360

MODERN CONCEPTS OF THE ANATOMYOF THE ANO-RECTAL REGION

By A. G. PARKS, M.D., M.Ch., F.R.C.S.Senior Surgical Registrar, Guy's Hospital

IntroductionIt is remarkable that the anatomy of the anal

canal should be still the subject of discussion.There are several reasons for this. The region isinaccessible in the cadaver because of the sur-rounding bony structure. Distinction betweenmuscle fibres and connective tissue is often difficultin fixed specimens and it is easy to create artefactsby blunt dissection. Many of the complicatedarrangements described in anatomical and surgicaljournals may well be due to excessive zeal in thisrespect.The academic anatomists of the I9th century

gave excellent but rather complicated descriptions;in recent years much has been written by surgeonsspecializing in ano-rectal disease. The articles ofMilligan and Morgan (I934), Milligan, Morgan,Jones and Officer (1937) and more recently Morganand Thompson (1956) are of special importance,as they summarize the views of surgical anatomists.There have been several excellent American con-tributions to this subject, those of Courtney (I950),Uhlenhuth (I953) and Gorsch (I955) beingespecially noteworthy.Three methods are available for the study of anal

anatomy: dissection of the cadaver, dissectionduring pelvic and perineal operations, and histo-logical examination. Each has limitations and atrue picture can be obtained only by integratingthe knowledge obtained from all three techniques.It is still not possible to give a final accountbecause of the complex nature of the region.

I have investigated the structure of the pelvicfloor, using the thick celloidin section techniquepreviously described (Parks, I956), and have alsostudied the anatomy during the perineal dissectionfor excision of the rectum. A detailed account ofthis work will be published in the near future. Thefollowing description, which is simplified for thesake of clarity, is an attempt to synthesize theopinions of previous authors with my ownobservations.

General DescriptionThe pelvic outlet is directed almost vertically

downwards and intra-abdominal pressure con-stantly exerts a force tending to drive the pelvicorgans out through it. The muscles of the pelvicfloor are arranged to prevent herniation ofabdominal contents, but at the same time they mustallow the egress of the alimentary and genito-urinary tracts. Most of the hiatus is closed by thetwo fan-shaped levator ani muscles; the only weakpoint is in the midline, where the viscera passthrough to the exterior. The muscles adjacent tothe viscera are well developed in order to protectthis source of weakness and are composed ofstriated voluntary muscle of somatic origin. Bytheir action voluntary control of the outflow of thevisceral tract is established.The anal canal is the termination of the ali-

mentary viscus and possesses its own intrinsicmuscle layers of smooth, involuntary muscle fibres.The inner circular layer is well developed to formthe internal sphincter ani and is ensheathed by thelongitudinal muscle coat.There is thus a fairly sharp division of the region

into visceral and somatic components which willform a useful basis for classification in theensuing description (Fig. i).

EmbryologyThe lower rectum and upper half of the anal

canal are formed from the primitive cloaca by thegrowth of a longitudinal septum which separatesthe genito-urinary tract in front from the alimentarytract behind. The muscle surrounding the cloacais modified in the course of development into thecomplex perineal musculature of the adult. Itseems likely that the most superficial part dif-ferentiates to form the subcutaneous and super-ficial parts of the external sphincter ani, the bulbo-cavernosus, ischiocavernosus and superficial trans-verse perinei muscles. The sphincter urethrae anddeep external sphincter muscles develop from thedeep part, most of which, however, remains as asling from the pubic arch, passing around the analcanal and genito-urinary tracts, which it still treatsas one. This becomes the pubo-rectalis muscle of

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July 1958 PARKS: Modern Concepts of the Anatomy of the Ano-Rectal Region 361

rUPPER LAMELLA OF ----'LEVATOR ANI

a) c)

