Você está na página 1de 8

1

Anatomy – Hour A (1-2pm)


Class of 2009 Co-Op
November 16, 2005
Dr. Kuhlmann
Writer: Jacob Clark
Pelvis & Perineum 2

As we all know, Dr. K talks pretty fast and it’s hard to take notes, but I did what I could
using multiple old Co-Ops and relistening to the lecture (it wasn’t easy). Have a great
Thanksgiving break (and if you are looking at this while you’re on break, STOP and
enjoy yourself)!

Dr. K started by showing a hemisected pelvis


1. 2 areas located posteriorly
a. The greater and lesser sacrosciatic notch
1. Sacrospinous and spinous ligament are oriented with the notches to
create greater and lesser sacrosciatic foramen
2. Anteriorly and Inferiorly
a. Obturator membrane
1. Obturator internus muscle
a. Defect in this muscle and the obturator membrane called
obturator canal

Anterior view looking down into the pelvis


1. The Sacrospinous ligament runs between the sacrum and the ischial spine. It forms
the inferior border of the Greater Sacrosciatic foramen and the superior border
of the Lesser Sacrosciatic foramen.
2. The Sacrotuberous Ligament runs between the sacrum and the ischial tuberosity.
It forms the inferior border of the Lesser Sciatic foramen.

Male / Female Pelvis


1. Greater (false) pelvis
a. Area of bony pelvis superior to the plane of the pelvic inlet
b. Contains abdominal viscera
2. Lesser (true) pelvis
a. Area of bony pelvis inferior to the plane of the pelvic inlet
b. Contains the pelvic viscera

Female Male
Pelvic Inlet Oval Heart-shaped
Longer transverse diameter
Pelvic Outlet Longer A-P diameter Shorter A-P diameter
Longer transverse diameter Shorter transverse diameter
Pelvic Cavity Divergent as proceed from the Convergent (funnel-shaped)
inlet to the outlet (cylindrical)
Pubic Arch > 90 degrees < 90 degrees

Different types of pelvis:


2
NOTE: You don’t need to remember the various measurements but know that there are
four types of pelvises.

1. Gynecoid
a. Most common female shape
2. Android
a. Most common male shape
3. Anthropoid
a. Long A-P diameter and short transverse diameter.
b. Higher risk for occiput posterior deliveries (babies face up).
4. Platypelloid
a. Very dysfunctional pelvis when it comes to obstetrics
b. Gestational age dependent
c. Often require C-section for delivery

Muscular Pelvis:

1. Piriformis
1. Originates from the lateral aspect of the sacrum
2. Passes (“exits”) through the greater sacrosciatic foramen
3. Interdigitations through which the nerves and arteries pass
a. Correlate well with the foramina
2. Obturator Internus
1. Passes (“exits”) through the lesser sacrosciatic foramen
3. Greater Canter of the Femur
1. Place of attachment for both the piriformis and the obturator internus
2. We should be able to see this clearly with the gluteal dissection

4. Intrinsic Musculature of the Pelvis

1. Pelvic diaphragm
• Creates 2 spaces:
1. Intra-pelvic (visceral) space  superior to the pelvic
diaphragm
a. Structures (such as uterus, rectum, urethra) are within
this space
2. Ischiorectal (ischioanal) space (fossa)  inferior to the pelvic
diaphragm
a. Filled primarily with fat and covered by the gluteus
maximus
b. Running through this area are structures including
branches of the pudendal nerves and arteries, and the
hemeroidal arteries
• Muscles of the pelvic diaphragm:
a) Levator ani muscles (main part of the pelvic diaphragm)
1. Pubococcygeus m.
a. Originates by the pubis, comes back to the coccyx
b. Bilateral
3
2. Puborectalis m.
a. Part of Pubococcygeus m.
b. Described as a condensation or the formation of a sling
c. Pulls rectum anteriorly, helping to maintain rectal
continence
3. Iliococcygeus m.
b) Coccygeus m. (also known as Ischiococcygeus m.)
(This muscle is NOT a component of Levator ani
muscles)

**Remember: The pelvic diaphragm is the primary support for the pelvic viscera!!

5. Urogenital Diaphragm – is also known as the deep pouch (space) and it fills in an
anterior defect in the pelvic diaphragm
1. Comprised of muscle, so there is a fascia on either side
a. Fascia of the UG diaphragm is composed of 2 layers:
1. Superior fascia
2. Inferior fascia (also known as perineal membrane)
**Anything inferior to the inferior fascia and just deep to the skin is part of the
Superficial Pouch (Space)!**
a) Continuous with Scarpa’s fascia along the anterior abdominal
wall

2. The urethra and the vagina pass through the UG diaphragm


3. In the male, just the urethra passes through

** The UG diaphragm does NOT contain the rectum!**

5. Muscles of UG diaphragm are between the superior & inferior fascia:


1. Sphincter urethrae m. (there is some question as to whether it
actually works as a sphincter)
2. Deep transverse perineal m.

