7 Anatomy Lect Pelvis.pptx

ANATOMY OF THE PELVIS AND PERINEUM Edward Linn MD FUNCTIONS OF THE PELVIS The strong and rigid pelvis is adapted to serve a number of roles in the human body. The main functions being: Transfer of weight from the upper axial skeleton to the lower appendicular components of the skeleton, especially d...

ANATOMY OF THE PELVIS AND PERINEUM Edward Linn MD FUNCTIONS OF THE PELVIS The strong and rigid pelvis is adapted to serve a number of roles in the human body. The main functions being: Transfer of weight from the upper axial skeleton to the lower appendicular components of the skeleton, especially during movement. Provides attachment for a number of muscles and ligaments used in locomotion. Contains and protects the abdominopelvic and pelvic viscera. “BONY PELVIS” THREE BONES OSSA COXAE (HIP) PELVIC GIRDLE SACRUM COCCYX PELVIC GIRDLE Ilium, Ischium and Pubis (all articulate in the acetabulum) Fusion occurs during growth and development to make one structure (via SIJ posteriorly and PS anteriorly) Ilium: largest of the 3 bones, iliac crest, ASIS, PSIS, sciatic notch Ischium: Strongest of the 3 bones, ischial spine, ischial tuberosity, ischial ramus Pubis: inferior ramus, pubic tubercle, superior ramus/pubic crest, pubic symphysis (PS) Note: obturator foramen is made up by the pubic and ischial rami THREE PARTS OF PELVIC BONE PELVIS BONE- ANTERIOR 1-Ischiopubic rami 2-Obturator foramen 3-Anterior superior iliac spine 4-Iliac crest 5-Iliac fossa 6-Ischial spine 7-Pubic tubercle 8-Pubic crest 9-Pubic symphysis 10-Sacro-iliac joint Anterior View: TRUE PELVIS (LESSER)- BY THE ILIO-PECTINEAL LINE (LATERAL PELVIC INLET) FROM THE PUBIC SYMPHYSIS (ANTERIOR) TO THE SACRAL PROMONTORY (POSTERIOR). FALSE PELVIS(GREATER)-ILIAC CREST TO ILIAC CREST (INCLUDES ALL OF THE ILIAC BONE). CHARACTERISTIC DIFFERENCES IN PELVIC STRUCTURE FEMALE Smoother, lighter Pelvic Inlet transverse diameter=13 cm. Pubic symphysis is shorter Pubic arch (subpubic) angle is wider Iliac wings are flared Enlarged pelvic outlet Less curvature of the sacrum/coccyx Main difference is to allow for adaptation for child-bearing MALE Pelvic Inlet transverse diameter =12 cm. Pubic symphysis is taller Pubic arch is narrower Iliac wings less flared Designed for strength and speed WHICH PELVIS? BONY PELVIS- VARIATIONS ISCHIAL TUBEROSITY Posteriorly, the superior ramus of the ischium forms a large swelling, the ischial tuberosity. It marks the lateral boundary of the pelvic outlet (along with ischial spine). When sitting, the weight is frequently placed upon the ischial tuberosity. The gluteus maximus covers it in the upright posture, but leaves it free in the seated position. ISCHIAL SPINE From the posterior border of the body of the ischium there extends backward a thin and pointed triangular eminence, the ischial spine. The coccygeus muscles, levator ani and pelvic fascia attach here. The sacrospinous ligament attaches here. GREATER SCIATIC FORAMEN The greater sciatic foramen is a major foramen of the pelvis. It is bounded as follows: anterolaterally by the greater sciatic notch posteromedially by the sacrotuberous ligament inferiorly by the sacrospinous ligament superiorly by the anterior sacroilliac ligament The piriformis muscle exits thru the GSF. Below the piriformis muscle, the sciatic nerve exits. PIRIFORMIS MUSCLE EXITING THROUGH THE GREATER SCIATIC FORAMEN. SCIATIC NERVE EXITS BENEATH THIS MUSCLE. LESSER SCIATIC FORAMEN An opening between the pelvis and the posterior thigh, the foramen is formed by the sacrotuberous ligament between the sacrum and the ischial tuberosity and the sacrospinous ligament between the sacrum and the ischial spine. The lesser sciatic foramen has the following boundaries: Anterior: ischial tuberosity Laterally: Lesser sciatic notch Superior: ischial spine and sacrospinous ligament Posterior and medially: sacrotuberous ligament The tendon of the Obturator internus, internal pudendal artery, pudendal nerve and the nerve to the obturator internus exit through the LSF. Lesser Sciatic