Pelvic Floor, Perineal, and Anal Sphincter Trauma During

Childbirth Diagnosis, Management and Prevention 2nd

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Foreword

Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management

was originally published in 2008, and rapidly became the indispensable
resource for midwives, obstetricians, urogynecologists, and colorectal sur-
geons treating perineal and anal sphincter trauma, as well as raising aware-
ness among all healthcare professionals.
The authors are not only major contributors to the generation of evidence
defining best practice in the diagnosis and management of pelvic floor trauma
during childbirth, but also global leaders in equipping healthcare providers to
treat it. Abdul H. Sultan and Ranee Thakar founded the PROTECT Training
program through the International Urogynecological Association. It is a “train
the trainer” program that equips midwives and obstetricians from around the
world with knowledge to offer optimal management of obstetrical trauma and
teach colleagues towards minimizing pelvic floor and perineal morbidity asso-
ciated with childbirth. This experience in personally teaching colleagues per-
meates the work making it comfortably accessible to readers from all
disciplines.
This second edition expands on this valuable asset through new material
on the impact of pregnancy on the pelvic floor, sexual function, and pre-­
existing bowel conditions. It broadens the scope, including obstetrical pelvic
floor trauma, neuropathy, and patient-reported outcomes after childbirth. And
it informs treatment by exploring prevention through care bundles, physical
therapy, and treatments. This broader and deeper scope is reflected in the new
title, Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth.
This interdisciplinary treatise incorporates excellent illustrations supporting
the most up-to-date evidence. We have no doubt that it will surpass its prede-
cessor to become an essential resource for healthcare providers in childbirth,
with the most up-to-date knowledge to help caregivers around the globe to
improve the lives of women who suffer from childbirth trauma by skills of
prevention, and best practice of treating it. Nothing short of a must have!

Vancouver, Canada Geoffrey Cundiff

Delft, Netherlands Fred Milani
Plymouth, UK Robert Freeman

v
Preface

With the recent international renewed push for vaginal over caesarean birth,
there is again a need for obstetric providers and trainees to understand how to
prevent and manage obstetric perineal and anal sphincter trauma. Over the
last decade, more research has emerged in this arena, including the benefit of
structured training programs and hands-on workshops to improve under-
standing of anatomy and repair of perineal and anal sphincter trauma. More
studies have emerged supporting early repair of sphincter trauma as well as
advantages of early pelvic floor physical therapy in the treatment of symp-
toms related to the trauma. Similarly, advances have been made in the imag-
ing of obstetric trauma, which have elucidated the anatomic contributions to
symptoms that gravely impact a new mother’s quality of life.
However, despite these advances, primary and delayed repair of anal
sphincter injuries are not universally optimal; continued research on the ideal
management is imperative. This also highlights the need to identify women at
risk for perineal and anal sphincter trauma in order to prevent it.
Our textbook aims not only to address the above issues, but also to provide
detailed education in anatomy, neuroanatomy, and pathophysiology. In addi-
tion, we examine pertinent issues such as female genital mutilation, manage-
ment of fecal incontinence and other pelvic floor disorders, and medicolegal
implications of obstetric trauma.
In producing this book, we would like to acknowledge our mentors for
their teaching and inspiration, the patients who inspire us question our prac-
tices, and the trainees who continue to contribute to the research. We would
also like to thank the multidisciplinary authors for their timely submission of
chapters, as well as Dr. Dee Fenner for her contribution to the first edition of
this book. Lastly, we extend our appreciation to our families for their perse-
verance and understanding.

