Lecture 2 - Pelvis 2: Internal Pelvic Organs Flashcards
(147 cards)
1
Q
What is the recto-uterine pouch? What is it lined by?
A
Region between the rectum and uterus in females lined by uterosacral ligament and rectovaginal septum
2
Q
Other name for recto-uterine pouch?
A
Pouch of Douglas
3
Q
What is the utero-vesicular pouch?
A
Region between the uterus and the bladder in females
4
Q
What is the recto-vesicular pouch?
A
Region between the bladder and the rectum in males
5
Q
Where is the female bladder located?
A
- Posterior to pubic bone
- Anterior to cervix and vagina
- Superior to urethra
- Inferior to uterus
6
Q
Where is the male bladder located?
A
- Posterior to pubic bone
- Anterior to rectum, vas deferens, and seminal vesicles
- Superior to prostate (neck of bladder fuses with the gland)
- Inferior to peritoneum and small intestine and sigmoid colon
7
Q
Lymph drainage of bladder?
A
Internal and external iliac nodes
8
Q
Which is longer: male or female urethra?
A
Male: 8 inches vs 2.5 inches
9
Q
4 parts of the male urethra? Provide length of each and what each crosses and/or receives.
A
- Pre-prostatic urethra: 1 cm from base of bladder to prostate and contains the internal urethral sphincter
- Prostatic: ~1 and 1/4 inches long, crosses prostate and receives the 2 ejaculatory ducts and ~15 or 20 prostatic ducts
- Membranous: 3/4 inch long and crosses UG diaphragm and contains the external urethral sphincer
- Spongy: 6 inches long and goes through corpus spongiosum and connects to bulbo-urethral glands
10
Q
What part of the male urethra would be injured by a blow to the pubic bone? Examples of how this would happen?
A
Spongy urethra, as a part lies just under the pubic bone
E.g. bike rider riding over lose manhole cover
11
Q
Is the male urethra in the pelvis or perineum?
A
Prostatic part is in pelvis and membranous and spongy parts are in the perineum
12
Q
Role of involuntary internal sphincter of neck of bladder in males?
A
Contracts during ejaculation to prevent retrograde ejaculation of semen into the bladder
13
Q
Is the female urethra in the pelvis or perineum?
A
Both
14
Q
What is a Foley catheter? Purpose?
A
Catheter to insert in urethra to reach bladder
Used if patient cannot urinate or to obtain uncontaminated urine sample
15
Q
Is a catheter easier to insert in males or females?
A
Females because urethra and not S-shaped
16
Q
What can block urinary flow?
A
- BPH = benign prostatic hyperplasia
- Traumatic disruption of the urethra
- Congenital defects of the urinary tract
- Obstructions: kidney stones passed into the urethra and cancer
17
Q
Is the bladder contained entirely in the pelvis?
A
When empty, yes
When full, it rises into the abdomen (becomes intra-abdominal) and peels the peritoneum away from the anterior abdominal wall
18
Q
What does the needle pierce in a suprapubic cystotomy?
A
- Skin
- Linea alba
- Transversalis fascia
- Space of Retzius filled with fat
- Bladder
19
Q
Does suprapubic cystotomy carry a risk of peritonitis or injury to bowels?
A
NOPE, because the needle does not touch the peritoneum
20
Q
Why are infections of the urethra and bladder more common in women?
A
- Urethra shorter
2. Urethra is more distensible
21
Q
Risk of urethral catheterization in men?
A
Urethral rupture
22
Q
Surgical treatment for bladder tumor?
A
Transurethral resection using a cytoscope
23
Q
What is a cytoscope?
A
Thin, lighted tube that can be inserted through the urethra and into the bladder
24
Q
What is a transurethral resection of the prostate (TURP)?
A
Instrument is inserted up urethra to remove the section of prostate blocking urine flow and a new urethra is formed around the inserted catheter that is left in place for a few days
25
Is urethral rupture in women common? Why?
NOPE because it's short
26
What is the vagina? Length?
4-6 inch long distensible fibromuscular tube with apposed walls
27
Where is the vagina located?
1. Posterior to the posterior wall of the urethra (fused together) and base of bladder
2. Anterior to the rectum
3. Superior to the vestibule of the perineum
4. Inferior to the cervix of the uterus
28
What forms the posterior border of the vagina? Why is this clinically relevant?
