Pelvic Vasculature
Arterial Supply
e aorta provides the blood supply to the pelvic structures. The
aorta bifurcates at approximately the level of L4 to L5 into the
right and le common iliac arteries. e common iliac arteries
Pelvic Vasculature
Arterial Supply
e aorta provides the blood supply to the pelvic structures. The
aorta bifurcates at approximately the level of L4 to L5 into the
right and le common iliac arteries. e common iliac arteries
Pelvic Vasculature
Arterial Supply
The aorta provides the blood supply to the pelvic structures. e
aorta bifurcates at approximately the level of L4 to L5 into the divide into the external iliac and internal iliac arteries; the inter-
nal iliac artery is also referred to as the hypogastric artery and
provides most vascularization to the pelvic viscera and
pelvic sidewall, and the gluteal muscles. e le common iliac
vein travels anterior to the sacrum and medial to the aortic
bifurcation and joins the right common iliac vein to form the
vena cava under the right common iliac artery. e external
iliac artery is located medial to the psoas muscle; it continues
its course caudally to ultimately give o the femoral artery anThe
crossing underneath the inguinal ligament. In the pelvis, the
external iliac artery has few branches; these include the infe-
rior epigastric artery and a variable superior vesical artery. The
external iliac vein is much larger and lies posterior and medial
to the artery. e external iliac vein also passes below the ingui-
nal ligament before reaching the thigh.
The inferior epigastric vessels supply the rectus abdominis
muscles. e inferior epigastric artery originates from the exter-
nal iliac artery and travels through the transversalis fascia into a
space between the rectus muscle and posterior sheath. In their
course from the external iliac vessels’ lateral position, the
inferior epigastric artery and vein run obliquely toward a more
medial location as they approach the umbilicus. e super-
cial epigastric vessels originate from the femoral artery, perfuse
the anterior abdominal wall, and branch extensively as they
approach the umbilicus.
The hypogastric artery branches into anterior and posterior
divisions. The posterior division runs toward the large sciatic
notch, dividing into the lateral sacral, iliolumbar, and superior
gluteal arteries. The internal iliac artery
branches’ anterior division into the obliterated umbilical, uterine, superior vesical,
obturator, vaginal, and inferior gluteal and internal pudendal
arteries. e internal iliac vein lies medial to the internal iliac
artery; the other veins travel with their corresponding arteries
(Figs. 2.24–2.26).
To reach the perineum, the internal pudendal artery
courses through the greater sciatic foramen, around the
sacrospinous ligament, and back in through the lesser sci-
aortic foramen. In this way, the pudendal artery ends up below
the pelvic diaphragm. Its branches supply the anal sphincter,
the pelvic diaphragm, and the female’s external genital structures
.
The internal iliac artery is a retroperitoneal struc-
ture; for any of its branches to be identified and accessed,
a retroperitoneal dissection must be performed. The ure-
ter should be identified before ligation of any lateral pelvic
vessel. Most of the blood supply to the uterus, tubes, and
ovaries derives from the uterine and ovarian arteries. The
uterine arteries originate from the anterior division of the
internal iliac arteries in the retroperitoneum. They usually
share a common origin with the obliterated umbilical artery
or superior vesical artery. The obliterated umbilical arteries,
also known as superior vesical arteries and as lateral umbilical-
cal ligaments are a useful landmark for the identification of
the uterine artery. Simply pulling up the obliterated umbilical-
cal artery permits easy identification of the uterine artery.
The uterine artery travels through the cardinal ligament over
the ureter and approximately 1.5 cm lateral to the cervix. It
then joins the uterus near the internal cervical os level,
branching upward and downward toward the uterine corpus
and inferiorly toward the cervix. The uterine corpus branches
anastomose with vessels that derive from the ovarian artery-
ies, thus providing collateral blood flow. The uterine artery
also sends a branch to the cervicovaginal confluence at the
lateral aspect of the vagina. The vagina also receives its blood
supply from this uterine branch, as well as from a vaginal
branch of the internal iliac artery, which anastomoses along
the lateral wall of the vagina. The ovarian arteries arise from
the abdominal aorta. The right ovarian vein drains to the
inferior vena cava (IVC), whereas the left ovarian vein drains
to the left renal vein. The ovarian vessels travel through the
infundibulopelvic ligaments in proximity to the ureter, along
the medial aspect of the psoas muscle.
