PelvicPelvic AnatomyAnatomy

RobertRobert E.E. Gutman,Gutman, MDMD ObjectivesObjectives

ƒƒ UnderstandUnderstand pelvicpelvic anatomyanatomy ƒ Organs and structures of the female pelvis ƒ Vascular Supply ƒ Neurologic supply ƒ Pelvic and retroperitoneal contents and spaces ƒ Bony structures ƒ Connective tissue (fascia, ligaments) ƒ Pelvic floor and abdominal musculature ƒƒ DescribeDescribe functionalfunctional anatomyanatomy andand relevantrelevant pathophysiologypathophysiology ƒ Pelvic support ƒ Urinary continence ƒ Fecal continence AbdominalAbdominal WallWall RectusRectus FasciaFascia LayersLayers

ƒƒ WhatWhat areare thethe layerslayers ofof thethe rectusrectus fasciafascia ƒƒ AboveAbove thethe arcuatearcuate line?line? ƒƒ BelowBelow thethe arcuatearcuate line?line? MedianMedial umbilicalumbilical fold Lateralligaments umbilical & folds folds BonyBony AnatomyAnatomy andand LigamentsLigaments BonyBony PelvisPelvis

ƒƒ 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? ƒƒ PubisPubis ƒƒ IschiumIschium ƒƒ IliumIlium

ClinicalClinical PelvimetryPelvimetry WhichWhich measurementsmeasurements thatthat cancan bebe mademade onon exam?exam?

ƒƒ InletInlet ƒƒ DiagonalDiagonal ConjugateConjugate ƒƒ MidplaneMidplane ƒƒ InterspinousInterspinous diameterdiameter ƒƒ OutletOutlet ƒƒ TransverseTransverse diameterdiameter ((intertuberousintertuberous)) andand APAP diameterdiameter ((symphysissymphysis toto coccyx)coccyx)

RetrospectiveRetrospective CaseCase ControlControl StudyStudy MRIMRI PelvimetryPelvimetry ƒƒ PelvicPelvic MRIMRI 19981998 –– 20022002 ƒƒ MedicalMedical recordrecord reviewreview ƒƒ PelvicPelvic examinationexamination ƒƒ PelvicPelvic floorfloor dysfunctiondysfunction symptomssymptoms ƒƒ 9898 totaltotal womenwomen ƒƒ 5959 withwith pelvicpelvic floorfloor disordersdisorders ƒƒ 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 ƒƒ WomenWomen withwith pelvicpelvic floorfloor disorders:disorders: ƒ Wider transverse inlet ƒ Wider intertuberous diameter ƒ Wider interspinous diameter ƒ Greater sacrococcygeal length ƒ Deeper sacral curvature ƒ Narrower AP outlet ƒƒ AfterAfter controllingcontrolling forfor age,age, racerace andand parityparity ƒ Wider transverse inlet (OR 3.4, p = .006) ƒ Shorter obstetrical conjugate (OR 0.2, p = .026) ƒ Wider interspinous diameter (OR 2.8, p = .069) PelvicPelvic VasculatureVasculature

ƒƒ OvarianOvarian arteriesarteries originateoriginate from:from: ƒ Aorta ƒƒ OvarianOvarian veinsveins returnreturn to:to: ƒ IVC and Left renal vein ƒƒ UreterUreter ƒ Below kidney, lateral/medial to ovarian A? ƒ Lateral ƒ Near pelvic brim, lateral/medial to ovarian A? ƒ Medial ƒ Over or under the uterine vessels? ƒ Under

BranchesBranches ofof thethe InternalInternal IliacIliac ArteryArtery

ƒƒ AnteriorAnterior DivisionDivision ƒƒ PosteriorPosterior DivisionDivision ƒƒ ObturatorObturator ƒƒ IliolumbarIliolumbar ƒƒ ObliteratedObliterated umbilicalumbilical ƒƒ LateralLateral sacralsacral ƒƒ SupSup && InfInf vesicalvesical ƒƒ SuperiorSuperior glutealgluteal ƒƒ UterineUterine ƒƒ VaginalVaginal ƒƒ MiddleMiddle rectalrectal ƒƒ PudendalPudendal ƒƒ 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

