1. Relations & boundaries Anterior Medial Lateral Ovaries Broad ligament (mesovarium) Ligament of ovary Fimbriae of the uterine tube Anterior Posterior Lateral

Fundus + body + Superior surface of urinary bladder sigmoid colon uterine artery supravaginal part Vaginal part of Anterior fornix of vagina posterior fornix of vagina lateral fornices of vagina Uterus cervix In pelvis Urinary bladder Rectum Ureters In perineum Urethra anal canal

vagina False pelvis Lower part of the anterior abdominal wall. Lumbar vertebrae. Iliac fossae and the iliacus muscle.

Inlet  symphysis pubis. • Promontory of sacrum, Ileopectineal (arcuate) lines. • ala of sacrum.

True True

pelvis Outlet • Coccyx Anterolaterally: ischiopubic ramus Posterolaterally: Sacrotuberous ligament. Pelvic walls Posterior surfaces of the bodies of: • Sacrum & coccyx, 1- Part of the hip bone below the pelvic inlet  the pubic bones, • piriformis muscles and their covering 2- Obturator internus and its covering fascia  the pubic rami, and of parietal pelvic fascia. 3- Sacrotuberous ligament.  symphysis pubis. 4- Sacrospinous ligament.

Urogenital • Mons pubis Transverse line passing through the 2 • Medial surfaces of the thighs triangle • Symphysis pubis. ischial tuberosities. • Ischiopubic rami, anteriorly. • ischial tuberosities

Female • • perineum Anal triangle Transverse line passing through the 2 Coccyx ischial tuberosity & posteriorly. ischial tuberosities. • Intergluteal folds • sacrotuberous ligaments. Anal canal • Perineal body, • Anococcygeal body. • Ischiorectal fossae. • urogenital diaphragm, and • lower part of vagina Prostate • Symphysis pubis (SP). Rectum (important for PR Examination) Medial margins of levator ani muscles (levator prostate) Superior: Neck of urinary bladder. Inferior: Urogenital diaphragm (UGD). Breast Base: Extends from 2nd to 6th ribs & from the sternum to the midaxillary line Apex (Nipple & Areola) • 2/3 of its base lies on the pectoralis major muscle • The nipple lies opposite 4th intercostal • its inferolateral 1/3 lies on: Serratus anterior & External oblique muscles. space. • Its superolateral part sends a process into the axilla “axillary tail or process”.

2. Muscles: Origin Insertion Action Nerve supply Piriformis Pelvic surface of the It leaves the pelvis through the Sacral plexus middle 3 sacral vertebrae. greater sciatic foramen to insert directly. into the greater trochanter of the • Lateral rotators of the femur at femur. the hip joint. Obturator Internus Inner surface of the It leaves the pelvis through the Nerve to obturator obturator membrane and lesser sciatic foramen to be internus. the hip bone. inserted into the greater trochanter of the femur.

Pubococcygeus 1. posterior surface of  perineal body and coccyx. - forms a sling around the prostate or 1. perineal branch of the body of the the vagina to support the prostate the fourth sacral pubis (levator prostatae) or constrict the nerve 2. Tendinous arch of vagina (sphincter vaginae) the obturator fascia - stabilizes the perineal body 2. perineal branch of Puborectalis 3. Spine of the maintaining fecal continence as it forms the pudendal nerve. ischium. a sling around the recto-anal Junction. Iliococcygeus  anococcygeal body and -

Levatores ani muscles ani Levatores the coccyx General functions of levator ani muscles: - Support pelvic organs - Resist the rise in intra pelvic pressure during the straining and expulsive efforts of the abdominal muscles (as in coughing). - Form the pelvic floor (pelvic diaphragm) which separate pelvis from perineum, traversed by urethra, vagina & rectum Ischiococcygeus  ischial spine anococcygeal body and the coccyx

