Female Pelvis and Perineum Flashcards
how many and what bones make up the pelvic girdle?
4 bones
* 2 Innominate bones - one on each side. each one is made up of 3 parts (ilium ischium and pubis)
* Sacrum - in the middle
* Coccyx
what level is the tuberculum of illiac crest and clinical relevance?
L5
where drs palpate to insert spinal or epidural block
where does the pelvic inlet and outlet come from? liek where is its landmark?
pelvic inlet = is S1 (sacral promontory) to pubic symphysis
pelvic oulet = is coccyx to pubic symphysis
ASIS and what else are in line with eachother?
pubic tubercle
boundaries of false pelvis and function
posterior = lumbur vertebrae
lateral = illiac fossae and illiacus muscle
anterior = anterior abdomina wall
function - support abdo contents and guides foetus out in childbirth
boundaries of pelvic outlet and is it smooth?
what is its importance
boundaries =
posterior - coccyx
lateral - ischial tuberosities
anterior - pubic arch
not smooth, 3 notches = 2 sciatic notches laterally and pubic arch notch anteriorly
leads to perineum: where external genitalia attach
whats the key ligament that forms the pelvic outlet?
sacrotuberous ligament
what are the main ligaments of the pelvis? (4) and 1 accessory ligament
Anterior Sacroiliac Ligament: Synovial joint to allow a very small amount of movement between the sacrum and the ilium.
Sacro-tuberous ligament and sacro-spinous ligament:
Convert the greater and lesser sciatic notches into greater and lesser sciatic foramina
Posterior Sacroiliac Ligament:
Fibrous tissue. Situated in a deep depression between the sacrum and the Ilium = supports weight of body.
The sacroiliac joint is stabilised by accessory ligaments, such as the ilio-lumbar ligament
Main strength comes from the Posterior sacro-iliac ligament
what structure leaves the pelvis at the lesser sciatic foramen?
What is the only muscle passing through the greater scaitic foramina? what does it do
clinical relevance
obtruator canal: Obturator vein artery and nerve to pass through the obturator canal.
and obturator internus
piriformis muscle
provide support
closely related to the sciatic nerve, arches over the nerve
and landmark for superiro and inferior gluteal nerves
label
Ano-coccygeal ligament:
* A musculo-tendinous structure in the floor of the pelvis
* Extends between the coccyx and the margin of the anus
difference between male and female pelvis
male:
heart shaped
50-60 degrees
female: gynecoid
round shaped
80-85 degrees
label what u can and what is shown?
pelvic diaphragm
The pelvic diaphragm is a wide but thin muscular layer of tissue that forms the inferior border of the abdominopelvic cavity
where does the coccygeus run from? and what does it do
posterior to levator ani
sacrospinous ligament to ischial spine
extends pelvic floor
what is the levator ani and where does it attach
posterior to the pubis
forms pelvic diaphragm/ pelvic floor
seperates pelvic cavity from perineum below
posterior pubis and spine of ischium
- linea thickening over the obturator internus
where does the urethra and vagina pass?
incompleet anterior part of pelvic diaphragm = urogenital hiatus
What attach at the gluteal lines?
there are 3: anterior, inferior and posterior
What is pubic symphysis diastasis?
after traumatic delivery - widening of the pubic symphysis causing dislocation without fracture radiologically more than 10mm
What is sacrospinous fixation?
Women who have had vaginal prolapse has this, where the vagina is hitched up to the SS
what 2 muscles make the pelvic diaphragm? (pelvic floor)
levator ani and coccygeus
What are the 2 divisions of the levator ani?
pubococcygeus (more anterior) and iliococcygeus (posterolateral fibres)
what are the further types of pubococcygeus
what are Pubovaginalis and pubourethralis muscle and where do they insert
What is the pubococcygeus proper muscle?
Function of pubococcygeus proper muscle?