Foramen OBTURATOR FORAMEN The obturator foramen is the hole created by the ischium and pubis bones of the pelvis through which nerves and blood vessels pass. Obturator nerve- runs above and in front of the obturator vessels, through the upper part of the obturator foramen. It is responsible for the sensory innervation of the skin of the medial aspect of the thigh. Obturator membrane or fascia covers the foramen OE and OI will attach here MUSCLES OF THE PELVIS PIRIFORMIS MUSCLE THE PIRIFORMIS IS A MUSCLE IN THE GLUTEAL REGION OF THE LOWER LIMB. IT IS ONE OF THE SIX MUSCLES IN THE LATERAL ROTATOR GROUP. IT ORIGINATES FROM THE ANTERIOR PART OF THE SACRUM AND FROM THE SUPERIOR MARGIN OF THE GREATER SCIATIC NOTCH. IT EXITS THE PELVIS THROUGH THE GREATER SCIATIC FORAMEN TO INSERT ON THE GREATER TROCHANTER OF THE FEMUR. PELVIC MUSCLES The Gemelli are two small muscles in the pelvis, and function as accessories to the tendon of the obturator internus, which is received into a groove between them. The Gemellus superior, the smaller of the two, arises from the outer surface of the ischial spine, blends with the upper part of the Thetendon Gemellus of the inferior Obturator arisesinternus, from theand ischial inserts tuberosity with it into , the medial immediately surfacebelow of thethe greater groove trochanter. for the Obturator internus tendon. It blends with the lower part of the tendon of the Obturator internus and is inserted with it into the greater trochanter. Helps rotate thigh laterally. LEVATOR ANI A BROAD, THIN MUSCLE, SITUATED ON THE SIDE OF THE PELVIS. IT IS ATTACHED TO THE INNER SURFACE OF THE SIDE OF THE LESSER PELVIS, AND UNITES WITH ITS FELLOW OF THE OPPOSITE SIDE TO FORM THE GREATER PART OF THE FLOOR OF THE PELVIC CAVITY. IT SUPPORTS THE VISCERA IN PELVIC CAVITY, AND SURROUNDS THE VARIOUS STRUCTURES THAT PASS THROUGH IT. IN COMBINATION WITH THE COCCYGEUS MUSCLE, IT FORMS THE PELVIC DIAPHRAGM. IT HELPS MAINTAIN URINARY AND FECAL CONTINENCE. PELVIC FLOOR MADE UP OF SEVERAL MUSCLES: THE LEVATOR ANI IS DIVIDED INTO THREE PARTS: ILIOCOCCYGEUS MUSCLE PUBOCOCCYGEUS MUSCLE -CONTROLS URINE FLOW AND CONTRACTS DURING ORGASM. A STRONG PUBOCOCCYGEUS MUSCLE IS LINKED TO A REDUCTION IN URINARY INCONTINENCE AND PROPER POSITIONING OF THE BABY'S HEAD DURING CHILDBIRTH. PUBORECTALIS MUSCLE COCCYGEUS: FROM THE COCCYX TO THE ISCHIAL SPINE ILIACUS MUSCLE THE ILIACUS IS A FLAT, TRIANGULAR MUSCLE WHICH FILLS THE ILIAC FOSSA. IT JOINS THE PSOAS MAJOR TO FORM THE ILIOPSOAS MUSCLE (STRONGEST HIP FLEXOR). IT PROCEEDS ACROSS THE ILIOPUBIC EMINENCE TO ITS INSERTION ON THE LESSER TROCHANTER OF THE FEMUR. BLOOD SUPPLY OF THE PELVIS COMMON ILIAC ARTERY THE COMMON ILIAC ARTERIES ARE TWO LARGE ARTERIES THAT ORIGINATE FROM THE AORTIC BIFURCATION AT THE LEVEL OF THE FOURTH LUMBAR VERTEBRA. THEY ARE ABOUT 4 CM LONG IN ADULTS AND MORE THAN A CENTIMETER IN DIAMETER. THE ARTERIES RUN INFEROLATERALLY, ALONG THE MEDIAL BORDER OF THE PSOAS MUSCLES TO THEIR BIFURCATION AT THE PELVIC BRIM, IN FRONT OF THE SACROILIAC JOINTS. THE COMMON ILIAC ARTERY, AND ALL OF ITS BRANCHES, EXIST AS PAIRED STRUCTURES. THE DISTRIBUTION OF THE COMMON ILIAC ARTERY IS BASICALLY THE PELVIS AND LOWER LIMB (AS THE FEMORAL ARTERY) EXTERNAL ILIAC ARTERY THE COMMON ILIAC ARTS BIFURCATE INTO THE EXTERNAL ILIAC ARTERY AND INTERNAL ILIAC ARTERY. THE EXTERNAL ILIAC ARTERY BECOMES THE COMMON FEMORAL ARTERY WHEN IT PASSES BENEATH THE INGUINAL LIGAMENT. INTERNAL ILIAC ARTERY The Internal Iliac Artery is the main artery of the pelvis. Branches- Obturator artery (50%) Uterine artery Vaginal artery Inferior vesicle artery Middle rectal artery RT COMMON ILIAC, INTERNAL AND EXTERNAL ILIAC ARTERY EXTERNAL AND INTERNAL ILIAC VEINS THE EXTERNAL ILIAC VEIN IS THE CONTINUATION OF THE COMMON FEMORAL VEIN. IT DRAINS BLOOD FROM THE LOWER EXTREMITY. THE INTERNAL ILIAC VEIN DRAINS BLOOD FROM THE PELVIC ORGANS. THEY MERGE TOGETHER TO FORM THE COMMON ILIAC VEIN ON EITHER SIDE. COMMON ILIAC VEIN The COMMON ILIAC VEINS are formed by the external iliac veins and internal iliac