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Pelvic Pain Line
The inferior limit of the paritoneum, except in the case of the large intestine, where the pain line occurs in the middle of the sigmoid colon.
Visceral afferent fibers
Reflex fibers run with the parasympathetics (S2-S4).
Pain fibers above the pain line run with sympathetics, except distal sigmoid colon and rectum.
Pain fibers below the pain line run with parasympathetics.
The pelvic plexus AKA
The inferior hypogastric plexus.
General lymph drainage of the pelvis
- all of pelvis must drain to one of four lymph nodes
- Inside pelvis
- -External iliac
- -Internal iliac
- -Common iliac
- Outside pelvis
- - lumbar
Where can a kindy stone lodge
- -where it enters bladder
- -crosses renal artery
- -crosses iliac
Ureters blood supply
renal artery, gonadal artery, common iliac, internal iliac
Parasympatheic innervation to the abdomen and pelvis
- Vagus nerve for anything that receives its blood supply from above the gonadal artery, L2
- L3 and lower get para from pervic splachnic S2 S3 S4 (keeps your dick off the floor)
Receives vagus nerve since blood supply is from the L2 level.
What space allows bladder distention?
- rectopubic space
- bladder can move into false pervis
What does the bladder rest on?
- In males the prostate
- In females the pelvic diaphragm, levator ani and coccygeal (S3, S4)
- -Superior vesical: branch of umbilical artery; usually several branches to anterosuperior aspect
- -Inferior vesical: supplies fundus and neck; in females, usually arises from vaginal artery (instead of branch of internal iliac directly)
- -Portion of fundus is supplied by vaginal artery in females and by deferential artery in males
- -Parasympathetics (S2 - 4) and their visceral afferent fibers are completely responsible for entire micturition reflex
- -Sympathetics: two routes to bladder, (1) superior hypogastric plexus (main route), and (2) sacral splanchnics (fibers that course down chain ganglia to pelvis); sympathetics cause contraction of internal sphincter (smooth muscle)
PAIN courses with visceral afferents that travel with sympathetics (T 11 – L 2) for superior bladder and para for inferior badder. Only superior aspect is covered in paritoneum.
- Pudendal nerve, S2 - 4, is somatic nerve Deep perineal nerve (branch of pudendal) Innervates sphincter urethrae
- muscle (of perineum); this muscle is a skeletal (voluntary) muscle
sacral and pelvic splanchnic nerves
sacral is sympathetic
pelvic is para
Testies Migration during development
starts at the level of L2, at the 28th week they reach the inguinal canal, during week 29 they are in the canal, week 30 and later they are in the scrotum.
-They bring blood supply with them from L2 so parasympathetic innervation is from vegus nerve.
located in the prostate and is very short
- made from the joining of the ductus deferns and the seminal duct
- -seminal duct secretes fructose for nutrition.
- Urethra and ejaculator duct transverse
- -only one lobe in the adult, 5 lobes during development
- Capsule of prostate is surrounded my fibrous sheath
- -artery and nerves sit inside sheeth and outside capsule
Prostate arterial and venous supply
-Arterial supply: (1) inferior vesical, (2) internal pudendal, and (3) middle rectal (all branches off the anterior internal iliac)
-venous plexus lies deep to sheath,superficial to capsule; receives deep dorsal vein and drains to both vertebral plexus and internal iliac.
-----Explains why prostate cancer can travel to the brain.
“hill” that receives openings of ejaculatory ducts.
continual recess around cervix; anterior, posterior & lateral fornices
Vagina Spacial relations
- Anterior relations: urinary bladder and uterus; (uterus also lies superior)
- Lateral relations: levator ani and ureter
- Posterior relations:
- 1. Rectum
- 2. Rectouterine pouch
- 3. Perineal body
Vagina arterial supply
- Vaginal artery: chief supply, branch of uterine artery or anterior internal iliac
- Other arteries to vagina:
- 1. Uterine, superior part
- 2. Inferior vesical
- 3. Middle rectal
- 4.Internal pudendal
Portions of the uterus?
Fundus, body, Isthmus, internal OS, cervix, external OS
-cervix has a vaginal portion and a supravaginal portion
- Anteverted & anteflexed
- -Sits on bladder
Anteverted: entire uterus is bent forward onto bladder, longitudinal axis of vagina makes 90 - 1000 angle with uterine cervix;
Anteflexed: Angle of uterine body is bent forward about 15 - 20 compared to uterine cervix
Ligaments of the uterus
- Broad ligament: peritoneum; attached to lateral sides of uterus;
- -portions: mesometrium (attached to uterus), mesovarium (to ovary) & mesosalpinx (to tube)
-infalmmation of uterous is salpinxgitis
Gubernaculum has two remnants: ovarian ligament and round ligament: ovarian ligament extends from ovary to uterus; round ligament extends from uterus, courses through inguinal rings & canal to end in labium majus
Uterosacral ligament: peritoneum and subserous fascia; attaches sacrum to cervix; helps “anchor” cervix, keeping it in midline
Pubocervical ligament is portion of pubovesical ligament
Lateral cervical ligament
- cardinal ligament; peritoneum and subserous fascia; located at inferior end of broad ligament; conveys uterine vessels; of the
- ligaments, greatest support; attached to cervix
- Listed in sequence, beginning with greatest support:
- 1. Pubococcygeus: portion of levator ani - dynamic
- 2. Urinary bladder - passive (uterus sits on top)
- 3. Ligaments of uterus
- a. Lateral cervical (cardinal ligament)
- b. Uterosacral
- c. Broad
- d. Ovarian and round: two remnants of gubernaculum
- e. Pubocervical
- passes anterior to ureter
- branch of internal iliac
- Uterine artery crosses superior to ureter; uterine artery divides into descending branches (vaginal and cervical branches)
- and larger ascending branch; many branches to uterus; usually supplies tube, may supply ovary