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Deep perineal pouch

The deep perineal pouch, also known as the deep perineal space, is an anatomical compartment within the urogenital triangle of the perineum, situated superior to the perineal membrane and inferior to the pelvic diaphragm, serving as a supportive structure for key urogenital organs and contributing to urinary continence.^[1]^[2] This trilaminar, triangular space is bounded superiorly by the fascia of the pelvic floor, inferiorly by the perineal membrane, laterally by the obturator fascia and ischiopubic rami, and posteriorly by the perineal body.^[1]^[3]^[4] Its contents include the external urethral sphincter, deep transverse perineal muscles, and branches of the internal pudendal artery and pudendal nerve, which are essential for sphincteric function and pelvic stability in both sexes.^[4]^[2] In males, the pouch encompasses the membranous urethra—a narrow segment approximately 1.5 cm in length—and the bulbourethral (Cowper's) glands, which secrete lubricating fluid during arousal, while in females, it contains the proximal urethra (about 4 cm long), the distal vagina, and additional muscles such as the compressor urethrae and urethrovaginalis that encircle the urethra and vagina for enhanced support.^[1]^[3]^[4] Functionally, the deep perineal pouch provides structural reinforcement to the pelvic floor, aiding in the maintenance of urinary continence through coordinated muscle action, and it facilitates the passage of neurovascular structures critical to perineal innervation and blood supply.^[2]^[1] Clinically, damage to this region, often from pelvic trauma or surgical interventions, can lead to urinary incontinence due to sphincter disruption or strictures in the membranous urethra, and in males, it may involve complications like Cowper's syringocele or infections of the bulbourethral glands.^[1]^[4]

Overview

Definition

The deep perineal pouch is an anatomic space located superior to the perineal membrane and inferior to the superior fascia of the urogenital diaphragm, forming a potential compartment within the urogenital triangle of the perineum.^[1]^[3] It is described as a triangular, trilaminar space that contributes to the supportive framework of the pelvic floor by enclosing key musculofascial elements involved in urogenital function.^[1] Historically, this region was referred to as the urogenital diaphragm, a term that encompassed the musculofascial layers providing sphincteric and structural support to the urethra and associated organs.^[1] The modern nomenclature, including the distinction of the perineal membrane as its inferior boundary, was introduced by Oelrich in 1983 to more accurately reflect the three-dimensional structure of the striated urogenital sphincter muscle and its fascial integrations within the pelvic floor layering system.^[1]^[5] This evolution in naming underscores its role as a distinct layer in the stratified anatomy of the perineum, aiding in urinary continence and pelvic organ support.^[1] The deep perineal pouch is distinguished from the superficial perineal pouch by its deeper position relative to the perineal membrane, with the former lying superior to this membrane and the latter inferior to it.^[1]^[3] This separation highlights the compartmentalized organization of the perineal spaces, each contributing uniquely to the overall pelvic floor architecture.^[1]

Location

The deep perineal pouch is situated within the urogenital triangle of the perineum, positioned inferior to the pelvic diaphragm and superior to the perineal membrane.^[2]^[3]^[1] This pouch occupies the anterior aspect of the perineum, lying anterior to the anal triangle and extending laterally from the pubic symphysis to the ischial tuberosities.^[2]^[4] The location of the deep perineal pouch exhibits minimal sexual dimorphism, remaining fundamentally similar in both males and females within the urogenital triangle, though it demonstrates slight variations in its spatial relations to the membranous urethra and, in females, the proximal vagina.^[4]^[1]

Anatomy

Boundaries

The deep perineal pouch, also known as the deep perineal space, is a distinct anatomical compartment within the urogenital triangle of the perineum, defined by specific fascial and bony boundaries that enclose its triangular structure.^[1] Its superior boundary is formed by the fascia of the pelvic floor, representing a continuation of the inferior fascia of the pelvic diaphragm, providing a direct relation to the pelvic floor above.^[1] The inferior boundary consists of the perineal membrane, which serves as the floor of this triangular space in cross-section.^[1]^[4] Anteriorly, the pouch is limited by the pubic symphysis and the arcuate pubic ligament, where the perineal membrane attaches to reinforce this forward extent.^[4] Posteriorly, it is bounded by the perineal body, the fibromuscular mass at the junction of the urogenital and anal triangles.^[1]^[4] Laterally, the boundaries are established by the ischiopubic rami and the lower portion of the obturator internus fascia, delineating the sides along the pelvic outlet.^[1]

