MALE PELVIS

Describe the location and orientation of pelvic organs and peritoneum in an anatomical male

Urinary system
Ureters In the pelvis
 On each side the ureter enter the pelvic cavity in the area anterior to the bifurcation of the common iliac artery.
 From that point it enters the posterosuperior angle of the bladder, just superior to the seminal gland
 In the pelvic, the ureter is crossed by the ductus deferens, that is, it lies posterolateral to the ductus deferens

Urinary bladder In the pelvis

 The bladder is the most anterior element of the pelvic viscera
 It is entirely situated in the pelvic cavity when empty, however, it expands superiorly into the abdominal cavity when full
o In adult, the bladder is located in lesser (true) pelvis
o Infants/children (<6 yo), it is located almost entirely in abdomen

Urethra In the pelvis

 The urethra begins at the base of the bladder and ends with
an external opening in the perineum
 It is longer in males than in females
 It bends twice along its course
o As the urethra exits the deep perineal pouch, it bends forward to
course anteriorly
o When the penis is flaccid, the urethra makes another bend
inferiorly (passing from the root to the body of the penis; disappears during erection)

Reproductive system
 The male reproductive system has components in the abdomen, pelvis, and perineum
 The major components are the testis, epididymis, ductus deferens, ejaculatory ducts, and the urethra and penis
 In addition, three types of accessory glands are associated with the system:
1. a single prostate
2. a pair of seminal vesicles
 3. a pair of bulbo-urethral glands

Testis  Not in the pelvis

 The testis originally develop high on the posterior abdominal wall, and then descend, normally
before birth through the inguinal canal in the anterior abdominal wall, and into the scrotum
of the perineum
 During descent, the testes carry their vessels, lymphatics, and nerves as well as their principal
drainage ductsthe ductus deferens (vas deferens).

Ductus (Vas) Deferens In the pelvis

 It travels through the inguinal canal
 It passes over inferior epigastric vessels
 It passes over ureter
o The ductus deferens is the only structure that passes between
the ureter and peritoneum
o It crosses the ureter within the ureteric fold of peritoneum
 In prostate: joins with seminal vesicle to form ejaculatory ducts

Seminal vesicles In the pelvis

 The seminal vesicles lies between bladder and rectum, superior to the prostate
 The duct of the seminal gland joins the ductus deferens to form the ejaculatory duct
o The ejaculatory ducts open into the prostatic urethra via small, slit-like openings located
adjacent to the prostatic utricle.
 NB = The urinary and reproductive tracts merge at this point.

Prostate In the pelvis

 The prostate gland lies immediately inferior to the bladder, posterior to the pubic symphysis, and anterior to the rectum
 It is shaped like an inverted rounded cone with a larger base and a narrower apex, which rests below on the pelvic floor
 It is subdivided into anatomical lobes which correlate to the clinical prostatic zones

Gastrointestinal system
Rectum
  It is continuous proximally with the sigmoid colon and distally with the anal canal
 The anal canal is in the perineum
Peritoneum
 The peritoneum drapes over pelvic viscera

Compare the location and divisions of the female and male urethrae

Female urethra
 The female urethra is short.
 It passes inferiorly through the pelvic floor into the perineum, where it passes
through the deep perineal pouch and perineal membrane before it opens
in the vestibule of the vagina that lies between the labia minora
 Two small paraurethral mucous glands (Skene’s glands) are found on the
superior aspect of the urethra

Male urethra
 The male urethra is longer
 It bends twice along its course
o As the urethra exits the deep perineal pouch, it bends forward to
course anteriorly
o When the penis is flaccid, the urethra makes another bend
inferiorly (passing from the root to the body of the penis)
 This second bend disappears during erection

