PERINEUM

Perineum is the region at the lower end of the trunk, in the interval between the two thighs.
The external genitalia are located in the perineum.
Transverse line joining the anterior parts of the ischial tuberosities, and passing immediately
anterior to the anus, dividing into two triangular areas:
- Anterior (Urogenital triangle): Contains external urogenital organs.
- Posterior (Anal triangle): Contains termination of anal canal and ischioanal fossa.

Anal Region:
Cutaneous Innervation
- Inferior rectal nerve (S2–4): Supplies skin around the anus and over the ischioanal fossa.
- Perineal branch of the fourth sacral nerve: Supplies skin posterior to the anus.
Anococcygeal Ligament:
- Fibrofatty mass permeated with muscle fibers.
- Derived from the levator ani and the external anal sphincter.
- Extends from the anus to the tip of the coccyx. - Supports the rectum.

PERINEAL BODY The perineal body, or the central point of the perineum, is a
fibromuscular node situated in the median plane, about 1.25 cm in front of the anal margin
and close to the bulb of the penis. Ten muscles of the perineum converge and interlace in the
perineal body.
Two unpaired: • External anal sphincter • Fibres of longitudinal muscle coat of anal canal.
Paired: • Bulbospongiosus • Superficial and deep transversus perinei • Levator ani.
Importance in Females:
- Crucial for the support of pelvic organs in females. - Sphincter urethrovaginalis is attached
here in females.
- Subject to potential damage during parturition or childbirth.
- Damage may result in prolapse of pelvic organs, including the urinary bladder, uterus,
ovaries, and rectum in females.
ISCHIOANAL FOSSA: The ischioanal fossa is a
wedge-shaped space situated one on each side
of the anal canal below the pelvic diaphragm. Its
base is directed downwards, towards the surface.
The apex is directed upwards.

Boundaries:
● Base:
○ Formed by the skin of the
perineum.
● Apex:
○ Formed by the line where the obturator fascia meets the inferior fascia of the
pelvic diaphragm or anal fascia.
● Anterior Boundary:
○ Limited by the posterior border of the perineal membrane.
● Posterior Boundary: Reaches:
○ a. Lower border of the gluteus maximus.
○ b. Sacrotuberous ligament.
● Lateral Wall: Vertical and formed by:
○ a. Obturator internus with the obturator fascia.
○ b. Medial surface of the ischial tuberosity, below the attachment of the
obturator fascia.
● Medial Wall: Slopes downwards and medially, formed by:
○ a. The levator ani with the anal fascia in the upper part.
○ b. The external anal sphincter, with the fascia covering it in the lower part.
Spaces and Canals of the Fossa
The arrangement of the fascia in this region forms the following spaces.
Perianal Space
- Perianal fascia is in the form of a septum that passes medially from the white line of Hilton
to the pudendal canal laterally.
- Separates a shallow subcutaneous perianal space from the deep ischioanal space.
- Small and shallow.
- Fat in the perianal space is tightly arranged in small loculi formed by complete septa.
- Infections in this space are very painful due to tension caused by swelling.
Ischioanal Space
- Large and deep space.
- Fat in this space is loosely arranged in large loculi formed by incomplete delicate septa.
- Infections in this space are less painful because swelling can occur without tension.
- Lunate fascia arches over the ischioanal fat, dividing the space into suprasegmental space
(above the fascia) and tegmental space (below the fascia).
Contents of Ischioanal Fossa (I2P4)

Clinicals:
● The two ischioanal fossae facilitate the expansion of the rectum and anal canal during
feces passage. Both the perianal and ischioanal spaces are susceptible to abscess
formation, sometimes leading to an ischioanal anorectal fistula.
● Abscesses can rupture internally into the anal canal or rectum, and externally onto the
perineum surface, potentially resulting in an external sinus. The ischioanal fat
provides a supportive cushion for the rectum and anal canal; its loss, as seen in
diseases like childhood diarrhea, may lead to rectal prolapse.
● An occasional hiatus of Schwalbe, a gap between the tendinous origin of levator ani
and the obturator fascia, may exist. Pelvic organs can rarely herniate through this gap,
causing an ischioanal hernia.

Urogenital Region:
The urogenital region is posteriorly bounded by the
inter ischial line, usually aligning with the posterior
border of the transverse perinei muscles. Its anterior and
lateral boundaries consist of the symphysis pubis and
ischiopubic rami. A strong perineal membrane divides
the urogenital region into two parts:

1. Above the perineal membrane: Deep perineal

space.
2. Below the perineal membrane: Superficial perineal space.
Superficial perineal spaces in male and female:
Perineal membrane:

The perineal membrane is an almost triangular membrane with the following features:

● Attachments:
○ Laterally attached to the periosteum of the ischiopubic rami.
○ Apex attached to the arcuate ligament of the pubis, where it is particularly
thick and referred to as the transverse perineal ligament.
○ Posterior border fused to the deep parts of the perineal body and continuous
with the fascia over the deep transversus perinei.
● Crossed or Pierced by:
○ Urethra, located 2–3 cm behind the inferior border of the pubic symphysis.
○ Artery to the bulb of the penis.
○ Duct of the bulbourethral gland.
○ Muscular branches to muscles.
○ Deep artery of the penis.
○ Urethral artery.
○ Dorsal artery and dorsal nerves of the penis.

