The puborectal continence reflex: a new regulatory mechanism controlling fecal continence

PURPOSE: Fecal continence is maintained by voluntary and involuntary contraction of the anal sphincter, and voluntary contractions of puborectal muscle. We investigated whether the puborectal muscle can control fecal continence not only by voluntary contractions but also by involuntary contractions. METHODS: We performed anorectal function tests in 23 healthy subjects. The anorectal pressure test was used to investigate voluntary contractions of the puborectal muscle. The balloon retention test was used to assess if the puborectal muscle can contract involuntarily. RESULTS: During the balloon retention test, we observed an involuntary contraction of the puborectal muscle, which gradually increased during progressive filling of the rectum. The maximal involuntary contraction of the puborectal muscle was significantly stronger and longer than its maximal voluntary contraction (150 versus 70 mmHg, P < 0.001 and 5.8 versus 1.5 min, P < 0.001). CONCLUSIONS: We found that the puborectal muscle is able to contract involuntarily during rectal dilatation. It is a new regulatory mechanism, called the puborectal continence reflex, which controls fecal continence by involuntary contraction of the puborectal muscle. It seems to be initiated by dilatation at the level of the puborectal muscle. Presumably, the puborectal continence reflex protects many patients with anal sphincter dysfunctions from fecal incontinence.