2024 Male & Female Perineum

OLFU MEDICINE GHSB - FINALS | Dr Sapo| June 8, 2021

OVERVIEW ANAL TRIANGLE (POSTERIOR)

• Anal Canal (Central)

CONTENTS
Anus - lower opening
• Ischioanal Fossa (Lateral)

• Ischial tuberosities
BOUNDARIES • Tip of Coccyx
• Sacrotuberous Ligaments

ANAL CANAL

• separates pelvic cavity to the

perineum
• Incomplete anteriorly an has space
called UROGENITAL HIATUS, for
the passage of urethra (male &
PELVIC DIAPHRAGM
female) and vagina (females)

• Madeup of 2 muscles:
Levator Ani
Coccygeous Muscle

PERINEUM

Rectum is continuous to the anal canal below the pelvic diaphragm

• 1.5 inches long
• Passes downward and backward from rectal ampulla

PECTINATE LINE
• Symphysis Pubis
• Ischiopubic Rami
BOUNDARIES • Ischial Tuberosities
• Sacratuberous Ligaments
• Tip of Coccyx

ROOF Pelvic Diaphragm

FLOOR Skin & Fascia

• Urogenital Triangle (Anterior)

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DIVISIONS
• Anal Triangle (Posterior)

 • Extends from: INTERNAL HEMORRHOIDS

ANORECTAL JUNCTION - superior ends of the anal column
JUNCTION OF THE UPPER & LOWER HALVES OF THE ANAL CANAL -
pectinate line
ANUS - opening

• Involuntary (made up of
INTERNAL ANAL smoothe muscles)
SPHINCTER • Innervated by inferior
hypogastric plexus

ANAL SPHINCTERS • Voluntary (made up of

skeletal muscles)
EXTERNAL ANAL • Innervated by inferior
SPHINCTER rectal nerve & perineal
branch of the 4th sacral
nerve

• Varicosities of the tributaries of the superior rectal vein which lie in the
anal columns
• Painless & Sensitive to Stretch
EXTERNAL ANAL • When anal canal is viewed proctoscope areas (3, 7, 11 o’clock
SPHINCTER PECTINATE positions are prone to varicosities)

EXTERNAL HEMORRHOIDS

INTERNAL ANAL
SPHINCTER

PECTINATE LINE

ABOVE BELOW

Embryologic Origin Hindgut Endoderm Ectoderm of Proctodeum

Epithelium Simple Columnar Stratified Squamous

EXTERNAL HEMORRHOIDS
Visceral (Inferior Somatic (Inferior Rectal
Innervation • Tributaries of the inferior rectal vein
Hypogastric Plexus) Nerve)
• Sensitive to pain, temperature, touch and pressure

Blood Supply Superior Rectal Artery Inferior Rectal Artery

Superior Rectal Vein → Middle & Rectal Inferior

Venous Drainage
Portal Vein Rectal Veins → IVC

Inferior Mesenteric Superficial Inguinal

Lymphatic Drainage
Nodes Nodes

Pain, Temperature,
Sensory Stretch
Touch, and Pressure

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 POSTERIOR VIEW OF ANAL CANAL ISCHIOANAL FOSSA / ISCHIORECTAL FOSSA

INFERIOR
MESENTERIC ARTERY

SUPERIOR RECTAL
ARTERY

Wedge-shaped space on each side of the anal canal

• Base - Skin
INFERIOR RECTAL BOUNDARIES • Medial - levator ani and anal canal
ARTERY • Lateral Wall - obturator internus

Inferior rectal vessels & nerve (branches to internal

pudendal vessels & pudendal nerve situated in the
BLOOD SUPPLY CONTENTS
pudendal canal
fat
UPPER HALF (SUPERIOR) LOWER HALF (INFERIOR)

Superior Rectal Artery / Superior Inferior Rectal Artery / Inferior

Hemorrhoidal Artery which is a branch Hemorrhoid Artery branch of internal
of Inferior Mesenteric Artery pudendal Artery

INFERIOR
MESENTERIC VEIN

SUPERIOR
HEMORRHOIDAL VEIN

• communicate with one another posterior to the anal canal

if there’s infection on one side, it can cross the opposite side, by crossing
behind the anal canal
• Posterior recess that ends deep the gluteus maximus muscle
• Anterior recess that extends forward between the perineal membrane and pelvic
diaphragm
VENOUS DRAINAGE

