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Anatomy Flashcards

1
Q

what are the functions of the bony pelvis

A

supports upper body when sitting and standing
transfer weight from vertebral column to the femurs to allow standing/ walking
attachment for muscles of locomotion and abdominal wall
attachment for external genitalia
protection of pelvic structures
passage of childbirth

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2
Q

what makes up the bony pelvis

A

2 hop bones
sacrum
coccyx

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3
Q

what makes up the pelvic girdle

A

sacrum

2 hip bones

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4
Q

what bones make up the hip bones

A

ilium
ischium
pubis

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5
Q

is the coccyx part of the pelvic girdle

A

no

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6
Q

what ages do the hip bones fuse

A

ischium and pubis fuse at 8

ilium doesn’t fuses with the other bones until 20s

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7
Q

what muscle sits in the iliac fossa

A

iliacus

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8
Q

what is the ischiopubic ramus

A

where the ischium and pubis fuse

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9
Q

what creates (bone boundaries) the pelvic inlet

A

sacral promontory (prominent part of sacrum as it goes into the inlet)
ilium
superior pubis ramus
pubic symphysis

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10
Q

what are the boundaries of the pelvic outlet

A 
pubic symphysis 
ischiopubic ramus 
ischial tuberosities 
sacrotuberous ligaments 
coccyx
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11
Q

what is the pelvic brim

A

bony edge of the pelvic inlet

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12
Q

what divides the pelvic cavity and the abdominal cavity

A

nothing they are continuous

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13
Q

what divides the pelvis and the perineum

A

the pelvic floor

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14
Q

what are the palpable landmarks of the pelvis

A 
pubic symphysis 
pubic tubercle 
ASIS
iliac crest 
sacrum 
coccyx 
ischial tuberosity PSIS 
ischial sines (on vaginal exam, approx 4 and 8 o'clock positions)
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15
Q

where do inguinal ligaments attach

A

between the ASIS and the pubic tubercle

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16
Q

what type of joint is the hip joint

A

synovial

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17
Q

what type of joint is the pubic symphysis

A

secondary cartilaginous

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18
Q

what type of joint is the SI joint

A

anterior aspect is synovial

posterior is a syndesmosis (fibrous ligaments)

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19
Q

what does the sacrospinous ligament attach between

A

sacrum and ischial spine

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20
Q

what does the sacrotuberous ligament attach between

A

sacrum and ischial tuberosity

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21
Q

what is the role of the sacrotuberous and sacrospinous ligaments

A

ensure the inferior part of the sacrum is not pushed superiorly when weight is suddenly transferred vertically through the vertebral column (jumping/ late pregnancy)

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22
Q

what do the sacrotuberous and sacrospinous ligaments form

A

greater and lesser sciatic foraminae

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23
Q

what notches form the sciatic foraminae

A

greater and lesser sciatic notches

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24
Q

what forms the obturator canal

A

obturator foramen and obturator membrane

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25
Q

what passes through the obturator canal

A

obturator nerve and vessels

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26
Q

what do fractures of the bony pelvis tend to involve

A

fractures in more than one place
joint dislocation
nerve/ vessel damage (life threatening haemorrhage)
damage to pelvic organs

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27
Q

how is the female pelvis different to the males

A

subpubic angle (and pubic arch) is wider
pelvic cavity shallower
AP (anterior posterior) and transverse diameters larger at both pelvic inlet and outlet
coccyx less curved - more room in pelvic outlet
males is heart shaped, females pelvic cavity more circular
males have more narrow sciatic notch

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28
Q

what is moulding

A

the movement of skull bones over one another to allow the foetal head to pass through the pelvis during labour

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29
Q

what allows moulding

A

presence of sutures and fontanelles

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30
Q

what are the fontanelles

A

anterior and posterior fonatelles (softs spots in skulls)

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31
Q

what is the vertex

A

area of the foetal skull- diamond shape from anterior, posterior fontanelles and the parietal eminences

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32
Q

is the occipitofrontal or biparietal diameter long in the foetal skull

A

occipitofrontal (foetal head is longer than it is wide)

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33
Q

why is the vertex important

A

as enables you to tell the position on the babies head in the womb

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34
Q

which diameter of the pelvis is wider

A

at pelvic inlet transverse is wider than AP

at outlet the AP diameter is wider than transverse

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35
Q

what is the orientations of the foetal head during childbirth

A

should enter pelvic cavity facing (transverse) right/ left direction
when descending through cavity head should rotate to OA (occipitoanterior) and be in flexed position (chin on chest)
should leave cavity (outlet) in OA position
in delivery head should be in extension

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36
Q

what is the station

A

the distance of the foetal head from the ischial spines = -ve number means head is superior, +ve number means head inferior

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37
Q

what rotation occurs after head is delivered

A

turned transversely and pulled down to delivery right shoulder, then up to deliver left

