Anal Physiology

  • Susan M. Parker
  • John A. Coller
Reference work entry


Normal bowel continence is a complex process that involves the coordinated interaction between multiple different neuronal pathways and the pelvic and perineal musculature. The importance of the anatomic relationships of the pelvic floor in maintaining normal continence has been suggested since the 1950s. Yet the complex series of neural and behavioral- mediated interactions, combined with a lack of an ideal study to take all elements into account, makes complete understanding of anorectal anatomy and physiology’s role in preserving continence difficult. Complicating this are multiple other factors that have a role in normal regulation such as systemic disease, emotional effects, bowel motility, stool consistency, evacuation efficiency, pelvic floor stability, and sphincter integrity.


  1. 1.
    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;28:1242–1244.CrossRefPubMedGoogle Scholar
  2. 2.
    Berglas B, Rubin IC. Study of the supportive structures of the uterus by levator myography. Surg Gynecol Obstet 1953;97:677–692.PubMedGoogle Scholar
  3. 3.
    Cherry DA, Rothenberger DA. Pelvic floor physiology. Surg Clin North Am 1988;68(6):1217–1230.PubMedGoogle Scholar
  4. 4.
    Mavrantonis C, Wexner SD. A clinical approach to fecal incontinence. J Clin Gastroenterol 1998;27(2):108–121.CrossRefPubMedGoogle Scholar
  5. 5.
    Woodburne RT. Essentials of Human Anatomy. New York: Oxford University Press; 1994.Google Scholar
  6. 6.
    Henry MM, Swash M, eds. Coloproctology and the Pelvic Floor. Oxford: Butterworth‐Heinemann; 1992:3–249.Google Scholar
  7. 7.
    Bourdelat D, Muller F, Droulle P, Barbet JP. Anatomical and Sonographical studies of the development of fecal continence and sphincter development in human fetuses. Eur J Pediatr Surg 2001;11:124–130.CrossRefPubMedGoogle Scholar
  8. 8.
    Dalley AF. The riddle of the sphincters. The morphophysiology of the anorectal mechanism reviewed. Am Surg 1987;53:298–306.Google Scholar
  9. 9.
    Wunderlich M, Swash M. The overlapping innervation of the two sides of the external anal sphincter by the pudendal nerves. J Neurol Sci 1983;59:97–109.CrossRefPubMedGoogle Scholar
  10. 10.
    Hamdy S, Enck P, Aziz Q, Uengoergil S, Hobson A, Thompson DG. Laterality effects of human pudendal nerve stimulation on corticoanal pathways: evidence for functional asymmetry. Gut 1999;45(1):58–63.CrossRefPubMedGoogle Scholar
  11. 11.
    Penninckx F, Lestar B, Kerremans R. The internal anal sphincter: mechanisms of control and its roles in maintaining anal continence. Clin Gastroenterol 1992;6:193–213.Google Scholar
  12. 12.
    Lestar B, Penninckx F, Kerremans R. The composition of anal basal pressure: an in vivo and in vitro study in man. Int J Colorectal Dis 1989;4:118–122.CrossRefPubMedGoogle Scholar
  13. 13.
    Sangwan Y, Solla J. Internal anal sphincter: advances and insights. Dis Colon Rectum 1998;41:1297–1311.CrossRefPubMedGoogle Scholar
  14. 14.
    Marcio J, Jorge N, Wexner S. Anatomy and physiology of the rectum and anus. Eur J Surg 1997;163:723–731.Google Scholar
  15. 15.
    Uher E, Swash M. Sacral reflexes: physiology and clinical application. Dis Colon Rectum 1998;41:1165–1177.CrossRefPubMedGoogle Scholar
  16. 16.
    Rossolimo G. Der Analreflex, seine physiologie und pathologie. Neurologisches Centralblatt 1891;4:257–259.Google Scholar
