More Fun in the Philippines - P&P

8/3/2019 More Fun in the Philippines - P&P

http://slidepdf.com/reader/full/more-fun-in-the-philippines-pp 1/9

Studying Pelvis & Perineum. More fun in the

Philippines! >:)

Pelvic Girdle A basin-shaped ring of bones that

connects the vertebral column to the twofemurs

The bony structure that surrounds thepelvis1. Hip/Pelvic bones (2)2. Sacrum3. Coccyx

Functions of Pelvic Girdle1. Bear the weight of the upper body when

sitting and standing

2. Transfer weight from axial to the lowerappendicular

3. Attachments of locomotor, abdominaland postural muscles

4. Protect the lower abdominal and pelvicviscera

5. Support the gravid uterus6. Attachments of erectile tissues of the

external genitalia7. Attachment of the pelvic floor

1. Pelvic Bone♥ a.k.a. Coxal Bones♥ Large irregularly shaped bones♥ Composed of 3 bones

1. Ilium2. Ischium3. Pubis

♥ Pubic Symphysis (Anteriorly)♥ Sacroiliac Joint (Posteriorly)♥ In children, the hip bones are separated

♥ United by the Triradiate Cartilage in theacetabulum

♥ After puberty, fuse to form the hip bone

1. Ilium∴ Superior, fan-shaped part of the hip bone⋅ Ala⋅ Body

∴ Iliac Crest∴ Iliac Spines⋅ ASIS⋅ PSIS⋅ AIIS⋅ PIIS

∴ Iliac Fossa∴ Iliac Tuberosity∴ Auricular Surface∴ Arcuate Line *

2. Ischium∴ Forms the lower and back part of the hip

bone∴ Body∴ Ischial Ramus **⋅ Superior⋅ Inferior

∴ Ischial Tuberosity∴ Ischial Spine

1. Greater Sciatic Notch2. Lesser Sciatic Notch

3. Pubis∴ Forms the lower and anterior part of thehip bone

∴ Body⋅ Pubic Crest⋅ Pubic Tubercle

∴ Pubic Ramus **⋅ Superior⋅ Inferior

∴ Pectineal Line / Pecten Pubis *⋅ Pubic Arch

⋅ Subpubic Angle

2. Sacrum♥ Wedge-shaped vertebra♥ 5 bones fused into 1♥ Concave anteriorly♥ Articulations:

٭ Lumbosacral Joint

xoxo: Gorj.




Philippines! >:)

٭ Sacroiliac Joint٭ Sacrococcygeal Joint

♥ Sacral Hiatus♥ Anterior and Posterior Sacral Foramina♥ Sacral Ala♥ Sacral Canal♥ Sacral Promontory

3. Coccyx♥ Tail bone♥ 4 vertebrae fused into 1

Clinics

1. Pelvic Fractures2. Coccydynia

Divisions of Pelvis1. Greater Pelvis∞ a.k.a. False Pelvis∞ Superior to the Pelvic Inlet∞ Bounded by the Iliac Alae and S1

vertebrae∞ Occupied by the abdominal viscera

(Ileum and Sigmoid)∝ Pelvic Inlet• Superior Pelvic Aperture• Pelvic Brim

Promontory and Ala ofSacrum

Linea Terminalis… Arcuate Line … Pecten Pubis … Pubic Crest

Symphysis Pubis∝ Pelvic Outlet• Inferior Pelvic Aperture

Tip of Coccyx Sacrotuberous Ligament Ischial Tuberosities Pubic Arch

2. Lesser Pelvis∞ a.k.a. True Pelvis∞ Between the Pelvic Inlet and Pelvic

Outlet∞ Bounded by the pelvic surfaces of hip

bone, sacrum and coccyx∞ Division (Pelvic Diaphragm)

