Peritoneum Flashcards
What are the most common male pelvis types
Android and anthropoid
What are the most common female pelvis types (white women)
Android and gynecoid
Most common pelvis types n black females
Gynecoid
Anthropoid
What pelvic type is uncommon in both sexes
Platypeloid
What is the normal female type of pelvis
Gynecoid
Describe the gynecoid pelvis
Pelvic inlet has a rounded oval shape and a wide transverse diameter
What sort of problem would a woman with a platypelloid or android pelvis encounter (masculine or funnel shaped)
Hazard to vaginal delivery of a fetus
In forensics, how is pelvis used
Determine sex
What are sex determining characteristics of pelvis
Pelvic girdle!
Why is the size of the lesser pelvis importan
It is the bony canal that the fetus passes through
How do you determine the capacity of the female pelvis for childbearing
Diameters of lesser pelvis are noted radiographically or manually examined
What is the true(obstetrical) conjugate
Minimum anteroposterior diameter of the lesser pelvis
How measure the true conjugate
From middle of sacral promontory to the posterosuperior margin (closest point) of the pubic symphysis
What does the true conjugate represent
Narrowest fixed distance through which baby head will pass
Why cant the true conjugate be measured directly during pelvic exam
Presence of the bladder
What is the diagonal conjugate
Sacral promontory with the tip of the middle finger to the inferior margin of the pubic symphysis on the examining hand —-withdraw hand and measure
Why is the diagonal conjugate helpful
Can be used to estimate true conjugate
How big should the true conjugate be
11cm or greater
Anatomical conjugate
Top of pubic symphysis to sacral promontory
True obstetric conjugate
Middle of pubic symphysis to sacral promontory
Dianagnol conjugate
Bottom of pubic symphysis to sacral promontory
Typical size of diagonal conjugate
11.5 cm
What is the narrowest part of the pelvic canal
The interspinous distance
What is the interspinous distance
The ischial spines extend toward each other
What is the pelvic canal
Passageway through the pelvic inlet, lesser pelvis, and pelvic outlet
Is the interspinous fixed
No it relaxes in late pregnancy
During a pelvic examination, if the ischial tuberosities are far enough apart to permit __ fingers to enter the vagina side by side
3
The __ angle is considered sufficiently wide to permit passage of an average fetal head at full term
Subpubic
What sort of injury causes fracture of pubic rami
Anteroposterior compression of the pelvis during crush accidents (when a heavy object fails on the pelvis)
What happens when the pelvis compressed laterally
The acetabula and ilia aresqueezed toward each other and may be broken
Fractures of the bony pelvic ring are almost always ___ fractures or a fracture combined with a joint ____
Multiple
Dislocation
Some pelvic fractures result from the tearing away of bone by the strong ligaments of the ___ joint
Sacro iliac joint
How do you get pelvic fractures
Directly
Indirectly through leg
What are the weak areas of pelvis where fractures often occur
Pubic rami
Acetabula (or around)
Sacroiliac joints
Alae of the ilium
What may pelvic fractures injure
Soft tissues, blood vessels, nerves,and organs
Fractures in pubo-obturator area common. What complication is common
Relationship with urinary bladder and urethra which may be ruptured or torn
What may falls on buttox from a high ladder cause
Femur through the acetabulum into the pelvic cavity injuring pelvic viscera, nerves and vessels.
In persons younger than 17 what a fracture in the acetabulum like
Fracture through triradiate cartilage into its three developmental parts
The larger cavity of the interpubic disc in females __ in size during pregnancy
Increases
What does an increase in interpubic disc cause
Increases the circumference of the lesser pelvis and contributes to increased flexibility of the pubic symphysis
What causes the pelvic ligaments to relax during the latter half of pregnancy , allowing increased movement of the pelvic joints
Relaxin
Relaxin of what joints allies 10-15% increase in diameter facilitates passage of the fetus
Sacroiliac joints and pubic symphysis
How does relaxin effect the movement of the coccyx
Allows it to more posteriorly
What is the one pelvic diameter that remains unaffected by relaxin
True (obstetrical) diameter between the sacral promontory and the posterosuperior aspect of the pubic sympathy sis
Relaxation of the sacro-iliac ligaments causes the interlocking mechanism of the ___ joint to become less effective, permitting greater rotation of the pelvis and contributing to the __ posture assumed during pregnancy
Sacral iliac
Lordotic
Why may lat pregnancy be associated with possibility of greater joint dislocation (throughout body)
Relaxation o ligaments not limited to pelvis
Spondylolysis
Part of vertebral arch to be separated from its body
Spondylolysis of L5
From separating of the vertebral body from the part of its vertebral arch bearing the inferior articular process.
The inferior process of L5 normally interlock with the articular process of the ___
Sacrum
What happens when sponylolyisis is bilateral
The body of L5 vertebrae may slide anteriorly not he sacrum (spondylolisthersis) so that it overlaps the sacral promontory
What happen with intrusion of L5 body into the pelvic inlet
Reduces AP diameter of the pelvic inlet which may interfere with parturition, it may also compress spinal nerves, causing low back or lower limb pain
How do obstetricians test for spondylolisthesis
Running fingers along the lumbar spinous process. An abnormally prominent L5 indicates that the anterior part of L5 vertenra and the vertebral column superior to it may have moved anteriorly relative to the sacrum and the vertebral arch of L5
How do we confirm sondylolisthesis
Medical images such as sagittal MRI are taken to confirm the diagnosis and to measure the AP diameter pelvic inlet
What does the pelvic floor do during childbirth? What does the cervix and uterus do during childbirth?
