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PELVIC WALLPELVIC WALL

By Dr/ Elsayed MetwallyBy Dr/ Elsayed Metwally

Lecturer of anatomy and embryologyLecturer of anatomy and embryology

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Pelvic musclesPelvic muscles

Piriformis muscle

Obturator internus muscle

Coccygeus muscle

Levator ani muscle

Pelvic wall muscles

Pelvic floor muscles

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Piriformis musclePiriformis muscle::

Origin:Origin: pelvic surface ofpelvic surface ofmiddle 3 sacral pieces.middle 3 sacral pieces.

Insertion:Insertion: top of greatertop of greater

trochanter of femur.trochanter of femur.Nerve supply:Nerve supply: S1, S2.S1, S2.

Action:Action: lateral rotation oflateral rotation ofthigh.thigh.

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Obturator internusObturator internus::

Origin:Origin: inner surface ofinner surface of

obturator membraneobturator membrane

Margins of obturatorMargins of obturator

foramen.foramen.Insertion:Insertion: medial side ofmedial side of

greater trochanter ofgreater trochanter of

femur.femur.

Nerve supply:Nerve supply: nerve tonerve toobturator internusobturator internus

Action:Action: lateral rotation oflateral rotation of

thighthigh

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Obturator fasciaObturator fascia

--It covers the pelvic surface of obturatorIt covers the pelvic surface of obturator

internus.internus.

-It is thickened in its upper part, forming-It is thickened in its upper part, forming

what is calledwhat is called tendinous archtendinous arch=white line.=white line.

The tendinous arch gives attachment toThe tendinous arch gives attachment to

levator ani muscle.levator ani muscle.

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Levator ani muscle:Levator ani muscle:

Origin:Orig

in: white line of obturatorwhite line of obturatorfascia (tendinous arch).fascia (tendinous arch).

Insertion: it can be differentiatedInsertion: it can be differentiated

into 3 parts:into 3 parts:

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InsertionInsertion::1.1. Pubococcygeus :Pubococcygeus : into perinealinto perineal

body & tip of coccyx fibers ofbody & tip of coccyx fibers ofthis part pass across the side ofthis part pass across the side of

prostate in male (levatorprostate in male (levator

prostate) and across the side ofprostate) and across the side of

vagina (sphincter vagina) invagina (sphincter vagina) in

female.female.

22. Iliococcygeus:. Iliococcygeus: into the sides ofinto the sides of

the last 2 pieces of coccyx andthe last 2 pieces of coccyx and

anococcygeal raphe whichanococcygeal raphe which

extends from apex of the coccyxextends from apex of the coccyxto anorectal junctionto anorectal junction

3.3. Puborectalis:Puborectalis: form a U form a U

shaped sling which helps theshaped sling which helps the

deep part of external analdeep part of external anal

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Nerve supplyNerve supply: Ventral rami of S3,4 sacral: Ventral rami of S3,4 sacral

nerve and inferior rectal nerve.nerve and inferior rectal nerve.

Action of levator ani:Action of levator ani:

1. Acting together both muscles increase the intra-1. Acting together both muscles increase the intra-

abdominal pressure so, it helps in defecationabdominal pressure so, it helps in defecation

and labour.and labour.

2. Puborectalis, supports external anal sphincter.2. Puborectalis, supports external anal sphincter.3. Pubococcygeus: supports the prostate in male3. Pubococcygeus: supports the prostate in male

and acts as sphincter for vagina in femaleand acts as sphincter for vagina in female

during labour, perineal body may be tornduring labour, perineal body may be tornleading to prolapse of uterus because theleading to prolapse of uterus because the

gap between the anterior border of the 2gap between the anterior border of the 2

levator ani becomes widerlevator ani becomes wider

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Coccygeus muscleCoccygeus muscle

OriginOrigin:: tip of ischialtip of ischial

spine.spine.

Insertion:Insertion: sides ofsides of

the last 2 sacralthe last 2 sacralpieces and 1stpieces and 1st

coccygeal piececoccygeal piece

NS: ventral ramus ofNS: ventral ramus of

S4.5S4.5

Action: supportAction: support

pelvic floorpelvic floor

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Nerves of the pelvisNerves of the pelvis

Sacral plexus

Sympathatic chain

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SACRAL PLEXUSSACRAL PLEXUS

formationformation::ventral rami ofventral rami ofL4,5 (lumbosacralL4,5 (lumbosacraltrunk) andtrunk) and

S1,2,3,4 .S1,2,3,4 .SiteSite:: in front ofin front ofpiriformis betweenpiriformis betweenit and its fasciait and its fascia

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Branches of the plexusBranches of the plexus::

From roots=6

From the plexus=6

Ventral branches= 3p

Dorsal branches=3p

Ventral branches=3

Dorsal branches=3

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From the plexus itself:From the plexus itself:

Tibial part of sciatic nerve (L4,5-S1,2,3)

Nerve to quadratus femoris (L4,5-S1).Nerve to obturatorinternus (L5- S1,2).

ral branches:

Dorsal branches:

Superior gluteal nerve (L4,5-S1).

