Va s c u l a r a n d I n t e r ve n t i o n a l R a d i o l o g y • R ev i ew

Bilhim et al.
Angiography of Male Pelvic Arteries

Vascular and Interventional Radiology

Review

FOCUS ON:

Angiographic Anatomy of the Male

Pelvic Arteries
Tiago Bilhim1,2,3 OBJECTIVE. The purpose of this article is to review the CT angiographic and digital
José António Pereira2 subtraction angiographic features of the male pelvic arteries.
Lúcia Fernandes 2,3 CONCLUSION. An increasing number of vascular procedures are being performed in
Hugo Rio Tinto 2,3 the male pelvis that require profound knowledge of the angiographic anatomy of the internal
João M. Pisco 2 iliac artery (IIA). The major branches of the IIA in men can be used to classify the branching
patterns. After the larger IIA branches are identified, identification of the smaller arteries or
American Journal of Roentgenology 2014.203:W373-W382.

Bilhim T, Pereira JA, Fernandes L, Rio Tinto H, relevant anatomic variants becomes easier.
Pisco JM

K
nowledge of the vascular anato-
my is essential to performing em-
bolization and revascularization
procedures in the male pelvis.
Pelvic arterial embolization to control se-
vere bladder, prostatic, and rectal hemor-
rhage due to neoplasms and after biopsy,
surgery, and trauma has been reported in the
last three decades. Hundreds of patients
Keywords: angiography, internal iliac artery, internal
pudendal artery, male anatomy, men, prostatic artery
have been treated with success [1–6]. Pros-
tatic arterial embolization for lower urinary
DOI:10.2214/AJR.13.11687 tract symptoms in patients with prostate en-
largement or benign prostatic hyperplasia is
Received August 7, 2013; accepted after revision
a promising minimally invasive image-
January 24, 2014.
guided therapy [7–11]. Arteriogenic erectile
T. Bilhim, H. Rio Tinto, and J. M. Pisco are paid dysfunction can be diagnosed with CT angi-
consultants for and have received speaker honoraria ography (CTA) or selective pelvic digital
from Cook Medical. H. Rio Tinto has received speaker subtraction angiography (DSA) and treated
honoraria from CeloNova Biosciences.
with angioplasty or surgery [12–17]. High-
1
Anatomy Department, Faculdade de Ciências Médicas, flow priapism is another indication for se-
Universidade Nova de Lisboa, Lisbon, Portugal.  lective pelvic arterial embolization [18].
2
Previous studies and books have focused
Interventional Radiology Department, Saint Louis
on the angiographic anatomy of the male
Hospital, Rua Luz Soriano, 182, Lisbon, 1200-249,
Portugal. Address correspondence to T. Bilhim and female pelvic arteries [19–28]. The
(tiagobilhim@hotmail.com).  purpose of this review is to provide a pic-
torial description of the male pelvic arter-
3
Radiology Department, Faculdade de Ciências Médicas, ies based on our experience with CTA and
Universidade Nova de Lisboa, Lisbon, Portugal. 
DSA in more than 300 male patients. All
WEB patients underwent both CTA and DSA with
This is a web exclusive article. selective angiography of the pelvic arteries
before prostatic arterial embolization. The
AJR 2014; 203:W373–W382
same radiologist interpreted the images
0361–803X/14/2034–W373 from all CTA and DSA examinations. This
review may be used for guidance before en-
© American Roentgen Ray Society dovascular procedures.
Anatomic Review of the Male
Pelvic Arteries
Classic anatomic descriptions of the male
internal iliac artery (IIA) are based on ca-
daveric specimens [20–24]. Several angi-
ographic studies and angiographic atlases
also focus on the anatomy of the pelvic arter-
ies [25–29]. The axial CTA anatomy of the
major branches of the IIA has also been re-
viewed [28, 29]. We believe the axial CTA
anatomy to be a key element in understand-
ing the relations between specific arteries on
CTA and DSA images.
The IIA usually ends at the superior edge
of the greater sciatic foramen by dividing
into posterior and anterior trunks that give
rise to many branches that supply most of
the pelvic viscera, the pelvic walls, the
perineum, and the gluteal region. The pa-
rietal and visceral arteries branch from the
IIA in numerous ways, and variations are
the norm. There are six parietal branches:
superior gluteal artery, inferior gluteal ar-
tery, obturator artery, iliolumbar artery, and
the superior and inferior lateral sacral ar-
teries. There are six visceral branches: in-
ternal pudendal artery, superior vesical and
inferior vesical arteries, vesiculodeferential
(or middle vesical) artery, prostatic artery,
and middle rectal (or hemorrhoidal) artery.
There are also important anatomic varia-
tions, such as accessory obturator and pu-
dendal arteries, middle rectal arteries, and
persistent sciatic arteries, which should be
identified when present [25–27].

