The Perineum, The Perineum, Perineal Pouches, Perineal Pouches, anatomic references anatomic references Dr shittu LAJDr shittu LAJ

objectivesobjectives It is expected that at the end of the lecture, It is expected that at the end of the lecture,

one would be able to:one would be able to: Explain the various terms perineum, pelvic Explain the various terms perineum, pelvic

diaphragm etcdiaphragm etc Describe the content of the perineal spaces Describe the content of the perineal spaces

in male and female.in male and female. Describe the anatomical relevance of some Describe the anatomical relevance of some

the fasciae etc the fasciae etc

PerineumPerineum a diamond-shaped space forming the outlet of the pelvis a diamond-shaped space forming the outlet of the pelvis

and is inferior to the pelvic and urogenital diaphragms. and is inferior to the pelvic and urogenital diaphragms. Boundaries:Boundaries: anterolaterally -Pubic symphysis, inf. Pubic rami, ischial anterolaterally -Pubic symphysis, inf. Pubic rami, ischial

rami, ischial tuberosities, rami, ischial tuberosities, Posteriolateral-sacrotuberous ligaments and coccyxPosteriolateral-sacrotuberous ligaments and coccyx Structures found in perineum: Structures found in perineum:

External genitalia. External genitalia. Anal canal and anal sphincters Anal canal and anal sphincters Ischiorectal /and ischioanal fossa and pudendal canal.Ischiorectal /and ischioanal fossa and pudendal canal. Consist of 2 unequal triangles namely:Consist of 2 unequal triangles namely: UG and Anal trianglesUG and Anal triangles

perineumperineum

Urogenital TriangleUrogenital Triangle anterior subdivision of the diamond-shaped perineum anterior subdivision of the diamond-shaped perineum This triangle defines the urogenital region of the This triangle defines the urogenital region of the

perineum. perineum. Boundaries: Boundaries: Anterior aspect (apex of triangle): pubic symphysis Anterior aspect (apex of triangle): pubic symphysis Lateral aspects: Ischial tuberosities (imaginary line Lateral aspects: Ischial tuberosities (imaginary line

joining both sides of the bones)joining both sides of the bones) Posterior aspect: tip of coccyx bone. Posterior aspect: tip of coccyx bone. Is the location of the terminal portion of the urinary Is the location of the terminal portion of the urinary

tract and genital tract tract and genital tract

Anal TriangleAnal Triangle posterior subdivision of the diamond-shaped posterior subdivision of the diamond-shaped

perineum, perineum, This triangle defines the anal region of the perineum. This triangle defines the anal region of the perineum. Boundaries:Boundaries: Apex of anal triangle = the tip of the coccyx bone. Apex of anal triangle = the tip of the coccyx bone. Sides of anal triangle = the sacrotuberous ligaments Sides of anal triangle = the sacrotuberous ligaments

and the gluteus maximus. and the gluteus maximus. Base of anal triangle = the ischial tuberosities Base of anal triangle = the ischial tuberosities

(imaginary line joining both sides of the bones). (imaginary line joining both sides of the bones). Contains terminal end of the gastrointestinal tract Contains terminal end of the gastrointestinal tract

(anus) (anus)

Boundaries between the Boundaries between the trianglestriangles

A line joining from one A line joining from one ischial tuberosityischial tuberosity to to the other one defines the border between the the other one defines the border between the two perineal triangles. two perineal triangles.

The perineal body lies in the middle of that line. The perineal body lies in the middle of that line. This line also marks the inferior border of the This line also marks the inferior border of the

urogenital diaphragm. urogenital diaphragm. NB: Superficial Transverse Perineal MuscleNB: Superficial Transverse Perineal Muscle

goes between the anal and UG triangles, and goes between the anal and UG triangles, and converges on the perineal body. converges on the perineal body.

