The Pelvic Cavity Consists of the Pelvic Inlet, Walls, and Floor and Contains Elements

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 Above piriformis: superior gluteal Greater sciatic notch, nerves and vessels Communication sacrotuberous and Below piriformis: inferior gluteal between pelvic Greater Sciatic sacrospinous vessels and nerves, sciatic nerve, cavity and lower Foramen ligaments, and the pudendal nerve, internal pudendal limb Ischial spine, it is vessels, posterior femoral cutaneous divided into 2 parts by nerves and the nerves to the obturator Above the pelvic the piriformis internus and quadrates femoris floor muscles Lesser sciatic notch, Communication Ischial spine, between gluteal Lesser Sciatic sacrospinous and Pudendal nerve and internal pudendal region and Foramen sacrotuberous vessels, tendon of obturator internus perineum ligaments Below pelvic floor Communication Obturator membrane, between pelvic Obturator obturator muscles, Obturator nerve and vessels cavity and Canal superior pubic ramus adductor region of thigh Gap between Communication pubic between pelvic symphysis and Dorsal vein of penis and clitoris cavity and perineal perineum membrane Separates the true from the false S1, alae of sacrum, pelvis, Pelvic Inlet arcuate line, linea communication terminalis, and pubic between the symphysis abdomen and the pelvic cavity Pubic symphysis, bodies and inferior rami of pubis, rami of Terminal parts of the urinary and GI Area enclosed is Pelvic Outlet ischium, and the Ischial tracts, and the vagina the perineum tuberosity, sacrotuberous ligament and coccyx

Male vs. Female Pelvis:

Characteristic Male Female Pelvic Inlet Heart-shaped, more distinct Circular, broader alae of sacrum promontory of sacrum Pubic Arch 50-60⁰ 80-85⁰ Ischial Spines Prominent Less prominent

Ligaments of the Skeletal Pelvis:

Ligament Connection Significance Ischial spine and margins of Create Sciatic Foramina and Sacrospinous sacrum and coccyx stabilize the sacrum by resisting upward tilting Ischial tuberosity to the PSIS and Create Sciatic Foramina and Sacrotuberous dorsolateral sacrum and coccyx stabilize the sacrum by resisting upward tilting Iliolumbar Transverse process of L5 to the Stabilize lumbosacral joints ilium Lumbosacral Transverse process of L5 to the Stabilize lumbosacral joints sacrum Anterior Sacro-iliac Runs anteriorly and inferiorly to Transmit forces from the lower the sacro-iliac joint limbs to the vertebral column Immediately posterosuperior to Largest, strongest sacro-iliac Interosseous Sacro-iliac the sacro-iliac joint and fills the ligament gap between the ilium and Transmit forces from the lower sacrum limbs to the vertebral column Posterior Sacro-iliac Covers the interosseous sacro- Transmit forces from the lower iliac ligament 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 L5, S1: Nerve to Lateral rotation of extended greater trochanter obturator internus hip, abduction of flexed hip Piriformis Anterior sacrum to greater L5, S1, S2 Lateral rotation of extended trochanter hip, abduction of flexed hip Posterior pubic bone, Inferior rectal Forms pelvic floor, supports obturator internus, Ischial branch of pudendal pelvic viscera, maintains spine to perineal nerve (S2-S4), and angle between rectum and Levator Ani membrane, perineal body, S4 ventral rami anal canal, reinforces around the anal canal, and external anal sphincter, acts anococcygeal ligament as vaginal sphincter Ischial spine and S3 and S4 anterior Forms pelvic floor, supports Coccygeus sacrospinous ligament to rami pelvic viscera, pulls coccyx coccyx and sacrum forward after defecation Inferior ramus of pubis Perineal Branches Compresses membranous External Urethral and walls of deep perineal of Pudendal Nerve urethra, relaxes during Sphincter pouch to membranous (S2-S4) micturition part of urethra Deep Transverse Ischial ramus to perineal Perineal Branches Perineal body of Pudendal Nerve Stabilizes perineal body (S2-S4) Ischiopubic ramus to its Perineal Branches Accessory sphincter of the Compressor Urethrae partner anterior to of Pudendal Nerve urethra urethra (S2-S4) Perineal body to its Perineal Branches Accessory sphincter of Sphincter partner, surrounding the of Pudendal Nerve urethra, may close the Urethrovaginalis urethral and vaginal (S2-S4) vagina openings Anal canal and aperture to Pudendal Nerve External Anal perineal body and (S2-S4) and Sphincter anococcygeal body branches directly Closes anal canal from S4 Ischial tuberosity and Pudendal Nerve Retain blood in penis or Ischiocavernosus ramus to crus of penis or (S2-S4) clitoris clitoris Perineal body to perineal Move blood into glans of membrane, corpus penis or clitoris, Bulbospongiosus cavernosum, bulb of Pudendal Nerve in men: remove residual vestibule, body of clitoris, (S2-S4) urine from urethra, pulsatile bulbospongiosus emission of semen Superficial Transverse Ischial tuberosity and Pudendal Nerve Stabilize the perineal body Perineal ramus to perineal body (S2-S4) 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

