Module Workshops Flashcards
Outline the blood supply to the uterus
Ovarian artery, from the abdominal aorta, supplies the fundus, uterine tubes and upper uterus.
The ovarian artery anastomoses with the uterine artery.
Uterine artery, from the internal iliac artery, supplies the remaining part of the uterus.
Vaginal artery, from the internal iliac artery, supplies the vagina.
Name the branches of the anterior and posterior divisions of the internal iliac artery
I Love Going Places In My Very Own Underwear
Iliolumbar
Lateral sacral
Gluteal (superior and inferior)
Pudendal (internal)
Inferior vesicle (vaginal in females)
Middle rectal
Vaginal
Obturator
Uterine
*First 3 branches orignate from the posterior division (superior gluteal only)
Outline the relations of the ovary
Posterior relations: Common iliac vein and artery, ureter
Lateral relations: Obturator nerve, artery and vein
Anterior superior relations: Obliterated umbilical artery (from the internal iliac artery, becomes the medial umbilical ligament)
Outline the blood supply and venous drainage of the ovary
Ovarian artery: Branches from the abdominal aorta
Uterine artery: Branch of the internal iliac artery. Forms an anastomoses with the ovarian artery
Paired ovarian veins drain the ovary.
Outline the lymphatic drainage of the ovary
Pre-aortic and para-aortic (sentinel node!) nodes.
Deep, not palpable
May also drain to superficial inguinal nodes
Describe the key features seen during speculum examination of the cervix and vagina
- External Os (ostium)
- Dome of the cervix
- Fornices (2 lateral, anterior and posterior)
NOTE: Nulliparous cervix is O like. Mutliparous cervix is inverted U shaped
Outline the autonomic and afferent innervation of the vagina
Autonomic supply
Upper 2/3rds: Receives sympathetic (T10-L2) and parasympathetic (S2-S4 pelvic splanchnics) supply via the hypogastric plexus
- Sympathetics from T10-L2 travel via superior hypogastric plexus. Split into R and L hypogastric nerves.
- The pelvic splanchnic nerves (S2-S4) join the (sympathetic) hypogastric nerves.
- Allows for the provision of autonomic sympathetic and parasympathetic supply to the vagina.
Lower 1/3rd: Receives sympathetic supply from the pudendal nerve (S2-S4), from the grey rami communicans, via the inferior rectal and perineal branches. NOTE does not have a parasympathetic supply.
Afferent
Upper 2/3rds: Travel back via the pelvic splanchnic nerves to S2,3 and 4. (REMEMBER THIS FOR REFERRED PAIN)
Lower 1/3rd: Travel back with the pudendal nerve, via the perineal branch, to S2-S4
Describe the pelvic floor, perineal membrane and the perineal pouches, their relationship to each other and their contents in the male and female
- Outline the ‘layers’ of the area
- Pelvic floor: Muscular layer. Supports the pelvic and abdominal organs. Maintains continence.
- Perineal membrane: A covering of the urogential triangle. Continuous with the fascia covering the abdominal wall and the fascia lata of the thigh (preventing fluid spread in rupture)
- Perineal pouches: Deep and superficial.
Contents of the perineal pouches
Deep perineal pouch: Urethra, external utheral sphincter, vagina (females), bulbourethral glands and deep transverse peritoneal muscles (males)
Superficial perineal pouch: Erectile tissues (penis/clitoris), Bartholin’s glands, greater vestibular glands, 3 muscles (ischiocavernous, bulbospongiosus and superficial transverse perineal muscles), perineal body
Outline the fascia of the peritoneum
Scarpa’s (membranous) ▻ Dartos Fascia (penis) ▻ Colle’s fascia (urogenital triangle)
Camper’s (fatty) ▻ Dartos Muscle (scrotum)
Outline the layers of the urogential triangle
Deep fascia of the pelvic floor
Deep perineal pouch
Perineal membrane (pierced by vagina and urethra)
Superficial perineal pouch
Perineal fascia
(Deep layer: Scarpa’s fascia, superficial layer: Camper’s fascia)
Identify the main muscles forming the pelvic floor and state their nerve supply.