veins. The left and right common iliac veins come together in the abdomen at the level of the fifth lumbar vertebra, forming the INFERIOR VENA CAVA. They drain blood from the pelvis and lower limbs. LEFT PELVIC ARTS AND VEINS IVC confluence L5 Aortic bifurcation L4 GONADAL ARTERY The term gonadal artery is a generic term for a paired artery, with one arising from the abdominal aorta for each gonad. Specifically, it can refer to: testicular artery in males ovarian artery in females ORGANS OF THE PELVIS DEVELOPMENT OF THE UNDIFFERENTIATED GONAD All fetuses begin with undifferentiated gonads which will develop into either the ovaries or testes depending on the XX or XY chromosomes around 7 weeks gestation The gonads begin as genital ridges (longitudinal ridges) derived from intermediate mesoderm and overlying epithelium o Initially do not contain any germ cells At 6-7 weeks' of gestation o Primordial germ cells from yolk sac migrate to the genital ridges o Epithelium of the genital ridges proliferates and penetrates the intermediate mesoderm to form the primitive sex cords  Primitive sex cords contributing to the development of specific cell types within the gonads GONADAL DEVELOPMENT Testes 7 weeks gestation - primitive sex cords continue to proliferate due to Y chromosome (SRY gene) Develop into the testicular cords forming:  Rete testis  Germ cells  Precursor cells that give rise to gametes (sperm and egg) Sertoli cells Will become network of tubules for sperm Synthesize anti-Mullerian hormone Leydig cells (derived from the intermediate mesoderm) in the eighth week, they begin production of testosterone – which drives differentiation of the internal and external genitalia Fetal testis development is not dependent on germ cells, while ovarian follicles require germ cells for their development GONADAL DEVELOPMENT Ovaries o Week 9 – ovaries begin to develop o Week 10 – ovarian cortex, inner medulla are distinguishable o No Y chromosome/no SRY; primitive sex cords degenerate (no not form testis cord) In females, primordial germ cells colonize the gonadal tissue and serve as the precursors for egg cells Ovarian Cortex Development: Within the gonadal ridges, the primordial germ cells interact with surrounding somatic cells and undergo further differentiation The outer region of the developing ovaries, known as the ovarian cortex, becomes populated with germ cells and supporting somatic cells Formation of Ovarian Follicles: Within the ovarian cortex, primordial germ cells undergo several rounds of division and differentiation to form oogonia Oogonia then differentiate into primary oocytes, which are surrounded by somatic cells called follicular cells to form primordial follicles These primordial follicles represent the earliest stages of egg development within the ovary INTERNAL GENITALIA DEVELOPMENT All embryos have two pairs of ducts, both ending at the cloaca. These are the: o Mesonephric (Wolffian) ducts o Paramesonephric (Mullerian) ducts Male o Testosterone + mesonephric ducts (Wolffian) = primary male genital ducts  give rise to the efferent ductules, epididymis, vas deferens and seminal vesicles o Paramesonephric ducts (Mullerian) degenerate in the presence of Anti-Mullerian hormone produced by Sertoli cells in the testes Female o Absence of testosterone (no Leydig cells), mesonephric ducts (Wolffian) degenerate o Absence of Anti-Mullerian hormone also allows for development of EXTERNAL GENITALIA DEVELOPMENT 3-5 weeks' gestation o Mesenchymal cells migrate to the perineum to form swellings on either side of the cloaca called cloacal folds (labioscrotal swelling)  Develop into scrotum or labia majora o On the cranial aspect of the cloacal folds, the mesenchymal cells fuse along the midline to form the genital tubercle o The genital tubercle is located just above the urogenital ostium 9 weeks' gestation o Genital tubercle undergoes elongation and sex differentiation leading to either the primordial male penis or primordial female clitoris EXTERNAL - MALE The development of the undifferentiated