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Anatomy - lasts > Pelvis and external genitalia > Flashcards

Pelvis and external genitalia Flashcards

1
Q

What parts make up the pelvic brim?

A

The pelvic brim is formed by the continuity of the pubic crest, pectineal line of the pubis, arcuate line of the ilium, and ala and promontory of the sacrum

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2
Q

Sex differences between male and female pelvis?

A

o Male- more acute subpubic angle, females – wider subpubic angle
o In men- more prominent sacral promontory – creates heart shaped inlet, in females – it is less prominent and oval shaped inlet results

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3
Q

What are the walls of the pelvis?

A

o Pelvic floor (pelvic diaphragm) – constitute of muscles: obturator internus, piriformis, levator ani and coccygeus
o Side walls: hip bones, clad by obturator internus and its fascia
o Posterior wall: sacrum, piriformis passing laterally into the greater sciatic foramen
o Anterior wall: aponeurosis of the three abdominal muscles

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4
Q

What are the Ligaments of the sacroiliac joint

A

• The ligaments are stronger posteriorly and weak anterior
o The ventral sacroiliac ligament joins the two bones above and below the pelvic brim
 It is stronger in females and indents the preauricular groove in females
o On the dorsal surface a group of ligaments constitute the interosseous sacroiliac ligament, which are attached to deep pits on the posterior surface of the lateral mass of the sacrum
 The most superficial fibres constitute the dorsal sacroiliac ligaments
o The posterior rami of the spinal nerves and vessels pass between these interosseous and dorsal ligaments

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5
Q

What factors contribute to joint stability of the sacroiliac joint?

A
  • Gliding movements opposed by dorsal sacroiliac ligaments and iliolumbar ligaments acting on L5
  • Opposing forward rotation of the sacral promontory around the joint are the sacrotuberous and sacroiliac ligaments
  • Whilst ligaments are intact along with the irregular bony surfaces, whilst intact prevent rotation and gliding – but are entirely dependant on this
  • Sacroiliac ligaments soften at the end of pregnancy to permit some sacral rotation
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6
Q

What are the origins, insertions and anatomical relations of the Sacrotuberous ligament:

A

Origin: posterior border of the ilium between the superior and inferior posterior iliac spines, transverse tubercles of the sacrum below the auricular surface and upper part of the coccyx
insertion: the ischial tuberosity.
— The falciform process is a prolongation forwards of the ischial attachment onto the ischial ramus
Relations:
- ligament is the degenerated origin of the long head of biceps femoris – to which the lower part of the ligaments continues as
- is pierced by the perforating cutaneous nerves, branches of the inferior gluteal artery and the coccygeal nerves
- lowest fibres of gluteus maximus are attached to the posterior surface of the ligament

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7
Q

Origins, insertions and relations of the sacrospinous ligament

A
  • Origin: attached to the base of the sacrum and the upper part of the coccyx
  • Insertion: ischial tuberosity
  • relations:
  • – the coccygeus muscle lies on its pelvic surface
  • – the sacropsinous ligament lies on the pelvic surface of the sacrotuberous ligamnet - and together they enclose the lesser sciatic foramen
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8
Q

Origins and insertions of the iliolumbar ligament?

A

Origin: transverse process of L5- from here it is shaped like a sideward V with upper and lower bands fanning outwards
Insertion:
– upper band passes to the iliac crest, giving partial origin to the quadratus lumborum and blending more lateral with the lumbar fascia
– The lower band- sometimes called the lumbosacral ligament – runs down and lateral to blend with the ventral sacroiliac ligament

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9
Q

Describe the ligaments and structure of the sacro-coccygeal joint?

A

structure: sacrum is separated from coccyx by fibrocartilage disc
ligaments:
- ventral sacrococcygeal
- two dorsal sacrococcygeal- one shorter deeper one which unite the adjecnet bones and a superficial one which closes the sacral hiatus
- lateral sacrococcygeal ligaments - run from transverse process of the coccyx each side to the inferolateral angle of the sacrum - completes the foramen for S5

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10
Q

What are the Origins and Insertions and relations and innervation of the piriformis muscle?

A

Origin: middle pieces from its own half of the sacrum and associated lateral mass, with the origin extending medially between the anterior sacral foramen
Insertion: Apex of the greater trochanter, with some fibres running along the greater trochanter to form a triangular tendon insertion with glut medius and minimus
Relations:
- completely fills greater sciatic foramen
- the sacral nerves and sacral plexus lie on the muscle
- in the buttocks its upper border lies along gluteus medius and lower along superior gemellus
Innervation: anterior rami of S1 and 2

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11
Q

What structure travel above and below the Piriformis in the greater sciatic foramen?
(hints infrapiriform is PIN PINS)

A

Supra piriform: superior gluteal nerve and vessels

Infrapiriform:

  • posterior cutaneous nerve of thigh
  • Inferior gluteal artery, vein and nerve
  • Nerve to Quadratus femoris
  • Pudendal nerve
  • Internal pudendal artery and vein
  • nerve to obturator internus
  • sciatic nerve
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12
Q

Structure of the Obturator canal and its contents?

A
  • is covered by the obturator membrane
  • the obturator membrane
  • the obturator canal is formed by the thickened superior edge of this ligamnet - attached to the anterior and posteriro obturator tubercles
  • the obturator canal contains: obturator artery, obturator vein and obturator nerve as they pass out of the pelvis.
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13
Q

Origins, insertions, path and innervation of the Obturator internus muscle?

