The Extraperitoneal Pelvic
Compartments
Yong Ho Auh, M.D.*
Jae Hoon Lim, M.D., Ph.D.**
Sophia T. Kung, M.D.*
Anatomy
The extraperitoneal space in the abdomen and pelvis is
defined by peritoneum internally and parietal muscu-
lar fascia, including the transversalis fascia and parie-
tal abdominal and pelvic fasciae, externally.1–8 In the
abdomen, the posterior part of the extraperitoneal
space (the so-called retroperitoneal space) is a large
compartment, stratified into three spaces by renal fas-
ciae: the most internal space (anterior pararenal space)
for digestive organs; the intermediate space (perirenal
space) for the kidneys, adrenals, and ureters; and the
most external space (posterior pararenal space) for
areolar and connective tissue.1 The anterior and lat-
eral parts of the abdominal extraperitoneal space is a
small single compartment that is continuous with the
posterior pararenal space, containing areolar and con-
nective tissue (properitoneal fat).
Most of the pelvic extraperitoneal space is inferiorly
located with a slight anterior extension with the urinary
bladder and a slight posterior extension with the rec-
tum. It is more stratified than the abdominal extraper-
itoneal space and complicated by gender differences
due to the different genital organs.9,10 (Fig. 7–1). It
consists of two compartments – the anterior and the
posterior – which are divided by Denonvillier’s fascia
(rectovesical septum in the male and rectovaginal sep-
tum in the female).2,11–15 The anterior compartment is
further divided into the prevesical space and the peri-
vesical space by the umbilicovesical fascia along with
the anterior pelvic fascia.2 The posterior compartment
is also further divided into the perirectal space and
M.A. Meyers et al., Meyers’ Dynamic Radiology of the Abdomen, DOI 10.1007/978-1-4419-5939-3_7,
Ó Springer ScienceþBusiness Media, LLC 2011
7
presacral space by the perirectal fascia and posterior
pelvic fascia (Fig. 7–2).11–16
Prevesical Space
The umbilicovesical fascia is central to the configura-
tion of the anterior compartment of the pelvic extra-
peritoneal space.1,9,10,17 The umbilicovesical fascia lies
anterior to the peritoneum and posterior to the trans-
versalis fascia. The umbilicovesical fascia has a trian-
gular configuration with its apex at the umbilicus
(Figs. 7–3 and 7–4). As it courses inferiorly, the fascia
surrounds the urachus, obliterated umbilical arteries,
and urinary bladder. The lateral edges of the triangle
are occupied by the obliterated umbilical arteries
that extend anteriorly from the anterior trunk of the
internal iliac artery.1,4,9,17 These edges (the medial
umbilical folds) are identifiable on CT as thin lines
(Figs. 7–4, 7–5, 7–6, and 7–7). Thus, the linear line on
CT at this level represents the obliterated umbilical
artery, the surrounding umbilicovesical fascia, and the
parietal peritoneum that they indent.9,10 The obliter-
ated urachus is often visible in the axial plane as a
median umbilical ligament, which slightly indents the
peritoneum to form a median umbilical fold (Figs. 7–4
and 7–7).9
*
Weill Cornell Medical College – New York Presbyterian Hospital,
New York City
**
Sungkyunkwan University School of Medicine, Samsung Medical
Center, Seoul, Korea
203
204  7. The Extraperitoneal Pelvic Compartments
a b
Fig. 7–1. Normal sagittal anatomy in a female.
(a) Sagittal T2 MR of the pelvis and (b) corresponding schematic drawing show normal
midline structures (urinary bladder (ub), uterus (ut), rectum (re)). Fat is demonstrated in the
prevesical space (*) behind the pubic bone, also known as the space of Retzius and in between
the vagina and rectum (arrow), within the rectovaginal septum (rvs). See legend to Fig. 7–3 for
key to abbreviations.
a b
Fig. 7–2. Simplified transverse diagram of the pelvic extraper-
itoneal compartments.
(a) Shows the name of the space and (b) lists the main structures
within the space. Denonvillier’s fascia (rectovaginal septum
in the female or the rectovesical septum in the male) separates
the anterior and posterior compartments of the pelvic extra-
peritoneal space. The anterior compartment is further divided
into the prevesical and perivesical spaces by the umbilicovesical
fascia. The posterior compartment is further divided by the
perirectal and posterior pelvic fascia into the perirectal and
presacral spaces.
Occasionally, an additional linear structure, most
likely representing the umbilical prevesical fascia, is
visible on CT anterior to the median and medial umbi-
lical folds. The umbilical prevesical fascia is probably
formed by apposition of the peritoneal layers that line
the medial recesses of the medial inguinal fossae.
These fused peritoneal layers may extend anterome-
dially, in front of the umbilicovesical fascia, to form
the umbilical prevesical fascia (Fig. 7–8).9 The umbi-
lical prevesical fascia is therefore analogous to the
rectovaginal septum (or rectovesical septum), which
is formed by extraperitoneal extension of the fused
peritoneal layers of the cul-de-sac. The lack of a con-
sensus in the anatomic literature on the presence of a
clearly identifiable umbilical prevesical fascia, and its
only occasional visualization on CT, may be related to
variations among individuals in the degree of fusion
and anteromedial extension of the peritoneal linings of
the medial inguinal fossae.4,9,17
After coursing around the urinary bladder
(Fig. 7–6), the umbilicovesical fascia blends with the
visceral layer of the pelvic fascia (adventitial layer of
the pelvic organs: bladder, uterine cervix, vagina,
seminal vesicle, and prostate). This layer then becomes
reflected onto the parietal layer of the pelvic fascia,
which lines the superior surface of the levator ani
muscles and the lateral pelvic walls in continuity with
the transversalis fascia (Fig. 7–3).1,9,17 Although the
umbilicovesical fascia is not consistently seen on CT
below the peritoneum, its presence is clearly indicated
by prevesical fluid collections.
 a b c

