1. Anorectal anatomy and physiology
Surgical anal canal ≈ 5 cm up to the Anorectal ring
Anatomic anal canal ≈ 3 cm up to the dentate line

2. The rectum 1/3 division Peritoneal coverage Valves of Houston
Anorectal angle
Fascial attachments; lateral ligament, Denonvillier fascia, rectosacral fascia

4. Anorectal anatomy and physiology
Dentate line (pectinate)
Anoderm
Transitional area
Columns of Morgagni
Internal hemmorrhoidal plexus

5. Anorectal anatomy and physiology

6. Anatomy of the anal canal
Anal glands
Anal sphincters
Levator ani
Anococcygeal raphi
Perianal spaces

7. External sphincter

8. Levator ani

9. Anorectal angle

10. Perianal & perirectal spaces

11. Blood supply of the anorectum
Portal circulation; inferior mesenteric artery → superior rectal artery
Systemic circulation; middle rectal artery, inferior rectal artery, middle sacral artery

12. Blood supply

13. Venous drainage

14. Lymphatic drainage of anus& rectum
Perirectal nodes
Inferior mesenteric nodes
Internal iliac nodes
Superficial inguinal nodes

15. Lymphatic drainage of rectum

16. Lymphatic drainage of anus

17. Nerve supply of the rectum
Sympathetic L1-3
Parasympathetic S2-4 (nervi ergentes)
The hypogastric plexus
Pelvic plexus

18. Nerve supply of the anus
Pudendal nerve (S2-4)
Sensory; internal pudendal
Motor
Internal sphincter; sympathetic & parasympathetic
External sphincter; inferior rectal branch of internal pudendal n, perineal branch of S4

19. Nerve supply

20. Physiology of defecation
Reflex
Sensation; receptive relaxation of the rectum, anal sampling, rectoanal reflex
Center; S2-4, cortical
Effectors; sphincters, rectal contraction, abdominal muscles, levator

21. Physiology of defecation

22. Continence mechanism Sensory function; proprioception, touch
Rectal reservoir function
Internal sphincter; involuntary, resting tone
External sphincter; voluntary, squeeze pressure
Levator ani
Anorectal angle
Anal cushions

23. Anal incontinence types
Major; solid feces
Minor; gas, liquid stools, night soiling

24. Anal incontinence Causes
Structural damage;
Rectal disease
Sphincter injury; birth trauma , surgery ….
Neurologic ;
Idiopathic

25. Anal incontinence diagnosis
History
Rectal examination; tone, squeeze pressure , soilage, ….
Endoscopy
Endoanal U/S
Manometry
Nerve studies

26. Endoanal Ultrasonography

27. Anal incontinence Treatment
Diet and drugs
Biofeedback
Sphincteroplasty
Gracilis flap ± electrical stimulator
Sacral nerve stimulation= neuromodulation
Artificial anal sphincter
colostomy

28. Sphincteroplasty

29. Artificial anal sphincter