Pelvic Floor Images: Anatomy

of the Levator Ani Muscle

Maolin Guo, M.B., Dawei Li, M.B.
Department of Radiology, Dalian University Hospital, Dalian, China
PURPOSE: The levator ani has been divided into many
functional portions based on necropic observation. Our
objective was to use a combination of CT and magnetic
resonance images to showa complete levator ani. METHODS:
Normal magnetic resonance images of the pelvis were
obtained at rest in 22 volunteers while in the lying position
(10 males, aged 2123 yr). The pelvic floor images of ten
cadavers (5 males) were obtained while in the supine
position by CT. Source magnetic resonance images were
used to measure the heights of the transverse portion of the
levator ani and the area of the genital hiatus. Source
magnetic resonance images and CT reconstructed images
were used to study the anatomy of the levator ani. RESULTS:
The levator ani had a transverse portion and a vertical
portion. The anterior transverse portion was found to be
basin-shaped, the middle transverse portion was funnel-
shaped, and the posterior transverse portion was dome-
shaped. The transverse portion sloped sharply downward to
form the vertical portion at the puborectalis plane. The
vertical portion was a muscular tube outside the intrahiatal
structures. The puborectalis was a u-shaped muscle outside
the vertical portion. One case of the deep transverse
perineal muscle was found in 22 volunteers. The volume
of the ischioanal fossa influenced the anatomic appearance
of the pelvic floor in cadavers. CONCLUSIONS: The
transverse portion of the levator ani has five kinds of shapes
in the different-coronal sections of the pelvis, which changes
from basin to dome in a lying position. The puborectalis is
outside the vertical portion and not part of the levator ani.
[Key words: Levator ani; Puborectalis; Anatomy; Magnetic
resonance imaging; Computed tomography]
I
n the last decades, there has been much discussion
about the anatomy of the levator ani. The levator
ani has been most often characterized as a basin-
shaped muscle, although this has been disputed by
many radiologists. The levator ani has been described
as a dome-shaped muscle
1,2
and the iliococcygeus as
a convex muscle.
3
The puborectalis has been charac-
terized in the literature as both a major component of
the levator ani
35
and not a component of the levator
ani.
6
More detailed imaging studies were needed to
clarify the anatomy. Our objective was to use a
combination of CT and magnetic resonance imaging
(MRI) to show a complete levator ani and define its
anatomic appearance and components.
SUBJECTS AND METHODS
We recruited 22 students: 12 nulliparous females
and 10 males (aged 2123 years), without pelvic floor
or defecation dysfunction. After discussion of the
possible risks and benefits, informed consent was
obtained from all the volunteers before examination.
Subjects were asked to empty their bladder before the
study. Before imaging, 200 ml of Vaseline was injected
into the rectum and a plastic tube with a diameter of
4 mm was inserted in the anal canal in six volunteers,
and a body coil was wrapped around the pelvis. All
volunteers underwent MRI of the pelvis at rest by using
a 1.5 T magnet (PHILIPS Intera Achieva 1.5 T). MRI
was performed by using standard pulse sequences.
Standard two-dimensional T1-weighted turbo SE
MRI were obtained in the coronal, midsagittal, and
anal axial sections with the following imaging
parameters: TR/TE
eff
, 1,3001,500/18; phase en-
codes, 320; field of view, 375-400 mm; slice thick-
ness, 3 mm interleaved. The puborectalis section was
confirmed by MRI to link the lower pubic symphysis
and the anorectal junction in the midsagittal image.
PDW turbo SE MRI were obtained in the puborectalis
section, TR/TE
eff
, 2000/14; phase encodes, 205; field
Correspondence to: Maolin Guo, M.B., Department of Radiology,
Dalian University Hospital, Dalian, China, e-mail: maolinguo@163.com
Dis Colon Rectum 2007; 50: 16471655
DOI: 10.1007/s10350-007-0262-1
* The American Society of Colon and Rectal Surgeons
Published online: 16 August 2007
1647
of view, 180 mm; slice thickness, 3 mm interleaved.
After the MRI was complete, the images were
electronically transferred to a workstation. Source
images were used to measure the heights of trans-
verse portion (TP), the area of the genital hiatus, etc.
Ten cadavers underwent CT imaging of the pelvis
by using a multislice spiral CT (PHILIPS Brilliance
16). CT scan parameters: tube voltage, 120 kV; tube
current, 200 mAs; slice thickness, 1 mm; alternation,
0.5 mm; pitch, 1; matrix, 512. All cadavers had
transverse scans; source CT images were sent to a
workstation (PHILIPS Brilliance 2.0), and the multi-
planar reconstructed images were reformed based on
transverse scan. CT reconstructed parameters were as
follows: slice thickness, 3 mm; alternation, 3 mm.
