THIRD BLOCK

Pelvic and Perineal Regions

THIRD BLOCK
Pelvis and Perineal Regions.
Theme # 1 Skeleton of the pelvic region

1. Identify the bones that comprise the pelvic skeleton.

2. Identify the surface projections of the anterior superior iliac spines, iliac crests, and pubic symphysis.

3. Describe 3 anatomical features that differentiate the male from the female pelvis.

4. Describe 3 anatomical features that differentiate the sacrum from the rest of the vertebral column.

Theme # 2 Organs within the female pelvic cavity

5. Identify and describe the positions respect to each other of the organs within the female cavity.

6. Describe the topographic anatomy of an empty bladder respect to a full bladder.

7. Describe the parts of the uterus and its relationship with the vagina.

8. Describe the position of the ovaries in relation to the uterine tubes and the uterus.

9. Explain how the peritoneum can be a site of an ectopic pregnancy.

10. Identify the common iliac, external, and internal iliac arteries. Mention the broad areas supplied by the branches of the internal iliac artery.

2
Pelvis and Perineal Regions.
Theme # 1 Skeleton of the pelvic region

1. Identify the bones that comprise the pelvic skeleton.

2. Identify the surface projections of the anterior superior

iliac spines, iliac crests, and pubic symphysis.

3. Describe 3 anatomical features that differentiate the

male from the female pelvis.

4. Describe 3 anatomical features that differentiate the

sacrum from the rest of the vertebral column.

3
 The Pelvis - skeleton
Pelvis

Ilium

Functions of the Pelvic Girdle

• Site of attachment of axial skeleton and lower limbs
• Transmits weight of upper body (upper limbs, head,
neck and trunk) to lower limb
• Involved in balance
• Protects and contains pelvic viscera (distal ureters,
bladder, rectum, sigmoid colon, reproductive organs)

Ischium
Pubis

Sacrum & coccyx

Fused (3 bones) bilateral hip bones 4
 Bony pelvis – inlet
Circular border between false and true pelves. It is completely ringed by bones

1. The profile is heart shaped because of the projection of body of S1

(red line) into the inlet, which forms the posterior aspect of the
ring. The projection is less in women, hence, it is transversely oval
in profile.
2. The wing-like (alae) sacral transverse processes (green line) extend
S1 the margin laterally. Ratio of S1 diameter to ala length is zero in
female but greater than 1 in male.
3. The margin continues laterally and carries forward to the pubic
symphysis as linea terminalis (purple line) formed by arcuate line
of ilium, pecten pubis and the pubic crest.
4. Pelvic viscera are locate in the pelvic cavity below the line of pelvic
inlet.
5. Fetus passes through the pelvic inlet from the abdomen in
women. Not so in men where the pelvis is for weight bearing.

Linea terminalis

Pubic symphysis
Think of the trunk (torso) symbols ▲(female) ▼(male) in relation to the pelvis
Beside weight bearing, female pelvis is also adapted for passage of fetus. 5
Male pelvis is solely for weight bearing. Weight of heavier torso is converge on the pelvis, hence, S1 projection
Bony pelvis – outlet

Pelvic outlet is diamond shaped.

It is formed by bone and ligaments unlike the inlet.
1. Anteriorly in the midline is the pubic symphysis
2. Pubic arch (formed by inferior pubic ramus, ischial
ramus and tuberosity) projects posteriorly and
laterally from pubic symphysis to form the margin of
the anterior half of the diamond.
3. Sacrotuberous ligament extends posteriorly from the
ischial tuberosity to coccyx and sacrum to form the
margin of the posterior half of the diamond.
4. Structures at the corners of the diamond (pubic
symphysis, ischial tuberosity and coccyx) are palpable.

6
 Bony pelvis – cavity

The bowl-shaped pelvic cavity is between –

Pelvic inlet - the red stipple line
Pelvic outlet - the blue stipple line

The cavity is enclosed by wall formed by

Two muscles – obturator internus and piriformis
Two ligaments – sacrospinous and sacrotuberous ligaments
1a Bones – Sacrum & coccyx and lower half of the pelvic bone
Piriformis
The cavity communicates with other parts via 3 main apertures in its wall:
1bSacrospinous 1. Greater sciatic foramen divided into 2 recesses by piriformis:
ligament a. Supra piriformis recess, a passage for superior gluteal neurovascular bundle
b. Infra piriformis recess, a passage for inferior gluteal neurovascular bundle, sciatic nerve and pudendal
Obturator 2 neurovascular bundle
3 2. Lesser sciatic foramen through which obturator internus exit the pelvis and pudendal
internus neurovascular bundle pass through to reenter the perineal part of the pelvis
3. Obturator canal through which the obturator neurovascular bundle get to the thigh.

