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Y3 Medicine > Repro. ANATOMY > Flashcards

Repro. ANATOMY Flashcards

1
Q

What are the functions of the Pelvis?

A
  • Support of upper body when sitting and standing
  • Transference of weight from vertebral column to femurs to allow standing and walking
  • Attachments of muscles for locomotion + abdominal wall
  • attachment for external genitalia
  • Protection of pelvic organs, blood supply, nerve, venous and lymphatic drainage
  • Passage for childbirth
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2
Q

The Bony pelvis consists of:

A

2 hip bones

Sacrum

Coccyx

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3
Q

Each hip bone is a fusion between:

A

Ilium

Ischium

Pubis

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4
Q

What is indicated by labels A, B and C

A

A - Iliac Crest

B - ASIS (Anterior Superior Iliac Spine)

C - Anterior Inferior Iliac Spine

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5
Q

What is indicated by labels A, B and C?

A

A - Iliac Crest

B - PSIS (Posterior Superior Iliac Spine)

C - Posterior Inferior Iliac Spine

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6
Q

What bony features are labelled below?

A

A - Ischiopubic ramus

B - Ischial tuberosity

C - Ischial spine

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7
Q

Which bony features of the Pubis are labelled below?

A

A - Ischiopubic ramus

B - Pubic arch

C - Sub-pubic angle

D - Pubic tubercle

E - Superior pubic ramus

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8
Q

What spaces within the pelvis are represented by the red and green lines here?

A

Red = Pelvic Inlet

Green = Pelvic Outlet

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9
Q

What bones form the borders of the Pelvic Inlet?

A
  • Sacral Promontory
  • Ilium
  • Superior pubic ramus
  • Pubic symphysis
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10
Q

What bones form the border of the Pelvic Outlet?

A
  • Pubic Symphysis
  • Ischiopubic Ramus
  • Ischial Tuberosities
  • Sacrotuberous ligaments
  • Coccyx
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11
Q

What is the Pelvic Cavity?

A
  • Lies within bony pelvis
  • Contains pelvic organs + supporting tissues
  • Continuous with abdominal cavity above
  • Lies between pelvic inlet and pelvic floor
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12
Q

What are the palpable surface landmarks of the pelvis?

A

Iliac crest

ASIS

PSIS

Ischial tuberosity

Coccyx

Pubic symphysis (on deep palpation)

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13
Q

What bony features of the pelvis are labelled below?

A

A - Iliac Crest

B - Ischiopubic ramus

C - Superior Pubic Ramus

D - Ischial spine

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14
Q

What bony features of the pelvis are labelled below?

A

A - ASIS

B - Pubic Tubercle

C - Ischial tuberosity

D - Ischial spine

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15
Q

What bony features of the pelvis are labelled below?

A

A - Iliac crest

B - Ischiopubic ramus

C - Pubic arch

D - Superior pubic ramus

E - Ischial tuberosity

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16
Q

Which joints of the pelvis are labelled below?

A

A - Sacroiliac joint

B - Obturator foramen

C - Pubic symphysis

D - hip joint

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17
Q

What are the names of the labelled ligaments?

A

A - Sacrospinous ligament

B - Sacrotuberous ligament

C - Sacrospinous ligament

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18
Q

Give the name of the labelled structure below:

A

A - Greater sciatic foramen

B - Lesser sciatic foramen

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19
Q

Explain why the ligaments of the pelvis relax during later pregnancy

A

Sacrotuberous and sacrospinous ligaments ensure inferior part of the sacrum is not pushed superiorly when weight is suddenly transferred vertically through vertebral column (e.g. when jumping or in late pregnancy)

Stops the sacrum from being pushed superiorly when transferring weight

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20
Q

What structures pass through obturator foramen?

A

Obturator nerve and vessels pass through obturator foramen via obturator canal

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21
Q

What does ‘Moulding’ refer to?

A

‘Moulding’ refers to movement of one bone over another to allow the foetal head to pass through the pelvis during labour.

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22
Q

What feature of the foetal skull allows for ‘moulding’ to occur during labour?

A

Fontanelles

The presence of fontanelles (sutures between bones not fully formed and membrane spaces) allows for the bones to slide over each other.

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23
Q

What is the ‘vertex’ of a foetal skull?

A

Area of the foetal skull

Outlined by anterior + posterior fontanelles and the parietal eminences

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24
Q

True or False:

The biparietal diameter of the foetal skull is LONGER than the occipitofrontal diameter

A

FALSE FALSE FALSE

The occipitofrontal diameter is longer than the biparietal diameter (the foetal skull is longer than it is wide)

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25
Q

What is the ideal position for the foetus to enter the pelvic cavity and why?

A

Foetus should ideally enter pelvic cavity transversely (facing right or left direction)

Within the pelvic inlet, the transverse diameter is wider than the AP diameter (foetus facing transversely because the occipitofrontal diameter is longer than biparietal diameter)

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26
Q

What does it mean by the ‘station’ in regards to foetal descent in the pelvis?

