ANORECTAL PHYSIOLOGY

Dr Basrul Hanafi ,dr, SpB-KBD

Digestive Division, Surgery Department
RSHS- FKUP - Bandung

INTRODUCTION
The

knowledge of the anatomy and physiology

of the anal canal and rectum are very important
Anal canal : 4 cm in length, proctoderm
Rectum : entoderm
Anorectal investigation has helped us to outline
the anatomy component parts of the sphincter
complex as well as to define the physiology of
defecation and the anal continence.

Embryology

ANATOMY

ANATOMY

Anal muscles

External sphincter muscles

Triple loop system of the

puborectalis muscle and
external sphincter

ARTERY
Artery hemorhoidalis from inferior
mesenteric artery=> Upper middle
rectum
Rectal

hemorrhoid artery from

internal iliac => distal 2/3 rectum

Rectal

hemorrhoid from pudenda

internal => internal and external

spinster

VEIN
Hemorhoidalis superior
Hemorhoidalis

medial

Hemorhoidalis inferior

LYMPH NODE OF THE ANORECTAL

INERVATION OF THE ANAL CANAL

Intramural autonomic nerve plexus

Continence of anal canal

Depend

on :

Consistency of the fecal

Tonus of the rectal (N ; 25 100 mmHg )

Angle of the anorectal ( N : 80 0 )

Factors of Anal Continence

The normal angulations of the anorectal

junction preserve by puborectalis m.
Length : 3.5-4.5 cm around sphincter
internal and external.

Factors of anal continence

Factor influence of anal incontinence

Funnel deformity.
Continence depend on
closing of the superior
anal canal

Short Anal canal =>

incontinence

Thin Mucosa and

atrophy (estrogen
deficiency, radiotherapy)
can make mucus and
fecal incontinence

Charles V. Mann, Richard E.Glass : Surgical Treatment of Anal Incontinence, Springer-Verlag, 1991

Defecation

Complex process, depend on :

Information from CNS : Brain and spinal cord
Pelvic floor function
Transit time and colon motility
Colon contain : Bile,fat,water, solid, Fiber and gas
gene
Age
Mental status
Hormonal status
The most important factors : Normal Condition (Anatomy and
Physiology) of the rectum and anus

Anal Pressure
Resting pressure

Defecation mechanism

Feces enter to rectum

Sphincter relaxation
Increase abdominal pressure
Anorectal angle increase
Peristaltic, power to forse the content
Feces out

Anorectal angle
Normal + 120 0

Abnormal angle >150 0

Cause of incontinence

Defecation

1. Position of the anorectal junction to coccyx, and 2.

Anorectal angle (ARA) , 3. Anal canal width (ACW)

Defecation
1.

Extrinsic factor to colonic motility

CNS : hypothalamus thyrotrophic releasing

hormone & corticotrophin releasing hormone

Spinal cord : paradigmatic Left colon

Defecation
2. Colon motility
Contraction :

Activity of large bowel

segmental
peristaltic

Colonic peristalsis

Defecation
3. Pelvic floor

Angle of the anorectal form by : traction of puborectalis

muscle control the solid fecal

internal anal Sphincter : control the liquid fecal

Anal cushions

: control the gas

Defecation

Pelvic floor
a. Normal puborectal sling
b. Anal in caudal posisitionl and puborectal
sling short
c. Anal displaced with puborectal sling
coccyx are long

Defecation
4. Rectum

Normal Rectum is Empty

Fill with fecal before and time of defecation

Rectum => as reservoir

5. Recto-sigmoid junction
There is evidence that defecation was control by recto
sigmoid junction

Defecation
6. Anal

Anus - angle with rectum

- 120o : when standing
- 115o : flexion of coccyges

Traction of puborectalis sling The angle

result : influence of continence to
incontinence because of flutter / shutter"
effect

Anorectal Investigation
Digital rectal examination,
Defecografi, => fixation of the rectum from sacrum, Anal
manometry, => resting measure, squeeze measure,
sphincter minimal sensory valve of rectum, maximal
rectum tolerance
Electromyography, => fiber density of external sphincter

Ballon expullsion,

Defecography

Squeezing

Resting

Straining

A: The striated muscle normally relax during

straining of defecation, so the anal canal pressure
decrease.
B. Paradoxical contraction means striated muscle
contract during defecation straining, the anal canal
pressure increase. It is shown in anismus

PUDENDAL ELECTRODE AND CONECTOR

Anal manometry & Electromyography

Normal subject
Changes in anal canal
pressure and smooth and
striated muscle activity
during straining.
After an initial rise, the anal
canal pressure fall, and this
is associated with loss of of
the internal anal sphincter
electrical slow wave activity.
The integrated
electromyography signal
from the striated external
anal muscle also fall

Descending perineal
syndrome (DPS)
During straining perineum
descent less than 2-3 cm,
more 3 cm decided as DPS
(fig. b)
Measure:
-Defaecography
-Perineometer
Clinic: Constipation or
incontinence
Etiology:
Chronic straining chronic
pudendal neuropathy

SCINTIGRAPHY
Normal: within 48
hours of
ingestion much of
the radioisotope
has been passed
from bowel

Severe
constipation due
to prolonged
transit time, over
the 4 days
radioisotope
does not
progress beyond
the thansverse
colon

Special investigations
Endorectal Ultrasonografy

Easy
Cheap
Relative allowance
Able to Identification
of muscles sphincters
defect, Correlation
with Gold standard
(Intra Op) 0.96

CINEPROCTOGRAPHY

Provide a picture of the successive phases of

defecation and may reveal disorder of defecation
(outlet obstruction constipation)

Documentation of functional and morphological

changes of anorectum and pelvic floor during
defecation

Endorectal Ultrasonography:

Special investigations
Anorectal manometry

Resting pressure as low : m.

sphincter anal internal
Squeeze pressure as low: m.
sphincter ani external
Ano-rectal sensation

Proctosigmoidoscopy
Fist

diagnostic procedure for patient with symptom of

defecation disorder
Previous digital examination is mandatory
The normal length of anal canal is 3-5 cm
Common finding related to chronic constipation is Solitary
rectal ulcer (SRU)
Anterior mucosal prolapsed anterior intussusceptions
circular intussusceptions complete rectal prolapsed
(all as the cause of SRU) are difficult to be detected
endoscope
defecography is the best tool.

Anal manometry & Electromyography

Normal subject
Changes in anal canal
pressure and smooth and
striated muscle activity
during straining.
After an initial rise, the anal
canal pressure fall, and this
is associated with loss of of
the internal anal sphincter
electrical slow wave activity.
The integrated
electromyographic signal
from the striated external
anal muscle also fall

Rectoanal inhibitory reflex:

Distention of the rectum followed by relaxation of the internal
anal canal muscle. This reflex absent in Hirsphrung disease

 The knowledge of the anatomy and

SUMMARY
physiology of the anal canal and rectum
are very important

Anorectal investigation has helped us

to outline the anatomy of the
component parts of the sphincter
complex as well as to define the
physiology of both defecation and the
anal continence.
The understanding of the processes of
defecation is vital to the correct