ANATOMY OF PELVIS AND

PERINEUM
OUTLINE
• 1) the Bony Pelvis, general description
• 2) structure of the walls, sex differences,
• 3) nerves of the walls, Blood vessels and lymphatics of the pelvis
• 4) joints of the pelvis, pelvic cavity and its contents in both sexes, the
rectum
• 5) Pelvic Diaphragm, urogenital diaphragm
• 6)Perineum---- Male, female
Soft tissues of pelvis (Ligaments )
• Broad Ligament of the Uterus
➢ Consists of two layers of peritoneum, extends from the lateral
margin of the uterus to the lateral pelvic wall, and serves to hold the
uterus in position.
➢ Contains the uterine tube, uterine vessels, round ligament of the
uterus, ovarian ligament, ureter (lower part), uterovaginal nerve
plexus, and lymphatic vessels.
➢ Does not contain the ovary but gives attachment to the ovary
through the mesovarium.
➢ Has a posterior layer that curves from the isthmus of the uterus (the
rectouterine fold) to the posterior wall of the pelvis alongside the
rectum.
Uterus, broad ligament
Female pelvis
Female pelvis
Soft tissues of pelvis (ligaments)

• 1. Mesovarium
➢Is a fold of peritoneum that connects the anterior surface of the
ovary with the posterior layer of the broad ligament.
• 2. Mesosalpinx
➢ Is a fold of the broad ligament that suspends the uterine tube.
• 3. Mesometrium
➢ Is a major part of the broad ligament below the mesosalpinx and
mesovarium.
Soft tissues of pelvis(ligaments, contd)
• . Round Ligament of the Uterus
➢ Is attached to the uterus in front of and below the attachment of the
uterine tube and represents the remains of the lower part of the
gubernaculum.
➢ Runs within the layers of the broad ligament, contains smooth
muscle fi bers, and holds the fundus of the uterus forward, keeping
the uterus anteverted and anteflexed.
➢ Enters the inguinal canal at the deep inguinal ring, emerges from the
superfi cial inguinal ring, and becomes lost in the subcutaneous tissue
of the labium majus.
Soft tissues (ligaments, contd)
• Ovarian Ligament (uteroovarian ligament):
➢ Is a fibromuscular cord that extends from the ovary to the uterus
below the uterine tube, running within the layers of the broad
ligament.
• Suspensory Ligament of the Ovary
➢ Is a band of peritoneum that extends upward from the ovary to the
pelvic wall and transmits the ovarian vessels, nerves, and lymphatics
Soft tissues of pelvis(ligaments, contd)
• Lateral or Transverse Cervical (Cardinal or Mackenrodt’s) Ligaments
of the Uterus
➢Are fibromuscular condensations of pelvic fascia from the cervix and
the vagina to the pelvic walls, extend laterally below the base of the
broad ligament, and support the uterus.
• Pubocervical Ligaments
➢ Are firm bands of connective tissue that extend from the posterior
surface of the pubis to the cervix of the uterus
Uterus and supporting structures
 Soft tissues (ligaments, contd)
• Pubovesical (Female) or Puboprostatic (Male) Ligaments
➢ Are condensations of the pelvic fascia that extend from the neck of the
bladder (or the prostate gland in the male) to the pelvic bone.
• Sacrocervical Ligaments
• Are firm fibromuscular bands of pelvic fascia that extend from the
lower end of the sacrum to the cervix and the upper end of the vagina.
Pelvic Soft tissues(ligaments, contd)
• Inferior Pubic (Arcuate Pubic) Ligament
➢Arches across the inferior aspect of the pubic symphysis and attaches
to the medial borders of the inferior pubic rami.
• Sacrouterine (uterosacral) Ligaments
➢ Hold the cervix back and upward and sometimes elevate a shelf-like
fold of peritoneum (rectouterine fold), which passes from the isthmus
of the uterus to the posterior wall of the pelvis lateral to the rectum.
➢ It corresponds to the sacrogenital (rectoprostatic) fold in the male
Soft tissues of pelvis (pouches)
• Rectouterine Pouch (Cul-de-sac of Douglas)
• Is a sac or recess formed by a fold of the peritoneum dipping down
between the rectum and the uterus.
• Lies behind the posterior fornix of the vagina and contains peritoneal
fluid and some of the small intestine.
• Rectovesical Pouch
Is a peritoneal recess between the bladder and the rectum in males,
