Pelvis

Pelvic bones ...............................................................................................................................2

Ilium ..................................................................................................................................................................................................... 2
Sacrum ................................................................................................................................................................................................ 4
Joints .........................................................................................................................................5
Angles formed within the pelvis.................................................................................................................................................... 7
Muscles of the pelvis ..................................................................................................................8
Pelvic diaphragm ............................................................................................................................................................................ 8
Urogenital diaphragm .................................................................................................................................................................. 9
Superficial perineal layer of muscle .................................................................................................................................... 10
Pelvic fascia and ligaments...................................................................................................................................................... 10
Anatomical regions .................................................................................................................. 11
Perineum......................................................................................................................................................................................... 12
Pudendal canal (Alcock’s canal) ............................................................................................................................................ 13
Urogenital triangle ...................................................................................................................................................................... 13
Perineal body (central tendon) attachments ................................................................................................................... 15
Anal triangle .................................................................................................................................................................................. 15
Ischioanal fossa ............................................................................................................................................................................ 15
Retropubic space of Retzius.................................................................................................................................................... 16
Pelvic viscera............................................................................................................................ 16
Urinary bladder............................................................................................................................................................................ 17
General description ......................................................................................................................................................................... 17
Internal structure ............................................................................................................................................................................. 17
Ureters ............................................................................................................................................................................................. 19
Rectum and anal canal .............................................................................................................................................................. 21
Male specific organs ................................................................................................................. 21
Prostate ........................................................................................................................................................................................... 21
Embryology ......................................................................................................................................................................................... 24
Ductus deferens / vas deferens ............................................................................................................................................. 24
Seminal vesicles ........................................................................................................................................................................... 25
Male urethra .................................................................................................................................................................................. 25
Spongy urethra .................................................................................................................................................................................. 27
Extravasation of urine ................................................................................................................................................................... 27
Testicles........................................................................................................................................................................................... 27
Scrotum ........................................................................................................................................................................................... 30
The penis......................................................................................................................................................................................... 31
Erections and ejaculation ............................................................................................................................................................. 34
Female specific organs ............................................................................................................. 34
Uterus ............................................................................................................................................................................................... 34
Ovaries ................................................................................................................................................................................................... 36
Female urethra .................................................................................................................................................................................. 37
Embryology of females vs males ............................................................................................... 38
Arterial supply pelvis ................................................................................................................ 39
Anterior division of internal iliac.......................................................................................................................................... 40
Anastomosis around ASIS ........................................................................................................................................................ 42
Venous drainage ...................................................................................................................... 43
Internal iliac vein......................................................................................................................................................................... 43
Batson’s plexus and cancer spread ...................................................................................................................................... 43
Nervous innervation to the pelvis ............................................................................................. 43
Obturator nerve ........................................................................................................................................................................... 43
Posterior femoral cutaneous nerve ..................................................................................................................................... 44
Perforating cutaneous nerve .................................................................................................................................................. 44
Pudenal nerve – S2, 3, 4 ............................................................................................................................................................ 45
Perineal branch of S4 ................................................................................................................................................................. 46
Autonomic nervous system..................................................................................................................................................... 46
Inferior hypogastric plexus .......................................................................................................................................................... 46
Lumbar and sacral sympathetic chain ................................................................................................................................... 47
Pelvic splanchnic / Parasympathetics / Nervi erigentes ............................................................................................... 47
General visceral afferents for pelvis ........................................................................................................................................ 47
Cutaneous innervations ............................................................................................................................................................ 48
Surgical notes for the anatomy diploma oral................................................................................................................... 49

Pelvic bones
 Prior to puberty, three pelvic bones are separated by triradiate cartilage.
Fuses at 15-17 to form acetabulum complete by 25
 ASIS and pubic symphysis are in same vertical plane
 Acetabulum = 2/5 ilium, 2/5 ischium and 1/5 pubis

Angles
Pubic symphysis to coccyx = horizontal line
Pubic sympysis to ASIS = vertical line
Gluteal lines
Posterior left
Inferior right

Ilium
 Wing / ala of ilium = The main body of the ileum lying superior to
acetabulum. Has two surfaces
 Iliac surface - inner concave containing the iliac fossa, is origin for
iliacus
 Boundaries: Arcuate line below, crest above, ASIS and PSIS
 Gluteal surface - external convex, attachment for gluteal muscles
between the three gluteal lines – posterior anterior and inferior
 Boundaries: ASIS and PSIS, Crest above, acetabulum below
 Posterior gluteal line: Shortes, behind it is attachment of glut max
 Anterior gluteal line: Medius between anterior and posterior
  Inferior gluteal line: Gluteus minimis between inf and anterior
 Iliac crest is thickened superior margin of the wing, from ASIS to PSIS
 Auricular surface of ilium – The part that connects with the sacrum
 Arcuate line is a continuation of pectineal line and is
immediately below the iliac fossa. Forms part of pelvic inlet
margin
 Greater sciatic notch – formed between PIIS and the ischial
spine
 Acetabular lip – another name for the acetabular labrum
 Iliopubic imminence – A groove from union of the ilium
and pubic bone, in line with the AIIS. The tendons for
iliacus and psoas run over it
 Lateral border of pelvic inlet
 Iliac tuberosity – Attachment of superior portion of
posterior sacroiliac ligament (as well as two muscles,
sacrospinalis and multifidus

Ischium
 Has a body (central), super ramus and inferior ramus (medial)
 Ischial tuberosity – Below lesser sciatic notch - holds load when seated
 Ischial spine – forms the lesser sciatic notch below the PIIS
 The nerve to obturator internus crosses the back of the ischial spine
 Superior gamellus, coccygeus and iliococcygeus muscles are attached
 Sacrospinous ligament
 Pudendal nerve and internal pudendal artery run
immediately adjacent to nerve to obturator internus,
on the sacrospinous ligament, not over the ischial
spine
 Ramus of ischium articulates with inferior rami of pubic
bone to help make obturator foramen

Pubis
 Two rami which form the obturator foramen
 Superior rami forms part of acetabulum
 Inferior rami joins the ischium
 Pectineal line – from pubic tubercle to iliopubic eminence then
continues as arcuate line
 Pubic symphysis, pubic tubercle and pubic crest in that order
 a terminalis – Pubic crest, pectineal line and arcuate line all
combined
 Obturator crest – The anterior margin of the superior ramus
 Attachment of obturator membrane superiorly
 Obturator membrane – Almost closes obturator foramen and as
Obturator notch
obturator externus and internus origins on either side. Both fall
short of the obturator notch superiorly, to allow passage of
neurovascular bundle
  At this point, the obturator nerve divides to anterior and posterior divisions

Pelvic inlet – Pubic crest, pectineal line, arcuate line, sacral ala and promontary of
sacrum. Forms an angle of 50-60 degrees with the horizontal from posterior to
anterior
 AP distance around 10-11cm
 Lateral diameter around 12-13cm
 Men heart shaped, females oval shaped

Pelvic outlet
Pubic symphysis, ischiopubic ramus, ischial tuberosity, sacrotuberous ligament,
coccyx. Dimensions taken from tip of sacrum due to mobility of coccyx

Sacrum
 Base articulates with L5
 Apex articulates with coccyx
 Auricular surface articulates with the ilium (SIJ)
 Sacral hiatus – Termination of the central canal
at the level of S4
 Sacral ala – Large and triangular on either side of
the body of base of sacrum
 Support psoas major + lumbar and sacral plexus
 Origin of some of iliacus
 Promontary of the sacrum – the part that sits
anterior most and has ala either side
 Dorsal surface of sacrum
 Median sacral crest - Central ridge of bone from
fusion of S1-3 spinous processes, gives rise to the
supraspinous ligament,
 Intermediate sacral crest – fusion of sacral articular processes (S1
and S5 are not fused, S1 articular process articulates with L5 and S5
with coccyx, called coccygeal cornu / sacral cornu
 Lateral sacral crest – Transverse processes fused, attachment of
sacroiliac and sacrotuberous ligament.
 Fusion not complete, allows posterior sacral foramen to transmit
nerves
 Pelvic (anterior) surface of sacrum
 Has four transverse ridges where the discs used to lie
 Sacral promontory superiorly
 Four anterior sacral foramina
Sex differences between male and female pelvis

 Subpubic angle - between the two ischiopubic rami as they meet the pubic symphysis is
much less in men than women
 Gothic vs roman arch
 Male deeper and narrower pelvis. Females shallow and wider
 Pelvic inlet in males is heart shaped due to a deep sacral promontory. In females it is oval
 Females have a greater sciatic notch that forms a angle of almost 90 degrees – an inverted
L whereas males are narrow
 Females have triangular obturator foramen, oval for men
 Sacrum in female: Shorter, wider, more curved posteriorly. Males: Long, narrow,
straighter.
 Acetabulum in females: Wider apart and face more medially in females, giving females the
characteristic ‘swinging hips’ gait
 Ischial tuberosities and spines are heavier and project further into the pelvic cavity in
males

Joints

Pubic symphysis
 Secondary cartilaginous joint – as occur in mindline (vertebral discs, manubriosternal etc)
 Strengthened by two ligaments
 Superior pubic ligament runs over top to pubic tubercles
 Strengthened by external oblique and rectus abdominis
 Inferior pubic ligament - known as arcuate pubic ligament
 Lower edge separated from fascia of urogenital diaphragm by opening that
transmits deep dorsal vein of the penis

Sacroiliac joint
 Atypical synovial joint (fibrocartilage)
 L5 may be sacralised
 Sacral surface has hyaline cartilage, the iliac surface has fibrocartilage
 Ligaments hold it in place

Ligaments
 Interosseous sacroiliac ligament – Connects sacral tuberosity to ilium tuberosity. Deep
to the posterior sacroiliac ligament. Prevents abduction of sacroiliac joint. Second
strongest ligament in the body
 Posterior sacroiliac ligament – From intermediate and lateral sacral crest 1-4 through to
posterior superior iliac spine and inner lip of iliac crest
-> Posterior spinal rami from sacrum exit between interosseous and posterior sacroiliac
ligaments
 Anterior sacroiliac ligament – Lateral margin of the auricular surface of the ilium to the
to the anterolateral surface of the sacral segments 1-3
 Sacrospinous ligament (blue) – Sides of the sacrum and coccyx to the spine of the
ischium.
 Forms the greater sciatic foramen. Ischiococcygeus sits on it in its pelvis surface
 Sacrotuberous ligament - Attaches to:
 Area between PSIS and PIIS
 Transverse tubercles of the sacrum + upper part of coccyx
 Medial surface of ischial tuberosity, with its upper edge prolonged
forwards to form the falciform process, attaching to a ridge just
below pudendal canal
 Blends with biceps femoris and gives origin to gluteus maximus
 Is pierced by three nerves: Inferior gluteal, perforating cutaneous and
coccygeal nerves

