Topography of the Inferior Rectal Artery:
A Possible Cause of Chronic, Primary Anal Fissure
BERND KLOSTERHALFEN, M.D., PETER VOGEL, M.D., HELMA RIXEN, M.D., CHRISTIAN MITTERMAYER, M.D.
Klosterhalfen B, Vogel P, Rixen H, Mittermayer C. Topography of the
infer,lot rectal artery: a possible cause of chronic, primary anal fissure.
Dis Colon Rectum 1989;32:43-52.
The authors believed that it might be possible to explain the local
frequency of the anal fissure at the posterior commissure by an ana-
tomic relationship, and examined the blood supply of the anus. The
inferior rectal artery is demonstrated by postmortem angiography and
by manual preparations (N = 41) and histologic study after angiog-
raphy of the vessels (N = 10). The blood supply at the different sites of
the anal canal are demonstrated by a morphometric study (N = 20).
The inferior rectal artery presents two variants in the postmortem
angiographies, type I (85.4 percent) and type 2 (14.6 percent). In type 1,
the posterior commissure is less pe•used than the other sections of the
anal canal. In addition, the blood supply may be more compromised by
contusion of the vessels passing vertically through the muscle fibers of
the sphincter ani internus muscle during increased sphincter tone. The
role of topography in the pathogenesis of the primary anal fissure is
illustrated in a model. [Key words: Inferior rectal artery, type 1, type 2;
Undersupplied posterior commissure; Primary chronic anal fissure]
THE PATHOGENESIS AND t r e a t m e n t of p r i m a r y a n a l
fissure have been a c o n c e r n of m e d i c i n e for centuries. T h e
q u e s t i o n of w h y the p r i m a r y a n a l fissure s o m e t i m e s
b e c o m e s c h r o n i c a n d s o m e t i m e s heals s p o n t a n e o u s l y has
n o t yet been answered. Likewise, there is still the q u e s t i o n
of w h y , in 80 to 90 p e r c e n t of the cases, the fissure is
Address reprint requests to Dr. Klosterhalfen: Department of Patho-
log,y, Rwth-Aachen, Pauwelsstr., 5100, Aachen, West Germany.
43
From the Department of Pathology,
Rwth-Aachen, Pauwelsstr., Aachen, West German~
localized at the p o s t e r i o r c o m m i s s u r e of the a n a l canal,
a n d w h y the rest of the circumference is rarely affected.
U n t i l n o w some theories exist, e.g., t r a u m a to the ano-
d e r m by h a r d stool, recurrent i n f l a m m a t i o n , a n d increased
tone of the s p h i n c t e r a n i i n t e r n u s muscle. Most theories
e x p l a i n the t r a n s i t i o n f r o m the acute to the c h r o n i c form,
b u t c a n n o t e x p l a i n fully w h y the fissure is localized in
preference at the p o s t e r i o r commissure. T h e a u t h o r s
directed their a t t e n t i o n to the arterial s u p p l y of the a n a l
canal.
Material and Methods
F o r d e m o n s t r a t i o n of the i n f e r i o r rectal artery a n d the
b l o o d s u p p l y at the different sites of the a n a l canal, three
different m e t h o d s were a p p l i e d :
1) p o s t m o r t e m a n g i o g r a p h y a n d m a n u a l p r e p a r a t i o n
(N = 41);
2) h i s t o l o g i c study after p o s t m o r t e m a n g i o g r a p h y of
the vessels (N = 10); a n d
3) m o r p h o m e t r i c s t u d y of the capillaries in the s u b a n -
o d e r m a l space a n d s p h i n c t e r a n i i n t e r n u s m u s c l e
(N = 20).
The Postmortem Angiography and Manual Prepara-
tion: F o r i l l u s t r a t i o n of the i n f e r i o r rectal artery a n d
p o s s i b l e a n a s t o m o s e s i n the area concerned, the i n f e r i o r
AA
"~'lz
KLOSTERHALFEN, ET A L
mesenteric artery, as well as the right and left internal iliac
artery, were injected with a mixture of barium-sulfate-
gelatine-water in a mixing ratio of 5:1:15. The rectum was
resected about 15 minutes later, together with the aorta
(cut off proximal to the bifurcation of the inferior mesen-
teric artery), the urinary bladder and, if present, the ute-
rus. T h e specimen was cut following the ventral medial
line, opened, and x-rayed with 100 mA, 0.03 s, and 100 kV.
T o avoid the superimposition of vessels, the macroscopic
preparation was performed after one or two weeks of
fixation in a 10 percent formalin bath. T h e age of the
patients examined postmortem varied from 36 to 87 years;
26 patients were men, 15 women. In all patients tested,
postmortem primary diseases and cause of death did not
influence the organs of the minor pelvis (Figs. 1 to 5).
Dis. Col. 8eRect.
January 1989
FIG. 1. Postmortem angiography of type
1 inferior rectal artery; the posterior com-
missure is less perfused. A: Inferior rectal
artery. B: Internal iliac artery. C: External
iliac artery. D: Superior rectal artery. E:
Posterior commissure. F: Anterior commis-
sure.
Histologic Study After Postmortem Angiography of
the Vessels: After postmortem angiography and manual
preparation, 10 of the preparations were cut sagittally,
parasagittally, coronally, and paracoronally for histo-
logic examination (Fig. 6). T h e histologic sections were
stained with hematoxylin and eosin and subsequently
scanned under the microscope with special attention to
the course of the vessels in the sphincter ani internus
muscle.
Morphometric Study of the Capillaries in the Suban-
odermal Space and Sphincter Ani Internus Muscle: In 20
cases the number of capillaries and arterioles in the sub-
anodermal space and sphincter ani intemus muscle were
determined. For this purpose the area of the subanoderm
and sphincter ani internus at the posterior and anterior
Volume32
Number 1 INFERIOR RECTAL ARTERY TOPOGRAPHY 45