AJR:203, October 2014 W373


Most anatomic descriptions do not con-
sider that larger or dominant arteries should
probably be addressed separately from the
smaller ones to keep things simpler and easi-
er to interpret during imaging examinations.
The tremendous variability in the male pel-
vic arteries is a major limitation when try-
ing to translate descriptions of the vascular
anatomy from cadaveric dissections into im-
aging studies.
Branching Patterns of the Internal
Iliac Artery
There have been many classifications of
the branching patterns of the IIA that have
tried to simplify the classification of all
branches of the IIA. We found the classifica-
tion used by Yamaki et al. [23] to be the most
useful and simplest for interpreting imaging
examinations [19]. In this classification, the
IIA is classified according to the branching
American Journal of Roentgenology 2014.203:W373-W382.
pattern of the three main branches: superi-
or gluteal, inferior gluteal, and internal pu-
dendal arteries. This classification is adapt-
ed from Adachi [24], who also included the
umbilical artery because it is a main branch
and a continuation of the main stem of the
IIA in embryos. The umbilical artery is the
main branch of the IIA during embryolog-
ic development, but this artery is no longer
important after birth. In adults, the umbili-
cal artery is obliterated in most part, and the
patent parts extend to the bladder (superior
vesical artery). Thus, from a clinical stand-
point, using a small artery for classification
of the IIA is not practical. The Yamaki clas-
sification [23] excludes the umbilical artery,
which allows adaptation of the original Ada-
chi classification [24], which had five types
with eight groups, into a simpler and more
useful classification with only four groups.
The four groups of the Yamaki classifica-
tion are A, B, C, and D. In group A (Fig. 1)
the IIA divides into two branches: the supe-
rior gluteal artery (posterior division) and
the common trunk of the inferior gluteal and
internal pudendal arteries (common anteri-
or gluteal-pudendal trunk, anterior division).
This is considered the basic branching pat-
tern of the IIA because it is the most frequent
(60–80%).
In group B (Fig. 2) the IIA divides into two
branches: the internal pudendal artery (ante-
rior division) and the common gluteal trunk
(posterior division) of the superior gluteal
and inferior gluteal arteries. In this group
the anterior division seems to be smaller be-
cause it consists of only the internal puden-
W374 AJR:203, October 2014
Bilhim et al.
Fig. 2—57-year-old man with group B bifurcation
of left internal iliac artery (IIA). Lateral projection
3D volume-rendered reformatted CT angiogram
shows left IIA dividing into two branches: internal
Fig. 1—62-year-old man with group A bifurcation
pudendal artery (anterior division) (thin white arrows)
of right internal iliac artery (IIA). Lateral projection
and common gluteal trunk (posterior division)
3D volume-rendered reformatted CT angiogram
(arrowhead) of superior gluteal (thin black arrow) and
shows right IIA dividing into two branches: superior
inferior gluteal (thick white arrow) arteries. Thick
gluteal artery (posterior division) (thin black arrow)
black arrow indicates obturator artery arising from
and common trunk of inferior gluteal and internal
posterior division.
pudendal arteries (common anterior gluteal–
pudendal trunk, anterior division) (arrowhead).
Common anterior gluteal–pudendal trunk bifurcates
into internal pudendal artery (thin white arrow) and
inferior gluteal artery (thick white arrow). Thick
black arrow indicates obturator artery arising from
superior gluteal artery (posterior division).
dal artery; the posterior division seems to be
larger because it consists of both the superior
and inferior gluteal arteries. Group B is the
second most frequent branching pattern, ob-
served in 15–30% of the population.
In group C (Fig. 3) the IIA simultaneously
divides into the three major branches: the su-
perior gluteal, inferior gluteal, and internal
pudendal arteries. These vessels are found in
5–7% of pelvic sides.
The group D pattern (Fig. 4) is very rare
and has only been described in one pelvic
side in cadavers (0.2%). We have seen only
one pelvic side with this variant. The IIA di-
vides into the common trunk for the superior Fig. 3—65-year-old man with group C bifurcation of
gluteal and internal pudendal arteries (ante- right internal iliac artery (IIA). Lateral projection 3D
volume-rendered reformatted CT angiogram shows
rior division) and the inferior gluteal artery IIA dividing simultaneously into superior gluteal (thin
(posterior division). black arrow), inferior gluteal (thick white arrow), and
internal pudendal arteries (thin white arrows). Thick
black arrow represents obturator artery arising from
Imaging Modalities Used for Studying superior gluteal artery.
the Male Pelvic Arteries
We usually perform CTA before DSA to arteries has also been studied with MR an-
study the vascular anatomy of the pelvic ar- giography [30–32]. However, we did not
teries and to plan and guide the DSA pro- achieve enough resolution with MR angi-
cedure. The vascular anatomy of the pelvic ography to study the smaller vessels inside

