ERS32 Anatomy Of The Male And Female Pelvis Viscera, Perineum And Breast Flashcards
Blood supply, Nervous supply of Organs in true pelvis
Main support: Pelvic diaphragm
Blood supply:
***Internal iliac artery branches
Nervous supply:
***Hypogastric plexus
(記住: 逢係比Hypogastric innervate既都係involuntary structures!!! ∵ Hypogastric —> Autonomic NS)
Pelvis sagittal section
- Urinary bladder (most anterior)
- Uterus (middle)
- Rectum (most posterior, 65% large bowel cancer, detected by Digital rectal exam, Proctosigmoidoscopy/Colonoscopy)
- **Retroperitoneal, not covered by mesentery, fixed in location
- **Ampulla (widest, most distensible)
—> 3x Transverse folds / ***Valves of Houston (help in rectal continence) (2 on left, 1 on right)
- Anal canal - Peritoneum
- cover Superior part of Bladder
- cover Anterior Rectum
- enclose Uterus
- protective layer -
**Puborectalis / Rectal sling
- part of **pelvic diaphragm, support ***Anorectal junction
- help in rectal continence - Potential space between bladder, rectum, uterus
- Male: **Rectovesical pouch
- Female: **Rectouterine pouch / Pouch of Douglas
Anatomical relationships of Rectum
Anterior:
Female: Uterus, **Rectouterine pouch
Male: Urinary bladder, **Rectovesical pouch
Posterior:
Both: Sacral bone (Sacrum), Sacral nerves, LN
Blood supply, Nerve supply, and Lymphatic drainage of Rectum
Blood supply:
1. Superior Rectal A+V (Inferior mesenteric artery) —> Inferior mesenteric vein
2. Middle Rectal A+V (Internal iliac artery) —> Internal iliac vein
3. Inferior Rectal A+V (Internal iliac artery —> Internal pudendal artery) —> Internal iliac vein
—> interconnected to form ***Rectal Anastomosis
Nerve supply:
***Hypogastric plexus (ANS)
Lymphatic drainage: 1. Pararectal nodes 2. Preaortic nodes 3. Inferior mesenteric nodes —> Intestinal trunk —> Cisterna chyli —> Thoracic duct
Spread of rectal cancer
- Posterior —> Sacral plexus (anatomical division) (severe pain)
- Anterior —> Bladder, Prostate, Seminal vesicle, Uterus, Vagina
- Lymphatics —> Involved deeper nodes —> Liver
Liver cirrhosis
Obstruction —> Portal hypertension —> blood shunted from Inferior mesenteric vein —> Rectal vein —> IVC —> ***dilatation of Rectal veins —> ***Haemorrhoids
(Inferior mesenteric vein入唔到Hepatic Portal vein)
Anal canal coronal section
高—>低
1. Rectum
-
**Anorectal junction (upper boundary)
- **Puborectalis muscle (lateral, outside rectal wall) / Rectal sling
—> **S4, S5 + **Pudendal nerve branches - Upper half of anal canal
- Anal column
- Anal sinus (space in between Anal column)
- ***Anal valve (connect lower border of columns) -
**Pectineal / Dentate line (lower boundary)
- Sphincter Ani Internus / Internal sphincter
—> Circular smooth muscles, Involuntary
—> **Inferior Hypogastric plexus (ANS i.e. involuntary) (Parasympathetic fibres) - Lower half of anal canal
- ***Ischiorectal fossa (lateral to lower half of anal canal)
—> SC fat, A+V, nerves -
**Anocutaneous line
- Sphincter Ani Externus / External sphincter (3 parts)
—> Striated muscle, Voluntary
—> **S4 (perineal branch) + ***Inferior Rectal nerve (Pudendal nerve branch) - Skin
Upper half vs Lower half Anal canal
Upper half
- Columnar (***Endoderm)
- Superior Rectal A+V
- ***Hypogastric plexus
- Pararectal LN
Lower half
- Stratified squamous (***Ectoderm)
- Inferior Rectal A+V
- ***Inferior Rectal nerve (Pudendal nerve / Somatic)
- Superficial Inguinal LN
Male Bladder, Prostate, Seminal Vesicles sagittal section
Bladder (Endoderm)
- Ureteric orifice
