Pelvis and Perineum Lecture Notes

Learning Objectives

1. Enumerate the bony and surface landmarks of the pelvis

2. Describe the component parts of the bony pelvis
3. Describe the divisions of the bony pelvis

4. Describe the joints and ligaments of the bony

pelvis
5. Differentiate between the female and male pelvis
6. Describe the structures that form the walls of the pelvis
7. Describe the muscles of the pelvis as to their attachments, action, and nerve supply
8. Describe the sacral plexus with regard to its formation and branches
9. Describe the autonomic nerves that supply the pelvis
10.Describe the arteries of the true pelvis
11.State the venous drainage of the pelvis
12.State the lymphatic drainage of the pelvis
13.Enumerate the boundaries of the perineum
14.Describe the divisions of the perineum
15.Describe the layers of the perineum
16.State the attachments of the Colles fascia
17.State the location of the superficial and deep
perineal spaces
18.Enumerate the structures found within the
superficial and deep perineal spaces in the male
and female
19.Discuss the attachments of Colles fascia in
relation to determining the flow of
extravasated urine in patients with a ruptured urethra
20.Enumerate the contents of the anal triangle
21.State the boundaries of the ischioanal fossa
 22.Enumerate the contents of the ischioanal fossa
23.State the source of arterial supply to the pelvis
24.State the venous drainage of the pelvis
25.Describe the perineal nerve with regard to
formation and distribution in the
perineum
26.Describe the pudendal canal as to its location and
contents

Joints and Ligaments

Lumbosacral joints
o Intervertebral disc between L5 and S1
and facet joints between their articular
surfaces
o Iliolumbar ligaments
Sacroiliac joints
o Reinforced by anterior and posterior
sacroiliac ligaments
Strongest ligament of the body
Sacrococcygeal joint
o Reinforced by anterior,
posterior, and lateral
sacrococcygeal ligaments
Sacrotuberous ligament
o Transforms the sciatic notch into the sciatic
foramen
Sacrospinous ligament
o Divides the sciatic foramen
into greater and lesser sciatic foramina
Symphysis pubis
o Between the pubic bones

Divisions of the Pelvis

False Pelvis (Pelvis major, greater pelvis)

o Lower part of the abdominal cavity
o Between the iliac crests and the pelvic inlet
True Pelvis (pelvis minor, lesser pelvis)
o Referred to as the pelvic cavity
o Between pelvic inlet and pelvic outlet
Pelvic inlet (pelvic brim)
o Posteriorly -> sacral promontory
o Laterally -> right and left iliopectineal lines
o Anteriorly -> symphysis pubis
Pelvic outlet
o Posteriorly -> coccyx
o Laterally -> ischial tuberosities
o Anteriorly -> pubic arch

Sex Differences of the Pelvis

 Classificatio
n of the Female Pelvis

Gynecoid typical female pelvis

Android male or funnel-shaped pelvis
Anthropoid antero-posterior diameter is greater than transverse diameter
Platypelloid transverse diameter is greater than antero-posterior diameter

Pelvic Walls

Anterior
o Symphysis pubis and bodies and rami of pubic bones
Lateral
o Hip bone, obturator foramen, sacrospinous and sacrotuberous ligaments, and
obtuartor internus mm.
Posterior
o Sacrum and coccyx, ilia, sacroiliac joints and associated ligaments
o Covered by the piriformis mm.
Inferior
o Formed by the pelvic diaphragm
 Muscles of the Pelvis

