PELVIS

1. Upper border of pubic ramus forms:

a. Pubic tubercle (NEET Pattern 2014)
b. Pubic symphysis
c. Arcuate line
d. Upper margin of obturator foramen
2. The type of joint between the sacrum and the coccyx
is a: (AIPG 2005)
a. Symphysis
b. Synostosis
c. Synchondrosis
d. Syndesmosis
3. Sacral promontory is the landmark for:
a. Origin of superior mesenteric artery (NEET Pattern
2013)
b. Termination of presacral nerve
c. Origin of inferior mesenteric artery
d. None of the above
4. Articular surface of the sacrum extends up to how
many
vertebrae in males? (NEET Pattern 2015)
a. 1 to 1 1/2
 PELVIS
b. 2 to 2 1/2
c. 3 to 3 1/2
d. 4 to 4 1/2
5. Lower limit of sacroiliac joint lies up to which level in
females? (NEET Pattern 2015)
a. 1 to 1 1/2
b. 2 to 1 1/2
c. 3 to 3 1/2
d. 4 to 4 1/2
6. Untrue about female pelvis is:
a. Subpubic angle is wide (>80 degrees)
b. Obturator foramen in triangular
c. Greater sciatic notch is wide (~90 degrees)
d. Long and narrow sacrum
7. Almost half of the females have which of the
following type of pelvis?
a. Anthropoid
b. Android
c. Platypelloid
d. Gynaecoid
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ANSWERS WITH EXPLANATIONS
1. c. Arcuate line
• Upper border of superior pubic ramus is called
pectineal line (or pecten pubis). It contributes to
arcuate line.
• Upper border of inferior pubic ramus forms lower
margin of obturator foramen.
2. a. Symphysis
• Sacro-coccygeal joint is a secondary cartilaginous
joint – symphysis, which always lie in the midline.
• Symphysis may turn into synostosis with advancing
age. For example, symphysis menti becomes a
synostosis after the age of
one year.
• Synchondrosis is a primary cartilaginous joint as seen
at the costo-chondral junctions of thoracis wall.
• Syndesmosis is a fibrous joint seen at some limited
locations, e.g. inferior tibio-fibular joint.
3. b. Termination of presacral nerve
• Superior hypogastric plexus (presacral nerve) lies in
front of the bifurcation of the abdominal aorta and
body of the fifth lumbar
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vertebra between the two common iliac arteries.
• Origin of superior mesenteric artery lies at L1 and
inferior mesenteric artery at L3 vertebral level.
4. c. 3 to 3 1/2
• Articular surface of the sacrum extends on to the
upper three or three and a half sacral vertebrae in
adult male.
• In females it extends on to the upper 2 or 2½ of the
sacral vertebrae.
5. b. 2 to 1 1/2
• Articular surface of the sacrum (lower limit of sacro
iliac joint) extends on to upper 2 or 2 1/2 of the sacral
vertebrae in females. .
• In males it extends on to the upper 3 or 3 1/2 of the
sacral vertebrae.
6. d. Long and narrow sacrum
• Female pelvis has short and wide sacrum
7. d. Gynaecoid
• The gynaecoid pelvis is the normal female type; its
pelvic inlet typically has a rounded oval shape and a
wide transverse diameter.
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• A platypelloid or markedly android (masculine or
funnel-shaped) pelvis in a woman may present with
difficult vaginal delivery of a
Fetus
ASSESSMENT QUESTIONS
1. Pelvic splanchnic nerves supply all EXCEPT: (AIIMS
2010)
a. Vermiform appendix
b. Urinary bladder
c. Uterus
d. Rectum
2. Pudendal nerve supplying motor part to external
sphincter
is derived from: (NEET Pattern 2013)
a. L5-S1 roots
b. S1- S2 roots
c. L2-L3 roots
d. S2-S3 roots
3. All of the following are true regarding the pudendal
nerve
EXCEPT: (AIPG)
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a. Both sensory and motor
b. Derived from S2, 3, 4 spinal nerve roots
c. Leaves pelvis through the lesser sciatic foramen
d. Only somatic nerve to innervate the pelvic organ
4. Pelvic pain is mediated by: (NEET Pattern 2013)
a. Pudendal nerve
b. Sciatic nerve
c. Autonomic nerves
d. None of the above
5. True about nervi erigentes are all EXCEPT:
a. An autonomic nerve (NEET Pattern 2015)
b. Parasympathetic outflow
c. Arise from ventral rami of S2, 3, 4
d. Joins superior hypogastric plexus
6. Preganglionic parasympathetic nerve fibers which
supply
pelvic viscera is/are: (PGIC 2003)
a. Ventral rami of S2,3,4
b. Hypogastric plexus
c. Pudendal nerve
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d. Pelvic Splanchnic nerve
e. Inferior mesenteric plexus
7. Which is NOT supplied by pelvic splanchnic nerves?
a. Rectum (AIIMS 2009,10)
b. Urinary bladder
c. Appendix
d. Uterus
8. Pudendal nerve block abolishes pain from: (JIPMER
2016)
a. Upper cervix
b. Superior part of vagina
c. Lower cervix
d. Inferior part of vagina
9. Root value of inferior rectal nerve supplying external
anal sphincter is:
a. L–3, 4, 5
b. L–5; S-1
c. S–2, 3, 4
d. S–4, 5
ANSWERS WITH EXPLANATIONS
1. a. Vermiform appendix
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• Pelvic splanchnic nerves are the parasympathetic
nerves to supply the pelvic viscera like urinary bladder,
uterus and rectum.
Appendix is a part of Mid-gut and is supplied by the
Vagus nerve.
2. d. S2-S3 roots
• Pudendal nerve is contributed by the anterior
primary ramus of S-2, 3, 4 in the sacral plexus and
supply external sphincters of
urethra, vagina and anal canal.
3. c. Leaves pelvis through the lesser sciatic foramen
• Pudendal nerve (S2–S4) passes out of the pelvic
cavity through the greater sciatic foramen (below the
piriformis muscle) and enters
the gluteal region.
• It travels around the posterior surface of the ischial
spine, and re-enters the pelvic cavity through the lesser
sciatic foramen.
• Next the pudendal nerve travels within the fascia of
the obturator internus muscle (called the pudendal
canal of Alcock) and gives
rise to the inferior rectal and perineal nerves, and
terminates as the dorsal nerve of the penis (or clitoris).
 PELVIS
• It is a somatic and mixed (sensory and motor) nerve
supplying skin and skeletal muscles of perineum.
• It is the only somatic nerve that supplies the terminal
portions of the pelvic organs (urethra, vagina and anal
canal).
4. c. Autonomic nerves
• Pelvic pain is carried by the autonomic nervous
system: Sympathetic component is carried by lumbar
splanchnic nerves (T-12, L1,2)
and parasympathetic component is nervi erigentes (S-
2,3,4).
5. d. Joins superior hypogastric plexus
• There is no answer in this question, because all the
statements are true.
