Anatomy

ANATOMY
• The pelvis
• The pelvic floor and muscles of pelvis
• The perineum
• The abdominal muscle
• The breast
• The reproductive tract
• The urinary tract
• The anorectal region
 The pelvis provides a protective shield for the
important pelvic contents
 It also support the trunk
 Through pelvis weight is transferred to the

lower limbs in walking & to the ischial

tuberosity in sitting
BONY PELVIS
 Innominate bone (Ilium, ischium and pubis)
 Sacrum
 Coccyx
 Joined anteriorly by pubic symphysis
 Posteriorly by sacro-iliac joint
BONY PELVIS
 Innominates & the sacrum articulates at the
symphysis pubis & at the right and left
sacroiliac joint, to form a bony ring.
 They are held together by strongest

ligaments in the body

 The ring of bone is deeper posteriorly than

anteriorly & forms a curved canal

 BONY PELVIS

Ring is deeper
posteriorly than
anteriorly and form
a curved canal
INLET
 The inlet of this canal is at the level of sacral
promontory (a protuberance on an organ or
other bodily structure) & superior aspect of
the pubic bones
INLET /SUPERIOR APETURE
Longest dimention at side
To side

At the level of sacral promontory and superior

aspect of pubic bone
OUTLET
 The outlet is formed by the pubic arch, ischial
spines, sacrotuberous ligament & the coccyx
PELVIS OUTLET
Longest dimention at
AP

Formed by pubic
arch,ischial
spine,sacrotuber
ous ligament and
coccyx
TRUE PELVIS
 The enclosed space between the inlet and
outlet is called the true pelvis
 The female true pelvis is differ from male
 It is shallower, having straight sides, a wider

angle between the pubic rami at the

symphysis & proportionately larger pelvic
outlet
FEMALE VS MALE PELVIS

Gynaecoid pelvis-rounded
 SUB PUBIC ANGLE

The angle that is formed just below the pubic

symphysis by the meeting of the inferior ramus
of the pubis on one side with the
corresponding part on the other side and that
is usually less than 90 degree in the male and
more than 90 in the female.
Narrow sub pubic arch is strongly associated
with prolonged labor and postpartum anal
incontinence.
TYPES OF PELVIS
 There are commonly four types of pelvis inlet
in females
FOUR TYPE OF PELVIC INLET
 Gynecoid means like a woman, womanly, female.
The gynecoid pelvis is more delicate, wider than,
and not as high as the male pelvis. The angle of the
female pubic arch is wide and round. The female
sacrum is wider than the male's and the iliac bone
is flatter.

 A platypoid pelvis is flattened at the inlet and has a

prominent sacrum. The subpubic arch is generally
wide but the ischial spines are prominent. This
pelvis favors transverse presentations.  Pelvic brim
is transverse kidney shape. The platypelloid pelvis
is very short (almost like a “flattened gynecoid
shape”). Only about 3% of women have a true and
pure pelvis of this type.
 An anthropoid pelvis is, like the gynecoid
pelvis, basically oval at the inlet, but the long
axis is oriented vertically rather than side to
side.
 An android pelvis is more triangular in shape

at the inlet, with a narrowed subpubic arch.

Larger babies have difficulty traversing this
pelvis as the normal areas for fetal rotation
and extension are blocked by boney
prominences. Smaller babies still squeeze
through. 
ASYMMETRICAL PELVIS
 Protuberant ischial spine, a heart shaped inlet
produced by an invasive sacral prominence is
an asymmetrical pelvis
 It can cause difficulties in child birth
 It is a result of rickets or trauma
Asymmetry pelvis e.g. Rickets
LIGAMENTS OF PELVIS
 Iliolumber ligament
 Supraspinous ligament
 Sacrospinous
 Sacrotuberous ligament
 Anterior sacroiliac ligament
 posterior sacroiliac ligament
 Pectineal ligament
 Inguinal ligament
STABILIZATION OF THE PELVIS
 The upper segment of sacrum is stabilize by
◦ Iliolumbar ligament
 The lower segment of sacrum is stabilize by
◦ Sacrospinous and
◦ Sacrotuberous ligament
Rotation of sacrum under loading
LUMBAR LORDOSIS IN PREGNANCY
 The sacrum supports the weight of the trunk
& upper limbs; usually loading of it pushes
the sacral prominence down & forward,
producing a complex and individual series of
changes, rotating the sacrum about a
generally transverse axis
Cont……….
 This causes the connecting ligament to
tighten.
 Thus loading of the sacral prominence (e.g. in

