Abstract
The visceral organs of the male pelvis have complex anatomic relationships with the surrounding extraperitoneal spaces, supplying arteries and adjacent pelvic musculature. Since various neoplastic, vascular, and traumatic pathologies can often involve multiple organs and spread into adjacent pelvic spaces, a keen understanding of this intricate anatomy can help radiologists to accurately characterize findings and improve recognition of the routes in which these conditions can spread. The purpose of this review is to examine the relationships between the anatomic compartments of the pelvic extraperitoneal space, summarize the pelvic arterial anatomy, and identify the pelvic muscles that support normal genitourinary function.
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Introduction
The use of cross-sectional modalities such as computer tomography (CT) and magnetic resonance imaging (MRI) in evaluating the male pelvis has become commonplace. Radiologists should have keen understanding of the fascial layers lining the muscles and visceral organs of the male pelvis and the extraperitoneal compartments that these layers form. The communication between these spaces dictates the spread and containment of different neoplastic and traumatic pathologies. Other common conditions in the male pelvis such as high-flow priapism and benign prostatic hyperplasia have a vasculogenic origin and treatment. Though the main arterial supply for several of the organs in the male pelvis are diminutive and difficult to visualize on cross-sectional imaging, radiologists should have a basic understanding of the key pelvic arterial branches arising from the internal iliac artery. The purpose of this review is to examine the relationships between the anatomic compartments of the pelvic extraperitoneal space, summarize the pelvic arterial anatomy, and identify the pelvic muscles that support normal genitourinary function.
Extraperitoneal pelvic spaces
The pelvis is primarily located within the extraperitoneal space, which is comprised of the space between the peritoneum internally and transversalis fascia externally [1,2,3,4]. The majority of the male pelvis is located within the inferior extraperitoneal space. This space consists of an anterior and a posterior compartment that is separated by the rectovesical septum, also known as the Denonvillier’s fascia [5, 6]. The anterior pelvic compartment is divided into the prevesical space and perivesical space, while the posterior compartment is divided into the perirectal space and presacral space.
Extraperitoneal anatomy
A key structure in the delineation of the anterior pelvic compartment is the umbilicovesical fascia. Located anterior to the peritoneum and posterior to the transversalis fascia, the apex of the umbilicovesical fascia is positioned at the umbilicus and creates a triangular shape as it courses inferiorly in the pelvis. The fascia envelopes the obliterated umbilical vessels, urachus/urachal remnant and bladder [7, 8]. The umbilicovesical fascia divides the anterior pelvis into the prevesical space and encases the smaller perivesical space, a small potential space that is typically imperceptible on imaging. The perivesical space is contiguous inferiorly with the prostate and seminal vesicles (Fig. 1). On cross-sectional imaging, the umbilicovesical fascia can be distinguished by indentifying the medial umbilical ligaments (obliterated umbilical arteries) and the urachal remnant, when present (Fig. 2).
Sagittal non-contrast CT images of the pelvis. Sagittal images a, b showing the normal midline structures of the male pelvis, including the bladder (B), prostate (P) and seminal vesicles (SV), which are surrounded by the perivesicular space (pevs, white line). The prevesical space (pvs, colored blue) is more anterior in the pelvis, bounded by the transversalis fascia and umbilicovesical fascia posteriorly. The space of Retzius (ret) is the prevesical space between the pubic symphysis and urinary bladder. The inferior boundary of the peritoneum (peri, red line) is also noted
Axial non-contrast CT images of the pelvis. a–c Normal Axial CT images of the pelvis from the level of the bladder dome to the umbilicus showing normal anatomic landmarks of the umbilicovesical fascia. The umbilicovesical fascia is superior to the bladder and has a triangular shape with its apex at the umbilicus. The lateral margins of the triangle are comprised of the obliterated umbilical arteries (ua) and umbilicovesical fascia. The urachal remnant (ura) is a thin ligament in the anterior midline. The ductus deferens (dd) appear as thin, curvilinear lines lateral to the obliterated umbilical arteries and traverse the prevesical space before entering the inguinal canal
The anterior boundary of the prevesical space is the transversalis fascia, which lines the inner surface of the transverse abdominal muscles. The lateral aspect is defined by the parietal pelvic fascia that covers the internal surface of the muscles of the pelvic floor. The space is bounded by the umbilicovesical fascia posteriorly and medially. Fat, loose fibrous tissue, and venous plexus occupies this space [9]. Posterior to the pubis, the space is commonly referred to as the space of Retzius.