Inferior gluteal nerve (L5- S1,2).

Common peroneal nerve (L4,5-S1,2)

TibQam

Obturator

Ya SICO

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PELVIC PART OF SYMPATHETIC TRUNKPELVIC PART OF SYMPATHETIC TRUNK

Definition:Definition: it is the lower partit is the lower part

of the sympathetic chain whichof the sympathetic chain whichenters the pelvis by crossingenters the pelvis by crossingthe front of ala of the sacrum.the front of ala of the sacrum.

Course & relationsCourse & relations::

The right and left one descendsThe right and left one descendsin front of sacrum medial toin front of sacrum medial toventral sacral foramina.ventral sacral foramina.

They unite together in front ofThey unite together in front of

the coccyx by a small ganglionthe coccyx by a small ganglioncalledcalled ganglion imparganglion impar..

Each trunk has 4 sacralEach trunk has 4 sacralganglions.ganglions.

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BranchesBranches::

ItIt GIVGIVes three branches:es three branches:

1.1. GGrey rami communicantesrey rami communicantes

(postganglionic fibers) to join all sacral(postganglionic fibers) to join all sacral

and coccygeal nerves.and coccygeal nerves.

2. Branches to2. Branches to iinferior hypogastric plexus.nferior hypogastric plexus.

3.3. VVascular branches to the arteries ofascular branches to the arteries ofperineum & lower limb.perineum & lower limb.

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PELVIC VESSELSPELVIC VESSELS

INTERNAL ILIACINTERNAL ILIACARTERYARTERY

OriginOrigin:: It is one of the 2It is one of the 2

terminal branches of theterminal branches of the

common iliac artery.common iliac artery.

Termination:Termination: ItIt endsends byby

division into anterior anddivision into anterior and

posterior division nearposterior division near

the upper border ofthe upper border of

greater sciatic foraminagreater sciatic foramina

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Branches of the anterior divisionBranches of the anterior division

Parietal branches:oIParietal branches:oI

1.1.Obturator artery.Obturator artery.

2.2.Inferior gluteal artery.Inferior gluteal artery.

3.3.Internal pudendalInternal pudendalartery.artery.

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Visceral branches:Visceral branches:

1-Umbilical artery and1-Umbilical artery andits superior vesicalits superior vesicalbranch.branch.

2-Inferior vesical artery2-Inferior vesical artery(in male) (vaginal(in male) (vaginalartery in female).artery in female).

3- Uterine artery (in3- Uterine artery (infemale).female).

4-Middle rectal artery4-Middle rectal artery

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Branches of the posteriorBranches of the posterior

division (ILS)division (ILS)

1. Iliolumbar artery.1. Iliolumbar artery.

2. Two lateral sacral2. Two lateral sacralarteries.arteries.

3. Superior gluteal3. Superior gluteal

artery.artery.

Some points about theome po nts a out t e

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Some points about theome po nts a out t ebranches of the internal iliacbranches of the internal iliac

artery (IIA):artery (IIA): Obturator artery:Obturator artery:

It runs forwards on the side wall of the pelvis toIt runs forwards on the side wall of the pelvis to

pass through the obturator canal to enter thepass through the obturator canal to enter thethigh.thigh. Inferior gluteal arteryInferior gluteal artery It is one of the two terminal branchs of theIt is one of the two terminal branchs of the

anterior division.anterior division. It passes through the greater sciatic notch belowIt passes through the greater sciatic notch below

the piriformis to enter the gluteal region,the piriformis to enter the gluteal region,supplying the gluteal muscles.supplying the gluteal muscles.

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Umbilical arteryUmbilical artery

It is the highest branch of the anterior division ofIt is the highest branch of the anterior division of

the IIA.the IIA.

It passes forwards on the side wall of the pelvis,It passes forwards on the side wall of the pelvis,

and then ascends upwards on the back of theand then ascends upwards on the back of theanterior abdominal wall to reach the umbilicus.anterior abdominal wall to reach the umbilicus.

Its proximal part gives theIts proximal part gives the superior vesicalsuperior vesical

arteryarteryto supply the bladder.to supply the bladder.

