B4 GARQ revised

Name the structures labelled A, B, C, and name the term for the anatomic structure that is demarcated by the blue line.

A, urethra. B, vagina. C, anal canal. Blue line demarcates the urogenital hiatus.

Describe the course of the ureter.

Abdominal part arises from renal pelvis descend along anterior surface of psoas major, and cross bifurcation of common iliac where they enter pelvic cavity. In pelvic part, ureters run down lateral pelvic walls until ischial spine, then turn toward the bladder, piercing the lateral aspect. In females, ureters are crossed anteriorly by uterine artery. In males, crossed anteriorly by the vas deferens instead.

Uterosacral ligament

Also known as sacrocervical ligaments, this fibrous fascial band on each side of the uterus passes from the cervix to the sacrum along the lateral pelvic wall.

Describe the perineal body

An irregulalar fibromuscular mass in the median plane between the anal canal and the perineal membrane - the central tendon of the perineum. Function is to maintain structural integrity of pelvic floor.

What is the urogenital triangle and what are its boundaries?

Anterior portion of the perineum containing the genitalia. Bounded by pubic symphysis, ischial rami, transverse line between ischial tuberosities.

Descibe the disposition of the uterus.

Anteversion and retroversion refer to the axis of the vagina. Normal uterus is anterverted. Anteflexion and retroflexion refer to bend relative to cervix. Uterus is normally anteflexed.

Name the phases of the CT examination shown (CT urography). During which time point do you expect the urinary bladder to be filled with contrast.

B is non-contrast, before contrast was administered. A is arterial/corticomedullary, the contrast is in the artery, cortex, and medulla. D, nephrographic phase, the contrast is fully dispersed in the kidneys. C, excretory phase, the contrast is now out of the kidney and in the ureters and bladder.

Enumerate the muscles that "attach" to it (intersect at it) in the adult

BEEDS, Bulbospongious, External anal sphincter, External urethral sphincter, deep and superfical transverse perineal muscles.

How is the pudendal nerve formed

From the ventral primary rami of S2-4. The three roots join just proximal to the sacrospinout ligament

What is the urogenital hiatus?

The gap between the anteromedial borders of the pelvic diaphragm through which the male urethra and female urethra and vagina pass

Describe the vaginal fornices

These are recesses formed between the margin of the cervix and vaginal wall. The posterior fornix is located close to the recto-uterine pouch of Douglas. The anterior fornix is not covered by peritoneum and not associated with vesico-uterine pouch. Lateral fornices connect anterior and posterior. Supplied by uterine artery.

Where do the perineal membrane and the superficial perineal fascia (Colles') become continuous (fuse) and what is the importance of this relationship?

These fascias become fused at the perineal body. Important for maintaining integrity of the perineal space, prevents prolapse of vagina, bladder, rectum, uterus; anchors perineal muscles.

Describe the sacroiliac joints

These join the sacrum with the ilia. Auricular surfaces of sacrum and ilium covered with articular cartilage. Anterior is synovial, posterior is syndesmosis. Supported by the anterior SI ligament, posterior SI ligament, interosseous SI ligament, sacrotuberous and sacrospinous ligaments.

Which structures receive autonomic innervation via the inferior hypergastric plexus.

Rectum, urinary bladder, prostate, seminal glands, uterus, vagina.

Path of sperm

Seminiferous tubules, straight tubules, rete testis, efferent ductules, epididymis, ductus deferens, seminal vesicle, ejaculatory ducts, prostatic urethra, membranous urethra, penile urethra, external urethral orifice.

What neck structures must be transversed to perform tracheostomy, from superficial to deep.

Skin, superficial cervical fascia with platysma, investing layer of deep cervical fascia, infrahyoid muscles (sternohyoid and sternothyroid), pretracheal layer of deep cervical fascia, trachea.

Describe the rectum. Include its location, length, flexures, peritoneal covering, and innervation.

This 15 cm muscular tube continues from the sigmoid colon at S3 and continues as the anus at the levator ani muscle. It bends dorsally at the sacral flexure, perforates the pelvic diaphragm at the anorectal flexure, and has 3 lateral flexures. Innervated by lumbar splanchnic (hypogastric plexus) and pelvic splanchnic nerves. Only top 2/3 have peritoneal covering.