- Ureteric fold / ridge (connect to Ureteric orifice)
- Trigone (below Ureteric fold) (Mesoderm)
Prostate - below bladder, above Perineal membrane - base attached to bladder, apex point inferiorly (倒三角) - ***fibromuscular CT 5 lobes: 1. Anterior lobe
- Median lobe
- highly **glandular, prone to **BPH (Transitional zone), detected by digital rectal exam
—> obstruct opening of neck of bladder
—> urinary retention in bladder
—> infection within bladder (can spread to kidney via ureter) - Posterior lobe
- prone to **malignancy, **Prostatic venous plexus —> Vertebral plexus —> CNS)
- Prostatic cancer has high level of Prostatic Acid Phosphatase (∵ secretory obstruction) —> Cancer Marker - Lateral lobes x2
- Ejaculatory duct (joined by Seminal vesicle: go between Median/Posterior lobe)
- Prostatic urethra
- Perineal body
-
**Urogenital diaphragm (derived from **Deep transverse perineal muscle)
- Bladder and Prostate sit on top
Above prostate
1. ***Internal urethral sphincter (Involuntary)
Below prostate
-
**Sphincter urethrae muscle (Voluntary)
- derived from **Urogenital diaphragm (derived from ***Deep transverse perineal muscle)
Blood supply, Nerve supply, Lymphatic drainage of Prostate
Blood supply:
1. **Inferior Vesical A+V (Internal iliac artery)
2. **Middle Rectal A+V (Internal iliac artery)
—> **Prostatic venous plexus (connection with **Vertebral vein posteriorly —> tumour in prostate can spread to spine/brain)
—> Internal iliac vein
Nerve supply:
- ***Hypogastric plexus
Lymphatic drainage:
- Internal iliac nodes
Male urethra
20 cm (Female: 4 cm)
- Prostatic urethra
- traverse Prostate
- **most dilatable part
- location of **opening of ejaculatory duct - Membranous urethra
- within Urogenital diaphragm
- surrounded by **Sphincter urethrae muscle (other structures within: **Bulbourethral gland (male), **Greater vestibular gland (female))
- **most fixed, narrowed —> prone to trauma during instrumentation / accidents - Spongy (Penile / Cavernous) urethra
- longest
- pierce Corpus spongiosum (erectile tissue; Corpus cavernosum another erectile tissue)
- Urethral lacunae (opening along urethra, frequently infected by STI: Gonococcus —> may develop stricture)
—> Urethral glands (underneath)
- ***Navicular fossa (terminal dilated part)
- External urethral orifice
Urethral sphincter:
- Internal urethral sphincter (involuntary (ANS), above prostate, 喺正bladder出口)
- Sphincter urethrae muscle / External urethral sphincter (voluntary, below prostate)
- derived from ***Urogenital diaphragm
Hypogastric plexus
Sympathetic (Prevertebral ganglia):
- L1, L2 (Lumbar + Sacral splanchnic nerve)
Parasympathetic:
- S2-S4 (Pelvic splanchnic nerve)
Aortic plexus
Sympathetic (Prevertebral ganglia): T5-T11 1. Celiac ganglion 2. Superior mesenteric ganglion 3. Inferior mesenteric ganglion
Parasympathetic: Vagus nerve (mainly) + S2-S4 (via Inferior mesenteric ganglion)
Summary of Prevertebral plexus / ganglia (self-understanding)
Major
- Celiac plexus
- Celiac ganglion
- Aorticorenal ganglion - Aortic plexus (T5-T11 (sympathetic), Vagus (parasympathetic))
- Celiac ganglion
- Superior mesenteric ganglion
- Inferior mesenteric ganglion
—> T12-L2 (sympathetic)
—> S2-S4 (parasympathetic)
Minor
- Superior Hypogastric plexus
- L1-L2 (Lumbar splanchnic nerves) —> sympathetic
- S2-S4 (Pelvic splanchnic nerves) —> parasympathetic - Inferior Hypogastric plexus
- continuation of Superior Hypogastric plexus
- Sacral splanchnic nerves —> sympathetic (係L2升降機落Sacral part)
