LARGE INTESTINE Dr. A. S.

D’ Souza 2006

The large intestine extends from the ileo-caecal junction to the anus is about 1.5meters long. Its caliber is
greatest near the caecum gradually diminishes to rectum, where it enlarges just above the anal canal.

Subdivisions
o Caecum (6cm)and appendix (2 - 20 cm, average 9cm) - Peritoneal
o Ascending colon (15cm) – Retro peritoneal
o Transverse colon (50cm) - Peritoneal
o Descending colon (25cm) - Retro peritoneal
o Sigmoid colon (40cm) - Peritoneal
o Rectum (12cm) - Retro peritoneal
o Anal canal (3.8cm)

General features
¾ It has a greater caliber than the small intestine
¾ It is for the most part fixed in position
¾ Its longitudinal muscle though a complete layer, is concentrated into three longitudinal taeniae coli
¾ The colonic wall is puckered into sacculations [haustrations]
¾ Small adipose projections appendices epiploicae are scattered over the free surface of the colon
[except caecum, appendix and rectum].

Taenia coli
These are three thick bands produced by the aggregations of longitudinal muscle layer of the large
intestine (A thin layer of longitudinal muscle is however present in between the taeniae). The taeniae are
absent on the appendix and the rectum. Each taenia is about 120cm long [within which 150cm of large gut
is inserted, so the gut shows sacculations].
In the caecum, ascending, descending and sigmoid colon their position is anterior, posteromedial and
posterolateral [called respectively as taenia libera, taenia mesocolica and taenia omentalis]. In transverse
colon however, taenia libera lies on the inferior surface, taenia mesocolica on the posterior surface and
taenia omentalis on the anterosurperior surface. The taeniae when traced down on the caecum converge at
the base of appendix and towards the recto-sigmoid junction spread out into the longitudinal muscle coat.

Appendices epiploicae
These are peritoneal pouches containing fat, and are present in the large gut [except caecum, appendix and
rectum], more on the transverse and sigmoid colon.

Caecum
The caecum lies in the right iliac fossa, occupies a triangular area, which is bounded above by the trans-
tubercular plane below by the inguinal ligament and medially by the right lateral plane.

Size: Length – 6cm

Breadth - 7.5cm
Shape
It is a large sac and its shape is variable. Based on the shape, it is classified into the following types.

1. Infantile type [ 2% ] – caecum is conical and the appendix is attached to its apex
2. Quadrate type [ 3% ] – conical caecum becomes quadrate by outgrowth of a saccule on each side.
These saccules are of equal size and the appendix arises from the depression between them.

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 3. Adult type [ 90% ] – two saccules grow at unequal rates, right more rapidly, so the appendicular
attachment is pushed closer to the ileocaecal junction
4. Exaggerated type [ 5% ] – is merely an exaggeration of type 3 right growing still further and the left
atrophying so that appendix attachment is very close to the ileocaecal junction.

Peritoneal relation
The caecum is peritoneal, covered by peritoneum on all sides. However in a small percentage of people its
upper posterior surface is not covered by peritoneum and the caecum is in direct contact with iliac fascia.

Relations
Anterior – Anterior abdominal wall, greater omentum [sometimes] and coils of small intestine

Posterior – Right iliacus, psoas major, lateral cutaneous nerve of the thigh, femoral nerve and retrocaecal
recess of Peritoneum with frequently appendix.

Medial – terminal part of the ileum ending at the ileocaecal junction and vermiform appendix

Arterial supply - Anterior and posterior caecal branches of the ileocolic artery

Venous drainage – veins drain into the ileocolic vein [Æ superior mesenteric vein - portal system]

Lymphatic drainage – into the ileocolic nodes Æ superior mesenteric nodesÆ pre-aortic nodes

Nerve supply – sympathetic fibres are derived from the superior mesenteric plexus [from T10 to L1
segments] and parasympathetic fibres are from both the vagus nerves.

Fig. Interior of the Caecum

Ileocaecal orifice
The ileum opens into posteromedial aspect of the large intestine, upper lip of the opening is considered as
the junction between caecum and ascending colon. On the surface orifice corresponds to the intersection
between trans-tubercular and right lateral planes (about 2cm below is appendicular opening).

