Sunteți pe pagina 1din 15

Pelvis - Exam answers (20)

Write short notes on the sciatic foramen

Write short notes on the anatomy of the uterine (fallopian) tubes.

Bilateral tubes connecting uterine cavity to the ovaries


10cm long
Travels laterally from uterine cornu to lateral pelvic wall
Suspended from the posterior aspect of the broad ligament
Mesosalpinx draped over
Pass superiorly over and termiate laterally to the ovaries
Two layers of smooth muscle, ciliated and non-ciliated collumnar cells

Structure
Intramural - 1cm within the uterine wall
Isthmus - narrowest segment immidiately lateral to uterus
Ampulla - widest and longest section
Infundibulum - funnel shaped lateral expansion, opens into peritoneal cavity at the ostium
Fimbrae - 25 finger like processes draped over ovary, 1 is usually longer

Arterial supply - terminal branch of uterine artery, tubal branch of ovarian artery
Venous drainage - plexus at lower end of broad ligament -> internal iliac vein
Lymphatic drainage - para-aortic LNs
Innervation - ovarian and uterine plexuses (T11-L1

Write short notes on the anatomy of the anterior division of the internal iliac artery.

Bifurcation of the internal iliac artery into anterior and posterior divisions
Shorter anterior division continues along superior margin of greater sciatic foramen to ischial spine
Anterior to piriformis muscle

Supplies
External genetalia
Anal canal
Perineum
Posterior and adductor region of thigh
Gluteal region
Pelvic muscles

Branches
Obliterated umbilical - distal part of fetal umbilical artery, becomes medial umbilical ligament, runs
superoanteriorly to anterior abdominal wall raising fold of peritoneum (median umbilical fold)
Superior vesical - persistent proximal part of fetal umbilical artery, runs anteriorly on obturator
internus, turns medially to meet bladder (SUPPLIES BLADDER, URETER, VAS)

Inferior vesicle (men) - arises below superior vesicle, runs medially across pelvic floor. (SUPPLIES
TRIGONE, LOWER BLADDER, VAS, SEMINAL VESICLE, PROSTATE)

Middle rectal - runs medially in lateral ligaments of rectum, anastamoses with superior and inferior
rectal arteries (SUPPLIES LOWER RECTUM)

Vaginal (women) - corresponds to inferior vesicle in men, branches to supply upper vagina

Uterine (women) - Terminal branch. Crosses pelvis in broad ligament on levator ani, crosses over
ureter and supplies, runs alongside uterus in broad ligament, turns laterally at entrance of uterine
tube and anastamoses with ovarian artery. (SUPPLIES UTERINE TUBE, CERVIX, VAGINA)

Obturator - Passes along pelvic side wall through obturator canal to medial compartment of thigh
- branches into anterior, posterior, acetabular and pubic branches
- SUPPLIES PELVIC MUSCLES AND HIP

Inferior gluteal - Terminal branch. Passes posteriorly between anterior rami of S1/2 or S2/3.
Passes through greater sciatic foramen below piriformis. Descends postero-medially to sciatic
nerve. SUPPLIES PELVIC FLOOR, BLADDER FUNDUS, GLUTEAL REGION, POSTERIOR
THIGH

Internal pudendal - Descends anterior to sacral plexus, passes through greater sciatic forament
(inferior to piriformis) and enters perineum through lesser sciatic foramen. SUPPLIES EXTERNAL
GENITALIA, PERINUEM
Branches ->
Perineal a (bulbospongiousus, ischiacavernosus, labia/scrotum, anal muscles, perineal body)
Inferior rectal
Bulb of clitoris/penis
Deep clitoris/penis
Dorsal clitoris/penis

USI MUV OPI

Write short notes on the anatomy of the venous drainage of the left testis.
Testicular venules reach the mediastinum testes
Emerge from the posterior testis and receives tributaries from epididymis
Veins pass superiorly and unite to form the pampiniform plexus
Plexus surrounds the testitcular artery, sits anterior to vas deferens within the spermatic cord
Prior to entering the superficial inguinal ring, become ~4 veins
2 veins leave the deep inguinal ring, becoming single testicular vein once it reach the psoas
Left testicular vein travels superiorly on psoas muscle to join the left renal vein at a right angle

Relations - ileum ant, psoas post, SMA/aorta medial, ureter testicular a. lateraly

Write short notes on the anatomy of the symphysis pubis

Secondary cartilagenous joint


Between bodies of pubic bones in midline
Surface of pubic bones covered in thin plate of hyaline cartilage
Two sides connected by fibrocartilage forming the interpubic disc

Articular surfaces - medial aspects of pubic bones

Ligaments
Superior pubic ligament
Inferior pubic ligament (arcuate ligament)

Relations
Anterior - proximal end of penile/clitoral shaft
Inferior - urethra, deep dorsal vein of penis/clitoris
Posterior - bladder (retropubic fat pad) prostate and venous plexus

Arterial supply - Obturator and inferior epigastric aa.

