Urogenital TriangleMale and Female December 2, 2003

Boundaries of the Urogenital TriangleThe urogenital (UG) triangle is the anterior portion of the perineum. It contains the root of the scrotum and penis in males and the external genitalia in females. It is bounded anteriorly by the pubic symphysis, laterally by the ischiopubic ramus on each side, and posteriorly by the posterioinferior margin of the urogenital diaphragm. The urogenital diaphragm is AKA the perineal membrane. It is made up of the inferior fascia of the urogenital fossa, the external urethral sphincter, and superficial fascia. Fascia of the UG TriangleThe fascia of the UG triangle is an extension of the fascial planes seen in the abdomen. The superficial fascia consists of a superficial and deep layer. The superficial fatty tissue is still referred to as Campers fascia. In the female, the Campers fascia makes up the mons pubis and labia majora. In males, the superficial fatty layer is not as abundant in the UG triangle. In the penis and scrotum, this layer is replaced with smooth muscle called Dartos fascia. The deep layer of superficial fascia in the abdomen is Scarpas fascia. It continues into the UG triangle where it is called Colles fascia or superficial perineal fascia (Netter 360,361). The penis and clitoris are covered with superficial fascia that is continuous with the superficial perineal fascia and dartos fascia. In the penis, there is deep fascia called Bucks fascia that functions in holding the erectile tissue together in the body of the penis (Netter 363). Ligaments of the Penis/ClitorisThe fundiform ligament is a specialization of the membranous layer of Scarpas fascia that passes from the lower abdominal wall to the base of the penis or clitoris. The suspensory ligament is a specialization of the deep fascia at the proximal end of the penis or clitoris. It attaches this end to the pubis and pubic symphysis. This ligament lies deep to the fundiform ligament. In the clitoris, these ligaments are not easily seen. Anatomy of the Female External GenitaliaThe female external genitalia is collectively referred to as the pudendum or vulva. Its structures include (Netter 359, 362): Mons pubisThis is the rounded, fat pad anterior to the pubic symphysis, pubic tubercles and superior pubic rami. It is formed by the Campers fascia and is covered with coarse hairs. At puberty, the amount of fat here increases and after menopause it decreases. Labia MajoraThe labia major is a pair of prominent skin folds posterior to the mons pubis. Each labium majus is largely made up of the round ligament of the uterus and fat. The labia majora lie at the sides of the pudendal cleft, which is a slit between the two labia. The external portion of the labia majora is covered with pigmented skin and coarse hair. The internal surface is hairless and pink in color.

Labia minoraThe labia minora are folds found in the pudendal cleft between the two labia major. They are hairless and do not contain fat. The labia minora immediately surround the vestibule of the vagina. ClitorisThe clitoris is an organ containing erectile tissue. It consists of a root and body which are formed by two crura, two corpra cavernosa, and a glans clitoris. Each crus of the clitoris is the lateral part of the corpus cavernosa and is covered by ischiocavernosus muscle. The glans clitoris and clitoris body are covered anteriroly by the labia majora which form a prepuce. Posteriorly, the labia minora form a frenulum of the clitoris. The clitoris is not related functionally to the urethra and is not involved in urination. It functions only as an organ of sexual arousal. VestibuleThe vestibule is the space between the labia minora. It contains the openings for the urethra, vagina, and glands. The urethral orifice is the opening to the urethra that is located anteriorly in the vestibule. The opening to the vagina is located posteriorly in the vestibule and is called the vaginal orifice. It is partially covered by a thin membrane called the hymen. Following childbirth, the hymen exists only as a few remnants known as hymenal caruncles. On each side of the vaginal orifice is the opening to the ducts of the greater vestibular glands. These produce and release a small amount of fluid to keep the vaginal orifice moist. Anatomy of the Male External GenitaliaThe penis is a common outlet for urine and semen. The anatomical structures of the penis are as follows (Netter 363,348): Root--The penis is attached by the root which is located in the superficial perineal pouch (between the urogenital diaphragm and deep perineal fascia). Body--The body of the penis is the free portion of the penis consisting of thin skin, connective tissue, blood, lymphatic vessels, fascia, erectile tissue, and part of the urethra. Glans penis--The distal portion of the penis expands to form a conical head called glans penis. This is made up of the corpus spongiosum erectile tissue. CoronaThe margin of the glans penis is called the corona. The corona is the site of separation of the glans from the body of the penis. Near the tip of the gland is the external urethral orifice. PrepuceThe prepuce is a fold of skin that covers the glans penis. The prepuce is commonly removed by circumcision. FrenulumThis is a median fold that passes from the deep layer of the prepuce to the urethral surface of the glans.