(a) insert a neuron (one in each segment) that innervates a sensory receptor in the skin of the perineum; (b) insert a neuron (one in each segment) that innervates the skeletal muscle of the perineum; and (c) insert a neuron (one in each segment) that innervates sweat glands in the perineum.

Somatic sensory have cell body in dorsal root ganglia and axons in dorsal horn and posterior root. Somatic motor have cell body in ventral horn through anterior root. Pre-ganglionic sympathetic arise from lateral horn, enter ventral root and ramus, enter sympathetic ganglia. Post-ganglionic sympathetic exits ganglia and innervates skin.

Scrotum fascia

Some damn englisman called it the testes. skin, dartos fascia (scarpa's), external spermatic (external oblique), cremasteric muscle and fascia (internal oblique), internal spermatic (transversalist fascia), tunica albugina and tunica vaginalis.

Superficial fascia of the body

Subcutaneous layer between dermis and deep fasica, composed of loose connective tissue and fat. Contains sweat glands, blood and lymphatic vessels, cutaneous nerves.

Describe the fascial compartments of the neck.

Superficial cervical fascia, subcutaneous tissue containing external jugular, cutaneous nerves, platysma muscle. Investing layer of deep cervical fascia invest sternocleidomastoid, trapezius, and infrahyoid muscles. Pre-vertrebral layer of deep cervical contains vertebral column, scalene muscles, and pre-vertebral. Pre-tracheal layer encloses pharynx, trachea, esophagus, larynx, thyroid. Carotid sheath encloses internal jugular, common or internal carotid, vagus nerve.

Name the skeletal muscles inferior to the perineal membrane, their function, and innervation

Superficial perineal pouch. Superficial transverse perineal muscle stabilizes perineal body, ischiocavernosus compressess corpus cavernosum, bulbospongiosus compresses corpus spongiosum, bulb of penis, vaginal orifice. Deep division of perineal nerve.

Describe arterial and venous drainage of rectum.

Superior rectum - IMA - superior rectal artery. Middle and inferior rectum - internal iliac artery anterior division. Anorectal junction and anal canal - internal iliac to internal pudendal to inferior rectal artery. Venous drainage follows arterial; superior rectum by superior rectal vein to IMV, middle rectal vein to internal iliac, inferior rectal to internal pudendal to internal iliac to IVC.

Briefly describe the adrenal (suprarenal) glands - location, blood supply, and innervation?

Suprarenal glands are separated by fibrous septum from kidney but lie superior. Supplied by superior (inferior phrenic), middle (AA), and inferior (renal) suprarenal arteries. Right suprarenal gland drains to IVC, left first joins left renal vein. Innervated by T10 - L1 (sympathetic) lesser and least splanchnic nerves, Vagus and S2-4 pelvic splanchnic (parasympathetic) via the celia ganglia.

What is an episiotomy and what is its purpose?

Surgical incision of the perineum and vaginal wall to enlarge exit passage for baby. Done to prevent soft-tissue tearing of the anal sphincter, rectum, perineal skin, pelvic muscles.

Describe the internal pudendal artery and its branches

This artery branches from the internal iliac, passes through greater sciatic foramen, curves around ischial spine to re-enter perineum through lesser sciatic foramen and obturator fascia. Divides into inferior rectal (external anal sphincter), perineal (superficial perineal muscles, scrotum/labia), artery of penis bulb/vestibule, deep artery of penis/clitoris, dorsal artery of penis/clitoris (deep perineal pouch)

Why is it important to know the location of the cricoid cartilage? Why is it important to know the position of the "strap muscles"? Why is it important to locate the common carotid arteries and internal jugular veins at the time of this procedure?

The cricoid cartilage marks the first tracheal ring, which is immediately inferior. The trachea, larynx, and thyroid glands are accessible through the midline between strap muscles, they can be retracted laterally to visualize the trachea. The common carotid and internal jugular are indicators of lateral boundaries and must not be cut.

Describe the erectile bodies of the penis.