*note: Given the interosseous sacroiliac ligament connects the two bones so
closely, it is said to be almost a syndesmosis, with the area anterior to it
being a synovial joint

Lumbosacral joint
 Transverse process of L5 to the ilium
 Iliolumbar ligament is shaped like a V lying on its side
 Apex of V attaches to the transverse process of L5
 Upper head attaches to iliac crest + gives origin for quadratus
lumborus + blends with lumbar fascia
 Lower head runs inferiorly and laterally to blend with anterior
sacroiliac ligament

Sacrococcygeal joint
 Secondary cartilaginous joint – as occur in mindline (vertebral discs, manubriosternal etc)

Greater sciatic foramen

Transmits in order
1. Superior gluteal vessels and nerve
2. Piriformis muscle – all below except superior
vessels/nerves
3. Inferior gluteal vessels and nerve
4. Sciatic nerve
5. Posterior cutaneous nerve of the thigh
6. Nerve to quadratus femoris (Inf gamellae)
7. Nerve to obturator internus (Sup gamellae)
8. Pudendal nerve
9. Internal pudendal artery and vein

Lesser sciatic foramen

 Tendon of obturator internus
 Nerve to obturator internus
 Internal pudendal vessels
 Pudendal nerve

Angles formed within the pelvis

 Pelvic bone in the upright position has the ASIS and pubic
symphysis in alignment vertically.
 The plane of the pelvic inlet forms an angle of 55/60
degrees with the horizontal (see picture)
 The plane of the pelvic outlet forms an angle of 15 degrees with
the horizontal
 The plane of least pelvic dimension – birthing line, is drawn
between pubic symphysis and the tip of the sacrum (S5)
 Plane of greatest pelvic dimension is between pubic symphysis
and S2-3

Sex differences between male and female pelvis

1. Subpubic angle - between the two ischiopubic rami as they meet the
pubic symphysis is much less in men than women Male deeper and
narrower pelvis. Females shallow and wider
2. Pelvic inlet in males is heart shaped due to a deep sacral promontory. In
females it is oval
3. Females have a greater sciatic notch angle – an inverted L (as it forms
almost 90 degree) whereas males are narrow
4. Females have triangular obturator foramen, oval for men
5. Sacrum in females is less curved and shorter

Common insertions and relevant points of bony pelvis

Ischial spine has the following attachments
 Sacrospinous ligament
 Forms upper edge of lesser sciatic notch
 Coccygeus muscle
 Superior gamellus

Ischial tuberosity
 All hamstrings
 Hamstring portion of adductor magnus
 Sacrotuberous ligament

Note that the levator ani attaches to the ischial spine along with the sacrospinous ligament.
This means that when pudendal nerve exits via greater sciatic foramen and re-enters via
lesser sciatic foramen, it returns into the perineum inferior to pelvic diaphragm, to then enter
obturator canal.

Muscles of the pelvis

p386

Pelvic wall muscles

Piriformis
 Arising from sacrum with origin extending medially between anterior sacral foramina
 Sacral plexus arises on top of muscle
 Both piriformis and sacral plexus are covered by strong membrane of pelvic fascia
attached to periosteum at margin of piriformis muscle
 Greater sciatic foramen
 Attaches to greater trochanter for external rotation
 Nerve to piriformis S1-S2

Obturator internus
 Arises from a large area around the obturator foramen –
Superior pubic rami, ischiopubic rami and part of internal
surface of ilium
 The obturator membrane covers over the obturator
foramen and obturator internus also arises from this
membrane – different to obturator fascia
 Passes through lesser sciatic foramen
 Covered on its internal surface with obturator fascia, which has a thickening over it called
tendinous arch

Pelvic diaphragm
Coccygeus + levator ani

Coccygeus
 Origin: Coccyx + distal sacrum
 Insertion: Ischial spine
 Action: Vestigial – used to wag tail
 Gluteal surface is actually sacrospinous ligament
 Innervation: Perineal branches S4-5

Levator ani
 Multiple subdivisions of head
 Pubococcygeus fibers
 Puborectalis fibers – its more medial subdivision. Its contraction moves the anus
forward, making a 90 degree angle with the rectum
 Levator prostate / levator vaginalis – Most anterior muscle fibers that swing
around prostate or vagina and meet with fibers from external anal sphincter / deep
transverse perineal
 Iliococcygeus fibers are most lateral – remember that this does not have an origin in
ilium – muscle migrated in humans, now goes to ischial spine
 Origin: Body of pubis anteriorly, tendinous arch over obturator fascia, around to ischial
spine posteriorly. Insertion is into coccyx muscle, the anococcygeal raphe and interlacing
with fibers from the other side
 Course: Fibers pass downwards, backwards, medially to meet in midline of opposite side
 Action
 Constant tonic contraction when upright. Keeps the downwardly mobile pelvic organs
within the pelvic cavity.
 Strong contraction pulls the lower end of the rectum upwards and forwards
 Innervation: Perineal branches of S3 and S4 on its pelvic surface. Pudendal nerve S2-4
on its perineal surface

Anococcygeal ligament and raphe

 Between tip of coccyx to the junction of rectum and anal canal
 Stretched during childbirth and defacation

Internal anal sphincter

 Formed from the circular muscle layer wall of the anus
 Located in proximal 2/3, smooth muscle
 Has fibers from puborectalis meeting it at almost a right angle and connecting to it

Urogenital diaphragm
Pudendal nerve (branch of deep perineal)
 Deep transverse perineal muscles - Left to right
ischiopubic rami with perineal body in the middle
 Fixes and stabilizes the perineal body
 External urethral sphincter – origin from
ischiopubic ramus, intermeshes with fibers from
other side. Located below prostate in males in
membranous urethra and bladder base for females
 S2-3-4 keeps shit off the floor
 Rectourethralis – Fibers passing from the rectal ampulla moving anteriorly to the
posterior portion of the urogenital diaphragm
 These fibers get cut in removal of rectum

Superficial perineal layer of muscle

All supplied by perineal nerve
 Superficial transverse perineal muscle – Has
ischial ramus posterior to attachment of perineal
membrane. Inserts into perineal body. Stabilises
perineal body
 Ischiocavernosus x2 – Surrounds left and right
crus and same attachments – angle between
ischiopubic rami and perineal membrane. Insert into
the corpus cavernosum of penis.
 Support erections and move penis slightly
 Bulbospongiosus x2 – Surrounds the bulb.
 Origin: Perineal body and the median raphe connecting the two togethers
 Insertion: Posterior fibers run anteriolaterally to insert into perineal membrane.
Fibers arising from raphe insert into dorsum of penis and bulbocavernosum muscle.
 Contraction expels contents of urethra
 External anal sphincter
 Extends for 2/3 of anal canal
 Tethered to anococcygeal ligament by its posterior fibers
 Connects to the perineal body anteriorly
 Forms a cylinder around anus and maintains
closure of the anus
 Innervation: Inferior rectal branch of perineal
nerve (S2)

Pelvic fascia and ligaments

Principles
 Over expansible areas, it is loose areolar. Over non-
expansile, it is thick and membranous
 It does not run over bare bone alone, except for
Waldeyer’s fascia
 Sacral plexus lies between pelvic fascia and piriformis
 Superior + inferior gluteal vessels pierce the pelvic
fascia
 The parietal peritoneum within the pelvis is
innervated by the obturator nerve. Visceral has no
innvervation

Obturator fascia – Invests the obturator internus.

Pelvic fascia – Thick black line
 Blends with superior urogenital fascia inferiorly
 Lines the pelvis laterally, which is membranous and tough
 Visceral layers cover organs – Dense around prostate (non-expansile), loose around
bladder, vagina, rectum (distensible)
 Levator ani has loose areolar version of pelvic fascia

Fascia of Waldeyer (presacral fascia) – lines sacral nerves and vessels and continues
anteriorly and laterally. Fuses with the mesorectal fascia lying above levator ani (where
peritoneum is not attached)– separate plane exists here between mesorectum and Waldeyer
fascia.

Denonvilliers (Rectovesical) fascia - between lower third of rectum

(no peritoneal covering) and bladder / prostate.

Urogenital fascia – Superior aspects lines external urethral sphincter

(orange above) and the inferior urogenital fascia is also known as the
perineal membrane (thick black below)

Perineal membrane – Runs along ischiopubic rami to the ischial

tuberosities and stops with a free posterior border. Separates deep Visceral
perineal pouch from superficial perineal pouch pelvic
fascia

Perineal fascia (Colle’s) – Covering all muscles of the superficial

perineal pouch (erectile muscles + external anal sphincter + superficial transverse perineal
muscle. Continuous with Scarpa’s?

Ligaments
Condensations of areolar tissues are called ligaments that surround iliac vessels and
hypogastric plexus
Lateral ligament of the uterus and bladder – Form around
neurovascular bundles
Puboprostatic ligament – A V shaped ligament with two
attachments on the pubic bone, leading to a single
attachment to the prostate, within the retropubic space of
Retzius
Pubovesical ligament
Round ligament of the uterus
Uterosacral ligament

Parietal pelvic fascia dotted

Anatomical regions Visceral line full

Pouch of douglas / retrovesical pouch

 Rectum has peritoneum covering its proximal anterior 2/3 (and lateral superior 1/3). At
the start of its inferior third, peritoneum is reflected onto upper vagina or bladder (female
vs male).
 These pouches are filled with coils of small intestine or sigmoid colon

Ischiorectal fossa
Wedge shaped situated either side of anal canal below levator ani
Apex: Meeting of obturator fascia with levator ani fascia
Anterior: Limited by posterior border of perineal membrane /
perineal body
Posterior: Gluteus maximus and sacrotuberous ligament
Medial: Levator ani muscle superiorly, external anal sphincter
inferiorly
Lateral: Ischial tuberosity and obturator internus
Floor: Perineal skin
Comments
 The two ischiorectal fossa are in continuity posterior to the anus
by a horse shoe shaped connection
 Contents
 Alcock’s pudendal canal in lateral wall
 Fat
 Internal pudendal artery, pudendal nerve
 Inferior rectal artery, nerve
 Perineal branch of S4
 Perforating cutaneous nerve
 Recesses – extensions of fossa beyond its boundaries
 Anterior recess – Above urogenital diaphragm almost to
body of pubis
 Posterior recess – Deep to sacrotuberous ligament
 Horse shoe recess – Connects the two fossae posteriorly
behind external anal sphincter

