31/32. Pelvic Viscera Flashcards
The parietal peritoneum does not reach the pelvic floor — what is the lowest point in males?
Rectovesical pouch — about 2 cm above the seminal vesicles
[abdominal fluid collects here; abscesses are likely to form here]
Pelvic peritoneum in males descends anterior abdominal wall, with a loose attachment here for insertion of the bladder as it fills. The peritoneum reflects onto the superior surface of the bladder, creating the ________ ______.
Pelvic peritoneum covers the convex superior surface of the bladder and slopes down the sides of roof to ascend lateral wall of pelvis, creating a _____ _____ on each side. It descends th eposterior surface of the bladder as much as 2 cm
Supravesical fossa
Paravesical fossa
The pelvic peritoneum in males — laterally forms folds over what 3 structures?
Ureters (ureteric fold)
Ductus deferens
Superior ends of seminal glands
The pelvic peritoneum reflects from the bladder and seminal glands onto the rectum, forming the _____ _____, which extends laterally and posteriorly to form a _______ _____ on each side of the rectum
Rectovesical pouch; pararectal fossa
The pelvic peritoneum ascends the rectum from inferior to superior, so the rectum is initially subperitoneal, and then __________
It engulfs the sigmoid colon beginning at the ________ junction
Retroperitoneal; rectosigmoid
What is the named space in males between the pubis and bladder?
Retropubic space
What is the named space in males between the rectum and the sacrum?
Retrorectal (presacral) space
What is the named space in males between the bladder and rectum?
Rectovesical pouch/fossa
The levator ani and associated musculature supporting the pelvic floor is weak; what is the named CT assisting in this support?
Endopelvic fascia
The endopelvic fascia exists beneath the peritoneum and covers viscera, pelvic wall, and floor; it is continuous with _____ ______
Endoabdominal fascia
The endopelvic fascia is thickened in certain areas, particularly the tendinous arch of the ____ ____ musculature
Levator ani
The endopelvic fascia forms the _______ ligament in males
It forms the ________ and _______ ligaments in females
Puboprostatic
Pubovesical; pubocervical
The endopelvic fascia forms the lateral ligament of the ____ and _____
Bladder; rectum
The endopelvic fascia forms the ______ ligament which supports the cervix in females
Cardinal (transverse cervical)
The endopelvic fascia forms the _______ in females, which is the thickened fascia from lateral vagina to tendinous arch of levator ani
Paracolpium
In terms of anatomic relationships, the ureter travels _____ the vas deferens
The bladder is _____ to the prostate
The seminal vesicles lie on the _____ surface of the bladder
The bulbourethral gland is located ______ the UG membrane
Under
Superior
Posterior
Within
Where is the prostate located in reference to the bladder and the UG membrane?
The prostate is immediately below the bladder but superior to the UG membrane
The ureters connect the kidneys to the urinary bladder and are retroperitoneal; they pass over the pelvic brim and enter the ______ pelvis. The ureters pass obliquely through the urinary bladder wall in a ________ direction.
Lesser; inferomedial
In males, the ureters run inferior to the ______ ______; in females, they run inferior to the ______ ______
Vas deferens; uterine artery
The ureters receive blood supply from multiple arteries — what are the 4 main branches?
Renal, gonadal, aortic, and internal iliac branches
What nerves supply the ureters?
Preaortic plexus
Hypogastric plexus
Pelvic splanchnics (parasympathetics S2-4)
How is the bladder oriented in terms of apex, fundus, body, and neck?
The apex points toward the pubic symphysis, the fundus just the opposite
The body lies between the apex and fundus, and the neck lies at the bottom
What ligament connects the apex of the bladder to the internal umbilical region? What is the obliterated embryological structure?
Median umbilical ligament (obliterated urachus)
Besides the median umbilical ligament anteriorly, what other ligaments support the bladder?
Lateral ligament (endopelvic fascia)
The superior surface of the bladder is triangular and bounded by a line connecting the _______
Ureters
T/F: the bladder typically rises above the pelvic brim
False; the bladder only rises above the pelvic brim when full — if it is empty it does not
________ muscle lines the bladder walls and is continuous with the ____ _____ sphincter, as well as the _______ sphincters
Detrusor; internal urethral; ureteric
[detrusor m. is visceral smooth m.]
What is the purpose of the sensory receptors in the bladder wall and posterior urethra?
They sense stretch when the bladder fills with urine, and play a role in the micturition reflex
The internal urethral sphincter in males is made up of ________ fibers and is continuous with smooth muscle called the ______ m.
Circular; detrusor
The external urethral sphincter in males is made up of skeletal fibers that are deficient in the _____ region of the urethra. It is located primarily at the level of the _______ urethra in males, but extends superiorly around the _____ urethra
Posterior; membranous; prostatic
What innervates the internal urethral sphincter?
