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SE book revision > Pelvis > Flashcards

Pelvis Flashcards

1
Q

Describe the borders of the inguinal canal

A

-Anterior: external oblique aponeurosis, reinforced by fibres of internal oblique lateral 1/3rd
-Posterior: Transversalis fascia, conjoint tendon medial 1/3rd
-Superior: arching fibres of internal oblique and transversus abdominis
-Inferior: Inguinal ligament, lacunar ligament medial 1/3rd

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1
Q

Where is the superficial ring located?

A

Defect in external oblique, superolateral to pubic tubercle. ‘Exit’ from inguinal canal

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2
Q

Where is the deep ring located?

A

-Defect in transversalis fascia
-~ 1.5-2cm above midpoint of inguinal ligament (midway between pubic tubercle and anterior superior iliac spine)
-‘Entrance’ to canal

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3
Q

What are the contents of the inguinal canal?

A

-Round ligament in females
-Spermatic cord
-Ilioinguinal nerve

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4
Q

What are the contents of the spermatic cord?

A

3 fascia
-External spermatic fascia (external oblique aponeurosis)
-Cremasteric fascia (Internal oblique aponeurosis)
-Internal spermatic fascia (Transversalis fascia)

3 nerves
-genital branch genitofemoral nerve
-Sympathetic fibres
-ilioinguinal nerve (lies outside spermatic cord)

3 arteries
-Cremastic artery
-Testicular artery
-Artery to vas deferens

3 other things
-Pampiniform plexus of veins
-Vas deferens
-Lymphatics

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5
Q

What is the difference between a direct and an indirect inguinal hernia?

A

-Direct: Does not enter inguinal canal, occurs as weakness within transversalis fascia. Lies above and medial to pubic tubercle
-Indirect: passes through deep ring to enter inguinal canal. Lies within inguinal region or in scrotum

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6
Q

Name the boundaries of hasselbach’s triangle

A

Lateral: inferior epigastric arteries
Medial: lateral border of rectus abdominis
Inferior: inguinal ligament

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7
Q

Describe the relationship of direct and indirect hernias in relation to hasselbach’s triangle

A

Direct hernia lies medial to inferior epigastric, protruding into hasselbach’s triangle

Indirect commences lateral to inferior epigastric artery

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8
Q

Describe where femoral hernias occur in relation to the pubic tubercle

A

Below and lateral to pubic tubercle

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9
Q

What is the femoral canal?

A

-Most medial compartment of the femoral sheath
-Femoral canal extends from femoral ring proximally to level of saphenous opening distally

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10
Q

Describe the contents of the femoral canal

A

-Fat
-Lymphatics
-Cloquet’s node

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11
Q

Describe the borders of the femoral ring

A

-Anterior: inguinal ligament
-Posterior: pectineal ligament overlying superior ramus of pubis
-Medial: lacunar ligament
-Lateral: femoral vein

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12
Q

What are the indications for repair of inguinal hernia?

A

Elective repair
-Symptomatic
-Asymptomatic to prevent complications

Emergency repair:
-Obstruction
-Strangulation
-Incarceration

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13
Q

Describe the male urethra

A

Pre-prostatic urethra
–>vertical course from bladder to prostate

Prostatic urethra
–> Widest part of urethra
–> Contains urethral crest with prostatic sinuses on both sides, seminal colliculus centrally

Membranous urethra
–>Narrowest part of urethra
–> surrounded by external urethral sphincter
–> bulbourethral glands posteriorly

Spongy urethra
–>Longest part of urethra
–>Bulbourehtral glands empty into it proximally
–> Has two expansions: intrabulbar fossa in bulb of penis, navicular fossa in glans

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14
Q

Why is understanding of bladder anatomy important in suprapubic catheterisation?