the pelvis. In addition, the lack of bony land-
marks on MR angiograms can be a limita-
tion when trying to match the findings with
the DSA findings.
American Journal of Roentgenology 2014.203:W373-W382.
Fig. 4—57-year-old man with group D bifurcation of
left internal iliac artery (IIA). Lateral projection 3D
volume-rendered reformatted CT angiogram shows
left IIA dividing into two branches: posterior division
with inferior gluteal artery (thin white arrows) and
anterior division (arrowhead). Anterior division gives
rise to superior gluteal artery (thick black arrow) and
internal pudendal artery (thin black arrows). Thick
white arrow indicates obturator artery arising from
superior gluteal artery.
Fig. 5—56-year-old man with group B bifurcation
of right internal iliac artery (IIA). Digital subtraction
angiogram of posterior division in neutral position
shows gluteal arteries. Superior gluteal artery
(thick white arrow) exits pelvis through superior
part of greater sciatic foramen and terminates
with superficial and deep muscular branches to
gluteal region (thin white arrows). Inferior gluteal
artery (thick black arrow) originates from posterior
division of IIA (group B bifurcation), exits pelvis
through inferior part of greater sciatic foramen, and
terminates in inferior aspect of gluteal region, having
numerous muscular branches (thin black arrows).
AJR:203, October 2014 W375
Angiography of Male Pelvic Arteries
For CTA examinations we use a 16-MDCT
scanner (Lightspeed, GE Healthcare). The
power settings are 100–120 kV and 200–300
mA; matrix, 512 × 512 pixels; FOV, 360 × 360
mm; voxel size, 0.7 × 0.7 × 1.25 mm; colli-
mation, 16 × 1.25 mm; and pitch, 1.3. Pow-
er injection settings are iodine contrast agent
volume, 100–120 mL (350–370 mg I/mL); in-
jection rate, 3.5–5 mL/s; and bolus triggering
in the abdominal aorta (above the renal arter-
ies). We use high threshold levels for acqui-
sition (200 HU), which require high arterial
opacification. The delay is usually 16–20 sec-
onds. A 30-mL saline flush before and after
contrast injection at the same rate as the con-
trast injection is performed in every patient.
We give the patient a vasodilator before acqui-
sition (0.5 mg sublingual nitroglycerin, Quila-
ban, Química Laboratorial Analítica Lda) to
help identify small arteries. It is important to
use high concentrations of iodine and to ad-
just the volume to patient weight to achieve
correct arterial opacification [33]. With this
protocol, the mean acquisition time is approx-
imately 13.4 seconds for a mean scanning
range of 31.3 cm. When 64-MDCT or great-
er scanners are used, it is important to adjust
the protocol, or acquisition may be too fast to
allow correct arterial opacification. Chang-
ing the pitch, the location of the bolus trigger-
ing (femoral arteries), and increasing the de-
lay after injection are some of the parameters
that may be adjusted to have a scanning dura-
tion that is not too fast (< 10 seconds). Over-
all, it takes 30–35 seconds from the contrast
injection until the end of acquisition with our
protocol. The acquired data are interpreted by
reading the axial reformats at 1.25 mm or less
in thickness, which allows study of the vas-
cular anatomy of the male pelvis. Postpro-
cessing is usually performed. We use axial,
sagittal, and coronal maximum intensity pro-
jections and volume rendering with 3D recon-
structions [34, 35].
Defining the anatomy of the male pelvic
arteries using DSA can be challenging. The
many branches of the IIA overlap, and de-
fining the best projection is important for
correct depiction of each artery. In our ex-
perience, the ipsilateral anterior oblique pro-
jection (steep oblique 35–40°) with cau-
dal-cranial angulation (–10°) allows easy
identification of the major branches of the
IIA. We use this projection to study the male
pelvic arteries and match these findings with
the CTA findings (Figs. 5 and 6). Using
neutral or contralateral oblique projections
shows overlapping IIA branches, and the im-
ages can be difficult to interpret. Instead, we
favor the use of a neutral position for the se-
lective DSA runs of the different branches of
the IIA. Most of the time, the catheter tip is
left near the bifurcation of the IIA, and io-
dine contrast injection is performed (6 mL at
3 mL/s) with nonionic contrast medium (io-
versol 350 mg I/mL). Intraarterial nitroglyc-
erin (50–200 μg) with or without papaverine
(30–100 mg) may be used to avoid spasm and
to improve depiction of smaller arteries, es-
pecially when the internal pudendal and pe-
nile arteries are being studied.
Characterization of the Arteries of
the Male Pelvis
This review is based on CTA with the cor-
responding DSA findings in the male pelvic
arteries. We first describe the larger branch-
es of the IIA and the Yamaki classification
and then the smaller branches of the IIA.
The description of the male pelvic arteries
has also been reported in previous studies,
atlases, and anatomy texts [23–27]. Howev-
er, we believe that the description of the vas-
cular anatomy of the male pelvis using both
CTA and DSA with steep oblique projections
provides a helpful tool to guide vascular and
interventional procedures.
Not all branches of the IIA are the same
size. The larger vessels used by Yamaki et al.
[23] to classify the branching patterns of the
IIA can be considered the terminal branch-
es of the IIA. Before identifying small arter-
ies it is paramount to correctly identify the
larger ones. The smaller arteries can then be
considered branches of the larger arteries.
The major branches of the male IIA are
the superior gluteal artery, inferior gluteal
artery, internal pudendal artery, and obtura-
tor artery. Although it is a major branch of
the IIA, the obturator artery was not used in
the Yamaki classification [23] because it can
have highly variable origins from inside or
outside the pelvic arteries [19].
After the larger arteries are identified, char-
acterization of the minor branches becomes
easier. These branches can be divided into
those that arise from the anterior division of
the IIA (superior vesical and inferior vesical
arteries, vesiculodeferential artery, prostatic
artery, middle rectal artery) or from the poste-
rior division of the IIA (iliolumbar artery, su-
perior and inferior lateral sacral arteries).
Superior and Inferior Gluteal Arteries
The superior gluteal artery is the largest
branch of the IIA originating from the pos-
 Bilhim et al.