A
  • Origin: from the margins of the obturator foramen and obturator membrane. Its insertions however also spread to the pelvic brim posteriorly, the greater sciatic notch and the falciform ridge (falciform insertion of sacrotuberous) of the ischium
  • Insertion: greater trochanter and trochanteric fossa - with a tricipital tendon - formed with inferior and superior gemelli
  • path: the fan shape of fibres converges at the lesser sciatic notch, and makes a right angled bend around the lesser sciatic notch to the buttocks – may leave a shallow groove
  • innervation: nerve to obturator internus
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14
Q

Origins and insertions and innervation of gemellus inferior

A
  • Origin: arises from the ischial tuberosity at the margin of the lesser sciatic notch
  • Insertion: tricipital tendon alogn with superior gemellus and obturator internus
  • — this tendon lies horizontal in teh buttock - beneath the piriformis and above the quadratis femoris
  • innervation: nerve to quadratus femoris
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15
Q

what are the origins, insertions and innervation of the superior gemellus

A
  • Origins: The superior gemellus arise from the ischial spine
  • Insertion: tricipital tendon
  • Innervations: nerve to obturator internus
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16
Q

What is the structure and contents of the pudendal canal?

A
  • contents: internal pudendal artery and veins and pudendal nerve- which exit into the deep perineal pouch
  • it is formed on the medial aspect of the obturator internus -by its covering with the obturator membrane
  • located in the lower lateral wall of the ischiorectal fossa.
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17
Q

What are the muscles of the pelvic floor

A

1) levator ani -each muscle arise in continuity over the spine of the ischium over the “white line” of obturator internus. All insert in the coccyx and anococcygeal ligament
- iliococcygeus
- pubococcygeus
2) Coccygeus

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18
Q

Origins, insertions and innervation of the coccygeus muscle

A
  • origin- the ischial spine, alongside the margin of piriformis
  • path lies on top of the sacrotuberous ligament
  • insertion: side of coccyx and lower sacrum
  • innervation: perineal branches of S4 and 5
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19
Q

Origins and insertions of the levator ani

A

Origin: in continuity from the ischial spine to the pubis, along the arcus tendineus (the white line on the obturator fascia)
– the iliococcygeus from the posterior half of the arcu tendinus
– pubococygeus from the anterior half of the arcus tendineus and body of pubis
Insertions: side of the coccyx and anococcygeal ligament and raphe
– U shaped loops formed by insertion pattern
Innervation: perineal branches of S3 and 4, which enter the pelvic surface of the muscle
— The inferior rectal branch of the pudendal nerve (S2) supplies the external sphincter and not the levator ani, S4 does not supply the sphincter

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20
Q

What are the functional divisions of the Pubococcygeus muscle?

A

o Pubococcygeus proper: The bulk of the posterior fibres arising from the white line sweep back on the iliococcygeus in a flat sheet to insert into the coccyx, anococcygeal ligament and raphe
o Puborectalis: Those arising from more anteriorly on the white line and periosteum of the pubis swing medially and join with its other side and the posterior fibres of the deep part of the external anal sphincter in a U shaped sling
o Levator prostatae: More medially fibres pass in a U shaped sling behind the prostate into the peroneal body
 In females – this is thepubovaginalis or sphincter vaginae – and inserts in the perineal body
o The most medial fibres are adjacent to the urethra and can exert ureteric action

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21
Q

What are the 2 rules that govern Pelvic fascia?

A

1) - over non expansile parts it is a strong membrane, over expansile or mobile parts it is a loosely felted areolar tissue
2) the fascia never extends over bare bone (exception is Waldeyer’s fascia

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22
Q

What is Waldeyer’s fascia? and how are spinal nerves and the sacral plexus related to this?

A

oThe fascia of Waldeyer originates from the hallow of the sacrum and sweeps downwards to attach at the ampulla of the rectum – its breaks the rule of no bony attachments
The spinal nerves lie external to this fascia on the pelvic wall, whereas the sacral plexus lie behind the fascia and in front of the perifomris and its branches do not penetrate the fascia
The superior and inferior gluteal vessels however have to pierces this fascia to reach the buttock

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23
Q

Structure of the rectouterine and rectovesical pouches, and relationships to nearby organs

A
  • created by reflection of peritoneum from the rectum onto the bladder in men and uterus in women
  • These pouches are the lowest parts of the peritoneal cavity 7.5cm and 5.5 cm from the anal margin in men and women –– can reach in fingertip exam
     They are normally occupied by coils of small intestine or sigmoid colon
    • Above the rectovesicle pouch are the upper part of the base of the bladder, and tips of seminal vesicles
    o Below – is the rest of the bladder base, seminal vesicles, prostate and end of each ureter and ductus deferens
    oThe rectovesical fascia (of Denonvillers) intervenes between this part of the rectum and the structures infront – in early stages of cancer- provides opportunity for spread
    •In front of the rectouterine pouch is the uppermost part of vagina (the fornix with the cervix projecting into it) . Below is just the vagina
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24
Q

Arterial Supply to the rectum

A

1) primary: superior rectal artery (the continuation of the inferior mesenteric)
2) middle rectal - travel in the lateral rectal ligaments
3) inferior rectal artery - penetrate the walls of the anal canal and run upwards
4) The median sacral – makes an unimportant supply to the posterior wall at the anorectal junction – but may cause bleeding in operations

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25
Q

venous supply to the rectum

A

veins correspond with arteries but anastomose to form plexuses x2
o Internal rectal plexus – lies in the submucosa
o The external rectal plexus – outside the muscular wall
o The lower end of the internal plexus is continuous with the vascular cushions of the anal canal
o as they follow arteries there is portal and systemic drainage

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26
Q

Lyphnode drainage of the rectum

A

• Lymphoid follicles in the wall
oFollows Median sacral artery to nodes on the hollow of the sacrum
oNodes on the side wall of the pelvis following the middle rectal artery
oAlong the inferior mesenteric artery to the preaortic nodes at the origin of this vessels

