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Pelvic Anatomyanatomy PelvicPelvic AnatomyAnatomy RobertRobert E.E. Gutman,Gutman, MDMD ObjectivesObjectives UnderstandUnderstand pelvicpelvic anatomyanatomy Organs and structures of the female pelvis Vascular Supply Neurologic supply Pelvic and retroperitoneal contents and spaces Bony structures Connective tissue (fascia, ligaments) Pelvic floor and abdominal musculature DescribeDescribe functionalfunctional anatomyanatomy andand relevantrelevant pathophysiologypathophysiology Pelvic support Urinary continence Fecal continence AbdominalAbdominal WallWall RectusRectus FasciaFascia LayersLayers WhatWhat areare thethe layerslayers ofof thethe rectusrectus fasciafascia AboveAbove thethe arcuatearcuate line?line? BelowBelow thethe arcuatearcuate line?line? MedianMedial umbilicalumbilical fold Lateralligaments umbilical & folds folds BonyBony AnatomyAnatomy andand LigamentsLigaments BonyBony PelvisPelvis TheThe bonybony pelvispelvis isis comprisedcomprised ofof 22 innominateinnominate bones,bones, thethe sacrum,sacrum, andand thethe coccyx.coccyx. WhatWhat 33 piecespieces fusefuse toto makemake thethe InnominateInnominate bone?bone? PubisPubis IschiumIschium IliumIlium ClinicalClinical PelvimetryPelvimetry WhichWhich measurementsmeasurements thatthat cancan bebe mademade onon exam?exam? InletInlet DiagonalDiagonal ConjugateConjugate MidplaneMidplane InterspinousInterspinous diameterdiameter OutletOutlet TransverseTransverse diameterdiameter ((intertuberousintertuberous)) andand APAP diameterdiameter ((symphysissymphysis toto coccyx)coccyx) RetrospectiveRetrospective CaseCase ControlControl StudyStudy MRIMRI PelvimetryPelvimetry PelvicPelvic MRIMRI 19981998 –– 20022002 MedicalMedical recordrecord reviewreview PelvicPelvic examinationexamination PelvicPelvic floorfloor dysfunctiondysfunction symptomssymptoms 9898 totaltotal womenwomen 5959 withwith pelvicpelvic floorfloor disordersdisorders 3939 withoutwithout pelvicpelvic floorfloor disordersdisorders Handa VL, et al. Architectural Differences in the Bony Pelvis of Women With and Without Pelvic Floor Disorders. Obstet Gynecol 2003;102:1283-90. RetrospectiveRetrospective CaseCase ControlControl StudyStudy MRIMRI PelvimetryPelvimetry WomenWomen withwith pelvicpelvic floorfloor disorders:disorders: Wider transverse inlet Wider intertuberous diameter Wider interspinous diameter Greater sacrococcygeal length Deeper sacral curvature Narrower AP outlet AfterAfter controllingcontrolling forfor age,age, racerace andand parityparity Wider transverse inlet (OR 3.4, p = .006) Shorter obstetrical conjugate (OR 0.2, p = .026) Wider interspinous diameter (OR 2.8, p = .069) PelvicPelvic VasculatureVasculature OvarianOvarian arteriesarteries originateoriginate from:from: Aorta OvarianOvarian veinsveins returnreturn to:to: IVC and Left renal vein UreterUreter Below kidney, lateral/medial to ovarian A? Lateral Near pelvic brim, lateral/medial to ovarian A? Medial Over or under the uterine vessels? Under BranchesBranches ofof thethe InternalInternal IliacIliac ArteryArtery AnteriorAnterior DivisionDivision PosteriorPosterior DivisionDivision ObturatorObturator IliolumbarIliolumbar ObliteratedObliterated umbilicalumbilical LateralLateral sacralsacral SupSup && InfInf vesicalvesical SuperiorSuperior glutealgluteal UterineUterine VaginalVaginal MiddleMiddle rectalrectal PudendalPudendal InferiorInferior glutealgluteal WhatWhat isis thethe collateralcollateral circulationcirculation afterafter hypogastrichypogastric arteryartery ligation?ligation? PudendalPudendal ArteryArtery BloodBlood SupplySupply toto thethe UreterUreter BloodBlood SupplySupply toto Colon/RectumColon/Rectum NervesNerves ofof thethe PelvisPelvis InnervationInnervation toto LevatorLevator AniAni 1212 freshfresh--frozenfrozen femalefemale cadaverscadavers EachEach innervatedinnervated S3S3--55 S4 alone 30% S3-4 40% S4-5 30% NoNo pudendalpudendal nervenerve supplysupply identifiedidentified SimilarSimilar findingsfindings inin ratrat studiesstudies Barber MD, et al. Innervation of the female levator ani muscles. Am J Obstet Gynecol 2002;187:64-71. Bremer RE, Barber MD, et al. Innervation of the Levator Ani and Coccygeus Muscles of the Female Rat. Anat Rec Part A 2003;275A:1031-41. NerveNerve InjuryInjury WhatWhat nervenerve cancan bebe injuredinjured with:with: PlacementPlacement ofof deepdeep laterallateral wallwall retractorsretractors onon PsoasPsoas atat laparotomylaparotomy?? HyperflexionHyperflexion ofof thethe hipships inin lithotomylithotomy positionposition oror tighttight underwear?underwear? LeaningLeaning onon thethe backback ofof thethe legslegs duringduring vaginalvaginal surgerysurgery oror