Ischiorectal fossa anatomy

and it’s suppuration

Dr.Niveditha S Dr.S.Chandak
Dr.Melissa P Dr.C.Mahkalkar
Ischiorectal fossa : Introduction
• The ischiorectal fossa is also known as ischoanal
fossa
• The ischiorectal fossa is a space filled with
fat lateral to the anal canal and just below the
pelvic diaphragm. The ischiorectal fossa has a
shape of a triangular pyramid with the apex at
the boundary of the anal canal and the obturator
fascia, and the base directed towards the perineal
surface.
• The ischiorectal fossa is divided into the perianal
space and the ischiorectal space by the perianal
fascia.
• The perianal fascia is an extension of
the insertion of the longitudinal
muscles of the anal canal outwards
between the subcutaneous external
sphincter and the external sphincter
muscle.
• This fascia extends across the
ischiorectal fossa to the tuberosity of
the ischium.
• The fat of the perianal space is closely
packed and finely granular, while large
lobules of avascular fat fill the
ischiorectal space.
Shape & Measurements
• Wedge shaped
• Vertical – 5 cm
• Anteroposterior – 5 cm
• Transverse – 2.5 cm
 Boundaries of Ischiorectal fossa
• The Apex  intersecting fibers of the
obturator internus and the levator ani muscles.
The sacrospinous ligament delimits the lateral-
posterior aspect.
• The Base  Base is oriented inferiorly and
posteriorly
The Base is bounded by the
gluteus maximus muscle and the sacrotuberous
ligament, the coccyx, the anococcygeal raphe,
the external anal sphincter, the posterior margin
of the superficial perineal fascia and the
posterior border of the transversus superficialis
muscle of the perineum
Boundaries of Ischiorectal fossa
• The Floor  is the skin of posterior
quadrants of perineum , limited by ischial
tuberosity and the coccyx.
• The Pyramid wall  comprises
the puborectalis muscle and
the pubococcygeal muscle covering the anal
canal, and the external anal sphincter.
• The Lateral wall  formed by the medial
aspect of the obturator fascia, the ischial
tuberosity, and the obturator internus
muscle. The fascia covering the lateral wall
duplicates to form the canal in which the
pudendal vessels run
• The ischiorectal fossa anteriorly continues to the pubic bones
between the muscular layers and the fascia of the levator ani muscle
above and the deep transverse perineal muscle and the compressor
urethra muscle below, running laterally to the urogenital organs. As a
result, the fatty space assumes a wedge-shape around the portion of
the pelvic viscera under the levator ani muscle, from the pubis to the
coccyx.
Fascia of Ischiorectal fossa
• Obturator fascia
• Anal fascia
• Perianal fascia
• Lunate fascia
Fascia of Ischiorectal fossa
• OBTURATOR FASCIA (yellow arrow) fascia
ofobturator internus muscle, covers the
pelvic surface of the muscle and is attached
around the margin of its origin
• ANAL FASCIA (red arrow) Theanal fascia is
the inferior layer of the diaphragmatic part
of thepelvic fascia
• PERIANAL FASCIA (blue arrow) Lateral most
septum derived from fusion of longitudinal
muscle of rectum and levator ani
• LUNATE FASCIA- (red arrow) lines the deepest part of fossa
arched shaped
Laterally- Covers the obturator fascia, forms medial wall of pudendal
canal & blends with periosteum of ischial tuberosity
Medially - Covers the anal fascia, blends with it at white line of Hilton
Summit- Called tegmentum
Recesses of the fossa
ANTERIOR RECESS- forward extension of fossa above perineal
membrane/ urogenital diaphragm and below the pelvic diaphragm
POSTERIOR RECESS- backward extension deep to
sacrotuberousligament on the side of coccyx

Two ischioanal fossaecommunicate with each other through a gap

behind the anal canal
Contents of ischiorectal fossa
• The contents of the ischiorectal fossa include the following structures, all prone to lesions or
compression:

1. Internal pudendal artery, vein, and nerve.

2. Inferior rectal artery and vein
3. Inferior rectal nerve
4. Posterior scrotal vessels and nerves
5. Lymphatics
6. Perineal branch of S4 and perforating cutaneous nerve
7. Subcutaneous fat is abundant on both sides of the anal canal which permits distension of the anal
canal during defecation.
The different adipose tissue around the anal canal and into the ischiorectal fossa could help the tone of
the plate of the levator ani muscle to balance the gradient pressures of the different intra-and extra-
peritoneal spaces of abdomen, pelvis, and perineum.
 Contents of ischiorectal fossa
• Pudendal canal is also known as Alcock’ canal.
• Inside Alcock's canal, on the lateral wall
• internal pudendal artery
• internal pudendal vein
• pudendal nerve
• Outside Alcock's canal, crossing the space transversely
• inferior rectal artery
• inferior rectal veins
• inferior anal nerves
• fatty tissue across which numerous fibrous bands extend from side to side allows
distension of the anal canal during defecation
Figure depicting Alcock’s canal
Embryology

• A distinct fascial septum connecting the parietal and visceral side of

the ischiorectal fossa is present in foetal specimens. The dense fibrous
connective tissue attaches inferiorly to the posterior side of the
anterior perineal membrane (urogenital diaphragm).In adult cadavers,
the connective fibres spread around the lobules of the fatty tissue
and hang firmly with dense fibrous tissue of the obturator
internus muscle, the gluteus maximus muscle, and the inferior surface
of the fascia of the levator ani muscle.
Surgical Consideration
• Ischiorectal fossa is highly susceptible to formation of abscesses.
• Several fistulous tracks end blindly in the fatty tissue.
• Most common etiologies for anal fistula are Crohn’s disease , foreign bodies,
infections (tuberculosis , actinomycosis and lymphogranuloma venerum) .
Trauma , hemorrhoidectomy & episiotomy are also possible cause.
• Anal fistulas and ischiorectal abscesses tend to be more common in males
between the ages of 30-48.
• Primary pathologic conditions originating in the ischiorectal fossa proper are
rare. Lesions include lipomatous tumors, aggressive angiomyxoma, vascular
lesions, and neurogenic tumors.
Surgical Consideration
• Medial border lesions of ischiorectal fossa may include urogenital and
anorectal diseases.
• Urogenital Space lesions includes – Bartholin gland cysts , Skene gland
cysts , Urethral diverticulum , Trauma and cervical & vaginal cancers.
Endometriosis is a rare occurrence.
• In males the D/D for mass in ischiorectal fossa is either trauma or
malignancy .
• Both genders may have urethral or bladder carcinoma.