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38
Q

what vessels can haemorrhage in pelvic trauma

A

common iliac artery and vein

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39
Q

what nerves can be damaged in pelvic trauma

A

lumbo sacral plexus

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40
Q

what nerve block are is marked by the ischial spines

A

pudendal

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41
Q

describe the path of the pudendal nerve

A

goes medial to ischial spine, leaves via greater sciatic foramen then comes back into pelvis via lesser sciatic foramen, winding under sacrospinous ligament

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42
Q

what structures does the pudendal nerve innervate

A

levator ani

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43
Q

what levels does the pudendal nerve originate from

A

L2,3,4

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44
Q

when does the anterior fontanelle close

A

18 months- 2 years

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45
Q

what does a sunken/ raised fontanelle mean

A 
sunken= dehydrated
raised= high ICP, hydrocephalus
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46
Q

what is anterior shoulder dystonia

A

when babies shoulder is stuck behind pubic symphysis

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47
Q

what organs are in the female pelvic cavity

A

ovaries, uterine tubes, uterus, superior part of vagina

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48
Q

what is the only true/primary organ of reproduction in females

A

ovaries

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49
Q

what does the levator ani muscle divide

A

the perineum and the pelvic cavity

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50
Q

what does the inferior part of the pareital perineum form

A
  • floor of peritoneal cavity

- roof over pelvic organs- covers superior aspect of organs

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51
Q

what are the two pouches in females

A

vesico-uterine (utero-vesico)

recto-uterine (pouch of Douglas)- deepest

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52
Q

how can a fluid collection in Pouch of Douglas can be drained

A

via a needle passed through the posterior fornix of the vagina

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53
Q

what is the peritoneum

A

very thin serous membrane layer that completely covers internal aspect of abdomen. Touching organs visceral, touching body wall parietal

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54
Q

what pouch do males have

A

rectovesicle

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55
Q

which pelvic organs are not subperitoneal

A

uterine tubes- these are intra peritoneal (within broad ligament)

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56
Q

what is the broad ligament

A

double layer of peritoneum that extends between the uterus and the lateral walls and floor of the pelvis

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57
Q

what is the role of the broad ligament

A

helps maintain the uterus in its correct midline position

contains the uterine tubes and the proximal part of the round ligament

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58
Q

are the fimbrae within the broad ligament

A

no open into peritoneal cavity

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59
Q

what is the round ligament

A

an embryological remnant of the gubernaculum -guides ovaries/testes down from abdo wall into final position

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60
Q

what is the path of the round ligament

A

attaches to the lateral aspect of the uterus
passes through the deep inguinal ring to attach to the superficial tissue of the female perineum
proximal part within the broad ligament

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61
Q

what is in the inguinal canal in females

A

round ligament of uterus

ilioinguinal nerve

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62
Q

what are the layers of the uterus body

A

perimetrium (outer layer)
myometrium (muscle layer - cramps and stretching)
endometrium (sheds during menstrual cycle)

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63
Q

what is an ectopic pregancy

A

implantation of a zygotes outwith the body of the uterus

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64
Q

where do most ectopic pregnancies occur

A

in the fallopian tubes

can occur in ovaries or abdomen

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65
Q

what is the risk at 8 weeks in ectopic pregnancies

A

rupture of fallopian tube

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66
Q

what holds the uterus in position

A

strong ligaments - uterosacral
endopelvic fascia
muscles of the pelvic floor - levator ani

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67
Q

what does the uterosacral fascia run between

A

cervix and sacrum

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68
Q

what is a uterine prolapse

A

movement of the uterus inferiorly

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69
Q

what is the most common position of the uterus

A

anteverted and anteflexed
-anterverted= cervix tipped anteriorly relative to the axis of the vagina
anteflexed= uterus tipper anteriorly relative to the axis of the cervix (mass of uterus lies over the bladder)

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70
Q

when does the uterus rise outwith the pelvic bones

A

12 weeks gestation

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71
Q

what is normal variation of the uterus position

A

retroverted and retoflexed

retroverted= cervix tipped posteriorly relative to the axis of the vagina 
retroflexed= uterus tipped posteriorly relative to the axis of the cervix
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72
Q

what zone must be sampled in a cervical smear

A

the squamo columnar junction (transformation zone)

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73
Q

where does fertilisation take place

A

in the ampulla

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74
Q

what is a bilateral salpingo-oophrectomy

A

removal of both uterine tubes and ovaries

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75
Q

what is a unilateral salpigectomy

A

removal of one of the uterine tubes

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76
Q

how can PID cause peritonitis

A

as fimbrae are communication between genital tract and peritoneal cavity

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77
Q

is a hysterosalpingogram what does radiopaque dye within the peritoneal cavity suggest