Perineum
The area distal to the pelvic diaphragm (levator ani + coccygeus)
Diamond shaped area between thighs. Divides into two triangles,
urogenital and anal by a line drawn between the two ischial
tuberosities
 Anteriorly: Arcuate pubic ligament, isciopubic rami, iscial
tuberosities.
 Laterally – Sacrotuberous ligament
 Posteriorly – Coccyx
 Roof = pelvic diaphragm
 Floor = Skin and fascia
 Perineal body – located at junction of two regions. Skeletal muscle, smooth muscle and
elastic fibers.
 Tear resistant for women between vagina and anus

Pudendal canal (Alcock’s canal)

 Extends from the lesser sciatic foramen to the posterior margin of the perineal membrane.
 Obturator internus fascia extends down below the levator ani muscle and fuses against the
ischial tuberosity / ischiopubic rami.
 This fascia then splits to enclose the neurovascular bundle – this splitting of fascia is what
is known as alcock’s canal
 Pudendal nerve, internal pudendal artery and vein are contained with
 Runs in the superolateral wall of the ischioanal fossa, giving off the inferior rectal nerve,
artery and vein

Urogenital triangle
 Between the two ischiopubic rami and the arcuate pubic
ligament
 About 3.5cm anterior to posterior
 Posterior border is an imaginary line between two ischial
tuberosities, with the perineal body in the midline
 Males contains urethra enclosed in root of penis
 Females contains vaginal orifice and external vaginal
genitalia

Three layers of fascia, two spaces. From deep to superficial:

 Superior urogenital fascia – lines the cranial side of the external urethral sphincter and
deep transverse perineal muscle, attached to the ischiopubic rami laterally
 Deep perineal pouch – between superior urogenital fascia superiorly and perineal
membrane inferiorly. Contents:
 Deep transverse perineal muscle x2 – horizontal muscle
 Sphincter urethrae muscle (External urethral sphincter)
 Pear shaped muscle, with thinner upper part extending superiorly to surround
lower parts of prostatic urethra
 Membranous part of urethra (for 1.5cm)
 Internal pudendal artery (sometimes divides early in Alcock’s canal, if so, you would
have dorsal artery of penis and perineal artery)
 Dorsal nerve of penis, perineal nerve
 Bulbourethral (Cowper) glands, adjacent (posterior a bit) to urethra, enclosed in
external urethral sphincter muscles. Pierce membrane to enter bulb of penile urethra
 5% of ejaculate, mucoproteins to lubricate urethra and neutralize acidic remaining
urine to make way for sperm.
  Supplies by the artery to the bulb off the perineal artery
 Perineal membrane –Tough fascia, attachment for penile musculature and supports
pelvic viscera
 3.5cm from anterior to posterior
 Extending across anterior ischial tuberosities with free
posterior edge
 Thickened to form the transverse perineal ligament
anteriorly, with a gap between the arcuate public
ligament
 Deep dorsal vein passes through here to
vescioprostatic plexus
 Fixed to the perineal body posteriorly
 Pierced by many structures. Different male vs female
 Ducts of bulbourethral glands
 Artery and nerve to bulb of penis * = superior urogenital fascia
 Dorsal arteries of penis
 Deep arteries of penis
 Posterior scrotal nerves and vessels
 Perineal nerve
 Superficial perineal pouch – Space between the
perineal membrane superior and superficial perineal
fascia (Colles) inferiorly. *
 It is open anteriorly to Scarpa’s fascia anterior to
pubic bone
 Open inferiorly to the penis and scrotum
 Closed posteriorly by the perineal membrane
merging with Colles fascia
 Contains:
 Perineal body (central tendon)
 Crus of penis or clitoris, bulb of penis or vestibule
 Greater vestibular glands in females (Bartholin’s glands)
 Erectile muscles ischiocavernosus and bulbospongiosis
 Branches of internal pudendal vessels and pudendal nerves
 Testis
 Spermatic cords
 Superficial perineal fascia of Colles – Attached along the posterior limit
of the perineal membrane meeting at perineal body
 Continuation of Scarpa’s fascia
 Extend off perineal membrane into rounded fascia around scrotum –
dartos fascia and cylindrical fascia for penis (Buck’s fascia).
 Rupture of penile urethra allows extravasation of urine beneath
Buck’s fascia, distends penis and scrotum and communicates with
scarpa’s fascia and could reach submammary space and axilla theoretically (but not
back as Scarpa’s obliterated in mid auxillary line)
 Skin
Perineal raphe: A continuous raphe from anus through to penis as a result of developmental
fusion. Continues through the scrotum as a raphe and internally as the scrotal septum, and
runs up through the ?ventral penis

Perineal body (central tendon) attachments

Attachments include
1. External anal sphincter
2. Bulbospongiosus muscle x2
3. Anterior fibers of levator ani (pubovaginalis) x 2
4. Deep transverse perineal muscle x 2
5. Superficial transverse perineal muscle x 2
6. One longitudinal muscle coat from the internal anal sphincter

Anal triangle

 External anal sphincter muscle

 Runs downwards and backwards
 Proximal fibers are annular, distal fibers from front to back
 Is in continuity with the puborectalis fibers of levator ani
 Attached anteriorly to perineal body
 Anal aperture - centrally
 Ischioanal fossae x2 – adjacent to anal aperture

Ischioanal fossa

 Wedge shaped space either side of the

4cm long anal canal
 Horse-shoe shaped posterior connection
between the two
 Each fossa is 5x5x5cm or so
 Has an anterior recess above the urogenital diaphragm on either side

Borders
 Anterior = perineal membrane
 Posterior = sacrotuberous ligament of which on its posterior surface is the sacrotuberous
ligament
 Lateral = obturator internus and the ischiopubic rami beneath levator ani
 Medial = Anal canal anteriorly, ischioanal fossa of the other side posteriorly
 Floor = perineal skin
 Roof = Obturator internus fascia meeting with the inferior fascia of the pelvic diaphragm

Contents
 Ischioanal fat
 Alcock’s canal in its lateral wall
 Pudendal branches of S4 running on the
underside of levator ani to reach the external
anal sphincter, which it helps innervate
 Posterior scrotal / labial nerves run through the
anterolateral surface to reach scrotum

Spaces within the ischiorectal fossa

 Perianal fascia – Extends from the white line of
Hilton to Alcock’s canal and bound above by the
perianal fascia and below by the perineal skin.
Abscesses here are very painful as it contains tight fat, unlike ischioanal abscesses above
the perianal fascia
 Alcock’s canal – described elsewhere

Hiatus of schwalbe – Rarely, a gap between the tendinous origin of levator ani and obturator
internus. Pelvic organs can herniate through this hiatus.

Retropubic space of Retzius

 Each inferolateral surface of the bladder slopes downwards and medially to meet on the
front of the pelvic diaphragm and obturator internus.
 A retroperoitoneal space exists between the anteroinferior bladder, the pubic bones and
symphysis and the obturator muscle
 Puboprostatic (or pubocesical) ligaments form the floor of the space
 Contents:
 Loose fatty tissue
 Deep dorsal vein of the penis entering the vesicoprostatic plexus

Pelvic viscera
Urinary bladder
General description
Muscular viscus that serves as a reservoir of urine
Tetrahedral in shape when empty, ovoid when distended

Structure: Tetrahedral
 Apex: Sharp, points towards the top of pubic
symphysis with remnants of urachus running in
median umbilical fold
 Base: Triangular, sits posterior
 Neck: The lowest part where the base and the
inferolateral surfaces come together to meet in the
midline.
 Inferolateral surface + superior surfaces
 Superior surface: Covered by peritoneum sweeping upwards onto anterior abdominal wall
 When bladder distends, peritoneum stripped from rectus abdominis because
transversalis fascia is loose and tenuous here

Relations
 Anterior = pubic symphysis/ retropubic space of retzius and anterior abdominal wall
 Posterior = Rectum + seminal vesicles + vas ampulla (or vagina and uterus)
 Inferolaterally = obturator internus, prostate
 Inferiorly = Levator ani

Ligamentous structures
 Lateral ligaments – From the inferolateral sides
of the bladder to the tendinous arch
 Lateral puboprostatic ligament = from anterior
end of tendinous arch extending down and
medially
 Medial puboprostatic ligament = From pubic
bone near pubic symphysis to prostatic sheath. Forms the floor of the retropubic space of
retziusz
 Median umbilical ligament – remnant of urachus
 Posterior ligaments – From side of base of bladder to lateral pelvic wall, enclosing
visceral venous plexus

Internal structure
Trigone: Triangular area at the base of the bladder between the ureters and internal urethra.
 Derived Embryologically from mesonephric ducts (intermediate mesoderm) whereas the
rest of the bladder is from the ventral cloaca (endoderm)
 Smooth surface
 Has its own superficial trigonal muscle which is
histologically different from all other parts of bladder,
which extends into the urethra in both sexes with
predominantly sympathetic innervation
 Distance between ureters varies from 2.5-5cm depending
on distension
 Fixed to the prostate in males and pelvic fascia in females –
very immobile
 Interureteric bar of Mercier – A transverse ridge running
between the ureters
 Uretero-urethral bar (Bell’s bar) x2 – running from
ureter to urethra along trigone
 Uvula vesicae – An elevation immediately posterior to
internal urethral orifice caused by enlarged median lobe of the prostate projecting
upwards.

Muscles
 Detrusor muscle - Three layers of muscle with profuse intermingling, can’t be separated
 Outer longitudinal
 middle circular
 Inner longitudinal
 Internal urethral sphincter – In males only! Not in females!