Spongy urethraThe spongy urethra is the longest portion of the urethra that passes through the bulb and corpus spongiosum of the penis. It opens at the external urethral orifice, which is the narrowest part of the urethra. In the glans of the penis, the spongy urethra is expanded. This is called the navicular fossa (Netter 368). The scrotum is the fibrous sac that houses the testes. It is found posterioinferior to the penis and is inferior t o the pubic symphysis. The layers of the scrotum were discussed in previous lectures. The testis was also previously dissected. This is the site of sperm production and consists of several structures that are listed in the syllabus and have already been discussed in previous lectures. Erectile Bodies of the Penis/ClitorisBoth the penis and clitoris contain vascular erectile tissue. The corpra cavernosa is the pair of primary erectile bodies in both the penis and clitoris. Both the penis and clitoris have pairs of structures called crura which attach the lateral portion of the corpus cavernosum to the ischiopubic ramus and the perineal membrane (urogenital diaphragm). In the penis, the corpus cavernosa usually come together and partially fuse on the dorsal side of the penis. The corpus spongiosum is also erectile tissue of the penis and clitoris. At its distal end, the corpus spongiosum becomes the glans penis or glans clitoris. It is attached to the perineal membrane at its proximal end at the bulb of the penis and the bulb of the vestibule. In the male, the corpus spongiosusm is found on the ventral side of the penis and has the spongy urethra running through it. In the penis, the erectile tissue is surrounded by a CT layer called tunica albuginea. Around the corpra cavernosa, the tunica albuginea is thick. It is thinner around the corpus spongiosum. This is because the spongy urethra is located within the corpus spongiosum. During an erection, hydrostatic pressure builds up due to the increase in blood flow to the erectile tissue. If the corpus spongiosum were to have too much pressure, the spongy urethra could be compressed and shut, causing a back up of the ejaculate into the bladder. Superficial perineal pouchThe superficial perineal pouch is a compartment bounded superficially by the superficial perineal fascia, deep by the perineal membrane (inferior fascia of the urogenital diaphragm), and laterally by the ischiopubic ramus. It contains the crura of the penis or clitoris, muscles, viscera, blood vessels, nerves, the proximal part of the spongy urethra in males, and the greater vestibular glands in females. The muscles of the superficial perineal pouch help to support the perineal body and pelvic viscera (Netter 360, 361, 355, 366). The ischiocavernous muscle is closely applied to the superficial portion of the crura of the penis and clitoris. It originates on the medial surface of the ischial tuberosity and the ischiopubic ramus and inserts on the corpus cavernosum and the crura of the penis and clitoris. It functions in compressing the corpus cavernosum. It is innervated by the deep branch of the perineal nerve and is supplied by the perineal artery.

