THE PELVIS: PART I THE PELVIC WALLS
foramina
BASIC ANATAOMY
The pelvis
- Main function
o Transmit the weight of the body from the
vertebral column to the femurs
o Contains, supports, and protects the pelvic
viscera
o Provides attachment of trunk and lower limb
muscle
- Two bony pelvis is composed of four bones
o Two hip bones
Form the lateral and anterior walls
Articulate with each other
Anteriorly: symphysis
pubis
Posteriorly: with sacrum
at the sacroiliac joints
o Sacrum and coccyx
Part of vertebral column and form
the back wall
- Word pelvis means a basin
- Divided into 2 parts by pelvic brim
o Which is formed by
Sacral promontory (anterior and
upper margin of S1) behind
Iliopectineal lines (a line that runs
downward and forward around
inner surface of ileum) laterally
Symphysis pubis (joint between
bodies of pubic bones) anteriorly
o Above the brim is the false pelvis
Forms the part of the abdominal
cavity
o Below the brim is the true pelvis
Orientation of the Pelvis
- The front of symphysis pubis and anterior superior
iliac spines should lie in the same vertical plane, This
means that
o Pelvic surface of symphysis pubis faces
upward and backward
o Anterior surface of sacrum is directed
forward and downward
False pelvis
- Is of little significance
- Bounded
o Behind by lumbar vertebrae
o Laterally by iliac fossae and iliacus muscle
o Front by lower part of anterior abdominal
wall
- Flares out at its upper end
- Should be considered as part of abdominal cavity
- Support the abdominal contents and after 3 rd month
of pregnancy helps support gravid uterus
- During early stage of labor, helps guide the fetus into
true pelvis
True pelvis
- Has an inlet, outlet, and a cavity
- Pelvic inlet (pelvic brim)
o Bounded
Posteriorly by sacral promontory
Laterally by iliopectineal line
Anteriorly by symphysis pubis
- Pelvic outlet
o Bounded
Posteriorly by coccyx
Laterall by ischial tuberosities
Anteriorly by pubic arch
Anteriorly is between
ischiopubic rami
Laterally are the sciatic
notches
o Divided
sacrotuberous
and sacrospinous
ligaments into
greater and
lesser sciatic
o Has 3 wide notches
o Diamond shaped
Ischiopubic rami and symphysis
pubis forming boundaries infront
Sacrotuberous ligaments and
coccyx forming boundaries behind
- Pelvic cavity
o Lies between the inlet and outlet
o Short, curved canal, with a shallow anterior
wall and a much deeper posterior wall
Structure of the pelvic walls
Anterior pelvic wall
- The shallowest
- Formed by bodies of pubic bones, pubic rami, and
symphysis pubis
Posterior pelvic wall
- Extensive and is formed by sacrum and coccyx and
by piriformis muscles and their covering of parietal
pelvic fascia
- Sacrum
o Consists of five rudimentary vertebrae fused
together to form a single wedge-shaped
bone with forward concavity
o Upper border or base of bone articulates
with 5th lumbar vertebrae
o Narrow inferior border articulated with
coccyx
o Laterally, articulates with two iliac bones to
form the sacroiliac joints
o Sacral promontory
Anterior and upper margins of first
sacral vertebra bulge forward as
the posterior margin of pelvic inlet
An important obstetric landmark
used when measuring the size of
pelvis
o Vertebral foramina together form the sacral
canal
Contains the anterior and posterior
roots of lumbar, sacral, and
coccygeal spinal nerves
Contains filum terminale, and
fibrofatty material
Contains the lower part of
subarachnoid space down as far as
lower border of 2nd sacral vertebra
o Lamina of 5th sacral vertebra, sometime 4 th,
fail to meet in the midline, forming the
sacral hiatus
o Anterior and posterior surface possess on
each side four foramina for passage of
anterior and posterior rami of upper four
sacralnerves
o Usually wider in proportion to its length in
female than in male
o Tilted forward so it forms an angle with 5 th
lumbar vertebra, called lumbosacral angle
- Coccyx
o Consists of four vertebrae fused together to
form a small triangular bone
o Articulates at its base with lower end of
sacrum
o Its vertebra consists of bodies only
But 1st vertebrae possesses a
rudimentary transverse process
and cornua (remains of pedicles
and superior articular processes , t
project upward o articulate with
sacral cornua)
- Piriformis muscle
o Origin: front of lateral mass of sacrum and
leaves pelvis to enter gluteal region by
passing laterally through greater sciatic