6. The Superficial Space (pouch) is composed of:


1. Ischiocavernosus m. – (bilaterally symmetric)
2. Bulbocavernosus m. (also known as Bulbospongiosus m.) –
(bilaterally symmetric)
3. Vestibular bulb - a pamipiniform (vine-like) plexus of veins that is
extremely vulnerable to bleeding during trauma in this region
(Straddle injury)
4. Bartholen’s gland
5. Superficial transverse perineal m. – (bilaterally symmetric)

** The fascia of the superficial pouch is contiguous with Scarpa’s fascia on the
anterior abdominal wall. Thus, a male who damages the urethra in a “straddle injury”
will have a uroma (pool of urine) that can extend up the anterior abdominal wall.
Similarly, a female who has a “straddle injury” can have blood extend up the anterior
4
abdominal wall.**

7. Building up of the layers of the pelvic diaphragm and UG diaphragm (notes p. 17)

The Neural Pelvis

1) Obturator nerve (know the course of the nerve)


* This nerve originates from L2-L4 and accompanies the obturator artery
and vein. It runs along the superior pelvic aperture, crosses the sacroiliac
joint and passes through the obturator canal, sending branches to the
Obturator internus muscle and the Adductor muscles of the thigh.

2) Lumbosacral trunk
* L4-L5, joins up with S1-S3.

3) Pudendal n. – from S2-4


1. More easily seen in the gluteal region when perineum is dissect out
a. Common area for this to be tagged
2. Leaves pelvis through Greater Sacrosciatic foramen, wraps around
and is encompassed in its own canal, Alcock’s (Pudendal) Canal
a. Pudendal canal contains Pudendal n., a., and v.
3. Provides main sensory innervation to perianal and perineum region
[384]
a. Don’t spend any time looking for the perforating cutaneous
because you won’t find it, probably not even clinically
4. Gives off branches through the deep pouch, such as the inferior rectal
n. (also known as hemorrhoidal n.), and terminates as the dorsal n.
of the penis/clitoris

**Majority of perineum innervation is from Pudendal nerve!**

4) Other nerves play a minor role in sensory innervation to the perineum:


1. Posterior femoral cutaneous n. (perineal branch)
2. Perforating cutaneous n. (never seen by Dr. Kuhlmann)
3. Ilioinguinal n.

5) Pudendal anesthesia
1. Dealt with very easily during the second stage of labor
2. Done through a catheter or a sleeve by palpating the sacrosciatic area
(notch), going into the sacrospinous ligament and then you can actually
get the anesthetic back near the pudendal n.

The Vascular Pelvis

A. Aorta terminates as the common iliac arteries that bifurcate into the
external and internal iliac aa. (int. iliac a. = hypogastric a.)
B. The external iliac is going to give rise to the deep circumflex a. and the
inferior epigastric a.
1. Inferior epigastric is one of the first branches you see as an
5
anastomosis
C. Internal iliac a. (hypogastric a.) splits into anterior and posterior divisions:
1) Anterior Division:
a. Umbilical a.
a) Runs until the level of the pubic symphysis, then
becomes obliterated as the medial or lateral umbilical
ligament
b) Also sends branches to the bladder
b. Obturator a.
a) Follows the obturator n. through the obturator canal
and supplies the medial area of the thigh
b) Also gives off vesicular branches to the bladder
c. Pudendal a.
a) Hemmorhoidal aa.
d. Inferior and posterior gluteal aa.
e. Vaginal a.
f. Uterine a.
g. Middle rectal a.

In the abdomen, blood flows from medial to lateral (aorta is medial)


In the pelvis, blood flows from lateral to medial (iliacs are lateral)

**Also, “Water runs under the bridge” (Males: ureter runs under Vas
Deferens, females: ureter runs under Uterine artery)

2) Posterior Division (easier to remember this and know others come from
ant.):
a. Iliolumbar a.
b. Lateral sacral a.
c. Superior gluteal a.

