9/13/2014

Pelvis and Perineum

Gray'sAnatomyforStudents,ThirdEdition
RichardL.Drake,A.WayneVogl,andAdamW.M.Mitchell
5,421532
Copyright2015,2010,2005byChurchillLivingstone,animprintofElsevierInc.

5
PelvisandPerineum
ADDITIONALLEARNINGRESOURCESforChapter5,PelvisandPerineum,onSTUDENTCONSULT(
www.studentconsult.com):

ImageLibraryillustrationsofpelvicandperinealanatomy,Chapter5

SelfAssessmentNationalBoardstylemultiplechoicequestions,Chapter5

ShortQuestionsthesearequestionsrequiringshortresponses,Chapter5

InteractiveSurfaceAnatomyinteractivesurfaceanimations,Chapter5

MedicalClinicalCaseStudies,Chapter5
Pelvickidney
Varicocele

ClinicalCases,Chapter5
Varicocele
Sciaticnervecompression
Pelvickidney
Leftcommoniliacarteryobstruction
Latrogenicuretericinjury
Ectopicpregnancy
Uterinetumor
FreeOnlineSelfStudyCourse:AnatomyandEmbryology

Anatomymodules18through22

1/121

9/13/2014

Pelvis and Perineum

Embryologymodules68through70

Conceptualoverview
Generaldescription
Thepelvisandperineumareinterrelatedregionsassociatedwiththepelvicbonesandterminalpartsofthevertebralcolumn.
Thepelvisisdividedintotworegions:

Thesuperiorregionrelatedtoupperpartsofthepelvicbonesandlowerlumbarvertebraeisthefalsepelvis(greater
pelvis)andisgenerallyconsideredpartoftheabdomen(Fig.5.1).

Fig.5.1
Pelvisandperineum.

Thetruepelvis(lesserpelvis)isrelatedtotheinferiorpartsofthepelvicbones,sacrum,andcoccyx,andhasaninlet
andanoutlet.
Thebowlshapedpelviccavityenclosedbythetruepelvisconsistsofthepelvicinlet,walls,andfloor.Thiscavityis
continuoussuperiorlywiththeabdominalcavityandcontainselementsoftheurinary,gastrointestinal,andreproductive
systems.
Theperineum(Fig.5.1)isinferiortothefloorofthepelviccavityitsboundariesformthepelvicoutlet.Theperineumcontains
theexternalgenitaliaandexternalopeningsofthegenitourinaryandgastrointestinalsystems.

Functions
2/121

9/13/2014

Pelvis and Perineum

Containsandsupportsthebladder,rectum,analcanal,andreproductivetracts
Withinthepelviccavity,thebladderispositionedanteriorlyandtherectumposteriorlyinthemidline.
Asitfills,thebladderexpandssuperiorlyintotheabdomen.Itissupportedbyadjacentelementsofthepelvicboneandbythe
pelvicfloor.Theurethrapassesthroughthepelvicfloortotheperineum,where,inwomen,itopensexternally(Fig.5.2A)and
inmenitentersthebaseofthepenis(Fig.5.2B).

3/121

9/13/2014

Pelvis and Perineum

Fig.5.2

4/121

9/13/2014

Pelvis and Perineum

Thepelvisandperineumcontainandsupportterminalpartsofthegastrointestinal,urinary,andreproductivesystems.
A.Inwomen.B.Inmen.
ContinuouswiththesigmoidcolonatthelevelofvertebraSIII,therectumterminatesattheanalcanal,whichpenetratesthe
pelvicfloortoopenintotheperineum.Theanalcanalisangledposteriorlyontherectum.Thisflexureismaintainedbymuscles
ofthepelvicfloorandisrelaxedduringdefecation.Askeletalmusclesphincterisassociatedwiththeanalcanalandtheurethra
aseachpassesthroughthepelvicfloor.
Thepelviccavitycontainsmostofthereproductivetractinwomenandpartofthereproductivetractinmen.

Inwomen,thevaginapenetratesthepelvicfloorandconnectswiththeuterusinthepelviccavity.Theuterusis
positionedbetweentherectumandthebladder.Auterine(fallopian)tubeextendslaterallyoneachsidetowardthepelvic
walltoopenneartheovary.

Inmen,thepelviccavitycontainsthesiteofconnectionbetweentheurinaryandreproductivetracts.Italsocontains
majorglandsassociatedwiththereproductivesystemtheprostateandtwoseminalvesicles.

Anchorstherootsoftheexternalgenitalia
Inbothgenders,therootsoftheexternalgenitalia,theclitorisandthepenis,arefirmlyanchoredto:

thebonymarginoftheanteriorhalfofthepelvicoutlet,and

athick,fibrous,perinealmembrane,whichfillsthearea(Fig.5.3).

Fig.5.3
Theperineumcontainsandanchorstherootsoftheexternalgenitalia.A.Inwomen.B.Inmen.
Therootsoftheexternalgenitaliaconsistoferectile(vascular)tissuesandassociatedskeletalmuscles.

Componentparts
Pelvicinlet
Thepelvicinletissomewhatheartshapedandcompletelyringedbybone(Fig.5.4).Posteriorly,theinletisborderedbythe
bodyofvertebraSI,whichprojectsintotheinletasthesacralpromontory.Oneachsideofthisvertebra,wingliketransverse
processescalledthealae(wings)contributetothemarginofthepelvicinlet.Laterally,aprominentrimonthepelvicbone
continuestheboundaryoftheinletforwardtothepubicsymphysis,wherethetwopelvicbonesarejoinedinthemidline.

5/121

9/13/2014

Pelvis and Perineum

Fig.5.4
Pelvicinlet.
Structurespassbetweenthepelviccavityandtheabdomenthroughthepelvicinlet.
Duringchildbirth,thefetuspassesthroughthepelvicinletfromtheabdomen,intowhichtheuterushasexpandedduring
pregnancy,andthenpassesthroughthepelvicoutlet.

Pelvicwalls
Thewallsofthetruepelvisconsistpredominantlyofbone,muscle,andligaments,withthesacrum,coccyx,andinferiorhalfof
thepelvicbonesformingmuchofthem.
Twoligamentsthesacrospinousandthesacrotuberousligamentsareimportantarchitecturalelementsofthewalls
becausetheylinkeachpelvicbonetothesacrumandcoccyx(Fig.5.5A).Theseligamentsalsoconverttwonotchesonthe
pelvicbonesthegreaterandlessersciaticnotchesintoforaminaonthelateralpelvicwalls.

6/121

9/13/2014

Pelvis and Perineum

Fig.5.5
Pelvicwalls.A.Bonesandligamentsofthepelvicwalls.B.Musclesofthepelvicwalls.
7/121

9/13/2014

Pelvis and Perineum

Completingthewallsaretheobturatorinternusandpiriformismuscles(Fig.5.5B),whichariseinthepelvisandexitthrough
thesciaticforaminatoactonthehipjoint.

Pelvicoutlet
Thediamondshapedpelvicoutletisformedbybothboneandligaments(Fig.5.6).Itislimitedanteriorlyinthemidlinebythe
pubicsymphysis.

Fig.5.6
Pelvicoutlet.
Oneachside,theinferiormarginofthepelvicboneprojectsposteriorlyandlaterallyfromthepubicsymphysistoendina
prominenttuberosity,theischialtuberosity.Together,theseelementsconstructthepubicarch,whichformsthemarginofthe
anteriorhalfofthepelvicoutlet.Thesacrotuberousligamentcontinuesthismarginposteriorlyfromtheischialtuberositytothe
coccyxandsacrum.Thepubicsymphysis,ischialtuberosities,andcoccyxcanallbepalpated.

Pelvicfloor
Thepelvicfloor,whichseparatesthepelviccavityfromtheperineum,isformedbymusclesandfascia(Fig.5.7).

8/121

9/13/2014

Pelvis and Perineum

Fig.5.7
Pelvicfloor.
Twolevatoranimusclesattachperipherallytothepelvicwallsandjoineachotheratthemidlinebyaconnectivetissueraphe.
Togethertheyarethelargestcomponentsofthebowlorfunnelshapedstructureknownasthepelvicdiaphragm,whichis
completedposteriorlybythecoccygeusmuscles.Theselattermusclesoverliethesacrospinousligamentsandpassbetween
themarginsofthesacrumandthecoccyxandaprominentspineonthepelvicbone,theischialspine.
ThepelvicdiaphragmformsmostofthepelvicfloorandinitsanteriorregionscontainsaUshapeddefect,whichisassociated
withelementsoftheurogenitalsystem.
Theanalcanalpassesfromthepelvistotheperineumthroughaposteriorcircularorificeinthepelvicdiaphragm.
Thepelvicfloorissupportedanteriorlyby:

theperinealmembrane,and

musclesinthedeepperinealpouch.
Theperinealmembraneisathick,triangularfascialsheetthatfillsthespacebetweenthearmsofthepubicarch,andhasa
freeposteriorborder(Fig.5.7).Thedeepperinealpouchisanarrowregionsuperiortotheperinealmembrane.
ThemarginsoftheUshapeddefectinthepelvicdiaphragmmergeintothewallsoftheassociatedvisceraandwithmusclesin
thedeepperinealpouchbelow.
Thevaginaandtheurethrapenetratethepelvicfloortopassfromthepelviccavitytotheperineum.

Pelviccavity
Thepelviccavityislinedbyperitoneumcontinuouswiththeperitoneumoftheabdominalcavitythatdrapesoverthesuperior
aspectsofthepelvicviscera,butinmostregions,doesnotreachthepelvicfloor(Fig.5.8A).

9/121

9/13/2014

Pelvis and Perineum

Fig.5.8
Pelviccavityandperitoneum.A.Inmen(sagittalsection).B.Inwomen(anteriorview).
Thepelvicvisceraarelocatedinthemidlineofthepelviccavity.Thebladderisanteriorandtherectumisposterior.Inwomen,
theuterusliesbetweenthebladderandrectum(Fig.5.8B).Otherstructures,suchasvesselsandnerves,liedeeptothe
peritoneuminassociationwiththepelvicwallsandoneithersideofthepelvicviscera.

Perineum

10/121

9/13/2014

Pelvis and Perineum

Theperineumliesinferiortothepelvicfloorbetweenthelowerlimbs(Fig.5.9).Itsmarginisformedbythepelvicoutlet.An
imaginarylinebetweentheischialtuberositiesdividestheperineumintotwotriangularregions.

Fig.5.9
Perineum.A.Inwomen.B.Inmen.

11/121

9/13/2014

Pelvis and Perineum

Anteriorly,theurogenitaltrianglecontainstherootsoftheexternalgenitaliaand,inwomen,theopeningsoftheurethra
andthevagina(Fig.5.9A).Inmen,thedistalpartoftheurethraisenclosedbyerectiletissuesandopensattheendof
thepenis(Fig.5.9B).

Posteriorly,theanaltrianglecontainstheanalaperture.

Relationshiptootherregions
Abdomen
Thecavityofthetruepelvisiscontinuouswiththeabdominalcavityatthepelvicinlet(Fig.5.10A).Allstructurespassing
betweenthepelviccavityandabdomen,includingmajorvessels,nerves,andlymphatics,aswellasthesigmoidcolonand
ureters,passviatheinlet.Inmen,theductusdeferensoneachsidepassesthroughtheanteriorabdominalwallandoverthe
inlettoenterthepelviccavity.Inwomen,ovarianvessels,nerves,andlymphaticspassthroughtheinlettoreachtheovaries,
whichlieoneachsidejustinferiortothepelvicinlet.

12/121

9/13/2014

Pelvis and Perineum

Fig.5.10
Areasofcommunicationbetweenthetruepelvisandotherregions.A.Betweenthetruepelvis,abdomen,andlower
limb.B.Betweentheperineumandotherregions.

Lowerlimb
Threeaperturesinthepelvicwallcommunicatewiththelowerlimb(Fig.5.10A):

theobturatorcanal,

thegreatersciaticforamen,and

thelessersciaticforamen.
Theobturatorcanalformsapassagewaybetweenthepelviccavityandtheadductorregionofthethigh,andisformedinthe
superioraspectoftheobturatorforamen,betweenbone,aconnectivetissuemembrane,andmusclesthatfilltheforamen.
Thelessersciaticforamen,whichliesinferiortothepelvicfloor,providescommunicationbetweentheglutealregionandthe
perineum(Fig.5.10B).
Thepelviccavityalsocommunicatesdirectlywiththeperineumthroughasmallgapbetweenthepubicsymphysisandthe
perinealmembrane(Fig.5.10B).

Keyfeatures
Thepelviccavityprojectsposteriorly
Intheanatomicalposition,theanteriorsuperioriliacspinesandthesuperioredgeofthepubicsymphysislieinthesame
verticalplane(Fig.5.11).Consequently,thepelvicinletisangled5060forwardrelativetothehorizontalplane,andthe
pelviccavityprojectsposteriorlyfromtheabdominalcavity.

13/121

9/13/2014

Pelvis and Perineum

Fig.5.11
Orientationofthepelvisandpelviccavityintheanatomicalposition.
Meanwhile,theurogenitalpartofthepelvicoutlet(thepubicarch)isorientedinanearlyhorizontalplane,whereastheposterior
partoftheoutletispositionedmorevertically.Theurogenitaltriangleoftheperineumthereforefacesinferiorly,whiletheanal
trianglefacesmoreposteriorly.

Importantstructurescrosstheuretersinthepelviccavity
Theuretersdrainthekidneys,coursedowntheposteriorabdominalwall,andcrossthepelvicinlettoenterthepelviccavity.
Theycontinueinferiorlyalongthelateralpelvicwallandultimatelyconnectwiththebaseofthebladder.
Animportantstructurecrossestheuretersinthepelviccavityinbothmenandwomeninwomen,theuterinearterycrosses
theureterlateraltothecervixoftheuterus(Fig.5.12A),andinmen,theductusdeferenscrossesovertheureterjustposterior
tothebladder(Fig.5.12B).

14/121

9/13/2014

Pelvis and Perineum

Fig.5.12
Structuresthatcrosstheuretersinthepelviccavity.A.Inwomen.B.Inmen.

Theprostateinmenandtheuterusinwomenareanteriortotherectum
Inmen,theprostateglandissituatedimmediatelyanteriortotherectum,justabovethepelvicfloor(Fig.5.13).Itcanbefelt
bydigitalpalpationduringarectalexamination.

Fig.5.13
15/121

9/13/2014

Pelvis and Perineum

Positionoftheprostategland.
Inbothsexes,theanalcanalandthelowerrectumalsocanbeevaluatedduringarectalexaminationbyaclinician.Inwomen,
thecervixandlowerpartofthebodyoftheuterusalsoarepalpable.However,thesestructurescanmoreeasilybepalpated
withabimanualexaminationwheretheindexandmiddlefingersofaclinician'shandareplacedinthevaginaandtheotherhand
isplacedontheloweranteriorabdominalwall.Theorgansarefeltbetweenthetwohands.Thisbimanualtechniquecanalsobe
usedtoexaminetheovariesanduterinetubes.

Theperineumisinnervatedbysacralspinalcordsegments
DermatomesoftheperineuminbothmenandwomenarefromspinalcordlevelsS3toS5,exceptfortheanteriorregions,
whichtendtobeinnervatedbyspinalcordlevelL1bynervesassociatedwiththeabdominalwall(Fig.5.14).Dermatomesof
L2toS2arepredominantlyinthelowerlimb.

Fig.5.14
Dermatomesoftheperineum.A.Inwomen.B.Inmen.
Mostoftheskeletalmusclescontainedintheperineumandthepelvicfloor,includingtheexternalanalsphincterandexternal
urethralsphincter,areinnervatedbyspinalcordlevelsS2toS4.
Muchofthesomaticmotorandsensoryinnervationoftheperineumisprovidedbythepudendalnervefromspinalcordlevels
S2toS4.

Nervesarerelatedtobone
Thepudendalnerveisthemajornerveoftheperineumandisdirectlyassociatedwiththeischialspineofthepelvis(Fig.5.15
).Oneachsideofthebody,thesespinesandtheattachedsacrospinousligamentsseparatethegreatersciaticforaminafrom
thelessersciaticforaminaonthelateralpelvicwall.

16/121

9/13/2014

Pelvis and Perineum

Fig.5.15
Pudendalnerve.
Thepudendalnerveleavesthepelviccavitythroughthegreatersciaticforamenandthenimmediatelyenterstheperineum
inferiorlytothepelvicfloorbypassingaroundtheischialspineandthroughthelessersciaticforamen(Fig.5.15).Theischial
spinecanbepalpatedtransvaginallyinwomenandisthelandmarkforadministeringapudendalnerveblock.

ParasympatheticinnervationfromspinalcordlevelsS2toS4controlserection
TheparasympatheticinnervationfromspinalcordlevelsS2toS4controlsgenitalerectioninbothwomenandmen(Fig.5.16).
Oneachside,preganglionicparasympatheticnervesleavetheanteriorramiofthesacralspinalnervesandentertheinferior
hypogastricplexus(pelvicplexus)onthelateralpelvicwall.

17/121

9/13/2014

Pelvis and Perineum

Fig.5.16
PelvicsplanchnicnervesfromspinallevelsS2toS4controlerection.
Thetwoinferiorhypogastricplexusesareinferiorextensionsoftheabdominalprevertebralplexusthatformsontheposterior
abdominalwallinassociationwiththeabdominalaorta.Nervesderivedfromtheseplexusespenetratethepelvicfloorto
innervatetheerectiletissuesoftheclitorisinwomenandthepenisinmen.

Musclesandfasciaofthepelvicfloorandperineumintersectattheperinealbody
Structuresofthepelvicfloorintersectwithstructuresintheperineumattheperinealbody(Fig.5.17).Thispoorlydefined
fibromuscularnodeliesatthecenteroftheperineum,approximatelymidwaybetweenthetwoischialtuberosities.Convergingat
theperinealbodyare:

18/121

9/13/2014

Pelvis and Perineum

Fig.5.17
Perinealbody.

thelevatoranimusclesofthepelvicdiaphragm,and

musclesintheurogenitalandanaltrianglesoftheperineum,includingtheskeletalmusclesphinctersassociatedwiththe
urethra,vagina,andanus.

Thecourseoftheurethraisdifferentinmenandwomen
Inwomen,theurethraisshortandpassesinferiorlyfromthebladderthroughthepelvicfloorandopensdirectlyintothe
perineum(Fig.5.18A).

Fig.5.18
Courseoftheurethra.A.Inwomen.B.Inmen.
19/121

9/13/2014

Pelvis and Perineum

Inmentheurethrapassesthroughtheprostatebeforecoursingthroughthedeepperinealpouchandperinealmembraneand
thenbecomesenclosedwithintheerectiletissuesofthepenisbeforeopeningattheendofthepenis(Fig.5.18B).Thepenile
partofthemaleurethrahastwoangles:

Themoreimportantoftheseisafixedanglewheretheurethrabendsanteriorlyintherootofthepenisafterpassing
throughtheperinealmembrane.

Anotherangleoccursdistallywheretheunattachedpartofthepeniscurvesinferiorlywhenthepenisiserect,this
secondangledisappears.
Itisimportanttoconsiderthedifferentcoursesoftheurethrainmenandwomenwhencatheterizingpatientsandwhen
evaluatingperinealinjuriesandpelvicpathology.

Regionalanatomy
Thepelvisistheregionofthebodysurroundedbythepelvicbonesandtheinferiorelementsofthevertebralcolumn.Itis
dividedintotwomajorregions:thesuperiorregionisthefalse(greater)pelvisandispartoftheabdominalcavitytheinferior
regionisthetrue(lesser)pelvis,whichenclosesthepelviccavity.
Thebowlshapedpelviccavityiscontinuousabovewiththeabdominalcavity.Therimofthepelviccavity(thepelvicinlet)is
completelyencircledbybone.Thepelvicfloorisafibromuscularstructureseparatingthepelviccavityabovefromtheperineum
below.
Theperineumisinferiortothepelvicflooranditsmarginisformedbythepelvicoutlet.Theperineumcontains:

theterminalopeningsofthegastrointestinalandurinarysystems,

theexternalopeningofthereproductivetract,and

therootsoftheexternalgenitalia.

Pelvis
Bones
Thebonesofthepelvisconsistoftherightandleftpelvic(hip)bones,thesacrum,andthecoccyx.Thesacrumarticulates
superiorlywithvertebraLVatthelumbosacraljoint.Thepelvicbonesarticulateposteriorlywiththesacrumatthesacroiliac
jointsandwitheachotheranteriorlyatthepubicsymphysis.

Pelvicbone
Thepelvicboneisirregularinshapeandhastwomajorpartsseparatedbyanobliquelineonthemedialsurfaceofthebone(
Fig.5.19A):

20/121

9/13/2014

Pelvis and Perineum

Fig.5.19
Rightpelvicbone.A.Medialview.B.Lateralview.
21/121

9/13/2014

Pelvis and Perineum

Thepelvicboneabovethislinerepresentsthelateralwallofthefalsepelvis,whichispartoftheabdominalcavity.

Thepelvicbonebelowthislinerepresentsthelateralwallofthetruepelvis,whichcontainsthepelviccavity.
Thelineaterminalisisthelowertwothirdsofthislineandcontributestothemarginofthepelvicinlet.
Thelateralsurfaceofthepelvicbonehasalargearticularsocket,theacetabulum,which,togetherwiththeheadofthefemur,
formsthehipjoint(Fig.5.19B).
Inferiortotheacetabulumisthelargeobturatorforamen,mostofwhichisclosedbyaflatconnectivetissuemembrane,the
obturatormembrane.Asmallobturatorcanalremainsopensuperiorlybetweenthemembraneandadjacentbone,providinga
routeofcommunicationbetweenthelowerlimbandthepelviccavity.
Theposteriormarginoftheboneismarkedbytwonotchesseparatedbytheischialspine:

thegreatersciaticnotch,and

thelessersciaticnotch.
Theposteriormarginterminatesinferiorlyasthelargeischialtuberosity.
Theirregularanteriormarginofthepelvicboneismarkedbytheanteriorsuperioriliacspine,theanteriorinferioriliac
spine,andthepubictubercle.

Componentsofthepelvicbone
Eachpelvicboneisformedbythreeelements:theilium,pubis,andischium.Atbirth,thesebonesareconnectedbycartilagein
theareaoftheacetabulumlater,atbetween16and18yearsofage,theyfuseintoasinglebone(Fig.5.20).

Fig.5.20
Ilium,ischium,andpubis.

Ilium
Ofthethreecomponentsofthepelvicbone,theiliumisthemostsuperiorinposition.
22/121

9/13/2014

Pelvis and Perineum

Theiliumisseparatedintoupperandlowerpartsbyaridgeonthemedialsurface(Fig.5.21A).

Fig.5.21
Componentsofthepelvicbone.A.Medialsurface.B.Lateralsurface.

Posteriorly,theridgeissharpandliesimmediatelysuperiortothesurfaceofthebonethatarticulateswiththesacrum.
ThissacralsurfacehasalargeLshapedfacetforarticulatingwiththesacrumandanexpanded,posteriorroughened
areafortheattachmentofthestrongligamentsthatsupportthesacroiliacjoint(Fig.5.21).

Anteriorly,theridgeseparatingtheupperandlowerpartsoftheiliumisroundedandtermedthearcuateline.
Thearcuatelineformspartofthelineaterminalisandthepelvicbrim.
Theportionoftheiliumlyinginferiorlytothearcuatelineisthepelvicpartoftheiliumandcontributestothewallofthelesseror
truepelvis.
Theupperpartoftheiliumexpandstoformaflat,fanshapedwing,whichprovidesbonysupportforthelowerabdomen,or
falsepelvis.Thispartoftheiliumprovidesattachmentformusclesfunctionallyassociatedwiththelowerlimb.The
anteromedialsurfaceofthewingisconcaveandformstheiliacfossa.Theexternal(gluteal)surfaceofthewingismarkedby
linesandrougheningsandisrelatedtotheglutealregionofthelowerlimb(Fig.5.21B).
Theentiresuperiormarginoftheiliumisthickenedtoformaprominentcrest(theiliaccrest),whichisthesiteofattachmentfor
musclesandfasciaoftheabdomen,back,andlowerlimbandterminatesanteriorlyastheanteriorsuperioriliacspineand
posteriorlyastheposteriorsuperioriliacspine.
Aprominenttubercle,thetuberculumoftheiliaccrest,projectslaterallyneartheanteriorendofthecresttheposteriorendof
thecrestthickenstoformtheiliactuberosity.
Inferiortotheanteriorsuperioriliacspineofthecrest,ontheanteriormarginoftheilium,isaroundedprotuberancecalledthe
anteriorinferioriliacspine.Thisstructureservesasthepointofattachmentfortherectusfemorismuscleoftheanterior
compartmentofthethighandtheiliofemoralligamentassociatedwiththehipjoint.Alessprominentposteriorinferioriliac
spineoccursalongtheposteriorborderofthesacralsurfaceoftheilium,wheretheboneanglesforwardtoformthesuperior
marginofthegreatersciaticnotch.
23/121

9/13/2014

Pelvis and Perineum

Intheclinic
Bonemarrowbiopsy
Incertaindiseases(e.g.,leukemia),asampleofbonemarrowmustbeobtainedtoassessthestageandseverityofthe
problem.Theiliaccrestisoftenusedforsuchbonemarrowbiopsies.Theiliaccrestliesclosetothesurfaceandiseasily
palpated.Abonemarrowbiopsyisperformedbyinjectinganestheticintheskinandpassingacuttingneedlethroughthecortical
boneoftheiliaccrest.Thebonemarrowisaspiratedandviewedunderamicroscope.Samplesofcorticalbonecanalsobe
obtainedinthiswaytoprovideinformationaboutbonemetabolism.

