Repro. ANATOMY Flashcards
(187 cards)
1
Q
What are the functions of the Pelvis?
A
- Support of upper body when sitting and standing
- Transference of weight from vertebral column to femurs to allow standing and walking
- Attachments of muscles for locomotion + abdominal wall
- attachment for external genitalia
- Protection of pelvic organs, blood supply, nerve, venous and lymphatic drainage
- Passage for childbirth
2
Q
The Bony pelvis consists of:
A
2 hip bones
Sacrum
Coccyx
3
Q
Each hip bone is a fusion between:
A
Ilium
Ischium
Pubis
4
Q
What is indicated by labels A, B and C
A
A - Iliac Crest
B - ASIS (Anterior Superior Iliac Spine)
C - Anterior Inferior Iliac Spine
5
Q
What is indicated by labels A, B and C?
A
A - Iliac Crest
B - PSIS (Posterior Superior Iliac Spine)
C - Posterior Inferior Iliac Spine
6
Q
What bony features are labelled below?
A
A - Ischiopubic ramus
B - Ischial tuberosity
C - Ischial spine
7
Q
Which bony features of the Pubis are labelled below?
A
A - Ischiopubic ramus
B - Pubic arch
C - Sub-pubic angle
D - Pubic tubercle
E - Superior pubic ramus
8
Q
What spaces within the pelvis are represented by the red and green lines here?
A
Red = Pelvic Inlet
Green = Pelvic Outlet
9
Q
What bones form the borders of the Pelvic Inlet?
A
- Sacral Promontory
- Ilium
- Superior pubic ramus
- Pubic symphysis
10
Q
What bones form the border of the Pelvic Outlet?
A
- Pubic Symphysis
- Ischiopubic Ramus
- Ischial Tuberosities
- Sacrotuberous ligaments
- Coccyx
11
Q
What is the Pelvic Cavity?
A
- Lies within bony pelvis
- Contains pelvic organs + supporting tissues
- Continuous with abdominal cavity above
- Lies between pelvic inlet and pelvic floor
12
Q
What are the palpable surface landmarks of the pelvis?
A
Iliac crest
ASIS
PSIS
Ischial tuberosity
Coccyx
Pubic symphysis (on deep palpation)
13
Q
What bony features of the pelvis are labelled below?
A
A - Iliac Crest
B - Ischiopubic ramus
C - Superior Pubic Ramus
D - Ischial spine
14
Q
What bony features of the pelvis are labelled below?
A
A - ASIS
B - Pubic Tubercle
C - Ischial tuberosity
D - Ischial spine
15
Q
What bony features of the pelvis are labelled below?
A
A - Iliac crest
B - Ischiopubic ramus
C - Pubic arch
D - Superior pubic ramus
E - Ischial tuberosity
16
Q
Which joints of the pelvis are labelled below?
A
A - Sacroiliac joint
B - Obturator foramen
C - Pubic symphysis
D - hip joint
17
Q
What are the names of the labelled ligaments?
A
A - Sacrospinous ligament
B - Sacrotuberous ligament
C - Sacrospinous ligament
18
Q
Give the name of the labelled structure below:
A
A - Greater sciatic foramen
B - Lesser sciatic foramen
19
Q
Explain why the ligaments of the pelvis relax during later pregnancy
A
Sacrotuberous and sacrospinous ligaments ensure inferior part of the sacrum is not pushed superiorly when weight is suddenly transferred vertically through vertebral column (e.g. when jumping or in late pregnancy)
Stops the sacrum from being pushed superiorly when transferring weight
20
Q
What structures pass through obturator foramen?
A
Obturator nerve and vessels pass through obturator foramen via obturator canal
21
Q
What does ‘Moulding’ refer to?
A
‘Moulding’ refers to movement of one bone over another to allow the foetal head to pass through the pelvis during labour.
22
Q
What feature of the foetal skull allows for ‘moulding’ to occur during labour?
A
Fontanelles
The presence of fontanelles (sutures between bones not fully formed and membrane spaces) allows for the bones to slide over each other.
23
Q
What is the ‘vertex’ of a foetal skull?
A
Area of the foetal skull
Outlined by anterior + posterior fontanelles and the parietal eminences
24
Q
True or False:
The biparietal diameter of the foetal skull is LONGER than the occipitofrontal diameter
A
FALSE FALSE FALSE
The occipitofrontal diameter is longer than the biparietal diameter (the foetal skull is longer than it is wide)
25
What is the ideal position for the foetus to enter the pelvic cavity and why?
Foetus should ideally enter pelvic cavity transversely (facing right or left direction)
Within the pelvic inlet, the transverse diameter is wider than the AP diameter (foetus facing transversely because the occipitofrontal diameter is longer than biparietal diameter)
26
What does it mean by the 'station' in regards to foetal descent in the pelvis?