A B C

Fig. 6—57-year-old man who has undergone internal pudendal artery angiography.
A, Lateral projection 3D maximum-intensity-projection reformatted CT angiogram shows internal pudendal artery (thick black arrows) making 90° curve under sciatic
American Journal of Roentgenology 2014.203:W373-W382.

notch to enter perineum. Beyond the curve, it terminates into two branches: perineal scrotal artery (thin black arrow) and penile artery (thick white arrow). Penile artery
terminates with dorsal artery of penis (thin white arrow).
B, Digital subtraction angiogram shows left internal pudendal artery with ipsilateral anterior oblique projection (35°) and caudal-cranial angulation (–10°). Internal
pudendal artery (thin white arrows) enters perineum and gives rise to muscular branches (thick white arrow). It then terminates into two branches: perineal scrotal artery
(thin black arrow) and penile artery (arrowhead). Penile artery gives rise to bulbar artery with normal capillary blush (thick black arrows) and terminates into cavernosal
artery (white curved arrow) and dorsal artery of penis (black curved arrow).
C, Axial maximum-intensity-projection reformatted CT angiogram of penile artery shows perineal scrotal artery (white straight arrows), bulbar artery with normal
capillary blush (black straight arrows), cavernosal artery (white curved arrow), and dorsal artery of penis (black curved arrow).

terior division. It follows a superiorly concave
trajectory and exits the pelvis underneath the
greater sciatic foramen above the pyriformis
muscle, has an archlike shape, and extends lat-
erally. Along its trajectory, the superior gluteal
artery gives rise to parietal muscular branch-
es, the iliolumbar artery, and the superior and
inferior lateral sacral arteries (Figs. 1–5). The
artery terminates into multiple branches op-
posite the iliac wing with several muscular
branches to the gluteal region (superficial and
deep branches). Knowledge of superior glu-
teal artery variants may help prevent vascular
damage after orthopedic operations [36].
The inferior gluteal artery is the second
largest branch of the IIA. It may originate
from the anterior (group A bifurcation) or
posterior (group B bifurcation) division of
the IIA. It follows a downward and outward
trajectory, exiting the pelvis through the in-
ferior aspect of the greater sciatic foramen,
beneath the pyriformis muscle and behind
the internal pudendal artery (Figs. 1–5). The
artery may overlap the internal pudendal ar-
tery (especially in group A bifurcations) be-
fore exiting the pelvis. An easy way to dif-
ferentiate these two arteries is to follow their
trajectory after they exit the pelvis: Where-
as the inferior gluteal artery maintains the
same trajectory downward and outward, the
internal pudendal artery reenters the pel-
vis, forming an almost 90° curve. The in-
ferior gluteal artery terminates on the infe-
rior aspect of the gluteal region, behind the
femoral neck, giving numerous muscular
branches in a downward and lateral manner
(unlike the internal pudendal artery), and
continues down the thigh, supplying branch-
es to the sciatic and posterior femoral cuta-
neous nerves [27]. Inadvertent embolization
of these branches can lead to buttock necro-
sis, nerve ischemia, and paralysis of the low-
er extremities [27, 37]. The coccygeal branch
of the inferior gluteal artery may also be a
relevant landmark for pelvic operations [38].
Anastomoses to the profunda femoris and
obturator arteries may be observed.
Internal Pudendal Artery
The internal pudendal artery is the artery
of the perineum and male external genitalia
(Figs. 1–4 and 6). It originates from the an-
terior division of the IIA and follows a down-
ward and outward trajectory, exiting the pel-
vis under the superior gluteal artery, on the
inferior aspect of the greater sciatic foramen,
beneath the pyriformis muscle, in front of
the inferior gluteal artery. It then crosses the
spine of the ischium and reenters the pelvis
through the lesser sciatic foramen. In the in-
trapelvic trajectory, it gives rise to the follow-
ing branches: superior and inferior vesical ar-
teries, middle rectal artery, prostatic artery,
and vesiculodeferential artery. In the perine-
um it has a trajectory forward, upward, and
inward in the lateral part of the ischioanal
fossa, along the inner margin of the ischio-
pubic ramus (Alcock canal). In the perineum
it gives rise to the following branches: small
muscular branches, inferior rectal artery, and
perineal scrotal artery (supplying the peri-
neal muscles, anus, and scrotum). The inter-
nal pudendal artery is also called the penile
artery from this point in its course. From an
imaging perspective, it is practical to assume
that the internal pudendal artery terminates
with two branches: the perineal scrotal artery
and the penile artery.
The penile artery gives rise to the bulbar
artery and to the urethral (spongiosal) artery.
The bulbar artery supplies the bulb of the ure-
thra, posterior corpus cavernosum, and bulbo-
urethral glands. Its recognition is easier when
the normal capillary blush is seen within the
bulbar spongiosa. The urethral artery supplies
the corpora spongiosa and forms anastomo-
ses with the dorsal artery of the penis at the
glans penis. The penile artery has two terminal
branches: deep artery of the penis (cavernosal
artery) and dorsal artery of the penis. The cav-

