SURGICAL ANATOMY AND EMBRYOLOGY 00394109/00 $8.00 + .

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EMBRYOLOGY AND ANATOMY

OF THE ANORECTUM
Basis of Surgery

Guilhem Godlewski, MD, and Michel Prudhomme, MD

Knowledge of the anorectal anatomy is essential for the understanding of

surgical techniques involving this area. Many publications about the develop-
ment and anatomy of this organ have been written,6,7,9, 12, 14, 17, l9 but this article
reminds surgeons about the fundamental principles of the development of this
part of the gut and points out the morphologic aspects that make the surgical
treatment of tumors, congenital malformations, perineal defects, and infection
difficult to perform.

EMBRYOLOGY

Normal Development

The rectum and anus develop at the dilated caudal part of the hindgut,
called the cloaca. This part is an endoderm-lined cavity, closed by the cloacal
membrane and well defined at 3 weeks of gestation. It receives the hindgut
allantoic diverticulum and mesonephric duct. At this point, it is a postanal gut
(Fig. 1A) that spreads out beyond the cloacal membrane and disappears at 5
weeks of gestation. Simultaneously, two parts develop in the cloaca: (1) the
primary urogenital sinus ventrally and (2) the anorectum dorsally. These are
separated by the urorectal septum (Fig. 1B). At 6 weeks of gestation, the cloacal
membrane is disrupted by the descent of the septum, while an anal membrane
develops in the primitive anal canal and blocks the hindgut from opening into
the proctodeum (Fig. lC).I5
The mesenchyme from the caudal eminence and from the urethral folds

From the Departement de Chirurgie Digestive, Laboratoire d’Anatomie Experimentale,

Facult6 de Nimes, Nimes, France

SURGICAL CLINICS OF NORTH AMERICA

-
VOLUME 80 * NUMBER 1 FEBRUARY 2000 319
320 GODLEWSKI & PRUDHOMME

Figure 1. Development of cloaca, hindgut, and primitive rectum from 4 to 7 wk. A, 4 wk:
Carnegie stage XIII. 6, 6 wk: Carnegie stage XVIII. C, 7 wk: urorectal septum.

covers the cloacal membrane laterally and forms the primary or superficial
perineum and cloacal sphincter, which will give the external and internal sphinc-
ters of the anus.I5The junction of the urorectal septum with the deep part of the
cloacal membrane forms the perineal body and deep perineum.
In adults, the anal canal runs from the levator ani muscle to the anal pit
(Fig. 2). It consists of two parts that differ by lining, nerve supply, and vascular
and lymphatic drainage. The upper part derives from the cloaca, and its mucous
membrane forms anal columns and sinuses covered by stratified columnar
epithelium. The inferior limit of the columns, corresponding to the anal valves,
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 321

Puborectalis m.
Loiigitudinal muscular
coat of rectum

Deep part of
external sphincter

Coiljoint longitudinal Sphincter ani intcrnus

coat
Superficial part of Submucous space
external sphincter

Ano cutaneous line

Intemiuscular septum
Subcutaneous part of
external sphincter Skin

Inferior rectal vein Cormgator 111

Figure 2. Coronal section of internal and external sphincters of the anus. Junction with
puborectalis muscle. m=muscle. (From Godlewski G, Leborgne J: Le rectum et la fosse
ischiorectale. In Chevrel JP: Anatomie Clinique: Le Tronc. Paris, Springer-Verlag, 1994, p
375; with permission.)

is located on the pectineal line, identified as the site of the primitive membrane.
The inferior part of the anal canal constitutes the pecten zone, described by
some investigators as the site of the anal membrane.I5It remains above the white
line of cloacal origin. The cutaneous part of the anal canal, located below the
white line, is of ectodermal origin and derives from the proctodeum. The anal
membrane, which is formed by the coalescence of the cloacal membrane with
the urorectal septum, disappears at 8 weeks of gestation (see Fig. 1C).
Externally, the anal pit is formed between the 5th and 10th weeks of
gestation. At 6 weeks, a longitudinal, oval depression is lined by two lateral
prominences and occupied by the cloacal membrane. At 7 weeks, anal tubercles
develop and fuse with each other and delineate the urogenital from the anal
part. At 8 weeks, the anal pit is well formed laterally, delineated by anal hillocks
and anteriorly by the inferior part of the urogenital septum.

Anorectal Anomalies

Anorectal anomalies occur in 2 in 10,000 births and are typically responsible

for imperforate anus.15The severity of the underlying malformation depends on
the extent of the abnormalities of the deep structures, that is, the pelvic rectum
and perineum. According to the extent of malformation, anorectal anomalies
could be classified into three typesT5:(1) low anomalies, involving the anus
below the pectineate line; (2) middle anomalies, involving the anus above the
pectineate line; and (3) high anomalies, involving the rectum above the levator
ani muscle.
322 GODLEWSKI & PRUDHOMME

Figure 3. Anorectal anomalies. A, Anorectal agenesia with vaginal or perineal fistula. 13,
High rectal atresia.

Low anomalies include anal stenosis or imperforation. They are caused by

malformative evolution of the anal pit, anal membrane thickening, excessive
regression of the postanal gut, and proliferation of the anal tubercles. Middle
anomalies include anorectal stenoses and anal agenesis, which are typically associ-
ated with a defect of the perineal body or rectoperineal fistulas. High anomalies
include anorectal agenesis and rectal atresia and are more severe abnormalities.
Anorectal agenesis is caused by the absence or agenesis of the postanal gut, and
no communication exists between the rectum and the perineum.I5In some cases,
communication with the urethra or bladder exists. In patients with anal atresia,
the opening of the anal canal is abnormal (i.e., imperforate anus, proctatresia, or
congenital absence of anal opening) because of the presence of a membranous
septum or the absence of the anal canal. The persistence of cloaca1 membrane is
the most frequent anomaly. In patients with low rectal atresia, no communication
exists between the hindgut and urogenital sinus (Fig. 3A). This malformation is
typically caused by the failure of migration of the urorectal septum, which
induces agenesis of the perineal body and deep perineum. Upper rectal atresia
involves the upper part of the rectum, which is deprived of lumen for several
centimeters while the anal pit and perineum are well formed (Fig. 3B). Also, other
abnormalities, such as esophageal or duodenal atresia, intestinal malrotation, or
urogenital defects may be present in these patients.
Common cloaca is a severe malformation and is caused by the total absence
of the urorectal septum. The urogenital and digestive systems are connected by
a common sinus on the ~erineum.'~

ADULT RECTUM

The rectum is the terminal part of the large intestine. In adults, the rectum
is in full continuity with the sigmoid colon at the level of S3 and ends at the
anocutaneous line. It is composed of two parts: (1) the pelvic rectum, or rectal
ampulla, which is a contractile reservoir, and (2) the perineal rectum, or anal
canal, whch is surrounded by a double sphincter that is divided into the smooth
muscle sphincter, called the internal anal sphincter, which is controlled by the
autonomic nervous system; and the striated muscle sphincter, called the external
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 323

anal sphincter, supplied by the cerebrospinal nervous system. The anal canal and
its sphincteric system regulate defecation.

