0542 ch 05(96-121).ps 2/7/05 9:44 AM Page 96 CHAPTERCHAPTER1 5 The pelvis and perineum The pelvis is the area of transition between the trunk and the • Ischial tuberosity lower limbs. The bony pelvis serves as the foundation for the • Ischial spine pelvic region and it provides strong support for the vertebral On the sacrum identify: [G 185; N 341; R 420; C 428] column upon the lower limbs. The pelvic cavity is continuous with the abdominal cavity, the transition occurring at the plane • Sacral promontory of the pelvic inlet (Fig. 5.01). The pelvic cavity contains the rec- • Anterior sacral foramina tum, the urinary bladder, and the internal genitalia. [G 185] • Coccyx The perineum is the region of the trunk that is located be- The hip bone and sacrum are connected by strong ligaments. tween the thighs. The pelvic diaphragm separates the pelvic On a model with pelvic ligaments, identify (Fig. 5.02A,B): cavity from the perineum (Fig. 5.01). The perineum contains the [G 186, 188; N 340; R 430; C 255, 257] anal canal, the urethra, and the external genitalia (penis and scrotum in the male, vulva in the female). • Sacrotuberous ligament This chapter begins with the dissection of structures in the • Sacrospinous ligament anal triangle that are common to both sexes. Dissection of in- • Obturator membrane ternal and external genitalia is divided into two sections, one for • Greater sciatic foramen male cadavers and one for female cadavers. Students will be ex- • Lesser sciatic foramen pected to demonstrate knowledge of both male and female anatomy in the pelvis and perineum. Each dissection team Note that the sacrotuberous ligament and sacrospinous liga- should partner with another dissection team that is working on ment convert the greater and lesser sciatic notches into the a cadaver of the opposite sex. greater and lesser sciatic foramina. The sacroiliac articulation is a synovial joint between the au- Skeleton of the Pelvis ricular surfaces of the sacrum and the ilium. It is strengthened by an anterior sacroiliac ligament and a posterior sacroiliac Refer to an articulated bony pelvis. The pelvis (L. pelvis, basin) ligament (Fig. 5.02A, B). is formed by two hip bones (os coxae) joined posteriorly by the Identify the pubic arch. Note that the subpubic angle sacrum (Fig. 5.02A). Each hip bone is formed by three fused (angle of the pubic arch) is wider in females than males. [G 190, bones: pubis, ischium, and ilium. The point of fusion of these 191; N 342; R 422; C 254, 255] three bones is the acetabulum. The coccyx is attached to the Identify the pelvic inlet (superior pelvic aperture). The sacrum. [G 185; N 341; R 422; C 253] bony rim of the pelvic inlet is called the pelvic brim. From an- On the hip bone, identify: [G 184; N 340; R 419; C 250] terior to posterior, identify the structures that form the pelvic brim: [G 191; N 341; R 421; C 253] • Iliac fossa • Iliopubic eminence • Superior margin of the pubic symphysis • Arcuate line • Posterior border of the pubic crest • Pecten pubis • Pecten pubis • Superior pubic ramus • Arcuate line of the ilium • Pubic symphysis • Pubic arch • Ischiopubic ramus—formed by the ischial ramus and the in- ferior pubic ramus Iliac crest • Obturator foramen Greater pelvis Pelvic brim Pelvic inlet KEY TO REFERENCES Lesser pelvis G = Grant’s Atlas, 11th ed., page number N = Netter’s Atlas, 3rd ed., plate number Pelvic R = Rohen’s Color Atlas of Anatomy, 5th ed., page number diaphragm C = Clemente’s Atlas, 4th ed., page number Perineum Ischial tuberosity 96 Figure 5.01. The pelvis on coronal section. 0542 ch 05(96-121).ps 2/7/05 9:44 AM Page 97 Chapter 5 / The Pelvis and Perineum ANAL TRIANGLE 97 Sacral promontory Anterior sacroiliac ligament Iliac crest Iliac fossa Posterior sacroiliac ligament Anterior sacral foramina Greater sciatic foramen Sacrospinous Coccyx ligament Ischial spine Lesser sciatic Iliopubic foramen Ischial tuberosity eminence A Pubic Arcuate line B Sacrotuberous ligament symphysis Obturator canal and pubic arch Obturator Ischial ramus membrane Pubic tubercle Pecten pubis Inferior pubic ramus Superior pubic ramus Superior margin of pubic symphysis Figure 5.02. Bones and ligaments of the pelvis. A. Anterior view. B. Posterior view. • Anterior border of the ala (wing) of the sacrum In the erect posture (anatomical position), the anterior su- • Sacral promontory perior iliac spines and the anterior aspect of the pubis are in the same vertical plane. In this position, the plane of the pelvic inlet Identify the pelvic outlet. The pelvic outlet is bounded on forms an angle of approximately 55 degrees to the horizontal. A each side by: [G 192; N 340; R 430; C 256] line connecting the