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Abdomen and Pelvis > Pelvis and Perineum > Flashcards

Pelvis and Perineum Flashcards

1
Q

Bony Pelvis

A

A. “ring of bone” formed by R/L hip bones, sacrum and coccyx
B. The pelvic girdle as a unit supports the abdomen as well as provides a dynamic link between the vertebral column
and lower limbs
C. Pelvis is divided by iliopectineal line (AKA pelvic brim)
1. pelvic major (false pelvis) – region above iliopectineal line 2. pelvic minor (true pelvis) – region below iliopectineal line

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2
Q

Bony Landmarks of Hip Bones

A

Ilium
Ischium
Pubis

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3
Q

Ilium

A

a. Body, iliac crest, iliac tubercle b. ASIS, AIIS, PSIS, PIIS
c. Auricular surface
d. Arcuate line
e. Iliopectineal line
f. Greater sciatic notch

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4
Q

Ischium

A

a. Body
b. Ischial spine
c. Lesser sciatic notch
d. Ischial tuberosity
e. Ramus

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5
Q

Pubis

A

a. Superior and inferior pubic rami
b. Pubic symphysis, pubic crest, pubic tubercle
c. Pectin pubis (pectineal line)
d. Iliopectineal line
e. Obturator canal – obturator nerve passes through

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6
Q

Sacrum

A

a. Base – superior portion
b. Apex – inferior portion c. Median sacral crest
d. Lateral sacral crest
e. Ala
f. Promontory
g. Sacral cornu
h. Sacral hiatus

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7
Q

Superior pelvic aperture – pelvic inlet (AKA pelvic brim)

A

boundaries (sacrum, ilium, pubis)

a. posterior – promontory and anterior border of ala of sacrum (sacrum) b. lateral – iliopectineal line (Ilium)
c. anterior – pubic symphysis, pectin pubis, pubic crest (pubic)

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8
Q

Inferior pelvic aperture – pelvic outlet, diamond shaped

A

boundaries

a. posterior – sacrum and coccyx
b. lateral – ischial tuberosities, sacrotuberous ligaments
c. anterior – pubic symphysis, arcuate ligament, rami of pubis and ischium

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9
Q

Pelvis Major (false pelvis)

A
  1. pelvic space above pelvic brim
  2. contains some abdominal viscera (ileum of SI and sigmoid colon) 3. Boundaries – abdominal wall, iliac fossae and L5/S1
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10
Q

Pelvis Minor (true pelvis)

A
  1. cavity of the pelvis…
    a. below pelvic brim
    b. above pelvic outlet (floor of the pelvis)
  2. contains pelvic viscera – urinary and reproductive organs
  3. boundaries – pelvic surfaces of hip bones, sacrum and coccyx
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11
Q

Acetabulum

A
  1. formed by junction of 3 hip bones
  2. acetabular notch, lunate, margin
  3. round in male
    features of the pelvis
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12
Q

Obturator foramen

A
  1. formed by rami of pubis and ischium
  2. large and fibrous with small opening (obturator canal)
  3. obturator nerve and BV pass through
    features of the pelvis
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13
Q

Joints of the pelvis- Sacroiliac joint

A

Synovial, irregular plane type
a. Bony Components – iliac bone and sacrum
b. Articular surfaces - “ear-shaped” auricular surfaces
c. Ligaments – SI ligaments (posterior, interosseous and anterior) d. Movements at the SI Joints
 Slight gliding and rotation  Research
(i) agreement there is movement
(ii) disagreement of magnitude and direction movement

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14
Q

Pubic Symphysis- Joints of the Pelvis

A

fibrocartilaginous joint
a. Bony components – two pubic bones
b. Articular surfaces – R/L pubic bodies
c. Interpubic disc – fibrocartilaginous, thicker in females d. Ligaments
 superior pubic ligament – connects superior pubic bodies, connects R/L pubic tubercles  inferior pubic ligament (arcuate ligament)

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15
Q

Vertebropelvic Ligaments

A
  1. Iliolumbar ligament – L4/5 to Iliac Crest
  2. Sacrotuberous ligament – lateral sacrum/coccyx (also PIIS) to ischial tuberosity 3. Sacrospinous ligament – caudal border of sacrum to ischial spine
  3. Ligaments of sacroiliac joint
    a. Posterior region– very strong
    b. Interosseous region – very strong c. Anterior region – thin
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16
Q

Anterior Pelvic Wall

A
  1. Bodies and rami (superior & inferior) of pubic bones
  2. Obturator internus muscle and fascia
  3. Pubic Symphysis
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17
Q

