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Home , Internal iliac artery, Internal pudendal artery, Middle rectal artery, Perineal artery, Superior gluteal artery, Vaginal artery

International Journal of Anatomy and Research, Int J Anat Res 2014, Vol 2(2):363-68. ISSN 2321- 4287 Original Article STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC Pavan P Havaldar *1, Sameen Taz 2, Angadi A.V 3, Shaik Hussain Saheb 4. *1,4 Assistant Professors Department of Anatomy, JJM Medical College, Davangere, Karnataka, India. 2 Assistant Professors Department of Anatomy, Sri Devaraj Urs Medical College, Kolar, Karnataka, India. 3 Professor & Head, Department of Anatomy, SSIMS & RC, Davangere, Karnataka, India. ABSTRACT Background: The is the chief pelvic artery. It supplies to the all pelvic viscera, musculoskeletal part of the . The branches of the anterior trunk of the internal iliac artery are the superior and inferior vesical, middle rectal, vaginal, obturator, uterine, internal pudendal and inferior gluteal. Knowledge of internal iliac artery is very helpful in pelvic surgery practice. Methods: 50 adult human pelvic halves were procured from embalmed cadavers of J.J.M. Medical College and S.S.I.M.S & R.C, Davangere, Karnataka, India for the study. Results: took origin from anterior division in 42 specimens (84%), most frequently with in 32 specimens (64%) and was found to be absent in 8 specimens (16%). The took origin most frequently from the anterior division of Internal iliac artery in 36 specimens (72%), from posterior division in 9 specimens (18%), from external iliac artery in 1 specimen (2%) and from inferior epigastric artery in 3 specimens (6%). The superior vesical artery, inferior vesical artery, uterine artery, and were found to be constant in their origin and course. Conclusions : The branches anterior division of internal iliac artery shows multiple variations, knowledge about these variation are helpful in pelvic surgeries. KEYWORDS: Middle rectal, Internal pudendal artery, obturator artery, inferior vesicle artery. Address for Correspondence: Dr. Pavan P Havaldar, Assistant Professor of Anatomy, JJM Medical College, Davangere -577004. India.

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Received: 17 April 2014 Peer Review: 17 April 2014 Published (O):31 May 2014 Accepted: 12 May 2014 Published (P):30 June 2014

INTRODUCTION In general, pursue the shortest and the where it divides into an anterior trunk, which most direct course in order to reach their continues in the same line towards the ischial objective and that this course is partly spine and a posterior trunk, which passes back determined by mechanical convenience. The to the greater sciatic foramen. The branches of angle at which branches leave a main arterial the anterior trunk of the internal iliac artery are stem certainly depends to a considerable extent the superior and inferior vesical, middle rectal, on haemodynamic factors. Each internal iliac vaginal, obturator, uterine, internal pudendal artery, approximately 4 cm long, begins at and inferior gluteal[1]. the common iliac bifurcation, level with the According to Braithwaite JL the obturator artery lumbosacral intervertebral disc and anterior to is more variable and arises as a direct branch the sacroiliac joint. It descends posteriorly to the from the anterior division of internal iliac artery superior margin of the greater sciatic foramen Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 363 Pavan P Havaldar, Sameen Taz, Angadi A.V, Shaik Hussain Saheb. STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC ARTERY. in 41.4% of instances, from theinferior epigastric pubis. These pubic branches anastomose and artery in 19.5%, from the superior gluteal artery the anastomotic channel is commonly (33%) so in 10%,from the inferior gluteal-internal large that the obturator artery derives its pudendal trunk in 10% and by a double originin from the inferior epigastric artery. This is known 6.4%. In only 23% of instances is a similar origin as an “accessory obturator artery”[6]. noted on both sides[2]. The obturator artery gives off a small branch to According to Lipschutz B Probably, no artery in the periosteum on the back of the pubic bone, the human body of proportionate size has so which anastomoses with the pubic branch of the voluminous a literature as the obturator artery. inferior epigastric artery. In over a third of cases It has been the subject ofrepeated anatomical this anastomotic connection opens up and no research. Middle rectal artery is not constant. It obturator artery arises from the internal iliac is present in only 72 per cent of the subjects artery. Such replacement by the branch from the observed. It varies in its calibre and origin.The inferior epigastric artery is named