4. Bony pelvis is formed by four bones united at
four joints.
BONES JOINTS
Two hip bones Two sacroilliac joints
Sacrum Pubic symphysis
Coccyx Sacroccygeal joint
5.
6. Plane of pelvic inlet
divides pelvis into two
parts
Line joining illiac
crest
Greater/False pelvis
Pelvic brim/inlet
Lesser/True pelvis
Pelvic diaphragm
CORONAL SECTION
8. Bones
Anteriorly Pubic symphysis and
pubic bones
Posteriorly Sacrum and coccyx
On each side Two rami of the pubis,
ischium with its ramus,
lower part of the illium
9.
10.
11. Ligaments
Ligaments
Sacrospinous ligament Attaches from the ischial spine to the
lateral border of the sacrum
APPLIED:: Above this lies the sciatic
nerve
and plexus, which is an important
structure to avoid during vault
suspensions
Sacrotuberous ligament Attaches from the posterior iliac spine along
the sacral border and attaches to the ischial
tuberosity
Anterior and Posterior
Sacroilliac ligaments
Attaches sacrum with illium
Sacrococcygeal ligament
Illiolumbar ligament Attaches 5th lumbar vertebrae to the illium
15. Muscles of the wall of pelvis
1. Obturator internus::
Origin: Pelvic surface of obturator membrane and
surrounding bone.
Insertion: Medial surface of greater trochanter
nv: Nerve to obturator internus muscle;
as: Internal pudendal and obturator arteries
action: lateral rotator of hip joint
16. 2. Pyriformis muscle
Origin: Anterior surface of sacral segments 2–4,
sacrotuberous ligament
Insertion: Superior border of greater trochanter
nv: Anterior rami of L5,S1,S2
as: Superior and inferior gluteal arteries, internal
pudendal
action: lateral rotator of hip joint
19. PELVIC FLOOR
Composed of pelvic diaphragm, which
extends from the pubis anteriorly to the coccyx
posteriorly.
It ressembles a hammock or a gutter because
it slopes from either side towards the median
plane, where it is traversed by the urethra,
anal canal and also vagina in the female.
20. Transverse section at the pelvic
diaphram
Pubic bone
Urethra
Vagina
Perineal body
Anorectal junction
Anococcygeal raphe
Coccyx
Sacrum
23. Muscles of the pelvic
diaphragm
Levator ani Ischiococcygeus or
coccygeus
Puborectalis,
pubovaginalis/levator
prostatae
Pubococcygeus
Illiococcygeus
24.
25.
26.
27.
28.
29.
30. Levator ani and coccygeus may be regarded
as one morphological entity.
They have a continuous linear origin from the
pelvic surface of the body of pubis, the
obturator fascia or white line and ischial spine
31. Levator ani
Pubococcygeus part
ANTERIOR FIBRES MIDDLE FIBRES POSTERIOR FIBRES
Male :: Levator
Prostatae
Female:: Sphincter
vaginae
Puborectalis Pubococcygeus proper
O: Medial part of the
pelvic surface of body
of pubis
O: Lateral part of the of
body of pubis pelvic
surface
O:Anterior part of the
white line on the
obturator fascia
I: Perineal body I: Sling around AR
junction and partly
continuous with
longitudinal muscle
coat of rectum
I: Anococcygeal
ligament and tip of
coccyx
32. Illiococcygeus part:
O: Posterior half of the white line on the
obturator fascia and pelvic surface of the
ischial spine.
I: Annococcygeal ligament and into the sides
of the last two pieces of coccyx.
33. Ischiococcygeus or Coccygeus:
It represents the posterior part of the
diaphragm.
Triangular in shape
Partly muscular and partly tendinuous
O: Pelvic surface of the ischial spine and
sacrospinous ligament.
I: Side of coccyx and into the fifth sacral
vertebrae.
34. Nerve supply:
A) Branch from fourth sacral nerve
B) Branch from inferior rectal nerve
C) Coccygeus is supplied by branch derived
from the fourth and fifth sacral nerves.
