Pelvic

Anatomy
Robert E. Gutman, MD
 Objectives
ƒ Understand pelvic anatomy
ƒ Organs and structures of the female pelvis
ƒ Vascular Supply
ƒ Neurologic supply
ƒ Pelvic and retroperitoneal contents and spaces
ƒ Bony structures
ƒ Connective tissue (fascia, ligaments)
ƒ Pelvic floor and abdominal musculature
ƒ Describe functional anatomy and relevant
pathophysiology
ƒ Pelvic support
ƒ Urinary continence
ƒ Fecal continence
Abdominal Wall
 Rectus Fascia Layers
ƒ What are the layers of the rectus fascia
ƒ Above the arcuate line?
ƒ Below the arcuate line?
Median umbilical fold
Medial umbilical
ligaments & folds
Lateral umbilical folds
Bony Anatomy and Ligaments
 Bony Pelvis
ƒ The bony pelvis is comprised of 2
innominate bones, the sacrum, and the
coccyx. What 3 pieces fuse to make the
Innominate bone?
ƒ Pubis
ƒ Ischium
ƒ Ilium
 Clinical Pelvimetry
Which measurements that can be
made on exam?
ƒ Inlet ƒ Diagonal Conjugate
ƒ Midplane ƒ Interspinous diameter
ƒ Outlet ƒ Transverse diameter
(intertuberous) and
AP diameter
(symphysis to
coccyx)
 Retrospective Case Control Study
MRI Pelvimetry
ƒ Pelvic MRI 1998 – 2002
ƒ Medical record review
ƒ Pelvic examination
ƒ Pelvic floor dysfunction symptoms
ƒ 98 total women
ƒ 59 with pelvic floor disorders
ƒ 39 without pelvic floor disorders

Handa VL, et al. Architectural Differences in the Bony Pelvis of Women With and
Without Pelvic Floor Disorders. Obstet Gynecol 2003;102:1283-90.
 Retrospective Case Control Study
MRI Pelvimetry
ƒ Women with pelvic floor disorders:
ƒ Wider transverse inlet
ƒ Wider intertuberous diameter
ƒ Wider interspinous diameter
ƒ Greater sacrococcygeal length
ƒ Deeper sacral curvature
ƒ Narrower AP outlet
ƒ After controlling for age, race and parity
ƒ Wider transverse inlet (OR 3.4, p = .006)
ƒ Shorter obstetrical conjugate (OR 0.2, p = .026)
ƒ Wider interspinous diameter (OR 2.8, p = .069)
 Pelvic Vasculature
ƒ Ovarian arteries originate from:
ƒ Aorta
ƒ Ovarian veins return to:
ƒ IVC and Left renal vein
ƒ Ureter
ƒ Below kidney, lateral/medial to ovarian A?
ƒ Lateral
ƒ Near pelvic brim, lateral/medial to ovarian A?
ƒ Medial
ƒ Over or under the uterine vessels?
ƒ Under
Branches of the Internal Iliac Artery
ƒ Anterior Division ƒ Posterior Division
ƒ Obturator ƒ Iliolumbar
ƒ Obliterated umbilical ƒ Lateral sacral
ƒ Sup & Inf vesical ƒ Superior gluteal
ƒ Uterine
ƒ Vaginal
ƒ Middle rectal
ƒ Pudendal
ƒ Inferior gluteal
What is the collateral circulation
after hypogastric artery ligation?
Pudendal Artery
Blood Supply to the Ureter
Blood Supply to Colon/Rectum
Nerves of the Pelvis
 Innervation to Levator Ani
ƒ 12 fresh-frozen
female cadavers
ƒ Each innervated S3-5
ƒ S4 alone 30%
ƒ S3-4 40%
ƒ S4-5 30%
ƒ No pudendal nerve
supply identified
ƒ Similar findings in rat
studies
Barber MD, et al. Innervation of the female levator ani muscles. Am J Obstet Gynecol
2002;187:64-71.
Bremer RE, Barber MD, et al. Innervation of the Levator Ani and Coccygeus Muscles
of the Female Rat. Anat Rec Part A 2003;275A:1031-41.
 Nerve Injury
What nerve can be injured with:
ƒ Placement of deep lateral wall retractors on
Psoas at laparotomy?
ƒ Hyperflexion of the hips in lithotomy position or
tight underwear?
ƒ Leaning on the back of the legs during vaginal
surgery or sacrospinous ligament fixation?
ƒ Making a pfannensteil incision?
ƒ Pelvic lymph node dissection?
 Ilioinguinal and Iliohypogastric
Nerve Injuries
ƒ Mapping in 11 fresh frozen
cadavers
ƒ Ilioinguinal nerve
ƒ Entered 3.1 ± 1.5 cm medial, 3.7
± 1.5 cm inferior to ASIS
ƒ Terminated 2.7 ± 0.9 cm lateral to
midline, 1.7 ± 0.9 cm superior to
pubic symphysis
ƒ Iliohypogastric nerve
ƒ Entered 2.1 ± 1.8 cm medial and
0.9 ± 2.8 cm lateral to ASIS
ƒ Terminated 3.7 ± 2.7 cm lateral to
midline and 5.2 ± 2.6 cm superior
to pubic symphysis

