The document discusses the anatomy of the pelvis. It provides details on bones and landmarks of the pelvis, including the pubic tubercle, pubic symphysis, sacral promontory, and sacroiliac joint. It also discusses muscles that form the pelvic diaphragm, nerves that innervate the pelvic organs like the pudendal nerve, and differences in the pelvis between males and females. Key points include structures formed by the pubic ramus, joints between sacral vertebrae, and nerves involved in pelvic pain sensation.
The document discusses the anatomy of the pelvis. It provides details on bones and landmarks of the pelvis, including the pubic tubercle, pubic symphysis, sacral promontory, and sacroiliac joint. It also discusses muscles that form the pelvic diaphragm, nerves that innervate the pelvic organs like the pudendal nerve, and differences in the pelvis between males and females. Key points include structures formed by the pubic ramus, joints between sacral vertebrae, and nerves involved in pelvic pain sensation.
The document discusses the anatomy of the pelvis. It provides details on bones and landmarks of the pelvis, including the pubic tubercle, pubic symphysis, sacral promontory, and sacroiliac joint. It also discusses muscles that form the pelvic diaphragm, nerves that innervate the pelvic organs like the pudendal nerve, and differences in the pelvis between males and females. Key points include structures formed by the pubic ramus, joints between sacral vertebrae, and nerves involved in pelvic pain sensation.
The document discusses the anatomy of the pelvis. It provides details on bones and landmarks of the pelvis, including the pubic tubercle, pubic symphysis, sacral promontory, and sacroiliac joint. It also discusses muscles that form the pelvic diaphragm, nerves that innervate the pelvic organs like the pudendal nerve, and differences in the pelvis between males and females. Key points include structures formed by the pubic ramus, joints between sacral vertebrae, and nerves involved in pelvic pain sensation.
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PELVIS
1. Upper border of pubic ramus forms:
a. Pubic tubercle (NEET Pattern 2014) b. Pubic symphysis c. Arcuate line d. Upper margin of obturator foramen 2. The type of joint between the sacrum and the coccyx is a: (AIPG 2005) a. Symphysis b. Synostosis c. Synchondrosis d. Syndesmosis 3. Sacral promontory is the landmark for: a. Origin of superior mesenteric artery (NEET Pattern 2013) b. Termination of presacral nerve c. Origin of inferior mesenteric artery d. None of the above 4. Articular surface of the sacrum extends up to how many vertebrae in males? (NEET Pattern 2015) a. 1 to 1 1/2 PELVIS b. 2 to 2 1/2 c. 3 to 3 1/2 d. 4 to 4 1/2 5. Lower limit of sacroiliac joint lies up to which level in females? (NEET Pattern 2015) a. 1 to 1 1/2 b. 2 to 1 1/2 c. 3 to 3 1/2 d. 4 to 4 1/2 6. Untrue about female pelvis is: a. Subpubic angle is wide (>80 degrees) b. Obturator foramen in triangular c. Greater sciatic notch is wide (~90 degrees) d. Long and narrow sacrum 7. Almost half of the females have which of the following type of pelvis? a. Anthropoid b. Android c. Platypelloid d. Gynaecoid PELVIS ANSWERS WITH EXPLANATIONS 1. c. Arcuate line • Upper border of superior pubic ramus is called pectineal line (or pecten pubis). It contributes to arcuate line. • Upper border of inferior pubic ramus forms lower margin of obturator foramen. 2. a. Symphysis • Sacro-coccygeal joint is a secondary cartilaginous joint – symphysis, which always lie in the midline. • Symphysis may turn into synostosis with advancing age. For example, symphysis menti becomes a synostosis after the age of one year. • Synchondrosis is a primary cartilaginous joint as seen at the costo-chondral junctions of thoracis wall. • Syndesmosis is a fibrous joint seen at some limited locations, e.g. inferior tibio-fibular joint. 3. b. Termination of presacral nerve • Superior hypogastric plexus (presacral nerve) lies in front of the bifurcation of the abdominal aorta and body of the fifth lumbar PELVIS vertebra between the two common iliac arteries. • Origin of superior mesenteric artery lies at L1 and inferior mesenteric artery at L3 vertebral level. 4. c. 3 to 3 1/2 • Articular surface of the sacrum extends on to the upper three or three and a half sacral vertebrae in adult male. • In females it extends on to the upper 2 or 2½ of the sacral vertebrae. 5. b. 2 to 1 1/2 • Articular surface of the sacrum (lower limit of sacro iliac joint) extends on to upper 2 or 2 1/2 of the sacral vertebrae in females. . • In males it extends on to the upper 3 or 3 1/2 of the sacral vertebrae. 6. d. Long and narrow sacrum • Female pelvis has short and wide sacrum 7. d. Gynaecoid • The gynaecoid pelvis is the normal female type; its pelvic inlet typically has a rounded oval shape and a wide transverse diameter. PELVIS • A platypelloid or markedly android (masculine or funnel-shaped) pelvis in a woman may present with difficult vaginal delivery of a Fetus ASSESSMENT QUESTIONS 1. Pelvic splanchnic nerves supply all EXCEPT: (AIIMS 2010) a. Vermiform appendix b. Urinary bladder c. Uterus d. Rectum 2. Pudendal nerve supplying motor part to external sphincter is derived from: (NEET Pattern 2013) a. L5-S1 roots b. S1- S2 roots c. L2-L3 roots d. S2-S3 roots 3. All of the following are true regarding the pudendal nerve EXCEPT: (AIPG) PELVIS a. Both sensory and motor b. Derived from S2, 3, 4 spinal nerve roots c. Leaves pelvis through the lesser sciatic foramen d. Only somatic nerve to innervate the pelvic organ 4. Pelvic pain is mediated by: (NEET Pattern 2013) a. Pudendal nerve b. Sciatic nerve c. Autonomic nerves d. None of the above 5. True about nervi erigentes are all EXCEPT: a. An autonomic nerve (NEET Pattern 2015) b. Parasympathetic outflow c. Arise from ventral rami of S2, 3, 4 d. Joins superior hypogastric plexus 6. Preganglionic parasympathetic nerve fibers which supply pelvic viscera is/are: (PGIC 2003) a. Ventral rami of S2,3,4 b. Hypogastric plexus c. Pudendal nerve PELVIS d. Pelvic Splanchnic nerve e. Inferior mesenteric plexus 7. Which is NOT supplied by pelvic splanchnic nerves? a. Rectum (AIIMS 2009,10) b. Urinary bladder c. Appendix d. Uterus 8. Pudendal nerve block abolishes pain from: (JIPMER 2016) a. Upper cervix b. Superior part of vagina c. Lower cervix d. Inferior part of vagina 9. Root value of inferior rectal nerve supplying external anal sphincter is: a. L–3, 4, 5 b. L–5; S-1 c. S–2, 3, 4 d. S–4, 5 ANSWERS WITH EXPLANATIONS 1. a. Vermiform appendix PELVIS • Pelvic splanchnic nerves are the parasympathetic nerves to supply the pelvic viscera like urinary bladder, uterus and rectum. Appendix is a part of Mid-gut and is supplied by the Vagus nerve. 