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Pelvis and Perineum
Pelvis and Perineum
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lower limb
Form iliosacral joint with the sacrum.
Boney projection into the pelvic cavity is the spine of the
ischium
Large aperture is the obturator foramen. Presense of
obturator foramen thought to be to help reduce the weight of
the pelvis
Female pelvis-Anterior view of a boney female pelvis
o Sub-pubic angle is MUCH greater.
o Ala of the ilium is more flared, are wider
o There is a sharp ridge that follows the entire pelvic inlet. It is
sharp bordered all the way around from the pubic symphysis
around to the sacrum on both sides. Called the pelvic brim or
inlet.
o Sharp ridge on the upper end of the S1 vertebra is the sacral
promontory
o There is bone that lies superior and inferior to the pelvic brim.
It divides the pelvic cavity from the abdominal cavity.
Superior to the pelvic brim is called the false pelvis. It
has ABDOMINAL organs. False pelvis lies between the
iliac crest and the iliac brim between the two iliac
fossae.
Inferior to the pelvic brim is the true pelvis and the
pelvic cavity
Side note: ASIS and pubic tubercle are on the same coronal plane.
Pelvis is on a 55 degree tilt.
The Perineum
In the anatomical position, it is a small region commonly referred to as
the crotch.
If you abduct the thighs to the Lithotomy postion (lying on his back,
thighs abducted.
In the male there are two diverticuli of the perineum (penis and
scrotum)
Plate 380
Male and Female--Boney Landmarks to make a diamond shaped
region that defines the perineum
o Pubic symphysis
o Two Ischial tuberosities
o Coccyx
Subdivisions of the diamond by drawing a line between the ischial
tuberosities
o Anal triangle
o Urogenital triangle
Plate 382-Penis (focus on anal triangle), Plate 379-Female perineum
Anus is in the anal triangle.
To the sides of the anus is a lot of fat in the ischioanal fossae
o Fat helps close the anal canal
Perineal body has lots of connective tissue and is on a plane almost
between the two ischial bodies
o External anal sphincter runs between the perinal body and the
coccyx in a circular pattern around the anus.
Episiotomy is an incision in the posterior vaginal wall to prevent
tearing of the vagina through the perineal body.
foramen
Pudendal gives off inferior rectal nn and then bifurcates
to form the perineal n and the dorsal n to the
penis/clitoris
o Pass through greater and lesser sciatic foramen
Pudendal nerve
Internal pudendal artery
Internal pudendal vein
Plate 392-Coronal section through the plane of the anus.
Notice the ischioanal fossae
o There is a base (skin)
o Medial wall (levator ani m.)
o Lateral wall (obturator internus m.)
o Apex of the pyramid is where levator ani m. takes origin
from the fascia of the obturator internus m.
o The fascia of the lateral wall splits to form a neurovascular
bundle
Pudendal n. and internal pudendal a. and v.
Inferior rectal nerve branches from this and travels
through the fat.
Plate 356
Levator ani take origin from the fascia of obturator internus. The
thickened portion of the fascia is called the tendonous arch.
Some fibers of Levator ani m. take origin from the pubis, but the
lateral most take origin from the obturator internus m.
Plate 393-Rectum and Anal Canal
Last 4 cm is the anal canal
o Upper anal canal has the longitunidal anal columns. The
superior rectal a and v lay in the submucosa of the anal
columns.
Lower ends of adjacent anal columns are called valves
and contain sinuses. The sinuses catch mucus and push
the mucus out during defacation to help prevent tearing
of the anal canal.
o Pectinate Line is the divider between endodermal origin and
ectodermal origin. It is the lower portion of the anal canal.
The white line of Hilton become Keratinized, have hair and
glands. Below the white line it is skin.
The pectinate line divides where the nerves and blood
supply change. Below the pectinate line is the somatic
nervous system and caval venous return. Above the line
is enteric nervous system and portal venous return.
Clinical Correlation!
Hemorrhoids
Two types: Internal and External
Internal
o Associated with the superior rectal veins and the veins in the
anal columns. If there is portal vein back up, one of the
places they make back up is the superior rectal vein.
o There is no pain with internal hemorrhoids
o They are SUBMUCOSAL
o Treated only when prolapsed by placing a rubber band around
the hemorrhoid
External Hemorrhoids
o Just deep to the skin around the anussubcutaneous
o There is pain with external hemorrhoids.
Affected persons
o Pregnant people
o Liver disease
o Chronic constipation
Fissures
Tear in the lining of the epithelium of the anal canal
Can lead to an abscess
If the fissure does not heal and the abscess remains in
communication with the anal canal, this is called a fistula
Perineal membrane meets the perineal body and the inferior pubic
arch.
o Potential space between the perineal membrane and Colles
Fascia is called the superficial perineal pouch/space.