The crux of the corpora cavernosa attach at the internal surface of the ischial rami. The bulb of the corpus spongiosum attaches at the urethra and distally forms the glans.

Broad ligament

This double layer of peritoneum attaches the uterus to the lateral pelvic walls. The mesometrium extends from the entire lateral surface of the uterus. The mesosalpinx is the mesentery of the fallopian tube. The mesovarium connects the ovaries to the broad ligament.

Ovarian ligament

This fibrous ligament connects the ovary to the lateral surface of the uterus. The proximal remnant of the gubernaculum.

Medial umbilical ligament

This fibrous remnant of the umbilical artery occupies the medial umbilical fold. It is the obliterated medial umbilical artery.

Suspensory ligament of ovary

This fold of peritoneum extends from the pelvic wall to the ovary and contains ovarian vessels, nerves, and lymphatics.

Describe the pubic symphysis. What structures hold this joint together?

This is a secondary cartilaginous joint, supported by the superior, inferior, and anterior pubic ligaments

What kind of image, how was it taken, what is shown?

This is the ovary, shown by ultrasound. An endovaginal probe was used. Ultrasound is used first in evaluation of the uterus, but MRI is better for soft-tissue characterization.

Median umbilical ligament

This is the remnant of the urachus that occupies the median umbilical fold in the peritoneum of the anterior abdominal wall.

Round ligament of uterus

This ligament attaches at the lateral surface of the uterus, passes through the inguinal canal, and attaches to the labia majora. The distal remnant of the gubernaculum.

Lateral umbilical ligament

This overs the inferior epigastric vessels.

Cardinal ligament

This transverse band of connective tissue connects the cervis to the lateral pelvic walls.

What is the perineal membrane - location, extent, attachments

Triangle shaped sheet of deep tough fascia in urogenital triangle. Located inferior to pelvic diaphragm, deep to skin, between deep and superficial perineal pouches. Attached to pubic ligament and ischiopubic rami.

If a patient presents with abdominal pain and you suspect gynecological reason, which imaging modality is first after the clinical exam?

Ultrasound

What is the pattern of lymphatic drainage of the ureters?

Upper - lateral aortic (lumbar) nodes. Middle - common iliac nodes. Inferior - external and internal iliac nodes.

What is the blood supply of the ureter? How does the topography of the ureteric blood supply differ between abdomen and pelvis, and what is the surgical significance of this positioning?

Upper ureter, renal artery (AA). Middle - gonadal and common iliac artery. Lower - superior vesical (umbilical), inferior vesical, uterine and vaginal artery, middle rectal artery. The upper and middle ureter are lateral of the their blood supply, but lower pelvic ureter is medial to blood supply. Surgical incisions should be on the non-vascular side.

Describe the ischioanal fossa; consider its boundaries and its contents

Wedge-shaped, fascia lined cavity between pelvic diaphragm and skin. Lateral wall is fascia of the obturator internus, medial wall is anal canal. Contains dense fat, inferior anal neurovasculature.

Describe the male and female urethra.

Femal is 4 cm long and straight, axis runs parallel to vagina, passes through pelvic diaphragm, external urethral sphincter, perineal membrane; opens at external urethral orifice in vestibuele. Male is 20 cm long and bends, pre-prostatic, prostatic goes through prostate, membranous passes deep perineal pouch and perineal membrane, spongy passes through root of penis to external urethral opening.

Describe the innervation of the bladder and the role(s) that its nerves play during bladder filling and bladder emptying. Be sure to include both motor and sensory innervation (and enumerate spinal cord segments involved).

Filling - Sympathetic, T11-L3 lumbar and sacral splanchnic nerves to hypogastric plexus, relax detrusor and consrict internal urethral sphincter. Emptying - parasympathetic, S2-4 pelvic splanchnic, contract detrusor and relax internal sphincter. Somatic - Pudendal (S2-4) voluntary control of external sphincter. Visceral afferent - above pain line follows sympathetic to T11-L3, below pain line follows pelvic splanchnic to S2-4.

Name the imaging tests for injury to the bladder and extravasation of urine.

Fluoroscopy is a continous X-ray that shows anatomy and motion. CT cystography, in which iodinated contrast is instilled retrograde into patient's bladder, and then pelvis is imaged with CT.