Relations

The deep perineal pouch maintains specific spatial relationships with surrounding anatomical structures, influencing its role in supporting urogenital and pelvic functions. Superiorly, it lies immediately inferior to the pelvic diaphragm, formed primarily by the levator ani muscle and its overlying fascia, which separates the pouch from the pelvic cavity containing organs such as the bladder and rectum.^[1] This relationship positions the pouch as a transitional space between the abdominal-pelvic contents and the external perineum, with the inferior fascia of the pelvic diaphragm directly overlying it.^[2] Inferiorly, the deep perineal pouch is delimited by the perineal membrane, a fibrous sheet that separates it from the superficial perineal pouch and contributes to the perineal body's central anchorage.^[1] The perineal body, a fibromuscular mass at the pouch's posterior-inferior aspect, provides attachment points for surrounding muscles and serves as a key landmark in the perineal region's midline.^[2] Anteriorly, the pouch closely relates to the membranous portion of the urethra, which traverses it longitudinally; in males, this segment is adjacent to the prostatic urethra superiorly and the urethral bulb inferiorly via the perineal membrane, while in females, it neighbors the proximal urethra and anterior vaginal wall.^[1] These relations underscore the pouch's involvement in urethral support and continence mechanisms. Posteriorly, it abuts the perineal body and extends toward the anal canal, with proximity to the ischioanal (ischiorectal) fossa laterally, facilitating interactions between urogenital and anal compartments.^[2] Medially, the pouch encompasses the external urethral sphincter complex, providing structural reinforcement around the urethra, whereas laterally it is bounded by the obturator fascia.^[4] These lateral relations connect the pouch to the pelvic sidewall, influencing neurovascular pathways in the perineum.^[3] Due to its position and fascial connections, the deep perineal pouch can communicate with adjacent spaces, including the superficial perineal pouch inferiorly via potential defects in the perineal membrane and the pelvic cavity superiorly through the urogenital hiatus.^[1] Such communications pose clinical risks, as infections or tumors originating in the perineum may spread to pelvic structures or vice versa, often via lymphatic drainage to iliac nodes or along pudendal neurovascular bundles.^[2]

The deep perineal pouch contains the membranous urethra (approximately 1.5–2 cm long) and bulbourethral (Cowper's) glands in males, and the proximal two-thirds of the urethra (approximately 3–4 cm long) and the distal vagina in females, in addition to muscles and neurovascular elements.^[1]

Muscles

The deep perineal pouch contains several key striated muscles that contribute to the structural integrity of the urogenital region. These muscles are primarily involved in forming supportive slings and sphincters around the urethra, with variations between males and females.^[1] The deep transverse perineal muscle is a bilateral pair of flat, transverse bands that form a sling-like structure across the midline. Originating from the medial surface of the ischiopubic rami, these muscles extend medially to insert into the perineal body, where their fibers interdigitate. They attach inferiorly to the perineal membrane and laterally to the pubic rami, providing foundational support within the pouch. Somatic innervation is supplied by the pudendal nerve.^[6]^[1]^[7] The sphincter urethrae, also known as the external urethral sphincter, is a cylindrical band of striated muscle fibers that encircles the membranous urethra within the deep perineal pouch. It originates from the ischiopubic ramus and inserts into the perineal body anteriorly, with additional attachments to the perineal membrane inferiorly. This muscle receives somatic innervation from the pudendal nerve.^[7]^[1] In females, the urogenital sphincter complex includes additional components such as the compressor urethrae and urethrovaginal sphincter, which play supporting roles in urethral closure. The compressor urethrae arises from the ischiopubic rami and extends anteriorly along the ventral aspect of the urethra, attaching to the perineal membrane. The urethrovaginal sphincter surrounds both the urethra and vagina, contributing to their compression and stabilization. Both are innervated somatically by the pudendal nerve.^[7]^[1] Collectively, these muscles contribute to urogenital support by reinforcing the pelvic floor.^[6]

Neurovascular elements

The internal pudendal neurovascular bundle, comprising the internal pudendal artery, vein, and pudendal nerve, enters the deep perineal pouch via the pudendal (Alcock's) canal, a tunnel formed by the obturator fascia along the lateral wall of the ischioanal fossa.^[1]^[8] This bundle travels from the lesser sciatic foramen, curving around the ischial spine and sacrospinous ligament, before branching within the pouch to supply the urogenital structures.^[2] Arterial supply to the deep perineal pouch derives from branches of the internal pudendal artery, notably the deep artery of the penis (in males) or clitoris (in females), which provides blood to the erectile tissues and urethral sphincter.^[1] Additional branches include the dorsal artery of the penis/clitoris and the artery to the bulb, ensuring vascular support to the membranous urethra and bulbourethral glands.^[1] Corresponding deep veins accompany these arteries, forming the deep veins of the penis/clitoris and draining deoxygenated blood into the internal pudendal vein, which ultimately joins the internal iliac vein.^[1]^[2] Innervation arises from the pudendal nerve (S2-S4), which divides in the deep perineal pouch into the perineal nerve and the dorsal nerve of the penis (males) or clitoris (females).^[9] The perineal nerve provides motor innervation to the deep transverse perinei muscle and external urethral sphincter, while also supplying sensory fibers to the skin of the perineum, posterior scrotum/labia, and vaginal vestibule.^[9] The dorsal nerve conveys sensory information from the glans and shaft of the penis/clitoris, contributing to sexual sensation and reflex arcs for erection/orgasm.^[9] Lymphatic vessels from the deep perineal pouch drain to the external and internal iliac lymph nodes, facilitating immune surveillance of the urogenital region.^[1]