Inferior hypogastric plexus (mixed autonomic supply)
What innervates the external urethral sphincter?
Deep perineal branch of pudendal n. (Somatic innervation)
What are the 4 named parts of the male urethra (from bladder to external)
Intramural
Prostatic
Membranous
Spongy
The _____ ______ is simply a posterior ridge on the urethra as it passes through the prostate.
The ____ ______ is an enlarged area on the above structure onto which the 2 ejaculatory ducts open, bringing sperm from the ____ _____ and fluid from the ____ ____
Urethral crest
Seminal colliculus; vas deferens; seminal vesicle
The ____ ____ is a remnant of the paramesonephric system associated with the prostate gland
The ____ ____ are depressions on either side of the ridge into which prostatic glands open and secrete an alkaline prostatic fluid
Prostatic utricle
Prostatic sinuses
The prostatic urethra is surrounded by the walnut-size prostate, which is made up of 2/3 ______, 1/3 _______ tissue. The base is closely related to the neck of the _______.
Gland; fibromuscular; bladder
The apex of the prostate is in contact with fascia on the superior aspect of the ______ sphincter and deep _____ muscles. Prostatic ducts open chiefly into the ____ ____
Urethral; perineal; prostatic sinuses
What is the largest male reproductive accessory organ?
Prostate
What benign condition is common in males after middle age, in which urination may be impeded by distortion of the prostatic urethra?
Hypertrophy of prostate
BPH is a common cause of what conditions?
Urethral obstruction Nocturia Dysruia Urinary urgency Cystitis Kidney damage
How are prostatic enlargements or tumors commonly diagnosed?
Digital rectal exam — abnormal finding is hard and irregular shape, indicating malignancy
The vas deferens enters the abdomen via the ______ inguinal ring. It passes superior to all structures, including the ureters and iliac vessels. It passes superiorly and medially to the ureter, expanding into an _______ before narrowing again and joining the duct of the ___ ____
Deep; ampulla; seminal vesicle
_______ ______ are bilateral, lobulated sacs lying lateral to the ampulla of the vas deferens. Their ducts and the vas deferens join on each side to form an _____ ______
Seminal vesicles; ejaculatory duct
What is the vascular supply to the seminal vesicles?
Umbilical aa.
Inferior vesicular aa.
Which region of the prostate do the ducts of the seminal vesicle join the vas deferens to form the ejaculatory ducts?
Posterior/inferomedial region
What supplies sympathetic innervation to the male reproductive organs in general?
Inferior hypogastric plexus T10-L2 via similar routes as bladder
What supplies parasympathetic innervation to the male reproductive organs in general?
Pelvic splanchnic nn.
Most visceral afferent fibers supplying the male reproductive organs travel with __________ fibers ___-___
Parasympathetic; S2-S4
Most visceral afferent fibers supplying the male reproductive organs travel with parasympathetic fibers S2-S4. Which organs are the exception to this?
Testis — for which the visceral afferents travel with sympathetics to T10 (d/t their embryological development higher in abdominal cavity)
Most lymphatic drainage from the vas deferens and inferior portion of the seminal vesicles is to the ____ ____ nodes; with the scrotal portion of the vas deferens draining into the ____ ____nodes
Internal iliac; external iliac
The prostate drains lymph chiefly in the ___ ____ nodes with some to the _______ nodes
Internal iliac; sacral
The superiolateral portion of the bladder drains lymph to the ____ nodes
The fundus and neck of the bladder drain to the _____ nodes
External iliac
Internal iliac
What pelvic viscera is associated with the pelvic cavity in females?
Bladder
Uterus and ovaries
Uterine tubes
Vagina
What 3 folds in the female pelvic cavity are comprised of 2 layers of peritoneum?
Rectouterine fold
Suspensory ligament of ovary
Broad ligament
What 2 pouches exist in the female pelvic cavity and are continuous with the abdominopelvic cavity?
Vesicouterine pouch Rectouterine pouch (culdesac of douglas)
What 3 spaces are associated with the female pelvic cavity?
Retropubic (prevesical) space
Retrovesical space
Retrorectal (presacral) space
The rectouterine and vesicouterine pouches in females are separated by the _______ ligament and the uterus.
Round
The _______ pouch can be surgically approached through the posterior fornix of the vagina
Note that the lateral extensions, which make up the _____ ____, can be the deepest.
Recesses lateral to the bladder are referred to as ________ ______, which get deeper as the bladder fills
Rectouterine
Pararectal fossa
Paravesical fossa
What structures are contained within the broad ligament in females?
Ovarian vessels (within the suspensory ligament itself) Uterine tube Ovary Uterus Proper ovarian ligament
What structures lie in the base of the broad ligament in females?
Uterine artery and vein
Ureter
What are the 3 named parts of the broad ligament in females?
