American Journal of Obstetrics and Gynecology (2005) 193, 67781

www.ajog.org

Arcus tendineus fascia pelvis: A further understanding

Todd S. Albright, DO, Alan P. Gehrich, MD, Gary D. Davis, MD, Farzaneh L. Sabi, MD,
Jerome L. Buller, MD
Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics/Gynecology, National
Capital ConsortiumdNIH (National Naval Medical Center, Uniformed Services University of Health Sciences,
Walter Reed Army Medical Center), Bethesda, MD
Received for publication July 24, 2004; accepted February 14, 2005

KEY WORDS
Arcus tendineus fascia
pelvis
White line
Anatomy
Rectovaginal septum
Rectovaginal fascia

Objective: The study was undertaken to further define the anatomy of the arcus tendineus fascia
pelvis (ATFP).
Study design: Thirty cadavers were dissected to find the average length, SD, and range of the
ATFP. Comparisons were made to height and pelvis type. The average distance between the
ischial spine and the attachment of the fascia of the rectovaginal septum (RVF) to the ATFP was
measured.
Results: The average length, SD, and range in centimeters for the ATFP are 9.0, 0.70, and 7 to
10.5, respectively. The length of the ATFP increased with height. No associations could be made
regarding pelvis type. The average distance between the ischial spine and the attachment of the
RVF to the ATFP is 2.15 cm with a SD and range of 0.21 and 1.75 to 2.5, respectively.
Conclusion: In this study, an average length for the ATFP is established and the distance between
the ischial spine and the attachment of the RVF to the ATFP is redefined.
2005 Mosby, Inc. All rights reserved.

The arcus tendineus fascia pelvis (ATFP), originally

termed the white line, is a brous thickening that is
made up of parietal fascia from surrounding muscles.1
These muscles are the pubococcygeous and iliococcygeous portions of the levator ani and the obturator
internus. The ATFP runs along the pelvic sidewall from
its origin near the pubic symphysis to its insertion on the
ischial spine bilaterally. Discussion regarding the ATFP

Supported by The Chief, Navy Bureau of Medicine and Surgery,

Washington, DC, Clinical Investigation Program.
The views expressed in this article are those of the authors and do
not reect the ocial policy or position of the Department of the
Navy, Department of Defense, or the US government.
Reprints not available from the authors.
0002-9378/$ - see front matter 2005 Mosby, Inc. All rights reserved.
doi:10.1016/j.ajog.2005.02.129

is sparse in anatomic texts and only 2 articles have been

dedicated to dening its anatomy.2,3 However, neither
study has accurately determined its length or attempted
to correlate its length to the pelvic morphology. Even
some of the most widely used anatomic texts do not give
an average length.4-7
The ATFP has 3 functional partsdthe anterior,
middle, and posterior segments. It is customary to refer
to the anterior segment as the most proximal and the
posterior segment as the most distal. The anterior
segment is attached to the lower posterior side of the
body of the pubic bone approximately 1 cm from the
pubic symphysis and extends posterior for approximately 3 cm. It has attachments to the proximal urethra
and anterior vaginal wall. It functions as a lateral
support for these structures. This portion of the ATFP,

678
including the histology, has been extensively studied by
DeLancey.8,9
The middle segment is approximately 3 cm long. It is
attached anteriorly to the anterolateral vagina. This
attachment becomes less prominent toward its midpoint.
At the midpoint of the middle segment, vessels from the
internal iliac artery running to the obturator internus
muscle lie laterally. When placing sutures in this area,
care must be taken to avoid going too deep into the
obturator internus muscle. At the distal end of the middle
segment are the fascial attachments of the arcus tendineous levator ani (ATLA) and the fascia of the rectovaginal septum (RVF).10 These attachments distinguish the
middle from the posterior segment of the ATFP.
The posterior segment is approximately 2 to 2.5 cm in
length and terminates on the ischial spine. It functions
as the anchor for the fascia and all of its attachments.
DeLancey noted that the distal attachment of the
posterior segment to the ischial spine is avulsed in
96% of parous women.11 This avulsion occurs primarily
in childbirth and it is remarkable that the eects of
prolapse are not seen for decades. This may in part be
due to the anchors provided by the ATLA and the
RVF. Aging, estrogen deciency, muscle atrophy, and/
or lifestyle factors involving chronic increases in intraabdominal pressure may ultimately be responsible.
The ATFP is an important factor in the support of
pelvic structures. In 1912, White rst noted its role in the
support of the bladder and proposed a technique for
cystocele repair.12 Many dierent modications have
occurred since Whites proposal. Richardson enhanced
our surgical correction with his concept of the sitespecic repair. He noted that the wide variety in
presentations of prolapse correlated with defects in the
dierent segments of the ATFP. He proposed the repair
of both cystocele and rectocele by correcting site-specic
defects in the ATFP.13-15 Given the increasing importance of the ATFP in the repair of pelvic organ prolapse,
a better understanding of this fascia is needed. The goal
of this study is to further dene the anatomy of the
ATFP and from these observations draw conclusions
concerning its function and repair.