The orifice is guarded by a valve, which consists of two flaps – upper and lower (upper is horizontal and
the lower is concave). At their ends the flaps meet and continue as frenula of the valve. Reduplication of
the mucosa and the muscle coat form each flap. The valve prevents reflux [from caecum to ileum] and
regulates the passage of ileal contents into the caecum [valve is kept in tonic contraction by sympathetic
innervation]. Entry of food into the stomach initiates contraction of the small intestine, expelling ileal
contents into the large intestine [gasto-ileal reflex].
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Vermiform Appendix
The vermiform appendix is a narrow, vermian (worm shaped) tube, arising from the posteromedial caecal
wall, about 2cm below the end of the ileum. A fold of peritoneum - mesoappendix suspends it. Although
appendix is a part of the large intestine, it is devoid of taenia coli, appendices epiploicae and sacculations.

Base of the appendix corresponds to a point 2cm below the intersection between trans-tubercular and right
lateral planes. The McBurney’s point is at the junction of medial two third and lateral one third of a line
that extends from the umbilicus to the right anterior superior iliac spine. This point represents the
maximum tenderness in patients with inflammation of the appendix.

The appendix presents a base, body and tip. The base is attached to the posteromedial wall of the caecum,
and the body is narrow and tubular. The canal [lumen] of the appendix is small and opens into the
caecum, sometimes the orifice is guarded by a semi lunar valve. The lumen may be partially or wholly
obliterated in the later decades of life.

Positions of the Appendix

It may occupy one of several positions
1. Retrocaecal / retrocolic [12 O’clock] – behind the caecum and lower ascending colon [ 65%]
2. Splenic [2 O’clock] - passing upwards and to the left directed towards the spleen (can be pre ileal –
or post ileal] – 2%)
3. Promontoric [3 O’clock] – very rare, the tip is directed towards the sacral promontory.
4. Pelvic [4 O’ clock] - The appendix passes downwards and medially, in females it may be closely
related to the right uterine tube or ovary – 30%
5. Mid inguinal [subcaecal / 6 O’clock] - passes downwards towards the inguinal ligament – 2%
6. Paracolic [11 O’clock] - tip of the appendix passing to the right side of the ascending colon

Note: Due to error in rotation of the midgut, the appendix and caecum may be situated in the left iliac
fossa or sub-hepatic region.

Diagram illustrating major positions of the appendix

Arterial supply
The main artery is the appendicular artery a branch form the inferior division of the ileocolic artery. It
runs behind the terminal ileum and enters the mesoappendix. The artery gives a recurrent branch and then
runs towards the tip of the appendix. Terminal part lies on the wall of the appendix and may be
thrombosed in appendicitis, resulting in gangrene. [In about 80% of individuals there are two or more
accessory arteries].

Venous drainage – into the corresponding veinsÆ superior mesenteric vein

Lymphatic drainage – into superior mesenteric nodes [via ileocolic nodes]

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Nerve supply
The parasympathetic nerves are derived from both vagus nerves and the sympathetic nerves are from T10
segment of the spinal cord.

Applied Anatomy
Inflammation of the appendix is appendicitis and is manifested by pain, vomiting, etc. pain is often felt
first in the umbilical region [referred pain] and then settles in the right iliac fossa due to local peritonitis.
In retrocaecal appendix patient may experience pain on extension of the hip joint [due to tension of the
irritated psoas major muscle].

Colon
Ascending colon
About 15cm in length and narrower than the caecum, it ascends to the inferior surface of the right lobe of
the liver. Here it bends abruptly forwards and to the left, at the right colic flexure to continue as the
transverse colon. The anterior surface and sides are covered by the peritoneum; posterior surface is related
to the fascia iliaca, ilio-lumbar ligament, quadratus lumborum, ilio-inguinal and ilio-hypogastic nerves,
lateral cutaneous nerve of the thigh, sub-costal vessels and nerve and lower pole of the right kidney.

Right colic flexure

This is at the junction of the ascending colon and transverse colon, related to the kidney posteriorly and
liver anteriorly. It is situated 2.5cm below the transpyloric plane and about 10cm from the median plane.

Transverse colon
It extends from the right colic flexure to the left colic flexure after crossing across the abdominal cavity.
The transverse colon describes an arch, with its convexity directed downwards and forwards. It is invested
by peritoneum, connecting it to the pancreas by the transverse mesocolon.

