PERINEUM

DR. ABDUL RASHAD

SENIOR LECTURER
DPT,MPHILL(OPT) ,MPPTA, MMTC (NZ), MSTC(AUS),
IASTM(GREECE)
UNITED COLLEGE OF PHYSICAL THERAPY
Perineum
• Area below the levator ani
• Boundaries
• Pubic arch
• Ischial tuberosities
• Sacrotuberous ligament
• Coccyx
Perineal Triangles
 Perineum
• Divided into two triangles
• Urogenital triangle
• Anal triangle
• Perineal body central point
of perineum
Urogenital Triangle
• Deep pouch
• Superficial pouch
• Perineal membrane
separates the two
• Deep is superior to
perineal membrane
• Roof is pelvic
fascia
 Deep Pouch in Male
• Membranous portion of
the urethra
• Sphincter urethra or
external sphincter
of bladder
• Perineal nerve
• Deep transverse perineal
muscle
Deep Pouch in Male
• Bulbourethreal glands
• Internal pudendal artery and
branches
• Artery to bulb
• Dorsal nerve of penis
• Branches of perineal nerve
 Deep Pouch in Female
• Vagina
• Urethra
• Sphincter urethra or external
sphincter of bladder
• Perineal nerve
• Deep transverse perineal muscle
• Internal pudendal artery
• Artery to bulb
• Dorsal nerve of clitoris
Sphincter Urethrae (Female)
• Sphincter urethrae
in the deep pouch
• Also called external
sphincter of
• bladder
Perineal branch of
pudendal S 2,3
Perineal Membrane (Male)
• Piercing membrane
• Spongy urethrae
• Ducts of bulbourethral glands
• Artery to bulb
• Internal pudendal artery
• Deep and dorsal arteries of
penis
• Dorsal nerve of penis
• Deep dorsal vein passes above
membrane
• Enters prostatic venous plexus
Superficial Pouch (Male)
Superficial Pouch (Male)
Superficial Pouch (Male)
 Colles’ Fascia
• Attached posteriorly to
perineal membrane
• Sides of pubic arch
• laterally
Deep fascia of thigh along a line
• drawn from pubic tubercle
• Anterior floor of pouch
• Layer of scrotum
• Surrounds penis as
far as glans
Passes up on to anterior
abdominal wall
Membranous Layer of Superficial or
Colles’ Fascia
• Posterior attached to posterior border
of perineal membrane
• Anterior it forms floor of superficial
pouch and forms layer of the scrotum
• Surrounds penis as far as glans
• Then on to anterior abdominal wall
• Attached to fascia lata from a
horizontal line from pubic tubercle
• Rupture of spongy urethra is
limited by the attachment of Colles’
fascia
Superficial Pouch (Male)
• Roof
• Perineal membrane
• Floor
• Colles’ or membranous layer of
superficial fascia
• Ruptured urethra in male
• Urine limited by the attachments
of Colles’ fascia in superficial
pouch
Superficial Pouch (Male)
• Penis corpus spongiosum
• Corpora cavernosa
• Spongy urethra
• Bulbospongiosus muscle
• Ischiocavernosus muscle
• Superficial transverse perinei muscle
• Internal pudendal artery
• Deep and dorsal arteries of penis
• Dorsal nerves of penis
• Scrotal vessels and nerves
Contents Superficial Pouch (Male)
• Root of penis
• Corpus spongiosum
• Bulb, body and glans
• Spongy portion of urethrae
• Crura and corpora cavernosa
Penis
Penis
Penis
• Deep artery enters crura of
corpora cavernosa
• Dorsal nerve of penis
• Dorsal artery of penis
• Deep dorsal vein lies on
dorsum between Colles’s
fascia and tunica albuginea
• Passes above perineal
membrane
• Enters prostatic venous
plexus
Penis
• Erectile tissue
• Helicine arteries
• Fibrous saccules arterioles
enter directly
• Dorsal vein open
• Parasympathetic causes
erection L2,3,4
• Ejaculation is via the
sympathetic impulses from
L1-L2
 Corpus Spongiosum
• Bulb posterior dilatation
• Body (horizontal)
• Glans dilated anteriorly
• Spongy urethra
• Dilated posteriorly in the bulb
• Uniform in body
• Dilated in the glans
• Fossa navicularis
• Meatus vertical slit
Spongy Urethra
Spongy Urethra
• Urethra unprotected
• Before it enters
• bulb
• Ducts of bulbo-urethral glands
• Enter intrabulbar fossa
Littre’ glands end in navicular
fossa
Muscles in Superficial Pouch (Male)