Rectal Ampulla

External Morphology
The rectum is in continuity with the sigmoid colon. The transition between
the rectum and the colon is called the rectosigmoid flexure and corresponds
dorsally to the lower part of the right root of the sigmoid mesocolon. All along
its vertical route in the pelvis, the rectal ampulla follows the concavity of the
sacrum and coccyx, giving a curve with the anterior concavity called the sacral
flexure. The end of this concavity, that is, the inferior part of the rectum, is
directed downward and forward and comes in contact with the apex of the
<wostatein men and at the posterior wall of the vagina in women (Fig. 4). Then,
changing direction, it goes through the pelvic diaphragm and becomes the anal
canal, characterized by an oblique, inferoposterior direction. The caudal bend
established by the anorectal junction is called the perineal flexure of the rectum
and is strongly pulled ventrally by the puborectalis part of the levator ani
muscle, connected as a loop to the deep part of the external anal sphincter. Its
projection is located 3 cm anteroinferior to the tip of the coccyx, which is an
osseous mark that is easily identified in the perineal approach of abdominoperi-
neal resection. From a frontal view, the rectum presents three lateral inflexions:
(1)two convex on the right side (superior and inferior) and (2) one intermediate
convex on the left side (Fig. 5).
The length of the rectum is approximately 12 cm. The diameter of the upper
part is similar to that of the sigmoid colon (approximately 4 cm). The middle
part is dilated with an expandable wall, forming the rectal ampulla. The inferior
part corresponds to the anorectal junction, characterized by a decreasing diame-
ter and giving off a funnel system in continuity with the lumen of the anal canal
(see Fig. 4A). The pelvic rectum has a thick, muscular wall with two longitudinal
anteroposterior bands following the corresponding taeniae coli. This longitudinal
muscular coat must be reached and liberated from fat tissue when rectal resec-
tion and anastomosis are performed. In the muscular rectal wall are numerous
dehiscences occupied by small arterial and venous branches. Haustrations, tae-
niae, and epiploic appendices are not present.

Internal Morphology
The endoluminal face of the rectal ampulla presents two types of folds: (1)
longitudinal and (2) horizontal. The longitudinal folds are made of mucosa and
disappear during rectal distension. The horizontal folds, called semilunar or rectal
valvulae, are caused by the thickening of the circular muscular layer and by
mucosal proliferation. Horizontal folds are enhanced by rectal distension and
are identified at the outer surface of the rectum as depressions. Three types of
transverse folds exist: (1) superior, (2) middle, and (3) inferior. The superior
circular and laterally implanted fold is located below the rectosigmoid flexure.
The middle fold is more conspicuous in the lumen than is the one outside of
the rectum. Its constitutes the upper limit of the ampulla (see Fig. 5 ) and
represents the junction between two embryologic parts of the rectum: (1) the
upper part, originating from the terminal hindgut, and (2) the middle part,
originating from the cloaca. This middle fold is located at the level where the
324 GODLEWSKI & PRUDHOMME

Visceral pelvic peritoneurn

Pelvic nctum
sacral flexure
Deferent duct
RecIWesical pouch

Ureter Seminal vesicle

Bladdcr
Perincsl flexure Levator ani m.
Prostate Anococcykeal ligament
SphiMer Anal canal and
urethra cxtmus sphincler ani externus

Bulbspngiosus m. Pcrineal body

S3
Visceral pelvic
peritoneum

Pelvic rectum (runpulla)

Recto-uterinepouch

A n m y g e a l ligament
ClitoliS
Vagina Spliinclcr ani externus
Fascia vaginorectal Sphincter ani intcrnus

B
Figure 4. A, Left parasagittal section of external morphology and relations of rectum in a
man. 6,Sagittal section of external morphology and relations of rectum in a woman.
m = muscle. (From Godlewski G, Leborgne J: Le rectum et la fosse ischiorectale. ln Chevrel
JP: Anatomie Clinique: Le Tronc. Paris, Springer-Verlag, 1994, p 368; with permission.)

peritoneum corresponds with the rectogenital fossa from the anterior face of the
rectum to the urogenital organs. The inferior fold is sometimes absent and is
located on the left side of the ampulla, 2 or 3 cm from the middle fold. In rare
cases, a fourth fold is present between the superior and middle folds on the left
side of the rectum.I9
Finally, the middle fold subdivides the rectal ampulla into two part^'^: (1)a
cranial supraperitoneal part, laterally free and suitable for distension in the
pelvirectal space (see Fig. 5) and responsible for the storage of feces, and (2) a
caudal part, embedded in a more confined position in the pelvic cavity and, in
healthy patients, empty between times of defecation. Nevertheless, in patients
with chronic constipation, the entire rectum may contain feces.
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 325

Iliac fascia
lliacus External iliac it

External iliac v.
Femoral nerve Parielal pclvic peritoiieuni
Psoas Ureter
Pararcctal fossa
Pelvireclal spacc (Pararectal spacc)

Genital a.
Parietal Pelvic fascia Visceral pelvic fascia
Inferior Iimgastric plexus and ganglia
Obturator fascia
Middle rectal a. with lateral ligament
Obturator internus

lillernal Pudendal a. lschioreclal fossa

Levator mi
Pudendal nerve

Inferior rectal a.
Sphinctcr ani internus
Sphincter
ani externus

Figure 5. Internal configuration of rectum. a= artery; v=vein. (From Godlewski G, Leborgne

J: Le rectum et la fosse ischiorectale. In Chevrel JP: Anatomie Clinique: Le Tronc. Paris,
Springer-Verlag, 1994, p 368; with permission.)

