Function of the anal sphincters following anterior resections of rectum

The purpose of the present work is to evaluate the function of the anal sphincter following anterior resections of the rectum. Our data have shown that the anorectal reflex did not depend on the presence of the rectal mucosa. The external anal sphincter contraction involves a reflex which is initiated by stretch receptors in the levator ani muscle. The internal anal sphincter relaxation is likely a local reflex involving nerve pathways not yet completely defined.     

A reappraisal of the anatomy of the levator ani muscle in man

A study of the attachments of the musculotendinous fibres of the levator ani muscle shows that it is made of two portions: a thick anterior portion which is mostly fleshy and a thin posterior portion which is mostly aponeurotic. The anterior portion consists of two layers: a superficial perineal layer and a deep pelvic layer. Both layers have a common origin from the back of the body of the pubic bone and the anterior part of the tendinous arch. In addition both layers make a U-shaped loop around the recto-anal junction. The posterior fibres of the deep pelvic layer received nerve supply only from the third and fourth sacral nerves. The rest of the muscle was supplied from the sacral nerves as well as the perineal branches of the pudendal nerve. The role of the anterior fibres in reinforcing the sphincters of the anal canal and fixation of the pelvic viscera is stressed. The close anatomical relation between the posterior portion of the muscle and the obturator internus suggests that the latter may play a role in supporting the weak posterior portion of the levator ani, especially during straining positions associated with lateral rotation at both hips.     

3D Topography of the Young Adult Anal Sphincter Complex Reconstructed from Undeformed Serial Anatomical Sections

Background

Pelvic-floor anatomy is usually studied by artifact-prone dissection or imaging, which requires prior anatomical knowledge. We used the serial-section approach to settle contentious issues and an interactive 3D-pdf to make the results widely accessible.

Method

3D reconstructions of undeformed thin serial anatomical sections of 4 females and 2 males (21–35y) of the Chinese Visible Human database.

Findings

Based on tendinous septa and muscle-fiber orientation as segmentation guides, the anal-sphincter complex (ASC) comprised the subcutaneous external anal sphincter (EAS) and the U-shaped puborectal muscle, a part of the levator ani muscle (LAM). The anococcygeal ligament fixed the EAS to the coccygeal bone. The puborectal-muscle loops, which define the levator hiatus, passed around the anorectal junction and inserted anteriorly on the perineal body and pubic bone. The LAM had a common anterior attachment to the pubic bone, but separated posteriorly into puborectal and “pubovisceral” muscles. This pubovisceral muscle was bilayered: its internal layer attached to the conjoint longitudinal muscle of the rectum and the rectococcygeal fascia, while its outer, patchy layer reinforced the inner layer. ASC contraction makes the ano-rectal bend more acute and lifts the pelvic floor. Extensions of the rectal longitudinal smooth muscle to the coccygeal bone (rectococcygeal muscle), perineal body (rectoperineal muscle), and endopelvic fascia (conjoint longitudinal and pubovisceral muscles) formed a “diaphragm” at the inferior boundary of the mesorectum that suspended the anorectal junction. Its contraction should straighten the anorectal bend.

Conclusion

The serial-section approach settled contentious topographic issues of the pelvic floor. We propose that the ASC is involved in continence and the rectal diaphragm in defecation.     

