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© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
D. Z. Bliss (ed.), Management of Fecal Incontinence for the Advanced Practice
Nurse, https://doi.org/10.1007/978-3-031-94526-7_4
4
Normal Defecation andMechanisms
forContinence
MônicaMilinkovicde la Quintana
,
Talitados SantosRosa
, GiselaMariaAssis
,
MariaHelenaBaenade MoraesLopes
,
andVeraLúciaConceiçãode GouveiaSantos
Abstract
The mechanism of fecal continence is a complex process, composed of a series
of events, which are inuenced by the consistency, volume, and speed with
which the fecal material reaches the rectum; the sensitivity and distensibility of
the rectum vault, and factors related to the sphincter muscles, which involve
sensorial and mechanical components that require muscular and nervous integ-
rity. The defecatory mechanism is complex and involves a sequence of events
that integrates smooth and striated muscle and the central, somatic, autonomic,
and enteric nervous systems. Normal defecation involves the rapid, semi-
voluntary emptying of the rectum and a variable part of the colon and requires a
high degree of coordination to achieve the evacuation of solid or semi-solid
Chapter author from the rst edition of this book:
Tania das Graças de Souza Lima, University of Rio de Janeiro, Rio de Janeiro, BR.
M. M. de la Quintana
Rehabilitation Nurse, São Paulo, Brazil
T. dos SantosRosa · V. L. C. de GouveiaSantos (*)
School of Nursing, University of São Paulo, São Paulo, Sao Paulo, Brazil
e-mail: veras@usp.br
G. M. Assis
Department of Maternal, Child and Psychiatric Nursing, University of Sao Paulo,
Sao Paulo, Brazil
e-mail: gisela.assis@usp.br
M. H. B. de MoraesLopes
School of Nursing, University of Campinas, São Paulo, Sao Paulo, Brazil
e-mail: mhbaena@unicamp.br
60
feces. In this chapter, the anatomical and physiological components of the ano-
rectal portion of the gastrointestinal tract will be explained, according to their
relevance to maintain continence.
4.1 Introduction
Fecal continence is a complex and essential function of the digestive system, which
involves multiple mechanisms: the transport of fecal material, the ability to delay
defecation to a socially appropriate location and moment, and the defecation of the
body’s wastes [1]. There are anatomical structures and physiological conditions,
such as the coordination of voluntary and involuntary mechanisms in the colon,
pelvic oor, and anorectal region, involving the internal and external anal sphinc-
ters, puborectalis muscle, and cyclic motor patterns in the sigmoid and rectum and
neural pathways, which together maintain continence under varying conditions [2].
These functions transform liquid intestinal contents into soft or pasty stools and
transport fecal matter through the colon to the rectum, where it is stored until the
desire for defecation is triggered through sensory and reex mechanisms [1].
Defecation is voluntarily delayed until an appropriate socio-environmental situ-
ation allows for that. All this activity with involuntary and conscious components is
highly complex and can lead to multiple forms of fecal incontinence when one or
more of these components fail. For many people suffering from anorectal diseases,
fecal continence represents a “challenge” rather than a daily physiological act in
their lives [1–3]. This chapter describes defecation physiology and the structures
responsible for maintaining it.
4.2 Anatomical Structures
4.2.1 Rectum
The rectum is a muscular tube measuring 12–15cm and serves to store the feces that
arrive from the sigmoid colon. Its muscle arrangement allows it to function both as
a reservoir, being able to accommodate passive distension, and as a stool propel-
lant [4].
Rectal capacity is a parameter reecting the overall size of the reservoir, whereby
a more spacious reservoir allows for the storage of more stool [4]. Rectal compli-
ance is a parameter reecting the distensibility of the rectal wall, i.e., the ratio of a
change in volume to a change in pressure (∆volume/ ∆pressure) [4]. The compli-
ance and hence the capacity of the rectum are related to produce the defecation. As
rectal distension increases, rectal compliance falls. The rectum tolerates volumes up
to about 300ml without showing any marked change in intraluminal pressure [5].
The ability of the rectum to passively accommodate distension during transient
sudden increases in intra-rectal pressure contributes to the maintenance of pressure
M. M. de la Quintana et al.
61
levels relatively lower than those of the anal canal. A compliant rectum, therefore,
is essential for maintaining continence [6] and changes in rectal compliance may
contribute to incontinence [7]. Rectal perception and adaptation to distension are
widely heterogeneous in people suffering from fecal incontinence [6, 8]. Some
studies show that rectal compliance is lower in incontinent patients [6, 9, 10], but
this nding was not conrmed by other studies [11, 12].
