The Pelvis The pelvic cavity consists of the pelvic inlet, walls, and floor and contains elements of the urinary, gastrointestinal, and reproductive systems. Inlet



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The Pelvis

The pelvic cavity consists of the pelvic inlet, walls, and floor and contains elements of the urinary, gastrointestinal, and reproductive systems.



  • Inlet: S1, alae of sacrum, arcuate line, linea terminalis (pubic crest, pecten pubis, arcuate line), and pubic symphysis

  • Walls: obturator internus, piriformis, sacrospinous and sacrotuberous ligaments, greater and lesser sciatic foramina, sacrum, coccyx, ischium, pubis

  • Floor: levator ani (3 parts: iliococcygeus, pubococcygeus, and puborectalis), coccygeus, perineal membrane, muscles of deep perineal pouch

Apertures of the Pelvis

Aperture

Boundaries

Contents

Significance

Greater Sciatic Foramen

Greater sciatic notch, sacrotuberous and sacrospinous ligaments, and the Ischial spine, it is divided into 2 parts by the piriformis

Above piriformis: superior gluteal nerves and vessels

Below piriformis: inferior gluteal vessels and nerves, sciatic nerve, pudendal nerve, internal pudendal vessels, posterior femoral cutaneous nerves and the nerves to the obturator internus and quadrates femoris muscles



Communication between pelvic cavity and lower limb

Above the pelvic floor



Lesser Sciatic Foramen

Lesser sciatic notch, Ischial spine, sacrospinous and sacrotuberous ligaments

Pudendal nerve and internal pudendal vessels, tendon of obturator internus

Communication between gluteal region and perineum

Below pelvic floor



Obturator Canal

Obturator membrane, obturator muscles, superior pubic ramus

Obturator nerve and vessels

Communication between pelvic cavity and adductor region of thigh

Gap between pubic symphysis and perineal membrane




Dorsal vein of penis and clitoris

Communication between pelvic cavity and perineum

Pelvic Inlet

S1, alae of sacrum, arcuate line, linea terminalis, and pubic symphysis




Separates the true from the false pelvis, communication between the abdomen and the pelvic cavity

Pelvic Outlet

Pubic symphysis, bodies and inferior rami of pubis, rami of ischium, and the Ischial tuberosity, sacrotuberous ligament and coccyx

Terminal parts of the urinary and GI tracts, and the vagina

Area enclosed is the perineum

Male vs. Female Pelvis:

Characteristic

Male

Female

Pelvic Inlet

Heart-shaped, more distinct promontory of sacrum

Circular, broader alae of sacrum

Pubic Arch

50-60⁰

80-85⁰

Ischial Spines

Prominent

Less prominent

Ligaments of the Skeletal Pelvis:

Ligament

Connection

Significance

Sacrospinous

Ischial spine and margins of sacrum and coccyx

Create Sciatic Foramina and stabilize the sacrum by resisting upward tilting

Sacrotuberous

Ischial tuberosity to the PSIS and dorsolateral sacrum and coccyx

Create Sciatic Foramina and stabilize the sacrum by resisting upward tilting

Iliolumbar

Transverse process of L5 to the ilium

Stabilize lumbosacral joints

Lumbosacral

Transverse process of L5 to the sacrum

Stabilize lumbosacral joints

Anterior Sacro-iliac

Runs anteriorly and inferiorly to the sacro-iliac joint

Transmit forces from the lower limbs to the vertebral column

Interosseous Sacro-iliac

Immediately posterosuperior to the sacro-iliac joint and fills the gap between the ilium and sacrum

Largest, strongest sacro-iliac ligament

Transmit forces from the lower limbs to the vertebral column



Posterior Sacro-iliac

Covers the interosseous sacro-iliac ligament

Transmit forces from the lower limbs to the vertebral column

Superior Pubic

Above the pubic symphysis




Inferior Pubic

Below the pubic symphysis




Muscles of the Pelvis:

Muscle

Attachments

Innervation

Action

Obturator Internus

Obturator membrane to greater trochanter

L5, S1: Nerve to obturator internus

Lateral rotation of extended hip, abduction of flexed hip

Piriformis


Anterior sacrum to greater trochanter

L5, S1, S2

Lateral rotation of extended hip, abduction of flexed hip

Levator Ani


Posterior pubic bone, obturator internus, Ischial spine to perineal membrane, perineal body, around the anal canal, and anococcygeal ligament