A

Station = distance of the foetal head from the ischial spines

-ve number = head is superior to spines

+ve number = head is inferior to spines

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27
Q

Explain the descend of the foetal head during labour

A
  • Enters the pelvic cavity/pelvic inlet in transverse position
  • While descending through cavity head should rotate within cavity
  • Should be in flexed position (chin on chest)
  • At pelvic outlet, the AP diameter is wider than transverse so ideally head should leave in occipitoanterior (OA) position
  • During delivery foetal head should be in extension
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28
Q

What is the next step once the baby’s head has been delivered?

A

Once head is delivered, there is a further rotation required so that shoulders and the rest of the baby can be delivered

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29
Q

What parts of the female reproductive system lie within the Pelvic Cavity?

A

Ovaries

Uterine Tubes

Uterus

Superior part of vagina

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30
Q

What parts of the female reproductive system lie within the Perineum?

A

Inferior part of vagina

Perineal muscles

Bartholin’s Glands

Clitoris

Labia

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31
Q

In women, where does excess fluid within the peritoneal cavity tend to collect?

A

Abnormal fluid collects within the Pouch of Douglas (rectouterine pouch)

Most inferior part of peritoneal cavity in anatomical position

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32
Q

What is a clinical method of draining excess fluid from the peritoneal cavity in women?

A

Fluid collects in Pouch of Douglas

Drained via needle passed through posterior fornix of vagina

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33
Q

What is the name of these pouches formed in the floor of the peritoneal cavity?

A

A - Rectouterine pouch (Pouch of Douglas)

B - Vesico-uterine Pouch

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34
Q

Identify the following (include side):

A

A - Right ovary

B - Right uterine tube

C - Vesico-uterine pouch

D - Rectouterine Pouch (pouch of Douglas)

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35
Q

What feature is this arrow pointing to?

A

Broad Ligament of the uterus

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36
Q

What is the Broad Ligament of the uterus?

A

Double layer of peritoneum

Extends between uterus and the lateral walls & floor of pelvis

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37
Q

What is contained within the Broad Ligament?

A

Uterine Tubes

Proximal part of Round Ligament

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38
Q

What is the function of the Broad Ligament?

A

Helps maintain the uterus in its correct midline position

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39
Q

What is the Round Ligament?

A

Embryological remnant ​

Attaches to lateral aspect of uterus

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40
Q

What is the course of the Round Ligament?

A

Attaches to lateral aspect of uterus

Passes through deep inguinal ring to attach to superficial tissue of female perineum

(guides ovaries from original place on posterior abdominal wall to position in perineum)

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41
Q

Which ligaments are labelled?

A

A - Broad Ligament

B - Round Ligament

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42
Q

Describe the layers of the body of the uterus?

A

3 layers

Perimetrium (outer)

Myometrium (muscle layer)

Endometrium (sheds during menstrual cycle)

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43
Q

What are Stone Babies?

A

Lithopedion

Embryo/baby develops in abdominal cavity but does not survive. If too large to be reabsorbed by the body the outside calcifies (part of a foreign body reaction) to shield the mother from the dead tissue and infection risk.

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44
Q

What are the 3 levels of support that hold the uterus in position?

A
  • Strong ligaments (e.g. uterosacral ligament)
  • Endopelvic fascia
  • Muscles of pelvic floor (e.g. levator ani)

Weakness of these supports can result in Uterine Prolapse (uterus moves inferiorly)

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45
Q

What is the most common position for the uterus to sit and explain what this means?

A

Anteverted and Anteflexed

Anteverted - cervix tipped anteriorly relative to axis of vagina

Anteflexed - uterus tipped anteriorly relative to axis of cervix

(Mass of uterus lies over the bladder)

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46
Q

What is a common variation for the uterus to sit which is not the normal?

A

Retroverted + Retroflexed

Retroverted - cervix tipped posteriorly relative to axis of vagina

Retroflexed - uterus tipped posteriorly relative to axis of cervix

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47
Q

What area of the vagina must be sampled in a cervical screening?

A

Squamo-columnar Junction (Transformation Zone)

(must use speculum to open walls of vagina to visualise the cervix)

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48
Q

Where does fertilisation tend to occur?

A

Ampulla

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49
Q

True or False:

The uterine (fallopian) tubes usually lie symmetrically in the pelvic cavity

A

FALSE

Do not usually lie symmetrically

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50
Q

Explain the communication between uterine tubes (fimbriae) and the peritoneal cavity.

Why is this relevant clinically?

A

Fimbriated end of uterine tubes open into peritoneal cavity (communication between genital tract and peritoneal cavity)

Infection could pass between the two areas (PID > peritonitis, ectopic pregnancy)

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51
Q

Which clinical test is pictured below and what is it assessing?

A

Hysterosalpingogram (HSG)

Patency of tubes

(in this image the radiopaque dye can be seen spilling out of end of uterine tube and into peritoneal cavity suggesting that the tube is patent)

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52
Q

True or False:

The ovaries secrete oestrogen and progesterone in response to anterior pitutary hormones FSH + LH

A

TRUE

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53
Q

What is the rough size of a normal ovary and where is it located?