pregnancy) is often, but not invariably,

accompanied by lumbar lordosis & its
associated adaptations, hip & knee flexion,
thoracic kyphosis & cervical extension with a
forward thrusting chin.
POSTNATAL EXTERNAL
STABILIZATION
 During pregnancy elevated level of estrogen,
progesterone and relaxin play a major role in
increases pelvic girdle joint laxity
 Normal hormonal level returns within a week
 Pelvic girdle returns to its pre pregnant stage

within 3-6 month

PUBIS SYMPHSIS LAXITY
 The gap of symphysis pubis, normally is 4-5
mm
 During pregnancy there will be an increase of

at least 2-3 mm
 In pregnant women symphysis width is up to

6.3mm -9mm,vertical shift 1.8mm at 35week

 upto1cm separation is normal
 More than 1-2 cm consider partial or

complete rupture
BIOMECHANICS
MOTION AT SACROILIAC JOINT
 The movements at sacroiliac joints are
nutation & counternutation
NUTATION
 Occurs in natural/relaxed spinal
extention,but it is called sacral flexion

 It is commonly used term to refer to

movement of the sacral promontory of the
sacrum anteriorly & inferiorly while the
coccyx moves posteriorly in relation to the
ilium
COUNTER NUTATION
 Occurs in natural/relaxed spinal flexion ,but
it is called sacral extension

 It refers to the opposite movement in which

the anterior tip of the sacral promontory
moves posteriorly & superiorly while the
coccyx moves anteriorly in relation to the
Ilium
THE PELVIC FLOOR AND MUSCLES
• Consist of bony, ligamentous and muscular
wall
• Bony shield provide protection e.g the urinary
bladder, ureters, pelvic genital organs,
rectum, blood vessels, lymphatic's and
nerves.
• Support trunk
• Transfer body weight to lower limb during
walking & ischial tuberosity during sitting
DEEPEST TO SUPERFICIAL LAYER

 Endopelvic fascia
 Levator Ani
 Urogenital diaphragm
 The external genitalia and skin
THE PELVIC FLOOR
 CONTENTS
 The pelvic viscera, (bladder, rectum, pelvic genital organs and
terminal part of the urethra) reside within the pelvic cavity (or
the true pelvis). This cavity is located within the lesser part of
the pelvis, beneath the pelvic brim.
 A number of muscles help make up the walls of the cavity;
the lateral walls include the obturator internus and
the pirformis muscle, with the latter also forming the
posterior wall

 the muscles that make up the inferior lining of the cavity,

the pelvic floor muscles. The pelvic floor is also known as
the pelvic diaphragm. 
 Fig 1.0 – An overview of the pelvic cavity and its walls. Note
the funnel shape of the pelvic floor.
PELVIC FLOOR STRUCTURE
 The pelvic floor is a funnel-shaped musculature structure. It
attaches to the walls of the lesser pelvis, separating the pelvic
cavity from the inferior perineum (region between the
genitalia and anus).
 In order to allow for urination and defecation, there are a few
gaps in the pelvic floor. There are two ‘holes’ that have
significance:
 The urogenital hiatus – An anteriorly situated gap, which
allows passage of the urethra (and the vagina in females).
 The rectal hiatus – A centrally positioned gap, which allows
passage of the anal canal.
 Between the urogenital hiatus and the anal canal lies a fibrous
node known as the perineal body which joins the pelvic floor
to the perineum 
The perineal body (or central tendon of
perineum)
 is a pyramidal fibro muscular mass in the middle
line of the perineum at the junction between
the urogenital triangle and the anal triangle. It is
found in both males and females. In males, it is
found between the bulb of penis and the anus; in
females, is found between the vagina and anus,
and about 1.25 cm in front of the latter.
 The perineal body is essential for the integrity of
the pelvic floor, particularly in females. Its rupture
during vaginal birth leads to widening of the gap
between the anterior free borders of levator
ani muscle of both sides, thus predisposing the
woman to prolapse of the uterus, rectum, or even
the urinary bladder.
FUNCTIONS
 As the floor of the pelvic cavity, the muscles have
important roles to play in the correct functions of the
pelvic and abdominal viscera.
 The roles of the pelvic floor muscles are:
 Support of abdomino pelvic viscera (bladder,
intestines, uterus etc.) through their tonic contraction.
 Resistance to increases in intra-pelvic/abdominal
pressure during activities such as coughing or lifting
heavy objects.
 Urinary and fecal continence. The muscle fibers have
a sphincter action on the rectum and urethra. They
relax to allow urination and defecation.
MUSCLES
 It is important to remember the funnel-
shaped structure when looking at the
diaphragm in more detail. There are three
components of the pelvic floor:
 Levator ani muscles (largest component).
 Coccygeus muscle.
 Fascia coverings of the muscles.
LEVATOR ANI MUSCLES
 Innervated by branches of the pudendal nerve,
roots S2, S3 and S4.
 The levator ani is a broad sheet of muscle. It is
composed of three separate paired muscles, called
the pubococcygeus, puborectalis and iliococcygeus.
 These muscles have attachments to the pelvis as
follows:
 Anterior – The pubic bodies of the hip bone.
 Laterally – Thickened fascia of the obturator
internus muscle, known as the tendinous arch.
 Posteriorly – The ischial spines of the hip bone.
 View of the inferior surface of the pelvic
floor, with the muscles labelled.
 Puborectalis
 Its tonic contraction bends the canal anteriorly, creating

