Diaphragma pelvis

diaphragma urogenitale

mm. Perinei

Blood vessels, lymph nodes and innervation of

urogenital organs

Miloš Grim & Petr Valasek

Anatomický ústav 1. lékařské fakulty,

Univerzita Karlova v Prazepřednáška pro posluchače všeobecného a zubního lékařství

Panevní dno

Pelvic floor

1. Pelvic diaphragm

2. Urogenital diaphragm

3. Perineal muscles

Vagina (kolpos) fornix, ostium, hymen, rugae, columns, urethral

carina, trigonal area of vagina, mucous membrane, muscular layer,

spongy layer, parakolpium, urogenital hiatus, pubovaginal m.,

promontorium of vagina, urethrovaginal sphincter muscle,

bulbospongiosus muscle,

Magnetic resonance image of female pelvis in sagittal plane

1. Diaphragma pelvis

Pelvic diaphragm

Pelvic diaphragmstriated muscles from tail somites/spine thus innervated from

sacral plexus

lig. anococcygeum, arcus tendineus m. l.a., centrum

tendineum perinei, hiatus urogenitalis, hiatus analis

M. levator anipars pubica – m. pubococcygeus

– m. pubovisceralis

m. pubovaginalis

m. puboprostaticus

m. puboperinealis

m. puborectalis

pars iliaca – m. iliococcygeus

M. coccygeus

M. levator ani (1,2,3) a m. cocygeus (4)

1 – m. pubococygeus

2 – m. iliococcygeus

3 – m. puborectalis

4 – m. coccygeus

5 – m. obturatorius int.

Levator ani

Pelvic diaphragm

Pelvic diaphragm

Diaphragma pelvis, view from perineum

Lacuna vasorum, lac. musculorum, canalis obturatorius

Suprapiriform foramen

infrapiriform foramen

Levator ani, tendinous arch of levator ani

Sling of the pubovaginalis muscle

Development of levator ani et external anal sphincter

2. Diaphragma urogenitale

Urogenital diaphragm

Diaphragma urogenitaleCloses hiatus urogenitalis – urethra (and vagina) pass through it.

It is connected with pelvic diaphragm in the centrum perinei.

On its surface lie erectile organs and glands.

muscles:

M. transversus perinei profundus (male only)

M. sphincter urethrovaginalis (female only)

M. compressor urethrae (female only)

M. transversus perinei superficialis (variable)

Fibrous structures:

Membrana perinei

Lig. transversum perinei (male only)

Centrum perinei (corpus perineale/perineal body)

Urogenital diapragmDeep transverse perineal muscle (in male only)

+ variable superficial transversal perineal muscle,

perineal membrane

Fibrous structure - perineal body

3. Mm. perinei

Perineal muscles

Perineum, hráz, in narrow (obstetric)

understanding:

transverse band of soft tissues between the anal

orifice and posterior rim of (commissura labiorum

posterior)

Broader (anatomical) term perineum (regio

perinealis) designates whole area of pelvic outlet

and is divided into anterior regio urogenitalis,

and posterior regio analis. Deep boundary of

perineum is the inferior surface of diaphragma

pelvis and thus fossa ischioanalis is part of it.

Organa genitalia feminina externa:mons pubis

rima pudendi

labia majora

praeputium clitoridis

glans clitoridis

frenulum clitoridis

labia minora

vestibulum vaginae

ostium urethrae externum

ostium vaginae

carunculae hymenales

commisura labiorum posterior perineum

opening of glandula vestibularis major

Perineal muscles of female, blood supply, inmnervation

Perineal region, regio perinealis - Urogenital triangle, regio

urogenitalis - Anal triangle, regio analis, - Ischio-anal

fossa, fossa ischioanalis (ischiorectalis) Perineum

Perineal region - blood supply, innervation

Mm. perinei, svaly hrázemm. regionis analis

m. sphincter ani externus

mm. regionis urogenitalis

m. sphincter urethrae externus

+ urethrovaginal sphincter

+ compressor urethrae

m. ischiocavernosus

m. bulbospongiosus

Fibrous structures:

Perineal body, Anococcygeal lig.

Fossa ischioanalisCorpus adiposum fossae ischioanalis

Canalis pudendalis (Alcockův kanál)

Perineal musclesMm. of urogenital triangle:

External urethral sphincter

(+ Urethrovaginal sphincter +

Compressor urethrae )

Ischiocavernosus,

Bulbospongiosus,

M. of anal triangle

External anal sphincter

Fibrous structures:

Perineal body, Anococcygeal lig.