• Nervi erigentes belong to the parasympathetic
component of autonomic nervous system. They arise
from the ventral primary ramus
of S2,3,4 and ascend from the inferior hypogastric
plexus via the right and left hypogastric nerves to reach
the superior hypogastric
plexus.
• Some authors are of the opinion that they do not join
the superior hypogastric plexus.
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6. a. Ventral rami of S2,3,4; d. Pelvic Splanchnic nerve
• Pelvic viscera are supplied by the inferior hypogastric
plexus situated by the sides of rectum.
• Each plexus is composed of both sympathetic and
parasympathetic fibres.
• The nerve cells in it are postganglionic
parasympathetic neurons. It receives postganglionic
sympathetic fibres from the superior
hypogastric plexus (presacral nerve) and preganglionic
parasympathetic fibres from the pelvic splanchnic
nerve (S2, S3, and S4).
7. c. Appendix
• Vermiform appendix is a part of mid-gut under the
supply of vagus nerve (not pelvic splanchnic nerves).
8. d. Inferior part of vagina
• Pudendal nerve supplies the structures in the
perineum, including the opening of vagina.
• Pelvic viscera (including cervix and major portion of
vagina) are supplied by the autonomic nervous system:
Lumbar splanchnic
nerves (sympathetic) and nervi erigentes
(parasympathetic).
9. c. S – 2, 3, 4
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• External anal sphincter is supplied by inferior rectal
nerve branch of pudendal nerve.
High Yield Points
•• Pelvic diaphragm is contributed by levator ani
(pubococcygeus and Iliococcygeus) and
ischiococcygeus muscles. Parts of pubococcygeus:
pubourethralis, puboprostaticus, pubovaginalis,
puborectalis are components of the diaphragm.
Ischiococcygeus (coccygeus) lies
immediately cranial to levator ani and is contiguous
with it, but is not a part of levator ani muscle.
•• The right and left puborectalis unite behind the
anorectal junction to form a muscular sling. Some
regard them as a part of the sphincter
ani externus.
•• Sacrospinous ligament may represent either a
degenerate part or an aponeurosis of the muscle
Ischiococcygeus.
ASSESSMENT QUESTIONS
1. Name the muscle forming pelvic diaphragm:
a. Deep transverse perinei
b. Sphincter urethrae
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c. Levator ani
d. None of the above
2. Levator ani muscle include all EXCEPT: (NEET Pattern
2016)
a. Puborectalis
b. Pubococcygeus
c. Iliococcygeus
d. Ischiococcygeus
3. All are content of sphincter of vagina EXCEPT:
a. Pubovaginalis
b. External urethral sphincter
c. Internal urethral sphincter
d. Bulbospongiosus
ANSWERS WITH EXPLANATIONS
1. c. Levator ani
• Pelvic diaphragm is contributed by levator ani
(pubococcygeus and Iliococcygeus) and
ischiococcygeus muscles.
• Parts of pubococcygeus: pubourethralis,
puboprostaticus, pubovaginalis, puborectalis are
components of the diaphragm.
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• Ischiococcygeus (coccygeus) lies immediately cranial
to levator ani and is contiguous with it, but is not a part
of levator ani muscle.
2. d. Ischiococcygeus
• Ischiococcygeus muscle is a component of pelvic
diaphragm, but is not included under levator ani
muscle.
− Levator ani muscle is subdivided into named portions
according to their attachments and the pelvic viscera
to which they are
related (pubococcygeus, iliococcygeus and
puborectalis).
− Pubococcygeus is often subdivided into separate
parts according to the pelvic viscera to which each part
relates (puboperinealis,
puboprostaticus or pubovaginalis, puboanalis,
puborectalis).
• Note: Ischiococcygeus (coccygeus) is not a part of
levator ani muscle, lies immediately cranial and
contiguous with it. Together with
levator ani muscle it forms the pelvic diaphragm.
3. c. Internal urethral sphincter
 PELVIS
• Internal urethral sphincter is present in males to
prevent retrograde ejaculation of semen into urinary
bladder, it is absent in females
ASSESSMENT QUESTIONS
1. Branch of internal iliac artery is/are: (PGIC 2014)
a. Inferior vesical artery
b. Inferior epigastric artery
c. Iliolumbar artery
d. Internal pudendal artery
e. Obturator artery
2. Internal pudendal artery is a branch of:
a. Anterior division of internal iliac (NEET Pattern 2015)
b. Posterior division of internal iliac
c. Anterior division of external iliac
d. Posterior division of external iliac
3. All are branches of the internal iliac artery except:
a. Ovarian artery (NEET Pattern 2012)
b. Superior vesical artery
c. Middle rectal artery
d. Inferior vesical artery
4. Artery to ductus deferens is a branch of:
 PELVIS
a. Superior vesical artery (NEET Pattern 2016)
b. Inferior vesical artery
c. Internal pudendal artery
d. Middle rectal artery
5. Accessory obturator artery is a branch of: (NEET
Pattern 2016)
a. Inferior epigastric
b. External iliac
c. Internal iliac
d. Obturator
ANSWERS WITH EXPLANATIONS
1. a. Inferior vesical artery; c. Iliolumbar artery; d.
Internal pudendal artery; e. Obturator artery
• Inferior epigastric artery is a branch of external (not
internal) iliac artery.
2. a. Anterior division of internal iliac
• Anterior division of internal iliac artery gives the
internal pudendal artery which accompanies pudendal
nerve in the pudendal canal
and supply the perineum region.
3. a. Ovarian artery
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• Ovarian artery is a branch of the abdominal aorta.
• Gonads develop in the abdomen region and gonadal
arteries are branches of abdominal aorta.
• As the gonads descend down to pelvic cavity, gonadal
arteries become longer (Testicular > Ovarian).
4. a. Superior vesical artery > b. Inferior vesical artery >
d. Middle rectal artery
• Vas deferens is usually derived from the superior
vesical artery, and occasionally from the inferior vesical
artery, both branches
of the internal iliac artery.
Note: It may also arise from middle rectal artery.
5. a. Inferior epigastric
• Accessory obturator artery is the pubic branch of
inferior epigastric artery, which itself is given by
external iliac artery.
• Lacunar ligament is medial boundary of femoral ring
and accessory obturator artery may lie on that in some
percentage of
population.
• In reduction of femoral hernia, we must be careful of
accessory obturator artery, while the lacunar ligament
is cut to enlarge the
 PELVIS
femoral ring to reduce the hernia.
ASSESSMENT QUESTIONS
1. Superficial inguinal lymphatics drain all of the
following
EXCEPT: (NRET Pattern 2005)
a. Anal canal below pectinate line
b. Glans penis
c. Urethra
d. Perineum
2. Infection/inflammation of all of the following causes
enlarged superficial inguinal lymph nodes EXCEPT:
a. Isthmus of uterine tube (AIPG 2004)
b. Inferior part of anal canal
c. Big toe
d. Penile urethra
3. Distal part of spongy male urethra drains via which
lymph nodes? (AIPG 2009)
a. Superficial inguinal
b. External Iliac
c. Deep inguinal
d. Aortic
 PELVIS
ANSWERS WITH EXPLANATIONS
1. b. Glans penis
• Glans penis drains into deep inguinal lymph nodes
(Cloquet).
