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Lymphatic drainage:
The lymphatic vessels of the testicular integument flow into the inguinal lymph nodes (nodi
lymphatici inguinales).
while the lymphatic vessels of the testicle itself are directed to the lumbar lymph nodes.
Innervation of the testicle, spermatic cord, and scrotum:
¾ Innervation of the testicle is carried out by the testicular plexus (plexus
testicularis),accompanying the testicular artery and surrounding the specified vessel with
a continuous network.
¾ The testicular plexus is a derivative of the abdominal aortic plexus(plexus aorticus
abdominalis), receiving sympathetic and sensitive nervefibers in the small and lower
internal nerves.
¾ Innervation of the VAS deferens is performed by the plexus deferentialis of the same name
surrounding the VAS deferens artery.
¾ Plexus the VAS deferens is a derivative of the lower hypogastric plexus
(plexushypogastricus inferior), which receives sympathetic fibers from the sacral
nodessympathetic trunk. Parasympathetic innervation of the VAS deferensperformed by
pelvic internal nerves (nn. splanchnici pelvini).
¾ Somatic innervation of the scrotum and spermatic cord is carried out by branches of the
lumbar and sacral plexuses.
¾ The ileo-inguinal nerve (n. ilioinguinalis) passes in the inguinal canal along the anterior
surface of the spermatic cord and gives off the anterior scrotal nerves (nn. Scrotales
anteriores), innervating the skin of the pubis and scrotum.
¾ Perineal nerve (n. perinealis) extending from the genital nerve (n. pudendus), passes in the
surface space of the perineum and gives the posterior scrotal nerves to the posterior surface
of the scrotum (nn. scrotales posteriores).
¾ The sexual branch of the femoral-genital nerve (r. genitalis n. genitofemoralis), a branch
of the lumbar plexus, in the inguinal canal lies behind the spermatic cord, innervates the
muscle that raises the testicle, the skin of the scrotum and the fleshy membrane.
Fig.193: Innervations of the testicle, spermatic cord, and scrotum. Source [193].
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The penis:
¾ The penis consists of two cavernous bodies and a spongy body. The cavernous and spongy
bodies of the penis are covered with a dense protein shell.
¾ From the protein shell to the depth of the penile bodies, processes trabeculae depart, and
cells are located between them.
¾ The cavernous bodies of the penis begin with the legs (crura penis) from the inner surface
lower branches of the pubic bones. At the level of pubic fusion of the end of the penisjoin
to form the septum of the penis (septum penis) and continueinto the body of the penis
(corpus penis), located on the back of it and forming the back of the penis (dorsum penis).
¾ The spongy body of the penis (corpus spongiosum penis) lies in the groove between
cavernous bodies and forms the urethral surface of the penis (facies urethralis).
¾ The spongy body of the penis is permeated through out the urethra, which opens with an
external opening on the head.The proximal part of the spongy body is thickened and is
designated as the sexual bulbmember (bulbus penis).
¾ The distal part forms the head of the penis (glans penis).The head of the penis has the shape
of a cone and resembles the cap of a mushroom. Into the recess the base of the head includes
the pointed ends of the cavernous bodies fused togetherin the penis.
¾ The posterior part of the head passes into the crown of the head (corona glandis), behindthe
last one is the neck (collum glandis). From the lower surface of the head of septum (septum
glandis) is directed into its thickness.
¾ The skin of the penis is elastic, mobile, and contains many sebaceous glands.
¾ On the back of the penis (dorsum penis) is so thin that branches can be seen through its
superficial vein.
¾ In the area of the penis head, the skin directly adheres to the spongy body of the penis and
fuses with it. Behind the neck of the head is the foreskin of the penis (praeputium penis)
— a fold of skin that usually moves freely over the head and closes it. The inner surface of
the foreskin contains the glands of the foreskin (glandulae praeputiales), which secrete a
special secret — preputial lubricant (smegma praeputialis).
¾ The foreskin on the urethral surface of the penis passes into the frenulum of the foreskin
(frenulum preputii), fixed to the lower surface of the glans.
Blood supply:
Blood supply to the penis is carried out by the deep and back arteries of the penis penis (a.
profunda penis et a. dorsalis penis) — branches of the internal genital artery (a. pudenda
interna).
Blood flow from the penis occurs along the deep dorsal vein of the penis (V. dorsalis penis
profunda), in the prostatic venous plexus (plexus venosus prostaticus), and by the
superficial dorsal veins of the penis (vv. dorsales penis superficiales) through the external
genital veins (vv. pudendae externae) in femoral vein (V. femoralis).
Lymphatic drainage:
Lymph outflow from the penis occurs in the inguinal and external ileum lymph nodes (nodi
lymphatici inguinales et iliaci externi).
