Pelvis Flashcards

1
Q

Pelvic Joints + Ligs

A
  • Secondary Cartilaginous
    • lumbosacral lig
    • IV disc
    • Iliolumbar lig
    • pubic symphysis
  • ZP (facet) plane synovial
    • sacroiliac
    • sacrococcygeal
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2
Q

pelvic diameters

A
  • Conj line = ant/post, sup PS -> mid sacral prom
  • true conj = back of PS -> prom, shorter than conj, narrowest btwn PS + prom, unaffected by pelvic lig relaxation
  • diagonal = bottom PS -> sacral prom, measured per vaginum, used to estimate true conj and to tell if wide enough for baby
  • oblique = sacroiliac joint -> iliopubic eminence
  • cant take conj/true conj w/o imaging
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3
Q

Pelvic Muscles

A
  • Floor = pelvic diaphragm = hammock - suspends viscera

- walls = obturator internus (lat ant wall) + piriformis (G. sciatic foramen -> femur)

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4
Q

Diaphragm + Innervation

A
  • diaphragm = levator ani + coccygeus
  • levator ani = levator ani n (S4), inf recta n. (from pudendal nerve, S3-S4), coccygeal plexus
  • Coccygeus = S3-S4
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5
Q

Levator Ani

A
  • puborectalis = from pubic bone, forms sling around GI tract
    • most medial, immediately lat to rectum -> maintains perineal flexure
    • relaxation = defecation
  • pubococcygeus = pubic bones -> coccyx at anococcygeal raphe (mid muscle)
  • iliococcygeus - ileum -> anococcygeal raphe (on outside)
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6
Q

Pelvic Borders

A
  • anterior wall = pubic bones, pubococcygeus, puborectalis
  • lat wall = obturator internus, piriformis
  • post wall = coccygeus
  • floor = pubococcygeus, puborectalis
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7
Q

Male Pelvic Cavity Spaces

A
  • Retropubic space = PS-bladder

- rectovesical space = rectum-bladder

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8
Q

Female Pelvic Cavity Spaces

A

• Rectopubic space (btwn pubis + rectum)
• Rectouterine pouch (of Douglas) = btwn uterus + rectum
• Vesicouterine pouch = btwn uterus + bladder
○ Paravesical space
○ Pararectal space
○ Retrorectal space

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9
Q

Thickened Pelvic Fascia

A
  • support viscera (in females)
  • pubovesical lig - from bone to bladder (thickened endopelvic lig)
  • transverse cervical lig (from uterus to wall)
  • uterosacral lig - from uterus back to sacrum
  • broad lig - peritoneal sheet, top of pelvic organs, from peritoneal cavity
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10
Q

Sacroiliac Lig

A
  • plane synovial + syndesmosis = compound joint
  • ant + post parts
  • blends w/2 other sacro-ligs
  • ossifies w/age
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11
Q

Pubic Symphysis

A
  • supported by sup/inf pubic arcuate ligs

- fibrocartilage + hyalin cartilage

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12
Q

Sacrotuberous + sacrospinous ligs

A
  • sacrotuberous lig (vertical) = sacrum -> ischial tuberosity
  • sacrospinous lig (horizontal) = sacrum -> ischial spine
  • prevent tilt up of sacrum
  • form G/L sciatic foramen
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13
Q

L5-S1

A
  • common disc herniation = spondylolisthesis, fracture of pars interarticularis)
  • forward sliding prevented by articular processes (ZP joints) + iliolumbar ligs
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14
Q

Transverse + Ant/Post (AP) diameter

A
  • transverse (inlet + outlet) - btwn ischial tuberosities = max diameter of inlet
  • AP diameter - lower border of PS + coccyx tip = max diameter of outlet
  • PS has inc mobility at end of pregnancy -> relaxing hormones to diameter + sacroiliac
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15
Q

urogenital diaphragm (UGD)

A

= deep perineal (DP) pouch

  • inf boundary = perineal mem (spans ischiopubic rami)
  • inferior to pelvic diaphragm
  • perineal body = central tendon
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16
Q

