Pelvic Vascular Anatomy
Pelvic vascular anatomy covers the arterial pedicles that are controlled in pelvic surgery, the thin-walled venous plexuses that bleed heavily, and the collateral networks that determine ischemic risk after ligation or embolization.
For bleeding and repair decisions, see Vascular Injury & Damage Control; for access, see Operative Exposure. Organ-specific companions include Bladder, Prostate, Uterus and Vagina.
Arterial supply
The common iliac artery divides near the pelvic brim into the external and internal iliac arteries; its vertebral level and relation to the ureter are variable. The external iliac passes beneath the inguinal ligament to become the femoral artery. The internal iliac supplies much of the pelvic viscera, pelvic wall, buttock and perineum.
The familiar anterior and posterior division pattern is a useful starting map, but shared trunks, absent branches and origins from another named artery occur. Anterior branches supply both visceral and parietal territories. The origins of the prostatic, vesical, vaginal, uterine and obturator arteries are confirmed at surgery rather than assumed from their names.[1][2]
Usual internal iliac branches
| Branch or group | Main territory and operative relationship |
|---|---|
| Superior vesical | Usually arises from the patent proximal umbilical artery and supplies the superior bladder. The superior vesical pedicle is controlled early in cystectomy. |
| Inferior vesical / prostatic branches | Supply the bladder base, prostate and adjacent structures in men. Origins and pedicle relationships vary. The cavernous nerves run beside the prostatic pedicle, not within the artery. |
| Vaginal branches | Supply the vagina and contribute to adjacent bladder/urethral circulation; communicate with uterine and pudendal branches. |
| Uterine | Supplies the uterus and cervix with ascending, descending and adnexal connections. Crosses above the ureter near the cervix. |
| Middle rectal | Variable contribution to the rectum, sometimes absent; communicates with superior and inferior rectal territories. |
| Obturator | Reaches the medial thigh through the obturator canal. It may arise from, or communicate with, the external iliac/inferior epigastric system over the superior pubic ramus. |
| Internal pudendal | Leaves below piriformis through the greater sciatic foramen, passes around the ischial spine/sacrospinous ligament and re-enters through the lesser sciatic foramen. Its branches supply the perineum, erectile tissues and lower anal canal. |
| Inferior gluteal | Usually an anterior-division branch, exiting below piriformis to the buttock. |
| Iliolumbar | Usually posterior division; supplies iliacus, psoas and adjacent lumbar structures. |
| Lateral sacral | Usually posterior division; supplies sacral and foraminal structures. |
| Superior gluteal | Usually posterior division; exits above piriformis to the gluteal region. |
The pudendal course and vulvovaginal anastomoses are described in the reconstructive anatomy review; the corona mortis requires separate attention below.[2][3]
Arteries entering from outside the internal iliac system
- Gonadal arteries: usually arise from the abdominal aorta. The ovarian vessels reach the adnexa in the infundibulopelvic ligament; the testicular vessels descend toward the deep inguinal ring and spermatic cord. The ovarian artery communicates with the uterine artery near the adnexa and uterine cornua.
- Superior rectal artery: continuation of the inferior mesenteric artery into the pelvis; supplies the rectum and contributes to the anal cushions through distal branches.
- Median sacral artery: usually arises from the posterior distal aorta and descends in front of the sacrum.
- External pudendal arteries: arise from the femoral system and supply anterior external genital tissues, with connections to internal pudendal branches. The labial fat pad has both superior external-pudendal and inferior internal-pudendal contributions. The commonly used inferiorly based Martius flap preserves the inferior pedicle and is not an exclusively external-pudendal flap.[2][4]
Relationships that change the dissection
Ureter and pelvic pedicles
At the pelvic brim, the ureter crosses anterior to the iliac vessels, often around the common iliac bifurcation or external iliac artery. Trace it into the operative field, because the crossing differs between sides. Near the cervix, the uterine artery crosses over the ureter ("water under the bridge"), classically about 1.5–2 cm lateral to the cervix. The distance changes with anatomy, traction, prolapse, masses and previous surgery. The ureter is identified before uterine artery clamping in hysterectomy, before suture placement during uterosacral suspension and before deep paravaginal dissection; final cystoscopy assesses ureteral patency after suspension.[13]
Around the prostate, the vascular pedicles and cavernous nerve pathways are close and variable. Division close to the prostate favors nerve preservation. The organ-specific dissection plane is used, adjusted for scarring and oncologic requirements.