1 ILI- -COCCYGEUS

. RECTUM.'---RECTU ANA ANAPUBO-COCCYGEUS" ANAL CANAL

-LONGITUDNAL 1MUSCLE L OF ANAL

. -CANALb) --PUBO-RECTALS-IN.- SPHINCTER J

~-

-GENITO-URINARY TRACT

--EXT. SPHINCTER ANI----

FIG. I.-To illustrate the muscular arrangements of the pelvic floor and anal canal.(a) Shows the visceral component with attached upper lamella of the levator ani;(b) demonstrates the somatic component. Fusion of the two produces the final formas seen in (c). The genito-urinary tract is represented by the simple tube labelled' urethra.'

adult anatomy, the most important element of thepelvic floor.The proctodaeum and external sphincter ani are

formed in response to the presence of the develop-ing rectum; if the latter is absent, the externalsphincter does not appear. The deep cloacalsphincter then encircles the vagina in the femaleand passes as a sling under the urethra in the male.These aberrations of development are importantfor the surgeon when he is attempting to create anew anal opening in cases of imperforate anus.The deep part of the cloacal sphincter is usuallythe only muscle capable of controlling the newanus; hence the rectum must be brought downthrough its arc. This entails dissecting betweenthe muscle and the vagina in the female andbetween the muscle and the urethra in the male.Attempts to bring the rectum through the levatorani behind the pubic muscle sling merely result in aperineal colostomy.

THE VOLUNTARY SPHINCTERSThe Somatic ComponentThis group of muscles encircles the viscera as

they pass through the pelvic hiatus; they form acontinuous layer (Goligher et al., I956), but maybe divided into three parts for convenience ofdescription.i. The Levator AniThe twin levatores ani muscles compose most of

the pelvic diaphragm. Innervation is derived frombranches of the lower sacral nerves (S4 and 5).Each muscle has an upper and lower lamella.

(a) The upper leaf. Striated muscle fibres arisingfrom the pubis are inserted into the antero-lateral

aspects of the longitudinal muscle coat of therectum. The largest components are inserted closeto the midline; laterally the lamella becomestenuous. A few fibres cross in front of the rectumto join those of the opposite side (the decussatingfibres of Lushka). The junction of the upper leaf ofthe levator ani with the longitudinal muscle formswhat has been called the conjoined longitudinalmuscle of the anal canal (Morgan and Thompson,I956). The levator prevents prolapse of theanterior wall of the upper half of the anal canaland may also act as a sphincter of the urethra n themale and of the vagina in the female. During theoperation of abdomino-perineal resection of therectum it is the highest structure which must bedivided anteriorly to free the rectum and allowdissection in the plane of Denonvillier's fascia.

It seems likely that muscles given such titles aslevator prostatae ' and ' deep transverse perinei'

by various authors are, in fact, portions of theupper lamella of the levator. The structure desig-nated the' membranous diaphragm ' by anatomistsis probably the connective tissue covering the lowersurface of this muscle. At least part of the externalsphincter urethrae in the male is formed by fibrespassing under the membranous urethra. The com-plex arrangements of the upper layer of the levatorand its associated fascial connections requirefurther elucidation and a fresh nomenclature.

(b) The lower leaf. The muscle takes originfrom a wide arc on the pelvic wall from the pubisto the spine of the ischium and is inserted into thecoccyx. It is a continuous sheet, but for con-venience may be divided into two parts, the pubo-coccygeus and ileo-coccygeus. The pelvic flooris completed by the coccygeus muscle, which is

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36a POSTGRADUATE MEDICAL JOURNAL July 1958

continuous with the levator ani. These musclescounteract the force exerted on the pelvic floor bythe pressure of the abdominal contents; the pubo-coccygeus, the part nearest the midline, is the mostpowerful.2. The Pubo-rectalis

This is continuous with the pubo-coccygeusand is, strictly speaking, the distal and mostpowerful part of the levator ani; it is sufficientlydifferent functionally, however, to justify separatedescription. It takes origin from the inferior sur-face of each side of the pubic arch, close to themidline in the male and further laterally in thefemale; passing backwards and downwards, itforms a sling behind the anal canal. It has fre-quently been confused with the deep part of theexternal sphincter ani. Although the fibres do notencircle the gut completely, its most importantfunction is that of an anal sphincter by drawing theanal canal forwards against the structures anteriorto it. It forms the highest part of the ' ano-rectal ring' (except anteriorly), which is felt ondigital palpation, and its presence gives depth to theanal canal. The pubo-rectalis is the main supportof the pelvic floor and if it is weakened by pro-longed stretching during childbirth, senile changesor chronic constipation the patient is liable to sufferfrom gynaecological or rectal prolapse. Underthese circumstances the anal canal is patulous andshallow.