foramen
o Insertion: upper border of greater trochanter
by of femur
o Action: a lateral rotator of femur at the hip
joint
o Nerve supply: branches of sacral plexus
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Lateral pelvic wall - Sacrotuberous ligament
o Strong and extends from lateral part of
- Formed by part of hip bone below pelvic inlet, sacrum and coccyx and posterior inferior
obturator membrane, sacrotuberous and iliac spine to ischial tuberosity
sacrospinous ligaments, and obturator internus - Sacrospinous ligament
muscle and its fascia o Strong and triangle shaped
- Hip bone o Attached by
o Consist of Its base to lateral part of sacrum
Ilium and coccyx
Lies superiorly Its apex to the spine of ischium
The upper flattened part - BOTH LIGAMENTS prevent lower end of sacrum and
of hip bone coccyx form being rotated upward at sacroiliac joint
Possess iliac crest by weight of the body
o Runs between o Also convert the greater and lesser sciatic
anterior and notches into foramina, the greater and
posterior superior lesser sciatic foramina
iliac spines
o Below these Obturator internus muscle
spines are
anterior and - Origin: pelvic surface of obturator membrane and
posterior inferior adjoining part of hip bone
iliac spines o Muscle fibers converge to a tendon, which
On inner surface is the leaves pelvis through lesser sciatic foramen
large auricular surface for - Insertion: greater trochanter of femur
articulation with sacrum - Action: laterally rotates femur at hip joint
Iliopectineal line - Nerve supply: nerve to obturator internus (branch
o Runs downward form sacral plexus)
and forward
around inner Inferior pelvic wall or Pelvic floor
surface of ilium
o Serves to divide - Support the pelvic viscera
false from true - Formed by pelvic diaphragm
pelvis - Stretches across pelvis and divides it into
Ischium o Main pelvic cavity (above)
Lies posteriorly and Contains pelvic viscera
inferiorly o Perineum (below)
Possesses an ischial spine
and ischial tuberosity Pelvic diaphragm
Pubis
- Formed by important levatores ani muscles and small
Lies anteriorly and
coccygeus muscle and its fascia
inferiorly
- It is incomplete anteriorly to allow passage of urethra
Has body and superior
in males and urethra and vagina in females
and inferior pubic rami
Body of pubis bears pubic Levator ani muscle
crest and pubic tubercle
and articulates with pubic - Wide thin sheet that has linear origin from back of
bone of opposite side at body of pubis
symphysis pubis - A tendinous arch formed by thickening of fascia
THE 3 SEPARATE BONES JOINED BY covering the obturator internus and spine of ischium
CARTILAGE AT ACETABULUM - From this origin, groups of fibers sweep downward
Deep depression on outer and medially to their insertion
surface of hip bone o Anterior fibers
Articulates with Levator prostatae or sphincter
hermispherical head of vaginae
femur Form a sling around the
Behind it is a large notch, prostate or vagina
greater sciatic notch Inserted into a mass of
o Separated from fibrous tissue, called
lesser sciatic perineal body in front
notch by spine anal canal
of the ischium Levator prostatae
These sciatic notches are o Support the
converted into greater and prostate and
lesser sciatic foramina by stabilize the
sacrotuberous and perineal body
sacrospinous ligaments
Sphincter vaginae
o Articulate with sacrum at sacroiliac joints
o Constrict vagina
and from anterolateral wall of pelvis
and stabilize
o Also articulate with one another anteriorly
perineal body
at symphysis pubis o Intermediate fibers
o Obturator foramen
Puborectalis
Large opening in the lower part of
Forms a sling around
hipbone
junction of rectum and
Bounded by part of ischium and
anal canal
pubis
Pubococcygeus
Filled in by obturator membrane
Passes posteriorly to be
inserted into small fibrous
Obturator membrane
mass, called
anococcygeal body
- Fibrous sheet that almost completely closes the
between tip of coccyx and
obturator foramen
anal canala
- Leaves a small gap called obturator canal
o Posterior fibers
o Passage of obturator nerve and vessels as
Iliococcygeus
they leave the pelvis to enter thigh
Inserted into
anococcygeal body and
Ligaments
coccyx
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 - Action: Inferior gluteal nerve
o Form an efficient muscular sling that Supplies gluteus maximus