W376 AJR:203, October 2014

 Angiography of Male Pelvic Arteries

ernosal artery divides into helicine arteries that

enter the lacunar spaces of the corpora caver-
nosa and is the most frequently injured artery
in high-flow priapism. The dorsal artery of the
penis supplies the glans penis and prepuce.
Patients with arteriogenic erectile dysfunc-
tion have vascular lesions that may be diag-
nosed with CTA and DSA [39]. The angle
and type of origin of the internal pudendal
artery and the presence of stenoses or occlu-
sions along its trajectory or in the terminal pe-
nile branches may be amenable to endovascu-
lar treatment or surgery in well-selected cases.

Obturator Artery
The obturator artery originates from the
IIA, from the anterior or posterior divisions,
in two thirds of cases (Figs. 1–4 and 7). In A B
one third of cases it arises from the inferior
Fig. 8—67-year-old man with aberrant or accessory obturator artery in right pelvic side. Obturator artery
epigastric artery (external iliac artery), being (thick black arrows) arises from external iliac artery near epigastric artery (white arrow, A) following trajectory
called aberrant, accessory, or corona mortis toward obturator foramen; supplies parietal muscular branches (curved arrow, B); and terminates into internal
American Journal of Roentgenology 2014.203:W373-W382.

(Fig. 8). This is an important feature because
this artery is frequently injured after pelvic
trauma and may be overlooked if one looks
only inside the pelvis [40–42].
When arising from the IIA, the obtura-
tor artery follows a straight trajectory, passes
forward and downward along the rim of the
Fig. 7—54-year-old man with group A internal iliac
artery (IIA). Obturator artery is in right pelvic side.
Digital subtraction angiogram shows right IIA in
ipsilateral anterior oblique projection (35°) and
caudal-cranial angulation (–10°). Obturator artery
(thick white arrow) terminates into internal and
external muscular branches (curved white arrows)
arising from common anterior gluteal–pudendal
trunk (anterior division) (white arrowhead), which
bifurcates into internal pudendal (thin white arrow)
and inferior gluteal (thick black arrow) arteries. Thin
black arrow marks posterior division from superior
gluteal artery. Parietal muscular branches (curved
black arrow) and prostatic artery (black arrowhead)
originate from obturator artery.
and external muscular branches (thin black arrows).
A, Lateral projection 3D volume-rendered reformatted CT angiogram.
B, Selective digital subtraction angiogram shows right accessory obturator artery in neutral position.
pelvis, and exits the pelvis through the upper
border of the obturator foramen. Alongside its
trajectory it supplies branches (parietal mus-
cular branches) and sometimes the vesical and
prostatic arteries (variants). It terminates into
two branches, the internal and external muscu-
lar branches, which run along the course of the
ischiopubic and iliopubic rami with a bifurca-
tion angle of almost 90°. The typical trajectory
and termination allow easy recognition. Anas-
tomoses to the inferior gluteal and profunda
femoris arteries are frequent.
When arising from the epigastric artery (ex-
ternal iliac artery), the obturator artery follows
a trajectory first inward then vertically down-
ward to the upper border of the obturator fora-
men. The artery may have the same branches
and termination previously described.
Characterization of the Minor
Branches of the Male Pelvic Arteries
The minor branches that arise from the
anterior division of the IIA are the superi-
or vesical and inferior vesical arteries, ve-
siculodeferential artery, prostatic artery, and
middle rectal artery (described later as vari-
ants). The minor branches that arise from the
posterior division of the IIA are the iliolum-
bar artery and superior and inferior lateral
sacral arteries.
The superior vesical artery (Fig. 9) is the
main continuation of the IIA before birth,
passing into the umbilical cord (umbili-
cal artery). Postnatally, the patent parts ex-
tend to the side of the bladder, distributing
numerous branches to the body and fundus.
The inferior vesical artery frequently arises
from a common trunk with the superior vesi-
cal artery from the proximal part of the an-
terior division of the IIA, vascularizing the
bladder base. Both vesical arteries have dis-
tinct trajectories depending on whether the
bladder is distended or empty. They may
also arise from the prostatic artery (vesico-
prostatic trunk). The prostatic artery usu-
ally arises from the anterior division of the
IIA, internal pudendal artery, superior vesi-
cal artery, or obturator artery [43, 44]. It may
have a common trunk with the inferior vesi-
cal, vesiculodeferential, or middle rectal ar-
teries. It supplies the prostate gland and may
have additional branches to the bladder base,
seminal glands, rectum, and anus. To per-
form prostate embolization safely, it is im-
portant to correctly identify and differentiate
the prostatic arteries from the vesical, rectal,
and penile arteries.
The vesiculodeferential or middle vesi-
cal artery is usually a branch of the superior
vesical artery distributed to the bladder base,
distal portion of the ureters, ductus deferens,
and the seminal glands. It may also arise
from the inferior vesical artery, prostatic ar-
tery, or anterior division of the IIA.
The iliolumbar artery and the superior and
inferior lateral sacral arteries (Fig. 10) arise
from the posterior division of the IIA. The ilio-
lumbar artery is the first branch that arises from