d e

Fig. 7–3. Schematic diagrams of the extraperitoneal pelvic spaces showing normal transverse anatomy (a, b, c, and d) at four different levels as shown on the sagittal diagram of the
pelvis (e).
apf – anterior pelvic fascia, c – sigmoid colon, cds – cul-de-sac, cx – cervix, uterine, p – peritoneum, tf – transversalis fascia, perf – perirectal fascia, pevs – perivesical space, ppf –
posterior pelvic fascia, prss – presacral space, prvs – prevesical space, re – rectum, rvs – rectovaginal septum, ua – obliterated umbilical arteries, ub – urinary bladder, urc –
Anatomy

urachus, ut – uterus, uvf – umbilicovesical fascia, vu – vesicouterine space.

 205
206  7. The Extraperitoneal Pelvic Compartments

a b

c d

Fig. 7–4. Normal axial CT appearance of the umbilicovesical fascia.

(a–d) Four sequential axial CT images of the pelvis from the umbilicus to the level of the urinary bladder showing the normal
appearance of the anatomic landmarks of umbilicovesical fascia. The normal fascia itself is usually too thin to be visible. Superior to
the urinary bladder, the umbilicovesical fascia has a triangular configuration with its apex at the umbilicus. The urachus is visible on
CT as a thin ligament (median umbilical ligament) in the midline (urc). The lateral edges of the triangle, the medial umbilical folds,
are comprised of the obliterated umbilical arteries (ua) and associated umbilicovesical fascia, also identifiable on CT as thin lines
which extend from the umbilicus, around the urinary bladder, to the anterior branch of the internal iliac artery (d). Thin lines lateral
to the obliterated umbilical arteries (c) represent each ductus deferens (dd), as the anterolateral portion traverses the prevesical space
on its way to the inguinal canal.

