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Perineum
Diamond-shaped area between the thighs has boundaries that mirror those of Deep Space of the Anterior Triangle
the bony pelvic outlet: Space lies deep to the perineal membrane and extends up into the pelvis
A: pubic symphysis, AL: ischiopubic rami and ischial tuberosities, Continuous superiorly with the pelvic cavity
PL:sacrotuberous ligaments, P:coccyx Contains
An arbitrary line joining the ischial tuberosities divides the perineum into an a) Portions of urethra and vagina
anterior triangle (urogenital triangle) and posterior triangle (anal triangle) b) Certain portions of internal pudendal artery branches,
Perineal Body c) Compressor urethrae
Fibromuscular mass found in the midline at the junction between these d) Urethrovaginal sphincter muscles
anterior and posterior triangles Comprise part of the striated urogenital sphincter complex.
Also called the Central Tendon of the Perineum Pelvic Diaphragm
Measures 2 cm tall and wide and 1.5 cm thick Found deep to the anterior and posterior triangles
Serves as the junction for several structures and provides significant Broad muscular sling provides substantial support to the pelvic viscera.
perineal support Composed of
Superficially, the bulbocavernosus, superficial transverse perineal, and a) Levator ani
external anal sphincter muscles converge on the central tendon. More b) Coccygeus muscle.
deeply, perineal membrane, portions of the pubococcygeus muscle, and c) Levator ani
internal anal sphincter contribute Composed of
1) Pubococcygeus
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2) Puborectalis Increasing uterine size, excessive straining, and hard stool create increased
3) Iliococcygeus pressure that ultimately leads to degeneration and subsequent laxity of the
Pubococcygeus Muscle cushions supportive connective tissue base.
Also termed the Pubovisceral Muscle These protrude into and downward through the anal canal
Subdivided based on points of insertion and function Leads to venous engorgement within the cushions (Hemorrhoids)
Include Venous stasis results in inflammation, erosion of the
1) Pubovaginalis cushions epithelium, and then bleeding.
2) Puboperinealis External Hemorrhoids
3) Puboanalis Those that arise distal to the pectinate line.
Insert into the vaginal, perineal body, and anus, respectively Covered by stratified squamous epithelium
Vaginal birth conveys significant risk for damage to the levator ani or to its Receive sensory innervation from the Inferior Rectal Nerve.
innervation Pain and a palpable mass are typical complaints.
Pubovisceral Muscle is more commonly damaged Following resolution, a hemorrhoidal tag may remain composed of
Injuries may predispose women to greater risk of pelvic organ prolapse or redundant anal skin and fibrotic tissue.
urinary incontinence Internal Hemorrhoids
Efforts are aimed at minimizing these injuries. Those that form above the dentate line
Covered by insensitive anorectal mucosa
Posterior Triangle May prolapse or bleed but rarely become painful unless they
contains undergo thrombosis or necrosis.
a) Ischioanal Fossae
b) Anal Canal Anal Sphincter Complex
c) Anal Sphincter Complex Two sphincters surround the anal canal to provide fecal continence
Anal Sphincter Complex a) External Sphincter
Consists of b) Internal Anal Sphincters
a) Internal anal sphincter Both lie proximate to the vagina
b) External anal sphincter One or both may be torn during vaginal delivery
c) Puborectalis muscle Internal Anal Sphincter (IAS)
d) Branches of the pudendal nerve and internal pudendal vessels Distal continuation of the rectal circular smooth muscle layer.
Receives predominantly parasympathetic fibers, which pass through the
Ischioanal Fossae pelvic splanchnic nerves.
Also known as Ischiorectal Fossae Supplied by the Superior, Middle, and Inferior Rectal Arteries
two fat-filled wedge-shaped spaces Contributes the bulk of anal canal resting pressure for fecal continence
found on either side of the anal canal and relaxes prior to defecation
comprise the bulk of the posterior triangle Measures 3- 4 cm in length
Each fossa has skin as its superficial base At its distal margin, it overlaps the external sphincter for 1-2 cm
Deep apex is formed by the junction of the levator ani and obturator internus Distal site at which this overlap ends (Intersphincteric Groove)
muscle. Palpable on digital examination.
