PelvicAnatomyLec [Autosaved] (1).pptx

Anatomy Lecture Pelvis, Perineum Matthew Tommasino, PA-C MS Program Director, Bay Shore and NUMC Skeletal System Three Bones • OSSA COXAE (HIP) • SACRUM • COCCYX http://www.kinetesisspineandjoint.ca/hipbursitis/ PELVIC GIRDLE  Ilium, Ischium and Pubis (all articulate in the acetabulum) ...

Anatomy Lecture Pelvis, Perineum Matthew Tommasino, PA-C MS Program Director, Bay Shore and NUMC Skeletal System Three Bones • OSSA COXAE (HIP) • SACRUM • COCCYX http://www.kinetesisspineandjoint.ca/hipbursitis/ 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: Pelvis-Lateral View 1- Iliac crest 2-Anterior superior iliac spine 3-Acetabulum 4-Superior pubic ramus 5-Inferior pubic ramus 6-Ischial spine 7-Ischial tuberosity 8-Obturator foramen 9-Greater sciatic notch 10-Lesser sciatic notch True pelvis (lesser)- by the iliopectineal 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). Acetabulum  Hip socket- where femur head articulates  The only area where all three bones of the pelvis (ilium, pubis and ischium) are joined together  Often the landmark used to describe location of the structures of the pelvic girdle Pubic Symphysis • Site at which two opposite pubis structures articulate Sacroiliac joint  Two sacroiliac joints, one on the left and one on the right. The SI joint is the joint in the bony pelvis between the sacrum and the iliac bone, which are joined by strong ligaments. The joint is a strong, weight bearing synovial joint.  anterior sacroiliac ligament  posterior sacroiliac ligament Clinical question…  Which of the following is the most common cause of SIJ dysfunction?  High Impact Trauma (i.e. MVA)  Pregnancy  Degenerative Arthritis  Multiple Sclerosis Clinical Question…  Which of the following physical exam findings is associated with Sacroiliac joint instability?  A. Ober’s test  B. Neer’s sign  C. Straight leg raise  D. Faber’s test Characteristic Differences in Pelvic Structure Female Male  Smoother, lighter   Pelvic Inlet transverse diameter=13 cm. Pelvic Inlet transverse diameter =12 cm.  Pubic symphysis is taller  Pubic symphysis is shorter  Pubic arch is narrower  Pubic arch (subpubic) angle is wider  Iliac wings less flared  Iliac wings are flared   Enlarged pelvic outlet Designed for strength and speed  Less curvature of the sacrum/coccyx  Main difference is to allow for adaptation for child bearing Male vs Female Pelvis 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 sacrospinous ligament attaches here.  The coccygeus muscles, levator ani and pelvic fascia attach here. Sacrotuberous ligament The sacrotuberous ligament is situated at the lower and back part of the pelvis. It is flat, and triangular in form; narrower in the middle than at the ends. It runs from the lower sacrum and the upper coccyx to the ischial tuberosity. Sacrospinous ligament The sacrospinous ligament is a thin, triangular ligament attached by its apex to the ischial spine, and medially, by its broad base, to the lateral margins of the sacrum and coccyx, deep to the sacrotuberous ligament with which its fibers are intermingled. 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. 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 Obturator internus The obturator internus muscle originates on the medial surface of the obturator membrane, the ischium and the rim of the pubis. It exits the pelvic cavity through the lesser sciatic foramen. It functions to help laterally rotate femur with hip extension and abduct femur with hip flexion, as well as to steady the femoral head in the acetabulum. • The obturator externus muscle (OE) is a flat, triangular muscle, which covers the outer surface of the anterior wall of the pelvis. • Extends from the anterior obturator fascia extending posteriorly to the medial greater trochanter • Aides in lateral motion of the hip and helps to adduct the hip joint when in flexion • 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 tendon of the Obturator internus, and inserts with it into the medial surface of the greater trochanter. • The Gemellus inferior arises from the ischial tuberosity , immediately below the groove 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 Puborectalis muscle Coccygeus: from the coccyx to the ischial spine the baby's head during childbirth. 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 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 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  The detrusor muscle is a layer of the urinary bladder wall made of smooth muscle fibers arranged in spiral, longitudinal, and circular bundles. Since the urinary bladder has a transitional epithelium, it does not produce mucus.  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. X Space of Retzius The space of Retzius is the extraperitoneal space between the pubic symphysis and urinary bladder. Rectovesical pouch The lowest point of the peritoneal cavity in the male pelvis Gubernaculum (pair)  As the scrotum and labia majora form in males and females, respectively, the gubernaculum aids in the descent of the gonads (both testes and ovaries).  The testes descend to a greater degree than the ovaries and ultimately pass through the inguinal canal. the gubernaculum provides an anchor for the testes and scrotum, referred to as the “scrotal ligament”.  