0.1.2 Anatomy - Pelvis And Perineum

Front 1

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Back 1

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Front 2

Identify the bony landmarks of the pelvis which can be palpated on the body surface or palpated per vagina or per rectum.

Back 2

Iliac Spine
Anterior Superior Iliac Spine
Posterior Superior Iliac Spine
Pubic Tubercle
Pubic Symphysis
Pubic Crest
Ischial Tuberosity
Median Sacral Crest
Coccyx

Front 3

List the openings in the bony pelvis, major structures passing through these openings, and with which spaces these openings communicate.

Back 3

1. Greater Sciatic Foramen (Superior to Piriformis) (gluteal & posterior thigh) - Superior gluteal nerve and vessels
2. Greater Sciatic Foramen (Inferior to Piriformis) (gluteal & posterior thigh) - Inferior gluteal nerve and vessels, internal pudendal artery and vein, pudendal, sciatic, posterior femoral cutaneous, perforating cutabeous nerves and nerve to obturator internus and quadratus femoris.
3. Lesser Sciatic Foramen (coming) (perineum) - Pudendal nerve and internal pudendal artery & vein
4. Lesser Sciatic Foramen (going) (perineum) - Tendon of obturator internus and internal prudendal vein
5. Obturator Canal (medial thigh) - Obturator nerve and vessels

Front 4

Describe the following dimensions of the birth canal: pelvic inlet, conjugate (antero-posterior) diameter, interspinous distance and pelvic outlet.

Back 4

Obstetrical Conjugate - >10 (Most Important) - Pubic symphisis to sacral promontory - does NOT expand during pregnancy

Interspinous -10cm Narrowest part of pelvic canal - widens during pregnancy

Pelvic Outlet - 13.5cm - widens during pregnancy

Front 5

List the muscles that make up the pelvic diaphragm.

Back 5

Pelvic Diaphragm = Levator Ani + Coccygeus

Levator Ani
1. Puborectalis
2. Pubococcygeus
3. Iliococcygeus.

Front 6

List the innervations and blood supply of the levator ani muscle.

Back 6

Innervated by ventral branches S4 and prudendal nerve

Front 7

List the major structures passing through the urogenital hiatus in males and females.

Back 7

Females - urethra and vagina, deep vein of the clitoris
Males - urethra, deep vein of the penis

Front 8

Describe the peritoneal reflections from the abdominal wall down to the pelvic cavity and the pouches of the peritoneal cavity in the male and female pelvis.

Back 8

Retropubic Space - provides room for bladder to expand (needle can enter bladder without passing through peritoneal cavity.)

Retrovessical Pouch (males) - space above bladder for it to expand

Retrouterine Pouch (females) - space above uterus

Vessicuouterine Pouch (females) - space between bladder and uterus

???

Front 9

Explain how bleeding in the upper abdomen (such as from liver or spleen lacerations) can reach the pelvic peritoneal pouches.

Back 9

X

Front 10

Describe the course of the ureter from the kidney to the bladder.

Back 10

X

Front 11

Explain what is meant by “water under the bridge”.

Back 11

X

Front 12

Describe the retropubic space.

Back 12

Retropubic Space: space between pubic symphysis and bladder - provides room for bladder to expand (needle can enter bladder without passing through peritoneal cavity.)

Front 13

Describe the structures which support the urinary bladder.

Back 13

Neck of the bladder is the most stable part.

1. Pubovessical (female) or Puboprostatic (male) Ligaments - fibromuscular bands from posterior pubic bone to neck
2. Membranes of the urogenital diaphragm and pelvic floor

Front 14

Compare the innervation of the internal and external urethral sphincters.

Back 14

X

Front 15

List the divisions of the male urethra.

Back 15

X

Front 16

Describe the muscles and nerves (visceral afferent, somatic efferent, sympathetic, parasympathetic) involved in normal micturition and urinary continence.

Back 16

X

Front 17

Describe the arterial and nerve supply and venous and lymphatic drainage of the rectum and anal canal above and below the pectinate line.

Compare and contrast their embryologic origin?

Back 17

Above the pectinate line (internal anal sphincter) -
Arteries - Inferior mesenteric artery becomes superior rectal artery at the pelvic brim. It branches off the left colic, sigmoid, superior rectal, middle and inferior rectal arteries.
Veins - Superior rectal veins, internal venous plexus - drain into internal ileac and then into the portal system through an anastomosis in the upper part of the anal canal.
Lymph - rectum to inferior mesenteric, anal canal to internal iliacs.
Nerves - Autonomic to S2-S4 (no pain)

Below the pectinate line (internal anal sphincter) -
Arteries - See above.
Veins - internal pudendal vein, middle rectal vens, inferior rectal veins, external venous plexus drain into pudendal system
Lymph - superficial inguinals
Nerves - S2, S3, S4 by way of the Pudendal (voluntary with pain)

External venous plexus drains directly into the systemic venous return

Front 18

Compare the internal and external submucosal venous plexuses of the anal canal.

