ThePelvis

LearningObjiective

1.Mastertheformationofpelvicdiaphragm.Knowthedispositionofthepelvicfascia.

2.Masterthedispositionandmainrelationsoftherectum.Knowthebloodsupplyandlymphdrainageoftherectum.Mastertheoftherectum.

3.Masterthemainrelationsofthebladder.Knowthebloodsupplyandlymphdrainageofthebladder.

4.Masterthedisposition,coveringsandrelationsoftheprostate.

5.Knowthedispositionandthebloodsupplyandlymphdrainageofovaryanduterinetubes.

6.Masterthedisposition,relationsoftheuterusandthefactorsresponsibleforitssupport.Knowthebloodsupplyandlymphdrainageoftheuterus.

7.Mastertherelationshipbetweenthefornixofvaginaandtherectouterinepouch.

8.Masterthebeginningandendingofcommoniliacarteryandvein;Masterthebeginningandendingofexternalandinternaliliacarteryandvein.Knowthebranchesofinternaliliacartery.Mastertherelationshipbetweenuterinearteryandureter.Knowthelymphnodesofthepelvis.

9.Knowtheformation,positionandmainbranchesofsciaticplexuses.

10.Knowthearrangementoftheautonomicnerves.

Keystone

1.Theformationofpelvicdiaphragm.

2.Thedispositionandmainrelationsoftherectum,bladder,prostate.

3.Thedisposition,relationsoftheuterusandthefactorsresponsibleforitssupport

4.Thebloodsupplyandlymphdrainageofrectumanduterus.

QuestionsRequiringShortAnswer

1.Describetheformationofpelvicdiaphragm.

2.Describethedispositionandmainrelationsoftherectum.

3.Describethemainrelationsofthebladder.

4.Describethedisposition,coveringsandrelationsoftheprostate.

5.Describethedisposition,relationsoftheuterusandthefactorsresponsibleforitssupport.

6.Describetherelationshipbetweenthefornixofvaginaandtherectouterinepouch.

7.Describethebeginningandendingofexternalandinternaliliacarteryandvein.

8.Describetherelationshipbetweenuterinearteryandureter.

ReadingandComprehension

RegionalAnatomyofPelvic

Section1ThepelvicWall

Ⅰ.Bonypelvis

Ⅰ)Composition:formedbypairedhipbones,sacrum,coccyx,andtheirarticulations

1.Twoportions

(1)Greaterpelvis

(2)Lesserpelvis

1)Terminalline(pelvicinlet):formedbypromontoryofsacrum,arcuateline,pectinofpubis,pubictubercle,upperborderofpubicsymphysis

2)Pelvicoutlet:formedbytipofcoccyx,sacrotuberousligament,ischialtuberosity,ramusofischium,inferiorramusofpubicsymphysis

Ⅱ)Musclesofthepelvicwall

1.Levatorani

(1)Levatorprostate(pubovaginalis)

(2)Puborectalis

(3)Pubococcygeus

(4)Iliococcygeus

2.Coccygeus

Ⅲ)Pelivicdiaphragm

1.Formedby

(1)Superiorfasciaofpelvicdiaphragm

(2)Levatoraniandcoccygeus

(3)Inferiorfasciaofpelvicdiaphragm

2.Hiatusofpelvicdiaphragm

Ⅳ)Pelvicfascia

1.Parietalpelvicfascia

(1)Linesthepelvicwallsandisregionallynamedaccordingtothemuscleitoverlies.

(2)Abovethepelvicinlet,itiscontinuouswiththefascialiningtheabdominalwalls.

(3)Superiorfasciaofpelvicdiaphragm

(4)Inferiorfasciaofpelvicdiaphragm

2.Visceralpelvicfascia

(1)Alayeroflooseconnectivetissuethatcoversandsupportsallthepelvicviscera.