Station = distance of the foetal head from the ischial spines
-ve number = head is superior to spines
+ve number = head is inferior to spines
27
Explain the descend of the foetal head during labour
* Enters the pelvic cavity/pelvic inlet in transverse position
* While descending through cavity head should rotate within cavity
* Should be in flexed position (chin on chest)
* At pelvic outlet, the AP diameter is wider than transverse so ideally head should leave in occipitoanterior (OA) position
* During delivery foetal head should be in extension
28
What is the next step once the baby's head has been delivered?
Once head is delivered, there is a further rotation required so that shoulders and the rest of the baby can be delivered
29
What parts of the female reproductive system lie within the Pelvic Cavity?
Ovaries
Uterine Tubes
Uterus
Superior part of vagina
30
What parts of the female reproductive system lie within the Perineum?
Inferior part of vagina
Perineal muscles
Bartholin's Glands
Clitoris
Labia
31
In women, where does excess fluid within the peritoneal cavity tend to collect?
Abnormal fluid collects within the **Pouch of Douglas** (rectouterine pouch)
Most inferior part of peritoneal cavity in anatomical position
32
What is a clinical method of draining excess fluid from the peritoneal cavity in women?
Fluid collects in Pouch of Douglas
Drained via needle passed through posterior fornix of vagina
33
What is the name of these pouches formed in the floor of the peritoneal cavity?
A - Rectouterine pouch (Pouch of Douglas)
B - Vesico-uterine Pouch
34
Identify the following (include side):
A - Right ovary
B - Right uterine tube
C - Vesico-uterine pouch
D - Rectouterine Pouch (pouch of Douglas)
35
What feature is this arrow pointing to?
Broad Ligament of the uterus
36
What is the Broad Ligament of the uterus?
Double layer of peritoneum
Extends between uterus and the lateral walls & floor of pelvis
37
What is contained within the Broad Ligament?
Uterine Tubes
Proximal part of Round Ligament
38
What is the function of the Broad Ligament?
Helps maintain the uterus in its correct midline position
39
What is the Round Ligament?
Embryological remnant
Attaches to lateral aspect of uterus
40
What is the course of the Round Ligament?
Attaches to lateral aspect of uterus
Passes through deep inguinal ring to attach to superficial tissue of female perineum
(guides ovaries from original place on posterior abdominal wall to position in perineum)
41
Which ligaments are labelled?
A - Broad Ligament
B - Round Ligament
42
Describe the layers of the body of the uterus?
3 layers
Perimetrium (outer)
Myometrium (muscle layer)
Endometrium (sheds during menstrual cycle)
43
What are Stone Babies?
Lithopedion
Embryo/baby develops in abdominal cavity but does not survive. If too large to be reabsorbed by the body the outside calcifies (part of a foreign body reaction) to shield the mother from the dead tissue and infection risk.
44
What are the 3 levels of support that hold the uterus in position?
* Strong ligaments (e.g. uterosacral ligament)
* Endopelvic fascia
* Muscles of pelvic floor (e.g. levator ani)
Weakness of these supports can result in Uterine Prolapse (uterus moves inferiorly)
45
What is the most common position for the uterus to sit and explain what this means?
Anteverted and Anteflexed
Anteverted - cervix tipped anteriorly relative to axis of vagina
Anteflexed - uterus tipped anteriorly relative to axis of cervix
(Mass of uterus lies over the bladder)
46
What is a common variation for the uterus to sit which is not the normal?
Retroverted + Retroflexed
Retroverted - cervix tipped posteriorly relative to axis of vagina
Retroflexed - uterus tipped posteriorly relative to axis of cervix
47
What area of the vagina must be sampled in a cervical screening?
Squamo-columnar Junction (Transformation Zone)
(must use speculum to open walls of vagina to visualise the cervix)
48
Where does fertilisation tend to occur?
Ampulla
49
True or False:
The uterine (fallopian) tubes usually lie symmetrically in the pelvic cavity
FALSE
Do not usually lie symmetrically
50
Explain the communication between uterine tubes (fimbriae) and the peritoneal cavity.
Why is this relevant clinically?
Fimbriated end of uterine tubes open into peritoneal cavity (communication between genital tract and peritoneal cavity)
Infection could pass between the two areas (PID \> peritonitis, ectopic pregnancy)
51
Which clinical test is pictured below and what is it assessing?