A

Almond sized and shaped

Located laterally in pelvic cavity

Sits within the Ovarian fossa in most people (shallow depression on lateral pelvis wall)

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54
Q

What is labelled below?

A

A - Anterior fornix

B - Posterior fornix

C - Lateral fornix

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55
Q

At what point are the vagina walls held apart?

A

Cervix

The vagina is a muscular tube - walls normally in contact

At superior part the cervix holds them apart forming a fornix (= space around the cervix)

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56
Q

What are the main structures felt for on palpation during Vaginal Digital Examination?

A
  1. Ischial Spines - laterally, 4 + 8 o’clock position
  2. Uterus position (e.g. anteverted) - bimanual palpation
  3. Adnexae - uterine tubes + ovaries, lateral fornix > press deeply in iliac fossa of same side (can detect masses or tenderness)
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57
Q

What are the borders of the diamond which forms the Urogenital and Anal Triangle?

A

Anterior - Pubic Symphysis

Posterior - coccyx

Lateral - Ischial spine

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58
Q

True or False:

The levator ani is one large muscle

A

FALSE

Made up of a number of smaller muscles

Skeletal muscle (voluntary), Forms majority of pelvic diaphragm

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59
Q

What is the function of the levator ani muscle?

A

Provides continual support for the pelvic organs

  • Tonic contraction
  • Reflexively contracts during times of increased intra-abdominal pressure

(weakness factor in prolapse)

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60
Q
A
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61
Q

What is the Perineal Body?

A

= Bundle of collagenous and elastic tissue into which the perineal muscles attach

Very important for pelvic floor strength and support

Located just deep to skin (can be damaged during labour)

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62
Q

What is the primary nerve of the perineum?

A

Pudendal Nerve (S2, 3, 4)

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63
Q

What is the Bartholin’s Gland in females?

A

aka Greater Vestibular Glands

Pea-sized compound alveolar glands located slightly posterior on right & left of vagina opening

Secretes mucous to lubricate vagina

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64
Q

Why are Bartholin’s Glands relevant clinically?

A

Can become infected quite easily and enlarge

Can be quite painful

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65
Q

What surface anatomy structures are labelled below?

A

A - Mons pubis

B - Labium majus

C - Labium minus

D - External Urethral Orifice

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66
Q

What surface anatomy structures are labelled below:

A

A - Clitoris

B - External Urethral Orifice

C - Vestibule

D - Vaginal Orifice (external opening into vagina)

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67
Q

What surface anatomy structures are labelled below:

A

A - Labium majus

B - Clitoris

C - Vestibule

D - Vaginal orifice

E - Anus

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68
Q

What are the borders of the bed of the breast?

A

From ribs 2-6

Lateral border of sternum to mid-axillary line

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69
Q

Name the structures of the breast labelled below:

A

A - Suspensory Ligaments (attach skin to breast)

B - Areola

C - Pectoralis Major

D - Lactating Lobules

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70
Q

Name the structures of the breast labelled below:

A

A - Retromammary Space (between fascia and breast)

B - Pectoralis Major

C - Non-lactating Lobules

D - Lactiferous Ducts

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71
Q

Name the structures of the breast labelled below:

A

A - Suspensory Ligaments

B - Retromammary Space

C - Lactiferous Ducts

D - Lactating Lobules

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72
Q

Explain the quadrants of the breast used to describe the position of a lump.

A

4 quadrants/clock face

9 o’clock = lateral, 3 o’clock = medial

12 o’clock = superior, 6 o’clock = inferior

9 >12 = Upper Outer

12 > 3 = Upper Inner

3> 6 = Lower Inner

6 > 9 = Lower Outer

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73
Q

Where does the majority of lymph from the breast drain to?

A

To ipsilateral axillary lymph nodes

Then to Supraclavicular nodes

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74
Q

What is the blood supply to the female breast?

A

Axillary (from Subclavian)

Internal Thoracic (internal mammary)

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75
Q

Why is the distinguishment between structures in the Pelvis or Perineum so important in terms of nerve supply?

A

Pelvis:

  • Body cavity
  • Sympathetic, Parasympathetic, Visceral afferent

Perineum:

  • Body Wall
  • Somatic motor, Somatic Snesory

levator ani muscle marks division between pelvis + perineum

76
Q

For the superior aspect of pelvic organs what is the nerve route and perception for ‘pain’?

A

(Organs touching the peritoneum)

Visceral afferents run alongside sympathetic fibres

Enter spinal cord T11-L2

Pain perceived as SUPRAPUBIC

77
Q

For the inferior aspect of pelvic organs what is the nerve route and perception of ‘pain’?

A

(Organs not touching peritoneum)

Visceral afferents run alongside parasympathetic fibres

Enter spinal cord at S2, S3, S4

Pain perceived in S2-4 dermatome (perineum)

78
Q

What is the difference in ‘pain’ sensation for structures crossing from pelvis to perineum (e.g. urethra, vagina)?

