The Importance of Puborectalis Muscle in Pelvic Floor Dysfunctions

Öz

The pelvic floor is a musculofascial unit with synergistic and antagonistic activity. The pelvic floor muscles are a subset of the pelvic floor and an integral part of its functionality. The puborectalis muscle, an important component of this system, plays a critical role, particularly in maintaining continence and supporting the rectum. It determines the anorectal angle and facilitates the passage of feces by relaxing during defecation. Pathology in any of the anterior, middle or posterior compartments of the pelvic floor muscles can cause pelvic floor dysfunction (PFD) associated with lower urinary tract and bowel symptoms. The puborectalis muscle, which is usually associated with posterior compartment dysfunction, can in some cases exhibit paradoxical contractions, causing problems such as urgency, constipation and faecal incontinence. Increased thickness of the puborectalis muscle has been reported in patients with deep infiltrating endometriosis. Puborectal muscle thickness and function may be an important variable to consider in PFD. Accurate assessment of this muscle may increase the effectiveness of pelvic floor physiotherapy, which is the first-line treatment option in PFD. In order to shed light on current approaches to pelvic floor physiotherapy, we wanted to highlight the role and importance of the puborectalis muscle in intercompartmental pathologies.

Anahtar Kelimeler

• Pelvic floor
• pelvic floor disorders
• pelvis.

Pelvik Taban Disfonksiyonlarında Puborektalis Kasının Önemi

Öz

Pelvik taban, sinerjistik ve antagonistik aktivite gösteren muskulofasyal bir birimdir. Pelvik taban kasları, pelvik tabanın alt kümesi olup fonksiyonelliğin ayrılmaz bir parçasıdır. Bu sistemin önemli bir bileşeni olan puborektalis kası, özellikle kontinansın korunması ve rektumun desteklenmesi açısından kritik bir rol oynamaktadır. Anorektal açı üzerinde belirleyici bir etkiye sahiptir ve defekasyon sırasında gevşeyerek dışkı geçişini kolaylaştırmaktadır. Pelvik taban kaslarının anterior, orta veya posterior kompartmanlarından herhangi birinde oluşan bir patoloji alt üriner sistem ve bağırsak semptomlarıyla ilişkili pelvik taban disfonksiyonlarına (PTD) neden olabilir. Genellikle posterior kompartman disfonksiyonlarıyla ilişkilendirilen puborektalis kası, bazı durumlarda paradoksal kontraksiyonlar göstererek aciliyet hissi, konstipasyon ve fekal inkontinans gibi problemlere neden olabilir. Derin infiltre endometriozis hastalarında puborektalis kas kalınlığında artış bildirilmiştir. Puborektalis kas kalınlığı ve fonksiyonelliği PTD’de göz önünde bulundurulması gereken önemli bir değişken olabilir. Bu kasın doğru şekilde değerlendirilmesi PTD’de birinci basamak tedavi seçeneği olan pelvik taban fizyoterapisinin etkinliğini arttırabilir. Pelvik taban fizyoterapisine yönelik güncel yaklaşımlara katkı sağlamak amacıyla, kompartmanlar arası patolojilerde puborektalis kasının konumu ve önemini vurgulamak hedeflenmiştir.

Anahtar Kelimeler

• Pelvik taban
• pelvik taban disfonksiyonları
• pelvis

Etik Beyan

Geçerli değil

Kaynakça

1. 1. Eickmeyer SM. Anatomy and Physiology of the Pelvic Floor. Phys Med Rehabil Clin N Am. 2017;28:455–60.
2. 2. Muro S, Akita K. Pelvic floor and perineal muscles: a dynamic coordination between skeletal and smooth muscles on pelvic floor stabilization. Anat Sci Int. 2023;98:407–25.
3. 3. Siccardi MA, Valle C. Anatomy, Bony Pelvis and Lower Limb: Pelvic Fascia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 [updated 2025 Jan].
4. 4. Roch M, Gaudreault N, Cyr MP, Venne G, Bureau NJ, Morin M. The female pelvic floor fascia anatomy: a systematic search and review. Life (Basel). 2021;11:1007.
5. 5. Andromanakos N, Filippou D, Karandreas N, Kostakis A. Puborectalis muscle and external anal sphincter: a functional unit? Turk J Gastroenterol. 2020;31:342–3.
6. 6. Quaghebeur J, Petros P, Wyndaele JJ, De Wachter S. Pelvic-floor function, dysfunction, and treatment. Eur J Obstet Gynecol Reprod Biol. 2021;265:143–9.
7. 7. Bø K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the conservative and nonpharmacological management of female pelvic floor dysfunction. Int Urogynecol J. 2017;28(2):191–213.
8. 8. Payne I, Grimm LM. Functional disorders of constipation: paradoxical puborectalis contraction and increased perineal descent. Clin Colon Rectal Surg. 2017;30(1):22–9.