Lateral Pelvic Wall

A
  1. Obturator internus muscle (covering the bony framework)
    a. P: pelvic surfaces of ilium and ischium, obturator membrane b. D: greater trochanter of femur
    c. N: nerve to obturator internus (L5-S2)
    d. A: ER femur, stabilize head of femur
  2. Obturator nerves and vessels and other branches of the internal iliac vessels
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18
Q

Posterior Pelvic Wall

A
  1. Sacrum and adjacent parts of the ilium 2. Sacroiliac joints and their ligaments 3. Piriformis muscle nd th
    a. P: pelvic surface of 2 and 4 sacral segments, superior margin of greater sciatic notch, sacrotuberous ligament
    b. D: greater trochanter of femur
    c. N: ventral rami of S1-2
    d. A: ER, ABduct femur, stabilize head of femur
    e. Clinical – myofascial trigger points, potential for entrapment of sciatic nerve..”piriformis syndrome”
  2. Sacral plexus and internal iliac vessels and their branches
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19
Q

Action of levator ani all three together

A

 raise the pelvic floor thus assisting in compressing abdominal/pelvic contents
(i) important with coughing, sneezing, forced expiration, vomiting, stabilization of trunk during lifting, etc..
 plays role in voluntary control of urination, fecal incontinence
 clinical implication
(i) women’s health – urinary incontinence (ii) SCI
(iii) cauda equina

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20
Q

Levator Ani (3 parts) – function support pelvic viscera, resists intra-abdominal pressure

A

a. Puborectalis – “U-shaped” muscle, lasso around anorectal junction
b. Pubococcygeus (main part of the levator ani) – main portion
c. Iliococcygeus
d. Attachments
 body of pubis, obturator membrane, ischial spine
 coccyx, walls of prostate or vagina, rectum, anal canal

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21
Q

Coccygeus (ishiococcygeus)

A

a. Attachments – ischial spine to coccyx and lower sacrum
b. Small portion of pelvic floor
c. Assists levator ani in supporting pelvic viscera, flex coccyx

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22
Q

Blood Vessels of the Pelvis Common iliac artery and external iliac artery

A

A. Common iliac artery
1. bifurcation at L4

B. External iliac artery (passes through false pelvis only) 1. runs along medial border of psoas

  1. gives off two branches
    a. inferior epigastric artery
    b. deep circumflex artery
  2. exits false pelvis deep to inguinal ligament and becomes femoral artery
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23
Q

Posterior division- Internal Iliac artery

A

a. Superior gluteal artery – passes through greater sciatic foramen → piriformis, 3 gluteal m & TFL
b. Iliolumbar artery (pelvic wall) – ascends → psoas major, iliacus and quadratus lumborum
c. Lateral sacral arteries (pelvic wall) → piriformis, structures in sacral canal, erector spinae

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24
Q

Anterior division (visceral branches)–Internal Iliac artery

A

a. Umbilical artery – superior urinary bladder
b. Superior vesical artery – superior urinary bladder, pelvic portion of ureter
c. Inferior vesical artery (male) – inferior urinary bladder, ductus deferens, prostate
d. Vaginal artery (female) – vagina, inferior urinary bladder
e. Uterine artery (female) – uterus, ligament of uterus, vagina
f. Middle rectal artery – seminal vesicles, lower portion of rectum
g. Internal pudendal artery - supplies perineium
h. Obturator artery – pelvic muscles, head of femur, muscles of medial thigh
i. Inferior gluteal artery – pelvic diaphragm, piriformis, quadratus femoris, upper hamstrings, gluteus
maximus, sciatic nerve

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25
Q

Other Blood Vessels

A

D. Superior rectal artery – upper portion of rectum (branch of inferior mesenteric artery)
E. Median sacral artery – lower lumbar vertebrae, sacrum and coccyx (branch of abdominal aorta)
F. Gonadal Arteries (branches of abdominal aorta)
1. Ovarian artery (female) – ovary
2. Testicular artery (male) - testicles

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26
Q

Lumbar Plexus

A
  1. Formed by the ventral primary rami of L1 - L4
  2. Roots split into anterior and posterior divisions within the psoas muscle 3. Terminal branches of lumbar plexus
    a. Ilioinguinal and Iliohypogastric nerves (L1) – pass inferolateral and anterior to quadratus lumborum  Supply skin to suprapubic and inguinal regions, motor supply to abdominals
    b. Lateral femoral cutaneous nerve (L2,L3) – cutaneous supply to anterior and lateral thigh
    c. Femoral nerve (L2, L3,L4) – posterior divisions, supply hip flexors and extensors of knee, lateral to BV as
    it enters thigh deep to inguinal ligament
    d. Obturator nerve (L2,L3,L4) – anterior divisions, supply adductors of thigh
    e. Genitofemoral nerve (L1,L2) – pierces anterior surface of psoas
     divides into genital and femoral (cutaneous – anterior thigh) branches
    f. Branch to lumbosacral trunk (L4) – contributes to formation of sacral plexus
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27
Q

