Organization of the Pelvis

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Pelvic Wall

False Pelvis (Greater)

Above the pelvic brim
Portion of abdomen between the iliac fossa

True Pelvis (Lesser)

What part of the pelvis lies BELOW the pelvic brim?

Borders of the True Pelvis

Pelvic Inlet: Pelvic inlet, brim and Superior pelvic aperture (P.I.S)
-Above=Public symphysis and crest
-Sides = Iliopectineal Line
-Posterior = Sacral promontory
Pelvic Outlet: Inferior pelvic aperture (P.I.I.S.C)
-Pubic symphysis
-Ischiopubic ramus
-Ischial tuberosities
-Sacrotuberous ligaments
-Coccyx

What separates the pelvis from the perineum? And forms the floor of the Pelvis?

The Pelvic Diaphragm

Where are the Pubic Tubercles and the ASIS in the anatomical position?

Located on the same vertical plane

Anterior Wall of the Pelvis

Pubic bone
Public symphysis

What are the components of the Lateral Wall of the Pelvis?

Hip bone below the pelvic inlet
Obturator internus muscle
Obturator membrane

Posterior Wall of the Pelvis

Piriformis muscle
Sacrum and coccyx

Function of the Piriformis muscle?

Laterally rotate the thigh

Pelvic Diaphragm

Levator Ani Muscle- Anteriorly
Coccygeus Muscle - Posteriorly

What structures passes through the Pelvic Diaphragm (front to back)

Urethra, Vagina and Anal canal

Is the Diaphragm complete or incomplete at the urogenital hiatus?

Incomplete so as to allow passage of urethra (m/f) and vagina (f)

Function of Pelvic Diaphragm

Supports all pelvic viscera
Involved in voluntary control of micturition and support of uterus

Male Pelvis

Which Pelvis is
Smaller angle ~45 deg
Heavier and thicker?

Female Pelvis

Which pelvis is >80 degrees (has a larger pelvic inlet and outlet) and is shallower and wider

T/F?
The Parietal Pelvic Fascia is continuous above with the fascia lining the abdominal wall

True: Eg. Transversalis fascia

T/F The Parietal Pelvic Fascia forms a looser connective tissue membrane on the pelvic surface of muscles and blends with the periosteum of the bony pelvic boundaries?

False - A RELATIVELY DENSE Membrane

Arcus Tendinous

Thickening of the obturator internus fascia and important as the origin of a large portion of the levator ani muscle

Superior Fascia of the Pelvic diaphragm

The Parietal fascia covering the pelvic surface of the pelvic diaphragm

Visceral Pelvic Fascia

Looser connective tissue investing the pelvic viscera (Uterus, vagina, bladder, rectum)

Subperitoneal Pelvic Fascia

Fatty continuation of the extraperitoneal fascia from the abdomen into the pelvis
All the ligaments formed blends medially with the visceral fascia covering the visceral organs and laterally with the parietal pelvic fascia

What are the ligaments formed from the condensations of the Subperitoneal Pelvic Fascia

Pubovesical ligaments
Lateral cervical ligaments
Uterosacral Ligament

Most important for support of the Pelvic floor (in females)?

Mackenrodt's Ligament

Blood Vessels of the Pelvis

Common Iliac Artery -> Bifurcates at the pelvic brim in front of sacroiliac joint into -> External and Internal iliac arteries.

External Iliac Artery

Continues the course of the Common Iliac artery along the pelvic brim

Internal Iliac artery

Passes downwards into the pelvis and contributes most of the its blood supply.

What are the exceptions of the Internal Iliac artery supply?

The Ovarian artery (branch of abd aorta)
Superior rectal artery (terminal branch of inferior mesenteric)

T/F Veins of the pelvis correspond closely to the arteries?

True

T/F The Common Iliac artery has branches

FALSE

T/F The rectum is a direct continuation of the sigmoid colon

TRUE

Rectum

Begins at rectosigmoid junction in front of S3 as a continuation of the sigmoid colon

T/F The rectum ends at the anorectal junction in front of the tip of the coccyx as the rectum pierces the pelvic diaphragm

TRUE

What is the lower part of the rectum?

Dilated, forming the Rectal Ampulla (latin for Flex)

T/F Ureters are retroperitoneal

True

Ureters

Descend on surface of psoas major muscles
Cross into pelvis OVER difurcation of Common Iliac arteries
Enters the urinary bladder at the superolateral angle, course obliquely through the wall app 3/4inch before opening into the bladder

What crosses over the Ureter in Males?

Ductus Deferens

What crosses over the Ureter in Females

The Uterine Artery:
Water (Ureter) runs under the bridge (Uterine artery)

Name the three sites for Kidney Stones

Junction of ureter and Renal pelvis
Where ureter crosses pelvic brim
Passage through the urinary bladder

Adult Bladder

Posterior to the pubis, rises into the abd as it fills, lifting peritoneum off inner surface of the anterior abd wall

What separates the bladder from the pubis?

The Retropubic space

The infant Bladder

Empty-lies largely above pelvic brim (an abd organ until age 8-10)

Where does the Neck of the Male Bladder rest?

On the Prostate gland - so its alittle higher in the pelvis

Where does the neck of the Female bladder rest?

On the urogenital diaphragm - so it has a lower position in the pelvis

Vagina

Fibromuscular tube extending anteroinferiorly

What are fornices?

Extensions of the vagina.
Vaginal recesses at upper end formed around the vaginal portion of the cervix

Which is LONGER - The posterior or anterior vaginal wall?

