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3002 > 67 Male pelvic viscera > Flashcards

67 Male pelvic viscera Flashcards

1
Q

What is the bladder and where does it lie?

A
  • Hollow muscular sac

* Sits on pelvic floor/ diaphragm posterior to pubic bones

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2
Q

How does the bladder fill and empty?

A
  • Fills when its detrusor muscle relaxes

* Empties when its detrusor muscle contracts

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3
Q

What passes through the urogenital triangle?

A

Urethra

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4
Q

Location of bladder apex?

A
  • At upper aspect of pubic symphysis

* ~ 5-7cms above pubic symphysis when bladder is full

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5
Q

Surfaces of bladder?

A
  • (Postero) - Superior
  • Inferolateral x 2
  • Base (trigone)
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6
Q

What structure extends from the apex of bladder?

A

Median umbilical ligaments - remnant of embryonic urachus

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7
Q

How is ureteric reflux prevented anatomically?

A
  • The ureters pass through the bladder wall obliquely, creating a flap valve that prevents urine that is in the bladder from backing up and returning into the ureter (ureteric reflux)
  • Pressure of urine in the full bladder, forcing the ureters closed
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8
Q

Male bladder anatomical relations of base of the bladder?

A
  • Related to prostate glands and it lies on the pelvic floor/ diaphragm
  • Internally the base of the bladder is seen as the trigone between the ureteric orifices and internal urethral orifice
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9
Q

Composition of bladder wall?

A
  • Formed by detrusor muscle

* Lined by transitional epithelium or urothelium (urine-proof and allows distension)

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10
Q

Difference in mucous membrane over the detrusor vs trigone

A
  • Mucous membrane is loose over the detrusor

* Smooth and more fixed over the trigone

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11
Q

What does the male have to prevent semen backflow into bladder?

A
  • Preprostatic smooth muscle (involuntary) - internal urethral sphincter (sympathetic)
  • Contracts during ejaculation to prevent retrograde ejaculation
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12
Q

What aspect of the female anatomy contributes to urinary continence?

A

The bladder neck is above the pelvic floor so that the pressure of pelvic organs as well as the levator ani contribute to urinary continence

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13
Q

What structures provide support to the bladder?

A

Fibromuscular and fascial condensations from the bladder, prostate and urethra to the pubis, lateral pelvic walls, rectum and sacrum that support the bladder

e.g:
• Puboprostatic (male) ligament
• Pubovescial (female) ligament

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14
Q

Rectovesical pouch?

A

In males separating the rectum from the bladder

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15
Q

Rectouterine pouch (of Douglas)

A

In females separating the rectum from the uterus

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16
Q

Vesicouterine pouch

A

In females separating the bladder from the uterus

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17
Q

Where about of bladder is there no peritoneum?

A

Apex

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18
Q

Bladder peritoneal relations

A
  • Retroperitoneal
  • As the bladder distends it pushes the peritoneum superiorly and posteriorly with the bladder then lying directly behind the anterior abdominal wall
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19
Q

Suprapubic catheter safe when?

A

Safe when bladder has distended up against anterior abdominal wall

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20
Q

Male bladder relations

A

Superior:
• Peritoneum
• Ileum
• Sigmoid colon

Base:
• Rectovesical pouch
• Rectum

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21
Q

Arterial supply of the bladder?

A
  1. Anterior trunks of internal iliac artery
  2. Internal iliac artery
  3. Obturator artery
  4. Inferior gluteal artery
  5. Superior vesical artery
  6. Inferior vesical artery (males) replaced by vaginal (females)
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22
Q

Venous drainage of the bladder?

A
  • Vesical venous plexus drains into the internal iliac veins via the inferior vesical veins
  • Males: vesical venous plexus is continuous with the prostatic venous plexus that also drains into the internal iliac veins
23
Q

From the prostate there are valve-less venous communications (Batson venous plexus) with the internal vertebral venous plexus that may facilitate ____?

A

Tumour spread

24
Q

Lymphatic drainage of the bladder?

A

Mainly to external iliac nodes (with some to internal and common iliac)

25
Q

Nerve supply of the bladder?

A
  1. Pelvic plexus (anterior part):
    - passes the rectum to reach bladder
  2. Parasympathetic:
    • Detrusor muscle
    • Afferent and efferent derived from pelvic splanchnic nerves (S2, 3, 4) that reach this muscle via pelvic plexus
  3. Sympathetic:
    • Preprostatic internal urethral sphincter and some to detrusor
    • Derived from T12, L1, L2, and then via the pelvic plexus
26
Q

2 options for bladder catheters

A

Placed:

  1. Urethrally (most common)
  2. Suprapubically
27
Q

What can repeated childbirth do to the pelvic floor/ diaphragm?

A

• Weaken the pelvic floor. diaphragm
• Allows the bladder to drop
=> affecting urinary continence

• Bladder calculi also not uncommon

28
Q

What happens to the superficial fascia/ subcutaneous tissue in male pelvis?

A
  • Camper’s fascia replaced by dartos muscle in scrotum
  • Scarpa’s fascia extends into the scrotum as Colles’/ perineal fascia - fuses with the fascia late of thigh below the inguinal ligament and with the perineal body posteriorly
29
Q

Injury to the male bladder and urethra (particularly anterior urethral injuries)?

A
  • May lead to urine extravasation/ bruising trapped under Scarpa’s and Colles’/ perineal fascia
  • Spread of urine/ bruising is limited to the lower anterior abdominal wall, upper thighs, penis and scrotum anteriorly with no extension posteriorly as the Colles’/ perineal fascia fuses to the perineal body
  • Butterfly wing patter of bruising (“blue swimming trunks”)
30
Q

Preprostatic urethra?

