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Behind the rectum some fibers bend back anteriorly to join the muscle on the other side, thereby Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA a sling. Other fibers insert into the sacrum and coccyx. Some of the most medial fibers within this group attach to the walls of the vagina and rectum. The iliococcygeus muscle arises from a series of tendon-like fibers that attach Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA the fascia of the obturator internus muscle (the arcus tendineus levator ani).

From these broad origins the fibers of the iliococcygeus insert into the anococcygeal raphe and the coccyx. The coccygeus anus doctor from the ischial spine and the sacrospinous ligament to insert into the borders of the coccyx and the lowest segment of the sacrum.

These muscles are covered on their superior and inferior surfaces by the superior and inferior fasciae of the pelvic diaphragm. These fasciae arise from the obturator internus fascia and also in certain areas from the pubic bones. They fuse at the urogenital hiatus Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA the urogenital diaphragm and vagina.

The iliococcygeus and coccygeus muscles receive Desonate (Desonide Gel)- Multum innervation from an anterior branch of the ventral rami of the third and complex sacral nerves while the pubococcygeus muscle is supplied by the pudendal nerve.

During labor, this sling pulls the presenting part anteriorly once it has passed the midplane to assist in rotation. The aorta lies on the lumbar spine slightly to the left of the vena cava, which it overlies (Fig. Both the fsh lh and Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA cava are subject to compression by the uterus in this location when a patient is supine.

At the level of the fourth lumbar vertebra (on a line between the tops of the iliac crests) the aorta bifurcates into the left and Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA common iliac arteries. After about 5 cm the common iliac arteries give off the internal lilac artery from their medial side and continue toward the inguinal ligament as the external iliac artery.

This division occurs in the area of the sacroiliac joint. Pelvic blood vessels and nerves. Reproduced, with permission from the CIBA Collection of Medical Illustrations by Frank H. The internal iliac artery supplies the viscera 9f the pelvis as well as many of the muscles of the pelvic wall and gluteal region. It usually divides into an anterior and posterior division 3 cm to 4 cm after leaving the common iliac artery.

The vessels of the posterior division (the iliolumbar, lateral sacral, and superior gluteal) leave the internal iliac artery from its lateral surface to provide some of the blood supply to the pelvic wall and gluteal muscles.

Trauma to these hidden vessels should be avoided during internal iliac artery ligation. The anterior division has both parietal and visceral branches. The Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA, internal pudendal, and inferior gluteal vessels primarily supply muscles, while the uterine, superior vesical, vaginal (inferior vesical), and middle rectal vessels supply the pelvic organs.

The internal iliac veins begin lateral and posterior to the arteries and have a much more plexiform arrangement. Although a glucophage external iliac vein lies above the pelvic brim, the internal iliac vein crosses the linea terminalis.

During obstructed labor, the internal iliac vein may be compressed for long periods of time, giving rise to the vulvar and pelvic soft tissue swelling seen in this situation. The legs, however, remain relatively uninvolved because of the external lilac vein's position above the true pelvis. Ligation of the internal iliac artery has proven to be helpful in the management of postpartum hemorrhage. Burchell's arteriographic coronary angiography have demonstrated that physiologically active anastomoses were immediately patent following ligation of the internal iliac artery and connected the following arteries of the internal iliac system with systemic blood vessels4: Internal iliac--Systemic Iliolumbar Lumbar Lateral Sacral Middle sacral Middle hemorrhoidal Superior hemorrhoidal(These were quite different than the anastomoses that had previously been hypothesized on purely anatomical grounds.

Further detailed anatomy of the internal iliac artery and its surgical exposure are covered in the first volume of this series (see Volume 1, Chapter 73, Surgical Management of Intractable Pelvic Hemorrhage). There are instances in which paralysis and numbness of the lower extremity chat following difficult vaginal delivery, which in some cases may be explained by nerve compression in the pelvis.

As Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA lumbar and sacral nerves exit from Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA intervertebral foramina, they form the lumbar and sacral plexuses (see Fig. The lumbar nerves Cysview (Hexaminolevulinate Hydrochloride Intravesical Solution)- FDA plexus lie deep within the psoas muscle on either side of the spine.



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