Image Analysis
One experienced radiologist (DL) evaluated the
images by using a Viewforum 2003 for a MRI
workstation (PHILIPS Medical Systems); two radiol-
ogists (MG, DL) reviewed each case in consensus.
The source coronal MRI was used to analyze the
shape of the TP at the bladder neck, vagina, anal
canal, ischial spine, and postanal section. The heights
of the TP were measured with electronic calipers in
the ischial spine section, including the outer, medial,
and inner three points; the baseline of the heights
was the line between the bilateral ischial tuberosity.
The sectional shape of the TP was estimated on
each coronal section as follows, and the varying
anatomic appearance of the TP was classified
according to the following five shapes:
1. Basin: If the mid point of the TP is below the
line between the outer and inner point, the TP will
be concave; the bilateral TP will form one basin
when viewed from above (Fig. 1A).
2. Funnel: If the three points are in a line and the
outer point is higher than the inner point, the TP will
Figure 1. Coronal T1-weighted turbo SEMRI (TR/TEeff, 1300-500/18; phase encodes, 320; field of view, 400 mm; A, B, C, D
obtained in the bladder neck, vagina, anal canal and postanal section) depicts the TPchanges shape frombasin to dome; the
bilateral TP form one basin in A, one funnel in B, two paradomes in C, two domes in D. A = anal canal; Acl = anococcygeal
ligament; B = bladder; Es = external anal sphincter; If =ischioanal fossa; Iom=internal obturator muscle; TP = transverse
portion; Pr = puborectalis; Spm = superficial transverse perineal muscle; V = vagina; VP = vertical portion.
1648 GUO AND LI Dis Colon Rectum, October 2007
be concave; the bilateral TP will form one funnel
when viewed from above (Fig. 1B).
3. Plate: The three points are in the same plane.
4. Paradomes: The height of the outer point Q the
midpoint > the inner point, and the mid point is
above the line of the outer and inner point (Fig. 2A).
5. Domes: If the mid point is the highest of the
three measurements, the TP will be convex; the
bilateral TP will form two domes when viewed from
below (Fig. 2B).
The midsagittal and anal axial coronal sections
were used to analyze the anatomic appearance of the
vertical portion (VP). The puborectalis section was
used to determine the width, length, and area of the
genital hiatus; we used the measurement of the
largest portion of the genital hiatus.
Statistical Analyses
Using two independent samples and a t-test
(SPSS
\
12.0 for Windows; SPSS Inc., Chicago, IL);
we assessed sex-related differences in measurements.
P < 0.05 was considered to indicate statistical
significance.
RESULTS
High-quality magnetic resonance images (MRIs)
were obtained in all 22 volunteers. It was found that
the levator ani has a transverse portion and a vertical
portion.
Transverse Portion of the Levator Ani
Figure 1 shows the shape of the TP on T1-weighted
turbo SE images in the coronal plane. Figure 1A is the
bladder neck section. The TP consists of the pubo-
coccygeus in this section. The pubococcygeus and the
puborectalis are between the bladder and the internal
obturator muscle; the two muscles form an oblique,
thin line with low signal intensity, and the pubococ-
cygeus is suspended atop the latter. In this section, the
bilateral TP form one basin.
Figure 1B is the vaginal section. The TP consists of
the pubococcygeus and iliococcygeus in this section.
The TP is a thick muscle outside the vagina and
inside the ischioanal fossa. In this section, the
bilateral TP form one funnel, and the puborectalis is
outside the neck of the funnel.
Figure 1C is the anal canal section. The TP consists
of the iliococcygeus in this section. The TP is above
the ischioanal fossa; the anal sphincters are inside the
ischioanal fossa; and the internal obturator muscle is
outside the ischioanal fossa. In this section, the
bilateral TP form two paradomes.
Figure 1D is the postanal section. The TP consists
of the coccygeus in this section. The TP is still above
the ischioanal fossa; the TP forms two domes. The
anococcygeal ligament is between the two domes.
Figure 2. T1-weighted turbo SE MRI (TR/TEeff, 1300-
500/18; phase encodes, 320; field of view, 400 mm; A-
male, B-female, obtained in the ischial spine section)
depicts the differences of the transverse portion between
genders: two paradomes in male, and two domes in
female.
Vol. 50, No. 10 THE PUBORECTALIS IS NOT ITS COMPONENT 1649
Figure 2 depicts the difference in the shape of the
TP between males and females at the ischial spine
section. The TP is two paradomes in 9 of 10 males
and two domes in 12 of 12 females and in 1 of
10 males. For the other sections, the anatomic
appearance of the TP was similar at the same section
between males and females; no marked difference
was found between genders.