Material and methods

Seven fresh and 23 embalmed cadavers in the anatomic
teaching laboratory at the Uniformed Services University
of Health Sciences were dissected to visualize the ATFP.
Visualization of the ATFP allowed for the following
measurements to be taken: length of the ATFP bilaterally, point of attachment of the RVF, obstetric conjugate,
biischial spine diameter, and patient height. Information
on patient age and race was also noted. Because this
information was obtained while teaching pelvic anatomy
to medical students and is consistent with the intent of the
donors, the Anatomic Materials Use Committee and the

Albright et al
Department of Clinical Investigation exempted this study
from Institutional Review Board approval.
An abdominal incision allowed access to the pelvis.
The dome of the bladder was removed, and the lateral
attachments of the midline organs were dissected, allowing visualization of the tendons entire path along
the pelvic sidewall. The path originates 1 cm lateral to
the pubic symphysis on the posterior, inferior border
of the pubic bone, proceeds lateral to the urethra in a
posterior direction, extends along the pelvic sidewall,
and ends at its insertion on the ischial spine. In many
cases, the tendon was not clearly dened along its entire
length. However, by using remnants of the tendon and
by using the ischial spine as an anatomic landmark
allowed for accurate measurement. No cadaver was
found to have detachment of the tendon from its origin
on the pubis.
First, the length of the ATFP was measured bilaterally
in centimeters while maintaining the curve of the pelvis.
Keeping the measuring tape in place, the distance between the midpoint of attachment of the RVF to the
ATFP and the ischial spine was measured. The RVF
attaches to the ATFP throughout its length. However,
this fascia condenses posteriorly. We like to refer to this
condensation as the arcus tendineus rectovaginalis. By
our observations, this posterior condensation of the
RVF is approximately 1 to 1.5 cm in width. It is the
midpoint of this condensation that attaches to the ATFP
and is where we began our measurement. Furthermore,
the obstetric conjugate and biischial spine diameter were
measured. The obstetric conjugate was measured from
the posterior inferior margin of the pubic symphysis to
the sacral promontory. The biischial spine diameter was
taken as the distance between the tips of the bilateral
ischial spines. Finally, the patients height was obtained
measuring heel to crown. Measurements of the obstetric
conjugate and the biishcial spine diameter along with
vaginal evaluation at dissection were used to diagnose
pelvis type. Information regarding pelvis type and height
were consistently obtained following the measurements
of the ATFP, and demographic data regarding the
cadavers were collected after all measurements were
taken. Demographic data were limited to the information
available to the anatomy laboratory.
Given the reported length of the ATFP to be 10 cm,
we assumed a signicant dierence in length of 0.5 cm
and a SD of 1 cm. Setting power at 80% and alpha at
.05, the necessary sample size was calculated to be 32
using the above parameters. However, because no prior
SD for the ATFP existed and noting a SD of 0.7 after
obtaining our measurements, it was found that only
16 cadavers were needed for statistical signicance.
Therefore, our results from 30 cadavers exceed the
number needed to meet statistical signicance. The
same is true for the distance at which the RVF attaches
to the ATFP.

Albright et al
Table

679

Cadaver demographics and measurements

Measurements (cm)
Age

Race

Pelvis

Height (in)

1
89
W
G
62
2
68
W
G
65
3
77
W
G
61
4
76
W
G
66
5
94
W
G
59
6
91
W
A
62.5
7
80
W
A
64
8
85
W
A
67.5
9
93
W
G
66
10
81
W
G
71
11
64
W
G
64
12
77
W
G
64.5
13
91
W
G
66
14
85
W
G
69
15
82
W
G
62
16
84
B
A
66
17
80
W
G
64
18
85
W
G
69
19
90
W
G
63
20
93
B
G
63
21
73
W
G
67
22
91
W
G
64.5
23
98
W
G
61
24
68
W
G
62
25
92
W
AND
63
26
89
W
G
65
27
74
W
G
62.5
28
76
B
A
63
29
83
W
G
66
30
71
W
G
62
Average
64.35
SD
2.668
Range
59-71
Average of right and left measurements
SD of right and left measurements