Supports the fetal head
Dilate to permit delivery of the fetus
What may be injured during childbirth
Perineum, levator ani, and ligaments of the pelvic fascia
What muscles are torn most often during childbirth
Pubococcygeus and puborectalis, the main and most medial parts of thee levator ani
Why are the pubococcygeus and puborectalis important
Encircle and support the urethra vagina, and anal canal
What happens when we weaken the levator ani and pelvic fascia from stretching or tearing during childbirth
Decrease support of the vagina, bladder, uterus or rectum of alter the position fo the neck of the bladder or urethra which may cause URINARY STRESS INCONTINENCE
Characterization of urinary stress incontinence
Dribbling of urine when intra-abdominal pressure is raised during coughing and lifting which can lead to prolapse of one or mor pelvic organs
Tearing of the puborectalis, produces what
Anorectal angle and increases the angle to maintain fecal continence is likely to result in various degrees of fecal incontinence
The ureter is crossed by the ___ ___ near the lateral part of the fornix of the vagina . Why is this clinically important
Uterine artery
The artery actually winds 50% or more of the way around the ureter, passing at least both superior and anterior to the ureter
URETER IS IN DANGER ONF BEING INADVERTENTLY CLAMPED, LIGATED, or TRANSECTED during a hystectomy when the uterine artery s ligated and severed to remove the uterus
What is the approximate point where the ureter and uterine artery cross
2 cm superior to the ischial spine
Why are ureters in danger during oophorectomy (excision of ovary)
Vulnerable to injury when ovarian vessels are ligated bc they are close to each other as they cross the pelvic brim
Occasionally the internal iliac artery becomes __ due to atherosclerotic cholesterol deposit
Senotic
Why does ligation of the iliac artery NOT reduce blood flow but DOES reduce bp
Numerous anastomoses between the artery’s branches and adjacent arteries
Example of collateral pathways to internal iliac artery
Lumbar and iliolumbar
Median sacral and lateral sacral
Superior rectal and middle rectal
Inferior gluteal and profunda femoris artery
Blood flow in the internal iliac artery is maintained, although it may be __ int he anastomotic branch
Reversed
The collateral pathways may maintain the blood supply to the pelvic viscera, gluteal region and genital organ
Woohoo
During childbirth, the fetal head may compress the nerves of the mothers ___ ___,
Sacral plexus
Symptoms of sacral plexus compression from childbirth
Pain in lower limbs
The ___ nerve is vulnerable to injury during surgery
Obturator
Injury to obturator nerve
Painful spasms oft he adductor muscles of the thigh and sensory deficits int he medial thigh region
Injury to the nerve to the levator ani, includingg its branches tot he pubococcygeus and/or puborectalis, due to stretching of the nerve during vaginal birth causes what
Loss of support of the pelvic viscera and urinary or fecal incontinence similar to that resulting from tearing of the muscle
Why may ureters be injured during abdominal retroperitoneal, pelvic, or gynecological operationsas a result of what
Inadvertently interrupting their blood supply
How do we prevent inadvertent injury to ureters
Identification during their full course
The longitudinal anastomoses between arterial branches to the ureter ares usually adequate to maintain the blood supply along the length or the ureter, but occasionally
They are not.
Traction on the ureter during surgery
May lead to delayed rupture of the ureter.
Delayed rupture of the ureter
Urethral segment becomes gangrenous and leaks or ruptures 7-10 days after surgery
It is useful to realize that although the blood supply to the abdomen all segment of the ureter approaches from a __ direction, the pelvic segment approaches from a ___ direction. The ureters should be retracted accordingly
Medial
Lateral
What happens if ureters are obstructed
As expansive muscular tubes, they dilate
Common cause or ureteric obstruction
Ureteric calculus
Large calculus cause what
Severe pain. Loud to groin. (From lateral abdominal to inguinal regions)
What is the pain from calculus described as
Colicky
Why get colicky pains with calculus
Hyperperistsalsis in the ureter, superior to the level of obstruction
Where do ureteric obstruction from calculus most commonly occur
- Junction of the ureters and renal pelvic
- where they cross the external iliac artery and the pelvic brim
- During their passage through the wall of the urinary bladder
How can be confirm a calculi
Radiograph, an IV urogram or CT scan
How can we remove ureteric calculi
Open surgery, endoscopy, or lithotripsy.