Describe the relationship of each kidney to the structures immediately anterior to it. Describe the relationship of the kidneys to the structures immediately posterior to them.

Left kidney anterior is stomach, spleen, pancreas, descending colon, jejenum. Right kidney anterior is liver, 2nd part of duodenum, ascending colon. Posterior is psoas major, quadratus lumborum, transversus abdominus, diaphragm.

Superficial fascia of abdominal wall

Lies deep to skin. Composed of Camper's fascia (superficial fatty layer) and Scarpa's fascia (deep membranous layer).

Describe the ovaries.

These are located on either side of the uterus in the pelvic cavity, they are the primary sex organs of the female. Medial end connected to ligament of ovary, lateral end connected to fimbriae. Supplied by ovarian artery from AA, and uterine artery from internal iliac. Covered by mesovarium.

Describe the pelvic plexus of nerves. Be sure to include discussion of the superior hypogastric plexus, the right and left hypogastric nerves, sacral splanchnic nerves, and pelvic splanchnic nerves.

Pelvic structures are innervated mainly by sacral and coccygeal spinal nerves. Superior hypogastric plexus (sympathetic and visceral afferent) liesinferior to aorta bifurcation, continuation of intermesenteric plexus. Divides into R and L hypogastric nerves which run lateral to rectum in hypogastric sheaths and join the pelvic splanchnic to form R and L inferior hypogastric plexi. Sacral splanchnic nerves (T12 -L2) are sympathetic, pelvic splanchnic (S2-4) are parasympathetic.

What is the anal triangle and what are its boundaries

Posterior triangle of the perineum. Bound by coccyx, sacrotuberous ligaments, ischial tuberosities.

Describe the uterus and cervix.

The uterus is a thick-walled, pear-shaped, hollow muscular organ between bladder and rectum. Fundus is most anterior, body is upper 2/3, and cervix is fibrous lower 1/3 of utuers. Functions to maintain the ovum and fetus. Arterial supply from internal iliac to uterine artery. Anterior is uterovesical pouch, covered by broad ligament, posterior is recto-uterine pouch.

Describe the perineum and state its boundaries.

A diamond shaped area inferior to the pelvis separated by the pelvic diaphragm. Bounded by the pubic symphysis, pubic and ischial rami, ischial tuberosities, sacrotuberous ligaments, sacrum/coccyx

What is the pudendal canal, where is it, and what are its contents?

A passage through the medial fascia of the obturator internus. Begins at posterior border of the ischio-anal fossa, runs almost to inferior pubic symphysis. Contains internal pudendal AV, pudendal N, obturator internus N.

What is a tracheostomy, and name when it would be performed.

A permanent or temporary opening (stoma) in the cervical trachea through surgical incision below the cricoid cartilage for the placement of a tracheal tube. Indicated for acute airway obstruction (foreign body, malignancy) or long-term mechanical ventilation

Penis fascia

Below skin is loose areolar tissue and superficial penile fascia. Deep penile fascia is continuous with deep perineal fascia. Tunica albuginea envelops the corpora cavernosa and corpus spongiosum.

What is the best imagine technique to assess the ureters and whether there is urinary leak from the ureters? A ureteric calculus?

CT urogram with contrast (MR urogram would work). CT of abdomen and pelvis without contrast for a ureteric calculus.

Describe the fallopian tubes

Composed of intrauterine part, isthmus (narrow), ampulla, and infundibulum with finger-like processes (fimbriae). Arterial supply is ovarian artery from abdominal aorta and uterine artery from internal iliac. Covered by broad ligament (mesometrium).

Superfical fascia of perineum

Composed of superficial fatty layer, continuous with Camper's fascia, and Colle's fascia, the deep membranous layer continous with Scarpa's fascia.

Name three locations where ureter is normally constriced. To what location would pain caused by ureteric calculus be referred. How is urinary reflux prevented?

