盆腔和会阴部解剖Pelvisandperineum.ppt
Pelvic,Bony pelvis,Composition:formed by paired hip bones,sacrum,coccyx,and their articulationsTwo portions Greater pelvisLesser pelvisTerminal line(pelvic inlet):formed by promontory of sacrum,arcuate line,pectin of pubis,pubic tubercle,upper border of pubic symphysisPelvic outlet:formed by tip of coccyx,sacrotuberous ligament,ischial tuberosity,ramus of ischium,inferior ramus of pubic symphysis,Anterior wall of the pelvis(posterior view),Posterior wall of the pelvis,Lateral wall of the pelvis,Inferior wall or floor of the pelvis,Muscles of pelvic wall,Piriform m.Obturator internus m.,Muscles of floor of pelvis and pelivic diaphragm,Muscles of floor of pelvisLevator ani 肛提肌Levateo prostate 前列腺提肌(pubovaginalis 耻骨阴道肌)Puborectalis 耻骨直肠肌Pubococcygeus 耻尾肌and iliococcygeus 髂尾肌Coccygeus 尾骨肌,Pelivic diaphragm 盆膈Superior fascia of pelvic diaphragm 盆膈上筋膜Levator ani 肛提肌Coccygeus 尾骨肌Inferior fascia of pelvic diaphragm盆膈下筋膜,Pelvic fascia,Parietal pelvic fascia A continuation of the transverse fascia into the pelvis.It covers the piriformis and obturator internus Attaches to the arcuate line of the pubis and ilium,thickens over the obturator internus to form the arcus tendineus,the origin of portions of the levator ani muscleAt the tendinous arch of levator ani it splits to cover both superior and inferior surfaces of the levator ani as superior and inferior fascia of pelvic diaphragm,Visceral pelvic fascia Lies between the peritoneum and the pelvic visceraIt is a continuation of the extraperitoneal connective tissueEnsheathes retroperitoneal viscera and forms septa between retroperitoneal organsRectovesical septum 直肠膀胱隔Rectovaginal septum 直肠阴道隔,Retropubic space 耻骨后隙Lies between pubic symphysis and urinary bladderPararectal space 直肠周间隙Lies around the rectus Retrorectal space 直肠后隙,Sagittal section of the male pelvis,Sagittal section of the female pelvis,Common iliac artery 髂总动脉,Common iliac arteryContinuation of abdominal aorta at level of L4 vertebra Terminates in front of sacroiliac joint by dividing into internal and external iliac arteries,Internal iliac artery 髂内动脉,Parietal iliac arteryObturator a.闭孔动脉Iliolumber a.髂腰动脉Lateral sacral a.骶外侧动脉Superior gluteal a.臀上动脉 Inferior gluteal a.臀下动脉,Visceral branches Umbilical a.脐动脉 superior vesical a.膀胱上动脉Inferior vesical a.膀胱下动脉Uterine a.子宫动脉Inferior rectal a.直肠下动脉Internal pudendal a.阴部内动脉,Uterine a.子宫动脉about 2cm from neck of uterus it crosses above and in front of ureter,Internal pudendal artery 阴部内动脉 Perineal arteryAnal artery artery of penis(clitoris),External iliac artery,Inferior epigastric arteryDeep iliac circumflex artery,Veins of pelvis,Internal iliac vein 髂内静脉Parietal tributaries:accompany with arteriesVisceral tributaries superior rectal veininferior mesenteric v.Rectal venous plexus inferior rectal veininternal iliac v.直肠静脉丛 anal veininternal pudendal v.Vesical venous plexus 膀胱静脉丛vesical v.Uterine venous plexus 子宫静脉丛uterine v.,External iliac vein 髂外静脉 accompany the arteryCommon iliac vein 髂总静脉 formed by union of internal and external iliac veins in front of sacroiliac joint,end upon L4L5 by uniting each other to form inferior vena cava,The lymphatic drainage of pelvis,Internal iliac lymph nodeSurround internal iliac vesselsReceive afferents from pelvic viscera,perineum,buttock and back of thighExternal iliac lymph nodes Lie along external iliac arteryReceive afferents from lower limb and some parts of pelvic visceraSacral lymph nodeCommon iliac lymph node Lie along common iliac arteryReceive afferents from all the above nodesEfferents pass to lumbar lymph node,Sacral plexus 骶丛,Formation:formed by anterior rami of L4 and L5 spinal nerves(the lumbrosacral trunk)and anterior rami of sacral and coccygeal nervesPosition:lies in pelvic cavity,anterior to sacrum and piriformis,BranchesSuperior gluteal Inferior gluteal PudendalPosterior femoral cutaneou Sciatic Common,Pudendal nerve block,Autonomic plexuses of plevic,Hypogastric plexus Superior hypogastric plexus 上腹下丛:lies in front of L5 between common iliac ateriesInferior hypogastric plexus下腹下丛(pelvic plexus):lie on each side of rectumSacral sympathetic trunkIs continuos above with the abdominal partHas 4or 5 ganglion,Relationships of rectus,AnteriorlyIn male Fundus of bladderSeminal vesicleProstate Ampulla ductus deferentisIn female neck of uterusVagina,PosteriorlySacrum and coccyxPiriformisMedian sacral vesselsAnterior branches of sacral and coccygeal nervesSacral sympathetic trunkLaterally Pelvic plexusSuperior and inferior rectal vesselsLevator ani,Vessels and lymphatics of rectum,Arteries Superior rectal a.Inferior rectal a.Median sacral a.Lymphatic drainge Lymphatics follow arterial blood supply to following nodes:Superior rectal ln.Inferior mesenteric ln.Pararectal ln.Internal iliac ln.Sacral ln.,Perineum,General featuresRegion of below pelvic diaphragmA