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Anatomy of the Anorectal Region and Pelvic Floor

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Anorectal Physiology

Abstract

The anorectal region and pelvic floor are crucial in maintaining continence and facilitating evacuation. The pelvic floor is a complex, three-dimensional mechanical apparatus that consists of several components: the pelvic organs and endopelvic fascia, the ligament and perineal membrane, the levator ani and superficial perineal muscles, and the pelvic nerves. The support for the pelvic organs comes from connections to the pelvis and its muscles. Any damage to the structural and functional interactions of the pelvic floor elements can potentially cause multicompartmental dysfunction. Anorectum and pelvic floor have multiple interconnections by fascia and ligaments, and these structures provide support for endopelvic viscera and aid in defecation with a coordinated action. Also, in females, the pelvic floor is part of the birth canal.

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References

  1. Vesalii Bruxellensis Andreae, de Humani corporis fabrica. De Recti intestini musculis. 1st ed. 1543. p. 228.

    Google Scholar 

  2. Church JM, Raudkivi PJ, Hill GL. The surgical anatomy of the rectum – a review with particular relevance to the hazards of rectal mobilisation. Int J Colorect Dis. 1987;2:158–66.

    Article  CAS  Google Scholar 

  3. Shafik A. A concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. Dis Colon Rectum. 1987;30:970–82.

    Article  CAS  PubMed  Google Scholar 

  4. Klosterhalfen B, Vogel P, Rixen H, Mitterman C. Topography of the inferior rectal artery. A possible cause of chronic, primary anal fissure. Dis Colon Rectum. 1989;32:43–52.

    Article  CAS  PubMed  Google Scholar 

  5. Stoss F. Investigations of the muscular architecture of the rectosigmoid junction in humans. Dis Colon Rectum. 1990;33:378–83.

    Article  CAS  PubMed  Google Scholar 

  6. Levi AC, Borghi F, Garavoglia M. Development of the anal canal muscles. Dis Colon Rectum. 1991;34:262–6.

    Article  CAS  PubMed  Google Scholar 

  7. Lunniss PJ, Phillips RKS. Anatomy and function of the anal longitudinal muscle. Br J Surg. 1992;79:882–4.

    Article  CAS  PubMed  Google Scholar 

  8. Tjandra JJ, Milsom JW, Stolfi VM, Lavery I, Oakley J, Church JM, Fazio V. Endoluminal ultrasound defines anatomy of the anal canal and pelvic floor. Dis Colon Rectum. 1992;35:465–70.

    Article  CAS  PubMed  Google Scholar 

  9. Dobson HD, Pearl RK, Orsay CP, Rasmusen M, Evenhouse R, Ai Z, Blew G, Dech F, Edison MI, Silverstein JC, Abcarian H. Virtual reality: new method of teaching anorectal and pelvic floor anatomy. Dis Colon Rectum. 2003;46:349–52.

    Article  PubMed  Google Scholar 

  10. Milligan ETC, Morgan CN. Surgical anatomy of the anal canal: with special reference to anorectal fistulae. Lancet. 1934;2:1150–6.

    Article  Google Scholar 

  11. Goligher JC, Leacock AG, Brossy JJ. The surgical anatomy of the anal canal. Br J Surg. 1955;43:51–61.

    Article  CAS  PubMed  Google Scholar 

  12. Garavoglia M, Borghi F, Levi AC. Arrangement of the anal striated musculature. Dis Colon Rectum. 1993;36:10–5.

    Article  CAS  PubMed  Google Scholar 

  13. Nivatvongs S, Gordon PH. Surgical anatomy. In: Gordon PH, Nivatvongs S, editors. Principle and practice of surgery for the colon, rectum and anus. St. Louis: Quality Medical Publishing; 1992. p. 3–37.

    Google Scholar 

  14. Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation II. Anatomy of the levator ani muscle with special reference to puborectalis. Investig Urol. 1975;12:175–82.

    Google Scholar 

  15. Oh C, Kark AE. Anatomy of the external anal sphincter. Br J Surg. 1972;59:717–23.

    Article  CAS  PubMed  Google Scholar 

  16. Bollard RC, Gardiner A, Lindow S, Phillips K, Duthie GS. Normal female anal sphincter: difficulties in interpretation explained. Dis Colon Rectum. 2002;45:171–5.

    Article  CAS  PubMed  Google Scholar 

  17. Fritsch H, Brenner E, Lienemann A, Ludwikowski B. Anal sphincter complex: reinterpreted morphology and its clinical relevance. Dis Colon Rectum. 2002;45:188–94.

