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Anatomy > 10 - pelvic viscera > Flashcards

10 - pelvic viscera Flashcards

1
Q

branches of aorta that supply pelvis and perineum and what they supply

A
  1. ovarian a.: paired arteries off the abdominal aorta, supply ovaries and fundus of uterus (anastomoses with uterine and vaginal aa)
  2. IMA - superior rectal a.: unpaired a. off the IMA to the rectum (and upper anal canal)
  3. Median sacral a.: unpaired artery off the distal aorta (anastomoses with lateral sacral and iliolumbar aa.)
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2
Q

location where aorta bifurcates

A

L4

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3
Q

location where common iliacs divide into internal and external iliac aa.

A

L5/S1

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4
Q

branches of common iliac artery that supply pelvis and perineum and what they supply

A

EXTERNAL ILIAC ARTERY:
1. External pudendal a. - branch of the femoral a.; supplies some skin of the perineum (aberrant obturator a.- if obturator a. comes off the inferior epigastric a.)

INTERNAL ILIAC ARTERY- MAJORITY OF BLOOD TO PELVIS & PERINEUM
Note: gender differences in the branches of the internal iliac artery: males have an Inferior vesical artery; females have uterine and vaginal arteries)

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5
Q

venous drainage of the pelvis and perineum

A

venous plexuses
internal iliac veins
external pudendal vein
external iliac vein

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6
Q

location where internal and external iliac vv. unite to form common iliac vein

A

L5/S1

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7
Q

location where union of common iliac veins into IVC occur

A

L4/L5

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8
Q

Branches of internal iliac artery (broad terms)

A
  1. branches to lower limb
  2. parietal branches
  3. visceral branches
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9
Q

branches of internal iliac a. that supply lower limb:

A
  1. Superior Gluteal a. (through greater sciatic foramen superior to piriformis m.)
  2. Inferior gluteal a. (through greater sciatic foramen inferior to piriformis m.)
  3. Obturator a. (Through obturator canal to medial compartment of thigh; may come from inferior epigastric a.)
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10
Q

parietal branches (from internal iliac a.)

A
  1. Iliolumbar: usually first branch off posterior aspect of Internal iliac a., ascends to supply iliacus, psoas major & quadratus lumborum
  2. Lateral Sacral (often multiple): descends on anterior aspect of sacrum to supply piriformis and the ventral rami
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11
Q

visceral branches (from internal iliac a.)

A
  1. Umbilical a.
    - -Superior vesical aa. (to superior aspect of bladder)
  2. Inferior Vesical a. (males only) To inferior aspect of bladder and male internal genitalia
  3. Middle Rectal a.
  4. Vaginal a. (females only, homologue to inf. vesical a.) also supplies inferior aspect of bladder
  5. Uterine a. (females only)
  6. Internal pudendal a. (travels in pudendal canal with pudendal n.)
    - -inferior rectal a. (to anal triangle)
    - -Branches to superficial and deep perineal pouches (in urogenital triangle)
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12
Q

lymphatic capillaries that drain the abdomen, pelvis, perineum, and lower extremities

A

-tend to follow blood vessels and ligaments and pass through small clusters of lymph nodes located on viscera or at bifurcations of vessels before draining into larger groups of nodes along major vessels. -Generally, if you know the blood supply to a structure, then you will also understand its lymphatic drainage

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13
Q

where does lymph of the rectum and upper portion of anal canal drain

A

intestinal trunk

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14
Q

where does lymph of pelvic/perineal structures (not rectum and upper portion of anal canal) drain?

A

left or right lumbar trunks along with lymph from lower limb

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15
Q

lymphatic pathway from rectum and anal canal

A
  • Rectum & Superior portion of anal canal drains via the inf. Mesenteric nodes to the intestinal trunk. Some lymph from the
  • midportion of the anal canal may drain deeply to the internal iliac nodes
  • Inferior anal lymph drains to the superficial inguinal nodes
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16
Q

lymphatic pathway of uterus

A
  • Fundus near uterine tubes - along round ligament of uterus to the superficial inguinal nodes
  • Rest of Uterus drains to the paraaortic nodes via the internal and external iliac nodes
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17
Q

lymphatic pathway of ovaries

A

travel along ovarian vessels directly to para-aortic nodes

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18
Q

lymphatic pathway of testes

A

-follows testicular vessels directly to para-aortic nodes. (Note: skin of scrotum drains to superficial inguinal nodes)

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19
Q

lymphatic pathway of the vagina

A
  • Superior & Middle lymphatics accompany the uterine & vaginal arteries to internal iliac nodes.
  • Vestibule drains mainly to superficial inguinal nodes (inferiormost one-quarter; same region receives somatic innervation from a branch of the pudendal nerve and blood supply/drainage from branches of the internal pudendal vessels)
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20
Q

lymphatic pathway of the prostate

A

-drains to the lymph nodes around the internal and common iliac arteries to reach the para-aortic nodes.