3. The External Sphincter AniThe muscle encircles the lower half of the anal

canal and is supplied by branches of the inferiorhaemorrhoidal nerves. Two main divisions arerecognized:

(a) The deep portion is placed just below thepubo-rectalis and is continuous with it, so that thetwo muscles cannot be separated by dissection.It has been suggested (Courtney, I950) that thispart of the external sphincter is composed of fibresof the pubo-rectalis which cross the midline andencircle the bowel at a lower level. It is not sucha powerful muscle as the pubo-rectalis.

(b) The superficial portion of the externalsphincter is situated deep to the anal verge; it ispart of an interlacing sheet of muscles whichinclude the superficial transversus perinei, ischio-cavernosus and bulbocavernosis. More deeplyplaced fibres have varying attachments from thecoccyx posteriorly, the skin of the midline of theperineum and to the perineal body (so-called)anteriorly. This part of the muscle is not circular,but takes the form of an anterio-posterior ellipse,which accounts for the slit-like appearance of theanus. Immediately under the skin of the analverge muscle fasciculi encircle the anus and con-

stitute the subcutaneous part of the externalsphincter; they are intersected by strands of thelongitudinal coat of the anal canal which passthrough to be inserted into the peri-anal skin.

THE ANAL CANALThe Visceral ComponentThe alimentary tract terminates by passing

through the somatic pelvic muscles to form theanal canal. It retains the three layers common toall alimentary viscera, namely, the longitudinalmuscle, circular muscle and mucosa. The musclecoats are composed of smooth, unstriped fibresinnervated by the autonomic nervous system.Their pale coloration contrasts markedly with thedusky red of the surrounding somatic muscleswhen seen at operation.I. The Longitudinal MuscleThe longitudinal muscle is continuous with the

outer coat of the rectum and changes to connectivetissue in the middle of the anal canal. It breaksup into strands near the anal margin which inter-sect the fasciculi of the subcutaneous part of theexternal sphincter. Finally, it is inserted into theskin of the anal verge. A few of the terminal fibresmay still consist of smooth muscle, but the majorityare collagenous interspersed with elastic fibres.Contraction of the longitudinal muscle or of anyof the muscles attached to it causes the skin topucker; hence the title ' corrugator cutis ani ' hasbeen given to the lowermost longitudinal fibres.Clinically, it produces a dimple around the anus,called the marginal groove. The insertion of thelongitudinal layer into the skin separates the peri-anal space from the ischio-rectal fossa (Fig. z).The longitudinal layer has numerous connective

tissue attachments to the surrounding somaticmuscles; in this way the visceral component iswelded into the voluntary sphincters. This is dis-cussed in detail below.

2. The Internal SphincterThe circular muscle is more bulky and powerful

than in the rest of the bowel and forms the internalsphincter. There is no sharp upper line of de-marcation ofthe sphincter; it merges imperceptiblyinto the circular muscle of the rectum. It is dividedinto numerous bundles separated by connectivetissue and anastomatic vascular channels whichconnect the superior haemorrhoidal and pudendalvessels. The lowermost fasciculi may reach theanal verge, but this relationship is variable becausethe anal canal is so mobile that it can be invertedor everted at will. The distal part of the internalsphincter may be subcutaneous in eversion and aninch or more from the anal verge on inversion.It is important that the surgeon be aware of the

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July 1958 PARKS: Modern Concepts of the Anatomy of the Ano-Rectal Region 363