Innervation:
Penile innervation is performed by the dorsal nerve of the penis (n. dorsalispenis),
extending from the sexual nerve (n. pudendus) and containing sensitive
andparasympathetic fibers. Sympathetic fibers from the lower submandibular
plexusapproach the penis along the internal genital artery.
181
Fig.194: Transvers sections showing the parts and blood supply penis. Source [194].
The male urethra:
The male urethra begins with an internal opening and consists of three parts: the prostate,
membranous and spongy.
Parts of the male urethra:
A) Posterior urethra:
1.Prostatic urethra: 4cm.
Has a narrowing at the level of the inner opening due to the muscular membrane of the bladder,
which plays the role of the involuntary sphincter of the urethra. To the extended versionthe prostate
part opens VAS deferens (ductus ejaculatorii) and prostatic ducts (ductuli prostatici).
2.The Membranous urethra: 2 cm.
The most narrowed part of the urethra, since it is located here external sphincter (m. sphincter
urethrae). Behind this part of the urethra the bulbourethral glands are located in the canal.
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B) Anterior urthera:
Spongy (penile) urethra: 15cm.
Forms two extensions: in areas of the bulb of the penis where the excretory ducts open
bulbourethral glands (ductus gl. bulbourethralis), and in the scaphoid fossa the urethra located in
the head of the penis. The spongy part ends with an external hole the urethra, which has a smaller
diameter.
Fig.195: Parts of male urethra. Source [195].
Urogenital area in females:
¾ The female genital area is located within the genitourinary area.
¾ The middle of the area is occupied by the genital cleft (rima pudendi), bounded laterally
by the labia majora pudendi, and in front and behind by the anterior and posterior lip spikes
(comissura labiorum anterior et posterior).
¾ The bulb of the vestibule (bulbus vestibuli) is an unpaired cavernous formation consisting
of the right and left lobes about 3,5x1,5x1 cm in size, located in the thickness of the labia
majora pudendi ,connected in front by an intermediate part of the bulb, consisting mainly
of the venous plexus, located between the external opening of the urethra and the clitoris.
¾ The labia minora pudendi (labia minora pudendi) are located between the labia majora,
laterally restrict the vestibule of the vagina (vestibulum vaginae), and in front lie on the
clitoris (clitoris) and form its foreskin (preputium clitoridis) and the bridle (frenulum
clitoridis). The posterior vestibule of the vagina is bounded by the frenulum labiorum
pudendi.
¾ Clitoris : consist of two cavernous bodies that form the head of the clitoris, the body of the
clitoris, and the legs of the clitoris that attach to the lower branches of the pubic bones. In
the vestibule of the vagina, the external opening of the urethra opens behind the clitoris.
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¾ The large gland of the vestibule (gl. vestibularis major, bartolinovs) is located in at the base
of the labia minora, lies at the posterior edge of the bulbs of the vestibule of the vagina,it
is projected on the back of the labia majora. The excretory duct opens in the vestibule of
the vagina at the border of the middle and posterior third of the labia minora.
Blood supply:
Fig.196: Urogenital area in females. Source [196].
A)Arterial:
Branches of the internal and external genital arteries (aa. pudendae interna et externae).
• From the internal genital artery (a. pudenda interna), the posterior labial branches (aa.
labiales posteriores), which supply blood to the posterior parts of the labia majora and
labia minora, and the deep and back clitoral arteries (a. profunda clitoridis et a. dorsalis
clitoridis).
• External genital arteries (aa. pudendae externae) depart from the femoral artery (a.
femoralis) and give the anterior labial arteries (aa. labiales anteriores), which supply blood
to the anterior parts of the labia majora and minora.
B)Venous:
• The outflow of blood from the external female genital organs for front lip veins (vv.
labiales anteriores) in external genitals of Vienna and later in the femoral vein.
• The veins at the rear lip (vv. labiales posteriores), into the inner sexual vein, and then into
the internal iliac vein; deep dorsal Vienna of the clitoris (V. dorsalis clitoridis profunda)
— in the vesical venous plexus (plexus venosus vesicalis) and by the vesical veins into the
internal iliac vein.
184
Fig.197: Blood supply of the vagina. Source [197].
Lymahtic drainage:
lymph outflow from the external female genitals occurs in the inguinal lymph nodes(nodi
lymphatici inguinales) and in the internal iliac lymph nodes(nodi lymphatici iliaci interna).
Female perineum:
¾ Corresponding to the exit of the pelvis, a diamond-shaped tissue array, bounded by the
pubic symphysis, the tip of the coccyx and sciatic bumps.
¾ Its space is conventionally divided into the anterior perineum, which is a skin-muscle-
fascial plate between the posterior junction of the labia majora and the anal opening, and
the posterior one, located between the anal opening and the tip of the coccyx.