Inferior rectal branch of pudendal nerve (S2-S4), and S4 ventral rami

Forms pelvic floor, supports pelvic viscera, maintains angle between rectum and anal canal, reinforces external anal sphincter, acts as vaginal sphincter

Coccygeus


Ischial spine and sacrospinous ligament to coccyx and sacrum

S3 and S4 anterior rami

Forms pelvic floor, supports pelvic viscera, pulls coccyx forward after defecation

External Urethral Sphincter


Inferior ramus of pubis and walls of deep perineal pouch to membranous part of urethra

Perineal Branches of Pudendal Nerve (S2-S4)

Compresses membranous urethra, relaxes during micturition

Deep Transverse Perineal


Ischial ramus to perineal body

Perineal Branches of Pudendal Nerve (S2-S4)

Stabilizes perineal body

Compressor Urethrae

Ischiopubic ramus to its partner anterior to urethra

Perineal Branches of Pudendal Nerve (S2-S4)

Accessory sphincter of the urethra

Sphincter Urethrovaginalis

Perineal body to its partner, surrounding the urethral and vaginal openings

Perineal Branches of Pudendal Nerve (S2-S4)

Accessory sphincter of urethra, may close the vagina

External Anal Sphincter

Anal canal and aperture to perineal body and anococcygeal body

Pudendal Nerve (S2-S4) and branches directly from S4

Closes anal canal

Ischiocavernosus

Ischial tuberosity and ramus to crus of penis or clitoris

Pudendal Nerve (S2-S4)

Retain blood in penis or clitoris

Bulbospongiosus

Perineal body to perineal membrane, corpus cavernosum, bulb of vestibule, body of clitoris, bulbospongiosus

Pudendal Nerve (S2-S4)

Move blood into glans of penis or clitoris,

in men: remove residual urine from urethra, pulsatile emission of semen



Superficial Transverse Perineal

Ischial tuberosity and ramus to perineal body

Pudendal Nerve (S2-S4)

Stabilize the perineal body

Viscera of the Pelvis:

  • Rectum and Anal Canal: the rectum is continuous with the sigmoid colon at S3 and below at the anal canal as it penetrates the pelvic floor

http://img.medscape.com/pi/emed/ckb/clinical_procedures/252558-270286-4033.jpg

  • Ureters: enter the pelvic cavity anterior to the bifurcation of the common iliac artery. They are crossed in the pelvis by the ductus deferens or uterine artery

  • Bladder: most anterior pelvic viscera, expands into abdominal cavity when full. Consists of a apex (toward top of pubic symphysis, connected to median umbilical ligament [urachus]), base (faces posteroinferiorly, smooth mucosa, contains trigone), and the inferolateral surfaces (cradled between levator ani and obturator internus muscles). The neck of the bladder is the most inferior and fixed area anchored to the pubic bones by pubovesical or puboprostatic ligaments

  • Urethra: begins at base of bladder and ends with external opening in perineum

    • Women: 4cm long and passes inferiorly through pelvic floor and into perineum, passing through deep perineal pouch and perineal membrane before opening into vestibule between labia minora. Skene’s glands are associated with the lower end of urethra.

    • Men: 20cm long and passes through prostate, deep perineal pouch, perineal membrane, and enters the root of the penis. The male urethra is divided into 4 parts:

- Preprostatic: 1cm, internal urethral sphincter (prevents semen from flowing backward into bladder).

-Prostatic: 3-4cm, contains urethral crest, prostatic sinus, seminal colliculus, and prostatic utricle. Connection between urinary and reproductive tracts occurs here.

-Membranous: narrow, passes through the deep perineal pouch where it is surrounded by the external urethral sphincter (skeletal muscle).

-Spongy: surrounded by erectile corpus spongiosum, forms a bulb at the end of the penis called the navicular fossa. The bulbourethral glands enter into the spongy urethra. Vulnerable to damage during catheterization.