the “abnormal middle rectal artery arises most frequently as a obturator artery”. The abnormal artery is present branch of the internal pudendal artery. This in a third of cases, when present it lies medial or origin occurs in 54 per cent of the cases lateral to the neck of the femoral hernia in a observed[3]. proportion of 1 to 10. That is to say, it is found The vaginal artery passes medially from the on the free edge of the lacunar ligament in about internal iliac and anastomose freely with 3% (1 in 30) of individuals, the same incidence descending branches of the uterine artery on as the thyroideaima artery. The middle rectal each side, to form two somewhat irregular artery is ‘badly named’. It is characterized by arterial channels, the azygos arteries in the three features: (1) It is often absent, especially midline, on the anterior and posterior aspects in the female; (2) very little of its blood goes to of the . An inferior vesical artery supplies the and that only to the muscle coats the fundus of the bladder, the , seminal there of and (3) most of its blood goes to the vesicles, and the lower end of prostate. The vaginal artery, usually a separate [4]. branch of the internal iliac artery, nevertheless often branches from the uterine artery. It In between 20 and 30% of subjects the place of supplies the very vascular walls of the upper the obturator artery is taken by an enlarged part of the vagina[7]. gives pubic branch of the inferior epigastric artery. This a long slender branch which runs on the surface branch descends almost vertically to the upper of the or in its substance called as part of the obturator foramen. The artery usually the ‘companion artery of the sciatic nerve’. The lies in contact with the external iliac and on inferior gluteal artery may, as in the foetus, the lateral side of the femoral ring; in such cases constitute the main artery of the lower limb and it would not be endangered in the operation for become continuous with the popliteal artery, strangulated femoral hernia. Occasionally, probably the normal companion artery of the however, it curves along the free margin of the sciatic nerve represents, this original vessel[8]. lacunar ligament, and if in such circumstances a femoral hernia occurred, the vessel would Bergman has reported that, internal iliac artery almost completely encircle, and might constrict, may be longer or shorter than usual. The the neck of the hernial sac; moreover, it would branches may arise without the artery dividing be in great danger of being wounded if an into anterior and posterior division. Branches of operation were performed for strangulation. the anterior and posterior divisions may Occasionally, some of the branches of the exchange origins[9]. Variations of branches of internal pudendal are supplied by an additional the anterior division as follows: vessel called the accessory pudendal, which Superior vesical artery : The number of superior generally arises from the internal pudendal vesicals varies from one to four. They commonly artery before its exit from the greater sciatic arise from the , but were also foramen[5]. The obturator and inferior epigastric found arising from the uterine (6 of 66 sides), arteries both supply branches to the back of the obturator (6 of 132 sides) and a large anastomosis Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 364 Pavan P Havaldar, Sameen Taz, Angadi A.V, Shaik Hussain Saheb. STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC ARTERY. between the superior and inferior vescial in western population. Although similar to the arteries was found in 60 of 70 specimens. Pick et al’s findings, observation of incidence of Inferior vesical artery: Anastomoses between origin of left obturator artery is only 0.5% (one the inferior vesical and uterine arteries were out of 316 ). Further the exact site of found in 60 of 70 specimens. origin has been documented in this study, which is at a distance of 8mm distal to the point of Middle rectal artery: This artery is occasionally bifurcation of the internal iliac artery. This rare absent. It usually arises from the internal iliac; abnormality in Indian population may be due to however, it has been reported as arising from different set of environmental or genetic factors. the inferior vesical or internal pudendal. Thus influencing the development of pelvic Vaginal artery: This artery usually arises from the vessels differently[11]. uterine artery, sometimes as several branches In cases of obstruction of the anterior division and sometimes from the internal iliac in common of internal iliac artery due to any cause, there with the uterine artery. The vaginal artery may will be sparing of obturator artery and its also arise from the middle rectal or superior branches especially the branch