a b
Fig. 7–5. A large prevesical hematoma shows the
c
typical ‘‘molar tooth’’ appearance.
(a) and (b) The urinary bladder (bl) is displaced
posteriorly by the body of the molar tooth (H) and
medially by ‘‘the roots’’ of the tooth (r).
(c) The hematoma extends into the inguinal canals (*).
Since the umbilicovesical fascia is rather firmly adher-
ent to the parietal peritoneum posteriorly (Figs. 7–7 and
7–8) and leaves only a theoretical potential space, the
umbilicovesical fascia along with anterior pelvic fascia
essentially divides the anterior compartment of the pel-
vis into two spaces – the prevesical space and the peri-
vesical space.9
The prevesical space lies predominantly anterior
and lateral to the umbilicovesical fascia. This space
begins at the umbilicus and communicates with the
properitoneal fat in the anterolateral abdominal
wall and flanks (Fig. 7–3). The anteroinferior
boundary of this space is the pubovesical ligament
(or puboprostatic ligament in the male). Most of the
prevesical fat is present anteriorly, particularly
behind the pubis, where the prevesical space is also
known as the retropubic space or the space of
Retzius (Fig. 7–1).1,2,4,9,17
Perivesical Space
A small space with little fat, the perivesical space, is
bounded by the umbilicovesical fascia and contains
the urinary bladder, urachus, and obliterated umbilical
arteries. Posterior to the bladder, the perivesical space is
continuous with the supravaginal portion of the cervix
and anterior portion of the vagina. Similarly, in males,
the perivesical space is continuous with the prostate and
seminal vesicles (Figs. 7–1, 7–2, and 7–3).9,17
Anatomy  207
Perirectal Space
The posterior compartment is smaller than the
anterior compartment and separated from the
anterior compartment by the rectovesical septum
in the male and the rectovaginal septum in the
female.11,12 The posterior compartment consists of
the perirectal space anteriorly and the presacral
space posteriorly (Fig. 7–2).2,13 The perirectal
space is outlined anteriorly by rectovesical or rec-
tovaginal septum, posteriorly by posterior pelvic
fascia and laterally by perirectal fascia, which is a
condensed connective tissue layer (Figs. 7–6, 7–8,
7–9, 7–10, and 7–11). In the female, this perirectal
fascia is recognized as the sacrouterine liga-
ment.4,18,19 These fasciae are difficult to identify
in normal subjects on cross-sectional images
(Figs. 7–6 and 7–7). However, in various disease
states, whether locoregional or systemic in etiology,
the perirectal fascia becomes visible as a dense
circular line. Local etiologies are likely related to
rectal pathology such as infection or neoplasm
(Figs. 7–10 and 7–11).16,20 Regional causes include
any pathology involving the abdominal or pelvic
extraperitoneal space like pancreatitis, retroperitoneal
bleeding, or acute urinary tract obstruction (Figs. 7–6,
7–7, 7–8, and 7–12). These processes may affect the
perirectal fascia through extraperitoneal fascial
planes. Systemic causes include generalized anasarca
due to sepsis or congestive heart failure that may
text continues on page 211
208  7. The Extraperitoneal Pelvic Compartments

a b

c d

Fig. 7–6. Prevesical fluid collection mimicking ascites in a patient following robotic prostatectomy.
(a) A heterogeneous fluid collection (*) in the anterior pelvis spares the properitoneal fat posterior to the rectus muscles, mimicking
the appearance of intraperitoneal fluid. However, the collection shows a ‘‘molar tooth’’ configuration displacing the urinary bladder,
which contains a Foley catheter balloon (arrow), posteriorly and medially, consistent with an extraperitoneal prevesical collection.
Incidentally seen is mildly thickened perirectal fascia (perf).
(b) More inferiorly, the urinary bladder, containing a Foley catheter (arrow) is again posteriorly and medially displaced.
(c, d) Following percutaneous drainage of the fluid, the bladder returns to its anterior position in the pelvis and resumes its normal
shape, confirming the extraperitoneal nature of the collection.

a b

Fig. 7–7. Asymmetric ‘‘molar tooth’’ prevesical fluid collection/hematoma.

(a) Axial CT of the pelvis in a patient with traumatic bladder injury demonstrates an asymmetric hematoma (*) in the prevesical
space between the umbilicovesical/anterior pelvic fascia and transversalis fascia/parietal pelvic fascia, displacing the urinary bladder
(ub) posteriorly and to the right side.
(b) Axial CT at a more caudal level showing the focal defect (black arrow) in the urinary bladder giving rise to the urinoma/
hematoma. Fluid also extends into the left femoral canal (white arrow).
 Anatomy  209

Fig. 7–8. Pelvic ascites.

Sagittal T2 weighted MR image of the pelvis demonstrating pelvic ascites (asc) displacing the
urinary bladder (ub) inferiorly. This is in contrast to extraperitoneal pelvic fluid that displaces the
urinary bladder posteriorly. Midline structures, the rectum (re), and fibroid uterus (ut) are noted.