LONGITUDINAL Ifl Upper lamella ofMUSCLE il LEVATOR ANI

COLUMNAREPITHELIUM//L ILIO-COCCYGEUS

INTERNAL /SUBMUCOUS \' SPHINCTER | PUBO-SPACE ANI f COCCYGEUS

.-9 , COCCYGEUS

MUCOSAL li- ANAL i PUBO-LIGAMENT 7 RECTALIS

SQUAMOUS >- .j^)\EXT.f SPHINCTEREPITHELIUM ,i_| (

.). ANI (deep part)

ISCHIO- - 2; --PERI-ANALRECTAL /7h^ SPACEFOSSA

\I\ Superficial andMARGINAL NORMAL subcutaneous part ofGROOVE SKIN EXT. SPHINCTER ANI

FIG. 2.-A diagrammatic coronal section through the anal canal.

distortion which can be induced by traction on theanal skin.The internal sphincter, being smooth muscle, is

not under voluntary control; it maintains a con-stant tone which is a minor factor in preservinganal continence. The muscle relaxes in response todistension of the gut proximal to it, allowingevacuation to take place. Intense spasm may becaused by an anal fissure and the increased muscletone will not subside then in response to the normalstimulus from the gut above.

3. The EpitheliumThe upper half of the anal canal is lined by

columnar epithelium identical with that of therectum. Full thickness skin at the anal margingradually changes to a thin layer of stratifiedsquamous epithelium at the middle of the canalwhere cutaneous and visceral mucosae meet. Thereare several interesting features of this junctionalregion. The change from squamous to columnarmucosal layers may be abrupt, but usually thereis a transitional region about X in. in breadth ofstratified mucus-secreting columnar epithelium.The highest level of the stratified zone has anundulating margin known as the pectinate or den-tate line; squamous metaplasia of the columnarepithelium caused by chronic haemorrhoidal pro-lapse may result in this line being higher than usual.The stratified epithelium of the anal canal isderived from the skin and has a rich somatic in-nervation from the haemorrhoidal nerves; thelower half of the canal is therefore very sensitive.

Above the dentate line visceral innervation impartsa low degree of sensitivity to the mucosa.The terminology of the epithelial lining of the

anal canal is unsatisfactory at the present time.The transition between columnar epithelium andstratified squamous epithelium is usually referredto as the muco-cutaneous junction, which is themeaning attributed to it in this paper. However,this is not the junction of true skin and columnarepithelium because there is a broad zone of strati-fied squamous mucosa (similar to that of the lip)between them. Hilton's ' white line,' described inhis well-known treatise, has been sought in vainby many workers (Ewing, I954); the term is con-fusing and should be avoided.A circle of punctate pits, the anal crypts, is

found at the muco-cutaneous junction; each has alower crescentic border known as an anal valve.Anal glands open into the deepest parts of thecrypts; they are probably rudiments of scentglands of lower mammals and are racemose in type.Their branches ramify in the submucosa of theanal canal and commonly penetrate the internalsphincter, ending blindly between it and the longi-tudinal muscle. Hermann and Desfosses firstdescribed them in I880 and suggested they werethe cause of peri-anal suppuration and fistula-in-ano. Micro-organisms seldom penetrate thealimentary wall unless an abnormality such as aperforating ulcer or infected diverticulum ispresent. Though this is a subject about whichthere is still controversy, it is the writer's opinionthat the anal glands provide the only likely path-

B1

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I34 POSTGRADUATE MEDICAL JOURNAL July 1958SUBMUCOUS SPACE

J.......i.'|

RECTAL MUCOSA

' < e· '"'.~','' '"LONGITUDINAL MUSCLE

ANAL GLAND AINTERNAL SPHINCTER ANI

- ..... j. ?:, ,.:i.';::.·.:'" ':a:,::?·SQUAMOUS MUCOSA. :'

·.:.:.:.' ',-

PERI-ANAL SPACE ili:; .:

ANAL SKIN -j |lIRe EXTERNAL SPHINCTER ANI

FIG. 3.-Celloidin section through the anal canal cut at 500[ to show an anal glandpenetrating the internal sphincter.

way for infection to cross the internal sphincter.Pus can then track downwards between the twovisceral muscles to the anal verge or through thelongitudinal muscle into the fascial planes of the ex-ternal sphincter and so into the ischio-rectal fossa.

