Pelvis, Pelvic cavity and contents common to both

Male and Female

Lecturer: Dante Roel Fernandez RT, M.D. Professor Department of

Anatomy Fatima College of Medicine

DEFINITION:DEFINITION:

- The pelvis is the region of the trunk - The pelvis is the region of the trunk located below the abdomen.located below the abdomen.

- "Pelvis" is loosely used to denote the - "Pelvis" is loosely used to denote the region where the trunk and lower region where the trunk and lower

extremities meet.extremities meet.

- The word pelvis means "basin" and is - The word pelvis means "basin" and is more correctly applied to the skeleton more correctly applied to the skeleton

of the regionof the region

Pelvis

• Loosely used to denote the region where the trunk and lower extremities meet.

• Means “Basin”

II. II. SURFACE SURFACE LANDMARKS:LANDMARKS:

1. Iliac crest: the most superior border of the hip region.

2. Anterior Superior Iliac Spine 2. Anterior Superior Iliac Spine (ASIS):(ASIS):

anterior end of iliac crest.

3. Posterior Superior Iliac Spine 3. Posterior Superior Iliac Spine (PSIS):(PSIS):

posterior end of the iliac crest.

4. Pubic Tubercle:4. Pubic Tubercle:

where the medial end of the inguinal ligament is attached. It is the bony projection at the supero-lateral border of the body of the pubic bone.

5. Symphysis Pubis:5. Symphysis Pubis:

lies in between the bodies of the pubic bone.

III. COMPOSITIONIII. COMPOSITIONThe pelvis is composed of two hip bones (os The pelvis is composed of two hip bones (os

coxae coxae or inominate hones), the sacrum and the or inominate hones), the sacrum and the coccyx.coccyx.

The hip bone is comprised of the ilium, The hip bone is comprised of the ilium, ischium, ischium, and pubis.and pubis.

- The hip bones form the lateral and anterior - The hip bones form the lateral and anterior boundaries of the pelvisboundaries of the pelvis

The 2 hip bones unite anteriorly at the The 2 hip bones unite anteriorly at the symphysis symphysis pubis. pubis.

The hip bones articulate posteriorly with the The hip bones articulate posteriorly with the sacrum.sacrum.

IV. IV. DIFFERENCES DIFFERENCES BETWEEN BETWEEN MALE AND FEMALE MALE AND FEMALE PELVISPELVIS

Male Male FemaleFemale

1. Bones1. Bones Heavier, rougher Heavier, rougher Lighter, Lighter, smoothersmoother

2. Sacrum Narrow, more curved Broader, less 2. Sacrum Narrow, more curved Broader, less curvedcurved

3. Ilium Lesser lateral flair Greater lateral 3. Ilium Lesser lateral flair Greater lateral flairflair

4. Greater Deeper, narrower Smaller, wider 4. Greater Deeper, narrower Smaller, wider sciatic notches sciatic notches

5. Iliac fossae Deeper Shallower5. Iliac fossae Deeper Shallower

PELVIS:MALE & FEMALE

MALE

HEAVIER

ROUGHER

NARROW CURVED SACRUM

FEMALE

LIGHTER

SMOOTHER

BROAD FLAT SACRUM

6.Sciatic spines More projecting Less projecting

7. Ischial tuberosity Inverted Everted

8. Symphysis pubis Longer Shorter

9. Subpubic angle Narrower, pointed Wider, more rounded

10. Margins of the More everted Less everted ischiopubic rami

11. Obturator foramen Oval Triangular

12. Superior aperture More heart shaped More oval shaped

13. Major pelvis Wider Narrower

14. Minor pelvis Deeper, narrower Shallower, wider

15. Capacity of Less More minor pelvis

V. V. TWO MAIN TWO MAIN DIVISIONS DIVISIONS OF OF THE PELVISTHE PELVIS

- - The pelvis is divided into two parts by the The pelvis is divided into two parts by the pelvic pelvic brim or pelvic inletbrim or pelvic inlet

- The pelvic brim or inlet is formed by:- The pelvic brim or inlet is formed by:1. sacral promontory1. sacral promontory

2. iliopectineal line2. iliopectineal line

3. upper border of the symphysis pubis3. upper border of the symphysis pubis

-Divisions:Divisions:

1. False/Greater Pelvis1. False/Greater PelvisAbove the pelvic inlet/brimAbove the pelvic inlet/brim

Boundaries:Boundaries:Behind: lumbar vertebraeBehind: lumbar vertebraeLateral: iliac fossa and iliacus muscleLateral: iliac fossa and iliacus muscleFront: lower part of the anterior abdominal Front: lower part of the anterior abdominal

wallwall

2. True/Lesser. pelvis2. True/Lesser. pelvisLies below the pelvic inlet/brimLies below the pelvic inlet/brim

Bounded inferiorly by the pelvic diaphragmBounded inferiorly by the pelvic diaphragmHas an inlet, outlet and a cavityHas an inlet, outlet and a cavity

