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Anatomy - pelvis and perineum


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Ala of sacrum
Wings articulating with ilium at sacroiliac joint
What enters pelvis at sacroiliac joint
Obturator nerve and lumbosacral trunk
Sacral promontory
Anterosuperior aspect, connected to L5 through lumbosacral joint
Coxal bones
Ilium, ischium, pubis
-Tubercle --> lateral aspect of iliac crest
-Greater and lesser sciatic notches
-Ischial spine
-Ischial tuberosity --> posterior, what we sit on
Ischiopubic rami
location of urogenital diaphragm
form subpubic angle
Sacrotuberous ligament
Between sacrum and ischial tuberosity
Greater sciatic foramen
Formed both by sacrotuberous and sacrospinous ligaments
-piriformis muscle goes through greater sciatic foramen to femur
Sacrospinous ligament
Between sacrum and ischial spine
-anterior to sacrotuberous ligament
Pathway of pudendal canal
Passes out the greater sciatic foramen, over the ischial spine, and back into lesser sciatic foramen, to travel on medial aspect of ischial ramus
Orientation of pelvis
It is tilted forward so that ASIS and pubic tubercle are on the same frontal plane
Genital hiatus
Hole in the pelvic diaphragm, where there is no muscle, just fascia.It overlies superior part of urogenital diaphragm. Urethra and vagina go through it
Levator ani muscles
Attach to tendinous arch of levator ani
Function of puborectal sling
It creates an angle between the rectum and anal canal, which allows you to retain fecal matter. The angle is almost 90, and the anal canal points down and posteriorly
Is ureter located in abdomen or pelvis
Upper half of ureter in abdomen, lower part in pelvis
Abdominal part is retroperitoneal
Relation of ureters
Male - relation to ductus deferens
Female - relation to uterine artery
Describe pathway of ureters
Ureters pierce posterolateral edge of bladder and run obliquely through muscular wall of bladder
Blood supply of ureters
Arteries supplying ureters arise from renal, gonadal, common and internal iliac, visceral and uterine
A lot of variation, many anastomose
Innervation of ureters
Ureteric nerves are derived from renal, aortic, superior and inferior hypogastric plexuses (T10-L1), both sympathetic and parasympathetic
Lymphatics of ureters
from upper part may join renal vessels, aortic nodes (lumbar), common, internal or external iliac
Describe bladder
Bladder is muscular sac for urine storage, approximately pyramid shaped.
Appearance of bladder depends on contents and surrounding viscera
Average bladder can be approached over pubic symphysis
Parts of bladder
Superior surface
Two inferolateral surfaces
Stabilization of bladder
Neck of bladder is held in place by ligaments, thickenings of endopelvic fascia, posteriorly held by rectovesical ligaments
-Median umbilical ligament attaches bladder to umbilicus
-There are also folds of peritoneum that serve to steady bladder (false ligaments)
Internal structure of bladder
Internal mucous layer is loosely attached to muscular layer - can fold when contracted. Over the trigone mucous layer is tightly bound and is always smooth.
What is muscular coat of bladder
Detrusor muscle, has 3 layers- external and internal longitudinal layers and middle circular layer
Internal urethral sphincter is derived from
middle circular layer
Which innervation contracts bladder
Blood supply of bladder
superior and inferior vesical - male
vaginal - female
Venous supply of bladder
Follow accompanying arteries and contribute to vesical venous plexus and prostatic venous plexus
Lymphatics of bladder
drain to external and internal iliac nodes
Male urethra has 4 parts. Name them
2.Prostatic - widest, most dilatable, has ejaculatory and prostatic ducts
3. Membranous - surrounded by sphincter urethra
4. Spongy - within corpus spongiosum, receives openings of bulbourethral glands
Blood supply of male urethra
Inferior vesical
Middle rectal
Internal pudendal
Describe female urethra
Female urethra is much shorter then male. It courses from bladder anterior to anterior wall of vagina and opens directly anterior to vagina and posterior to clitoris
Which glands empty to terminal portion of female urethra
Where does ductus deferens go through
Inguinal canal to deep inguinal ring to back side of prostate and bladder
Ductus deferens is directly continuous with
In pelvis ductus deferens
is covered with peritoneum
Posterior to bladder ductus deferens
crosses over ureter, lies between bladder and rectum
Seminal vesicles
Single coiled tube
-Proximal end of tube is constricted, straight duct that joins ductus deferens to form ejaculatory duct
-provides bulk of volume to semen
Blood supply of seminal vesicles
Inferior vesical
Middle rectal
Ejaculatory ducts
Commence at base of prostate and courses between median and right lobe
Terminates by opening on seminal colliculus
Describe prostate
Partly glandular and partly fibromuscular, secretions make up 20% of semen volume
-It is situated between neck of bladder and urogenital diaphragm, conical in shape
Parts of prostate
Base - adjacent to bladder
Apex - inferior
Lobes - anterior, posterior, lateral (R + L), middle
