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Module 7: Urogenital > Module Workshops > Flashcards

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1
Q

Outline the blood supply to the uterus

A

Ovarian artery, from the abdominal aorta, supplies the fundus, uterine tubes and upper uterus.

The ovarian artery anastomoses with the uterine artery.

Uterine artery, from the internal iliac artery, supplies the remaining part of the uterus.

Vaginal artery, from the internal iliac artery, supplies the vagina.

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2
Q

Name the branches of the anterior and posterior divisions of the internal iliac artery

A

I Love Going Places In My Very Own Underwear

Iliolumbar

Lateral sacral

Gluteal (superior and inferior)

Pudendal (internal)

Inferior vesicle (vaginal in females)

Middle rectal

Vaginal

Obturator

Uterine

*First 3 branches orignate from the posterior division (superior gluteal only)

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3
Q

Outline the relations of the ovary

A

Posterior relations: Common iliac vein and artery, ureter

Lateral relations: Obturator nerve, artery and vein

Anterior superior relations: Obliterated umbilical artery (from the internal iliac artery, becomes the medial umbilical ligament)

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4
Q

Outline the blood supply and venous drainage of the ovary

A

Ovarian artery: Branches from the abdominal aorta

Uterine artery: Branch of the internal iliac artery. Forms an anastomoses with the ovarian artery

Paired ovarian veins drain the ovary.

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5
Q

Outline the lymphatic drainage of the ovary

A

Pre-aortic and para-aortic (sentinel node!) nodes.

Deep, not palpable

May also drain to superficial inguinal nodes

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6
Q

Describe the key features seen during speculum examination of the cervix and vagina

A
  • External Os (ostium)
  • Dome of the cervix
  • Fornices (2 lateral, anterior and posterior)

NOTE: Nulliparous cervix is O like. Mutliparous cervix is inverted U shaped

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7
Q

Outline the autonomic and afferent innervation of the vagina

A

Autonomic supply

Upper 2/3rds: Receives sympathetic (T10-L2) and parasympathetic (S2-S4 pelvic splanchnics) supply via the hypogastric plexus

  • Sympathetics from T10-L2 travel via superior hypogastric plexus. Split into R and L hypogastric nerves.
  • The pelvic splanchnic nerves (S2-S4) join the (sympathetic) hypogastric nerves.
  • Allows for the provision of autonomic sympathetic and parasympathetic supply to the vagina.

Lower 1/3rd: Receives sympathetic supply from the pudendal nerve (S2-S4), from the grey rami communicans, via the inferior rectal and perineal branches. NOTE does not have a parasympathetic supply.

Afferent

Upper 2/3rds: Travel back via the pelvic splanchnic nerves to S2,3 and 4. (REMEMBER THIS FOR REFERRED PAIN)

Lower 1/3rd: Travel back with the pudendal nerve, via the perineal branch, to S2-S4

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8
Q

Describe the pelvic floor, perineal membrane and the perineal pouches, their relationship to each other and their contents in the male and female

- Outline the ‘layers’ of the area

A
  • Pelvic floor: Muscular layer. Supports the pelvic and abdominal organs. Maintains continence.
  • Perineal membrane: A covering of the urogential triangle. Continuous with the fascia covering the abdominal wall and the fascia lata of the thigh (preventing fluid spread in rupture)
  • Perineal pouches: Deep and superficial.

Contents of the perineal pouches

Deep perineal pouch: Urethra, external utheral sphincter, vagina (females), bulbourethral glands and deep transverse peritoneal muscles (males)

Superficial perineal pouch: Erectile tissues (penis/clitoris), Bartholin’s glands, greater vestibular glands, 3 muscles (ischiocavernous, bulbospongiosus and superficial transverse perineal muscles), perineal body

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9
Q

Outline the fascia of the peritoneum

A

Scarpa’s (membranous) ▻ Dartos Fascia (penis) ▻ Colle’s fascia (urogenital triangle)

Camper’s (fatty) ▻ Dartos Muscle (scrotum)

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10
Q

Outline the layers of the urogential triangle

A

Deep fascia of the pelvic floor

Deep perineal pouch

Perineal membrane (pierced by vagina and urethra)

Superficial perineal pouch

Perineal fascia

(Deep layer: Scarpa’s fascia, superficial layer: Camper’s fascia)

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11
Q

Identify the main muscles forming the pelvic floor and state their nerve supply.