Histological structure
 Mucous membrane interior surface from transitional cell epithelium, thrown into
rugae when empty
 Muscular layers
 Adventitia – fibroelastic tissue

General facts
 No glands
 Arterial: Multiple superior vesical arteries. Inferior vesical artery.
 Minor inferior contributions: Obturator artery. Inferior gluteal artery. Uterine and
vaginal arteries
 Venous drainage: Do not follow the arteries. Is via the vesicoprostatic venous plexus
 Forms a plexus on the inferolateral surface of the bladder in the groove between
bladder and prostate
 Plexus passes posteriorly in the posterior ligament of the bladder to train into internal
iliac veins
 Communicate: With prostatic venous plexus in males, in females with other veins at
the base of the broad ligament.
 Lymphatics: Chiefly external iliac lymph nodes, but also some to internal iliac lymph
nodes – not what you would expect!
Innervation: - Derived from nerves arising from the inferior hypogastric plexus
 Parasympathetic via pelvic splanchnic S2-4
 Contraction of detrusor for micturition
 Inhibitory to the internal urethral sphincter
  Afferent for awareness of distention is conveyed to posterior column of the spinal cord
- the gracile fasciculus
 Fibers conveyed pain form over distention are conveyed to the anterolateral white
columns of the spinal cord (spinothalamic tract)
 Sympathetic T11-L2 segments. Inhibition of detrusor, vasomotor and contraction of
bladder neck during ejaculation.
 Pain from stones is conveyed by both sympathetic and parasympathetic fibers

Types of neurogenic bladder - clinical

 Automatic reflex bladder – When the spinal micturition center is completely transected
anywhere above S2,3,4. You lose volumtary inhibition and initiation of micturition. The
bladder will instead empty every 1-4 hours by a reflex contraction of detrusor.
 A lesion above S2 but below T4-6, patient is still aware when their bladder is full
 Autonomous bladder – Destruction of just S2,3,4. Becomes completely flaccid and will
distend with no ability to contract detrusor. It will overdistend and patient will get
dribbling, they can contract abdominal muscles or push suprapubically to empty out some
urine.
 Destruction of the sensory afferents for bladder distention will lead to a large amount of
urine collecting without any reflexcontraction e.g tabes dorsalis (syphilis causing
demyelination of the dorsal columns of the spinal cord e.g the gracile fasciculus)

Gender specific facts

In males: Peritoneum only covers the very top of the base of
the bladder, as it is below the rectovesical pouch.
 Vas and seminal vesicles: Situated either side of midline
posterior to the base
 Prostate’s base (its upper surface) lies against the bladder
*
neck (lower surface)
 Males have an internal urethral sphincter – at the distal
bladder neck, circular smooth muscle becomes continuous
with the prostate and seminal vesicle, sympathetic input
* = ant fornix
In females: The bladder is adherent to the anterior vaginal
wall and the upper part of the ‘uterine cervix’
 The bladder neck is related to pelvic fascia
 No internal urethral sphincter – distal bladder neck has
longitudinally arranged muscles
 Posterior to bladder is the vesicouterine pouch – peritoneum
doesn’t reach the vaginal fornix
 Body of uterus slides on bladder as it fills/empties

Ureters
See abdomen notes. Summary
Anteriorly = 3+1
-A mesentery
-Gonadal artery
-Colic artery
+R has duodenum
In abdomen
Posterior relations of both:
 Genitofemoral nerve
 Psoas
 SIJ
Anterior relations of right ureter
 Duodenum
 Right gonadal artery
 Right colic artery, ileocolic artery and root of mesentery
Anterior relations of left ureter
 Left gonadal artery
 Left colic artery
 Sigmoid mesentery

In pelvis
 Within pelvis, only one structure lies more superficial in the pelvis: Vas deferens, or
uterine artery (which lies above and in front of the ureter near the uterine cervix
 Crosses pelvic brim at the bifurcation of common iliac artery (level of the sacroiliac joint)
 Runs OVER external iliac then anterior to internal iliac
 Posterior to ovary
 Initially it runs backwards, downwards and laterally to cross from above done: Obturator
nerve, obliterated umbilical artery, obturator artery +
vein
 This occurs along the anterior margin of the greater
sciatic notch
 Reaches the level of the ischial spine, turns anteriorly and
medially
 Pierce the bladder wall at its upper lateral angle obliquely
and runs a short distance in the submucosa
 Vas crosses ureter superficially then runs medially to
ureter
 Seminal vesicle lies just above the point where ureter enters bladder
 The valve-like flap in mucosa keeps the ureters shut to prevent reflux during increases
bladder pressure, except when ureteric vermiculations occur to jet urine into bladder.
 4-5 times per minute
 Undergoes vermiculations – Kelly’s sign, push ureter, it
vermiculates (male gynecologist)
 Females: Ureter runs in the base of the broad ligament
(connects sides of uterus to walls and floor of pelvis

Blood supply
 Renal artery
 Gonadal artery
 Small branches from the aorta
 Common + internal iliac artery
 Superior vesical artery + in women, the uterine artery
 *In the cranial section, the vessels approach medially
 *In the caudal section, the vessels approach laterally
 *Rich blood supply exists in the adventitia of the ureter

Venous drainage – renal vein, gonadal vein, internal iliac vein, vesical venous plexus
Lymph drainage – Cranially, R ureter drains to paracaval or interaortocaval lymph nodes.
Caudally, ureters drain into pelvic lymph nodes (internal iliac or obturator)
Innervation of the ureter –
 Parasympathetics: Right vagus -> coeliac ganglion -> renal artery. Pacemaker cells in the
renal pelvis coordinate the muscular contractions
 Additional parasympathetics come from the sacral plexus, which reach the kidney via
the ureter!
 Sympathetic trunk – regulates vascular tone
 Pain afferents – To do with stretch of the ureter and collecting system and is derived from
different segments, sympathetically superiorly and parasympathetically inferiorly
 Transmitted via the: subcostal, genitofemoral and ilioinguinal nerves

Superior ureteric pain = T12 and L1 upper lumbar referred pain

Middle ureteric obstruction = inguinal, scrotal, medial aspect of thigh (L1, L2)
Lower ureteric obstruction = perineal pain S2-S4

Histology
1. Mucosa – transitional epithelium
2. Lamina propria – elastic and connective tissue with vessels
3. Tunica muscularis - Inner longitudinal muscle layers, outer circular layer. The distal
third has additional outer longitudinal layer
4. Adventitia – connective tissue with rich vascular plexus

Rectum and anal canal

 Refer to abdomen notes
 Rectum starts at S3 where sigmoid mesocolon ends
 Rectum ends at rectal ampulla where rectococcygeus forms a sling
 Anal canal has upper and lower portion separated by pectinate line
 Upper is endoderm. Columnar. Superior rectal A/V. Paraaortic lymph. Hypogastric plex
 Lower is ectoderm. Stratified. Inferior rectal A/V/N. Superficial inguinal lymph.

Male specific organs

Prostate
Solid, unpaired, fibromuscular viscus found in the male
pelvis cavity in continuity with the neck of the bladder. It is
involved in transmitting the prostatic urethra and
ejaculation of seminal fluid, of which the prostate contributes 30% volume to.

Structure and relations

Around the size of a chestnut with a pyramid shape, with its:
 Base is its superior surface which is continuous with the structure of the bladder, receives
the urethra
 Apex is directed down and rests on the urogenital diaphragm
 Anterior surface behind the retropubic space
 Posterior surface lying infront of the ampulla of the rectum, separated by Denonvilliers
fascia
 Inferolateral surface – Related to the anterior muscle fibers of levator ani (levator
prostate)

General facts
 Size of a chestnut – broader than it is long
 Has urethra traversing between anterior one third and
posterior two thirds
 Acini embedded in fibromuscular stroma – connective
tissue and smooth muscle
 Paraurethral glands of skene are the female equivalent.
Contributes 30% of seminal fluid
 Clasped by levator prostate part of levator ani
 Seminal vesicles are superior and posterior to prostate – related to bladder, not prostate
 Ejaculatory ducts pierce the posterior surface of
the prostate below the bladder, run 2cm obliquely
to enter ½ way along prostate into prostatic
urethra
 Has its own prostatic duct that empties into the
urethra via ‘prostatic sinuses’
 Anterior: Pubic symphysis, retropubic space,
posterior: rectum, lateral: levator ani. superior:
bladder
 Arterial supply:
 Primarily from prostatic branch form the
inferior vesical artery. Sends a ‘capsular
Picture not accurate for denonvilliers – fused
branch’ which approaches the prostate at a against posterior prostate
laterodorsal angle at 4 and 8 o’clock on cystoscopy
during a TURP
 Internal pudendal and middle rectal offer a few branches – middle rectal can be
significant
 Venous drainage: Vesicoprostatic venous plexus, lying between true and false capsules in
the groove between the bladder and prostate both anteriorly and laterally but not
posteriorly - This receives the deep dorsal vein of the penis anteriorly
 Drains to internal iliac vein through the posterior ligament of the bladder
 Drains to internal and external vertebral venous plexus (Of Batson) through veins
passing through anterior sacral foramina - valveless
 Lymph: Pelvic floor to internal iliac nodes – some can go to external iliac
 Neurovascular bundle – Sympathetics come from the superior hypogastric plexus via the
hypogastric nerve, the inferior hypogastric plexus transmits S2-4 parasympathetics via
nerves known as the cavernous nerves.
 Cavernous nerve lies between true and false prostate
 Continues on to the penis for erections
 Sympathetic innervation of the prostate gland causes the prostatic muscle
(continuation of bladder muscle) to contract

Fascia of the prostate

 True capsule
 Surrounds the prostate gland anteriorly and laterally
 Is in direct continuity with the fibromuscular stroma of the prostate and is inseparable
 Is important for staging
 Absent at the base and the apex
 False capsule – layer of pelvic fascia that covers the
prostate and bladder in the same
 Denonvillier’s fascia – extends from the rectal
ampulla to the floor of the rectovesical pouch.
 Attached to the perineal body inferiorly
 Adherent to prostate posteriorly
 Separates the bladder base and prostate from
rectum
 Covers the posterior surface of the seminal
vesicles and ampulla of the vas

For details on the prostatic urethra, see the urethra section

Clinical divisions of the prostate

Zones
1. Peripheral zone – 70% of volume. Surrounds distal urethra at the prostate apex and
continues posteriorly and laterally to the base – deficient anteriorly, which instead has
fibromuscular stroma
2. Central zone – 25% volume, contains ejaculatory ducts and verumontanum
3. Transitional zone – 5%, around urethra

Lobes
 Anterior – in front of urethra, small section,
unimportant as mostly stroma, few acini. Connects the
two lateral lobes
 Median – Wedge shaped between ejaculatory ducts and
proximal urethra. This is the section that obstructs
urethra when periphery of prostate grows and pushes it
in. Enlargement here also causes the uvula vesicae –
 pouching in the trigone of bladder. Can be likened to the transitional zone + central zone
combined
 Posterior – Expands out laterally. Commonest site of cancer.

