Sie sind auf Seite 1von 40

Figure71.A.Contrastcystogram.

(ImagecontributedbyLauraAvery,MD,DepartmentofRadiology,Massachusetts
GeneralHospital.)

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page72

TRANSITIONTOTHEPCEANATOMY

7.INFRAPERITONEALREGIONANDPERINEUM

Case
54yearoldmanwithnoPMHbroughttotheEmergencydepartmentforevaluationofabdominalpainaftera
multivehicleaccident.Heisapoliceofficerwhowasarestraineddriverinpursuitafterabankrobberywhenhe
lostcontrolofhisvehicle,strikingawallathighvelocity.Hehadimmediatelowerabdominalandpelvicpainat
thelevelofhislapbelt.Physicalexamisnotableforsignificantevolvingecchymosisinahorizontalband
stretchingapproximately4cmbelowhisumbilicus(CasewrittenbyCynthiaCooper,MD,MassachusettsGeneral
Hospital).
Acystogramstudyisorderedtobetterdefinetheinjury,andcontrastisinstilledintothebladderthroughaFoley
catheter.Asyoureviewtheimageswiththeradiologyresident,sheasksyoutopointoutanyintraperitoneal
contrastmaterialandtoexplaintherouteofthecontrastmaterialfromcathetertoperitonealcavity.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page73

Figure71.Organizationofthepelvisandperineum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page74

5.ORGANIZATIONOFTHEINFRAPERTIONEALREGION
ANDPERINEUM
5.1.ORGANIZATIONOFTHEINFRAPERITONEALREGIONANDPERINEUM
Organization
Infraperitonealregion.Thepelvisisasmallregion,crowdedwithmanyanatomicalstructures,andfurther
complicatedbytheterminologyusedtodescribeit.Thetermpelvis[Latin,pelvis,abasin)canbeusedtorefer
tothelowerportionofthetrunkwall,toabonyringconsistingofthetwohip(innominate)bonesandthe
sacrum,tothelimbgirdleattachingthelowerlimbtotheaxialskeleton,ortotheinferiormostportionofthe
abdominopelviccavity.
Forthisdiscussion,thetermpelviccavitywillrefertothenarrowspaceenclosedbythebonypelvisandthe
musclesofthepelvicsidewallsandpelvicfloor(Figure71).Theterminfraperitonealregionwillrefertoamore
extensiveterritoryincludingthepelviccavityandextendingupwardtotheinferiorboundaryoftheperitoneal
sac.Thecontentsoftheinfraperitonealregionincludethepelvicbones,theskeletalmusclesofthepelvic
sidewallsandpelvicfloor,thepelvicorgans,neurovascularstructures,andtheextraperitoneal(infraperitoneal)
looseconnectivetissuesurroundingandstabilizingthepelviccontents.
Inbothsexes,thepelvicorgansincludethebladder,urethra,andrectum.Thefemalepelvicorgansincludethe
ovaries,uterinetubes,uterus,andvagina(Figure71,upperimage).Themalepelvicorgansincludethe
prostate,seminalvesicles,andpelvicportionsoftheductusdeferentes(vasdeferens)(Figure71,lower
image).
Perineum.Theslopingpelvicfloor,consistingofthecoccygeusandlevatoranimuscles,providestheboundary
betweentheinfrapertionealregionsuperiortothepelvicfloorandtheperineuminferiortothepelvicfloor.The
perineumistheregionbetweenthepelvicfloorsuperiorly,theinferiorportionofthepelvicsidewallslaterally,
andtheperinealskininferiorly.
Thecontentsoftheperineumincludetheskeletalmusclesphinctersoftheurethra,vagina,andanalcanal,the
erectiletissueofthefemaleandmaleexternalgenitalia,theskeletalperinealmusclescoveringtheexternal
genitalia,theneurovascularsupplytotheperinealstructures,andlooseconnectivetissuecontinuouswiththe
subcutaneousfat.

Dissectionstrategy
Inthislaboratory,youwillcompleteyourstudyoftheabdominopelviccavityandperitonealsac,beginningwith
theinferiorportionoftheperitonealsacanditsrelationshiptothemaleandfemalepelvicorgans.Youwillnext
completeyourstudyofthelayersandregionsoftheabdominopelviccavitybyliftingtheperitonealsacoffthe
pelvicorgansandexploringtheinfraperitonealconnectivetissuesurroundingandsupportingthepelvicorgans.
Youwillfirststudythepelvicorgans,theiranatomicalrelationships,andneurovascularsupplyinyouranatomical
donor,andalsostudytheperinealanatomyofyourdonorincludingtheexternalgenitaliaandtheexternal
orificesoftheurethraandanalcanal.Whenyouhavefinishedthestudyofyourownanatomicaldonor,you
shouldstudythepelvicandperinealanatomyofadonoroftheoppositesex.
Weknowthat,formanyreasons,thepelvisandperineumaretechnicallyandemotionallychallengingregionsto
dissect.Yourcolleagueswillincludestudentsofvaryinglevelsofsexualexperienceanddifferentsexual
orientations.Someofyourclassmatesmayhaveexperiencedsomeformofsexualtrauma.Yourcustomary
sensitivityandtactwillbeparticularlywelcomeduringthislab.Pleaseletyourinstructorsknowifwecanhelp.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page75

Otheranatomycourseshaveadoptedamuchmoreinvasiveapproachtodissectingthepelvisandperineum.In
Foundationsanatomy,wehaveadoptedalessinvasiveapproachthatmorecloselyparallelsactualsurgical
practice.

Figure72.Bones,ligaments,andmusclesofthepelvicsidewallandpelvicfloor,medialview.(Substantially
modifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page76

5.2.MUSCULOSKELETALPELVIS
Pelvicbones,ligaments,andmembranes
Theadultbonypelvisisanirregularring,consistingofthepairedhip(innominate)bonesanteriorlyandlaterally,
andfivefusedsacralvertebraeand35coccygealvertebraeposteriorly(Figures72and73).
Eachadulthipboneconsistsofthreeseparatebones,theilium,ischium,andpubis,whichfuseinlate
adolescence(Figure72).Instandardanatomicalposition,averticallinethroughtheanteriorsuperioriliacspine
intersectsthepubictubercle,andthepelvicinlet(pelvicbrim)facesmoreanteriorlythansuperiorly.Ifthepelvis
isabasin,thebasinistipped.
Pelvicjoints.Theleftandrighthipbonesmeetanteriorlyatthepubicsymphysisandformthesacroiliacjoints
posteriorly(Figure72).Thepubicsymphysisisafibrocartilaginousjointthatpermitsonlyslightstretchingand
compression.Theleftandrightsacroiliacjointsaresynovialjointsthatpermitonlyslightgliding.
Pelvicinlet,pelvicoutlet,andpelviccavity.Thewingsoftheiliacbonesliesuperiortothepelvicinletand
surroundthe'falsepelvis',thelowerportionofabdominalcavity
Theboundariesofthepelvicinlet(pelvicbrim)arethesuperiormarginofthepubicsymphysisandpubic
bonesanteriorly,thearcuatelinebetweentheiliumandischiumlaterally,andthesacrumposteriorly.
Theboundariesofthepelvicoutletaretheischiopubicramiandsacrotuberousligamentslaterally,andthetip
ofthecoccyxposteriorly.Thepelviccavity('truepelvis')lieswithinthebonypelvisbetweenthepelvicinlet
andpelvicoutlet.
Pelvicdenseconnectiveligamentsandmembranes.Thepelvicligamentsandmembranesaresturdydense
connectivetissuestructures(Figures72and73).Theobturatormembraneclosestheobturatorforamenexcept
forasmallpassage,theobturatorcanal.Thesacrotuberousligamentattachestheischialtuberositytothe
sacrumandposteriorilium.Thesacrospinousligamentattachestheischialspinetothesacrum.Theperineal
membraneclosestheanteriorportionofthepelvicoutletbetweentheischiopubicrami,exceptfortheopenings
oftheurethrainbothsexes,andthevaginainfemales.Theperinealbodyisaknotoffibromuscularconnective
tissueattheposteriormarginoftheperinealmembrane.
Openingsbetweenthepelvicbonesandpelvicligamentsallowneurovascularstructuresandmusclestotravel
betweenthepelviccavityandtheperineum(lessersciaticforamen)andbetweenthepelviccavityandlowerlimb
(obturatorcanal,greatersciaticforamen,andintervalbetweenthepelvicinletandinguinalligament).

