1
Q
Where does the female reproductive system lie?
A
Within both the pelvic cavity and the perineum
2
Q
What features of the female reproductive system lie within the pelvic cavity?
A
- ovaries
- uterine tubes
- uterus
- superior part of vagina
3
Q
What features of the female reproductive system lie within the perineum?
A
- inferior part of vagina
- perineal muscles
- bartholins glands
- clitoris
- labia
4
Q
What separates the true and false pelvis?
A
Separated by an imaginary line that link sacral promontory and the pubic symphysis anteriorly
5
Q
What is the only true / primary organ of reproduction in females?
A
Ovary
6
Q
The inferior part of the parietal peritoneum forms what?
A
- floor of peritoneal cavity
- roof over pelvic organs
7
Q
Name the pouches created by the parietal peritoneum in females
A
- vesico-uterine
- recto-uterine (pouch of douglas)
8
Q
What is the broad ligament of the uterus composed of and where is it found?
A
- composed of a double layer of peritoneum
- extends between the uterus and the lateral walls and floor of the pelvis
9
Q
What is the role of the broad ligament of the uterus and what is contained within it?
A
- helps maintain the uterus in its correct midline position
- contains within it the uterine tubes and the proximal part of the round ligament
- draped over uterine tubes
10
Q
What is the round ligament of the uterus composed of and where is it found?
A
- it is an embryological remnant (remnant of gubernaculum)
- attaches to the uterine horns laterally
- passes through the deep inguinal ring and the inguinal canal to attach to the superficial tissue of the female perineum
- specifically the fatty superficial fascia of the labia medura
11
Q
Name the three layers of the body of the uterus
A
- perimetrium
- myometrium
- endometrium
12
Q
Where does implantation of the zygote occur?
A
Implantation occurs in the body of uterus
13
Q
Where does the cervix prroject?
A
Projects into superior aspect of vagina
14
Q
What is the most common position of the uterus?
A
- anteverted and anteflexed
- anteverted; cervix tipped anteriorly relative to the axis of the vagina
- anteflexed; uterus tipped anteriorly relative to the axis of the cervix (the mass of the uterus lies over the bladder)
15
Q
Describe normal variations of the position of the uterus
A
- retroverted and retroflexed
- retroverted; cervix is tipped posteriorly relative to the axis of the vagina
- retroflexed; uterus tipped posteriorly relative to the axis of the cervix
16
Q
The uterus is held in position by what 3 levels of support?
A
- number of strong ligaments (e.g. uterosacral ligaments)
- endopelvic fascia
- muscles of the pelvic floor (e.g. levator ani)
17
Q
What junction is sampled during cervical smear?
A
The squamo-columnar junction (transformation zone)
18
Q
The opening into the cervix from the vagina is called what?
A
External cervical os
19
Q
Where does fertilisation occur?
A
In the ampulla of the uterine tubes
20
Q
What is a bilateral salpingo-oophrectomy?
A
Removal of both uterine tubes and ovaries
21
Q
What is a unilateral salpingectomy?
A
Removal of one of the uterine tubes
22
Q
What is the ostium of the uterine tube?
A
The opening though which the egg will pass from ovary into uterine tube, this opens into the peritoneal cavity
23
Q
What is the thickest walled section of the uterine tubes?
A
The isthmus
24
Q
What is the role of hysterosalpingograms?
A
To assess the patency of the uterus and uterine tubes
25
What do the ovaries secrete?
Oestrogen and progesterone in response to anterior pituitary hormones FSH and LH
26
Where do the ovaries develop and where do they move to?
- develop on the posterior abdominal wall
| - move onto the lateral wall of the pelvis
27
What is the vagina?
A muscular tube whose walls are normally in contact (except superiorly where the cervix holds them apart forming a fornix)
28
What are the four parts of the fornix?
- anterior
- posterior
- 2 x lateral
29
What is the fornix?
Space around the cervix, separates cervix from superior vagina
30
How can the position of the uterus be assessed?
By bimanual palpation
31
What are the adnexae?