Pelvic Peritoneum, Rectal and Perirectal Fasciae, and Perirectal

Fat and Spaces
The rectal ampulla is included in a space superiorly covered by the visceral
peritoneum, laterally limited by the visceral pelvic fasciae,I9 anteriorly by the
urogenital organs and their fasciae, and dorsally by the sacrum and the presacral
fasciae. Inferiorly, this space is closed by the partial fusion of levator ani muscle
and rectum. Effectively, some contingents of this muscle fuse with the longitudi-
nal muscular layer of the rectal wall and end in the corium of perianal skin,
whereas others directly end on the superior fascia of the pelvic diaphragm.
Although the visceral pelvic peritoneum almost completely surrounds the
rectosigmoid flexure and is adherent to its muscular coat, the peritoneum is
related only to the upper two thirds of the rectum where it is put down as a
sheet with an obliquely directed line of reflexion lower in the frontal plane than
in the rectal lateral sides (see Fig. 4). In the median plane, the peritoneum is
attached to the posterior wall of the vagina in women, forming the rectouterine
pouch, and in men, it is attached to the seminal vesicles, deferent ducts, and
bladder, forming the rectovesical pouch of the peritoneum. In women, the
rectouterine pouch (or Douglas’ recess) is located lower than is the rectovesical
pouch in men, permitting easier transanal exploration of the pelvic peritoneal
cavity in women. The distance from the pouch to the anus is 5.5 cm in women
versus 7.5 cm in men.19 In women, Douglas’ recess is laterally limited by two
peritoneal folds, called the rectou terine folds, corresponding to sacrorectal and
rectouterine ligaments. In Douglas’ recess, the peritoneum is attached to the
-
rectum at the medial plane, where the longitudinal muscular coat of the organ
326 GODLEWSKI & PRUDHOMME

is visible. On both sides of the rectum, the peritoneum is progressively lifted up

by fat tissue and is easily divided during excision. Finally, two parts exist in the
rectum: (1) an upper part, which is partially intraperitoneal, and ( 2 ) a lower
part, which is subperitoneal and difficult to approach. The lower part is also
more likely exposed to and at risk for postoperative infection, especially after
lower rectal surgery.
The fasciae are composed of loose connective tissue differently positioned
around the rectum. Two types of fasciae exist: (1) the rectal fascia and ( 2 ) the
perirectal fascia. The rectal fascia constitutes a cylindric sheath surrounding the
rectum at the contact of its muscular coat. It is thcker in the lower part of the
pelvis than in the upper part of the rectum. Between the rectum and the fascia,
branches of rectal arteries, veins, nerves, and pararectal lymph nodes are inter-
spersed within a large layer of perirectal fat.
The perirectal fasciae are stronger than the rectal fascia. They are composed
of fibroareolar connective tissue and make a clear delineation between the
rectum and the other pelvic organs and spaces: they are anterior, dorsal, and
lateral to the rectum.
Anteriorly, in men, the fascia between the rectum and seminal vesicles and
prostate is the rectovesical fascia (Denonvilliers' fascia), intimately adherent to
the anterior surface of the lower rectum. This fascia must be removed with the
rectum in cases of tumoral excision. Surgeons must identify this plane of dissec-
tion to gain low access as far as possible when the tumor is low. In women, the
anterior or rectogenital fascia is easier to excise, with attachment to the vagina
being slighter except frequent large venous plexus (Fig. 6). The fascia attached
to the bottom of Douglas' recess corresponds to the pelvic peritoneal recess in
embryos and is secondarily closed during rectal de~elopment.'~ This fascia is an
important parameter of pelvic sustentation in women. Its weakness may cause
posterior prolapse and rectoceles.
Dorsally are two posterior frontal fasciae: (1) a posterior fascia, called the
presacral fascia or Waldeyer s' fascia, laid out on the sacral concavity, cranially

Paravesical space
paracystiiiiii
Vesicovagiiial fascia
Panela1 pelvic fascia

Visceral pel\ ic fascia

?enass ple\us Rectovaginalfascia
liitcriial iliac a Parniiieler

Middle rain1 a

Rectal nene
2 pnraprwtiuiii
PClVlC splallcllllic a R a l a l slalks
iiene
Interior ramus of sacral lien c Presacral space
Presacral fascia
Reclal fascia

Figure 6. Rectal and perirectal fasciae and spaces. Transverse section through the pelvic
organs. Fasciae and spaces (right). Arteries; pelvic, splanchnic, and hypogastric nerves;
and venous plexus (left). Bladder (B). Uterus (U). Rectum (R). a=artery; v=vein.
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 327

originating on the anterior surface of S2 or S3, and caudally fixed to the posterior
surface of the rectum fascia, 2 to 5 cm above the anorectal junction; and (2) an
anterior fascia corresponding to the rectal fascia and covering the posterior
surface of the rectum (see Fig. 6). Between these fasciae is a retrorectal space
that constitutes the posterior part of the mesorectum. The presacral fascia, also
called the suspensor ligament of the rectum," must be dissected near the rectum to
perform mobilization of the organ in lower rectal surgery for the treatment of
cancer. On both sides, the presacral fascia is in continuity with the parietal pelvic
fascia, covering the sacral plexus, pyriform, and coccygeus muscles.
Superolateral to the levator ani muscle, the rectal space and mesorectum
are limited by the visceral pelvic fascia, which is fixed to the anterior branches
of the internal iliac artery and the hypogastric inferior plexus (see Fig. 6). This
neurovascular visceral pelvic fascia presents a lateral expansion, forming the
lateral ligament of the rectum, called the rectal stalks or pillars,", containing the
branches of presacral nerves (i.e., the right and left hypogastric nerves), and
covering the middle rectal artery. On both sides of the high rectum, the stalks
contain the right and left hypogastric nerves, which obliquely travel anteroinferi-
orly in the perirectal fat to join the inferior hypogastric plexus. On both sides of
the middle or lower rectum, the inconstant middle rectal artery arrives trans-
versely across the pelvic visceral fasciae extension, called the lateral ligament of
the rectum, to the rectal wall. The stalks divide the fat and connective tissue of
the posterior compartment of the pelvirectal space into the pararectal and ret-
rorectal spaces (Figs. 6 and 7). Hemostasis and section of the rectal stalks are
important keys of rectum mobilization during the excision of lower rectal tu-
mors. On both sides, the presacral and visceral pelvic fasciae join together at the
level of the anterior sacral foramina, where the pelvic splanchnic nerves arrive,
having originated from the second and third anterior sacral nerves. These nerves
run forward in the pelvic visceral fascia and travel to the inferior hypogastric
plexus and ganglia. They ensure the nerve supply of the pelvic organs. During

