BMS305&207

Perineum, divisions, pouches &

ischiorectal fossa Pudendal nerve and
vessels

Prof.Dr.Mona Attia
Professor of in Galala University
Faculty of Medicine, Spring 2024
Galala University

gu.edu.eg
 G A L A L A U N I V E R S I T Y T H E F U T U R E S T A R T S H E R E

BMS305&207
Perineum, divisions, pouches & ischiorectal fossa Pudendal
nerve and vessels

Prof.Dr.Mona Attia
Professor of in Galala University

T H E F U T U R E S T A R T S H E R E
4/19/2024
 Intended learning outcomes

Perineum, divisions, pouches & ischiorectal

fossa : Pudendal nerve and
1. Define the perineum, its boundaries, and vessels
subdivisions. 1. Describe site, mode of formation
2. Discuss the boundaries and contents of the and contents of the pudendal
ischiorectal fossa. canal.
3. Compare the boundaries and contents of the 2. Recognize the origin, course and
superficial and deep perineal pouches in the male branches of the pudendal nerve
and female. with emphasis on site of block.
4-Recognize the structures and features of the male and 3. Discuss the beginning, course
female external genitalia and branches of internal
pudendal vessels.
 Perineum
• Shape and boundaries: The
perineum is the diamond-shaped
outlet of the pelvis located below
the pelvic diaphragm.
• The perineum is divided by a
transverse line between the ischial
tuberosities into the anal and
urogenital triangles.
• The sensory and motor
innervation to the perineum is
provided by the pudendal nerve (S2,
3, 4) of the sacral plexus. The blood
supply is provided by the internal
pudendal artery, a branch of the
internal iliac artery.
 Perineum
Anal triangle: It contains the anal canal surrounded
by the fat-filled ischioanal fossa. The anal canal
is guarded by a smooth-muscle internal anal
sphincter innervated by the ANS and an
external anal sphincter of skeletal muscle innervated
by the pudendal nerve.
• Pudendal canal: It transmitting the pudendal
nerve and internal pudendal vessels is found on the
lateral aspect of the ischioanal fossa.
 •The anal canal is about 1.5 in. (4 cm) long and
passes downward and backward from the rectal
ampulla to the anus.
• The mucous membrane of the upper half of the
anal canal is derived from hindgut endoderm.
• It has the following important anatomic
features:
• It is lined by columnar epithelium.
• It is thrown into vertical folds called anal columns.

Upper half The nerve supply is derived from the autonomic

hypogastric plexuses. It is sensitive only to stretch.
The arterial supply is that of the hindgut: The superior rectal
artery, a branch of the inferior mesenteric artery.
The venous drainage is mainly by the superior rectal vein
(portal)
 Perineum
The mucous membrane of the lower half of the
anal canal is derived from ectoderm. It has the
following important features:
It is lined by stratified squamous epithelium,
which gradually merges at the anus with the perianal
epidermis. There are no anal columns.

• The nerve supply is from the somatic inferior rectal

nerve; it is thus sensitive to pain, temperature,
touch, and pressure.
• The arterial supply is the inferior rectal artery, a
branch of the internal pudendal artery.The venous
drainage is by the inferior rectal vein, a tributary of
the internal pudendal vein, which drains into the
internal iliac vein (systemic). NB. The pectinate line
indicates the level where the upper half of the
anal canal joins the lower half
Discuss the boundaries and contents of the ischiorectal fossa.
The ischiorectal fossa (ischioanal fossa): is a wedge-
shaped space located on each side of the anal canal.
The base of the wedge is superficial and formed by the skin.
The apex of the wedge is formed by the junction of the
medial and lateral walls.

The lateral wall is formed by the lower part of

the obturator internus muscle, covered with
pelvic fascia includes the pudendal canal.

