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2019 | OriginalPaper | Hoofdstuk

4. Anatomy of the pelvis, pelvic organs and reproductive system

Auteurs : PhD Marco C. DeRuiter, PhD Gerrit-Jan Kleinrensink, MD, PhD Bernadette S. de Bakker

Gepubliceerd in: Textbook of Obstetrics and Gynaecology

Uitgeverij: Bohn Stafleu van Loghum

Summary

Knowledge of the functional anatomy of the pelvic organs with the surrounding tissues is a key element of safe clinical practice. The internal pelvic organs are firmly attached to each other and the encircling bony pelvic girdle and musculofascial pelvic floor by endopelvic fascia structures. This close relationship combining local anchoring and stretching properties of the mesenchymal tissues with the contractility of the pelvic floor is essential for good daily functioning of the male and female pelvic organs. In this chapter, the localization, composition of the organ tissues and changes during life are discussed in relation to their functions in urinary and faecal continence, vaginal delivery, fertilization, locomotion and how they prevent the formation of, for example, cystocele, enterocele, rectocele and vaginal prolapse. Attention is also paid to the development of the reproductive organs, which is essential to understand the wide range of variations and congenital malformations, but also to understand the complex anatomy of the pelvis with its vascularization and innervation patterns.

vorige hoofdstuk Reproductive medicine: ethical reflections

volgende hoofdstuk Essentials of history taking and physical examination

Alleen toegankelijk voor geautoriseerde gebruikers

Anorectal canal

The rectum and anus form the last part of the large intestine. The rectal and anal part are actually separate units.

The rectum is the part of the large intestine caudal to the arcuate line of the pelvis. The rectum measures about 10–15 cm (without the anal canal: about 4 cm.) 1/3 of the rectum is completely intraperitoneal, 1/3 partly intraperitoneal and extraperitoneal and 1/3 completely extra (sub)peritoneal.

The rectum forms an angle of 90–115 degrees with the anal canal, which widens to 130 ̊ during defecation, caused by contraction of the puborectal sling.

The anus/ anal canal (as surgically defined) forms the last part of the large intestine and consists of three parts (from caudal → cranial or outward → inward): (1) the anus (1 cm) often covered with brownish skin; (2) the intermediate zone (anal pecten/anatomical anal canal and (3) the transitional zone from the mucocutaneous line to the insertion of the puborectal muscle)

Denonvilliers’ fascia

A strong and densely connective tissue (fascia or septum) between the vagina and the rectum to prevent cele formation. An important surgical marking point in rectal and vaginal surgery

Gubernaculum

The gubernaculum ligament develops between the ovary/testis and labio/scrotal swelling and pierces through the abdominal wall at the future inguinal canal and is essential for the descent of the testis. The female counterpart in the adult is the round ligament of the uterus

Endopelvic fascia

The fascial structures in between the muscular lateral pelvic walls (parietal fascia) and the outer borders of the internal organs (visceral fascia). Superiorly bordered by the peritoneum and inferiorly by the pelvic floor

Inguinal canal

An oblique, 4 cm long canal in which the testes descend into the scrotum. In the female the round ligament of the uterus (ligamentum teres) is found in this canal formed by the much smaller processus vaginalis. In the female the processus vaginalis obliterates earlier than in the male, preventing the ovaries from descending. From the inside out, the canal is formed by the deep inguinal ring (annulus inguinalis profundus), then runs a course through the 3 layers of the abdominal wall (transverse, internal oblique and external oblique abdominal muscles) and ends in the superficial inguinal ring (annulus inguinalis superficialis)

Levator ani muscle

Originates bilaterally from the internal fasciae covering the obturator internus muscles (the tendinous arch of the levator ani) on a line between the pubic bones and ischial spines. It comprises three individual muscles: puborectal, pubococcygeal and the iliococcygeal muscle

Pelvic diaphragm

It consists of two coccygeal and two levator ani muscles with covering fascial layers. The left and right coccygeal muscles run from the ischial spines and sacrospinous ligaments towards the coccyx and inferior part of the sacrum

Pelvic floor

The inferior fibromuscular border of the lesser pelvis which is often divided into an anterior urogenital diaphragm and a posterior pelvic diaphragm

Pelvic inlet

The ring-like border between the greater and lesser pelvis formed by the sacrum with its the sacral promontory, the rims on both insides of the iliac bones and the ventral pubic symphysis

Pelvic outlet

The inferior border of the lesser or true pelvis bordered bilaterally by the ischiopubic rami, the ischial tuberosities, the sacrotuberous ligaments, the sacrum and the coccyx

Perineum

The diamond-shaped area between the coccyx, the two ischial tuberosities and pubic symphysis including the pelvic floor and associated structures. The perineum can be divided into an anterior triangular urogenital part and a posterior triangular anal part

Pudendal nerve

The most important somatic nerve (S2–S4) carrying motor and sensory information both to and from to the perineum and part of the pelvic floor

Retropubic space (or cavum Retzii)

Loose areolar tissue devoid of large nerves and vessels in between the pubic bone and the urinary bladder. It allows expansion of the urinary bladder. This space can also be used as a surgical plane to the bladder neck, prostate with minimal damage to the supplying tissues

Tendinous arch of the levator ani muscle

Tendinous attachment of the levator ani muscle to the obturator internal muscle

Tendinous arch (or white line) of the pelvic fascia

A thick band of condensed tissue within the parietal pelvic fascia on the lateral pelvic wall can be recognized that runs from the pubis symphysis to the ischial spine. All the internal organs are suspended to this arch

Visceral innervation of the pelvis

The efferent and afferent visceral fibres that control the function of the erectile organs, glands, urethra, vagina, anorectum and the internal anal and ureteral sphincters (composed of smooth muscle cells)

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Titel: Anatomy of the pelvis, pelvic organs and reproductive system
Auteurs: PhD Marco C. DeRuiter
PhD Gerrit-Jan Kleinrensink
MD, PhD Bernadette S. de Bakker
Uitgeverij: Bohn Stafleu van Loghum
Boek: Textbook of Obstetrics and Gynaecology
Print ISBN: 978-90-368-2130-8

Elektronisch ISBN: 978-90-368-2131-5

Copyright: 2019
DOI: https://doi.org/10.1007/978-90-368-2131-5_4

Bohn Stafleu van Loghum

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