Superficial pouch Superficial pouch

PERINEUM in Male or Female- TISSUE LAYERS PERINEUM in Male or Female- TISSUE LAYERS OF THE UROGENITAL TRIANGLEOF THE UROGENITAL TRIANGLE

Skin Skin Subcutaneous Tissue -- Subcutaneous Tissue -- Camper's FasciaCamper's Fascia. . Superficial Membranous Fascia: Attach to the Superficial Membranous Fascia: Attach to the

posterior aspect of the UG diaphragm, just posterior aspect of the UG diaphragm, just anterior to the central tendon of the perineum. anterior to the central tendon of the perineum. Scarpa's Fascia: Scarpa's Fascia: Abdominal superficial Abdominal superficial

membranous fascia. membranous fascia. Colle's Fascia: Colle's Fascia: Superficial membranous fascia, Superficial membranous fascia,

continuous with Scarpa's, in the region posterior to continuous with Scarpa's, in the region posterior to the scrotum/vagina. the scrotum/vagina.

Darto's Fascia: Darto's Fascia: Superficial membranous fascia of Superficial membranous fascia of the penis in malethe penis in male only only

SUPERFICIAL PERINEAL SUPERFICIAL PERINEAL SPACESPACE All structures between the superficial All structures between the superficial

membranous fascia and the perineal membrane. membranous fascia and the perineal membrane. Investing Fascia in male and Gallaudet's Investing Fascia in male and Gallaudet's

(Deep) Fascia in female: (Deep) Fascia in female: Inferior border of the Inferior border of the bulbospongiosus muscle. Converges with Buck's bulbospongiosus muscle. Converges with Buck's fascia at the base of the penis. fascia at the base of the penis.

Buck's Fascia: Buck's Fascia: Superior (deep) border of the Superior (deep) border of the bulbospongiosus muscle. Converges with bulbospongiosus muscle. Converges with investing fascia at the base of the penis. investing fascia at the base of the penis.

True Suspensory Ligament of the True Suspensory Ligament of the Penis/Clitoris: Penis/Clitoris: Superior to and continuous with Superior to and continuous with deep fascia, continuous with transversus deep fascia, continuous with transversus abdominis fascia of anterior abdominal wall. abdominis fascia of anterior abdominal wall.

Female perineum and pelvic Female perineum and pelvic floorfloor

MUSCLES / CORPORA / VESSELS / NERVESMUSCLES / CORPORA / VESSELS / NERVES

All the structures are found in the superficial perineal space All the structures are found in the superficial perineal space with all the muscles attached to the perineal body with all the muscles attached to the perineal body

Corpus Spongiosum in male and two Vestibular Bulbs in Corpus Spongiosum in male and two Vestibular Bulbs in female with female with Bulbospongiosus MuscleBulbospongiosus Muscle covering it. covering it.

Corpus Cavernosum with Corpus Cavernosum with Ischiocavernosus MusclesIschiocavernosus Muscles covering them; Crura of the Penis /Clitoris (composed of covering them; Crura of the Penis /Clitoris (composed of Corpora Cavernosa). Corpora Cavernosa).

Bulb of the penis/vestibular bulbs in femaleBulb of the penis/vestibular bulbs in female (of the corpus (of the corpus spongiosum) spongiosum)

Superficial Transverse Perineal MuscleSuperficial Transverse Perineal Muscle: The posterior : The posterior border of the UG diaphragm. Attaches to the perineal body border of the UG diaphragm. Attaches to the perineal body and counters the action of the bulbospongiosus muscle. and counters the action of the bulbospongiosus muscle.

It generally holds the UG structures in place. It generally holds the UG structures in place. Perineal Nerves, branches of the pudendal nerve. Perineal Nerves, branches of the pudendal nerve.

SUPERIOR MEMBRANE OF THE SUPERIOR MEMBRANE OF THE UROGENITAL DIAPHRAGMUROGENITAL DIAPHRAGM

Urethral and Vagina openings in the femaleUrethral and Vagina openings in the female Greater Vestibular (Bartholin's) Gland Greater Vestibular (Bartholin's) Gland -- --

located at the posterior aspect of the located at the posterior aspect of the vestibular bulb -- in the superficial perineal vestibular bulb -- in the superficial perineal space. space.