Outline the potential consequences of damage to this area.

A

Pelvic floor muscles:

  • Levator Ani: Pubococcygeus, puborectalis and iliococcygeus

Innervated by the pudendal nerve (S2-S4)

  • Coccygeus (aka ischiococcygeus)

Innervated by the anterior rami of S4 and S5

Functions: Support organs, maintain continence and resist intrabado./pelvic pressure

Damage to the area may lead to prolapse and incontinence.

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12
Q

Explain the significance of the perineal body and outline the potential consequences of damage to this structure

*Clinical link

A

The perineal body is a thickening of fibromuscular tissue.

Located between the vagina/bulb of the penis and the anus.

Functions: An attachment site for muscles of the pelvic floor/perineum and the perineal membrane. Supports against prolapse in females

  • Attaching muscles = BLP (Levator Ani, bulbospongiosus and Superficial and deep tranverse perineal)

Consequences of damage: Increased risk of prolapse, incontinence

  • Episiotomy: A ‘managed’ incision made to the perineum during childbirth to prevent the perineal body and anal sphincter from tearing.
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13
Q

Identify the organs of the pelvis

A

Urinary: Pelvic uteter, urinary bladder, urethra

Genital:

  • Male: Ductus deferens (vessel for sperm transport), seminal vesciles, prostate
  • Female: Uterine tubes, ovaries, uterus, vagina

Digestive: Rectum, anal canal

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14
Q

Describe the recesses formed by the peritoneum and state their significance

A

Double foldings of peritoneum drape over the pelvic organs forming the:

Females:

  • Rectouterine pouch of Douglas: Between the uterus and the rectum. This is the most inferior point in the female body. Fluid may collect in this recess when standing or supine.

Radiopaedia: Abscess, infection, ascites, haemoperitoneum, and even intraperitoneal drop metastases preferentially collects here.

  • Vesicouterine pouch: Between the uterus and the bladder.

Males:

  • Rectovesical pouch: Between the bladder and the rectum
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15
Q

Identify the main branches of the internal iliac artery.

(ILGPIMVOU)

Describe their location and basic distribution.

A

Common iliac artery ➙ External and internal iliac branches

Internal iliac artery ➙ Anterior and posterior divisions

Divides at the superior border of the greater sciatic foramen

Branches of posterior (first 3) and anterior divisions:

Iliolumbar

Lateral sacral

Gluteal (superior and inferior)

Pudenal (internal)

Inferior vesicle (vaginal in females)

Middle rectal

Vaginal

Obturator

Umbilical and uterine (females only)

  • The umbilical artery (carries deoxygenated blood to the placenta) obliterates to become the medial umbilical ligament
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16
Q

List structures that may be palpated by rectal examination

A

Females: Anus, uterus

Males: Anus, prostate

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17
Q

List structures that can be palpated by vaginal examination

A

Visual inspection ➙ speculum ➙ palpation

PV exam: Vagina, cervix, fornices

Bimanual exam: Uterus, ovaries and uterine tubes

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18
Q

Describe the course of the nerve supplies to the pelvic and urogenital diaphragms and perineum

A

The pudendal nerve (S2-S4)

  • Motor to pelvic floor muscles and sensory to the perineum
  1. Exits the pelvis via the greater sciatic foramen
  2. Re-enters the pelvis via the lesser sciatic foramen
  3. Travels laterally along the ischioanal fossa (via the pudendal/Alcock’s canal)
  4. Divides into serveral branches
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19
Q

Ischioanal fossae: Explain borders, content, normal function and how infection can spread around the region

A

Borders: Located laterally to the anus within the anal triangle

  • See image

Content: Adipose tissue, pudendal/Alcock’s canal (contains pudendal nerve and internal pudendal artery/vein), inferior rectal nerve and vessels, lymphatics

Normal function: Allow for the expansion of the anal canal during defecation, supports the anal canal

Spread of infection: Vulnerable to spread of infection from the anal canal. Abscesses may form and infection may spread to the opposite fossa, passing behind the anal canal. Fistulas may form (with the anus)

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20
Q

Outline the borders of the perineum and its divisions

A

Anterior: Pubic symphysis

Lateral: Ischiopubic rami and sacrotuberous ligament

Posterior: Tip of the coccyx

Divided into the anal and urogential triangles via a ‘line’ between the ischial tuberosities

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21
Q

Axillary nodes may be removed in patients with breast cancer. This procedure may lead to damage to which nerve?