Both the uterine tubes and ovaries together
32
Describe palpation of the adnexae
- uterine tubes and ovaries
- place examining fingers into lateral fornix
- press deeply with other hand in the iliac fossa on the same side
- repeat on other side
- can detect large masses or tenderness affecting these structures
33
Describe palpation of the ischial spines
- laterally
| - 4 and 8 o clock positions
34
What is the perineum?
Shallow space between pelvic diaphragm (levator ani) and the skin
35
What forms the floor or the pelvis and the roof of the the perineum?
The pelvic diaphragm
36
Where is the perineum found?
In the urogenital triangle (pubic symphysis, to ischial spines and then posteriorly to the coccyx)
37
What type of muscle if levator ani?
- skeletal muscle
| - voluntary control
38
What are the roles of the levator ani muscle?
- forms majority of pelvic diaphragm with its fascial coverings
- provides continual support for the pelvic organs
- tonic contraction
- reflexively contracts further during situations of increased intra-abdominal pressure
39
What nerve supplies the levator ani muscle?
- S3, 4, 5 sacral nerves
| - also fibres from pudendal nerve S2,3,4
40
The perineal muscles are supplied by what nerve?
The pudendal nerve
41
Describe the perineal body
- bundle of collagenous and elastic tissue into which the perineal muscles attach
- important for pelvic floor strength
- can be disrupted during labour
- located just deep to the skin
- ball shaped bundle between urogenital and anal triangle
42
What are the bartholins glands?
- greater vestibular glands
- located at posterior end of erectile tissue
- secrete a lubricating fluid
- roughly pea sized normally
43
The bed of the female breast extends from where?
- from ribs 2-6
| - lateral border of sternum to midaxillary line (axillary tail, extension of fatty tissue)
44
What lies posterior to the female breast?
- lie on deep fascia covering the pec major and serratus anterior
- retromammary space lies between fascia and breast
45
The female breast is firmly attached to the skin via what?
Suspensory ligaments
46
What is the role of the retromammary space?
Lets breast tissue move relative to underlying muscle
47
How are lumps in the female breast described / assessed?
- position is described in relation to the four quadrants or a clock face
- assess whether it s fixed to any underlying tissue, e.g. the pectoral fascia
- both the axilla and supraclavicular area should be assessed
- fixed or mobile can be assessed by asking the patient to put hands on hips to engage pectoral muscles
48
What are the four quadrants of the breast?
- upper inner
- lower inner
- lower outer
- upper outer
49
Most lymph (>75%) from the breast drains to where?
- the ipsilateral axillary lymph nodes
| - then to the supraclavicular nodes
50
Lymph from inner breast quadrants can drain to where?
The parasternal lymph nodes
51
Lymph from the lower inner breast quadrant can drain to where?
The abdominal lymph nodes
52
What are the three levels of axillary node clearance?
- all levels are based on the pectoralis minor
- level one; inferior and lateral to the pectoralis minor
- level two; deep to pectoralis minor
- level three; superior and medial to pectoralis minor
53
What is the blood supply (mainly) to the medial aspect of the female breast?
- branch of the subclavian
| - internal thoracic (also called the internal mammary)
54
What is the blood supply to the lateral aspect of the female breast?
- thoracic and thoracoacromial arteries
- these are branches of axillary artery
- also the posterior intercostal artery in the 2nd, 3rd and 4th intercostal spaces (also known as lateral mammary branches)
55
Describe the venous drainage of the female breast
- drainage mirrors arterial supply, mainly axillary vein and some internal thoracic vein to go back up to subclavian
56
What separates the pelvic cavity from the perineum?
Pelvic floor
57
What are the three layers of the pelvic floor?
- pelvic diaphragm
- muscles of perineal pouches
- perineal membrane
58
The pelvic floor plays what roles?
- important role in providing support to pelvic organs
| - plays an important role in maintaining both faecal and urinary incontinence
59
What is the deepest layer of the pelvic floor?
The pelvic diaphragm
60
The pelvic diaphragm consists of what and has what appearance?
