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(ImagecontributedbyLauraAvery,MD,DepartmentofRadiology,Massachusetts
GeneralHospital.)
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TRANSITIONTOTHEPCEANATOMY
7.INFRAPERITONEALREGIONANDPERINEUM
Case
54yearoldmanwithnoPMHbroughttotheEmergencydepartmentforevaluationofabdominalpainaftera
multivehicleaccident.Heisapoliceofficerwhowasarestraineddriverinpursuitafterabankrobberywhenhe
lostcontrolofhisvehicle,strikingawallathighvelocity.Hehadimmediatelowerabdominalandpelvicpainat
thelevelofhislapbelt.Physicalexamisnotableforsignificantevolvingecchymosisinahorizontalband
stretchingapproximately4cmbelowhisumbilicus(CasewrittenbyCynthiaCooper,MD,MassachusettsGeneral
Hospital).
Acystogramstudyisorderedtobetterdefinetheinjury,andcontrastisinstilledintothebladderthroughaFoley
catheter.Asyoureviewtheimageswiththeradiologyresident,sheasksyoutopointoutanyintraperitoneal
contrastmaterialandtoexplaintherouteofthecontrastmaterialfromcathetertoperitonealcavity.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Figure71.Organizationofthepelvisandperineum.(SubstantiallymodifiedfromNetterAtlasofHumanAnatomy,
6thEdition.Philadelphia:Elsevier,2014.)
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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5.ORGANIZATIONOFTHEINFRAPERTIONEALREGION
ANDPERINEUM
5.1.ORGANIZATIONOFTHEINFRAPERITONEALREGIONANDPERINEUM
Organization
Infraperitonealregion.Thepelvisisasmallregion,crowdedwithmanyanatomicalstructures,andfurther
complicatedbytheterminologyusedtodescribeit.Thetermpelvis[Latin,pelvis,abasin)canbeusedtorefer
tothelowerportionofthetrunkwall,toabonyringconsistingofthetwohip(innominate)bonesandthe
sacrum,tothelimbgirdleattachingthelowerlimbtotheaxialskeleton,ortotheinferiormostportionofthe
abdominopelviccavity.
Forthisdiscussion,thetermpelviccavitywillrefertothenarrowspaceenclosedbythebonypelvisandthe
musclesofthepelvicsidewallsandpelvicfloor(Figure71).Theterminfraperitonealregionwillrefertoamore
extensiveterritoryincludingthepelviccavityandextendingupwardtotheinferiorboundaryoftheperitoneal
sac.Thecontentsoftheinfraperitonealregionincludethepelvicbones,theskeletalmusclesofthepelvic
sidewallsandpelvicfloor,thepelvicorgans,neurovascularstructures,andtheextraperitoneal(infraperitoneal)
looseconnectivetissuesurroundingandstabilizingthepelviccontents.
Inbothsexes,thepelvicorgansincludethebladder,urethra,andrectum.Thefemalepelvicorgansincludethe
ovaries,uterinetubes,uterus,andvagina(Figure71,upperimage).Themalepelvicorgansincludethe
prostate,seminalvesicles,andpelvicportionsoftheductusdeferentes(vasdeferens)(Figure71,lower
image).
Perineum.Theslopingpelvicfloor,consistingofthecoccygeusandlevatoranimuscles,providestheboundary
betweentheinfrapertionealregionsuperiortothepelvicfloorandtheperineuminferiortothepelvicfloor.The
perineumistheregionbetweenthepelvicfloorsuperiorly,theinferiorportionofthepelvicsidewallslaterally,
andtheperinealskininferiorly.
Thecontentsoftheperineumincludetheskeletalmusclesphinctersoftheurethra,vagina,andanalcanal,the
erectiletissueofthefemaleandmaleexternalgenitalia,theskeletalperinealmusclescoveringtheexternal
genitalia,theneurovascularsupplytotheperinealstructures,andlooseconnectivetissuecontinuouswiththe
subcutaneousfat.
Dissectionstrategy
Inthislaboratory,youwillcompleteyourstudyoftheabdominopelviccavityandperitonealsac,beginningwith
theinferiorportionoftheperitonealsacanditsrelationshiptothemaleandfemalepelvicorgans.Youwillnext
completeyourstudyofthelayersandregionsoftheabdominopelviccavitybyliftingtheperitonealsacoffthe
pelvicorgansandexploringtheinfraperitonealconnectivetissuesurroundingandsupportingthepelvicorgans.
Youwillfirststudythepelvicorgans,theiranatomicalrelationships,andneurovascularsupplyinyouranatomical
donor,andalsostudytheperinealanatomyofyourdonorincludingtheexternalgenitaliaandtheexternal
orificesoftheurethraandanalcanal.Whenyouhavefinishedthestudyofyourownanatomicaldonor,you
shouldstudythepelvicandperinealanatomyofadonoroftheoppositesex.