Constrictions at ureteropelvic junction, pelvic inlet (where common iliac crosses), site of entrance to bladder. Pain follows T11-L2 spinal segments back, and the cutaneous areas of T11 - T12 are from "loin to groin", as well as scrotum and labia. The oblique entry of ureters into the bladder creates a one way valve, and contractions of the detrussor muscle act as a sphincter to prevent reflux.

Name the skeletal muscles superior to perineal membrane and their function and innervation.

Deep perineal pouch. Deep transverse perineal muscle stabilizes perineal body, external urethral sphincter compresses urethra, compressor urethrae in females is accessory sphincter, urethrovaginalis sphincter is accessory sphincter. Deep division of perineal nerve.

Describe the neurovasculature of the penis.

Deep to superficial penile fascia is the superficial dorsal vein. Deep to Buck's fascia is the deep dorsal vein accompanied by dorsal artery and dorsal nerve. Deep arteries run through the corpora cavernosum. Arteries are fed by internal pudendal artery. Veins drain to internal pudendal and internal iliac. L1 Ilioinguinal and S2-4 pudendal to dorsal nerve innervate the penis.

Describe the bladder with special attention to the detrussor, trigone, entrance of uereter, point of exit of urethrea, internal urethral sphincter.

Detrusor is the muscular coat of the bladder composed of smooth muscle arraned in 3 layers. Trigone is a smooth mucous membrane covering the internal surface of the bladder that ia adherent to the underlying muscular coat. Ureters enter the bladder through lateral angles, and ureteric orifices are located at superior angles of tirgone. Ureters enter obliquely, forming one-way valve preventing urine reflux. Internal urethral orifice is located at inferior angle of trigone. Internal urethral sphincter is where detrusor muscle fibers converge on the bladder neck in males, preventing reflux of seminal fluid into bladder.

Describe the location of the kidneys relative to the vertebral column and indicate the differences in position of the right and left kidneys. Describe the unique arrangement of fat and fasciae associated with the kidney (and adrenal gland).

Kidneys located T12 to L3, right kidney slightly lower than left due to liver, located retroperitoneally. Kidney -> renal fibrous capsule -> perirenal fat -> renal fascia -> pararenal fat. Renal fascia encloses adrenal glands, but they are seprated from kidneys by fibrous tissue.

Describe/diagram the internal iliac artery. Identify the branch, or branches, that: (a) supply the body wall; (b) supply the lower extremity and (c) supply pelvic viscera. Be sure to discuss the differences between visceral branches in the male and female.

I love going places in my very own underwear - Iliolumbar, Lateral sacral, superior and inferior Gluteal, internal Pudendal, Inferior vesical (male), middle rectal, vaginal, obturator, umbilical (superior vesical) and uterine (female). Posterior division (I, L, s G) go to body wall. Anterior division (besides inferior gluteal) go to organs. Obturator supplies lower extremities.

Where is a tracheostomy performed? Why should the suprasternal notch, tracheal rings, thyroid gland, and thyroid cartilage be palpated/identified at the beginning of the procedure?

Ideal performed between cricoid cartilage and sternal notch (between 2nd and 3rd tracheal rings). Suprasternal notch is inferior boundary, thyroid cartilage marks superior boundary, thyroid gland must be avoided, and tracheal rings can help indicate the correct location.

What is the significance of the peritoneal relationships of the rectum in terms of a breach in the rectal wall and the spread of infection?

If there is a breach to the superior or middle rectum which have peritoneal coverings, there is a greater chance of developing of peritonitis. Inferior third breach carries lower risk for peritonitis.

Name these structures

Iliac fossa, iliac crest, superior pubic ramus, ischiopubic ramus, femoral head, greater trochanter, anterior sacral foramina.

What are the posterior relationships of the bladder in male and female.

In male, bladder is separated from rectum by rectovesicular septum, and prostate and seminal vesiscle lie posteroinferiorly. In females, bladder is directly anterior to the vaginal canal and inferior portion of uterus.

Describe the attachments of the erectile bodies in male and female

Ischiocavernosus attaches along the ishcial rami, inserts into the crus of the penis or clitoris. Bulbospongiosus, as bulb of penis and vestibular bulbs, are unattached.

What are the cavernous nerves?