Obturator internus
o Origin: obturator membrane
o Leaves the pelvis through the lesser sciatic foramen
o Inserts: greater trochanter
o Action: lateral rotation of the hip
o Nerve Supply: nerve to the obturator internus
Piriformis
o Origin: pelvic surface of the sacrum

o Leaves the pelvis through the greater

sciatic foramen
o Inserts on greater trochanter
o Action: lateral rotation of the hip joint
o Nerve Supply: sacral plexus
Pelvic Diaphragm
o Levator ani
Origin: body of the pubis, tendinous arch
Pubococcygeus main anterior part
o Puboprostaticus pass across the side of the prostate
o Pubovaginalis pass across the lateral walls of the vagina
Puborectalis forms a muscular sling around the anorectal junction
Iliococcygeus posterior part of the levator ani
Action: supports the pelvic viscera
 Sphincter action
to the anorectal junction and vagina
Nerve Supply: nerve to the levator ani, inferior rectal nerve, coccygeal plexus
o Coccygeus (ischiococcygeus)
Origin: ischial spine
Insertion: sacrum and coccyx
Action: assists the levator ani in supporting pelvic viscera
Nerve Supply: perineal branches of S4, S5
Clinical Correlation
o Injury to the pelvic floor perineum, levator ani, and pelvic fascia may be injured
during child birth; pubococcygeus is stretched and torn
Loss of support for the pelvic viscera uterine and/or vaginal prolapsed
Alteration in the position of the neck of the urinary
bladder and urethra
stress incontinence

Nerves of the Pelvis

Sacral Plexus
o Anterior rami of spinal nerves L4 and L5
and S1-S4
o Branches to the lower limbs
Sciatic
Superior gluteal
Inferior gluteal
 Nerve to obturator internus & superior
gemellus
Nerve to quadrates femoris & inferior
gemellus
Perforating cutaneous
nerve
Posterior cutaneous nerve
of thigh
o Branches to pelvic muscles,
viscera and perineum
Pudendal nerve (S2, 3, 4)
Motor muscles of the
perineum
Sensory lower
half of anal canal,
perianal skin,
external genitalia
Nerve to piriformis
Pelvic splanchnic nerves parasympathetic innervation to pelvic viscera
Perforating cutaneous nerve
Branch from the lumbar plexus obturator nerve (L2, 3, 4)
Autonomic nerves
o Superior hypogastric plexus contains
sympathetic, parasympathetic, and visceral
afferent fibers
o Inferior hypogastric plexuses contains
postganglionic sympathetic, preganglionic
parasympathetic and visceral afferent fibers
o Sacral splanchnic nerves from sacral portion of
sympathetic trunks
o Pelvic splanchnic nerves sacral outflow of
parasympathetic division of ANS

Clinical Correlation

Piriformis Syndrome
o ~15% of the population, sciatic nerve
travels throughpiriformis causing
sciatica and pain in gluteal region made worse by sitting,
climbing stairs, or performing squats
Injury to Pelvic Nerves
o Compression of mothers sacral plexus by
fetal head during delivery causing pain
in the mothers lower limbs
o Injury to obturator nerve during
surgical removal of cancerous lymph
nodes from lateral pelvic wall causing weakness or
paralysis of adductor muscles of thigh and sensory
deficits in medial thigh region

Arteries of the Pelvis

 Common Iliac Artery
o Begins at the level of L4 bifurcation of
the abdominal aorta
o Ends anterior to the sacroiliac joint
External iliac artery
o Leaves the false pelvis to become the
femoral
o Branches:
Inferior epigastric artery
Deep circumflex iliac artery

Arteries of the True Pelvis

Internal Iliac Artery

o Posterior division
Iliolumbar anastomoses with deep circumflex
Lateral sacral
Superior gluteal largest of the branches
o Anterior Division
Obturator exits the pelvic cavity through the obturator canal
Umbilical patent portion superior vesical artery (bladder)
 Obliterated portion medial umbilical
ligament
Inferior vesical inferior aspect of male
urinary bladder, pelvic part of ureter, prostate
gland, seminal vesicles
Middle rectal lower part of
rectum, prostate gland, seminal
vesicles
Internal pudendal enters the
perineum through the lesser sciatic
foramen
Main arterial supply to the
perineum
Inferior gluteal
Uterine
Vaginal
Superior rectal artery continuation of the inferior
mesenteric artery
Median sacral artery arises from abdominal aorta
before it bifurcates
Ovarian artery
Testicular artery does not enter the pelvis, goes
through spermatic cord