Weknowthat,formanyreasons,thepelvisandperineumaretechnicallyandemotionallychallengingregionsto
dissect.Yourcolleagueswillincludestudentsofvaryinglevelsofsexualexperienceanddifferentsexual
orientations.Someofyourclassmatesmayhaveexperiencedsomeformofsexualtrauma.Yourcustomary
sensitivityandtactwillbeparticularlywelcomeduringthislab.Pleaseletyourinstructorsknowifwecanhelp.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Otheranatomycourseshaveadoptedamuchmoreinvasiveapproachtodissectingthepelvisandperineum.In
Foundationsanatomy,wehaveadoptedalessinvasiveapproachthatmorecloselyparallelsactualsurgical
practice.
Figure72.Bones,ligaments,andmusclesofthepelvicsidewallandpelvicfloor,medialview.(Substantially
modifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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5.2.MUSCULOSKELETALPELVIS
Pelvicbones,ligaments,andmembranes
Theadultbonypelvisisanirregularring,consistingofthepairedhip(innominate)bonesanteriorlyandlaterally,
andfivefusedsacralvertebraeand35coccygealvertebraeposteriorly(Figures72and73).
Eachadulthipboneconsistsofthreeseparatebones,theilium,ischium,andpubis,whichfuseinlate
adolescence(Figure72).Instandardanatomicalposition,averticallinethroughtheanteriorsuperioriliacspine
intersectsthepubictubercle,andthepelvicinlet(pelvicbrim)facesmoreanteriorlythansuperiorly.Ifthepelvis
isabasin,thebasinistipped.
Pelvicjoints.Theleftandrighthipbonesmeetanteriorlyatthepubicsymphysisandformthesacroiliacjoints
posteriorly(Figure72).Thepubicsymphysisisafibrocartilaginousjointthatpermitsonlyslightstretchingand
compression.Theleftandrightsacroiliacjointsaresynovialjointsthatpermitonlyslightgliding.
Pelvicinlet,pelvicoutlet,andpelviccavity.Thewingsoftheiliacbonesliesuperiortothepelvicinletand
surroundthe'falsepelvis',thelowerportionofabdominalcavity
Theboundariesofthepelvicinlet(pelvicbrim)arethesuperiormarginofthepubicsymphysisandpubic
bonesanteriorly,thearcuatelinebetweentheiliumandischiumlaterally,andthesacrumposteriorly.
Theboundariesofthepelvicoutletaretheischiopubicramiandsacrotuberousligamentslaterally,andthetip
ofthecoccyxposteriorly.Thepelviccavity('truepelvis')lieswithinthebonypelvisbetweenthepelvicinlet
andpelvicoutlet.
Pelvicdenseconnectiveligamentsandmembranes.Thepelvicligamentsandmembranesaresturdydense
connectivetissuestructures(Figures72and73).Theobturatormembraneclosestheobturatorforamenexcept
forasmallpassage,theobturatorcanal.Thesacrotuberousligamentattachestheischialtuberositytothe
sacrumandposteriorilium.Thesacrospinousligamentattachestheischialspinetothesacrum.Theperineal
membraneclosestheanteriorportionofthepelvicoutletbetweentheischiopubicrami,exceptfortheopenings
oftheurethrainbothsexes,andthevaginainfemales.Theperinealbodyisaknotoffibromuscularconnective
tissueattheposteriormarginoftheperinealmembrane.
Openingsbetweenthepelvicbonesandpelvicligamentsallowneurovascularstructuresandmusclestotravel
betweenthepelviccavityandtheperineum(lessersciaticforamen)andbetweenthepelviccavityandlowerlimb
(obturatorcanal,greatersciaticforamen,andintervalbetweenthepelvicinletandinguinalligament).
Pelvicsidewalls
Thepelvicsidewallsareformedbythelateralportionofthebonypelvis,theobturatormembrane,andtwo
lowerlimbmusclesthatariseontheinternalsurfaceofthebonypelvis,passthroughpelvicapertures,andinsert
onthefemur(Figures72and73).
Thepiriformismusclearisesontheinternalsurfaceofthesacrum,leavesthepelviccavitythroughthegreater
sciaticforamen,andinsertsontheposteriorfemur.
Theobturatorinternusmusclearisesontheinternalsurfaceoftheobturatormembrane,leavesthepelvic
cavitythroughthelessersciaticforamen,andinsertsontheposteriorfemurneartheinsertionofthe
piriformismuscle.
Contractionofthepiriformisandobturatorinternusmusclesexternallyrotatesthelowerlimbatthehipjoint.
Table71,intheAppendixforthislabmanual,summarizestheactions,innervation,andattachmentsofthe
pelvicsidewallmuscles.
Innervation.Thelowerlimbmuscles,includingpiriformisandobturatorinternus,areskeletalmusclesreceiving
somaticsensoryandsomaticmotorinnervationfrombranchesofthelumbosacralnerveplexus.Youwillstudy
thelowerlimbmuscles,andthelumbosacralnerveplexus,duringLabs8and9.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Figure73.Bones,ligaments,andmusclesofthepelvicsidewallandpelvicfloor,superiorview.(Substantially
modifiedfromNetterAtlasofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Pelvicfloor
Theskeletalmusclesofthepelvicfloorincludethecoccygeusandlevatoranimuscles(Figures72and73).The
pelvicfloormusclesclosethepelvicoutletposteriortotheperinealmembrane,exceptfortheopeningofthe
anus,andthelevatoranimusclealsoplaysanimportantroleinmaintaininganalcontinence.