Pubis
Theanteriorandinferiorpartofthepelvicboneisthepubis(Fig.5.21).Ithasabodyandtwoarms(rami).

Thebodyisflatteneddorsoventrallyandarticulateswiththebodyofthepubicboneontheothersideatthepubic
symphysis.Thebodyhasaroundedpubiccrestonitssuperiorsurfacethatendslaterallyastheprominentpubic
tubercle.

Thesuperiorpubicramusprojectsposterolaterallyfromthebodyandjoinswiththeiliumandischiumatitsbase,which
ispositionedtowardtheacetabulum.Thesharpsuperiormarginofthistriangularsurfaceistermedthepectenpubis(
pectinealline),whichformspartofthelineaterminalisofthepelvicboneandthepelvicinlet.Anteriorly,thislineis
continuouswiththepubiccrest,whichalsoispartofthelineaterminalisandpelvicinlet.Thesuperiorpubicramusis
markedonitsinferiorsurfacebytheobturatorgroove,whichformstheuppermarginoftheobturatorcanal.

Theinferiorramusprojectslaterallyandinferiorlytojoinwiththeramusoftheischium.

Ischium
Theischiumistheposteriorandinferiorpartofthepelvicbone(Fig.5.21).Ithas:

alargebodythatprojectssuperiorlytojoinwiththeiliumandthesuperiorramusofthepubis,and

aramusthatprojectsanteriorlytojoinwiththeinferiorramusofthepubis.
Theposteriormarginoftheboneismarkedbyaprominentischialspinethatseparatesthelessersciaticnotch,below,from
thegreatersciaticnotch,above.
Themostprominentfeatureoftheischiumisalargetuberosity(theischialtuberosity)ontheposteroinferioraspectofthe
bone.Thistuberosityisanimportantsitefortheattachmentoflowerlimbmusclesandforsupportingthebodywhensitting.

Sacrum
Thesacrum,whichhastheappearanceofaninvertedtriangle,isformedbythefusionofthefivesacralvertebrae(Fig.5.22).
ThebaseofthesacrumarticulateswithvertebraLV,anditsapexarticulateswiththecoccyx.Eachofthelateralsurfacesof
thebonebearsalargeLshapedfacetforarticulationwiththeiliumofthepelvicbone.Posteriortothefacetisalarge
roughenedareafortheattachmentofligamentsthatsupportthesacroiliacjoint.Thesuperiorsurfaceofthesacrumis
characterizedbythesuperioraspectofthebodyofvertebraSIandisflankedoneachsidebyanexpandedwingliketransverse
processtermedtheala.Theanterioredgeofthevertebralbodyprojectsforwardasthepromontory.Theanteriorsurfaceofthe
sacrumisconcavetheposteriorsurfaceisconvex.Becausethetransverseprocessesofadjacentsacralvertebraefuselateral
tothepositionoftheintervertebralforaminaandlateraltothebifurcationofspinalnervesintoposteriorandanteriorrami,the
posteriorandanteriorramiofspinalnervesS1toS4emergefromthesacrumthroughseparateforamina.Therearefourpairsof
anteriorsacralforaminaontheanteriorsurfaceofthesacrumforanteriorrami,andfourpairsofposteriorsacralforaminaon
theposteriorsurfacefortheposteriorrami.Thesacralcanalisacontinuationofthevertebralcanalthatterminatesasthe
sacralhiatus.

24/121

9/13/2014

Pelvis and Perineum

Fig.5.22
Sacrumandcoccyx.A.Anteriorview.B.Posteriorview.C.Lateralview.

Coccyx
Thesmallterminalpartofthevertebralcolumnisthecoccyx,whichconsistsoffourfusedcoccygealvertebrae(Fig.5.22)and,
likethesacrum,hastheshapeofaninvertedtriangle.Thebaseofthecoccyxisdirectedsuperiorly.Thesuperiorsurfacebears
afacetforarticulationwiththesacrumandtwohorns,orcornua,oneoneachside,thatprojectupwardtoarticulateorfuse
withsimilardownwardprojectingcornuafromthesacrum.Theseprocessesaremodifiedsuperiorandinferiorarticular
processesthatarepresentonothervertebrae.Eachlateralsurfaceofthecoccyxhasasmallrudimentarytransverseprocess,
extendingfromthefirstcoccygealvertebra.Vertebralarchesareabsentfromcoccygealvertebraethereforenobonyvertebral
canalispresentinthecoccyx.
Intheclinic
Pelvicfracture
Thepelviscanbeviewedasaseriesofanatomicalrings.Therearethreebonyringsandfourfibroosseousrings.Themajor
bonypelvicringconsistsofpartsofthesacrum,ilium,andpubis,whichformsthepelvicinlet.Twosmallersubsidiaryringsare
theobturatorforamina.Thegreaterandlessersciaticforaminaformedbythegreaterandlessersciaticnotchesandthe
sacrospinousandsacrotuberousligamentsformthefourfibroosseousrings.Therings,whicharepredominantlybony(i.e.,the
pelvicinletandtheobturatorforamina),arebrittlerings.Itisnotpossibletobreakonesideoftheringwithoutbreakingtheother
sideofthering,whichinclinicaltermsmeansthatifafractureisdemonstratedononeside,asecondfractureshouldalwaysbe
suspected.Fracturesofthepelvismayoccurinisolationhowever,theyusuallyoccurintraumapatientsandwarrantspecial
mention.Owingtothelargebonysurfacesofthepelvis,afractureproducesanareaofbonethatcanbleedsignificantly.Alarge
hematomamaybeproduced,whichcancompressorganssuchasthebladderandtheureters.Thisbloodlossmayoccur
rapidly,reducingthecirculatingbloodvolumeand,unlessthisisreplaced,thepatientwillbecomehypovolemicandshockwill
develop.Pelvicfracturesmayalsodisruptthecontentsofthepelvis,leadingtourethraldisruption,potentialbowelrupture,and
nervedamage.

Joints
Lumbosacraljoints
Thesacrumarticulatessuperiorlywiththelumbarpartofthevertebralcolumn.Thelumbosacraljointsareformedbetween
vertebraLVandthesacrumandconsistof:
25/121

9/13/2014

Pelvis and Perineum

thetwozygapophysialjoints,whichoccurbetweenadjacentinferiorandsuperiorarticularprocesses,and

anintervertebraldiscthatjoinsthebodiesofvertebraeLVandSI(Fig.5.23A).

Fig.5.23
Lumbosacraljointsandassociatedligaments.A.Lateralview.B.Anteriorview.
Thesejointsaresimilartothosebetweenothervertebrae,withtheexceptionthatthesacrumisangledposteriorlyonvertebra
LV.Asaresult,theanteriorpartoftheintervertebraldiscbetweenthetwobonesisthickerthantheposteriorpart.
Thelumbosacraljointsarereinforcedbystrongiliolumbarandlumbosacralligamentsthatextendfromtheexpandedtransverse
processesofvertebraLVtotheiliumandthesacrum,respectively(Fig.5.23B).

Sacroiliacjoints
Thesacroiliacjointstransmitforcesfromthelowerlimbstothevertebralcolumn.TheyaresynovialjointsbetweentheL
shapedarticularfacetsonthelateralsurfacesofthesacrumandsimilarfacetsontheiliacpartsofthepelvicbones(Fig.5.24A
).Thejointsurfaceshaveanirregularcontourandinterlocktoresistmovement.Thejointsoftenbecomefibrouswithageand
maybecomecompletelyossified.

26/121

9/13/2014

Pelvis and Perineum

Fig.5.24
Sacroiliacjointsandassociatedligaments.A.Lateralview.B.Anteriorview.C.Posteriorview.
Eachsacroiliacjointisstabilizedbythreeligaments:

theanteriorsacroiliacligament,whichisathickeningofthefibrousmembraneofthejointcapsuleandrunsanteriorly
andinferiorlytothejoint(Fig.5.24B)

theinterosseoussacroiliacligament,whichisthelargest,strongestligamentofthethree,andispositioned
immediatelyposterosuperiortothejointandattachestoadjacentexpansiveroughenedareasontheiliumandsacrum,
therebyfillingthegapbetweenthetwobones(Fig.5.24A,C)and

theposteriorsacroiliacligament,whichcoverstheinterosseoussacroiliacligament(Fig.5.24C).

Pubicsymphysisjoint
Thepubicsymphysisliesanteriorlybetweentheadjacentsurfacesofthepubicbones(Fig.5.25).Eachofthejoint'ssurfaces
iscoveredbyhyalinecartilageandislinkedacrossthemidlinetoadjacentsurfacesbyfibrocartilage.Thejointissurroundedby
interwovenlayersofcollagenfibersandthetwomajorligamentsassociatedwithitare:

27/121

9/13/2014

Pelvis and Perineum

Fig.5.25
Pubicsymphysisandassociatedligaments.

thesuperiorpubicligament,locatedabovethejoint,and

theinferiorpubicligament,locatedbelowit.
Intheclinic
Commonproblemswiththesacroiliacjoints
Thesacroiliacjointshavebothfibrousandsynovialcomponents,andaswithmanyweightbearingjoints,degenerative
changesmayoccurandcausepainanddiscomfortinthesacroiliacregion.Inaddition,disordersassociatedwiththemajor
histocompatibilitycomplexantigenHLAB27,suchasrheumatoidarthritis,psoriasis,andinflammatoryboweldisease,can
producespecificinflammatorychangeswithinthesejoints.

Orientation
Intheanatomicalposition,thepelvisisorientedsothatthefrontedgeofthetopofthepubicsymphysisandtheanterior
superioriliacspineslieinthesameverticalplane(Fig.5.26).Asaconsequence,thepelvicinlet,whichmarkstheentranceto
thepelviccavity,istiltedtofaceanteriorly,andthebodiesofthepubicbonesandthepubicarcharepositionedinanearly
horizontalplanefacingtheground.

28/121

9/13/2014

Pelvis and Perineum

Fig.5.26
Orientationofthepelvis(anatomicalposition).

Differencesbetweenmenandwomen
Thepelvisesofwomenandmendifferinanumberofways,manyofwhichhavetodowiththepassingofababythrougha
woman'spelviccavityduringchildbirth.

Thepelvicinletinwomeniscircular(Fig.5.27A)comparedwiththeheartshapedpelvicinlet(Fig.5.27B)inmen.The
morecircularshapeispartlycausedbythelessdistinctpromontoryandbroaderalaeinwomen.

Fig.5.27
Structureofthebonypelvis.A.Inwomen.B.Inmen.Theangleformedbythepubicarchcanbe
approximatedbytheanglebetweenthethumbandindexfingerforwomenandtheanglebetweentheindex
fingerandmiddlefingerformenasshownintheinsets.

Theangleformedbythetwoarmsofthepubicarchislargerinwomen(8085)thanitisinmen(5060).

29/121

9/13/2014

Pelvis and Perineum

Theischialspinesgenerallydonotprojectasfarmediallyintothepelviccavityinwomenastheydoinmen.

Truepelvis
Thetruepelvisiscylindricalandhasaninlet,awall,andanoutlet.Theinletisopen,whereasthepelvicfloorclosestheoutlet
andseparatesthepelviccavity,above,fromtheperineum,below.

Pelvicinlet
Thepelvicinletisthecircularopeningbetweentheabdominalcavityandthepelviccavitythroughwhichstructurestraverse
betweentheabdomenandpelviccavity.Itiscompletelysurroundedbybonesandjoints(Fig.5.28).Thepromontoryofthe
sacrumprotrudesintotheinlet,formingitsposteriormargininthemidline.Oneithersideofthepromontory,themarginis
formedbythealaeofthesacrum.Themarginofthepelvicinletthencrossesthesacroiliacjointandcontinuesalongthelinea
terminalis(i.e.,thearcuateline,thepectenpubisorpectinealline,andthepubiccrest)tothepubicsymphysis.

Fig.5.28
Pelvicinlet.

Pelvicwall
Thewallsofthepelviccavityconsistofthesacrum,thecoccyx,thepelvicbonesinferiortothelineaterminalis,twoligaments,
andtwomuscles.

Ligamentsofthepelvicwall
Thesacrospinousandsacrotuberousligaments(Fig.5.29A)aremajorcomponentsofthelateralpelvicwallsthathelpdefine
theaperturesbetweenthepelviccavityandadjacentregionsthroughwhichstructurespass.

30/121

9/13/2014

Pelvis and Perineum

Fig.5.29
Sacrospinousandsacrotuberousligaments.A.Medialviewofrightsideofpelvis.B.Functionoftheligaments.

Thesmallerofthetwo,thesacrospinousligament,istriangular,withitsapexattachedtotheischialspineanditsbase
attachedtotherelatedmarginsofthesacrumandthecoccyx.

Thesacrotuberousligamentisalsotriangularandissuperficialtothesacrospinousligament.Itsbasehasabroad
attachmentthatextendsfromtheposteriorsuperioriliacspineofthepelvicbone,alongthedorsalaspectandthelateral
marginofthesacrum,andontothedorsolateralsurfaceofthecoccyx.Laterally,theapexoftheligamentisattachedto
themedialmarginoftheischialtuberosity.
Theseligamentsstabilizethesacrumonthepelvicbonesbyresistingtheupwardtiltingoftheinferioraspectofthesacrum(
Fig.5.29B).Theyalsoconvertthegreaterandlessersciaticnotchesofthepelvicboneintoforamina(Fig.5.29A,B).

Thegreatersciaticforamenliessuperiortothesacrospinousligamentandtheischialspine.

Thelessersciaticforamenliesinferiortotheischialspineandsacrospinousligamentbetweenthesacrospinousand
sacrotuberousligaments.

Musclesofthepelvicwall
Twomuscles,theobturatorinternusandthepiriformis,contributetothelateralwallsofthepelviccavity.Thesemuscles
originateinthepelviccavitybutattachperipherallytothefemur.

Obturatorinternus
Theobturatorinternusisaflat,fanshapedmusclethatoriginatesfromthedeepsurfaceoftheobturatormembraneandfrom
associatedregionsofthepelvicbonethatsurroundtheobturatorforamen(Fig.5.30andTable5.1).

31/121

9/13/2014

Pelvis and Perineum

Fig.5.30
Obturatorinternusandpiriformismuscles(medialviewofrightsideofpelvis).
Table5.1
Musclesofthepelvicwalls

Muscle

Origin

Insertion

Anterolateralwalloftruepelvis
Medialsurfaceof
Obturator
(deepsurfaceofobturator
greatertrochanterof
internus
membraneandsurroundingbone) femur
Medialsideof
Anteriorsurfaceofsacrum
superiorborderof
Piriformis
betweenanteriorsacralforamina greatertrochanterof
femur

Innervation
Nerveto
obturator
internusL5,
SI

Function
Lateralrotationofthe
extendedhipjoint
abductionofflexedhip

Branches Lateralrotationofthe
fromSI,and extendedhipjoint
S2
abductionofflexedhip

Themusclefibersoftheobturatorinternusconvergetoformatendonthatleavesthepelviccavitythroughthelessersciatic
foramen,makesa90bendaroundtheischiumbetweentheischialspineandischialtuberosity,andthenpassesposteriorto
thehipjointtoinsertonthegreatertrochanterofthefemur.
Theobturatorinternusformsalargepartoftheanterolateralwallofthepelviccavity.

Piriformis
Thepiriformisistriangularandoriginatesinthebridgesofbonebetweenthefouranteriorsacralforamina.Itpasseslaterally
throughthegreatersciaticforamen,crossestheposterosuperioraspectofthehipjoint,andinsertsonthegreatertrochanterof
thefemurabovetheinsertionoftheobturatorinternusmuscle(Fig.5.30andTable5.1).
Alargepartoftheposterolateralwallofthepelviccavityisformedbythepiriformis.Inaddition,thismuscleseparatesthe
greatersciaticforamenintotworegions,oneabovethemuscleandonebelow.Vesselsandnervescoursingbetweenthepelvic
cavityandtheglutealregionpassthroughthesetworegions.
32/121

9/13/2014

Pelvis and Perineum

Aperturesinthepelvicwall
Eachlateralpelvicwallhasthreemajoraperturesthroughwhichstructurespassbetweenthepelviccavityandotherregions:

theobturatorcanal,

thegreatersciaticforamen,and

thelessersciaticforamen.

Obturatorcanal
Atthetopoftheobturatorforamenistheobturatorcanal,whichisborderedbytheobturatormembrane,theassociated
obturatormuscles,andthesuperiorpubicramus(Fig.5.31).Theobturatornerveandvesselspassfromthepelviccavityto
thethighthroughthiscanal.

Fig.5.31
Aperturesinthepelvicwall.

Greatersciaticforamen
Thegreatersciaticforamenisamajorrouteofcommunicationbetweenthepelviccavityandthelowerlimb(Fig.5.31).Itis
formedbythegreatersciaticnotchinthepelvicbone,thesacrotuberousandthesacrospinousligaments,andthespineofthe
ischium.
Thepiriformismusclepassesthroughthegreatersciaticforamen,dividingitintotwoparts.

Thesuperiorglutealnervesandvesselspassthroughtheforamenabovethepiriformis.

33/121

9/13/2014

Pelvis and Perineum

Passingthroughtheforamenbelowthepiriformisaretheinferiorglutealnervesandvessels,thesciaticnerve,the
pudendalnerve,theinternalpudendalvessels,theposteriorfemoralcutaneousnerves,andthenervestotheobturator
internusandquadratusfemorismuscles.

Lessersciaticforamen
Thelessersciaticforamenisformedbythelessersciaticnotchofthepelvicbone,theischialspine,thesacrospinousligament,
andthesacrotuberousligament(Fig.5.31).Thetendonoftheobturatorinternusmusclepassesthroughthisforamentoenter
theglutealregionofthelowerlimb.
Becausethelessersciaticforamenispositionedbelowtheattachmentofthepelvicfloor,itactsasarouteofcommunication
betweentheperineumandtheglutealregion.Thepudendalnerveandinternalpudendalvesselspassbetweenthepelviccavity
(abovethepelvicfloor)andtheperineum(belowthepelvicfloor),byfirstpassingoutofthepelviccavitythroughthegreater
sciaticforamenandthenloopingaroundtheischialspineandsacrospinousligamenttopassthroughthelessersciaticforamen
toentertheperineum.

Pelvicoutlet
Thepelvicoutletisdiamondshaped,withtheanteriorpartofthediamonddefinedpredominantlybyboneandtheposteriorpart
mainlybyligaments(Fig.5.32).Inthemidlineanteriorly,theboundaryofthepelvicoutletisthepubicsymphysis.Extending
laterallyandposteriorly,theboundaryoneachsideistheinferiorborderofthebodyofthepubis,theinferiorramusofthepubis,
theramusoftheischium,andtheischialtuberosity.Together,theelementsonbothsidesformthepubicarch.

Fig.5.32
Pelvicoutlet.
Fromtheischialtuberosities,theboundariescontinueposteriorlyandmediallyalongthesacrotuberousligamentonbothsides
tothecoccyx.
Terminalpartsoftheurinaryandgastrointestinaltractsandthevaginapassthroughthepelvicoutlet.
Theareaenclosedbytheboundariesofthepelvicoutletandbelowthepelvicflooristheperineum.
Intheclinic
Pelvicmeasurementsinobstetrics
Transverseandsagittalmeasurementsofawoman'spelvicinletandoutletcanhelpinpredictingthelikelihoodofasuccessful
vaginaldelivery.Thesemeasurementsinclude:

34/121

9/13/2014

Pelvis and Perineum

thesagittalinlet(betweenthepromontoryandthetopofthepubicsymphysis),

themaximumtransversediameteroftheinlet,

thebispinousoutlet(thedistancebetweenischialspines),and

thesagittaloutlet(thedistancebetweenthetipofthecoccyxandtheinferiormarginofthepubicsymphysis).
Thesemeasurementscanbeobtainedusingmagneticresonanceimaging,whichcarriesnoradiationriskforthefetusormother
(Fig.5.33).

Fig.5.33
SagittalT2weightedmagneticresonanceimageofthelowerabdomenandpelvisofapregnantwoman.

Pelvicfloor
Thepelvicfloorisformedbythepelvicdiaphragmand,intheanteriormidline,theperinealmembraneandthemusclesinthe
deepperinealpouch.Thepelvicdiaphragmisformedbythelevatoraniandthecoccygeusmusclesfrombothsides.Thepelvic
floorseparatesthepelviccavity,above,fromtheperineum,below.

Thepelvicdiaphragm
Thepelvicdiaphragmisthemuscularpartofthepelvicfloor.Shapedlikeabowlorfunnelandattachedsuperiorlytothepelvic
walls,itconsistsofthelevatoraniandthecoccygeusmuscles(Fig.5.34andTable5.2).

35/121

9/13/2014

Pelvis and Perineum

Fig.5.34
Pelvicdiaphragm.
Table5.2
Musclesofthepelvicdiaphragm

Muscle

Origin
Insertion
Inalinearoundthepelvic Theanteriorpartis
wallbeginningonthe
attachedtothesuperior
posterioraspectofthe
surfaceoftheperineal
pubicboneand
membranetheposterior
extendingacrossthe
partmeetsitspartneron
Levatorani
obturatorinternusmuscle theothersideatthe
asatendinousarch
perinealbody,around
(thickeningofthe
theanalcanal,and
obturatorinternusfascia) alongtheanococcygeal
totheischialspine
ligament
Ischialspineandpelvic

Lateralmarginofcoccyx

Innervation Function
Branches
Contributestothe
directfrom formationofthepelvic
theanterior floor,whichsupportsthe
ramusofS4, pelvicvisceramaintains
andbythe ananglebetweenthe
inferiorrectal rectumandanalcanal
branchofthe reinforcestheexternal
pudendal
analsphincterand,in
nerve(S2to women,functionsasa
S4)
vaginalsphincter
Contributestothe
Branches
formationofthepelvic
36/121

9/13/2014

Pelvis and Perineum

Coccygeus surfaceofthe
sacrospinousligament

andrelatedborderof
sacrum

fromthe
floor,whichsupportsthe
anteriorrami pelvicviscerapulls
ofS3andS4 coccyxforwardafter
defecation

Thepelvicdiaphragm'scircularlineofattachmenttothecylindricalpelvicwallpasses,oneachside,betweenthegreatersciatic
foramenandthelessersciaticforamen.Thus:

thegreatersciaticforamenissituatedabovethelevelofthepelvicfloorandisarouteofcommunicationbetweenthe
pelviccavityandtheglutealregionofthelowerlimband

thelessersciaticforamenissituatedbelowthepelvicfloor,providingarouteofcommunicationbetweenthegluteal
regionofthelowerlimbandtheperineum.

Levatorani
Thetwolevatoranimusclesoriginatefromeachsideofthepelvicwall,coursemediallyandinferiorly,andjointogetherinthe
midline.Theattachmenttothepelvicwallfollowsthecircularcontourofthewallandincludes:

theposterioraspectofthebodyofthepubicbone,

alinearthickeningcalledthetendinousarch,inthefasciacoveringtheobturatorinternusmuscle,and

thespineoftheischium.
Atthemidline,themusclesblendtogetherposteriortothevaginainwomenandaroundtheanalapertureinbothsexes.
Posteriortotheanalaperture,themusclescometogetherasaligamentorraphecalledtheanococcygealligament(
anococcygealbody)andattachestothecoccyx.Anteriorly,themusclesareseparatedbyaUshapeddefectorgaptermed
theurogenitalhiatus.Themarginsofthishiatusmergewiththewallsoftheassociatedvisceraandwithmusclesinthedeep
perinealpouchbelow.Thehiatusallowstheurethra(inbothmenandwomen),andthevagina(inwomen),topassthroughthe
pelvicdiaphragm(Fig.5.34).
Thelevatoranimusclesaredividedintoatleastthreecollectionsofmusclefibers,basedonsiteoforiginandrelationshipto
viscerainthemidline:thepubococcygeus,thepuborectalis,andtheiliococcygeusmuscles.

Thepubococcygeusoriginatesfromthebodyofthepubisandcoursesposteriorlytoattachalongthemidlineasfar
backasthecoccyx.Thispartofthemuscleisfurthersubdividedonthebasisofassociationwithstructuresinthe
midlineintothepuboprostaticus(levatorprostatae),thepubovaginalis,andthepuboanalismuscles.

Asecondmajorcollectionofmusclefibers,thepuborectalisportionofthelevatoranimuscles,originates,in
associationwiththepubococcygeusmuscle,fromthepubisandpassesinferiorlyoneachsidetoformaslingaroundthe
terminalpartofthegastrointestinaltract.Thismuscularslingmaintainsanangleorflexure,calledtheperinealflexure,
attheanorectaljunction.Thisanglefunctionsaspartofthemechanismthatkeepstheendofthegastrointestinal
systemclosed.