Superior wne
(Hindgut origin) Upper Irans\wse fold

Ano rectal line Middle transverse fold

Middle wnc
(Cloaca origin) Levator ani

Anal colunuis
Anal \ d w s
Columnar wne
Trdnsitiond zone
Ano cutaneous line
Spliinckr mi,esternus
Skin mne
Spliincler mi internus

Figure 7. Coronal section of ischiorectal fossa with lateral relations of rectum. (From
Godlewski G, Leborgne J: Le rectum et la fosse ischiorectale. In Chevrel JP: Anatomie
Clinique: Le Tronc. Paris, Springer-Verlag, 1994, p 371; with permission.)
328 GODLEWSKI & PRUDHOMME

rectal excision, the dissection of the mesorectum at the medial contact of the
inferior hypogastric plexus and ganglia may prevent, especially in men, denerva-
tion of the urogenital organs.’” l4
In its pelvic portion, the rectum is surrounded by perirectal fat forming the
mesorectum, which is differently located according to the level of the organ.8At
the peritoneal level, the perirectal fat follows the right limb of the sigmoid
mesocolon and is confined at the dorsal face of the rectum, containing superior
rectal vessels and branches of presacral nerves (i.e., the left and right hypogastric
nerves). At the subperitoneal level, fat surrounds the posterior three fourths of
the rectum and disappears on its anterior surface at the level of the rectogenital
fascia (see Fig. 8). This fat contains branches of the superior and middle rectal
arteries, veins, rami of the inferior hypogastric plexus, and lymph nodes, so the

Figure 8. Pelvic MR image with axial acquisitions in a man. A, Axial T1-weighted with fat
suppression. Rectum (R). Bladder (B). Pelvic visceral fascia (PVF) with inferior hypogastric
plexus and vessels. Retrovesical recess (RVR). Mesorectum (MR). 13,Obturator internus
(01)and levator ani (LA) muscles. lschiorectal or ischioanal fossa (IRF). Bladder (B). Anal
canal (AC). (Courtesy of M. Mattei-Gazagnes, MD, Nimes, France.)
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 329

mesorectum must be excised in surgery to treat cancer, partially for the excision
of high rectal tumors and totally for the excision of middle or lower rectal
tumors.20

Rectal Relationships
The anterior relationships of the rectum are different in both sexes (see Fig.
4) and can be defined according to the line of attachment to the peritoneum:
above is the rectogenital or rectovesical pouch or recess, and below is the
posterior surface of genital organs. Above the line of attachment, in women, the
Douglas' pouch separates the anterior surface of the rectum from the posterior
surface of the uterus and the superior recess of the vagina. This pouch contains
ileal coils and the sigmoid colon. Below the line of attachment is the rectovaginal
fascia and the posterior surface of the vagina. In men, the rectovesical pouch is
divided into two parts by a small coronal peritoneal fold attached to the deferent
ducts and seminal vesicles. The posterior part is a rectogenital recess, and the
anterior part, a vesicogenital recess. Beyond and forwards this is the base of the
bladder. Inferior to the visceral peritoneal reflexion, the rectum is attached to
the seminal vesicles, deferent ducts, and prostate. Laterally, it is attached to the
implantation of the ureters in the bladder. Between the rectum and the prostate
is the prostatoperitoneal membrane (Denonvilliers' fascia), which is intimately
adherent to the prostatic fascia and runs down to the superior surface of the
urogenital diaphragm.
The posterior surface of the rectum is attached medially to the anterior
surface of S3, S4, and S5; the coccyx; the median sacral artery; and the right
branches of the superior rectal artery, called the ganglion (coccygeal, Walter's)
impar. The posterior surface is attached laterally to the anterior rami of the
lower three sacral and coccygeal nerves, sympathetic trunks, lateral sacral arter-
ies, coccygei, and levator ani muscles. The pelvic splanchnic nerves issued from
the sacral nerves run from the anterior sacral foramina to reach the lateral wall
of the rectum and join together with right and left hypogastric presacral nerves
to form the pelvic p l e x ~ s . 'These
~ nerves are included in connective tissue that
forms the sacrorectal and rectouterine ligaments. The rectouterine ligaments are
located in the vicinity of perirectal visceral fascia and are strong elements for
orientation and attachment of the pelvic organs, especially the rectum. They
must be divided for mobilization of the rectum during excision for lower rectal
adenocarcinoma.
The lateral surface of the rectum has two levels of relationships determined
by the line of attachment to the pelvic peritoneum, obliquely fixed inferoanteri-
orly on the lateral wall of the rectum. Superior to this is the pararectal fossa of
pelvic peritoneum, which is largely open with the abdomen when the rectal
ampulla is empty and which contains the ileal loops and sigmoid. When the
rectum is'distended, its lateral surface gets in touch with the parietal pelvic
peritoneum and fascia, upper part of the levator ani muscle, pelvic ureter, and
posterior branches of the internal iliac artery and vein. In women, the rectum is
related to the uterine tube, ovary, and fossa when they are in horizontal position.
Below the line of peritoneal attachment, the rectum corresponds with the visceral
pelvic fascia, pelvic splanchnic (Eckard's) nerves, sacral splanchnic nerve, presa-
cral nerve with the right and left hypogastric nerves, and inferior hypogastric
plexus and ganglia (i.e., the pelviperineal ganglionic plexus) (Fig. 9). Distally,
correspondence is with the pelvirectal space with the origin of the anterior
branches of the internal iliac vessels, middle rectal artery, and lymphatic nodes
following the vessels (see Fig. 7). Beyond these are the piriformis, levator
330 GODLEWSKI & PRUDHOMME

