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RDS Test 3 > B8.044 Pelvic Vessels, Nerves, and Lymphatics > Flashcards

B8.044 Pelvic Vessels, Nerves, and Lymphatics Flashcards

1
Q

general principles surrounding pelvic vasculature

A

most arteries of the pelvis are from the internal iliac arteries, but several are off the abdominal aorta
generally arteries and veins run together and have the same names

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2
Q

bifurcation of the AA

A

L4
same level as top of iliac crest
spinal taps performed here

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3
Q

pelvic arteries that come directly off of the AA

A

superior rectal artery (branch of IMA)
median sacral artery
ovarian and testicular arteries

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4
Q

testicular and ovarian venous return

A

L veins return blood to the L renal vein

R veins return blood to the IVC, lower pressure vessel

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5
Q

varicocele

A

incidence much more frequent on L side than R side

L renal vein is higher pressure than the IVC

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6
Q

renal vein entrapment syndrome

A

weight gain and sagging abdominal viscera can lead to compression of the L renal vein by the SMA

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7
Q

divisions of the internal iliac arteries

A

60% of the time: anterior and posterior
20% of the time: anterior, middle, posterior
10% of the time: different branch pattern

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8
Q

arteries from the posterior division of the internal iliac

A

superior gluteal
iliolumbar
lateral sacral

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9
Q

arteries from the anterior division of the internal iliac

A 
obturator artery
umbilical artery
superior vesicular artery
uterine artery
vaginal artery
inferior vesicular artery
middle rectal artery
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10
Q

terminal branches of the internal iliac

A

inferior gluteal

internal pudendal

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11
Q

accessory obturator artery

A

present in 27% of people

branch off of external iliac artery w inferior epigastric

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12
Q

which arteries arise from the middle division of the internal iliac, when present

A

middle rectal artery
inferior gluteal artery
internal pudendal artery

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13
Q

arteries that serve the rectum

A
  1. superior rectal - off IMA
  2. middle rectal - off internal iliac
  3. inferior rectal - off internal pudendal (an internal iliac branch)
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14
Q

rectal venous return

A
  1. superior rectal vein - returns blood to the portal system
  2. middle rectal vein - returns blood to the IVC
  3. inferior rectal vein - returns blood to the IVC
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15
Q

venous plexus of the anus and inferior rectum

A

just underneath the mucosa

internal rectal plexus above the pectinate line, external rectal plexus in the perianal space

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16
Q

what causes hemorrhoids

A

increase in portal hypertension, lots of abdominal straining (with constipation), pregnancy, obesity, and other conditions can cause and engorgement of blood in either or both of the venous plexuses

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17
Q

external hemorrhoids

A

inferior to the pectinate line
painful
somatic innervation

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18
Q

internal hemorrhoids

A

superior to the pectinate line
painless
may go unnoticed for years unless they bleed or prolapse with defecation

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19
Q

first degree internal hemorrhoid

A

bulges into the anal canal during bowel movements

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20
Q

second degree hemorrhoid

A

bulges from the anus during bowel movements, then goes back inside by itself

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21
Q

third degree hemorrhoid

A

bulges from the anus during bowel movements and must be pushed back in with a finger

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22
Q

fourth degree hemorrhoid

A

protrudes from anus all the time

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23
Q

treatment for internal hemorrhoids

A

rubber band ligation

takes 7-10 days to necrose and fall off

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24
Q

collateral arterial circulation in the pelvis

A 
branches from the aorta:
ovarian artery
IMA
lumbar and vertebral arteries
middle sacral artery
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25
Q

ovarian artery

A

anastomoses freely with uterine artery (thus serves both the ovaries and the fundus of the uterus)
also anastomoses with the vaginal artery

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26
Q

inferior mesenteric artery

A

forms superior rectal arteries which anastomose with the middle and inferior rectal arteries from the internal iliac and internal pudendal arteries