• Anal canal below pectinate line drains into superficial
inguinal lymph nodes, and above the pectinate line
into internal iliac lymph
nodes.
• Proximal urethra drains into iliac and distal urethra
into inguinal lymph nodes
• Perineum majorly drains into superficial inguinal
lymph nodes.
2. d. Penile urethra
• Lymphatics from the penile urethra (and glans penis)
mainly run towards deep inguinal lymph nodes.
• Though few lymphatics may end up in the superficial
inguinal lymph nodes.
• Isthmus of uterine tube, inferior part of anal canal
and big toe all drain towards the superficial group of
lymph nodes.
• Lymphatics from the isthmus follow the round
ligament of uterus and lymphatics from the great toe
follow the great saphenous
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vein, both reaching the superficial inguinal lymph
nodes.
3. c. Deep inguinal
• Distal spongy urethra and the glans penis drain into
the deep inguinal lymph nodes of Cloquet and
Rosenmuller.
• Spongy part of male urethra mainly drains into the
deep inguinal lymph nodes. Some lymphatics may end
in the superficial inguinal/
external iliac lymph nodes as well.
• Lymphatics from the prostatic and membranous
urethra pass mainly to the internal iliac lymph nodes.
Some lymphatics from these
areas may end in the external iliac lymph nodes also.
• Eventually all the lymphatics reach the aortic lymph
nodes → Thoracic duct → Left sided neck veins.
• Female urethra drains into both the internal and
external iliac lymph nodes.
• Lymph drainage of penis: Penile skin → Superficial
lymph nodes; Glans → Deep inguinal and External iliac
lymph nodes.
ASSESSMENT QUESTIONS
1. Ureter is present in which wall of ovarian fossa?
 PELVIS
a. Anterior (DNB Pattern- 2016)
b. Posterior
c. Medial
d. Lateral
2. Ovarian fossa is formed by all EXCEPT:
a. Obliterated umbilical artery (NEET Pattern 2015)
b. Internal iliac artery
c. Ureter
d. Round ligament of ovary
ANSWERS WITH EXPLANATIONS
1. b. Posterior
• Behind the ovarian fossa are retroperitoneal
structures, including the ureter, internal iliac vessels,
obturator vessels and nerve, and
the origin of the uterine artery.
2. d. Round ligament of ovary
• Round ligament of ovary is infero-medial to the
ovary.
Clinical Correlations
 PELVIS
•• Spinal anesthesia up to spinal nerve T10 is
necessary to block pain for vaginal delivery and up to
spinal nerve T4 for cesarean section (due
to the sympathetic fibre levels being at higher level
than motor or sensory blockade).
•• Lumbar spinal anaesthesia (spinal block), in which
the anesthetic agent is introduced with a needle into
the spinal subarachnoid space and
it anaesthetizes the intraperitoneal, subperitoneal and
somatic structures.
–– It produces complete anesthesia inferior to
approximately the waist level.
–– The perineum, pelvic floor, and birth canal are
anesthetized, and motor and sensory functions of the
entire lower limbs, as well as sensation
of uterine contractions, are temporarily eliminated.
•• Caudal epidural block, in which the anesthetic agent
is administered using an in-dwelling catheter in the
sacral canal, and it anaesthetizes
the subperitoneal and somatic structures.
–– The entire birth canal, pelvic floor, and most of the
perineum are anesthetized, but the lower limbs are not
usually affected and the mother
 PELVIS
is aware of uterine contractions.
•• Pudendal nerve block is provides local anesthesia
over the perineum (S2–S4 dermatomes) and the
inferior quarter of the vagina.
–– It does not block pain from the superior birth canal
(uterine cervix and superior vagina), so the mother is
able to feel uterine contractions.
Fig. 38: Obstetric blocks: (A) Spinal block; (B) Caudal
epidural block; (C) Pudendal block.
ASSESSMENT QUESTIONS
1. The following group of lymph nodes receives
lymphatics
from the uterus EXCEPT: (AIPG 2005)
a. External iliac
b. Internal iliac
c. Superficial inguinal
d. Deep inguinal
2. Ovarian pathology is referred to: (AIIMS 2010)
a. Gluteal region
b. Anterior thigh
c. Medial part of thigh
d. Back of thigh
 PELVIS
3. All are true regarding uterus EXCEPT: (PGIC 2014)
a. Lymph vessels from fundus drain to para-aortic
lymph nodes
b. Broad ligament provides primary support to uterus
c. Mainly supplied by uterine artery
d. Supplied by ovarian artery
e. Posterior surface is related to intestine
4. Lymphatic drainage of uterine cervix is all EXCEPT:
a. Obturator
b. Sacral
c. External iliac
d. Internal iliac
5. Lymphatic drainage of the cervix occurs by all of the
following lymph nodes EXCEPT: (AIPG 2006)
a. Parametrial lymph nodes
b. Deep inguinal lymph nodes
c. Obturator lymph nodes
d. External iliac lymph nodes
6. All the following pairs are correct concerning the
lymphatics
of uterus EXCEPT:
 PELVIS
a. Fundus: Para-aortic
b. Mid-uterus: External iliac
c. Cervix: Superficial inguinal lymph nodes
d. Cervix: Sacral
ANSWERS WITH EXPLANATIONS
1. d. Deep inguinal
• Lymphatics from the uterus reach the superficial
inguinal lymph nodes but not the deep inguinal.
• The lymphatics follow the round ligament of uterus
to reach the superficial inguinal lymph nodes.
• Upper part of the uterus like fundus, drain mainly
into the para-aortic lymph nodes.
• Lymphatics from cervix region spread towards
external iliac as well as internal iliac group of lymph
nodes.
2. c. Medial part of thigh
• Ovarian pathology may irritate the obturator nerve
lying in the vicinity, which leads to a referred pain in
the medial thigh (Dermatome:
L-2).
 PELVIS
• Obturator nerve (L-2, 3 & 4) is the nerve of medial
thigh and supplies the skin on the medial thigh. This
type of pain is a somatic
referred pain.
• Another example is the pain felt in the knee joint in a
case of Perthes’ disease, which is pathology of hip joint
but referred somatic
pain is felt in the knee joint, since, both the joints are
supplied by a common nerve – the obturator nerve.
• The visceral pain of the ovary is carried by the
visceral nerves having root value T – 10, 11. Hence,
visceral referred pain from the
ovarian pathology will be felt in the skin bearing
dermatome T: 10, 11.
• Pain in the medial thigh could be a referred pain from
viscera like ureter, hind gut, uterus, urinary bladder. Or
it could be a somatic
referred pain irritating obturator nerve as in a case of
appendicitis, pelvic abscess or ovarian pathology as in
the present case.
