Moore's Blue Boxes - Pelvis

Front 1

Pelvic Girdle

Back 1

Variations in male and female pelves

gynecoid = female --> rounded, oval shape with wide transverse diameter

android = male --> funnel shaped

females have wide pubic arch, shallow pelvis, larger pelvic outlet

Front 2

Pelvic Conjugates

Back 2

minimum AP diameter of lesser pelvis = true conjugate from middle of sacral promontory to the closest point of the pubic symphysis (narrowest distance through which a baby’s head must fit)

estimated properly using the diagonal conjugate from sacral promontory to pubic symphysis (bladder is in the way for the true measurement)

Front 3

Pelvic Fractures

Back 3

crush accidents --> fractures of pubic rami, acetabulum, and ala of ilium

usually multiple fractures combined with a joint dislocation (i.e. trying to break a pretzel in 1 place, but breaking it in many)

often effects all of the nerves, arteries and muscles closely surrounding the fracture

Front 4

Spondylolysis and Spondylolisthesis

Back 4

defect allowing vertebral arch of a vertebral body to separate from the body

happens with L5’s vertebral arch interlocking with the sacrum (characterized by an abnormally protruding L5 process along back)

bilateral = spondylolisthesis

anterior displacement of L5 vertebral body may interfere with parturition or compress spinal nerves

Front 5

Changes in Pelvic Ligaments and Joints during Pregnancy

Back 5

increased levels of relaxin cause pelvic ligaments to relax, allowing increased movement of pelvic joints (and posterior movement of coccyx)

permits a 10-15% increase in transverse diameter

relaxation of sacroiliac ligaments --> “swayback” posture assumed during pregnancy

Front 6

Injury to Pelvic Floor

Back 6

perineum, levator ani, and pelvic fascia may be injured during childbirth (pubococcygeus is most often torn)

this weakening may cause change in position of bladder and urethra --> urinary stress incontinence (dribbling of urine when intra-abdominal pressure is increased)

Front 7

Prenatal "relaxation" training for childbirth

Back 7

attempts to learn how to relax muscles of the pelvic floor voluntarily while increasing intra-abdominal pressure (natural response is to contract during pressure)

facilitates passage of fetus through birth canal providing decreasing resistance during uterine contractions

Front 8

Injury to Pelvic Nerves

Back 8

sacral plexus --> compression by baby’s head during childbirth

obturator nerve --> vulnerable during surgical procedure along pelvic wall

Front 9

Iatrogenic injury of the ureters during uterine / ovarian artery ligation

Back 9

“water under the bridge” = ureter passes inferior to uterine artery near the fornix

Important to ligate correct structure during hysterectomy and ovariectomy

Front 10

Ligation of internal iliac and collateral circulation

Back 10

collateral pathways when internal iliac is ligated to stop pelvic bleeding: lumbar --> iliolumbar, median sacral --> lateral sacral, superior rectal --> middle rectal

help maintain blood supply to pelvic viscera, gluteal region, and genital organs

Front 11

Iatrogenic compromise of ureteric blood supply

Back 11

ureters can be injured during abdominal, retroperitoneal, pelvic, or gynecological operations through inadvertent interruption of their blood supply

abdominal supply from medial direction, pelvic supply from lateral direction

Front 12

Ureteric calculi (kidney stone)

Back 12

pain caused by larger stones = colicky pain from hyperperistalsis superior to level of obstruction
may cause complete or intermittent obstruction of urinary flow
most often occurs at 3 sites

junction at renal pelvis

passing through pelvic brim over the split of the common iliacs

junction at urinary bladder
removed through surgery, endoscopy, or lithotripsy (shock waves break up stone into fragments)

Front 13

Cystocele - hernia of bladder

Back 13

damage to perineal muscles in the female causes loss of bladder support and herniation into vaginal wall

may also result from prolapse of pelvic viscera (due to injury of pelvic floor from childbirth)