FtG. 2. Preparation of rectum from dor-

sal after o p e n i n g at ventral medial line;
this preparation is equivalent t o postmor-
tem a n g i o g r a p h y of Fig. 1. A: C o m m o n
iliac artery. B: External iliac artery. C:
Internal iliac artery. D: Superior rectal
artery. E: Inferior rectal artery. F: Levator
ani muscle. G: Posterior commissure. H:
Anterior commissure.

commissure, as well as the lateral parts of the anal canal
between the anocutaneous and anorectal line, was calcu-
lated in square millimeters from each histologic slice.
T h e vessels in these areas are determined by an ordinary
count under the microscope with X 250 magnification.
T o simplify this procedure, the authors used a grid divid-
ing the areas to be examined in determined squares (Figs.
7 to 9).
T h e n u m b e r of vessels in an area of square millimeters
in size is then referred to an area of 100 mmZ; thus deter-
m i n i n g the vessel density/100 m m z for the anterior and
posterior commissure and the lateral part of the subano-
dermal space and sphincter ani internus muscle. T o
compare the various areas of the anal canal, the vessel
density of the anterior commissure was set as 100 percent,
the posterior commissure and lateral area percentually
calculated.
Results
Results of Postmortem Angiography and Manual
Preparation: Angiography in 41 patients showed that the
An
~J~U KLOSTERHALFEN, ET AL.
FIG.3. Section of Fig. 2; typical course of type 1 inferior rectal artery. A: Inferior rectal artery. B: Levator ani muscle. C: Posterior commissure. D:
Anterior commissure.
inferior rectal artery can be found in two variants: 1) T y p e
1. This type forms no or only minute arterial branches of
small caliber at the posterior commissure (Figs. 1 to 3).
T y p e 1 was found in 35 of 41 cases (85.4 percent). 2) T y p e
2. Here the inferior rectal artery supplies the posterior
commissure as well; there is no difference in the vasculari-
zation to be found, in comparison with other parts of the
circumference of the anal canal (Figs 4 and 5). T y p e 2 was
found in 6 of 41 cases (14.6 percent).
In seven cases (17.7 percent) major branches at the
posterior commissure were found, and in one case (2.4
percent) with a type 1 artery, the posterior commissure
was also supplied through the superior rectal artery. A
sufficient blood supply at the posterior commissure
appears to depend mainly on the presence of a type 2
artery that, in the material examined, was found in only
14.6 percent of the cases.
Histologic Study After Postmortem Angiography of
the Vessels: T h e sphincter ani internus muscle is a con-
strictor muscle of smooth muscle with an annular or
Dis. Col. & Red.
January 1989
circular course. Each portion is divided by intermuscular
septa, described by Wilde. 1 In these septa, consisting of
fibre,elastic connective tissue, the major arterial vessels go
as far as the subanodermal space, the bed of the anal
fissure. These septa and the a c c o m p a n y i n g vessels pass in
a direction perpendicular to the fiber course of the sphinc-
ter ani internus muscle (Fig. 6). Minor lateral vessel
branches in the muscular fibers, however, take a direction
parallel to the musculature; the result is a delicate net-
work with its m a j o r branches inside the fibroelastic
intermuscular septa.
Morphometric Study of the Capillaries in the Subano-
dermal Space and Sphincter Ani Internus Muscle
Subanoclerrnal Space: Usually the vascularization with
the highest density is found at the anterior commissure.
In two cases (10 percent) there were more arterial vessels in
the lateral parts than at the anterior commissure. Similar
or equal degrees of vascularization of the anterior com-
missure and the lateral area were found in ten cases (50
percent). In this context, however, the ratio of the total
Volume32
Number 1 I N F E R I O R RECTAL ARTERY T O P O G R A P H Y
FIG. 4. Postmortem angiography of type
2 inferior rectal artery; the posterior com-
missure is supplied by a branch of large
caliber. A: Superior rectal artery. B: Medial
rectal artery. C: Internal iliac artery. D:
Inferior rectal artery. E: Posterior commis-
sure. F: Anterior commissure.
