Perineum

It is the diamond-shaped lower end of the trunk

Glossary : peri : around, ineo - discharge, evacuate
Location : it lies below the pelvic diaphragm, between the upper parts
of the thighs.
Boundaries :
Anteriorly : Inferior margin of symphysis pubis.
Posteriorly : Tip of coccyx.
Anterolateral : Fused rami of pubis and ischium and ischial tuberosity.
Posterolateral : Sacrotuberous ligaments.
Divisions of the Perineum :
❖ By a line joining the anterior parts of the ischial tuberosities, the
perineum is divided into two triangles :
❖ Anteriorly :Urogenital triangle
❖ Posteriorly : Anal triangle
 Perineum

Urogenital triangle Anal triangle

Contains Contains
1 External genitalia in male 1 Anal Canal in the median plane
or female 2 Ischiorectal fossa on either
2 Superficial perineal pouch side of anal canal
3-Deep perineal pouch 3 Pudendal canal in side wall of
ischiorectal fossa
 Urogenital triangle:
Contains these fascial layers
1 The membranous layer of the superficial fascia of the perineum (Colles
fascia).
2 The perineal membrane
It is a triangular fibrous sheet which lies across the pubic arch.
The perineal membrane :
• Forms the floor of the deep perineal pouch.
• Forms the roof of the superficial perineal pouch
Urogenital Diaphragm
⮚ It is a triangular musculofascial diaphragm situated in the anterior part of the
perineum
⮚ It fills the gap of the pubic arch
⮚ It is formed by the sphincter urethrae and the deep transverse perineal
muscles
⮚ These two muscles are enclosed between a superior and an inferior layer of fascia of
the urogenital diaphragm.
⮚ The inferior layer of fascia is the perineal membrane.
Perineum contains two flbro muscular masses which are :
A- Anococcygeal raphe (and body) :
• It is a fibromuscular mass which extends from the tip of coccyx to the
recto anal junction.
• It is easily stretched during defaecation and labour and recoiled
by the coccygeus muscles.
•It supports the lower part of the rectum.
B- Perineal body (central tendon of the perineum) : (remnant of
urorectal septum)
•It is a fibromuscular mass situated in the median plane, in front of anus.
Relations :
•In the male : it lies between anal canal and bulb of the penis.
• In the female : it lies between anal canal and lower part of vagina.
⮚ Importance : perineal body supports the uterus and vagina.
⮚ Rupture of it during labour may result in prolapse of uterus
 Muscles attached to the perineal body : 3 paired and 3 single muscles :

3 paired muscles 3 single muscles

1. Superficial transverse perineal. 1. Bulbospongiosus.

2. Deep transverse perineal. 2. Superficial part of external

3. Levator prostate or urethral sphincter (sphincter

sphincter vaginae part of urethrae).

levator ani. 3. Superficial part of external anal sphincter

Dr. Ahmed
Salman
 Muscles of perineum
Nerve Supply : All muscles in superficial and deep perineal pouches are supplied by
perineal branch of pudendal nerve

❑ Muscles of Superficial Perineal Pouch :

1 Ischiocavernosus :
Site : Each covers the crus penis.
Action : it compresses crus penis to maintain erection of penis.

2 Bulbospongiosus :
Site : covers bulb of penis. In female, it is splitted into two parts to cover bulbs of
vestibule.
Action : In Male ,Assist in erection of penis and eject last drops of urine during
micturition.
In Female: act as sphincter vagina and help in erection of clitoris
3 Superficial transverse perineal:
Site : on posterior edge of perineal membrane in front of anus.
Action : fixationthe perineal body.
Muscles of the Deep perineal Pouch : These muscles form the urogenital diaphragm.
1 Sphincter urethrae :
Site : it surrounds membranous urethra.
Attachments : it is formed of two parts :
⮚ Inferior (or superficial) part :
⮚ Superior (or deep) part :
⮚ Action : It represents the voluntary control of urethra.

2- Deep transverse perineal

Site : on deep surface of posterior border of the perineal membrane.
Action : fixation of perineal body.
 Sup. transverse perineal muscle Deep transverse perineal muscle

Bulbospongiosus muscle Ischiocavernosus muscle

a
n
The perineal fascia

consists of superficial and deep layers

Superficial perineal fascia, consists of a superficial fatty layer and a deep

membranous layer (Colles fascia).

The superficial fatty layer

In females, It makes up the substance of the labia majora and mons pubis

It is continuous with the fatty layer of subcutaneous tissue of the abdomen

(Camper fascia)

In males, the fatty layer is replaced with smooth (dartos) muscle.

It is continuous with the fatty layer of subcutaneous tissue of the abdomen .

In both sexes, it is continuous posteriorly with the ischio-anal fat pad in the
anal region .
The membranous layer (Colles fascia).

is attached To

Posteriorly : The posterior margin of the perineal membrane and the

perineal body

Laterally, the fascia lata (deep fascia) of the upper medial aspect of the
thigh.

Anteriorly, in the male, the membranous layer of subcutaneous tissue is

continuous with the fascia of the penis and scrotum

On each side of the scrotum, the membranous layer becomes continuous with
the membranous layer of subcutaneous tissue of the abdomen (Scarpa fascia) .

