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Block 3 Week 7 > Pelvic Walls, Nerves, and Vasculature > Flashcards

Pelvic Walls, Nerves, and Vasculature Flashcards

1
Q

What makes up the pelvic floor?

A

-coccygeus, levator ani muscles (puborectalis, iliococcygeous, pubococcygeous)
and their fascias
-Perineal membrane (inferior fascia of UG diaphragm)
-muscles of deep perineal pouch

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2
Q

What is the perineal membrane?

A

inferior fascia of UG diaphragm

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3
Q

What separates the pelvic cavity from the perineum?

A

pelvic floor

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4
Q

What is the origin and insertion of the coccyeous muscle?

A

(origin) the ischial spine and the sacrospinous ligament

(insertion) to coccyx and inferior sacrum

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5
Q

What is the function of the coccygeous muscle?

A

supports pelvic viscera, pulls coccyx forward after defecation

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6
Q

The levator ani consists of three paired muscles, what are they?

A

puborectalis
iliococcygeus
pubococcygeus

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7
Q

What is the puborectalis and where does it arise from?

A

arises from right and left pubic bodies

U-shaped sling

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8
Q

Where does the pubococcygeus arise from and attach to?

A

from posterior part of pubic body and anterior tendinous arch and
attaches at coccyx

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9
Q

The pubococcygeus is divided into several sections which were….?

A

pubovaginalis
puboprostaticus
puboanalis

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10
Q

The iliococcygeus muscle arises from the (blank)

A

posterior tendinous arch and ischial spine

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11
Q

The iliococcygeous forms a ligament/raphe between what 2 things?

A

the anal aperature and the coccyx

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12
Q

Is the iliococcygeous muscle thick?

A

no it is thin and poorly developed

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13
Q

What is the importance of the levator ani?

A

for support, continence, as a vaginal sphincter, defecation and urination

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14
Q

What is the innervation to the levator ani?

A

Direct branches from ventral rami of S4 and inferior rectal branch of pudendal nerve (S2-S4)

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15
Q

What muscles insert at the perineal body?

A

bublospongiosus muscle, sup. transverse perineal muscle, pubococcyeus mucsle, external anal sphincter muscle

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16
Q

Other than the main muscles that insert at the perineal body, what are some additional fibers that insert there?

A

deep transverse perineus
external urethral sphincter
puborectalis

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17
Q

What is the clinical relevance of knowing the muscles that insert at the perineal body?

A

episiotomy

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18
Q

The common iliac splits into the internal and external iliacs at the level of the IV disc between (blank and blank)

A

L5 and S1

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19
Q

The internal iliac splits into what?

A

the anterior and posterior divisions

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20
Q

What supplies the pelvic viscera, walls, floors, perineal structure, gluteal region and thigh with blood?

A

anterior and posterior branches of internal iliac

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21
Q

Besides the anterior and posterior branches of the internal iliac, what also supplies the pelvic region?

A

gonadel artery (from aorta)
median sacral artery (from aorta)
superior rectal artery (from IMA)

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22
Q

The internal iliac’s anterior branch,branches into what 8 arteries?

A 
umbilical -> superior vesical artery
obturator
inferior vesical (males)
vaginal (female)
middle rectal
uterine (or artery to ductus deferens)
internal pudendal
inferior gluteal
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23
Q

The posterior branch of the internal illiac branches into what 3 arteries?

A

iliolumbar
lateral sacral
superior gluteal

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24
Q

The internal iliac’s anterior branch,branches into what 8 arteries?

A 
umbilical-> superior vesical artery
obturator
inferior vesical (males)
vaginal (female)
middle rectal
uterine (or artery to ductus deferens)
internal pudendal
inferior gluteal
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25
Q

The posterior branch of the internal illiac branches into what 3 arteries?

A

iliolumbar
lateral sacral
superior gluteal

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26
Q

(blank) is the first branch of the anterior trunk of internal illiac and gives rise to the superior vesical artery.

A

umbilical artery

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27
Q

What does the umbilical artery turn into?

