--

Pelvis

Lateral Pelvic Walls bull have a bony framework formed by the hip

bones including the obturator foramen bull obturatorforamen is closed by the obturator

membrane bull walls are covered by obturator internus

nun

bull each obturator muscle exits lesser sciatic foramen turns sharply laterally to attach to femur

bull obturator nerves amp vessels run medial to the obturator internus muscles

Ligaments or folds amp pouches of the pelvis ~ - broad ligament of tile uterus

o consists of 2 layers qip-eritolzeum

-Pelvic Diaphgram bull forms pelvic floor amp supports all of the pelvic viscera bull formed by

o levator ani o coccygeus o + their fascial coverings

~ contraction = raises entire pelvic floor bull CLINICAL CORRELATION

~ Injury to Pelvic Floor ~ during childbirth pelvic floor supports the fetal

head while the cervix of the uterus is dilating ~ the perineum levator ani (LA) amp pelvic fascia

may be injured ~ ~he main muscle that is often tom is theV- pubococcyjettS (main amp most medial part of LA) yr ~ it encircles amp supports urethra vagma amp anal

canal ~ dam~eJJlay c~ stress inC(Joti1lpoundnce

-ibbling of u~ __

D __

o extends from the lateral margin of the uterus to lateral pelvic wall o function hold uterus in position o contains

bull uterine tube bull uterine vessels bull round ligament of uterus bull ovarian ligament bull ureter Oower part) bull uterovaginal nerve plexus bull lymphatic vessels

o does~tDvary but gives attaclunent to it o has a p~terior part that curves from the isthmus of the uterus (the rectouterine fold) to the posterior

wall of the pelvis alongside the rectum

bull Sj2 - iound ligament of uterus

bull mesy~oa~_

bull fold of peritoneum that connects the anterior surface of the ova with the posterior laver of broad ligament

bull mesosal inx-shy-- bull fold of the broad ligament that suspends the uterine tube

bull mesometrium bull major part of the b~ lgmeo t below

-- shy m~~lpinx amp me -QYarium~

o attached to uterus in front of amp below the attachment of the uterine tube amp represents the remains of the lower part of the gubernaculum

o runs within the layers of the broad ligament o contains

bull smooth muscle fibers bull holds the fundus of the uterus fOlward (keeping the uterus anteyeted amp anteflexedL

o enters inguinal canal at the dew inguinal ring shyo emerges from superficial inguinal ring and dissipates into the subcutaneous tissue of the labia majora

bull Sj2 - ligament of the ovary (ovarian ligament) o jibrom1(sr1ar cord that extends from ovary to the uterus below the uterine tube o rullS within layers of broad ligament

bull Sj2ruspensory ligament of the ovary o band ifperitoneum that extends upward from ovary to pelvic wall o contains

bull ovarian artery + vein bull ovarian nerve bull lymphatics

bull Sj2 - lateral or transverse cervical (cardinal or Mackenrodts) ligaments of the uterus 2SJ~ 0 jibromuscular condensations of pelvic fascia from the cervix amp vagina to the pelvic walls P 0 extends laterally below the base of the broad ligament amp support the uterus

o transmits uterine artery + nerve + uterovaginal nerve plexus bull ~pubocervicalligaments

o firm bands of CT that extend from the posterior surface of the pubis to the cervix of the uterus bull Sj2 - pubovesicalligament

- 0 condensations of the pelvic fascia that extend from the neck of the bladder to the pelvic bone bull O-c puboprostatic ligament

o condensations of the pelvic fascia that extend from the neck of the prostate to the pelvic bone

bull pound--sacrocervialligaments o firm fibromuscular bands of pelvic fascia that extend from the lower end of the sacrum to the cervix amp

upper end of vagina bull Sj2 c3 - inferior pubic (arcuate pubic) ligament

o arches across the inferior aspect of the pubic symphysis amp attaches to the medial borders of the inferior pubic rami

bull Sj2 - rectouterine ligaments ---- 0 hold the Ce17Jix back amp upward

o corresponds to the sacrogenital (rectoprostatic) fold in 0

bull ~ - rectouterine pouch (aka cul-de-sac of Douglas) o sac or recess formed by a fold of the peritoneum dipping down between the rectum amp uterus o lies behind the posterior forni-x of the vagina

bull 0 - rectovisical pouch o peritoneal recess between the bladder amp rectum

bull ~ - vesicouterine pouch o peritoneal recess between the bladder and uterus

B Right lateral view of male C Right laterlll view of female

Important numbers Important numbers )gt6 rectovesical pouch ~ vesicouterine pouch -P 6 rectouterine pouch -V middot CLINICAL CORRELATION

~ Culdocentesis bull aspiration of fluid from rectouterine pouch by a needle puncture of the posterior vaginal

fornixnear middle between the uterosacral ligaments bull done when a ruptured ectopic pregnancy or ovarian cyst is suspected

Pelvic Viscera

Ureter amp Urinary Bladder

Ureters bull muscular tube that transmits urine by peristaltic waves bull 3-ltonstrictions along its course

o at origin where the pelvis of the ureter joins the tIXe1tr peJVs middot o when it crosses pelv-ic brim o junction with bladder

bull course o crosses the pelvic brim in front of the bifurcation of the common iliac artery o descends retroperitoneally on the lateral pelvic wall o runs medial to the umbilical artery amp obturator vessels amp posterior to OY2ty

o forms the posterior boundary of the ovarian fossa bull ~ - accompanied by uterine artery (runs above amp anterior to it in the base of the broad ligament

because of this the ureter is in danger of being injured inthe process of hxsterectomy

~ o mnemoruc water (ureter) p uc uvdcr (be brl(lgeJtentlC4l~

bull 2 bull() shyo passes posterior amp inferior to ductuS-deferens o lies in front of the seminal vesicle before entering the posterolateral aspect of bladder

bull blood supply - from aorta renal gonadal common amp internal iliac umbilical superior amp inferior vesical amp middle rectal aa

bull nerve supply o derive from adjacent autonomic plexuses (renal aortic superior amp inferior hypogastic)

0

o ureters are superior to pelvic pain line o afferent (pain) fibers from the ureters follow sympathetic fibers retrogradely to reach spinal ganglia

amp spinal cord segments Tll - LlL2

From ] 8mllY

D Anterior view

Blood Supply Nerve Supply Urinary Bladder

bull situated below the peritoneum amp is slightly lower in the $ than in the 0

bull extends upward above the pelvic brim as it fills

l(lOUI

A U I ~

bull has a uvula which is a small eminence at the ap ex of its trigone projecting into orifice of urethra

bull trigone is bounded by 2 orifices of the ureters amp internal urethral orifice around which is a thick circular layer called the internal sphincter (sphincter vesicae)

bull has bundles of smooth muscle fibers that as a whole are known as the detrusor muscle of the bladder bull blood supply

-~I-~~K( ---7lI~4li-

~shyv_i8l

oArterial Supply $ Aterial Supply o arterial supply

Y -0 - superior amp inferior vesical arteries (from internal iliac) fmiddot$ _vaginal artery (from internal iliac)

o venous supply ~ 0 -prostatic plexus of veins (drain to internal iliac veins) bull $ - vesical plexus of veins (drain to internal iliac veins)

2

B Veins Female

oVenous Drainage ~ Venous Drainage

o nerve supply

bull

~ loampshybull parasympathetic nerve ~lvic splanchnic

nerves oriwatin~ frpm S2-S4)we

bull contract detrusor muscles of bladder wall bull relaxes the internal urethral sphincter bull promotes emptying

bull sympathetic nerve ~ - bull relaxes detrusor muscles of bladder wall

bull constricts internal urethral sphincter

CLINICiL CORRELATION gt Suprapubic cystomy

bull as bladder fills it extends superiorly into abdomen bull the bladder then lies adjacent to this wall without interoention ofthe peritoneum bull consequently the distended bladder may be punctured or approached surgicallyfor the

introduction of indwelling catheters or instruments without traversing the peritoneum gt Rupture of bladder

bull ~ erior rupture of bladder frequently tears the peritoneu resulting in passage (extravasation) of urine into the peritoneal cavity

bull osterior rupture of bladder usually results in passage of urine subperitoneally into the penneum

~ Cystoscopy bull interior of the bladder and 3 orifices can be examined by inserting a cystoscope through the

urethra into the bladder gt Bladder cancer

bull most common symptom blood in urine

bull note in ~ enlargement of the bladder can be palpated during a digital exam through the anterior fornix of the cervL=shy

Relations of the urinary bladder

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

bull Sj2 - iound ligament of uterus

bull mesy~oa~_

bull fold of peritoneum that connects the anterior surface of the ova with the posterior laver of broad ligament

bull mesosal inx-shy-- bull fold of the broad ligament that suspends the uterine tube

bull mesometrium bull major part of the b~ lgmeo t below

-- shy m~~lpinx amp me -QYarium~

o attached to uterus in front of amp below the attachment of the uterine tube amp represents the remains of the lower part of the gubernaculum

o runs within the layers of the broad ligament o contains

bull smooth muscle fibers bull holds the fundus of the uterus fOlward (keeping the uterus anteyeted amp anteflexedL

o enters inguinal canal at the dew inguinal ring shyo emerges from superficial inguinal ring and dissipates into the subcutaneous tissue of the labia majora

bull Sj2 - ligament of the ovary (ovarian ligament) o jibrom1(sr1ar cord that extends from ovary to the uterus below the uterine tube o rullS within layers of broad ligament

bull Sj2ruspensory ligament of the ovary o band ifperitoneum that extends upward from ovary to pelvic wall o contains

bull ovarian artery + vein bull ovarian nerve bull lymphatics

bull Sj2 - lateral or transverse cervical (cardinal or Mackenrodts) ligaments of the uterus 2SJ~ 0 jibromuscular condensations of pelvic fascia from the cervix amp vagina to the pelvic walls P 0 extends laterally below the base of the broad ligament amp support the uterus

o transmits uterine artery + nerve + uterovaginal nerve plexus bull ~pubocervicalligaments

o firm bands of CT that extend from the posterior surface of the pubis to the cervix of the uterus bull Sj2 - pubovesicalligament

- 0 condensations of the pelvic fascia that extend from the neck of the bladder to the pelvic bone bull O-c puboprostatic ligament

o condensations of the pelvic fascia that extend from the neck of the prostate to the pelvic bone

bull pound--sacrocervialligaments o firm fibromuscular bands of pelvic fascia that extend from the lower end of the sacrum to the cervix amp

upper end of vagina bull Sj2 c3 - inferior pubic (arcuate pubic) ligament

o arches across the inferior aspect of the pubic symphysis amp attaches to the medial borders of the inferior pubic rami

bull Sj2 - rectouterine ligaments ---- 0 hold the Ce17Jix back amp upward

o corresponds to the sacrogenital (rectoprostatic) fold in 0

bull ~ - rectouterine pouch (aka cul-de-sac of Douglas) o sac or recess formed by a fold of the peritoneum dipping down between the rectum amp uterus o lies behind the posterior forni-x of the vagina

bull 0 - rectovisical pouch o peritoneal recess between the bladder amp rectum

bull ~ - vesicouterine pouch o peritoneal recess between the bladder and uterus

B Right lateral view of male C Right laterlll view of female

Important numbers Important numbers )gt6 rectovesical pouch ~ vesicouterine pouch -P 6 rectouterine pouch -V middot CLINICAL CORRELATION

~ Culdocentesis bull aspiration of fluid from rectouterine pouch by a needle puncture of the posterior vaginal

fornixnear middle between the uterosacral ligaments bull done when a ruptured ectopic pregnancy or ovarian cyst is suspected

Pelvic Viscera

Ureter amp Urinary Bladder

Ureters bull muscular tube that transmits urine by peristaltic waves bull 3-ltonstrictions along its course

o at origin where the pelvis of the ureter joins the tIXe1tr peJVs middot o when it crosses pelv-ic brim o junction with bladder

bull course o crosses the pelvic brim in front of the bifurcation of the common iliac artery o descends retroperitoneally on the lateral pelvic wall o runs medial to the umbilical artery amp obturator vessels amp posterior to OY2ty

o forms the posterior boundary of the ovarian fossa bull ~ - accompanied by uterine artery (runs above amp anterior to it in the base of the broad ligament

because of this the ureter is in danger of being injured inthe process of hxsterectomy

~ o mnemoruc water (ureter) p uc uvdcr (be brl(lgeJtentlC4l~

bull 2 bull() shyo passes posterior amp inferior to ductuS-deferens o lies in front of the seminal vesicle before entering the posterolateral aspect of bladder

bull blood supply - from aorta renal gonadal common amp internal iliac umbilical superior amp inferior vesical amp middle rectal aa

bull nerve supply o derive from adjacent autonomic plexuses (renal aortic superior amp inferior hypogastic)

0

o ureters are superior to pelvic pain line o afferent (pain) fibers from the ureters follow sympathetic fibers retrogradely to reach spinal ganglia

amp spinal cord segments Tll - LlL2

From ] 8mllY

D Anterior view

Blood Supply Nerve Supply Urinary Bladder

bull situated below the peritoneum amp is slightly lower in the $ than in the 0

bull extends upward above the pelvic brim as it fills

l(lOUI

A U I ~

bull has a uvula which is a small eminence at the ap ex of its trigone projecting into orifice of urethra

bull trigone is bounded by 2 orifices of the ureters amp internal urethral orifice around which is a thick circular layer called the internal sphincter (sphincter vesicae)

bull has bundles of smooth muscle fibers that as a whole are known as the detrusor muscle of the bladder bull blood supply

-~I-~~K( ---7lI~4li-

~shyv_i8l

oArterial Supply $ Aterial Supply o arterial supply

Y -0 - superior amp inferior vesical arteries (from internal iliac) fmiddot$ _vaginal artery (from internal iliac)

o venous supply ~ 0 -prostatic plexus of veins (drain to internal iliac veins) bull $ - vesical plexus of veins (drain to internal iliac veins)

2

B Veins Female

oVenous Drainage ~ Venous Drainage

o nerve supply

bull

~ loampshybull parasympathetic nerve ~lvic splanchnic

nerves oriwatin~ frpm S2-S4)we

bull contract detrusor muscles of bladder wall bull relaxes the internal urethral sphincter bull promotes emptying

bull sympathetic nerve ~ - bull relaxes detrusor muscles of bladder wall

bull constricts internal urethral sphincter

CLINICiL CORRELATION gt Suprapubic cystomy

bull as bladder fills it extends superiorly into abdomen bull the bladder then lies adjacent to this wall without interoention ofthe peritoneum bull consequently the distended bladder may be punctured or approached surgicallyfor the

introduction of indwelling catheters or instruments without traversing the peritoneum gt Rupture of bladder

bull ~ erior rupture of bladder frequently tears the peritoneu resulting in passage (extravasation) of urine into the peritoneal cavity

bull osterior rupture of bladder usually results in passage of urine subperitoneally into the penneum

