Pelvic

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Pelvic

• ??????? ?????
• ???

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Bony pelvis

• Composition formed by paired hip bones, sacrum,
  coccyx, and their articulations
• Two portions
• Greater pelvis
• Lesser pelvis
• Terminal line ( pelvic inlet) formed by
  promontory of sacrum, arcuate line, pectin of
  pubis, pubic tubercle, upper border of pubic
  symphysis
• Pelvic outlet formed by tip of coccyx,
  sacrotuberous ligament, ischial tuberosity, ramus
  of ischium, inferior ramus of pubic symphysis

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Muscles of pelvic wall

• Piriform m.
• Obturator internus m.

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Muscles of floor of pelvis and pelivic
diaphragm

• Muscles of floor of pelvis
• Levator ani ???
• Levateo prostate ?????(pubovaginalis ?????)
• Puborectalis ?????
• Pubococcygeus ???and iliococcygeus ???
• Coccygeus ???

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• Pelivic diaphragm ??
• Superior fascia of pelvic diaphragm ?????
• Levator ani ???
• Coccygeus ???
• Inferior fascia of pelvic diaphragm?????

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Pelvic fascia

• Parietal pelvic fascia
• A continuation of the transverse fascia into the
  pelvis. It coves the piriformis and obturator
  internus
• Attaches to the arcuate line of the pubis and
  ilium, thickens over the obturator internus to
  form the arcus tendineus, the origin of portions
  of the levator ani muscle
• At the tendinous arch of levator ani it splits to
  cove both superior and inferior surfaces of the
  levator ani as superior and inferior fascia of
  pelvic diaphragm

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• Visceral pelvic fascia
• Lies between the peritoneum and the pelvic
  viscera
• It is a continuation of the extraperitoneal
  connective tissue
• Ensheathes retroperitoneal viscera and forms
  septa between retroperitoneal organs
• Rectovesical septum ?????
• Rectovaginal septum ?????

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• Retropubic space ????
• Lies between pubic symphysis and urinary bladder
• Pararectal space
• ?????
• Lies around the rectus
• Retrorectal space ????

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Common iliac artery ????

• Common iliac artery
• Continuation of abdominal aorta at level of L4
  vertebra
• Terminates in front of sacroiliac joint by
  dividing into internal and external iliac
  arteries

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Internal iliac artery ????

• Parietal iliac artery
• Obturator a. ????
• Iliolumber a.????
• Lateral sacral a. ?????
• Superior gluteal a. ????
• Inferior gluteal a. ????

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• Visceral branches
• Umbilical a.???? superior vesical a. ?????
• Inferior vesical a.?????
• Uterine a.????
• Inferior rectal a.?????
• Internal pudendal a. ?????

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• Uterine a. ????about 2cm from neck of uterus it
  crosses above and in front of ureter

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• Internal pudendal artery ?????
• Perineal artery
• Anal artery
• Dorsal artery of penis (clitoris)

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External iliac artery

• Inferior epigastric artery
• Deep iliac circumflex artery

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Veins of pelvis

• Internal iliac vein ????
• Parietal tributaries accompany with arteries
• Visceral tributaries
• ?superior rectal vein?inferior
  mesenteric v.
• ?Rectal venous plexus ?inferior rectal
  vein?internal iliac v.
• ????? ?anal vein?internal pudendal v.
• ?Vesical venous plexus ??????vesical v.
• ?Uterine venous plexus ??????uterine v.

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• External iliac vein ???? accompany the
  artery
• Common iliac vein ???? formed by union of
  internal and external iliac veins in front of
  sacroiliac joint, end upon L4L5 by uniting each
  other to form inferior vena cava

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The lymphatic drainage of pelvis

• Internal iliac lymph node
• Surround internal iliac vessels
• Receive afferents from pelvic viscera, perineum,
  buttock and back of thigh
• External iliac lymph nodes
• Lie along external iliac artery
• Receive afferents from lower limb and some parts
  of pelvic viscera
• Sacral lymph node
• Common iliac lymph node
• Lie along common iliac artery
• Receive afferents from all the above nodes
• Efferents pass to lumbar lymph node

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Sacral plexus ??

• Formation formed by anterior rami of L4 and L5
  spinal nerves (the lumbrosacral trunk) and
  anterior rami of sacral and coccygeal nerves
• Position lies in pelvic cavity, anterior to
  sacrum and piriformis

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• Branches
• Superior gluteal
• Inferior gluteal
• Pudendal
• Posterior femoral cutaneou
• Sciatic Common

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Pudendal nerve block
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Autonomic plexuses of plevic

• Hypogastric plexus
• Superior hypogastric plexus ???? lies in front
  of L5 between common iliac ateries
• Inferior hypogastric plexus???? (pelvic plexus)
  lie on each side of rectum
• Sacral sympathetic trunk
• Is continuos above with the abdominal part
• Has 4or 5 ganglion

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Relationships of rectus

• Anteriorly
• In male
• Fundus of bladder
• Seminal vesicle
• Prostate
• Ampulla ductus deferentis
• In female
• neck of uterus
• Vagina

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• Posteriorly
• Sacrum and coccyx
• Piriformis
• Median sacral vessels
• Anterior branches of sacral and coccygeal nerves
• Sacral sympathetic trunk
• Laterally
• Pelvic plexus
• Superior and inferior rectal vessels
• Levator ani

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Vessels and lymphatics of rectum

• Arteries
• Superior rectal a.
• Inferior rectal a.
• Median sacral a.
• Lymphatic drainge Lymphatics follow arterial
  blood supply to following nodes
• Superior rectal ln.
• Inferior mesenteric ln.
• Pararectal ln.
• Internal iliac ln.
• Sacral ln.