The medial wall is formed

by the sloping levator ani
muscle and the anal canal.
Posterior wall :
Anterior wall: Formed by : The sacrotuberous
Formed by : ligament
The posterior border The lower border of the gluteus
of the perineal maximus , overlapping the ligament
membrane
The superficial &
deep transversus
perini muscles
Ischioanal Fossa and •Contents of ischiorectal Fossa:
• 1- It is filled with dense fat, which supports the anal canal
Infection and allows it to distend during defecation.
The ischioanal fossae (ischiorectal fossae) •2-The pudendal nerve and internal pudendal vessels are
are filled with fat that is poorly embedded in a fascial canal( pudendal canal).
vascularized. The close proximity to the •3-The inferior rectal vessels and nerve (branches from
anal canal makes them particularly internal pudendal vessels and pudendal nerve respectively)
vulnerable to infection. Infection cross the fossa to reach the anal canal.
commonly tracks laterally from the
anal mucosa through the external
anal sphincter. Infection of the perianal
hair follicles or sweat glands may also be
the cause of infection in the fossae.
Rarely, a perirectal abscess bursts
downward through the levator ani
muscle. An ischioanal abscess may
involve the opposite fossa by the
spread of infection across the
midline behind the anal canal.
Pudendal Canal
Position :
It is a fascial tunnel in the lateral wall of ischio-rectal fossa
It lies just above the sacro-tuberous ligament
Site & extent :
It extends from the lesser sciatic foramen to the posterior border of the perineal membrane.
Formation :
Formed by the splitting of the obturator fascia below the tendinous arch into 2 layers that
envelop the pudendal nerve & internal pudendal vessels.
Contents:
-Pudendal nerve, internal pudendal artery, internal pudendal vein
 Urogenital Triangle
• The urogenital triangle forms
the anterior aspect of the
perineum and
• contains the superficial and
root structures of the
external genitalia.
• The urogenital triangle is
divided into superficial and
deep perineal spaces
(pouches).
 Perineal membrane
Shape:
It is a strong triangular fibrous membrane which lies in the
interval between the 2 sides of the pubic arch.
The superior surface forms the floor of the deep perineal
pouch
The inferior surface forms the roof of the superficial
perineal pouch Attachments:
Lateral margin:
Attached to the medial border of ischio-pubic ramus
Posterior free border:
It is fused with Colle’s fascia and pelvic fascia.
Anterior border:
Is narrow and thickened to form the transverse ligament
of perineum
In the gap between this border and the lower
margin of the symphysis pubis the deep dorsal
vein of penis or clitoris passes to join the prostatic
or vesical venous plexus .
Figure 10.12 Arrangement
of the superficial fascia in
the
urogenital triangle. Note the
superficial and deep
perineal spaces
(pouches) relative to the
perineal membrane.
The superficial perineal pouch is located between the perineal membrane
of the urogenital diaphragm and the superficial perineal (Colles’) fascia.

Superficial Perineal Pouch

It is a fascial space present in the urogenital triangle
just under the skin.
Boundaries:
Roof : Perineal membrane .
Floor : The membranous layer of superficial fascia
of the perineum
Posteriorly: Closed by fusion between the roof &
floor along the posterior border of the perineal
membrane.
Anteriorly: Opened and is continuous with the
space deep to the membranous layer of the
superficial fascia of the anterior abdominal wall.
On each side: Closed by fusion of the roof &
floor with the sides of the pubic arch
 Superficial Perineal Pouch
It contains:
• 1-Crura of penis or clitoris: erectile
tissue
• 2-Bulb of penis (in the male): erectile
tissue; contains urethra
• Bulbs of vestibule (in the female):
erectile tissue in lateral walls of
vestibule
• Ischiocavernosus muscle: skeletal
muscle that covers crura of penis or
clitoris
• Bulbospongiosus muscle: skeletal
muscle that covers bulb of penis or
bulb of vestibule
• Greater vestibular (Bartholin) gland
(in female only): homologous to
Cowper gland
 Perineum, Injury to the bulb of the penis
In the male, injury to the bulb of the penis may result in
extravasation of urine from the urethra into the superficial
perineal space.
From this space, urine may pass into the scrotum, into the
Superficial Perineal Pouch in male
penis, and onto the anterior abdominal wall in the plane
deep to Scarpa fascia.
 Deep perineal pouch
(Urogenital diaphragm)