A

Above levator ani = pelvis

  • Visceral afferents
  • Parasympathetic
  • Spinal cord levels S2, S3, S4

Below levator ani = perineum

  • Somatic sensory
  • Pudendal Nerve
  • Spinal cord S2, S3, S4
  • Localised pain within perineum
79
Q

What is the sensory and motor innervation of the Pudendal nerve?

A

Sensory - external genitalia (M+F), skin around anus/anal canal/perineum

Motor - pelvic muscles, external urethral sphincter, external anal sphincter

80
Q

Describe the sympathetic autonomic nerves of the pelvis

A

Sacral sympathetic trunks

T11-L2

Superior Hypogastric Plexus (plexus of nerves anterior to AA bifurcation, contains sympathetic function for the urogenital system)

81
Q

Describe the parasympathetic autonomic nerves of the pelvis

A

Sacral outflow (S2, S3, S4)

Pelvic Splanchnic Nerves

Emerge from spinal roots > mixes with sympathetics in Inferior Hypogastric Plexus (supplies viscera of pelvic cavity, gives rrise to prostatic plexus in males + uterovaginal plexus in females)

82
Q

Which of the following organs (that touch the peritoneum) are supplied by visceral afferents back to T11-L2?

Options: Uterus, Cervix, Ovaries, Uterine Tubes, Superior vagina

A

Uterine Tubes

Uterus

Ovaries

83
Q

Which of the following organs (inferior to peritoneum) are supplied by visceral afferents back to S2-S4?

Options: Uterus, Cervix, Ovaries, Uterine Tubes, Superior vagina

A

(Pelvic Splanchnic nerves + parasympathetic fibres)

Cervix

Superior vagina

84
Q

From the following list: which of these organs/structures are supplied by the Pudendal nerve in ‘pain’ sensation?

Options: Inferior vagina, Superior vagina, Uterus, Perineal muscles, Skin, Cervix, Glands, Ovaries

A

Pudendal nerve (S2-S4)

Inferior vagina, perineal muscles, glands, skin

Uterus + ovaries = visceral afferents T11-L2

Superior vagina, cervix = visceral afferents S2-S4

85
Q

In regards to pain from female repro system which two sets of spinal cords are most important?

A

T11-L2

S2-S4

86
Q

At what level is a spinal & epidural anaesthetic injected?

A

L3-L4 (L5) Region

87
Q

At what level does the spinal cord end?

A

L2 vertebrae

Spinal cord becomes cauda equina

(subarachnoid space ends at level S2)

88
Q

What layers does the needle pass through for epidural anaesthetic?

A

Supraspinous ligament

Interspinous ligament

Ligamentum flavum

Epidural space (fat + veins)

89
Q

Identify the ligaments labelled A, B and C.

A

A - Supraspinous ligament

B - Interspinous ligament

C - Ligamentum flavum

90
Q

Which structures of the spine are labelled below?

A

A - Ligamentum flavum

B - Epidural Space

C - Subarachnoid Space

D - Arachnoid Mater

E - Dura Mater

91
Q

Which structures of the spine are labelled below?

A

A - Ligamentum flavum

B - Epidural Space

92
Q

During a spinal anaesthetic what structures does the needle pass through?

A

(Same location as epidural anaesthetic - L3/L4)

  • Supraspinous ligament
  • Interspinous ligament
  • Ligamentum flavum
  • Epidural space (fat + veins)
  • Dura mater
  • Arachnoid mater

Reaches Subarachnoid space (contains CSF)

93
Q

What are some signs in the lower limbs that show spinal anaesthetic is working?

A

Sympathetic fibres supply all arterioles (sympathetic tone)

BLOCKADE of sym. tone to all arterioles in low limb = Vasodilation

Effects:

  • Skin of lower limbs looks Flushed
  • Warm lower limbs
  • Reduced sweating
94
Q

What is the course of the Pudendal nerve once it exits the spine?

A
  • Exits pelvis via greater sciatic foramen
  • Passes posterior to sacrospinous ligament
  • Re-enters pelvis via lesser sciatic foramen
  • Travels in pudendal canal (passage within obtruator fascia with internal pudendal artery + vein)
  • Branches to supply perineum
95
Q

What landmarks are used for pudendal nerve block?

A

Pudendal nerve crosses lateral aspect of sacrospinous ligament

Can palpate ischial spine through vagina as landmark to administer block

96
Q

What are some possible clinical uses for a pudendal nerve block?

A

Forceps delivery

Painful vaginal delivery

Episiotomy incision

97
Q

How can the pudendal nerve and sphincter be damaged during labour?

A
  • Branches of pudendal nerve can be stretched with resultant stretch of nerve fibres
  • Fibres within levator ani (puborectalis) or external anal sphincter muscl could be torn (muscle is weakened)

Could result in faecal incontinence and pelvic floor weakness

98
Q

What is an Episiotomy?