Pelvicsidewalls
Thepelvicsidewallsareformedbythelateralportionofthebonypelvis,theobturatormembrane,andtwo
lowerlimbmusclesthatariseontheinternalsurfaceofthebonypelvis,passthroughpelvicapertures,andinsert
onthefemur(Figures72and73).
Thepiriformismusclearisesontheinternalsurfaceofthesacrum,leavesthepelviccavitythroughthegreater
sciaticforamen,andinsertsontheposteriorfemur.
Theobturatorinternusmusclearisesontheinternalsurfaceoftheobturatormembrane,leavesthepelvic
cavitythroughthelessersciaticforamen,andinsertsontheposteriorfemurneartheinsertionofthe
piriformismuscle.
Contractionofthepiriformisandobturatorinternusmusclesexternallyrotatesthelowerlimbatthehipjoint.
Table71,intheAppendixforthislabmanual,summarizestheactions,innervation,andattachmentsofthe
pelvicsidewallmuscles.
Innervation.Thelowerlimbmuscles,includingpiriformisandobturatorinternus,areskeletalmusclesreceiving
somaticsensoryandsomaticmotorinnervationfrombranchesofthelumbosacralnerveplexus.Youwillstudy
thelowerlimbmuscles,andthelumbosacralnerveplexus,duringLabs8and9.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page77

Figure73.Bones,ligaments,andmusclesofthepelvicsidewallandpelvicfloor,superiorview.(Substantially
modifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page78

Pelvicfloor
Theskeletalmusclesofthepelvicfloorincludethecoccygeusandlevatoranimuscles(Figures72and73).The
pelvicfloormusclesclosethepelvicoutletposteriortotheperinealmembrane,exceptfortheopeningofthe
anus,andthelevatoranimusclealsoplaysanimportantroleinmaintaininganalcontinence.
Thebonyattachmentsofthepelvicfloormusclesincludethepubis,ischialspine,andcoccyx(Figure73).
Betweenthepubisandtheischialspine,levatoraniattachestothetendinousarchoflevatorani,athickeningof
theobturatorinternusliningfascia.Table72,intheAppendixforthislabmanual,summarizestheactions,
innervation,andattachmentsofthepelvicfloormuscles.Youarenotrequiredtolearnthemuscleattachments
indetail.
Theslopingpelvicfloorsupportstheconsiderableweightoftheabdominalandpelvicorgans.Contractionofthe
levatoranimusclesraisesthepelvicfloorand,incooperationwiththeanterolateralabdominalwallmuscles,
decreasesthevolumeoftheabdominalcavityandincreasesintraabdominalpressure,forexampleduringa
Valsalvamaneuver.
Thepuborectalisportionofthelevatoranimuscleformsaslingaroundtherectum,drawingtheanorectal
junctiontowardthepubis,positioningtherectumobliquely,ratherthanvertically,andformingasharpkinkthat
narrowsthelumen.Thepubovaginalisandpuboprostaticusmusclesformsimilar,iflesssubstantial,slingsand
mayplayaroleinmaintainingurinarycontinence.
Innervation.Thepudendalnerve,abranchofthelumbosacralplexus,providesmotorinnervationtothepelvic
floormuscles.

5.3.INFRAPERTIONEALREGION
Peritoneum
Theinferiorportionoftheperitonealsacdrapesthesuperiorsurfacesofthepelvicorgans,formingtheroofof
theinfrapertionealregion(Figures71and74).
Theparietalperitoneumliningtheanteriorabdominalwallreflectsontothebladdertocoveritssuperiorsurface
asvisceralperitoneum(Figures74and75).Exceptforitssuperiorsurface,thebladderisanextraperitoneal
organembeddedinthelooseconnectivetissueinferiortotheperitonealsac.
Thesigmoidmesocolongraduallyshortensasitapproachestherectum,andtherectumhasnomesentery
(Figure74).Visceralperitoneumcoverstheanteriorandlateralsurfacesoftheproximalrectumandtheanterior
surfaceofthemiddlerectum,thenreflectsanteriorlyontotheuterusinfemales(Figure74,upperimage)orthe
bladderinmales(Figure74,lowerimage).
Infemales,visceralperitoneumcoversthesurfacesoftheovaries,uterinetubes,anduterus(Figure74,upper
image).Lateraltotheuterus,theperitoneumformsadoublelayeredperitonealfold,thebroadligamentthat
extendsfromtheuterustothepelvicsidewalls,whereitiscontinuouswiththeparietalperitoneum.
Neurovascularstructurestravelwithinthebroadligamenttosupplythefemalepelvicorgans.Thevaginalies
inferiortotheperitonealsac,withintheinfraperitonealconnectivetissuebelowtheperitonealsac.
Inmales,onlythesuperiortipsoftheseminalvesiclescontacttheperitonealsac,ifatall.Theprostate,the
remainderoftheseminalvesicles,andthepelvicportionsoftheductusdeferentes(vasdeferens)liewithinthe
looseconnectivetissueinferiortotheperitonealsac.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page79

Figure74.Femalepelvis,superiorviewandmalepelvis,superiorview.(SubstantiallymodifiedfromNetterAtlas
ofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page710

Peritonealreflectionsandrecesses.Blood,excessperitonealfluid,andotherfluidstendtocollectinthe
peritonealrecessessuperiortothepelvicorgans.Infemales,thevesicouterinerecessisformedwherethe
visceralperitoneumreflectsoffthesuperiorsurfaceofthebladderandontotheanteriorsurfaceoftheuterus
(Figure74,upperimageandFigure76,upperimage).Therectouterineperitonealrecess(pouchofDouglas)
formswherethevisceralperitoneumreflectsofftheanteriorsurfaceoftherectumandontotheposterior
surfaceoftheuterus.
Inmales,therectovesicalrecessformswherethevisceralperitoneumreflectsofftheanteriorsurfaceofthe
rectumandontothesuperiorsurfaceofthebladder(Figure74,lowerimageandFigure76,lowerimage).

Hysterectomy
Hysterectomyissurgicalremovaloftheuterus.Hysterectomywithbilateralsalpingooophorectomyisremovalofthe
uterus,uterinetubes,andovaries.Hysterectomymaybeperformedasanopenabdominalprocedure,asaminimally
invasivelaparoscopicprocedure,orthroughavaginalapproach.Hysterectomywasconsideredarelativelyroutine
procedureinthedecadeswhenmanyofourfemaledonorsenteredmiddleage.

Identifyingperitonealregionsandrecesses
Liftthesigmoidcolonandanyloopsofsmallboweloutofthepelviccavity,detachinganyadhesionsthatrestrict
them.Adhesionsmaybeparticularlytroublesomeindonorswhohaveundergonepelvicsurgery.Ifyouexperience
anydifficultyinfreeingloopsofbowelfromthepelvis,orifaperforationoccurs,askaninstructortohelp.Notethe
presenceofextensiveperitonealadhesionsinyourLaboratoryNotesandObservationsLog.
Usingthebulbbasterandpapertowels,removeanyfluidcollectedinthepelviccavity.
Beginninganteriorly,identifythepubicsymphysis(Figure74).Followtheparietalperitoneumfromtheanterior
abdominalwalltothesuperiorsurfaceofthebladderwhereitbecomesvisceralperitoneum(Figure74).Theempty
bladderliesposteriortothepubicsymphysisandinferiortothepelvicinlet.Thedistendedbladderrisesseveral
centimeterssuperiortothepubicsymphysis.
Ifyourdonorisfemale,identifytheuterus(ifpresent)andthevisceralperitoneumcoveringtheanteriorandposterior
surfacesoftheuterus.Ifyourfemaledonorhasundergonepelvicsurgery,suchashysterectomyorhysterosalpingo
oophorectomy,noteyourfindingsintheNotesandObservationsLog.
Betweenthebladderanduterus,identifythevesicouterinerecess,formedwherethevisceralperitoneumreflectsoff
thesuperiorsurfaceofthebladderandontotheanteriorsurfaceoftheuterus(Figure74,upperimage).Lateralto
theuterus,identifythebroadligament,adoublelayeredfoldofperitoneumbetweenthelateralsurfaceofthe
uterusandthepelvicsidewalls.
Beginninganteriorly,followthesigmoidcoloninferiorlytotherectum.Thetransitionfromsigmoidcolontorectum
isgradual,ratherthanabrupt.Unlikethesigmoidcolon,therectumlacksamesentery,taeniaecoli,haustra
(sacculations),andepiploicappendices(Figure74).
Ifyourdonorismale,identifytherectovesicalrecess,formedwherethevisceralperitoneumreflectsofftheanterior
surfaceoftherectumandontothesuperiorsurfaceofthebladder(Figure74,lowerimage).Ifpossible,palpatethe
lobulatedtipsoftheseminalvesicleswithintherectovesicalrecess.
Ifyourdonorisfemale,identifytherectouterinerecess('pouch'ofDouglas),formedwherethevisceralperitoneum
reflectsofftheanteriorsurfaceoftherectumandontotheposteriorsurfaceoftheuterus(Figure74,upper
image).
Identifythevisceralperitoneumcoveringtheanteriorandposteriorsurfacesoftheuterus.Lateraltotheuteruson
eachside,identifythebroadligamentandfollowitlaterallyfromtheuterustothepelvicsidewallswherethetwo
peritoneallayersdiverge,andthebroadligamentbecomescontinuouswiththeparietalperitoneum.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page711

Figure75.Infraperitonealconnectivetissueandligaments,femaleinfrapertionealregion.(Substantially
modifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page712

Infraperitonealconnectivetissue,ligaments,andfasciae
Forthisdiscussion,theterminfraperitonealconnectivetissuereferstotheregionofextraperitonealconnective
tissueinferiortotheperitonealsac.Likeallextraperitonealconnectivetissue,theinfraperitonealconnective
tissueconsistsofmanyadipocytesembeddedinameshworkofcollagenfibers(Figure75).Collagenfibersin
theinfraperitonealconnectivetissuelateraltothepelvicorganscondenseassupportingligaments.Thelateral
vesicalligament,transversecervical(cardinal)ligament(ofMackenrodt)infemales,andthemesorectumare
supportingligamentsattachingthepelvicvisceratotheliningfasciaofthepelvicsidewalls.Theneurovascular
supplytothepelvicorgansrunswithintheseconnectivetissueligaments.Thepelvicsupportingligamentsarefar
lessrobustthantheyappearinFigure75.