Embryology
Refer to instant anatomy
http://www.instantanatomy.net/abdomen/areas/urinarytract/pductsdevelopment.html

Clinical
 PR exam detects enlargement of lateral lobes, but the median lobe expands into the base of
bladder and cannot be detected.
 BPH is not a generalized enlargement but a localized adenomatous growth of the
periurethral glands – those that are found anywhere around the urethra
 In cancer, the acini in the larger peripheral zones are the source of cancer.
 TURPS are done above the seminal colliculus (verumontanum) to avoid damage to
external urethral sphincter

Ductus deferens / vas deferens

 Thick walled muscular tube that transmits spermatozoa from the head of the epididymis
to the ejaculatory ducts
 Has a long and narrow lumen except at its lumen where it is sacculated

Course
 Enters abdomen through deep inguinal ring and passes along side wall of pelvis to reach
posterior bladder
 No structure intervenes between it and peritoneum – i.e it is THE most superficial
structure, followed by the ureters
 Although it is posterior to inferior epigastric artery
 Runs along obturator fascia, superficial to:
obliterated umbilical vein, obturator
neurovasculature, external iliac vessels and
ureter
 They pass medially and inferiorly, lying parallel
to each other and medial to seminal vesicles
posterior to the bladder
 Here, they dilate to form ampulla, storage for
semen
 They are ampullated behind bladder, not
prostate
 Vas opens into ejaculator duct of the prostate
 Seminal vesicles open into ampulla of vas
 Enter the prostate and form ejaculatory ducts which open either side of the urethral crest
on the verumontanum

General facts
 Extremely thick muscular wall compared to lumen
 Pseudostratiied / columnar epithelium with stereocilia
 Arterial: Artery to the vas = branch of superior (sometimes inferior) vesical artery, can
also get supply to middle rectal
 Accompanies vas to lower pole of epididymis
 Anastomoses with testicular artery
 Innervation: Sympathetic from first lumbar ganglion. Provides motor to smooth muscle
of vas for emission and ejaculation, travelling via superior hypogastric plexus to
hypogastric nere

Vasectomy
 Median incision in the upper part of the scrotum below the penis
 Vas lies in the posterior portion of the spermatic cord – incised here
 1:5000 chance of recanalization of the vas
 Can be done with local or general
 Usually done with scrotal incision
 Sex can be had within around a week, but 25 ejaculations and negative semen analysis
required to prove infertility

Seminal vesicles
Coiled, sacculated, muscular tubes within the male pelvis involved in the production and
expiulsion of the bulk of seminal fluid.

Relations
 Posterior to neck of bladder, with ampulla of the vas medial, the prostate
anteroinferior and separated from the rectum posteriorly by Denonvilliers
fascia.
 The duct of the seminal vesicle joins the ductus deferens to form the
ejaculatory duct
 Sympathetic innervation also from the cavernous nerves

Facts
 Produce 60% of seminal fluid
 Columnar or pseudostratified epithelium
 Lie against base of bladder above prostate
 Tips are just covered by peritoneum of rectovesical pouch
 Thin wall, thin layer of muscle – inner circular and outer longitudina
 Arterial: Inferior vesical and middle rectal
 Lymph: To iliac nodes
 Nervous: Sympathetics from the superior hypogastric plexus via the hypogastric nerve,
parasympathetics from the inferior hypogastric plexus via the pelvis splanchnics

Male urethra
A tubular passage transmitting urine and seminal fluid in males and only urine in females
20cm in males. Extends from the internal urethral orifice of the bladder to the external
urethral orifice at the glans penis
Has natural curvatures giving it an s shaped appearance in the flaccid state, turning into a J
shape in the erect state

Three parts
1. Prostatic – 2.5cm from bladder neck to end of prostate
2. Membranous – 2cm from prostate to entering the bulb
through urogenital diaphragm
3. Spongy – From bulb to external urethral
meatus
a. Bulbous portion within bulb
b. Pendulous portion within the corpus
spongiosum Verumontanum
c. Whole thing can be referred to as the
penile urethra

Narrowings
 Internal urethral sphincter
 External urethral sphincter (membranous urethra)
 Just proximal to the opening of the navicular fossa
 External urethral meatus (narrowest part)

Dilatations
 Prostatic urethra
 Bulbous urethra
 Navicular fossa

Prostatic urethra: Widest zone of urethra.

Traverses at the junction of the anterior one third and
posterior two thirds of the prostate

Urethral crest – the posterior longitudinal midline ridge

created by the median lobe!
 Prostatic ducts open either side of this ridge via the
prostatic sinuses

Verumontanum (Seminal colliculus)

 Ridge that is located on the posterior surface of the distal prostatic urethra
 Lies just proximal to the external urethral sphincter
 Prostatic utricle lies at its summit
 Ejaculatory ducts open on this crest lateral to the prostatic utricle
 Clinically important as during a TURP, this is the lower margin of where you can resect, as
below this is the external urethral sphincter and can cause incontinence

Prostatic utricle
 Opens on the summit of the verumontanum
 Remnant of uterus and vagina from fused paramesonephric (Mullerian) ducts
 Is a 5.5cm long cul de sac in the median lobe of the prostate
Spongy urethra
15cm long
 Begins in the bulbous part of the urethra, with the intrabulbar dilatation
 Takes a near 90 degree turn from running inferiorly to running anteriorly
 Continues through the corpus spongiosum, which is shaped like a transverse slit
 The external urethral meatus is a saggital slit, forming an X shaped exit to spiral urine
 Glands of Littre (Li-trey) (urethral glands) open into the urethral lacunae which run
along the entirety of the spong urethra except terminal fossa
 Function is to secrete mucus to protect epithelium against urine
 Urethral lacunae (of Morgagni) are pit-like recesses along
the spongy urethra with the glands of Littre opening
 Lacuna magna – an especially large urethral lacunae that
opens into the roof of the navicular fossa. This can be
associated with bleeding and dysuria in children
 Navicular fossa – a dilatation just proximal to the external
urethral meatus
 Statified squamous epithelium here (whole lining prior
to this is transitional epithelium – like rest of urinary
tract).
 Insertion of objects into urethra should be pointed
towards legs when penis is held against anterior
abdominal wall because of these lacunae
 Blood supply: Every artery found within penis.

Extravasation of urine

Bulbous rupture
 Most common site of urethral rupture is the bulbous
urethra
 Bulbous urethra can be crushed against the edge of the
pubic bone
 Extravasation into superficial perineal pouch -> tracts to
penis, testis, anterior abdominal wall deep to Scarpa’s fascia

Above urogenital diaphragm

 Urine will leak around bladder and prostate in extraperiteal space

Testicles
The testis are the male gonad, homologous with the ovaries in
the female. They are paired viscera located within the scrotal
sac and are involved in production of gametes well as the
predominantly male hormone testosterone.
Description
 They are ovoid / elliptical in shape, approximately 4cm long, 3cm x 3 x 2.5m, 20-25ml in
volume
 Described as having a superior pole, an inferior pole, a medial and lateral side and an
anterior and posterior border
 They lie obliquely within the scrotum, with its superior pole slightly lateral and its inferior
pole slightly medial
 Left testis is longer than the right, due to a longer
spermatic cord on the left. This occurs because the left
testis begins its descent before the right
 Position of torted testis: Transverse lie, twisting towards
the midline

Immediate relations pertinent to description

 Posteriolaterally, attached to the testis is the epididymis
 Posteromedially is the continuation as the vas

Arterial:
 Testicular artery – runs in spermatic cord and gives off branch to epididymis and reaches
posterior surface of testis then divides to medial and lateral branches
 Branches do not penetrate mediastinum testis
 Sweep horizontally within tunica albuginea and pierce the substance of testis
 Cremasteric and vas arteries – Anastomose with testicular artery within the epididymis
Venous:
 Pampiniform plexus – Venules drain to mediastinum testis then to spermatic cord,
surround the testicular artery for countercurrent heat exchange. Multiple veins then
merge into two veins as they exit deep ring, then converge to single vein on psoas major
Lymphatic drainage - Follows testicular artery to the paraaortic nodes at the level of L2
where the testicular arteries arise (just above umbilicus)
 Overlying scrotal skin drains superficially to inguinal nodes
Nervous innervation
 Sympathetics only. Preganglionic: T10 sympthetic outflow from spinal cord -> greater OR
lesser splanchnics -> coeliac ganglion -> synapse
 Postganglionic follow testicular artery to both
testicle and epididymis
 Sensory – From testicle. Follow the same path as
sympathetics

Anatomical structures within testis

1. Tunica vaginalis – Remnant of processus
vaginalis. Covers the anterior surface and sides
of each testicle

Sinus of epididymis
  Parietal lamina Reflected onto the internal surface of the scrotum at the posterior edge
of the gland. Extends up on the medial side of the cord
 Visceral lamina – overs the testis and is reflected inwards on the anterolateral surface
of the epididymis
 Hydrocoeles typically accumulate between parietal and visceral layers
 Tunica albuginea – Surrounds the testical
 Mediastinum testis – Continuous with the tunica albuginea, posteriorly it projects into
the testicular parenchyma and radiate septa which divide the testicle parenchyma into
lobules
 Seminiferous tubules – Coiled structures within the lobules, usually 2 per lobule but
can have 3-4. They are each 60cm long. Lead to a straight tubule connecting to rete testis
 Rete testis – tubes connecting the seminiferous tubules to the efferent ductules, contained
within the mediastinum testis
 Efferent ductules - connect rete testis to epididymis, 15-20 in number
 Epididymis – posterior and lateral surface of testis. Single tube 7m long. Spermatozoa
mature here and are stored.
o Has a head, body, tail or caput, corpus and cauda
o Covered by a thin capsule and tunica vaginalis in its anterior half
(where the head lies)
o Whole epididymis is strongly adherent to testis through fibrous
tissue
 Vas deferens – Posterior and medial surface of testicle. Direct continuation
of epididymis from the tail
a. 45cm long and extremely muscular (smooth), ciliated epithelium.
 Mediastinum testes – Fibrous connective tissue extending from the top to
near the bottom of the testis. Provides support for rete testis and vessels.
 Projections known as septa extend to the tunica albuginea, forming lobules in which
the tubules are contained.
 Up to 400 different lobules
 Hydatid of morgana / Appendix testis – appendix testis.
Paramesonephric remnant (along with prostatic utricle
 Sinus of epididymis – Slit like structure within tunica
vaginalis that allows passage of the efferent ductules
 Processus vaginalis – Precedes the testis descent through
canal. Testis move in behind it. The processus obliterates
proximally and its distal remnant merges at its margins with
the tunica albuginea, much like the cornea and conjunctiva
o Fail to obliterate means there is a connection between
peritoneum and scrotum, which is a type of congenital
hernia
o Localized persistence of part of processes leads to hydrocoele

Embryological remnants of significance

 Appendix testis – Remnant of the mullerian duct on the superior pole of the testis located
at the groove between head of epididymis and testical parenchyma.
 Appendix epididymis – Caudal end of the mesonephric duct
 Paradidymis – 3-4 small tubes found in the distal spermatic cord just above the head of
the epididymis, remnants of the caudal mesonephric tubules
Histology of testis
Leydig cells – located between the seminiferous tubules, testosterone
Sertoli cells – Lie against the basal lamina and are the true epithelium (sustenacular cells) of
the seminiferous tubules. They form an anastomosing network within which the germ cells
are embedded. They secrete and androgen binding protein to maintain an enormously high T
level in the area
Blood-testis barrier – Tight junctions between the sertoli cells epithelium, prevents antigenic
response to organisms own sperm

Conversion to spermatozoa
 Spermatogonia – outermost layer of seminiferous tubules
 Primary spermatocytes – one more in, undergo meiosis and half their chromosomes
 Secondary spermatocytes – very short half life, rapidly differentiate into
 Spermatids – which undergo metamorphosis called spermiogenesis to become
 Spermatozoa

Epididymis
Comma shaped structure that lies on the superior and posterolateral surface of the testicle. It
is made up of highly coiled tubes involved in the storage and maturation of spermatozoa
From above down, it is difivded into
 Head
 body
 tail
The head is attached to the rete testis via the afferent ductules. A distinct groove exists
between the epididymis and the testis, which is the fold of visceral tunica vaginalis
invaginating to form the sinus of the epididymis.

