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ENDO exam 2 > Pelvis Perineum Anatomy (ketchum) 1 and 2 > Flashcards

Pelvis Perineum Anatomy (ketchum) 1 and 2 Flashcards

1
Q

what are the three bones of the pelvis

A

ileum
ischium
pubis

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2
Q

what are the parts of the ilium?

what does the ilium articulate with?

A

ala (wing)
body–> participates in formation of the upper 2/5th of the acetabulum

articulates with the sacrum posteriorly

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3
Q

what portion of the acetabulum does the ischium contribute

A

the body forms the posterior-inferior 2/5th of the acetabulum

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4
Q

what portion of the pubis contributes to the acetabulum and how much of the acetabulum is pubis making up?

A

superior ramus forms the anterior 1/5th of the acetabulum

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5
Q

what is the pubic symphysis

A

fibrocartilaginous disc linking two pubis bones

thicker in females and responsive to hormonal changes during pregnancy
only site of movement of the pelvis during pregnancy

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6
Q

what type of joint is the sacroiliac joint and what type of motion occurs here

A

synovial joint b/w sacrum and ilium

gliding motion (primarily)

can be rotatory

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7
Q

what ligaments reinforce the sacroiliac joint

A

anterior and posterior and interosseous sacroiliac ligaments

sacrotuberous ligament (sacrum to ischial tuberosity)

sacrospinous (ischeal spine to the sacrum)

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8
Q

what ligaments prevent rotatory movement of the sacroiliac joint

A

interosseous sacroiliac and sacrotuberous ligaments

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9
Q

what type of joint is the lumbosacral joint

A

fibrocartilaginous between L5 and S1

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10
Q

where does the iliolumbar ligament attach

A

from transverse process of LV5 to iliac crest

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11
Q

what is the terminal line

A

a line along the pubic and iliac bones to the base/pelvic surface of sacrum

aka the pelvic inlet

divides the pelvis into two portions

1) major (false) pelvis above the line
2) minor (true) pelvis below the line

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12
Q

what is the pelvic outlet

A

the line from the tip of the coccyx to the lower boundary of the pubic symphysis

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13
Q

what is the normal erect position? at what angle is the pelvis sitting

A

pelvis normally tips at 50-60 degrees from the horizontal

base of the sacrum is 4” higher than the symphysis

ASIS and the symphysis lie in roughly the same vertical plane!!

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14
Q 
how is the female pelvis different than the male pelvis?
major pelvis
iliac crests
minor pelvis
sacrum
subpubic angle
A 
shallower major and minor pelvis 
iliac crests (anterior) are more everted

shallower, wider minor pelvis
relatively greater diameters

broader, less concave sacrum

pelvic inlet wider & more oval

subpubic angle greater

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15
Q

what are the four types of pelves

A

android
anthropoid
gynecoid
platypelloid

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16
Q

android pelvis

A

most common male pelvis (30 percent of females)

heart shaped pelvic inlet

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17
Q

anthropoid pelvis

A

2nd most common male pelvis (20 percent females)

exaggerated anterior and posterior inlet

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18
Q

gynecoid pelvis

A

most common female pelvis (47 percent of females)

slightly oval-shaped pelvic inlet

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19
Q

platypelloid pelvis

A

least common in both sexes (~3% of female pelves)

exaggerated transverse inlet diameter

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20
Q

what are the pelvic diameters of the superior aperture

A

true congugate
diagonal conjugate
transverse
oblique

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21
Q

what are the pelvic diameters of the inferior aperture

A

transverse
anterior sagittal
posterior sagittal

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22
Q

true conjugate

A

sacral promontory to pubic symphysis (upper border)

can measure by palpation (OB)

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23
Q

diagonal conjugate

A

from the sacrovertebral angle to the inferior margin of the symphysis

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24
Q

transverse diameter of the superior aperture? inferior aperture?

A

superior–> greatest width (horizontal) of superior aperture

inferior–> b/w the inner surfaces of the ischial tuberosity

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25
Q

oblique diameter of the superior aperture

A

from the sacroiliac articulation of one side to the iliopectineal eminence of the other side

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26
Q

anterior and posterior sagittal diameters of the inferior aperture

A

anterior -> from transverse diameter to the symphysis

posterior–> from the transverse diameter to the sacrococcygeal junction

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27
Q

anything beneath the pelvic diaphragm is considered what….

