Contemporary views on female pelvic anatomy.

he durable surgical repair of pelvic organ pro-lapse and its related disorders remains a significant challenge. The pelvic reconstructive surgeon needs an intimate knowledge of relevant surgical landmarks as well as a fundamental understanding of the biomechanics of pelvic organ support in order to successfully restore normal visceral anatomy and function. Rather than presenting a detailed description of female pelvic anatomy, this review provides a discussion of the contemporary understanding of female pelvic organ support, with emphasis on the functional and surgical anatomy of the vagina, ure-thra, and pelvic floor, as well as a discussion of obtura-tor anatomy, as several new innovative procedures now use the transobturator approach. The pelvic bones are the ilium, ischium, pubic rami, sacrum, and coccyx. The bony pelvis is the rigid foundation to which all of the pelvic structures are ultimately anchored. Although pelvic surgeons often visualize the orientation of the pelvis in the supine or lithotomy position, it is important to understand and discuss the bony pelvis from the perspective of a standing woman. In the standing woman, the pelvis is oriented such that the anterior superior iliac spine and the front edge of the pubic symphysis are in the same vertical plane, perpendicular to the floor (Figure 1). As a consequence, the pelvic inlet is tilted anteriorly and the ischiopubic rami and genital hiatus are parallel to the ground. In the upright position , the bony arches of the pelvic inlet are oriented in an almost vertical plane. This directs the pressure of the intra-abdominal and pelvic contents toward the bones of the pelvis instead of the muscles and endopelvic fascia attachments of the pelvic floor. Thus, in the standing position, the bony pelvis is oriented such that forces are dispersed to minimize the pressures on the pelvic viscera and musculature and will transmit the forces to the bones that are better suited to the long-term, cumulative stress of daily life. Where the pubic rami articulate in the midline, they are nearly horizontal. Much of the weight of the abdominal and pelvic viscera is supported by the bony articulation inferiorly. Varied shape, orientation associated with prolapse Variations in the orientation and shape of the bony pelvis have been associated with the development of pelvic organ prolapse. Specifically, a loss of lumbar lordosis and a pelvic inlet that is less vertically oriented is more common in women who develop genital prolapse than in those …