Thefinalpartofthelevatoranimuscleistheiliococcygeus.Thispartofthemuscleoriginatesfromthefasciathat
coverstheobturatorinternusmuscle.Itjoinsthesamemuscleontheothersideinthemidlinetoformaligamentor
raphethatextendsfromtheanalaperturetothecoccyx.
Thelevatoranimuscleshelpsupportthepelvicvisceraandmaintainclosureoftherectumandvagina.Theyareinnervated
directlybybranchesfromtheanteriorramusofS4andbybranchesofthepudendalnerve(S2toS4).
Intheclinic
Defecation
Atthebeginningofdefecation,closureofthelarynxstabilizesthediaphragmandintraabdominalpressureisincreasedby
contractionofabdominalwallmuscles.Asdefecationproceeds,thepuborectalismusclesurroundingtheanorectaljunction
37/121

9/13/2014

Pelvis and Perineum

relaxes,whichstraightenstheanorectalangle.Boththeinternalandtheexternalanalsphinctersalsorelaxtoallowfecesto
movethroughtheanalcanal.Normally,thepuborectalslingmaintainsanangleofabout90betweentherectumandtheanal
canalandactsasapinchvalvetopreventdefecation.Whenthepuborectalismusclerelaxes,theanorectalangleincreasesto
about130to140.Thefattytissueoftheischioanalfossaallowsforchangesinthepositionandsizeoftheanalcanaland
anusduringdefecation.Duringevacuation,theanorectaljunctionmovesdownandbackandthepelvicfloorusuallydescends
slightly.Duringdefecation,thecircularmusclesoftherectalwallundergoawaveofcontractiontopushfecestowardtheanus.
Asfecesemergefromtheanus,thelongitudinalmusclesoftherectumandlevatoranibringtheanalcanalbackup,thefeces
areexpelled,andtheanusandrectumreturntotheirnormalpositions.

Coccygeus
Thetwococcygeusmuscles,oneoneachside,aretriangularandoverliethesacrospinousligamentstogethertheycomplete
theposteriorpartofthepelvicdiaphragm(Fig.5.34andTable5.2).Theyareattached,bytheirapices,tothetipsoftheischial
spinesand,bytheirbases,tothelateralmarginsofthecoccyxandadjacentmarginsofthesacrum.
ThesecoccygeusmusclesareinnervatedbybranchesfromtheanteriorramiofS3andS4andparticipateinsupportingthe
posterioraspectofthepelvicfloor.

Theperinealmembraneanddeepperinealpouch
Theperinealmembraneisathickfascial,triangularstructureattachedtothebonyframeworkofthepubicarch(Fig.5.35A).
Itisorientedinthehorizontalplaneandhasafreeposteriormargin.Anteriorly,thereisasmallgap(bluearrowinFig.5.35A)
betweenthemembraneandtheinferiorpubicligament(aligamentassociatedwiththepubicsymphysis).

38/121

9/13/2014

Pelvis and Perineum

Fig.5.35
Perinealmembraneanddeepperinealpouch.A.Inferiorview.B.Superolateralview.
Perinealmembraneanddeepperinealpouch.C.Medialview.
Theperinealmembraneisrelatedabovetoathinspacecalledthedeepperinealpouch(deepperinealspace)(Fig.5.35B),
whichcontainsalayerofskeletalmuscleandvariousneurovascularelements.
Thedeepperinealpouchisopenaboveandisnotseparatedfrommoresuperiorstructuresbyadistinctlayeroffascia.The
partsoftheperinealmembraneandstructuresinthedeepperinealpouch,enclosedbytheurogenitalhiatusabove,therefore
contributetothepelvicfloorandsupportelementsoftheurogenitalsysteminthepelviccavity,eventhoughtheperineal
membraneanddeepperinealpouchareusuallyconsideredpartsoftheperineum.
Theperinealmembraneandadjacentpubicarchprovideattachmentfortherootsoftheexternalgenitaliaandthemuscles
associatedwiththem(Fig.5.35C).
Theurethrapenetratesverticallythroughacircularhiatusintheperinealmembraneasitpassesfromthepelviccavity,above,
totheperineum,below.Inwomen,thevaginaalsopassesthroughahiatusintheperinealmembranejustposteriortothe
urethralhiatus.
Withinthedeepperinealpouch,asheetofskeletalmusclefunctionsasasphincter,mainlyfortheurethra,andasastabilizerof
theposterioredgeoftheperinealmembrane(Fig.5.36andTable5.3).
39/121

9/13/2014

Pelvis and Perineum

Fig.5.36
Musclesinthedeepperinealpouch.A.Inwomen.B.Inmen.
Table5.3
Muscleswithinthedeepperinealpouch

Muscle

Origin
Fromtheinferiorramus
ofthepubisoneach
sideandadjacentwalls
ofthedeepperineal
pouch

Insertion

Innervation
Perineal
External
Surrounds
branchesof
urethral
membranouspartof
thepudendal
sphincter
urethra
nerve(S2to
S4)
Perineal
Deep
branchesof
Medialaspectofischial
transverse
Perinealbody
thepudendal
ramus
perineal
nerve(S2to
S4)
Perineal
Compressor
Blendswithpartneron branchesof
Ischiopubicramuson
urethrae(in
othersideanteriorto
thepudendal
eachside
womenonly)
theurethra
nerve(S2to
S4)
Passesforwardlateral Perineal
tothevaginatoblend branchesof
Sphincter
withpartneronother
thepudendal
urethrovaginalis Perinealbody
sideanteriortothe
nerve(S2to
(inwomenonly)
urethra
S4)

Function
Compressesthe
membranousurethra
relaxesduring
micturition

Stabilizestheposition
oftheperinealbody

Functionsasan
accessorysphincterof
theurethra
Functionsasan
accessorysphincterof
theurethra(alsomay
facilitateclosingthe
vagina)
40/121

9/13/2014

Pelvis and Perineum

Anteriorly,agroupofmusclefiberssurroundtheurethraandcollectivelyformtheexternalurethralsphincter.

Twoadditionalgroupsofmusclefibersareassociatedwiththeurethraandvaginainwomen.Onegroupformsthe
sphincterurethrovaginalis,whichsurroundstheurethraandvaginaasaunit.Thesecondgroupformsthecompressor
urethrae,oneachside,whichoriginatefromtheischiopubicramiandmeetanteriortotheurethra.Togetherwiththe
externalurethralsphincter,thesphincterurethrovaginalisandcompressorurethraefacilitateclosingoftheurethra.

Inbothmenandwomen,adeeptransverseperinealmuscleoneachsideparallelsthefreemarginoftheperineal
membraneandjoinswithitspartneratthemidline.Thesemusclesarethoughttostabilizethepositionoftheperineal
body,whichisamidlinestructurealongtheposterioredgeoftheperinealmembrane.

Perinealbody
Theperinealbodyisanilldefinedbutimportantconnectivetissuestructureintowhichmusclesofthepelvicfloorandthe
perineumattach(Fig.5.37).Itispositionedinthemidlinealongtheposteriorborderoftheperinealmembrane,towhichit
attaches.Theposteriorendoftheurogenitalhiatusinthelevatoranimusclesisalsoconnectedtoit.

Fig.5.37
Perinealbody.
Thedeeptransverseperinealmusclesintersectattheperinealbodyinwomen,thesphincterurethrovaginalisalsoattachesto
theperinealbody.Othermusclesthatconnecttotheperinealbodyincludetheexternalanalsphincter,thesuperficialtransverse
perinealmuscles,andthebulbospongiosusmusclesoftheperineum.
Intheclinic
Episiotomy
Duringchildbirththeperinealbodymaybestretchedandtorn.Traditionallyitwasfeltthatifaperinealtearislikely,the
obstetricianmayproceedwithanepisiotomy.Thisisaprocedureinwhichanincisionismadeintheperinealbodytoallowthe
headofthefetustopassthroughthevagina.Therearetwotypesofepisiotomies:amedianepisiotomycutsthroughthe
perinealbody,whileamediolateralepisiotomyisanincision45fromthemidline.Thematernalbenefitsofthisprocedurehave
beenthoughttobelesstraumatictotheperineumandtoresultindecreasedpelvicfloordysfunctionafterchildbirth.However,
morerecentevidencesuggeststhatanepisiotomyshouldnotbeperformedroutinely.Reviewofdatahasfailedtoshowa
decreaseinpelvicfloordamagewithroutineuseofepisiotomies.

Viscera
Thepelvicvisceraincludepartsofthegastrointestinalsystem,theurinarysystem,andthereproductivesystem.Theviscera
arearrangedinthemidline,fromfronttobacktheneurovascularsupplyisthroughbranchesthatpassmediallyfromvessels
andnervesassociatedwiththepelvicwalls.

Gastrointestinalsystem
41/121

9/13/2014

Pelvis and Perineum

Pelvicpartsofthegastrointestinalsystemconsistmainlyoftherectumandtheanalcanal,althoughtheterminalpartofthe
sigmoidcolonisalsointhepelviccavity(Fig.5.38).

Fig.5.38
Rectumandanalcanal.A.Leftpelvicboneremoved.B.Longitudinalsection.

42/121

9/13/2014

Pelvis and Perineum

Rectum
Therectumiscontinuous:

above,withthesigmoidcolonataboutthelevelofvertebraSIII,and

below,withtheanalcanalasthisstructurepenetratesthepelvicfloorandpassesthroughtheperineumtoendasthe
anus.
Therectum,themostposteriorelementofthepelvicviscera,isimmediatelyanteriorto,andfollowstheconcavecontourofthe
sacrum.
Theanorectaljunctionispulledforward(perinealflexure)bytheactionofthepuborectalispartofthelevatoranimuscle,sothe
analcanalmovesinaposteriordirectionasitpassesinferiorlythroughthepelvicfloor.
Inadditiontoconformingtothegeneralcurvatureofthesacrumintheanteroposteriorplane,therectumhasthreelateral
curvaturestheupperandlowercurvaturestotherightandthemiddlecurvaturetotheleft.Thelowerpartoftherectumis
expandedtoformtherectalampulla.Finally,unlikethecolon,therectumlacksdistincttaeniaecolimuscles,omental
appendices,andsacculations(haustraofthecolon).
Intheclinic
Digitalrectalexamination
Adigitalrectalexamination(DRE)isperformedbyplacingtheglovedandlubricatedindexfingerintotherectumthroughthe
anus.Theanalmucosacanbepalpatedforabnormalmasses,andinwomen,theposteriorwallofthevaginaandthecervixcan
bepalpated.Inmen,theprostatecanbeevaluatedforanyextraneousnodulesormasses.Inmanyinstancesthedigitalrectal
examinationmaybefollowedbyproctoscopyorcolonoscopy.Anultrasoundprobemaybeplacedintotherectumtoassessthe
gynecologicalstructuresinfemalesandtheprostateinthemalebeforeperformingaprostaticbiopsy.

Analcanal
Theanalcanalbeginsattheterminalendoftherectalampullawhereitnarrowsatthepelvicfloor.Itterminatesastheanus
afterpassingthroughtheperineum.Asitpassesthroughthepelvicfloor,theanalcanalissurroundedalongitsentirelengthby
theinternalandexternalanalsphincters,whichnormallykeepitclosed.
Theliningoftheanalcanalbearsanumberofcharacteristicstructuralfeaturesthatreflecttheapproximatepositionofthe
anococcygealmembraneinthefetus(whichclosestheterminalendofthedevelopinggastrointestinalsysteminthefetus)and
thetransitionfromgastrointestinalmucosatoskinintheadult(Fig.5.38B).

Theupperpartoftheanalcanalislinedbymucosasimilartothatliningtherectumandisdistinguishedbyanumberof
longitudinallyorientedfoldsknownasanalcolumns,whichareunitedinferiorlybycrescenticfoldstermedanalvalves.
Superiortoeachvalveisadepressiontermedananalsinus.Theanalvalvestogetherformacirclearoundtheanal
canalatalocationknownasthepectinateline,whichmarkstheapproximatepositionoftheanalmembraneinthe
fetus.

Inferiortothepectinatelineisatransitionzoneknownastheanalpecten,whichislinedbynonkeratinizedstratified
squamousepithelium.Theanalpectenendsinferiorlyattheanocutaneousline(whiteline),orwheretheliningofthe
analcanalbecomestrueskin.
Intheclinic
Carcinomaofthecolonandrectum
Carcinomaofthecolonandrectum(colorectum)isacommonandoftenlethaldisease.Recentadvancesinsurgery,
radiotherapy,andchemotherapyhaveonlyslightlyimproved5yearsurvivalrates.Thebiologicalbehavioroftumorsofthecolon
andrectumisrelativelypredictable.Mostofthetumorsdevelopfrombenignpolyps,someofwhichundergomalignantchange.
Theoverallprognosisisrelatedto:

thedegreeoftumorpenetrationthroughthebowelwall,

thepresenceorabsenceoflymphaticdissemination,and

43/121

9/13/2014

Pelvis and Perineum

thepresenceorabsenceofsystemicmetastases.
Giventhepositionofthecolonandrectumintheabdominopelviccavityanditsproximitytootherorgans,itisextremely
importanttoaccuratelystagecolorectaltumors:atumorinthepelvis,forexample,couldinvadetheuterusorbladder.
Assessingwhetherspreadhasoccurredmayinvolveultrasoundscanning,computedtomography,andmagneticresonance
imaging.

Urinarysystem
Thepelvicpartsoftheurinarysystemconsistoftheterminalpartsoftheureters,thebladder,andtheproximalpartofthe
urethra(Fig.5.39).

Fig.5.39
Pelvicpartsoftheurinarysystem.

Ureters
Theuretersenterthepelviccavityfromtheabdomenbypassingthroughthepelvicinlet.Oneachside,theuretercrossesthe
pelvicinletandentersthepelviccavityintheareaanteriortothebifurcationofthecommoniliacartery.Fromthispoint,it
continuesalongthepelvicwallandfloortojointhebaseofthebladder.
Inthepelvis,theureteriscrossedby:

theductusdeferensinmen,and

theuterinearteryinwomen.

Bladder
Thebladderisthemostanteriorelementofthepelvicviscera.Althoughitisentirelysituatedinthepelviccavitywhenempty,it
expandssuperiorlyintotheabdominalcavitywhenfull(Fig.5.39).
44/121

9/13/2014

Pelvis and Perineum

Theemptybladderisshapedlikeathreesidedpyramidthathastippedovertolieononeofitsmargins(Fig.5.40A).Ithasan
apex,abase,asuperiorsurface,andtwoinferolateralsurfaces.

Fig.5.40
Bladder.A.Superolateralview.B.Thetrigone.Anteriorviewwiththeanteriorpartofthebladdercutaway.

Theapexofthebladderisdirectedtowardthetopofthepubicsymphysisastructureknownasthemedianumbilical
ligament(aremnantoftheembryologicalurachusthatcontributestotheformationofthebladder)continuesfromit
superiorlyuptheanteriorabdominalwalltotheumbilicus.

Thebaseofthebladderisshapedlikeaninvertedtriangleandfacesposteroinferiorly.Thetwouretersenterthebladder
ateachoftheuppercornersofthebase,andtheurethradrainsinferiorlyfromthelowercornerofthebase.Inside,the
mucosalliningonthebaseofthebladderissmoothandfirmlyattachedtotheunderlyingsmoothmusclecoatofthewall
unlikeelsewhereinthebladderwherethemucosaisfoldedandlooselyattachedtothewall.Thesmoothtriangular
areabetweentheopeningsoftheuretersandurethraontheinsideofthebladderisknownasthetrigone(Fig.5.40B).

Theinferolateralsurfacesofthebladderarecradledbetweenthelevatoranimusclesofthepelvicdiaphragmandthe
adjacentobturatorinternusmusclesabovetheattachmentofthepelvicdiaphragm.Thesuperiorsurfaceisslightly
domedwhenthebladderisemptyitballoonsupwardasthebladderfills.
45/121

9/13/2014

Pelvis and Perineum

Neckofbladder
Theneckofthebladdersurroundstheoriginoftheurethraatthepointwherethetwoinferolateralsurfacesandthebase
intersect.
Theneckisthemostinferiorpartofthebladderandalsothemostfixedpart.Itisanchoredintopositionbyapairoftough
fibromuscularbands,whichconnecttheneckandpelvicpartoftheurethratotheposteroinferioraspectofeachpubicbone.

Inwomen,thesefibromuscularbandsaretermedpubovesicalligaments(Fig.5.41A).Togetherwiththeperineal
membraneandassociatedmuscles,thelevatoranimuscles,andthepubicbones,theseligamentshelpsupportthe
bladder.

Fig.5.41
Ligamentsthatanchortheneckofthebladderandpelvicpartoftheurethratothepelvicbones.A.Inwomen.
B.Inmen.

Inmen,thepairedfibromuscularbandsareknownaspuboprostaticligamentsbecausetheyblendwiththefibrous
capsuleoftheprostate,whichsurroundstheneckofthebladderandadjacentpartoftheurethra(Fig.5.41B).

46/121

9/13/2014

Pelvis and Perineum

Althoughthebladderisconsideredtobepelvicintheadult,ithasahigherpositioninchildren.Atbirth,thebladderisalmost
entirelyabdominaltheurethrabeginsapproximatelyattheuppermarginofthepubicsymphysis.Withage,thebladder
descendsuntilafterpubertywhenitassumestheadultposition.
Intheclinic
Bladderstones
Insomepatients,smallcalculi(stones)forminthekidneys.Thesemaypassdowntheureter,causinguretericobstruction,and
intothebladder(Fig.5.42),whereinsolublesaltsfurtherprecipitateonthesesmallcalculitoformlargercalculi.Often,these
patientsdevelop(ormayalreadyhave)problemswithbladderemptying,whichleavesresidualurineinthebladder.Thisurine
maybecomeinfected,whichaltersthepHoftheurine,permittingfurtherprecipitationofinsolublesalts.Ifsmallenough,the
stonesmayberemovedviaatransurethralrouteusingspecializedinstruments.Ifthestonesaretoobig,itmaybenecessary
tomakeasuprapubicincisionandenterthebladderretroperitoneallytoremovethem.

Fig.5.42
Intravenousurogramdemonstratingastoneinthelowerportionoftheureter.A.Controlradiograph.B.Intravenous
urogram,postmicturition.
Intheclinic
Suprapubiccatheterization
Incertaininstancesitisnecessarytocatheterizethebladderthroughtheanteriorabdominalwall.Forexample,whenthe
prostateismarkedlyenlargedanditisimpossibletopassaurethralcatheter,asuprapubiccathetermaybeplaced.Thebladder
isaretroperitonealstructureandwhenfullliesadjacenttotheanteriorabdominalwall.Ultrasoundvisualizationofthebladder
maybeusefulinassessingthesizeofthisstructureand,importantly,differentiatingthisstructurefromotherpotential
abdominalmasses.Theprocedureofsuprapubiccatheterizationisstraightforwardandinvolvesthepassageofasmallcatheter
onaneedleinthemidlineapproximately2cmabovethepubicsymphysis.Thecatheterpasseseasilyintothebladderwithout
compromiseofotherstructuresandpermitsfreedrainage.
Intheclinic
Bladdercancer
Bladdercancer(Fig.5.43)isthemostcommontumoroftheurinarytractandisusuallyadiseaseofthesixthandseventh
decades,althoughthereisanincreasingtrendforyoungerpatientstodevelopthisdisease.Approximatelyonethirdofbladder
tumorsaremultifocalfortunately,twothirdsaresuperficialtumorsandamenabletolocaltreatment.Bladdertumorsmayspread
throughthebladderwallandinvadelocalstructures,includingtherectum,uterus(inwomen),andlateralwallsofthepelvic
cavity.Prostaticinvolvementisnotuncommoninmalepatients.Thediseasespreadsviatheinternaliliaclymphnodes.Spread
todistantmetastaticsitesrarelyincludesthelung.Treatmentforearlystagetumorsincludeslocalresectionwithpreservationof
47/121

9/13/2014

Pelvis and Perineum

thebladder.Diffusetumorsmaybetreatedwithlocalchemotherapymoreextensivetumorsmayrequireradicalsurgical
removalofthebladderand,inmen,theprostate.Largebladdertumorsmayproducecomplications,includinginvasionand
obstructionoftheureters.Uretericobstructioncanthenobstructthekidneysandinducekidneyfailure.Moreover,bladder
tumorscaninvadeotherstructuresofthepelviccavity.

Fig.5.43
Intravenousurogramdemonstratingasmalltumorinthewallofthebladder.

Urethra
Theurethrabeginsatthebaseofthebladderandendswithanexternalopeningintheperineum.Thepathstakenbytheurethra
differsignificantlyinwomenandmen.

Inwomen
Inwomen,theurethraisshort,beingabout4cmlong.Ittravelsaslightlycurvedcourseasitpassesinferiorlythroughthe
pelvicfloorintotheperineum,whereitpassesthroughthedeepperinealpouchandperinealmembranebeforeopeninginthe
vestibulethatliesbetweenthelabiaminora(Fig.5.44A).

48/121

9/13/2014

Pelvis and Perineum

49/121

9/13/2014

Pelvis and Perineum

Fig.5.44
Urethra.A.Inwomen.B.Inmen.C.Prostaticpartoftheurethrainmen.
Theurethralopeningisanteriortothevaginalopeninginthevestibule.Theinferioraspectoftheurethraisboundtotheanterior
surfaceofthevagina.Twosmallparaurethralmucousglands(Skene'sglands)areassociatedwiththelowerendofthe
urethra.Eachdrainsviaaductthatopensontothelateralmarginoftheexternalurethralorifice.

Inmen
Inmen,theurethraislong,about20cm,andbendstwicealongitscourse(Fig.5.44B).Beginningatthebaseofthebladder
andpassinginferiorlythroughtheprostate,itpassesthroughthedeepperinealpouchandperinealmembraneandimmediately
enterstherootofthepenis.Astheurethraexitsthedeepperinealpouch,itbendsforwardtocourseanteriorlyintherootofthe
penis.Whenthepenisisflaccid,theurethramakesanotherbend,thistimeinferiorly,whenpassingfromtheroottothebodyof
thepenis.Duringerection,thebendbetweentherootandbodyofthepenisdisappears.
Theurethrainmenisdividedintopreprostatic,prostatic,membranous,andspongyparts.

Preprostaticpart.
Thepreprostaticpartoftheurethraisabout1cmlong,extendsfromthebaseofthebladdertotheprostate,andisassociated
withacircularcuffofsmoothmusclefibers(theinternalurethralsphincter).Contractionofthissphincterpreventsretrograde
movementofsemenintothebladderduringejaculation.

Prostaticpart.
Theprostaticpartoftheurethra(Fig.5.44C)is3to4cmlongandissurroundedbytheprostate.Inthisregion,thelumenofthe
urethraismarkedbyalongitudinalmidlinefoldofmucosa(theurethralcrest).Thedepressiononeachsideofthecrestisthe
prostaticsinustheductsoftheprostateemptyintothesetwosinuses.
Midwayalongitslength,theurethralcrestisenlargedtoformasomewhatcircularelevation(theseminalcolliculus).Inmen,the
seminalcolliculusisusedtodeterminethepositionoftheprostateglandduringtransurethraltransectionoftheprostate.

50/121

9/13/2014

Pelvis and Perineum

Asmallblindendedpouchtheprostaticutricle(thoughttobethehomologueoftheuterusinwomen)opensontothecenter
oftheseminalcolliculus.Oneachsideoftheprostaticutricleistheopeningoftheejaculatoryductofthemalereproductive
system.Thereforetheconnectionbetweentheurinaryandreproductivetractsinmenoccursintheprostaticpartoftheurethra.

Membranouspart.
Themembranouspartoftheurethraisnarrowandpassesthroughthedeepperinealpouch(Fig.5.44B).Duringitstransit
throughthispouch,theurethra,inbothmenandwomen,issurroundedbyskeletalmuscleoftheexternalurethralsphincter.

Spongyurethra.
Thespongyurethraissurroundedbyerectiletissue(thecorpusspongiosum)ofthepenis.Itisenlargedtoformabulbatthe
baseofthepenisandagainattheendofthepenistoformthenavicularfossa(Fig.5.44B).Thetwobulbourethralglandsin
thedeepperinealpoucharepartofthemalereproductivesystemandopenintothebulbofthespongyurethra.Theexternal
urethralorificeisthesagittalslitattheendofthepenis.
Intheclinic
Bladderinfection
Therelativelyshortlengthoftheurethrainwomenmakesthemmoresusceptiblethanmentobladderinfection.Theprimary
symptomofurinarytractinfectioninwomenisusuallyinflammationofthebladder(cystitis).Theinfectioncanbecontrolledin
mostinstancesbyoralantibioticsandresolveswithoutcomplication.Inchildrenunder1yearofage,infectionfromthebladder
mayspreadviatheureterstothekidneys,whereitcanproducerenaldamageandultimatelyleadtorenalfailure.Early
diagnosisandtreatmentarenecessary.
Intheclinic
Urethralcatheterization
Urethralcatheterizationisoftenperformedtodrainurinefromapatient'sbladderwhenthepatientisunabletomicturate.When
insertingurinarycatheters,itisimportanttoappreciatethegenderanatomyofthepatient.Inmen:

Thespongyurethraissurroundedbytheerectiletissueofthebulbofthepenisimmediatelyinferiortothedeepperineal
pouch.Thewallofthisshortsegmentofurethraisrelativelythinandanglessuperiorlytopassthroughthedeepperineal
pouchatthispositiontheurethraisvulnerabletodamage,notablyduringcystoscopy.

