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Review of Pevic Anatomy

for Gynaecologists
Professor Emeritus Moira OBrien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin

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Female Pelvis

Smout et al., 1969

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Overview

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Pubic Symphysis
Secondary cartilagenous joint
Articular surface of medial aspect of
body of pubis
Covered with hyaline articular cartilage
Disc of fibro-cartilage in between
A cavity may develop in the disc but it is
not lined with synovial membrane
There is normally very little movement
at the pubic symphysis, except during
the latter months of pregnancy

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Sacroiliac Joint
Modified synovial plane joint
Articular surfaces are rough
The capsule is attached just beyond
the articular margin
The interosseous sacroiliac ligament
is one of the strongest ligaments in the
body and is posterior to the joint
This articulation is almost immobile,
except during pregnancy

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Sacroiliac Joint Accessory Ligaments

Sacrotuberous ligaments
Sacrospinous ligaments
Iliolumbar ligaments
Posterior superior iliac spine is middle of
the joint posteriorly at the level S2
S2 is end of dura, arachnoid mater and
subarachnoid space
During gait, the amount of accessory
movement at the sacroiliac joint helps to
protect the lumbar intervertebral discs

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Abnormalities of Pelvis

Spina bifida occulta

Unilateral lumbarisation
Unilateral sacralisation
Stress fractures of the
sacrum, pubic arch and neck
of femur may be first signs of
osteoporosis

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Walls of Pelvis
Sacrum and coccyx posterior
Os coxae below pelvic brim
Piriformis covers middle three
pieces of sacrum
Passes out of the pelvis through
the greater sciatic foramen
Muscles
Obturator internus muscle
Origin of levator ani
Coccygeus
Smout et al., 1969

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Lateral Walls of Pelvis

Obturator nerve
Obturator artery and vein
Parietal peritoneum supplied by
the obturator nerve
Pain may be referred to hip or
knee joints
Common iliac divides into
external and internal iliac
Internal divides into anterior and
posterior division branches
Smout et al., 1969

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Pelvic Fascia
Pelvic fascia can be divided into three:
1. Pelvic wall
Pelvic fascia is a strong membrane over
the piriformis and obturator internus
Fuses with the periosteum at their
margins
2. Pelvic floor
Fascia is covered with loose areolar tissue
Loose areolar fat tissue lies in the extraperitoneal
space between peritoneum and the viscera forming a
dead space

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Pelvic Fascia
3. Pelvic viscera
Fascia of pelvic viscera is loose or
dense depending on dispensability of
organ
Smout et al., 1969

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Pelvic Ligaments
Condensation around vessels form
ligaments in the pelvis
Cardinal ligament condensation of
fascia around uterine artery
Lateral ligament of the rectum is a
condensation of fascia around the
middle rectal vessels and branches of
the hypogastric plexus
Waldyers fascia suspends the lower part of the ampulla
of the rectum to the hollow of sacrum
Contains the superior rectal vessels and lymphatics
Smout et al., 1969

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Pelvic Floor
Urogenital diaphragm
Perineal membrane and the superficial
transverse perineii
The pelvic floor is a dome-shaped
striated muscular sheet
The levator ani is made up mainly of
the pubococcygeus, the puborectalis
and the iliococcygeus
It encloses the bladder, uterus and rectum
Together with the anal sphincters, has an important role in
regulating storage and evacuation of urine and stool
Stoker, 2009

Deep Perineal Pouch:

Urogenital Diaphragm
Superior is the areolar tissue on the
under surface of the levator ani
The sphincter urethrae around urethra
and transverse perineii in the deep
pouch
Perineal membrane fills in pubic arch
below the muscles
Muscles are supplied by perineal
branch of pudendal nerve
In lateral portion of the deep pouch, run
dorsal nerve of clitoris and internal
pudendal artery and vena commitans

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perineal
membrane

deep pouch
superficial
pouch

sphincter
urethrae

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Levator Ani
Arises, anteriorly, from the posterior
surface of the body of pubis lateral to
the symphysis
Posterior from the inner surface of the
spine of the ischium
Between these two points, from a
tendinous arch called the white line
(arcus tendineus) adherent to the
obturator fascia
Last,1984