- S2-S4 (Pelvic splanchnic nerves) —> parasympathetic
Pelvic diaphragm
Lateral wall of PD: **Obturator internus
Posterior wall of PD: **Piriformis
Function of PD:
- ***Support + Stabilise Pelvic viscera at floor of pelvic cavity
- ***Sphincter for Anorectal junction (唔關anal sphincter事)+ Vagina
PD / Perineal damaged during childbearing:
Uterine / other pelvic viscera prolapse
- weakness of pelvic floor —> pelvic viscera (e.g. Uterus) protrude from pelvic diaphragm into Vagina
***Urogenital diaphragm and Pelvic diaphragm (lateral view)
- Pubic arch (anterior)
- Sacrum (posterior)
- Pelvic inlet (superior)
- Pelvic outlet (inferior)
- Urogenital diaphragm (anterior, horizontal)
- enclosed inside **Deep perineal pouch by **Perineal membrane
- connect to Pelvic diaphragm via **Perineal body (fibromuscular structure)
- transected by **Urethra, Vagina
—> ***Sphincter urethrae muscle / External urethral sphincter - Pelvic diaphragm (slightly angulated)
- **Levator ani muscle
—> **Puborectalis (part of Pubococcygeus, innermost) —> support Anorectal junction
—> Pubococcygeus
—> Iliococcygeus
- ***Coccygeus muscle
5+6 —> transects pelvic cavity at lower end
- Perineal body
- posterior to Prostate / Vagina
Upper area (extend into Pelvic inlet): True pelvic cavity
- Pelvic viscera
—> **Internal iliac artery
—> **Hypogastric plexus
Lower area (extend into Pelvic outlet): Perineum
- External genitalia
—> **Internal pudendal artery (anterior branch of Internal iliac artery)
—> **Pudendal nerve
***Urogenital diaphragm and Pelvic diaphragm (bottom view)
- Urogenital diaphragm (anterior)
- Urethra —> Sphincter urethrae muscle / External urethral sphincter
- Vagina (female) - Perineal body
- Anal canal (posterior to Perineal body)
- ***Anococcygeal raphe
- fibrous structure connecting both sides of Pelvic diaphragm
Pelvic diaphragm muscles:
- Levator ani muscle
- Puborectalis (part of Pubococcygeus, innermost) —> support Anorectal junction
- Pubococcygeus
- Iliococcygeus - Coccygeus muscle
***Nerve supply of Pelvic diaphragm
**S4-S5 + **Pudendal nerve branches
Female pelvis coronal section
Uterus (下—>上):
- Cervix
- External os
- Cervical canal
- Internal os - Body
- **Round / Proper ligament of uterus (maintain normal position of uterus)
—> pass through **Inguinal canal (lower end of Abdominal wall)
—> beneath ***Labia majora (Gubernaculum remnant stick to Labioscrotal folds) - Fundus
- Cornu (Entry point of Uterine tube into Uterus)
Other structures:
5. Ovaries
- Ureter
- beneath **Uterine artery
—> **Hysterectomy (removing uterus)
—> Accidental ligation of Ureter - Vagina
Female pelvis sagittal section
- Urogenital diaphragm
- support **Bladder (anterior) + **Vagina
- enclosed inside Deep perineal pouch by Perineal membrane
- Sphincter urethrae muscle (voluntary)
- Perineal body (connect to Pelvic diaphragm) - Pelvic diaphragm
-
**Broad ligament (double fold of Peritoneum)
- cover Bladder (superior) + Uterus (all around) + Rectum (anterior) + Fallopian tube (lateral) + Ovary (partly) + Pelvic inlet (Suspensory ligament of ovary)
- **Mesosalpinx (cover Fallopian tube)
- **Mesovarium (partly cover Ovary)
- **Rectouterine pouch -
**Suspensory ligament of ovary (extension of Broad ligament into Pelvic inlet)
- cover **Ovarian A+V
- Ureter (posterior to ligament)
Ovaries
Close connection with Fimbriae
- **Support:
1. Ligament proper of Ovary / Ovarian ligament —> attach Ovary to Uterus
2. Suspensory ligament of Ovary (contain ***Ovarian A+V)