A. Pelvic Inlet or Pelvic BrimA. Pelvic Inlet or Pelvic Brim

Boundaries:Boundaries:Posterior — sacral promontory Posterior — sacral promontory Lateral — iliopectineal lines Lateral — iliopectineal lines Anterior — symphysis pubisAnterior — symphysis pubis

B. Pelvic OutletB. Pelvic Outlet

Boundary:Boundary:Posterior — coccyxPosterior — coccyxLateral — ischial tuberosities Lateral — ischial tuberosities Anterior — pubic archAnterior — pubic arch

C. Pelvic CavityC. Pelvic Cavity

- Lies between the inlet and the outlet- Lies between the inlet and the outlet

- Short, curved canal, with a shallow anterior - Short, curved canal, with a shallow anterior wall wall and a much deeper posterior wall.and a much deeper posterior wall.

VI. COMPOSITION VI. COMPOSITION OF OF THE THE WALLS OF WALLS OF THE THE PELVIC WALLPELVIC WALL

- Includes the supporting framework of - Includes the supporting framework of bones, joints, ligaments, and bones, joints, ligaments, and

membranesmembranes

- The majority of the framework is - The majority of the framework is internally lined internally lined with muscles which are with muscles which are

covered with fascia.covered with fascia.

- The bones comprising the framework - The bones comprising the framework are are the sacrum and the coccyx from the sacrum and the coccyx from behind, behind, the lower half of the hip bones at the lower half of the hip bones at the the sides and in front.sides and in front.

- The joints are the sacro-coccygeal joint, - The joints are the sacro-coccygeal joint, a a pair of sacro-iliac joints and the pubic pair of sacro-iliac joints and the pubic symphysis.symphysis.

- The ligaments include the ligaments of - The ligaments include the ligaments of the the joints and joints and also the sacrotuberous also the sacrotuberous and and sacrospinous ligamentssacrospinous ligaments

The membranes are:The membranes are:

1. Perineal Membrane — tills up the greater part of 1. Perineal Membrane — tills up the greater part of the pubic archway.the pubic archway.

2. Obturator Membrane — almost completely closes 2. Obturator Membrane — almost completely closes the obturator foramen except in the anterior-superior the obturator foramen except in the anterior-superior aspect where it leaves a gap, called the aspect where it leaves a gap, called the obturator obturator canal, canal, by which the obturator nerve escape from the by which the obturator nerve escape from the pelvis.pelvis.

Vll. BOUNDARIES Vll. BOUNDARIES OF OF THE PELVIC CAVITYTHE PELVIC CAVITY

• Anterior Pelvic Wall- the shallowest wall- formed by the posterior surface of the bodies of the pubic bones, pubic rami, and symphysis pubis.

Posterior Pelvic WallPosterior Pelvic Wall

- formed by the sacrum, coccyx, and piriformis muscles and a covering of parietal pelvic fascia.

Lateral Pelvic wallLateral Pelvic wall

- formed by the parts of the innominate bone below the pelvic inlet, obturator membrane, sacrotuberous and sacrospinous ligaments, and the obturator internus muscle with its fascia.

Inferior Pelvic WallInferior Pelvic Wall

- supports the viscera of the pelvis

- formed by the pelvic diaphragm

- the pelvic cavity floor divides the pelvis into the main pelvic cavity above and the perineum below.

Vlll. Vlll. MUSCLESMUSCLES

1. Obturator Internus1. Obturator InternusOrigin : Obturator membrane and adjoining Origin : Obturator membrane and adjoining

parts parts of the hip boneof the hip bone

Insertion : Medial surface of the greater trochanter of Insertion : Medial surface of the greater trochanter of the femur. the femur.

Nerve Supply : Nerve to obturator internus from the Nerve Supply : Nerve to obturator internus from the sacral plexus sacral plexus Action : Lateral rotator of the femur when standing.Action : Lateral rotator of the femur when standing.Functions as an abductor when the hip joint is flexed.Functions as an abductor when the hip joint is flexed.

Obturator FasciaObturator Fascia

- It is the most definite layer of fascia in the - It is the most definite layer of fascia in the pelvic canal.pelvic canal.

- It lines the free surface of the obturator - It lines the free surface of the obturator internus.internus.