The ureter is supplied by small branches of the blood
vessels it crosses: the common iliac, internal iliac, and supe-
rior and inferior vesical arteries. Above the pelvic brim the
blood supply enters from the medial side; below the pelvic
brim the blood supply to the ureter enters laterally. The
blood supply to the bladder includes the superior and infe-
rior vesical arteries, which are branches of the anterior trunk
of the internal iliac artery. The blood supply to the rectum
and anus consists of an anastomotic arcade of vessels from
the superior rectal branch of the IMA and the middle and
inferior rectal branches of the internal pudendal artery (seea retroperitoneal dissection must be performed. The ure-
ter should be identified before ligation of any lateral pelvic
vessel. Most of the blood supply to the uterus, tubes, and
ovaries derives from the uterine and ovarian arteries. The
uterine arteries originate from the anterior division of the
internal iliac arteries in the retroperitoneum. They usually
share a common origin with the obliterated umbilical artery
or superior vesical artery. The obliterated umbilical arteries,
also known as superior vesical arteries and as lateral umbili-
cal ligaments, are a useful landmark for the identification of
the uterine artery. Simply pulling up the obliterated umbili-
cal artery permits easy identification of the uterine artery.
The uterine artery travels through the cardinal ligament over
the ureter and approximately 1.5 cm lateral to the cervix. It
then joins the uterus near the level of the internal cervical os,
branching upward and downward toward the uterine corpus
and inferiorly toward the cervix. The uterine corpus branches
anastomose with vessels that derive from the ovarian arter-
ies, thus providing collateral blood flow. The uterine artery
also sends a branch to the cervicovaginal confluence at the
lateral aspect of the vagina. The vagina also receives its blood
supply from this uterine branch, as well as from a vaginal
branch of the internal iliac artery, which anastomoses along
the lateral wall of the vagina. The ovarian arteries arise from
the abdominal aorta. The right ovarian vein drains to the
inferior vena cava (IVC), whereas the left ovarian vein drains
to the left renal vein. The ovarian vessels travel through the
infundibulopelvic ligaments in proximity to the ureter, along
the medial aspect of the psoas muscle.
The ureter is supplied by small branches of the blood
vessels it crosses: the common iliac, internal iliac, and supe-
rior and inferior vesical arteries. Above the pelvic brim the
blood supply enters from the medial side; below the pelvic
brim the blood supply to the ureter enters laterally. The
blood supply to the bladder includes the superior and infe-
rior vesical arteries, which are branches of the anterior trunk
of the internal iliac artery. The blood supply to the rectum
and anus consists of an anastomotic arcade of vessels from
the superior rectal branch of the IMA and the middle and
inferior rectal branches of the internal pudendal artery
Venous Drainage
e IVC receives the venous ow from the right and common
iliac veins and is located to the right of the aortic bifurca-
tion. Similar to the arterial correspondents, the external iliac
vein primarily drains the lower limbs, whereas the internal
iliac vein drains the pelvic viscera, walls, gluteal region, and
perineum. In most instances the major veins are mirror images
of their arterial counterparts. However, the smaller vessels can
vary from one individual to another. e inferior epigastric,
deep circumex iliac, and pubic veins are all pelvic tributaries
of the external iliac vein. e external iliac vein is the upper
continuation of the femoral vein. e nomenclature of the ves-
sel changes at the mid-inguinal point, posterior to the inguinal
ligament. e deep circumex iliac vein crosses the anterior
surface of the external iliac artery before entering the external
iliac vein. Inferior to the entry point of the deep circumex
iliac vein, the inferior epigastric vein enters the external iliac
vein cephalad to the inguinal ligament. e pubic vein forms a
bridge between the obturator vein and the external iliac vein.
On the le side, the external iliac vein is always medial to its
corresponding artery. However, on the right side, it starts oun a medial position and gradually becomes posterior, as it gets
closer to the point of fusion.
e internal iliac vein receives the middle rectal, obtu-
rator, lateral sacral, inferior gluteal, and superior gluteal
veins as tributaries. e obturator vein enters the pelvis by
way of the obturator foramen, where it takes a posterosupe-
rior route along the lateral pelvic wall, deep to its artery. In
some instances the vessel is replaced by an enlarged pubic
vein, which then joins the external iliac vein. e superior
and inferior gluteal veins are accompanying veins of their
corresponding arteries. e tributaries of the superior glu-
teal veins are named aer the branches of the corresponding
artery. ey pass above piriformis and enter the pelvis via the
greater sciatic foramen before joining the internal iliac vein as
a single branch. e inferior gluteal veins form anastomoses
with the rst perforating vein and medial circumex femoral
vein before entering the pelvis via the greater sciatic foramen.
e middle rectal vein is a product of the rectal venous plexus
that drains the mesorectum and the rectum. It also receives
tributaries from the bladder, as well as gender-specic tribu-
taries from the prostate and seminal vesicle or the posterior
wall of the vagina. It terminates in the internal iliac vein aer
travelling along the pelvic part of levator ani. Finally, the lat-
eral sacral veins travel with their arteries before entering the
internal iliac vein.