All these nodes need to be removed in a radical resection

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27
Q

Nervous innervation of teh rectal

A
  • SNS from the hypogastric plexus and by fibres that accompany the inferior mesenteric to the superior rectal from the coeliac plexus
  • PNS: S2 and 3 (or S3 and 4) by pelvic splanchinic nerves – motor to the rectal muscle
  • Pain accompanies SNS and PNS (as is the case with the bladder)
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28
Q

Parts of the bladder and their relationships to other organs

A
  • The base - backwards
  • apex - points towards the pubic bone
  • the posteriorlateral surfaces - make a 3 sided pyramid with the superior surface between apex and base
  • neck - continuous with urethra
    relations
  • apex- connected to the median umbilcial ligaments (which lies in the median umbilcial fold) and the retropubic space containing puboprostatic/ pubovesical ligaments lie
  • base: On each side to the midline the – ductus deferens and seminal vesicles are applied to its surface and ureter on its upper part
    oThe trigone lies in its lowest part
  • inferolateral - retropubic space in front and each surface lies on levator ani
  • superior surface: covered with peritoneum
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29
Q

What are the internal features of the Trigone?

A
  • smooth walled - triangle shaped with apex pointing down
  • ureteral orifice lie at each upper corner
  • the interureteric bar connects the two ureteric orifices
  • the internal urethral orifice lies at the apex of the triangle inferiorly
  • in men the uvula vesicae - is a bump formed by the protrusion of the median lobe of the prostate into the trigone
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30
Q

What is the arterial and venous supply to the prostate?

A

•Superior and inferior vesical arteries supply most
•Small contributions to the lower part from the obturator, inferior gluteal, uterine and vaginal arteries
•The superior vesical arteries often raise a small mesentery of peritoneum running from the side wall of the pelvis to the upper part of the bladder
•Venous drainage: plexus that converges on the vesicoprostatic plexus in the groove between bladder and prostate and drains backwards across the pelvic floor to the internal iliac veins
o In females a similar plexus communicating with veins in the base of the broad ligament

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31
Q

Innervation of the bladder

A

• PNS: pelvic splanchnic nerves  motor supply
o Also conveys fibres that sense full bladder however these are conveyed by the gracile tract
• SNS: L1 and 2 segments of the cord via the superior hypogastric and pelvic plexuses
o Vasomotor tone and inhibit detrusor muscle and control internal sphincter
• Pain: via SNS and PNS

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32
Q

What is the Path of the Ureters in the Pelvis?

A

1) Crosses the pelvic brim at the bifurcation of the common iliac
o On the left it underlies the apex of the sigmoid mesocolon
2) It runs over the external iliac artery and vein
3) it then runs down the side wall of the pelvis in front of the internal iliac artery and behind the ovary
o In order from above down: it crosses the obturator nerve, obliterated umbilical artery, obturator artery and obturator vein
 On the right the appendix if in pelvic position may lie adjacent
4) Upon reaching the ischial spine – it turns forwards and medially above the pelvic floor to enter the base of the bladder at its upper lateral angle
o Here the ductus deferens crosses the ureter superficially and runs down medially to it
5) The upper end of the seminal vesiclals lies in the point where the ureter enters the bladder

In females on the pelvic floor the ureter lies in the base of the broad ligament – adhering to its posterior peritoneal layer where it is crossed superficially by the uterine artery
– to reach the bladder in females it lies ontop of then penetrates the lateral cervical ligament crossing the lateral vaginal fornix -1to 2cm cm from the cervix before entering the balder in front of the fornix
 During hysterectomy- the ureters are major hazards
• Of note: in both sexes only one thing lies superficial to the ureter in the pelvis- the ductus deferens and the uterine artery in their sexes

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33
Q

What are the Surfaces of the prostate and their relations to near by organs ?

A

1) Base is the upper surfaced: fused with the bladder neck and perforated by the urethra
2) Apex: where the prostatic urethra emerges and becomes the membranous urethra where it prenetrates the urogenital diaphragm
3) Anterior surface is at the back of the retropubic and connected to the bodies of the pubic bone by the puboprostatic ligaments
4) Inferolateral – are clasped by the levator prostate parts of the levator ani
5) Posterior: has a vertical median groove – palpable on rectal exam
Separated from the rectum by the rectovesical fascia
The ejaculatory ducts pierce the posterior surface just below the bladder and pass obliquely through the gland for 2cm to the prostatic urethra

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34
Q

What are the lobes of the prostate?

A

• Five lobes: anterior, middle, posterior and 2x lateral – no clear distinction between these
o Anterior lobe: is small, lies in front of the urethra – almost entirely stroma tissue with few acini
o Middle – is the region between the urethra and ejaculatory ducts – place of benign prostatic hypertrophy – due to location – hypertrophy causes elongation and obstruction of ureter
 Minor degress of hypertrophy cause the uvula vesicae on the trigone
o Rest of the gland is made up of the posterior (behind the ejaculatory ducts) and lateral lobes (lateral to ducts)
 Together considered as right and left lobes

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35
Q

What are the True and false capsules of the prostate?

A

true capsule- a thin layer of connective tissue around the prostate. A condensation of pelvic fascia outside of this true capsule forms a false capsule
o The prostatic plexus of veins lie between the two capsules

36
Q

What is the arterial and venosus supply to the prostate?

A

•Main arterial supply: prostatic branch of the inferior vesical artery
o Smaller branches: from middle rectal, internal pudendal vessels passing to the lower parts
Occasionally – middle rectal is major supply
•Veins: veins run between the two capsules and into vesicoprostatic plexus at the front and side of the groove between the bladder and prostate
oThis plexus receives the deep dorsal vein of the penis and drains back into the internal iliac veins

37
Q

What is the urthreal crest and prostatic utricle and seminal colliculus and their significance?

