Review of pelvic_anatomy_by- dr. armaan singh

1. Complete Review of Pevic Anatomy
By- Dr. Armaan SinghBy- Dr. Armaan Singh

2. Female Pelvis
Smout et al., 1969

3. Overview

4. 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

5. 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

6. • 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
Sacroiliac Joint Accessory Ligaments

7. 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

8. 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

9.  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
Lateral Walls of Pelvis

10. 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

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

12. 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
 Waldyer’s 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

13. 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

14. 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
superficial
pouch
deep pouch
sphincter
urethrae
perineal
membrane

15. 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

16.  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
Levator Ani

17.  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
Levator Ani

18. 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

19. 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

20. 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

21. • 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
Female Bladder

22. 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,

23. 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

24. • 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
Urethra

25. Urethra
 Urethra is supported by the fascia of
the pelvic floor including pubo-
vesical 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

26.  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
Uterus

27. • 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
Uterus

28. • 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
Cervix

29. • 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
Cervix

30. Supports of Uterus
• Upper
• Round ligament
• Broad ligament anteverted
• Transverse ligament
• Pubocervical
• Uterosacral
• Lower
• Levator ani, coccygeus
• Perineal body

31. 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

32. 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

33. Transverse Ligament
 Transverse or cardinal or Mackenrodt’s
ligament
 Thickening of visceral layer of pelvic fascia
around uterine artery
 Lateral to medial in base of broad ligament

34. 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

35. Blood Supply
• Uterine from internal iliac
• Ovarian from aorta at L2
• Vaginal arteries from internal iliac
• Anterior and posterior arcuate run in middle
layer

36.  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
Blood Supply

37. 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

38. Lymphatics of Uterus and Vagina

39. Nerve Supply of Uterus
• Pain from cervix via
parasympathetic S2,3
• Pain from body via
sympathetic to T11 and
T12

40. 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

41. • 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
Contents of Broad Ligament

42.  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
Broad Ligament

43. Broad Ligament

44. 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

45. 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

46. • 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
Ovary

47.  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
Ovary

48. 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

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

50. • 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 pubo-vaginalis portion
of the levator ani
Vagina

51.  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
deep
pouch
superficial
Vagina

52. Perineum
perineal body central
point of perineum

53. 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

54. Blood and Nerve Supply Vagina
• Uterine artery
• Vaginal
• Internal pudendal
• Labial
• Ilio Inguinal nerve supplies the anterior
wall
• Labial nerves supply the posterior wall

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

56. 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

57. 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

58. 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

59.  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
Rectum

60. Blood Supply of Rectum
 Superior rectal, continuation of inferior
mesenteric artery
 Runs in Waldyer’s 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

61. 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

62. 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

63. Peri Anal Fascia
 Perianal fascia continuation of longitudinal
coat of rectum
 Medial to deep and superficial external
sphincters
 Attached at Hilton’s line
 Passes to lateral wall
 Above subcutaneous sphincter

64.  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
Anal Canal

65.  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
Muscles of Anal Canal

66.  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
Muscles of Anal Canal

67.  Upper two thirds lined by
columnar epithelium
 Lower third by skin
 Junction of two is Hilton’s 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
Anal Canal

68. 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

69. 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

70. Lymphatic Drainage
Upper third
 Pre aortic inferior mesenteric
 Waldeyer’s 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

71. 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

72. 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

73. 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

74.  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
Ischiorectal Fossa

75. 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

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

77. 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.