Genital System Anatomy 2025 PDF

Artist Of Anatomy DR/ Ibrahim Amr New look 2025 ARTIST OF ANATOMY DR/ IBRAHIM AMR Bony Pelvis - The bony pelvis consists of: 2 hip bones (anterolaterally) & sacrum & coccyx (posteriorly). - The 2 hip bones ar...

Artist Of Anatomy DR/ Ibrahim Amr New look 2025 ARTIST OF ANATOMY DR/ IBRAHIM AMR Bony Pelvis - The bony pelvis consists of: 2 hip bones (anterolaterally) & sacrum & coccyx (posteriorly). - The 2 hip bones articulate: (a) anteriorly to from symphysis pubis (secondary cartilaginous joint) (b) posteriorly with sacrum to form sacroiliac joint (synovial plane joint) - The normal anatomical position of the pelvis: - tip of coccyx & upper border of symphysis pubis are at the same horizontal plane. - anterior superior iliac spine & pubic tubercle are at the same vertical plane. 1 ARTIST OF ANATOMY DR/ IBRAHIM AMR SACRUM - It is a triangular bone formed of 5 fused sacral vertebrae - It has base, apex and 3 surfaces (anterior (pelvic), posterior and lateral) Base: - formed of body of 1st sacral vertebra and ala of sacrum - the anterior border of 1st sacral vertebra is called sacral promontory (1) Pelvic surface: - it shows 4 pairs of ventral sacral foramina for passage of: - ventral rami of sacral nerves - Lateral sacral arteries - Structures attached to the pelvic surface: (a) Three muscles: - Iliacus (origin): on the ala - Piriformis (origin): on middle 3 pieces - Coccygeus (insertion): on 5th sacral piece (b) Three ligaments: - Anterior longitudinal ligament - Lumbosacral ligament - Anterior sacroiliac ligament - Structures related to the pelvic surface: Two viscera: - Pelvic colon & Pelvic mesocolon: to the upper 2 pieces - Rectum: related to lower 3 sacral vertebrae Three vessels: - Lateral sacral arteries: enter the ventral sacral foramina (right and left) - Median sacral artery: - Superior rectal artery: Four Nerves: - Ventral rami of upper 4 sacral nerves (right and left) 2 ARTIST OF ANATOMY DR/ IBRAHIM AMR 4 Structures are related to ala of the sacrum: (from medial to lateral) - sympathetic trunk - lumbosacral trunk - iliolumbar artery - obturator nerve 3 ARTIST OF ANATOMY DR/ IBRAHIM AMR (2) Lateral surface: - Auricular surface: for articulation with ilium to form sacroiliac joint - Rough area behind the auricular surface: for attachment of interosseous sacroiliac ligament - The narrow lower part is for attachment of the sacrospinous and sacrotuberous and posterior sacroiliac ligament (3) Dorsal surface: - It has 4 dorsal sacral foramina: which give exit for: - dorsal rami of sacral nerves - terminal parts of lateral sacral arteries - Median sacral crest: - represents fused spines - Intermediate sacral crest: - represents fused articular processes - Lateral sacral crest: - represents fused transverse processes 4 ARTIST OF ANATOMY DR/ IBRAHIM AMR THE PELVIC CAVITY - The pelvic cavity is divided into: (1) Greater pelvis (false pelvis): - lies above the level of pelvic inlet - it is a part of the abdominal cavity (2) Lesser pelvis (true pelvis): - lies below the level of pelvic inlet Lesser pelvis (True pelvis) - The true pelvis has an inlet and an outlet - Boundaries of the pelvic inlet (pelvic brim): (from posterior to anterior) - Promontory of sacrum (posteriorly) - Ala of sacrum - Arcuate line - Pectin pubis - Pubic crest - Upper border of symphysis pubis … (anteriorly) - The plane of the pelvic inlet forms an angle of 60° with the horizontal plane. 5 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Boundaries of pelvic outlet: - Posteriorly: Apex of coccyx - Anteriorly: Lower border of symphysis pubis - On each side: pubic arch, Ischial tuberosity and sacro-tuberous ligament - Boundaries of cavity of true pelvis: - Anterior & Inferior: 2 pubic bones and symphysis pubis - Posterior & Superior: sacrum and coccyx - Laterally: ischium and ilium below arcuate line 6 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Differences between male and female pelvis: Male pelvis Female pelvis Pelvic inlet Heart-shaped Round or oval Pelvic outlet Narrower Wider Pubic arch Narrow forming an acute angle Its Wide forming an obtuse angle margins are more everted Its margins are not everted Symphysis pubis Long Short Pelvic cavity Long segment of a short cone Short segment of a long cone Sacrum Body: ala = 2:1 Body: ala = 1:1 Ventral surface is more curved Ventral surface is less curved Long and narrow Short and board Auricular surface is opposite upper Auricular surface is opposite 3 sacral pieces 2.5 sacral pieces Pre-auricular Less apparent More apparent sulcus Greater sciatic Deep and narrow Wide and shallow notch Ischial Inverted Everted tuberosity Ischial spine Projects more inwards Projects more outwards Coccyx Projects forwards Projects more outwards Acetabulum Wider than the female Narrower than the male Diameters of - Inlet: - Inlet: inlet and outlet (A/P diameter=10cm) (A/P diameter=11cm) (Transverse= oblique=12cm) (Transverse diameter=13cm) (Oblique diameter=13cm) - Outlet: - Outlet: (A/P diameter=8cm) (A/P=transverse diameter=11cm) (Transverse diameter=8.5cm) Obturator Oval and large Triangular and small foramen 7 ARTIST OF ANATOMY DR/ IBRAHIM AMR The sacral canal - It extends from the 1st piece to the last sacral piece (posteriorly) - it ends by the sacral hiatus which is bounded laterally by 2 sacral cornua - Contents of sacral canal: (1) Dura and arachnoid mater with subarachnoid space containing CSF fluid. - It ends opposite 2nd piece of the sacrum (2) Filum terminale: - it is an extension from the pia mater. - it is attached to back of 1st piece of coccyx (3) Cauda equina: - roots of sacral nerves (5 pairs) and coccygeal nerves (1 pair) (4) branches from Lateral sacral arteries (5) internal vertebral venous plexus - Structures which get exit from sacral hiatus: (1) filum terminale (2) fifth pair of sacral nerves (3) one pair of coccygeal nerves 8 ARTIST OF ANATOMY DR/ IBRAHIM AMR Pelvic Peritoneum (1) In male: - The peritoneum lining lower part of anterior abdominal wall is reflected backwards to cover superior