genitalia into the male genitalia is driven by the presence of androgens from the testes, namely dihydrotestosterone (DHT). o Elongation of the genital tubercle to form phallus o The urethral folds are pulled to form the urethral groove  The close by 4th month, forming the penile urethra genital swellings become the scrotal swellings, moving caudally to eventually form the scrotum EXTERNAL - FEMALE  Undifferentiated until 9 weeks gestation; differentiation @ 12 weeks' gestation  Genital tubercle forms the clitoris  Urethral folds and labioscrotal swellings do not fuse, but instead form the labia minora and labia majora respectively  Urogenital groove therefore remains open, forming the vestibule into which the urethra and vagina open GONADAL DESCENT While the gonads arise in the upper lumbar region, they are each tethered to the scrotum or labia by the gubernaculum – a ligamentous structure formed from mesenchyme. Testes o o As the body of the fetus grows, the testes become more caudal o During their descent, the testes retain their original blood supply, with the testicular arteries branching from the lumbar aorta o The scrotal ligament is the adult remnant of the gubernaculum Gubernaculum shortens and pulls the testes down to the vicinity of the deep inguinal ring around the 28th week, and reach the scrotum by the 33rd week Ovaries o The ovaries initially migrate caudally in a similar fashion to the testes from their origin on the posterior abdominal wall to within true pelvis o o The gubernaculum attaches to the paramesonephric ducts becomes the ovarian ligament and round ligament of the uterus URINARY BLADDER THE URINARY BLADDER IS THE ORGAN THAT COLLECTS URINE EXCRETED BY THE KIDNEYS BEFORE DISPOSAL BY URINATION. A HOLLOW MUSCULAR, AND DISTENSIBLE ORGAN, THE BLADDER SITS ON THE PELVIC FLOOR. URINE ENTERS THE BLADDER VIA THE URETERS AND EXITS VIA THE URETHRA. URINARY BLADDER IN MALES, THE BASE OF THE BLADDER LIES BETWEEN THE RECTUM AND THE PUBIC SYMPHYSIS. IT IS SUPERIOR TO THE PROSTATE AND SEPARATED FROM THE RECTUM. IN FEMALES, THE BLADDER SITS INFERIOR TO THE UTERUS AND ANTERIOR TO THE VAGINA; THUS, ITS MAXIMUM CAPACITY IS LOWER THAN IN MALES. URINARY BLADDER, CLINICALLY… Since the urinary bladder has a transitional epithelium, it does not produce mucus. The urinary bladder can hold up to 1000 ml. If urinary retention occurs due to an obstruction of the urethra, urgency begins at 150 ml and becomes progressively more ‘urgent’ with every 100 ml. Bladder over-distension leads to progressively weakened detrusor and urinary retention Patients in the hospital who require catheterization commonly put out between 500 and 600 ml. URINARY BLADDER The detrusor muscle is a layer of the urinary bladder wall made of smooth muscle fibers arranged in spiral, longitudinal, and circular bundles. When the bladder is stretched, this signals the parasympathetic nervous system to contract the detrusor muscle. This encourages the bladder to expel urine through the urethra. SPACE OF RETZIUS THE EXTRAPERITONEAL SPACE BETWEEN THE PUBIC SYMPHYSIS AND URINARY BLADDER. RECTOVESICAL POUCH: MALE PELVIS The lowest point of the peritoneal cavity PROSTATE Classically said to be slightly larger than a walnut. The mean weight of the "normal" prostate in adult males is about 11 grams, usually ranging between 7 and 16 grams. It surrounds the urethra just below the urinary bladder and can be felt during a rectal exam. Prostatic urethra runs through the center of the prostate The prostate has 5 lobes Anterior Middle Posterior-most common carcinoma** 2 Lateral PROSTATIC LOBES SEMINAL VESICLES THE SEMINAL VESICLES ARE A PAIR OF SIMPLE TUBULAR GLANDS POSTEROINFERIOR TO THE URINARY BLADDER OF THE MALE. THEY ARE LOCATED WITHIN THE PELVIS. EACH SEMINAL VESICLE SPANS APPROXIMATELY 5 CM. (10 CM UNCURLED). THE EXCRETORY DUCT OF EACH SEMINAL GLAND OPENS INTO THE VAS DEFERENS AS IT ENTERS THE PROSTATE GLAND. THE SEMINAL VESICLES SECRETE 70% OF THE FLUID THAT ULTIMATELY BECOMES SEMEN. DUCTUS (VAS) DEFERENS THE VAS DEFERENS (ALSO