A

• The urethral crest: is a midline longitudinal ridge, located posteriorly on the postatic urethra
o The seminal colliculus is a small swelling in the midline of the crest to which the prostatic utricle opens into
• The prostatic utricle is an embryological remnant of the union of the caudal ends of the paramesonephric ducts (homologue of the uterus)
• The ejaculatory ducts open alongiside the prostatic utricle
• The prostatic ducts open on the urethral crest and in the sulcus on each side

38
Q

What is the path of the Ductus deferens in the Pelvis?

A

o In its course no structure intervenes between it and the peritoneum

1) Hooks around the interfoveolar ligament and inferior epigastric aftery at the deep inguinal ring
2) After this it then crosses the external iliac artery and vein. Obliterated umbilical artery, obturator artery, vein and nerve, lying on the obturator fascia, covered by peritoneum
3) It then curves medially and forwards and crosses the ureter and approaches it opposite fellow
4) It then curves downwards, side by side, and dilates as it reaches the apex of the bladder
5) The fusiform dilatation is the ampulla – where spermatozoa are formed
6) The ampullae lie parallel and medial to the seminal vesicles
7) The vas joins the outlet of the seminal vesicle to form the ejaculatory duct – which then opens on the side of the urethral crest

39
Q

What are the parts of the uterus?

A

• Parts: fundus, body, isthmus, cervix
o Fundus: is the part above the entrance of the uterine tubes. Is covered by peritoneum which continues over its front and back
o The body: tapers down from the fundus and flattens anterior-posterior
The cornu is at the junction of the fundus and body and receives the uterine tubes
the body Is enclosed by peritoneum – which laterally becomes the broad ligament
 Has 2 surfaces: intestinal – covered by peritoneum and bowel lying on top and vesical – lying on top of the bladder with peritoneum of the vesicouterine pouch intervening
o Cavity: narrow slit in the virgin but grows in pregnancy
o Isthmus: is the narrow part continuous with the cervix (the lower uterine segment- is what is termed at full term by obstetricians
oCervix: has supra and infravginal parts
 Infravaginal parts are covered by the fornix of the vagina – continuation of vaginal walls above the os
 Supravaginal part has intestinal and vesical surfaces- intestinal covered by peritoneum which forms rectouterine pouch (of douglas) and vesical has no peritoneal covering but is attached to the trigone by rather dense connective tissue
• The canal of the cervix is continuous with the cavity of the body via the internal os
• The external os is circular in nulliparous, but a transverse slit after child birth and is continuous with the vagina = normally level with the ischial spines

40
Q

what are the parts of the Uterine Tubes? and what is the peritoneal covering of the tubes?

A

After emerging from the cornu- the tubes lie in the upper edge of the broad ligament
o The peritoneum that embraces it is known as the mesosalpinx
Parts: intramural, isthmus, ampulla and infundibulum
o Isthmus: straight and narrow part next to the uterus after emerging
o Ampulla: wide part continuing from the isthmus
o Infundibulum: trumpet like expansion, with fimbriated end- adjacent to the ovary. Its open end lies behind the broad ligament

41
Q

what is the Arterial Supply the Uterus and course of the resepctive arteries?

A

Uterus: supplied by uterine artery off the internal iliac
o From the internal iliac- it passes across the pelvic floor, over the top of the ureter – in the base of the broad ligament
o It then reaches the side of the supravaginal part of the cevix- giving a branch to the cervix and vagina, before it turns upwards to run between the layers of the broad ligament as far as the entrance of the uterine tubes
o At the uterine tube it anastomoses end on end with the tubal branch of the ovarian artery

Uterine tube: supplied by the tubal branch of the ovarian artery. The tubal artery runs below the tube in the layers of the broad ligament. Anastamoses with uterine artery

42
Q

What lymphnodes do each parts of the uterus drain to?

A

Body and fundus of the uterus drain into the external iliac nodes.
o May also reach inguinal nodes via the round ligament and the inguinal canal
Tube: via ovarian vessels into the aortic nodes
Cervix: external and internal iliac nodes by vessels that run Infront of or behind the ureter, and sacral nodes by uterosacral ligaments
o Cervix does not drain to inguinal nodes

43
Q

Attachments of the Round ligament of the Uterus

A
  • is from the junction of the uterus and tube to the deep inguinal ring, continuing through the canal and attaches at the fibrofatty tissue of the labia majus
  • is continuous with teh ligament of the ovary which attaches this to teh uterus
44
Q

Attachments for the cardinal and uteroscral ligaments and their contents?

A

o Lateral Ligament (cardinal ligament): thickenings of connective tissue in the broad ligament – extend from the cervix and fornix–> attache at pelvic sidewall to the lateral vaginal wall
 The ureter, uterine artery, inferior hypogastric plexus lie on the upper surface of the tissue and the cervical branch of the uterine artery pass through it
oUterosacral ligaments: extend backwards from the cervix below the peritoneum, and diverge around the rectouterine pouch and rectum to insert to the facia of the piriformis
 Oppose forward pull of the round ligament

45
Q

parts of the broad ligamnet

A

1) Mesometrium – Surrounds the uterus and is the largest subsection of the broad ligament. It runs laterally to cover the external iliac vessels, forming a distinct fold over them. The mesometrium also encloses the proximal part of the round ligament of the uterus.
2) Mesovarium – Part of the broad ligament associated with the ovaries. It projects from the posterior surface of the broad ligament and attaches to the hilum of the ovary, enclosing its neurovascular supply. It does not, however, cover the surface of the ovary itself.
3) Mesosalpinx – Originates superiorly to the mesovarium, enclosing the fallopian tubes.
- – forms the suspensory ligament of the ovary - which atatches it to the pelvic wall and transmits ovarian vessels and lymphatics

46
Q

Structures crossed by the lateral attachment of the broad ligament at the pelvic wall?

