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Neurogastroenterol Motil (2006) 18, 507–519

doi: 10.1111/j.1365-2982.2006.00803.x


Pelvic floor: anatomy and function

Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.), Program, Mayo Clinic College of
Medicine, Rochester, MN, USA

uterus, and rectum. These defects are closed by
connective tissue anterior to the urethra, anterior to
the rectum (i.e. the perineal body), and posterior to the
rectum (i.e. the postanal plate). Together with the
viscera (i.e. the bladder and anorectum), the pelvic floor
is responsible for storing and evacuating urine and
stool; these somatovisceral reflexes require coordination between visceral components (e.g. rectal contraction, rectal sensation, and internal sphincter
relaxation) and somatic components (e.g. external
sphincter contraction and relaxation).

Abstract The pelvic floor is a dome-shaped striated
muscular sheet that encloses the bladder, uterus, and
rectum, and, together with the anal sphincters, has an
important role in regulating storage and evacuation of
urine and stool. This article reviews the anatomy,
nerve supply, pharmacology, and functions of the anal
sphincters and the pelvic floor. The internal and
external anal sphincters are primarily responsible for
maintaining faecal continence at rest and when continence is threatened, respectively. Defecation is a
somato-visceral reflex regulated by dual nerve supply
(i.e. somatic and autonomic) to the anorectum. The
net effects of sympathetic and cholinergic stimulation
are to increase and reduce anal resting pressure,
respectively. Faecal incontinence and functional defecatory disorders may result from structural changes
and/or functional disturbances in the mechanisms of
faecal continence and defecation.

Pelvic floor
The levator ani or pelvic diaphragm is subdivided into
four muscles, i.e. pubo-coccygeus, ileo-coccygeus, coccygeus, and puborectalis. These muscles are attached
peripherally to the pubic body, the ischial spine, and to
the arcus tendinus, a condensation of the obturator
fascia in between these areas (Fig. 1).
It is unclear whether the puborectalis should be
regarded as a component of the levator ani complex or
the external anal sphincter. Based on developmental
evidence, innervation and histological studies, the
puborectalis appears distinct from the majority of the
levator ani.1 On the other hand, the puborectalis and
external sphincter complex are innervated by separate
nerves originating from S2)4 (see below), suggesting
phylogenetic differences between these two muscles.2

Keywords fecal incontinence, constipation, defecation, anal sphincter, obstructed defecation, pelvic
floor, anatomy, functions.

There is increasing enthusiasm for viewing the pelvic
floor from a global perspective, discounting the traditional segregation into anterior, middle, and posterior
compartments. The pelvic floor is a dome-shaped
muscular sheet that predominantly contains striated
muscle and has midline defects enclosing the bladder,
Address for correspondence
Adil E. Bharucha, MD, Mayo Clinic, Charlton 8-110,
200 First St SW, Rochester, MN 55905, USA.
Tel.: 507 266 2305; fax: 507 538 5820;
Received: 19 January 2006
Accepted for publication: 31 March 2006 
2006 The Author
Journal compilation  2006 Blackwell Publishing Ltd

Rectum and anal canal
The rectum is 15–20 cm long, and extends from the
recto-sigmoid junction at the level of third sacral
vertebra to the anal orifice (Fig. 2). The upper and
lower rectum are separated by a horizontal fold. The


94 Obturator internus Levator ani Pelvirectal space Longitudinal muscle space Circular muscle layer Iliococcygeus Transverse folds Pubococcygeus Rectal ampulla Ischiorectal fossa Anal columns Gluteus maximus Semitendinosus Deep Superficial Subcutaneous Parts of sphincter ani externus Anal sinuses Skin Sphincter ani internus Figure 2 Diagram of a coronal section of the rectum.3 The lower part. and adjacent structures. derived from the cloaca. Reprinted with permission from Dyck and Thomas. In humans. and can distend towards the peritoneal cavity. generally contains faeces.A. anal canal. The pelvic barrier includes the anal sphincters and pelvic floor muscles. Bharucha Neurogastroenterology and Motility Figure 1 Pelvic view of the levator ani demonstrating its four main components: puborectalis.4. except during defecation. Reprinted with permission from Bharucha. there are fewer enteric ganglia in the rectum compared with the colon and very few ganglia in the anal sphincter. pubococcygeus.5 upper rectum is derived from the embryological hindgut.95 connective tissue. and coccygeus. and is generally empty in normal subjects. iliococcygeus. is surrounded by condensed extra-peritoneal 508  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd . E.