Innervation - Pudendal branches, genitofemoral, iliohypogastric/ilioinguinal

Variant - joint width varies by age (smaller with age), congenital widening, tissue-fluid space may
form within interpubic disc

Write short notes on the anatomy of the sacrum

Triangular posterior pelvic bone made up of five progressively smaller sacral vertebrae
Concave anteriorly, tapers to apex inferiorly

Features
Superior surface
- S1 forms base, slopes anteroinferiorly
- anterior projecting sacral promontory
- costal elements of S1 form pelvic brim with arcuate line of ilium
- superior articular process has posterior facet for L5
Lateral surface
- sacral ala of S1 project laterally (lateral masses)
- ear shaped auricular surface for articulation with ilium
- sacral tuberosity is rough surface posterior to articular surface for attachment of SIJ ligaments

Anterior surface
- smooth concave surface with four anterior sacral foramina
- fused costal elements lateral to the foramina form lateral mass

Posterior surface
- Irregular, rough, convex
- median sacral crest projects dorsally in the midline, formed by fused SPs
- intermediate sacral crest medial to foramina (fusion of articular cartilages)
- lateral sacral crest - lateral to foramina (TPs)

Inferior surface
- sacral hiatus, continuous with sacral canal
- sacral cornu project beside hiatus

Articulations - SIJ, L5/S1, sacrococcygeal joint

Relations
Anterior - piriformis, sacral plexus, peritoneum, rectum, mesorectum
Post - Posterior sacroliac ligaments, erector spinae, subcutaneous tissue
Lat - ilium
Sup - L5

Attachements
- sacrotuberous and sacrospinous ligaments
- posterior and anterior sacroiliac ligaments
- lumbrosacral and sacro iliac ligaments
- sacrococcygeal ligament

- iliacus, piriformis, erector spinae

Ossification - primary centres of body appear 10-12/40


Secondary centres appear in puberty

Variants
Lumbarisation of S1/sacralisation of L5
Agenisis

Write short notes on the anatomy of the anal canal


Last 4cm of the alimentary tract
Continuation of rectum extending to the anal verge at the skin surface
Anorectal junction slung forwards by look of puborectalis muscle --> anal canal turns posteriorly
Consists of muscular fibres forming the internal and external anal sphincters

Internal - thickened downward projection of inner circular muscle from rectum


- extends 3/4 way down canal

External - continuous muscular tube (deep, superficial and subcutaneous)


- curves medially inferiorly to lie below the end of internal sphincter (intersphincteric groove in
mucosa)
- blends with puborectalis of levator ani

Mucous membrane
- stratified squamous
- longitudinal anal columns in upper 1/3rd of canal connect at the pectinate line by horizontal anal
valves with pockets forming anal sinuses and containing anal glands
- inferiorly the mucosa becomes cutanous at the dentate or white line

Arterial supply
- superior rectal artery (IMA)
- middle rectal a (internal iliac)
- inferior rectal a (internal pudendal from the internal iliac) (via ischioanal fossa)

Venous drainage
- superior rectal --> portal
- inferior and middle rectal --> internal iliac veins

Innervation
External sphincter - pudendal branches
Internal sphincter - autonomic (pelvic plexus and pelvic splanchnic)

Lymph - upper --> rectum; lower -->superificial inguinal

Variation - imperforate rectum

Write short notes on the anatomy of the uterus


Muscular pelvic organ which accomodates the developing embryo
Inverted pear shape
8x5x3cm
Usually anteverted and anteflexed

Made up of:
Fundus
- convexity above entrance of uterine tubes at lateral cornu
- covered by pelvic peritoneum

Body
- flattened anteroposteriorly, shaped like inverted triangle in AP
- tapers downward from fundus
- enclosed by periotoneum that laterally becomes broad ligament

Cervix
- tapered inferior end
- supravaginal and vaginal parts
- protrudes inferiorly into vaginal vaults and is surrounded by fornices
- cervical canal continous with uterus at internal os
- lower opening into vagina is external os