3. Mesovarium
Blood supply:
- ***Ovarian A + Uterine A (Ovarian / Tubal branches)
- ***Left Ovarian vein —> Left Renal vein / Right Ovarian vein —> IVC
Nerve: ***Aortic plexus
Lymphatics: Paraaortic nodes
Clinical significance:
***Ovarian torsion secondary to tumour with long Mesovarium / Mesosalpinx —> Ovary closely related to Obturator nerve (in Ovarian fossa) —> Referred pain to medial thigh/knee
Fallopian tube
Support:
- ***Mesosalpinx
4 parts:
(Uterine part)
1. Isthmus (narrowest)
2. Ampulla (widest, 95% of fertilisation)
3. Infundibulum
4. Fimbriae (finger-like structures: close connection with Ovaries)
Blood supply: **Ovarian + **Uterine A+V
Clinical significance:
- ***Pelvic inflammatory disease (ascending infection from perineum —> uterine cavity —> pelvic cavity)
- ***Ectopic pregnancy (Ampulla)
- Uterosalphingography: inject dye to test patency of tube
Vagina
Anterior + Posterior fornices (potential space around cervix where vagina is attached)
**PF close relationship with Rectouterine pouch
—> Dilatation and Curettage
—> **puncture superior wall into Rectouterine pouch
—> bacteria spread from vagina to pelvic cavity, peritoneum
—> ***Pelvic inflammatory disease / Infection
- **Support:
- Upper part: PD, Pelvic fascia
- Middle part: UD
- Lower part: Perineal body (posterior to vagina, prolapse of uterus if damaged)
Blood supply:
- Vaginal branch of Uterine A, Internal iliac A, Middle Rectal A, Internal Pudendal A
- Vaginal venous plexus —> Internal iliac V
Nerve:
- Upper: Uterovaginal plexus (from Inferior hypogastric plexus)
- Lower: Pudendal nerve
Lymphatics:
- Upper / Middle part: Internal + External iliac nodes
- Lower: Internal iliac nodes + Superficial inguinal nodes
Clinical correlations:
- ***Posterior fornix —> Pelvic inflammatory disease
- Bimanual, Digital examinations: diagnosis of tumour, determine location, position of uterus
Uterus
Position:
- Anteverted (Round ligament) + Anteflexed
Support:
- UD + PD (Primary support)
- Broad ligament —> Pelvic Fasciae condensation (Secondary support)
Blood supply:
Uterine A+V (Internal iliac artery)
—> Uterine venous plexus
—> Internal iliac vein
Nerve supply:
- Hypogastric plexus
Lymphatic drainage:
- External / Internal iliac nodes + Sacral nodes
Clinical significance:
- ***Hysterectomy (removing uterus) —> Accidental ligation of Ureter (beneath Uterine artery)
- ***Destruction of PD —> Uterine prolapse
- ***Retroverted uterus —> Infertility because of abnormal position
Pelvic Fasciae Condensation
Collection of CT derived from muscular fasciae at Pelvic walls, floor
—> formation of:
1. Transverse cervical ligament (Cardinal ligament)
2. Uterosacral ligament
3. Pubocervical ligament
Position of Uterus, Cervix, Vagina
- Axis of Uterine body
- Axis of Cervix
- Axis of Vagina
Axis of Uterine body + Axis of Cervix:
- Angle of anteflexion (obtuse angle)
Axis of Vagina + Axis of Cervix:
- Angle of anteversion (obtuse angle)
Normal position of uterus:
- Anteverted (round ligament) + Anteflexed
- supported by PD, UD, Broad ligament
Abnormal position of uterus:
- Retroverted uterus (Uterine body tilted posteriorly)
—> Infertility (sometimes)
Perineum
- Region between pelvic outlet and inlet below PD (Levator ani muscle)
- 2 main potential spaces: **Superficial + **Deep perineal pouches / spaces
Structures:
- External genitalia (Male / Female)
Blood supply:
- Internal pudendal artery branches
Nerve:
- Pudendal nerve
Perineal body
Female > Male
- attachment of
1. **Levator ani muscle (PD)