A

o The line of lateral attachment laterally crosses: the obturator nerve, superior vesical or obliterated umbilical ligaments, obturator artery and vein

47
Q

Where is the ovary located in the pelvis

A

The ovary lies in the side wall of the pelvis in the shallow ovarian fossa in the angle between internal and external iliac artery

48
Q

What is the path of the ovarian artery?

A

• Path of the ovarian: It branches just below the renal artery runs down behind the peritoneum of the infracolic compartment and behind the colic vessels and crosses the ureter obliquely on the poas muscle
o It then enters the broad ligament – it gives off a branch to the uterus which anastomoses with the uterine artery and ends entering the ovary

49
Q

venous drainage of the Ovary?

A

• Veins: the ovarian veins form a plexus in the mesovarium and suspensory ligament the plexus drains into a pari of veins that accompany the ovarian artery  they combine to one vein and on the right drain into the IVC and left into the renal vein

50
Q

Relations of muscles and organs to vagina and the vaginal fornix?

A

• The vaginal fornix- surrounds the cervix – divided into anterior, posterior and lateral fonixes
o Posterior fornix is covered by peritoneum of the pouch of douglas- the only part of the vaginal to be covered by the peritoneum
o The ureter lies adjacent to the lateral fonix and the passes infront of the anterior fornix to enter the bladder
• Below the cervix the anterior vaginal wall is in contact with the balder and below the bladder, the ureter is embedded in the vaginal wall
• The vagina passes through the pubovaginalis part of the levator ani, through the urogenital diaphragm and perineal membrane to the superficial perineal space to become the vestibule of the vagina

51
Q

What is the vesicouterine pouch?

A

The vesicouterine pouch Is formed by the peritoneum drapping from the back of the bladder onto the front of the uterus

52
Q

What are the divisions of the Internal Iliac artery (Hint I Love GGoing Places in My very own underwear)

A

Anterior divsion
I: Iliolumbar
L: Lateral Sacral
G: gluteal - superior

Posterior division 
G- gluteal - inferior 
P- internal pudendal 
I: inferior vesicel (vaginal in females) and superior vesical 
M: middle rectal 
V: vaginal (females only) 
O: Obturator artery 
U: umbilical and uterine arteries
53
Q

Outline the Venous drainage of the pelvis?

A

The internal iliac vein is 3cm long and begins at the greater sciatic notch passes upwards and forwards out of the pelvis. It lies above and behind its internal iliac artery

  • recieves the veins that follows the arterial branches
  • recieves the plexuses - the uterine/ vesicoprostatic and rectal plexuses

the lateral sacral veins drain into both the vertebra venous system and internal ilaic –> coughing increases pressure –> metastatic deposits from pelvis as the systems are linked

54
Q

Which nerve in the pelvis is not related to the posterior pelvic wall?

A

All nerves except the obturator nerve (lateral wall) are related to the posterior wall – these include the sacral plexus + branches, sacral sympathetic trunk, inferior hypogastric plexus and pelvic splanchnic (PNS, nervi erigentes)

55
Q

The path of the obturator nerve?

A

1) formed from L2-4
2) peirces the medial border of psoas
3) To reach the pelvis it then passes down medially on the sacral ala (medial to SIJ)
4) It then runs forwards between the iliac vessels and the fascia on the obturatus internus muscle
 Between the external and internal iliacs – it is separated from the ovary by peritoneum
 pain from the ovary may be felt in the medial thigh as peritoneum is innervated by the nerve
5) The nerve travels along the side wall of the pelvis to reach the obturator foramen
 At the obturator foramen the nerve lies highest against the pubic bone – artery and nerve below it
6) In the foramen – the nerve divides into anterior and posterior divisions – the anterior passes anterior to the upper border of obturator internus, the posterior gives a branch to the obturator internus and pierces the muscle

56
Q

What is the lumbosacral trunk?

A

Lumbosacral trunk: Much of the L4 and all of the L5 anterior rami enter the sacral plexus – L4 gives off its branch to the lumbar plexus and emerges from the medial border of the psoas, where it joins L5 to become the lumbosacral trunk.
o This nerve crosses the alar of the sacrum to enter the pelvic brim
- here it is separated from the obturator nerve by the iliolumbar artery and veins
o It joins the sacral plexus

57
Q

The sacral trunk- braches from the sacral nerves - before forming the anterior and posterior division (hint: the 6Ps

A

•There are 6, three from behind and thee from in front of the anterior rami.
From behind
1) piriformis (S1 and 2). 2) Perforating cutaneous nerve (S2,3)
3) posterior femoral cutaneous nerve (S2,3) branching

from infrotn

1) the pelvic splanchnic (S2,3),
2) pudendal nerve (S2,3,4)
3) perineal branch (S4) branching

58
Q

What are the branches from the anterior and posterior divisions of the sacral plexus? to assist SLIP DSP mnemonic

A

Anterior- All of these nerves are destined from the flexor compartment of the lower limb

1) Tibial part of sciatic (L4,5,S1,2,3)
2) nerve to obturator internus ((L5, S1, S2)
3) nerve to quadratus femoris

from the posterior part - all travel to extensore compartment of lower limb

1) common peroneal L4, 5, S1 and 2
2) superior gluteal nerve (L4-S1)
3) inferior gluteal nerve (L5-S2)
4) coccygeal plexus - S4-C1

nmeumonic 
SLIP, DSP
S: superior gluteal nerve
L: lumbosacral trunk
I: inferior gluteal nerve
P: posterior femoral cutaneous nerve
D: direct branches to lateral rotators (including nerve to piriformis, nerve to obturator internus, nerve to quadratus femoris, etc), and pelvic floor
S: sciatic nerve
P: pudendal nerve
59
Q