sacrospinoussacrospinous ligamentligament fixation?fixation? MakingMaking aa pfannensteilpfannensteil incision?incision? PelvicPelvic lymphlymph nodenode dissection?dissection? IlioinguinalIlioinguinal andand IliohypogastricIliohypogastric NerveNerve InjuriesInjuries Mapping in 11 fresh frozen cadavers Ilioinguinal nerve Entered 3.1 ± 1.5 cm medial, 3.7 ± 1.5 cm inferior to ASIS Terminated 2.7 ± 0.9 cm lateral to midline, 1.7 ± 0.9 cm superior to pubic symphysis Iliohypogastric nerve Entered 2.1 ± 1.8 cm medial and 0.9 ± 2.8 cm lateral to ASIS Terminated 3.7 ± 2.7 cm lateral to midline and 5.2 ± 2.6 cm superior to pubic symphysis Whiteside JL, et al. Anatomy of ilioinguinal and iliohypogastric nerves in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol. 2003;189:1574-8. NerveNerve InjuryInjury DuringDuring UterosacralUterosacral LigamentLigament SuspensionSuspension Siddique SA, et al. Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:642-5. NameName thethe 77 SurgicalSurgical andand AnatomicAnatomic SpacesSpaces PrevesicalPrevesical (space(space ofof Retzius)Retzius) VesicovaginalVesicovaginal andand vesicocervicalvesicocervical ParavesicalParavesical RectovaginalRectovaginal PararectalPararectal RetrorectalRetrorectal PresacralPresacral ComponentsComponents ofof PelvicPelvic SupportSupport BonyBony pelvispelvis EndopelvicEndopelvic FasciaFascia (fibromuscular(fibromuscular layer)layer) PelvicPelvic diaphragmdiaphragm UrethralUrethral ClosureClosure PressurePressure 33 componentscomponents • RhabdosphincterRhabdosphincter •• CircularCircular smoothsmooth musclemuscle •• NonNon-- neuromuscularneuromuscular ––Vascular cushions ––Mucosa ––Connective tissue PelvicPelvic DiaphragmDiaphragm ComponentsComponents LevatorLevator aniani MusclesMuscles PuborectalisPuborectalis PubococcygeusPubococcygeus IliococcygeusIliococcygeus CoccygeusCoccygeus musclesmuscles AnalAnal ContinenceContinence MechanismMechanism ““EndopelvicEndopelvic FasciaFascia”” FibromuscularFibromuscular layerlayer FunctionallyFunctionally singlesingle sheetsheet ofof connectiveconnective tissuetissue LigamentousLigamentous condensationscondensations VasculatureVasculature NervesNerves LevelsLevels ofof SupportSupport LevelLevel II Uterosacral and cardinal ligaments Support uterus and vaginal apex LevelLevel IIII Lateral attachments of endopelvic fascia and vagina to arcus tendineus fascia pelvis Support bladder, vagina, and rectum LevelLevel IIIIII Perineal membrane and perineal body Support UVJ and perineum DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol.1992;166:1717-24. UterosacralUterosacral LigamentLigament 1515 femalefemale cadaverscadavers USLUSL attachesattaches toto S1S1--33 andand variablyvariably toto S4S4 LessLess vitalvital structuresstructures belowbelow intermediateintermediate portionportion MeanMean distancesdistances fromfrom USLUSL toto ureterureter Cervical 0.9 ± 0.4 cm Intermediate 2.3 ± 0.9 cm Sacral 4.1 ± 0.6 cm IschialIschial spinespine toto ureterureter 4.94.9 ±± 2.02.0 cmcm IschialIschial spinespine consistentlyconsistently beneathbeneath intermediateintermediate portionportion USLUSL tensiontension transmittedtransmitted toto ureterureter mostmost nearnear cervixcervix CervixCervix andand intermediateintermediate portionsportions strongeststrongest Buller JL et al. Uterosacral Ligament: Description of Anatomic Relationships to Optimize Surgical Safety. Obstet Gynecol 2001;97:873-9. MRIMRI VaginalVaginal ApexApex DistancesDistances Sup/Sup/InfInf Ant/PostAnt/Post Right/LeftRight/Left CervicalCervical 1.61.6 ±± 0.50.5 1.11.1 ±± 0.50.5 4.74.7 ±± 0.40.4 VaginalVaginal superiorsuperior anterioranterior medialmedial JunctionJunction toto IschialIschial SpineSpine PosteriorPosterior 5.35.3 ±± 0.80.8 1.01.0 ±± 1.01.0 FornixFornix toto inferiorinferior anterioranterior S2S2 Gutman RE et al. Anatomic Relationship Between the Vaginal Apex and the Bony Architecture of the Pelvis: a MRI Evaluation. Am J Obstet Gynecol 2005; Leffler KS et al. Attachment of the rectovaginal septum to the pelvic sidewall. Am J Obstet Gynecol 2001;185:41-3. PelvicPelvic DiaphragmDiaphragm FunctionsFunctions CloseClose genitalgenital hiatushiatus CreatesCreates levatorlevator plateplate LevatorsLevators TonedToned InterrelationshipInterrelationship ofof LigamentousLigamentous andand MuscularMuscular SupportSupport MuscularMuscular SupportSupport LongLong--termterm supportsupport ClosureClosure ofof genitalgenital hiatushiatus LevatorLevator plateplate LigamentousLigamentous supportsupport ShortShort--termterm supportsupport TetherTether visceraviscera duringduring relaxationrelaxation ofof pelvicpelvic diaphragm.diaphragm.
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