Fig. 7–9. Abdominopelvic carcinomatosis mimicking a prevesical collection.

Axial CT of the pelvis in a patient with metastatic ovarian cancer showing pelvic ascites (a) and
peritoneal seeding of tumor (*). Like a prevesical fluid collection, the ascites obliterates the
properitoneal fat posterior to the rectus muscles. The ascites also takes a ‘‘molar tooth’’
configuration, again mimicking an extraperitoneal prevesical collection; however, in this case,
the fluid extends laterally around the sigmoid colon (c) rather than the urinary bladder and the
‘‘root’’ portions are located more superiorly in the pelvis, characterizing this fluid collection as
intraperitoneal in nature.
210  7. The Extraperitoneal Pelvic Compartments

a b

c d

Fig. 7–10. Abdominal aortic rupture with extension of hemorrhage from the posterior pararenal compartments into the pelvic prevesical
space and further into the left inguinal canal.
(a) Axial CT of the abdomen demonstrates retroperitoneal hemorrhage (*) surrounding the aorta and in the left posterior pararenal
space, displacing the left kidney anteriorly. There is thickening of the left renal fascia and stranding within the perirenal space
(arrowheads). Note, however, that there is no extension of fluid to the right side.
(b) Dense, heterogeneous hematoma (*) extends into the infraconal extraperitoneal pelvic fat, lateral to the parietal peritoneum and
medial to the iliopsoas muscle and iliac vessels.
(c, d) Extension of hematoma into the prevesical space, forming a unilateral root of a molar tooth (*) with spread of fluid into the left
inguinal canal (arrow). The left obliterated umbilical artery is seen in (c) (arrowhead) coursing towards the umbilicus.
 Abnormal Imaging Features  211

a b

Fig. 7–11. Spontaneous rectus sheath hematoma communicating with the prevesical space.
(a) A large right rectal sheath hematoma (*) extends into the prevesical space (black arrows) through the thin
layer of transversalis fascia.
(b) At a more inferior level, the prevesical collection deviates the urinary bladder to the left.

result in thickening of all fasciae including the peri-
rectal fascia.
Although the surgical and anatomical literature,
even today, does not provide a consensus on the pre-
sence of these fasciae and, if present, on the compo-
nents and morphology of the fascial planes, cross-
sectional images clearly depict their existence and
morphology.13,16,20
The perirectal space is mainly filled by adipose
tissue, but it also contains rectal arteries and veins,
splanchnic nerves, lymphatics, and perirectal lymph
nodes (Fig. 7–10). This space readily communicates
with the subperitoneal space of the sigmoid
mesocolon.2,13
Presacral Space
The presacral space is situated in front of the
sacrum and the coccyx, and defined anteriorly by
the posterior pelvic fascia and posteriorly by parie-
tal pelvic fascia (Figs. 7–2 and 7–3). It contains
areolar and connective tissue, devoid of vascular,
nervous, or lymphatic structures. It is not recog-
nized on cross-sectional images in the normal sub-
ject. It is delineated, however, in disease states as
the fasciae become more conspicuous (Figs. 7–7,
7–10, and 7–11). This space is usually involved by
pathology of the sacrum or coccyx: fracture
(Fig. 7–13), infection (Fig. 7–14), or neoplasm
(Fig. 7–15) or by extension of rectal pathology
(Figs. 7–10 and 7–11). In contrast to the prevesical
space, the presacral space is tighter, smaller, and
limited (Figs. 7–2 and 7–3).2,13–15
Abnormal Imaging Features
Prevesical Fluid Collections
Because the umbilicovesical fascia along with the
anterior pelvic fascia lies anterior and lateral to the
urinary bladder, prevesical effusions assume in
cross section a ‘‘molar tooth’’ configuration as
they accumulate between the umbilicovesical fascia
along with the anterior pelvic fascia and the trans-
versalis fascia or parietal pelvic fascia. The ‘‘crown’’
portion of the molar tooth lies anterior to the urin-
ary bladder, between the umbilicovesical fascia and
transversalis fascia of the anterior abdominal wall,
displacing the bladder posteriorly (Figs. 7–9 and
7–16). The ‘‘root’’ portion of the molar tooth
extends posteriorly and inferiorly, between the
umbilicovesical fascia along with the anterior pelvic
fascia and the parietal pelvic fascia, displacing
the bladder medially or away from the midline if
the roots are asymmetrical in size (Figs. 7–5, 7–12,
7–13, and 7–17).9,10 The root portion has also been
referred to as a paravesical collection, but it is
simply the postero-inferior extension of prevesical
212  7. The Extraperitoneal Pelvic Compartments