Hysterosalpingogram (HSG)
Patency of tubes
(in this image the radiopaque dye can be seen spilling out of end of uterine tube and into peritoneal cavity suggesting that the tube is patent)
52
True or False:
The ovaries secrete oestrogen and progesterone in response to anterior pitutary hormones FSH + LH
TRUE
53
What is the rough size of a normal ovary and where is it located?
Almond sized and shaped
Located laterally in pelvic cavity
Sits within the Ovarian fossa in most people (shallow depression on lateral pelvis wall)
54
What is labelled below?
A - Anterior fornix
B - Posterior fornix
C - Lateral fornix
55
At what point are the vagina walls held apart?
Cervix
The vagina is a muscular tube - walls normally in contact
At superior part the cervix holds them apart forming a fornix (= space around the cervix)
56
What are the main structures felt for on palpation during Vaginal Digital Examination?
1. Ischial Spines - laterally, 4 + 8 o'clock position
2. Uterus position (e.g. anteverted) - bimanual palpation
3. Adnexae - uterine tubes + ovaries, lateral fornix \> press deeply in iliac fossa of same side (can detect masses or tenderness)
57
What are the borders of the diamond which forms the Urogenital and Anal Triangle?
Anterior - Pubic Symphysis
Posterior - coccyx
Lateral - Ischial spine
58
True or False:
The levator ani is one large muscle
FALSE
Made up of a number of smaller muscles
Skeletal muscle (voluntary), Forms majority of pelvic diaphragm
59
What is the function of the levator ani muscle?
Provides continual support for the pelvic organs
* Tonic contraction
* Reflexively contracts during times of increased intra-abdominal pressure
(weakness factor in prolapse)
60
61
What is the Perineal Body?
= Bundle of collagenous and elastic tissue into which the perineal muscles attach
Very important for pelvic floor strength and support
Located just deep to skin (can be damaged during labour)
62
What is the primary nerve of the perineum?
Pudendal Nerve (S2, 3, 4)
63
What is the Bartholin's Gland in females?
aka Greater Vestibular Glands
Pea-sized compound alveolar glands located slightly posterior on right & left of vagina opening
Secretes mucous to lubricate vagina
64
Why are Bartholin's Glands relevant clinically?
Can become infected quite easily and enlarge
Can be quite painful
65
What surface anatomy structures are labelled below?
A - Mons pubis
B - Labium majus
C - Labium minus
D - External Urethral Orifice
66
What surface anatomy structures are labelled below:
A - Clitoris
B - External Urethral Orifice
C - Vestibule
D - Vaginal Orifice (external opening into vagina)
67
What surface anatomy structures are labelled below:
A - Labium majus
B - Clitoris
C - Vestibule
D - Vaginal orifice
E - Anus
68
What are the borders of the bed of the breast?
From ribs 2-6
Lateral border of sternum to mid-axillary line
69
Name the structures of the breast labelled below:
A - Suspensory Ligaments (attach skin to breast)
B - Areola
C - Pectoralis Major
D - Lactating Lobules
70
Name the structures of the breast labelled below:
A - Retromammary Space (between fascia and breast)
B - Pectoralis Major
C - Non-lactating Lobules
D - Lactiferous Ducts
71
Name the structures of the breast labelled below:
A - Suspensory Ligaments
B - Retromammary Space
C - Lactiferous Ducts
D - Lactating Lobules
72
Explain the quadrants of the breast used to describe the position of a lump.
4 quadrants/clock face
9 o'clock = lateral, 3 o'clock = medial
12 o'clock = superior, 6 o'clock = inferior
9 \>12 = Upper Outer
12 \> 3 = Upper Inner
3\> 6 = Lower Inner
6 \> 9 = Lower Outer
73
Where does the majority of lymph from the breast drain to?
To ipsilateral axillary lymph nodes
Then to Supraclavicular nodes
74
What is the blood supply to the female breast?
Axillary (from Subclavian)
Internal Thoracic (internal mammary)
75
Why is the distinguishment between structures in the Pelvis or Perineum so important in terms of nerve supply?
Pelvis:
* Body cavity
* Sympathetic, Parasympathetic, Visceral afferent
Perineum:
* Body Wall
* Somatic motor, Somatic Snesory
levator ani muscle marks division between pelvis + perineum
76
For the superior aspect of pelvic organs what is the nerve route and perception for 'pain'?
(Organs touching the peritoneum)
Visceral afferents run alongside sympathetic fibres
Enter spinal cord T11-L2
Pain perceived as SUPRAPUBIC
77
For the inferior aspect of pelvic organs what is the nerve route and perception of 'pain'?
(Organs not touching peritoneum)
Visceral afferents run alongside parasympathetic fibres
Enter spinal cord at S2, S3, S4
Pain perceived in S2-4 dermatome (perineum)
78
What is the difference in 'pain' sensation for structures crossing from pelvis to perineum (e.g. urethra, vagina)?