Pelvic Viscera

1. Female pelvis
A. The Uterus (has 3 parts: cervix, body, and fundus)
1) Visceral peritoneum is thrown up on the uterus and goes behind the uterus
a. Called the broad ligament
1. Fold of visceral peritoneum
2) Ligaments:
1. Broad ligament
a. Composed of an anterior and posterior leaf
1. It is a sheet of visceral peritoneum folded over (remember the
uterus and fallopian tubes are covered with peritoneum –
they are retroperitoneal)
2. Suspensory ligament of uterus
3. Round ligament – extends laterally from the uterus anterior to the
fallopian tube (which is anterior to the ovary). This is important to
remember so that you won’t tie off the wrong structure in a tubal ligation!
6
4. Uterosacral ligament (also known as sacrouterine ligament or
sacrocervical ligament) – extends from cervix to sacral area; supports the
uterus and vagina

3. Blood supply
a. Uterine a. – primary source of blood to the uterus
1. Bifurcates at the level of the uterus into:
a. Descending branch
1. Anatomoses with vaginal a.
b. Ascending branch
1. Joins the ovarian artery to become the uteroovarian a.

4. Support for the pelvis (on scale of 1 –> 10 w/ 10 = greatest support)


a. Round ligament (2)
b. Uterosacral ligament - extends from uterus to the sacral region (8)
c. Transverse cervical ligament (Machenrodt’s, or cardinal ligament)
a) contains the ureter, uterine a., and uterine v. (10)
d. Suspensory ligament – mustn’t offer support, since he gave it a (-1)
e. Pubocervical ligament – originates from the pubic area and attaches to
the cervix and perhaps a lower segment of the uterus
**f. Pelvic diaphragm - main support for pelvic viscera! (10)
a) If support is lost, the urethra can become prolapsed out into the
vagina

5. Spaces or Pouches
1. When doing gynecology, the goal is to create these spaces
a. Once one creates these spaces, dissection and surgery can be
done with relative impunity
1. Paravescicular space
a. Surrounding the bladder
b. Create this space when trying to identify the
blood vessels to the uterus
1. Particularly true in radical surgery when
you’ve got to remove a patient’s bladder,
cervix, uterus, and rectum in cases
that are referred to as exoneration for various
gynelogical malignancies such as cervical
cancer and advanced uterine cancer
2. Retro space of Sylvius (Retropubic space)
a. Can cause you problems at the time of caesarian
when you’re trying to dissect down and
identify the direction to go. It is quite
vascular and bleeds a lot
1. Most common cause of bleeding in this
area is from the retractor.
3. Space of Douglas
a. Space between the cervix and the rectum
4. Pararectal Space
a. Important for colorectal surgeons (cancer, etc.)
7
Bladder

A. Males: the prostate gland is inferior to the bladder


Females: the pelvic diaphragm is inferior to the bladder
B. Levator ani and pubic symphysis rest on the anterior border of bladder
C. Areas of the bladder emphasized:
1. Dome - superior portion of the bladder
2. Trigone - area of bladder shaped like a triangle. The corners are the 2
ureteric orifices on the lateral sides and the urethra
a. In surgery, cuts into the dome of the bladder heal easily
b. However, cuts in the trigone heal poorly and may cause
problems
D. The muscle of the bladder is the detrusor m. (smooth muscle)
1. 3-4 layers of muscle that can distend quite readily, especially in pregnancy
when there is significant relaxation going on.
a. With a woman in labor, getting lots of fluids, one can palpate the bulge
of the bladder up past the umbilicus
E. Pretty much sitting anteriorly and inferiorly within the pelvis

-parasympathetic stimulation contracts the bladder!


** Prostate hypertrophy or cancers may result in significant
urinary retention because the neck of the bladder may be
constricted.
** However, since females have a shorter urethra, they are more
vulnerable to incontinence.
The Urethra

A. In males, the urethra has three components:


1. Prostatic urethra - passes through prostate gland (first part of urethra)
2. Membranous urethra - passes through UG diaphragm (second part of
the urethra)
3. Spongy urethra - runs through the corpus spongiosum of the penis (last
part of the urethra)
B. In females, there is only a membranous urethra
C. Prostatic utricle is the homologue to the upper vagina and the uterus

Rectum
Note: **Distal 1/3 of rectum not covered by peritoneum and rectum
does not go through the UG diaphragm.**
1. Contains 3-4 incomplete valves that are important for maintaining continence
2. Anal region has blood vessels (responsible for hemorrhoids)
3. External Anal Sphincter (voluntarily controlled):
a. Deep, Internal, Superficial components
4. Internal Anal Sphincter (involuntarily controlled)

**Continence controlled by sphincteric control, puborectalis muscle (sling), and


additionally deep, superficial, and subcutaneous components.
8