Pelvic Viscera

A
  • pelvic diaphragm + below peritoneum
  • ureters, urinary bladder, urethra, rectum
  • male: prostate, ductus deferens, seminal vesicles, ejaculatory ducts, bulbourethral glands (below pelvic diaphragm)
  • female: ovaries, uterine tubes, uterus, vagina
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17
Q

ureters

A
  • upper half in abs (retroperitoneal), lower half in pelvis
  • males: crossed by DD, btwn that and peritoneum
  • females: crossed by uterine art, post part of ovarian fossa
  • pierce post-lat edge of bladder, go oblique thru muscular wall
  • when ligating uterine tube, watch for ureter
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18
Q

Ureter blood supply

A
  • any art they pass
  • renal, gonadal, common + internal iliac, vesical, uterine
  • variation from anastomoses
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19
Q

Ureter Innervation + lymphatics

A
  • innervation = ureteric nerves from renal, aortic, sup/inf hypogastric plexus (T10-L1), symp + parasymp
  • lymphatics => renal vessels, lateral aortic + lumbar nodes, common/int/ext iliac nodes
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20
Q

Bladder

A
  • urine storage
  • over pubic symph when full (suprapubic lithotomy)
  • prone to rupture in ab trauma + ant. pelvic fracture
  • young more prone (not protected)
  • cystitis = bladder infection, females more prone (short urethra)
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21
Q

Bladder Surface

A
  • apex, base/fundus/, int lat surface, neck
  • trigone -> appears smooth due to embryology, covered w/mucous layer
  • top = urethral crest
  • internal urethral orifice + sphincter (prevents backflow of semen into bladder)
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22
Q

Bladder stabilization

A
  • median umbilical lig -> attaches bladder to umbilicus
  • false ligs -> folds of peritoneum
  • thickening of endopelvic fascia (pubovescial = female, puboprostatic = male)
  • rectovesical lig = posterior
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23
Q

Internal Surface of Bladder

A
  • Internal mucous layer, folds when contracted

- muscle = detrusor (smooth) - expands when full, contracts by parasymp stim (pelvic splanchnics)