surface then upper part of posterior surfaces of the urinary bladder. - Then, above the seminal vesicle to cover front of middle third of rectum to form rectovesical pouch (7.5 cm above the anal orifice) - Then it passes upwards to cover front and sides of the rectum (2) In female: - The peritoneum is reflected from lower part of abdominal wall to superior surface of urinary bladder - Then it is reflected on front of uterus (at junction between body and cervix) to form uterovesical pouch. - it covers anterior surface of body, fundus, posterior surface of body and cervix of uterus, then it covers upper part of posterior wall of vagina (posterior fornix) - Then peritoneum reflects on front of middle third of rectum to form recto-uterine pouch (Douglas pouch) (5.5cm above the anal orifice) 9 ARTIST OF ANATOMY DR/ IBRAHIM AMR Muscles of pelvic wall - Muscles of pelvic wall are piriformis and obturator internus muscles Piriformis Obturator internus Origin pelvic surface of - inner surface of obturator membrane middle three sacral pieces - inner surface of ilium (S2+S3+S4) (below arcuate line) Insertion - top of greater trochanter - medial side of greater trochanter of femur of femur Nerve - Nerve to Piriformis - Nerve to obturator internus supply (S1,2) (L5- S1,2) Action lateral rotation of thigh - Obturator fascia: - It covers the obturator internus muscle - It is thickened in its upper part forming the tendinous arch (white line) - It is splitted 1.5 inches above the ischial tuberosity to form pudendal canal 10 ARTIST OF ANATOMY DR/ IBRAHIM AMR Muscles of the pelvic floor (pelvic diaphragm) - Muscles of pelvic floor are levator ani and coccygeus muscles (1) levator ani muscle: it forms the greater part of the pelvic floor Origin - Body of pubis & white line & ischial spine Insertion - it can be differentiated into 3 parts: (1) Puborectalis: - passes backwards at anorectal junction - it forms U-shaped sling around external anal sphincter (2) Pubococcygeus: - inserted into perineal body & tip of coccyx - its fibers pass across side of prostate in male (levator prostate) and side of vagina in female (sphincter vagina) (3) Iliococcygeus: - inserted into the sides of the last 2 pieces of coccyx and ano-coccygeus raphe (which extends from apex of coccyx to the anorectal junction) 11 ARTIST OF ANATOMY DR/ IBRAHIM AMR Nerve - Ventral rami of S3, S4 sacral nerves supply and inferior rectal nerve Action (1) Both muscles act together increasing the intra-abdominal pressure so, it helps in defecation and labour (2) Puborectalis: - supports external anal sphincter (3) Pubococcygeus: - supports the prostate in male and acts as sphincter for vagina - Clinical note: - During labour, perineal body may be torn leading to prolapse of uterus because the gap between the 2 levator ani becomes wider - Minor parts of levator ani muscle: (1) levator prostate: U- shaped sling behind the prostate (2) Pubo-vaginalis: (sphincter vagina) U- shaped sling behind the vagina (3) pubo-uretheralis: U- shaped sling behind the urethra (2) Coccygeus muscle: - It is a small muscle that lies behind the levator ani Origin: - tip of ischeal spine Insertion: - sides of the last 2 sacral pieces and 1st coccygeal piece 12 ARTIST OF ANATOMY DR/ IBRAHIM AMR Internal iliac artery Origin: - It is smaller one of 2 terminal branches of common iliac artery Course: - it begins at lumbosacral angle opposite to the sacroiliac joint - It passes backwards and downwards - It ends near upper border of greater sciatic foramina by dividing into anterior and posterior divisions Branches of anterior division: (a) Parietal branches: 1. Obturator artery 2. Internal pudendal artery 3. Inferior gluteal artery (b) Visceral branches: 1. Umbilical artery (and its superior vesical branch) 2. Inferior vesical artery (in male) (replaced by vaginal artery in female) 3. Uterine artery (in female) 4. Middle rectal artery Branches of posterior division: - Iliolumbar artery - 2 lateral sacral arteries - Superior gluteal artery 13 ARTIST OF ANATOMY DR/ IBRAHIM AMR Internal Iliac Vein - It is the main vein draining the pelvis - It is formed by union of most of the veins which accompany branches of internal iliac artery just above the greater sciatic foramen - It receives the following tributaries: - Internal pudendal vein - Inferior gluteal vein - Obturator vein - Middle rectal vein - Vesical veins - Uterine vein in female - Vaginal vein in female - Superior gluteal vein - Lateral sacral veins - there are also visceral tributaries of internal iliac vein which arise from venous plexuses around or in walls of the viscera such as: (1) Vesical venous plexus (2) Prostatic venous plexus (3) Uterine venous plexus (4) Vaginal venous plexus (5) Rectal venous plexus - Median sacral vein: - It closely accompanies the median sacral artery and ends in the left common iliac vein - Superior rectal vein: - It ascends close to left side of the superior rectal artery and continues up as inferior mesenteric vein 14 ARTIST OF ANATOMY DR/ IBRAHIM AMR Median Sacral Artery: (Embryologically, this artery represents continuation of aorta) Origin: - from back of the abdominal aorta just above its bifurcation Course & - It descends in midline in front of L4,5 vertebrae and relations: sacral promontory and concavity of sacrum behind the rectum Termination: - it ends by formation of a swelling (Glomus coccygeum) in front of the coccyx Branches: - Last (fifth) pair of the lumbar arteries - Small branches to the sacral canal - Small branches to the rectum 15 ARTIST OF ANATOMY DR/ IBRAHIM AMR Sacral Plexus Formation: - It is formed by ventral rami of L4,5 and S1,2,3,4 - Ventral rami of L4 and L5 form lumbosacral trunk, which emerge from medial margin of psoas major to join the 1st sacral nerve anterior to sacroiliac joint Site: - on posterior pelvic wall, in front of piriformis and behind the parietal pelvic fascia, sigmoid colon and rectum Branches: (a) From the Plexus itself: (1) Ventral branches: - Nerve to quadrates femoris (L4,5 - S1) - Nerve to obturator internus (L5- S1,2) - Tibial part of sciatic nerve (L4,5 - S1,2,3) (2) Dorsal branches: - Superior gluteal nerve (L4,5 - S1) - Inferior gluteal nerve (L5 - S1,2) - Common peroneal part of sciatic nerve (L4,5 - S1,2) (b) from the Roots of the plexus: (1) Ventral branches: - Pudendal nerve (S2,3,4) - Pelvic splanchnic nerve (S2,3,4): - gives parasympathetic supply to pelvic organs - Perineal branch of S4 (supply external and sphincter) (2) Dorsal branches: - Nerve to Piriformis (S1,2) - Perforating cutaneous nerve (S2,3) - Posterior cutaneous nerve of thigh (S1,2,3) The two Terminal branches are pudendal & sciatic nerves 16 ARTIST OF ANATOMY DR/ IBRAHIM AMR Perineum - It is lowermost part of the trunk including structures that occupy pelvic outlet - Boundaries of perineum: (1) Anterior angle: inferior pubic ligament (inferior to the symphysis pubis) (2) Posterior angle: tip of the coccyx (3) Lateral angles: two ischial tuberosities (4) On each side: - Pubic arch (anterior) - Sacrotuberous ligament and gluteus maximus muscle (posterior) - Divisions of perineum: - The perineum is divided by an imaginary line that passes through the center of perineum and connects the 2 ischial tuberosities into 2 triangles: (1) Urogenital triangle: (anterior to the imaginary line) (2) Anal triangle: (posterior to the imaginary line) 17 ARTIST OF ANATOMY DR/ IBRAHIM AMR Urogenital Triangle - Boundaries: - Anterior: inferior pubic ligament - On each side: pubic arch - Posterior: an imaginary line that connects the 2 ischial tuberosities - contents of this triangle are enclosed in two spaces which are known as superficial and deep perineal spaces or pouches. - The 2 spaces are separated by a fibrous membrane called perineal membrane Fascia of the urogenital triangle (1) The superficial fascia is differentiated into 2 layers: - superficial fatty layer - deep membranous layer (Colle’s fascia). - Colle’s fascia: is continuous anteriorly with deep membranous layer of anterior abdominal wall which is called Scarpa`s fascia - it closes the superficial perineal pouch inferiorly. - posteriorly, it is attached to the posterior border of perineal membrane. - on each side, it is attached to the pubic arch (2) The deep fascia has 2 layers: - Pelvic fascia (Superior fascia of urogenital diaphragm) - Perineal membrane (Inferior fascia of urogenital diaphragm) 18 ARTIST OF ANATOMY DR/ IBRAHIM AMR The perineal membrane (urogenital membrane) - It is stretched between 2 pubic arches in urogenital triangle but leaving a space anteriorly between its anterior border and symphysis pubis - It has 2 free borders: anterior & posterior - It lies horizontally in the standing position - It separates the superficial perineal pouch (inferior to it) from the deep perineal pouch (superior to it) - Its posterior border is attached to Colle’s fascia to close superficial perineal pouch posteriorly - Its anterior and posterior borders are attached to the pelvic (superior) fascia of urogenital diaphragm to close deep perineal pouch anteriorly & posteriorly 19 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Structures piercing the perineal membrane: in female in male - Urethra - Urethra - Vagina - Ducts of bulbo-uretheral gland - Internal pudendal artery - Internal pudendal artery - Artery of the bulb - Artery of the bulb - Dorsal nerve of clitoris - Dorsal nerve of penis 20 ARTIST OF ANATOMY DR/ IBRAHIM AMR Perineal pouches - The urogenital triangle contains 2 pouches separated by perineal membrane (1) Superficial perineal pouch: - open space that is continuous with the space deep to membranous layer of superficial fascia of the lower part of anterior abdominal wall ( ) (2) Deep perineal pouch: - completely closed space between superior and inferior fascia of urogenital diaphragm Deep Perineal Pouch - Boundaries: - Roof: Superior fascia of urogenital diaphragm - Floor: Perineal membrane - Anterior, posterior and on each side: - the roof and floor fuse together to close the space - Contents of deep perineal pouch: In female In male - Urethra - Membranous urethra - Vagina - Bulbo-uretheral gland - Internal pudendal vessels - Internal pudendal vessels - vessels of the bulb - vessels of the bulb - Dorsal nerve of clitoris - Dorsal nerve of penis - Muscles: - Muscles: - sphincter urethrae - sphincter urethrae - deep transverse perineal muscles - deep transverse perineal muscles 21 ARTIST OF ANATOMY DR/ IBRAHIM AMR Superficial Perineal Pouch - Boundaries: - Roof: perineal membrane - Floor: Colle`s fascia - Posterior and on each side: the roof and floor fuse together - Anterior: it is open and continuous with the space deep to membranous layer of superficial fascia of lower part of the anterior abdominal wall ( ) - Contents of superficial perineal pouch: In Female In Male (1) Root of clitoris: (1) Root of penis: (2 bulbs and 2 crura) (a bulb and 2 crura) (2) Muscles: (2) Muscles: - Ischiocavernosus - Ischiocavernosus - Bulbo-spongiosus - Bulbo-spongiosus - Superficial transverse perineal muscles - Superficial transverse perineal muscles (3) Arteries: (3) Arteries: - 3 branches of internal pudendal artery - 3 branches of internal pudendal artery (its 2 terminal branches & labial artery) (its 2 terminal branches & scrotal artery) (4) Nerves: (4) Nerves: - Dorsal nerve of clitoris - Dorsal nerve of penis - labial nerves - Scrotal nerves (5) one Vein: (5) one Vein: - Deep dorsal vein of the clitoris - Deep dorsal vein of the penis (6) Greater vestibular gland: 22 ARTIST OF ANATOMY DR/ IBRAHIM AMR Perineal body (central perineal tendon) - It is a fibro-muscular mass that is present in the center of perineum (or center of the posterior border of the perineal membrane) - It lies between the vaginal and anal orifices - The perineal body serves for attachment of 10 perineal muscles: - urethral sphincter - external anal sphincter - right and left levator ani - right and left superficial and deep transverse perineal muscles (4 in number) - right and left bulbo-spongiosus (It is liable to be ruptured during labour leading to pelvic uterine