Entheseal pain of levator ani muscle: A novel etiology in chronic pelvic pain and lower urinary tract symptoms—A urodynamic perspective

Background: Emerging evidence implicates levator ani muscle (LAM) entheseal pain as a novel etiology, yet its association with lower urinary tract symptoms (LUTS) remains underexplored. This study investigates the urodynamic manifestations of LUTS in patients with LAM entheseal pain. Methods: In this retrospective cohort, women with chronic pelvic pain (CPP) and LUTS underwent standardized palpation and were stratified into three groups: isolated LAM muscular pain, isolated LAM entheseal pain, and combined muscular and entheseal pain. Symptom prevalence and comprehensive urodynamic parameters were compared across groups. Results: A total of 307 patients were enrolled. Enthesis-related pain groups exhibited significantly higher prevalences of urinary symptoms, including urinary frequency (muscle pain, n = 81 vs. entheseal pain, n = 32 vs. combined pain, n = 194: 82.7% vs. 87.5% vs. 85.1%, p = 0.011), residual urinary sensation (46.9% vs. 65.6% vs. 63.4%, p < 0.001), and painful bladder symptoms (45.7% vs. 59.4% vs. 61.9%, p < 0.001). Additionally, these groups demonstrated significantly higher rates of pain-related comorbidities, including bearing-down sensation (33.3% vs. 37.5% vs. 49.0%, p < 0.001), dysmenorrhea (22.2% vs. 25.0% vs. 35.1%, p < 0.001), irritable bowel syndrome (29.6% vs. 32.4% vs. 44.3%, p < 0.001), and systemic myofascial pain (28.4% vs. 40.6% vs. 52.6%, p < 0.001). However, direct comparison between isolated muscular and entheseal pain groups revealed no significant differences in LUTS or pain comorbidities, whereas combined pain group demonstrated the highest symptom prevalence. Notably, no significant intergroup differences were observed in urodynamic parameters. Conclusion: This study demonstrates that LAM entheseal pain represents a distinct, clinically palpable entity in CPP. The inability of urodynamic evaluation to distinguish it from myofascial pain suggests that associated LUTS may reflect a shared final pathway of central sensitization rather than peripheral structural dysfunction. Its association with morning stiffness further supports a divergent pathophysiology.