The posterior pelvic compartment is delineated from the anterior compartment by the rectovesicular septum. The posterior compartment can be subdivided into the perirectal space anteriorly and presacral space posteriorly. The perirectal space is outlined by the rectovesical septum anteriorly, mesorectal fascia laterally and posterior pelvic fascia posteriorly [10, 11]. In addition to the rectum and adjacent adipose tissue, the space also contains rectal arteries and veins, lymphatics and perirectal lymph nodes. Details of this space are beyond the scope of this paper. The pararectal space is a potential space between the mesorectal fascia and the parietal pelvic fascia [1, 11, 12]. The presacral space is located posteriorly within the posterior pelvic compartment. It is situated in front of the sacrum and coccyx, defined anteriorly by posterior pelvic fascia and posteriorly by the parietal pelvic fascia [8, 13].
Extraperitoneal fluid collections
Hemorrhage and extraperitoneal bladder rupture are the most common etiologies of fluid accumulation in the prevesical space. On cross-sectional imaging, collections in this space are classically described as having a “molar tooth” appearance [8]. The “crown” component of the tooth is visualized when fluid resides between the transversalis fascia and the umbilicovesical fascia causing the bladder to be displaced posteriorly. The “root” components are formed when the fluid extends into the space between the umbilicovesical fascia and the parietal pelvic fascia (Fig. 3). Though the “root” portion is sometimes referred to as a paravesicular collection, it represents extension of the perivesical space [14]. Fluid in this location compresses the bladder and displaces it medially [1].
68-year-old male with acute blood loss. Axial non-contrast CT of the pelvis demonstrates a hematoma within the right iliacus muscle (IL) and a large fluid collection within the prevesical space between the bladder (BL) and anterior abdominal wall. The collection assumes a “molar tooth” configuration, with fluid anterior to the bladder forming the “crown” (C) and medial to the bladder forming the “roots” (R) of the molar tooth. The triangle-shaped umbilicovesical fascia (uvf) is spared
Given the narrow configuration of the umbilicovesical fascia, isolated fluid accumulation in the perivesical space is rare. Traumatic or iatrogenic injuries that involve fluid collections or extravasation into the perivesical space is most commonly found with concomitant prevesical fluid. The perivesical space above and anterior to the bladder is often spared in patients with prevesical fluid collections (Fig. 3). The adjacent prevesical fluid delineates a triangular-shaped fatty space that contains the urachus and obliterated umbilical arteries.
Communication of the extraperitoneal spaces
Although infrequently identified clinically, fluid from the prevesical space can extend into the perivesical space. This space is contiguous with the prostate and seminal vesicles along the posterior portion of the bladder, likely facilitating communication between the compartments [1]. The perivesical space is also directly contiguous with the pararectal space, a potential space. Rarely, large perivesical collections can extend into the pararectal space and subsequently into the presacral space (Fig. 4). Although there are conflicting reports in the literature [2], it is believed that the mesorectal fascia prevents the extension of perivesical fluid into the perirectal space [11, 15, 16].
67-year-old male with pelvis fractures following trauma. a There is a focal asymmetric hematoma within the right prevesical space (*) with mild leftward displacement of the bladder (B). b The hematoma extends from the prevesical space through the space between the visceral and parietal pelvic fascia into the pararectal space (prs) and continues posteriorly into the presacral (pss) space
The deep inguinal ring, the proximal opening of the inguinal canal, is formed by an ovoid opening of the transversalis fascia. Fluid originating in the perivesical space can extend to the scrotum via this orifice (Fig. 5).