number of vessels in the anterior commissure compared
with the posterior commissure is more important, because
extreme cases show only 35 percent of the arterial vessels
at the posterior commissure. This ratio was found in
three cases (15 percent). In eight cases (40 percent) this
ratio amounts to about 50 percent, and in another five
cases (25 percent) to about 65 percent. In only four cases
(20 percent) was this ratio higher than 80 percent. Among
them, there were two preparations provided with a type 2
artery, as shown in the postmortem angiography. Thus,
in only two preparations was high arterial vasculariza-
tion of the posterior commissure (higher than 80 percent)
associated with a type 1 artery. Figure 8 shows the nearly
equal ratios of the type 2 arteries in cases 1 and 2.
SphincterAnilnternus Muscle: Here as well, the vessel
density of the posterior commissure is more sparse than
that of the anterior commissure and the lateral parts;
'i/
however, the ratio posterior to anterior commissure is
higher; in only six cases (30 percent) it is lower than 80
percent. Parallel to the results of the count of the suban-
odermal space the arterial ratio in the sphincter ani inter-
nus muscle is low when the vessel density in the
subanodermal space is low (Fig. 9).
Discussion
From these results new aspects arise that might be of
importance to the pathogenesis of the primary, chronic
anal fissure: 1) T h e postmortem angiography shows that
in 85 percent of the cases in nonselected autopsies the
posterior commissure is to be considered the end of the
capillary system of the inferior rectal artery. Anastomoses
of rectal arteries at this site of the anal canal are rareY 2)
T h e morphometric study illustrates that the occurrence of
a type I artery usually is connected with a lower vasculari-
AO
"~O
FI(; 5. T y p i c a l c o u r s e ot type 2 i n f e r i o r rectal artery. A: I n f e r i o I reclal artery. B: I~evator a n i muscle. C: P o s t e r i o r c o m m i s s u r e . D: A n t e r i o r
commissule.
zation ratio posterior/anterior commissure. 3) T h e major
arterial vessels, passing vertically to the direction of the
muscle course inside the intermuscular septa, are liable to
be subject to a particularly strong contusion during
increased sphincter tone. T h e resulting decrease in blood
supply might lead to a pathogenetically relevant ische-
mia at the posterior commissure.
T h e following conclusions may be drawn from these
anatomic particularities considering the pathogenesis of
the primary anal fissure.
T h e frequent occurrence of fissures at the posterior
commissure has not been given adequate attention. Some
theories can partly explain satisfactorily why fissures
occur, but they cannot explain the preferential localiza-
tion at the posterior commissure.
T h e theory of the triple-loop system considers the par-
ticular structures in the sphincter ani externus muscle. 3
This is a theory that labels an anatomic substrate as the
cause for preferential localization at the posterior com-
Dis. Col. geRect.
KLOSTERHALFEN, ET AL. January 1989
missure. The triple-loop system explains the occurrence
of the acute and chronic primary anal fissures at this site
of the anal canal as a result of the V-form contour and the
missing counterpart of the sphincter ani externus muscle.
A second mechanism of fissure formation involves anal
sinuses being incorporated into the anoderm laceration
and causing recurrent inflammations. 4Recurrent inflam-
mations inside these epithelial ducts might explain the
transition from the acute to the chronic form.
There is now a third anatomicopathologic explana-
tion, the topography of the inferior rectal artery. With
this hypothesis, a modified model on the pathogenesis of
primary acute and chronic anal fissures can be estab-
lished, assuming the pathogenetic course running in
three stages (Fig. 10).
T h e first pathogenetic phase can consist of various
provoking elements, as discussed above. Among them,
the general anatomy of the sphincter apparatus (triple-
loop system), the anal sinuses, and other diverse inflam-
Volume52
Number 1 INFERIOR RECTAL ARTERY TOPOGRAPHY 49

