8. Pelvic Walls
• Anterior pelvic wall – is
formed primarily by the
bodies and rami of the
pubic bones and the pubic
symphysis
• Lateral pelvic walls –
formed by the hip bones
and the obturator internus
muscles , obturator
membrane,sacrotuberous
and sacrospinous
ligaments.
11. PELVIC DIAPHRAGM- pelvic
floor (inferior wall)
• It is a gutter shaped,
muscular partition
which separates the
pelvic cavity from the
perineum.
• It surrounds the
anal canal
vagina and
urethra
.
12. Components or Parts
• Two muscles on each side:
I.Levator Ani II. Coccygeus. (large muscle)
III.Obturator internus IV. Piriformis (small muscle)
• Two fasciae enclosing the muscles:
I. Superior fascia of pelvic diaphragm.
II. Inferior fascia of pelvic diaphragm.
Morphologically Levator ani and coccygeus form a
single entity which is divided into
pubococcygeus
iliococcygeus
Ischiococcygeus
LEVATOR ANI
COCCYGEUS
15. Openings of the pelvic diaphragm
• HIATUS URO-
GENITALIS:
• HIATUS
RECTALIS:
• HIATUS OF
SCHWALBE?
16. PERINEAL BODY
• pyramidal fibro-muscular
node intervencing
between anal canal and
urogenital apparatus.its
apex receives attachment
to rectovescile fascia.
17. Applied Anatomy
• Perineal body may be
torn in female during
parturition. If it is
not properly
repaired, hiatus uro-
genitalis becomes
wider when the
Levator Ani
contracts. Through
this gap pelvic
viscera may be
displaced downwards
producing prolapse of
the uterus.
21. Levator ani
• Levator prostatae or
sphincter vaginae :
• The anterior fibres
form a sling around the
prostate ( levator
prostste) or vagina
(sphincter vaginae).
• Inserted into the
perineal body infront of
the anal canal.
23. • Pubo-rectalis:
• The fibers which wind round the posterior aspect of the ano-
rectal junction and are continuous with the fibers of opposite
muscle. It lies at a lower level than the ano-coccygeal raphe and
forms a part of ano-rectal ring to maintain the continence of faeces.
25. Levator ani- insertion
• Anterior fibres:
Levator prostatae or
sphincter vaginae-
perineal body
• Intermediate fibres:
puborectalis-
anococcygeal raphe
• Posterior fibres-
iliococcygeus-
anococcygeal raphe
and coccyx
26.
27. Levator Ani
NERVE SUPPLY AND ACTION
• Innervated by the perineal branch of S4 from its
pelvic surface.
• Perineal branch of the pudental nerve S2,S3 from its
perineal surface.
• Help to support the pelvic viscera; acting together
they raise the pelvic floor and assist the abdominal
muscles in forced expiration activities.
29. Coccygeus muscle
• This muscle is also
known as ischio-
coccygeus.
• Triangular in shape
• Lies behind Levator
Ani muscle
• Most of the
posterior fibers
degenerate to form
the sacro-spinous
ligament
NERVE SUPPLY: by
the 4th & 5th sacral
nerves.
coccygeus
30. Coccygeus Muscle
• Origin: ischial spine and
sacrospinus ligament,
Insertion: inferior end of
the sacrum,and upper
two pieces coccyx
• Innervation: branches of
S4 and S5
• Action :Forms a small
part of the pelvic
diaphragm that supports
the pelvic viscera, flexes
the coccyx
31.
32. FUNCTION OF LEVATOR ANI
• Supports pelvic viscera and counteracts the
downward thrust of the diaphragm during intra
abdominal pressure.
• Male, anterior fibres of levator ani elevates
prostate –levator prostatae.
• Female-anterior fibres constricts the vagina and
acts as sphincter vaginae,prevents downwards
displacement of uterus through vaginal canal
• Coccygeus muscle pulls the coccyx forwards after
it is displaced during defecation or parturition.
33. CONTD
• Defaecation:pubo rectal sling relaxes and rectum
and anal canal form a straight line,at the same
time pubo anal fibres elevates anus.
• In parturition –pubo rectal sling , upon which
foetal head rests, allow forward rotation of the
head into the lower part of birth canal.
• Micturation-pubo coccygegei relax as intra
abdominal presuure rises and bladder neck
descends,stimulates contraction of detrusor
muscle of urinary bladder and helps to void urine.