e internal and external iliac veins unite at the sacroiliac
joint, on the right side of the h lumbar vertebra, to form the
common iliac vein. e right common iliac vein is almost ver-
tical and shorter than the le common iliac vein, which takes
a more oblique course. e right obturator nerve crosses the
right common iliac vein posteriorly; the sigmoid mesocolon
and superior rectal vessels cross the le common iliac vein ante-
riorly. e internal pudendal vein drains to the internal iliac
vein, whereas the median sacral veins drain into the common
iliac vessels directly. e median sacral veins unite into a single
vessel before entering the le common iliac vein. e internal
pudendal veins receive inferior rectal veins and either clitoral
and labial or penile bulb and scrotal veins before joining theCommon iliac fosan a medial position and gradually becomes posterior, as it gets
closer to the point of fusion.
e internal iliac vein receives the middle rectal, obtu-
rator, lateral sacral, inferior gluteal, and superior gluteal
veins as tributaries. e obturator vein enters the pelvis by
way of the obturator foramen, where it takes a posterosupe-
rior route along the lateral pelvic wall, deep to its artery. In
some instances the vessel is replaced by an enlarged pubic
vein, which then joins the external iliac vein. e superior
and inferior gluteal veins are accompanying veins of their
corresponding arteries. e tributaries of the superior glu-
teal veins are named aer the branches of the corresponding
artery. ey pass above piriformis and enter the pelvis via the
greater sciatic foramen before joining the internal iliac vein as
a single branch. e inferior gluteal veins form anastomoses
with the rst perforating vein and medial circumex femoral
vein before entering the pelvis via the greater sciatic foramen.
e middle rectal vein is a product of the rectal venous plexus
that drains the mesorectum and the rectum. It also receives
tributaries from the bladder, as well as gender-specic tribu-
taries from the prostate and seminal vesicle or the posterior
wall of the vagina. It terminates in the internal iliac vein aer
travelling along the pelvic part of levator ani. Finally, the lat-
eral sacral veins travel with their arteries before entering the
internal iliac vein.
e internal and external iliac veins unite at the sacroiliac
joint, on the right side of the h lumbar vertebra, to form the
common iliac vein. e right common iliac vein is almost ver-
tical and shorter than the le common iliac vein, which takes
a more oblique course. e right obturator nerve crosses the
right common iliac vein posteriorly; the sigmoid mesocolon
and superior rectal vessels cross the le common iliac vein ante-
riorly. e internal pudendal vein drains to the internal iliac
vein, whereas the median sacral veins drain into the common
iliac vessels directly. e median sacral veins unite into a single
vessel before entering the le common iliac vein. e internal
pudendal veins receive inferior rectal veins and either clitoral
and labial or penile bulb and scrotal veins before joining the
right and le common iliac arteries. e common iliac arteriesivide into the external iliac and internal iliac arteries; the inter-
nal iliac artery is also referred to as the hypogastric artery and
provides most of the vascularization to the pelvic viscera and
pelvic side wall and the gluteal muscles. e le common iliac
vein travels anterior to the sacrum and medial to the aortic
bifurcation and joins the right common iliac vein to form the
vena cava under the right common iliac artery. e external
iliac artery is located medial to the psoas muscle; it continues
its course caudally to ultimately give o the femoral artery aer
crossing underneath the inguinal ligament. In the pelvis, the
external iliac artery has few branches; these include the infe-
rior epigastric artery and a variable superior vesical artery. e
external iliac vein is much larger and lies posterior and medial
to the artery. e external iliac vein also passes below the ingui-
nal ligament before reaching the thigh.
e inferior epigastric vessels supply the rectus abdominis
muscles. e inferior epigastric artery originates from the exter-
nal iliac artery and travels through the transversalis fascia into a
space between the rectus muscle and posterior sheath. In their
course from the lateral position of the external iliac vessels, the
inferior epigastric artery and vein run obliquely toward a more
medial location as they approach the umbilicus. e super-
cial epigastric vessels originate from the femoral artery, perfuse
the anterior abdominal wall, and branch extensively as they
approach the umbilicus.
e hypogastric artery branches into anterior and posterior
divisions. e posterior division runs toward the large sciatic
notch, dividing into the lateral sacral, iliolumbar, and superior
gluteal arteries. e anterior division of the internal iliac artery
branches into the obliterated umbilical, uterine, superior vesical,
obturator, vaginal, and inferior gluteal and internal pudendal
arteries. e internal iliac vein lies medial to the internal iliac
artery; the other veins travel with their corresponding arteries
(Figs. 2.24–2.26).
To reach the perineum, the internal pudendal artery
courses through the greater sciatic foramen, around the
sacrospinous ligament, and back in through the lesser sci-
atic foramen. In this way the pudendal artery ends up below
the pelvic diaphragm. Its branches supply the anal sphincter,
the pelvic diaphragm, and the external genital structures in
the female.
The internal iliac artery is a retroperitoneal struc-
ture; for any of its branches to be identified and accessed,