Uro gynaecology- antomy of perineum

1. Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical
College
Chennai 1

2. Professors:
 Prof. Dr. G. Sivasankar, M.S., M.Ch.,
 Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr. J. Sivabalan, M.S., M.Ch.,
 Dr. R. Bhargavi, M.S., M.Ch.,
 Dr. S. Raju, M.S., M.Ch.,
 Dr. K. Muthurathinam, M.S., M.Ch.,
 Dr. D. Tamilselvan, M.S., M.Ch.,
 Dr. K. Senthilkumar, M.S., M.Ch.
Dept Of Urology, KMC and GRH,
Chennai 2

3.  Narrow area of soft parts located between the
musculature of the gluteal and thigh areas
 Has a diamond shape configuration , bordered
by the ischiopubic rami and pubic symphysis
anterior half- UROGENITAL TRIANGLE
posterior half- ANAL TRIANGLE
- located below the pelvic diaphragm, fascia of
pelvic diaphragm in the region of urogenital
hiatus is fused
with inferior fascia of urogenital diaphragm
Dept Of Urology, KMC and GRH,
Chennai 3

4. Dept Of Urology, KMC and GRH,
Chennai 4

5.  Anterior- pubic symphysis
Anterolateral- ischiopubic rami
Inferolateral- ischial tuberosities
Posterolateral- sacrotuberous ligaments and
gluteus maximus
Posterior- coccyx
 SUBDIVISIONS; A Imaginary line between the
two ischial tuberosites divides the perineal into
two regions anterior – urogenital triangle,
posterior- anal triangle
Dept Of Urology, KMC and GRH,
Chennai 5

6. Dept Of Urology, KMC and GRH,
Chennai 6

7.  Boundaries
Lateral - Ischiopubic rami
Posterior - imaginary line b/w ischial
tuberosities
Anterior - inferior margin of pubic
symphysis
Roof - Levator ani muscle
Dept Of Urology, KMC and GRH,
Chennai 7

8. Dept Of Urology, KMC and GRH,
Chennai 8

9. From superficial to deep
 Skin and adipose tissue
 Membranous layers of superficial fascia
 Superficial perineal pouch
 Deep perineal pouch or urogenital diaphragm
Dept Of Urology, KMC and GRH,
Chennai 9

10.  Known as camper’s fascia , similar layer in ant
abdominal wall
 Layers of tissue continues into the anal triangle
of perineum posteriorly
 Provides the bulk of tissue occupy the ishioanal
fossae on either side of midline raphe
Dept Of Urology, KMC and GRH,
Chennai 10

11.  Deep to camper’s fascia
 counter part of scarpa’s fascia of abdominal
wall
 Attached to to ischiopubic rami laterally and to
posterior edge of urogenital musculature
posteriorly
 Provides an anatomic barrier between the
urogenital spasces anteriorly and ischioanal
fossae posteriorly
Dept Of Urology, KMC and GRH,
Chennai 11

12. Dept Of Urology, KMC and GRH,
Chennai 12

13. Dept Of Urology, KMC and GRH,
Chennai 13

14.  Space between the fascia of gallaudet and perineal
membrane
Composed of followed structures
 External perineal fascia of gallaudet
 Muscles of superficial compartment
-Ischiocavernous
- Bulbospongiosus
-Superficial transverse perineus
 Paired Erectile tissues
- corpora cavernosa
- corpora spongiosa
Dept Of Urology, KMC and GRH,
Chennai 14

15.  Right & left vestibular glands (Bartholins)
 Perineal membrane
 Vasculature
 Nerves
Dept Of Urology, KMC and GRH,
Chennai 15

16. Dept Of Urology, KMC and GRH,
Chennai 16

17.  most superficial in the superficial pouch
 covers the external abdominal oblique muscle
and deep fascia
 Covers the muscle and b/w the erectiles , joins
the deeper lying perineal membrane
Dept Of Urology, KMC and GRH,
Chennai 17

18.  ISCHIOCAVERNOSUS;
- Paired muscle have bony origin that begins
posteriorly at the anterior part of the ischial
tuberosities and continues forward in the
ischiopubic ramus
- inserts upon tunica albuginea of proximal
parts of shafts of corpora
-contraction of ischiocavernosus results in
constriction of venous flow from corpous
cavernosa penis that contributes to erection of
penis
Dept Of Urology, KMC and GRH,
Chennai 18

19. Dept Of Urology, KMC and GRH,
Chennai 19

20.  Arise from perineal body and membrane
 Join in the midline of male penile bulb by
fusing along midline raphe
 Assists in urethral compression in micturition
and ejaculation
Dept Of Urology, KMC and GRH,
Chennai 20

21.  Arise bilaterally from ischial tuberosities and
insert anteromedially into centrally perineal
body
 Assisting in maintenance of faecal and urinary
incontinence
 Supplied by perineal branch of pudendal nerve
Dept Of Urology, KMC and GRH,
Chennai 21