When rectal complacency is compromised, a small volume of feces can generate
a high intra-rectal pressure, which causes incontinence by overcoming anal resis-
tance [13]. In addition, a decrease in rectal capacity and the maximum tolerable
volume is directly related to the increase in defecation frequency and decrease in
continence, due to an increase in rectal pressure at lower volumes [13].
4.2.2 Anal Canal
The anal canal is understood to be the nal segment of the digestive system where
its physiological occlusion occurs due to the tonus of two concentric muscular cyl-
inders, namely: external anal sphincter and internal anal sphincter. At its upper end,
the muscular structure of the anal canal includes the innermost bundle of the levator
muscle of the anus, called the puborectal bundle, which relates directly to the upper
portion of the external anal sphincter muscle [14].
The anal mucosa is congured into folds with vascular cushions (expansions of
vascular tissue within the mucosa) that can expand to form a seal that aids in main-
taining resting anal tone and promoting continence [15, 16]. The anal vascular cush-
ions contribute to approximately 15% of the resting anal tone [15, 16].
The extension of the anal canal varies as a function of the individual tonicity as
the action of the musculature inuences it. Its function emphasizes the importance
of the participation of the puborectal bundle of the levator ani muscle. This bundle
is a main factor in maintaining continence through its anterior traction of the limit
of the anal canal. The length extension of 4cm for the anal canal can be described
as “normal,” from its lower end in the anal orice to its upper opening in the rectal
ampulla, but its length varies according to the individual’s age and sex [14].
4.3 The Pelvic Floor andtheSphincter Apparatus
The set of muscular structures that act in the anorectal region is composed of four
muscles related to each other [14]:
• Levator ani muscle
• Internal anal sphincter
• External anal sphincter
• Longitudinal anal muscle
4 Normal Defecation andMechanisms forContinence
62
4.3.1 Levator Ani Muscle
The pelvic diaphragm is comprised of two muscles that occlude the inferior opening
of the bony pelvis: the levator ani muscle and the coccygeus muscle, the latter with
no relevant function in fecal continence. The levator ani muscle is the main muscle
responsible for the support of the rectum and for assisting in fecal continence [17].
The levator ani muscle is funnel-shaped, with an anterior funnel. On its posterior
inner surface rests the rectum, extending from the coccyx to its inferior opening in
the anal canal. The levator ani muscle is composed of three distinct bundles: two
acting on the rectum support, like a net, anchored in an anteroposterior insertion on
the fascia of the internal obturator muscle, by means of a structure described as the
tendinous arch [18].
These bundles are described as the ileococcygeus muscle posteriorly, and the
pubococcygeus anteriorly. The third bundle, called puborectalis muscle, is located
inferiorly to the two bundles described and contributes to the squeeze in the proxi-
mal part of the anal canal, while external anal sphincter exerts continence mecha-
nism in the distal anal canal [16]. It has a muscular handle shape with bilateral
anterior insertions on the posterior surface of the pubis, with its posterior arch fac-
ing the anal canal, where it fuses with the upper extremity of the external anal
sphincter. Its contraction in conjunction with the external anal sphincter exerts
anterosuperior traction, causing angulation between the rectum and the anal canal,
which is named anorectal angle [18, 19] (see Figs.4.1 and 4.2).
The anorectal angle is formed by the longitudinal axis of the anal canal and the
posterior wall of the rectum. It presents around 90°, under normal resting condi-
tions, whereas with voluntary squeeze of the external anal sphincter and puborecta-
lis muscle, the angle becomes more acute (70°) in order to close off the anal canal
and maintain continence. The angle becomes more obtuse (110 a 130°) during def-
ecation, through the relaxation of puborectal and pelvic oor muscles, resulting in
alignment of the rectum with respect to the anal canal [7] (see Fig.4.2).
4.3.2 Internal Anal Sphincter Muscle
The internal anal sphincter is a circular muscle, located externally of the submucosa
of the anal canal. It is formed by a caudal continuity of the inner circular layer of the
Fig. 4.1 Pelvic oor containing the pelvic muscles and ligaments. (Use authorized by Dr. Afonso
Henrique da Silva e Sousa Jr. and Dr. Ilario Froehner Junior)
M. M. de la Quintana et al.