    Article  PubMed  Google Scholar 

  18. Morren GL, Beets-Tan RGH, van Engelshoven JMA. Anatomy of the anal canal and perianal structures as defined by phased-array magnetic resonance imaging. Br J Surg. 2001;88:1506–12.

    Article  CAS  PubMed  Google Scholar 

  19. Williams AB, Bartram CI, Halligan S, Marshall MM, Nicholls RJ, Kmiot WA. Endosonographic anatomy of the normal anal compared with endocoil magnetic resonance imaging. Dis Colon Rectum. 2002;45:176–83.

    Article  CAS  PubMed  Google Scholar 

  20. Jorge JMN, Habr-Gama A. The value of sphincter asymmetry index in anal incontinence. Int J Color Dis. 2000;15:303–10.

    Article  CAS  Google Scholar 

  21. Swash M. Histopathology of pelvic floor muscles in pelvic floor disorders. In: Henry MM, Swash M, editors. Coloproctology and the pelvic floor. London: Butterworth-Heinemann; 1992. p. 173–83.

    Google Scholar 

  22. Fraser ID, Condon RE, Schulte WJ, Decosse JJ, Cowles VE. Longitudinal muscle of muscularis externa in human and nonhuman primate colon. Arch Surg. 1981;116:61–3.

    Article  CAS  PubMed  Google Scholar 

  23. Courtney H. Anatomy of the pelvic diaphragm and anorectal musculature as related to sphincter preservation in anorectal surgery. Am J Surg. 1950;79:155–73.

    Article  CAS  PubMed  Google Scholar 

  24. Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation III. The longitudinal anal muscle: anatomy and role in sphincter mechanism. Investig Urol. 1976;13:271–7.

    CAS  Google Scholar 

  25. Lawson JON. Pelvic anatomy II. Anal canal and associated sphincters. Ann R Coll Surg Engl. 1974;54:288–300.

    CAS  PubMed  PubMed Central  Google Scholar 

  26. Roux C. Contribution to the knowledge of the anal muscles in man. Arch Mikr Anat. 1881;19:721–3.

    Article  Google Scholar 

  27. Haas PA, Fox TA. The importance of the perianal connective tissue in the surgical anatomy and function of the anus. Dis Colon Rectum. 1977;20:303–13.

    Article  CAS  PubMed  Google Scholar 

  28. Gordon PH. Anorectal anatomy and physiology. Gastroenterol Clin N Am. 2001;30:1–13.

    Article  CAS  Google Scholar 

  29. Lilius HG. Investigation of human fetal anal ducts and intramuscular glands and a clinical study of 150 patients. Acta Chir Scand Suppl. 1968;383:1–88.

    Google Scholar 

  30. Chiari H. Über die Nalen Divertik Fel der Rectum-schleimhaut und Ihre Beziehung zu den anal fisteln. Wien Med Press. 1878;19:1482.

    Google Scholar 

  31. Parks AG. Pathogenesis and treatment of fistula-in-ano. BMJ. 1961;1:463–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Abel AL. The pecten band: pectenosis and pectenectomy. Lancet. 1932;1:714–8.

    Article  Google Scholar 

  33. Goligher J. Surgery of the anus, rectum and colon. London: Bailliére Tindall; 1984. p. 1–47.

    Google Scholar 

  34. Kaiser AM, Ortega AE. Anorectal anatomy. Surg Clin N Am. 2002;82:1125–38.

    Article  PubMed  Google Scholar 

  35. Skandalakis JE, Gray SW, Ricketts R. The colon and rectum. In: Skandalakis JE, Gray SW, editors. Embryology for surgeons. The embryological basis for the treatment of congenital anomalies. Baltimore: Williams & Wilkins; 1994. p. 242–81.

    Google Scholar 

  36. Mayo WJ. A study of the rectosigmoid. Surg Gynecol Obstet. 1917;25:616–21.

    Google Scholar 

  37. Balli R. The sphincters of the colon. Radiology. 1939;33:372–6.

    Article  Google Scholar 

  38. Otis WJ. Some observations on the structure of the rectum. J Anat Physiol. 1898;32:59–63.

    Google Scholar 

  39. Abramson DJ. The valves of Houston in adults. Am J Surg. 1978;136:334–6.

    Article  CAS  PubMed  Google Scholar 

  40. Cawthorn SJ, Parums DV, Gibbs NM, A’Hern RP, Caffarey SM, Broughton CIM, Marks CG. Extent of mesorectal spread and involvement of lateral resection margin as prognostic factors after surgery for rectal cancer. Lancet. 1990;335:1055–9.

