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Anatomy for MRCS > Pelvis and Perineum > Flashcards

Pelvis and Perineum Flashcards

1
Q

Prostate in relation to rectum?

A

Prostate is anterior to rectum

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2
Q

In men does the ductus deferens cross the ureter?

A

Yes

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3
Q

2 important angles of the urethra?

A

Bends anteriorly via perineum

In external penis where it droops

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4
Q

What is the perineum innervated by?

A

S3-S5
Rectum is S5 in both genders
In men S3 = penis and scrote

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5
Q

Which ligaments support the lumbosacral joint

A

iliolumbar and lumbosacral - both attach to transverse process of L5

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6
Q

Which three ligaments support the sacro-iliac joint?

A

Anterior sacro-iliac = thickening of fibrous membrane from joint capsule

Interosseous ligament = strongest. Positioned poster-superior

Posterior sacro-iliac ligament = covers interosseous ligament

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7
Q

Which ligaments does the pelvic wall have?

What is so important about them?

A

Sacrospinous = attaches to margin of sacrum/coccyx, inserting on ischial spine

Sacrotuberous = Broad base attaches to PSIS + along sacrum/coccyx. Inserts ischial tuberosity
- This is superficial to the sacrospinous

These ligaments turn the sciatic notches into foramen

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8
Q

Which muscle divides the greater sciatic notch into 2?

A

Piriformis

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9
Q

What passes via obturator canal?

A

Obturator nerve and vessels

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10
Q

What passes through greater sciatic foramen?

A

Above piriformis = superior gluteal vessels and nerve

Below piriformis = inferior gluteal nerve and vessels, Pudendal nerve + internal pudendal vessels, then 4 more nerves:
Sciatic nerve
Posterior femoral cutaneous nerve
Nerve to quadratus femoris
Nerve to Obturator internus
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11
Q

What passes through lesser sciatic foramen?

A

Tendon of obturator internus

Pudendal nerve and internal pudendal vessels

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12
Q

Which muscles make up the pelvic floor?

A

Levator ani = pubococcygeus, puborectalis and iliococcygeus

Coccygeus

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13
Q

Pelvic floor muscles - origin, insertion + innervation

A
  1. Pubococcygeus:
    Origin = inner pubis and obturator fascia
    Insertion = Fuses medially at perineal body, attaches to coccyx and anococcygeal ligament.
  2. Iliococcygeus:
    Origin = Coccyx and anococcygeal ligament . Posterolaterally attaches to ischial spine and along tendinous arch of obturator fascia.
    Insertion = Anteromedially fuses with pubococcygeus
  3. Puborectalis:
    Origin = Extends from pubic bone
    Insertion = Forms U-shaped sling around anal canal.

INFERIOR RECTAL BRANCH OF PUDENDAL

Coccygeus - pulls coccyx forward post defecation
Origin = ischial spine + pelvic surface of sacrospinous ligament
Insertion = Lateral margin of coccyx
ANTERIOR RAMI OF S3/S4

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14
Q

What innervates the muscles of the deep pouch?

A

Perineal branch of pudendal nerves

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15
Q

Which parts of the rectum are extraperitoneal?

what surrounds the extraperitoneal parts of the rectum and why is this clinically significant?

A

Posterior upper third
Posterolateral middle third
Whole lower third

Surrounded by mesorectal fat = has LN’s
So must be dissected out if rectal cancer.

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16
Q

What level does sigmoid colon form rectum?

A

L3

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17
Q

What are the two fascial layers of the rectum?

A

Fascia of Denonvilliers = anterior = separates rectum and prostate

Waldeyers fascia = posterior = separates rectum and sacrum
- this must be dissected to mobilise mesorectum from sacrum and coccyx in LAR

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18
Q

Arterial supply to rectum?

Venous drainage?

A

SRA from IMA
MRA from internal iliac
IRA from internal pudendal

Superior rectal vein

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19
Q

Lymphatic drainage of the rectum?

A

Upper part = mesenteric

Lower part = internal iliac

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20
Q

Where does anal canal begin and stop?

A

From levator ani to anal verge

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21
Q

What is the structure and cell type of the upper 2/3rds of the anal canal?

Artery and vein?

A

Columnar epithelium

6-10 longitudinal folds = columns of Morgagni
At the bottom of these = sinuses
3 major sinuses at 3, 7 and 11-o-clock where major arteries feed the vascular plexi

Superior rectal artery and vein

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22
Q

Does the upper 2/3rds of the anal canal have sensation?

What is its lymphatic drainage?

