today’s dissection gluteal rg… · perineum - today’s word & intellectual challenge - •...

Gluteal RegionGluteal Region- Today- Today’’s Dissection -s Dissection -

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Gluteal RegionGluteal Region- A Practical Lesson -- A Practical Lesson -

•• Reflect Reflect ONLYONLY the gluteus the gluteus

maximus m.maximus m.

•• To reveal theTo reveal the

ischioanal triangleischioanal triangle

•• Do Do NOTNOT dissect dissect

•• Deeper than theDeeper than the

sacro-spinous andsacro-spinous and

-tuberous ligaments-tuberous ligaments

•• Lateral to the sciaticLateral to the sciatic

nervenerve

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PerineumPerineum

- Today- Today’’s Word & Intellectual Challenge -s Word & Intellectual Challenge -

•• The region that closes the pelvic outletThe region that closes the pelvic outlet

•• Divided into two spaces (triangles)Divided into two spaces (triangles)

•• Ischioanal (Anal) triangleIschioanal (Anal) triangle

•• Urogenital (UG) triangleUrogenital (UG) triangle

•• Means Means ““modest or privatemodest or private””

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Abdominopelvic RegionAbdominopelvic Region

PerineumPerineum

PerinealPerineal Triangles (2) Triangles (2)

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PerinealPerineal

RecessesRecesses

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PerinealPerineal Vasculature Vasculature

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Ischioanal (Anal) TriangleIschioanal (Anal) Triangle

•• Divided into two lateral fossae by theDivided into two lateral fossae by the

rectumrectum

•• BoundariesBoundaries

•• Lateral: Sacrotuberous ligamentsLateral: Sacrotuberous ligaments

•• Posterior: CoccyxPosterior: Coccyx

•• Anterior: Perineal body (muscle)Anterior: Perineal body (muscle)

•• Superior (roof): Pelvic diaphragmSuperior (roof): Pelvic diaphragm

•• Inferior (floor): SkinInferior (floor): Skin

LandmarksLandmarks

SacrotuberousSacrotuberous

ligamentligament

ContentsContents

•• Levator ani muscleLevator ani muscle

•• Ischioanal fat padIschioanal fat pad

•• Pudendal (AlcockPudendal (Alcock’’s) canals) canal

•• Pudendal neurovascular bundle andPudendal neurovascular bundle and

their peripheral branchestheir peripheral branches

•• Anococcygeal (perineal) bodyAnococcygeal (perineal) body

•• Convergence of musclesConvergence of muscles

•• Rectum and anusRectum and anus

Inferior Rectal NervesInferior Rectal Nerves

VasculatureVasculature

Pudendal CanalPudendal Canal

Central Tendon of the PerineumCentral Tendon of the Perineum- Perineal Body -- Perineal Body -

•• Area of fusion among theArea of fusion among the

•• Posterior margin of the UG diaphragmPosterior margin of the UG diaphragm

•• Perineal fasciaPerineal fascia

•• Pelvic diaphragmPelvic diaphragm

•• External anal sphincterExternal anal sphincter

•• Same in males and femalesSame in males and females

•• In females, fusion is more extensive and theIn females, fusion is more extensive and the

fused tissue is yellow fibroelastic connectivefused tissue is yellow fibroelastic connective

tissuetissue

Perineal BodyPerineal Body

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MaleMale FemaleFemale

Perineal BodyPerineal Body

PerineumPerineum

Urogenital triangleUrogenital triangle

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Urogenital (UG) TriangleUrogenital (UG) Triangle- Subdivided into 2 Parallel Planes -- Subdivided into 2 Parallel Planes -

•• Deep perineal Deep perineal ““spacespace””

(also called superior perineal pouch) (also called superior perineal pouch)

•• Superficial perineal Superficial perineal ““spacespace””

(also called inferior perineal pouch) (also called inferior perineal pouch)

