Pelvis

• The term “pelvis” literally means

a basin.
• It is made up of four bones:
• Two hip bones, sacrum, and,
bound to each other by the
ligaments
 The functions of the pelvis
• It supports the weight of the • It contains the pelvic viscera
body and transmits it to the (urinary bladder and rectum in
lower limbs successively through both sexes and uterus in female)
sacrum, sacroiliac joints, hip and
bones, and then to femora in the • Protects the pelvic viscera.
standing position, and ischial
tuberosities in the sitting • It provides attachments for
position muscles.
• In the female, it provides bony
support for the birth canal.
 JOINTS AND LIGAMENTS OF THE
PELVIS
SYMPHYSIS PUBIS
• It is a secondary cartilaginous joint
between the bodies of two pubic
bones.
• The articular surfaces are covered
by hyaline cartilage which are then
united by a disc of fibrocartilage.
• The joint is surrounded and
strengthened by the fibrous
ligaments, especially above and
below.
 JOINTS AND LIGAMENTS OF THE
PELVIS
SACROILIAC JOINTS
• It a plane synovial joints formed by
union of the auricular surfaces of the
sacrum and the ilium on each side.
• The joint is surrounded and
strengthened by:
1. Interosseous sacroiliac ligament.
2. Ventral sacroiliac ligament.
3. Dorsal sacroiliac ligament.
4. Iliolumbar ligaments
 Stability of the Sacroiliac Region
• The sacrum hangs from
sacroiliac joints forming the
posterior wall of the pelvis.
• The body weight of the sacrum
tends to cause forward rotation
of the upper end of sacrum and
concomitant backward rotation
of its lower end.
Stability of the Sacroiliac Region Cont’d
• Ligaments resisting forward • Ligaments resisting the
rotation of the upper end of backward relation of the lower
sacrum are: end of the sacrum are as follows:
1. Interosseous sacroiliac 1. Sacrotuberous ligament.
ligament. 2. Sacrospinous ligament.
2. Posterior sacroiliac ligament. 3. Sacrococcygeal joint.
3. Iliolumbar ligament.
 SACROCOCCYGEAL JOINT
• It is a secondary cartilaginous joint
between the apex of sacrum and the
base of coccyx.
• The bones are united by thin
intervertebral disc.
• Ventral and dorsal sacrococcygeal
ligaments strengthen the
sacrococcygeal joint, and intercornual
ligaments (connecting cornua of
sacrum and coccyx).
• The coccyx moves a little backward
during defecation and parturition.
Differences between the male and female
pelvis
Differences between the male and female
pelvis
 OBSTETRIC PELVIS (TRUE PELVIS)
• The pelvis is divided into the false or greater pelvis above, and true or lesser
pelvis below.
• The plane of division is pelvic inletformed by the sacral promontory behind
and linea terminalis at the sides and front.
• The linea terminalis may be traced as a continuous line from behind forward
as the arcuate line of the ilium, the iliopectineal line (pecten), and the pubic
crest.
• The false pelvis is really a part of the abdominal cavity proper.
• The true pelvis is involved in the process of birth, hence called obstetric
pelvis/true pelvis.
• Therefore, the student must know its size, form, and dimensions in detail
 REGIONS OF THE TRUE PELVIS
• The true pelvis presents the pelvic
inlet, pelvic outlet, and pelvic cavity.
Boundaries of the Pelvic Inlet
Posteriorly:
• Sacral promontory and anterior
margins of alae of the sacrum.
Laterally:
• Arcuate and pectineal lines.
In front:
• Upper margin of pubic symphysis and
pubic crests.
 REGIONS OF THE TRUE PELVIS
Boundaries of the Pelvic Outlet Boundaries of the Pelvic Cavity
Anteriorly: • Anteriorly: Pelvic surfaces of the
• Lower margin of the pubic symphysis. bodies of pubic bone,
Anterolaterally:
• pubic rami, and pubic symphysis.
• Conjoint ischiopubic ramus on each side.
Laterally: • Posteriorly: Pelvic surfaces of the
• Ischial tuberosity on each side.
sacrum and coccyx.
Posterolaterally: • Laterally: Pelvic surfaces of the
• Sacrotuberous ligament on each side. ilium ischium below the
Posteriorly: • arcuate line.
• Tip of the coccyx.
PELVIC DIAMETERS: Conjugate Diameters
1. External conjugate: It is the distance between the
upper margin of pubic symphysis to the tip of the
spine of S1 vertebra.
2. True conjugate: It is the distance between the
midpoint of sacral promontory to the upper margin of
the pubic symphysis. It corresponds to the
anteroposterior diameter of the pelvic inlet.
3. Diagonal conjugate: It is the distance from midpoint
of the sacral promontory to the lower margin of the
pubic symphysis. It is the most useful measurement
clinically. Normally it measures about 5 inches (12.5
cm). It can be measured roughly by per vaginal (P/V)
examination, of course without discomfort to the
patient.
4. Obstetrical conjugate: It is the shortest distance
between the pelvic surface of the pubic symphysis and
sacral promontory
 PELVIC DIAMETERS: Diameters at the
Pelvic Inlet
1. Anteroposterior: It extends from
the midpoint of the sacral promontory
to the midpoint of the upper margin
of pubic symphysis.
2. Oblique: It extends from the
sacroiliac joint of one side to the
iliopectineal eminence of the other
side.
3. Transverse: It is the maximum
transverse diameter of the pelvic inlet
(i.e., greatest width of the pelvic inlet)
 PELVIC DIAMETERS: Diameters at the
Mid-Pelvic Cavity
1. Anteroposterior: It extends from
the middle of the pubic symphysis
to the middle of 3rd sacral
vertebra.
2. Oblique: It extends from the
lower end of the sacroiliac joint of
one side to the middle of the
obturator membrane of the other
side.
3. Transverse: It is the greatest
width of the pelvic cavity
PELVIC DIAMETERS: Diameters at the
Pelvic Outlet
1. Anteroposterior: It extends from
the tip of the sacrum to the lower
margin of the pubic symphysis.
2. Oblique: It extends from the
middle of the sacrotuberous
ligament of one side to the junction
of ischiopubic ramus of the
opposite side.
3. Transverse: It extends between
the inner aspects of the two ischial
tuberosities.
 TYPES OF THE FEMALE PELVIS