Parts of the male urethra

1. Intramural (preprostatic)Lies in neck of bladder, surrounded by internal urethral sphincter (involuntary control)
2. ProstaticLies in the prostate, the reproductive tract merges with urinary system here
3. Intermediate (membranous)passes through deep perineal pouch, surrounded by external urethral sphincter (voluntary
control)
4. Spongycourses through corpus spongiosum, bulbo-urethral glands open in proximal portion
Describe the autonomic innervation to the pelvic viscera
 Remember = Sympathetic fibers enter the inferior
hypogastric plexuses from the hypogastric nerves.
Sympathetic innervation
 The presynaptic neurons arise travel via lumbar splanchnic nn.  Ultimately, these nerves are derived from preganglionic
 They SYNAPSE with the postsynaptic fibers in superior/inferior fibers that leave the spinal cord in the anterior roots,
mesenteric ganglions mainly of T10 to L2.
 Postsynaptic axons travel in superior hypogastric plexus  Most of the fibers come from the lumbar splanchnics (L1-
(inferior to bifurcation of aorta) L2), while the rest come from the lesser and least thoracic
 Divides to form hypogastric nn (right and left). splanchnic nerves (via the inferior mesenteric ganglion -->
superior hypogastric plexus --> hypogastric nn.).
Sympathetic functions
 Vasoconstriction,
 Inhibit peristalsis of rectum,
 Maintain/increase anal/urethral sphincter tone- (”Nervous bladder” response),
 Ejaculation

Parasympathetic innervation
 Parasympathetics is via pelvic splanchnic nn.
 Arise from anterior/ventral rami S2-S4 (presynaptic axons)
 They SYNAPSE with postsynaptic neurons in wall of organ

Parasympathetic functions
 Vasodilation
 Stimulate bladder contraction
 Increase digestive secretions,
 Increases peristalsis including anal canal,
 Decrease anal sphincter tone while stimulating rectal smooth muscle,
 Contract detrusor muscle while inhibiting internal urethral sphincter contraction,
 Erection
  NB = The sympathetic and parasympathetic fibers join to form inferior hypogastric plexus
o Transmit sympathetic, parasympathetic and visceral afferent fibers to pelvic viscera and erectile tissues of the perineum

Define the pathways for general visceral afferent nerves from the pelvic organs

Reflexes Innervation
 Reflexive sensation (information that does not reach consciousness, i.e., urge to defecate or micturate) travel back with
parasympathetic fibers (back to S2-S4 spinal cord levels)

Visceral Afferent Innervation

 Paths of general visceral afferent fibers conducting pain differ depending on whether they are located above or below the pelvic
pain line (determines where the visceral afferents travel and who they travel with)
o Pelvic pain line corresponds to the inferior limit of the peritoneum.
 Above pain line, aspects of viscera in contact with peritoneum and they include ovaries, uterine tubes, part of
bladder and uterus
 Below pain line, subperitoneal pelvic viscera or parts of viscera include cervix & upper ¾ of the vagina, lower
bladder
 Visceral afferent fibers from organs above the pelvic pain line travel with sympathetic fibers (back to T10-L2 spinal cord levels)
o Pain fibers from areas of pelvic viscera in contact with peritoneum will refer to dermatomes T10-L2
 Visceral afferent fibers from organs below the pelvic pain line travel with parasympathetic fibers (back to S2-S4 spinal cord
levels)
o Pain fibers from portions of pelvic viscera not in contact with peritoneum will refer to dermatomes S2-S4
 Pelvic pain line exception is the GIT, where the ‘pain line’ occurs in the middle of the sigmoid colon
o Distal (or inferior) half of sigmoid colon will be supplied by parasympathetic innervation although it is wrapped with
peritoneum
Pain Sensations from Specific Organs
 Above pelvic pain line,
o Ductus deferens– gvas ascend with lumbar splanchnics (sympathetic fibers) to T11-L2 spinal sensory ganglia
o Superior bladder – gvas ascend via lumbar splanchnics (sympathetic fibers) to the T10-L2 spinal cord

 Below pelvic pain line

 o Prostate, seminal vesicles, inferior bladder, & rectum – all structures are below pelvic pain line thus GVAs travel to
S2-4

Testes
 The testes are embryologically derived from the same level as the kidneys.
 Therefore, they share a common level of autonomic innervation, which is 90% sympathetic originating from the T10-L1
segments, and the rest parasympathetic originating from the S2–S4 segments.