~ Cystoscopy bull interior of the bladder and 3 orifices can be examined by inserting a cystoscope through the

urethra into the bladder gt Bladder cancer

bull most common symptom blood in urine

bull note in ~ enlargement of the bladder can be palpated during a digital exam through the anterior fornix of the cervL=shy

Relations of the urinary bladder

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

bull ~ - rectouterine pouch (aka cul-de-sac of Douglas) o sac or recess formed by a fold of the peritoneum dipping down between the rectum amp uterus o lies behind the posterior forni-x of the vagina

bull 0 - rectovisical pouch o peritoneal recess between the bladder amp rectum

bull ~ - vesicouterine pouch o peritoneal recess between the bladder and uterus

B Right lateral view of male C Right laterlll view of female

Important numbers Important numbers )gt6 rectovesical pouch ~ vesicouterine pouch -P 6 rectouterine pouch -V middot CLINICAL CORRELATION

~ Culdocentesis bull aspiration of fluid from rectouterine pouch by a needle puncture of the posterior vaginal

fornixnear middle between the uterosacral ligaments bull done when a ruptured ectopic pregnancy or ovarian cyst is suspected

Pelvic Viscera

Ureter amp Urinary Bladder

Ureters bull muscular tube that transmits urine by peristaltic waves bull 3-ltonstrictions along its course

o at origin where the pelvis of the ureter joins the tIXe1tr peJVs middot o when it crosses pelv-ic brim o junction with bladder

bull course o crosses the pelvic brim in front of the bifurcation of the common iliac artery o descends retroperitoneally on the lateral pelvic wall o runs medial to the umbilical artery amp obturator vessels amp posterior to OY2ty

o forms the posterior boundary of the ovarian fossa bull ~ - accompanied by uterine artery (runs above amp anterior to it in the base of the broad ligament

because of this the ureter is in danger of being injured inthe process of hxsterectomy

~ o mnemoruc water (ureter) p uc uvdcr (be brl(lgeJtentlC4l~

bull 2 bull() shyo passes posterior amp inferior to ductuS-deferens o lies in front of the seminal vesicle before entering the posterolateral aspect of bladder

bull blood supply - from aorta renal gonadal common amp internal iliac umbilical superior amp inferior vesical amp middle rectal aa

bull nerve supply o derive from adjacent autonomic plexuses (renal aortic superior amp inferior hypogastic)

0

o ureters are superior to pelvic pain line o afferent (pain) fibers from the ureters follow sympathetic fibers retrogradely to reach spinal ganglia

amp spinal cord segments Tll - LlL2

From ] 8mllY

D Anterior view

Blood Supply Nerve Supply Urinary Bladder

bull situated below the peritoneum amp is slightly lower in the $ than in the 0

bull extends upward above the pelvic brim as it fills

l(lOUI

A U I ~

bull has a uvula which is a small eminence at the ap ex of its trigone projecting into orifice of urethra

bull trigone is bounded by 2 orifices of the ureters amp internal urethral orifice around which is a thick circular layer called the internal sphincter (sphincter vesicae)

bull has bundles of smooth muscle fibers that as a whole are known as the detrusor muscle of the bladder bull blood supply

-~I-~~K( ---7lI~4li-

~shyv_i8l

oArterial Supply $ Aterial Supply o arterial supply

Y -0 - superior amp inferior vesical arteries (from internal iliac) fmiddot$ _vaginal artery (from internal iliac)

o venous supply ~ 0 -prostatic plexus of veins (drain to internal iliac veins) bull $ - vesical plexus of veins (drain to internal iliac veins)

2

B Veins Female

oVenous Drainage ~ Venous Drainage

o nerve supply

bull

~ loampshybull parasympathetic nerve ~lvic splanchnic

nerves oriwatin~ frpm S2-S4)we

bull contract detrusor muscles of bladder wall bull relaxes the internal urethral sphincter bull promotes emptying

bull sympathetic nerve ~ - bull relaxes detrusor muscles of bladder wall

bull constricts internal urethral sphincter

CLINICiL CORRELATION gt Suprapubic cystomy

bull as bladder fills it extends superiorly into abdomen bull the bladder then lies adjacent to this wall without interoention ofthe peritoneum bull consequently the distended bladder may be punctured or approached surgicallyfor the

introduction of indwelling catheters or instruments without traversing the peritoneum gt Rupture of bladder

bull ~ erior rupture of bladder frequently tears the peritoneu resulting in passage (extravasation) of urine into the peritoneal cavity

bull osterior rupture of bladder usually results in passage of urine subperitoneally into the penneum

~ Cystoscopy bull interior of the bladder and 3 orifices can be examined by inserting a cystoscope through the

urethra into the bladder gt Bladder cancer

bull most common symptom blood in urine

bull note in ~ enlargement of the bladder can be palpated during a digital exam through the anterior fornix of the cervL=shy

Relations of the urinary bladder

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

o ureters are superior to pelvic pain line o afferent (pain) fibers from the ureters follow sympathetic fibers retrogradely to reach spinal ganglia

amp spinal cord segments Tll - LlL2

From ] 8mllY

D Anterior view

Blood Supply Nerve Supply Urinary Bladder

bull situated below the peritoneum amp is slightly lower in the $ than in the 0

bull extends upward above the pelvic brim as it fills

l(lOUI

A U I ~

bull has a uvula which is a small eminence at the ap ex of its trigone projecting into orifice of urethra

bull trigone is bounded by 2 orifices of the ureters amp internal urethral orifice around which is a thick circular layer called the internal sphincter (sphincter vesicae)

bull has bundles of smooth muscle fibers that as a whole are known as the detrusor muscle of the bladder bull blood supply

-~I-~~K( ---7lI~4li-

~shyv_i8l

oArterial Supply $ Aterial Supply o arterial supply

Y -0 - superior amp inferior vesical arteries (from internal iliac) fmiddot$ _vaginal artery (from internal iliac)

o venous supply ~ 0 -prostatic plexus of veins (drain to internal iliac veins) bull $ - vesical plexus of veins (drain to internal iliac veins)

2

B Veins Female

oVenous Drainage ~ Venous Drainage

o nerve supply

bull

~ loampshybull parasympathetic nerve ~lvic splanchnic

nerves oriwatin~ frpm S2-S4)we

bull contract detrusor muscles of bladder wall bull relaxes the internal urethral sphincter bull promotes emptying

bull sympathetic nerve ~ - bull relaxes detrusor muscles of bladder wall

bull constricts internal urethral sphincter

CLINICiL CORRELATION gt Suprapubic cystomy

bull as bladder fills it extends superiorly into abdomen bull the bladder then lies adjacent to this wall without interoention ofthe peritoneum bull consequently the distended bladder may be punctured or approached surgicallyfor the

introduction of indwelling catheters or instruments without traversing the peritoneum gt Rupture of bladder

bull ~ erior rupture of bladder frequently tears the peritoneu resulting in passage (extravasation) of urine into the peritoneal cavity

bull osterior rupture of bladder usually results in passage of urine subperitoneally into the penneum

~ Cystoscopy bull interior of the bladder and 3 orifices can be examined by inserting a cystoscope through the

urethra into the bladder gt Bladder cancer

bull most common symptom blood in urine

bull note in ~ enlargement of the bladder can be palpated during a digital exam through the anterior fornix of the cervL=shy

Relations of the urinary bladder

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

2

B Veins Female

oVenous Drainage ~ Venous Drainage

o nerve supply

bull

~ loampshybull parasympathetic nerve ~lvic splanchnic

nerves oriwatin~ frpm S2-S4)we

bull contract detrusor muscles of bladder wall bull relaxes the internal urethral sphincter bull promotes emptying

bull sympathetic nerve ~ - bull relaxes detrusor muscles of bladder wall

bull constricts internal urethral sphincter

CLINICiL CORRELATION gt Suprapubic cystomy

bull as bladder fills it extends superiorly into abdomen bull the bladder then lies adjacent to this wall without interoention ofthe peritoneum bull consequently the distended bladder may be punctured or approached surgicallyfor the

introduction of indwelling catheters or instruments without traversing the peritoneum gt Rupture of bladder

bull ~ erior rupture of bladder frequently tears the peritoneu resulting in passage (extravasation) of urine into the peritoneal cavity

bull osterior rupture of bladder usually results in passage of urine subperitoneally into the penneum

~ Cystoscopy bull interior of the bladder and 3 orifices can be examined by inserting a cystoscope through the

urethra into the bladder gt Bladder cancer

bull most common symptom blood in urine

bull note in ~ enlargement of the bladder can be palpated during a digital exam through the anterior fornix of the cervL=shy

Relations of the urinary bladder

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

- --+--a Colis of Inleslne _ -t- Coils of intesline

bull superior surface coils of intestine bull apex pubic symphysis bull anterior surface coils of intestine bull fundus rectum bull neck prostate bull inferolateral fascia covering of levator ani

Micturition (urination)

bull superior surface uterus bull apex pubic symphysis bull anterior surface coils of intestine bull fundus anterior wall of vagina bull inferolateral fascia covering of levator ani

bull initiated by stimulating stretch rece tors in detru de in bladder wall by the t volume bull involves the following processes

o ~mpathetic - r bull efferent fibers relax bladder amp constrict internal sphincter = inhibits emptying

V)t middot afferent fibers stretch receptors in bladder wall to S2-S4 throug e V IC s anchnic

paramsympathetic pee s ~ bull preganglionic fibers in pelvic splanchnic nerves synapse at inferior hypogastric plexus

bull postganglionic fibers ladder musculature contract detrusor muscles and relax internal sphincter enhance micturition

o general somatic e f~te pu en al nerve causes voluntary relaxation of external urethral sphincter o at the end of micturition the external urethral hincter contracts and bulbospongiosus nun in the 0

to~Cpel the last few drops of urine from theJJjethra

oInternal Genital Organs

Testis bull develops retroperitoneally amp descends into scrotum retroperitoneally bull covered by tunica albu inea bull produces spermatozoa amp secretes sex hQrmones bull vasculature

o testicular artery (come directly off of aorta) o pampiniform plexus of veins drains testis o lymphatic drainage to lumbar aortic nodes o remember scrotal lymph drains to supeificial inguinal lYmph nodes

Epididymis shybull consists of a head body amp tail and contains convoluted duel (about 6m long) bull function maturation amp storage of spermatozoa in the head amp body amp propulsion of the spermatozoa into the

ductus deferens Ductus Deferens

bull thick-walled tube that enters the pelvis at the deep inguinal ring at the lateral sides of the epigastric artery bull course

o crosses medial side of the umbilical artery amp obturator nerve amp vessels

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

o passes superior to the ureter near the wall of the bladder o dilated to become the ampulla of the ductus deferens at its terminal part o ends by joining the duct of t11e sellllnal gfaiid to form the ejaculatory duct shy

bull contains fructose (food for the sperm) bull vasculature

o tiny artery to the ductus deferens usually arises from a superior (sometimes inferior) vesical artery o lymphatic drainage of ductus deferens is to external iliac lrmph nodes

bull INN sympathetic nerves of the hypogastric plexus amp parasympathetic nerves of pelvic plexus Ejaculatory Ducts

bull arises by umon of ductus deferens and duct of seminal gland bull arise near the neck of the bladder and pass antero-inferiorly bull through posterior part of the prostate bull ducts open on either side of prostatic utricle bull vasculature

o arteries to the ductus deferentes o veins join prostatic and vesical venous plexuses o lymph drainage to eternal iliac lymph nodes

Seminal Vesicles bull enclosed by a dense endopelvic fascia amp are

lobulated glandular structures bull lie inferior amp lateral to the ampullae of the

ductus deferens against the fundus (base) of the bladder

bull produce the alkaline constituent of the seminal fluid

bull vasculature o arteries derived from inferior vesical amp

middle rectal o veins inferior vesical vein amp middle rectal vein o lymph superior part-external iliac nodes

inferior part-internal iliacJ1fVieJ Prostate Gland

bull located at the base of the urinary bladder amp 2 3 is made up of glandular tissue and 13 is fibromuscular

bull has 5 lobes o anterior lobe (isthmus) lies in front of

the urethra amp has no glandular tissue B PosIrlorvow ~

o middle (median) lobe lies between urethra amp Y ejaculatory ducts amp IS prone to benign hypertroph obstructing the internal urethral orifice

o inferiorposterior lobe lies behind the urethra amp inferior to the ejaculatory ducts contains glandular tissue amp is prone to carcinomatous tramormation It is easily papable by digital rectal examination

o right amp left lateral lobes situated on either side of urethra amp form the main mass of the gland

bull secretes prostate-specific antigen (PSA) prostaglandins citric acid amp acid phosphatase amp proteolytic enzymes

bull relationships of the prostate gland

o base (superior aspect) is closely related to the neck of the bladder o apex (inferior aspect) is in contact with fascia on the superior aspect of the urethral sphincter amp deep

perineal muscles o anterior surface or isthmus is in contact with the retropubic space o posterior surface is related to the ampulla of the rectum o inferolateral surfaces are related to the levator ani

bull vasculature o arteries branches of the internal iliac cutel (inferior vesical aa internalp7tdendal amp middle rectal aa) o veins join to form the prostatic venous plexus ~ internal vertebral ven07tS plex7ts o lymphatics internal iliac nOdes amp sacral lymph Ilodes

bull CLINICAL CORRELKrION

Jfo prostatic enlargement amp prostatic cancer enlarged prostate projects into the urinary bladder amp blocks urine by distorting the prostatic urethra-middle lohe is usually enlarged 13gt I-~

~ can be palpated during a digital rectal exam (PR) ~ cancer can spread through blood amp lymphatics

o communication between prostatic l)en07tS plex7ts amp

ex~1 vertebraLpfxttS facilitates spread of cancer to

bull lumbar vertebrae bull proximal extremity of femur

Prostate _~~~iIiII~ bull os coxae (pelvis)

bull ribsProstahe urethra o spread by lymphaJi~s

bull Obturator nodes Pubis bull Perivesical nodes

bull Hypogastric nodes bull Iliac nodes

Sagittal sec1ion bull Para-aortic nodes ~ can spread to neighboring structures

o can spread to seminal vesicles o can spread to the base of the urinary bladder which in turn may cause obstruction in the

ureters (causes hydroureters) o can spread to rectum (direct contact)

~ Injury of rostatic lexus causing erectile dysfunction (ED) amp Incontinence o prostate is supplied by prostatic plexus (inferior continuation of the inferior hypogastric

plexus)

o this plexus also gives rise to the cavernous nerves that convey fibers that cause erection o these networks are combinations of parasympathetic amp sympathetic o duringprostatectoffiY these plexuses may have to be sacrificed because of their close

relationship to theprostate and thus the patient may suffer erecile 4YJtplctiancampm1nary incoftiaeme

Bulbourethral Glands (Cowpers Glands) bull lie posterolateral to the intermediate part of the urethra largely embedded within the external urethral