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 Bilhim et al.

A B C

Fig. 9—66-year-old man with benign prostatic hyperplasia. Example of minor branches of anterior division of internal iliac artery (IIA).
A, Sagittal lateral maximum-intensity-projection CT angiogram of left ITA shows superior (thin white arrow) and inferior (thin black arrow) vesical arteries arise from
American Journal of Roentgenology 2014.203:W373-W382.

common trunk from proximal part of anterior division of IIA (thick white arrow) and vascularize bladder. Prostatic artery (thick black arrow) has proximal origin from
anterior division close to vesical arteries.
B, Digital subtraction angiogram shows left vesical arteries in ipsilateral anterior oblique projection (35°) and caudal-cranial angulation (–10°) and superior (black arrow)
and inferior (white arrow) vesical arteries.
C, Digital subtraction angiogram shows left prostatic artery (white arrow) in ipsilateral anterior oblique projection (35°) and caudal-cranial angulation (–10°) and
vesiculodeferential artery (black arrow).

the IIA trunk or from the posterior division. It
runs superolaterally in a recurrent manner to
the iliac fossa. At the level of L5, it divides into
an iliac branch for the iliacus muscle and ili-
um and a lumbar branch for the psoas major
and quadratus lumborum muscles. The lumbar
branch anastomoses with the fourth lumbar ar-
tery and thus may be a source of type 2 endole-
ak after endovascular aortic repair. This anas-
tomosis also becomes enlarged in aortoiliac
occlusive disease. The lumbar branch also sup-
plies a spinal branch to the cauda equina and
branches to the sacrococcygeal plexus. Embo-
lization of this artery can lead to paresthesia
and paralysis due to nerve damage [27].
The lateral sacral arteries may arise as in-
dependent branches or via a common trunk,
usually from the posterior division of the
IIA. The superior lateral sacral artery passes
inward with a medial course to enter the first
or second sacral foramen. The inferior lat-
eral sacral artery has an initial lateral trajec-
tory then passes obliquely across the front of
the pyriformis muscle and sacral nerves to
the inner side of the anterior sacral foram-
ina and descends in front of the sacrum, giv-
ing off branches that enter the anterior sacral
foramina. Both arteries supply the contents
of the sacral canal and the skin and muscles
on the dorsum of the sacrum and anastomose
with the median sacral artery (when present)
and with contralateral sacral arteries.
The median sacral artery (Fig. 11) is a small,
unpaired artery not always present; instead, it
can be replaced by the lateral sacral arteries.
This artery represents the caudal end of the
embryonic dorsal aorta, being vestigial after
birth. It usually arises from the posterior sur-
face of the distal abdominal aorta just superior
to the bifurcation. It runs vertically, anterior to
the bodies of the last one or two lumbar verte-
brae, the sacrum, and the coccyx, close to the
inferior mesenteric artery, and has a central lo-
cation. Its terminal branches anastomose with
the lateral sacral arteries and with the rectal
branches of the inferior mesenteric artery.
Important Anatomic Variants
Accessory Pudendal Arteries
Accessory pudendal arteries (APAs) are
superior to the pelvic diaphragm and take a
path posterior to the pubic bone to finally en-
ter the penile hilum. They provide a unilat-
eral or bilateral arterial blood supply to the
corpora cavernosa [45]. Two different types
of intrapelvic APAs have been identified. The
first is lateral APAs that course along the an-
terolateral aspect of the prostate and can be
found running in intimate contact with the
prostatic base and surface or closer to the en-
dopelvic fascia, a few millimeters away from
the gland (Fig. 12). The other type is apical
APAs, which are inferior and lateral to the pu-
bovesical ligaments, close to the anterolateral
aspect of the prostatic apex (Fig. 13). The role
of the APAs in erectile function recovery after
surgery remains to be proved [46].
The differences in prevalence and clinical
relevance of APAs are mainly due to the def-
inition used [47, 48]. APAs that provide the
main blood supply to the corpora cavernosa
were only found in 3.2% of the patients in
our experience. If one considers an APA any
artery located within the periprostatic region
running parallel to the dorsal vascular com-
plex [49], including large anastomoses be-
tween the vesical or prostatic arteries and the
penile artery, a higher prevalence of approxi-
mately 20–30% is observed [44, 49]. Either
way, when arterial embolization of the male
pelvic organs is being considered, any type
of APAs may be associated with unwanted
untargeted embolization to the penis. Inter-
ventional radiologists should be aware of this
anatomic variant.
Middle Rectal Arteries
In our experience, middle rectal (or hem-
orrhoidal) arteries are present in only 30–
40% of patients [50]. Most middle rectal
arteries (70%) originate from common pros-
tatorectal trunks arising from the internal
pudendal or inferior gluteal arteries or the
common anterior gluteal–pudendal trunk
(Fig. 14). They then follow an initial trajec-
tory vertically downward, change direction