Themembranouspartoftheurethrarunssuperiorlyasitpassesthroughthedeepperinealpouch.

Theprostaticpartoftheurethratakesaslightconcavecurveanteriorlyasitpassesthroughtheprostategland.
Inwomen,itismuchsimplertopasscathetersandcystoscopesbecausetheurethraisshortandstraight.Urinemaytherefore
bereadilydrainedfromadistendedbladderwithoutsignificantconcernforurethralrupture.Occasionally,itisimpossibletopass
anyformofinstrumentationthroughtheurethratodrainthebladder,usuallybecausethereisaurethralstrictureorprostatic
enlargement.Insuchcases,anultrasoundofthelowerabdomenwilldemonstrateafullbladder(Fig.5.45)behindtheanterior
abdominalwall.Asuprapubiccathetermaybeinsertedintothebladderwithminimaltraumathroughasmallincisionunderlocal
anesthetic.

51/121

9/13/2014

Pelvis and Perineum

Fig.5.45
Ultrasounddemonstratingthebladder.A.Fullbladder.B.Postmicturitionbladder.

Reproductivesystem
Inmen
Thereproductivesysteminmenhascomponentsintheabdomen,pelvis,andperineum(Fig.5.46A).Themajorcomponents
areatestis,epididymis,ductusdeferens,andejaculatoryductoneachside,andtheurethraandpenisinthemidline.In
addition,threetypesofaccessoryglandsareassociatedwiththesystem:

52/121

9/13/2014

Pelvis and Perineum

53/121

9/13/2014

Pelvis and Perineum

Fig.5.46
Reproductivesysteminmen.A.Overview.B.Testisandsurroundingstructures.

asingleprostate,

apairofseminalvesicles,and

apairofbulbourethralglands.
Thedesignofthereproductivesysteminmenisbasicallyaseriesofductsandtubules.Thearrangementofpartsandlinkage
totheurinarytractreflectsitsembryologicaldevelopment.

Testes
Thetestesoriginallydevelophighontheposteriorabdominalwallandthendescend,normallybeforebirth,throughtheinguinal
canalintheanteriorabdominalwallandintothescrotumoftheperineum.Duringdescent,thetestescarrytheirvessels,
lymphatics,andnerves,aswellastheirprincipaldrainageducts,theductusdeferens(vasdeferens)withthem.Thelymph
drainageofthetestesisthereforetothelateralaorticorlumbarnodesandpreaorticnodesintheabdomen,andnottothe
inguinalorpelviclymphnodes.
Eachellipsoidshapedtestisisenclosedwithintheendofanelongatedmusculofascialpouch,whichiscontinuouswiththe
anteriorabdominalwallandprojectsintothescrotum.Thespermaticcordisthetubeshapedconnectionbetweenthepouchin
thescrotumandtheabdominalwall.
Thesidesandanterioraspectofthetestisarecoveredbyaclosedsacofperitoneum(thetunicavaginalis),whichoriginally
connectedtotheabdominalcavity.Normallyaftertesticulardescent,theconnectioncloses,leavingafibrousremnant.

54/121

9/13/2014

Pelvis and Perineum

Eachtestis(Fig.5.46B)iscomposedofseminiferoustubulesandinterstitialtissuesurroundedbyathickconnectivetissue
capsule(thetunicaalbuginea).Spermatozoaareproducedbytheseminiferoustubules.The400to600highlycoiled
seminiferoustubulesaremodifiedateachendtobecomestraighttubules,whichconnecttoacollectingchamber(therete
testis)inathick,verticallyorientedlinearwedgeofconnectivetissue(themediastinumtestis),projectingfromthecapsule
intotheposterioraspectofthegonad.Approximately12to20efferentductulesoriginatefromtheupperendoftheretetestis,
penetratethecapsule,andconnectwiththeepididymis.
Intheclinic
Testiculartumors
Tumorsofthetestisaccountforasmallpercentageofmalignanciesinmen.However,theygenerallyoccurinyoungerpatients
(between20and40yearsofage).Whendiagnosedatanearlystage,mostofthesetumorsarecurablebysurgeryand
chemotherapy.Earlydiagnosisoftesticulartumorisextremelyimportant.Abnormallumpscanbedetectedbypalpation,and
diagnosiscanbemadeusingultrasound.Simpleultrasoundscanningcanrevealtheextentofthelocaltumor,usuallyatan
earlystage.Surgicalremovalofthemalignanttestisisoftencarriedoutusinganinguinalapproach.Thetestisisnotusually
removedthroughascrotalincision,becauseitispossibletospreadtumorcellsintothesubcutaneoustissuesofthescrotum,
whichhasadifferentlymphaticdrainagethanthetestis.

Epididymis
Theepididymiscoursesalongtheposterolateralsideofthetestis(Fig.5.46B).Ithastwodistinctcomponents:

theefferentductules,whichformanenlargedcoiledmassthatsitsontheposteriorsuperiorpoleofthetestisandforms
theheadoftheepididymisand

thetrueepididymis,whichisasingle,longcoiledductintowhichtheefferentductulesalldrain,andwhichcontinues
inferiorlyalongtheposterolateralmarginofthetestisasthebodyoftheepididymisandenlargestoformthetailofthe
epididymisattheinferiorpoleofthetestis.
Duringpassagethroughtheepididymis,spermatozoaacquiretheabilitytomoveandfertilizeanegg.Theepididymisalso
storesspermatozoauntilejaculation.Theendoftheepididymisiscontinuouswiththeductusdeferens.

Ductusdeferens
Theductusdeferensisalongmuscularductthattransportsspermatozoafromthetailoftheepididymisinthescrotumtothe
ejaculatoryductinthepelviccavity(Fig.5.46A).Itascendsinthescrotumasacomponentofthespermaticcordandpasses
throughtheinguinalcanalintheanteriorabdominalwall.
Afterpassingthroughthedeepinguinalring,theductusdeferensbendsmediallyaroundthelateralsideoftheinferiorepigastric
arteryandcrossestheexternaliliacarteryandtheexternaliliacveinatthepelvicinlettoenterthepelviccavity.
Theductdescendsmediallyonthepelvicwall,deeptotheperitoneum,andcrossestheureterposteriortothebladder.It
continuesinferomediallyalongthebaseofthebladder,anteriortotherectum,almosttothemidline,whereitisjoinedbythe
ductoftheseminalvesicletoformtheejaculatoryduct.
Betweentheureterandejaculatoryduct,theductusdeferensexpandstoformtheampullaoftheductusdeferens.The
ejaculatoryductpenetratesthroughtheprostateglandtoconnectwiththeprostaticurethra.
Intheclinic
Vasectomy
Theductusdeferenstransportsspermatozoafromthetailoftheepididymisinthescrotumtotheejaculatoryductinthepelvic
cavity.Becauseithasathicksmoothmusclewall,itcanbeeasilypalpatedinthespermaticcordbetweenthetestesandthe
superficialinguinalring.Also,becauseitcanbeaccessedthroughskinandsuperficialfascia,itisamenabletosurgical
dissectionandsurgicaldivision.Whenthisiscarriedoutbilaterally(vasectomy),thepatientisrenderedsterilethisisauseful
methodformalecontraception.

Seminalvesicle
Eachseminalvesicleisanaccessoryglandofthemalereproductivesystemthatdevelopsasablindendedtubularoutgrowth
fromtheductusdeferens(Fig.5.46A).Thetubeiscoiledwithnumerouspocketlikeoutgrowthsandisencapsulatedby
connectivetissuetoformanelongatestructuresituatedbetweenthebladderandrectum.Theglandisimmediatelylateralto
andfollowsthecourseoftheductusdeferensatthebaseofthebladder.
Theductoftheseminalvesiclejoinstheductusdeferenstoformtheejaculatoryduct(Fig.5.47).Secretionsfromtheseminal
vesiclecontributesignificantlytothevolumeoftheejaculate(semen).

Prostate
55/121

9/13/2014

Pelvis and Perineum

Theprostateisanunpairedaccessorystructureofthemalereproductivesystemthatsurroundstheurethrainthepelviccavity
(Figs.5.46Aand5.47).Itliesimmediatelyinferiortothebladder,posteriortothepubicsymphysis,andanteriortotherectum.

Fig.5.47
Theprostategland.Zonalanatomy.
Theprostateisshapedlikeaninvertedroundedconewithalargerbase,whichiscontinuousabovewiththeneckofthebladder,
andanarrowerapex,whichrestsbelowonthepelvicfloor.Theinferolateralsurfacesoftheprostateareincontactwiththe
levatoranimusclesthattogethercradletheprostatebetweenthem.
Theprostatedevelopsas30to40individualcomplexglands,whichgrowfromtheurethralepitheliumintothesurroundingwall
oftheurethra.Collectively,theseglandsenlargethewalloftheurethraintowhatisknownastheprostatehowever,the
individualglandsretaintheirownducts,whichemptyindependentlyintotheprostaticsinusesontheposterioraspectofthe
urethrallumen(seeFig.5.44C).
Secretionsfromtheprostate,togetherwithsecretionsfromtheseminalvesicles,contributetotheformationofsemenduring
ejaculation.
Theejaculatoryductspassalmostverticallyinananteroinferiordirectionthroughtheposterioraspectoftheprostatetoopen
intotheprostaticurethra.

Bulbourethralglands
Thebulbourethralglands(seeFig.5.46A),oneoneachside,aresmall,peashapedmucousglandssituatedwithinthedeep
perinealpouch.Theyarelateraltothemembranouspartoftheurethra.Theductfromeachglandpassesinferomediallythrough
theperinealmembrane,toopenintothebulbofthespongyurethraattherootofthepenis.
Togetherwithsmallglandspositionedalongthelengthofthespongyurethra,thebulbourethralglandscontributetolubrication
oftheurethraandthepreejaculatoryemissionfromthepenis.
Intheclinic
Prostateproblems
Prostatecancerisoneofthemostcommonlydiagnosedmalignanciesinmen,andoftenthediseaseisadvancedatdiagnosis.
Prostatecancertypicallyoccursintheperipheralzoneoftheprostate(seeFig.5.47)andisrelativelyasymptomatic.Inmany
cases,itisdiagnosedbyadigitalrectalexamination(DRE)(Fig.5.48A)andbybloodtests,whichincludeserumacid
phosphataseandserumprostatespecificantigen(PSA).Inrectalexams,thetumorousprostatefeelsrockhard.The
diagnosisisusuallymadebyobtaininganumberofbiopsiesoftheprostate.Ultrasoundisusedduringthebiopsyprocedureto
imagetheprostateforthepurposeoftakingmeasurementsandforneedleplacement.Benignprostatichypertrophyisadisease
oftheprostatethatoccurswithincreasingageinmostmen(Fig.5.48B).Itgenerallyinvolvesthemorecentralregionsofthe
prostate(seeFig.5.47),whichgraduallyenlarge.TheprostatefeelsbulkyonDRE.Owingtothemorecentralhypertrophic
changeoftheprostate,theurethraiscompressed,andaurinaryoutflowobstructiondevelopsinanumberofpatients.With
time,thebladdermaybecomehypertrophiedinresponsetotheurinaryoutflowobstruction.Insomemalepatients,the
obstructionbecomessoseverethaturinecannotbepassedandtransurethralorsuprapubiccatheterizationisnecessary.
56/121

9/13/2014

Pelvis and Perineum

Despitebeingabenigndisease,benignprostatichypertrophycanthereforehaveamarkedeffectonthedailylivesofmany
patients.

Fig.5.48
AxialT2weightedmagneticresonanceimagesofprostateproblems.A.Asmallprostaticcancerintheperipheral
zoneofanormalsizedprostate.B.Benignprostatichypertrophy.

Inwomen
Thereproductivetractinwomeniscontainedmainlyinthepelviccavityandperineum,althoughduringpregnancy,theuterus
expandsintotheabdominalcavity.Majorcomponentsofthesystemconsistof:

anovaryoneachside,and

57/121

9/13/2014

Pelvis and Perineum

auterus,vagina,andclitorisinthemidline(Fig.5.49).

Fig.5.49
Reproductivesysteminwomen.
Inaddition,apairofaccessoryglands(thegreatervestibularglands)areassociatedwiththetract.

Ovaries
Likethetestesinmen,theovariesdevelophighontheposteriorabdominalwallandthendescendbeforebirth,bringingwith
themtheirvessels,lymphatics,andnerves.Unlikethetestes,theovariesdonotmigratethroughtheinguinalcanalintothe
perineum,butstopshortandassumeapositiononthelateralwallofthepelviccavity(Fig.5.50).

58/121

9/13/2014

Pelvis and Perineum

Fig.5.50
Ovariesandbroadligament.
Theovariesarethesitesofeggproduction(oogenesis).Matureeggsareovulatedintotheperitonealcavityandnormally
directedintotheadjacentopeningsoftheuterinetubesbyciliaontheendsoftheuterinetubes.
Theovarieslieadjacenttothelateralpelvicwalljustinferiortothepelvicinlet.Eachofthetwoalmondshapedovariesisabout
3cmlongandissuspendedbyamesentery(themesovarium)thatisaposteriorextensionofthebroadligament.
Intheclinic
Ovariancancer
Ovariancancerremainsoneofthemajorchallengesinoncology.Theovariescontainnumerouscelltypes,allofwhichcan
undergomalignantchangeandrequiredifferentimagingandtreatmentprotocolsandultimatelyhavedifferentprognoses.Ovarian
tumorsmostcommonlyoriginatefromthesurfaceepitheliumthatcoverstheovaryandiscontinuousatasharptransitionzone
withtheperitoneumofthemesovarium.Manyfactorshavebeenlinkedwiththedevelopmentofovariantumors,includinga
strongfamilyhistory.Ovariancancermayoccuratanyage,butmoretypicallyitoccursinolderwomen.Canceroftheovaries
mayspreadviathebloodandlymphatics,andfrequentlymetastasizesdirectlyintotheperitonealcavity.Suchdirectperitoneal
cavityspreadallowsthepassageoftumorcellsalongtheparacolicguttersandovertheliverfromwherethisdiseasemay
59/121

9/13/2014

Pelvis and Perineum

disseminateeasily.Unfortunately,manypatientsalreadyhavemetastaticanddiffusedisease(Fig.5.51)atthetimeof
diagnosis.

Fig.5.51
Sagittalmagneticresonanceimagedemonstratingovariancancer.
Intheclinic
Imagingtheovary
Theovariescanbevisualizedusingultrasound.Ifthepatientdrinksenoughwater,thebladderbecomesenlargedandfull.This
fluidfilledcavityprovidesanexcellentacousticwindow,behindwhichtheuterusandovariesmaybeidentifiedby
transabdominalscanningwithultrasound.Thistechniquealsoallowsobstetriciansandtechnicianstoviewafetusandrecordits
growththroughoutpregnancy.Somepatientsarenotsuitablefortransabdominalscanning,inwhichcaseaprobemaybepassed
intothevagina,permittingclosevisualizationoftheuterus,thecontentsoftherectouterinepouch(pouchofDouglas),andthe
ovaries.Theovariescanalsobevisualizedlaparoscopically.

Uterus
Theuterusisathickwalledmuscularorganinthemidlinebetweenthebladderandrectum(seeFig.5.50).Itconsistsofabody
andacervix,andinferiorlyitjoinsthevagina(Fig.5.52).Superiorly,uterinetubesprojectlaterallyfromtheuterusandopen
intotheperitonealcavityimmediatelyadjacenttotheovaries.

Fig.5.52
Uterus.Anteriorview.Theanteriorhalvesoftheuterusandvaginahavebeencutaway.
Thebodyoftheuterusisflattenedanteroposteriorlyand,abovetheleveloforiginoftheuterinetubes(Fig.5.52),hasa
roundedsuperiorend(fundusoftheuterus).Thecavityofthebodyoftheuterusisanarrowslit,whenviewedlaterally,andis
shapedlikeaninvertedtriangle,whenviewedanteriorly.Eachofthesuperiorcornersofthecavityiscontinuouswiththelumen
ofauterinetubetheinferiorcorneriscontinuouswiththecentralcanalofthecervix.
60/121

9/13/2014

Pelvis and Perineum

Implantationoftheblastocystnormallyoccursinthebodyoftheuterus.Duringpregnancy,theuterusdramaticallyexpands
superiorlyintotheabdominalcavity.
Intheclinic
Hysterectomy
Ahysterectomyisthesurgicalremovaloftheuterus.Thisisusuallycompleteexcisionofthebody,fundus,andcervixofthe
uterus,thoughoccasionallythecervixmaybeleftinsitu.Insomeinstancestheuterine(fallopian)tubesandovariesare
removedaswell.Thisprocedureiscalledatotalabdominalhysterectomyandbilateralsalpingooophorectomy.Hysterectomy,
oophorectomy,andsalpingooophorectomymaybeperformedinpatientswhohavereproductivemalignancy,suchasuterine,
cervical,andovariancancers.Otherindicationsincludeastrongfamilyhistoryofreproductivedisorders,endometriosis,and
excessivebleeding.Occasionallytheuterusmayneedtoberemovedpostpartumbecauseofexcessivepostpartumbleeding.A
hysterectomyisperformedthroughatransversesuprapubicincision(Pfannenstiel'sincision).Duringtheproceduretremendous
careistakentoidentifythedistaluretersandtoligatethenearbyuterinearterieswithoutdamagetotheureters.

Uterinetubes
Theuterinetubesextendfromeachsideofthesuperiorendofthebodyoftheuterustothelateralpelvicwallandareenclosed
withintheuppermarginsofthemesosalpinxportionsofthebroadligaments(seep.483).Becausetheovariesaresuspended
fromtheposterioraspectofthebroadligaments,theuterinetubespasssuperiorlyover,andterminatelaterallyto,theovaries.
Eachuterinetubehasanexpandedtrumpetshapedend(theinfundibulum),whichcurvesaroundthesuperolateralpoleofthe
relatedovary(Fig.5.53).Themarginoftheinfundibulumisrimmedwithsmallfingerlikeprojectionstermedfimbriae.The
lumenoftheuterinetubeopensintotheperitonealcavityatthenarrowedendoftheinfundibulum.Medialtotheinfundibulum,
thetubeexpandstoformtheampullaandthennarrowstoformtheisthmus,beforejoiningwiththebodyoftheuterus.

Fig.5.53
Uterinetubes.
Thefimbriatedinfundibulumfacilitatesthecollectionofovulatedeggsfromtheovary.Fertilizationnormallyoccursinthe
ampulla.
Intheclinic
Tuballigation
Afterovulation,theunfertilizedeggisgatheredbythefimbriaeoftheuterinetube.Theeggpassesintotheuterinetubewhereit
isnormallyfertilizedintheampulla.Thezygotethenbeginsdevelopmentandpassesintotheuterinecavitywhereitimplantsin
theuterinewall.Asimpleandeffectivemethodofbirthcontrolistosurgicallyligate(clip)theuterinetubes,preventing
spermatozoafromreachingova.Thissimpleshortprocedureisperformedundergeneralanesthetic.Asmalllaparoscopeis
passedintotheperitonealcavityandspecialequipmentisusedtoidentifythetubes.

Cervix

61/121

9/13/2014

Pelvis and Perineum

Thecervixformstheinferiorpartoftheuterusandisshapedlikeashort,broadcylinderwithanarrowcentralchannel.The
bodyoftheuterusnormallyarchesforward(anteflexedonthecervix)overthesuperiorsurfaceoftheemptiedbladder(Fig.
5.54A).Inaddition,thecervixisangledforward(anteverted)onthevaginasothattheinferiorendofthecervixprojectsintothe
upperanterioraspectofthevagina.Becausetheendofthecervixisdomeshaped,itbulgesintothevagina,andagutter,or
fornix,isformedaroundthemarginofthecervixwhereitjoinsthevaginalwall(Fig.5.54B).Thetubularcentralcanalofthe
cervixopens,below,astheexternalos,intothevaginalcavityand,above,astheinternalos,intotheuterinecavity.
Intheclinic
Carcinomaofthecervixanduterus
Carcinomaofthecervix(Fig.5.55)anduterusisacommondiseaseinwomen.Diagnosisisbyinspection,cytology
(examinationofthecervicalcells),imaging,biopsy,anddilatationandcurettage(D&C)oftheuterus.Carcinomaofthecervix
anduterusmaybetreatedbylocalresection,removaloftheuterus(hysterectomy),andadjuvantchemotherapy.Thetumor
spreadsvialymphaticstotheinternalandcommoniliaclymphnodes.

Fig.5.55
Picturetakenthroughaspeculuminsertedintothevaginademonstratingcervicalcancer.SeeFig.5.83Eonp.524
foraviewofthenormalcervix.

62/121

9/13/2014

Pelvis and Perineum

Fig.5.54
Uterusandvagina.A.Anglesofanteflexionandanteversion.B.Thecervixprotrudesintothevagina.

Vagina
Thevaginaisthecopulatoryorganinwomen.Itisadistensiblefibromusculartubethatextendsfromtheperineumthroughthe
pelvicfloorandintothepelviccavity(Fig.5.56A).Theinternalendofthecanalisenlargedtoformaregioncalledthevaginal
vault.

63/121

9/13/2014

Pelvis and Perineum

Fig.5.56
Vagina.A.Lefthalfofpelviscutaway.B.Vaginalfornicesandcervixasviewedthroughaspeculum.
Theanteriorwallofthevaginaisrelatedtothebaseofthebladderandtotheurethrainfact,theurethraisembeddedin,or
fusedto,theanteriorvaginalwall.
Posteriorly,thevaginaisrelatedprincipallytotherectum.
Inferiorly,thevaginaopensintothevestibuleoftheperineumimmediatelyposteriortotheexternalopeningoftheurethra.From
itsexternalopening(theintroitus),thevaginacoursesposterosuperiorlythroughtheperinealmembraneandintothepelvic
cavity,whereitisattachedbyitsanteriorwalltothecircularmarginofthecervix.
Thevaginalfornixistherecessformedbetweenthemarginofthecervixandthevaginalwall.Basedonposition,thefornixis
subdividedintoaposteriorfornix,ananteriorfornix,andtwolateralfornices(Fig.5.56AandseeFig.5.54).
Thevaginalcanalisnormallycollapsedsothattheanteriorwallisincontactwiththeposteriorwall.Byusingaspeculumto
openthevaginalcanal,aphysiciancanseethedomedinferiorendofthecervix,thevaginalfornices,andtheexternalosofthe
cervicalcanalinapatient(Fig.5.56B).
Duringintercourse,semenisdepositedinthevaginalvault.Spermatozoamaketheirwayintotheexternalosofthecervical
canal,passthroughthecervicalcanalintotheuterinecavity,andthencontinuethroughtheuterinecavityintotheuterinetubes
wherefertilizationnormallyoccursintheampulla.

Fascia
Fasciainthepelviccavitylinesthepelvicwalls,surroundsthebasesofthepelvicviscera,andformssheathsaroundblood
vesselsandnervesthatcoursemediallyfromthepelvicwallstoreachtheviscerainthemidline.Thispelvicfasciaisa
continuationoftheextraperitonealconnectivetissuelayerfoundintheabdomen.

Inwomen

64/121

9/13/2014

Pelvis and Perineum

Inwomen,arectovaginalseptumseparatestheposteriorsurfaceofthevaginafromtherectum(Fig.5.57A).Condensations
offasciaformligamentsthatextendfromthecervixtotheanterior(pubocervicalligament),lateral(transversecervicalor
cardinalligament),andposterior(uterosacralligament)pelvicwalls(Fig.5.57A).Theseligaments,togetherwiththeperineal
membrane,thelevatoranimuscles,andtheperinealbody,arethoughttostabilizetheuterusinthepelviccavity.Themost
importantoftheseligamentsarethetransversecervicalorcardinalligaments,whichextendlaterallyfromeachsideofthe
cervixandvaginalvaulttotherelatedpelvicwall.
Intheclinic
Therectouterinepouch
Therectouterinepouch(pouchofDouglas)isanextremelyimportantclinicalregionsituatedbetweentherectumanduterus.
Whenthepatientisinthesupineposition,therectouterinepouchisthelowestportionoftheabdominopelviccavityandisa
sitewhereinfectionandfluidstypicallycollect.Itisimpossibletopalpatethisregiontransabdominally,butitcanbeexamined
bytransvaginalandtransrectaldigitalpalpation.Ifanabscessissuspected,itmaybedrainedthroughthevaginaortherectum
withoutnecessitatingtransabdominalsurgery.

65/121

9/13/2014

Pelvis and Perineum

Fig.5.57
Pelvicfascia.A.Inwomen.B.Inmen.
66/121

9/13/2014

Pelvis and Perineum

Inmen
Inmen,acondensationoffasciaaroundtheanteriorandlateralregionoftheprostate(prostaticfascia)containsandsurrounds
theprostaticplexusofveinsandiscontinuousposteriorlywiththerectovesicalseptum,whichseparatestheposteriorsurface
oftheprostateandbaseofthebladderfromtherectum(Fig.5.57B).

