Lifecycle anatomy

seminal vesicles

70% of ejaculate do NOT store sperm secretions promote maturation, mobility, capacitation of sperm glob on to cervix also liquefy clot so sperm can swim up cervical canal Fructose to nourish sperm

Visceral innervation of pelvic organs and blood vessels Sympathetic: Parasympathetic:

: lowest segments of spinal cord (T10-L2) : S2-S4

Leiomyomas (uterine fibroids)

Benign solid masses of the uterus that develop from overgrowth of the uterine smooth muscle tissue. MYOMETRIUM

spongy urethra

Bulbar urethra -> bulb of penis in superficial perineal space Pendulous urethra -> traverse visible portion of penis SURROUNDED BY CORPUS SPONGIOSUM

Sacral Plexus (SOMATIC)

Continuous with lumbar plexus, with it forms Lumbosacral plexus L4 - S4 anterior surface of piriformis muscle on GSF Roots are lumbosacral trunk L4,5 and ventral rami of sacral spinal nerves S1-3

CT or ultrasound for renal stones?

Debatable, but CT is optimal for determining size of stones in patients

Ductus Deferens enters abdominopelvic cavity via:

Deep Inguinal Ring

Pelvic Outlet

Diamond shaped bound by: Pubic symphysis, pubic arch, ischial tuberosities, sacrotuberous ligaments, and coccyx. most inferior extent of TRUE pelvis, but not most inferior part of pelvic cavity Also defines the boundaries of the perineum Floor of pelvic cavity defined by pelvic diaphragm

Ureter relationship to seminal vesicles and ductus deferens

Ductus Deferens above ureter (posterolateral corner of bladder) Seminal vescicle in female, distal ureter runs below uterine artery, then forward alongside cervix to reach the bladder

Mullerian agenesis

Everything is normal except no uterus and upper vagina, no tubes. Have ovaries, normal hair distribution, and are 46XX

What muscles in deep perineal pouch do men and women share?

External urethral spincter (more complex in women) Deep transverse perineal muscle (smooth in women, skeletal in men)

Uterine Lymphatic drainage:

Fundus: follows ovarian/gonadals to para-aortic ln and some may follow round ligament to superficial inguinal Ln Body: follow uterine artery to internal iliac LN Cervix: internal iliac and sacral nodes

Typical female pelvis type: Typical male pelvis type:

GYNECOID Pelvis ANDROID Pelvis

Pelvic fractures - vertically unstable fracture

Hemipelvis is displaced superiorly by upward force

Blockage of tubes detected by this procedure:

Hysterosalpingogrpahy can detect tubal occlusion

2 distinct sets of blood vessels supply for pelvis and perineum

IMA Internal iliacs

Prostate lymph drainage

Internal iliac and sacral nodes

Obturator Nerve

L2-L4 medial compartment of thigh Damage to = weakness of ADDUCTOR muscles of thigh

Superior gluteal nerve

L4-S1 gluteus medius and minimus

Sciatic Nerve

L4-S3 posterior compartment of thigh, leg, foot Often sciatica with pregnancy

Inferior gluteal nerve

L5-S2 gluteus maximus

pelvic diaphragm forms the fibromuscular floor, made of sheet composed of:

Levator ani Coccygeus Superior and inferior layer of fascia investing the muscles

visceral pelvic fascia

Losse CT, around tubes and pelvic organs - bladder, rectum, uretus, prostate, vagina unconfining allows organs to distend (except for prostatic fascia in males)

broad ligament of uterus

Mesometrium = Biggest area Mesovarium Mesosalpinx Round, Ovarian, Cardinal ligaments all housed here

There is NO communiication between pelvic cavity above and perineum below

Muscle fibers of pelvic diaphragm are continuous with smooth-muscle coats of the pelvic effluents

What pierces the obturator membrane:

Obturator canal - obturator nerve and vessels, passing to thigh obturator membrane is surgical anchor for slings placed to relieve urinary incontinence

Lateral boundary of pelvic cavity

Obturator internus muscles, posterolateraly are the greater sciatic foramina and piriformis muscles

Ovarian innervation

Ovarian nerve plexus

Somatic pain from perineum during delivery:

PUDENDAL NERVE, S2 - S4

extraperitoneal fascia

Packing material, like fatty fascia around kidneys Fills space between peritoneum, parietal pelvic fascia on floors and walls, and visceral pelvic fascia around the organs.