A

No sensation

Internal iliac nodes

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23
Q

What is the anal transitional zone?

A

Area between columnar and squamous zones

= dentate line

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24
Q

Lower third of the anal canal - cell type, sensation, vasculature and lymphatics?

A

Non-keratinsing squamous epithelium = NO GLANDS
Exquisitely sensitive

Middle and inferior rectal arteries and veins

Superficial inguinal LN’s

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25
Q

Internal vs external anal sphincter?

A

Internal = smooth muscle continuous with the circular muscle of rectum

  • surrounds upper 2/3rds of canal
  • sympathetic nerve supply

External = striated muscle which also surrounds internal one but extends more distally
- S234: S2/3 = inferior rectal branch of pudendal, S4 = perineal branch

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26
Q

Embryologically where does the ureter develop from?

A

Out-pouching of the mesonephric duct in embryo

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27
Q

Are the ureters intra or retroperitoneal?

A

Retro

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28
Q

What crosses the ureter?

A 
Men = ductus deferens 
Women = uterine artery
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29
Q

Relation of ureter to bifurcation of iliacs?

A

Anterior

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30
Q

Arterial supply of the ureter?

A 
Proximal = renal arteries
Middle = aortic branches, gonadal branches and common iliacs
Distal = Internal iliac
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31
Q

Lymphatic drainage of ureter?

A 
upper = para-aortic nodes
Lower = common iliac does
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32
Q

What is connected to the apex of the bladder?

What is this a remnant of?

A

Median umbilical ligament = ascends superiorly to umbilicus

Embryological remnant of urachus

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33
Q

Is bladder retroperitoneal?

Clinical significance ?

A

Yes, although peritoneum is draped on the top of it

As bladder distends it will separate transversalis fascia from peritoneum = can use suprapubic catheter without penetrating peritoneum.

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34
Q

What fixes the neck of the bladder in place?

A 
Men = Puboprostatic ligament
Women = pubovesical
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35
Q

Arterial supply to bladder?

Venous supply to bladder?

A

Inferior and superior vesicle arteries = branch of internal iliacs

Venous:
Men = vesicoprostatic plexus
Women = Vesicouterine plexus

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36
Q

Lymphatics of the bladder?

A

Mainly external iliac nodes

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37
Q

Female urethra: External urethral sphincter innervation + lymphatic drainage ?

A

Pudendal nerve

Whole female urethra drains to the internal iliac nodes

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38
Q

Four parts of the male urethra?

A
  1. pre-prostatic
    - Between bladder and prostate, stellate lumen
    - only about 2cm long
    - Has striated muscle to prevent retrograde ejaculation = internal sphincter
  2. Prostatic part:
    - surrounded by prostate
    - midway has circular elevation = seminal colliculus
  3. Membranous part:
    - Narrowest part
    - surrounded by external sphincter = first point of resistance
    - traverse perineal membrane
  4. Spongy part / penile part:
    - Travels through corpus spongiosum
    - covered by bucks fascia
    - Dilated at origin as infrabulbar fossa, dilated at navicular fossa too in glans of penis
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39
Q

Which section of male urethra is covered in bucks fascia?

A

Penile / spongy part

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40
Q

Which part of male urethra has the internal and external sphincter?

Muscle type?

A

Pre-prostatic = internal = striated muscle- autonomic

Membranous = external- somatic

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41
Q

Lymphatic drainage of male urethra?

A

Penile / spongy part = deep inguinal

Prostatic / membranous = internal iliac

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42
Q

What peritoneal pouch is formed where the peritoneum sits between the bladder and uterus?

A

Vesicouterine pouch

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43
Q

What pouch forms where the peritoneum sits between the rectum and uterus?

A

Recto-uterine pouch / POUCH OF DOUGLAS

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44
Q

What is the ligament called, formed by the large fold of peritoneum lateral to each uterus?

A

Broad ligament

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45
Q

What are the 3 parts to the broad ligament?

A

Mesometrium = extends from lateral pelvic wall to the uterus

Mesosalpinx = suspends uterine tubes

Mesovarium = Posterior extension attaching to ovaries

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46
Q

What is the suspensory ligament of the ovary called?

What does it contain?

A

Infundibulopelvic ligament

Ovarian vessels, nerves and lymphatics = all enter at superior pole

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47
Q

What ligament attaches to the inferior pole of the ovary?

What does this ligament continue as within the broad ligament?

A

Ligament of ovary

This continues anterolaterally in the broad ligament as ROUND LIGAMENT OF UTERUS

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48
Q

What is the main structural support of the uterus?

A

Central perineal tendon.