ƒƒ 1212 freshfresh--frozenfrozen femalefemale cadaverscadavers ƒƒ EachEach innervatedinnervated S3S3--55 ƒ S4 alone 30% ƒ S3-4 40% ƒ S4-5 30% ƒƒ NoNo pudendalpudendal nervenerve supplysupply identifiedidentified ƒƒ 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: ƒƒ PlacementPlacement ofof deepdeep laterallateral wallwall retractorsretractors onon PsoasPsoas atat laparotomylaparotomy?? ƒƒ HyperflexionHyperflexion ofof thethe hipships inin lithotomylithotomy positionposition oror tighttight underwear?underwear? ƒƒ LeaningLeaning onon thethe backback ofof thethe legslegs duringduring vaginalvaginal surgerysurgery oror sacrospinoussacrospinous ligamentligament fixation?fixation? ƒƒ MakingMaking aa pfannensteilpfannensteil incision?incision? ƒƒ PelvicPelvic lymphlymph nodenode dissection?dissection? IlioinguinalIlioinguinal andand IliohypogastricIliohypogastric NerveNerve InjuriesInjuries ƒƒ Mapping in 11 fresh frozen cadavers ƒƒ Ilioinguinal nerve ƒ Entered 3.1 ± 1.5 cm medial, 3.7 ± 1.5 cm inferior to ASIS ƒ Terminated 2.7 ± 0.9 cm lateral to midline, 1.7 ± 0.9 cm superior to pubic symphysis ƒƒ Iliohypogastric nerve ƒ Entered 2.1 ± 1.8 cm medial and 0.9 ± 2.8 cm lateral to ASIS ƒ 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 ƒƒ PrevesicalPrevesical (space(space ofof Retzius)Retzius) ƒƒ VesicovaginalVesicovaginal andand vesicocervicalvesicocervical ƒƒ ParavesicalParavesical ƒƒ RectovaginalRectovaginal ƒƒ PararectalPararectal ƒƒ RetrorectalRetrorectal ƒƒ PresacralPresacral

ComponentsComponents ofof PelvicPelvic SupportSupport

ƒƒ BonyBony pelvispelvis

ƒƒ EndopelvicEndopelvic FasciaFascia (fibromuscular(fibromuscular layer)layer)

ƒƒ PelvicPelvic diaphragmdiaphragm

UrethralUrethral ClosureClosure PressurePressure

33 componentscomponents • RhabdosphincterRhabdosphincter •• CircularCircular smoothsmooth musclemuscle •• NonNon-- neuromuscularneuromuscular ––Vascular cushions ––Mucosa ––Connective tissue PelvicPelvic DiaphragmDiaphragm ComponentsComponents

ƒƒ LevatorLevator aniani MusclesMuscles ƒƒ PuborectalisPuborectalis ƒƒ PubococcygeusPubococcygeus ƒƒ IliococcygeusIliococcygeus

ƒƒ CoccygeusCoccygeus musclesmuscles

AnalAnal ContinenceContinence MechanismMechanism

““EndopelvicEndopelvic FasciaFascia””

ƒƒ FibromuscularFibromuscular layerlayer ƒƒ FunctionallyFunctionally singlesingle sheetsheet ofof connectiveconnective tissuetissue ƒƒ LigamentousLigamentous condensationscondensations ƒƒ VasculatureVasculature ƒƒ NervesNerves

LevelsLevels ofof SupportSupport

ƒƒ LevelLevel II ƒ Uterosacral and cardinal ligaments ƒ Support uterus and vaginal apex ƒƒ LevelLevel IIII ƒ Lateral attachments of endopelvic fascia and vagina to arcus tendineus fascia pelvis ƒ Support bladder, vagina, and rectum ƒƒ LevelLevel IIIIII ƒ Perineal membrane and perineal body ƒ Support UVJ and perineum

DeLancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol.1992;166:1717-24.