Superior Fascial of the UG diaphragm travels superior to the
perineal membrane and creates the deep perineal pouch/ space.
Muscles stop as the shaft of the penis extends out from the body
wall.
Superficial transverse perineal mm are paired mm that converge on
the perineal body.
Plate 382-Erectile
Bulb of the penis is unpaired. When the bulb loses its attachment
and extend beyond the body wall it becomes the corpus
spongiosum. It travels on the ventral surface of the penis.
Crura of the penis are laterally paired. When they extend into the
shaft, the become the corpus cavernosum.
What do the muscles do that coat the bulb? (bulbospongiosum)
o During arousal and ejaculation. Makes the penis turgid.
o Squeezing the last bits of urine out.
What do the muscles that coat the crura (ischiocavernosum)
o Maintain turgidity of the penis during arousal and ejaculation.
o NOT used for urinary function
There is a dense connective tissue septum between the corpus
cavernosum
Corpus spongiosum expands distally to become the glans of the
penis.
Every new born male has a foreskin (prepuce) which is a double fold of
skin over the glans of the penis.
Removal is called that circumcision.
Balonitis is inflammation of the glans of the penis
Posthitis is inflammation of the foreskin of the penis.
Some situations where the foreskin is tightly adhered to the glans.
This is called Phimosis
Paraphimosis is when it retracts, but does not re-cover the glans.
mid line vein called the superficial dorsal vein. Very irregular
course.
There is a thick layer of Deep fascia called bucks fascia. It is very
thick and tough. Deep to Bucks Fascia there is a series of nerves
and vessels
o Deep Dorsal vein is mid line and runs sort of between where
the two corpus cavernosa come together.
o The deep dorsal vein is flanked on either side by the Right
and Left Dorsal Vein.
o Lateral to the two dorsal arteries are the dorsal nerves.
In the core of the corpus caversona is the deep artery of the penis.
Plate 411-Nerves of the male Perineum
Three branches of the pudenal nerve
o Inferior rectal nerve-Mixed Nerve
o Perineal nerve-Mixed Nerve
o Dorsal nerve of the penis-Pure Sensory
Plate 405-Vessels of the UG triangle
Internal Pudenal Artery gives of the inferior rectal then perineal
artery
Labia minor DO NOT have fat. They do have erectile tissue that
engorge during sexual arousal.
An Episiotomy is a posterior cut from the vaginal orifice through the
perineal body to aid in delivery. Two methods:
o MedialHealing takes longer, less risk of bleeding
o Mediolateralhigher risk of bleeding
o BOTH START AT THE SAME SPOT
Vaginal Orifice is typically irregular. The tags of irregular tissue are
remnants of the hymen. In some cases it can be an imperforate
hymen, it is usually perforated through normal gym class activities.
The vaginal orifice changes with age and activity (tampons, sexual
activity, exercise)
Plate 395
Ischiocavernosus mm and bulbospongiosum mm are the same idea.
Superficial transverse perineal mm.
There are TWO bulbospongiosum mm in females to maintain the
patency of the vaginal orifice. They overlay the bulbs of the
vestibule (erectile tissue. The bulbs of the vestibule come together
anteriorly and STOP. They DO NOT extend into the shaft of the
clitoris.
The ischiocaverosus mm overlay the crura of the clitoris.
The shaft of the clitoris only has TWO erectile bodies (the crura)
Plate 379
The crus of the clitoris is much easier to fine that the bulbe of the
vestibule.
Observe the crura converge to form the shaft of the clitoris.
Deep transverse perineal mm are the same. The differnce in deep
pouch mm are caused by the vagina (damn vaginas). The sphincter
urethrae has a compressor vaginae portion.
Plate 366
Two bulbs of the vestibule flank the urethra flanked by the
bulbospongiosus mm.
Two crura flanked by the ischiocavernosus mm.
Lesser vestibular glands (paraurethral glands) lay only the urethra between
the urethra and the vagina as it approaches the external urethral orifice.
They are the homolog of the prostate. They produce a female ejaculate.
There is a dense network of on the anterior vaginal wall (the G SpotG
stands for Grafenberg)
Plate 360
Just getting oriented.
brim
rectouterine pouch.
Plate 366-Urinary BladderFemale
Thick muscular wall known as the detrusor muscle. It is smooth
muscle
Lined by a mucus membrane that is loosely attached
When the bladder is non distended, it will have rugae
There is an area where the mucus membrane is bound tightly to the
detruser muscle in the area bouned by the three orifices. This is
called the trigone. There are NO RUGAE
o Two ureters
o Urethra
The ureters pass through the bladder wall very obliquely to cause
the urine to stay in the bladder. The muscle walls will compress the
ureters when the bladder is distended.
In the female, there is no true sphincter. There is an internal
urethra sphincter of sorts made by the portion of the detruser
Detruser motor innervation is parasympathetic
o General contraction except in the area of the urethra orifice.