基于经会阴实时三维超声评估生物反馈电刺激联合盆底肌锻炼治疗产后盆底功能障碍的临床疗效

摘要 目的：探讨经会阴实时三维超声评估生物反馈电刺激联合盆底肌锻炼治疗产后盆底功能障碍的临床疗效。方法：选择2020年9月至2022年9月我院收治的96例产后盆底功能障碍患者,根据随机数字表法将患者分为两组,对照组（48例）采用盆底肌锻炼治疗,研究组（48例）采用生物反馈电刺激联合盆底肌锻炼治疗。治疗前后采用经会阴实时三维超声检查,对比两组治疗前后的盆底功能障碍调查表（PFDI-20）、盆底障碍影响简易问卷7（PFIQ-7）评分、静息和Valsalva动作状态下的肛提肌超声参数。分析肛提肌超声参数与PFDI-20、PFIQ-7评分的相关性。结果：两组治疗后PFDI-20、PFIQ-7评分,静息和Valsalva动作状态下肛提肌裂孔前后径、肛提肌裂孔左右径、肛提肌裂孔面积较治疗前降低（P＜0.05）,静息时肛提肌厚度较治疗前增加（P＜0.05）。研究组治疗后PFDI-20、PFIQ-7评分,静息和Valsalva动作状态下肛提肌裂孔前后径、肛提肌裂孔左右径、肛提肌裂孔面积低于对照组（P＜0.05）,静息时肛提肌厚度大于对照组（P＜0.05）。静息和Valsalva状态下肛提肌裂孔前后径、肛提肌裂孔左右径、肛提肌裂孔面积与PFDI-20、PFIQ-7评分呈正相关（P＜0.05）,静息状态肛提肌厚度与PFDI-20、PFIQ-7评分呈负相关（P＜0.05）。结论：经生物反馈电刺激联合盆底肌锻炼治疗后肛提肌裂孔大小较治疗前降低,肛提肌厚度较治疗前增加,且与PFDI-20、PFIQ-7评分改善有关,经会阴实时三维超声可客观、有效评价产后盆底功能障碍患者的治疗效果。     

Comparative and functional morphology of musculus canalis ani in tetrapod mammals and primates]

Comparative anatomy of structure and function of the M. canalis ani in tetrapode mammals and primates is described for the first time. The muscle itself lies on the sphincter ani internus in the area between the anorectal ("pectinate") and anocutaneal ("white") lines and its circumference is intact around the entire anal canal. The canalis ani muscle orginates from the superior part of the sphincter ani internus and concomitantly receives additional fibers from the longitudinal muscle. Caudally the muscle dips back into the sphincter ani internus and, at the same time, a small portion of the fibers go to the longitudinal muscle and, likewise, a portion also sets itself on the perinaal skin. On the basis of its morphological relationship to the convoluted vessels of the rectal venous plexus, the canalis ani muscle appears to be able to complete the closing of the anus in the continence phase to such an extent that a complete closing of the anal lumen is guaranted.     

A possible role for endogenous glucocorticoids in orchiectomy-induced atrophy of the rat levator ani muscle: studies with RU 38486, a potent and selective antiglucocorticoid

We employed RU 38486, a potent and selective antiglucocorticoid, to study a possible role for endogenous glucocorticoids in atrophy of the levator ani muscle secondary to castration of male rats. RU 38486 was shown to block [3H]triamcinolone acetonide binding to cytosol from levator ani muscle. Daily oral administration of RU 38486 to castrated rats partially prevented atrophy of the levator ani muscle, as well as a decrease in RNA concentration. In a control group receiving RU 38486 alone, the levator ani underwent significant (20%) hypertrophy. Administration of exogenous dexamethasone also caused pronounced atrophy of the levator ani muscle. This atrophy was prevented, to a significant degree, by simultaneous oral administration of RU 38486. It is concluded that endogenous glucocorticoids, the actions of which are blocked by RU 38486, may be involved in regulation of the mass of the levator ani muscle in intact rats.     

Functional properties of muscle autografts substituted for the rat levator ani muscle

The present report deals with the functional properties (contraction parameters and neuromuscular transmission) of muscle grafts and transposed muscles substituted for the levator ani muscle in the rat. The experiments were divided into four main groups. Group I - the levator ani [LA] was excised and replaced in its own bed. Group II - the extensor digitorum longus, a fast muscle (with or without predenervation), and Group III - the soleus, a slow twitch muscle, were substituted for the LA. In group IV, the gracilis anterior muscle was either freely grafted in place of the LA or transposed a) with intact innervation, b) with its vascular supply intact or c) with preserved neuro-vascular supply. The optimum results of twitch and tetanic tension, and the amplitude of stimulation EMG responses was found in the case of LA resutured into its own bed and in the case transposition of the gracilis anterior muscle had been performed with its neuro-vascular supply intact in place of the LA. On the basis of these functional findings and morphological and anatomical observations (Grim et al. 1982), a surgical procedure is suggested for patients with anal incontinence (Grim et al. 1981, Dittertová-Vlasáková et al. 1982).     

Cytosolic androgen receptor in regenerating rat levator ani muscle.

