Perineum

Perineum
• Is diamond shaped region positioned inferior to the pelvic floor
between the thighs.
• Its peripheral boundaries is the pelvic inlet
• Its ceiling is the pelvic diaphragm (levator ani and coccygeus muscles)
• Lateral walls are formed by the walls of pelvic cavity below the levator
ani muscle.
It is subdivide into two triangles namely:-
Uroogenital triangle
Anal triangle
Borders and ceiling of the perineum
Borders and ceiling of the perineum
• The margin of the perineum is
marked by the pubic symphysis
anteriorly, the tip of the coccyx
posteriorly and the ischial
tuberosities on the lateral sides.
• An imaginary line between two
ischial tuberosities divide the
perineum into urogenital and anal
triangles.
• Levator ani muscle form the roof
of the perineum.
Perineal membrane and dep perineal pouch
• Perineal membrane is a thick fibrous
sheet that fills the urogenital triangle.
• It has a free posterior border, which is
anchored in the midline to the perineal
body.
• Laterally it is attached to the pubic arch.
• Immediately superior to the perineal
membrane is a thin region called deep
perineal pouch.
• The deep perinea pouch contain skeletal
muscles that form urethral sphincter.
Perineal membrane and dep perineal pouch
• Both perineal pouch and perineal
membrane provide support for
the external genitalia which are
attached to the inferior surface.
• Urethra pass through the dep
perineal pouch and perineal
membrane.
• In women the vagina also pass
through these structures
posterior tot the urethra.
Ischio-anal fossae and their anterior recesses
• These are wedge shaped gutters that
occur between the levator ani
muscles and adjacent pelvic wall as
the two structures diverge from each
other.
• In the anal triangle, these gutters one
on each side are called ischial anal
fossae.
• The lateral wall of each ischial anal
fossae is formed by the ischium,
obturator internus muscle and
sacrotuberous ligament.
Ischio-anal fossae and their anterior recesses
• Ischio-anal fossae allow movement
of the pelvic diaphragm and
expansion of the anal canal during
defecation.
• The ischio-anal fossae of the anal
triangle are continuous anteriorly
with recesses that project into the
urogenital triangle superior to the
dee perineal pouch .
• The ischio-anal fossae and their
anterior recesses are filled with fat.
Anal triangle
• It faces posteroinferiorly and is defined
laterally by the medial margins of the
sacrotuberous ligaments, posteriorly y
the coccyx and anteriorly by a horizontal
line between the two ischial spines.
• The ceiling of the anal triangle if formed
by the levator ani muscle.
• The anal aperture is located centrally in
the anal triangle and is related on either
side to the ischial anal fossa.
• External anal sphincter surround s the
anal canal.
Urogenital triangle
• Is the anterior half of the perineum
and is oriented in the horizontal plane.
• It contains the roots of the external
genitalia and the openings of the
urogenital system.
• Laterally it is defined by the
ischiopubic rami.
• Posteriorly by an imaginary line
between the ischial tuberosities.
• Anteriorly by the inferior margin of the
pubic symphysis.
Urogenital triangle
• The roof of urogenital triangle is
formed by the levator ani muscle.
• Unlike the anal triangle, urogenital
triangle contains perineal membrane
and deep perineal pouch.
• Anterior extension of ischio-anal fossae
occur between the perineal pouch and
levator ani muscle on each side.
• Superfical perineal pouch is between
the perineal membrane and
membranous superficial fascia of the
perineum.
Structures in the superficial perineal pouch
• Erectile structures (penis in men
and clitoris in women).
• Skeletal muscles associated with
erectile tissues.
Erectile tissues
• Two sets of erectile structures join
to form penis in men and clitoris in
women.
• A pair of cylindrical shaped corpora
cavernosa one on each side of
urogenital triangle attached to the
pubic arch by their crura.
• The distal end of corpora cavernosa
form the body of clitoris in women
and penis in men.
Erectile tissues
• The second set of erectile tissue
surround the openings of the
urogenital system.
• In women, the bulb of vestibule
are situated one on each side of
the vaginal opening.
• A small band of erectile tissue
connect the anterior ends of the
erectile tissues to a single, small
pea-shaped erectile mass called
the glans clitoris.