70-year-old male with hemoglobin drop. a Axial non-contrast CT image of the pelvis demonstrates a large rectus sheath hematoma (*) with extension into the prevesical and right pararectal (para) space with leftward displacement of the bladder (B). b Sagittal non-contrast CT shows extension of hematoma into the right inguinal canal (thick white arrow) through the small gap in the transversalis fascia (tf) associated with the deep inguinal ring. c and d Coronal and axial non-contrast CT images show the hematoma (*) extending into the right inguinal canal (thick white arrow)
The sheath of the femoral canal represents a short funnel-shaped extension of the extraperitoneal space into the abdominal wall [17]. The transversalis fascia forms the anterior wall of the sheath. The femoral vessels course along the lateral aspect of the canal and are directly continuous with the external iliac vessels that reside within the prevesicular space [18]. Hemorrhage in the femoral canal can extend along the sheath and communicate with the perivesical space. This finding is frequently encountered in patients that develop large hematomas following femoral arterial catheterization (Fig. 6).
57-year-old male status post cardiac catheterization. a, b Axial CT pelvis images demonstrates a hematoma in the right femoral sheath (rfs) extending into the prevesical space (pvs). The anterior femoral sheath is formed by the transversalis fascia, allowing direct extension of a hematoma at the arterial access site into the prevesical space. c There is extension of hematoma into the right femoral canal (fc)
Below the umbilicus, the posterior sheath of the abdominis muscle terminates at the arcuate line, a horizontal line that denotes the inferior extent of the posterior rectus sheath [19]. Likewise, the paired inferior epigastric vessels cross the transversalis fascia below the arcuate line (Fig. 7). Fluid collections may traverse between the rectus sheath inferiorly into the prevesical space at these vascular insertion sites. Larger collections may also directly penetrate through the thinned transversalis fascia inferior to the arcuate line into the prevesical space [20] (Fig. 8).
a Graphic diagram showing the anatomic relationship between the inferior epigastric vessels and the rectus abdominis (ra) muscle in the sagittal plane. The posterior rectus sheath (prs) terminates at the arcuate line. The inferior epigastric artery (iea) penetrates the transversalis fascia (tf) below the arcuate line (al). Sagittal (b) and axial (c) CT angiogram maximum intensity projection images (MIP) of the pelvis evaluating perforator arteries showing the inferior epigastric artery penetrating the transversalis fascia below the arcuate line (dotted line). The anterior rectus sheath (ars), pubic bone (pb), inferior rib (rib), and peritoneum (peri) are noted
92-year-old male with spontaneous right rectus sheath hematoma. a, b Axial non-contrast CT pelvis images demonstrates a large hematoma within the right rectus sheath(*). c The hematoma penetrates the transversalis fascia (thick white arrow) into the prevesical space (pvs), below the arcuate line as the posterior rectus sheath has terminated. Blood within the prevesical space displaces the bladder to the left
Disease processes can also extend from the perivesical space to the retroperitoneal space. The perivesical space is contiguous with the extraperitoneal fat of the anterior abdominal wall below the transversalis fascia. There is direct extension from the perivesical space to the properitoneal and retroperitoneal fat, serving as a conduit to the anterior pararenal, perirenal and posterior pararenal spaces [8] (Fig. 9). Extension of retroperitoneal fluid inferiorly into the pelvis occurs more commonly than prevesical fluid extending superiorly into the retroperitoneum. Furthermore, fluid extending from the perirenal space into the pelvis occurs more frequently than fluid originating from the pararenal spaces [21].
78-year-old male with bladder rupture following cystoscopy. a, b Axial non-contrast CT images of the pelvis shows a moderate volume of extravasated urine in the prevesical space (*) and a trace volume of urine within the right pararectal space (prs). The mesorectal fascia (mrf) prevents fluid from entering the perirectal space (peri). c There is extension of urine from the prevesical space into the retroperitoneum via the right posterior pararenal space (rpps), displacing the partially visualized right kidney (rk) anteriorly
Pelvic arterial vasculature
Within the male pelvis, the internal iliac artery serves as the predominant vessel providing the majority of blood flow to the pelvic viscera and surrounding musculature. Many of the smaller terminal branches of the internal iliac artery are below the resolution of cross-sectional imaging. Nevertheless, a detailed understanding of the internal iliac artery branches and common variants is vital in performing revascularization and embolization procedures for conditions such as vasculogenic erectile dysfunction, high-flow priapism, and benign prostatic hyperplasia [18, 22,23,24].