PUDENDAL CANAL:

● Location: Present in the lateral wall of the ischioanal fossa, just above the
sacrotuberous ligament.
● Extent: Extends from the lesser sciatic notch to the posterior border of the perineal
membrane.
● Formation: Space between the obturator fascia and the lunate fascia, or formed by
the splitting of the obturator fascia.

Contents of the Pudendal Canal:

1. Pudendal Nerve (S2–4):

In the posterior part of the canal, it gives off

the inferior rectal nerve.

Divides into a larger perineal nerve and a

smaller dorsal nerve of the penis.

2. Internal Pudendal Artery:

In the posterior part of the canal, it gives off

the inferior rectal artery.

In the anterior part of the canal, it divides into

the perineal artery and the artery of the penis.

Accompanied by a vein.
PUDENDAL NERVE:

Origin: Arises from the sacral plexus in the pelvis, derived from spinal nerves S2–4.

● Course:
○ Originates in the pelvis.
○ Enters the gluteal region through the greater sciatic notch.
○ Leaves the gluteal region through the lesser sciatic notch to enter the
pudendal canal in the lateral wall of the ischioanal fossa.
○ Terminates by dividing into branches.

Branches:

Internal Pudendal Artery:

Chief artery of the perineum and external genital organs. Smaller in females than in males.

Origin: Smaller terminal branch of the anterior division of the internal iliac artery, given off in
the pelvis.

Course: Enters the gluteal region through the greater sciatic notch.

Leaves the gluteal region through the lesser sciatic notch to enter the pudendal canal.

Branches:

● Inferior Rectal Artery

● Perineal Artery
● Artery of the Penis or Clitoris: which gives off
1. Artery to the bulb.
2. Urethral artery.
3. Deep artery of the penis or clitoris.
4. Dorsal artery of the penis or clitoris.
Urethral Sphincter Mechanism:

The urethral sphincter mechanism comprises intrinsic smooth and skeletal muscles, separate
from the pubourethralis component of the levator ani. It surrounds the middle third of the
urethra, blending with the smooth muscle of the bladder neck above and the smooth muscle
of the lower urethra and vagina below. The circularly disposed skeletal muscle fibers form the
rhabdosphincter, the primary part of the external urethral sphincter. In females, there is no
proximal urethral sphincter.

Actions:

● Compresses the urethra, especially when the bladder contains fluid.

● Contracts to expel the final drops of urine.

Nerve Supply: Perineal branch of the pudendal nerve and pelvic splanchnic nerves.

Compressor Urethrae:

○ Arises from the ischiopubic rami, with fibers passing anteriorly to form a flat
band anterior to the urethra.
○ Some fibers extend medially to reach the lower wall of the vagina.
○ Within the urethral wall.

Sphincter Urethrovaginalis:

Arises from the perineal body, with fibers extending forward on either side of the urethra and
vagina. Forms a flat band anterior to the urethra below the compressor urethrae.

Actions: elongation and compression of the membranous urethra, aiding continence in

females.
 Preliminary Consideration of Boundaries and Contents of Pelvis

Pelvis is formed by articulation of each of the two hip bones with the sacrum behind and with
each other in front.

The pelvis is divided by the plane of the pelvic inlet or pelvic brim, or superior aperture of the
pelvis into two parts:
a. Upper part is known as the greater or false pelvis which lodges the abdominal viscera.
b. Lower part is known as the lesser or true pelvis.
The plane of the pelvic inlet passes from the sacral promontory to the upper margin of the
pubic symphysis. The greater or false pelvis includes the two iliac fossae, and forms a part of
the posterior abdominal wall. The lesser or true pelvis contains the pelvic viscera.

Lesser Pelvis:
The pubic arch is formed by the ischiopubic rami of the two sides and by the lower margin of
the pubic symphysis which is rounded off by the arcuate pubic ligament.

Pelvic Cavity: The pelvic cavity is continuous above with the abdominal cavity at the pelvic
brim, and is limited below by the pelvic diaphragm. Curved, first directed downwards and
backwards, then downwards and forwards (J-shaped).

Contents of the Pelvic Cavity:

● Anterior Part: Urinary bladder, Prostate (in males) below neck of the urinary bladder.
● Posterior Part: Sigmoid colon and rectum.
● Between Bladder and Rectum (Genital Septum):
○ In males: Small septum containing ductus deferens, seminal vesicle, and ureter
on each side.
○ In females: Large septum containing uterus, uterine tubes, round ligament of
the uterus, ligaments of the ovary, ovaries, vagina, and ureters.