~phincteL bull ducts of these glands pass through the perineal membrane with the intermediate urethra and open through

minute aperatures into the proximal part of the PJ11JJ 7t1CChraJn-thebulbopound tD~nis bull secrete a mucus-like substance

oUrethra bull divided into 4 parts

1 preprostatlc urethra P-shy

2 prostatic urethra ~ ~ bull has urethral crest -

bull located on the postenor wall or prostatlc urethra -~ ~ bull has numerous openings for prostatic ducts ~ bull has an ovoid-shaped enlargement called the semzna colzmtls Q

o 2 ejaculatory ducts amp prostatic utricle opens here - of urelhra - Antenor view

bull prostatic sinus groove between urethral crest amp wall of prostatic urethra that receives the ducts of the prostate gland

3 membranous urethra 4 spongy urethra

oErection bull stimulation ofP1RASYMPATHETIC fibers from pelvic splanchnic nerves

o causes bull dilation of arteries sup-plying erect jle tissue bull causes engorgement of corpora cavernosa amp corpus spongiosum es~es vtn~~~ampgml~~s~~el]s

bull maintained by contraction of the bulbospongiosus amp ischiocavers s bull mnemonic device ~ noint (erection by narasympathetic) amp shoot (ejaculation by sympathetic)

oEjaculation bull begins with nervous stimulation bull friction to la s enis result in exci tion of SYMP THETI fibers

o causes bull contraction of smooth muscle of epidid mal ducts ductus ~ferens seminal vesicles amp prostate

gland-- _-- _------ bull occurs as a result ofJQntractionof smootlunusde-s bull involves contraction of the sphincter of the bladder preventing the entry of urine into prostatic urethra amp

reflux of semen into bladder ~ detrumesence (remission)

o after ejaculation the penis becomes flaccid o sympathetic stimulation causes

bull -bulbospongiosus amp ischicavernous mm to relax bull drainage of blood from cavernosus spaces into deep dorsal vein

~ Internal Genital Organs

A

Vagina bull extends between the vestibule amp cervix of uterus

Ulenbnl IOOCtlan

1 ~~iiiiii~~z--UtetnO lube

OIIarIan artery

Vaginai artary

bull serves as the excretory channel for the products of menstruation also receives penis during coitus

poucn

- Vag

bull has 4 fornices that forms the recess VaslcoolamB ~~e between eh cervix amp wall of the vagina

o posterior related to the rectottterine pouch

o anterior o 2 lateral

bull opens into the vestibule amp is partially closed by a membranous crescentic fold the hymen

bull relations of the vagina o anteriorly fundus of urinary bladder amp urethra o laterally levato~ visceral pelvic fascia amp ureters o posteriorly anal canal rectum amp rectouterine pouch

V sltbula of vagina

B Median seclion

bull vasculature o arterial supply

bull superior part of vagina derived from uterine aa bull middle + inferior part of vagina derived from vaginal amp internal

pudendal aa Pampinirorm 0 venous drainage

bull veins form vaginal venous plexuses along the sides of Ulerlneastery

vagma bull these veins communicated with uterine venous plexus

and drain to internal iliac veins through uterine vein

o lymphatics bull superior part internal amp external iliac lYmph nodes bull middle part internal iliac lYmph nodes bull inferior part sacral amp common iliac nodes bull external orifice supeificial inguinal lYmph nodes ~ v

B Posterior view

A

~OIYiIgITIII

bull

Uterus bull pear-shaped hollow muscular organ that lies in the true pelvis bull lies between rectum amp urinary bladder

supravaginalpart between the isthmus amp vagina bull separated from the bladder anteriorly by loose CT amp from the rectum posteriorly by the

rectouterine pouch bull laginalpart protrudes into the vagina amp surrounds the external os of the uterus bull Note between external os amp internal os lies cervical canal

bull the wall of the body of the uterus has 3 layers o perimetrium outer serous coat - consists of peritoneum supported by a thin layer of CT o myometrium middle muscular coat of smooth muscle - main branches of BVs amp NN are located in

this segment o endometrium inner mucous coat which firmly adheres to the myometrium and is actively involved

in the menstrual cycle differing in structure with each stage if conception occurs the blastocyst beomes implanted in this layer if no conception the inner surface is shed through menstruation

bull relations of the uterus o peritoneum covers the uterus anteriorly amp superiorly (except for the cervix) o anteriorly vesicouterine pouch supenor surface of bladder o laterally broad ligament amp ureters o posteriorly rectouterine pouch amp loops of intestine in pouch amp anterior surface of rectum

bull vasculature of the uterus o arterial uterine aa o venous uterine venous plexus o lymphatics 3 main routes

bull uterine fundus amp superior uterine body to bull rest of uterine body to ex~rnal iliac lymp

osition of the uterus

Anteflexion

PS

bull parts of the uterus

o adult uterus is usually ante Verted (tipped anterosuperiorly relative to the axis of the Vagina)

o adult uterus is also anteflexed (uterine body is flexed or bent anteriorly relative to the cervi) so that the mass lies over the bladder amp====- -====--

o the other position is retro exed

bull the uterus is exed or bent posteriorly relative to the cervix over the rectum ins tea of the bladder

o body of the uterus bull superior 23 of the structure

Retroflexionbull includes bull fundus of the uterus - rounded part of the body that lies superior to

the orifices of the uterine tubes bull isthmus of the uterus - relatively constricted part of the body (about

1cm long) just superior to the cervix bull uterine horns - superolateral regions where the uterine tubes enter the

uterus bull body of the uterus lies between the 2 peritoneal membranes (broad ligament)

amp is freely moveable o cervix of the uterus

bull the cylindrica~ narrow inferior part of the uterus which has a

nodes

~

~

bull uterine cervi to external amp internal iliac lymph nodes AND sacral lymph nodes bull Innervation of vagina amp uterus

o vagina (inferior part) somatic from deep perineal nerve (branch of pudendal

3

Pelvic subshypenloneal vl5cera

nerve) o vagina (most) + entire uterus

- PostsynaptIC sympalheilc bull PresynaptIC parasympalhellC

- PostsynaptIC parasympalheC - VIsceral allerenls runnng

willi sym pati1e1lC 0Ild pasYlT1POlhele Idlers

- SomaUc rrIInl - SomabC molOt

~===~ PlIineum

=visceral innervations bull nerves f~m uterovaginal nerve lexus bull uterovaginal nerve p exus extends from the inferior

hypogastric plexus bull sympathetic parasympathetic amp visceral afferent

fibers run through this plexus bull sympathetic innervation

bull inferior thoracic spinal cord segments shylum~121anchnic nerves - intermesentericshyhypga~tric-uterovaginal Elexus

ntenor Vie

bull parasympathetic innervation bull S2-S4 - pelvic splanchnic nerves - inferior hypogastric-uterovaginal plexus

bull visceral afferent fibers bull carry pain sensation from the intraperitoneal uterine fundus amp body - lower thoracicshy

upper lumbar spinal ganglia bull those from subperitoneal uterine cervL amp vagina (inferior to pelvic pain line) travel

with parasympathetic fibers to S2-S4

bull CLINICAL CORRELATIONS ysterectomy

o excision of the uterus through the lower anterior abdominal wall or through vagina o because uterine artery crosses anterior to the ureter near the lateral fornix of the ~ the ureter is in danger of being inadvertently clamped or severed when uterine artery is tied

PAP TestPAP Smear o procedure used to detect early signs of cervical

cancer o spatula is placed in the os of the cervix o spatula is rotated to scrape the mucosa of the

cervical canal o microscopy is used to find tumor cells

Tren 1(epktuqI) antSIfinLl

CS~ fltxIIl00 ~ (lurnbaf ~ml

COIdO oa_ CSF

S llfft1abtal~

~ Caudal Epidural Anesthesia Rectum

o method used to make childbirth painless o anesthetic agent is injected into sacral canal blocking

S2-S4 including pain fibers from the uterine cervix upper vagina amp afferent fibers from pudendal nerve

o thus the entire birth canal pelvic floor amp a major part of the perineum is anesthetized

o because visceral afferent fibers from the uterine fundus ascend to the upper lumbar spinal ganglia they are not affected by this block amp sensations of the uterine contraction are still received

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

oUrethra bull divided into 4 parts

1 preprostatlc urethra P-shy

2 prostatic urethra ~ ~ bull has urethral crest -

bull located on the postenor wall or prostatlc urethra -~ ~ bull has numerous openings for prostatic ducts ~ bull has an ovoid-shaped enlargement called the semzna colzmtls Q

o 2 ejaculatory ducts amp prostatic utricle opens here - of urelhra - Antenor view

bull prostatic sinus groove between urethral crest amp wall of prostatic urethra that receives the ducts of the prostate gland

3 membranous urethra 4 spongy urethra

oErection bull stimulation ofP1RASYMPATHETIC fibers from pelvic splanchnic nerves

o causes bull dilation of arteries sup-plying erect jle tissue bull causes engorgement of corpora cavernosa amp corpus spongiosum es~es vtn~~~ampgml~~s~~el]s

bull maintained by contraction of the bulbospongiosus amp ischiocavers s bull mnemonic device ~ noint (erection by narasympathetic) amp shoot (ejaculation by sympathetic)

oEjaculation bull begins with nervous stimulation bull friction to la s enis result in exci tion of SYMP THETI fibers

o causes bull contraction of smooth muscle of epidid mal ducts ductus ~ferens seminal vesicles amp prostate

gland-- _-- _------ bull occurs as a result ofJQntractionof smootlunusde-s bull involves contraction of the sphincter of the bladder preventing the entry of urine into prostatic urethra amp

reflux of semen into bladder ~ detrumesence (remission)

o after ejaculation the penis becomes flaccid o sympathetic stimulation causes

bull -bulbospongiosus amp ischicavernous mm to relax bull drainage of blood from cavernosus spaces into deep dorsal vein

~ Internal Genital Organs

A

Vagina bull extends between the vestibule amp cervix of uterus

Ulenbnl IOOCtlan

1 ~~iiiiii~~z--UtetnO lube

OIIarIan artery

Vaginai artary

bull serves as the excretory channel for the products of menstruation also receives penis during coitus

poucn

- Vag

bull has 4 fornices that forms the recess VaslcoolamB ~~e between eh cervix amp wall of the vagina

o posterior related to the rectottterine pouch

o anterior o 2 lateral

bull opens into the vestibule amp is partially closed by a membranous crescentic fold the hymen

bull relations of the vagina o anteriorly fundus of urinary bladder amp urethra o laterally levato~ visceral pelvic fascia amp ureters o posteriorly anal canal rectum amp rectouterine pouch

V sltbula of vagina

B Median seclion

bull vasculature o arterial supply

bull superior part of vagina derived from uterine aa bull middle + inferior part of vagina derived from vaginal amp internal

pudendal aa Pampinirorm 0 venous drainage

bull veins form vaginal venous plexuses along the sides of Ulerlneastery

vagma bull these veins communicated with uterine venous plexus

and drain to internal iliac veins through uterine vein

o lymphatics bull superior part internal amp external iliac lYmph nodes bull middle part internal iliac lYmph nodes bull inferior part sacral amp common iliac nodes bull external orifice supeificial inguinal lYmph nodes ~ v

B Posterior view

A

~OIYiIgITIII

bull

Uterus bull pear-shaped hollow muscular organ that lies in the true pelvis bull lies between rectum amp urinary bladder

supravaginalpart between the isthmus amp vagina bull separated from the bladder anteriorly by loose CT amp from the rectum posteriorly by the

rectouterine pouch bull laginalpart protrudes into the vagina amp surrounds the external os of the uterus bull Note between external os amp internal os lies cervical canal

bull the wall of the body of the uterus has 3 layers o perimetrium outer serous coat - consists of peritoneum supported by a thin layer of CT o myometrium middle muscular coat of smooth muscle - main branches of BVs amp NN are located in

this segment o endometrium inner mucous coat which firmly adheres to the myometrium and is actively involved

in the menstrual cycle differing in structure with each stage if conception occurs the blastocyst beomes implanted in this layer if no conception the inner surface is shed through menstruation

bull relations of the uterus o peritoneum covers the uterus anteriorly amp superiorly (except for the cervix) o anteriorly vesicouterine pouch supenor surface of bladder o laterally broad ligament amp ureters o posteriorly rectouterine pouch amp loops of intestine in pouch amp anterior surface of rectum

bull vasculature of the uterus o arterial uterine aa o venous uterine venous plexus o lymphatics 3 main routes

bull uterine fundus amp superior uterine body to bull rest of uterine body to ex~rnal iliac lymp

osition of the uterus

Anteflexion

PS

bull parts of the uterus

o adult uterus is usually ante Verted (tipped anterosuperiorly relative to the axis of the Vagina)

o adult uterus is also anteflexed (uterine body is flexed or bent anteriorly relative to the cervi) so that the mass lies over the bladder amp====- -====--

o the other position is retro exed

bull the uterus is exed or bent posteriorly relative to the cervix over the rectum ins tea of the bladder

o body of the uterus bull superior 23 of the structure

Retroflexionbull includes bull fundus of the uterus - rounded part of the body that lies superior to

the orifices of the uterine tubes bull isthmus of the uterus - relatively constricted part of the body (about

1cm long) just superior to the cervix bull uterine horns - superolateral regions where the uterine tubes enter the

uterus bull body of the uterus lies between the 2 peritoneal membranes (broad ligament)

amp is freely moveable o cervix of the uterus

bull the cylindrica~ narrow inferior part of the uterus which has a

nodes

~

~

bull uterine cervi to external amp internal iliac lymph nodes AND sacral lymph nodes bull Innervation of vagina amp uterus

o vagina (inferior part) somatic from deep perineal nerve (branch of pudendal

3

Pelvic subshypenloneal vl5cera

nerve) o vagina (most) + entire uterus

- PostsynaptIC sympalheilc bull PresynaptIC parasympalhellC

- PostsynaptIC parasympalheC - VIsceral allerenls runnng

willi sym pati1e1lC 0Ild pasYlT1POlhele Idlers

- SomaUc rrIInl - SomabC molOt

~===~ PlIineum

=visceral innervations bull nerves f~m uterovaginal nerve lexus bull uterovaginal nerve p exus extends from the inferior

hypogastric plexus bull sympathetic parasympathetic amp visceral afferent

fibers run through this plexus bull sympathetic innervation

bull inferior thoracic spinal cord segments shylum~121anchnic nerves - intermesentericshyhypga~tric-uterovaginal Elexus

ntenor Vie

bull parasympathetic innervation bull S2-S4 - pelvic splanchnic nerves - inferior hypogastric-uterovaginal plexus

bull visceral afferent fibers bull carry pain sensation from the intraperitoneal uterine fundus amp body - lower thoracicshy

upper lumbar spinal ganglia bull those from subperitoneal uterine cervL amp vagina (inferior to pelvic pain line) travel

with parasympathetic fibers to S2-S4

bull CLINICAL CORRELATIONS ysterectomy

o excision of the uterus through the lower anterior abdominal wall or through vagina o because uterine artery crosses anterior to the ureter near the lateral fornix of the ~ the ureter is in danger of being inadvertently clamped or severed when uterine artery is tied

