Physical Therapy for Women's Health - 4th Year Students - SVU

4. BONES OF THE FEMALE PELVIS:

5. JOINTS OF THE FEMALE PELVIS:
SACROILIAC JOINT
SYMPHYSIS PUBIS
LUMBOSACRAL JOINT
SACROCOCCYGEAL JOINT

6. 1-Sacroiliac Joint:
-Sacroiliac joint is a large diarthrodial
synovial joint with irregular elevations
and depressions that produce interlocking
between the concave sacral surface that
is covered by hyaline cartilage and the
convex iliac surface that is covered
by fibrocartilage.
-The sacroiliac joints are essential for
effective load transfer between the
spine and the lower extremities.

7. -The SIJ ROM in flexion-
extension is about 3°, axial rotation is about 1.5° and lateral bending is
about 0.8°.​

8. 2-Symphysis Pubis:​
-It is a unique Non synovial joint
consisting of a thick interpubic
fibrocartilaginous disc sandwiched
between the thin hyaline articular
surfaces of the pubic bones.
-It resists tensile, shearing and compressive
forces and is capable of a small amount of
movement (Amphiarthrosis) under
physiological conditions in most adults (up
to 2 mm shift and 1° rotation).

9. -The main motions
of the symphysis
pubis are
superior/inferior
glide, separation/
compression.
-The functions of the
joint are to absorb
shock during
walking and allow
delivery of a baby.

10. 3-Lumbosacral Joint:​
-It is a joint between the fifth lumbar
vertebta and the first sacral vertebra.
-It is formed by two separate articulations:
 Anterior Intervertebral Disc L5-S1:
It is a translational wedge-shaped
Fibrocartilage disc.
 The Facet Joints:
two zygapophysial synovial joints formed
between the articular processes of L5 and
S1which are covered by Hyaline cartilage.

11. 4-Sacrococcygeal Joint:
-It is an articulation between the apex of
the sacrum and the base of the coccyx.
-This joint is a symphysis, having the two
bones lined by hyaline cartilage and
connected by an interposed fibrous disc.
-The slight movements within the joint are
limited to one degree of freedom: flexion-
extension to increase the anteroposterior
Pelvic diameter during labor and defecation.

12. LIGAMENTS OF THE FEMALE PELVIS:
-Iliolumbar Ligament
-Anterior and Posterior Sacroiliac Ligaments
-Anterior and Posterior Sacrococcygeal Ligaments
-Sacrospinous Ligament
-Sacrotuberous Ligament
-Superior and Inferior (Arcuate) Pubic Ligaments

13. Anterior View of the female pelvic Ligaments

14. Posterior View of the female pelvic ligaments

15. 1-Obturator foramen:​
• Filled with obturator membrane​
• Obturator canal with obturator​
neurovascular bundle to medial​
compartment of thigh.
2-Greater Sciatic foramen: piriformis
m., sciatic n. and branches of sacral
nerve plexus
3-Lesser Sciatic foramen: pudendal
n. and obturator internus tendon.
OPENINGS OF THE FEMALE PELVIS:

16. MUSCLES OF THE FEMALE PELVIS:​
Layer One:
• Bulbocavernosus muscle
• Ischiocavernosus muscle
• Superficial transverse perineal m.
• External anal sphincter muscle
• Gluteus maximus muscle

17. Layer Two:
*External urethral sphincter m. *Sphincter urethral vaginalis muscle
*Compressor urethrae m. *Deep transverse perineal muscle

18. Layer Three:
*Levator ani muscle
(pubococcygeus,
puborectalis and
iliococcygeus)
*Coccygeus
(Ischiococcygeus) m.
*Piriformis muscle
*Obturator internus m.

