Blood supply, Nerve

supply of pelvic organs

Arterial supply
• Anterior division of internal iliac artery
• Ovarian artery
• Superior rectal artery
Internal iliac artery
• One of the bifurcation of common iliac artery (bifurcation occurs over
the sacroiliac articulation)
• Ureter lies anteriorly and internal iliac vein lies posteriorly
• At the superior margin of the greater sciatic foramen it divides into an
anterior division and posterior division
• The anterior division continues down to the ischial spine anterior
to piriformis
 Internal iliac artery

Posterior division Anterior division

Visceral Parietal
Visceral Parietal

Iliolumbar Lateral sacral Superior gluteal

• Superior vesical
• Inferior gluteal
• Uterine
• Obturator
• Inferior vesical
• Internal
• Middle rectal
pudendal
• Vaginal
Uterine artery
• Origin: arises either directly from internal iliac artery or in common
with obliterated umbilical artery
• Course: runs downwards and forwards along the lateral pelvic wall
(almost in the same direction as the ureter until it reaches the base of
the broad ligament), it then turns medially and crosses the ureter
anteriorly from above and at right angle to it; about 1.5-2cms lateral
to, at the level of internal os. On reaching the side of the uterus, it
runs upwards and takes a spiral course along the lateral uterine wall
between the layers of broad ligament. Ultimately, it anastomoses end
on with the tubal branch of the ovarian artery in the mesosalphinx.
Uterine artery- Branches
• Ureteric – as it cross it
• Descending cervical
• Circular artery to cervix- anterior and posterior branches of the artery
to the cervix of both sides
• Segmental arcuate arteries (branches from the ascending part)- pierce
1/3rd of myometrium and divide into anterior and posterior branches.
Anastomose with corresponding branches of opposite side at the
midline. From arcuate arteries, a series of radial arteries arise at right
angles which stretch through entire myometrium
• Near the myo-endometrial junction, the radial arteries divide into-
• Short basal artery- basal endometrium
• Spiral artery- supplies to as far as the superficial portion of the endometrium
and ends in extensive capillary plexus
• Fundal branch
• Twigs to round ligament
• Tubal branch
• Ovarian anastomotic branch
Vaginal artery
• Origin: Arises either from the uterine artery or directly from the
anterior division of the internal iliac artery. It is in relation to the
lateral fornix and then runs down along the lateral wall of the vagina
• Numerous transverse branches are sent off anteriorly and posteriorly,
which anastomose with the similar branches of the other side to form
azygos arteries of the vagina—one anterior and one posterior
• Other arteries contributing to azygos arteries are: (i) Descending
cervical, (ii) Circular artery to the cervix, (iii) Inferior vesical, and (iv)
Internal pudendal
Vesical arteries
• Variable in number
• supply the bladder and the terminal part of the ureter
• Inferior vesical artery supplies the middle-third of vagina and urethra

Middle rectal artery

• It arises either directly from the anterior division of the internal iliac
or in common with inferior vesical artery. It supplies rectum, the
lower-third of the vagina
Internal pudendal artery
• It is one of the parietal branches of the anterior division of the internal iliac artery
• It leaves the pelvic cavity along with its vein and pudendal nerve through the
greater sciatic foramen and reenters the ischiorectal fossa to lie in the pudendal
canal (Alcock’s canal) after winding round the ischial spine. Here, it gives off
inferior rectal artery.
• Thereafter, it sends numerous branches to supply the perineal and vulval
structures, including the vestibular bulb and clitoris. The terminal branches of the
artery anastomose with superficial and deep pudendal arteries—branches of the
femoral artery.
• Helps in maintaining the blood supply of the bladder when the vesical branch of
the internal iliac artery is ligated.
Ovarian artery
• Each ovarian artery arises from the front of the aorta, a little below
the renal artery
• It enters the pelvic cavity after crossing the external iliac vessels. It
then runs medially along the infundibulopelvic ligament to enter the
mesovarium. As it enters the hilum of the ovary, it breaks up into
numerous branches to supply the organ.
• Branches given to structures other than the ovary are: Ureter, Uterine
tube, Round ligament, Uterine anastomotic
Superior rectal artery
• This artery is a continuation of the inferior mesenteric artery and
descends down to the base of pelvic mesocolon
• It then divides into two and each courses down on either side of the
rectum to supply it by numerous branches
Pelvic veins
• The peculiarities are:
• There is a tendency to form plexuses
• The plexuses anastomose freely with each other
• The veins may not follow the course of the artery
• They have no valves.
Ovarian veins
• The ovarian veins on each side begin from the pampiniform plexus,
which lies in between the layers of broad ligament near the
mesovarium
• Beyond the infundibulopelvic ligament, there are two ovarian veins
on each side, which ascend up along the course of the corresponding
artery
• Higher up, the veins become one and ultimately drains into left renal
vein on the left side and inferior vena cava on the right side.
Uterus, vagina, and bladder
• Venous drainage from the uterine, vaginal and vesical plexuses chiefly
drain into internal iliac vein