• The four types of the female

pelvis have been described (after
Caldwell and Moloy)
1. Gynecoid.
2. Android.
3. Platypelloid.
4. Anthropoid.
Clinical correlation: Fractures of the pelvis
• The pelvis is like a ring. It is very strong and usually requires a direct violence
of high velocity to fracture it.
• The weak sites of the ring are sacroiliac region, pubic rami, and pubic
symphysis. Lateral compression of pelvis usually results in fracture through
both pubic rami or fracture of pubic ramus on one side associated with
dislocation of pubic symphysis.
• Anteroposterior compression may cause dislocation of pubic symphysis or
fracture through pubic rami accompanied by dislocation of the sacroiliac joints.
• The displacement of part of the pelvic ring indicates that the ring is broken at
two places. The soft tissues likely to injure in pelvic fracture are urinary
bladder, urethra, and rectum.
 Pelvic Walls and Associated Soft Tissue
Structures
• The walls of pelvis are formed by the bones and ligaments which are
partly clothed by the muscles covered with fascia and parietal
peritoneum. The pelvis presents five walls:
• Anterior wall
• Posterior wall
• Two lateral walls (right and left)
• Inferior wall (or pelvic floor)
 Anterior Wall
• The anterior wall is the
shallowest wall
• It is formed by the pelvic
surfaces of the bodies of the
pubic bone, the pubic rami, and
the pubic symphysis.
 Posterior Wall
• The posterior wall is extensive
and is formed by the pelvic
surfaces of the sacrum and
coccyx.
• It is lined by the piriformis
muscles with their covering
fascia
 Lateral Wall
The lateral wall is formed by the:
• Pelvic surface of the hip bone
below the pelvic inlet,
• Obturator membrane,
• Sacrotuberous and sacrospinous
ligaments, and
• Obturator internus muscle with
its covering fascia
 Inferior Wall (or Pelvic Floor)
• The inferior wall is formed by the pelvic diaphragm, which in turn is
formed by the levator ani and coccygeus muscles with their covering
fasciae.
• The pelvic diaphragm stretches across the true pelvis and
• The pelvic diaphragm divides it into the main pelvic cavity above and
the perineum below.
• The floor of the pelvic cavity supports the pelvic viscera
Soft tissue structures on the pelvic walls
The soft tissue structures on the
pelvic walls from deep to
superficial, are arranged as
follows:
1. Muscles.
2. Nerves.
3. Pelvic fascia.
4. Blood vessels.
5. Peritoneum
 MUSCLES OF THE PELVIS
The muscles of the pelvis are:
1. Obturator internus (L5; S1, S2).
2. Piriformis S1, S2).
3. Levator ani (S2, S3, S4).
4. Coccygeus (S4, S5)
 MUSCLES OF THE PELVIS
• The muscles of the pelvis are:
1. Obturator internus (L5; S1, S2).
2. Piriformis S1, S2).
3. Levator ani (S2, S3, S4).
4. Coccygeus (S4, S5)
 PELVIC DIAPHRAGM
• The pelvic diaphragm is a muscular
partition between the true pelvis
and the perineum.
• It forms the gutter-shaped pelvic
floor.
• It is formed by the large levator ani
and small coccygeus muscles of two
sides and their covering fasciae.
• It is incomplete anteriorly to allow
passage for the urethra in the males,
and the urethra and vagina in the
females
 PELVIC DIAPHRAGM
Functions Openings
• The pelvic diaphragm provides • Hiatus urogenitalis
principal support to the pelvic • Hiatus rectalis
viscera and has a sphincteric
action on the rectum and
vagina.
• It also assists in increasing the
intra abdominal pressure during
defecation, micturition, and
parturition.
 Clinical correlation: Injury of pelvic
diaphragm
• The pelvic diaphragm may be
injured (tearing of perineal
body) during difficult childbirth.
• As a result it becomes weak and
can no longer provide sufficient
support to the pelvic viscera.
• This may lead to uterine
prolapse and rectal prolapse.
 PELVIC FASCIA
The pelvic fascia is present in the
form of two layers:
• Parietal layer
• Visceral layer
 NERVES OF THE PELVIS
The nerves of the true pelvis are divided into two groups
• Somatic nerves
• Autonomic nerves.
 SOMATIC NERVES
The following neural structures are to be studied under this heading
1. Lumbosacral trunk (Formed by L4 and L5)
2. Sacral plexus (Formed by L4, L5, S1, S2, S3 Nerves)
3. Coccygeal plexus (Formed by S4, S5 and coccygeus)
 SOMATIC NERVES
Lumbosacral trunk Coccygeal Plexus
• Formed by L4 and L5 • It is a small nerve plexus formed by
the ventral rami of S4, S5 and
coccygeal nerve.
• It lies on the pelvic surface of the
coccygeus.
• It supplies coccygeus and part of
the levator ani.
• It pierces the coccygeus and
supplies the skin from the coccyx to
the anus.
 SOMATIC
NERVES