These are post-ganglionic parasympathetic nerve that facilitate erection in the penis and clitoris. They arise from cell bodies in the inferior hypograstric plexus (ventral rami of S2-4 -> pelvic splanchnic -> inferior hypogastric plexus -> cavernosus nerves

Indicate the two methods that best determine a) the local stage of disease and b) the nodal and distant metastatic stage of disease in the rectum. Give at least two advantages and one disadvantage for each imaging method you have proposed to perform the local staging. The local extent of the disease determines whether the patient will undergo surgery or radio-chemotherapy as a primary (first) treatment. What questions must you ask your patient to clarify whether he/she can safely undergo the imaging test you plan to request? Your patient tells you that he has had total hip replacements. Does this affect your decision of ordering the planned examination to determine the patient's local stage of his rectal cancer? Describe what you can do to clarify the situation.

Local stage of disease best determined by MRI or US, distal metastases by CT or PET scan. MRI has no radiation exposure and offers excellent detail, but expensive. US is cheap and offers no radiation, but there is less anatomic detail. Before injecting contrast, ask about allergies, renal insufficiency, implantable medical devices, pregnancy. If patient has metal, some metals proclude MRI. Clarify which metal is used, and then use CT or US instead if metal is magnetic.

Name the dedicated imaging exam to assess functional disorders of the pelvic floor.

MR defecography or MR defecogram

What are the best imaging techniques for detailed assessment of the uterus and ovaries.

MRI has superior soft-tissue contrast and can image all planes. CT with IV contrast improves contrast between uterus and surrounding tissues.

Describe these "features" of the pelvic bone (os coxae): obturator foramen, ischial spine, ischial tuberosity, greater and lesser sciatic notches, greater and lesser sciatic foramina.

Obturator foramen is the largest hole; sciatic notches above and below ischial spine; sciatic foramina between notches and sacrotuberous and sacrospinous ligaments.

Describe the gross structure of a kidney (cortex, medulla, major and minor calyces, renal pelvis, renal sinus), including its blood supply and venous drainage.

Parenchyma organized into outer cortex and medulla. The medulla is divided into renal pyramids that end in renal papilla emptying into minor calyces which fuse to form major calyces. The major calyces meet at the large central renal pelvis. The renal sinus is the cavity within the kidney containing the pelvis, calyces, blood vessels, nerves, and fat. Glomeruli and convoluted tubules in cortex, loops of henle and collecting tubules in medulla. Supplied by renal artery from AA which divides into smaller, drained by renal vein to IVC.

Name and describe the layer of skeletal muscle that forms the floor of the abdominopelvic cavity.

Pelvic diaphragm. Levator ani attaches to pubic bone, tendinous arch, coccyx. Innervated by pudendal nerve, resists intra-abdominal pressure, supports pelvic viscera. Coccygeus attaches to sacrum/coccyx and ischial spine. Innervated by branches of S4 and S5, helps support pelvic viscera and pulls coccygeus anteriorly.

Describe plane of pelvic outlet

Pelvic outlet described by the coccyx, sacrotuberous ligaments, ischial rami, ischial tuberosities, infrior margin of pubic symphysis.

Define and describe the plane of the pelvic inlet

The pelvic inlet is the superior pelvic aperture formed by the linea terminalis; formed by sacral promontory, ala of sacrum, arcuate line of ileum, pectin pubis, superior pubic crest, and pubic symphysis.

How do the sacral spinal cord segments 2, 3, and 4 provide innervation to the distal GI tract, pelvic viscera, and erectile tissue.

The pelvic splanchnic nerves arise from the anterior ramie of S2-4 from pre-ganglionic parasympathetic nerves with cell bodies in the lateral horn.

Where is a pudendal nerve block administered.

The pudendal trunk as it enters the lesser sciatic foramen and hooks around the lateral aspect of the sacrospinous ligament near its attachment to the ischial spine. One must identify the sacrospinous ligament and ischial spine.

What is the rectal ampulla? What are the anterior structures to the rectum in males and females?

The rectal ampulla is a dilation of the rectum directly superior to the pelvic diaphragm which holds feces. In males, seminal glands, prostate gland, vas deferens, urinary bladder are anterior. In females, uterus and vagina are anterior..