- consists of two muscle groups; levator ani and coccygeus
- levaotr ani is more medial and anterior
- coccygeus is more lateral and posterior
- has the appearance of a sling
61
What is the urogenital hiatus?
- anterior gap between the medial borders of the pelvic diaphragm
- allows for the passage of urethra (both males and females) and vagina
62
What are the attachment points of the levator ani?
- pubic bones, ischial spines and tendinous arch of levator ani
- perineal body, coccyx and walls of organs in midline
63
Name the three parts of levator ani
- puborectalis; most medial, fibres around the rectum area and attached to pubic bone
- pubococcygeus; pubic bone to midline organs and coccyx
- iliococcygeus; ileus to coccyx and midline organs
64
Additional support to the pelvic organs comes from where?
```
- endopelvic fascia; some loose areolar tissue, some fibrous (collagen and elastic fibres)
Pelvic ligaments e.g.
- fibrous endo-pelvic fascia
- uterosacral (attaches to cervix)
- transverse cervical (cardinal)
- lateral ligament of the bladder
- lateral rectal ligaments
```
65
Where does the deep perineal pouch lie?
- lies below the fascia covering the inferior aspect of the pelvic diaphragm
- lies above the perineal membrane
66
What does the deep perineal pouch contain?
- contains part of the urethra (and vagina in females)
- bulbourethral glands in males
- neurovascular bundle for penis / clitoris
- extensions of the ischioanal fat pads
- smooth muscle (females)
- deep transverse perineal muscle (males)
- external urethral sphincter
- compressor urethrae
67
What do bulbourethral glands screte?
- in males
- also referred to as cowpers glands
- secrete lubricating mucus into male urethra
68
What is the perineal membrane?
- thin sheet of tough, deep fascia
69
Where the is the perineal membrane located and what are its attachments?
- superficial to deep perineal pouch
| - attaches laterally to the sides of the pubic arch, closing the urogenital triangle
70
Where is the superficial perineal pouch found in both males and females?
Lies below the perineal membrane
71
What is contained within the superficial perineal pouch in females?
- contains female erectile tissue and associated muscle
- clitoris and crura; corpus cavernosum
- bulbs of vestibule; paired
- associated muscles; bulbopsongiosus and ischiocavernosus
- also contains greater vestibular glands, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
72
What do bartholins glands secrete?
Lubricating mucus
73
The superficial perineal pouch contains what in males?
- contains root of penis
- bulb; corpus spongiosum, crura, corpus cavernosum -
- associated muscles; bulbospongiosus and ischiocavernosus
- also contains proximal spongy (penile) urethra, superficial transverse perineal muscles and branches of internal pudendal vessels and pudendal nerve
74
Name the layer of the pelvic floor from deep to superficial
- pelvic diaphragm
- deep peroneal pouch
- perineal membrane
- superficial perineal pouch
- muscles of the superficial perineal pouch
75
What is the role of puborectalis?
- forms a sling around anorectum junction
- when contracts creates a bend
- this prevents faeces from progressing passed this bend
76
Describe how injury can occur to the pelvic floor
- pregnancy
- childbirth; stretching or tearing, pudendal nerve damage
- chronic constipation
- obesity
- heavy lifting
- chronic cough or sneeze
- previous injury to pelvis / pelvic floor
- menopause
77
What does urinary continence depend on?
- urinary bladder neck support
- external urethral sphincter
- smooth muscle in urethral wall
78
Describe a vaginal prolapse
- herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
- presents as a lump in vaginal wall
- urethrocele, cystocele (bladder herniation), rectocele, enterocele (pouch of douglas herniation)
79
What are the classic symptoms of uterine prolapse?
- dragging sensation
- feeling of 'lump'
- urinary incontinence
80
What are the 4 degrees of vaginal prolapse?