The bulbospongiosus muscle of the female is a pair of skeletal muscles that originate on the perineal body and the fascia of the vestibular bulb. They surround the vaginal orifice, covering the bulb of the vestibule and insert in the perineal membrane and corpus cavernosa of the clitoris. Their action is to compress the vestibular bulb and constrict the vaginal orifice. In the male, the bulbospongiosus muscle originates at the perineal body and on the midline of the bulb of the penis. It inserts on the perineal membrane, dorsal surface of the corpus spongiosum, and the deep penile fascia. Its action is to compress the bulb of the penis and the spongy urethra. In both the male and female, the bulbospongiousus is innervated by the deep branch of the perineal nerve and is supplied by the perineal artery. During childbirth, it is often necessary to make a cut in the perineum to create a wider space for the birth canal. This process is called an episiotomy and is done through the muscles. If the cut were made in other locations, the central tendinous point (perineal body) could be damaged and would no longer be able to lift up to support the pelvic viscera. The superficial transverse perineus muscle originates on the medial surface of the ischial ramus and inserts on the perineal body. Its action is to fix and stabilize the perineal body. It is innervated by a deep branch of the perineal nerve and is supplied by the perineal artery. The superficial perineal pouch contains the perineal artery and veins. The perineal artery is a branch of the internal pudendal artery that courses superficial to the superficial transverse perineus muscle alongside the perineal nerve. It supplies the muscles of the superficial perineal space. Also within the superficial perineal pouch is the artery to the bulb of the penis or clitoris and the deep artery of the penis/clitoris. The artery to the bulb of the vestibule is a branch of the internal pudendal artery that supplies the vestibule and surrounding tissues. It courses into the deep perineal space. The artery to the bulb of the penis supplies the bulb of the penis and associated structures and is a branch off of the internal pudendal artery. It also courses into the deep perineal space. The deep artery of the penis supplies the corpus cavernosum and is a terminal branch of the internal pudendal artery. The deep artery of the clitoris supplies the corpus cavernosum of the clitoris. It is also a terminal branch of the internal pudendal artery (Netter 383, 384,385). The superficial perineal pouch contains the perineal nerve and the anterior scrotal and labial nerves. The perineal nerve is a branch of the pudendal nerve. It gives rise to posterior scrotal or labial branches that supply the posterior skin of the scrotum and labium respectively. The perineal nerve also gives off a deep perineal nerve branch which innervates the muscles of the superficial perineal pouch. The anterior scrotal/labial nerves are branches of the ilioinguinal nerve which supply the skin on the posterior aspect of the scrotum and labia majora respectively (Netter 391,393). Deep Perineal PouchThe deep perineal pouch is bounded superficially by the perineal membrane, deep by the superficial fascia of the urogenital diaphragm, and laterally by the ischiopubic ramus. It contains muscles, blood vessels, nerves, the

membranous urethra and bulbourethral glands in the male, and a portion of the female vagina. The deep transverse perineus muscle is separated from the superficial transverse perineus muscles by the perineal membrane. It originates on the medial surface of the ischial ramus and inserts on the perineal body. Its action is to fix and stabilize the perineal body. It is innervated by a deep branch of the perineal nerve and is supplied by the internal pudendal artery. The deep perineal pouch contains vessel branches that arise from the internal pudendal artery and vein. These branches pass through the perineal membrane to enter the superficial perineal space where they supply the structures as described above. These vessels include: dorsal artery of the penis/clitoris, deep artery of the penis/clitoris, and artery to the bulb of the penis/vestibule (Netter 383, 384,385). The deep perineal pouch contains the dorsal nerve of the penis/clitoris and branches of the deep perineal nerve. The dorsal nerves are branches of the pudendal nerve and provide sympathetic motor innervation to the penis/clitoris (Netter 391, 393). The deep dorsal vein of the penis/clitoris is the main route by which blood is drained from the erectile tissue. It is a tributary to the prostatic/vesical venous plexus which crosses just under the pubic symphysis. The superficial dorsal vein of the penis/clitoris drain the skin and superficial fascia of the penis and clitoris. Clinical Correlates Rupture of the Urethra in Males and Extravasation of UrineA fracture of the bony pelvis can cause rupture to the intermediate portion of the urethra. This results in leakage of urine and blood into the deep perineal pouch. The spongy urethra commonly ruptures at the bulb of the penis. This is often due to an injury that results from a forceful blow to the perineum (a straddle injury). The rupture of the spongy urethra results in the passage of urine into the superficial perineal space. Urine can pass into the loose connective tissue of the scrotum, around the penis, and into the Scarpas fascia of the abdomen. Urine cannot pass into the thighs or posteriorly into the anal triangle because of the way their fascia is arranged. Blood can also pass in the same areas if a vessel is ruptured into the superficial perineal pouch. Anal Fissures and Perianal Abscesses(Part of yesterdays lectures, I accidentally left it off!); The ischioanal fossa is sometimes the site of infection due to an abscess (accumulation of pus). The ischioanal fossa can become infected in many ways including inflammation of the anal sinuses, a pelvirectal abscess, a tear in the anal mucous membrane, and a penetrating wound in the anal region. Urethral CatheterizationA catheter is done to remove urine in a person who cant urinate (micturate), to irrigate a bladder, or to obtain a sample of blood that isnt contaminated. When inserting a catheter, one should be aware of the curves in the urethra in order to prevent injury.