Inferior boundary of pelvic cavity

Pelvic diaphragm - sling like muscle

Urethral and paraurethral glands homologue

Prostate gland

In anatomical position (anterior tilt of pelvis), these structures are in same vertical plane:

Pubic Crest and ASIS - pelvic inlet faces anteriorly - outlet faces posteriorly and inferiorly axis of true pelvis is curved, not straight shot for baby in birth Pubic bones and pubic symphysis are inferior to the plane of the pelvic inlet and thus bear the weight of the abdominopelvic organs

Pelvic diaphragm innervation

S3-S5 nerves on pelvic surface S2-S4 PUDENDAL nerves on perineal surface. double innervation allows contraction of specific portions of diaphragm

Fibrous extensions in testes

Septa testis, divide testis into compartments filled with seminiferous tubules

ALL PELVIC ORGANS ARE SUPPLIED WITH SYMPATHETIC AND PARASYMPATHETIC AUTONOMICS!

That's it, that's the card

Fascial Ligaments

Thickenings of the extraperitoneal pelvic fascia, forming sheaths around blood vessels and nerves that travel from the pelvic wall to the pelvic viscera = supports or roadways

Uterine blood supply

Uterine artery (in cardinal ligament), Distal ureter passes under Hysterectomy: Ureter injury happens often, when it is inadvertently clamped off/ligated can also happen with ligation of gonadl arteries

Anterior pouch between bladder and uterus formed by peritoneum

VESICO UTERINE POUCH

Where does the ureter pelvic portion begin?

When it crosses the pelvic brim, anterior to common iliac bifurcation

pelvic brim separates what:

abdominal and pelvic parts abdominopelvic cavity

rectal hiatus

anal canal (posterior opening)

Ovary borders

anterior: Mesovetrium posterior: free lateral: suspensory ligament Medially: ovarian ligament

True Pelvis

area inferior to the pelvic brim between the pubic bones anteriorly and the sacrum posteriorly, house pelvic cavity and contains pelvic viscera

Ureter blood supply:

branches of common and internal iliac arteries

sacrotuberous ligament

broad insertion from coccyx, sacrum, and posterior superior iliac spine, inserts on ischial tuberosity prevent posterior rotation or sacrum due to body weight, "bracing ligaments" for sacro-iliac joints

vesicouretral reflux (VUR)

common source of UTI too little musculature, intramural ureter being too short, valve not closing Urine reflux = renal infections and kidney damage

Suspensory ligament

contains ovarian artery and vein that descend from abdomen

Autonomic and visceral sensory nerves of perineum and pelvis

- Autonomic/Sensory to Visceral organs (inferior hypogastric aks Pelvic plexus)

Cardinal ligament

extends from the lateral surface of the cervix to the lateral fornix of vagina and houses, the uterine vasculature. CONTAINS UTERINE ARTERY -> WATER UNDER BRIDGE

Anterior Division - Middle rectal artery

- Course medially to reach the lower rectum where it anastomoses with inferior and superior rectal arteries

Anterior Division - Internal Pudendal artery

- Descends and leaves pelvis lateral to ISCHIAL SPINE - along with pudendal nerve - MAIN BLOOD SUPPLY FOR PERINEUM

Ovarian Lymphatic Drainage

follow ovarian arteries to Para-Aortic nodes

glans of clitoris homologue

glans penis

Openings formed by sacrotuberous and sacrospinous ligaments

greater and lesser sciatic foramina superior and inferior to ischial spine

Rectum lymph drainage

iliac and inferior mesenteric lymph nodes

ectopic pregnancy

implantation of the fertilized egg in any site other than the normal uterine location most in wall of uterine tube vaginal bleeding abdominal pain tubal rupture and blood loss!