and the vesicouterine pouch is a peritoneal sac between the bladder
and the uterus in females.
Pouch of Douglas (yellow arrow, pouch
between uterus and rectum
Clinical significance of the pelvic pouches
• Culdocentesis is aspiration of fluid from the cul-de-sac of Douglas
(rectouterine pouch) by a needle puncture of the posterior vaginal
fornix near the midline between the uterosacral ligaments;
➢ because the rectouterine pouch is the lowest portion of the
peritoneal cavity, it can collect fluid.
➢This procedure is done when there is lower abdominal or pelvic pain
and when a ruptured ectopic pregnancy or ovarian cyst is suspected.
Pelvic soft tissues( URETER)
• Ureter
➢ Is a muscular tube that transmits urine by peristaltic waves.
➢Its about 25 to 30cm in length
➢ Has three constrictions along its course:
❖ at its origin where the pelvis of the kidney joins the ureter,
❖ where it crosses the pelvic brim,
❖ and at its junction with the bladder.
Soft tissues of pelvis(ureter)
• The Ureter
➢ Crosses the pelvic brim in front of the bifurcation of the common
iliac artery;
➢descends retroperitoneally on the lateral pelvic wall;
➢and runs medial to the umbilical artery and the obturator vessels and
posterior to the ovary, forming the posterior boundary of the ovarian
fossa.
The ureter
• In females, the ureter is accompanied in its course by the uterine
artery in the pelvis around the uterus
• The uterine artery runs above and anterior to it in the base of the
broad ligament of the uterus.
• Because of its location, the ureter is in danger of being injured in the
process of hysterectomy.
ureter
• Passes posterior and inferior to the ductus deferens and lies in front
of the seminal vesicle before entering the posterolateral aspect of the
bladder in males.
• ■ Enters obliquely through the base of the bladder and opens by a
slit-like orice that acts as a valve, and the circular fibers of the
intramural part of the ureter act as a sphincter.
• When the bladder is distended, the valve and sphincter actions
prevent the reflux of urine from the urinary bladder into the ureter.
• ■ Receives blood from the aorta and the renal, gonadal, common and
internal iliac, umbilical, superior and inferior vesical, and middle rectal
arteries.
ureter
• From its beginning at the pelvis of kidney to the its entrance into the
bladder, the ureter receives blood supply from the:
➢ abdominal aorta
➢ the renal artery
➢ gonadal artery,
➢ common and internal iliac arteries,
➢ umbilical artery
➢ superior and inferior vesical arteries
➢ middle rectal arteries.
Clinical significance/ ureter
• Damage of the ureter:
➢in the female, damage may occur during a hysterectomy or surgical
repair of a prolapsed uterus because it runs under the uterine artery.
➢ The ureter is inadvertently clamped, ligated, or divided during a
hysterectomy when the uterine artery is being ligated to control
uterine bleeding
Urinary bladder
• Is situated below the peritoneum
• Extends upward above the pelvic brim as it fills up
• may reach as high as the umbilicus if fully distended.

• Has the apex at the anterior end and the fundus or base as its
posterior triangular portion.
• Between the apex and the fundus is the body of the bladder, which
stores urine

• Has a neck, which is the area where the fundus and the inferolateral
surfaces come together, leading into the urethra.
Urinary bladder
• Has a uvula, which is a small eminence at the apex of its trigone,
projecting into the orifice of the urethra.
• The trigone is bounded by the two orifices of the ureters and the
internal urethral orifice.
• The fundus (base) contains the trigone
• Around the internal urethral orifice is a thick circular layer of muscle
called the internal sphincter (sphincter vesicae).
• Has bundles of smooth muscle fibers that, as a whole, are known as
the detrusor muscle of the bladder.
Urinary bladder, female
pelvis organs/male
Urinary bladder, male
Urinary bladder and urethra, male & female
Urinary bladder
Key facts about the urinary bladder

Parts Body, which collects the urine.