7
Bony pelvis – division of the cavity
Bony pelvis – anatomical position
Bony pelvis – sex difference

•Differences linked to function

• Pregnancy and childbirth in females
• Heavier build and larger muscles of men
•Main differences
• Pelvis is heavier and has more pronounced muscle
attachment sites in male than in female
• Pubic arch is narrower and the subpubic angle more
acute in men than women
• Ischial tuberosities are closer in men than in women,
and the pelvis outlet is thus comparatively smaller.
• All of the ilia are less flared in men than in women, so
the greater pelvis is deeper.
• Pelvic inlet is heart-shaped in men and more
transversely oval in women
• Obturator foramen is round in men and oval in women
• Female pelvis is broader than in men, to allow the
passage of the fetal head 10
 Bony pelvis – landmarks & surface projections, anterior
1 Anterior superior iliac spine
2 Inguinal ligament
•Anterior superior iliac spine (ASIS) 3 Pubic tubercle
• Site of lateral attachment of inguinal ligament 4 pubic symphysis
• Site of attachment of sartorius and tensor fascia lata muscles 5 Superficial inguinal ring
•Pubic tubercle 6 Deep inguinal ring
• Medial point of attachment of inguinal ligament 7 Femoral artery
•Pubic symphysis 8 Femoral vein
• Secondary cartilaginous joint 9 Femoral canal
• Location of T12 dermatome along its superior margin 10 Femoral nerve
•Midpoint between pubic tubercle and ASIS marks the site for palpating the femoral
artery and vein (the midinguinal point)
•Iliac crest
• Follows a curve between the anterior and posterior superior iliac spines
• Highest point is at approximately the level of the umbilicus-level of L4
vertebral body
• Supracristal plane passes between the highest points of the iliac crests
•Intergluteal or natal cleft
• The cleft between the buttocks
• Site of pilonidal sinus and abscess formation

11
 Bony pelvis – landmarks, posterior & lateral

Gluteal region and posterior aspect of thigh: Lateral aspect of hip joint: palpable structures
palpable structures 1 Anterior superior iliac spine
1 Posterior superior iliac spine 2 Iliac crest
2 Coccyx 3 Posterior superior iliac spine
3 Ischial tuberosity 4 Symphysis pubis
4 Greater trochanter 5 Greater trochanter 12
The Pelvis - skeleton - features that differentiate sacrum

Unlike other vertebrae of other segment of the spine

1. The 5 vertebrae of the sacrum fused together to form alarge thick wedge shaped bone
2. It shape describe a base, an apex, two auricular surfaces and an anterior and a posterior surfaces
3. It is the only set of vertebrae wedge between two bones to transmit upper body weight to the two legs
4. It is the caudal most vertebrae of the spine
5. Anteriorly concave to form the posterior wall of the pelvic cavity
13 crests.
6. Unlike the smooth anterior surface (save some horizontal ridges), posterior surface displayed three longitudinal
Pelvic organs - female
Theme # 2 Organs within the female pelvic cavity

5. Identify and describe the positions respect to each other of the organs within the
female cavity.

6. Describe the topographic anatomy of an empty bladder respect to a full bladder.

7. Describe the parts of the uterus and its relationship with the vagina.

8. Describe the position of the ovaries in relation to the uterine tubes and the uterus.

9. Explain how the peritoneum can be a site of an ectopic pregnancy.

10. Identify the common iliac, external, and internal iliac arteries. Mention the broad
areas supplied by the branches of the internal iliac artery.

14
Pelvic organs – female, relative positions within the cavity
1. Pubic symphysis
2. Urinary bladder
3. Uterus
4. Uterine tube
• The pelvic cavity is lined by peritoneum continuous with the 5. Ovary
peritoneum of the abdominal cavity. 6. Vagina
• Pelvic peritoneum drapes over the superior aspects of the 4 7. Rectum
8. Ana canal
pelvic viscera and does not reach the pelvic floor in most 5
regions.
• The pelvic viscera are located in the midline of the pelvic 3
cavity. The bladder is anterior and the rectum is posterior. 7
• In women, the uterus lies between the bladder and rectum.
Other structures, such as vessels and nerves, lie deep to the 2
1
peritoneum in association with the pelvic walls and on either 6
side of the pelvic viscera.
8

15
 Pelvic organs – topography of empty vs full bladder
1 2
3

• The bladder is the most anterior

1. External iliac artery
element of the pelvic viscera. 2. Common iliac artery
• It is entirely situated in the pelvic 3. Internal iliac artery
cavity and triangular pyramid in 4. Ureter
5. Superior surface
shape when empty. 6. Neck of bladder
• It expands superiorly into the 7. urethra
abdominal cavity and assume
spherical shape when full.