Corona mortis
Corona mortis describes arterial and/or venous connections between the obturator and external iliac or inferior epigastric systems over the superior pubic ramus. Venous connections are particularly important. The term is not limited to an accessory obturator artery.[3]
A 2020 systematic review of 13 anatomical, imaging and operative studies, comprising 1,455 hemipelves, estimated an overall prevalence near 46%, with marked between-study heterogeneity. The venous type was more frequent than the arterial type (42% vs 25%). A crossing vessel should be anticipated. Bleeding can be rapid and hard to expose in hernia repair, pelvic-fracture packing and Burch colposuspension. Inspect the retropubic surface during Burch, hernia, fracture and other dissections near Cooper's ligament; a vessel that must be divided is clipped and divided before traction tears it.[3]
Collateral arterial circulation
| Connection | Systems linked |
|---|---|
| Superior ↔ middle/inferior rectal | Inferior mesenteric ↔ internal iliac/pudendal |
| Ovarian ↔ uterine | Aortic gonadal ↔ internal iliac |
| Lumbar ↔ iliolumbar | Aorta ↔ internal iliac |
| Median ↔ lateral sacral | Aorta ↔ internal iliac |
| Gluteal ↔ femoral/circumflex branches | Internal iliac ↔ femoral/profunda circulation |
| Obturator ↔ inferior epigastric/external iliac | Internal ↔ external iliac systems |
Collateral pathways may preserve pelvic perfusion after unilateral internal iliac ligation. Bilateral ligation can cause pelvic or bowel ischemia and is rarely indicated even in extremis.[1] Embolization may target selected bleeding branches based on the vascular anatomy. Shock, atherosclerosis, prior embolization, radiation and previous surgery can reduce the available circulation. Hemorrhage-control decisions are covered in the vascular management pathway.[1]
Residual ovarian supply and non-target passage depend on the patient's vascular map. A thermal study in 20 women found that the boundary between uterine and ovarian supply to the cornual area shifts across the cycle, with ovarian supply predominating in the follicular phase and uterine supply in the luteal phase.[10]
Related embolization procedures use the same map. Prostatic artery embolization requires mapping variable prostatic arterial origins and accessory supply. Vesical, rectal and penile anastomoses require protection to prevent nontarget ischemia; missed prostatic supply can cause incomplete embolization.[11] Ovarian and pelvic vein embolization targets refluxing ovarian veins or internal iliac tributaries on either side when symptoms and venous mapping implicate them.[12]
Venous anatomy
Pelvic visceral plexuses communicate extensively with one another, the iliac systems, gonadal veins and vertebral and paravertebral channels. Pelvic veins are thin-walled and plexiform, and many channels lack effective valves. Venous variants and collateral recruitment can be substantial, especially with obstruction or reflux.[5]
Vesical and prostatic plexuses
The vesical and prostatic venous plexuses communicate around the bladder and prostate and drain toward the internal iliac system.[19] The deep dorsal penile vein connects with the prostatic plexus.[16] Inadequate dorsal venous complex control can cause bleeding during apical prostate dissection.[17] Suture ligation, stapling, athermal division with selective ligation and temporary bulldog clamping have been described for dorsal venous complex control, with timing varying by technique.[17] In a single-surgeon randomized trial of 300 men undergoing robot-assisted radical prostatectomy, 15-month pad-free continence was 87% with suture ligation plus suspension, 73% with stapling and 75% with cut-and-suture ligation.[18]
Uterine, vaginal and ovarian veins
The uterine and vaginal plexuses communicate across the pelvis and drain through uterine and vaginal veins into the internal iliac systems, with additional connections to the ovarian veins. The right ovarian vein usually drains to the IVC and the left to the left renal vein; duplicated trunks and variant junctions occur. Valves may be absent or incompetent, but cross-pelvic and gonadal–iliac communications are present.[5]
Symptoms are correlated with reflux, obstruction and collateral pathways. Left ovarian venous reflux can contribute to pelvic venous disease, including when left renal vein compression raises outflow pressure.[5] Venous embolization addresses selected abnormal pathways; uterine artery embolization is an arterial treatment.[5]