supports and maintains pelvic viscera in muscle
position Nerve to the quadrates femoris
o Resits the rise in intrapelvic pressure during muscle
straining and expulsive efforts of abdominal Also supplies inferior
muscles gemellus muscle
o As sphincter action of anorectal junction Nerve to the obturator internus
o In female, serve also as sphincter of vagina muscle
- Nerve supply Also supplies superior
o Perineal branch of 4th sacral nerve gemellus muscle
o Perineal branch of pudendal nerve Posterior cutaneous nerve of the
thigh
Coccygeus muscle Supplies the skin of
buttock and back of the
- Small triangular muscle thigh
- Arises from spine of ischium o Branches to pelvic muscle, pelvic viscera,
- Inserted into lower end of sacrum and into coccyx and perineum
- Action: assist levatores ani in supporting pelvic Pudendal nerve
viscera S2, 3, 4
- Nerve supply: branch of 4th and 5th sacral nerves
Leaves pelvis through
greater sciatic foramen
Pelvic fascia
Enters perineum through
lesser sciatic foramen
- Forme dof connective tissue
Nerves to the piriformis muscle
- Continuous above with fascia lining the abdominal
wall Pelvis splanchnic nerves
- Below, continuous with fascia of perineum S2, 3, 4
- Can be divided into Constitute sacral part of
o Parietal pelvic fascia parasympathetic system
Lines the walls of pelvis Distributed to the pelvic
Named according to muscle it viscera
overlies Perforating cutaneous enrve
Becomes continuous through Supplies skin of lower
opening with fascia covering the medial part of buttock
inferior surface of pelvic
diaphragm, in the perineum Branches of the lumbar plexus
Covers the sphincter urethrae
muscle and perineal membrane - Lumbosacral trunk
Forms the superior fascial layer of o Formed from part of anterior ramus of 4 th
urogenital diaphragm lumbar nerve that emerges from medial
o Visceral pelvic fascia border of psoas muscle and joins anterior
Covers and supports all pelvic ramus ofth lumbar nerve
visvera o Enters pelvis by passing down in front
In some area, it thickens and sacroiliac joint and joins sacral plexus
extends from viscus to pelvic wall
and provides support - Obturator nerve
o L2, 3, and 4
Pelvic peritoneum o Branch of lumbar plexus
o Emerges from medial border of psoas
- Lines the pelvic walls muscle in abdomen
- Is reflected onto pelvic visvera and become o Accompanies lumbosacral trunk down into
continuous with visceral peritoneum pelvis
o Crosses infront sacroiliac joint and runs
Nerves of the Pelvic forward on lateral pelvic wall in angle
between internal and external iliac vessels
Sacral plexus o Reaching obturator canal, splits into anterior
and posterior divisions
- Lies on posterior pelvic wall in front of piriformis Pass through canal to enter
muscle adductor region of thigh
- Formed from o Branches
o Anterior ramie of 4th and 5th lumbar nerves Sensory branches supply parietal
o Anterior ramie of 1st, 2nd, 3rd, 4th sacral peritoneum on lateral wall of pelvis
nerves
- 4th lumbar nerve joinsthe 5th lumbar nerve to form Autonomic nerves
the lumbosacral trunk
o Passes down into pelvis - Pelvic part of the Sympathetic trunk
o Joins sacral nerves as they emerge from o Continuous above, behind common iliac
anterior sacral foramina vessels, with abdominal part
- Relations o Runs down behind rectum on from of
o Anteriorly sacrum, medial to anterior sacral foramina
Internal iliac vessels and branches o Has 4 or 5 segmentally arranged ganglia
Rectum o Below, 2 trunk converge and finally unit in
o Posteriorly front of coccyx
Piriformis muscle o Branches
- Branches Gray rami communicantes to sacral
o Branches to the lower limb that leave pelvis and coccygeal nerves
through greater sciatic foramen Fibers that join hpogastric plexus
Sciatic nerve - Pelvic splanchnic nerves
L4 and 5; S1, 2, and 3 o Form the parasympathetic part of
Largest branch of plexus autonomic nervous system in pelvis
Largest nerve in the body o Preganglionic fibers
Superior gluteal nerve Aries form 2nd, 3rd, 4th sacral nerves
Supplies gluteus medius Synapse in ganglia in inferior
and minimus and tensor hypogastric plexus or in wall of
fasciae latae muscles viscera
- Superior hypogastric plexus
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 o Situated in front of promontory of sacrum
o Formed as continuation of aortic plexus and
from branches of 3rd and 4th lumbar