A

uterine tube is patent

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78
Q

how big are the ovaries

A

almond sized

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79
Q

what hormones do the ovaries secrete

A 
oestrogen (FSH stimulated)
and progetserone (LH stimulated)
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80
Q

where do the ovaries develop

A

on posterior abdominal wall

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81
Q

where are ovaries

A

ovarian fossa, on lateral walls of pelvic cavity

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82
Q

why is a speculum needed for a smear test

A

as vaginal walls usually in contact

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83
Q

what is a fornix

A

space around cervix, formed as cervix holds superior aspect of vagina apart

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84
Q

what are the four parts of the fornix

A

anterior, posterior and 2x lateral

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85
Q

what can be palpates on vaginal digital exam

A 
ischial spines (4 and 8 o clock positions) 
position of the uterus (e.g. anteverted) 
adnexae (= uterine tubes and ovaries together) (place examining fingers into lateral fornix, press deeply with other hand in the iliac fossa on same side- can detect large masses/ tenderness)
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86
Q

what is the perineum

A

shallow space between the pelvic diaphragm (levator ani) and skin

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87
Q

what are the two triangles of the perineum

A

urogenital and anal

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88
Q

what are the parts of the levator ani muscle

A

skeletal (voluntary control, majority) and smooth (tonic and reflex contraction - increased intraabdominal pressure (sneezing, lifting heavy objects)_

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89
Q

what is the nerve supply to the levator ani

A

‘nerve to levator ani’

  • S3,4,5
  • dual supply form pudendal
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90
Q

what nerve supplys the perineal muscles

A

pudendal

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91
Q

what is the perineal body

A

bundle of collagenous and elastic tissue into which the perineal muscles attach
important for pelvic floor strength
locates just deep to skin

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92
Q

what are the bartholins glands

A

secrete mucous/ lubrication for anterior opening of vagina

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93
Q

what is the male version of bartholins glands

A

koupers gland

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94
Q

what type of tissue is erectile in females

A

clitoris and crura

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95
Q

where is the bed of breast tissue found

A

ribs 2-6
lateral border of sternum to mid axillary line
lie of deep fascia covering pec major and serratus anterior

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96
Q

what is the retro mammary space

A

lies between fascia and breast, allows breast to move independently of muscles

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97
Q

what attaches the breast to the skin

A

supsensory ligaments

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98
Q

what is within the breat

A

suspensory ligaments
fat
lactating and non lactating lobules
lactiferous ducts

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99
Q

what does a fixed mass in breast mean

A

has grown through to pectoral fascua

to assess whether fixed ask patient to place hands firmly on hips (contracts pec muscle)

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100
Q

what are the four quadrants of breast called

A

upper and lower inner

upper and lower outer

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101
Q

what quadrant is the axilary tail of breast in

A

upper outer

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102
Q

describe the lymph drainage of the breast

A

75% will drain to ipsilateral axillary lymph nodes then to supraclavicular nodes
lymph from inner quadrants can drain to the parasternal lymph nodes
lymph from lower inner can drain to abdominal lymph nodes

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103
Q

what can happen in axillary nodes removed in treatment of breast cancer

A

can get lymphedema as upper limb also drains to here

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104
Q

what is in the axilla

A

brachial plexus branches
axillary artery (& branches) and axillary vein (& tributaries)
axillary lymph nodes
all embedded in axillary fat

105
Q

what are the levels use of axillary nodes to describe the extent of “axillary node clearance”

A

all in relation to pec minor:
Level I – inferior and lateral to pectoralis minor

Level II – deep to pectoralis minor

Level III – superior and medial to pectoralis minor

106
Q

what is the blood supply to the breast

A

lateral thoracic and internal thoracic (aka internal mammary) from the subclavian and axillary

same venous drainage

107
Q

which nerve types supply structures in the pelvis

A

body cavity so sympathetic, parasympathetic and visceral afferent

108
Q

which nerve types supply structures in the perineum

A

body wall so somatic motor and sensory

109
Q

what innervation controls uterine contraction (cramping in menstruation and during labour)

A

hormonal- sympathetic and parasympathetic

110
Q

what innervation controls pelvic floor muscle contraction (e.g. during sneezing)

A

somatic motor

111
Q

what nerve type carries pain from adnexae (ovaries + fallopian tubes) and uterus

A

visceral afferents

112
Q

what nerve type carries pain from the vagina

A

visceral afferents (pelvic part) and somatic sensory (perineum)

113
Q

what nerve type carries pain from the perineum

A

somatic sensory

114
Q

how do sensory nerves from superior aspects of pelvic organs/ touching the peritoneum reach the CNS

what does the mean for pain perception

A

visceral afferents
run alongside sympathetic fibres
enter spinal cord between T11-L2

pain is perceived as suprapubic

115
Q

how do sensory nerves from the inferior aspect of pelvic organs / not touching peritoneum reach the CNS

what does the mean for pain perception

A

visceral afferents
run alongside parasympathetic fibres
enter spinal cord at levels S2,3,4

pain perceived in S2,3,4 dermatome (peritoneum)

116
Q

how do sensory nerves from Structures crossing from pelvis to perineum above levator ani (in the pelvis) reach the CNS