The gubernaculum has two vestigial remnants in females, the ovarian ligament and the round ligament of the uterus which respectively serve to support the ovaries and uterus in the pelvis 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- most commonly develops benign prostatic hypertrophy  Posterior-most common carcinoma**  2 Lateral ACA Prostate Screening recommendations: •Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years. •Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an early age (younger than age 65). •Age 40 for men at even higher risk (those with more than one firstdegree relative who had prostate cancer at an early age). Ref: American Cancer Society Recommendations for Prostate C ancer Early Detection 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. Lipofuscin granules give the secretion its yellowish color. 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) Internal 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. External spermatic fascia  The external spermatic fascia is a thin membrane, extending downward around the surface of the spermatic cord and testis.  It is derived from the abdominal external oblique muscle 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 Epididymitis: An inflammation of the tube at the back of the testicle that carries sperm. This causes swollen scrotum, painful urination, blood in semen, pain in testicle and discharge from penis. Scrotum and Testicles…  Tunica albuginea is a layer of connective tissue covering the testicles or ovaries  Tunica vaginalis is the serous covering of the testis.  It is a pouch of serous membrane, derived from the processus vaginalis of the peritoneum, which in the fetus preceded the descent of the testis from the abdomen into the scrotum. Scrotum and testicle cont…  Dual-chambered protuberance of skin and muscle, containing the testicles and divided by a septum. It is an extension of the perineum, and is located between the penis and anus.  The testicle (testis, plural testes) is the male gonad. They are components of both the reproductive system and the endocrine system. The primary functions of the testes are to produce sperm (spermatogenesis) and to produce androgens primarily testosterone. The testes reside within the scrotum.  Seminiferous Tubules: (~1/2 million per testes) where sperm production takes place.  Interstitial Cells: production of testosterone Cremasteric muscle lies in the deep tissue of the scrotum and will contract and relax based on the needs of the testes. Clinical Question…  20-year-old male presents to the ER complaining of severe right testicular pain for the past 2 hours. He states the pain was abrupt, rates it 10/10 and radiating up. He also c/o nausea and vomiting. Which of the following physical exam findings is consistent with this patients diagnosis?  A. Positive Prehn’s sign  B. Negative Prehn’s sign  C. Absent Cremasteric reflex  D. Positive Cremasteric reflex Rectouterine pouch of Douglas  Also called the posterior cul de sac, is the lowest point of the female peritoneal cavity.  Fluid aspiration of peritoneal  Note that the vagina is longer posteriorly. Urogenital and Anal triangles Vagina  A fibromuscular elastic tubular tract which is a sex organ and has two main functions: sexual intercourse and childbirth. 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. Clinical Question  A 23-year-old female presents to the clinic c/o vaginal itching and pain for the past 2 days. She states that there is a thick white vaginal discharge present. She denies any bleeding and denies any recent sexual partners. Which of the following is the best treatment for this patient?  A. Rocephin 250 mg IM  B. Diflucan 150 mg  C. Doxycycline 100 mg BID for 7 days  D. Both A and C 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 buttonlike portion is near the front junction of the labia minora (inner lips), above 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 Perineum 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  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  Cornua (horns)=lateral regions of fundus associated with intramural fallopian tubes  Isthmus=portion of corpus connecting to the cervix Fundus ua n r o C Corpus Isthmus Cervix  Lower 1/3 of the uterus, below the internal os  Uterine cavity is 6 cm long, triangular in shape and lined endometrial mucosa  Myometrium=muscular middle layer  Serosa=outer layer which extends to the peritoneal reflection Ovaries  The ovary is an ovum-producing reproductive organ, found in pairs as part of the female reproductive system. They are both gonads and endocrine glands. 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 ovarian ligaments.  Each one 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. Her 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  (Also known as oviducts and salpinges) two very fine tubes lined with ciliated epithelia, leading from the ovaries into the uterus, via the utero-tubal junction  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. 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. Her VS BP 90/60 mm/hg, HR 110, RR 20. Which is the next test that should be done?  A. bHcg  B. Bedside pregnancy  C. Transvaginal Sonogram  D. CT scan Clinical Question  30 year old male presents to the clinic c/o swelling, redness and pain to the right testicle for the past 24 hours which has gotten worse over the last 12 hours. He also admits to dysuria and fever. On physical exam he has a positive prehn’s sign. Which of the following is the most likely diagnosis?  A. Varicocele  B. Epididymitis  C. Testicular Torsion  D. Hydrocele Questions??