6
7 16
Pelvic organs – female, uterus & vagina, their relationships
5

c 6
b
1. Fundus 1 d
2. Body a
3. Cervix
4. Vagina
8
e
5. Uterine tube 7
a. Intramural part of uterine tube
b. Isthmus 2
c. Ampulla
d. Infundibulum
e. Fimbrae
6. Suspensory ligament of ovary 3
7. Ovary
8. Ligament of ovary
9. Round ligament of uterus

4
Coronal section 17
Pelvic organs – female, ovaries relative position to the
uterine tubes & the uterus

uterus
Ovary
uterus
Broad ligament
of uterus

Posterior view Sagittal section

18
Pelvic organs – female, ovaries relative position to the
uterine tubes & the uterus

19
Pelvic organs – female, peritoneum as site of ectopic pregnancy

20
Pelvic organs – female, peritoneum as site of ectopic
pregnancy
Theme # 2 Organs within the female pelvic cavity

5. Identify and describe the positions respect to each other of the organs within the
female cavity.

6. Describe the topographic anatomy of an empty bladder respect to a full bladder.

7. Describe the parts of the uterus and its relationship with the vagina.

8. Describe the position of the ovaries in relation to the uterine tubes and the uterus.

9. Explain how the peritoneum can be a site of an ectopic pregnancy.

10. Identify the common iliac, external, and internal iliac arteries. Mention the broad
areas supplied by the branches of the internal iliac artery.

21
Pelvic organs – vascular supply, internal iliac artery and some of its branches
Abdominal aorta bifurcates @ L4/L5 IV disc into:
- Left common iliac (cut) and
- Right common iliac
L5
Left common iliac vein (cut)

S1

Right common iliac artery bifurcates anterior to sacroiliac joint @ L5/S1 IV disc into:
- Right internal iliac &
- Right external iliac

Ureter
Internal pudendal artery
Inferior gluteal artery
Middle rectal artery

Uterus
Uterine (artery of ductus deferens) and vaginal (inferior vesical) arteries
Urinary bladder Obturator artery

Superior vesical artery

22
Pelvic organs – vascular supply, internal iliac artery and some of its branches

23
Pelvic organs – vascular supply, internal iliac artery and some of its branches

Male Female

24
THIRD BLOCK
Pelvis and Perineal Regions.

Theme # 3 Organs within the male pelvic cavity

11. Identify and describe the positions respect to each other of the organs within the male cavity.

12. Identify the prostate and the prostatic urethra.

13. Identify the testicles, seminal vesicles, and the vas deferens.

14. Trace the route of the spermatozoa from the testicles to the penile urethra.

Theme # 4: Perineal region

15. Identify the four bones that form the angles of the diamond shape of the perineum.

16. Identify the urogenital and the anal triangles in both female and male.

17. Identify the external genitalia of the female.

18. Describe the position of the urethral and vaginal openings.

19. Identify the external genitalia of the male.

20. Identify the pelvic diaphragm and describe its function.

25
Pelvis and Perineal Regions.

Theme # 3 Organs within the male pelvic cavity

11. Identify and describe the positions respect to each

other of the organs within the male cavity.

12. Identify the prostate and the prostatic urethra.

13. Identify the testicles, seminal vesicles, and the vas

deferens.

14. Trace the route of the spermatozoa from the testicles

to the penile urethra.

26
Pelvic organs – male, relative positions within the cavity

Urinary
bladder Seminal
Pubic vesicle
symphysis Rectum
Prostate
Bulbourethral
gland
gland

27
Pelvic organs – male, testicles & vas deferens
Urinary
bladder
Urinary
bladder

Prostate

Root

Shaft Penis

Testis
Testis Testis
28
 Pelvic organs – male, seminal vesicles
• Paired tubular gland (1) that coiled
on itself and held together by dense 3 2 3
3 endopelvic fascia to give appearance
1 1
2 of lobulalation.
1
• It is located between the base of the
bladder in front (2) and rectum
4 4
behind. It is inferolateral to the
ampullae of the ductus deferens (3)
• It develops as a diverticula of the
ductus deferens.
• Its narrow lower end join the
ampullae of the ductus deferens to
form the ejaculatory ducts which
pierce the posterior surface of the
prostate gland (4) to empty into the
prostatic urethra.
• The alkaline secretion from this gland
is rich in fructose and choline
29
Pelvic organs – male, bulbourethral glands