- 1st; when cervix is dropping into vagina
- 2nd; cervix is now dropping to level just inside the opening of the vagina
- 3rd; cervix is now outside the vagina
- 4th; entire uterus is outside the vagina
81
Describe sacrospinous fixation as a treatment of vaginal prolapse
- sutures placed in sacrospinous ligament
- just medial to the ischial spine
- to repair cervical / vault descent
- performed vaginally
- risk of injruy to pudendal NVB and sciatic nerve
82
Describe incontinence repair surgery in females
- trans-obturator approach
- mesh through obturator canal
- space in obturator foramen for passage of obturator NVB
- creates a sling around the urethra
- incisions though vagina and groin
83
What are the primary male reproductive organs?
The testes
84
Name the male accessory reproductive organs
- the vas deferens
- seminal glands
- prostate gland
- penis
85
How long is the male urethra?
Around 20cm long
86
What is the most anterior organ of the pelvis in the male?
The bladder (when empty)
87
What are the anatomical relationships of the male bladder?
- in the male, the prostate gland lies inferior to the bladder
- the rectum lies posteriorly
88
The bladder wall in the male is mainly formed by what?
The detrusor muscle
| - fibres encircle ureteric orifices and tighten when bladder contracts (prevents reflux of urine)
89
What does the detrusor muscle form around the neck of the bladder in males and what is its function?
- forms the internal urethral sphincter
| - contracts during ejaculation to prevent retrograde ejaculation
90
Where do the testes originate and where do they travel to?
- On the posterior wall of the abdominal cavity
- by birth, they have descended into the scrotum
- through the anterior abdominal wall (inguinal canal)
91
What is the vas deferns?
The tube that sperm pass through follows the testis into the scrotum
92
What is the conjoint tendon?
- the medial end of the combined aponeuroses of internal oblique and transversus abdominis
- anchors muscles inferiorly to the pubic bone
93
What is the tunica vaginalis?
- inside the scrotum the testis sit within a sac called the tunica vaginalis
- testis pushes into the tunica vaginalis
94
What is a hydrocele?
Excess fluid within the tunica vaginalis
95
Where is sperm produced?
Seminiferous tubules
96
What aids in keeping the sperm 1 degree below body temperature?
Dartos muscle helps to control temperatue
97
What is the route of sperm?
- sperm pass into the rete testis
- then into head of epididymis
- epididymis becomes vas deferens
- vas deferens passes superiorly in spermatic cord, to deep inguinal ring
- at deep inguinal ring, the vas deferens turns medially into the pelvis
- travels posterior to bladder
- within the pelvis each vas deferens connects with the duct from a seminal gland to form an ejaculatory duct containing semen
- the right and left ejaculatory ducts join together within the prostate gland and drain into urethra
- the urethra opens at the external urethral meatus of the penis
98
Where is the epididymis located?
- At the posterior aspect of the testis
- its proximal end is located at posterior aspect of the superior pole of the testis
- barely palpable when normal
99
Where can the vas deferens be palpated?
- within the spermatic cord
| - in scrotum, superior to testis
100
What are the arterial supply to the testis?
Arteries from lateral aspect of abdominal aorta
101
What is the venous drainage of the testis?
- left testicular vein to left renal vein
| - right testicular vein to IVC
102
What are the roles of the prostatic urethra?
- drains urine from bladder
| - passes semen in ejaculation
103
What is the role of the seminal glands?
Produces seminal fluid, rich in fructose
104
What is the role of bulbourethral (cowpers) glands?
- mucus secretion
- lubricates urethra
- neutralises acidity
105
Where is the prostate gland found?
- surround the prostatic urethra
| - inferior aspect in contact with the levator ani muscle
106
What are the zones of the prostate and which zone is most important clinically?
- peripheral zone and central zone
- most prostate cancers arise from peripheral zone
- peripheral zone is the part felt on digital rectal examination
107
What occurs during a vasectomy?
The vas deferens is transected and its lumen sutured closed (bilaterally)
108
The root of the penis attaches where?
- the root of the penis laterally attached to the ischium of the pelvis
109
What are the 3 cylinders of erectile tissue in the penis?
- corpus cavernosum right and left; posterior, transmit the deep arteries of penis
- corpus spongiosum; anteriorly, transmits the spongy urethra, expands distally to form the glans penis
110
Where is the superficial perineal pouch found in males?