A

Long thoracic nerve

Innervates the serratus anterior muscle.

Damage causes winging of the scapula.

Thoracodorsal nerve may also be injured

Innervates latissimus dorsi

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22
Q

Name the layers of the abdominal wall

A
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23
Q

Outline the contents of the deep perineal pouch of the urogenital triangle

A

A potential space between the deep fascia of the pelvic floor muscles and the perineal membrane

Females:

  • Urethra
  • External urethral sphincter
  • Vaginal

Males:

  • Bulbourethral/Cowper’s glands (watery pre-ejaculate)
  • Deep transverse perineal muscles
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24
Q

Outline the borders of the perineum and name the structure which allows for division into anterior and posterior triangles

A

Anterior: Pubic symphysis

Lateral: Ischiopubic rami and sacrotuberous ligament

Posterior: Tip of the coccyx

The ischial tuberosities mark the division of the perineum

***Perineal membrane (layer of strong fascia) only seen in the urogenital triangle, not the anal triangle***

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25
Outline the contents of the anal triangle
* **Anal aperture** * **External anal sphincter muscle** * **Ischioanal fossae** either side of the anus * Contains adipose and connective tissue which allows for expansion of the anal canal during defecation. * Contains the **Pudendal/Alcock's canal**: Pudendal nerve and internal pudendal artery/vein
26
Outline the contents of the superficial perineal pouch of the urogenital triangle
A potential space between the perineal membrane and the superficial perineal fascia **Erectile tissues:** * Clitoris/penis **3 muscles:** * Bulbospongiosus * Ischiocavernous * Superficial transverse perineal **Bartholin's gland** * Can become infected → bartholinitis. **Perineal body** seen at the posterior border
27
State the positions of the sacrospinous and sacrotuberous ligaments
**Sacrospinous:** Sacrum → ischial spine **Sacrotuberous:** Sacrum → Ischial tuberosity
28
State the names of the parametrial ligaments
**Function to support the uterus** ## Footnote **P**ubocervical **T**ranverse cervical **S**acrocervical
29
Through which structure are ovarian vessels transported?
**The suspensory ligmament**
30
Which 'space' allows for the movement of breast tissue over pectoralis fascia?
**The retromammary space** * Exists between the breast tissue and the pectoral fascia * The existance of this space prevents movement of the breast tissue during contraction of pectoralis major * In malignancy the breast tissue will move superiorly relative to contraction of the pectoralis major muscle
31
Outline the quadrants of the breast
32
Outline the lymphatic drainage of the breast
**75 % → Axillary nodes** * Central, Humeral, Apical, Pectoral and Subscapular **Paravertebral** * Allows for spread to the brain **Parasternal** **Clavicular** **Abdominal** ⋆ Due to a valveless lymphatic system existing between the breasts malignancy may spread across the midline
33
Outline the pelvic cavity shapes associated with males and females ## Footnote *Inlet, outlet, cavity and pubic arch*
34
Outline the birth canal measurements used in pelvimetry ## Footnote *- Which pelvic girdle shape is best adapted for delivery*
Best adapted pelvic girdle shape: **Gynecoid** **Birth canal measurements:** * **Intertuberous** * **Interspinous** * **Diagonal conjugate** * **True conjugate** (diagonal conjugate - pubic symphysis depth)
35
Outline the lymphatic drainage of the pelvic region ## Footnote *Superficial inguinal, deep inguinal, external iliac, internal iliac and para-aortic*
36
Describe/draw the structure of the placenta
37
Describe the structure, funtion and positions of the penis, prostate, urethra, seminal vesicles and bulbourethral glands
38
Outline the lobes and zone of the prostate ## Footnote *In which regions are BPH and prostatic cancer most likely to occur?*
39
Outline/draw the relations of the prostate ## Footnote *State the clinical significance of these relations*