The tail is continuous with the vas deferens

Scrotum
Scrotum is a sac found as an extension off of the perineum, which has the function of
supporting the male gonads at a temperature that is conducive towards spermatogenesis

From superficial to deep, structures are:

1. Scrotal skin
2. Dartos muscle – Part of the panniculus carnosus.
Smooth muscle
I Sends a sheet into the midline fibrous septum
II Sympathetic innervation from genital branch of the
genitofemoral nerve (probably)
III Responsible for the wrinkly appearance of scrotum
IV Regulates temperature – reducing or increasing
surface area for heat loss
V Continuation of Colles fascia
3. External spermatic fascia, cremasteric fascia, internal spermatic fascia
4. Parietal and visceral tunica vaginalis, which is deficient posteriorly
5. Median scrotal septum – Fibrous connective tissue creating a left and right compartment
within scrotum. Continuation of perineal raphe

Blood supply to scrotum:

 Superficial external pudendal artery
 Deep external pudendal artery
 Posterior scrotal branches of the perineal artery (given off in Alcock’s canal)
 Cremasteric artery – branch of the inferior epigastric

Venous drainage: Same as the arteries, but named veins

Lymphatic drainage: Medial group of superficial inguinal lymph nodes

Innervation of skin of scrotum:

 Ilioinguinal nerve +genital branch of the genitofemoral nerve supplies anterior third of
scrotum down to anterior axial line
 Posterior two thirds:
 Laterally (labium majus) = perineal branch of the posterior femoral cutaneous nerve
 Medially (labium minus) = scrotal branches from perineal branch of the pudendal
nerve (S3)
 Dartos muscle innervated by genital branch of the genitofemoral nerve sympathetic fibers

Clinical dermatomal knowledge of scrotum: This is important in spinal analgesia. A low

spinal anaesthetizes skin of posterior 2/3 of scrotum (labium majus) at S3, but to get anterior
1/3 of scrotum, needs to be L1 which is 7 levels higher

Panniculus carnosus – side knowledge

This refers to the muscles found within the superficial fatty layer under the skin. Other
examples are platysma and palmaris brevis in hand.
Other animals use it too: ruminants may tense their panniculus to frustrate birds trying to
perch on them. Echidnas whole body is covered in it – enables them to roll into a spikey ball.

The penis
Anatomical position for penis is erect and facing upwards. Underside is ventral, the top
side is dorsal

Root
 Two crura are attached at angle between pubic rami and the perineal membrane.
 Each crus receives the deep artery of the penis near anterior end
 Surrounded by ischiocavernosus muscle to help propel blood in and provide some
mobility
 Continues as corpus cavernosum
 Bulb – posterior margin of corpus spongiosum, attached to the perineal membrane.
  Urethra enters its anterior portion so that most of bulb is posterior
to urethra
 Receives the arteries of the bulb near urethra and bulbourethral
glands

Body
Two corpus cavernosum and two parts of corpus spongiosum fused
together.
 The tunica albuginea between all three corpora are fused together to form a septum (some
animals have a bone here called os penis)
 Suspensory ligament of the penis
 Glans – Distal expansion of corpus spongiosum.

Neck – found just below the glans

Head – Glans of the penis

 Extension of corpus spongiosum
 Has a saggital slit, the external urethral meatus
 ‘Corona glandis’ is the overhanging area of the glans which
projects over the neck
 Smegma – secreted from the preputial glands on the corona glandis and neck of the penis.
Characteristic odour and relevant to rape

Fascial layers – From deep to superficial

Tunica albuginea – Has two layers, a superficial longitudinal and a deep circular layer
 Superficial longitudinal layer - encircles the corpus cavernosum and corpus spongiosum
as a whole
 The deep circular layer – Run around each corpus cavernosum separately and are fused in
the middle between to the two corpora cavernosum forming the septum of the penis
 The septum is complete proximally but distally replaced by fibrous bands like the teeth
of a comb which is called the ‘pectiniform septum’

Buck’s fascia – Surrounds all three corpora. Continuation of Colles fascia

 Deep dorsal vein of the penis lies within Buck’s fascia and gets
compressed against the tunica albuginea during erection
 Superficial fascia / skin – Contains within it the superficial dorsal
vein of penis

Ligaments – Attach to the root of the penis

 Suspensory ligament – From pubic symphysis and blends with
Bucks fascia. Pierces by the deep dorsal vein of the penis
 Fundiform ligament – Runs down from linea alba and surrounds
penis like a sling

Muscles
 Ischiocavernosus x2 – Attached to left and right crus. Contraction forces blood from
cavernous space to crura and corpus cavernosa to maintain Septum
Superficial
erections dorsal vein
 Bulbospongiosus x2 – Attaches to the bulb, used to contract
Deep dorsal vein
additional semen or urine. Anterior fibers also assist in Dorsal A + N
maintaining erections

Blood supply – 3 paired arteries

Deep artery
 Artery to the bulb of the penis runs through cavernous of penis
spongiosum. Goes to glans of penis and anastomosis with dorsal
artery of the penis. From the internal pudendal artery and
pierces perineal membrane
 Dorsal artery of penis supplies skin and glans of penis. From
the internal pudendal artery, pierces perineal membrane
 Deep artery of the penis – Provides helicine branches to the
corpus cavernosum
 Sole function is erection
 No anastomosis with dorsal artery of bulbar artery
 Intimal cushion and valve, special features, parasympathetic innervation by the
cavernous nerve
 Superficial dorsal artery of the penis – From superficial external pudendal arteries.
Supplies skin and fascia of the pneis

Venous drainage
 Deep dorsal vein - Main return. Pierces the suspensory ligament, runs between
transverse perineal ligament and arcuate pubic ligament and drains to vesicoprostatic
plexus. Gets compressed during erection between Bucks
fascia and tunica albuginea
 Superficial dorsal vein – Drains skin of penis. Divides to
join the superficial external pudendal vein -> and great
saphenous veins
 Veins accompany the arteries and drain to internal iliac
veins

Lymphatics
 Distal urethra follows the skin and drains to superficial
inguinal lymph nodes.
 Glans and corpora drain to deep inguinal nodes, especially
the lymph node of cloquet


Innervation:
 Dorsal nerve of the penis – supplies sensory to the entire penis including glans.
Innervates ischiocavernosus and Bulbospongiosus motor
 Cavernous nerves – sympathetic and parasympathetics from the inferior hypogastric
plexus on the lateral surface of rectum anterior to Denonvilliers fascia
 Run posterolateral to prostate, almost adherent to it, lying between lateral pelvic fascia
(LPF) and prostatic fascia (PF)
  Follows the prostatovesicular artery which
provide landmark of nerve sparing
prostatectomy
 Cavernous nerve leaves pelvis lateral to
membranous urethra and anterior to bulbous
urethra, entering the root of the penis and
supplying the helicine arteries of the deep artery of
the penis with parasympathetics

Peyronie’s disease - Fibrous thickening of one of the

corpora, preventing it from getting engorged witih
blood. This leads to angulation of the penis

Phimosis – Narrowing of the prepuce preventing retraction of the skin over the glans

Erections and ejaculation

Erection is parasympathetic
 Genital branches of the pelvic splanchnic nerves cause vasodilation of arteries of erectile
tissue (nervi erigentes)
 Increased pressure may occlude the veins preventing drainage, but the mainstay of
erection is increased penile blood flow
Ejaculation is sympathetic and somatic
 Sympathetic: Spinal outflow form T11-L2 to epididymis, vas, seminal vesicles, ejaculatory
duct, superficial trigonal bladder muscles causes the fluid to make it to prostatic urethra
(emission)
 Internal urethral opening of bladder neck constricts to prevent retrograde ejaculation
 Somatic: Rhythmic contraction of bulbospongiosus (perineal nerve) causes ejaculation

Female specific organs

Uterus
 Muscular organ that provides a nidus for the developing embryo
 Shape of a flattened pear
 8 x 5 x 3 cm (3 x 2 x 1 inches)

Structure
 Fundus – Area ABOVE the entrance of the tubes – like fundus of stomach. Convex. Covered
in peritoneum that continues over front and back of the body
 Body – Enclosed in peritoneum, laterally extending to the walls and floor of pelvis as the
broad ligament. Anterior surface faces the bladder with the vesicouterine pouch
intervening. Posterior surface faces upwards with coils of intestines on it. Lowest ½ cm of
the body which is continuous with the cervix is the isthmus
 Cervix – Tapers inwards, with lower ends clasped by vault of the vagina, which it
protrudes into. Therefore at the tapering of the vaginal (lower) portions is the external os
and at the canal of the cervix, which is continuous with the body of the uterus, is the
internal os (supravaginal portion of the cervix).
 External os is circular in nuliparious women, but a transverse slit after birth. External
os is level with ischial spines
 The vaginal portion is surrounded by vaginal tissue,
known as the fornices of the vagina. The posterior fornix
is the deepest.
 Posteriorly: Rectouterine pouch (of Douglas)
 Anteriorly: Attached to the bladder, above the trigone by
dense connective tissue (the cervix sits below the
vesicouterine pouch)
*Body of uterus is rarely midline. When it deflects to one side,
the cervix is deflected to the other side, meaning that one side of
cervix will lie closer to the ureter

