Normal Female Pelvic Anatomy
By Andrew L. Deutsch and Barbara B. Gosink
I NTERPRETATION of diagnostic imaging
studies of the female pelvis requires a thor-
ough understanding of the anatomy of this region
as well as an appreciation of the changes in
appearance that occur in response to the complex
endocrine events during a normal menstrual
cycle. This review will emphasize the salient
features of female pelvic anatomy and its physio-
logic alterations as seen on radiographs, ultra-
sound scans, and CT.
PELVIC MUSCULATURE
The pelvic diaphragm serves as a partition
between the peritoneum and pelvic cavity and
represents one of the principal means of support
of the pelvic viscera. The muscles comprising the
pelvic diaphragm are optimally delineated on
CT. The levator ani comprises the central mus-
cular portion of the pelvic diaphragm. It consists
of two paired components, the larger medial
pubococcygeus muscle and the smaller lateral
ileococcygeus.’ The levator ani surrounds and
encases the urethra, vagina, and rectum that pass
through a central cleft between the paired pubo-
coccygeus muscles. Posteriorly, the pelvic dia-
phragm is completed by the triangular-shaped
paired coccygeus muscle that arises from the
ischial spine and inserts into the lateral border of
the lower sacrum.
Three additional muscles are important ana-
tomic landmarks on pelvic imaging by
ultrasonography. The piriformis is a paired trian-
gular muscle that lies flattened against the poste-
rior wall of the minor pelvis and covers most of
the greater sciatic notch before passing through
it to insert on the greater trochanter of the
femur.’ Caution must be exercised not to mistake
the piriformis muscle for the normal ovary that
often lies directly anterior to it on the pelvic
sonogram (Fig. 1A).’ The obturator internus is a
fan-shaped muscle that arises from the circum-
ference of each obturator fossa and covers the
lateral pelvic wall as it extends inferiorly to exit
the pelvis through the lesser sciatic notch. At the
midlevel of each obturator internus muscle lie
the obturator vessels and obturator chain of
lymph nodes. Each psoas muscle arises from the
transverse processes of the lumbar spine and
Semmars ,n Roentgenobgy, Vol. XVII, No. 4 (October).
passes inferiorly to meet the iliacus muscle at the
level of the pelvic inlet to form the iliopsoas. The
external iliac artery and vein cross the iliopsoas
at the level of the sacroiliac joint. This muscle
and the accompanying vessels are well defined on
pelvic CT scans (Fig. 1B). On sonography, the
iliopsoas has a characteristic appearance result-
ing from the high amplitude specular reflector
representing the interface between the psoas and
iliacus (Fig. 1A). The paired rectus muscles run
longitudinally on each side of the midline of the
lower abdominal wall and are optimally defined
by either CT or ultrasonography.
BOWEL
The rectum lies in the posterior pelvic com-
partment and is commonly visualized on son-
ography as a tubular structure posterior to the
uterus. The appearance of the rectum may vary
widely, but usually contains gas, which produces
high level echoes and acoustic shadowing. When
distended with fecal material, the rectosigmoid
may simulate a solid or complex mass. Real-time
imaging is seldom helpful in characterizing the
rectosigmoid as bowel because of the limited
peristalsis in this region. Repeat scanning follow-
ing a cleansing enema may sometimes be
required to allow differentiation from a disease
process.’
A fluid-filled segment of rectosigmoid or small
bowel may insinuate itself between the uterus
and ovary, mimicking a cystic adnexal mass. The
fluid-filled small bowel loop often has a charac-
teristic fusiform shape and occasionally linear
echoes emanate from the mucosal folds.” Real-
time scanning may be very helpful in differen-
tiating a fluid-filled small bowel loop from a
From the University of California. San Diego. Calif
Andrew L. Deutsch: Ultrasound Fellow. Vererans Admin-
istration Medical Center, San Diego, Calif: Barbara R.
Gosink: Chief, Ultrasound Division. Veterans Administra-
tion Medical Cenier, and Associate Professor of’ Kadiology.
University of CaliJornia at San Diego.
Address reprint requests to Barbara B. Gosink. M.D.,
Veterans Administration Medical Center, 3350 La Jolla
Village Drive, San Diego, Calif. 92161.
0 I982 by Grune & Stratton, Inc.
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1982 241