Peritoneum
Theperitoneumofthepelvisiscontinuousatthepelvicinletwiththeperitoneumoftheabdomen.Inthepelvis,theperitoneum
drapesoverthepelvicviscerainthemidline,forming:

pouchesbetweenadjacentviscera,and

foldsandligamentsbetweenvisceraandpelvicwalls.
Anteriorly,medianandmedialumbilicalfoldsofperitoneumcovertheembryologicalremnantsoftheurachusandumbilical
arteries,respectively(Fig.5.58).Thesefoldsascendoutofthepelvisandontotheanteriorabdominalwall.Posteriorly,
peritoneumdrapesovertheanteriorandlateralaspectsoftheupperthirdoftherectum,butonlytheanteriorsurfaceofthe
middlethirdoftherectumiscoveredbyperitoneumthelowerthirdoftherectumisnotcoveredatall.

67/121

9/13/2014

Pelvis and Perineum

68/121

9/13/2014

Pelvis and Perineum

Fig.5.58
Peritoneuminthepelvis.A.Inwomen.B.Inmen.

Inwomen
Inwomen,theuterusliesbetweenthebladderandrectum,andtheuterinetubesextendfromthesuperioraspectoftheuterus
tothelateralpelvicwalls(Fig.5.58A).Asaconsequence,ashallowvesicouterinepouchoccursanteriorly,betweenthe
bladderanduterus,andadeeprectouterinepouch(pouchofDouglas)occursposteriorly,betweentheuterusandrectum.In
addition,alargefoldofperitoneum(thebroadligament),withauterinetubeenclosedinitssuperiormarginandanovary
attachedposteriorly,islocatedoneachsideoftheuterusandextendstothelateralpelvicwalls.
Inthemidline,theperitoneumdescendsovertheposteriorsurfaceoftheuterusandcervixandontothevaginalwalladjacentto
theposteriorvaginalfornix.Itthenreflectsontotheanteriorandlateralwallsoftherectum.Thedeeppouchofperitoneum
formedbetweentheanteriorsurfaceoftherectumandposteriorsurfacesoftheuterus,cervix,andvaginaistherectouterine
pouch.Asharpsickleshapedridgeofperitoneum(rectouterinefold)occursoneachsidenearthebaseoftherectouterine
pouch.Therectouterinefoldsoverlietheuterosacralligaments,whicharecondensationsofpelvicfasciathatextendfrom
thecervixtotheposterolateralpelvicwalls.

Broadligament
Thebroadligamentisasheetlikefoldofperitoneum,orientedinthecoronalplanethatrunsfromthelateralpelvicwalltothe
uterus,andenclosestheuterinetubeinitssuperiormarginandsuspendstheovaryfromitsposterioraspect(Fig.5.58A).The
uterinearteriescrosstheuretersatthebaseofthebroadligaments,andtheligamentoftheovaryandroundligamentofthe
uterusareenclosedwithinthepartsofthebroadligamentrelatedtotheovaryanduterus,respectively.Thebroadligamenthas
threeparts:
69/121

9/13/2014

Pelvis and Perineum

themesometrium,thelargestpartofthebroadligament,whichextendsfromthelateralpelvicwallstothebodyofthe
uterus

themesosalpinx,themostsuperiorpartofthebroadligament,whichsuspendstheuterinetubeinthepelviccavityand

themesovarium,aposteriorextensionofthebroadligament,whichattachestotheovary.
Theperitoneumofthemesovariumbecomesfirmlyattachedtotheovaryasthesurfaceepitheliumoftheovary.Theovaries
arepositionedwiththeirlongaxisintheverticalplane.Theovarianvessels,nerves,andlymphaticsenterthesuperiorpoleof
theovaryfromalateralpositionandarecoveredbyanotherraisedfoldofperitoneum,whichwiththestructuresitcontains
formsthesuspensoryligamentoftheovary(infundibulopelvicligament).
Theinferiorpoleoftheovaryisattachedtoafibromuscularbandoftissue(theligamentoftheovary),whichcoursesmedially
inthemarginofthemesovariumtotheuterusandthencontinuesanterolaterallyastheroundligamentoftheuterus(Fig.
5.58A).Theroundligamentoftheuteruspassesoverthepelvicinlettoreachthedeepinguinalringandthencoursesthrough
theinguinalcanaltoendinconnectivetissuerelatedtothelabiummajusintheperineum.Boththeligamentoftheovaryand
theroundligamentoftheuterusareremnantsofthegubernaculum,whichattachesthegonadtothelabioscrotalswellingsinthe
embryo.

Inmen
Inmen,thevisceralperitoneumdrapesoverthetopofthebladderontothesuperiorpolesoftheseminalvesiclesandthen
reflectsontotheanteriorandlateralsurfacesoftherectum(Fig.5.58B).Arectovesicalpouchoccursbetweenthebladderand
rectum.

Nerves
Somaticplexuses
Sacralandcoccygealplexuses
Thesacralandcoccygealplexusesaresituatedontheposterolateralwallofthepelviccavityandgenerallyoccurintheplane
betweenthemusclesandbloodvessels.TheyareformedbytheventralramiofS1toCo,withasignificantcontributionfromL4
andL5,whichenterthepelvisfromthelumbarplexus(Fig.5.59).Nervesfromthesemainlysomaticplexusescontributetothe
innervationofthelowerlimbandmusclesofthepelvisandperineum.Cutaneousbranchessupplyskinoverthemedialsideof
thefoot,theposterioraspectofthelowerlimb,andmostoftheperineum.

70/121

9/13/2014

Pelvis and Perineum

Fig.5.59
Sacralandcoccygealplexuses.

Sacralplexus
ThesacralplexusoneachsideisformedbytheanteriorramiofS1toS4,andthelumbosacraltrunk(L4andL5)(Fig.5.60).
Theplexusisformedinrelationtotheanteriorsurfaceofthepiriformismuscle,whichispartoftheposterolateralpelvicwall.
Sacralcontributionstotheplexuspassoutoftheanteriorsacralforaminaandcourselaterallyandinferiorlyonthepelvicwall.
Thelumbosacraltrunk,consistingofpartoftheanteriorramusofL4andalloftheanteriorramusofL5,coursesverticallyinto
thepelviccavityfromtheabdomenbypassingimmediatelyanteriortothesacroiliacjoint.

71/121

9/13/2014

Pelvis and Perineum

Fig.5.60
Componentsandbranchesofthesacralandcoccygealplexuses.
Grayramicommunicantesfromgangliaofthesympathetictrunkconnectwitheachoftheanteriorramiandcarrypostganglionic
sympatheticfibersdestinedfortheperipherytothesomaticnerves(Fig.5.61).Inaddition,specialvisceralnerves(pelvic
splanchnicnerves)originatingfromS2toS4deliverpreganglionicparasympatheticfiberstothepelvicpartoftheprevertebral
plexus(Figs.5.59and5.60).

72/121

9/13/2014

Pelvis and Perineum

Fig.5.61
Sympathetictrunksinthepelvis.
Eachanteriorramushasventralanddorsaldivisionsthatcombinewithsimilardivisionsfromotherlevelstoformterminal
nerves(Fig.5.60).TheanteriorramusofS4hasonlyaventraldivision.
Branchesofthesacralplexusincludethesciaticnerveandglutealnerves,whicharemajornervesofthelowerlimb,andthe
pudendalnerve,whichisthenerveoftheperineum(Table5.4).Numeroussmallerbranchessupplythepelvicwall,floor,and
lowerlimb.
Table5.4
Branchesofthesacralandcoccygealplexuses(spinalsegmentsinparenthesesdonotconsistentlyparticipate)

Branch
SACRALPLEXUS
Sciatic

Spinal
Motorfunction
segments
Allmusclesintheposteriororhamstring
compartmentofthethigh(includingthehamstring
partoftheadductormagnus)exceptfortheshort
73/121

9/13/2014

Pelvis and Perineum

headofthebiceps
L4toS3
Allmusclesintheposteriorcompartmentofthe
leg
Allmusclesinthesoleofthefoot
Tibialpart

Sensory(cutaneous)function

Skinonposterolateralandlateralsurfaces
offootandsoleoffoot

L4toS2

Commonfibularpart
Skinontheanterolateralsurfaceoftheleg
anddorsalsurfaceofthefoot

Motorfunction
Shortheadofbicepsintheposteriorcompartment
ofthethigh
Allmusclesintheanteriorandlateral
compartmentsoftheleg
Extensordigitorumbrevisinthefoot(also
contributestothesupplyofthefirstdorsal
interosseousmuscle)
Sensory(cutaneous)function

Motorfunction

S2toS4

Skeletalmusclesintheperineumincludingthe
externalurethralandanalsphinctersandlevator
ani(overlapsinsupplyofthelevatoraniand
externalsphincterwithbranchesdirectlyfrom
ventraldivisionofS4)
Sensory(cutaneous)function

Pudendal
Mostskinoftheperineum.Penisand
clitoris

L4toS1

Motorfunction

L5toS2

Motorfunction

Superiorgluteal
Gluteusmedius,gluteusminimus,and
tensorfasciaelatae

74/121

9/13/2014

Pelvis and Perineum

Inferiorgluteal
Gluteusmaximus

L5toS2

Motorfunction

L4toS1

Motorfunction

S1,S3

Sensory(cutaneous)function

S2,S3

Sensory(cutaneous)function

S1,S2

Motorfunction

Nervetoobturatorinternusand
superiorgemellus
Obturatorinternusandsuperiorgemellus

Nervetoquadratusfemorisandinferior
gemellus
Quadratusfemorisandinferiorgemellus

Posteriorfemoralcutaneous(posterior
cutaneousnerveofthigh)
Skinontheposterioraspectofthethigh

Perforatingcutaneous
Skinoverglutealfold(overlapswith
posteriorfemoralcutaneous)

Nervetopiriformis
Piriformismuscle
Motorfunction
75/121

9/13/2014

Pelvis and Perineum

S4
Nervestolevatorani,coccygeus,and
externalanalsphincter
Smallpatchofskinbetweenanusand
coccyx

Pelvicsplanchnicnerves

Levatorani,coccygeus,andexternalanal
sphincter.(Overlapswithpudendalnerve)
Sensory(cutaneous)function

Motor(visceral)function
Visceralmotor(preganglionicparasympathetic)to
pelvicpartofprevertebralplexus
S2,S3(4) Stimulateerection,modulatemobilityin
gastrointestinalsystemdistaltotheleftcolic
flexure,inhibitorytointernalurethralsphincter
Sensory(visceral)function

Visceralafferents(thatfollowthe
parasympathetics)frompelvicvisceraand
distalpartsofcolon.Painfromcervixand
possiblyfrombladderandproximalurethra
COCCYGEALPLEXUS

S4toCo

Sensory(cutaneous)function

Anococcygealnerves
Perianalskin
Mostnervesoriginatingfromthesacralplexusleavethepelviccavitybypassingthroughthegreatersciaticforameninferiorto
thepiriformismuscle,andentertheglutealregionofthelowerlimb.Othernervesleavethepelviccavityusingdifferentroutes
afewnervesdonotleavethepelviccavityandcoursedirectlyintothemusclesinthepelviccavity.Finally,twonervesthat
leavethepelviccavitythroughthegreatersciaticforamenlooparoundtheischialspineandsacrospinousligamentandpass
mediallythroughthelessersciaticforamentosupplystructuresintheperineumandlateralpelvicwall.

Sciaticnerve.
ThesciaticnerveisthelargestnerveofthebodyandcarriescontributionsfromL4toS3(Figs.5.59and5.60).It:

formsontheanteriorsurfaceofthepiriformismuscleandleavesthepelviccavitythroughthegreatersciaticforamen
inferiortothepiriformis

passesthroughtheglutealregionintothethigh,whereitdividesintoitstwomajorbranches,thecommonfibularnerve
(commonperonealnerve)andthetibialnervedorsaldivisionsofL4,L5,S1,andS2arecarriedinthecommonfibular
partofthenerveandtheventraldivisionsofL4,L5,S1,S2,andS3arecarriedinthetibialpart

innervatesmusclesintheposteriorcompartmentofthethighandmusclesinthelegandfootand

carriessensoryfibersfromtheskinofthefootandlateralleg.

Pudendalnerve.
ThepudendalnerveformsanteriorlytothelowerpartofthepiriformismusclefromventraldivisionsofS2toS4(Figs.5.59
and5.60).It:

76/121

9/13/2014

Pelvis and Perineum

leavesthepelviccavitythroughthegreatersciaticforamen,inferiortothepiriformismuscle,andentersthegluteal
region

coursesintotheperineumbyimmediatelypassingaroundthesacrospinousligament,wheretheligamentjoinstheischial
spine,andthroughthelessersciaticforamen(thiscoursetakesthenerveoutofthepelviccavity,aroundtheperipheral
attachmentofthepelvicfloor,andintotheperineum)

isaccompaniedthroughoutitscoursebytheinternalpudendalvesselsand

innervatesskinandskeletalmusclesoftheperineum,includingtheexternalanalandexternalurethralsphincters.
Intheclinic
Pudendalblock
Pudendalblockanesthesiaisperformedtorelievethepainassociatedwithchildbirth.Althoughtheuseofthisprocedureisless
commonsincethewidespreadadoptionofepiduralanesthesia,itprovidesanexcellentoptionforwomenwhohavea
contraindicationtoneuraxialanesthesia(e.g.,spinalanatomy,lowplatelets,tooclosetodelivery).Pudendalblocksarealso
usedforcertaintypesofchronicpelvicpain.Theinjectionisusuallygivenwherethepudendalnervecrossesthelateralaspect
ofthesacrospinousligamentnearitsattachmenttotheischialspine.Duringchildbirth,afingerinsertedintothevaginacan
palpatetheischialspine.Theneedleispassedtranscutaneouslytothemedialaspectoftheischialspineandaroundthe
sacrospinousligament.Infiltrationisperformedandtheperineumisanesthetized.

Otherbranchesofthesacralplexus.
Otherbranchesofthesacralplexusinclude:

motorbranchestomusclesoftheglutealregion,pelvicwall,andpelvicfloor(superiorandinferiorglutealnerves,nerveto
obturatorinternusandsuperiorgemellus,nervetoquadratusfemorisandinferiorgemellus,nervetopiriformis,nervesto
levatorani)and

sensorynervestoskinovertheinferiorglutealregionandposterioraspectsofthethighandupperleg(perforating
cutaneousnerveandposteriorcutaneousnerveofthethigh)(Figs.5.59and5.60).
Thesuperiorglutealnerve,formedbybranchesfromthedorsaldivisionsofL4toS1,leavesthepelviccavitythroughthe
greatersciaticforamensuperiortothepiriformismuscleandsuppliesmusclesintheglutealregiongluteusmedius,gluteus
minimus,andtensorfasciaelatae(tensoroffascialata)muscles.
Theinferiorglutealnerve,formedbybranchesfromthedorsaldivisionsofL5toS2,leavesthepelviccavitythroughthe
greatersciaticforameninferiortothepiriformismuscleandsuppliesthegluteusmaximus,thelargestmuscleinthegluteal
region.
Bothsuperiorandinferiorglutealnervesareaccompaniedbycorrespondingarteries.
ThenervetotheobturatorinternusandtheassociatedsuperiorgemellusmuscleoriginatesfromtheventraldivisionsofL5
toS2andleavesthepelviccavitythroughthegreatersciaticforameninferiortothepiriformismuscle.Likethepudendalnerve,
itpassesaroundtheischialspineandthroughthelessersciaticforamentoentertheperineumandsupplytheobturatorinternus
musclefromthemedialsideofthemuscle,inferiortotheattachmentofthelevatoranimuscle.
Thenervetothequadratusfemorismuscleandtheinferiorgemellusmuscle,andtheposteriorcutaneousnerveofthe
thigh(posteriorfemoralcutaneousnerve)alsoleavethepelviccavitythroughthegreatersciaticforameninferiortothe
piriformismuscleandcoursetomusclesandskin,respectively,inthelowerlimb.
Unlikemostoftheothernervesoriginatingfromthesacralplexus,whichleavethepelviccavitythroughthegreatersciatic
forameneitheraboveorbelowthepiriformismuscle,theperforatingcutaneousnerveleavesthepelviccavitybypenetrating
directlythroughthesacrotuberousligamentandthencoursestoskinovertheinferioraspectofthebuttocks.
Thenervetothepiriformisandanumberofsmallnervestothelevatoraniandcoccygeusmusclesoriginatefromthesacral
plexusandpassdirectlyintotheirtargetmuscleswithoutleavingthepelviccavity.

77/121

9/13/2014

Pelvis and Perineum

Theobturatornerve(L2toL4)isabranchofthelumbarplexus.Itpassesinferiorlyalongtheposteriorabdominalwallwithin
thepsoasmuscle,emergesfromthemedialsurfaceofthepsoas,passesposteriorlytothecommoniliacarteryandmediallyto
theinternaliliacarteryatthepelvicinlet,andthencoursesalongthelateralpelvicwall.Itleavesthepelviccavitybytraveling
throughtheobturatorcanalandsuppliestheadductorregionofthethigh.

Coccygealplexus
ThesmallcoccygealplexushasaminorcontributionfromS4andisformedmainlybytheanteriorramiofS5andCo,which
originateinferiorlytothepelvicfloor.Theypenetratethecoccygeusmuscletoenterthepelviccavityandjoinwiththeanterior
ramusofS4toformasingletrunk,fromwhichsmallanococcygealnervesoriginate(Table5.4).Thesenervespenetratethe
muscleandtheoverlyingsacrospinousandsacrotuberousligamentsandpasssuperficiallytoinnervateskinintheanaltriangle
oftheperineum.

Visceralplexuses
Paravertebralsympatheticchain
Theparavertebralpartofthevisceralnervoussystemisrepresentedinthepelvisbytheinferiorendsofthesympathetictrunks
(Fig.5.62A).Eachtrunkentersthepelviccavityfromtheabdomenbypassingoverthealaofthesacrummediallytothe
lumbosacraltrunksandposteriorlytotheiliacvessels.Thetrunkscourseinferiorlyalongtheanteriorsurfaceofthesacrum,
wheretheyarepositionedmediallytotheanteriorsacralforamina.Fourgangliaoccuralongeachtrunk.Anteriorlytothecoccyx,
thetwotrunksjointoformasinglesmallterminalganglion(theganglionimpar).

78/121

9/13/2014

Pelvis and Perineum

Fig.5.62
Pelvicextensionsoftheprevertebralplexus.A.Anteriorview.B.Anteromedialviewofrightsideofplexus.
Theprincipalfunctionofthesympathetictrunksinthepelvisistodeliverpostganglionicsympatheticfiberstotheanteriorrami
ofsacralnervesfordistributiontotheperiphery,mainlytopartsofthelowerlimbandperineum.Thisisaccomplishedbygray
ramicommunicantes,whichconnectthetrunkstothesacralanteriorrami.
Inadditiontograyramicommunicantes,otherbranches(thesacralsplanchnicnerves)joinandcontributetothepelvicpartof
theprevertebralplexusassociatedwithinnervatingpelvicviscera(Fig.5.62A).

Pelvicextensionsoftheprevertebralplexus
79/121

9/13/2014

Pelvis and Perineum

Thepelvicpartsoftheprevertebralplexuscarrysympathetic,parasympathetic,andvisceralafferentfibers(Fig.5.62A).Pelvic
partsoftheplexusareassociatedwithinnervatingpelvicvisceraanderectiletissuesoftheperineum.
Theprevertebralplexusentersthepelvisastwohypogastricnerves,oneoneachside,thatcrossthepelvicinletmediallyto
theinternaliliacvessels(Fig.5.62A).Thehypogastricnervesareformedbytheseparationofthefibersinthesuperior
hypogastricplexus,intorightandleftbundles.ThesuperiorhypogastricplexusissituatedanteriortovertebraLVbetweenthe
promontoryofthesacrumandthebifurcationoftheaorta.
WhenthehypogastricnervesarejoinedbypelvicsplanchnicnervescarryingpreganglionicparasympatheticfibersfromS2to
S4,thepelvicplexuses(inferiorhypogastricplexuses)areformed(Fig.5.62).Theinferiorhypogastricplexuses,oneon
eachside,courseinaninferiordirectionaroundthepelvicwalls,mediallytomajorvesselsandsomaticnerves.Theygiveorigin
tothefollowingsubsidiaryplexuses,whichinnervatethepelvicviscera:

therectalplexus,

theuterovaginalplexus,

theprostaticplexus,and

thevesicalplexus.
Terminalbranchesoftheinferiorhypogastricplexusespenetrateandpassthroughthedeepperinealpouchandinnervate
erectiletissuesofthepenisandtheclitorisintheperineum(Fig.5.62B).Inmen,thesenerves,calledcavernousnerves,are
extensionsoftheprostaticplexus.Thepatternofdistributionofsimilarnervesinwomenisnotentirelyclear,buttheyarelikely
extensionsoftheuterovaginalplexus.

Sympatheticfibers
Sympatheticfibersentertheinferiorhypogastricplexusesfromthehypogastricnervesandfrombranches(sacralsplanchnic
nerves)oftheuppersacralpartsofthesympathetictrunks(Fig.5.62A).Ultimately,thesenervesarederivedfrom
preganglionicfibersthatleavethespinalcordintheanteriorroots,mainlyofT10toL2.Thesefibers:

innervatebloodvessels,

causecontractionofsmoothmuscleintheinternalurethralsphincterinmenandtheinternalanalsphinctersinbothmen
andwomen,

causesmoothmusclecontractionassociatedwiththereproductivetractandwiththeaccessoryglandsofthe
reproductivesystem,and

areimportantinmovingsecretionsfromtheepididymisandassociatedglandsintotheurethratoformsemenduring
ejaculation.

Parasympatheticfibers
ParasympatheticfibersenterthepelvicplexusinpelvicsplanchnicnervesthatoriginatefromspinalcordlevelsS2toS4(Fig.
5.62A).They:

aregenerallyvasodilatory,

stimulatebladdercontraction,

80/121

9/13/2014

Pelvis and Perineum

stimulateerection,and

modulateactivityoftheentericnervoussystemofthecolondistaltotheleftcolicflexure(inadditiontopelvicviscera,
someofthefibersfromthepelvicplexuscoursesuperiorlyintheprevertebralplexus,orasseparatenerves,andpass
intotheinferiormesentericplexusoftheabdomen).

Visceralafferentfibers
Visceralafferentfibersfollowthecourseofthesympatheticandparasympatheticfiberstothespinalcord.Afferentfibersthat
enterthecordinlowerthoraciclevelsandlumbarlevelswithsympatheticfibersgenerallycarrypainhowever,painfibersfrom
thecervixandsomepainfibersfromthebladderandurethramayaccompanyparasympatheticnervestosacrallevelsofthe
spinalcord.
Intheclinic
Prostatectomyandimpotence
Itmaybenecessarytoperformradicalsurgerytocurecanceroftheprostate.Todothis,theprostateanditsattachments
aroundthebaseofthebladder,includingtheseminalvesicles,mustberemovedenmasse.Partsoftheinferiorhypogastric
plexusinthisregiongiverisetonervesthatinnervatetheerectiletissuesofthepenis.Impotencemayoccurifthesenerves
cannotbeorarenotpreservedduringremovaloftheprostate.Forthesamereasons,womenmayexperiencesexual
dysfunctionifsimilarnervesaredamagedduringpelvicsurgery,forexample,duringatotalhysterectomy.

Bloodvessels
Arteries
Themajorarteryofthepelvisandperineumistheinternaliliacarteryoneachside(Fig.5.63).Inadditiontoprovidingablood
supplytomostofthepelvicviscera,pelvicwallsandfloor,andstructuresintheperineum,includingerectiletissuesofthe
clitorisandthepenis,thisarterygivesrisetobranchesthatfollownervesintotheglutealregionofthelowerlimb.Othervessels
thatoriginateintheabdomenandcontributetothesupplyofpelvicstructuresincludethemediansacralarteryand,inwomen,
theovarianarteries.

81/121

9/13/2014

Pelvis and Perineum

Fig.5.63
Branchesoftheposteriortrunkoftheinternaliliacartery.

Internaliliacartery
Theinternaliliacarteryoriginatesfromthecommoniliacarteryoneachside,approximatelyattheleveloftheintervertebraldisc
betweenLVandSI,andliesanteromedialtothesacroiliacjoint(Fig.5.63).Thevesselcoursesinferiorlyoverthepelvicinlet
andthendividesintoanteriorandposteriortrunksatthelevelofthesuperiorborderofthegreatersciaticforamen.Branches
fromtheposteriortrunkcontributetothesupplyofthelowerposteriorabdominalwall,theposteriorpelvicwall,andthegluteal
region.Branchesfromtheanteriortrunksupplythepelvicviscera,theperineum,theglutealregion,theadductorregionofthe
thigh,and,inthefetus,theplacenta.

Posteriortrunk
Branchesoftheposteriortrunkoftheinternaliliacarteryaretheiliolumbarartery,thelateralsacralartery,andthesuperior
glutealartery(Fig.5.63).

Theiliolumbararteryascendslaterallybackoutofthepelvicinletanddividesintoalumbarbranchandaniliacbranch.
Thelumbarbranchcontributestothesupplyoftheposteriorabdominalwall,psoasandquadratuslumborummuscles,
andcaudaequina,viaasmallspinalbranchthatpassesthroughtheintervertebralforamenbetweenLVandSI.Theiliac
branchpasseslaterallyintotheiliacfossatosupplymuscleandbone.