38. • Nerve supply :
nerve to obturator
internus
(L5,S1,S2)
• Action:
1. Helps to stabilize
the hip,
2. Lateral rotator of
femur in erect
posture and the
abductor of
femur when the
hip joint is flexed.
39. Piriformis: triangular muscle one on either
side on the front of the posterior wall of true
pelvis.
• Origin:The piriformis
muscle originates from
the anterior surface of
the sacrum (S2 vertebrae
to S4), the upper margin
of the sciatic notch, the
Sacro tuberous ligament
and adjoining areas of
the sacroiliac joint.
• Insertion: The piriformis
then inserts into the
superior medial aspect of
the greater trochanter of
the femur .
• Nerve supply: Ventral
rami of first and second
sacral nerves S1 S2.
40.
41. • There are several clinical tests but no single test is specific for piriformis syndrome
1. Piriformis sign - In supine position when the patient is relaxed the
ipsilateral foot is externally rotated and active efforts to bring the
foot in midline results in pain which is otherwise a positive sign.
2. Lasegue sign or straight leg raise (SLR test) - In a supine position, the
hip and knee is flexed to 90 degrees then keeping the hip
flexed extend the knee , if the patient reports posterior thigh pain it
is a positive lasegue test.
3. Freiberg sign - Pain is experienced during passive internal rotation of
hip joint.
4. Pace sign - Pace sign, revealed with the FAIR (flexion, adduction, and
internal rotation test, involves the recreation of sciatic symptoms.
42. 1. The FAIR test - performed with the patient in a side lying position,
with the affected side up, the hip flexed to an angle of 60 degrees,
and the knee flexed to an angle of 60 degrees to 90 degrees. The hip
is stabilised and the examiner internally rotates and adducts the hip
by applying downward pressure to the knee. Alternatively, the FAIR
test can be performed with the patient supine lying or seated with
the knee and hip flexed, the hip is medially rotated. The patient
resists external rotation and abduction of the hip. The FAIR test
result is positive if sciatic symptoms are recreated.
2. Beatty test - Lying on the unaffected side, lift and hold the superior
knee approximately 4 inches off the examination table. If sciatic
symptoms are recreated, the test result is positive.
43.
44. PELVIC FASCIA:2 layers
• Parietal layer:
Continuation of fascia
transversalis of anterior
abdominal wall.
1. Obturator fascia :covers
obturator internus
muscle.
2. fascia covering piriformis
: thin layer . sacral
plexus lies between this
fascia and piriformis
muscle.
3. superior fascia of pelvic
diaphragm: cover
superior surace of pelvic
diaphragm
• Visceral layer :
• condensation of loose areolar
tissue around the extra
peritoneal parts of viscera and
blood vessels.
• Its loose, thin around urinary
bladder thick around prostate.
• Its condensation around the
neurovascular structures form
the ligament of the pelvic organs-
supports the pelvic organs
urinary bladder and uterus.
45.
46. Peritoneum of pelvis :
• Male pelvis : passes down from
the anterior abdominal wall on to
the superior surface of urinary
bladder , passes down on the
posterior surface of the urinary
bladder till it reaches upper end of
seminal vesicle , then it turns
backwards to reach anterior
aspect of rectum forming a
shallow peritoneal pouch
Rectovesical Pouch.
• The peritoneum then passes up on
the front of middle third of rectum
and front and lateral aspect of the
upper third of rectum-then its
becomes continuous with parietal
layer of the peritoneum. then it
reflected on the anterior aspect of
the rectum to form deep
rectouterine pouch in female.
47. • Female pelvis :peritoneum
passes down from the anterior
abdominal wall on the superior
surface of the urinary bladder,
then passes down a little on its
posterior surface to be
reflected on the anterior
surface of the uterus forming
the uterovesical pouch.
• Covers the top of uterus
passes on its posterior surface
and posterior aspect of the
posterior fornix of the vagina,
then it reflected on the anterior
aspect of the rectum to form
deep rectouterine pouch.
48. Nerves of pelvis :
somatic and autonomic nerves
• Somatic nerves :
• Lumbosacral trunk,
• sacral plexus and
• coccygeal plexus .
• SACRAL PLEXUS :LIES
INFRONT OF PIRIFORMIS
DEEP TO PELVIC FASCIA
IN THE POSTERIOR WALL
OF TRUE PELVIS.
• VENTRAL RAMI EMERGE
FROM VENTRAL SACRAL
FORAMEN AND UNITE
INFRONT OF THE
PIRIORMIS WHERE THEY
ARE JOINED BY THE
LUMBOSACRAL TRUNK.