    Article  CAS  PubMed  Google Scholar 

  41. Heald RJ, Husband EM, Ryall RD. The mesorectum in rectal cancer surgery—the clue to pelvic recurrence? Br J Surg. 1982;69:613–6.

    Article  CAS  PubMed  Google Scholar 

  42. Cantlie J. The sigmoid flexure in health and disease. J Trop Med Hyg. 1915;18:1–7.

    Google Scholar 

  43. Ewing MR. The significance of the level of the peritoneal reflection in the surgery of rectal cancer. Br J Surg. 1952;39:495–500.

    Article  CAS  PubMed  Google Scholar 

  44. Boxall TA, Smart PJG, Griffiths JD. The blood-supply of the distal segment of the rectum in anterior resection. Br J Surg. 1963;50:399–404.

    Article  CAS  PubMed  Google Scholar 

  45. Nano M, Dal Corso HM, Lanfranco G, Ferronato M, Hornung JP. Contribution to the surgical anatomy of the ligaments of the rectum. Dis Colon Rectum. 2000;43:1592–8.

    Article  CAS  PubMed  Google Scholar 

  46. Quirke P, Durdey P, Dixon MF, Williams NS. Local recurrence of rectal adenocarcinoma due to inadequate surgical resection. Histopathological study of lateral tumour spread and surgical excision. Lancet. 1986;1:996–8.

    Article  Google Scholar 

  47. Jorge JMN, Habr-Gama A, Souza AS Jr, Kiss DR, Nahas P, Pinotti HW. Rectal surgery complicated by massive presacral hemorrhage. Arq Bras Circ Dig. 1990;5:92–5.

    Google Scholar 

  48. Wang Q, Shi W, Zhao Y, Zhou W, He Z. New concepts in severe presacral hemorrhage during proctectomy. Arch Surg. 1985;120:1013–20.

    Article  CAS  PubMed  Google Scholar 

  49. Zama N, Fazio VW, Jagelman DG, Lavery IC, Weakley FL, Church JM. Efficacy of pelvic packing in maintaining hemostasis after rectal excision for cancer. Dis Colon Rectum. 1988;31:923–8.

    Article  CAS  PubMed  Google Scholar 

  50. Crapp AR, Cuthbertson AM. William Waldeyer and the rectosacral fascia. Surg Gynecol Obstet. 1974;138:252–6.

    CAS  PubMed  Google Scholar 

  51. Tobin CE, Benjamin JA. Anatomical and surgical restudy of Denonvilliers’ fascia. Surg Gynecol Obstet. 1945;80:373–88.

    Google Scholar 

  52. Sonneland J, Anson BJ, Beaton LE. Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of 600 specimens. Surg Gynecol Obstet. 1958;106:385–98.

    CAS  PubMed  Google Scholar 

  53. Michels NA, Siddharth P, Kornblith PL, Park WW. The variant blood supply to the small and large intestines: its importance in regional resections. A new anatomic study based on four hundred dissections with a complete review of the literature. J Int Col Surg. 1963;39:127–70.

    Google Scholar 

  54. Steward JA, Rankin FW. Blood supply of the large intestine. Its surgical considerations. Arch Surg. 1933;26:843–91.

    Article  Google Scholar 

  55. Griffiths JD. Surgical anatomy of the blood supply of the distal colon. Ann R Coll Surg Engl. 1956;19:241–56.

    CAS  PubMed  PubMed Central  Google Scholar 

  56. Drummond H. The arterial supply of the rectum and pelvic colon. Br J Surg. 1914;1:677–85.

    Article  Google Scholar 

  57. Ayoub SF. Arterial supply of the human rectum. Acta Anat. 1978;100:317–27.

    Article  CAS  PubMed  Google Scholar 

  58. Didio LJA, Diaz-Franco C, Schemainda R, Bezerra AJC. Morphology of the middle rectal arteries: a study of 30 cadaveric dissections. Surg Radiol Anat. 1986;8:229–36.

    Article  CAS  PubMed  Google Scholar 

  59. Bernstein WC. What are hemorrhoids and what is their relationship to the portal venous system? Dis Colon Rectum. 1983;26:829–34.