• It is situated within the deep

perineal pouch lateral to the
membranous part of the urethra.
• The duct from each gland passes
inferomedially through the perineal
membrane to open into the bulb of
the spongy urethra at the root of
the penis.
• Secretion from this gland lubricate
the urethra in pre-ejaculatory
emission

30
Prostate gland

31
 Male pelvic cavity – prostate gland, size, capsule, surfaces & relations
Prostate is 4 cm in transverse diameter, 3 cm in vertical dimension and 2 cm thick
It is behind the lower margin of the pubic symphysis and in front of rectal ampulla

Superior (vesical) surface

Related to bladder neck & pierced by
the urethra more anteriorly

Capsules Inferolateral surfaces

TRUE: from prostatic stroma Is related to levator ani muscles
FALSE: from pelvic fascia
Prostatic venous plexus is Posterior surface
sandwiched between the 2 capsule Anterior surface Separated from rectal
Separated from pubic ampulla by rectovesical
bone by retropubic space fascia and pierced by rt &
containing fat. This lt ejaculatory ducts
surface is attached to the
Apex bone by puboprostatic
Supported by the ligament
urogenital diaphragm

32
Pelvic organs – male, spermatozoa from the testicles to the penile urethra

3 3

4 4
5
5 6
2

1
1
33
 Theme # 4:

Perineal region

34
THIRD BLOCK
Pelvis and Perineal Regions.

Theme # 4: Perineal region

15. Identify the four bones that form the angles of the diamond shape of the perineum.

16. Identify the urogenital and the anal triangles in both female and male.

17. Identify the external genitalia of the female.

18. Describe the position of the urethral and vaginal openings.

19. Identify the external genitalia of the male.

20. Identify the pelvic diaphragm and describe its function.

35
Perineal region – bony landmarks of the perineum
• The perineum is inferior to the floor of the pelvic cavity.
• Boundaries form the pelvic outlet.

36
Perineal region – division of the perineum in both sexes
A superficial region below the pelvic diaphragm through which the anal canal and the lower parts
of the genital and urinary tracts traversed to open to the exterior.

37
Perineal region – female external genitalia, urethral & vaginal openings

Mons pubis

Labia majora

Prepuce of clitoris

Glans of clitoris

External urethra orifice

Openings of paraurethral (Skene’s) ducts

Labia minora

Vaginal orifice

Openings of greater vestibular (Batholin’s) glands

38
 Pelvic diaphragm:– shape and location

1. Funnel-shaped muscular partition that separate the

pelvic cavity above from the perineum below.
2. This muscular partition extends from the pubis to the
coccyx and from lateral wall to lateral wall.
3. The partition transmits urethra, vagina (in females)
and anal canal.

39
 Pelvic diaphragm: muscles, male
Pelvic diaphragm

Levator ani Coccygeus Arcus tendinous Perineal body

(muscle) (muscle) (thickened line of fascia) (central tendon)

For urethra

For anal canal Perineal fascia (perineal membrane and content of

the deep perineal space) covers the anterior U
shaped (urogenital) defect in the pelvic diaphragm

Levator ani muscles main part of the pelvic diaphragm

Puboprostaticus
Puborectalis
Pubococcygeus
Iliococcygeus
They originate from the tendinous arch on both sides
Meet at the midline raphae

Coccygeus, which overlies sacrospinous ligament

& connects sacrum and coccyx to the ischial
spine, completed levator ani posteriorly

40
 Pelvic diaphragm: muscles, female

Urethra
Pubovaginalis replaces
Vagina puboprostaticus in male

Rectum

41
 Pelvic diaphragm: functions

1. Support functions: collectively supports the pelvic viscera and head of the fetus
2. Pressure manipulation: When they contract as a unit, the pelvic floor is raised to increase
abdominal pressure. such as when coughing, sneezing, urinating, defecating, lifting heavy objects.
3. Micturition: Important in voluntary control of urination
4. Fecal continence: tonic contraction of puborectalis slung around anorectal junction maintain
continence. This muscle relaxes during defecation.
5. Muscle attachment: perineal surface provides attachment for muscles associated with erectile
tissues of the root of penis and clitoris