Front 14

Suprapubic cystotomy

Back 14

distended bladder lies adjacent to anterior abdominal wall and above the pubic symphysis

can be approached with in-dwelling catheter or other instruments for removal of calculi or foreign bodies without entering the peritoneal cavity

Front 15

Rupture of bladder

Back 15

injury to inferior part of abdominal wall or pelvic fractures may rupture distended bladder

rupture often tears peritoneum, resulting in extravasation of urine into the peritoneal cavity

posterior rupture --> urine into perineum

Front 16

Cystoscopy

Back 16

examination of interior of the bladder and its 3 orifices

used for tumor removal (transurethral resection of a tumor)

Front 17

Male and Female urethra differences

Back 17

female urethra = more distensible and elastic (catheter passing and cystoscopes are easier)

infections of urethra (UTI) or bladder more common in females because it is shorter and more open to the exterior through the vestibule of the vagina

Front 18

Male sterilization (deferentectomy / vasectomy)

Back 18

part of vas deferens is ligated through incision in the superior part of the scrotum

unexpelled sperm degenerate in epididymis and proximal part of vas deferens

reversal is often successful in younger men and short post-op delays

Front 19

Abscesses in seminal glands

Back 19

pus can enter peritoneal cavity upon rupture of abscesse

enlarged glands can be felt of rectal exam with moderately filled bladder

Front 20

Hypertrophy of the prostate

Back 20

BHP (benign hypertrophy of prostate) = impedes urination by distortion of prostatic urethra and can affect virtually every male that lives long enough
Can cause nocturia (voiding at night), dysuria (pain during urination), and urgency
Examined through a digital rectal exam

Malignant  hard and often irregular (spreads to internal iliac and sacral nodes)
radical prostatectomy, along with the removal of the seminal glands, performed for serious cases

Front 21

Distension of the vagina

Back 21

when distended, usually in region of the posterior fornix (allows palpation of sacral promontory during a pelvic exam AND also occurs during intercourse)

especially distended during parturition (in AP direction)

Front 22

Digital examination through the vagina

Back 22

palpation of sacral promontory, irregularities in ovaries (cysts), and pulsations of uterine arteries

Front 23

Vaginal fistulae

Back 23

obstetrical trauma may lead to weaknesses or tears in vaginal wall and beyond

develop into open communications (fistulas) between the vaginal lumen and that of the adjacent bladder, urethra, rectum, or perineum

Front 24

Culdoscopy and culdocentesis

Back 24

inserted through posterior fornix to examine ovaries or Fallopian tubes (to assess a tubal pregnancy)

replaced by laparoscopy to prevent bacterial infection and better visualization of pelvic structures

abscess or fluid drainage in rectouterine pouch of Douglas through incision made in posterior fornix (culdocentesis)

Front 25

Cervical Cancer, exam, pap smear

Back 25

Pap smears have decreased the incidence of cervical cancer by detection of premalignant conditions

Spatula of external os of uterus scrape cells from mucosa of vaginal cervix and cells are examined under microscrope

Front 26

Exam of the uterus

Back 26

bimanual palpation = two fingers into vagina, with other hand pressing on pubic region of the anterior abdominal wall

determination of size and characteristics (i.e. normal anteverted position) of uterus

softening of the isthmus = early sign of pregnancy

Front 27

Lifetime changes in normal anatomy of uterus

Back 27

birth = relatively large (w/ adult proportions) due to maternal hormones

childhood = relatively small until puberty

after puberty = monthly changes in size, weight, density in relation to menstrual cycle

pregnancy = expansion to large proportions

menopause = marked decrease in size, involution

Front 28

Disposition of uterus and uterine prolapse

Back 28

normal  anteverted and anteflexed

retroverted uterus is more likely to prolapse under intra-abdominal pressure (at risk during pregnancy)

exacerabated with the disruption of perineal body

Front 29

Hysterectomy

Back 29

done in response to uterine and cervical cancer

removed through the anterior abdominal wall or vagina

Front 30

Anesthesia for Childbirth

Back 30

General -- renders mother unconscious and unaware of labor and delivery with childbirth occurring passively under control of hormones
Spinal block -- subarachnoid space of L3-L4, produces anesthesia inferior to the waist level

