ANATOMI ANOREKTAL

Dr. Asih Anggraeni, SpOG (K)

ANATOMY ANORECTAL
ANATOMY:
Anal Sphincter:
internal sphincter
external sphincter

Puborectalis muscle
Anatomy of the anal sphincter
FUNCTION OF ANAL SPHINCTER AND
PUBORECTALIS

Puborectalis: control continence over solid stool

Internal sphincter: control of liquid faeces
External sphincter provide internal sphincter in times
of sudden need, such as raised intra abdominal
presures
Anal cushion  the amount of blood flowing through
its arteriovenous channels provide control over flatus
 Sphincters
Internal anal sphincter
Voluntary or involuntary?
• Involuntary
Type of muscle?
• Smooth muscle
Tonically contracted
 Sphincters
External anal sphincter
Voluntary or involuntary?
• Voluntary
Type of muscle?
• Striated muscle
Nerve and segment?
• Pudendal nerve (S2-S4)
 Bowel Neuroanatomy
Neural controls
Extrinsic (3)
1) Sympathetic
2) Parasympathetic
3) Somatic
Intrinsic (2)
1) Myenteric plexus
2) Submucosal plexus

SNS and PNS modulate the enteric nervous

system as opposed to directly controlling
smooth muscle of bowel
 Neuroanatomy & Physiology
Autonomic neural pathways
Parasympathetic
• Upper via Vagus nerve innervates…
– Upper segments of GI tract to splenic flexure
• Lower via Pelvic splanchnic nerves (nervi
erigentes)
– S2-S4 to the descending colon and rectum
• Function
– Stimulates GI secretion, motor activity
– Relaxes sphincters and blood vessels
 Neuroanatomy & Physiology
Autonomic neural pathways
Sympathetic
• Hypogastric nerve
– L1, L2, L3 to the lower colon, rectum, and sphincters
• Function
– Inhibition of GI secretion, motor activity
– Contraction of GI sphincters and blood vessels
Somatic
• Pudendal nerve
– S2-S4
– External anal sphincter and pelvic floor
 Bowel - Autonomic Nervous
System
Parasympathetics
Increases colonic motility
Sympathetics
Promote storage
• Enhance anal tone
• Inhibit colonic contractions
• Bilateral sympathectomy has little clinical
effect
 Parasympathetic Control
Neurotransmitter
• Ach
• Near the neurons of myenteric and submucosal
plexuses
Nerve(s)
• Vagus
– From esophagus to mid transverse colon
• Pelvic nerve
– Supplies mid-transverse colon to rectum
Lack of PNS innervation to ….
• Small intestine
Function(s)
• Increase peristalsis, stimulate secretions, relax
sphincter, increase gut motility
 Bowel – Autonomic Nervous
System
Parasympathetic nervous system
PNS functions
• Increase peristaltis
• Stimulates secretions
• Relaxes sphincters
• Increases gut motility
 Sympathetic Control
Neurotransmitter
Norepinephrine
Location
Intermediolateral SC (T5-L2)
Superior and inferior mesenteric nerves (T9-T12)
Hypogastric (T12-L3)
Functions
Decrease peristalsis
Inhibits secretions
Contracts sphincters
Decreases gut motility
 Neuroanatomy & Physiology
Intrinsic nervous system
Submucosal (Meissner) plexus
Myenteric (Auerbach) plexus
Regulate segment-to-segment movement
of the gastrointestinal (GI) tract
May be considered a 3rd part of the ANS
 Intrinsic Nervous System
Myenteric plexus (Auerbach)
Located between the longitudinal and circular layers of
muscle in the tunica muscularis
Controls tonic and rhythmic contractions
Exerts control primarily over digestive tract motility
Submucosal plexus (Meissner)
Buried in the submucosa
Senses the environment within the lumen
Regulates GI blood flow
Controls epithelial cell function (local intestinal secretion
and absorption)
May be sparse or missing in some parts of GI tract
Partially controlled by autonomic nervous system
 Intrinsic Nervous System
3 types of neurons in enteric system
1. Sensory neurons (5 types)
– Chemoreceptors sensitive to acid, glucose and amino
acids have been demonstrated which, in essence, allows
"tasting" of lumenal contents. Sensory receptors in
muscle respond to stretch and tension
2. Motor neurons
• Control GI motility and secretion, and
possibly absorption
3. Interneurons
• Largely responsible for integrating
information from sensory neurons and
providing it to motor neurons
 Intrinsic Nervous System
Enteric neurotransmitters
Acetylcholine
• Excitatory
– Stimulate smooth muscle contraction
– Increase intestinal secretions,
– Release of enteric hormones
– Dilation of blood vessels
Norepinephrine
• Derived from extrinsic sympathetic neurons
• Inhibitory
Functions autonomously
but normal digestive function requires
communication between the intrinsic system and
CNS
 Normal Defecation
Rectosigmoid distention stimulates
rectorectal reflex
Bowel proximal to bolus
• contracts
Bowel distal to bolus
• relaxes

Reflex relaxation of internal anal sphincter

Rectoanal inhibitory reflex
Correlates with the “urge to go”
Volitional contraction of levator ani
 Normal Defecation
Volitional control of levator ani
Opens proximal anal canal
Relaxes external sphincter and
puborectalis
Allows straighter anorectal passage
May increase with
Valsava
Increasing intraabdominal pressure
(squat)
 Normal Defecation
Defecation deferred by volitionally
contracting (2)…
Puborectalis
External anal sphincter
Then, internal anal sphincter relaxation
reflex will fade (within approx 15 sec) and
urge will resolve until triggered again
 Normal Defecation
Protective mechanisms
EAS will tense in response to small
colonic contractions
• Via spinal cord reflex (conus) and modulated
by higher centers
 Anatomy Perineum

Fakultas Kedokteran Universitas Indonesia

Pemeriksaan lanjutan :

• Anal manometry
• EMG
• Anal endosonography
• USG 3D/4D
• MRI
TERIMA KASIH

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