JIGJIGA UNIVERSITY

Anatomy of perineum

FOR MEDICINE STUDENTS

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 Perineum
• The perineum is a diamond-shaped area bounded by the
pelvic outlet
• Extend from:
• The mons pubis anteriorly
• The medial surfaces of the thighs laterally, and
• The gluteal folds and superior end of the intergluteal
(natal) cleft posteriorly
• It is separated from the pelvic cavity by the pelvic
diaphragm.
Superficial surface of the urogenital triangle

Urogenital triangle

Urogenital triangle
 Division of perineum
• A transverse line joining the anterior ends of the
ischial tuberosities divides the diamond-shaped
perineum into two triangles
– Anal triangle
• Lies posterior to this line
• Contains the anal canal, anus and ischioanal
fossa
– Urogenital triangle
• Anterior to this line
• Contains external genitalia
 The root of the scrotum and penis in males
and the vulva of females
 Boundaries of perineum
• Anteriorly- Pubic
symphysis
• Anterolaterally-
Ischiopubic ramus
• Laterally- Ischial
tuberosities
• Posterolaterally-
Sacrotuberous ligaments
• Posteriorly- Inferior
most sacrum and coccyx
• Inferior pelvic aperture (pelvic outlet) is closed
by:
– Urogenital diaphragm: anterior part
– Pelvic diaphragm: posterior part

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 Urogenital triangle
• The urogenital triangle is
bounded
• Anteriorly- by pubic arch
• Anterolaterally- by
ischiopubic ramus
• Laterally- by ischial
tuberosities
• Posteriorly- by transverse
line joining the ischial
tuberosities
 Urogenital triangle

• Urogenital diaphragm
– Strong triangular membrane and thin sheet of
muscles stretching across the urogenital triangle from
the rami of the pubis and the ischium
– A small gap at the apex of the triangle, posterior to
the pubic symphysis, exists for passage of
• Deep dorsal vein and dorsal nerve of penis or
clitoris
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• Perineal membrane
– Thick fibrous sheet that fills the urogenital triangle
– Covers the anterior part of the pelvic outlet

– Has a free posterior border, which is anchored in the midline

to the perineal body.
– Immediately superior to the perineal membrane is a thin
region termed the deep perineal pouch, containing a layer of
skeletal muscle and neurovascular tissues
– The perineal membrane and deep perineal pouch provide
support for the external genitalia.

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• Perineal membrane is pierced by
– Urethra

– Vagina (in female)

– Ducts of bulbourethral glands

– Deep and dorsal arteries of the penis or clitoris

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• Perineal body
– Irregular fibromuscular mass located in the median
plane between anal canal and perineal membrane
• Posterior to the vestibule of the vagina or bulb of the penis
and anterior to the anus and anal canal

– Lies deep to the skin, with relatively little overlying

subcutaneous tissue
– Contains collagenous and elastic fibers and both
skeletal and smooth muscle
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– Site of convergence of several muscles
• Bulbospongiosus
• External anal sphincter
• Superficial and deep transverse perineal muscles
• Smooth and voluntary slips of muscle from the
external urethral sphincter, levator ani, and
muscular coats of the rectum

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 Disruption of perineal body
• The perineal body is especially important structure in
women because its support of the pelvic viscera
• Stretching or tearing of the perineal body can occur
during childbirth.
• As a result, prolapse of pelvic viscera, including
– prolapse of the bladder (through the urethra) and

– prolapse of the uterus and/or vagina (through the vaginal

orifice) may occur

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 Episiotomy
• It is surgical incision of the perineum and
inferoposterior vaginal wall
• It is made to enlarge the vaginal orifice during vaginal
surgery and labor
• Prevent jagged tears of the perineal muscles

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 Fasciae and pouches of urogenital triangle

Perineal fascia
• Consists of superficial and deep layers

1.Superficial perineal fascia

– Subcutaneous tissue of the perineum
– Consists of a fatty superficial layer and a deep
membranous layer (Colles fascia)

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– Fatty layer
• In females
– makes up the substance of the labia majora and mons pubis
– continuous anteriorly and superiorly with the fatty layer
of subcutaneous tissue of the abdomen (Camper fascia)
• In males
– It is replaced in the penis and scrotum with smooth
(dartos) muscle
– Continuous between the penis or scrotum and the thighs
with the fatty layer of subcutaneous tissue of the
abdomen
• In both sexes, it is continuous posteriorly with the ischioanal
fat-pad in the anal region

