Anatomi Pelvis

Nur Afrainin Syah

With Courtesi to Prof Yanwirasti
Fakultas Kedokteran Universitas Andalas
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Bones
Muscles

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 THE PELVIS
contains :
 the lower part of the alimentary canal,
 the urinary bladder, parts of the
urethra
 parts of the reproductive system
 Bones of Pelvis
 Formed by two hip bones at the front
and sides, and by the sacrum and
coccyx behind
 The bony pelvis is divided into two
parts:
1. The true (lesser) pelvis
2. The false (greater) pelvis
 The Lesser Pelvis

 Has :
 an upper pelvis aperture
 a cavity
 a lower aperture
 Upper Pelvic Aperture =
Pelvic Inlet = Pelvic Brim
This plane scopes downward and forward
Passing from promontorium to the pubic
symphysis
Forms an angle about 48 degrees with
horizontal
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Diameters:
1. Antero posterior = conjugate diameter
passes from the upper margin of the
pubis symphysis to the middle of the
sacral promontory

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2. The Obstetrical Conjugate Diameter
From the back of the pubic symphysis to the
sacral promontory
Slightly shorter than the antero posterior
3.The Diagonal Conjugate Diameter
Only diameter that can be measured
pervaginam
The distance between the lower margin of the
pubic symphysis and the sacral promontory
When the sacral promontory cannot be
reached pervaginam, the antero posterior
diameter of the inlet is considered to be
adequat for successful parturition

When the promontory can be palpated, the

pelvis is regarded as contracted
4. The transverse diameter
passes across the widest part of the inlet

5. The oblique diameter

extends from the sacra-iliac joint one side
to the ilio-pubic eminence of the opposite
side
 Pelvic Cavity
 Passes downward and backward
 Longer behind than in front
 Diameters :
1. Antero posterior = conjugate diameters
2. Transverse diameter
3. The oblique diameter

Spina Ischiadica
 Lower Pelvic Aperture

Diamond shaped
Extends from the arcuate pubic ligament
and the inferior rami of the pubic in front
to the tip of the coccyx behind
Bounded laterally by the ischial
tuberosities an the sacrotuberous
ligaments
 Diameters
1. The antero posterior or conjugate
diameter passes from the lower margin of
the pubic symphysis to the tip of the
coccyx
2. The tranverse diameter, extends between
the ischial tuborosities
3. The oblique diameter
extends from the junction of the ischial
and pubic rami of one side to the point of
crossing of the sacrotuberous and
sacrospinous ligaments of the other side
Planes of the outlet forms an angle of about
10 to is degrees with the horizontal
 Classification of pelvis
 The shape and size of inlet are
important to parturition
 Four main shapes are recognized

All four types may be found in the female,

the gynecoid ±50%
The types frequently overlap one another
 Axis of Birth Canal
The path followed by the fetal head in its course
through the pelvic cavity
A guide to the direction of pull of the obstetrical
forceps
Extends downward and backward in the axis of
the inlet as far as ischial spines
Then, the axis of the birth canal turns forward
and downward, and continues in the axis of the
vagina which is parallel to the plane of the inlet
 Radiographic Pelvimetry
Provides information concerning the shape and
diameters of the pelvis
Five measurements are especially important:
1. The transverse diameter of the inlet
2. The obstetrical conjugate
3. The distance between the ischial spines
4. The distance between the ischial tuberosities
5. The posterior sagital diameter
(The distance between the midpoint of a line drawn
between the ischial tuberosities and the apex of sacrum)
 Disproportion about the fetal head
(average size) and the pelvis is likely to
occur :
1. If the obstetrical conjugate is less than
10 cm
2. If the distance between the ischial spines
is less than 8,5 cm
3. If the distance between the ischial
tuberosities is less than 8 cm
 Indication of radiographic pelvimetry
1. One or more pelvic diameters are smaller than
average or that the pelvis has an unusually
configuration
2. When the fetal head remains about the level of
the true pelvis after the onset of labor
3. In nulliparous women with breech presentation
4. In women with histories of previous obstetry
difficulties, pelvic fractures, inflammatory
disease of the pelvic bones
 Sexual Differences
In The Female
The bones are usually thinner and
lighter
The muscular marking are not a
prominent
The cavity is less funnel shaped
The distances between the ischial
spines and between the ischial
tuberosities are greater
The arcus pubis more than 90 degree
 In The Male

The inlet is variable

The ischial spines are heavier,
they project farther into the pelvic
cavity
The angulus pubis less than 90
degrees
 Growth of bony pelvis
• At Birth
No differences
• At Puberty
The pelvis growth rapidly, especially in
girls growth at puberty is influenced by
hormones, but is also sensitive to
nutritional and other environmental
changes
 Walls of Pelvis
• Having three planes
1. External plane
comprises the gluteral muscles
2. Intermediate plane
consist of bones and ligaments
(membrane and the sacrotuberous and
sacrospinosus ligaments)
3. The internal plane
Formed by muscles and fasciae that are
attached to the intermediate plane by
peritoneum
 Walls of pelvis

