Pelvic Neurovasculature Practice Quiz

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The external iliac veins lie medial to the external iliac artery.
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The external iliac veins lie medial to the external iliac artery. The
external iliac veins are not the veins that join to make the inferior
vena cava. First, the external and internal iliac veins join to form
Describe the pelvic veins. a common iliac vein on each side. Then, the common iliacs join
to form the inferior vena cava. The inferior vena cava can be
imaged--it can be seen in axial CT scans or with a venogram.
Veins are not imaged using an arteriogram--an arteriogram is for
arteries! Instead, veins can be imaged with a venogram, a test
where contrast is injected into the venous system.
Ischial spine
------------
The ischial spine is the only answer choice on the lateral pelvic
wall. It arises just superior to the lesser sciatic notch and serves as
the site of attachment of the sacrospinous ligament. The coccyx
is the most inferior part of the vertebral column, resulting from
the fusion of the four coccygeal vertebrae. It articulates with the
sacrum, which means that it is associated with the posterior wall
What bony landmark on the lateral pelvic wall may be used as a
of the pelvis. The ischial tuberosity protrudes posteroinferiorly, not
reference for localizing female pelvic anatomy or pain phenome-
laterally, from the body of the ischium. This is where weight rests
na?
when the body is in the sitting postion. The ischial tuberosity also
serves as the site of attachment for the sacrotuberous ligament.
The obturator canal is the space in the obturator foramen that is
not covered with obturator membrane. It transmits the obturator
nerve and vessels, and it is on the anterior, not lateral, side of
the pelvis. Finally, the pectineal line is the ridge on the pubis that
creates the anterior border of the pelvic inlet and is an important
landmark of the inguinal region.
It is relaxed during defecation. It is a funnel-shaped skeletal mus-
cle. It is referred to as the pelvic diaphragm. It projects into the
Describe the pelvic floor.
anal triangle. Ir defines the true pelvic cavity along with the pelvic
brim.
Puborectalis muscle
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Puborectalis is the part of levator ani that is closest to the vagi-
na and urethra. This muscle may be injured during a difficult
childbirth. By doing Kegel exercises, where women contract and
Following pregnancy and delivery, a 32-year-old woman contin-
relax the pelvic floor, these injured muscles may be strengthened
ued to have problems with urinary incontinence which developed
and urinary continence may be improved. Besides levator ani,
during pregnancy. Her obstetrician counseled her to strengthen
coccygeus is the second muscle that makes the pelvic floor.
the muscle bordering the vagina and urethra, increasing its tone
However, it extends between the ischial spine and the side of the
and exerting pressure on the urethra. This physical therapy was
coccyx/lower sacrum, so it is not next to the vagina and urethra
soon adequate to restore urinary continence. What muscle was
and is not important for maintaining urinary continence. Ischiocav-
strengthened?
ernosus compresses the corpus cavernosum. It is closely applied
to the crus penis/clitoris in the perineum. Obturator internus and
piriformis laterally rotate and abduct the thigh. Although these
muscles originate in the pelvis, they are functionally more impor-
tant to the lower limb.
Pelvic splanchnic nerves
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Pelvic splanchnic nerves carry parasympathetic fibers from the
lateral horn of the spinal cord at the S2, 3, and 4 levels. They
can be seen coming off of the ventral primary rami of S2, 3,
and 4 and going to the inferior hypogastric plexus. These nerves
provide parasympathetic innervation to the pelvic viscera and
the GI tract distal to the left colic flexure. (Remember, the vagus
gives parasympathetic innervation to the rest of the gut.) Sacral
splanchnic nerves come off the sacral sympathetic chain ganglia,
carrying sympathetic fibers that will go to the inferior hypogastric
plexus. To remember the difference between the pelvic and sacral