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• Membranous layer
– Attached posteriorly to the posterior margin of the
perineal membrane and the perineal body
– Laterally, it is attached to the fascia lata of the thigh
– In males
• Anteriorly, it is continuous with dartos fascia of the penis
and scrotum
• It is continuous with the membranous layer of subcutaneous
tissue of the abdomen (Scarpa fascia)
– In females
• Passes superior to the fatty layer forming the labia majora
and becomes continuous with the membranous layer of the
subcutaneous tissue of the abdomen

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2. Deep perineal fascia
– Intimately invests the ischiocavernosus,
bulbospongiosus, and superficial transverse perineal
muscles
– Attached laterally to the ischiopubic rami
– Anteriorly,
• It is fused to the suspensory ligament of the penis or the
clitoris and
• It is also continuous with the deep fascia covering the
external oblique muscle of the abdomen and the rectus
sheath

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 Superficial perineal pouch
• Potential space between the perineal fascia and the
perineal membrane.
• Bounded laterally by the ischiopubic rami
• In males, the superficial perineal pouch contains:
– Root (bulb and crura) of the penis and associated
muscles (ischiocavernosus and bulbospongiosus)
– Proximal (bulbous) part of the spongy urethra
– Superficial transverse perineal muscles
– Deep perineal branches of the internal pudendal
vessels and pudendal nerves

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• In females, the superficial perineal pouch
contains:
– Clitoris and associated muscle (ischiocavernosus)
– Bulbs of the vestibule and the surrounding muscle
(bulbospongiosus)
– Greater vestibular glands
– Deep perineal branches of the internal pudendal
vessels and pudendal nerves
– Superficial transverse perineal muscles

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 Deep perineal pouch
• Boundaries
– Inferiorly: perineal membrane
– Superiorly: inferior fascia of the pelvic diaphragm
– Laterally: inferior portion of the obturator fascia
• Contents:
– In both sexes
• Part of urethra
• Inferior part of external urethral sphincter muscle
• Anterior extensions of the ischioanal fat pads

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• In males
– Intermediate part of urethra
– Deep transverse perineal muscles
– Bulbourethral glands, embedded within the deep
perineal musculature
– Dorsal neurovascular structures of the penis
• In females
– Proximal part of urethra
– A mass of smooth muscle in the place of deep
transverse perineal muscles
– Dorsal neurovasculature of the clitoris

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 Anal triangle

Boundaries
• Posteriorly: Tip of coccyx
• Anteriorly: Line joining ischial tuberosities
• Posteriolaterally: Sacrotuberous ligament
• Contents
– Anal canal
– External anal sphincter
– Ischioanal fossae
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 Ischioanal fossae
• Located on each side of the anal canal between the skin of
the anal region and the pelvic diaphragm
• The apex of each fossa lies superiorly where the levator ani
muscle arises from the obturator fascia

• Wide inferiorly and narrow superiorly, are filled with fat

and loose connective tissue

• The two ischioanal fossae communicate by means of the
deep postanal space over the anococcygeal ligament (body).

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• Each ischioanal fossa is bounded
– Laterally: by the ischium and the inferior part of the
obturator internus, covered with obturator fascia
– Medially: by the external anal sphincter, with a roof formed
by the levator ani
– Posteriorly: by the sacrotuberous ligament and gluteus
maximus
– Anteriorly: by the bodies of the pubic bones, inferior to the
origin of the puborectalis
• These parts of the fossae, extending into the UG triangle superior to
the perineal membrane known as the anterior recesses of the ischio-
anal fossae. 36
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Contents
• It is filled mostly with fat
– These fat bodies support the anal canal but are readily
displaced to permit expansion of the anal canal during the
passage of feces
• The fat bodies are traversed by several neurovascular
structures
– They are branches of the internal pudendal vessels and the
pudendal nerve, lying enclosed in a fascial tunnel called the
pudendal canal
• Inferior anal/rectal vessels and nerves
• Two cutaneous nerves
– Perforating branch of S2 and S3
– Perineal branch of the S4 nerve

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 Pudendal canal (Alcock canal) & its neurovasculature