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24
Q

Blood Supply of Male Urethra

A

inf vesical, mid rectal, int. pudendal art

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25
Prostatic Urethra
- Urethral crest -> seminal colliculus vesicles (have ejaculatory ducts + prostatic utricle)
26
female urethra (3)
- smaller than male (cystitis) - From bladder -> DP pouch/mem -> vestibule ant to vag opening - urethral glands + Paraurethral ducts -> external urethra margin
27
Male reproductive tract/path of semen (8)
- testes -> seminiferous tubules -> epididymis -> ductus/vas deferens -> seminal vesicle -> ejaculatory duct -> urethra -> penis
28
Testes (4)
- from post ab wall -> ab canal -> outside body - lymph drainage = lumbar lymph nodes - tissue covering = ext/int spermatic fascia, cremaster muscle - blood supply = testicular a/v, pampiniform plexus
29
Ductus (vas) deferens (5)
- cont. w/epididymis, small lumen, thick walls, covered w/peritoneum - in scrotum, tortuous, then straight - traverses ing canal; at deep ring, separates from sperm cord, enters true pelvis - crosses over ureter btwn bladder (post to it) & rectum - enlarges (ampulla), joins seminal vesicle duct to form ejaculatory duct
30
Seminal Vesicles (3)
- coiled tube, prox end constricts, joins DD to form ejaculatory duct - Provides most semen, joins sperm from DD - Blood supply: inf vesicle + mid rectal arts (w/veins)
31
Ejaculatory duct (2)
= union of seminal vesicle ducts + ductus deferens | - Terminal opening of seminal colliculus
32
Bulbourethral glands (3)
= 2 glands in DP pouch - go thru perineal mem, drain to spongy urethra - Pre semen – cleans out leftovers in urethra before semen comes thru
33
Prostate (6)
= glandular, fibromuscular, has lobes, makes 20% semen - urethral crest – down from trigone - seminal colliculus – bump in middle - prostatic utricle – from vaginal embryology - ejaculatory duct openings – below utricle, on each side - prostatic sinus – sides of colliculus; prost duct openings
34
Prostate Blood Supply/Venous Drainage (2)
- Blood supply: inf vesical, int pudendal, mid rectal arts | - Venous: prostatic venous, vesicular, internal vertebral plexus
35
Prostatic Changes (5)
- 45-50yrs -> BPH = urine flow blocked in prostatic urethra - malignant, nodular = prost cancer (= prostatectomy) - DRE + serum level test for PSA (inc in cancer) - Prostatectomy - preserve prost nerve plexus (impotence) - If resecting plexus, do sural n. grafts
36
Female Viscera (6)
- ovaries, uterine tubes, uterus, cervix, vagina, greater vestibular glands
37
Ovaries (3)
- in true pelvis, develop like testes, ovulate oocytes into peritoneal cavity - Oocytes -> uterine tube -> uterus - Held in place by: ○ ovarian lig ○ suspensory lig – holds ovary to wall ○ Mesovarium – part of broad lig
38
Ovaries Blood Supply/Nerves (2)
- Blood Supply: ovarian arts + veins (R to vena cava, L to renal vein, drainage same as testicular vein) - Nerves: pelvic splanchnics -> parasymp
39
Uterus (3)
- in true pelvis - Blastocytes implant here -> when fertilized, implant in wall - Enlarges in preggos, atrophies in old age (dec hormones)
40
Uterus Parts (4)
○ Fundus - top, above opening of uterine tubes ○ Body - btwn layers of peritoneum ○ Isthmus - btwn body and cervix ○ Cervix - Surrounds internal opening
41
3 layers of Uterus Wall
- Perimetrium: peritoneum + areolar tissue - Myometrium: most of wall, smooth muscle - Endometrium: inner mucous coat, epithelium
42
Cervix, External Os, Fornix (5)
- Cervix - surrounds int os (near isthmus) - External os -> vagina - Fornix - recess around protruding cervix - Uterus anteverted + anteflexed = on top of bladder - If retroverted + retroflexed uterus => implantation + fertility problems
43
Uterus Support (5)
- thickenings of endopelvic fascia (transverse cervical + uterosacral ligs) - Levator ani - UGD - Other pelvic organs (esp. bladder) - Uterine ligs
44
Transverse cervical (cardinal) ligs, uterosacral ligs (3)
- transverse cervical (cardinal) ligs: cervix & lat fornices of vagina to lat pelvic wall - uterosacral ligs (supportive): sides of cervix to mid sacrum; palpable on rectal exam - Homologues of gubernaculum ○ Round Lig: uterus -> labia majora ○ Ovarian Lig: ovary -> uterus
45
Broad Lig (5)
- peritoneum over uterus + adnexa in pelvis - Mesosalpinx = suspends uterine tube - Mesovarium = suspends ovary - Mesometrium = main part below ovary + uterine tube - Suspensory lig of ovary: ovarian vessels covered w/peritoneum
46
Blood Supply/Venous Drainage to Uterus (3)
- uterine art (some from ovarian + vaginal a.) - Uterus gives blood to fetus (needs a lot) -> inc blood in preggos - Venous Drainage: -> uterine plexus -> internal iliac veins
47
Uterus Lymphatics (4)
- Fundus - lumbar, external iliac - Body - external iliac - Cervix - internal iliac, sacral - Area where uterine tubes join uterus has lymph drainage -> follows round lig, drains to superficial ing. nodes
