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1F. The Muscles and Fasciæ of the Perineum
FIG. 405 - The perineum. The integument and superficial layer of superficial fascia reflected. The perineum corresponds to the outlet of the pelvis. Its deep boundaries are—in front, the pubic arch and the arcuate ligament of the pubis; behind, the tip of the coccyx; and on either side the inferior rami of the pubis and ischium, and the sacrotuberous ligament. The space is somewhat lozenge-shaped and is limited on the surface of the body by the scrotum in front, by the buttocks behind, and laterally by the medial side of the thigh. A line drawn transversely across in front of the ischial tuberosities divides the space into two portions. The posterior contains the termination of the anal canal and is known as the anal region; the anterior, which contains the external urogenital organs, is termed the urogenital region. The muscles of the perineum may therefore be divided into two groups: 1. Those of the anal region. 2. Those of the urogenital region: A, In the male; B, In the female. 1. The Muscles of the Anal Region Corrugator cutis ani. Sphincter ani externus. Sphincter ani internus. The Superficial Fascia.—The superficial fascia is very thick, areolar in texture, and contains much fat in its meshes. On either side a pad of fatty tissue extends deeply between the Levator ani and Obturator internus into a space known as the ischiorectal fossa. The Deep Fascia.—The deep fascia forms the lining of the ischiorectal fossa; it comprises the anal fascia, and the portion of obturator fascia below the origin of Levator ani. Ischiorectal Fossa (fossa ischiorectalis) (Fig. 405).—The fossa is somewhat prismatic in shape, with its base directed to the surface of the perineum, and its apex at the line of meeting of the obturator and anal fasciæ. It is bounded medially by the Sphincter ani externus and the anal fascia; laterally, by the tuberosity of the ischium and the obturator fascia; anteriorly, by the fascia of Colles covering the Transversus perinæi superficialis, and by the inferior fascia of the urogenital diaphragm; posteriorly, by the Glutæus maximus and the sacrotuberous ligament. Crossing the space transversely are the inferior hemorrhoidal vessels and nerves; at the back part are the perineal and perforating cutaneous branches of the pudendal plexus; while from the forepart the posterior scrotal (or labial) vessels and nerves emerge. The internal pudendal vessels and pudendal nerve lie in Alcock’s canal on the lateral wall. The fossa is filled with fatty tissue across which numerous fibrous bands extend from side to side. The Corrugator Cutis Ani.—Around the anus is a thin stratum of involuntary muscular fiber, which radiates from the orifice. Medially the fibers fade off into the submucous tissue, while laterally they blend with the true skin. By its contraction it raises the skin into ridges around the margin of the anus. The Sphincter ani externus (External sphincter ani) (Fig 405) is a flat plane of muscular fibers, elliptical in shape and intimately adherent to the integument surrounding the margin of the anus. It measures about 8 to 10 cm. in length, from its anterior to its posterior extremity, and is about 2.5 cm. broad opposite the anus. It consists of two strata, superficial and deep. The superficial, constituting the main portion of the muscle, arises from a narrow tendinous band, the anococcygeal raphé, which stretches from the tip of the coccyx to the posterior margin of the anus; it forms two flattened planes of muscular tissue, which encircle the anus and meet in front to be inserted into the central tendinous point of the perineum, joining with the Transversus perinæi superficialis, the Levator ani, and the Bulbocavernosus. The deeper portion forms a complete sphincter to the anal canal. Its fibers surround the canal, closely applied to the Sphincter ani internus, and in front blend with the other muscles at the central point of the perineum. In a considerable proportion of cases the fibers decussate in front of the anus, and are continuous with the Transversi perinæi superficiales. Posteriorly, they are not attached to the coccyx, but are continuous with those of the opposite side behind the anal canal. The upper edge of the muscle is ill-defined, since fibers are given off from it to join the Levator ani. Nerve Supply.—A branch from the fourth sacral and twigs from the inferior hemorrhoidal branch of the pudendal supply the muscle. Actions.