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Levator Ani
Unites with the opposite side to form
most of the floor of the pelvic cavity
The fibres pass downward and
backward to the middle line of the floor
of the pelvis
Inserted from before backwards, into
perineal body
Side of the rectum and anal canal
Anococcygeal raphe
The side of the last two segments of
the coccyx
Last 1984

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Levator Ani
The anterior fibres, pubovaginalis,
pass behind the vagina, unites with
the opposite side
Inserted into the perineal body, the
central point of the perineum
Joining the fibres of the sphincter ani
externus and transversus perineii
Last 1984

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Levator Ani
The puborectalis forms a U-shaped
sling, holding the anorectal anteriorly,
blending with the deep fibres of the
external anal sphincter
Anococcygeal raphe lies between the
coccyx and the margin of the anus
Nerve supply, inferior rectal nerve
and perineal branch fourth sacral
Last 1984

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Levator Ani
In women, the levator muscles or their
nerve supply, can be damaged in
pregnancy or childbirth
There is some evidence that these
muscles may also be damaged during
a hysterectomy
Pelvic surgery using the "perineal
approach" (between the anus and
coccyx) is an established cause of
damage to the pelvic floor. This
surgery includes coccygectomy

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Empty Female Bladder

Bladder has a apex, triangular superior
surface, base and two inferolateral
surfaces, neck inferiorly
Posterior or base is fixed, the two
ureters enter obliquely at the junction
of the superior surfaces and base
The internal urethral orifice or neck is
at the junction of the base and two
inferolateral surfaces
The interior of the bladder is lined with
transitional epithelium which is thrown into folds
in the empty bladder, except for the smooth
triangular area of base called trigone

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Female Bladder
Pubo vesical ligaments connect the
neck to the pubic bone
Base is attached to the supravaginal
portion of the cervix and anterior
fornix of vagina
Peritoneum only covers superior
surface
Blood supply, superior and inferior
vesical arteries
Venous plexus into internal iliac vein

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Control of Micturition
Smooth or detrusor muscle at the
neck is the internal sphincter,
supplied by the sympathetic
Parasympathetic contracts
detrusor muscle and relaxes
internal sphincter
Sphincter urethra or external
sphincter is striated muscle
Supplied by perineal branch of
pudendal nerve S2,3,4,

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Structure of Female Urethra

Urethra 3-5 cm long
Enters deep pouch where it is
surrounded by
Sphincter urethra, also called external
sphincter of bladder
Urethra pierces perineal membrane
No fascia between lower two thirds of
urethra and vagina
Opens into vestibule, between clitoris
and vagina

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Urethra

Muscular layer continuous with bladder

Spongy erectile tissue
Plexus of veins
Mucous membrane transitional
Distal non keratinising stratified squamous
Para urethral glands and ducts open into
urethra, homologues of prostatic glands

Smout et al 1969

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Urethra
Urethra is supported by the fascia of
the pelvic floor including pubovesical and pubocervical ligaments
If this support is insufficient, the
urethra can move downwards
In times of increased abdominal
pressure resulting in stress urinary
incontinence (SUI)
The physical changes that can occur during pregnancy,
delivery and menopause can predispose to SUI
Nuggaard and Heit in Bayliss 2010

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Uterus
Normal uterus is anteverted
i.e. anterior to vertical plane going
through the vagina
Posterior fornix deeper
Anteflexed
Bent anteriorly junction of body and
cervix
Pear-shaped muscular organ
8 cm long; 5 cm width; 3 cm thick
Non-pregnant state
Pelvic organ

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Uterus
Fundus
Body
Cervix opens into vault or fornices
of vagina
Fundus is the portion above
entrance of uterine tubes
Covered with peritoneum
Body
Triangular cavity

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Cervix
Isthmus is a circular borderline area
between the body and cervix
Isthmus is the supra vaginal portion
of cervix, the lower uterine segment
Intravaginal is surrounded by gutter
by fornices of vagina,
Posterior is deeper covered with
peritoneum
Internal os is the opening from the
cavity of body
Spindle shaped cavity cervix
External os is the opening into vagina

