Gross 2 Pelvic Region and Perineum Flashcards
What is the Pelvic Inlet?
This divides the abdominal and pelvic cavities .
- Has an oblique plane that runs along the pelvic brim, and divides the pelvis into greater and lesser pelves
What is the Greater Pelvis? What is the Lesser Pelvis? What is Pelvic Outlet?
Greater Pelvis: The area of the pelvis NOT enclosed by bones
Lesser Pelvis: The area of the pelvis enclosed by bones
Pelvis Outlet: Inferior aperture of the pelvis; plane at the level of the pubic arch and coccyx
What contents are in the Pelvic Cavity? (Greater and Lesser Pelvis)
The Greater Pelvis contains some parts of small and large intestine
The Lesser Pelvis contains:
- Terminal parts of ureters
- Urinary bladder
- Rectum
- Genital organs
- Blood vessels } Supplies Pelvis and LE
- Lymphatics } Supplies Pelvis and LE
- Nerves } Supplies Pelvis and LE
What are the Muscular Walls of the Pelvic Cavity, what muscles accompany the walls?
Lateral wall: Obturator Internus
Posterosuperior: Piriformis
Floor: - Coccygeus (Ischiococcygeus)
- Levator Ani (Puborectalis, Pubococcygeus, and
Iliococcygeus)
What are the Fascial and Ligamentous structures of the Pelvic Walls? (5)
- Obturator Internus fascia
- Obturator Membrane
- Anterior SI joint ligament
- Sacral-Tuberous Ligament
- Sacral-Spinous Ligament
Where is the Perineum/Perineal Compartment?
The area below the pelvic diaphragm and deep to external region of skin including genitals to gluteal folds, and area between thighs
How is the Perineum/Perineal Compartment divided?
Its divided into two regions by a transverse line joining the anterior ends of the ischial tuberosities; then two oblique plane intersect at the transverse line creating:
- Urogenital Triangle
- Anal Triangle
What contents are in the Anal Triangle?
Contains the Ischioanal fossa and a Median part.
Median Part contains:
- Anal canal: Rectum to Anus
- Internal Anal Sphincter: Within anal canal; smooth muscle innervated by parasym. (Pelvic splanchnic)
- External Anal Sphincter: Skeletal muscle innervated by inferior rectal nerve (Pudendal)
- Perineal Body: Fibrous mass anterior to anus, attachment site for superficial transverse perineal muscle, bulbospongiosum, and outer layer of the external anal sphincter
- Anococcygeal ligament: From posterior aspect of anal canal to coccyx; attachment site for pubococcygeus and iliococcygeus and external anal sphincter
What is the Neurovasculature in the Ischioanal Fossa?
The main structures are in the Pudendal Canal:
Pudendal Nerve:
- Gives a branch of inferior rectal nerve (Motor to external anal sphincter;Sensory to skin around anus)
- Gives off sensory branches to external genitalia
Internal Pudendal Artery:
- Gives off an Inferior Rectal artery; supplies blood to the rectum and anus
-Gives off arteries to external genitalia
Internal Pudendal Vein
- Gives off an inferior rectal vein; drains blood form the rectum and anus
- Branches drain blood from external genitalia
Where is the Urogenital Triangle?
Its bordered by the pubic symphysis, inferior pubic ramus and ischium, posteriorly by the anal triangle and superiorly by levator ani muscle
- Divided into a superficial and deep space by the perineal membrane
What is in the Superficial Space of the Urogenital Triangle?
- Superficial Transverse Perineal Muscle
- Bulbospongiosum Muscle
- Ischiocavenosus Muscle
All innervates by pudendal
What is in the Deep Space of the Urogenital Triangle?
Known as the Urogenital Diaphragm
- External Sphincter Urethra muscle
- Compressor Urethra Muscle
- Deep Transverse Perineal Muscle
- Urethrovaginal Sphincter Muscle (Females)
All innervated by pudendal
What is the the function of the Urogenital Triangle and what nerve innervates this area?