Fundus (base), which contains the trigone.
Trigone, which houses the urethra.

Capacity Average capacity is 400 to 600 mL, but can be as high as 1000 m

Function Collect urine

Provide sensation and motor control of urination
Urinary bladder/ blood supply
• Receives blood supply:
➢from the superior vesical artery (both sexes)
➢From the inferior vesical artery (males)
➢and from the vaginal artery in females

• Its venous blood is drained by the prostatic (or vesical) plexus of

veins, which empties into the internal iliac vein.

• NB: The inside surface of the bladder is lined with transitional

epithelium
Urinary bladder, innervation
• Is innervated by nerve fibers from the vesical and prostatic plexuses
of nerves.
• The parasympathetic nerve (pelvic splanchnic nerve, originating from
S2–S4):
➢stimulates the detrusor muscle of the bladder wall to contract,
➢ whilst relaxing the internal urethral sphincter, and thereby promotes
emptying.

• The sympathetic nerve ( mostly from the hypogastric nerve plexus):

➢ relaxes the detrusor of the bladder wall
➢and constricts the internal urethral sphincter
Urinary bladder (innervation, motor control)
• Sensations from the bladder are transmitted to the central nervous
system (CNS) via general visceral afferent fibers (GVA).
• Whereas GVA nerve fibers on the superior surface of the bladder
follow the course of the sympathetic efferent nerves back to the CNS
• , GVA nerve fibers on the inferior portion follow along with the
parasympathetic efferent nerve fibers to CNS

• NB: these neuronal pathways enable one to (1) know the bladder is
full, and (2) motor control to void/urinate at one’s own will
The ureter
Ureter and bladder
Female bladder and urethra
Clinical significance, urinary bladder
• Bladder cancer usually originates in cells lining the inside of the
bladder (transitional epithelial cell carcinoma)
• The most common symptom is blood in the urine (hematuria).
• Other symptoms include frequent urination and pain upon urination
(dysuria).
• This cancer may be induced by organic carcinogens that are
deposited in the urine after being absorbed from the environment
and also by cigarette smoking.
urethra
• Is serves as a passage for urine from the urinary bladder to the
exterior, but in male, it also serves as a passage for semen.
• ■ Male urethra is approximately 18cm to 22 cm long and consists of
three parts:
• prostatic, membranous, and spongy.
• The lowest part of the membranous urethra is liable to rupture or to
penetration by a catheter.
• ■ Female urethra is approximately 4 cm long, and its external
urethral orifice is situated between the labia minora, in front of the
vaginal opening but behind the glans clitoris
External genitalia, female
Male urethra
• The male urethra is an 18-22 cm long muscular tube that conveys
urine from the urinary bladder.
• Hence it runs from the internal urethral orifice of the bladder to
the external urethral orifice located at the tip of the glans penis.
• The urethra also functions to provide an exit for semen (sperm) and
glandular secretions) during ejaculation.
• Thus, in males, the urethra is a part of the urinary system as well as
the reproductive system,
➢NB: as compared to the female uretha it is very short and it is not
part of the reproductive system.
Male urethra
• When the penis is in a flaccid (non-erect) state, the urethra presents a
double curvature and is divisible into four parts, which are the:
➢Preprostatic (intramural) part
➢Prostatic urethra
➢Membranous (intermediate) urethra
➢Spongy (Penile) urethra
Male urethra
Key facts about the male urethra

Parts Preprostatic, prostatic, membranous, spongy parts

Histology Transitional and stratified squamous epithelia

Arterial supply Prostatic branches of the inferior vesical and middle rectal arteries