Ligaments/Supports - pubocervical, transverse cervical, uterosacral, levator ani

Relations
- Ant - bladder, uretovesical pouch
- Post - rectum, POD
- Lat - uterine tubes, broad ligament, uterine vessels
- Sup - bladder, peritoneum
- Inf - vagina

Arterial supply - uterine aa (ascned in broad ligament); ovarian aa (anastamotic trunk)

Venous drainage - uterine vein --> internal iliac v

Innervation - inferior hypogastric and ovarian plexuses

Lymph - para-aortic, internal/external iliac

Variations
- Agenesis
- Arcuate - mild indentation at fundus
- Bicornate - divided into two horns
- Unicornate - failure of one Mullerian duct to develop
- Septate -
- Didelphys - duplication of horns and cervix

Write short notes on the anatomy of the ischioanal (ischiorectal) fossa


Fascia lined wedge shaped spaces on either side of the anal canal
Between skin of anal region and pelvic diaphragm
Filled with loose connective tissue and fat
Supports anal canal and allows distention

Walls
Apex is superior from intersection of levator ani and obturator internus
Lateral - obturator internus/obturator fascia and ischium
Medial/Superior - external anal sphincter and sloping walls of levator ani
Posterior - sacrotuberous ligament
Anterior - body of pubic bones and inferior pubic rami
Floor
- anteriorly - perineal membrane and deep perineal pouch
- posterioly - skin

Contents
Fat body of ischioanal fossa
Inferior rectal/anal vessels and nerves
Perforating branch of S2/S3
Perineal branch of S4

Write short notes on the anatomy of the prostate gland

Unpaired accessory structure of the male reproductive tract shaped like an inverted cone
Surrounds prostatic urethra in the pelvic cavity
4x3x2cm
Strong CT layer forms true capsule, pelvic fascia forms superficial false capsule

Base - upper surface, fused with neck of bladder, perforated by urethra


Apex - tapered inferior end, rests below pelvic floor, urethra emerges from front
Anterior surface - posterior to the retropubic space, connected to pubic bones by puboprostatic
ligaments
Posterior surface - separated from lower rectum by recto-vesical fascia; pierced by ejaculatory
ducts just below bladder
Inferolateral surface - clasped by levator ani
Zones - peripheral, central, transitional (anterolateral to proximal urethra)

Relations
- ant - pubic symphysis
- post - rectum
- sup - bladder
- inf - urogenital membrane
- lateral - prostatic venous plexus, levator ani

Arterial supply - prostatic branch of inferior vesical (small branches of middle rectal and internal
pudendal)

Venous - prostatic plexus --> internal iliac

Lymph - obturator and internal iliac LNs, some to external iliac and para-aortic

Innervation - Pelvic splanchnic and inferior hypogastric plexus

Write short notes on the anatomy of the sacrospinous and sacrotuberous ligaments

Stablising ligaments of the posterior pelvis that help define the aperatures between the pelvic cavity
and adjacent regions

Sacrospinous
Thin triangular ligament
Originates inferior sacrum and coccyx anteriorly
Attaches to ischial spine
Lies on pelvic aspect of sarcrotuberous ligament

Relations
Ant - coccygeous
Post - sacrotuberour ligament, internal pudendal vessels and nerve
Sup - greater sciatic foramen
Inf - lesser sciatic foramen

Sacrotuberous
Flat, strong ligament of the posterior pelvic wall
Triangular shape
Broad base originates at posterior border of ilium, PSIS, PIIS, transverse tubercles of the sacrum
and coccyx
Attach to medial surface of ischial tuberosity

Relations
Post - gluteus maximus
Ant - sacrospinous ligament
Sup - forms posterior border of the greater sciatic foramen
Inf - forms boundary of perenium and lesser sciatic foramen
Pierced by coccygeal n and inferior gluteal a.

Write short notes on the anatomy of the posterior division of the internal iliac artery

Internal iliac arises at level of L5/S1 anteromedial to SIJ at bifurcation of common iliac a.
Bifurcates into anterior and posterior divisions at the level of the superior border of the greater
sciatic foramen

Posterior division travels posteriorly and has three branches:

Superior gluteal --> largest branch --> passes between lumbrosacral trunk and S1 --> leaves
pelvis in greater sciatic foramen above piriformis --> supplies gluteus maximus, medius and
minimus and overlying skin

Iliolumbar --> passes superiorly out of pelvis anterior to lumbrosacral trunk --> runs laterally deep
to psoas --> lumbar and iliac branches supply psoas, quadratus lumborum, erector spinae iliacus
and iliac bone

Lateral sacral --> frequently double --> course medially and inferiorly on posterior pelvic wall -->
branches pass through anterior sacral foramina to supply bone, soft tissue, sacral canal and skin
and muscles posterior to sacrum

Variations - variable number of branches of lateral sacral artery

Write short notes on the anatomy of the sacroiliac joint.