Vagal fibers included iii root

bglit lumbar splanchiiic nen'c

Len himbar splanchiiic iicn'c
Superior hypogastric plexus
(prcsncral iienc)
Len hypgaslric nen'e 3rd sacral nen'c
bglit Iiypogaslric a e n c
41h sacral nen'c

Y
Snioolh iiiuscle sphincter of urethra

+&ctcr ani intcrnus

(snioah iiiiixle sphiiicter)
lnrerior hypogastric (pelvic) plexus and ganglia
(pelviperincal ganglionic plexus)

Figure 9. Autonomic nerve supply of the rectum in a woman. Parasympatheticfibers (dotted

line). (From Bossy J: Atlas of Neuroanatomy and Special Sense Organs. Philadelphia, WB
Saunders, 1970, p 323.)

ani muscle, and coccygei muscle, covered by the superior fascia of the pelvic
diaphragm.
During excision of high rectal tumors, the autonomic nerves can be pre-
served because they are located far from the rectal wall and are easily dissected
in the mesorectum. In excision of low rectal tumors, a noninvasive attitude for
autonomic nerve supply is sometimes impossible because the pelvic nerves are
short, being located in the vicinity of the rectal wall of the inferior hypogastric
plexus.

Anal Canal

General Morphology
The superior limit of the anal canal begins at the anorectal line, where the
rectum becomes more narrow and changes direction abruptly to go inferoposter-
ior to end at the anocutaneous line. The anal canal is generally 3 or 4 cm in
length, and the anterior wall is shorter than is the posterior wall. When the anal
canal is empty, the lumen is an anteroposterior slit that becomes cylindric during
defecation. The anal canal is surrounded by a double-muscular sphincter system,
including the internal anal sphincter, which is composed of a thickening of the
circular muscle coat of the rectum, surrounds the superior three fourths of the
anal canal, and is controlled by the autonomic nervous system; and the external
anal sphincter, which is composed of striated muscle and forms a ring sur-
rounding the anal canal (see Figs. 2 and 5).
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 331

Inner Morphology
The lumen of the anal canal is divided into three parts: (1) the columnar
zone; (2) the transitional zone, or pecten; and (3) the cutaneous zone (see Fig.
5 ) . The columnar zone corresponds to the superior half of the anal canal (see
Fig. 7 ) . It begins at the level of the anorectal line and covers a ring 1.5 cm high;
in this zone, the mucosa presents 8 to 10 longitudinal folds, called anal columns,
each of which contains terminal branches of the superior rectal vessels. Enlarge-
ment of the veins is responsible for internal hemorrhoids. Compared with the
pink color of the low rectum caused by subjacent arterial radicles, the columnar
zone is lined by purple mucosa colored by the subjacent rectal venous plexus.
The epithelium here is columnar or squamous. The base of each column is
enlarged and joined with small mucosal folds, called anal valves. The alignment
of the valves forms the pectineal or dental line, which is considered the level of
insertion of the anal membrane during embryonal development.'6 This line is
the superior border of the squamous epithelium and must be visualized at the
beginning of mucosectomy and the level of ileoanal anastomosis.
Above the anal valves and between the columns are small recesses called
anal sinuses, which sometimes submit to infection; abscess formation; or anal
fissures. In the area of the sinuses, the anal glands, composed of small acini
surrounded by a lymphoid follicle, are numerous and infiltrate the submucosa
and the adjacent internal sphincter. Every gland empties into the anal canal by
a duct arriving in a small anal crypt. When the duct is not working, the gland
could be distended by secretions, inducing abscess or fi~tu1a.I~
The transitional zone (see Fig. 7 ) succeeds to the columnar part of the anal
canal, below the dental line. It extends for approximately 1.5 cm. Its pluristrati-
fied, bluish-colored epithelium is caused by the presence of an underlying rectal
venous plexus. The submucosa of this zone contains dense connective tissue
forming a strong attachment of the lining to the muscular coat of the anal canal.
The inferior border of the transitional zone is marked by a purple ring called the
white line. This line corresponds to the transition between the anal pluristratified
mucous membrane and anal skid9 and is located between the subcutaneous
part of the external anal sphincter and the lower border of the internal sphincter
(intersphincteric groove).
The cutaneous zone proceeds to the white line and extends approximately
8 mm (see Fig. 5). This zone, of white or brown coloration, contains sweat and
sebaceous glands called circumanal glands.

Relationships of the Anal Canal

The anal canal is surrounded by a contractile musculoaponeurotic sheath
composed of vertical fibers that are issued from the levator ani muscle (see Fig.
2); circular fibers constituting the external anal sphincter; longitudinal fibers
passing ventrally to the perineal body, forming the rectourethralis muscle; and
others from the rectococcygeal muscle.
Dorsally, the anal canal is related to the anococcygeal ligament, to the
terminal fibers of levator ani muscle, and to the tip of the coccyx. The ligament
must be sectioned during anoperineal resection for the treatment of cancer.
Ventrally are the perineal body and the muscles of the urogenital diaphragm. In
men, beyond the perineal body are the bulbospongiosus muscle, the bulb of the
corpus spongiosus penis, and the urethra (see Fig. 4A) and in women, the vagina
(see Fig. 4B). Laterally, the ischiorectal or ischioanal fossa is occupied by lobular
fat tissue containing the inferior rectal vessels and nerves (see Figs. 5 and 7).
332 GODLEWSKl & PRUDHOMME