2. **External ani sphincter
3. **Bulbospongiosus
4. **Superficial transverse perineal muscle
***Perineum bottom view
- Pubic arch (anterior)
- Sacrum (posterior)
- Ischial tuberosity (lateral)
Line across Ischial tuberosity
4. Perineal body (centre of line)
- Urogenital triangle (anterior)
- Urethra
- Vagina - Anal triangle (posterior)
- Anal canal
- **Ischiorectal fossa (space lateral to lower half of anal canal, mainly SC fat, A/V supply, nerve)
- **Anococcygeal body / ligament (posterior to perineal body)
Ischiorectal fossa
- Filled with ***SC adipose tissue
- ***Poor blood supply (vulnerable to infection / abscess)
Contents:
- **Internal Pudendal vessels (Internal iliac A) —> within **Pudendal canal
- ***Pudendal nerve —> within Pudendal canal
- ***External anal sphincter
- External anal venous plexus
***Male Urogenital triangle
2 potential spaces in Perineum
- Deep perineal pouch
- bounded by Superior fascia of UD (deep layer) + Inferior fascia of UD (Perineal membrane)
Contents:
- UD / Deep transverse perineal muscle —> Sphincter urethrae (Perineal branch of Pudendal nerve)
- ***Membranous urethra
- ***Bulbourethral glands
- Internal pudendal vessels
- Dorsal nerve of penis
(Sphincter urethrae vs Sphincter vesicae (bladder / Internal urethral sphincter): Involuntary (ANS), NOT part of DPP)
- Superficial perineal pouch
- below Inferior fascia of UD
- Superficial fascia (出) (Camper’s fascia —> Dartos muscle)
- **Membranous fascia (入) (Scarpa’s fascia, fibrous CT —> **Colles’ fascia)
Contents:
- ***External genitalia
- ***Ischiocavernosus muscle
- ***Bulbospongiosus muscle
- ***Superficial transverse perineal muscle —> fix position of Perineal body
- Deep perineal branch of Pudendal nerve + Internal pudendal vessels
Male Perineum sagittal section
- Skin
- ***Superficial perineal pouch
- Superficial fascia (Camper’s fascia)
- Membranous fascia (Scarpa’s fascia, fibrous CT)
—> extend to Penile shaft + extend down to Perineum, connect with Perineal body (Colle’s fascia) - ***Deep perineal pouch
- Perineal membrane
—> enclose Deep transverse perineal muscle / Urogenital diaphragm within Deep perineal pouch - Urethra
- transects Deep perineal pouch, Perineal membrane, Urogenital diaphragm
—> pass through Corpus spongiosum
Male External genitalia
Erectile tissues - specialised tissues with vascular sinuses —> filled with blood —> expand —> erection
Root of penis:
- ***Crus of penis
- ***Bulb of penis (attach to inferior floor of UD, also pierced by Urethra —> Spongy urethra)
(Root separated from Body at ***pubic symphysis)
Body of penis:
- ***Corpus cavernosum
-
**Corpus spongiosum
- pierced by Urethra
- expanded part —> **Glans penis (Corona glandis: the circumference)
- opens at Navicular fossa —> External urethral orifice
1-4 —> **Micturition + **Erection
Other structures:
- ***Ischiocavernosus muscle (striated muscle)
- cover Crus of penis
- enclose Corpus cavernosum - ***Bulbospongiosus muscle (striated muscle)
- cover Bulb of penis
5 + 6 —> assists in **Micturition + **Erection
—> compress Bulb of penis
—> pull Root of penis (Crus + Bulb) —> erection
Scrotum:
- Testes + Epididymis
Blood supply of Male external genitalia
Arterial:
***Internal Pudendal artery
Branches:
- ***Deep artery of penis —> Corpus cavernosum
- ***Dorsal artery of penis —> Corpus cavernosum, skin, superficial layer
- Inferior Rectal A —> Lower 1/3 anal canal
- Perineal A —> Scrotum, Superficial transverse perineal muscle