NB: The analogous structure in the male, the NB: The analogous structure in the male, the Bulbourethral gland, is in the deep perineal Bulbourethral gland, is in the deep perineal space, while the female homolog is in the space, while the female homolog is in the superficial perineal space. superficial perineal space.

Anal triangleAnal triangle

PERINEAL MEMBRANEPERINEAL MEMBRANE Lies in the inferior border of the UG Lies in the inferior border of the UG

diaphragm. diaphragm. It divides the superficial perineal space It divides the superficial perineal space

from the deep perineal space. from the deep perineal space. That is, It is the superior border of the That is, It is the superior border of the

superficial perineal pouchsuperficial perineal pouch, and the inferior , and the inferior border of the border of the deep perineal pouchdeep perineal pouch. .

Central Tendon of the Perineum Central Tendon of the Perineum (Male), or (Male), or Perineal Body Perineal Body (female)(female) Is the the junction of most of the musculature of the pelvic Is the the junction of most of the musculature of the pelvic

diaphragm. diaphragm. It is the central support for pelvic diaphragm, which in turn It is the central support for pelvic diaphragm, which in turn

supports the pelvis. supports the pelvis. If it is damaged, incontinence results.If it is damaged, incontinence results. It is an attachment point for both the perineum and the pelvis. It is an attachment point for both the perineum and the pelvis. Point where fibers from pelvis unite with those of external anal sphincter. Point where fibers from pelvis unite with those of external anal sphincter. It is the posterior attachment point of the urogenital diaphragm. It is the posterior attachment point of the urogenital diaphragm. Point where external genitalia (corpora) muscles attach. Point where external genitalia (corpora) muscles attach. Point where superficial transverse perineal muscles attach. Point where superficial transverse perineal muscles attach.

Endopelvic Fascia: The name of the visceral fascia in the Endopelvic Fascia: The name of the visceral fascia in the pelvis. pelvis.

DEEP PERINEAL SPACEDEEP PERINEAL SPACE Male Muscles of the UG Diaphragm: Male Muscles of the UG Diaphragm:

Sphincter Urethrae MuscleSphincter Urethrae Muscle: To stop urination. : To stop urination. Primary musculature in the male. They are circular fibers which compress the Primary musculature in the male. They are circular fibers which compress the

urethra upon contraction, to stop urination. urethra upon contraction, to stop urination. Deep transverse perineal muscleDeep transverse perineal muscle: Muscle located in the posterior aspect : Muscle located in the posterior aspect

of the UG diaphragm. of the UG diaphragm. Deep dorsal vein/artery of the penis or clitoris (branch of pudendal Deep dorsal vein/artery of the penis or clitoris (branch of pudendal

vein) vein) Deep dorsal nerve of penis or clitoris (branch of pudendal nerve) Deep dorsal nerve of penis or clitoris (branch of pudendal nerve) Urethra passes through it in femaleUrethra passes through it in female Bulbourethral (Cowper's) glandsBulbourethral (Cowper's) glands -- in the Deep Perineal Space. -- in the Deep Perineal Space. Urethra passes through it in male. Urethra passes through it in male. Female Muscles of the UG Diaphragm: Female Muscles of the UG Diaphragm:

Compressor Urethrae MuscleCompressor Urethrae Muscle -- passes anterior to the urethra. -- passes anterior to the urethra. Sphincter Urethrae MuscleSphincter Urethrae Muscle -- Passes posterior to the urethra and blends -- Passes posterior to the urethra and blends

fibers with the compressor urethra. fibers with the compressor urethra. It inserts on the Perineal Body. It inserts on the Perineal Body.

Urethrovaginal SphincterUrethrovaginal Sphincter -- circular, voluntary fibers around the posterior -- circular, voluntary fibers around the posterior of the urethra. When they contract, both the vagina and the urethra of the urethra. When they contract, both the vagina and the urethra constrict. constrict.

