Lab 15

Rectum – descriptive anatomy, relations, structure, blood supply, innervation

Urinary bladder - descriptive anatomy, relations, structure, blood supply, innervation
ANATOMY OF LARGE INTESTINE - Rectum

Rectum is the last part of large intestine: it continues sigmoid colon at the level of S3 – rectosigmoid jonction – and ends by
anal orifice.

Rectum has two parts separated by the medial borders of levator ani muscles:

- Ampulla of rectum – located in pelvis

- Anal canal – passes through pelvic diaphragm and posterior perineum
ANATOMY OF LARGE INTESTINE - Rectum

Rectum has a slightly sinuous trajectory and presents curvatures in the sagittal and frontal planes.

In the sagittal plane:

- Sacral flexure – concave anteriorly

- Perineum flexure – concave posteriorly
ANATOMY OF LARGE INTESTINE - Rectum

Rectum has a slightly sinuous trajectory and presents

curvatures in the sagittal and frontal planes.

In the sagittal plane:

- Sacral flexure – concave anteriorly

- Perineum flexure – concave posteriorly
ANATOMY OF LARGE INTESTINE - Rectum

Rectum has a slightly sinuous trajectory

and presents curvatures in the sagittal and
frontal planes.

In the sagittal plane:

- Sacral flexure – concave anteriorly

- Perineum flexure – concave posteriorly
ANATOMY OF LARGE INTESTINE - Rectum

In the frontal plane:

- Superior curvature – concave to the left

- Inferior curvature – concave to the right
ANATOMY OF LARGE INTESTINE - Rectum

Lodge of rectum – in males:

- Posterior – sacrum and coccyx – piriformis and coccygeus

muscles
- Lateral – levator ani muscles
- Anterior – rectovesical fascia
- Inferior – levator ani muscle
- Superior – peritoneum; the lodge communicates to
retroperitoneal space.

Rectum is covered by a fibrous sheath – rectal fascia that is part

of perineum visceral fascia.
ANATOMY OF LARGE INTESTINE - Rectum

Lodge of rectum – in males:

- Posterior – sacrum and coccyx –

piriformis and coccygeus muscles
- Lateral – levator ani muscles
- Anterior – rectovesical fascia
- Inferior – levator ani muscle
- Superior – peritoneum; the lodge
communicates to retroperitoneal space.

Rectum is covered by a fibrous sheath –

rectal fascia that is part of perineum visceral
fascia.
ANATOMY OF LARGE INTESTINE - Rectum

Relations of rectum ampulla in males

- Posterior – sacrum, coccyx with piriformis and coccygeus muscles, median and lateral sacral vessels, sacral sympathetic
chains, anterior branches of sacral nerves, sacral lymph nodes.
- Anterior – anterior face of rectum is partially covered by peritoneum that reflects on posterior face of urinary bladder and
forms the rectovesical excavation described by Douglas. Superior from the excavation we have sigmoid colon and intestinal
loops; inferior from the excavation, it is in relation through rectovesical septum to prostate, seminal vesicles, ductus
deferens and fundus of urinary bladder.
ANATOMY OF LARGE INTESTINE - Rectum

Lateral faces have two segments due to the

reflection of peritoneum from the superior
part of rectum to the lateral walls of pelvis –
pararectal recesses.

Superior segment is in contact to sigmoid

colon and intestinal loops.

Inferior segment – inferior hypogastric

vegetative plexus, ureters
ANATOMY OF LARGE INTESTINE - Rectum

Lodge of rectum – in females:

- Posterior – sacrum and coccyx – piriformis

and coccygeus muscles
- Lateral – levator ani muscles
- Anterior – rectovaginal septum
- Inferior – levator ani muscle
- Superior – peritoneum; the lodge
communicates to retroperitoneal space.

Rectum is covered by a fibrous sheath – rectal

fascia that is part of perineum visceral fascia.
ANATOMY OF LARGE INTESTINE - Rectum

Lodge of rectum – in females:

- Posterior – sacrum and coccyx –

piriformis and coccygeus muscles
- Lateral – levator ani muscles
- Anterior – rectovaginal septum
- Inferior – levator ani muscle
- Superior – peritoneum; the lodge
communicates to retroperitoneal
space.

Rectum is covered by a fibrous sheath –

rectal fascia that is part of perineum
visceral fascia.
ANATOMY OF LARGE INTESTINE - Rectum

Relations of rectum ampulla in females

Anterior face is covered by peritoneum that

reflects on the posterior wall of vagina and
forms the rectouterine excavation described
by Douglas – deeper than in males.

Excavation described by Douglas represents

the lowest point of peritoneal cavity.

Inferior from the excavation, through

rectovaginal septum, it has relations to
posterior wall of vagina.
ANATOMY OF LARGE INTESTINE - Rectum

Relations of rectum ampulla in females

Anterior face is covered by peritoneum that

reflects on the posterior wall of vagina and
forms the rectouterine excavation
described by Douglas – deeper than in
males.