Structure of the sacral sympathetic trunk

A
  • It Crosses the pelvic brim behind the common iliac vessels, in the concavity of the sacrum, medial to the anterior sacral foramina
  • Each trunk has 4 ganglia, they converge at a small swelling Infront of the cocxyc- the ganglion impar
  • Somatic branches are given off to the sacral nerves (lower limb and perineum) and smaller vascular filaments to the lateral and median sacral nerves.
  • Visceral branches join the inferior hypogastric plexus
60
Q

Structure of the inferior Hypogastric plexus

A

There are two (unlike the midline superior hypogastric plexus), and collectively forms the pelvic plexus
•Lies lateral to the rectum, withing the pelvic parietal fascia on the side wall of the pelvis
•Its sympathetic supply is from the superior hypogastric plexus by the hypogastric nerve and also via the by branches from the sacral ganglia sympathetic trunk
• Run in leashes of nerves, which lie in condensation of fascia (ligaments), along with visceral branches of the internal iliac arteries and veins in neurovascular bundles – lateral ligaments of the bladder, cervix and rectum

61
Q

What nerves are responsible for the Cutaneous innervation of the perineum

A

•Skin each side of the anal triangle is supplied by the inferior rectal nerve (S3,4), the perineal branch of S4 and some twigs of the coccygeal plexus (S5)
•In the urogenital triangle: the ilioinguinal nerve (L1) supplies the anterior 1/3 of the scrotum/ labia majorus
oThe skin of the penis/ clitoris is supplied by the dorsal nerve (L2)
oThe posterior 2/3 of the scrotum/ labia majrous is supplied laterally by the perineal branch of the posterior femoral cutaneous and medially (labia minora) by the scrotal (labial) branches of the perineal branch of the Pudendal nerve (S3)
• Pudendal nerve block will not anaethetise whole vulva- only posterior 2/3- therefore anterior part must be infiltrated with anaesthetic

62
Q

Components of the internal anal sphincter

A

•Often describes as having 3 parts – deep, superficial, subcutaneous- based on attachments- however all are continuous with eachother
•The deep part is continuous with the puborectalis, except in the anterior midline where the puborectalis continues past, leaving only the sphincter surrounding the anus
oAnorectal ring: The region where the puborectalis fuses with the puborectalis (which is also the level of the upper end of the internal anal sphincter)  it is palpable on DRE
•The middle (superficial) part is attached at the perineal body and to the coccyx superficial to the anococcygeal ligament
•The subcutaneous part is a circular ring of fibres whose lower end curves inwards to lie below the lower end of the internal sphincter
• The intersphenteric groove: is a landmark on the mucosal – formed by the apposition of the internal and external anal sphincters in the vertical plane

63
Q

Name the internal mucosal features of the anal canal:

A

•Anal columns: formed In the upper 1/3rd of the anal canal by a dozen longitudinal ridges in the mucous membrane
•Anal valves: mucous folds that join the adjacent anal collums together
•Anal sinuses: are pockets formed by the valves and columns- 10 anal glands open into these
o Some glands penetrate the internal sphincter
•The pectinate line (dentate line): is the level of the anal valves
oBelow this is the pecten – a smooth surfaced area – this continues and is continuous at the anal margin (anus) with the skin of the buttock  is stratified, non keratinsing epithelium – no hair follicles or glands
• Above the pectinate line- immediately above there is a zone of transition from columnar epithelium of the rectum to stratified squamous, with a gradual transition between these two cell types
• Anal fissures extend from the anal margin to the pectinate line
• Intersphenteric groove: the mucous membrane is particularly attached to the lower part of the internal spincter
o Submucous space: above the interspheric groove – the submucosa is lax

64
Q

arterial supply to the anus

A

• Arterial supply: upper end of the canal is via superior rectal artery – with its branches terminating in the anal columns
o Small part of the muscular wall is supplied by the middle rectal and median sacral arteries
o The lower part I supplied by the inferior rectal which has crossed the ischioanal fossa

65
Q

Venous drainage of the anus and haemorrhoids?

A

• Venous supply- corresponds to the artery supply and are continuous with the rectal venous plexus
o The upper part oof the canal drains via the superior rectal artery and inferior mesenteric to the portal system
o Lower part drains into the internal iliac via the inferior and middle rectal veins
o Therefore is a site portal -systemic anastomosis
o Whilst the vessels are called the rectal plexus – the site of anastomosis is in the anal canal
o The internal rectal venous plexus – forms a cushion like masses in 3, 7 and 11o’clock – help assist closure of the canal
 Sites of haemorrhoids – increased incidence of constipation – due to Hypertension in this system – due to portal drainage

66
Q

What are the contents of the ischioanal (ischiorectal fossa)?