Posterior (because of angle betw vagina and cervix)

Which is DEEPER and LONGER - The anterior, posterior or lateral fornices?

Posterior (because of angle betw vagina and cervix)

What are the anterior borders/Relations of the Vagina?

Bladder - above
Urethra - Below

What separates the vagina from the anal canal?

Perineal Body:
A lot of muscles embedded here, site for episiotomy

What are the posterior borders/Relations of the Vagina?

Upper 1/3= Uterorectal pouch of Douglas
Middle 1/3 = Rectal Ampulla
Lower 1/3 = Perineal body

What is the deepest part of the Vagina?

Upper 1/3=Uterorectal pouch of Douglas

Structure of the Uterus

Fundus = Above entrance of the uterine tubes
Body = Beneath the entrance of the uterine tubes
Cervix = Narrow inferior portion

How does the cervix communicate with the body?

Through the Internal Os

How does the cervix communicate with the Vagina

External Os

Fornices

Recesses encircling the intravaginal portion of the cervix
Anterior, Posterior and Lateral

What is the lower portion of the body of the uterus adjoining the supravaginal segment of the Cerix?

Isthmus of the Uterus

Anteversion

Longitudinal axis of uterus is bent forward ~90 deg relative to the vagina.

Longitudinal axis of uterus bent forward or backward?

Forward

Anteflexion

Body of uterus is bent forward at junction of the internal Os and cervical canal

Why is the normal Uterus anteflexed?

Intrinsic to fibromuscular wall of the body and cervix

Why is the normal uterus considered to be Anteversioned?

Pull exerted on the cervix by uterosacral ligaments.

Uterine Tubes

Located on either side of uterus immediately below the fundus in the free edge of the broad ligament

What are the segments of the uterine tubes?

Infundibulum= funnel shaped lateral end - Fimbriae (fingerlike processes of the infundib), Ovarian fimbbria (attached to the ovary
Ampulla= widest part of tube and site of fertilizt
Isthmus = Narrowest part of tube closest to uterine wall
Intramural part - segment piercing the uterine wall

Where is the usual site for fertilization?

Ampulla of the uterine tube

this part of the infundibulum attaches to the ovary

Ovarian Fimbria

What is the narrowest part of the uterine tube

Isthmus

T/F The uterine tubes are functionally a muscular continuation of the Uterus

True

How can pathogenic organisms enter the body during sex?

Through vagina->cervix-->uterus-->uterine tubes

What usually follows the entry of a pathogenic organism in the body during sex?

Salpingitis

What is Salpingitis

Leakage of pus into the peritoneal cavity causing Pelvic peritonitis

What is an ectopic pregnancy?

Implantation and growth of a fertilized ovum outside the uterine cavity

Where does ectopic pregnancies usually occur?

Uterine tube

How is an ectopic pregnancy life threatening?

Eroding action of the trophoblast quickly destroys the wall of the tube and causes an effusion of a large amt of blood into the uterovesical pouch or the uterorectal pouch of Douglas

Is the broad ligament a Single or double layered fold?

Double layered extending from lateral margins of uterus to lateral pelvic walls

How is the ovary attached to the posterior layer?

By the Mesovarium

Is the ovary attached to the posterior or anterior layer of the broad ligament?

Posterior

What is the Mesosalpinx?

The part of the broad ligament forming the mesentery of the uterine tube

Mesometrium

Major part of the broad ligament, below the mesovarium and mesosalpinx

Suspensory Ligaments of the Ovary

Lateral-most part of the broad ligament which encloses the ovarian vessels, nerves and lymphatics

What structures are enclosed by the Broad ligament?

Uterine tubes (in upper free border)
Ovarian ligaments
Round ligaments
Uterine and ovarian blood vessels

Ovarian and Round Ligament

What are the derivatives of the Gubernaculum?

Ovarian ligament

Runs in the posterior lamina of the broad ligament from uterine pole of ovary to uterus just below uterotubal junction

Round Ligament

Runs in the anterior lamina of the broad ligament from pt just below uterotubal junction to labia majora via inguinal canal.

What are the chief supports of the Uterus?

Levator Ani muscles
Perineal body
Transverse cervical ligaments (Cardinal ligament, Mackenrodt's ligament)
Uterosacral ligament

Uterine Artery

Main blood supply of the Uterus

T/F The uterine artery runs in the base of the broad ligament and crosses the ureter at 90 deg near the lateral fornix of the vagina?

True

T/F The uterine artery ascends along the lateral border of the uterus within the broad ligament and ends by anastomosing with the ovarian artery?

This is true. Before ascending it also gives off descending cervical and vaginal branches

What is prolapse of the Uterus?

Downward displacement of the uterus

What usually accompanies prolapse of the Uterus?

Prolapse of the vagina

How is prolapse of the uterus caused?

Weakening of the Levator ani muscles, perineal body or ligaments supporting the uterus during childbirth or due to poor muscle tone.

When does prolapse of the uterus usually occur?

During menopause when the pelvic fascias tend to atrophy along with the pelvic organs.

T/F The ovarian ligament connects the ovary to the uterus?

True. The Ovarian ligament aka the upper part of the gubernaculum

Ovarian Fossa

Position of ovary in young nulliparous woman

What are the borders of the Ovarian Fossa?

Anterior-External Iliac vessels
Posterior - Internal iliac vessels and ureter

Why is Ovarian pain sometimes perceived on the medial side of the thigh?

Because the ovary lies close to the obturator nerves in the ovarian fossa. So inflammation of the ovary or peritenum in the ovarian fossa may affect the obturator nerve

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