3. b. Broad ligament provides primary support to
uterus
 PELVIS
• Lymphatics from the uterine fundus drain towards
the para-aortic lymph nodes.
• Broad ligament is a fold of peritoneum and poor
support of uterus. Primary supports of uterus are
muscular supports.
• Uterus is supplied by uterine (mainly) and ovarian
arteries.
• Posterior surface of uterus is related to coils of the
terminal ileum and to the sigmoid colon. It is covered
with peritoneum and forms
the anterior wall of the rectouterine pouch.
4. a. Obturator
• Uterus drains into all the lymphatic destinations
mentioned in the choices, hence this appears to be a
wrong question, though some
standard textbooks do not mention obturator lymph
nodes in the lymphatic drainage.
5. b. Deep inguinal lymph nodes
• Lymphatic drainage from the cervix does not drain
into the deep inguinal lymph nodes.
• Obturator lymph nodes receive a minor component
of lymphatic drainage from the cervix.
 PELVIS
• The lymphatics of cervix mainly move towards the
internal iliac lymph nodes. Additionally it drain towards
external iliac; rectal and
the sacral lymph nodes as well.
• Parametrial lymph nodes receive the lymphatics of
cervix and direct them towards their further
destination.
6. c. Cervix: Superficial inguinal lymph nodes
• Uterine cervix do not drain into the inguinal lymph
nodes (superficial or deep).
• Fundus and upper part of the body: Pre- and para-
aortic lymph nodes along the ovarian vessels (few
lymphatics from the lateral
angles of the uterus travel along the round ligaments
of the uterus and drain into superficial inguinal lymph
nodes .
• Middle part of the body : External iliac nodes via
broad ligament.
• From cervix, on each side the lymph vessels drain in
three directions:
− Laterally: External iliac and obturator nodes.
− Posterolaterally: Internal iliac nodes
− Posteriorly: Sacral nodes
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Clinical Correlations
•• Prolapse of uterus may occur if the supports are
weakened.
•• During parturition the muscular supports undergo
lot of stretching and may give up, leading to uterus
being pushed inside vagina and come out
into the perineum.
•• Surgical support: The cardinal ligaments have
enough fibrous content to provide anchor for the wide
loops of sutures during several surgical
Procedures
ASSESSMENT QUESTIONS
1. Hypogastric Sheath is a condensation of: (AIPG
2010,11)
a. Scarpa’s fascia
b. Colle’s fascia
c. Pelvic fascia
d. Inferior layer of Urogenital diaphragm
2. Which is NOT a part of the hypogastric sheath:
a. Transverse cervical ligament
b. Broad ligament
c. Lateral ligament of bladder
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d. Uterosacral ligament
3. Support of prostate is: (NEET Pattern 2013)
a. Pubococcygeus
b. Ischiococcygeus
c. Iliococcygeus
d. None of the above
4. Supports of the uterus are all EXCEPT: (AIIMS 2006)
a. Uterosacral ligament
b. Broad ligament
c. Mackenrodt’s’ ligament
d. Levator ani
5. Which of the following doesnot prevent prolapse of
uterus?
a. Perineal body
b. Pubocervical ligament
c. Broad ligament
d. Transverse cervical ligament
ANSWERS WITH EXPLANATIONS
1. c. Pelvic fascia
• Hypogastric sheath is a condensation of pelvic fascia.
 PELVIS
• It lies along the postero-lateral pelvic walls and
carries the neuro-vascular bundles towards the pelvic
viscera.
• It also provides pelvic viscera support.
2. b. Broad ligament.
• Hypogastric sheath is a condensation of the pelvic
fascia which transmits vessels and nerves along the
lateral pelvic wall towards
the pelvic viscera.
• Broad ligament of uterus is not a part of the
hypogastric sheath. It is a peritoneal fold.
• Parts of the hypogastric sheath:
− Anterior lamina – Lateral ligament of bladder.
− Middle lamina – Transverse cervical ligament,
rectovesical septum in males.
− Posterior lamina – Presacral fascia, uterosacral
ligament (containing middle rectal vessels).
Note: The endopelvic fascia lies between, and is
continuous with, both visceral and parietal layers of
pelvic fascia.
3. a. Pubococcygeus
 PELVIS
• Anterior fibers of pubococcygeus surround the
prostate to form levator prostatae muscle, which
supports the prostate.
• Pubovaginalis in the female is the equivalent of
levator prostate in the male.
• Both originate from the posterior pelvic surface of
the body of the pubis bone. Fibres pass inferiorly,
medially and posteriorly to
insert into a midline raphe, the central perineal
tendon.
4. b. Broad ligament
• Broad ligament is a double fold of peritoneum and is
a weak support of uterus, its function as uterine
support is comparatively
insignificant.
• The best supports of pelvic viscera are the muscular
supports like Levator ani.
• The pelvic fascia condensations like utero-sacral and
Mackenrodt’s ligaments are considered as good
supports of uterus.
5. c. Broad ligament
• Broad ligament is a peritoneal fold and poor support
of uterus.
 PELVIS
• Perineal body is a central perineal tendon, which
receives attachment of perineal muscles, which
support the pelvic viscera.
• Pubocervical and Transverse cervical ligaments are
the pelvic fascia condensations, which are good
supports of pelvic viscera
with parasympathetic fibres.
ASSESSMENT QUESTIONS
1. Maximum number of mucosal folds are found in
which part
of fallopian tube? (NEET Pattern 2015)
a. Infundibulum
b. Ampulla
c. Isthmus
d. Interstitial portion
2. Which part of the uterine tube acts as anatomical
sphincter?
a. Intramural part
b. Isthmus
c. Ampulla
d. Infundibulum
 PELVIS
3. The sensory supply of the fallopian tube and ovary is
from:
a. T6 to T8
b. T8 to T10
c. T10 to T12
d. L2 to L4
ANSWERS WITH EXPLANATIONS
1. a. Infundibulum
• The mucosa is thrown into longitudinal folds, which
are most pronounced distally at the infundibulum and
decrease to shallow
bulges in the intrauterine (intramural) portion.
2. b. Isthmus > a. Intramural part
• The arrangement of the muscles at the isthmus is
such that it can work like a sphincter, preventing the
oocyte from entering the
uterine cavity.
• Some authors mention the location of sphincter at
the junction of uterus and uterine tube (intramural
part).
3. c. T10 to T12
 PELVIS
• Visceral afferent fibres travel with the sympathetic
nerves and enter the cord through corresponding
dorsal roots (T12 ±2).
ASSESSMENT QUESTIONS
1. All are parts of vulva EXCEPT: (NEET Pattern 2012)
a. Labia minora
b. Labia majora
c. Perineal body
d. Clitoris
2. All is true about Bartholin gland EXCEPT:
a. Homologous of male bulbo-urethral gland
b. Present in the superficial perineal pouch
c. Located at the junction of anterior 1/3 and middle
1/3 of
labia majora
d. Opens into the vestibule between hymen and labia
minora
ANSWERS WITH EXPLANATIONS
1. c. Perineal body
• The female external genitalia (or vulva/pudendum)
consists of a vestibule of vagina and its surrounding
structures such as mons
 PELVIS
pubis, labia majora, labia minora, clitoris, vestibular
bulb and pair of greater vestibular glands.