A

-When empty, bladder is tetrahedral in shape, with apex anteriorly and body between apex and fundus
-Fundus meets remaining surfaces of bladder at the bladder neck
-As it fills with urine, it extends superiorly betrween rectus abdominis and peritoneum but without entering peritoneal cavity
-Therefore in normal patient suprapubic catheterisation can be performed safely extra-peritoneal
-However in pt with previojs abdominal surgery, adhesions can cause loop of bowel to lie anterior to bladder

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15
Q

Describe the relations of the bladder in the male

A

Superior: peritoneum
Inferior: pubic bones, obturator internus, levator ani
Fundus: rectum
Bladder neck: prostate, with seminal vesicles posteriorly

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16
Q

Describe the blood supply to the bladder

A

Branches of the anterior division internal iliac

Males:
–> superior vesical artery (superior)
–> inferior vesical (inferior)

Females:
–> superior vesical (superior
–> vaginal (inferior)

Contributions also from obturator and inferior gluteal arteries

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17
Q

Describe the layers of the bladder

A

In to out:
-Mucosa (transitional cells)
-Lamina propria
-Detrusor muscle

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18
Q

Where are the seminal vesicles located?

A

-Between the fundus of the bladder and the rectum, superior to the prostate

note: above the seminal vesicles is a fold of peritoneum: the rectovesical pouch

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19
Q

Describe the lobes of the prostate

A

Anterior lobe: Anterior to urethra
Posterior lobe: Posterior to urethra (part palpated during DRE)
Lateral lobes: form bulk of prostate
Median lobe: between urethra and ejaculatory ducts, close to bladder neck

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20
Q

Where do most prostate cancers occur?

A

Lateral lobe
Peripheral zone

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21
Q

What are the zones of the prostate?

A

Peripheral zone–> lateral lobe
Central zone –> median lobe (close to ejaculatory ducts)
Transitional zone –> surrounding prostatic urethra (where BPH is most common)

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22
Q

What is the most common prostatic malignancy?

A

Adenocarcinoma (75% occur in peripheral zone of the prostate)

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23
Q

Describe the gleason staging system for adenocarcinoma

A

-Cancer is microscopically graded 1-5 according to differentiation (1 is well differentiated, 5 is poorly differentiated)
-Prostate cancers tend to be multifocal: therefore the most common is given a primary grade, and the next most common a secondary grade.
-If there are 3 patterns, the dominant pattern is the first number, and the second is the highest grade

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24
Q

How does prostate cancer metastasise?

A

-Local invasion is perineural, following the autonomic nerves

Other sites:
–>via lymphatic channels to sacral, iliac and para-aortic nodes
–> haematological to bone (pelvis, femur, vertebra) and distant viscera: liver, lungs

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25
Q

Describe the embryological development of the testes

A

-Develop in superior posterior abdominal wall, extraperitoneally, from where they descend to the region of the inguinal canal later in foetal development, before reaching scrotum around the time of birth
-Therefore, this is the path along which an undescended testicle may lie
-Undescended testes commonly lie at the level of the superficial ring/inguinal canal

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26
Q

What is cryptorchidism?

A

Cryptorchidism is the absence of one or more testis from the scrotum

Note: a retractile testis is a testicle which can be brought into the scrotum with manipulation, but retracts spontaneously or with gentle pressure

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27
Q

Name some causes of cryptorchidism

A

Agenesis
Intra-abdominal arrest
Incomplete descent
Ectopic descent

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28
Q

What is the difference between orchidopexy and orchidectomy?

A

Orchidopexy is a procedure to bring and fix an undescended testicle into the scrotum

Orchidectomy is the surgical removal of one or both testicles

29
Q

Name some indications for orchidopexy

A

-Treatment of testicular torsion (usually during adolescence)
-Cryptorchidism (usually in children)

Orchidopexy is performed to reduce risks of infertility, testicular malignancy, traumatic injury to the testis, development of inguinal hernia, testicular torsion in adolescents and to maintain appearance of normal scrotum

30
Q

What is a varicocele

A

Dilatation of the pampiniform plexus of veins

31
Q

Where do the left and right testicular veins drain?