a b

c
Fig. 7–12. CT cystogram in a patient with pelvic fractures
causing extraperitoneal bladder rupture and a presacral
hematoma.
After administration of iodinated contrast medium via a
Foley catheter, axial CT demonstrates a focal bladder
defect (arrowhead) with leakage of contrast medium (a, b)
into the prevesical (*) and perivesical spaces (long arrow).
A fluid collection (b) in the presacral space (arrowheads)
containing a hematocrit level (short arrows), indicating
layering of blood, is consistent with a hematoma due to a
sacral fracture (black arrow) (c) more superiorly. Also, in
(c) contrast medium extends into the extraperitoneal fat
posteriorly and the properitoneal fat (*) anterolaterally.
The triangular perivesical fatty triangle, surrounding the
urachus and obliterated umbilical artery, is partially
demarcated by contrast media (white arrow).

Fig. 7–13. Spared triangular perivesical fatty space in a

patient with a prevesical urinoma.
Axial image from a CT cystogram in a patient with an
anastomotic leak from the urinary bladder following renal
transplantation. The triangular perivesical fatty space
around the urachus and obliterated umbilical arteries
(arrows) is spared, outlined by a surrounding prevesical
collection, some of which is opacified by contrast medium
(*) leaking from the urinary bladder.
 Abnormal Imaging Features  213

a b

Fig. 7–14. Two cases of rectal cancer.

(a) Right-sided rectal mass (*) approaches the perirectal fascia (perf) which is thickened. A small lymph node is seen in the left
perirectal space (arrow).
(b) Circumferential rectal mass (*) penetrates the perirectal fascia, approaching the pelvic side wall and contacting the right
piriformis muscle (arrows).

a b

Fig. 7–15. Perirectal abscess secondary to sigmoid diverticulitis.

(a) Sigmoid diverticulosis with inflammatory stranding in the sigmoid mesocolon (arrowheads).
(b) Abscess (*) in the perirectal space (pers). Note the thickened, prominent perirectal fascia (perf) and posterior pelvic fascia (ppf).