to the head of vesical artery. femur. The parietal branches of obturator artery Obturator artery: This artery is variable in origin. are important collaterals in aortoiliac and It may arise from the common iliac, anterior femoral arterial occlusive diseases. The division of the internal iliac (41.4%), inferior increased length of the left obturator artery, epigastric (25% based on observations in 4044 owing to the origin from the posterior division bodies), superior gluteal (10%), inferior gluteal- of internal iliac, may have an additional internal pudendal trunk (10%), inferior gluteal advantage while grafting[12]. (4.7%), internal pudendal (3.8%) or external iliac In study of Kawanishi Y et al, examination of (1.1%). The obturator has also been found arising 290 units of internal iliac arteries (IIA) in 145 from the adjacent to its profunda patients showing repeated incomplete erectile branch. In only 23% of cases is a similar origin response to intracavernosal injections with found on both sides of the body. prostaglandin (E1) was done. The pelvic arterial Uterine artery: The uterine artery usually arises arrangement, evaluated by three dimensional from the internal iliac but may arise in common computer tomographic angiography, was with the vaginal artery or middle rectal artery. classified anatomically into five types as follows: The artery may be doubled or composed of Type 1 (normal or basic type): in which the multiple parts. internal pudendal artery (IPA) originates from Internal pudendal artery : This artery may arise the anterior trunk at the level between the in common with obturator or the umbilical. It lineaterminalis and major ischial notch. may end as a , with the artery to Type 2: the IPA originates from the anterior the penis arising from the internal iliac. trunk of the IIA at the level of the major ischial Inferior gluteal artery: This artery may form a notch or more distally. common trunk with the superior gluteal[9]. Type 3: the IPA originates directly from the IIA According to Holub Z et al study ,Laparoscopic at the level proximal to the linea terminalis. dissection of the uterine artery close to the origin Type 4: the IPA originates together with the of the uterine artery can be carried out safely in superior and inferior gluteal artery within 1 cm the most frequent types of surgicalclassification. of each other and The meticulous dissection of the uterine artery Type 5: the penile blood supply is dependent on in cases in which the uterine artery does not arteries other than the IPA, such as the obturator arise typically from an unobliterated segment of artery. the internal iliac artery was recommended[10]. Among the 290 units, eight could not be Pick et al, have documented that the obturator classified due to poor image quality. There was artery arising from the posterior division of the no statistically significant difference in blood internal iliac artery can occur in 3.28% of cases Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 365 Pavan P Havaldar, Sameen Taz, Angadi A.V, Shaik Hussain Saheb. STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC ARTERY. flow parameters among the types of IIAs, but considerable variation in its origin. It took origin there was a statistically significant difference in most frequently from the anterior division of the IPA type at the age of onset of Erectile internal iliac artery in 36specimens (72%). Out Dysfunction (ED). Type I (153 units or 53%) of which, directly from anterior division in 20 anatomy, was more common in patients who specimens (40%), with ilio-lumbar artery in 5 developed ED at an advanced age. Types 2, 3 and specimens (10%), with inferior gluteal artery in 4 were more common in patients with onset of 3 specimens (6%), with inferior vesical artery in ED at an early age. Compared with patients with 2 specimens (4%), with middle rectal artery in 1 the common type of IIAs bilaterally, patients with specimen (2%), with internal pudendal artery in any of the variations bilaterally are at risk of early 4 specimens (8%) and with uterine artery in 1 onset of ED. Congenital factors might contribute specimen (2%). to the development of ED. If a man has bilateral FiG. 1: Internal iliac artery and its branches. variation from the common type (type 1), he might develop ED approximately 10 years earlier than those who are identical in every way except for their IPA (type 1) arrangements[13]. Anterior division internal iliac artery shows more variations in its branches and having more clinical importance because of its more clinical importance we have undertaken this work which is very helpful in pelvic surgery practice. MATERIALS AND METHODS 50 formalin fixed adult human pelvic halves were procured from the Department of Anatomy, Table No. 1: Analysis of Figure 1.