35. Arterial supply:
Levator ani:: Inferior gluteal artery, internal
pudendal artery and its branches inferior rectal
and perienal arteries
Coccygeus:: Inferior gluteal artery
39. Applied
Radical retropubic prostatectomy, the dorsal
vein complex is best divided distally before its
ramification.
Part of this complex runs within the anterior
and lateral wall of the striated sphincter; thus
care must be taken not to injure the sphincter
when securing hemostasis.
One or more accessory obturator veins drain
into the underside of the external iliac vein and
can be easily torn during lymphadenectomy.
40.
41.
42.
43. The most caudal portion of the pelvic plexus
gives rise to the innervation of the prostate and
the important cavernosal nerves.
Prostatic apex_--5 and 7 clock
Membranous urethra– 3 and 9 clock
Spongy urethra– 1 and 11 clock
44. Relations of levator ani
Superior Pelvic fascia separating
bladder, prostate rectum
and peritoneum from it
Infeior Anal fascia
Anterior Separated by a triangular
space for the passage of
urethra and vagina
Posterior Free
Related to anterior margin of
coccygeus
45. Muscles of the pelvic diaphragm
type I (slow-twitch) fibers
type II (fasttwitch) fibers
Pelvic diaphragm is not flat or bowl
shaped. At the urogenital and anal hiatus,
the muscles lie in a near-vertical configuration.
Behind the anus, they flatten to form a nearly
horizontal diaphragm referred to as the levator
plate.
46. Actions of levator ani and
coccygeus
Fixes the perineal body and support the pelvic
viscera.
Resist increase in intraabdominal pressure
and help to maintain continence of the bladder
and rectum.
In micturition, defeacation and parturition, a
particular pelvic outlet is open, but contraction
of fibres around other openings resists
increased i/a pressure and prevents any
prolapse.
47. Applied
Muscles of the pelvic floor may be injured
during parturition.
When the perineal body is torn, and has not
been repaired satisfactorily, the contraction of
anterior fibres of the levator ani increases the
normal gap in the pelvic floor and results in
prolapse of uterus.
48. PERINEUM
Introduction
It is the region at the lower end of trunk.
It forms the lower division of pelvis that lies
below the pelvic diaphragm.
Openings
MALE FEMALE
Gastrointestinal system Gastrointestinal system
Common opening for
genital and urinary systems
Genital system
Urinary system
50. DEEP
BOUNDARIES
ANTERIOR Upper part of
the pubic arch
and the
arcuate or
inferior pubic
ligament
POSTERIOR Tip of coccyx
On each side Conjoined
ischiopubic rami
Ischial
tuberosity
Sacrotuberous
ligament
51. Divisions of the perineum
A transverse line joining the anterior parts of
the ischial tuberosities divides the perineum
into two triangular areas ::
Posteriorly anal region or triangle
Anteriorly anogenital region or triangle
53. PERINEAL BODY
Fibromuscular node situated in the median
plane1.25 cm in front of anal margin.
It consists of muscle, collagenous and elastic
fibres.
54. It is very important in female for support of
pelvic organs.
It may be damaged during parturition or
childbirth.
This may result in prolapse of UB, uterus, even
rectum.
An episiotomy when performed must angle
laterally to avoid damage to these fibers.
Damage to the perineal body during perineal
prostatectomy risks postoperative urinary
incontinence.
59. Contents of ischioanal fossa
Pad of fat
Inferior rectal nerve and vessels supplying
mucous membrane, external sphincter and
skin around anus.
Pudendal canal with its contents
Posterior scrotal or posterior labial nerves and
vessels.
Perineal branch of 4th sacral nerve supplies
skin posterior to anus.
Pereforating cutaneous branch of S2,S3.
60. Clinical anatomy
The two ischioanal fossae allow distension of
the rectum and anal canal during passage of
faeces.
Both perianal and ischioanal spaces are
common sites of abscesses.
Loss of ischioanal fat in debilitating diseases
like diarrohea in children may result in
prolapse of rectum
61.
62. Pudendal canal
Fascial canal in the lateral wall of the
ischioanal fossa.
Fascia of the canal is fused with the lower part
of obturator fascia laterally, with the lunate
fascia above, with the perianal fascia medially
and with the sacrotuberous ligament below.
Contents:: pudendal nerve and internal
pudendal vessels.