Structures Crossing the Pelvic Inlet/Brim:

● Median sacral vessels. ● Lumbosacral trunk.

● Sympathetic trunk. ● Iliolumbar artery.
 ● Obturator nerve.
● Internal iliac vessels.
● Medial limb of sigmoid mesocolon
with superior rectal vessels (left).
● Ureter.
● Sigmoid colon.
● Ovarian vessels in females.
● Ductus deferens in males/round
ligament of the uterus in females.
● Lateral umbilical ligament.
● Median umbilical ligament or
urachus.
● Autonomic nerve plexuses.
● Coils of intestine and pregnant
uterus.
● Full urinary bladder

Pelvic Girdle: The gynecoid pelvis, representing the normal female type, exhibits a pelvic
inlet with a rounded oval shape and a wide transverse diameter. A woman with an android
pelvis, characterized by a more masculine or funnel-shaped structure, may encounter
challenges in achieving successful vaginal delivery.
Out of the various types mentioned, only a gynaecoid pelvis permits a normal delivery of the
child. The other three represent different types of contracted pelvis.
The pelvic muscles can be grouped into two categories:

1. Short Lateral Rotators of the Hip Joint:

○ Piriformis
○ Obturator internus
2. Pelvic Diaphragm: Levator ani and coccygeus, together with corresponding muscles
on the opposite side, constitute the pelvic diaphragm.

The diaphragm separates the pelvis from the perineum.

The levator ani and coccygeus may be regarded as one morphological entity, divisible from
before backwards into the pubococcygeus, the iliococcygeus and the ischiococcygeus or
coccygeus. They have a continuous linear origin from the pelvic surface of the body of the pubis,
the obturator fascia or white line or tendinous arch and the ischial spine. The muscle fibres
slope downwards and backwards to the midline, making a gutter-shaped pelvic floor.

Nerve Supply

The levator ani is supplied by: 1 A branch from the fourth sacral nerve. 2 A branch from the
inferior rectal nerve.

The coccygeus is supplied by a branch derived from the fourth and fifth sacral nerves.
Actions of Levator Ani and Coccygeus:

1. Closure of Pelvic Outlet:

○ Levator ani and coccygeus muscles work together to close the posterior part of
the pelvic outlet.
2. Perineal Body Fixation and Pelvic Viscera Support:
○ Levator ani muscles fixate the perineal body and provide support to the pelvic
viscera.
3. Counteracting Increased Intra-abdominal Pressure:
○ During activities such as coughing, sneezing, lifting, and other efforts, levator
ani and coccygei muscles counteract or resist increased intra-abdominal
pressure, aiding in maintaining bladder and rectum continence.
4. Preventing Prolapse through Pelvic Floor:
○ Levator ani and coccygei muscles resist increased intra-abdominal pressure
during micturition, defecation, and parturition, preventing prolapse through
the pelvic floor.
5. Role in Micturition, Defecation, and Parturition:
○ During micturition, defecation, and parturition, specific pelvic outlets are open.
Contraction of fibers around other openings resists increased intra-abdominal
pressure, preventing prolapse.
6. Sling Formation by Puborectalis:
○ Puborectalis muscles form a sling, pulling the anorectal junction forwards and
preventing untimely descent of feces.
7. Coccygeus Support for Coccyx:
○ Coccygeus muscles pull forwards and support the coccyx after it has been
pressed backward during defecation, parturition, or childbirth.
Sacroiliac Joint:

Type of Joint Synovial (Plane)

Articular Surfaces
- Auricular surface of the sacrum (covered with fibrocartilage)
- Auricular surface of the ilium (covered with hyaline cartilage)
Ligaments
● - Fibrous capsule attached close to the margins of articular surfaces; lined by synovial
membrane
● - Ventral sacroiliac ligament (thickening of anterior and inferior parts of fibrous
capsule; lower part attached to preauricular sulcus)
● - Interosseous sacroiliac ligament (massive and strong, chief bond of union between
sacrum and ilium; covered by dorsal sacroiliac ligament)
● - Dorsal sacroiliac ligament (covers interosseous ligament; consists of short
transverse fibers and long posterior sacroiliac ligament; continuous laterally with
sacrotuberous ligament)
● - Iliolumbar, sacrotuberous, and sacrospinous ligaments (vertebropelvic ligaments;
accessory ligaments important for joint stability)

Factors Providing Stability

Stability is the primary requirement of the joint as it transmits body weight from the vertebral
column to the lower limbs. Stability is maintained by a number of factors which are as follows.
1. Interlocking of the articular surfaces.
2. Thick and strong interosseous and dorsal sacroiliac ligaments play a very important
role in maintaining stability
3. Vertebropelvic ligaments, i.e. iliolumbar, sacrotuberous and sacrospinous are equally
important in this respect.
4. With advancing age, partial synostosis of the joint takes place which further reduces
movements.