  17. 17.
    Henry MM, Parks AG, Swash M. The anal reflex in idiopathic faecal incontinence: an electrophysiological study. Br J Surg 1980;67:781–783.CrossRefPubMedGoogle Scholar
  18. 18.
    Bartolo DC, Jarratt JA, Read NW. The cutaneo‐anal reflex: a useful index of neuropathy? Br J Surg 1983;70(11): 660–663.CrossRefPubMedGoogle Scholar
  19. 19.
    Chan CL, Ponsford S, Swash M. The anal reflex elicited by cough and sniff: validation of a neglected clinical sign. J Neurol Neurosurg Psychiatry 2004;75(10):1449–1451.CrossRefPubMedGoogle Scholar
  20. 20.
    Amarenco G, Ismael SS, Lagauche D, et al. Cough anal reflex: strict relationship between intravesical pressure and pelvic floor muscle electromyographic activity during cough. Urodynamic and electrophysiological study. J Urol 2005;173(1):149–152.CrossRefPubMedGoogle Scholar
  21. 21.
    Bors E, Blinn K. Bulbocavernosus reflex. J Urol 1959;82: 128–130.PubMedGoogle Scholar
  22. 22.
    Podnar S. Electrodiagnosis of the anorectum: a review of techniques and clinical applications. Tech Coloproctol 2003;7: 71–76.CrossRefPubMedGoogle Scholar
  23. 23.
    Gowers WR. The automatic action of the sphincter ani. Proc R Soc Lond (Biol) 1877;26:77–84.CrossRefGoogle Scholar
  24. 24.
    Denny‐Brown D, Robertson EG. An investigation of the nervous control of defecation. Brain 1935;58:256–310.CrossRefGoogle Scholar
  25. 25.
    van Duijvendijk P, Slors F, Taat CW, Heisterkamp SH, Obertop H, Boeckxstaens GEE. A prospective evaluation of anorectal function after total mesorectal excision in patients with a rectal carcinoma. Surgery 2003;133:56–65.CrossRefPubMedGoogle Scholar
  26. 26.
    Duthie HL, Bennett RC. The relation of sensation in the anal canal to the functional anal sphincter: a possible factor in anal continence. Gut 1963;4:179–182.CrossRefPubMedGoogle Scholar
  27. 27.
    Chiarioni G, Bassotti G, Stanganini S, Vantini I, Whitehead WE. Sensory retraining is key to biofeedback therapy for formed stool fecal incontinence. Am J Gastroenterol 2002;97(1):109–117.CrossRefPubMedGoogle Scholar
  28. 28.
    Tomita R, Tanjoh K, Fujisaki S, Fukuzawa M. The role of nitric oxide (NO) in the human internal anal sphincter. J Gastroenterol 2001;36(6):386–391.CrossRefPubMedGoogle Scholar
  29. 29.
    de Lorijn F, Omari TI, Kok JH, Taminiau AJM, Benninga MA. Maturation of the rectoanal inhibitory reflex in very premature infants. J Pediatr 2003;143:630–633.CrossRefPubMedGoogle Scholar
  30. 30.
    Lubowski DZ, Nichols RJ, Swash M, Jordan MY. Neural control of internal anal sphincter function. Br J Surg 1987;74:668–670.CrossRefPubMedGoogle Scholar
  31. 31.
    Saigusa N, Belin BM, Choi HJ, et al. Recovery of the rectoanal inhibitory reflex after restorative proctocolectomy: does it correlate with nocturnal continence? Dis Colon Rectum 2003;46(2): 168–172.CrossRefPubMedGoogle Scholar
  32. 32.
    O'Riordain MG, Molloy RG, Gillen P, Horgan A, Kirwan WO. Rectoanal inhibitory reflex following low stapled anterior resection of the rectum. Dis Colon Rectum 1992;35(9):874–878.CrossRefPubMedGoogle Scholar
  33. 33.
    Kaur G, Gardiner A, Duthie GS. Rectoanal reflex parameters in incontinence and constipation. Dis Colon Rectum 2002;45(7): 928–933.CrossRefPubMedGoogle Scholar
  34. 34.
    Pfefferkorn MD, Croffie JM, Corkiins MR, Gupta SK, Fitzgerald JF. Impact of sedation and anesthesia on the rectoanal inhibitory reflex in children. J Pediatr Gastroenterol Nutr 2004;38(3): 324–327.CrossRefPubMedGoogle Scholar