—The action of this muscle is peculiar. (1) It is, like other muscles, always in a state of tonic contraction, and having no antagonistic muscle it keeps the anal canal and orifice closed. (2) It can be put into a condition of greater contraction under the influence of the will, so as more firmly to occlude the anal aperture, in expiratory efforts unconnected with defecation. (3) Taking its fixed point at the coccyx, it helps to fix the central point of the perineum, so that the Bulbocavernosus may act from this fixed point. The Sphincter ani internus (Internal sphincter ani) is a muscular ring which surrounds about 2.5 cm. of the anal canal; its inferior border is in contact with, but quite separate from, the Sphincter ani externus. It is about 5 mm. thick, and is formed by an aggregation of the involuntary circular fibers of the intestine. Its lower border is about 6 mm. from the orifice of the anus. Actions.—Its action is entirely involuntary. It helps the Sphincter ani externus to occlude the anal aperture and aids in the expulsion of the feces. 2. A. The Muscles of the Urogenital Region in the Male (Fig. 406). Transversus perinæi superficialis. Ischiocavernosus. Bulbocavernosus. Transversus perinæi profundus. Sphincter urethræ membranaceæ. Superficial Fascia.—The superficial fascia of this region consists of two layers, superficial and deep. The superficial layer is thick, loose, areolar in texture, and contains in its meshes much adipose tissue, the amount of which varies in different subjects. In front, it is continuous with the dartos tunic of the scrotum; behind, with the subcutaneous areolar tissue surrounding the anus; and, on either side, with the same fascia on the inner sides of the thighs. In the middle line, it is adherent to the skin on the raphé and to the deep layer of the superficial fascia. The deep layer of superficial fascia (fascia of Colles) (Fig. 405) is thin, aponeurotic in structure, and of considerable strength, serving to bind down the muscles of the root of the penis. It is continuous, in front, with the dartos tunic, the deep fascia of the penis, the fascia of the spermatic cord, and Scarpa’s fascia upon the anterior wall of the abdomen; on either side it is firmly attached to the margins of the rami of the pubis and ischium, lateral to the crus penis and as far back as the tuberosity of the ischium; posteriorly, it curves around the Transversi perinæi superficiales to join the lower margin of the inferior fascia of the urogenital diaphragm. In the middle line, it is connected with the superficial fascia and with the median septum of the Bulbocavernosus. This fascia not only covers the muscles in this region, but at its back part sends upward a vertical septum from its deep surface, which separates the posterior portion of the subjacent space into two. The Central Tendinous Point of the Perineum.—This is a fibrous point in the middle line of the perineum, between the urethra and anus, and about 1.25 cm. in front of the latter. At this point six muscles converge and are attached: viz., the Sphincter ani externus, the Bulbocavernosus, the two Transversi perinæi superficiales, and the anterior fibers of the Levatores ani. 
FIG. 406 - Muscles of male perineum. The Transversus perinæi superficialis (Transversus perinæi; Superficial transverse perineal muscle) is a narrow muscular slip, which passes more or less transversely across the perineal space in front of the anus. It arises by tendinous fibers from the inner and forepart of the tuberosity of the ischium, and, running medialward, is inserted into the central tendinous point of the perineum, joining in this situation with the muscle of the opposite side, with the Sphincter ani externus behind, and with the Bulbocavernosus in front. In some cases, the fibers of the deeper layer of the Sphincter ani externus decussate in front of the anus and are continued into this muscle. Occasionally it gives off fibers, which join with the Bulbocavernosus of the same side. Variations are numerous. It may be absent or double, or insert into Bulbocavernosus or External sphincter. Actions.—The simultaneous contraction of the two muscles serves to fix the central tendinous point of the perineum. The Bulbocavernosus (Ejaculator urinæ; Accelerator urinæ) is placed in the middle line of the perineum, in front of the anus. It consists of two symmetrical parts, united along the median line by a tendinous raphé. It arises from the central tendinous point of the perineum and from the median raphé in front. Its fibers diverge like the barbs of a quill-pen; the most posterior form a thin layer, which is lost on the inferior fascia of the urogenital diaphragm; the middle fibers encircle the bulb and adjacent parts, of the corpus cavernosum urethræ, and join with the fibers of the opposite side, on the upper part of the corpus cavernosum urethræ, in a strong aponeurosis; the anterior fibers, spread out over the side of the corpus cavernosum penis, to be inserted partly into that body, anterior to the Ischiocavernosus, occasionally extending to the pubis, and partly ending in a tendinous expansion which covers the dorsal vessels of the penis. The latter fibers are best seen by dividing the muscle longitudinally, and reflecting it from the surface of the corpus cavernosum urethræ. Actions.