Transcript Pelvis and perineum

Pelvic
山东大学医学院 解剖教研室
李振华
Bony pelvis
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Composition: formed by
paired hip bones, sacrum,
coccyx, and their articulations
Two portions
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Greater pelvis
Lesser pelvis
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Terminal line ( pelvic inlet):
formed by promontory of
sacrum, arcuate line, pectin of
pubis, pubic tubercle, upper
border of pubic symphysis
Pelvic outlet: formed by tip of
coccyx, sacrotuberous
ligament, ischial tuberosity,
ramus of ischium, inferior
ramus of pubic symphysis
Muscles of pelvic wall
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Piriform m.
Obturator internus m.
Muscles of floor of pelvis
and pelivic diaphragm
Muscles of floor of pelvis
Levator ani 肛提肌
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Levateo prostate 前列腺提肌
(pubovaginalis 耻骨阴道肌)
Puborectalis 耻骨直肠肌
Pubococcygeus 耻尾肌and
iliococcygeus 髂尾肌
Coccygeus 尾骨肌
Pelivic diaphragm 盆膈
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Superior fascia of pelvic diaphragm 盆膈上筋膜
Levator ani 肛提肌
Coccygeus 尾骨肌
Inferior fascia of pelvic diaphragm盆膈下筋膜
Pelvic fascia
Parietal pelvic fascia
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A continuation of the transverse
fascia into the pelvis. It coves the
piriformis and obturator internus
Attaches to the arcuate line of the
pubis and ilium, thickens over the
obturator internus to form the
arcus tendineus, the origin of
portions of the levator ani muscle
At the tendinous arch of levator
ani it splits to cove both superior
and inferior surfaces of the
levator ani as superior and
inferior fascia of pelvic
diaphragm
Visceral pelvic fascia
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Lies between the
peritoneum and the pelvic
viscera
It is a continuation of the
extraperitoneal connective
tissue
Ensheathes retroperitoneal
viscera and forms septa
between retroperitoneal
organs
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Rectovesical septum
直肠膀胱隔
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Rectovaginal septum
直肠阴道隔
Retropubic space
耻骨后隙
Lies between pubic
symphysis and urinary
bladder
Pararectal space
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直肠周间隙
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Lies around the rectus
Retrorectal space
直肠后隙
Common iliac artery 髂总动脉
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Common iliac artery
Continuation of
abdominal aorta at level
of L4 vertebra
Terminates in front of
sacroiliac joint by
dividing into internal
and external iliac
arteries
Internal iliac artery 髂内动脉
Parietal iliac artery
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Obturator a. 闭孔动脉
Iliolumber a.髂腰动脉
Lateral sacral a.
骶外侧动脉
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Superior gluteal a.
臀上动脉
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Inferior gluteal a.
臀下动脉
Visceral branches
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Umbilical a.脐动脉→ superior
vesical a. 膀胱上动脉
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Inferior vesical a.膀胱下动脉
Uterine a.子宫动脉
Inferior rectal a.直肠下动脉
Internal pudendal a.
阴部内动脉
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Uterine a. 子宫动脉—about 2cm from neck of uterus it
crosses above and in front of ureter
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Internal pudendal
artery 阴部内动脉
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Perineal artery
Anal artery
Dorsal artery of penis
(clitoris)
External iliac artery
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Inferior epigastric artery
Deep iliac circumflex
artery
Veins of pelvis
Internal iliac vein 髂内静脉
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Parietal tributaries: accompany with arteries
Visceral tributaries
→superior rectal vein→inferior mesenteric v.
①Rectal venous plexus
→inferior rectal vein→internal iliac v.
直肠静脉丛
→anal vein→internal pudendal v.
②Vesical venous plexus 膀胱静脉丛→vesical v.
③Uterine venous plexus 子宫静脉丛→uterine v.
External iliac vein
髂外静脉– accompany
the artery
Common iliac vein
髂总静脉– formed by
union of internal and
external iliac veins in
front of sacroiliac joint,
end upon L4~L5 by
uniting each other to
form inferior vena cava
The lymphatic drainage of pelvis
Internal iliac lymph node
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Surround internal iliac vessels
Receive afferents from pelvic viscera,
perineum, buttock and back of thigh
External iliac lymph nodes
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Lie along external iliac artery
Receive afferents from lower limb
and some parts of pelvic viscera
Sacral lymph node
Common iliac lymph node
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Lie along common iliac artery
Receive afferents from all the above
nodes
Efferents pass to lumbar lymph node
Sacral plexus 骶丛
Formation: formed by
anterior rami of L4 and
L5 spinal nerves (the
lumbrosacral trunk) and
anterior rami of sacral
and coccygeal nerves
Position: lies in pelvic
cavity, anterior to
sacrum and piriformis
Branches
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Superior gluteal
Inferior gluteal
Pudendal
Posterior femoral
cutaneou
Sciatic Common
Pudendal nerve block
Autonomic plexuses of plevic
Hypogastric plexus
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Superior hypogastric plexus
上腹下丛: lies in front of L5
between common iliac
ateries
Inferior hypogastric plexus下
腹下丛 (pelvic plexus): lie on
each side of rectum
Sacral sympathetic trunk
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Is continuos above with the
abdominal part
Has 4or 5 ganglion
Relationships of rectus
Anteriorly
 In male
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Fundus of bladder
Seminal vesicle
Prostate
Ampulla ductus deferentis
In female
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neck of uterus
Vagina
Posteriorly
 Sacrum and coccyx
 Piriformis
 Median sacral vessels
 Anterior branches of sacral
and coccygeal nerves
 Sacral sympathetic trunk
Laterally
 Pelvic plexus
 Superior and inferior rectal
vessels
 Levator ani
Vessels and lymphatics of rectum
Arteries
 Superior rectal a.