49
Q

Fascia of the cervix?

A

Pubocervical ligament = cervix to anterior pelvic wall

Transverse cervical / cardinal = cervix to lateral pelvic wall
- most important in stabilisation!!

Uterosacral = Cervix to posterior pelvic wall

50
Q

Lymphatic drainage of the vagina?

A

Superior = iliac nodes

Inferior = superficial nodes

51
Q

Organ sites that metastasise to para-aortic LN’s early?

A

Testis
Ovaries
Uterine fundus

52
Q

Lymphatic drainage of uterus, ovaries and cervix ?

A

Ovaries and uterine fundus = para-arotic via gonadal vessels

Uterine body = Iliac LN’s via broad ligament

Cervix = iliacs

53
Q

Blood supply of uterus?

A

Uterine artery = branch of internal iliac

54
Q

3 arteries, 3 nerves and 3 others of the spermatic cord PLUS where they come from / what they do?

A

Arteries:

  1. Testicular artery = branch of abdominal aorta, supplies testis and epididymis
  2. Cremasteric artery = from inferior epigastric
  3. Artery of vas. deferens = arises from inferior vesicle artery

Nerve:

  1. Sympathetic = lie on the arteries
  2. Genital of GF = supplies cremaster
    (3. ilioinguinal)

Other:

  1. Vas deferens = transmits sperm and accessory gland secretion
  2. Pampiform plexus = venous plexus, drains into R or L testicular vein
  3. Lymphatics - to lumbar or para-aortics
55
Q

Testes embryology - where do they start, where in 3rd month, where at 7th month?

A

Posterior wall L2
third month = iliac fossa
7th = deep inguinal ring

56
Q

What surrounds the testis?

A

Tunica vaginalis

The parietal layer is adjacent to the internal spermatic fascia

57
Q

What is the tunica vaginalis derived from?

A

Peritoneum

58
Q

What surrounds the seminiferous tubules and interstitial tissue?

What do the seminiferous tubules form and what does this lead to

A

Tunica albuginea

Seminiferous tubules form retes testis

this then leads to efferent ductules > head of epididymis

59
Q

Artery and venous supply of testis?

A

Testicular artery arises from aorta just below renal arteries

Pampiform plexus
L goes to left renal
R directly to IVC

60
Q

LN’s of the testis?

A

Para-aortic

61
Q

Course of the vas deferens?

A

Ascends in scrotum then passes through inguinal canal exiting deep ring
Then bends medially around inferior epigastric artery
Crosses external iliac vein and artery to enter pelvic inlet
Crosses ureter
Joined by seminal vesicle = ejaculatoy duct
Penetrates prostate and feeds into prostatic part of urethra

62
Q

Arterial supply of scrotum?
Lymphatic drainage?
Sensory innervation?

A

Anterior and posteiror scrotal arteries

Inguinal’s

Anterior = ilioinguinal
Posterior - pudendal

63
Q

Layers you cut through in scrotal surgery?

A 
Skin
Dartos fascia
External spermatic fascia
Cremasteric fascia / muscle 
Internal spermatic fascia
Parietal layer of tunica vaginalis
64
Q

Where do the posteiror and median lobes of the prostate sit in relation to the urethra?

A

Posterior

65
Q

What separates the rectum and prostate?

A

Denonvilliers fascia

66
Q

Prostate - arterial supply, venous supply + LN’s?

Innervation of prostate?

A

Inferior vesical artery from internal iliac

Prostatic venous plexus

Internal iliac LN’s

Inferior hypogastric plexus

67
Q

Which roots make up the lumbar plexus?

A

L1-L3 + part of L4

68
Q

Ilioinguinal nerve - root and course?

A

L1
Descends around abdominal wall in plane between transversus abdominus and internal oblique
Then passes via inguinal canal

69
Q

Ilioinguinal nerve - innervation?

A

No motor function in thigh, but innervates abdominal wall muscles

Sensory = anteromedial thigh and adjacent perineum

70
Q

Genitofemoral nerve - root and course?

A

L1/L2

Descends anteroinferiorly through the psoas muscle, then passes on the anterior surface of psoas
Femoral branch passes under inguinal ligament
Genital branch enters inguinal canal

71
Q

Genitofemoral nerve - innervation?

A

No motor, but in men genital branch innervates cremasteric muscle of spermatic cord

Sensory:
Genital = anterior perineum
Femoral = anterior central upper thigh

72
Q

Femoral nerve - root and course?

A

L2-L4

Passes through gap between inguinal ligament and pelvic bone
Enters femoral triangle

73
Q

Innervation of femoral nerve?