Transverse mesocolon
It is a peritoneal fold, which suspends the transverse colon from the posterior abdominal wall. In addition
to the transverse colon it contains the anastomosis between the middle colic and left colic arteries, nerves
and lymphatics of the transverse colon and loose areolar tissue with fat.

Left colic flexure

This is at the junction of the transverse colon and descending colon in the left hypochondriac region.
Topographically situated at a point 2.5cm above the transpyloric plane and 10cm to the left of midline.
The left flexure is above, more acute and on a more posterior plane than the right flexure. It is suspended
from the diaphragm by a triangular peritoneal fold - phrenico-colic ligament.

Descending colon
It descends through the left hypochondriac and lumbar regions to the iliac crest; it then curves medially in
front of the iliacus and psoas major to continue as the sigmoid colon at the inlet of the lesser pelvis. The
descending colon is retro-peritoneal (peritoneum covering it on the front and sides).

Sigmoid colon [Pelvic colon]

It begins at the left pelvic brim [inlet], at first descending close to the left pelvic wall and then in between
the rectum and urinary bladder in males and rectum and uterus in females [may reach the right pelvic
wall]. It finally comes back to the midline in level with the third piece of the sacrum, where it bends
downwards and continues as the rectum.

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Sigmoid mesocolon
It is a peritoneal fold that suspends the sigmoid colon from the posterior pelvic wall. The root of the
mesocolon is anterior to the bifurcation of the left common iliac artery. It contains the sigmoid colon,
sigmoid branches of the inferior mesenteric artery, branch from the superior rectal artery, lymphatics and
nerves of the sigmoid colon and fat.

RECTUM

Rectum is the lower dilated part of the large gut placed between the sigmoid colon above and anal
canal below.
Rectum in human beings is not straight as the name implies. In fact it is curved both in antero-
posterior and side to side directions.
Though rectum is a part of the large intestine the three cardinal features [sacculations, taenia coli and
appendices epiploicae] of the large intestine are absent on the wall of the rectum.

Diagram to show curvatures of the rectum

Situation and Extent
¾ It is situated in the lesser pelvis anterior to the lower three pieces of sacrum and coccyx.
¾ It begins as a continuation of the sigmoid colon at the level of S3; recto-sigmoid junction is indicated
by the lower end of the sigmoid mesocolon.
¾ It ends by becoming continuous with the anal canal at the ano-rectal junction, which lies 2 - 3 cm in
front and a little below the tip of the coccyx [in males corresponds to the apex of the prostate].

Measurements
Length – 12 cm [5 inches], Upper part has the same [4cm] diameter as that of sigmoid colon but in the
lower part it is dilated to form the rectal ampulla.

Course and Direction

The beginning and the end of rectum are in the median plane, with two types of curvatures in its course.

A. Two antero-posterior curves

1. Sacral flexure – follows the concavity of the sacrum and coccyx
2. Perineal flexure – convex forwards at the ano-rectal junction, and is maintained by the pubo-rectal
sling of the levator ani.
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B. Three lateral curves
1. Upper lateral curve – convex to the right at the junction of third and fourth sacral vertebrae.
2. Middle curve – [most prominent] convex to the left at the level of the sacro-coccygeal junction.
3. Lower curve – convex to the right at the tip of the coccyx.

Peritoneal relations
Posterior surface of the rectum is not covered by the peritoneum. Anterior surface is partly covered by the
peritoneum. In the upper third peritoneum covers the front and sides of the rectum, in the middle third it
covers the front only and the lower third is devoid of peritoneal covering.

Traced in front of the rectum, peritoneum is reflected in males to the upper part of the urinary bladder
forming the recto-vesical pouch (bottom of this pouch is situated about 7.5 cm from the anal orifice). In
females, the peritoneum is reflected to the upper one fourth of the posterior wall of the vagina and then to
the posterior surface of the uterus, forming the recto-uterine pouch. The bottom of this pouch lies about
5.5 cm from the anus. Traced on each side, the peritoneum is reflected from the upper third of the rectum
to the lateral pelvic wall forming a pair of para-rectal fossae.

General relations
Peritoneal covered upper two thirds is related to the sigmoid colon and coils of small intestine.
Non-peritoneal lower part forms the rectal ampulla and is related to the following.