J.J.M. Medical College and S.S.Institute of Medi- Length of Sex Side Origin Level Of division cal Sciences and Research Centre, Davangere. the IIA 2cm above greater Male Right Between L4 & L5 6cm Specimens were collected during routine dissec- sciatic foramen tion practicals conducted by the Department of BRANCHES FROM THE COMMON TRUNK : NIL Anatomy, J.J.M. Medical College and S.S.Institute BRANCHES FROM DIVISIONS : of Medical Sciences and Research Centre, I) ANTERIOR DIVISION Davangere. A horizontal section through the 1) Obliterated umbilical artery Present - normal 2) Superior vesical artery Present - normal at the fourth lumbar vertebral level 3) Obturator artery Present - normal was taken. The pelvic specimen thus obtained 4) Inferior vesical artery Present - normal was divided into two equal halves by cutting 5) Middle rectal artery Present through the pubic symphysis, the and 6) Internal pudendal artery Present 7) Inferior gluteal artery Present - normal coccyx. The level of origin of internal iliac artery II) POSTERIOR DIVISION was noted. The individual branches (parietal, 1) Ilio-lumbar artery Present - normal visceral) arising from the anterior and posterior 2) Superior gluteal artery Present - normal divisions were dissected upto their terminations 3) Lateral sacral artery Present - normal VARIATIONS : Length is long. Internal pudendal artery and middle rectal artery - inside the pelvis. common trunk from anterior division. RESULTS The obturator artery took origin from the The level of division of internal iliac artery took posterior division of internal iliac artery in 9 place above the greater sciatic foramen in 34 specimens (18%), from external iliac artery in 1 specimens (68%), at the upper border of greater specimen (2%), from inferior epigastric artery in sciatic foramen in 7 specimens (14%), and below 3 specimens (6%) and was found to be absent in the upper border of greater sciatic foramen in 9 1 specimen (2%). specimens (18%). superior vesical artery were Out of 33 specimens, the inferior vesical artery constant in their origin and course in all the took origin from anterior division, alone in 14 specimens. The obturator artery presents specimens (42%), along with internal pudendal Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 366 Pavan P Havaldar, Sameen Taz, Angadi A.V, Shaik Hussain Saheb. STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC ARTERY. artery in 9 specimens (28%), with obturator specimens (6%) and with inferior vesical artery artery in 4 specimens (12%), with middle rectal in 4 specimens (8%). It made its exit from the artery in 2 specimens (6%) and double inferior pelvis through the greater sciatic foramen below vesical artery was found in 4 specimens (12%). the pyriformis muscle. Out of 50 specimens, middle rectal artery took The inferior gluteal artery took origin both from origin from anteriordivision, alone in 2 anterior and posterior divisions of internal iliac specimens(4%), with internal pudendal artery in artery. Anterior division gave rise to inferior 32specimens (64%), with inferior vesical artery gluteal artery directly in 11 specimens (22%), in 3 specimens (6%), with obturator artery in 1 with internal pudendal artery in 24 specimens specimen (2%), with inferior gluteal artery in 4 (48%), with ilio-lumbar artery in 1 specimen specimens (8%) and was found to be absent in 8 (2%), with obturator artery in 2 specimens (4%), specimens (16%). with lateral sacral artery in 2 specimens (4%) and Fig. 2: Internal iliac artery and its branches. double inferior gluteal artery was found in 2 specimens (4%). Posterior division gave rise to inferior gluteal artery directly in 2 specimens (4%), with obturator artery in 1 specimen (2%) and the inferior gluteal artery was found to be absent in 5 specimens (10%). It made its exit from the pelvis through the greater sciatic foramen below the pyriformis muscle. Out of 17 specimens, uterine artery took origin from anterior division directly in 15 specimens (88%) and double uterine artery was observed in 2 specimens (12%). Out of 17 specimens, vaginal artery took origin from anterior Table No. 2: Analysis of Figure 2. divisiondirectly in 15 specimens ( 8 8 % ) and with internal pudendal artery in 2 Length of the Level Of Sex Side Origin IIA division specimens (12%). 