PELVIS & PERINEUM CLINICAL CORRELATIONS | 3B

CACAO | CIONELO | GONZALES | ICARO | JIMENEZ | SARILE | TARROBAL | TENORIO

BONY PELVIS VS PELVIC GIRDLE

BONY PELVIS
Composed of four bones namely the sacrum, coccyx and two innominate bones (fusion of the ilium, ischium and pubis) Joined by sacroiliac synchondroses to the sacrum and to one another at the symphysis pubis -

PELVIC GIRDLE
Contains the coxial bone containing the ischium, pubis and their relative components The pelvis contains both coxal bone components and sacrum and coccyx Serves as an attachment of the lower limbs to the axial skeleton

BOUNDARIES OF PELVIC INLET AND PELVIC OUTLET

PELVIC INLET
ANTERIOR: Pubic Crest of Pubic Symphysis POSTERIOR: anterior margin of the base of the sacrum (or the Ala of thesacrum) and sacrovertebral angle (or sacral promontory) LATERAL: iliopectineal line (Arcuate line + Pecten Pubis)

PELVIC OUTLET
ANTERIOR: Pubic Arch LATERAL: Ischial Tuberosities POSTEROLATERAL: inferior margin of the sacrotuberous ligament POSTERIOR: tip of the Coccyx

FALSE PELVIS VS TRUE PELVIS

FALSE PELVIS
Aka Greater Pelvis Expanded portion above and in front of pelvic brim - Above the pelvic inlet - has ilia on the side - incomplete in the front, with a wide interval between anterior borders of ilia - bounded by vertebra posteriorly - supports abdominal contents - after first trimester, supports gravid uterus (in females)

TRUE PELVIS
- aka Lesser Pelvis - below and behind the pelvic brim - between the pelvic inlet and pelvic outlet bones are more complete compared to false pelvis - bounded by ischium and pubis, laterally and anteriorly - bounded by sacrum and coccyx posteriorly - internal borders are solid and immobile - posterior wall is twice the anterior wall

PELVIMETRY
the process of measuring the dimensions and capacity of the pelvis, especially of the adult female pelvis the diameter of the osseous birth canal are compared with that of the infants head to determine whether the pelvis is of sufficient diameter to allow normal vaginal delivery - used in leading the decision of natural, operative vaginal delivery or conducting a Caesarean section

PERINEUM
- area of tissue that marks externally the approximate boundary of the outlet of the pelvis and gives passage to the urogenital ducts and rectum - area between the anus and the posterior part of the external genitalia - diamond shaped region demarcated by four angles: anteriorly by the symphysis pubis, posteriorly by the tip of the coccyx and laterally by the two ischial tuberosities - divided into two triangles by a line joining the two ischial tuberosities, these are the urogenital triangle anteriorly and anorectal triangle posteriorly

BORDERS OF THE UROGENITAL AND ANAL TRIANGLE

UROGENITAL TRIANGLE
ANTERIORLY Pubic Symphysis POSTERIORLY line joining the ischial tuberosities and perineal body LATERALLY Pubic Arch

ANAL TRIANGLE
ANTERIORLY - Perineal membrabe POSTEROLATERALLY Sacrotuberous membrabe

PERINEAL BODY
- central tendon of the perineum - pyramidal fibromuscular mass situated in the middle of the junction of urogenital triangle and anal triangle - In males, it is found between the bulb of the penis and the anus, while in females, it is found between the vagina and the anus. - essential for the integrity of the pelvic floor, especially in females. It provides attachment to the following muscles: - External anal sphincter muscle - Bulbospongiosus muscle - Superficial transverse perineal muscle - Levator ani muscle (anterior fibers) - External urinary sphincter - Deep transverse perineal muscle

ANORECTAL FISTULA AND GOODSALLS RULE

Anorectal Fistula - Also known as fistula-in-ano, this is an abnormal communication between the anus and the perianal skin, thus creating a passageway for spread of infection from the surrounding anal glands into the intramuscular spaces. It can occur spontaneously, or secondary to perianal or perirectal abscess. It may also be secondary to trauma, Crohns disease, anal fissures, carcinoma, radiation therapy, actinomycoses, or chlamydial infections. Types 1. Transsphincteric fistulae are the result of ischiorectal abscesses, with extension of the tract through the external sphincter. Account for about 25% of all fistulae. 2. Intersphincteric fistulae are confined to the intersphincteric space and internal sphincter. They result from perianal abscesses. Account for about 70% of all fistulae.

3. Suprasphincteric fistulae are the result of supralevator abscesses. They pass through the levator ani muscle, over the top of the puborectalis muscle, and into the intersphincteric space. Account for about 5% of all fistulae.

4. Extrasphincteric fistulae bypass the anal canal and sphincter mechanism, passing through the ischiorectal fossa and levator ani muscle, and open high in the rectum. Accounts for about only 1% of all fistulae. Goodsalls Rule - This rule is used to predict the direction of the extent of the fistula based on its origin. If the patient is in lithotomy position, it states that: If the external opening is anterior to an imaginary line drawn horizontally through the anal canal, the fistula usually runs directly into the anal canal. If the external opening is posterior to the line, the fistula usually curves to the posterior midline of the anal canal. However, it must be noted that: the further away the external opening is from the anus, the less reliable Goodsall's rule becomes. Additionally, the trajectory of a complex fistula is unpredictable.

CALDWELL-MOLLOY PELVIC CLASSIFICATION OF PELVIS

PELVIS TYPE
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DESCRIPTION
Appears in 50% of the population It is the normal female type. Inlet is slightly transverse oval. Sacrum is wide with average concavity and inclination. Side walls are straight with blunt ischial spines. Sacro-sciatic notch is wide. Subpubic angle is 90-100 25% occurrence It is ape-like type. All anteroposterior diameters are long. All transverse diameters are short. Sacrum is long and narrow. Sacro-sciatic notch is wide. Subpubic angle is narrow. 20% occurence It is a male type. Inlet is triangular or heartshaped with anterior narrow apex. Side walls are converging (funnel pelvis) with projecting ischial spines. Sacro-sciatic notch is narrow. Subpubic angle is narrow <90 Least common type (5%) It is a flat female type. All anteroposterior diameters are short. All transverse diameters are long. Sacro-sciatic notch is narrow. Subpubic angle is wide.

IMAGE

GYNECOID PELVIS

ANTHROPOID PELVIS

ANDROID PELVIS

PLATYPELLOID PELVIS

PELVIC DIAMETERS AND CONJUGATES

Pelvic Diameters Normal Values
(AP) Anatomic (AP)Obstetric (AP)Diagonal Transverse Oblique 11.0 cm 10.0 cm 12.0 cm 13.0 cm 13.0 cm

INLET

Pelvic Diameters

Normal Values
AP Transverse AP Transverse (Bispinous) 12.75 cm 12.5 cm 12.0 cm 9.5-10.0 cm

MIDPLANE OUTLET
Parameters
Ischial Spines Pelvic Side Walls Concavity of Sacrum Sacrosciatic Notch Biischial Diameter of Outlet

Greatest Dimension Least Dimension

Pelvic Diameters
(AP) Anatomic (AP) Obstetric Transverse (Biischial)

Normal Values
9.5-11.5 cm 11.5 cm 11.0 cm

PARAMETERS IN CLINICAL ASSESSMENT OF THE MIDPELVIS

Normal
Blunt Divergent Concave/Deep Wide >8cm

Contracted
Prominent Convergent Shallow/Flat Narrow <8cm