Mesovarium - between ovary and round ligament of uterus
Mesosalpinx - between the uterine tube and round ligament of uterus
Mesometrium - going to the uterus
Underneath the broad ligament is the ______ ______, which thickens in a certain area becoming the ______ ligament — which runs right below the uterine artery
Endopelvic fascia; cardinal
The female endopelvic fascia is sometimes collectively referred to as the _____ ______. It supports the viscera and conducts neurovasculature to organs.
Hypogastric sheath
What provides the main support for the uterus?
The cardinal ligament (aka the transverse cervical ligament)
What ligament is found within the rectouterine fold?
Uterosacral ligament
Although the cardinal ligament provides the MAIN support for the uterus, what other 3 ligaments are involved in supporting this organ?
Round ligament
Pubocervical ligament
Uterosacral ligament
What blood vessels are found in the pubocervical ligament?
Superior vesicular artery and vein
What vessels are found in the uterosacral ligament?
Middle rectal artery and vein
The uterus is commonly divided into what 3 parts?
Fundus
Body
Cervix
The ____ of the uterus protrudes into the vagina, forming the vaginal ________, as well as the internal and external os
Cervix; fornices
The major changes that occur in the uterus during the menstrual cycle are primarily in the ______
Endometrium
What are the 3 layers of the uterine wall?
Perimetrium
Myometrium
Endometrium
When referring to uterine position, _______ refers to the angle between the cervix and vagina, and ______ refers to the angle between the uterine body and cervix.
The 2 normal positions of the uterus using the terms above are _____ and ______
Verted; flex
Anteverted; anteflexed
A retroverted uterus is usually genetic — but can be caused by what other conditions?
Fibroids
Endometriosis
PID
Labor
A retroverted uterus does not have an effect on fertility, but can be associated with what symptoms?
LBP
Dysuria
Dysparunia
Although uncommon, pregnant retroflexed uterus can be trapped by the curve of the ____
Sacrum
What condition concerning the uterus can occur when pelvic ligaments (especially the cardinal ligament) OR pelvic diaphragm weakens/tears?
Uterine prolapse — can be first, second, or third degree
What is the main cause of pelvic organ prolapse in females? What are some other causes?
Pregnancy
Other causes include aging, menopause, and obesity
What are the 3 histological layers of the uterine tubes?
Mucosa
Muscularis
Serosa
The uterine tubes lie in the free edge of the _____ ligament and function to carry ova to the uterine cavity; assisted by motile _____ within the tube
The _____ layer folds change during menstruation, though not as dramatically
Broad; cilia
Mucosal
What are the named regions of the uterine tubes? Where in the tube does fertilization typically occur?
Fimbria
Infundibulum
Ampulla (fertilization site)
Isthmus
The ovaries lie on the lateral walls of the female pelvis. They are covered laterally by what structures?
Fimbrae of the uterine tubes
What are the anterior, lateral, and medial attachments of the ovaries?
Anteriorly to broad ligament via mesovarium
Laterally to suspensory ligament
Medially to proper ovarian ligament
The _______ is the recess between the cervix and vaginal wall
Fornix
The opening to the vaginal vestibule can be partially closed by a membranous ______, which may be imperforate in 1:1000
Hymen
The female urethra is adjacent to the _______ wall of the vagina. It penetrates the _____ membrane and opens anterior to the vaginal vestibule
Anterior; urogenital
The female urethral sphincters differ from males in what ways?
The sphincter proximity and length differs — in females they are arranged superficial -> deep instead of proximal/distal
Which urethral sphincter aids in reflex closure of the urethra during acute instances of increased intra-abdominal pressure d/t coughing, sneezing, laughing, etc.?
EUS
In which part of the EUS is striated muscle length and thickness lost with age?
Proximal EUS
Pelvic floor exercises can increase the size of what urethral sphincter?
External
In the female pelvic viscera, most lymph drains to the __________ nodes
However there are exceptions:
The round ligament, fundus (+ external genitalia) drain to _____ nodes. The ovary, uterine tube, and fundus drain to _____ nodes
Iliac
Superficial inguinal; lumbar
What provides primary efferent innervation to female internal viscera?
Inferior hypogastric plexus
The ovarian plexus is composed of parasympathetics from _____ n. and sympathetics from _____
vagus; T10/11
What imaginary line is considered the inferior limit of the peritoneum?
Pelvic pain line
What provides general visceral afferents above the pelvic pain line?
Sympathetic to T12-L2
Includes structures within the broad ligament (body and fundus of uterus)
What provides general visceral afferents below the pelvic pain line?
Parasympathetics to pelvic (S2-4)
Anesthesia specifically targets pelvic pain line differences. What are the 3 types of nerve blocks utilized?
Spinal block or lumbar puncture — blocks from waist down (intra and sub-peritoneal plus somatic areas)
Caudal block — blocks sub-peritoneal and somatic areas innervated by pudendal n.
Pudendal nerve block — blocks areas innervated by the pudendal nerve
