Pelvic Contents Peculiar to Males and Females - Wong.pdf

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TOPIC: Pelvic Contents Peculiar to Male and Female

LECTURER: Sammy Wong, MD

4.2

JANUARY 25, 2016

PELVIC CONTENTS PECULIAR TO MALES

- Prostate

- Seminal vesicle

- Vas deferens

PROSTATE

- fibromuscular glandular organ that surrounds theprostatic urethra

- 1.25 in. (3 cm) long, conical in shape- lies between the neck of the bladder above and the

urogenital diaphragm below - Parts:

o base - lies against the bladder neck above

o apex - liesagainst the urogenital diaphragmbelow

- Produces a thin, milky, alkaline fluid containing citricacid and acid phosphatase that is added to the

seminal fluid at the time of ejaculation to helpneutralize the acidity in the vagina.

RELATIONS

Superior The base of the prostate is continuous with

the neck of the bladder

Inferior The apex lies on the upper surface of the

urogenital diaphragm.

Anterior

Symphysis pubis, separated from it by the

extraperitoneal fat in the retropubicspace(cave of Retzius)

Puboprostatic ligaments – connects thefibrous sheath of the prostrate to the posterioraspect of the pubic bones

Posterior

anterior surface of the rectal ampulla

rectovesical septum/Fascia ofDenonvilliers separates the prostrate from

the rectal ampulla

Lateral anterior fibers of the levator ani as they run

posteriorly from the pubis

SNELL:- The urethra enters the center of the base of the prostateand leaves

the prostrate just above the apex on the anterior surface.

- Rectovesical Septum (Fascia of Denonvillier) – formed in fetal lifeby the fusion of the walls of the lower end of the rectovesical pouch of

peritoneum, which originally extended down to the perineal body

COVERINGS OF THE PROSTATE- Covered by a fibrous capsule, a part of the visceral

layer of the pelvic fascia. It is continuous with the

fibromuscular septa around the glandular tissue



[4.2: Pelvic Contents Peculiar to Male and Female]


LOBES OF THE PROSTATE

- Incompletely divided into 5 lobes:

Anterior (Isthmus)- lies in front of the urethra - devoid of glandular tissue

Median (Middle)

- wedge-shaped; situated betweenthe urethra and the ejaculatoryducts.

- Its upper surface is related to thetrigone of the bladder

- Rich in glands

Posterior- situated behind the urethra and

below the ejaculatory ducts - contains glandular tissue

Right and LeftLateral

- lie on either side of the urethra - separated from one another by a

shallow vertical groove on theposterior surface of the prostate.

- contain many glands

BLOOD SUPPLY- Inferior vesical artery- Middle rectal artery- Internal pudendal artery (Dr. Wong’s ppt, 20171D)

**All 3 arteries arise from the internal iliac artery

VENOUS DRAINAGE

Prostatic venous plexus

LocationLies outside the capsule of the prostate(base)

Tributaries Deep dorsal vein of the penis

Vesical veins

Drainage Internal iliac vein

Communications(2017 1D)

Superiorly: Vesical venous plexus (drains the

urinary bladder) Posteriorly: Internal pudendal vein (Internal

vertebral venous plexus, acc. to Moore)

Doc Wong/Snell Clinical Notes: Connects withvertebral veins (extradural plexuses) whichserves as a pathway for mestastasis to thevertebral column

LYMPHATIC DRAINAGE- Internal iliac nodes (Snell)

- Sacral and External iliac nodes (included in 20171D, Dr.

Wong’s ppt)

IN SNELL (not in the objectives):

Nerve Supply: Inferior hypogastric plexuses The sympathetic nerves stimulate the smooth muscle of the

prostate during ejaculation

Prostatic urethrao begins at the neck of the bladder; 1.25 in. (3 cm

longo passes through the prostate from the base to the

apexo becomes continuous with the membranous part o

the urethrao prostatic urethra is the widest and mos

dilatableportion of the entire urethra o Urethral crest - longitudinal ridge on the posterio

wallo Prostaticsinus- a groove on each side of the

crest; the prostatic glands open into thesegrooves.

o Prostatic utricle- depression on the summit of theurethral crest; an analog of the uterus andvaginain females.

o On the edge of the mouth of the utricle are theopenings of the two ejaculatory ducts.