Peritoneum and peritoneal cavity at its upper fourth forming the Douglas pouch
Can be injured during a botched abortion, an instrument can enter the posterior fornix and rupture the peritoneum causing peritonitis
29
What is the vaginal fornix? Subdivisions?
Recess formed between the margin of the cervix and the vaginal wall forming a gutter around the cervix: anterior, posterior, and lateral fornices
30
What is the external opening of the vagina called?
Introitus
31
Is the female vagina in the pelvis or perineum?
Both
32
Lymphatic drainage of the vagina?
1. Pelvic portion (upper 2/3rds): superficial inguinal nodes
| 2. Perineal portion (lower 1/3rd): internal iliac nodes
33
Arterial supply of vagina?
1. Vaginal branch of the internal iliac artery
| 2. Vaginal branch of the uterine artery
34
Can kidney stones be felt through the vagina?
YUP
35
Position of uterine artery in relation to vagina?
Lateral
36
Can a neoplasm in the Douglas pouch be felt with a finger in the vagina?
YUP
37
What neoplasms often invade the vagina?
Rectal neoplasms
38
Are vaginal fornices found in all women?
They disappear with age as the vagina shrinks
39
What is a cystocele?
Fallen bladder bulges into vagina due to distention of vagina
40
What is a rectocele?
Rectum bulges through tear in rectovaginal septum into the vagina
41
Where is the uterus located?
1. Posterior to the utero‑vesicular pouch, coils of small intestine and sigmoid colon, and the supravaginal cervix rests on the posterior bladder wall
2. Anterior to the pouch of Douglas, coils of small intestine and/or sigmoid colon
3. Inferior to colon
4. Superior to vagina and bladder
5. Medial to the broad and round ligaments of the uterus, ureters, the uterine artery and vein, uterine tubes, the ligament of the ovary
42
3 parts of the uterus?
1. Fundus
2. Body
3. Cervix
43
What is the uterus? Shape and size?
Hollow, muscular, pear shaped organ about 8 cm long
The uterine cavity is triangular in coronal section but only a slit in sagittal section
44
Consistency of cervix?
1. Non‑pregnant cervix has the consistency of a nose
| 2. Pregnant cervix has the consistency of one's lips
45
Other name for the ligament of the ovary?
Utero-ovarian ligament
46
What can cause compression of the ureter in the pelvis? Consequence?
Compressed by a growth from the uterus leading to kidney disease
47
What is the broad ligament of the uterus? What does it enclose?
Double fold of peritoneum connecting the lateral margin of the uterus to the sidewall of the pelvis
Encloses the uterine tubes
48
Arterial supply to uterus?
1. Ovarian artery for upper body and fundus
| 2. Uterine artery for lower body and cervix
49
Lymph drainage of uterus?
1. Upper part: para-aortic nodes near renal arteries as lymph follows the ovarian artery OR superficial inguinal nodes through the round ligament of the uterus
2. Most of uterus: internal iliac nodes
50
Through what structure can fluid in the recto-uterine pouch be drained?
Through vagina
51
Through what structure can fluid in the utero-vesicular pouch be drained?
Through the bladder
52
2 indications to ligate the uterine artery?
1. Hysterectomy
| 2. Treatment for serious postpartum hemorrhage
53
What are the round ligament of the uterus and the ligament of the ovary?
The inferior pole of the ovary is attached to a fibromuscular band of tissue (the ligament of the ovary), which courses medially in the margin of the mesovarium to the uterus and then continues anterolaterally as the round ligament of the uterus, which passes over the pelvic inlet to reach the deep inguinal ring and then courses through the inguinal canal to end in connective tissue related to the labium majus in the perineum
54
Origin of ligament of ovary and round ligament of uterus?
Both are remnants of the gubernaculum, which attaches the gonad to the labioscrotal swellings in the embryo
55
Can a lump in the groin be due to uterine cancer?
YUP
56
What runs along the round ligament of the uterus?
1. Medially: artery of Sampson from uterine artery and small cremasteric arteries
2. Laterally: nerves
57
Why does pregnancy cause round ligament pain?
The round ligament of the uterus is stretched during pregnancy as the uterus rises into the abdomen
58
What supports the pelvic organs in the female other than the pelvic floor? 3 thickenings? What is special about these?