• Horizontal passageway within the obturator fascia

• Content
– Internal pudendal artery and vein
– Pudendal nerve
– Nerve to the obturator internus
• The internal pudendal vessels supply and drain blood
from the perineum; the pudendal nerve innervates most
of the same area

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 Pudendal canal & its neurovasculature cont…

• As the artery and nerve enter the canal, they give rise to
the inferior rectal artery and nerve.
– Which pass medially to supply the external anal sphincter and
perianal skin
• Toward the distal (anterior) end of the pudendal canal,
the artery and nerve both bifurcate, giving rise to
– Perineal nerve and artery: distributed mostly to the
superficial pouch
– Dorsal artery and nerve of the penis or clitoris: run
in the deep pouch

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 Pudendal canal & its neurovasculature cont…

• The perineal nerve has two branches:

– Superficial perineal nerve: gives rise to posterior scrotal or labial
(cutaneous) branches, and
– Deep perineal nerve: supplies the muscles of the deep and
superficial perineal pouches, the skin of the vestibule, and the
mucosa of the inferior most part of the vagina.

• The dorsal nerve of the penis or clitoris is the primary

sensory nerve serving the male or female organ, especially
the sensitive glans at the distal end

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 Starvation and rectal prolapse
• The fat bodies of the ischioanal fossae, along
with the buccal fat pads, are among the last
reserves of fatty tissue to disappear with
starvation
• In the absence of the support provided by the
ischioanal fat, rectal prolapse is relatively
common.

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 Ischioanal Abscesses
• The ischioanal fossae are occasionally the sites
of infection, which may result in the formation of
ischioanal abscesses
• These collections of pus are quite painful
• A perianal abscess may rupture spontaneously
and fistula is formed
– Opening internally into the anal canal, rectum, or
externally onto perianal skin

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 Anal canal
• Terminal part of the large intestine that extends from the
superior aspect of the pelvic diaphragm to the anus
• About 4 cm
• Begins where the rectal ampulla abruptly narrows at the
level of the U-shaped sling formed by the puborectalis
muscle
• Ends at the anus, the external outlet of the alimentary
tract

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• Surrounded by internal and external anal
sphincters
• Descends posteroinferiorly between the
anococcygeal ligament and the perineal body
• Normally collapsed except during passage of
feces
– both sphincters must relax before defecation can
occur

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• The inferior comb-shaped limit of the anal valves
forms an irregular line, the pectinate line
– Indicates the junction of the superior part of the anal canal
(visceral; derived from the hindgut) and the inferior part
(somatic; derived from the embryonic proctodeum)

• The anal canal superior to the pectinate line differs

from the part inferior to the pectinate line in its arterial
supply, innervation, and venous and lymphatic
drainage
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 Vasculature of anal canal

• Arterial supply
– Superior rectal artery: supplies the anal canal
superior to the pectinate line
– Inferior rectal arteries: supply the inferior part of
the anal canal as well as the surrounding muscles
and perianal skin
– Middle rectal arteries: assist with the blood supply
to the anal canal by forming anastomoses with the
superior and inferior rectal arteries

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Venous drainage
• The internal rectal venous plexus drains in both
directions from the level of the pectinate line
– Superior to the pectinate line: drains into the superior rectal
vein (a tributary of the inferior mesenteric vein) and the portal
system
– Inferior to the pectinate line: drains into the inferior rectal
veins (tributaries of the caval venous system) around the margin
of the external anal sphincter
– The middle rectal veins (tributaries of the internal iliac veins)
mainly drain the muscularis externa of the rectal ampulla and
form anastomoses with the superior and inferior rectal veins
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Lymphatic drainage
– Superior to the pectinate line
• Drain into the internal iliac lymph nodes

– Inferior to the pectinate line

• Drain into the superficial inguinal lymph nodes

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 Innervation of anal canal
• Superior to the pectinate line
– visceral innervation from the inferior hypogastric plexus
(sympathetic, parasympathetic, and visceral afferent
fibers)
– inferior to the pelvic pain line; all visceral afferents travel
with the parasympathetic fibers to spinal sensory ganglia
S2 - S4
– sensitive only to stretching
• Inferior to the pectinate line
– somatic, derived from the inferior anal (rectal) nerves,
branches of the pudendal nerve
– sensitive to pain, touch, and temperature
– Somatic efferent fibers stimulate the contraction of the
voluntary external anal sphincter
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 Hemorrhoids
• Internal hemorrhoids (piles)
– Prolapses of the rectal mucosa containing the
normally dilated veins of the internal rectal venous
plexus
– Owing to the presence of abundant arteriovenous
anastomoses, bleeding from internal hemorrhoids is
usually bright red
• External hemorrhoids
– Thromboses (blood clots) in the veins of the external
rectal venous plexus and are covered by skin