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21
Q

lymphatic pathway of erectile tissues

A

lymph from erectile tissues and perineal spaces drains deeply (to either external or internal iliac nodes)

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22
Q

superficial lymph from the perineum

A
  • tends to drain first to the superficial inguinal nodes (then through the external iliac nodes …).
  • Of all the abdominopelvic/ perineal nodes, these are the only ones that are superficial enough to be palpated on a patient.
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23
Q

lymph nodes in the pelvis and metastasis

A

highly interconnected, therefore, lymphatic drainage & metastatic cancer can pass in almost any direction
to any pelvic or abdominal organ.

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24
Q

cisterna chyli

A
  • located on the bodies of L1 and L2 vertebrae between the aorta and right diaphragmatic crus.
  • receives lymph from intestinal trunk and right and left lumbar trunks
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25
Q

intestinal trunk

A

drains lymph from pre-aortic nodes that lie on the abdominal aorta surrounding the origins of the Celiac, SMA, IMA.

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26
Q

right and left lumbar trunks

A

drain lymph from para-aortic (a.k.a. lateral aortic) nodes lying on either side of the abdominal aorta. These trunks receive lymphatics from all NON-gut derived structures inferior to the diaphragm

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27
Q

where do superficial inguinal nodes receive lymph from?

A
  • a portion of the uterine fundus (by the round ligament)
  • the distal portions of the vagina
  • the distal portions of the anal canal -the scrotum and labia.
  • Skin of the perineum
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28
Q

peritoneum in the pelvis

A
  • the peritoneum of the abdominopelvic cavity covers the superior surfaces of the pelvic viscera, therefore, most pelvic viscera are considered subperitoneal
  • of all the pelvic viscera, only the uterine tubes are completely covered by peritoneum, have a mesentery (part of the broad ligament of the uterus), and are considered to be intraperitoneal (a misnomer, as they are not derived from the gut tube)
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29
Q

location of empty, adult bladder

A

-located entirely within lesser pelvis. It is the most anteriorly positioned of the pelvic viscera, lying just posterior to the pubic symphysis

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30
Q

composition of bladder walls

A
  • composed mainly of the detrusor muscle (smooth muscle fibres).
  • Some of these smooth muscle fibres, located in the neck of the bladder, form the internal urethral sphincter
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31
Q

main parts of the bladder

A
  • apex (points toward superior end of pubic
    symphysis)
  • fundus (opposite apex, convex posterior wall)
  • body (between apex and fundus)
  • base (smooth-walled portion of posterior surface; shaped like an inverted triangle, the Trigone: defined by two ureteric openings and the internal urethral orifice)
  • neck (inferior)
32
Q

neck of the bladder

A
  • leads to the urethra
  • sits on prostate gland (in males)
  • Contains an internal urethral sphincter
    (smooth m.)
  • Stabilized by the pubovesical ligament in
    females and by the puboprostatic ligament in males
33
Q

urethra

A

muscular tube that conveys urine to the external urethral orifice. In both males and females, the urethra begins at the internal urethral orifice in the neck of the bladder where it is surrounded by the smooth m. internal urethral sphincter (much better developed in males)

34
Q

female urethra

A

-4-5 cm long and ends at the external urethral orifice located in the vestibule of the vagina, anterior to the vaginal orifice

35
Q

components of male urethra

A
  • 18-22cm long (ish) and the external urethral orifice is in the glans penis
  • the male urethra is subdivided into 4 parts:
    1. Preprostatic: contained within neck of bladder; surrounded by internal urethral sphincter
    2. Prostatic: widest part, where the ejaculatory ducts & prostatic ducts both open
    3. Intermediate/ membranous: passes through the deep perineal pouch; surrounded by external urethral sphincter
    4. Spongy: passes through the corpus spongiosum; bulbourethral glands drain here
36
Q

blood supply of bladder

A
  • Primary blood supply is from the superior vesicle arteries (off the umbilical a.). The posteroinferior aspect of the bladder receives blood from the inferior vesical a. in males and the vaginal a. in females.
  • Venous drainage is via the vesical plexus which drains to the internal iliac v. or internal vertebral plexus (via the lateral sacral v.)
37
Q

lymphatic drainage of bladder

A

-Lymph from the bladder goes primarily to the internal iliac nodes, however, some lymph from superolateral aspect travels to the external iliac nodes

38
Q

inferior vesicle a.