Boundaries:Roof :
Pelvic fascia.
• Deep Perineal Pouch (Space): A completely Floor :
closed space situated deep to superficial pouch is Perineal membrane.
formed by the fasciae and muscles of the On each side:
urogenital diaphragm.
• It contains: Sphincter urethrae muscle—serves Ischio-pubic ramus.
as voluntary external sphincter of the urethra Anteriorly and posteriorly:
• Deep transverse perineal muscle The pelvic fascia fuses with both the anterior and
• Bulbourethral (Cowper) gland (in the male only)— posterior borders of the perineal membrane.
duct enters bulbar urethra
 Deep perineal pouch (Urogenital diaphragm)
(Urogenital diaphragm)
• The muscular urogenital diaphragm is
located in the perineum inferior to the pelvic
diaphragm. It is formed by 2 muscles
(sphincter urethrae and deep
transverse perineus muscles)
which extend horizontally between the
2 ischiopubic rami.
• The diaphragm is penetrated by the
urethra in the male and the urethra and
vagina in the female.
• The sphincter urethrae muscle serves
as an external urethral sphincter
(voluntary muscle of micturition) which
surrounds the membranous urethra
and maintains urinary continence.
NB. The 2 muscles enclosed between a
superior and an inferior layer of fascia of the
urogenital diaphragm. The inferior layer of
fascia is often referred to the perineal
membrane.
Perineal Body
It is the midpoint of perineum .
It is a fibromuscular mass situated in
the midline between the anal canal
posteriorly and the bulb of the penis or
lower 1/3 of the vagina anteriorly
Attachments:1- Muscles:
Anteriorly : Bulbo-spongiosus
Posteriorly: External anal sphincter
From both sides: Superficial and deep
transverse perinei
Superiorly : Levator ani muscle ; the
latter assist the perineal body in supporting
the posterior wall of the vagina.
2- Fibrous elements:
Perineal membrane , Colle’s & pelvic
fascia
Male external genitalia(Crura and Bulb)

Crura of penis are

continuous with the
corpora cavernosa of the
penis. Bulb of penis is
continuous with corpus
spongiosus of the penis
(contains urethra).
• Corpora cavernosa
and corpus
spongiosus form the
shaft of the penis.
Figure 10.17 Root of penis
and perineal muscles.
Figure 10.13 Thepenis.
A,B. The three bodies
of erectile tissue,
the two corpora
cavernosa, and the
corpus spongiosum
with the
glans. C. The penile
urethra slit open to
show the folds of
mucous
membrane and
glandular orifices in
the roof of the
urethra.
Figure 10.18 Root and
body of the clitoris
and the perineal
muscles.in female
Female external genitalia

Crura of the clitoris are continuous

with the corpora cavernosa of the
clitoris. Bulbs of vestibule are
separated from the vestibule by the
labia minora.

Urethra and vagina empty into

the vestibule. Duct of greater
vestibular glands enters the
vestibule.
Superficial Perineal Pouch
External genitalia
 Figure 10.8 Course and branches of the pudendal nerve in
Course of the pudendal nerve the male.

The pudendal nerve is a branch of the

sacral plexus (S2 to 4 anterior rami). It
leaves the main pelvic cavity through the
greater sciatic foramen, enters the
gluteal region of the lower limb, and curls
around the attachment of the
sacrospinous ligament at the ischial
spine it passes through the lesser
sciatic foramen and
enters the posterior aspect of the
perineum. The nerve then runs forward in
the pudendal canal.
 1. with emphasis on site of block. pudendal Figure 10.8 Course and branches of the pudendal nerve in the
nerve
male.
Branches
1- Inferior rectal nerve: This runs medially across the
ischioanal fossa and supplies the external anal
sphincter, the mucous membrane of the
lower half of the anal canal, and the perianal skin .
2-Dorsal nerve of the penis (or clitoris): This is
distributed to the penis (or clitoris) .
3- Perineal nerve: This supplies the muscles in the
urogenital triangle , (sphincter urethrae muscle) and
the skin on the posterior surface of the
scrotum (or labia majora).
Anal Sphincter Nerve Block and
Anesthetizing Perianal Skin
By blocking the branches of the inferior rectal
nerve and the perineal branch
of the fourth sacral nerve, the anal sphincters will
relax and the perianal skin anesthetized.
Internal Pudendal Artery
Is a branch of the internal iliac artery. It travels
with the pudendal nerve and passes from
the pelvis through the greater sciatic
foramen and enters the perineum
through the lesser sciatic foramen.
Branches
1-Inferior rectal artery: This supplies the lower
half of the anal canal
2- Branches to the penis in the male and to the
labia and clitoris in the female.

Internal Pudendal Vein

The internal pudendal vein receives tributaries
of the Internal Pudendal Artery
 MCQs
• 3- Which of the followings form the lateral wall of the • 1- Which part of the male urethra when ruptured
ischiorectal fossa: leading to swelling of anterior abdominal wall:
A- Levator ani muscle A- External uretheral sphincter.
B- External anal sphincter B- Membranous urethera.
C-Internal anal sphincter C- Penile urethra.
D- Obturator internus muscle D- Prostatic urethra.
E-Obturator externus muscle E- Internal uretheral sphincter