A

visceral afferents
parasympathetic
spinal cord levels S2, S3 and S4

117
Q

how do sensory nerves from Structures crossing from pelvis to perineum below levator ani (in the perineum) reach the CNS

A

somatic sensory
pudendal nerve
spinal cord levels S2, S3 and S4
localised pain within perineum

118
Q

what is the origin of the sympathetic nerves supplying the pelvis

A

Sacral sympathetic trunks
T11-L2
Superior hypogastric plexus

119
Q

what is the origin of the parasympathetic nerves supplying the pelvis

A

Sacral outflow (S2, 3, 4)
Pelvic splanchnic nerves
Emerge from spinal roots
Mixes with sympathetics in inferior hypogastric plexus

(splanchnic nerves are paired visceral nerves, carrying fibers of the autonomic nervous system (visceral efferent fibers) as well as sensory fibers from the organs (visceral afferent fibers). All carry sympathetic fibers except for the pelvic splanchnic nerves, which carry parasympathetic fibers)

120
Q

visceral afferents back to T11-L2 are from what in females

A

pelvic organs which touch the peritoneum:
uterine tubes
uterus
ovaries

121
Q

visceral afferents back to S2-S4 are from what in females

A

pelvic organs inferior to peritoneum:
cervix
superior vagina

122
Q

pudendal nerves back to S2-S4 are from what in females

A 
organs/structures within the perineum: 
inferior vagina 
perineal muscles 
glands
skin
123
Q

how do you tell whether pelvoc body cavity structures have autonomic or visceral afferent innervation

A

touching peritoneum?
yes= more superior= follows sympathetics back= T11-L2

no= more inferior= follows parasympathetics back= S2,3,4

124
Q

what levels does the spinal cord become the cauda equina

A

L2

125
Q

what level does the subarachnoid space end

A

S2

126
Q

what level is an epidural injected

A

L3-4 (L5) region (usually in line with most superior point on iliac crest (L4-5 space)

127
Q

what does the needle pass through in an epidural

A 
skin 
subcutaneous tissue
supraspinous ligament 
interspinous ligament 
ligamentum flavum 
epidural space (fat and veins)
128
Q

what level is a spinal anaesthetic done

A

L3/4

129
Q

what does the needle pass through in a spinal anaesthetic

A 
skin 
subcutaneous tissue 
supraspinous ligament 
interspinous ligament 
ligamentum flavum 
epidural space (fat and veins)
dura mater 
arachnoid mater 
subarachoidnoid space (contains CSF)
130
Q

where do sympathetic nerves exit the spinal cord

A

T1-L2

131
Q

what is the path of sympathetic nerves from spinal cord

A

exit T1-L2
Travel to sympathetic chains running the length of vertebral column
Pass into all spinal nerves (anterior and posterior rami / named nerves)

132
Q

what happens to sympathetic nerves below L2 level

A

sympathetic ganglia receive fibers from L2 level via the sympathetic chain and distribute them via connections with lumbar, sacral and coccygeal spinal nerves

133
Q

do the femoral, sciatic, obturator and pudendal nerves all have sympathetic fibres

A

yes- All spinal nerves and their named nerves contain sympathetic fibres

134
Q

are all arterioles supplied by sympathetic fibres

A

yes- provide sympathetic tone

135
Q

what does blockade of sympathetic tone to all arterioles in the lower limb cause

A

= Vasodilation

  • skin of lower limbs looks flushed
  • warm lower limbs
  • reduced sweating

(all these signs that spinal anaesthetic is working
can cause hypotension

136
Q

what supplies the somatic motor and sensory to the perineum

A

pudendal

137
Q

what is the pudendal nerve a branch of

A

sacral plexus S2,3,4

138
Q

what will a pudendal nerve block make numb

A

majority of perineum

139
Q

what is the path of the pudendal nerve

A

exits pelvis via greater sciatic foramen
passes posterior to the sacrospinous
ligament
re enters pelvis/ perineum via lesser sciatic foramen
travels in pudendal canal (passageway within obturator fascia) with internal pudendal artery and vein and nerve to obturator internus
branches to supply to perineum

140
Q

what can be used as a landmark in a pudendal nerve block

A

ischial spin can be use to find where it corsses the lateral aspect of the sacrospinous ligament

141
Q

when is a pudendal nerve block given

A

during labour- forceps delivery, painful vaginal delivery, episiotomy incision
perineal suturing post delivery- LA is injected along site of tear/ episiotomy to anaesthetise branches of pudenda;

142
Q

what can be damaged in vaginal delivery

A

branches of pudendal nerve fibres stretched
fibres within levator ani (puborectalis) or external anal sphincter can be torn which weaken the muscle (can be 1sr, 2nd or 3rd degree tears)
as a result= weak pelvic floor and faecal incontinence

143
Q

what is an episiotomy

A

posterolateral (or mediolateral but this puts anal sphincter at risk) incision made into relatively safe fat filled ischioanal fossa
this avoids the incision extending into the rectum

