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The relationship between the pubo-urethral ligaments and the urogenital diaphragm in the human female.

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The Relationship between the Pubo-urethral
Ligaments and the Urogenital Diaphragm
in the Human Female
Department of Anatomy and Department of Gynecology and Obstetrics,
State University of New York at Buffalo, Buffalo, N e w York 14214
The connective tissue supports of the human female urethra
have been investigated in 14 cadavers and 20 fetuses. In all cases the urethra was
found to be suspended from the pubic bone by bilaterally symmetrical anterior,
posterior and intermediate pubo-urethral ligaments. The anterior and posterior
ligaments were formed by reflections of the inferior and superior fascial layers
of the urogenital diaphragm. The intermediate ligament represented a fusion of
these fascial layers and no transverse perineal ligament was found.
It is suggested that the term pubovesical ligament is a misnomer since this
band of connective tissue passes from the pubic bone to the urethra and not to
the bladder. It is thus analogous to the puboprostatic ligament of the male. An
anatomical defect in the pubo-urethral ligaments might be a contributing factor
to urinary stress incontinence in the female.
A major contribution to our knowledge
of the connective tissue supports of the
female urethra has been made by Zacharin
(’63, ’68). In his study of the “suspensory
mechanism” he described anterior, posterior and intermediate pubo-urethral
The purpose of this investigation was
three-fold. First, we wished to study the
connective tissue supports of the adult female urethra to determine the validity of
Zacharin’s observations. Secondly, the investigation was aimed at determining the
relationship of the urethral supports to
other established structures of the pelvis
and perineum. Thirdly, the studies were
extended to determine the same relationships in the fetus.
In every specimen studied the urethra
was found to be suspended under the arch
of the publis by bilaterally symmetrical
dense connective tissue bands which had a
small but very firm attachment to the
anterior or posterior surface of the pubic
bone just lateral to the pubic symphysis.
The point of attachment was approximately at the junction of the lower onefifth with the upper four-fifths of the bone.
From these points of attachment the bands
blended with the surrounding periosteum.
In a parasagittal plane both anterior and
posterior bands fanned out as they passed
from their superior bony attachment inferiorly to attach to the superior and superolateral aspects of the urethra. The
anterior and posterior bands were thus
joined together under the arch of the pubis
Gross dissection was performed on 14 in a parasaggital plane to form an interadult embalmed cadavers of females mediate ligament. This intermediate ligaranging in age from 22 to 91 years. Twenty ment, which fused with the urethra informalin-fixed female fetuses ranging in feriorly, lacked a direct superior bony
size from 10 to 33 cm crown rump length attachment. The urethra was thus found
were dissected under a Bausch and Lomb to be suspended by a connective tissue
stereozoom microscope. After dissection sling throughout its entire length.
tissue blocks were removed, dehydrated
The anterior band, or anterior puboand embedded in paraffin. Sections cut at urethral ligament, was continuous antero7 I“. were stained with acid orcein and the -Gomori one-step trichrome method.
Received Oct. 19, ’70. Accepted N O ~24,
. ’70.
ANAT. REC., 170: 281-284.
28 1
superiorly with the suspensory ligament of in sagittal sections. Anterior, intermediate
the clitoris and shared its pubic attach- and posterior pubo-urethral ligaments were
ment. Postero-laterally the posterior pubo- well defined. In the smaller specimens the
urethral ligament blended, as described relationship of the pubo-urethral ligaments
by Zacharin, with the arcus tendineus of to the urogenital diaphragm could not be
determined due to difficulty in dissecting
the levator ani.
When the arcus tendineus was cut, the very delicate fascia of the diaphragm.
however, the posterior pubo-urethral liga- The larger fetuses examined did, however,
ment retained an attachment to connective appear to have the same superior contissue inferior to the pelvic diaphragm. tinuity between the layers of the uroCareful dissection combining pelvic and genital diaphragm and the pubo-urethral
perineal approaches revealed that the pos- ligaments.
Histologic sections showed the puboterior pubo-urethral ligament was in fact
a modified reflection of the superior fascia urethral ligaments to consist of dense colof the urogenital diaphragm. Similarly lagen, both smooth and striated muscle,
the anterior pubo-urethral ligament was a and elastic fibers.
superior extension of the inferior fascia
of the urogenital diaphragm (see fig. 1 ) .