(2)Ensheathesretroperitonealvisceraandformsseptabetweenretroperitonealorgans

1)Rectovesicalseptum

2)Rectovaginalseptum

3)Vesicovaginalseptum

Ⅴ)Spacesofpelvicfascia

1.Retropubicspace－liesbetweenpubicsymphysisandurinarybladder

2.Pararectalspace－liesaroundtherectum

3.Retrorectalspace

Section2Vessels,LymphandNervesofthePelvis

Ⅰ.Arteriesofthepelvis

Ⅰ)Commoniliacartery

1.ContinuationofabdominalaortaatlevelofL4vertebra

2.Rundownwardandlaterallytoendoppositethesacroiliacjointbydividingintointernalandexternaliliacarteries.

Ⅱ)Internaliliacartery

1.Parietalbranches

(1)Obturatora.

(2)Iliolumbera.

(3)Lateralsacrala.

(4)Superiorgluteala.

(5)Inferiorgluteala.

2.Visceralbranches

(1)Umbilicala.→superiorvesicala.

(2)Inferiorvesicala.

(3)Uterinea.－about2cmfromneckofuterusitcrossesaboveandinfrontofureter

(4)Inferiorrectala.

(5)Internalpudendala.

1)Course:leavesthepelvisthroughtheinfrapiriformforamenandenterstheglutealregion.Itenterstheperineumthroughthelessersciaticforamenandthenpassesforwardinthepudendalcanalwiththepudendalnerve.

2)Branches

①Analartery

②Perinealartery

③Dorsalarteryofpenis(clitoris)

Ⅲ)Externaliliacartery

Ⅱ.Veinsofthepelvis

Ⅰ)Internaliliacvein

1.Parietaltributaries:accompanywitharteries

2.Visceraltributaries

1)Rectalvenousplexus→superiorrectalvein→inferiormesentericv.

→inferiorrectalvein→internaliliacv.

→analvein→internalpudendalv.

2)Vesicalvenousplexus→vesicalv.

3)Uterinevenousplexus→uterinev.

Ⅱ)Externaliliacvein－accompanytheartery

Ⅲ)Commoniliacvein－formedbyunionofinternalandexternaliliacveinsinfrontofsacroiliacjoint,enduponL4~L5byunitingeachothertoforminferiorvenacava

Ⅲ.Thelymphaticdrainageofpelvis

Ⅰ)Internaliliaclymphnode

1.Surroundinternaliliacvessels

2.Receiveafferentsfrompelvicviscera,perineum,buttockandbackofthigh

Ⅱ)Externaliliaclymphnodes

1.Liealongexternaliliacartery

2.Receiveafferentsfromlowerlimbandsomepartsofpelvicviscera

Ⅲ)Sacrallymphnode

Ⅳ)Commoniliaclymphnode

1.Liealongcommoniliacartery

2.Receiveafferentsfromalltheabovenodes

3.Efferentpasstolumbarlymphnode

Ⅳ.Nervesofthepelvis

Ⅰ)Sacralplexus

1.Formation:formedbyanteriorramiofL4andL5spinalnerves(thelumbrosacraltrunk)andanteriorramiofsacralandcoccygealnerves

2.Position:liesinpelviccavity,anteriortosacrumandpiriformis

3.Branches

(1)Superiorgluteal

(2)Inferiorgluteal

(3)Posteriorfemoralcutaneousn.

(4)Pudendaln.

(5)Sciaticn.

Ⅱ)Autonomicplexusesofplevic

1.Hypogastricplexus

2.SuperiorhypogastricplexusliesinfrontofL5betweencommoniliacateries

3.Inferiorhypogastricplexus(pelvicplexus):lieoneachsideofrectum

Ⅲ)Sacralsympathetictrunk

1.Iscontinuousabovewiththeabdominalpart

2.Has4or5ganglion

Section3PelvicVicera

Ⅰ.Rectum

Ⅰ)Relationshipsofrectum

1.Anteriorly

(1)Inmale

1)Fundusofbladder

2)Seminalvesicle

3)Prostate

4)Ampullaductusdeferentis

5)Pelvicpartofureter

(2)Infemale

1)Neckofuterus

2)Vagina

2.Posteriorly

(1)Sacrumandcoccyx

(2)Piriformis

(3)Medianandlateralsacralvessels

(4)Anteriorbranchesofsacralandcoccygealnerves

(5)Sacralsympathetictrunkandganglionimpar

3.Laterally

(1)Pelvicplexus

(2)Superiorandinferiorrectalvessels

(3)Levatorani

Ⅱ)Vascularsupplyofrectum

1.Arteries

(1)Superiorrectala.