Lithotripsy
Uses shock waves to break up a stone into small fragments that are passed int he urging
How can you get loss of bladder support, leading to a collapsed bladder onto the anterior vaginal wall
Damage to pelvic floor during childbirth, lesion of the nerves supplying them , or rupture of the fascial support of the vagina can result in a loss of bladder support
When the intra-abdominal pressure increases ,the base of the bladder and upper urethra is pushed against the what
Anterior wall of the vagina, which lacking support will turn bulges into the vaginal lumen and may protrude through the vaginal orifice into the vestibule-cystocele
Cystocele
Herniation of the urinary bladder
Even in the absence of a cystocele, the weakened support to the vagina or pelvic floor may result in a lack of support of the __, which runs in close proximity to what
Urethra
The anterior abdominal wall
Lack of support may alter the normal placement, direction, or angle of the urethra . What is this called
Urethrocele
Issue with urethrocele
Diminishing the usual passive compression of the urethra that helps maintain urinary continence during temporary increases in intraabdominal pressure (cough, sneeze) causing urodynamic stress incontinence
Rodurodynamic stress incontinence treatment
Pelvic floor muscles exercises, pessaries, pharmacotherapy
Surgery-retethering of the vagina and/or theplacent of support directly to the urethra to resort its direction and enable passive compression
Where does the superior surface of the empty bladder lie
Level of superior margin of the pubic symphysis
As the bladder fulls , it extends superiorly abover the symphysis into the loose are areolar tissue between the parietal peritoneum and anterior abdominal wall
Ok
Then it lies adjacent to the walll without the intervention of the peritoneum
Suprapubic cystotomy
Distended bladder may be punctured
How can we access the distended bladder surgically
Superior to the pubic symphysis for the introduction of the indwelling catheters or instruments without transversing the peritoneum and entering the peritoneal cavity.
What else can be removed through a suprapubic extraperitoneal incision
Urinary calculi, foreign bodies and small tumors
Why does a distended bladder rupture with injuries to the inferior part of the anterior abdominal wall or by fractures of the pelvi.
Superior position of the distended bladder
What happens if bladder ruptures
Escape of urine extraperitoneally or intraperitoneally
Rupture of the superior part othe the bladder results in what
Tears the peritoneum, resulting in extravasation of using into the peritoneal cavity
Posterior rupture of the bladder
Passage of urine extraperitoneally into the perineum
Cystoscope
Examines bladder
How d we do transurethral resection of a tumor with a cytoscope
Passed into bladder through the urethra
Then use high frequency electrical current, the tumor is removed in small fragments, which are washed from the bladder with after
Female urethra
Distensible bc it contains considerable elastic tissue, as well as smooth muscle.
Why are catheters/cytoscope easier in females
Urethra can be easily dilated without injury
Why are infections or the urethra and bladder more common in females
It is short, more distendible and is open to the exterior through the vestibule of the vagina
What may be palpated through fetal examination
Structures related to antero-inferior part of the rectum. (Prostate and seminal glands in males and cervix in females
Pelvic surfaces of sacrum and coccyx, ischial spines and tuberosities (both sexes)
What pathologies can you feel in a rectal exam
Enlarged internal iliac lymph nodes pathological thickening of the ureters, swellings in the ischio-analabscesses and abnormal contents int he rectovesical pouch int he male or recto-uterine pouch in the female
OR tenderness of the inflamed appendix if it descended into the lesser pelvis
Protoscope
Examines and biopsies the internal aspect of the rectum
Sigmoidoscope
Curvatures of the rectum and its acute flexion at the rectosigmoid junction have to be kept in mind so the patient does not undergo unnecessary discomfort
Useful landmark for sigmoidoscope
Transverse rectal folds, but may also impede passageway!
When respecting the rectum in males, the plane of the rectovesical septum is located so that the prostate and urethra can be separated from the rectum. Why
These organs are not damaged during surgery
Deferenectomy/vasectomy
Part of ductus deferens is ligated and/or excised through an incision in the superior part of the scrotum so that ejaculated fluid fromt he seminal glands, prostate, and bulbourethral glands contains no sperm
If u have a vasectomy, what happens to the sperms
Degenerate in the epididymis and the proximal part of the ductus deferens
Reversal of a deferentectomy
Ok 7 years after. Ends of sectioned ductus deferentes are reattached under an operating microscope
Abscess in seminal gland
Collection fo pic that may rupture
Where does pus from a a ruptures abscess in seminal gland go
Peritoneal cavity
How can you palpate seminal glands
Rectal exam espicially if enlarged or full and bladder is distended
Treatment for gonococci
Massage seminal glands through rectal exam to release their secretion for examination
BHP
Common Middle Age effecting every male whol lives long enough
What does an enlarged prostate cause
Projects into the urinary bladder and impedes urination by distorting the prostatic urethra
Which prostatic lobule enlarges most
Middle
It obstructs the internal urethral orifice
In BHP the most a persons trains to pee, the more what
The valve like prostatic mass obstructs the urethra
BHP is a common cause of urethral obstruction, leading to —— , ___, and ___
Nocturnal, dysuria, urgency
BHP also increases risk of bladder __ and kidney ___
Infection
Damage
How examine prostate
Through rectum for enlargement and tumors
What does palpability of prostate depend on
Fullness of bladder. Full bladder offers mores resistance holding the prostate in place making it more palpable
What does a malignant prostate feel like
Hard and irregular
In metastic prostatic cancer, where does it metasticize
Initially to the internal iliac and sacral lymph nodes and later to distant nodes
Also via venous routes (by way of the internal vertebral venous plexus to the vertebrae and brain
Bc of the close relationship of the prostate to the prostatic urethra, obstructions may be relieved ___
Endoscopically
Transurethral resection of the prostate TURP
Through urethra into prostatic urethraand allor part of prostate is removed.
