Background:  The puborectalis muscle is believed to play an important role in anal continence. However, to date, there is very limited evidence to support this hypothesis.
Aims:  This study was designed to test for an association between puborectalis trauma and ballooning of the levator hiatus on the one hand and anal incontinence on the other hand.
Methods:  The records of 397 women who had attended a tertiary urogynaecological clinic were reviewed in a retrospective study. The history included questions on faecal urgency, soiling, faecal and flatus incontinence. Examination included puborectalis muscle assessment by palpation and 4D pelvic floor ultrasound.
Results:  Mean age on presentation was 54 (19–89) years. Median vaginal parity was 2 (0–9). Of 397 women, 89 complained of faecal urgency, 65 of faecal incontinence (FI), 67 of soiling and 91 of flatus incontinence. Seventy‐seven patients were diagnosed with puborectalis avulsion, of which 38 were bilateral. Puborectalis avulsion was not associated with FI (P = 0.801), faecal urgency (P = 0.894), soiling (P = 0.768) and flatus incontinence (P = 0.187). Hiatal dimensions at rest or on Valsalva were also found not to be associated with symptoms of anal incontinence.
Conclusions:  Surprisingly, we found no association between avulsion of the puborectalis muscle and hiatal biometry on the one hand and anal continence on the other hand. These findings argue against a major role of the puborectalis muscle in anal continence.