Connective tissue just above the pelvic floor
3 thickenings:
1. The cardinal ligaments from the cervix to side walls of the pelvis
2. The uterosacral ligaments from the cervix to the sacrum
3. The pubocervical fascia from the cervix to the pubic bones
Considered visceral ligaments and comprised of varying smooth muscle, connective tissue and other structures
59
Other name for cardinal ligaments?
Mackenrodt’s ligaments
60
Principal support of the side wall of the uterus?
Broad ligament of the uterus
61
What do the broad ligament of the uterus and the uterus form?
Partition of the pelvis with anterior compartment containing the bladder and posterior compartment containing the rectum
62
What is a uterine prolapse? Other name?
Uterus pushed down and displaces the vagina
= uterus procedentia
63
What is an enterocele?
Herniation into the Douglas pouch and vagina usually containing small intestine
64
What is an urethrocele?
Herniation of the urethra into the vagina
65
What do the disorders of pelvic support (all the -celes) result from?
Loss or weakening of fascial supports secondary to:
1. Stress of child bearing in vaginal birth
2. Surgical damage (e.g. operative delivery)
3. Chronic straining activities like lifting weights or constipation
4. Episiotomy
5. Genetic weakness
6. Involutional changes (decrease in size of uterus after birth)
66
What is a hernia?
Abnormal protrusion of abdominal or pelvic content
67
What is the suspensory ligament of the ovary?
Raised fold of peritoneum containing the ovarian vessels, nerves, and lymphatics
68
Other name for suspensory ligament of the ovary?
Infundibulopelvic ligament
69
What is important to avoid when doing laparoscopic surgeries into the abdomen to see pelvic organs? How?
Epigastric vessels, by transilluminating the skin
70
How far from the midline do epigastric vessels run?
4-8 cm from midline
71
What is the 2nd most common surgery in America?
Hysterectomy
72
What is the 1st most common surgery in America?
C-section
73
What the top 3 commonest gynecologic malignancy worldwide?
1. Endometrial cancer
2. Ovarian cancer
3. Cervical cancer
74
In what women is cervical cancer more common?
Young women (30% of patients are less than 35 yo)
75
What is a cervicectomy performed for? Describe it.
Early carcinoma of the cervix
Cervix and upper vagina are resected and the body of the uterus is anastomosed to the remained of the vagina
76
Does a cervicectomy kill fertility?
NOPE
77
What are the most common benign tumors in women?
Fibroids (75% of women have them in their lifetime)
78
Other names for fibroids?
Leiomyomas = smooth muscle tumors
79
What is located directly medial to the ureters?
Lateral fornices
80
What do fibroids cause?
1. Heavy menstrual bleeding = menorrhagia
2. Pain
3. Pressure
4. Urinary frequency
5. Constipation
6. Enlarged abdomen
7. Dyspareunia = painful sexual intercourse
81
When do fibroids often appear?
During childbearing years
82
4 types of fibroids? Most common*? Most likely to be symptomatic#?
1. *Intramural
2. #Submucosal
3. Subserosal
4. Pedunculated (hanging from a stalk attached to the uterus)
83
Describe uterine artery embolization. Most common side effect? Risks?
1. Enter femoral artery with catheter
2. Go up external iliac artery to common iliac artery
3. Enter contralateral common iliac artery to internal iliac artery
4. Push in polyvinyl particles to block the uterine artery
5. Fibroids die without blood supply
Most common side effect: pain and cramping
Risks: pain, infection, hemorrhage, need for hysterectomy, embolization of wrong vessel
84
Can all women be treated for fibroids by UAE?
NOPE
85
What is an ectopic pregnancy?
Pregnancy in a location other than the endometrium of the uterine cavity - at first the developing zygote can get nutrients from environment until it is no longer enough, leading to necrosis
86
Where do most ectopic pregnancies occur?
80% in the ampulla of the oviduct
87
What is maternal mortality due to in ectopic pregnancies?
Hemorrhage into peritoneal cavity following rupture of the uterine tube
88
2 other names for uterine tube?
1. Oviduct
| 2. Fallopian tube
89
4 parts of uterine tube? Describe each.
1. Infundibulum: extends beyond the broad ligament of the uterus and opens into the peritoneal cavity
2. Ampulla: wide, thin-walled part of the tube
3. Isthmus: narrow thick-walled part closer to the uterus
4. Intramural part: part of the tube within the wall of the uterus
90
What are the fimbriae of the infundibulum of the uterine tube?
Small finger-like projections on the margin of the infundibulum that which drape the ovary
91
Implications of communication between uterine tube and peritoneal cavity?