a. True Pelvic Cavityb. Perineum

Clinical SignificancePelvic Diameters and Conjugates

1. Pelvic Inlet

2. Pelvic Cavity / Midpelvis Plane of Greatest Dimension Plane of Least Dimension

3. Pelvic Outlet

Parameters in ClinicalAssessment of the Midpelvis

Parameters Normal Contracted

Ischial Spines Blunt Prominent

Pelvic Side Walls Divergent Convergent

Concavity ofSacrum

Concave /Deep

Shallow /Flat

SacrosciaticNotch

Wide Narrow

Biischial Diameterof Outlet

> 8cm < 8cm

1. Pelvic InletΩ Anteroposterior Diameters∆ True or Anatomic Conjugate∆ Obstetric Conjugate∆ Diagonal Conjugate

Ω Transverse DiameterΩ Oblique Diameter∆ Left Oblique Diameter∆ Right Oblique Diameter

xoxo: Gorj.




Philippines! >:)

2. Pelvic Cavity / MidpelvisΩ Plane of Greatest Dimension∆ Anteroposterior Diameter∆ Transverse Diameter

Ω Plane of Least Dimension∆ Anteroposterior Diameter∆ Transverse / Bispinous Diameter

3. Pelvic OutletΩ Anteroposterior Diameter∆ Anatomic∆ Obstetric

Ω Transverse / Biischial Diameter

Pelvic Diameters Normal Values

1.

Inlet

(AP) Anatomic 11.0 cm(AP) Obstetric 10.0 cm(AP) Diagonal 12.0 cm

Transverse 13.0 cmOblique 13.0 cm

Pelvic DiametersNormalValue

2.

Midplane

GreatestDimension

AP 12.75 cm

Transverse 12.5 cm

LeastDimension

AP 12.0 cm

Transverse(Bispinous)

9.5-10 cm

Pelvic Diameters Normal Values

3.

Outlet

(AP) Anatomic 9.5-11.5 cm

(AP) Obstetric 11.5 cmTransverse (Biischial) 11.0 cm

Variations in Male and Female Pelvis1. Gynecoid 2. Android3. Anthropoid 4. Platypelloid

Bony Pelvis Male Female

General Structure

Thick and

Heavy

Thin and

LightGreater Pelvis Deep Shallow

Lesser Pelvis Narrow and

DeepWide andShallow

Pelvic Inlet Heart-Shaped,Narrow

Oval,Wide

Pelvic Outlet Small Large

Pubic Arch and Subpubic Angle

<70degrees

>80degrees

Obturator Foramen Round Oval

Acetabulum Large Small

Greater Sciatic Notch Narrow Wide

Pelvic Axis◊ “Pelvis is not a barrel”◊ Curved line in the median plane defined

by the center point of the pelvic cavity atevery level

◊ Serve as the passageway of the fetusduring vaginal delivery♦ Axis 1: directed downward and

posterior♦ Axis 2: directed downward and

anterior

Anatomical Position of the Pelvis⇒ The ASIS and Anterior aspect of the

Pubic Symphysis lie in the same verticalline in such that the pelvic surface of thesymphysis pubis faces upward andbackward.

Pelvic Foramina⇒ “The Pelvis is a Basin with Holes in its

Walls”

xoxo: Gorj.




Philippines! >:)

→ Anterior Sacral Foramina→ Greater Sciatic Foramen→ Lesser Sciatic Foramen→ Obturator Foramen

⇒ “For the wires (Pudendal Nerve) to gainentrance to the apartment below(Perineum), without going through thefloor (Pelvic Floor), they have to piercethe wall (Greater Sciatic Foramen) to getoutside the building and then returnthrough a second hole (Lesser SciaticForamen).”

