Dr goston Szl Clinical anatomy of the male

Dr. Ágoston. Szél Clinical anatomy of the male pelvis and pelvic floor Semmelweis University Deaprtment of Anatomy, Histology and Embryology 2019 1

The pelvis as a whole 2

The pelvis greater pelvis = pelvis major, iliac fossa (part of the abdominal cavity, false pelvis) promontory borderline = linea terminalis pubic symphysis lesser pelvis = pelvis minor, true pelvis 3

Bony constituents of the pelvis promontory linea terminalis pubic tubercle pubic torus symphysis lower edge of symphysis ischial spine sacrococcygeal joint ischial tuberosity 4

posterior sacroiliac ligament interosseal sacroiliac ligaments iliac bone sacrum sacroiliac joint cavity cartilagineous discs sacrotuberous ligament greater sciatic foramen sacrospinous ligament anterior sacroiliac ligament lesser sciatic foramen ant. and post. symphyseal ligaments cartilagineous disks pubic bone fibrocartilagineous discs symphysis 5

Bones and ligaments of pelvis intervertebral foramen L 5 lumbosacral joint iliac crest sacrum iliac fossa ant. sup. iliac spine sacroiliac joint INGUINAL LIGAMENT 1. subinguinal hiatus ant. inf. iliac spine 2. greater sciatic foramen arcuate line SACROSPINOUS LIGAMENT linea terminalis pecten of pubic bone pubic tubercle symphyseal surface coccygeal bone 3. lesser sciatic foramen SACROTUBEROUS LIGAMENT 5. inferior pelvic aperture 4. obturator foramen 6

Diameters of pelvis sup. pelvic aperture amplitude (wide part) of pelvis (d-h) true anatomical conjugate (a-b) angustia (narrow part) of pelvis (e-g) true obstetric conjugate (a-c) internal diagonal conjugate (a-e) inf. pelvic aperture axis of pelvis (k-k) 7

Parts of lesser pelvis (pelvic canal, true pelvis, birth canal) pelvic inlet (sup. pelvic aperture) axis of pelvis linea terminalis amplitude (wide part) of pelvis angustia (narrow part) of pelvis interior of pelvis pelvic outlet (inf. pelvic aperture) 8

Important diameters of pelvic inlet 11 cm 12 cm 13 cm oblique diameter transverse diameter median diameter interspinal distance (25 -26 cm) intercristal distance (28 -29 cm) 9

Variations of the shape of pelvic inlet Classification of Caldwell & Moloy 10

Sexual differences in the shape of pelvis female inlet outlet cavity of pelvis pubic arch 11

Superior pelvic aperture heart-shaped, oval, ellipsoid Transverse diameter 12

circular mediane diameter Amplitude of pelvis transverse diameter 13

rhomboidshaped mediane diameter (conjugate) Inferior pelvic aperture 14

Openings and muscular components of pelvis iliacus psoas maj. & min. intervertebral foramen suprapiriform hiatus 2. greater sciatic foramen 1. subinguinal hiatus muscular and nervous, lacunae, vascular lacuna, lymphatic lacuna obturator canal piriformis infrapiriform hiatus ischiococcygeus 4. obturator foramen 3. lesser sciatic foramen int. obturator tendinous arch (levator ani removed) 5. inferior pelvic aperture gluteus max. 15

Pelvis as seen from above urogenital & anal hiatus obturator canal pubococcygeus iliococcygeus tendinous arch rectococcygeus ischiococcygeus greater sciatic foramen sacrotuberous lig. ant. sacroccocygeus 16

Parts of levator ani muscle urogenital hiatus inferior ramus of pubic bone centrum tendineum ischiadic tubercle sacrotuberous ligament sphincter of vagina puborectalis pubococcygeus iliococcygeus 17

Levator ani muscle insertion of levator ani on the pelvic wall greater sciatic foramen sacrospinous lig. obturator membrane lesser sciatic foramen sacrotuberous lig. 18

Maintenance of the intraabdominal pressure thoracic diaphragm abdominal wall pelvic diaphragm 19

Maintenance of the intraabdominal pressure thoracic diaphragm abdominal wall pelvic diaphragm 20

Pelvic floor as seen from below urethra vagina deep transverse perineal A superficial transverse perineal obturator int. B obturator fascia pubococcygeus* puborectalis iliococcygeus ischiococcygeus external anal sphincter centrum tendineum external anal sphincter anococcygeal lig. levator ani* pubovaginalis* levator of prostate 21

Parts of levator ani muscle rectum symphysis perineal flexure puboprostatic lig. puborectalis levator of prostate 22

Parts of levator ani muscle urogenital hiatus inf. ramus of pubic bone centrum tendineum ischiadic tubercle levator of prostate pubovaginalis (sphincter of vagina) puborectalis pubococcygeus iliococcygeus sacrotuberous lig. 23

Pararectal space (paraproctium) and fasciae slows down the propagation of metastatic prostate cancer* rectoprostatic fascia* (Denonvilliers) rectoprostatic space (Denonvilliers) rectal fascia proper (visceral pelvic fascia) presacral fascia (parietal pelvic fascia) sup. rectosacral space** rectosacral fascia (Waldeyer) inf. rectosacral space inf. ** rectovaginal fascia* (Denonvilliers) space without blood and lymph vessels („holy plane”)** 24

A B peritoneum pelvic fascia (visceral layer) endopelvic fascia (parietal layer) frontal section at the level of urinary tract (A) frontal section at the level of rectum (B) anterior continuation of ischiorectal fossa sagittal section ischiorectal fossa 25