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Cervix
Cervical canal is lined by columnar
epithelium
External os
Junction of columnar of the cervical
canal
Stratified epithelium of the intravaginal
portion
Site of cancer of cervix
Cervical smear
At birth cervix is larger than the body
Fully developed
Cervix is one third of body

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Supports of Uterus

Upper
Round ligament
Broad ligament anteverted
Transverse ligament
Pubocervical
Uterosacral
Lower
Levator ani, coccygeus
Perineal body

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Round Ligament
Round ligament and ligament of
ovary
Develop from the gubernaculum
Side of uterus, junction fundus and
body
Inguinal canal to labium majus
Ante version

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Pubocervical Ligament
Attached
Anteriorly to posterior aspect of body
of body of pubis
Passes to neck of bladder
Anterior fornix of vagina
Pubocervical ligaments help to
Maintain normal angle of 45
between the vagina and horizontal
Decrease may cause a cystocoele

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Transverse Ligament
Transverse or cardinal or
Mackenrodts ligament
Thickening of visceral layer of pelvic
fascia around uterine artery
Lateral to medial in base of broad
ligament

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Uterosacral Ligament
Uterosacral contains fibrous tissue
Non-striated muscle
Attached from the cervix to the
middle of sacrum
Contains lymphatics draining cervix
to sacral glands
Uterosacral help to keep uterus
anteverted
If uterus is anteverted it cannot
prolapse

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Blood Supply

Uterine from internal iliac

Ovarian from aorta at L2
Vaginal arteries from internal iliac
Anterior and posterior arcuate run in
middle layer

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Blood Supply

Serous layer
Myometrium
No submucous layer
Endometrium
Compact at surface of uterine cavity
and spongy layer are supplied by
spiral arteries
Basal layer is not shed during
menstruation; supplied by radial branches
Veins below artery
Plexus in lower edge broad ligament into internal
iliac

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Embolization of Fibroids
Fibroids vary in size and position in
uterine wall
May enlarge and compress ureters
or other structures in pelvis
A small catheter is inserted in the
groin, into the femoral artery
Small particles are introduced
through the catheter into the uterine
artery
They block the blood supply to the fibroids
The fibroids thus starved of blood shrivel and die over the
next few months

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Lymphatics of Uterus and Vagina

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Nerve Supply of Uterus

Pain from cervix via
parasympathetic S2,3
Pain from body via
sympathetic to T11 and
T12

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Broad Ligament
Fold of peritoneum from side of uterus
to side wall of pelvis
Framework of pelvic fascia
Parametric fat
Anterior surface looks inferiorly
Free upper border
Base lies on pelvic floor

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Contents of Broad Ligament

Uterine tubes
Ovarian vessels
Uterine vessels
Epoophoron
Paroophoron
Round ligament of uterus and
ligament of ovary
Transverse ligament
Ovary attached to posterior layer
Ureter in base below uterine artery

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Broad Ligament
Uterine tube lies in medial four fifths
of free border of broad ligament
Lateral one fifth
Contains ovarian vessels
Infundibulo-pelvic or suspensory
ligament of ovary
Epoophoron
Parallel tubules remains of
mesonephric tubules
Gartner's duct remains of
mesonephric duct, may form cysts

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Broad Ligament

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Uterine Tube

Intramural
Isthmus
Ampulla
Infundibulum surrounded by fimbria
Lined ciliated columnar epithelium
Beats towards uterus
Peritoneum loosely attached to ampulla
Tightly to isthmus, if ectopic implanted
here, ruptures earlier
Fimbria surrounding opening into peritoneal cavity
Ovarian fimbria is longest

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Ovary
Attached to posterior layer of broad
ligament meso ovarian
Covered with germinal epithelium
Related to side wall of pelvis which is
covered with peritoneum
Obturator internus muscle
Obturator nerve supplies the parietal
peritoneum
Posterior to ovary is the ureter
Ligament of ovary medially

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Ovary
Obturator nerve supplies the parietal
peritoneum
Irritation of the peritoneum of the side
wall by bleeding at ovulation or by
lesions involving the ovary
May result in referred pain to medial
side of the thigh or the knee

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Ovary
Blood supply
One ovarian artery from lateral
aspects of aorta L2
Right vein drains into inferior vena
cava
Left drains into left renal vein
Lymphatics into para aortic
glands L2

