Pelvis II

Question 1

The parietal layer of the pelvic fascia is derived from what?

Answer 1

a continuation of the transversalis fascia.

Question 2

Parietal pelvic fascia forms what?

Answer 2

the deep fascia of the obturator internus, levator ani, coccygeus and piriformis muscles. Therefore, the parietal pelvic fascia lines the walls of the true pelvis.

Question 3

What are the two clinically relevant thickenings of the parietal pelvic fascia?

Answer 3

tendinous arch of the levator ani and the tendinous arch of the pelvic fascia (aka the white line).

Present in men and women

Question 4

What is the tendinous arch of the levator ani?

Answer 4

serves as the origin of the intermediate portion of the levator ani fibers.

Question 5

What is the tendinous arch of the pelvic fascia?

Answer 5

This arch runs from the pubis to the sacrum and is an important suture point for pelvic surgery.

Question 6

What are the three important thickenings of visceral pelvic fascia?

Answer 6

1) pubovesical (female) or puboprostatic (male) ligaments
2) Transverse Cervical Ligament (a.k.a. Cardinal Ligament or Mackenrodts’s ligament, female)
3) Uterosacral (female) and Sacrogenital (male) ligaments

Question 7

What do the pubovesical (female) or puboprostatic (male) ligaments do?

Answer 7

These ligaments stabilize the neck of the bladder and the prostate (in males).

Question 8

What does the Transverse Cervical Ligament (a.k.a. Cardinal Ligament or Mackenrodts’s ligament, female) do in women?

Answer 8

This ligament extends from the cervix to the lateral walls of the pelvis and it conveys the uterine vessels.

Question 9

What do the Uterosacral (female) and Sacrogenital (male) ligaments do?

Answer 9

This ligament extends from the cervix/prostate to the posterior wall of the pelvis. These ligaments help to stabilize the cervix or prostate gland.

Question 10

What does the seminal vesicle secrete?

Answer 10

It secretes an alkaline, fructose‐rich fluid that mixes with and contributes to the volume of the semen.

Secretions from the seminal vesicle contribute significantly to the volume of the ejaculate and provides a nutrient source for the spermatozoa (fructose).

Question 11

Where is the seminal vesicle in relation to the vas deferens?

Answer 11

It is an elongated structure situated between the bladder and rectum and is immediately lateral to the vas deferens

Question 12

The ampulla of the vas and the seminal vesicle unite inferiorly to form what?

Answer 12

the ejaculatory duct (runs in the prostate between the median and posterior lobes)

Question 13

Where does the ejaculatory duct enter the urethra? What part of the urethra?

Answer 13

passes thru the posterior aspect of the prostate at an anterior/inferior angle to empty into the prostatic urethra at the seminal colliculus

Question 14

What does the prostate gland produce?

Answer 14

It produces an alkaline liquid that contributes significantly to the volume of ejaculate.

NOTE: It is immediately inferior to the bladder, posterior to the pubic symphysis and anterior to the rectum

Question 15

Where do the secretions of the prostate gland empty into the urethra?

Answer 15

at the prostatic sinuses

Question 16

What are the structural components of the prostate?

Answer 16

a base (superior, related to the neck of the bladder) and an apex (inferior, related to the superior fascia of the UGD) and two inferolateral surfaces (related to the levator ani).

Question 17

What are the 5 anatomical lobes of the prostate gland?

Answer 17

The anterior lobe lies in the midline, anterior to the urethra.

The posterior lobe lies in the midline, posterior to the urethra and inferior to the ejaculatory ducts.

The median lobe lies in the midline, posterior to the urethra and superior to the ejaculatory ducts.

The two lateral lobes lie on either side of the urethra

Question 18

Which prostate lobes are most commonly involved in patient complaints of the prostate?

Answer 18

median and posterior

Question 19

Which prostate lobe is most commonly associated with cancer (carcinoma)?

Answer 19

The posterior lobe lies posterior to the urethra and inferior to the ejaculatory ducts and is most commonly involved in cancer (>55 yrs, feels “rock hard” on palpation).

Question 20

Where does the median lobe sit and what is most commonly involved in with older (at least middle aged) patients?

Answer 20

The middle lobe lies posterior to the urethra and superior to the ejaculatory ducts and is most commonly involved in benign hypertrophy (enlargement) of the prostate (common in middle age).

Benign hypertrophy distorts the urethra and impedes urination

Question 21

Where does the abdominal aorta bifurcate?

Answer 21

L4 (into the common iliac arteries)

Question 22

Where do the common iliac arteries split?

Answer 22

sacroiliac joint (The internal iliac artery is the artery of the pelvis. The external iliac artery continues into the lower limb as the femoral artery.)

Question 23

What are the parietal branches of the anterior portion of the internal iliac arteries?

Answer 23

1. Obturator Artery—to the medial compartment of the thigh 2. Internal Pudendal Artery—to the perineum
2. Inferior Gluteal Artery—to the gluteal region

Question 24

What are the visceral branches of the anterior portion of the internal iliac arteries?

Answer 24

1. Superior Vesical Artery—to the bladder, commonly a branch of the obliterated artery)
2. Inferior Vesicle Artery/Vaginal Artery—to the bladder and vagina respectively
3. Middle Rectal Artery—to the rectum
4. Uterine Artery—to the uterus, females only

Question 25

What are the parietal branches of the posterior portion of the internal iliac arteries?