• Bulbospongiosus muscle
• Ischiocavernosus muscle
• Superficial transverse perinei
muscle
• Supplied by perineal
branches of pudendal nerve
• Enter pouch by piercing
Colles’ fascia
Vessels and Nerves
• Deep and dorsal arteries of
penis
• Deep dorsal vein
• Scrotal nerves
• Perineal nerve
• Dorsal nerve of penis
Lymphatics
• Skin of scrotum to medial
superficial inguinal
• glands
Testes to para aortic glands
at L2
Nerve Supply
• Preganglionic of sympathetic
from L1 and L2 cause
ejaculation
• Parasympathetic
preganglionic from S2,3,4
cause erection
Female Pelvis and Perineum
Superficial Pouch (Female)
• Mons pubis
• Labia majora
• Labia minora
• Dorsal prepuce
• Frenulum of glans
• Vestibule
Superficial Pouch (Female)
Superficial Pouch (Female)
• Urethra
• Vagina
• Clitoris
• Crura of clitoris
• Ischiocavernosa
• Bulbs of vestibule join, pass
to glans
• Bulbospongiosus
• Bartholin’s or vestibular
glands
Superficial Pouch (Female)
• Crura and glans of clitoris
• Covered by
ischiocavernosus muscle
• Bulbs of vestibule
• Inferior greater vestibular
or Bartholin’s glands
beside vagina
• Covered by
bulbospongiosus muscle
Superficial Pouch (Female)
Superficial Pouch (Female)
• Cutaneous anteriorly
• Ilioinguinal nerve
• Labial vessels and nerve
posteriorly
• Motor
• Perineal branches of
pudendal
Structure of Female Urethra
• Muscular layer continuous with bladder
• Spongy erectile tissue
• Plexus of veins
• Mucous membrane transitional
• Distal non-keratinising stratified
• squamous
No fascia between lower two thirds of urethra
and vagina
Vagina
• Fornices, gutters which
surround the cervix
• Anterior shallow
• Posterior deeper
• Superior covered with
peritoneum of the pouch of
Douglas
• Lateral: uterine artery above
ureter
Vagina
• Upper portion of the vagina is
clasped
• By the pubovaginalis portion of
the levator ani
• Bulbospongiosus muscles
surrounds outlet
• Hymen
Vagina
• Erectile tissue
• Muscular
• wall Pelvic
• fascia
Non-keratinised stratified squamous
• epithelium
• Urethra lower third anterior wall
No fascia between lower two thirds
of urethra and vagina
Anal Triangle
• Anal canal
• Ischiorectal fossa
Anal Canal
• Anorectal junction: below
ampulla of rectum
• Anus: 4 cm
• Anterior: perineal body
• Posterior: anococcygeal
body
• Lateral: ischiorectal
fossae
Anal Canal
• Upper two thirds
• Columnar epithelium
• Anal columns contain radicles
of superior rectal artery and
veins
• 4, 7, 11 o’clock position
• Anal valves along
pectinate line
• Anal sinus, Hilton white line;
internal sphincter
• Subcutaneous deep
• Lower third skin
Muscles of Anal Canal
• Anorectal ring
• Internal sphincter
• Puborectalis
• Puborectal fascia
• External sphincter
• Deep; true sphincter
• Inferior rectal nerve
• Superficial S4
• Subcutaneous; true sphincter
• Inferior rectal nerve
Muscles of Anal Canal
• Anorectal ring
• Puborectalis
• Internal sphincter
• Upper two thirds
• Perianal fascia is medial to
deep and superficial sphincter
• Passes to lateral wall forms
pudendal canal
• Above subcutaneous
sphincter
Blood and Nerve Supply
• Mucosa upper two thirds
• Superior rectal artery
• Autonomic nerves
• Lower third
• Inferior rectal
• Somatic nerves
Venous Drainage
• Mucosa upper two thirds
• Superior rectal vein
• Portal system
• Lower third
• Inferior rectal vein
• Vein into systemic
• system
Portal systemic anastomosis
4,7,11 o’clock
Lymphatic Drainage
• Upper third
• Pre-aortic inferior mesenteric
• Waldeyer’s fascia passes from
sacrum to the ampulla of rectum
• Encloses superior rectal vessels
and lymphatics
• Internal iliac
• Lower third
• Inferior rectal cross ischiorectal fossa
• Medial superficial inguinal glands
Embryology of Anal Canal
• Upper two thirds
• Cloaca
• Lower third
• Proctodeum
Ischiorectal Fossa
• Wedge shaped fossa
• Apex: origin of levator ani
from obturator internus
• Lunate fascia
• Base: perianal fascia and
subcutaneous fat
• Medial: levator ani
• External anal sphincters
Ischiorectal Fossa (Female)
• Anterior: posterior border
perineal membrane
• Posterior: sacrotuberous
ligament, gluteus maximus
Ischiorectal Fossa (Male)
• Lateral: fascia on medial aspect
of obturator internus ani
• Pudendal canal
• Ischial tuberosity
Ischiorectal Fossa
• Soft ischiorectal fat
• Lunate fascia above the fat
• Inferior rectal vessels pass
above the fat to reach medial
wall
• Perineal branch of S4

Ischiorectal fossa
Pudendal Canal
• Runs posterior to anterior
• Contents
• Pudendal nerve
• Inferior rectal nerve
• Dorsal nerve of penis or clitoris
• Perineal nerve
• Scrotal or labial nerves
Pudendal Block
Dermatomes