A

Posterolateral (mediolateral) incision

Made into relatively ‘safe’ fat filled ischioanal fossa during labour

Avoids incision extending into rectum

99
Q

What are Langer Lines?

A

Langer lines of skin tension

Correspond to natural orientation of collagen fibres in dermis (generally perpendicular to orientation of underlying muscle fibres)

100
Q

Which layers of the anterolateral abdominal wall are labelled below?

A

A - External oblique

B - Internal oblique

C - Transversus abdominis

101
Q

Which layers of the anterolateral abdominal wall are labelled below?

A

A - Skin

B - Superficial fascia

C - Rectus Abdominis

D - Rectus Sheath

102
Q

Which layers of the anterolateral abdominal wall are labelled below?

A

A - Rectus Sheath

B - Rectus abdominis

C - Internal oblique

D - Transversus abdominis

103
Q

Which muscle is shown below?

What are the attachments of this muscle?

A

External Oblique

Attachment - lower ribs, iliac crest, pubic tubercle, linea alba

(fibres run in same direction as external intercostals

104
Q

Which muscle is shown below?

What are the attachments of this muscle?

A

Internal Obliques

Attachments - lower ribs, thoracolumbar fascia, iliac crest, linea alba

(fibres run in same direction is internal intercostals)

105
Q

Which muscle is shown below?

What are the attachments of this muscle?

A

Transversus Abdominis

Attachments - lower ribs, thoracolumbar fascia, iliac crest, linea alba

106
Q

Which muscle and feature are labelled below?

A

A - Rectus Abdominis

B - Tendinous Intersections

107
Q

What is the function of the tendinous intersections of the rectus abdominis?

A

Divides each rectus abdominis into 3 or 4 smaller muscles

Improves mechanical efficiency

108
Q

What is the linea alba?

A

= Midline blending of aponeurosis of anterolateral abdominal muscles

Formed by the interweaving of the muscle aponeuroses

Runs from xiphoid process to pubic symphysis

109
Q

What is the Rectus Sheath?

A

= Combined aponeuroses of anterolateral abdominal wall muscles

  • Surrounds rectus abdominis muscles
  • Strong, fibrous layer
  • Immediately deep to superficial fascia
110
Q

What is labelled below?

A

A - Posterior Rectus Sheath

B - Anterior Rectus Sheath

111
Q

True or False:

When undertaking a suprapubic incision, e.g. LSCS, the anterior and posterior rectus sheath will be cut

A

FALSE

Only the anterior rectus sheath will be cut

112
Q

During a surgery, is the rectus sheath left to heal or stitched closed?

A

Stitched closed

Rectus sheath is a strong, fibrou layer/covering - stiched closed after operation to increase strength of wound and reduce risk of complications, e.g. incisional hernia

113
Q

Which structures of the internal surface of the abdominal wall are labelled below?

A

A - Transversus abdominis

B - Internal oblique

C - External oblique

114
Q

Which structures of the internal surface of the abdominal wall are labelled below?

A

A - Transversalis fascia

B - Extra peritoneal feat

C - Parietal peritoneum

115
Q

Which structures of the internal surface of the abdominal wall are labelled below?

A

A - ilioinguinal nerve

B - Inguinal ligament

116
Q

Name all the structures of the abdominal wall labelled below?

A

A - Transversus abdominis

B - Internal oblique

C - External oblique

D - ilioinguinal nerve

E - Inguinal ligament

F - Transversalis fascia

G - Extra peritoneal fat

H - Parietal peritoneum

117
Q

What is the nerve supply to the anterolateral abdominal wall?

A

Enters from lateral direction

  • 7th - 11th intercostal nerves become Thoracoabdominal nerves
  • Subcostal (T12)
  • iliohypogastric (L1)
  • ilioinguinal (L1)

Travel in plane between internal oblique and transversus abdominis

118
Q

What is the blood supply to the anterior abdominal wall (also name origin of artery and location)?

A

Superior Epigastric arteries

  • Continuation of internal thoracic artery
  • Emerges at superior aspect of abdominal wall
  • Lies posterior to rectus abdominis

Inferior Epigastric arteries

  • Branches of external iliac artery
  • Emerges at inferior aspect of abdominal wall
  • Lies posterior to rectus abdominis
119
Q

What is the blood supply to the lateral abdominal wall (also name origin and location)?

A

Intercostal and Subcostal arteries

  • Continuations of posterior intercostal arteries
  • Emerge at lateral aspect
120
Q

Which arteries of the abdomen are labelled below?

A

A - Intercostal & Subcostal arteries

B - Superior Epigastric

C - Inferior Epigastric

121
Q

True or False:

When incising muscles, incise in same direction as muscle fibres

A

TRUE

Incise in same direction as muscle fibres to minimise traumatic injury to muscle fibres

122
Q

What is an LSCS Incision?

A

Lower (uterine) Segment Caesarean Section

123
Q

In an LSCS incision what happens to the rectus muscles?

A

The rectus muscles are NOT cut

Separated from each other in lateral direction (moving towards nerve supply)

124
Q

During an LSCS incision what layers are seen when opening and which layers need stitched closed?