42
Perineal region – male external genitalia

Root of penis

Shaft of
penis
Penile
Glans of Scrotal
urethra
penis and sac
prepuce 43
Perineal region – male external genitalia, root of penis
Muscles:
superficial transverse perineal (1),
ischiocavernosus (2)
Bulbospongiosus (3)

Erectile tissue:
bulb of the penis or the vestibular bulbs (4)
crus of the penis or clitoris (5),

Central tendon of the perineum (6)

5 5
Gland:
2
greater vestibular glands (female)
2 4
duct of the bulbourethral gland (male)
(7) 3
4
3 Neurovascular:
branches of the internal pudendal vessels,
perineal nerve and its branches.
1 6 (8)
7 8
Perineal region – male external genitalia, root of penis

Muscles:
Deep transverse perineal muscle (1)
sphincter urethrae (2)

Membranous part of the urethra (3)

Gland: 1 4 2 3 4
Bulbourethral gland in male (4)

23
4
Neurovascular:
Branches of the internal pudendal vessels,
pudendal nerve.
Perineal region – male external genitalia,
root of penis, superficial dissection

Bulbospongiosus covering bulb

the of penis

Ischiocavernosus muscles
overlying crus of penis

Inferior fascia covering the deep

transverse pereneal muscles

Superficial transverse perineal

muscle
Perineal region – male external genitalia, shaft of penis
Skin and fascial layers
Skin and superficial fascia:
1. Covers the deep fascia and superficial nerves and vessels. Freely mobile except over
the glans
2. Membranous layer which is devoid of fat is continuous proximally with the
subcutaneous tissue of the anterior abdominal wall and traceable around the scrotum.
3. Distally the skin is reflected over the glans at the corona to form the prepuce which
attached to the undersurface of the glans by the frenulum

Deep (Buck) fascia:

1. Envelopes the 3 corpora of the penis along with the deep dorsal
vessels and nerves.
2. Proximally anchored to the pubic symphysis by suspensory ligament.
3. Distally, it terminate at the corona by fusing with the corpora

Tunica albugenia
1. Dense layer of fibrous envelope around the erectile tissue.
2. Very dense around corpora cavernosa to maintain turgidity
after engorgement by impeding venous return
3. Less dense and more elastic around corpus spongiosum hence
less turgid during erection to permit passage of ejaculate
Perineal region – male external genitalia, shaft of penis
Erectile tissues
Dorsal artery Deep dorsal
vein

Corpora cavernosa
1. Paired erectile tissue dorsal to corpus spongiosum
2. Extends distally into the concave proximal surface of the glans
3. Continue proximally below the pubic symphysis into the
perineum where it diverge as crura
4. Each crus tapers posteriorly and attached to the inferior
surface of the perineal membrane and adjacent pubic and
ischial rami

Corpus spongiosum
1. Continue distally with a uniform diameter except terminally
where it expanded as the glans.
2. Prominent margin of the glans is the corona
3. It continues proximally as the bulb of the penis which attached to
the inferior surface of the perineal membrane as the part of
penile root.
 Perineal region – male external genitalia, scrotal sac

1 A pouch of skin and fascia derived from embryonic labioscrotal swelling.

2 It contains the testes, epididymides and the lower parts of the spermatic cords.
3
1 Superficial inguinal ring
2 Spermatic cord
4 3 External spermatic fascia
4 Ilio-inguinal nerve
5 Cremasteric fascia
5
6 Internal spermatic fascia
6 7 Ductus deferens
7 8 8 Testicular artery & pampiniform plexus
9 Scrotal sac
10 Tunica albuginea covering testis
11 Tunica vaginalis, visceral layer
9 12 Tunica vaginalis, parietal layer
10 13 Superficial fascia with dartos muscle fibres

Right spermatic cord from superficial inguinal

13
12 11 ring to the testis in the scrotal sac
 Perineal region – male external genitalia, testis
1
2
3
4
1 = Ductus deferens 15
2 = Testicular artery
11
5 3 = Pampiniform plexus
4 = Internal spermatic fascia
14
5 = Cremasteric fascia
8 7
6 = External spermatic fascia
7 = Parietal layer of T. vaginalis
6 8 = Fat
9 = Head of epididymis
10 = Testis
9
11 = Epididymis (body)
12 = Tail of epididymis
13 = Inferior pole 10
14 = Superior pole
15 = Efferent ductules

Lateral view
12
13
Left testis and spermatic cord within Cut in the parietal layer of the tunica vaginalis Epididymis is revealed after removal of the
their fascial sleeves. revealed the testis and head of the epididymis. tunica vaginalis and pampiniform plexus.
The End