144
Q

what incision is made in a lower segment CS and an abdominal hysterectomy

A

suprapubic/ pfannenstiel/ bikini line incision

145
Q

what incision for a laparotomy

A

vertical midline

146
Q

what should you follow when making incisions if possible

A

langer lines

147
Q

what are the layers of the anterolateral abdo wall

A

skin
superficial fascia
(medial= rectus sheath, rectus adnominus)
(lateral= external and internal oblique then transversus abdominus)

148
Q

what are the attachments of the external obliques

A

lower ribs
iliac crest
pubic tubercle
linea alba

149
Q

what is the linea alba

A

midline blending of the aponeuroses

150
Q

what direction do the fibres of the external obliques run in

A

hand in pockets- same as external intercostals

151
Q

what are the attachments of the internal obliques

A

lower ribs
thoracolumbar fascia
iliac crest
linea alba

152
Q

what direction do the fibres of the internal obliques run in

A

hands on chest- same as internal intercostals

153
Q

what are the attachments of the transversus abdominis

A

lower ribs
thoracolumbar fascia
iliac crest
linea alba

154
Q

what direction do the fibres of the transversus abdominis run in

A

directly across

155
Q

what are the tendinous intersections of the rectus abdominis

A

divide each side into 3/4 smaller muscles

improves mechanical efficiency

156
Q

what does the linea alba attach to top and bottom

A

xiphoid process

pubic symphysis

157
Q

what is the rectus sheath

A

combined aponeuroses of anterolateral wall muscles that surrounds the rectus abdominis

158
Q

what must be done after the rectus sheath is cut

A

is stitched close (is a strong fibrous layer) to increase the strength of the wound and reduce risk of incisional hernias

159
Q

what part of rectus sheath is cut in a suprapubic incision

A

only anterior rectus sheath (not posterior)

160
Q

what nerves become the thoracoabdominal nerves

A

7th - 11th intercostal nerves

161
Q

what is the nerve supply to the anterolateral abdominal wall

A

7th-11th intercostal nerves -> thoracoabdominal nerves
subcostal (T12)
iliohypogastric (L1)
ilioinguinal (L1)

162
Q

where do the nerves that supply the anterolateral abdo wall travel

A

from lateral direction, in plane between internal oblique and transverse abdominis

163
Q

what is the blood supply to the anterior abdominal wall

A

superior epigastric arteries (continuation of internal thoracic): lies posterior to rctus abdominis
inferior epigastric arteries (branch of external iliac): lies posterior to rectus abdominis

164
Q

what is the blood supple to the lateral abdominal wall

A

intercostal and subcostal arteries

continuations of posterior intercostal arteries

165
Q

what is the best way to incise muscle

A 
incise in same direction as fibres to minimise traumatic injury 
avoid nerves (esp motor nerves)
avoid interrupting blood supply
166
Q

what is cut in a lower lower segment C section

A 
skin 
superficial fascia 
anterior rectus sheath- pulled apart in lateral direction (moving rectus abdominis towards their nerve supply) 
fascia 
peritoneum 
(retract bladder)
uterine wall 
amniotic sac
167
Q

what layers need to be stitched closed after a LSCS

A

skin
fascial layer if high BMI
rectus sheath
uterine wall with visceral peritoneum

168
Q

what layers to you go through in a laparotomy

A

skin
fascia
linea abla
peritoneum

169
Q

what layers need to be stitched closed after a laparotomy

A

peritoneum and linea alba
fascia (if high BMI)
skin

170
Q

midline incisions are relatively bloodless- what are the implications of this

A

healing may not be as good- increases wound complications (dehiscence, incisional hernia)

171
Q

what site is a laparoscopy done at

A

sub umbilical incision may be all that is required lateral port may be required

172
Q

what must be avoid in laparoscopy lateral ports

A

inferior epigastric artery

173
Q

in laparoscopy, how can the position of the uterus be manipulated to view pelvic organs bettter

A

grasping the cervix with forceps inserted through the vagina

174
Q

what is the path of the inferior epigastric artery

A

branch of external iliac
emerges medial to the deep inguinal ring (deep inguinal ring is halfway between asis and pubic tubercle)
then passes in a superomedial direction posterior to the rectus abdominus

175
Q

what is the difference between an abdominal and vaginal hysterectomy

A

abdo- removal of the uterus via an incision in the abdo wall (often same incision as for LSCS)

vaginal- removal of uterus via the vagina

176
Q

how do you differentiate the ureter from the uterine artery in a hysterectomy

A

uterer passes inferior to the artery (water under the bridge)
ureter will often vermiculate (involute) when touched