Distension of the ScrotumThe scrotum is easily distended. Some causes of distension include indirect inguinal hernias and inflammation of the testis due to infection or bleeding. Palpation of the TestisThe testis can be palpated through the soft, pliable scrotum. The right testis normally is located at a higher level than the left. Erection, Emission, and EjaculationDuring stimulation in a male, the AV anastamoses are closed so that blood cannot bypass the corpora cavernosa as normal. As a result, blood flows into the arteries and causes the cavernous spaces of the corpora in the penis to dilate. The bulbospongiosus and ischiocavernosus muscles compress the venous plexuses and impede venous blood return. The result is that the corpora cavernosa and corpus spongiosum become enlarged, rigid, and the penis becomes erect. Emission is the process by which semen is delivered to the prostatic urethra through the ejaculatory ducts. The prostate adds fluid to the seminal fluid as the smooth muscle of the prostate contracts. Ejactulation involves the expulsion of the semen from the urethra through the external orifice. This is due to sympathetic and parasympathetic innervation. The penis will gradually return to a flaccid state following the ejaculation, the arteries will constrict, the muscles will relax, and more blood will flow into the veins. HypospadiasA congenital anomaly of the penis in which the external urethral orifice is on the ventral aspect of the penis or another abnormal location. This results from the failure of fusion of the urogenital folds during development. Phimoisis, Paraphimosis, and CircumcisionPhimosis is a condition in which the prepuce fits tightly over the glans penis and cannot be retracted. Paraphimosis is the retraction of the prepuce over the glans such that it constricts the neck of the gland, causing problems with drainage of blood and tissue fluid. This leads to an enlargement of the glans penis so that the prepuce cannot be drawn back over it. Circumcision is the surgical excision of the prepuce and is often performed on male infants for religious reasons or just for hygiene reasons. Perineal Injuries During ChildbirthDuring childbirth, the mothers perineal body can be torn resulting in permanent weakness of the pelvic diaphragm. If it is obvious that a perineal body tear will occur during childbirth, an episiotomy will be performed as described above. VaginismusThis is involuntary spasms of the perivaginal and levator ani muscles. The bulbospongiosus and transverse perineal muscles are thought to be responsible for this condition which can cause dysparenunia in mild cases and prevents vaginal entry in more severe cases. Female CircumcisionThis involves the removal of the prepuce of the clitoris, and also part or all of the labia minora and clitoris. This disfiguring procedure is illegal, but is widely practiced in many cultures because it is thought to inhibit sexual gratification. Dilation of the UrethraThe female urethra is distensible because of the amount of elastic tissue and smooth muscle it contains. Because of this, it is often easier to insert

catheters and cytoscopes in females. The female urethra is easily infection b/c it is open to the exterior through the vestibule of the vagina. Infection of the Greater Vestibular GlandsThe greater vestibular glands are palpable when they are infected. These glands are the site or origin of most vulvar or adenocarcinomas. Inflammation of these glands is called bartholinitis. These glands can also become occluded due to the accumulation of mucin; this is called a Bartholins cyst. Pudendal and Ilioinguinal Nerve BlocksIn order to relieve some of the pain of childbirth, a pudendal nerve block can be performed by injecting an anesthetic medication into the tissue around the pudendal nerve near the ischial spine. An ilioinguinal nerve block is done to decrease sensation in the anterior part of the perineum. Anorectal IncontinenceDuring a traumatic childbirth, the pudendal nerves can become stretched and damaged. This may lead to anorectal incontinence. Vulvar TraumaTrauma in the vulvar area can lead to disruption of the vessels to the bulbs of the vestibule. Injuries such as this often result hematomas in the vulvar structures.