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Perineal Muscles
 Bulbospongiosus
Origin: perineal body
Insertion:
Male
– Perineal membrane,
– Dorsal aspect of
corpora spongiosum
and cavernosa, and
Female
– Pubic arch and
– Corpora cavernosa of
clitoris
 Bulbospongiosus…
Innervation
• Muscular (deep) branch of perineal nerve
Action:
• supports and fixes perineal body/pelvic floor
• compresses bulb of penis /greater vestibular gland
• Sphincter of vagina
• Assists erection
 Ischiocavernosus
• Origin
– Internal surface of
ischiopubic ramus and
ischial tuberosity
• Insertion
– Inferior and medial aspects
of crus and to perineal
membrane
• Innervation
– Muscular (deep) branch of
perineal nerve, a branch of
pudendal nerve (S2 - S4)
• Main Action
– Maintains erection of penis
or clitoris
 Superficial Transverse Perineal

• Origin

– Internal surface of
ischiopubic ramus
and ischial
tuberosity
• Insertion
– perineal body
 Superficial Transverse Perineal…

• Innervation : Muscular (deep) branch of

perineal nerve.
• Main Action: Supports and fixes perineal
body/pelvic floor
 Deep Transverse Perineal

Origin
• Internal surface of Ischiopubic ramus and ischial tuberosity

Insertion
• perineal body and external anal sphincter

Innervation
• Muscular (deep) branch of perineal nerve

Main Action
• Supports and fixes perineal body/pelvic floor
EXTERNAL GENITALIA
 Testes
• Each testes is approximately 4 cm long and
2.5 cm in diameter
• Each testis (testicle) is surrounded by two tunics
– Tunica vaginalis: outer; derived from the
peritoneum
– Tunica albuginea: deep; dense connective
tissue capsule

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• The testes develop retroperitoneally in the dorsal wall of
the embryonic abdominal cavity
• They are moved during fetal development and lie within
the two sides of the scrotum.
• Because of the migration from the abdominal cavity, each
testis carries with it a serous sac, the tunica vaginalis,
derived from the peritoneum
– The tunic consists of an outer parietal layer lining the scrotum
and an inner visceral layer, covering the tunica albuginea on
the anterior and lateral sides of the testis 67
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• The tunica albuginea is thickened on the posterior side
of the testis to form the mediastinum testis and divide
it into about 250 pyramidal compartments or testicular
lobules
• Each lobule is occupied by one to four seminiferous
tubules and endocrine interstitial cells (Leydig cells)
• Seminiferous tubules produce male reproductive cells,
the spermatozoa, whereas interstitial cells secrete
testicular androgens
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 Testes: Neurovasculature
• The long testicular arteries, which branch from
the abdominal aorta, supply the testes
• Testicular veins arise from a network called
pampiniform plexus that surrounds the testicular
artery
– The plexus absorbs heat from the arterial blood,
cooling it before it enters the testes.
– Thus, it provides an additional avenue for
maintaining the testes at their cool homeostatic
temperature
• The testes are served by both divisions of the
autonomic nervous system
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Cryptorchidism
 Occurs in about 5% of newborn males in which one
or both testes fail to descend into the scrotum.
 An undescended testis, which may be located in
either inguinal canal (typically) or in the pelvic
cavity is sterile because viable sperm cannot be
produced at the higher temperature there.
 Surgical correction within 6–18 months after birth
is recommended to avoid damage to sperm-forming
cells.
 Left uncorrected, undescended testes have an
increased likelihood of developing testicular cancer.
Hydrocele
• A hydrocele is the presence of excess fluid in a tunica
vaginalis of the testes.
• The fluid accumulation results from secretion of an
abnormal amount of serous fluid from the visceral
layer of the tunica vaginalis.