Rectum
• Venous drainage from the rectal plexus drains via superior rectal vein
into the inferior mesenteric vein. The middle and inferior rectal veins
drain into the internal pudendal vein and thence to the internal iliac
vein.
Nerve supply- Somatic and
Autonomic
• SOMATIC
• Both the motor and sensory part of the somatic supply to the pelvic
organs are through:
(i) Pudendal nerve—S2 , S3 , S4
(ii) Ilio-inguinal nerve—L1 , L2
(iii) Genital branch of genitofemoral nerve—L1 , L2
(iv) Posterior cutaneous nerve of thigh
• AUTONOMIC -principally from the sympathetic and partly from the
parasympathetic systems
Pudendal Nerve (S2 , S3 , S4 )
• The sensory component supplies the skin of the vulva, external
urethral meatus, clitoris, perineum and lower vagina
• The motor fibers supply all the voluntary muscles of the perineal
body, levator ani and sphincter ani externus
• Levator ani, in addition, receives direct supply from S3 and S4 roots
• Anterior half of vulval skin is supplied by the ilioinguinal and genital
branch of genitofemoral nerves
• Posterior part of the vulva, including the perineum is supplied by the
posterior cutaneous nerve of thigh.
Parasympathetic
• The parasympathetic fibers (nervi erigentes) are derived from the S2 ,
S3 , and S4 nerves and join the hypogastric nerve of the
corresponding side to form pelvic plexus
• The fibers are mainly sensory to the cervix
• Thus, from the vaginal plexus, the nerve fibers pass on to the uterus,
upper-third of vagina, urinary bladder, ureter and rectum.
Sympathetic
• The sympathetic system carries both the sensory and motor fibers
• The motor fibers arise from the segments D5 and D6 and the sensory
fibers from the segments D10 to L1
• The fibers from the preaortic plexus of the sympathetic system are
continuous with those of the superior hypogastric plexus
Sympathetic
• This plexus lies in front of 5th lumbar vertebra and more often wrongly called
presacral nerve
• While passing over the bifurcation of aorta, it divides into right and left
hypogastric nerves
• The hypogastric nerve joins the pelvic parasympathetic nerve of the
corresponding side and forms the pelvic plexus (right and left) or inferior
hypogastric plexus or Frankenhauser plexus
• This plexus lies in the loose cellular tissue, posterolateral to the cervix below
the uterosacral folds of peritoneum
• The pelvic plexus then continues along the course of the uterine artery as
paracervical plexus
OVARIAN PLEXUS
• Ovarian plexus is derived from the coeliac and renal ganglia
• The fibers accompany the ovarian vessels to supply to ovary, Fallopian
tube and the fundus of the uterus
• The sensory supply of the tube and ovary is from D10 to D12.
Lymphatic supply- Inguinal nodes
• Superficial: There are two groups. One lying horizontally and parallel
to the inguinal ligament and the other is placed vertically along the
long saphenous vein
• Superficial group receive afferents from gluteal region, anterior
abdominal wall below the umbilicus, vulva, perineum, vagina below
the hymen, anal canal below the Hilton’s line and cornu of the uterus
(along the round ligament)
• The efferents from the superficial inguinal lymph nodes drain into the
deep inguinal nodes and external iliac lymph nodes passing through
the inguinal canal.
Deep inguinal lymph nodes
• These nodes receive afferents from deep femoral vessels, glans
clitoris and few from superficial inguinal nodes
• They are 5–6 in number and lie on the medial side of the femoral vein
• The uppermost gland of this group is called the gland of Cloquet or
the gland of Rosenmüller, which lies beneath the inguinal ligament in
the femoral canal
• Efferents from the deep nodes pass through the femoral canal and
drain to the external iliac nodes
• Internal iliac nodes receive afferents from all the pelvic viscera, deeper
perineum, muscles of the thigh and buttock. These glands receive the
afferents from the obturator (obturator canal) and the sacral nodes (along
the median and lateral sacral vessels)
• External iliac nodes There are three groups: (i) Lateral—lateral to external
iliac artery, (ii) Middle (anterior)—in between the artery and vein, and (iii)
Medial—medial to the vein. These glands receive drainage from the
cervix, upper vagina, bladder, lower abdominal wall and from the inguinal
nodes. Afferents are from internal iliac, inferior epigastric, circumflex iliac
and obturator nodes. The efferents ultimately drain into the common iliac
group. In carcinoma cervix, the medial and middle groups are involved
• Common iliac lymph nodes are arranged in three groups: (i) Lateral,
(ii) Intermediate and (iii) Medial. They receive afferents from external
and internal iliac nodes and send efferents to the lateral aortic nodes