 Majority of pain afferents from the testicle travel back to the spinal cord with the sympathetic nerves
o Moves retrograde along inferior hypogastric plexus  hypogastric nerve  superior hypogastric plexus  lumbar
splanchnics and inferior mesenteric ganglion  spinal cord levels T10 – L1
 This may explain the “kick in the stomach” feeling accompanying testicular injury

Describe the branches of the internal iliac artery and the structures they supply

Internal iliac artery

 The internal iliac artery originates from the common iliac artery on each side and lies anteromedial to the sacro-iliac joint
 It courses inferiorly over the pelvic inlet and then bifurcates into anterior and posterior divisions
o It descends posteromedially into the lesser pelvis, medial to the external iliac vein and obturator nerve and lateral to the
peritoneum
o Branches from the posterior divisions supply the lower abdominal wall, the posterior pelvic wall, and the gluteal region
o Branches from the anterior division supply the pelvic viscera, the perineum, the gluteal region, the adductor compartment
of the thigh, in the fetus, the placenta
Anterior division
1. Umbilical artery
o Prenatally, the umbilical arteries conduct oxygen- and nutrient-deficient
blood to the placenta for replenishment
o After birth, this vessel becomes the medial umbilical ligament which
raises a fold of the peritoneum called medial umbilical fold

2. Obturator artery
 o Runs along obturator fascia of lateral pelvic wall, and exit the pelvis via obturator canal together with the obturator nerve
above and vein below
o Its muscular branches supplies the pelvic muscles, nutrient artery to ilium, head of femur, and muscles of medial
compartment of thigh
o Its pubic branch anastomose with an aberrant or accessory obturator artery which is a pubic branch of the inferior
epigastric artery (a branch of the external iliac artery)

3. Superior vesicle artery

o Originates from the root of the umbilical artery
o Supplies the superior aspect of the urinary bladder. In males, it supply the ductus deferens (via artery to ductus
deferens)

4. Inferior vesicle artery

o In males, it supplies branches to the bladder, ureter, seminal vesicle, and prostate
o In females, the equivalent is the vaginal artery, and supplies branches to the vagina and adjacent parts of the bladder
and rectum

5. Middle rectal artery

o It supplies the rectum.
o It anastomoses with the superior rectal artery (branch of the inferior mesenteric artery) and the inferior rectal artery
(branch of internal pudendal artery)

6. Internal pudendal artery

o It is the main artery of perineum. It is larger in males than in females
o Supplies muscles and skin of anal and urogenital triangles and erectile tissues (clitoris and penis)

7. Inferior gluteal artery

Posterior divisions
1. Iliolumbar artery
o Its lumbar branch supplies the psoas major, iliacus, and quadratus lumborum muscles; cauda equina in vertebral canal
 2. Lateral sacral artery
It supplies the piriformis, structures in sacral canal, erector spinae, and overlying skin

3. Superior gluteal artery

Discuss the clinical significance of the ductus deferens and ureter and their relationships to pelvic vasculature

Path of ductus (vas) deferens

 In males, the ductus deferens is only structure that passes between the ureter and the peritoneum.
 It crosses the ureter within the ureteric fold of peritoneum.
 The ureter lies posterolateral to the ductus deferens and enters the
posterosuperior angle of the bladder, just superior to the seminal gland.
 The ductus deferens transport spermatozoa from the tail of the epididymis
in the scrotum to the ejaculatory duct in the pelvic cavity.
 It ascend in the scrotum as a component of the spermatic cord and passes
through the inguinal canal.
 After passing through the deep inguinal ring, it bends medially around the lateral
side of the inferior epigastric artery and crosses the external iliac artery and
external vein at the pelvic inlet to enter the pelvic cavity

Vasectomy
 In this procedure, the ductus deferens are ligated and/or excised through an incision
in the superior part of the scrotum
 Subsequent ejaculated fluid contains no sperms. The un-expelled sperm degenerate

Explain the process of erection and ejaculation

Erection
  Stimulation of parasympathetic nerves (cavernous nerves) causes the smooth muscle in branches of internal pudendal
artery (helicine) to relax
 As the arteries relax, blood flows to the penis increases, goes into the cavernous spaces within the erectile bodies (corpora of
penis) which becomes engorged.
 Contraction of the bulbospongiosus and ischiocavernosus muscles (innervated by the pudendal nerve) impedes venous outflow.
That is, it compresses vein coming from corpora cavernosa and impede the return of venous flow (blood is not leaving)