W378 AJR:203, October 2014

 Angiography of Male Pelvic Arteries

A B C

Fig. 10—62-year-old man with benign prostatic hyperplasia. Example of minor branches of posterior division of internal iliac artery. Iliolumbar artery (thin white arrows,
A and C) runs to iliac fossa, where it divides into iliac branch (thin black arrows, A and C) for iliacus muscle and ilium and lumbar branch (thick white arrows, A and C)
for psoas major and quadratus lumborum muscles. Superior lateral sacral artery (black arrowheads, B and C) passes inward and enters first or second sacral foramen.
Inferior lateral sacral artery (thick black arrows, B and C) descends in front of sacrum, giving off branches that enter anterior sacral foramina.
A, Coronal maximum-intensity-projection CT angiogram.
American Journal of Roentgenology 2014.203:W373-W382.

B, Lateral projection 3D volume-rendered reformatted CT angiogram shows right pelvic side.

C, Digital subtraction angiogram shows left superior gluteal artery (posterior division) in neutral position.

transversely medially, and terminate in the
rectum, bifurcating into rectal branches that
follow a vertical downward trajectory. Anas-
tomoses to the superior rectal and inferior
mesenteric arteries are frequently found. An
anal blush in the perineum with anastomoses
to the inferior rectal artery is another distinc-
tive feature.
Persistent Sciatic Artery
A persistent sciatic artery is seen in
0.03–0.06% of individuals and represents a
rare embryologic anomaly [27, 51–53]. It is
caused by persistence of the sciatic artery,
which normally regresses after the third
month of embryologic life as the femoral ar-
tery develops from the external iliac artery.
When the femoral system fails to develop,
the sciatic artery maintains its patency af-
ter birth and becomes the main supply to the
lower extremity, and the superficial femo-
ral artery fails to develop (complete type).
In addition, failure of complete involution of
the sciatic artery may lead to the presence
of a hypoplastic sciatic artery with a pat-

A B

Fig. 11—54-year-old man with benign prostatic
hyperplascia. Sagittal maximum-intensity-projection
CT angiogram shows median sacral artery (black
arrows) arising from posterior surface of distal
abdominal aorta (thin white arrow) and running
anterior to bodies of last two lumbar vertebrae,
sacrum, and coccyx and posterior to inferior
mesenteric artery (thick white arrow).
Fig. 12—67-year-old man with benign prostatic hyperplasia. Example of right-sided lateral accessory pudendal
artery (APA).
A, Lateral projection 3D volume-rendered reformatted CT angiogram of right pelvic side shows lateral APA
(thin straight arrows) arising from internal pudendal artery (thick straight arrow) and passing behind pubic bone,
overlapping obturator artery (curved arrow).
B, Digital subtraction angiogram of right APA in ipsilateral anterior oblique projection (35°) and caudal-cranial
angulation (–10°) shows lateral APA (thin black arrows) terminating as penile artery (thin white arrow) with
dorsal artery of penis (thick white arrow) and cavernosal artery (white arrowhead). Internal pudendal artery
terminates in perineum with perineal scrotal artery and no penile artery (thick black arrow). Prostatic arteries
(black arrowheads) arise from lateral APA. Obturator artery (curved arrow) overlaps APA.