Coccygeus Lower end of sacrum and coccyx Assist the levator ani in supporting the branches of the 4th pelvic viscera and 5th sacral

nerves The Dartos muscle Lies within the superficial fascia & replaces Scarpa’s fascia It Regulates testicular temperature, The genital branch which promotes spermatogenesis. of the GFN (L1,2) The cremaster Found between the external and internal layers of spermatic Cresmasteric reflex is used for Sensory: femoral muscle fascia, insert into the tunica vaginalis underneath the testis. evaluation of testicular pain branch of (GFN) & If normal reflex is present: Epididymitis Ilioinguinal N. If absent (no Testicle rise): Testicular Motor: genital Torsion, but also absent in 50% of boys branch of (GFN). under age 30 months. 3. Others Overview Function Perineal Body • Perineal body is an irregular fibromuscular mass of  Gives attachment to perineal muscles variable size and consistency, located at midpoint of  Plays an important role in visceral support especially in the line between the ischial tuberosities female • Lies in the subcutaneous tissue, posterior to vaginal  Forms the central point of the perineum & blends anteriorly vestibule and anterior to the anal canal & anus with the perineal membrane Anococcygeal • The anococcygeal body is a complex musculotendinous  Receives insertion of fibers of levator ani muscle body structure • Situated between the anterior aspect of the coccyx and the posterior wall of the anorectal canal Boundaries Contents Superficial • Inferiorly: deep membranous layer of superficial fascia • Bulbs of vestibule: on each side of vaginal orifice. (colle’s fascia). • Crura of clitoris. • Superiorly: Inferior fascia of the urogenital diaphragm • Superficial perineal muscles:

(Perineal membrane) • Bulbospongiosus muscle, surrounds orifice of vagina and • Laterally: ischiopubic rami covers vestibular bulb. • Ischiocavernosus muscle, covers crus of clitoris on each /spaces side. • Superficial transverse perineal muscles. • Greater vestibular (Bartholin) glands: on each side of vaginal orifice. • Perineal branch of pudendal nerve supplying muscles & skin. Deep • Inferiorly: Inferior fascia of the urogenital diaphragm • Part of urethra & Part of vagina

Perineal PouchesPerineal (Perineal membrane) • Sphincter urethrae muscle, which is pierced by urethra & vagina. • Superiorly: Superior fascia of the urogenital diaphragm • Deep transverse perineal muscles • Laterally: Inferior portion of obturator internus fascia. • Internal pudendal vessels • Dorsal nerve of clitoris Ischiorectal Fossa • Base: Skin of the perineum. • Dense fat. • Medial wall: Levator ani & anal canal. • Pudendal nerve & internal pudendal vessels within the • Lateral wall: Obturator internus, covered with fascia. pudendal canal (A fascial canal formed by obturator fascia) • Inferior rectal nerve & vessels crossing the fossa to reach anal canal. ligaments of • fibrous strands which connect the skin with deep fascia of pectoralis major. cooper • Separates lobes and lobules of mammary gland (mammary gland is separated from the deep fascia covering the underlying muscle by a layer of loose areolar tissue which forms the retromammary space)

4. Supply Arteries Veins Lymph Nerves Innervation Ovaries Ovarian (abdominal aorta) Ovarian (to inferior vena To para-aortic lymph nodes Ovarian plexus (in abdomen) cava & left renal vein) (in abdomen) Uterine tube  Ovarian  Ovarian  Para-aortic  Ovarian plexus  Uterine  Uterine  Internal iliac  Inferior hypogastric plexus Uterus Uterine (internal iliac artery in Uterine plexus (to To internal iliac lymph Inferior hypogastric plexus (in pelvis) pelvis) internal iliac vein) nodes (in pelvis) Vagina Vaginal (internal iliac artery in pelvis) Vaginal plexus (to & Vaginal branch of the uterine artery internal iliac vein) Pelvis (I) Internal iliac artery (IIA): (I) Internal iliac veins: LNs and vessels are • Somatic: Sacral plexus • Arises in front of the collect tributaries arranged in a chain along • Autonomic: sacroiliac joint. It descends corresponding to the the main blood vessels. 1. Sympathetic: downward & backwards over branches of the internal Thus, there are external (I) Pelvic part of sympathetic trunk: The 2 the pelvic inlet. iliac artery. iliac, internal iliac, and sympathetic trunks unite inferiorly in front • It divides at the upper border common iliac nodes. of the coccyx and form a single ganglion of the greater sciatic (II) Ovarian vein: Lymph from Common iliac (Ganglion Impar). foramen into Anterior & - Right vein drains into nodes, ovaries, uterine II- Superior & Inferior Hypogastric plexuses Posterior divisions.1 IVC tubes & fundus of uterus 2. Parasympathetic: (II) Ovarian artery: - Left vein drains into left passes to Lateral aortic Pelvic splanchnic nerves (From S 2, 3 & 4). MNM: Sacral two, three, four. Keep shut of the floor. Arises from the abdominal aorta. renal Vein. (para-aortic) nodes.