177
Q

what is the perineum

A

shallow space between levator ani and perineal skin

178
Q

what are the contents of the perineum

A 
distal ends of pelvic organs
external genitalia 
perineal muscles 
blood and nerve supply 
lymphatic drainage
179
Q

what passes through the levator ani muscle in men

A

rectum and urethra

180
Q

what are the functions of the levator ani muscle

A

forms roof of perineum and floor of pelvis

supports pelvic organs and assists in maintaining faecal and urinary continence

181
Q

what are the nerve roots of the pudendal nerve

A

S2,3,4

182
Q

what type of nerve fibres does the pudendal nerve contain

A 
somatic motor (to levator ani and muscles of the perineum)
somatic sensory (from the perineum) 
sympathetic (as in all other spinal nerves)
183
Q

what is contained within the ischioanal fossa

A

fat pad
pudendal canal (contains pudendal nerves and internal pudendal vessels)
inferior rectal branches of the pudendal nerve
lymphatics

184
Q

where is the ischioanal fossa

A

lateral to the anal canal

185
Q

why might a perianal abscess spread readily though the ischioanal fossa

A

as large space filled with fat and loose connective tissue

fat has poor blood supply and few immune cells- minimal barrier to spread of infection

186
Q

what type of tissue is the crura and bulbs

A

erectile

187
Q

what are the roles of the perineal muscles

A

males- assist in erection, ejaculation and in final part of micturition
females- assist in pelvic floor support

188
Q

what can be damage in hysterectomy during ligation of the uterine artery

A

ureter

189
Q

what is the path of sperm

A

seminiferous tubules, rete teste, epididymis, ductus (vas) deferens in spermatic cord, ejaculatory duct, prostatic urethra, membranous urethra, spongy urethra, external urethral meatus of penis

190
Q

what is the only pouch in males

A

rectovesical

191
Q

when a female is in anatomical position where will abnormal fluid collect

A

rectouterine (pouch of douglas)

192
Q

how can fluid from the pouch of douglas be drained

A

via a needle placed through the posterior fornix of the vagina

193
Q

name the structure formed by a double layer of peritoneum, extending between the uterus and the lateral pelvic walls and floor?

A

broad ligament

194
Q

what is the uterine round ligament a remnant of

A

the gubernaculum

195
Q

what is the role of the round ligament of the uterus

A

maintaining anteflexion of the uterus

196
Q

what is uterine prolapse

A

when the uterus descends into the vagina

197
Q

what can cause uterine prolapse

A

weakened pelvic support

increased intraabdominal pressure

198
Q

what is a cystocele

A

hernial protrusion of bladder into vaginal wall

199
Q

what is a rectocele

A

hernial protrusion of rectum into vaginal wall

200
Q

what is the role of of the external urethral sphincter

A

final control of urination

201
Q

what are the components of the fluid secreted by the seminal vesicles

A

proteins, enzymes, fructose, mucus, vitamin C, flavins, phosphorylcholine and prostaglandin

202
Q

what is the main function of the fluid secreted by the prostate gland

A

activating sperm

203
Q

what are the functions of the fluid/ mucus secreted by the bulbourethral (cowpers) glands

A

lubricates urethra and helps to neutralise acid in vagina

204
Q

what is contained in the spermatic cord

A

ductus (vas) deferens, testicular artery, venous drainage (pampiniform venous plexus), sympathetic
nerve fibres, genital branch of genitofemoral nerve and lymphatics

205
Q

what is the path of the vas deferens

A

begins at the tail of the epididymis, ascends through the scrotum posterior to the testis and medial to the epididymis, travels through the abdominal wall as part of the spermatic cord, crosses over the external iliac vessels to enter the pelvis, travels along the lateral wall of the pelvis and ends by joining the duct of the seminal gland to form the ejaculatory duct

206
Q

where is the occiput in brow presentations

A

occipito POSTERIOR - head is not flexed when in this position

207
Q

what way can a baby in the occiptio transverse position be rotated

A

to occipito anterior via manual rotation or using vaccum extraction/ kielland’s rotational forceps

208
Q

what are the degrees of perineal tears

A

1st- skin, superficial
2nd- into perineum posterior to vagina
3rd- into anal sphincter
4th- both sphincters and anal mucosa

209
Q

what is the posterior fourchette

A

small transverse fold just behind the vaginal opening where the labia minora meet each other

210
Q

why is the ischioanal fossa important in women

A

where posterolateral episiotomies are made

211
Q

what is the major structure incised in a medial episiotomy

A

perineal body

212
Q

what is the path of the pudendal nerve

A

emerges from the pelvis and courses through the gluteal region through the greater sciatic foramen, below the piriformis muscle. It then turns forward around the sacrospinous ligament and leaves the gluteal region through the lesser sciatic foramen (between sacrotuberous and sacrospinous ligaments).
It is then directed into the pudendal canal, which lies on the obturator fascia above the falciform ridge on the ischial tuberosity.
They pass forward in the fascial canal (Alcock’s) on obturator internus (lateral wall of ischio-anal fossa), with the nerve usually lying inferior to the artery.