48
Uterus Innervation (3)
- uterovaginal plexus - parasymp from S2-S4 - symp from T12-L2 lumbar splanchnics, intermesenteric, hypogastric plexuses)
49
Vagina (3)
= fibromuscular tube from cervix to vestibule (btwn labia minora), walls in contact w/each other - sup end of vagina surrounds cervix, extends sup = ant/post/lat fornix - post. fornix related to rectouterine pouch
50
Pt w/peritonitis infection (3)
- do culdocentesis to check for abnormal fluid in pouch of Douglas - Inferiorly -> somatic info from pudendal nerve – feel pain - Superiorly -> viscera, don’t feel pain – don’t need anesthesia when removing fluid
51
Vaginal Sphincters (4)
- Pubovaginalis (part of levator ani) - urethrovaginal sphincter (smooth muscle) - Bulbospongiosus - external urethral sphincter
52
Vaginal Blood Supply + Venous Drainage (2)
- Blood supply: Uterine + Vag a. (overlap), mid rectal & int pudendal a. - Drainage: internal iliac vein
53
Vaginal lymphatics + nerves of upper 2/3 (2)
- lymph - int/ext. iliac | - visceral innervation: uterovaginal plexus (from inf. Hypogastric plexus) -> parasymp/symp & afferent fibers
54
Uterine Tubes (4)
- 3-layered structure (serosa, muscle and epithelium). - hollow tubes -> peritoneal cavity -> uterus - convey oocyte to uterus and sperm to oocyte - fimbria brings floating oocyte into uterine tube and thru it via peristalsis
55
Uterine Tube Parts (4)
1. infundibulum – has fimbriae 2. ampulla 3. isthmus 4. uterine portion
56
Uterine Tube Blood Supply/drainage/lymph (2)
- Blood supply/drainage: ovarian + uterine arteries/veins | - Lymph: lumbar nodes
57
Peritonitis
more in females due to continuity of vagina/uterus w/ab cavity
58
Ectopic pregnancy (5)
- outside of uterine cavity if oocyte fertilized - Tubal – in uterine tube (not viable -> insufficient space + blood supply) - Abdominal – in ant. ab wall = "stone baby" = Lithopedion ○ Ectopic fetus detected by immune sys ○ Sometimes viable, present as normal - Ovarian – ovary itself - Cervical – moves too far, in cervix
59
Rectum (3)
= Cont w/sigmoid colon at S2/S3 (lower end of sigmoid mesocolon) + w/anal canal (passes thru pelvic diaph) - Anorectal junction in front of tip of coccyx; 80 degree turn - Lower part dilated (ampulla) -> no sacculation/appendices/mesentery (only sup front/sides covered in peritoneum)
60
Rectum Blood Supply (3)
- Sup (inf mesentery)/mid. (inf vesical-male; uterine-female)/inf. (int pudendal a) rectal arts + veins - portal (sup) + caval (mid./inf) systems
61
Rectum Innervation
- Hindgut innervation - Symp: lumbar splanchnics/sup. hypogastric plexus - Parasymp: pelvic splanchnics/inf. hypogastric plexus
62
Failure of Hammock: Prolapse of Pelvic Viscera
- potential from childbirth or trauma - Cystocele = bladder prolapse via vagina - Uterine prolapse = end of cervix, prolapse via vagina - Rectocele = rectal prolapse
63
Perineum
- inf to pelvic diaphragm + urogenital hiatus - same boundaries as pelvic outlet, btwn legs externally, shallow compt. internally - floor = skin & fascia; roof = pelvic diaphragm + fascia - divided into ant urogenital triangle + post anal triangle
64
Deep perineal pouch (aka UGD)
- Superior to perineal mem - Reinforces pelvic diaphragm, supports pelvic viscera - Further outside = superficial perineal pouch
65
Contents of Perineal Pouches
- Superficial Pouch ○ 2 Erectile Bodies = corpus cavernosum/crus + corpus spongiosum/bulb ○ 3 Muscles = bulbospongiosus, ischiocavernosus, superficial transverse perineal m. - Deep Pouch ○ Muscles = deep transverse perineal, external urethral sphincter (M/F), urethrovaginal sphincter (F), compressor urethrae (F/M)
66
Male Urethra: Preprostatic
short, from base of bladder, surrounded by internal urethral sphincter
67
Male Urethra: Prostatic
- length of prostate, widest/most dilatable part - closer to ant prostate - gets ejaculatory/prostatic duct openings
68
Male Urethra: Membranous
- in DP pouch (UGD), surrounded by external urethral sphincter
69
Male Urethra: Spongy
- in corpus spongiosum, longest, widens => navicular fossa - openings of bulbourethral glands - out to external urethral orifice, surrounded by erectile tissue
70
Prostate Innervation/Lymph
- Innervation: pelvic splanchnic nerves (parasymp) + inferior hypogastric plexus (symp) - S2-S4 (also to bladder, rectum, penis) - Lymph: internal iliac + sacral nodes
71
Vaginal lymphatics + nerves of lower 1/3 (3)
- Lymphatics: superficial inguinal - Innervation: somatic innervation: from deep perineal branch of Pudendal n. -> symp + somatic afferent fibers - NO parasymp (only part of vagina sensitive to touch and temperature)
72
Rectum Cont
- Teniae coli – spread out to form single layer - 3 perm transverse rectal folds/valves of Houston - Upper part of rectum = fecal reservoir