Venous Dorsal vein of the penis and pudendal veins

drainage

Innervation Prostatic plexus

Male urethra
• The wall of the urethra is made up of mucous, submucous and muscular
layers.
• The prostatic urethra is surrounded by prostatic tissue,
• while the penile urethra (spongy urethra) surrounded by erectile tissue of
the corpus spongiosum.
• Its mucous membrane (mucosa) consist of a lining pseudostratified
columnar epithelium,
• mainly transitional epithelium on the short part adjoining the urinary
bladder
• and stratified squamous epithelium on the part near the external
urethral orifice.
Male urethra
• The submucosa consists of loose connective tissue,
• while the muscular coat is made up of an inner longitudinal layer
and an outer circular layer of smooth muscle.
• In addition, the membranous part is surrounded by striated muscle
that forms the external urethral sphincter.
Male urethra
• Preprostatic urethra:
• The initial part of the male urethra, which passes through the bladder
musculature (“bladder neck”), just below the internal urethral
orifice, is referred to as the pre-prostatic urethra or intramural
part of the urethra.
• Ideally it is about 0.5-1.5 cm in length but varies depending on
whether the bladder is filled with urine or empty.
Male urethra
Prostatic urethra
• The prostatic urethra is the part of the urethra that passes through
the prostate.
• It is about 3-4 cm long
• it extends from the base of the bladder, just below the pre-prostatic
urethra, to the membranous part of the urethra.
• The prostatic urethra is surrounded by the internal urethral
sphincter near its middle part;
• it is widest in the middle.
Prostatic urethra
• The posterior part of the prostatic urethra has an elevation called
the urethral crest;
• the prostatic sinuses open up on either side of this crest, which bring
prostatic fluid into the urethral lumen.
• The ejaculatory ducts also open up in the prostatic urethra, which
carry the sperms from the testes and the fluid from the seminal
vesicles into the urethra.
• Thus the urinary and reproductive tracts merge at this point.
• This is a common site of obstruction to the outflow of urine in
patients with benign hypertrophy of the prostate.
Membranous urethra
• The membranous or intermediate part of the urethra is the second
shortest part of the urethra that connects the prostatic urethra to
the penile urethra.

• It is 1-1.5 cm long and it is surrounded by the external urethral

sphincter.

• The external urethral sphincter plays an important role in voluntary

control of urinary flow.
Spongy (Penile) urethra
• The spongy urethra is the last and longest part of the urethra.
• It is approximately 15 cm long
• It is divisible into two main parts - the pendulous urethra and the
bulbar urethra.
• The pendulous urethra runs along the length of the penis, while
the bulbar urethra is located in the bulb of the penis.
• The spongy urethra opens to the outside through the urethral
meatus (external urethral orifice), which is a vertical slit-like opening
slightly behind the tip of the penis. The bulbourethral glands and the
glands of Littre open into the spongy urethra.
Spongy (penile) urethra
• The spongy urethra opens to the outside through the urethral
meatus (external urethral orifice),
• urethral meatus is a vertical slit-like opening slightly behind the tip of
the penis.
• The bulbourethral glands and the glands of Littre open into the
spongy urethra.
Blood supply to male urethra/ nerve
• The arterial blood supply of the male urethra includes:
➢ the prostatic branches of the inferior vesical and middle rectal
arteries.
• Venous return:
➢Veins of the urethra, such as the dorsal veins of the penis and
the pudendal veins, drain into the prostatic venous plexus.
• Lymphatic drainage:
➢The lymphatic vessels of the urethra drain mainly into the internal
iliac lymph nodes. Some others drain into the external iliac lymph
nodes.
• Innervation by the prostatic plexus
Clinical significance/ male urethra
• Common congenital malformations affecting the male urethra
includes hypospadias and epispadias in which the meatus (external
urethra orifice) is not located at the distal end of the penis.
• hypospadias:
• Relatively rare congenital condition
• the urethral meatus is on the underside of the penis. The position of
the meatus on the underside of the penis varies; could be just below
the tip at the head; or, the middle or base of the penis; or rarely, close
to the scrotum
• It may be associated abnormally downward curvature called chordee
which interferes with urination and copulation
• This usually requires surgical correction before 18 months of age
• In epispadias,
➢ the meatus is located higher than normal.
➢ It is a much more uncommon form of malformation in which there is
an apparent deficiency of the upper wall of the urethra.
➢This may be associated with bladder abnormalities like bladder
extroversion