Anterior
In males: Base of the urinary bladder, pair of seminal vesicles, ampullae of vas and posterior surface of
the prostate. All these structures are separated from the rectum by the rectovesical fascia.
In females: Related to the lower part of the vagina.

Posterior [relations are same in both the sexes]

1. Bones / ligaments - Lower 3 pieces of sacrum, coccyx and anococcygeal ligament.

2. 3 Muscles – Levator ani, piriformis and coccygeus.
3. Vessels – Median sacral, superior rectal and lower lateral sacral.
4. Nerves – Sympathetic chain with ganglion impar, anterior primary rami of S3, S4, S5 and Co1 and
pelvic splanchnic nerves.
5. Lymph nodes, lymphatics and fat.

Mucosal folds
Two types of mucosal folds are found in the interior of rectum - temporary and permanent. Temporary
folds disappear when the rectum is distended and are mostly longitudinal in direction in the lower part of
the rectum.

Permanent folds – are horizontal in direction, semi-lunar in shape. Each fold [valve] is formed due to the
reduplication of mucous membrane containing submucous tissue and thickening of circular muscle coat.

First valve – situated close to recto-sigmoid junction, opposite to S3 vertebra.

Second valve – is the largest and most constant, lies immediately above the rectal ampulla. It projects
from the anterior and right wall just below the anterior peritoneal reflection.
Third fold – inconstant and on the left, is about 2.5cm below the second fold.

[Sometimes a fourth may be present on the left about 2.5cm above the middle fold].

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Arterial supply
Four arteries – unpaired superior rectal, median sacral and pair of middle rectal, supply the rectum

Superior rectal artery - is the principal artery of the rectum, it is a continuation of the inferior mesenteric
artery. It reaches the recto-sigmoid junction and divides into right and left branches. Branches of both
sides subdivide into smaller branches, which pierce the rectal wall and form a plexus in the submucous
coat of the lower part of the rectum. From the plexus straight vessels descend through the anal columns
and anastomose at the pectinate line with the branches of the inferior rectal artery.
Middle rectal arteries – branches from the anterior division of the internal iliac artery, run in the lateral
ligaments of the rectum and supply its lower part.
Median sacral – is an unpaired branch from the aorta. It descends in the median plane and supplies the
posterior wall of lower rectum.

Venous drainage
Rectal veins are arranged in a plexus around the lower part of the rectum and anal canal and are arranged
in two sets.

Internal plexus – surrounds the anal canal above the white line (of Hilton), between the mucous
membrane and internal anal sphincter. It is continuous above with the radicles of the superior rectal vein
and communicates with the external venous plexus.
External plexus – surrounds the anal canal, situated between the peri-anal skin and subcutaneous part of
the external sphincter and continuous with the inferior rectal veins.

Venous blood is then drained as follows

1. From the upper part of the plexus about six veins pass upwards through the anal columns and sub
mucous coat of the rectum. These veins unite to form the trunk of the superior rectal vein that drains
into the inferior mesenteric vein [portal system].
2. Middle rectal vein – arises on each side from the plexus, passes along the lateral pelvic wall and
drains into the internal iliac vein [systemic vein].
3. From the lower part of the plexus inferior rectal vein arises and drains into the internal pudendal vein
[systemic vein].

Importance of the rectal veins

Rectal veins are sites of communication between the portal and systemic veins. The radicles of superior
rectal veins are devoid of valves; in increased portal venous pressure these are likely to be distended.

Lymphatic drainage
From the upper part – Lymphatics accompany the superior rectal artery and drain into inferior mesenteric
nodes.
From the lower part – Lymphatics pass into the internal iliac nodes.

Nerve supply

1. Sympathetic – fibres supplying the rectum are derived from the superior hypogastric plexus [L1, L2].
Sympathetic are primarily vasomotor; they stimulate the internal sphincter and are inhibitory to the
rectal musculature.
2. Parasympathetic – are derived from the pelvic splanchnic nerves [S2, S3, S4]. These are secretomotor
to the glands, stimulate peristalsis and relax the sphincters. Sensation of distension passes through the
parasympathetic nerves.