PAP TestPAP Smear o procedure used to detect early signs of cervical

cancer o spatula is placed in the os of the cervix o spatula is rotated to scrape the mucosa of the

cervical canal o microscopy is used to find tumor cells

Tren 1(epktuqI) antSIfinLl

CS~ fltxIIl00 ~ (lurnbaf ~ml

COIdO oa_ CSF

S llfft1abtal~

~ Caudal Epidural Anesthesia Rectum

o method used to make childbirth painless o anesthetic agent is injected into sacral canal blocking

S2-S4 including pain fibers from the uterine cervix upper vagina amp afferent fibers from pudendal nerve

o thus the entire birth canal pelvic floor amp a major part of the perineum is anesthetized

o because visceral afferent fibers from the uterine fundus ascend to the upper lumbar spinal ganglia they are not affected by this block amp sensations of the uterine contraction are still received

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

OIIarIan artery

Vaginai artary

bull serves as the excretory channel for the products of menstruation also receives penis during coitus

poucn

- Vag

bull has 4 fornices that forms the recess VaslcoolamB ~~e between eh cervix amp wall of the vagina

o posterior related to the rectottterine pouch

o anterior o 2 lateral

bull opens into the vestibule amp is partially closed by a membranous crescentic fold the hymen

bull relations of the vagina o anteriorly fundus of urinary bladder amp urethra o laterally levato~ visceral pelvic fascia amp ureters o posteriorly anal canal rectum amp rectouterine pouch

V sltbula of vagina

B Median seclion

bull vasculature o arterial supply

bull superior part of vagina derived from uterine aa bull middle + inferior part of vagina derived from vaginal amp internal

pudendal aa Pampinirorm 0 venous drainage

bull veins form vaginal venous plexuses along the sides of Ulerlneastery

vagma bull these veins communicated with uterine venous plexus

and drain to internal iliac veins through uterine vein

o lymphatics bull superior part internal amp external iliac lYmph nodes bull middle part internal iliac lYmph nodes bull inferior part sacral amp common iliac nodes bull external orifice supeificial inguinal lYmph nodes ~ v

B Posterior view

A

~OIYiIgITIII

bull

Uterus bull pear-shaped hollow muscular organ that lies in the true pelvis bull lies between rectum amp urinary bladder

supravaginalpart between the isthmus amp vagina bull separated from the bladder anteriorly by loose CT amp from the rectum posteriorly by the

rectouterine pouch bull laginalpart protrudes into the vagina amp surrounds the external os of the uterus bull Note between external os amp internal os lies cervical canal

bull the wall of the body of the uterus has 3 layers o perimetrium outer serous coat - consists of peritoneum supported by a thin layer of CT o myometrium middle muscular coat of smooth muscle - main branches of BVs amp NN are located in

this segment o endometrium inner mucous coat which firmly adheres to the myometrium and is actively involved

in the menstrual cycle differing in structure with each stage if conception occurs the blastocyst beomes implanted in this layer if no conception the inner surface is shed through menstruation

bull relations of the uterus o peritoneum covers the uterus anteriorly amp superiorly (except for the cervix) o anteriorly vesicouterine pouch supenor surface of bladder o laterally broad ligament amp ureters o posteriorly rectouterine pouch amp loops of intestine in pouch amp anterior surface of rectum

bull vasculature of the uterus o arterial uterine aa o venous uterine venous plexus o lymphatics 3 main routes

bull uterine fundus amp superior uterine body to bull rest of uterine body to ex~rnal iliac lymp

osition of the uterus

Anteflexion

PS

bull parts of the uterus

o adult uterus is usually ante Verted (tipped anterosuperiorly relative to the axis of the Vagina)

o adult uterus is also anteflexed (uterine body is flexed or bent anteriorly relative to the cervi) so that the mass lies over the bladder amp====- -====--

o the other position is retro exed

bull the uterus is exed or bent posteriorly relative to the cervix over the rectum ins tea of the bladder

o body of the uterus bull superior 23 of the structure

Retroflexionbull includes bull fundus of the uterus - rounded part of the body that lies superior to

the orifices of the uterine tubes bull isthmus of the uterus - relatively constricted part of the body (about

1cm long) just superior to the cervix bull uterine horns - superolateral regions where the uterine tubes enter the

uterus bull body of the uterus lies between the 2 peritoneal membranes (broad ligament)

amp is freely moveable o cervix of the uterus

bull the cylindrica~ narrow inferior part of the uterus which has a

nodes

~

~

bull uterine cervi to external amp internal iliac lymph nodes AND sacral lymph nodes bull Innervation of vagina amp uterus

o vagina (inferior part) somatic from deep perineal nerve (branch of pudendal

3

Pelvic subshypenloneal vl5cera

nerve) o vagina (most) + entire uterus

- PostsynaptIC sympalheilc bull PresynaptIC parasympalhellC

- PostsynaptIC parasympalheC - VIsceral allerenls runnng

willi sym pati1e1lC 0Ild pasYlT1POlhele Idlers

- SomaUc rrIInl - SomabC molOt

~===~ PlIineum

=visceral innervations bull nerves f~m uterovaginal nerve lexus bull uterovaginal nerve p exus extends from the inferior

hypogastric plexus bull sympathetic parasympathetic amp visceral afferent

fibers run through this plexus bull sympathetic innervation

bull inferior thoracic spinal cord segments shylum~121anchnic nerves - intermesentericshyhypga~tric-uterovaginal Elexus

ntenor Vie

bull parasympathetic innervation bull S2-S4 - pelvic splanchnic nerves - inferior hypogastric-uterovaginal plexus

bull visceral afferent fibers bull carry pain sensation from the intraperitoneal uterine fundus amp body - lower thoracicshy

upper lumbar spinal ganglia bull those from subperitoneal uterine cervL amp vagina (inferior to pelvic pain line) travel

with parasympathetic fibers to S2-S4

bull CLINICAL CORRELATIONS ysterectomy

o excision of the uterus through the lower anterior abdominal wall or through vagina o because uterine artery crosses anterior to the ureter near the lateral fornix of the ~ the ureter is in danger of being inadvertently clamped or severed when uterine artery is tied

PAP TestPAP Smear o procedure used to detect early signs of cervical

cancer o spatula is placed in the os of the cervix o spatula is rotated to scrape the mucosa of the

cervical canal o microscopy is used to find tumor cells

Tren 1(epktuqI) antSIfinLl

CS~ fltxIIl00 ~ (lurnbaf ~ml

COIdO oa_ CSF

S llfft1abtal~

~ Caudal Epidural Anesthesia Rectum

o method used to make childbirth painless o anesthetic agent is injected into sacral canal blocking

S2-S4 including pain fibers from the uterine cervix upper vagina amp afferent fibers from pudendal nerve

o thus the entire birth canal pelvic floor amp a major part of the perineum is anesthetized

o because visceral afferent fibers from the uterine fundus ascend to the upper lumbar spinal ganglia they are not affected by this block amp sensations of the uterine contraction are still received

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

A

~OIYiIgITIII

bull

Uterus bull pear-shaped hollow muscular organ that lies in the true pelvis bull lies between rectum amp urinary bladder

supravaginalpart between the isthmus amp vagina bull separated from the bladder anteriorly by loose CT amp from the rectum posteriorly by the

rectouterine pouch bull laginalpart protrudes into the vagina amp surrounds the external os of the uterus bull Note between external os amp internal os lies cervical canal

bull the wall of the body of the uterus has 3 layers o perimetrium outer serous coat - consists of peritoneum supported by a thin layer of CT o myometrium middle muscular coat of smooth muscle - main branches of BVs amp NN are located in

this segment o endometrium inner mucous coat which firmly adheres to the myometrium and is actively involved

in the menstrual cycle differing in structure with each stage if conception occurs the blastocyst beomes implanted in this layer if no conception the inner surface is shed through menstruation

bull relations of the uterus o peritoneum covers the uterus anteriorly amp superiorly (except for the cervix) o anteriorly vesicouterine pouch supenor surface of bladder o laterally broad ligament amp ureters o posteriorly rectouterine pouch amp loops of intestine in pouch amp anterior surface of rectum

bull vasculature of the uterus o arterial uterine aa o venous uterine venous plexus o lymphatics 3 main routes

bull uterine fundus amp superior uterine body to bull rest of uterine body to ex~rnal iliac lymp

osition of the uterus

Anteflexion

PS

bull parts of the uterus

o adult uterus is usually ante Verted (tipped anterosuperiorly relative to the axis of the Vagina)

o adult uterus is also anteflexed (uterine body is flexed or bent anteriorly relative to the cervi) so that the mass lies over the bladder amp====- -====--

o the other position is retro exed

bull the uterus is exed or bent posteriorly relative to the cervix over the rectum ins tea of the bladder

o body of the uterus bull superior 23 of the structure

Retroflexionbull includes bull fundus of the uterus - rounded part of the body that lies superior to

the orifices of the uterine tubes bull isthmus of the uterus - relatively constricted part of the body (about

1cm long) just superior to the cervix bull uterine horns - superolateral regions where the uterine tubes enter the

uterus bull body of the uterus lies between the 2 peritoneal membranes (broad ligament)

amp is freely moveable o cervix of the uterus

bull the cylindrica~ narrow inferior part of the uterus which has a

nodes

~

~

bull uterine cervi to external amp internal iliac lymph nodes AND sacral lymph nodes bull Innervation of vagina amp uterus

o vagina (inferior part) somatic from deep perineal nerve (branch of pudendal

3

Pelvic subshypenloneal vl5cera

nerve) o vagina (most) + entire uterus

- PostsynaptIC sympalheilc bull PresynaptIC parasympalhellC

- PostsynaptIC parasympalheC - VIsceral allerenls runnng

willi sym pati1e1lC 0Ild pasYlT1POlhele Idlers

- SomaUc rrIInl - SomabC molOt

~===~ PlIineum

=visceral innervations bull nerves f~m uterovaginal nerve lexus bull uterovaginal nerve p exus extends from the inferior

hypogastric plexus bull sympathetic parasympathetic amp visceral afferent

fibers run through this plexus bull sympathetic innervation

bull inferior thoracic spinal cord segments shylum~121anchnic nerves - intermesentericshyhypga~tric-uterovaginal Elexus

ntenor Vie

bull parasympathetic innervation bull S2-S4 - pelvic splanchnic nerves - inferior hypogastric-uterovaginal plexus

bull visceral afferent fibers bull carry pain sensation from the intraperitoneal uterine fundus amp body - lower thoracicshy

upper lumbar spinal ganglia bull those from subperitoneal uterine cervL amp vagina (inferior to pelvic pain line) travel

with parasympathetic fibers to S2-S4

bull CLINICAL CORRELATIONS ysterectomy

o excision of the uterus through the lower anterior abdominal wall or through vagina o because uterine artery crosses anterior to the ureter near the lateral fornix of the ~ the ureter is in danger of being inadvertently clamped or severed when uterine artery is tied

PAP TestPAP Smear o procedure used to detect early signs of cervical

cancer o spatula is placed in the os of the cervix o spatula is rotated to scrape the mucosa of the

cervical canal o microscopy is used to find tumor cells

Tren 1(epktuqI) antSIfinLl

CS~ fltxIIl00 ~ (lurnbaf ~ml

COIdO oa_ CSF

S llfft1abtal~

~ Caudal Epidural Anesthesia Rectum

o method used to make childbirth painless o anesthetic agent is injected into sacral canal blocking

S2-S4 including pain fibers from the uterine cervix upper vagina amp afferent fibers from pudendal nerve

o thus the entire birth canal pelvic floor amp a major part of the perineum is anesthetized

o because visceral afferent fibers from the uterine fundus ascend to the upper lumbar spinal ganglia they are not affected by this block amp sensations of the uterine contraction are still received

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

~

~

bull uterine cervi to external amp internal iliac lymph nodes AND sacral lymph nodes bull Innervation of vagina amp uterus

o vagina (inferior part) somatic from deep perineal nerve (branch of pudendal

3

Pelvic subshypenloneal vl5cera

nerve) o vagina (most) + entire uterus

- PostsynaptIC sympalheilc bull PresynaptIC parasympalhellC

- PostsynaptIC parasympalheC - VIsceral allerenls runnng

willi sym pati1e1lC 0Ild pasYlT1POlhele Idlers

- SomaUc rrIInl - SomabC molOt

~===~ PlIineum

=visceral innervations bull nerves f~m uterovaginal nerve lexus bull uterovaginal nerve p exus extends from the inferior

hypogastric plexus bull sympathetic parasympathetic amp visceral afferent

fibers run through this plexus bull sympathetic innervation

bull inferior thoracic spinal cord segments shylum~121anchnic nerves - intermesentericshyhypga~tric-uterovaginal Elexus

ntenor Vie

bull parasympathetic innervation bull S2-S4 - pelvic splanchnic nerves - inferior hypogastric-uterovaginal plexus

bull visceral afferent fibers bull carry pain sensation from the intraperitoneal uterine fundus amp body - lower thoracicshy

upper lumbar spinal ganglia bull those from subperitoneal uterine cervL amp vagina (inferior to pelvic pain line) travel

with parasympathetic fibers to S2-S4

bull CLINICAL CORRELATIONS ysterectomy

o excision of the uterus through the lower anterior abdominal wall or through vagina o because uterine artery crosses anterior to the ureter near the lateral fornix of the ~ the ureter is in danger of being inadvertently clamped or severed when uterine artery is tied

PAP TestPAP Smear o procedure used to detect early signs of cervical

cancer o spatula is placed in the os of the cervix o spatula is rotated to scrape the mucosa of the

cervical canal o microscopy is used to find tumor cells

Tren 1(epktuqI) antSIfinLl

CS~ fltxIIl00 ~ (lurnbaf ~ml

COIdO oa_ CSF

S llfft1abtal~

~ Caudal Epidural Anesthesia Rectum

o method used to make childbirth painless o anesthetic agent is injected into sacral canal blocking

S2-S4 including pain fibers from the uterine cervix upper vagina amp afferent fibers from pudendal nerve

o thus the entire birth canal pelvic floor amp a major part of the perineum is anesthetized

o because visceral afferent fibers from the uterine fundus ascend to the upper lumbar spinal ganglia they are not affected by this block amp sensations of the uterine contraction are still received