and does not resemble a single nerve. the external sphincter appears as a single muscle bundle anteriorly. but affected in Shy–Dra¨ger syndrome.e. spinal and supraspinal reflexes are also involved in the process. these neurones are relatively spared in amyotrophic lateral sclerosis. the ICCs are located along the periphery of the muscle bundles within the circular layer. ascending fibres from the inferior hypogastric plexus travel via superior hypogastric and aortic plexuses to reach the inferior mesenteric plexus. innervate the external anal and urethral sphincters. third. located posterior to the urinary bladder. and sensory input from the lower anal canal as also the skin around NERVE SUPPLY TO THE PELVIC FLOOR Sympathetic and parasympathetic innervation The anorectum and pelvic floor are supplied by sympathetic.7 Sympathetic preganglionic fibres originate from the lowest thoracic ganglion in the paravertebral sympathetic chain and join branches from the aortic plexus to form the superior hypogastric plexus (Fig. Indeed. The hypogastric nerves unite with preganglionic parasympathetic fibres originating from ventral rami of the second. The internal sphincter is not merely a thickened extension of the circular smooth muscle layer surrounding the colon. middle. prostatic plexus. The external sphincter is enveloped by conjoint longitudinal fibres in men and women. and inferior rectal plexus. travelling cephalad in the plane of the myenteric plexus to supply a variable portion of the left colon. Brodmann area 4.8 Excitatory pathways play an important role in colonic propulsive activity. In contrast. 3).12. these fibres form the ascending colonic nerves. and posterior scrotal nerves.0 cm) ÔanatomicalÕ or ÔembryologicalÕ anal canal.e. and uterovaginal plexus. i. The external sphincter is composed of superficial. Sacral parasympathetic pathways to the colon have excitatory and inhibitory components. Number 7. The literature describes a longer (approximately 4. The pudendal nerve branches into inferior rectal. subcutaneous and deep portions.9 Inhibitory pathways allow colonic volume to adapt to its contents.Volume 18. or a modified columnar epithelium. The superior hypogastric plexus provides branches to the uteric and ovarian (or testicular) plexus. July 2006 Pelvic floor anatomy and function nerves to form the inferior hypogastric plexus. the deep portion blends with the puborectalis. The proximal 10 mm of the anal canal is lined by columnar. The next 15 mm (which includes the valves) is lined by stratified.10 There are subtle differences in the degree of bilateral hemispheric representation between subjects. that initiates colonic relaxation ahead of a faecal bolus. the interstitial cells of Cajal (ICC) are organized in dense networks along the submucosal and myenteric borders. Parasympathetic fibres in the superior and middle rectal plexuses synapse with postganglionic neurones in the myenteric plexus in the rectal wall.13 Somatic branches originating from Onuf’s nucleus travel in the pudendal nerve. The anal canal is an anterioposterior slit.3 In men. The anal valves and the distal end of the ampullary part of the rectum mark the proximal margin of the ÔshortÕ and ÔlongÕ anal canal respectively. among women. these motor neurones are smaller than usual a-motor neurones and resemble autonomic motor neurones. non-hairy. ultimately innervating the descending and sigmoid colon. stratified epithelium (the pecten). The anal canal is surrounded by the internal and external anal sphincters. and also mediate descending inhibition. perineal. guinea-pig). and often the fourth sacral  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd 509 . in dogs. with its lateral walls in close contact.5 cm) ÔsurgicalÕ or ÔclinicalÕ anal canal and a shorter (approximately 2. rectal-type mucosa. The inferior rectal nerve conveys motor fibres to the external anal sphincter. the rectal circular muscle layer is tightly packed with poorly defined septa while the internal anal sphincter contains discrete muscle bundles separated by large septa.g. The nerve supply to the rectum and anal canal is derived from the superior.6 In the rectum. The most distal 5–10 mm is lined by hairy skin. In other species (e.11 however. Though they supply striated muscles under voluntary control. Motor neurones in Onuf’s nucleus. vesical plexus. muscular branches and in the coccygeal plexus. the conduction velocity in pudendal nerve fibres is comparable with that of peripheral nerves. Distal to that is about 10 mm of thick.0–4. In addition. especially during defecation. After entering the colon. In the internal anal sphincter. this trilaminar pattern is preserved around the sphincter circumference. The alternative term for this plexus (i. which is located in the sacral spinal cord. parasympathetic and somatic fibres. presacral nerve) is misleading because it is seldom condensed. faeces transport may be entirely organized by the enteric nervous system. Somatic innervation Cortical mapping with transcranial magnetic stimulation suggests that rectal and anal responses are bilaterally represented on the superior motor cortex. In contrast to other somatic motor neurones in the spinal cord. and divides into right and left hypogastric nerves. The inferior hypogastric plexus gives rise to the middle rectal plexus.