  35. 35.
    Heyt GJ, Oh MK, Alemzadeh N, et al. Impaired rectoanal inhibitory response in scleroderma (systemic sclerosis): an association with fecal incontinence. Dig Dis Sci 2004;49(6): 1040–1045.CrossRefPubMedGoogle Scholar
  36. 36.
    Rao SSC. Pathophysiology of adult fecal incontinence. Gastroenterology 2004;126:S14–S22.CrossRefPubMedGoogle Scholar
  37. 37.
    Sangwan YP, Coller JA, Barrett RC, Murray JJ, Roberts PL, Schoetz DJ Jr. Prospective comparative study of abnormal distal rectoanal excitatory reflex, pudendal nerve terminal motor latency, and single fiber density as markers of pudendal neuropathy. Dis Colon Rectum 1996;39:794–798.CrossRefPubMedGoogle Scholar
  38. 38.
    Beck DE, Wexner SD. Fundamentals of Anorectal Surgery. 2nd ed. Philadelphia: WB Saunders; 1998:19–20.Google Scholar
  39. 39.
    Parks AG. Anorectal incontinence. Proc R Soc Med 1975;68: 681–690.PubMedGoogle Scholar
  40. 40.
    Jorgensen J, Stein P, King DW, Lubowski DZ. The anorectal angle is not a reliable parameter on defaecating proctography. Aust N Z J Surg 1993;63(2):105–108.CrossRefPubMedGoogle Scholar
  41. 41.
    Jorge JM, Wexner SD, Marchetti F, Rosato GO, Sullivan ML, Jagelman DG. How reliable are currently available methods of measuring the anorectal angle? Dis Colon Rectum 1992;35(4): 332–338.CrossRefPubMedGoogle Scholar
  42. 42.
    Broen PM, Penninckx FM. Relation between anal electrosensitivity and rectal filling sensation and the influence of age. Dis Colon Rectum 2005;48(1):127–133.CrossRefGoogle Scholar
  43. 43.
    Bharucha AE, Fletcher JG, Harper CM, et al. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence. Gut 2005;54(4): 546–555.CrossRefPubMedGoogle Scholar
  44. 44.
    Rasmussen O. Anorectal function. Dis Colon Rectum 1994;37(4):386–403.CrossRefPubMedGoogle Scholar
  45. 45.
    van Dam JH, Ginai AZ, Gosselink MJ, et al. Role of defecography in predicting clinical outcome of rectocele repair. Dis Colon Rectum 1997;40(2):201–207.CrossRefPubMedGoogle Scholar
  46. 46.
    Bartolo DC, Roe AM, Locke‐Edmunds JC, Virjee J, Mortensen NJ. Flap‐valve theory of anorectal continence. Br J Surg 1986;73(12):1012–1014.CrossRefPubMedGoogle Scholar
  47. 47.
    Miller R, Bartolo DC, Cervero F, Mortensen NJ. Differences in anal sensation in continent and incontinent patients with perineal descent. Int J Colorectal Dis 1989;4(1):45–49.CrossRefPubMedGoogle Scholar
  48. 48.
    Berkelmans I, Heresbach D, Leroi AM, et al. Perineal descent at defecography in women with straining at stool: a lack of specificity or predictive value for future anal incontinence? Eur J Gastroenterol Hepatol 1995;7(1):75–79.PubMedGoogle Scholar
  49. 49.
    Lowry AC, Simmang CL, Boulos P, et al. Consensus statement of definitions for anorectal physiology and rectal cancer: report of the Tripartite Consensus Conference on Definitions for Anorectal Physiology and Rectal Cancer, Washington, DC, May 1, 1999. Dis Colon Rectum 2001;44(7):915–919.CrossRefPubMedGoogle Scholar
  50. 50.
    Ron Y, Avni Y, Lukovetski A, et al. Botulinum toxin type‐A in therapy of patients with anismus. Dis Colon Rectum 2001;44(12):1821–1826.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2007

Authors and Affiliations

  • Susan M. Parker
  • John A. Coller

There are no affiliations available

Personalised recommendations