Often followed by a severe headache due to circulation of agent to cranial cavity when laying down
pudendal nerve block -- local anesthesia over S2-S4 dermatomes (majority of perineum), but mother can still feel uterine contractions
caudal epidural block -- must administered in advance of actual delivery, lower limbs not affected, bathes pain fibers from uterus are blocked but mother can still feel contractions

Front 31

Infections of the female genital tract

Back 31

infections of vagina, uterus, and tubes may result in peritonitis (confluence of uterine tubes and peritoneal cavity)

infections from peritoneal cavity may result in salpingitis (major cause of female infertility)

Front 32

Patency of the uterine tubes

Back 32

hysterosalpingography -- radiographic procedure injecting dye into uterus and tubes

endoscopy -- exam of interior of tubes, through vagina and uterus

Front 33

Ligation of the Uterine Tubes

Back 33

surgical method of birth control (oocytes degenerate and are absorbed)

abdominal or laparoscopic tubal ligation

Front 34

Ectopic Tubal Pregnancy

Back 34

pyosalpinx may prevent blastocyst from reaching uterus and can implant in the uterine tube (ectopic tubal pregnancy)

most common site = ampulla of uterine tube

can result in rupture and severe hemorrhage

on right side, often mistaken for acute appendicitis (parietal peritoneum inflammation and referred pain to right lower quadrant)

Front 35

Remnant of Embryonic Ducts

Back 35

epoophoron = remnants of mesonephric tubules of mesonephron (embryonic kidney)
persistent duct of the epoophoron (duct of Gartner)  forms the ductus deferens and ejaculatory duct in males

lies between layers of broad ligament
can occasionally accumulate fluid --> Gartner duct cysts

Front 36

Laparoscopic exam of pelvic viscera

Back 36

diagnose dz like ovarian cysts, tumors, endometriosis

Front 37

Rectal Exam

Back 37

prostate / seminal glands and cervix can be palpated through the rectum

palpation of ischial spines, enlarged lymph nodes, swellings of ischioanal fossae

proctoscope / sigmoidoscope = visualize internal aspect of rectum and must be careful to go around transverse rectal folds

Front 38

Resection of Rectum (treatment for cancer)

Back 38

prostate and urethra must be separated from the rectum to prevent damage during procedure

Front 39

Disruption of perineal body

Back 39

final support of pelvic viscera in females (can be stretched or torn during childbirth)

can cause prolapse of pelvic viscera like the bladder, uterus or vagina

any damage from infection, trauma or inflammation can also results in a fistula

possible herniations if levator ani are separated too

Front 40

Episiotomy

Back 40

incision of the perineum made to enlarge the vaginal orifice

decreases trauma to the pelvic diaphragm

median episiotomies can result in tearing down to the anus and incontinence and pelvic prolapse

mediolateral episiotomies = better alternative, directing tearing away from the anus and perineal body

Front 41

Rupture of urethra in males and extravasation of urine

Back 41

fractures of pelvis can rupture the intermediate part of the urethra and extravasation of urine into deep perineal pouch (extraperitoneal distribution)

rupture of spongy urethra usually occurs at bulb of penis (straddle injury or incorrect passage of a transurethral catheter and extravasation in superficial perineal pouch

urine cannot pass into thighs due to fascia lata and it is also contained within perineal pouches due to perineal membrane

Front 42

Starvation and Rectal Prolapse

Back 42

fat bodies of ischioanal fossae are the last reserves of fatty tissue to disappear with starvation

can result in rectal prolapse

Front 43

Pectinate line as landmark

Back 43

approximates level of transition from visceral to parietal, affecting types of tumors that occurs and where they might metastasize