Potential pathway for infection into the peritoneal cavity (peritonitis) from the vagina, uterus, or the tubes
92
What is a major cause of infertility and ectopic pregnancy in women? What is this called?
Blockage of the uterine tubes resulting from an infection such as gonorrhea and chlamydia => salpingitis
93
Incidence of ectopic pregnancies?
1 in 250
94
What is a tubal ligation used for? How is it done? What to note?
Very common method of permanent birth control via laparoscopy
Note: 20% success rate of re-anastomosis
95
Arterial supply to uterine tubes?
1. Uterine artery
| 2. Ovarian artery
96
Lymphatic drainage of uterine tubes?
1. Internal iliac nodes
| 2. Para-aortic nodes
97
Is the peritoneal cavity open or closed?
Open in females
| Closed in males
98
What is pelvic inflammatory disease?
Infection of reproductive organs often due to STDs
99
What is the leading cause of maternal mortality?
Ectopic pregnancy
100
What can a ruptured ectopic tubal pregnancy be misdiagnosed as? Explain.
As an appendicitis because the appendix lies close to the ovaries and the oviduct on the right side + referred pain to the RLQ
101
How is patency of the uterine tubes determined? Purpose?
Hysterosalpingogram (HSG)
Purpose: to determine fertility (should be smooth and free flowing with free spillage into the peritoneal cavity bilaterally) or to check for unicornuate uterus or mispositioning of the uterus (retroverted/anteverted, etc.)
102
Describe how a hysterosalpingogram is performed.
1. Insert a catheter into the vagina and accessing the cervix
2. Under fluoroscopy, radiopaque contrast is injected
3. Multiple images are taken
103
What is a unicornuate uterus? What does it often lead to?
Uterine malformation where the uterus is formed from only one of the paired Müllerian ducts, while the other Müllerian duct does not develop or only develops in a rudimentary fashion
It often leads to preterm delivery and sometimes miscarriages (less frequently)
104
Shape and size of ovary?
Almond shaped organ, 3cm long x 1.5 cm wide x 1 cm thick
105
What is the ovary attached to posteriorly?
Attached to the back of the broad ligament of the uterus by the mesovarium
106
Position of ovary? What to note?
Appears to lie in an ovarian fossa bounded by:
1. External iliac artery
2. Internal iliac artery
3. Obturator nerve
Note: the position of the ovary is extremely variable and it even may be found in the pouch of Douglas
107
Arterial blood supply of ovary?
Ovarian artery by entering from above within the suspensory ligament of the ovary
108
Where do the ovarian/testicular veins drain?
- Right: IVC
| - Left: renal vein
109
Lymphatic drainage of ovary?
Para-aortic nodes
110
Why is ovarian cancer so deadly?
Cause it drains to para-aortic nodes so not visible
111
How does the position of the ovary change with pregnancy?
During pregnancy the ovary and the broad ligament of the uterus are carried superiorly
After childbirth, the ovaries often do not return to their original position or sometimes descend into the Douglas pouch
112
3 parts of the broad ligament of the uterus? Describe each.
1. Mesometrium: the largest part of the broad ligament, which extends from the lateral pelvic walls to the body of the uterus
2. Mesosalpinx: the most superior part of the broad ligament, which suspends the uterine tube in the pelvic cavity
3. Mesovarium: a posterior extension of the broad ligament, which attaches to the ovary
113
Side effect of ovary in Douglas pouch?
Pain during intercourse
114
What is a teratoma?
Germ cell tumor with all 3 germ layers
115
What is the prostate? Size and shape?
Fibromuscular organ about the size and shape of a chestnut
116
Position of prostate?
1. Posterior to the pubic bone
2. Anterior to the rectum
3. Superior to the urogenital diaphragm
4. Inferior to the bladder
117
Why is the relation between the prostate and rectum important?
Because of the prevalence of prostate cancer; every man over the age of 40 should have a rectal exam to determine if there is enlargement or cancer of the prostate
118
Prevalence of BPH? Consequence?
All men over the age of 40 to 50
May interfere with urination by obstructing the prostatic urethra (incomplete bladder voiding) and cause nocturia
119
What is the usual cause of death of prostate cancer?
Renal failure because the cancer interferes with the ureter
120
3 surgical approaches to the prostate?