Conceptual framework

Urogenital diaphragm

The urogenital diaphragm is traditionally defined as a musculofascial layer that separates the deep perineal pouch from the upper pelvic cavity, consisting of inferior and superior fascial layers with intervening musculature.^[10] This structure spans the anterior pelvic outlet, occupying the urogenital triangle between the symphysis pubis and ischial tuberosities, and functions as a supportive barrier in the perineum.^[10] Key components include the perineal membrane, which serves as the primary inferior element—a thick fibrous sheet attaching to the ischiopubic rami and forming the base of the diaphragm.^[11] The superior fascia lies above the perineal membrane, with muscles such as the deep transverse perineal and sphincter urethrae situated between these layers, collectively enclosing the contents of the deep perineal pouch.^[1] In historical anatomical literature, such as editions of Gray's Anatomy prior to the 2000s, the urogenital diaphragm was described as a distinct, robust supportive structure akin to a muscular sheet, emphasizing its role in maintaining pelvic integrity.^[11] By acting as the inferior limit of the deep perineal pouch, it helps prevent the descent of pelvic organs into the perineum.

Modern anatomical perspective

In contemporary anatomy, the deep perineal pouch is conceptualized not as a discrete, solid entity like the historical urogenital diaphragm, but as a functional sphincteric region situated between the superior fascia of the urogenital diaphragm and the perineal membrane, facilitating urethral continence through integrated muscular and fascial support. This shift emphasizes the pouch's role in dynamic pelvic floor mechanics rather than a rigid barrier, with the perineal membrane serving primarily as a fibromuscular condensation anchoring urogenital structures to the ischiopubic rami.^[12]^[13] The Federative International Programme on Anatomical Terminology (FIPAT), through Terminologia Anatomica Humana (TAH), has updated nomenclature post-2000 to reflect this view, officially designating the structure as saccus profundus perinei (deep perineal pouch) and reclassifying the perineal membrane (membrana perinealis) as a supportive condensation rather than a complete diaphragmatic layer, abandoning terms like diaphragma urogenitalis due to their inaccuracy in describing an open, non-enclosed space extending superiorly into the pelvis. This terminology integrates the pouch within a broader fibromuscular complex of the pelvic floor, where skeletal muscles like the levator ani blend seamlessly with smooth muscle components for coordinated support, avoiding isolation as a standalone compartment.^[13]^[14] Imaging modalities such as MRI and CT further substantiate this perspective by visualizing the deep perineal pouch as a potential rather than fixed space, with coronal and sagittal MRI slices revealing the ventral perineal membrane's continuity with the compressor urethrae and levator ani, while axial views highlight its fibrous dorsal bands without distinct laminar separation. In nulliparous women, 3T MRI demonstrates these relationships as blended tissues rather than discrete layers, supporting the pouch's role in a continuous pelvic floor continuum.^[15] Ongoing controversies center on fully abandoning the "urogenital diaphragm" term in favor of "deep perineal space," as the former perpetuates misconceptions of a trilaminar, enclosed structure that misrepresents the sphincter urethrae and open fascial relations, potentially hindering precise surgical planning; proponents argue for exclusive use of space-based terminology to align with embryological and functional evidence.^[16]