sympathetic ganglia
o Contains sympathetic and sacral
parasympathetic nerve fibers and visceral
afferent nerve fibers
o Divides inferiorly to form
Right hypogastric nerves
Left hypogastric nerves
- Inferior hypogastric nerves
o Lie on each side of rectum, base of bladder,
and vagina
o Each plexus is formed from
Hypogastric nerve
Pelvic splanchnic nerve
o Contains
Postganglionic sympathetic fibers
Preganglionic and postganglionic
parasympathetic fibers
Visveral afferent fibers
o Branches pass to pelvic viscera via small
subsidiary plexus
Arteries of the Pelvis
Common iliac artery
- Each ends at pelvic inlet in front of sacroiliac joint
- Divides into external and internal iliac arteries
External iliac artery
- Runs along medial border of psoas muscle, following
pelvic brim
- Gives off inferior epigastric and deep circumflex iliac
branches
- It leaves false pelvis by passing under inguinal
ligament to become femoral artery
Arteries of the true pelvis (enter the pelvic cavity)
- Internal iliac artery
- Superior rectal artery
- Ovarian artery
- Medial sacral artery
Internal iliac artery
- Passes down into pelvis to upper margin of greater
sciatic foramen where it divides into anterior and
posterior division
o Branches of these divisions supply pelvic
viscera, perineum, pelvic walls, and
buttocks
- Branches of the anterior division
o Umbilical artery
From proximal part of umbilical
artery arises the superior vesical
artery
Supplies upper portion of
bladder
o Obturator artery
Runs forward along lateral wall of
pelvis with obturator nerve
Leaves pelvis through obturator
canal
o Inferior vesical artery
Supplies base of bladder and
prostate and seminal vesicles in
male
Also give off artery to the vas
deferens
o Middle rectal artery
Commonly, arises with inferior
vesical artery
Supplies muscle of lower rectum
Anatomoses with superior rectal
and inferior rectal arteries
o Internal pudendal artery
Leaves pelvis through greater
sciatic foramen and enters gluteal
region below piriformis muscle
It then enters perineum by passing
through lesser sciatic foramen
Pass forward in pudendal canal
with pudendal nerve
Its branches supply musculature of
anal canal and skin and muscle of
perineum
o Inferior gluteal artery
Leaves pelvis through greater
sciatic foramen below piriformis
muscle
Passes between 1st and 2nd or 2nd
and 3rd sacral nerves
o Uterine artery
Runs medially on floor of pelvis
Crosses the ureter superiorly
Passes above lateral fornix of
vagina to reach uterus
Here, ascends between
layers of broad lgament
along lateral margin of
uterus
Ends by following uterine tube
laterally,
Anatomose with ovarian
artery
Gives off vaginal branch
o Vaginal artery
Usually takes the place of inferior
vesical artery present in male
Supplies vagina and base of
bladder
- Branches of the posterior division
o Iliolumbar artery
Ascends across pelvic inlet
posterior to external iliac vessels,
psoas, and iliacus muscle
o Lateral sacral arteries
Descend in front of sacral plexus
Gives off branches to neighboring
structures
o Superior gluteal artery
Leaves pelvis through greater
sciatic foramen above piriformis
muscle
Supplies gluteal region
Superior rectal artery
- Direct continuation of inferior mesenteric artery
o Name changes as latter artery crosses
common iliac artery
- Supplies mucous membrane of rectum and upper
half of anal canal
Ovarian artery
- Arises from abdomal part of aorta (at the level f L1)
- Long and slender and passes downward and laterally
behind peritoneum
- Crosses the external iliac artery at pelvic inlet and
enters suspensory ligament of ovary
- It then passes into broad ligament and enters ovary
by way of mesovarium
Median sacral artery
o Small artery that arises t bifurcation of aorta
o Descends over anterior surface of sacrum
and coccyx
Veins of the Pelvis
External iliac vein
- Begins behind inguinal ligament
- Continuation of femoral vein
- Runs along medial side of corresponding artery
- Joins internal iliac vein to form common iliac vein
- Receives inferior epigastric and deep circumplex iliac
veins
Internal iliac vein
- Begins by joining together of tributaries that
correspond to branches of internal iliac artery
- Passes upward in front of sacroiliac joint
- Joins external iliac vein to form common iliac vein
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Median sacral vein Surface landmarks