Figure 1 shows that the transverse portion is above
the ischioanal fossa and changes shape from basin to
dome. Figure 2 reveals the differences in the TP
between males and females.
Vertical Portion of the Levator Ani
Figure 3 shows the anatomic appearance of the VP
on T1-weighted turbo SE images in the anal axial
coronal section and midsagittal section.
Figure 3A shows how the muscle bundles of the
TP slope sharply downward to form the VP. The
puborectalis and the external anal sphincter are
outside the VP; the internal anal sphincter is inside
the VP.
Figure 3B shows the puborectalis pulls forward
the anococcygeal ligament
7
(Acl, one part of the TP)
and the longitudinal muscle
8
(Lm, one part of the
VP) to form an angle; we named it the Acl-Lm angle.
The anorectal angle
9
(ARA) is in front of the Acl-Lm
angle.
Genital Hiatus
Figure 4 depicts the genital hiatus at the pubo-
rectalis and pubovaginalis plane, not at the horizon-
tal plane.
Figure 4A shows that the puborectalis is a u-
shaped (horseshoe-shaped) muscle outside the VP
and that the VP encloses the intrahiatal structures.
The area of the genital hiatus was measured in this
section.
Figure 4B shows the pubovaginalis, which is
below the puborectalis plane; the two planes are
approximately 3 mm apart.
Cadaver CT Images
The quality of the source CT images was good in
nine of ten (90 percent) and poor in one (10 percent).
The TP in four of nine cadavers was the same as
normal volunteers (Fig. 5A); the posterior of the TP
in four of nine cadavers was basin-shaped, its
ischioanal fossa was smaller than others, and the
pelvic floor did not descend (Figs. 5B and C); the TP
in one of nine cadavers was funnel-shaped.
In four of nine cadavers, there was air in the tissue
spaces and natural cavities; this made the anatomic
layers easier to recognize (Fig. 6).
Figure 3. T1-weighted turbo SE MRI (TR/TEeff, 1300-500/
18; phase encodes, 320; field of view, 400 mm; A-anal axial
coronal section, B-midsagittal section) depicts how the VP
continuous with the TP, the relationship between the Acl-
Lm angle and the anorectal angle. Acl = anococcygeal
ligament; Es = external anal sphincter; Is = internal anal
sphincter; Lm = longitudinal muscle; Pr = puborectalis; T =
plastic tube; TP = transverse portion; VP = vertical portion.
1650 GUO AND LI Dis Colon Rectum, October 2007
One Case of Deep Transverse
Perineal Muscle
Dorschner et al.
10
studied the deep transverse
perineal muscle in 50 males by necropsy observation
and 12 healthy patients by MRI expecting to find that
it does not exist. However, 1 female of 22 volunteers
had a seldom-seen muscle layer inside the anterior
pelvic floor. We reviewed all our images, including
CT images of 120 patients; only 1 in all 152 subjects
(0.66 percent) had this muscular layer. This muscular
layer, located between the TP (or the pelvic dia-
phragm) and the superficial transverse perineal
muscle, was attached to the inferior ramus of pubis,
converged on the two sides of vagina, inserted to the
ischioanal fossa, and separated the ischioanal fossa in
the coronal, transverse, and parasagittal sections
(Fig. 7). Based on those imaging features, we
concluded that the seldom-seen muscle layer is the
deep transverse perineal muscle.
MEASUREMENT
Table 1 shows the mean gender-related variations
in measurements. The pelvic outlet measurements
were significantly smaller in males than in females.
The TP was paradome-shaped in males and dome-
shaped in females at the ischial spine section. The
Figure 5. CT reconstructed images of three cadavers (A, B, C-ischial spine section) depicts the relationship between the
volume of the ischioanal fossa and the sectional shape of the transverse portion.
Figure 4. PDW turbo SE MRI (TR/TEeff, 2000/14; phase
encodes, 205; field of view, 180 mm; A-puborectalis
section, B-pubovaginalis section) depicts the anatomic
layers of the genital hiatus. A = anal canal; If = ischioanal
fossa; Iom = internal obturator muscle; Is = internal
sphincter; Pr = puborectalis; Pv = pubovaginalis; VP =
vertical portion.
R
Vol. 50, No. 10 THE PUBORECTALIS IS NOT ITS COMPONENT 1651
area measurements of the genital hiatus were signif-
icantly smaller in males than in females.
