SDR Lab Flashcards
Piriformis innervation
L5, S1, S2
Piriformis inserts on the ___ and originates from the ___
greater trochanter anterior surface of the sacrum
Obturator internus originates and inserts
originates: obturator membrane inserts: greater trochanter
Obturator innervated by:
L5, S1
Levator ani origination and insertion
originates: pubic bone to iischial spine, creating a tendinous arch Inserts: perineal membrane and the anaococcygeal ligament
Levator ani innervation
S2-4; S4 and inferior rectal branch of the pudendal nerve
Coccygeus muscle origination and insertion
Originates on ischial spine and sacrospinous ligament Inserts: lateral margin of the coccyx and sacrum
Coccygeus muscle innervation
S3, S4
What lies in the ischial anal fossa
fat, pudendal nerve, internal pudendal vessels
Ischiocavernosus origin and insertion
Origin: ischial tuberosity and rami Insertion: crus of penis
Bulbosphongiosum origin and insertion
origin: perineal body and midline raphe insertion: pernieal membrane and corpus carvernosum
Superficial transverse perineal muscle origin and insertion
Origin: ischial tuberosity and ramus Insert: perineal body
Deep perineal pouch is between
UGD and perineal membrane
What is in the deep perineal pouch in males?
- membranous urethra 2. External urethral sphincter 3. Deep transverse perineal muscle 4. Bulbourethral glands 5. Internal pudendal vessels 6. Dorsal nerve of penis
Colle’s Fascia blends ___ attaches ___
blends campers and Scarpas attches to the perineal membrane and ischiopubic rami
Rectum begins at what point of the vertebra?
S3
Rectum vessels
Superior Middle Inferior rectal artery
Rectum lymph
pararectal internal iliac nodes
Nerves of rectum
Top 1/2 = autonomic afferent bottom 1/2 = inferior hypogastric plexuses
Median umbilical ligament is a remnant of
urachus
Where do the ureters cross things?
- ANTERIOR to bifurcation of common iliac 2. Ductus deferens
How does the bladder connect to the umbilicus?
median umbilical ligament (remnant of the urachus)
Bladder blood supply
Vesical arteries from the internal iliac
Bladder lymph
internal and external iliac nodes
Bladder nerves
inferior hypogastric plexuses
Urethra from bladder to prostate (and opening)
1cm, (internal urethral sphincter)
Urethra prostate length
3-4 cm
Where is the external urethral sphincter?
On the membranous urethra at the deep pouch
Where is the spongy urethra?
With the corpus spongiosum and connects the bulbourethral glands
Prostate arteries
inferior vesical middle rectal
Prostate veins
Prostatic venous plexus to internal iliac
Prostate nerves
Inferior hypogastric plexuses
What do the bulbourethral glands do?
Lubricats the urethra and contributes to the pre-ejaculatory emissions (duct passes thru the perineal membrane to open into the bulb of the spongy urethra)
Internal Iliac origination point
L5 and S1
Anterior Trunk branches
Inferior gluteal Middle Rectal Obturator Inferior vesical/vaginal Internal pudendal Umbilical Uterine Deferential
Inferior vesical artery feeds
bladder ureter seminal vesicles prostate
Obturator artery feeds
thru obturator cannal feeds adductor region not the obturator internus (that’s by internal pudendal)
lympathics from the internal and external iliac run
to common iliac to lateral aortic to thoracic duct
How does the ovary to the back of the broad ligament?
by the mesovarium
Ovary blood
ovarian artery from the abdominal aorta
Ovary lympoh
para-aortic nodes
Ovary nerves
aortic plexus
Fallopian tubes/uterine tubes blood supply?
ovarian and uterine arteries
uterus blood
uterine artery from internal iliac
nerve supply of uterus
inferior hypogastric plexus
lymph of uterus
para-aortic nodes internal and external iliac nodes superficial inguinal nodes
vagina arterial supply
vaginal and uterine arteries from the internal iliac
vagina nerves
inferior hypogastric plexus
vagina lymph
upper 1/3: internal and external iliac mid 1/3: internal iliac lower 1/3: superficial inguinal nodes
What 5 things support the uterus?
- Pelvic diaphragm 2. perineal body 3. cardinal ligament 4. pubocervical ligament 5. sacrocervical ligament
Where does the cardinal ligament attach?
cervix and upper vagina to the lateral pelvic wall
Where does the pubocervical ligament attach?
cervix to the pubic bone
Where does the sacrocervical ligament attach?
cervix and vagina to the lower end of the sacrum
What does the mesoalphinx cover?
The fallopian/uterine tube
What are the parts of the broad ligament?