The development of the cytosolic androgen receptor was studied after degeneration and regeneration of the rat levator ani muscle after a crush lesion. Muscle regeneration appears to recapitulate myogenesis in many respects. It therefore provides a model tissue in sufficiently in large quantity for investigating the ontogenesis of the androgen receptor. The receptor in the cytosol of the normal levator ani muscle has binding characteristics similar to those of the cytosolic receptor in other androgen-sensitive tissues. By day 3 after a crush lesion of the levator ani muscle, androgen binding decreased to 25% of control values. This decrease was followed by a 4-5 fold increase in hormone binding, which attained control values by day 7 after crush. Androgen binding remained stable at the control value up to day 60 after crushing. These results were correlated with the morphological development of the regenerating muscle after crushing. It is concluded that there is little, if any, androgen receptor present in the early myoblastic stages of regeneration; rather, synthesis of the receptor may occur after the fusion of myoblasts and during the differentiation of myotubes into cross-striated muscle fibres.     

The suspensory muscle of the duodenum

The suspensory muscle of the duodenum continues the muscular layers of the duodenum, which is consequently surrounded on its mesenteric border only by the muscularis mucosae. Between the muscle bundles of the suspensor there is much loose connective and adipose tissue. Microganglions of no more than 90 cells may be found between the muscle bundles of the suspensor. In their superior part, the muscle bundles have connective sheaths, which are continuous with the adventitia of the aorta and celiac trunk. It is most probable that the suspensor acts like a sphincter and is innervated contrarily to the duodenum.     

Recruitment of knee joint ligaments

On the basis of earlier reported data on the in vitro kinematics of passive knee-joint motions of four knee specimens, the length changes of ligament fiber bundles were determined by using the points of insertion on the tibia and femur. The kinematic data and the insertions of the ligaments were obtained by using Roentgenstereophotogrammetry. Different fiber bundles of the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments were identified. On the basis of an assumption for the maximal strain of each ligament fiber bundle during the experiments, the minimal recruitment length and the probability of recruitment were defined and determined. The motions covered the range from extension to 95 degrees flexion and the loading conditions included internal or external moments of 3 Nm and anterior or posterior forces of 30 N. The ligament length and recruitment patterns were found to be consistent for some ligament bundles and less consistent for other ligament bundles. The most posterior bundle of each ligament was recruited in extension and the lower flexion angles, whereas the anterior bundle was recruited for the higher flexion angles. External rotation generally recruited the collateral ligaments, while internal rotation recruited the cruciate ligaments. However, the anterior bundle of the posterior cruciate ligament was recruited with external rotation at the higher flexion angles. At the lower flexion angles, the anterior cruciate and the lateral collateral ligaments were recruited with an anterior force. The recruitment of the posterior cruciate ligament with a posterior force showed that neither its most anterior nor its most posterior bundle was recruited at the lower flexion angles. Hence, the posterior restraint must have been provided by the intermediate fiber bundles, which were not considered in the experiment. At the higher flexion angles, the anterior bundles of the anterior cruciate ligament and the posterior cruciate ligament were found to be recruited with anterior and posterior forces, respectively. The minimal recruitment length and the recruitment probability of ligament fiber bundles are useful parameters for the evaluation of ligament length changes in those experiments where no other method can be used to determine the zero strain lengths, ligament strains and tensions.     

Substance P-immunoreactive nerve fibres in the anterior segment of the rabbit eye

Summary Substance P-immunoreactive nerve terminals were found in several locations in the anterior segment of the rabbit eye. In the iris they occurred in the sphincter muscle and were randomly distributed in the iris stroma with some fibres running close to the dilator muscle. In the ciliary body these immunoreactive elements were few and occurred within bundles of nerve fibres, while in the ciliary processes they were more numerous with a predominantly subepithelial location. Blood vessels in the anterior uvea were often surrounded by substance P-immunoreactive fibres. No substance P-fibres were found in the cornea, while the sclera contained very few such elements.Using conventional in vitro techniques it was found that the sphincter pupillae muscle of the iris responded to electrical stimulation with a contraction that was resistant to cholinergic and adrenergic blockade, but was inhibited by the neuronal blocker tetrodotoxin. This indicates the existence of a non-cholinergic, non-adrenergic neuronal mediator of the contractile response. Exogenously applied substance P produced a long-lasting contraction of the spincter muscle, an observation compatible with the view that substance P is the noncholinergic, non-adrenergic neurotransmitter involved.     

