You are on page 1of 14

Anatomy 5.

December 13, 2011


Dr. Elevazo

Pelvis and Perineum


OUTLINE
1. Pelvis
2. Perineum
I. Pelvis
I. Perineum
A. False Pelvis
A. Perineal Fasciae
B. True Pelvis (True Walls)
B. Anal Triangle
II. Pelvic Diaphragm
C. Ischiorectal Fossa
III. Pelvic Peritoneum
D. Urogenital Triangle
IV. Arteries of Pelvis
II. Perineal Body
V. Veins of Pelvis
III. Urogenital Diaphragm
VI. Lymph nodes of Pelvis
IV. Vulva
VII. Nerves of Pelvis
V. Pudendal Nerve
VIII. True Pelvis
IX. Clinical Pelvimetry (Inadequate)
X. Pelvic Differences
XI. Pelvic Types
XII. Pelvic Structures
XIII. Weak Areas of Pelvis

Objectives:
Identify principal anatomic landmarks in the pelvis and perineum.
Identify parts of the bones of the pelvis grossly.
Differentiate the gross features of the male pelvis from the female pelvis
Describe the arrangement and peritoneal relations of the pelvic organs in
both sexes.
Describe the pelvic diaphragm.
Describe the blood supply, innervations and lymphatic drainage of the
pelvis.
Describe the boundaries and subdivisions of the perineum in both sexes.
Name the layers of the urogenital diaphragm.
Distinguish the contents of the superficial and deep perineal pouches in
the male and female.
Describe the contents of the posterior (anal) triangle.
Describe the blood supply, innervations and lymphatic drainage of
perineum.

PELVIS
I. PELVIS

basin in Latin
continuous with abdomen
walls: bony, muscular, ligamentous
pelvic inlet/outlet
Functions:
o transmits weight from trunk to lower limbs
o supports and protects pelvic viscera
o provides attachment for muscles of trunk and lower limbs
(maintenance of posture and locomotion)
o passage during childbirth
*See PLATE 241 (Bony Framework of Abdomen), Netter.
PELVIC BRIM (PELVIC INLET/ SUPERIOR PELVIC APERTURE)
Boundaries
o Anterior: symphysis pubis
o Posterior: promontory and ala of sacrum
o Lateral: iliopectineal line or linea terminalis (arcuate line and
pecten pubis)
Divides the pelvis into:
1. false pelvis (greater pelvis)
2. true pelvis (lesser pelvis)
*See PLATES 334 (Measurements, Female pelvis) and 336 (Bones and
Ligaments of Pelvis, Median sagittal section), Netter.

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

A. FALSE PELVIS

Boundaries:

o Anterior: lower part of abdominal wall


o Posterior: L5 and S1
o Lateral: iliac fossae and iliacus muscles
varies in size - flare of iliac bones
not clinically significant
Functions:
rd
o supports the abdominal viscera and gravid uterus (after 3
month)
o guides the fetus into the true pelvis
lies above the linea terminalis

*See PLATES 241 and 336, Netter.


B. TRUE PELVIS (TRUE WALLS)
formed by bones and ligaments that are partly lined with muscles
covered with fascia and parietal peritoneum
Walls:
o Anterior: bodies and rami of pubic bones and symphysis pubis
o Posterior: sacrum, coccyx, piriformis muscle and fascia
o Lateral: hip bone, obturator foramen (obturator membrane,
obturator muscle and its fascia), sacrotuberous & sacrospinous
ligaments
inferior or floor: pelvic diaphragm
lies below the linea terminalis
the portion important in childbearing