Function:
- Expulse urine after bladder empties
- Expulse semen
- Maintain erection by compressing veins into the bulb of the penis
Innervation:
- Pudendal N.
What structures of the pelvic floor and perineum may be torn or stretched during childbirth?
- Muscles of perineum, levator ani, and ligaments of the pelvic fascia and the nerves supplying these structures
What happens if the structures of the pelvic floor are torn or stretched during childbirth?
- Urinary incontinence
- Fecal Incontinence
What are the arteries in the Internal Iliac-Anterior Division for males?
- Umbilical (With a Superior Vesical B.)
- Obturator
- Inferior Vesicle
- Inferior Gluteal
- Middle Rectal
- Internal Pudendal (With Dorsal A. to Penis, and Inferior Rectal A. branches)
What are the arteries in the Internal Iliac-Anterior Division for females?
- Umbilical (With a Superior Vesical B.)
- Obturator
- Uterine (With Vaginal A.)
- Inferior Gluteal
- Middle Rectal
- Internal Pudendal (With Dorsal A. to Clitoris, and Inferior Rectal A. branches)
What pelvic arteries arise from the Aorta?
- Superior Rectal: comes off inferior mesenteric
- Testicular/Ovarian: Off aorta
- Medial Sacral: Off posterior aspect of abdominal aorta
What is the function of the Umbilical Artery?
Before birth, the umbilical arteries are the main continuation of the internal iliac arteries, through the umbilical ring into the umbilical cord
What is the function of the Obturator Artery?
Arises close to the origin of the umbilical A., to the obturator muscles
(supplies obturator Internus/Externus)
What is the function of the Inferior Vesical Artery?
Occurs consistently only in males. In females it may occur as a branch of internal iliac or as a branch of the uterine artery. Supplies the prostate, seminal vesicle, bladder and Vas Deferens
What is the function of the Vaginal A.?
Supplies numerous branches to the anterior and posterior surfaces of the vagina
What is the function of the Middle Rectal Artery?
Supplies the rectum
What is the function of the Inferior Gluteal Artery?
Supplies the muscles and skin of the gluteal area and the posterior surface of the thigh
What is the function of the Iliolumbar Artery?
The iliolumbar A. has two branches: Iliac branch and Lumbar branch.
- The Iliac branch supplies the iliacus and ilium
- The lumbar branch supplies the psoas major and quadratus lumborum
What is the function of the Lateral Sacral Artery?
- Supplies the Erector Spinae muscles of the back and the skin overlying the sacrum
What is the function of the Superior Gluteal Artery?
The largest branch of the posterior division, supplies the Glute. muscles (Glute med., min and TFL) (superficial B supplies Glute max)
What are the nerve roots of the Nerve to Obturator Internus? What is the function of this nerve?
(L5-S2)
Its a motor nerve to the Obturator Internus
- Also supplies Superior Gemellus
Creates the lateral wall of the pelvic floor area
What are the nerve roots of the Nerve to Piriformis? What is the function of this nerve?
(S1-S2)
Its motor to Piriformis
Creates posterior superior border of pelvic walls
What are the nerve roots of the Pudendal Nerve? What is the function of this nerve?
(S2-S4)
This is a mixed nerve
-Sensory: External Genitalia of both sexes and the skin around the anus, anal canal and perineum
- Motor: Perineal muscles, the external urethral sphincter and the external anal sphincter
What are the 4 Pudendal Nerve entrapment sites? What can cause these entrapments? What are the symptoms associated with this?
- Below Piriformis
- Between sacrotuberous and sacrospinous ligament
- Pudendal Canal
- Terminal Branches
Causes:
- Prolonged compression (Long distance cycling)
- Traction/stretch (Vaginal birth)
Symptoms:
- Genito-anal numbness
- Fecal and/or urinary incontinence
What are the nerve roots for Nerve to Levator Ani and Nerve to Coccygeus? What is the function of these nerves?