Other borders include: External Anal Sphincter (EAS)
Obturator internus muscle fascia and ischial tuberosity (L) Striated muscle ring
Anal canal and sphincter complex (IM) Anteriorly attaches to the perineal body
Inferior fascia of the downwardly sloping levator ani (SM) Posteriorly connects to the coccyx (anococcygeal ligament)
Maximus muscle and sacrotuberous ligament (P) Maintains a constant resting contraction to aid continence
Inferior border of the anterior triangle (A). Provides additional squeeze pressure when continence is threatened, yet
Fat found within each fossa provides support to surrounding organs yet allows relaxes for defecation.
rectal distention during defecation and vaginal stretching during delivery. Three parts include
Injury to vessels in the posterior triangle can lead to hematoma formation in the a) Subcutaneous
ischioanal fossa b) Superficial
Potential for large accumulation in these easily distensible spaces. c) Deep Portions
Two fossae communicate dorsally, behind the anal canal Deep portion is composed fully or in part by the puborectalis muscle
Episiotomy infection or hematoma may extend from one fossa into the Receives blood supply from the inferior rectal artery
other. Branch of the internal pudendal artery
Somatic motor fibers from the Inferior Rectal Branch of the Pudendal
Nerve supply innervation.
IAS and EAS may be involved in fourth-degree laceration during vaginal delivery
Reunion of these rings is integral to defect repair
Anal Canal
Distal continuation of the rectum
Begins at the level of levator ani attachment to the rectum and ends at the anal
skin.
4-5 cm length
Mucosa consists of
a) Columnar epithelium (uppermost portion)
b) Simple stratified squamous epithelium (begins at dentate or pectinate line
Pudendal Nerve
continues to the anal verge)
Formed from the anterior rami of S24 spinal nerves
Keratin and skin adnexa join the squamous epithelium.
Courses between the piriformis and coccygeus muscles
Has several lateral tissue layers
Exits through the greater sciatic foramen
Inner layers include
Posterior to the sacrospinous ligament
a) Anal Mucosa
Medial to the ischial spine
b) Internal Anal Sphincter
When injecting local anesthetic for a pudendal nerve block, the ischial spine
c) Intersphincteric Space
serves an identifiable landmark
Contains continuation of the rectums longitudinal smooth Runs beneath the sacrospinous ligament and above the sacrotuberous ligament
muscle layer. Reenters the lesser sciatic foramen to course along the obturator internus
Outer layer contains muscle.
a) Puborectalis Muscle (S) Lies within the pudendal canal (Alcock canal)
b) External Anal Sphincter (I) Formed by splitting of the obturator internus investing fascia
Within the anal canal, three highly vascularized submucosal arteriovenous Relatively fixed as it courses behind the sacrospinous ligament and within
plexuses (anal cushions) the pudendal canal
Aid complete closure of the canal and fecal continence when apposed. May be at risk of stretch injury during downward displacement of the
pelvic floor during childbirth
Posterior Division
Extend to the buttock and thigh
Include the superior gluteal, lateral sacral, and iliolumbar
arteries. during internal iliac artery ligation
Many advocate ligation distal to the posterior division to avoid
compromised blood flow to the areas supplied by this division
Lymphatics
Endometrium is abundantly supplied with lymphatic vessels that are confined
largely to the basalis layer.
Lymphatics of the underlying myometrium are increased in number toward
the serosal surface and form an abundant lymphatic plexus just beneath
it.
Lymphatics from the cervix terminate mainly in the internal iliac nodes
Blood Supply
Situated near the bifurcation of the common iliac vessels
During pregnancy, there is marked hypertrophy of the uterine vasculature
Lymphatics from the uterine corpus are distributed to two groups of nodes.
Supplied principally from the Uterine and Ovarian Arteries
Vessels drains into the Internal Iliac Nodes
Uterine Artery
After joining certain lymphatics from the ovarian region, terminates in the
main branch of the Internal Iliac Artery
Paraaortic Lymph Nodes.
previously called the Hypogastric Artery
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Innervation On its surface, there is a single layer of cuboidal epithelium, (Germinal
Peripheral nervous system is divided Epithelium of Waldeyer)
a) Somatic Division Beneath this epithelium, the cortex contains oocytes and developing
Innervates skeletal muscle follicles.
b) Autonomic Division Medulla
Innervates smooth muscle, cardiac muscle, and glands. Central portion
Pelvic visceral innervation is predominantly autonomic Composed of loose connective tissue.
Further divided in Sympathetic and Parasympathetic There are a large number of arteries and veins and small number of
Components. smooth muscle fibers.
Sympathetic Innervation to pelvic viscera begins with the Superior Supplied with both sympathetic and parasympathetic nerves.