London, UK Abdul H. Sultan

Croydon, UK  Ranee Thakar
Chicago, IL, USA  Christina Lewicky-Gaupp

vii
Contents

1 Anatomy of the Pelvic Floor, Perineum

and Anal Sphincter��������������������������������������������������������������������������   1
Ranee Thakar, Dee E. Fenner, and Christopher X. Hong
2 Pathophysiology and Effects of Pregnancy
on the Pelvic Floor��������������������������������������������������������������������������� 17
John O. L. DeLancey and Fernanda Pipitone
3 
Diagnosis of Obstetric Anal Sphincter Injuries (OASIs)�������������� 37
Abdul H. Sultan and Ranee Thakar
4 
Episiotomy, First and Second Degree Tears���������������������������������� 49
Sara Webb and Ranee Thakar
5 Management of Acute Obstetric Anal Sphincter
Injuries (OASIs) ������������������������������������������������������������������������������ 61
Abdul H. Sultan and Ranee Thakar
6 Short and Long-term Maternal and Neonatal
Outcomes of Caesarean Section������������������������������������������������������ 89
Clare Richards and Mairead Black
7 Sexual Dysfunction After Childbirth �������������������������������������������� 105
Lisa C. Hickman and Christina Lewicky-Gaupp
8 Impact of Pregnancy and Childbirth on Pre-existing
Bowel Conditions ���������������������������������������������������������������������������� 119
Peter Rimmer and Rachel Cooney
9 Perineal and Anal Sphincter Wound Healing
Complications���������������������������������������������������������������������������������� 135
Nicola Adanna Okeahialam, Ranee Thakar,
and Abdul H. Sultan
10 
Post-partum Problems and the Perineal Clinic���������������������������� 161
Ranee Thakar, Abdul H. Sultan, and Christina Lewicky-Gaupp
11 
Management of Subsequent Pregnancy After
Incontinence and Prolapse Surgery������������������������������������������������ 179
Sarah A. Collins and Victoria Handa

ix
x Contents

12 Prevention of Perineal Trauma ������������������������������������������������������ 191

Nicola Adanna Okeahialam, Timothy J. Draycott,
and Ranee Thakar
13 Female Genital Mutilation�������������������������������������������������������������� 209
Juliet Albert
14 Anorectal
 Pathophysiology and Investigations������������������������������ 227
S. Mark Scott
15 Anal
 Sphincter Imaging of Obstetric Trauma������������������������������ 255
Giulio A. Santoro, Patrizia Pelizzo, and Abdul H. Sultan
16 Obstetric Pelvic Floor Trauma ������������������������������������������������������ 271
Ingrid Volløyhaug
17 Pelvic
 Floor and Sphincter Neuropathy After Childbirth����������� 293
Conor P. O’Brien
18 Physical Therapy After OASIs�������������������������������������������������������� 317
Hege Hoelmo Johannessen and Siv Mørkved
19 Non-surgical
 Management of Anal Incontinence�������������������������� 331
Wendy Ness
20 Surgical
 Management of Anal Incontinence���������������������������������� 345
Gregory Thomas and Carolynne Vaizey
21 Obstetric Rectovaginal Fistulas������������������������������������������������������ 359
Brittany Roberts, Gifty Kwakye, Dee Fenner,
and Rebecca G. Rogers
22 Patient
 Reported Outcomes After Childbirth ������������������������������ 373
J. Oliver Daly
23 Education
 and Training in OASIS�������������������������������������������������� 389
Joanna C. Roper, Ranee Thakar, and Abdul H. Sultan
24 Litigation
 After Pelvic Floor and Anal Sphincter Injuries���������� 403
Michael Mylonas KC and Shivi Nathan
Index���������������������������������������������������������������������������������������������������������� 415
 Anatomy of the Pelvic Floor,
Perineum and Anal Sphincter
1
Ranee Thakar, Dee E. Fenner,
and Christopher X. Hong

Overview 1.1 Introduction

Test your learning and check your under-
standing of this book’s contents: use the In this chapter reviewing the anatomy of the pel-
“Springer Nature Flashcards” app to access vic floor, rectum, and anal sphincter complex,
questions. To use the app, please follow the anatomical structures are referred to by their
instructions below: (1) Go to https://flash- accepted terms in Terminologia Anatomica, the
cards.springernature.com/login. (2) Create international standard for human anatomical ter-
a user account by entering your e-mail minology [1]. Non-preferred terms are stated in
address and assigning a password. (3) Use parentheses adjacent to accepted terms.
the following link to access your SN
Flashcards set: ▶ https://sn.pub/wqrf89. If
the link is missing or does not work, please 1.2 Embryology
send an e-mail with the subject “SN
Flashcards” and the book title to custom- In the early embryo, the allantois, and the hindgut
[email protected]. open into a common cavity—the cloaca
(Fig. 1.1a). This is an endoderm-lined cavity that
is in contact with the surface of the ectoderm. An
Learning Objectives ectodermal depression develops under the root of
the tail of the embryo and sinks in toward the gut
• To describe the functional and structural anat- until only the thin cloacal membrane remains
omy of the pelvic floor, perineum, and anal between the gut and the outside [2]. This ectoder-
sphincter complex. mal depression is called the proctodeum. The
• To describe anatomical relationships between cloacal membrane is thus comprised of the cloa-
structures of this region. cal endoderm and the ectoderm of the procto-
deum, or the anal pit. Partitioning of the cloacal
membrane takes place during the fifth to seventh
R. Thakar
Department of Obstetrics and Gynaecology, week of development when the urorectal septum,
Croydon University Hospital, Surrey, UK which is mesodermal in origin, expands toward
D. E. Fenner · C. X. Hong (*) the tail of the embryo between the hindgut and the
Department of Obstetrics and Gynecology, University allantois to fuse with the cloacal membrane
of Michigan, Ann Arbor, MI, USA (Fig. 1.1b). The area of fusion becomes the peri-
e-mail: [email protected]; neal body and separates the dorsal anal membrane
[email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 1

