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Block II > Male Ext Genitalia; Clinical Correlation to Urethral Injury > Flashcards

Male Ext Genitalia; Clinical Correlation to Urethral Injury Flashcards

1
Q

Sscrotum fascia- what are their extensions and attachments?

A
  • Ext oblique extends to form the ext spermatic fascia
    • ​ Attaches to the borders of the external inguinal ring.
  • Int oblique extends to form the cremaster muscle & fascia
    • ​Attaches to the
      • inguinal ligament & iliopsoas laterally
      • pubic tubercle medially.
  • Transversalis fascia becomes the int spermatic fascia in the scrotum
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2
Q

Layers of testis

A

Some Dirty Englishmen Called It Testis

  • Skin
  • Dartos fascia (has smooth muscle) - continues with Colle’s and Scarpa’s
  • Ext spermatic fascia
  • Cremasteric fascia
  • Internal spermatic fascia
  • Testis
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3
Q

Anatomy of epididymus

A
  • Head, body, and tail
  • Tail is continuous with ductus deferens
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4
Q

Course & contents of spermatic cord

A

Spermatic cord travels through the inguinal canal into the scrotum

  • Testicular artery
  • Cremaster
  • Genitofemoral nerve femoral branch
  • Pampiniform plexus of veins
  • Testis
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5
Q

Scrotal lymphatics

A
  • Does not cross the median raphe
  • Drains into the superficial inguinal nodes on the ipsilateral side
    *
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6
Q

The smooth muscle of the dartos fascia is continuous with what other fascia?

A

Colles fascia

Scarpa’s fascia

Darto’s fascia of penis

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7
Q

As scarpa’s fascia goes downward, it becomes what ?

A

Darto’s fascia- the outermost fascia.

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8
Q

The deep/buck’s fascia surrounding the penis envelops the

A

wraps around the corpus cavernosa and corpus spongiosum individually

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9
Q

Anterior distal urethral lesion results in extravasation where and between what fascia?

A

Into scrotum and abdomen under Scarpa’s/Dartos

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10
Q

The fascia of scrotum connect via the tunica vaginalis (extension of parietal peritoneum) that surrounds the testis

A

Parietal peritoneal surface of the tunica can produce fluid, but if it’s not absorbed –> hydrocele

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11
Q

Course of the vas deferens

A

Goes from tail of epididymus, up the spermatic cord, through the superficial & deep inguinal rings, posterior to the inferior epigastric artery, anterior to the ureter, and joins with the duct of the seminal vesicles to drain into the ejaculatory ducts.

Cut in vasectomy

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12
Q

Anatomy of testis

A
  • Comes down from spermatic cord
  • Has epididymis on anterior surface
  • Has small body at its upper pole called the appendix testis
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13
Q

Vascular supply of the testicle

A
  • Testicular (internal spermatic) artery - biggest
    • From abdominal aorta
    • Transverses in retroperitoneum, then through inguinal ring
  • Artery of vas deferens/Deferential artery
    • ​From internal iliac artery OR superior vesical artery
  • Cremasteric (external spermatic) artery
    • From inferior epigastric artery
    • Primarily supplies tunica vaginalis
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14
Q

Testicular venous drainage (not an LO)

A

Pampiniform plexus: group of veins anastomose with each other and the deferential veins.

Left testis drains into the left renal vein

Right testis drains into anterior surface of the IVC

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15
Q

Where do lymphatics from the testis drain? Difference in the course between right and left?

A

Left testis lymphatics drain into the para-aortic and interaortocaval lymph nodes to drain in the thoracic duct.

Right testis lymphatics runs along the vena cava and then move to the left side of your body to reach those nodes.

Thus, the left doesn’t cross over, but the right will cross to the left due to generalized lymphatic flow and thoracic duct

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16
Q

Testicular tumor - what approach do you use and why?

A

You take the inguinal approach instead of the scrotal appraoch to avoid spreading the tumor via the differences in lymphatic drainage.

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17
Q

Testicular cancer (micrometastatic or residual disease) follow what lymph node chain?

A

Ipsilateral lymph node chain

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18
Q

Ultrasounds for scrotal contents - uses

A
  • Can use high frq because testicles are so close to skin
  • Determine if theres a hydrocele or testicular torsion
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19
Q

3 layers of scrotum seen on ultrasound

A
  • Outer hyper-reflective layer (skin)
  • Hypo-reflective intermediate
  • Hyper-reflective inner layer (tunica albuginea)

The testicle itself is a smooth, homogenous structure

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20
Q

Mediastinum testis - what does it do and what does it look like on an ultrasound?