- most medial fibres pass around vagina and urethra (respectively) and insert into perineal body
arises from anterior half of tendinous arch and posterior aspect of the body of pubis (on pelvic surface of iliococcygeus
help to support lower GI and repro tract - important in incontinence
what is perineal body, what muscles are involved?
a fibro-muscular structure located in the midline of the perineum.
prevents prolapse
- ischiocavernosus and bulbocavernosus
What is the puborectalis muscle?
fibres form sling around the rectum - junction between rectum and anal canal: ano-rectal junction
What does the ano-rectal junction allow?
anal angle to be maintained helping in incontinence
What is the innervation to the levator ani muscles?
pudendal nerve (S2 - S4)
How is the area of female perineum divided?
diamond-shaped area split into 2 triangles: urogenital and anal triangle by an artificial line between the ischial tuberosity
What does the urogenital and anal triangle contain?
uro-genital triangle = vulva, urethra, perineal body
anal triangle = anus and ischio-rectal fossae
What is the ischiorectal fossa? clin rel
lateral to anus and is filled with fat and so easily infected - allows for expansion of the anal canal during defacation
boundaries of urogenital and anal triangle
divisions of urogential diaphragm
How is the deep and superficial perineal pouch separated? label
3 layers of fascia: superficial perineal fascia (colles fascia) - a continuation of scarpas fascia, inferior fascia (perineal membrane) and superior fascia of genital diaphragm
What is the perineal membrane?
A thick fascial, triangular structure attached to the pubic arch
- continuous with perineal area to allow root of genitalia to attach
Where are the perineal pouches?
deep =
- superiorly by superior fascia of urogential diaphragm
- inferiorly by perineal membrane
- Deep transverse perineal muscles
- External/voluntary urethral sphincter
- Urethra
- Perineal branch of the pudendal nerve
- Perineal branch of the internal pudendal vessels
What is and what are contents of the superficial perineal pouch?
Space’ inferior to the perineal membrane and superior to the fascial layers of the skin is called the superficial perineal pouch
- erectile tissue => crura, bulb of vestibule
- muscles => ischiocavernosis, bulbospongiosis, superficial transverse perineal muscle
- urethra, vagina clitoris
- greater vestibular glands/Bartholin’s glands
- perineal branch of pudendal nerve
- perineal branch of internal pudendal artery (passes forward to supply the perineal structures)
females = vagina, clitoris
label the female external genitalia
ABC
Where do the superficial transverse perineal muscle insert into?
the perineal body
What is the round ligament of ovary? Where does the round ligament of the uterus terminate?
remnant of gubernaculum
infront of the superficial fascia of perineal pouch
What is a Bartholin gland cyst?
cyst on Bartholin gland when the secretions can’t be released and can become infected to form an abcess
What nerve supplies most of the structures in the perineum?
pudendal nerve
label the nerves of teh lumbur plexus
label the sacral plexus
How do the nerves of the sacral plexus travel?
exits the pelvic cavity through the greater sciatic notch below the piriformis muscle. Then winds around ischial spine and re-enters the pelvic cavity below pelvic diaphragm
What does the perineal branch of the pudendal nerve supply and what is all the nervosu supply of labia majora??
posteior 2/3 of labia majora, urethra, vagina and perineal muscle (ischiocavernosis and bulbospongiosus)
anterior nerve branches of lumbar plexus which has contribution from ilioinguinal nerve L1 (genitofemoral i think)
What is an episotomy?
cutting vagina to make sure no tears of essential muscles - cut mediolatrally
How do we know where to do pudendal nerve block?
feeling ischial spine
What are the spaces between bladder and other structures?
- uterovesical pouch = between bladder and uterus
- recto-uterine pouch (pouch of Doughlas) = between rectum and uterus
- recto-pubic space = anterior to bladder and full of fat
What is this
pubovesical ligament
wraps around the neck and urethra and attaches to the pubic symphysis
What is the venous drainage of the bladder? men vs women
females = utero vaginal plexus
men = inferior prostatic plexus
vesical venous plexus => internal iliac vein
- VVP also communicates inferiorly with utero-vaginal plexus in females / inferior prostatic plexus in men which both drain into the internal iliac vein
What happens in the prolapse of uterus?
tone of levator ani and ligaments weaken which could be caused during childbirth or poor muscular tone
label female urethra
What is the external urethral sphincter?