Whiteside JL, et al. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar
placement and low transverse incisions. Am J Obstet Gynecol. 2003;189:1574-8.
 Nerve Injury During Uterosacral
Ligament Suspension

Siddique SA, et al. Relationship of the uterosacral ligament to the sacral plexus and to
the pudendal nerve. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:642-5.
 Name the 7 Surgical and
Anatomic Spaces
ƒ Prevesical (space of Retzius)
ƒ Vesicovaginal and vesicocervical
ƒ Paravesical
ƒ Rectovaginal
ƒ Pararectal
ƒ Retrorectal
ƒ Presacral
 Components of Pelvic Support

ƒ Bony pelvis

ƒ Endopelvic Fascia
(fibromuscular layer)

ƒ Pelvic diaphragm
Urethral Closure Pressure

3 components
• Rhabdosphincter
• Circular smooth
muscle
• Non-
neuromuscular
– Vascular cushions
– Mucosa
– Connective tissue
 Pelvic Diaphragm
Components

ƒ Levator ani Muscles

ƒ Puborectalis
ƒ Pubococcygeus
ƒ Iliococcygeus

ƒ Coccygeus muscles
Anal Continence Mechanism
 “Endopelvic Fascia”
ƒ Fibromuscular layer
ƒ Functionally single sheet of connective
tissue
ƒ Ligamentous condensations
ƒ Vasculature
ƒ Nerves
 Levels of Support
ƒ Level I
ƒ Uterosacral and cardinal ligaments
ƒ Support uterus and vaginal apex
ƒ Level II
ƒ Lateral attachments of endopelvic fascia and vagina
to arcus tendineus fascia pelvis
ƒ Support bladder, vagina, and rectum
ƒ Level III
ƒ Perineal membrane and perineal body
ƒ Support UVJ and perineum

DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet

Gynecol.1992;166:1717-24.
 Uterosacral Ligament
ƒ 15 female cadavers
ƒ USL attaches to S1-3 and variably to S4
ƒ Less vital structures below intermediate portion
ƒ Mean distances from USL to ureter
ƒ Cervical 0.9 ± 0.4 cm
ƒ Intermediate 2.3 ± 0.9 cm
ƒ Sacral 4.1 ± 0.6 cm
ƒ Ischial spine to ureter 4.9 ± 2.0 cm
ƒ Ischial spine consistently beneath intermediate
portion
ƒ USL tension transmitted to ureter most near
cervix
ƒ Cervix and intermediate portions strongest
Buller JL et al. Uterosacral Ligament: Description of Anatomic Relationships to Optimize
Surgical Safety. Obstet Gynecol 2001;97:873-9.
 MRI Vaginal Apex
Distances Sup/Inf Ant/Post Right/Left
Cervical 1.6 ± 0.5 1.1 ± 0.5 4.7 ± 0.4
Vaginal superior anterior medial
Junction to
Ischial
Spine
Posterior 5.3 ± 0.8 1.0 ± 1.0
Fornix to inferior anterior
S2

Gutman RE et al. Anatomic Relationship Between the Vaginal Apex and the Bony
Architecture of the Pelvis: a MRI Evaluation. Am J Obstet Gynecol 2005;
Leffler KS et al. Attachment of the rectovaginal septum to the pelvic sidewall. Am J
Obstet Gynecol 2001;185:41-3.
 Pelvic Diaphragm
Functions

ƒ Close genital hiatus

ƒ Creates levator plate

Levators Toned
 Interrelationship of Ligamentous
and Muscular Support
Muscular Support
ƒ Long-term support
ƒ Closure of genital hiatus
ƒ Levator plate
Ligamentous support
ƒ Short-term support
ƒ Tether viscera during relaxation of pelvic
diaphragm.
Analogy to Ship in Dry Dock
 Pelvic Floor Dysfunction
URINARY DYSFUNCTION
•Lower urinary tract symptoms
•Incontinence
•Voiding difficulties

VAGINAL DYSFUNCTION DEFECATORY DYSFUNCTION

•Protrusion symptoms •Incontinence
•Sexual dysfunction •Defecatory disorders
Risk Factors for Pelvic Organ Prolapse
Predispose Incite Promote Decompensate

Congenital Vaginal Obesity Aging

delivery
Racial Surgery Smoking Menopause

Gender Neuropathy Lung disease Neuropathy

Myopathy Constipation Myopathy

Recreation Debilitation

Occupation Medication
 Mechanisms of Prolapse
Neuromuscular Failure

ƒ Myopathic injury
ƒ Direct muscular compromise
ƒ Denervation
ƒ Neuropathic injury
ƒ Stretching – Chronic injury
ƒ Compression – Acute injury
ƒ Combinations
 Consequences of
Neuromuscular Compromise

Normal tone Loss of tone

Fecal Continence Mechanism
 Mechanisms of Prolapse
ƒ Ligamentous Failure

ƒ Connective tissue compromise

ƒ Stretching – Chronic injury
ƒ Tears – Acute injury
ƒ Combinations
Lower Urinary Tract and
Continence Mechanism
Perineal Descent
Pathophysiology of Prolapse

Detachment Attenuation

Inciting
Promoting
Factors

Neuropathy Myopathy
 Summary
ƒ Pelvic floor dysfunction is common and
can be debilitating.
ƒ Important to understand normal anatomy
and pathophysiology to properly care for
women with these conditions and to avoid
surgical complications.