The Perineum: inferior to the floor of the pelvic cavity

  • Contains: Terminal openings of the GI and urinary systems, External openings of reproductive tract, and Roots of the external genitalia

  • Bounded by: the pubic symphysis, coccyx, ischiopubic rami (Anterolateral), and sacrotuberous ligaments (posteriorly), levator ani (roof)

  • Pudendal nerve (S2-S4) and Pudendal artery are main nerve and artery of the region

  • 2 Triangles: divided by imaginary line between the two Ischial tuberosities

    • Urogenital: anterior triangle, in the horizontal plane, contains openings of the urinary systems and reproductive systems (in the Urogenital hiatus), the perineal membrane anchored to the perineal body, the superficial perineal pouch (contains erectile fibers), and this triangle functions to anchor the external genitalia (via the perineal membrane and deep perineal pouch)

    • Anal : posterior triangle, faces posteriorly, contains the anus and the external anal sphincter (3 skeletal muscle parts: deep, superficial, and subcutaneous)

  • Ischio-anal Fossae: Inverted wedge shaped gutters between the levator ani muscles, deep perineal pouch, and the adjacent pelvic walls (ischium, obturator internus, and sacrotuberous ligament).

    • The anterior recesses project into the Urogenital triangle superior to the deep perineal pouch

    • Allow movement of the pelvic diaphragm and expansion of the anal canal during defecation

    • Normally filled with fat

Layers of Pelvic Floor: Deep to Superficial




Structure

Contents

1

Levator ani and coccygeus muscles

Skeletal muscle

2

Superior fascia

Ischio-anal fossae and recesses (fat)

3

Deep Perineal Pouch

External urethral sphincter, sphincter urethrovaginalis, compressor urethrae, deep transverse perineal muscles, bulbourethral glands

4

Perineal Membrane

Fibrous membrane

5

Superficial Perineal Pouch

Erectile structures that form the penis or clitoris, bulbs of vestibule, glans clitoris, corpus spongiosum (proximal part is bulb of penis)

skeletal muscles: ischiocavernosus, bulbospongiosus, superficial transverse perineal



6

Inferior (superficial) fascia

A membranous deep layer, Colles’ fascia , which is attached to the perineal membrane and ischiopubic rami (it does not extend into the anal triangle or into the thigh). It defines the external limits of superficial perineal pouch and enters the scrotum/labia and extends around the body if the penis/clitoris

*Because this layer is continuous with the abdomen, infectious materials that accumulate in the superficial perineal pouch can track out of the perineum and enter the lower abdominal wall*

Male Reproductive System:

Structure

Location

Function

Key Features

Testis

Inside scrotum, attached to abdominal wall by spermatic cords

Produce sperm cells in seminiferous tubules

Tunica vaginalis, tunica albuginea, rete testis, mediastinum testis

Epididymis

Posterolateral side of testes

Stores sperm as they mature before ejaculation

Head (efferent ductules), (true epididymis) body and tail

Ductus Deferens

Scrotum, inguinal canal, bends medially around inferior epigastric a., crosses external iliac v. and a. , pelvic cavity, crosses ureter, inferomedially along bladder, anterior to rectum, and enters duct of seminal vesicle

Transports sperm from the tail of the epididymis to the ejaculatory duct

Very long

Ejaculatory Duct

Through prostate gland

Carries secretions of ductus deferens and seminal vesicles into urethra

Penetrates prostate to enter urethra

Urethra

From neck of bladder to the external urethral opening in tip of penis

Conducts urine from bladder to outside of body

4 parts: preprostatic, prostatic, membranous, and spongy

Penis

Outside of body in pubic region, attached to the pubic arch and anchored to the perineal membrane

Conducts urine and semen

Copulatory organ Erectile tissue, composed of 2 corpora cavernosa and a corpus spongiosus. As a bulb, roots (crura), body , and glans

Prostate Gland

Inferior to bladder, posterior to pubic symphysis, and anterior to rectum

Contributes secretions to semen

Surrounds urethra

Seminal Vesicles

Between bladder and rectum

Contributes significant secretions to semen

Accessory gland

Bulbourethral Glands

Within deep perineal pouch, lateral to membranous urethra

Contribute to lubrication of the urethra and pre-ejaculatory emissions

Ducts open into spongy urethra at the root of the penis

Female Reproductive System:

Structure

Location

Function

Key Features

Ovaries

Adjacent to lateral pelvic wall just inferior to pelvic inlet

Produce egg cells

Suspended by mesovarium, connected to body wall by suspensory ligament and to uterus by ligament of ovary

Uterine Tubes

Project laterally from body of uterus, passing superiorly over ovaries

Conduct egg cells into body of uterus

Enclosed by mesosalpinx, Have fimbriae, infundibulum, and ampulla (usual site of fertilization)

Uterus

Midline, between bladder and rectum

Holds developing fetus during pregnancy

Consists of a fundus, body, and cervix (canal forms external and internal os, and it forms fornix at junction with vaginal wall)

Vagina

Extends from cervix, through pelvic floor, and perineum to the outside of the body (introitus). Between bladder and rectum.

Accepts semen deposited during intercourse, serves as birth canal during childbirth

Copulatory organ in women

Clitoris

Beneath pubic symphysis and the underside of the ischiopubic rami and anchored to the perineal membrane

Great sensitivity

Composed of the glans and the corpora cavernosa: has a root and a body

Greater Vestibular Glands

Located posterior to the bulbs of the vestibule on either side of the vaginal opening

Produce lubricating secretions during arousal

Also called Bartholin’s Glands, found in superficial perineal pouch

Para-urethral Glands

Located on either side of the urethra, its ducts open into the vestibule at the lateral margins of the urethral opening

Produce lubricating secretions

Also called Skene’s Glands

Erectile Tissues:

  • Erection is a vascular event mediated by the parasympathetic fibers of the pelvic splanchnic nerves (anterior rami of S2-S4)

  • The pelvic splanchnics branch from the hypogastric plexus and pass through the deep perineal pouch and perineal membrane to innervate the erectile structures in the superficial perineal pouch

  • Stimulation of these nerves causes branches of the internal pudendal arteries to relax, allowing blood to fill the penis or clitoris, causing erection

  • Branches of the Pudendal nerve (S2-S4) carry sensory nerves from the penis/clitoris

Fascia, Peritoneum and Ligaments: continuation of extraperitoneal connective tissue of the abdomen

Fascia

Location/Function

Rectovaginal

Separates the posterior surface of the vagina from the rectum

Pubocervical Ligament

Stabilize the uterus in the pelvic cavity

Transverse Cervical Ligament

(Cardinal Ligament) Stabilize the uterus in the pelvic cavity

Uterosacral Ligament

Stabilize the uterus in the pelvic cavity

Vesico-uterine Pouch

Between the bladder and the uterus

Pouch of Douglas (recto-uterine)

Between uterus and rectum

Recto-uterine Folds

Raised ridge of peritoneum on each side near the base of the recto-uterine pouch. Covers the Uterosacral ligaments.

Broad Ligament

Runs from lateral pelvic walls to the uterus and covers the ovaries, uterine tubes, round ligaments and ligaments of ovaries (remnants of gubernaculum)

Prostatic

Contains and surrounds the prostatic plexus of veins

Rectovesical Pouch

Occurs between the bladder and the rectum

Rectovesical Septum

Separates the posterior surface of the prostate and the base of the bladder from the rectum

Suspensory Ligament of Penis

Supports base of body of penis, attached superiorly to pubic symphysis

Fundiform Ligament of Penis

Supports body of penis, attached to the linea alba of the anterior abdominal wall and splits into 2 bands that unite under the penis

Important Nerves in the Pelvis:

Sacral Plexus:

  • Formed by the anterior rami of the lumbosacral trunk (L4-L5) and S1-S4. S4 only has a ventral division.

  • It is located anteriorly to the piriformis muscle.

  • The pelvic visceral nerves (S2-S4) provide parasympathetic fibers to the inferior hypogastric plexus

  • Major Branches include: sciatic, superior and inferior gluteal, pudendal nerve, nerve to obturator internus, nerve to quadrates femoris and inferior gemellus, piriformis, and levator ani, posterior cutaneous and perforating cutaneous nerves

Coccygeal Plexus:

  • Formed by the anterior rami of S4-Co

  • Form the anococcygeal nerves

  • Penetrate the coccygeus muscle, overlying sacrospinous and sacrotuberous ligaments, passing superficially to innervate the skin in the anal triangle

Superior Hypogastric Plexus: situated anterior to vertebrae L5 between the promontory of the sacrum and the bifurcation of the aorta.