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 Epididymis

• Elongated coma shaped structure

• Applied to superior and posterolateral surface of testis
• Efferent ductules of the testis transport newly developed
sperms to the epididymis from the rete testis
• Formed by minute convolutions of the duct of the
epididymis, so tightly compacted that they appear solid
• Sperm are stored in the epididymis and undergo the final
maturation steps required for their ability to fertilize an egg

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Parts
• The epididymis consists of:
– Head of the epididymis
• The superior expanded part that is composed of
lobules formed by the coiled ends of 12 - 14
efferent ductules
– Body of the epididymis
• Consists of the convoluted duct of the epididymis
– Tail of the epididymis
• Continuous with the ductus deferens, the duct
that transports the sperm from the epididymis to
the ejaculatory duct for expulsion via the urethra
during ejaculation
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 Scrotum
• It is a cutaneous fibromuscular sac for the testes
and associated structures.
• It is situated posteroinferior to the penis and inferior
to the pubic symphysis.
• Internally, the scrotum is divided into two
compartments
• One for each testis, by a prolongation of the dartos
fascia.
 Arterial Supply of the Scrotum

• Anterior scrotal arteries:

Term. branch ext. pudendal
artery
• Posterior scrotal
arteries: Term. branch
supf. perineal artery
• Cremasteric arteries:
branch of inf. epig. artery
 Venous and Lymphatic Drainage of the Scrotum

Venous Drainage
• The scrotal veins, draining primarily to the
external pudendal veins
Lymphatic Drainage
• Superficial inguinal lymph nodes
 Innervation of the Scrotum
Anterior – derived from lumbar plexus:
 Anterior scrotal nerves: br. ilioing.N
The genital branch of the genitofemoral nerve.
The posterior- derived from sacral plexus:
Posterior scrotal nerves: br. supf. per. N
The perineal branch of the posterior femoral
cutaneous nerve
 Penis

• The penis is the male copulatory organ and

provides the common outlet for urine and semen.
• The penis consists of a root, body, and glans.
 Penis…
• It is composed of three
cylindrical bodies of
erectile cavernous
tissue:
 The paired corpora
cavernosa dorsally and
 Single corpus
spongiosum ventrally.
 Root of penis
• It is the attached part consists
of the crura, bulb, and
ischiocavernosus and
bulbospongiosus muscles
• It is located in the superficial
perineal pouch.
• The crura and bulb of the
penis contain masses of
erectile tissue.
 The body of the penis
• It is the free pendulous part
that is suspended from the
pubic symphysis.
• The body of the penis has no
muscles.
• The penis consists of thin
skin, connective tissue,
blood and lymphatic vessels,
the corpora cavernosa, and
the corpus spongiosum
 Glans of penis
• Distally, the corpus spongiosum expands to form the
conical glans of the penis, or head of the penis.
• At the neck of the glans, the skin and fascia of the
penis are prolonged as a double layer of skin, the
prepuce (foreskin), which in uncircumcised males
covers the glans.
 Ligaments of penis
• The suspensory
ligament - arises from
the anterior surface of
the pubic symphysis
• The fundiform
ligament - descends in
the midline from the
linea alba superior to
the pubic symphysis
 Arterial Supply of the Penis
The penis is supplied mainly
by branches of the internal
pudendal arteries
• Dorsal arteries of the
penis
• Deep arteries of the penis
• Arteries of the bulb of the
penis
• In addition, superficial and
deep branches of the
external pudendal arteries
supply the penile skin
 Venous Drainage of the Penis

• Deep dorsal vein of the penis, drain into

prostatic plexus, drain blood from the
cavernous spaces
• Superficial dorsal vein(s), drain into supf. Ext.
pud. V, drain blood from the superficial
coverings of the penis.
 Lymphatic Drainage of the Penis

• Superficial inguinal lymph nodes drain lymph

from the skin of the penis
• Deep inguinal and external iliac nodes, drain lymph
from the glans and distal spongy urethra
• Internal iliac nodes drain lymph from the cavernous
bodies and proximal spongy urethra
 Innervation of the Penis

Derived from the S2 & S4.