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

--

Ovaries bull lie on the posterior aspect of the broad ligament on the side wall of the pelvic minor amp are bounded by

external amp internal iliac vessels bull not covered by peritoneum bull not enclosed in the broad ligament but their anterior surface is attached to the posterior surface of the broad

ligament via mesovarium bull vascularity

o supplied mainly by ovarian aa o drained by ovarian vv right ovarian vein drains into the IVC while the left ovarian vein joins left renal

vell o lymphatic drainage to ngiamp left lumbar lYmJ2h nodes

Uterine Tubes bull extend from uterus to the uterine end of ovaries amp connect the uterine cavity with the peritoneal cavity bull each subdivided into 4 parts

o uterine part o isthmus o ampulla Oongest amp widest part) o infundibulum (funnel-shaped termination formed of funbrae-fllgerlike projections)

bull fertilization usually takes place in the inf undibulum or ampulla Vasculature of ovaries amp uterine tubes

bull arterial supply o ovarian arteries (arise directly from abdominal aorta) o at pelvic brim they cross over the external iliac vessels amp enter the suspensory ligaments o ovarian artery sends branches through the mesovarian to supply the ovaries and the mesosalpinx to

supply the uterine tubes bull venous drainage

o pampiniform plexus of veins in braod ligament near the ovaries amp uterine tubes r1nervation of ovaries amp uterine tubes

bull nerves descend along the ovarian vessels fromt eh ovanO

al1 plexus and from the uterine (pelvic) plexus bull remember that ovaries and uterine tubes are superior to the pelvic pain line amp thus the visceral afferent pain

fibers ascend retrogradely with sympathetic fibers of the ovarian plexus amp lumbar splanchnic nerves to the cell bodiews in the Tll-U spinal sensory ganglia

bull visceral afferent fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) amp inferior hypogastric plexuses and pelvic splanchnic nerves to S2-S4spinal sensory ganglia

Rectum bull has a lower dilated part called the ampulla which lies above pelvic

diaphgram amp stores feces bull has a mucous membrane amp a circular muscle layer that forms 3 permanent

transverse fold s (l-Ioustons valves) bull vascularity

o arterial superior middle amp inferior rectal aa amp middle sacral ao A_bull

o venous drainage bull superior rectal vein -- portal system bull middle + inferior rectal veins -- IVC

o lymphatic drainage bull superior half of rectum pararectal lymph nodes - shy

inferior mesenteric lymph nodes bull inferior half of rectum sacral lymph nodes or internal iliac lymph nodes

bull innervation o receives parasympathetic nerve fibers by way of pelvic splanchnic nerve

Defecation bull initiated by distention of the rectum bull afferent impulses transmitted to the spinal cord by the pelvic splanchnic nerve

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

o i peristalsis

bull sympathetic o peris talsis o maintains tone in the internal sphincter o contains vasomotor amp sensory (pain) fibers

Nerve Supply to the Pelvis

bull sacral plexus formed by L4 L5 Sl-S4 1 superior gluteal nerve (L4-S1)

bull gluteus medius gluteus minimus tensor fascia lata muscles 2 inferior gluteal nerve (L5-S2)

bull gluteus maximus muscle 3 sciatic nerve (L4-S3)

bull articular branches to hip joint and muscular branches to flexors of knee (hamstring muscles) and all muscles in leg and foot

4 nerve to the obturator internus muscle (L5-S2) bull obturator internus amp superior gamellus

5 nerve to the quadratus femoris muscle (L5-S1) bull quadratus femoris amp inferior gamellus

6 posterior femoral cutaneous nerve (Sl-S3) bull gives rise to several inferior cluneal nerves amp perineal branches

7 pudendal nerve (S2-S4) bull gives rise to inferior rectal nerve perineal nerve bull terminates as dorsal nerve of penis or clitoris

8 branches to the pelvis bull nerve to the piriformis muscle (S1-S2) bull nerves to the levator ani amp coccygeus mm (S3-S4) bull nerve to the sphincter ani externus mucle (pelvic splanchnic nerves S2-S4)

bull Pelvic autonomic nerves 1 superior hypogastric plexus

bull continuation of the aortic plexus below the bifurcation of the aorta amp receives lower 2 lumbar splanchnic nerves

bull ends by bifurcation into the right amp left hypogastric nerves 2 hypogastric nerve

bull lateral extension of the superior hypogastric plexus bull provides branches to sigmoid colon and colon

3 inferior hypogastric (pelvic) plexus bull formed by union of

bull hypogastric nerve bull pelvic splanchnic nerves bull sacral splanchnic nerves

bull contains pelvic ganglia bull consists of both preganglionic amp postganglionic fibers bull gives rise to middle rectal plexus uterovaginal plexus vesical plexus differential plexus

prostatic plexus 4 sacral splanchnic nerves

bull consists primarily of preganglionic fibers

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

---------

5 Pelvic splanchnic nerves (nervi erigentes) bull from S2-S4 bull are the only splanchnic nerves that carry parasympathetic fibers

Jeyelopment

Development of the Urinary System bull from metanephric mesoderm develop th~g~~=s~bull from the ureteric bud developes th 0 ec

o the ureteric bud penetrates the metanephric mesoderm forming t~enal Relvis o failure of the ureteric bud to contact the metanephric mesoderm results in kidney agenesis (failure of

an organ to form MesonepllrlC

bull ureter grows down to join bladder dUCl Metanephoric ap

bull Phases of Kidney Development ~ (A-D) JIIIII f enCi pElvis

Ureteric bUd

~

Trle g een poriorrgt o f the aCMlng as umiddoteter1c bUd delivdlvE36 the rEd pOliengt

ore file metSlleprxlc bUd deuro1xsa~ CLINICAL CORRELATIONS ~ Kidney Agenesis

---- o caused by 3 things

1 non union of ureteric bud and metanephric ~esoderm

MelO1ep1Ylc mES91chyna

~-No Jrelaic bud

of Ureteric bud

MetOlephric m 91EJichyme 2 failure of ureteric bud formation from mesonephric duct

3 absence of a metanephric cap ~ Duplication of Ureters

o ureteric buds which grow from the mesonephric duct divide into 2 and connect with metanephric mesoderm

Metalephric

Future

o duplication of the ureter is common (1 150) meenChyrne

Eaty civii irn of uret euro( iC bud

uret6S CD

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

e

Accessory artery

bull ascent of the kidneys o kidneys start off in the pelvic region with hilum pointed

anteriorly (5th - 6th week)

o as the pelvis amp abdomen grow the kidneys slowly move upward

o by the 7th week the hilum points medially amp kidneys have migrated to the abdomen

o by about the 9th week the kidneys lie retroperitoneally at the level of L 1

o

CLINICAL CORRELATIONS bull Pelvic Kidney

o during the ascent of the kidneys they pass through the arterial fork formed-hy th~ries

o when one these kidneys does not pass through the arterial fork it is arrested in the pelvis close to the iliac artery

bull Accessory Renal Arteries o develop from the aorta amp enter the superior or inferior pole of the

kidney o persistence of embryonic vessels that formed during the ascent of thl

kidneys results in these accessory arteries

ltenOl a rtsle

bull

Noma YI

development of the urinary bladder

bull Horseshoe Kidney o while the kidneys are ascending through the arterial fork

and they are pushed too close together the lower poles fuse to form a horseshoe kidney ~

o the urogenital sinuE is formed by the division of the clo~ca by the uro-rectal septum o the urogerutaI sinus divides into 3 parts

1 cranial part bull develops into the urinary bladder proper amp utacbu~

2 pelvic part bull ( - develops into the prostatic amp membranous urethra amp bulbourethral glands amp

prostate bull S - develops into the lower vagina

3 caudal part bull ( - develops into the penile urethta

bull yen -develops into the vestibge o note initially the trigone of the blad der has mesodermal epithelium but later the bladder is lined entirely

by endodermal epithtmom

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

o note bull o -mesonephric ducts form the origin of the ejaculatory ducts as they pierce the prostate bull Sj2 - the ducts degenerate

o summary bull from the mesonephric ducts in Os develops

bull ejaculatory ducts shybull epididymis bull deferent duct bull seminal vesicle shy

bull from the endoderm of the urogenital sinus develops bull uriilary bladdershybull pelvic part - shybull caudal part -shy

o the bladder is initially continuous with the a1antojs o overtime the allantois degenerates and forms a cord-like structure called the urachus o urachus is between the apex of the bladder and umbilicus o incomplete closure of the allantois can result in 4 anomalies

CLINICAL CORRELATIONS bull Urachal Cyst

o found anywhere along the allantois canal o these cysts have a connection to the urinary bladder amp can become

infected

B adder 2 Urethra J Urachus - (fibroU5

remanent of the allan ois) 4 Umblicus 5 Umbilical cyst 6 Urachal cysts

bull Urachal fistula

bull InternalExternal Fistula o internal fistula is a diverticulum

in the upper part of the bladder (urachal div ticulum)

o external fistula is a blind terminating sac that emerges from the umbilicus 1 Bladder 2 Urethra

(urachal sinus)

L B adder 2 Urethra 3 Umblicus 4 Out1io of the urine externally ~uninterruPted urachal

fistula

o when the lumen of the intraembryonic portion allantois persists a urachal fistula forms

o with this there is a direct communication between the urinary bladder amp the exterior at the umbilicus

bull Exstrophy of Urinary Bladder o defect between the umbilicus amp

genital tubercle o non-migration of mesoderm into

this region o mucosa of the bladder is exposed o associated with epispadias

3 Urachus (fibrous relict of the allantois) 4 Urn licus

(U Ile outflo onto the skin 6 Internal fully ls (urachus

dlvenlculum) 7 ElCternal fistula (urachal sinus)

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

Development of the Genital System bull sex of the fetus is obviously determined at fertilization bull on the Y chromosome is a region called testis determiningfactor (SRY) bull presence of the SRY gene determines development of a 0 amp absence of the SRY gene determines

development of a ~

bull genitalgonadal ridges o formed by proliferation of the epithelium amp condensation

of mesenchyme o appear as a pair of longitudinal ridges adjacent to the

mesonephric duct o primordial germ cells invade genital or gonadal ridges

Gemliii Mesonephric o germ cells have an inductive influence on the development Mge ridge

of testis amp ovary A B bull primordial germ cells are necessary for the development of testis or

ovary

bull failure of the primordial germ cells to reach the gonad or genital ridge results in failure of gonads to develop

)Ip~ PoimonlW Germ Cells

Mesonephric Aorta bull genital development has 2 phases duel

o indifferent phase bull initially both mesonephric (wolffian) amp paramesonephric

(mullerian) ducts are present

o differentiation phase Primitive sex cordsbull SOX9 or WNT4 are expressed in the genital ridges that

determines whether a testis or ovary will be formed bull genital system consists of the following

o gonads or primitive sex glands o genital ducts o external genitalia

bull all 3 components pass through the indifferentdifferentiation phases

bull finally ~ or 0 genitalia develops

o in 0 bull SOX9 indyces tea differentiation bull SRY directlY or indirectlY through SOX9 produces steroidgenesis factor 1 (SF1) bull SF1 stimulates differentiation of Sertoli amp Leydig cells amp paramesonephric duct regression

results--- shybull Leydig cells produce testosterone and helps in the further differentiation of 0 external

genitalia

o In ~ bull ~ is the ovary determining gene bull 1 induces ovarian differentiation bull D~Linhibits thenuct3eA-ef- QX9 bull estrogens also playa role in sexual differentiation by stimulating paramesonephric ducts to

form female genitalia

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

bull Summary

44 + H + X

Corti I Lord dev lop

JlJiliun ica albugillPJ J2 tunica albu ineJ

bull development of external genitalia of (5 o~genital tubercle enlarges to form most of the penis (glans amp erectile bodies) o as penis enlarges urethral folds are pulled forward and fuse in the midline

CLINICAL CORRELATIONS - (5 VI-Iypospadias of Penis amp Scrotum

o failure of urethral or scrotal folds to fuse in the midline o this abnormal opening is along the inferior (midline) of the penis amp can be anywhere from the

perineum to the glans ~ Epispadias of Penis

o urethral meatus found on dorsum of penis o genital tubercle develops on the urorectal septum instead of the cloacal membrane

~ Decent of the Testis

LJr~(cJ

bull formation of uterus and vagina o uterus

bull the paramesonephric duct grows toward the urogenital sinus (UGS)

bull from UGS sinovaginal bulbs proliferate to form vaginal plate

bull the vagina is separated from the U GS by the hymen

c== o vagma bull from the pelvis arise sinovaginalbulbs

1 1 from the vagl11a p ate A bull proliferation continues cranially to join uterus bull finally canalization amp absorption of septum occurs

U tCtl IlC

lub

~

UrolJenn al 5 1(111 5gt

B

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

tube

Indentation

Uterus breomls umcoills Atresia of CEIIlX

Most Common

bull formation of external genitalia of ~ o genital tubercle forms the~

o urethral and labioscrotal folds DO NOT fuse in midline bull unfused urethral groove persists as the vestibule of the vagina bull -urethral folds =labia minora bull tkbioscrotal folds = labia majora

CLINICAL CORRELATIONS ~ Anatomic Variants of Uterus amp Vagina

o uterus amp vagina abnormalities can be caused by bull persistence of utgine septum of paramesonephric

ducts bull obliteration of uterine canal

bull summary o shuctures derived from the paramesonephric (Mullerian)

duct bull uterine tubes -- 1 rudimentary horn

bull uterus shybull upper vagina amp for~Ol-_ltlt-___

o lower vagina develops fro 0 enital sinusect gt o from the gubernaculum

bull (5 - gubernaculum tes tis bull ~ - ovarian ligament + round ligament of uterus

Perineum

bull anteriorly pubic symphysis bull antero-Iaterally ischiopubic rami bull laterally ischial tuberosities bull postero-Iaterally sacrotuberous ligament bull posteriorly coccyx bull divided into urogenital triangle amp anal triangle

Urogenital L1 bull Superficial perineal space (pouch)

o between perineal membrane amp Colles fascia (continuation of Scarpas fascia) o contents

(5 ~ superficial transverse perineal m superficial transverse perineal m shy

ischiocavernosus mm - ischiocavernosus rum

bulbospongiosus mm ~ bulbospongiosus mm

crus of penis v crus of clitoris

bulb of penis bulb of vestibule glands

branches of internal pudendal vessels branches of internal pudendal vessels

perineal nerve amp branches perineal nerve amp branches

greater vestibularglands

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

o Colles fascia bull continuous with dartos tunic of scrotum with superficial fascia of penis amp Scarpas fascia of

anterior abdominal wall shyo Perineal membrane

bull it is the infenorfascia ofthe urogenital diaphragm

bull pierced by urethra bull thickened anteriorly to form transverse ligament of perineum

o MM in the superficial perineal space bull ischiocay~mosus mm

bull from ischial tuberosities amp ischN bic rami into corpus cavernosum (crus) bull INN perineal branch of u dendal n bull Action maintain erection by compressing crus amp deep dorsal vein of penis

bull bulbospongiosus mm bull 0 - from perineal body and fibrous raphe of bulb of penis to corpus spongiosum

amp perineal membrane bull yen - from perineal body to ubic arch and dorsum of clitoris bull INN perineal branch o(puden~ bull 0 Action compress bulb to maintain erection bull yen Action compress erectile tissue of vestibular bulbs and constrict vaginal orifice

bull superficial transverse perineal m bull from ischial rami amp tuberosities to central tendon (perineal body) bull IlN perineal branch of pudendal nerve -shybull Action stabilize central reruion

o perineal body (central tendon of perineum) bull fibromuscular mass located in center of perineum between anal canal and vagina (or bulb of

penis) bull site of attachment for

bull superficial amp dee transverse perineal mm bull bulbos ongiosu~ bull smooth amp voluntary sli s of muscle from external urethral sphincter amp levator ani bull external anal sphincter rom

bull CLINICAL CORRELATION bull Disruption of Perineal Body

~ especially important structure in s2 because it is the final support of the pelvic Viscera