    Article  CAS  PubMed  Google Scholar 

  60. Miscusi G, Masoni L, Dell'Anna A, Montori A. Normal lymphatic drainage of the rectum and the anal canal revealed by lymphoscintigraphy. Coloproctology. 1987;9:171–4.

    Google Scholar 

  61. Block IR, Enquist IF. Studies pertaining to local spread of carcinoma of the rectum in females. Surg Gynecol Obstet. 1961;112:41–6.

    Google Scholar 

  62. Gerstenberg TC, Nielsen ML, Clausen S, Blaabgerg J, Lindenberg J. Bladder function after abdominoperineal resection of the rectum for anorectal cancer. Am J Surg. 1980;91:81–6.

    Google Scholar 

  63. Orkin BA. Rectal carcinoma: treatment. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. New York: McGraw-Hill; 1992. p. 260–369.

    Google Scholar 

  64. Balslev I, Harling H. Sexual dysfunction following operation for carcinoma of the rectum. Dis Colon Rectum. 1983;26:785.

    Article  CAS  PubMed  Google Scholar 

  65. Danzi M, Ferulano GP, Abate S, Califano G. Male sexual function after abdominoperineal resection for rectal cancer. Dis Colon Rectum. 1983;26:665–8.

    Article  CAS  PubMed  Google Scholar 

  66. Weinstein M, Roberts M. Sexual potency following surgery for rectal carcinoma. A follow-up of 44 patients. Ann Surg. 1977;185:295–300.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  67. Bauer JJ, Gerlent IM, Salky B, Kreel I. Sexual dysfunction following proctectomy for benign disease of the colon and rectum. Ann Surg. 1983;197:363–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  68. Walsh PC, Schlegel PN. Radical pelvic surgery with preservation of sexual function. Ann Surg. 1988;208:391–400.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  69. Lee ECG, Dowling BL. Perimuscular excision of the rectum for Crohn’s disease and ulcerative colitis. A conservative technique. Br J Surg. 1972;59:29–32.

    Article  CAS  PubMed  Google Scholar 

  70. Metcalf AM, Dozois RR, Kelly KA. Sexual function in women after proctocolectomy. Ann Surg. 1986;204:624–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  71. Duthie HL, Gairns FW. Sensory nerve endings and sensation in the anal region in man. Br J Surg. 1960;47:585–95.

    Article  CAS  PubMed  Google Scholar 

  72. Wendell-Smith CP. Studies on the morphology of the pelvic floor [Ph.D. thesis]. University of London. 1967.

    Google Scholar 

  73. Paramore RH. The Hunterian lectures on the evolution of the pelvic floor in non-mammalian vertebrates and pronograde mammals. Lancet. 1910;1(1393–1399):1459–67.

    Article  Google Scholar 

  74. Percy JP, Swash M, Neill ME, Parks AG. Electrophysiological study of motor nerve supply of pelvic floor. Lancet. 1981;1:16–7.

    Article  CAS  PubMed  Google Scholar 

  75. Russell KP. Anatomy of the pelvic floor, rectum and anal canal. In: Smith LE, editor. Practical guide to anorectal testing. New York: Igaku-Shoin Medical Publishers; 1991. p. 744–7.

    Google Scholar 

  76. Parks AG, Porter NH, Hardcastle J. The syndrome of the descending perineum. Proc R Soc Med. 1966;59:477–82.

    CAS  PubMed  PubMed Central  Google Scholar 

  77. Bannister JJ, Gibbons C, Read NW. Preservation of faecal continence during rises in intra-abdominal pressure: is there a role for the flap valve? Gut. 1987;28:1242–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  78. Bartolo DCC, Roe AM, Locke-Edmunds JC, Virjee J, Mortensen NJMcC. Flap-valve theory of anorectal continence. Br J Surg. 1986;73:1012–4.

    Article  CAS  PubMed  Google Scholar 

  79. Lindsey I, Guy RJ, Warren BF, Mortensen NJMcC. Anatomy of Denonvilliers’fascia and pelvic nerves, impotence, and implications for the colorectal surgeon. Br J Surg. 2000;87:1288–99.

    Article  CAS  PubMed  Google Scholar 

  80. Sudeck P. Über die Gefassversorgung des Mastdarmes in Hinsicht auf die Operative Gangran. Munch Med Wochenschr. 1907;54:1314.