A

the superior vesical artery

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28
Q

What happens after birth to the umbilical artery?

A

it becomes a solid fibrous cord and creates a medial umbilical fold and medial umbilical ligament

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29
Q

What does the superior vesical artery supply?

A

supplies superior bladder and distal ureter

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30
Q

What often comes off the superior vesical artery?

A

artery of the ductus deferens

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31
Q

What is this:
It usually is the second branch off of the anterior trunk of the internal illiac. It runs along obturator fascia on the lateral wall of the pelvis and leaves the pelvis through the obturator canal.

A

Obturator artery

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32
Q

What does the obturator artery supply?

A

the adductor region of the thigh

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33
Q

Where does the obturator artery run?

A

it runs along the obturator fascia on the lateral wall of the pelvis

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34
Q

What is a common variation of the obturator artery?

A

presence of an accessory obturator artery arising from inferior epigastric artery and descending the normal path of the main branch

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35
Q

Why is it important to know the variations of the obturator artery?

A

important for hernia repair surgeries

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36
Q

What artery is the equivalent to the vaginal artery in the male?

A

inferior vesical artery

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37
Q

What does the inferior vesical artery supply?

A

supplies the bladder, distal ureter, seminal vesicles (male)

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38
Q

What does the vaginal artery supply?

A

supplies the vagina, bladder and rectum and anastomoses with the uterine artery and superior vesical artery

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39
Q

What supplies the inferior rectum where it anastomoses with the superior and inferior rectal arteries and the seminal glands and prostate or vagina?

A

middle rectal artery

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40
Q

Where does the middle rectal artery arise from?

A

Either from the internal iliac artery
or in common with the inferior vesicle artery or
internal pudendal artery

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41
Q

What does the middle rectal artery spply?

A

supplies,

inferior rectum, seminal glands, prostate or vagina

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42
Q

Where do we find the uterine artery?

A

within the cardinal ligament and arises from the umbilical artery (usually)

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43
Q

Does the uterine artery pass under or over the ureter?

A

over

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44
Q

The uterine artery is homologous to what?

A

to the artery to the ductus deferens

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45
Q

The umbilical artery divides into branches that supply what?

A

A branch that supplies the vagina and cervix

A branch that supplies the body and fundus of the uterus

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46
Q

The uterine artery anastomoses with what?

A

the ovarian artery

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47
Q

What is enlarged during pregnancy?

A

the uterine artery

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48
Q

What all does the uterine artery supply?

A

the utereus, the ovary, ovarian tubes

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49
Q

Explain the path of the internal pudendal artery.

A

leaves the pelvis through the greater sciatic foramen and enters the ischioanal fossa via the lesser sciatic foramen with the pudendal nerve and passes through the pudendal canal

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50
Q

The internal pudendal artery divides into what?

A

deep and dorsal branches of the clitoris or penis as it exits the pudendal canal.

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51
Q

What is the main artery of the perineum?

A

internal pudendal artery

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52
Q

Explain the path of the inferior gluteal artery

A

passes posteriorly between the sacral nerves and leaves the pelvis though the greater sciatic foramen (inf. to piriformis).

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53
Q

What does the inferior gluteal artery supply?

A

the muscles and skin of the buttock and posterior thigh

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54
Q

What does the inferior gluteal artery anastomose with?

A

a network of vessels around the hip joint

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55
Q

What is the largest branch of the internal iliac artery?

A

superior gluteal artery

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56
Q

What is the terminal continuation of the posterior division of the internal illiac?

A

the superior gluteal artery

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57
Q

How does the superior gluteal artery pass through the pelvic cavity?

A

Courses posteriorly and between nerves of the lumbosacral trunk and S1, leaves the pelvis through the greater sciatic foramen (superior to piriformis).

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58
Q

What does the superior gluteal artery supply?

A

supplies the muscles and skin of the gluteal region as well as supplying branches to adjacent muscles and bones of the pelvic wall

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59
Q

What is the path the iliolumbar artery takes?

A

ascends laterally back out of the pelvic inlet and divides

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60
Q

What does the iliolumbar artery branch into?