- 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

o 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.

o 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

o 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)

o 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).

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

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

o Normally filled with fat

Layers of Pelvic Floor: Deep to Superficial Structure Contents 1 Levator ani and Skeletal muscle coccygeus muscles 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 Erectile structures that form the penis or clitoris, bulbs of vestibule, glans Pouch clitoris, corpus spongiosum (proximal part is bulb of penis) skeletal muscles: ischiocavernosus, bulbospongiosus, superficial transverse perineal 6 Inferior (superficial) A membranous deep layer, Colles’ fascia , which is attached to the fascia 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 Inside scrotum, attached to Produce sperm cells in Tunica vaginalis, tunica Testis abdominal wall by spermatic cords seminiferous tubules albuginea, rete testis, mediastinum testis Stores sperm as they Head (efferent Epididymis Posterolateral side of testes mature before ductules), (true ejaculation epididymis) body and tail Scrotum, inguinal canal, bends medially around inferior epigastric Ductus a., crosses external iliac v. and a. , Transports sperm from Deferens pelvic cavity, crosses ureter, the tail of the Very long inferomedially along bladder, epididymis to the anterior to rectum, and enters ejaculatory duct duct of seminal vesicle Carries secretions of Ejaculatory ductus deferens and Penetrates prostate to Duct Through prostate gland seminal vesicles into enter urethra urethra From neck of bladder to the Conducts urine from 4 parts: preprostatic, Urethra external urethral opening in tip of bladder to outside of prostatic, membranous, penis body and spongy Copulatory organ Erectile tissue, Outside of body in pubic region, composed of 2 corpora Penis attached to the pubic arch and Conducts urine and cavernosa and a corpus anchored to the perineal semen spongiosus. As a bulb, membrane roots (crura), body , and glans Prostate Inferior to bladder, posterior to Contributes secretions Gland pubic symphysis, and anterior to to semen Surrounds urethra rectum Seminal Between bladder and rectum Contributes significant Accessory gland Vesicles secretions to semen Within deep perineal pouch, Contribute to Ducts open into spongy Bulbourethra lateral to membranous urethra lubrication of the urethra at the root of l Glands urethra and pre- the penis ejaculatory emissions

Female Reproductive System:

Structure Location Function Key Features Adjacent to lateral pelvic wall Suspended by Ovaries just inferior to pelvic inlet Produce egg cells mesovarium, connected to body wall by suspensory ligament and to uterus by ligament of ovary Enclosed by mesosalpinx, Project laterally from body of Have fimbriae, Uterine Tubes uterus, passing superiorly over Conduct egg cells infundibulum, and ampulla ovaries into body of uterus (usual site of fertilization) Consists of a fundus, body, Holds developing and cervix (canal forms Uterus Midline, between bladder and fetus during external and internal os, rectum pregnancy and it forms fornix at junction with vaginal wall) Extends from cervix, through Accepts semen pelvic floor, and perineum to deposited during Vagina the outside of the body intercourse, serves as Copulatory organ in (introitus). Between bladder and birth canal during women rectum. childbirth Beneath pubic symphysis and Composed of the glans the underside of the ischiopubic and the corpora Clitoris rami and anchored to the Great sensitivity cavernosa: has a root and perineal membrane a body Greater Located posterior to the bulbs of Produce lubricating Also called Bartholin’s Vestibular the vestibule on either side of secretions during Glands, found in Glands the vaginal opening arousal superficial perineal pouch Located on either side of the Para-urethral urethra, its ducts open into the Produce lubricating Also called Skene’s Glands Glands vestibule at the lateral margins secretions of the urethral opening