Lies below the perineal membrane
111
The superficial perineal pouch contains what in males?
- bulb - corpus spongiosum
- crura - corpus cavernosum
- associated muscles; bulbospongiosus and ischicavernosus
- also contains proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
112
What is the blood supply to the penis?
- deep arteries of the penis
| - branches from internal pudendal artery from internal iliac
113
What is the blood supply to the scrotum?
- via the internal pudendal and branches from external iliac artery
114
Lymph from scrotum and most of the penis (not glans) drains to where?
- drains to superficial inguinal lymph nodes
| - superficial fascia of groin
115
Lymph from the testes drains to where?
- lumbar lymph nodes
| - around abdominal aorta
116
If the structure is in the pelvis, what kinds of innervation could be important?
- body cavity so
| - sympathetic, parasympathetic and visceral afferents
117
If the structure is in the perineum what kinds of innervation could be important?
- body wall so
| - somatic motor and somatic sensory
118
Uterine cramping (e.g. during menstruation) occurs due to what nerve modalities?
Hormonal influence of sympathetic and parasympathetics
119
Uterine contractions (e.g. during labour) occurs due to what nerve modalities?
Hormonal influence of sympathetic and parasympathetics
120
Pelvic floor muscle contraction (e.g. during sneezing) occurs due to what nerve modalities?
Somatic motor
121
Pain from the adnexae (ovaries and fallopian tubes) occurs due to what nerve modalities?
Visceral afferents
122
Pain from the uterus occurs due to what nerve modalities?
Visceral afferents
123
Pain from the vagina occurs due to what nerve modalities?
Visceral afferents (pelvic pain) / somatic sensory (perineum)
124
Pain from the perineum occurs due to what nerve modalities
Somatic sensory
125
The superior aspects of the pelvic organs (touching the peritoneum) have what innervation?
- visceral afferents
- run alongside sympathetic fibres (not in but alongside)
- enter spinal cord between levels T11-L2
- pain is perceived by patient as suprapubic
126
The inferior aspects of the pelvic organs (not touching the peritoneum) have what innervation?
- visceral afferents
- run alongside parasympathetic fibres
- enter spinal cord at levels S2, S3, S4
- pain perceived in S2, S3, S4 dermatome (perineum)
127
Pain from structures crossing from pelvis to perineum (e.g. urethra, vagina) above levator ani have what innervation?
- in the pelvis
- visceral afferents
- parasympathetic
- spinal cord levels S2, S3 and S4
128
Pain from structures crossing from pelvis to perineum (e.g. urethra, vagina) below levator ani have what innervation?
- in the perineum
- somatic sensory
- pudendal nerve
- spinal cord levels S2, S3 and S4
- localised pain within perineum
129
Where do the sympathetics of the pelvis originate?
- sacral sympathetic trunks
- T11-L2
- superior hypogastric plexus
130
Where do the parasympathetics of the pelvis originate?
- sacral outflow (S2, S3, S4)
- pelvic splanchic nerves
- emerge from spinal roots
- mixes with sympathetics in inferior hypogastric plexus
131
What is the role of the superior hyogastric plexus?
Provides visceral and motor information to the perineum and pelvis
132
What bone is formed by the fusion of the ilium, ischium and pubis?
The innominate bone (hip bone)
133
The sacrotuberous ligament runs from where?
The sacrum to the ischium tuberosity
134
The sacrospinous ligament runs from where?
Sacrum and superior part of coccyx onto ischial spine
135
What forms the greater and lesser sciatic foramen?
The sacrospinous ligament
136
Describe the obturator membrane
- partly on lateral wall of pelvis but mostly anterior facing
- thickened membrane / fascia that almost completely fills the obturator foramen in pelvis
- allows for passage of obturator neurovascular bundle (obturator canal)
137
Where can the obturator canal be found?
On the anterior aspect of the obturator ligament
138
What forms the tendinous arch of levator ani?
A band of thickened fascia from the obturator muscle
139
What forms most of the fleshy part of the lateral pelvic wall?
Obturator internus
140
The majority of arteries of pelvis and perinuem arise from where?