Biischial
spine

Obstetric
conjugate

ATFP
Right

ATFP
left

RVF
right

RVF
left

11
11.5
10.5
12.5
10
10
10.5
11
12.5
13
11.5
11.5
11.5
12.5
12.25
12.5
12
12
13
11.5
12.5
12
10
11.5
9.25
10.5
10.5
10
10.5
10
11.317
1.044
9.25-13

11
12
10
13
10
12.5
12.5
12.5
12
12.5
11
10.5
10
12
10.5
14
12.5
12
13
12
12
11.5
11
11
10
11.5
11
11.5
12
11.5
11.617
1.006
10-14

9
9
8
9.5
7
8
9
10
9.5
9.5
8.5
8.5
9.25
9.5
10
9.5
9
8.75
9.25
9
10.5
8.5
9
9.25
8.5
9
9.25
9.25
9.25
8.5
9.025
0.674
7-10.5
8.991
0.703

8.25
8.5
7.5
9
7
8.5
8.5
10
9.5
10
8
8.5
10
9.5
9.5
9.5
9
9
10
8.5
10
9
8.5
9
8.5
9
9
9.5
9.25
8.75
8.958
0.740
7-10

2.25
2.5
2.25
2.5
1.75
2
2
2.25
2
2.5
2
2
2.25
2.25
2
2.25
2
2
2
2
2.5
2
2
2.25
2
2.5
2
2
2.5
2.25
2.158
0.213
1.75-2.5
2.154
0.206

2.25
2.5
2
2.25
2
2
2.25
2.25
2
2.5
2
2
2.25
2.5
2
2
2
2.25
2
2
2.25
2
1.75
2
2
2.5
2
2.25
2.5
2.25
2.150
0.203
1.75-2.5

W, White; B, black; G, gynecoid; A, anthropoid; AND, android.

The average length of the ATFP and the average

distance of the attachment of the RVF to the ATFP
were computed from the measurements. SDs and ranges
were then computed. Comparisons between the lengths
of the ATFP and patient height and pelvis type were
made. Also, to account for possible dierences between
the fresh and embalmed cadavers, their average length
of the ATFP was compared. Statistical computations
were performed with SPSS 12.0 (SPSS Inc, Chicago, Ill).

Results
The 30 cadavers used for dissection were made up of 27
white and 3 black women. Their average height was
64.35 inches with a range of 59 to 71 inches. A total of
24 gynecoid, 5 anthropoid, 1 android, and no platypel-

loid pelvis types were diagnosed. Cadaver demographic

information can be seen in the Table.
The average length of the ATFP was 8.99 cm with a
SD of 0.703 cm and a range of 7 to 10.5 cm. Measurements of the right and left ATFP were obtained for each
cadaver and can be seen in the Table. Of note, the length
of the ATFP on the right and left sides showed variability. The dierence in length between the 2 sides
ranged from 0 to 0.75 cm. The average length of the
ATFP was then compared with the height of the
cadavers. Although an exact association between height
and length could not be determined, a trend toward
increasing length of the ATFP can be seen in the Table as
cadaver height increases. As for comparing length and
pelvis type, there were not enough anthropoid, android,
or platypelloid pelvises to draw any conclusions. The

680

Albright et al

Figure 2 Artistic impression of the ATFP with attachment of

the ATLA and the RVF.

Figure 1 Picture of the ATFP with attachment of the arcus

tendineus levator ani and the rectovaginal fascia. RVF,
Rectovaginal fascia; ATLA, arcus tendineus levator ani; C,
point of convergence of the ATLA and RVF onto the ATFP;
IS, ischial spine; P, body of pubic bone; V, vagina. (Modied
from Leer et al Am J Obstet Gynecol 2001;185:41-3.)

average length of the ATFP of the fresh and embalmed

cadavers was 8.88 and 9.02, respectively, P = .678. By
using P ! .05 as statistically signicant, there was no
statistically signicant dierence between the fresh and
embalmed cadavers.
The average distance of the attachment of the RVF
to the ATFP as measured from the ischial spine was
2.154 cm with a SD of 0.206 cm and a range of 1.75 to
2.5 cm. Measurements of the right and left sides of
attachment were obtained for each cadaver and can be
seen in the Table. Again, small discrepancies were
observed between the left and right distances.
Regarding the general pelvic measurements, the average length of the biischial spine diameter was 11.317
cm with a SD of 1.044 cm and a range of 9.25 to 13 cm.
The average length of the obstetric conjugate is 11.617
cm with a SD of 1.006 cm and a range of 10 to 14 cm.
The individual measurements can be seen in the Table.
No comparison was made between the average length of
the ATFP and these measurements. Rather, these measurements helped in the diagnosis of the pelvis type of
the cadaver and are noted as points of interest.

