PERINEAL POUCH😊

PERINEAL POUCH

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ㅤ	Anterior Urethral Injury	Posterior Urethral Injury
Injured Part	• Penile/bulbar urethra	• Membranous/ prostatic urethra
Mode of Injury	• Direct trauma/straddle injury	• Secondary to pelvic fracture
Features	• Superficial perineal hematoma • around penis/scrotum	• Deep perineal hematoma, • Vermooten sign (Floating prostate)

• Contrast flows out of the urethra.

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Common Features

• Blood at tip of meatus.

• Inability to pass urine.

• Inferior layer of urogenital diaphragm (Perineal membrane)

Extravasation of Urine

Injury to:

• Membranous urethra
• Urine goes to deep perineal pouch

• Bulbar urethra
• Urine goes to superficial perineal pouch
• Causes D/T deficient anterior wall

Extravasation of Urine into:

• Scrotum

• Anterior abdominal wall
• under the scarpa's fascia and
• anterior to the pubis bone

• Upper thigh till Holden's Line
• Urine entering the thigh prevented by Fascia lata

Deep Fascia of Thigh - fascia lata

• Modifications:
1. Iliotibial Tract
2. Intermuscular septum
3. Saphenous opening

ISCHIORECTAL FOSSA/ISCHIOANAL FOSSA

• SLO: Sphincter → Levator Ani → Obturator interni

Contents

• Fat

• Inferior rectal nerves & vessels

• Pudendal canal & its contents

Applied Anatomy

Drainage of Ischiorectal Fossa Abscess

• Risk of injury to inferior rectal nerves & vessels
• due to their horizontal course

• Horseshoe recess:
• Communication of both IRF → spread abcess C/L

Pelvic Diaphragm

• Super-most layer of perineum.

• Separates pelvis from perineum.

3 Components

• Pubococcygeus

• Iliococcygeus

• Ischiococcygeus

Modifications of Pubococcygeus

• Pubourethralis

• Pubovaginalis

• Puborectalis
• Muscle of Continence
• Forms anorectal angle (90°).

Perineal Body

• Central point

• supports the structure.

Paired Muscles (4)

• Superficial transverse perinei

• Deep transverse perinei

• Bulbospongiosus

• Levator ani

Unpaired Muscles (2)

• External anal sphincter

• Longitudinal muscle of anal canal

Note

• Ischiocavernosus is not a part of the perineal body.

Levator Ani Muscle

Nerve Supply

• Pudendal nerve (S2-S4): Supplies puborectalis, parts of pubococcygeus.

• Nerve to levator ani (S3-S4): Supplies pubococcygeus, iliococcygeus.

Blood Supply

• Inferior gluteal artery

• Superior gluteal artery

• Inferior vesical artery (in males)

• Uterine artery (in females)

Actions

• Pelvic organ support

• Continence

• Defecation/Micturition

• Parturition

Clinical Significance

• Pelvic floor dysfunction:
• Urinary/fecal incontinence, prolapse.
• Causes: Childbirth trauma, aging, obesity, chronic straining.

• Levator ani syndrome:
• Chronic pelvic pain due to muscle spasm.
• Treatment: Physical therapy, biofeedback.

• Kegel exercises:
• Strengthens levator ani