Openingtheinfraperitonealspaceandidentifyingthepelvicsidewallandpelvicfloormuscles
Useforcepsoraclamptolifttheparietalperitoneumfromtheinternalsurfaceoftheanteriorabdominalwall.
Reflecttheperitoneumposteriorlywhereitreflectsontothesuperiorsurfaceofthebladder.
Usingyourfingers,andremainingascloseaspossibletotheinternalsurfaceofthepubicsymphysis,openthe
retropubicspace(ofRetzius)betweenthepubicbonesandtheanteriorsurfaceofthebladder.Theinferiorlimitof
theretropubicspaceistheliningfasciacoveringtheperinealmembrane(Figure75).
Fromthepubicsymphysis,worklaterallyintheextraperitonealconnectivetissueandseparatetheparietal
peritoneumfromthepelvicsidewallsasfarposteriorlyandinferiorlyaspossible.
Gentlyremoveanyremaininglooseconnectivefromthepelvicsidewalls,andidentifythetendinousarchoflevator
ani,athickeningoftheobturatorinternusfasciaandthesuperiorattachmentofthelevatoranimuscle(Figure7
blah).
Superiortothetendinousarchoflevatorani,identifytheobturatorinternusmuscleanditsliningfascia.Inferiorto
thetendinousarch,identifythedownwardslopingsurfaceofthelevatoranimuscleanditsfascia.Followthelevator
animuscleinferiorlyasfaraspossible(Figure73).
Useforcepsoraclamptolifttheperitoneumfromtheinternalsurfaceoftheposteriorabdominalwallandrectum,
andreflecttheperitoneumanteriorly.Ifpossible,identifythemesorectum(aconnectivetissuestructureandnota
peritonealstructure)lateraltotherectum.
Ifyourdonorisfemale,followtheureteranteriorlytowardthebladderand,ifpossible,identifythethickeningofthe
infraperitonealconnectivetissueasthetransversecervical(cardinal)ligament(ofMackenrodt).Superiortothe
ureter,identifytheuterineartery,ifpossible.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page713

Figure76.Bladder.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,
2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page714

Bladderanduretha
Bladder.Theemptybladderliesentirelywithinthebonypelviccavity,surroundedbyinfraperitonealconnective
tissue.Thesuperiorsurfaceofthebladder,coveredbyvisceralperitoneum,facestheabdominalcavity.Asthe
bladderfills,thesuperiorsurfaceascendsintotheabdominalcavity,liftingtheinferiorperitonealsacasitrises
(Figure76,upperimage).Theapexofthebladderfacesthepubicsymphysis,andtheroundedfundusfaces
posteriorly.Thebladderendsinferiorly,atitsneck,wherethebladderiscontinuouswiththeurethra(Figure76,
lowerimage).
Thebladderservesasareservoirforurineproducedinthekidneysandconveyedtothebladderbyperistaltic
contractionsoftheureters.Urineisstoredinthebladderuntilitisexpelledthroughtheurethraduring
micturition(urination).Transitionalepithelium(urothelium),capableofconsiderableexpansionandcontraction,
linestheurinarysystemfromtherenalcalycestotheurethra.Thedetrusormuscleformsthebulkofthethick
bladderwall,exceptatthetrigone(Figure76,lowerimage).
Thetrigoneisatriangularareaontheposteroinferiorbladderwalljustabovethebladderneck(Figure76,lower
image).Theleftandrighturetersenterthebladderlumenatthesuperioranglesofthetrigone,afterpursuingan
obliquecoursethroughthebladderwall.Theurethraleavesthebladderattheinferiorangleofthetrigone.In
males,theprostatesurroundsthebladderneckandsuperiorportionoftheurethra(Figure76,upperimage).
Urethra.Thefemaleurethra,closelyboundtotheanteriorwallofthevagina,isapproximately4cminlength,
measuredfromtheinferiorangleofthetrigonetotheexternalurethralmeatus,locatedjustanteriortothe
vagina.
Themaleurethra,approximately15cminlength,passesthroughtheprostateastheprostaticurethra,through
theperinealmembraneasthemembranousurethra,andthroughthepenisasthepenileorspongyurethra
(Figure76,lowerimage).Contractionoftheinternalurethralsphincter,consistingofsmoothmuscle,closesthe
bladderneckduringejaculation,anddirectsejaculateintotheurethraratherthanintothebladder.The
membranousurethraisthenarrowest,andweakest,portionofthemaleurethra.
Theexternalurethralsphincter,foundinbothsexes,surroundstheurethraintheperineum(Figure76,lower
image).
Micturition.Asthebladderfills,increasingintravesicalpressurecompressesthedistalureterswithinthebladder
wall,preventingrefluxofurinefromthebladderintotheureters.Severaltimesperminute,contractionsofthe
ureterovercomeintravesicalpressureandejecturineintothebladder.
Micturition(urination)requiressimultaneouscontractionofthesmoothdetrusormuscleinthebladderwall,and
relaxationoftheskeletalurethralsphinctersandpelvicfloormuscles.
Neurovascularsupply.Thesuperiorandinferiorvesicalarteries,branchesoftheinternaliliacarteries,supplythe
bladder.Bloodfromthebladderdrainstothevesicalvenousplexusesandthentotheinternaliliacveins.
Thepelvicsplanchnicnerves(S2,S3,S4),provideparasympatheticvisceralmotorfibersnervestothedetrusor
muscle.Thelumbarsplanchnicnerves(L1,L2)providevisceralmotorfiberstotheinternalurethralsphincter
muscleinmales.Stretchimpulsesfollowparasympatheticpathways.Painimpulsesfollowbothparasympathetic
andsympatheticpathways.

Uretersandbladder
Withintheretroperitoneum,identifytheureterattherenalpelvis.Followtheureterinferiorlythroughthe
extraperitoneallooseconnectivetissuetothebladder.Identifythethreenarrowestportionsoftheureter,atthe
junctionoftheureterandtherenalpelvis,atthepointwheretheuretercrossesthepelvicinletandiliacvessels,and
withinthewallofthebladder.Uretericcalculi(stones)oftenlodgeintheselocationsastheydescend,causing
intensepainandsmoothmusclecramping(uretericcolic).
Identifythebladderapexandfundus.Intheretropubicspace,identifytheneckofthebladder.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page715

Ifyourdonorismale,identifytheprostatesurroundingthebladderneckintheinferiorportionoftheretropubic
space.Prostateenlargementcompressestheureter,makingurinationdifficult.

Figure77.Rectum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,
2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page716

Rectum
Therectumisthepelvicportionofthegastrointestinaltractbetweenthesigmoidcolonandtheanalcanal
(Figure77).
Attherectosigmoidjunction,severalcharacteristicfeaturesofthecolonarelost(Figure7).Thetaeniaecoli
widentoformacontinuousouterlayeroflongitudinalsmoothmusclearoundtherectum,theepiploic
appendagesdisappear,andthetwolayersofthesigmoidmesocolondivergeandbecomecontinuouswiththe
parietalperitoneum.Visceralperitoneumpartiallycoversthesuperiorandmiddleportionsoftherectum.The
inferiorportionoftherectumliesentirelyembeddedwithintheinfraperitonealconnectivetissueofthepelvic
cavity.Theanalcanalliesinferiortothelevatoranimuscle,embeddedwithintheischioanalfat.

Totalmesentericexcision(TME)andrectalcancersurgery
Thesurgicaltermmesorectalfascia(ormesorectum)referstoacondensationoftheinfraperitonealconnectivetissue
aroundtherectumnottoaperitonealstructure.Themesorectalfasciasurroundsthemiddlerectalvesselsandthe
lymphnodesandlymphaticvesselsdrainingtherectum.Totalmesorectalexcisionforrectalcarcinomaremovesthe
rectum,mesorectalfascia,andlymphnodesasfarposteriorlyastheliningfasciacoveringthesacrum.
Attheanorectaljunction,atthelevelofthepelvicfloor,therectumiscontinuouswiththeanalcanal.Theanal
canallieswithintheperineuminferiortothepelvicfloor.
Therectumstoresfecespriortodefecation.Toniccontractionofthelevatoranimuscledrawsthedistalrectum
anteriorly,changingtheorientationoftherectumfromverticaltooblique,narrowingthelumenattheanorectal
junction,andpreventingorlimitingtheperistalticpassageoffecesintotheanalcanal.Theinternalandexternal
analsphinctermusclesclosetheanalcanal.Thepuborectalismuscle,internalanalsphincter,andexternalanal
sphinctermusclesmustrelaxinorderfordefecationtooccur.
Neurovascularsupply.Thesuperiorrectalartery,abranchoftheinferiormesentericartery,suppliesthe
superiorrectum.Thesuperiorrectalarteryformsananastomosiswiththemiddlerectalartery,ifpresent,and
withtheinferiorrectalartery,abranchoftheinternalpudendalartery.Thesuperiorrectalveinsdraintothe
inferiormesentericvein,atributaryoftheportalvein.Theinferiorrectalveinsdraintotheinternaliliacveins,
tributariesoftheinferiorvenacava.
Thesuperiorrectalveins,inferiorrectalveins,andmiddlerectalveins(ifpresent)representaportalcaval
anastomosis.Inportalhypertension,venousbloodisshuntedfromthesuperiorrectalveins(portaltributaries)to
theinferiorrectalveins(cavaltributaries)toreturntotheheartthroughtheinferiorvenacava.
Thepelvicsplanchnicnerves(S2,S3,S4),supplyvisceralmotorfiberstorectalsmoothmuscleandglandsand
conveystretchimpulsesfromtherectalwall.Visceralmotorfibersinthelumbarsplanchnicnerves(L1,L2)are
primarilyvasomotor.Painimpulsesfollowbothparasympatheticandsympatheticpathways.