Erectile tissues
• In men, a single large erectile tissue
called corpus spongiosum is the
structural equivalent to the bulb of
vestibule, glans clitoris and
interconnecting bands of erectile
tissue in women.
• It is anchored at its base to the
perineal membrane and extends to
form the ventral part of the body of
the penis.
• It enclose the urethra and expands at
its distal end to form the glans penis.
Clitoris
• Is composed of two corpora
cavernosa and the glans clitoris
• It has an attached part (root) and a
free part (body).
• The root of the clitoris consist of
the two crura while the body is
formed by unattached parts of the
corpora cavernosa, it angles
posteriorly and is embedded in the
connective tissue of the perineum.
Clitoris
• The body of the clitoris is
supported by a suspensory
ligament that attaches to the pubic
symphysis.
• The glans clitoris is attached to the
distal end of the body and its
connected to the bulb of the
vestibule.
• The glans clitoris is exposed in the
perineum and the body can be
palpated through skin.
Penis
• Is composed of two corpora
cavernosa (dorsal) and the single
corpus spongiosum (ventral).
• It has attached root and a free
body.
• The root consist of two crura
which are proximal parts of
corpora cavernosa and the bulb
of the penis which is a proximal
part of the corpus spongiosum.
Penis
• The body is formed by free part of
the corpora cavernosa and the
related free part of the corpus
spogiosum.
• The body of the penis is
supported by the suspensory
ligaments of the penis attached
to the pubic symphysis superiorly
to the and a more superficially
positioned fundiforrm ligament
attached above to the linea alba.
Erection
• Both the penis and clitoris erection is a
vascular event which is caused by the
filling of blood in the erectile tissue.
• It is caused by stimulation of the
parasympathetic nerves (S2-S4) carried
in the pelvic splanchnic nerves.
• Arteries supplying the clitoris and
penis are branches of the internal
pudendal artery.
• Pudendal nerve (S2-S4) carry general
sensory fibres from the penis and
clitoris
Greater vestibular glands
• Are also known as Bartholin’s glands
present in women.
• They are small pea-shaped mucous
glands lying posterior to the bulbs of the
vestibule on each side of the vaginal
opening in the superficial perinea pouch.
• They are homologous to the
bulbourethral glands in men.
• The duct of Bartholins glands opens into
the vestibule of the vagina.
• It produces secretion during sexual
arousal.
Muscles
• The superficial perineal pouch
contains three pairs of muscles
namely:-
Ischiocavernosus
Bulbospongiosus
Superficial transverse perineal
muscles
Ischiocavernosus
• The two ischicavernosus muscles
cover the crura of the penis in
men or clitoris in women.
• Each muscle is anchored to the
margin of the ischial tuberosity
and related ischial ramus.
• It forces blood into the distal
part of erect penis and clitoris.
Bulbospongiosus
• The two bulbospongiosus muscles are
associated with the bulb of the
vestibule in women and corpus
spongiosum in men.
• In women it is attached posteriorly to
the perineal body and courses
anterolaterally over the greater
vestibular gland and bulb of the
vestibule.
• In men they are joined in the midline
by a raphae on the inferior surface of
the bulb of the penis.
Bulbospongiosus
• The raphae is anchored posteriorly to
the perineal body.
• In both sexes, the muscle
compresses the attached part of the
erectile tissue so that blood is
pushed more distal.
• In men it facilitate the emptying of
penile urethra during urination and
their reflex contraction is responsible
for the pulsatile emission of semen
during ejaculation.
Superficial transverse perineal muscles
• They are paired and course
parallel to the posterior to the
margin of the inferior surface of
the perineal membrane
• They are attached to the ischial
tuberosities and rami and
extends medially to the perineal
body.
Superficial features of external genitalia in
women
• The clitoris and vestibular
apparatus together with a number
of kin and tissue folds form the
vulva.
• On either side of the midline are
two folds of skin called the labia
minora.
• The region enclosed between the
labia minora into which the
urethra and the vagina opens is
called the vestibule
Superficial features of external genitalia in
women
• The labia minora bifurcate
anteriorly into medial and lateral
folds.
• The medial folds unite to form the
frenulum of the clitoris while the
lateral folds unite to form the
prepuce (hood) of the clitoris.
• Posterior to the vestibule the labia
minora unite to form a transverse
ford called the frenulum of labia
minora (fourchete)
Superficial features of external genitalia in
women
• The vaginal orifice is surrounded by a
ring-like fold of membrane called the
hymen.