It inserts on the Perineal Body. It inserts on the Perineal Body.

Male perineumMale perineum

STRADDLE INJURYSTRADDLE INJURY Blood investing the superficial perineal space will not Blood investing the superficial perineal space will not

get into the deep perineal space. It will be stopped at get into the deep perineal space. It will be stopped at the following borders: the following borders:

Superior Border: Arcuate line in the abdominal wall. Superior Border: Arcuate line in the abdominal wall. Lateral Borders: Inguinal Ligaments (facia lata Lateral Borders: Inguinal Ligaments (facia lata

blending with sup. perineal fascia).blending with sup. perineal fascia). Deep border: Perineal Membrane.( posterior Deep border: Perineal Membrane.( posterior

continuous of the 2 sup. perineal fasciae around the continuous of the 2 sup. perineal fasciae around the superficial perineal muscles.superficial perineal muscles.

In male, the spread of urine in case of urethral injury In male, the spread of urine in case of urethral injury would be towards the scrotum, penis and the anterior would be towards the scrotum, penis and the anterior abdomen.abdomen.

Pelvic DiaphragmPelvic Diaphragm It is the inferior border of the pelvis, separating the pelvis from the perineum. It is the inferior border of the pelvis, separating the pelvis from the perineum.

It supports the pelvic organs. It supports the pelvic organs. Genital Hiatus: Genital Hiatus: An opening in the pelvic diaphragm, where there is no muscle, just fascia.An opening in the pelvic diaphragm, where there is no muscle, just fascia. It overlies the superior part of the urogenital diaphragm. It overlies the superior part of the urogenital diaphragm. The structures that go through it are:The structures that go through it are: Urethra Urethra Vagina (female) Vagina (female) Genital Hiatus of the UG-Diaphragm:Genital Hiatus of the UG-Diaphragm: Is located in between the arcuate ligament and transverse perineal ligament. Is located in between the arcuate ligament and transverse perineal ligament. Arcuate Ligament: Arcuate Ligament: Anterior border of genital hiatus, located just deep to Anterior border of genital hiatus, located just deep to

the pubic symphysis. the pubic symphysis. Transverse Perineal Ligament: Transverse Perineal Ligament: Posterior border of the genital hiatus, Posterior border of the genital hiatus,

located just anterior to the muscular part of the UG diaphragm. located just anterior to the muscular part of the UG diaphragm. It is the fusion of the inferior and superior membranes of the UG diaphragm. It is the fusion of the inferior and superior membranes of the UG diaphragm. The Deep Dorsal Vein / Nerve of Penis or clitoris goes below the genital The Deep Dorsal Vein / Nerve of Penis or clitoris goes below the genital

hiatus. hiatus. The The pelvic splanchnic nervespelvic splanchnic nerves go through the hiatus to join the dorsal go through the hiatus to join the dorsal

nerve on the other side. nerve on the other side.

Pelvic floor-Levator Ani MusclesPelvic floor-Levator Ani Muscles Attaches to the tendinous arch (arcus tendineus) of the levator Attaches to the tendinous arch (arcus tendineus) of the levator

ani. ani. It extends all the way from the pubis back to the ileum, and It extends all the way from the pubis back to the ileum, and

sweeps medially back to the coccyx. sweeps medially back to the coccyx. Ileococcygeus Muscle: Ileococcygeus Muscle: The posterolateral part of the levator The posterolateral part of the levator

ani muscle, associated with the ilium. ani muscle, associated with the ilium. Pubococcygeus Muscle: Pubococcygeus Muscle: The anteromedial part of the levator The anteromedial part of the levator

ani muscle, associated with the pubis. ani muscle, associated with the pubis. Puborectalis Muscle: Puborectalis Muscle: The most medial part of the The most medial part of the

pubococcygeus muscle, going around the rectum. pubococcygeus muscle, going around the rectum. Puborectal SlingPuborectal Sling are the muscle fibers of the puborectalis are the muscle fibers of the puborectalis

that swing around the rectum, holding it in place. that swing around the rectum, holding it in place. FUNCTION OF THE PUBORECTAL SLING: It creates an FUNCTION OF THE PUBORECTAL SLING: It creates an

angle between the rectum and anal canal, which allows you to angle between the rectum and anal canal, which allows you to retain fecal matter. The angle is almost 90, and the anal canal retain fecal matter. The angle is almost 90, and the anal canal points down and posteriorlypoints down and posteriorly