19. Origins:
Puborectalis: Posterior surface of bodies of pubic bones
Pubococcygeus: Posterior surface of bodies of pubic bones
Just lateral to puborectalis
Iliococcygeus: Tendinous arch of interal obturator fascia
Ischiococcygeus: Ischial spine and Sacrospinous ligament
Insertions:
Puborectalis: None (forms 'puborectal sling' posterior to rectum)
Pubococcygeus: Anococcygeal ligament, Coccyx, Perineal body and
musculature of vagina
Iliococcygeus: Anococcygeal ligament, Coccyx
Ischiococcygeus: Inferior end of sacrum, coccyx

23. Functions of the female pelvic floor muscles:
1.To support the pelvic organs as pubovaginalis which forms
a ‘U’ shaped sling, supports the vagina which in turn supports
the bladder and uterus and to provide a volitional sphincteric action on urethra .
2.Puborectalis plays an accessory role to the action of external anal sphincter.
3.Counteracts the downward thrust of increased intra-abdominal pressure (local
core) and Ischiococcygeus helps to stabilize sacroiliac & sacrococcygeal joints.
4.Facilitates anterior internal rotation of the presenting part of the fetus when
it presses on the pelvic floor during the second stage of normal labor.

24. -The sacral plexus supplies the
buttocks, lower limb, and
structures of the pelvis.
-It is formed by union of the
anterior rami of L4-S4 nerves.
-The pudendal nerve (S2–S4)
is a mixed nerve supplies most
of the perineum and muscles
of the pelvic diaphragm.
NERVES OF THE FEMALE PELVIS:​​

25. -The pudendal nerve crosses the
greater sciatic foramen between
piriformis and ischioccoygeus,
entering the perineum through
the lesser sciatic foramen.
Sensory branches:
-Inferior rectal nerve
-Perineal nerve with its
superficial and deep branches.
-Dorsal nerve of clitoris

26. Motor Branches:​
-Bulbocavernosus​ m.
-Ischiocavernosus​ m.
-Levator ani muscles​
-Transverse perineal muscles​
-External urethral sphincter​ m.
-External anal sphincter​ m.

29. -The female bony pelvis is divided into:
•Greater (False) pelvis: above the
pelvic (inlet) brim and has no obstetric
importance.
•Lesser (True) pelvis: between the
pelvic (inlet) brim and the pelvic outlet
and it is related to the child -birth.
-The Pelvic Inlet (Brim)Boundaries:
Sacral promontory, alae of the
sacrum, sacroiliac joints, arcuate
line, pectineal line, pubic crests and
upper border of symphysis pubis.
-The Pelvic Outlet Boundaries:
Lower border of symphysis
pubis, pubic arch, ischial tuberosities,
sacrotuberous and sacrospinous
ligaments and tip of the coccyx.

31. *The Male Pelvis:
-The male pelvic inlet is narrower and is more heart shaped.
-In general, the male pelvis is taller and narrower.
-The pubic arch forms a much more acute angle (subpubic
angel <90 degrees) and the pubic arch is higher in the male.
-The obturator foramens in the male are round.
*The Female Pelvis:
-The female pelvic inlet is more circular and wider.
-The female pelvis is broader and flattened.
-The pubic arch forms an obtuse angle (subpubic angel>90 degrees).
-The obturator foramen in the female they are oval.
The Differences Between Male and Female Pelvis:

34. *Some other related differences:
-Acetabular anteversion angle
is Greater in females.
-Neck shaft angle of femur is
Lesser in females.
-Alpha angle is Lesser in females
-Femoral offset is Lesser in females.
-Hip flexion and internal rotation
range of motion is Greater in females.
-Weaker hip abduction.
-Lower hamstring stiffness.
-Q angle is Greater in females.

35. Four types of female pelvis:
1- Gynecoid pelvis(50%):
•It is the normal female type allow easy childbirth.
•Inlet is slightly transverse oval.
•Side walls are straight with blunt ischial spines.
•Subpubic angle is 90-100°.
2- Anthropoid pelvis (25%):
•All anteroposterior diameters are long.
•All transverse diameters are short.
•Outlet is large but Inlet diameters favor the engagement of the fetal head
in an occiput-posterior position that may slow down the progress of labor .
•Subpubic angle is narrow.

36. 3- Android pelvis (20%):​
•It is a male type and Childbirth is difficult and more complicated.​
•Inlet is triangular or heart-shaped with anterior narrow apex.​
•Side walls are converging (funnel pelvis)
with projecting ischial spines.​
•Subpubic angle is narrow <90°.​
4- Platypelloid pelvis (5%):​
•It is a flat female type.​
•All anteroposterior diameters are short.​
•All transverse diameters are long.​
•Inlet is specifically kidney-shaped so difficult
fetal head engagement.
•Subpubic angle is wide.​

37. The Female Reproductive System:
-The female reproductive system consists of both:
external and internal genitalia.
-The external genitalia consist of the following: mons
pubis, labia majora, labia minora, vestibule, clitoris and
vestibular glands.
-The internal genitalia consist of the following: Vagina,
uterus, ovaries and uterine (Fallopian) tubes.