Strong weight bearing joint transmitting weight from lower limbs to the vertebral column
They are synovial joints between the L shaped articular facets on the lateral surfaces of the sacrum
and the similar facets on the medial ilia
Irrregular contour which resist movement
Become fibrous with age

Capsule - synovial capsule attached to margins of hyaline cartilage

Ligaments
Anterior sacroiliac ligament
Interosseous sacroiliac ligament
Posterior sacroliliac ligament
Sacrotuberous
Sacro spinous
Relations
Anterior - piriformis
Posterior - erector spinae

Innervation
Posterior rami of S1-2
Obturator
Superior gluteal

Variants
Fibrous adhesions and obliteration of joint cavity with age
Soften in pregnancy

Write short notes on the anatomy of the rectum

Continuation of alimentary tract from sigmoid colon to anus


12cm long
No mesentary
Commences at end of sigmoid colon at S3

Three lateral curves - upper and lower convex right; middle convex left
Three transverse folds correspond to curves

Relations
Surrounded by mesorectum
Peritoneum covers upper third anteriorly and laterally, middle third anteriorly; reflects forward as the
rectovesical (male) or rectouterine (female) pouch

Ant - bladder/prostate (male) uterus (female)


Post - sacrum/coccyx
Inf - anus/ pelvic floor
Sup - Sigmoid
Lat - mesorectum and lymph nodes

Arterial supply (in thirds from sup--> inf)


Superior rectal artery from IMA
Middle rectal artery from internal iliac a
Inferior rectal artery from internal pudendal a (IIA)
Anastamose

Veins
Follwo arteries

Lymph - mesorectal, internal iliac, presacral and preaortic


Innervation
Inferior mesenteric plexus
Inferior hypogastric plexus

Variations
Imperforate rectum
Fistulae

Write short notes on the anatomy of the pelvic floor (levator ani).

Levator ani is a broad thin muscle which makes up the funnel shaped pelvic floor within the lesser
pelvis
Supports pelvic viscera

Consists of:

Pubococcygeus
O - body of pubis and anterior half of obturator fascia
I - anococcygeal ligament/raphe and coccyx
Subdivisions - puborectalis, puboanalis, pubourethralis/puboprotaticus

Iliococcygeus
O - ischial spine and posteior half of obturator fascia
I - side of coccyx/anococcygeal raphe

Arterial supply - internal iliac (inferior gluteal)


Venous drainage - inferior gluteal

Innervation - Sacral plexus (S3-4), pudendal nerve

Variations - iliococcygeus may be replaced by fibrous tissue

Write short notes on the anatomy of the testis and epididymis.

Testis and epididymis make up part of the male reproductive system


Responsible for sperm production, storage and testosterone

Testis
Ovoid organ that is suspended in the scrotum by the spermatic cord
Size varies with age - adult 4x2x3
Right and left separated by median scrotal septum
Multiple fibrous septae divide into lobules
Drain into seminiferous tubules --> converge on mediastinum testes--> rete tesis--> convey sperm
to head of epididymis (attached posterolaterally)

Tunica albuginea - tough outer fibrous coat tightly adherent to testis, thickened posteriorly at
mediastinum tesis

Tunica vaginalis - covers surface of testis except for where epididymis and cord attaches; closed
peritoneal sac which is remnant of embryonic processes vaginalis

Appendix testis - small cyst attached to upper pole within tunica vagnalis; prone to torsion

Relations
Postlaterally - epididymis
Post - vas
Medially - median scrotal septum
Anterolaterally - tunica vaginalis
Sup - spermatic cord
Inf - scrotum

Arterial supply - testicular artery--> divides into medial and lateral branches, anastamose with
cremasteric and ductal arteries

Venous drainage - venules reach mediastinum testes --> pass upwards to form pampiniform
plexus--> travel through spermatic cord surrounding testicular artery --> form 3-4 veins at
superficial inguinal ring--> form 2 veins at deep inguinal ring --> join to form single testicular vein at
psoas--> Right to IVC at acute angle, Left to renal vein at right angle.