¾ The pelvic floor is divided anatomically into two triangular areas using an imaginary line
connecting the two sciatic tubercles: the urogenital area in front and the anal area in the
back.
¾ The thickness of the perineum is made up of muscles and their fascia, located in two layers
and forming the pelvic floor. Muscles of the perineum are distributed in two directions to
form two triangular aperture, which are aligned with their bases almost at a right angle.
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Tendon center of the perineum.
In the center of the perineum between the anal opening and the entrance to the vagina, there
is a fibromuscular formation called the tendon center of the perineum. This tendon center
is the site of attachment of several muscle groups and fascial layers.
Fig.198: The female pernineum. Source [198].
Surgical anatomy of the anal canal:
The length of the anal canal us about 4 cm; 1/3 above and 2/3 below the dentate line.
The anatomical canal; extends from the perinale skin to the dentate line.
The surgical canal; extends from the anorectal ring to the anal verge.
¾ Syntopy:
x Anterior;
x In male; Bulbus penis, posterior border of urogenital diaphragm and the perineal center.
Posterior:
o Coccyx and corpus anococcygeum.
At the flanks;
o Ischio-rectal fossa.
¾ Holotopy:
x Lesser pelvis.
¾ Skeletopy:
x S3.
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¾ Peritoneal relations:
¾ Retroperitoneal organ (Primary).
Fig.199: The anal canal. Source [199].
187
CHAPTER TEN: PERINEAL HERNIAS.
M.Y.Persov, M.Sh F .Mekhaeel ,S.Sameh
Perineal hernias are a rare type of hernias which results from weakness of endopelvic fascia and
muscles that form the pelvic diaphragm (The levator ani; the puborectalis, iliococcygeus and
pubococcygeus muscles and the coccygeus muscles).
Classification:
A) According to the site:
1.Anterior hernias are seen in women only, present as a mass in the labium majus and are due to
protrusion through the urogenital diaphragm.
2.Posterior hernias are seen in both men and women and present as a mass below the lower margin
of the gluteus maximus or protruding through the lateral part of the levator ani (between ischial
tuberosities).
B) According clinical presentation:
1.Congenital.
2.Acquired;
A) The primary acquired variety is attributed to increased intra-abdominal pressure, such as
vaginal birth, aging, obesity, or chronic constipation. Neurogenic atrophy of the pelvic floor is
another plausible etiology of some of the cases of primary perineal hernia.
B) Secondary; due to:
1. Pelvic exenteration and abdominoperineal excision of rectum.
2. Following extralevator abdominoperineal excision for low rectal cancer.
3.Coccygectomy and sacrectomy, perineal prostatectomy, and cystoureterectomy.
4.Pelvic irradiation, non-healing perineal wounds, tobacco use, and hysterectomy may increase
the risk of hernia development.
These hernias usually present with symptoms within 1 year or the original surgery and are 4 times
more common in women than men attributable to the larger female pelvic outlet.
Contents:
Are usually bowel and omentum but leiomyoma and bladder diverticulum have been reported.
Diagnosis:
¾ Common symptoms from perineal hernia include discomfort and pain, difficulty with
micturition from bladder herniation or ulceration and ischemic changes of the sac.
¾ symptoms of bowel obstruction are unusual due to the laxity of the surrounding tissues.
¾ Fluoroscopic cystocolpoproctography.
Differential diagnosis:
Swellings in the perineum such as Bartholin cysts, lipoma, epidermoid cysts, and sciatic hernias.
Surgical Repair:
Surgical approaches:
1. Abdominal (either open or laparoscope);
The transabdominal approach through a lower midline incision provides excellent exposure of
pelvic structures for safe reconstruction of the pelvic floor. Trendelenburg positioning allows for
structures to fall out of the pelvis for optimal visualization.
After the sac is ligated and excised, native tissue like uterosacral ligaments can be re-approximated
in women. Alternatively, the sac may be eliminated by suturing the posterior wall of the cervix to
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the anterior wall of the rectum. More commonly composite or biological mesh or autologous tissue
such as muscle flaps can be used to fill the defect.
2.Perineal approach:
The perineal approach affords less exposure as compared to the transabdominal technique but is
less morbid. This procedure can be performed with patient in Lloyd Davis position or prone
jackknife position. The sac is opened, the contents reduced, the sac excised, and the hernia ring
closed.
Perineal repair with absorbable and composite meshes (PTFE, Vypro) led to 100 % recurrence
whereas high-tension repair using a non-absorbable mesh resulted in very low recurrence rates of
5 %, while
mesh or muscle flap have best results.
3.Combined approach:
The combined approach is advantageous of being able to reconstruct the pelvic floor from both
aspects, however there is higher morbidity.
Fig.200: Repair of perineal hernia through perineal approach. Source [200].
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