The Pelvis Ii

THE PELVIS II
Dr. Mbira
The walls of the pelvis
• Anterior(antero-inferior) wall
• Bodies and rami of the pubic bones as well as the pubic symphysis.
• Posterior(postero-lateral) wall
• Piriformis muscle
• Lateral walls
• Obturator membrane covering the obturator foramen.
• Obturator internus muscle
Pelvic floor
• The floor of the pelvis supports the pelvic organs/viscera and is
formed by the pelvic diaphragm.
• It stretches across the bottom of the pelvis and divides it into the
pelvic cavity above and the perineum below.
• The pelvic diaphragm is formed by the larger levator ani muscle and
the smaller coccygeus muscle.
• The pelvic floor has a large opening anterior called the urogenital
hiatus that allows the passage of the urethra in males and the vagina
and urethra in females.
• Levator ani is a broad sheet of muscle that has several components:
Pelvic floor
• Levator ani originates from:
• The back of the body of the pubic bone
• The fascia covering obturator internus
• The spine of the ischium.
• It inserts thus:
• Anterior fibres(levator prostatae/sphincter vaginae) insert into the perineal body.
• The intermediate fibres
• Pubococcygeus inserts into the anococcygeal body.
• Puborectalis forms a sling around the junction between the rectum and the anus.
• The posterior fibres(iliococcygeus) insert into the anococcygeal body and the
coccyx.
• Coccygeus muscle arises from the ischial spines and inserts into the
sacrum and coccyx.
• The levator ani and coccygeus muscles help to support the pelvic
viscera with levator ani being the main support.
• Levator ani fibres that surround the (prostatic)urethra, vagina and
anorectal junction act as sphincters.
• Levator ani is innervated by a perineal branch of the 4th sacral nerve
and also a perineal branch of the pudendal nerve.
• Coccygeus is innervated by branches of the 4th and 5th sacral nerves.
Nerves
• Sacral and coccygeal nerves and the pelvic part of the autonomic
nervous system.
• The piriformis and coccygeus muscles on the posteroinferior walls of
the pelvis are intimately associated with these nerves as the exit from
the vertebral column with the nerve fibres interdigitating with the
muscle fibres in some instances.
Sacral plexus
• It is joined just below the pelvic brim by the lumbosacral trunk(L4,L5).
• Most of the nerves arising from this plexus exit the pelvis via the greater
sciatic foramen.
• Branches include:
• Sciatic – largest nerve in the body
• Pudendal – main nerve of the perineum
• Superior and inferior gluteal
*Obturator nerve runs in the lateral wall of the pelvis but does not supply any
pelvic structure.
• The coccygeal plexus is formed by S4,5 and the coccygeal nerves. It
supplies the muscle coccygeus, part of levator ani and a bit of skin
between the anus and coccyx.
• The pelvic autonomic nerves carry both sympathetic and
parasympathetic innervation to the pelvic viscera as well as
vasomotor sympathetic innervation to pelvic vessels and to vessels of
the lower limbs.
• 4 main divisions of pelvic autonomic nerves:
• Sacral sympathetic trunks – provide sympathetic innervation to lower limbs.
• Periarterial plexus on major pelvic arteries(internal iliac, gonadal, superior
rectal) – provide sympathetic vasomotor innervation to these vessels and
their branches.
• Hypogastric plexus – Sympathetic innervation to pelvic viscera.
• Pelvic splanchnic nerves – Parasympathetic innervation to pelvic viscera, as
well as descending and sigmoid colon.
• The hypogastric and pelvic splanchnic nerves normally merge in the

pelvis.
• Visceral afferent innervation of the pelvis is carried by both
sympathetic and parasympathetic fibres.
• Reflex sensation concerning the viscera is carried by parasympathetic
fibres to the spine.
• Visceral afferents above the pain line(above the peritoneal reflection)
are transported by the sympathetic nerves i.e the hypogastric plexus
while afferents below the pain line are carried by the parasympathetic
nerves.
Blood vessels
• There is a rich network of anastomoses and collaterals in the pelvis.
• In females, there are 6 arteries entering the lesser/true pelvis while in
males there are 4:
• Paired internal iliac and ovarian(in females) arteries.
• Single median sacral artery.
• Single superior rectal artery.
• The internal iliac artery(from common iliac) is the main supply.
• The external iliac courses on the lateral wall but does not give
branches.
• The superior rectal artery is the distal continuation of the inferior
mesenteric artery. At the level of S3 it divides into 2 branches that descend
on each side of the rectum and anastomose with middle and inferior rectal
arteries.
• The median sacral artery is a small vessel that arises posteriorly from the
abdominal aorta just proximal to its bifurcation as the common iliacs.
• The ovarian/testicular arteries arise from the aorta just inferior to the renal
arteries.
• The internal iliac runs for a short course(about 4cm) after arising from the
bifurcation of the common iliac and at the superior border of the greater
sciatic foramen divides into an anterior and posterior division.
• The anterior division supplies the pelvic viscera i.e bladder, rectum and
reproductive organs:
• Umbilical artery – Gives off superior vesical artery which in turn gives off the artery to the
vas deferens.
• Obturator artery
• Inferior vesical/vaginal artery – Inferior vesical(in males) may also be the origin of the
artery to the vas.
• Middle rectal
• Uterine
• Internal pudendal – its terminal branches are the deep and dorsal arteries to the
penis/clitoris. Internal pudendal also gives off the inferior rectal artery.
• Inferior gluteal artery – supplies the muscles and skin of the gluteal region and posterior
thigh.
• The posterior division of the internal iliac has 3 branches:
• Superior gluteal
• Iliolumbar
• Lateral sacral
• The venous drainage:

• Pelvic venous plexuses around the viscera form veins that follow the arteries and
eventually join to form the internal iliac vein which join with the external iliac vein to
form the common iliac vein.
• Venous blood can also drain through the superior rectal vein into the inferior
mesenteric vein and onto the portal venous system.
• Another route is through the lateral sacral veins to the internal vertebral venous plexus.
Lymphatics
• Lymphatics are arranged in clusters around the major vessels but the
rectum also has some groups of lymphnodes arranged around it.
• The 4 main groups are:
• External iliac lymph nodes – lie above the pelvic brim and receive lymph from
superior part of the pelvis.
• Internal iliac lymph nodes – lie deep in the pelvis and receive from inferior
parts of the pelvis, deep perineum and the gluteal region.
• Sacral lymph nodes – located along the median sacral artery and receive from
the posteroinferior part of the pelvis.
• Common iliac lymph nodes – receive lymph from the above 3 groups.

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THE PELVIS II

• The hypogastric and pelvic splanchnic nerves normally merge in the

• The venous drainage:

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