The internal iliac artery arises from the common iliac artery bifurcation and descends in the pelvis to the level of the greater sciatic foramen, where it branches into the anterior and posterior trunks. The anterior division supplies the pelvic organs, while the posterior division supplies the musculature and osseous structures of the pelvis. There is significant variation in the branch pattern of these tributary arteries. A commonly used classification system created by Yamaki et al. [25] describes four distinct groups based on the branching pattern of the superior gluteal, inferior gluteal and internal pudendal arteries (Fig. 10). In the most frequent pattern of internal iliac artery branching seen in up to 80% of individuals, the common trunk of the inferior gluteal and internal pudendal arteries form the anterior division, while the superior gluteal artery forms the posterior division (Fig. 11). While it is also a major branch of the internal iliac artery, the obturator artery is not included in the Yamaki classification due to the high variability of its origin [25].
Yamaki classification of the internal iliac artery. a The superior gluteal artery (SG) forms the posterior division. The inferior gluteal artery (IG) and internal pudendal artery (IP) arise from a common trunk, forming the anterior division. b The superior and inferior gluteal arteries arise from a common trunk (posterior division). The internal pudendal artery arises independently from the internal iliac artery (anterior division). c The superior gluteal, inferior gluteal and internal pudendal arteries all arise independently from the internal iliac artery. d the superior gluteal and internal pudendal arteries arise from a common trunk (anterior division). The inferior gluteal artery arises independently (posterior division)
47-year-old male with erectile dysfunction. Oblique maximal intensity projection (MIP) images of a CT angiogram of the pelvis demonstrates the most common internal iliac artery (thick white arrow) branching pattern. The superior gluteal artery (thick black arrow) forms the posterior division and the common inferior gluteal–pudendal trunk (white arrowheads) forms the anterior division. The internal pudendal artery (thin white arrow) is one of the terminal branches of the anterior division of the internal iliac artery. The prostatic artery (black arrowhead) arises from the common gluteal–pudendal trunk
There are many branching variations of the anterior division vessels, which include the inferior gluteal, internal pudendal, superior vesical, inferior vesical, obturator and middle rectal arteries [3]. The superior vesical artery is the first branch arising from the anterior division and supplies the distal ureter, body and fundus of the bladder, proximal vas deferens and seminal vesicles. The inferior vesical artery supplies the bladder base, vas deferens and seminal vesicles and often arises from a common branch with the middle rectal artery. The internal pudendal artery is one of the terminal branches of the anterior division and gives off the perineal artery, inferior rectal artery and scrotal artery in the perineum, which supply the perineal muscle, anus and scrotum, respectively [26]. The internal pudendal artery is referred to as the penile artery within the perineum. These vessels are often too diminutive to identify on CT or MRI.
The penis is supplied by the penile artery, which consists of the bulbourethral artery, dorsal penile artery and cavernous, or deep artery. The bulbourethral artery supplies the penile bulb, glans penis, urethra and corpus spongiosum. The dorsal penile artery courses along the dorsal aspect of the corpora cavernosa and supplies the glans penis and prepuce, giving off branches to the corpus spongiosum and urethra. There are often paired cavernous arteries, one in the center of each corpus cavernosum, each giving off branches into the sinusoidal spaces. Focal lesions within the penile artery branches may result in arteriogenic erectile dysfunction [3, 27, 28].
The testis and epididymis receive arterial blood supply from three different sources. The testicular artery arises from the abdominal aorta at L2–L3 and supplies approximately two-thirds of total blood supply. The cremasteric artery arises from the inferior epigastric artery and anastomoses with the testicular artery at the lower pole of the testis. The deferential artery of the Vas can arise from the superior or inferior vesical artery. This artery supplies the vas deferens before anastomosing with the testicular artery close to the mediastinum testis [29].
