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MD3002 > *PELVIS: Walls, floor, neurovascular supply > Flashcards

*PELVIS: Walls, floor, neurovascular supply Flashcards

1
Q

Identify the bones making up the hip bone.

A

Ilium
Ischium
Pubis

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2
Q

Identify the bones making up the pelvis.

A

Hip bones
Sacrum
Coccyx

They articulate and form the pelvis

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3
Q

What are the main parts of the pelvis ? What are these parts divided by ?

A

The pelvis is divided into a greater (false) pelvis and a lesser (true) pelvis, divided by the pelvic brim

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4
Q

Identify the main pelvic ligaments. What is the significance of these ligaments ?

A

Sacrotuberous ligament
Sacrospinous ligament

They form the greater and lesser sciatic foramina

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5
Q

Identify the main attachments of the sacrotuberous and sacrospinous ligaments.

A
  • Sacrotuberous ligament: from posterior-inferior iliac spine, sacrum and coccyx to ischial tuberosity
  • Sacrospinous ligament: from sacrum, coccyx and sacrotuberous ligament to the ischial spine
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6
Q

Identify the main pelvic gateways, and state their contents.

A

1) Greater sciatic notch: Sciatic Nerve and Gluteal Neurovascular Bundle (superior and inferior gluteal nerves and vessels)
2) Obturator foramen: Obturatory Neurovascular Bundle (obturator nerve, and vessels)
3) Retro-inguinal space: Femoral Neurovascular Bundle
4) Lesser sciatic notch: Pudendal nerve, Internal pudendal vessels

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7
Q

What are other names of the pelvic inlet ? What are its boundaries ?

A

Pelvic inlet = Pelvic brim= Superior pelvic aperture = Linea terminalis (i.e. boundary between lesser and greater pelvis), formed by:

  • Pubic symphysis (anteriorly)
  • Pubic crest (anteriorly)
  • Pectineal line (anteriorly)
  • Arcuate line of ilium (laterally)
  • Sacral ala and sacral promontory (posteriorly)
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8
Q

What are other names of the pelvic outlet ? What are the boundaries of the pelvic outlet ?

A

Pelvic outlet = inferior pelvic aperture

  • Pubic symphysis
  • Ischiopubic ramus
  • Ischial tuberosity
  • Sacrotuberous ligament
  • Sacrum and coccyx
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9
Q

Distinguish between male and female pelvis.

A

GENERAL STRUCTURE
Male: Thick and heavy
Female: Thin and light

GREATER PELVIS
Male: Deep
Female: Shallow

LESSER PELVIS
Male: Narrow and deep, tapering
Female: Wide and shallow, cylindrical

PELVIC INLET
Male: Heart shaped, narrow
Female: Oval and rounded, wide

PELVIC OUTLET
Male: Comparatively small
Female: Comparatively large

PUBIC ARCH AND SUPRAPUBIC ANGLE
Male: Wide (>80 degree)
Female: Narrow (<70 degree)

OBTURATOR FORAMEN
Male: Round
Female: Oval

ACETABULUM
Male: Large
Female: Small

GREATER SCIATIC NOTCH
Male: Narrow (around 70 degrees), inverted V
Female: Almost 90 degrees

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10
Q

Identify the main pelvic diameters, stating normal values for them. What is their clinical significance ?

A

Diagonal conjugate: 12.5 cm
(only measurement that can be done during physical examination, during bimanual vaginal exam)
(If you subtract 1 and a half from this, can predict obstetric one)

Obstetric conjugate (Conjugata vera): 11 cm
(diameter that will determine if birth is vaginal or has to go through C section. If less than 9 cm, unless fetus is underdeveloped, cannot delivery it vaginally)
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11
Q

Identify the main pelvic walls.

A

1) Antero-inferior wall
− formed by pubic symphysis, body and rami of the pubis

2) Postero-superior wall
− Sacrum
− Piriformis (divides the greater sciatic foramen)

3) Lateral wall:
− Obturator internus, with obturator fascia

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12
Q

Define pelvic floor/pelvic diaphragm. What is inferior to it ?

A
  • The most inferior region of the abdomino-pelvic cavity,
  • Inferior to it the perineum (pudendal region), divided into deep and superficial compartments anteriorly by the perineal membrane
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13
Q

Describe the “hammock” found in the pelvic.