seminal vesicles blood supply

inferior vesical and middle rectal arteries

What muscles in the superficial perineal pouch do men and women share?

ischiocavernosus bulbospongiosus superficial transverse perineal

pubococcygeus muscle

large part origin: anteriorly on the body of the pubis, borders of urogenital hiatus inserts: posteriorly on the anococcygeal ligament and coccyx

Levator ani

largest and most important portion of pelvic diaphragm broad origin, stretching from body of the pubis to the ischial spine. between these two bony attachments, its fascicles originate from an arched thickened band of pelvic fascia on the obturator internus: the TENDINOUS ARCH

Pelvic pain line

line is associated with the inferior limits of the peritoneum Above the line VA pain fibers return via sympathetic fibers to thoracolumbar sensory ganglia Below the line VA pain fibers return via parasympathetic fibers to sensory ganglia of S2-S4 All reflexive sensation return via parasympathetic fibers to the sensory ganglia of S2-S4

Anterior boundary of pelvic cavity

mainly open to the anterior abdominal wall except for the bodies of the pubic bones and pubic symphysis inferiorly

obturator foramen is covered by:

obturator membrane

Superior boundary of pelvic cavity

open to abdominal cavity

Obturator internus muscle

origin: Broad from pelvic surfaces of hip bone, arcuate line, and from internal surface of the obturator membrane posteriorly its fibers taper to tendon that makes a 90 degree turn as it leaves the pelvic cavity through the LSF, turning around the bony margin og the lesser sciatic notch, inerting on greater trochanter of femur

Piriformis muscle

origin: sacrum, course through greater sciatic foramen to femur's greater trochanter fills a lot of GSF, sacral plexus lies on it

ovarian blood supply

ovarian artery from abdominal aorta

Ovarian venous drainage

ovarian plexus of veins, ultimately feeding two ovarian veins

prostatic urethra

passes through the prostate gland Seminal colliculus = rounded mound, containing prostatic utricle (hole) ... homologue of vagina.... ejaculatory duct openings in here = 2 SMALL SLITS ON THE COLLICULUS, on either side of prostatic utricle Prostatic ducts (channels aka prostatic ducts) = numerous bulbourethral glands in DEEP PERINEAL POUCH, lateral to the external urethral sphincter around the INTERMEDIATE URETHRA

Pelvic diaphragm function

pelvic floor musculature contracts tonically to support pelvic organs, muscle tone increases when one bears down -> prevent accidental loss of gas, stool, or urine. when actively contracting... it flattens and LIFTS UPWARD. This helps the anterior abdominal muscles to RAISE ABDOMINAL PRESSURE When things need to LEAVE the pelvis (gas, stool, urine, fetus) ... the pelvic floor RELAXES, while the bladder, bowel, uterus contract.

body of clitoris homologue

penile shaft

seminal vesicles nerve supply

plexus of fibers from pelvic plexus SYMPATHETIC FIBERS SIGNAL MUSCLE TO EJACULATE

Coccygeus muscle

posterior to levator ani muscle. from ischial spine to coccyx and sacrum (follows sacrospinous ligament)

ovary function

produce ova, store eggs, estrogen and progesterone

Prostatic innervation

prostatic plexuses, offshoots of pelvic nerve plexus. During ejaculation SYMPATHETIC FIBERS signal the prostate's smooth musculature to CONTRACT and glands to secrete prostatic fluid via urethra.