Thebonyattachmentsofthepelvicfloormusclesincludethepubis,ischialspine,andcoccyx(Figure73).
Betweenthepubisandtheischialspine,levatoraniattachestothetendinousarchoflevatorani,athickeningof
theobturatorinternusliningfascia.Table72,intheAppendixforthislabmanual,summarizestheactions,
innervation,andattachmentsofthepelvicfloormuscles.Youarenotrequiredtolearnthemuscleattachments
indetail.
Theslopingpelvicfloorsupportstheconsiderableweightoftheabdominalandpelvicorgans.Contractionofthe
levatoranimusclesraisesthepelvicfloorand,incooperationwiththeanterolateralabdominalwallmuscles,
decreasesthevolumeoftheabdominalcavityandincreasesintraabdominalpressure,forexampleduringa
Valsalvamaneuver.
Thepuborectalisportionofthelevatoranimuscleformsaslingaroundtherectum,drawingtheanorectal
junctiontowardthepubis,positioningtherectumobliquely,ratherthanvertically,andformingasharpkinkthat
narrowsthelumen.Thepubovaginalisandpuboprostaticusmusclesformsimilar,iflesssubstantial,slingsand
mayplayaroleinmaintainingurinarycontinence.
Innervation.Thepudendalnerve,abranchofthelumbosacralplexus,providesmotorinnervationtothepelvic
floormuscles.
5.3.INFRAPERTIONEALREGION
Peritoneum
Theinferiorportionoftheperitonealsacdrapesthesuperiorsurfacesofthepelvicorgans,formingtheroofof
theinfrapertionealregion(Figures71and74).
Theparietalperitoneumliningtheanteriorabdominalwallreflectsontothebladdertocoveritssuperiorsurface
asvisceralperitoneum(Figures74and75).Exceptforitssuperiorsurface,thebladderisanextraperitoneal
organembeddedinthelooseconnectivetissueinferiortotheperitonealsac.
Thesigmoidmesocolongraduallyshortensasitapproachestherectum,andtherectumhasnomesentery
(Figure74).Visceralperitoneumcoverstheanteriorandlateralsurfacesoftheproximalrectumandtheanterior
surfaceofthemiddlerectum,thenreflectsanteriorlyontotheuterusinfemales(Figure74,upperimage)orthe
bladderinmales(Figure74,lowerimage).
Infemales,visceralperitoneumcoversthesurfacesoftheovaries,uterinetubes,anduterus(Figure74,upper
image).Lateraltotheuterus,theperitoneumformsadoublelayeredperitonealfold,thebroadligamentthat
extendsfromtheuterustothepelvicsidewalls,whereitiscontinuouswiththeparietalperitoneum.
Neurovascularstructurestravelwithinthebroadligamenttosupplythefemalepelvicorgans.Thevaginalies
inferiortotheperitonealsac,withintheinfraperitonealconnectivetissuebelowtheperitonealsac.
Inmales,onlythesuperiortipsoftheseminalvesiclescontacttheperitonealsac,ifatall.Theprostate,the
remainderoftheseminalvesicles,andthepelvicportionsoftheductusdeferentes(vasdeferens)liewithinthe
looseconnectivetissueinferiortotheperitonealsac.
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Figure74.Femalepelvis,superiorviewandmalepelvis,superiorview.(SubstantiallymodifiedfromNetterAtlas
ofHumanAnatomy,6thEdition.Philadelphia:Elsevier,2014.)
AdaptedfromClinicalAnatomy:TheLogicalApproach.T.VanHouten,1997.Allrightsreserved.
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Peritonealreflectionsandrecesses.Blood,excessperitonealfluid,andotherfluidstendtocollectinthe
peritonealrecessessuperiortothepelvicorgans.Infemales,thevesicouterinerecessisformedwherethe
visceralperitoneumreflectsoffthesuperiorsurfaceofthebladderandontotheanteriorsurfaceoftheuterus
(Figure74,upperimageandFigure76,upperimage).Therectouterineperitonealrecess(pouchofDouglas)
formswherethevisceralperitoneumreflectsofftheanteriorsurfaceoftherectumandontotheposterior
surfaceoftheuterus.
Inmales,therectovesicalrecessformswherethevisceralperitoneumreflectsofftheanteriorsurfaceofthe
rectumandontothesuperiorsurfaceofthebladder(Figure74,lowerimageandFigure76,lowerimage).
Hysterectomy
Hysterectomyissurgicalremovaloftheuterus.Hysterectomywithbilateralsalpingooophorectomyisremovalofthe
uterus,uterinetubes,andovaries.Hysterectomymaybeperformedasanopenabdominalprocedure,asaminimally
invasivelaparoscopicprocedure,orthroughavaginalapproach.Hysterectomywasconsideredarelativelyroutine
procedureinthedecadeswhenmanyofourfemaledonorsenteredmiddleage.
Identifyingperitonealregionsandrecesses