• Skenes glands open into the urethra
while greater vestibular glands opens into
the vagina.
• Lateral to the labia minora are two broad
folds called labia majora. They unite
anteriorly to form the mons pubis.
• Posteriorly, labia majora do not unite and
they form what is known as posterior
commissure which overlies the perineal
body.
Superficial features of external genitalia in
men
• Comprises of the penis and the
scrotum.
• The scrotum is a male homologue
of the labia majora in women.
• The penis consist of the root and
the body.
• The pendulous part of the penis
(body) is covered by skin while the
tip is covered by the glans penis
Superficial fascia of the urogenital triangle
• Perineal fascia has a deep
membranous fascia called Colles
fascia which is attached to the
perineal membrane hence does
not extend into the anal triangle.
• It lines the scrotum or labia and
extends into the body of the
penis or clitoris.
• It encloses the perineal pouch.
Superficial features of external genitalia in
men
• The inferior margin of the urethral
opening is continuous with a
midline raphae of the penis
• The base of the raphae is
continuous with the frenulum of
the glans penis.
• The base of the glans penis is
expanded to form a raised circular
margin called the corona of glans.
• In uncircumcised men, the skin
prepuce covers the glans penis.
Nerve supply to the
perineum
Somatic and visceral
Somatic nerves
• The major somatic nerve of the
perineum is the pudendal nerve.
• It originates from the sacral
plexus and carries fibres from
the spinal levels S2-S4.
• It leaves the pelvis through the
greater sciatic foramen inferior
to the piriformis muscle and
enter the perineum through the
inferior sciatic foramen
Other somatic nerves of the perineum
Include:-
Ilio-inguinal nerve
Genital branch of genital
femoral nerve
Posterior femoral cutaneous
nerve.
Anococcygeal nerves
Pudendal nerve
• It travels in the ischioanal fossae
through the pudendal canal
together with pudendal vessels.
• It has three major terminal
branches namely:-
Inferior rectal nerve
Perineal nerve
Dorsal nerve of the clitoris or
penis
Visceral nerves of the perineum
They enter the perineum by two
roots:-
Post ganglionic sympathetic to
the skin via the pudendal nerve.
Those to the erectile tissue via
the inferior hypogastric plexus.
They are parasympathetics that
stimulates erection from spinal
levels S2-S4.
 Blood supply and
lymphatic drainage
Arteries, Veins and lymphatics
Arteries
• The most significant artery of
the perineum is the internal
pudendal artery.
• Other arteries entering the area
include:_
External pudendal artery
Testicular artery in men
 And cremasteric artery
Internal pudendal artery
• Originates as a branch of the anterior
trunk of internal iliac artery in the pelvis.
• It leaves the pelvis together with the
pudendal nerve through the greater
sciatic foramen and enter the perineum
through the lesser sciatic foramen.
• Its terminal branches are similar to
those of the pudendal nerve and
include:- the inferior rectal artery,
perineal arteries and a branch to the
erectile tissues of the penis or clitoris
External pudendal arteries
• Consist of the superficial and
deep vessels which originates
from the femoral artery in the
thigh.
• They course medially into the
perineum and supply related
skin of the penis and scrotum in
men and clitoris and labia
majora in women.
Testicular and cremasteric arteries
• In men, testicular artery originate from
the abdominal aorta and descend into
the scrotum through the inguinal canal
to supply the testis.
• Cremasteric arteries originates from
the inferior epigastric artery
accompanying the spermatic cord into
the scrotum.
• In women, a small cremasteric artery
follow the round ligament of the
uterus through the inguinal canal
Veins
• Generally they accompany the
arteries and have similar names.
• They drain into the internal
pudendal vein in the pelvis.
• The deep dorsal vein of the penis
or clitoris drain into the plexus of
veins around the prostate in men
and bladder in females.
• External pudendal vein drains
into the femoral vein in the thigh
Lymphatic drainage of the perineum
• Lymph from the deep parts
accompany the internal
pudendal artery and drain into
internal iliac nodes.
• Lymphatic channels from
superficial parts drain into
superficial inguinal nodes.
• Lymph from the testis drain into
lateral aortic nodes and pre-
aortic nodes in the abdomen.