38. The External genitalia:
1-Mons pubis→ is a mass of
subcutaneous adipose tissue located
anterior to the pubic symphysis.
2-Labia majora→ are two
longitudinal skin folds covered with
pubic hair. They are the most lateral
part of the vulva, extending from the
mons pubis to the perineum.
3-Labia minora→ are two
longitudinal, thin and hairless skin
folds found between the labia majora.
They surround the vaginal vestibule.

39. 4-Vestibule→ the region between the labia minora and it has uretheral and
vaginal orifices.
•Urethral meatus​: is an extension of a tube from the bladder to the outside of
the body to excrete urine.
•Introitus of vagina​:is the opening to the vagina that is surrounded or partially
covered by the hymen.
5-Clitoris→ is a sensitive organ that located at the most superior part of
the vulvar vestibule.
6-Vestibular glands→
•Skene's glands​: are located around the lower end of the urethra lubricating the
urethra and provide antimicrobial function.
•Bartholin's glands​: are found on each side of the vaginal introitus that serve to
lubricate the vulva.

40. The Internal genitalia:
1-The Vagina→
-It is a fibromuscular canal (birth canal) that
represents the outermost internal female
reproductive organ.
-Its upper end is attached to the cervix of the uterus.
These structures form a pouch (vaginal fornix)
which has anterior, posterior and two lateral parts.
While its lower end (vaginal orifice) opens into the
vaginal vestibule just behind the urethral orifice. It
constitutes the excretory channel for the
uterine secretion and menstrual blood.

41. -The vaginal canal is directed upwards and backwards forming
an angle of 45° with the horizontal in the upright posture.
-The length of the anterior vaginal wall
is about 7 cm and that of the posterior wall
is about 9 cm while its diameter
is about 2.5 cm, being widest in the upper part
and narrowest at its introitus.
-The upper end of vagina is above the pelvic floor.
-The vaginal internal surface has a Rugae to
increase its surface area and provide the space necessary for vaginal microbiota.

42. Relations:-
-Anterior wall:
*The upper one-third → the base of the bladder.
*The lower two-thirds → the urethra.
-Posterior wall:
*The upper one-third → the pouch of Douglas.
*The middle-third → the anterior rectal wall.
*The lower-third → the perineal body & anus.
-Lateral walls:
*The upper one-third → pelvic cellular tissue and fat.
*The middle-third → the levator ani muscles.
*The lower-third → the bulbocavernosus muscles and
Bartholin’s glands.

44. 2-The Uterus→
-It is a hollow pyriform muscular organ
situated in the pelvis between the bladder
in front and the rectum behind.
-The uterus normally sits in a position of
anteversion (90° between long axis of cervix to
long axis of vagina) and anteflexion (120° long
axis of body to long axis of cervix).
-The uterus measures about 8 cm long,
5 cm wide at the fundus and its walls are about
1.25 cm thick. Its weight varies from 50–80 g.

45. -The uterus is divided into three parts:
1)Body (corpus): It is triangular measuring about 5 cm
and lies between the openings of the tubes and the isthmus.
It is consisted of both: fundus (the part which lies above
the openings of the uterine tubes) and uterine cavity.
2)Isthmus: It is the constricted part of the uterus, located
between the body and the cervix measuring about 0.5 cm.
3)Cervix: the lowermost portion of the uterus. It is
cylindrical and measures about 2.5 cm in length and diameter. It
consists of both: supravaginal and vaginal parts. Also, it has
internal os, external os and a cervical canal.

47. Structures:
*Body: The wall consists of 3 layers from outside inwards:
♦ Perimetrium → It is the serous coat which invests
the entire organ except on the lateral borders.
♦ Myometrium → It consists of thick bundles of
smooth muscle fibers held by connective tissues and
are arranged in various directions.
♦ Endometrium → The inner mucous lining of the
cavity and it consists of functional and basal layers.
Endometrium is changed to decidua during pregnancy.
*Cervix: It is composed mainly of fibrous connective tissues while the smooth
muscle fibers average 10–15%. Also, it has: endocervix and ectocervix.