Radical prostactomy
All is removed with seminal glands, ejactulatory ducts, and terminal parts of the deferent ducts
TURP
Preserve nerves and bv associated with the capsule of the prostate that pass to and from the penis, increasing the possibility for patient to retain sexual function after surgery as well as restoring normal urinary control
How does the female genital tract communicate with the peritoneal cavity . What is the clinical importance
Through the Ostia of the uterine tubes. Infections of the vagina, uterus, and tubes may result in peritonitis
Salpingitis
Inflammation of a tube may result from infections that spread from the peritoneal cavity
Major cause of infertility in women
Blockage of the uterine tubes, often the result of salpingitis
How see potency of the uterine tubes
Radiographically procedure involving injection of a water soluble radioopaque material or CO2 gas into he uterus and tubes through the external os of the uterus (hysterosalpingography)
How see indication that tubes are patent on radiograph
Accumulation of radioopaque fluid or the appearance of gas bubbles in the pararectal fossa (pouch) region of the peritoneal cavity
Hysteroscopy to determine potency of uterine tubes
Examination of the interior of the tubes using a narrow endoscopic instrument (hysteroscope), which is introduced through the vagina and uterus
Tubal sterilization
Permanent , surgical method of birth control. Oocytes released from the ovaries that enter the tubes of these patients degenerate and are soon absorbed .
Can be done laparoscopically or abdominal approach
How do open abdominal tubal sterilization
Through a short suprapubic incision made at the pubic hairline and involves removal of a segment or all of the uterine tube.
How do laparoscopic tubal sterilization
Done with a fiber optic laparoscope inserted through a small incision usually near the umbilicus. Then tubal continuity is interrupted by applying cautery, rings, or clips
Hysteroscopic sterilization
Nonsurgical
Placement of nickel titanium alloy inserts into the openings of each uterine tube. Scar tissue forms around the implants, blocking the uterine tubes. Takes 3 months
Do u need contraception right after hysteroscopic sterilization
Yea may take over 3 months
How can you tell that hysteroscopic sterilization works
Hysterosalpingography done 3 months after to ensure uterine tubes are blocked
Tubal pregnancy
Most common ectopic gestation
1/250 pregnancies
If ectopic pregnancy not caught what may happen
Rupture of the uterine tube and severe hemorrhage into the abdominaopelvic cavity during the first 8 weeks o gestation.
What happens when tubal pregnancy ruptures
Death embryo and threat to mothers life
Pyosalpinx
Collection of pus may develop in uterine tube and may occlude by adhesions
What happens to morula if have pyosalpinx
May not be able to pass along the tube to the uterus, although sperms have obviously done so
What happens if a blastocyst forms and there is pyosalpinx
It may implant in the mucosa of the uterine tube producing an ectopic tubal pregnancy.
Most common site of tubal pregnancy
Ampulla
Increased risk of what with faulty tubal sterilization
Ectopic tubal pregnancy
On the right side, the __ often lies close to the ovary and uterine tube
Appendix
What may a ruptured tubal pregnancy and resulting peritonitis be misdiagnosed as
Appendicitis
Where is pain referred to ruptured right tubal pregnancy and appendicitis
Right lower quadrant of abdomen
Occasionally the mesosalpinx between the uterine tube and the ovary contains ___ ___
Embryonic remnants
Epoophoron
Forms from remnants of. The mesonephric tubules of the mesonephric, the transitory embryonic kidney
Persistent duct of the epoophoron (duct or Gardner)
Remnant of the mesonephric duct that forms the ductus deferens and ejaculatory duct in the male
Where does the duct of the epoophoron (duct or garter) lie
Between layers of the broad ligament along each side of the uterus and/or vagina
Vesicular appendage
Sometimes attached to the infundibulum or the uterine tube. It is the remains of the cranial end of the mesonephric duct that forms the ductus epididymis.