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splanchnics, just remember that the sacral splanchnics are named
after a spinal cord segment, just like the thoracic, lumbar, and
cervical splanchnics that you know and love. These all carry sym-
pathetic fibers. Pelvic splanchnics are not named after a spinal
cord segment and they're different--they carry parasympathetic
fibers.
Preganglionic parasympathetic nerve fibers within the pelvic (in- The grey rami communicantes are structures that postganglion-
ferior hypogastric) plexus arise from S2, 3, 4 and enter the plexus ic sympathetic neurons travel on to get out of the sympathetic
via: trunk and rejoin a spinal nerve. There are gray rami in the pelvis.
The white rami communicantes are structures that preganglionic
sympathetic fibers use to get out of a spinal nerve to enter the
sympathetic trunk. White rami are seen between the T1 to L2
levels, but not in the pelvis. Finally, the hypogastric nerves carry
postganglionic sympathetic nerves from the superior hypogastric
plexus to the inferior hypogastric plexus.
Under; cervix
While performing a hysterectomy, the resident must ligate the
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uterine artery. To avoid iatrogenic injury to the ureters, she must
Remember--the ureter passes under the uterine artery, in the
be aware that the ureter passes ___________ the artery at the
inferior portion of the mesometrium, near the cervix! This is a very
level of the ______________.
important relationship--see Netter Plate 370 for a picture.
Levator ani
------------
Urinary stress incontinence happens when the bladder can't han-
dle increased compression during exercise, coughing, or sneez-
ing. This form of incontinence is the result of relaxation of the
pelvic muscles and displacement of the urethrovesiculal junction.
Remember--levator ani is the major pelvic muscle which elevates
After giving birth, a patient complains of urinary stress incon- the pelvic floor. So, if this muscle became injured during a vaginal
tinence characterized by dribbling of urine with an increase in birth, a woman might experience urinary incontinence.
intra-abdominal pressure. Her physician suspects injury to the The bulbospongiosus muscle is found in the perineum; it com-
pelvic floor during delivery which may have altered the position presses the vestibular bulb and constricts the vaginal orifice.
of the neck of bladder and the urethra. Which muscle was most Coccygeus is a smaller muscle found posterior to levator ani. It
likely damaged during the vaginal delivery? also elevates the pelvic floor, but it is not as important as levator
ani. So, injury to coccygeus alone would not cause incontinence.
Obturator internis is a muscle which leaves the pelvis through the
lesser sciatic foramen and inserts on the greater trochanter of the
femur; it laterally rotates and abducts the thigh. Finally, piriformis is
a muscle that leaves the pelvis through the greater sciatic foramen
and inserts on the greater trochanter; it also allows for lateral
rotation and abduction of the thigh.
Pelvic splanchnics, pudendal nerve, S2 dorsal root, S2 ventral
primary ramus
NOT sacral splanchnics
---------------
The sacral splanchnic nerves do not come out of the sacral nerve
roots--instead, these nerves come from the sacral sympathetic
ganglia. So, anesthesia bathing the sacral nerve roots would not
A caudal epidural block is a form of regional anesthetic used in affect the sacral splanchnic nerves, which are coming from the
childbirth. Within the sacral canal, the anesthetic agent bathes the sympathetic trunk. The sacral splanchnic nerves contribute to the
sacral spinal nerve roots which would anesthetize which nerves? inferior hypogastric plexus and provide sympathetic innervation to
the vascular smooth muscle of the pelvic viscera.
The pelvic splanchnic nerves are comprised of fibers from S2,
3, and 4, and pudendal nerve is made of the ventral primary
rami of S2-4. These nerves would be numbed if the sacral nerve
roots were anesthetized. Finally, the S2 dorsal root and S2 ventral
primary ramus would also be anesthetized by the caudal epidural
block.
Levator ani
---------
Urinary stress incontinence happens when the bladder can't han-
dle increased compression during exercise, coughing, or sneez-