- At the margins of the muscles it fuses with the - At the margins of the muscles it fuses with the periosteum, except the ff: periosteum, except the ff:

a. Inferiorly where it joins the edge of the a. Inferiorly where it joins the edge of the falciform process of the sacrotuberous ligament.falciform process of the sacrotuberous ligament.

b. At the upper (anterior) edge of the obturator, b. At the upper (anterior) edge of the obturator, where it passes over the border of the muscle to join where it passes over the border of the muscle to join the obturator membrane and to form the floor of the the obturator membrane and to form the floor of the obturator canal which transmits the obturator vessels obturator canal which transmits the obturator vessels and nerves.and nerves.

- It gives rise to almost the entire levator ani.- It gives rise to almost the entire levator ani.

- Under the origin of the levator ani, it is located in - Under the origin of the levator ani, it is located in the sidewall of the ischio rectal fossa, and near the sidewall of the ischio rectal fossa, and near the the falciform process, it splits to form the falciform process, it splits to form the Alcock's Alcock's canal canal where the pudendal nerve and the where the pudendal nerve and the internal pudendal artery and vein pass through.internal pudendal artery and vein pass through.

PiriformisPiriformis

0: Primarily from the 20: Primarily from the 2nd, nd, 3rd, and 43rd, and 4thth piece of piece of the sacrum, leaves the pelvis via the greater sciatic the sacrum, leaves the pelvis via the greater sciatic foramen and enters the gluteal region and runs foramen and enters the gluteal region and runs across the uppermost part of the hack of the hip across the uppermost part of the hack of the hip joint.joint.

I: the greater trochanter of the femur.I: the greater trochanter of the femur.

NS: Anterior primary rami of the first and NS: Anterior primary rami of the first and second second sacral nerves. sacral nerves.

A: lateral rotator of the thighA: lateral rotator of the thigh

Pelvic DiaphragmPelvic Diaphragm

The coccygeus and the levator ani form a muscular The coccygeus and the levator ani form a muscular sheath called the pelvic diaphragm.sheath called the pelvic diaphragm.CoccygeusCoccygeus

0: ischial spine0: ischial spine

I: Side of the last piece of the sacrum and the I: Side of the last piece of the sacrum and the first piece of the coccyx.first piece of the coccyx.

NS: Lower sacral nerves.NS: Lower sacral nerves.

A: acts with the levator ani to support the A: acts with the levator ani to support the pelvic pelvic visceraviscera

Levator AniLevator Ani

0: Originates from the inner side of the pubis, along 0: Originates from the inner side of the pubis, along a line extending laterally from the inferior margin of a line extending laterally from the inferior margin of the symphysis to the obturator canal, and from the the symphysis to the obturator canal, and from the obturator fascia along the arcus tendinous which obturator fascia along the arcus tendinous which extends from the pubis to the spine.extends from the pubis to the spine.

I: Median raphe behind the anus; the anococcygeal I: Median raphe behind the anus; the anococcygeal ligament into the tip and aisles of the coccyx and ligament into the tip and aisles of the coccyx and into an aponeurosis that is attached to the anterior into an aponeurosis that is attached to the anterior sacrococcygeal ligament.sacrococcygeal ligament.

Divisions: Iliococcygeus, pubococcygeus, Divisions: Iliococcygeus, pubococcygeus, puborectalis.puborectalis.

- Behind the rectum, some of the fiber bundles from - Behind the rectum, some of the fiber bundles from the muscles of the two sides interdigitate, while the muscles of the two sides interdigitate, while some terminate in the anococcygeal ligament.some terminate in the anococcygeal ligament.

- Some fiber bundles also interdigitate across the - Some fiber bundles also interdigitate across the median line in front of' the rectum, and some are median line in front of' the rectum, and some are inserted into the walls of the rectuminserted into the walls of the rectum

NS: By the branches of the anterior primary NS: By the branches of the anterior primary rami rami of the coccygeal and lower sacral nerves (for of the coccygeal and lower sacral nerves (for the the pelvic surface) and by the branches of the pelvic surface) and by the branches of the

inferior hemorrhoidal nerve (for the perineal inferior hemorrhoidal nerve (for the perineal surface).surface).

A: together with the coccygeus, forms a A: together with the coccygeus, forms a muscular muscular support for the pelvic viscera.support for the pelvic viscera.

- constricts the rectum and pulls it forward.- constricts the rectum and pulls it forward.

- The puborectalis forms a U-shaped sling around - The puborectalis forms a U-shaped sling around the anorectal junction assisting to maintain fecal the anorectal junction assisting to maintain fecal continencecontinence

-Assists the abdominal muscles in compressing the Assists the abdominal muscles in compressing the abdominal contents; they are called into use in abdominal contents; they are called into use in forced expiration, in vomiting, and in defecation.forced expiration, in vomiting, and in defecation.