1 Branches of internal iliac artery: Posterior division Supplies: Anterior division supplies: 1. Posterior abdominal wall. 1. Gluteal region. 2. Perineum. 3. Pelvic viscera. 4. Medial (adductor) region of thigh 5. The fetus (through the umbilical arteries). 2. Posterior pelvic wall. Branches from anterior division: 3. Gluteal region. 1. Obturator artery. Branches from posterior division: 2. Inferior Gluteal artery. 1. Iliolumbar artery. 3. Umbilical artery: Gives the superior vesical artery: The distal part of this artery fibroses and forms the Medial Umbilical Ligament. 2. Lateral sacral arteries (2 branches.) 4. Inferior Vesical artery in male or vaginal in female: In the male it supplies the Prostate and the Seminal Vesicles. 3. Superior gluteal artery.  The artery of the Vas Deferens (in male) arises from the superior or the inferior vesical artery. 5. Middle rectal artery *Blue = parietal branches* 6. Internal pudendal artery: It is the main arterial supply to the perineum. *Orange = visceral branches* 7. Uterine artery: Crosses the Ureter superiorly and supplies the uterus & uterine tubes.

Anal canal Arteries Veins Lymph Nerves Innervation Upper half Superior rectal artery (continuation Superior rectal vein Para-rectal nodes drained Visceral motor (sympathetic & (sensitive to of the inferior mesenteric artery) drained into the inferior into inferior mesenteric parasympathetic). stretch) mesenteric vein (portal lymph nodes circulation). Lower half Inferior rectal a. (branch of internal Inferior rectal vein Superficial inguinal lymph Somatic motor & sensory nerves (Inferior (sensitive to pudendal artery) drained into the internal nodes rectal N. branch of pudendal N.): supplies pain) pudendal vein (Systemic external sphincter muscle of the anus and circulation). skin of the anal region. Testis Testicular artery: Pampiniform plexus Testicular Lymphatics: It is a direct branch from the converge as it approaches Follow arteries and veins abdominal aorta. the inguinal canal and form End in Lumbar (para-aortic) the Testicular vein. nodes -Right Vein drains into IVC. Lymph from scrotum, -Left Vein drains into Left penis, prepuce: Renal Vein. Terminate in Superficial Inguinal nodes Prostate Inferior vesical artery Prostatic venous plexus: Internal iliac lymph nodes. Drains into internal iliac veins. Continuous superiorly with the vesical venous plexus and posteriorly to the internal vertebral venous plexus Breast 1. Perforating and mammary -Veins are corresponding Subareolar & Deep lymphatic2 plexuses of the breast drainage: branches of internal thoracic to the arteries. • Central & lateral parts (75%) → pectoral group of axillary LN (internal mammary) artery. -Circular venous plexus is • Upper part → apical group of axillary LN. 2. Mammary branches of lateral found at the base of • Medial part → internal thoracic (parasternal) LN, but Some pass thoracic artery. nipple, Finally draining across the sternum to anastomose with that of opposite breast. 3. Mammary branches of lateral into axillary & internal • Inferomedial part lymphatics anastomose with lymphatics of rectus cutaneous branches of posterior thoracic veins. sheath & linea alba, and some vessels pass deeply to anastomose with Intercostal arteries. the sub diaphragmatic lymphatics. - لولوه الصغيّر

2 Lies on the deep fascia covering pectoralis major.