—This muscle serves to empty the canal of the urethra, after the bladder has expelled its contents; during the greater part of the act of micturition its fibers are relaxed, and it only comes into action at the end of the process. The middle fibers are supposed by Krause to assist in the erection of the corpus cavernosum urethræ, by compressing the erectile tissue of the bulb. The anterior fibers, according to Tyrrel, also contribute to the erection of the penis by compressing the deep dorsal vein of the penis as they are inserted into, and continuous with, the fascia of the penis. The Ischiocavernosus (Erector penis) covers the crus penis. It is an elongated muscle, broader in the middle than at either end, and situated on the lateral boundary of the perineum. It arises by tendinous and fleshy fibers from the inner surface of the tuberosity of the ischium, behind the crus penis; and from the rami of the pubis and ischium on either side of the crus. From these points fleshy fibers succeed, and end in an aponeurosis which is inserted into the sides and under surface of the crus penis. Action.—The Ischiocavernosus compresses the crus penis, and retards the return of the blood through the veins, and thus serves to maintain the organ erect. Between the muscles just examined a triangular space exists, bounded medially by the Bulbocavernosus, laterally by the Ischiocavernosus, and behind by the Transversus perinæi superficialis; the floor is formed by the inferior fascia of the urogenital diaphragm. Running from behind forward in the space are the posterior scrotal vessels and nerves, and the perineal branch of the posterior femoral cutaneous nerve; the transverse perineal artery courses along its posterior boundary on the Transversus perinæi superficialis. The Deep Fascia.—The deep fascia of the urogenital region forms an investment for the Transversus perinæi profundus and the Sphincter urethræ membranaceæ, but within it lie also the deep vessels and nerves of this part, the whole forming a transverse septum which is known as the urogenital diaphragm. From its shape it is usually termed the triangular ligament, and is stretched almost horizontally across the pubic arch, so as to close in the front part of the outlet of the pelvis. It consists of two dense membranous laminæ (Fig. 407), which are united along their posterior borders, but are separated in front by intervening structures. The superficial of these two layers, the inferior fascia of the urogenital diaphragm, is triangular in shape, and about 4 cm. in depth. Its apex is directed forward, and is separated from the arcuate pubic ligament by an oval opening for the transmission of the deep dorsal vein of the penis. Its lateral margins are attached on either side to the inferior rami of the pubis and ischium, above the crus penis. Its base is directed toward the rectum, and connected to the central tendinous point of the perineum. It is continuous with the deep layer of the superficial fascia behind the Transversus perinæi superficialis, and with the inferior layer of the diaphragmatic part of the pelvic fascia. It is perforated, about 2.5 cm. below the symphysis pubis, by the urethra, the aperture for which is circular and about 6 mm. in diameter by the arteries to the bulb and the ducts of the bulbourethral glands close to the urethral orifice; by the deep arteries of the penis, one on either side close to the pubic arch and about halfway along the attached margin of the fascia; by the dorsal arteries and nerves of the penis near the apex of the fascia. Its base is also perforated by the perineal vessels and nerves, while between its apex and the arcuate pubic ligament the deep dorsal vein of the penis passes upward into the pelvis. If the inferior fascia of the urogenital diaphragm be detached on either side, the following structures will be seen between it and the superior fascia: the deep dorsal vein of the penis; the membranous portion of the urethra; the Transversus perinæi profundus and Sphincter urethræ membranaceæ muscles; the bulbourethral glands and their ducts; the pudendal vessels and dorsal nerves of the penis; the arteries and nerves of the urethral bulb, and a plexus of veins. 
