Human Anatomy Review

Pelvis and
Parineum

The Pelvis and Perineum

I. Subdivisions of Pelvis

False pelvis (the greater pelvis)

Above pelvic brim

False pelvis starts superior to arcuate line and illiopubic

eminence to the iliac crest.
Boundaries

lower anterior abdominal wall

iliac fossae and iliacus muscle

lumbar vertebra

True pelvis (the lesser pelvis)

Structures that enter the true pelvis are the ureter, internal iliac artery, and
veins come out of here

Pelvic inlet (pelvic brim)

From sacral promontory to the superior part of the pubic

symphysis

Pelvis outlet

From the tip of the coccyx to the inferior part of the pubic
symphysis

Pelvic cavity (between inlet and outlet)

Boundaries

pubic symphysis

iliopectineal line

sacral promontory
-The colored diagram in the slides show the true pelvis with the pelvic diaphragm as
the inferior border and the perineum is bounded superiorly by the pelvic diaphragm

III. Bony Pelvis

Components of pelvis

Hip bones (ilium, ischium, pubis - fuse at acetabulum)

Coccyx

Sacrum

Joints of pelvis

Sacroiliac joint (synovial plane joint)

Pubic symphysis (fibrocartilage)

Sacrococcygeal joint (flexible)

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Pelvis and
Parineum

Important in childbirth
Obturator membrane

This is important for orientation in the pelvis

Almost completely closes the obturator foramen

A gap, obturator canal, allows the obturator artery and nerve to exit
the pelvis to enter the thigh and the obturator vein to enter the pelvis from
the thigh
Ligaments of pelvis

Iliolumbar ligament (L5 to iliac crest)

Sacrotuberous ligament

Sacrospinous ligament

Coccygeus m. rest on this ligament.if you cut through this

muscle you will see this ligament

Sacroiliac ligaments

Anterior sacroiliac ligament

Posterior sacroiliac ligament

Interosseous sacroiliac ligament

The strongest of the three that hold the sacroiliac joint

together

IV. Differences in the Male and Female Pelvis

Depth - female is shallower than male

Shape of pelvic inlet - oval in female, heart-like in the male

Size of pelvic outlet - larger in female-due to childbirth

Size of pelvic cavity - roomer and distance from inlet to outlet is shorter in
female

Ischial tuberosities - everted in female, inverted in male

Sacrum - shorter, wider and flatter in female
Pubic arch - rounder and wider in female

V. Muscles of Pelvis
-The first two help to create the wall of muscle in the pelvis

Piriformis m.-important in the gluteal region because was a landmark for

superior and inferior regions, important in the pelvis because of the sacral nerves
found at the base of the pelvic cavity

Sacrum through greater sciatic foramen to greater trochanter of femur

Nerve: anterior rami of S1 and S2

Action: lateral rotator of hip joint

Obturator internus m.
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Pelvis and
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Obturator membrane and adjacent bone through lesser sciatic foramen

to greater trochanter of femur

Nerve: anterior rami of L5 and S1

Action: lateral rotator of hip joint

Pelvic diaphragm

Consists of muscles and their fasciae

Supports the pelvic viscera

Coccygeus m. (ischio-)

Ischial spine to sacrum and coccyx

If you cut this muscle, what do you see?

Sacrospinous ligament

Nerve: anterior rami of S4 and S5

Levator ani mm. (tendinous arch)

We will not have to differentiate the below mm. in our

dissection but are responsible for the cross sections.

Iliococcygeus m. - tendinous arch to raphe between

anal canal and coccyx (more lateral)

Pubococcygeus m. - pubis to vagina/prostate, anorectal

junction to perineal body

Perineal body is important because it

can be damaged during childbirth

Puborectalis m. - part of external anal sphincter from

pubis to junction of anus and rectum

Most medial-forms a sling at the anal-rectal

junction, its keeping everything up

Nerve supply - anterior rami of S3 and S4

Review: Posterior to Anterior -Piriformis Obturator internus
Coccygeusiliococcygeuspubococcygeuspuborectalis
VI. Nerves of Pelvis

Sacral plexus (to pelvic mm., viscera and perineum)

Posterior pelvic wall on anterior surface of piriformis m.

Anterior rami of L4-L5 and S1-S4

L4-L5 form lumbosacral trunk

Pudendal n. (S2-S4) leaves via greater sciatic foramen within

Alcocks canal, inferior to piriformis and passes into the lesser sciatic
foramen
-Alcocks canal is important for a pudendal nerve block.