Above levator ani = pelvis
* Visceral afferents
* Parasympathetic
* Spinal cord levels S2, S3, S4
Below levator ani = perineum
* Somatic sensory
* Pudendal Nerve
* Spinal cord S2, S3, S4
* Localised pain within perineum
79
What is the sensory and motor innervation of the Pudendal nerve?
Sensory - external genitalia (M+F), skin around anus/anal canal/perineum
Motor - pelvic muscles, external urethral sphincter, external anal sphincter
80
Describe the sympathetic autonomic nerves of the pelvis
Sacral sympathetic trunks
T11-L2
**_Superior Hypogastric Plexus_** (plexus of nerves anterior to AA bifurcation, contains sympathetic function for the urogenital system)
81
Describe the parasympathetic autonomic nerves of the pelvis
Sacral outflow (S2, S3, S4)
**_Pelvic Splanchnic Nerves_**
Emerge from spinal roots \> mixes with sympathetics in _Inferior Hypogastric Plexus_ (supplies viscera of pelvic cavity, gives rrise to prostatic plexus in males + uterovaginal plexus in females)
82
Which of the following organs (that touch the peritoneum) are supplied by visceral afferents back to T11-L2?
Options: Uterus, Cervix, Ovaries, Uterine Tubes, Superior vagina
Uterine Tubes
Uterus
Ovaries
83
Which of the following organs (inferior to peritoneum) are supplied by visceral afferents back to S2-S4?
Options: Uterus, Cervix, Ovaries, Uterine Tubes, Superior vagina
(Pelvic Splanchnic nerves + parasympathetic fibres)
Cervix
Superior vagina
84
From the following list: which of these organs/structures are supplied by the Pudendal nerve in 'pain' sensation?
Options: Inferior vagina, Superior vagina, Uterus, Perineal muscles, Skin, Cervix, Glands, Ovaries
Pudendal nerve (S2-S4)
Inferior vagina, perineal muscles, glands, skin
Uterus + ovaries = visceral afferents T11-L2
Superior vagina, cervix = visceral afferents S2-S4
85
In regards to pain from female repro system which two sets of spinal cords are most important?
T11-L2
S2-S4
86
At what level is a spinal & epidural anaesthetic injected?
L3-L4 (L5) Region
87
At what level does the spinal cord end?
L2 vertebrae
Spinal cord becomes cauda equina
(subarachnoid space ends at level S2)
88
What layers does the needle pass through for epidural anaesthetic?
Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Epidural space (fat + veins)
89
Identify the ligaments labelled A, B and C.
A - Supraspinous ligament
B - Interspinous ligament
C - Ligamentum flavum
90
Which structures of the spine are labelled below?
A - Ligamentum flavum
B - Epidural Space
C - Subarachnoid Space
D - Arachnoid Mater
E - Dura Mater
91
Which structures of the spine are labelled below?
A - Ligamentum flavum
B - Epidural Space
92
During a spinal anaesthetic what structures does the needle pass through?
(Same location as epidural anaesthetic - L3/L4)
* Supraspinous ligament
* Interspinous ligament
* Ligamentum flavum
* Epidural space (fat + veins)
* Dura mater
* Arachnoid mater
Reaches Subarachnoid space (contains CSF)
93
What are some signs in the lower limbs that show spinal anaesthetic is working?
Sympathetic fibres supply all arterioles (sympathetic tone)
BLOCKADE of sym. tone to all arterioles in low limb = Vasodilation
Effects:
* Skin of lower limbs looks **Flushed**
* **Warm** lower limbs
* **Reduced sweating**
94
What is the course of the Pudendal nerve once it exits the spine?
* Exits pelvis via greater sciatic foramen
* Passes posterior to sacrospinous ligament
* Re-enters pelvis via lesser sciatic foramen
* Travels in pudendal canal (passage within obtruator fascia with internal pudendal artery + vein)
* Branches to supply perineum
95
What landmarks are used for pudendal nerve block?
Pudendal nerve crosses lateral aspect of sacrospinous ligament
Can palpate ischial spine through vagina as landmark to administer block
96
What are some possible clinical uses for a pudendal nerve block?
Forceps delivery
Painful vaginal delivery
Episiotomy incision
97
How can the pudendal nerve and sphincter be damaged during labour?
* Branches of pudendal nerve can be stretched with resultant stretch of nerve fibres
* Fibres within levator ani (puborectalis) or external anal sphincter muscl could be torn (muscle is weakened)
Could result in faecal incontinence and pelvic floor weakness
98
What is an Episiotomy?