2. c. Located at the junction of anterior 1/3 and middle
1/3 of labia majora
• Bartholin gland is located at the junction of middle
1/3 and posterior 1/3 of labia majora.
• The duct opens in the postero-lateral wall of vagina
(vestibule).
• The epithelium of the Bartholin duct is cuboidal near
the gland, but becomes transitional and finally
stratified squamous near the
opening of the duct.
Clinical Correlations
•• Episiotomy is a surgical incision of the perineum
(and the posterior vaginal wall) to enlarge the vaginal
opening during childbirth.
•• It is done during second stage of labour to quickly
enlarge the opening for the baby to pass through.
•• There are two types of episiotomies.
––Median Episiotomy starts at the frenulum of the
labia minora and proceeds directly downward cutting
through the skin → vaginal
 PELVIS
wall → perineal body → superficial transverse perineal
muscle.
––Mediolateral Episiotomy starts at the frenulum of
the labia minora and proceeds at a 45-degree angle
cutting through the skin → vaginal
wall → bulbospongiosus muscle.
ASSESSMENT QUESTIONS
1. Superficial perineal space contains all EXCEPT:
a. Root of penis (NEET Pattern 2012)
b. Urethral artery
c. Great vestibular glands (Bartholin glands)
d. Membranous urethra
2. Superficial muscles of perineum: (NEET pattern
2014)
a. Ischiocavernosus
b. Bulbocavernosus
c. Levator ani
d. Ischio-coccygeus
3. Urogenital diaphragm is contributed by all EXCEPT:
a. Sphincter urethra (NEET Pattern 2012)
b. Perineal body
 PELVIS
c. Colles’ fascia
d. Perineal membrane
4. All are the contents of deep perineal pouch EXCEPT:
a. Bulb/Root of penis (AIIMS 2008; AIPG 2009)
b. Dorsal nerve of penis
c. Sphincter urethra
d. Bulbo urethral glands
5. NOT a part of superficial perineal pouch: (AIIMS
2011)
a. Posterior scrotal nerves
b. Sphincter urethrae
c. Ducts of bulbourethral glands
d. Bulbospongiosus muscle
6. Nerve supply to the perineum is: (NEET Pattern
2012)
a. Pudendal nerve
b. Inferior rectal nerve
c. Pelvic splanchnic nerves
d. Hypogastric plexus
7. All of the following are attached to perineal body
EXCEPT:
 PELVIS
(NBE 2013)
a. Superficial transverse perinei
b. Iliococcygeus
c. Bulbospongiosus
d. Ischio-cavernosus
8. The deep perineal space:
a. Is formed superiorly by the perineal membrane
b. Contains a segment of the dorsal nerve of the penis
c. Is formed inferiorly by Colles’ fascia
d. Contains the greater vestibular glands
ANSWERS WITH EXPLANATIONS
1. d. Membranous urethra
• Membranous urethra is a content of deep perineal
pouch, which continues as spongy urethra in superficial
perineal pouch.
2. a. Ischiocavernosus
• Muscles in the superficial perineal pouch are
ischiocavernosus, bulbospongiosus and superficial
transverse perinei.
3. c. Colles’ fascia
 PELVIS
• Urogenital diaphragm contains the deep perineal
pouch and is lined inferiorly by the perineal membrane
and not Colles’ fascia.
• Colles’ fascia lies at the floor (inferior lining) of
superficial perineal pouch.
• Urogenital diaphragm is a triangular musculo-fascial
diaphragm in the anterior part of perineum. It is
contributed by mainly two
muscles: sphincter urethrae and deep transverse
perinei. These muscles are enclosed within a superior
and inferior fascia. The
inferior fascia is also called as perineal membrane.
• Perineal body is a fibromuscular body attached at the
posterior border of perineal membrane in the midline.
Both the fascia of urogenital
diaphragm are attached to the perineal body. Perineal
body is a good support of pelvic viscera and is attached
by numerous muscles of
the perineum including the muscles of urogenital
diaphragm – deep transverse perinei and sphincter
urethrae.
4. a. Bulb/Root of penis
 PELVIS
• Bulb/Root of penis lies in the superficial perineal
pouch and not the deep perineal pouch.
• Bulb of vagina/ root of clitoris also lie in the
superficial perineal pouch.
• Contents of deep perineal space in males:
Membranous part of urethra, Muscles of urogenital
diaphragm (Sphincter urethra and
Deep transverse perinei), Bulbo-urethral glands of
Cowper, Internal pudendal vessels and branches,
Dorsal nerve of penis and
muscular branches of perineal nerve.
• Contents of deep perineal space in females: Part of
urethra (same as in males), Part of vagina, Muscles of
urogenital diaphragm (same
as males), Internal pudendal vessels and branches
(same), Dorsal nerve of clitoris and muscular branches
of perineal nerve.
5. b. Sphincter urethrae
• Sphincter urethrae (external urethral sphincter) is
present in the wall of membranous urethra, in the
deep perineal pouch, it also
extends vertically, around the anterior aspect of the
prostatic urethra.
 PELVIS
• Posterior scrotal nerves are the branches of pudendal
nerve, and do pass the superficial perineal pouch.
• Cowper’s bulbourethral gland is present in the deep
perineal pouch, but it’s duct pierces the perineal
membrane and opens into the
bulbous urethra in the superficial perineal pouch.
• Bulbospongiosus muscle is a content of superficial
perineal pouch, functions as a vaginal sphincter in a
female; and for a male it help
to empty the urethra of the urine/semen.
• The superficial perineal pouch is a fully enclosed
compartment, Its inferior border (floor) is the perineal
fascia (Colles’ fascia and
superior border (roof) is the perineal membrane.
• The contents are muscles : ischiocavernosus,
bulbospongiosus muscle, superficial transverse
perineal muscle. Other contents are: Crura of
penis (males) / Crura of clitoris (females), bulb of penis
(males) / Vestibular bulbs (females), Greater vestibular
glands (female).
6. a. Pudendal nerve
 PELVIS
• Pudendal nerve is the nerve of perineum. It is a
mixed (sensory and motor) nerve to supply skin and
skeletal muscles of perineum.
7. d. Ischio-cavernosus
• Ischio-cavernosus is not a midline muscle and is not
attached to the central perineal tendon (perineal
body).
• Superficial and deep transverse perineal muscles,
both attach to the perineal body.
• Iliococcygeus (pelvic diaphragm) has attachment to
the perineal body
• Bulbospongiosus is a muscle in the superficial
perineal pouch which covers bulb of penis (or vagina)
and attaches to perineal body.