Different surfaces of the Bladder

A
  1. anterior surface of the bladder - located posterior to pubic symphysis 2. superior surface of the bladder
    a. Males: located inferior to the peritoneum of the abdominal cavity
    b. Females: located inferior to uterus and vesicouterine pouch (peritoneal space between bladder and uterus) 3. posterior surface of the surface
    a. Males: located anterior to the following structures…rectovesical pouch (peritoneal space between bladder and rectum), rectum, seminal vesicles and ampulla of ductus deferens
    b. Females: located anterior to the vagina
28
Q

Landmarks of the bladder

A
  1. apex – anterior
  2. fundus – posterior portion
  3. neck – inferior portion leading to urethra,
    a. males – prostate gland located inferior to neck
    b. females – urogenital diaphragm is located inferior to the neck
  4. trigone – posterior wall…”triangle” formed by two openings of ureters and opening of urethra, specialized
    smooth muscle of the bladder wall
29
Q

3 muscles of the Bladder

A
  1. detrusor…smooth muscle that lines the walls of the bladder
  2. internal urethral sphincter…smooth muscle that forms a sphincter at the junction of the bladder and urethra 3. external urethral sphincter…skeletal muscle that forms a sphincter around the urethra as it passes through the
    urogenital diaphragm
30
Q

When the bladder fills with urine

A

a. at 150 ml…begin to be slightly aware of bladder…
b. more than 300 or 400 ml = increase stimulus of stretch receptors in bladder wall c. 600+ ml = urgency…up to 1 liter possible!
 distention of bladder stimulates
(i) the parasympathetic nerves (S2-4) to contract the detrusor muscle of the bladder wall
1. higher CNS centers can voluntarily inhibit this parasympathetic reflex
(ii) the parasympathetic nerves (S2-4) to relax the internal urethral sphincter
(iii) voluntary relaxation of external urethral sphincter

31
Q

Testes

A

(often classified as external genitalia along with scrotum and penis) a. Develop retroperitoneally and descend into the scrotum

b. Function: produce sperm and sex hormones
c. Sperm produced in seminiferous tubules

32
Q

Epididymis

A

a. Head, body and tail
b. Convoluted duct which is approximately 20 feet long c. Two functions:
 Storage and maturation of sperm in head  propulsion of sperm into ductus deferens

33
Q

Ductus deferens

A

a. arises from the epididymis
b. travels up through spermatic cord and inguinal canal
c. enters pelvis via deep inguinal ring (landmark…just lateral to inferior epigastric artery) d. ends as the ampulla of the ductus deferens
e. merges with seminal vesicle and becomes the ejaculatory duct
f. ejaculatory duct passes through the prostate and enters the prostatic urethra
g. epididymis contains fructose which provides nutrition for sperm

34
Q

Seminal vesicle

A

a. located along the posterolateral portion of the bladder just lateral to the ductus deferens
b. function: produce seminal fluid (contains fructose and choline)
 NOTE: fructose is not produced anywhere else in the body…forensic science tests use fructose to determine if sexual assault has occurred, the presence choline crystals also help determine if semen is present (Florence’s test)
c. Sperm is not stored in the seminal vesicle

35
Q

Prostate gland

A

a. Located at the base of the urinary bladder and surrounds the urethra
b. Ejaculatory duct passes through and enters prostatic urethra
c. Produce fluid that combines with sperm and the fluid of seminal vesicle and bulbourethral glands to form
semen (seminal fluid)
d. Also secretes PSA (prostate-specific antigen) and acid phosphatase

36
Q

Prostate consists of five sections or lobes

A

 Anterior lobe = isthmus, located anterior to urethra, no glandular tissue

 Middle lobe – located between urethra and ejaculatory ducts
(i) This is the region (along with the lateral lobes) that is prone to benign hypertrophy (BPH – benign prostatic hypertrophy)
(ii) Physically constricts urethra and obstructs urine flow
1. increased frequency of urinating, nocturia, difficulty initiating and stopping urination, feeling
that bladder is not completely emptied

 Posterior lobe – posterior to urethra and inferior to ejaculatory duct,
(i) This lobe is easily palpated with a digital exam
(ii) Prostatic cancer often begins this lobe…thus if advanced then grows to involve other lobes and
begins to obstruct urethra…unfortunately difficulty in urination might be the first symptom a
patient complains of…PSA values provide earlier detection.