2. d. S2-S3 roots • Pudendal nerve is contributed by the anterior primary ramus of S-2, 3, 4 in the sacral plexus and supply external sphincters of urethra, vagina and anal canal. 3. c. Leaves pelvis through the lesser sciatic foramen • Pudendal nerve (S2–S4) passes out of the pelvic cavity through the greater sciatic foramen (below the piriformis muscle) and enters the gluteal region. • It travels around the posterior surface of the ischial spine, and re-enters the pelvic cavity through the lesser sciatic foramen. • Next the pudendal nerve travels within the fascia of the obturator internus muscle (called the pudendal canal of Alcock) and gives rise to the inferior rectal and perineal nerves, and terminates as the dorsal nerve of the penis (or clitoris). PELVIS • It is a somatic and mixed (sensory and motor) nerve supplying skin and skeletal muscles of perineum. • It is the only somatic nerve that supplies the terminal portions of the pelvic organs (urethra, vagina and anal canal). 4. c. Autonomic nerves • Pelvic pain is carried by the autonomic nervous system: Sympathetic component is carried by lumbar splanchnic nerves (T-12, L1,2) and parasympathetic component is nervi erigentes (S- 2,3,4). 5. d. Joins superior hypogastric plexus • There is no answer in this question, because all the statements are true. • Nervi erigentes belong to the parasympathetic component of autonomic nervous system. They arise from the ventral primary ramus of S2,3,4 and ascend from the inferior hypogastric plexus via the right and left hypogastric nerves to reach the superior hypogastric plexus. • Some authors are of the opinion that they do not join the superior hypogastric plexus. PELVIS 6. a. Ventral rami of S2,3,4; d. Pelvic Splanchnic nerve • Pelvic viscera are supplied by the inferior hypogastric plexus situated by the sides of rectum. • Each plexus is composed of both sympathetic and parasympathetic fibres. • The nerve cells in it are postganglionic parasympathetic neurons. It receives postganglionic sympathetic fibres from the superior hypogastric plexus (presacral nerve) and preganglionic parasympathetic fibres from the pelvic splanchnic nerve (S2, S3, and S4). 7. c. Appendix • Vermiform appendix is a part of mid-gut under the supply of vagus nerve (not pelvic splanchnic nerves). 8. d. Inferior part of vagina • Pudendal nerve supplies the structures in the perineum, including the opening of vagina. • Pelvic viscera (including cervix and major portion of vagina) are supplied by the autonomic nervous system: Lumbar splanchnic nerves (sympathetic) and nervi erigentes (parasympathetic). 9. c. S – 2, 3, 4 PELVIS • External anal sphincter is supplied by inferior rectal nerve branch of pudendal nerve. High Yield Points •• Pelvic diaphragm is contributed by levator ani (pubococcygeus and Iliococcygeus) and ischiococcygeus muscles. Parts of pubococcygeus: pubourethralis, puboprostaticus, pubovaginalis, puborectalis are components of the diaphragm. Ischiococcygeus (coccygeus) lies immediately cranial to levator ani and is contiguous with it, but is not a part of levator ani muscle. •• The right and left puborectalis unite behind the anorectal junction to form a muscular sling. Some regard them as a part of the sphincter ani externus. •• Sacrospinous ligament may represent either a degenerate part or an aponeurosis of the muscle Ischiococcygeus. ASSESSMENT QUESTIONS 1. Name the muscle forming pelvic diaphragm: a. Deep transverse perinei b. Sphincter urethrae PELVIS c. Levator ani d. None of the above 2. Levator ani muscle include all EXCEPT: (NEET Pattern 2016) a. Puborectalis b. Pubococcygeus c. Iliococcygeus d. Ischiococcygeus 3. All are content of sphincter of vagina EXCEPT: a. Pubovaginalis b. External urethral sphincter c. Internal urethral sphincter d. Bulbospongiosus ANSWERS WITH EXPLANATIONS 1. c. Levator ani • Pelvic diaphragm is contributed by levator ani (pubococcygeus and Iliococcygeus) and ischiococcygeus muscles. • Parts of pubococcygeus: pubourethralis, puboprostaticus, pubovaginalis, puborectalis are components of the diaphragm. PELVIS • Ischiococcygeus (coccygeus) lies immediately cranial to levator ani and is contiguous with it, but is not a part of levator ani muscle. 2. d. Ischiococcygeus • Ischiococcygeus muscle is a component of pelvic diaphragm, but is not included under levator ani muscle. − Levator ani muscle is subdivided into named portions according to their attachments and the pelvic viscera to which they are related (pubococcygeus, iliococcygeus and puborectalis). − Pubococcygeus is often subdivided into separate parts according to the pelvic viscera to which each part relates (puboperinealis, puboprostaticus or pubovaginalis, puboanalis, puborectalis). • Note: Ischiococcygeus (coccygeus) is not a part of levator ani muscle, lies immediately cranial and contiguous with it. Together with levator ani muscle it forms the pelvic diaphragm. 3. c. Internal urethral sphincter PELVIS • Internal urethral sphincter is present in males to prevent retrograde ejaculation of semen into urinary bladder, it is absent in females ASSESSMENT QUESTIONS 1. Branch of internal iliac artery is/are: (PGIC 2014) a. Inferior vesical artery b. Inferior epigastric artery c. Iliolumbar artery d. Internal pudendal artery e. Obturator artery 2. Internal pudendal artery is a branch of: a. Anterior division of internal iliac (NEET Pattern 2015) b. Posterior division of internal iliac c. Anterior division of external iliac d. Posterior division of external iliac 3. All are branches of the internal iliac artery except: a. Ovarian artery (NEET Pattern 2012) b. Superior vesical artery c. Middle rectal artery d. Inferior vesical artery 4. Artery to ductus deferens is a branch of: PELVIS a. Superior vesical artery (NEET Pattern 2016) b. Inferior vesical artery c. Internal pudendal artery d. Middle rectal artery 5. Accessory obturator artery is a branch of: (NEET Pattern 2016) a. Inferior epigastric b. External iliac c. Internal iliac d. Obturator ANSWERS WITH EXPLANATIONS 1. a. Inferior vesical artery; c. Iliolumbar artery; d. Internal pudendal artery; e. Obturator artery • Inferior epigastric artery is a branch of external (not internal) iliac artery. 2. a. Anterior division of internal iliac • Anterior division of internal iliac artery gives the internal pudendal artery which accompanies pudendal nerve in the pudendal canal and supply the perineum region. 3. a. Ovarian artery PELVIS • Ovarian artery is a branch of the abdominal aorta. • Gonads develop in the abdomen region and gonadal arteries are branches of abdominal aorta. • As the gonads descend down to pelvic cavity, gonadal arteries become longer (Testicular > Ovarian). 