Posterolateral (mediolateral) incision
Made into relatively 'safe' fat filled ischioanal fossa during labour
Avoids incision extending into rectum
99
What are Langer Lines?
Langer lines of skin tension
Correspond to natural orientation of collagen fibres in dermis (generally perpendicular to orientation of underlying muscle fibres)
100
Which layers of the anterolateral abdominal wall are labelled below?
A - External oblique
B - Internal oblique
C - Transversus abdominis
101
Which layers of the anterolateral abdominal wall are labelled below?
A - Skin
B - Superficial fascia
C - Rectus Abdominis
D - Rectus Sheath
102
Which layers of the anterolateral abdominal wall are labelled below?
A - Rectus Sheath
B - Rectus abdominis
C - Internal oblique
D - Transversus abdominis
103
Which muscle is shown below?
What are the attachments of this muscle?
External Oblique
Attachment - lower ribs, iliac crest, pubic tubercle, linea alba
(fibres run in same direction as external intercostals
104
Which muscle is shown below?
What are the attachments of this muscle?
Internal Obliques
Attachments - lower ribs, thoracolumbar fascia, iliac crest, linea alba
(fibres run in same direction is internal intercostals)
105
Which muscle is shown below?
What are the attachments of this muscle?
Transversus Abdominis
Attachments - lower ribs, thoracolumbar fascia, iliac crest, linea alba
106
Which muscle and feature are labelled below?
A - Rectus Abdominis
B - Tendinous Intersections
107
What is the function of the tendinous intersections of the rectus abdominis?
Divides each rectus abdominis into 3 or 4 smaller muscles
Improves mechanical efficiency
108
What is the linea alba?
= Midline blending of aponeurosis of anterolateral abdominal muscles
Formed by the interweaving of the muscle aponeuroses
Runs from xiphoid process to pubic symphysis
109
What is the Rectus Sheath?
= Combined aponeuroses of anterolateral abdominal wall muscles
* Surrounds rectus abdominis muscles
* Strong, fibrous layer
* Immediately deep to superficial fascia
110
What is labelled below?
A - Posterior Rectus Sheath
B - Anterior Rectus Sheath
111
True or False:
When undertaking a suprapubic incision, e.g. LSCS, the anterior and posterior rectus sheath will be cut
FALSE
Only the anterior rectus sheath will be cut
112
During a surgery, is the rectus sheath left to heal or stitched closed?
Stitched closed
Rectus sheath is a strong, fibrou layer/covering - stiched closed after operation to increase strength of wound and reduce risk of complications, e.g. incisional hernia
113
Which structures of the internal surface of the abdominal wall are labelled below?
A - Transversus abdominis
B - Internal oblique
C - External oblique
114
Which structures of the internal surface of the abdominal wall are labelled below?
A - Transversalis fascia
B - Extra peritoneal feat
C - Parietal peritoneum
115
Which structures of the internal surface of the abdominal wall are labelled below?
A - ilioinguinal nerve
B - Inguinal ligament
116
Name all the structures of the abdominal wall labelled below?
A - Transversus abdominis
B - Internal oblique
C - External oblique
D - ilioinguinal nerve
E - Inguinal ligament
F - Transversalis fascia
G - Extra peritoneal fat
H - Parietal peritoneum
117
What is the nerve supply to the anterolateral abdominal wall?
Enters from lateral direction
* 7th - 11th intercostal nerves become Thoracoabdominal nerves
* Subcostal (T12)
* iliohypogastric (L1)
* ilioinguinal (L1)
Travel in plane between internal oblique and transversus abdominis
118
What is the blood supply to the anterior abdominal wall (also name origin of artery and location)?
**_Superior Epigastric arteries_**
* Continuation of internal thoracic artery
* Emerges at superior aspect of abdominal wall
* Lies posterior to rectus abdominis
**_Inferior Epigastric arteries_**
* Branches of external iliac artery
* Emerges at inferior aspect of abdominal wall
* Lies posterior to rectus abdominis
119
What is the blood supply to the lateral abdominal wall (also name origin and location)?
Intercostal and Subcostal arteries
* Continuations of posterior intercostal arteries
* Emerge at lateral aspect
120
Which arteries of the abdomen are labelled below?
A - Intercostal & Subcostal arteries
B - Superior Epigastric
C - Inferior Epigastric
121
True or False:
When incising muscles, incise in same direction as muscle fibres
TRUE
Incise in same direction as muscle fibres to minimise traumatic injury to muscle fibres
122
What is an LSCS Incision?
Lower (uterine) Segment Caesarean Section
123
In an LSCS incision what happens to the rectus muscles?
The rectus muscles are NOT cut
Separated from each other in lateral direction (moving towards nerve supply)
124
During an LSCS incision what layers are seen when opening and which layers need stitched closed?