A

Left testicular vein: left renal vein

Right testicular vein: IVC at a more oblique angle. Therefore left sided varicoceles are more common

32
Q

What is a hydrocele?

A

A hydrocele is a collection of fluid in the tunica vaginalis, the double layer of peritoneum that invests the testes.

Hydroceles can be primary (idiopathic) or secondary

33
Q

Name some differential diagnoses for scrotal swellings

A

-Epididymal cyst
-Sebaceous cyst
-Testicular malignancy
-Epididymo-orchitis
-Inguinal hernia
-Hydrocele
-Varicocele

34
Q

Describe the course of the ureter

A

-Originates at renal pelvis
-Runs anterior to transverse processes of L1-L5 towards SI joint
-Enters pelvis at bifurcation of common iliac vessels (at pelvic brim) then courses anterior to internal iliac down lateral pelvic sidewall
-Enters bladder posterolaterally at level of ischial spine, courses in wall for 1-2cm before opening into bladder at internal ureteric orifice

35
Q

Name the vessel that crosses the ureter as it enters pelvic brim

A

External iliac artery

36
Q

Describe the relationship of the ureter to the uterine artery in the female pelvis

A

Ureter passes beneath the uterine artery, lateral to the cervix

In males passes beneath the ductus deferens as the ductus courses along lateral wall of pelvis

37
Q

Describe how you would quickly identify the ureter during intra-abdominal surgery

A

-Courses along sacroiliac joints
-Crosses external iliac just distal to iliac bifurcation
-Lies medial to internal iliac on posterolateral pelvic sidewall
-visible peristalsis

38
Q

Name the constrictions of the ureter

A

Pelviureteric junction
Pelvic brim
VUJ

39
Q

Describe the blood supply to the ureter

A

Segmental supply from 4 sources:
-Renal
-Gonadal
-Internal iliac
-Superior and inferior vesical

40
Q

What type of epithelium lines the ureter?

A

Transitional epithelium

41
Q

What serious complication can arise following ureteric obstruction?

A

-Hydronephrosis and renal dysfunction
-Drainage of the kidney is usually required via percutaneous nephrostomy or retrograde ureteric stenting

42
Q

Describe where ureteric calculi may be identified on a plain radiograph of the kidney, ureters and bladder (XR KUB)

A

Course of the ureter can be correlated with bony anatomy visible on a plain film radiograph

–> Passing inferiorly over tips of transverse processes of lumbar vertebrae
–> Passing over SI joint to level of ischial spines then turning medially to enter bladder

43
Q

Name the most common type of ureteric stone (by composition)

A

Calcium oxalate (85% of stones)

44
Q

Name the type of stone (by composition) that is most commonly responsible for staghorn calculi

A

Struvite (can also be calcium oxalate or uric acid)

45
Q

Name the radiolucent stone that occurs in acidic urine

A

Urate stones

46
Q

Other than calculi, name some other causes of unilateral hydronephrosis

A

Intrinsic:
-Stricture
-TCC renal pelvis/ureter

Extrinsic
-Tumour (colonic, cervical, prostatic)
-Abnormal vasculature at PUJ
-Retroperitoneal fibrosis
-Post radiation fibrosis
-AAA

47
Q

Describe the relations of the uterus

A

Anterior: Vesicouterine pouch, bladder
Posterior: recto-uterine pouch (of douglas) and rectum
Lateral: transverse cervical ligament, broad ligament, ureters

48
Q

Describe the arterial supply to the uterus

A

-Predominantly from uterine artery (from internal iliac anterior division)
-Also from ovarian arteries (from abdominal aorta just inferior to renal arteries)

49
Q

Describe the course of the internal iliac artery

A

-Originates at L5-S1 vertebral level at bifurcation of the common iliac artery anterior to sacroiliac joint
-Enters pelvis medial to external iliac vein and obturator nerve
-Terminates into anterior and posterior divisions superior to greater sciatic foramen

