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Urogenital Triangle K.E. Byrd X620 2017 10-18-2017 HS 2017 MED-X620 Male & Female Perineum; Urogenital Triangle Kenneth E. Byrd, PhD [email protected] 274-3355 HS 2017 MED-X620 IUSOM Re-Introduction to the Perineum P&P_2_Male-Female Perineum; Urogenital Triangle 1 of 20 K.E. Byrd X620 2017 10-18-2017 UG Triangle DEFINED: - Deep “Space/Pouch” - Superficial “Space/Pouch” REMEMBER: “perineum” is diamond shaped- space (black line on LARGE figure represents that area. Pir Coc Obt.Int. LA 2 parts of UG Triangle: I. “Deep Space” (UGD) PS II. “Superficial Space” UGTriangle perineum UGD NOTE: UG Diaphragm (UGD aka deep pouch/space) is a structure found in Urogenital Triangle of the Perineum skin NO UGD in posterior Anal Region!!!! Pelvic Diaphragm vs. Perineum vs. UGD U P (Pelvic floor) (contains ext. genitalia) Perineum Membranous layer (perineal compartment) Subcutaneous perineal tissue (Colles’ fascia) Anterior view: frontal section through UG Triangle Skin P&P_2_Male-Female Perineum; Urogenital Triangle 2 of 20 K.E. Byrd X620 2017 10-18-2017 Nerve Supply Perineum Blood Supply Perineum Common Iliac Artery Internal iliac artery Pudendal N. (S2,3,4) Inf. Rectal Gluteal Region Perineal Post. Scrotal/Labial Superficial Perineal Dorsal artery penis/clitoris Nerves Arteries NOTE: Rectal aa. = Hemorrhoidal aa. Arteries of the Perineum (Labial artery) P&P_2_Male-Female Perineum; Urogenital Triangle 3 of 20 K.E. Byrd X620 2017 10-18-2017 Pudendal Nerve (VPR S2,3,4) BOTH GSE motor & GSA sensory…!!!!! Co = Coccygeus VPR S1,2,3,4,5 Co VPR S2,3,4 (Labial nn.) GSF Pudendal N. PS SSL ObF Nerve Ob.Int. Supply to Perineum (clitoris) (Labial nn.) P&P_2_Male-Female Perineum; Urogenital Triangle 4 of 20 K.E. Byrd X620 2017 10-18-2017 Perineum Boundaries – aa., vv.,& nn. Basic pattern same in both sexes (e.g. penile clitoral) Female UG Triangle P&P_2_Male-Female Perineum; Urogenital Triangle 5 of 20 K.E. Byrd X620 2017 10-18-2017 Sup. What is in the female “deep space/pouch”? Ant. O Post. U C V R B UGD UG Triangle Urethra Vagina Muscles within Female superficial perineal space 1. Ischiocavernosus 2.2. BulbospongiosusBulbospongiosus 3. Superficial Transverse Perineal (STP) X = Perineal X Body (Tendon) (critical in episiotomy!!!) P&P_2_Male-Female Perineum; Urogenital Triangle 6 of 20 K.E. Byrd X620 2017 10-18-2017 Urogenital Diaphragm (UGD) – Female - Four Muscles (skeletal) 1. External urethral sphincter (sphincter urethrae) 2. Deep transverse perineal Urogenital Diaphragm (UGD) – Female 3. Compressor urethrae 4. Sphincter uretho-vaginalis A. Superior Fascia – incomplete/missing (blotto!) B. Deep perineal pouch (space) – 4 muscles, nn., aa., vv. C. Inferior Fascia perineal membrane Sup. aka Membranous urethra Vagina Mu V Post. Ant. Deep perineal pouch (space) Inferior Fascia (perineal membrane) Inf. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469827/ Sup. Ant. * X Inf. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469827/ P&P_2_Male-Female Perineum; Urogenital Triangle 7 of 20 K.E. Byrd X620 2017 10-18-2017 Smooth musc. – involun. Detrusor ANS GVE nn. Smooth musc. – involun. Internal urethral sphincter (IUS) ANS GVE nn. * * Skeletal musc. – volun. * * *Pudendal n. Female Urethra • 2-6 cm long • wider than male Female UGD-Bladder Anatomical Relationships…..(for fun & profit) Sup. Sagittal view (aka sphincter urethrae membranaceae) Ant. Post. UGD U V Inf. Paraurethral (Skene’s) ducts usually open onto vestibule on either side of urethra; BUT occasionally open on posterior wall of urethra. P&P_2_Male-Female Perineum; Urogenital Triangle 8 of 20 K.E. Byrd X620 2017 10-18-2017 Inferior View: Superficial Perineum of Female Ant. Crus PS Ischiopubic ramus U V UGD 8 4 Post. Bartholin’s (aka Greater Vestibular) Glands Typically open into vagina at 8 o’clock & 4 o’clock positions Female Perineum I: – Deep Space I UG II ÷ NOTE: frontal section post. to urethra & through vagina Female Perineum I: – Deep Space Deep space = UGD •perineal muscles (4 skeletal muscles) •vagina (passes through) •urethra (membranous) – passes through •terminal branches of internal pudendal artery & vein •terminal branches of the pudendal nerve P&P_2_Male-Female Perineum; Urogenital Triangle 9 of 20 K.E. Byrd X620 2017 10-18-2017 Female Perineum II: – Superficial Space I UG II ÷ NOTE: frontal section post. to urethra & through vagina Female Perineum II. - Superficial Space – •perineal muscles (erectile) + superf. transverse perineal (STP) •external genitalia bulb of vestibule crura •greater vestibular glands (Bartholin’s) •terminal branches of internal pudendal artery & vein •terminal branches of the pudendal nerve Male UG Triangle P&P_2_Male-Female Perineum; Urogenital Triangle 10 of 20 K.E. Byrd X620 2017 10-18-2017 Sup. What is in the male “deep space/pouch”? Ant. Post. ♂ only two skeletal muscles in male UGD!!) * UG Diaphragm (UGD) Inf. fascia aka perineal membrane of UGD * = “incomplete/missing superior fascia of UGD Review of Male UG Fascial Layers 1 Perineal membrane Penile/Spongy Superf. Penile fascia Smooth muscle; ANS P&P_2_Male-Female Perineum; Urogenital Triangle 11 of 20 K.E. Byrd X620 2017 10-18-2017 Review of Male UG Fascial Layers 2 Urinary extravasation!!! Membranous urethra Deep penile Fascia (“Buck’s”) Penile/spongy urethra = bulb of penis If injury to bulb of the penis results in urethral injury tearing Buck's fascia, then extravasated blood and urine accumulates in the superficial perineal space. Such urine extravasation involving compromised Buck's fascia causes blood collection in the superficial pouch, resulting in a 'butterfly'-shaped region around the penis. Urogenital Diaphragm (UGD) – Male Urogenital Diaphragm (UGD) –Male - only Two Muscles (skeletal) A. Superior Fascia – incomplete/missing 1. External Urethral Sphincter (sphincter urethrae) B. Deep Perineal Pouch (space) – 2 muscles + nn. + aa., vv. 2. Deep Transverse Perineal C. Inferior Fascia = Perineal membrane 1 2 = Bulbourethral (Cowper’s) glands; located posterior and lateral to membranous urethra at bulb of penis, enclosed by transverse fibers of sphincter urethrae membranaceae muscle & empty into male spongy urethra! MU Post. Ant. UGD Inf. fascia (perineal membrane) Inf. P&P_2_Male-Female Perineum; Urogenital Triangle 12 of 20 K.E. Byrd X620 2017 10-18-2017 Mid-Sagittal View of Male UGD & Related Adnexa Sup. Ant. Post. ANS GVE Involuntary! aka UGD Pudendal GSE Voluntary! * Inf. = embedded in Deep Transverse * Perineal muscle fibers of UGD!!! Male Perineum I: - Deep Space (Ant. Recess of ischiorectal fossa!) Deep perineal space I UG Superficial perineal space II ÷ UGD is the Deep Space/Pouch!!!!!! NOTE: frontal section through prostate, urethra, penis bulb Male Perineum I: Deep space/pouch Deep space/pouch = UGD •perineal muscles (2 skeletal muscles) •urethra (membranous) – passes through UGD •bulbourethral glands (Cowper’s) •terminal branches of internal pudendal artery •terminal branches of the pudendal nerve P&P_2_Male-Female Perineum; Urogenital Triangle 13 of 20 K.E. Byrd X620 2017 10-18-2017 Male Perineum II: - Superficial Space (Ant. Recess of ischiorectal fossa!) Deep perineal space I Superficial UG perineal space II ÷ UGD is the Deep Space/Pouch!!!!!! NOTE: frontal section through prostate, urethra, penis bulb Male Perineum II. - Superficial space/pouch – •perineal muscles associated with…… •external genitalia - bulb of penis (urethra spongy/penile) - crura •terminal branches of internal pudendal artery •terminal branches of the pudendal nerve Female External Genitalia P&P_2_Male-Female Perineum; Urogenital Triangle 14 of 20 K.E. Byrd X620 2017 10-18-2017 What’s in the Female Female External Genitalia - Lithotomy Position Superficial “space/pouch”? Vestibule = region enclosed between labia minora Labia minora (“hood”) 1. Anterior (superiorly) – split Frenulum clitoris a. medial/lower folds = frenulum clitoris b. lateral/upper folds = fuse over ** clitoris 2. Posterior (inferiorly) – frenulum (aka fourchette) * * Openings in the vestibule – 1. Urethra 2. Paraurethral (Skene’s) glands* Fourchette 2. Vaginal 3. Greater Vestibular (Bartholin’s) glands (4 & 8 o’clock)* Vulva = clitoris and vestibular apparatus Hymen – covers the vaginal orifice in non-sexually active females (Dutch for gland) Muscles within Female Superficial Perineal Space 1. Ischiocavernosus 2. Bulbospongiosus X = Perineal body 3. Superficial aka Central Tendon transverse perineal Perineal body avoidance (STD) critical in episiotomy!!! X Mediolateral Episiotomies P&P_2_Male-Female Perineum; Urogenital Triangle 15 of 20 K.E. Byrd X620 2017 10-18-2017 Episiotomy is incision of the pudendum (portions of the vestibule). Note: Perineal Body/Central Tendon - Median or midline incision - Mediolateral incision L1 Ilioinguinal N. Mons Pubis Perineal Branch Post. Femoral Cutaneous N. Thigh X Ischial Spine: Injection Landmark for Pudendal N. (S2,3,4) P&P_2_Male-Female Perineum; Urogenital Triangle 16 of 20 K.E. Byrd X620 2017 10-18-2017 Pudendal Nerve Block Transvaginal technique showing the needle extended beyond the needle guard and passing through sacrospinous ligament to reach and infiltrate the pudendal nerve. Male External Genitalia P&P_2_Male-Female Perineum; Urogenital Triangle 17 of 20 K.E. Byrd X620 2017 10-18-2017 What’s in the Male superficial “space/pouch”? Glans Male External Genitalia Body of Penis Corpus Cavernosum Corpus PC PT Spongiosum Ischiopubic ramus Crus * = Inf. fascia of UGD aka Bulb Penis * X Perineal* Membrane IT IT Sympathetic stimulation maintains a tonic contractile state of the intimal cushion, smooth muscle lying in the
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