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Bottom Line Concepts

Terms in this set (96)

What nerve innervates the perineum?
Pudendal nerve
What is the most important landmark on the pelvis?
Ischial spine
Pudendal nerve travels along it
What does the pelvic diaphragm do?
Supports the pelvic viscera and plays an important role in urinary/fecal continence
Pubococcygeus portion
Considered the strongest muscle of the pelvic diaphragm
Puborectalis portion of pelvic diaphragm
Plays an important role in fecal continence as it forms a muscular sling around the ano-rectal junction
What do kegel exercises do?
Strengthen the pelvis diaphragm/floor muscles
What happens if the pelvic diaphragm is torn?
Prolapse of the uterus
Prolapse of the bladder
Prolapse of the rectum
What is the primary artery of the perineum?
Internal pudendal artery
What innervates the pelvic organs?
Inferior hypogastric plexus
What vascularizes pelvic organs?
Internal iliac artery
I love going places in my very own underwear
Branches of iliac artery

I: iliolumbar artery
L: lateral sacral artery
G: gluteal (superior and inferior) arteries
P: (internal) pudendal artery
I: inferior vesical (vaginal in females) artery
M: middle rectal artery
V: vaginal artery (females only)
O: obturator artery
U: umbilical artery and uterine artery (females only)
Injury to the pelvic floor
- tears to the pelvic diaphragm can occur during childbirth
- Pubococcygeus is typically considered the strongest of these pelvic floor muscles
- Tears of the pubococcygeus muscle can significantly weaken the pelvic diaphragm leading to loss of support of the pelvic visera including the bladder and rectum
Prolapsed uterus
Weakening of the pelvic diaphragm can also result in prolapse of the uterus
Treatment includes hysterectomy or pelvic floor reconstruction
Risk for prolapsed uterus
- Pregnancy/multiple childbirths
- Significant weight gain
- Chronic cough-COPD
Sampson Artery
An important anastomosis of the uterine artery and ovarian artery
Occurs at the round ligament of the uterus
Identified and dissected during hysterectomoies
Round ligament
Uterine horn to labia majora
Broad ligament
Double fold of peritoneum that extends laterally from each side of the uterus to the sidewalls of the pelvic cavity
1. Mesosalpinx
2. Mesovarium
3. Mesometrium
Mesoalpinx
Ensheaths the uterine tube
Mesovarium
Posterior extension with suspends the ovary
Mesometrium
Extends from the uterine body to the sidewalls of the pelvis
Uterosacral ligaments
Branch off of the cervix and help maintain the anteverted position of the uterus
Transverse cervical (Cardinal ligaments or Makenrodt's liagment) ligaments
Thickenings of the endopelvic facia that connect the cervix to the pelvic side walls
Support the uterus
Transmit the uterine artery
Uterine artery
Transverses through the base of the cardinal ligament and that the ureter passes the beneath the uterine artery
Which lymph nodes do most of the pelvic cavity/organs drain into?
Internal illiac vessels which then drain into common iliac nodes, which drain into the para-aortic nodes
Where does the lymph of the ovaries drain into?
Para-aortic nodes (lumbar nodes)
Lymph from the superficial perineal drains where?
The superficial inguinnal lymph nodes
Where do deep perineal structures flow?
Internal iliac nodes
Where do lymph from the glands of the clitoris flow into?
Deep inguinal nodes
Where will all of the lymph from the lower lymph and perineum drain into?
Thoracic duct to the left subclavian
Where do the majority of ectopic pregnancies occur?
In the uterine tubes
Pudendal nerve block
Performed by injecting a local anesthetic near the pudendal nerve
Can utilize either a transcutaneous or transvaginal approach
Transvaginal pudendal nerve block
Accomplished by inserting a needle through the posterolateral vaginal wall just beneath the pelvic diaphragm and angled towards the ischial spine, placing the needle in the vicinity of the pudendal nerve
Transcutaneous approach
Physician palpates the ischial spine through the wall of the vagina and advances the needle in to the vicinity of the boney spine/pudendal nerve
Pudendal canal
Transversing along the lateral aspect of the each ischional fossa
This important canal or passageway is formed by the splitting of the fascia of the obturator internus muscle on the lateral wall of the ischioanal fossa