Outline the potential consequences of damage to this area.
Pelvic floor muscles:
- Levator Ani: Pubococcygeus, puborectalis and iliococcygeus
Innervated by the pudendal nerve (S2-S4)
- Coccygeus (aka ischiococcygeus)
Innervated by the anterior rami of S4 and S5
Functions: Support organs, maintain continence and resist intrabado./pelvic pressure
Damage to the area may lead to prolapse and incontinence.
Explain the significance of the perineal body and outline the potential consequences of damage to this structure
*Clinical link
The perineal body is a thickening of fibromuscular tissue.
Located between the vagina/bulb of the penis and the anus.
Functions: An attachment site for muscles of the pelvic floor/perineum and the perineal membrane. Supports against prolapse in females
- Attaching muscles = BLP (Levator Ani, bulbospongiosus and Superficial and deep tranverse perineal)
Consequences of damage: Increased risk of prolapse, incontinence
- Episiotomy: A ‘managed’ incision made to the perineum during childbirth to prevent the perineal body and anal sphincter from tearing.
Identify the organs of the pelvis
Urinary: Pelvic uteter, urinary bladder, urethra
Genital:
- Male: Ductus deferens (vessel for sperm transport), seminal vesciles, prostate
- Female: Uterine tubes, ovaries, uterus, vagina
Digestive: Rectum, anal canal
Describe the recesses formed by the peritoneum and state their significance
Double foldings of peritoneum drape over the pelvic organs forming the:
Females:
- Rectouterine pouch of Douglas: Between the uterus and the rectum. This is the most inferior point in the female body. Fluid may collect in this recess when standing or supine.
Radiopaedia: Abscess, infection, ascites, haemoperitoneum, and even intraperitoneal drop metastases preferentially collects here.
- Vesicouterine pouch: Between the uterus and the bladder.
Males:
- Rectovesical pouch: Between the bladder and the rectum
Identify the main branches of the internal iliac artery.
(ILGPIMVOU)
Describe their location and basic distribution.
Common iliac artery ➙ External and internal iliac branches
Internal iliac artery ➙ Anterior and posterior divisions
Divides at the superior border of the greater sciatic foramen
Branches of posterior (first 3) and anterior divisions:
Iliolumbar
Lateral sacral
Gluteal (superior and inferior)
Pudenal (internal)
Inferior vesicle (vaginal in females)
Middle rectal
Vaginal
Obturator
Umbilical and uterine (females only)
- The umbilical artery (carries deoxygenated blood to the placenta) obliterates to become the medial umbilical ligament
List structures that may be palpated by rectal examination
Females: Anus, uterus
Males: Anus, prostate
List structures that can be palpated by vaginal examination
Visual inspection ➙ speculum ➙ palpation
PV exam: Vagina, cervix, fornices
Bimanual exam: Uterus, ovaries and uterine tubes
Describe the course of the nerve supplies to the pelvic and urogenital diaphragms and perineum
The pudendal nerve (S2-S4)
- Motor to pelvic floor muscles and sensory to the perineum
- Exits the pelvis via the greater sciatic foramen
- Re-enters the pelvis via the lesser sciatic foramen
- Travels laterally along the ischioanal fossa (via the pudendal/Alcock’s canal)
- Divides into serveral branches
Ischioanal fossae: Explain borders, content, normal function and how infection can spread around the region
Borders: Located laterally to the anus within the anal triangle
- See image
Content: Adipose tissue, pudendal/Alcock’s canal (contains pudendal nerve and internal pudendal artery/vein), inferior rectal nerve and vessels, lymphatics
Normal function: Allow for the expansion of the anal canal during defecation, supports the anal canal
Spread of infection: Vulnerable to spread of infection from the anal canal. Abscesses may form and infection may spread to the opposite fossa, passing behind the anal canal. Fistulas may form (with the anus)
Outline the borders of the perineum and its divisions
Anterior: Pubic symphysis
Lateral: Ischiopubic rami and sacrotuberous ligament
Posterior: Tip of the coccyx
Divided into the anal and urogential triangles via a ‘line’ between the ischial tuberosities
Axillary nodes may be removed in patients with breast cancer. This procedure may lead to damage to which nerve?