A

Contents:
1) ischioanal (or ischiorectal) fat pad
2) pudendal canal: lies in a fibrous sheath on the lateral wall and itself contains the pudendal nerve and internal pudendal vessels
3) inferior rectal branches of the pudendal nerve
4) posterior scrotal (labial) nerves and vessels
5) perineal branch of S4
perforating cutaneous nerve
6) lymphatic trunks

67
Q

What are the boundaries of the ischiorectal fossa (to reread textbook on this one)

A

roof: levator ani muscle
floor: deep transverse perineal fascia
medial wall: external anal sphincters/anal canal; levator ani muscle
lateral wall: ischial tuberosity; obturator internus muscle; obturator fascia
apex: intersection of the levator ani and obturator internus muscle
base
anteriorly: posterior border of the perineal body, urogenital diaphragm
posteriorly: sacrotuberous ligament; gluteus maximus muscle

68
Q

Which muscles attach to the perineal body

A

• Is a midline fibromuscular mass- where muscle gain attachment – these include
o External anal sphincter
o External urethral sphincter
o Levator prosatatae/ pubovaginalis of levator ani
o Bulbospongiosus muscle
o Superficial and deep transverse perinei
• It lies between the anal canal and the posterior margin of the perineal membrane (in females is therefore between the anal canal and pudendal cleft)

69
Q

Outline the origins and insertions and structure of the anococcygeal muscle and raphe

A

•Fibres from the iliococcygeus and pubococcygeus interdigitate in front of the coccyx at the anococcygeal raphe- this diverges from the skin, and travels to the upper end of the anal canal
• The anoccoygeal ligament – is a fibromuscular mass between the raphe and skin, and seperates the two ischiorectal/anal fossa behind the lower part of the anal canal
o Fibres from the intermediate (superficialis) part of the external sphincter to attach to the coccyx
o Lateral to this the sacrotuberous ligament limits the ischioanal fossa

70
Q

Insertions and contents of the deep perineal pouch and membrane

A
  • the deep perineal pouch is formed between the perineal membrane and the Superior perineal fascia (which is ill defined)
  • the perineal membrane inserts to the ischiopubic rami on each side - anterior to just behind the pubic angle and as far back as the ischial tuberosity
  • – its anterior part is the transverse perineal ligament- which the dorsal vein of the penis travels over between it and the arcuate pubic ligament

contents

  • muscles: sphincter urethrae, deep transverse perineal muscles
  • bulbourethral glands in men - ducts pierce the membrane to enter the penile urethra
  • membranous urethra
71
Q

The structure and contents to the superficial perineal pouch

A
  • enclosed by the superficial perineal fascia (of Colles)- which is a continuation of Scarpa’s fascia of teh abdomen - attaching at the Glans of the penis and the perineal membrane
  • contents :
    o the root of the penis
    o superficial perineal msucles
    o associated nerves and vessels
72
Q

Outline the structure of the penis (parts, muscles and fascia)

A
  • parts: root, glans and body
  • root is attached to teh perineal membrane - consists of the bulb and the crus on each side attached at the pubic ramus
  • the body- formed by teh coming together of the crus and the bulb at the base
  • – crus is part of the corpus cavernosum, bulb is part of the corpus spongiosum
  • the urethra runs in the corpus spongiosum

connective tissue

  • the tunica albuginae of the corpus - form a circle around the 3 erectile tissues
  • each erectile tissue is covered in a fascia - which fuse between the two cavernosum to create a septum and all three fuse at the base to attach to the pubic symphysis to form teh suspensory ligament of the penis
  • Buck’s fascia - a continuation of Colles fascia - forms another circular layer
73
Q

Blood supply of the penis (arterial and venous)

A
  • The deep dorsal vein lies in the midline beneath Bucks fascia, with a dorsal artery on each side and more laterally a dorsal nerve –> drains to vesicoprostatic plexus
  • The superficial dorsal vein lies deep to the skin, and is accompanied by lymphatcis from the skin and anterior part of the urethra –> drains to superficial external pudendal

artery
• The penis receives 3 pairs of arteries – all are branches of the internal pudendal
• The artery to the bulb supplies the corpus spongiosum, including glans
• The deep artery of the penis supplies the corpus cavernosum
• The dorsal artery supplies the skin, fascia and glans
• The dorsal artery and the artery of the bulb anastomose via the corpus spongiosum continuity with the glans
o The deep artery remains separate supplying the corpus cavernosum only – function is erection

74
Q

What the the superficial perineal muscles? and their origins and insertions and innervations

A

1) bulbospongiosus and ischiocavernosus
2) Superficial transverse perineal muslces are paired along the posterior border of the perineal membrane

•The bulbospongiosus – arises from the perineal body and in front of that – a median raphe that joins them together
oIts posterior fibres are directed forward and laterally over the bulb to be inserted in the perineal membrane
oThe fibres arising from the raphe – are inserted into a dorsal fibrous expansion on the penis; the more posterior of these fibres clasp the corpus spongiosum, whilst the anterior extend onto the corpus cavernosum of the penis
•The ischiocavernosum: arises from the perineal membrane and the ramus of the ischium- its fibres travel over the crus of the penis and insert at the upper surface of the commencement of the corpus cavernosum – assists in erection
•The superficial transverse perineal: arises from the ischial ramus behind its attachment to the perineal membrane and inserts to the perineal body. It stabalises the perineal body
• Nerve supply: all 3 muscles supplied by the perineal branch of the pudendal nerve (S2,3)

75
Q

What are the parts of the mail urethra and what is the navicular fossa?

A

• Consists of – prostatic, membranous and spongy parts – is 20cm long
• The spongy urethra (penile urethra) lies in the corpus spongiosum
o 2 parts: the bulbous and pendulous parts
 After piercing the perineal membrane – the ureter enters the bulb of the penis – and immediately takes a right angle turn- the part in the bulb of the penis is the bulbous part
 After the root of the penis – it is the pendulous part
•The navicular fossa – lies just proximal to the external urethral meatus. It is a short dilated region – covered with stratified squamous epithelium (as opposed to transitional)
o In the fossa, there are small lacunae (blind ended pockets) on the anterior and lateral walls where the urethral glands (of Littre) open facing in the proximal direction (ie against the stream)

76
Q

What are the branches of the internal pudendal artery?