Clinical significance

Functional roles

The deep perineal pouch contributes to sphincteric function primarily through its muscular components, such as the external urethral sphincter, which encircles the membranous urethra and enables voluntary contraction to maintain urinary continence.^[1] This striated muscle, innervated by the pudendal nerve, provides active closure of the urethra during periods of increased intra-abdominal pressure, preventing involuntary urine leakage.^[17] In females, additional structures like the compressor urethrae muscle within the pouch enhance this function by compressing the urethra against the pubic symphysis.^[1] The pouch also plays a supportive role in stabilizing urogenital structures against intra-abdominal pressure rises, such as those occurring during coughing or lifting, through the perineal membrane and associated muscles that anchor the membranous urethra in males and the urethra and vagina in females.^[18] This stabilization maintains the position of the urethrovesical junction, facilitating effective urethral closure and continence.^[17] Sexual dimorphism is evident in these functions: in males, the pouch supports the membranous urethra via the sphincter urethrae and deep transverse perineal muscles, while in females, it aids vaginal closure through the urethrovaginal sphincter complex, which constricts both the urethra and adjacent vaginal walls.^[1]^[17] During micturition, relaxation of the external urethral sphincter in the deep perineal pouch allows urine voiding, coordinated with detrusor muscle contraction in the bladder via parasympathetic innervation, while the internal urethral sphincter relaxes involuntarily.^[17] This voluntary relaxation initiates the process, ensuring controlled release.^[1] Additionally, the pouch provides indirect support for defecation through the deep transverse perineal muscles, which attach to the perineal body—a central tendon that reinforces pelvic floor integrity and helps prevent organ prolapse under strain.^[1]^[19]

Surgical and pathological relevance

The deep perineal pouch is surgically accessed via perineal incisions in procedures such as radical perineal prostatectomy, where the space is entered to reach the prostate apex while preserving surrounding neurovascular structures.^[20] In urethroplasty for strictures involving the membranous urethra, the pouch provides critical exposure for reconstruction, as the urethra traverses this space between the perineal membrane and pelvic floor fascia.^[21] Pudendal nerve blocks, used for perineal anesthesia in urologic and obstetric interventions, target the nerve as it courses through the deep perineal pouch, often guided by landmarks near the ischial spine to minimize risks of vascular injury.^[9] Pathologically, weakness or damage to the muscles within the deep perineal pouch, such as the external urethral sphincter and deep transverse perineal muscle, contributes to stress urinary incontinence by impairing urethral closure during increased intra-abdominal pressure.^[1] Surgical interventions targeting pelvic floor structures have been employed to restore continence in select cases of intrinsic sphincter deficiency. Infections like perineal abscesses can originate superficially but spread into deeper perineal spaces, potentially forming complex collections that require drainage to prevent extension to the pelvic cavity.^[22] Similarly, anorectal fistulas may track through the pouch, complicating management due to its proximity to the urogenital structures and necessitating imaging for delineation.^[23] Trauma to the deep perineal pouch, including pudendal nerve entrapment, often arises from compressive forces in the space, leading to chronic perineal pain, sensory deficits, and pelvic floor dysfunction; this is particularly relevant in cyclists or post-surgical scarring.^[24] During childbirth, stretching or laceration of the pouch's contents can cause pudendal neuropathy or sphincter injury, contributing to long-term incontinence or dyspareunia.^[25] Diagnostic imaging plays a key role in evaluating pouch integrity, with transperineal ultrasound providing dynamic assessment of muscle layers post-trauma or surgery, and MRI offering detailed visualization of abscesses, fistulas, or prolapse involving the space.^[26]^[27] From a modern anatomical perspective, the traditional view of the urogenital diaphragm as a discrete structure enclosing the deep perineal pouch has been refuted, revealing it as a continuous fascial layer without clear boundaries; this shift, established in seminal work, informs contemporary understandings of pelvic floor anatomy.^[16]