SEMINAL VESICLE

- Two lobulated organs about 2 in.(5 cm) long lying on theposterior surface of the bladder

- Each seminal vesicle consists of a much-coiledtubeembedded in connective tissue

- The terminal part of the vas deferens lies on the media

side of each vesicle

.





RELATIONS OF THE SEMINAL VESICLE

Anterior Posterior surface of the urinary bladder, from

near the termination of ureter to base ofprostrate

Posterior Rectum separated by rectovesical fasciaMedial Ampulla of the vas deferens

Lateral Veins of prostatic plexus

SECRETIONS OF THE SEMINAL VESICLE - the secretions are added to the seminal fluid and are

composed of the following:

1. Fructose – nourishment for the sperm cells2. Proteins – for coagulation3. Enzymes – destroys abnormal sperm cells4. Prostaglandins – induce contractions to help in the

transport of sperm through the female reproductivetract

BLOOD SUPPLY/VENOUS/LYMPHATIC DRAINAGE

Blood SupplyInferior vesicle arteryMiddle rectal arteries

Venous DrainageInternal Iliac veins (Snell)Inferior vesicle and Middle rectalveins (2017 1D)

Lymphatic Drainage Internal iliac nodes

TERMINATION OF THE SEMINAL DUCT

- Inferiorly, each seminal vesicle narrows and joins the vas

deferens of the same side to form the ejaculatory duct.

VAS (DUCTUS) DEFERENS

- thick-walled tube about 18 in. (45 cm) long- conveys mature sperm from the epididymis to the

ejaculatory duct and the urethra.

COURSE OF THE VAS DEFERENS

Arises from the lower end or tail of the epididymis(globus minor)

passes through the inguinal canal

emerges from the deep inguinal ring

passes around the lateral margin of the inferiorepigastric artery

passes downward and backward on the lateral wall of thepelvis

crosses the ureter in the region of the ischial spine.

runs medially and downward on the posteriorof thebladder

Dilates terminally to form the ampulla of the vas deferens

The inferior end of the ampulla narrows down and joinsthe duct of the seminal vesicle to form the ejaculatory duct

BLOOD SUPPLY/VENOUS/LYMPHATIC DRAINAGE

Blood supply

Deferential artery (artery to theductus deferens) which arises fromeither a superior (SNELL: inferior)vesical artery or the internal iliac artery

Venous drainageSuperior or inferior vesical veins which drain into the internal iliac vein

Lymphatic drainage Internal and external iliac nodes





EJACULATORY DUCT

- each <1 in. (2.5 cm) long and- formed by the union of the vas deferens and the duct of

the seminal vesicle - pierce the posterior surface of the prostate and open into

the prostatic part of the urethra, close to the margins of theprostatic utricle

- functions by draining the seminal fluid into the prostatic

urethra

PELVIC CONTENTS PECULIAR TO FEMALES

- Ovary (paired)

- Fallopian tube/uterine tube/oviduct (paired)

- Uterus (unpaired)

OVARY

- paired, almond-shaped organ

- 1.5 x 0.75 in. (4x2 cm)

- responsible for the production of female germ cells (ova), and

female sex hormones (estrogen and progesterone)

- surrounded by tunica albuginea (thin, fibrous capsule)

which is covered externally by a modified area of

peritoneum called germinal epithelium (this layer does

not give rise to the ova)

- lies against the lateral wall of the pelvis in a deep

depression called ovarian fossa

- variable in position but commonly found hanging down in

the rectouterine pouch (pouch of Douglas)

- bounded:

o above by the external iliac vessels

o behind by the internal iliac vessels and

ureter

- posterior in relation to the uterus and obliterated umbilical

artery

- Oophoritis – inflammation of the ovaries, often seen with

salpingitis (inflammation of the fallopian tube)