urethral sphincter. sphincter inhibition during colonic distention. anterior part of the external anal sphincter. Conversely. Reprinted with permission from Dyck and Thomas. The posterior scrotal branches innervate the skin. tonic external sphincter activity.94 Motor fibres of the right and left pudendal nerves have overlapping distributions within the external anal sphincter. ischiocavernosus. The perineal nerve divides into posterior scrotal (or labial) branches and muscular branches. Bharucha Neurogastroenterology and Motility Figure 3 Sympathetic. parasympathetic and pudendal nerve supply to the anorectum. Sherrington observed that stimulation of the right pudendal nerve caused circumferential contraction of the external anal sphincter. while muscular branches are distributed to the transverse perinei. and the levator ani. bulbospongiosus.A. and the cutaneo- the anus. E. 510  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd .

The anal canal responds to distention and to innocuous mucosal proximo-distal mechanical shearing stimuli.21 However.e. Janig and Koltzenburg found no afferent fibres that were selectively activated by noxious stimuli. the number of spinal visceral afferent neurones is relatively small.8. perhaps explaining why it is exquisitely sensitive to light touch.26 These neurophysiological changes are detectable within minutes after tissue irritation.16 The anal canal is lined by numerous free and organized nerve endings (i. Tonic afferents were predominantly unmyelinated slowly-conducting C fibres while most phasic afferents were faster conducting myelinated Ad fibres. including the colon. These intraganglionic laminar endings detect mechanical deformation of the myenteric ganglia. and occasionally at the cessation of a distention stimulus.17–19 There are more afferent neurones supplying the colon in the sacral.14 In addition to mucosal nerve endings.e. The early literature based on dissections by several workers suggested that the puborectalis was innervated from below by the pudendal nerve.15. there are also low threshold. but not colonic or anal distention.e. further investigations are necessary to clarify this important point. slowly adapting mechanoreceptors in the guinea-pig rectum. interpreted by the patient as a desire to pass wind or motion. an electrophysiological study concluded that preoperative stimulation of the sacral nerves above the pelvic floor invariably (i. Number 7. The afferents innervating the anal canal responded to shearing stimuli. but not in the external anal sphincter. 2 Thus. compared with lumbar segments in the cat. Phasic colonic afferents generally discharged at the onset. Two different theories have been proposed to explain visceral pain perception.25 More than 90% of all unmyelinated pelvic afferents are silent. Therefore.22 Silent afferents can respond to chemical stimuli or tissue irritation. However. Highintensity stimuli increase firing of low-threshold afferents and also activate high-threshold afferents.e. or jointly by the inferior rectal and perineal branches of the pudendal nerve.Volume 18.23. mediated by sequential activation of visceral nociceptors and central pain-specific neurones in the spinal dorsal horn.24 Janig and Morrison identified three different classes of mechanosensitive visceral afferents in the cat colon. 19 of 20 experiments) resulted in electromyogram (EMG) activity in the ipsilateral puborectalis. have documented high threshold visceral afferent fibres that only respond to noxious mechanical stimuli. Meissner’s corpuscles. 7500 vs 4500 neurones.22 Tonic afferents fired throughout colonic distention and accurately encoded the intensity of distention between 20 and 100 mmHg. being activated by electrical stimulation. Krause end-bulbs. July 2006 Pelvic floor anatomy and function as they are more likely to lack resting activity and respond to pressure increments with a wider range of discharge frequency.25 Physiological processes are generally accompanied by low level activity. thereby activating nociceptive pathways and triggering pain. anal reflex were not affected by sectioning either pudendal nerve. Sensory traffic is conveyed by unmyelinated small C fibres and larger A fibres.and high-threshold mechanoreceptors converge on spinothalamic and other ascending tract cells. Proponents of the specificity theory suggested that pain was a distinct sensory modality. i. Golgi-Mazzoni bodies and genital corpuscles). Cervero and Janig reconciled these opposing concepts in a convergence model wherein input from low.e. electrophysiological studies of visceral afferent fibres in other organs. are likely to persist for the duration of irritation and have been implicated to explain visceral hypersensitivity. Subsequently. rectal distention is perceived as a more localized sensation of rectal fullness. Animal models and clinicopathological findings in humans suggest that pelvic nerves travelling to the sacral segments are more important for conveying non-noxious and noxious colonic sensations than lumbar colonic (sympathetic) nerves. The nerve supply to the puborectalis has been the subject of controversy. Sensory innervation In contrast to colonic distention. becoming responsive to even innocuous mechanical stimuli after sensitization.14 However.22 In general. arguing against the specificity theory. pattern or intensity theory.5% or less of the total number of spinal afferent neurones supplying skin and deep somatic structures. but not even by extreme noxious stimuli. sacral afferents may be better suited for conveying afferent information than lumbar afferents.20. pain and temperature. in the cat colon. The alternative hypothesis for pain perception. and transmission of non-painful sensations. attributes pain perception to spatial and temporal patterns of impulses generated in nonspecific visceral afferent neurones. i. However. the puborectalis was regarded as being derived not from the levator ani but from the external anal sphincter. which generally evokes ill-defined discomfort and eventually pain. mediation of regulatory reflexes. i. only 2.  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd 511 .