Inferior rectal n.

Dorsal n. of penis or clitoris

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Pelvis and
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Perineal n.

Nerves to piriformis m.

Perforating cutaneous n.
Sacral plexus leaves the pelvis through greater sciatic foramen (N468)

Sciatic n. (L4-5, S1-3)

Superior gluteal n. (L4-5, S1)

Inferior gluteal n. (L5, S1-2)

Nerve to obturator internus m. (L5, S1-2)

Nerve to quadratus femoris m. (L5, S1)

Posterior cutaneous n. of thigh (S1-3)

VII. Arteries of Pelvis

Common iliac a.(from aorta, branches at L4)

Internal iliac a. (anterior division)

Obturator a. - obturator canal

Nerve will be present with vein and artery

Several times last year, artery came off inferior

epigastric and youll find just the nerve

Umbilical a. - superior vesical aa. to top of bladder

Umbilical a becomes occluded and continues as the

medial ligament

Uterine a. - crosses ureter anteriorly

Vaginal a. - vagina and base of bladder

Inferior vesical a. - base of bladder

Middle rectal a.-may or may not originate from internal iliac,

may have common branch with inferior vesical a.

Internal pudendal a. - greater sciatic foramen with pudendal n.

on the obturator internus m., called Alcocks canal

Inferior gluteal a. - below piriformis m.

Provides blood to the gluteus maximus

Internal iliac a. (posterior division)

Iliolumbar a. - passes superiorly across pelvic inlet

Lateral sacral a. - anterior to sacral plexus

Superior gluteal a. - greater sciatic foramen superior to

piriformis m.

exits pelvis between the lumbosacral trunk, where

L4/L5 merge with S1 and form a V
Common iliac a.

External iliac a.

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Inferior epigastric a.
Deep circumflex iliac a.
The external iliac a. continues as femoral a. as it passes beneath
inguinal ligament
Superior rectal a.

Inferior mesenteric a.
Middle (median) sacral a.

Bifurcation of abdominal aorta (L4)

Ovarian or testicular a.

Abdominal aorta

VIII. Veins of Pelvis

External iliac v.

Continuation of femoral v.

Internal iliac v.

Joins with external iliac v. to form common iliac v. which merge to

form the inferior vena cava (at L5)

Middle (median) sacral v.

Drains into the left common iliac v.

IX. Lymphatics of Pelvis

Lymphatic drainage from the pelvis is primarily to

external and internal iliac nodes

common iliac nodes

X. Perineum

The perineum is a diamond-shaped region

The boundaries of the perineum

pubic symphysis - anteriorly

ischiopubic rami - anterolaterally

ischial tuberosity - laterally

sacrotuberous ligament - posterolateral

coccyx - posteriorly
A line connecting the ischial tuberosities divides the perineum into the

urogenital triangle (anterior)

anal triangle (posterior)

XI. Urogenital Diaphragm

The urogenital diaphragm is a triangular muscle in the anterior part of the
perineum in the pubic arch

It is formed by the sphincter urethrae m. and deep transverse perineal m.

It is covered by the superior and inferior fascia (perineal membrane)

XII. Urogenital Triangle

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Pelvis and
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Superficial perineal space

Between the urogenital diaphragm and superficial perineal (Colles)

fascia

The contents of this space include

ischiocavernosus mm.

bulbospongiosus mm.

superficial transverse perineal m.

perineal body

greater vestibular (Bartholins) glands in female

Deep perineal space

Lies between superior and inferior fasciae of the urogenital diaphragm

The contents of this space

deep transverse perineal m.

sphincter urethrae m.

urogenital diaphragm

bulbourethral glands in male

secrete into the bulbous portion of the urethra

XIII. Anal Triangleposterior portion of perineum

The anal triangle contains the two ischiorectal (anal) fossae
The ischiorectal fossae lie on either side of the midline of the perineum
This fossae lies between the levator ani and the obturator internus mm.
The pudendal canal (Alcocks) contains the internal pudendal vessels and
pudendal n.