Front 44

Anal Fissures and Perianal Abscesses

Back 44

infections of ischioanal fossae due to cryptitis (inflammation of anal sinuses), tear in anal mucous membrane, wound in anal region

diagnosed through fullness and tenderness between anus and ischial tuberosity

anal fissues -- painful because of innervation by inferior rectal nerves

may cause fistulae from spread of infection

Front 45

Hemorrhoids

Back 45

internal -- bright red because of arteriovenous anastomoses

result from breakdown of muscle layer deep to mucosa

can prolapse through anus and strangulate / ulcerate
external --> thromboses in external veins covered by skins

prolonged toilet sitting, chronic constipation
can be caused by portal hypertension and portocaval anastomoses, but most commonly occur without it
superior to pectinate line -- internal hemorrhoids are not painful (visceral pain)
inferior to pectinate line -- external hemorrhoids are more painful (somatic pain)

Front 46

Anorectal Incontinence

Back 46

stretching of pudendal nerves during traumatic childbirth can cause nerve damage and anorectal incontinence

Front 47

Urethral Catheterization

Back 47

removes urine from those who cannot void themselves and used to obtain uncontaminated samples of urine
curves of the male urethra must be considered when inserting catheter

short segment of intermediate part of urethra is unprotected, as you leave the penis

most vulnerable segment = intermediate part
urethral stricture = results from external trauma of penis or infection of urethra
external urethral orifice --> narrowest and least distensible part of urethra (if it passes through this opening, it should be okay throughout)

Front 48

Distention of the Scrotum

Back 48

indirect inguinal hernia may make the scrotum as large as a soccer ball

orchitis = inflammation of testes, causes bleeding, lymphatic obstructions, and can produce an enlarged scrotum

Front 49

Palpation of the Testes

Back 49

left testis commonly lies more inferior than the right

epdidymis and ductus deferens are other palpable structures

Front 50

Hypospadias

Back 50

congenital anomaly where the urogenital folds do not fuse on the ventral surface of the developing penis to form the spongy urethra

associated with inadequate production of androgens by fetal testes

external urethral orifice can be on the ventral aspect of penis (glanular hypospadias), on the penile body (penile hypospadias), or in the perineum (scrotal hypospadias)
Phimosis, paraphimosis, and circumcision

prepuce usually elastic enough to be retracted over the glans penis

phimosis = hard to retract prepuce

paraphimosis = constricts neck of glans and prevent drainage of blood and tissue fluid

circumcision is performed to help these conditions

Front 51

Female Circumcision

Back 51

illegal and actively discourage because the disfiguring procedure (usually resulting in complete removal of the clitoris) can inhibit sexual arousal and gratification

Front 52

Vulvar Trauma

Back 52

bulbs of the vestibule are highly vascularized and susceptible to trauma

can result in hematomas of labia majora

Front 53

Infection of Greater Vestibular Glands

Back 53

Bartholinitis = inflammation of the glands resulting from occlusion of gland ducts or pathogenic organisms

Front 54

Administration of pudendal and ilioinguinal nerve blocks

Back 54

Pudendal nerve block -- injection where pudendal nerve crosses sacrospinous ligament (near ischial spine) either through overlying skin or vagina (being careful to avoid the baby’s head)

Ilioinguinal nerve block -- remove sensation from anterior perineum

Front 55

Kegel exercises for increased development of female perineal muscles

Back 55

muscles are relatively underdeveloped in females (due to lack of demands in males related to urination, penile erection, and ejaculation)

can contribute to the support of the pelvic viscera and prevent urinary stress incontinence and postpartum prolapse of pelvic viscera

exercises that get women used to relaxing these muscles through intra-abdominal pressure

Front 56

Vaginismus

Back 56

involuntary spasms of perivaginal and levator ani muscles through initial distension of superificial perineal muscles

encountered clinically during pelvic exam and can cause painful intercourse