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Puboprostatic ligament

The puboprostatic ligament is a strong connective tissue structure in males that connects the prostate gland to the pubic bone. It provides support and stabilization to the prostate and bladder neck, anchoring them to the anterior pelvic wall. It is considered the male counterpart of the pubovesical ligament in females.

The ligament is clinically important in urologic and pelvic surgery, particularly during radical prostatectomy, bladder neck suspension, and incontinence procedures.

Synonyms

  • Prostatic pubic ligament

  • Male pubovesical ligament (functional equivalent)

  • Pubourethral ligament (sometimes used interchangeably, but distinct in some texts)

Attachments and Course

  • Origin (anterior attachment): Posterior surface of the pubic bone (pubic symphysis and superior pubic ramus)

  • Course: Runs posteriorly and inferiorly as a dense fibrous band along the pelvic floor, often blending with pelvic fascia

  • Insertion (posterior attachment): Anterolateral surface of the prostate gland and upper part of the prostatic urethra, adjacent to the bladder neck

Relations

  • Anteriorly: Pubic symphysis and retropubic space (space of Retzius)

  • Posteriorly: Prostate gland and bladder neck

  • Laterally: Endopelvic fascia and pelvic sidewalls

  • Inferiorly: External urethral sphincter complex and membranous urethra

Function

  • Provides support and anchorage for the prostate gland within the pelvis

  • Stabilizes the bladder neck and proximal urethra

  • Maintains urethral alignment during intra-abdominal pressure changes

  • Plays a role in continence mechanisms by supporting the urethra

Clinical Significance

  • Surgically important during radical prostatectomy: preservation of the puboprostatic ligament may help maintain urinary continence

  • Can be involved in pelvic trauma with disruption leading to urethral or bladder neck displacement

  • Serves as a landmark in urologic procedures for access to the retropubic space

  • Equivalent structure in females is the pubovesical ligament, supporting the bladder

MRI Appearance

T1-weighted images:

  • Ligament appears as a thin, low-signal intensity band between pubic bone and prostate

  • Fat in the retropubic space appears bright, outlining the ligament

T2-weighted images:

  • Ligament remains dark (low signal intensity)

  • Adjacent prostate and periprostatic fat appear higher in signal, providing contrast

STIR (Short Tau Inversion Recovery):

  • Ligament remains dark due to suppression of fat signal

  • Inflammatory or traumatic changes may appear as focal bright areas near the ligament

T1 Fat-Sat Post-Contrast:

  • Normal ligament shows little or no enhancement

  • Pathologic changes (postoperative scarring, inflammation, tumor spread) may enhance

CT Appearance

Non-Contrast CT:

  • Difficult to directly visualize; appears as a thin soft tissue density band in the retropubic space

  • Fat planes around ligament help indirect visualization

  • Calcification or fibrosis may appear as dense linear changes

Post-Contrast CT:

  • Normal ligament enhances minimally

  • Pathology (inflammation, tumor infiltration) may appear as thickening or enhancing soft tissue along its course

MRI image

Puboprostatic ligament MRI axial anatomy image-img-00000-00000

MRI image

Puboprostatic ligament MRI sag anatomy image-img-00000-00000

CT image

Puboprostatic ligament ct axial anatomy image-img-00000-00000