- In the female, this constricts the vagina from side - In the female, this constricts the vagina from side to side; the anterior borders of the two levators act to side; the anterior borders of the two levators act in association with the bulbospongiosus muscles as in association with the bulbospongiosus muscles as a "vaginal sphincter".a "vaginal sphincter".

- The whole muscle is important in the mechanism - The whole muscle is important in the mechanism of parturition; supporting the head of the child of parturition; supporting the head of the child during the expulsive efforts of the uterus and the during the expulsive efforts of the uterus and the abdominal muscles.abdominal muscles.

IX. PELVIC JOINTSIX. PELVIC JOINTS1. Sacro-iliac joint1. Sacro-iliac joint- very strong synovial joints between the auricular - very strong synovial joints between the auricular surfaces of the sacrum and the iliac bonessurfaces of the sacrum and the iliac bones- Ligaments:- Ligaments:

a. anterior sacroiliaca. anterior sacroiliacb. posterior sacroiliacb. posterior sacroiliacc. interosseous sacroiliacc. interosseous sacroiliacd. sacrotuberousd. sacrotuberouse. sacrospinouse. sacrospinous

- the sacrospinous and sacrotuberous ligaments - the sacrospinous and sacrotuberous ligaments prevent rotation movement at the sacroiliac jointprevent rotation movement at the sacroiliac joint

- with limited amount of movement- with limited amount of movement

- mainly acts to transmit the weight of the body from - mainly acts to transmit the weight of the body from the vertebral column to the bony pelvisthe vertebral column to the bony pelvis

2. Sacro-coccygeal joint2. Sacro-coccygeal joint

- a cartilaginous joint between the bodies of - a cartilaginous joint between the bodies of the the last sacral vertebra and the first coccygeallast sacral vertebra and the first coccygeal

vertebravertebra

3. Symphysis pubis3. Symphysis pubis

- a cartilaginous joint between the 2 pubic - a cartilaginous joint between the 2 pubic bones bones

- almost with no possible movement- almost with no possible movement

X. PELVIC PERITONEUMX. PELVIC PERITONEUMThe peritoneum extends downwards from the The peritoneum extends downwards from the

posterior wall of the abdomen over the pelvic brim posterior wall of the abdomen over the pelvic brim into the pelvis.into the pelvis.As far as the 3rd piece of the sacrum, it covers As far as the 3rd piece of the sacrum, it covers

the dorsal wall as a continuous sheath. except along the dorsal wall as a continuous sheath. except along the root of the medial limb of the pelvic mesocolon the root of the medial limb of the pelvic mesocolon where it is reflected off the sacrum as the two layers where it is reflected off the sacrum as the two layers of that fold.of that fold.

At the third sacral piece, the mesocolon At the third sacral piece, the mesocolon terminates and peritoneum is spread over the front terminates and peritoneum is spread over the front and sides of the rectum and over the dorsal wall of and sides of the rectum and over the dorsal wall of the pelvic cavity on each side of it, forming the floors the pelvic cavity on each side of it, forming the floors of the pararectal fossae.of the pararectal fossae.

As these fossae are traced downwards, they As these fossae are traced downwards, they become shallower and gradually covers less and less become shallower and gradually covers less and less of the sides of the rectal wall until it reaches the of the sides of the rectal wall until it reaches the middle third of the rectum which it covers only in middle third of the rectum which it covers only in front.front.

-At the middle third of the rectum. it covers only the At the middle third of the rectum. it covers only the front.front.

- At the junction of the middle and lower thirds of the - At the junction of the middle and lower thirds of the rectum, the peritoneum leave the rectum and the rectum, the peritoneum leave the rectum and the dorsal wall of the pelvis and curves forwards to the dorsal wall of the pelvis and curves forwards to the back of the vagina and the roots of the broad back of the vagina and the roots of the broad ligaments.ligaments.it extends forwards:it extends forwards:

- As the upper layer of the broad ligament on - As the upper layer of the broad ligament on both both sides.sides.

Over the uppermost part of the back of the Over the uppermost part of the back of the vagina vagina and the intestinal surface of the uterusand the intestinal surface of the uterus

Curving over the fundus of the uterus Curving over the fundus of the uterus and the free edge of each broad ligament. it and the free edge of each broad ligament. it now passes backwards as the lower layer of now passes backwards as the lower layer of the ligament and over the lower or vesical the ligament and over the lower or vesical surface of the uterus and is then reflected surface of the uterus and is then reflected forwards to cover the upper surface of the forwards to cover the upper surface of the urinary bladder.urinary bladder.

When the bladder is empty. the When the bladder is empty. the peritoneum forms the peritoneum forms the paravesical fossae.paravesical fossae.