Identifyingtherectumand'mesorectum'
Identifytherectosigmoidjunctionandthedisappearanceofthetaeniaecoli,epiploicappendices,andsigmoid
mesocolon.
Ifpossible,identifythethreelateralcurvaturesoftherectum.Thesuperiorcurvatureisconvexright,themiddle
curvatureiscomplexleft,andtheinferiorcurvatureisagainconvexright.Identifyingthelateralcurvatureswillbe
difficultiftherectumisverydistended.
Ifpossible,followtherectuminferiorlytothepelvicfloor.
Drawtherectumanteriorlyandidentifythelooseinfraperitonealconnectivetissueposteriorandlateraltothe
rectum.Ifpossible,identifythemesorectalfasciaandoneortwolymphnodes.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page717

Figure78.Femalepelvis,lateralview.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,6thEdition.
Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page718

Femalepelvicorgans
Thefemalepelvicorgansincludetheovaries,uterine(Fallopian)tubes,uterus,andvagina(Figures74and75).
Ovaries.Theovariesprovideasupportiveclimateforthematurationofoocytes.Ovarianendocrinefunctions
includetheproductionofprogesterone,estradiol,andtestosterone.Theregionoftheposteriorlayerofthe
broadligamentsuspendingtheovariesisthemesovarium.Atovulation,ruptureoftheovarianfollicleand
overlyingvisceralperitoneumpropelstheoocytebrieflyintotheperitonealspace(cavity).
Uterinetubes.Atovulation,smoothmusclecontractionswithinthefimbriaeoftheuterinetubedrawtheoocyte
fromtheperitonealspaceintotheuterinetube(fromtheLatinfimbria,afringe).Theepithelialliningofthe
uterinetubeincludesbothsecretoryandciliatedcells;theciliasweeptheoocytetowardtheuterinecavity.
Duringitspassagetotheuterus,theoocytepassessuccessivelythroughtheampulla,isthmus,andintrauterine
portionsoftheuterinetube.
Theregionofthebroadligamentsurroundingtheuterinetubeisthemesosalpinx.Thefemaleperitonealcavity
iscontinuouswiththeoutsideworldthroughtheuterinetube,uterus,andvagina.Boththemesovariumandthe
mesosalpinxareregionsofthelargerbroadligament.
Uterus.Theepithelialliningsurroundingtheuterinecavityistheendometrium.Inthepostpubertalfemale,the
innerlayeroftheendometriumproliferatesevery28daystoformavascularsecretoryepitheliuminpreparation
forimplantationoftheblastocyst.Ifimplantationdoesnotoccur,theouterpartoftheepitheliumdetachesand
isshedduringmenstruation.Thebulkoftheuterinewallconsistsofathicksmoothmusclelayer,the
myometrium,whichcancontracttoshedtheendometrialliningduringmenstruationorexpelaninfantduring
childbirth.
Theuterusconsistsofafundus,extendingsuperiortotheuterinetubes,awidebodysurroundingtheuterine
cavity,andanarrowcervix,whichextendsinferiorlyintothevagina.Theinternalosofthecervixopensintothe
uterinecavity;theexternalosopensintothevagina.
Initsmostcommonsituation,theanteriorsurfaceoftheuterusleansanteriorlyoverthebladder(anteversion),
andcurvesanteriorly(anteflexion)sothatitsinferiorsurface(facingthebladder)isconcave(Figure78).Other
positionsarenowconsiderednormal,andtheuterusisseldomintheexactmidline.Iftheuterusleans
posteriorlyitisretroverted;ifitcurvesposteriorlyitisretroflexed.
Thecervixoftheuterusisanchoredtothepelvicsidewallsbyligamentouscondensationsoftheextraperitoneal
connectivetissue,includingthepairedtransverse(cardinal)ligaments(ofMackenrodt)(Figure79).The
peritoneumofthebroadligamentpassessuperiortothetransversecervicalligament.Withinthetransverse
cervicalligament,theuterinearterypassessuperiortotheureter,arelationshipofconsiderableimportance
duringpelvicsurgery.
Vagina.Thevaginaisasturdycorrugatedfibromusculartubeflattenedfromsidetosidebetweenthebladder
andrectumandattachedtothematitsanteriorandposteriorsurfaces(Figure78).Instandardanatomical
position,thevaginareclinesposteriorlyontotherectum,andisobliquelyhorizontalinorientation.Superiorly,
thevaginaiscontinuouswiththecervix.Acuffofvaginaltissuefoldsupwardaroundthecervixtoenclosea
continuousspace.Theanteriorportionofthiscontinuousspaceistheanteriorfornix;theposteriorportionisthe
posteriorfornix(Figure78).Thevaginainferiortotheperinealmembraneisthevaginalvestibule.Theintroitusis
theperinealopeningofthevagina.
Duringarousal,theerectiletissueofthevestibularbulbssurroundingtheintroitusandinferiorportionofthe
vaginaswellandthevaginaelongates.Vaginallubricationconsistsprimarilyofatransudationoftissuefluid
throughthemucousmembraneofthevaginalwallandasmallmucouscomponentsecretedfromthegreater
vestibularglands(ofBartholin)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page719

Figure79.Femalepelvis,coronalsectionthroughtheuterus.(SubstantiallymodifiedfromNetterAtlasofHuman
Anatomy,6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page720

Neurovascularsupply.Alongarterialanastomosissuppliesthefemalepelvicorgans,consistingoftheovarian
arteries,branchesoftheabdominalaorta,andtheuterineandvaginalarteries(directorindirectbranchesofthe
internaliliacarteries)(Figures74and79).Theleftandrightarterialanastomosesfollowsthelateralmarginsof
thefemalepelvicorgans.
Theovarianveinsdraindirectlytotheinferiorvenacava.Theuterineandvaginalveinsdraintotheinternaliliac
vessels,vesicalplexus,andanextensionofthevesicalplexusintothebroadligament.
Thevagusnerveprovidesparasympatheticvisceralmotorinnervationtotheovaryandtheadjacentportionof
theuterinetube.Thepelvicsplanchnicnerves(S2,S3,S4)provideparasympatheticvisceralmotorinnervationto
theremainingfemalepelvicvisceraandtotheerectiletissueoftheexternalgenitalia.Theleastsplanchnicnerve
(T12)andlumbarsplanchnicnerves(L1,L2)providevasomotorandinhibitorysympatheticvisceralmotor
innervationtothefemalepelvicandperinealorgans.
Lymphaticvesselsfromtheovaryandadjacentuterinetubefollowtheovarianvesselsfromthepelvistopara
aorticlymphnodeslateraltotheoriginoftheovarianartery.Lymphaticvesselsfromtheremainingfemalepelvic
organsdrainprimarilytointernaliliaclymphnodes.

Femalepelvis
Ifyourdonorhasundergonepelvicsurgery,determinewhethertheuterus,uterinetubes,andovariesarepresent.
EnterthisinformationinyourLaboratoryNotesandObservationslog.Iftheuterusispresent,determinewhetherit
isantevertedandanteflexed,retrovertedandretroflexed,orinsomeotherposition.
Withinthebroadligament,identifythenarrowuterinetubesattheirentrancetotheuterusandthemuscular
fimbriaesurroundingtheinfundibulum(openingoftheuterinetube).Identifythemesosalpinxtheportionofthe
broadligamentsurroundingtheuterinetube.
Followtheuterinetubeslaterallyandidentifytheovaryandthemesovarium,theportionofthebroadligament
suspendingtheovaryfromtheposteriorlayerofthebroadligament.
Palpatetheligamentoftheovaryandfollowitmediallytotheuteruswhereitiscontinuouswiththeroundligament
oftheuterus.Followtheroundligamenttothedeepringoftheinguinalcanal,whereitleavesthepelviccavityto
entertheinguinalcanal.
Identifythefundusoftheuterussuperiortotheentranceoftheuterinetubesandidentifythebodyoftheuterus
inferiortotheuterinetubes.Followthebodyoftheuterusinferiorlyandpalpatethecervixinitsextraperitoneal
location.
Justlateraltotheuterus,identifytheuterinearterywithinthebroadligament.Theuterinearteryentersthebroad
ligamentthroughthetransversecardinalligament,whereitrunssuperiortotheureter.Inthislocation,theureter
isindangerofinadvertentligationorinjuryduringhysterectomyorotherfemalepelvicsurgery.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page721

Figure710.Malepelvis,lateralview.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,6thEdition.
Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page722

Malepelvicorgans
Themalepelvicorgansincludethepelvicportionsoftheductusdeferentes(vasadeferentes),theseminal
vesicles,andtheprostate(prostategland)(Figure710).Seminalfluid(semen)consistsofspermatozoaandarich
fluidsecretedbytheseminalvesicles,prostate,andbulbourethralglands.Atejaculation,smoothmuscle
contractionsinthewallsoftheductusdeferentes,seminalvesicles,andprostatepropelspermatozoaandfluid
intotheprostaticurethra.Seminalfluidservesasapropulsivemediumandasamicroenvironmentessentialfor
spermmetabolismandmotility.
Ductusdeferentes.Fromtheepididymis,thepairedductusdeferentesascendfromthetesteswithinthe
spermaticcord,passthroughtheinguinalcanal,andcrossthepelviccavitywithintheinfraperitonealconnective
tissuetoreachtheposteriorsurfaceofthebladderandprostategland(Figure710).Eachductusdeferens
archessuperiortotheureter,widenstoformanampulla,andjoinsaseminalvesicletoformanejaculatoryduct.
Duringarousal,slowperistalticcontractionsoftheductusdeferentescarryspermsuperiorlyforstorageinthe
ampullapriortoejaculation.

