Pelvis and Perineum

Dissecting room workshop

Prepared by Dr Mandeep Gill Sagoo

RESOURCE DESCRIPTION
This anatomy practical session will allow students to understand the anatomy of pelvis and
perineum. Students will explore the bony structure and position of pelvis and identify the
important landmarks. Pelvic diaphragm, perineum and ischioanal fossa will be discussed and
identified.

Osteology and ligaments:

The osseous pelvis is the bridge between the spine and the lower extremities. Pelvis is formed
from two hip (innominate) bones, a sacrum and a coccyx. Each hip bone is formed by the
fusion of 3 ossification centres at the triradiate cartilage of the acetabulum: the ilium, the
ischium, and the pubis).

Identify the following structures on the bony pelvis and radiographs:

• Ilium
Iliac crest (palpable on you)
Iliac fossa
Iliac tuberosity
Auricular surface
Anterior Superior Iliac Spine (ASIS) (palpable on you)
Anterior Inferior iliac spine (AIIS)
Posterior Superior Iliac Spine (PSIS)
Posterior Inferior iliac spine (PIIS)
Gluteal surface
Arcuate line

• Ischium
Ischial spine
Ischial tuberosity

• Pubis
Pubic crest
Pubic tubercle
Pubic symphysis
Pectineal line

• Sacrum
Sacral Promontory
Sacral ala

• Greater sciatic notch

• Lesser sciatic notch
• Obturator foramen

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 • Acetabulum

Identify the following structures on an articulated skeletal pelvis and demonstrate their
boundaries.
• Greater (false) pelvis
• Lesser (true) pelvis
• Pelvic inlet
• Pelvic Outlet
• Subpubic angle

Considering all the above features, try to identify the sex of the skeleton / bony pelvis on your
tables/stations.

Try to find differences in features of four types of pelvis relevant for Obstetrics &
Gynaecology: Android, Gynaecoid, Anthropoid and Platypelloid.

Explain the orientation of the pelvis in the anatomical position (pelvic inclination). What angles
do the pelvic inlet and outlet make with a horizontal plane in the anatomical position?

Identify the following ligaments and their attachments on a plastic model.

• Inguinal ligament
• Iliolumbar ligament
• Sacroiliac ligament (anterior, posterior and interosseous)
• Sacrotuberous ligament
• Sacrospinous ligament
• Annococcygeal ligament

Note that the sacrospinous and sacrotuberous ligaments convert the greater and lesser
sciatic notches into greater & lesser sciatic foramina respectively.

Peritoneal pouches and ischioanal fossa:

Identify and revise the relationship of urinary bladder with other pelvic organs in a
specimen/radiograph.

The peritoneum is a serous membrane which has two layers: visceral and parietal peritoneum.
There is a potential space between these two layers which is known as peritoneal cavity.

No viscera are present in the peritoneal cavity but most of the abdominal and pelvic viscera
are related to the peritoneum, in one or the other way.

Identify the following peritoneal pouches:

• Rectovesical pouch (in male pelvis)
• Rectouterine pouch (in female pelvis)
• Uterovesical pouch (in female pelvis)
• Pararectal fossae (in both)

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The rectovesical (in males) / rectouterine (in females – pouch of Douglas) pouch is the
deepest part of the pelvic peritoneal cavity and as such is the place where gravity dependent
fluid (pus, infection etc.) accumulation may occur in the erect posture.

The ischioanal fossa

It is a wedge-shaped space filled with fat and connective tissue located lateral to the anal
canal (present bilaterally) and inferior to the pelvic diaphragm. The two ischioanal fossae
communicate by means of deep postanal space over the annococcygeal ligament.

The fat and connective tissue in this fossa are easily compressed by an enlarging rectum /
anal canal or vagina during defaecation and parturition respectively.

Identify the following structures that form the boundaries of the ischioanal fossa on the
plastic model (See the image provided in the lecture slides).

Boundary Structures Forming Boundary

Medial External anal sphincter with fibres of

levator ani, both these structures surround
anal canal.
Lateral Obturator internus muscle, fascia and
ischium
Posterior Sacrotuberous ligament, gluteus maximus
Anterior Ischiopubic rami
Inferior Perineal skin
Superiorly Levator ani

Note that the ischioanal fossae have both anterior and posterior recesses. Anterior recesses
(on either side) extend into the urogenital triangle (in-between perineal membrane and pelvic
diaphragm). The posterior recesses communicate each other in a space between gluteus
maxima muscles and annococcygeal ligament.

Identify the pudendal (Alcock’s) canal in the inferior aspect of the lateral wall of ischioanal
fossa.

Trace the internal pudendal vessels and pudendal nerve from pelvic cavity to gluteal region
and then into the pudendal canal on a wet specimen/ plastic model. Notice pudendal nerve
and vessels hook around the ischial spine which is an important landmark for pudendal
blocks.

Pelvic diaphragm and perineum:

The pelvic diaphragm/pelvic floor is a bowl-shaped diaphragm that separates the pelvic
cavity from the perineum. It dynamically supports the pelvic viscera and resists the increase
in abdominopelvic pressure.

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Identify the following muscles of pelvic floor on the specimen/model and note their
innervation and action:
• Levator ani muscle (3 parts - Puborectalis, Pubococcygeus, Iliococcygeus)
• Coccygeus muscle

Compare the pelvic diaphragm in males and female pelvic models and identify the urethral,
genital and anal openings.

Note that part of levator ani arises from the tendinous arch (white line) which is a thickening
of the obturator internus fascia.

Identify the muscles that form the walls of the true pelvis and note their nerve supply and
action
• Obturator internus and its fascia (laterally)
• Piriformis (posteriorly)

The perineum
It is a diamond-shaped space bounded by the outlet of the pelvis. An imaginary line joining
the ischial tuberosities divide the perineum into two triangular spaces. The anterior space is
known as urogenital triangle and the posterior is known as anal triangle.
Identify the following boundaries of perineum:

Anterior Inferior aspect of the pubic symphysis

Anterolaterally Ischiopubic ramus and ischial tuberosity
Posterolaterally Sacrotuberous ligaments on either side
Posterior coccyx

Trace the boundaries of perineum in a bony pelvis.

The Perineal membrane (inferior fascia of urogenital diaphragm) is a tough fascial

sheet in a urogenital diaphragm. It separates the space into the superficial perineal pouch
from the deep perineal pouch. The superficial perineal pouch is located between skin & the
superficial fascia of perineum (anteriorly) and the perineal membrane (posteriorly). The deep
perineal pouch is between the perineal membrane (anteriorly) and the superior fascia of the
urogenital diaphragm (posteriorly).

Identify the contents of deep and superficial perineal pouches.

Identify and compare the following muscles in a male and female pelvis model:

• Bulbospongiosus (note the difference in shape and size in males and females)
• Ischiocavernosus (note the difference in shape and size in males and females)
• Superficial transverse perineal muscle
• Deep transverse perineal muscle
• External anal sphincter
• External urethral sphincter

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Note that the perineal muscles (along with pelvic diaphragm, pelvic slings and perineal body)
provide support to the pelvic organs.

Identify the perineal body. Identify and name the muscles that converge on the perineal body.

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