The prostate artery most commonly arises from the internal pudendal artery or the common gluteal–pudendal trunk [30]. In patients with benign prostatic hyperplasia, the prostate artery branches may be enlarged, which allows for improved visibility and identification prior for patients who undergo prostate arterial embolization [31].
Pelvic musculature
The pelvic muscles function to support the abdominopelvic viscera and maintain urinary and fecal continence. The obturator internus and piriformis form a portion of the pelvic wall and function primarily as muscles of the leg (Fig. 12). The levator ani forms a large portion of the pelvic floor, dividing into the pubococcygeus, iliococcygeus, and puborectalis (Fig. 13), which each have separate attachments to the pelvic viscera; fibers from the pubococcygeus coursing inferolateral to the prostate and attaching to the perineal body are referred to as the puboprostaticus [3].
Normal musculature of the male pelvis. a, b Axial T2-weighted images of the pelvis at the level of the bladder (b) and prostate (p) shows the typical appearance of several muscles that form a portion of the male pelvic wall, including the obturator internus (oi) and piriformis. Obturator externus (oe) and pectineus (pec) muscles are also seen; these muscles are external to the pelvis. c, d Coronal T2-weighted images of the pelvic floor musculature; the corpora cavernosa (cc) and corpus spongiosum of the penis are also visualized
Axial T2-weighted images of the pelvis showing a normal appearance of the levator ani (la), which forms a large portion of the pelvic floor. The levator ani is composed of the pubococcygeus (pc), puborectalis (pr), and iliococcygeus (ic). These individual muscles can be difficult to delineate, but have separate attachments to the pelvic viscera
Medial fibers from the pubococcygeus course directly lateral to the urethra and the urethral sphincter while passing through the pelvic floor, assisting in urinary continence. The external urethral sphincter is striated and is able to sustain contractions for long periods. Urinary continence due to diminished sphincter dysfunction can be treated with a number of different surgical and interventional techniques [32].
The pelvic muscles are surrounded by fascia that is continuous with the perineal fascia inferiorly. The perineum is divided into an anterior urogenital triangle and posterior anal triangle by the interischial line, an arbitrary line connecting the ischial tuberosities. The urogenital triangle is divided by the perineal membrane into superficial and deep perineal spaces. In males, the superficial perineal space encompasses the scrotum and root of the penis. The ischiocavernosus muscles attach to the medial ischial tuberosity and covers the undersurface of the crus penis, converging in the dorsal penis to form the corpora cavernosa. The bulbospongiosus is found in the midline in males, consisting of two symmetric parts united by a median raphe. Bulbospongiosus fibers attach to the fibromuscular perineal body and then fan out into other structures; anterior fibers spread out over the corpora cavernosa and middle fibers surround the corpus spongiosum [33] (Fig. 14).
Normal MRI images of the pelvic musculature. a Axial T2-weighted images of the pelvis at the base of the penis (*) show normal appearance of the ischiocavernosus (isc) and bulbospongiosus (bul) muscles. b More inferior in the pelvis, the midline positioning of the bulbospongiosus is more apparent. c Coronal T2-weighted images at the base of the penis show the ischiocavernosus muscles converging to form the corpora cavernosa (cc) and the bulbospongiosus surrounding the corpus spongiosum (cs)
Conclusion
The visceral organs of the male pelvis have complex anatomic relationships with the surrounding extraperitoneal spaces, supplying arteries and adjacent pelvic musculature. Awareness of this intricate anatomy assists radiologists in the characterization of the various pathological processes that may originate in the pelvis, and improves recognition of the complex routes in which these conditions can spread.
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Luk, L., Taffel, M.T. Cross-sectional anatomy of the male pelvis. Abdom Radiol 45, 1951–1960 (2020). https://doi.org/10.1007/s00261-019-02369-6
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DOI: https://doi.org/10.1007/s00261-019-02369-6