Vasectomy
Vasectomyisclippingorresectionofbothductusdeferentes.Thisproceduremaybeperformedpercutaneously
throughtheposteriorscrotum.Disruptionoftheductusdeferentespreventsspermatozoafromleavingthe
epididymis.Followingvasectomy,themaleejaculateconsistsentirelyofsecretionsfromtheprostategland,seminal
vesicles,andbulbourethralglands.
Seminalvesicles.Thepairedseminalvesiclesareelongated,lobulatedsacslocatedposteriortothebladderand
prostategland.Theseminalvesiclesproduceapproximately30%ofseminalfluidbyvolume.Theejaculatory
ductspassthroughtheprostateanddrainspermatozoaandfluidintotheprostaticurethraattheseminal
colliculus,aprominenceontheposteriorwalloftheprostaticurethra(Figure710).
Prostate.Theprostateconsistsofsmallsecretoryglandsembeddedinafibromuscularstroma.Theprostatic
glandsproduceapproximately60%ofseminalfluidbyvolume.Prostaticfluidenterstheprostaticurethra
throughsmallopeningslateraltotheseminalcolliculusandtheopeningsoftheejaculatoryducts.Theremaining
10%ofseminalfluidiscontributedbythebulbourethralglands(ofCowper)whichopenintothespongyurethra
(describedbelow).
Theprostateissurroundedbyanouterlayerofdenseconnectivetissue,the'true'prostaticcapsule.Skeletal
musclefibersfromtheexternalurethralsphinctermuscleextendsuperiorlyontotheanteriorsurfaceofthe
prostate.Theprostaticfascia(the'false'prostaticcapsule)isacondensationofinfraperitonealconnectivetissue
similartotheGerotafasciasurroundingthekidney,enclosesalayeroflooseinfraperitonealconnectiveandthe
neurovascularsupplytotheprostategland.Posteriorly,thethickerrectoprostaticfascia(ofDenonvillier)
separatestheprostateandrectum.

Prostatesurgery
Duringopenorlaparoscopicprostatesurgery,careistakentopreservethedelicateneurovascularstructuresrunning
withinthelooseconnectivetissuebetweentheprostaticcapsuleandtheprostaticfascia.Injurytonerveswithinthis
spacecancauseerectiledysfunction(lossofparasympatheticvisceralinnervationtosmoothmuscleinpenileerectile
tissue),retrogradeejaculationintothebladder(lossofsympatheticvisceralmotorinnervationtotheinternalurethral
sphincter),orboth.Transurethralsurgicalapproachesforbenignprostateenlargementcanminimizetheriskofnerve
injury,sinceresectionislimitedtoprostatictissuedeeptotheprostaticcapsule.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page723

Figure711.Detailofprostateandseminalvesicles.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page724

Currentterminologydividestheprostateintoaperipheralzone,palpableduringrectalexamination,a
transitionalzonewithintheperipheralzone,andacentralzonesurroundingtheurethra(Figure711).The
peripheralzoneisthemostcommonsiteoforiginforprostaticcarcinoma.Benignprostatichyperplasiaismore
likelytoaffectthetransitionalzone.
Bulbourethralglands.Thebulbourethralglands(ofCowper)arelocatedinferiortotheprostateandsuperiorto
theperinealmembrane.Thebulbourethralglandssecreteaclearmucus.Theductsofthebulbourethralglands
passthroughtheperinealmembraneandopenintothespongyurethrawithinthepenilebulb.Bulbourethral
secretionbeginsatarousalandprecedesejaculation.
Neurovascularsupply.Thearteryoftheductusdeferens,abranchofthesuperiorvesicalarterysuppliesthe
ductusdeferensfrompelvistoscrotum.Branchesoftheinferiorvesicalarteriessupplytheseminalvesicles.The
prostaticartery,abranchoftheinternaliliacartery,suppliestheprostate.Bloodfromthemalepelvicorgans
drainstothevesicalvenousplexus,thentotheinternaliliacveins.Lymphfromthemalepelvicorgansdrainsto
theiliacnodes.
Parasympatheticvisceralmotorfibersaresecretorytotheductusdeferentes,seminalvesicles,andprostateand
initiateperistalticcontractionsoftheductusdeferentesduringarousal.Sympatheticvisceralmotorfibersinitiate
contractionofsmoothmuscleintheseminalvesiclesandprostateduringejaculation.Sensationfromthemale
pelvicorgansfollowsbothparasympatheticandsympatheticpathways.

Malepelvis
Atthedeepinguinalring,identifytheductusdeferensbeneaththeperitoneum.Followtheductusdeferensthrough
theextraperitonealconnectivetissuetotheposteriorsurfaceofthebladder.
Usingforcepsoraclamp,lifttheperitoneumattherectovesicalrecessandinciseit.Usingbluntdissection,identify
thetipsofthelobulatedseminalvesicles.
Usebluntdissectiontofollowtheseminalvesiclesinferiorly.Identifytheejaculatoryductformedjointlybytheductus
deferentesandseminalvesicle.Identifytheampullaoftheductusdeferentesjustsuperiortotheejaculatoryduct.

Identifytheposteriorsurfaceoftheprostate.Ifpossible,followtheprostateinferiorlytotheperinealmembrane.At
theperinealmembrane,theurethraleavestheprostate,becomesthemembranousurethra,passesthroughthe
perinealmembranetoenterthepenilebulbwithintheperineum.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page725

Figure712.Femaleandmaleperineum,inferiorview.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page726

5.4.PERINEUM
Theperineumistheregionbetweentheperinealskininferiorly,thepelvicfloorsuperiorly,andtheinferior
portionofthepelvicsidewallslaterally(Figure71,77,and79).Theinferiorsurfaceoftheperineumisa
diamondshapedregionbetweenthelowerlimbs,extendingfromthepubicsymphysisposteriorlyalongthe
ischiopubicramiandischialtuberositiestothecoccyx.Alinedrawnthroughtheischialtuberositiesdividesthe
surfaceoftheperineumintoananteriorurogenitalregion(triangle)andaposterioranalregion(triangle).

Theurogenitalregioncontainstheerectiletissueoftheexternalgenitalia,theskeletalperinealmusclesand
fasciae,theopeningoftheurethrainbothsexes,andtheopeningofthevaginainfemales.

Theanalregioncontainstheanus,analsphincters,andischioanalconnectivetissuecontinuouswiththe
subcutaneousfat(Figure77).Theneurovascularsupplytotheperineum,thepudendalnerveandinternal
pudendalvessels,enterstheischioanalfossafromtheglutealregionandrunsanteriorlyalongtheinferior
portionoftheinternalobturatormuscle(Figures77and79).

Perinealconnectivetissue'skeleton'.Achainofdenseconnectivetissuestructuresspanstheperineumfrom
pubistococcyx,supportingtheabdominopelvicvisceraandprovidingattachmentfortheperinealmusclesand
anus(Figure71).
Thesturdyperinealmembrane,locateddeeptotheurogenitaltriangle,spanstheintervalbetweenthe
ischiopubicrami,leavingaperturesforthedorsalveinofthepenisorclitoris,theurethrainbothsexes,andthe
vaginainfemales.Themaleandfemaleexternalgenitaliaattachtotheperinealmembraneandadjacent
inferiorsurfacesoftheperinealmembrane.
Withintheperineum,theexternalgenitaliaandtheperinealmusclesandfascialieinferiortotheperineal
membrane.Theurethralsphinctersmusclesanddeepperinealmuscleliesuperiortotheperinealmembrane.
Theperinealbodyisathickknotoffibrousconnectivetissuelocatedattheposteriorborderoftheperineal
membrane.Theanalconnectivetissueandanalsphinctersattachtheanusanteriorlytotheperinealbodyand
perinealmembrane.Theanococcygealligamentattachestheanusposteriorlytothecoccyx.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page727

Figure713.Analcanal.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:
Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page728