Pelvic Joints1. Sacroiliac Joint2. Sacrococcygeal Joint3. Pubic Symphysis

1. Sacroiliac Joint♣ Strong, weight bearing compound joint♣ Both Synovial and Syndesmois type of

joint♣ Synovial: Auricular surfaces of the

sacrum and ilium↣ Irregular but congruent elevations and depressions that interlock

♣ Syndesmosis: Tuberosities of sacrumand ilium

♣ Ligaments:↣ Anterior Sacroiliac Ligaments↣ Interosseous Sacroiliac Ligaments↣ Posterior Sacroiliac Ligaments↣ Sacrotuberous Ligament↣ Sacrospinous Ligament

2. Sacrococcygeal Joint♣ S5 and Coccyx♣ Ligaments:

↣ Anterior Sacrococcygeal Ligament↣ Lateral Sacrococcygeal Ligament↣ Posterior Sacrococcygeal Ligament

3. Pubic Symphysis Joint♣ Joint between the two pubic bone♣ Cartilaginous joint consisting of

fibrocartilage interpubic disc♣ Ligaments:

↣ Superior Interpubic Ligament↣ Inferior (Arcuate) Interpubic Ligament

Pelvic Wall Muscles1. Obturator Internus

enters lesser sciatic notch2. Piriformis

enters greater sciatic notch

Pelvic Floor Muscles‣ Funnel-shaped pelvic diaphragm‣ Incomplete anteriorly to allow passage of

urethra and vagina‣ Inferior limit of the pelvic cavity proper

1. Levator AniĬ Anterior Fibers

ī Levator Prostatae/Sphincter

VaginaeĬ Intermediate Fibersī Puborectalisī Pubococcygeus

Ĭ Posterior Fibersī Iliococcygeus

Ĭ Origin : linear thickening of theobturator fasciaī Body of Pubis ī Tendinous Arch ī Ischial Spine

2. Coccygeus

Pelvic Cavity⁙ A funnel-shaped space containing:

⁘ Distal parts of the urinary system(distal ureter and urinary bladder )

⁘ Rectum

xoxo: Gorj.




Philippines! >:)

⁘ Pelvic Genital⁘ Organs

⁘Pelvic Blood Vessels, Lymphatics andNerves

Borders

Superior Pelvic Inlet

Inferior Pelvic Floor / Diaphragm

Lateral Wall Hip Bones & ObturatorForamen closed by Obturator

Mebrane

Posterior Wall Saccrum, Coccyx, & PiriformisAnterior Wall Pubic Bone & Pubic Symphisis

Pelvic Fascia⊛ Connective tissue that covers the pelvic

cavity⊛ 2 types:1. Membranous Pelvic Fascia

Continuous with the TransversalisFascia

Layers: Parietal Pelvic Fascia Visceral Pelvic Fascia

2. Endopelvic Fascia

Connective tissue that fills the spacebetween the Parietal and VisceralPelvic Fascia

Pelvic Peritoneum Parietal peritoneum lining the abdominal

cavity continues inferiorly into the pelviccavity but does not reach the pelvic floor. Covers the superior and superolateral

surfaces of the pelvic viscera Variations:

Ovaries – not covered withperitoneum

Uterine Tubes / Fallopian Tubes

Peritoneal Reflections and Recess Supravesical Fossa

Pararectal Fossa

Male: Rectovesical Pouch

Female: Uterovesical Pouch Rectouterine Pouch (Pouch/Cul-

de-sac of Douglas) Rectovesical Pouch (s/p

Hysterectomy)

Pelvic Viscera

1. Urinary Bladder2. Rectum3. Neurovascular Structures

a. Pelvic Arteriesb. Veinsc. Pelvic Nervesd. Pelvic Lymphatics

1. Urinary Bladder Temporary reservoir for urine

A hollow, distensible viscus with strongmuscular wall Posterior to the pubic bones separated

by a potential space Retropubic Spaceof Retzius

External Parts: Apex, Fundus, Body, Neck

Walls: Detrusor Muscle

Orifice: Ureteral Orifices & Urethral Orifice

Bladder Trigone 2 ureteric and internal urethral orifices

Sphincters: Internal Urethral Sphincter

(Involuntary) External Urethral Sphincter

(Voluntary)

xoxo: Gorj.