A

the iliac branch and the lumbar branch

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61
Q

What branch of the iliolumbar passes laterally into the iliac fossa (supplies the iliacus and ilium)

A

iliac branch

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62
Q

What branch of the iliolumbar supplies the posterior abdominal wall, the cauda equina, the psoas major and quadratus lumborum muscles?

A

lumbar branch

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63
Q

What does the iliac branch of the iliolumbar artery supply?

A

supplies the iliacus and ilium

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64
Q

What does the lumbar branch of the iliolumbar artery supply?

A

supplies the posterior abdominal wall, the psoas muscle and quadratus lmborm and the cauda equina

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65
Q 
What is this:
Usually two (superior and inferior) arteries on each side arising from a the posterior trunk of the internal illiac
A

lateral sacral arteries

66
Q

What gives off spinal branches which supply the sacral meninges enclosing the roots of the sacral nerves?

A

lateral sacral arteries

67
Q

What do the lateral sacral arteries supply?

A

supply the erector spinae muscles and skin covering the sacrum

68
Q

What do the spinal branches off of the lateral sacral arteries supply?

A

supplies the sacral meninges and encloses roots of sacral nerves

69
Q

There is collateral circulation to the posterior abdominal and pelvic wall and spinal cord, how is this achieved?

A

lumbar (abdominal aorta) and iliolumbar arteries (posterior trunk of internal iliac)

70
Q

There is collateral circulation to the back and spinal cord, how is this achieved?

A

median sacral (abdominal aorta) and lateral sacral (iliolumbar /posterior trunk of internal iliac)

71
Q

There is collateral circulation to the rectum, how is this achieved?

A

superior rectal (IMA) and middle rectal (anterior division of internal iliac)

72
Q

There is a collateral circulation to the gluteal muscles and hip joint, how is this achieved?

A

inferior gluteal artery (anterior division of internal iliac) and deep artery of the thigh (femoral artery)

73
Q

What happens if you blockage of right internal iliac and left internal iliac?

A

you will get Leriche syndrome which will result in impotence and (claudation) loss of sensation in buttocks and thighs

74
Q

There is collateral circulation to the posterior abdominal and pelvic wall and spinal cord, how is this achieved?

A

lumbar (abdominal aorta) and iliolumbar arteries (posterior trunk of internal iliac)

75
Q

There is collateral circulation to the back and spinal cord, how is this achieved?

A

median sacral (abdominal aorta) and lateral sacral (iliolumbar /posterior trunk of internal iliac)

76
Q

There is collateral circulation to the rectum, how is this achieved?

A

superior rectal (IMA) and middle rectal (anterior division of internal iliac)

77
Q

There is a collateral circulation to the gluteal muscles and hip joint, how is this achieved?

A

inferior gluteal artery (anterior division of internal iliac) and deep artery of the thigh (femoral artery)

78
Q

What happens if you blockage of right internal iliac andleft internal iliac?

A

you will get Leriche syndrome which will result in impotence and (claudation) loss of sensation in buttocks and thighs

79
Q

There is collateral circulation to the posterior abdominal and pelvic wall and spinal cord, how is this achieved?

A

lumbar (abdominal aorta) and iliolumbar arteries (posterior trunk of internal iliac)

80
Q

There is collateral circulation to the back and spinal cord, how is this achieved?

A

median sacral (abdominal aorta) and lateral sacral (iliolumbar /posterior trunk of internal iliac)

81
Q

There is collateral circulation to the rectum, how is this achieved?

A

superior rectal (IMA) and middle rectal (anterior division of internal iliac)

82
Q

There is a collateral circulation to the gluteal muscles and hip joint, how is this achieved?

A

inferior gluteal artery (anterior division of internal iliac) and deep artery of the thigh (femoral artery)

83
Q

What happens if you blockage of right internal iliac andleft internal iliac?

A

you will get Leriche syndrome which will result in impotence and (claudation) loss of sensation in buttocks and thighs

84
Q

Pelvic veins follow the course of all internal iliac artery branches except for the (balnk) arteries.