4. a. Superior vesical artery > b. Inferior vesical artery > d. Middle rectal artery • Vas deferens is usually derived from the superior vesical artery, and occasionally from the inferior vesical artery, both branches of the internal iliac artery. Note: It may also arise from middle rectal artery. 5. a. Inferior epigastric • Accessory obturator artery is the pubic branch of inferior epigastric artery, which itself is given by external iliac artery. • Lacunar ligament is medial boundary of femoral ring and accessory obturator artery may lie on that in some percentage of population. • In reduction of femoral hernia, we must be careful of accessory obturator artery, while the lacunar ligament is cut to enlarge the PELVIS femoral ring to reduce the hernia. ASSESSMENT QUESTIONS 1. Superficial inguinal lymphatics drain all of the following EXCEPT: (NRET Pattern 2005) a. Anal canal below pectinate line b. Glans penis c. Urethra d. Perineum 2. Infection/inflammation of all of the following causes enlarged superficial inguinal lymph nodes EXCEPT: a. Isthmus of uterine tube (AIPG 2004) b. Inferior part of anal canal c. Big toe d. Penile urethra 3. Distal part of spongy male urethra drains via which lymph nodes? (AIPG 2009) a. Superficial inguinal b. External Iliac c. Deep inguinal d. Aortic PELVIS ANSWERS WITH EXPLANATIONS 1. b. Glans penis • Glans penis drains into deep inguinal lymph nodes (Cloquet). • Anal canal below pectinate line drains into superficial inguinal lymph nodes, and above the pectinate line into internal iliac lymph nodes. • Proximal urethra drains into iliac and distal urethra into inguinal lymph nodes • Perineum majorly drains into superficial inguinal lymph nodes. 2. d. Penile urethra • Lymphatics from the penile urethra (and glans penis) mainly run towards deep inguinal lymph nodes. • Though few lymphatics may end up in the superficial inguinal lymph nodes. • Isthmus of uterine tube, inferior part of anal canal and big toe all drain towards the superficial group of lymph nodes. • Lymphatics from the isthmus follow the round ligament of uterus and lymphatics from the great toe follow the great saphenous PELVIS vein, both reaching the superficial inguinal lymph nodes. 3. c. Deep inguinal • Distal spongy urethra and the glans penis drain into the deep inguinal lymph nodes of Cloquet and Rosenmuller. • Spongy part of male urethra mainly drains into the deep inguinal lymph nodes. Some lymphatics may end in the superficial inguinal/ external iliac lymph nodes as well. • Lymphatics from the prostatic and membranous urethra pass mainly to the internal iliac lymph nodes. Some lymphatics from these areas may end in the external iliac lymph nodes also. • Eventually all the lymphatics reach the aortic lymph nodes → Thoracic duct → Left sided neck veins. • Female urethra drains into both the internal and external iliac lymph nodes. • Lymph drainage of penis: Penile skin → Superficial lymph nodes; Glans → Deep inguinal and External iliac lymph nodes. ASSESSMENT QUESTIONS 1. Ureter is present in which wall of ovarian fossa? PELVIS a. Anterior (DNB Pattern- 2016) b. Posterior c. Medial d. Lateral 2. Ovarian fossa is formed by all EXCEPT: a. Obliterated umbilical artery (NEET Pattern 2015) b. Internal iliac artery c. Ureter d. Round ligament of ovary ANSWERS WITH EXPLANATIONS 1. b. Posterior • Behind the ovarian fossa are retroperitoneal structures, including the ureter, internal iliac vessels, obturator vessels and nerve, and the origin of the uterine artery. 2. d. Round ligament of ovary • Round ligament of ovary is infero-medial to the ovary. Clinical Correlations PELVIS •• Spinal anesthesia up to spinal nerve T10 is necessary to block pain for vaginal delivery and up to spinal nerve T4 for cesarean section (due to the sympathetic fibre levels being at higher level than motor or sensory blockade). •• Lumbar spinal anaesthesia (spinal block), in which the anesthetic agent is introduced with a needle into the spinal subarachnoid space and it anaesthetizes the intraperitoneal, subperitoneal and somatic structures. –– It produces complete anesthesia inferior to approximately the waist level. –– The perineum, pelvic floor, and birth canal are anesthetized, and motor and sensory functions of the entire lower limbs, as well as sensation of uterine contractions, are temporarily eliminated. •• Caudal epidural block, in which the anesthetic agent is administered using an in-dwelling catheter in the sacral canal, and it anaesthetizes the subperitoneal and somatic structures. –– The entire birth canal, pelvic floor, and most of the perineum are anesthetized, but the lower limbs are not usually affected and the mother PELVIS is aware of uterine contractions. •• Pudendal nerve block is provides local anesthesia over the perineum (S2–S4 dermatomes) and the inferior quarter of the vagina. –– It does not block pain from the superior birth canal (uterine cervix and superior vagina), so the mother is able to feel uterine contractions. Fig. 38: Obstetric blocks: (A) Spinal block; (B) Caudal epidural block; (C) Pudendal block. ASSESSMENT QUESTIONS 1. The following group of lymph nodes receives lymphatics from the uterus EXCEPT: (AIPG 2005) a. External iliac b. Internal iliac c. Superficial inguinal d. Deep inguinal 2. Ovarian pathology is referred to: (AIIMS 2010) a. Gluteal region b. Anterior thigh c. Medial part of thigh d. Back of thigh PELVIS 3. All are true regarding uterus EXCEPT: (PGIC 2014) a. Lymph vessels from fundus drain to para-aortic lymph nodes b. Broad ligament provides primary support to uterus c. Mainly supplied by uterine artery d. Supplied by ovarian artery e. Posterior surface is related to intestine 4. Lymphatic drainage of uterine cervix is all EXCEPT: a. Obturator b. Sacral c. External iliac d. Internal iliac 5. Lymphatic drainage of the cervix occurs by all of the following lymph nodes EXCEPT: (AIPG 2006) a. Parametrial lymph nodes b. Deep inguinal lymph nodes c. Obturator lymph nodes d. External iliac lymph nodes 6. All the following pairs are correct concerning the lymphatics of uterus EXCEPT: PELVIS a. Fundus: Para-aortic b. Mid-uterus: External iliac c. Cervix: Superficial inguinal lymph nodes d. Cervix: Sacral ANSWERS WITH EXPLANATIONS 1. d. Deep inguinal • Lymphatics from the uterus reach the superficial inguinal lymph nodes but not the deep inguinal. • The lymphatics follow the round ligament of uterus to reach the superficial inguinal lymph nodes. • Upper part of the uterus like fundus, drain mainly into the para-aortic lymph nodes. • Lymphatics from cervix region spread towards external iliac as well as internal iliac group of lymph nodes. 