UPPER HALF (SUPERIOR) LOWER HALF (INFERIOR)

joins via the Superior Rectal joins via Inferior Rectal (Hemorrhoidal)
(Hemorrhoidal) Vein which empties to Vein which empties to the internal

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Inferior Mesenteric Vein pudendal vein

 PUDENDAL CANAL UROGENITAL TRIANGLE (ANTERIOR)

pubic arch
symphysis

ischial tuberosity

• lls the pubic arch

PUDENDAL UROGENITAL DIAPHRAGM MADE UP OF 2 MUSCLES

CANAL 1. Deep transverse perineal muscle
2. Sphincter urethrae - surrounds urethra

Superior Fascia
BOUNDARIES
Inferior fascia - perineal membrane

Located lateral to the ischioanal fossa SUPERFICIAL FASCIA

CONTENTS OF PUDENDAL CANAL / ALOCKS CANAL

GREATER
SCIATIC
FORAMEN

PUDENDAL
NERVE
LESSER
SCIATIC
FORAMEN
INTERNAL
PUDENDAL
ISCHIAL SPINE ARTERY
PERINEUM

1. Internal pudendal artery

2. Internal Pudendal Vein (not shown)
3. Pudendal Nerve
• these 3 structures will exit to the pelvic cavity by traversing the greater sciatic
foramen, they will then curve posterior to the ischial spine and enter the
perineum by traversing the lesser sciatic foramen

COLLES FASCIA - superficial fascia of perineum

it is continues with the dartos fascia of the scrotum and penis together with the
superifcial fascia of the lower abdomen called camper’s fascia

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 CORONAL VIEW ALONG PERINEUM DEEP PERINEAL POUCH / SPACE (FEMALE)

urethra

portion of vagina
UROGENITAL DIAPHRAGM (4) - located between the pubic arch, covered by a
fascia above and below
SUPERFICIAL PERINEAL SPACE
1. SUPERIOR FASCIA OF UROGENTIAL DIAPHRAGM
2. INFERIOR FASCIA OF UROGENITAL DIAPHRAGM OR PERINEAL
MEMBRANE
3. COLLES FASCIA - superficial fascia of perineum
ischiocavernosus muscle
DEEP PERINEAL POUCH - space between superior & inferior fascia
SUPERFICIAL PERIENAL POUCH - space between perineal membrane and
colles fascia
crura of the penis

DEEP PERINEAL POUCH / SPACE

bulb of the penis
bulbourethral gland

bulbocavernosus muscle

Located between superificial perineal fascia (colles fascia) and perineal membrane
(inferior fascia)

MALE FEMALE

Bulb of penis and bulbocavernosus Bulb of vestibule and bulbocavernosus

Crura of penis and ischiocavernosus Crura of clirtoris and ischiocavernosus

- Greater vestibular (Bartholin) Gland

Superficial Transverse Perineal Muscle

Located between perineal memrbrane (inferior fascia) and superior fascia of the
urogenital diaphragm Perineal nerves and vessels

MALE FEMALE Perineal Branches from pudendal nerve

Membranous Urethra Urethra SUPERFICIAL PERINEAL POUCH / SPACE (FEMALE)

Bulbourethral Gland (Cowper’s Gland) -

- Portion of the vagina

Deep transverse perineal muscles (Urogenital Diaphragm)

External Urethral Sphincter (Sphincter Urethrae)

ischiocavernosus ms
Internal Pudendal Vessels
crura of clitoris
Dorsal nerve of the penis or clitoris
bulbocavernosus ms
bulb of the vestibule

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 MALE UROGENTIAL TRIANGLE VENOUS DRAINAGE OF THE PENIS

prostatic venous plexus

dorsal vein

• Penis
CONTENTS
• Scrotum

erectile bodies drain to venous plexus that empty into a single, large deep dorsal
vein into the prostatic venous plexus

LYMPHATIC DRAINAGE
BULBOURETHRAL GLAND
• seen between deep perineal pouch medial group of superficial inguinal
• embedded in the sphincter urethrae SKIN
nodes
muscle
• pour / empties their secretion into the Drains into internal iliac nodes (deep
ERECTILE BODIES
penile urethra lymphondes)

MALE URETHRA

PENIS prostatic urethra

• ROOT
Crus - covered by ischiocavernosus
Bulb - covered by bulbocavernosus membranous urethra