- As the peritoneum sweeps forwards - As the peritoneum sweeps forwards from the rectum to the vagina it forms the from the rectum to the vagina it forms the floor of the floor of the rectouterine pouch (of rectouterine pouch (of Douglas)Douglas)

- On the vesical surface of the uterus, - On the vesical surface of the uterus, the peritoneum extends down only to the the peritoneum extends down only to the junction of its body and neck and is then junction of its body and neck and is then reflected onto the bladder. making the reflected onto the bladder. making the bottom of the bottom of the utero-vesical pouchutero-vesical pouch

- From the bladder, it passes on the - From the bladder, it passes on the anterior wall of the abdomen and the sidewall anterior wall of the abdomen and the sidewall of the pelvis.of the pelvis.

X1. CLINICAL CORRELATIONX1. CLINICAL CORRELATION

A. Pelvic Measurements in ObstetricsA. Pelvic Measurements in Obstetrics

1. External Pelvic Measurements1. External Pelvic Measurements-The only method to get accurate and -The only method to get accurate and

factual information about the shape and factual information about the shape and dimensions of the pelvic cavity is by dimensions of the pelvic cavity is by x-ray x-ray pelvimetry.pelvimetry.

2.Internal Pelvic Measurements2.Internal Pelvic Measurements

Made by internal examination of the ff:Made by internal examination of the ff:

1. Pubic arch — spread fingers under the pubic 1. Pubic arch — spread fingers under the pubic arch arch to to examine its shape.examine its shape.

2. Lateral walls — palpate and check if it is 2. Lateral walls — palpate and check if it is concave, concave, straight or converging.straight or converging.

3. Posterior wall — palpate the sacrum and 3. Posterior wall — palpate the sacrum and determine if it is straight or curveddetermine if it is straight or curved

4. Ischial tuberosities — distance between the 4. Ischial tuberosities — distance between the ischial tuberosities may be estimated by using a closed ischial tuberosities may be estimated by using a closed

fist.fist.

B. Caldwel and Moloy Classification - based on the B. Caldwel and Moloy Classification - based on the diameters of the pelvic inletdiameters of the pelvic inlet

1. Gynecoid (41%)1. Gynecoid (41%)2. Android (33%)2. Android (33%)3. Anthropoid (24%)3. Anthropoid (24%)4. Platypelloid (2%)4. Platypelloid (2%)

C. Fractures of the PelvisC. Fractures of the Pelvis- Usually brought about by direct trauma.- Usually brought about by direct trauma.- Secondary hemorrhage is common cause of - Secondary hemorrhage is common cause of

death.death.- Associated with damage to pelvic viscera.- Associated with damage to pelvic viscera.

D. Uterine and Vaginal ProlapseD. Uterine and Vaginal Prolapse- Due to injury to pelvic floor via difficult - Due to injury to pelvic floor via difficult

childbirth.childbirth.

XII. ORGANS XII. ORGANS IN IN THE PELVIS THE PELVIS COMMON TO BOTH COMMON TO BOTH MALES AND MALES AND FEMALESFEMALES

1. Urinary Bladder1. Urinary Bladder

2. Sigmoid Colon2. Sigmoid Colon

3. Rectum3. Rectum

URINARY BLADDERURINARY BLADDER

I Hollow with strong muscular walls.I Hollow with strong muscular walls.- Receives the urine from the kidneys through - Receives the urine from the kidneys through

the ureters, and contains it until the muscular walls the ureters, and contains it until the muscular walls contract and expel it through the urethra in the contract and expel it through the urethra in the process of micturition.process of micturition.

- Lies in the lower anterior part of the pelvis - Lies in the lower anterior part of the pelvis immediately below the peritoneum, amidst the immediately below the peritoneum, amidst the extraperitoneal tissue, whose areolar element is extraperitoneal tissue, whose areolar element is condensed around it to ensheath it.condensed around it to ensheath it.

ADULT URINARY BLADDERADULT URINARY BLADDER

- Entirely contained in the pelvic cavity when empty.- Entirely contained in the pelvic cavity when empty.- When distended. its neck remains stationary as it - When distended. its neck remains stationary as it balloons upwards lifting up the peritoneum and balloons upwards lifting up the peritoneum and stripping it off the anterior wall of the abdomenstripping it off the anterior wall of the abdomen

CHILD URINARY BLADDERCHILD URINARY BLADDER

- Even when empty, it is in contact with the - Even when empty, it is in contact with the abdominal wall for at birth the pelvis is too small. abdominal wall for at birth the pelvis is too small. - As the pelvis enlarges. the bladder gradually sinks - As the pelvis enlarges. the bladder gradually sinks and a larger part of the bladder is accommodated in and a larger part of the bladder is accommodated in the pelvis by the sixth year. the pelvis by the sixth year. - It becomes a wholly pelvic organ shortly after - It becomes a wholly pelvic organ shortly after puberty.puberty.