82/121

9/13/2014

Pelvis and Perineum

Thelateralsacralarteries,usuallytwo,originatefromtheposteriordivisionoftheinternaliliacarteryandcourse
mediallyandinferiorlyalongtheposteriorpelvicwall.Theygiverisetobranchesthatpassintotheanteriorsacral
foraminatosupplyrelatedboneandsofttissues,structuresinthevertebral(sacral)canal,andskinandmuscleposterior
tothesacrum.

Thesuperiorglutealarteryisthelargestbranchoftheinternaliliacarteryandistheterminalcontinuationofthe
posteriortrunk.Itcoursesposteriorly,usuallypassingbetweenthelumbosacraltrunkandanteriorramusofS1,toleave
thepelviccavitythroughthegreatersciaticforamenabovethepiriformismuscleandentertheglutealregionofthelower
limb.Thisvesselmakesasubstantialcontributiontothebloodsupplyofmusclesandskinintheglutealregionandalso
suppliesbranchestoadjacentmusclesandbonesofthepelvicwalls.

Anteriortrunk
Branchesoftheanteriortrunkoftheinternaliliacarteryincludethesuperiorvesicalartery,theumbilicalartery,theinferior
vesicalartery,themiddlerectalartery,theuterineartery,thevaginalartery,theobturatorartery,theinternalpudendalartery,
andtheinferiorglutealartery(Fig.5.64).

83/121

9/13/2014

Pelvis and Perineum

Fig.5.64
Branchesoftheanteriortrunkoftheinternaliliacartery.A.Male.B.Female.

Thefirstbranchoftheanteriortrunkistheumbilicalartery,whichgivesorigintothesuperiorvesicalarteryandthen
travelsforwardjustinferiortothemarginofthepelvicinlet.Anteriorly,thevesselleavesthepelviccavityandascends
ontheinternalaspectoftheanteriorabdominalwalltoreachtheumbilicus.Inthefetus,theumbilicalarteryislargeand
carriesbloodfromthefetustotheplacenta.Afterbirth,thevesselclosesdistallytotheoriginofthesuperiorvesical
arteryandeventuallybecomesasolidfibrouscord.Ontheanteriorabdominalwall,thecordraisesafoldofperitoneum
termedthemedialumbilicalfold.Thefibrousremnantoftheumbilicalarteryitselfisthemedialumbilicalligament.

Thesuperiorvesicalarterynormallyoriginatesfromtherootoftheumbilicalarteryandcoursesmediallyandinferiorly
tosupplythesuperioraspectofthebladderanddistalpartsoftheureter.Inmen,italsomaygiverisetoanarterythat
suppliestheductusdeferens.

Theinferiorvesicalarteryoccursinmenandsuppliesbranchestothebladder,ureter,seminalvesicle,andprostate.
Thevaginalarteryinwomenistheequivalentoftheinferiorvesicalarteryinmenand,descendingtothevagina,
suppliesbranchestothevaginaandtoadjacentpartsofthebladderandrectum.

Themiddlerectalarterycoursesmediallytosupplytherectum.Thevesselanastomoseswiththesuperiorrectalartery,
whichoriginatesfromtheinferiormesentericarteryintheabdomen,andtheinferiorrectalartery,whichoriginatesfrom
theinternalpudendalarteryintheperineum.

Theobturatorarterycoursesanteriorlyalongthepelvicwallandleavesthepelviccavityviatheobturatorcanal.
Togetherwiththeobturatornerve,above,andobturatorvein,below,itentersandsuppliestheadductorregionofthe
thigh.

84/121

9/13/2014

Pelvis and Perineum

Theinternalpudendalarterycoursesinferiorlyfromitsoriginintheanteriortrunkandleavesthepelviccavitythrough
thegreatersciaticforameninferiortothepiriformismuscle.Inassociationwiththepudendalnerveonitsmedialside,the
vesselpasseslaterallytotheischialspineandthenthroughthelessersciaticforamentoentertheperineum.The
internalpudendalarteryisthemainarteryoftheperineum.Amongthestructuresitsuppliesaretheerectiletissuesof
theclitorisandthepenis.

Theinferiorglutealarteryisalargeterminalbranchoftheanteriortrunkoftheinternaliliacartery.Itpassesbetween
theanteriorramiS1andS2orS2andS3ofthesacralplexusandleavesthepelviccavitythroughthegreatersciatic
forameninferiortothepiriformismuscle.Itentersandcontributestothebloodsupplyoftheglutealregionand
anastomoseswithanetworkofvesselsaroundthehipjoint.

85/121

9/13/2014

Pelvis and Perineum

Theuterinearteryinwomencoursesmediallyandanteriorlyinthebaseofthebroadligamenttoreachthecervix(Figs.
5.64Band5.65).Alongitscourse,thevesselcrossestheureterandpassessuperiorlytothelateralvaginalfornix.Once
thevesselreachesthecervix,itascendsalongthelateralmarginoftheuterustoreachtheuterinetube,whereitcurves
laterallyandanastomoseswiththeovarianartery.Theuterinearteryisthemajorbloodsupplytotheuterusandenlarges
significantlyduringpregnancy.Throughanastomoseswithotherarteries,thevesselcontributestothebloodsupplyof
theovaryandvaginaaswell.

Fig.5.65
Uterineandvaginalarteries.

Ovarianarteries
Inwomen,thegonadal(ovarian)vesselsoriginatefromtheabdominalaortaandthendescendtocrossthepelvicinletand
supplytheovaries.Theyanastomosewithterminalpartsoftheuterinearteries(Fig.5.65).Oneachside,thevesselstravelin
thesuspensoryligamentoftheovary(theinfundibulopelvicligament)astheycrossthepelvicinlettotheovary.Branches
passthroughthemesovariumtoreachtheovaryandthroughthemesometriumofthebroadligamenttoanastomosewiththe
uterineartery.Theovarianarteriesenlargesignificantlyduringpregnancytoaugmenttheuterinebloodsupply.

Mediansacralartery
86/121

9/13/2014

Pelvis and Perineum

Themediansacralartery(Figs.5.64Aand5.65)originatesfromtheposteriorsurfaceoftheaortajustsuperiortotheaortic
bifurcationatvertebrallevelLIVintheabdomen.Itdescendsinthemidline,crossesthepelvicinlet,andthencoursesalongthe
anteriorsurfaceofthesacrumandcoccyx.Itgivesrisetothelastpairoflumbararteriesandtobranchesthatanastomosewith
theiliolumbarandlateralsacralarteries.

Veins
Pelvicveinsfollowthecourseofallbranchesoftheinternaliliacarteryexceptfortheumbilicalarteryandtheiliolumbarartery(
Fig.5.66A).Oneachside,theveinsdrainintointernaliliacveins,whichleavethepelviccavitytojoincommoniliacveins
situatedjustsuperiorandlateraltothepelvicinlet.

87/121

9/13/2014

Pelvis and Perineum

Fig.5.66
Pelvicveins.A.Inamanwiththeleftsideofthepelvisandmostofthevisceraremoved.B.Veinsassociatedwith
therectumandanalcanal.

88/121

9/13/2014

Pelvis and Perineum

Withinthepelviccavity,extensiveinterconnectedvenousplexusesareassociatedwiththesurfacesoftheviscera(bladder,
rectum,prostate,uterus,andvagina).Together,theseplexusesformthepelvicplexusofveins.Thepartofthevenousplexus
surroundingtherectumandanalcanaldrainsviasuperiorrectalveins(tributariesofinferiormesentericveins)intothehepatic
portalsystem,andviamiddleandinferiorrectalveinsintothecavalsystem.Thispelvicplexusisanimportantportacavalshunt
whenthehepaticportalsystemisblocked(Fig.5.66B).
Theinferiorpartoftherectalplexusaroundtheanalcanalhastwoparts,aninternalandanexternal.Theinternalrectalplexus
isinconnectivetissuebetweentheinternalanalsphincterandtheepitheliumliningthecanal.Thisplexusconnectssuperiorly
withlongitudinallyarrangedbranchesofthesuperiorrectalveinthatlieoneineachanalcolumn.Whenenlarged,these
branchesforminternalhemorrhoids,whichoriginateabovethepectinatelineandarecoveredbycolonicmucosa.Theexternal
rectalplexuscirclestheexternalanalsphincterandissubcutaneous.Enlargementofvesselsintheexternalrectalplexus
resultsinexternalhemorrhoids.
Thesingledeepdorsalveinthatdrainserectiletissuesoftheclitorisandthepenisdoesnotfollowbranchesoftheinternal
pudendalarteryintothepelviccavity.Instead,thisveinpassesdirectlyintothepelviccavitythroughagapformedbetweenthe
arcuatepubicligamentandtheanteriormarginoftheperinealmembrane.Theveinjoinstheprostaticplexusofveinsinmen
andthevesical(bladder)plexusofveinsinwomen.(Superficialveinsthatdraintheskinofthepenisandcorrespondingregions
oftheclitorisdrainintotheexternalpudendalveins,whicharetributariesofthegreatsaphenousveininthethigh.)
Inadditiontotributariesoftheinternaliliacvein,mediansacralveinsandovarianveinsparallelthecoursesofthemedian
sacralarteryandovarianartery,respectively,andleavethepelviccavitytojoinveinsintheabdomen:

Themediansacralveinscoalescetoformasingleveinthatjoinseithertheleftcommoniliacveinorthejunctionofthe
twocommoniliacveinstoformtheinferiorvenacava.

Theovarianveinsfollowthecourseofthecorrespondingarteriesontheleft,theyjointheleftrenalveinand,onthe
right,theyjointheinferiorvenacavaintheabdomen.

Lymphatics
Lymphaticsfrommostpelvicvisceradrainmainlyintolymphnodesdistributedalongtheinternaliliacandexternaliliacarteries
andtheirassociatedbranches(Fig.5.67),whichdrainintonodesassociatedwiththecommoniliacarteriesandthenintothe
lateralaorticorlumbarnodesassociatedwiththelateralsurfacesoftheabdominalaorta.Inturn,theselateralaorticorlumbar
nodesdrainintothelumbartrunks,whichcontinuetotheoriginofthethoracicductatapproximatelyvertebrallevelTXII.

89/121

9/13/2014

Pelvis and Perineum

Fig.5.67
Pelviclymphatics.
Lymphaticsfromtheovariesandrelatedpartsoftheuterusanduterinetubesleavethepelviccavitysuperiorlyanddrain,via
vesselsthataccompanytheovarianarteries,directlyintolateralaorticorlumbarnodesand,insomecases,intothepreaortic
nodesontheanteriorsurfaceoftheaorta.
Inadditiontodrainingpelvicviscera,nodesalongtheinternaliliacarteryalsoreceivedrainagefromtheglutealregionofthe
lowerlimbandfromdeepareasoftheperineum.

Perineum
Theperineumisadiamondshapedregionpositionedinferiorlytothepelvicfloorbetweenthethighs.Itsperipheralboundaryis
thepelvicoutletitsceilingisthepelvicdiaphragm(thelevatoraniandcoccygeusmuscles)anditsnarrowlateralwallsare
formedbythewallsofthepelviccavitybelowtheattachmentofthelevatoranimuscle(Fig.5.68A).

90/121

9/13/2014

Pelvis and Perineum

Fig.5.68
Bordersandceilingoftheperineum.A.Boundariesoftheperineum.B.Perinealmembrane.
Theperineumisdividedintoananteriorurogenitaltriangleandaposterioranaltriangle.

91/121

9/13/2014

Pelvis and Perineum

Theurogenitaltriangleisassociatedwiththeopeningsoftheurinarysystemsandthereproductivesystemsand
functionstoanchortheexternalgenitalia.

Theanaltrianglecontainstheanusandtheexternalanalsphincter.
Thepudendalnerve(S2toS4)andtheinternalpudendalarteryarethemajornerveandarteryoftheregion.

Bordersandceiling
Themarginoftheperineumismarkedbytheinferiorborderofthepubicsymphysisatitsanteriorpoint,thetipofthecoccyxat
itsposteriorpoint,andtheischialtuberositiesateachofthelateralpoints(Fig.5.68A).Thelateralmarginsareformedbythe
ischiopubicramianteriorlyandbythesacrotuberousligamentsposteriorly.Thepubicsymphysis,theischialtuberosities,and
thecoccyxcanbepalpatedonthepatient.
Theperineumisdividedintotwotrianglesbyanimaginarylinebetweenthetwoischialtuberosities(Fig.5.68A).Anteriortothe
lineistheurogenitaltriangleandposteriortothelineistheanaltriangle.Significantly,thetwotrianglesarenotinthesame
plane.Intheanatomicalposition,theurogenitaltriangleisorientedinthehorizontalplane,whereastheanaltriangleistilted
upwardatthetranstubercularlinesothatitfacesmoreposteriorly.
Theroofoftheperineumisformedmainlybythelevatoranimusclesthatseparatethepelviccavity,above,fromtheperineum,
below.Thesemuscles,oneoneachside,formaconeorfunnelshapedpelvicdiaphragm,withtheanalapertureatitsinferior
apexintheanaltriangle.
Anteriorly,intheurogenitaltriangle,aUshapeddefectinthemuscles,theurogenitalhiatus,allowsthepassageofthe
urethraandvagina.

Perinealmembraneanddeepperinealpouch
Theperinealmembrane(seepp.457459)isathickfibroussheetthatfillstheurogenitaltriangle(Fig.5.68B).Ithasafree
posteriorborder,whichisanchoredinthemidlinetotheperinealbodyandisattachedlaterallytothepubicarch.Immediately
superiortotheperinealmembraneisathinregiontermedthedeepperinealpouch,containingalayerofskeletalmuscleand
neurovasculartissues.Amongtheskeletalmusclesinthepouch(seep.459,Fig.5.36)istheexternalurethralsphincter.
Theperinealmembraneanddeepperinealpouchprovidesupportfortheexternalgenitalia,whichareattachedtoitsinferior
surface.Also,thepartsoftheperinealmembraneanddeepperinealpouchinferiortotheurogenitalhiatusinthelevatorani
providesupportforthepelvicviscera,above.
Theurethraleavesthepelviccavityandenterstheperineumbypassingthroughthedeepperinealpouchandperineal
membrane.Inwomen,thevaginaalsopassesthroughthesestructuresposteriortotheurethra.

Ischioanalfossaeandtheiranteriorrecesses
Becausethelevatoranimusclescoursemediallyfromtheiroriginonthelateralpelvicwalls,above,totheanalapertureand
urogenitalhiatus,below,invertedwedgeshapedguttersoccurbetweenthelevatoranimusclesandadjacentpelvicwallsasthe
twostructuresdivergeinferiorly(Fig.5.69).Intheanaltriangle,thesegutters,oneoneachsideoftheanalaperture,are
termedischioanalfossae.Thelateralwallofeachfossaisformedmainlybytheischium,obturatorinternusmuscle,and
sacrotuberousligament.Themedialwallisthelevatoranimuscle.Themedialandlateralwallsconvergesuperiorlywherethe
levatoranimuscleattachestothefasciaoverlyingtheobturatorinternusmuscle.Theischioanalfossaeallowmovementofthe
pelvicdiaphragmandexpansionoftheanalcanalduringdefecation.

92/121

9/13/2014

Pelvis and Perineum

Fig.5.69
Ischioanalfossaeandtheiranteriorrecesses.A.Anterolateralviewwithleftpelvicwallremoved.B.Inferiorview.C.
Anterolateralviewwithpelvicwallsanddiaphragmremoved.

93/121

9/13/2014

Pelvis and Perineum

Theischioanalfossaeoftheanaltrianglearecontinuousanteriorlywithrecessesthatprojectintotheurogenitaltriangle
superiortothedeepperinealpouch.Theseanteriorrecessesoftheischioanalfossaeareshapedlikethreesidedpyramidsthat
havebeentippedontooneoftheirsides(Fig.5.69C).Theapexofeachpyramidisclosedandpointsanteriorlytowardthe
pubis.Thebaseisopenandcontinuousposteriorlywithitsrelatedischioanalfossa.Theinferiorwallofeachpyramidisthe
deepperinealpouch.Thesuperomedialwallisthelevatoranimuscle,andthesuperolateralwallisformedmainlybythe
obturatorinternusmuscle.Theischioanalfossaeandtheiranteriorrecessesarenormallyfilledwithfat.
Intheclinic
Abscessesintheischioanalfossae
Theanalmucosaisparticularlyvulnerabletoinjuryandmaybeeasilytornbyhardfeces.Occasionally,patientsdevelop
inflammationandinfectionoftheanalcanal(sinusesorcrypts).Thisinfectioncanspreadbetweenthesphincters,producing
intersphinctericfistulas.Theinfectioncantractsuperiorlyintothepelviccavityorlaterallyintotheischioanalfossae.

Analtriangle
Theanaltriangleoftheperineumfacesposteroinferiorlyandisdefinedlaterallybythemedialmarginsofthesacrotuberous
ligaments,anteriorlybyahorizontallinebetweenthetwoischialtuberosities,andposteriorlybythecoccyx.Theceilingofthe
analtriangleisthepelvicdiaphragm,whichisformedbythelevatoraniandcoccygeusmuscles.Theanalapertureoccurs
centrallyintheanaltriangleandisrelatedoneithersidetoanischioanalfossa.Themajormuscleintheanaltriangleisthe
externalanalsphincter.
Theexternalanalsphincter,whichsurroundstheanalcanal,isformedbyskeletalmuscleandconsistsofthreepartsdeep,
superficial,andsubcutaneousarrangedsequentiallyalongthecanalfromsuperiortoinferior(Fig.5.68B,Table5.5).The
deeppartisathickringshapedmusclethatcirclestheupperpartoftheanalcanalandblendswiththefibersofthelevatorani
muscle.Thesuperficialpartalsosurroundstheanalcanal,butisanchoredanteriorlytotheperinealbodyandposteriorlytothe
coccyxandanococcygealligament.Thesubcutaneouspartisahorizontallyflatteneddiscofmusclethatsurroundstheanal
aperturejustbeneaththeskin.Theexternalanalsphincterisinnervatedbyinferiorrectalbranchesofthepudendalnerveandby
branchesdirectlyfromtheanteriorramusofS4.
Intheclinic
Hemorrhoids
Ahemorrhoidisanengorgementofthevenousplexusatorinsidetheanalsphincter.Itisacommoncomplaintandhas
prevalenceofapproximately4%intheUnitedStates.Hemorrhoidshaveaslightgeneticpredispositionhowever,straining
duringbowelmovements,obesity,andsedentarylifestylecanalsoproducehemorrhoids.Thesymptomsincludeirritation,pain,
andswelling.Hemorrhoidsoccurringattheanalverge(distalboundaryoftheanalcanal)aretypicallycalledexternal
hemorrhoids.Internalhemorrhoidsoccurinsidetherectumandhaveatendencytobleed.Prolapsedhemorrhoidsareinternal
hemorrhoidsthatpassoutsidetheanalcanalandformlumps,whichmayundergothrombosisandbecomepainful.Thereare
manytreatmentsforhemorrhoids,whichincludeligationabovethepectinate(dentate)lineusingsimplerubberbandsorsurgical
excision.Surgerytothisregionisnotwithoutcomplicationsandcaremustbetakentopreservetheinternalanalsphincter.In
thebackofeveryphysician'smindistheconcernthattherectalbleedingorsymptomsmaynotbeattributabletohemorrhoids.
Therefore,excludingatumorwithinthebowelisasimportantastreatingthehemorrhoids.
Table5.5
Musclesoftheanaltriangle

Muscles
Origin
EXTERNALANALSPHINCTER
Deeppart

Insertion

Function

Closes
Pudendalnerve(S2andS3)
anal
andbranchesdirectlyfromS4
canal

Surroundssuperior
aspectofanalcanal

Superficial
Surroundslower
part
partofanalcanal
Subcutaneous Surroundsanal
part
aperture

Innervation

Anchoredtoperinealbody
andanococcygealbody

Urogenitaltriangle
Theurogenitaltriangleoftheperineumistheanteriorhalfoftheperineumandisorientedinthehorizontalplane.Itcontainsthe
rootsoftheexternalgenitalia(Fig.5.70)andtheopeningsoftheurogenitalsystem.

94/121

9/13/2014

Pelvis and Perineum

Fig.5.70
Erectiletissuesofclitorisandpenis.A.Clitoris.B.Penis.
Theurogenitaltriangleisdefined:

laterallybytheischiopubicrami,

posteriorlybyanimaginarylinebetweentheischialtuberosities,and

anteriorlybytheinferiormarginofthepubicsymphysis.
Aswiththeanaltriangle,therooforceilingoftheurogenitaltriangleisthelevatoranimuscle.
Unliketheanaltriangle,theurogenitaltrianglecontainsastrongfibromuscularsupportplatform,theperinealmembraneand
deepperinealpouch(seepp.457459),whichisattachedtothepubicarch.
95/121

9/13/2014

Pelvis and Perineum

Anteriorextensionsoftheischioanalfossaeoccurbetweenthedeepperinealpouchandthelevatoranimuscleoneachside.
Betweentheperinealmembraneandthemembranouslayerofsuperficialfasciaisthesuperficialperinealpouch.The
principalstructuresinthispoucharetheerectiletissuesofthepenisandclitorisandassociatedskeletalmuscles.

Structuresinthesuperficialperinealpouch
Thesuperficialperinealpouchcontains:

erectilestructuresthatjointogethertoformthepenisinmenandtheclitorisinwomen,and

skeletalmusclesthatareassociatedmainlywithpartsoftheerectilestructuresattachedtotheperinealmembraneand
adjacentbone.
Eacherectilestructureconsistsofacentralcoreofexpandablevasculartissueanditssurroundingconnectivetissuecapsule.

Erectiletissues
Twosetsoferectilestructuresjointoformthepenisandtheclitoris.
Apairofcylindricallyshapedcorporacavernosa,oneoneachsideoftheurogenitaltriangle,areanchoredbytheirproximal
endstothepubicarch.Theseattachedpartsareoftentermedthecrura(fromtheLatinforlegs)oftheclitorisorthepenis.
Thedistalendsofthecorpora,whicharenotattachedtobone,formthebodyoftheclitorisinwomenandthedorsalpartsofthe
bodyofthepenisinmen.
Thesecondsetoferectiletissuessurroundstheopeningsoftheurogenitalsystem.

Inwomen,apairoferectilestructures,termedthebulbsofthevestibule,aresituated,oneoneachside,atthevaginal
openingandarefirmlyanchoredtotheperinealmembrane(Fig.5.70A).Smallbandsoferectiletissuesconnectthe
anteriorendsofthesebulbstoasingle,small,peashapederectilemass,theglansclitoris,whichispositionedinthe
midlineattheendofthebodyoftheclitorisandanteriortotheopeningoftheurethra.

Inmen,asinglelargeerectilemass,thecorpusspongiosum,isthestructuralequivalenttothebulbsofthevestibule,
theglansclitoris,andtheinterconnectingbandsoferectiletissuesinwomen(Fig.5.70B).Thecorpusspongiosumis
anchoredatitsbasetotheperinealmembrane.Itsproximalend,whichisnotattached,formstheventralpartofthebody
ofthepenisandexpandsovertheendofthebodyofthepenistoformtheglanspenis.Thispatterninmenresultsfrom
theabsenceofavaginalopeningandfromthefusionofstructuresacrossthemidlineduringembryologicaldevelopment.
Astheoriginallypairederectilestructuresfuse,theyenclosetheurethralopeningandformanadditionalchannelthat
ultimatelybecomesmostofthepenilepartoftheurethra.Asaconsequenceofthisfusionandgrowthinmen,the
urethraisenclosedbythecorpusspongiosumandopensattheendofthepenis.Thisisunlikethesituationinwomen,
wheretheurethraisnotenclosedbyerectiletissueoftheclitorisandopensdirectlyintothevestibuleoftheperineum.

Clitoris
Theclitorisiscomposedoftwocorporacavernosaandtheglansclitoris(Fig.5.70A).Asinthepenis,ithasanattachedpart
(root)andafreepart(body).

Unliketherootofthepenis,therootoftheclitoristechnicallyconsistsonlyofthetwocrura.(Althoughthebulbsofthe
vestibuleareattachedtotheglansclitorisbythinbandsoferectiletissue,theyarenotincludedintheattachedpartof
theclitoris.)

Thebodyoftheclitoris,whichisformedonlybytheunattachedpartsofthetwocorporacavernosa,anglesposteriorly
andisembeddedintheconnectivetissuesoftheperineum.
Thebodyoftheclitorisissupportedbyasuspensoryligamentthatattachessuperiorlytothepubicsymphysis.Theglans
clitorisisattachedtothedistalendofthebodyandisconnectedtothebulbsofthevestibulebysmallbandsoferectiletissue.
Theglansclitorisisexposedintheperineumandthebodyoftheclitoriscanbepalpatedthroughskin.