A

perineum

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28
Q

what is the genital hiatus

A

where the urethra and vagina (or male counterparts) pass through the pelvic diaphragm

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29
Q

what is the urogenital diaphragm

A

a second diaphragm that is in the perineum that supports midline structures such as urethra, vagina, prostate

it is a voluntary muscular sheet between the ischiopubic rami

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30
Q

attachments of the obturator internus

where does it exit the pelvis

A

origin
obturator membrane
rim of obturator foramen

insertion
greater trochanter of femur
leaves the pelvis as a tendon thru the lesser sciatic notch

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31
Q

action of obturator internus

A

external rotation of thigh

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32
Q

innervation of the obturator internus

A

nerve to obturator internus

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33
Q

attachments of the piriformis

where does it exit the pelvis

A

origin–> sacrum
insertion–> greater trochanter of femur

exits pelvis through greater sciatic foramen

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34
Q

2 actions of the piriformis

A

external rotation of the thigh

abduction of the thigh

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35
Q

innervation of the piriformis

A

ventral rami of S1 and S2

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36
Q

what muscles make up the inner walls of the minor pelvis

A

obturator internus

piriformis

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37
Q

what muscles make up the pelvic diaphragm

A

levator ani (pubococcygeus, iliococcygeus, puborectalis)

coccygeus

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38
Q

what innervates the levator ani muscles

A

perineal branches of S3 and S4

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39
Q

what are the attachments of the iliococcygeus muscle

A

origin:
arcus tendineus obturator fascia

insertion:
coccyx
anococcygeal lig.

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40
Q

what is the action of the iliococcygeus muscle

A

support pelvis viscera

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41
Q

what are the attachments of the pubococcygeus muscle

A

origin: pubis

insertion:
coccyx
anococcygeal lig.

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42
Q

what is the action of the pubococcygeus

A

support pelvic viscera

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43
Q

what are the attachments of the puborectalis

A

origin–> pubis

insertion–> puborectalis muscle (attaches onto itself

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44
Q

what is the action of the puborectalis

A

support pelvic viscera

maintain anorectal junction

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45
Q

what are the attachments of the coccygeus

A

origin–> ischial spine and sacrotuberous ligament

insertion–> coccyx and lower part of sacrum

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46
Q

what is the action of the coccygeus

A

support pelvic viscera (it is the most posterior muscle of the pelvic diaphragm)

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47
Q

what are the urinary tract elements in the pelvis

A

pelvic portion of ureter

urinary bladder

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48
Q

what are the gastro-intestinal tract elements of the pelvis

A

rectum and anal canal

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49
Q

what are the female and male reproductive organs in the pelvis

A

F–> vagina, uterus, uterine tubes, ovaries

M–> pelvic portion of vas deferens
seminal vesicles
prostate gland

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50
Q

what is endopelvic fascia

A

lining of the pelvic walls and floor

this lining consists of membranous lining and loose CT
covers and surrounds pelvic contents

fills space b/w peritoneum and muscles

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51
Q

pelvic peritoneum

A

does NOT contact floor and walls of pelvis

it is draped over superior aspects of pelvic structures

forms distinctive folds and pouches

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52
Q

what are the pouches made by peritoneum in the female

what is the significance of these pouches

A

rectouterine pouch–> b/w rectum and uterus

vesicouterine pouch–> b/w superior aspect of the urinary bladder and uterus

these are areas where material might collect/build up

also locations of ectopic pregnancy

53
Q

what pouch does peritoneum form in the male

A

rectovesical pouch b/w bladder and rectum

54
Q

what is the broad ligament

A

found only in females

reaches laterally across the pelvis and is folded over the uterus

formed during formation of uterus and vagina from paramesonephric ducts

55
Q

what is the perineum

A

diamond shaped area between the coccyx and the pubis

often referred to as the centrol (perineal body)

56
Q

what are the boundaries of the perineum

A

anterior - pubis, ischiopubic rami

posterior - ischial tuberosities, sacrotuberous ligaments, & coccyx

superior - separated from pelvic cavity by pelvic diaphragm

inferior – skin surface (posteriorly), superficial fascia (anteriorly)