RELATIONSRELATIONS

Anteriorly — related to the transversalis fascia and Anteriorly — related to the transversalis fascia and pubic hones.pubic hones.

Posterior — male: seminal vesicles, vasa deferentia, Posterior — male: seminal vesicles, vasa deferentia, pelvic colon and rectum pelvic colon and rectum

Supero-posteriorly — female: uterusSupero-posteriorly — female: uterus

SHAPE SHAPE AND AND SURFACESSURFACES- In the adult, the hardened empty bladder has - In the adult, the hardened empty bladder has

a three-sided pyramid form. a three-sided pyramid form. - A full adult bladder is spherical or widely - A full adult bladder is spherical or widely

ovoid.ovoid.

- In the infant, the bladder has an oval - In the infant, the bladder has an oval shape shape pointed at both end and the pointed at both end and the

ureters enter ureters enter it posteriorly near its lower endit posteriorly near its lower end

- In the cadaver, it may be found - In the cadaver, it may be found contracted or flaccid and collapsed by the contracted or flaccid and collapsed by the weight of the intestines.weight of the intestines.

PARTS OF THE URINARY BLADDERPARTS OF THE URINARY BLADDER

- An apex, a base and three surfaces: the - An apex, a base and three surfaces: the superior surface and a pair of infero-lateral superior surface and a pair of infero-lateral surfaces.surfaces.

- The surfaces and the base are triangular in - The surfaces and the base are triangular in outline, slightly convex and separated by well-outline, slightly convex and separated by well-defined blunt borders.defined blunt borders.

- The base and the infero-lateral surfaces - The base and the infero-lateral surfaces meet at the neck and is continuous with the meet at the neck and is continuous with the urethra.urethra.

NECK OF THE ADULT BLADDERNECK OF THE ADULT BLADDER

- In the male, it is continuous with the prostate - In the male, it is continuous with the prostate which surrounds the first part of the urethra; which surrounds the first part of the urethra;

- it is connected with the pubo-prostatic - it is connected with the pubo-prostatic ligament in front and at the sides and posteriorly it ligament in front and at the sides and posteriorly it is related to the commencement of the ejaculatory is related to the commencement of the ejaculatory ducts.ducts.

- In the female, it abruptly narrows to become - In the female, it abruptly narrows to become one with the urethra; in front and at the sides, the one with the urethra; in front and at the sides, the pubo-vesical ligaments are attached to it and is pubo-vesical ligaments are attached to it and is related posteriorly to the vagina.related posteriorly to the vagina.

APEX OF THE ADULT BLADDERAPEX OF THE ADULT BLADDERThe anterior angle of the bladder. The anterior angle of the bladder.

- It is immediately behind the upper margin of the - It is immediately behind the upper margin of the pubis about an inch from the skin.pubis about an inch from the skin.

- It is continuous with strong fibrous cord – the - It is continuous with strong fibrous cord – the median umbilical ligament which runs upward in the median umbilical ligament which runs upward in the medial line of the back of the anterior abdominal wall to medial line of the back of the anterior abdominal wall to the umbilicus; the umbilicus;

-the ligament lies in between the transversalis -the ligament lies in between the transversalis fascia and the peritoneum.fascia and the peritoneum.

- This ligament is the elongated, attenuated - This ligament is the elongated, attenuated urachus, urachus, the shrunken cephalic part of the ventral the shrunken cephalic part of the ventral section of the cloaca of the embryosection of the cloaca of the embryo

- Its lumen occasionally persists at birth and in the - Its lumen occasionally persists at birth and in the adult the vesical end of the ligament usually contains a adult the vesical end of the ligament usually contains a narrow cavity which may or may not be continuous with narrow cavity which may or may not be continuous with the cavity of the bladder.the cavity of the bladder.

SUPERIOR SURFACE:SUPERIOR SURFACE:

- Covered with peritoneum.- Covered with peritoneum.

- Since the bladder is below the peritoneum, it is - Since the bladder is below the peritoneum, it is the only surface coated by the peritoneum.the only surface coated by the peritoneum.

- The ureters join the bladder at the posterior - The ureters join the bladder at the posterior angles of this surface.angles of this surface.

- In the male, the pelvic colon and coils of the - In the male, the pelvic colon and coils of the ileum ileum rest on the upper surface.rest on the upper surface.