The pudendal nerve and internal pudendal vessels enter the canal after exiting the lesser sciatic foramen in-route toward the perineum
Alcock's canal
Pudendal nerve and internal pudendal vessels traverse through this canal within in ischioanal fossae
Colles fascia
(a continuation of Scarpa's fascia from the abdomen) is also known as the superficial perineal fascia
Perineal membrane
separates the superficial and deep perineal spaces
Superficial space
houses the erectile bodies
Damage to the urethra inferior to the perineal membrane results into extravasation into the superficial perineal space
Deep perineal space
houses the external urethral sphincter
Above perineal membrane results in the extravasation into the deep perineal space
Bartholin's glands (Greater vestibular glands)
superficial space and can get infected
Perineal body "the central tendon of the perineum"
fibromuscular condensation between the vagina and the rectum
What membrane separates the superficial from the deep perineal space?
Perineal
Prostatic venous plexus
Drains venous blood from the prostate into the nearby iliac veins within the pelvis
Communicates with the venous plexus surrounding the vertebral column (batsons plexus)
Why do neoplastic cells from prostate cancer spread to the boney vertebral column?
Prostatic venous plexus which drains venous blood from the prostate communicates with the venous plexus surrounding the vertebral column
Where do the testes drain?
Right testicular vein drains into the IVS whereas the left testicular vein drains into the left renal vein
Varicocele
Varicose veins of pampiniform plexus are more common on the left side
What vascularizes the perineum in men?
Internal pudendal artery
What nerves are responsible for erection?
Pelvic splanchnic
Can result in erectile dysfunction
What innervates genitourinary organs?
Inferior hypogastric plexus (autonomic nerves)
External urethral sphincter
Surrounds the membranous urethra and is under voluntary control
Internal urethral sphincter
Innervated by sympathetic splanchnics
Surgical intervention along the aorta/bifurcation can damage these nerves
Ultimately these nerves play an important role in the sexual response
Prevent retrograde ejaculation of sperm into the bladder by constricting the internal urethral sphincter
Where do superficial structures like the skin of the penis and the skin of the scrotum drain their lymph?
Inguinal lymph nodes
Where do deeper structures like the erectile tissues within the penis drain their lymph?
Iliac nodes
Where do lymph from the testes drain?
Lumbar (aortic nodes)
Cavernous nerves
Branch of the pelvic splanchnic nerves
Cause dilation of blood vessels within the erectile tissue of the penis, resulting in engorgement and erect
Rupture of the membranous urethra
can result in urine/blood extravasation in the deep perineal space surrounding the bladder and prostate
Rupture of the spongy urethra
Result in extravasation of blood/urine into the superficial perineal space and into the scrotal sac/penis and along the anterior abdominal wall
Point, squeeze and shoot
Erection: parasympathetic
Emission: sympathetic
Ejaculation: somatic
Cowper's Glands
Produce an alkaline mucous secretion known as pre-ejaculate
Branches of the internal pudendal
1. Inferior rectal: anal sphincter
2. Perineal artery: perineal structures
3. Dorsal penile: vascular supply to the penis
Process of innervation of the bladder
1. Sympathetic stimulation contracts the internal sphincter, allowing the bladder to fill
2. Visceral sensory nerve detects fullness within the bladder walls
3. Parasympathetic nerves then stimulate the detrusor to contract and relax the internal sphincter, thereby facilitating micturition
Pelvic fractures lead to what urethral damage?
Rupture of the membraneous urethra can result in urine/blood extravasation in the deep perineal space surrounding the bladder and prostate
Straddle injuries
Rupture of spongy urethra results in extravasation of blood/urine into the superficial perineal space and into the scrotal sac/penis and along the anterior abdominal wall
where does the majority of the lymph of the breast drain?
Axillary nodes
What are the 5 groups of axillary lymph?
1. Pectoral nodes (majority)
2. Humeral nodes
3. Subscapular nodes
4. Central nodes
5. Apical nodes
Where does lymph drain on the right breast side?
Right Lymphatic duct
Where does lymph from the left breast drain?
thoracic duct
Sentinel node biospy
Used to determine whether cancer has spread beyond a primary tumor in the lymphatic system
First nodes in to which a tumor drains
1. Inject tracer material into tumor
2. Then identify sentinel nodes and remove them
3. If the sentinel nodes are free of cancer, it is unlikely cancer spread and removing addition lymph nodes may be unnecessary
What does peau d orange indicate
Breast tumor that blocked small superficial lymphatic channels resulting in edema and prominent skin changes
What does breast dimpling indicate?
Breast tumor can pull on and contract the connective tissue (suspensory) of the breast
Ductal carcinoma
Originating from the epithelium lining the ducts
Lobar carcinoma
Originating from terminal ductules
Breasts are innervated by what nerves?
Intercostal nerves
Supraclavicular nerves
Breasts are vascularized by what vessels?
Axillary artery
Internal (mammary) thoracic artery
Intercostal arteries
Colostrum and milk contain what?
1. Lymphocytes
2. Monocytes
3. Lactalbumin
4. Fat-soluble vitamins
5. Minerals
6. IgA
7. Caseins
8. Lactose
9. Lipids
What produces the majority of sperm?
Seminal glads
Prostate gland does the rest (25)
What innervates the breast?
Intercostals
Supraclavicular neres
Breasts are vascularized by what?
Axillary artery
Internal thoracic artery
Intercostal artery
What produces 70% of semen?
Seminal gland
What is the pathway of semen?
1. Seminal vesicle
2. Epididymus
3. Vas deferens
4. Ejaculatory duct
5. Urethra
6. Penis
What produces 25% of seminal fluid?
Prostate
What artery supplies the testes?
Testicular artery which is a branch of the abdominal aorta
What artery supplies the pelvic viscera and structures in the perineum?
anterior branch of the internal illiac
Pathway of the internal pudendal artery?
1. Exits the greater sciatic forman
2. Around the ischial spine
3. Reenters the lesser scietic foramen
What can happen to the prostatic plexus during surgery?
Can be damaged which can also damage the pelvic splanchnics which are responsible for erection
What artery supplies the penis?
Internal pudendal artery
Which artery is responsible for engorgement of the corpora during an erection?
Deep penile arteries
What vein drains erectile bodies?
Deep dorsal vein which joins the prostatic venous plexus
Where do deeper structues like the erectile tissues drain?
Iliac nodes
Where do superficial structures drain?
Inguinal lymph nodes
What muscle forms the largest part of the pelvic floor?
Levator ani innervated by the pudendal nerve
Perineal body
Fibromuscular mass where several muscles of the perineum converge, considered essential for the integrity of the pelvic floor
Rupture/tears during vaginal birth can predispose to organ prolapse
Ampulla
Longest and widest portion of the uterine tube that is normally the site of fertilization
Lymph from the Glans of the clitoris travel to the
Deep inguinal nodes
Where does the upper 3/4 of the vagina drain?
Iliac lymph node
Where does the lower 1/4 of the vagina drain?
Inguinal lymph node
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