A

Layers when opening: Skin + fascia, rectus sheath (anterior), rectus abdominis (separated laterally), fascia + peritoneum, retract bladder, uterine wall, amniotic sac

Layers to stitch closed:

  • Uterine wall (with visceral peritoneum)
  • Rectus sheath
  • Fascial layer (if increased BMI)
  • Skin
125
Q

During a Laparotomy which layers are seen when opening and when layers need stitched closed?

A

Layers when opening: Skin + fascia, Linea alba, Peritoneum

Layer to stitch closed:

  • Peritoneum + Linea Alba
  • Fascia (if increased BMI)
  • Skin
126
Q

Which possible incisions can be made for a laparoscopy procedure?

A

Sub-umbilical incision

Lateral port (be careful to avoid inferior epigastric artery)

127
Q

What is the route of the inferior epigsatric artery?

A

Branch of external iliac artery

Emerges medial to deep inguinal ring (inguinal ring halfway between ASIS + pubic tubercle)

Passes in superomedial direction posterior to rectus abdominis

128
Q

What is the difference between an abdominal and vaginal hysterectomy?

A

Abdominal hysterectomy - uterus removed via incision in abdominal wall (often same incision as LSCS)

Vaginal hysterectomy - removal of uterus via the vagina

129
Q

What points can be used to differentiate the ureter from the uterine artery in a hysterectomy?

A
  • Ureter passes inferior to the artery (‘water under the bridge’)
  • Ureter will often ‘vermiculate’ when touched
130
Q

Which muscles make up the pelvic diaphragm?

A

Levator Ani (puborectalis, pubococcygeus, iliococcygeus)

Coccygeus

(has appearance of sling with aterior gap between medial borders)

131
Q

Which components of the pelvic floor are labelled below?

A

A - Urethra

B - Prostate

C - Levator Ani

D - Rectum

132
Q

What components of the pelvic floor are labelled below?

A

A - Levator ani

B - Coccygeus

C - Ischial Spine

133
Q

Which components of the pelvic diaphragm are labelled below?

A

A - Urethra

B - Prostate

C - Vagina

D - Rectum

E - Levator Ani

F - Coccygeus

G - Ischial Spine

134
Q

What is the Urogenital hiatus?

A

Anterior gap between medial boarders of pelvic diaphragm

Allows for passage of urethra (and vagina in women)

(also rectal hiatus as well but muscles attach so less of a gap)

135
Q

What are the attachments of the levator ani?

A

Pubic bones, ischial spines, tendinous arch of levator arch

Perineal body, coccyx, walls of organs in midline

136
Q

Name the muscles labelled below?

A

A - Iliococcygeus

B - Pubococcygeus

C - Puborectalis

137
Q

What is the normal contraction and innvervation of the levator ani?

A

Tonically contracted most of time (must relax to allow urination and defaecation)

Innervated by Pudendal nerve and nerve to levator ani

138
Q

Name the labelled ligaments of the pelvis?

A

A - Utero-sacral ligament

B - Transverse Cervical ligament

C - Tendinous arch of pelvic fascia

139
Q

Name the labelled ligaments of the pelvis

A

A - Lateral ligament of bladder

B - Tendinous arch of pelvic fascia

C - Tendinous arch of levator ani (covers obturator internus)

140
Q

Which pelvic ligaements provide additional support in the pelvis?

A
  • Fibrous endo-pelvic fascia
  • Uterosacral
  • Transverse cervical (cardinal)
  • Lateral ligament of bladder
  • Lateral Rectal ligaments
141
Q

Where does the deep perineal pouch sit and what does it contain?

A

Lies below fascia covering inferior aspect of pelvic diaphragm

AND above perineal membrane

Contains parts of urethra, vagina (females), bulbourethral glands (males), neuovascular bundle for penis/clitoris, extensions of ischioanal fat pads, muscles

142
Q

Which components of the deep perineal pouch are labelled below?

A

A - Dorsal vein of clitoris/penis

B - External urethral sphincter

C - Compressor urethrae

143
Q

Which components of the deep perineal pouch?

A

A - Bulbourethral Gland

B - External Urethral Sphincter

C - Compressor urethrae

D - Deep transverse perineal muscle

144
Q

Which components of the deep perineal pouch is labelled?

A

A - Dorsal vein of clitoris/penis

B - External urethral sphincter

C - Compressor urethrae

D - Smooth muscle (deep transverse perineal in males as thought to be skeletal muscle)

145
Q

What is the perineal membrane?