~ stretching or tearing of this attachment of the perineal mm from the perineal body can occur during childbirth removing the support

~ as a resultprolapse ofpelvic viscera including prolapse of the bladder (through the urethra) amp prOfapse of the uterus and or vagina (through vaginal orifice) may occur

bull Episiotomy ~ during vaginal surgery amp labor anJwotomy (surgical incision of the perineum amp

infero-posterior vaginal wall) is often made to enlarge the vaginal orifice amp to prevent a jagged tear of the perineal muscles

o greater vestibular (Bartholins) gl~nds

bull lie deep to vestibular bulbs in s2 bull homologous to bulbow ethral

ducts into the vestibule between the ilir=iili~~~~~~~~-ltiitc~-

Superficial contents of 0 pouch Superficial contents of s2 pouch

bull Deep Perineal space (pouch) o between superior and inferior fascia of urogenital diaphragm o contents

0 s2

deep transverse perineal muscle -shy -deep transverse perineal muscle

sphincter urethrae (internal) sphincter urethrae (internal) shy

bulbourethral glands - shy

branches of internal pydendal vessels amp nerves branches of internal pudendal vessels amp nerves

external urethral sphincter

o CLINICAL CORRELATION bull rupture of urethra in Os amp extravasation of urine

ort1~ I1l11fn)leQal_ pan mwettn

~MIIQj ~1If rJ

A

--shyOI~~~~f-1- -_e Deo(l IBool1 -01 ltC--~Il- ~~~~laquolo

______~ lKlion

~ rupture ofintermediate part ofthe urethra results in extravasation of urine amp blood into the deep perineal pouch

o fluid may pass superiorly through the UG hiatus amp distribute extraperitoneally around the prostate amp bladder

~ rupture ofthe spongy urethra in the bulb of the penis results in urine passing (extravasating) into the superficial erineal s ace

o attachments of the perineal fascia determine the direction of flow of the extravasated urine

o urine amp blood may pass into the LcT in the scrotum around the penis amp superiorly deep to Scarpas fascia (continuous with Dartos fascia)

o note urine cannot pass far intot he thighs because the membranous layer of superficial perineal fascia blends with the fascia lata (deep fascia)

o note urine cannot pass posteriorly into the anal ~ because the superficial amp deep layers of perineal fascia are continuous with each other the posterior edge

- shy

o MM of deep perineal space bull deep transverse perineal m

bull 6 - from ischial rami to perineal body bull yen - from ischial rami to perineal body amp wall of vagina bull INN perineal branches of pudendal nerve bull Action stabilizes perineal body amp in 6 supports prostate gland amp in yen supports vagina

bull sphincter urethrae bull from inferior pubic ramus to perineal body bull INN perineal branch of pudendal nerve bull 6 Action encircles amp constricts the membranous urethra bull yen Action inferior part attaches to anterolateral wall of vagina that compresses both the

urethra amp vagina bull urogenital diaphragm (UG diaphragm)

bull consists of the deep transverse perineal m amp sphincter urethrae bull has inferior amp superior fascia bull inferior fascia provides support for the bulb of the penis in 6

bull bulbourethral (Cowpers) glands bull on posterolateral sides of membranous urethra bull ducts pass through inferior fascia of UG diaphgram to open into the bulbous portion

Wrr 1 )W- N

-shyAIIlIf

A MedJan Merion

of spongy urethra

Anal ) bull ischiorectal (ischioanal) fossa

SactaJ plexus

6---h- Pudendal nerveIseIlilll spine_iI-_+___~

InIriolt anal (raelal) netVe

Dorsal nerve of peniS

II1II nerves

Pudendal Canal

bull Anal Canal Artrin~ Vlnl

F10m IIfartot JUIIHioIII119llC ar1~f)

~ Nbullbull --------t-H1 Ik+bf-------shybull _alort__

iiIIJId PJs~atMtk) and SQffli)ry

t - shyP middotmiddot------------------gt~iiMllrru ltv _ - --- - ------ - -- -- - ---P~1ine o

~ ~

o internal anal sphincter bull involuntary amp surrounds superior 23 of anal

canal

bull thickening of circular muscular layer bull contraction stimulated by sympathetic fibers

from superior rectal (periarterial) amp hypogastic plexuses

bull inhibited by parasympathetic fibers o interior of anal canal

bull superior half has anal columns (contain terminal branches of superior rectal a + v)

bull inferior ends of these columns are joined by anal valves

bull anal sinuses are superior to these valves amp

secrete mucus to aid in defecation bull inferior anal sinuses form the pectinate line

o contents bull

o

LymphaftC

To o-t o

ischioanal fat - allows distention of anal canal during defecation

bull inf rectal nerves amp vessels - branches of internal pudendal vessels amp pudendal nerve

bull perineal branches of posterior femoral cutaneous nerve bull there is corrunurllcation of both fossae posteriorly

through the postanal space above the anococrygeallig

bull puJlendal (Alcocks) cJlnal bull on lateral wall bull fascial canal formed by a split in the obturator

internus fascia bull structures running inside canal

o pudendal artel-Y amp vein o pudendal nenre o nerve to the obturator internus -

begins at the level of the U-shaped sling formed by puborectalis muscle ends at the anus surrounded by an internal amp external anal sphincter external anal sphincter

bull large amp voluntary bull blends superiorly with the puborectalis muscle bull has subcutaneous superficial amp deep parts bull supplied by S4 through inferior rectal nerve

external urethral sphincter

o CLINICAL CORRELATION bull rupture of urethra in Os amp extravasation of urine

ort1~ I1l11fn)leQal_ pan mwettn

~MIIQj ~1If rJ

A

--shyOI~~~~f-1- -_e Deo(l IBool1 -01 ltC--~Il- ~~~~laquolo

______~ lKlion

~ rupture ofintermediate part ofthe urethra results in extravasation of urine amp blood into the deep perineal pouch

o fluid may pass superiorly through the UG hiatus amp distribute extraperitoneally around the prostate amp bladder

~ rupture ofthe spongy urethra in the bulb of the penis results in urine passing (extravasating) into the superficial erineal s ace

o attachments of the perineal fascia determine the direction of flow of the extravasated urine

o urine amp blood may pass into the LcT in the scrotum around the penis amp superiorly deep to Scarpas fascia (continuous with Dartos fascia)

o note urine cannot pass far intot he thighs because the membranous layer of superficial perineal fascia blends with the fascia lata (deep fascia)

o note urine cannot pass posteriorly into the anal ~ because the superficial amp deep layers of perineal fascia are continuous with each other the posterior edge

- shy

o MM of deep perineal space bull deep transverse perineal m

bull 6 - from ischial rami to perineal body bull yen - from ischial rami to perineal body amp wall of vagina bull INN perineal branches of pudendal nerve bull Action stabilizes perineal body amp in 6 supports prostate gland amp in yen supports vagina

bull sphincter urethrae bull from inferior pubic ramus to perineal body bull INN perineal branch of pudendal nerve bull 6 Action encircles amp constricts the membranous urethra bull yen Action inferior part attaches to anterolateral wall of vagina that compresses both the

urethra amp vagina bull urogenital diaphragm (UG diaphragm)

bull consists of the deep transverse perineal m amp sphincter urethrae bull has inferior amp superior fascia bull inferior fascia provides support for the bulb of the penis in 6

bull bulbourethral (Cowpers) glands bull on posterolateral sides of membranous urethra bull ducts pass through inferior fascia of UG diaphgram to open into the bulbous portion

Wrr 1 )W- N

-shyAIIlIf

A MedJan Merion

of spongy urethra

Anal ) bull ischiorectal (ischioanal) fossa

SactaJ plexus

6---h- Pudendal nerveIseIlilll spine_iI-_+___~

InIriolt anal (raelal) netVe

Dorsal nerve of peniS

II1II nerves

Pudendal Canal

bull Anal Canal Artrin~ Vlnl

F10m IIfartot JUIIHioIII119llC ar1~f)

~ Nbullbull --------t-H1 Ik+bf-------shybull _alort__

iiIIJId PJs~atMtk) and SQffli)ry

t - shyP middotmiddot------------------gt~iiMllrru ltv _ - --- - ------ - -- -- - ---P~1ine o

~ ~

o internal anal sphincter bull involuntary amp surrounds superior 23 of anal

canal

bull thickening of circular muscular layer bull contraction stimulated by sympathetic fibers

from superior rectal (periarterial) amp hypogastic plexuses

bull inhibited by parasympathetic fibers o interior of anal canal

bull superior half has anal columns (contain terminal branches of superior rectal a + v)

bull inferior ends of these columns are joined by anal valves

bull anal sinuses are superior to these valves amp

secrete mucus to aid in defecation bull inferior anal sinuses form the pectinate line

o contents bull

o

LymphaftC

To o-t o

ischioanal fat - allows distention of anal canal during defecation

bull inf rectal nerves amp vessels - branches of internal pudendal vessels amp pudendal nerve

bull perineal branches of posterior femoral cutaneous nerve bull there is corrunurllcation of both fossae posteriorly

through the postanal space above the anococrygeallig

bull puJlendal (Alcocks) cJlnal bull on lateral wall bull fascial canal formed by a split in the obturator

internus fascia bull structures running inside canal

o pudendal artel-Y amp vein o pudendal nenre o nerve to the obturator internus -

begins at the level of the U-shaped sling formed by puborectalis muscle ends at the anus surrounded by an internal amp external anal sphincter external anal sphincter

bull large amp voluntary bull blends superiorly with the puborectalis muscle bull has subcutaneous superficial amp deep parts bull supplied by S4 through inferior rectal nerve

bull bulbourethral (Cowpers) glands bull on posterolateral sides of membranous urethra bull ducts pass through inferior fascia of UG diaphgram to open into the bulbous portion

Wrr 1 )W- N

-shyAIIlIf

A MedJan Merion

of spongy urethra

Anal ) bull ischiorectal (ischioanal) fossa

SactaJ plexus

6---h- Pudendal nerveIseIlilll spine_iI-_+___~

InIriolt anal (raelal) netVe

Dorsal nerve of peniS

II1II nerves

Pudendal Canal

bull Anal Canal Artrin~ Vlnl

F10m IIfartot JUIIHioIII119llC ar1~f)

~ Nbullbull --------t-H1 Ik+bf-------shybull _alort__

iiIIJId PJs~atMtk) and SQffli)ry

t - shyP middotmiddot------------------gt~iiMllrru ltv _ - --- - ------ - -- -- - ---P~1ine o

~ ~

o internal anal sphincter bull involuntary amp surrounds superior 23 of anal

canal

bull thickening of circular muscular layer bull contraction stimulated by sympathetic fibers

from superior rectal (periarterial) amp hypogastic plexuses

bull inhibited by parasympathetic fibers o interior of anal canal

bull superior half has anal columns (contain terminal branches of superior rectal a + v)

bull inferior ends of these columns are joined by anal valves

bull anal sinuses are superior to these valves amp

secrete mucus to aid in defecation bull inferior anal sinuses form the pectinate line

o contents bull

o

LymphaftC

To o-t o

ischioanal fat - allows distention of anal canal during defecation

bull inf rectal nerves amp vessels - branches of internal pudendal vessels amp pudendal nerve

bull perineal branches of posterior femoral cutaneous nerve bull there is corrunurllcation of both fossae posteriorly

through the postanal space above the anococrygeallig

bull puJlendal (Alcocks) cJlnal bull on lateral wall bull fascial canal formed by a split in the obturator

internus fascia bull structures running inside canal

o pudendal artel-Y amp vein o pudendal nenre o nerve to the obturator internus -

begins at the level of the U-shaped sling formed by puborectalis muscle ends at the anus surrounded by an internal amp external anal sphincter external anal sphincter

bull large amp voluntary bull blends superiorly with the puborectalis muscle bull has subcutaneous superficial amp deep parts bull supplied by S4 through inferior rectal nerve

o vasculature amp lymphatic drainage bull above pectinate line

bull superior rectal artery bull note middle rectal artery assists with anastomosing

superior amp inferior rectal aa bull superior rectal vein ~ portal system bull drainage to internal iliac lYmph nodes ~ common iliac

nodes ~ lumbar (aortic) nodes bull ~NN inferior hYPOfClftric plexus (sympathetic

parasympathetic amp visceral afferent fibers ~ S2 - S4)

bull below pectinate line bull inferior rectal artery bull inferior rectal vein ~ systemic system (IVC) bull drainage to supeificial inguinal lYmph nodes bull JNN inJrior anal rectal nenes (branches ofBpde~

nerve at convey pain touch temperature bull MM of anal ~

o obturator internus bull INN nerve to the obturator bull Action lateral rotation of thigh

o sphincter ani externus bull from tip of coccyx amp annococcygealligament to perineal body bull INN inferior rectal nerve bull Action closes the anus

o LEVATOR ANI MUSCLE bull consists ofpuborectalis pubococrygeus iiiococrygeus bull INN Nerve to Levator Ani (branches of S4) and perineal branch of pudendal nerve bull Action supports amp raises pelvic floor

o coccygeus bull from ischial spine amp sacrospinous ligament to coccyx bull INN branches of S4 amp S5 nerves bull Action supports amp raises pelvic floor

MM of 0 pelvic diaphragm MM of ~ pelvic diaphragm

External Genitalia amp Associated Sttuctures

Faciae amp Ligaments ev deep fascia of penis (Bucks fascia)

o continuation of the deep perineal fascia o continuous with the fascia covering the external oblique muscle amp rectus sheath

y tunica albuginea -shyo dense fibrous layer that envelops both the corpora cavernosa amp corpus spongiosum o more dense around corpora cavernosa (impedes venous return upon erection) and more elastic around

corpus sponglOsum e tunica vaginalis I

o serous sac of peritoneum that covers the front amp sides of the testis amp epididymis o consists of a parietal layer that forms the innermost layer of the scrotum amp a visceral layer adherent to

the testis and epididymis evprocessus vaginalis

o diverticulum of the peritoneum that transverses the inguinal canal e gubernaculum

Q- 0 - fibrous cord that connects the fetal testis to the floor of the developing scrotum bull pulls the testis down (aids in testis decent)

0 yen -homologues are round ligament amp ovarian ligaments

0 External Genitalia

Scrotum 1 scrotum layers

1( thin skin 2 superficial (dartos) fascia

bull continuous with superficial penile fascia amp superficial perineal fascia (Colles fascia) bull responsible for wrinkling the scrotal skin bull note cremaster muscle elevates testis

3 external spermatic fascia bull continuous with external oblique a on~sis of ant abdominal wall