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. Runs from lateral pelvic walls to the uterus and covers the ovaries, Broad Ligament 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 L4-S3 Posterior thigh, and the Skin of foot (tibial part) Sciatic Inferior to piriformis leg and foot and lateral leg (common fibular part) Pudendal S2-S4 Skeletal muscles of Inferior to piriformis, perineum (external Skin of perineum, penis, (accompanied by through lesser sciatic urethral and anal and clitoris internal pudendal foramen sphincters, levator ani) vessels) L4-S1 Gluteus medius, gluteus Superior Gluteal Superior to piriformis minimus, and tensor fascia latae Inferior Gluteal L5-S2 Gluteus maximus Inferior to piriformis Nerve to Obturator L5-S2 Obturator internus and internus Superior gemellus Nerve to quadrates L4-S1 Quadrates femoris and femoris and inferior Inferior to piriformis inferior gemellus gemellus Posterior Femoral S1, S3 Skin of posterior thigh Cutaneous Inferior to piriformis S2, S3 Perforating Cutaneous Through sacrotuberous Skin over gluteal fold ligament Nerve to Piriformis L5, S1, S2 Piriformis Nerves to levator ani, Levator ani, coccygeus, Skin between anus and coccygeus, and external S4 and external sphincter coccyx anal sphincter Visceral: stimulate Visceral: visceral erection, modulate afferents from pelvic Pelvic Splanchnic mobility of GI system viscera and parts of Nerves S2-S4 distal to left colic distal colon. Pain from flexure, inhibits internal cervix and possibly from urethral sphincter bladder and proximal urethra Anococcygeal Nerves S4-Co Perianal skin

Dermatomes of the Perineum and Pelvic Floor

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.

o 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

o 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 o Vesicular

o 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

o Prostate

o Uterus

o 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 Lumbar nodes and pre-aortic nodes Uterine Tubes Pelvic Viscera, Gluteal region, deep areas of Internal Iliac Nodes Perineum Superficial tissues of Penis/Clitoris and Superficial Inguinal Nodes Scrotum/Labia Majora Glans Penis/Clitoris, Labia Minora, and lower Deep Inguinal Nodes and External Iliac Nodes Vagina

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 Bony rings of pelvis: Large hematoma, Cause significant Pelvic Fracture pelvic inlet and disruption/compression of bleeding obturator foramina urethra, bowel, nerves/vessels Fibrous and synovial Pain and discomfort in sacro- Can be caused by Sacro-iliac joints components of joint iliac region rheumatoid arthritis, IBD, and psoriasis Problems emptying bladder, Residual urine left in Urinary Stones Kidneys, Ureters, pain referred to pubic, flank, bladder may become bladder, urethra inguinal areas, and infected and alter pH lateral/medial thighs. Bladder, sometimes Other complications of urinary, Bladder Cancer rectum, uterus, GI, and/or reproductive tracts Can spread via internal prostate gland, and as the cancer spreads iliac lymph nodes lateral pelvic walls Bladder Infection Bladder, urethra Cystitis (inflammation of Women more bladder) susceptible because of short urethras Testicular Cancer testes Abnormal lumps felt in Occur in younger scrotum patients Prostate Hard, enlarged prostate, Prostate cancer is one Problems Prostate gland, urethra problems urinating due to of the most common compressed urethra cancers in men Uterus, uterine tubes, Reproductive malignancy, Pfannenstiel’s incision Hysterectomy ovaries endometriosis, excessive used (transverse bleeding Suprapubic) External hemorrhoids cause Pectinate line Internal and External pain, swelling (pudendal nerve distinguishes between Hemorrhoids rectal venous plexuses innervation), internal external and internal at or inside the anal hemorrhoids usually bleed, but hemorrhoids sphincter do not cause pain Caused by straining, obesity, sedentary life Abscess in ischio- Anal canal, ischio-anal Tear in anal canal leading to Infection may tract into anal fossae fossae infection pelvic cavity or laterally into the i-a fossae Straddling injury, urine collects Proximal spongy in scrotum and deep to urethra is most superficial abdominal fascia. In commonly ruptured Urethral Rupture Urethra, surrounding pelvic fractures the Most serious is related tissues/fascias prostatic/membranous urethra to disruption of may be torn and urine will puboprostatic ligaments collect inside the true pelvis Hydrocele, Testes, scrotum, Hydrocele- enlarged scrotum Varicocele pampiniform venous Varicocele- “bag of worms” plexus