Ejaculation
 Sympathetic innervation stimulates contraction of internal genital organs during orgasm and contracts the internal urethral
sphincter
o The internal urethral sphincter prevents retrograde ejaculation into the bladder, so that the ejaculate only goes out the
urethra. The muscles below help with this too!
 Contraction of the urethral muscle = parasympathetic response (S2–S4 nerves)
 Contraction of the bulbospongiosus muscles via pudendal nerves (S2–S4)

 NB = Testis are the male reproductive glands that produce spermatozoa and male hormones (testosterone)

 Tunica Albuginea lies deep to the visceral layer of the tunica vaginalis

 Seminiferous tubules  straight tubules  rete testis  efferent ductules  head of epididymis  body of epididymis  tail of
epididymisvas (ductus) deferens

Clinical relevance
 Disruption of the sympathetic nerves can result in retrograde ejaculation. This can occur during the repair of an abdominal aortic
aneurysm, for example, if the aneurysm involves the bifurcation of the aorta.

Describe the lymphatic drainage of the male pelvis

 Perineumdrain superficial inguinal nodes
 Pelvic viscera, including inferior part of rectumdrain into internal and external iliac nodes
o Superior portion of rectum drains to inferior mesenteric nodes
 Gonadsdrain into para-aortic/lumbar nodes
Varicocele vs Testicular Torsion
 A varicocele is a collection of dilated veins that arise from the pampiniform plexus
o It is similar to varicose veins that develop in the legs
o It is a common nonacute scrotal condition

 Testicular torsion occurs when an excessively mobile testis rotates on its cord structures
o Impairs venous return causes venous congestion and edema, which impedes arterial blood inflow
o Considered a urological emergency, if left uncorrected, ischaemia of the testis will occur
o To prevent recurrence testes are surgically fixed to the scrotal septum
o An absent cremasteric reflex also is a sensitive indicator for a male with testicular torsion

FEMALE PELVIS

Describe the location, orientation of pelvic organs and peritoneum in an anatomical female

Urinary system
Ureters
 In the pelvis, the ureter is crossed by the uterine artery that is, it is passes UNDER the uterine artery.
o Catch phrase to remember “water (urine) passes under the bridge (uterine artery)”

Urinary bladder
 In adult, it is located in lesser (true) pelvis
 In infants/children (<6 yo), it located almost entirely in abdomen

Urethra
 The female urethra is short.
 It passes inferiorly through the pelvic floor into the perineum, where it passes through the deep perineal pouch and perineal
membrane before it opens in the vestibule of the vagina that lies between the labia minora
 Two small paraurethral mucous glands (Skene’s glands) are found on the superior aspect of the urethra

Reproductive system
Ovary
 It is located laterally between the uterus and the lateral pelvic wall
 The ligament of the ovary- tethers the ovary to the uterus

Uterine tubes (oviducts or fallopian tubes)

 Extend laterally from the uterine horns and open into the peritoneal cavity near the ovaries

Uterus
 Lays on the superior border of the bladder in the true pelvis
 Typically, the uterus is anteverted and anteflexed, so that the body of the uterus rests upon the empty bladder, one of several
means by which passive support for the uterus may be provided.
 Located in the midline between the bladder and rectum.
 It consists of a body and a cervix, and inferiorly it joins the vagina.

Vagina
 It extends from the superiormost aspect of the vaginal part of the cervix of the uterus to the vaginal orifice
 The vagina is related
o Anteriorly to urinary bladder and urethra
o Laterally to the levator ani, visceral pelvic fascia, and ureters
o Posteriorly to the anal canal, rectum, and recto-uterine pouch

Gastrointestinal system
Rectum
 Continuous proximally with the sigmoid colon and distally with the anal canal
 Anal canal is in the perineum

Peritoneum
 Drapes over pelvic viscera
Identify features of the uterus and associated structures and supports