4 cremaster muscle amp fascia bull continuous with internal oblique muscle of ant abdominal wall bull note it is NOT a continuation of the aponeurosis

5 internal spermatic fascia bull continuous with the tra(ersus abdominus aponeurosis

6 parietal layer of the tunica vaginalis bull remnant of the proccesus vaginalis

7 testis covered by visceral layer of tunica vaginalis = tunica albuginea bull gives the testis a shiny appearance

2 no fat and sparse hairs e blood supply

o external pudendal aa o posterior scrotal branches of the internal pudendal aa

e INN o ant scrotal branch of iliojngJ inaln~e o genital branch of the e 0 rv~ o post scrotal branch of the perineal branch of pudendal nerv o perineal branch of the posterior femoral cutaneous nerve

Penis bull consists of 3 masses of vascular erectile tissue 2 x corpora cavernosa amp corpus spongiosum (all bounded by

tunica albuginea bull root 2 crura amp bulb of penis bull body single corpus spongiosum amp 2 x corpora cavernosa bull head glans penis which is formed by the terminal part of the corpus spongiosum amp covered by a free fold of

skin - prepuce (frenulum of prepuce is a median ventral fold passing from the deep surface of the prepuce) bull preputial glands small sebaceous glands of the corona the neck of the glans penis amp inner surface of the

prepuce which secrete smegma dOrsal 0

B Inferior VteW

Corpus C8wmotum

Urellm

~ External Genitalia

Labia Majora bull 2 longitudinal folds of skin that run downward and backward from the mons pubis bull homologous to scrotum in 0 bull contain terminations of round ligaments of the uterus

Labia Minora bull hairless amp contain no fat bull divided into

o upper ~ateral) parts above clitoris fuse to form the prepuce of the clitoris o lower (medial) parts below clitoris fuse to form the frenulum of the clitoris

Vestibule of the vagina (urogenital sinus) bull space between the labia minora bull has openings for urethra vagina amp ducts of the greater vestibular glands in its floor

Clitoris bull homologous to penis in 0 bull consists of erectile tissue that is enlarged as a

result of engorgement with blood bull consists of 2 crura 2 corpora cavernosa amp a

glans Bell no co~pus sponglOsum bull glans clitoris is derived from corpora cavernosa

Bulbs of the vestibule bull homologues of the bulb of the penis in 0

Nerve Supply of the Perineal Region

Pudendal Nerve (S2-S4) bull passes through greater sciatic foramen between piriformis amp coccygeus mm bull wraps around ischial spine and enters perineum with internal pudendal artery through lesser sciatic foramen bull enters pudendal canal bull gives rise to inferior rectal nerve amp perineal nerve bull in 0 terminates as the dorsal nerve of the penis bull in ~ terminates as the dorsal nerve of the clitoris

Inferior Rectal Nerve bull arises within pudendal canal bull divides into several branches crosses the ischiorectal fossa bull innervates spincter ani externus amp skin around anus

- )erineal Nerve bull arises within pudendal canal bull divides into a deep branch - supplies all of the perineal mm bull divides into a superficial (posterior scrotal or labial) branch - supplies the sc~_or labia majora

Dorsal Nerve of the Penis in 0 (or clitoris in ~) bull pierces perineal membrane bull runs between two layers of the suspensory ligament of the penis or clitoris bull runs deep to the deep fascia on the dorsum of the penis or clitoris bull innervates skin prepuce amp glans in both 0 amp ~

Anteoo ( labial commissure

VbuIe

labium minus

VaPl onte

Ftanulum 01 )

Iaba moro ~ Peroneal body ~~

An Anococcygeal

body

A InIrior view (lithotomy posillon)

Superflclal transWlr5e peJl1eal

Corpus caverrlOSum of clilOrtS

Urethrn Crus 01 chloris

B Transverse section

8 t1vt_

cl Silft)lIbdc

Psy~1WI4I _Mlnd5~~ftC~==---

mtemaJ pclderdaIe

lnfooo feclaJ a Jff-s~-IlIitf

Lampralor am

A Inlenor view

Vasculature of the Perineal Region

Internal Pudendal Artery bull arises from internal iliac artery bull leaves pelvis through greater sciatic foramen between piriformis amp coccygeus nun bull immediately enters through lesser sciatic foramen ( hooks around ischial spine)

o remember pudendal nerve follows the EXACT same pathway bull passes along the lateral wall of the ischiorectal fossa in the pudendal canal bull gives rise to

1 inferior rectal artery bull arises within pudendal canal amp pierces its wall bull breaks into several branches and supplies nun and skin around anal canal

2 perineal arteries bull supply superficial perineal nun and give rise to transverse perineal branches amp posterior scrotal

(or labial) branches 3 artery of the bulb

bull arises within the deep perineal space amp pierces perineal membrane bull in 0 supplies bulb of the penis amp bulbourethral glands bull in yen supplies vestibular bulbs amp greater vestibular glands

4 urethral artery bull pierces perineal membrane enters the corpus spongiosum of penis amp continues to glans penis

5 deep arteries of the penis or clitoris bull terminal branches of the pudendal artery bull pierce the perineal membrane amp run through the center of the corpus spongiosum or clitoris to

supply erectile tissue 6 dorsal arteries of the penis or clitoris

bull pierce perineal membrane amp pass through the suspensory ligament of the penis or clitoris bull run along its dorsum on each side of the dorsal vein and deep to Bucks fascia amp superficial to

the tunica albuginea to supply the glans and prepuce External pudendal artery

bull arises from the femoral artery bull emerges through the saphenous ring to pass medially over spermatic cord or the round ligament of the uterus

to supply the skin above the pubis penis amp scrotum or labium majora

FemoIlt

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

External Genitalia amp Associated Sttuctures

Faciae amp Ligaments ev deep fascia of penis (Bucks fascia)

o continuation of the deep perineal fascia o continuous with the fascia covering the external oblique muscle amp rectus sheath

y tunica albuginea -shyo dense fibrous layer that envelops both the corpora cavernosa amp corpus spongiosum o more dense around corpora cavernosa (impedes venous return upon erection) and more elastic around

corpus sponglOsum e tunica vaginalis I

o serous sac of peritoneum that covers the front amp sides of the testis amp epididymis o consists of a parietal layer that forms the innermost layer of the scrotum amp a visceral layer adherent to

the testis and epididymis evprocessus vaginalis

o diverticulum of the peritoneum that transverses the inguinal canal e gubernaculum

Q- 0 - fibrous cord that connects the fetal testis to the floor of the developing scrotum bull pulls the testis down (aids in testis decent)

0 yen -homologues are round ligament amp ovarian ligaments

0 External Genitalia

Scrotum 1 scrotum layers

1( thin skin 2 superficial (dartos) fascia

bull continuous with superficial penile fascia amp superficial perineal fascia (Colles fascia) bull responsible for wrinkling the scrotal skin bull note cremaster muscle elevates testis

3 external spermatic fascia bull continuous with external oblique a on~sis of ant abdominal wall

4 cremaster muscle amp fascia bull continuous with internal oblique muscle of ant abdominal wall bull note it is NOT a continuation of the aponeurosis

5 internal spermatic fascia bull continuous with the tra(ersus abdominus aponeurosis

6 parietal layer of the tunica vaginalis bull remnant of the proccesus vaginalis

7 testis covered by visceral layer of tunica vaginalis = tunica albuginea bull gives the testis a shiny appearance

2 no fat and sparse hairs e blood supply

o external pudendal aa o posterior scrotal branches of the internal pudendal aa

e INN o ant scrotal branch of iliojngJ inaln~e o genital branch of the e 0 rv~ o post scrotal branch of the perineal branch of pudendal nerv o perineal branch of the posterior femoral cutaneous nerve

Penis bull consists of 3 masses of vascular erectile tissue 2 x corpora cavernosa amp corpus spongiosum (all bounded by

tunica albuginea bull root 2 crura amp bulb of penis bull body single corpus spongiosum amp 2 x corpora cavernosa bull head glans penis which is formed by the terminal part of the corpus spongiosum amp covered by a free fold of

skin - prepuce (frenulum of prepuce is a median ventral fold passing from the deep surface of the prepuce) bull preputial glands small sebaceous glands of the corona the neck of the glans penis amp inner surface of the

prepuce which secrete smegma dOrsal 0

B Inferior VteW

Corpus C8wmotum

Urellm

~ External Genitalia

Labia Majora bull 2 longitudinal folds of skin that run downward and backward from the mons pubis bull homologous to scrotum in 0 bull contain terminations of round ligaments of the uterus

Labia Minora bull hairless amp contain no fat bull divided into

o upper ~ateral) parts above clitoris fuse to form the prepuce of the clitoris o lower (medial) parts below clitoris fuse to form the frenulum of the clitoris

Vestibule of the vagina (urogenital sinus) bull space between the labia minora bull has openings for urethra vagina amp ducts of the greater vestibular glands in its floor

Clitoris bull homologous to penis in 0 bull consists of erectile tissue that is enlarged as a

result of engorgement with blood bull consists of 2 crura 2 corpora cavernosa amp a

glans Bell no co~pus sponglOsum bull glans clitoris is derived from corpora cavernosa

Bulbs of the vestibule bull homologues of the bulb of the penis in 0

Nerve Supply of the Perineal Region

Pudendal Nerve (S2-S4) bull passes through greater sciatic foramen between piriformis amp coccygeus mm bull wraps around ischial spine and enters perineum with internal pudendal artery through lesser sciatic foramen bull enters pudendal canal bull gives rise to inferior rectal nerve amp perineal nerve bull in 0 terminates as the dorsal nerve of the penis bull in ~ terminates as the dorsal nerve of the clitoris

Inferior Rectal Nerve bull arises within pudendal canal bull divides into several branches crosses the ischiorectal fossa bull innervates spincter ani externus amp skin around anus

- )erineal Nerve bull arises within pudendal canal bull divides into a deep branch - supplies all of the perineal mm bull divides into a superficial (posterior scrotal or labial) branch - supplies the sc~_or labia majora

Dorsal Nerve of the Penis in 0 (or clitoris in ~) bull pierces perineal membrane bull runs between two layers of the suspensory ligament of the penis or clitoris bull runs deep to the deep fascia on the dorsum of the penis or clitoris bull innervates skin prepuce amp glans in both 0 amp ~

Anteoo ( labial commissure

VbuIe

labium minus

VaPl onte

Ftanulum 01 )

Iaba moro ~ Peroneal body ~~

An Anococcygeal

body

A InIrior view (lithotomy posillon)

Superflclal transWlr5e peJl1eal

Corpus caverrlOSum of clilOrtS

Urethrn Crus 01 chloris

B Transverse section

8 t1vt_

cl Silft)lIbdc

Psy~1WI4I _Mlnd5~~ftC~==---

mtemaJ pclderdaIe

lnfooo feclaJ a Jff-s~-IlIitf

Lampralor am

A Inlenor view

Vasculature of the Perineal Region

Internal Pudendal Artery bull arises from internal iliac artery bull leaves pelvis through greater sciatic foramen between piriformis amp coccygeus nun bull immediately enters through lesser sciatic foramen ( hooks around ischial spine)

o remember pudendal nerve follows the EXACT same pathway bull passes along the lateral wall of the ischiorectal fossa in the pudendal canal bull gives rise to

1 inferior rectal artery bull arises within pudendal canal amp pierces its wall bull breaks into several branches and supplies nun and skin around anal canal

2 perineal arteries bull supply superficial perineal nun and give rise to transverse perineal branches amp posterior scrotal

(or labial) branches 3 artery of the bulb

bull arises within the deep perineal space amp pierces perineal membrane bull in 0 supplies bulb of the penis amp bulbourethral glands bull in yen supplies vestibular bulbs amp greater vestibular glands

4 urethral artery bull pierces perineal membrane enters the corpus spongiosum of penis amp continues to glans penis

5 deep arteries of the penis or clitoris bull terminal branches of the pudendal artery bull pierce the perineal membrane amp run through the center of the corpus spongiosum or clitoris to

supply erectile tissue 6 dorsal arteries of the penis or clitoris

bull pierce perineal membrane amp pass through the suspensory ligament of the penis or clitoris bull run along its dorsum on each side of the dorsal vein and deep to Bucks fascia amp superficial to

the tunica albuginea to supply the glans and prepuce External pudendal artery

bull arises from the femoral artery bull emerges through the saphenous ring to pass medially over spermatic cord or the round ligament of the uterus

to supply the skin above the pubis penis amp scrotum or labium majora

FemoIlt

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

Penis bull consists of 3 masses of vascular erectile tissue 2 x corpora cavernosa amp corpus spongiosum (all bounded by

tunica albuginea bull root 2 crura amp bulb of penis bull body single corpus spongiosum amp 2 x corpora cavernosa bull head glans penis which is formed by the terminal part of the corpus spongiosum amp covered by a free fold of

skin - prepuce (frenulum of prepuce is a median ventral fold passing from the deep surface of the prepuce) bull preputial glands small sebaceous glands of the corona the neck of the glans penis amp inner surface of the

prepuce which secrete smegma dOrsal 0

B Inferior VteW

Corpus C8wmotum

Urellm

~ External Genitalia

Labia Majora bull 2 longitudinal folds of skin that run downward and backward from the mons pubis bull homologous to scrotum in 0 bull contain terminations of round ligaments of the uterus

Labia Minora bull hairless amp contain no fat bull divided into

o upper ~ateral) parts above clitoris fuse to form the prepuce of the clitoris o lower (medial) parts below clitoris fuse to form the frenulum of the clitoris

Vestibule of the vagina (urogenital sinus) bull space between the labia minora bull has openings for urethra vagina amp ducts of the greater vestibular glands in its floor

Clitoris bull homologous to penis in 0 bull consists of erectile tissue that is enlarged as a

result of engorgement with blood bull consists of 2 crura 2 corpora cavernosa amp a

glans Bell no co~pus sponglOsum bull glans clitoris is derived from corpora cavernosa

Bulbs of the vestibule bull homologues of the bulb of the penis in 0

Nerve Supply of the Perineal Region

Pudendal Nerve (S2-S4) bull passes through greater sciatic foramen between piriformis amp coccygeus mm bull wraps around ischial spine and enters perineum with internal pudendal artery through lesser sciatic foramen bull enters pudendal canal bull gives rise to inferior rectal nerve amp perineal nerve bull in 0 terminates as the dorsal nerve of the penis bull in ~ terminates as the dorsal nerve of the clitoris

Inferior Rectal Nerve bull arises within pudendal canal bull divides into several branches crosses the ischiorectal fossa bull innervates spincter ani externus amp skin around anus

- )erineal Nerve bull arises within pudendal canal bull divides into a deep branch - supplies all of the perineal mm bull divides into a superficial (posterior scrotal or labial) branch - supplies the sc~_or labia majora

Dorsal Nerve of the Penis in 0 (or clitoris in ~) bull pierces perineal membrane bull runs between two layers of the suspensory ligament of the penis or clitoris bull runs deep to the deep fascia on the dorsum of the penis or clitoris bull innervates skin prepuce amp glans in both 0 amp ~

