Pelvic Viscera

Question 1

Describe the vaginal fornices and what can be palpated.

Answer 1

Anterior fornix: posterior bladder wall
Lateral fornices: oviduct, ureters, ovaries
Posterior fornix *visceral peritoneum: palpate the uterus and access the rectouterine pouch.

Question 2

Describe the two ligaments associated with the ovaries and the three ligaments supporting the uterus.

Answer 2

Ovaries:

1. the proper ovarian ligament - attaches the ovaries to the uterus
2. the suspensory ligament of the ovaries - remnant of the caudal genital ligament, elevated by containing the ovarian artery and vein

Uterus:

1. Round ligament
2. Uterosacral ligament
3. Transverse cervical ligament - cardinal

Question 3

Describe lymphatic drainage of the pelvic viscera

Answer 3

Most of them are following the origin of the blood vessels to the internal iliac arteries and would drain into internal iliac lymph nodes.

The exception is the ovaries which would drain into aortic lymph nodes since the gonadal arteries come right off of the aorta.

Question 4

Describe sympathetic and parasympathetic innervation of the pelvic viscera.

Answer 4

Sympathetic:
Cell bodies are in the lateral horns of L1-L2 > preganglionic axons travel out the ventral root > spinal nerve > ventral rami> white communicans > through the paravertebral > lumbar splanchnics into the prevertebral> descend to the 1. Superior mesenteric plexus 2. Inferior mesenteric plexus 3. Inferior hypogastric plexus
> from there, postganglionic either follows blood vessels OR leaves the inferior hypogastric plexus and synapse directly on smooth muscle

Parasympathetic:
Cell bodies are located in the ventral horn of S2, S3, S4 > ventral rami > pelvic splanchnics> 1. Inferior hypogastric plexus OR 2. Wall of the viscera they innervate.

Question 5

Describe visceral afferent nerves and the pelvic pain line.

Answer 5

Although for most of the body, sympathetics carry pain afferents and parasympathetic carries reflex, in the pelvic both sympathetic and parasympathetic carries pain fibers.

Above the pelvic pain line: fundus and body of the uterus, uterine tubes, ovaries
Sympathetic: visceral pain will travel via hypogastric plexus to T11-L2. This is why uterine contractions manifest as lower back pain.

Below the pelvic pain line: cervix, upper vagina, bladder
Parasympathetic: travel with pelvic splanchnic nerves to the S2-S4 spinal cord levels.

Question 6

Describe the sympathetic autonomic structures

Answer 6

Lumbar splanchnics carry preganglionic sympathetic fibers from levels T11-L2 to the preaortic ganglia, also contain visceral afferents

Intermesenteric plexus - contains post and preganglionic sympathetic nerve fibers running between prearotic ganglia, ends at the bifurcation of the aorta and becomes the superior hypogastric plexus

Superior hypogastric plexus - contains pre-and postganglionic sympathetic fibers from the intermesenteric plexus. Also has visceral afferent fibers passing through it. NO SYNAPSES

Right and Left hypogastric nerves - carries pre and postganglionic sympathetic fibers from the superior hypogastric plexus down into the pelvis, also carry visceral afferent fibers

Inferior hypogastric plexuses - contain cell bodies of postganglionic sympathetic neurons, preganglionic sympathetics synapse here and postganglionic fibers travel with branches of the internal iliac artery.

This plexus contains - pre and postganglionic sympathetic nerves,
Pre and postganglionic parasympathetic nerves, and visceral afferents.

Question 7

Three types of hysterectomy.

Answer 7

Radical: uterus, upper portion of vagina is removed

Total: fibroids and noncancerous, you leave the fallopian tubes and ovaries in tact so hormones are being made, cut the uterus, remove the cervix and seal the anterior vaginal opening. Then place peritoneum over it.

Partial: cervix is left, this allows you to leave the support structures in tact. Ovaries and fallopian tubes are intact.

Question 8

Describe the rectum and its blood supply.

Answer 8

Superior rectal artery: continuation of the inferior mesenteric artery.
The venous drains back into the portal vein.

Middle rectal artery: branch off the internal iliac, when it drains, it will go into the caval system.

Inferior rectal: also branch of internal iliac so it also drains into caval system.

Question 9

What is the innervation of the rectum?

Answer 9

Peristalsis of the rectum is the caused by parasympathetics.

The motor signal is going through the pelvic splanchnic nerves to the rectal plexus.

Question 10

Describe the male reproductive tract in detail.

How is the urethra divided.

• erection is parasympathetic
• ejaculation is sympathetic -seems like there is more control for it so makes more sense.