BONY PELVIS
Composed of four bones:

o 2 hip (coxal or innominate) bones


joined anteriorly at the symphysis pubis
o sacrum
where ilium is attached at sacroiliac joint
th
notch above the 5 lumbar vertebra by lumbosacral
joint
o coccyx
sacrococcygeal joint
*symphysis pubis and sacroiliac joint important during the
latter half of the pregnancy. With increasing levels of sex
hormones and the presence of relaxin, there will be relaxation
of these pelvic joints as well as softening of the pelvic
ligament that support these joints. These joints increase the
diameter of your pelvic inlet and that of your pelvic outlet and
midpelvis at around 1.5 to 2 cm, which will facilitate delivery
of the head of the fetus through the birth canal.
*See PLATE 334, Netter.
o HIP BONE
consists of three bones that fuse after puberty:
o ILIUM: superior
iliac crest
anterior and posterior superior iliac spines
anterior and posterior inferior Iliac spines
auricular surface (posterior)

Page 1 of 14

arcuate line + pectineal line = iliopectineal line or linea


terminalis
o ISCHIUM: postero-inferior
ischial spine
ischial tuberosity
o PUBIS: anterior
body
superior pubic ramus (helps form acetabulum)
inferior pubic ramus (helps form obturator foramen)

three bones joined by cartilage at the area of the


acetabulum cup-like depression on the lateral surface
of the hip bone.
greater sciatic notch between ischial spine and ilium
lesser sciatic notch between ischial spine and ischial
tuberosity
ligaments:
o sacrotuberous
o sacrospinous
obturator foramen covered by membrane

o SACRUM
5 rudimentary vertebrae fused together
o COCCYX
4 vertebrae fused together

*See PLATE 336 (Bones and Ligaments of Pelvis, Lateral view),


Netter.

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 2 of 14

II. PELVIC DIAPHRAGM


floor or inferior wall of the pelvic cavity
formed by:
o Levatores ani muscles
o Coccygeus muscles
o their covering fasciae
incomplete anteriorly (urogenital hiatus) for passage of urethra in
both sexes and vagina in females

o Intermediate fibers:
puborectalis: forms a sling around the junction of
rectum and anal canal
o important in the maintenance of anorectal
flexure/perineal flexure to maintain anal continence.
pubococcygeus: into anococcygeal body
o Posterior fibers: iliococcygeus into anococcygeal body
and coccyx
Actions:
o muscular sling that supports and maintains pelvic viscera
in position
o resist rise in intra-abdominal pressure
o sphincteric
Nerve Supply:
o perineal branches of S4
o pudendal nerve (S2-S4)

COCCYGEUS MUSCLES
o Origin: ischial spine
o Insertion: sacrum and coccyx
o Action: assist levatores ani
o Nerve Supply:
th
branches of 4
5th sacral nerves

LEVATOR ANI MUSCLES


o Origins:
body of pubis
tendinous arch of obturator fascia
ischial spine
Insertions:
o Anterior fibers: levator prostatae or sphincter vaginae
into perineal body
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 3 of 14

in perineum: forms the superior fascial layer of

urogenital diaphragm

PELVIC FASCIA
o consists of connective tissue
o continuous with endoabdominal fascia
o below, continuous with fascia of perineum
o divided into:
parietal pelvic fascia
visceral pelvic fascia
*See PLATE 345 (Endopelvic Fascia and Potential Spaces, Female:
superior view), Netter.

Visceral Pelvic Fascia


covers pelvic viscera
fuses with parietal layer when viscous comes in contact
with pelvic wall or organs penetrate the pelvic wall; in
these areas, the parietal layer thickens to form the
tendinous arch of pelvic fascia which extend from pubis
to sacrum; named according to their attachments
examples:
pubovesical/puboprostatic ligament
sacrogenital ligaments
o Endopelvic Fascia
Loose connective tissue in between the parietal and
visceral pelvic fascia. (may be loose/condensed)
Loose beneath the pubis and bladder
Condensed Hypogastric Sheath (between
retropubic and retrorectal spaces)
3 laminae (Hypogastric Sheath)
Anterior Lamina: Lateral ligament of the bladder
(conveying superior vesical arteries and veins)
Posterior Lamina: Lateral ligament of the rectum
(conveying middle rectal artery and vein)
Middle Lamina:
*Males: Rectovesical septum
*Females: Cardinal/transverse cervical ligament
*In the areas where you have loose endopelvic fascia, these are the
areas where you have less blood vessels, nerves, and lymphatics, and
these are the areas that we usually want to insinuate our fingers
when we do blunt dissection.
*See PLATE 348 (Urinary Bladder: Orientation and Supports, Superior
view with peritoneum and vesical fascia removed)

o Parietal Pelvic Fascia


lines the muscular walls and floor of pelvis
named according to the muscle it overlies
where pelvic diaphragm is deficient anteriorly, it is
continuous with inferior fascial layer of pelvic diaphragm
fuses with periosteum when in contact with bone
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 4 of 14