2. c. Medial part of thigh • Ovarian pathology may irritate the obturator nerve lying in the vicinity, which leads to a referred pain in the medial thigh (Dermatome: L-2). PELVIS • Obturator nerve (L-2, 3 & 4) is the nerve of medial thigh and supplies the skin on the medial thigh. This type of pain is a somatic referred pain. • Another example is the pain felt in the knee joint in a case of Perthes’ disease, which is pathology of hip joint but referred somatic pain is felt in the knee joint, since, both the joints are supplied by a common nerve – the obturator nerve. • The visceral pain of the ovary is carried by the visceral nerves having root value T – 10, 11. Hence, visceral referred pain from the ovarian pathology will be felt in the skin bearing dermatome T: 10, 11. • Pain in the medial thigh could be a referred pain from viscera like ureter, hind gut, uterus, urinary bladder. Or it could be a somatic referred pain irritating obturator nerve as in a case of appendicitis, pelvic abscess or ovarian pathology as in the present case. 3. b. Broad ligament provides primary support to uterus PELVIS • Lymphatics from the uterine fundus drain towards the para-aortic lymph nodes. • Broad ligament is a fold of peritoneum and poor support of uterus. Primary supports of uterus are muscular supports. • Uterus is supplied by uterine (mainly) and ovarian arteries. • Posterior surface of uterus is related to coils of the terminal ileum and to the sigmoid colon. It is covered with peritoneum and forms the anterior wall of the rectouterine pouch. 4. a. Obturator • Uterus drains into all the lymphatic destinations mentioned in the choices, hence this appears to be a wrong question, though some standard textbooks do not mention obturator lymph nodes in the lymphatic drainage. 5. b. Deep inguinal lymph nodes • Lymphatic drainage from the cervix does not drain into the deep inguinal lymph nodes. • Obturator lymph nodes receive a minor component of lymphatic drainage from the cervix. PELVIS • The lymphatics of cervix mainly move towards the internal iliac lymph nodes. Additionally it drain towards external iliac; rectal and the sacral lymph nodes as well. • Parametrial lymph nodes receive the lymphatics of cervix and direct them towards their further destination. 6. c. Cervix: Superficial inguinal lymph nodes • Uterine cervix do not drain into the inguinal lymph nodes (superficial or deep). • Fundus and upper part of the body: Pre- and para- aortic lymph nodes along the ovarian vessels (few lymphatics from the lateral angles of the uterus travel along the round ligaments of the uterus and drain into superficial inguinal lymph nodes . • Middle part of the body : External iliac nodes via broad ligament. • From cervix, on each side the lymph vessels drain in three directions: − Laterally: External iliac and obturator nodes. − Posterolaterally: Internal iliac nodes − Posteriorly: Sacral nodes PELVIS Clinical Correlations •• Prolapse of uterus may occur if the supports are weakened. •• During parturition the muscular supports undergo lot of stretching and may give up, leading to uterus being pushed inside vagina and come out into the perineum. •• Surgical support: The cardinal ligaments have enough fibrous content to provide anchor for the wide loops of sutures during several surgical Procedures ASSESSMENT QUESTIONS 1. Hypogastric Sheath is a condensation of: (AIPG 2010,11) a. Scarpa’s fascia b. Colle’s fascia c. Pelvic fascia d. Inferior layer of Urogenital diaphragm 2. Which is NOT a part of the hypogastric sheath: a. Transverse cervical ligament b. Broad ligament c. Lateral ligament of bladder PELVIS d. Uterosacral ligament 3. Support of prostate is: (NEET Pattern 2013) a. Pubococcygeus b. Ischiococcygeus c. Iliococcygeus d. None of the above 4. Supports of the uterus are all EXCEPT: (AIIMS 2006) a. Uterosacral ligament b. Broad ligament c. Mackenrodt’s’ ligament d. Levator ani 5. Which of the following doesnot prevent prolapse of uterus? a. Perineal body b. Pubocervical ligament c. Broad ligament d. Transverse cervical ligament ANSWERS WITH EXPLANATIONS 1. c. Pelvic fascia • Hypogastric sheath is a condensation of pelvic fascia. PELVIS • It lies along the postero-lateral pelvic walls and carries the neuro-vascular bundles towards the pelvic viscera. • It also provides pelvic viscera support. 2. b. Broad ligament. • Hypogastric sheath is a condensation of the pelvic fascia which transmits vessels and nerves along the lateral pelvic wall towards the pelvic viscera. • Broad ligament of uterus is not a part of the hypogastric sheath. It is a peritoneal fold. • Parts of the hypogastric sheath: − Anterior lamina – Lateral ligament of bladder. − Middle lamina – Transverse cervical ligament, rectovesical septum in males. − Posterior lamina – Presacral fascia, uterosacral ligament (containing middle rectal vessels). Note: The endopelvic fascia lies between, and is continuous with, both visceral and parietal layers of pelvic fascia. 3. a. Pubococcygeus PELVIS • Anterior fibers of pubococcygeus surround the prostate to form levator prostatae muscle, which supports the prostate. • Pubovaginalis in the female is the equivalent of levator prostate in the male. • Both originate from the posterior pelvic surface of the body of the pubis bone. Fibres pass inferiorly, medially and posteriorly to insert into a midline raphe, the central perineal tendon. 4. b. Broad ligament • Broad ligament is a double fold of peritoneum and is a weak support of uterus, its function as uterine support is comparatively insignificant. • The best supports of pelvic viscera are the muscular supports like Levator ani. • The pelvic fascia condensations like utero-sacral and Mackenrodt’s ligaments are considered as good supports of uterus. 5. c. Broad ligament • Broad ligament is a peritoneal fold and poor support of uterus. PELVIS • Perineal body is a central perineal tendon, which receives attachment of perineal muscles, which support the pelvic viscera. • Pubocervical and Transverse cervical ligaments are the pelvic fascia condensations, which are good supports of pelvic viscera with parasympathetic fibres. ASSESSMENT QUESTIONS 1. Maximum number of mucosal folds are found in which part of fallopian tube? (NEET Pattern 2015) a. Infundibulum b. Ampulla c. Isthmus d. Interstitial portion 2. Which part of the uterine tube acts as anatomical sphincter? a. Intramural part b. Isthmus c. Ampulla d. Infundibulum PELVIS 3. The sensory supply of the fallopian tube and ovary is from: a. T6 to T8 b. T8 to T10 c. T10 to T12 d. L2 to L4 ANSWERS WITH EXPLANATIONS 1. a. Infundibulum • The mucosa is thrown into longitudinal folds, which are most pronounced distally at the infundibulum and decrease to shallow bulges in the intrauterine (intramural) portion. 2. b. Isthmus > a. Intramural part • The arrangement of the muscles at the isthmus is such that it can work like a sphincter, preventing the oocyte from entering the uterine cavity. • Some authors mention the location of sphincter at the junction of uterus and uterine tube (intramural part). 