A

-supplies parts of bladder and ureters as well as the seminal vesical, prostate and ductus deferens

39
Q

vaginal a.

A

-usually gives branches to the inferior aspect of the female bladder

40
Q

vas deferens

A
  • 18 inches long
  • transports sperm from the epididymis & testis to the ejaculatory duct of the urethra.
  • begins at the tail of the epididymis, travels in the spermatic cord through the inguinal canal, then crosses the ureter to reach the posterior aspect of bladder.
  • At distal end, it becomes dilated to form an ampulla, then narrows to join the duct of the seminal vesicle, here forming the ejaculatory duct
41
Q

seminal vessicles

A
  • A highly coiled tubular gland, the secretions of the seminal vesicles contribute nutrients to the liquid portion of semen.
  • The walls of the seminal vesicles contract during ejaculation and their secretory product is released into the ejaculatory duct.
42
Q

bulbourethral (Cowper’s) glands

A

-These small glands located in the deep perineal pouch of males also contribute to semen (they drain into the spongy portion of the urethra)

43
Q

features of the prostate

A
  • secretions play a role in the activation of sperm -situated inferior to the neck of the bladder
  • the apex of the gland, which points inferiorly, is supported inferiorly by the muscles of the deep perineal space
  • The base of the gland is closely related to the neck of the bladder
  • The ejaculatory ducts pierce the posterior surface of the prostate and open into the prostatic urethra.
44
Q

Lobes of the prostate

A

• Anterior/Isthmus (anterior to urethra;
fibromuscular)
• (Infero)posterior (post. To urethra & inf. To
ejaculatory ducts)
• Right & Left Lateral (lateral to urethra)
• Middle (between urethra and ejaculatory ducts,
primary source of benign hypertrophy of the prostate - BHP)

45
Q

blood supply of male internal genital organs

A

-Venous drainage is via the prostatic plexus which drains to either the internal iliac v. or internal vertebral plexus via the lateral sacral v

46
Q

lymphatic drainage of male internal genital organs

A
  • Lymph drains to the lymph nodes around the internal and common iliac arteries to reach the para-aortic nodes.
  • Carcinoma of the prostate spreads by both hematogenous and lymphatic routes. The tumor spreads through the pelvic lymphatics to the lymph nodes around the internal and common iliac arteries and the aorta (para-aortic nodes). Hematogenous spread via the pelvic veins occurs late in the disease and produces systemic metastases. Generally, prostatic carcinoma shows a tendency to cause bony metastases because there are many connections between the prostatic venous plexus and the internal vertebral veins.
47
Q

vagina

A
  • musculomembranous tube between vestibule and cervix
  • The vaginal fornix is a recess within the superior end of the vagina, around the inferior end of the cervix. It has anterior,
    posterior and lateral parts. The posterior fornix is the deepest.
  • Anteriorly, the vagina is related to the urethra and bladder. Posteriorly it is related to the anal canal, rectum and
    rectouterine pouch
48
Q

uterus parts and position

A

parts:
-body (with its rounded fundus)
-Isthmus (constriction)
-cervix, inferior third of uterus which extends into the upper part of the vagina. The cervical canal opens into the
vagina at the external os and into the uterus at the internal os

normal position is anteflexed (uterine body is bent anteriorly relative to the axis of the cervix) and anteverted (the cervix
is tipped anteriorly relative to the axis of the vagina)

49
Q

uterine tube parts

A
  1. infundibulum, with it’s fimbriae that capture ovulated gametes
  2. ampulla: the widest and longest part, where fertilization typically occurs 3. isthmus: thick-walled part
  3. uterine (intramural) part that passes through the wall of the uterus
50
Q

ovaries

A
  • female gonads
  • Embryological gubernaculum is divided into 2 by the uterus:
    1. (Proper) ovarian ligament (between ovary & lateral angle of the uterus)
    2. Round ligament of the uterus (between uterus and labium majus - through the inguinal canal)
51
Q

peritoneum on the uterus

A

-The peritoneum hangs over the ovarian vessels creating the suspensory ligament of the ovary