LIGAMENTS OF THE OVARY

Mesovarium

o attaches the ovary to the posterior surface of the

broad ligament of the uterus

o derived from the peritoneum

Suspensory ligament (infundibulopelvic ligament)

o part of the broad ligament between the

attachment of the mesovarium and lateral wall of

the pelvis

o

where the blood supply, lymph drainage, andnerve supply of the ovary pass over the pelvic

inlet

Round ligament of the ovary

o remains of the proximal part of the gobernaculum

ovary

o connects the inferomedial margin of the ovary to

the upper end of the lateral wall of the uterus

BLOOD SUPPLY

Ovarian artery – from abdominal aorta at the level of L1

VENOUS DRAINAGE

Ovarian vein – drains into inferior vena cava (right) and

renal vein (left)

LYMPHATIC DRAINAGE

Paraaortic nodes – at the level of L1

NERVE SUPPLY Aortic plexus

Sympathetic fibers carry the afferent impulses from the

ovary and enter the T10 of the spinal cord

FALLOPIAN TUBE

- also called uterine tube, salpinges or oviducts - pair of tubes about 10 cm (4 in) long- lies on the upper border of the broad ligament- connects the peritoneal cavity laterally (in the region of the ovary)

with the uterine cavity medially- main organ that conveys the egg from the ovary to the uterus- two very fine tubeslined with ciliated epithelia leading from the

ovaries into the uterus via the utero-tubal junction - serves as a conduit along which the spermatozoa travel to reach

the ovum- divided into 4 parts:

o infundibulumo ampullao isthmuso intramural part

- to check the patency of the fallopian tube, air is injected andchecked with an X-ray to check for air in the peritoneal cavity

COMMUNICATIONS OF THE FALLOPIAN TUBE

Abdominal ostium – opening into peritoneal cavity

Uterine part of the tube or intramural – opening to the

uterus

PARTS OF THE FALLOPIAN TUBE

Infundibulum

o funnel-shaped lateral end that projects beyond

the broad ligament and overlies the ovary

o fimbriae – finger-like processes on the free edge

of the funnel and are draped over the ovary

Ampulla

o widest part of the tube

o most common site of fertilization

Isthmus

o narrowest part of the tube

o lateral to the uterus





Intramural part

o segment that pierces the uterine wall

BLOOD SUPPLY

Uterine artery – from the internal iliac artery

Ovarian artery – from abdominal aorta

VENOUS DRAINAGE

Uterine vein

Ovarian vein

LYMPHATIC DRAINAGE

Internal iliac nodes

Paraaortic nodes

NERVE SUPPLY

sympathetic and parasympathetic nerves from the inferior

hypogastric plexus

TUBAL LIGATION

isthmus of fallopian tube

permanent form of birth control in which a woman’s

fallopian tubes are surgically cut or blocked off to prevent

pregnancy

usually restricted to woman who already have children

the ova that are discharged from the ovarian follicles

degenerate in the tube proximal to the obstruction

restoration of the continuity of the uterine tubes can be

attempted, and, in about 20% of women, fertilization

occurs

UTERUS

- entirely a pelvic organ (located in the lesser/true pelvis)

- a hollow pear-shaped organ with thick muscular walls

- dimensions of nullipara: 8 cm (l) x 5 cm (w) x 2.5 cm

(thickness)

- 30-40 g

- lies between urinary bladder in front and rectum behind

- serves as a site for the reception, retention, and nutrition

of fertilized ovum

RELATIONS OF THE UTERUS

POSITIONS OF THE UTERUS

Anteversion (most common) – long axis of the uterus is

bent forward on the long axis of the vagina, with an angle

of 90 degrees

Anteflexion (most common) – long axis of the uterus is

bent forward at the level of the internal os with the long

axis of the cervix, with an angle of 170 degrees

In erect position, with bladder empty, uterus lies in an

almost horizontal plane

Retroversion – fundus and body of the uterus are ben

backward on the vagina so that they lie in the rectouterine

pouch (pouch of Douglas)

Retroflexion – body of the uterus is bent backward on the

cervix

PARTS OF THE UTERUS

Funduso lies above the entrance of the uterine tube

Anteriorly Body of uterus: uterovesical pouchsuperior surface of the bladderSupravaginal cervix: superior surface of thebladderVaginal cervix: anterior fornix of the vagina