Uterus
 The uterus is a thick-walled, hollow muscular organ
 Body of the uterus is the superior 2/3 (i.e., between fundus and inferior portion of the uterus)
  Fundus is the superior portion of uterus
 Uterine horns is the superolateral regions where uterine tubes enter
 Cervical canal is the inferior extension of the uterus
 Cervix is the inferior 1/3 of the uterus (below body)
o At superior aspect of cervix is a narrowing of the uterine cavity called the internal os
 Inferior part of cervix protrudes into the superior part of the vaginal canal and open as external os of
the uterus and is sounded by a narrow recessvaginal fornix (posterior, anterior and lateral parts)
o The posterior vaginal fornix is the deepest part and is closely related to the recto-uterine pouch

Supportive structures
 In the female pelvic cavity, condensations of extraperitoneal endopelvic fascia form the
following ligaments, that provide passive support to the cervix:
1. Pubocervical ligament extend from the cervix to the anterior pelvic wall
2. Transverse or cardinal ligament extend from the cervix to later pelvic wall
3. Uterosacral ligaments extend from the cervix to posterior pelvic wall

 The cervix is the least mobile part of the uterus because of this
 These fibromuscular ligaments (condensations of endopelvic fascia), together with the
perineal membrane, the levator ani muscles, and the perineal body, are thought to
stabilize the uterus in the pelvic cavity

 NB = The most important of these ligaments are the transverse cervical or cardinal ligaments, which extend laterally from
each side of the cervix and vaginal vault to the related pelvic wall.

Uterus position in the uterus

 Normally, the uterus is anteverted and anteflexed, so that the body of the uterus rests upon the empty bladder, one of several
means by which passive support for the uterus may be provided

 Flexion describes the angle between the long axis of the upper uterine
cavity and the isthmus and cervical canal.
o In an anteflexed uterus, the long axis of the uterine body is
tipped anteriorly; a retroflexed uterus is tipped posteriorly.
 Angle of anteflexion170o
  Version describes the angle between the cervix and vagina.
o In an anteverted uterus, the axis of the cervix is bent anteriorly, in a retroverted uterus, the cervix is bent posteriorly.
 Angle of anteversion90o

 Other positions include excessive anteflexion (B), anteflexion with retroversion (C), and retroflexion with retroversion (D)

Describe the autonomic innervation to the pelvic viscera

Sympathetics
 Presynaptic neurons travel via lumbar splanchnic nerve.
 SYNAPSE in superior/inferior mesenteric ganglions
 Postsynaptic axons travel in superior hypogastric plexus (inferior to bifurcation of aorta)
 Divides to form hypogastric nn.

Functions
Vasoconstriction,
Inhibit peristalsis of rectum,
Maintain/increase anal/urethral sphincter tone- (”Nervous bladder” response)

Parasympatheticsvia pelvic splanchnic nn.

 Arise from anterior/ventral rami S2-S4 (presynaptic axons)
 SYNAPSE with postsynaptic neurons in wall of organ

Functions
 Vasodilation,
 Increase digestive secretions,
 Increases peristalsis including anal canal,
 Decrease anal sphincter tone while stimulating rectal smooth muscle,
  Contract detrusor muscle while inhibiting internal urethral sphincter contraction

*NB = inferior 1/5th of vagina is somatically innervated

*NB = Sympathetic and parasympathetic fibers join to form inferior hypogastric plexus which transmit sympathetic, parasympathetic and
visceral afferent fibers to pelvic viscera and erectile tissues of the perineum

Define the pathways for general visceral afferent nerves from the pelvic organs

Reflexes Innervation
 Reflexive sensation (information that does not reach consciousness, i.e., urge to defecate or micturate) travel back with
parasympathetic fibers (back to S2-S4 spinal cord levels)

Visceral Afferent Innervation

 Paths of general visceral afferent fibers conducting pain differ depending on whether they are located above or below the pelvic
pain line (determines where the visceral afferents travel and who they travel with)
o Pelvic pain line corresponds to the inferior limit of the peritoneum.
 Above pain line, aspects of viscera in contact with peritoneum and they include ovaries, uterine tubes, part of
bladder and uterus
 Below pain line, subperitoneal pelvic viscera or parts of viscera include cervix & upper ¾ of the vagina, lower
bladder
 Visceral afferent fibers from organs above the pelvic pain line travel with sympathetic fibers (back to T10-L2 spinal cord levels)
o Pain fibers from areas of pelvic viscera in contact with peritoneum will refer to dermatomes T10-L2
 Visceral afferent fibers from organs below the pelvic pain line travel with parasympathetic fibers (back to S2-S4 spinal cord
levels)
o Pain fibers from portions of pelvic viscera not in contact with peritoneum will refer to dermatomes S2-S4
 Pelvic pain line exception is the GIT, where the ‘pain line’ occurs in the middle of the sigmoid colon
o Distal (or inferior) half of sigmoid colon will be supplied by parasympathetic innervation although it is wrapped with
peritoneum