Analcanal
Analregion.Theanalregionliesinferiortothelevatoranimuscle,medialtothepelvicsidewallsandobturator
internusmusclesandfascia,anteriortothesacrumandcoccyx,andposteriortotheperinealmembrane.The
pairedischioanalfossae(fromtheLatin,fossa,atrenchorditch)arewedgeshaped,fatfilledareasbetweenthe
pelvicsidewallsandtheanalcanalandpelvicfloor.Thelooseconnectivetissuefillingtheischioanalfossaeis
continuouswiththesubcutaneousfatoftheperineum.
Analcanal.Therectumiscontinuouswiththeanalcanal,themostdistalportionofthedigestivesystem,atthe
levelofthepelvicfloor(Figure7).Thepectinateline,alongthemarginsoftheanalsinuses,markstheboundary
betweentheportionoftheanalcanalderivedfromtheembryoniccloaca(superiortothepectinateline),andthe
portionderivedfromtheembryonicbodywall(inferiortothepectinateline).Thisembryonicdistinctionprovides
thebasisforunderstandingthecharacteristiclining,muscles,bloodsupply,andinnervationofthetworegions.
Superiortothepectinateline,mucousmembranelinestheanalcanalandthesmoothmuscleoftheinternal
analsphinctercontinuesinthewallofthecanal.Theanalcushions,consistingofsmoothmuscle,fibrous
connectivetissueandtheveinsoftheinternalrectalvenousplexus,narrowthelumenoftheanalcanaland
formpartoftheanalcontinencemechanism.
Inferiortothepectinateline,anoderm,aspecializedtypeofskin,linestheanalcanalandtheskeletalexternal
analsphinctermuscleoverlapsandblendswiththeouterfibersoftheinternalanalsphinctermuscle
surroundingtheanalcanal.Theanodermiscontinuouswiththepigmentedperinealskinoftheanalverge.
Continenceanddefecation.Thecomponentsoftheanalcontinencemechanismincludetheobliqueorientation
oftherectumwithinthepelviccavity,thekinkformedbythepuborectalismuscleasitdrawstheanorectal
junctionanteriorly,andtheprotrusionoftheanalcushionsintothecanal.Toniccontractionofpuborectalis,the
internalanalsphincter,andtheexternalanalsphincterclosetheanalcanal,resistingthepropulsiveforcesof
intestinalperistalsis.Lymphfromtheanalcanalsuperiortothepectinatelinedrainstoparaaorticnodes.
Justsuperiortotheanorectaljunction,thepuborectalisportionofthelevatoranimuscledrawstherectum
sharplytowardthepubis,narrowingthelumenandformingtheanorectalanglethatfunctionsaspartoftheanal
continencemechanism.Thisfeatureispalpableduringrectalexaminationastheanorectalring.Therectumalso
curvesfromsidetoside.Thesuperiorflexureisconvexright,themiddleflexureisconvexleft,andtheinferior
flexureisagainconvexright.
Neurovascularsupply.Likethemucosaandmusclelayers,theembryonicoriginofthetworegionsoftheanal
canaldeterminestheirneurovascularsupply.
Superiorrectalbranchesoftheinferiormesentericarterysupplytheanalcanalsuperiortothepectinateline,
andthesuperiorrectalveinsdraintotributariesoftheportalvein.Visceralmotorparasympatheticfibers
fromthepelvicsplanchnicnervessupplysmoothmuscleandglandsinthewalloftheanalcanal.Sympathetic
visceralmotorfibersfromthelumbarsplanchnicnerves(L1,2)supplytheinternalanalsphincter.Visceral
sensationfollowsbothparasympatheticandsympatheticpathways.
Inferiorrectalbranchesoftheinternalpudendalarterysupplytheanalcanalinferiortothepectinateline,and
theinferiorrectalveinsdraintotributariesoftheinternaliliacveins.Somaticmotorbranchesfromthe
pudendalnerve,abranchofthelumbosacralplexus,supplytheskeletalmuscleoftheanalcanalinferiorto
thepectinateline.Somaticsensationfrominferioranalcanal,andfromtheperineumingeneral,returnsin
branchesofthepudendalnerve,

Hemorrhoids
Internalhemorrhoidsaredilationsofveinsintheinternalrectalplexus.Sincevisceralsensoryfibersconveysensation
fromtheinternalrectalplexusandsurroundingtissue,internalhemorrhoidsaretypicallypainless.External
hemorrhoidsaredilationsofveinsintheexternalrectalplexus.Sincesomaticsensorynervesconveysensationfromthe
regionoftheexternalrectalplexus,dilatedandthrombosedexternalhemorrhoidsmaybeextremelypainful.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page729

Figure714.Surfacefeaturesofthefemaleperineum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page730

Femaleperineum
Surfacefeatures.Thefemaleexternalgenitalia,knowncollectivelyasthevulva,includethemonspubis,labia
majora,labiaminora,clitoris,andthevestibuleandintroitusofthevagina(Figure711).
Hairyskincoversthemonspubisandlabiamajora(singularlabiummajus),overlyingathickfibrofattyloose
connectivetissuewithmanycollagenfibers.
Amucousmembranecoversthelabiaminora(singularlabiumminus)andvestibuleofthevagina.Thevestibule
(fromtheLatin,vestibulum,thespaceoutsideanentranceway)istheareabetweenthelabiaminora
surroundingtheexternalvaginalorifice(introitus)andexternalurethralorifice(meatus).Thevestibularglands(of
Bartholin)secreteaclearmucusintothevestibuleduringsexualarousal.
Theexternalorificeofthefemaleurethralieswithinthevestibuleanteriortothevaginaandseveralcentimeters
posteriortotheclitoris1.

Identifyingsurfacefeaturesofthefemaleperineum
Manystudentsfinddissectingtheperineumemotionallychallenging.Pleaserememberthatyouranatomicaldonor
knowinglyconsentedtothisstepinyourmedicaleducation.Checkinwithyourlaboratorypartners,andyourself,to
makesurethateveryoneisreasonablycomfortablebeforeyoubegin.

Drainallfluidfromtheinterioroftheblackbagintothebucketattheendofthetable.Positionthehipsofyour
anatomicaldonorasclosetotheendofthetableaspossible.Placeawhiteplasticblockunderthebuttocks.

Abductthelowerlimbsofyourdonoraswidelyaspossible.Slowoutwardpressurewilleventuallyallowyouto
abductthelimbs.Placinganotherwhiteplasticblockbetweenthekneesmayhelpholdthelowerlimbsin
abduction.

Bypalpation,identifytheinferioredgeofthepubicsymphysis.Followthepubicsymphysisposteriorlytothe
ischiopubicramusandischialtuberosity.

Reviewthebonyboundariesofthesuperficialperineum,urogenitaltriangle,andanaltriangle.
Anteriorly,identifythemonspubis,aroundedprominenceanteriortothepubicsymphysis.Followthemonspubis
posteriorlytoitscontinuationasthepairedlabiamajora.

Gentlyseparatethelabiamajora,andidentifythepairedlabiaminoramedialtothelabiamajora.
Gentlyseparatethelabiaminora,andidentifythevestibuleofthevagina.Withinthevestibule,identifythevaginal
orifice(introitus).Anteriortotheintroitus,identifytheexternalurethralorifice(meatus).

Followthelabiaminoraanteriorlytothefrenulumoftheclitoris(Latin,frenulum,alittlehalter).Identifytheglansof
theclitorisattheanteriormarginofthevestibule.Fromtheglans,palpatethebodyoftheclitorissuperiorlytoits
attachmentontheinferiormarginofthepubicsymphysis.

Bypalpation,identifytheperinealbody(Figure711).Palpatethesharpposteriormarginoftheperinealmembrane.
Posteriorly,identifythepigmentedskinsurroundingtheanus(Figure711).Ifpossible,palpatethetipofthecoccyx
andtheanococcygealligamentposteriortotheanus.

Anincompleteunderstandingofthelocationofthefemaleurethrahasledmorethanonemedicalstudenttoattempturinarycatheterinsertionintothe
glansoftheclitoris.Althoughthemaleurethraextendstothetipofthepenis,thefemaleurethradoesnotextendintotheclitorisatall.Attemptsto
catheterizetheclitoriswillbefutileorworse.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page731

Figure715.Deeperfeaturesofthefemaleperineum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page732

Femaleerectiletissue.Vascularerectiletissueformsthesubstanceoftheclitorisandvestibularbulbsinfemales
andthepenisinmales.Theerectiletissueconsistsofdenseconnectivetissuepartitionslinedwithendothelium
toformspongelikecavernousspaces.Thecavernousspacesnormallycontainonlyasmallamountofblood.
Duringsexualarousal,thecavernousspacesexpandwithblood,andtheerectiletissuebecomesrigid.Athick
tunicaalbuginea,consistingofdenseconnectivetissue,surroundsthevascularerectiletissueandlimitsoutward
expansion.
Thepairedcorporacavernosaoftheclitorisattachalongtheischiopubicramiandadjacentinferiorsurfacesof
theperinealmembraneastwocrura(fromtheLatincrus,aleg).Thecrurajoinanteriorlytoformthebodyofthe
clitoris(Figure715).Thetipoftheclitorisexpandsslightlytoformtheglans.Thevestibularbulbssurroundthe
introitusofthevaginaandextendsuperiorlyaroundtheinferiorvagina.
Perinealmuscles.Exceptfortheinternalanalsphincter,andvascularsmoothmuscleinthewallsoftheperineal
bloodvesselsandcavernousspaces,themusclesoftheperineumareskeletalmuscles.Inferiortotheperineal
membrane,thebulbospongiosusmusclescovertheexternalsurfacesofthevestibularbulbs,andthe
ischiocavernosusmusclescovertheexternalsurfacesofthecrura.Theflimsyandinconstantsuperficial
transverseperinealmusclesanddeeptransverseperinealmusclesattachtosuperficialanddeepsurfacesofthe
perinealmembrane.Superiortotheperinealmembrane,thecompressorurethralisandsphincterurethrae
normallyclosetheexternalurethralorifice,exceptduringmicturition.Posteriortotheperinealmembrane,the
externalanalsphincter,consistingofskeletalmuscle,surroundsthesmoothmuscleoftheinternalanal
sphincter.Theanalsphinctermusclescompresstheanalcanalandmaintainanalcontinence.
Neurovascularsupply.Theinternalpudendalartery,abranchoftheinternaliliacartery,istheprimarilyblood
supplytotheperineum.Thepudendalnerve,abranchofthelumbosacralplexus,conveyssomaticsensation
fromtheperineumandconveyssomaticmotorfiberstothepelvicfloormusclesandtoallskeletalperineal
muscles.Theneurovascularsupplytotheperineumenterstheischioanalfossainferiortotheischialspine,runs
anteriorlyalongthemedialsurfaceoftheobturatorinternusmuscletosupplyallperinealstructuresexceptthe
vascularsmoothmuscleandglands(Figure715).

