PELVIC WALL

By Dr/ Elsayed Metwally Lecturer of anatomy and embryology

Pelvic muscles
Piriformis muscle Pelvic wall muscles Obturator internus muscle

Coccygeus muscle Pelvic floor muscles Levator ani muscle

Piriformis muscle:
Origin: pelvic surface of
middle 3 sacral pieces.

Insertion: top of greater

trochanter of femur.

Nerve supply: S1, S2. Action: lateral rotation of

thigh.

Obturator internus:
Origin: inner surface of obturator membrane Margins of obturator foramen. Insertion: medial side of greater trochanter of femur. Nerve supply: nerve to obturator internus Action: lateral rotation of thigh

Obturator fascia
-It covers the pelvic surface of obturator internus. -It is thickened in its upper part, forming what is called tendinous arch=white line. The tendinous arch gives attachment to levator ani muscle.

Levator ani muscle:

Origin: white line of obturator fascia (tendinous arch). Insertion: it can be differentiated into 3 parts:

Insertion:
1. Pubococcygeus : into perineal body & tip of coccyx fibers of this part pass across the side of prostate in male (levator prostate) and across the side of vagina (sphincter vagina) in female. 2. Iliococcygeus: into the sides of the last 2 pieces of coccyx and anococcygeal raphe which extends from apex of the coccyx to anorectal junction 3. Puborectalis: form a U shaped sling which helps the deep part of external anal

 Nerve supply: Ventral rami of S3,4 sacral

nerve and inferior rectal nerve. Action of levator ani: 1. Acting together both muscles increase the intraabdominal pressure so, it helps in defecation and labour. 2. Puborectalis, supports external anal sphincter. 3. Pubococcygeus: supports the prostate in male and acts as sphincter for vagina in female

during labour, perineal body may be torn leading to prolapse of uterus because the gap between the anterior border of the 2 levator ani becomes wider

Coccygeus muscle
Origin: tip of ischial
spine. Insertion: sides of the last 2 sacral pieces and 1st coccygeal piece NS: ventral ramus of S4.5 Action: support pelvic floor

Nerves of the pelvis

Sacral plexus

Sympathatic chain

SACRAL PLEXUS
formation: ventral rami of L4,5 (lumbosacral trunk) and S1,2,3,4 . Site: in front of piriformis between it and its fascia

Branches of the plexus:

Ventral branches= 3p From roots=6 Dorsal branches=3p

From the plexus=6

Ventral branches=3

Dorsal branches=3

Branches of the plexus:

A) from the roots of the plexus:(3p+3p=6p) Ventral branches :
1-Pudendal nerve (S2,3,4).(for genitalia) 2-Pelvic splanchnic nerve (S2,3,4)(for pel viscera) 3-Perineal branch of S4 ( external anal sphincter). Dorsal branches: 1-Piriformis nerve (S1,2) 2-Posterior cutaneous nerve of thigh (S2,3). 3-Perforating cutaneous nerve (S2,3).

From the plexus itself:

ral branches:

Tibial part of sciatic nerve (L4,5-S1,2,3) Nerve to quadratus femoris (L4,5-S1). Nerve to obturator internus (L5- S1,2).

Tib Qam Obturator Ya SICO

Dorsal branches:

Superior gluteal nerve (L4,5-S1). Inferior gluteal nerve (L5- S1,2). Common peroneal nerve (L4,5-S1,2)

PELVIC PART OF SYMPATHETIC TRUNK

Definition: it is the lower part

of the sympathetic chain which enters the pelvis by crossing the front of ala of the sacrum. Course & relations: The right and left one descends in front of sacrum medial to ventral sacral foramina. They unite together in front of the coccyx by a small ganglion called ganglion impar. Each trunk has 4 sacral ganglions.

Branches:
It GIVes three branches:
1. Grey rami communicantes (postganglionic fibers) to join all sacral and coccygeal nerves. 2. Branches to inferior hypogastric plexus. 3. Vascular branches to the arteries of perineum & lower limb.

