Lecture 19 DA

Question 1

Name 4 paired viscera in the pelvis for males.

Answer 1

Ureters
Vas deferens
Seminal vesicles
Ejaculatory ducts

Question 2

Name 4 unpaired viscera in the pelvis for males.

Answer 2

Bladder
Prostate
Pelvic colon
Rectum

Question 3

Are paired viscera at the midline?

Answer 3

Some are, others are non-midline.

Question 4

Where do paired viscera refer pain to?

Answer 4

The same side of the body.

Question 5

Where do unpaired viscera refer pain to?

Answer 5

To the midline, as they have nerve supply from both sides of the spinal cord.

Question 6

What are the layers of the ureters?

Answer 6

• Serosa, most superficial
• Muscularis, circular and longitudinal
• Mucosa within

Question 7

Does continence depend on gravity? How is this clinically relevant?

Answer 7

No, one can pee upside down. If a surgeon is unsure of a structure, a peristaltic wave can be felt.

Question 8

How do the ureters pierce the bladder?

Answer 8

Posterolaterally, entering obliquely.

Question 9

What is the ureter called when within the bladder?

Answer 9

Intramural ureter, a functional sphincter.

Question 10

Where does the ureter enter the bladder?

Answer 10

Through ureteral orifices.

Question 11

What happens when urine fills the bladder?

Answer 11

Bladder walls stretch, and close the intramural ureter, which is a functional sphincter.

Question 12

Where does the ureter get its blood supply?

Answer 12

From every vessel it comes close to.

Question 13

What crosses the ureter in males and females?

Answer 13

In males, it is crossed only by the vas deferense, just as it enters the bladder.
In females, uterine arteries cross over it at the pelvic brim, also just as it enters the bladder.
Aside from that, it is the most anterior structure in both males and females.

Question 14

What is a consequence of a high calcium diet on the urinary system?

Answer 14

High calcium can result in uretery calculi - kidney stones.
They can lodge at narrowings of the ureter:
Kidney hilum
Pelvic brim
Proximal to intramural ureter

Question 15

Why are uretery calculi (kidney stones) so painful?

Answer 15

When they lodge at a narrowing, they cause the muscle to spasm, causing referred pain to overlying dermatome, the loin area, up to the scrotum in males, and vulva in females.

Question 16

Are pain fibres involved in uretery calculi symathetic or parasympathetic?

Answer 16

They are sympathetic, referring to T11-L1 dermatomes.

Question 17

Why can’t opioids be used as an analgesic in uretery calculi pain?

Answer 17

It stimulates further ureter muscle spasm, worsening the pain.

Question 18

What are two anatomical variations in the ureter?

Answer 18

1% - bifed ureter, that terminate as one before reaching the bladder, endangered in surgery.
0.2% - pelvic horseshoe kidney, kidneys are merged inferiorly.

Question 19

How does pelvic horseshoe kidney occur?

Answer 19

As kidneys develop in the pelvic cavity, they start at the midline, but as the body elongates, the can’t get to the appropriate spot and the horseshoe structure stays within the pelvis.

Question 20

Is there any pathology associated with a pelvic horseshoe kidney?

Answer 20

No, but it can be mistaken for another structure.

Question 21

Where does the bladder lie in women? Why is this significant?

Answer 21

Lies anteriorly, resting in part on the vagina. Vaginal prolapse means less support for the bladder,

Question 22

Does the bladder have a peritomeum?

Answer 22

Yes, it does on its superior surface, which descends berween the rectum and uterus, and between the bladder and uterus. As the bladder fills, the perotineal coat is pushed upwards.

Question 23

What happens to the bladder neck? What supports it?

Answer 23

It becomes continuous with the urethra. It needs most support from the vagina, as well as some from the levator ani.

Question 24

What happens to continence of urine during childbirth and why?

Answer 24

When the levator ani is stretched, it leads to urine incontinence.

Question 25

What is the urachus? What does it become?

Answer 25

At embryonic stages, the apex of the bladder is connected to the umbilicus via a duct, called urachus.

Question 26

What becomes the median umbilical ligament?

Answer 26

Before it degenerates after birth, the urachus is called the median umbilical ligament, and connects the bladder’s apex to the umbilicus. It is patent/open, and urine passes from the bladder out the umbilicus.

Question 27

How is the urachus clinically signifcant?

Answer 27

It can remain patent in adulthood, urine will leak out of the umbilicus.

Question 28

Is the bladder abdominal or pelvic?

Answer 28

It is abdominal in children as their pelvis is too small. They can pee longer distances due to their abdominal muscles. It sinks after 6 years.

Question 29

What are the layers of the bladder?

Answer 29

It has a mucosa lining it, and its muscle layer is called the detrusor urinae muscle.

Question 30

What is the trigone?

Answer 30

Triangular area inferiorly, in the posterior mid portion of the bladder, where the ureters enter. Made of smooth muscle, different to detrusor urinae, which can stretch, the trigone can’t.

Question 31

How is the detrusor urinae different to the trigone?

Answer 31

Detrusor urinae can stretch, the trigone cant.

Question 32

What is the internal urethral sphincter? Do females have one?

Answer 32

Females do not have one. It is found at the end of the trigone, and prevents backflow of semen into the bladder from the prostatic urethra, rather than preventing urinary backflow.

Question 33

What is the Turp procedure, and what is a consequence of this?

Answer 33

When the prostate is removed, but can damage the internal urethral sphincter. People who have this have backfllow of seminal fluid into the bladder.

Question 34

What is a consequence of prostate hypertrophy?

Answer 34

A tight bladder neck, difficulty in micturition.

Question 35

What nerves are involved in the micturition reflex?

Answer 35

Involves parasympathetic fibres via S2-S4 for detrusor contraction.
Internal urethral sphincter relaxing - sympathetic T12-L1, involuntary.
External urethral sphincter, levator ani - pudendal nerve S2-S4.

Question 36

What happens when there is a significant obstruction along the urethra?

Answer 36

A catheter puncture is neede, called suprapubic puncture.

Bladder must be full to stretch the peritoneum, so there is no danger of puncturing the perotineum.

Question 37

What are the dangers of suprapubic punctures?

Answer 37

There is a danger of puncturing the:
Perotineum
Intestines
Retropubic space (veins here)
Blood vessels of the bladder
Inferior epigastrics

Question 38

Where is the urethra in females?

Answer 38

Shorter in females, and anterior to the vagina, below the clitoris, but is variable.

Question 39

Where is the urethra in males?

Answer 39

It passes through the prostate, called prostatic urethra, and then called membranous urethra after passing levator ani. It is longer in males.

Question 40

How does urethral catherisation differ in males and females?

Answer 40

Simpler in females as its shorter.
Males must be navigated, and is possible to pierce the posterior wall of the urethra, causing a fistula, and abnormal hole.

Question 41

What is a fistula?

Answer 41

An abnormal hole. One can occur during urethral catheterisation, where the posterior wall of the urethra can be pierced.

Question 42

What is the clinical significance of no internal urethral sphincter in females?

Answer 42

They are more at risk of urinary incontinence.

Question 43

How many curvatures does the rectum have?

Answer 43

Two.

Question 44

What is the purpose of transverse rectal folds?

Answer 44

Aids in faecal (Theres no oil here, move on) storage and passage of air.

Question 45

What is the perineum?

Answer 45

When the rectum becomes continuous with the anal canal, called perineum.

Question 46

What is found superior to the perineum?

Answer 46

Ampulla recti. Faeces are stored here before excretion.

Question 47

What has a pelvic perotineum?

Answer 47

Anterior and superior rectum, uterus and superior bladder.