The internal iliac artery
EXCEPT; gonadal artery, superior rectal artery
141
Where does the gonadal artery arise from?
Arises around L2 from abdominal aorta, can be testicular or ovarian artery
142
The superior rectal artery is a continuation of what?
The inferior mesenteric artery
143
What artery is found in males but not in females (not gonadal)?
Inferior vesical artery - this is replaced by the vaginal artery in females
144
The vesicle arteries give off what branches?
The prostatic branch and artery to the vas deferens
145
Name the arteries of the male perineum
- dorsal artery of penis
- deep artery
- anterior scrotal artery
- internal pudendal artery
- perineal artery
- posterior scrotal artery
146
The internal pudendal artery terminates as what?
The dorsal artery of the penis
147
The anterior scrotal artery is a branch of which other artery?
The external iliac
148
What is the medial umbilical ligament?
Remnant of the umbilical artery which connected the internal iliac artery to the placenta through the umbilical cord
149
What anastamoses occur in the female pelvis?
- an anastamosis occurs between the uterine artery and the ovarian artery
- an anastamosis occurs between the uterine artery and the vaginal artery
150
What does 'water under the bridge' refer to in the female pelvis?
- ureter under the uterine artery
| - need to be aware of this during hysterectomy
151
What does vermiculate mean and what structure can do this?
- means it can wiggle
| - ureter can do this during surgery, helps to differentiate it from uterine artery
152
Which ureter is most likely to be damaged during hysterectomy and why?
- left
- right hand side lies a little more laterally and crosses external iliac artery into the pelvis
- the left sits medially and crosses the common iliac
153
Name the arteries of the female perineum
- common iliac
- dorsal artery of clitoris
- labial arteries
- internal pudendal artery
- inferior rectal artery
- perineal artery
154
Describe the venous drainage of the pelvis
- form a number of venous plexuses
- drain mainly into internal iliac vein however some wil drain via the superior rectal vein back up into the hepatic portal system
- some will drain via lateral sacral veins into internal vertebral venous plexus
155
What is the clinical significance of the lateral sacral veins of the pelvis?
They provide an alternate collateral pathway to the superior or inferior vena cava and it can provide a pathway for metastases
156
Name the nerves of the lateral pelvic wall
- obturator nerve (nothing to do with pelvis but lies on lateral wall)
- sciatic nerve
- pudendal nerve
- nerve to levator ani
- sacral plexus
- pelvic splanchic nerves
157
Where do the nerves of the pelvis originate?
- the sacral plexus
| - lumbar plexus also joins the sacral plexus
158
Name the somatic nerves of the pelvis
- sciatic nerve
- pudendal nerve
- levator ani nerve
- pelvic splanchic nerves
159
Pelvis splanchic nerves originate where and provide what modality?
- from anterior rami of S2, S3, S4
| - carry parasympathetic innervation
160
Name the lymph node groups that can be found in the pelvis
- deep inguinal
- internal iliac
- sacral
- pararectal
- lumbar
- inferior mesenteric
- external iliac
- common iliac
- superficial inguinal
161
The superior parts of the pelvic organs / pelvic viscera drain lymph to where?
- external iliac nodes
| - then common iliac, aortic, thoracic duct, venous system
162
The inferior parts of the pelvic viscera and areas of the deep perineum drain lymph to where?
- to internal iliac first
| - then common iliac, aortic, thoracic duct, venous system
163
The superficial perineum drains lymph to where?
To the superficial inguinal nodes
164
The ovaries and testes drain lymph to where and why?
- towards lumbar lymph nodes
| - due to embryological origin on posterior abdominal wall
165
Name functions of the bony pelvis
- support of the upper body
- transference of weight
- attachment for muscles
- attachment for external genitalia
- protection of pelvic organs
- passage for childbirth
166
The bony pelvis consists of what?
- 2 hip bones (innominate bones)
- sacrum
- coccyx
167
Where does the fusion of the three bones of the hip bone occur?