prolapse) 23 ARTIST OF ANATOMY DR/ IBRAHIM AMR Anal Triangle - It is the posterior division of the perineum - Boundaries: - Anterior: an imaginary line connecting the two ischial tuberosities. - Posterior: tip of coccyx - On each side: - sacro-tuberous ligament - Contents of anal triangle: (1) Lower part of anal canal: in the middle (2) Ischio-anal (Ischio-rectal) fossa: on each side Ischiorectal Fossa - it is filled with fatty tissue to give a space that can accommodate the distended anal canal during defecation - Contents of ischiorectal fossa: (1) Ischiorectal bad of fat (2) Nerves: - Inferior rectal nerve - scrotal or labial nerve - perineal branch of S4 (3) Vessels: - Inferior rectal vessels - scrotal or labial vessels - transverse perineal vessels 24 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Boundaries of ischiorectal fossa: Anterior boundary: - Posterior border of the perineal membrane - superficial and deep transversus perineal muscles Posterior boundary: - sacrotuberous ligament Inferior boundary: - skin of perineum on each side of anus Superior boundary: - linear origin of levator ani (white line) Medial boundary: - sloping. - It is formed by: levator ani muscle and external anal sphincter Lateral boundary: - vertical. - It is formed by: obturator internus muscle, obturator fascia and pudendal canal 25 ARTIST OF ANATOMY DR/ IBRAHIM AMR Pudendal canal - It is a tunnel formed by splitting of obturator fascia on the lateral wall of ischiorectal fossa about 1.5 inches above ischial tuberosity. - The canal connects the ischiorectal fossa with the urogenital triangle - The contents of the canal: (1) Internal pudendal vessels (2) Pudendal nerve 26 ARTIST OF ANATOMY DR/ IBRAHIM AMR Internal Pudendal Artery Origin: - from anterior division of internal iliac artery Course and distribution: -It leaves the pelvis through greater sciatic foramen (below the piriformis) - It then reaches the gluteal region, - then, leaves that region by passing behind tip of ischial spine (between pudendal nerve medially, and nerve to obturator internus laterally) - then, it enters the lesser sciatic foramen, which leads to the pudendal canal which transmits it to the deep perineal pouch - It ends by piercing the perineal membrane a short distance posterior to the symphysis pubis - then, it divides into 2 terminal branches: (deep + dorsal arteries of penis or clitoris) - It is the main artery for supply of the male and female perineum Branches: (1) Inferior rectal artery: runs in the ischiorectal fossa (2) Urethral artery (3) Perineal artery (labial or scrotal): - It runs in superficial perineal pouch to scrotum or labia majora (4) Artery of the bulb of vestibule (or penis) (5) Deep artery of the clitoris (or penis) (6) Dorsal artery of clitoris (or penis) 27 ARTIST OF ANATOMY DR/ IBRAHIM AMR Pudendal Nerve Origin: - It is the smaller of the two terminal branches of the sacral plexus (S2,3,4) Course: - It has the same course of internal pudendal artery (but as it passes from greater to lesser sciatic foramen, it crosses the back of the sacrospinous ligament) - it ends in posterior part of pudendal canal by dividing into 2 terminal branches: (1) the perineal nerve. (2) dorsal nerve of penis (or clitoris) 28 ARTIST OF ANATOMY DR/ IBRAHIM AMR Branches of pudendal nerve: (1) Inferior rectal nerve: - it arises in the posterior part of pudendal canal - it traverses the ischiorectal fossa from lateral to medial side - it supplies: - inferior surface of levator ani muscle - external anal sphincter (2) Perineal nerve: - it is the larger of the 2 terminal branches - it divides into: (a) scrotal or labial nerve: - runs forwards to supply skin of scrotum or labia majora (b) muscular branches: - to all perineal muscles and external urethral sphincter (3) Dorsal nerve of penis or clitoris: - it pierces the anterior part of the perineal membrane to enter the superficial perineal pouch where it runs on dorsum of penis or clitoris lateral to the dorsal artery - it supplies sensory fibers to skin of penis or clitoris 29 ARTIST OF ANATOMY DR/ IBRAHIM AMR Male genital system - it consists of: (a) external genital organs: - Penis - Scrotum (b) Internal genital organs: - Testes - Epididymis - Vas deferens - Seminal vesicles - Ejaculatory ducts - Prostate 30 ARTIST OF ANATOMY DR/ IBRAHIM AMR Scrotum - It is a dark skin fold situated at the lowermost part of anterior abdominal wall - Its cavity is divided into 2 compartments by an incomplete fascial septum - Each half contains a testis - The scrotum is formed of skin and superficial fascia - The superficial fascia is differentiated into 2 layers: (1) Superficial layer: - It contains no fat, but contains Dartos muscle (an involuntary muscle supplied by sympathetic fibers which cause skin wrinkling in cold weather) (2) Deep membranous layer: (Colle’s fascia) 31 ARTIST OF ANATOMY DR/ IBRAHIM AMR Penis - It is the external male genital organ for micturition and sexual intercourse - Parts: (1) Root of penis: - It is the attached part of penis which is situated in superficial perineal pouch - It consists of: bulb and 2 crura - The bulb: - it is the proximal expanded part of the corpus spongiosum. - it is covered by bulbo-spongosus muscle - it is pierced by urethra, arteries of the bulb and duct of bulbourethral gland - The crura: - they are the proximal part of the corpus cavernosum - They are firmly attached to pubic arch - covered by ischiocavernosus muscle - they are pierced by deep artery of the penis (2) Body of penis: - It is the free part of the penis - its anterior most area is called glans penis (1) Corpus spongiosum: - It is traversed by: the penile urethra - It ends by glans penis (2) Corpora cavernosa: - They are traversed by: deep artery of penis 32 ARTIST OF ANATOMY DR/ IBRAHIM AMR Arterial supply of penis: (1) Dorsal artery of penis: - for glans penis and it lies on each side of the deep dorsal vein (2) Deep artery of penis: (cavernosal artery) - for the corpus cavernosum and it lies in the corpus cavernosum (3) Artery of bulb: - for the bulb and corpus spongiosum and it lies on each side of urethra (4) Superficial external pudendal artery: - for the skin and fascia - The first three arteries arise from the internal pudendal artery - The last one arises from the femoral artery. - All of them are paired Venous drainage: (1) Superficial dorsal vein of penis: superficial to fascia penis (2) Deep dorsal vein of penis: deep to fascia penis Lymphatic drainage: - To superficial inguinal lymph nodes 33 ARTIST OF ANATOMY DR/ IBRAHIM AMR Testis - They are 2 oval glands 5 cm long, 3 cm wide, and 2 cm thick - it presents 2 borders: anterior and posterior - Posterior border: is related to: (1) Epididymis, laterally (2) Vas deferens, medially - Covering of the testis: (1) Skin (2) Dartos muscle (3) Colle’s fascia (4) External spermatic fascia (derived from external oblique aponeurosis) (5) Cremasteric muscle and fascia (derived from internal oblique muscle) (6) Internal spermatic fascia (derived from fascia transversalis) (7) Tunica vaginalis (8) Tunica albuginea (fibrous coat of testis) (9) tunica vasculosa 34 ARTIST OF ANATOMY DR/ IBRAHIM AMR Arterial supply of testis: - Testicular artery: which arises from the abdominal aorta opposite L2 Venous drainage: - by testicular vein to: - The left testicular vein drains into the left renal vein - The right testicular vein drains into the inferior vena cava Lymphatic drainage: - para-aortic Lymph nodes (at the level of L2) - Clinical notes: - Varicocele: - is a condition in which veins of pampiniform plexus are elongated and dilated - It is a common disorder in adolescents and young adults, with most occurring on left side - This is thought to be because: (1) left testicular vein joins left renal vein at right angle (2) the left testis is slightly lower than the right one (3) pressure of sigmoid colon on the left testicular vein - Rarely, malignant disease of the left kidney extends along the renal vein and blocks exit of testicular vein, so a rapidly developing left-sided varicocele should therefore always lead one to examine the left kidney. 35 ARTIST OF ANATOMY DR/ IBRAHIM AMR Epididymis - Parts of the epididymis: (1) Head: - attached to the upper end of testis by 12-30 efferent ductules (2) Body: (3) Tail: - attached to lower end of the testis, and continues as vas deferens - Sinus of epididymis: - It is a recess of tunica vaginalis, which lies between testis and lateral side of body of the epididymis - How to know the side of testis right or left? (1) Epididymis lies posterior (2) Sinus of epididymis is directed laterally (3) Vas deferens arises from the tail of epididymis, which is directed inferiorly 36 ARTIST OF ANATOMY DR/ IBRAHIM AMR Vas Deferens - it is a thick-walled cord-like duct, 30-45 cm in length, it has a very narrow lumen. Beginning: - at the lower end of the tail of the epididymis Course: - It ascends along posterior border of testis, medial to epididymis - It runs up in the posterior part of the spermatic cord, where it is surrounded by the pampiniform venous plexus - It enters the inguinal canal, within the spermatic cord - it enters the pelvis by passing through the deep inguinal ring, where it curves lateral to the inferior epigastric artery - It descends along lateral pelvic wall crossing: obturator vessels and nerves, obliterated umbilical artery, and external iliac vessels - close to base of urinary bladder, it crosses front of ureter - It presents a dilated ampulla which lies medial to the seminal vesicle behind the base of the urinary bladder - At the base of prostate, it narrowens and joins duct of seminal vesicle to form the ejaculatory duct Arterial supply: - artery of vas, which arises from the superior or inferior vesical artery 37 ARTIST OF ANATOMY DR/ IBRAHIM AMR Spermatic Cord - Site: - it is formed at deep inguinal ring and passes through the inguinal canal to enter the scrotum where it is attached to the testis - Coverings: (1) Internal spermatic fascia: - derived from fascia transversalis (2) Cremasteric muscle and fascia: - derived from the internal oblique muscle (3) External spermatic fascia: - from aponeurosis of external oblique muscle - Contents: (1) Vas deferens (2) Artery of the vas: a branch of the superior or inferior vesical artery (3) Testicular artery: a branch of the abdominal aorta (4) Cremasteric artery: a branch of the inferior epigastric artery (5) Genital branch of genitofemoral nerve: it supplies the cremasteric muscle (6) Sympathetic fibers (7) Pampiniform venous plexus: - which ends at the deep inguinal ring to form the testicular vein (8) Lymphatic vessels: that drains testis and ascends to para-aortic lymph nodes (9) Vestigue of processus vaginalis (obliterated processus vaginalis) 38 ARTIST OF ANATOMY DR/ IBRAHIM AMR Seminal Vesicle - There are two large pouches about 5 cm long - Relations: - Anteriorly: base of urinary bladder - Posteriorly: rectum - Medially: vas deferens - Its lower end joins the vas deferens to form the ejaculatory duct - Arterial supply: - inferior vesical artery - middle rectal artery Ejaculatory Duct - It is about 2 cm long - It is formed by union of duct of seminal vesicle and terminal part of vas deferens close to the base of the prostate - it penetrates base of prostate and passes antero-inferiorly to open into the prostatic urethra 39 ARTIST OF ANATOMY DR/ IBRAHIM AMR Prostate - It is a firm partly glandular and partly fibro-muscular organ - Site: - between lower border of symphysis pubis (anteriorly) and ampulla of rectum (posteriorly) - Shape: - it is conical in shape and presents a base and an apex - it has an anterior, posterior and 2 lateral surfaces - The base: - directed up and surrounds the neck of urinary bladder - penetrated by the urethra - The apex: - directed down. - it is in direct contact with superior fascia of urogenital diaphragm N.B: Urogenital diaphragm: - consists of deep transverse perineal muscle and sphincter urethra and invested by superior and inferior fascia 40 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Surfaces of prostate: (1) Posterior surface: - lies in direct contact with the ampulla of the rectum - can be palpated by per-rectal (P/R) examination. (2) Anterior surface: - connected to the pubic bone by puboprostatic ligament - The urethra emerges from this surface above and in front of apex of gland (3) Inferolateral surfaces: (one on each side) - related to the levator prostate (part of levator ani muscle) - Structures inside prostate: (1) Prostatic urethra: - pierced by ducts of prostatic acini and by 2 ejaculatory ducts (2) Ejaculatory duct: - run down and forwards one on each side to open into prostatic urethra (3) Prostatic utricle: - extends up and backwards from prostatic urethra into the median lobe 41 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Lobes of prostate: (Anatomical lobes) (1) Median lobe: - lies behind the prostatic urethra, and bounded by an ejaculatory duct on each side - It projects up behind internal urethral orifice to form uvula of the bladder (2) Right and left lateral lobes: - lie on each side of the prostatic urethra (3) Anterior lobe: (isthmus) - connects the lateral lobes in front of the urethra and contains few glandular tissue (4) Posterior lobe: - Prostatic capsules: (1) Inner true capsule: - a firm fibromuscular layer. (2) Outer false capsule: (prostatic sheath) - formed by pelvic fascia 42 ARTIST OF ANATOMY DR/ IBRAHIM AMR Arterial supply of prostate: - inferior vesical artery - middle rectal artery Venous drainage of prostate: - prostatic venous plexus (between two capsules of prostate) which drains into the internal iliac vein. - The prostatic venous plexus is also connected to vertebral venous plexus by valveless veins (this is how prostate cancer spreads to the vertebrae) Lymph drainage of prostate: - sacral and internal iliac lymph nodes 43 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Clinical notes: - Benign prostatic hyperplasia: - benign enlargement of the prostate - it is common in men older than 50 years (senile enlargement) - it is present in 95% of men older than 70 years - prostatic acini of mucosal and submucosal glands are involved in the disease - the median lobe of the gland enlarges upward and encroaches within sphincter vesicae leading to leakage of urine into prostatic urethra which causes an intense reflex desire to micturate - The enlargement produces distortion of the urethra so that the patient experiences difficulty in passing urine and stream is weak - The enlargement of the uvula vesicae (due to the enlarged median lobe) results in formation of a pouch of stagnant urine behind the urethral orifice within the bladder. - The stagnant urine frequently becomes infected, and the inflamed bladder (cystitis) adds to the patient’s symptoms. - Malignant prostatic tumor: - it is the second most common cancer in men. - Prostatic acini of the outer group are involved in the disease. 44 ARTIST OF ANATOMY DR/ IBRAHIM AMR Female External Genital Organs (1) Mons pubis: - An anterior thick skin fold, having a collection of subcutaneous fat and hairy (2) Labia majora: - 2 rounded thick skin folds. - the space between them is called pudendal cleft (3) Labia minora: - 2 thin skin folds. - the space between them is called vestibule of vagina (4) Clitoris: - It resembles the penis in male. - It lies in anterior part of the pudendal cleft. - It consists of 2 corpora cavernosa (forming the body of the clitoris) which enlarge anteriorly to form glans clitoris (5) Urethral orifice: - It lies between the glans clitoris anteriorly and vaginal orifice posteriorly (6) Vaginal orifice: - It lies posterior to the urethral orifice 45 ARTIST OF ANATOMY DR/ IBRAHIM AMR Uterus - It is a pear shaped hollow muscular organ. - Dimensions: - its size is 1, 2, 3 inches (thickness, width, length) - Parts: (1) Fundus: - the upper rounded free part. (2) Body: it has 2 surfaces anterior and posterior. (3) Cornua: - It is the junction between the fundus and the body. - It lies in the lateral angle of the uterus (4) Cervix: - It is the lower narrow part that protrudes into the vagina. - it divides into vaginal and supra-vaginal parts. - It is one inch width and length - Its canal is connected to uterine cavity by an opening called internal os. - Its canal is connected to the vagina by external os. 46 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Position of the uterus: - The normal position is anteflexion & anteversion (AVF position) - Anteflexed: forward angle between long axis of body of uterus and that of cervix is an obtuse angle = 170 degrees - Anteverted: forward angle between long axis of the vagina and that of the cervix = 90 degrees If the uterus is directed backwards, it is called retroverted, retroflexed (RVF) - Body of uterus: - It has 2 surfaces (1) Anterior (vesical) surface: - it is separated from the urinary bladder by uterovesical pouch (2) Posterior (intestinal) surface: - it is separated from the rectum by recto-uterine pouch (Douglas pouch) which contains coils of sigmoid colon and terminal ileum - Laterally: - Uterine tube - Uterine artery - Ligament of ovary - Round ligament of uterus - Broad ligament 47 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Cervix of uterus: - it and divides it into: (1) Supra vaginal part: Anteriorly: - it has no peritoneal covering - it is related to base of urinary bladder Posteriorly: - it is covered by peritoneum (Douglas pouch) Laterally: - It gives attachment to the broad ligament - it is related to Ureter and uterine vessels (2) Vaginal part: - it projects through the anterior wall the vagina - it is surrounded by 4 vaginal fornices - it opens into vagina through external os. N.B: - In nulliparous, external os is small and rounded, but in female who have borne babies, it has a transverse slit shape with anterior and posterior lips 48 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Peritoneal covering of the uterus: - The peritoneum is reflected from lower part of anterior abdominal wall to cover upper surface of urinary bladder, then reflected on front of the uterus to