Comment
The ATFP is a point of attachment for many gynecologic
procedures. As this tendon is increasingly used in prolapse and incontinence procedures, it becomes more
important to have a thorough understanding of its
anatomic course and attachments. Ocelli et al3 dissected
2 cadavers and determined the ATFP length to be 10 cm.
This is the length that is quoted by most gynecologists in
discussions regarding the ATFP. Leer et al10 dissected
a total of 24 cadavers and determined the lengths for
anterior and posterior segments of the ATFP. A total

Figure 3 Diagram of ATFP highlighting observed vectors of

attachments.

length was not stated, but adding the anterior and

posterior segments would give a length of 8.55 cm. This
more closely resembles our nding of 8.99 cm, which is
signicantly less than the often-quoted 10 cm.
The rectovaginal septum separates the vagina from
the rectum. Its origin has been vigorously debated in
earlier literature.16-20 Here, we are concerned with its
attachment to the ATFP. We now know that defects in
this attachment result in rectocele formation. Leer
et al10 obtained an average distance of 4.8 cm for the
attachment of the RVF to the ATFP as measured from
the ischial spine. However, our observations in this
study place this point at 2.15 cm from the ischial spine.
It might be that Leer et al chose a dierent point of
reference than what was indicated in the article. Our
illustration, Figure 1, is a modication of the picture in
the article by Leer et al.10 It should be noted that the
rectovaginal septum has minor attachments to the
ATFP all along its lateral border. We measured only
the condensation of these attachments at its distal end.
We were able to consistently identify this condensation
in all cadavers. Also, we noted that condensations of the
ATLA and the RVF attach at the same point on the
ATFP (Figure 2). This observation makes inherent sense
from an engineering standpoint (Figure 3). The attachment of the RVF at a distance of 4.8 cm from the ischial

Albright et al
spine would change the forces applied to the ATFP,
making the tendon less ecient. It also places the
attachment of the RVF to the ATFP very near, if not
directly over, vessels leading to the obturator internus
muscle. This is also stated by Ocelli et al.3 Therefore,
placing sutures in an attempt to reattach RVF to the
ATFP during a posterior repair would entail a high risk
of potential catastrophic bleeding. With our ndings,
such risky placement would not be warranted. Our
results indicate no need to place sutures beyond this
attachment during a paravaginal repair. This issue has
previously been questioned by Cornella.9 We surmise
that there may be no structural benet of placing the
sutures as far back as the ischial spine.
Making associations to cadaver height further adds
information when building a model of the pelvis. Even
though a direct correlation to height could not be made,
an obvious trend toward increasing length with increasing height was seen. Because this seems to follow
reasonable logic, we believe the exceptions are most
likely caused by dierences in cadaver morphology, such
as fat, atrophy, and edema.
There are aspects of this study that could be improved. First, our measurements were taken to the
nearest quarter of a centimeter. Taking the measurements to the nearest tenth of a centimeter would have
increased accuracy. However, the change in the average
value would have been small. Second, slicing the relevant area of the pelvis into sections would provide for a
more detailed measurement, but this would have added
signicant time and cost to the study. Our dissections
did allow complete visualization for these measurements. Third, when comparing the length of the ATFP
to cadaver height, one must consider that osteoporosis
would have aected the results in this age group. It
would have been more accurate to compare the length of
the ATFP with a hip to heel length measurement of the
cadavers. Fourth, even though our study reaches statistical signicance, studies involving a larger number of
dissections that are more diverse in ethnicity and pelvic
types would truly dene a standard length of the ATFP.
Finally, the study would have been more complete by
measuring the distance of all the attachments to the
ATFP as these measurements are needed for a complete
reconstruction of a pelvic model.
Our dissection of 30 cadavers is the largest study to
date to specically examine the length of the ATFP. We
therefore propose our nding of approximately 9 cm to
be used as the current standard length. This study also

681
redenes the attachment of the RVF. By establishing an
average length for the ATFP and points of attachment,
computer modeling of the pelvis will become more
accurate and in turn will help improve on medical and
surgical therapies.

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