Pelvic fractures - Rotationally unstable fracture

pubic symphysis is separated, anterior sacroiliac, sacrotuberous, sacrospinous ligaments are risrupted

Anterior and posterior sacroiliac ligaments

reinforce the SI joints limit movements between sacrum and ilium as weight of trunk forces the sacrum down like a wedge between the two hip bones

Anterior division - Vaginal artery

- often replaces the inferior vesicle artery in females

Vagina stuff

- smooth muscle - posterior to is the rectum and recto-uterine pouch - Passes through urogenital hiatus, opens in vestibule - Surrounded by PUBOVAGINALIS portionof Levator Ani - numerous transverse rugae - becomes smooth age as estrogen declines - Vaginal vault = expanded superior end

Wall of uterine tube

- smooth muscle contracts for peristalisis - Cilia beat to help egg toward uterus

Bladder innervation - visceral afferents

- stretch, fullness, burning/pain - urgency - Follow pelvic splanchnic nerves to CNS, parasympathetic pathways

Vaginal blood supply

- uterine, vaginal and internal pudendal arteries - Venous: uretovaginal plexus -> internal iliac veins

Pudendal nerve

-S2-S4 -somatic sensory and motor innervation of the perineum, pelvic floor, and external genitalia -innervates all but one muscle of the pelvic floor

Round ligament of uterus

-connects uterine fundus to labia majora - travels medially through round inguinal canal; above the artery of Sampson - Turns sharply laterally and takes on name of OVARIAN LIGAMENT - Provides stability for uterus, help maintain anteflexion

Bladder blood supply

-superior vesical art -inferior vesical art (males) -vaginal art (females)

Posterior boundary of pelvic cavity

sacrum and piriformis muscles

perineal raphe and pudendal cleft homologue

scrotal raphe

labia majora homologue

scrotum

Pelvic fractures - Both rotationally and vertically unstable

see desktop

Uterus orientation

see image Causes for retroversion: development, normal variation, previous pregnancies, adhesions, fibroids, endometriosis important for gynecological procedures

Pelvic inlet

somewhat oval and defined by pelvic brim. Important when fetus descends into true pelvis, "engagement of fetus"

Vestibule of vagina homologue

spongy urethra lumen

Scrotum lymph drainage

superficial inguinal nodes

False Pelvis

superior to pelvic brim - belongs to abdomen not pelvis, contains cecum, colon, loops of intestine.

Rectum blood supply

superior, middle, inferior rectal a,v

Uretosacral ligament

support for lower uterus

Fascial ligaments - Pubocervical ligament

supports the bladder neck and base

ureter

sympathetic = regulate vascular tone parasympathetic = contract/peristalsis

iliolumbar ligament

transverse process of L5 to iliac crest prevents rotation of L5 on the sacrum

urogenital hiatus

u shaped, urethral opening and vagina (anterior opening)

Vaginal Lymphatic Drainage

upper 3/4: internal and external iliac LN lower 1/4: superficial inguinal LN

Uterine venous drainage:

uretovaginal plexus to internal iliac veins

Fecal incontinence

vaginal delivery, anything that disrupts the puborectalis, anal sphincter muscles, or pudendal nerve can contribute

Venous drainage bladder

vesical venous plexus -> internal iliac veins

labia minora homologue

wall and penoscrotal raphe

4 columns in women: 2 crura/2 corpora cavernosa (2 vestibular glands)

3 columns in men: 2 crura/1 corpora cavernosa (1 corpus spongiosum)

prostate gland

30% of ejaculate odor enzymes to enhance sperm motility liquefy semen muscular contraction of prostate squeezes the prostatic fluid from it rests on levator ani -> reaches the external urethral sphincter inferiorly superior surface = base inferior surface = apex Peripheral zone = 70% cancers Transition zone = BPH

sacrospinous ligament

connects sacrum to ischial spine Deep to sacrotuberous ligament prevent posterior rotation or sacrum due to body weight, "bracing ligaments" for sacro-iliac joints

Fascial ligament - Lateral cervical/Cardinal ligament

contains the UTERINE ARTERIES and URETERS = HYSTERECTOMY RISK

layer of the uterus

endometrium (mucosa, uterine glands), myometrium, perimetrium (with parametrium of visceral pelvic fascia underlying) Endometrium zona basalis (basal layer) zona functionalis (functional layer)