III. PELVIC PERITONEUM


Male
o from the anterior abdominal wall to superior/posterior
surfaces of bladder upper ends of seminal vesicles
anterior and lateral surfaces of the rectum posterior
abdominal wall
o rectovesical pouch
Female
o peritoneum from upper surface of bladder reflects onto the
uterus (isthmus, anterior wall, fundus, posterior wall)
upper part of the posterior vaginal wall anterior/ lateral
rectal wall
o due to interposition of uterus, the peritoneal reflection forms
2 pouches:
vesicouterine (anterior)
rectouterine or pouch of Douglas

IV. ARTERIES OF PELVIS


Superior rectal a.
o branch of inferior mesenteric a.
o rectum and upper half of anal canal
Ovarian a.
o abdominal aorta (L1)
o crosses pelvic brim, enters suspensory ligament and the
superolateral part of the broad ligament (mesovarium) to
supply ovary/tubes
Median sacral a.
o bifurcation of aorta
o anterior surface of sacrum and coccyx
th
o gives off 5 pair of lumbar arteries

Internal iliac a.
o Anterior division
Obturator a.
Superior vesical a.
Upper portion of the urinary bladder
Patent proximal portion of the umbilical artery
Uterine a.
At the area of isthmus, divides into:
Uterine branch
Cervical branch
Inferior vesical a.
Middle rectal a.
Vaginal a.
Internal pudendal a.
Inferior gluteal a.
Enters the gluteal region and emerges below the piriformis
ms. to supply the gluteus maximus ms.
o Posterior division
Iliolumbar a.
ascend across pelvic inlet
Lateral sacral a.
descend in front of sacral plexus
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 5 of 14

Superior gluteal a.
leaves pelvis via greater sciatic foramen
supplies gluteal region
Enters the gluteal region and emerges above the piriformis
ms. to supply the gluteus minimus and gluteus medius
muscles.
V. VEINS OF THE PELVIS
Internal iliac v.
o its tributaries correspond to the branches of IEA
o joins external iliac vein to form the common iliac vein
Median sacral v.
o accompanies the artery
o joins left common iliac vein
Superior Rectal V.
o drains into the inferior mesenteric vein
Ovarian V.
o the right drains into the IVC while the left empties into the left
renal vein

VI. LYMPH NODES OF THE PELVIS


highly interconnected
many nodes can be removed without disturbing drainage
interconnections allow cancer to spread in virtually any direction
Pararectal Nodes
o minor groups of nodes

o lie in the connective tissue along the branches of the


internal iliac vessels
Table 1. FOUR PRIMARY GROUPS OF NODES:

Location

Receive
lymph
from

External
Iliac
lymph
nodes
above the
pelvic
brim,
along
external
iliac
vessels

- inguinal
lymph
nodes
- pelvic
viscera
- superior
parts of
middle
to
anterior
pelvic
organs

Internal
Iliac
Lymph
nodes
around the
anterior
and
posterior
divisions
of the
internal
iliac a. &
origins of
gluteal a.
- inferior
pelvic
viscera
- deep
perineu
m
- gluteal
region

Drainage
COMMON ILIAC
LYMPH NODES

Sacral
Lymph
nodes
concavity
of sacrum,
adjacent
to median
sacral
vessels

Posteroinferior
pelvic
viscera

INTERN
AL OR
COMMO
N ILIAC
LYMPH
NODES

Common
Iliac
lymph
nodes
superior to
pelvis,
along
common
iliac blood
vessels

- ext. Iliac
lymph
nodes
- int. Iliac
lymph
nodes
- sacral
lymph
nodes
- some
pelvic
organs
(not
constant
) i.e.
neck of
bladder,
inf.
vagina
lumbar
(caval/aort
ic) nodes