The Pelvic Veins

Veins follow corresponding arteries

o External iliac vein
o Internal iliac vein
o Median sacral vein
o Common iliac vein -> IVC

The Pelvis: Lymphatics

Lymph nodes arranged in a chain

along main blood vessels
Named after associated blood vessel
o External iliac nodes
o Internal iliac nodes
o Common iliac nodes
The Perineum

Urogenital triangle anterior

portion
o Contains the external
genitalia and urogenital
passages
Anal triangle posterior portion
o Contains the anal canal
and ischioanal fossae

Urogenital Triangle

Layers
o

Skin
o Superficial fascia
Fatty layer (Campers)
Membranous layer (Colles fascia; scarpa)
Continuous with dartos fascia of the penis and Scarpas fascia of the
anterior abdominal wall
Attached to fascia lata just distal to the inguinal ligament; inferior
fascia of the urogenital diaphragm
 o Inferior fascia of the urogenital
diaphragm perineal membrane
o Urogenital diaphragm composed of the sphincter urethrae and deep transverse
perineal muscles
o Superior fascia of the urogenital diaphragm
Perineal Spaces
o Superficial perineal space between Colles fascia and the inferior fascia of the
urogenital diaphragm
o Deep perineal space between the superior and inferior fascia of the urogenital
diaphragm (perineal membrane)
Superficial Perineal Space
o Contents in males
Root of the penis and associated muscles
Proximal portion of the spongy
urethra
Superficial transverse perineal
muscle
Branches (tributaries) of
the internal pudendal
artery and vein
Perineal branch of
pudendal nerve
o Contents in females
Root of the clitoris and associated
muscles bulbospongiosus
and ischiocaveronsus
Part of the urethra
Superficial perineal
muscle
Branches (tributaries) of the internal
pudendal artery and vein
Perineal branch of the
pudendal nerve Figure 1 Superficial Perineal space - males
 Greater vestibular glands (Bartholins) glands
Deep Perineal Space
o Content in males
Membranous portion of
the urethra
Urogenital diaphragm

Deep transverse
Branches (tributaries) of
the internal pudendal
artery and vein
Dorsal nerve of the penis
Bulbourethral (Cowpers)
glands
o Content in females
Part of the urethra and vagina
Urogenital diaphragm
Branches (tributaries) of Figure 2 Superficial Perineal space - females
the internal pudendal artery and
vein
Dorsal nerve of the clitoris

Anal Triangle

Contents
o Anal canal
o Ischioanal fossae
o External anal sphincter

Ischioanal Fossa

On each side of the anal canal

Boundaries:
o Base: skin
o Medial wall: anal canal with levator
ani and external anal sphincter
o Lateral wall: ischium and obturator internus
o Posterior wall: sacrotuberous ligament and
gluteus maximus
o Anterior wall: urogenital diaphragm
Contents:
o Fat support anal canal
o Pudendal nerve and internal
pudendal artery and vein
o Pudendal (Alcocks) canal fibrous
tunnel on the lateral wall of the
ischioanal fossa Figure 3 Deep Perineal Space - males
Pudendal Nerve

Branches:
o Inferior rectal motor to external anal
sphincter
o Dorsal nerve of the penis (clitoris)
o Perineal nerve motor to muscles in urogenital
triangle; sensory to skin on posterior
surface of the scrotum (labia
majora)
Pudendal Nerve Block
o Injecting local anesthesia around the
pudendal nerve as it
exits the pudendal canal near the
ischial spine
o Provides anesthesia over S2-S4
dermatomes and lower of
vagina Figure 4 Deep Perineal Space - females

Ischioanal Abscess

May result from inflammation of the anal sinuses, a tear in the anal mucous membrane, or
a penetrating would on the anal region
Fullness and tenderness between the anus and ischial tuberosity