Fissure-in-ano is an ulcer in the mucosa of thelower half of the anal canal; the acute variety isshallow and its base is composed of connectivetissue fibres of the peri-anal space which runlongitudinally. If the ulceration deepens to involvethe internal sphincter, the fissure becomes chronicin type and heals very slowly. It is possible thatinfection in the anal glands accounts for theindolent nature of this type.The Connective Tissue of the Anal RegionThe various parts of the anal mechanism are

fused into one functional unit by connective tissue.But for this, any of the three layers of the visceralcomponent would prolapse through the anal hiatus.

All muscles have a fascial sheath and inter-fascicular connective tissue. It has been suggestedthat the longitudinal muscle sends penetratingstrands into the somatic sphincters, because fibroustissue can be traced from the longitudinal layerinto the surrounding muscles in histological sec-tions. It is more probable, however, that these

strands are the intermuscular fascial sheaths whichare merely attached to the longitudinal coat. Theseattachments are attenuated in cases of rectal pro-lapse and then the visceral and somatic componentscan be separated easily by dissection, suggestingthat sliding occurs in the plane between them.This may also be the explanation of the ' conicalanus ' described by Morgan and Thompson (I956).The two muscle coats are only loosely adherentin most parts of the alimentary tract; in the analcanal, however, the longitudinal layer is firmlyattached to the fibrous stroma which surrounds andintersects the internal sphincter. The epitheliumis also attached to the connective tissue of theinternal sphincter to prevent mucosal prolapse;this occurs chiefly in the middle of the anal canal,the region of the anal crypts. Known as themucosal ligament, it is especially interestingbecause it is concentrated around the anal glands.It forms an interrupted circle of ligamentousstrands composed of collagen and smooth musclefibres. It has been suggested (Morgan and Thomp-son, I956) that the mucosal ligament is formed byfibres of the longitudinal muscle layer whichpenetrates the internal sphincter and pass to themuco-cutaneous junction. The writer does notbelieve this to be the case; the appearance of con-

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July I953 PARKS: Modern Concepts of the Anlatomy of the Ano-Rectal Region 365UPPER LAMELLA

OF LEVATOR ANI

..:... ...........RECTAL MUCOSAPC.

·..::: .. ..: ..

JUNCTIONEXTERNAL SPHINCTER ANI

INTERNAL SPHINCTER ANI!

THE EXTERNAL SPHINCTER.

FIG. 4.-A coronal section through the pelvic floor and anal canal. Thick section cutat 200o.

tinuous fibres passing from the longitudinal layerthrough the internal sphincter into the submucosais due more probably to the interlacing of con-nective tissue at this point.The SubmucosaThe mucosal ligament divides the space between

the epithelium and internal sphincter into twoparts. The submucous space containing the ter-mination of the superior haemorrhoidal vessels issituated above the ligament; the peri-anal space isbelow it. Internal haemorrhoids are dilated ter-minal branches of the superior haemorrhoidal veinin the submucous space. The mucosal ligament isattenuated by repeated haemorrhoidal prolapse;if it disappears altogether, the mucosa is free todescend with any rise in intra-abdominal pressureand will not return spontaneously into the analcanal (a third degree haemorrhoid).The peri-anal space extends around the lower

half of the anal canal and the anal verge. The ter-mination of the longitudinal muscle limits it cir-cumferentially and separates it from the ischio-rectal fossa. It contains blood vessels, connectivetissue and branches of the anal glands. Distensionof the space causes considerable pain because it is

liberally innervated by the inferior haemorrhoidalnerve; for this reason peri-anal haematomata andabscesses are both painful conditions.