A

1) inferior rectal - given off before the pudendal canal
2) perineal - given off in the pudendal canal
- – 2 branches- posterior scrotal/ labial and transverse perineal
3) artery to the bulb
4) terminal: deep and dorsal artery of the penis

in females: 4th branch is the clitoral artery and 5th deep and dorsal artery of the clitoris

77
Q

What are the branches of the pudendal nerve?

A

1) inferior rectal - before canal
2) inside the canal it divides into its terminal branches - the dorsal nerve of the penis and perineal nerve

the perineal nerve - also gives off the posterior scrotal branch, and branches to the superficial and deep perineal muscles, and external urethral sphincter

78
Q

List the features of female external genitalia

A
  • The vulva- is the collective term for female external genitalia – includes mons pubis, labia majora, labia minora, clitoris, vestibule of the vagina and greater vestibular glands
  • The vestibule of the vagina: is bound by the labia minora- and contains the external urthral meatus, vaginal orifice and the ducts of the greater vestibular glands
79
Q

What are the branches of the lumbar plexus?

A 
o	L1: iliohypogastric and ilioinguinal 
o	L1,2: genitofemoral 
o	L2,3- posterior divisions- lateral femoral cutaneous 
o	L2,3,4- posterior divisions- femoral 
o	L2,3,4- anterior divisions- Obturator
80
Q

What does the iliohypogastric nerve supply

A

o Supply skin over the inguinal region and in front of scrotum
o Motor: internal oblique and transverse abdominus- which form roof of inguinal canal and reach the conjoint tendon

81
Q

What does the genitofemoral nerve supply?

A

• Genitofemroal nerve: L1 is the femoral part – supplies skin just below the middle of the inguinal ligament
o L2 is the genital part: supplies the spermatic cord- tunica vaginalis, spermatic fascia and motor to cremaster. No skin supply
 In females supplies the fascia of the round ligament in the inguinal canal and a small area of anterior labial skin

82
Q

What does the lateral femoral cutaneous nerve supply?

A

• Lateral femoral cutaneous nerve: wholly sensory nerve—to iliac fascia, peritoneum of the iliac fossa and lateral side of the thigh down to the knee. Emerges from the lateral border of the psoas (occasionally off the femoral) and enters the thigh by passing under the lateral part of the inguinal ligament

83
Q

What are the branches of the femoral nerve?

A

Superficial: 2x cutaneous and 2 muscular
Deep: supply the quadriceps femorus – a branch for each vastus and 2x for rectus femoris, and once cutaneous- the saphenous nerves

Superficial branches:
o Nerve to pectineus- often double and runs behind the femoral sheat to reach the muscle
oNerve to sartorius- pierces the muscle and may continue as the intermediate femoral cutaneous nerve
oIntermediate femoral cutaneous nerve- often perieces sartorius- and supplies the skin and fascia lata down to the knee
oMedial femoral cutaneous nerve: supplies the upper medial side of the knee, and an anterior branch reaches the front of the knee, but the medial side of the thigh is supplied by the obturator nerve

Deep branches:
oThe nerve to rectus femoris – is usually double and the upper branch supplies the hip joint
oNerve to vastus lateralis – runs down with the lateral femoral circumflex artery between vastus intermedius and rectus femoris
oNerve to vastus intermedius- sinks into the anterior surface of that muscle
oNerve to vastus medialis: enters the upper part of the subartorial canal and sinks into the muscle
Suplies most branches to the knees, bar a few from the other nerves to vasti
oThe saphenous nerve: crosses the femoral artery in the subsartorial canal and gives some twigs to the subsatorial plexus and runs to emerge below the posterior border of sartorius
 Here its infrapatellar branch – pierces the sartorius to run into the patellar plexus
 It supplies the skin and periosteium over the subcutaneous surface of the tibia
 The saphenous nerve – now cutaneous – runs with the great saphenous vein over the medial malloulsu and terminates on the medial side of the foot- just short of the big toe

84
Q

Branches of the obturator nerve

A

• Exits the medial surface of psoas and lies on the ala of the sacrum – lateral to the lumbosacral trunk – where it slide down the side wall of the pelvis between the origin of the internal iliac artery and the ilum – from between the angle of the external and internal iliac vessels it runs to the obturator foramen
o Supplies parietal peritoneum of the side wall of the pelvis (females ovary lies here)
• In the obturator canal – it splits into anterior and posterior divisions
o Posterior: supplies obturator externus, where it then pierces the upper border of the muscle and runs into the thigh – deep to adductor brevis, where is runs ontop of the adductor magnus- where it supplies its pubic part (ischial supplied by adductor magnus).
 A slender branch accompanies the femoral artery to the popliteal fossa to supply the knee joint
o Anterior division: passes over the obturator externus and supplies the hip joint. It runs down on top of adductor brevis deep to adductor longus and pectineus – it supplies the two adductor muscles and may assist the femoral to supply gracillis. It alos supplie gracillis
 It supplies the lower medial side of the thigh by a cutaneous branch which runs through the ssubsartorial plexus

85
Q

What is the structure and branches of the sacral plexus

A

•There are a dozen branches- 6 before each constituent divides into its anterior and posterior divisions, and 3 from each of the anterior and posterior divisions

branches from the anterior rami (the 6Ps)

1) nerve to piriformis- S1-2
2) peforating cutaenous - S2-3
3) Posterior femoral cutaenous - S2-3
4) pelvic splanhcnic - S2-4
5) Pudendal - S2-4
6) perineal - S4

Branches from the anterior division

1) Nerve to quadratus femoris- L4-S1
2) nerve to obturator internus - L5-S2
3) tibial nerve - part of sciatic - L4-S3

Branches from teh posterior division

1) Superior gluteal - L4-S1
2) inferior gluteal- L5-S2
3) common peroneal op sciatic - L4-S2

Anatomy - lasts (7 decks)

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