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Vagina
Fornices, gutters which surround the
cervix
Normal anteverted antiflexed
Anterior fornix is shallow anterior wall is
shorter than posterior
Posterior deeper, covered with
peritoneum of the pouch of Douglas
Most dependent part of peritoneal cavity
Walls in contact except superior
Opens into vestibule of vagina

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Uterine Artery
Uterine artery lies superior to the
ureter at lateral fornix of vagina
Base of broad ligament

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Vagina

Erectile tissue
Muscular wall
Pelvic fascia
Nonkeratinised stratified squamous
epithelium
Urethra lower third anterior wall
No fascia between lower two thirds of
urethra and vagina
Upper portion of the vagina is clasped by the pubovaginalis portion of the levator ani

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Vagina
Deep pouch
Sphincter urethrae, deep transverse
perineii, pierces perineal membrane,
opens into vestibule of vagina
Hymen fold of mucous membrane at
external opening
Lateral are the bulbs of vestibule
Covered by bulbospongiosus muscle
Greater vestibular (Bartholin's) glands lie
behind the bulbs of vestibule
Ducts open into orifice of the vagina
Posterior to vagina is the perineal body

superficial

deep
pouch

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Perineum

perineal body central

point of perineum

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Peritoneum on Uterus and Vagina

Reflected from the superior surface of
the bladder
Junction of the supravaginal portion of
the cervix and the body of the uterus
forming the utero vesical pouch
Peritoneum then covers body, fundus
and posterior surface body and then
the supravaginal cervix and posterior
fornix of vagina
Peritoneum then reflected on to junction of upper
two thirds and lower third of rectum forming
Pouch of Douglas is most dependent part of
female peritoneal cavity

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Blood and Nerve Supply Vagina

Uterine artery
Vaginal
Internal pudendal
Labial
Ilio Inguinal nerve supplies the
anterior wall
Labial nerves supply the
posterior wall

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Lymphatics of Vagina
Internal iliac
Lower third
Medial group of proximal
superficial inguinal glands

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Pelvic Plexus

Lumbar splanchnics L1-L2

Presacral nerve
Anterior to body of L5
Divide into pelvic plexuses
Postganglionic of sympathetic
that relayed in lumbar and
sacral ganglia causes
contraction of sphincters of
bladder and anal canal

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Pelvic Parasympathetic
Preganglionic have cell bodies in
lateral column of segments S2,3,4
Ganglia found close to or in wall
of organ
Supplies intestine from splenic
flexure to upper two thirds of anal
canal, bladder
Motor to walls and inhibitory to
sphincters
Parasympathetic causes erection

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Rectum
Rectum is a continuation of pelvic
colon
Starts at the third piece of the
sacrum
Ends 5 cm from the tip of coccyx
Lower end is dilated at the ampulla,
at the anorectal junction
There are no taeniae and no
appendices epiplociae on the
rectum

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Rectum
It has an antero-posterior curve,
above it is angled anteriorly by the
puborectalis
Below convex forwards
Three lateral curves
Two concave to left, one to right,
where the valves of Houston, which
consist of circular muscle and
mucous membrane
Peritoneum covers upper third on front and sides
Middle third on front, none on lower third

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Blood Supply of Rectum

Superior rectal, continuation of inferior
mesenteric artery
Runs in Waldyers fascia from hollow of
sacrum to the lower part of the
ampulla of the rectum
Supplies mucous membrane as far
mucocutaneous junction of anal canal
Venous drainage into portal system
Middle rectal the muscle layer
Small twigs from median sacral

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Anal Canal

Starts at anorectal junction

Below ampulla of rectum
Passes backwards
Approx 4 cm
Ends at anus
Anterior: perineal body
Posterior: anococcygeal body
Lateral: ischiorectal fossae

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Muscles of Anal Canal

The anal sphincter is a multilayered
cylindrical structure
The inner smooth muscle of the
internal sphincter
Surrounds upper two thirds
Lower two thirds the outer striated
muscle layer of the external sphincter
Anorectal ring formed by puborectalis
and the deep part of the external
sphincter

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Peri Anal Fascia

Perianal fascia continuation of
longitudinal coat of rectum
Medial to deep and superficial
external sphincters
Attached at Hiltons line
Passes to lateral wall
Above subcutaneous sphincter