Pain Sensations from Specific Organs

 Above pelvic pain line
 o Ovaries & uterine tubesGVAs ascend with lumbar splanchnics (sympathetic fibers) to T11-L2 spinal sensory ganglia
o Uterus (fundus & body) & superior bladder GVAs ascend via lumbar splanchnics (sympathetic fibers) to the T10-L2
spinal cord

 Below pelvic pain line

o Cervix & upper ¾ of the vaginaGVAs travel with parasympathetics to S2-4 (recall that inferior 1/5th of vagina is
somatically innervated)
o Lower bladder & rectum  all structures are below pelvic pain line thus GVAs travel to S2-4

Review somatic innervation of the pelvis

Nerve Origin Innervation

Articular branches to hip joint and
muscular branches to flexors of the knee
Sciatic L4-S3
in the thigh and all muscles in the leg and
foot
Gluteus medius, gluteus minimus and
Superior gluteal L4-S1
tensor fasciae latae muscles
Nerve to quadratus femoris (and Quadratus femoris and inferior gemellus
L4-S1
inferior gemellus) muscles
Inferior gluteal L5-S2 Gluteus maximus
Nerve to obturator internus (and Obturator internus and superior gemellus
L5-S2
superior gemellus) muscles
Nerve to piriformis S1, S2 Piriformis muscle
Cutaneous branches to the buttocks and
Posterior cutaneous nerve of thigh S2, S3 uppermost medial and posterior surfaces
of the thigh
Cutaneous branches to medial part of the
Perforating cutaneous S2, S3
buttocks
 Structures in perineum: sensory branches
to external genitalia; muscular branches to
Pudendal S2-S4
perineal muscles, external urethral
sphincter, and external anal sphincter
Pelvic viscera via inferior hypogastric and
Pelvic splanchnic S2-S4
pelvic plexuses
Nerves to levator ani and
S3, S4 Levator ani and coccygeus muscles
coccygeus

Nerves of pelvis
 The pelvis is innervated mainly by the sacral and coccygeal spinal nerves and the pelvic part of the autonomic nervous system

 The piriformis and coccygeus muscles form a bed for the nerve plexuses

Sacral plexus
 The sacral plexus is located on the posterolateral wall of the lesser pelvis.
  The two main nerves arising from the sacral plexus, the sciatic and pudendal nerves, lie external to the parietal pelvic fascia.

 Most branches of the sacral plexus leave the pelvis through the greater sciatic foramen

Coccygeal plexus
 Small network of nerve fibers formed by the anterior rami of S4 and S5 and the coccygeal nerves

 It lies on the pelvic surface of the coccygeus and supplies this muscle, part of the levator ani, and the sacrococcygeal joint

 The anococcygeal nerves that originate from the coccygeal plexus penetrate the muscle and the overlying sacrospinous and
sacrotuberous ligaments and pass superficially to innervate skin in the anal triangle of perineum

Clinical Relevance

Epidural block (at L3/L4)

 Here, the anesthesia is introduced into the epidural space which bathes
spinal nerve roots, including the pain fibers from the uterus, cervix and
superior vagina and the afferent fibers from the pudendal nerve.
o The entire birth canal, pelvic floor, and majority of the perineum are
anesthetized, but the lower limbs are not usually affected

 Pain fibers from the uterine body (superior to the pelvic pain line) ascend to
the inferior thoracic–superior lumbar levels and are not affected by the anesthetic,
so the mother is aware of her uterine contractions

Spinal anesthesia
 Here, the anesthetic agent is introduced into the spinal subarachnoid space
 It produces complete anesthesia inferior to approximately the waist level
o Perineum, pelvic floor, and birth canal are anesthetized, and motor and sensory functions of the entire lower limbs, as well
as sensation of uterine contractions, are temporarily blocked