A. H. Sultan et al. (eds.), Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth,
https://doi.org/10.1007/978-3-031-43095-4_1
2 R. Thakar et al.

a
Oesophagus

Stomach Spleen

Pancreas
Gallbladder
Liver

Yolk stalk Superior

Allantoic mesenteric
stalk artery
Allantois
Proctodeum
Inferior
Umbilical
mesenteric
cord
artery
Cloacal
Cloaca Hindgut
membrane

b
Diaphragm

Liver

Spleen

Gallbladder

Pancreas

Yolk stalk
Colon
Allantoic
stalk
Urinary
Umbilical bladder
cord
Urorectal
Genital septum
tubercle
Ureter
Urogenital
sinus Rectumn

Anus

Fig. 1.1 (a) Development of the gastrointestinal tract at urorectum toward the cloacal membrane. (Figure from
about 5 weeks. (b) Fetus showing development of the ano- previous version)
rectum after 5 weeks, demonstrating the growth of the

from the larger ventral urogenital membrane. The rectal septum also divides the cloacal musculature
anal membrane breaks down by the eighth week into anterior and posterior parts. The posterior
of gestation, establishing the anal canal. The uro- portion develops into the EAS, while the anterior
1 Anatomy of the Pelvic Floor, Perineum and Anal Sphincter 3

portion becomes the superficial transverse peri- sacrotuberous ligaments. The deep limit of the
neal muscle, the bulbospongiosus muscle, the perineum is the inferior surface of the pelvic dia-
ischiocavernosus muscle, and the perineal mem- phragm and its superficial limit is the skin. The
brane. This explains why a single nerve—the perineum can be divided into two triangular
pudendal nerve—supplies all musculature into parts by drawing an arbitrary line transversely
which the cloacal membrane divides [3]. between the ischial tuberosities [6]. The anterior
Knowledge of embryology is also important triangle, which contains the external urogenital
to understand the differences in the linings, inner- organs, is known as the urogenital triangle and
vation, vascular supply, and lymphatic drainage the posterior triangle, which contains the termi-
of the anal canal. The parts derived from the nation of the anal canal, is known as the anal
endoderm are lined by columnar epithelium and triangle.
innervated by autonomic nerves, with the lym-
phatics and veins draining toward the abdomen.
The parts derived from the ectoderm are lined by 1.3.1 The Urogenital Triangle
stratified squamous epithelium and have a
somatic nerve supply, with the veins draining The urogenital triangle (Fig. 1.2a) is bound
toward the external iliac system and the lymphat- anteriorly and laterally by the pubic symphysis
ics to the inguinal lymph nodes. and the ischiopubic rami. Traditionally, the uro-
The upper two-thirds of the anal canal is genital triangle has been thought to be divided
derived from the cloaca and the lower third devel- into two compartments: the superficial and
ops from the proctodeum. This junction, about deep perineal spaces, separated by the perineal
1–2 cm from the anocutaneous line (anal verge), membrane, which spans the space between the
creates a demarcating line called the pectinate ischiopubic rami [6]. However, more recent
line (dentate line). At this line, the epithelium studies of this region describe the perineal
transitions between stratified squamous and sim- membrane as a complex structure with many
ple columnar cells. parts [7]. It is composed of two regions: one
Little is known about the development of the dorsal and one ventral. The dorsal region con-
EAS and levator ani muscles. Although closely sists of bilateral transverse fibrous sheets that
associated, histologic embryo studies suggest the attach the lateral wall of the vagina and perineal
external sphincter and levator ani arise from two body to the ischiopubic ramus. The ventral
distinct primordia [4]. The puborectalis muscle is region is a solid three-­dimensional tissue mass
a portion of the levator ani and shares primordial in which several structures are embedded. It
cells with the ilio- and pubococcygeous muscles. contains the compressor urethrae muscle, the
The EAS begins to take form after 8 weeks of urethrovaginal sphincter muscle of the distal
gestation and is clearly distinct from the puborec- urethra, and the urethra itself with surrounding
talis at that time [5]. connective tissue (Fig. 1.3). The ventral margin
of this mass is continuous with the insertion of
the arcus tendineus fascia pelvis into the pubic
1.3 Muscles of the Perineum bone. The levator ani muscles are attached to
the cranial surface of the perineal membrane.
The perineum corresponds to the outlet of the The vestibular bulb and clitoral crus lie on the
pelvis and is somewhat lozenge-shaped. caudal surface of the membrane and are fused
Although the area between the vagina and anus with it, with no natural plane of cleavage
is colloquially referred to as the “perineum” in between these erectile structures and the mem-
clinical settings, the proper anatomical term for brane. Therefore, the structure of the perineal
this area is the “perineal body.” The anatomic membrane is not a trilaminar sheet with perfo-
perineum it is bound anteriorly by the pubic rating viscera, but a complex three-dimensional
arch, posteriorly by the coccyx, and laterally by structure with two distinctly different dorsal
the ischiopubic rami, ischial tuberosities, and and ventral regions [8].
4 R. Thakar et al.