Posteriorly Body of the uterus: rectouterine pouch(pouch of Douglas), coils of ileum andsigmoid colon

Laterally Body of uterus: broad ligament, uterineartery and veinSupravaginal cervix: ureter

Vaginal cervix: lateral fornix of the vagina





Bodyo lies below the entrance of the uterine tubes

Cervixo narrow part of the uterus

o pierces the anterior wall of vagina and divided into the

supravaginal and vaginal part of the cervix

Cavityo triangular in coronal section

o just a cleft in sagittal plane

o

cervical canal – cavity of the cervix whichcommunicates with the cavity of the body (internal os)

and with the vagina (external os)

o in nullipara (women who have never given birth),

external os is circular

o in para (women who have given birth at least once),

vaginal part of the cervix is wider and external os

becomes a transverse slit (possesses an anterior and

posterior lip)

Myometriumo muscular wall

o thick and made up of smooth muscle supported by the

connective tissue

o stretches during pregnancy to accommodate fetus

o contracts during labor (to deliver fetus and placenta)

and in recovery phase (to prevent blood loss and

uterine atony)

Endometriumo mucous membrane lining the body of the uterus

o continue above with the mucous membrane lining the

uterine tubes and below with the mucous membrane

lining the cervix

o no submucosa

o undergo extensive changes during menstrual cycle in

response to ovarian hormones

o site of embryo implantation

o shed in menstruation, if no pregnancy occurs

Parametriumo visceral pelvic fascia that surrounds the supravaginal

part of the cervix

o where uterine artery crosses the ureter on each side of

the cervix

Perimetriumo consists of loose connective tissue

SUPPORTS OF THE UTERUS

The uterus is upported mainly by the ton of levatores ani muscleand the subperineal condensation of pelvic fascia on the uppersurface of the levatores ani muscles, which form three importantligaments:

o pubocervicalo transverse cervicalo sacrocervical

Levatores ani muscles and pelvic fascia on their upper surfaceeffectively support the pelvic viscera and resist the intraabdominal

pressure transmitted downward through the pelvis Levatores ani and Perineal body

o form a broad muscular sheet stretching across the pelviccavity

o medial edges of the anterior parts are attached to the cervixof the uterus by the pelvic fascia

o some fibers are inserted into a fibromuscular structure calledperineal body (lies in the perineum between the vagina andanal canal, important in making the integrity of the pelvicfloor, supports the vagina, and indirectly, the uterus)

Pubocervical ligaments

o consist of 2 firm bands of connective tissue

that pass to the cervix from posterior surface

of the pubis

o positioned on either side of the neck of the

bladder, to which they give some support

(pubovesical ligaments)

o attaches the lateral cervix to the symphysis

pubis

Transverse cervical (cardinal) ligaments

o a.k.a. Mackenrodt’s ligament

o fibromuscular condensation of pelvic fascia

that passes to the cervix and the upper end

of vagina from the lateral walls of the pelvis

o located at the base of the broad ligament

o contains the uterine artery and the uterine

vein

o attaches the lateral cervix to the lateral pelvic

wall at the ischial spine

o strongest of the uterine ligaments

Sacrocervical ligaments

o a.k.a. uterosacral/rectouterine ligament

o

consist of two firm fibromuscular bands ofpelvic fascia that pass to the cervix and

upper end of vagina from the lower end of

the sacrum

o form two ridges, one on either side of the

rectouterine pouch

o helps in anteversion and anteflexion of the

uterus as it pulls the cervix backward,

therefore the uterus is bent forward

Lax structures with minor role in support: Round ligament

o remains of lower half of the gubernaculum ovary

o extends between superolateral angle of uterus,

through the deep inguinal ring and inguinal canal,to the subcutaneous tissue of labium majus

o helps keep the uterus anteverted and anteflexed

o considerably stretched during pregnancy

Broad ligament

o strongest among the 5

o two layered folds of peritoneum with mesothelium

that extends across the pelvic cavity from lateral

margins of uterus to lateral pelvic walls

o superior: two layers are continuous and form the

upper free edge





o inferior: separate to cover the pelvic floor

o holds uterus in its normal position

o connects the sides of the uterus to walls and

floors of pelvis

o serves as the mesentery for the uterus, the

uterine tubes, and the ovaries

o contents:- uterine tube (upper free border)

