As we all know, Dr. K talks pretty fast and it’s hard to take notes, but I did what I could
using multiple old Co-Ops and relistening to the lecture (it wasn’t easy). Have a great
Thanksgiving break (and if you are looking at this while you’re on break, STOP and
enjoy yourself)!
Female Male
Pelvic Inlet Oval Heart-shaped
Longer transverse diameter
Pelvic Outlet Longer A-P diameter Shorter A-P diameter
Longer transverse diameter Shorter transverse diameter
Pelvic Cavity Divergent as proceed from the Convergent (funnel-shaped)
inlet to the outlet (cylindrical)
Pubic Arch > 90 degrees < 90 degrees
1. Gynecoid
a. Most common female shape
2. Android
a. Most common male shape
3. Anthropoid
a. Long A-P diameter and short transverse diameter.
b. Higher risk for occiput posterior deliveries (babies face up).
4. Platypelloid
a. Very dysfunctional pelvis when it comes to obstetrics
b. Gestational age dependent
c. Often require C-section for delivery
Muscular Pelvis:
1. Piriformis
1. Originates from the lateral aspect of the sacrum
2. Passes (“exits”) through the greater sacrosciatic foramen
3. Interdigitations through which the nerves and arteries pass
a. Correlate well with the foramina
2. Obturator Internus
1. Passes (“exits”) through the lesser sacrosciatic foramen
3. Greater Canter of the Femur
1. Place of attachment for both the piriformis and the obturator internus
2. We should be able to see this clearly with the gluteal dissection
1. Pelvic diaphragm
• Creates 2 spaces:
1. Intra-pelvic (visceral) space superior to the pelvic
diaphragm
a. Structures (such as uterus, rectum, urethra) are within
this space
2. Ischiorectal (ischioanal) space (fossa) inferior to the pelvic
diaphragm
a. Filled primarily with fat and covered by the gluteus
maximus
b. Running through this area are structures including
branches of the pudendal nerves and arteries, and the
hemeroidal arteries
• Muscles of the pelvic diaphragm:
a) Levator ani muscles (main part of the pelvic diaphragm)
1. Pubococcygeus m.
a. Originates by the pubis, comes back to the coccyx
b. Bilateral
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2. Puborectalis m.
a. Part of Pubococcygeus m.
b. Described as a condensation or the formation of a sling
c. Pulls rectum anteriorly, helping to maintain rectal
continence
3. Iliococcygeus m.
b) Coccygeus m. (also known as Ischiococcygeus m.)
(This muscle is NOT a component of Levator ani
muscles)
**Remember: The pelvic diaphragm is the primary support for the pelvic viscera!!
5. Urogenital Diaphragm – is also known as the deep pouch (space) and it fills in an
anterior defect in the pelvic diaphragm
1. Comprised of muscle, so there is a fascia on either side
a. Fascia of the UG diaphragm is composed of 2 layers:
1. Superior fascia
2. Inferior fascia (also known as perineal membrane)
**Anything inferior to the inferior fascia and just deep to the skin is part of the
Superficial Pouch (Space)!**
a) Continuous with Scarpa’s fascia along the anterior abdominal
wall
** The fascia of the superficial pouch is contiguous with Scarpa’s fascia on the
anterior abdominal wall. Thus, a male who damages the urethra in a “straddle injury”
will have a uroma (pool of urine) that can extend up the anterior abdominal wall.
Similarly, a female who has a “straddle injury” can have blood extend up the anterior
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abdominal wall.**
7. Building up of the layers of the pelvic diaphragm and UG diaphragm (notes p. 17)
2) Lumbosacral trunk
* L4-L5, joins up with S1-S3.
5) Pudendal anesthesia
1. Dealt with very easily during the second stage of labor
2. Done through a catheter or a sleeve by palpating the sacrosciatic area
(notch), going into the sacrospinous ligament and then you can actually
get the anesthetic back near the pudendal n.
A. Aorta terminates as the common iliac arteries that bifurcate into the
external and internal iliac aa. (int. iliac a. = hypogastric a.)
B. The external iliac is going to give rise to the deep circumflex a. and the
inferior epigastric a.
1. Inferior epigastric is one of the first branches you see as an
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anastomosis
C. Internal iliac a. (hypogastric a.) splits into anterior and posterior divisions:
1) Anterior Division:
a. Umbilical a.
a) Runs until the level of the pubic symphysis, then
becomes obliterated as the medial or lateral umbilical
ligament
b) Also sends branches to the bladder
b. Obturator a.
a) Follows the obturator n. through the obturator canal
and supplies the medial area of the thigh
b) Also gives off vesicular branches to the bladder
c. Pudendal a.
a) Hemmorhoidal aa.
d. Inferior and posterior gluteal aa.
e. Vaginal a.
f. Uterine a.
g. Middle rectal a.
**Also, “Water runs under the bridge” (Males: ureter runs under Vas
Deferens, females: ureter runs under Uterine artery)
2) Posterior Division (easier to remember this and know others come from
ant.):
a. Iliolumbar a.
b. Lateral sacral a.
c. Superior gluteal a.
Pelvic Viscera
1. Female pelvis
A. The Uterus (has 3 parts: cervix, body, and fundus)
1) Visceral peritoneum is thrown up on the uterus and goes behind the uterus
a. Called the broad ligament
1. Fold of visceral peritoneum
2) Ligaments:
1. Broad ligament
a. Composed of an anterior and posterior leaf
1. It is a sheet of visceral peritoneum folded over (remember the
uterus and fallopian tubes are covered with peritoneum –
they are retroperitoneal)
2. Suspensory ligament of uterus
3. Round ligament – extends laterally from the uterus anterior to the
fallopian tube (which is anterior to the ovary). This is important to
remember so that you won’t tie off the wrong structure in a tubal ligation!
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4. Uterosacral ligament (also known as sacrouterine ligament or
sacrocervical ligament) – extends from cervix to sacral area; supports the
uterus and vagina
3. Blood supply
a. Uterine a. – primary source of blood to the uterus
1. Bifurcates at the level of the uterus into:
a. Descending branch
1. Anatomoses with vaginal a.
b. Ascending branch
1. Joins the ovarian artery to become the uteroovarian a.
5. Spaces or Pouches
1. When doing gynecology, the goal is to create these spaces
a. Once one creates these spaces, dissection and surgery can be
done with relative impunity
1. Paravescicular space
a. Surrounding the bladder
b. Create this space when trying to identify the
blood vessels to the uterus
1. Particularly true in radical surgery when
you’ve got to remove a patient’s bladder,
cervix, uterus, and rectum in cases
that are referred to as exoneration for various
gynelogical malignancies such as cervical
cancer and advanced uterine cancer
2. Retro space of Sylvius (Retropubic space)
a. Can cause you problems at the time of caesarian
when you’re trying to dissect down and
identify the direction to go. It is quite
vascular and bleeds a lot
1. Most common cause of bleeding in this
area is from the retractor.
3. Space of Douglas
a. Space between the cervix and the rectum
4. Pararectal Space
a. Important for colorectal surgeons (cancer, etc.)
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Bladder
Rectum
Note: **Distal 1/3 of rectum not covered by peritoneum and rectum
does not go through the UG diaphragm.**
1. Contains 3-4 incomplete valves that are important for maintaining continence
2. Anal region has blood vessels (responsible for hemorrhoids)
3. External Anal Sphincter (voluntarily controlled):
a. Deep, Internal, Superficial components
4. Internal Anal Sphincter (involuntarily controlled)