3. c. T10 to T12 PELVIS • Visceral afferent fibres travel with the sympathetic nerves and enter the cord through corresponding dorsal roots (T12 ±2). ASSESSMENT QUESTIONS 1. All are parts of vulva EXCEPT: (NEET Pattern 2012) a. Labia minora b. Labia majora c. Perineal body d. Clitoris 2. All is true about Bartholin gland EXCEPT: a. Homologous of male bulbo-urethral gland b. Present in the superficial perineal pouch c. Located at the junction of anterior 1/3 and middle 1/3 of labia majora d. Opens into the vestibule between hymen and labia minora ANSWERS WITH EXPLANATIONS 1. c. Perineal body • The female external genitalia (or vulva/pudendum) consists of a vestibule of vagina and its surrounding structures such as mons PELVIS pubis, labia majora, labia minora, clitoris, vestibular bulb and pair of greater vestibular glands. 2. c. Located at the junction of anterior 1/3 and middle 1/3 of labia majora • Bartholin gland is located at the junction of middle 1/3 and posterior 1/3 of labia majora. • The duct opens in the postero-lateral wall of vagina (vestibule). • The epithelium of the Bartholin duct is cuboidal near the gland, but becomes transitional and finally stratified squamous near the opening of the duct. Clinical Correlations •• Episiotomy is a surgical incision of the perineum (and the posterior vaginal wall) to enlarge the vaginal opening during childbirth. •• It is done during second stage of labour to quickly enlarge the opening for the baby to pass through. •• There are two types of episiotomies. ––Median Episiotomy starts at the frenulum of the labia minora and proceeds directly downward cutting through the skin → vaginal PELVIS wall → perineal body → superficial transverse perineal muscle. ––Mediolateral Episiotomy starts at the frenulum of the labia minora and proceeds at a 45-degree angle cutting through the skin → vaginal wall → bulbospongiosus muscle. ASSESSMENT QUESTIONS 1. Superficial perineal space contains all EXCEPT: a. Root of penis (NEET Pattern 2012) b. Urethral artery c. Great vestibular glands (Bartholin glands) d. Membranous urethra 2. Superficial muscles of perineum: (NEET pattern 2014) a. Ischiocavernosus b. Bulbocavernosus c. Levator ani d. Ischio-coccygeus 3. Urogenital diaphragm is contributed by all EXCEPT: a. Sphincter urethra (NEET Pattern 2012) b. Perineal body PELVIS c. Colles’ fascia d. Perineal membrane 4. All are the contents of deep perineal pouch EXCEPT: a. Bulb/Root of penis (AIIMS 2008; AIPG 2009) b. Dorsal nerve of penis c. Sphincter urethra d. Bulbo urethral glands 5. NOT a part of superficial perineal pouch: (AIIMS 2011) a. Posterior scrotal nerves b. Sphincter urethrae c. Ducts of bulbourethral glands d. Bulbospongiosus muscle 6. Nerve supply to the perineum is: (NEET Pattern 2012) a. Pudendal nerve b. Inferior rectal nerve c. Pelvic splanchnic nerves d. Hypogastric plexus 7. All of the following are attached to perineal body EXCEPT: PELVIS (NBE 2013) a. Superficial transverse perinei b. Iliococcygeus c. Bulbospongiosus d. Ischio-cavernosus 8. The deep perineal space: a. Is formed superiorly by the perineal membrane b. Contains a segment of the dorsal nerve of the penis c. Is formed inferiorly by Colles’ fascia d. Contains the greater vestibular glands ANSWERS WITH EXPLANATIONS 1. d. Membranous urethra • Membranous urethra is a content of deep perineal pouch, which continues as spongy urethra in superficial perineal pouch. 2. a. Ischiocavernosus • Muscles in the superficial perineal pouch are ischiocavernosus, bulbospongiosus and superficial transverse perinei. 3. c. Colles’ fascia PELVIS • Urogenital diaphragm contains the deep perineal pouch and is lined inferiorly by the perineal membrane and not Colles’ fascia. • Colles’ fascia lies at the floor (inferior lining) of superficial perineal pouch. • Urogenital diaphragm is a triangular musculo-fascial diaphragm in the anterior part of perineum. It is contributed by mainly two muscles: sphincter urethrae and deep transverse perinei. These muscles are enclosed within a superior and inferior fascia. The inferior fascia is also called as perineal membrane. • Perineal body is a fibromuscular body attached at the posterior border of perineal membrane in the midline. Both the fascia of urogenital diaphragm are attached to the perineal body. Perineal body is a good support of pelvic viscera and is attached by numerous muscles of the perineum including the muscles of urogenital diaphragm – deep transverse perinei and sphincter urethrae. 4. a. Bulb/Root of penis PELVIS • Bulb/Root of penis lies in the superficial perineal pouch and not the deep perineal pouch. • Bulb of vagina/ root of clitoris also lie in the superficial perineal pouch. • Contents of deep perineal space in males: Membranous part of urethra, Muscles of urogenital diaphragm (Sphincter urethra and Deep transverse perinei), Bulbo-urethral glands of Cowper, Internal pudendal vessels and branches, Dorsal nerve of penis and muscular branches of perineal nerve. • Contents of deep perineal space in females: Part of urethra (same as in males), Part of vagina, Muscles of urogenital diaphragm (same as males), Internal pudendal vessels and branches (same), Dorsal nerve of clitoris and muscular branches of perineal nerve. 5. b. Sphincter urethrae • Sphincter urethrae (external urethral sphincter) is present in the wall of membranous urethra, in the deep perineal pouch, it also extends vertically, around the anterior aspect of the prostatic urethra. PELVIS • Posterior scrotal nerves are the branches of pudendal nerve, and do pass the superficial perineal pouch. • Cowper’s bulbourethral gland is present in the deep perineal pouch, but it’s duct pierces the perineal membrane and opens into the bulbous urethra in the superficial perineal pouch. • Bulbospongiosus muscle is a content of superficial perineal pouch, functions as a vaginal sphincter in a female; and for a male it help to empty the urethra of the urine/semen. • The superficial perineal pouch is a fully enclosed compartment, Its inferior border (floor) is the perineal fascia (Colles’ fascia and superior border (roof) is the perineal membrane. • The contents are muscles : ischiocavernosus, bulbospongiosus muscle, superficial transverse perineal muscle. Other contents are: Crura of penis (males) / Crura of clitoris (females), bulb of penis (males) / Vestibular bulbs (females), Greater vestibular glands (female). 6. a. Pudendal nerve PELVIS • Pudendal nerve is the nerve of perineum. It is a mixed (sensory and motor) nerve to supply skin and skeletal muscles of perineum. 