Sacral plexus Formed by

(L4, L5, S1, S2, S3)
 Branches of the sacral plexus
FROM ROOT TERMINAL FROM PELVIC FROM DORSAL SURFACE
SURFACE
Muscular branches Sciatic Nerve to quadratus Superior gluteal nerve
(L4, L5; S1, S2, S3) femoris (L4, L5; S1) (L4, L5; S1)

Pelvic splanchnic Pudendal Nerve to obturator • Inferior gluteal nerve

nerves (S2, S3, S4) internus (L5, S1; S2) (L5; S1, S2)
• Posterior cutaneous nerve
of the thigh (S1, S2, S3)
• Perforating cutaneous
nerve (S2, S3)
• Perineal branch of 4th
sacral nerve (S4)
 AUTONOMIC NERVES
• The autonomic nerves in the pelvis includes the:
• Sacral Sympathetic trunks
• Inferior hypogastric plexuses.
 Sacral Sympathetic Trunks
• The right and left sympathetic
trunks descend in the pelvis
between the bodies of sacral
vertebrae and the pelvic sacral
foramina.
 Ganglia
• There are four or five sacral ganglia in each
trunk and the common ganglion impar.
Branches
1. The gray rami communicate to the ventral
rami of all the sacral and coccygeal nerves.
2. The small branches to the median sacral
artery.
3. The sacral splanchnic nerves to the
inferior hypogastric plexus from the upper
ganglia and to the rectum from the lower
ganglia.
4. The small branches to the coccygeal body
from the ganglion impar
 Inferior Hypogastric Plexuses
• The two inferior hypogastric • It receives postganglionic
plexuses (right and left) sympathetic fibres from the
• Both plexuses are situated by superior hypogastric plexus
the sides of rectum. (presacral nerve) and
preganglionic parasympathetic
• Each plexus is composed of both fibres from the pelvic
sympathetic fibres and splanchnic nerve (S2, S3, and
parasympathetic fibres. S4).
• The nerve cells in it are • It also receives sensory fibres
postganglionic parasympathetic from the viscera.
neurons.
 Divisions of the Right and Left Inferior
hypogastric Plexuses
• Each plexus (right and left) • Prostatic plexus supplies prostate,
inferior hypogastric plexuses seminal vesicles and ejaculatory
surrounds the corresponding ducts. It gives rise to cavernous nerves
internal iliac artery and divides of the penis which supply the erectile
tissue of bulb and crura of penis.
into subsidiary plexuses to supply
the pelvic organs. Uterine and vaginal plexuses.
• The uterine plexus supplies the
The subsidiary plexuses are:
uterus, uterine tubes, and ovaries.
• Rectal plexus supplies the rectum • The vaginal plexus supplies the vagina
• Vesical plexus supplies the urinary and sends cavernous nerves to the
bladder, adjoining parts of the erectile tissue of the bulbs of the
ureters and seminal vesicles. vestibule and clitoris.
 VESSELS OF THE TRUE PELVIS
• The vessels of the pelvis are:
• Arteries (superior rectal, internal iliac, median sacral, and ovarian).
• Veins (internal iliac, superior rectal, median sacral and ovarian veins,
and pelvic venous plexuses).
• Lymph vessels and associated lymph nodes.
Internal Iliac Artery: course and branches in relation to the hip bone,
Internal iliac artery: divisions and branches.
 Branches of the internal iliac artery
DIVISIONS BRANCHES
Anterior Divisions • Superior vesical artery
• Obturator artery
• Inferior vesical artery (in male)
• Middle rectal artery
• Internal pudendal artery
• Inferior gluteal artery (largest)
• Uterine artery (in female)
• Vaginal artery (in female)
Posterior Divisions • Iliolumbar artery
• Lateral sacral arteries
• Superior gluteal artery
 VESSELS OF THE TRUE PELVIS
Veins Lymph
• Internal iliac • The internal iliac lymph nodes
• Superior rectal • The sacral lymph nodes
• Median sacral and ovarian veins
• Pelvic venous plexuses