Hypogastric Nerves: the entrance of the prevertebral plexus into the pelvis, crossing the pelvic inlet medially to the internal iliac vessels. Formed b y the separation of the superior hypogastric plexus into right and left bundles.

Inferior Hypogastric Plexus: form when hypogastric nerves are joined by the pelvic splanchnic nerves carrying parasympathetic fibers. Gives rise to:

  • Rectal plexus

  • Uterovaginal Plexus

  • Prostatic Plexus

  • Vesical Plexus

  • Cavernous Nerves: terminal branches supplying the erectile tissues of the penis and clitoris

  • Sympathetics: T10-L2, innervate blood vessels, contract internal anal and urethral sphincters, smooth muscle contraction of reproductive glands and tract, and move secretions from the epididymis and accessory glands into the urethra to form semen.

  • Parasympathetics: S2-S4, vasodilatory, contract bladder, stimulate erection, modulate enteric nervous system of the colon distal to left colic flexure.

  • Visceral Afferents: follow sympathetic (these VAs carry pain) and parasympathetic (these VAs carry receptor information) fibers to the spinal cord

Pudendal Nerve: leaves greater sciatic foramen inferior to piriformis, passes around sacrospinous ligament, then enters the anal triangle by passing through the lesser sciatic foramen to supply the perineum. 3 terminal branches:

  • Inferior Rectal Nerve: external anal sphincter, levator ani, skin of anal triangle

  • Perineal Nerve: motor to muscles of deep and superficial perineal pouches and sensory to skin of scrotum/labia

  • Dorsal Nerve of Penis/Clitoris: sensory to penis/clitoris

Nerve

Cord Levels

Motor

Sensory

Sciatic

L4-S3

Inferior to piriformis



Posterior thigh, and the leg and foot

Skin of foot (tibial part) and lateral leg (common fibular part)

Pudendal

(accompanied by internal pudendal vessels)



S2-S4

Inferior to piriformis, through lesser sciatic foramen



Skeletal muscles of perineum (external urethral and anal sphincters, levator ani)

Skin of perineum, penis, and clitoris

Superior Gluteal

L4-S1

Superior to piriformis



Gluteus medius, gluteus minimus, and tensor fascia latae




Inferior Gluteal

L5-S2

Inferior to piriformis



Gluteus maximus




Nerve to Obturator internus

L5-S2

Obturator internus and Superior gemellus




Nerve to quadrates femoris and inferior gemellus

L4-S1

Inferior to piriformis



Quadrates femoris and inferior gemellus




Posterior Femoral Cutaneous

S1, S3

Inferior to piriformis






Skin of posterior thigh

Perforating Cutaneous

S2, S3

Through sacrotuberous ligament






Skin over gluteal fold

Nerve to Piriformis

L5, S1, S2

Piriformis




Nerves to levator ani, coccygeus, and external anal sphincter

S4

Levator ani, coccygeus, and external sphincter

Skin between anus and coccyx

Pelvic Splanchnic Nerves

S2-S4

Visceral: stimulate erection, modulate mobility of GI system distal to left colic flexure, inhibits internal urethral sphincter

Visceral: visceral afferents from pelvic viscera and parts of distal colon. Pain from cervix and possibly from bladder and proximal urethra

Anococcygeal Nerves

S4-Co




Perianal skin

Dermatomes of the Perineum and Pelvic Floor

http://www.glowm.com/resources/glowm/graphics/figures/v1/0810/006f.jpg

Arteries of the Pelvis:

The Internal Iliac Artery on each side is the major artery for the pelvis and perineum; it originates from the Common Iliac Artery anteriorly to the disc between L5 and S1, courses inferiorly over the pelvic inlet, dividing into anterior and posterior trunks at the level of the superior border of the greater sciatic foramen.