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27
Q

lumbar and vertebral arteries

A

anastomose with the iliolumbar artery

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28
Q

middle sacral artery

A

anastomoses with the lateral sacral artery

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29
Q

fibroid embolization

A

catheter placed through femoral artery and threaded into uterine artery
emboli used to disrupt blood flow to fibroid
only do this post-reproductive years

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30
Q

branches from the external iliac artery

A 
deep iliac circumflex artery
obturator artery (in 27%)
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31
Q

phleboliths

A

vein stones

arise due to calcification of the wall or thrombus of pelvic veins

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32
Q

epidemiology of phleboliths

A

rarely seen in developing countries

uncommon in children and more common in adults who consume a low fiber diet (about 50% of 60 year olds in US)

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33
Q

somatic pelvic nerves

A

sacral and coccygeal plexus

34
Q

lumbosacral trunk

A

L4 and L5 ventral nerve rami combined

35
Q

relationship between superior gluteal artery and pelvic nerves

A

generally leaves the pelvis by passing in between the lumbosacral trunk and S1 ventral ramus

36
Q

relationship between inferior gluteal artery and pelvic nerves

A

passes out of the pelvis in between the S2 and S3 ventral rami

37
Q

pudendal nerve

A

S2,3,4

distribution: external urethral and anal sphincters, motor and sensory to external genitalia

38
Q

pudendal nerve mnemonic

A

S2,3,4 keep the poop, pee, penis off the floow

via pelvic splanchnic and cavernous nerves

39
Q

sacral splanchnic nerves

A

postganglionic sympathetic nerve that leaves the sacral portion of the sympathetic chain

40
Q

pelvic splanchnic nerves

A

parasympathetic

41
Q

course of the sympathetic chain

A

travels down into the tip of the coccyx where the right and left chains join together at the ganglion impar
preganglionic sympathetic fibers no longer exit from the spinal cord below L1
postganglionic sympathetic axons continue to leave the sympathetic chain to join both dorsal and ventral rami at every spinal level since all spinal nerves need sympathetic innervation

42
Q

course of the parasympathetic nervous system

A

preganglionic parasympathetic nerves have their cell bodies in the lateral column of the spinal cord at S2,3,4
travel down within the cauda equina to exit out of the ventral foramen of the sacrum at S2,3,4

43
Q

innervation of the penis

A

dorsal nerve of the penis for sensation

autonomic innervation for vasodilation/ erection via prostatic plexus and cavernous nerves

44
Q

erection

A

parasympathetic stimulation through the pelvic splanchnic, inferior hypogastric, and prostatic nerve plexuses + cavernous nerves
allows vasodilation of the helical arteries allowing more than 5-10 fold blood into the erectile tissue sinusoidal spaces

45
Q

function of bulbospongiosus and ischiocavernous muscles

A

contract to help limit venous blood flow out of the erectile tissue and keep blood in the distal penis and out of the base of the penis

46
Q

what is emission

A

delivery of sperm from the vas deferens, prostatic secretions and seminal secretions into the prostatic urethra

47
Q

emission innervation

A

sympathetic innervation (L1,2 sacral splanchnic and inferior hypogastric nerves) to smooth muscle in walls of vas deferens, prostate, and seminal vesicle

48
Q

ejaculation

A

forceful removal of semen from the urethra
internal urethral sphincter must remain closed
external urethral sphincter must open
bulbospongious muscles contract forcing semen from the penis base

49
Q

internal urethral sphincter

A

smooth muscle
innervated by sympathetics
at junction of the bladder with the prostate

50
Q

external urethral sphincter

A

skeletal muscle

at the pelvic diaphragm

51
Q

innervation of bulbospongiosus

A

pudendal nerve S2,3,4

52
Q

detumescence

A

loss of an erection
follows sympathetic discharge required for emission and causes constriction of the helical arteries reducing blood flow into the cavernous tissue