FIG. 6. Sagittal section t h r o u g h transition zone subanodermal space/sphincter ani internus; an arteriole filled with contrast m e d i u m , r u n n i n g
vertically to the muscle fibers, then into the subanodermal space, can be seen. A: Arteriole. B: Sphincter ani internus. C: Subanodermal space.

matory processes are considered to be of central impor-
tance. Pathologically altered modes of defecation, for
instance, chronic obstipation accompanied by hard stool
passages, diarrheas, or abuse of laxatives, act as the direct
causes. T h e second phase is decisive for determining
whether the fissure remains acute and heals, or turns into
a chronic fissure. In the case of a laceration at the poste-
rior commissure, individuals with a type 1 artery supply-
ing their anal canal run the risk that the existing
laceration of the anoderm due to the primary perfusion
insufficiency does not heal properly.
In the third phase, an additional aggravating factor is
added: the frequent sphincter spasm, 5-9 either the con-
sequence or cause of the fissure, further decreases the
blood supply at the primarily, already less perfused
posterior commissure. T h e other areas of the anus do
not respond in the same way to the ischemia provoked
by increased sphincteral tone because the n u m b e r of
vessels is higher.
Surgical treatment of chronic, primary anal fissure
favors procedures that, by means of expansion or inci-
sion, produce dilatation of the anal canal. Racamier 10
introduced the method of sphincter expansion. Morgan tl
performed an ambulatory treatment with injections into
the sphincter ani internus muscle of local anesthetics
difficult to resorb. T h e painful spasm is abolished for
about one to four weeks.
T h e anterior sphincterotomy by Eisenhammer, 12 the
lateral sphincterotomy by Miles, 13 and the lateral subcu-
taneous sphincterotomy by Notaras 14and Hoffmann and
Goligher 15all dilate, by means of a partial incision of the
sphincter ani internus muscle, the narrowed anal canal.
Dilatation of the anal canal may reduce the ischemia and
supports the healing of the chronic anal fissure.
 FIG. 7. Sagittal section through anus at anterior commissure after passage of contrast medium; filled vessels are marked, A: Anoderm. B:
Subanodermal space.