A

umbilical artery, iliolumbar artery and some of the internal pudendal artery (i.e deep dorsal vein).

85
Q

In the pelvis, the veins all drain into the (blank) which drain into the (blank)

A

internal iliac veins

common iliac veins

86
Q

Where are there extensive interconnected venous plexuses?

A

around the bladder, rectum, prostate, uterus, vagina which collectively form the pelvic plexus of veins

87
Q

The venous plexus surrounding rectum and anal canal drains via (blank) and (blank).

A

Superior rectal veins

middle and inferior rectal veins

88
Q

Where do superior rectal veins drain into?

A

into IMV so into the hepatic portal system

89
Q

Where do middle and inferior rectal veins drain into?

A

into internal illiac and common iliac so into the caval system

90
Q

Why is it important the the rectal veins have different ways of drainage?

A

This is called the portal-caval shunt and it is important because if you have blockage of one vein you will still have venous drainage

91
Q

The inferior part of the rectal plexus around anal canal has 2 parts, which are?

A

internal rectal plexus and external venous plexus

92
Q

The (blank) that drains the erectile tissue of the penis and clitoris passes directly into the pelvic cavity.

A

deep dorsal vein

93
Q

What does the deep dorsal vein join with ?

A

the prostatic or vesical venous plexuses

94
Q

Ovarian veins on the left join the (blank)

A

renal vein

95
Q

On the right, the ovarian veins join the (blank)

A

IVC

96
Q

How does the lymphatic drainage work in the pelvis?

A

it follows the venous drainage therefore most drainage via internal iliac nodes

97
Q

What lymphatic nodes drain this:
perineum (skin, penis, scrotum and vulva), uterus (area of round ligament), lower limb, gluteal region, anal canal (below pectinate line), vagina (external orifice)

A

superficial inguinal nodes

98
Q

What lymphatic nodes drain this:

perineum (clitoris and glans penis, distal spongy urethra)

A

Deep inguinal nodes

99
Q

What lymphatic nodes drain this:

anterosuperior pelvic viscera

A

External iliac nodes

100
Q

What lymphatic nodes drain this:
most pelvic viscera (inferior aspects), anal canal (above pectinate line), deep perineal strucutres (vagina, urethra), inferior rectum, prostate

A

internal iliac nodes

101
Q

What are some minor nodes?

A

sacral and pararectal

102
Q

What lymphatic nodes drain this:

gonads

A

lumbar nodes

103
Q

How does drainage of lymphatics occur?

A

drainage into common iliac nodes, then lumbar trunks, ultimately into cisterna chylli

104
Q

Where does the inferior gluteal nerve come from?

A

L5-S2 nerves

105
Q

Where do the lumbosacral trunk, sciatic nerve, pudendal nerve, superior gluteal nerve, inferior gluteal nerve all leave the pelvis through?

A

from the sacral plexus and leave pelvis via greater sciatic foramen

106
Q

What two muscles form a bed for sacral and coccygeal nerves?

A

the piriformis and coccygeus muscles

107
Q

The piriformis and coccygeus muscles form a bed for (blank and blank) nerves.

A

sacral and coccygeal nerves

108
Q

(blank) primarily innervate the lower limb and perineum.

A

somatic nerves

109
Q

(blank) passes through the lesser pelvis passing through the obturator membrane and innervates the medial thigh (does not innervate the actual pelvis).

A

obturator nerve (L2-L4)

110
Q

Explain how the lumbosacral trunk starts

A

The lumbosacral trunk comprised of the anterior division of the fifth and a part of the fourth lumbar nerve; it appears at the medial margin of the psoas major and runs downward over the pelvic brim to join the first sacral nerve.

111
Q

Where does the sciatic nerve come from?

A

L4-S3 (passes through but does not innervate the pelvis)

112
Q

Where does the pudendal nerve come from?

A

S2-S4

113
Q

Where does the superior gluteal nerve come from?

A

L4-S1

114
Q

Where does the inferior gluteal nerve come from?