Conversely. preserving continence. the external sphincter contracts to augment anal tone.2 mmHg) than low (11 ± 7. sympathetic stimulation either evoked internal anal sphincter relaxation.40 while cats and rabbits predominantly contain type 2 or fast-twitch muscle fibres.40 Puborectalis The tonically active puborectalis muscle maintains the resting anorectal angle. the recto-anal inhibitory reflex (RAIR)] is mediated by intrinsic nerves. Bharucha Neurogastroenterology and Motility essential for the reflex. The only other striated muscles that display resting activity are the puborectalis.e.32 Anal relaxation induced by rectal distention [i.A. and after high spinal anaesthesia (T6–T12).e. the anal pressure during rectal distention was similar among the three groups.34 Other non–adrenergicnon–cholinergic neurotransmitters. However. from complex studies in which anal resting pressure was sequentially recorded before surgery (i. separated by profuse connective tissue. vasoactive intestinal peptide (VIP) and ATP may also participate in the RAIR. Penninckx et al. or induced by increased intra-abdominal pressure. studies under general anaesthesia or after pudendal nerve block suggest the external anal sphincter generally accounts for 25%. because they were obtained. While cadaveric studies suggested the puborectalis was supplied by the pudendal nerve.41 External sphincter fibres are circumferentially oriented. slow twitch) fibres predominate in the human anal sphincter. external urethral sphincter. suggesting that this excitatory sympathetic discharge does not contribute to anal pressure during rectal distention. perhaps explaining why resting anal sphincter tone is reduced. When continence is threatened.36 ANAL SPHINCTER TONE AND REFLEXES Internal anal sphincter The internal sphincter is primarily responsible for ensuring the anal canal is closed at rest.28–30 or contraction followed by relaxation. i.31 Anal resting pressure is not stationary but varies during the day.27 The other contributors to anal resting tone include the external anal sphincter.e. The decline in anal resting pressure was significantly greater after high (32 ± 3. puborectalis contraction during a sudden rise in abdominal pressure reduces the anorectal angle. the anal mucosal folds and the puborectalis muscle. as relaxation is more pronounced and prolonged in children with sacral agenesis. abdominoperineal resection). cricopharyngeus and the laryngeal abductors. This ÔsqueezeÕ response may be voluntary. Frenckner and Ihre investigated the contribution of myogenic tone and the extrinsic (sympathetic and parasympathetic) nerves to anal resting tone by assessing anal pressure at rest and in response to rectal distention under baseline conditions. estimated that anal resting tone was generated by nerve-induced activity in the internal sphincter (45% of anal resting tone). including the size of the probe and the location at which pressure was measured. preserving continence. electrophysiological stimulation studies in humans suggest this muscle is supplied. but voluntary contraction of the external sphincter is preserved in tabes dorsalis. circadian variations that are dependent on the sleep–wake cycle and ultradian (20– 40 min in length) rhythms that are independent of the sleep–awake cycle have also been described. strictly ipsilaterally. by branches originating from the sacral plexus above the pelvic floor. Resting or tonic activity depends on monosynaptic reflex drive. extrinsic nerves may modulate the reflex. the external sphincter relaxes during defecation. and very small.38 Conversely.e. the relative contributions of these factors to anal resting tone are influenced by several factors.8.35. morphological studies reveal an efferent descending nitrergic rectoanal pathway. type 1 (i. E. suggesting there is a tonic excitatory sympathetic discharge to the internal anal sphincter in humans.37 or by merely moving a finger across the anal canal lining. fatigue-resistant.1 mmHg) anaesthesia or after pudendal nerve blockade (10 ± 3. in part. as it is preserved in patients with cauda equina lesions or after spinal cord transection. The extrinsic nerves are not External anal sphincter Though resting sphincter tone is predominantly attributed to the internal anal sphincter. However.39 The fibre distribution also favours tonic activity. after curarization. after low spinal anaesthesia (L5–S1).9 mmHg). In addition to spontaneous relaxation of the internal sphincter. the external sphincter (35%) and the anal haemorrhoidal plexus (15%).28 These figures should be regarded as estimates. and in the resected specimen before and after verapamil. Moreover.2 Disruption of the puborectalis inevitably causes significant 512  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd . Moreover. myogenic tone in the internal sphincter (10%).33 The RAIR is probably mediated by nitric oxide (NO).27 A separate study assessed anal pressures before and after pudendal nerve blockade. This reflex is absent in Hirschsprung’s disease. up to 50% of resting anal tone.