A

-“Hammock”: The pelvic side walls and floor are in contact with the central pelvic organs

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14
Q

What are the main components of the pelvic diaphragm ?

A

Formed by:
-Levator ani (iliococcygeus + Pubococcygeus)
-Coccygeus (a.k.a. ischiococcygeus)
muscles with their fasciae covering their superior and inferior surfaces.

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15
Q

Describe the innervation of Coccygeus, and of Levator Ani.

A

Coccygeus is innervated by S4-5

Levator ani is innervated by S3-4

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16
Q

What is the origin of Levator Ani ?

A

Originates from pubis, ischial spine and tendinous arch of levator ani

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17
Q

Describe the anatomical specificity of levator ani.

A

Contains a gap between the medial borders of levator ani, called Urogenital hiatus and anal hiatus

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18
Q

Identify the main muscles making up levator ani.

A

Iliococcygeus + Pubococcygeus

19
Q

What are the main divisions of Pubococcygeus (one of the two muscles making up Levator Ani).

A

− puborectalis (puborectal sling, important in faecal continence)
− puboperineal
− pubovaginalis (female) or puboprostaticus (male)

Forms part of anococcygeal body

20
Q

What are the main functions of Levator Ani ? State a way in which one of these can go wrong, and a way of avoiding this.

A

⚬ Supports the pelvic organs

⚬ Makes the anorectal angle more acute
and augments the external anal sphincter
− Maintain faecal continence

⚬ Augments the urethral sphincter
− Maintain urinary continence

⚬ Forms a vaginal sphincter

⚬ Actively contracted coughing, sneezing,
forced expiration

Weakness may cause incontinence or prolapse (pelvic floor exercise help avoid that)

21
Q

Define annococcygeal and perineal bodies.

A

Pelvic diaphragm muscles of each side meet in the midline to form the anococcygeal body (a.k.a. raphe or ligament) and perineal body (a.k.a. central tendon of perineum)

22
Q

Identify structures supporting the pelvic floor.

A

⚬ The pelvic floor is supported anteriorly by
− the perineal membrane
− muscles in the deep perineal pouch

23
Q

Define perineal membrane.

A

The perineal membrane is a thick, triangular fascial sheet that fills the space between the arms of the pubic arch (also divides perineum anteriorly into deep and superficial compartments)

24
Q

Identify any lining of the pelvic cavity.

A

Lined by peritoneum continuous with the peritoneum of the abdominal cavity
− In most regions, does not reach the pelvic floor

25
Q

Identify the lowest point of the pelvic cavity.

A

The rectouterine (in females)/rectovesical (in males) pouch is the lowest point in the pelvic cavity

26
Q

Identify the main components of the pre-vertebral plexuses.

A

⚬ The prevertebral plexuses are formed by:
− Preganglionic and postganglionic sympathetic fibres (T1-L2 (3))
− Preganglionic parasympathetic fibres (vagus or S2-4)
− Visceral afferent fibres

27
Q

Where do the pre-vertebral plexuses form ? What are the main ones ?

A

⚬ The prevertebral plexuses are formed around the abdominal aorta. They condense around the origins of the branches of abdominal aorta:

− Coeliac plexus
− Renal plexus
− Superior mesenteric plexus 
− Inferior mesenteric plexus (together with superior mesenteric plexus, form aortic plexus)
− Superior hypogastric plexus
28
Q

What is another name for pre-vertebral plexuses?

A

Pre-vertebral plexus = pre-aortic plexus

29
Q

Where are the cell bodies of the postganglionic sympathetic fibers of the pre-vertebral plexus found ?

A
  • Cell bodies of postganglionic sympathetic fibres are scattered throughout the prevertebral plexus
  • Some of these cell bodies are organized into ganglia, while others are more randomly distributed
  • Ganglia are clustered around the roots of the major branches of the abdominal aorta
  • Efferents from these ganglia are distributed along the branches of the corresponding arteries
30
Q

Identify the main pelvic autonomic nerves, along with their type (motor, sensory etc.).

A

1) Sacral sympathetic trunks
− 4 pairs of sacral sympathetic ganglia + ganglion impar
− Lumbar and sacral splanchnic nerves
− Both motor and sensory

2) Parasympathetic fibres from S2-4 spinal segments
− Nervi erigentes (Pelvic splanchnic nerves)
− Both motor and sensory

3) Hypogastric plexuses
− Superior hypogastric plexus
− Inferior hypogastric plexus

4) Periarterial plexuses
− postsynaptic, sympathetic, vasomotor fibres to the arteries (superior rectal, ovarian and internal iliac arteries)

31
Q

Describe the anatomical location of the superior hypogastric plexus.