    • Posterior trunk: lower posterior abdominal wall, posterior pelvic wall, and gluteal region

      • Iliolumbar Artery: divides into lumbar, spinal, and iliac branches

      • Lateral Sacral Arteries

      • Superior Gluteal Artery

    • Anterior Trunk: pelvic viscera, perineum, gluteal region, and the adductor region of the thigh.

      • Umbilical Artery

      • Superior Vesical Artery

      • Inferior Vesical Artery or Vaginal Artery

      • Middle Rectal Artery

      • Obturator Artery

      • Internal Pudendal Artery: many branches to perineum

        • Inferior Rectal Artery

        • Perineal Artery: Transverse Perineal Branch and Posterior Scrotal/Labial Artery

        • Artery of Bulb of Penis/Vestibule

        • Urethral Artery

        • Deep Artery of Penis/Clitoris

        • Dorsal Artery of Penis/Clitoris

      • Inferior Gluteal Artery

      • Uterine Artery

External Pudendal Arteries: a superficial and a deep vessel that originate from the femoral artery: enter the perineum and supply the skin of the penis/clitoris and scrotum/labia majora

Testicular/Ovarian Arteries: originate from the abdominal Aorta

Cremasteric Arteries: originate from the inferior epigastric branch of the external iliac artery, accompanying the spermatic cord into the scrotum

Veins:

The veins of the pelvis drain into the internal iliac veins which join the common iliac veins. Veins associated with the rectum and anal canal drain into the portal system. The Pelvic Plexus is an important portacaval shunt when the hepatic system is blocked.



  • Internal Pudendal Vein

  • Internal Iliac Vein

  • Obturator Vein

  • Pelvic Plexus

    • Vesicular

    • Rectum: internal (between internal anal sphincter and epithelium lining the anal canal) and external (encircles the external anal sphincter and is subcutaneous)parts drain via the superior, middle, and inferior rectal veins into the portal and caval systems

    • Prostate

    • Uterus

    • Vagina

  • Deep Dorsal Vein: drains erectile tissues of penis or clitoris. Joins the prostatic plexus in men or the vesicle plexus in women

  • Median Sacral Veins: join to empty into the left common iliac or the junction of the common iliac veins

  • Ovarian Veins: the left one joins the left renal vein and the right one joins the IVC

  • External Pudendal Veins: come from great saphenous vein in thigh and drain the superficial skin of the penis or clitoris and scrotum or labia majora

Important Anastomoses:

  • Uterine artery with Ovarian and vaginal arteries (uterine and vaginal from anterior internal iliac and ovarian from abdominal aorta)

  • Middle rectal artery (from anterior internal iliac) with superior rectal artery (inferior mesenteric)and the inferior rectal artery (internal pudendal)

  • Median Sacral artery (from posterior abdominal aorta) with the iliolumbar and lateral sacral arteries (from posterior internal iliac)

  • Pelvic Plexus: rectum, bladder, prostate, uterus, vagina

  • Dorsal Artery of Penis with Deep Artery of Penis and the Urethral Artery

Lymph Drainage: Remember that lymph follows the major arterial supplies!

Region

Nodes Providing Drainage

Testes, Ovaries and related parts of Uterus and Uterine Tubes

Lumbar nodes and pre-aortic nodes

Pelvic Viscera, Gluteal region, deep areas of Perineum

Internal Iliac Nodes

Superficial tissues of Penis/Clitoris and Scrotum/Labia Majora

Superficial Inguinal Nodes

Glans Penis/Clitoris, Labia Minora, and lower Vagina

Deep Inguinal Nodes and External Iliac Nodes

Clinical Correlations:

  • Femoral Artery: palpated midway between ASIS and pubic tubercle, inferior to inguinal ligament

  • Bone Marrow Biopsy: iliac crest often used because it lies close to the surface and is easily palpated

  • Obstetric Pelvic Measurements: transverse and Sagittal measurements of pelvic inlet and outlet can help predict likelihood of safe vaginal delivery. Obtained by using radiographs and MRIs

  • Defecation: quadrates lumborum, rectus abdominis, external and internal obliques, and transversus abdominis contract to raise intra-abdominal pressure. The puborectalic (levator ani) relaxes to allow straightening of the anorectal angle (increase angle from 90⁰ to about 135⁰) as the external and internal anal sphincters relax to shorten the anal canal and allow passage of feces

  • Episiotomy: an incision in the skin and perineal body to allow room for the fetus to pass through the vagina to prevent stretching and tearing of the perineal body. A clean incision is easier to suture than a complex jagged tear. A posterolateral episiotomy bypasses the perineal body and a median episiotomy cuts through the perineal body.