Anal Sphincters
The walls of the anal canal are surrounded by two annular sphincters: (1)
the internal anal sphincter and the external anal sphincter (see Fig. 2).
The internal anal sphincter is a thickening of the circular muscle layer of
the rectum extended from the anorectal line to the anocutaneous line. In the
horizontal position, the anocutaneous line corresponds to the external pit of the
anal canal, whereas the subcutaneous part of the external sphincter is more
peripheral (see Figs. 2 and 5). This sphincter is a smooth muscular coat enwrap-
ping the upper three quarters of the anal canal in a strip 30 mm high and
exceeding the superior edge of the external sphincter by approximately 1 crn.I9
The external anal sphncter is a circular, striated muscle surrounding the
internal suhincter and controlled bv the cerebrosuinal nervous svstem. It is
composedof three parts: (1)deep, (2f superficial, anh (3) subcutaneoks (see Figs.
2, 5, and 8).19
The deep part surrounds the upper portion of the anal canal, and its
superior fibers are mixed with the puborectal part of the levator ani muscle (see
Fig. 2). The anterior fibers are partially continuous with the superficial transverse
perineal muscle.
The superficial part is elliptic and enwraps the inferior half of the internal
sphincter down to the level of the anocutaneous line (see Fig. 2). It is the most
stable part of the sphincter, anteriorly attached to the perineal body by the
rectourethralis muscle and posteriorly to the anococcygeal ligament.
The subcutaneous part is a ring, vertically flat and 15 mm thick, surrounding
the cutaneous zone of the anal ~ana1.I~ Located below the inferior level of the
internal sphincter and of the superficial part of the external sphincter, it runs
beneath the intersphincteric groove in the subcutaneous perianal tissue. Anteri-
orly, some fibers are attached to the perineal body and posteriorly to the anococ-
cygeal ligament.
The puborectalis part of the levator ani muscle joins the anal sphincteric
apparatus at the level of the anorectal line and pulls ventrally the anterior bend
of anorectal flexure. Its fibers skirt around the medial face of the deep and
superficial parts of the external sphincter and fuse with the longitudinal smooth
muscle coat of the rectum to realize the conjoint longitudinal coat of the anal
canal interposed between the external and internal sphincters (see Fig. 2) and
descending around the anus to be fixed to the perianal subcutaneous connective
tissue. This longitudinal coat gives off 10 to 12 fibroelastic septa radiating in
three direction~'~:
1. Most of them run through the subcutaneous part of the external sphincter
and become fixed to the corium of perianal skin.
2. The most lateral fibers pass between the superficial and subcutaneous
parts of the external sphincter and disappear in.the ischiorectal fossa.
3. The most medial fibers run through the internal sphincter to become
attached to the submucosal layer of the anal canal or pass between the
inferior border of the internal sphincter and the subcutaneous part of the
external sphincter to form the anal intermuscular septum. These fibers
are fixed to the subcutaneous chorion of the intersphincteric groove and
anal skin.
The fibers, crossing over the subcutaneous part of the external sphincter
and becoming fixed to the chorion of perianal skin, form the corrugator cutis
ani muscle, responsible for the puckering of anal verge called corruptor reflex
(see Fig. 2).
At the level of the anorectal junction, the puborectalis muscle and the deep
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 333

part of the external and internal sphincters form a homogeneous anorectal ring
that loops the sides and back of the anorectal flexure and form a sling that pulls
the gut anteriorly toward the pubis. Surgical or traumatic damage of any part
of this sling may cause anal incontinence.
During sleep, the tonus of both anal sphincters keeps the anal canal closed.
During defecation, the tonus of muscles is released, and the anal canal is opened
with prolapse of mucous membrane. The external sphincter is voluntarily con-
tracted, allowing anal occlusion. The internal sphincter is controlled by the
autonomic lumbar sympathetic nerve supply, which causes rectal repletion (i.e.,
relaxation of the rectal wall and contraction of the anal tonus), and by pelvic
splanchnic nerves carrying parasympathetic fibers that command defecation (i.e.,
contraction of the rectal wall and relaxation of the anal tonus).

VASCULARIZATION

Rectal Arteries

The blood supply of the rectum is dependent on the median sacral, superior
rectal, middle rectal, and inferior rectal arterie~.~,
9,

Median Sacral Artery

The median sacral artery arises from the back of the aortic bifurcation, runs
down on the midline in front of L5 and the sacrum, and ends on the coccygeal
body. In the retrorectal space, it gives branches to the posterior surface of the
anal canal.

Superior Rectal Artery

The superior rectal artery follows the course of the inferior mesenteric
artery, and is individualized after the emergence of the inferior sigmoid artery
(Figs. 10 and 11).It crosses the left iliac vessels, reaches the posterior surface of
the rectosigmoid flexure, and is divided into two branches in front of S3. The
right branch, which is larger than the left, runs vertically in continuity with the
inferior mesenteric artery on the posterior surface of the rectal ampulla, provid-
ing radicles for the right surface of the ampulla. The left branch runs horizontally
and irrigates the left and anterior surface of the ampulla.
Commonly, a dorsal branch from the superior rectal artery irrigates the
dorsal surface of the ampulla (see Fig. 11). Anastomotic marginal arteries are
not present. The collateral branches pierce the muscular coat to form a submuco-
sal network, with radicles running in the anal columns. The superior rectal
artery supplies the entire rectal wall and mucosa of the anal canal.

Middle Rectal Artery

The middle rectal arteries are visceral branches of the internal iliac artery
(see Fig. 10). They are bilateral but typically asymmetric. In 22% of cases, the
middle rectal artery is ~nilateral.'~ Typically, these arteries originate from the
anterior trunk of the internal iliac artery, but in some cases, they arise from the
internal pudendal or inferior gluteal artery. From their origin, the middle rectal
arteries run transversely across the pelvirectal fossa, sustaining the lateral liga-
334 GODLEWSKI & PRUDHOMME

Inferior
mesenteric a.

Sigmoid arler).

Median sacral a.
Superior rectal a.
Iliolun~bara.
Inlemal iliac a.
Umbilical a.
Obturator a.

Inferior gluteal a.
Uterine a.
Middle rectal a.

Internal
pudendal artery Inferior rectal a.

Figure 10. Anterior view of rectal arteries. a=artery. (From Godlewski G, Leborgne J: Le
rectum et la fosse ischiorectale. ln Chevrel JP: Anatomie Clinique: Le Tronc. Paris,
Springer-Verlag, 1994, p 376; with permission.)

Figure 11. Blood supply of superior rectal artery (SRA). Vascular injection of an abdomino-
perineal resection. Right (RB) and left (LB) branches. Inferior rectal artery (IRA). (From
Godlewski G, Leborgne J: Le rectum et la fosse ischiorectale. ln Chevrel JP: Anatomie
Clinique: Le Tronc. Paris, Springer-Verlag, 1994, p 376; with permission.)
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 335

ment of the rectum (i.e., the visceral pelvic fascia), and give off three or four
rectal and genital branche~.'~

Inferior Rectal Artery

These arteries supply the anterior muscular coat of the anal canal (see Fig.
11).The inferior rectal artery arises bilaterally from the internal pudendal arter-
ies. It runs transversely from Alcock's canal to the anal canal, following the
posterior border of the urogenital diaphragm and running across the ischiorectal
fossa (see Fig. 10). The ending branches of this artery irrigate the internal and
external anal sphincters, levator ani muscle, and submucosa of the anal canal.
The terminal radicles of the different arteries correspond with the wall of
the rectum through small, convoluted arteries surrounded by perirectal fat. They
are distributed in two ways: (1) some are superficial and spread out in the
muscular coat of the rectum, and (2) others are intraparietal and spread out in
the submucosa (see Fig. 11).