AJR:203, October 2014 W379

 Bilhim et al.

type (complete vs incomplete), unilateral or

bilateral location, and possible complications
of this variant is important to plan treatment
and avoid amputations due to complications.

Relevant Collateral Pathways

There are many potential collateral path-
ways connecting the thoracic and abdomi-
nal aorta to the IIA, the IIA from one side
to the other, and the IIA to the external ili-
ac and common femoral branches. Many of
these collaterals become enlarged and may
be visualized with CTA and DSA in cases of
aortoiliac or femoral occlusive disease [54].
The systemic to systemic collateral pathways
are intercostal arteries to deep and superfi-
cial iliac circumflex arteries; lumbar arteries
A B to iliolumbar artery to deep iliac circumflex
artery; median sacral artery to lateral sacral
Fig. 13—53-year-old man with benign prostatic hyperplasia. Example of right-sided apical accessory arteries; superior gluteal artery to inferior
pudendal artery (APA). gluteal artery to lumbar arteries to medial
American Journal of Roentgenology 2014.203:W373-W382.

A, Coronal maximum-intensity-projection CT angiogram shows apical APA (thin black arrows) arising from
distal part of obturator artery (white arrow). Apical APA runs close to apex of prostate behind pubic bone and lateral femoral circumflex arteries; and
and terminates as penile artery (thick black arrow). Bulbar artery with normal capillary blush (arrowhead) superior to inferior epigastric arteries. The
also is evident. ventral pathways are less frequently seen.
B, Digital subtraction angiogram of apical APA in ipsilateral anterior oblique projection (35°) and caudal-
cranial angulation (–10°) shows obturator artery (white arrow), apical APA (thin black arrow), penile artery They are found in more proximal aortic oc-
(thick black arrow), and capillary blush of bulbar artery (arrowhead). clusive disease and include the celiac truck,
superior mesenteric artery, and inferior mes-
ent femoral system (incomplete type). Most patients) with buttock pain and sciatic nerve enteric artery.
persistent sciatic arteries are unilateral (70– compression [27, 51, 52]. Other possible Transverse root communications con-
80%) and of the complete type (79%). This symptoms include intermittent claudication, nect the left and right IIAs at the pubic
variant can go unnoticed and be an inciden- ischemia, and a pulsating mass [51, 52]. Ste- area. They arise from distal branches of the
tal finding (50% of patients) or present clini- nosis or occlusion may be present in as many obturator or internal pudendal arteries [27].
cally after aneurysm formation (40–50% of as 10% of patients. Imaging to identify the They may be present in individuals with
normal anatomy or represent transverse
communications between the left and right
IIAs, providing contralateral circulation in
IIA occlusive disease.
The corona mortis, or crown of death, is
an entity that has been described as either an
aberrant obturator artery originating from
the external iliac system or, more broadly, as
an anastomotic branch between the external
and internal iliac systems through the obtu-
rator vessels (codominant obturator arteries
originating from both the internal and exter-
nal iliac arterial systems). This variant can
be damaged after trauma [55, 56] or surgery
[57] or cause type 2 endoleak after IIA an-
eurysm repair [58]. When the corona mortis
is present, embolization of the IIA branch-
es must be performed extremely carefully to
A B avoid unwanted embolization to the abdomi-
Fig. 14—67-year-old man with benign prostatic hyperplasia. Example of left-sided middle rectal artery. Middle
nal wall and lower extremity [59].
rectal artery (thin black arrow) arises from anterior division of internal iliac artery (arrowhead, B) and vascularizes
rectal wall (thick black arrow) with anastomoses to superior rectal and inferior mesenteric arteries (thick white Conclusion
arrow, B). Anal blush in perineum with anastomoses to inferior rectal artery also is evident (thin white arrows, B). Diagnostic and interventional radiologic
A, Axial maximum-intensity-projection CT angiogram.
B, Digital subtraction angiogram shows middle rectal artery in ipsilateral anterior oblique projection (35°) and procedures on the male pelvic arteries are
caudal-cranial angulation (–10°). becoming more frequent as prostate em-

W380 AJR:203, October 2014


bolization for benign prostatic hyperplasia
and revascularization of arteriogenic erec-
tile dysfunction become more frequently
performed. The male IIA is complex, hav-
ing many branches that may be difficult to
identify and differentiate. Profound knowl-
edge of the male vascular pelvis is necessary
to interpret and correctly identify all IIA
branches. In this study, we performed a pic-
torial review with CTA and DSA of the male
IIA branches, focusing on the imaging proto-
cols and anatomic details necessary to guide
interventional procedures.
Acknowledgment
This review reflects in part the doctoral
thesis of T. Bilhim, titled “Embolização das
artérias prostáticas no tratamento da hip-
erplasia benigna da prostata,” for the Fac-
uldade de Ciências Médicas, Universidade
Nova de Lisboa, Lisbon, Portugal, May 2011.
American Journal of Roentgenology 2014.203:W373-W382.
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