collection.2,21 Large amount of ascites, either locu-
lated or free, may form a molar tooth appearance in
the pelvis, mimicking a prevesical fluid collection
(Fig. 7–18). However, with collections of intraper-
itoneal fluid, the urinary bladder is displaced infer-
iorly rather than posteriorly and medially (Figs. 7–
18 and 7–19). Furthermore, the ‘‘root’’ portion is
formed by accumulation of ascites in the bilateral
pararectal fossae or parasigmoidal fossae and
therefore located more superiorly. Additionally,
ascites usually preserves the properitoneal fat
while the extraperitoneal prevesical collection
usually obliterates this fat (Figs. 7–5, 7–9, 7–16,
7–17, 7–18, 7–19, and 7–20).
The umbilicovesical fascia that surrounds the
urachus and obliterated umbilical arteries is not
usually visible on CT or MRI. The presence of
the umbilicovesical fascia becomes obvious when
there is adjacent prevesical fluid. The prevesical
collections surround but do not involve a trian-
gular segment of fat in the anterior abdominal
wall, which represents the superior extension of
214  7. The Extraperitoneal Pelvic Compartments
aa
Fig. 7–16. Perirectal abscess due to anastomotic leak following a low anterior resection.
(a) Axial CT of the pelvis showing oral contrast leaking at the anastomotic site (arrow) into the perirectal space.
(b) Large abscess with layering oral contrast and locules of gas occupies the perirectal space and tracks to the presacral space
(arrowheads).
Fig. 7–17. Large heterogeneous ganglioneuroma (*)
arising in the presacral space displaces the colon and
urinary bladder (ub) anteriorly and obliterates the
presacral fat.
the perivesical space along the urachus and oblit-
erated umbilical arteries.9 The prevesical collec-
tions usually obliterate the properitoneal fat
except this triangular segment (Figs. 7–13 and
7–21).
Below the arcuate line, which lies approximately
halfway between the umbilicus and pubic symphy-
sis, the rectus abdominis muscles are lined poster-
iorly by only a thin layer of transversalis fascia.
This is because the posterior lamina of the apo-
neurosis of the internal oblique muscle and the
aponeurosis of the transversus abdominis muscle,
bb
which form the posterior rectus sheath superiorly,
pass anterior to the rectus abdominis muscles below
the arcuate line. At this level, prevesical collections
can extend directly through the thin transversalis
fascia, along perforating branches of the inferior
epigastric vessels, to come into direct contact with
the rectus abdominis muscles (Figs. 7–13 and 7–16).
Fluid can then extend along these muscles into the
more superior portions of the rectus sheath.9 Simi-
larly, rectus sheath hematomas can follow the same
pathway into the prevesical space (Fig. 7–20). In
fact, when large collections involve both of these
compartments, it can be difficult to determine
whether the effusions originated in the prevesical
space or the rectus sheath.9
The anterolateral portion of the vas deferens
courses within the prevesical space before it enters
the internal inguinal ring to become part of the sper-
matic cord. Prevesical fat accompanying the vas defe-
rens and retroperitoneal fat accompanying the testicu-
lar vessels form the internal spermatic fascia, which is
the innermost layer of the spermatic cord. It follows,
then, that prevesical fluid can extend along the vas
deferens into the inguinal canal and subsequently
into the scrotum (Figs. 7–5 and 7–16).9
Like the vas deferens, the distal portion of the
round ligament courses within the prevesical space as
it enters the internal inguinal ring after hooking
around the proximal inferior epigastric vessels.22
As the external iliac vessels course below the ingu-
inal ligament to become the femoral vessels, they
are enveloped by the femoral sheath, which consists
of a downward prolongation of transversalis fascia

a b
Fig. 7–18. Leaking contrast medium from the base of the urinary bladder into the prevesical and presacral spaces in a CT cystogram in a
patient with multiple pelvic fractures.
(a, b) Midline sagittal and parasagittal CT images of the pelvis demonstrating leakage of iodinated contrast medium (arrowhead)
from the urinary bladder (ub) neck into the prevesical space (arrow, prvs) and presacral space (arrow, prss). Foley catheter is evident
on the midline sagittal image (short black arrow).
(c) Further lateral parasagittal CT of the pelvis showing contrast medium migrating superiorly and laterally in the prevesical space
(arrow).
anteriorly and iliac fascia posteriorly. This sheath is
occupied by the femoral artery and vein laterally and
by the femoral canal medially. Since the external iliac
vessels lie lateral to the peritoneum, within a com-
partment that is continuous anterolaterally with the
prevesical space, prevesical fluid can track along the
external iliac vessels, below the inguinal ligament,
and into the femoral sheath (Fig. 7–17).2–4,9
The prevesical space is continuous laterally with the
extraperitoneal fat of the anterior abdominal wall,
which in turn is continuous with the properitoneal and
retroperitoneal fat. Thus, prevesical effusions can
extend laterally around the parietal peritoneum to
come into contact with the iliopsoas muscles and exter-
nal iliac vessels and then extend superiorly from the
infrarenal retroperitoneal space into pararenal compart-
ments (Figs. 7–5, 7–12, and 7–13). When large collec-
tions involve both the abdominal and pelvic extraper-
itoneal compartments, it can be difficult to predict
whether the effusions originated in the prevesical
space or the retroperitoneum (Figs. 7–5 and 7–12).5–10
Perivesical Fluid Collections
Perivesical collections are rarely seen without asso-
ciated prevesical fluid. Perivesical collections are
small since the fluid is within a relatively narrow
space around the urinary bladder confined by the
umbilicovesical fascia. This is not to imply that the
thin umbilicovesical fascia is impregnable, as
Abnormal Imaging Features  215
c
extension of contrast medium from the prevesical
space into the perivesical space or more frequently
vice versa is common in vivo, resulting in partial or
complete obliteration of the perivesical fat (Fig. 7–13).
The triangular perivesical fatty space around the
supravesical portions of the urachus and obliterated
umbilical arteries often remains isolated in the middle
of a prevesical fluid collection (Figs. 7–13 and 7–21).
Clinically, these effusions may be mistaken for
bladder wall thickening or perivesical tumor exten-
sion. Additionally, perivesical fluid posterior to the
bladder may be mistaken for intraperitoneal fluid
within the cul-de-sac.9,10
Perirectal Pathology
In contrast to the prevesical space where the most
common abnormal findings are related to spontaneous
or traumatic hematoma or other fluid collections,
abnormal findings in the perirectal space are mostly
related to rectal pathology (Figs. 7–10, 7–11, and
7–14). Identifying fasciae and the resulting spaces is
important for detecting and localizing pathologic pro-
cesses and determining extent of the disease, thus influ-
encing clinical management and therapy.
It is particularly helpful in the staging and manage-
ment of rectal cancer. Because the perirectal space is
mainly filled with adipose tissue, the extent of rectal
cancer beyond the rectal wall is readily seen. If the
tumor has reached the perirectal fascia, it is most likely
text continues on page 219
216  7. The Extraperitoneal Pelvic Compartments