- ***Artery to Bulb of penis —> Bulb, Corpus spongiosum, Bulbourethral gland
- Urethral artery —> Spongy urethra
Vein:
- ***Internal pudendal vein —> Internal iliac vein
- **Deep dorsal vein (同Dorsal artery平排) —> **Prostatic venous plexus (Vertebral plexus —> CNS)
- ***Superficial dorsal vein —> Femoral vein
Lymphatic drainage of Male external genitalia
Deep penis:
***Internal iliac nodes + Deep inguinal nodes
Superficial penis:
***Inguinal nodes
Scrotum:
Medial group of ***superficial inguinal nodes
Nerve supply of Male external genitalia
- **Pudendal nerve: **S2-S4 (Only Sympathetic, ***Hypogastric plexus)
- Inferior rectal nerve
—> External anal sphincter, Skin of lower 1/3 of anal canal, Perianal skin - Perineal nerve
—> ALL striated muscle of perineum + Posterior skin of scrotum (Posterior scrotal branch)
(Anterior skin of scrotum: Ilioinguinal + genitofemoral nerves) - Dorsal nerve of penis
- Ischiocavernosus muscle + Bulbospongiosus muscle:
- ***Perineal branches of Pudendal nerve - Ejaculation (Vas deferens, Prostate, Seminal vesicle):
- **L1, L2 (*Sympathetic)
Female Urogenital triangle
Deep perineal pouch:
- ***Urethra: 3.8 cm
- ***Greater vestibular glands (~ Bulbourethral gland) + Paraurethral glands (lateral to Urethra)
- **Deep transverse perineal muscle (UD) —> **Sphincter urethrae
- Internal pudendal vessels
- Dorsal nerve of clitoris
Superficial perineal pouch:
-
**Ischiocavernosus muscle
- cover **Crus of ***clitoris
- assist erection -
**Bulbospongiosus muscle
- cover **Bulb of **vestibule
- surround vaginal orifice
- compress **Deep dorsal vein of clitoris —> erection - ***Superficial transverse perineal muscle —> fix position of Perineal body
1+2+3 —> ***Perineal branch of Pudendal nerve
- ***Clitoris (~ External genitalia in male)
- Deep perineal branches of perineal nerve + Internal pudendal vessels
- Greater vestibular glands (~ Bulbourethral gland)
- ***Bulb of vestibule
Female External genitalia
Similar to male except:
- ***Presence of vaginal canal (8 cm)
- ***Absence of extra-abdominal gonads
- ***Urethra does not traverse clitoris (penis)
- ***Bulb of vestibule x2
Partly pass through **Superficial perineal pouch
1. **Labia majora
- ***Labia minora
- Fourchette (posterior)
- Prepuce and Frenulum of clitoris (anterior) - Mon pubis = anterior to pubis
- Vestibular fossa
- Clitoris
Root of clitoris: - Bulb of vestibule (split by vaginal opening)
- ***Crus of clitoris
Body of clitoris:
3. ***Corpus spongiosum
—> Glans of clitoris (expanded part)
- ***Corpus cavernosum
Other structures:
- ***Ischiocavernosus muscle (striated muscle)
- cover Crus of clitoris - ***Bulbospongiosus muscle (striated muscle)
- cover Bulb of vestibule
6 + 7 —> assists in ***Erection of clitoris
- Vaginal orifice: Hymen
- Urethra
- opens directly to outside (***does NOT pierce Corpus spongiosum)
Blood supply of Female external genitalia
Arterial:
Internal Pudendal artery + Vaginal artery (Branch of Internal iliac A —> lower 1/3 of vagina)
Internal Pudendal artery Branches:
- ***Deep artery of clitoris
- ***Dorsal artery of clitoris
- Posterior Labial artery (Posterior Scrotal A in Male)
- Perineal artery
- ***Artery of Bulb of vestibule
- Urethral artery
Vein:
- Internal Pudendal vein —> Internal iliac vein
- Deep dorsal vein of clitoris —> Vesical plexus of veins
Lymphatic drainage of Female external genitalia
Superficial inguinal nodes
Nerve supply of Female external genitalia
- Pudendal: S2-S4
(- Parasympathetic? - continuation of Crus of clitoris?)