Vestigial structures may form __
Cysts
Big ornate uterus
Incomplete fusion of the embryonic paramesonephric ducts, from which the uterus is formed, results in a variety of congenital anomalies …like DUPLICATION IN THE FORM OF A BICORNATE UT
Unicornate uterus
Receiving a uterine duct only from the right or left
Uterus didelphys
Completely doubled uterus
Normal position of the uterus
Anteverted and anteflexed, so that the body of the uterus rests upon the empty bladder, one of several means by which passive support for the uterus may be provided
The size and disposition of the uterus may be examined by ___ ___
Bimanual palpating
How do bimanual palpation
Two gloved fingers of examiners dominant hand are passes superiorly in the vagina, while the other hand is pressed inferno posteriorly not he pubic region of the anterior abdominal wall
Softening of the uterine isthmus (hears sign)
Cervix feels as though separated from body ofthe uterus..early sign of pregnancy
Rectovaginal exam
Uterus if retroverted and retroflezed one finger in vagina and one in butt hole
Position of uterus in bimanual palpation
Anterverted and anteflexed
Uterus birth
Body to cervical ration 2:1 due to preparation influence of maternal hormones
After birth uterus and child
1:1 with the cervix being of greater diameter
During infancy the uterus is mainly an __ organ
Abdominal
Puberty uterus
2:1
Uterus in postpubertal, premenopausal, nonpregnant woman
Body is pear shaped, thick walled superior two thirds of the uterus lies within the pelvic cavity
Monthly changes in size, weight, and density in relation to normal menstruated cycle
Uterus in pregnancy
Gravis-expands greatly to accommodate the fetus, becoming larger and increasingly thin walled
End of pregnancy
Fetus drops as the head becomes engaged into e lesser pelvis and uterus becomes nearly membranous, with the fundus dropping below its highest level at which time it extends superiorly to the costal margin, occupying most of the abdominopellvic cavity
Uterus immediately after delivery
Large uterus becomes thick walled and edematous but its size reduced rapidly
Multiparous nongravid uterus
Large and nodular body and usually extends into the lower abdominal cavity, often causing a slight protrusion of the inferior abdominal wall in lean women
Uterus menopause
Decreases in size
Involuted and regresses to a markedly smaller size, once again 1:1
Cervical cytology
Allows detection and treatment of premalignant cervical conditions
In Pap test a vaginal speculum is able to go into __ os of the uterus
External to gather supravaginal cervical mucosa
Who should get cervical cancer screening
30-65 get cytology and testing for hpv every 5 years
What is the leading cause of cervical cancer in women
HPV
Why no get HPV test 21-29
High prevelance of HPV in this population. Just get cytology every three years
Cervical cancer spread to bladder. How
No peritoneum between anterior cervix and the base of bladder
What nodes does cervical cancer spread to
Internal iliac or sacral
Hematogenous spread of cervical cancer
Iliac veins or via internal vertebral venous plexus
Hystectomy
Uterine disease (fibroids, endometriosis, or uterine or cervical cancer)
How may the uterus be approached and removed
Anterior abdominal wall or through vagina
Transabdominal approach or trasvaginal approach
Radical hystectomy
Removal of the ovaries in addition to uterus
Subtotal hysterectomy
Uterus divided at the isthmus
Cervical or total hysterectomy
Vaginal for ice are incised, encircling the cervic to separate the uterus from the vagina. Superior end of the vagina is then closed by suture. Ligation of the uterine artery is performed distal to the vaginal artery and the vaginal branches to enable maximal blood flow to the superior end of the vagina to facilitate healing
The vagina can be markedly __, particularly in the region of the posterior part of the fornix
Distended
Distension of the posterior part of the fornix allows what
Palpating of the sacral promontory during pelvic exam
The vagina is especially distended by the fetus during parturition, particularly in the _ direction when the fetus’s shoulders are distended
AP
Ilateral distension of the vagina is limited by the __ ___ and __ __
Ischial spines which project posteromedially and the sacrospinous ligaments extending from the spines to the lateral margins of the sacrum and coccyx
The birth canal is deep ___ and narrow ___ . What does this cause
AP
Transversely
Fetus shoulders to rotate into the AP plane
What can be palpated during a digital pelvic exam (vagina and or rectum)
Cervix, ischial spines, sacral promontory
Pulsation of the __ arteries may be felt through the lateral parts of the fornix, as may irregularities of the ovaries, such as ___
Uterine
Cysts
Pwhat may cause a vaginal fistulae
Obstetrical trauma during long and difficult labor may result in weaknesses, necrosis, or tears in the vaginal wall and sometimes beyond, radiation treatment for pelvic cancer, surgical complications, IBD, diverticulitis
Traumas to the vagina may cause fistula connecting the vagina to what
Bladder, ureter, urethra, bowel, or rectum
What fistula allow using to enter the bladder
Vesicovaginal
Ureterovaginal
Urethrovaginal
Flow of urine into vagina is continuous with __ and __ fistula but occurs only during micturition from __ fistula
Vesicovaginal, ureterovaginal
Urethrovaginal
What sort of vaginal fistula allow fecal matter or gas to enter vagina
Entero or rectovaginal fistula
What is culdocentesis
Incision made int he posterior part of the vaginal fornix
Why do a culdocentesis
Pelvic abscess in the rectouterine pouch can be drained
Or
Fluid in peritoneal cavity can be aspirated
Laparoscopy of pelvic viscera
Insert laparoscope into the peritoneal cavity through a small incision below the umbilicus. Insufflation of carbon dioxide creates a pneumoperitoneum to provide space to visualize, and the pelvis is elevated so that gracvity will pull the intestines into the abdomen
General anesthesia for birth
For emergency procedures
Is the mother conscious if there is general anesthesia
No
Under general anesthesia how does birth happen
Passively under the control of maternal hormones with the assistance os an obstetrician
Regional anesthesia or analgesia
Epidural, spinal or pudendal block, affects one area of the body
What is the mother consious of with regional analgesia
Yup. She is also conscious of uterine contractions and can bear down orpush to assist the contractions and expel the fetus.