 R/L Lateral lobes – located on each side of the urethra and represent a major portion of the gland

37
Q

Venous return–Two pathways…the prostatic venous plexus drains into

A

(i) The internal iliac which drains into the IVC and travels back the heart
(ii) The vertebral venous plexus which drains into the cranial dural sinuses
(iii) These two pathways are potential explanations as to why prostate CA metastasizes to the
heart/lungs and vertebral column/brain

38
Q

Male Reproductive Organs

A 
Testes
Epididymis
prostate gland
seminal vesicle
Ductus deferens
39
Q

Bulbourethral gland (Cowper’s Gland)

A

a. Two small glands located posterior to membranous urethra

b. Secrete mucus like secretion into urethra

40
Q

Scrotum

A

 Cutaneous pouch that does not contain any fat (allows for maintaining lower temperature)
 Contains testes and epididymis
 Layers continuous with layers of the abdominal wall
(i) As testes descend they “push” through the abdominal wall and “pull” the layers down to form the inguinal canal, spermatic cord and scrotum.
(ii) Cremaster muscle continuous with internal oblique muscle
(iii) Cold external temperature and sexual arousal will cause scrotum to pull testes up
(iv) Warm external temperature will cause scrotum to relax a allow testes to descend…attempt to
dissipate heat

41
Q

Penis

A

 Body is formed by three columns…one corpus spongiosum and two corpus cavernosa
 Root consists of two crura and bulb of the penis
 Head (glans penis) formed by terminal portion of the corpus spongiosum
 Urethra

42
Q

Urethra

A

(i) Passes through the corpus spongiosum (ii) Prostatic urethra
1. surrounded by the prostate gland
2. urethral crest is located on posterior wall
a. seminal colliculus is oval raised portion that contains openings of ejaculatory ducts, prostatic ducts and prostatic utricle (blind outpocket that is analogus to vagina and uterus in female)
3. ejaculatory ducts, prostatic ducts enter urethra here (iii) Membranous urethra
1. external urethral sphincter
(iv) Spongy (cavernous) urethra
1. passes through the length of the penis within the corpus spongiosum
2. duct of bulbourethral gland enters here

43
Q

Ovaries

A

a. Located lateral to infundibulum of the uterine tube
b. Contain ovarian follicles
c. Function – secrete estrogen and progesterone
d. Ovulation…oocyte is released from the ovary into the peritoneal cavity near the ostium of the
infundibulum, the fimbriae of the infundibulum trap the oocyte and bring it into the uterine tube

44
Q

Uterine Tube

A

a. Intramural portion – lies within the uterine wall
b. Isthmus – has thick muscular wall and extends from uterine wall to ampulla c. Ampulla – dilated, longest segment
 Common site for fertilization
 Also common location for ectopic implantation
d. Infundibulum – distal segment, terminates in fimbriae, contains abdominal ostium which opens into the
the peritoneal cavity

45
Q

Uterus

A

a. Located between rectum and bladder b. Function
 Facilitates movement of sperm from the cervix
 Provides safe, nourishing environment for embryo/fetus
 Contracts to push fetus and placenta out during childbirth

46
Q

Divisions of the Uterus

A

 Body (upper 2/3 of the uterus) contains…
(i) Fundus
1. rounded portion of the uterus located above the uterine tubes
(ii) Isthmus
1. narrow region of the body that connects to the cervix
 Cervix (neck)
(i) Narrow cylinder that enters and projects into the vagina
1. Internal os
2. Cervical canal
3. External os is the opening into the vagina

47
Q

Position of the uterus varies

A

 Anteverted (50%)
 Retroverted (25%)
 Midposition (25%)

48
Q

3 layers of the wall of the uterus

A

 Perimetrium (outer serous coat)
 Myometrium (middle muscular coat)
 Endometrium (inner mucos coat)

49
Q

structures provide support of the uterus

A 
 Pelvic diaphragm
 Urogenital diaphragm
 Round ligament of the uterus
 Transverse cervical ligament
 Uterosacral ligament
 Pubocervical ligament
 Broad ligament
50
Q