213
Q

where is a needle inserted in a pudendal nerve block

A

palpate ischial spines vaginally
The pudendal nerve is immediately inferior to the tip of the spine and an anaesthetic needle may be passed through the vaginal wall, or through the overlying skin, aimed just below the ischial spine and at the pudendal nerve
As the fetus’s head is usually stationed within the lesser pelvis at this stage, it is important that the physician’s finger is always positioned between the needle tip and the baby’s head during the procedure.

214
Q

what is the motor and sensory innervation provided by the pudendal nerve

A

The pudendal nerve is the main motor innervation to the perineum, as well as providing sensory innervation to most of the skin of the perineum and the external genitalia. It provides innervation to the perineal muscles, the external anal sphincter and external urethral sphincter.

215
Q

are uterine contractions numbed by a pudendal nerve block

A

pudendal nerve block provides local anaesthesia over dermatomes S2–S4, which is the majority of the perineum, and the inferior quarter of the vagina. It does not block pain from the superior birth canal (uterine cervix and superior vagina), so the mother is able to feel uterine contractions.

216
Q

what fetal nerve injuries can occur during birth

A

The fetal skull has no mastoid processes. These will form at around 4 years, drawn out by sternocleidomastoid as the child lifts its head. At birth there is no protection for the facial nerve (VII) emerging from the stylomastoid foramen and it may be injured during forceps delivery.

If an arm is delivered first, pulling on that arm to speed delivery could drag it into forced abduction which may put undue traction on the lower trunk of the brachial plexus (C8 and T1). This could cause Klumpke’s palsy, loss of the function of all the small muscles of the hand. There would be clawing of all the fingers and sensory loss on the medial aspect of the upper limb.

If the head is delivered, but the baby is “stuck” by a shoulder, then pulling on the head, particularly at an angle, may force the shoulder and neck apart, putting undue traction on the upper trunk of the brachial plexus (C5 and 6). This could cause Erb’s or “Waiter’s Tip” palsy, where the arm is adducted and internally rotated at the shoulder and the elbow is extended and pronated. Sensory loss is to the lateral aspect of the upper limb

217
Q

what nerve injuries can be caused to the mother during birth

A

Keeping a patient in the lithotomy position for too long, with her legs and knees pressed hard up against side-supports, may cause neurapraxia of the common fibular (peroneal) nerve leading to a temporary foot-drop.

218
Q

what does the needle pass through in a spinal anaesthetic

A 
skin 
subcutaneous fat
supraspinous ligament 
interspinous ligament 
ligamentum flavum 
epidural space (fat and blood vessels) 
dura 
arachnoid mater
219
Q

what is the path of the needle in an epidural

A

inserted at L3/4 and passes through, or just to the side of the interspinous ligament, and through the ligamentum flavum to enter the epidural “space”. The anaesthetic spreads within the “space” to anaesthetise the emerging nerve roots

220
Q

what levels is a spinal anaesthetic done

A

L3/4

221
Q

where does the spinal cord end

A

L2

222
Q

what position is the patient in when getting a spinal anaesthetic

A

chin to chest to curve lumbar spine and increase intervertebral space

the top of the iliac crest should be palpated – the plane between the two superior aspects of the iliac crests passes through the spinous process of L4. After deep palpation, the dimple between the spinous processes is identified as the point to insert the needle.

223
Q

what are the potential side effects of a spinal anaesthetic

A

During a spinal anaesthetic an injection of local anaesthetic will mix with the CSF and rapidly block the nerve roots with which it comes in contact. It may be done for emergency Caesarean section. However, the spinal anaesthetic may cause post-spinal headache, and if it reaches the cervical cord in high enough concentration, may cause respiratory arrest.

224
Q

what are the potential side effects of an epidural anaesthetic

A

the anaesthetic must block T10 to L1 in the first stage of labour, but extend to include S2 to S5 in the second stage. Clearly, such a block may well cause temporary, neurological side effects in the bladder and in the lower limbs. The patient may need urinary catheterisation, and be unable to walk

225
Q

how long does a spinal anaesthetic take to work

A

10 mins

226
Q

why must you aspirate before injecting a pudendal nerve block

A

to make sure not injecting into pudendal vessels (can cause seizures, arrest, local LA toxicity)

227
Q

when is a spinal anaesthetic CI

A

obesity (morbid)
bleeding difficulties
infection
spinal surgery

228
Q

why is hypotension a risk of regional anaesthetics

A

causes vasodilation

229
Q

what are the three layers of the pelvic floor

A

pelvic diaphragm
muscles of perineal pouches (deep transverse perineal muscle, external urethral sphincter, compressor urethrae)
perineal membrane

230
Q

what is the pelvic diaphragm

A

deepest layers of pelvic floor

made of levator ani (mostly) and coccygeus

231
Q

what is the anterior gap between the medial borders of the pelvic diaphragm

A

urogenital hiatus= passage for urethra and vagina

232
Q

where does the levator ani attach

A

puborectalis- pubic bones to around anus
pubococcygeus- pubic bones, creates a midline raphe near coccyx, joins with tendinous arch of levator ani
ilio-coccygeus- ischial spine to midline also joints to fibrous arch

all of these attach to onto perineal body and organs in midline

233
Q

what is the fibrous arch of the levator ani

A

a thickened band of the fascia covering the inner aspect of the obturator internus muscle