Within the acetabulum
- this occurs during embryological development however complete ossification does not occur until adulthood
168
Name the bony features of the ilium
- iliac crest; palpable, runs between ASIS and PSIS
- anterior superior iliac spine; anterior end of iliac crest, palpable landmark
- posterior superior iliac spine
- iliac fossa; internal aspect of the ilium, attachment of iliacus muscle
169
Name the bony features of the ischium
- ischiopubic ramus; part of both ischium and pubis
- ischial tuberosity; posteriorly, bony bumps you sit on
- ischial spine; posterior, important clinical landmark
170
Name the bony features of the pubis
- pubic tubercles; attachment point for inguinal ligament (other attachment being ASIS)
- come together at pubic symphysis to from pubic arch
- angle that is located inferior to the pubic arch is known as the sub-pubic angle
- superior pubic ramus
- ischiopubic ramus
171
What is the pelvic inlet?
- the entrance to the pelvic cavity proper from the abdominal cavity
- aka pelvic brim
172
What is the pelvic outler
The inferior aspect of the pelvic cavity
173
What makes up the pelvic inlet?
- sacral promontory
- ilium
- superior pubic ramus
- pubic symphysis
174
What makes up the pelvic outlet?
- pubic symphysis
- ischiopubic ramus
- ischial tuberosities
- sacrotuberous ligaments
- coccyx
175
Name the palpable surface landmarks of the pelvis
- pubic symphysis
- pubic tubercle
- ASIS
- iliac crest
- sacrum
- PSIS
- coccyx
- ischial tuberosity
- sacral promontory also palpable on vaginal examination (4 and 8 oclock positions)
176
Name the joints of the pelvis
- hip joint (synovial)
- pubic symphysis (secondary cartilaginous)
- hip joint (synovial)
- sacroiliac joint
177
Describe the sacroiliac joint
- synovial joint
- often described as synovial anteriorly and a syndesmoses posteriorly (fibrous joint)
- main function is to transfer weight from the axial skeleton to the hip bones, very little movement occurs here
178
Name the two important ligaments of the pelvis to be aware of
- sacrotuberous ligament
| - sacrospinous ligament
179
Where does the sacrospinous ligament run?
Runs in relation to bony attachments, sacrum and ischial spine
180
Where does the sacrotuberous ligament run?
Between sacrum and ischial tuberosity
181
What is the function of the ligaments of the pelvis?
- protection against sudden weight transfer
- these ligaments relax after pregnancy
- ensure the inferior part of the sacrum is not pushed superiorly when weight is transferred anteriorly through the sacral column
- SI joint moves through a rotational axis, so the joint rotates slightly anteriorly when weight is bearing
182
Under what hormonal influence do the ligaments of the pelvis relax during pregnancy?
Relaxin
183
The presence of the 2 ligaments of the pelvis allows for what foraminae to be formed?
The greater and lesser sciatic foraminae
184
What forms the tendinous arch in the pelvis?
- the obturator neurovascular bundle is covered by the obturator internus muscle
- this is then covered medially by the obturator fascia
- this fascia thickens centrally to form the tendinous arch
185
The tendinous arch is an attachment point for what?
The pelvic diaphragm
186
Describe the differences in male and female bony pelvis
- the AP and transverse diameters of the female pelvis are larger than the male, both at the pelvis inlet and outlet
- the subpubic angle (and pubic arch) in the female is wider than the male
- the pelvic cavity is more shallow in the female
187
What is moulding?
Refers to the movement of one bone over another to allow for the foetal head to pass through the pelvis during labour
188
What allows for moulding of the foetal skull?
- fontanelles, areas where the bones have not ossified
- posterior fontanelle; between parietal and occipital bone, triangular shaped
- anterior fontanelle; frontal and parietal bone, diamond shaped
189
What is the bregma of the foetal skull?
The point at which the coronal suture and saggital suture intersect each other, around about the anterior fontanelle
190
What is the vertex of the foetal skull?
- highest point of the skull
| - an area of the foetal skull outline by the anterior and posterior fontanelles and the parietal eminences
191
What are the parietal eminences?