Excavation described by Douglas represents

the lowest point of peritoneal cavity.

Inferior from the excavation, through

rectovaginal septum, it has relations to
posterior wall of vagina.
ANATOMY OF LARGE INTESTINE - Rectum
ANATOMY OF LARGE INTESTINE - Rectum

Relations of anal canal in males

- Posterior – anococcygeal ligament,

levator ani muscles
- Anterior – tip of prostate,
membranous urethra, transverse
muscle of perineum, bulbourethral
glands, bulb of penis.

Between anal canal and urethra –

rectovesical space.
ANATOMY OF LARGE INTESTINE - Rectum

Lateral – ischiorectal fossa

ANATOMY OF LARGE INTESTINE - Rectum

Relations of anal canal in females

Anterior – posterior wall of vagina.

Rectovagina space –central tendon
of perineum.
ANATOMY OF LARGE INTESTINE - Rectum

Internal configuration of rectum ampulla

Mucosa presents:
- Transverse folds
One on the right wall – the biggest, described
by Kohlrausch
Two on the left wall

Transverse folds correspond to transverse

grooves on the surface and are created by a
mucosa fold that contains submucosa and
circular muscle fibers.
ANATOMY OF LARGE INTESTINE - Rectum

Internal configuration of anal canal

Mucosa presents:
- Anal columns of Morgagni – 8-10 longitudinal folds;
pyramid shape with the base towards anus; contain
longitudinal muscle fibers and branches of superior
rectal vessels.
- Anal valves Morgagni – semilunar folds that unite the
bases of surrounding anal columns.
- Anal sinuses Morgagni – fossa made by anal valves

The circular area that corresponds to prominent parts of

columns represents hemorrhoid area – internal rectal
venous plexus in submucous space (internal
hemorrhoids).
The area of anal columns is the columnar area that is
limited inferiorly by pectinate line – passes through the
base of anal columns.
Pectinate line corresponds to the middle part of internal
anal sphincter muscle and represents the junction area
between the endoderm rectum and ectoderm rectum
ANATOMY OF LARGE INTESTINE - Rectum

Mucosa presents:
- Anal columns of Morgagni – 8-10 longitudinal folds; pyramid shape with the base towards anus; contain longitudinal muscle fibers
and branches of superior rectal vessels.
- Anal valves Morgagni – semilunar folds that unite the bases of surrounding anal columns.
- Anal sinuses Morgagni – fossa made by anal valves

Pectinate line corresponds to the middle part of internal anal sphincter muscle and represents the junction area between the endoderm
rectum and ectoderm rectum
ANATOMY OF LARGE INTESTINE - Rectum

Inferior from pectinate line there is the transition area –

pecten – limited inferiorly by the white line of Hilton.

White line of Hilton – is a white-blue colored circular

groove that points the limit between internal anal
sphincter and the subcutaneous part of external anal
sphincter.
ANATOMY OF LARGE INTESTINE - Rectum

Anal canal and rectum as seen from the median sagittal plane. a the mucosa (M), b circular musculature (CM) of
the rectum and internal anal sphincter (IAS), c longitudinal muscle (LM), d levator ani muscle (LAM) and external
anal sphincter (EAS)
ANATOMY OF LARGE INTESTINE - Rectum
ANATOMY OF LARGE INTESTINE - Rectum

Rectum – structure

External tunic – peritoneum in the anterior and superior part;

adventitia – lax connective tissue

Muscle layer – smooth muscle fibers:

- External longitudinal layer
- Internal circular layer – at the level of anal canal it forms the
internal anal sphincter. Longitudinal fibers separate internal anal
sphincter from external anal sphincter (striate) – superficial and
deep parts.

Submucosa tunic – it is very lax allowing the prolapse of mucosa;

contains blood vessels – venous plexuses. At the level of pecten, it
contains smooth muscle cells and collagen fibers – possible stenosis.

Mucosa layer
Until pectinate line – simple cylinder epithelium
Between pectinate line and white line – stratified squamous
epithelium non keratin.
In cutaneous area – modified skin – stratified squamous epithelium
gets keratin.
Anal verge – between this modified skin and perineum skin.
ANATOMY OF LARGE INTESTINE - Rectum

Muscle layer – smooth muscle fibers:

- External longitudinal layer

- Internal circular layer – at the level of anal canal it
forms the internal anal sphincter. Longitudinal fibers
separate internal anal sphincter from external anal
sphincter (striate) – superficial and deep parts.
ANATOMY OF LARGE INTESTINE - Rectum

Arteries of rectum

Superior from pectinate line – superior rectal artery,

branch of inferior mesenteric artery.

Inferior from pectinate line – inferior rectal arteries,

branch of internal pudendal artery (internal iliac artery).

Middle rectal arteries distribute to the anterior and

lateral walls of the inferior part of ampulla and anal
canal without mucosa.
ANATOMY OF LARGE INTESTINE - Rectum

Veins of rectum

They originate in rectal venous plexus located inside

submucosa.
Superior from pectinate line, they drain into superior
rectal vein – inferior mesenteric vein – portal vein.