Identifyingdeeperstructuresinthefemaleperineum
Returntothetransverseskinincisionthroughtheanteriorabdominalwallsuperiortothepubicsymphysis.Usinga
clamporyourfinger,identifytheplanebetweenthefibroussubcutaneousfatandthepubicsymphysis.Stayingas
closeaspossibletothebone,usebluntdissectiontoopenthisplanetotheinferiormarginofthepubicsymphysis.

Attheinferiormarginofthepubicsymphysis,identifythesmallsuspensoryligamentoftheclitoris.Bypalpation,
identifytheclitoriswithinthesurroundinglooseconnectivetissueinferiortothesuspensoryligamentandtheinferior
marginofthepubicsymphysis.Usingbluntdissection,removethelooseconnectivetissueobscuringtheclitoris.

Gentlycompleteashallowskinincisionsuperficialtotheischiopubicramus(Figure711,incision5A).Incision5A
shouldextendthroughskinonlyandshouldfollowagenerouscurveposteriortothetipofthecoccyx.

Bypalpation,identifytheischiopubicrami,andusebluntdissectiontorevealtheischiocavernosusmusclesonthe
externalsurfacesofthecruraofthecorporacavernosaoftheclitoris.Followtheischiocavernosusmusclesandcrura
posteriorlyalongtheirattachmenttotheischiopubicrami.

Theclitorismakesasharpdownwardbendatthepubicsymphysis.Followthebodyoftheclitorisinferiorlytothe
glansoftheclitorisattheanteriormarginofthevestibuleofthevagina.

Dissectmediallyintheplanebetweentheperinealstructures(clitorisandbulbsofthevestibule)andthethickfatof
thelabiamajora.Oneachsideofthebody,reflecttheskinandsubcutaneousfatmediallyasasinglecutaneousflap.
Clampsattachedtotheedgesoftheflapsmaybehelpfulinsecuringamedialpositionforthem.

Bypalpation,identifythelocationofthebulbsofthevestibule.Usingbluntdissection,removethelooseconnective
tissueontheirlateralsurfaces,andidentifythebulbospongiosusmusclesontheexternalsurfacesofthebulbs.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page733

Figure716.Surfacefeaturesofthemaleperineum.
(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,

6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page734

Maleperineum
Surfacefeatures.Themaleexternalgenitaliaincludethepenisandthetesteswithinthescrotum(Figure713).
Thescrotumisapouchofpigmentedskinsurroundingthetestes.Duringembryonicdevelopment,thetestes
ariseinthelumbarportionoftheretroperitoneumanddescendthroughtheinguinalcanalintheanterior
abdominalwalltoreachthescrotum.Thetestiscompletesitsdescentonlyweeksbeforebirth.
Withinthescrotum,aseptumseparatestheleftandrighttestes.Themedianrapheofthescrotum,amidline
seam,overliestheapproximatepositionofthescrotalseptum(Figure713).ThesmoothDartosmusclelies
withinthesubcutaneousconnectivetissueofthescrotum.ContractionoftheDartosmusclecontractsand
wrinklesthescrotalskin;typicallyinresponsetocoldtemperature.
Theanatomicaltermsforthedorsalandventralsurfacesandofthepenisareaccurateonlyforthefullyerect
penis.Thedorsalsurfaceoftheflaccidpenisfacesanteriorly.
Liketheclitoris,thepenisconsistsofelongatedmassesofvascularerectiletissue.Thebodyandglansofthe
penisarecoveredwithskincontinuouswiththescrotalskin.Inuncircumcisedmales,theprepuce,aredundant
foldofskin,normallyextendsdistallytosurroundtheglans.Asthepenisbecomeserectduringsexualarousal,
theprepuceretractstoexposetheglans.Themaleurethraentersthebulbofthepenisinferiortotheperineal
membrane,andopensatthetipoftheglansastheexternalurethralorifice(meatus).Themaleexternalurethral
orificeiseasiertofindthanthefemaleexternalurethralorifice,butthemaleurethraismoredifficultto
catheterize,duetoitsconsiderablygreaterlengthandserpentinecourse.

Circumcision
Malecircumcision,commonlypracticed,issurgicalremovaloftheprepuceofthepenis.Thetermfemale
circumcision,orgenitalcutting,involvesaspectrumofpracticesrangingfromremovaloftheprepuceoftheclitoristo
moreextensivepracticesinvolvingremovaloftheclitorisitselfandthelabiamajoraandminora.

Identifyingsurfacefeaturesofthemaleperineum
Manystudentsfinddissectingtheperineumemotionallychallenging.Pleaserememberthatyouranatomicaldonor
knowinglyconsentedtothisstepinyourmedicaleducation.Checkinwithyourlaboratorypartners,andyourself,to
makesurethateveryoneisreasonablycomfortablebeforeyoubegin.
Drainallfluidfromtheinterioroftheblackbagintothebucketattheendofthetable.Positionthehipsofyour
anatomicaldonorasclosetotheendofthetableaspossible.Placeawhiteplasticblockunderthebuttocks.
Abductthelowerlimbsofyourdonoraswidelyaspossible.Slowoutwardpressurewilleventuallyallowyouto
abductthelimbs.Placinganotherwhiteplasticblockbetweenthekneesmayhelpholdthelowerlimbsinabduction.
Bypalpation,identifytheinferioredgeofthepubicsymphysis.Followthepubicsymphysisposteriorlytothe
ischiopubicramusandischialtuberosity.
Reviewthebonyboundariesofthesuperficialperineum,urogenitaltriangle,andanaltriangle.
Identifythebodyandglansofthepenis(Figure713).Ifyourdonorisuncircumcised,identifytheprepuce,ahoodof
skinextendingovertheglans.Ifyourdonoriscircumcised,theprepucewassurgicallyremoved.Ifso,document
thisfindinginyourObservationsLog.Atthetipoftheglanspenis,identifytheexternalurethralorifice(meatus).
Identifythewrinkled,pigmentedskinofthescrotumandthemedianraphe(seam)ofthescrotum.Themedian
rapheoverliesthescrotalseptum.Withinthescrotum,palpatetheleftandrighttestes.
Bypalpation,identifytheperinealbody(Figure713).Ifpossible,identifythesharpposteriormarginoftheperineal
membrane.
Posteriorly,identifythepigmentedskinsurroundingtheanus.Ifpossible,palpatethetipofthecoccyxandthe
anococcygealligamentposteriortotheanus.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page735

Figure717.Deeperfeaturesofthemaleperineum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page736

Deeperstructures
Maleerectiletissue.Likethefemaleclitorisandvestibularbulbs,themalepenisconsistsofvascularerectile
tissuesurroundedbyathickdenseconnectivetissuetunicaalbuginea.Thevascularerectiletissueisacomplex
systemofadjoiningconnectivetissuecompartmentslinedbyvascularendotheliumtoformcavernousspaces.
Thecavernousspacesnormallycontainonlyasmallamountofblood.Duringsexualarousal,thecavernous
spacesexpandwithblood,andtheerectiletissuebecomesturgidandfirm.Athicktunicaalbuginea,consistingof
denseconnectivetissue,surroundsthevascularerectiletissueandlimitsoutwardexpansion.
Thepairedcorporacavernosaattachalongtheischiopubicramiandadjacentinferiorsurfacesoftheperineal
membrane,andcontinueanteriorlyintothebodyofthepenis.Themidlinecorpusspongiosumbeginsasabulb
attachedtotheperinealbodyandperinealmembraneandcontinuesanteriorintothebodyofthepenis.The
corpusspongiosumflaresdistallytoformaconspicuousglans.Theglansfitslikeacapoverthedistaltipsofthe
corporacavernosa.
Perinealmuscles.Inferiortotheperinealmembrane,theskeletalbulbospongiosusmusclecoversthebulbofthe
penisandtheproximalportionofthepenilebody.Thepairedskeletalischiocavernosusmusclescoverthe
externalsurfacesofthecruraandcontinueontotheproximalportionofthepenilebody.Contractionofthe
ischiocavernosusmusclesmayhelpstabilizetheerectpenis.Aninconstantsuperficialperinealmusclemayalso
bepresent.Superiortotheperinealmembrane,theexternalurethralsphincternormallyclosestheexternal
urethralorifice,exceptduringmicturition.Theinternalurethralsphincter,foundinmalesonly,isasmooth
musclesphincterthatclosestheneckofthebladderandpreventsretrogradeejaculationintothebladder.
Posteriortotheperinealmembrane,theexternalanalsphincter,consistingofskeletalmuscle,surroundsthe
smoothmuscleoftheinternalanalsphincter.Theanalsphinctermusclescompresstheanalcanalandmaintain
analcontinence.
Neurovascularsupply.Theinternalpudendalartery,abranchoftheinternaliliacartery,istheprimarilyblood
supplytotheperineum.Thepudendalnerve,abranchofthelumbosacralplexus,conveyssomaticsensation
fromtheperineumandconveyssomaticmotorfiberstothepelvicfloormusclesandtoallskeletalperineal
muscles.Theneurovascularsupplytotheperineumenterstheischioanalfossainferiortotheischialspine,runs
anteriorlyalongthemedialsurfaceoftheobturatorinternusmuscletosupplyallperinealstructuresexceptthe
vascularsmoothmuscleandglands(Figure7).Parasympatheticandsympatheticvisceralmotorfibersdescend
fromthepelvicautonomicplexusesalongtheurethratoreachtheperinealerectiletissue.Parasympathetic
visceralmotorfibersarefromthepelvicsplanchnicnerves(S2,S3,S4).Sympatheticvisceralmotorfibersarefrom
thelumbarsplanchnicnerves(L1,L2).