*See PLATE 386 (Lymph Vessels and Nodes of Pelvis and Genitalia:
Female), Netter.
VII. NERVES OF THE PELVIS
Sacral and coccygeal plexuses
Pelvic part of the ANS:
o Sympathetic fibers to the pelvic viscera
Sacral sympathetic trunk
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 6 of 14

Periarterial plexuses
Hypogastric plexuses
o Parasympathetic fibers to the pelvic viscera
Pelvic splanchnic nerves (S2-S4)
Superior hypogastric plexus
o continuation of aortic plexus and conveys branches from L3 and
L4 sympathetic ganglia
o divides into R and L inferior hypogastric nerves at the area of
the pelvic brim
Inferior hypogastric plexuses
o formed when the hypogastric nerves merge with the pelvic
splanchnic nerves
o give off branches to viscera via subsidiary pelvic plexuses
(uterovaginal, vesical, rectal)
Ovarian plexuses
o from aortic and renal plexus
*See PLATE 392 (Nerves of Pelvic Viscera: Female), Netter.
VIII. TRUE PELVIS
significant in obstetrics
has four IMAGINARY PLANES:
o inlet/brim
o outlet
o midpelvis (least pelvic dimensions)
o greatest pelvic dimension
Diameters:
o antero-posterior
o transverse
o oblique
o posterior sagittal

PELVIC INLET / BRIM


o AP diameter (Conjugate)
true
diagonal: 11.5 cm
obstetric (>10 cm): DC - 1.5/2 cm (narrowest AP diameter)
Three anteroposterior diameters of the pelvic inlet are illustrated: the true
conjugate, the more important obstetrical conjugate, and the clinically
measurable diagonal conjugate. The anteroposterior diameter of the

Variations in length of the diagonal conjugate dependent on


height and inclination of the symphysis pubis. (P. = sacral
promontory; Sym. = symphysis pubis.)

Vaginal examination to determine the diagonal conjugate. (P =


sacral promontory; S = symphysis pubis.)
o transverse diameter: 13.5 cm (measured by X-Ray)
o oblique diameter: 13 cm
o post sagittal diameter: 4 cm
*See PLATE 334 (Measurement, Female pelvis: anterior view)

midpelvis is also shown. (P = sacral promontory; Sym = symphysis

pubis.)

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 7 of 14

Adult female pelvis demonstrating anteroposterior and transverse


diameters of the pelvic inlet and transverse (interspinous)
diameter of the midpelvis. The obstetrical conjugate is normally
greater than 10 cm.

MIDPELVIS
o interspinous diameter = 10 cm (narrowest transverse)
o A-P diameter: 11.5 cm
o post sagittal diameter : 4.5 cm
o ENGAGEMENT engaged: if the widest leading part (usually
widest circumference of the head) is negotiating the pelvic
inlet; time when the presenting (lowermost) part of the fetus
descends and is engaged in the mothers pelvis; lightening;
usually takes place 2-3 weeks prior to labor

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 8 of 14

PELVIC CAVITY
o Pelvic Walls
Anteroinferior
Lateral
Posterior (posterolateral wall and roof)
o Pelvic Floor

XI. PELVIC TYPES (CALDWELL-MOLOY CLASSIFICATION)

The four parent pelvic types of the CaldwellMoloy


classification. A line passing through the widest transverse
diameter divides the inlets into posterior (P) and anterior (A)
segments.
IX. CLINICAL PELVIMETRY (INADEQUATE)
PELVICT INLET
o sacral promontory easily accessible
o DC <11.5 cm
MIDPELVIS
o ischial spines quite prominent/ interspinous diameter <10 cm
o sidewalls convergent
o concavity of the sacrum is shallow
PELVIC OUTLET
o biischial diameter < 8 cm (closed fist)
o shape of subpubic arch more angular
X. PELVIC DIFFERENCES