Anatomy of the cruciate ligaments and their function in extension and flexion of the human knee joint

The areas of the femoral origin of the cruciate ligaments have approximately the shape of sectors of ellipses, the one for the anterior ligament on the lateral condyle posteroproximally and the one for the posterior ligament on the medial condyle distally. By means of a new technique of dissection, combined with the use of X-rays, the change in distance between the origin and insertion and so the change of tension of single bundles of the ligaments could be analyzed. Only a rather thin bundle in each cruciate ligament is in constant tension: "guiding bundles." The maximal diminution of distance between the origin and insertion for some bundles is 65%. In the anterior cruciate ligament the majority of fibres are taut in extreme extension: "limiting bundles." The same is true in the posterior cruciate ligament in extreme flexion. There are also some fibres, especially in the posterior cruciate ligament, that are taut only in an intermediate position. The geometric analysis of the function of different groups of fibers was performed by a modification of Menschik's concept of a four-bar link.     

Coccygeus and levator ani muscles in the rabbit: morphology and proprioceptive innervation

The Authors have studied the morphological features and the proprioceptive nervous component in the coccygeus and levator ani muscles of the rabbit, using Ruffini's and Barker-Ip's impregnations. The coccygeus muscle originates from ischiatic spine and inserts on the last three sacral vertebrae and on the first four or five caudal vertebrae. The levator ani muscle originates from the ischiatic spine and the coccygeus muscle aponeurosis and inserts directly on the caudal vertebrae 3-5 or 4-6. The proprioceptive innervation in both muscles is constituted by muscle spindles and Golgi tendon organs with a typical structure. Muscle spindles are more numerous than Golgi tendon organs and the spindle density is higher in the levator ani muscle.     

A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. The involuntary action of the external anal sphincter: histologic study.

The histologic changes in the external anal sphincter after internal anal sphincter excision were studied in 20 dogs. An external sphincter biopsy was taken before internal sphincterectomy and 2 weeks and monthly thereafter for 10 months. The excised material was studied microscopically after being stained with hematoxylin and eosin, Verhoeff-van Gieson and succinic dehydrogenase. 70% of external sphincter specimens before internal sphincter excision showed smooth muscle fibers scattered between the striated fibers. These smooth fibers could be responsible for the resting tone of the external sphincter. After internal sphincter excision, characteristic histologic changes could be identified in the external sphincter. From the 2nd week to the 5th month after excision, the external sphincter showed degenerative and hypertrophic changes. From the 6th to the 10th month, there were regeneration of the striated muscle fibers and increase in the number of smooth fibers so that by the 10th month a 'compound' muscle of striated and smooth fibers was identified. Two theories were put forward to explain the smooth fiber preponderance in the external sphincter after internal sphincter excision: mutant and replacement theories. The increased nonstriated element in the external sphincter seems to be a structural-functional adaptation so that the external sphincter takes on the involuntary function of the excised muscle.     

A comparison of quantitative ultrastructural and contractile characteristics of muscle fibre types of the perch,Perca fluviatilis L.

Summary Quantitative ultrastructural and physiological parameters were investigated in three types of muscle fibres ofPerca fluviatilis: white fibres from the m. levator operculi anterior, pink (intermediate) fibres of the m. hyohyoideus and deep red fibres of the m. levator operculi anterior. Times to peak tension and half relaxation times of isometric twitches increased in the mentioned order. The extent of contact between the T system and the sarcoplasmic reticulum and the relative volume and surface area of the terminal cisternae showed an inverse relation with the time to peak tension of the twitch. The maximal isometric tetanic force per unit cross section area was similar for all three investigated types. The inverse relation between the time to peak tension of the twitch and the relative length of contact between T system and SR is in agreement with data obtained for fast- and slow twitch muscle fibres of the carp,Cyprinus carpio L.Abbreviations LOPA musculus levator operculi anterior - HH musculus hyohyoideus - SR Sarcoplasmic reticulum     

Subject specific finite elasticity simulations of the pelvic floor

An anatomically realistic computational model of the pelvic floor and anal canal regions was used in this study to examine the mechanics of normal defecatory function within the female pelvic floor. This subject specific, MRI-based model enabled mechanical simulations to be performed and quantitatively assessed against experimental data retrieved from the same volunteer. The levator ani muscle group mesh was used as the domain over which the governing equations of finite elasticity were solved using the finite element method with a Mooney-Rivlin material law. Deformation of the levator ani was simulated during a 'bear down' maneuver in order to visualize the way this muscle group functions in an asymptomatic subject. A pressure of 4 kPa was imposed on the mesh and the computed mesh displacements were compared to those obtained from dynamic MR images with an average, experimentally consistent, downwards displacement of 27.2 mm being achieved. The RMS error for this movement was 0.7 mm equating to a percentage error of 2.6% in the supero-inferior direction and 13.7 mm or 74.5% in the antero-posterior direction.     