63.
64.
65. Pudendal nerve (S2,S3,S4)
Chief nerve of perineum and of external
genitalia.
O: from sacral plexus in the pelvis. It is derived
from spinal nerves S2,S3,S4.
Course: pelvis---greater sciatic notch---lesser
sciatic notch----pudendal canal
66. Branches::
Inferior rectal nerve:: it pierces medial wall of
pudendal canal, crosses ischioanal fossa from
lateral to medial side supplying skin around
anus and EAS.
Perineal nerve :: Large terminal branch, runs
forward below the internal pudendal vessels. It
divides into medial and lateral posterior
scrotal or labial nerves and muscular
branches.
67. Dorsal nerve of penis or clitoris ::
smaller terminal branch.
runs forwards first in the pudendal canal
above the internal pudendal artery and then
in deep perineal space.
Next it passes in the gap between apex of
perineal membrane and arcuate pubic
ligament, runs on dorsum of the penis or
clitoris and ends supplying body of the penis
or clitoris and of the glans.
68. Clinical anatomy
Pudendal nerve crosses close to ischial spine
hence is vulnerable to injury during a
sacrospinous ligament culdosuspension.
In vaginal operations GA can be replaced by a
pudendal nerve block.
69.
70.
71. Internal pudendal arterty
Chief artery of the perineum and of the
external genital organs.
O: smaller terminal branch of IIA
Course is similar to that of pudendal nerve.
Relations
In the pelvis: it runs downwards and leaves by
piercing the parietal pelvic fascia ---through
greater sciatic foramen--- enters gluteal region.
72. In the gluteal region: lies between the
pudendal nerve medially and nerve to the
obturator internus laterally. Leaves through
lesser sciatic foramen.
In the pudendal canal: runs downwards and
forwards where it is related to dorsal nerve
above and perineal nerve below.
73. In the deep perineal space: artery of the penis
or clitoris runs forwards close to the side of
pubic arch, medial to the dorsal nerve of
penis/clitoris.
It ends a little behind the arcuate pubic
ligament by dividing into deep and dorsal
arteries of penis or clitoris.
74. Branches
Inferior rectal artery Skin mucous membrane of the anal
region
Perineal artery Branches into transverse perineal ,
posterior scrotal/labial branches
Artery of the penis/clitoris
a. Artery to the bulb Bulb of penis/vestibule
Post. Part of urethra
b. Urethral artery Corpus spongiosum
Ant. Part of urethra
c. Deep artery of penis/clitoris Crus and corpus cavernosum
d. Dorsal artery of penis/clitoris Skin and fasciae of body of penis and of
the glans or the glans clitoridis
75. Internal pudendal vein
Tributaries of internal pudendal vein follow the
branches of the internal pudendal artery. The
vein drains into internal illiac vein.
They communicate freely with the dorsal vein
complex by piercing the levator ani.
These vessels enter the pelvic venous plexus
on the lateral surface of the prostate and are a
common, often unexpected, source of bleeding
during apical dissection of the prostate.
77. Clinical anatomy
The cutaneous nerve of perineum are derived
from S2,S3,S4.
These segments also supply parasympathetic
fibres to the pelvic organs.
Diseases of these organs may, therefore,
cause referred pain in the perineum.
78.
79.
80.
81.
82. Superficial fascia
Made up of superficial fatty layer and deep
membranous layer or Colle’s fascia.
Attachments
Posteriorly Posterior border of perineal body
Each side Pubic arch below the crus of penis
Anteriorly Continuous with the dartos fascia, fascia
of penis, fascia of scarpa
83. Deep fascia
Made up of one layer that lines the deep
perineal space inferiorly.
This fascia of the urogenital diaphragm is thick
and is called perineal membrane.
85. Blood and urine can accumulate in the
scrotum and penis deep to the dartos fascia
after an anterior urethral injury.
In the perineum, their spread is limited by the
fusions of Colles fascia to the ischiopubic rami
laterally and to the posterior edge of the
perineal membrane; the resulting hematoma is
therefore butterfly shaped.