**Clinical significance:** The peripheral zone of the prostate is close to neurovascular structures (**dorsal venous plexus** and **autonomic fibres of the cavernous nerve**). These structures, which go on to innervate and vascularise the penis, may be **invaded in carcinoma** - allowing spread. Commonly spreads via **Batson's plexus** to **vertebral bodies**, may present as back pain. ## Footnote Also, **damage** to these **neurovascular structures** during **prostatic surgery** may cause **erectile dysfunction.**
40
Outline the lymphatic drainage of the male urogenital system
41
Explain the structures and mechanisms involved in erection, emission and ejaculation
42
Explain how the passage of the urethra through the prostate can relate to disease of the prostateor or difficulties in voiding of urine
* Prostatic enlargement, as seen in BPH and late stages of prostate cancer, may cause the prostatic urethra to become compressed. * This in turn causes urinary symptoms, such as: nocturia, most-micturition dribbling, weak stream, urinary hesitancy and polyuria. * This may lead to acute urinary retention - a medical emergency. * Treatment for BPH includes α-receptor antagonists to relax the smooth muscle of the prostatic urethra and relieve urinary symptoms.
43
List the structures palpable upon rectal examination of the male and explain their expected position
* Prostate (felt anteriorly) * Rectal wall
44
Describe the structure, coverings, embryological origin and descent of the testis
45
Describe the layers of the spermatic cord and the main contents of the cord
**Spermatic cord layers**: External spermatic fascia, cremasteric fascia and muscle and the internal spermatic fascia **Main contents of the spermatic cord:** * Pampiniform plexus: Acts as a heat exchanger to 'cool' blood before reaching the testes * Vas deferens * Autonomic nerves * Genital branch of the genitofemoral nerve * Lymph vessels * Testicular, cremasteric and vas deferens arteries
46
Describe direct and indirect inguinal hernias. ## Footnote *How may they be differentiated from a femoral hernia?*
**Direct inguinal hernia:** Passes through the anterior abdominal wall into the inguinal canal, exiting via the superficial ring **Indirect inguinal hernia:** Passes through the deep inguinal ring, along the canal and out of the superficial ring **Femoral hernia** - Below and lateral to the pubic tubercle
47
Define the terms hydrocele, spermatocoel, varicocoele, priapism and hypospadias
**Hydrocoele:** Accumulation of fluid within the tunica vaginalis. Resultant of incomplete obliteration of the connection with the peritoneal cavity (failure of the ligamentous remnant of processus vaginalis to form) **Spermatocoele:** Cystic accumulation of sperm, arising from the head of the epididymis **Varicocoele:** Enlargement of vein. More common in the left testes due to drainage to the acute angle of the left renal vein. **Priapism:** Involuntary, elonged erection that is unrelated to sexual stimulation **Hypospadias:** Congential deformity of the penis in which the urethral opening is located in an 'abnormal position' e.g. along the shaft of the penis. Opening seen on the ventral aspect of the penis
48
Outline the **cremasteric reflex** and how it may be elicited
Sees retraction of the testes due to contraction of the cremasteric muscle. Elicited through gentle touch to the inner thigh. Tests L1 spinal root value.
49
Describe the relations of the kidneys anterior, posterior and superior
50
Describe the position of the kidneys ## Footnote *\*Left and right differ\**
Approximately 3 vertebrae in length **Left:** * Anterior to the **11th and 12th ribs** **Right:** * Anterior to the **12th rib** **Renal hilum:** L1 (transpyloric plane) * Idicates position of the renal vessels and pelvis **Renal angle:** The angle formed between the **12th rib** and the lateral border of the **erector spinae muscle**
51
Describe the coverings of the kidneys ## Footnote *How do they relate to support and infection spread?*
Kidneys → renal capsule → perirenal fat → Gerota's fascia → pararenal fat → fascia of the posterior abdominal wall **Clinical signficance:** * Gerota's fascia is incomplete on the posterior aspect, allowing for pus or extravasated urine to to track down alongside the ureter * The kidney is poorly 'fixed' and so prone to injury during blunt trauma (rapid deceleration)