• BODY
Corpus cavernosum (2) - continuation of the crura penile urethra
Corpus spongiosum - continuation of the bulb
- transvered by penile (spongy) urethra
- Glans - expanded distal portion

crus

bulb
LENGHT COMMENTS

corpora cavernosa 1.5 inches wides and most dilatable

PROSTATIC URETHRA

crus MEMBRANOUS 0.5 inches least dilatable

URETHRA

bulb corpus spongiosum

6 inches receive openings of
PENILE (SPONGY
bulbourethral glands
URETHRA)
narrowest portion
• BULBOCAVERNOSUS
compress the penile part of the
urethra and empty it of residaul
ERECTION urine or semen
compress the deep dorsal vein
• ISCHIOCAVERNOSUS monami | 6 of 8
compress the crus of the penis

 FEMALE UROGENTIAL TRIANGLE GREATER VESTIBULAR GLAND / BARTHOLIN’S GLAND

• Paired structures located at the

superficial perineal pouch
• Drains its secretion into the vestibule
by a small duct
• Secrete lubricating mucus
• Homologous of the male bulborethral
glands

LESSER VESTIBULAR GLAND / SKENE / PARAURETHRAL GLANDS

• Open into the vestibule by small

ducts on either side or the external
urethral orifice
• Corresponds the prostate in males
VULVA

• Mons Pubis
• Labia Majora
• Labia Minora
EXTERNAL GENITALIA • Clitoris
• Vestibule VESTIBULE
• Vestibular Bulbs
• Greater Vestibular Glands

CLITORIS Opening of External Urethral Ori ce

Skene’s Gland
• Greater Vestibular Gland
bulb
(Bartholin’s Gland)
• Lesser Vestibular Gland (Skene Opening of Vagina
• ROOT
Gland)
Crus (2)
• Vagina
• BODY
• Urethra
Opening of Bartholin’s Gland

BULB OF VESTIBULE

bulb of vestibule

• corresponds to the bulb of the penis

• covered by bulbospongiosus muscle

VAGINA

• 3 inches long
• Upper half of the vagina lies within
the true pelvis
FEMALE URETHRA
• lower half lies within the perineum vagina
• cervix pierced its upper anterior wall
forming spaces called fornices
• Upper fornix - has a relationship with
cul de sac of Douglas

urethra
• 1.5 inches long HYMEN
• Opens behind the clitoris - thin mucosa fold at the vaginal orifice
in a virgin
- perforated at its center

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 EPISIOTOMOY
SIGMOIDOSCOPY • surgical incision through the
sigmoid is gently inserted perineal skin in a
into the anus and anal canal
posterolateral direction to
in the direction of the
avoid anal sphincters
umbilicus to ensure that the
instrument passes along the
• when its obvious to the
long axis of the canal obstetrician that the
* sigmoidoscope should be perineum will r=tear before
directed towards the the baby’s head emerges
umbilicus through the vaginal orifice
• Breech deliveries and
URETHRAL RUPTURE forceps deliveries are
• common side of the usually preceded by an
rupture is within the episiotomy
bulb of the penis
• urine extravasates into MIDLINE MEDIOLATERAL
the superficial perineal
space and then passes SURGICAL REPAIR Easy More Diffucult
forward over the
scrotum beneath the FAULTY HEALING Rare More Common
membranous layer of
POSTOPERATIVE PAIN Minimal Common
superficial fascia
ANATOMIC RESULTS Excellent Occasional Faulty
CATHETERIZATION
BLOOD LOSS Less More
(MALE)
• penis is held erect at a DYSPAREUNIA Rare Occassional
right angle to the
anterior abdominal EXTENSIONS Common Uncommon
wall to make the S-
shape to J-shape

• course of male urethra PUDENDAL NERVE BLOCK

is usually S-shaped • Transvaginal Procedure
• Bony Landmark: Ischial Spine
Index finger is inserted through the vagina to palpate the ischial spine
Needle of the syringe is then passed through the vaginal mucous
membrane toward the ischial spine
CATHETERIZATION
(FEMALE) • Perineal Procedure
• Urethra is straight, and • Bony Landmark: Ischial Tuberosity
only minor resistance is Tuberosity is palpated subcutaneously
felt as catheter passes Needle is introduced into the pudendal anal along the medial side of the
through the external tuberosity
urethral sphincter Canal lies about 1 inch deep to the free surface of the ischial tuberosity

CYSTITIS
• infection of the urinary
bladder
• short length of the
female urethra
predisposes to
ascending infection

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