Mesometrium Mesoalphinx Mesovarium
Where is the uterine artery
courses medially and anteriorly in the base of the broad ligament to reach the cervix Crosses the ureter and passes superiorly to the lateral vaginal fornix Enlarges in pregnancy
Superior gluteal from
from: L4-S1
Superior gluteal to:
gluteus medius, gluteus minimus, tensor fascia latae
Inferior gluteal from
L5-S2
Inferior gluteal to
gluteus maximus
Posterior femoral cutaenous nerve from
S1, S3
Posterior femoral cutaenous nerve to
skin of the posterior aspect of the thigh
Perforating cutaneous from
S2,S3
Perforating cutaneous to
skin over gluteal fold
Nerve to piriformis from
L5, S1, S2
Nerves to levator ani, coccygeus, and external anal sphincter from
S4
Coccygeal plexus from
S4 to coccyx
Coccygeal plexus to
perianal skin
adnexa
uterine tubes and ovaries
Anteversion
whole uterus makes a right angle or angle greater than 90 compared to the vagina
Anteflexion
fundus pears a forward angle relative to the servix
Speculum exam:
speculum placed into the vaginal vault to assess the walls of the vagina and external surface of the cervix then take pap smaer for cervical aner
Cystocele
bladder protrudes into the anterior aspects of the vagina
Descensus fo the cervix and uterus
cervix and uterus “fall” thru the vagina = protrusion
enterocele
peritonum protrusion between the rectum and vagina result of herniation of pouch of douglas due to weakening of rectovaginal septum and uterosacral ligament
rectocele
rectum protrudes into posterior aspect of vagina
urethrocele
urethra protrusion into vagina
hysterosalpinogram
radiolgic study to evaluate the uterus and oviducts
bicornuate uterus
mullerian duct anomaly in utero
incompetent cervix
dialtion of the cervix during pregnancy
sonoohistogram
ultrasound and inected water to evaluate abnormal bleeding, fibroids, or polyps
Ectopic pregnancy can cause
hemorrage and maternal death
ectopic pregnancy risk factors
pelvic infection (gonorrhea and chlamydia) surgical history previous ectopic pregnancy
Ectopic pregnancy symptoms
amenorrhea minor vainal bleeding kpelvic pain + hCG exam
Fix ectopic pregnancy by
- methotrexane If not: salpingECtomy (surgical itervention to remove it and the uterine tube) SalpingOStomy removes ectopic but leaves the tubes (though high risk for another ectopic pregnancy)
Adenomyosis
occurence of bleeding associated with ectopic endometrial tissue within the myometrium
Places to watch to not damage ureter
Uretovesicular junction Junction uterine artery and ureter Infundibulopelvic ligament
Where does the dorsal aorta terminate?
L4
Uterine artery divides into
tortuous ascending branch (in the broad ligament anastamoses with the ovarian) descending branch arcuate
Post-partum hemorrhage
30# of deaths in pregnancy > 500cc vaginally >1000cc C section hematocrit drop by >10%
Intervention for post-partum hemorrhage
IV hydration uterine massage drugs to contract uterus: Pitocin then bimanual uterine compressions to compress the uterus Then uterine artery ligation (O’Leary Suture) with the broad ligament or internal iliac artery ligation last: hysterectomy
Uterine fibroids (leiomyomas)
benign tumors of smooth muscle can cause bleeding, pain, urinary frequency, sometimes abdominal enlargement
4 places for stone from ureter
- Ureteropelvic junction (UPJ) 2. ureter corsses the external iliac artery 3. ureter crosses into the pelvis (pelvic brim) 4. Ureter unters the bladder (UVJ)
Treatments of Ureteral Calculus
epectant management extracorporeal shock wave lithotripsy (ESWL) Ureteroscopy with laser lithrotripsy Ureteroscopy with basket extraction sten placement uretolithomy
Expectant management
watch if pass if < 9mm
Extracorporeal Shock Wve Lithotripsy (ESWL)
non invasive sound/shock waves to break the stones into dust good for higher in kidney/upper ureter
Uteroscopy with laser lithotripsy
most common zap the stone into dust
Uteroscopy with basket extraction
pull out stone with a basket small stones only otherwise ureter damage
stent placemnt
dilate ureter and releave pain “double J”
Ureterolithotomy
open surgery
Teardrop bladder can be caused by
blood compression from both sides puboprostatic and pubourethral ligament torn
suprapubic cystomy
catheter is inserted just above the pubic bone intot he bladder and urine is drained
immediate or delayed repair of urethral injuries better?
delayed
Intra vs Extra peritoneal ruptures
Intra: operate immediately in the peritoneal Etra: usually don’t require surgery but can drain fluid
prostate cancer risk factors
family history diet (not proven) androgens ethnicity (AA) Age
Transrectal ultrasound
insert an ultrasound probe up the rectum to help visualize the prostate
Prostate cancer grading scale
Gleason Grading Higher score = more cancer Top 2 most common cell types, add #s Prostate cancer lowest core = 6
Treatments for Prostate Cancer (8)
Watchful waiting Radical prostatectomy External beam radiation therapy (EBRT) Brachytherapy Cyberknife Cyrosurgery High intensitivy focused ultrasound Hormonal therapy
Cyberknife
robotic radiation tool that zaps the tumor higher radiation doses
cyrosurgery
freeze cencerous cell but can’t freeze around urethra 100% impotence
Hormonal therapy
anti-androgen
Radical Prostatectomy types
Perineal Retropubic Laparoscopic (8hrs) Laparoscopic w/Robotic Assistance (2hrs)
Perineal:
old-fashioned (as is retropubic) incision right under the scrotum in the perineum
Radical prostatectomy complications
incontenence (5%) impotence (25-100%) - nerves for erection very small but try nerve-sparing prostatectomy
Urologic robic procedures include
radical prostatectomy simple prostaectomy for benign masses radical cystectomy partial nephrectomy UPJ obstruction bladder diverticulectomy