Sagittal section of the male pelvis rectovesical pouch ileum sigmoid colon presacral fascia peritoneum rectal fascia proper rectum rectosacral fascia (Waldeyer) seminal vesicle peritoneal cavity bladder prevesical space (Retzius)* puboprostatic lig. ejaculatory duct rectosacral space rectoprostatic space/fascia (Denonvilliers)* anococcygeal lig. prostate urogenital diaphragm ext anal sphincter int. anal sphincter anus anal centrum perineum prostatic part of urethra *pre- and infraperitoneal space spf. abdominal fascia (Scarpa) scrotum *remnant of rectovesical pouch (septum) 26

Schematic view of pelvic floor and urogenital diaphragm (frontal section) pelvic diaphragm (levator ani) visceral pelvic fascia sup. fascia of pelvic floor endopelvic fascia (parietal pelvic fascia) obturator fascia inf. fascia of urogenital diaphragm (perineal fascia) obturator internus inf. fascia of pelvic floor sup. fascia of urogenital diaphragm parietalisfascia pelvis urogenital diaphragm (deep transverse perineal muscle) 27

Schematic view of pelvic floor and urogenital diaphragm (saggittal section) A B va to ra r loo (le cf lvi ni ) pe urogenital diaphragm (deep transv. perineal muscle. ) 28

Pelvic and urogenital diaphragm vulva bulbocavernosus inf. ramus of pubic bone ischiocavernosus deep transv. perineal muscle centrum tendineum spf. transv. perineal muscle ischiadic tubercle obturator internus m. levator ani ext. anal sphincter anococcygeal lig. 29

subarcuate hiatus symphysis centrum tendineum arcuate ligament of pubis urethra ischiadic tubercle inferior rectal artery anococcygeal ligament coccygeal bone gluteus maximus inferior ramus of pubic bone urogenital diaphragm external anal sphincter levator ani inferior rectal nerve sacrotuberous ligament 30

glans of clitoris corpus of clitoris crus of clitoris urethral orifice bulb of vestibule ischiocavernosus bulbospongiosus hymen inferior fascia of urogenital diaphragm (perineal membrane) greater vestibular gland superficial transverse perineal muscle centrum tendineum gluteus maximus anococcygeal ligament external anal sphincter levator ani 31

dorsal penile vein corpus cavernosum corpus spongiosum ischiocavernosus crus of penis bulbospongiosus centrum tendineum urogenital diaphragm external anal sphincter bulb of penis superficial transverse perineal muscle gluteus maximus levator ani 32

endopelvic fascia levator ani obturator internus prostate pelvis (infraperitoneum) prostatic part of urethrae urogenital diaphragm „ischiorectal fossa” dorsal penile nerve superior fascia of urogenital diaphragm deep perineal space. urogen. diaphragm, urethral sphincter, bulbourethral gland, vessels, nerves membraneous part of urethra deep penile artery inferior fascia of urogenital diaphragm (perineal membrane) crus of penis artery of bulb of penis ischiocavernous bulbourethral gland bulb of penis superficial perineal space scrotal nerves spongy part of urethra inner surface of thigh bulbospongiosus spf. perineal fascia (Colles) deep femoral fascia 33

levator ani pelvic fascia vagina obturator fascia paracolpium pelvis deep perineal space, urogenital diaphragm obturator internus obturator membrane „ischiorectal fossa” superior fascia of urogenital diaphragm dorsal nerve of clitoris deep artery of clitoris internal pudendal artery crus of clitoris artery of bulb inferior fascia of urogenital diaphragm (perineal membrane) superficial prineal space labial nerves deep femoral fascia ischiocavernosus bulb of vestibule bulbospongiosus hymen inner surface of thigh greater vestibular gland labium majus superficial perineal fascia (Colles) labium minus 34

Spaces of the pelvis in sketch obturator internus pelvic diaphragm (levator ani) peritoneal cavity 1. 2. 3. peritoneum pelvis infraperitoneal space pudendal canal (Alcock) „ischiorectal fossa” deep perineal space urogenital diaphragm (deep transv. perineal) 4. deep perineal pouch superficial perineal space ischiocavernosus fascia perinei spf. (Colles) bulbospongiosus 35

Internal iliac artery common iliac uterine internal iliac umbilical (sup. vesical) iliolumbal external iliac lateral sacral inferior gluteal internal pudendal obturator superior gluteal middle rectal inf. vesical 36

Internal pudendal artery common iliac internal pudendal (greater sciatic foramen) lateral sacral laterales (pelvic sacral foramens) external iliac femoral external pudendal dorsal penile (subarcuate hiatus) deep penile (urogenital diaphragm) internal pudendal (lesser sciatic foramen) inf. rectal a. of bulb of penis perineal post. scrotal ant. scrotal 37

Bibliography • Szentágothai J, Réthelyi M: Funkcionális anatómia. Medicina, 1985. • Lippert H: Lehrbuch Anatomie, Urban & Fischer, München, 2000. • Szél Á: Klinikai anatómia, Semmelweis, Budapest, 1999. • Snell RS: Clinical Anatomy, Little, Brown & Co, Boston, 1995. • Moore KL, Dalley AF: Clinically Oriented Anatomy, Lippincott, 1999. • Renz-Polster H, Krautzig S, Braun J: Innere Medizin, Urban & Fischer, München, 2004. • Putz R, Pabst R: Sobotta. Alliter, Budapest, 2004. • Patel R: Applied Peritoneal Anatomy, www. my. ESRorg. • Tirkes T et al: Peritoneal Anatomy. Gastrointestinal Imaging, https: //doi. org/10. 1148/rg. 322115032.