Inferior from pectinate line, they drain into inferior

rectal vein – internal pudendal veins – iliac vein –
inferior vena cava.
A portocaval anastomosis is thus achieved.

Middle rectal veins drain from the walls of ampulla and

anal canal into iliac veins.
ANATOMY OF LARGE INTESTINE - Rectum

Lymph nodes of rectum

They originate in a mucous and a submucous plexus – pararectal lymph nodes.

They form three pedicles:
- Superior pedicle – superior rectal nodes – inferior mesenteric nodes – drain lymph superior from pectinate line.
- Middle pedicle – middle rectal nodes along middle rectal veins – internal iliac nodes. They drain from the inferior part of
ampulla and anal canal.
- Inferior pedicle – drain from the inferior part of anal canal into superficial inguinal nodes.
ANATOMY OF LARGE INTESTINE - Rectum

Superior from pectinate line – sympathetic fibers from inferior mesenteric plexus that arrive along the superior rectal arteries
(red) and parasympathetic fibers of pelvic splahnic nerves (S2-S4) (blue).
Middle rectal plexus distribute to the inferior part of rectum ampulla – sympathetic fibers (red) and parasympathetic fibers
(blue) from inferior hypogastric plexus.
Inferior hypogastric plexus – sympathetic fibers from hypogastric nerves and parasympathetic fibers from pelvic splanchnic
nerves.
ANATOMY OF LARGE INTESTINE - Rectum

Inferior anal plexus accompanies inferior rectal artery – anal canal and internal anal sphincter.
At the inferior part of anal canal – inferior rectal nerves – somatic nerves for external anal sphincter.
ANATOMY OF LARGE INTESTINE - Rectum
 Urinary bladder

- descriptive anatomy, relations, structure, blood supply, innervation -

ANATOMY OF URINARY BLADDER

Urinary bladder – parts

- Apex – median umbilical ligament – urachus

- Fundus
- Cervix – urethra
- Body – medial umbilical ligaments – obliterated umbilical arteries

Urinary bladder – empty

- Anterior face
- Posterior face
- Inferior face or fundus
- Lateral borders
- Cervix – between anterior face and fundus

Urinary bladder – full

- Anterior face
- Posterior face
- Inferior face or fundus
- Lateral faces
ANATOMY OF URINARY BLADDER
Lodge – male
- Anterior – pubic symphysis, anterior abdominal wall
- Posterior – recto-vesico-prostatic septum (prostate-peritoneal ligament)
- Lateral – internal obturator muscle, levator ani muscles
- Inferior – prostate
- Superior - peritoneum
ANATOMY OF URINARY BLADDER
Lodge – female
- Anterior – pubic symphysis, anterior abdominal wall
- Posterior – vesico-vaginalis septum
- Lateral – internal obturator muscle, levator ani muscles
- Inferior – vagina and urogenital diaphragm
- Superior - peritoneum
ANATOMY OF URINARY BLADDER

Relations - Posterior face

- or posterior and superior
- Covered by peritoneum
- Rectum – male
- Uterus – female
- Sigmoid colon
- Small intestine loops
- appendix
ANATOMY OF URINARY BLADDER

Relations - anterior face

- Anterior wall of pelvis
- Prevesical space – Retzius space
ANATOMY OF URINARY BLADDER

Relations – fundus – male

Prostatic segment – anterior and inferior

Deferential segment
- Seminal vesicles
- Ampulla of ductus deferens
- Interdeferential trigone
- Rectum
ANATOMY OF URINARY BLADDER
Relations – fundus – female

Superior third – cervix of uterus

Distal two thirds

- anterior wall of vagina
- Vesico-vaginal septum

Relations of cervix – urogenital diaphragm

Relations of apex – pubic symphysis

ANATOMY OF URINARY BLADDER

Relations of cervix – urogenital diaphragm

Relations of apex – pubic symphysis

ANATOMY OF URINARY BLADDER

Internal configuration
Trigone of bladder – Lieutaud Urethra orifice
Ureteric orifice Uvula of bladder
Interureteric crest
ANATOMY OF URINARY BLADDER
ANATOMY OF URINARY BLADDER

Arterial blood supply – 4 pedicles

- Superior – umbilical artery Vesical venous plexus
- Inferior – internal iliac artery
- Anterior – internal pudendal artery and inferior epigastric artery
- Posterior – middle rectal artery (male) and uterine and vaginal artery (female)
ANATOMY OF URINARY BLADDER

External layer
- Tunica serosa – peritoneum
- Tunica fibrosa

Tunica muscularis
- External layer – longitudinal
- Middle layer – circular
- Internal layer – plexus

Musculus detrusor vesicae

M. Sphincter vesicae

Tunica mucosa
ANATOMY OF URINARY BLADDER

1. Aortic plexus, superior and inferior hypogastric plexus

(thoracic-abdominal sympathetic system)
2. Pelvic splanchnic nerves (parasympathetic system)