52
Q

broad ligaments

A
  • consist of double folds of peritoneum that extend from the lateral wall of the pelvis to enclose the uterus, uterine tubes and ovaries. They are divided into three parts:
    1. Mesometrium: major part of the broad ligament, inferior to the mesosalpinx and mesovarium
    2. Mesosalpinx: mesentery of the uterine tube
    3. Mesovarium: mesentery of the ovaries
53
Q

stabilization of the uterus

A

stabilised by condensations of the pelvic fascia that form ligaments. The pelvic fascia is connective tissue that occupies the space inferior to the peritoneum and within the muscular pelvic walls and floor. It is an inferior continuation of the transversalis fascia that lines the abdominal wall.

54
Q

pubocervical ligament

A
  • pelvic fascia

- between cervix and pubis

55
Q

uterosacral ligamtent

A
  • pelvic fascia

- between cervix and sacrum

56
Q

transverse cervical (cardinal) ligament

A
  • pelvic fascia

- between cervix and lateral pelvic walls.

57
Q

blood supply to female internal genitalia

A
  • Uterine a. - direct branch off the internal iliac. Courses in the base of the broad ligament, OVER the ureters, to reach the cervix. Major blood supply to the uterus and anastomoses with the ovarian a. (from abdominal aorta) and the vaginal a.
  • Ovarian a. - direct branch off the abdominal aorta. Creates a fold of peritoneum called the suspensory ligament of the ovary. Supplies the ovaries and the fundus of the uterus.
  • Vaginal a. -either a direct branch off the internal iliac or a branch off the uterine a. Supplies parts of vagina and often gives off an artery to the inferior aspect of the bladder
  • Internal pudendal a. - supplies the most inferior part of the vagina
58
Q

lymphatic drainage of the female internal genitalia

A

Lymphatics of uterus:
-Fundus near uterine tubes - along round ligament of uterus to the superficial inguinal nodes
Lymph from the remainder of the Uterus and the ovaries drains deeply.

Lymphatics from the vagina:
-The Vestibule & the inferiormost one-quarter of the vagina (same region that receives somatic innervation from a branch of the pudendal nerve and blood supply/drainage from branches of the internal pudendal vessels) also drains to the superficial inguinal nodes Lymph from the remainder of the vagina drains deeply.

59
Q

rectum

A
  • begins at vertebral level S3 as a continuation of the Sigmoid Colon (rectosigmoid junction)
  • The appendices epiploicae (bags o’ fat) & teniae coli (longitudinal bands of smooth muscle on the colon) both end at the rectosigmoid junction.
  • The rectum dilates at the rectal ampulla, just superior to the pelvic diaphragm.
  • The rectum ends at the level of the pelvic diaphragm where it becomes continuous with the anal canal at the anorectal flexure (80° bend).
60
Q

blood supply of rectum and anal canal

A
  • Superior rectal a./v. - from/to IMA/IMV (portal) (terminate inside the anal columns, supplies region above pectinate line)
  • Middle rectal a./v. - from/to Internal iliac a./v. (caval) (anastomose with both superior and inferior rectal vessels)
  • Inferior rectal a./v. - from/to Internal pudendal a./v. (caval) (supplies region below pectinate line)
61
Q

lymphatic drainage of rectum and anal canal

A
  • Inferior anal lymph drains to the superficial inguinal nodes
  • More superior anal lymph drains deeply to the internal iliac nodes
  • Rectum (and superior 2/3 of the anal canal) drains to the Inferior mesenteric nodes and the intestinal trunk
62
Q