Pampiniform and testicular drainage
The pampiniform plexus surrounds the testicular artery within the spermatic cord and participates in heat exchange. The right testicular vein usually drains to the IVC and the left to the left renal vein. These asymmetrical outflow routes, valve function and venous pressure help explain the predominance of left varicocele. See Testicles & Scrotum.[5]
Presacral and vertebral plexuses
The presacral network includes median and lateral sacral veins and connections with veins entering the sacral foramina and vertebral system. Injury can cause major hemorrhage, and traction or blind attempts to clamp a retracted vessel can enlarge the defect. In 52 unembalmed female cadavers, the left common iliac vein was the closest vessel cephalad to the sacral promontory midpoint (mean 27 mm, range 9–52 mm) and laterally (mean 22 mm, range 9–35 mm).[6] The middle sacral artery and vein lay a mean 4 mm and 7 mm from the midpoint, and the sacral venous plexuses a mean 34 mm (range 4–86 mm).[6] The authors describe the location of these vessels as highly variable and advise exposing the anterior longitudinal ligament before placing sutures.[5][6]
Control starts with directed pressure and exposure, followed by a source-specific repair or hemostatic strategy with help. Instruments are not driven blindly into a sacral foramen. Detailed relationships are in The Presacral Space; active bleeding management is in Vascular Injury & Damage Control.
The valveless vertebral venous plexus (Batson's plexus) communicates with pelvic veins and allows bidirectional flow.[5] It offers a potential route for tumor or infection spread.[5]
Iliac veins
The external iliac vein is generally medial to its artery in the distal pelvis, while more proximal relationships and tributaries vary. The left common iliac vein passes beneath the right common iliac artery; this is the anatomic substrate of May–Thurner syndrome.[5]
Unexpected tributaries can cross a lateral or presacral dissection. One descriptive study examined 40 iliac venous systems in 20 cadavers and found presacral external-iliac tributaries in 20 systems from 15 cadavers. Its 75% figure refers to cadavers. These branches are anticipated during exenteration, sacrectomy, sacrocolpopexy and lateral pelvic surgery.[7]
Lymphatic orientation
Lymphatic drainage is regional, overlapping and sometimes bilateral. Cancer-specific staging, mapping and previous treatment determine a lymphadenectomy template, and the nodal basins below are orientation only.
| Territory | Useful orientation |
|---|---|
| Bladder and prostate | Obturator, external iliac and internal iliac nodes, then common iliac and presacral nodes in extended drainage. |
| Cervix and uterus | Obturator, external iliac, internal iliac and parametrial nodes, then common iliac and para-aortic nodes. |
| Upper vagina | Internal and external iliac nodes. |
| Lower vagina and vulva | Superficial inguinal nodes, then deep inguinal (Cloquet's) and external iliac nodes. |
| Testis and ovary | Testicular drainage follows the gonadal vessels to retroperitoneal nodes. Ovarian drainage can reach para-aortic, paracaval and pelvic iliac nodes.[14] |
| Rectum and anus | The upper rectum drains mainly through mesorectal and superior rectal nodes toward the inferior mesenteric chain; the lower rectum also has internal iliac drainage. The anal canal drains to inferior mesenteric and internal iliac nodes above the dentate line and to inguinal and external iliac nodes below it.[15] |
| Penis | Inguinal drainage can be bilateral. In penile cancer, the usual progression is superficial then deep inguinal nodes, followed by ipsilateral pelvic nodes; the glans does not routinely bypass the groin. |
| Male anterior urethra | Superficial/deep inguinal drainage, then pelvic nodes; use the lesion's exact location in staging. |
| Male posterior urethra | Pelvic nodal drainage. |
| Female urethra | Proximal third drains toward pelvic nodes; distal two-thirds toward superficial/deep inguinal nodes. |
The penile and urethral rows follow the current EAU guidelines.[8][9] The remaining rows are standard anatomy-text descriptions. Gonadal drainage toward retroperitoneal nodes differs from the predominantly inguinal drainage of external genital skin. See the organ-specific anatomy pages for further detail.