Pelvic floorPelvic floor

Pubovaginalis / PuboprostaticPubovaginalis / Puboprostatic:: There is also There is also a pubovaginalis part in the female, and less a pubovaginalis part in the female, and less prominent puboprostatic part in the male. prominent puboprostatic part in the male.

Obturator Internus MuscleObturator Internus Muscle: The muscle : The muscle underlying the underlying the obturator membraneobturator membrane, which , which covers the obturator foramen. covers the obturator foramen.

Coccygeus Muscles:Coccygeus Muscles: Laterally attaches to the Laterally attaches to the ischial spine, and medially attaches to the ischial spine, and medially attaches to the lateral aspect of the sacrum. lateral aspect of the sacrum.

Arcus Tendineus:Arcus Tendineus: The fascia that lines the The fascia that lines the attachment between the obturator internus attachment between the obturator internus muscle and levator ani. muscle and levator ani.

Urogenital DiaphragmUrogenital Diaphragm The part of the pelvic diaphragm that extends The part of the pelvic diaphragm that extends

medially, between the medially, between the ischiopubic rami.ischiopubic rami. It is located It is located inferior to the pelvic diaphragm. inferior to the pelvic diaphragm. Anteriorly, it encloses the sphincter urethrae Anteriorly, it encloses the sphincter urethrae

muscle. muscle. Posteriorly, it encloses the deep transverse Posteriorly, it encloses the deep transverse

perianal muscle. perianal muscle. Anteriorly, it encircles the urethra on either side.Anteriorly, it encircles the urethra on either side. The anterior recess of the anal fossae becomes The anterior recess of the anal fossae becomes

smaller and smaller as you move anteriorly. smaller and smaller as you move anteriorly. It encloses the It encloses the Deep PerinealDeep Perineal

Pelvic Roof / PeritoneumPelvic Roof / Peritoneum The pelvis roof is defined by the inferior limit of The pelvis roof is defined by the inferior limit of

peritoneum, coming down from the abdomen. peritoneum, coming down from the abdomen. Peritoneum covers the anterior aspect of rectum, Peritoneum covers the anterior aspect of rectum,

then reflect off the uterus (in female), forming the then reflect off the uterus (in female), forming the Rectouterine Pouch (of Douglas)Rectouterine Pouch (of Douglas). .

That is, the inferior most peritoneal recess of the That is, the inferior most peritoneal recess of the abdomen. abdomen. Male analogous structure is Male analogous structure is rectovesical recess, rectovesical recess,

reflection between the rectum and seminal vesicles, reflection between the rectum and seminal vesicles, which are directly posterior to the bladder. which are directly posterior to the bladder.

The peritoneum then covers the uterus and The peritoneum then covers the uterus and uterine tubes, before going back up the anterior uterine tubes, before going back up the anterior abdominal wall. abdominal wall.

Peritoneum does Peritoneum does not not cover all of the rectum. cover all of the rectum.

ISCHIOANAL FOSSAEISCHIOANAL FOSSAE Is a potential spaces surrounding the anal canal, Is a potential spaces surrounding the anal canal, Found in the anal triangle region, Found in the anal triangle region, located between the skin of the anal region and the located between the skin of the anal region and the

pelvic diaphragm. pelvic diaphragm. The spaces are triangle-shaped. The spaces are triangle-shaped. Boundaries: Boundaries:

The apex forms superiorly at the lateral border of the The apex forms superiorly at the lateral border of the levator ani muscles, where they connect to the obturator levator ani muscles, where they connect to the obturator membrane. membrane.