Philippines! >:)

Innervation:

Pudendal Nerve (S2-S4) Motor to External Urethral

Sphincter

Sympathetic Supply T10-T12 via Pelvic Plexus and

Hypogastric Plexus Motor to Internal Urethral

Sphincter Inhibitory to Detrusor Muscle

Parasympathetic Supply S2-S4 via Pelvic Splanchnic

Nerves and Inferior HypogastricPlexus

Motor to Detrusor Muscle Inhibitory to Internal Urethral

Sphincter

2. Rectum Pelvic part of the digestive tract

Continuous proximally with the sigmoidcolon Superior third is covered by peritoneum

on its anterolateral surface Related to Prostate in males, Cervix and

Vagina in females Rectosigmoid junction

S3 vertebrae Taenia Coli spread to form a

continuous outer longitudinal layer ofsmooth muscle

No fatty omental appendices

FLEXURES Anterior Flexures Sacral Flexure Anorectal Flexure (80º)

Lateral Flexures (Valve of Houston)

Superior (Left) Intermediate (Right)

Inferior (Left)

DILATATION Rectal Ampulla Terminal portion of the rectum Stores fecal material

Innervation: Parasympathetic (S2-S4) Pelvic Splanchnic Nerves Hypogastric Plexus

Rectal Plexus

Sympathetic (Lumbar Spinal Cord) Lumbar Splanchnic Nerves Hypogastric Pelvic Plexus

3. Neurovascular Structuresa. Pelvic Arteries⊗ 6 Main Arteries1. (2) Internal Iliac

2. (2) Ovarian Artery*Female Reproductive Module3. Median Sacral Artery4. Superior Rectal Artery

1. Internal Iliac Artery Arises from the common iliac artery (L4-

L5 IV Disc) Usually crossed by the ureter Principal Artery of the Pelvis Divisions:

Anterior Division (8 branches)ت Umbilical Artery

* Superior Vesical Artery ت Obturator Arteryت Inferior Vesical Arteryت Uterine Artery / Ductus Deferens

Artery

xoxo: Gorj.




Philippines! >:)

ت Vaginal Arteryت Middle Rectal Arteryت

Internal Pudendal Artery* Inferior Rectal Artery ت Inferior Gluteal Artery

Posterior Division (3 branches)ت Iliolumbar Arteryت Lateral Sacral Arteryت Superior Gluteal Artery

Blood Supply of the Rectum Inferior Mesenteric Artery Superior Rectal Artery

Internal Iliac Artery Middle Rectal Artery

Internal Pudendal Artery Inferior Rectal Artery

Abdominal Aorta Median Sacral Artery

Blood Supply of the Urinary Bladder Umbilical Artery Superior Vesical Artery

Internal Iliac Artery Inferior Vesical Artery

b. Pelvic Veins Pelvic Venous Plexus Usually drain in one of the following:

Internal Iliac Vein* Caval Circulation

Superior Rectal Vein* Portal Circulation

Lateral Sacral Vein* Internal Vertebral Venous Plexus

Veins Draining the Rectum 2 Groups of Rectal Venous Plexus Internal Rectal Venous Plexus

(Submucosa) External Rectal Venous Plexus

(External Muscularis) Drainage:

Superior Rectal Vein* Inferior Mesenteric Vein

Middle Rectal Vein* Internal Iliac Vein

Inferior Rectal Vein* Internal Pudendal Vein

Veins Draining the Urinary Bladder Drains via Vesical Venous Plexus

* Internal Iliac Vein

c. Pelvic Nerves Lumbo-Sacral and Coccygeal Spinal

Nerves Pelvic Part of Autonomic Nervous

System Somatosensory (Skin and Skeletal

Muscles) Lumbo-Sacral and Coccygeal Spinal

Nerves Visceral (Smooth Muscles)

Pelvic Part of Autonomic NervousSystem Lumbo-Sacral and Coccygeal Spinal

Nerves Iliohypogastric Ilioinguinal Genitofemoral Obturator Nerve Femoral Nerve Sciatic Nerve (Common Peroneal,

Tibial)

Superior Gluteal Nerve Inferior Gluteal Nerve Nerve to Piriformis Nerve to Obturator Internus and

Gemellus Superior Nerve to Quadratus Femoris and

Gemellus Inferior

xoxo: Gorj.