CALLED DUCTUS DEFERENS ) ARE TWO DUCTS, CONNECTING THE LEFT AND RIGHT EPIDIDYMIS TO THE EJACULATORY DUCTS IN ORDER TO MOVE SPERM. EACH TUBE IS ABOUT 30 CENTIMETERS LONG AND IS SURROUNDED BY SMOOTH MUSCLE. ITS EPITHELIUM IS LINED BY STEREOCILIA. PENIS The primary sexual organs that the male uses in mating. Specifically, the penis is the organ that introduces sperm into the female vagina during copulation. Glans penis- the free end of the penis. Body- the part of the penis extending from the roots. Roots (crura)- these begin at the caudal border of the pelvic ischial arch Corpus Cavernosum- a pair of sponge-like regions of erectile tissue which contain most of the blood in the penis during penile erection. PENIS AND URETHRA THE CORPUS SPONGIOSUM IS THE MASS OF SPONGY TISSUE SURROUNDING THE PENILE URETHRA. AT THE SUMMIT OF THE GLANS IS THE SLIT-LIKE VERTICAL EXTERNAL URETHRAL ORIFICE, ALSO KNOWN AS THE MEATUS. PENIS The superficial dorsal vein of the penis drains the prepuce and skin of the penis, and, running backward in the subcutaneous tissue, inclines to the right or left, and opens into the corresponding superficial external pudendal vein, a tributary of the greater saphenous vein. In contrast to the deep dorsal vein, it lies outside Buck’s fascia. It is possible for the vein to rupture, which presents in a manner similar to penile fracture. Deep dorsal vein lies beneath the deep fascia of the penis; it receives the blood from the glans penis and corpora cavernosa and courses backward in the mid-line between the dorsal arteries; near the root of the penis. PENIS Buck’s fascia- (deep fascia of the penis) is a layer of deep fascia covering the three erectile bodies of the penis. The deep dorsal vein of the penis is inside Buck's fascia. Darto’s fascia- fascia immediately under the penile and scrotal skin. SPERMATIC CORD The name given to the cord-like structure in male containing the vas deferens, testicular artery, Pampiniform plexus of veins, nerve to cremaster (genital branch of the genitofemoral nerve), Lymphatic vessels Tunica vaginalis (remains of the processus vaginalis) SPERMATIC FASCIA The pampiniform plexus of veins, testicular artery, the ductus (vas) deferens, lymphatic vessels, and testicular nerves all run deep to the internal spermatic fascia, which loosely invests the cord; it is a continuation downward of the transversalis fascia. EPIDIDYMIS part of the male reproductive system. It is a single, narrow, tightly-coiled tube (six to seven meters in length) connecting the ducts from the rear of each testicle to its vas deferens CREMASTER MUSCLE LIES IN THE DEEP TISSUE OF THE SCROTUM AND WILL CONTRACT AND RELAX BASED ON THE NEEDS OF THE TESTES. RECTOUTERINE POUCH OF DOUGLAS Also called the posterior cul de sac, is the lowest point of the female peritoneal cavity. Fluid aspiration from the peritoneal cavity Note that the vagina is longer posteriorly. UROGENITAL AND ANAL TRIANGLES VAGINA A fibromuscular elastic tubular tract which has two main functions: sexual intercourse and childbirth. It is a collapsible squamous epithelial lined “tube.” This passage leads from the opening of the vulva to the uterus, but the vaginal tract ends at the cervix. The vaginal opening is much larger than the urethral opening, and both openings are protected by the labia. LABIA MAJORA They are two prominent longitudinal cutaneous folds that extend downward and backward from the mons pubis to the perineum They constitute the lateral boundaries of the pudendal cleft (furrow at the base of the mons pubis), which contains the labia minora, interlabial sulci, clitoral hood (or prepuce- a fold of skin that surrounds and protects the glans of the clitoris), clitoral glans, and the external openings of the urethra and the vagina. PERINEUM the surface region in both males and females between the pubic symphysis and the coccyx. The perineum is the region of the body inferior to the pelvic diaphragm and between the legs. It is a diamond-shaped area on the inferior surface of the trunk that includes the anus