Levator ani

Origin: Inner surface of the side of the lesser pelvis

Insertion: Inner surface of coccyx, levator ani of opposite side, and into structures that penetrate it.

Artery: Inferior gluteal artery

Nerve: Levator ani nerve (S4) - inferior rectal nerve from pudendal nerve (S3, S4) - coccygeal plexus

Action: Supports the viscera in pelvic cavity

Description: The Levator ani is a broad, thin muscle, situated on the side of the pelvis. It is attached to the inner surface of the side of the lesser pelvis, and unites with its fellow of the opposite side to form the greater part of the floor of the pelvic cavity. It supports the viscera in this cavity, and surrounds the various structures which pass through it.

The confusing terminology used to describe the levator ani muscle in the literature obscures the consistent agreement concerning the origin and insertion of individual muscle components (1) but the levator ani muscle is often divided into three main parts:

1. Iliococcygeus muscle: The Iliococcygeus arises from the ischial spine and from the posterior part of the tendinous arch of the pelvic fascia, and is attached to the coccyx and anococcygeal raphé; it is usually thin, and may fail entirely, or be largely replaced by fibrous tissue. An accessory slip at its posterior part is sometimes named the Iliosacralis.

2. Pubococcygeus muscle: The Pubococcygeus arises from the back of the pubis and from the anterior part of the obturator fascia, and is directed backward almost horizontally along the side of the anal canal toward the coccyx and sacrum, to which it finds attachment. Between the termination of the vertebral column and the anus, the two Pubococcygei muscles come together and form a thick, fibromuscular layer lying on the raphé formed by the Iliococcygei. The greater part of this muscle is inserted into the coccyx and into the last one or two pieces of the sacrum.

3. Puboanalis muscle (Puborectalis; sphincter recti): This U-shaped muscle loops around the anorectal junction, contributing to the maintenance of the anorectal angle, which is crucial for continence. It originates from the pubic bone and inserts into the perineal body and the rectum.

The Levator ani arises, in front, from the posterior surface of the superior ramus of the pubis lateral to the symphysis; behind, from the inner surface of the spine of the ischium; and between these two points, from the obturator fascia. Posteriorly, this fascial origin corresponds, more or less closely, with the tendinous arch of the pelvic fascia, but in front, the muscle arises from the fascia at a varying distance above the arch, in some cases reaching nearly as high as the canal for the obturator vessels and nerve.

The fibers pass downward and backward to the middle line of the floor of the pelvis; the most posterior are inserted into the side of the last two segments of the coccyx; those placed more anteriorly unite with the muscle of the opposite side, in a median fibrous raphé (anococcygeal raphé), which extends between the coccyx and the margin of the anus. The middle fibers are inserted into the side of the rectum, blending with the fibers of the Sphincter muscles; lastly, the anterior fibers descend upon the side of the prostate to unite beneath it with the muscle of the opposite side, joining with the fibers of the Sphincter ani externus and Transversus perinaei, at the central tendinous point of the perineum. The anterior portion is occasionally separated from the rest of the muscle by connective tissue. From this circumstance, as well as from its peculiar relation with the prostate, which it supports as in a sling, it has been described as a distinct muscle, under the name of puboprostatic muscle (Levator prostatae). In the female the anterior fibers of the Levator ani descend upon the side of the vagina and are called pubovaginalis muscle.

Nerve Supply.—The Levator ani is supplied by a branch from the fourth sacral nerve and by a branch which is sometimes derived from the perineal, sometimes from the inferior hemorrhoidal division of the pudendal nerve.

Actions.—The Levatores ani constrict the lower end of the rectum and vagina. They elevate and invert the lower end of the rectum after it has been protruded and everted during the expulsion of the feces. They are also muscles of forced expiration. The Coccygei pull forward and support the coccyx, after it has been pressed backward during defecation or parturition. The Levatores ani and Coccygei together form a muscular diaphragm which supports the pelvic viscera.