Deep (superior) spaceDeep (superior) space

Superficial (inferior) spaceSuperficial (inferior) space

•• Filled by 2 muscles and their superior andFilled by 2 muscles and their superior and

inferior fasciaeinferior fasciae

•• Deep transverse perineus muscleDeep transverse perineus muscle

•• Sphincter urethrae muscleSphincter urethrae muscle

Deep Perineal SpaceDeep Perineal Space- Contents -- Contents -

Deep (superior) spaceDeep (superior) space

Deep Perineal SpaceDeep Perineal Space- Boundaries -- Boundaries -

•• Superior: Superior fascial layer of the UGSuperior: Superior fascial layer of the UG

diaphragmdiaphragm

•• Inferior: Inferior fascial layer of the UGInferior: Inferior fascial layer of the UG

diaphragmdiaphragm

•• Anterior: Pubic symphysisAnterior: Pubic symphysis

•• Lateral: Ischiopubic (conjoined) ramiLateral: Ischiopubic (conjoined) rami

•• Posterior: Closed (fasciae are fused)Posterior: Closed (fasciae are fused)

Deep (superior) spaceDeep (superior) space

•• Filled by erectile tissue and their overlyingFilled by erectile tissue and their overlying

musclesmuscles

•• Cavernous and bulbous erectile tissueCavernous and bulbous erectile tissue

•• Ischiocavernosus and bulbospongiosusIschiocavernosus and bulbospongiosus

muscles, respectivelymuscles, respectively

Superficial Perineal SpaceSuperficial Perineal Space- Contents -- Contents -

Superficial (inferior) spaceSuperficial (inferior) space

Superficial Perineal SpaceSuperficial Perineal Space- Boundaries -- Boundaries -

•• Superior: Inferior fascial layer of theSuperior: Inferior fascial layer of the

UG diaphragmUG diaphragm

•• Inferior: CollesInferior: Colles’’ fascia fascia

•• Anterior: Pubic symphysisAnterior: Pubic symphysis

•• Lateral: Ischiopubic (conjoined ramiLateral: Ischiopubic (conjoined rami

•• Posterior: Closed; Fused to the UGPosterior: Closed; Fused to the UG

diaphragmdiaphragm

Superficial (inferior) spaceSuperficial (inferior) space

Deep Perineal Deep Perineal ““SpaceSpace””

Superficial Perineal Superficial Perineal ““SpaceSpace”” (SPS) (SPS)

Superior (the pelvic diaphragm)Superior (the pelvic diaphragm)

Inferior (the skin of the perineum)Inferior (the skin of the perineum)

Superior Fascia of the UG DiaphragmSuperior Fascia of the UG Diaphragm

Inferior Fascia of the UG DiaphragmInferior Fascia of the UG Diaphragm

(Colles(Colles’’ Fascia; Contiguous with Scarpa Fascia; Contiguous with Scarpa’’s Fascia)s Fascia)

Inferior Fascia of the SPSInferior Fascia of the SPS

Anterior Abdominal WallAnterior Abdominal Wall- Superficial Fascia -- Superficial Fascia -

•• Superficial layerSuperficial layer

•• Fatty = Camper's fasciaFatty = Camper's fascia

•• Deep layerDeep layer

•• Membranous = Scarpa's fasciaMembranous = Scarpa's fascia

•• Contiguous with the membranousContiguous with the membranous

fascia of the perineum (Collesfascia of the perineum (Colles’’ fascia) fascia)

Clinical Significance of theClinical Significance of the

Superficial Fascial ConnectionsSuperficial Fascial Connections

A Major Cause for theA Major Cause for the

Clinical Significance?Clinical Significance?

StrabismusStrabismus SibilanceSibilance

Perineum (Sagittal Section)Perineum (Sagittal Section)

FemaleFemale MaleMale

OrangeOrange = Deep perineal space = Deep perineal spaceRedRed = Superficial perineal space = Superficial perineal space

U!