86. Boundaries of urogenital region
Urogenital region is divided into two parts by
strong perineal membrane
Posteriorly Interischial line
Anteriorly Symphysis pubis
Laterally Ischiopubic rami
87. Perineal membrane (male)
Triangular membrane
Attachments
Laterally Periosteum of ischipubic
rami
Apex Arcuate ligament of pubis
It is particularly thick in this
area called transverse
perineal ligament
Posterior Fused to perineal body and
is continuous with the
fascia over deep
transverse perinei
90. Deep perineal space
Previous view: space between superior fascia
of UGD and perineal membrane that contained
urethra and urethral sphincter.
Present view: urethral sphincter is known to be
contained inside the urethra. UGD does not
exist. The deep perineal space is thin and
open above.
94. Contents
TUBES Part of urethra
Muscles Sphincter urethrae
Deep transversus perinei
Nerves on each side Dorsal nerve of pens
Muscular branches from
perineal nerve
Vessels Artrey of penis
Stems of origin of four branches
namely a.to bulb, urethral a,
deep and dorsal a. of penis
Glands Bulbourethral glands
95. Deep transverse perinei: Together with
superfiial transverse perinei it acts to tether the
perineal body in median plane. This gives
dynamic support for pelvic viscera.
Distal urethral sphincter : consists of intrinsic
striated and smooth muscles of urethra and
pubourethralis component of levator ani.
96. Bulk of fibres surround the membranous
urethra.
Circularly disposed striated muscle fibres
called rhabdosphincter forms main part of
distal urethral sphincter mechanism.
Some fibres attach to inner surface of the
ischiopubic ramus forming compressor
urethrae.
97.
98.
99.
100.
101. Superficial perineal space
Superficial space of the urogenital region
situated superficial to the perineal membrane.
Superficial Colle’s fascia
Deep Perneal membrane
On each side Ischiopubic rami
Posteriorly Closed by the fusion of
perineal membrane with
colle,s fascia
Anteriorly Open and continuous with
the spaces of the scrotum
penis, and anterior
102. Contents
Tubes Two corpora cavernosa,one corpus
spongiosum traversed by urethra
Muscles Ischiocavernosus
Bulbospongiosus
Superficial transverse perinei
Nerves Post. Scrotal, branch to bulb and muscular
branches from perineal nerve
Long perineal nerve from post. Cutaneous
nerve of thigh.
Vessels Post. Scrotal and transverse perinei
Four branches from artery of penis
Glands and
ducts
Only ducts of bulbourethral glands
103. Action of superficial perineal
muscle
Ischiocavernosus--- It helps in maintaining
erection of the penis and clitoris
Bulbospoingiosus--- post fibres helps in
ejaculation of semen and ejection of last drops
of urine; middle fibres assist in the erection of
spongiosum ; ant fibres helps in erection of
penis by compressing deep dorsal vein of
penis.
106. Female perineum
Pudendum includes
Mons pubis
Labia majora
Labia minora
Clitoris
Vestibule of thye vagina
Bulbs of the vestibule
Greater vestibular glands
Pudendum Female urogenital
region
110. Deep perineal space(female)
Boundaries are same as that of male.
Contents
Tubes Parts of urethra and vagina
Muscles Sphincter urethrae
Compressor urethrae
Sphincter urethrovaginalis
Nerves Dorsal nerve of clitoris
Muscular branches from
perineal membrane
Vessels Artery of clitoris
Stems of origin of artery to
bulb, urethral artery, deep
111.
112. Urethral sphicter mechanism
Consists of intrinsic smooth muscle, intrinsic
skeletal muscle and is anatomically separate
from pubourethralis.
It surrounds more than the middle third of
urethra and blends above and below with
smooth muscles.
Skeletal muscle fibres are circularly disposed,
called rhabdosphincter.
113. Actions: compresses urethrae when bladder
contains fluid. It contracts to expel the final
drops of urine.
Compressor urethrae and sphincter
urethrovaginalis produce elongation as well as
compression of the membranous urethrae an
thus aid continence in females.
All are supplied by perineal nerve.
114.
115.