- In the female, it is related to the overhanging - In the female, it is related to the overhanging uterus and a loop of the ileumuterus and a loop of the ileum

INFERO-LATERAL SURFACEINFERO-LATERAL SURFACE

- Forms the dorsal wall of the retropubic - Forms the dorsal wall of the retropubic space of space of Retzius.Retzius.- Related to the retropubic fat which separates each - Related to the retropubic fat which separates each of them from the pubic bone, the obturator internus of them from the pubic bone, the obturator internus and the levator ani; as the bladder fills, it comes into and the levator ani; as the bladder fills, it comes into relation with a greater area of the side wall and the relation with a greater area of the side wall and the pelvis and with the obturator vessels and nerves.pelvis and with the obturator vessels and nerves.

BASE OR POSTERIOR SURFACEBASE OR POSTERIOR SURFACE

- It is separated from the upper surface by a - It is separated from the upper surface by a rounded border; the ureters begin to go through the rounded border; the ureters begin to go through the bladder wall at the corners where the borders join bladder wall at the corners where the borders join the posterior angles of the upper surface.the posterior angles of the upper surface.

- In the male, the seminal vesicles, and the - In the male, the seminal vesicles, and the ampulla of the vas deferens cover it, except the ampulla of the vas deferens cover it, except the small area in the middle below the upper border small area in the middle below the upper border which is covered with peritoneum of the rectovesical which is covered with peritoneum of the rectovesical pouch.pouch.

MUCOUS COATMUCOUS COAT

- When the bladder is full it is smooth but it has - When the bladder is full it is smooth but it has less elasticity, and is therefore wrinkled when the less elasticity, and is therefore wrinkled when the bladder is empty.bladder is empty.

- The - The trigone trigone is a triangular area that is a triangular area that occupies most of the inner surface of its posterior occupies most of the inner surface of its posterior wall.wall.

- In this trigone, the mucous membrane is - In this trigone, the mucous membrane is smooth even when the bladder is empty, because it smooth even when the bladder is empty, because it is elastic and is tightly bound by areolar tissue to the is elastic and is tightly bound by areolar tissue to the muscular coat.muscular coat.

- It is also thinner than the rest of the mucous - It is also thinner than the rest of the mucous coat and allows the blood in the blood vessels to be coat and allows the blood in the blood vessels to be seen through it.seen through it.

OPENINGS IN THE BLADDEROPENINGS IN THE BLADDER

There are three openings in the bladder.There are three openings in the bladder.

1. two orifices of the ureters.1. two orifices of the ureters.

2. internal urethral orifice at the commencement of 2. internal urethral orifice at the commencement of the urethra. the urethra.

- It is a y-shaped slit situated at the lower angle - It is a y-shaped slit situated at the lower angle of the trigone.of the trigone.

- Between the limbs of the slit, the mucous - Between the limbs of the slit, the mucous membrane in the male is bulged forward by the membrane in the male is bulged forward by the median lobe median lobe of the prostate.of the prostate.

VESSELS OF THE URINARY BLADDERVESSELS OF THE URINARY BLADDER

A. ArteriesA. Arteries

1. Superior vesical branches of the umbilical artery. 1. Superior vesical branches of the umbilical artery.

2. Inferior vesical branch of the internal iliac artery. 2. Inferior vesical branch of the internal iliac artery.

B. VeinsB. Veins- - Form plexuses which are dense around the neck Form plexuses which are dense around the neck

and and around the ends of the ureters.around the ends of the ureters.

- The plexuses are drained by the inferior vesical - The plexuses are drained by the inferior vesical veins.veins.

- some of them being interrupted in small - some of them being interrupted in small glands that lie on the infero-lateral surface.glands that lie on the infero-lateral surface.

- From the posterior part, some pass to the - From the posterior part, some pass to the external glands but most go to the internal iliac external glands but most go to the internal iliac nodes.nodes.

- Vessels from the neck are associated with - Vessels from the neck are associated with those from the prostate that run to the sacral and those from the prostate that run to the sacral and median common iliac nodes.median common iliac nodes.

Nerve supplyNerve supply

Upper lumbar nerves through the hypogastric Upper lumbar nerves through the hypogastric plexus (sympathetic).plexus (sympathetic).

Pelvic splanchnic which arises from the 2nd , Pelvic splanchnic which arises from the 2nd , 3rd, and 4th sacral nerves (parasympathetic) — for 3rd, and 4th sacral nerves (parasympathetic) — for emptying the urinary bladder.emptying the urinary bladder.