Philippines! >:)

Pudendal Nerve Nerve to Levator Ani and Coccygeus

Lateral Cutaneous Nerve of the Thigh

Posterior Cutaneous Nerve of theThigh

Pelvic Part of Autonomic NervousSystem Sacral Sympathetic Trunk Periarterial Plexuses Hypogastric Plexuses Superior Hypogastric Plexus Inferior Hypogastric Plexus

Pelvic Splanchnic Nerves

d. Pelvic Lymphatics External Iliac Nodes Internal Iliac Nodes Sacral Lymph Nodes Common Iliac Nodes

Perineum A shallow compartment of the body

bounded by the pelvic outlet and the

inferior surface of the pelvic diaphragm In anatomical position, it is the narrowregion between the proximal part of thethighs.

In abducted position, it is diamond inshape

Symphysis Pubis Ischial Tuberosities Tip of Coccyx

Division of the Perineum Via a transverse line that joins the

two ischial tuberosities The center of the line marks the

position of the Perineal Body Converts the diamond into two

triangles

Triangles of Perineum 1. Urogenital Triangle

Forms the anterior of perineum

Bounded by: Pubic symphysis Ischial Tuberosities Transverse line connecting the

tuberosities Male / Female Repro. System

2. Anal Triangle Forms the posterior of perineum Bounded by:

Transverse line connecting thetuberosities

Sacrotuberous Ligament andGluteus Maximus

Tip of the coccyx Contents:

Ischiorectal Fossa Anal Canal

ISCHIOANAL FOSSA

Wedge-shaped space located oneach side of the anal canal Walls:

Base: skin

Medial Wall: sloping levator ani and anal

canal Lateral Wall: Obturator Internus and

Pelvic Fascia Roof: Levator Ani

Contents: Pudendal Nerve (Alcock Canal) Internal Pudendal Artery and

Vein (Alcock Canal) Fat

xoxo: Gorj.




Philippines! >:)

ANAL CANAL Terminal Part of the GIT

Rectal Ampulla

* Anus Surrounded by 2 Sphincters

Internal Anal Sphincter External Anal Sphincter

Support: Perineal Body Anococcygeal Ligament

1. Internal Anal Sphincter Involuntary sphincter

Thickening of the circular muscle layer(Upper 2/3)

Sphincter Relaxes when the rectalampulla dilates

Innervation: Sympathetic (Superior rectal and

Hypogastric Plexus) Stimulatory

Parasympathetic (PelvicSplanchnic Nerves) Inhibitory

2. External Anal Sphincter Voluntary sphincter (Inferior 2/3) Attached to Perineal Body and

Anococcygeal Ligament Blends with puborectalis 3 types:

Deep

Superficial Subcutaneous

Innervation: Deep – Nerve to Levator Ani and

Inferior Rectal nerve Superficial and Subcutaneous –

Inferior Rectal Nerve

Internal Features Columns of Morgagni Contains the terminal portion of

the superior rectal artery and vein Proximal End

* Anorectal Line Distal End

* Pectinate Line/ Dentate Line

Pectinate Line / Dentate Line Marks the area of transitional zone Above : Simple Columnar Epithelium

Below : Stratified Squamous Non-

Keratinizing Epithelium Superior Hindgut Superior Rectal Artery Superior Rectal Vein Inferior Hypogastric Plexus Internal Iliac Lymph Nodes

Inferior

Proctodeum Inferior Rectal Artery Inferior Rectal Vein Superficial Inguinal Lymph

Nodes Inferior Rectal Nerve

Anal Valve and Anal Sinuses Valves connects the columns of

Morgagni Sinuses are small recesses

Anoderm, Pecten, Anocutaneous Line

Corrugator Cutis Ani Muscle

Surgical Anal Canal vs AnatomicalAnal Canal

xoxo: Gorj.

Documents

More Fun in the Philippines - P&P