© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION CHAPTER 5 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gynecologic Anatomy © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORand Physiology SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Deana Hays Nicole R. Clark The editors acknowledge Nancy J. Hughes, Nancy M. Steele, and Suzanne M. Leclaire, who were the authors of the © Jones & Bartlett Learning,previous edition LLC of this chapter. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The women’s health movement encourages (2) the sacrum, and (3) the coccyx. The innomi- women to be© knowledgeable Jones & Bartlett about their Learning, bodies, to nateLLC bones consist of the pubis,© the Jones ischium, & andBartlett Learning, LLC appreciate theNOT unique FOR form SALE and function OR DISTRIBUTIONof the fe- the ilium, all of which are fusedNOT together FOR at SALE the OR DISTRIBUTION male body, and to take responsibility for caring and acetabulum (Corton, 2012). The ilium comprises making decisions about their bodies that will posi- the posterior and upper portion of the innominate tively affect their health. This chapter reviews fe- bone, forming what is known as the iliac crest. It male anatomy and physiology in terms of how they articulates with the sacroiliac joint posteriorly, and © Jonesdirectly & affect Bartlett gynecologic Learning, health and LLC well-being. together with© its Jones ligaments & is Bartlettthe major contributorLearning, LLC Female anatomy and physiology are often re- to pelvic stability. The pubic bones articulate anteri- NOT ferredFOR to SALE as reproductive OR DISTRIBUTION anatomy and physiology. orly with the symphysisNOT FOR pubis SALE and, with OR their DISTRIBUTION inferior Gynecology is defined as the branch of medicine angles from the descending rami, form the impor- dealing with the study of diseases and treatment tant bony landmark of the pubic arch ( Figure 5-1). of the female reproductive system. Regardless of The ischial spines are bony prominences that are whether a woman is pregnant or ever intends to clinically important because they are used as land- © Jones & Bartlettreproduce, Learning, her gynecologicLLC care has historically© Jonesmarks when& Bartlett performing Learning, pudendal blocksLLC and in NOT FOR SALE ORfocused DISTRIBUTION on reproduction. This example of namingNOT other FOR medical SALE procedures OR DISTRIBUTION such as sacrospinous lig- provides insight into why women often continue ament suspension ( Anderson & Gendry, 2007). The to be essentialized to reproductive functions by ischial spines are also used to assess progression of clinicians. fetal descent during childbirth. The authors of this chapter assume the reader The sacrum and the coccyx shape the posterior has had basic human anatomy and physiology con- portion of the pelvis. The sacrum is formed by the tent. Readers© requiring Jones a &more Bartlett in-depth Learning, discussion fusionLLC of the five sacral vertebrae,© Jones which includes & Bartlett Learning, LLC are referredNOT to general FOR anatomy SALE andOR physiology DISTRIBUTION the important bony landmark ofNOT the sacral FOR prom SALE- OR DISTRIBUTION references. ontory, and joins the coccyx at the sacrococcygeal symphysis. The coccyx is formed by the fusion of four rudimentary vertebrae, is usually movable, PELVIC ANATOMY and is itself a key bony landmark. The true pelvis © Jones & Bartlett Learning, LLC constitutes the© Jonesbony passageway & Bartlett through Learning, which LLC Pelvic Bones and Pelvic Joints NOT FOR SALE OR DISTRIBUTION the fetus mustNOT maneuver FOR to SALE be born ORvaginally. DISTRIBUTION The pelvis is composed of (1) two hip bones called The best-known classification of the female the innominate bones (also known as ox coxae), pelvis is the Caldwell–Moloy (1933) classification, 77 © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284078916_CH05_077_094.indd 77 01/07/16 12:16 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 78 Chapter 5: Gynecologic Anatomy and Physiology © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 5-1 Bones of the female pelvis. Sacral promontory Sacroiliac Ilium © Jones &synchondrosis Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Linea terminalis Sacrum © Jones & Bartlett Learning,Sacrococcygeal LLC © Jones & Bartlett Learning, SacrLLCosciatic NOT FOR SALE OR DISTRIBUTIONsymphysis NOT FOR SALE OR DISTRIBUTIONnotch Coccyx Ischial spine Pubis © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTAcetabulum FOR SALE OR DISTRIBUTION Iliopectineal eminence Ischium Symphysis pubis © Jones & Bartlett Learning,Ischial LLC tuberosity Obturator© Jones foramen & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION which includes four basic pelvic types: gynecoid, passing laterally through the greater sciatic fora- android, anthropoid, and platypelloid (Figure 5-2). men and inserts in the upper border of the greater © Jones & BartlettEach Learning, pelvic type LLC is classified in accordance with© Jonestrochanter & Bartlettof the femur. Learning, The origin of LLC the obturator NOT FOR SALE ORthe DISTRIBUTIONcharacteristics of the posterior segment of theNOT internus FOR muscleSALE includes OR DISTRIBUTION the pelvic surfaces of the inlet. The development of this classification re- ilium and ischium and the obturator membrane. It sulted in the realization that most pelves are not exits the pelvis through the lesser sciatic foramen, pure types but rather a mixture of types ( Kolesova & where it attaches to the greater trochanter of the Vetra, 2012). hip, enabling it to function in external hip rotation (Anderson & Gendry, 2007; Corton, 2012). Pelvic Support© Jones & Bartlett Learning, LLCThe deep perineal space is a pouch© Jones that lies & supe Bartlett- Learning, LLC Pelvic supportNOT structures FOR SALEinclude ORnot DISTRIBUTIONonly the riorly to the perineal membraneNOT (Figure FOR 5-3). SALEThis OR DISTRIBUTION muscles and connective tissue of the pelvic floor, deep space is continuous with the pelvic cavity and but also the fibromuscular tissue of the vaginal contains the compressor urethrae and urethrovagi- wall and endopelvic connective tissue (Richter & nal sphincter muscles, the external urethral sphinc- Varner, 2007). The piriformis and obturator internus ter, parts of the urethra and vagina, branches of the © Jonesmuscles & Bartlettand their fasciae Learning, form part LLC of the walls of pudendal artery,© Jones and the &dorsal Bartlett nerve and Learning, vein of LLC NOT theFOR pelvic SALE cavity. OR The DISTRIBUTIONpiriformis muscle originates the clitoris (Corton,NOT 2012).FOR TheSALE perineal OR membrane DISTRIBUTION at the front of the sacrum, near the third and fourth (also known as the urogenital diaphragm, although sacral foramina. This muscle leaves the pelvis by this label is a misnomer) is a sheet made up of dense © Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9781284078916_CH05_077_094.indd 78 01/07/16 12:17 PM © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gynecologic Anatomy and Physiology 79 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION FIGURE 5-2 Caldwell–Moloy classification of pelves. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC Anthropoid© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Gynecoid Android © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Platypelloid © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE ORfibrous DISTRIBUTION tissue that spans the opening of the anteriorNOT pubococcygeus FOR SALE is furtherOR DISTRIBUTION divided into the pubovag- pelvic outlet. The perineal membrane attaches to inalis, puboperinealis, and puboanalis. the side walls of the vagina and provides support The levator ani and coccygeus muscles form the to the distal vagina and urethra by attaching these pelvic floor, and the related fascia form a support- structures to the bony pelvis (Corton, 2012). ive sling for the pelvic contents. The muscle fibers The levator ani muscle is a critical component insert at various points in the bony pelvis and form of pelvic support;© Jones indeed, & it Bartlettis often considered Learning, the functionalLLC sphincters for the vagina,© Jones rectum, & andBartlett Learning, LLC most importantNOT muscle FOR of SALEthe pelvic OR floor DISTRIBUTION