Clitoris
Ischiopubic ramus

Superficial perineal fascia

Urethra
Ischiocavernosus muscle
Vagina
Perineal membrane

Bulbospongiosus
(bulbocavernosus) muscle
Perineal body
Superficial transverse
perineal muscle

Deep
Anus
External Superficial
anal Subcutaneous
sphincter Gluteus maximus
Pubococcygeus
Levator Puborectalis
ani liococcygeus Anococcygeal
ligament
Coccyx

Clitoris Ischiocavernosus
Ischiopubic ramus muscle

Bulbospongiosus muscle Vestibular bulb

Perineal
Superficial perineal
membrane
compartment
Greater vestibular
Ischial tuberosity gland
Perineal body

External anal
sphincter
Anococcygeal ligament
Coccyx

Fig. 1.2 The superficial compartment contains the super- with a floor formed by the perineal membrane. (b) The left
ficial transverse perineal muscle, the bulbospongiosus bulbospongiosus muscle has been removed to demon-
muscle, and the ischiocavernosus muscle (a). These three strate the vestibular bulb and greater vestibular gland
muscles form a triangle on either side of the perineum, (Bartholin’s gland). (Figure from previous version)
1 Anatomy of the Pelvic Floor, Perineum and Anal Sphincter 5

Fig. 1.3 The perineal

membrane. The position
of the perineal Ventral region of the
membrane is shown perineal membrane
without the overlying
erectile tissues (clitoral
crura and vestibular
bulbs), along with the
associated components
of the striated urogenital
sphincter: the
urethrovaginal sphincter
(*) and the compressor
Dorsal region of the
urethrae muscle (•) © perineal membrane
Delancey

Just beneath the skin of the anterior perineum muscle and the EAS in the central fibromuscu-
lies the superficial perineal fascia (Colles’ fas- lar perineal body. Anteriorly, its fibres pass for-
cia). As described above, the erectile tissues are ward on either side of the vagina and insert into
fused to the caudal surface of the perineal mem- the corpora cavernosa clitoridis, a fasciculus
brane complex. The erectile tissues are covered crossing over the body of the organ that com-
by the bulbospongiosus (bulbocavernosus) and presses the deep dorsal vein of the clitoris.
the ischiocavernosus muscles. The superficial This muscle diminishes the orifice of the
transverse perineal muscles attach the perineal vagina and contributes to the erection of the
body to the ischial tuberosities bilaterally. All of clitoris.
these perineal muscles are innervated by a branch
of the pudendal nerve, which is a mixed motor 1.3.1.3 Ischiocavernosus Muscle
and sensory nerve. The ischiocavernosus muscle is elongated,
broader at the middle than at either end, and situ-
1.3.1.1 Superficial Transverse Perineal ated on the lateral boundary of the perineum
Muscle (Figs. 1.2a and 1.4). It arises by tendinous and
The superficial transverse muscle is a narrow slip fleshy fibres from the inner surface of the ischial
of a muscle, which arises from the inner and fore- tuberosity, behind the crus clitoridis, from the
part of the ischial tuberosity and is inserted into surface of the crus and from the adjacent portions
the central tendinous part of the perineal body of the ischial ramus. The ischiocavernosus com-
(Fig. 1.2a). The muscle from the opposite side, presses the crus clitoridis and retards blood flow
the EAS from behind, and the bulbospongiosus through the veins, thus serving to maintain erec-
in the front all attach to the central tendon of the tion of the clitoris.
perineal body [6].