A

Mediastinum testis drains the seminiferous tubules into the rete testes

On an ultrasound, it’s a highly reflective linear structure at the posterior superior aspect of the testicle

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21
Q

Cremasteric Reflex

A
  1. Stroking the inner thigh stimulates the ilioinguinal nerve (L1)
  2. Activates motor neurons in the genital branch of the genitofemoral nerve
  3. Ipsilateral cremasteric contraction & Testicular elevation
22
Q

Structure of penis

A
  • Corpus cavernosa: paired erectile bodies that prolongate proximally as the crus and attaches to the pubic arch
    • ​Separated by a septum proximally, but is permeable distally to allow free communication between their vascular spaces
  • Urethra travels through the corpus spongiosum, with its proximal segment known as the bulb
    • Reaches into the glans penis: expansion of corpus spongiosum
23
Q

Cross-section of the penis

A
  • In the dartos, you see the superficial dorsal veins
  • Buck’s fascia goes around the corpora cavernosa and the corpus spongiosum
  • Urethra is inside the corpus spongiosum
  • Cavernosal artery runs through the middle of the corpora cavernosa to supply the erectile tissue
  • Tunica albuginea (holds rigidity of erections) has an outer longitudinal layer and an inner circular layer.
24
Q

Tunica albuginea

A

​Tunica albiginea: tough, collagenous connective tissue layer that envelops the corpora cavernosa; holds rigidity of erections

  • Circular inner layer bundles support and contain the cavernous tissue
  • Intracavernous pillars radiating from the inner layer act as struts to support the erectile tissue during erection
    • The corpus spongiosum lacks this to ensure a low-pressure structure during erection
  • Longitudinal outer-layer bundles extend from the glans to the proximal crura
    • Insert into the inferior pubic rami, but absent at the 5’ and 7’ o clock positions
25
Q

The superficial artery of penis arises from ____.

The deep artery of the penis arises from ____.

Branches of the common penile artery.

A

Superficial artery from the external pudendal artery.

Deep artery from the internal pudendal, which becomes the common penile artery after giving off a branch to the perineum

  • Dorsal
  • Bulbourethral
  • Cavernous

Joins to form a vascular ring near the glans

26
Q

Penile venous drainage

A

Tiny venules inside the corpora tissues travel within the trabeculae between the tunica and peripheral sinusoids to form the subtunical venous plexus and exiting as emissary veins.

27
Q

Lymphatics from the skin of the penis drain where?

A

Superficial inguinal lymph nodes

Subinguinal lymph nodes

28
Q

Lymphatics from the shaft o the penis drain where?

A

They coverge on teh dorsal side and ramify to both sides of the groin to drain into inguinal lymph nodes

29
Q

Lymphatic drainage & Penile Cancer

A

Penile cancer will spread to the superficial inguinal lymph nodes –> must dissect it and remove the lymphatic tissue there.

30
Q

Sensory innervation of penis

A

Dorsal nerves, especially at the glans

31
Q

Where is the penis’ somatic nerve supply originate from?

A

Somatic nerve supply from S2,S3, and S4 travels along the pudendal nerve on the dorsal side.

32
Q

Autonomic stimulation of erection/detumescence

A

Erection requires sacral parasympathetic stimulation of

  • Pelvic splanchnics (S2-S4)
  • Cavernous nerves

Detumescence requires thoracolumbar sympathetic stimulation of the sympathetic trunk

33
Q

What muscles are involved in erections?

A

Corpus cavernosum smooth muscle is contracted at all times

Bulbospongiosus muscle covers the corpus spongium; it propels the ejaculate

Ischiocavernosus muscles/erector penis acts as a pump to increase penile turgor beyond arterial pressure

34
Q

Erection & Ejaculation

A
  1. Parasympathetic fibers of pelvic splanchnics (S2-S4) & cavernous nerves
    1. relax cavernous vessels
    2. engorges erectile tissue with blood
    3. cause bulbourethral & urethral glands to secrete mucous
  2. _​_Sympathetic fibers
    1. Contracts seminal vesicles & prostate to move sperm to prostatic urethra –> combine with bulbourethral secretions + penile urethral gland secretions
  3. Pudendal nerves & thoracic sympathetic stimulation causes internal urethral sphincter & bulbospongiosus to contract & ejaculate
    1. Help from parasympathetic stimulation of urethral smooth muscle
35
Q

Which artery is responsible for engorgement of the glans durign erection?