Long thoracic nerve
Innervates the serratus anterior muscle.
Damage causes winging of the scapula.
Thoracodorsal nerve may also be injured
Innervates latissimus dorsi
Name the layers of the abdominal wall
Outline the contents of the deep perineal pouch of the urogenital triangle
A potential space between the deep fascia of the pelvic floor muscles and the perineal membrane
Females:
- Urethra
- External urethral sphincter
- Vaginal
Males:
- Bulbourethral/Cowper’s glands (watery pre-ejaculate)
- Deep transverse perineal muscles
Outline the borders of the perineum and name the structure which allows for division into anterior and posterior triangles
Anterior: Pubic symphysis
Lateral: Ischiopubic rami and sacrotuberous ligament
Posterior: Tip of the coccyx
The ischial tuberosities mark the division of the perineum
***Perineal membrane (layer of strong fascia) only seen in the urogenital triangle, not the anal triangle***
Outline the contents of the anal triangle
- Anal aperture
- External anal sphincter muscle
-
Ischioanal fossae either side of the anus
- Contains adipose and connective tissue which allows for expansion of the anal canal during defecation.
- Contains the Pudendal/Alcock’s canal: Pudendal nerve and internal pudendal artery/vein
Outline the contents of the superficial perineal pouch of the urogenital triangle
A potential space between the perineal membrane and the superficial perineal fascia
Erectile tissues:
- Clitoris/penis
3 muscles:
- Bulbospongiosus
- Ischiocavernous
- Superficial transverse perineal
Bartholin’s gland
- Can become infected → bartholinitis.
Perineal body seen at the posterior border
State the positions of the sacrospinous and sacrotuberous ligaments
Sacrospinous: Sacrum → ischial spine
Sacrotuberous: Sacrum → Ischial tuberosity
State the names of the parametrial ligaments
Function to support the uterus
Pubocervical
Tranverse cervical
Sacrocervical
Through which structure are ovarian vessels transported?
The suspensory ligmament
Which ‘space’ allows for the movement of breast tissue over pectoralis fascia?
The retromammary space
- Exists between the breast tissue and the pectoral fascia
- The existance of this space prevents movement of the breast tissue during contraction of pectoralis major
- In malignancy the breast tissue will move superiorly relative to contraction of the pectoralis major muscle
Outline the quadrants of the breast
Outline the lymphatic drainage of the breast
75 % → Axillary nodes
- Central, Humeral, Apical, Pectoral and Subscapular
Paravertebral
- Allows for spread to the brain
Parasternal
Clavicular
Abdominal
⋆ Due to a valveless lymphatic system existing between the breasts malignancy may spread across the midline
Outline the pelvic cavity shapes associated with males and females
Inlet, outlet, cavity and pubic arch
Outline the birth canal measurements used in pelvimetry
- Which pelvic girdle shape is best adapted for delivery
Best adapted pelvic girdle shape: Gynecoid
Birth canal measurements:
- Intertuberous
- Interspinous
- Diagonal conjugate
- True conjugate (diagonal conjugate - pubic symphysis depth)
Outline the lymphatic drainage of the pelvic region
Superficial inguinal, deep inguinal, external iliac, internal iliac and para-aortic
Describe/draw the structure of the placenta
Describe the structure, funtion and positions of the penis, prostate, urethra, seminal vesicles and bulbourethral glands
Outline the lobes and zone of the prostate
In which regions are BPH and prostatic cancer most likely to occur?