Lumbosacral plexus

A
  • L1-S4
  • Pelvic portions of the lumbosacral plexus include only ventral rami of L4-S4. The connection between the lumbar plexus and sacral plexus is formed by the lumbosacral trunk (L4-L5)
  • several branches destined to innervate structures of lower limb, pelvic, and perineal structures
63
Q

branches of lumbosacral plexus that innervate lower limb structures

A
  • Obturator n. (arises in the posterior abdominal wall, travels through the pelvis and then enters the lower limb by passing through the obturator canal with the obturator vessels)
  • Superior gluteal n., inferior gluteal n., sciatic n., n. to quadratus femoris, posterior femoral cutaneous n. (all of these nerves arise from the sacral plexus and exit the pelvis through the greater sciatic foramen to reach the gluteal region)
64
Q

branches of lumbosacral plexus that innervate pelvic and perineal structures

A
  • N. to piriformis
  • N. to obturator internus
  • N. to levator ani
  • N. to coccygeus
  • Pudendal n. (THE nerve of the perineum, also assists in the innervation of levator ani). 2 nerves from this are:
    1. Inferior rectal n.
    2. Perineal nn.
65
Q

coccygeal plexus

A
  • S4-Co1

- cutaneous nerves of the anal triangle and part of the perineum

66
Q

Presynaptic sympathetics

A

-destined for pelvic and perineal structures originate in lumbar and sacral regions of the sympathetic chain in lumbar & sacral splanchnic nerves (which are examples of abdominopelvic splanchnic nerves, with presynaptic neurons in the lateral horn of spinal cord segments T10-L2) and synapse on prevertebral ganglia (inferior mesenteric, hypogastric)

67
Q

1st few lumbar splanchnic nerves

A
  • upper portion of lumbar trunks - synapse in the Inferior mesenteric ganglion - supply hindgut viscera (goes to rectum and upper portion of anal canal in the pelvis & perineum)
  • GVE innervation
68
Q

lower lumbar splanchnic and sacral splanchnic nerves

A
  • lower lumbar & sacral portions of trunks -synapse in hypogastric ganglia (Superior & Inferior) - supply remaining pelvic structures & the perineum
  • GVE innervation
69
Q

arasympathetics

A

Presynaptic PARASYMPATHETIC cell bodies destined for all pelvic viscera (including the hindgut derived rectum and upper portion of the anal canal) are located in the lateral horn of S2-S4 spinal cord segments. The processes of these neuronal cell bodies arise from S2-S4 ventral rami as pelvic splanchnic nerves. These axons pass through hypogastric plexuses and mostly travel to their target organs with the sympathetics (except in the case of hindgut viscera)

70
Q

GVEs functions

A
  • Contract smooth muscle sphincters of the urethra and anal canal
  • Contract smooth muscles of vas deferens (peristalsis)
  • Causes ejaculation
71
Q

GVEp functions

A
  • Relax internal sphincters of the urethra and anal canal (by counteracting the sympathetics)
  • Stimulate contraction of rectum
  • Stimulate bladder contraction (detrusor muscle)
  • Stimulate contraction of smooth muscles in the urethra
  • Stimulate erection (by counteracting the sympathetics which are constricting the vessels in the erectile tissues). This is produced by the cavernous nerves which are the only parasympathetic nerves that extend outside of the body cavities.
72
Q

superior and inferior hypogastric plexuses

A
  • receive their presynaptic parasympathetic fibres from cell bodies that lie in the lateral horns of spinal cord segments S2-S4
  • send their fibres to the plexus via Pelvic Splanchnic Nerves.
73
Q

subsidiary plexuses of inferior hypogastric plexus

A
  • lie on their target organs:
  • Rectal plexus
  • Uterovaginal plexus
  • Prostatic plexus
  • –Cavernous nerves
  • Vesical plexus
74
Q

visceral pain from gut derived viscera until the pelvic pain line

A
  • GVA
  • travels back to the CNS on the sympathetic pathway to reach cell bodies in the dorsal root ganglia between T5 & L2
  • More superior viscera have GVA neurons in more cranial segments of the spinal cord
75
Q

visceral pain from gut derived viscera inferior to pelvic pain line

A

travels back on the parasympathetic pathway to reach cell bodies in the dorsal root ganglia between S2 & S4.

76
Q

pelvic pain line

A

determined by the inferior limit of the peritoneum across the pelvis EXCEPT IN THE CASE OF THE ALIMENTARY CANAL, where it occurs in the middle of the sigmoid colon. The portion of pelvic viscera in contact with peritoneum will have pain that follows the sympathetic pathway. The portion of the organ below the peritoneum (subperitoneal) will have pain that follows the parasympathetic pathway back to the spinal nerve, these GVA axons will diverge from the GVE pathway at the spinal nerve to reach their cell body in the dorsal root ganglion.

Anatomy (8 decks)

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