UterosacralUterosacral LigamentLigament ƒƒ 1515 femalefemale cadaverscadavers ƒƒ USLUSL attachesattaches toto S1S1--33 andand variablyvariably toto S4S4 ƒƒ LessLess vitalvital structuresstructures belowbelow intermediateintermediate portionportion ƒƒ MeanMean distancesdistances fromfrom USLUSL toto ureterureter ƒ Cervical 0.9 ± 0.4 cm ƒ Intermediate 2.3 ± 0.9 cm ƒ Sacral 4.1 ± 0.6 cm ƒƒ IschialIschial spinespine toto ureterureter 4.94.9 ±± 2.02.0 cmcm ƒƒ IschialIschial spinespine consistentlyconsistently beneathbeneath intermediateintermediate portionportion ƒƒ USLUSL tensiontension transmittedtransmitted toto ureterureter mostmost nearnear cervixcervix ƒƒ 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

ƒƒ CloseClose genitalgenital hiatushiatus

ƒƒ CreatesCreates levatorlevator plateplate LevatorsLevators TonedToned InterrelationshipInterrelationship ofof LigamentousLigamentous andand MuscularMuscular SupportSupport MuscularMuscular SupportSupport ƒƒ LongLong--termterm supportsupport ƒƒ ClosureClosure ofof genitalgenital hiatushiatus ƒƒ LevatorLevator plateplate LigamentousLigamentous supportsupport ƒƒ ShortShort--termterm supportsupport ƒƒ TetherTether visceraviscera duringduring relaxationrelaxation ofof pelvicpelvic diaphragm.diaphragm. AnalogyAnalogy toto ShipShip inin DryDry DockDock PelvicPelvic FloorFloor DysfunctionDysfunction

URINARY DYSFUNCTION •Lower urinary tract symptoms •Incontinence •Voiding difficulties

VAGINAL DYSFUNCTION DEFECATORY DYSFUNCTION •Protrusion symptoms •Incontinence •Sexual dysfunction •Defecatory disorders RiskRisk FactorsFactors forfor PelvicPelvic OrganOrgan ProlapseProlapse

Predispose Incite Promote Decompensate

Congenital Vaginal Obesity Aging delivery Racial Surgery Smoking Menopause

Gender Neuropathy Lung disease Neuropathy

Myopathy Constipation Myopathy

Recreation Debilitation

Occupation Medication

MechanismsMechanisms ofof ProlapseProlapse

NeuromuscularNeuromuscular FailureFailure

ƒƒ MyopathicMyopathic injuryinjury ƒ Direct muscular compromise ƒ Denervation ƒƒ NeuropathicNeuropathic injuryinjury ƒ Stretching – Chronic injury ƒ Compression – Acute injury ƒ Combinations ConsequencesConsequences ofof NeuromuscularNeuromuscular CompromiseCompromise

Normal tone Loss of tone FecalFecal ContinenceContinence MechanismMechanism

MechanismsMechanisms ofof ProlapseProlapse

ƒƒ LigamentousLigamentous FailureFailure

ƒƒ ConnectiveConnective tissuetissue compromisecompromise ƒƒ StretchingStretching –– ChronicChronic injuryinjury ƒƒ TearsTears –– AcuteAcute injuryinjury ƒƒ CombinationsCombinations

LowerLower UrinaryUrinary TractTract andand ContinenceContinence MechanismMechanism PerinealPerineal DescentDescent PathophysiologyPathophysiology ofof ProlapseProlapse

Detachment Attenuation

Inciting Promoting Factors

Neuropathy Myopathy SummarySummary

ƒƒ PelvicPelvic floorfloor dysfunctiondysfunction isis commoncommon andand cancan bebe debilitating.debilitating. ƒƒ ImportantImportant toto understandunderstand normalnormal anatomyanatomy andand pathophysiologypathophysiology toto properlyproperly carecare forfor womenwomen withwith thesethese conditionsconditions andand toto avoidavoid surgicalsurgical complications.complications.