Nerve to Levator Ani: S3-S4
- Motor to muscles the make up the levator ani muscles
Nerve to Coccygeus: S4
- Motor to coccygeus m.
Function: Supporting and raising the pelvic visceral structures. It also helps in proper sexual functioning, defecation and urination
What are the nerves that may be injured during childbirth?
- Pudendal N.
- Nerve to Levator Ani
- Nerve to Coccygeus
A lesion of the pudendal nerve would affect what muscle in the anal triangle?
External anal sphincter m.
What would be a concerning symptoms of pudendal nerve lesion?
- Urinary incontinence
- Fecal incontinence
What is the Autonomic Innervation (sympathetic/parasympathetic) of the pelvis?
Sympathetic: L1-L2 anterior rami form the superior hypogastric and run into the pelvis to form the inferior hypogastric plexus
Parasympathetic: S2-S4 anterior rami leave as pelvic splanchnic nerves to enter the inferior hypogastric plexus
What is the role of the pelvic visceral afferents? Why is important?
- Reflex information travel with parasympathetic fibers
- Nociceptive/pain information ABOVE the pelvic pain line follow sympathetic fibers retrograde
- Nociceptive/pain information BELOW the pelvic pain line follow sympathetic fibers retrograde
- This is important because referred pain from viscera reflect in the area of skin innervated by that dermatome
(L1,L2 dermatome v S2,S3,S4 dermatome)
What is the Autonomic Nervous System of the Pelvis for a Male?
Its from the Inferior Hypogastric, the nerve will split into:
- Rectal Plexus
- Vesical Plexus > Deferential Plexus
- Prostate Plexus > Cavernous Plexus
What is the Autonomic Nervous System of the Pelvis for a Female?
Its from the Inferior Hypogastric, the nerve will spit into:
- Rectal Plexus
- Vesical Plexus > Cavernous Plexus
- Uterovaginal Plexus
What is the Sympathetic and Parasympathetic effect on the Seminal Gland and Prostate?
Sympathetic: Contraction (Ejaculation)
Parasympathetic: Stimulate secretions
What is the Sympathetic and Parasympathetic effect on the Uterus?
Sympathetic: Contraction or relaxation
Parasympathetic: Stimulat secretions
What is the Sympathetic and Parasympathetic effect on the Arteries?
Sympathetic: Vasoconstriction
Parasympathetic: Vasodilation
What is the Sympathetic and Parasympathetic effect on the Genitals?
Sympathetic: Causes ejaculation and vasoconstriction resulting in remission of erection
Parasympathetic: Produces engorgement (erection) of erectile tissues of the external genitals
What is the Sympathetic and Parasympathetic effect on the Urinary tract/Kidneys?
Sympathetic: Vasoconstriction of renal vessels slow urine formation; internal sphincter of bladder contracts to maintain urinary continence and to prevent retrograde ejaculation
Parasympathetic: Vasodilation (Urination at bladder)
What is the Sympathetic and Parasympathetic effect on the Rectum?
Sympathetic: Contracts internal anal sphincter
Parasympathetic: Contracts the rectum, inhibits the anal sphincter to cause defecation
What do the Urinary organs contain and what is their function?
- Pelvic portion of ureter (carries urine from kidney)
- Urinary bladder (Stores urine)
- Urethra (Conduit for urine to the exterior)
What arteries supply the ureter?
Branches from the Renal, Abdominal aorta, common iliac, internal iliac and uterine/inferior vesicle arteries
The ureter is also a retroperitoneal organ, its between parietal peritoneum and posterior abdominal wall
Where is the Urinary bladder located?
Its a infraperitoneal organ (almost completely covered with visceral peritoneum)
- Its anterior to vagina (female) and prostate (male)
How does the urethra differ between male and female? (length, parts, vascular supply)
Length:
- Male: 18-22cm
- Female: 4cm
Male parts:
- Intramural
- Prostatic
- Membranous
- Spongy
Vascular Supply:
- Male: Inferior vesical and middle rectal
- Female: internal pudendal and vaginal
What is Ureteric Calculi? Where is pain felt?