superior aspect of the pubis with the tip of • Inferior margin of the pubic symphysis the coccyx lies in the horizontal plane. [G 184; N 340; R 424] • Ischiopubic ramus • Ischial tuberosity • Sacrotuberous ligament Anal Triangle • Tip of the coccyx Before you dissect . The pelvic inlet divides the pelvis into the greater (false) pelvis and lesser (true) pelvis (Fig. 5.01). The greater pelvis is The perineum is a diamond-shaped area between the thighs situated superior to the pelvic brim and is bounded bilaterally by that is divided for descriptive purposes into two triangles (Fig. the ala of the ilium. The lesser pelvis is located inferior to the 5.03). The anal triangle is the posterior part of the perineum pelvic brim. The inferior border of the lesser pelvis is the pelvic and it contains the anal canal and anus. The urogenital trian- diaphragm. [G 185] gle is the anterior part of the perineum and contains the urethra Scrotum Pubic symphysis Labium minus Labium majus Ischiopubic ramus UUrogenitalrogenital ∆ UUrogenitalrogenital ∆ AAnalnal ∆ Ischial tuberosity AAnalnal ∆ Anus Tip of coccyx Figure 5.03. Boundaries of the urogenital and anal triangles in the male and female. 0542 ch 05(96-121).ps 2/7/05 9:44 AM Page 98 98 ANAL TRIANGLE Chapter 5 / The Pelvis and Perineum and the external genitalia. At the outset of dissection, it is im- portant to understand that the pelvic diaphragm separates the pelvic 12. Clean the posterior surface of the gluteus maximus cavity from the perineum (Fig. 5.01). [G 185] muscle (Fig. 5.05). Do not save the inferior cluneal The order of dissection will be as follows. Dissection of the nerves, but take care not to cut the deep fascia of the anal triangle will begin with removal of skin from the gluteal re- posterior thigh. gion and partial reflection of the gluteus maximus muscle. The 13. Use your hands to define the superior margin of the nerves and vessels of the ischioanal fossa will be dissected. The gluteus maximus muscle and separate it from the fat will be removed from the ischioanal fossa to reveal the infe- gluteal aponeurosis, which overlies the gluteus medius rior surface of the pelvic diaphragm. muscle (Fig. 5.05). The plane between the gluteus maximus muscle and the gluteus medius muscle can be found by observing the different directions of their Dissection Instructions muscle fibers. 14. Use scissors to cut the proximal attachment of the glu- SKIN INCISIONS teus maximus muscle very close the posterior surface 1. If the lower limb has been dissected previously, reflect of the sacrum and coccyx (dotted line in Fig. 5.05). the gluteus maximus muscle laterally and move ahead Start superiorly and work inferiorly. Insert your fin- to the dissection of the ischioanal fossa. If the lower gers under the superior margin of the gluteus max- limb has not been dissected, continue with step 2. imus muscle and loosen it from deeper structures as 2. Place the cadaver in the prone position. you cut. 3. Refer to Figure 5.04. 15. Inferiorly, the gluteus maximus muscle is attached to 4. Make an incision that follows the lateral border of the the sacrotuberous ligament. Use scissors to detach sacrum and the iliac crest from the tip of the coccyx (S) the gluteus maximus from the sacrotuberous ligament to the midaxillary line (T). If the back has been but do not cut the ligament. skinned, this incision has been made previously. 16. Reflect the gluteus maximus muscle laterally until the 5. Make a midline skin incision from “S” to the posterior inferior gluteal nerve and vessels prevent further re- edge of the anus. flection. The entire length of the sacrotuberous liga- 6. Make an incision that encircles the anus. ment should be visible. 7. Make an incision from the anterior edge of the anus down the medial surface of the thigh to point “D” (ap- ISCHIOANAL FOSSA proximately 7.5 cm down the medial thigh). The ischioanal (ischiorectal) fossa is a wedge-shaped 8. Make an oblique skin incision from “D” across the area on either side of the anus. The apex of the wedge is posterior surface of the thigh to point “E” on the lat- directed superiorly and the base is beneath the skin. The eral surface of the thigh. Point E should be approxi- ischioanal fossa is filled with fat that helps accommodate mately 30 cm inferior to the iliac crest. the fetus during childbirth or the distended anal canal dur- 9. Make a skin incision along the lateral side of the thigh ing the passage of feces. The ischioanal fat is part of the su- from “T” to “E.” 10. Remove the skin from medial to lateral and place it in the tissue container. 11. Remove the superficial fascia from the surface of the Line of detachment Gluteus maximus m.