Layers when opening: Skin + fascia, rectus sheath (anterior), rectus abdominis (separated laterally), fascia + peritoneum, retract bladder, uterine wall, amniotic sac
Layers to stitch closed:
* Uterine wall (with visceral peritoneum)
* Rectus sheath
* Fascial layer (if increased BMI)
* Skin
125
During a Laparotomy which layers are seen when opening and when layers need stitched closed?
Layers when opening: Skin + fascia, Linea alba, Peritoneum
Layer to stitch closed:
* Peritoneum + Linea Alba
* Fascia (if increased BMI)
* Skin
126
Which possible incisions can be made for a laparoscopy procedure?
Sub-umbilical incision
Lateral port (be careful to avoid inferior epigastric artery)
127
What is the route of the inferior epigsatric artery?
Branch of external iliac artery
Emerges medial to deep inguinal ring (inguinal ring halfway between ASIS + pubic tubercle)
Passes in superomedial direction posterior to rectus abdominis
128
What is the difference between an abdominal and vaginal hysterectomy?
Abdominal hysterectomy - uterus removed via incision in abdominal wall (often same incision as LSCS)
Vaginal hysterectomy - removal of uterus via the vagina
129
What points can be used to differentiate the ureter from the uterine artery in a hysterectomy?
* Ureter passes inferior to the artery ('water under the bridge')
* Ureter will often 'vermiculate' when touched
130
Which muscles make up the pelvic diaphragm?
Levator Ani (puborectalis, pubococcygeus, iliococcygeus)
Coccygeus
(has appearance of sling with aterior gap between medial borders)
131
Which components of the pelvic floor are labelled below?
A - Urethra
B - Prostate
C - Levator Ani
D - Rectum
132
What components of the pelvic floor are labelled below?
A - Levator ani
B - Coccygeus
C - Ischial Spine
133
Which components of the pelvic diaphragm are labelled below?
A - Urethra
B - Prostate
C - Vagina
D - Rectum
E - Levator Ani
F - Coccygeus
G - Ischial Spine
134
What is the Urogenital hiatus?
Anterior gap between medial boarders of pelvic diaphragm
Allows for passage of urethra (and vagina in women)
(also rectal hiatus as well but muscles attach so less of a gap)
135
What are the attachments of the levator ani?
Pubic bones, ischial spines, tendinous arch of levator arch
Perineal body, coccyx, walls of organs in midline
136
Name the muscles labelled below?
A - Iliococcygeus
B - Pubococcygeus
C - Puborectalis
137
What is the normal contraction and innvervation of the levator ani?
Tonically contracted most of time (must relax to allow urination and defaecation)
Innervated by Pudendal nerve and nerve to levator ani
138
Name the labelled ligaments of the pelvis?
A - Utero-sacral ligament
B - Transverse Cervical ligament
C - Tendinous arch of pelvic fascia
139
Name the labelled ligaments of the pelvis
A - Lateral ligament of bladder
B - Tendinous arch of pelvic fascia
C - Tendinous arch of levator ani (covers obturator internus)
140
Which pelvic ligaements provide additional support in the pelvis?
* Fibrous endo-pelvic fascia
* Uterosacral
* Transverse cervical (cardinal)
* Lateral ligament of bladder
* Lateral Rectal ligaments
141
Where does the deep perineal pouch sit and what does it contain?
Lies below fascia covering inferior aspect of pelvic diaphragm
AND above perineal membrane
Contains parts of urethra, vagina (females), bulbourethral glands (males), neuovascular bundle for penis/clitoris, extensions of ischioanal fat pads, muscles
142
Which components of the deep perineal pouch are labelled below?
A - Dorsal vein of clitoris/penis
B - External urethral sphincter
C - Compressor urethrae
143
Which components of the deep perineal pouch?
A - Bulbourethral Gland
B - External Urethral Sphincter
C - Compressor urethrae
D - Deep transverse perineal muscle
144
Which components of the deep perineal pouch is labelled?
A - Dorsal vein of clitoris/penis
B - External urethral sphincter
C - Compressor urethrae
D - Smooth muscle (deep transverse perineal in males as thought to be skeletal muscle)
145
What is the perineal membrane?