Subdivided into :
-Two lateral walls
-A posterior walls
-A floor
 Lateral walls
Bony framework: the part of the hip
bone below the terminal line
Pelvic surface is covered by the
obturator internus muscle and the
obturator fascia
In the posterior part, it is crossed by
the ureter and in it anterior part by the
round ligament (teres)
At the junction of the lateral and posterior
walls, a bony framework is lacking
The space between hipbone and sacrum
is filled by the sacrotuberous and
sacrospinosus ligaments
The sacrospinosum ligament divide the
space into :
- the greater sciatic foramina
- the lasser sciatic foramina
Posterior walls is formed by:
Sacrum and coccyx
The lateral part which are covered by
the piriformis and coccygeus
The median sacral artery and
symphathetic trunks pass downward
on the sacrum
 Floor of the pelvis
Comprises the structure that give
support to the abdominal and the
pelvic viscera
Chiefly by:
- peritoneum above
- pelvic diaphragm below
 The Peritoneum
Reaches the lowest level
Reflected from the rectum to the urinary
bladder in the male to from the rectovecal
pouch, or to uterus and vagina in the female
to form the recto-uterine pouch
The connective tissue between peritoneum
and the pelvic diaphragm contain blood
vessels, nerve plexus, lower part of the
urethra and the terminal part of the ductus
deferens
The lower parts of the floor of the
pelvis has two openings
Both in the median plane
The posterior, for the rectum pass
through the pelvic diaphragm
The anterior, for the urethra in the
male for the urethra and vagina in the
female
 The Pelvic Diaphragm
Consist of:
1. The levator ani muscle
the more important muscles of the pelvic
diaphragm
2. Coccygeus (ischiococcygeus) muscle the
relatively un important
 Levator ani
Variable in thickness and in strength
Lie almost horizontally in the floor of the
pelvis
Between the posterior part and left crura in
front, there is urogenital hiatus
The hiatus transmits:
-vagina (female)
- urethra and rectum (both sex)
These organs lie immediately about these
muscles, so receive important support from
this muscles
 The Levator Ani
Consist of three parts:
1. Iliococcygeus
2. Pubococcygeus
3. Puborectalis
Designated according to the direction
and attachment of their fibers
 The Iliococcygeus
 Most posterior part of the levator ani
 It rised from the pelvic aspect of the
ischial spine and from the tendinous arch
of the levator ani behind the level of the
obturator canal
 Its fibers pass obliquely and are inserted
into the sides of the coccyx and into the
anococcygeal ligament
 The Pubococcygeus
The main part of the levator ani
Arises from the back of the body of the
pubis and runs backward in a sagittal plane
toward the coccyx
It has several insertion
1. In the male
it runs backward, some of its more
medial fibers are inserted into the
prostate
2. In the female
some of its medial fibers are inserted
into the urethra and vagina (pubovaginalis)
3. Other
a. Together with fibers from the
contralateral muscle, encircle the
urethra and vagina (spinchter
vagina)
b. Inserted into the perineal body and
few continue and a few continue to
the walls of the anal canal
 The most lateral of the
pubococcygeus

• Arises from the tendinous arch of

the levator ani
• Pass behind the anal canal and
reach the and coccygeal ligament
 The Puborectalis

• A conspicuous part of the levator ani

• Passes backward and unites with a
corresponding part of the contralateral
muscle to form a muscular sling behind the
ano rectal junction
• It blends with the sphincter ani externus
and has been considered as a part of that
muscle
 Nerve Supply
• The levator ani and coccygeus are
supplied by branches of the ventral rami
of the third an fourth sacral nerves
• The anterior part of the levator ani is
supplied by the perineal branch of the
pudendal nerve
 Action
• The pelvic diaphragm help to support the
pelvic viscera
• Resists increases in intra abdominal
pressure
• Together with the anterior abdominal
muscles, it enables the diaphragm to the
function effectively in all activities requiring
increased intra abdominal pressure
 Different parts of the levator
ani, such as:
• Levator prostate
which lie directly
below the
bladder and are
in the control of
micturition
• Pubovaginalis
 The Puborectal
• Responsible for the flexure at the ano
rectal junction
• Its relaxation during defecation permits a
straightening at this junction
The pubococcygeus
• Capable of conciderable relaxation during
parturition
• But, it is frequently torn or damaged
 Fascia of pelvic diaphragm

• A part of the parietal pelvic fascia

• Arranged in two layers:

1. The superior fascia

- covers the pelvic surface of the
levator ani and coccygeus
- thin over the coccygeus
2. The inferior fascia
• Thinner than superior
• Covers the lower surface of the
levator ani and coccygeus
• Forms the medial wall of the
ischiorectal fossa
 Pelvic Fascia
Comprises : the parietal fascia and the visceral
fascia
Parietal Pelvic Fascia
• A part of the general layer that lines the
inner aspect of the abdominal and pelvic
walls
• Continuity with the fascia transversalis and
the fascia iliaca
• Forms a part of the floor of the pelvis
• It lines the lateral walls of the pelvis
(obturator fascia) and lines the posterior wall
incompletely
 Visceral Pelvic Fascia
• Formed by the extraperitoneal tissue that serves
as a packing for organs and as sheaths for
vesssels
• It lies between the peritoneum and parietal
fascia
• Continous above with the extra peritoneal tissue
of tha abdomen
• When the organ pass through the floor of the
pelvis, this fascia continous with the parietal
• Special thickening of the parietal and
visceral fasciae form sheaths for
blood vessels and nerve
• Some of these sheaths are termed
ligament and may contain large
numbers of smooth muscle fibers