somatostatin. in mice and humans.45 The internal anal sphincter is more sensitive to adrenergic compared to cholinergic agonists. ›.28 diltiazem83 Angiotensin II50 Model Effects In vitro – human and monkey Healthy subjects and incontinent patients In vitro – opossum In vitro – human and monkey In vitro – human and monkey a – contraction. increased. did not improve FI flResting pressure Either contraction. modulate distinct facets of internal sphincter functions.43 Conversely. but relaxed them after muscarinic receptors were blocked.49 The effects of neurotransmitters on the internal anal sphincter vary among species. The RAIR was preserved in eNOS)/) and W/Wv mice but was absent in nNOS)/) mice. enkephalin. A recent study using knockout mice suggests that the isoforms of nitric oxide synthase (NOS). Thus. choliner- Table 1 Effects of pharmacological modulation on anal sphincter tone and pressures Pharmacological agent Adrenergic agents44 Phenylephrine (a1 agonist)53.e. probably via non-adrenergic– non-cholinergic mechanisms. Nitic oxide mediates internal sphincter tone and the RAIR.47 While basal internal anal sphincteric tone was comparable in nNOS)/) and wild mice. underscoring the importance of this muscle in maintaining continence. While VIP may also contribute to relaxation of the internal sphincter. electrical activity of the internal anal sphincter increases during urinary bladder emptying in humans. W/Wv mice). relaxation or no change Relaxation – upper anal canal No change – lower anal canal flResting pressure ›Resting pressure flResting pressure Healthy human subjects Incontinent patients Healthy human subjects Rat internal anal sphincter FI. sympathetic nerves excite while parasympathetic nerves inhibit the sphincters. Stimulation of adrenergic a and b receptors contracted and relaxed human internal sphincter strips respectively (Table 1). angiotensin II contributes to basal tone and contracts the internal anal sphincter in rats50 but not in the opossum. diltiazem.e.44. Electrophysiological recordings reveal both short. The internal anal sphincter is densely innervated by adrenergic nerves in humans and monkeys.82 Nicotine44 Bethanechol83 Loperamide84 Others – glucagon. b2 and b3) adrenoreceptor agonists81 Acetylcholine.44 All three b adrenoreceptor receptor subtype (b1. it was significantly (approximately twofold) higher in eNOS)/) mice and also significantly (approximately 25%) lower in mice that lacked c-Kit expressing ICC (i. the b3 receptor effect is mediated by a cyclic guanylate monophosphate (GMP)-mediated pathway similar to NO.e. Sacral reflexes The pelvic floor striated muscles contract reflexly in response to stimulation of perineal skin (i.48. incontinence. 54 b (b1. reduced. which is consistent with the selective loss of nNOS and the RAIR in Hirschsprung’s disease. Number 7.42 Sacral reflexes also regulate anal sphincter tone during micturition.Volume 18. July 2006 Pelvic floor anatomy and function gic agonists either contracted or relaxed internal anal sphincter strips in humans. muscarinic receptor stimulation contracted internal sphincter strips. probably via nonadrenergic–non-cholinergic mechanisms.  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd 513 Contributes to basal tone ›Resting pressure .46 Nicotinic agonists also relaxed internal sphincter strips. returning to normal after micturition. a somatosomatic reflex) or anal mucosa (i. the external anal sphincter relaxed during micturition in humans. Other studies have confirmed that nNOS is primarily responsible for mediating relaxation of the internal anal sphincter. The cutaneoanal reflex is elicited by scratching or pricking the perianal skin and involves the pudendal nerves and S4 roots. the role played by carbon monoxide in this process is controversial. Thus. ketanserin. faecal incontinence.45 Table 1 summarizes the effects of neurotransmitters and pharmacological agents that modulate internal anal sphincter tone.e. b2 and b3) agonists relax the opossum internal anal sphincter. i. the latter corresponds to the visible anal sphincter contraction. a viscerosomatic reflex). b – relaxation ›Resting pressure in healthy subjects. neuronal (nNOS) and endothelial (eNOS).latency and long-latency responses. PHARMACOLOGY In contrast to non-sphincteric regions.44 In the vervet monkey. fl. cats and dogs.