Succinic dehydrogenase activity of the respiratory muscles of a fresh-water teleost, Bagarius bagarius (Ham.) (Sisoridae, Pisces).

Functional morphology including the origin, insertion, and innervation of the respiratory muscles in relation to buccal pressure pump and opercular suction pumps in a fresh-water bottom dwelling siluroid fish, Bagarius bagarius have been studied. Histochemical studies were made on the succinic dehydrogenase activity of adductor mandibulae, retractor tentaculi, levator operculi, dilatator operculi, adductor operculi, intermandibularis, interhyoideus, hyohyoideus superior and constrictor branchialis. The intensity of reaction reveals the presence of three types of muscle fibres in some of the respiratory muscles. The muscle containing red muscle fibres are mostly innervated by the branches of the VIIth cranial nerve. The retractor tentaculi consists of superficial white muscle fibres and the interior part is dominated by red muscle fibres. The muscles (adductor operculi, levator operculi, dilatator operculi, interhyoideus, hyohyoideus superior) concerned with the opercular suction pumps are of mixed type and consist of white and red muscle fibres, whereas adductor mandibulae and intermandibularis are made up entirely of white muscle fibres. The adductor muscle bundles of the constrictor branchialis, which are responsible for movement of gill filaments, are dominated by the red muscle fibres. The abductor part, however, is made up entirely of white muscle fibres.     

Muscle phenotype remains unaltered after limb autotomy and unloading

Loss of chelipeds in crustaceans results in severe atrophy of the major muscle responsible for lifting the limb, the anterior levator. We decided to test if this loss of mechanical load altered muscle phenotype as measured by SDS-PAGE analysis of levator total protein and actomyosin fractions. Levator muscles of adult crayfish, Procambarus clarkii, with either functional regenerate limbs or lack of limb buds (papilla stage) were compared with those from normal contralateral limbs and those from pristine animals. We find that there is no difference in protein profiles among the three conditions. However, the total protein profile for the dually excited levator muscle is unique compared to those of fast or slow muscles of the abdomen (L and SEL, respectively), which receive only phasic or tonic excitatory innervation. The levator myosin heavy chain profile is similar to that of slow phenotype muscles such as the SEL and opener. We conclude that load does not influence levator phenotype. This is likely due either to the intact innervation and continued activation of the levator during atrophy or to the maintenance of passive tension on the muscle. J. Exp. Zool. 289:10-22, 2001.     

Histochemical and stereological analysis of the levator ani (pubocaudal) muscle in nulliparous and multiparous beagles

Fiber-type composition and several stereological parameters of the levator ani (pubocaudal) muscle were evaluated in five nulliparous and five multiparous beagles using myosin ATPase-histochemistry and systematically selected muscle cross-sections. With respect to the narrow canine pelvic cavity, this study was also undertaken to determine whether vaginal birth of at least seven litters causes similar neuromuscular changes in the canine levator ani (pubocaudal) muscle analoguous to those seen in the pelvic floor muscles of women after vaginal delivery. The canine pubocaudal muscle is comprised of approximately equal amounts of slow twitch type I and fast twitch type II (IIA, IIS) fibers. The muscles of both the nulliparous and multiparous beagles did not display any signs indicative of denervation or myopathology. The multiparous dogs exhibited significantly increased mean absolute muscle (1720 mm(3)) and total fiber-type I volumes (850 mm(3)) as well as relevantly increased mean diameter of type I fibers (72.0 microm) when compared with the nulliparous group. The canine levator ani (pubocaudal) muscle is not pathologically affected by vaginal deliveries and seems to adapt to numerous successive pregnancies and births through fiber-type I hypertrophy.