• 2- Which of the followings is a content of deep

perineal pouch in male:
• 4- Which of the followings form the medial wall of the
ischiorectal fossa: A- Bulb of the penis.
A- Pudendal canal. B- Ischiocavernosus muscle.
B- Perineal membrane. C- Pudendal canal.
C- Levator ani muscle. D- Sphincter urethrae muscle.
D- Obturator internus muscle. E- Bulbospongiosus muscle.
• E-Obturator externus muscle
5- 46-year-old woman has a history of
infection in her perineal region. A comprehensive 6-A 58-year-old man is diagnosed as having
examination reveals a tear of the a slowly growing tumor in the deep perineal
superior boundary of the superficial perineal space. Which of the following structures
space. Which of the following structures would most likely be injured?
(A) Bulbourethral glands
would most likely be injured?
(B) Crus of penis
(A) Pelvic diaphragm
(C) Bulb of vestibule
(B) Colles’s fascia
(D) Spongy urethra
(C) Superfi cial perineal fascia
(E) Great vestibular gland
(D) Deep perineal fascia
(E) Perineal membrane

8-A 42-year-old woman who has had six

7-A general surgeon is giving a lecture to a
team of surgery residents. She describes children develops a weakness of the urogenital
characteristics of structures above the pectinate diaphragm. Paralysis of which of
line of the anal canal, which include: the following muscles would cause such a
(A) Stratifi ed squamous epithelium symptom?
(B) Venous drainage into the caval system (A) Sphincter urethrae
(C) Lymphatic drainage into the superfi cial (B) Coccygeus
inguinal nodes (C) Superfi cial transversus perinei
(D) Visceral sensory innervation (D) Levator ani
(E) External hemorrhoids (E) Obturator internus
 9-An obstetrician performs a median episiotomy 10-A 39-year-old man is unable to expel the
on a woman before parturition to last drops of urine from the urethra at the
prevent uncontrolled tearing. If the perineal body is end of micturition because of paralysis of
damaged, the function of which of the external urethral sphincter and
the following muscles might be impaired? bulbospongiosus
(A) Ischiocavernosus and sphincter urethrae muscles. This condition may
(B) Deep transverse perineal and obturatorinternus occur as a result of injury to which of the
(C) Bulbospongiosus and superfi cial transverse perineal following nervous structures?
(D) External anal sphincter and sphincter urethrae (A) Pelvic plexus
(E) Bulbospongiosus and ischiocavernosus (B) Prostatic plexus
(C) Pudendal nerve
11- Adolescent patient presents (D) Pelvic splanchnic nerve
with an infection within the ischiorectal (E) Sacral splanchnic nerve
fossa. Which of the following structures is
most likely injured?
(A) Vestibular bulb
(B) Seminal vesicle
(C) Greater vestibular gland
(D) Inferior rectal nerve
(E) Internal pudendal artery
Define the lateral wall of ischioanal fossa? 12-A 22-year-old victim of an automobile
accident has received destructive damage to
Define the contents of ischioanal fossa?
structures that form the boundary of the
perineum. Which of the following structures is spared?
Writs the medial wall of ischioanal fossa? (A) Pubic arcuate ligament
(B) Tip of the coccyx
Mentions the branches of Internal Pudendal Artery?
(C) Ischial tuberosities
Mentions the branches of Pudendal nerve? (D) Sacrospinous ligament
(E) Sacrotuberous ligament
Define the contents of Superficial Perineal Pouch ?

13-A 26-year-old man comes to a hospital with fever, nausea, pain, and itching in
the perineal region. On examination by a urologist,
he is diagnosed as having infected bulbourethral
(Cowper’s) glands. Which of the following structures is/are affected by this
infection?
(A) Superfi cial perineal space
(B) Sphincter urethrae
(C) Production of sperm
(D) Testis
(E) Seminal vesicles
14-. An obstetrician is about to perform a pudendal
block so a woman can experience less pain when she 15. A trauma surgeon in the emergency department at
delivers her child. He recalls what he learned in a local center examines a 14-year-old boy with
medical school about this nerve. Which of the extensive pelvic injuries after a hit and run accident.
following statements is correct? The surgeon inspects the ischiorectal fossa because it:
(A) It passes superficial to the sacrotuberous ligament. (A) Accumulates urine leaking from rupture of the bulb of the
(B) It innervates the testis and epididymis in a male. penis
(C) It provides motor fi bers to the coccygeus. (B) Contains the inferior rectal vessels
(D) It can be blocked by injecting an anesthetic near the (C) Has a pudendal canal along its medial wall
inferior margin of the ischial spine. (D) Is bounded anteriorly by the sacrotuberous ligament
(E) It arises from the lumbar plexus. (E) Contains a perineal branch of the fifth lumbar nerve

Thank you
Mona.Attia@
Gu.edu.eg