52
Outline the innervation of the kidneys
**Sympathetic and parasympathetic fibres** arise from the **renal nerve plexus**. These fibres are supplied by abdominopelvic splanchnic nerves. **Visceral afferents follow sympathetic fibres** to spinal cord segments **T11 -L3.** * Referred pain seen to T11 -L3 dermatomes due to the origin of the painful stimuli being confused following synapsing of the visceral afferents.
53
State the narrow regions of the ureter ## Footnote *Clinical significance*
Uteropelvic junction (UPJ), pelvic brim and the vesicoureteric junction (VUJ) **Clinical significance:** Common regions for obstruction by renal calculi
54
Outline the relations of the urinary bladder
55
Outline the blood supply, venous and lymphatic drainage of the bladder
**Blood supply:** Arises from anterior branches of the internal iliac artery * Inferior vescile (M)/ Vaginal (F) * Superior vesicle **Venous drainage:** **Lymphatic drainage:** Varies for different parts of the bladder. The internal iliac nodes are usually the primary site of lymphadenopathy
56
Describe the basic structure of the urinary bladder
57
Describe the structures and neural input that contributes to urinary continence ## Footnote *Storage and micturition*
58
State the structures that induce difficulty during male and female catheterisation
**Female:** * External urethral sphincter * External urethral orifice **Male:** * Navicular fossa * Fexible bend in the spongy urethra * Fixed bend at the juntion between the membranous and spogy urethra * Prostate
59
Outline the layers of the anterior abdominal wall passed through during insertion of a suprapubic catheter
MUST NOT PASS THROUGH THE PERITONEUM - distension of the bladder will usually 'lift' bowel loops and peritoneum clear of the route of the catheter
60
Outline the facial layers covering the penis
61
Which structure serves as a radiological landmark for the ureters?
* L2-L5 transverse processes * Vesicouteric junction seen 1 cm above the ischial spine
62
Describe the anatomical relations of the ureters
63
Draw the main features of the kidney
64
Outline the arterial supply of the kidneys
65
State the type of epithelium seen within the urinary system
**Transitional epithelium** Stratified cuboidal epithelium . Normally 4-6 layers, allows for 'stretching'. Seen in the bladder, ureters, urethra and renal pelvis.
66
State the structures which contribute to the walls of the inguinal canal
67
Outline the anesthesia available for childbirth
Analgesia → conscious of uterine contractions, able to push Anesthesia → Complete blockade of pain and feeling, unable to assit labour Epidural block: Allows participatory childbirth * L3-L4 * Birth canal, pelvic floor and majority of peritoneum is anesthetised but lower limbs unaffected * Uterine body pain fibres ascend to thoracic/lumbar levels - not affected, mother is aware of contractions Spinal anesthesia: Complete anesthesia below the waist * Subarachnoid space, L3-L4 * Severe spinal headache may arise (enters cranial cavity once pt flat) Pudendal nerve block: Peripheral nerve block providing anesthesia over S2-S4 dermotomes and inferior quarter of the vagina * Mother still able to feel uterine contractions * Administered near the sacrospinous ligament
68
Outline possible penile pathologies ## Footnote *Priapism, Phimosis, Paraphimosis and Peyronies*
**Priapism:** Persistent erection in the absence of stimulation and unrelieved by ejaculation Treatment: Catheterisation, alpha antagonists **Phimosis:** Inability to retract the foreskin **Paraphimosis:** Foreskin becomes 'stuck' behind the corona of the penis **Peyronie's:** Unusual curvature of the penis due to fibrosis and plaque formation within penile tissue
69
Outline the neurovascular supply of the scrotum ## Footnote *Clinical link: Consequences for anaesthetic*
**Anterolateral:** **Lumbar** plexus **(ilio-inguinal nerve)** **Posteroinferior: Sacral** plexus **(pudendal)** **Clinical link:** More superior spinal anaesthetic must be used to anesthetize the anterolateral aspect of the scrotum

Module 7: Urogenital (29 decks)

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