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The Muscles and Fasciæ of the Pelvis


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IV. Myology
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The Muscles and Fasciæ of the Pelvis
Obturator internus.
Levator ani.
Piriformis.
Coccygeus.
The muscles within the pelvis may be divided into two groups: (1) the Obturator internus and the Piriformis, which are muscles of the lower extremity, and will be described with these (pages 476 and 477); (2) the Levator ani and the Coccygeus, which together form the pelvic diaphragm and are associated with the pelvic viscera. The classification of the two groups under a common heading is convenient in connection with the fasciæ investing the muscles. These fasciæ are closely related to one another and to the deep fascia of the perineum, and in addition have special connections with the fibrous coverings of the pelvic viscera; it is customary therefore to describe them together under the term pelvic fascia.   1
 
Pelvic Fascia.—The fascia of the pelvis may be resolved into: (a) the fascial sheaths of the Obturator internus, Piriformis, and pelvic diaphragm; (b) the fascia associated with the pelvic viscera.   2
  The fascia of the Obturator internus covers the pelvic surface of, and is attached around the margin of the origin of, the muscle. Above, it is loosely connected to the back part of the arcuate line, and here it is continuous with the iliac fascia. In front of this, as it follows the line of origin of the Obturator internus, it gradually separates from the iliac fascia and the continuity between the two is retained only through the periosteum. It arches beneath the obturator vessels and nerve, completing the obturator canal, and at the front of the pelvis is attached to the back of the superior ramus of the pubis. Below, the obturator fascia is attached to the falciform process of the sacrotuberous ligament and to the pubic arch, where it becomes continuous with the superior fascia of the urogenital diaphragm. Behind, it is prolonged into the gluteal region.   3
  The internal pudendal vessels and pudendal nerve cross the pelvic surface of the Obturator internus and are enclosed in a special canal—Alcock’s canal—formed by the obturator fascia.   4
  The fascia of the Piriformis is very thin and is attached to the front of the sacrum and the sides of the greater sciatic foramen; it is prolonged on the muscle into the gluteal region. At its sacral attachment around the margins of the anterior sacral foramina it comes into intimate association with and ensheathes the nerves emerging from these foramina. Hence the sacral nerves are frequently described as lying behind the fascia. The internal iliac vessels and their branches, on the other hand, lie in the subperitoneal tissue in front of the fascia, and the branches to the gluteal region emerge in special sheaths of this tissue, above and below the Piriformis muscle.   5


FIG. 402– Coronal section of pelvis, showing arrangement of fasciæ. Viewed from behind. (Diagrammatic.) (See enlarged image)
 
  The diaphragmatic part of the pelvic fascia (Fig. 402) covers both surfaces of the Levatores ani. The inferior layer is known as the anal fascia; it is attached above to the obturator fascia along the line of origin of the Levator ani, while below it is continuous with the superior fascia of the urogenital diaphragm, and with the fascia on the Sphincter ani internus. The layer covering the upper surface of the pelvic diaphragm follows, above, the line of origin of the Levator ani and is therefore somewhat variable. In front it is attached to the back of the symphysis pubis about 2 cm. above its lower border. It can then be traced laterally across the back of the superior ramus of the pubis for a distance of about 1.25 cm., when it reaches the obturator fascia. It is attached to this fascia along a line which pursues a somewhat irregular course to the spine of the ischium. The irregularity of this line is due to the fact that the origin of the Levator ani, which in lower forms is from the pelvic brim, is in man lower down, on the obturator fascia. Tendinous fibers of origin of the muscle are therefore often found extending up toward, and in some cases reaching, the pelvic brim, and on these the fascia is carried.   6
  It will be evident that the fascia covering that part of the Obturator internus which lies above the origin of the Levator ani is a composite fascia and includes the following: (a) the obturator fascia; (b) the fascia of the Levator ani; (c) degenerated fibers of origin of the Levator ani.   7
  The lower margin of the fascia covering the upper surface of the pelvic diaphragm is attached along the line of insertion of the Levator ani.   8
  At the level of a line extending from the lower part of the symphysis pubis to the spine of the ischium is a thickened whitish band in this upper layer of the diaphragmatic part of the pelvic fascia. It is termed the tendinous arch or white line of the pelvic fascia, and marks the line of attachment of the special fascia (pars endopelvina fasciæ pelvis) which is associated with the pelvic viscera.   9


FIG. 403– Median sagittal section of pelvis, showing arrangement of fasciæ. (See enlarged image)
 