57
Q

what is the perineum divided into

A

anal triangle and urogenital triangle (line connecting ischial tuberosities)

58
Q

what are the boundaries of the anal triangle

A

anterior - posterior edge of urogenital triangle
posterior - boundaries of perineum
lateral - ischiopubic rami and obturator internus m. below the arcus tendineus

superior - the roof of the anal triangle is formed by the inferior aspect of the pelvic diaphragm
inferior- skin and superficial fascia of perineum

59
Q

what are the boundaries of the ischioanal fossa

A

superior - levator ani and pelvic diaphragm

inferior - skin of the perineum

posteiror- posteriorly the right and left ischioanal fossa communicate

anterior - components of the external anal sphincter and UG diaphragm fuse

anterior recesses- extend anteriorly between the levator ani and urogenital diaphragm

60
Q

what muscles are in the urogenital diaphragm

A

shincter urethrae muscle which surrounds the urethra (in the female this is called the urethrovaginalis b/c it also surrounds the vagina)

compressor urethrae
-this extends laterally from the sphincter

deep transverse perineal muscle

61
Q

what membrane covers the UG diaphragm more externally?

A

perineal membrane

62
Q

what fascia layer covers the perineal membrane

A

colle’s fascia

63
Q

what is the ligament that is an anterior thickening of the perineal membrane

what is the significance of this ligament

A

trasnverse perineal ligament

this is the stopping point of the perineal membrane so that is does not extend to the pubis

allows passage of the deep dorsal vein of penis (or clitoris) to enter pelvis

64
Q

where is the superior fascia of the UG diaphragm derived

A

transversalis fascia

65
Q

what components are in the superficial perineal space ?

A

erectile bodies
musculature
vessels
nerves

66
Q

what components are in the deep perineal space (between the inferior and superior fascia of UG diaphragm)

A

muscles of UG diaphragm

Vessels and nerves

67
Q

moving externally to internal what are the layers you hit in the perineum area….

A 
skin
superficial fascia (campers then colle's (scarpa's) fascia)
superficial perineal space 
perineal membrane
deep perineal space 
superior fascia of UG diaphragm
ischioanal fossa
pelvic diaphragm (levator ani muscles)
extraperitoneal CT
peritoneum
peritoneal space in pelvis

see last slide in the pelvis perineum 1 powerpoint

68
Q

where does the bladder sit

A

behind the pubic symphysis

69
Q

what are the 4 surfaces of the bladder

A

superior
inferolateral (two)
inferoposterior - base of bladder

70
Q

what is the apex of the bladder and what arises there

A

junction of inferolateral and superior surfaces

median umbilical ligament (urachus) arises here

71
Q

where do ureters enter the bladder

A

superior -lateral angles

72
Q

what is the neck of the bladder

A

junction of inferolateral and inferoposterior surfaces

which surrounds urethral opening

73
Q

what space separates the bladder from the pubic rami

A

prevescial fascial space

74
Q

what sits posterior to the bladder in the male

A

rectum
ductus deferens
seminal vesicles

75
Q

what sits posterior to the bladder in females

A

cervix and upper vagina

76
Q

what is the muscular wall of the bladder and what is it innervated by

A

“detrusor” innervated by parasympathetics

77
Q

what is the mucous membrane of the bladder

A

transitional epithelium

78
Q

what is the trigone of the bladder

A

area between the orifices of the ureters superiorly and internal urethral orifice inferiorly

79
Q

what innervates the trigone

A

sympathetics–> prevents retrograde urine flow

80
Q

what are the three vessels that innervate the bladder

A

superior vesicle (from umbilical) (major)

middle vesicle (from superior vescial)

inferior vesical (from anterior division of internal iliac artery) 
-vaginal artery in
81
Q

what is the venous drainage of the bladder like

A

Does NOT follow arteries

drains into dense venous plexus around base & neck
prostatic plexus of the male
vesico-vaginal plexus of the female

drains with deep dorsal v. of penis to internal iliac v.

this probably means that metastatic cancer in the prostate will spread easily to bladder area

82
Q

where does the pelvic ureter enter the pelvis (by crossing what structures?)