A

L5-S2 nerves from the sacral plexus and leave pelvis via greater sciatic foramen

115
Q

Where do the lumbosacral trunk, sciatic nerve, pudendal nerve, superior gluteal nerve, inferior gluteal nerve all leave the pelvis through?

A

from the sacral plexus and leave pelvis via greater sciatic foramen

116
Q

(blank) is the main nerve of the perineum and the chief sensory nerve to the external genitalia

A

pudendal nerve

117
Q

How does the pudenedal nerve travel through the pelvis?

A

out of the pelvis via greater sciatic foramen and into the perineum via the lesser sciatic foramen

118
Q

What do the terminal branches of the pudendal nerve innervate?

A

innervates the exerternal urethra sphincter, external anal sphincter, sensory to external genitalia and skin surrounding the anus and perineum

119
Q

Tell me about the coccygeal plexus

A

lies on the pelvic surface of the coccygeus

innervates coccygeus and part of levator ani

120
Q

What nerves arise from the coccygeal plexus?

A

anococcygeal nerves

121
Q

What is the main function of the periarterial plexus?

A

vasomotion of the arteries they accompany

122
Q

What do the parasympathetic pelvic autonomic nerves do?

A

vasodilation leading to erection
bladder contraction
contraction of rectum
modulation of ENS (the part not innervated by the vagus)
(causing peeing, and defecation, erection)

123
Q

Autonomic nerves enter the pelvic cavity via four main routes, what are they?

A

1) Sacral sympathetic trunks
2) Periarterial plexuses
3) Hypogastric plexuses:
- Superior hypogastric plexus
- Inferior hypogastric plexus
4) Pelvic splanchnic nerves

124
Q

Autonomic nerves enter the pelvic cavity via four main routes, what are they?

A

1) sacral sympathetic trunks
2) periarterial plexuses
3) hypogastric plexuses
4) pelvic splachnics

125
Q

What is the sacral sympathetic trunk?

A

it is the continuation of the lumbar sympathetic trunk to innervate the lower limbs

126
Q

What does the sacral sympathetic trunk do?

A

sends grey communicating rami to each anterior ramus of sacral and coccygeal nerves
sends small branches to inferior hypogastric plexus (sacral splachnics)

127
Q

What is the main function of the sacral sympathetic trunk?

A

provides postsynaptic fibers to the sacral plexus for sympathetic innervation of the lower limb
(contributes to only 10% of sympathetic innervation)

128
Q

What kind of fibers are in the periarterial plexuses?

A

postsynaptic, sympathetic, vasomotor fibers

129
Q

Where do the fibers of the periarterial plexus go?

A

go to the superior rectal, ovarian and internal iliac arteries and their branches

130
Q

Is the periarterial plexus the major route for sympathetic fibers to enter the pelvis?

A

No, it is a minor route

131
Q

What is the main function of the periarterial plexus?

A

vasomotion of the arteries they accompany

132
Q

What is the most important route by which sympathetic fibers are conveyed to pelvic viscera?

A

hypogastric plexuses

133
Q

What kind of fibers are wtihin the hypogastric plexus?

A

networks of sympathetic, parasympathetic, and visceral afferent nerve fibers

134
Q

There are 2 hypogastric plexuses?

A

superior and inferior

135
Q

What is made up of the continuation of the aortic plexus, branches off the L3, L4 and lumbar splachnics (sympathetic)?

A

superior hypogastric plexus

136
Q

Explain how superior hypogastric plexus turns into the inferior hypogastric plexus

A

superior hypogastric plexus divides into right and left hypogastric nerves once it enters the pelvis, they descend laterally to the rectum andthen converge with pelvic splachnics and forms the left and right inferior hypogastric plexuses.

137
Q

How do parasympathetic fibers get to the superior hypogastric plexus?

A

through right and left hypogastric nerves

138
Q

How do you get to the inferior hypogastric plexus?

A

the right and left hypogastric nerves join together withpelvic splachnics and sacral splachnics

139
Q

The hypogastric plexus contains what kind of fibers?