Answer 10

Urethra::::::::::::
Right below the bladder is the prostate. The urethral opening in the bladder is the preprostatic portion of the urethra.—–
—-The urethra going through the prostate is the prostatic portion–
—–Membranous portion is the short segment of urethra going through the Urogenital diaphragm.——
—The spongy portion is after that and is the longest portion of the urethra.—–

Vas deferens (ductus deferens): derivative of the mesonephric duct. It joins the coiled seminal vesicle at the short segment called the ejaculatory duct which opens directly into the prostatic portion of the urethra. 
------before the sperm enter the ejaculatory duct, it hangs out in the ampulla of the vas deferens-------the seminal vesicles produce most of the volume of the ejaculate and primarily fructose which maintains the sperm while in the ampulla 

In the prostatic portion of the urethra is also the PROSTATIC SINUS - little holes where fluid from the prostate can also enter
-there is also an elevation called the SEMINAL Colliculus which is the remnant of the paramesonephric duct.

Once everything enters the prostatic urethra, there is no going back

Question 11

Describe the male pelvic blood supply

Answer 11

The inferior vesical artery - a branch of the internal illiac artery supplies the bladder, vas deferens, prostate and seminal vesicles.

The internal pudendal comes off just distal to that artery and supplies - they are the main blood supply to the perineurium, sending branches to the erectile tissue, superfifical and deep pouches, and anal canal.

Venous drainage from the perineum is from the internal pudendal vein which as a branch of the internal iliac will drain into IVC.

Erectile bodies go through the deep dorsal vein, through a little opening below the pubic bone into the prostatic venous plexus which will ultimately go into the iliac and then IVC.

Question 12

What is benign prostatic hyperplasia?

what are the zones and significance?

Answer 12

Its a thickening of the TRANSITIONAL zone of the prostate which will narrow the prostatic urethra resulting in difficulty urinating.

Transitional zone - 5% of prostatic volume
-site of BPH
10% of cancers

central zone - is intermediate for volume and least for cancer

Peripheral is 70% of volume and 80% region of all prostatic cancers.

Question 13

Describe prostate cancer and prostatectomy

Answer 13

Its an adenocarcinoma which is a very slow growing cancer.

Symptoms are like benign prostate

Question 14

What is the neurovascular organization of the pelvis from lateral to medial

Answer 14

Lateral to medial, concentric layers of:

Somatic nerve

Vessels

Autonomic nerves.

Question 15

Describe pevlic autonomics (their function)

Answer 15

Sympathetic

• peristalsis of the male reproductive tract *only peristalsis that is sympathetically innervated)
• contraction of smooth muscle sphincters (internal urethral sphincter so bladder can fill)
• convey pain above the pelvic pain line

Parasympathetic

• peristalsis of rectum
• contraction of detrusor muscles
• inhibit smooth muscle sphincters (anal)
• convey pain below the pelvic pain line.

Question 16

Where would uterine pain be felt?

Where would ovarian pain be felt?

Where would cervical pain be felt?

Answer 16

Both are sympathetics.

Visceral afferents…

Uterine: are lumbar splanchnic nerves

Ovarian are up the ovarian plexus (postganglionic ONLY) thoracic splanchnics

Uterine: T11-L1 - suprapubic - hypogastric

Ovarian: T10/T11 dermatome - umbilicus

Cervix is below the line so its parasympathetics, will go through pelvic splanchnics. S2 dermatome

Question 17

Describe the vagina structure, blood supply and innervation

Answer 17

The vaginal apex is at the level of the ischial spine.

The vaginal space is between the labia minora and is where the urethral meatus and vagina open to.

Vagina has two blood supplies, both off the internal iliac artery.

Pelvic vagina - vaginal artery
Perineal vagina - internal pudendal artery

Innervation is also two different kinds (autonomics and somatic)
Pelvic vagina: (autonomic) Uterovaginal plexus and pain through pelvic splanchnics
Perineal vagina: (somatic) pudendal nerve (S2,S3,S4), pain is also via pudendals)

Question 18

Describe the structure of the uterus

Blood supply

Sensation?

Answer 18

3 layers

1. endometrium
2. Myometrium: muscular layer
3. perimetrium: covered by peritonium (broad ligament)

Its normally anteflexed and anteverted. When the bladder fills, it will become more retroflexed.

It has a fundus, body and cervix. Body is where implantation occurs. The lower uterine segment is what is used for cessarian.
The cervix can be subdivided into cervicouterine junction, internal os, canal, external os.

Cervix is surrounded by a pericervical ring which is what the cardinal attaches to. Also uterosacral ligaments.

Blood supply:

• –suspensory ligament (which goes through the infundibulum) supplies the ovaries) and continues to become the proper ovarian ligament which connects ovary to body of uterus and from there become the round ligament.
• —uterine artery coming off of the vaginal artery which supplies the pelvic vagina, it is coiled and runs within the cardinal ligament. It expects the uterus to expand.

Water under the bridge (bridge is the uterine artery), under is the ureter.

Sensation: body and fundus is above the pelvic pain line
-cervix is below the pelvic pain line.