12~I -

ii i+1 +i -- ,-
i+ + . ! +ii i, ..........
,||i+ i+, ''++ !, 'i

1 2+ 3 4 S g ? ~3 g !8 11 12 !3 14 !5 16 i7 i8 !9 20
C~SE

FIG. 8. Result of vessel count in subanodermal space; cases 1 and 2 are angiographically determined type 2 arteries.
Volume32
Number I INFERIOR RECTAL ARTERY TOPOGRAPHY 51

FIG. 9. Result of vessel c o u n t in sphincter ani internus; in contrast to subanodermal space, posterior commissure of constrictor muscle is (in
comparison with other parts of the anal canal) intensely per[used. PC = posterior commissure. LP = lateral part.

I TRI
pLF-LOOp-SYS'rEM I I ANALC~YpTS/ANALSINllUSON..
[NFLANM~T
I It ~ARD
CONSI
STOOST~NCu
L DIARR~'tOEA I f HAENORRHOIDS

. . . . I I L
I. STAGE

TYPE 2
LRESTR. C I R C U L A T I O N ~ [NORMAL CIRCULATION NORMAL ClRCULATIO[
2. STAGE

[ S P I N C T E R S M U S
3. STAGE

CHRONICANAL ] H E A fi
FISSURE

FIG. 10. Possible model of pathogenesis of chronic, primary anal fissure.


52 KLOSTERHALFEN, ET AL.
References
1. Wilde FR. The analintermuscular septum. Br J Surg 1949;36:279-
85.
2. Reifferscheid M. Die Gef~ssarchitektur des Mastdarmes in ihrer
Bedeutung filr die Technik und Wahl der Anastomosenh6hebei
der tiefen Resektion. Coloproctology 1985;8:197-204.
3. Shafik A. A new concept of the anatomy of the anal sphincter
mechanism and the physiology of defecation. I. The external
anal sphincter: a triple-loop system. Invest Urol 1975;12:412-9.
4. Shafik A. A new concept of the anatomy of the anal sphincter
mechanism and the physiology of defecation. X. Anorectal sinus
and band: anatomic nature and surgical significance. Dis Colon
Rectum 1980;23:170-9.
5. Kuypers JH. Is there really sphincter spasm in anal fissure? Dis
Colon Rectum 1983;26:493-4.
6. Nothmann BJ, Schuster MM. Internal anal sphincter derangement
with anal fissures. Gastroenterology 1974;67:216-20.
Dis.Col.~ Rect.
January 1989
7. Henry MM, Thamson JP. The anal sphincter. Scand J Gastroen-
terol 1984;93(suppl):53-7.
8. Duthie HL, Bennett RD. Anal sphincteric pressure in fissure in
ano. Surg Gynecol Obstet 1964;119:19-21.
9. Hancock BD. The internal sphincter and anal fissure. Br J Surg
1977;64:92-5.
10. Racamier JC. Extension, massage et percussion cadancee dans le
traitment des contractures musculaires. Rec Med Fr Estrang
1838; 1:74.
11. Morgan CN. Oil-soluble anesthetics in rectal surgery. Br Med J
1935;2:938-42.
12. Eisenhammer ST. The surgical correction of chronic internal anal
contracture. S Aft Med J 1951;25:486-9.
13. Miles WE. Rectal surgery. London: Cassdell, 1939:138.
14. Notaras MJ. Lateral subcutaneous sphincterotomy for anal fissure:
a new technique. Proc R Soc Med 1969;62:713.
15. Hoffmann DC, Goligher JC. Lateral subcutaneous internal sphinc-
terotomy in treatment of anal fissure. Br Med J 1970;3:673-5.