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Supports of the rectum
Rectum is maintained in position by the following structures
1. Pubo-rectal sling of the levator ani maintains the ano-rectal flexure.
2. Pelvic floor.
3. Fascia of Waldeyer and a pair of lateral ligaments of the rectum, which are derived as special bands
from the pelvic fascia. [Fascia of Waldeyer – attaches the lower part of the rectal ampulla to the
sacrum, lateral ligaments – present on either side of the rectum and attach rectum to the postero lateral
walls of the pelvis.]
4. Pelvi-rectal and ischiorectal fat act as loose packing around the rectum and anal canal.
5. Recto vesical fascia [of Denonvillier’s] and peritoneum form minor supports.

Fig. Arterial supply of rectum and anal canal

Applied Anatomy

1. Digital examination of the rectum – In a normal person following structures of importance can be
palpated by a finger passed per rectum
In both the sexes – Ano-rectal sling, ischiorectal fossae, ischial spines
In males – Posterior surface of the prostate, seminal vesicles and vasa deferentia
In females – Perineal body, cervix etc.
2. Proctoscopy and sigmoidoscopy – interior of the rectum and or anal canal can be examined under
direct vision with a proctoscope or a sigmoidoscope.
3. Prolapse of the rectum – Incomplete or mucosal prolapse may occur through the anus. Complete
prolapse is a condition in which the whole thickness of the rectal wall protrudes through the anus.
4. Neurological disturbances – In spite of identical innervations of the rectum and urinary bladder, rectal
involvement in nervous lesions is less severe than that of the bladder.

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 ANAL CANAL Dr. A. S. D’ Souza

Anal canal is the terminal part of the alimentary tube. It begins at the ano-rectal junction where the
rectal ampulla suddenly becomes narrow.
The canal measures 3. 8 [2.5 – 5] cm in length, directed downwards and backwards. It opens at the
anal orifice [anus] situated in the cleft between the buttocks.
Sphincter ani muscles, the tone of which keeps the canal closed except during defecation, surround the
anal canal.

Relations
Anterior
1. Perineal body
2. In males – Bulb of the penis and spongy urethra
3. In females – lower part of the posterior wall of the vagina

Posterior: Ano-coccygeal ligament, tip of the coccyx and fibro-fatty tissue

On either side – Ischiorectal fossa with its contents

Interior of the canal

The interior of the anal canal can be divided into three parts for descriptive purposes
1. Upper part – lies above the pectinate line
2. Middle part in between the pectinate line and white line of Hilton
3. Lower part lies below the White line

Upper part
It is about 15 mm in length, lined by semi-transparent mucous membrane with simple columnar
epithelium [epithelium can vary to stratified columnar or stratified squamous]. In the living, color of this
area is plum red due to the presence of the internal rectal venous plexus outside the mucous membrane.

Features
1. Anal columns – are permanent longitudinal mucosal folds, 6 -10 in number. Each column is formed
by the reduplication of mucous membrane containing radicles of the superior rectal vessels and
muscularis mucosa. In portal hypertension the superior rectal venous radicles may get distended.
2. Anal valves – are crescentic mucosal folds connecting the lower ends of the anal columns. The free
margins of these valves are directed upwards. A wavy line called pectinate or dentate line indicates
position of these valves. Sometimes the valve is torn during the passage of hard faeces leading to a
condition - anal fissure.
3. Anal Sinuses – These are recesses above the valves and between the columns. Floor of the sinuses
receive ducts of the tubular anal glands.
4. Anal papillae – seen sometimes as epithelial processes projecting from the free margin of the anal
valves. The papillae represent the remnants of the anal membrane.

Middle [Intermediate] part

This is also called pecten, measuring 15mm in length extending in between the pectinate line and Hilton’s
line. It is lined by stratified squamous non-keratinized epithelium without sebaceous and sweat glands and
has bluish pink color in the living.

Lower part - It is about 8mm long and is lined by true skin with sweat and sebaceous glands.

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Pectinate line [Dentate line]
It forms the muco-cutaneous junction of the anal canal and corresponds with the position of the anal
membrane. It is situated at the middle of the internal anal sphincter. This line divides the anal canal into
upper and middle parts, which differ in development, blood supply, lymph drainage and nerve supply.