a b

c d

e f

Fig. 7–19. Extension of fluid across fascial planes from the abdomen to the pelvis in a patient with duodenal perforation following
ERCP.
(a) Gas and inflammatory soft tissue stranding (arrowheads) in superior portion of the right retroperitoneum abutting the ‘‘bare
area’’ of the liver and right hemidiaphragm emanating from (b) a perforation in the second portion of the duodenum (arrow).
(c) Fluid and gas mainly accumulate in the perirenal space. Inflammatory changes are also seen in the adjacent right posterolateral
abdominal wall, affecting the muscle (arrows), subcutaneous fat, and dermal layer (arrowheads) despite a ‘‘clean’’ posterior pararenal
space.
(d) Fluid tracks into the infrarenal extraperitoneal space (*) and (e) extends to the contiguous prevesical space (arrows).
(f) Note apparent thickening of the right aspect of the urinary bladder wall (arrowheads) due to the inflammatory nature of the
prevesical fluid. The urinary bladder also is compressed and displaced to the left by the prevesical fluid collection (*). Note crescentic
thickening of perirectal and posterior pelvic fascia (arrows).
 Abnormal Imaging Features  217

a b

c d

Fig. 7–20. Pelvic nodal metastatic disease from prostate cancer with edematous changes secondary to lymphatic blockage.
(a, b) Axial pelvic CT demonstrates multiple heterogeneously enhancing metastatic nodes in the left obturator and external iliac
regions with adjacent thickening of the perirectal fascia (perf, arrow).
(c) Necrotic nodes in the left external iliac region (*) extend superiorly associated with
(d) diffuse thickening of the transversalis fascia (arrowheads), umbilico-prevesical fascia (thin black arrow), and fused umbilicov-
esical fascia and parietal peritoneum (white arrow). Edematous changes are also present in the extraperitoneal space (wavy black
arrows).
218  7. The Extraperitoneal Pelvic Compartments

a b

c d

Fig. 7–21. Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia.
During pancreatitis (a, c, e) and after resolution of pancreatitis (b, d, f) at same corresponding levels.
(a) Axial CT at the level of the uncinate process shows mild inflammatory stranding inferior to the pancreatic body (*). Thickening
of the adjacent left anterior renal fascia (arrows) and right posterior renal fascia (arrowheads) is present.
(c) At a more caudal level, inflammatory changes track inferiorly with thickening of the bilateral infraconal extraperitoneal fasciae
(arrowheads).
(e) In the pelvis, the perirectal fascia (perf) and posterior pelvic fascia (ppf), not seen in normal patients, are mildly thickened. The
umbilicovesical fascia (uvf), also not typically identifiable, is evident, closely apposed to the urinary bladder. The right obliterated
umbilical artery (ua) and ductus deferens (dd) are also visualized. After resolution of pancreatitis, follow-up CT scan at similar levels
(b, d, f) demonstrates resolution of fascial thickening.