1.3.1.2 Bulbospongiosus Muscle 1.3.2 The Anal Triangle

The bulbospongiosus muscle (bulbocavernosus
muscle) runs on either side of the vaginal ori- This area includes the anal canal, the anal sphinc-
fice, covering the lateral aspects of the vestibu- ters, and the ischioanal fossa.
lar bulb anteriorly and the greater vestibular
gland (Bartholin’s gland) posteriorly 1.3.2.1 Anal Canal
(Figs. 1.2b and 1.4). Some fibres merge poste- The rectum terminates in the anal canal (Fig. 1.5a,
riorly with the superficial transverse perineal b). Definitions of the anal canal vary among sur-
6 R. Thakar et al.

Fig. 1.4 Histologic cross section of the pelvis perpendicular to the urethra and vagina at the level of the distal vagina
(Reproduced from Urogenitalmuskulatur des Dammes by Otto Kalischer, 1900 [9])

geons and anatomists [10]. The surgical anal be accessed digitally at this site for measurement
canal is approximately 4 cm long and extends of the pudendal nerve terminal motor latency
from the anocutaneous line to the anorectal junc- using a modified electrode [13] (see Chap. 9).
tion (anorectal ring), which is defined as the The perineum can also be anaesthetised by injec-
proximal level of the levator–EAS complex [11]. tion of local anaesthetic into the pudendal nerve
This clinical description correlates with a digital at this site. Anteriorly, the perineal body sepa-
or sonographic examination but does not corre- rates the anal canal from the vagina.
spond to the histological architecture [12]. The The anal canal is surrounded by an inner epi-
embryological anal canal extends from the anal thelial lining, a vascular subepithelium, the inter-
valves (see below) to the anal margin and is nal anal sphincter (IAS), the EAS, and
approximately 2 cm long [3]. fibromuscular supporting tissue. The lining of the
The anal canal is attached posteriorly to the anal canal varies along its length due to its
coccyx by the anococcygeal ligament, a midline embryologic derivation. The proximal anal canal
fibromuscular structure that runs between the is lined with rectal mucosa (columnar epithe-
posterior aspect of the EAS and the coccyx lium) and is arranged in vertical mucosal folds
(Fig. 1.2). The anus is surrounded laterally and called the anal columns (columns of Morgagni)
posteriorly by loose adipose tissue within the (Fig. 1.5a). Each column contains a terminal rad-
ischioanal fossa, which is a potential pathway for ical of the superior rectal artery and vein. The
spread of perianal sepsis from one side to the vessels are largest in the left-lateral, right-­
contralateral side. The pudendal nerves pass over posterior, and right-anterior quadrants of the wall
the ischial spines at this point (Fig. 1.6) and can of the anal canal where the subepithelial tissues
1 Anatomy of the Pelvic Floor, Perineum and Anal Sphincter 7

a
Longitudinal muscle of rectum

Circular muscle of rectum

Levator ani

Columns of morgagni

Deep external sphincter

Dentate line

Conjoint longitudinal coat

Superficial external sphincter

Internal sphincter
Subcutaneous external sphincter
Corrugator cutis ani

Levator ani
muscle
Deep External
Superficial
Subcutaneous sphincter ani
Corrugator
cutis ani
Perianal skin

Fig. 1.5 (a) Coronal section of the anorectum. (b) Anal sphincter complex and levator ani muscle. (Figure from previ-
ous edition)

expand into three anal cushions. These cushions this area causes profuse discomfort, whereas
seal the anal canal and help maintain continence treatment can be carried out with relatively few
of flatus and liquid stools. The columns are joined symptoms in the upper canal, which is lined by
together at their inferior margin by crescentic insensate columnar epithelium [13]. As a result
folds called anal valves [3]. About 1–2 cm from of tonic circumferential contraction of the sphinc-
the anocutaneous line, the anal valves create a ter, the skin is arranged in radiating folds around
demarcation called the pectinate line (dentate the anus called the anal margin [12]. These folds
line). The anoderm covers the last 1–2 cm of the appear to be flat or ironed out when there is
distal canal below the pectinate line and consists underlying sphincter damage. The junction
of modified squamous epithelium that lacks skin between the columnar and squamous epithelia is
adnexal tissues such as hair follicles and glands referred to as the anal transitional zone, which is
but contains numerous somatic nerve endings. variable in height and position and often contains
Since the epithelium in the lower canal is well-­ islands of squamous epithelium extending into
supplied with sensory nerve endings, acute dis- columnar epithelium. Sensory receptors in this
tension or invasive treatment of hemorrhoids in zone likely play a role in maintaining continence
8 R. Thakar et al.