Thin sheet of tough, deep fascia (last passive support of pelvic organs - together with perineal body)
Attaches laterally to sides of pubic arch, closing urogenital triangle
Has openings for the urethra (+ vagina)
146
Name the layers of the perineum
A - Perineal Membrane
B - Deep Perineal muscles
C - Pelvic Diaphragm
147
Name the following:
A - Urethra
B - Crura
C - Bulb
D - Perineal membrane
148
Name the following:
A - Ischiocavernosus
B - Bulbospongiosus
C - Superficial Transverse Perineal
149
Name the following:
A - Ischiocavernosus
B - Bulbospongiosus
C - Superficial transverse perineal
150
Name the following:
A - Crura
B - Bulb
C - Perineal membrane
D - Greater vestibular glands (aka Bartholin Gland, same as Couppers gland in males)
151
What is the erectile tissue within the superficial perineal pouch (male + female)?
Male:
* Bulb (anterior cylinder) - corpus spongiosum
* Crura (2 posterior cylinders) - corpus cavernosum
Female:
* Clitoris + crura - corpus cavernosum
* Bulb (split into 2) - corpus spongiosum
152
What is the function of the pelvic floor?
* Provides support to pelvic organs
* Normally tonicaly contracted
* Actively contracts during increased pressure (cough, sneeze, vomiting)
* Helps maintain continence
* Urinary - external urethral sphincter, compressor urethrae, levator ani
* Faecal
* Tonic contraction of puborectalis bends anorectum anteriorly
* Active contraction maintains continence after rectal filling
153
What are some risk factors of pelvic floor injuries?
* Pregnancy
* Childbirth (stretching or tearing, pudendal nerve damage)
* Chronic constipation
* Obesity
* Heavy lifting
* Chronic cough or sneeze
* Previous injury to pelvis/pelvic floor
* Menopause
154
What parts of the pelvic floor are essential for continence?
Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall
155
What is a Vaginal Prolapse?
Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
Presents as lump in vaginal wall
156
What is the difference between a Urethrocele, Cystocele, Rectocele and Enterocele?
**Urethrocele** - urethra sags or presses into vagina
**Cystocele** - prolapsed bladder, bulges into vagina
**Rectocele** - front wall of rectum into back wall of vagina
**Enterocele** - descending of small intestine into lower pelvic cavity (pushes on top part of vagina + creates bulge)
157
What is a Uterine prolapse?
Descent of uterus (starts to move down and potentially out through vagina)
Presents as dragging sensation, feeling of 'lump', urinary incontinence
158
Define the different degrees of uterine prolapse
1st - cervix drops down into vagina, descend of uterus to above hymen
2nd - uterine descent to level of hymen
3rd - cervix completely exited vagina, can be felt on outside
4th - both cervix + uterus outwith vagina
159
Explain the Sacrospinous fixation for treatment of prolapse
Sutures placed in sacrospinous ligament (medial to ischial spine) to repair cervical/vault descend
Performed vaginally
Risk of injury to pudendal NVB and sciatic nerve
160
Explain the trans-obturator approach for incontinence surgery
Approach through obturator foramen
Feed mesh through obturator canal (space in obturator foramen for passage of obturator NVB)
Create sling around urethra
Incisions through vagina + Groin
161
Name the ligaments of the lateral pelvic wall labelled below:
A - Obturator Membrane
B - Sacrospinous ligament
C - Sacrotuberous ligament
162
Name the points of the lateral pelvic wall:
A - Obturator internus (LR of hip)
B - Coccygeus
C - Piriformis (LR of hip)
D - Levator ani
163
Name the points of the lateral pelvic wall labelled:
A - Obturator Canal
B - Sacral Plexus
C - Tendinous arch of levator ani (thickened fascia lying over obturator internus)
D - Levator Ani
164
Where do the majority of arteries of pelvis + perineum arise from and what are the main exceptions?
Internal Iliac artery
Exceptions - Gonadal artery (L2 abdominal aorta), Superior Rectal artery (IMA)
165
Nae these major arteries of the pelvis and perineum
A - Gonadal artery (L2 abdominal aorta - supply testes/ovary)
B - Abdominal aorta
C - Inferior Mesenteric artery
D - Superior Rectal artery (supply rectum)
E - External Iliac
F - Internal Iliac
166
How are the sections of the internal iliac artery separated?
Anterior Division - visceral
Posterior Division - parietal
167
Name the arteries of the male labelled A, B, C and the divisions lavelled D and E?
A - Common Iliac
B - Internal Iliac
C - Gluteal arteries
D - Anterior division
E - Posterior division
168
Name the arteries of the anterior division labelled A, B, C, D and E.
Also explain how artery C differs in females
A - Obturator artery (into obturator canal)
B - Internal Pudendal artery
C - Superior + Inferior Vesical arteries
D - Middle Rectal artery
E - Prostatic branch of Inferior Vesical artery
Some texts state females don't have an inferior vesical artery (equivalent in females = vaginal artery)
169
Name the arteries of the male pelvis labelled A, B, C, D and E.