7. d. Ischio-cavernosus • Ischio-cavernosus is not a midline muscle and is not attached to the central perineal tendon (perineal body). • Superficial and deep transverse perineal muscles, both attach to the perineal body. • Iliococcygeus (pelvic diaphragm) has attachment to the perineal body • Bulbospongiosus is a muscle in the superficial perineal pouch which covers bulb of penis (or vagina) and attaches to perineal body. 8. b. Contains a segment of the dorsal nerve of penis. • Dorsal nerve of penis is a content of both superficial and deep perineal pouch. Other choices are applicable to superficial perineal Pouch ASSESSMENT QUESTIONS 1. Boundaries of ischiorectal fossa are: (NEET Pattern 2014) a. Posterior : Perineal membrane PELVIS b. Anterior : Sacrotuberous ligament c. Lateral : Obturator internus d. Medial : Gluteus maximus 2. During incision and drainage of ischiorectal abscess, which nerve is/are injured? (PGIC 2012) a. Superior rectal nerve b. Inferior rectal nerve c. Superior gluteal nerve d. Inferior gluteal nerve e. Posterior labial nerve 3. Pudendal canal is a part of: (NEET Pattern 2014) a. Colles fascia b. Obturator fascia c. Scarpa’s fascia d. None 4. All of the following pairs about the boundaries of ischiorectal fossa are correct EXCEPT: a. Anterior: Perineal membrane b. Posterior: Gluteus maximus PELVIS c. Medial: Levator ani d. Lateral: Obturator externus 5. UNTRUE about ischiorectal fossa: a. Obturator fascia meets anal fascia at the apex b. A communication is present between the two IRF in front of anal canal c. Alcock’s canal is located at the lateral wall d. Inferior rectal nerve and vessels pass through it ANSWERS WITH EXPLANATIONS 1. c. Lateral : Obturator internus • Lateral boundaries of ischiorectal fossa is the ischial bone with obturator internus muscle covered by obturator fascia. • Perineal membrane lies anterior and sacrotuberous ligament and gluteus maximus are posterior. 2. b. Inferior rectal nerve; e. Posterior labial nerve • Dissection of ischiorectal fossa, may involve injury to inferior rectal, pudendal, posterior scrotal (or labial) nerve and vessels along with perforating branches of S2-S3 and perineal branches of S4 nerve. 3. b. Obturator fascia PELVIS • Pudendal canal is formed in the obturator fascia in the lateral wall of the ischiorectal fossa. 4. d. Lateral: Obturator externus • Obturator internus is present at the lateral wall of ischiorectal fossa. It is covered by obturator fascia, which has pudendal canal in it. 5. b. A communication is present between the two IRF in front of anal canal • A communication is present between the two IRF in behind the anal canal. • Apex (roof): Meeting point of obturator fascia (covering obturator internus) and inferior fascia of the pelvic diaphragm (covering levator ani muscle) • Alcock’s pudendal canal is present in the lateral wall of ischiorectal fossa and send inferior rectal nerve and vessels medially through the fossa towards the anal canal ASSESSMENT QUESTIONS 1. All are true about the trigone of the urinary bladder EXCEPT: (AIIMS 2006) PELVIS a. Mucosa is loosely associated to the underlying musculature b. Mucosa is smooth c. It is lined by transitional epithelium d. It is derived from the absorbed part of the mesonephric duct 2. Urethral crest is due to: (AIIMS 2013) a. Opening of prostatic glands b. Puboprostatic spread c. Insertion of detrusor d. Insertion of trigone 3. Where is the cave of Retzius present? (NEET Pattern 2012) a. Between urinary bladder and rectum b. Between urinary bladder and cervix c. In front of the bladder d. Between the cervix and the rectum 4. All are related to posterior surface of urinary bladder EXCEPT: (JIPMER 2001) a. Ureter b. Rectum through rectovesical pouch PELVIS c. Seminal vesicles d. Vas deferens 5. FALSE regarding trigone of bladder: (NEET Pattern 2015) a. Lined by transitional epithelium b. Mucosa smooth and firmly adherent c. Internal urethral orifice lies at lateral angle of base d. Developed from mesonephric duct 6. In bladder injury pain is referred to all EXCEPT: a. Upper part of thigh (NEET Pattern 2012) b. Lower abdominal wall c. Flank d. Penis 7. If a missile enters the body just above the pubic ramus through the anterior abdominal wall it will most likely pierce which of the following structures? ( AIIMS 2000) a. Abdominal aorta b. Left renal vein c. Urinary bladder d. Spinal cord PELVIS ANSWERS WITH EXPLANATIONS 1. a. Mucosa is loosely associated to the underlying musculature • Mucosa is tightly adherent to the underlying musculature in the trigone of urinary bladder. • The mucosa appears smooth at the trigone because of this tight adherence, since folding is not possible in the mucosa. • In other places the mucosa is highly folded or stretched according to the state of distension. • Trigone of bladder is derived by the absorption of the mesonephric duct in to the bladder wall. • Transitional epithelium lines the urinary bladder throughout its extent, including the trigone. 2. d. Insertion of trigone • The superficial trigone muscle becomes continuous with the smooth muscle of the proximal urethra, and extends in the male along the urethral crest as far as the openings of the ejaculatory ducts. 3. c. In front of the bladder PELVIS • Cave of Retzius (retropubic space) is the extraperitoneal space between the pubic symphysis and urinary bladder. • It is basically a preperitoneal space, behind the transversalis fascia and in front of peritoneum. 4. a. Ureter • Ureters join the superolateral angles of urinary bladder (not related to the posterior surface). • Relations of posterior surface of urinary bladder: − Upper part is separated from rectum by the rectovesical pouch containing coils of the small intestine. − Lower part is separated from rectum by the terminal parts of vas deferens and seminal vesicles. − The triangular area between the vas deferens is separated from the rectum by rectovesical fascia (of Denonvillier’s). 5. c. Internal urethral orifice lies at lateral angle of base • Internal urethral orifice lies at the apex (no the lateral angle of base) of urinary bladder. • It’s the ureters that open at lateral angles. 6. c. Flank PELVIS • This is a wrong question with no appropriate answer. The best possible option is flank region, as little is known about the functional significance of thoracolumbar afferents. • Pain fibres of urinary bladder are carried by both sympathetic and parasympathetic fibres. • Parasympathetic fibres (nervi erigentes) are derived from S2, S3, S4 segments of the spinal cord and the referred pain is felt in the corresponding dermatomes in perineum and posterior thigh. • Sympathetic fibres are derived from T11, 12 and L1, 2 segments of the spinal cord and the pain is referred to the lumbar region, inguinal region, and anterosuperior thigh. 