PELVIC VESSELS
INTERNAL ILIAC
ARTERY Origin: It is one of the 2 terminal branches of the common iliac artery. Termination: It ends by division into anterior and posterior division near the upper border of greater sciatic foramina

Branches of the anterior division

Parietal branches:oI 1.Obturator artery. 2.Inferior gluteal artery. 3.Internal pudendal
artery.

Visceral branches:
1-Umbilical artery and its superior vesical branch. 2-Inferior vesical artery (in male) (vaginal artery in female). 3- Uterine artery (in female). 4-Middle rectal artery

Branches of the posterior division (ILS)

1. Iliolumbar artery. 2. Two lateral sacral arteries. 3. Superior gluteal artery.

Some points about the branches of the internal iliac artery (IIA):
Obturator artery:
It runs forwards on the side wall of the pelvis to pass through the obturator canal to enter the thigh. Inferior gluteal artery It is one of the two terminal branchs of the anterior division. It passes through the greater sciatic notch below the piriformis to enter the gluteal region, supplying the gluteal muscles.

Umbilical artery
It is the highest branch of the anterior division of
the IIA. It passes forwards on the side wall of the pelvis, and then ascends upwards on the back of the anterior abdominal wall to reach the umbilicus. Its proximal part gives the superior vesical artery to supply the bladder. Its distal part becomes obliterated and forms the medial umbilical ligament.

Inferior vesical artery

It supplies the base of the bladder,
prostate, lower part of the ureter and seminal vesicle. It gives origin for the artery of vas deferens

Middle rectal artery

-It passes medially to reach the middle of the rectum. -It supplies the seminal vesicle ad prostate in males. Uterine artery -See the uterus later on.

Iliolumbar artery
It passes upwards and laterally to divide into
iliac and lumbar branches, supplying the 3 muscles; iliacus, psoas major and the quadrates lumborum. Lateral sacral arteries Two in number, each one divides into two. So the end result is 4 pairs of lateral sacral arteries. Each pair of the artery passes through the anterior sacral foramina to supply the contents of the sacral canal.

Superior gluteal artery

It is the continuation of the posterior
division of the IIA. It descends between the 2 nervous structures; lumbosacral and 1st sacral It leaves the pelvis through the greater sciatic notch above the piriformis to enter the gluteal region, supplying the gluteal muscles.

MEDIAN SACRAL ARTERY

Origin: the back of the
abdominal aorta just above its bifurcation. Termination: it ends by formation of a swelling called Glomus coccygeum, in front of the coccyx. Branches: 1. 5th lumbar artery. 2. branches to the sacral canal. 3. branches to the rectum. Embryologically, this artery represents the continuation of the aorta.

PELVIC FASCIA
It can be divided into: Parietal: it covers the pelvic wall as: - fascia over the obturator muscle (obturator fascia), - fascia over the piriformis (Piriformis fascia). Visceral (endopelvic fascia): it lies in between the pelvic organs. It is in the form of either: -Loose areolar CT around distensible organs (as urinary bladder, vagina and rectum). -Tough and membranous around non-distensible organs (as prostate).

Fascia of pelvic floor:

Superior fascia of pelvic diaphragm: it covers the superior surface of levator ani. Inferior fascia of pelvic diaphragm: it covers the inferior surface of levator ani. Pelvic ligaments: as the lateral ligament of the urinary bladder, lateral ligament of the uterus (Cardinal ligament), Waldayer s ligament (in front of the rectum), puboprostatic, pubovesical, uterosacral and round ligament of the uterus.

Obturator fascia:
It covers the obturator internus muscle. It is thickened along a line from the ischial
spine to back of the body pubic bone forming the white line. It is splitted 1.5 inches above the ischial tuberosity to form the pudendal canal

Thank you
Dr El-sayed Metwally