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Perineum

• ??????? ?????
• ???

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• General features
• Region of below pelvic diaphragm
• A diamond-shape space whose boundaries are those
  of the pelvic outlet
• Lower border of symphysis pubis
• Rami of pubis and ischium
• Ischial tuberosities
• Sacrotuberous ligament
• The coccyx

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• Two triangles
• An imaginary line drawn between the two
  ischial tuberosities divides perineum into
  anterior and posterior triangles
• Urogenital region???? (anterior)-differs in male
  and female
• Anal region ?? (posterior)-similar in both sexes

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Anal region ??

• Anal sphincters ?????
• Internal
• Smooth muscle (thickened circular muscle coat)
• Surrounds upper two-thirds of anal canal
• Autonomic nerve supply
• External
• Striated muscle
• Surrounds lower two-thirds of anal canal
• Three parts-subcutaneous, superficial and deep
• Innervation by anal nerves of pudendal nerve and
  branches of S4

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Ischioanal fossa ?????
Paired, wedge-shaped, fat-filled spaces on either
side of anal canal

• Boundaries
• Apex-conjunctive area of inferior fascia of
  pelvic diaphragm and fascia covering the
  obturator internus
• Base-skin of anal region
• Medial-sphincter ani externus, levator ani,
  coccygeus and inferior fascia of pelvic diaphragm
• Lateral-ischial tuberosity, obturator internus
  and fascia

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• Anterior
• Posterior border of urogenital diaphragm
• Forward projection of anterior recess of fossa
  between pelvic diaphragm above and urogenital
  diaphragm below
• Posterior
• backward projection of posterior recess of fossa
  between gluteus maximus, sacrotuberous ligament
  and coccyx

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• Contents
• Fat
• Internal pudendal artery and vein and their
  rectal branches
• Pudendal nerve and its inferior rectal branch

Vessels and nerves enter from gluteal region,
through lesser sciatic foramen, travel on a
fascial canal-the pudental canal ???
(Alcocks) -on the lateral wall of fossa, and
extend forward into urogenital region
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• Branches
• Superior gluteal
• Inferior gluteal
• Pudendal
• Posterior femoral cutaneou
• Sciatic Common

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Pudendal nerve block
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Urogenital region ????

• Superficial fascia has two layers
• The superficial or fatty layer
• The deep or membranous layer (superficial fascia
  of perineum ????? or Colles fascia)
• Anteriorly- it is continuous with
• Dartos of the scrotum
• Fascia of the penis
• Membranous layer of superficial fascia of the
  abdominal wall known as the fascia of Scarpa
• Deep fascia has two layers
• Superior fascia of urogenital diaphragm ???????
• Inferior fascia of urogenital diaphragm ???????

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Superior fascia of urogenital diaphragm
Deep perineal space
Inferior fascia of urogenital diaphragm
Superficial perineal space
superficial fascia of perineum
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??????????,?????,?????,?????(???)
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Superficial perineal space ????

• Boundaries
• Lies between inferior fascia of urogenital
  diaphragm and superficial fascia of perineum
• Space open anteriorly (In rupture of cavernous
  part of urethra, urine can extravasate from
  scrotum upward in front of symphysis pubis into
  anterior abdominal wall deep to membranous fascia
  of Scarpa)

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• Contents
• Posterior part-superficial transverse perineal
  muscle
• Lateral part-crus penis (male), crus of clitoris
  (female) and ischiocavernousus covering them
• Central part-bulb of urethra (male), bulb of
  vestibule (female) and bulbocavernousus covering
  them
• Branches of pudendal nerves and internal pudendal
  vessels

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Deep perineal space ????

• Lies between superior and inferior fascia of
  urogenital diaphragm
• Contents
• Deep transverse perineal muscle
• Bulbourethral gland (male)
• Sphincter of urethra????? (male),urethrovaginal
  sphincter???????
• Ateries, veins and nerves

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Urogenital diaphragm ????

• Triangular in shape
• Attached laterally to ischiopubic rami and
  ischial tuberosities
• Formed by sphincter of urethra, deep transverse
  perineal muscle, superior and inferior fascia of
  urogenital diaphragm

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Perineal central tendon ?????

• Wedge-shape fibromuscular mass
• In female, between anal canal and lower end of
  vagina,
• In male, between anal canal and root of penis
• It is larger in the female than in the male and
  five support to the posterior wall of the vagina

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• Origin or insertion of several small muscles and
  insertion of part of palvic diaphragm
• These muscles are
• Sphincter ani externus
• Levator ani
• Superficial transverse muscle perineum
• Deep transverse muscles perineum
• Bulbocavernousus
• Sphincter of urethra (male) or urethrovaginal
  sphincter (female)

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