form uterovesical pouch, then covers anterior surface of body of uterus, fundus of uterus, posterior surface of body and cervix of uterus and upper ¼ of posterior wall of vagina, then the peritoneum reflects on front of middle 1/3 of rectum to form recto-uterine pouch - Laterally: the peritoneum forms the broad ligament - Broad ligament: - a double-layered fold of peritoneum - it extends from side of the uterus to the side wall of the pelvis - It has two borders: (1) free upper border: containing the uterine tube (2) attached lower border (root): - contains uterine vessels - attached to the floor of the pelvis 49 ARTIST OF ANATOMY DR/ IBRAHIM AMR N.B: - The ureter runs below root of broad ligament from backwards forwards. - The ovary is attached to the broad ligament by a short peritoneal fold called mesovarium. - Contents of the broad ligament: (1) Uterine tube: in the upper free border (except its fimbriated end) (2) Ligaments: Ligament of ovary & Round ligament of uterus (3) Arteries: Uterine artery & ovarian artery (4) parametrium: - condensation of fat, autonomic nerves and lymphatics (5) embryological remnants: (Epoophron, paraoophron, vesicular appendix and Gartner’s duct) - Parts of broad ligament: (1) Mesometrium: - between pelvic floor, ligament of ovary and body of uterus (2) Mesosalpinx: - between uterine tube, mesovarium and ligament of ovary (3) Suspensory ligament of ovary: - it connects the infundibulum of uterine tube and upper end of ovary to the pelvic wall - it transmits ovarian vessels and nerves 50 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Ligaments of the uterus: (the first 3 are attached to the cervix) (1) Pubocervical ligament: - from junction of cervix and vagina, passes around urethra to back of pubis (2) Uterosacral ligament: - extends from cervix, passes around sides of rectum to front of the sacrum (3) Transverse cervical ligament: (Cardinal, lateral cervical, Mackenrodt’s) - extends from cervix and lateral fornix of vagina to lateral wall of the pelvis - the most important ligament that prevents uterine prolapse (4) Ligament of the ovary: - extends from uterine end of the ovary to the cornua of uterus (posterior) (5) Round ligament of uterus: - extends from cornua of uterus (anterior), runs within the broad ligament - then, it enters the inguinal canal to be inserted into labia majora (6) Broad ligament: - Factors keeping the uterus in position (uterine support): (1) Levator ani (2) Ligaments of the uterus (3) Perineal body (4) Urogenital diaphragm - Clinical point: Weakness of uterine supports leads to: downward descend (telescoping) of the uterus through the vagina (uterine prolapse) 51 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Arterial supply of the uterus: Uterine artery: - it arises from the anterior division of the internal iliac artery. - It has a tortuous course. - it runs medially on floor of the pelvis (in root of broad ligament) - 2 cm lateral to the cervix, it crosses over the ureter to ascend along the side of the uterus - Below uterine tube, it turns laterally to anastomose with the ovarian artery - It supplies ureter, upper vagina, uterus and medial part of uterine tube. - it gives the following branches: (1) ureteric branches (2) vaginal branches (3) cervical branches (4) uterine branches (5) tubal branches (6) anastomotic branch to anastomose with branches of ovarian artery - Venous drainage of uterus: - Uterine venous plexus which drains into internal iliac vein - Lymph drainage of uterus: (1) Fundus, upper part of body para-aortic LNs (along ovarian vessels) (2) Cornuae superficial inguinal LNs (along the round ligament) (3) Lower part of the body external iliac lymph nodes (4) Cervix internal iliac, external iliac and sacral lymph nodes 52 ARTIST OF ANATOMY DR/ IBRAHIM AMR Uterine (Fallopian) Tubes - They are two tubes, each of them is 12 cm long musculo-membranous tubes showing great mobility. - one of the ends opens into the peritoneal cavity next to the ovary, the other one crosses the wall of the uterus to open into its interior. - Parts of the tube: (from medial to lateral) (1) Intramural part (interstitial part): - it passes through the wall of uterus (2) Isthmus: adjacent to the uterus (3) Ampulla: - widest longest part where fertilization takes place (4) Infundibulum: - It is funnel-shaped and situated near the ovary - It has finger like processes (fimbriae) at its free end - Its opening into the peritoneal cavity is called abdominal osteum - During ovulation, fimbriae trap the non-fertilized ovum and sweep it into the ampulla through the abdominal osteum 53 ARTIST OF ANATOMY DR/ IBRAHIM AMR The Vagina - It is a fibromuscular tube (from 7cm to 10cm in length) - It descends antero-inferiorly from the cervix of uterus to vestibule of vagina - Shape: - a tube with anterior and posterior walls. - The anterior one is shorter (3 inches) while the posterior is 4 inches - Relations: (Three structures to each surfaces) Anteriorly: (1) Cervix of the uterus (2) Urinary bladder (3) Urethra Posteriorly: (1) upper 1/4th: covered by peritoneum of Douglas pouch (2) middle 2/4th: related to the rectum (3) its lower 1/4th: separated from anal canal by the perineal body 54 ARTIST OF ANATOMY DR/ IBRAHIM AMR Laterally: (1) Upper third: lateral fornix is closely related to the ureter, (here, the ureter is crossed by the uterine artery) (2) Middle third: - levator ani (sphincter vagina, pubovaginalis part) (3) Lower third: - traverse deep perineal pouch - it is related to greater vestibular gland - Superiorly: the vagina communicates with the cervical canal - Inferiorly: the vagina opens into vaginal vestibule - The vaginal recess around the cervix is called fornix - There are 4 vaginal fornices: - Two lateral fornices: one on each side, is closely related to the ureter and uterine artery - Anterior fornix: is shallow - Posterior fornix: is the deepest one, known as the seminal pool - Clinical notes: - Paracentesis: in peritonitis, accumulation of body fluid, blood or, pus in Douglas pouch is easily