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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.
A. FALSE PELVIS
Boundaries:
BONY PELVIS
Composed of four bones:
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o SACRUM
5 rudimentary vertebrae fused together
o COCCYX
4 vertebrae fused together
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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
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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.
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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
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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
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
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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
pubis.)
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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
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PELVIC CAVITY
o Pelvic Walls
Anteroinferior
Lateral
Posterior (posterolateral wall and roof)
o Pelvic Floor
MALE
FALSE PELVIS
PELVIC INLET
heartshaped
PELVIC CAVITY
PELVIC OUTLET
ISCHIAL
TUBEROSITIES
SACRUM
PUBIC ARCH
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
FEMALE
Shallow
Oval
roomier; shorter distance
between inlet and outlet
Larger
Everted
shorter,wider, flatter
more rounded and wider
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
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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
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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
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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
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- 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
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