1 - Pelvic Viscera I (Male) Flashcards
What attaches to the apex of the urinary bladder to suspend it in place?
Median Umbilical Ligament
How can you access the bladder w/out entering the peritoneal cavity?
What is a suprapubic cystostomy?
Surgically above pubis
Suprapubic catheterization to draw urine from the bladder if urethra is obstructed
What is the Detrusor Muscle?
What nerves stimulate it?
What nerves inhibit it?
Detrusor are layered smooth muscular coat of bladder
Stimulated by parasympathetics of pelvic splanchnic nerves
Inhibited by sympathetics fibers of T12-L2 though hypogastric nerve
What is the internal urethral sphincter of bladder?
Is it found in females?
What type of sphincter is it? (voluntary or involuntary)
What stimulates it?
What inhibits it?
What is the role of sympathetics wrt ejaculation?
Found only in males
Involuntary Sphincter
Stimulated by sympathetics to contract
Inhibited by parasympathetics to relax, leading to urination
Sympathetics also stimulate contraction to prevent retrograde ejaculation
What is the trigone, and what are the three corners?
What prevents urine from reentering the ureters?
What can occur as bladder wall constricts ureter?
Inverted triangular region, smooth region
Upper corner = openings for ureters
Lower apex = Internal Orifice of Urethra
Contraction of muscles of bladder wall prevents reflex of urine into ureter
Bladder wall can constrict ureter leading to kidney stones
How does Micturition (urination) occur?
Parasympathetic stimulation causese contraction of detrusor muscles and relaxation of internal urethral sphincter (in males)
What nerves innervate the deterusor and internal sphincter of bladder?
What can a spinal cord injury to S2-S4 cause?
Parasympathetics
Spinal Cord Injury to S2-S4 can cause loss of parasympathetics leading to a dilated, flaccid bladder (neurogenic bladder)
What supplies Afferents to bladder?
Where is referred pain from the bladder?
Sacral nerves (S2-S4) via pelvic splanchnic nerves and T11-L2
Referred pain from bladder is to tip of penis (S2-S4) or hypogastric region of abdominal wall (L1)
Where do the lymphatics of the bladder drain?
Internal Iliac Nodes
What is the location of the female urethra wrt vagina?
What structures does it pass through?
Urethra anterior to vagina
Passes through Pelvic and Urogenital Diaphragms
Where is the External Urethral Sphincter?
What type of control is it under (voluntary/involuntary)?
What innervates it?
Surrounds urethra within the urogenital diaphragm
Under voluntary control
Innervated by Perineal Branch of Pudendal Nerve (somatics)
Why are bladder infections more common in females? (Cystitis)
Why are urethra injuries more common in females?
Urethra is short, bacteria have shorter distance to travel
Injury to vagina can involve urethra due to close relationship
What level does the rectum arise from?
What structures are absent from the rectum?
What level is the Anorectal Junction?
S3
Taenia coli, haustra, appendices epiploicae
Anorectal Junction is at level of pelvic diaphragm
What posterior structures can be palpated during rectal exam?
Sacrum
Coccyx
Piriformis
Sympathetic Trunk
What anterior structures can be palpated in rectal exam for males?
What lies between the base of bladder and rectum in males?
What is a clinical application?
Ductus deferens, seminal vesicles, prostate
Rectovesical Septum (Denonvilliers) lies between base of bladder and rectum
Plan for separating bladder and prostate from rectum when excising cancerous rectum
What anterior structures can be palpated via rectal exam in females?
What can limit spread of infections/cancer in females?
Vagina
Cervix
Rectovaginal Septum (of Denonvilliers) separates vagina from rectum, can limit spread of infection or cancer
What lateral structures can be palpated via rectal exam in males and females?
Ischial Spine
Ischial Tuberosity
Sacrotuberous Ligament
What is unique about the lower 1/3 of rectum vs the upper 2/3?
There is no peritoneum
What is the rectovesical pouch?
Males: Clinical? (Peritonitis)
Females: Clinical? (Peritonitis, Perforated Duodenal Ulcer, Ruptured Ectopic Pregnancy)
Males: Formed by reflection of peritoneum from rectum to superior-posterior surface of bladder; lowest part of peritoneal cavity
Clinical: Peritoneal Excudates (peritonitis) will drain into this pouch when patient is in sitting/supine
Females: Formed by reflection of peritoneum from rectum to posterior vagina and uterus; lowest part of peritoneal cavity
Clinical: Peritoneal Exudates (peritonitis), acid from perforated duodenal ulcer or blood from ruptured etopic pregnancy will drain into this pouch when patient is sitting/supine; cause peritoneal tenderness
How can hard stool or proctoscope damage the rectum?
They can tear Transverse Rectal Folds; leads to infection of retal wall
What five arteries supply the rectum?
Superior Rectal (1 from Inferior Mesenteric Artery) - major blood supply
Middle Rectal Arteries (2 from Internal Iliac)
Inferior Rectal Arteries (2 from Pudendal Arteries)
What anastomoses for veins form in the rectum?
Connects Portal Venous System (Superior Rectal Vein) and Systemic Venous System (Middle/Inferior Rectal Veins)
What is the lymphatic drainage pattern of the rectum?
Inferior Mesenteric Nodes
What is the innervation of the rectum?