116. Superficial perineal
space(female)
Boundaries are same
Cotents
Contents Bodyof clitoris, urethral orifice,
vaginal orifice, bulbs of vestibule
Muscles Ischiocavernosus, bulbospongiosus,
superficial transverse perinei
Nerves Post. labial, branch to bulb and
muscular branches from perineal
nerve, Long perineal nerve from
post. Cutaneous nerve of thigh.
Vessels Post. Labial and transverse perinei
Four branches from artery of clitoris
Glands and ducts Greater vestibular glands and ducts
117. FASCIA
Fascia divided into three strata:
1. Inner stratum– Rectal fascia , Denonviller’s
fascia
2. Intermediate stratum– Most of the support of
the pelvic organs comes from the retroperitoneal
connective tissue derived from the intermediate
stratum. Pubovesical, pubocervical fascia.
3. Outer stratum-- transversalis fascia continuous
with the endopelvic and lateral pelvic fascia.
118. Six potential spaces
Prevesical space
Vesicovaginal space
Rectovaginal space
Retrorectal space
Paravesical space
Pararectal space
119.
120.
121. PELVIC FASCIA
It is distributed in the extraperitoneal space of
the pelvis.
Parietal pelvic
fascia
Visceral pelvic fascia
Covers lateral
pelvic wall and
floor
Surrounds the pelvic
viscera
122.
123.
124.
125. Fascia is dense and membranous over non
expansile structures and loosely arranged over
viscera and pelvic floor.
Parietal fascia of lateral pelvic wall : Fascia
covering the muscles of lateral pelvic wall is
condensed to form thick and strong
membranes and is attach from illiopectineal
line to inf border of pubic bone.
127. Parietal fascia of the pelvic floor: covers both
the surfaces of pelvic diaphragm.
Loosely arranged.
However its condensed at places to form
fibromuscular ligaments which support the
pelvic viscera.
128. Visceral pelvic fascia
It is attatched along a line extending from the
middle of back of pubis to the ischial spine.
It is loose and cellular around distensible
organs and dense around non distensible
organs like prostate.
129. Ligaments
The pubovesical ligaments (pubourethral
ligament) are homologous to the puboprostatic
ligaments in males and run from the pubic
bone to the bladder neck. Supports urethra
and bladder neck.
Vesicopelvic ligament (perivesical+
endopelvic): Defects in this fascia or ligament
can result in lateral cystocele defects.
130.
131.
132.
133. Broad ligament: The broad ligament contains
the fallopian tube and ovary and lies on the
posterolateral surface of the uterus attaching it
to the pelvic wall.
Round ligament: It attaches the lateral walls
of the uterine body to the pelvic sidewalls. It
contains the ovarian ligaments and is
homologous to the gubernaculum of the male.
Infundibulopelvic ligament: It contains the
ovarian vessels.
134. Applied
The ureter is vulnerable to injury as it passes
near the ligaments that support the uterus and
ovary .
It crosses the infundibulopelvic ligament under
the ovarian artery and is just medial to the
uterine artery.
It also passes near the cardinal ligament and
lies in close proximity to the cervix.
135. De Lancey’s levels of support
Level 1 : Cardinal ligament, uterosacral
ligament
Fibres are oriented vertically and suspend the
uterus and upper vagina. (lateral cystocele
defect)
Level 2: paravaginal attatchments to the ATFP
and
and to the ATRV.
More horizontal in its orientation and is
attached to the mid vagina. ( Anterior wall
prolapse)
Level 3: Levator ani , perineal body (urethral
136.
137.
138. Applied
Nerves from the pelvic plexus travel through
the cardinal and uterosacral ligaments with the
vessels, and damage to these during a
hysterectomy can result in bladder
dysfunction.
139. Uterosacral ligaments: used in apical
suspensions. The ureter lies lateral to the
anterior portion of the uterosacral ligament
(closest at the area of the cervix).
There is potential for sacral nerve
entrapment (S1 and S2 to S4 nerve trunks)
during a suspension as the nerve crosses
over these areas.
140. Pelvic fascia ( MALE)
ATFP:: extends from the puboprostatic
ligament to the ischial spine.
The lateral branches of the dorsal
venouscomplex are directly beneath the arcus
tendineus fasciae pelvis; thus the endopelvic
fascia should be opened lateral to this
landmark in radical prostatectomy.
