormal contractile mechanism at many dysfunctional endplates. These endplates constitute the sites of active trigger points [23].