Identifyingdeeperstructuresinthemaleperineum
Returntotheinguinalregion,andidentifythespermaticcordasthecordanditsfascialcoveringsemergefromthe
superficialinguinalring.Palpatethepathofthespermaticcordfromthesuperficialinguinalringtothescrotum.
Makeashallowskinincisionsuperficialtothepathofthespermaticcord.Yourincisionshouldextendthroughskin
only.Onceyouhavecompletedtheskinincision,usebluntdissectiontorevealtheunderlyingstructures.
Identifythecremastermuscleonthesurfaceofthespermaticcordanditscoverings.Thecremastermuscleisaslip
oftheinternalabdominalobliquemusclethatjoinedthespermaticcordduringitspassagethroughtheinguinal
canal.Contractionofthecremastermuscleelevatesthetestis,usuallyaspartofareflex.
Usingbluntdissection,openthefascialcoveringsofthespermaticcordandidentifythetesticularvesselsandthe
ductusdeferens.Followthespermaticcordinferiorlytothescrotum.
Usingtheblunttippedscissors,openthethinskinofthescrotum,andidentifythetestisandepididymis.Identifythe
inferiorpoleofthetestisandtheproperligamentofthetestisattachingthetestistotheskinofthescrotum.In
testiculartorsion,thetestisrotatesonitslongaxisbetweenthespermaticcordsuperiorlyandtheproperligament
inferiorly.Testiculartorsionmaycompromisethevascularsupplytothetestis.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page737

Identifyingdeeperstructuresinthemaleperineum(continued)
Returntothetransverseskinincisionmadethroughtheanteriorabdominalwallatthesuperiormarginofthepubic
symphysis.Usingaclamporyourfinger,identifytheplanebetweenthesubcutaneousfatandthepubicsymphysis.
Stayingascloseaspossibletothebone,usebluntdissectiontoopenthisplanetotheinferiormarginofthepubic
symphysis.Attheinferiormarginofthepubicsymphysis,identifythesuspensoryligamentofthepenisandits
attachmenttothepenis.
Gentlycompleteashallowskinincisioninthemidlineofthemaleperineum(Figure713,incision5B).Incision5B
shouldextendthroughskinonlyandshouldavoidtheanusbywidelyencirclingit.Onceyouhavecompletedthe
midlineskinincision,usebluntdissectiontoseparatetheperinealskinfromtheunderlyingstructures.Onbothsides
ofthebody,reflecttheskinandsubcutaneousfatlaterallyascutaneousflaps.Clampsattachedtotheedgesofthe
flapsmaybehelpfulinsecuringtheirpositionoutsidethedissectionfield.
Inthemidline,identifythebulbandbodyofthemidlinecorpusspongiosum.Identifythepairedbulbospongiosus
musclesattachingtotheexternalsurfaceofthecorpusspongiosum.Thecorpusspongiosumsurroundsthespongy
(penile)portionoftheurethra.
Lateraltothecorpusspongiosumonthebodyofthepenis,identifytheleftandrightcorporacavernosa.Followthe
corporacavernosaposterioralongtheischiopubicramus.Identifytheischiocavernosusmusclesontheexternal
surfacesofthecorporacavernosa.

Mechanismofarousalandejaculation.Duringarousal,parasympatheticvisceralmotorfibersinitiateinhibitionof
vascularsmoothmuscleinthearteriessupplyingthecavernousspacesoftheperinealerectiletissue.The
arteriesexpandandstraightenandbloodflowtothecavernousspacesincreases.Outwardexpansionofthe
cavernousspacesiscontainedbytherelativelyinelastictunicaalbugineasurroundingthemaleandfemale
erectiletissue,andtheperipheralveinsdrainingthecavernousspacesarecompressedagainstthetunica.
Vascularengorgementoftheerectiletissueresultsfrombothincreasedarterialinflowanddecreasedvenous
outflow.Infemales,transudationoffluidoccursthroughthevaginalmucousmembrane.Inmales,peristaltic
contractionsoftheductusdeferentesdeliverspermtothedilatedampullaoftheductspriortoejaculation.
Duringejaculation,sympatheticvisceralmotorfibersrestorevasoconstrictionofthearteriessupplyingthe
cavernousspaces.Asarterialinflowiscurtailedandpressureinthecavernousspacesdecreases,compressionof
theveinsalsodecreasesandvenousoutflowincreases.Inmales,sympatheticvisceralmotorfibersinitiate
contractionsoftheseminalvesicalsandejaculatoryducts,andtheinternalurethralsphinctercontractsto
preventejaculatefromenteringthebladder.Orgasminbothsexesinitiatesreflexcontractionsofsmooth
muscleinthepelvicviscera,andreflexcontractionsofperinealsmoothmuscle.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

5.5.ENDOFLAB
Systemreviewchecklist
Bonesandligaments
Pubicsymphysis
Ischiopubicramus
Ischialtuberosity
Perinealmembrane(bypalpation)
Perinealbody(bypalpation)
Anococcygealligament(bypalpation)

Pelvicsidewallandpelvicfloormuscles
Internalobturatormuscle
Levatoranimuscle
Femalepelvis









Broadligament
Mesovarium
Mesosalpinx
Bladder
Rectum
Uterus
Uterinetube
Ovary
Roundligamentoftheuterus

Malepelvis
Bladder
Rectum
Prostategland
Ductusdeferens
Seminalvesicles

Femaleperineum








Monspubis
Labiamajora
Labiaminora
Vestibuleofthevagina
Externalurethralorifice
Vaginalorifice(introitus)
Glans,body,andcruraoftheclitoris
Ischiocavernosusmuscle
Bulbospongiosusmuscle

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Page738

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page739

Systemreviewchecklist(continued)
Maleperineum








Scrotum
Testis
Spermaticcord
Glans,body,andcruraofthepenis
Ischiocavernosusmuscle
Bulbospongiosusmuscle
Vessels
Commoniliacvessels
Externalandinternaliliac

Endoflabchecklist
Sharpsanddissectioninstruments



Removealldissectioninstrumentsfromtheplasticbodybag.
Countallsharpsincludinghypodermicneedles,scalpels,andscissors.
Removescalpelbladesfromscalpelhandlesanddiscardbladesinthered`sharpscontainers.
Wipeandstoredissectioninstrumentsinthebluedissectionkitboxes.

Careofyouranatomicaldonor



Spraythealldissectedtissues.
Replaceallmusclesandskinflapsintheiroriginalanatomicpositions.
Makesuretheflannelclothismoistandcompletelycoversthebodyincludingthehandsandfeet.
Verifythatfluidisdrainingfromthetableintothestainlesssteelbucketatthefootandnotaccumulatingin
theplasticbodybag.Checkthatthefluidbucketislessthanfull.Iffluidinthebucketisapproachingthe
level,notifyaninstructor.
Ziptheblackplasticbag.

Beforeleavinglab
Lookforfluidspillsaroundyourdissectiontableandwipethemupwithpapertowels.
Verifythatonlyhumantissuehasbeendiscardedinthewhitetissuebucket(notglovesorpapertowels)and
thatonlypapertowelsandgloveshavebeendiscardedinthegraytrashbarrels(nothumantissueexceptvery
smalltissuepiecesclingingtopapertowels).
Turnoffalloverheadlightsatyourdissectiontableandatanyothertableswherestudentsarenolonger
working.Ifanylightsatyourtablearenotworking,notifyyourinstructor.
Removeglovesandwashyourhandsbeforeleavinglab.

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

Lab7

INFRAPERTIONEALREGIONANDPERINEUM

Page740

5.8.APPENDIX
Youarenotrequiredtolearntheattachmentsofthesemuscles(grayarea)indetail.

Pelvicsidewallmuscles
Table71

PELVICSIDEWALLMUSCLES
Obturatorforamenandgreatersciaticforamenclosure;hipexternalrotation
MUSCLE

ACTION

Obturatorinternus

Piriformis

INNERVATION

Hipjointexternal
rotation

Nervetoobturator
internus

Hipjointexternal
rotation

Nervetopiriformis

PROXIMAL

DISTAL

ATTACHMENT

ATTACHMENT

Pelvis(internalmargin
ofobturatorforamen)
Obturatormembrane
Sacrum(internal
surface),thengreater
sciaticforamen

Femur(greater
trochanter)

Femur(greater
trochanter)

Pelvicfloormuscles
Table72

PELVICFLOORMUSCLES
Pelvicoutletclosure,abdominopelvicviscerasupport,orcontinence(byassistingperinealsphincters)
MUSCLE

Coccygeus

Levatorani
Pubococcygeus

Puborectalis*
Pubovaginalis**(female)
Puboprostaticus**(male)

Ischiococcygeus
(iliococcygeus)

ACTION

INNERVATION

Abdominopelvicviscera
support

AnteriorramiofS2S4
spinalnerves

Coccygealprotraction

Pudendalnerve

Abdominopelvicviscera
support

Abdominalcavityvolume
decrease(andpressure
increase)

Assistingsphinctersin
maintainingcontinence

AnteriorramiofS2S4
spinalnerves

Pudendalnerve

AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.

LATERAL

MEDIAL

ATTACHMENT

ATTACHMENT

Ischialspine
Sacrospinousligament

Pubis(body)

Tendinousarchof
levatorani(thickening
ofinternalobturator
fascia)

Ischialspine

Coccygealvertebrae

Perinealbody
Perinealmembrane
Medianrapheposteriortorectum
Medianrapheposteriortovagina
Medianrapheposteriortoprostate
Anococcygealligament