Table 2. Pelvic Differences

MALE
FALSE PELVIS
PELVIC INLET

heartshaped

PELVIC CAVITY
PELVIC OUTLET
ISCHIAL
TUBEROSITIES
SACRUM
PUBIC ARCH

XII. PELVIC STRUCTURES


MALE

FEMALE
pelvic colon
Rectum
terminal coils of ileum
urinary bladder
ureter (subperitoneal)
Ureter
seminal vesicles
Uterus
prostate gland
Ovaries
ductus (vas) deferens
uterine tube
ejaculatory duct
upper half of the vagina
sigmoid colon

*For Male: See PLATE 346, Netter.


*For Female: See PLATE 342, Netter.

FEMALE
Shallow
Oval
roomier; shorter distance
between inlet and outlet
Larger
Everted
shorter,wider, flatter
more rounded and wider

*See PLATE 334, Netter.

*See PLATE 334, Netter.

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

XIII. WEAK AREAS OF THE PELVIS


Pubic rami
Acetabulum (immediately surrounding)
Region of sacroiliac joint
Alae of the ilium

PERINEUM
I. PERINEUM
located below pelvic diaphragm
anatomically, is the entire pelvic outlet
diamond-shaped
separated from the pelvic cavity by the fascia covering the inferior
aspect of the pelvic diaphragm (formed by the levator ani and
coccygeus muscles)
Boundaries:
o Anterior: symphysis pubis
o Anterolateral: ischiopubic rami

Page 9 of 14

o Posterior: coccyx
o Posterolateral: sacrotuberous lig.
o Lateral: Ischial tuberosities
Divided into two triangles by a transverse line joining the anterior
ends of the ischial tuberosities:
1. Urogenital triangle anterior to line; contains superficial/deep
perineal pouches
2. Anal triangle posterior to line; ischiorectal fossa; Alcocks/
pudendal canal

A. PERINEAL FASCIAE
Superficial
1. Fatty layer
o continuous with that of ischiorectal fossa, thigh and
abdominal wall
o in males, replaced by dartos muscle (which contracts in
response to cold and reduces the surface area of the scrotal
skin) in scrotum and penis
o in females, makes up the substance of the labia majora and
mons pubis
2. Membranous layer (Colles)
o attached laterally to fascia lata of thighs and posteriorly to
the free margin of the perineal membrane
o continuous with the membranous layer of superficial fascia
of the anterior abdominal wall (Scarpas fascia)
o in males, it is continuous with the dartos fascia of the penis
and scrotum
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 10 of
14

o in females, it passes superior to the fatty layer forming the


labia majora and becomes continuous with the membranous
layer of the subcutaneous tissue of the abdomen
Deep (Investing or Gallaudet)
o invests the muscles of the superficial perineal pouch
(ischiocavernosus, bulbocavernosus and superficial transverse
perineal ms)
o attached anteriorly to suspensory ligament of penis/clitoris &
laterally to ischiopubic rami
o continuous w/ the deep fascia of the anterior abdominal wall
o In females, it is fused with the suspensory ligament of the
clitoris, and, as in males, with the deep fascia of the abdomen
B. ANAL TRIANGLE
anterior triangle
contains Ischiorectal fossa and Alcocks / pudendal canal and anal
canal/ anus
Boundaries:
o Posterior: coccyx
o Lateral: ischial tuberosity
o Posterolateral: sacrotuberous ligament
o Midline: anus; on each side, ischiorectal fossa
Nerve supply
o Skin (of anus): inferior rectal nerve
Lymph drainage
o Skin (of anus): medial group of the superficial inguinal nodes

Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

C. ISCHIORECTAL/ ISCHIOANAL FOSSA


wedge-shaped space on sides of anal canal
fascia-lined & is located between the skin of the anal region and
the pelvic diaphragm
Base: skin
Edge: medial & lateral walls
o Medial wall: levator ani muscle & anal canal
o Lateral wall: obturator internus and its covering fascia
Contents:
o Dense fat
supports anal canal but are readily displaced to permit
descent and expansion of the anal canal during the passage
of feces
o Pudendal nerve & internal pudendal vessels in pudendal canal
Ischioanal fossa
Alcock canal is a passageway within the obturator fascia that
covers the medial aspect of the obturator internus
o Inferior rectal vessels & nerve
Branch of pudendal nerve