22. Dept Of Urology, KMC and GRH,
Chennai 22

23.  Crura arise from ischial tuberosities and rami of ischia
 Two crura are attached to pubic bone by deep fascial
connection and bend ventrally become corpus
cavernosa, joined in midline fibrous septum,
 ventral groove between occupied by corpus
spongiousm
 Each corpus cavernosa is surrounded by tough fibrous
tunica albuginea , join at median septum ,this septum
perforated distally
 Appropriate stimuli and para sympathetic out flow
results in vasodilatation of arteries and relaxation of
smooth muscle with compression of pheripheral
venules against tunica albuginea provides basis for
erection
Dept Of Urology, KMC and GRH,
Chennai 23

24. Dept Of Urology, KMC and GRH,
Chennai 24

25.  Midline corpus spongiosum ends as glans
penis and transmits penile urethra,
surrounded by a dense fibroelastic tunica
albuginea
 begins as expanded penile bulb, formed by
fusion of two analagen within superficial
perineal pouch , urethra passes into penile bulb
after transversing urethral sphincter and
perineal membrane
 At distal end of pendoulous portion of penis ,
urethral lumen expands as fossa navicularis
Dept Of Urology, KMC and GRH,
Chennai 25

26. Dept Of Urology, KMC and GRH,
Chennai 26

27.  LIE within the superficial pouch, deep to
proximal ends of vestibular bulbs and on either
side of vaginal introtius
 Ducts of these mucous secreting glands open at
5,0 & 7’0 clock positions relative to vaginal
introtius
Dept Of Urology, KMC and GRH,
Chennai 27

28.  Provides roof for superficial pouch and floor for
deep pouch
 Free posterior border anchored in midline to
perineal body & attach laterally to pubic arch
 Superior to perineal membrane- deep perineal
pouch contain layer of skeletal and neuro vascular
tissue
 Perineal membrane and deep perineal pouch
provide support for external genitalia attach to
inferior surface
Dept Of Urology, KMC and GRH,
Chennai 28

29. Dept Of Urology, KMC and GRH,
Chennai 29

30.  Fibromuscular layer between pelvic floor limited
inferoirly by perineal membrane
 Superiorfascia
peri prostatic sheath is composed of pelvic fascia and
aponeurotic tissue , this tissue anchors prostate to sheath of the
bladder above , urogenital diaphragm inferiorly , levator ani
laterally , rectovesical fascia posteroirly.
superior layer of pelvic diaphragm and perineal membrane fuse
anteroirly, form tough fibrous- transverse perineal ligament
Inferior fascia
located between two sides of pubic arch is known as perineal
membrane
deep fascia on inferior fascia is thickened to form perineal
membrane continous with deep layer fascia anteriorly and
posteriorly ; perineal membrane is pierced by urethra
Dept Of Urology, KMC and GRH,
Chennai 30

31.  Deep transversus perineus
 Sphincter urethra
 Compressor urethra
 Sphincter uretherovaginalis
 Transversus vaginalis
Dept Of Urology, KMC and GRH,
Chennai 31

32. Dept Of Urology, KMC and GRH,
Chennai 32

33.  Deep tranversus perineus ;
arise from fascia of pudendal canal , dorsal to
distal to distal part of sphincter urethra ,
intermingled with sphincter urethra, external
anal sphincter & smooth muscle of
rectourethral muscle
 Sphincter urethra ;
inferior to prostate in urogenital hiatus, fibers
of sphincter urethra are omega like , below the
pelvic diaphragm ,sphincter expands to fill
interval between the pudendal canals.
Dept Of Urology, KMC and GRH,
Chennai 33

34. Dept Of Urology, KMC and GRH,
Chennai 34

35.  COMPRESSOR URETHRA;
arises laterally as slendor tendon near the
anterior border of ischial tuberosity, expands as
band it reaches the urethra and becomes
continous with muscle of opposite side
SPHINCTER URETHROVAGINALIS
thin flat muscle that surronds both vagina
and urethra,fibers are continous across the
midline vagina and continous with compressor
urethrae ventrally.
Dept Of Urology, KMC and GRH,
Chennai 35

36.  TRANVERSUS VAGINALIS
Fan shaped muscle from compressor
urethrae to inserts into anterior halfof lateral
wall of vagina , superoir to level of
urethrovaginalis
Dept Of Urology, KMC and GRH,
Chennai 36

37. Dept Of Urology, KMC and GRH,
Chennai 37

38.  Most significiant artery – internal pudendal
artery
orginates as a branch of anteroir trunk of
internal iliac artery , passes around ischial
spine enter perineum by course thro lesser
sciatic foramen& accompany pudendal nerve
BRANCHES;
- Inferior rectal artery
- perineal artery
- branches to erectile tissue of penis & clitoris
Dept Of Urology, KMC and GRH,
Chennai 38