the pelvic floor muscles also contract. also generally relaxes during defecation (Fig. phenylephrine did not significantly improve incontinence scores or resting anal pressure compared with placebo. 0. approximately 60% of patients so treated developed headaches with nitroglycerine and approximately 25% of patients had a relapse. which are of relatively low amplitude. 1. the pelvic barrier. sitz baths).60 One possibility is that the relative contributions of voluntary effort and rectal contraction to defecation vary. in a randomized double-blind placebocontrolled crossover study of 36 patients with FI. The rectal contractile response to distention normally subsides as the rectum accommodates or relaxes.6 cm in subject 1.7 cm in subject 2) and opening of the anorectal junction. may impede evacuation because while a Valsalva manoeuvre may increase intrarectal pressure. it can generally be postponed. excessive straining and particularly a Valsalva manoeuvre. the controls were frequently not treated with standard conservative therapy (i.54 MECHANISMS OF CONTINENCE AND DEFECATION Faecal continence is maintained by anatomical factors (i. Bethanechol and botulinum toxin have also been used to treat anal fissures. 0. Current concepts suggest that minimal straining to initiate defecation is not abnormal because many asymptomatic subjects strain to initiate defecation.58 However.96 514  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd .17 The pelvic floor.53 However. partly because a barostat rather than manometry is necessary to optimally characterize rectal contractions. The experience from numerous clinical trials is discussed in detail elsewhere. particularly the puborectalis.. evacuation was associated with perineal descent (2. increasing outlet resistance. it is necessary to assess the balance between these two sometimes opposing forces by measuring the net recto-anal force during evacuation. The beneficial effects of loperamide in faecal incontinence (FI) may be attributable not only to reduced diarrhoea. which often occur after awakening or meals. recto-anal sensation.59 Thus.51 However. Simultaneous assessments of intrarectal pressures and pelvic floor activity (by manometry. Stool is often transferred into the rectum by colonic high-amplitude propagated contractions. This contractile response requires the ability to perceive stool in the rectum and perhaps also in the anal canal. right panel. Bharucha Neurogastroenterology and Motility Denny-Brown and Robertson observed that rectal distention evoked rectal contraction and anal sphincter relaxation. 4).2% glyceryl trinitrate) have been extensively tested and widely used to treat anal fissures. In both subjects. the relative contributions of increased intra-abdominal pressure generated by voluntary effort56 and rectal contraction57 to the ÔpropulsiveÕ force during defecation are unclear. but also to increased anal resting tone. subject 1) and puborectalis contraction (black arrow. Moreover. depending on the circumstances prior to defecation.e. and rectal compliance.2% nifedipine or 2% diltiazem) are probably more effective than nitrates for treating anal fissures with a lower incidence of side effects.A.e. in earlier controlled studies. the rectal curvatures and transverse rectal folds). subject 2) during rectal evacuation. Reprinted with permission from Bharucha et al.g. facilitating evacuation. During evacuation. the voluntary effort may range from being negligible when stool is soft to considerable when stool is hard and situated in the upper rectum. Indeed. the anorectal angle increased by 36 in subject 1 and declined by 10 in subject 2. Topical calcium channel blockers (e.55 Rest Rest Evacuation Evacuation Figure 4 Sagittal dynamic MRI images of normal puborectalis relaxation (left panel.e. The external sphincter and/or puborectalis can be contracted voluntarily. E.52 The a1 adrenoreceptor agonist phenylephrine applied to the anal canal increased anal resting pressure by 33% in healthy subjects and in incontinent patients. fibre supplementation. If defecation is inconvenient. per-anal exogenous nitrates (i. the anal APPLIED PHARMACOLOGY Because anal fissures are often associated with increased anal resting tone. EMG or imaging) reveal that increased intrarectal pressure and anal relaxation are required for normal defecation. For example. However.