Ligamentous
Upper aspect of the uterus
Broad ligament: The wide fold of peritoneum that connects the sidewalls of the uterus to the
walls and floor of the pelvis. Has three subdivisions:
 Mesometrium – Mesentry of the uterus, this forms the bulk of the ligament
 Mesosalpinx – Mesentry of the fallopian tubes
 Mesovarium – mesentry of ovaries. Surface of ovary is without peritoneum to allow exit of
eggs to be taken up by tubes
 In the base of the broad ligament runs the uterine artery and ureters – uterine artery is
more superficial / anterior (water goes under the bridge)
 Contents
 Gartner’s duct can be found in broad ligament – embryological remnant of
mesonephric duct
 Uterine artery
 Ureter
 Round ligament

Cardinal ligament

Fallopian tubes
 Embraced by the upper edge of the broad ligament known as the mesosalpinx - free
peripherally to catch eggs
 10cm long. Outer longitudinal muscle and inner circular muscle to propel eggs more
prominent peripherally than at the isthmus. Surface epithelium is a mixture of ciliated and
non-ciliated columnar epithelial lining
 Isthmus – proximal 1cm, embedded in uterus wall, narrow and straight.
 Ampulla – more distal, becomes wider
 Infundibulum – Trumped shaped expansion most peripherally with fimbriae (finger
processes) to catch eggs
 Open end lies behind the broad ligament adjacent to lateral pelvic wall and ovary

Blood supply of the uterus and uterine tubes

 Uterine artery running in the base of the broad ligament supplies uterus and vagina
 Anastomosis with the ovarian artery superior to the ureter

Obstetric angle – Narrowest length within the female pelvis that the baby must traverse.
 AP = Lower border of pubic symphysis to the last fused point of th sacrum – the coccyx is
very bendable and therefore isn’t considered.
 Transverse = Between ischial spines

Ovaries
Almond shape gondads of the female responsible for
producing gametes (oocyte)
Lie in the ovarian fossa, which is on the lateral pelvic
wall below the pelvic brim, below the bifurcation of the
common iliac arteries. It is bound by:
 Anteriorly = The external iliac vessels
 Inferiorly = The uterine tubes
 Posteriorly = The ureter and external iliac vein /
internal iliac artery + obturator nerve.

Ligaments and attachments

Mesovarium = attaches the ovary to the posterior aspect
of the broad ligament.
Ligament of the ovary – Attaches ovary to the uterus
Suspensory ligament of the ovary – Attaches the ovary to the lateral wall of the pelvis. The
ovarian artery enters into it at the lateral wall of the pelvis

Arterial – ovarian artery

Venous – Ovarian vein
Lymphatics – para-aortic
Innervation – sympathetics via ovarian artery form thoracolumbar outflow for vasomotor
and pain. No parasympathetics
Female urethra
 4cm long
 From the bladder neck, it passes downwards and forwards embedded in the anterior wall
of the vagina
 Pierces perineal membrane
 Opens into vestibule of vagina above the vaginal orifice
 Has the same transverse then saggital slit as the
male to help spiral urine

Paraurethral glands of Skene

 Located in distal urethra near the vagina
 Female equivalent of prostate
 Responsible for female ejaculate that contains PSA
 Have ducts which open adjacent to urethra
 Surrounded by tissue which, along with clitoris,
engorges with blood during arousal

Bartholins glands
 Female equivalent of bulbourethral glands
 Located in superficial perineal pouch in females (vs deep perineal
pouch in males)
 Secrete mucus to lubricate the vaginal opening (other lubricant
comes from higher up)
 Open in the angle between the labia minora and hymen (or where
it would have been)
Bulbospongiosus – Sphincter of the vaginal introitus

A = transverse cervical ligament

B = Pubocervical ligament
C = rectovaginal septum
D = Uterosacral ligament

Embryology of females vs males

Arterial supply pelvis

 Aorta bifurcates at L4. Iliac bifurcates at pelvic brim opposite SIJ (L5/S1)
 Internal iliac artery branches into an anterior and a posterior division.
 All vessels lie within parietal pelvic fascia
 Only branches that pass out of pelvis pierce the fascia (except obturator vessels)
Anterior division of internal iliac
Three bladder associated. Three viscera associated. Three parietal associated.
The vessels arise at different levels and must be traced to their destination to be identified
Internal pudendal and inferior gluteal and continuations of the anterior division

Bladder associated
 Superior vesical – First branch, multiple. Runs along pelvic wall then turn medially. Often
raises a bit of peritoneum with it
 Supplies vas and adjacent ureter at upper bladder
 Inferior vesical – Runs across pelvic floor, supplies trigone and lower part of bladder,
ureter, vas and seminal vesicle.
 Gives rise to the prostatic artery -
 Obliterated umbilical – continuation of superior vesical. Runs in medial umbilical fold

Viscera associated
 Middle rectal – Arises near or with inferior vesical, or is absent, more commonly in
females. Before netering wall of middle rectum, divides into a leash of branches
 Also may give rise to the prostatic artery
 Uterine – Passes superficial to the ureter running in the base of the broad ligament. It
turns up at the cervix. At the enterance of
uterine tube it anastomoses with tubal branch
of ovarian artery.
 Vaginal – often is a branch of uterine. Supplies
vascular walls of vagina.

Parietal associated
 Obturator – Runs out of obturator canal with
nerve lying superior to it within pelvis. Course
within limb discussed in lower limb notes.
Briefly – divides to medial and lateral. Medial
anastomoses with medial circumflex femoral
artery.

 Inferior gluteal – Passes below S1 or

sometimes S2 nerve root. Runs down buttocks

Internal pudendal artery– Leaves pelvis via the greater sciatic foramen inferior to piriformis,
lying in front of the inferior gluteal artery and lateral to the pudendal nerve
 Loops around sacrospinous ligament to then loop back in to the pelvic region via the lesser
sciatic foramen, deep to levator ani, immediately entering Alcock’s canal
 Inferior rectal artery – given off in Alcock’s canal, pierces obturator fascia to enter
ischioanal fossa
 Exits Alcock’s canal and enters deep perineal pouch
running along ischiopubic ramus above perineal
membrane. Divides almost immediately within the
deep perineal pouch

Terminal divisions of the internal pudendal artery

Perineal artery – Given off at the posterior edge of the

perineal membrane, which it pierces to enter into the
superficial perineal pouch. Supplies musculature here.
 Posterior scrotal artery or in females the posterior
labial artery which pierce the perineal membrane.
 There are actually two branches of these - medial
and lateral branches of the dorsal scrotal artery.
 Transverse perineal artery – supplies structures of the superficial pouch
Artery to the bulb –Pierces the perineal membrane adjacent to urethra behind bulbourethral
ducts to enter corpus spongiosum
 Supplies spongiosum and glans of penis and forms anastomois with dorsal penile
artery but not deep artery of the penis within corpus cavernosum
 Gives off a small artery to the bulbourethral glands
  Probably comes from perineal artery according to lasts, but instant anatomy picture
suggests its from dorsal artery of penis

Dorsal artery of the penis – Pieces membrane and runs along medial side of crus to reach
dorsum of penis.
 Pierces the suspensory ligament of the penis and runs deep to Buck’s fascia of the penis,
between the deep dorsal vein and with the dorsal penile nerves laterally
 Pass to glans of penis and anastomose with bulb artery of penis

Deep artery of the penis – Branch that pierces membrane to enter the crus. Has helicine
branches that supply the corpus cavernosum tissue

Posterior division of internal iliac artery – all parietal branches

 Iliolumbar – Passes upwards and out of pelvis anterior to lumbosacral trunk and
posterior to obturator nerve, running laterally deep to psoas.
 Lumbar branch: Really the 5th lumbar segmental artery. Gives a spinal branch into
foramen of L5/S1. Supplies QL, psoas, erector spinae via posterior branch
 Iliac branch: All of iliac fossa – iliacus, iliac bone, anastomosis around ASIS
 Deep and superficial circumflex iliac arteries
 Ascending branch of lateral circumflex femoral artery
 Upper branch of deep division of superior gluteal artery
 Lateral sacral – Runs lateral to the foramina of the sacrum, anterior to fascia and anterior
to the nerve roots and anterior to piriformis, which it supplies.
 Spinal branches enter anterior sacral foramina and exit via posterior sacral foramina.
Supply meninges and nerve roots, then muscles over the sacrum. Common variation:
upper sacral supplies first two, lower sacral supplies next two.
 This artery takes over from the segmental lumbar arteries
 Superior gluteal – Pierces pelvic fascia between lumbosacral trunk and S1. Branches:
 Superficial branch - sinks into gluteus maxiumus (unlike the superior gluteal nerve!).
 Deep branch – Runs between glut min and medius, divides to upper and lower. Upper
joints ASIS anastomosis, lower joints the trochanteric anastomosis (but not the
cruciate anastomosis)

*Note: The lumbar branch of the iliolumbar artery and the lateral sacral branches have almost
the exact same function: They supply spinal branches into the foramen of L5-S5 which
innervates the meninges and spinal nerve root

Anastomosis around ASIS

 Superficial circumflex iliac arteries – from femoral artery

 Deep circumflex iliac artery
 The ascending branch of the lateral circumflex femoral artery
 Upper branch of the deep division of the superior gluteal artery
Venous drainage
-Much like IVC bifurcation lies to the right and dorsal to aorta, all the iliac veins follow the
arteries to the right and dorsal.
-Pelvic veins have no valves. Coughing / increases in intrabdominal pressure may overwhelm
the IVC, pushing blood from pelvic viscera into vertebral venous drainage
*Clinically significant because it means pelvic viscera can drain up vertebrae, into posterior
intercostal and then on to azygous / SVC veins. Bypasses the diaphragm.