A

Motor = anterior thigh, illiacus and pectineus

Sensory = Anterior thigh, anteromedial knee + medial leg/foot

74
Q

Obturator nerve - root and course?

A

L2-L4

travels within the psoas major, and emerges from medial part
Passes posterior to common iliac artery, medial to internal iliac artery
Passes through obturator canal

75
Q

Obturator nerve innervation?

A

Medial muscles of thigh EXCEPT adductor magnus head attached to ischium + pectineus
Also innervates obturator internus

Sensory = upper medial thigh

76
Q

Lateral cutaneous nerve - root and path?

A

L2, L3

Passes between inguinal ligament and pelvic bone

77
Q

Lateral cutaneous nerve innervation?

A

Parietal peritoneum in RIF

Anterolateral thigh.

78
Q

What makes up the sacral plexus?

A

Anterior rami of S1-S4

Lumbosacral trunk = L4/L5

79
Q

What muscle is the sacral plexus formed anteriorly too?

A

Piriformis muscle

80
Q

Sciatic nerve - roots and course?

A

L4-S3

Leaves pelvis via greater sciatic foramen, inferior to piriformis
Descends between superficial and deep gluteal muscles
Then passes into gluteal region = Common peroneal and tibial

81
Q

What does common peroneal supply vs tibial nerve?

A

Common peroneal:
Motor = short head of biceps, anterior and lateral leg compartments
Also extensor digitorum brevis + contributes to first dorsal interossei
Sensory = Skin on anterolateral leg and dorsal foot

Tibial:
Motor = Posteiror hamstrings EXCEPT short head of biceps, posterior compartment of the leg, muscles in sole of the foot
Sensory = Posterolateral and medial foot + sole of foot

82
Q

Pudendal nerve - roots and course?

A

S2-S4

Leaves pelvis below piriformis, via greater sciatic foramen
Immediately curves around the sacrospinous ligament where it joins ischial spine, and passes via the lesser sciatic foramen
Accompanied by internal pudendal vessels

83
Q

What does pudendal nerve innervate?

A

Skin and muscles of perineum
Includes external urethral sphincter + anal sphincter and levator ani

Sensory = Skin of perineum + penis / clitoris

84
Q

Superior gluteal nerve - roots and course?

A

L4-S1

Leaves greater sciatic foramen above the piriformis
Travels in plane between gluteus medium and minimum

85
Q

What does superior gluteal nerve supply?

A

Gluteus medius and minimus

Terminates innervating tensor fascia lata

86
Q

Inferior gluteal nerve - roots and course?

A

L5-S2

Leaves pelvic cavity via greater sciatic foramen below piriformis
Penetrates gluteus maximus

87
Q

Inferior gluteal nerve supplies?

A

Gluteus maximus

88
Q

Nerve to obturator internus and superior gemellus - roots and course?

A

L5-S2

Leaves via greater sciatic foramen inferior to piriformis. Then passes around ischial spine and via lesser sciatic foramen

89
Q

Nerve to quadratus femoris and inferior gemellus - roots and course?

A

L4 - S1

Greater sciatic foramen, inferior to piriformis
Passes anterior to plane of deep gluteal muscles

90
Q

Posterior cutaneous nerves - roots and course?

A

S1, S3

Leaves via greater sciatic foramen inferior to piriformis
Immediately medial to sciatic nerve
Descends through gluteal region deep to gluteus maximus

91
Q

Posteiror cutaneous nerve innervation?

A

Skin on posterior thigh

92
Q

Perforating cutaneous nerve - root and course?

A

S2, S3

Unusual route and penetrates directly through sacrotuberous ligament to reach inferior buttocks

93
Q

Perforating cutaneous nerve innervation?

A

Skin over gluteal fold

94
Q

How does the nerve to piriformis leave the pelvic cavity?

A

It doesn’t, oiiiii

95
Q

Hypogastric plexus - route and what it eventually innervates?

A

Starts as superior hypogastric plexus anterior to L5, near aortic bifurcation
Enters pelvis as 2 hypogastric nerves. Crosses pelvic inlet medial to internal iliac vessels

Forms inferior hypogastric plexus when hypogastric nerves are joined by the splanchnic nerves

Inferior hypogastric plexus gives rise too:
Rectal plexus
Uterovaginal plexus
Prostatic plexus
Vesical plexus

Terminal branches innervate erectile tissue of penis/clitoris

96
Q

Penile erection - parasympathetic vs sympathetic innervation?