Answer 25

1. Iliolumbar Artery 2. Lateral Sacral Artery 3. Superior Gluteal Artery.

Question 26

Where does the iliolumbar artery run and what does it supply?

Answer 26

passes superiorly between psoas major and the vertebral column and supplies psoas major, iliacus, and quadrates lumborum

Question 27

Where does the lateral sacral artery run and what does it supply?

Answer 27

passes anterior to the sacral ventral rami and supplies sacral canal

Question 28

Where does the superior gluteal artery run and what does it supply?

Answer 28

it is the terminal branch of the posterior portion of the internal iliac artery and typically runs between the lumbosacral trunk and ventral ramus S1 to exit the pelvis vis the greater sciatic foramen

Question 29

Where does the obturator artery run and what does it supply?

Answer 29

passes through the obturator canal with the obturator nerve to supply the medial thigh

Question 30

Where does the internal pudendal artery run and what does it supply?

Answer 30

exits pelvis thru the greater sciatic foramen between the performs and coccygeus with the pudendal nerve

Question 31

Where does the obturator artery run and what does it supply?

Answer 31

exits pelvis thru the greater sciatic foramen after passing between S2 and S3 (bigger than the internal pudendal a.)

Question 32

Where does the umbilical artery run and what does it supply?

Answer 32

The umbilical artery is the first visceral branch. It passes to toward the bladder where it gives off several small superior vesical arteries and a small artery to the ductus deferens.

Question 33

Distal to giving off the small artery to the ductus deferens and small superior vesicle arteries, the umbilical artery atrophies and continues on as what?

Answer 33

the medial umbilical ligament.

Question 34

Where does the middle rectal artery run and what does it supply?

Answer 34

The middle rectal artery passes to the middle third of the rectum where it anastomoses with the superior and inferior rectal arteries. It often arises near the internal pudendal and inferior gluteal arteries.

Question 35

Where does the inferior vesical artery run and what does it supply?

Answer 35

The inferior vesicle artery supplies the deep surfaces of the bladder and the prostate & seminal vesicles in men. It supplies the deep surface of the bladder and often forms vaginal branches (2-3) in women

Question 36

What does the uterine artery travel in?

Answer 36

usually forms as a separate branch and crosses the floor of the pelvis in the transverse cervical ligament at the base of the broad ligament

Question 37

What does the ovarian ligament run in?

Answer 37

the mesovarium (follows the suspensory ligament)

Question 38

What ligament does the uterine artery run with?

Answer 38

the cardinal ligament (situated just at the base of the broad ligament)

Question 39

What is the blood supply to the rectum and anal canal?

Answer 39

the superior (off the IMA), the middle (off the internal iliac), and the inferior (from the internal pudenal a.) rectal arteries

Question 40

Are the superior, middle, and inferior rectal arteries canal or portal?

Answer 40

superior is portal, inferior and middle are caval

Question 41

What are the nerve root contributions of the lumbosacral trunk?

Answer 41

L4-L5

Question 42

What is the sacral plexus composed of?

Answer 42

formed by the ventral rami of S1 to S4 plus the lumbosacral trunk which is comprised of contributions from L4 and L5 which enters the pelvis from the lumbar plexus by passing ventral to the sacroiliac joint.

Question 43

What is the Coccygeal Plexus formed by? What does it do?

Answer 43

formed by a minor contribution from S4 + ventral rami of S5 and Co. This plexus forms the anococcygeal nerves which innervate the skin in the anal triangle.

Question 44

Where is the Superior hypogastric plexus located?

Answer 44

at the sacral promontory just inferior to the bifurcation of the aorta. It is comprised of nerve fibers connecting the aortic autonomic plexus with the inferior hypogastric (or pelvic) plexus below. This plexus receives preganglionic sympathetic fibers from the lumbar splanchnics (sympathetic).

Question 45

What are Hypogastric nerves formed by?

Answer 45

The hypogastric nerves are formed by the separation of the fibers in the superior hypogastric plexus into right and left bundles. These are still mostly preganglionic sympathetic fibers. These structures contain no ganglia. They are the principal sympathetic roots to the inferior hypogastric plexus.

Question 46

Where is the Inferior hypogastric plexus (or pelvic plexus) located?

Answer 46

located on the pelvic floor on either side of the rectum.

Question 47

What are the inferior hypogastric (pelvic) plexuses formed from?

Answer 47

the hypogastric nerves are joined by sacral splanchnic nerves (pre‐ganglionic sympathetic fibers) and pelvic splanchnic nerves carrying preganglionic parasympathetic fibers from S2‐4. Most of the fibers that enter are either preganglionic sympathetic fibers from the lumbar/sacral splanchnics or preganglionic parasympathetic fibers from the pelvic splanchnics. Sympathetic lumbar/sacral splanchnic fibers synapse in un‐named collateral ganglia within the inferior hypogastric plexus. Parasympathetic pelvic splanchnic fibers synapse in terminal ganglia within the inferior hypogastric plexus or more commonly, within the walls of the hindgut or pelvic viscera.

Question 48

What structures drain to the internal iliac nodes?

Answer 48

deep perineum

Question 49

What structures drain to the superficial inguinal nodes?

Answer 49

superficial penis/clitoris, scrotum/labia majora

Question 50

What structures drain to the deep inguinal nodes?

Answer 50

glans penis/clitoris, labia minora, vagina

Question 51

What structures drain to the aortic nodes?

Answer 51

ovaries