盆腔和会阴部解剖Pelvisandperineum.ppt

Pelvic Bony pelvisnComposition: formed by paired hip bones, sacrum, coccyx, and their articulationsnTwo portions qGreater pelvisqLesser pelvisnTerminal line ( pelvic inlet): formed by promontory of sacrum, arcuate line, pectin of pubis, pubic tubercle, upper border of pubic symphysisnPelvic 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 wallnPiriform m.nObturator internus m.Muscles of floor of pelvis and pelivic diaphragm Muscles of floor of pelvisLevator ani 肛提肌肛提肌nLevateo prostate 前列腺提肌前列腺提肌(pubovaginalis 耻骨阴道肌耻骨阴道肌)nPuborectalis 耻骨直肠肌耻骨直肠肌nPubococcygeus 耻尾肌耻尾肌and iliococcygeus 髂尾肌髂尾肌Coccygeus 尾骨肌尾骨肌Pelivic diaphragm 盆膈盆膈nSuperior fascia of pelvic diaphragm 盆膈上筋膜盆膈上筋膜nLevator ani 肛提肌肛提肌nCoccygeus 尾骨肌尾骨肌nInferior fascia of pelvic diaphragm盆膈下筋膜盆膈下筋膜Pelvic fascia Parietal pelvic fascia nA continuation of the transverse fascia into the pelvis. It covers the piriformis and obturator internus nAttaches 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 musclenAt 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 nLies between the peritoneum and the pelvic visceranIt is a continuation of the extraperitoneal connective tissuenEnsheathes retroperitoneal viscera and forms septa between retroperitoneal organsqRectovesical septum 直肠膀胱隔直肠膀胱隔qRectovaginal septum 直肠阴道隔直肠阴道隔Retropubic space 耻骨后隙耻骨后隙nLies between pubic symphysis and urinary bladderPararectal space 直肠周间隙直肠周间隙nLies around the rectus nRetrorectal space 直肠后隙直肠后隙Sagittal section of the male pelvis Sagittal section of the female pelvis Common iliac artery 髂总动脉髂总动脉nCommon iliac arterynContinuation of abdominal aorta at level of L4 vertebra nTerminates in front of sacroiliac joint by dividing into internal and external iliac arteries Internal iliac artery 髂内动脉髂内动脉Parietal iliac arterynObturator a. 闭孔动脉闭孔动脉nIliolumber a.髂腰动脉髂腰动脉nLateral sacral a. 骶外侧动脉骶外侧动脉nSuperior gluteal a. 臀臀上动脉上动脉 nInferior gluteal a. 臀下动脉臀下动脉 Visceral branches nUmbilical a.脐动脉脐动脉→ superior vesical a. 膀胱上动脉膀胱上动脉nInferior vesical a.膀胱下动脉膀胱下动脉nUterine a.子宫动脉子宫动脉nInferior rectal a.直肠下动脉直肠下动脉nInternal pudendal a. 阴部内动脉阴部内动脉 nUterine a. 子宫动脉子宫动脉—about 2cm from neck of uterus it crosses above and in front of ureternInternal pudendal artery 阴部内动脉阴部内动脉 qPerineal arteryqAnal arteryq artery of penis (clitoris) External iliac arterynInferior epigastric arterynDeep iliac circumflex artery Veins of pelvisInternal iliac vein 髂内静脉髂内静脉nParietal tributaries: accompany with arteriesnVisceral tributaries →superior rectal vein→inferior mesenteric v.①Rectal venous plexus →inferior rectal vein→internal iliac v.直肠静脉丛直肠静脉丛 →anal vein→internal pudendal v. ②Vesical venous plexus 膀胱静脉丛膀胱静脉丛→vesical v.③Uterine venous plexus 子宫静脉丛子宫静脉丛→uterine v.  External iliac vein 髂外静脉髂外静脉– accompany the arteryCommon iliac vein 髂总静脉髂总静脉– formed by union of internal and external iliac veins in front of sacroiliac joint, end upon L4~L5 by uniting each other to form inferior vena cavaThe lymphatic drainage of pelvisInternal iliac lymph nodenSurround internal iliac vesselsnReceive afferents from pelvic viscera, perineum, buttock and back of thighExternal iliac lymph nodes nLie along external iliac arterynReceive afferents from lower limb and some parts of pelvic visceraSacral lymph nodeCommon iliac lymph node nLie along common iliac arterynReceive afferents from all the above nodesnEfferents pass to lumbar lymph node Sacral plexus 骶丛骶丛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 BranchesnSuperior gluteal nInferior gluteal nPudendalnPosterior femoral cutaneou nSciatic CommonPudendal nerve blockAutonomic plexuses of plevicHypogastric plexus nSuperior hypogastric plexus 上腹下丛上腹下丛: lies in front of L5 between common iliac ateriesnInferior hypogastric plexus下下腹下丛腹下丛 (pelvic plexus): lie on each side of rectumSacral sympathetic trunknIs continuos above with the abdominal partnHas 4or 5 ganglion Relationships of rectusAnteriorlynIn male qFundus of bladderqSeminal vesicleqProstate qAmpulla ductus deferentisnIn female qneck of uterusqVagina PosteriorlynSacrum and coccyxnPiriformisnMedian sacral vesselsnAnterior branches of sacral and coccygeal nervesnSacral sympathetic trunkLaterally nPelvic plexusnSuperior and inferior rectal vesselsnLevator ani Vessels and lymphatics of rectumArteries nSuperior rectal a.nInferior rectal a.nMedian sacral a.Lymphatic drainge Lymphatics follow arterial blood supply to following nodes:nSuperior rectal ln.nInferior mesenteric ln. nPararectal ln.nInternal iliac ln.nSacral ln.PerineumGeneral featuresnRegion of below pelvic diaphragmnA diamond-shape