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ing. This form of incontinence is the result of relaxation of the
pelvic muscles and displacement of the urethrovesiculal junction.
Remember--levator ani is the major pelvic muscle which elevates
the pelvic floor. So, if this muscle became injured during a vaginal
birth, a woman might experience urinary incontinence.
Coccygeus is a smaller muscle found posterior to levator ani. It
also elevates the pelvic floor, but it is not as important as levator
After giving birth, a patient complains of dribbling of urine while
ani. So, injury to coccygeus alone would not cause incontinence.
coughing, sneezing, or laughing. Which muscle was most likely
Obturator internis is a muscle which leaves the pelvis through
damaged during the vaginal delivery?
the lesser sciatic foramen and inserts on the greater trochanter
of the femur; it laterally rotates and abducts the thigh. Piriformis
is a muscle that leaves the pelvis through the greater sciatic
foramen and inserts on the greater trochanter; it also allows for
lateral rotation and abduction of the thigh. The transverse perineal
muscle is a muscle of the perineum-- it fixes and stabilizes the
perineal body/central tendinous point.
Sacral plexus
------------
The sacral plexus includes contributions from L4 through part
of S4. It supplies motor innervation to muscles of the pelvic di-
aphragm, muscles of the urogenital diaphragm, and muscles of
the posterior hip, posterior thigh, leg and foot. It supplies sensory
innervation to the skin of the perineum, posterior thigh, leg and
foot. So, this patient's pain and weakness in the thigh, as well as
his inability to empty his rectum, point to damage in the sacral
A patient presents complaining of blood-stained stools and the
plexus.
inability to completely empty his rectum. He also has pain along
The inferior hypogastric plexus lies between the pelvic viscera
the back of his thigh and weakness of the posterior thigh muscles.
and the pelvic wall-- it supplies sympathetic innervation to the
Digital examination reveals a tumor in the posterolateral wall of
vascular smooth muscle of the pelvic vessels and parasympa-
the rectum. Pressure on what nerve plexus could cause the pain
thetic innervation to the pelvic viscera (from the pelvic splanch-
in his lower limb?
nic nerves). The inferior mesenteric plexus supplies sympathetic
innervation to the smooth muscle of the vessels supplying the
descending colon, sigmoid colon and rectum. The lumbar plexus
innervates the muscles of the lower abdominal wall, the cremaster
muscle, psoas major and minor, quadratus lumborum,and iliacus.
Finally, the superior hypogastric plexus is the continuation of the
intermesenteric plexus--it supplies the vascular smooth muscle of
the pelvic viscera and transmits pain sensation from the pelvic
viscera.
Levator ani
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The levator ani is the muscle immediately lateral to the ampulla of
the rectum, so this is where the cancer would have spread. This
In a patient with rectal cancer located in the wall of the ampulla, muscle is important for elevating the pelvic floor. The obturator
you find that the cancer has spread to the muscle immediately internus and piriformis muscles are lateral and posterior to the
lateral to the ampulla. This muscle is the: rectum--they would not be affected by the cancer. The sphincter
urethrae encircles and compresses the urethra. Bulbospongeosus
is a muscle in the perineum which compresses the bulb of the pe-
nis and the spongy urethra in men and compresses the vestibular
bulb and constricts the vaginal orifice in women.
Umbilical artery
--------------
The umbilical artery supplies the superior part of the bladder
by giving off the superior vesical arteries. In males, this artery
supplies the ductus deferens via the artery of the ductus deferens.
Blood supply to the superior portions of the bladder typically
Distal to those branches, the umbilical artery is not patent, and it
arises from the ____________ arteries.
becomes the medial umbilical ligament. The middle rectal artery
supplies blood to the middle of the rectum, while the obturator
artery supplies blood to the medial thigh and hip. The inferior
gluteal artery supplies blood to gluteus maximus, and the uterine
artery supplies blood to the uterus.

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Preganglionic parasympathetics to the inferior hypogastric plexus
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Although all the other splanchnic nerves carry sympathetic fibers,
the pelvic splanchnic nerves transmit preganglionic parasympa-
thetic fibers from S2, 3, and 4. These fibers are carried to the
The pelvic splanchnic nerves primarily carry ____________ to the inferior hypogastric plexus. The parasympathetic fibers from the
_____________ plexus. inferior hypogastric plexus supply the smooth muscle of the pelvic
viscera, while the sympathetic fibers from the inferior hypogastric
plexus supply vascular smooth muscle of vessels supplying the
pelvic viscera. The superior hypogastric plexus is a continuation
of the intermesenteric plexus--it contributes sympathetic fibers to
the inferior hypogastric plexus through hypogastric nerves.
Obturator internus
------------------
The fascia of obturator internus has two specializations. First,
there is a strong band on the medial edge of obturator internus that
stretches between the spine of the ischium and the superior pubic
ramus. This is the arcus tendineus levator ani, which gives origin
to the levator ani muscles. The other specialization is the obturator
membrane, which nearly covers the entire obturator foramen,
only leaving space for the obturator nerves and vessels to exit.
The arcus tendineus levator ani is a thickening of fascia of the:
Coccygeus is a muscle that elevates the pelvic diaphragm--it is
found posterior to levator ani. Obturator externus is not found it
the pelvis--it takes origin from the external surface of the obturator
membrane and inserts on the femur. It is an important muscle for
laterally rotating the thigh. The piriformis muscle takes origin from
the anterior surfaces of S2 to S4, both between and lateral to the
sacral foramina. It exits the pelvis via the greater sciatic foramen,
inserting on the greater trochanter of the femur in order to rotate
the thigh laterally.
Pelvic splanchnic nerves
-------------
Pelvic splanchnic nerves come from the anterior branches of
S2 through S4. These are parasympathetic nerves, which send
parasympathetic neurons to the hypogastric plexus, and therefore
the pelvic viscera and distal colon. Hypogastric nerves are from
the superior hypogastric plexus. These nerves transmit sympa-
The sacral outflow of the parasympathetic (craniosacral) system
thetic neurons to the hypogastric plexus, and therefore the pelvic
enters the pelvic plexus via:
viscera. The pudendal nerve is a branch of the sacral plexus.
It provides motor innervation to the muscles of the perineum,
and it is the primary sensory innervation to the genitalia. Sacral
splanchnic nerves are from the second and/or third ganglia of
the sacral sympathetic trunk. These provide a secondary way
for sympathetic neurons to reach the hypogastric plexus, and
therefore the pelvic viscera.

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