  The endopelvic part of the pelvic fascia is continued over the various pelvic viscera (Fig. 403) to form for them fibrous coverings which will be described later (see section on Splanchnology). It is attached to the diaphragmatic part of the pelvic fascia along the tendinous arch, and has been subdivided in accordance with the viscera to which it is related. Thus its anterior part, known as the vesical layer, forms the anterior and lateral ligaments of the bladder. Its middle part crosses the floor of the pelvis between the rectum and vesiculæ seminales as the rectovesical layer; in the female this is perforated by the vagina. Its posterior portion passes to the side of the rectum; it forms a loose sheath for the rectum, but is firmly attached around the anal canal; this portion is known as the rectal layer.   10
  The Levator ani (Fig. 404) is a broad, thin muscle, situated on the side of the pelvis. It is attached to the inner surface of the side of the lesser pelvis, and unites with its fellow of the opposite side to form the greater part of the floor of the pelvic cavity. It supports the viscera in this cavity, and surrounds the various structures which pass through it. It arises, in front, from the posterior surface of the superior ramus of the pubis lateral to the symphysis; behind, from the inner surface of the spine of the ischium; and between these two points, from the obturator fascia. Posteriorly, this fascial origin corresponds, more or less closely, with the tendinous arch of the pelvic fascia, but in front, the muscle arises from the fascia at a varying distance above the arch, in some cases reaching nearly as high as the canal for the obturator vessels and nerve. The fibers pass downward and backward to the middle line of the floor of the pelvis; the most posterior are inserted into the side of the last two segments of the coccyx; those placed more anteriorly unite with the muscle of the opposite side, in a median fibrous raphé (anococcygeal raphé), which extends between the coccyx and the margin of the anus. The middle fibers are inserted into the side of the rectum, blending with the fibers of the Sphincter muscles; lastly, the anterior fibers descend upon the side of the prostate to unite beneath it with the muscle of the opposite side, joining with the fibers of the Sphincter ani externus and Transversus perinæi, at the central tendinous point of the perineum.   11


FIG. 404– Left Levator ani from within. (See enlarged image)
 
  The anterior portion is occasionally separated from the rest of the muscle by connective tissue. From this circumstance, as well as from its peculiar relation with the prostate, which it supports as in a sling, it has been described as a distinct muscle, under the name of Levator prostatæ. In the female the anterior fibers of the Levator ani descend upon the side of the vagina.   12
  The Levator ani may be divided into iliococcygeal and pubococcygeal parts.   13
  The Iliococcygeus arises from the ischial spine and from the posterior part of the tendinous arch of the pelvic fascia, and is attached to the coccyx and anococcygeal raphé; it is usually thin, and may fail entirely, or be largely replaced by fibrous tissue. An accessory slip at its posterior part is sometimes named the Iliosacralis. The Pubococcygeus arises from the back of the pubis and from the anterior part of the obturator fascia, and “is directed backward almost horizontally along the side of the anal canal toward the coccyx and sacrum, to which it finds attachment. Between the termination of the vertebral column and the anus, the two Pubococcygei muscles come together and form a thick, fibromuscular layer lying on the raphé formed by the Iliococcygei” (Peter Thompson). The greater part of this muscle is inserted into the coccyx and into the last one or two pieces of the sacrum. This insertion into the vertebral column is, however, not admitted by all observers. The fibers which form a sling for the rectum are named the Puborectalis or Sphincter recti. They arise from the lower part of the symphysis pubis, and from the superior fascia of the urogenital diaphragm. They meet with the corresponding fibers of the opposite side around the lower part of the rectum, and form for it a strong sling.   14
 
Nerve Supply.—The Levator ani is supplied by a branch from the fourth sacral nerve and by a branch which is sometimes derived from the perineal, sometimes from the inferior hemorrhoidal division of the pudendal nerve.   15
  The Coccygeus (Fig. 404) is situated behind the preceding. It is a triangular plane of muscular and tendinous fibers, arising by its apex from the spine of the ischium and sacrospinous ligament, and inserted by its base into the margin of the coccyx and into the side of the lowest piece of the sacrum. It assists the Levator ani and Piriformis in closing in the back part of the outlet of the pelvis.   16
 
Nerve Supply.—The Coccygeus is supplied by a branch from the fourth and fifth sacral nerves.   17
 
Actions.—The Levatores ani constrict the lower end of the rectum and vagina. They elevate and invert the lower end of the rectum after it has been protruded and everted during the expulsion of the feces. They are also muscles of forced expiration. The Coccygei pull forward and support the coccyx, after it has been pressed backward during defecation or parturition. The Levatores ani and Coccygei together form a muscular diaphragm which supports the pelvic viscera.   18