[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anatomy](https://durgical.com/en/anatomy/) › [Pelvis](https://durgical.com/en/anatomy/region/pelvis/) › Puborectalis [Muscular system](https://durgical.com/en/anatomy/system/muscular-system/) · [Pelvis](https://durgical.com/en/anatomy/region/pelvis/) # Puborectalis The puborectalis is a U-shaped sling of the pelvic floor around the [rectum](https://durgical.com/en/anatomy/rectum/); it bends the rectum forward to hold stool in and relaxes to let it out. [See in 3D →](https://durgical.app/?from=durgipedia&lang=en#region=pelvis&select=puborectalis&side=r) Opens in the Durgical app, no sign-up needed. ## What it is A U-shaped sling from the pubic bone around the back of the rectum. ## What it does Pulls the rectum forward to make a bend that keeps stool in; it relaxes to let the bowel empty. It can be torn off the bone in a difficult birth (levator avulsion). ## Key points - Its sling pulls the anorectal junction towards the pubis, creating the anorectal angle; the angle sharpens when it contracts and opens when it relaxes to let stool pass - With the deep external anal sphincter and the upper internal anal sphincter it forms the anorectal ring, felt on rectal examination; cutting this ring in fistula surgery causes incontinence - Lowest, innermost part of the levator complex, below the pubococcygeus; unlike the rest of the [levator ani](https://durgical.com/en/anatomy/levator-ani/), its fibres do not reach the [coccyx](https://durgical.com/en/anatomy/coccyx/) ## Key facts **Origin** Back of the body of the pubis, either side of the symphysis **Insertion** Loops behind the anorectal junction to the opposite side (U-shaped sling) **Action** Pulls the anorectal junction forward (anorectal angle about 90°); faecal continence; relaxes for defecation **Nerve** Nerve to levator ani (S3–S4) and [pudendal nerve](https://durgical.com/en/anatomy/pudendal-nerve/) (S2–S4) branches **Blood supply** Inferior rectal and internal pudendal arteries ## Relations **In front** Back of the pubis either side of the [pubic symphysis](https://durgical.com/en/anatomy/pubic-symphysis/); between its two limbs run the urethra and, in women, the [vagina](https://durgical.com/en/anatomy/vagina/) **Behind** Loops behind the anorectal junction, where it is felt as a ridge on rectal examination **Above** [Pubococcygeus](https://durgical.com/en/anatomy/pubococcygeus-muscle/), lying above and lateral to it **Below** Deep part of the [external anal sphincter](https://durgical.com/en/anatomy/external-anal-sphincter/), with which it blends **Lateral** [Obturator internus](https://durgical.com/en/anatomy/obturator-internus/) fascia and the anterior part of the ischioanal fossa ## How to find it On digital rectal examination it is felt as a firm sling on the back wall at the top of the [anal canal](https://durgical.com/en/anatomy/anal-canal/). When the person squeezes, the finger is pulled forward towards the pubis; when the person bears down, the sling should relax and descend. ## Examination - Rectal examination with squeeze and push: the sling should relax on straining; paradoxical tightening suggests dyssynergic defecation (anismus) - Palpation of its pubic attachment on vaginal examination: a gap or missing muscle beside the pubis suggests levator avulsion ## On imaging 3D/4D transperineal ultrasound shows the levator hiatus in the axial plane and the muscle's attachment to the pubis (avulsion, an overstretched or «ballooning» hiatus). Dynamic MR or X-ray defecography measures the anorectal angle at rest, on squeezing and on straining. ## Common problems - Stretching or tearing in vaginal birth. - Pelvic organ prolapse. - Urinary or faecal incontinence. - Overactive, painful pelvic floor (pain with sex, pelvic pain). ## How it is diagnosed Pelvic examination, sometimes ultrasound or MRI of the pelvic floor. ## Treatment - Pelvic floor muscle training (Kegel exercises) with a physiotherapist. - A pessary (a removable support placed in the vagina). - Surgery for prolapse that bothers the person. ## Clinical notes - Levator avulsion after vaginal birth, most often with forceps and in the first birth, is linked to later pelvic organ prolapse - In dyssynergic defecation the sling fails to relax, the angle stays closed and emptying is obstructed; biofeedback training is one approach described - Obstetric anal sphincter injury and puborectalis damage often occur together, adding to the risk of faecal incontinence ## Anatomical variants - Some texts count it as part of the external anal sphincter complex rather than the levator ani; it tends to thin with age ## Development In anorectal malformations (imperforate anus) the level at which the rectal pouch ends relative to this sling guides the repair and the outlook for continence; in the posterior sagittal repair the rectum is brought down inside the sling and the sphincter muscles. ## Related conditions - [Anorectal abscess and fistula](https://durgical.com/en/conditions/anorectal-abscess-and-fistula/) - [Rectal prolapse](https://durgical.com/en/conditions/rectal-prolapse/) - [Fecal incontinence](https://durgical.com/en/conditions/fecal-incontinence/) ## Test yourself Think of the answer, then tap the question to see it. ## What angle does the puborectalis create, and how does it change with contraction and relaxation? The anorectal angle: it sharpens when the puborectalis contracts and opens when it relaxes to let stool pass. ## Which structures form the anorectal ring, and why does it matter in fistula surgery? Puborectalis, deep external anal sphincter and upper internal anal sphincter; cutting this ring causes incontinence. ## On rectal examination with squeeze and push, what finding suggests dyssynergic defecation? Paradoxical tightening of the puborectalis on straining instead of relaxation and descent. ## How does the puborectalis differ from the rest of the levator ani in its attachments? It loops behind the anorectal junction as a sling from the pubis; its fibres do not reach the coccyx. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anatomy/puborectalis/) Educational information, not medical advice. For any symptom, see a health professional. ## Its names **Official Latin (TA2)** musculus puboanalis TA2 2406 **Official Spanish (DeCS)** Músculo puboanal DeCS D017773 **English (TA2)** Puborectalis **Also called** puborectalis muscle ## Related - [Pubococcygeus](https://durgical.com/en/anatomy/pubococcygeus-muscle/) Sources: Terminologia Anatomica (TA2); [DeCS](https://decs.bvsalud.org/es/ths/resource/?id=31203&filter=ths_termall&q=Diafragma%20P%C3%A9lvico); [Anatomy, Abdomen and Pelvis: Levator Ani Muscle](https://www.ncbi.nlm.nih.gov/books/NBK556078/); [Anatomy, Abdomen and Pelvis: Pelvic Floor](https://www.ncbi.nlm.nih.gov/books/NBK482200/). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/anatomy/puborectalis/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anatomy/puborectalis/