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Musculus Puborectalis – Function & Clinical Role

The musculus puborectalis is a key pelvic floor muscle that wraps around the anal canal and plays a central role in controlling bowel movements and maintaining fecal continence.

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The musculus puborectalis is a key pelvic floor muscle that wraps around the anal canal and plays a central role in controlling bowel movements and maintaining fecal continence.

What is the Musculus Puborectalis?

The musculus puborectalis (also referred to as the puborectalis muscle) is a paired skeletal muscle of the pelvic floor and forms part of the levator ani muscle group. It originates bilaterally from the pubic bone (os pubis) and wraps in a sling-like fashion around the anorectal junction – the point where the rectum meets the anal canal. This unique anatomical arrangement creates the so-called puborectal sling, which is fundamental to the muscle's role in fecal continence and defecation.

Anatomy and Location

The musculus puborectalis is located within the lesser pelvis and forms part of the pelvic diaphragm, the muscular floor of the pelvis. It runs from the pubic bones posteriorly on both sides to encircle the anorectal junction. This configuration produces the anorectal angle, a key anatomical feature for maintaining bowel control.

The Anorectal Angle

At rest, the puborectalis muscle pulls the anorectal junction anteriorly, creating an angle of approximately 80 to 100 degrees between the rectum and the anal canal. This angle acts as a mechanical barrier, preventing involuntary leakage of stool. During defecation, the muscle relaxes, the angle widens, and stool can pass through the anal canal.

Function

The musculus puborectalis fulfills several essential functions within the pelvic floor:

Fecal continence: By maintaining the anorectal angle, the muscle is a primary contributor to fecal continence – the ability to voluntarily retain stool and gas.
Defecation: During bowel movements, coordinated relaxation of the muscle opens the anorectal angle and allows stool to pass.
Pelvic organ support: As part of the levator ani, it provides structural support to the pelvic organs, including the bladder, uterus (in women), and rectum.
Micturition and childbirth: The muscle is indirectly involved in bladder control and plays a role during vaginal delivery.

Clinical Significance

Dysfunction of the musculus puborectalis can give rise to several clinically relevant conditions:

Fecal Incontinence

Weakness or injury of the muscle – for example following childbirth, surgical procedures, or neurological disease – can lead to fecal incontinence, where individuals are unable to adequately control the release of stool or gas.

Anismus (Puborectalis Dyssynergia)

Anismus, also referred to as puborectalis dyssynergia or pelvic floor dyssynergia, is a condition in which the puborectalis muscle paradoxically contracts rather than relaxes during straining for defecation. This results in obstructed defecation, characterized by excessive straining, a sensation of incomplete evacuation, and chronic constipation.

Rectal Prolapse and Pelvic Floor Descent

A weakened puborectal sling can contribute to rectal prolapse (protrusion of the rectum through the anus) or pelvic organ prolapse, as the supportive function for the pelvic organs is diminished.

Diagnosis

Several diagnostic techniques are used to assess the musculus puborectalis:

Anorectal manometry: Measures pressure within the anal canal and rectum to evaluate muscle strength and coordination.
Defecography (MRI or X-ray defecography): Imaging during simulated defecation to visualize the anorectal angle and muscle behavior in real time.
Endoanal ultrasound: Provides structural imaging of the muscle, identifying tears, scarring, or atrophy.
Electromyography (EMG): Assesses electrical muscle activity to detect neuromuscular disorders affecting the puborectalis.

Treatment

Treatment depends on the underlying disorder:

Pelvic floor physiotherapy: Targeted exercises to strengthen the puborectalis muscle and improve continence.
Biofeedback therapy: A technique used particularly for anismus to help patients learn to consciously relax the puborectalis muscle during defecation attempts.
Botulinum toxin injections: In cases of therapy-resistant anismus, injections of botulinum toxin into the puborectalis can induce temporary muscle relaxation and restore normal defecation.
Surgical intervention: In severe cases such as significant rectal prolapse or sphincter injury, surgical repair may be necessary.

References

Standring, S. (Ed.) (2021). Gray's Anatomy: The Anatomical Basis of Clinical Practice (42nd ed.). Elsevier.
Bharucha, A. E. & Wald, A. (2019). Anorectal disorders. American Journal of Gastroenterology, 114(6), 944–959.
Mitterberger, M. et al. (2008). Ultrasound of the pelvic floor. European Journal of Radiology, 65(2), 258–266.

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