(2)Inferiorrectala.

(3)Mediansacrala.

2.Lymphaticdraingeofrectum

(1)Pararectalln.

(2)Superior→superiorrectalln.

(3)Inferior→internaliliacln.

(4)Posterior→sacralln.

Ⅱ.Relationshipsofurinarybladder

Ⅰ)Superiorsurface(coveredbyperitoneum)

1.Smallintestine

2.Sigmoidcolon

3.Bodyofuterus,whenbladderifempty

Ⅱ)Posteriorsurface

1.Inmales

(1)Seminalvesicle

(2)Ampullaofductusdeferens

(3)Rectum

2.Infemales

(1)Vagina

(2)Neckofuterus

Ⅲ)Inferolateralsurfaces(devoidofperitoneum)

1.Anteriorly－retropubicpadoffatandpubicbone

2.Posteriorly－fasciaoverlyingobturatorinternusandlevatoranimuscles

Ⅳ)Apex－pubicsymphysis(anteriorly)

Ⅴ)Neck(belowandleastmobile)

1.Inthemale,restsofprostateandurogenitaldiaphragm

2.Inthefemale,restsdirectlyonpelvicfasciasurroundingtheshorturethra

Ⅲ.Relationshipsofuterus

Ⅰ)Anteriorly－separatedbyvesicouterinepouchfromsuperiorsurfaceofurinarybladder

Ⅱ)Posteriorly－separatedbyrectouterinepouchandrectovaginalseptumfromrectum

ThePerineum

LearningObjiective

1.Mastertheconcept,boundaryandpartsofperineum.

2.Masterthegeneralfeatureoftheanalcanal.Knowthecompositionofanalsphincters.

3.Masterthelocation,boundariesandcontentsofischiorectalfossa.

4.Knowthecourseandbranchesofthepudendalnerveandinternalpudendalartery.

5.Knowthedispositionofthefasciaofurogenitalregion.

6.Mastertheformationofurogenitaldiaphragm.

7.Mastertheformationandcontentsofsuperficialanddeepperinealspaces.

Keystone

1.Thelocation,boundariesandcontentsofischiorectalfossa.

2.Theformationofurogenitaldiaphragm.

3.Thecompositionofanalsphincters.

4.Theformationandcontentsofsuperficialanddeepperinealspaces.

QuestionsRequiringShortAnswer

1.Describetheconcept,boundaryandpartsofperineum.

2.Describethegeneralfeatureoftheanalcanal.Knowthecompositionofanalsphincters.

3.Describethelocation,boundariesandcontentsofischiorectalfossa.

4.Describetheformationofurogenitaldiaphragm.

5.Describetheformationandcontentsofsuperficialanddeepperinealspaces.

ReadingandComprehension

Perineum

Ⅰ.Generalfeatures

Ⅰ)Regionofbelowpelvicdiaphragm

Ⅱ)Adiamond-shapespacewhoseboundariesarethoseofthepelvicoutlet

1.Lowerborderofsymphysispubis

2.Ramiofpubisandischium

3.Ischialtuberosities

4.Sacrotuberousligament

5.Tipofcoccyx

Ⅲ)Classificationintotwotriangles

Theperineumisdividedintoanteriorandposteriortrianglesbyjoiningtheischialtuberositieswithanimaginaryline.