A

Thin sheet of tough, deep fascia (last passive support of pelvic organs - together with perineal body)

Attaches laterally to sides of pubic arch, closing urogenital triangle

Has openings for the urethra (+ vagina)

146
Q

Name the layers of the perineum

A

A - Perineal Membrane

B - Deep Perineal muscles

C - Pelvic Diaphragm

147
Q

Name the following:

A

A - Urethra

B - Crura

C - Bulb

D - Perineal membrane

148
Q

Name the following:

A

A - Ischiocavernosus

B - Bulbospongiosus

C - Superficial Transverse Perineal

149
Q

Name the following:

A

A - Ischiocavernosus

B - Bulbospongiosus

C - Superficial transverse perineal

150
Q

Name the following:

A

A - Crura

B - Bulb

C - Perineal membrane

D - Greater vestibular glands (aka Bartholin Gland, same as Couppers gland in males)

151
Q

What is the erectile tissue within the superficial perineal pouch (male + female)?

A

Male:

  • Bulb (anterior cylinder) - corpus spongiosum
  • Crura (2 posterior cylinders) - corpus cavernosum

Female:

  • Clitoris + crura - corpus cavernosum
  • Bulb (split into 2) - corpus spongiosum
152
Q

What is the function of the pelvic floor?

A
  • Provides support to pelvic organs
    • Normally tonicaly contracted
    • Actively contracts during increased pressure (cough, sneeze, vomiting)
  • Helps maintain continence
  • Urinary - external urethral sphincter, compressor urethrae, levator ani
  • Faecal
    • Tonic contraction of puborectalis bends anorectum anteriorly
    • Active contraction maintains continence after rectal filling
153
Q

What are some risk factors of pelvic floor injuries?

A
  • Pregnancy
  • Childbirth (stretching or tearing, pudendal nerve damage)
  • Chronic constipation
  • Obesity
  • Heavy lifting
  • Chronic cough or sneeze
  • Previous injury to pelvis/pelvic floor
  • Menopause
154
Q

What parts of the pelvic floor are essential for continence?

A

Urinary bladder neck support

External urethral sphincter

Smooth muscle in urethral wall

155
Q

What is a Vaginal Prolapse?

A

Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia

Presents as lump in vaginal wall

156
Q

What is the difference between a Urethrocele, Cystocele, Rectocele and Enterocele?

A

Urethrocele - urethra sags or presses into vagina

Cystocele - prolapsed bladder, bulges into vagina

Rectocele - front wall of rectum into back wall of vagina

Enterocele - descending of small intestine into lower pelvic cavity (pushes on top part of vagina + creates bulge)

157
Q

What is a Uterine prolapse?

A

Descent of uterus (starts to move down and potentially out through vagina)

Presents as dragging sensation, feeling of ‘lump’, urinary incontinence

158
Q

Define the different degrees of uterine prolapse

A

1st - cervix drops down into vagina, descend of uterus to above hymen

2nd - uterine descent to level of hymen

3rd - cervix completely exited vagina, can be felt on outside

4th - both cervix + uterus outwith vagina

159
Q

Explain the Sacrospinous fixation for treatment of prolapse

A

Sutures placed in sacrospinous ligament (medial to ischial spine) to repair cervical/vault descend

Performed vaginally

Risk of injury to pudendal NVB and sciatic nerve

160
Q

Explain the trans-obturator approach for incontinence surgery

A

Approach through obturator foramen

Feed mesh through obturator canal (space in obturator foramen for passage of obturator NVB)

Create sling around urethra

Incisions through vagina + Groin

161
Q

Name the ligaments of the lateral pelvic wall labelled below:

A

A - Obturator Membrane

B - Sacrospinous ligament

C - Sacrotuberous ligament

162
Q

Name the points of the lateral pelvic wall:

A

A - Obturator internus (LR of hip)

B - Coccygeus

C - Piriformis (LR of hip)

D - Levator ani

163
Q

Name the points of the lateral pelvic wall labelled:

A

A - Obturator Canal

B - Sacral Plexus

C - Tendinous arch of levator ani (thickened fascia lying over obturator internus)

D - Levator Ani

164
Q

Where do the majority of arteries of pelvis + perineum arise from and what are the main exceptions?

A

Internal Iliac artery

Exceptions - Gonadal artery (L2 abdominal aorta), Superior Rectal artery (IMA)

165
Q

Nae these major arteries of the pelvis and perineum

A

A - Gonadal artery (L2 abdominal aorta - supply testes/ovary)

B - Abdominal aorta

C - Inferior Mesenteric artery

D - Superior Rectal artery (supply rectum)

E - External Iliac

F - Internal Iliac

166
Q

How are the sections of the internal iliac artery separated?

A

Anterior Division - visceral

Posterior Division - parietal

167
Q

Name the arteries of the male labelled A, B, C and the divisions lavelled D and E?

A

A - Common Iliac

B - Internal Iliac

C - Gluteal arteries

D - Anterior division

E - Posterior division

168
Q

Name the arteries of the anterior division labelled A, B, C, D and E.

Also explain how artery C differs in females

A

A - Obturator artery (into obturator canal)

B - Internal Pudendal artery

C - Superior + Inferior Vesical arteries

D - Middle Rectal artery

E - Prostatic branch of Inferior Vesical artery

Some texts state females don’t have an inferior vesical artery (equivalent in females = vaginal artery)

169
Q

Name the arteries of the male pelvis labelled A, B, C, D and E.