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Anal Canal
Lateral sheet passes between soft
ischiorectal fat and subcutaneous fat
to lateral wall
Splits to form pudendal canal and is
Continuous superiorly with the lunate
fascia, which passes above soft
ischiorectal fat
It is medial to deep and superficial
sphincter
Above subcutaneous sphincter

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Muscles of Anal Canal

Puborectalis portion levator ani holds
the anorectal junction anteriorly
Deep and subcutaneous parts of
external are true sphincters
No bony attachments
Superficial attached to coccyx and the
perineal body

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Muscles of Anal Canal

Anorectal ring
Internal sphincter
Puborectalis
Puborectal fascia
External sphincter
Deep, true sphincter, no bony
attachments
Inferior rectal nerve S3,4
Superficial S4
Subcutaneous, true sphincter
Inferior rectal nerve S3,4

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Anal Canal
Upper two thirds lined by
columnar epithelium
Lower third by skin
Junction of two is Hiltons white line skin
Anal columns contain radicles of superior
rectal artery and veins 4,7,11
At the lower end joining the columns are
mucosal folds called anal valves
Anal sinuses lie behind
Skin supplied by inferior rectal vessels
and nerves

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Blood and Nerve Supply

Upper two thirds

Columnar epithelium
Superior rectal artery
Autonomic nerves
Derived from cloacae
Lower third
Skin
Inferior rectal S3,4,
Somatic nerves
Derived from proctodeum

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Venous Drainage
Mucosa upper two thirds
Superior rectal vein
Portal system
Lower third
Inferior rectal vein
Vein into systemic system
Portal systemic anastomosis 4,7,11

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Lymphatic Drainage
Upper third
Pre aortic inferior mesenteric
Waldeyers fascia passes from sacrum to
the ampulla of rectum
Encloses superior rectal vessels and
lymphatics
Internal iliac
Lower Third
Inferior rectal cross ischio-rectal fossa
Medial superficial inguinal glands

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Anal Sphincters
The internal and external anal
sphincters are primarily
responsible for maintaining faecal
continence at rest and when
continence is threatened,
respectively.
Defecation is a somato-visceral
reflex regulated by dual nerve
supply (i.e. somatic and
autonomic) to the anorectum.
Bharucha 2006

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Anal Sphincters
The net effects of sympathetic and
cholinergic stimulation are to
increase and reduce anal resting
pressure, respectively.
Faecal incontinence and
functional defecatory disorders
may result from structural
changes and/or functional
disturbances in the mechanisms
of faecal continence and
defecation.
Bharucha 2006

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Ischiorectal Fossa
Ischiorectal fossa contents
Soft ischiorectal fat
Lunate fascia above the fat
Inferior rectal vessels pass above
the fat to reach medial wall
Perineal branch of S4
ischiorectal fossa

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Ischiorectal Fossa
Ischiorectal fossa contents
lunate fascia above the soft
ischiorectal fat
Inferior rectal vessels and nerve
pass above lunate fascia and the
fat to reach medial wall
Subcutaneous fat lies below
perianal fascia
Perineal branch of S4
Lymphatics cross fossa

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Pudendal Canal

Runs posterior to anterior

Pudendal canal contents
Pudendal nerve
Inferior rectal nerve
Dorsal nerve of clitoris
Perineal nerve
Labial nerves
Internal pudendal vessels

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Pudendal Block
Pudendal nerve
Lies on the sacrospinous ligament
Anaesthetizes posterior wall of the
vagina
Ilioinguinal nerve supplies the anterior
wall

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Age, pregnancy, family history, and hormonal status all

contribute to the development of pelvic organ prolapse. The
vagina is suspended by attachments to the perineum,
pelvic side wall and sacrum via attachments that include
collagen, elastin, and smooth muscle. Surgery can be
performed to repair pelvic floor muscles. The pelvic floor
muscles can be strengthened with Kegel exercises.
Disorders of the posterior pelvic floor include rectal
prolapse, rectocele, perineal hernia, and a number of
functional disorders including anismus. Constipation due to
any of these disorders is called "functional constipation"
and is identifiable by clinical diagnostic criteria.

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