- round ligaments (of ovary and uterus)

- uterine and ovarian blood vessels, lymphvessels, and nerves

- Epoophoron - vestigial structure that lies in

the broad ligament above the attachment of

the mesovarium (remains of mesonephros)

- Paroophoron – vestigial structure that lies in

the broad ligament just lateral to the uterus

(remains of mesonephros)

o Parts: mesometrium, mesosalpinx, mesovariumo Mesometrium – largest part of the broad ligament;

ensheaths the uterus

o Mesosalpinx – most superior part of the broad

ligament; suspends the uterine tubes in the pelvic

cavity; between uterine tube and mesovarium

o Mesovarium – posterior extension of the broad

ligament; ensheaths the ovaryo Suspensory ligaments – form part of the broad

ligament that lies lateral to the attachment of

mesovarium

BLOOD SUPPLY

Uterine arterieso from internal iliac artery

o runs medially in the base of broad ligament

o crosses above the ureter at right angles

o reaches the cervix at the level of the internal os

o ascends along the lateral margin of the uterus within

the broad ligament

o ends by anastomosing with ovarian artery (assist in

supplying the uterus)

o gives off small descending branch that supplies the

cervix and vagina

VENOUS DRAINAGE

Uterine vein – drains into internal iliac vein

LYMPHATIC DRAINAGE

Paraaortic nodes (L1) – fundus

External and internal iliac nodes – body and cervix

Superficial inguinal nodes – round ligament

NERVE SUPPLY

sympathetic and parasympathetic nerves from

branches of the inferior hypogastric plexus (where

uterine nerves arise)

References:Snell, R. S. (2014). Clinical Anatomy by Regions, 9th Edition. Philadelphia:Lippincott Williams & Wilkins.

2017 1D Transcription 4.02 (lecture by Dr. Sammy Wong)2016 1C Transcription (lecture by Dr. De Jesus)

QUIZ:

1. Which of the following separates the prostate from its posterior

relation?

a. Puboprostatic Ligament

b. Fascia of Denonvilier ’s

c. Rectovesical septum

d. A and B

e. B and C

2. Which of the following is not a tributary of the prostatic venous

plexus?

a. Deep dorsal vein of the penis

b. Vesical vein

c. Internal Iliac vein

d. B and C

3. The terminal part of the ductus deferens is ___ to each seminal

vesicle.a. medial

b. lateral

c. posterior

d. anterior

4. The vas deferens takes these courses EXCEPT:

a. Passes through the superficial inguinal ring

b. Emerges from the deep inguinal ring

c. Passes around the lateral margin of the external iliac

artery

d. Runs medially and downward on the posterior surface

of the bladder

5. The deferential artery may arise from all of the following EXCEPT

a. Superior Vesical Artery

b. Inferior Vesical Artery

c. Internal iliac Arteryd. External iliac Artery

6. The opening of the salphinges is used to demarcate between:

a. corpus and cervix uterine

b. supravaginal and vaginal cervix

c. fundus and body of uterus

d. A and C

7. The following arises from the internal iliac artery EXCEPT:

a. ovarian artery

b. uterine artery

c. middle rectal artery

d. internal pudendal artery

8. Which of the following does not drain into the internal iliac nodes?

a. Seminal vesicle

b. Body of the uterus

c. Round ligament of the uterus

d. uterine tubes

9. This keeps the uterus bent forward:

a. Cardinal Ligament

b. Pubocervical ligament

c. Round ligament

d. Infundibulopelvic ligament

10. Most common site of fertilization:

a. Infundibulum

b. Ampulla

c. Isthmus

d. Intramural partAnswers: ECACDCACCB

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Pelvic Contents Peculiar to Males and Females - Wong.pdf