M. sphincter ani externuspars subcutanea – just under skin around anus,

split by connective tissue radiating into nearby skin

pars superficialis – lies above the subcutaneous

part, 0,5 - 1,5 cm thick and 1,5 cm high – strongest

part of the sphincter

pars profunda – forms a ring at the level of m.

puborectalis and together they make m.

compressor recti, the most important part of

continentia alvi

Function: permanent contraction – relaxes only

during defecation

Innervation: n. pudendus

M. sphincter ani externus (yellow)

Muscles and cavernous tissues in regio urogenitalis: m.bulbospongiosus,

m. ischocavernosus, m. compressor urethrae, m. sphincter

urethrovaginalis,

m. transverus perinei superficialis, m. levator ani, m. sphincter ani

externus, centrum perinei, crus, corpus, glans clitoridis, bulbus vestibuli

Female external genitalia and perineal muscles - Bulbospongiosus,

Ischocavernosus, Compressor of urethra, Urethrovaginal sphincter,

Superficial transverse perineal muscle

Ischioanal fossa, middle part

Ischioanal fossa

M. sphincter urethrae externuslies in and above the level of diaphragma urogenitale,

around the urethra, it contains slow muscle fibres for long-

term contraction – tone

caudal fibres pass onto sides of vagina, cranial to the apex

of prostate

Innervation via plex. hypogastricus inferior from

motoneurons of Onuf nucleus in S2 a S3

M. sphincter urethrovaginalis, M. compressor urethrae

Zijta M et al. Clin Anat

26:110–114 (2013)

Axial T2-weighted image

of a 26-year-old nullipara.

C demonstrates

the multidirectional

organization of the

complex pelvic floor anatomy.

The per-voxel vector values

are color coded as follows:

green (anteroposterior direction),

blue (craniocaudaldirection),

and red (mediolateral direction).

3. Mm. perinei

Perineal muscles

DEVELOPMENT

DSCN3423.JPG

kuře

Gallus gallus domesticus

křepelka

Coturnix coturnix japonica

Segmental origin of muscles

quail chickED3

ED10

Svaly DK

Příklad: somit 32

Molecular analysis of chick cloacal

musculature development

Phase 1 – migration do leg - „In“

Pax3

MyoD

ED3.5

ED 5

ED 5 ED 6 ED 7

ED 8 ED 9

Phase 2 – extension from leg - „Out“

MyoD

26

32

The base of a leg gives off muscle cells for

cloaca

GFP chick kuře

ED 4 ED10wing

Mouse cloacal-perineal muscles

1. Also murine cloacal muscles develop

from flexors

11.5 13.0

12.5

14.5

13.5

LASAE

Valasek et al., Development 2005

MyoD

wt

cMet -/-

in cMet-/-

2. cMet -/- confirms migratory mechanism

MyHC

Pelvic floor

&

BIRTH

Female pelvic types:

A. Gynecoid (40%) typical, smooth anterior and posterior segment.

B. Android (30%) narrow anterior segment - wedged aditus pelvis.

C. Anthropoid (20%) aditus pelvis anteroposterior oval.

D. Platypeloid (výskyt 3%) aditus pelvis transverse oval.

The levator hiatus in axial plane with minimally distensible (left) and

highly distensible puborectalis muscle (middle) compared to the

dimensions of fetal head at the term (right).The ultrasound data sets of 227 nulliparous women examined at 36–38 week’s

gestation were investigated. Minimal hiatal diameters were measured at rest, on

Valsalva and pelvic floor muscle contraction. Results: some women will have to

distend only 25%, others by 245%.

Since childbirth-related trauma to the levator ani is common and clinically

important, one should consider potential preventative measures. One

approach would be to avoid vaginal delivery by performing elective

Caesarean Section. (Švabik et al. 2009)

Normal condition Avulsion after childbirth

MRI picture of levator ani muscle

Perineal region - blood supply, innervation

n. pudendus a a. pudenda interna

n. genitofemoralis (lateral)

n. cutaneus femoris posterior

n. ilioinguinalis

n. pudendus

https://www.sciencedirect.com/science/article/pii/S22

56208717300317

Magnetic resonance image of female pelvis in plane of urogenital

hiatus (level 2 according to DeLancey)

Symphysis

Tendinous arch

of levator ani

Tendinous arch

of pelvic fasciaUrethra

Vagina

Anal canal

Puborectal

sling

(levator ani)

Anatomy of the pelvic outlet (scheme based on MRI)

Urogenital

hiatus

Plexus hypogastricus Inferior,

parasympathetic fibres from

sacral nerves

Zdroje ilustrací:

Gray´s Anatomy,

Sobottův atlas anatomie člověka, Grada, 2007

Grim, Druga: Základy anatomie, 5. díl

Benninghoff, Drenckhahn: Anatomie I., II.

Carlson,B.M.: Human Embryology and Developmental

Anatomy, archiv autora

Doporučená literatura:

Čihák R: Anatomie 2, Grada 2002, (3. vydání březen 2013)

Grim, M., Druga, R.et al: 5. Anatomie krajin těla. Praha,

Karolinum, Galén, 2010; 3. Trávicí, dýchací, močopohlavní a

endokrinní systém, Praha, Karolinum, Galén, 2005,

Lüllmann-Rauch R.: Histologie, překlad 3. vydání , Grada 2012

Sadler T. W: Langmanova lékařská embryologie, překlad 10.

vydání , Grada 2011,

Junqueira´s Basic Histology 12th Edition, 2010