space whose boundaries are those of the pelvic outletqLower border of symphysis pubisqRami of pubis and ischiumqIschial tuberositiesqSacrotuberous ligament qThe coccyxTwo triangles An imaginary line drawn between the two ischial tuberosities divides perineum into anterior and posterior trianglesnUrogenital region尿生殖区尿生殖区 (anterior)－differs in male and femalenAnal region 肛区肛区 (posterior)－similar in both sexes Anal region 肛区肛区Anal region 肛区肛区Anal sphincters 肛门括约肌肛门括约肌nInternal qSmooth muscle (thickened circular muscle coat)qSurrounds upper two-thirds of anal canalqAutonomic nerve supplynExternal qStriated muscleqSurrounds lower two-thirds of anal canalqThree parts－subcutaneous, superficial and deepqInnervation 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 坐骨肛门窝坐骨肛门窝 BoundariesnApex－conjunctive area of inferior fascia of pelvic diaphragm and fascia covering the obturator internusnBase－skin of anal regionnMedial－sphincter ani externus, levator ani, coccygeus and inferior fascia of pelvic diaphragmnLateral－ischial tuberosity, obturator internus and fasciaPaired, wedge-shaped, fat-filled spaces on either side of anal canalnAnteriorqPosterior border of urogenital diaphragmqForward projection of anterior recess of fossa between pelvic diaphragm above and urogenital diaphragm belownPosteriorqbackward projection of posterior recess of fossa between gluteus maximus, sacrotuberous ligament and coccyx ContentsnFatnInternal pudendal artery and vein and their rectal branchesnPudendal nerve and its inferior rectal branch Vessels and nerves enter from gluteal region, through lesser sciatic foramen, travel on a fascial canal－the pudendal canal 阴部管阴部管 (Alcock’s)－on the lateral wall of fossa, and extend forward into urogenital regionUrogenital region 尿生殖区尿生殖区Superficial fascia has two layersnThe superficial or fatty layernThe deep or membranous layer (superficial fascia of perineum 会阴浅筋膜会阴浅筋膜 or Colles fascia) Anteriorly－ it is continuous with:qDartos of the scrotumqFascia of the penisqMembranous layer of superficial fascia of the abdominal wall known as the fascia of ScarpaDeep fascia has two layersnSuperior fascia of urogenital diaphragm 尿生殖隔上筋膜尿生殖隔上筋膜nInferior fascia of urogenital diaphragm 尿生殖隔下筋膜尿生殖隔下筋膜Camper’s fasciaPosition of penisScarpa’s fasciaFascia laterLine of fusionPosition of scrotumSuperior fascia of urogenital diaphragmInferior fascia of urogenital diaphragmsuperficial fascia of perineumDeep perineal space Superficial perineal space Fascia of the penisFascia of ScarpaDartos of the scrotum会阴深隙会阴深隙：上、下两层膜，中间夹着肉，四周均封闭，尿殖管穿过（如座垫）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）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 会阴浅隙会阴浅隙BoundariesnLies between inferior fascia of urogenital diaphragm and superficial fascia of perineumnSpace 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)ContentsnPosterior part－superficial transverse perineal musclenLateral part－crus penis (male), crus of clitoris (female) and ischiocavernousus covering themnCentral part－bulb of urethra (male), bulb of vestibule (female) and bulbocavernousus covering themnBranches of pudendal nerves and internal pudendal vesselsDeep perineal space 会阴深隙会阴深隙nLies between superior and inferior fascia of urogenital diaphragmnContents qDeep transverse perineal muscleqBulbourethral gland (male)qSphincter of urethra尿道括约肌尿道括约肌 (male)，urethrovaginal sphincter尿道阴道括尿道阴道括约肌约肌qAteries, veins and nervesUrogenital diaphragm 尿生殖隔尿生殖隔nTriangular in shapenAttached laterally to ischiopubic rami and ischial tuberositiesnFormed by sphincter of urethra, deep transverse perineal muscle, superior and inferior fascia of urogenital diaphragmPerineal central tendon 会阴中心腱会阴中心腱nWedge-shape fibromuscular massnIn female, between anal canal and lower end of vagina, nIn male, between anal canal and root of penisnIt is larger in the female than in the male and five support to the posterior wall of the vaginanOrigin or insertion of several small muscles and insertion of part of pelvic diaphragmnThese muscles are: qSphincter ani externus qLevator ani qSuperficial transverse muscle perineum qDeep transverse muscles perineum qBulbocavernousus qSphincter of urethra (male) or urethrovaginal sphincter (female)Sphincter ani externusLevator ani Superficial transverse muscle perineum Bulbocavernousus Deep transverse muscles perineum Sphincter of urethra (male) or urethrovaginal sphincter (female) Circumcision  腹腹 前前 壁壁 阴阴 囊囊 皮肤皮肤 皮肤皮肤 浅筋膜浅筋膜 肉膜肉膜 腹外斜肌腱膜腹外斜肌腱膜 精索外筋膜精索外筋膜 腹内斜肌腹内斜肌 腹横肌腹横肌 提睾肌提睾肌 腹横筋膜腹横筋膜 精索内筋膜精索内筋膜 腹膜腹膜 睾丸鞘膜睾丸鞘膜 （（ 壁层、壁层、 脏层）脏层）。