9. 9. Grob ATM, Hitschrich N, van de Waarsenburg MK, Withagen MIJ, Schweitzer KJ, van der Vaart CH. Changes in global strain of puborectalis muscle during pregnancy and postpartum. Ultrasound Obstet Gynecol. 2018;51(4):537–42.
10. 10. Rossetti SR. Functional anatomy of pelvic floor. Arch Ital Urol Androl. 2016;88:28–37.
11. 11. Wein AJ. Re: Update of the Integral Theory and System for management of pelvic floor dysfunction in females. J Urol. 2020;203:667–9.
12. 12. Barton A, Serrao C, Thompson J, Briffa K. Transabdominal ultrasound to assess pelvic floor muscle performance during abdominal curl in exercising women. Int Urogynecol J. 2015;26(12):1789–95.
13. 13. Harm-Ernandes I, Boyle V, Hartmann D, Fitzgerald CM, Lowder JL, Kotarinos R, et al. Assessment of the pelvic floor and associated musculoskeletal system: guide for medical practitioners. Female Pelvic Med Reconstr Surg. 2021;27(12):711–8.
14. 14. Park H, Han D. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. J Phys Ther Sci. 2015;27(7):2113–5.
15. 15. Verbeek M, Hayward L. Pelvic floor dysfunction and its effect on quality of sexual life. Sex Med Rev. 2019;7(4):559–64.
16. 16. Tim S, Mazur-Bialy AI. The most common functional disorders and factors affecting female pelvic floor. Life (Basel). 2021;11:1300.
17. 17. Welk B, Baverstock R. Is there a link between back pain and urinary symptoms? Neurourol Urodyn. 2020;39(2):523–32.
18. 18. Emerich Gordon K, Reed O. The role of the pelvic floor in respiration: a multidisciplinary literature review. J Voice. 2020;34(2):243–9.
19. 19. Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: a randomized controlled trial. Medicine (Baltimore). 2021;100(1):e24158.
20. 20. Petros P. The Integral System. Cent European J Urol. 2011;64:110–9.
21. 21. Nambiar AK, Arlandis S, Bø K, Cobussen-Boekhorst H, Costantini E, de Heide M, et al. European Association of Urology Guidelines on the diagnosis and management of female non-neurogenic lower urinary tract symptoms. Part 1: Diagnostics, overactive bladder, stress urinary incontinence, and mixed urinary incontinence. Eur Urol. 2022;82(1):49–59.
22. 22. Hodges PW, Sapsford R, Pengel LHM. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362–71.
23. 23. Mittal, R. K., & Tuttle, L. J. (2022). Anorectal Anatomy and Function. Gastroenterology clinics of North America, 51(1), 1–23.
24. 24. van den Noort F, Grob ATM, Slump CH, van der Vaart CH, van Stralen M. Automatic segmentation of puborectalis muscle on three-dimensional transperineal ultrasound. Ultrasound Obstet Gynecol. 2018;52(1):97–102.
25. 25. Pecchio S, Mancarella M, Fuso L, Menato G, Biglia N, Liban Mariani L. Ultrasound functional evaluation of the puborectalis muscle and anal sphincter apparatus in patients with deep infiltrating endometriosis. Gynecol Reprod Endocrinol Metab. 2022;4:45–51.
26. 26. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic floor physical therapy for pelvic floor hypertonicity: a systematic review of treatment efficacy. Sex Med Rev. 2022;10:209–30.
27. 27. Kenne KA, Wendt L, Brooks Jackson J. Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors. Sci Rep. 2022;12(1):20896.
28. 28. Banihashem S, Chalakinia N, Eslami P, et al. Impact of biofeedback therapy for pelvic floor-related constipation to improve sexual function. Gastroenterol Hepatol Bed Bench. 2020;13(Suppl1):S75-S80.
29. 29. Bjørsum-Meyer T, Christensen P, Baatrup G, Jakobsen MS, Asmussen J, Qvist N. Dyssynergic patterns of defecation in constipated adolescents and young adults with anorectal malformations. Sci Rep. 2020;10(1):22047.
30. 30. Das S, Hansen HHG, Hendriks GAGM, van den Noort F, Manzini C, van der Vaart CH, et al. 3D ultrasound strain imaging of puborectalis muscle. Ultrasound Med Biol. 2021;47(3):569–81.
31. 31. Manzini C, van den Noort F, Grob ATM, Withagen MIJ, van der Vaart CH. The effect of pessary treatment on puborectalis muscle function. Int Urogynecol J. 2021;32(10):2667–76.
32. 32. Hagovska M, Svihra J, Urdzik P. Predictive value of pelvic floor muscle morphometry using 3D/4D ultrasound in relation to the success of pelvic floor muscle training in women with stress urinary incontinence. Int J Environ Res Public Health. 2022;19(22):14909.
33. 33. Padoa A, McLean L, Morin M, Vandyken C. The overactive pelvic floor and sexual dysfunction. Part 2: Evaluation and treatment of sexual dysfunction in OPF patients. Sex Med Rev. 2021;9(1):76–92.
34. 34. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):680–91.
35. 35. MacCraith E, O’Brien FJ, Davis NF. Biodegradable materials for surgical management of stress urinary incontinence: a narrative review. Eur J Obstet Gynecol Reprod Biol. 2021;259:153–60.