SIGMOID COLONSIGMOID COLON

- about 10-15 inches in length, mobile and - about 10-15 inches in length, mobile and hanging down in the pelvic cavity in the form of a hanging down in the pelvic cavity in the form of a looploopcommences at the level of the pelvic brim as the commences at the level of the pelvic brim as the continuation of the descending colon attached to the continuation of the descending colon attached to the posterior pelvic wall by the fan-shapedposterior pelvic wall by the fan-shaped

- - sigmoid mesocolon - sigmoid mesocolon - supplied by the supplied by the sigmoid branches sigmoid branches of the inferior mesenteric arteryof the inferior mesenteric arterydrained by veins corresponding to the arteriesdrained by veins corresponding to the arterieswith lymph vessels draining to the nodes along the with lymph vessels draining to the nodes along the sigmoid arteries and from these nodes, to the sigmoid arteries and from these nodes, to the inferior mesenteric nodesinferior mesenteric nodes

nerve supply: sympathetic and parasympathetic nerve supply: sympathetic and parasympathetic nerves from the nerves from the inferior hypogastric plexusinferior hypogastric plexus

RECTUMRECTUM

- the part of the alimentary canal into which the - the part of the alimentary canal into which the feces pass from the colon to await discharge from the feces pass from the colon to await discharge from the body by the act of defecation.body by the act of defecation.

- around five inches long with a diameter that - around five inches long with a diameter that varies with the bulk of its contents. varies with the bulk of its contents.

- the continuation of the pelvic colon at the - the continuation of the pelvic colon at the level of S3 vertebralevel of S3 vertebra

- becomes continuous to the anal canal at the - becomes continuous to the anal canal at the level of pelvic diaphragmlevel of pelvic diaphragm

Flexures of the RectumFlexures of the Rectum

- Other than its antero-posterior curves, it has - Other than its antero-posterior curves, it has three sideward bends, the upper and lower flexures three sideward bends, the upper and lower flexures are concave towards the left, the middle one towards are concave towards the left, the middle one towards the right the right

- Most obvious when the gut is distended.- Most obvious when the gut is distended.- Internally the flexures are marked as the - Internally the flexures are marked as the

three prominent crescenteric shelves known as the three prominent crescenteric shelves known as the horizontal folds of the rectum or horizontal folds of the rectum or Houston's valves.Houston's valves.

- The folds are produced by an infolding of the - The folds are produced by an infolding of the mucous and submucous coats and majority of the mucous and submucous coats and majority of the circular muscle coat.circular muscle coat.

- Three are usually present but the lowest of - Three are usually present but the lowest of the three is often absent or small.the three is often absent or small.

Peritoneal Covering of the RectumPeritoneal Covering of the Rectum

Upper third — with peritoneal covering at its Upper third — with peritoneal covering at its front front and its sidesand its sides

Middle third — with peritoneal covering in frontMiddle third — with peritoneal covering in front

Lower third — devoid of peritoneum. Lower third — devoid of peritoneum.

Embedded in loose fascia below the level of Embedded in loose fascia below the level of peritoneum.peritoneum.

- The only difference in the peritoneal relations - The only difference in the peritoneal relations in the female is that when the peritoneum leaves the in the female is that when the peritoneum leaves the rectum, it passes forwards on the upper part of the rectum, it passes forwards on the upper part of the back of the vagina and then onwards over the uterus back of the vagina and then onwards over the uterus and its sidesand its sides

General Relations of the RectumGeneral Relations of the Rectum

PosteriorlyPosteriorly

1. Branches of the superior rectal artery1. Branches of the superior rectal artery

2. The sacrum and coccyx and anococcygeal body in 2. The sacrum and coccyx and anococcygeal body in the middle and the piriformis, coccygeous and the middle and the piriformis, coccygeous and levator ani on each sidelevator ani on each side

3. For the side of the upper third of the rectum: loop 3. For the side of the upper third of the rectum: loop of the ileum or pelvic colon.of the ileum or pelvic colon.

4. The lower 2/3 is related to the fat on the 4. The lower 2/3 is related to the fat on the coccygeus and levator ani and to the condensed coccygeus and levator ani and to the condensed areolar tissue around the middle rectal artery.areolar tissue around the middle rectal artery.

AnteriorlyAnteriorly

In the malesIn the males

The upper 2/3, being covered with peritoneum, is The upper 2/3, being covered with peritoneum, is related to the ileum or pelvic colon. The lower third related to the ileum or pelvic colon. The lower third is separated from the bladder by the seminal is separated from the bladder by the seminal vesicles and vas deferens. and is directly related to vesicles and vas deferens. and is directly related to the sheath of the prostate below the bladder.the sheath of the prostate below the bladder.

In the femalesIn the females

The upper 2/3, being clothed with peritoneum, is The upper 2/3, being clothed with peritoneum, is related to the intestines. The lower third is directly related to the intestines. The lower third is directly related to the middle third of the vagina.related to the middle third of the vagina.

Thank you for listeningThank you for listening