the anorectal angle (90 degrees) at the anorectal

junction (where the rectum meets the anus)
 The main function of this thick muscle is to maintain

faecal continence – during defecation this muscle

relaxes
Pubococcygeus
 The muscle fibres of the pubococcygeus are the main

constituent of the levator ani. The fibres travel around

the margin of the urogenital hiatus and run posterio
medially, attaching at the coccyx and anococcygeal
ligament.
 As the fibres run inferiorly and medially, some fibres

divide and loop around the prostate in males (levator

prostatae) and around the vagina in females
(pubovaginalis). Some also terminate in the perineal
body.
 Iliococcygeus
 The iliococcygeus has thin muscle fibres,
They attach posteriorly to the coccyx and the
anococcygeal ligament.
 Coccygeus
 Innervated by the anterior rami of S4 and S5.

 The coccygeus is the smaller, and most posterior,

pelvic floor component. The levator ani muscles
situated anteriorly. It originates from the ischial
spines and travels to the lateral aspect of the
sacrum and coccyx, along
the sacrospinous ligament.
Clinical Relevance: Pelvic Floor Dysfunction
 The pelvic floor support acts to support the pelvic
viscera, and assist in their functions. If the muscles of
the floor become damaged, then dysfunction of these
viscera can occur.
 The levator ani muscles are involved in supporting
the foetal head during cervix dilation in childbirth.
During the second phase of childbirth, the levator ani
muscles and/or the pudendal nerve are at high risk of
damage. Pubococcygeus and puborectalis are the most
prone to injury due to them being situated most
medially.
 Due to their role in supporting the vagina, urethra and
anal canal, injury to these muscles can lead to a number
of problems. The primary problems include urinary
stress incontinence and rectal incontinence.
 Urinary incontinence is most noticeable during
activities where there are increased abdominal
pressure – coughing, sneezing and lifting heavy
objects.

 Prolapse of the pelvic viscera (such as the bladder

and vagina) can occur if there is trauma to the
pelvic floor or if the muscle fibres have poor tone.
Prolapse of the vagina can also occur if there is
damage to the perineal body in childbirth.
 This may be avoided by episiotomy(surgical cut in
the perineum), which itself can cause damage to
the vaginal mucosa and submucosa but helps
prevent uncontrolled tearing of the perineal
muscles. If the medial fibres of the puborectalis are
torn within the perineal body, then rectal herniation
can also occur.
There are a number of risk factors which can
increase the chances of prolapse: –
 Age

 Number of vaginal deliveries

 Family history of pelvic floor dysfunction

 Weight

 Chronic coughing (e.g from a lung disorder)

 The pelvic floor can be repaired surgically, however

a way to generally strengthen the muscles is to

carry out pelvic floor exercises on a regular basis
(Kegel exercises).
LEVATOR ANI
 Type l fiber (slow twitch)
 Type ll fiber (fast twitch)

◦ Type lla fiber (oxidative)