50
Q

What territory is supplied by the anterior branch of the internal iliac artery

A

pelvic organs, muscles of pelvis, medial thigh, perineum

51
Q

Name the branches of the anterior division of the internal iliac artery and the territory they supply

A

3 visceral, 3 parietal, 3 urinary

3 parietal
-Inferior gluteal
-Obturator
-internal pudendal

3 visceral
-Uternine
-vaginal
-MIddle rectal

3 urinary
-Superior vesical
-inferior vesical
-umbilical (foetal only)

52
Q

Name the branches of the posterior division of the internal iliac artery and the territory they supply?

A

pILS

Iliolumbar
-Psoas major, iliacus, quadratus lumborum

Lateral sacral
-Piriformis, sacral canal, erector spinae

Superior gluteal
-Piriformis, gluteal muscles, tensor fascia lata

53
Q

Describe the broad ligament of the uterus

A

Double layer of peritoneum within which is folded:
-Uterine tube
-Ligament of ovary
-Round ligament of uterus

-Broad ligament helps fix uterus in place in the pelvis
-Peritoneum which forms broad ligament passes from uterus laterally to side walls + floor of pelvis

54
Q

Describe the course of the ovarian artery

A

-Branch of abdominal aorta, originating inferior to renal arteries
-Descends on posterior abdominal wall where it lies anterior to ureter and gives branches to it
-It then crosses external iliac close to its origin and enters pelvis, where it runs in suspensory ligament of ovary and broad ligament of uterus
-Terminates in branches to ovary and fallopian tube

55
Q

Describe the relations of the vagina

A

Anterior: bladder and urethra

Supero-lateral: ureter

Posterior: ampulla of rectum, pouch of douglas, perineal body, anal canal

Inferiorly: anal canal is seprated from vagina by perineal body

Lateral: levator ani, uterine artery, urogenital diaphragm

56
Q

Which muscles form the pelvic floor?

A

Formed by 3 components of levator ani (pubococcygeus, iliococcygeus and puborectalis)

And coccygeus

57
Q

What are the origins of levator ani?

A

-Originates from posterior of body of pubis bone, spine of ischium, fascia covering obturator internus

58
Q
A
59
Q
A
60
Q

What are the attachments of the ligaments of the pelvis?

A

Sacrospinous ligament: Sacrum  ischial spine
Sacrotuberous ligament: Sacrum  ischial tuberosity

Sacrospinous ligament lies medial to and in front of sacrotuberous ligament

61
Q
A

-Obturator internus and piriformis arise within the pelvis and then exit pelvis via the sciatic foramina
Oburator internus arises from obturator membrane (covers obturator foramen)

62
Q
A

-They exit pelvis through sciatic foramina to insert onto the GT of the femur

63
Q
A
64
Q
A
65
Q
A
66
Q

Describe the insertion of levator ani

A

-Pubococcygeus: forms sling around vagina in female, prostate in male. Inserts into perineal body

-Puborectalis: forms sling around rectum and anus, inserts into anal sphincter

-Iliococcygeus: coxxyx, ano-coccygeal ligament

67
Q

What is innervation to the pelvic floor?

A

Levator ani + coccygeus –> S3+S4 nerve roots

Perineal muscles, external urethral and anal sphincter –> pudendal nerve

68
Q

What is the origin of the pudendal nerve?

A

S2-S4

69
Q

What is the distribution of the pudendal nerve?

A

-Perineum, including perineal muscles and external urethral and anal sphincters
-Sensation to genitalia

70
Q

Pudendal nerve block

A

-Performed for childbirth
-Ischial spines can be palpated inside vagina between 4 and 8 o’clock
-Pudendal nerve passes behind sacrospinous ligament and is found 1cm anteromedial and 1cm posteromedial to ischial spine
-Can be accessed here for anaesthetic blockade

SE book revision (6 decks)

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