• Dorsal nerve of the penis, Term. br. of pud. N,
provide sensory and sympathetic innervation.
• Branches of the ilioinguinal nerve supply the skin at
the root of the penis.
• Cavernous nerves: from prost. N plexus, PSN stim,
innervate the helicine arteries of the erectile tissue.
 Impotence
• It is inability to achieve erection
Cause
• Lesion of the prostatic plexus or cavernous
nerves
Treatment: sildenafil (Viagra)
Female External Genitalia (vulva and pudendum)

• The female external genitalia include:

 the mons pubis and
 labia majora
 labia minora
 Clitoris
 bulbs of the vestibule
 greater and lesser vestibular glands.
 Mons Pubis
• The mons pubis is the rounded, fatty eminence
anterior to the pubic symphysis.
• Formed by a mass of fatty subcutaneous
tissue
• The amount of fat increases at puberty and
decreases after menopause.
• The surface of the mons is continuous with the
anterior abdominal wall.
• After puberty, the mons pubis is covered with
coarse pubic hairs.
 Labia Majora
• The labia majora are prominent folds of skin that
indirectly provide protection for the urethral and
vaginal orifices.
• The external aspect covered with pubic hair &
pigmented skin containing many sebaceous glands
• The internal aspects of the labia are smooth, pink, and
hairless.
 Labia Majora…
• The labia are thicker anteriorly & join to form the
anterior labial commissure.
• Posteriorly, in nulliparous women they merge to form
a ridge, the posterior labial commissure.
• This commissure usually disappears after the first
vaginal birth.
 Labia Minora
• The labia minora are rounded folds of fat-free, hairless
skin.
• Surround the vestibule
• Anteriorly, the labia minora form two laminae.
• The medial laminae of each side unite as the
frenulum of the clitoris.
• The lateral laminae unite to form the prepuce
(foreskin) of the clitoris.
 Labia Minora…
• In young women, especially virgins, it connected
posteriorly by a small transverse fold, the
frenulum of the labia minora (fourchette).
• Contains many sebaceous glands and sensory
nerve endings.
 Clitoris

• The clitoris is an erectile

organ located where the
labia minora meet
anteriorly.
• It functions solely as an
organ of sexual arousal.
• The clitoris is highly
sensitive and enlarges on
tactile stimulation.
 Vestibule
• It is the space surrounded by the labia minora.
• The orifices of the urethra and vagina and the
ducts of the greater and lesser vestibular glands
open to the vestibule.
 Bulbs of the Vestibule
• They are paired masses of
elongated erectile tissue
• 3 cm in length.
• The bulbs lie along the
sides of the vaginal orifice.
Bulb of
• They are covered inferiorly vestibule
and laterally by the
bulbospongiosus muscles
• The bulbs are homologous
with the bulb of the penis
of the corpus spongiosum.
 Vestibular Glands

• Greater vestibular glands

• The lesser vestibular glands
 Greater vestibular glands

• They are 0.5 cm in diameter

• Located on each side of the
vestibule, posterolateral to
the vaginal orifice
• They are round or oval and
• Partially surrounded by the
bulbospongiosus muscles.
• These glands secrete mucus
into the vestibule during
sexual arousal Greater
vestibular gland
 The lesser vestibular glands
The lesser vestibular glands are small glands
on each side of the vestibule.
• These glands secrete mucus into the vestibule,
which moistens the labia and vestibule.
 Arterial Supply of the Vulva

• External pudendal arteries.

• Internal pudendal artery supplies most of
the skin, external genitalia, and perineal
muscles.
• Labial arteries are branches of the internal
pudendal artery.
Venous and Lymphatic Drainage of the Vulva
Venous Drainage
• The labial veins are tributaries of the internal
pudendal veins
Lymphatic Drainage
• Superficial inguinal lymph nodes.
• Deep inguinal nodes & the internal iliac
nodes drains the glans of the clitoris and
anterior labia minora.
Innervation of the Vulva
The anterior aspect (mons pubis, anterior labia)
by derivatives of the lumbar plexus:
The anterior labial nerves, derived from the
ilioinguinal nerve, and
The genital branch of the genitofemoral nerve.
Innervation of the Vulva…
The posterior aspect: derived from sacral plexus:
Posterior cutaneous nerve of the thigh laterally
The pudendal nerve (Posterior labial nerves &
dorsal nerve of the clitoris) centrally.
Cavernous nerves from the uterovaginal nerve
plexus supply the bulb of the vestibule and erectile
bodies of the clitoris
 THANK YOU FOR
YOUR ATTENTION!!