 2006 The Author Journal compilation  2006 Blackwell Publishing Ltd 515 . These findings are consistent with the concept that patients with impaired relaxation of the anal sphincter and pelvic floor tend to have impaired perineal descent while patients with normal (or excessive) relaxation of the pelvic floor with a hypertensive anal sphincter have increased perineal descent. recent studies using a dynamometer68 and dynamic MRI69 also demonstrated weakness of the puborectalis in FI. The elaborate somatic defecation response depends on centres above the lumbo-sacral cord. Anal sphincter pressures are reduced in most. Indeed. Garry observed that colonic stimulation in cats induced colonic contraction and anal relaxation even after destruction of the lumbo-sacral cord. of stool consistency. catecholaminergic and muscarinic agents but not 5-HT) and EFS89. puborectalis dyssynergia) are preferably avoided because the muscle dysfunction can affect either or both muscles. reduced or increased rectal sensation) in patients with symptoms of difficult defecation. there is considerable evidence that functional defecatory disorders do not comprise a single entity. a detailed characterization of anorectal sensorimotor functions and pelvic floor motion assessed by magnetic resonance imaging (MRI) followed by a principal component analysis in 52 patients with a functional defecatory disorder revealed that three factors best explained the phenotypic variance among patients. Thus. liquid or stool.64–66 Indeed. the central nervous system plays a greater role in regulating anorectal sensorimotor functions compared with other regions of the gastrointestinal tract.85 Reduced anal resting and/or squeeze pressures Exaggerated transient relaxation of internal sphincter86 Thinning of the internal sphincter (US)87 Rectal fibrosis (histology) Loss of smooth muscle and fibrosis (histology)88 Reduced response to pharmacological agents (e.63 In addition to inadequate Faecal incontinence While most attention has focused on anal sphincter weakness.g. recent studies have demonstrated a wide spectrum of anorectal sensorimotor disturbances (e. US. faecal incontinence. EFS.67 While most attention has focused on anal sphincter weakness. sphincter may also relax independent of rectal distention. 5-HT. disturbances of rectal compliance and perception. electrical field stimulation. July 2006 Pelvic floor anatomy and function expulsion forces.90 Hypertrophy with polyglucosan inclusions (US and histology)91 Rectum and internal sphincter – scleroderma and FI Internal sphincter – neurogenic FI Internal sphincter – neurogenic FI Internal sphincter – proctalgia fugax and constipation Internal sphincter – pruritus ani Internal sphincter – chronic anal fissure Abnormal transient relaxation (ambulatory manometry)92 Increased resting pressure and less frequent transient anal relaxation (ambulatory manometry)93 FI. However.Volume 18.66 These factors were primarily weighted by perineal descent during evacuation. Alternative terms for dyssynergic defecation (e. Number 7. increased perineal descent. mental faculties and mobility often contribute to FI. hypertensive anal sphincter.g. ultrasound.g. and probably craniad to the spinal cord itself. 5-hydroxytryptamine.62 APPLIED ANATOMY AND FUNCTIONAL DISORDERS OF DEFECATION AND CONTINENCE Functional disorders of defecation Functional defecation disorders are characterized by paradoxical contraction or failure of relaxation of the pelvic floor muscles during attempted defecation (dyssynergic defecation) or inadequate propulsive forces during attempted defecation (inadequate defecation). The traditional paradigm of a functional defecatory disorder was limited to constipated patients with pelvic floor dyssynergia. but not all incontinent patients (Table 2). the inward traction exerted by the Table 2 Structural and functional disturbances of the human anal sphincters in disease Sphincter – condition Finding (method) Internal and external sphincters – FI Sphincter defects. allowing the anal epithelium to periodically ÔsampleÕ and ascertain whether rectal contents are gas.61 These mechanisms underscore that defecation is an integrated somato-visceral reflex. Moreover. anorectal location at rest and resting anal pressure. anismus. concluding that the gut Ôseems not to have wholly surrendered its independenceÕ. scarring and atrophy (US and MRI)69.