1. Suprapubic approach
2. Perineal approach
3. Transurethral approach (TURP)
121
Where does prostate cancer spread?
May spread via 3 routes:
1. Direct invasion of the adjacent organs by the cancer
2. Via the venous drainage - there are connections between the prostatic venous plexus and the vertebral valveless venous plexus so can establish secondary growths and enter the skull
3. Through the lymphatic channels to the internal iliac and obturator lymph nodes
122
Other name for spongy urethra?
Penile urethra
123
How long is the vas deferens? What is this comparable to?
18 inches long (like the thoracic duct)
124
Where can infection of the prostate/urethra spread?
Along the vas deferens to the epididymis and testis
125
What is orchitis? What can it result of a complication of? Consequence?
Infection of testis
Can result as a complication of mumps
Inflammatory reaction may raise pressure within the testis leading to atrophy of the seminiferous tubules and eventual sterility
126
What can cause prostatic urethra infection?
Prostatectomy
127
What are seminal vesicles?
Two inches long lobulated sacs
128
Can the seminal vesicles be felt on a rectal exam?
YUP IF ENLARGED
129
What is a retrograde urethrogram done for in men?
Check patency of vas deferens
130
What is a vasectomy? Reversible? What is this called?
Ligation of vas deferens by removing a section or by sectioning the tube or by tying the tube with suture (at upper part of the scrotum)
Can be reversed (vasovasostomy) in 25% to 75% of cases, depending upon which report you believe
Usually not successful after 5 years of vasectomy
131
Consequence of vasectomy?
Ejaculated fluid contains no sperm - the sperm is absorbed in the tail of the epididymis and proximal part of the vas
After 7 years: complete lack of spermatogenesis and thickened and convoluted basement membrane around seminiferous tubules
132
What can cause pus to enter the peritoneal cavity in men?
Abscesses in the seminal vesicles that rupture
133
Are the testosterone levels affected by a vasectomy?
NOPE because Leydig cells are normal
134
What are varicoceles? What are they a common cause of? Is it common?
Enlargement of testicular veins
Common cause of low sperm production and decreased sperm quality
Occurs in approximately 15-20% of all males and in 40% of infertile males
135
In which testicule are varicoceles more common? Why?
Much more common (approximately 80-90%) in the left testicle than in the right because of several anatomic factors:
1. The angle at which the left testicular vein enters the left renal vein
2. The lack of effective antireflux valves at the juncture of the testicular vein and renal vein
3. The increased renal vein pressure due to its compression between the superior mesenteric artery and the aorta (ie, nutcracker syndrome)
136
Symptoms of ectopic pregnancy?
1. Abdominal/pelvic pain
2. Bleeding
3. Ammenorrhea
137
Other name for intramural uterine tube?
Pars interstitialis
138
Other name for body of uterus?
Corpus
139
What are the uterine cornua?
Points where the uterus and the fallopian tubes meet and the round ligament attaches
140
4 risk factors for ectopic pregnancies?
1. Pelvic infections
2. Tubal reconstruction surgery
3. Previous ectopic pregnancy
4. Scarring due to ruptured appendix
141
Diagnosis of ectopic pregnancy?
1. High hCG
2. No intrauterine pregnancy
3. Adnexal mass on sonogram
4. Diagnostic laparoscopy
142
Treatments for ectopic pregnancy?
1. Methotrexate
2. Salpingectomy: uterine tube removal
3. Salpingostomy: surgical incision in the uterine tube to remove it, no need to stitch
143
Describe the pathway of the ovarian artery.
1. Arises from aorta below renal vessels
2. Courses into retroperitoneal space
3. Crosses anterior to ureter and enters infundibulopelvic ligament
4. Branches into mesovarium to supply ovary and uterine tube
5. Unites with ascending branch of uterine artery
144
How are fibroids diagnosed?
1. Physical exam
2. Bimanual exam
3. Ultrasonography
4. CT
5. MRI
145
6 treatments for fibroids?
1. Observation
2. Medical management with oral contraceptive pill or Lupron
3. Myomectomy
4. Hysterectomy
5. Uterine artery embolization (UAE)
6. Endometrial ablation: burning the lining so less receptors to hormones
146
Location of seminal vesicles?
- Posterior to bladder
- Superior to prostate
- Anterior to rectum
147
What is the space of Retzius?
Extraperitoneal space between the pubic symphysis and urinary bladder, between the transversalis fascia and the peritoneum