What is the mother conscious of with regional anesthesia
Induces complete block of pain and feeling and does not allow a woman to assist with labor
Epidural block : where is indwelling catheter placed
Into epidural space (fat filled) at L3-L4
How does epidural block work
Anesthesia bathes the spinal nerve roots , including the pain fibers from the uterine cervix and superior vagina and the afferent fibers fromt he pudendal nerve.
What is anesthetize with epidural
Entire birth canal, pelvic floor, majority of the perineum
LOWER LIMBS NOT AFFECTED
Why is a mother aware of uterine contractions with an epidural block
The pain fibers from the uterine body (superior to the pelvic pain line) ascend to the inferior thoracic superior lumbar levels. So mother is aware of uterine contractions
The spinal epidural space does not continue into the cranial cavity, so the anesthetic agent cant ascend beyond the __ __
Foramen magnum
Spinal anesthesia
Anesthetic agent is introduced through the dura and arachnoid matter with a needle into the spinal subarachnoid space at L3-L4
Where get anesthesia with spinal anesthesia
Perineum, pelvic floor, and birth canal
Also motor and sensory function of entire lower limbs as well as sensation of the uterine contractions are temporarily blocked
Why use spinal anesthesia
Limited duration procedures, such as postpartum sterilization or forceps delivery or for second stage of labor
How long does spinal anesthesia last
30-250 minutes
If the labor is extended or the level of spinal anesthesia is inadequate can we readminister spinal anesthesia
May be hard…
Spinal anesthesia: bs the anesthetic agent is heavier than CSF, it remains in the inferior spinal subarachnoid space while the patient is inclined. What happens if patient lies flat
Circulate into the cerebral subarachnoid space int he cranial cavity
Severe spinal headache
From spinal anesthesia
Get anesthetic headache with epidural
No
Risk of both epidural and spinal anesthesia
CSF can leak out of subarachnoid space’;
How get leak of CSF with epidural
Needle inadvertently pierces the dura and arachnoid mater
How get leak of CSF with spinal anesthesia
Needle deliberately pierces the dura and arachnoid
What happens when get CSF leak
Decreases pressure within the canal, which can lead to a severe headache.
How can you treat headachefrom anesthesia
Autologous blood patch in which a small amount of patients blood is injected into the epidural space to fill the hole made by the needle
Pudendal nerve block
Peripheral nerve block that gives anesthesia over s2-s4 dermatomes and the inferior quarter of the vagina
Does pudendal nerve block, block pain from the superior birth canal (cervix and superior vagina)
No
Can mother feel contractions with pudendal nerve block
Yop
What removes support from the pelvic floor
Levator ani and/or pelvic fascia, which may occur during childbirth, or disruption of the perineal body
Perineal body
Final support of the pelvic viscera, linking muscles that extend across the pelvic outlet, like crossing beams supporting the overlying pelvic diaphragm
What can disrupt the perineal body
Trauma, inflammatory disease, and infection, which may result in the formation of the fistula of the vagina
Prolapse of pelvic viscera can happen to what:
Urethrocele Cystocele Uterovaginal prolapse Rectocele Enterocele
Urethrocele
Prolapse of the lower anterior vaginal wall that involves only the urethra
Cystocele
Prolapse of the anterior vaginal wall involving the bladder
Uterovaginal prolapse
Prolapse of the uterus, cervix, or upper vagina
Uterovaginal prolapse
Prolapse of the uterus , cervic, or upper vagina
Rectocele
Prolapse of the lower posterior vaginal wall involving the rectum
Enterocele
Prolapse of the upper posterior vaginal wall involving the rectovaginal pouch
Pelvic organ prolapse quantification (POP-Q)
Quantifying and describing pelvic organ prolapse . Relies on measurements of non defined points
What is the point of reference in POP-Q
Hymenal ring
1st degree prolapse
Prolapse of the organ halfway to the hymen
2nd degree prolapse
Prolapse of the organ to the hymen
3rd degree prolapse
Prolapse of the organ past the hymen
4th degree prolapse
Maximum descent of the organ
Treatment for pelvic organ prolapse
Pelvic floor exercises (kegal)
Pessaries (devices inserted into he vagina to support the prolapsed organ)
Surgery
Episiotomy
Surgical incision fo the perineum and inderoposterior vaginal wall used to enlarge the vaginal orifice, with intention of decreasing excessive traumatic tearing of the perineum and uncontrolled jagged tears of the perineal muscles
When is episiotomy indicated
When descent of the fetus is arrested or protracted when instrumentation is necessary (forceps) or to expedite delivery when there are signs of fetal distress
Median episiotomy
Incise perineal body
Scar will not be greatly different from fibrous tissue surrounding it.