Outline/draw the relations of the prostate
State the clinical significance of these relations
Clinical significance: The peripheral zone of the prostate is close to neurovascular structures (dorsal venous plexus and autonomic fibres of the cavernous nerve). These structures, which go on to innervate and vascularise the penis, may be invaded in carcinoma - allowing spread. Commonly spreads via Batson’s plexus to vertebral bodies, may present as back pain.
Also, damage to these neurovascular structures during prostatic surgery may cause erectile dysfunction.
Outline the lymphatic drainage of the male urogenital system
Explain the structures and mechanisms involved in erection, emission and ejaculation
Explain how the passage of the urethra through the prostate can relate to disease of the prostateor or difficulties in voiding of urine
- Prostatic enlargement, as seen in BPH and late stages of prostate cancer, may cause the prostatic urethra to become compressed.
- This in turn causes urinary symptoms, such as: nocturia, most-micturition dribbling, weak stream, urinary hesitancy and polyuria.
- This may lead to acute urinary retention - a medical emergency.
- Treatment for BPH includes α-receptor antagonists to relax the smooth muscle of the prostatic urethra and relieve urinary symptoms.
List the structures palpable upon rectal examination of the male and explain their expected position
- Prostate (felt anteriorly)
- Rectal wall
Describe the structure, coverings, embryological origin and descent of the testis
Describe the layers of the spermatic cord and the main contents of the cord
Spermatic cord layers: External spermatic fascia, cremasteric fascia and muscle and the internal spermatic fascia
Main contents of the spermatic cord:
- Pampiniform plexus: Acts as a heat exchanger to ‘cool’ blood before reaching the testes
- Vas deferens
- Autonomic nerves
- Genital branch of the genitofemoral nerve
- Lymph vessels
- Testicular, cremasteric and vas deferens arteries
Describe direct and indirect inguinal hernias.
How may they be differentiated from a femoral hernia?
Direct inguinal hernia: Passes through the anterior abdominal wall into the inguinal canal, exiting via the superficial ring
Indirect inguinal hernia: Passes through the deep inguinal ring, along the canal and out of the superficial ring
Femoral hernia - Below and lateral to the pubic tubercle
Define the terms hydrocele, spermatocoel, varicocoele, priapism and hypospadias
Hydrocoele: Accumulation of fluid within the tunica vaginalis. Resultant of incomplete obliteration of the connection with the peritoneal cavity (failure of the ligamentous remnant of processus vaginalis to form)
Spermatocoele: Cystic accumulation of sperm, arising from the head of the epididymis
Varicocoele: Enlargement of vein. More common in the left testes due to drainage to the acute angle of the left renal vein.
Priapism: Involuntary, elonged erection that is unrelated to sexual stimulation
Hypospadias: Congential deformity of the penis in which the urethral opening is located in an ‘abnormal position’ e.g. along the shaft of the penis. Opening seen on the ventral aspect of the penis
Outline the cremasteric reflex and how it may be elicited
Sees retraction of the testes due to contraction of the cremasteric muscle.
Elicited through gentle touch to the inner thigh. Tests L1 spinal root value.
Describe the relations of the kidneys
anterior, posterior and superior
Describe the position of the kidneys
*Left and right differ*
Approximately 3 vertebrae in length
Left:
- Anterior to the 11th and 12th ribs
Right:
- Anterior to the 12th rib
Renal hilum: L1 (transpyloric plane)
- Idicates position of the renal vessels and pelvis
Renal angle: The angle formed between the 12th rib and the lateral border of the erector spinae muscle
Describe the coverings of the kidneys
How do they relate to support and infection spread?