Kidney stones (calculi)
- Can be smooth or spiky
Symptoms vary on location, size and type of calculi
- Pain reported from flank to inguinal region
- May cause partial or complete obstruction of urine flow
With Ureteric Calculi, how can a clinician distinguish if pain is arising from a ureter vs. somatic tissue referring to the flank and inguinal region?
- Pain traveling from loin to groin
- Pain with urination
- Blood in urine
- Foul smell of urine
(Its not aggravated or eased by changes in position of the trunk or hip)
What are the structures associated with the male reproductive system? (6)
- Testes
- Epididymis
- Ductus Deferens
- Seminal Vesicle (glands)
- Prostate gland
- Penis
What is the function of the testes? Where does it blood supply from?
Produce spermatozoa
Male hormones (testosterone)
Blood supply:
- Testicular A.
- Pampiniform Venous Plexus
Why is temperature control important for males reproductive system? What are some structures that maintain temperature?
Its critical for spermatozoa production and health
Structures that maintain temp. are muscles and fascia
- Skin
- Dartos muscle (smooth m. on skin of testes)
- Cremaster muscle (envelopes testes)
- Spermatic fascia: Internal/External (surrounds testes)
- Tunica vaginalis (sac surrounding testes)
- Tunica Albuginea (Surrounding testes, thick white coat)
What is the path the Ductus Deferens takes?
Begins at end of epididymis once the coiling ends
Path:
-Spermatic cords
-Inguinal canals
-Ampulla of ductus deferens
-Joins semina vesicle
-Forms ejaculatory ducts
What is the role of the Seminal Vesicle and Prostate?
What spermatozoa arrives via the vas deferens
- It then mixes with a fluid in the seminal vesicle and becomes semen
- Secretions from the seminal vesicle pass to ejaculatory ducts though prostate
- The prostate gland secretes fluid that mixes with semen and flows into the prostatic urethra
What are the effects of Prostate Hypertrophy? Is this common?
- Affects urination
- Compressing bladder
- Compressing prostatic urethra
- Common after middle age
What symptoms of a hypertrophied prostate?
- Nocturia (the need to wake up in the middle of the night to urinate)
- Dysuria (Pain or discomfort when urinating
- Urgency
What are the structures associated with the female reproductive system?
- Vagina
- Uterus
- Uterine Tube
- Ovaries
What is the location and function of the Vagina?
Location:
- Posterior to urinary bladder
- Anterior to rectum
Function:
- Canal for menstrual fluid
- Inferior part of birth canal
- Receives the penis and ejaculate during sexual intercourse
In the vagina, what is the Fornix? What is the Vestibule of the Vagin?
Fornix: The superior end of the vagina which is located at the site of the cervix
Vestibule of the vagina: External opening
What is the location of the Uterus? What is the function?
Location:
- Superior to vagina
- Anterior to rectum
- Infraperitoneal
Functions as a site of nourishment for a fetus prior to birth (aka “womb”)
What are the 3 layers of the uterus?
- Perimetrium: Connective tissue layer
- Myometrium: Muscle layer
- Endometrium: Simple columnar cells that allow for secretion of substances for embryo development
What are the structural support of uterus and its location?
- Broad Lig.: Anterior and posterior areas of uterus extends laterally to uterine tubes
- Ovarian Lig.: Lateral uterus to ovary
- Round Lig.: Body of uterus through inguinal canal and ends at labia
- Suspensory Lig.: From lateral ovaries to pelvic brim and is for ovarian vessels
Where are the Uterine (Fallopian) Tubes located, and what are the functions?
Location: From superior lateral aspect of uterus and related to the ovaries
Function: Allows for the transport of the ova to the uterus
What is the function of the Ovaries?
- Develop ova
- Main site for development of progesterone and estrogen
- Once ovum matures, it gets released where fimbriae will sweep into infundibulum
The ovaries are suspended by ovarian ligament and suspensory ligament
The ovaries and fimbriae are not directly atteched