The results of this study have confirmed
The fascia of the urogenital diaphragm
was therefore found to be reflected onto the findings of Zacharin. The major support
both the anterior and posterior aspects of between the pubic bone and the bladder
the pubic bone to a level more superior and urethra in the female have classically
and medial than usually described. The been called the “pubovesical ligaments.” It
diaphragm did not appear to meet an- is now clear that this is a misnomer for
teriorly to form a transverse perineal liga- the inferior attachments of the ligaments
ment as in the male.
are to the urethra and should therefore
In our study of fetal material the sup- more properly be called the pubo-ure thral
port of the urethra appeared to be identical ligaments as suggested by Curtis, Anson
with that of the adult cadaver as viewed and McVay (’39). Krantz (’51) also de-
Fig. 1 Note continuity between superior and inferior fasciae of urogenital diaphragm ( U . G . D.)
and pubo-urethral ligaments ( P . U. L.) Vagina, V; Urethra, U.
scribed heavy fibrous bands arising from
the lateral aspect of the female urethra
and inserting on the pubic bone on each
side. He pointed out their analogy to the
puboprostatic ligaments in the male.
The term “pubovesical ligaments” is also
objectionable because i t refers only to the
posterior pubo-urethral ligament; the remaining anterior and intermediate pubourethral portions of the suspensory mechanism generally remaining undescribed.
The superior and inferior fascial layers
of the urogenital diaphragm are usually
described as meeting each other anteriorly
to close off the deep perineal space. Diagrams of the urogenital diaphragm seen in
full face from below usually show this
union as a transverse structure which has
been called the transverse perineal ligament. Based on this investigation it is felt
that this description is also oversimplified.
The lateral attachments of the urogenital
diaphragm fascial layers appear to continue more superiorly in the female than
is usually described. These superior reflections form the suspensory mechanism of
the female urethra, the inferior fascia
forming the anterior pubo-urethral ligament, and the superior fascia forming the
posterior pubo-urethral ligament. Curtis,
Anson and McVay (’39) similarly observed
a superior reflection of the superior fascia
of the urogenital diaphragm. They described how bilateral bands, formed from
this fascia, attached to the pubic bone
above and “spread out upon reaching the
urethral wall.”
The point of junction of the inferior and
superior fascial layers of the urogenital
diaphragm, rather than forming a transverse ligament, is in fact the intermediate
pubo-urethral ligament which is the bottom part of the U-shaped suspensory
mechanism of the urethra.
The presence of the same general arrangements of urethral support in fetuses
indicates that the observed relationships
in adult cadavers did not result from obstetrical or postpartum changes.
The striated muscle found consistently
in the pubo-urethral ligaments may represent a reflection of the external striated
muscle of the urethral wall and/or a continuation of the most anterior part of the
pubococcygeus muscle.
The supports of the female urethra are
of great clinical importance to the obstetrician and gynecologist. As Krantz (’51)
has pointed out, the urethra and bladder
function as a unit that may be likened
to a lever system with the urethral supports
as a fulcrum. One of the anatomical defects contributing to true urinary stress
incontinence in the female could be an
inadequacy of the pubo-urethral ligaments.
Power (’54) has also pointed out that the
integrity of the “pubovesical ligaments” is
important for maintenance of continence
and the process of micturition.
It is hoped that the reexamination of
urethral supporting structures will contribute to understanding the pathogenesis
of cystocele and urethrocele and suggest
ways of improving surgical techniques for
correcting such defects. The clinical applications of these anatomical observations
will be published elsewhere.
Curtis, A. H., B. J. Anson and C. B. McVay 1939
The anatomy of the pelvic and urogenital diaphragms, in relation to urethrocele and cystocele. Surg. Gyn. Ob., 68: 161-166.
Krantz, K. E. 1951 The anatomy of the
urethra and anterior vaginal wall. Amer. J. Ob.
and Gyn., 62: 374-386.
Power, R. M. H. 1954 A n anatomical contribution to the problem of continence and incontinence in the female. Amer. J. Ob. and Gyn.,
67: 302-314.
Zacharin, R. F. 1963 The suspensory mechanism of the female urethra. J. Anat., 97:
1968 The anatomic supports of the female urethra. Ob. Gyn., 32: 754-759.
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pubo, diaphragm, urogenital, female, ligament, urethral, human, relationships
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