7. c. Urinary bladder • A distended urinary bladder may be ruptured by injuries of lower abdominal wall, as mentioned in the question. • Spinal cord terminates at L1 vertebral level; left renal vein is given at L1-2 level and abdominal aorta bifurcates at L4. None of the mentioned structures reach the level of pubic ramus. PELVIS of the following features, EXCEPT: (AIPG) a. Is the widest and most dilatable part b. Presents a concavity posteriorly c. Lies closer to anterior surface of prostate d. Receives Prostatic ductules along its posterior wall 2. NOT true about prostatic urethra: (AIIMS 2009,10) a. Trapezoid shape in cross section b. Presence of veru montanum c. Opening of prostatic ducts d. Urethral crest on posterior wall 3. Bulbourethral glands open into which part of the urethra? a. Membranous (NEET Pattern 2012) b. Spongy c. Prostatic d. Intramural 4. WRONG statement about male urethra is: a. Length of male urethra is 20 cm b. Membranous urethra has shortest length PELVIS c. Narrowest lumen is at the external urethral meatus d. Prostatic urethra has the widest lumen ANSWERS WITH EXPLANATIONS 1. b. Presents a concavity posteriorly • Prostatic urethra presents an anterior (and not posterior) concavity, which becomes more prominent in the membranous part. It runs downwards and forwards to exit prostate slightly anterior to its apex. • Though the lumen of the prostatic urethra does show a posterior concavity, as observed in a cut section of prostate. • Prostatic urethra is considered as the widest and most dilatable part, though recent literature mentions that bulbous part of spongy urethra has the widest lumen. • Prostatic urethra passes more anteriorly through the prostate and is at the junction of anterior 1/3 and posterior 2/3 rd of prostate. Hence, it lies closer to the anterior surface of the prostate. • It receives multiple openings of prostatic ductules at its posterior wall. PELVIS 2. a. Trapezoid shape in cross section • Transverse section of prostate shows crescent (semilunar) shaped lumen of urethra (and not trapezoid). • Veru montanum (seminal colliculus) is a rounded elevation on the posterior wall of prostatic urethra showing three openings. • Prostatic urethra has a midline elevation on the posterior wall of prostatic urethra called urethral crest. • There are multiple openings found on the sides of urethral crest for the glandular secretions of prostate 3. b. Spongy • Bulbourethral glands are present in males in relation with membranous urethra (in the deep perineal pouch), whereas the duct opens into the bulbous spongy urethra (in superficial perineal pouch). 4. d. Prostatic urethra has the widest lumen • Male urethra has a total length of 20 cm and is divided mainly into 4 parts. • Membranous urethra has the shortest length - 1.5 cm. PELVIS • The narrowest lumen is present at the external urethral meatus and the second narrowest is in the membranous urethra. • The widest lumen is present in the bulbous part of penile urethra, second widest is the prostatic urethra. ASSESSMENT QUESTIONS 1. Scarpa’s fascia gets attached to: (JIPMER 2010) a. Inguinal ligament b. Fascia lata of thigh c. Conjoint tendon d. Pubic crest 2. A 16-year-old boy presents to the emergency department with straddle injury and rupture of the bulbous urethra. Extravasated urine from this injury can spread into which of the following structures? a. Scrotum b. Ischiorectal fossa c. Deep perineal space d. Thigh PELVIS 3. Injury to the male urethra above the perineal membrane due to a pelvic fracture, causes urine to accumulate in all of the following EXCEPT: a. Space of Retzius b. Deep perineal pouch c. Superficial perineal pouch d. Peritoneal cavity 4. Injury to the male urethra below the perineal membrane causes urine to accumulate in: (AIPG 2007) a. Superficial perineal pouch b. Deep perineal pouch c. Space of Retzius d. Pouch of Douglas 5. A patient exposed to bomb explosion injury presents with rupture of the fundus of urinary bladder. The extravasated urine reaches: PELVIS a. Space of Retzius b. Deep perineal pouch c. Superficial perineal pouch d. Peritoneal cavity 6. After fracture of the penis (injury to the tunica albuginea) with intact Buck’s fascia, there occurs hematoma: a. The penis and scrotum b. At the perineum in a butterfly shape c. Penis, scrotum, perineum and lower part of anterior abdominal wall d. Shaft of the penis only. 7. In penile injury, Colle’s fascia prevents extravasation of urine in: (NEET pattern 2013) a. Ischiorectal fossa b. Perineum c. Abdomen d. Thigh ANSWERS WITH EXPLANATIONS 1. b. Fascia lata of thigh PELVIS • Scarpa’s fascia is the deep membranous layer of superficial fascia of anterior abdominal wall. • It crosses the inguinal ligament and gets attached to the fascia lata of thigh along Holden’s line, below and parallel to inguinal ligament. 2. a. Scrotum • Extravasation of urine may result from rupture of the bulbous spongy urethra below the perineal membrane; the urine may pass into the superficial perineal pouch and spread inferiorly into the scrotum, anteriorly around the penis, and superiorly into the lower part of the abdominal wall. • The urine cannot spread laterally into the thigh because the perineal membrane and the superficial fascia of the perineum are firmly attached to the ischiopubic rami and are connected with the deep fascia of the thigh (fascia lata). • It cannot spread posteriorly into the anal region (ischiorectal fossa) because the perineal membrane and Colles’s fascia are continuous with each other around the superficial transverse perineal muscles. PELVIS 3. d. Peritoneal cavity • Rupture of membranous part of the urethra may lead to urine escaping into the space around the prostate and bladder and extraperitoneal space (but not the peritoneal cavity). • If the urogenital diaphragm is also disrupted urine leaks into deep perineal space and into the superficial perineal space (as the perineal membrane is also ruptured). • The most common type of urethral injury is at the junction of posterior and anterior (bulbous) urethra. Radiologists consider a type III urethral injury as a combined anterior/posterior urethral injury. 4. a. Superficial perineal pouch • Superficial perineal pouch lies below the perineal membrane and has the spongy part of urethra lying in it. • Any injury to the spongy urethra like the bulbous rupture of urethra leads to the extravasation of urine into the superficial perineal pouch. PELVIS • The urine can track from the superficial pouch towards the anterior abdominal wall and reach just anterior to the external oblique aponeurosis. • Perineal membrane separates the deep perineal pouch from the superficial and prevents urine from entering the deep perineal pouch from superficial. • Space of Retzius is an extra-peritoneal space lying between the pubic bones and the urinary bladder. • Membranous rupture of urethra (above the perineal membrane) may cause accumulation of blood and urine in this space. • Pouch of Douglas is the recto-vesical (or recto- uterine) pouch of peritoneum. Douglas pouch is intra- peritoneal and also well separated from the superficial pouch. Neither of the two varieties of urethral rupture the urine can reach into this space. 