234
Q

what are the three parts of the levator ani

A

Puborectalis
Pubococcygeus
Iliococcygeus

235
Q

what innervates the levator ani

A

pudendal and nerve to levator ani

236
Q

when is the pevlic floor contracted

A

tonically contracted most of the time

actively contracts during coughing, sneezing, vomiting etc

237
Q

other than muscles wheat else supports the pelvic organs

A

endo-pelvic fascia

  • connective tissue
  • some loose areolar tissue
  • some fibrous (collagen and elastic)
pelvic pigaments 
-fibrous endopelvic fascia 
-uterosacral 
-transverse cervical (cardinal)
lateral ligament of the bladder
-lateral rectal ligaments
238
Q

what is the cardinal pelvic ligament

A

transverse cervical

239
Q

what are where is the deep perineal pouch

A

lies between fascia convering inferior aspect of pelvic diaphragm and the perineal membrane

contains:

  • urethra
  • vagina
  • bulbourethral glands in males
  • neurovascular bundle for penis/ clitoris
  • extensions of ischioanal fat pads and muscles
240
Q

what is the difference in the deep transverse perineal muscle in males and females

A

males- skeletal

females- smooth

241
Q

what muscles assists the external urethral sphincter

A

compressor urethrae

242
Q

what is the perineal membrane

A

thin sheet of tough deep fascia
superficial to the perineal pouch
attaches laterally to the sides of the pubic arch, closes urogenital triangle
has opening for the urethra and vagina in females)

243
Q

what is the role of the perineal membrane

A

(with perineal body) is last passive support of the pelvic organs

244
Q

wheres is the superficial perineal pouch

A

below the perineal membrane

245
Q

what does the superficial perineal pouch contain in men

A

root of penis:

  • bulb-> corpus spingiosum
  • crura -> coprus cavernosum
  • associated muscles: bulbospongiosus and ischiocavernosus

proximal spongy urethra
superficial transverse perineal muscle
branches of internal pudendal vessels
pudendal nerve

246
Q

what type of tissue ans the bulb and crura

A

erectile

247
Q

what forms the coprus cavernosum and spongiosum

A 
spongiosum= bulb 
cavernosum= crura
248
Q

which muscle of superficial perineal pouch doesnt insert into perineal body

A

ischiocavernosum

249
Q

what does the superficial perineal pouch contain in females

A

Clitoris and crura – corpus cavernosum
Bulbs of vestibule – paired
Associated muscles – bulbospongiosus and ischiocavernosus

greater vestibular glands (bartholins- unlike male cowpers which are in deep perineal pouch)
superficial transverse perineal muscle
branches of internal pudendal vessels and pudendal nerve

250
Q

what are the functions of the pelvic floor

A

supports pelvic floor

helps maintain continence

251
Q

what muscles maintain urinary continence

A

External urethral sphincter, compressor urethrae, levator ani, smooth muscle in urethral wall, urinary bladder neck support

252
Q

what muscles contain faecal continence

A

Tonic contraction of puborectalis bends the anorectum anteriorly
Active contraction maintains continence after rectal filling
anal sphincters
muscles of pelvic floor

253
Q

what can cause injury to pelvic floor

A 
pregnancy 
child birth 
chronic constipation 
obesity 
heavy lifting  
chronic cough or sneeze 
previous injury to pelvis/pelvic floor 
menpause
254
Q

what is a vaginal prolapse

A

herniation of urethra, bladder, cervix, uterus, rectum or rectouterine pouch through supporting fascia
presents as lump in vagina

255
Q

what are the types of vaginal prolapse

A

Cystocele- bladder protruding into anterior vaginal wall
Enterocele- bowel protruding into posterior vaginal wall
Urethrocele- urethra protruding into anterior vaginal wall
rectocele- rectum protuding into posterior vaginal wall

256
Q

how does a uterine prolapse present

A

dragging sensation
feeling of lump
urinary incontinence

257
Q

what are the degress of uterine prolapse

A

1st- cervix into upper vagina
2nd – cervix lower into vagina but still above the opening
3rd - cervix into open environment
4th - uterus and cervix outwith vagina

258
Q

what are vaginal prolapses repaired

A

Sacrospinous fixation:
Sutures placed in sacrospinous ligament, just medial to the ischial spine
To repair cervical/vault descent
Performed vaginally
Risk of injury to pudendal NVB and sciatic nerve

Incontinence surgery:
Trans-obturator approach
Mesh through obturator canal
Space in obturator foramen for passage of obturator NVB
Create a sling around the urethra
Incisions through vagina & groin

Reproduction (51 decks)

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