Prostatic sheath
derived from pelvic fascia and is continuous with puboprostatic ligaments, has prostatic veins
Important is stopping spread of cancer
Name features of posterior wall of prostatic urethra
Urethral crest - crest extends down from trigone
Seminal colliculus- large bump in middle, has prostatic utricle and openings of ejaculatory ducts
Prostatic sinus - openings of prostatic ducts
Prostatic utricle is a remnant of
Age changes in prostate
At age 45-50 prostate may undergo benign hypertrophy, resulting in blockage of urine flow. Median lobe can act as valve - more pressure more completely urethra is blocked
Prostate cancer is diaagnosed by
PSA blood test and/or palpation through rectum
Blood supply of prostate
Inferior vesical
Internal pudendal
Middle rectal
Venous supply of prostate
Prostatic venous plexus
communicates with vesicular plexus and internal vertebral plexus
Lymph of prostate
Internal iliac and sacral nodes
Bulbourethral glands
Two small, round glands situated within deep perineal pouch. Duct of each gland penetrates perineal membrane and passes obliquely forwards to spongy urethra
Lowest point of peritoneum in males
rectovesical space
Pararectal fossa
depressions in pelvic floor, just lateral to rectum
Where is ovary located
True pelvis, ovarian fossa
What holds in place ovary
Ovarian ligament
Suspensory ligament
Ovarian fossa boundaries
Anterior - obliterated umbilical artery
Posterior - ureter and external iliac artery
Blood supply ovaries
Ovarian artery
Ovarian veins empty into
Right - vena cava
Left - renal vein
Ovary lymph drains to
Lumbar nodes
Uterine tubes
Hollow tubes that open to peritoneal cavity and empty into uterus, convey oocyte toward uterus and sperm towards oocyte
Uterine tubes have 4 parts . What are they
Infundibulum - part with fimbriae
Uterine portion
Fertilization occurs at
ampulla of uterine tubes
Three layers of uterine tube
Serosa, muscle and epithelium
Part of broad ligament attached to uterine tube is called
Blood supply of uterine tubes
Ovarian + uterine arteries
Lymph drainage of uterine tubes
Lumbar nodes
Why does peritonitis occur more often in females
Due in large part to continuity of vagina/uterus with abdominal cavity
Ectopic pregnancy
Implantation outside of uterus
Hollow, thick muscular organ that allows implantation of fertilized oocyte and provides nourishment for developing embryo
Uterus is shaped like inverted pear and contained entirely in pelvis.
In old age atrophies
Uterus has 4 parts - what are they
Fundus - top rounded part, lies above opening of uterine tubes
Body - movable part above internal os of cervix, between layers of peritoneum, anterior part is in contact with urinary bladder, posterior part is in contact with rectum
Isthmus - between body and cervix
Cervix - part that surrounds internal openign
External os of cervix opens in
anterior wall of vagina
Lateral side of cervix
Normal position of uterus
Wall of uterus consists of 3 layers
Perimetrium - peritoneum + thin layer of areolar tissue
Myometrium - most of substance of uterus
Endometrium - nutritional layer, epithelium
Endometrium in areas other then uterus
Homologues of gubernaculum
Round ligament
Ovarian ligament
Ligaments that hold uterus in place
Transverse cervical and uterosacral
Structures most important in uterine support
Levator ani
Urogenital diaphragm
Other pelvic organs
Uterine ligaments
Blood supply of uterus
Mostly uterine artery with some of vaginal and ovarian
Venous drainage of uterus
Uterine plexus --> internal iliac veins
Lymphatic drainage of uterus
Fundus - drains to lumbar and external iliac
Body - external iliac
Cervix - internal iliac and sacral
Regions where uterine tubes joins uterus has lymphatic drainage following roung ligament and drains to superficial inguinal nodes
Innervation of uterus
Uterovaginal plexus
parasympathetic - S2-S4
sympathetic - T12 - L2
2 parts of broad ligament
Mesosalpinx and mesovarium
Collapsed fibromuscular tube that extends from cervix to vestibule
4 muscles serve as vaginal sphincters
1. Pubovaginalis
2. External urethral sphincter
3. Urethrovaginal sphincter
4. Bulbospongiosus
Blood supply of vagina
Uterine and vaginal
Venous drainage of vagina
internal iliac
Lymphatic drainage of vagina
Upper 2/3 drain into internal and external iliac
Lower 1/3 drains to superficial inguinal
Innervation of vagina
Upper 2/3 - visceral innervation
Lower 1/3 - somatic innervation
Continuous with sigmoid colon at level of S2, indicated by lower end of sigmoid mesocolon
Continuous with anal canal by passing through pelvic diaphragm
Rectum differs from descending colon
1. Haustra
2. Mesentery
3. Epiploic appendages
4. Ampulla
5. Teniae coli
What is the name of position for examination of perineum
Lithotomy position
Transverse line divides pelvis into two parts - what are they
Urogenital and anal triangle
Urogenital triangle contains
bulb of penis
scrotum in male
vestibule, vaginal + urethral orifices in female
Urogenital diaphragm
Sits in urogenital triangle
Strengthens genital hiatus
Homologous structure of penis

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