1.Urogenitalregion(anterior)－differsinmaleandfemale

2.Analregion(posterior)－similarinbothsexes

Ⅱ.Analregion

Ⅰ)Analcanal

1.Continuationofrectum,4cmlong

2.Atanorectaljunctionturnsdownwardandbackward

3.Angleformedatanorectaljunctionmaintainedbypuborectalis

4.Analsphincters

(1)Internal

1)Smoothmuscle(thickenedcircularmusclecoat)

2)Surroundsuppertwo-thirdsofanalcanal

3)Autonomicnervesupply

(2)External

1)Striatedmuscle

2)Surroundslowertwo-thirdsofanalcanal

3)Threeparts－subcutaneous,superficialanddeep

4)InnervationbyanalnervesofpudendalnerveandbrancheofS4

(3)AnorectalRing

1)Atjunctionofrectumandanalcanal

2)Consistsofthicknedmuscle

3)Contributingstructures

①Superficialanddeeppartsofsphincteraniexternus

②Sphincteraniinternus

③Puborectalis

Ⅱ)Ischioanalfossa

1.Paired,wedge-shaped,fat-filledspacesoneithersideofanalcanal

2.Frequentsiteofinfection(ischioanalabscess)

3.Boundaries

(1)Apex－conjunctiveareaofinferiorfasciaofpelvicdiaphragmandfasciacoveringtheobturatorinternus

(2)Base－skinofanalregion

(3)Medial－sphincteraniexternus,levatorani,coccygeusandinferiorfasciaofpelvicdiaphragm

(4)Lateral－ischialtuberosity,obturatorinternusandfascia

(5)Anterior－Forwardprojectionofanteriorrecessoffossabetweenpelvicdiaphragmaboveandurogenitaldiaphragmbelow

(6)Posterior－backwardprojectionofposteriorrecessoffossabetweengluteusmaximus,sacrotuberousligamentandcoccygeus

4.Contents

(1)Fat

(2)Internalpudendalarteryandvenandtheirrectalbranches

(3)Pudendalnerveanditsinferiorrectalbranch

leavesthepelvisthroughtheinfrapiriformforamenandenterstheglutealregion.

Enterstheperineumthroughthelessersciaticforamenandthenpassesforwardinthepudendalcanalwiththeinternalpudendalvessels.

Vesselsandnervesenterfromglutealregion,throughlessersciaticforamen,travelonafascialcanal－thepudentalcanal(Alcock’s)－onthelateralwalloffossa,andextendforwardintourogenitalregion

Ⅲ.Urogenitalregion

Therearethreelayersoffasciaandtwospaces.Thecontentsoftheurogenitalregiondifferinthetwosexes

Ⅰ)Superficialfasciahastwolayers

1.Thesuperficialorfattylayer－iscontinuouswiththesuperficialfasciaofthethighandwiththefatoftheischioanalfossae

2.Thedeepormembranouslayer(superficialfasciaofperineumorCollesfascia)－isattached

(1)Posteriorlytotheposteriorborderoftheurogenitaldiaphragm

(2)Laterallytopubicarchandischialtuberosity

(3)Anteriorlyitiscontinuouswith:

1)Dartosofthescrotum

2)Fasciaofthepenis

3)MembranouslayerofsuperficialfasciaoftheabdominalwallknownastheScarpa’sfascia

Ⅱ)Deepfasciahastwolayers

1.Superiorfasciaofurogenitaldiaphragm

2.Inferiorfasciaofurogenitaldiaphragm

3.Laterally:threelayers(superficialfasciaofperineum,superiorandinferiorfasciaofurogenitaldiaphragm)areattachedtothesidesofthepubicarch

4.Infront:thesuperiorandinferiorfasciaofurogenitaldiaphragmfusetogetherformingtheso-called:transverseperinealligament

5.Posteriorly:thethreelayers(superficialfasciaofperineum,superiorandinferiorfasciaofurogenitaldiaphragm)fusetogether

Ⅲ)Twoperinealspaces

1.Superficialperinealspace

(1)Boundaries

1)Liesbetweeninferiorfasciaofurogenitaldiaphragmandsuperficialfasciaofperineum

2)Itisclosedbehindandlaterally

3)AnteriorlythespacecommunicatesfreelywiththepotentialspacelyingbetweentheScarpa’sfasciaandtheanteriorabdominalmuscles.

(2)Spaceopenanteriorly(Inruptureofcavernouspartofurethra,urinecanextravasatefromscrotumupwardinfrontofsymphysispubisintoanteriorabdominalwalldeeptoSc