- Accompany correpondingartery - Iliac crest

- End by joining left common iliac vein o Can be felt through skin along its entire
lenth
Lymphatics of the Pelvis - Anterior superior iliac spine
o Situated at anterior end of iliac crest
- Lymph nodes and vessels are arranged in chain along o Lies at upper lateral end of fold of groin
main blood vessels - Posterior superior iliac spine
- Nodes are named after blood vessels with which they o Situated at posterior end of iliac crest
are associated, such as o Lies at the bottom of small skin dimple
o External iliac nodes, Internal iliac nodes, and On a level of 2nd sacral spine
common iliac nodes o Which coincides with lower limit of
subarachnoid space
Joint of the pelvis o Also coincides with level of the middle of
sacroiliac joint
Sacroiliac joints - Pubic tubercle
o Can be felt on the upper border of pubis
- Strong synovial joins o Attached to is the medial end of inguinal
- Formed between auricular surfaces of sacrum and ligament
iliac bones o Can be palpated easily in male by
- Sacrum invaginating the scrotum form below with
o Carries weight of trunk examining finger
o Shape of the bone contributes little to o In female, can be palpated through lateral
stability of the joints margin of labium majus
- Posterior and interosseous sacroiliac ligaments - Pubic crest
o Strong and suspend sacrum betwe 2 iliac o Ridge of bone on superior surface of pubic
bones bone, medial to pubic tubercle
- Anterior sacroiliac ligament (thin and lies in front of - Symphysis pubis
the joint) o Lies in midline between bodies of pubic
- Upward rotatory movement of lower end of bone is bones
prevented by strong sacrotuberous and sacrospinous o Can be palpated as solid structure through
ligaments fat that is present in this region
- Iliolumbar ligaments - Spinous process of sacrum
o Connects the tip of 5th lumbar transverse o Fused with each other in midline to form
process to iliac crest median sacral crest (can be felt beneath
- Movements skin in uppermost part of cleft between
o Limited amount of movement buttocks)
o Primary function is to transmit weight of - Sacral hiatus
body from vertebral column to bony pelvis o Situated on posterior aspect of lower end of
- Nerve supply: from branches of sacral spinal nerves sacrum
o Lies about 2 in (5 cm) above tip of coccyx
Symphysis pubis and beneath skin of cleft between buttocks
- Coccyx
- Cartilaginous joint between 2 pubic bones o Inferior surface and tip can be palpated in
- Articular surface are covered by layer of hyaline cleft between buttocks about 1 in. (2.5 cm)
cartlilage behind anus
- Connected together by fibrocartilaginous disc o Anterior surface can be palpated with
- Surround by ligaments that extend from one pubic gloved finger in anal canal
bone tootehr
- Movements Viscera
o No movement is possible
- Urinary bladder
Sacrococcygeal joint o In adults
Empty bladder is a pelvic organ
- Cartilaginous joint between bodies of last sacral and lies posterior to symphysis
vertebra and 1st coccygeal vertebra pubis
- Cornua of sacrum and coccyx are joined by ligaments As bladder fills, can be palpated
- Movements: extensive flexion and extension through anterior abdominal wall
above symphsysis pubis
Sex differences of the Pelvis Peritoneum covering becomes
peeled from from anterior
Male Female abdominal wall so that the front of
False pelvis Deep Shallow bladder is in direct contact with
Pelvic inlet Heart shaped (due of Transversely oval abdominal wall
indentation produced o In children (until age 6)
by promontory of An abdominal organ even when
sacrum empty
Pelvic cavity Roomier in female and distance between Because the capacity of
inlet and outlet is much shorter pelvic cavity is not great
Pelvic outlet Larger in female than in male enough to contain it
Neck of bladder lies just below the
level of upper border of symphysis
Ischial Turned in Everted
pubis
tuberosities - Uterus
Sacrum Shorter, wider, flatter in female than in male o nd
2 month of pregnancy, fundus of uterus
Subpubic More rounder and wider in female than in can be palpated through lower part of
angle (pubic male anterior abdominal wall
arch) o Fundus rises above the level of umbilicus
and reaches xiphoid process by 9th month
pregnancy
RADIOGRAPHIC ANATOMY

SURFACE ANATOMY

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