Function of external urethral sphincter
What is the internal urethral sphincter used for?
in deep perineal pouch
straited/skeletal muscle under voluntary control - pudendal nerve
contracts and constricts the urethra
preventing backflow of seminal fluid into the bladder during ejaculation
Features of the umbilical artery
*Carries blood to placenta
*Becomes Medial umbilical fold
*Gives the superior vesical artery - supplies superior aspect of bladder
Where is inferior vesical artery found?
only in men
Feature of vaginal artery
Features of internal pudendal artery
*Supplies the inferior aspect of the bladder (IN MEN = INF VESICAL)
*All the structures of the perineum
*Gives Inferior Rectal branches in the ischioanal fossa and
*Perineal branches (terminal branch of the internal pudendal) towards the clitoris in the urogenital triangle
What does the inferior gluteal artery supply?
*Levator ani, coccygeus and piriformis (also gluteal muscles)
What does the dorsal artery of the penis supply?
What is the female version of the dorsal artery of penis?
branch of internal pudendal artery => runs forward on the penis and supplies blood to erectile tissue
Dorsal artery of clitoris
Function of the uterus
Function of uterine tube
Function of ovary
Function of vagina
uterus - reception, retention and nutrition of the fertilised ovum
uterine tube -
- recieves ovum from ovary and provides a site where fertilisation can happen (at ampulla)
- provides nourishment for fertilised ovum and transports it to cavity of uterus
- channel for sperm
ovary - production of ova and female sex hormones
vagina - female genital canal which forms part of the birth canal
label and
Structure of uterus
What are fornices?
- fundus
- body (muscular wall)
fornices = superior portion of vagina extending into recesses formed by vaginal portion of cervix
Structure of ovaries
What is the change in ovary surface?
- oval shaped
- connected to lateral wall of uterus through round ligament of uterus
- lies in the ovarian fossa
- position can vary
before puberty => smooth
after puberty => progressively scarred
menopause => small and pitted
Structure of uterine tubes
- Infundibulum => between ampulla and finbriae
- ampulla => widest part
- isthmus => narrowest portion
- intramural => pierces the uterine wall
uterien tube end at teh fimbrae where ovaries sit
Structure of vagina
How is the area surrounding vaginal lumen divided?
- 8-10cm length
- Muscular tube
- Upper half of vagina lies ABOVE pelvic floor and lower part BELOW
- Lined by stratified, non-keratinised squamous epithelium
- Bartholin glands present
4 parts:
- anterior fornix
- posterior fornix (blood/pus can build up here and so remove by passing instrument through the anterior fornix
- 2 lateral fornices
importance/ clin rel of posterior fornix
blood/pus can build up here and so remove by passing instrument through the anterior fornix
What are positions of the uterus?
- anteversion = uterus is bent forward on the long axis of vagina
- anteflexion = uterus is bent forward on long axis of uterus
what is retroflexion?
angle is messed up
Retroversion of the uterus occurs when a woman’s uterus (womb) tilts backward rather than forward. It is commonly called a “tipped uterus.”
what pouches are formed due to the peritineum of the pelvis (broad ligament of the uterus)
Uterovesical pouch:
Between the bladder and the uterus
Rectouterine pouch:
Between the rectum and the uterus
What is the broad ligament?
flat sheet of peritoneum which is divided into 3 sections:
1. mesometrium (largest portion running laterally to the side of the uterus)
2. mesosalphinx (drapes over top of uterine tubes = mesentry of uterine tube)
3. mesovarium (stick ovary to posterior surface of broad ligament)
label al the ligaments and what they are
cardinal ligament?
at the base of the broad ligament and contains the uterine artery and vein - attaches from the side of the cervix to lateral bony wall of the pelvis
uterosacral ligament?
from cervix and insert onto the uterus
sacrocervical ligament?
attaches from cervix to anterior aspect of sacrum
pubocervical ligament?
connecting the side of the cervix to the pubic symphysis
round ligament of the uterus?
remnant from development- passes ant: to/through inguinal canal
round ligament of the ovary?
attaches ovary to lateral uterus wall
label broad ligament