Landmarks for a pudendal nerve block is the ischial tuberosity,

because an inch superior to that is the pudendal nerve

Boundaries

Superficial and deep transverse perineal mm. - anterior

Gluteus maximus m. and sacrotuberous ligament - posterior

Levator ani m. and external anal sphincter m. - superomedial

Obturator internus m. - lateral

XIV. Urinary Bladder

Functions to store urine (500ml)

Located behind pubic bones in pelvis
When fully distended, it can reach umbilicus
Segments

apex - anterior

superior surface - peritoneum

fundus and body - posteroinferior

neck - leads to urethra/inferolateral

uvula - projects into urethral orifice at the the apex of the trigone

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Interior features

Trigone - bounded by internal urethral orifice and orifices of two

ureters

Interureteric ridge - between two orifices of ureters

Detrusor muscle - smooth muscle

Sphincter vesicae - internal urethral sphincter (smooth muscle)

Uvula vesicae - prostate median lobe

Blood supply

Superior and inferior vesical aa.

Vein from the vesical venous plexus drain into internal iliac v.

Lympathic drainage

Internal and external iliac nodes

Nerves

The nerves that supply the bladder are continuous with the inferior
hypogastric plexus

The sympathetic fibers (T11 - L2) inhibit contraction of detrusor

muscle

The parasympathetic fibers (pelvic splanchnic nn.) stimulate

contraction of detrusor muscle and inhibit action of sphincter vesicae

XV. Male Urethra

Description

Extends from urinary bladder to external urethral orifice

The male urethra is ~8 in length

Prostatic urethra

Widest and most dilatable segment

Urethral crest (seminal colliculus)

Prostatic sinus - openings of prostate gland

Prostatic utricle - vagina/uterus of female

Ejaculatory ducts open in the edge of mouth of utricle

Membranous urethra - sphincter urethrae m.
Spongy urethra

Consists of a bulbous and penile segments

Bulbourethal ducts open

Urethral glands open

XVI. Female Urethra

Description

Extends from urinary bladder to external urethral orifice

The female urethra is ~1.5 in length

The ducts of Skene gland (mucus) open into urethra

XVII. Rectum

Description
The rectum is ~5 in length
It begins at S3 and extends to tip of coccyx
Puborectalis m. forms sling at rectoanal junction

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Transverse folds of rectum in rectal walls

Left wall - superior and inferior

Right wall middle

Also called valves of Houston

XVIII. Arteries of Rectum

Arteries

Superior rectal a.

Continuation of inferior mesenteric a.

Divides and anastomoses with middle and inferior rectal aa.

Middle rectal a.

Branch of internal iliac a.

Inferior rectal a.

Branch of internal pudendal a.

XIX. Veins of Rectum

Veins

Superior rectal v.

Drains into inferior mesenteric v.

Inferior then drains to Splenic v which then merges with the

superior mesenteric v to form the Portal v.

Middle rectal v.

Drains into internal iliac v.

Inferior rectal v.

Drains into internal pudendal v.

**This drainage is unique because there are both drainage to the portal v and IVC***

XX. Rectum

Lymphatics

Inferior mesenteric nodes (superior and middle third)

Internal iliac nodes (lower third)

The rectum is only sensitive to stretch
Nerves

Nerve supply is from parasympathetic and sympathetic systems

Sympathetic - superior hypogastric plexus

Parasympathetic - inferior hypogastric plexus

XXI. Anal Canal

***This region is important, expect anatomical questions differentiating between
regions in the anal canal***

Description

The anal canal is ~1.5 in length

It lies below pelvic diaphragm to anus

Upper half

Lined by columnar epithelium (goblet cells)

Anal columns (Morgagni) - 5-10 folds

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Anal valve - at lower ends of columns

Superior rectal a. and v.
Autonomic hypogastric plexus - sensitive to only stretch
Pectinate line

Separates the visceral portion (inferior hypogastric plexus) and

somatic portion (inferior rectal n.)
Lower half

Lined by stratified squamous epithelium

No anal columns

Inferior rectal a.

Inferior rectal n. - thus sensitive to pain, temperature and pressure

Inferior rectal v.
Anal sphincter

Internal anal sphincter

Involuntary control

Thickened inner circular smooth muscle at superior anal canal

External anal sphincter

Voluntary control

Skeletal muscle

Three parts

Subcutaneous - lower end of anal canal

Superficial - attached to coccyx and perineal body

Deep - blends with puborectalis m.

XXII. Hemorrhoids
Internal hemorrhoids are prolapses of internal rectal venous plexus - beneath
mucous membrane

External hemorrhoids are usually thromboses in veins of external rectal

venous plexus - sides of external sphincter

The superior, middle and inferior rectal veins anastomose and form a portal
and systemic venous communication

A pressure increase in the portal system may cause enlargement of superior

rectal veins leading to internal hemorrhoids

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