◦ Type llb fiber (glycolytic)
 Genetic factor is responsible for lack of
standardization of exercise
THE EXTERNAL GENITAL MUSCLES
THE EXTERNAL GENITAL MUSCLES
 Superficial Genital Muscles
 Blubospongiosus
 Ischiocavernosus
 Superficial transverse perineal muscle
 Intermediate muscles:
 Compressor Urethrae,
 Sphincter Urethrae
PELVIC WALLS AND FLOORS
 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

(proximal surface of the ilium and ischium; obturator membrane,
greater trochanter of the femur)
POSTERIOR PELVIC WALL
Formed by the sacrum and coccyx, adjacent
parts of the ilia, and the S-I joints; piriformis
muscle covers the area
THE PERINEUM
 External genital organ
 Inervation---pudendal nerve (S2-S4)
 Two Triangles
 Anal triangle (posterior) contains the anus
 Urogenital triangle (anterior) contains the

root of the scrotum and penis in males or the

external genitalia in females
THE ABDOMINAL MUSCLE

Rectus are supplied by lower

six thoracic
Obliqus and transverse
abdominalis are supplied
by lower six thoracic
vertebra,iliohypogastric
and ilioinguinal
THE BREAST
• The are, effectively, modified sweat glands that
develop on the ‘milk line’- a process that is
largely hormone-driven
• Blood supply
internal mammary artery
lateral thoracic, thoraco acromial arteries
• Lymphatics
anterior axillary nodes
internal thoracic nodule
• Nerve Supply
T3-6
DIFFERENT STAGES OF BREAST
DEVELOPMENT:

 Intra-uterine development
 Puberty
 Adult ‘resting’ period
 Pregnancy and lactation
 Involution (Mammary gland undergoes
massive cell death & tissue remodeling
as it returns to the pre pregnant state)
 Post-menopausal atrophy
DUCTS, DUCTULES AND LOBULES
• Each breast has around 10-12 duct systems-
each with numerous lobules
– A lobule consists of a terminal ductule
– Terminal ductules empty into the ducts

• The largest ducts drain into the lactiferous

ducts and sinus to drain to the nipple.

• The lobules and ducts are surrounded by

supportive stroma and adipose tissue
THE REPRODUCTIVE TRACT
 Nullipars uterus (fluoroscopic study ,method of
estimating the potential capacity of human uterine
cavity & fallopian tubes ) measurement—9cm
long,6cm wide,4cm thick
 After implantation endometrium called deciduia (it
is formed under the influence of progesterone )
 RETRACTION (is the very imp process for stopping
the [Link] starts from uterine wall after
placenta seperation called post partum
[Link] this process blood vessels blocked
& closed to its uterine end
LIGAMENT
◦ The Ovarian Ligament(ovary-uterus)
◦ Broad lig(overy-abdomen wall)
◦ Round lig(attached both side of fundus- labia
majora) help utreus anteverted
◦ Transverse cervical lig/
Mackenrodt’s ligaments/cardinal lig
(cervix and the lateral vagina- lateral pelvic wall
uterosacral ligaments.)
◦ Pubocervical lig
THING TO REMEMBER
 The round ligament can be a source of pain
during pregnancy, due to the increased force
placed on the ligament by the expanding
uterus
 25 cm long
 Smooth muscle—peristaltic waves
 Enter in the bladder at upper corner of

trigone about 2cm away from the

urethrovesical junction----prevent reflux of
urine.
BLADDER
URETHRAE
 Detrussor muscle – smooth muscles
surrounds bladder
 3-4cm in length

◦ Urethrae proper –
 Anteriorly type l slow twitch striated fiber
 Posteriorly –no muscle spindle ,lie against vagina
 Innervation – Parasympathetic to
detrussor (S2-S4)); Sympathetic to
internal sphincter (T12-L1/L2)
RECTUM
 Alimentary canal (GI Tract) connects sigmoid
colon with anus
 Follows the curve of the sacrum and coccyx
 Innervated by sympathetic (T12/L1)and
parasympathetic nerves (S2-S4)
ANAL CANAL
 Anal canal 4cm long
 Closed by puborectal portion of levator ani,

internal, external sphincter

 IAS

◦ Smooth m/s
◦ Maintain resting pressure 70 cm of H2O
ANAL CANAL
 EAS
◦ Slow and fast fiber for phasic contraction
◦ By further 70 cm of H2O(stop passing wind)

◦ Inability to generate 50 cm of H2O result in fecal

urgency and soiling
THANKS