A
  • In bladder neck
  • Internal urethral sphincter
  • Smooth muscle - involuntary

• ~ 0.5-1.5 cm from bladder neck to upper aspect of verumontanum/ seminal colliculus

31
Q

Prostatic urethra?

A

• Receiving ejaculatory duct

  • ~ 3-4 cm
  • Descends through anterior prostate
  • Has a urethral crest with the veumontanum/ seminal colliculus that has the prostatic utricle and ejaculatory duct openings on each side
32
Q

Membranous urethra?

A

Surrounded by external urethral sphincter (striated muscle)

33
Q

Spongy urethra?

A

In bulb of penis (bulbar urethra) and corpus spongiosum (penile urethra)

34
Q

List of male urethra

A
  1. Preprostatic - internal urethral sphincter
  2. Prostatic
  3. Membranous - external urethral sphincter
  4. Spongy - bulbar and penile
35
Q

Function of prostate gland?

A
  • Genital function rather than urinary

* Slightly acid seminal secretion

36
Q

General anatomy of prostate gland?

A
  • Fibromuscular (anterior part) and glandular
  • Upside-down pyramid
  • In tough capsule supported by puboprostatic ligaments
37
Q

Anatomical relations of prostate gland

A
  • Base
  • Apex
  • Posterior surface to Denonvillier’s fascia and rectum
  • Anterior surface to pubic symphysis (prostatic venous plexus in-between these)
  • 2 infer-lateral surface to pelvic floor/ diaphragm
38
Q

Lobes/ zones of prostate gland?

A
  1. Transition 5% - around urethra, anterior to ejaculatory ducts (BPH)
  2. Central 25% - posterior to transition, contains ejaculatory ducts
  3. Peripheral 70% - around transition and central (Ca)
39
Q

Position and role of the seminal vesicals?

A
  • Left + right seminal vesicles (glands) lie just above the prostate gland between the bladder & rectum
  • Secrete seminal fluid to nourish sperm
40
Q

Formation of ejaculatory ducts?

A

Dilated ampullary end of the vas/ductus deferens + Duct from the seminal vesicle = Ejaculatory duct (passes through prostate to enter the prostatic urethra)

41
Q

Blood supply of prostate and urethra?

A
  1. Prostate gland + proximal male urethra:
    • Inferior vesical (+ middle rectal)
  2. Female urethra:
    • Vaginal
    • Internal pudendal
42
Q

Venous drainage of prostate and urethra?

A
  1. Prostate gland + proximal male urethra:
    • Prostatic venous plexus
    • Drains into internal iliac vein
  2. Female urethra:
    • Veins equivalent to the arterial supply - e.g. vaginal + internal pudendal veins
43
Q

Lymphatic drainage of prostate and proximal urethra?

A

Mainly to internal iliac lymph nodes (prostate may drain to presacral nodes too)

44
Q

Nerve supply of prostate and proximal urethra?

A
  1. Somatic motor for control of striated muscle (external urethral sphincter)
  2. Autonomic both sympathetic + parasympathetic
  3. Somatic sensation
  • S2, S3, S4 pudendal nerve + its perineal branches: for somatic motor (+ sensory)
  • PS: pelvic splanchnic nerve to pelvic plexus (afferent + efferent)
  • Sympathetic: from L1 + L2 via superior hypogastric plexus to pelvic plexus (afferent + efferent)
45
Q

What does sympathetic nerves counteract?

A

Counteracts parasympathetic control of detrusor to allow bladder filling, but shuts preprostatic internal urethral sphincter for ejaculation

46
Q

3 stages of micturition (urination)?

A
  1. Storage:
    • Parasympathetic to detrusor “switched off” in spinal cord to allow bladder to relax + fill
  2. “Full” causes desire to micturate/ urinate:
    • Afferents (sensory) to spinal cord, then “M” Centre in pons: stimulates preganglionic, parasympathetic neurones at S2, S3, S4
  3. Void:
    • 1y neurons stimulate 2y neurons in bladder wall ganglia causing detrusor contraction
    • Simultaneous relaxation of external urethral sphincter (striated muscle) – pudendal nerve (S2, S3, S4) & contraction of abdominal wall; sensation of urine in urethra maintains the reflex
47
Q

What is the usual volume (male) in bladder?

A
  • Normal = ~ 400ml

* If reach 500ml: pain in lower abdomen + perineum

48
Q

What controls detrusor muscle?

A
  • Essentially under parasympathetic control
  • Counteracted via the sympathetic to allow the bladder musculature to relax so that the bladder fills without any increase in tension
49
Q

What is the autonomic stretch reflex?

A
  • Stretch receptors send signals via the parasympathetic pelvic splanchnics (afferents) to cord segments S2, S3, S4
  • This triggers reflexes in the parasympathetic efferents (pelvic splanchnics to pelvic plexus & then to bladder wall) to cause detrusor (bladder) contraction
50
Q

What is the importance of autonomic stretch reflex that prevails in the untrained infant?

A

Bladder empties automatically when full

51
Q

Effect of training on on the autonomic stretch reflex of the bladder?

A

Afferents (sensory) ascend up the spinal cord to trigger cortical inhibition in the frontal lobe; this superimposes cortical control on the “M” (micturition) Centre in the pons that in turn (via reticulospinal & corticospinal pathways) usually controls or stimulates preganglionic parasympathetic neurones at S2, S3, S4 cord segments

52
Q

Which clinical scenerios result in detrusor control returning to automatic, infant reflex?

A

Cord transection above S2 or loss of cortical control following a stroke cause a return to the automatic infant reflex (the bladder empties when full)

53
Q

What clinical scenario results in a paralysed detrusor muscle and the bladder distending until there is overflow incontinence?

A

If the sacral segments 2, 3, 4 are destroyed, detrusor is paralysed & the bladder distends until there is overflow incontinence

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