diamond-shape space whose boundaries are those of the pelvic outletLower border of symphysis pubisRami of pubis and ischiumIschial tuberositiesSacrotuberous ligament The coccyx,Two triangles An imaginary line drawn between the two ischial tuberosities divides perineum into anterior and posterior trianglesUrogenital region尿生殖区(anterior)differs in male and femaleAnal region 肛区(posterior)similar in both sexes,Anal region 肛区,Anal region 肛区,Anal sphincters 肛门括约肌Internal Smooth muscle(thickened circular muscle coat)Surrounds upper two-thirds of anal canalAutonomic nerve supplyExternal Striated muscleSurrounds lower two-thirds of anal canalThree partssubcutaneous,superficial and deepInnervation by anal nerves of pudendal nerve and branches of S4,AnteriorlyIn the male:Opposite the terminal phalanx are the contents of the rectovesical pouch,the posterior surface of the bladder,the seminal vesicles,and the vasa deferentia Opposite the middle phalanx are the rectoprostatic fascia and the prostate.Opposite the proximal phalanx are the perineal body,the urogenital diaphragm,and the bulb of the penis.In the female:Opposite the terminal phalanx are the rectouterine pouch,the vagina,and the cervix.Opposite the middle phalanx are the urogenital diaphragm and the vagina.Opposite the proximal phalanx are the perineal body and the lower part of the vagina.PosteriorlyThe sacrum,coccyx,and anococcygeal body can be felt.LaterallyThe ischiorectal fossae and ischial spines can be palpated,Ischioanal fossa 坐骨肛门窝,BoundariesApexconjunctive area of inferior fascia of pelvic diaphragm and fascia covering the obturator internusBaseskin of anal regionMedialsphincter ani externus,levator ani,coccygeus and inferior fascia of pelvic diaphragmLateralischial tuberosity,obturator internus and fascia,Paired,wedge-shaped,fat-filled spaces on either side of anal canal,AnteriorPosterior border of urogenital diaphragmForward projection of anterior recess of fossa between pelvic diaphragm above and urogenital diaphragm belowPosteriorbackward projection of posterior recess of fossa between gluteus maximus,sacrotuberous ligament and coccyx,ContentsFatInternal pudendal artery and vein and their rectal branchesPudendal nerve and its inferior rectal branch,Vessels and nerves enter from gluteal region,through lesser sciatic foramen,travel on a fascial canalthe pudendal canal 阴部管(Alcocks)on the lateral wall of fossa,and extend forward into urogenital region,Urogenital region 尿生殖区,Superficial fascia has two layersThe superficial or fatty layerThe deep or membranous layer(superficial fascia of perineum 会阴浅筋膜 or Colles fascia)Anteriorly it is continuous with:Dartos of the scrotumFascia of the penisMembranous layer of superficial fascia of the abdominal wall known as the fascia of ScarpaDeep fascia has two layersSuperior fascia of urogenital diaphragm 尿生殖隔上筋膜Inferior fascia of urogenital diaphragm 尿生殖隔下筋膜,Superior fascia of urogenital diaphragm,Inferior fascia of urogenital diaphragm,superficial fascia of perineum,Deep perineal space,Superficial perineal space,会阴深隙：上、下两层膜，中间夹着肉，四周均封闭，尿殖管穿过（如座垫）,会阴浅隙：上、下两层膜，中间东西多，三边都封闭，前上方敞着（如口袋）,Superficial perineal space 会阴浅隙,BoundariesLies between inferior fascia of urogenital diaphragm and superficial fascia of perineumSpace open anteriorly(In rupture of cavernous part of urethra,urine can extravasate from scrotum upward in front of symphysis pubis into anterior abdominal wall deep to membranous fascia of Scarpa),ContentsPosterior partsuperficial transverse perineal muscleLateral partcrus penis(male),crus of clitoris(female)and ischiocavernousus covering themCentral partbulb of urethra(male),bulb of vestibule(female)and bulbocavernousus covering themBranches of pudendal nerves and internal pudendal vessels,Deep perineal space 会阴深隙,Lies between superior and inferior fascia of urogenital diaphragmContents Deep transverse perineal muscleBulbourethral gland(male)Sphincter of urethra尿道括约肌(male)，urethrovaginal sphincter尿道阴道括约肌Ateries,veins and nerves,Urogenital diaphragm 尿生殖隔,Triangular in shapeAttached laterally to ischiopubic rami and ischial tuberositiesFormed by sphincter of urethra,deep transverse perineal muscle,superior and inferior fascia of urogenital diaphragm,Perineal central tendon 会阴中心腱,Wedge-shape fibromuscular massIn female,between anal canal and lower end of vagina,In male,between anal canal and root of penisIt is larger in the female than in the male and five support to the posterior wall of the vagina,Origin or insertion of several small muscles and insertion of part of pelvic diaphragmThese muscles are:Sphincter ani externus Levator ani Superficial transverse muscle perineum Deep transverse muscles perineum Bulbocavernousus Sphincter of urethra(male)or urethrovaginal sphincter(female),Circumcision,腹 前 壁 阴 囊 皮肤 皮肤 浅筋膜 肉膜 腹外斜肌腱膜 精索外筋膜 腹内斜肌 腹横肌 提睾肌 腹横筋膜 精索内筋膜 腹膜 睾丸鞘膜（壁层、脏层）,