39. Dept Of Urology, KMC and GRH,
Chennai 39

40.  Inferoir rectal artery;
orginates from IPA in anal cross ischio anal
fossa medially to branch supply muscle and
skin
anastomoses with middle and superior rectal
artery to form network of vessel
PERINEAL ARTERY;
branch of IPA runs thro perineal membrane ,
supplies transversus perini, perineal body &
posterior attachment of bulb of penis
posterior scortal artery –terminal branch
supplies the scrotal skin & dartos muscle
,perineal membrane
Dept Of Urology, KMC and GRH,
Chennai 40

41.  Internal pudendal artery gives a branch to bulb
of penis before it divides into deep and dorsal
artery of penis
Artery to bulb supplies corpus spongiousm
Deep artery of penis supplies corpus cavernosa
on each side
Dorsal artery run on dorsal aspect of penis
supplies circumflex branch to corpus cavernosa
& spongiousm end by anastomosing in coronal
sulcus and supply glans penis
Dept Of Urology, KMC and GRH,
Chennai 41

42.  VENOUS DRAINAGE
Internal pudendal veinae commitant of IPA
unites as single ending in internal iliac vein
perineal tributaries receive veins from penile bulb
and scrotum
LYMHATIC DRAINAGE
Lymphatics from skin of penis and scrotum
drain into superficial inguinal node
Glans, corpora cavernosa,spongiousm drain
directly into deep inguinal node
Dept Of Urology, KMC and GRH,
Chennai 42

43.  Formed from ventral rami of s1,s2,s3 , leaves the
greater sciatic foramen ,then cross the sacrospinous
ligament near the tip of spine of ischium and
passes thro lesser sciatic foramen
 Receive a branch from s4 as passes thro coccygeus
muscle, passes b/w sacrospinous ligament it
enters the pudendal canal of alcock
 Three main branches
inferior rectal nerve
perineal nerve
dorsal nerve of penis or clitoris
Dept Of Urology, KMC and GRH,
Chennai 43

44. Dept Of Urology, KMC and GRH,
Chennai 44

45.  Inferior rectal nerve ;
orginates from pudendal nerve enters pudendal
canal, passes thro fat of ischioanal fossa supplies
levator ani ,distal part of analcanal , external anal
sphincter and overlying subcutaneous tissue and skin
. Perineal branch;
pierces the obturator fascial wall of pudendal canal,
passes thro perineal membrane and superficial
transverse perineus muscle
transverse motor branch divides to supply
musculature of superficial and deep pouches , external
anal sphincter and levator ani
branch of perineal nerve supplies bulbospongiosus ,
bulb of urethra corpus spongiosum and urethral
mucosa
Dept Of Urology, KMC and GRH,
Chennai 45

46.  Dorsal nerve of penis or clitoris
terminal branch continues in pudendal canal ,
emerges from anterior edge of urethro genital
compartment by piercing the transverse
perineal ligament , nerve deep to suspensory
ligament of penis and penetrate deep fascia to
supply the superficial fascia and skin.
Dept Of Urology, KMC and GRH,
Chennai 46

47.  BOUNDARIES
Base – anteriorly by transverse line thro ischial
tuberosites (ie) superficial transverse
muscle, posterior edge of deep compart-
ment and anterior extremity of perineal
body
Posterolaterally- sacrotuberous ligament and
inferior border of gluteus maximus
muscle
Apex - coccyx
Dept Of Urology, KMC and GRH,
Chennai 47

48. Dept Of Urology, KMC and GRH,
Chennai 48

49.  Median raphe and anus divide anal triangle into
two smaller triangle that forms two ischioanal
fossae
 Pyramid shaped , apex pointed superoirly b/w
levator ani and obturator internus, base formed by
fibrofatty tissue and skin , fossa filled with fat
 Each ischioanal fossa has anterior extension
beneath the posterior part of deep compartment
called as anterior recess. Similarly posterior recess
extend posterolaterally beneath sacrotuberous
ligament and anococcygeal ligament.
Dept Of Urology, KMC and GRH,
Chennai 49

50. Dept Of Urology, KMC and GRH,
Chennai 50

51.  Anal sphincter
divided into internal and external anal sphincter
Internal sphincter
thickening of inner circular smooth muscle layer
of rectum
External sphincter
divided into subcutaneous, superficial, and deep
portions.
Dept Of Urology, KMC and GRH,
Chennai 51

52. MUSCLES OF PELVIC
WALL
ORIGIN INSERTION
DEEP Surrounds superior aspect
of anal canal
SUPERFICIAL Surrounds lower part of
anal canal
Attached to perineal body
and anococcygeal body
SUBCUTANEOUS Surrounds anal aperture
Dept Of Urology, KMC and GRH,
Chennai 52

53.  Blood supply
internal pudendal arteries and veins
Nerve supply
inferior rectal nerve
Dept Of Urology, KMC and GRH,
Chennai 53

54. Thank you
Dept Of Urology, KMC and GRH,
Chennai 54