Pelvic Viscera II

Question 1

Overview of female viscera

Answer 1

fascia and peritoneal reflections

Question 2

Viscera of female

Answer 2

bladder
uterus and ovaries
uterine tubes
vagina

Question 3

Female pelvic organs

Answer 3

1. ovary
2. uterus
3. vagina
4. bladder
5. uterine tube

Question 4

Peritoneal Folds

Answer 4

comprised of two layers of peritoneum

• suspensory ligament of ovary
• rectouterine fold
• broad ligaments

Question 5

peritoneal Fossae

- what are separated by

Answer 5

aka pouches

continuous with abdominopelvic cavity

1. vesicouterine pouch
2. rectouterine pouch (cul-de-sac of douglas)

• separated by broad ligament

Question 6

peritoneal spaces

Answer 6

1. retropubic ( prevesical)
2. retrovesical
3. retrorectal ( presacral)

Question 7

Laparoscopic approach for rectouterine pouch

Answer 7

rectouterine pouch can be surgically approached thru posterior fornix of vagina

• lateral extension (pararectal fossa) can be deepest
• recesses lateral to the bladder = paravesical fossa

Question 8

Broad ligament and contents

Answer 8

1. round ligament
   - mesometrium (2)
   - mesoalpinx (3)
   - mesovarium (1)
2. uterine tube
3. proper ovarian ligament
4. ovary
5. uterus
6. ovarian vessels (within suspensory ligament)
7. endopelvic fascia ( cardinal ligament)

Question 9

Female Endopelvic Fascia

• describe
• thickened area

Answer 9

• Beneath peritoneum & covering viscera, pelvic wall and floor; continuous with transversalis
  fascia

Thickened in areas forming:
1. Tendinous arch of levator ani
2. Lateral ligament of bladder and
rectum
3. Pubovesical (female)
4. Cardinal (transverse cervical) - ligament supporting cervix
5. paracolpium- thickened fascia from lateral vagina to tendinous arch

Question 10

Female endopelvic fascia

• components and describe
• function

Answer 10

aka hypogastric sheath

• support viscera and conduct neurovasculature to organs

1. pubocervical ligament
   - superior vesicular a. and v.
2. cardinal ligament (aka trasnverse cerivical ligament)
   - uterine a. and v. superior edge
   - provides main support for uterus
3. uterosacral ligament
   - middle rectal a. and v.
   - found within rectouterine fold

Question 11

Uterus

Answer 11

3 layers

1. fundus
2. body
3. cervix- protrudes into vagina, forming vaginal fornices
   - internal os
   - external os

major changes during the menstrual cycle are primarily in endometrium

Question 12

Uterine Positions

- side effects of position

Answer 12

1. verted- angle btw cervix and vagina
2. flex- angle btw uterine body and cervix
3. retroverted uterus- usually genetic, but may be caused by fibroids, endometriosis, PID, labor

no effect on fertility, but associated with lower back pain, dysuria, dysparenunia

Question 13

uterine prolapse

Answer 13

can occur when pelvic ligaments (especially the cardinal ligament) diaphragm weakens/tears

pregnancy is believed to be main cuase of pelvic organ prolapse

• aging, menopause, obesity contribute

Question 14

Uterine/ Fallopian tube

• components
• location
• functions

Answer 14

fimbria-> infundibulum-> ampulla-> isthmus-> intrauterine

• lie in free edge of broad ligament
• carries ova to the uterine cavity, assisted by motile cilia within the tube
• mucosal layer folds change during menstruation, though not as dramaticallymucosa

Question 15

layers of uterine

Answer 15

mucosa

muscularis

seros

Question 16

Ovaries

• components
• location

Answer 16

1. suspensory ligament
2. ovary
3. ovarian ligament

• lie on lateral wall of the pelvis
• covered laterally by fimbrae of the uterine tube
• attached
  1. broad ligament via mesovarium
  2. suspensory ligament
  3. medially to ovarian ligament (round ligament of ovary)

Question 17

Vagina

- componets and describe

Answer 17

1. cervix of uterus
2. fornix (posterior)
   - recess between cervix and vaginal wall
3. vagina
4. vestibule
   - opening to the vestibule can be partially closed by membranous hymen

Question 18

Female Urethra

Answer 18

• adjacent to anterior wall of the vagina
• penetrates UG triangle
• opens anterior to vaginal vestibule

Question 19

Female Urethral Sphincter

- types and describe

Answer 19

1. External urethral sphincter
   - skeletal m ( deep perineal branch of pudendal n)
   - striated
   - aids in reflex closure of urethra during acute instances of increased intra-abdominal pressure (coughing, sneezing, laughing)
   - proximal eus is where striated muscle length and thickness are lost with aging
   - pelvic floor exercises can increase EUS size
2. Internal urethral sphincter
   - smooth muscle (inferior hypogastric plexus)
   - cannot be easily separated from EUS

Question 20

Lymphatic Drainage for female pelvis

Answer 20

most lymph drains to iliac nodes

exceptions
- round ligament and part of uterine fundus and external genitalia-> superficial inguinal nodes

• ovary, uterine tube, part of uterine fundus-> Lumbar nodes

Question 21

Visceral motor innervation of female pelvis

Answer 21

1. superior hypogastric plexus
   - sympathetic
2. inferior hypogastric plexus
   - mixed autonomic
   - primary efferent innervation to female internal viscera
3. sacral splanchnic nerve
4. pelvic splanchnic nerve
   - parasympathetic
5. ovarian plexus
   - associated with ovarian artery
   - composed of parasympathetic from vagus n. and sympathetic from T10/11

Question 22

Pelvic Pain line

Answer 22

inferior limit to the peritoneum

Superior: GVA-> sympathetic to T12-L2
- structures within broad ligament (body and fundus of uterus)

Inferior: GVA-> parasympathetic to pelvic (S2-4)
- pelvic splanchnic

Question 23

Anesthesia Delivery

Answer 23

Specifically targets pelvic pain line differences
A. Spinal block or lumbar puncture: blocks from the waist down (intra- and sub-peritoneal plus
somatic areas)
B. Caudal block (epidural): blocks sub- peritoneal and somatic areas innervated by the pudendal nerve (sub-peritoneal plus
somatic area)
C. Pudendal nerve block: blocks areas innervated by the pudendal nerve (part of
somatic structures)