53
Q

mixed autonomic plexuses of the pelvis

A

hypogastric plexuses
superior hypogastric plexus gives rise to L and R hypogastric nerve
L and R hypogastric nerves connect to R and L inferior hypogastric plexuses

54
Q

inferior hypogastric plexuses

A

vesicle plexus
rectal plexus
prostatic plexus (males)
uterovaginal plexus (females)

55
Q

support of the vaginal in the pelvis

A

middle 3rd: levator ani muscles, upper portion of the cardinal ligaments

56
Q

cervical pain fibers

A

accompany parasympathetics from S2,3,4

57
Q

fibers to the muscles and skin of the vulva

A

pudendal nerve and its branches

58
Q

major function of perineal membrane

A

supports the urethra and maintains the urethrovesical junction

59
Q

epidemiology of double/bifid ureter

A

1-4% of the population

60
Q

how to distinguish the ureter from pelvic vessels during surgery

A
  1. identify peristalsis after stimulation by touching

2. identified Auberbach’s nerve plexuses which surround it

61
Q

pudendal canal (Alcock’s canal)

A

thickening of the epimysium on the medial aspect of the obterator internus muscle
contains the pudendal nerve and internal pudendal artery and vein

62
Q

use of pudendal nerve block

A

provide some relief from the pain of childbirth

injection of local anesthetic

63
Q

how to administer a pudendal nerve block

A

pudendal nerve wraps around the ischial spine to gain access to the urogenital region
OB palpates ischial spine transvaginally and injects near this location

64
Q

when can you not due a transvaginal pudendal nerve block

A

if baby’s head is too far down the birth

can be done transperineally

65
Q

innervation of most of the female external genitalia

A

S3 dermatome

S4-S5 surround perineum and anus

66
Q

first stage of birthing

A

dilation of cervix and distention of the lower uterine segment
visceral pain
mediated by T10-L1 segments of spine

67
Q

second stage of birthing

A

distention of the pelvic floor, vagina, and perineum
somatic pain added
mediated by S2-S4 segments of spine

68
Q

motor pathways to the uterus

A

leave spinal cord at T7-8

any sensory block below this can be used for analgesia during labor

69
Q

lumbar epidural/lumbar spinal blocks

A

used for 1st stage of labor

injected into subarachnoid space

70
Q

epidural

A

drug injected into extradural space, filled with venous blood and fat
drug travels via diffusion

71
Q

caudal epidural block/ pudendal nerve block

A

used for 2nd stage of labor

72
Q

pudendal nerve block vs. caudal epidural block

A

caudal is a “saddle block”

pudendal is the least invasive, good for those who want to “participate more in birthing process”

73
Q

epidural meds

A 
local anesthetics (bupivicaine, chloroprocaine, lidocaine)
delivered in combo with opioids or narcotics (fentanyl and sufentanil)
74
Q

when are epidurals placed

A

when cervix is dilated to 4-5 cm

in true active labor

75
Q

spinal block vs epidural

A

spinal block similar but injected into subarachnoid space
faster effect than epidural
used if a C-section needs to be done, but its too late to start an epidural

76
Q

how to find caudal epidural space

A

sacral hiatus

77
Q

bottom line regarding lymphatic drainage of the pelvis

A

follows vebous drainage
anterior and middle pelvic organs at the level of the roof of the bladder drain into external iliac nodes
pelvic nodes highly interconnected, so drainage can pass in almost any direction

78
Q

nodal evidence of inflamed hemorrhoids

A

enlarged superficial inguinal nodes

79
Q

external vaginal lymphatic drainage

A

inferior vulva to superficial inguinal

rest to internal iliac (clitoris, labia minora, urethra)

80
Q

testicular lymphatic drainage

A

lumbar aortic/ IVC nodes

81
Q

prostate lymphatic drainage

A

internal iliac and sacral

82
Q

seminal vesicle lymphatic drainage

A

internal and external iliac

RDS Test 3 (15 decks)

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