 Inferior rectal a.
 Median sacral a.
 Lymphatic drainge
Lymphatics follow arterial
blood supply to following
nodes:
 Superior rectal ln.
 Inferior mesenteric ln.
 Pararectal ln.
 Internal iliac ln.
 Sacral ln.
Perineum
山东大学医学院 解剖教研室
李振华
General features
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Region of below pelvic
diaphragm
A diamond-shape space
whose boundaries are
those of the pelvic outlet
 Lower border of
symphysis pubis
 Rami of pubis and
ischium
 Ischial tuberosities
 Sacrotuberous ligament
 The coccyx
Two triangles
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An imaginary line drawn between
the two ischial tuberosities
divides perineum into anterior
and posterior triangles
Urogenital region尿生殖区
(anterior)－differs in male and
female
Anal region 肛区 (posterior)－
similar in both sexes
Anal region 肛区
Anal sphincters 肛门括约肌
 Internal
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Smooth muscle (thickened
circular muscle coat)
Surrounds upper two-thirds of
anal canal
Autonomic nerve supply
External
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Striated muscle
Surrounds lower two-thirds of
anal canal
Three parts－subcutaneous,
superficial and deep
Innervation by anal nerves of
pudendal nerve and branches
of S4
Ischioanal fossa 坐骨肛门窝
Paired, wedge-shaped, fat-filled spaces on either side of anal canal
Boundaries
 Apex－conjunctive area of
inferior fascia of pelvic
diaphragm and fascia covering
the obturator internus
 Base－skin of anal region
 Medial－sphincter ani
externus, levator ani,
coccygeus and inferior fascia
of pelvic diaphragm
 Lateral－ischial tuberosity,
obturator internus and fascia
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Anterior
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Posterior border of urogenital diaphragm
Forward projection of anterior recess of fossa between pelvic
diaphragm above and urogenital diaphragm below
Posterior
 backward projection of posterior recess of fossa between
gluteus maximus, sacrotuberous ligament and coccyx
Contents
 Fat
 Internal pudendal artery and vein and their rectal branches
 Pudendal nerve and its inferior rectal branch
Vessels and nerves enter from gluteal region, through lesser sciatic
foramen, travel on a fascial canal－the pudental canal 阴部管 (Alcock’s)
－on the lateral wall of fossa, and extend forward into urogenital region
Branches
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Superior gluteal
Inferior gluteal
Pudendal
Posterior femoral cutaneou
Sciatic Common
Pudendal nerve block
Urogenital region 尿生殖区
Superficial fascia has two layers
 The superficial or fatty layer
 The deep or membranous layer
(superficial fascia of perineum
会阴浅筋膜 or Colles fascia)
Anteriorly－ it is continuous with:
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Dartos of the scrotum
Fascia of the penis
Membranous layer of superficial
fascia of the abdominal wall
known as the fascia of Scarpa
Deep fascia has two layers
 Superior fascia of urogenital
diaphragm 尿生殖隔上筋膜
 Inferior fascia of urogenital
diaphragm 尿生殖隔下筋膜
Scarpa’s fascia
Line of fusion
Camper’s fascia
Position of penis
Fascia later
Position of scrotum
Superior fascia of urogenital diaphragm
Deep perineal space
Inferior fascia of urogenital diaphragm
Superficial perineal space
superficial fascia of perineum
Fascia of Scarpa
Fascia of the penis
Dartos of the scrotum
会阴深隙：上、下两层膜，中间夹着肉，四周均封闭，尿殖管穿过（如座垫）
会阴浅隙：上、下两层膜，中间东西多，三边都封闭，前上方敞着（如口袋）
Superficial perineal space 会阴浅隙
Boundaries
 Lies between inferior fascia
of urogenital diaphragm and
superficial fascia of
perineum
 Space open anteriorly (In
rupture of cavernous part of
urethra, urine can
extravasate from scrotum
upward in front of
symphysis pubis into
anterior abdominal wall
deep to membranous fascia
of Scarpa)
Contents
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Posterior part－superficial transverse perineal muscle
Lateral part－crus penis (male), crus of clitoris (female) and
ischiocavernousus covering them
Central part－bulb of urethra (male), bulb of vestibule (female) and
bulbocavernousus covering them
Branches of pudendal nerves and internal pudendal vessels
Deep perineal space 会阴深隙
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Lies between superior and inferior fascia of urogenital diaphragm
Contents
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Deep transverse perineal muscle
Bulbourethral gland (male)
Sphincter of urethra尿道括约肌 (male)，urethrovaginal sphincter尿道阴道括
约肌
Ateries, veins and nerves
Urogenital diaphragm 尿生殖隔
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Triangular in shape
Attached laterally to
ischiopubic rami and
ischial tuberosities
Formed by sphincter of
urethra, deep
transverse perineal
muscle, superior and
inferior fascia of
urogenital diaphragm
Perineal central tendon 会阴中心腱
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Wedge-shape fibromuscular mass
In female, between anal canal and lower end of vagina,
In male, between anal canal and root of penis
It is larger in the female than in the male and five support to the
posterior wall of the vagina
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Origin or insertion of
several small muscles
and insertion of part of
palvic diaphragm
These muscles are:
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Sphincter ani externus
Levator ani
Superficial transverse
muscle perineum
Deep transverse muscles
perineum
Bulbocavernousus
Sphincter of urethra
(male) or urethrovaginal
sphincter (female)
Sphincter of urethra (male) or
urethrovaginal sphincter (female)
Bulbocavernousus
Deep transverse muscles perineum
Superficial transverse muscle perineum
Levator ani
Sphincter ani externus