Its distal part becomes obliterated and forms theIts distal part becomes obliterated and forms the

medial umbilical ligamentmedial umbilical ligament..

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Inferior vesical arteryInferior vesical artery

It supplies the base of the bladder,It supplies the base of the bladder,

prostate, lower part of the ureter andprostate, lower part of the ureter and

seminal vesicle.seminal vesicle.

It gives origin for theIt gives origin for the artery of vasartery of vas

deferensdeferens

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Middle rectal arteryMiddle rectal artery

-It passes medially to reach the middle of-It passes medially to reach the middle of

the rectum.the rectum.

-It supplies the seminal vesicle ad prostate-It supplies the seminal vesicle ad prostate

in males.in males.

Uterine arteryUterine artery

-See the uterus later on.-See the uterus later on.

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Iliolumbar arteryIliolumbar artery

It passes upwards and laterally to divide intoIt passes upwards and laterally to divide intoiliac and lumbar branches, supplying the 3iliac and lumbar branches, supplying the 3muscles; iliacus, psoas major and the quadratesmuscles; iliacus, psoas major and the quadrates

lumborum.lumborum. Lateral sacral arteriesLateral sacral arteries

Two in number, each one divides into two. So theTwo in number, each one divides into two. So theend result is 4 pairs of lateral sacral arteries.end result is 4 pairs of lateral sacral arteries.

Each pair of the artery passes through the anteriorEach pair of the artery passes through the anteriorsacral foramina to supply the contents of thesacral foramina to supply the contents of thesacral canal.sacral canal.

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MEDIAN SACRAL ARTERYMEDIAN SACRAL ARTERY OriginOrigin::the back of thethe back of the

abdominal aorta justabdominal aorta justabove its bifurcation.above its bifurcation.

TerminationTermination::it ends byit ends byformation of a swellingformation of a swellingcalledcalled GlomusGlomuscoccygeum,coccygeum, in front ofin front of

the coccyx.the coccyx. Branches:Branches:

1. 5th lumbar artery.1. 5th lumbar artery.

2. branches to the sacral2. branches to the sacralcanal.canal.

3. branches to the rectum.3. branches to the rectum. EmbryologicallyEmbryologically, this, this

artery represents theartery represents thecontinuation of the aorta.continuation of the aorta.

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PELVIC FASCIAPELVIC FASCIA

It can be divided into:It can be divided into:

Parietal:Parietal: it covers the pelvic wall as:it covers the pelvic wall as:

- fascia over the obturator muscle (- fascia over the obturator muscle (obturator fasciaobturator fascia),),

- fascia over the piriformis (- fascia over the piriformis (Piriformis fasciaPiriformis fascia).).

Visceral (endopelvic fascia):Visceral (endopelvic fascia): it lies in between theit lies in between the

pelvic organs. It is in the form of either:pelvic organs. It is in the form of either:

-Loose areolar CT around distensible organs (as-Loose areolar CT around distensible organs (asurinary bladder, vagina and rectum).urinary bladder, vagina and rectum).

-Tough and membranous around non-distensible-Tough and membranous around non-distensible

organs (as prostate).organs (as prostate).

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Fascia of pelvic floor:Fascia of pelvic floor:

Superior fascia of pelvic diaphragmSuperior fascia of pelvic diaphragm:: ititcovers the superior surface of levator ani.covers the superior surface of levator ani.

Inferior fascia of pelvic diaphragmInferior fascia of pelvic diaphragm:: it coversit covers

the inferior surface of levator ani.the inferior surface of levator ani.

Pelvic ligaments:Pelvic ligaments: as the lateral ligament ofas the lateral ligament ofthe urinary bladder, lateral ligament of thethe urinary bladder, lateral ligament of theuterus (Cardinal ligament), Waldayeruterus (Cardinal ligament), Waldayer ss

ligament (in front of the rectum), puboprostatic,ligament (in front of the rectum), puboprostatic,pubovesical, uterosacral and round ligament ofpubovesical, uterosacral and round ligament ofthe uterus.the uterus.

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Obturator fascia:Obturator fascia:

It covers the obturator internus muscle.It covers the obturator internus muscle.

It is thickened along a line from the ischialIt is thickened along a line from the ischialspine to back of the body pubic bonespine to back of the body pubic bone

forming theforming the white linewhite line..

It is splitted 1.5 inches above the ischialIt is splitted 1.5 inches above the ischial

tuberosity to form the pudendal canaltuberosity to form the pudendal canal

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Thank youThank you

Dr El-sayed MetwallyDr El-sayed Metwally