Anteoo ( labial commissure

VbuIe

labium minus

VaPl onte

Ftanulum 01 )

Iaba moro ~ Peroneal body ~~

An Anococcygeal

body

A InIrior view (lithotomy posillon)

Superflclal transWlr5e peJl1eal

Corpus caverrlOSum of clilOrtS

Urethrn Crus 01 chloris

B Transverse section

8 t1vt_

cl Silft)lIbdc

Psy~1WI4I _Mlnd5~~ftC~==---

mtemaJ pclderdaIe

lnfooo feclaJ a Jff-s~-IlIitf

Lampralor am

A Inlenor view

Vasculature of the Perineal Region

Internal Pudendal Artery bull arises from internal iliac artery bull leaves pelvis through greater sciatic foramen between piriformis amp coccygeus nun bull immediately enters through lesser sciatic foramen ( hooks around ischial spine)

o remember pudendal nerve follows the EXACT same pathway bull passes along the lateral wall of the ischiorectal fossa in the pudendal canal bull gives rise to

1 inferior rectal artery bull arises within pudendal canal amp pierces its wall bull breaks into several branches and supplies nun and skin around anal canal

2 perineal arteries bull supply superficial perineal nun and give rise to transverse perineal branches amp posterior scrotal

(or labial) branches 3 artery of the bulb

bull arises within the deep perineal space amp pierces perineal membrane bull in 0 supplies bulb of the penis amp bulbourethral glands bull in yen supplies vestibular bulbs amp greater vestibular glands

4 urethral artery bull pierces perineal membrane enters the corpus spongiosum of penis amp continues to glans penis

5 deep arteries of the penis or clitoris bull terminal branches of the pudendal artery bull pierce the perineal membrane amp run through the center of the corpus spongiosum or clitoris to

supply erectile tissue 6 dorsal arteries of the penis or clitoris

bull pierce perineal membrane amp pass through the suspensory ligament of the penis or clitoris bull run along its dorsum on each side of the dorsal vein and deep to Bucks fascia amp superficial to

the tunica albuginea to supply the glans and prepuce External pudendal artery

bull arises from the femoral artery bull emerges through the saphenous ring to pass medially over spermatic cord or the round ligament of the uterus

to supply the skin above the pubis penis amp scrotum or labium majora

FemoIlt

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

Clitoris bull homologous to penis in 0 bull consists of erectile tissue that is enlarged as a

result of engorgement with blood bull consists of 2 crura 2 corpora cavernosa amp a

glans Bell no co~pus sponglOsum bull glans clitoris is derived from corpora cavernosa

Bulbs of the vestibule bull homologues of the bulb of the penis in 0

Nerve Supply of the Perineal Region

Pudendal Nerve (S2-S4) bull passes through greater sciatic foramen between piriformis amp coccygeus mm bull wraps around ischial spine and enters perineum with internal pudendal artery through lesser sciatic foramen bull enters pudendal canal bull gives rise to inferior rectal nerve amp perineal nerve bull in 0 terminates as the dorsal nerve of the penis bull in ~ terminates as the dorsal nerve of the clitoris

Inferior Rectal Nerve bull arises within pudendal canal bull divides into several branches crosses the ischiorectal fossa bull innervates spincter ani externus amp skin around anus

- )erineal Nerve bull arises within pudendal canal bull divides into a deep branch - supplies all of the perineal mm bull divides into a superficial (posterior scrotal or labial) branch - supplies the sc~_or labia majora

Dorsal Nerve of the Penis in 0 (or clitoris in ~) bull pierces perineal membrane bull runs between two layers of the suspensory ligament of the penis or clitoris bull runs deep to the deep fascia on the dorsum of the penis or clitoris bull innervates skin prepuce amp glans in both 0 amp ~

Anteoo ( labial commissure

VbuIe

labium minus

VaPl onte

Ftanulum 01 )

Iaba moro ~ Peroneal body ~~

An Anococcygeal

body

A InIrior view (lithotomy posillon)

Superflclal transWlr5e peJl1eal

Corpus caverrlOSum of clilOrtS

Urethrn Crus 01 chloris

B Transverse section

8 t1vt_

cl Silft)lIbdc

Psy~1WI4I _Mlnd5~~ftC~==---

mtemaJ pclderdaIe

lnfooo feclaJ a Jff-s~-IlIitf

Lampralor am

A Inlenor view

Vasculature of the Perineal Region

Internal Pudendal Artery bull arises from internal iliac artery bull leaves pelvis through greater sciatic foramen between piriformis amp coccygeus nun bull immediately enters through lesser sciatic foramen ( hooks around ischial spine)

o remember pudendal nerve follows the EXACT same pathway bull passes along the lateral wall of the ischiorectal fossa in the pudendal canal bull gives rise to

1 inferior rectal artery bull arises within pudendal canal amp pierces its wall bull breaks into several branches and supplies nun and skin around anal canal

2 perineal arteries bull supply superficial perineal nun and give rise to transverse perineal branches amp posterior scrotal

(or labial) branches 3 artery of the bulb

bull arises within the deep perineal space amp pierces perineal membrane bull in 0 supplies bulb of the penis amp bulbourethral glands bull in yen supplies vestibular bulbs amp greater vestibular glands

4 urethral artery bull pierces perineal membrane enters the corpus spongiosum of penis amp continues to glans penis

5 deep arteries of the penis or clitoris bull terminal branches of the pudendal artery bull pierce the perineal membrane amp run through the center of the corpus spongiosum or clitoris to

supply erectile tissue 6 dorsal arteries of the penis or clitoris

bull pierce perineal membrane amp pass through the suspensory ligament of the penis or clitoris bull run along its dorsum on each side of the dorsal vein and deep to Bucks fascia amp superficial to

the tunica albuginea to supply the glans and prepuce External pudendal artery

bull arises from the femoral artery bull emerges through the saphenous ring to pass medially over spermatic cord or the round ligament of the uterus

to supply the skin above the pubis penis amp scrotum or labium majora

FemoIlt

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

Vasculature of the Perineal Region

Internal Pudendal Artery bull arises from internal iliac artery bull leaves pelvis through greater sciatic foramen between piriformis amp coccygeus nun bull immediately enters through lesser sciatic foramen ( hooks around ischial spine)

o remember pudendal nerve follows the EXACT same pathway bull passes along the lateral wall of the ischiorectal fossa in the pudendal canal bull gives rise to

1 inferior rectal artery bull arises within pudendal canal amp pierces its wall bull breaks into several branches and supplies nun and skin around anal canal

2 perineal arteries bull supply superficial perineal nun and give rise to transverse perineal branches amp posterior scrotal

(or labial) branches 3 artery of the bulb

bull arises within the deep perineal space amp pierces perineal membrane bull in 0 supplies bulb of the penis amp bulbourethral glands bull in yen supplies vestibular bulbs amp greater vestibular glands

4 urethral artery bull pierces perineal membrane enters the corpus spongiosum of penis amp continues to glans penis

5 deep arteries of the penis or clitoris bull terminal branches of the pudendal artery bull pierce the perineal membrane amp run through the center of the corpus spongiosum or clitoris to

supply erectile tissue 6 dorsal arteries of the penis or clitoris

bull pierce perineal membrane amp pass through the suspensory ligament of the penis or clitoris bull run along its dorsum on each side of the dorsal vein and deep to Bucks fascia amp superficial to

the tunica albuginea to supply the glans and prepuce External pudendal artery

bull arises from the femoral artery bull emerges through the saphenous ring to pass medially over spermatic cord or the round ligament of the uterus

to supply the skin above the pubis penis amp scrotum or labium majora

FemoIlt

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

Venous drainage of the penis bull deep dorsal vein of the penis

o unpaired vein that lies in the dorsal midline deep to Bucks fascia amp superficial to tunica albuginea o leaves perineum through gap between the arcuate pubic ligament amp the transverse perineal

ligament (aka cardinal ligament or Mackenrodts ligament) o drains to pelvic amp prostatic venous plexuses

bull superficial dorsal vein of the penis o runs toward the pubic symphysis between the superficial amp deep fasciae o terminates in the external (superficial) pudendal veins - drain to greater saphenous vein

Lymph nodes amp vessels bull lymphatic drainage of the perineum

o drain to superficial inguinal lymph nodes _- external iliac nodes - lumbar (aortic) nodes-

CS ~ lower abdominal wall lower abdominal wall

buttocks

buttocks

perns labia majora

scrotum lower parts of vagina

lower parts of anal canal - lower parts of anal canal

o dram to deep inguinal lymph nodes - external iliac nodes - lumbar (aortic) nodes 1 CS - glans penis ~ 2 ~ - clitoris amp labia minora --

bull lymphatic drainage of pelvis o drain to internal iliac nodes - common iliac nodes - lumbar (aortic) nodes

1 upper part of rectum - 2 vagina 3 other pelvic organs

o drain to inferior mesenteric nodes - aortic nodes 1 uppermost part of rectum

o drain directlY to aortic nodes 1 CS - testis amp epididymis 2 ~ - ovaries j

A bull Glare plInII ris) B bull SpongyJlUbot - c - 5Jl1I1 or bOdy of p~lJn

Ib _ )

cJ LumtMtor = Clttnmonlllac _1IICJlIIIIlu c=l E~ellac _ S __l~l

_ Oeep InQtlill ~ OlJeGlIOn 01 of ~

A VoJv[ 8 = GpoundaN ddonllitbiJI mnxa C a-Uleltl

= Wmbou = CltgtmmonIlOlt _JnttmallMc c=J EXlIImai-c _ _ l~

_ 0000 tngUoMI _ SOcI1Il -+ DNdIon or fIlM 0 ~

Anterior view rior J1ew

o -Lymphatic drainage ~ - Lymphatic drainage

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

pe1vs ry h+ -- Le+-+ pel- bon ~S~poundf~C Sacrum pound ColC-Ij~ u

~rcclu~1-r-lAlstuboccJ CI rlC4rI e cd-hrt-ch eamp ---ubu-cJ e at-U Jcs~~ill i oc cr epoundtshy

supoundJ1 c n6~iic~ CtJt4+cheS 4e ~e -ctc poss~

pelJl c LeJ- Bnm pe-Vf G outleishy

poundtn- ~ pbic So rn P~f ~hioF~ c r~ ) Lr foSrgt peo rt)~Q(1

l er ~ CAAtJ ( i~ +P CI t- (0c~ aC ) flO) tshy

0- Lt(t SCrUA -+-utbeltC ~ ptt~ ~JjS

~i ~ Sgt rOM tU ~t

fJubi~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

~~ -

ltamp Icl L

~cJ-

_btCtd~

Cerli r---~-T-~

~ pudevd~ Recto~ne PttLh

- de-~ T)0(j ~ povck-

--- shy

Fo~~

Utero eg ~ =) cLsO =flfgte~ ( - h ~ 6lA deler IS d~ed -

CQ~da- =) pasrer ~rrWx

or o

(Y)(l e) pubo pro ~ r

f cI6()(~ Q4hs -

-1he pelvic d-iAphr~M

p pLLboco~eCLU6

~r oretnf(x shy

C-tck ~ SphLVctcr

bull Ufi~1 If) cocJinGl ce bull

=

plAbo Y~llo fS

h cutshy

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

~o Co ~eouS oLo ack

V~ampl(re -

~+evrnC(1 JJi QC- -Artu-y

o6i1era+e al

LtrY) 6~h ccJ crl-erY

~

~aL~-iI$(J ~ A lli c LUr-lt b q r

~+engt ~r~1

r A

K- ~ YIldcf Ie r~d-cJ

-

f utea I J1 lotcrc1a~

~

8+r~) no u r fle

Jeio

cb~~e-r 1shy~~ -h-Jtleuro

bull ullClr~ bQdder =-= shy

LHo~(c1l

dISA~~

p~~

~~

sb(jc- ~

Co~~ (td-ro hed-a)

V~id~

absorbed partshy~ mc=sonep r- C cloct

JJ

~-Uvulct~ Veti cQ lt=-

In1bYlu (jr~

o (~cc Ce ~ ~ oJ

tjr~rQ

r Gt 4( - Uq e

i nhlbHt)~ +0

L-ter re~rQ n e(

(Spwctur Ytti=eJ ~

reg Mew$~p~ MeM rneh-u M

Lob~

f- CCjo G tdc j d ct

prt-~ shyI ~6

IL--shy

Urdtr~

=== VrfQUS -= to tl ncJ ~ r- -trIJe

CA~ nre ~t-- middotImiddoth~I os

cuvi~ I CA()~

lJtevine Qrtey~4= brQr-~ =-sf- exremal iIi0( Uftcry

5Ljpor~ t U+U

CD p~iC ~r(JM qb-jeal 80~

Cd- d aty)~ G bam~

~ - L 2shy

SJ - S~

0 reg

l-t pojcl-h--k copy

~ LF)

oON-t c pleocuampreg (~ - Lz)

CE)

-

e TrtlnbvEYse CerIcCt feu~ c Urero S CtCXQ ~do

A PLtbO c ervlca Asua

kpoundup LcJ~ middotdjMfh ro~ -

-gt p~ S~GL- of

4 SI-tlt p~~elL(

~rrlf

PQfQ ~

lJtero YdncJ P~~

~P H~f(Ij~-h-iG - sur

jshy H~~~~hi~ N

ltk la--

-t rcre $1p~~~c

IT

() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra

rr ~~14-ube-oGi-1 15C~L

--QrYh

pQ2~ ---t~ tgtbnv-Qtoshy ~

-t()(~M~~

Lshol - ~

e pudev da1 rlo(le

=gt Abc eampSe2

S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-

0()1 crnG I

F~sc~ ~ rs~ ~~I

extcr ( 01 Co YI GI -ophlYlcTc=r

1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd

Loamp~ cNOIvJecl ~ ~1 IR spc~

pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T

(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I

V~Scamp

6~ Aal isk10 ry PcU sca c- amp-0 M

ilP -te e +0a lIpound

~ e Is-hie rc~ -p-SSCL

~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--

~~vy- C 0 1A-5~

Corpo r a 5po~iosu f~~~~O--

cs

3 6v-O

6uJ6Cl Q0(t1 O~LLb~

reg Mew$~p~ MeM rneh-u M

Lob~

f- CCjo G tdc j d ct

prt-~ shyI ~6

IL--shy

Urdtr~

=== VrfQUS -= to tl ncJ ~ r- -trIJe

CA~ nre ~t-- middotImiddoth~I os

cuvi~ I CA()~

lJtevine Qrtey~4= brQr-~ =-sf- exremal iIi0( Uftcry

5Ljpor~ t U+U

CD p~iC ~r(JM qb-jeal 80~

Cd- d aty)~ G bam~

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oON-t c pleocuampreg (~ - Lz)

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F~sc~ ~ rs~ ~~I

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pJOV-jol f ( r dt 0 (~ laquo3 CIuks

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cloeurotd space

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