Pudendal nerve branches
- Inferior rectal nerve
- External anal sphincter - Perineal nerve
- ALL striated muscle of SPP
- Ischiocavernosus muscle + Bulbospongiosus muscle - Dorsal nerve of clitoris
Female Urinary bladder coronal section
- Deep perineal pouch
- Deep transverse perineal muscle / Urogenital diaphragm - Sphincter urethrae
- inside DPP
- incompletely developed
- damage to UD —> urinary incontinence - Superficial perineal pouch
- Crus of clitoris
—> Ischiocavernosus muscle
- Bulb of vestibule ***x2
—> Bulbospongiosus muscle - Urethra
- opens directly to outside (does ***NOT pierce Corpus spongiosum)
- split Bulb of vestibule into 2 - Levator ani muscle
Clinical correlations of External genitalia
- Haemorrhoids
- Varicosities of Superior (internal haemorrhoids) / Inferior rectal veins (external haemorrhoids)
- Rectal venous plexus: Anastomosis of superior, middle, inferior rectal veins (valveless)
- Predisposing factors: Chronic constipation, Portal hypertension, Pregnancy, Rectal tumour - Rectal examination
- Assess tone of external anal sphincter
- Assess prostatic enlargement / rectal tumour (Male)
- Detect presence of Pelvic adnexa (lump in uterine appendages), Pelvic inflammatory disease, Ectopic pregnancy, tumour (Female) - Episiotomy
- posterolateral incision of perineal skin
- Pudendal nerve block performed prior - Pudendal nerve block
- childbirth to relieve pain
- inject anaethetics near nerve as it crosses sacrospinous ligament near ischial spine - Urethral catheterisation (Male)
- to avoid trauma of membranous urethra
—> pull penis upward
—> changes shape of urethra from S to J-shaped
- if **rupture of penile urethra
—> urine leak into **SPP
—> continuity of superficial perineal fasciae with abdominal wall and penile superficial fasciae
—> urine can pass upward into ***anterior abdominal wall
Breast sagittal section
- Composed Adipose tissue + Mammary glands
- Attached to Anterior chest wall on top of Pectoralis muscle
- Puberty —> Female hormone —> ↑ number size of glands, ducts, adipose tissue
- Dimpling of skin / Peau d’orange:
—> Tumour cells infiltrate Fibrous septa + Suspensory ligament
—> Blockage of lymph vessel in the skin by cancer cells (Dermal lymphatic spread)
- Skin
- Adipose tissue
- ***Fibrous septa
- separate adipose tissue into compartments
- attach to fascia of anterior chest wall via Suspensory ligament - ***Suspensory ligament
- extend from skin to deep fascia —> attach to fascia of anterior chest wall - Mammary glands
- in groups (15-20 lobes in each gland) —> lead to Lactiferous ducts —> Nipple - ***Lactiferous ducts
- ***Ampulla (dilated part of Lactiferous ducts)
- lead to Nipple - Areola (乳暈)
- Retromammary space
- between breast tissue and deep fascia - Pectoralis muscle (Major + Minor)
Blood supply of Breast
- Lateral thoracic A+V
- Thoracoacromial A+V
- Axillary A+V branches
- Internal thoracic A+V branches
- Anterior intercostal A+V branches
Lymphatic drainage of Breast
-
**Anterior axillary nodes / Pectoral nodes (Lateral quadrants)
—> **Central axillary nodes
—> ***Apical axillary nodes
—> Subclavian trunk
—> Right: Right lymphatic duct / Left: Thoracic duct - ***Internal thoracic nodes (Medial quadrants)
- ***Posterior intercostal nodes