8. b. Contains a segment of the dorsal nerve of penis.
• Dorsal nerve of penis is a content of both superficial
and deep perineal pouch. Other choices are applicable
to superficial perineal
Pouch
ASSESSMENT QUESTIONS
1. Boundaries of ischiorectal fossa are: (NEET Pattern
2014)
a. Posterior : Perineal membrane
 PELVIS
b. Anterior : Sacrotuberous ligament
c. Lateral : Obturator internus
d. Medial : Gluteus maximus
2. During incision and drainage of ischiorectal abscess,
which
nerve is/are injured? (PGIC 2012)
a. Superior rectal nerve
b. Inferior rectal nerve
c. Superior gluteal nerve
d. Inferior gluteal nerve
e. Posterior labial nerve
3. Pudendal canal is a part of: (NEET Pattern 2014)
a. Colles fascia
b. Obturator fascia
c. Scarpa’s fascia
d. None
4. All of the following pairs about the boundaries of
ischiorectal
fossa are correct EXCEPT:
a. Anterior: Perineal membrane
b. Posterior: Gluteus maximus
 PELVIS
c. Medial: Levator ani
d. Lateral: Obturator externus
5. UNTRUE about ischiorectal fossa:
a. Obturator fascia meets anal fascia at the apex
b. A communication is present between the two IRF in
front of anal canal
c. Alcock’s canal is located at the lateral wall
d. Inferior rectal nerve and vessels pass through it
ANSWERS WITH EXPLANATIONS
1. c. Lateral : Obturator internus
• Lateral boundaries of ischiorectal fossa is the ischial
bone with obturator internus muscle covered by
obturator fascia.
• Perineal membrane lies anterior and sacrotuberous
ligament and gluteus maximus are posterior.
2. b. Inferior rectal nerve; e. Posterior labial nerve
• Dissection of ischiorectal fossa, may involve injury to
inferior rectal, pudendal, posterior scrotal (or labial)
nerve and vessels along
with perforating branches of S2-S3 and perineal
branches of S4 nerve.
3. b. Obturator fascia
 PELVIS
• Pudendal canal is formed in the obturator fascia in
the lateral wall of the ischiorectal fossa.
4. d. Lateral: Obturator externus
• Obturator internus is present at the lateral wall of
ischiorectal fossa. It is covered by obturator fascia,
which has pudendal canal in it.
5. b. A communication is present between the two IRF
in front of anal canal
• A communication is present between the two IRF in
behind the anal canal.
• Apex (roof): Meeting point of obturator fascia
(covering obturator internus) and inferior fascia of the
pelvic diaphragm (covering
levator ani muscle)
• Alcock’s pudendal canal is present in the lateral wall
of ischiorectal fossa and send inferior rectal nerve and
vessels medially
through the fossa towards the anal canal
ASSESSMENT QUESTIONS
1. All are true about the trigone of the urinary bladder
EXCEPT:
(AIIMS 2006)
 PELVIS
a. Mucosa is loosely associated to the underlying
musculature
b. Mucosa is smooth
c. It is lined by transitional epithelium
d. It is derived from the absorbed part of the
mesonephric duct
2. Urethral crest is due to: (AIIMS 2013)
a. Opening of prostatic glands
b. Puboprostatic spread
c. Insertion of detrusor
d. Insertion of trigone
3. Where is the cave of Retzius present? (NEET Pattern
2012)
a. Between urinary bladder and rectum
b. Between urinary bladder and cervix
c. In front of the bladder
d. Between the cervix and the rectum
4. All are related to posterior surface of urinary bladder
EXCEPT: (JIPMER 2001)
a. Ureter
b. Rectum through rectovesical pouch
 PELVIS
c. Seminal vesicles
d. Vas deferens
5. FALSE regarding trigone of bladder: (NEET Pattern
2015)
a. Lined by transitional epithelium
b. Mucosa smooth and firmly adherent
c. Internal urethral orifice lies at lateral angle of base
d. Developed from mesonephric duct
6. In bladder injury pain is referred to all EXCEPT:
a. Upper part of thigh (NEET Pattern 2012)
b. Lower abdominal wall
c. Flank
d. Penis
7. If a missile enters the body just above the pubic
ramus through the anterior abdominal wall it will most
likely pierce which of the
following structures? ( AIIMS 2000)
a. Abdominal aorta
b. Left renal vein
c. Urinary bladder
d. Spinal cord
 PELVIS
ANSWERS WITH EXPLANATIONS
1. a. Mucosa is loosely associated to the underlying
musculature
• Mucosa is tightly adherent to the underlying
musculature in the trigone of urinary bladder.
• The mucosa appears smooth at the trigone because
of this tight adherence, since folding is not possible in
the mucosa.
• In other places the mucosa is highly folded or
stretched according to the state of distension.
• Trigone of bladder is derived by the absorption of the
mesonephric duct in to the bladder wall.
• Transitional epithelium lines the urinary bladder
throughout its extent, including the trigone.
2. d. Insertion of trigone
• The superficial trigone muscle becomes continuous
with the smooth muscle of the proximal urethra, and
extends in the male along
the urethral crest as far as the openings of the
ejaculatory ducts.
3. c. In front of the bladder
 PELVIS
• Cave of Retzius (retropubic space) is the
extraperitoneal space between the pubic symphysis
and urinary bladder.
• It is basically a preperitoneal space, behind the
transversalis fascia and in front of peritoneum.
4. a. Ureter
• Ureters join the superolateral angles of urinary
bladder (not related to the posterior surface).
• Relations of posterior surface of urinary bladder:
− Upper part is separated from rectum by the
rectovesical pouch containing coils of the small
intestine.
− Lower part is separated from rectum by the terminal
parts of vas deferens and seminal vesicles.
− The triangular area between the vas deferens is
separated from the rectum by rectovesical fascia (of
Denonvillier’s).
5. c. Internal urethral orifice lies at lateral angle of base
• Internal urethral orifice lies at the apex (no the
lateral angle of base) of urinary bladder.
• It’s the ureters that open at lateral angles.
6. c. Flank
 PELVIS
• This is a wrong question with no appropriate answer.
The best possible option is flank region, as little is
known about the functional
significance of thoracolumbar afferents.
• Pain fibres of urinary bladder are carried by both
sympathetic and parasympathetic fibres.
• Parasympathetic fibres (nervi erigentes) are derived
from S2, S3, S4 segments of the spinal cord and the
referred pain is felt in the
corresponding dermatomes in perineum and posterior
thigh.
• Sympathetic fibres are derived from T11, 12 and L1, 2
segments of the spinal cord and the pain is referred to
the lumbar region,
inguinal region, and anterosuperior thigh.
7. c. Urinary bladder
• A distended urinary bladder may be ruptured by
injuries of lower abdominal wall, as mentioned in the
question.
• Spinal cord terminates at L1 vertebral level; left renal
vein is given at L1-2 level and abdominal aorta
bifurcates at L4. None of the
mentioned structures reach the level of pubic ramus.