Internal iliac vein

 Begins above the greater sciatic notch from the confluence of the gluteal veins and all the
other veins that correspond to the iliac arterial branches.
 Also receives a bunch of plexuses
 Vesicoprostatic plexus (or uterine plexus)
 Rectal venous plexus – also communicate with the inferior mesenteric artery -> portal
vein

Batson’s plexus and cancer spread

Batson’s plexus refers to the valveless veins of the sacral canal, which drain into the
basivertebral veins.
The pathway of malignant spread is:
Vesicoprostatic plexus -> internal iliac vein + presacral veins.
Presacral veins -> Batson’s plexus within sacral canal (through anterior sacral foramina)
Batson’s plexus -> basivertebral veins -> communicates with the azygos system superiorly

Deep dorsal vein

 Drains most of the blood from the corpora
 Runs in midline, pierces suspensory ligament, goes through gap between perineal
membrane and arcuate pubic ligament
 Passes between the two puboprostatic ligaments and enters vesicoprostatic plexus

Vesicoprostatic plexus - Sits in front and at the sides of the bladder, in the groove between
bladder and prostate. Drains prostate, deep dorsal vein of penis and inferior bladder

Nervous innervation to the pelvis

Sacral plexus
410
Most of sacral plexus is explained in lower limb notes

Obturator nerve
 Anterior rami of spinal nerves L2-4. The ventral division (femoral is dorsal division).
 Emerges from medial surface of psoas
 Passes on the medial side of the SIJ (on the ala)
 Appears in the angle between internal and external iliac
arteries
 Here, the ovary is immediately anterior to it and only
separated from it via peritoneum.
 Ovarian pain can refer along nerve to skin of medial thigh
 Supplies peritoneum in this area
 Runs through obturator foramen most anterior / against
pubic bone, artery and vein behind
 Divides into two branches
 Anterior branch runs anterior to obturator externus and
anterior to adductor brevis but posterior to pecitneus and
then adductor longus
 Supplies hip joint
 Supplies brevis, longus, gracilis and medial skin over
adductors
 Posterior branch pierces obturator externus and supplies it. Then supplies adductor
portion of adductor magnus and sends a twig to knee joining femoral

Abnormal obturator nerve – should have been called abnormal femoral nerve. Comes off
the posterior division of L3-4 like femoral. Runs above pubic bone under inguinal ligament
like femoral. Helps supply pectineus. Present in 1/3 of individuals

Posterior femoral cutaneous nerve

 Leaves greater sciatic foramen between the ischium and sciatic nerve, superficial to sciatic
nerve
 Has two cutaneous branches relevant to the pelvis
 Gluteal branches – Curles around lower border of gluteus maximum, supplies skin
over convexity of the gluteal region
 Perineal branch – winds medially and forward between fascia lata and gracilis to
supply posterior portion of scrotum or labium majus

Perforating cutaneous nerve

 Posterior surface of S2-3
 Pierces sacrotuberous ligament
 At posterior edge of ischioanal fossa briefly
 Pierces or passes over lower border of gluteus maxius
 Supplies skin to buttocks just where they lose contact
 Variations:
 Can be absent – 1/3 of people
 Can arise from Posterior cutaneous nerve of the thigh
 Can arise from other sacral nerves lower down
Pudenal nerve – S2, 3, 4
Exits greater sciatic foramen, re-enters via the lesser sciatic foramen into Alcock’s canal,
adjacent to internal pudendal artery. It divides
entirely within Alcock’s canal. The dorsal nerve of the
penis and the perineal nerve both enter deep
perineal pouch and run above and below the internal
pudendal artery

Branches:
Inferior rectal nerve –Given off in posterior Alcock’s
canal. Somatic, supplies external anal sphincter + pain
and sensation below pectinate line

Dorsal nerve of penis – Runs through deep perineal

pouch above internal pudendal artery
 Pierces the perineal membrane between the deep and dorsal penile arteries (stays lateral
to the dorsal penile artery.
 Supplies skin around dorsum of penis and glans, few branches to corpus cavernosum
 No branches within deep pouch

Perineal nerve – Runs through deep perineal

pouch, below internal pudendal artery.
Divides into two branches
‘Superficial perineal nerve’ -> Becomes posterior
scrotal
‘Deep branch of the perineal nerve’ -> also known
as the ‘muscular branch’
Branches described:
1. Deep transverse perineal muscle and external
urethral sphincter (urogenital diaphragm)
2. Ischiocavernosus
3. Bulbospongiosus
4. Sensory to urethra
5. Superficial transverse perineal muscle
6. Posterior scrotal or labial

Clinical perineal nerve blocks

Pudendal nerve block
 Does not anaesthetize the anterior perineum which is supplied by ilioinguinal and
genitofemoral nerve
 Majority of external genitalia
 Urethra
 Anus
 Perineum
 Most of external anal sphincter
 Sphincter of bladder

Indications
Analgesia of second stage of labour
Repair of perineal laceration
Instrumental delivery
Minor surgery of the lower vagina and perineum

Technique - Needle placed 1cm inferior and medial to the ischial spine (via CT guidance or
intravaginal palpation) – Here the pudendal nerve lies medial to the pudendal vessels
OR: The ischial tuberosities are palpated and the needle inserted medially to them
Contraindication: Infection in the ischioanal space or adjacent structures
Confirmation of effectiveness: Anal wink reflex (perineal reflex) – stroke skin around anus,
reflex contraction of external anal sphincter, completely abolished after bilateral successful
blocks

Penile nerve block

 You need to anaesthetize the dorsal nerve, which runs deep

to Bucks fascia
 Bucks fascia is continued as the suspensory ligament of the
penis which attaches to the pubic symphysis
 The dorsal nerve runs just under the pubic symphysis
(pubic arch)
 Bilateral injections, or an abundant single injections are
used
 A ventral branch from the dorsal nerve is given off to
supply the frenulum, which may require a ventral ring block

Perineal branch of S4
 Enters perineum by passing between iliococcygeus and ischiococcygeus
 Supplies motor to these muscles (pelvic diaphragm) and continues through ischioanal
fossa to supply skin to area between tip of coccyx and anus

Autonomic nervous system

Inferior hypogastric plexus
The inferior hypogastric plexus is the connection between all autonomics within the pelvis.
It is found lateral to the rectum within pelvic fascia and is 5cm in the AP direction.
-Is enlarged into a ganglia of its own
-Receives sympathetic contribution from the hypogastric nerve
(from superior hypogastric plexus)
-About half of these fibers are myelinated preganglionic and synapse
-Other fibers and sympathetic and parasympathetic which do not synapse in ganglion
-Receives its parasympathetic contribution from pelvic splanchnics between S2-4

The Superior hypogastric plexus is a midline unpaired plexus of sympathetic fibers

Lumbar and sacral sympathetic chain

Sympathetic chain traverses the entire vertebral column down to coccyx.
 Responsible for pelvic and hindgut sympathetics
 Travel to superior hypogastric plexus, with the inferior hypogastric
plexus receiving somatic branches only from the lumbar and sacral
sympathetic contributions
 The superior hypogastric plexus sends its visceral sympathetics via
the hypogastric nerve (there are two) down to the the inferior
hypogastric plexus
 The ganglion impar is the convergence of both sympathetic chains
over the coccyx

Fertility relevance of pelvic sympathvetics

The superior hypogastric plexus provides innervation via the hypogastric nerve to the
internal urethral sphincter at the bladder neck, which prevents retrograde ejaculation

Pelvic splanchnic / Parasympathetics / Nervi erigentes

 The pelvic splanchnic nerves are parasympathetic fibers that arise from S2-4 and supply
the hindgut via the inferior hypogastric plexus, taking over from the vagal trunks
 Some fibers from the left ascend up above superior hypogastric plexus to lie with the
inferior mesenteric artery to supply the distal 1/3 transverse colon and beyond
 They contain preganglionic parasympathetic fibers as well as visceral afferent to pelvic
organs
 Functions include
 Motility of the rectum and distal colon
 Erection
 Transmission of pain sensation for hindgut (note in foregut and midgut, pain is from
sympathetic)
 Hirschprung’s disease: Congenital lack of pelvic ganglia – no motility

General visceral afferents for pelvis

 Pain sensation within the pelvis is divided into sympathetic, parasympathetic and somatic
 The pelvic pain line separates sympathetic visceral afferent fibers above, with
parasympathetic visceral afferent fiberes below
 Anything that is touched by peritoneum is above the pelvic pain line – i.e sympathetic
(superior bladder, superior 2/3 of rectum, superior uterus etc
 Structures supplied by the pudendal nerve have somatic innervation.

Cutaneous
innervations

Scrotum innervation
 Anterior scrotal nerve – off ilioinguinal nerve
(L1)
 Posterior femoral cutaneous nerve (S2-3)
 Posterior scrotal nerve (off perineal nerve, from
pudendal) = S2-4

Perianal innervation
 Perineal skin between genitalia and anus = S4
 Perianal skin = S5
Surgical notes for the anatomy diploma oral
Ureter injury and repair
 Ureter arteries travel longitudinally within the
adventitia
 Abdominal ureter perfused medially by the
renal artery / gonadals / aorta and the pelvic
ureter is perfused laterally by the iliacs and
inferior vesical

1. Find the ureter and gently mobilize it

2. Remove damaged / scarred area
3. Spatulate each end and anastomose
4. Can wrap it in omentum or retroperitoneal
fat to improve blood supply / reduce
fibrosis likelihood Spatulation of the ureter – widens lumen

Ureteroureterostomy – end to end anastomosis of ureters (mostly

upper and mid ureter)
Ureterpyelostomy – When ureter avulsed from the renal pelvis, you
just reimplant it
Transureteroureterostomy – When the ureter length is inadequate
for a ureteroureterostomy, you can mobilize the ureter from one side
and attach it on to the ureter of the other side
Ureteroneocystostomy – When the pelvic ureter is injured, blood
supply normally ruined. You make a new entry into the bladder higher
up (superomedial to its native entrance)
Vesicopsoas hitch – Pelvic injury to ureter with loss of blood supply
(essentially, length of pelvic ureter is lost). Mobilize the bladder
and pull it superiorly and laterally, then suture it onto the psoas
muscle to keep it there. Then, make a hole in the bladder and
implant the ureter. Urachus, obliterated umbilical artery and
occasionally the superior vesical artery of that side need to be
ligated. Genitofemoral nerve and femoral nerve can be damaged
running through psoas

Urethral injury
Pelvic fractures or penetrating injuries to ureter the bulb
 Suprapubic catheter then delayed repair 6-12 weeks later after resolution of pelvic trauma
 Done through a perineal incision, end to end anastomosis with cather lift in situ

Bulbous repairs
 Typically present months later as the urine does not leak everywhere and is due to
stricture
 Stricture can be repair by end to end anastomosis after resection of stricture, but if there is
too much tension, a buccal mucosal graft can be done
Radical cystectomy and ileal conduit
Bladder removed
Section of distal ileum taken out and the two ends of bowel anastomosed
Ureters attached to ileum and then ileum brought to abdominal wall for drainage with stoma