Hypogastric Plexus (Presacral Nerve) Sympathetic nerves: Ovarian Plexus that accompanies the ovarian
Beginning below the aortic bifurcation and extending downward vessels
retroperitoneally, this plexus is formed by sympathetic fibers arising from Originates in the renal plexus.
spinal levels T10-L2. Others are derived from the plexus that surrounds the ovarian
At the level of the sacral promontory, divides into a Right and a Left branch of the uterine artery.
Hypogastric Nerve, which run downward along the pelvis side walls Parasympathetic input: Vagus Nerve
Sensory afferents follow the ovarian artery and enter at T10 spinal
cord level.
Parasympathetic Innervation
Derives from neurons at spinal levels S2-S4
Axons exit as part of the anterior rami of the spinal nerves for those levels.
These combine on each side to form the pelvic splanchnic nerves (Nervi
Erigentes)
Blending of the two Hypogastric Nerves (sympathetic) and the two Pelvic
Splanchnic Nerves (parasympathetic) gives rise to the Inferior Hypogastric Fallopian Tubes
Plexus (Pelvic Plexus) Called Oviducts
Retroperitoneal plaque of nerves lies at the S4-S5 level Serpentine tubes extend 8-14 cm from the uterine cornua
From here, fibers of this plexus accompany internal iliac artery branches Anatomically classified along their length as an
to their respective pelvic viscera. a) Interstitial Portion
Inferior Hypogastric Plexus b) Isthmus
Divides into three plexuses c) Ampulla
a) Vesical Plexus d) Infundibulum
Innervates the bladder and the middle rectal travels to the Interstitial Portion
rectum Most proximal
b) Uterovaginal Plexus (Frankenhuser Plexus) Embodied within the uterine muscular wall.
Reaches the proximal fallopian tubes, uterus, and upper Isthmus
vagina. Narrow 2-3 Mm
Extensions of the inferior hypogastric plexus also reach the perineum Adjoins the uterus and widens gradually
along the vagina and urethra to innervate the clitoris and vestibular bulbs Ampulla
Composed of variably sized ganglia, but particularly of a large ganglionic 5-8 mm
plate that is situated on either side of the cervix, proximate to the More lateral
uterosacral and cardinal ligaments Infundibulum
Most afferent sensory fibers from the uterus ascend through the inferior funnel-shaped fimbriated distal extremity of the tube
hypogastric plexus and enter the spinal cord via T10-T12 and L1 spinal opens into the abdominal cavity
nerves Latter three extrauterine portions are covered by the Mesosalpinx at the
Transmit the painful stimuli of contractions to the central nervous superior margin of the broad ligament.
system Extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and
Sensory nerves from the cervix and upper part of the birth canal pass through endosalpinx
the pelvic splanchnic nerves to the second, third, and fourth sacral nerves.
Those from the lower portion of the birth canal pass primarily through the Mesosalpinx
Pudendal Nerve. Single-cell mesothelial layer
Anesthetic blocks used in labor and delivery target this innervation. Functioning as visceral peritoneum
Ovaries Myosalpinx
During childbearing years: 2.5 -5 cm in length, 1.5-3 cm in breadth, and 0.6-1.5 Smooth muscle
cm in thickness. Arranged in an inner circular and an outer longitudinal layer.
Usually lie in the upper part of the pelvic cavity In the distal tube, the two layers are less distinct and are replaced
Rest in a slight depression on the lateral wall of the pelvis (Ovarian Fossa of near the fimbriated extremity by sparse interlacing muscular fibers.
Waldeyer) Tubal musculature undergoes rhythmic contractions constantly, the
Between the divergent external and internal iliac vessels. rate of which varies with cyclical ovarian hormonal changes.
Uteroovarian Ligament Endosalpinx
Originates from the lateral and upper posterior portion of the uterus Tubal mucosa
Beneath the tubal insertion level Single columnar epithelium composed of ciliated and secretory cells
Extends to the uterine pole of the ovary resting on a sparse lamina propria
3-4 mm in diameter In close contact with the underlying myosalpinx.
Made up of muscle and connective tissue Ciliated cells are most abundant at the fimbriated extremity, but
covered by Mesovarium elsewhere, they are found in discrete patches
Blood supply traverses to and from the ovary through this double-layered Mucosa is arranged in longitudinal folds that become progressively
mesovarium to enter the ovarian hilum. more complex toward the fimbria
Consists of a cortex and medulla Ampulla: lumen is occupied almost completely by the arborescent mucosa
Young women: outermost portion of the cortex is smooth Current produced by the tubal cilia is such that the direction of flow is
Tunica Albuginea: dull white surface toward the uterine cavity.