DISCUSSION
Levator Ani
Based on traditional ideas, the levator ani includes
the puborectalis, pubococcygeus, and iliococcy-
geus.
5
This old idea dates back to 1900; Holl et al.
considered the puborectalis to be part of the levator
ani.
4
However, Shafik
6
did not consider the pubo-
rectalis a component of the levator ani based on
necropic observation.
Images showed that there is a transverse muscular
layer above the ischioanal fossa, which includes
three major muscle bundles: pubococcygeus, iliococ-
cygeus, and coccygeus. These muscle bundles slope
sharply downward to form the vertical portion; the
puborectalis is below the transverse portion and
outside the vertical portion.
Based on imaging features, the three muscle
bundles form an indivisible layer of muscle; the
levator ani has a transverse portion and a vertical
portion, but the puborectalis is not part of these two
portions.
Transverse Portion
The anatomic appearance of the TP has been a
matter of discussion in previous studies; a variable
shape of the TP was reported by the authors.
13,6
Shafik
6
made sagittal, parasagittal, and coronal sec-
tions passing through the genital hiatus, and he
described the Blevator plate^ as funnel-shaped in
those sections. Hjartardottir et al.
2
reported that the
levator ani was dome-shaped at rest. Singh et al.
3
described the iliococcygeus as a thin muscle with an
upward convexity; it slopes forward and medially.
Figure 6. CT reconstructed images of two cadavers (A-anal axial coronal section, B-puborectalis section, C-midsagittal
section) depicts the anatomic layers with air in the tissue spaces. A = anal canal; If = ischioanal fossa; Iom = internal
obturator muscle; Pr = puborectalis; Pb = perineal body; U = urethra; Ut = uterus; V = vagina; VP = vertical portion.
Figure 7. Case report (A-vaginal coronal section, B-transverse section, C-parasagittal section) depicts the location and
appearance of the deep transverse perineal muscle. A = anal canal; Dpm = deep transverse perineal muscle; If =
ischioanal fossa; Spm = superficial transverse perineal muscle; TP = transverse portion; U = urethra; V = vagina.
1652 GUO AND LI Dis Colon Rectum, October 2007
In the volunteers, images showed the TP to be
basin-shaped in the bladder neck section, funnel-
shaped in vaginal section, paradome shaped in anal
section, and dome-shaped in the postanal section, so
that the shape changes from basin to dome. We must
stress that this evolution only can be seen with the
subjects in the supine position at rest. The ischial
spine section is a special section in which the TP
differs in shape between males and females; normal-
ly the TP consisted of two paradomes in males and
two domes in females. In cadavers, our images
showed the volume of the ischioanal fossa influ-
enced the shape of the TP. Therefore, the section,
gender, volume of the ischioanal fossa, and other
elements affect the shape of the TP.
Our studies indicated that the TP has a variable
shape in the different coronal sections of the pelvic
floor, which perhaps is the reason that different
shapes have been reported by authors.
Vertical Portion
The VP is continuous with the TP. It is an
important anatomic structure; its function is to
increase the size of the genital hiatus.
6
The anatomic
appearance of the VP has been detailed in studies by
many researchers. The VP is a muscular tube that
encloses the intrahiatal structures to form the inter-
mediate layer of the longitudinal muscle, which was
called the Bsuspensory sling^ or a tunnel Bdilator^ by
Shafik.
6
Rociu et al.
11
used endoanal MRI, including
an endoanal coil with a diameter of 19 mm, to assess
the anatomy of all sphincter muscles in 100 healthy
volunteers; the endoanal images especially had
shown the longitudinal muscle (one part of the VP)
clearly.
In our studies, the VP was observed in the anal
axial coronal and midsagittal images. We found that
it was possible to visualize the VP with a plastic tube
in the anal canal. The muscle bundles of the TP
slope sharply downward to form the VP. The
puborectalis and the external anal sphincter was
outside the VP, and the internal anal sphincter was
inside the VP.
Ischioanal Fossa
The ischioanal fossa is the biggest soft tissue
structure in the pelvic floor. Located between the
perianal skin and the pelvic diaphragm, its anterior
region becomes thinner until it converges on the
bladder anteriorly. The ischioanal fossa is filled with
adipose tissue and fibrous bands. The TP is above
the fossa, the VP and the anal sphincters are inside
the fossa, the internal obturator muscle is outside it,
and the perineal skin is below it. The cadaver CT
images demonstrated that a deformed ischioanal
fossa will result in a deformed pelvic floor.
Puborectalis
Based on Shafik_s theory, the puborectalis is a
Bcommon tunnel^ sphincter or a tunnel Bconstrictor^
that provides an Bindividual^ sphincter for each
intrahiatal organ
6
; therefore, the puborectalis has
the function to decrease the size of the genital
hiatus.