A

Superior hypogastric plexus lies in front of the inferior part of the abdominal aorta and its bifurcation (promontory of the sacrum)

32
Q

Describe the main nerve origins of the superior hypogastric plexus.

A

Formed as:
−continuation of the aortic plexus
−sympathetic fibres from L3 and L4 sympathetic ganglia
−parasympathetic fibres from the pelvic splanchnic nerves

33
Q

Describe the anatomical location of the inferior hypogastric (PELVIC) plexus.

A

Inferior hypogastric plexus lies on each side of the rectum, the base of the bladder and the vagina.

34
Q

Describe the main nerve origins of the inferior hypogastric (PELVIC) plexus.

A
  • Formed by sympathetic fibres from hypogastric nerves (from the superior hypogastric plexus) and parasympathetic fibres from the pelvic splanchnic nerves
  • From this plexus, secondary plexuses will originate and pass to the rectum, bladder, prostate, seminal gland, cervix and vagina
35
Q

What is the clinical significance of the inferior hypogastric (pelvic) plexus ?

A

Susceptible to injury during surgical operations

36
Q

Describe the visceral afferent innervation of the pelvis.

A

• Visceral afferent fibres travel with autonomic nerves

• All visceral afferent fibres conducting unconscious (reflexive) sensation travel with parasympathetic fibres
WHEREAS
Visceral afferent fibres conducting pain travel with sympathetics or parasympathetics

• Pelvic pain line
−inferior limit of the peritoneum
−middle of the sigmoid colon

• Visceral pain impulses from organs (or part of an organ) superior to the pain line follow sympathetic fibres
WHEREAS
 Visceral pain impulses from organs (or part of an organ) inferior to the pain line follow parasympathetic fibres

37
Q

Describe the somatic innervation of the pelvis.

A

Pudendal nerve (from S2-4)

38
Q

Describe the anatomical path of the pudendal nerve.

A

Passes through the greater sciatic foramen, then curves posterior to the ischial spine and sacro-spinous ligament, and runs forwards into the perineum inferior to levator ani

39
Q

Describe the arterial supply of the pelvis.

A

-The common iliac artery → internal iliac artery (opposite the sacroiliac joint at the level of the L5 disc) → internal iliac artery divides into anterior and posterior trunks

Supplies buttock and medial thigh, posterior pelvic and abdominal walls, pelvic viscera, perineum

ALSO
-Trochanteric anastomosis: Between lateral and medial circumflex femoral and superior and inferior gluteal arteries

40
Q

Describe the veinous drainage of the pelvis.

A

Most pelvic viscera have an extensive venous plexus that drains into the internal iliac or internal pudendal vein

The internal iliac vein drains equivalent areas to the artery, then joins the external iliac vein to form the common iliac vein that meets its opposite to form the inferior vena cava at the level of L5.

41
Q

Describe the lymphatic drainage of the pelvis.

A

 Tend to parallel the venous drainage, with exceptions
 Common, external, internal iliac and sacral lymph nodes
 Very interconnected (so cancer of one organ can disseminate by all these routes)

42
Q

Identify the possible shapes of the pelvic inlet.

A

1) Android (more common in males)
2) Gynecoid (more common in females)
3) Anthropoid
4) Platypelloid (more common in males)

43
Q

How are pouches in the pelvis formed ? Identify the main ones.

A

Pouches are formed in the pelvic because parietal peritoneum folds on itself.

1) Supravesical fossa (where the parietal peritoneum reflects onto superior surface of bladder)
2) Paravesical fossa (where the parietal peritoneum reflects onto lateral surfaces of bladder)
3) Vesico-uterine pouch (in females, between uterus and bladder)
4) Recto-uterine pouch (of Douglas) (in females, between uterus and rectum)
5) Rectovesical pouch (in males, between rectum and bladder)
6) Pararectal fossae (where the parietal peritoneum reflects onto either side of rectum, in superior part of rectum)

44
Q

Is rectum intra or retroperitoneal ?

A

Both. Superior part is intra, inferior part if retro.

MD3002 (95 decks)

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