The lateral aspect of the fossae are the obturator internus The lateral aspect of the fossae are the obturator internus muscles. muscles.

The base of each fossa (triangular base) is the perianal The base of each fossa (triangular base) is the perianal skin. skin.

The medial aspect of each fossa is the anal canal. The medial aspect of each fossa is the anal canal. The posterior aspect of each fossa is the sacrotuberous The posterior aspect of each fossa is the sacrotuberous

ligament and gluteus maximus muscle. ligament and gluteus maximus muscle.

ISCHIOANAL FOSSAISCHIOANAL FOSSA As you go more anteriorly, the region of the ischioanal fossae As you go more anteriorly, the region of the ischioanal fossae

becomes thinner, until it converges on the bladder anteriorly. There is becomes thinner, until it converges on the bladder anteriorly. There is very little of the anterior recess left, right next to the pubic symphysis very little of the anterior recess left, right next to the pubic symphysis most anteriorly. most anteriorly.

Anterior Recess of the Ischioanal Fossae is formed by the reflection Anterior Recess of the Ischioanal Fossae is formed by the reflection of the fossa, anteriorly, with the urogenital diaphragm or extends of the fossa, anteriorly, with the urogenital diaphragm or extends superior to the urogenital diaphragmsuperior to the urogenital diaphragm . . This recess is between the pelvic diaphragm (superior border) and This recess is between the pelvic diaphragm (superior border) and

UG diaphragm (inferior border). UG diaphragm (inferior border). NB: If an abscess were to get into the anterior recess, the fluid NB: If an abscess were to get into the anterior recess, the fluid

would be would be superior to the UG diaphragm and inferior to the pelvic superior to the UG diaphragm and inferior to the pelvic diaphragm.diaphragm.

Posterior Recess of the Ischioanal Fossae is just superior to the Posterior Recess of the Ischioanal Fossae is just superior to the gluteus maximus muscle and sacrotuberous ligament, where it gluteus maximus muscle and sacrotuberous ligament, where it reflects on the posterior part of the pelvic diaphragm. reflects on the posterior part of the pelvic diaphragm. This is inferior to the pelvic diaphragm. This is inferior to the pelvic diaphragm.

Contents of Ischioanal Fossae: Contents of Ischioanal Fossae: fat and loose connective tissuefat and loose connective tissue -- which allows the expansion of the anal canal and therefore the -- which allows the expansion of the anal canal and therefore the passage of stored feces. passage of stored feces.

Ischianal canalIschianal canal

PELVIMETRYPELVIMETRY

Pelvic Inlet: Pelvic Inlet: Line from upper part of pubic symphysis Line from upper part of pubic symphysis back to the sacral promontory. back to the sacral promontory.

Pelvic Outlet: Pelvic Outlet: Line from the lower part of pubic Line from the lower part of pubic symphysis back to tip of coccyx. symphysis back to tip of coccyx.

True Conjugate Diameter: True Conjugate Diameter: Measured along the pelvic Measured along the pelvic inlet. inlet.

Diagonal Conjugate Diameter:Diagonal Conjugate Diameter: Measured from the Measured from the bottom of the pubic symphysis back to the sacral bottom of the pubic symphysis back to the sacral promontory. promontory.

Obstetrical Conjugate Diameter: Obstetrical Conjugate Diameter: The smallest The smallest opening, from the widest part of the pubic symphysis, opening, from the widest part of the pubic symphysis, back to the sacral promontory. back to the sacral promontory.