Pelvic Bones
Pelvis
Composed of four bones
a) Sacrum
b) Coccyx
c) Two Innominate Bones
Each innominate bone is formed by the fusion of three bones
1) Ilium
2) Ischium
3) Pubis
Joined to the sacrum at the sacroiliac
synchondroses and to one another at the Planes and Diameters of the Pelvis
symphysis pubis Pelvis is described as having four imaginary planes:
Conceptually divided into false and true components a) The plane of the pelvic inlet (Superior Strait)
a) False Pelvis b) The plane of the pelvic outlet (Inferior Strait)
Lies above the linea terminalis c) The plane of the midpelvis: least pelvic dimensions
Bounded: p:lumbar vertebra, l: iliac fossa, a:lower portion of the d) The plane of greatest pelvic dimension: no obstetrical significance.
anterior abdominal wall
b) True Pelvis
Portion important in childbearing
Obliquely truncated, bent cylinder with its greatest height
posteriorly.
Borders:
S:linea terminalis
I: pelvic outlet
P: anterior surface of the sacrum
L:inner surface of the ischial bones and the sacrosciatic
notches and ligaments
A: pubic bones, ascending superior rami of the ischial bones,
and obturator foramina.
Sidewalls converge
Pelvic Inlet
Extending from the middle of the posterior margin of each
Also called the Superior Strait
ischium are the ischial spines.
Superior plane of the true pelvis
Great obstetrical importance because the distance
Bounded:
between them usually represents the shortest diameter
P: promontory and alae of the sacrum
of the true pelvis.
L: linea terminalis
Serve as valuable landmarks in assessing the level to which the presenting part
A: horizontal pubic rami and the symphysis pubis.
of the fetus has descended into the true pelvis
During labor, fetal head engagement (fetal heads biparietal diameter)
Aid pudendal nerve block placement.
passing through this plane.
Sacrum
To aid this passage, the inlet of the female pelvis typically is more
Forms the posterior wall of the true pelvis
nearly round than ovoid.
Upper anterior margin corresponds to the promontory that may be felt
Nearly round or gynecoid pelvic inlet in approximately half of white
during bimanual pelvic examination in women with a small pelvis. Provide
women.
a landmark for clinical pelvimetry
Four diameters of the pelvic inlet are usually described:
Normally, the sacrum has a marked vertical and a less pronounced
a) Anteroposterior
horizontal concavity, which in abnormal pelves may undergo important
b) Transverse
variations.
c) Two oblique diameters
Straight line drawn from the promontory to the tip of the sacrum usually
Distinct anteroposterior diameters have been described using specific
measures 10 cm
landmarks.
Distance along the concavity averages 12 cm
a) Anteroposterior Diameter
Most cephalad
Termed the True Conjugate
Extends from the uppermost margin of the symphysis pubis to the
sacral promontory
Clinically important Obstetrical Conjugate is the shortest distance
between the sacral promontory and the symphysis pubis.
Normally, this measures 10 cm or more, but cannot be
measured directly with examining fingers.
Estimated indirectly by subtracting 1.5-2 cm from the
Diagonal Conjugate
Determined by measuring the distance
Transverse diameter is constructed at right angles to
the obstetrical conjugate
Pelvic Joints Represents the greatest distance between the linea
A: pelvic bones are joined together by the symphysis pubis. terminalis on either side
Consists of fibrocartilage and the superior and Inferior Pubic Ligaments.
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Usually intersects the obstetrical conjugate at a point
approximately 5 cm in front of the promontory and
measures approximately 13 cm.
Each of the two oblique diameters extends from one sacroiliac
synchondrosis to the contralateral iliopubic eminence.
Each eminence is a minor elevation that marks the union site of the
ilium and pubis.
These oblique diameters average less than 13 cm.
Pelvic Shapes
Caldwell-Moloy anatomical classification of the pelvis based on shape, and its
concepts aid an understanding of labor mechanisms.
Greatest transverse diameter of the inlet and its division into anterior and
posterior segments are used to classify the pelvis as
a) Gynecoid
b) Anthropoid
c) Android
d) Platypelloid
Posterior segment determines the type of pelvis
Anterior segment determines the tendency.
Both determined because many pelves are not pure but are mixed
types.
Gynecoid pelvis with an android tendency means that the posterior pelvis
is gynecoid and the anterior pelvis is android shaped.
Configuration of the gynecoid pelvis would intuitively seem suited for
delivery of most fetuses.
Gynecoid pelvis was found in almost half of women.