Broad Ligament

A

(i) Double fold of peritoneum that extends from the uterus to the pelvic wall (ii) Supports ovary, uterine tubes and uterus
(iii) The broad ligament folds over and contains many structures
1. uterine tube, round ligament, many duct remnants of the embryo 2. ovarian artery, vein and nerve
3. uterine artery, vein and nerve

51
Q

Clinical Anatomy for Female reproductive parts

A

 Cervical cancer is MC gynecological malignancy
 Uterine fibrinoids
(i) Benign neoplasms of smooth muscle origin
(ii) Potential locations…if large enough can palpate through abdominal wall
1. located within the myometrium
2. beneath the endometrium – expand inward into the uterine cavity
3. along external serosal layer – expand outward into peritoneal cavity
(iii) potential to cause infertility if fibrinoids blocks uterine tubes

52
Q

Vagina

A

a. Tube that connects the uterus to the vestibule
b. Dilates/extends the width of the pelvic outlet during childbirth
c. External orifice opens into the vestibule…hymen membranous fold separates
d. Fornix encircles the cervix of the uterus

53
Q

3 Regions of the Fornix

A

(i) Anterior fornix – can palpate bladder on digital exam (ii) Lateral fornix (R/L)
(iii) Posterior fornix – can palpate rectum on digital exam
1. site for culdocentesis – insert needle to collect fluid sample to assess pelvic conditions (PID, ectopic pregnancy, etc) or to collect oocytes for in vitro fertilization procedures

54
Q

Female external genitalia (4)

A

vestibule
clitoris
labia minora
labia majora

55
Q

Labia minora and majora

A

labia minora
 medial to labia majora
 form lateral walls of the vestibule

c. labia majora
 Analogous to the scrotum
 Contains connective tissue layers
 Round ligament passes through inguinal canal and ends blindly in the labia major

56
Q

Clitoris

A

 body and glans formed from two corpus cavernosa  located anterior to opening of the urethra

(i) urethra
1. descends short distance from bladder to urethral opening 2. passes through pelvic floor and urogenital diaphragm

57
Q

Vestibule

A

 region in which the vagina and urethra open into after the pass the urogenital diaphragm

58
Q

5 Boundaries of Perineum

A
  1. Pubic Symphysis - anterior
  2. Ischiopubic rami - anterolateral
  3. Ischial tuberosities - lateral
  4. Sacrotuberous ligaments - posterolateral
  5. Coccyx – posterior
59
Q

Perineum can be divided into two smaller triangles

A
  1. urogenital triangle

2. anal triangle

60
Q

Vertical Boundaries of Perineum

A
  1. Floor = pelvic diaphragm

2. Roof = skin/fascia

61
Q

Urogenital Triangle– Superficial perineal space

A

a. space located between superficial perineal fascia (Colle’s fascia) and inferior fascia of urogenital diaphragm (perineal membrane)
b. muscles of the superficial perineal space  ischiocavernosus muscles
 bulbospongiosus muscles
 superficial transverse perineal

62
Q

Deep perineal space–Urogenital Triangle

A

a. space located between inferior fascia of urogenital diaphragm (perineal membrane) and superior fascia of
urogenital diaphragm
b. muscles of the deep perineal space
 urogenital diaphragm comprised of
(i) deep transverse perineal muscle
(ii) sphincter urethrae
(iii) sphincter urethrovaginalis muscle (female) (iv) compressor urethrae (female)

63
Q

Muscles of the anal triangle

A

a. obturator internus
b. levator ani muscle
c. sphincter ani externus
d. coccygeus

64
Q

rectum

A

rectum extends from sigmoid colon to anal canal

(i) dilated portion known as ampulla for storage of feces, located just superior to pelvic diaphragm
(ii) venous blood flow connects to
1. IVC system (via inferior and middle rectal vein)
2. portal venous system (via superior rectal vein)

65
Q

Anal Canal

A

 pelvic diaphragm separates anal canal from rectum
 anal canal begins at the pelvic diaphragm and ends at the anus
 divided into visceral portion (upper 2/3) and skeletal portion (lower 1/3)
(i) pectinate line divides visceral and somatic portions

66
Q

visceral portion (upper 2/3) of Anal Canal

A

(i) internal anal sphincter – smooth muscle
(ii) internal hemorrhoids occur in visceral region (thus above pectinate line)
(iii) venous return is mostly through portal system

67
Q

somatic portion (lower 1/3) of Anal Canal

A

(i) External hemorrhoids occur in somatic portion (thus below the pectinate line)
ii) External anal sphincter
(iii) Venous return is mostly through caval system (back to IVC)

Abdomen and Pelvis (4 decks)

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