References
1. Wahlgren CM, Aylwin C, Davenport RA, et al. European Society for Vascular Surgery (ESVS) 2025 clinical practice guidelines on the management of vascular trauma. Eur J Vasc Endovasc Surg. 2025;69:179–237. doi:10.1016/j.ejvs.2024.12.018.
2. Yavagal S, de Farias TF, Medina CA, Takacs P. Normal vulvovaginal, perineal, and pelvic anatomy with reconstructive considerations. Semin Plast Surg. 2011;25:121–129. doi:10.1055/s-0031-1281481.
3. Noussios G, Galanis N, Chatzis I, et al. The anatomical characteristics of corona mortis: a systematic review of the literature and its clinical importance in hernia repair. J Clin Med Res. 2020;12:108–114. doi:10.14740/jocmr4062.
4. Wilson A, Pillay S, Greenwell T. How and why to take a Martius labial interposition flap in female urology. Transl Androl Urol. 2017;6(Suppl 2):S81–S87. doi:10.21037/tau.2017.04.38.
5. Zurcher KS, Staack SO, Spencer EB, et al. Venous anatomy and collateral pathways of the pelvis: an angiographic review. Radiographics. 2022;42:1532–1545. doi:10.1148/rg.220012.
6. Wieslander CK, Rahn DD, McIntire DD, et al. Vascular anatomy of the presacral space in unembalmed female cadavers. Am J Obstet Gynecol. 2006;195:1736–1741. doi:10.1016/j.ajog.2006.07.045.
7. Kanjanasilp P, Ng JL, Kajohnwongsatit K, et al. Anatomical variations of iliac vein tributaries and their clinical implications during complex pelvic surgeries. Dis Colon Rectum. 2019;62:809–814. doi:10.1097/DCR.0000000000001335.
8. European Association of Urology. Penile cancer guideline. 2026. Regional lymphatic drainage and management.
9. European Association of Urology. Primary urethral carcinoma guideline. 2026. Diagnostic evaluation and staging.
10. Cicinelli E, Einer-Jensen N, Barba B, et al. Blood to the cornual area of the uterus is mainly supplied from the ovarian artery in the follicular phase and from the uterine artery in the luteal phase. Hum Reprod. 2004;19(4):1003–1008. doi:10.1093/humrep/deh171.
11. Bilhim T. "Prostatic artery embolization: An update." Korean J Radiol. 2023;24(4):313–323. doi:10.3348/kjr.2022.0814
12. Hanna J, Bruinsma J, Temperley HC, et al. "Efficacy of embolotherapy for the treatment of pelvic congestion syndrome: A systematic review." Ir J Med Sci. 2024;193(3):1441–1451. doi:10.1007/s11845-024-03608-6
13. Manodoro S, Frigerio M, Milani R, Spelzini F. "Tips and tricks for uterosacral ligament suspension: how to avoid ureteral injury." Int Urogynecol J. 2018;29(1):161–163. doi:10.1007/s00192-017-3497-y
14. Ataei Nakhaei S, Sadeghi R, Mostafavi SM, et al. "Sentinel node mapping in ovarian tumors: A study using lymphoscintigraphy and SPECT/CT." Contrast Media Mol Imaging. 2024;2024:5453692. doi:10.1155/2024/5453692
15. Lee MH, Kim DH. "Low rectal cancers at initial staging MRI." Radiographics. 2023;43(11):e230080. doi:10.1148/rg.230080
16. Kho YY, Lee SHE, Chin K, et al. "US of the penis: Beyond erectile dysfunction." Radiographics. 2024;44(6):e230157. doi:10.1148/rg.230157
17. Tüfek I, Atuğ F, Argun B, et al. "The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy." J Endourol. 2012;26(12):1605–1608. doi:10.1089/end.2012.0153
18. Feng T, Heulitt G, Lee JJ, Liao M, Li HF, Porter JR. "Randomised comparison of techniques for control of the dorsal venous complex during robot-assisted laparoscopic radical prostatectomy." BJU Int. 2020;126(5):586–594. doi:10.1111/bju.15133
19. Shehata R. "Venous drainage of the urinary bladder." Acta Anat (Basel). 1979;105(1):61–64. doi:10.1159/000145108