A

A - Obturator artery

B - Medial Umbilical Ligament (remnant of umbilical artery - connects internal iliac to placenta)

C - Superior + Inferior Vesical Arteries

D - Gluteal arteries

E - Internal Pudendal artery

170
Q

Name the aspects of the internal abdominal wall labelled.

A

A - Lateral Umbilical Fold (inferior epigastric vessels)

B - Medial Umbilical Fold (remnant of umbilical artery)

C - Median Umbilical Fold (urachus)

171
Q

Name the arteries of the male perineum labelled.

A

A - Dorsal artery of penis (supplies corpus spongiosum)

B - Deep Artery (supplies corpus cavernosum)

C - Internal Pudendal artery

D - Perineal artery

E - Posterior scrotal artery

F - Anterior scrotal artery (from external iliac)

172
Q

What is the origin arterial supply to the male perineum?

A

Most branches from Internal Pudendal (from internal iliac, terminates as dorsal artery + deep artery of penis)

Exception = Anterior Scrotal Artery (comes from external iliac)

173
Q

Name the arteries of the female pelvis labelled A, B, C and the divisions labelled D and E.

A

A - Internal Iliac artery

B - Gluteal arteries

C - Obturator artery

D - Anterior divison

E - Posterior division

174
Q

Name the arteries of the the female pelvis A, B, C and D.

Which surgical procedure is artery A important to identify?

A

A - Uterine Artery

B - Internal Pudendal Artery

C - Middle Rectal artery (superior rectal off IMA)

D - Vaginal artery (branch of uterine artery, inferior vesical artery in males)

Artery A relevant for hysterectomy + ligation

175
Q

Name the arteries of the female pelvis labelled A, B, C, D and E.

A

A - Obturator artery

B - Medial umbilical ligament (remnant of umbilical artery)

C - Superior Vesical arteries

D - Uterine artery

E - Vaginal artery

176
Q

What are the two most important anastamosis of the female reproductive system?

A
  1. Between Uterine artery and Ovarian artery

Ovarian artery has tubal + ovarian branch which moves towards uterus and anastamoses with uterine artery

  1. Between Uterine artery and Vaginal artery

Vaginal artery comes off uterine artery and then anastamoses with it again around superior aspect of vagina

Inferior aspect of vagina - inferior pudendal artery branches anastamose with vaginal artery

177
Q

Name the arteries labelled A, B, C, D and E.

A

A - Ovarian artery

B - Tubal branch

C - Ovarian branch

D - Uterine artery

E - Vaginal artery

178
Q

Name the arteries labelled A, B, C and D.

A

A - Internal Iliac artery

B - Uterine artery

C - Vaginal artery

D - Internal pudendal artery

179
Q

What is the anatomical relation between the Ureter and Uterine artery in women?

A

‘Water under the Bridge’

Ureter passes directly underneath uterine artery

Relevant for ligation of uterine artery in Hysterectomy (ureter damage assoc. with hysterectomy)

180
Q

Name the arteries of the female perineum labelled below.

A

A - Dorsal artery of clitoris

B - Internal Pudendal artery

C - Inferior Rectal Artery

D - Perineal artery

E - Labial artery (of internal pudendal/internal iliac)

F - Labial artery (of external iliac)

181
Q

True or False:

The venous drainage of the pelvis is mainly into External iliac vein

A

FALSE

Drains mainly to Internal iliac vein

Some drain into hepatic portal system via superior rectal vein

Some drain via Lateral Sacral veins into Internal Vertebral venous plexus

182
Q

While venous drainage in the pelvis mainly drains into internal iliac vein, what are two other some blood will drain to?

A

Hepatic Portal system - via superior rectal vein,

Internal Vertebral Venous Plexus - via Lateral sacral veins (pre-sacral sits in middle), risks with infection/cancer spread

183
Q

Name the labelled nerves of the lateral wall of the pelvis.

A

A - Obturator nerve

B - Sciatic nerve

C - Pudendal

D - Nerve to Levator ani

E - Sacral plexus

F - Pelvic splanchnic nerves (parasym.)

184
Q

Which lymph node are labelled here?

A

A - Sacral

B - Internal Iliac

C - External Iliac

D - Deep Inguinal

E - Pararectal

185
Q

Which lymph node are labelled here?

A

A - Lumbar

B - Inferior Mesenteric

C - Common iliac

D - Deep Inguinal

E - Superficial Inguinal

186
Q

What is the lymphatic drainage route for the following:

Superior Pelvic Viscera

Inferior Pelvic Viscera

Superficial Perineum

A
  1. External iliac nodes > common iliac > aortic > thoracic duct > venous system
  2. Deep perineum > internal iliac nodes > common iliac > aortic > thoracic duct > venous system
  3. Superficial inguinal nodes
187
Q

What is Trans-peritoneal spread?

A

Disease can penetrate through peritoneal layer (acts as a barrier normally until penetrated) and disseminate into the peritoneal cavity

Y3 Medicine (8 decks)

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