drained through the posterior fornix of the vagina - vagina is separated from recto-uterine pouch only by a few mm of tissue, so care must be taken to avoid penetrating wall of rectum by needle during paracentesis 55 ARTIST OF ANATOMY DR/ IBRAHIM AMR The Ovary - site: - in nullipara, it is located within a depression called the ovarian fossa, on the lateral pelvic wall at level of anterior superior iliac spine - Size and shape: - It is about size and shape of an almond (3 length × 2 width × 1 cm thickness) - Surfaces of ovary: Lateral surface: - related to peritoneum of lateral pelvic wall and obturator nerves and vessels Medial surface: - covered with fimbriated end of the uterine tube - Borders of ovary: Anterior (attached) border: - attached to the mesovarium Posterior (free) border: - is free - Ends of ovary: Tubal (upper): - attached to fimbria and suspensory ligament of the ovary Uterine (lower): - attached to lateral angle of uterus by ligament of ovary 56 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Ligaments of the ovary: (1) Suspensory ligament: - It connects upper end of ovary to lateral pelvic wall - it contains ovarian vessels and nerves (2) Ovarian ligament: - It connects uterine (lower) end of ovary to the lateral angle of the uterus (3) Mesovarium: - It connects the anterior border of ovary to upper layer of broad ligament Arterial supply: - Ovarian arteries: - which arises from the abdominal aorta opposite L2 - It runs through the suspensory ligament of ovary to the mesosalpinx then it enters the mesovarium to reach the ovary Venous drainage: - Pampiniform venous plexus: drains into ovarian vein - Right ovarian vein: drains into inferior vena cava - Left ovarian vein: drains into left renal vein Lymphatic drainage: - It accompanies the ovarian vessels to reach the para-aortic LNs at level of L2 Nerve supply: - Symphathetic: from the lateral horn cells of spinal segment T10,11 - Parasympathetic: from inferior hypogastric plexus (pelvic splanchnic nerve, S2,3,4) 57 ARTIST OF ANATOMY DR/ IBRAHIM AMR The Female Mammary Gland (Breast) - Shape: - hemispherical in shape, has an extension into the axilla, called the axillary tail - there are variations according to sex, age, body weight, lactiferous status - Size and contour: - They are variable, but the location and size of its base are fairly constant - Base of the mammary gland: - It rests upon the deep fascia covering pectoralis major, serratus anterior and external oblique muscles - it is separated from underlying muscles by loose areolar tissue, superficial to deep fascia, called retro-mammary space - The base: extends from 2nd to 6th ribs and from lateral margin of sternum to mid-axillary line - The nipple: (in male and preadolescent females) lies opposite to 4th or 5th intercostal space - Arterial supply: (1) branches from internal thoracic artery: - perforating branches - anterior intercostals arteries (2) branches from axillary artery: - lateral thoracic artery - thoraco-acromial artery - Venous drainage: - Through veins accompanying the supplying arteries 58 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Lymphatic drainage: (1) Superficial lymphatics: to sub-areolar and circum-areolar lymphatic plexus (2) Deep lymphatics: - Upper lateral & central parts of the breast: to apical group of axillary lymph nodes - Lower lateral: to anterior (pectoral) group of axillary LNs - Upper medial: to parasternal (internal thoracic) LNs - Lower medial: to anterior abdominal wall LNs (rectus sheath + sub-peritoneal plexus) - Tail of the axilla: to posterior (subscapular) axillary LNs - Clinical notes: (a) Anatomical analysis of the physical signs of cancer of the breast: (1) Invasion of deep fascia, - fibrosis of retro-mammary space leads to fixation of breast (Advanced cases) (2) Invasion of suspensory ligaments, - leads to shortening of ligaments which causes dimpling of overlying skin (3) If tumor tissue blocks deep lymphatics, - lymph from the skin cannot be drained away, and the skin becomes pitted and edematous, resemble texture of the skin of orange (Peau d’orange) (4) invasion of lactiferous ducts, - leads to shortening of ducts which will cause retracted (inverted) nipple 59 ARTIST OF ANATOMY DR/ IBRAHIM AMR (b) In case of breast abscess, incision must be done in a radial direction to minimize ducts damage Development of the mammary gland - Mammary glands appear at first as a thickening of the epidermis called mammary line or mammary ridge. - In a 7-week embryo, this line extends on each side of the body from base of the forelimb to the region of the hind limb - In animals, several mammary glands are formed along this ridge. - In human, the ridge disappears except for a small part in the pectoral region. - This localized area thickens, becomes slightly depressed, and sends off 15 to 20 solid cords, which in turn give rise to small solid buds - By the end of prenatal life, the epithelial cords form: lactiferous ducts. while the buds form: small ducts & alveoli of the gland - Initially, the lactiferous ducts open into a small epithelial pit. - This pit is transformed into nipple by proliferation of underlying mesenchyme - At the 5th month, the areola is recognized as a circular pigmented area of skin around nipple. 60 ARTIST OF ANATOMY DR/ IBRAHIM AMR - Abnormalities of the mammary gland: (1) Polythelia: - numerous nipples along mammary line. - They are liable to be mistaken for moles (2) Polymastia: - It occurs when a remnant of the mammary line develops into a complete breast (3) Retracted Nipple or Inverted Nipple: - due to failure of development of the nipple - It is important clinically: because normal sucking of infants cannot occur and the nipple is prone to infection (4) Micro-mastia: - very small breast on one side resulting from lack of development (5) Macro-mastia: - diffuse hypertrophy of one or both breasts (6) Gynecomastia: - Unilateral or bilateral enlargement of male breast usually at puberty - cause is unknown, but condition is probably related to hormonal imbalance 61