Advances in Anatomy Embryology and Cell Biology Vol. 175 Editors F. Beck, Melbourne B. Christ, Freiburg W. Kriz, Heidelberg E. Marani, Leiden W. Kummer, Gießen R. Putz, München Y. Sano, Kyoto T. H. Schiebler, Würzburg K. Zilles, Düsseldorf
Springer-Verlag Berlin Heidelberg GmbH
H. Fritsch A. Lienemann E. Brenner B. Ludwikowski Clinical Anatomy of the Pelvic Floor With 42 Figures and 1 Table BD
Prof. Dr. Helga Fritsch Institut für Anatomie, Histologie und Embryologie Leopold-Franzens-Universität Müllerstr. 59 6010 Innsbruck Austria Dr. Andreas Lienemann Ludwig Maximilians Universität Medizinische Klinik, Radiologie Ziemsenstrasse 1 80336 München Germany ISSN 0301-5556 ISBN 978-3-540-49993-0 Dr. Erich Brenner Institut für Anatomie Histologie und Embryologie Leopold-Franzens-Universität Müllerstr. 59 6010 Innsbruck Austria Dr. Barbara Ludwikowski St Johanns Spital Landesklinik für Kinderchirurgie Müllner Hauptstrasse 48 5020 Salzburg Austria Library of Congress Cataloging-in-Publication Data Clinical anatomy of the pelvic floor / H. Fritsch... [et al.]. p.; cm. - (Advances in anatomy, embryology, and cell biology; v. 175) Includes bibliographical references and index. ISBN 978-3-540-49993-0 ISBN 978-3-642-18548-9 (ebook) DOI 10.1007/978-3-642-18548-9 1. Pelvic floor-anatomy. 2. Pelvic floor-histology. 3. Pelvic floor-magnetic resonance imaging. I. Fritsch, H. (Helga), 1957- II. Series. [DNLM: 1. Pelvic Floor-anatomy & histology. 2. Magnetic Resonance Imaging. WP 155 C641 2004] This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. springeronline.com Springer-Verlag Berlin Heidelberg 2004 Originally published by Springer-Verlag Berlin Heidelberg New York in 2004 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature. Typesetting: Stürtz, Würzburg Printed on acid-free paper 27/3150/AG-5 4 3 2 1 0
Acknowledgements This work has been initiated by Prof. Dr. Dr. h.c. K. Fleischhauer and Prof. Dr. Dr. h.c. F. Stelzner (Surgeon) at the Anatomical Institute of the University of Bonn; it has been continued at the Institute of Anatomy at the University of Lübeck with the support of Prof. Dr. Dr. h.c. mult. W. Kühnel. During the time in Lübeck, it has been supported by the DFG (Fr. 829/1 1, 829/1 2). It is still carried on with cooperations of urologists, surgeons and radiologists at the Department of Clinical and Functional Anatomy, Institute of Anatomy, Histology and Cell Biology, at the University of Innsbruck. Our work is dedicated to our friends Andres and Harald who lived and worked with us and who died too early.
Contents 1 Introduction... 1 2 Morphological Approaches for a Spatial Insight into the Anatomy of the Pelvic Floor... 3 2.1 Macroscopic Dissections... 3 2.2 Sections of Fetal Pelves... 3 2.3 Sections of Adult Pelves... 4 2.4 Three-Dimensional Reconstructions... 4 2.5 Magnetic Resonance Imaging... 4 3 Subdivision... 7 3.1 Posterior Compartment... 7 3.2 Anterior Compartment... 8 3.3 Middle Compartment... 8 3.4 Perineal Body... 8 4 Compartments... 9 4.1 Posterior Compartment... 9 4.1.1 Connective Tissue Structures... 9 4.1.2 Muscles... 14 4.1.3 Reinterpreted Anatomy, Function and Fundamentals in Neuroanatomy... 17 4.1.4 Surgical and Obstetric Relevance... 19 4.1.5 Important Vessels, Nerves and Lymphatics... 22 4.2 Anterior Compartment... 22 4.2.1 Connective Tissue Structures... 22 4.2.2 Muscles... 25 4.2.3 Reinterpreted Anatomy, Function and Fundamentals in Neuroanatomy... 26 4.2.4 Urological and Obstetric Relevance... 27 4.2.4.1 Important Vessels, Nerves and Lymphatics inthemale... 28 4.2.4.2 Important Vessels, Nerves and Lymphatics in the Female... 28 4.3 Middle Compartment... 29 4.3.1 Connective Tissue Structures... 29 4.3.2 Muscles... 31 VII
4.3.3 Reinterpreted Anatomy, Function and Fundamentals of Neuroanatomy... 31 4.3.4 Obstetric Relevance... 32 4.3.5 Important Vessels, Nerves and Lymphatics... 33 5 Perineal Body... 35 5.1 Connective Tissue Structures and Muscles inthemale... 35 5.2 Connective Tissue Structures and Muscles in the Female... 35 5.3 Reinterpreted Anatomy, Function and Fundamentals of Neuroanatomy... 36 5.4 Surgical, Urological, and Obstetric Relevance... 39 6 Summary and Conclusions... 41 References... 61 Subject Index... 65 VIII
Abbreviations ac b bp cu dtm eas if ilc isc is lam lm md nvp oi p pbo pc pr r rup rvp u v vup Anal canal Bladder Bulbus penis Cervix uteri Deep transverse perineal muscle External anal sphincter Ischioanal fossa Iliococcygeal muscle Ischiococcygeal muscle Internal sphincter Levator ani muscle Longitudinal muscular layer Müllerian duct Nerve vessel plate Obturator internus muscle Prostate Pubic bone Pubococcygeal muscle Puborectalis muscle Rectum Recto-uterine pouch Recto-vesical pouch Urethra Vagina Vesico-uterine pouch IX