Rectal Veins

Plexus
The rectal veins originate from three rectal venous plexuses (Fig. 12): the (1)
external and (2) internal rectal plexuses and (3) the perimuscular plexus.
The external rectal plexus is located between the subcutaneous external
sphincter and the skin of the anal canal9 Laterally, it extends in the space
separating the different parts of the external sphincter. The enlargement of this
plexus causes external hemorrhoids. The strong attachment of elastic septa in
the perianal space, between subcutaneous sphincter muscle and skin, explains
the painful complications of hemorrhoid^.'^ The internal rectal plexus is located
in the submucous space of the anal canal and rectal a r n p ~ l l a Extended
.~ above

Figure 12. Anterior view of rectal veins. m=muscle; v=veins. (Adapted from Healy JE,
Seybold WD: A Synopsis of Clinical Anatomy. Philadelphia, WB Saunders, 1969, p 213.)
336 GODLEWSKI & PRUDHOMME

the pectinate line, it runs in the anal column, giving off the venous ampulla,
which constitutes the origin of internal hemorrhoids. The perimuscular plexus
receives venous blood from the sphincteric system? These three plexuses, which
are separated widely, have a common site of spontaneous portacaval anastomo-
sis on each side of the anocutaneous line.

Veins
The rectal veins (see Fig. 12) include the inferior, middle, and superior rectal
veins and the median sacral vein. The inferior rectal veins begin from the
external rectal plexus and drain the inferior part of the anal canal in the internal
pudendal veins and the internal iliac veins (systemic route). The middle rectal
veins originate from the submucosal plexus of the rectal ampulla and from the
perimuscular plexus. They run in the lateral ligament of the rectum and join the
internal iliac veins (systemic route). These veins, like their corresponding artery,
are not present in all people.*8The superior rectal vein drains the upper part of
the internal rectal and perimuscular plexus. It is formed by five or six veins
piercing the muscular coat of the rectum and converging into a large vein that
directly empties into the inferior mesenteric vein (portal route). The median
sacral vein is an accessory route that drains the perimuscular plexus. It joins the
left common iliac vein (systemic route) and constitutes a complementary portaca-
Val anastomosis.

Rectal Lymph Nodes

Lymphatic drainage is important to carcinomatous dissemination. The

lymph vessels begin in the intramural lymphatic plexuses beneath the rectal
mucous membrane and anal skin. From the plexuses, extramural channels are
formed and reach pararectal lymph nodes (first nodal level) located in the
perirectal fat. The collectors drain in three nodal sites: (1) superior, (2) middle,
and (3) inferior rectal nodes (Fig. 13).
The superior rectal lymph nodes drain the rectal wall above the middle
fold. Lymphatic vessels reach an intermediate group located in the superior
rectal artery bifurcation (principal lymph node of the rectum), and then end in
the periaortic lymph nodes (called the inferior mesenteric lymphocenter) and in the
left lumbar para-aortic lymph nodes.
The middle rectal lymph nodes drain the lymph of the rectal ampulla below
the middle fold and above the mucocutaneous junction. The lymphatic channels
accompany the middle rectal vessels to the internal iliac nodes in the pelvirectal
fossa. Some inferior lymph nodes below the pectinal line drain through the
levator ani muscle, run across the ischiorectal fossa, and reach the internal
pudendal collectors. Some posterior nodes directly reach the posterior sacral
and common iliac nodes.
The inferior rectal nodes exclusively drain the anal canal below the muco-
cutaneous junction (i.e., the white line). The vessels run laterally across the
ischiorectal fossa and reach the superficial inguinal lymph nodes. The superior
part of the anal canal between the pectinate line and the white line has double
lymphatic drainage: the internal iliac and the superficial inguinal lymph
nodes.
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 337

Inferior
mesenteric nodes

Common iliac
nodes

Internal
iliac a. Principal reclal nodes

Inlernal
iliac nodes
Middle rectal a
Pararectal
nodes
Superficial
inguinal nodes
Inferior
reclal a.

Figure 13. Rectal lymph nodes. a=artery. (From Godlewski G, Leborgne J: Le rectum et
la fosse ischiorectale. In Chevrel JP: Anatomie Clinique: Le Tronc. Paris, Springer-Verlag,
1994, p 379; with permission.)

INNERVATION

The rectal area is supplied by the autonomic nervous system and cerebrospi-
nal nerves.14,18The pelvic wall of the rectum and internal anal sphincter of the
anal canal derive their sympathetic nerve supply from the lumbar part of the
trunk and from the superior hypogastric plexus by means of plexuses following
the inferior mesenteric and superior rectal arteries and are identified as the
presacral and right and left hypogastric r ~ e r v e sThe
. ~ parasympathetic supply to the
rectum and upper half of the anal canal is derived from the pelvic splanchnic
nerves arising from third and fourth sacral nerves and joining the inferior
hypogastric plexus and ganglia located on the sides of the rectum in the pararec-
tal visceral fasciae (see Fig. 9).3The sympathetic nerve supply is inhibitory to the
musculature of the rectum and facilitator to the tonus of the internal sphincter, so
it works spontaneously for constipation. The parasympathetic supply, causing
movement of the musculature of the rectum and inhibiting the internal sphincter,
acts for defecation.z4
Afferent impulses supporting sensations of physiologic rectal distension are
conveyed. by splanchnic nerves. Visceral pain is conducted by sympathetic and
parasympathetic nerves. This autonomic nervous organization explains constipa-
tion induced by autonomic nerve damage or by low rectal resection including
removal of the rectal wall and of its sensory nerve receptors.
In surgical resection of the rectum for inflammatory disease, the dissection
must be performed close to the rectal wall to avoid nerve damage, secondary
impotence, and bladder dysfunction. In tumor resection, nerve conservation
depends on the development and location of the tumor.
The external anal sphmcter is supplied by the rectal nerves (Fig. 14). The
anterior rectal nerve arises from the superficial perineal ramus of the internal
pudendal nerve. The fibers arrive from S2. The middle rectal nerve or inferior
338 GODLEWSKI & PRUDHOMME

s3

s5

Pudendal 11.
Perineal branch 0fS4
Inlerior rectal 11.
Dorsal 11. ofpenis

Muscular
branch of perineal n.