A

Dorsal artery

36
Q

Which artery supplies teh bulb and corpus spongiosum?

A

Bulbourethral artery

37
Q

Fundiform ligament

A

Fundiform ligament: thickening of superficial fascia that is superficial to the suspensory ligament; it descends from the linea alba, splits to surround the penis, and then unites and blends inferiorly with the dartos fascia, forming the scrotal septum

“sling” around the base of the penis for support

38
Q

Suspensory ligament

A

Arises from Buck’s fascia

Initiates at the pubic symphysis and terminated at the tunica albuginea of the corpora cavernosa

Anchors the penis

39
Q

Anterior vs posterior male urethra

A

Anterior urethra: distal from external urethral sphincter

  • Membranous urethra
  • Spongy urethra

Posterior urethra: proximal to external urethral sphincter

  • Internal urethral sphincter
  • External urethral sphincter
  • Prostatic urethra
  • Pre-prostatic urethra
40
Q

In placing a catheter in men, where will you feel slight resistance?

A

Membranous urethra.

Due to increase in striated sphicnteric resistance (patient is uncomfortable) or prostatic enlargement.

41
Q

Two sphincters for urinary continence

A

External urinary sphincter: under voluntary control of skeletal muscle

Internal urinary sphincter: under involuntary control of smooth muscle; Contracts during ejaculation due to sympathetics

42
Q

4 parts of the urethra

A
  • Preprostatic part: before the prostate
  • Prostatic part: before ext urethral sphincter
  • Membranous part
  • Spongy part
43
Q

Rupture of the urethra with Buck’s fascia intact

A

Urinary leakage confined to penis

44
Q

Penile urethra with Buck’s fascia ruptured -> where is urine extravasation?

A

Scrotum; penis; superficial pouch; perneum; deep to Colles’ fascia; deep to Darto’s fascia; lower abdominal wall; deep to Scarpa’s fascia

Fluid collects between Buck’s fascia and dartos layer.

No pelvic drainage

45
Q

A male driver has sustianed severe trauma to the pelvic region in a car crash, resulting in a tearing of the prostato membranous urethral junction (just superior to the ext urethral sphincter). Blood and urine from this injury will collect where?

  • Anterior lower abdominal wall deep to Scarpa’s fascia
  • Beneath the deep (Buck’s) fascia of the penis
  • Beneath the superficial perineal (Colles’) fascia
  • Deep to the dartos fascia of the scrotum and penis
  • Subperitoneal (retroperitoneal) space
A

It’s proximal to the urethral sphincter, so subperitoneal/retroperitoneal space.

46
Q

Dissemination of cancer cells form the left testis would enter the testicular veins and then first enter which of the following veins?

A

Left renal.

Left drainage -> spermatic cord -> left renal vein.

47
Q

Rupture of the male urethra can lead to extravasation of urine. If the injury perforates the penile urethra and Buck’s fascia, into which of the followign spaces might the colleciton of urine be found?

  • Beneath the dartos and the Buck’s fascia
  • Between the Camper’s superficial fascia and the Scarpa’s fascia of lower abdominal wall
  • Deep to Scarpa’s fascia of lower abdominal wall
  • Exteranl to dartos fascia of the scrotum
  • In the retroperitoneum of the lower pelvis
A

Deep to the Scarpa’s fascia of lower abdominal wall.

Around the penis itself, the fluid would be between the dartos fascia and the Buck’s fascia, not beneath both fascial layers

48
Q

Rupture of urethra at the prostatomembranous junction

A

Leakage into the retroperitoneum

49
Q

Rupture of what part of the urethra will cause accumulation of fluid in the superficial perineal pouch?

A

Spongy urethra only; can also go up to abdominal wall because Colles’ fascia is continuous with Scarpa’s fascia

Note: “bulbar urethra” is a part of spongy urethra

50
Q

Cavernous nerves provide efferent fibers to what?

A

Erectile bodies of the penis.

Cavernous nerves are post-ganglionic parasympathetic fibers; the preganglionic fibers derive from the pelvic splanchnic nerve (S2-S4)

51
Q

What nerve feeds the glands penis?

A

Pudendal nerve

52
Q

What plexus innervates the seminal vesicles?

A

Inferior hypogastric plexus

Block II (17 decks)

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