.
The perineal fascia (deep perineal, investing, or Gallaudet fascia)

⮚ Invests the ischiocavernosus, bulbospongiosus, and superficial transverse

perineal muscles.
⮚ It is also attached laterally to the ischio-pubic rami.
⮚ Anteriorly, it is fused to the suspensory ligament of the penis
 The perineal fascia

Superficial perineal fascia Deep perineal (Gallaudet fascia)

The superficial The membranous layer

fatty layer (Colles fascia)
It is continuous It is attached to fascia lata
with (Camper
It is continuous with
fascia)
(Scarpa fascia)
DEEP FASCIA OR PERINEAL MEMBRANE
PERINEAL MEMBRANE
Rupture of the
Urethra 1- Spongy
Urethra
Cause : (Straddle injury)
a) Sever blow to perineum
b) Falling on metal beam
The urine extravasates into the superficial perineal pouch and then passes
forward into loose connective tissue of the scrotum ,around the penis
beneath the membranous layer of the subcutaneous connective tissue of
lower part of anterior abdominal wall.
Site of rupture
2-Membranous part
Cause:
a) Fracture Pelvis
b) Fault catheterisation
The urine escapes into the deep perineal pouch and may be pass upward
around the prostate and bladder (extra peritoneal) through urogenital hiatus.

IN BOOTH CASES
The urine cannot passes into thigh because attachment of colles fascia
with fasciae lata below inguinal ligament.
Also cannot passes posteriorly to anal triangle due to fusion of superfacial and
deep layer of perineal fascia around posterior edge of perineal membrane
Pudendal canal:
Location : Fascial canal in lower part of the lateral wall of
ischiorectal fossa Extend: From the lesser sciatic foramen to the
posterior border of the perineal membrane.
contents: 1- pudendal nerve 2- internal pudendal vessels
Pudendal Nerve :

It is the somatic nerve of the perineum and external genitalia.

It arises from the sacral plexus;S2,3,4

Course and Relations :

∙ The nerve leaves the pelvis through the greater sciatic foramen below the

piriformis to enter the gluteal region.

∙ In the glutealregion,the nerve crosses the sacrospinous
ligament
medial to the internal pudendal vessels which cross the ischial spine.

∙ The nerve and the vessels pass through the lesser sciatic foramen to enter

the pudendal canal in side wall of ischiorectal fossa.

∙ In the posterior part of pudendal canal, the nerve gives inferior rectal N. and

then divides into 2 terminal branches which are the perineal N. and dorsal
nerve of penis (or clitoris).
 Pudendal nerve (Yellow ) crosses the
sacrospinous ligament medial to
the internal pudendal Artery (RED)

Dr. Ahmed
Salman
Branches and Distribution :
1 Inferior rectal N. (mixed)
• Motor to external canal sphincter
• Sensory to anal canal below pectinate line, skin around the anus .
2 Perineal nerve (mixed) : it gives :
• Motor : to all muscles in the superficial and deep perineal pouches.
• Sensory : It gives 2 scrotal (labial) nerves,

they pierce perineal membrane to supply posterior 2/3 of scrotum (or labium

majora).
3 Dorsal nerve of penis or clitoris (sensory) :
- It enters the deep perineal pouch, then pierces the perineal membrane to
enter the superficial perineal pouch.
- Then it runs on dorsum of penis, supplying its skin and glans.
Internal Pudendal Artery:
It is the artery of perineum and external genital organs.
It is one of the two terminal branches of anterior division of internal iliac artery.
Course and Relations :

∙ In the pelvis : it descends in front of sacral plexus and piriformis and leaves

the pelvis (with pudendal N.) below the piriformis to enter the gluteal region.

∙ In gluteal region: The artery crosses the tip of the ischial spine and passes

through the lesser sciatic foramen to enter the pudendal canal in side wall of
ischiorectal fossa.
∙ In the pudendal canal and perineum :
At the end of the pudendal canal, it enters the deep perineal pouch then
pierces the perineal membrane to enter the superficial perineal pouch to run
close to the side of pubic arch
It ends by dividing into dorsal and deep arteries of the penis
Dr. Ahmed
Salman
Branches and Distribution :
two in the pudendal canal, two in the deep perineal pouch and two terminal in
the superficial perineal pouch.
A. In the pudendal canal :
1 Inferior rectal A. : It supplies anal canal below the pectinate line.
2 Perineal A. : it gives
⮚ Two scrotal (or labial) arteries to scrotum (or labia majora)
⮚ Transverse perineal A. which anastomoses with its corresponding one .
B- In the deep perineal pouch :
3 Artery of bulb : supplies bulbourethral glands and pierces perineal
membrane to supply bulb of root of penis (or bulb of vestibule).
4 Urethral A. : pierces perineal membrane to enter superficial perineal pouch to
supply corpus spongiosum and urethra.
C-Superficial perineal pouch :
5 Dorsal A. of penis : runs on dorsum of penis,
supplying its skin, fascia and glans of penis.
6 Deep A. of penis : runs in corpus cavernosum, supplying its cavernous tissue.
Internal pudendal artery Internal pudendal nerve

Inferior rectal Inferior rectal N

Perineal A Perineal N

Two scrotal (or iibial) Two scrotal (or iibial)

Transverse perineal A

Artery of the bulb

Urethral artery

Dorsal artery of the penis Dorsal nerve of penis or clitoris

Deep artery of the penis
 Perineal pouches

Dr. Ahmed
Salman
Deep Perineal pouch :

Boundaries :

Floor : Perineal membrane (inferior fascia of urogenital diaphragm)

Roof: Inferior fascia of pelvic diaphragm (levator ani)

On either side : Obturator fascia.