    Google Scholar 

  81. Griffiths JD. Extramural and intramural blood supply of the colon. BMJ. 1961;1:322–6.

    Google Scholar 

  82. Lindstrom BL. The value of the collateral circulation from the inferior mesenteric artery in obliteration of the lower abdominal aorta. Acta Chir Scand. 1950;1:677–85.

    Google Scholar 

  83. Petros PE. The anatomy and dynamics of pelvic floor function and dysfunction. In: Petros PE, editor. The female pelvic floor—function, dysfunction and management according to the integral theory. 2nd ed. Berlin/Heidelberg/New York: Springer; 2006. p. 13–50.

    Google Scholar 

  84. Petros PE. The integral system. Cent European J Urol. 2011;64:110–9.

    Article  PubMed  PubMed Central  Google Scholar 

  85. Petros PEP, Woodman PJ. The integral theory of continence. Int Urogynecol J. 2008;19:35–40.

    Article  Google Scholar 

  86. Petros PEP. The Integral Theory System. A simplified clinical approach with illustrative case histories. Pelviperineology. 2010;29:37–51.

    Google Scholar 

  87. Petros PEP. Anatomy and surgical cure of descending perineal syndrome. Int Urogynecol J. 2018; https://doi.org/10.1007/s00192-018-3557-y.

  88. Lipschuetz M, Cohen SM, Liebergall-Wischnitzer M, Zbedat K, Hochner-Celnikier D, Lavy Y, et al. Degree of bother from pelvic floor dysfunction in women one year after first delivery. European J Obst Gynecol Repr Biol. 2015;191:90–4.

    Article  Google Scholar 

  89. Durnea CM, Khashan AS, Kenny LC, Durnea UA, Dronan JC, O’Sullivan SM, et al. What is to blame for postnatal pelvic floor dysfunction in primiparous women – pre-pregnancy or intrapartum risk factors? Eur J Obstet Gynecol Reprod Biol. 2017; 214: 36–43.

    Google Scholar 

  90. Fitzpatrick M, O’Herlihy C. The effects of labour and delivery on the pelvic floor. Best Pract Res Clin Obstet Gynaecol. 2001;15:63–79.

    Article  CAS  PubMed  Google Scholar 

  91. Rogers RG, Leeman LM, Borders N, Fullilove AM, Teaf D, Hall RJ, et al. The contribution of the second stage of labor to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women. BJOG. 2014;121:1145–54.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  92. Bozkurt M, Yumru AE, Sahin L. Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor. Taiwan J Obstet Gynecol. 2014;53:452–8.

    Article  PubMed  Google Scholar 

  93. Vila Pouca MCP, Ferreira JPS, Oliveira DA, Parente MPL, Natal Jorge RM. Viscous effects in pelvic floor muscles during childbirth: a numerical study. Int J Numer Meth Biomed Engng. 2017:e2927.

    Google Scholar 

  94. Goldberg RP. Effects of pregnancy and childbirth on the pelvic floor. In: Culligan PJ, Goldberg RP, editors. Urogynecology in primary care. 1st ed. London: Springer; 2007. p. 21–33.

    Chapter  Google Scholar 

  95. Woodman PJ, Graney DO. Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair. Clin Anat. 2002;15:321–34.

    Article  PubMed  Google Scholar 

  96. Farouk R, Duthie GS, Bartolo DCG. Functional anorectal disorders and physiological evaluation. In: Beck DE, Wexner SD, editors. Fundamentals of anorectal surgery. New York: McGraw-Hill, Inc.; 1992. p. 68–88.

    Google Scholar 

  97. O’Beirne J, editor. New views of the process of defecation and their application to the pathology and treatment of diseases of the stomach, bowels and other organs. Dublin: Hodges and Smith; 1833.

    Google Scholar 

  98. Kumar D, Wingate DL. Colorectal motility. In: Henry MM, Swash M, editors. Coloproctology and the pelvic floor. Oxford: Butterworth-Heinemann Ltd.; 1992. p. 72–85.

    Google Scholar 

  99. Haller A. The large intestine. In: Cullen W, editor. First lines of physiology. A reprint of the 1786 edition (sources of science 32). New York, London: Johnson Reprint Corporation; 1966. p. 139–40.

    Google Scholar 

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Jorge, J.M.N., Bustamante-Lopez, L.A., Froehner, I. (2020). Anatomy of the Anorectal Region and Pelvic Floor. In: Oliveira, L. (eds) Anorectal Physiology. Springer, Cham. https://doi.org/10.1007/978-3-030-43811-1_1

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