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Clinical Anatomy of the Female Pelvis 1

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Clinical Anatomy of the Female Pelvis 1 Clinical Anatomy of the Female Pelvis 1 Clinical Anatomy of the Female Pelvis 1 Helga Fritsch CONTENTS 1.1 Introduction 1.1 Introduction 1 1.2 Morphological and The pelvic fl oor constitutes the caudal border of the Clinical Subdivision of the Female Pelvis 1 human’s visceral cavity. It is characterized by a com- plex morphology because different functional systems 1.3 Compartments 7 join here. A clear understanding of the pelvic anatomy 1.3.1 Posterior Compartment 7 1.3.1.1 Connective Tissue Structures 7 is crucial for the diagnosis of female pelvic diseases, for 1.3.1.2 Muscles 10 female pelvic surgery as well as for fundamental mech- 1.3.1.3 Reinterpreted Anatomy and anisms of urogenital dysfunction and treatment. Clinical Relevance 12 Modern imaging techniques are used for the diag- 1.3.1.4 Important Vessels, Nerves and Lymphatics of the Posterior Compartment: 13 nosis of pelvic fl oor or sphincter disorders. Further- 1.3.2 Anterior Compartment 14 more, they are employed to determine the extent of 1.3.2.1 Connective Tissue Structures 14 pelvic diseases and the staging of pelvic tumors. In 1.3.2.2 Muscles 15 order to be able to recognize the structures seen on 1.3.2.3 Reinterpreted Anatomy and CT and MRI as well as on dynamic MRI, a detailed Clinical Relevance 16 1.3.2.4 Important Vessels, Nerves and Lymphatics knowledge of the relationship of the anatomical enti- of the Anterior Compartment: 16 ties within the pelvic anatomy is required. 1.3.3 Middle Compartment 17 The Terminologia Anatomica [15] contains a mix- 1.3.3.1 Connective Tissue Structures 17 ture of old and new terms describing the different 1.3.3.2 Muscles 17 structures of the pelvis. Throughout this chapter the 1.3.3.3 Reinterpreted Anatomy and Clinical Relevance 17 actual anatomical terms are used and compared with 1.3.3.4 Important Vessels, Nerves and Lymphatics clinical terms. Furthermore, they are defi ned and il- of the Middle Compartment: 20 lustrated (see Table 1.1). 1.4 Perineal Body 20 1.4.1 Connective Tissue Structures and Muscles in the Female 20 1.4.2 Reinterpreted Anatomy and Clinical Relevance 21 1.2 Morphological and References 23 Clinical Subdivision of the Female Pelvis This chapter is dedicated to my friend Harald The anatomy of the female pelvis and perineum Hötzinger who was an excellent radiologist shows a lack of conceptual clarity. These regions are and a good co-worker. best understood when they are clearly described and subdivided according to functional and clinical re- quirements: The actual clinical subdivision discerns H. Fritsch, MD an anterior, a middle and a posterior compartment. Professor, Division of Clinical and Functional Anatomy, Department of Anatomy, Histology and Embryology, Whereas an anterior and posterior compartment may Medical University of Innsbruck, Müllerstrasse 59, 6020 Inns- be found in the male as well as in the female, a middle bruck, Austria compartment can only be found in the latter. The 2 H. Fritsch Table 1.1. Box of terms and defi nitions Term Figure Terminologia Anatom- Clinical Defi nition Renaming Exis- ica (TA) term (accord- tence ing to our English Latin results) 1. Anococcy- Corpus – TA: The term corpus, rather Not + Anococcy- geal body; anococ- than ligamentum, is used in necessary geal body anococcy- cygeum; TA because it is a stratifi ed geal liga- corpus non-ligamentous structure in ment anococ- which fl eshy muscle attach- cygeum ments underlie a tendon 2. Perineal Corpus – TA: The perineal body is Though + Perineal body perineale; fi bromuscular rather than tendinous, body centrum tendinous and quite unlike not neces- perinei the centrum tendineum of the sary diaphragm Our option: The perineal body itself is tendinous, nev- ertheless it cannot be com- pared with the fl at centrum tendineum of the diaphragm 3. Perineal Mem- – Dense connective tissue Not + Perineal membrane brana between external urethral necessary membrane perinea sphincter (and transverse perineal muscle in male) and pubic bone 4. Rectum Rectum Ano rec- Our option: The clinical term Necessary + Anorectum and anal et canalis tum includes both, the rectum and to pick up canal analis the anal canal, not taking into in TA account that they are of dif- ferent origin 5. – – – Our option: Small space be- Necessary + Presacral tween presacral fascia and to pick up (sub)com- sacral and coccygeal vertebrae in TA part ment containing vessels 6. Presacral Fascia Waldeyer’s Caudal part of the parietal + Presacral fascia presacra- fascia (?) pelvic fascia fascia lis Clinical Anatomy of the Female Pelvis 3 Term Figure Terminologia Anatom- Clinical Defi nition Renaming Exis- ica (TA) term (accord- tence ing to our English Latin results) 7. ––Mesorec-Our option: Compartment Necessary + Perirectal tum fi lled by the rectal adventitia to pick up compart- including nerves, vessels, in TA ment lymph nodes 8. ––Waldeyer’s Our option: Outer connective Necessary + Rectal fascia (?) tissue lamella of the rectal to pick up fascia or adventitia, bordering the in TA “Grenz- perirectal compartment lamelle” 9. Inferior Plexus Pelvic Autonomic nerve plexus Exclusive- + Inferior hypogas- hypo- plexus within the recto-uterine or ly into the hypogastric tric plexus; gastricus recto-vesical fold old and plexus pelvic inferior; clinical plexus plexus term: pelvicus pelvic plexus 10. Uterosacral Li. rec- – Dense connective tissue run- Exclu- + Uterosacral ligament touteri- ning from the edges of the sively into ligament or recto- num cervix uteri to the region of the utero- uterine the sacrospinous ligament, sacral ligament then ascending and joining ligament the pelvic parietal fascia 11. Rec- Rectovagi- Fascia – Our option: Plate of dense Exclu- + tovaginal nal fascia; recto- connective tissue, smooth sively into fascia rectovagi- vaginalis; muscle cells and nerves, local- the term nal septum septum ly arranged between rectum rectovagi- (female) rectovagi- and vagina nal/rec- nale togenital septum 4 H. Fritsch Table 1.1. Box of terms and defi nitions (Continued) Term Figure Terminologia Anatom- Clinical Defi nition Renaming Exis- ica (TA) term (accord- tence ing to our English Latin results) 12. Anal – – – Includes all muscle layers Necessary + sphincter of the anal canal: internal to pick up complex (smooth) sphincter, longitudi- in TA nal (smooth) muscle, external (striated) sphincter 13. Pu- Medial Lig. – Most confusing structure! Exclu- + bovesical pubovesical mediale Our option: there is only sively into ligament ligament, pubovesi- one structure running from the term pubovesi- cale, m. the pubic bone to the vesical pubovesi- calis, lateral pubovesi- neck. It mainly consists of cal muscle pubovesical calis, lig. smooth muscle cells inter- ligament laterale mingled with strands of dense pubovesi- connective tissue calis 14. Levator Levator ani M. levator – Muscle that constitutes the + ani muscle ani main part of the pelvic dia- phragm and is composed of the Mm. pubococcygei, ilio- coccygei, and puborectales of each side 15. Tendi- Tendinous Arcus – Our option: This structure + nous arch arch of tendineus originates from the pubic of the pel- the pelvic fasciae bone laterally, it is connected vic fascia fascia pelvis with the superior fascia of the pelvic diaphragm “white line” laterally and with the pubo- vesical ligament medially. It may falsely be called Lig. laterale puboprostaticum or Lig. laterale pubovesicale Clinical Anatomy of the Female Pelvis 5 Term Figure Terminologia Anatom- Clinical Defi nition Renaming Exis- ica (TA) term (accord- tence ing to our English Latin results) 16. Para- – – – Our option: Fat pad at the Necessary + visceral fat lateral side of the bladder that to pick up pad develops in situ. Functionally in TA necessary for the movements of bladder 17. Broad Broad liga- Lig. latum – Peritoneal fold between the + ligament ment of the uteri uterus and the lateral wall of uterus the pelvis 18. Recto- Recto-uter- Plica – Peritoneal fold passing from + uterine fold ine fold recto- the cervix uteri on each side uterina of the rectum to the posterior pelvic wall 19. Recto- Recto-uter- Excavatio Space of Deep peritoneal pouch situat- + uterine ine pouch rec- Douglas ed between the recto-uterine pouch touterina folds of each side 20. Vesico- Vesico- Plica vesi- – Peritoneal fold between blad- + uterine fold uterine fold couterina der and uterus on each side 21. Vesico- Vesico- Excavatio – Slight peritoneal pouch be- + uterine uterine vesi- tween the vesico-uterine folds pouch pouch couterina of each side 22. Trans- Transverse Lig. trans- Cardinal Connective tissue structures Necessary 0 verse cervical versum ligament that should extend from the to omit cervical ligament, cervicis, side of the cervix to the lat- ligament cardinal lig. cardi- eral pelvic wall or cardinal ligament nale Our option: The cardinal liga- ligament ment does not exist 23. Meso- Mesosal- Mesosal- Identical Double fold of peritoneum at + salpinx pinx pinx the upper margin of the broad ligament 24. Mes- Mesovar- Mesovar- Identical Double fold of peritoneum + ovarium ium ium attached at the dorsal portion of the broad ligament 25. Meso- Mesome- Mesome- – So-called meso of the uterus, According + metrium trium trium greatest portion of broad to Höckel is mor pho- ligament genetic unit of cer vix and pro xi- mal vagina. Necessary to redefi ne 6 H. Fritsch term “compartment” is routinely used by radiologists ologists and with the course of the vessels and nerves. and all surgeons operating on the pelvic fl oor. This An “extra” middle compartment that is characteristic term is not identical with the term “space”. According for the female is presented in detail at the end of this to former literature a lot of spaces are supposed to chapter. be arranged in the region of the pelvis: retrorectal, What is our common knowledge about the bor- pararectal, rectoprostatic, rectovaginal, retropubic, ders of the different pelvic compartments and what paravesical, etc.
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