Perineum
Shallow compartment bounded by pelvic outlet 1. Pelvic diaphragm fascia separates it from pelvic cavity 2. Surface diamond-shaped A. Mons pubis - anterior B. Medial thighs - lateral C. Gluteal folds - posterior 3. Bony boundaries A. Pubic symphysis B. Ischiopubic rami C. Ischial tuberosities D. Sacrotuberous lig E. Sacrum F. Coccyx 4. Anal canal 5. Urogenital triangle 6. Perineal body
Anal triangle
Urogenital triangle
Perineal body
Central tendon of perineum
1. Irregular mass of collagenous and elastic muscles
2. Skeletal and smooth muscles posterior vaginal vestibule/bulb of penis and anterior angus
3. Muscle convergence
A. Bulbospongiosus
B. External anal sphincter
C. Superficial and deep transverse perineal
D. External urethral sphincter
E. Levator ani
F. Muscular coats of rectum
4. Blends w/ posterior border of perineal membrane anteriorly and rectovesical or rectovaginal septum superiorly
Perineal fascia
Superficial fatty layer of subcutaneous peritoneal fascia
Deep membranous layer of subcutaneous peritoneal fascia
Deep perineal fascia
Investing or Gallaudet 1. Invests A. Ischiocavernosus B. Bulbospongiosus C. Superficial transverse perineal 2. Attaches A. Ischiopubic rami laterally B. Suspensatory lig of penis/clitoris anteriorly 3. Continuous w/ deep fascia in abdomen
Superficial perineal pouch
Deep perineal pouch
1. Boundaries A. Perineal membrane - inf B. Inf fascia pelvic diaphragm - sup C. Obturator fascia - lat 2. Both sexes A. Part of urethra B. Inf part external erethral sphincter m. C. Ant extension of ischio-anal fat pads 3. Males A. Intermediate urethra B. Deep transverse perineal m. C. Bulbourethral glands D. Dorsal neurovascular structures of penis 4. Females A. Prox urethra B. Mass of smooth muscle C. Dorsal neuorvasculature of clitoris
Anal triangle
Ischio-anal (ischiorectal) fossae
Part of anal triangle
Pudendal canal (Alcock canal)
Part of anal triangle
1. Horizontal passageway w/in obturator fascia
2. Enter at lesser sciatic notch
A. Internal pudendal a. And v.
B. Pudendal n.
C. N. To obturator internus
3. Internal pudendal vessels and pudendal n. Serve most of perineum
A. Micturation
B. Defecation
C. Erection
D. Ejaculation
E. Parturition
4. Internal pudendal a. And n. -> inf rectal a. And n.
A. Passes medially -> external sphincter and peri-anal skin
B. Inf. Rectum
Pudendal n.
S2-S4
1. Major n. Of perineum
2. Exits sacral foramina, under greater sciatic foramen
3. Enters perineum via lesser sciatic foramen
4. Branches
A. Inferior rectal n. - external sphincter and anal canal inf pectinate line
1. Communicates w/ perineal br. Of post cutaneous n. In thigh
B. Perineal n.
C. Dorsal n. Of penis/clitoris
Perineal n.
2. Deep n. -> muscles of deep and superficial perineal pouches, skin of vestibule, mucosa innermost vagina
Dorsal n. Of penis/clitoris
Primary sensory n. Of penis/clitoris
Anal canal
Terminal portion of GI tract from superior pelvic diaphragm -> anus
Internal anal sphincter
Part of anal canal
1. Involuntary
2. Sup 2/3 anal canal
3. Thickening circular muscle layer
A. Tonic contraction stim
1. Sympathetic superior rectal
2. Sympathetic hypogastric
B. Inhibited
1. Parasympathetic pelvic splanchnic n.
2. Distension rectal ampulla
3. Requires voluntary contraction of sphincter to inhibit defecationExternal anal sphincter
Part of anal canal 1. Voluntary 2. Inf 1/3 anal canal 3. Attached A. Perineal body - ant B. Coccyx - post 4. Subcutaneous, superficial, deep parts - zones instead of bellies 5. Mostly S4 innervation via inf rectal n.
Anal columns
Part of anal canal
1. Sup 1/2 mucous layer - longitudinal columns
A. Terminal branches sup rectal a. And v.
Anorectal junction
Part of anal canal
1. Where rectum joins anal canal
A. Anal columns end and join anal valves
B. Recesses -> mucus when compressed by feces
Pectinate line
Inf limit anal canal, separate visceral and somatic portions
1. Sup and inf differ
A. Histology
B. Arterial supply
C. Innervation
D. Venous and lymphatic drainage
2. Sup to pectinate line
A. Supply from IMA
1. Superior rectal a.
B. Drain portal venous system
C. Lymph -> internal iliac nodes
D. Hypogastric plexus
1. Sympathetic- tone sphincter
2. Parasympathetic- relax sphincter
3. Visceral afferent travel w/ S2-S4
3. Inf to pectinate line
A. Supply from internal iliac a.
B. Drain caval venous system via inf rectal v.
C. Lymph -> sup inguinal nodes
D. Inf rectal n.
1. Sensory: pain, touch, temp
2. Somatic: sphinctersSuperficial perineal muscles
Superficial transverse perineal