Page 11 of
14

arise from ischial ramus


inserted into the perineal body
Function: fix perineal body in center of perineum
Nerve Supply: perineal branch of pudendal nerve
o Contents: (FEMALE)
a. Root of the clitoris
crura/bulb of the Vestibule
b. Bulbospongiosus Muscles
c. Ischiocavernosus Muscles
d. Superficial Transverse Perineal Muscles
e. The Greater Vestibular Glands
Secretes a mucous fluid to prepare the vagina for the
reception of the penis during sexual contact

Nerve supply: perineal branch of the pudendal nerve

D. UROGENITAL TRIANGLE
contains superficial and deep perineal pouches
closed by a thin sheet of tough, deep fascia, the perineal
membrane, which stretches between the two sides of the pubic
arch, covering the anterior part of the pelvic outlet
Boundaries:
o anterior: pubic arch
o lateral: ischial tuberosities
o anterolateral: ischiopubic rami
Contents:
o Male: penis and scrotum
o Female: vulva and the orifices of the urethra and vagina
Pouches/Spaces
1. SUPERFICIAL PERINEAL POUCH
o potential space between perineal membrane & Colles fascia
o closed behind due to fusion
o Laterally, closed by attachment to ischiopubic / pubic arch
o Anteriorly, it communicates freely with the potential space
located behind the superficial fascia of the anterior
abdominal wall and muscles
o Contents: (MALE)
a. Root of penis
b. Bulbospongiosus ms
covers bulb of penis & posterior corpus spongiosum
Function: empty urethra of urine/semen and assist
erection of penis
Compress the deep dorsal vein of the penis, impeding
venous drainage of the cavernous spaces and helping
promote enlargement and turgidity of the penis
c. Ischiocavernosus ms
covers crura of penis
Function: maintains erection of penis by compressing
outflow veins and pushing the blood from the root to
the body of the penis
d. Superficial transverse perineal ms
lie in posterior part
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

2. DEEP PERINEAL POUCH


o closed space that is contained between the superficial and
deep layers of fascia
o bounded inferiorly by the perineal membrane, superiorly by
the inferior fascia of the pelvic diaphragm, and laterally by
the inferior portion of the obturator fascia
o it includes the fat-filled anterior recesses of the ischioanal
fossae
o Contents: (MALE)
a. Membranous urethra = in. Long surrounded by sphincter
urethrae ms
b. Sphincter urethrae or external urethral sphincter =
maintain urinary continence
c. Bulbourethral glands = 2 small glands that lie beneath the
sphincter urethrae ms; ducts pierce the perineal
membrane and enter penile urethra
d. Deep Transverse perineal muscles
e. Internal pudendal vessels and branches = enters pouch
and passes forward, giving rise to the artery to the bulb of
the penis, deep artery of penis & dorsal artery of penis
f. Dorsal nerve of the penis = passes forward through the
pouch and supplies the skin of the penis
o Contents: (FEMALE)
a. Part of urethra
b. Part of vagina
c. Sphincter urethrae
d. Deep transverse perineal muscle
e. Internal pudendal vessels
f. Dorsal nerves of clitoris
II. PERINEAL BODY
Central point of the perineum is the midpoint of the line joining
the ischial tuberosities. It is also the location of the perineal body.
Irregular mass, variable in size and consistency, and containing
collagenous and elastic fibers, and both skeletal and smooth
muscle
Located in center of perineum, in front of anus/anal canal,
posterior to the vestibule or bulb of the penis
Attached to perineal membrane by fascia & tendons
Anteriorly, it blends with the posterior border of the perineal
membrane and superiorly with the rectovesical or rectovaginal
septum
Site of interdigitation of the ff muscles.
o Bulbospongiosus ms. in front
o Sphincter ani externus ms behind