Figure 14. Nerve supply of external sphincter ani. n = nerve. (From Godlewski G, Leborgne
J: Le rectum et la fosse ischiorectale. ln Chevrel JP: Anatomie Clinique: Le Tronc. Paris,
Springer-Verlag, 1994, p 380; with permission.)

rectal nerve arrives from S3. The posterior rectal nerve comes from the perineal
branch of the fourth sacral nerve.”
The nerve supply of the anal canal must be interpreted according to the
double origin of the anal canal. The upper part of the anal canal-above the
pectinate line-is derived from the endodermal cloaca and is supplied by
the autonomic nerves. This part of the anal canal has selective sensitivity for the
intraluminal difference in tension, explaining the inhibitor and facilitator re-
flexes. The inferior part of the anal canal is derived from the ectodermal procto-
deum, where the skin lining is supplied by cerebrospinal nerves called rectal
nerves. This part is sensitive and responds to pain and tactile and thermal
stimuli. This nerve supply explains the painful character of external hemor-
rhoids, abscesses, and fistulas. Internal hemorrhoids are typically less painful.

APPLIED ANATOMY
Clinical and Traditional Explorations
Clinical rectal examinations can be performed by exploration with the index
finger. The different parts of the anal canal are successively explored, including
the subcutaneous part of the external sphincter, the internal sphincter above the
white line, the superficial and deep parts of the external sphincter, and the
puborectalis part of the levator ani muscle. Beyond the anal canal, the rectal
ampulla is explored. The regularity of the mucous membrane and of the trans-
verse folds is judged. Anatomic structures related to the rectum may be palpated
through the wall of the rectum.

Conventional Examinations
Conventional examinations include anuscopy, rectoscopy, and barium en-
ema with double contrast.
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 339

Figure 15. A, Endoanal ultrasound of a woman. Anal mucosa (AM). Sphincter ani internus
(SAI) and externus (SAE). Vagina (V). B, Endorectal ultrasound in a man. Rectal mucosa
(RM). Deferent duct (DD). Seminal vesicle (SV). (From Godlewski G, Leborgne J: Le rectum
et la fosse ischiorectale. In Chevrel JP: Anatomie C l i q u e : Le Tronc. Paris, Springer-Verlag,
1994, p 381; with permission.)

Modern Imaging

The following imaging methods permit morphologic and functional exami-

nation. Defecography provides a dynamic analysis of defe~ation.'~ The transit
time, dyskinetic abnormalities of the levator ani muscle, and opening defects of
the sacrorectal flexure can be explored in the staging of chronic constipation,
rectocele, and significant defects of the perineum in women.
Endorectal sonography allows physicians to analyze the size, topography,
and parietal involvement of rectal tumors.'O The mucous membrane is identified
as a hypoechoic layer, the tumor as a hyperechoic site, the metastatic lymph
nodes as hypoechoic zones, and the perirectal fat as hyperechoic tissue (Fig. 15).
Computed tomography allows for precise staging of the rectal tumors, that
is, parietal involvement, fat and pelvic organ extension, and juxtatumoral and
distal adenopathies. CT is a two-dimensional examination.
MR imaging provides three-dimensional analysis (Figs. 8, 16, and 17) with
340 CODLEWSKl & PRUDHOMME

Figure 16. Pelvic MR image. A, T1-weighted sagittal view of the pelvis of a woman. Rectum
(R). Uterus (U). Bladder (B). Anococcygeal muscle (ACM). B,TBweighted sagittal view of
a man. Rectum (R). Prostate (P). Bladder (B). Levator ani muscle (LA). (From Godlewski
G, Leborgne J: Le rectum et la fosse ischiorectale. In Chevrel JP: Anatomie Clinique: Le
Tronc. Paris, Springer-Verlag, 1994, p 382; with permission.)
 EMBRYOLOGY AND ANATOMY OF THE ANORECTUM 341

Figure 17. Tl-weighted pelvic MR images. Frontal spin echo acquisitions in pelvis of a
man. A, Posterior acquisitions through the rectal ampulla (RA) and the anal canal (AC).
Levator ani muscle (LA). lschiorectal fossa (IRF). Coxal bone (CB). B, Acquisitions through
the anal flexure. Rectal ampulla (RA). Anal canal (AC). Levator ani (LA) and obturator
internus (01)muscles. (Courtesy of M. Mattei-Gazagnes, MD, Nimes, France.)
342 GODLEWSKI & PRUDHOMME

acquisitions in the frontal, sagittal, and transverse planes. The morphology and
topographic relationships of the rectum and the positioning of the levator ani
muscle are well defined. The rectal tumors, the invasion of perirectal fat, and
lymphatic metastases can be evaluated clearly on MR imaging.I6

SUMMARY

The rectum is a pelvic organ, complex in its morphology and its topographic
relationships. Its double embryologic origin explains the two types of tumors
that develop in the rectum: (1) lieberkiihnian adenocarcinoma in the pelvic
rectum and (2) squamous epithelioma in the anal canal. Its venous and lymphatic
supply, intensively developed, realizes early pathway of tumoral dissemination.
The pelvic relationships of the rectum and anus explain the technical difficulty
of rectal surgery, especially when subperitoneal resection and anastomosis are
concerned. Imaging of this area permits an early diagnosis of rectal tumors and
allows a less invasive surgery with a carcinologic precision.

ACKNOWLEDGMENTS
The authors acknowledge Martine Mattei-Gazagnes for her contribution to the MR
imaging and Marie-Helene Laencina and Etienne Lenteires for their technical assistance.

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Address reprint requests to

Guilhem Godlewski, MD
Dkpartement de Chirurgie Digestive
Laboratoire d’Anatomie ExpCrimentale
FacultP de Nimes
Avenue Kennedy
F30900 Nimes. France