A - Obturator artery
B - Medial Umbilical Ligament (remnant of umbilical artery - connects internal iliac to placenta)
C - Superior + Inferior Vesical Arteries
D - Gluteal arteries
E - Internal Pudendal artery
170
Name the aspects of the internal abdominal wall labelled.
A - Lateral Umbilical Fold (inferior epigastric vessels)
B - **Medial** Umbilical Fold (remnant of umbilical artery)
C - **Median** Umbilical Fold (urachus)
171
Name the arteries of the male perineum labelled.
A - Dorsal artery of penis (supplies corpus spongiosum)
B - Deep Artery (supplies corpus cavernosum)
C - Internal Pudendal artery
D - Perineal artery
E - Posterior scrotal artery
F - Anterior scrotal artery (from external iliac)
172
What is the origin arterial supply to the male perineum?
Most branches from Internal Pudendal (from internal iliac, terminates as dorsal artery + deep artery of penis)
Exception = Anterior Scrotal Artery (comes from external iliac)
173
Name the arteries of the female pelvis labelled A, B, C and the divisions labelled D and E.
A - Internal Iliac artery
B - Gluteal arteries
C - Obturator artery
D - Anterior divison
E - Posterior division
174
Name the arteries of the the female pelvis A, B, C and D.
Which surgical procedure is artery A important to identify?
A - Uterine Artery
B - Internal Pudendal Artery
C - Middle Rectal artery (superior rectal off IMA)
D - Vaginal artery (branch of uterine artery, inferior vesical artery in males)
Artery A relevant for hysterectomy + ligation
175
Name the arteries of the female pelvis labelled A, B, C, D and E.
A - Obturator artery
B - Medial umbilical ligament (remnant of umbilical artery)
C - Superior Vesical arteries
D - Uterine artery
E - Vaginal artery
176
What are the two most important anastamosis of the female reproductive system?
1. Between Uterine artery and Ovarian artery
Ovarian artery has tubal + ovarian branch which moves towards uterus and anastamoses with uterine artery
2. Between Uterine artery and Vaginal artery
Vaginal artery comes off uterine artery and then anastamoses with it again around superior aspect of vagina
Inferior aspect of vagina - inferior pudendal artery branches anastamose with vaginal artery
177
Name the arteries labelled A, B, C, D and E.
A - Ovarian artery
B - Tubal branch
C - Ovarian branch
D - Uterine artery
E - Vaginal artery
178
Name the arteries labelled A, B, C and D.
A - Internal Iliac artery
B - Uterine artery
C - Vaginal artery
D - Internal pudendal artery
179
What is the anatomical relation between the Ureter and Uterine artery in women?
'Water under the Bridge'
Ureter passes directly underneath uterine artery
Relevant for ligation of uterine artery in Hysterectomy (ureter damage assoc. with hysterectomy)
180
Name the arteries of the female perineum labelled below.
A - Dorsal artery of clitoris
B - Internal Pudendal artery
C - Inferior Rectal Artery
D - Perineal artery
E - Labial artery (of internal pudendal/internal iliac)
F - Labial artery (of external iliac)
181
True or False:
The venous drainage of the pelvis is mainly into External iliac vein
FALSE
Drains mainly to Internal iliac vein
Some drain into hepatic portal system via superior rectal vein
Some drain via Lateral Sacral veins into Internal Vertebral venous plexus
182
While venous drainage in the pelvis mainly drains into internal iliac vein, what are two other some blood will drain to?
Hepatic Portal system - via superior rectal vein,
Internal Vertebral Venous Plexus - via Lateral sacral veins (pre-sacral sits in middle), risks with infection/cancer spread
183
Name the labelled nerves of the lateral wall of the pelvis.
A - Obturator nerve
B - Sciatic nerve
C - Pudendal
D - Nerve to Levator ani
E - Sacral plexus
F - Pelvic splanchnic nerves (parasym.)
184
Which lymph node are labelled here?
A - Sacral
B - Internal Iliac
C - External Iliac
D - Deep Inguinal
E - Pararectal
185
Which lymph node are labelled here?
A - Lumbar
B - Inferior Mesenteric
C - Common iliac
D - Deep Inguinal
E - Superficial Inguinal
186
What is the lymphatic drainage route for the following:
Superior Pelvic Viscera
Inferior Pelvic Viscera
Superficial Perineum
1. External iliac nodes \> common iliac \> aortic \> thoracic duct \> venous system
2. Deep perineum \> internal iliac nodes \> common iliac \> aortic \> thoracic duct \> venous system
3. Superficial inguinal nodes
187
What is Trans-peritoneal spread?
Disease can penetrate through peritoneal layer (acts as a barrier normally until penetrated) and disseminate into the peritoneal cavity