  • Digital Rectal Examination: can palpate anal mucosa, posterior wall of vagina and cervix or the prostate gland.

  • Suprapubic Catheterization: catheterize the bladder through the anterior abdominal wall above the pubic symphysis.

  • Urethral Catheterization: women are easier because the urethra is very short and nearly straight. The male anatomy can make it more challenging, the spongy urethra is vulnerable to injury because of its angles.

  • Vasectomy: surgical dissection and division of the ductus deferens, can be performed through skin above inguinal canal instead of entering the abdomen or pelvis

  • Tubal Ligation: clip the uterine tubes to prevent eggs from entering the uterus to be fertilized

  • Recto-uterine Pouch (Pouch of Douglas): site of collection for infected fluids and materials in the pelvic cavity because it is the lowest portion of the abdominopelvic cavity

  • Pudendal Block: given where the pudendal nerve crosses the lateral aspect of the sacrospinous ligament near its attachment to the Ischial spine. Ischial spines are palpated transvaginally, and the needle is passed through the skin above the medial aspect of the Ischial spine

  • Prostatectomy and Impotence: when the prostate is removed, the seminal vesicles are removed with it and the pelvic splanchnic nerves in the inferior hypogastric plexus may be disturbed causing erectile dysfunction/impotence



Clinical Finding

Anatomy Involved

Patient Presents With

Miscellaneous

Pelvic Fracture

Bony rings of pelvis: pelvic inlet and obturator foramina

Large hematoma, disruption/compression of urethra, bowel, nerves/vessels

Cause significant bleeding

Sacro-iliac joints

Fibrous and synovial components of joint

Pain and discomfort in sacro-iliac region

Can be caused by rheumatoid arthritis, IBD, and psoriasis

Urinary Stones

Kidneys, Ureters, bladder, urethra

Problems emptying bladder, pain referred to pubic, flank, inguinal areas, and lateral/medial thighs.

Residual urine left in bladder may become infected and alter pH

Bladder Cancer

Bladder, sometimes rectum, uterus, prostate gland, and lateral pelvic walls

Other complications of urinary, GI, and/or reproductive tracts as the cancer spreads

Can spread via internal iliac lymph nodes

Bladder Infection

Bladder, urethra

Cystitis (inflammation of bladder)

Women more susceptible because of short urethras

Testicular Cancer

testes

Abnormal lumps felt in scrotum

Occur in younger patients

Prostate Problems

Prostate gland, urethra

Hard, enlarged prostate, problems urinating due to compressed urethra

Prostate cancer is one of the most common cancers in men

Hysterectomy

Uterus, uterine tubes, ovaries

Reproductive malignancy, endometriosis, excessive bleeding

Pfannenstiel’s incision used (transverse Suprapubic)

Hemorrhoids

Internal and External rectal venous plexuses at or inside the anal sphincter

External hemorrhoids cause pain, swelling (pudendal nerve innervation), internal hemorrhoids usually bleed, but do not cause pain

Pectinate line distinguishes between external and internal hemorrhoids

Caused by straining, obesity, sedentary life



Abscess in ischio-anal fossae

Anal canal, ischio-anal fossae

Tear in anal canal leading to infection

Infection may tract into pelvic cavity or laterally into the i-a fossae

Urethral Rupture

Urethra, surrounding tissues/fascias

Straddling injury, urine collects in scrotum and deep to superficial abdominal fascia. In pelvic fractures the prostatic/membranous urethra may be torn and urine will collect inside the true pelvis

Proximal spongy urethra is most commonly ruptured

Most serious is related to disruption of puboprostatic ligaments



Hydrocele, Varicocele

Testes, scrotum, pampiniform venous plexus

Hydrocele- enlarged scrotum

Varicocele- “bag of worms”







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