49.
50. Ureter
• The two ureters are muscular tubes that extend from
the kidneys to the posterior surface of the urinary
bladder
• The urine is propelled along the ureter by peristaltic
contractions
• Each ureter measures about 25 cm long
• Have three constrictions along its course, where the
renal pelvis joins the ureter, where it is kinked as it
crosses the pelvic brim, and where it pierces the
bladder wall
51. Ureter
• The renal pelvis is the funnel-shaped expanded
upper end of the ureter
• It lies within the hilum of the kidney and receives the
major calyces
• It enters the pelvis by crossing the bifurcation of the
common iliac artery in front of the sacroiliac joint
• It runs down the lateral wall of the pelvis and turns
forward to enter the lateral angle of the bladder
52.
53. Relations, Right Ureter
• Anterior: The duodenum, the terminal part of
the ilium, the right colic and iliocolic vessels,
the right testicular or ovarian vessels, and the
root of the mesentery of the small intestine
• Posterior: The right psoas muscle, and the
bifurcation of the right common iliac artery
54.
55. Relations, Left Ureter
• Anterior: The sigmoid colon and sigmoid
mesocolon, the left colic vessels, the left
testicular or ovarian vessels
• Posterior: The left psoas muscle, and the
bifurcation of the left common iliac artery
56. Blood Supply
• Upper end is supplied by the renal artery
• Middle portion is supplied by testicular or ovarian
artery
• In the pelvis is supplied by the superior vesical artery
• The lymph drains to the lateral aortic nodes and the
iliac nodes
57.
58. Nerve Supply
• Renal, testicular (or ovarian), and hypogastric
plexus (in the pelvis)
• Afferent fibers travel with the sympathetic
nerves and enter the spinal cord in the first
and second lumbar segments
60. Mega ureter
• Ureters wider than 7 to 8 mm
• Normal ureteral diameter is rarely greater than 5
mm
• Primary MGU is 2-4 times more common in boys
than girls
• Slight predilection (1.6 to 4.5 times) for the left
side
• Bilateral in approximately 25% of patients
• In 10% to 15% of children contralateral kidney may
62. Pathophysiology
• Distal end of the ureter, as it becomes intramural
and subsequently submucosal, rearranges the
muscular layers in its wall.
• All layers become longitudinally oriented
• Ureteral adventitia fuses to the bladder trigone by
attachment to Waldeyer's sheath
• Sympathetic and parasympathetic innervation to the
distal ureter and UVJ area is believed to modulate
primarily ureteral peristalsis
63. Diagnosis
Ultrasound
• Distinguishes MGU from UPJ obstruction based
on the presence or absence of a dilated ureter
VCUG
• to rule out reflux
Renal scintigraphy
• Provides objective, reproducible parameters of
function and obstruction
64. Whitaker's perfusion test & ureteral
opening pressure
• To evaluate obstruction, but their invasiveness
and requirement for anaesthesia are drawbacks
in children
Magnetic resonance urography
66. Management
Primary Refluxing Megaureter
• Medical management is often the initial approach
• Surgery
– Endoscopic subureteric injection, is recommended
for persistent high-grade reflux in older children
• Reconstructive surgery of a dilated ureter
– distal ureterostomy for unilateral reflux
– vesicostomy for bilateral disease
67. • Secondary Refluxing or Obstructive
Megaureter
– Management of secondary MGUs is initially
directed at their root cause
• Primary “Dilated” Nonrefluxing
Megaureter: Nonobstructive versus
Obstructive
– Expectant management is preferred
– Antibiotic suppression & radiologic surveillance is
appropriate in most cases
– Surgical correction
68. • Surgical Options
– Plication or infolding for moderately
dilated ureter
Complications
Persistent reflux and obstruction
Postoperative VUR
69. Ectopic ureter
• Ureter whose orifice terminates anywhere
other than the normal trigonal position
• Lateral ectopia : an orifice more cranial
and lateral than normal
• Caudal ectopia : orifice is more medial
and distal than the normal position
70. • 80% are associated with a duplicated collecting system
• Females :
– More than 80% are duplicated
– Urethra and vestibule are the most common sites
• Males:
– most ectopic ureters drain single systems
– posterior urethra is the most common site
• Drainage into the genital tract involves the seminal
vesicle three times more often than the ejaculatory
duct and vas deferens combined