References

[1]
Anatomy, Abdomen and Pelvis: Deep Perineal Space - StatPearls
Aug 8, 2023 · The deep perineal pouch is in the urogenital triangle of the perineum below the pelvic diaphragm. It presents as a triangular, trilaminar space with sphincter ...Anatomy, Abdomen And Pelvis... · Structure And Function · Muscles
[2]
The Perineum - Boundaries - Contents - Innervation - TeachMeAnatomy
### Summary of Deep Perineal Pouch
[3]
Deep perineal pouch | Radiology Reference Article | Radiopaedia.org
Dec 27, 2019 · The deep perineal pouch is an anatomic space superior (deep) to the perineal membrane in the urogenital triangle of the perineum.
[4]
Perineal region: Anatomy, definition and supply - Kenhub
May 8, 2025 · Deep transverse perinei: Span the deep perineal pouch with a transverse but incomplete course. Bulbospongiosus: Aids ejaculation or vaginal ...Perineal body · Perineal nerve · Perineal raphe · Glans penis
[5]
https://pubmed.ncbi.nlm.nih.gov/6846873/
[6]
Muscles of the Pelvis and Perineum - UAMS College of Medicine
Muscles of the Pelvis and Perineum ; deep transverse perineus, medial surface of the ischial ramus, contralateral muscle and perineal body/central tendinous ...
[7]
Anatomy, Abdomen and Pelvis, Sphincter Urethrae - StatPearls - NCBI
Jun 4, 2023 · The second part is known as the urethral compressor muscle and extends anteriorly to connect with the ischial rami. The third part surrounds ...
[8]
Anatomical spaces of the pelvic cavity - Kenhub
Each pudendal neurovascular bundle enters the canal at the lesser sciatic notch and journey to the deep perineal pouch. The pudendal neurovascular bundle also ...
[9]
Anatomy, Abdomen and Pelvis, Pudendal Nerve - StatPearls - NCBI
Feb 10, 2023 · In either sex, while in the deep perineal space (pouch), the deep perineal nerve innervates the 2 deep, transverse perineal muscles and, more ...Missing: neurovascular elements
[10]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2617789/
[11]
[PDF] Contemporary views on female pelvic anatomy
Dec 4, 2005 · Although historically anatomists and clinicians have used the term urogenital diaphragm to describe this structure, this term has been ...
[12]
https://doi.org/10.1002/ar.1092050213
[13]
deep perineal pouch 3432
### Summary of Deep Perineal Pouch from Terminologia Anatomica Humana
[14]
Structure of the Perineal Membrane in Females - NIH
The structure of the perineal membrane is a complex 3-dimensional structure with two distinctly different dorsal and ventral regions.
[15]
Anatomy of the perineal membrane as seen in magnetic resonance ...
Recent cadaver research demonstrates the perineal membrane's ventral and dorsal portions and close relationship to the levator ani muscle.Missing: CT | Show results with:CT
[16]
an erroneous concept casting its shadow over the sphincter urethrae ...
Urogenital diaphragm: an erroneous concept casting its shadow over the sphincter urethrae and deep perineal space. J Am Coll Surg. 2004 Feb;198(2):279-90.Missing: debate abandon term favor
[17]
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3469827/
[18]
Urogenital Diaphragm - an overview | ScienceDirect Topics
The urogenital diaphragm is a fibromuscular layer directly below the pelvic diaphragm also known as the deep perineal pouch ... deep fascia of the pelvic floor.
[19]
Pelvic floor and perineal muscles: a dynamic coordination between ...
Mar 24, 2023 · The findings suggest new concepts of pelvic floor stabilization mechanisms, such as dynamic coordination between skeletal and smooth muscles.
[20]
Radical Perineal Prostatectomy - Journal of Urological Surgery
Radical perineal prostatectomy (RPP) is an alternative approach to the surgical treatment of patients with clinically organ-con?ned prostate cancer (≤cT2).
[21]
Pankaj M. Joshi Mélanie Aubé-Peterkin Sanjay B. Kulkarni Govind ...
May 11, 2023 · Despite its effectiveness for surgical treatment of urethral strictures, urethroplasty ... in the upper and lower layer of the deep perineal pouch ...
[22]
a challenge and a solution. III. Plication of muscles of deep perineal ...
The surgical procedure consists essentially of plication of the external urethral sphincter and other muscles in the deep perineal pouch thereby increasing ...
[23]
Perianal abscess | Radiology Reference Article - Radiopaedia.org
Mar 25, 2025 · Infection and anal gland drainage obstruction from the perianal fistula may lead to an acute perianal abscess. ... Deep perineal pouch ...
[24]
Understanding New Ideas in Cryptoglandular Fistula-in-Ano
The anatomy of anterior perineum, especially superficial and deep perineal space are equally important to explain anterior patterns of abscesses and fistulas.
[25]
Anatomy, Abdomen and Pelvis, Pudendal Nerve | Point of Care
Feb 10, 2023 · As the pudendal nerve approaches the pubic symphysis from the deep perineal space ... pudendal nerve entrapment or pudendal neuralgia.[16] ...
[26]
A biomechanical perspective on perineal injuries during childbirth
Both superficial and deep perineal pouch were included, namely the perineal body, ischiocavernosus, bulbospongiosus, superficial and deep transverse perineal ...
[27]
Dynamic magnetic resonance imaging of the female pelvic floor—a ...
Jan 28, 2019 · In anal incontinence, both endorectal ultrasound and pelvic MRI are ... deep perineal space. MR defecography interpretation and normal ...
[28]
Imaging of Unusual Perineal Masses | AJR
The deep perineal space is made up of the urogenital diaphragm, its investing fascia, and the structures that pass through it, namely the urethra ...
[29]
[PDF] Modern Aspects of the Fascial Structure of the Pelvic ... - Cronicon
Dec 31, 2021 · What is considered the superior fascia of the urogenital diaphragm is only a part of the fascia of the pelvis, and not an independent structure.