Common iliac artery

Lateral sacral artery
Hypogastric artery

Superior gluteal artery

Inferior epigastric artery

Deep circumflex iliac artery

External iliac artery

Medial umbilical ligament

Obturator artery

Umbilical artery
Uterine artery
Superior vesical artery

Vaginal artery

Piriformis Symphysis pubis

muscle
Coccygeus Pelvic diaphragm
muscle
Inferior Alcock’s Obturator internus muscle
gluteal artery Internal canal
pudendal
Sacro-
artery
tuberous Pudendal nerve
ligament

Fig. 1.6 Sagittal view of the pelvis demonstrating the pathway of the pudendal nerve and blood supply. (Figure from
previous edition)

by providing a highly specialised sampling during imaging (see Chap. 10). In females, the
mechanism (see Chap. 8). EAS is shorter anteriorly (Fig. 1.8) [15]. The
deep EAS is intimately related to the puborectalis
1.3.2.2 Anal Sphincter Complex muscle and does not have posterior attachments
The anal sphincter complex consists of the EAS [16]. The superficial EAS is fused anteriorly to
and IAS separated by the conjoint longitudinal the perineal body and attached posteriorly to the
coat (Figs. 1.5a and 1.7). Although they form a anococcygeal ligament, which is attached to the
single unit, they are distinct in structure and tip of the coccyx [13]. The subcutaneous part is
function. circular, but may have attachments to the perineal
body anteriorly and the anococcygeal ligament
External Anal Sphincter posteriorly. As the only EAS subcomponent that
Structurally, the EAS (Figs. 1.5a and 1.7) is sub- is circular in shape, this is the only part that
divided into three parts: subcutaneous, superfi- crosses the midline of the perineum. In females,
cial, and deep [14]. Though these subdivisions the bulbospongiosus and the superficial trans-
are not easily demonstrable during anatomical verse perineal muscles fuse with the EAS in the
dissection or surgery, they may be of relevance lower part of the perineum [13].
1 Anatomy of the Pelvic Floor, Perineum and Anal Sphincter 9

Fig. 1.7 Histologic cross section of the pelvis and anal sphincter complex at the level of the anal canal. (Modified from
Urogenitalmuskulatur des Dammes by Otto Kalischer, 1900 [9])

Internal Anal Sphincter part of the puborectalis, with smooth muscle

The IAS is a thickened continuation of the circu- from the longitudinal muscle of the rectum [13].
lar smooth muscle of the bowel and ends with a Traced downward, it separates opposite the lower
well-defined rounded edge 6–8 mm above the border of the IAS, with the fibrous septae fanning
anal margin at the junction of the superficial and out to pass through the EAS and ultimately attach
subcutaneous part of the EAS (Fig. 1.5, Fig. 1.7). to the skin of the lower anal canal and perianal
In contrast to the EAS, which has a reddened region [14].
appearance due to its striated muscle composi-
tion, the IAS has a pale appearance to the naked 1.3.2.3 Innervation of the Anal
eye. Sphincter Complex
As the IAS is a continuation of the circular fibres
The Longitudinal Layer and the Conjoint of the rectum, it shares the same innervation:
Longitudinal Coat sympathetic (L5) and parasympathetic nerves
The longitudinal layer is situated between the (S2–S4). It remains in a state of tonic contraction
EAS and IAS and consists of a fibromuscular and accounts for 50–85% of the anal canal rest-
layer, the conjoint longitudinal coat, and the ing tone [11]. The conjoint longitudinal coat is
intersphincteric groove (intersphincteric space) innervated by autonomic fibres from the same
with its connective tissue components [17] origin. The EAS is innervated by the inferior rec-
(Fig. 1.5a). The longitudinal layer has a muscular tal branch of the pudendal nerve. In contrast to
and fibroelastic component. The muscular com- the other striated muscles, the EAS contributes
ponent is formed by the fusion of the striated up to 30% of the unconscious resting tone
muscle fibres from the puboanalis, the innermost through a reflex arc at the cauda equine level.
10 R. Thakar et al.