PUDENDAL CANAL OF ALCOCK`SPUDENDAL CANAL OF ALCOCK`S It runs along the It runs along the lateral wall of the ischioanal fossaelateral wall of the ischioanal fossae, just medial to the , just medial to the

obturator internus muscle. obturator internus muscle. It runs along the It runs along the medial surface of the ischial tuberositymedial surface of the ischial tuberosity. . It goes out at the greater sciatic foramen, then runs laterally along the It goes out at the greater sciatic foramen, then runs laterally along the

ischial spine and sacrospinous ligament, and then comes back in through ischial spine and sacrospinous ligament, and then comes back in through the lesser sciatic foramen, and then runs along the medial aspect of the the lesser sciatic foramen, and then runs along the medial aspect of the ischiopubic ramus. ischiopubic ramus.

It contains pudendal artery, pudendal vein, and pudendal nerve.It contains pudendal artery, pudendal vein, and pudendal nerve. Internal Pudendal Artery and VeinInternal Pudendal Artery and Vein: :

A branch of the anterior division of the internal iliac artery / vein. A branch of the anterior division of the internal iliac artery / vein. Pudendal Nerve:Pudendal Nerve:

The nerve innervating the perineal regionThe nerve innervating the perineal region Branches of the Pudendal Canal: Branches of the Pudendal Canal:

Inferior Rectal Artery, Vein, and Nerve: Goes to the rectal area. Inferior Rectal Artery, Vein, and Nerve: Goes to the rectal area. Perineal Artery, Vein, and Nerve: Goes to the Urogenital area. Perineal Artery, Vein, and Nerve: Goes to the Urogenital area. Deep Dorsal Artery, Vein, and Nerve: Goes to the shaft of the penis (clitoris). Deep Dorsal Artery, Vein, and Nerve: Goes to the shaft of the penis (clitoris).

It travels along the superior aspect of the UG diaphragm. It travels along the superior aspect of the UG diaphragm. Applied anatomy:Applied anatomy: Pudendal nerve blockPudendal nerve block

Pudendal canalPudendal canal

Pudendal nerve entrapmentPudendal nerve entrapment is a recognized cause of chronic perineal pain,is a recognized cause of chronic perineal pain, Symptoms- pain in the penis, scrotum, labia, Symptoms- pain in the penis, scrotum, labia,

perineum, or anorectal region. perineum, or anorectal region. Pudendal nerve entrapment is a clinical diagnosis Pudendal nerve entrapment is a clinical diagnosis

made in patients with the typical history of perineal made in patients with the typical history of perineal pain aggravated by sitting, pain aggravated by sitting,

relieved by standing, and absent when recumbent or relieved by standing, and absent when recumbent or sitting on a toilet seat. sitting on a toilet seat.

No widely accepted confirmatory test is available, No widely accepted confirmatory test is available, although a neurophysiologic examination may confirm although a neurophysiologic examination may confirm nerve damage.nerve damage.

The differential diagnosis is chronic non-bacterial The differential diagnosis is chronic non-bacterial prostatitis, which is the most common symptomatic prostatitis, which is the most common symptomatic type of prostatitis, or chronic pain syndrome type of prostatitis, or chronic pain syndrome

pudendal nerve is predisposed to pudendal nerve is predisposed to entrapmententrapment

At the level of the ischial spine At the level of the ischial spine within the pudendal canal. within the pudendal canal. At the ischial spine, the nerve can be compressed between At the ischial spine, the nerve can be compressed between

the sacrotuberous and sacrospinous ligaments. the sacrotuberous and sacrospinous ligaments. Sometimes, the nerve is ensheathed by ligamentous Sometimes, the nerve is ensheathed by ligamentous

expansions that form a perineural compartment. expansions that form a perineural compartment. At the pudendal canal, the pudend al nerve can be At the pudendal canal, the pudend al nerve can be

compressed by the falciform process of the sacrotuberous compressed by the falciform process of the sacrotuberous ligamentligament

If thickened, the duplication of the obturator fascia also may If thickened, the duplication of the obturator fascia also may act as an entrapment site act as an entrapment site

TreatmentTreatment Conservative management with analgesic etcConservative management with analgesic etc Pudendal nerve block?Pudendal nerve block? CT-guided steroid and anaesthetic agent injectionCT-guided steroid and anaesthetic agent injection