Vagina innervation

fibers of uretovaginal plexus motor supply not well understood sensory upper 3/4: pelvic splanchnic nerves (Parasym) sensory lower 1/4: somatic, Pudendal nerves

iliococcygeus muscle

origin: tendinous arch and ischial spine inserts: anococcygeal ligament and coccyx

Vas Deferens

sympathetic = CONTRACTS during orgasm

bladder - internal sphincter

sympathetic = contracts Parasymptathetic = relaxes/inhibits

Erectile tissue of penis or clitoris

sympathetic = ejaculation parasympathetic = cavernous nerve from prostatic plexus stimulates erection, erection also involves sensory stimuli from pudendal nerve, as well as motor innervation of ischiocavernosus mm and bulbospongiosus

rectum

sympathetic = inhibits peristalsis Parasympathetic = contracts/modulates GI tract distal to left colic flexure

anal canal (internal sphincter)

sympathetic = maintain tone parasympathetic = inhibit tone during defecation

Bladder- detrusor

sympathetic = relaxes parasymp = CONTRACTS

vas deferens innervation

sympathetic fibers from pelvic plexus signal smooth muscle of its wall to contact and expel sperm during ejaculation

Puborectalis muscle

thick, narrow, medial and inferior portion of levator ani Origin: body of the pubis and passes posteriorly to loop around the JUNCTION OF THE RECTUM AND ANAL CANAL, forming a muscular sling around the anorectal junction. responsible for the posterior-coursing path of the anal canal as this canal angles away from the anterior-coursing rectum... ANORECTAL FLEXURE contraction = tightens the sling, constricting lumen regulates the size of feces passed, helps to resist feces when socially unacceptable. Volitional control helps fecal incontinence

Cancers of pelvic organs and lymphatic spread

- Commonly spread through successive sets of iliac nodes - Presenting complaint can be enlarged nodes - Subcutaneous inguinal nodes in women drain the vulva AND deeper vagina and potentially cervix!

Visceral Afferents

- Conscious sensations from pelvic organs and are POORLY localized and mainly percieved as pain - Travel with both Sympathetic and Parasympathetic pathways

Lymphatics of pelvis

- Follow course of major blood vessels. Follow branches of internal iliac vessels and filter lymph through the external, internal, and common iliac nodes. Sacral nodes drain directly to common iliac nodes.

Perineal lymphatics drain through:

- INGUINAL NODES before the ILIAC NODES

The hub or autonomic and visceral-afferent nerve supplies:

- Inferior hypogastric or pelvic plexus - meshwork, medial to internal iliac arteries

Anterior Division - Inferior gluteal artery

- Large, exits through the lower part of GSF - supplies gluteal region, anastomoses with SGA here

Postpartum hemmorrhage tactics

- Ligate both internal iliac arteries, reduce pressure head to uterus by 70% - Downstream organs are not affected bc of collaterals - Approach through anterior abdominal wall and then through peritoneum

Prostatic and Vesical plexuses

- Major route for metabolic spread of cancer is prostatic plexus to internal vertebral plexus

Pelvic lymphatics, collectively drain to:

- Para-aortic (retroperitoneal) nodes - Then drain to lumbar lymph trunks, then CHYLE CISTERN, and THORACIC DUCT

MICTURITION

- Parasympathetics signal Detrusor muscles to contract and signal urethral sphincter to relax. - contact abs, raises intraabdominal pressure, to squeeze bladder to descend while in pelvic diaphragm relaxes - Smooth musculature in urethra wall contracts, shortening the urethra and therefore widening the internal urethral orifice ===FLOW - Anxiety (peeing in public) SYMPATHETIC stimulation CONSTRICTS the internal urethral sphincter.