A

enters the pelvis by crossing iliac vessels anteriorly

83
Q

what crosses anterior to the ureter in males

A

ductus deferens

84
Q

what crosses anterior/superior to the ureter in females

A

uterine artery

85
Q

what is the significance of the ureters staying in the wall of the bladder for about 2 cm before opening at the ureteral orifices …

A

since ureters have no valves this path creates a means of preventing backflow of urine

contraction of bladder closes the ureters during urination
compression of ureter by distended bladder

86
Q

what is the vascular supply to the ureters

A

common iliac
internal iliac
vasiculodefernetial (male)
uterine (or inferior vesical artery) (female)

venous supply follows arteries

87
Q

what are the 4 parts of the male urethra

A

intramural–> wall of bladder

prostatic –> from internal urethral orifice through prostate gland (1 inch)

membranous–> through urogenital diaphragm , surrounded by sphincter urethrae m.

penile (Spongy) –> from inferior surface of urogenital diaphragm through spongy body of penis

88
Q

what are the two lumiinal dilations of the male urethra

A

within the bulb (bulbar portion)

within the glans penis (fossa navicularis)

89
Q

what are the two glands that open into the penile urethra

A

bulbourethral (Cowper’s) glands
opens into bulbar portion

urethral glands (of Littre)
numerous small glands
in proximal 2/3 of spongy body

90
Q

what are the two parts of the female urethra

A

superior portion
surrounded by urethral glands
paraurethral glands correspond to prostate in male
homolog is the prostate glands

membranous
pierces urogenital diaphragm

91
Q

what is the rectum? at what level of vertebrae does it originate

A

terminal 6-8 inches of large bowel

originates at level of 3rd sacral vertebrae (rectosigmoid junction)

92
Q

what morphological features distinguish the rectum from sigmoid colon

A

rectum has no mesocolon and is therefore retroperitoneal

teniae coli spread out as longitudinal m surrounding entire rectum

93
Q

what is the rectum proper

A

from origin to perineal flexure

dilated caudal portion is the ampulla

94
Q

what is the anal canal

A

perineal flexure to anus

anatomical and clnical anal canal differ

95
Q

what is the anatomical anal canal and what is the clnical anal canal

A

anatomical–> from level of upper surface of pelvic diaphragm to anus 1- 1.5 inches long

clinical –> from pectinate line to anal verge (1/2 inch long)

96
Q

what part of the rectum contacts the peritoneum

A

ventral rectum

97
Q

what structures are palpable on exam in a rectal exam of the male

A 
contents of rectovesical pouch
				posterior surface of bladder
				seminal vesicles
				distal vas deferens
				prostate
				sacrum, coccyx, ischial spines
98
Q

what structures are palpable on exam in rectal of female

A

contents of rectouterine pouch

cervix
vagina
sacrum, coccyx ischial spines

99
Q

what are the muscular/tissue layers of the rectum

A

outer longitudinal–> blends with fibers of levator ahi at anal region
inner circular muscle–> thickened to form internal anal sphincter

submucosal layer –> loose connective tissue

mucosal layer

100
Q

what are plica transversales

A

transverse rectal folds

these are semilunar folds of mucosa, sucmucosa and cirucular muscle

three folds typically
2 from left
1 from right

lowest is 2 inches above anus
highest is at the rectosigmoid junction

101
Q

what are rectal columns

A

mucous membrane overlying submucosal arteries and veins

102
Q

what are anal valves

A

archlike folds of mcuous membrane connecting caudal ends of rectal columns

these cover the anal sinues

103
Q

what is the pectinate line

A

irregular circumferential line formed by anal valves and base of rectal columns

dividing line (with variation) for….
1) venous drainage
superior–> drains to middle an superior rectal
inferior –> inferior rectal v

2) lymphatic drainage
superior–> drains to pelvic nodes
inferior –> inguinal nodes

3) Nerve supply
superior –> autonomics
inferior–> somatic

4) Epithelial lining
superior–> typical GI tract mucous lining
inferior –> stratified squamous epithelium

