Mechanism
Defecation is a complex process that involves an intricate interaction between anal function and sensation, rectal
compliance, stool consistency, stool volume, colonic transit, and mental alertness. An alteration in any of these
can lead to incontinence.
A large component of continence is the function of the anal sphincter complex. It consists of the internal anal
sphincter (IAS) muscle, the external anal sphincter (EAS) muscle, and the puborectalis (PR). The smooth
muscle of the IAS is innervated by the autonomic nervous system. The IAS is responsible for more than half of
the resting tone. The striated muscle of the EAS is innervated by the inferior branch of the pudendal nerve and is
responsible for about a third of the resting tone. Defecation is a result of voluntary relaxation of the EAS and PR
that are innervated by the S3 to S4 nerves in response to rectal distension that is dictated by receptors in the
pelvic floor and the anal transition zone.
Normal defecation and anal continence are complex processes that require: (1) a competent anal sphincter complex, (2)
normal
anorectal sensation, (3) adequate rectal capacity and compliance, and (4) conscious control.
The internal anal sphincter (IAS) and provides 70 to 85 percent of the anal canal's resting pressure (Frenckner, 1975). As a
result, the IAS contributes substantially to the maintenance of fecal continence at rest.
The external anal sphincter (EAS) The EAS provides the anal canal's squeeze pres- sure and is mainly responsible for
maintaining fecal continence when continence is threatened
In addition, although resting sphincter tone is gener- ally attributed to the IAS, the EAS maintains a constant state of resting
contraction and may be responsible for approximately 25 percent of the anal canal's resting pressure. During defeca- tion,
however, the EAS relaxes to allow stool passage.
The puborectalis muscle is. Its constant tone contributes to the anorectal angle, which aids in preventing rectal contents from
entering the anus (Fig. 38-10, p. 800). Similar to the EAS, this muscle can be contracted voluntarily or in response to sudden
increases in abdominal pressure.
Innervation to the rectum and anus
floor muscles can detect the presence ofstool in the rectum and the degree ofdistention. Througb these neural
pathways, information regarding rectal distention and contents are transmitted and processed. With this,
sphincter action can be coordinated.
The rectoanal inhibitory reilex (RAIR) refers to the transient relaxation of the IAS and contraction ofEAS
induced by rectal distention when stool first arrives in the rectum. This rdlex is
mediated by the intrinsic nerves in the rectoanal wall and allows the sensory-rich upper anal canal to come in
contact with or "sample" the rectal contents {Whitehead, 1987). Specifically, the IAS relaxes t o allow the
anal epithelium to ascertain whether rectal contents are gas. liquid, or solid stools (Miller, 1988).
Following integration of this neural infonnation, defu:a- tion a n ensue in the appropriate social setting.
.Alternatively, i f .required, defu:ation can generally be postponed, as the rectum can accommodate its contents
and the EAS or [Link] mus- cle or both can be voluntarily contracted.
the rectum can relax to admit the increased rectal volwne in a process known as acc(l'lllmot/atirm. The
rectum is a highly compliant reservoir that permits stool storage. At. rectal volwne rises, an urge to
defecate is perceived. I f this urge is volwuarily suppressed, the rectum relaxes to con- tinue stool
accommodation. A loss o f rectal compliance may decrease the ability of the rectal wall to stretch or
accommo- date, and as a teSult, rectal pressure may remain high. [Link] may place greater demands on the
other components of the conti- nence mechaniAm such as the anal sphincter complex
conti- nence is an acquired capacity to suppress the natural urge to defecate