5. d. Peritoneal cavity • Rupture of the dome (superior wall) of the urinary bladder, leads to rupture of peritoneum and results in an intraperitoneal PELVIS extravasation of urine within the peritoneal cavity (ascites). • It is caused by a compressive force on a full bladder. 6. d. Shaft of the penis only • Penile Fracture - Diagnosis of albugineal rupture is usually made from a characteristic history of severe pain with a cracking or popping sound during acute bending of the erect penis, followed by immediate detumescence, penile swelling, and deformity. • Albugineal rupture is associated with urethral injury in 10–20% of cases. • Penile hematoma is confined to the shaft when the Buck’s fascia is intact. • If the Buck fascia has been violated, the swelling and ecchymosis are contained within the Colles fascia. In this instance, a “butterflypattern” ecchymosis may be observed over the perineum, scrotum, and lower abdominal wall. 7. a. Ischiorectal fossa • Colle’s fascia attachments prevents extravasation of urine into the ischiorectal fossa. PELVIS • Penile injuries may lead to extravasation of urine into penile and scrotal layers, perineum, anterior abdominal wall. • Urine is prevented from entering the thigh by fascia lata attachments. ASSESSMENT QUESTIONS 1. All of the following statements are true about sphincter urethra EXCEPT: (AIIMS 2014) a. Located at the bladder neck b. Originate from ischiopubic ramus c. Is a voluntary muscle d. Supplied by pudendal nerve 2. Sphincter urethrae is present in: (NEET Pattern 2012) a. Prostatic urethra b. Spongy urethra c. Membranous urethra d. Penile urethra 3. Vaginal sphincter is formed by all EXCEPT: (AIIMS 2009, 10) a. Internal urethral sphincter PELVIS b. External urethral sphincter c. Pubovaginalis d. Bulbospongiosus ANSWERS WITH EXPLANATIONS 1. a. Located at the bladder neck • Sphincter urethra (external urethral sphincter) is a content of deep perineal pouch (not the bladder neck). • It is a skeletal (voluntary) muscle, supplied by somatic pudendal nerve (S2,3,4) and works for urinary continence. • It takes its origin from the ischiopubic ramus on each side and unite with the muscle of the opposite side by means of a tendinous raphe. • Internal urethral sphincter (sphincter vesicae) is located at the bladder neck, is a smooth (involuntary) muscle engaged in preventing retrograde ejaculation of semen, supplied by L1 sympathetic fibres. 2. c. Membranous urethra PELVIS • External urethral sphincter (sphincter urethrae) is present in relation to the membranous urethra, in the deep perineal pouch. 3. a. Internal urethral sphincter • Internal urethral sphincter do not function as vaginal sphincter. In some textbook it is mentioned internal urethral sphincter is absent in females. • Muscles that compress the vagina and act as sphincters include the pubovaginalis, external urethral sphincter (especially its urethrovaginal sphincter part), and bulbospongiosus. • The External urethral sphincter surrounds the vagina also and works as urethro-vaginal sphincter. It is innervated by the nerve fibres of Onuf’s nucleus (S-2, 3, 4) via the pudendal nerve. • Pubo-vaginalis is a part of pubo-coccygeus (Levator ani) and functions as genital tract sphincter. Levator ani muscle forms the Pelvic diaphragm. • Bulbo-spongiosus is a muscle of superficial perineal pouch and is a constrictor of genital tract. PELVIS • Internal urethral sphincter: Females lack the internal urethral sphincter. It is actually the anatomical bladder neck (pre-prostatic) sphincter observed in males. The internal urethral sphincter prevents retrograde passage of semen into the urinary bladder during ejaculation. It is innervated by the L-1 sympathetic fibres. L-1 fibres should not be cut while performing lumbar sympathectomy otherwise, would result in retrograde ejaculation of semen. • Urinary continence in females is maintained by the following muscles: Sphincter urethrae, Compressor urethra, Sphincter urethrovaginalis, Pubo-urethralis (part of Levator ani muscle). Rectum ASSESSMENT QUESTION 1. Pelvic fascia between rectum and sacrum is: a. Denonvillier’s fascia b. Colle’s fascia c. Waldeyer’s fascia d. Scarpa’s fascia PELVIS 898 ANSWERS WITH EXPLANATIONS 1. c. Waldeyer’s fascia • Waldeyer’s fascia (presacral fascia) lines the anterior aspect of the sacrum, enclosing the sacral vessels and nerves. • It is limited postero-inferiorly, as it fuses with the mesorectal fascia, lying above the levator ani muscle. • Identification and preservation of the Waldeyer’s fascia is of fundamental importance in preventing complications and reducing local recurrences of rectal cancer. • Denonvillier’s fascia is a membranous partition separating the rectum from the prostate and urinary bladder; this structure in the male corresponds to the fascia rectovaginalis in the female. Clinical Correlations •• Internal hemorrhoids are varicosities of the superior rectal veins. They are located above the pectinate line and are covered by rectal mucosa. These present with painless bleeding. PELVIS •• External hemorrhoids are varicosities of the inferior rectal veins. They are located below the pectinate line near the anal verge and are covered by skin. These present with painful bleeding. ASSESSMENT QUESTIONS 1. Anal canal NOT supplied by: (AIIMS 2015) a. Superior rectal artery b. Inferior rectal artery c. Median sacral artery d. Middle rectal artery 2. All form anorectal ring EXCEPT: (AIIMS 2013) a. External anal sphincter b. Internal anal sphincter c. Puborectalis d. Anococcygeal raphe ANSWERS WITH EXPLANATIONS 1. d. Middle rectal artery • Middle rectal artery supplies the rectum, but ‘not’ the anal canal. PELVIS • The anal canal is supplied by terminal branches of the superior rectal artery and the inferior rectal artery branch of the internal pudendal artery, together with a small contribution from the median sacral artery. • The arterial supply to the epithelium of the lower anal canal in the midline, particularly posteriorly, is relatively deficient and is thought to predispose to the occurrence of acute and chronic anal fissures, which are most commonly found in the midline, especially posteriorly. 2. d. Anococcygeal raphe • Anorectal ring is a muscular present at the junction of rectum and anus. it is formed by fusion of fibres of puborectalis, uppermost fibres of external anal sphincter and internal anal sphincter. • Anococcygeal raphe a fibrous median raphe in the floor of the pelvis, which extends between the coccyx and the margin of the anus and is not a component of anorectal ring. PELVIS • Damage to the anorectal ring results in rectal incontinence.