Hilton’s line
It separates the middle and lower parts and is the color contrast between the bluish pink area above and
pigmented skin below. The line is represented by the inter-sphinteric groove at the lower end of the
internal anal sphincter.

Musculature of the anal canal

A. Anal sphincters.
B. Conjoint longitudinal muscle coat.
C. Ano-rectal ring.

Fig. Showing the anal sphincters

Anal sphincters
1. External anal sphincter – It is a voluntary sphincter and surrounds the entire length of the anal canal.
External anal sphincter is supplied by inferior rectal branch of the pudendal nerve and perineal branch of
the fourth sacral nerve. It consists of three parts (External sphincter though described as having 3 parts it
forms a single functional and anatomical entity)

Subcutaneous part – lies below the level of the internal sphincter, surrounds the lower part as a
flattened band.
Superficial part – is elliptical in shape, arises from the tip of the coccyx and anococcygeal body and
is inserted into the perineal body.
Deep part – surrounds the upper part of the internal sphincter and is fused with the puborectalis. It
arises from the ano-coccygeal ligament and is inserted into the perineal body.

2. Sphincter ani internus –is involuntary, formed by the thickening of the circular muscle coat of this part
of the gut. It surrounds the upper 30mm of the anal canal [lies above the subcutaneous part and deep to
the superficial and deep parts of the external sphincter] extending to the level of the white line of Hilton.

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Ano-rectal ring
It is a muscular ring at the ano-rectal junction, and is formed by the fusion of the pubo-rectalis, deep part
of the external anal sphincter and internal anal sphincter. Surgical division of this ring results in faecal
incontinence.

Conjoint Longitudinal coat

It is formed by the fusion of puborectalis with the longitudinal muscle coat of the rectum. It lies in
between the internal and external anal sphincters. Traced downwards it becomes fibro-elastic and at the
level of white line breaks up into a number of fibro-elastic septa, which spread fanwise, pierce the
subcutaneous part of the external sphincter and gain attachment to skin around the anus. The most lateral
of these septa forms the peri-anal fascia.

Venous drainage
1. The internal rectal venous plexus drains mainly into the superior rectal vein, but communicates freely
with the external plexus [and thus with the middle and inferior rectal veins], representing a
communication between portal and systemic circulations.
Veins present in three anal columns situated at 3, 7 and 11 o’clock position [as seen in lithotomic
position] are large and constitute potential sites for the formation primary internal piles.
2. External rectal venous plexus – is outside the muscular coat of the rectum and anal canal, with free
communication with internal plexus. Lower part of this plexus is drained by inferior rectal vein [into
the pudendal vein] and middle part into the middle rectal vein [internal iliac vein].

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Nerve supply
1. Above the pectinate line – autonomic nerves supply the canal; sympathetic from inferior hypogastric
plexus [L1, L2] and parasympathetic are from the pelvic splanchnic nerve [S2, S3, S4].
2. Below the pectinate line – supplied by somatic nerve – inferior rectal nerve S2, S3, S4.

Upper part- 15mm Middle part – 15mm Lower part – 8mm

Location Above the pectinate line In between the pectinate Below the white line
line & white line

Lining epithelium & Simple columnar Stratified squamous non- True skin
color Pink to red kertinised [Shiny, bluish] Dull white or brown

Anal columns, + ---- ----

sinuses & valves
Sweat & sebaceous ----- ----- +
glands

External sphincter Deep part Superficial part Subcutaneous part

Internal sphincter + + ---

Development Endodermal [cloaca] Ectodermal [Proctodeum]

Arterial supply Superior rectal Middle & inferior rectal

Lymphatic Internal iliac nodes Superficial inguinal [Medial, horizontal]

Nerve supply & Sympathetic –L1, L2.
sensitivity Para – S2, S3, S4.
Sensitive to stretch &
distension [like gut]
Piles Internal [painless]
Inferior rectal nerve [somatic] S2, S3, S4
Sensitive to pain, temp, touch etc [like skin]
External [painful]