- bony bumps on the lateral aspects of the parietal bony
- points of secondary ossification
- will eventually smooth over
192
Which diameter is the largest in the foetal skull?
- the occipito-frontal diameter is longer than the biparietal diameter
- i.e. the foetal head is longer than it is wide
193
What diameter is biggest at the pelvic inlet in females?
The transverse diameter of the pelvis is wider than the AP diameter
194
What is the 'station'?
- the distance of the foetal head from the ischial spines
- a negative number means the head is superior to the spines
- a positive number means the head is inferior to the spines
195
Whilst descending through the pelvic cavity, what should the foetal head do?
- rotate
| - be in a flexed position, i.e. chin on chest
196
Which diameter is biggest at the pelvic outlet in females?
The AP diameter is wider than the transverse diameter
197
During delivery the foetal head should be in what position?
Extension
198
At the pelvic inlet, the foetal head should be in what position?
Transverse
199
In terms of pain from the female reproductive system, what are the two important spinal cord levels?
T11-L2
S2-S4
200
Anaesthetic is injected into where for a spinal or epidural?
L3-L4 (L5) region
201
For an epidural anaesthetic, the needle passes through what?
- supraspinous ligament
- interspinous ligament
- ligamentum flavum
- epidural space (fat and veins)
202
For a spinal anaesthetic, the needle passes through what?
- supraspinous ligament
- interspinous ligament
- ligamentum flavum
- epidural space (fat and veins)
- dura mater
- arachnoid mater
- finally reaches subarachnoid space (contains CSF)
203
Why can hypotension occur with spinal anaesthetic?
- all spinal nerves and their named nerves contain sympathetic fibres
- sympathetic fibres supply all arterioles
- blockade of sympathetic tone to all arterioles in lower limb leads to vasodilation
- this leads limb to be warm, skin to be flushed, less sweaty and hypotension
204
The pudendal nerve contains what modalities?
Somatic motor and somatic sensory
205
Describe the route of the pudendal nerve
- exits pelvis via greater sciatic foramen
- passes posterior to sacrospinous ligament
- re-enters pelvis / perineum via lesser sciatic foramen
- travels in pudendal canal
- branches to supply structures of the perineum
206
What landmark is used to locate the pudendal nerve?
- the ischial spine
| - the pudendal nerve crosses posterior to the lateral aspect of the sacrospinous ligament
207
When can pudendal nerve blocks be utilised?
- can be used during labour; forceps delivery, painful vaginal delivery, episiotomy incision
- perineal suturing post delivery
208
What is an episiotomy?
Where the skin and perineal muscles are cut in a planned incision
209
Name examples of common obs and gynae surgical incisions
- lower segment caesarean section (suprapubic incision)
- laparotomy
- laparoscopy
- abdominal (and vaginal) hysterectomy
210
Where do the external obliques attach?
- Run antero-inferiorly from aspects of ribs 5-12 to the iliac crest, pubic tubercle
and linea alba
- posteriorly is a free edge between costal margins and iliac crest
- anteriorly the muscle fibres form an aponeurosis at around about midclavicular line and also at the umbilical line
211
What forms the inguinal ligament?
- the thickened inferior edge of external oblique curves back on itself and forms the ligament
- between ASIS and pubic tubercle
212
Where do the internal obliques attach?
- between lower ribs, thoracolumbar fascia, anterior two thirds of iliac crest and linea alba
- run in opposite direction to external oblique
- run in same direction as internal intercostalis
213
Where does transversus abdominus attach?
- between costal cartilage of ribs 7-12 (internal aspects), iliac crest and linea alba
- deep to internal oblique
- neurovascular plane lies between internal oblique and transversus abdominus muscle in the anterolateral abdominal wall
214
Where does rectus abdominus lie?
- between 5th to 7th costal cartilage and pubic symphysis and pubic crest
- 3 times wider superiorly than inferiorly
215
What divides up the rectus abdominus?
- tendinuous intersections
| - created improved mechanical efficiency
216
What forms the linea alba and where does it run?
- formed by the interweaving of the muscle aponeuroses
| - runs from the xiphoid process to the pubic symphysis