 PELVIS
of the following
features, EXCEPT: (AIPG)
a. Is the widest and most dilatable part
b. Presents a concavity posteriorly
c. Lies closer to anterior surface of prostate
d. Receives Prostatic ductules along its posterior wall
2. NOT true about prostatic urethra: (AIIMS 2009,10)
a. Trapezoid shape in cross section
b. Presence of veru montanum
c. Opening of prostatic ducts
d. Urethral crest on posterior wall
3. Bulbourethral glands open into which part of the
urethra?
a. Membranous (NEET Pattern 2012)
b. Spongy
c. Prostatic
d. Intramural
4. WRONG statement about male urethra is:
a. Length of male urethra is 20 cm
b. Membranous urethra has shortest length
 PELVIS
c. Narrowest lumen is at the external urethral meatus
d. Prostatic urethra has the widest lumen
ANSWERS WITH EXPLANATIONS
1. b. Presents a concavity posteriorly
• Prostatic urethra presents an anterior (and not
posterior) concavity, which becomes more prominent
in the membranous part. It
runs downwards and forwards to exit prostate slightly
anterior to its apex.
• Though the lumen of the prostatic urethra does show
a posterior concavity, as observed in a cut section of
prostate.
• Prostatic urethra is considered as the widest and
most dilatable part, though recent literature mentions
that bulbous part of spongy
urethra has the widest lumen.
• Prostatic urethra passes more anteriorly through the
prostate and is at the junction of anterior 1/3 and
posterior 2/3 rd of prostate.
Hence, it lies closer to the anterior surface of the
prostate.
• It receives multiple openings of prostatic ductules at
its posterior wall.
 PELVIS
2. a. Trapezoid shape in cross section
• Transverse section of prostate shows crescent
(semilunar) shaped lumen of urethra (and not
trapezoid).
• Veru montanum (seminal colliculus) is a rounded
elevation on the posterior wall of prostatic urethra
showing three openings.
• Prostatic urethra has a midline elevation on the
posterior wall of prostatic urethra called urethral crest.
• There are multiple openings found on the sides of
urethral crest for the glandular secretions of prostate
3. b. Spongy
• Bulbourethral glands are present in males in relation
with membranous urethra (in the deep perineal
pouch), whereas the duct
opens into the bulbous spongy urethra (in superficial
perineal pouch).
4. d. Prostatic urethra has the widest lumen
• Male urethra has a total length of 20 cm and is
divided mainly into 4 parts.
• Membranous urethra has the shortest length - 1.5
cm.
 PELVIS
• The narrowest lumen is present at the external
urethral meatus and the second narrowest is in the
membranous urethra.
• The widest lumen is present in the bulbous part of
penile urethra, second widest is the prostatic urethra.
ASSESSMENT QUESTIONS
1. Scarpa’s fascia gets attached to: (JIPMER 2010)
a. Inguinal ligament
b. Fascia lata of thigh
c. Conjoint tendon
d. Pubic crest
2. A 16-year-old boy presents to the emergency
department
with straddle injury and rupture of the bulbous
urethra.
Extravasated urine from this injury can spread into
which of
the following structures?
a. Scrotum
b. Ischiorectal fossa
c. Deep perineal space
d. Thigh
 PELVIS
3. Injury to the male urethra above the perineal
membrane due
to a pelvic fracture, causes urine to accumulate in all of
the
following EXCEPT:
a. Space of Retzius
b. Deep perineal pouch
c. Superficial perineal pouch
d. Peritoneal cavity
4. Injury to the male urethra below the perineal
membrane
causes urine to accumulate in: (AIPG 2007)
a. Superficial perineal pouch
b. Deep perineal pouch
c. Space of Retzius
d. Pouch of Douglas
5. A patient exposed to bomb explosion injury presents
with
rupture of the fundus of urinary bladder. The
extravasated
urine reaches:
 PELVIS
a. Space of Retzius
b. Deep perineal pouch
c. Superficial perineal pouch
d. Peritoneal cavity
6. After fracture of the penis (injury to the tunica
albuginea)
with intact Buck’s fascia, there occurs hematoma:
a. The penis and scrotum
b. At the perineum in a butterfly shape
c. Penis, scrotum, perineum and lower part of anterior
abdominal wall
d. Shaft of the penis only.
7. In penile injury, Colle’s fascia prevents extravasation
of urine in: (NEET pattern 2013)
a. Ischiorectal fossa
b. Perineum
c. Abdomen
d. Thigh
ANSWERS WITH EXPLANATIONS
1. b. Fascia lata of thigh
 PELVIS
• Scarpa’s fascia is the deep membranous layer of
superficial fascia of anterior abdominal wall.
• It crosses the inguinal ligament and gets attached to
the fascia lata of thigh along Holden’s line, below and
parallel to inguinal ligament.
2. a. Scrotum
• Extravasation of urine may result from rupture of the
bulbous spongy urethra below the perineal membrane;
the urine may pass
into the superficial perineal pouch and spread
inferiorly into the scrotum, anteriorly around the penis,
and superiorly into the lower
part of the abdominal wall.
• The urine cannot spread laterally into the thigh
because the perineal membrane and the superficial
fascia of the perineum are firmly
attached to the ischiopubic rami and are connected
with the deep fascia of the thigh (fascia lata).
• It cannot spread posteriorly into the anal region
(ischiorectal fossa) because the perineal membrane
and Colles’s fascia are continuous
with each other around the superficial transverse
perineal muscles.
 PELVIS
3. d. Peritoneal cavity
• Rupture of membranous part of the urethra may lead
to urine escaping into the space around the prostate
and bladder and
extraperitoneal space (but not the peritoneal cavity).
• If the urogenital diaphragm is also disrupted urine
leaks into deep perineal space and into the superficial
perineal space (as the
perineal membrane is also ruptured).
• The most common type of urethral injury is at the
junction of posterior and anterior (bulbous) urethra.
Radiologists consider a type
III urethral injury as a combined anterior/posterior
urethral injury.
4. a. Superficial perineal pouch
• Superficial perineal pouch lies below the perineal
membrane and has the spongy part of urethra lying in
it.
• Any injury to the spongy urethra like the bulbous
rupture of urethra leads to the extravasation of urine
into the superficial perineal pouch.
 PELVIS
• The urine can track from the superficial pouch
towards the anterior abdominal wall and reach just
anterior to the external oblique
aponeurosis.
• Perineal membrane separates the deep perineal
pouch from the superficial and prevents urine from
entering the deep perineal
pouch from superficial.
• Space of Retzius is an extra-peritoneal space lying
between the pubic bones and the urinary bladder.
• Membranous rupture of urethra (above the perineal
membrane) may cause accumulation of blood and
urine in this space.
• Pouch of Douglas is the recto-vesical (or recto-
uterine) pouch of peritoneum. Douglas pouch is intra-
peritoneal and also well
separated from the superficial pouch. Neither of the
two varieties of urethral rupture the urine can reach
into this space.