Self limiting , resisting further tearing
When further tearing occurs with median episiotomy
Directed toward the anus and the sphincter damage or anovaginal fistulae are potential sequelae
What are median episiotomy associated with
Increased incidence of severe lacerations, associated in turn with an increased incidence of long term incontinence, pelvic prolapse and anovaginal fistulae
Mediolateral episiotomies
Lower incidence of severe laceration and are less likely to be associated with damage to the anal sphincter and canal
Incision in mediolateral episiotomies
Median incisive, which then turns laterally as it proceeds posteriorly, circumventing the perineal body and directing further tearing away from the anus
What may rupture the intermediate part of the urethra in males
Fractures of the pelvic girdle, espicially those resulting from separation of pubic symphysi and puboprostatic ligaments
Rupture of the intermediate part of the urethra results in what
Extravasion of urine and blood into the deep perineal pouch
Fluid in the deep perineal pouch may pass where
Superiorly through the urogenital hiatus and distribute extraperitoneally around the prostate and bladder
What is the common site of rupture of the spongy part of the urethra
Bulb of the penis
Does spongy urethra rupture result in extravasion of urine
Yup
How rupture spongy urethra
Forceful blow to the perineum, such as falling on a metal bean or incorrect passage of a transurethral catheter or device that fails to negotiate the angle of the urethra in the bulb
What happens if rupture the corpus spongiform and spongy urethra
Urine passing from it into the superficial perineal space
What determines the direction of flow of extravasated urine
Attachments of perineal fascia
Urine may pass into the loose CT in the scrotum, around the penis, and superiorly , creep to the membranous layer of subcutaneous CT of the inferior abdominal wall. Where can urine not pass
Thigh bc the membranous layer of superficial perineal fascia blends with the fascia lata, enveloping the thigh muscles, just distal to the inguinal ligament
Posteriorly into the anal triangle bc the superficial and deep layers of perineal fascia are continuous with each other around the superioficl aperineal msucles and with the posterior edge of the perineal membrane between them,
Rupture of a blood vessel inthe ___ __ __ resulting from trauma would results in similar containment of blood in the pouch
Superficial perineal pouch
The fat bodies of the __-__ fossa are among the lsat reserves of fatty tissue to disappear with starvation
Ischio-anal
In absence of support from ischio-anal fat, what is common
Rectal prolapse
Pectinate line/dentate/mucocutaneous line
Approximates the level of important anatomical change related to transition from visceral to parietal, affecting things like metasticization
Ischial-anal abscesses
Infection in ischio-anal fossa may cause abscess
Painful
How may infections react the ischio-anal fossa
After cryptitis(inflammation of anal tissue
Extension from a pelvirectal abscess
After a tear in the anal mucous membrane
From a penetrating wound int he anal region
Diagnostic signs of ischio anal abscess
Fullness and tenderness between the anus and the ischial tuberosity
A peri-anal abscess may rupture
Opening into the anal canal, rectum, or peri-anal skin.
Bc the is how-anal fossa communicate posteriorly through the _ __ __, an abscess in one fossa may spread to the other one and form what?
Deep postanal space
Horseshoe shaped abscess around the posterior aspect of the anal canal
In chronically constipated persons, the anal __ and __ may be town by hard feces
Valves
Mucosa
Anal fissure
Usually located in the posterior midline, inferior to the anal valves
Why are anal fissures painful
Supplied by sensory fibers of the inferior rectal nerves
A perinatal abscess may follow infection of an anal fissure, and the infection may spread where
Ischioanal fossa and form ischio anal abscesses or spread into the pelvis and form a pelvirectal abscess
Anal fistula
May result from the spread of an anal infection and cryptitis
Describe anal fistula
One end opens into the anal canal and the other end opensinto an abscess in the ischio anal fossa or into the peri anal skin
Internal hemorrhoids
Prolapses of rectal mucosa containing the normally dilated veins of the internal rectal venous plexus
What causes internal hemorrhoids
Breakdown of the mucularis mucosa, a smooth muscle layer deep to the mucosa
Internal hemorrhoids that prolapse into or through the anal canal are often compressed by the contracted __, impeding blood flor
Sphincters. As a result they tend to strangulate or ulcerated
Why is blood from internal hemorrhoids bright red
Blood from abundant anteriovenous anastomoses
External hemorrhoids
Thrombosis in the veins of the external rectal venous plexus and are covered by skin
Predisposing factors for hemorrhoids
Pregnancy, chronic constippation , prolonged toilet sitting, any disorder that impedes venous return, including increased intra abdominal pressure
The anastomoses between the superior, middle and inferior rectal veins form clinically important communications between the _ and _ venous systems
Portal
Systemic
The superior rectal vein drains into what
IMV
The middle and inferior rectal veins drain into
Systemic systemic from the IVC
Any abnormal increase in pressure int he valveless portal system of veins of the trunk may cause enlargement of the superior rectal veins, resulting in what
Increase in blood flow or stasis in the internal rectal venous plexus
Portal hypertension that occurs in relation to hepatic cirrhosis, the __ anastomoses between the _ and _ veins amay become varicose
Portocaval
Middle and inferior rectal veins
The veins of the rectal plexus normally appear ___
Varicose
Internal hemorrhoids occur most commonly in the absence of __ __
Portal hypertension
Anal canal superior to pectinate line
Visceral:innervated by visceral afferent pain fibers, so that an incision or needle insertion in this region is painless.
Internal hemorrhoids are painful?