Posteriorly : The pouch is closed by union of roof and floor.

Anteriorly : The pouch is closed by union of roof and floor below symphysis
pubis to form the transverse perineal ligament.
The transverse perineal ligament
Is separated from the symphysis pubis by an oval opening. Through this
opening
In male the deep dorsal vein of penis enters the pelvis to join the prostatic
venous plexus.
In female, the deep dorsal vein of clitoris joins the vesical venous plexus
 Contents of Deep Perineal pouch

Male Female

Urogenita • Membranous urethra • Part of the urethra

l • Bulbourethral glands • Part of vagina
Structure
s
Muscles • Sphincter urethrae
• Deep transverse perineal muscles
(These two muscles form the urogenital diaphragm.)

Vessels ▪ Internal pudendal A. ▪ Internal pudendal A.

▪ Artery of bulb. ▪ Artery of bulb of vestibule.
▪ Urethral A.
▪ Perineal A.
▪ Perineal A.
Nerves ▪ Dorsal N. of penis. ▪ Dorsal N. of clitoris.
▪ Perineal N. ▪ Perineal N.
N.B. : the greater vestibular glands of the female lie in the
superficial perineal pouch, the bulbourethral glands of the male lie in
the deep perineal pouch
Deep perineal pouch in male
Deep perineal pouch in female
Superficial Perineal Pouch:
Boundaries :
Floor : Membranous layer of the superficial fascia of the perineum (Colles fascia).
Roof : Perineal membrane.
On either side : both roof and floor are attached to the side of the pubic arch .
Posteriorly : The pouch is closed by union of the roof and floor.
Anteriorly : The pouch is opened and continuous with the interval between the
membranous layer of anterior abdominal wall and the external oblique aponeurosis
 Contents of Superficial Perineal Pouch

Male Female
Urogenital • Root of penis (2 crura +Bulb) • Root of clitoris (2 crura)
Structures • Penile urethra in corpus • Two bulbs of vestibule
spongiosum (bulb of • Greater vestibular glands.
penis)
Muscles • Two ischiocavernosus • Two ischiocavernosus
muscles cover the 2 crura • Bulbospongiosus muscle
• Bulbospongiosus • Two superficial transverse
muscle covers bulb of perineal muscles.
penis.
• Two superficial transverse
perineal muscles.
Vessels • Dorsal A. of penis. • Dorsal A. of clitoris.
• Deep A. of penis. • Deep A. of clitoris.
• Two scrotal arteries • Two labial arteries.

Nerves • Dorsal N. of penis. • Dorsal N. of clitoris.

• Two scrotal nerves • Two labial nerves
Superficial perineal pouch in
male
Superficial perineal pouch in female
Ischiorectal fossa
Location : It is wedge
shaped space on either
side of the anal canal

Dr. Ahmed
Salman
Boundaries : It has
1. Apex : it is the origin of levator ani from the lateral pelvic wall (White line)
2. Base : skin on either side of the anal orifice (skin of the base is
supplied by inferior rectal N.).
3. Anteriorly : the posterior border of the perineal membrane
4. Posteriorly : sacrotuberous ligament covered by lower border of
gluteus maximus muscle.
5. Lateral wall : is vertical formed by :
⮚ Lower part of obturator internus muscle and lower part of obturator
fascia splitting to form pudendal canal.
⮚ Medial surface of ischial tuberosity.
6. Medial wall : formed by :
⮚ Levator ani muscle (lower surface).
⮚ External anal sphincter.
Levator Ani

Obturator
internus

External Anal
sphincter
Ischiorectal
Dr. Ahmed
fossa
Salman
Contents of Ischiorectal fossa :
1. Pudendal nerve.
2. Internal pudendal vessels.
3. Inferior rectal nerve.
4. Inferior rectal vessels.
5. Posterior scrotal nerves.
6. Posterior scrotal vessels.
7. Perforating cutaneous N. (S2, S3) .
8. Pad of Fat : It is rich in fibroelastic fibres and has
two functions :

• It acts as a cushion support for rectum and anal canal.

• It allows distention of the rectum and anal canal during
defaecation,
Then compress them after termination of the act.
Applied Anatomy:
Infections in the ischiorectal pad of fat is common and lead to abscess
formation.
The abscess may rupture medially into the anal canal or downwards into the
skin at the fossa. This may leads to anal fistula
Dr. Ahmed
Salman