Innervation - Sympathetic only. Lesser splanchnic to coeliac ganglia

Lymph - para-aortic

Variations - Bilobed, cryptorchidism, hydrocels,

Epididymis
Stores spermatazoa until ejaculation
Highly coiled tube within fibrous tissue courses along posterolateral testis
6-7 cm but 6m if unravelled

Head
Largest part at superior pole, connects to efferent ductules

Body - separated from testis by sinus of epididymis

Tail - inferior pole; adherent to testis


Vas deferens ascends medially from the tail
Artery - branch of testicular a
Venous - pampiniform plexus
Innervation as per testis
Lymph - para-aortic

Variations - paradidymis - mass of residual tubes at lower end of spermatic cord

Write short notes on the sacral plexus.

Plexus of nerves in the posterior pelvis responsible for innervation of the lower limb and muscles of
the pelvis and perineum

Flat, triangular.
In posterior wall of pelvis in plane between muscles and blood vessels
Branches leave pelvis through greater sciatic foramen either above or below piriformis

Formed by lumbrosacral trunk (L4/5) and upper four sacral rami

Relations
Ant - pelvic fascia, internal iliac vessels, ureter, sigmoid colon
Post - piriformis muscle
Superior gluteal vessels run between lumbrosacral trunk and S1
Inferior gluteal vessels run between S2/3

Branches

L4-S3 - sciatic nerve - post compartment of thigh and adductor magnus --> tibial/common peroneal
L4, 5, S1 - quatratus femoris
L4, 5, S1 - superior gluteal nerve --> glut med/minimus, TFL

L5, S1, S2 - obturator internus


L5, S1, S2 - inferior gluteal nerve --> glut max

Sciatic Queen Sings Of Injustice

S1, 2 - piriformis
S1,2,3 - post fem cutanous nerve --> posterior thigh
S2, 3 - perforating cutanous n --> inferior gluteal
S2,3,4 - pudendal --> sphintors and pelvic gloor, sensory to perineum
S4 - perineal branch of S4

The 5 P's
Variations -
Division of tibial and common peroneal may occur at any place
May lie posterior to piriformis

Write short notes on the ovary

Paired ovoid female reproductive organ in the pelvis


Responsible for follicle maturation and ovulation
Lies almost vertically in the adnexa with upper pole tilted laterally
Encapsulated by CT layer (tunica albuginea)

Relations
Upper pole overlapped by fimbrae of uterine tube, attached to suspensory lig of ovary
Lower pole attached to uterus via ligament of ovary
Anterior - attached to broad ligament via mesovarium
Sup/post - coils of sigmoid and ileum
Lateral - angle of internal and external iliac vessels, ovarian vessels

Arterial supply - ovarian artery, descends from aorta in retroperitoneum on psoas m


Venous drainage - ovarian vein R--> IVC, L--> left renal vein

Vessels enter suspensory ligament at lateral extremity

Lymph - para-aortic LNs

Innervation
Aortic plexus (T10-11)
Inferior hypogastric plexus

Variation
Agenesis
Abdominal ovary

Write short notes on the anatomy of the psoas muscle.

Long fusiform muscle located antero lateral to the lumbar region of the vertebral column and the
lesser pelvis
Joins iliacus muscles to form iliopsoas
Hip flexor group

O - Transvers processes of L1-5, Bodies of T12-L5


I - Lesser trochanter
N - Ventral rami of L1-L4 (from lumbar plexus
A - hip flexor, hip external rotator

Relations
Lumbar plexus lies between muscle layers
Femoral nerve emerges from lateral border
Anteror - gonadal vessels, ureter
Posterior - lumbar spine/posterior pelvis

A - iliolumbar branch of internal iliac a/ anastamoses with last lumbar a


V - iliolumbar vein

Variations
Psoas and iliacus are independent
Longitudinal divisions into fasicles
Accessory slip lateral to femoral nerve

Write short notes on the anatomy of the inguinal (Pouparts) ligament.

Contents of spermatic cord

Write short notes on the anatomy of the testes


Write short notes on the anatomy of the uterus.
Write short notes on the anatomy of the rectum and anus.
Write short notes on the anatomy of the epididymes
Write short notes on the anatomy of the Fallopian (uterine) tubes
.
Write short notes on the anatomy of the uterus.
Write short notes on the anatomy of the anus
Write short notes on the anterior division of the internal iliac artery