5. d. Peritoneal cavity
• Rupture of the dome (superior wall) of the urinary
bladder, leads to rupture of peritoneum and results in
an intraperitoneal
 PELVIS
extravasation of urine within the peritoneal cavity
(ascites).
• It is caused by a compressive force on a full bladder.
6. d. Shaft of the penis only
• Penile Fracture - Diagnosis of albugineal rupture is
usually made from a characteristic history of severe
pain with a cracking or
popping sound during acute bending of the erect penis,
followed by immediate detumescence, penile swelling,
and deformity.
• Albugineal rupture is associated with urethral injury
in 10–20% of cases.
• Penile hematoma is confined to the shaft when the
Buck’s fascia is intact.
• If the Buck fascia has been violated, the swelling and
ecchymosis are contained within the Colles fascia. In
this instance, a “butterflypattern”
ecchymosis may be observed over the perineum,
scrotum, and lower abdominal wall.
7. a. Ischiorectal fossa
• Colle’s fascia attachments prevents extravasation of
urine into the ischiorectal fossa.
 PELVIS
• Penile injuries may lead to extravasation of urine into
penile and scrotal layers, perineum, anterior
abdominal wall.
• Urine is prevented from entering the thigh by fascia
lata attachments.
ASSESSMENT QUESTIONS
1. All of the following statements are true about
sphincter
urethra EXCEPT: (AIIMS 2014)
a. Located at the bladder neck
b. Originate from ischiopubic ramus
c. Is a voluntary muscle
d. Supplied by pudendal nerve
2. Sphincter urethrae is present in: (NEET Pattern
2012)
a. Prostatic urethra
b. Spongy urethra
c. Membranous urethra
d. Penile urethra
3. Vaginal sphincter is formed by all EXCEPT: (AIIMS
2009, 10)
a. Internal urethral sphincter
 PELVIS
b. External urethral sphincter
c. Pubovaginalis
d. Bulbospongiosus
ANSWERS WITH EXPLANATIONS
1. a. Located at the bladder neck
• Sphincter urethra (external urethral sphincter) is a
content of deep perineal pouch (not the bladder neck).
• It is a skeletal (voluntary) muscle, supplied by somatic
pudendal nerve (S2,3,4) and works for urinary
continence.
• It takes its origin from the ischiopubic ramus on each
side and unite with the muscle of the opposite side by
means of a tendinous
raphe.
• Internal urethral sphincter (sphincter vesicae) is
located at the bladder neck, is a smooth (involuntary)
muscle engaged in preventing
retrograde ejaculation of semen, supplied by L1
sympathetic fibres.
2. c. Membranous urethra
 PELVIS
• External urethral sphincter (sphincter urethrae) is
present in relation to the membranous urethra, in the
deep perineal pouch.
3. a. Internal urethral sphincter
• Internal urethral sphincter do not function as vaginal
sphincter. In some textbook it is mentioned internal
urethral sphincter is
absent in females.
• Muscles that compress the vagina and act as
sphincters include the pubovaginalis, external urethral
sphincter (especially its
urethrovaginal sphincter part), and bulbospongiosus.
• The External urethral sphincter surrounds the vagina
also and works as urethro-vaginal sphincter. It is
innervated by the nerve fibres
of Onuf’s nucleus (S-2, 3, 4) via the pudendal nerve.
• Pubo-vaginalis is a part of pubo-coccygeus (Levator
ani) and functions as genital tract sphincter. Levator ani
muscle forms the Pelvic
diaphragm.
• Bulbo-spongiosus is a muscle of superficial perineal
pouch and is a constrictor of genital tract.
 PELVIS
• Internal urethral sphincter: Females lack the internal
urethral sphincter. It is actually the anatomical bladder
neck (pre-prostatic)
sphincter observed in males. The internal urethral
sphincter prevents retrograde passage of semen into
the urinary bladder during
ejaculation. It is innervated by the L-1 sympathetic
fibres. L-1 fibres should not be cut while performing
lumbar sympathectomy
otherwise, would result in retrograde ejaculation of
semen.
• Urinary continence in females is maintained by the
following muscles: Sphincter urethrae, Compressor
urethra, Sphincter urethrovaginalis,
Pubo-urethralis (part of Levator ani muscle).
Rectum
ASSESSMENT QUESTION
1. Pelvic fascia between rectum and sacrum is:
a. Denonvillier’s fascia
b. Colle’s fascia
c. Waldeyer’s fascia
d. Scarpa’s fascia
 PELVIS
898
ANSWERS WITH EXPLANATIONS
1. c. Waldeyer’s fascia
• Waldeyer’s fascia (presacral fascia) lines the anterior
aspect of the sacrum, enclosing the sacral vessels and
nerves.
• It is limited postero-inferiorly, as it fuses with the
mesorectal fascia, lying above the levator ani muscle.
• Identification and preservation of the Waldeyer’s
fascia is of fundamental importance in preventing
complications and reducing
local recurrences of rectal cancer.
• Denonvillier’s fascia is a membranous partition
separating the rectum from the prostate and urinary
bladder; this structure in the
male corresponds to the fascia rectovaginalis in the
female.
Clinical Correlations
•• Internal hemorrhoids are varicosities of the superior
rectal veins. They are located above the pectinate line
and are covered by rectal
mucosa. These present with painless bleeding.
 PELVIS
•• External hemorrhoids are varicosities of the inferior
rectal veins. They are located below the pectinate line
near the anal verge and are
covered by skin. These present with painful bleeding.
ASSESSMENT QUESTIONS
1. Anal canal NOT supplied by: (AIIMS 2015)
a. Superior rectal artery
b. Inferior rectal artery
c. Median sacral artery
d. Middle rectal artery
2. All form anorectal ring EXCEPT: (AIIMS 2013)
a. External anal sphincter
b. Internal anal sphincter
c. Puborectalis
d. Anococcygeal raphe
ANSWERS WITH EXPLANATIONS
1. d. Middle rectal artery
• Middle rectal artery supplies the rectum, but ‘not’
the anal canal.
 PELVIS
• The anal canal is supplied by terminal branches of the
superior rectal artery and the inferior rectal artery
branch of the internal
pudendal artery, together with a small contribution
from the median sacral artery.
• The arterial supply to the epithelium of the lower
anal canal in the midline, particularly posteriorly, is
relatively deficient and is
thought to predispose to the occurrence of acute and
chronic anal fissures, which are most commonly found
in the midline,
especially posteriorly.
2. d. Anococcygeal raphe
• Anorectal ring is a muscular present at the junction of
rectum and anus. it is formed by fusion of fibres of
puborectalis, uppermost
fibres of external anal sphincter and internal anal
sphincter.
• Anococcygeal raphe a fibrous median raphe in the
floor of the pelvis, which extends between the coccyx
and the margin of the
anus and is not a component of anorectal ring.
 PELVIS
• Damage to the anorectal ring results in rectal
incontinence.