Page 12 of
14

o Superficial/deep transverse perineal muscles at the sides


o Muscle slips from external urethral sphincter, levator ani and
muscular coats of rectum
III. UROGENITAL DIAPHRAGM
Triangular musculofascial diaphragm in the anterior triangle
Formed by sphincter urethrae or external urethral sphincter &
deep transverse perineal ms enclosed bet the superior & inferior
fasciae
Inferior fascia = perineal membrane
Superior fascia = inferior fascia of the pelvic diaphragm
Anterior: fasciae fuse, leaving a small gap beneath symphysis
pubis
Posterior: fasciae fuse w/ each other & w/ Colles fascia &
perineal body
Lateral: attached to pubic arch
Urogenital Triangle: Female
o Contents:
a. External genitalia
b. Orifices of urethra & vagina

IV. VULVA
Collective name for female external genitalia
Includes:
o mons pubis
o labia majora & minora
o clitoris
o vestibule of vagina
o vestibular bulb
o greater vestibular glands
Blood Supply
o branches of external & internal pudendal arteries
Venous Drainage
o follows course of arteries
Lymphatic Drainage
o skin: medial group of superficial inguinal nodes
Nerve Supply
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 13 of
14

o Anterior: ilioinguinal nerve & genital branch of genitofemoral


nerve
o Central: pudendal nerve
o Posterior: perineal branch of post. cutaneous n. of thigh
V. PUDENDAL NERVE
Main nerve of perineum and chief sensory nerve of the external
external genitalia
Ant. Div. of ventral rami of S2-S4
Leaves pelvis via greater sciatic foramen, crosses beneath ischial
spine medial to int. pudendal a. Alcocks or pudendal canal
by means of its branches supplies the external anal sphincter and
the muscles and skin of the perineum
3 branches:
o Inferior Hemorrhoidal n. ext. anal sphincter, mucous
membrane of lower half of anal canal & perianal skin
o Perineal n. ms. in urogenital triangle & skin of post surface of
scrotum / labia majora
o Dorsal nerve of clitoris / penis distributed to the penis /
clitoris

- if right handed- use the left hand, insert the index and
middle finger within the vaginal canal and feel for the
ischial spine
- Behind the mucosa, inject 1mL of anesthetic (aspirate
first to make sure that the needle does not hit the blood
vessels)
- At the area of the sacrospinous ligament, inject 3cc of
Lidocane
- Go behind the sacrospinous ligament until to the area of
loose connective tissue, inject 3cc of anesthetic
- Incompletely withdraw the needle, go a little above the
ischial spine and inject the rest of the anesthetic solution
- If successful, after 3-4 minutes there will be no pain felt
when vulva is pinched
o Perineal method
- needle inserted medial to ischial tuberosity
- inject straight into the skin that covers the area medial to
the ischial tuberosity
o Under & beyond ischial spine int. pudendal n.
o Incompletely w/drawn & directed laterally to ischial
tuberosity perineal br of post. femoral cutaneous nerve
E. OBSTETRIC LACERATIONS
Attenuation of the perineal body, associated with diastasis of
the puborectalis and pubococygeus part of levator ani
muscle that may result in the formation of cystocele,
rectocele and/or enterocele.

CLINICAL CORRELATON
A. EPISIOTOMY
- incision in the area of perineum and inferoposterior vaginal
wall
B. PROCTOEPISIOTOMY (midline episiotomy)
- start at the midline going down directly into the anal canal
C. MEDIOLATERAL EPISIOTOMY
- start at the midline going laterally and posteriorly, cutting
through the bulbocavernosus muscle
*if the doctor is right-handed, it is called right mediolateral
episiotomy
D. PUDENDAL NERVE BLOCK
15 cm 22 gauge needle with guard or introducer
15 ml local anesthetics (Lidocane)
Methods
o Transvaginal method
- needle directed to ischial spine & sacrospinous ligament
Group 16 | Dizon, Doce, Domingo, Domogan, Doria, Du, Eamilao, Escano

Page 14 of
14