a b

Fig. 1.8 (a) Computer reconstruction demonstrating the Isometric view of the anal sphincter complex and rectum.
anal sphincter complex: external anal sphincter (EAS), (c) Midline view of the anal sphincter complex and rec-
puborectalis muscle (PRM), and internal anal sphincter tum. (Figure from previous version)
(IAS*). Bl Bladder, Ut uterus, V vagina, R rectum. (b)

1.3.2.4 Vascular Supply and the EAS drain via the inferior rectal branch
The anorectum receives its major blood supply of the internal pudendal vein into the internal
from the superior rectal artery (superior haem- iliac vein [13].
orrhoidal artery), the terminal branch of the
inferior mesenteric artery, and the inferior rectal 1.3.2.5 Lymphatic Drainage
artery (inferior haemorrhoidal artery), a branch The anorectum has a rich network of lym-
of the internal pudendal artery. To a lesser phatic plexuses. The pectinate line represents
degree, it also receives blood from the middle the interface between the two different sys-
rectal artery (middle haemorrhoidal artery), a tems of lymphatic drainage. Above the pecti-
branch of the internal iliac artery. Together, nate line (the upper anal canal), the IAS and
these arteries form a wide intramural network of the conjoint longitudinal coat drain into the
collateral vessels [18]. The venous drainage of inferior mesenteric and internal iliac nodes.
the upper anal canal mucosa, IAS, and conjoint Lymphatic drainage below the pectinate line,
longitudinal coat passes via the terminal which consists of the lower anal canal epithe-
branches of the superior rectal vein into the lium and the EAS, proceeds to the external
inferior mesenteric vein. The lower anal canal inguinal lymph nodes.
1 Anatomy of the Pelvic Floor, Perineum and Anal Sphincter 11

1.3.2.6 Ischioanal Fossa tribution from the conjoint longitudinal coat and
The ischioanal fossa (ischiorectal fossa) extends the medial fibres of the puborectalis muscle.
around the anal canal and is bound anteriorly by Therefore, the support of the pelvic structures,
the perineal membrane, superiorly by the fascia and to some extent the hiatus urogenitalis
of the levator ani muscle, and medially by the between the levator ani muscles, depends on the
EAS complex at the level of the anal canal. The integrity of the perineal body.
lateral border is formed by the obturator fascia
and inferiorly by a thin transverse fascia, which
separates it from the perianal space. The ischio- 1.5 The Pelvic Floor
anal fossa contains fat and neurovascular struc-
tures, including the pudendal nerve and the The pelvic floor, or pelvic diaphragm, is a muscu-
internal pudendal vessels, which enter through lotendineous sheet that spans the pelvic outlet
the pudendal canal (Alcocks’s canal). and consists mainly of the symmetrically paired
levator ani muscles (Fig. 1.9). The fasciae invest-
ing the muscles are continuous with the visceral
1.4 Perineal Body pelvic fascia above, perineal fascia below, and
obturator fascia laterally. The pelvic floor sup-
The perineal body is the central point between ports the urogenital organs and the anorectum,
the urogenital and anal triangles of the perineum exiting the pelvis through their respective fora-
(Fig. 1.2). Its three-dimensional form has been men. The muscles of the levator ani differ from
likened to that of the cone of the red pine, with most other skeletal muscles in that they: (1)
each “petal” representing an interlocking struc- maintain constant tone, except during voiding,
ture, such as a fascia insertion site or a muscle of defaecation, and manoeuvres that cause an
the perineum [19]. Within the perineal body, increase in intraabdominal pressure (e.g.,
there are interlacing muscle fibres from the bul- Valsalva manoeuvre); (2) have the ability to con-
bospongiosus, superficial transverse perineal, tract quickly in response to an abrupt increase in
and EAS muscles. Above this level there is a con- intraabdominal pressure (such as a cough or

Fig. 1.9 Left: Levator ani muscles from below after the muscle seen from above. The internal obturator muscles
vulvar structures and perineal membrane have been have been removed to clarify levator muscle origins. ©
removed. * Subcutaneous portion of the external anal DeLancey (modified from Kearney, 2004)
sphincter. † Arcus tendineus levator ani. Right: Levator ani