A 
Parasymp = erection
Sympathetic = Ejaculation and detumescence
97
Q

Penile erection - which are the somatic nerves, what nucleus they relay from and muscles innervated?

A

Dorsal penile and pudendal

Efferent fibres via Onuf’s nucleus

Ischiocavernous and bulbocavernous

98
Q

Where does internal iliac originate, and where does it divide into anterior and posteiror trunk?

A

Originates at L5/S1 just anterior to the sacroiliac joint

Divides into posterior and anterior trunks at superior border of greater sciatic foramen

99
Q

Internal iliac posterior trunk - branches and supply?

A

Iliolumbar:
- Divides into iliac and lumbar branch
- iliac = skin and muscles in RIF
Lumbar = psoas and quadratus lumborum

Lateral sacral:

  • Medial and inferior branches
  • Supply muscle and skin behind sacrum

Superior gluteal:

  • leaves pelvic cavity above piriformis via greater sciatic foramen
  • Divides into superficial and deep branches
  • Deep travels between medium and minimus
  • superficial Passes on deep surface of maximus
100
Q

Anterior trunk branches of internal iliac artery?

A 
Umbilical
Superior vesical
Inferior vesical (men) - vaginal artery in women = equivalent 
Inferior gluteal 
Middle rectal
Internal pudendal 
Obturator 
Uterine (women)
101
Q

Anterior trunk of internal iliac - Umbillical

Path
Embryology

A

Continues inferiorly before ascending on anterior abdominal wall to reach umbilicus

In foetus it is very large, in adults it becomes a fibrous cord
This cord is called medial umbilical ligament

102
Q

Anterior trunk of internal iliac - superior vesical

What does it supply?

A

Superior aspect of bladder and distal ureter

In men also supplies ductus deferens

103
Q

Anterior trunk of internal iliac - inferior vesical

Men or women?
What it supplies?

A

Men
Female equivalent = vaginal artery

Bladder ureter, seminal vesicle and prostate / vagina

104
Q

Anterior trunk of internal iliac - Obturator artery

Path and supply?

A

Leaves pelvis via obturator canal

Supplies adductor region

105
Q

Anterior trunk of internal iliac - Internal pudendal

Path and supply?

A

Greater sciatic foramen then the lesser sciatic foramen passing over sacrospinous ligament as it joins ischial spine

Erectile tissue

106
Q

Anterior trunk of internal iliac - inferior gluteal

Path

A

Passes between anterior rami of S1/S2/S3

Leaves greater sciatic foramen inferior to piriformis

107
Q

Anterior trunk of internal iliac - Uterine artery

Path

Supply

what it anastomoses with

A

Travels medially in base of the broad ligament to reach cervix
Crosses ureter and passes superior to lateral vaginal fornix

Anastomoses with. ovarian artery

108
Q

What are the ovarian arteries a branch of and what do they travel in?

A

Branch of aorta

Travel in suspense sort ligament of the ovaries = infundibulopelvic ligament

109
Q

Whats the vein draining clitoris / penis?

A

Single deep dorsal vein

110
Q

Left vs right ovarian vein drainage?

A

Left into renal vein

Right into IVC

111
Q

Borders of the perineum?

A

tip of coccyx posteriorly
Pubic symphysis anteriorly
Laterally = ischiopubic ramus anteriorly, sacrotuberous ligament posteriorly

Roof = levator ani

112
Q

How do we divide the perineum into two?

A

line between two ischial tuberosities

Anterior = urogenital triangle

Posteiror = anal triangle

113
Q

Contents of anal triangle?

A

External anal sphincter = S234

114
Q

Contents of urogenital triangle?

A

Males = bulb and crura of penis, superficial transverse perineal muscles and posteiror scrotal arteries and nerves

Females = Internal pudendal becomes posteiror labial artery, Muscles again, crura of clitoris, greater vestibular gland

115
Q

Three branches of the pudendal nerve and what they innervate?

A

Infeiror rectal = external anal sphincter + skin of anal triangle

Perineal = Skeletal muscles in perineal pouch + branches into scrotal / labial nerves

Dorsal nerve of penis / clitoris = sensory

116
Q

As the internal pudendal artery and pudendal nerve pass around ischial spine, which lies lateral?

A

Artery lies lateral

117
Q

Where do the testicular artery and cremasteric artery branch from?

A 
Testicular = aorta
Cremasteric = from the infeiror epigastric of the external iliac
118
Q

Layers of spermatic cord?

A

Internal spermatic fascia = Transversalis fascia
Cremasteric fascia = Internal oblique
External spermatic fascia = External oblique

Anatomy for MRCS (7 decks)

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