Penis
96/121

9/13/2014

Pelvis and Perineum

Thepenisiscomposedmainlyofthetwocorporacavernosaandthesinglecorpusspongiosum,whichcontainstheurethra(
Fig.5.70B.)Asintheclitoris,ithasanattachedpart(root)andafreepart(body):

Therootofthepenisconsistsofthetwocrura,whichareproximalpartsofthecorporacavernosaattachedtothepubic
arch,andthebulbofthepenis,whichistheproximalpartofthecorpusspongiosumanchoredtotheperineal
membrane.

Thebodyofthepenis,whichiscoveredentirelybyskin,isformedbythetetheringofthetwoproximalfreepartsofthe
corporacavernosaandtherelatedfreepartofthecorpusspongiosum.
Thebaseofthebodyofthepenisissupportedbytwoligaments:thesuspensoryligamentofthepenis(attachedsuperiorlyto
thepubicsymphysis),andthemoresuperficiallypositionedfundiformligamentofthepenis(attachedabovetothelineaalba
oftheanteriorabdominalwallandsplitbelowintotwobandsthatpassoneachsideofthepenisanduniteinferiorly).
Becausetheanatomicalpositionofthepenisiserect,thepairedcorporaaredefinedasdorsalinthebodyofthepenisandthe
singlecorpusspongiosumasventral,eventhoughthepositionsarereversedinthenonerect(flaccid)penis.
Thecorpusspongiosumexpandstoformtheheadofthepenis(glanspenis)overthedistalendsofthecorporacavernosa(
Fig.5.70B).

Erection
Erectionofthepenisandclitorisisavasculareventgeneratedbyparasympatheticfiberscarriedinpelvicsplanchnicnerves
fromtheanteriorramiofS2toS4,whichentertheinferiorhypogastricpartoftheprevertebralplexusandultimatelypass
throughthedeepperinealpouchandperinealmembranetoinnervatetheerectiletissues.Stimulationofthesenervescauses
specificarteriesintheerectiletissuestorelax.Thisallowsbloodtofillthetissues,causingthepenisandclitoristobecome
erect.
Arteriessupplyingthepenisandclitorisarebranchesoftheinternalpudendalarterybranchesofthepudendalnerve(S2toS4)
carrygeneralsensorynervesfromthepenisandclitoris.

Greatervestibularglands
Thegreatervestibularglands(Bartholin'sglands)areseeninwomen.Theyaresmall,peashapedmucousglandsthatlie
posteriortothebulbsofthevestibuleoneachsideofthevaginalopeningandarethefemalehomologuesofthebulbourethral
glandsinmen(Fig.5.70).However,thebulbourethralglandsarelocatedwithinthedeepperinealpouch,whereasthegreater
vestibularglandsareinthesuperficialperinealpouch.
Theductofeachgreatervestibularglandopensintothevestibuleoftheperineumalongtheposterolateralmarginofthevaginal
opening.
Likethebulbourethralglandsinmen,thegreatervestibularglandsproducesecretionduringsexualarousal.

Muscles
Thesuperficialperinealpouchcontainsthreepairsofmuscles:theischiocavernosus,bulbospongiosus,andsuperficial
transverseperinealmuscles(Fig.5.71andTable5.6).Twoofthesethreepairsofmusclesareassociatedwiththerootsofthe
penisandclitoristheotherpairisassociatedwiththeperinealbody.

97/121

9/13/2014

Pelvis and Perineum

Fig.5.71
Musclesinthesuperficialperinealpouch.A.Inwomen.B.Inmen.
Table5.6
Musclesofthesuperficialperinealpouch

Muscles

Origin
Ischial
Ischiocavernosus tuberosity
andramus
Inwomen:
perineal
bodyIn
men:
Bulbospongiosus perineal
body,
midline

Insertion
Crusofpenisandclitoris
Inwomen:bulbofvestibule,
perinealmembrane,bodyof
clitoris,andcorpus
cavernosumInmen:
bulbospongiosus,perineal
membrane,corpus

Innervation Function
Pudendal Movebloodfromcrurainto
nerve(S2to thebodyoftheerectpenis
S4)
andclitoris
Movebloodfromattached
partsoftheclitorisandpenis
Pudendal intotheglansInmen:
nerve(S2to removalofresidualurine
S4)
fromurethraafterurination
pulsatileemissionofsemen
98/121

9/13/2014

Pelvis and Perineum

raphe
Superficial
transverse
perineal

cavernosum

Ischial
tuberosity Perinealbody
andramus

duringejaculation
Pudendal
nerve(S2to Stabilizetheperinealbody
S4)

Ischiocavernosus
Thetwoischiocavernosusmusclescoverthecruraofthepenisandclitoris(Fig.5.71).Eachmuscleisanchoredtothe
medialmarginoftheischialtuberosityandrelatedischialramusandpassesforwardtoattachtothesidesandinferiorsurface
oftherelatedcrus,andforcesbloodfromthecrusintothebodyoftheerectpenisandclitoris.

Bulbospongiosus
Thetwobulbospongiosusmusclesareassociatedmainlywiththebulbsofthevestibuleinwomenandwiththeattachedpart
ofthecorpusspongiosuminmen(Fig.5.71).
Inwomen,eachbulbospongiosusmuscleisanchoredposteriorlytotheperinealbodyandcoursesanterolaterallyoverthe
inferiorsurfaceoftherelatedgreatervestibularglandandthebulbofthevestibuletoattachtothesurfaceofthebulbandtothe
perinealmembrane(Fig.5.71A).Otherfiberscourseanterolaterallytoblendwiththefibersoftheischiocavernosusmuscle,and
stillotherstravelanteriorlyandarchoverthebodyoftheclitoris.
Inmen,thebulbospongiosusmusclesarejoinedinthemidlinetoarapheontheinferiorsurfaceofthebulbofthepenis.The
rapheisanchoredposteriorlytotheperinealbody.Musclefiberscourseanterolaterally,oneachside,fromtherapheand
perinealbodytocovereachsideofthebulbofthepenisandattachtotheperinealmembraneandconnectivetissueofthebulb.
Othersextendanterolaterallytoassociatewiththecruraandattachanteriorlytotheischiocavernosusmuscles.
Inbothmenandwomen,thebulbospongiosusmusclescompressattachedpartsoftheerectcorpusspongiosumandbulbsof
thevestibuleandforcebloodintomoredistalregions,mainlytheglans.Inmen,thebulbospongiosusmuscleshavetwo
additionalfunctions:

Theyfacilitateemptyingofthebulbouspartofthepenileurethrafollowingurination(micturition).

Theirreflexcontractionduringejaculationisresponsibleforthepulsatileemissionofsemenfromthepenis.

Superficialtransverseperinealmuscles
Thepairedsuperficialtransverseperinealmusclesfollowacourseparalleltotheposteriormarginoftheinferiorsurfaceofthe
perinealmembrane(Fig.5.71).Theseflatbandshapedmuscles,whichareattachedtoischialtuberositiesandrami,extend
mediallytotheperinealbodyinthemidlineandstabilizetheperinealbody.

Superficialfeaturesoftheexternalgenitalia
Inwomen
Inwomen,theclitorisandvestibularapparatus,togetherwithanumberofskinandtissuefolds,formthevulva(Fig.5.72).On
eithersideofthemidlinearetwothinfoldsofskintermedthelabiaminora.Theregionenclosedbetweenthem,andintowhich
theurethraandvaginaopen,isthevestibule.Anteriorly,thelabiaminoraeachbifurcate,formingamedialandalateralfold.
Themedialfoldsunitetoformthefrenulumoftheclitoris,thatjoinstheglansclitoris.Thelateralfoldsuniteventrallyoverthe
glansclitorisandthebodyoftheclitoristoformtheprepuceoftheclitoris(hood).Thebodyoftheclitorisextendsanteriorly
fromtheglansclitorisandispalpabledeeptotheprepuceandrelatedskin.Posteriortothevestibule,thelabiaminoraunite,
formingasmalltransversefold,thefrenulumofthelabiaminora(thefourchette).

99/121

9/13/2014

Pelvis and Perineum

Fig.5.72
Superficialfeaturesoftheperineuminwomen.A.Overview.B.Closeupofexternalgenitalia.
Withinthevestibule,thevaginalorificeissurroundedtovaryingdegreesbyaringlikefoldofmembrane,thehymen,whichmay
haveasmallcentralperforationormaycompletelyclosethevaginalopening.Followingruptureofthehymen(resultingfrom
firstsexualintercourseorinjury),irregularremnantsofthehymenfringethevaginalopening.
Theorificesoftheurethraandthevaginaareassociatedwiththeopeningsofglands.Theductsoftheparaurethralglands(
Skene'sglands)openintothevestibule,oneoneachsideofthelateralmarginoftheurethra.Theductsofthegreater
vestibularglands(Bartholin'sglands)openadjacenttotheposterolateralmarginofthevaginalopeninginthecreasebetween
thevaginalorificeandremnantsofthehymen.
Lateraltothelabiaminoraaretwobroadfolds,thelabiamajora,whichuniteanteriorlytoformthemonspubis.Themons
pubisoverliestheinferioraspectofthepubicsymphysisandisanteriortothevestibuleandtheclitoris.Posteriorly,thelabia
majoradonotuniteandareseparatedbyadepressiontermedtheposteriorcommissure,whichoverliesthepositionofthe
perinealbody.

Inmen
Superficialcomponentsofthegenitalorgansinmenconsistofthescrotumandthepenis(Fig.5.73).Thescrotumisthemale
homologueofthelabiamajorainwomen.Inthefetus,labioscrotalswellingsfuseacrossthemidline,resultinginasingle
scrotumintowhichthetestesandtheirassociatedmusculofascialcoverings,bloodvessels,nerves,lymphatics,anddrainage
ductsdescendfromtheabdomen.Theremnantofthelineoffusionbetweenthelabioscrotalswellingsinthefetusisvisibleon
theskinofthescrotumasalongitudinalmidlineraphethatextendsfromtheanus,overthescrotalsac,andontotheinferior
aspectofthebodyofthepenis.

100/121

9/13/2014

Pelvis and Perineum

Fig.5.73
Superficialfeaturesoftheperineuminmen.A.Overview.B.Closeupofexternalgenitalia.
Thepenisconsistsofarootandbody.Theattachedrootofthepenisispalpableposteriortothescrotumintheurogenital
triangleoftheperineum.Thependulouspartofthepenis(bodyofpenis)isentirelycoveredbyskinthetipofthebodyis
coveredbytheglanspenis.
Theexternalurethralorificeisasagittalslit,normallypositionedatthetipoftheglans.Theinferiormarginoftheurethralorifice
iscontinuouswithamidlinerapheofthepenis,whichrepresentsalineoffusionformedintheglansastheurethradevelopsin
thefetus.Thebaseofthisrapheiscontinuouswiththefrenulumoftheglans,whichisamedianfoldofskinthatattachesthe
glanstomorelooselyattachedskinproximaltotheglans.Thebaseoftheglansisexpandedtoformaraisedcircularmargin
(thecoronaoftheglans)thetwolateralendsofthecoronajoininferiorlyatthemidlinerapheoftheglans.Thedepression
posteriortothecoronaistheneckoftheglans.Normally,afoldofskinattheneckoftheglansiscontinuousanteriorlywith
thinskinthattightlyadherestotheglansandposteriorlywiththickerskinlooselyattachedtothebody.Thisfold,knownasthe
prepuce,extendsforwardtocovertheglans.Theprepuceisremovedduringmalecircumcision,leavingtheglansexposed.

Superficialfasciaoftheurogenitaltriangle
Thesuperficialfasciaoftheurogenitaltriangleiscontinuouswithsimilarfasciaontheanteriorabdominalwall.
Aswiththesuperficialfasciaoftheabdominalwall,theperinealfasciahasamembranouslayeronitsdeepsurface.This
membranouslayer(Colles'fascia),isattached:

101/121

9/13/2014

Pelvis and Perineum

posteriorlytotheperinealmembraneandthereforedoesnotextendintotheanaltriangle(Fig.5.74),and

Fig.5.74
Superficialfascia.A.Lateralview.B.Anteriorview.

totheischiopubicramithatformthelateralbordersoftheurogenitaltriangleandthereforedoesnotextendintothethigh(
Fig.5.74).
Itdefinestheexternallimitsofthesuperficialperinealpouch,linesthescrotumorlabia,andextendsaroundthebodyofthe
penisandclitoris.

102/121

9/13/2014

Pelvis and Perineum

Anteriorly,themembranouslayeroffasciaiscontinuousoverthepubicsymphysisandpubicboneswiththemembranouslayer
offasciaontheanteriorabdominalwall.Inthelowerlateralabdominalwall,themembranouslayerofabdominalfasciais
attachedtothedeepfasciaofthethighjustinferiortotheinguinalligament.
Becausethemembranouslayeroffasciaenclosesthesuperficialperinealpouchandcontinuesuptheanteriorabdominalwall,
fluidsorinfectiousmaterialsthataccumulateinthepouchcantrackoutoftheperineumandontothelowerabdominalwall.This
materialwillnottrackintotheanaltriangleorthethighbecausethefasciafuseswithdeeptissuesatthebordersofthese
regions.
Intheclinic
Urethralrupture
Urethralrupturemayoccurataseriesofwelldefinedanatomicalpoints.Thecommonestinjuryisaruptureoftheproximal
spongyurethrabelowtheperinealmembrane.Theurethraisusuallytornwhenstructuresoftheperineumarecaughtbetweena
hardobject(e.g.,asteelbeamorcrossbarofabicycle)andtheinferiorpubicarch.Urineescapesthroughtheruptureintothe
superficialperinealpouchanddescendsintothescrotumandupontotheanteriorabdominalwalldeeptothesuperficial
fascia.Inassociationwithseverepelvicfractures,urethralrupturemayoccurattheprostatomembranousjunctionabovethe
deepperinealpouch.Theurinewillextravasateintothetruepelvis.Theworstandmostseriousurethralruptureisrelatedto
seriouspelvicinjurieswherethereiscompletedisruptionofthepuboprostaticligaments.Theprostateisdislocatedsuperiorly
notonlybytheligamentousdisruptionbutalsobytheextensivehematomaformedwithinthetruepelvis.Thediagnosiscanbe
madebypalpatingtheelevatedprostateduringadigitalrectalexamination.

Somaticnerves
Pudendalnerve
Themajorsomaticnerveoftheperineumisthepudendalnerve.Thisnerveoriginatesfromthesacralplexusandcarriesfibers
fromspinalcordlevelsS2toS4.Itleavesthepelviccavitythroughthegreatersciaticforameninferiortothepiriformismuscle,
passesaroundthesacrospinousligament,andthenenterstheanaltriangleoftheperineumbypassingmediallythroughthe
lessersciaticforamen.Asitentersandcoursesthroughtheperineum,ittravelsalongthelateralwalloftheischioanalfossain
thepudendalcanal,whichisatubularcompartmentformedinthefasciathatcoverstheobturatorinternusmuscle.This
pudendalcanalalsocontainstheinternalpudendalarteryandaccompanyingveins.
Thepudendalnerve(Fig.5.75)hasthreemajorterminalbranchestheinferiorrectalandperinealnervesandthedorsalnerve
ofthepenisorclitoriswhichareaccompaniedbybranchesoftheinternalpudendalartery(Fig.5.76).

103/121

9/13/2014

Pelvis and Perineum

104/121

9/13/2014

Pelvis and Perineum

Fig.5.75
Pudendalnerve.A.Inmen.B.Inwomen.

105/121

9/13/2014

Pelvis and Perineum

Fig.5.76
Arteriesintheperineum.

Theinferiorrectalnerveisoftenmultiple,penetratesthroughthefasciaofthepudendalcanal,andcoursesmedially
acrosstheischioanalfossatoinnervatetheexternalanalsphincterandrelatedregionsofthelevatoranimuscles.The
nerveisalsogeneralsensoryfortheskinoftheanaltriangle.

106/121

9/13/2014

Pelvis and Perineum

Theperinealnervepassesintotheurogenitaltriangleandgivesrisetomotorandcutaneousbranches.Themotor
branchessupplyskeletalmusclesinthesuperficialanddeepperinealpouches.Thelargestofthesensorybranchesis
theposteriorscrotalnerveinmenandtheposteriorlabialnerveinwomen.

Thedorsalnerveofthepenisandclitorisentersthedeepperinealpouch(Fig.5.75).Itpassesalongthelateralmargin
ofthepouchandthenexitsbypassinginferiorlythroughtheperinealmembraneinapositionjustinferiortothepubic
symphysiswhereitmeetsthebodyoftheclitorisorthepenis.Itcoursesalongthedorsalsurfaceofthebodytoreach
theglans.Thedorsalnerveissensorytothepenisandclitoris,particularlytotheglans.

Othersomaticnerves
Othersomaticnervesthatentertheperineumaremainlysensoryandincludebranchesoftheilioinguinal,genitofemoral,
posteriorfemoralcutaneous,andanococcygealnerves.

Visceralnerves
Visceralnervesentertheperineumbytworoutes:

Thosetotheskin,whichconsistmainlyofpostganglionicsympathetics,aredeliveredintotheregionalongthepudendal
nerve.Thesefibersjointhepudendalnervefromgrayramicommunicantesthatconnectpelvicpartsofthesympathetic
trunkstotheanteriorramiofthesacralspinalnerves(seep.487andFig.5.61).

Thosetoerectiletissuesentertheregionmainlybypassingthroughthedeepperinealpouchfromtheinferiorhypogastric
plexusinthepelviccavity(seep.494andFig.5.62B).Thefibersthatstimulateerectionareparasympatheticfibers,
whichentertheinferiorhypogastricplexusviapelvicsplanchnicnervesfromspinalcordlevelsofS2toS4(seeFig.
5.62A,B).

Bloodvessels
Arteries
Themostsignificantarteryoftheperineumistheinternalpudendalartery(Fig.5.76).Otherarteriesenteringtheareainclude
theexternalpudendal,thetesticular,andthecremastericarteries.

Internalpudendalartery
Theinternalpudendalarteryoriginatesasabranchoftheanteriortrunkoftheinternaliliacarteryinthepelvis(Fig.5.76).
Alongwiththepudendalnerve,itleavesthepelvisthroughthegreatersciaticforameninferiortothepiriformismuscle.Itpasses
aroundtheischialspine,wherethearterylieslateraltothenerve,enterstheperineumbycoursingthroughthelessersciatic
foramen,andaccompaniesthepudendalnerveinthepudendalcanalonthelateralwalloftheischioanalfossa.
Thebranchesoftheinternalpudendalarteryaresimilartothoseofthepudendalnerveintheperineumandincludetheinferior
rectalandperinealarteries,andbranchestotheerectiletissuesofthepenisandclitoris(Fig.5.76).

Inferiorrectalarteries
Oneormoreinferiorrectalarteriesoriginatefromtheinternalpudendalarteryintheanaltriangleandcrosstheischioanal
fossamediallytobranchandsupplymuscleandrelatedskin(Fig.5.76).Theyanastomosewithmiddleandsuperiorrectal
arteriesfromtheinternaliliacarteryandtheinferiormesentericartery,respectively,toformanetworkofvesselsthatsupplythe
rectumandanalcanal.

Perinealartery
Theperinealarteryoriginatesneartheanteriorendofthepudendalcanalandgivesoffatransverseperinealbranch,anda
posteriorscrotalorlabialarterytosurroundingtissuesandskin(Fig.5.76).

Terminalpartoftheinternalpudendalartery
Theterminalpartoftheinternalpudendalarteryaccompaniesthedorsalnerveofthepenisorclitorisintothedeepperineal
pouchandsuppliesbranchestothetissuesinthedeepperinealpouchanderectiletissues.
Branchesthatsupplytheerectiletissuesinmenincludethearterytothebulbofthepenis,theurethralartery,thedeeparteryof
thepenis,andthedorsalarteryofthepenis(Fig.5.76).
107/121

9/13/2014

Pelvis and Perineum

Thearteryofthebulbofthepenishasabranchthatsuppliesthebulbourethralglandandthenpenetratestheperineal
membranetosupplythecorpusspongiosum.

Aurethralarteryalsopenetratestheperinealmembraneandsuppliesthepenileurethraandsurroundingerectiletissue
totheglans.

Neartheanteriormarginofthedeepperinealpouch,theinternalpudendalarterybifurcatesintotwoterminalbranches.A
deeparteryofthepenispenetratestheperinealmembranetoenterthecrusandsupplythecrusandcorpus
cavernosumofthebody.Thedorsalarteryofthepenispenetratestheanteriormarginoftheperinealmembraneto
meetthedorsalsurfaceofthebodyofthepenis.Thevesselcoursesalongthedorsalsurfaceofthepenis,medialtothe
dorsalnerve,andsuppliestheglanspenisandsuperficialtissuesofthepenisitalsoanastomoseswithbranchesofthe
deeparteryofthepenisandtheurethralartery.
Branchesthatsupplytheerectiletissuesinwomenaresimilartothoseinmen.

Arteriesofthebulbofthevestibulesupplythebulbofthevestibuleandrelatedvagina.

Deeparteriesoftheclitorissupplythecruraandcorpuscavernosumofthebody.

Dorsalarteriesoftheclitorissupplysurroundingtissuesandtheglans.

Externalpudendalarteries
Theexternalpudendalarteriesconsistofasuperficialvesselandadeepvessel,whichoriginateinthefemoralarteryinthe
thigh.Theycoursemediallytoentertheperineumanteriorlyandsupplyrelatedskinofthepenisandscrotumortheclitorisand
labiamajora.

Testicularandcremastericarteries
Inmen,thetesticulararteriesoriginatefromtheabdominalaortaanddescendintothescrotumthroughtheinguinalcanalto
supplythetestes.Also,cremastericarteries,whichoriginatefromtheinferiorepigastricbranchoftheexternaliliacartery,
accompanythespermaticcordintothescrotum.
Inwomen,smallcremastericarteriesfollowtheroundligamentoftheuterusthroughtheinguinalcanal.

Veins
Veinsintheperineumgenerallyaccompanythearteriesandjointheinternalpudendalveinsthatconnectwiththeinternal
iliacveininthepelvis(Fig.5.77).Theexceptionisthedeepdorsalveinofthepenisorclitoristhatdrainsmainlytheglans
andthecorporacavernosa.Thedeepdorsalveincoursesalongthemidlinebetweenthedorsalarteriesoneachsideofthebody
ofthepenisorclitoris,passesthoughthegapbetweentheinferiorpubicligamentandthedeepperinealpouch,andconnects
withtheplexusofveinssurroundingtheprostateinmenorbladderinwomen.

108/121

9/13/2014

Pelvis and Perineum

Fig.5.77
Perinealveins.
Externalpudendalveins,whichdrainanteriorpartsofthelabiamajoraorthescrotumandoverlapwiththeareaofdrainageof
theinternalpudendalveins,connectwiththefemoralveininthethigh.Superficialdorsalveinsofthepenisorclitoristhatdrain
skinaretributariesoftheexternalpudendalveins.
109/121

9/13/2014

Pelvis and Perineum

Lymphatics
Lymphaticvesselsfromdeeppartsoftheperineumaccompanytheinternalpudendalbloodvesselsanddrainmainlyinto
internaliliacnodesinthepelvis.
Lymphaticchannelsfromsuperficialtissuesofthepenisortheclitorisaccompanythesuperficialexternalpudendalblood
vesselsanddrainmainlyintosuperficialinguinalnodes,asdolymphaticchannelsfromthescrotumorlabiamajora(Fig.
5.78).Theglanspenis,glansclitoris,labiaminora,andterminalinferiorendofthevaginadrainintodeepinguinalnodesand
externaliliacnodes.

Fig.5.78
Lymphaticdrainageoftheperineum.
Lymphaticsfromthetestesdrainviachannelsthatascendinthespermaticcord,passthroughtheinguinalcanal,andcourse
uptheposteriorabdominalwalltoconnectdirectlywithlateralaorticorlumbarnodesandpreaorticnodesaroundtheaorta,
atapproximatelyvertebrallevelsLIandLII.Thereforediseasefromthetestestrackssuperiorlytonodeshighintheposterior
abdominalwallandnottoinguinaloriliacnodes.

Surfaceanatomy
Surfaceanatomyofthepelvisandperineum
Palpablebonyfeaturesofthepelvisareusedaslandmarksfor:

locatingsofttissuestructures,

visualizingtheorientationofthepelvicinlet,and
110/121

9/13/2014

Pelvis and Perineum

definingthemarginsoftheperineum.
Theabilitytorecognizethenormalappearanceofstructuresintheperineumisanessentialpartofaphysicalexamination.
Inwomen,thecervixcanbevisualizeddirectlybyopeningthevaginalcanalusingaspeculum.
Inmen,thesizeandtextureoftheprostateinthepelviccavitycanbeassessedbydigitalpalpationthroughtheanalaperture.

Orientationofthepelvisandperineumintheanatomicalposition
Intheanatomicalposition,theanteriorsuperioriliacspinesandtheanteriorsuperioredgeofthepubicsymphysislieinthe
sameverticalplane.Thepelvicinletfacesanterosuperiorly.Theurogenitaltriangleoftheperineumisorientedinanalmost
horizontalplaneandfacesinferiorly,whereastheanaltriangleismoreverticalandfacesposteriorly(Figs.5.79and5.80).

Fig.5.79
Lateralviewofthepelvicareawiththepositionoftheskeletalfeaturesindicated.Theorientationofthepelvicinlet,
urogenitaltriangle,andanaltriangleisalsoshown.A.Inawoman.B.Inaman.