FIG. 407 - Coronal section of anterior part of pelvis, through the pubic arch. Seen from in front. (Diagrammatic.) The superior fascia of the urogenital diaphragm is continuous with the obturator fascia and stretches across the pubic arch. If the obturator fascia be traced medially after leaving the Obturator internus muscle, it will be found attached by some of its deeper or anterior fibers to the inner margin of the pubic arch, while its superficial or posterior fibers pass over this attachment to become continuous with the superior fascia of the urogenital diaphragm. Behind, this layer of the fascia is continuous with the inferior fascia and with the fascia of Colles; in front it is continuous with the fascial sheath of the prostate, and is fused with the inferior fascia to form the transverse ligament of the pelvis. The Transversus perinæi profundus arises from the inferior rami of the ischium and runs to the median line, where it interlaces in a tendinous raphé with its fellow of the opposite side. It lies in the same plane as the Sphincter urethræ membranaceæ; formerly the two muscles were described together as the Constrictor urethræ. The Sphincter urethræ membranaceæ surrounds the whole length of the membranous portion of the urethra, and is enclosed in the fasciæ of the urogenital diaphragm. Its external fibers arise from the junction of the inferior rami of the pubis and ischium to the extent of 1.25 to 2 cm., and from the neighboring fasciæ. They arch across the front of the urethra and bulbourethral glands, pass around the urethra, and behind it unite with the muscle of the opposite side, by means of a tendinous raphé. Its innermost fibers form a continuous circular investment for the membranous urethra. Nerve Supply.—The perineal branch of the pudendal nerve supplies this group of muscles. Actions.—The muscles of both sides act together as a sphincter, compressing the membranous portion of the urethra. During the transmission of fluids they, like the Bulbocavernosus, are relaxed, and only come into action at the end of the process to eject the last drops of the fluid. 2. B. The Muscles of the Urogenital Region in the Female (Fig. 408). Transversus perinæi superficialis. Ischiocavernosus. Bulbocavernosus. Transversus perinæi profundus. Sphincter urethræ membranaceæ. The Transversus perinæi superficialis (Transversus perinæi; Superficial transverse perineal muscle) in the female is a narrow muscular slip, which arises by a small tendon from the inner and forepart of the tuberosity of the ischium, and is inserted into the central tendinous point of the perineum, joining in this situation with the muscle of the opposite side, the Sphincter ani externus behind, and the Bulbocavernosus in front. Action.—The simultaneous contraction of the two muscles serves to fix the central tendinous point of the perineum. The Bulbocavernosus (Sphincter vaginæ) surrounds the orifice of the vagina. It covers the lateral parts of the vestibular bulbs, and is attached posteriorly to the central tendinous point of the perineum, where it blends with the Sphincter ani externus. Its fibers pass forward on either side of the vagina to be inserted into the corpora cavernosa clitoridis, a fasciculus crossing over the body of the organ so as to compress the deep dorsal vein. Actions.—The Bulbocavernosus diminishes the orifice of the vagina. The anterior fibers contribute to the erection of the clitoris, as they are inserted into and are continuous with the fascia of the clitoris, compressing the deep dorsal vein during the contraction of the muscle. The Ischiocavernosus (Erector clitoridis) is smaller than the corresponding muscle in the male. It covers the unattached surface of the crus clitoridis. It is an elongated muscle, broader at the middle than at either end, and situated on the side of the lateral boundary of the perineum. It arises by tendinous and fleshy fibers from the inner surface of the tuberosity of the ischium, behind the crus clitoridis; from the surface of the crus; and from the adjacent portion of the ramus of the ischium. From these points fleshy fibers succeed, and end in an aponeurosis, which is inserted into the sides and under surface of the crus clitoridis. Actions.—The Ischiocavernosus compresses the crus clitoridis and retards the return of blood through the veins, and thus serves to maintain the organ erect. The fascia of the urogenital diaphragm in the female is not so strong as in the male. It is attached to the public arch, its apex being connected with the arcuate pubic ligament. It is divided in the middle line by the aperture of the vagina, with the external coat of which it becomes blended, and in front of this is perforated by the urethra. Its posterior border is continuous, as in the male, with the deep layer of the superficial fascia around the Transversus perinæi superficialis. Like the corresponding fascia in the male, it consists of two layers, between which are to be found the following structures: the deep dorsal vein of the clitoris, a portion of the urethra and the Constrictor urethra muscle, the larger vestibular glands and their ducts; the internal pudendal vessels and the dorsal nerves of the clitoris; the arteries and nerves of the bulbi vestibuli, and a plexus of veins. The Transversus perinæi profundus arises from the inferior rami of the ischium and runs across to the side of the vagina. The Sphincter urethræ membranaceæ (Constrictor urethræ), like the corresponding muscle on the male, consists of external and internal fibers. The external fibers arise on either side from the margin of the inferior ramus of the pubis. They are directed across the pubic arch in front of the urethra, and pass around it to blend with the muscular fibers of the opposite side, between the urethra and vagina. The innermost fibers encircle the lower end of the urethra. 
FIG. 408 - Muscles of the female perineum. (Modified from a drawing by Peter Thompson.) Nerve Supply.—The muscles of this group are supplied by the perineal branch of the pudendal.
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