The Para-visceral SpacesThe submucus and peri-anal spaces are part of

the visceral component, though the lower of thetwo is covered by cutaneous epithelium which hasmigrated into the lower half of the anal canal.There are several other spaces in the tissues sur-rounding the gut. The most important is theischio-rectal fossa bounded medially by the levatorani, the anal sphincters and, at its lowest part,the termination of the longitudinal muscle (separ-ating it from the peri-anal space). The lateral wallis formed by the internal surface of the ischiumand muscles attached to it. The fossae on eitherside communicate posteriorly through the spacebetween the anal canal and the coccyx. Perinealskin forms the floor of the fossa.

There is a para-rectal space above the levatoresani which contains fat and blood vessels. Anabscess in this space may break through thelevator muscles and burst in the perineum; ifdrainage is incomplete a ano-rectal fistula mayform.

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366 POSTGRADUATE MEDICAL JOURNAL July 1958

DiscussionAn attempt has been made to give an account

of the principles of ano-rectal anatomy. In con-clusion, three aspects will be emphasized:

I. The concept of visceral and somatic com-ponents in the ano-rectal mechanism is a help invisualizing the complicated anatomy of the region.The anal canal is the termination of the alimentaryviscus; it is, in fact, a tube the lumen of whichis controlled by the pelvic floor sphincters. Thevisceral muscles play only a small part in analcontrol and the internal sphincter may be dividedcompletely without fear of loss of bowel control.Total section of the somatic sphincters, however,causes incontinence.

2. Normal anal function would not be possiblewithout the interlocking of the various elementswith connective tissue. Prolapse of one kind oranother will result from attenuation of the fibrousstroma. The longitudinal muscle layer holds acentral position in the connective tissue frameworkof the region and is indirectly attached to most ofthe constituent parts of the anal canal and sur-rounding sphincter muscles.

3. The muco-cutaneous junction is of greatinterest and surgical importance. It is a water-shed of vascular and lymphatic drainage and theboundary between visceral and somatic innerva-tion. The attachment of the epithelial layer to theinternal sphincter at this level is important for thesurgeon who may find difficulty in separating the

two without damaging part of one or the other.This applies particularly to the operation of sub-mucous haemorrhoidectomy (Parks, I956). Theanal glands which open into the crypts at the muco-cutaneous junction may have greater significancethan is generally ascribed to them at present.A proper knowledge of ano-rectal anatomy is not

merely of academic interest; it is of immensevalue to the surgeon operating in this region. Thetechnical application of anatomical principles willhelp to reduce post-operative discomfort andmorbidity.

I am much indebted to Dr. C. P. Wendell Smithfor his helpful criticism and to Miss Sylvia Tread-gold for the line illustrations.

BIBLIOGRAPHY

COURTNEY, H. (1950), Amer. 7. Surg., 79, I55.EWING, M. R. (i954), Proc. roy. Soc. Med., 47, 525.GOLLIGHER, J. C., LEACOCK, A. G., and BROSSY, J. J.

(x955), Brit. J. Surg., 43, Sx.GORSCH, R. V. (x955), 'Proctologic Anatomy,' Williams and

Wilkins, Baltimore.HERRMANN, G., and DESFOSSES, L. (I88o), Comptes rend.

Acad. des Sci., 90, 13 .MILLIGAN, E. T. C., and MORGAN, C. N. (I934), Lancet,

ii, I 50.MILLIGAN, E. T. C., MORGAN, C. N. (1934), JONES,L. E., and OFFICER, R. (I937), Lancet, ii, III9.MORGAN, N. C., and THOMPSON, H. R. (1956), Ann. roy. Coll.

Surg. Engl., I9, 88.PARKS, A. G. (i955), Brit. J. Surg., 43, 337.PARKS, A. G. (1956), Ibid., 44, 209.UHLENHUTH, E. (1953), 'Problems in the Anatomy of the

Pelvis,' Lippincott, Philadelphia.

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