1cm below Female Right Between L5 & S1 5 cm upper border DISCUSSION & CONCLUSION of GSF In the present study, obturator artery took origin BRANCHES FROM THE COMMON TRUNK : NIL BRANCHES FROM DIVISIONS : directly from external iliac artery in I) ANTERIOR DIVISION 1specimen(2%). It correlate with the 1) Obliterated umbilical artery Present - normal observations of Bergman(1.1%)[9], Braithwaite 2) Superior vesical artery Present - normal JL(1.1%)[2], Jakubowicz and Czerniawska - 3) Obturator artery Present 4) Middle rectal artery Present Grzesinska(1.3%)[14]. This is a low incidence 5) Internal pudendal artery Present gives middle rectal artery when compared to the observations of 6) Inferior gluteal artery Present - normal Missankov (25%)[15]. 7) Uterine artery Present - normal 8) Vaginal artery Present - normal In the present study, obturator artery took origin II) POSTERIOR DIVISION from inferior epigastric artery in 3 specimens 1) Ilio-lumbar artery Present - from anterior division (6%). This is a low incidence when compared 2) Superior gluteal artery Present - normal with the observations of Bergman(25%)[9], 3) Lateral sacral artery Present - normal Braithwaite JL(19.5%)[2], Jakubowicz and VARIATIONS : Length is long. Obturator artery and ilio-lumbar common trunk from anterior division. Internal pudendal artery gives middle rectal artery. Czerniawska - Grzesinska(26%)[14]. Pai MM[16] observed the origin of obturator artery from The internal pudendal artery took origin from the external iliac artery and inferior epigastric artery anterior division, alone in 3 specimens (6%), in 19%. along with middle rectal artery in 15 specimens In the present study, middle rectal artery took (30%), with inferior gluteal artery in 25 origin from anterior division directly in 2 specimens (50%), with obturator artery in 3 specimens (4%), with internal pudendal artery Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 367 Pavan P Havaldar, Sameen Taz, Angadi A.V, Shaik Hussain Saheb. STUDY OF VARIATIONS IN ANTERIOR DIVISION OF INTERNAL ILIAC ARTERY. in 32 specimens (64%), with inferior vesical REFERENCES artery in 3 specimens (6%), with obturator artery in 1 specimen (2%) and with inferior [1]. Clark WEL. The tissues of the body. 5th ed., gluteal artery in 4 specimens (8%). Middle rectal Oxford-Clarendon Press;1965 .p.190-97. [2]. Braithwaite JL. 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Int J Morphol 2007;25(3):639-41. pudendal artery in 2 specimens (12%). [13]. Kawanishi Y, Muguruma H, Sugiyama H, Kagawa Bergman[9] states that, vaginal artery usually J, Tanimoto S,Yamanaka M, et al. Variations of arises from the uterine artery, sometimes as the internal pudendal artery as a congenital contributing factor to age at onset of erectile several branches, and sometimes from the dysfunction in Japanese. BJU Int 2008;102(2):259. internal iliac in common with the uterine artery. [14]. Jakubowicz M and Czarniawska-Grzesinska M. The vaginal artery may also arise from the middle Variability in origin and topography of the rectal or superior vesical artery. Middle rectal inferior epigastric and obturator arteries. Folia artery took origin from anterior division, most Morphol 1996;55:121-26. [15]. Missankov AA, Asvat R and Maoba KI. Variations frequently with internal pudendal artery and of the pubic vascular anastomoses in black South was found to be absent significantly. Superior A.V Angadi Taz, Sameen Havaldar, P Pavan Africans. Acta Anat 1996;155:212-14. : vesical artery, inferior vesical artery, uterine [16]. Pai MM, Krishnamurthy A, Prabhu LV, Pai MV, artery, vaginal artery, superior gluteal artery and Kumar SA and Hadimani GA. Variability in the lateral sacral artery were found to be fairly origin of the obturator artery. Clinics Basic Research 2009; 64(9): 897-901. constant in their origin and course. The [17]. Reddy S, Vollala VR and Rao M. Absence of knowledge of anterior division of internal iliac inferior gluteal artery : a rare observation. artery very important in pelvic surgeries. International Journal of Morphology 2007;25(1):95-98. Conflicts of Interests: None How to cite this article this cite to How 2014;2(2):363-68. Res Anat IntJ ILIACARTERY.

Int J Anat Res 2014, 2(2):363-68. ISSN 2321-4287 368