No
Inferior to the pectinate line
Anal canal is somatic, supplied by the inferior anal (rectal) nerves containing somatic sensory fibers
External hemorrhoids painful
Yup
Anorectal incontinence
Stretching of the pudendal nerves during a traumatic childbirth can cause pudendal nerve damage and anorectal incontinence
Urethral catheterization
Remove urine
When inserting catheters or urethral sounds, what is important
The curves of the male urethra must be considered
Just distal to the perineal membrane, the spongy urethra is well covered inferiorly and posteriorly by erectile tissue of the bulb of the penis, however a short segment of the __ part of the urethra is unprotected
Intermediate
Bc the intermediate urethra is unprotected, what is a problem
Must negotiate the area bc urethral wall is thin so vulnerable to rupture from the insertion of urethral catheters and sounds
The intermediate part or urethra is __ distendible
Least
How does the intermediate part of the urethra run
Inferno-anteriorly as it passes through the external urethral sphincter. Proximally it takes a slight curve that is concave anteriorly as it transverse the prostate
Urethral stricture
From external trauma of the penis or infection of the urethra.
What are urethral sounds used for
Dilate the constricted urethra
What is the narrowest and least distendible part of the urethra
External urethral orifice
The scrotum is easily distended. What may enter the scrotum in an inguinal hernia
Intestines . Making it as large as a soccer ball
Orchitis
Inflammation of the testes
What causes orchitis
Mumps, bleeding in the subcutaneous tissue, or chronic lymphatic obstruction (elephantitis)
Is it normal for one testicle to be slightly larger than the other
Yup
Which testicle is usually more inferior
Left
About half of testicular cancer occur between what ages
20-34
Hypospadias
1/300
Glandular hypospadias
External urethral orifice is on the ventral aspect of the glans penis
Penile hypospadias
On body of penis
Penoscrotal or scrotal hypospadias
In the perineum
Embryological basis for hypospadias
Failure of urogenital folds to fuse on the ventral surface of the penis
Hypospadias is associated with inadequate production of ___ by the fetal testes
Androgens
Phimosis
Prepuce fits too tight over glans penis . Can’t be retracted
Smegma
Oily secretions of cheesy consistency accumulate in the preputial sac, causing irritation
Paraphimosis
Retraction fo the prepuce over the corona of the glans penis constricts the neck of the glans so much that there is interference with the drainage of blood and tissue fluid
Circumcision
Surgical excision of the prepuce
Impotence
Lesion of prostatic plexus or cavernous nerves
How treat impotence
Surgically implanted , semirigid or inflatable penile prosthesis may assume the role of the erectile bodies
Erectile dysfunction
Absence of nerve
Hypothalamus and endocrine disorders may reduce testosterone
How can ED be overcome
Meds, injections that increase blood flow into the cavernous sinusoids by causing relaxation of SM
Female genital cutting
Remove prepuce of clit and clit and labia minora and may include suturing of the vaginal ostium
Why would you have female genital cutting
Inhibit sexual arousal and gratification
Vulvar trauma happens how
Disruption of vessels as the result of trauma (athletic injuries such as jumping hurdles, sexual assault, obstetrical injury)
Vulvar hematoma
PAINFUL
Blood in labia majora
Can lead to scarring and fistula
When are the greater vestibular glands palpable
When infected
Occlusion of the vestibular gland duct
Predispose the individual to infection of the greater vestibular gland
The greater vestibular gland is the site of most vulva ____
Adenocarcinoma
Bartholinitis
Inflammation of the greater vestibular (bartholinitis) glands
What may cause bartholinitis
Pathogenic organism
What may enlarged greater vestibular glands impinge
Wall of the rectum
Occlusion of the vestibular gland duct without infection can result in the accumulation of ___
Mucin
Causing a bartholin gland cyst
Pudendal nerve block
Injecting a local anesthetic agent into the tissues surrounding the pudendal nerve
Where is the injection for a pudendal nerve block made
Where pudendal nerve crosses the lateral aspect of the sacrospinous ligament near its attachment to the ischial spine or in the initial part of the pudendal canal
Why is it important that the physicians finger is always positioned between the needle tip and the baby’s head during pudendal nerve block
Fetus head usually stationed in lesser pelvis
Ilio inguinal nerve block
Abolish sensation from the anterior part of the perineum
When patients with pudendal or ilio inguinal nerve block complain of pain what is it from
Result of overlapping innervation by the perineal branch at the posterior cutaneous nerve of the thigh.
Superficial transverse perineal muscle, bulbospongiosus, and external anal sphincter
Commonly attach to the perineal body, forming crossing beams over the pelvic outlet to support the perineal body and pelvic diaphragm
Why are female perineal muscles underdeveloped in comparison to men
Absence of functional demands related to urination, penile erection, and ajaculation
What do the female perineal muscles do
Support pelvic viscera and help prevent urinary stress incontinence and post partum prolapse of viscera
Kegal
Use perineal muscles such as successive interruption of urine flow while urinating
Vaginismus
Involuntary muscle spasms that occur when vaginal penetration is attempted
Vaginismus may cause dyspareunia. What that
Painful intercourse
Vaginismus can be __
Psychological
Treatment for vaginismus
Muscle relaxation techniques and desensitization with the use of vaginal dilatory of increasing diameter