Fig.5.80
Anteriorviewofthepelvicarea.A.Inawomanshowingthepositionofthepubicsymphysis.B.Inamanshowingthe
positionofthepubictubercle,pubicsymphysis,andanteriorsuperioriliacspine.

111/121

9/13/2014

Pelvis and Perineum

Howtodefinethemarginsoftheperineum
Thepubicsymphysis,ischialtuberosities,andtipofthesacrumarepalpableonpatientsandcanbeusedtodefinethe
boundariesoftheperineum.Thisisbestdonewithpatientslyingontheirbackswiththeirthighsflexedandabductedinthe
lithotomyposition(Fig.5.81).

Fig.5.81
Inferiorviewoftheperineuminthelithotomyposition.Boundaries,subdivisions,andpalpablelandmarksare
indicated.A.Inaman.B.Inawoman.

Theischialtuberositiesarepalpableoneachsideaslargebonymassesnearthecreaseofskin(glutealfold)between
thethighandglutealregion.Theymarkthelateralcornersofthediamondshapedperineum.

Thetipofthecoccyxispalpableinthemidlineposteriortotheanalapertureandmarksthemostposteriorlimitofthe
perineum.

Theanteriorlimitoftheperineumisthepubicsymphysis.Inwomen,thisispalpableinthemidlinedeeptothemons
pubis.Inmen,thepubicsymphysisispalpableimmediatelysuperiortowherethebodyofthepenisjoinsthelower
abdominalwall.
112/121

9/13/2014

Pelvis and Perineum

Imaginarylinesthatjointheischialtuberositieswiththepubicsymphysisinfront,andwiththetipofthecoccyxbehind,outline
thediamondshapedperineum.Anadditionallinebetweentheischialtuberositiesdividestheperineumintotwotriangles,the
urogenitaltriangleanteriorlyandanaltriangleposteriorly.Thislinealsoapproximatesthepositionoftheposteriormarginofthe
perinealmembrane.Themidpointofthislinemarksthelocationoftheperinealbodyorcentraltendonoftheperineum.

Identificationofstructuresintheanaltriangle
Theanaltriangleistheposteriorhalfoftheperineum.Thebaseofthetrianglefacesanteriorlyandisanimaginarylinejoining
thetwoischialtuberosities.Theapexofthetriangleisthetipofthecoccyxthelateralmarginscanbeapproximatedbylines
joiningthecoccyxtotheischialtuberosities.Inbothwomenandmen,themajorfeatureoftheanaltriangleistheanalaperture
inthecenterofthetriangle.Fatfillstheischioanalfossaoneachsideoftheanalaperture(Fig.5.82).

Fig.5.82
Analtrianglewiththeanalapertureandpositionoftheischioanalfossaeindicated.A.Inaman.B.Inawoman.

Identificationofstructuresintheurogenitaltriangleofwomen
Theurogenitaltriangleistheanteriorhalfoftheperineum.Thebaseofthetrianglefacesposteriorlyandisanimaginaryline
joiningthetwoischialtuberosities.Theapexofthetriangleisthepubicsymphysis.Thelateralmarginscanbeapproximatedby
linesjoiningthepubicsymphysistotheischialtuberosities.Theselinesoverlietheischiopubicrami,whichcanbefeltondeep
palpation.
Inwomen,themajorcontentsoftheurogenitaltrianglearetheclitoris,thevestibule,andskinfoldsthattogetherformthevulva
(Fig.5.83A,B).
113/121

9/13/2014

Pelvis and Perineum

Fig.5.83
114/121

9/13/2014

Pelvis and Perineum

Structuresintheurogenitaltriangleofawoman.A.Inferiorviewoftheurogenitaltriangleofawomanwithmajor
featuresindicated.B.Inferiorviewofthevestibule.Thelabiaminorahavebeenpulledaparttoopenthevestibule.
Alsoindicatedaretheglansclitoris,theclitoralhood,andthefrenulumoftheclitoris.C.Inferiorviewofthevestibule
showingtheurethralandvaginalorificesandthehymen.Thelabiaminorahavebeenpulledfurtherapartthanin
Figure5.83B.D.Inferiorviewofthevestibulewiththeleftlabiumminuspulledtothesidetoshowtheregionsofthe
vestibuleintowhichthegreatervestibularandparaurethralglandsopen.
E.Viewthroughthevaginalcanalofthecervix.F.Inferiorviewoftheurogenitaltriangleofawomanwiththeerectile
tissuesoftheclitorisandvestibuleandthegreatervestibularglandsindicatedwithoverlays.
Twothinskinfolds,thelabiaminora,enclosebetweenthemaspacetermedthevestibuleintowhichthevaginaandtheurethra
open(Fig.5.83C).Gentlelateraltractiononthelabiaminoraopensthevestibuleandrevealsasofttissuemoundonwhichthe
urethraopens.Theparaurethral(Skene's)glands,oneoneachside,openintotheskincreasebetweentheurethraandthelabia
minora(Fig.5.83D).
Posteriortotheurethraisthevaginalopening.Thevaginalopening(introitus)isringedbyremnantsofthehymenthatoriginally
closesthevaginalorificeandisusuallyrupturedduringthefirstsexualintercourse.Theductsofthegreatervestibular
(Bartholin's)glands,oneoneachside,openintotheskincreasebetweenthehymenandtheadjacentlabiumminus(Fig.
5.83D).
Thelabiaminoraeachbifurcateanteriorlyintomedialandlateralfolds.Themedialfoldsuniteatthemidlinetoformthefrenulum
oftheclitoris.Thelargerlateralfoldsalsouniteacrossthemidlinetoformtheclitoralhoodorprepucethatcoverstheglans
clitorisanddistalpartsofthebodyoftheclitoris.Posteriortothevaginalorifice,thelabiaminorajoin,formingatransverseskin
fold(thefourchette).
Thelabiamajoraarebroadfoldspositionedlateraltothelabiaminora.Theycometogetherinfronttoformthemonspubis,
whichoverliestheinferioraspectofthepubicsymphysis.Theposteriorendsofthelabiamajoraareseparatedbyadepression
termedtheposteriorcommissure,whichoverliesthepositionoftheperinealbody.
Thecervixisvisiblewhenthevaginalcanalisopenedwithaspeculum(Fig.5.83E).Theexternalcervicalosopensontothe
surfaceofthedomeshapedcervix.Arecessorgutter,termedthefornix,occursbetweenthecervixandthevaginalwallandis
furthersubdivided,basedonlocation,intoanterior,posterior,andlateralfornices.
Therootsoftheclitorisoccurdeeptosurfacefeaturesoftheperineumandareattachedtotheischiopubicramiandtheperineal
membrane.
Thebulbsofthevestibule(Fig.5.83F),composedoferectiletissues,liedeeptothelabiaminoraoneithersideofthe
vestibule.Theseerectilemassesarecontinuous,viathinbandsoferectiletissues,withtheglansclitoris,whichisvisibleunder
theclitoralhood.Thegreatervestibularglandsoccurposteriortothebulbsofthevestibuleoneithersideofthevaginalorifice.
Thecruraoftheclitorisareattached,oneoneachside,totheischiopubicrami.Eachcrusisformedbytheattachedpartofthe
corpuscavernosum.Anteriorly,theseerectilecorporadetachfrombone,curveposteroinferiorly,andunitetoformthebodyof
theclitoris.
Thebodyoftheclitorisunderliestheridgeofskinimmediatelyanteriortotheclitoralhood(prepuce).Theglansclitorisis
positionedattheendofthebodyoftheclitoris.

Identificationofstructuresintheurogenitaltriangleofmen
Inmen,theurogenitaltrianglecontainstherootofthepenis.Thetestesandassociatedstructures,althoughtheymigrateinto
thescrotumfromtheabdomen,aregenerallyevaluatedwiththepenisduringaphysicalexamination.
Thescrotuminmenishomologoustothelabiamajorainwomen.Eachovaltestisisreadilypalpablethroughtheskinofthe
scrotum(Fig.5.84A).Posterolateraltothetestisisanelongatedmassoftissue,oftenvisibleasaraisedridgethatcontains
lymphaticsandbloodvesselsofthetestis,andtheepididymisandductusdeferens.Amidlineraphe(Fig.5.84B)isvisibleon
theskinseparatingleftandrightsidesofthescrotum.Insomeindividuals,thisrapheisprominentandextendsfromtheanal
aperture,overthescrotumandalongtheventralsurfaceofthebodyofthepenis,tothefrenulumoftheglans.

115/121

9/13/2014

Pelvis and Perineum

116/121

9/13/2014

Pelvis and Perineum

Fig.5.84
Structuresintheurogenitaltriangleofaman.A.Inferiorview.B.Ventralsurfaceofthebodyofthepenis.C.Anterior
viewoftheglanspenisshowingtheurethralopening.D.Lateralviewofthebodyofthepenisandglans.E.Inferior
viewoftheurogenitaltriangleofamanwiththeerectiletissuesofthepenisindicatedwithoverlays.
Therootofthepenisisformedbytheattachedpartsofthecorpusspongiosumandthecorporacavernosa.Thecorpus
spongiosumisattachedtotheperinealmembraneandcanbeeasilypalpatedasalargemassanteriortotheperinealbody.
Thismass,whichiscoveredbythebulbo
s pongiosusmuscles,isthebulbofpenis.
Thecorpusspongiosumdetachesfromtheperinealmembraneanteriorly,becomestheventralpartofthebodyofthepenis
(shaftofpenis),andeventuallyterminatesastheexpandedglanspenis(Fig.5.84C,D).
Thecruraofthepenis,onecrusoneachside,aretheattachedpartsofthecorporacavernosaandareanchoredtothe
ischiopubicrami(Fig.5.84E).Thecorporacavernosaareunattachedanteriorlyandbecomethepairederectilemassesthat
formthedorsalpartofthebodyofthepenis.Theglanspeniscapstheanteriorendsofthecorporacavernosa.

Clinicalcases
Case1
Varicocele
A25yearoldmanvisitedhisfamilyphysicianbecausehehadadraggingfeelingintheleftsideofhisscrotum.He
wasotherwisehealthyandhadnoothersymptoms.Duringexamination,thephysicianpalpatedthelefttestis,which
wasnormal,althoughhenotedsoftnodularswellingaroundthesuperioraspectofthetestesandtheepididymis.In
hisclinicalnotes,hedescribedthesefindingsasabagofworms(Fig.5.85).Thebagofwormswasavaricocele.
Thevenousdrainageofthetestisisviathepampiniformplexusofveinsthatrunswithinthespermaticcord.Avaricoceleisa
collectionofdilatedveinsthatarisefromthepampiniformplexus.Inmanyways,theyaresimilartovaricoseveinsthatdevelop
inthelegs.Typically,thepatientcomplainsofadraggingfeelinginthescrotumandaroundthetestis,whichisusuallyworse
towardtheendoftheday.Thefamilyphysicianrecommendedsurgicaltreatment,witharecommendationforsurgerythroughan
inguinalincision.Asimplesurgicaltechniquedividestheskinaroundtheinguinalligament.Theaponeurosisoftheexternal
obliquemuscleisdividedintheanteriorabdominalwalltodisplaythespermaticcord.Carefulinspectionofthespermaticcord
revealstheveins,whicharesurgicallyligated.Anotheroptionistoembolizethevaricocele.Inthistechnique,asmallcatheteris
placedviatherightfemoralvein.Thecatheterisadvancedalongtheexternaliliacveinandthecommoniliacveinandintothe
inferiorvenacava.Thecatheteristhenpositionedintheleftrenalvein,andavenogramisperformedtodemonstratetheorigin
ofthelefttesticularvein.Thecatheterisadvanceddownthelefttesticularveinintotheveinsoftheinguinalcanalandthe
pampiniformplexus.Metalcoilstooccludethevesselsareinjected,andthecatheteriswithdrawn.Thepatientaskedhowblood
woulddrainfromthetestisaftertheoperation.Althoughthemajorveinsofthetestishadbeenoccluded,smallcollateralveins
runningwithinthescrotumandaroundtheouteraspectofthespermaticcordpermitteddrainagewithoutrecurrenceofthe
117/121

9/13/2014

Pelvis and Perineum

varicocele.

Fig.5.85
Lefttesticularvenogramdemonstratingthepampiniformplexusofveins.
Case2
Sciaticnervecompression
Ayoungmandevelopedpaininhisrightglutealregion,intheposterioraspectofthethighandaroundtheposterior
andlateralaspectsoftheleg.Onfurtherquestioning,hereportedthatthepainalsoradiatedoverthelateralpartofthe
foot,particularlyaroundthelateralmalleolus.TheareasofpaincorrespondtodermatomesL4toS3nerves.Overthe
followingweeks,thepatientbegantodevelopmuscularweakness,predominantlyfootdrop.Thesefindingsareconsistentwith
lossofthemotorfunctionandsensorychangeinthecommonfibularnerve,whichisabranchofthesciaticnerveinthelower
limb.Acomputedtomography(CT)scanoftheabdomenandpelvisrevealedamassintheposterioraspectoftherightsideof
thepelvis.Themasswasanteriortothepiriformismuscleandadjacenttotherectum.Ontheanteriorbellyofthepiriformis
muscle,thesciaticnerveisformedfromtherootsofL4toS3nerves.Themassinthepatient'spelviscompressedthisnerve,
producinghissensoryandmotordysfunction.Duringsurgery,themasswasfoundtobeabenignnervetumorandwasexcised.
Thispatienthadnolongstandingneurologicaldeficit.
Case3
Pelvickidney
118/121

9/13/2014

Pelvis and Perineum

Ayoungwomanvisitedherfamilypractitionerbecauseshehadmildupperabdominalpain.Anultrasound
demonstratedgallstoneswithinthegallbladder,whichexplainedthepatient'spain.However,whenthetechnician
assessedthepelvis,shenotedamassbehindthebladder,whichhadsonographicfindingssimilartoakidney(Fig.
5.86).Whatdidthesonographerdonext?Havingdemonstratedthispelvicmassbehindthebladder,thesonographerassessed
bothkidneys.Thepatienthadanormalrightkidney.However,theleftkidneycouldnotbefoundinitsusualplace.The
techniciandiagnosedapelvickidney.Apelvickidneycanbeexplainedbytheembryology.Thekidneysdevelopfromacomplex
seriesofstructuresthatoriginateadjacenttothebladderwithinthefetalpelvis.Asdevelopmentproceedsandthefunctionsof
thevariouspartsofthedevelopingkidneyschange,theyattainasuperiorpositionintheupperabdomenadjacenttothe
abdominalaortaandinferiorvenacava,ontheposteriorabdominalwall.Adevelopmentalarrestorcomplicationmayprevent
thekidneyfromobtainingitsusualposition.Fortunately,itisunusualforpatientstohaveanysymptomsrelatingtoapelvic
kidney.Thispatienthadnosymptomsattributabletothepelvickidneyandshewasdischarged.

Fig.5.86
Sagittalcomputedtomogramdemonstratingapelvickidney.
Case4
Leftcommoniliacarteryobstruction
A65yearoldmanwasexaminedbyasurgicalinternbecausehehadahistoryofbuttockpainandimpotence.On
examinationhehadareducedperipheralpulseontheleftfootcomparedtotheright.Ondirectquestioning,thepatient
revealedthatheexperiencedsevereleftsidedbuttockpainafterwalking100yards.Afterashortperiodofrest,hecould
walkanother100yardsbeforethesamesymptomsrecurred.Healsonoticedthatoverthepastyearhewasunableto
obtainanerection.Hesmokedheavilyandwasonnootherdrugsortreatment.Thepainintheleftbuttockisischemicin
nature.Hegivesatypicalhistoryrelatingtolackofbloodflowtothemuscles.Asimilarfindingispresentwhenmuscular
branchesofthefemoralarteryareoccludedorstenosed.Suchpatientsdevelopsimilar(ischemic)paininthecalfmuscles
calledintermittentclaudication.Howdoesthebloodgettotheglutealmuscles?Bloodarrivesattheaorticbifurcationandthen
passesintothecommoniliacarteries,whichdivideintotheinternalandexternaliliacvessels.Theinternaliliacarterythen
dividesintoanteriorandposteriordivisions,whichinturngiverisetovesselsthatleavethepelvisbypassingthroughthe
greatersciaticforamenandsupplytheglutealmuscles.Theinternalpudendalarteryalsoarisesfromtheanteriordivisionofthe
internaliliacarteryandsuppliesthepenis.Thepatient'ssymptomsoccurontheleftside,suggestingthatanobstructionexists
onthatsideonly.Becausethepatient'ssymptomsoccurontheleftsideonly,thelesionislikelyintheleftcommoniliacartery(
Fig.5.87)andispreventingbloodflowintotheexternalandinternaliliacarteriesontheleftside.HowwillIbetreated?asked
thepatient.Thepatientwasaskedtostopsmokingandbeginregularexercise.Othertreatmentoptionsincludeunblockingthe
lesionbyballooningtheblockagetoreopenthevesselsorbyasurgicalbypassgraft.Stoppingsmokingandregularexercise
improvedthepatient'swalkingdistance.Thepatientunderwentthelessinvasiveprocedureofballooningthevessel
(angioplasty)andasaresulthewasabletowalkunhinderedandtohaveanerection.

119/121

9/13/2014

Pelvis and Perineum

Fig.5.87
Digitalsubtractionaortoiliacangiogram.A.Normalcirculationpattern.B.Occludedleftcommoniliacartery.
Case5
Iatrogenicuretericinjury
A50yearoldwomanwasadmittedtohospitalforsurgicalresectionoftheuterus(hysterectomy)forcancer.The
surgeonwasalsogoingtoremoveallthepelviclymphnodesandcarryoutabilateralsalpingooophorectomy
(removalofuterinetubesandovaries).Thepatientwaspreparedforthisprocedureandunderwentroutinesurgery.
Twentyfivehoursaftersurgery,itwasnotedthatthepatienthadpassednourineandherabdomenwasexpanding.An
ultrasoundscandemonstratedaconsiderableamountoffluidwithintheabdomen.Fluidwithdrawnfromtheabdomen
wastestedandfoundtobeurine.Itwaspostulatedthatthispatient'suretershadbeendamagedduringthesurgery.The
pelvicpartoftheuretercoursesposteroinferiorlyandexternaltotheparietalperitoneumonthelateralwallofthepelvisanterior
totheinternaliliacartery.Itcontinuesinitscoursetoapointapproximately2cmsuperiortotheischialspineandthenpasses
anteromediallyandsuperiortothelevatoranimuscles.Importantly,theuretercloselyadherestotheperitoneum.Theonly
structurethatpassesbetweentheureterandtheperitoneuminmenistheductusdeferens.Inwomen,however,astheureter
descendsonthepelvicwall,itpassesundertheuterineartery.Theuretercontinuesclosetothelateralfornixofthevagina,
especiallyontheleft,andenterstheposterosuperiorangleofthebladder.Itwasatthispointthattheureterwasinadvertently
damaged.Knowingtheanatomyandrecognizingthepossibilityofuretericdamageenabledthesurgeonstoreestablish
continuityoftheuretersurgically.Thepatientwashospitalizedafewdayslongerthanexpectedandmadeanuneventful
recovery.
Case6
Ectopicpregnancy
A25yearoldwomanwasadmittedtotheemergencydepartmentwithacomplaintofpaininherrightiliacfossa.The
painhaddevelopedrapidlyoverapproximately40minutesandwasassociatedwithcrampsandvomiting.Thesurgical
internmadeaninitialdiagnosisofappendicitis.Thetypicalhistoryforappendicitisisacentralabdominal,colicky
(intermittentwaxingandwaning)pain,whichoveraperiodofhourslocalizestobecomeaconstantpainintherightiliacfossa.
Thecentralcolickypainistypicalforapoorlylocalizedvisceraltypeofpain.Astheparietalperitoneumbecomesinflamed,the
painbecomeslocalized.Althoughthispatientdoeshaverightiliacfossapain,thehistoryisnottypicalforappendicitis
(althoughitmustberememberedthatpatientsmaynotalwayshaveaclassicalhistoryforappendicitis).Thesurgicalintern
askedamoreseniorcolleagueforanopinion.Theseniorcolleagueconsideredotheranatomicalstructuresthatliewithinthe
rightiliacfossaasapotentialcauseofpain.Theseincludetheappendix,thececum,andthesmallbowel.Musculoskeletalpain
andreferredpaincouldalsobepotentialcauses.Inwomen,painmayalsoarisefromtheovary,fallopiantube,anduterus.Ina
youngpatient,diseasesoftheseorgansarerare.Infectionandpelvicinflammatorydiseasemayoccurintheyoungerpatient
andneedtobeconsidered.Thepatientgavenohistoryofthesedisorders.Uponfurtherquestioning,however,thepatient
revealedthatherlastmenstrualperiodwas6weeksbeforethisexamination.Theseniorphysicianrealizedthatapotential
causeoftheabdominalpainwasapregnancyoutsidetheuterus(ectopicpregnancy).Thepatientwasrushedforanabdominal
120/121

9/13/2014

Pelvis and Perineum

ultrasound,whichrevealednofetusorsacintheuterus.Shewasalsonotedtohaveapositivepregnancytest.Thepatient
underwentsurgeryandwasfoundtohavearupturedfallopiantubecausedbyanectopicpregnancy.Wheneverapatienthas
apparentpelvicpain,itisimportanttoconsiderthegenderrelatedanatomicaldifferences.Ectopicpregnancyshouldalwaysbe
consideredinwomenofchildbearingage.
Case7
Uterinetumor
A35yearoldwomanvisitedherfamilypractitionerbecauseshehadabloatingfeelingandanincreaseinabdominal
girth.Thefamilypractitionerexaminedthelowerabdomen,whichrevealedamassthatextendedfromthesuperior
pubicramitotheleveloftheumbilicus.Thesuperiormarginofthemasswaseasilypalpated,buttheinferiormargin
appearedtobelesswelldefined.Thispatienthasapelvicmass.Whenexaminingapatientinthesupineposition,the
observershoulduncoverthewholeoftheabdomen.Inspectionrevealedabulgeinthelowerabdomentothelevelofthe
umbilicus.Palpationrevealedahardandslightlyirregularmasswithwelldefinedsuperiorandlateralbordersandalesswell
definedinferiorborder,givingtheimpressionthatthemasscontinuedintothepelvis.Thelesionwasdulltopercussion.
Auscultationdidnotrevealanyabnormalsounds.Thedoctorponderedwhichstructuresthismassmaybearisingfrom.When
examiningthepelvis,itisimportanttorememberthesexdifferences.Commontobothmenandwomenaretherectum,bowel,
bladder,andmusculature.Certainpathologicalstatesarealsocommontobothsexes,includingthedevelopmentofpelvic
abscessesandfluidcollections.Inmen,theprostatecannotbepalpatedtransabdominally,anditisextremelyrareforitto
enlargetosuchanextentinbenigndiseases.Aggressiveprostatecancercanspreadthroughoutthewholeofthepelvis,
althoughthisisoftenassociatedwithbowelobstructionandseverebladdersymptoms.Inwomen,anumberoforganscan
developlargemasses,includingtheovaries(solidandcystictumors),theembryologicalremnantswithinthebroadligaments,
andtheuterus(pregnancyandfibroids).Thephysicianaskedfurtherquestions.Itisalwaysimportanttoestablishwhetherthe
patientispregnant(occasionally,pregnancymaycomeasasurprisetothepatient).Thispatient'spregnancytestwasnegative.
Afterthepatientemptiedherbladder,therewasnochangeinthemass.Thephysicianthoughtthemassmightbeacommon
benigntumoroftheuterus(fibroid).Toestablishthediagnosis,heobtainedanultrasoundscanofthepelvis,whichconfirmed
thatthemassstemmedfromtheuterus.Thepatientwasreferredtoagynecologist,andafteralongdiscussionregardingher
symptomatology,fertility,andrisks,thesurgeonandthepatientagreedthatahysterectomy(surgicalremovaloftheuterus)
wouldbeanappropriatecourseoftherapy.Thepatientsoughtaseriesofopinionsfromothergynecologists,allofwhomagreed
thatsurgerywastheappropriateoption.Thefibroidwasremovedwithnocomplications.
Case8
Uterinefibroids
A52yearoldwomanwasreferredtoagynecologist.Magneticresonanceimaging(MRI)indicatedthepresenceof
uterinefibroids.Afteralongdiscussionregardinghersymptomatology,fertility,andrisks,shewasofferedthechoice
betweenahysterectomy(surgicalremovaloftheuterus)oruterinearteryembolization.Auterinearteryembolizationisa
procedurewhereaninterventionalradiologistusesacathetertoinjectsmallparticlesintotheuterinearteries.Thisreducesthe
bloodsupplytothefibroidsandcausesthemtoshrink.Thepatientoptedfortheuterinearteryembolization.AnMRIperformed6
monthsaftertheembolizationprocedureshowedafavorablereductioninthesizeoftheuterinefibroids(Fig.5.88).

Fig.5.88
SagittalMRIofthepelviccavity.A.Measurementofafibroidbeforetheuterinearteryembolization.B.Measurement
ofafibroid6monthsaftertheembolization.Thesizeofthefibroidhasdecreased.

121/121