79 DenonvilliersÕ fascia is intimately adherent to the anterior mesorectal fat but only loosely adherent to the seminal vesicles. Thus. Bharucha Neurogastroenterology and Motility shown that a subset of patients with a defecatory disorder have excessive perineal descent.72 Indeed. and exaggerated anal sphincter relaxation during rectal distention. An association between faecal and urinary incontinence has been observed in case series73 and a population-based study. Left-sided colectomy may result in postoperative colonic transit delays in the unresected segment. In addition to colonic denervation. reduced rectal capacity was associated with the symptom of urgency and with rectal hypersensitivity. it is conceivable that excessive straining during defecation may predispose to POP. external sphincter weakness. be associated with incomplete resection and/or local recurrence. the deep parasympathetic nerves situated in the narrow space between the rectum and the prostate and seminal vesicles may be damaged.g. leading to impotence. Thus.68 However. and gastroenterologists/colorectal surgeons respectively. symptoms (e. a recent controlled study demonstrated that women with FI had a lower risk of severe POP compared with age-matched women without FI. During anterior rectal dissection.67 The rectal capacity (i.80 For benign disease. which is associated with POP. middle and posterior compartment. predisposing to FI. anal sphincter pressures do not always distinguish continent from incontinent subjects. perhaps a marker of coexistent irritable bowel syndrome. and improved after biofeedback therapy. this probably represents parasympathetic denervation. exaggerated rectal sensation. in theory. and managed separately by urologists. and understanding the consequences of rectal resection.e. It is conceivable that pelvic organ prolapse (POP) and FI are associated.75 A long denervated segment is more likely to be associated with non-propagated colonic pressure waves and delayed colonic transit than a short denervated segment.74 An association between functional defecatory disorders and dysfunctional urinary voiding has also been demonstrated. because both conditions share similar risk factors. correlated more closely with symptoms than squeeze pressures. These nerves may be disrupted during a low anterior resection. the choice is less straightforward because dissection behind.70 On the other hand. the balloon volume at the maximum imposed pressure) is also reduced in a subset of women with idiopathic FI. Impaired rectal sensation allows stool to enter the anal canal. a low anterior resection may also damage the anal sphincter and reduce rectal compliance. gynaecologists. rather than in front of the fascia may.77 Defecation may also be affected after surgical section of pelvic nerves in humans. excessive perineal descent may cause a pudendal neuropathy.69 Moreover. as ascending intramural fibres travel in a retrograde manner from the pelvis to the ascending colon. Moreover. repetitive rectal contractions during rectal distention. The relationship between perineal descent. preventing nerve injury during surgical dissection. 516  2006 The Author Journal compilation  2006 Blackwell Publishing Ltd . patients often suffer from more than one deficit. E. particularly obstetric trauma. The sigmoid colon and rectum are also supplied by descending fibres that run along the inferior mesenteric artery. Other studies have ACKNOWLEDGMENTS The author is supported by grants RO1-HD-41129 and RO1-DK-68055 from the National Institutes of Health.76 in contrast to anal sphincter injury.67. rectal compliance may recover with time. which in turn may cause anal sphincter weakness. puborectalis was reduced in FI. most surgeons will tend to stay posterior to DenonvilliersÕ fascia in an attempt to protect the pelvic nerves. underscoring the importance of rectal compliance and sensation for maintaining continence. FI is a heterogeneous disorder. Surgical implications From a therapeutic perspective.78. and pudendal neuropathy needs to be further clarified in prospective studies. it is conceivable that in subjects with POP.A. despite a higher prevalence of risk factors for pelvic floor injury.71 However. Global pelvic floor dysfunction Based on the predominant manifestation. is associated with reduced rectal compliance. For malignant disease.72 These findings suggest that FI is predominantly caused by anorectal dysfunctions rather than by generalized pelvic floor weakness. an understanding of anatomy is particularly important for managing anal fistulae. straining. pelvic floor disorders are traditionally classified into those affecting the anterior. leaving a denervated segment that may be short or long depending on whether the dissection line includes the origin of the inferior mesenteric artery. straining to begin or complete voiding and the sense of incomplete emptying) and objective disturbances of voiding occurred more frequently in women with a defecatory disorder than in healthy controls. and perhaps leak before the external sphincter contracts.

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