104
Q

what is the pecten

A

area immediately below pectinate line

characterized by great amount of CT creating blue-white appearance

105
Q

what is the anal verge

A

caudal most portion of anal canal

skin picks up sweat glands and hairs

106
Q

what are the three major arterial suppliers to the rectum

A

superior rectal - from inferior mesenteric

  • near rectosigmoid junction it divides into right and left branches
  • does NOT supply upper 1/5 to 1/4 of rectum

middle rectal - variable in origin (from internal iliac or other pelvic artery)
-middle of rectum

inferior rectal- from internal pudendal
-supplies external anal sphincter and perianal portion of levator ani muscle

107
Q

what is the venous drainage of the rectum

A

to two intercommunicating plexus

submucosal (subcutaneous plexus)
-within submucosa immediatley under skin of anal canal
superior rectal above pectinate line
inferior rectal below pectinate line

perimuscular plexus

  • drains muscular wall of rectum below level of peritoneum
  • mostly drains into middle rectal vein
108
Q

where does most of the blood supply to the pelvis originate

A

internal iliac

109
Q

where does the internal iliac divide and into what?

A

divides at the upper border of piriformis and divides into anterior and posterior trunks

anterior–> arises lateral to the pelvic plexus

110
Q

what are the 3 branches off the posterior trunk of internal iliac

A

iliolumbar
lateral sacral
superior gluteal

111
Q

what does the iliolumbar branch into and what do these supply

A

lumbar branch–> supplies psoas and quadratus lumborum

iliac branch-> supplies iliacus

112
Q

what does the lateral sacral artery supply

A

it is multiple arteries (mostly just 2)

first branch–> enters sacral foramne
-supplies–> structures of vertebral canal, skin and muscle over dorsum of sacrum
anastomoses with superior gluteal artery

second–> descends along sacrum medial to anterior foramina

113
Q

where does the superior gluteal artery leave the pelvis

A

greater sciatic foramen above piriformis muscle

114
Q

what are the 8 branches of the anterior trunk of the internal iliac artery

A 
umbilical (superior vesicle)
middle rectal
inferior rectal 
obturator 
internal pudendal
inferior gluteal 
uterine and vaginal 
vesiculodeferential
115
Q

what are two other vessels that supply pelvis but are not branches of the internal iliac a

A

middle sacral–> arises from aorta along anterior surface of sacrum–> sends small communicating branches to the lateral sacral arteries

superior rectal artery–> branch of the inferior mesenteric –> distributes to posterior wall of rectum

116
Q

what are the main venous drainage systems of the pelvis

A

internal iliac v.

iliolumbar v.

***note lots of anastomotic connections exist in the pelvis which creates multiple routes of transmission for infections and metastases

117
Q

what are the cruciate anastomoses of the pelvis

A

gluteal artery and perforating branch of profunda femoris

118
Q

what does the obturator a. communicate with

iliac branch of iliolumbar communicates with?
lumbar branch of iliolumbar?

A

medial femoral circumflex

deep circumflex iliac a.
lumbar branches of aorta

119
Q

internal pudendal communicates with what

A

external pudendal a.

120
Q

lateral sacral aa. communicate with…

A

middle sacral artery

121
Q

superior rectal artery communicates with …

A

middle and inferior rectal arteries

122
Q

what forms the lumbosacral plexus

A

the lumbar plexus (T12-L5)

sacral plexus (S1-S4)

123
Q

what do the anterior divisions of the lumbosacral plexus supply? posterior divisions?

A

anterior–> original flexor muscles

posterior–> extensor muscles

124
Q

where do the anterior and posterior divisions of the lumbar plexus leave the pelvis? sacral plexus?

A

lumbar plexus–> on anterior aspect of thigh

sacral–> leave posteirorly entering the buttocks

125
Q

what 5 nerves make up the anterior division of the lumbar plexus

A 
iliohypogastric
ilioinguinal 
genitofemoral 
obturator
L4 contribution to sacral plexus
126
Q

what 3 nerves make up the posterior division of the lumbar plexus

A

lateral femoral cutaneous
femoral n
accessory obturator n.

127
Q

what 4 nerves makes up the anterior portion of the sacral plexus

A

tibial portion of sciatic
n to quadratus femoris
n. to obturator internus
pudendal

128
Q

what 5 nerves make up the posterior division of the sacral plexus

A 
superior gluteal n.
inferior gluteal n. 
common fibular portion of sciatic
n. to piriformis
posterior femoral cutaneous

ENDO exam 2 (4 decks)

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