and, in females the vagina. CLITORIS The clitoris is a female sexual organ. The visible button-like portion is near the front junction of the labia minora (inner lips), anterior to the opening of the urethra. The clitoris is the human female's most sensitive erogenous zone and the primary source of female sexual pleasure. The glans (head) of the human clitoris is roughly the size and shape of a pea and has more sensory nerve endings than any other part of the human body. External Genitalia Mons pubis Perineu m BROAD LIGAMENT The broad ligament of the uterus is the wide fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis. It may be divided into three parts: Mesometrium - the mesentery of the uterus; the largest portion of the broad ligament Mesosalpinx - the mesentery of the fallopian tube Mesovarium - the mesentery of the ovaries. CONTENTS OF THE BROAD LIGAMENT Reproductive Uterine tubes (or Fallopian tube) Ovary Vessels ovarian artery uterine artery Ligaments ovarian ligament round ligament of uterus suspensory ligament of the ovary = Infundibulopelvic ligament or IP The broad ligament serves as a mesentery for the uterus, ovaries, and the uterine tubes. ROUND LIGAMENT OF THE UTERUS Originates at the uterine horns (the points where the uterus and the fallopian tubes meet). It leaves the pelvis via the deep inguinal ring, passes through the inguinal canal and continues on to the labia majora where its fibers spread and mix with the tissue of the mons pubis. The function of the round ligament is maintenance of the anteversion of the uterus UTERUS Or womb is a major female hormone-responsive reproductive sex organ. One end, the cervix, opens into the vagina, while the other is connected to both fallopian tubes.  Corpus=upper 2/3 of the uterus  Fundus=cephalad to line connecting the fallopian tubes  Cornu=lateral regions of fundus associated with intramural fallopian tubes  Isthmus=portion of corpus connecting to the cervix ANATOMY OF THE UTERUS Cervix- lower 1/3 of the uterus, below the internal os Uterine cavity - 6 cm long, triangular shape and lined with endometrial mucosa Myometrium- muscular middle layer Serosa- outer layer which extends to the peritoneal reflection OVARIES The ovary is an ovum and hormone producing (endocrine gland) reproductive organ, found in pairs as part of the female reproductive system. Each ovary is pearly-white in color and located alongside the lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery and in front of the ureter and the internal iliac artery. OVARIES The ovaries are not attached to the fallopian tubes but to the outer layer of the uterus via the uteroovarian ligaments. Each ovary is about 4 cm x 3 cm x 2 cm in size. CLINICAL QUESTION: 32-year-old female presents to the ER for severe right sided abdominal pain for the past 6 hours. Patient states that she has never had this pain before. She admits to vaginal bleeding. VS: BP 90/60 mm/hg, HR 110, RR 20. Which of the following is the most likely diagnosis? A. Appendicitis B. Ovarian Torsion C. Ectopic Pregnancy D. Ovarian Cyst FALLOPIAN TUBES Two very fine tubes lined with ciliated epithelia, leading from the ovaries into the uterus, via the utero-tubal junction (Also known as oviducts and salpinges). The tube allows passage of the ovum from the ovary to the uterus. Its different segments are (lateral to medial): the infundibulum with its associated fimbriae near the ovary, the ampullary region that represents the major portion of the lateral tube, the isthmus which is the narrower part of the tube that links to the uterus, and the intramural) part that transverses the uterine musculature. FEMORAL HERNIA Occur just below the inguinal ligament, when abdominal contents pass through a naturally occurring weakness called the femoral canal. Femoral hernias are a relatively uncommon (3% of all hernias). Occur in both males and females, much more common in WOMEN because of the wider bone structure of the female pelvis. Femoral hernia never enters the scrotum in men. NAME THE FOLOWING: A-F QUESTIONS??