Continued on next page


ee
Fig. 7–21. Pancreatitis causing mild thickening of all extraperitoneal fasciae including the remote perirectal fascia. (Continued)
inoperable, and if the tumor has penetrated the fascia
and reached the pelvic side wall, it is incurable. How-
ever, thickening of the fascia alone that may be due to
reactive inflammatory changes may not necessarily
represent tumor involvement. Similarly, perirectal
lymph node involvement is also problematic. Enlarged
lymph nodes may be often due to hyperplastic nature
rather than actual tumor involvement. It is because of
these false positives that cross-sectional imaging has a
high sensitivity but low specificity in the staging of
rectal cancer.16
Perirectal abscess and cellulitis are associated with
Crohn disease and infectious proctitis in homosexual
males. In these cases, a more important anatomic
consideration that may impact therapy is the levator
ani muscle. The clinical implications and surgical
approaches for supralevator abscess and the more
common infralevator one are quite different. Since
the perirectal fascia and space are located superior to
the levator ani, any abscess confined to the perirectal
space which can be easily identified belongs to the
supralevator region.20 Perirectal abscesses can result
from the inferior migration of an abscess arising
from a sigmoid diverticulitis, as the subperitoneal
space of the sigmoid mesocolon directly communi-
cates with the perirectal space (Fig. 7–11).
Presacral Space Pathology
Hematomas can develop following fracture of the
sacrum and coccyx (Fig. 7–13). Since this space is the
Abnormal Imaging Features  219
ff
most dependent among the pelvic extraperitoneal
spaces in the supine position, any fluid collection
that develops in the pelvic extraperitoneal spaces,
including a hematoma, can track into the presacral
space along the fascial planes (Figs. 7–12 and 7–22).
Primary or secondary bone tumor from the sacrum or
coccyx may also involve this space (Fig. 7–15).
Extension Across Fascial Planes
In many clinical situations, it is not uncommon to
see fluid collections in one space migrate to
another space illogically, beyond the boundaries
of discrete fascial planes. For example, in the pel-
vis, there may be posterior extension of a prevesi-
cal fluid collection into the perirectal space or pre-
sacral space (Figs. 7–8, 7–12, and 7–22). In the
retroperitoneum, an anterior pararenal collection
may communicate with the perirenal space or pos-
terior pararenal space (Fig. 7–12).
There are several hypotheses to explain these illogi-
cal or paradoxical phenomena. First, there are likely
individual variations in fascial anatomy among sub-
jects, i.e., the fascial planes may not be intact in their
entirety or may be fenestrated. Second, these fascial
planes may be broken or ruptured directly due to
trauma or digested as in a case of pancreatitis or
disrupted by acute supprative infection. The acute
and rapid accumulation of fluid collection may cause
direct damage to the fascia allowing fluid collections
220  7. The Extraperitoneal Pelvic Compartments

a b

d
c

f
e

Fig. 7–22. Prostate abscess causing mild thickening of all extraperitoneal fasciae including remote renal fascia.
During abscess (a, c, e) and after resolution of abscess (b, d, f) at same corresponding levels.
(a) Axial CT of the pelvis demonstrates a prostatic abscess on the right (*) with associated thickening of the perirectal fascia (arrowheads).
(c) More superiorly at the level of the sacrum, multiple thickened fasciae are seen. The transversalis fascia (white arrows) is evident as
thin lines, posterior to the rectus muscles. Slight thickening of the urachus (wavy arrow) in the midline and obliterated umbilical
arteries (ua, black arrows) on either side are evident. The thin line, anterior to these structures (white arrowhead), represents the
umbilico-prevesical fascia.
(e) Inflammatory changes extend to the remote renal compartments with thickening of the renal fascia bilaterally and inflammatory
stranding of the perirenal spaces (arrowheads).
(b, d, f) After resolution of the abscess, a follow-up CT shows resolution of fascial thickening.

to break fascial planes. Finally, while these fascial
planes may act as barriers, to contain these collec-
tions to prevent the spread of a disease process out of
an involved compartment, ironically they may in fact
act as a speedy conduit for the propagation of a
disease process, providing a path for fluid to track
along and facilitating transport to a site distant from
the inciting source.5–8 For example, pancreatitis
frequently results in perirectal fascial thickening
(Fig. 7–6) and a prostate abscess may induce thicken-
ing of the distant renal fascia (Fig. 7–7).
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