48. Uterine Nerve Supply:
-The afferent fibers mostly ascend through the inferior hypogastric plexus
to enter the spinal
cord via T10-L1.
-Sympathetic:
uterovaginal plexus
From the inferior
Hypogastric plexus.
-Parasympathetic:
the pelvic splanchnic
nerves (S2-S4).

49. Ligaments of the uterus:
-They can be divided by where
they attach to the uterus:
*Superior aspect→ supported by
the broad ligament (mesovarium,
mesosalpinx and mesometrium)
and the round ligament.
*Middle aspect→ supported by
the cardinal, pubocervical and
uterosacral ligaments.

50. -Broad ligament→ extends from the sides of uterus to the lateral walls and floor of pelvis,
made of mesosalpinx (encloses uterine tube), mesovarium (carries ovarian vessels and
nerves), mesometrium (contains part of Mackenrodt’s ligament).
-Uterovesical fold→ extends from the junction of uterine body and cervix to the bladder;
creates uterovesical pouch.
-Rectovaginal fold→ extends from the posterior vaginal fornix to
the rectum; creates rectouterine (pouch of Douglas).
-Round ligament→ extends from the lateral cornu of uterus through
broad ligament to the connective tissue of labia majora.
-Transverse cervical (Mackenrodt’s) ligament→ extend from the
lateral pelvic walls to the supravaginal part of cervix; carries uterine artery.
-Pubocervical ligaments→ extend from the anterior aspect of the cervix and upper vagina to
the posterior aspect of the pubic bones.
-Uterosacral ligament→ extend from the anterior side of sacrum to sides of the cervix and
uterine body.

53. 3-The uterine (Fallopian) tubes→
-The uterine tubes are paired structures,
measuring about 10 cm and are situated
in the medial three fourth of the upper
free margin of the broad ligaments.
-Each tube has got two openings:
*one communicating with the lateral
angle of the uterine cavity, called
uterine opening
*The other is on the lateral end of the
tube, called pelvic opening or
abdominal ostium.

54. parts: There are four parts, from medial to lateral, they are:
(1)Intramural or Interstitial→ lying in the uterine wall
and measures 1.25 cm in length and 1 mm diameter.
(2)Isthmus→ almost straight and measures
about 2.5 cm in length and 2.5 mm in diameter.
(3)Ampulla→ tortuous part and measures
about 5 cm in length which ends in wide.
(4)infundibulum→ measuring about 1.25 cm
long with a maximum diameter of 6 mm. one
of the abdominal ostium is attached to the outer
pole of the ovary called ovarian fimbria.
functions: (1) transport of gametes, (2) to facilitate
fertilization, and (3) survival of zygote through its secretion.

56. 4-The ovaries→
-The ovaries are paired reproductive glands or
gonads in female that are concerned with:
*Germ cell maturation, storage and its release.
*Steroidogenesis.
-Each ovary is oval and pinkish grey in color and
the surface is scarred during reproductive age.
-It measures about 3 cm in length, 2 cm in breadth
and 1 cm in thickness. Each ovary presents two ends:
tubal and uterine, two borders: mesovarium and free
posterior and two surfaces: medial and lateral.

57. -The ovaries are intraperitoneal structures. In
nulliparous women , the ovary lies in the
shallow depression (ovarian fossa) on the
lateral pelvic wall.
-It is attached to the posterior layer of the broad
ligament by the mesovarium, to lateral pelvic wall by infundibulopelvic
(suspensory) ligament and to the uterus by the ovarian ligament.
-Sympathetic supply comes down along the ovarian
artery from T9-T10 segment. While parasympathetic
supply through the inferior hypogastric plexus from
pelvic splanchnic nerves (S2-4).

58. Structures:
*Cortex: It consists of stromal
cells which are thickened
under the germinal epithelium
to form tunica albuginea.
During reproductive period,
The cortex is studded with
numerous follicles in various
developmental phases.
*Medulla: It consists of highly vascular stroma in the center of the ovary. This
stroma forms tissue of the hilum by which the suspensory ligament is attached,
and through which blood vessels enter. it does not contain any ovarian follicles.