Pudendal nerve block

 It is a peripheral nerve block that provides local anesthesia over the S2–S4 dermatomes (the majority of the perineum) and the
inferior quarter of the vagina
o Does not block pain from the superior birth canal (uterine cervix and superior vagina), so the mother is able to feel uterine
contractions
  In regional analgesia, a woman is conscious of uterine contractions and can “bear down” or push to assist the contractions and
expel the fetus
 In regional anesthesia, complete blockade of pain and feeling and does not allow a woman to assist with labor

Describe the branches of the internal iliac artery and the structures they supply

Anterior trunk of internal iliac artery

1. Umbilical artery
o Prenatally, the umbilical arteries conduct oxygen- and nutrient-deficient blood to the placenta for replenishment
2. Superior vesical artery
3. Obturator artery
4. Uterine Artery
o Descends on the lateral wall of the pelvis and passes medially to reach junction of uterus and vagina. Remember: Passes
directly superior to the ureter. Phrase “water (urine) passes under the bridge (uterine artery)”
5. Internal pudendal artery
o Main artery of perineum
6. Middle rectal artery
7. Inferior gluteal artery

Posterior Trunk
1. Iliolumbar artery
2. Lateral sacral artery
3. Superior gluteal artery

 Six main arteries enter the lesser pelvis of anatomical females:

o Paired internal iliac and ovarian arteries
o Unpaired median sacral and superior rectal arteries

Uterine artery
 The uterine artery is an additional branch of the internal iliac artery in females. It may arise from the umbilical artery.
 Developmentally, it is the homolog of the artery to the ductus deferens in males
 The uterine artery passes directly superior to the ureter.
 On reaching the side of the cervix, the uterine artery divides into
o a smaller descending vaginal branch, which supplies the cervix and vagina
o a larger ascending branch, which runs along the lateral margin of the uterus,
 supplying it.
 The ascending branch bifurcates into ovarian and tubal branches,
which continue to supply the medial ends of the ovary and uterine tube
and anastomose with the ovarian and tubal branches of the ovarian
artery
 Remember: The ovary and uterus receive blood supply via
1. Ovarian artery—from abdominal aorta
2.Uterine artery—from internal iliac artery
o Supplies superior and middle part of vagina
o Inferior part of the vagina is supplied by the vaginal artery

Pelvic Veins
 Pelvic veins follow the course of all branches of the internal iliac
artery except for the umbilical artery and the iliolumbar artery

 On each side, the veins drain into internal iliac veins, which leave
the pelvic cavity to join common iliac veins situated just superior and
lateral to the pelvic inlet

• The ovarian veins follow the course of the corresponding arteries

• On the left, they join the left renal vein
• On the right, they join the inferior vena cava in the abdomen

Discuss the clinical significance of the ureter and its relationship to pelvic vasculature

 The ureter crosses the common iliac artery or the beginning of the external iliac artery

 Run on the lateral walls of the pelvis, parallel to the anterior margin of the greater sciatic
 notch
  At this point the uterine artery passes superior to the descending ureter, and winds
halfway or more around it
o Remember = “water (urine) passes under the bridge (uterine artery)”
o This relationship is an important consideration in pelvic surgeries in which the
uterine artery must be ligated.

 The ureter then curves anteromedially to enter the bladder

 Arterial supply from ureteric branches extending from the common iliac, internal iliac, and ovarian arteries

 Ureters are primarily superior to the pelvic pain line. Hence, afferent (pain) fibers from the ureters follow sympathetic fibers in a
retrograde direction to reach spinal cord segments of T10–L3

Describe the lymphatic drainage of the male pelvis

 Perineumdrain superficial inguinal nodes
 Pelvic viscera, including inferior part of rectumdrain into internal and external iliac nodes
o Superior portion of rectum drains to inferior mesenteric nodes
 Gonadsdrain into para-aortic/lumbar nodes

The lymphatic drainage of the reproductive system follows the vascular supply. Therefore, the perineum is drained by superficial
inguinal nodes, the pelvic viscera, including upper 2/3 of vagina is drained by internal and external iliac nodes. However, because
the gonads originate in the abdomen and receive their blood supply from the aorta they are drained by para-aortic/lumbar nodes.