A

postganglionic sympathetic and preganglionic parasympathetic fibers as well as visceral afferent fibers

140
Q

(blank) form sub-plexuses known as pelvic plexuses (middle rectal, uterovaginal, vesical, prostate) which travel with appropriate branches of the internal iliac artery to target organ.

A

Inferior hypogastric plexus

141
Q

Terminal branches of the inferior hypogastric plexus will penetrate and pass through the (blank) innervate erectile tissues (release NO)

A

deep perineal pouch

142
Q

Where do pelvic splachnics originate?

A

from the anterior rami of S2-S4

143
Q

What do pelvic splachnics do?

A

convey presynaptic parasympathetic fibers

144
Q

(blank) join the hypogastric nerves to form the inferior hypogastric plexus and also supply the superior hypogastric plexus.

A

Pelvic splachnics

145
Q

How do you get parasympathetic innervation of the pelvic viscera and descending and sigmoid colon?

A

via the pelvic splachnics

146
Q

Visceral afferent fibers travel with (blank)

A

autonomic nerves

147
Q

How do visceral afferent fibers travel?

A

they follow the course of sympathetic and parasympathetic fibers in the pelvis.

148
Q

The course of pain fibers depends upon whether the pain is arising from above or below the (blank)

A

pelvic pain line

149
Q

The pelvic pain line refers to organs being above (or in contact with) or below the (blank)

A

peritoneum

150
Q

Superior to the pain line, how do visceral afferents travel?

A

follow sympathetic fibers and reach cell bodies in inferior thoracic/upper lumbar spinal ganglia (only true for the pelvis!)

151
Q

Inferior to the pain line, how do visceral afferents travel?

A

follow parasympathetic fibers to reach cell bodies in spinal sensory ganglia of S2-4

152
Q

What is the only exception to the pain line rule?

A

large intestine, the pelvic pain line is located in the middle of the sigmoid colon.

153
Q

T or F

Pain from below the pain line is less likely to be felt consciously

A

T

154
Q

Explain how males get an erection.

A

parasympathetics (pelvic splachinics S2-4)
make dilation and straightening of helicine arteries and engorgement of corpus cavernosum and contraction of bulbospongiosus and ischiocavernosus muscles and traps blood

155
Q

Explain how males have emission.

A

sympathetic nerves L1-L2
Sperm and other secretions released in prostatic urethra, contraction of ductus deferens, seminal glands and prostate
Contraction of internal urethral sphincter

156
Q

Explain male ejaculation.

A

Somatomotor (S2-S4), Sympathetic

somatomotor: Contraction of bulbospongiosus, levator ani, EAS, gluteal muscles
sympathetic: Propulsion of semen along the penile urethra

157
Q

Explain male remission

A

(detumescence/resolution) – Sympathetic
Vasoconstriction and recoil of helicine arteries, flaccid
Relaxation of bulbospongiosus and ischiocavernosus muscles, drainage of blood into deep dorsal vein
Refractory period

158
Q

Explain female arousal

A

Parasympathetic (Pelvic splanchnic nerves, S2-S4)
Increased vestibular and vaginal secretions
Erection of clitoris (similar mechanism to erection of the penis)

159
Q

Explain female plateau

A

(lasts minutes to hours) – Sympathetic (L1-L2 nerves)
Vascular engorgement (clitoris, labia, breasts, lower vagina)
Erection of nipples
Sex flush (reddening of chest)
Dilation of upper vagina
Tenting of the uterus (lengthening of vagina)

160
Q

Explain female orgasm

A

Somatomotor (S2-S4), Sympathetic
Contraction of bulbospongiosus, ischiocavernous (~1 second intervals, variable)
Dilation of cervix
Uterine contractions (oxytocin)
Dipping of the uterus (shortening of vagina)

161
Q

Explain female resolution

A

(detumescence) – Sympathetic
Return of pre-arousal stage
Relaxation of bulbospongiosus and ischiocavernosus muscles, drainage of blood into deep dorsal vein
No refractory period

Block 3 Week 7 (8 decks)

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