Parasympathetics from pelvic splanchnic nerves via inferior hypogastric plexus
Sympathetics from Superior and Inferior Hypogastric Plexus
What is a rectal prolapse?
Abnodmal descent of rectum through anal canal
Can occur in young children due to lack of sacrum curvature
Can ocur if not enough suppor from puborectalis muscle of levator ani
What is a bony landmark for beginning of anal canal?
Where does it bend?
What two structures does it descend between?
Coccyx
Anorectal Junction
Anococcygeal Body / Perineal Body
What aids the two anal sphincters?
What type of sphincter is the Internal Anal Sphincter?
What type is the External anal Sphincter?
Puborectalis part of Levator Ani
Internal = Involuntary; parasympathetics relax
External = Voluntary; Inferior Rectal Nerve CLOSES anal canal
What are the 3 parts to the external anal sphincter?
Deep Park - fused w/puborectalis
Superficial - Keeps in median plane by attachment to perineal body and anococcygeal body
Subcutaneous - surrounds anus
What is the location of the sling formed from puborectalis muscle?
Anorectal Junction
Border between rectum and anal canal
Interior Anal Canal - Upper Half of Mucous Membrane
What is the location of Portal-Caval anastomoes?
What indicate the pectinate line?
What is the innervation of the upper half?
Blood supply of upper half?
What are lymphatics of upper half?
Anal Columns
Anal Valves indicate pectinate line
Stretch receptors into hypogastric plexus of autonomic, NO SOMATIC
Superior Rectal from Inferior Mesenteric (Artery and Vein)
Lymphatics drain Inferior Mesenteric Nodes
What indicates start of lower half of anal canal?
Innervation?
Blood supply?
Lymphatics?
Below Pectinate Line is lower half of anal canal
Innervation = Somatic Sensory via Inferior Rectal Nerve (br. of pudendal)
Blood Supply = Inferior Rectal Artery (br. of Internal Pudendal)
Lymphatics = Medial Nodes of Superficial Inguinal Lymph Nodes (inferior to inguinal ligament in thigh)
What is key about the union of Superior and Inferior Rectal Veins?
Portal-Caval anastomoses
Superior = Portal
Inferior = Caval (Systemic)
If liver circulation is obstructred (currhosis) blood can reverse normal flow due to valveless portal system
What are Internal hemorrhoids?
Varicosities of tributaries of Superior Rectal Veins
Not as painful due to visceral afferents
What are External Hemorrhoids?
Varicosities of Inferior Rectal Veins covered by skin
Painful due to somatics of Inferior Rectal Nerve
What damage can occur to anal valves?
Hard stools in chronic constipation can tear anal valves and mucosis;
Anal canal can become infected and form fistula through wall into ischiorectal fossa
Can reuslt in Perianal Abscess (collection of pus)
What are cmplications with an abscess of fat in the Ischiorectal Fossa?
Can spread from one side to the opposite
Can spread anterior to Anterior Recess of Ischiorectal Fossa to urogenital structors
What does the ductus deferens cross OVER?
What is the distal part dilated as?
What forms the Ejaculator Duct?
Ductus Deferens cross over External Iliac Artery and Ureter
Distal dilation is Ampulla of Ductus Deferens
Ejaculatory Duct = Ampulla Ductus Deferens + Duct of Seminal Vessicle
What is the seminal vessicle an outgrowth of?
Ductus Deferens
What is the location of the prostate? (Sup/Inf/Pos/Ant)
Superior - Bladder
Inferior - Urogenital Gap in pelvic diaphragm and urogenital diaphragm
Posterior - Rectum
Anterior - Pubic bones
What are the five lobes of the prostate gland?
Median: Located between Urethra and Ejaculatory Duct; Common site for Benign Prostatic Hyperplasia (BPH); median lobe bulges into bladder resulting in dripping of urin into urethra at night
Right/Left Lateral Lobes: Separated by prostatic urethra; may become enlarged by BPH and compress urethra
Posterior; Inferior to ejaculator duct, posterior to prostatic urethra, common site for carcinoma
Anterior: Anterior to prostatic urethra; no clinical
What prostate lobes are at risk for BPH?
What prostate lobe is at risk for carcinoma?
Median, Right/left Lateral Lobes
Posterior
What is blood supply to prostate?
Veins?
What is risk of prostatic carcinoma?
What is the route of metastis?
Lymphatics?
Arteries - Inferior Vesical Artery
Veins - Valveless prostatic venous plexus
Prostatic Carcinoma - Can spread easily via venous communication to psinal column and cord and to brain
Protstaic Venous Plexus - Vesical Venous Plexus - Internal Iliac V - Lateral Sacral V - Internal Vertebran Venous Plexus and Radicular Veins
Lymphatics drain internal iliac nodes
What is the widest and most dilatable part of the urethra?
What is the seminal colliculus?
Prostatic Urethra
Seminal Colliculus has slit like orifice leading to vestigal prostatic utricle; on each side is opening for ejaculatory duct
What is Iatrogenically Induced Sterility?
Dusruption of sympathtic nerve fibers to ductus deferens, prostate, and seminal vesicles = NO EMISSION
Surgery in Pelvis
Does NOT affect ERECTION (parasympathtics)
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Surgical enlargement of prostatic urethra w/BPH can damage the internal urethral sphincter resulting in retrograde ejaculation