The vesicle venous plexus surrounds the bladder
Plate 369The uterus
Domed portion of the uterus that extends superiorly to the entrance
of the fallopian tubes is the fundus. All the uterus is the body and
the fundus is part of the body.
The portion of the uterus that narrows as it enters the vagina is the
cervix.
o There is a vaginal and a supravaginal portion of the cervix
mesosalpinx
The portion that suspends the ovary is called the mesovarium
Plate 372
Better illustration of the mesometrium, mesosalpinx and
mesovarium
The mesovarium is at a right angle with the mesometrium and
mesosalpinx
The germinal epithelium is on the exterior of the ovary. The
germinal epithelium is a mesothelium continuous with the
peritoneum.
When the egg is released from the surface of the ovary, it is
released into the peritoneal cavity. The fimbrae of the uterine tube
find it.
The peritoneal cavity is open to the environment through the
uterine tube.
Endometriosis is when the endometrium establishes itself outside of
the uterus.
Plate 371
In the mesosalpinx you may find vestigial mesonephric ducts called
the opoophoron.
The surface of the ovary will change as the woman ages. The older
woman will have a pitted appearance due to all the ovulations.
There may be a vesicle associated with a fimbriae that is the
embryonic remnant that would have been the epididymus in the
male called the vesicular appendage
The distal part of the uterine tube is called the infudibulum. Its
fluted, trumpet shaped that has the finger like fimbriae associated
with it. Usually there is one fibriae that is attached to the ovary.
The ampulla of the uterine tube is the longest portion. This is
where the egg is usually fertilized
The isthmus is the narrowed portion before it enters the uterine
wall
The uterine portion of the uterine tube pierces the wall of the
uterus.
The uterine wall is thick, mostly due to the smooth muscular wall
called the myometrium
The cervix has two parts: supravaginal and vaginal. Most of the
tissue in the wall of the cervix is mostly fibrous. The lining of the
cervix is not sloughed like the endometrium of the body
Where the body opens into the cervix is the internal os.
Where the cervix a vagina open is the external os
Because the cervix juts into the vagina, there is a recess between
the vagina and cervix, called the vaginal fornix.
Three functions of the vagina.
o Lower birth canal
o Female organ of copulation
o Duct for the passage of menses
The epithelium transitions in the vaginal portion of the cervix
o Supra vaginal cervix and uterus-Columnar
o Vagina and vagnial cervix-non keratinized stratified squamous
Plate 369
The portion of the uterus that is fixed is the supravaginal cervix.
o Most of the uterus is highly mobile
There are thickenings in the endopelvic fascia
o Transverse cervical ligaments come from the lateral walls
Also called cardinal ligament
The uterine artery is in the transverse cervical ligament.
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days.
Ejaculation
o Rhythmic, spasmodic contraction of perineal muscles, levator
ani, external anal sphincter, gluteal muscles
o Propulsion of semen along penile urethra
o Initiated by secretions entering penile urethra
o Mostly under control of the somatic muscles.
o Probably initiated by emission
Detumescence/Resolution
o Return of erectile tissues to flaccid state
o Involves a refractory period (minutes to days depending on
age and overall health of the male)
o Sympathetic control causes helecine arteries to recoil and the
blood drains.
FEMALE SEX RESPONSE
Arousal/Excitement
o Increased secretions; vestibular and vaginal
Mostly serous. There are no glands in the vagina, it
kinda of like oozing from the vaginal wall. Mucous
comes from the cervix
o Erection of clitoris
Plateau (minutes to hours)
o General vascular engorgement (clitoris, labia, breast, lower
vagina)
o Erection of nipples
o Sex flush; reddish vascular flushing of skin over breasts,
chest
o Dilation of upper vagina
o Uterine tenting
Orgasm
o Rhythmic contractions of perineal muscles (~1 second
intervals)
o Number of and intensity of rhythmic contractions highly
variable
o Dilation of cervix
o Uterine contractions (due to release of oxytocin)
Theory is it will help move the sperm toward the uterine
tube
o Uterine dipping
Resolution
o Return to pre-excitement stage
o No refractory period
Plate 410-Autonomics
Pelvic splancnic come off of S2, S3 and S4.
There are a lot of autonomics on the ventral aorta. When the aorta
bifurcates, some travel will the common iliac, but a lot stay central
and form the superior hypogastric plexus (all sympathetic) and will
give rise to the right and left hypogastric nerves.
The R and L hypogastric will coalesce to form the inferior
hypogastric plexus posterior to the rectum along with the pelvic
spanchnic nerves (therefore the inferior hypogastric plexus is both
sympathetic and parasympathetic
Plate 408
Perineal drainage will drain into the inguinal nodes, then into the pelvis
along with the vessel nodes
Big thing to remember are the testicles have different drainage than
the penis and the scrotum
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