Kidneys → renal capsule → perirenal fat → Gerota’s fascia → pararenal fat → fascia of the posterior abdominal wall
Clinical signficance:
- Gerota’s fascia is incomplete on the posterior aspect, allowing for pus or extravasated urine to to track down alongside the ureter
- The kidney is poorly ‘fixed’ and so prone to injury during blunt trauma (rapid deceleration)
Outline the innervation of the kidneys
Sympathetic and parasympathetic fibres arise from the renal nerve plexus. These fibres are supplied by abdominopelvic splanchnic nerves.
Visceral afferents follow sympathetic fibres to spinal cord segments T11 -L3.
- Referred pain seen to T11 -L3 dermatomes due to the origin of the painful stimuli being confused following synapsing of the visceral afferents.
State the narrow regions of the ureter
Clinical significance
Uteropelvic junction (UPJ), pelvic brim and the vesicoureteric junction (VUJ)
Clinical significance: Common regions for obstruction by renal calculi
Outline the relations of the urinary bladder
Outline the blood supply, venous and lymphatic drainage of the bladder
Blood supply: Arises from anterior branches of the internal iliac artery
- Inferior vescile (M)/ Vaginal (F)
- Superior vesicle
Venous drainage:
Lymphatic drainage: Varies for different parts of the bladder. The internal iliac nodes are usually the primary site of lymphadenopathy
Describe the basic structure of the urinary bladder
Describe the structures and neural input that contributes to urinary continence
Storage and micturition
State the structures that induce difficulty during male and female catheterisation
Female:
- External urethral sphincter
- External urethral orifice
Male:
- Navicular fossa
- Fexible bend in the spongy urethra
- Fixed bend at the juntion between the membranous and spogy urethra
- Prostate
Outline the layers of the anterior abdominal wall passed through during insertion of a suprapubic catheter
MUST NOT PASS THROUGH THE PERITONEUM - distension of the bladder will usually ‘lift’ bowel loops and peritoneum clear of the route of the catheter
Outline the facial layers covering the penis
Which structure serves as a radiological landmark for the ureters?
- L2-L5 transverse processes
- Vesicouteric junction seen 1 cm above the ischial spine
Describe the anatomical relations of the ureters
Draw the main features of the kidney
Outline the arterial supply of the kidneys
State the type of epithelium seen within the urinary system
Transitional epithelium
Stratified cuboidal epithelium . Normally 4-6 layers, allows for ‘stretching’. Seen in the bladder, ureters, urethra and renal pelvis.
State the structures which contribute to the walls of the inguinal canal
Outline the anesthesia available for childbirth
Analgesia → conscious of uterine contractions, able to push
Anesthesia → Complete blockade of pain and feeling, unable to assit labour
Epidural block: Allows participatory childbirth
- L3-L4
- Birth canal, pelvic floor and majority of peritoneum is anesthetised but lower limbs unaffected
- Uterine body pain fibres ascend to thoracic/lumbar levels - not affected, mother is aware of contractions
Spinal anesthesia: Complete anesthesia below the waist
- Subarachnoid space, L3-L4
- Severe spinal headache may arise (enters cranial cavity once pt flat)
Pudendal nerve block: Peripheral nerve block providing anesthesia over S2-S4 dermotomes and inferior quarter of the vagina
- Mother still able to feel uterine contractions
- Administered near the sacrospinous ligament
Outline possible penile pathologies
Priapism, Phimosis, Paraphimosis and Peyronies
Priapism: Persistent erection in the absence of stimulation and unrelieved by ejaculation
Treatment: Catheterisation, alpha antagonists
Phimosis: Inability to retract the foreskin
Paraphimosis: Foreskin becomes ‘stuck’ behind the corona of the penis
Peyronie’s: Unusual curvature of the penis due to fibrosis and plaque formation within penile tissue
Outline the neurovascular supply of the scrotum
Clinical link: Consequences for anaesthetic
Anterolateral: Lumbar plexus (ilio-inguinal nerve)
Posteroinferior: Sacral plexus (pudendal)
Clinical link: More superior spinal anaesthetic must be used to anesthetize the anterolateral aspect of the scrotum