Back 18

?

Front 19

Describe the basic process of defaecation.

Back 19

1. Increase in intra-abdominal pressure
2. Puborectalis muscle relaxes (straightens anorectal junction)
3. External anal sphincter relaxes (shortens canal)
4. Rectum contracts pushing feces into canal, then internal anal sphincter contracts to push it out.

Front 20

Describe the developmental mechanism of anal agenesis, anal stenosis, membranous anal atresia (imperforate anus), rectal agenesis, anorectal agenesis.

Back 20

X

Front 21

Describe the development of a urachal cyst, sinus and fistula and explain their clinical significance.

Back 21

X

Front 22

Compare and contrast the visceral pain pathways for structures above the peritoneal floor of the pelvis versus structures below the peritoneal floor.

Back 22

X

Front 23

Describe the nervous pathways for control of erection, emission and ejaculation.

Back 23

X

Front 24

Describe the anatomical lobes of the prostate gland and the relationship of the median lobe and posterior lobe to the ejaculatory ducts.

Back 24

X

Front 25

List the lobes of the prostate, and the symptoms most commonly involved, in benign prostatic enlargement.

Back 25

X

Front 26

Explain why prostate cancer often leads to erectile and urinary dysfunction. Which nerves are involved?

Back 26

X

Front 27

Describe the surgical procedure called TURP (Trans-Urethral Resection of the Prostate) and common postoperative complications resulting from the procedure.

Back 27

X

Front 28

Describe the nerves that might be compromised during open prostatectomy and the consequence on sexual functioning and urinary continence.

Back 28

X

Front 29

List the common sites of prostate cancer metastasis and explain how prostate cancer cells can travel to the central nervous system.

Back 29

X

Front 30

Explain the clinical importance of the relationship of the posterior fornix to the rectouterine pouch.

Back 30

X

Front 31

Explain the differences in sensory innervation of the pelvic part of the vagina versus the perineal part of the vagina.

Back 31

X

Front 32

Explain how lower genitourinary infections in females, such as gonorrhea and chlamydia, can gain access to the pelvic peritoneal spaces.

Back 32

X

Front 33

Explain how/where the female ureter is at risk during ligation of uterine vessels.

Back 33

X

Front 34

Define ectopic pregnancy, list the sites of occurrence and the most common site.

Back 34

X

Front 35

Define the term “uterine prolapse” and explain why it is more common in multiparous (multiple vaginal deliveries) women.

Back 35

X

Front 36

Define “cystocoele” and explain why it is more common in multiparous women.

Back 36

X

Front 37

Define “stress urinary incontinence” and explain which structures may be injured during vaginal delivery to lead to this condition.

Back 37

X

Front 38

Describe development of a double and bicornuate uterus and the clinical significance.

Back 38

X

Front 39

Discuss the importance of vaginal and rectal examinations and pap smears in relation to the detection and prevention of uterine and ovarian cancer.

Back 39

X

Front 40

List areas supplied by branches of the internal iliac artery in males and females.

Back 40

X

Front 41

Describe the course of the internal pudendal artery and pudendal nerve in the pelvis and perineum.

Back 41

X

Front 42

Describe the course of the obturator nerve, artery and vein.

Back 42

X

Front 43

List the ventral rami contributing to the sacral plexus and describe the relationship of this plexus to the piriformis muscle.

Back 43

X

Front 44

List the terminal branches of the sacral plexus.

Back 44

X

Front 45

Explain how inflammation or a tumour near the lateral wall of the pelvis (such as a ruptured ovarian cyst or ovarian cancer) might cause pain in the medial thigh.

Back 45

X

Front 46

Describe the nerve fibres found in superior and inferior hypogastric plexus.

Back 46

X

Front 47

Describe the lymphatic drainage of the urinary bladder, prostate gland, ductus deferens and seminal vesicles, testes, scrotum, penis, ovaries, uterine tubes, fundus, body and cervix of uterus, pelvic part of vagina, vaginal vestibule, anal canal above the pectinate line and anal canal below the pectinate line.

Back 47

X

Front 48

Describe the bony landmarks used for determining the position of the pudendal nerve during a transvaginal pudendal nerve block and list the areas anaesthetised.

Back 48

X

Front 49

Compare and contrast the areas into which urine can extravasate following an intrapelvic versus an extrapelvic rupture of the urethra.

Back 49

X

Front 50

Contrast the nerves blocked when using lumbar versus sacral epidural anaesthesia during childbirth.

Back 50

X

Front 51

Compare and contrast the structures cut when performing an oblique versus a midline episiotomy.

Back 51

X

Front 52

List the boundaries of the superficial perineal pouch. Explain why extravasated urine will not pass into the thighs or the ischioanal fossa.

Back 52

X

Front 53

Describe a varicocoele.

Back 53

X

Front 54

Explain the developmental mechanism responsible for the formation of hypospadias and epispadias.

Back 54

X