Parasympathetic fibers

- Preganglionic - S2-S4 - Run in Pelvin Splanchnic Nerves - Ganglia of synapse are intramural, in target organs

Anterior Division - Uterine artery

- Runs medially to cardinal ligament, where ureter runs under - UTERINE SURGERY CAN DAMAGE THE URETER HERE - Has vaginal branch, sometimes sole source of vaginal artery

Somatic nerves of the perineum and pelvis

- Somatic to MSK and skin structures (sacral plexus)

Venous plexuses

- Vesical around lower bladder, communicates with prostatic plexus in males and vaginal and uterine plexuses in females - All drain to internal iliac vein, which then goes on to communicated with internal vertebral venous plexus - NO VALVES IN THESE ROUTES!

Posterior division - iliolumbar artery

- ascends out of the pelvis on lateral part of sacrum, to help supply iliacus and psoas muscles in iliac fossa, plus quadratum lumborum

Internal iliac and vein

- common iliac runs along pelvic brim, divides into internal and external iliac arteries, this fork is on SI joint. - Ureter descends directly anterior to it - Internal iliac descends along LATERAL Pelvic wall = Anterior and Posterior divisions

What forms the pelvic brim?

- crests of pubic bones - pectineal lines - arcuate lines of iliam - sacral promontory - anterior border of sacral ala *arcuate line turns into pectinate line anteriorly

Posterior division - Superior Gluteal artery

- descends and exits the pelvis through GSF, to supply gluteal region. Exits superior to piriformis (inferior gluteal exits inferior to pirifrormis)

Posterior division - Lateral sacral artery

- descends anterior to anterior sacral foramina, sends branches in

Anterior Division - Umbilical artery

- first branch - runs forward to abdominal wall, distal portion is obliterated umbilical artery/fibrous cord

Anterior Division - Obturator artery

- follows obturator nerve through the obturator canal at the top of the obturator foramen. Supplies medial thigh muscles.

PCOS

- leads to disrupted menstrual cycles, fertility problems, and sex hormone imbalances

Anterior Division - Superior vesical arteries

- on top of bladder, a bunch of em - Run down from umbilical artery

Ovarian cancer

- originate in uterine tube, or ovary - spread throughout peritoneal cavity creating hundreds of tumor implants on abdominal and pelvic visceral organs

Sympathetic fibers

- postganglionic - reach the inferior hypogastric plexus by descending in the hypogastric nerves that flow over the common iliac arteries - Fibers from the sacral splanchnic nerves join the inferior hupogastric plexus from the sacral sympathetic trunk

IMA

- serves distal GI - Sigmoid branches = serve the pelvic and abdominal parts of sigmoidal colon - Superior rectal artery supplies the upper rectum - Belong to hepatic portal system, along with portocaval anastomoses and hemorrhoidal veins

Rectovaginal septum

- strong fascia between vagina and rectum - endometriosis and cancer create Nodularity - Palpate with SHOCKER

Anterior Division - Inferior Vesical Artery

- to fundus of bladder - Gives PROSTATIC branches in males - Also in males gives: artery to ductus deferens branch - occurs in almost all males, but half of females

Gonad lymphatics

- travel along the gonadal blood supply to lumbar para-aortics, without interacting with any pelvic nodes - RPLND -> retroperitoneal lymph node dissection surgical maneuver that removes these nodes for study

male pelvis characteristics

-Heavy -Narrow, tapering -Deep -Inlet round -Outlet Narrow, <70 degrees -Acute angle of pubic arch - Larger acetabulum

female pelvis characteristics

-Lighter -Wider -More shallow -Oval shaped inlet -Wide outlet -Wider sacrum with steeper curve -Flattened sacral promontory -Obtuse angle of pubic arch, >80 degrees, ischial tuberosities farther apart - smaller acetabulum

pelvic floor stability

1) bony and ligamentous girdle - transfers body weight from vertebral columns to lower limbs 2) pelvic floor - closes off abdominopelvic cavity from perineum below

vas deferens blood supply

Artery to vas deferens, derived from inferior vesical artery

Greater vestibular glands homologue

Bulbourethral glands

Visceral afferents to uterus and vagina important cuz:

CONDUCT PAIN DURING LABOR AND DELIVERY

Women with endometriosis, trauma, bladder infections, etc = chronic pelvic pain

Often develop tender, hypertrophic, spastic levator ani muscles, which can exacerbate their pelvic pain even after the initiating cause has been treated/removed. Spastic muscles treated with physical therapy, injections of marcaine/kenalog, botox

Three parts of the pelvic fascia

Parietal pelvic fascia Visceral pelvic fascia Extraperitoneal fascia Peritoneum

parietal pelvic fascia

Part of the general fascia that lines the inner/deep aspect of the abdominal and pelvic walls. Covers the pelvic surfaces of the OBTURATOR INTERNUS and PIRIFORMIS muscles, forms envelope around the pelvic diaphragm **TENDINOUS ARCH** of LEVATOR ANI is thickened part of it

Prostate venous drainage

Prostatic venous plexus -> internal iliac veins -> internal vertebral venous plexus = PROSTATE CANCER

Posterior pouch between uterus and rectum by peritoneum

RECTO UTERINE POUCH of Douglas - lowest point of peritoneal cavity - ascites fluid, blood, pus can build up when female stands - sampled though CULDOCENTESIS, needle aspiration through posterosuperior vaginal wall at posterior fornix

Types iof hysterectomy:

Radical -> it all gone Partial -> uterus body to the internal os, tubes remain Total -> Uterus body with all of cervix, tubes remain

Bladder innervation- parasympathetic

S2-S4, Pelvic splanchnic nerves. Key to micturition = detrusor contraction. *stretch, motor

Insertions of the fascicles of the LEVATOR ANI:

Slope posteriorly and down to midline: 1) perineal body 2) Walls of pelvic effluents (urethra, vagina, anal canal) 3) Anococcygeal ligament 4) coccyx

Urinary incontinence

Stress incontinence results from weakening of of the muscles of fascia ligaments Giving birth can yield the following: - Levator ani tear - Overstretching fascial supports - pudendal-nerve damage Evaluating a patient for stress incontinence = TESTING THE STRETCH OF PELVIC DIAPHRAGM MUSCLES Mid-urethral sling can be implanted to fix stress incontinence Sling sits nelow the urethra in a tension-free fashion and replaces the backboard by closing the urethra when there is an increase in abdominal pressure Kegel Exerceises -> strengthen pelvic diaphragm, avoid organ prolapse and incontience (urinary and fecal) Sacral neuromodulation -> target is S3, to treath urgency in urinary incontinence.

Urinary bladder positioning

Subperitoneal, almost entirely in pelvic cavity BUT ... when distended... can rise high in abdomen as high as umbilicus, shape change to round balloon superior surface opposes peritoneal cavity Apex ---> urachus -> median umbilical ligament on anterior abdominal wall Neck -> inferior point, urethra

Bladder lymph drainage

Superior: common and external iliac LN Inferior: internal iliac LN

Fascial Ligament - Uterosacral Ligament

Supports the cervix and vagina

Rectum innervation

Sympathetic: lumbar splanchnic nerves to inferior mesenteric and pelvic plexuses Parasympathetic: pelvic splanchnic nerves the pelvic plexus Sensory: follows parasympathetics

uterine innervation

Sympathetics probably vasomotor Afferents from uterus run alongside efferents in lumbar splanchnic nerves. Cell bodies in lower thoracic and upper lumbar dorsal root ganglia = referral of labor pain to low back

Uterine Fundus and Body

T10-L2 S2 - S4 for subperitoneal parts

Bladder innervation- sympathetic

T11-L2, least and lumbar splanchnic nerves via inferior hypogastric and vesical plexus of nerves Facilitate continence and bladder filling by RELAXING the detrusor muscle *pain, touch, temp

Bladder perforation

Usually trauma or iatrogenic if subperitoneal, manage conservatively If at the dome = intraperitoneal, urgent surgical closure.