At the puborectalis plane, the puborectalis is a u-
shaped muscle. The puborectalis binds the VP to the
pubic symphysis, then the VP encloses the intrahiatal
structures; this anatomic relation is shown by our
images.
Table 1.
Gender-Related Variations in Healthy Students
Measurement Males (mm) (n = 10) Females (mm) (n = 12) P Value
a
Pelvic outlet
Width 96.6 T 6 118.8T 8.8 <0.05
Pubococcygeal line 77.8 T 8.2 78.7 T 10.8 <0.05
TP at ischial spine
Outer point height 63.7 T 3.9 59.7 T 5.4 <0.05
Midpoint height 58.6 T 4.3 65.8 T 7.4 <0.05
Inner point height 44.5 T 4.2 51.3 T 8 <0.05
Thickness 2.6T 0.8 2.3T 0.9 <0.05
Genital hiatus
Maximum width 29.5 T 2.8 35.1 T 3 <0.05
Length 51.7 T 4 50.8 T 4.9 <0.05
Area 1,164 T 169.7 1,282.2T 179.1 <0.05
Data are means T standard deviations unless otherwise indicated.
a
Two-independent samples t-test.
Vol. 50, No. 10 THE PUBORECTALIS IS NOT ITS COMPONENT 1653
Genital Hiatus
Based on Shafik_s theory, the size of the genital hiatus
(Blevator tunnel^) is regulated by the puborectalis and
the VP (Fig. 8).
6
This study found that the size of the
genital hiatus differs between male and female subjects.
Anorectal Angle
It is common knowledge that the puborectalis is
outside the vertical portion of the levator ani
6
and
not the anal canal; this anatomic relationship also is
shown in our images. In the midsagittal MRI, the
puborectalis holds the anococcygeal ligament and
the longitudinal muscle at an angle, which we have
called the BAcl-Lm angle.^ The puborectalis does not
touch the anorectal junction, so the anorectal angle
should be produced by the Acl-Lm angle.
Limited
Some tiny anatomic structures still cannot be
revealed by images. For example, we failed to
identify the Bhiatal ligament.^
6
For the anatomic appearance and components of
the levator ani, the authors had different opinions;
the major differences are listed in Table 2, which
outlines our findings and views.
Figure 8. Diagram illustrating the levator tunnel by
Shafik.
6
(Reprinted with permission from The American
Society of Colon and Rectal Surgeons.)
Table 2.
Demonstration of Comparison with Previous Studies
Structures Previous Studies Present Studies
Lam
Cadaver Basin. Traditional idea. Dome or basin or funnel
Funnel. Shafik
6
Living with supine Dome. Hjartardottir et al.
2
Evolution from basin to dome
Upward convexity. Singh et al.
3
Component Pr, Pc, Ic. Holl et al. (Zhang
4
) Pc, Ic, Cc
Puborectalis Not one part of Lam. Shafik
6
Not one part of Lam
Functional portion TP and VP. Shafik
6
TP and VP
Others
Genital hiatus Inside VP. Shafik
6
Inside VP
Puborectalis Outside VP. Shafik
6
Outside VP
Longitudinal muscle Between sphincters. Shafik
8
Between sphincters
Anorectal angle Levator-anal angle. Piloni et al.
12
Acl-Lm angle
Dpm Not exist. Dorschner et al.
10
Exist
Acl =anococcygeal ligament; Cc =coccygeus; Dpm=deep transverse perineal muscle; Ic =iliococcygeus; Lam=levator
ani muscle; Lm=longitudinal muscle; Pc =pubococcygeus; Pr =puborectalis; TP=transverse portion; VP=vertical portion.
Figure 9. Photo of pelvic floor muscles (viewed from left-
below). A=anal canal; C=coccyx; Cc=coccygeus; Es =ex-
ternal anal sphincter; Ic = iliococcygeus; Iom= internal
obturator muscle; Pc =pubococcygeus; Pr =puborectalis.
1654 GUO AND LI Dis Colon Rectum, October 2007
CONCLUSIONS
The levator ani includes a transverse portion and a
vertical portion; the two portions consist of three
muscle bundles: pubococcygeus, iliococcygeus, and
coccygeus (Fig. 9). The shape of the transverse
portion changes from basin to dome in the lying
position. The longitudinal muscle is between the
internal and external anal sphincter. The puborectalis
is not part of the two portions. The puborectalis
binds the vertical portion to the pubic symphysis,
and then the vertical portion encloses the intrahiatal
structures.
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