LN communicate with other side + LN in anterior abdominal wall
Pelvis inlet
前 —> 後
- Linea terminalis
- Pubic crest
- Pecten pubis
- Arcuate line - Margin of ala
- Promontory
Function: child delivery
Diagonal conjugate (長d): **Indirect measurement of **pelvic inlet and if contracted —> baby vaginal delivery will be delayed in ***early part of child labour
Obstetric / True conjugate (最窄個位): Direct measurement of pelvic inlet
Pelvis structure
- Pubis
- Ilium
- Ischium
—> converge into Acetabulum (for head of femur)
Stabilised by Sacrospinous ligament, Sacrotuberous ligament
**Ischial tuberosity: sitting bone
Blood supply:
Common iliac artery —> Internal iliac artery (Anterior + Posterior —> iliolumbar, lateral sacral, superior gluteal) + External iliac artery
Summary of supply
Pelvic viscera
- Internal iliac artery
- Hypogastric plexus
Rectum
- Superior + Middle + Inferior Rectal A+V —> Rectal anastomosis
- Hypogastric plexus
- Pararectal + Preaortic + Inferior mesenteric LN
Pelvic diaphragm
- S4-5 + Pudendal nerve
Upper Anal canal
- Superior rectal A+V (Inferior mesenteric A)
- Hypogastric plexus
- Pararectal LN
Internal anal sphincter
- Inferior hypogastric plexus
Lower Anal canal
- Inferior rectal A+V (Internal iliac A)
- Inferior rectal nerve
- Superior Inguinal LN
External anal sphincter
- S4 + Inferior Rectal nerve (Pudendal nerve)
Prostate
- Inferior Vesical A+V + Middle Rectal A+V (Internal iliac A) —> Prostate venous plexus
- Hypogastric plexus
- Internal iliac LN
External genitalia
- Internal pudendal artery (Internal iliac A)
- Pudendal nerve
Ovary
- Ovarian + Uterine A+V
- Aortic plexus
- Paraaortic LN
Fallopian tube
- Ovarian + Uterine A+V
Vagina
- Vaginal branch of Uterine A + Internal iliac A + Middle Rectal A + Internal Pudendal A
- Vaginal venous plexus —> Internal iliac V
- Upper: Uterovaginal plexus
- Lower: Pudendal nerve
- Upper: Internal + External iliac LN
- Lower: Internal iliac LN + Superficial inguinal LN
Uterus
- Uterine A+V (Internal iliac A) —> Uterine venous plexus
- Hypogastric plexus
- External / Internal iliac LN + Sacral LN
記:
- Ovarian: 自己另外 (Abdominal aorta)
- Uterine: Internal iliac
Male external genitalia
- Internal pudendal artery
- Penis: Dorsal artery + Deep artery + Artery to Bulb of penis —> Internal pudendal vein + Deep dorsal + Superficial dorsal vein
- Penis: Pudendal nerve (S2-4 Sympathetic Hypogastric plexus) —> Inferior rectal + Perineal + Dorsal nerve
- Ischiocavernosus + Bulbospongiosus: Perineal branch of Pudendal nerve
- Ejaculation: L1-2 Sympathetic
- Deep penis: Internal iliac LN + Deep inguinal LN
- Superficial penis: Inguinal LN
- Scrotum: Superficial inguinal LN
Female external genitalia
- Internal pudendal artery + Vaginal artery (Lower vagina)
- Dorsal artery + Deep artery + Artery to Bulb of vestibule —> Internal pudendal vein + Deep dorsal
- External genitalia: Pudendal (S2-4) —> Inferior rectal + Perineal + Dorsal nerve
- Ischiocavernosus + Bulbospongiosus: Perineal branch of Pudendal nerve
- Superficial inguinal LN
Breast:
- Lateral thoracic A+V, Thoracoacromial A+V, Axillary A+V branches, Internal thoracic A+V branches, Anterior intercostal A+V branches
- Anterior axillary LN + Internal thoracic LN + Posterior intercostal LN