Applied Anatomy
1. Internal piles are saccular dilatations of internal rectal venous plexus and occur above the pectinate
line and hence are painless. They bleed profusely during straining at stool. The primary piles occur in
3, 7 and 11 o’clock position of the anal wall [enlargement of three main radicles of the superior rectal
vein in the anal columns]. Varicosities in other positions of the lumen are called secondary piles.
2. External piles occur below the pectinate line and are therefore very painful.
3. Anal fissure – It is caused by rupture of one of the anal valves, usually due to passage of dry and or
hard stool in a constipated person. Each valve is lined by mucous membrane above, and with skin
below. Because of the involvement of the skin the condition is extremely painful and is associated
with spasm of the sphincters.
4. Fistula in ano – is caused by spontaneous rupture of an abscess around the anus or may follow
surgical drainage of the abscess. (Fistula is an abnormal epithelialized track connecting two cavities or
one cavity with exterior)

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 ISCHIO-RECTAL (ISCHIO-ANAL) FOSSA

The ischio-rectal fossa is a wedge shaped space situated one on each side of the anal canal below the
pelvic diaphragm. It is filled with fat, which acts as elastic cushion to allow the expansion of the rectum
and anal canal during defecation. Its base is directed downwards and apex directed upwards. Medial wall
slopes downward and lateral wall is vertical.

Boundaries
1. Base - formed by the skin and superficial fascia.
2. Apex – formed by meeting of the obturator fascia with the inferior fascia of the pelvic diaphragm
[anal fascia]. This corresponds to the origin of levator ani from the lateral pelvic wall.
3. Lateral – formed by obturator internus muscle, covered by obturator fascia and medial surface of the
ischial tuberosity.
4. Medial - formed by external anal sphincter with fascia covering on the lower part and levator ani with
anal fascia in the upper part.
5. Posterior – Sacro-tuberous ligament covered by lower fibres of gluteus maximus.
6. Anterior – Transverus pernei superficialis and profundus muscles, separated by the perineal
membrane.

Measurements Vertical – 5 cm
Antero-posterior – 5 cm
Transverse – 2.5 cm

Recesses of the fossa

These are narrow extensions of the fossa.
1. Anterior recess – extends forwards above the urogenital diaphragm, almost up to the posterior surface
of the body of the pubis.
2. Posterior recess – It is smaller than anterior and extends deep to the sacrotuberous ligament.
3. Horse shoe recess – connects the two fossae behind the anal canal.

Fascial disposition and subdivision of the fossa

1. Perianal space – It is bounded below by the skin and above by the perianal fascia [Perianal fascia is
the upper most lateral septum from the lower end of the conjoint longitudinal muscle coat of the anal
canal.] Perianal space is subdivided into numerous compartments containing fat by fibro elastic septa.
Infections of this space are so extremely painful due to the tension caused by swelling.
2. Ischiorectal space – It is larger and the fat in this space is loosely arranged in large loculi within the
delicate septa [infections of this space are less painful]. This space is situated between perianal fascia
and lunate fascia. Lunate fascia is arranged in an arched manner, begins laterally at the pudendal canal
and medially merges with the fascia covering deep part of the external anal sphincter.
3. Suprategmental space – It is situated above the lunate fascia, contains loose fat.
4. Pudendal canal – It is a fascial tunnel situated in the lateral wall of the fossa above the ischial
tuberosity. It extends from the lesser sciatic foramen to the posterior limit of the deep perineal pouch.
Pudendal canal contains internal pudendal vessels and pudendal nerve.

Contents
1. Ischiorectal pad of fat
2. Pudendal nerve – divides into dorsal nerve of the penis and perineal nerve
3. Internal pudendal vessels
4. Inferior rectal nerve and vessels – pass transversely through the fat from lateral to medial wall of the
fossa
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5. Posterior scrotal / labial nerve and vessels
6. Perineal branch of the 4th sacral nerve
7. Perforating cutaneous branches of S2, S3.

Applied Anatomy
1. Peri anal and ischiorectal spaces are rich in fat and poor in vascularity and so are relatively common
sites for abscess. An abscess in the perianal space is painful and can burst through the perianal skin.
An abscess in the ischorectal space may burst into the anal canal to produce fistula in ano.
2. Through the horseshoe recess, a unilateral abscess may become bilateral.
3. The occasional gap between tendinous origin of the levator ani and the obturator fascia is - hiatus of
Schwalbe. Pelvic viscera may herniate into the ischiorectal fossa through this gap leading to
ischiorectal hernia.

Fig. Coronal section through the ischio-anal fossa

Fig. Sagittal [ antero-posterior] section

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