Pelvis & Perineum
-
Upload
rohanshah1 -
Category
Documents
-
view
372 -
download
9
Transcript of Pelvis & Perineum
--
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
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
- --+--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 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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
~
~
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
--
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
---------
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
~~ -
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$(J ~ A lli c LUr-lt b q r
~+engt ~r~1
r A
K- ~ YIldcf Ie r~d-cJ
-
f utea I J1 lotcrc1a~
~
8+r~) no u r fle
Jeio
cb~~e-r 1shy~~ -h-Jtleuro
bull ullClr~ bQdder =-= shy
LHo~(c1l
dISA~~
p~~
~~
sb(jc- ~
Co~~ (td-ro hed-a)
V~id~
absorbed partshy~ mc=sonep r- C cloct
JJ
~-Uvulct~ Veti cQ lt=-
In1bYlu (jr~
o (~cc Ce ~ ~ oJ
tjr~rQ
r Gt 4( - Uq e
i nhlbHt)~ +0
L-ter re~rQ n e(
(Spwctur Ytti=eJ ~
reg Mew$~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
~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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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 $1p~~~c
IT
() Uro~~a A 4- Etvno U~Ic reg ~~ql A =- Qn4 CQra
rr ~~14-ube-oGi-1 15C~L
--QrYh
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
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~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
pQ2~ ---t~ tgtbnv-Qtoshy ~
-t()(~M~~
Lshol - ~
e pudev da1 rlo(le
=gt Abc eampSe2
S~e on eac1-L- Sid e of --tie Cltol coaQ gt Isho ltR~cteoQ Foss Clt-
0()1 crnG I
F~sc~ ~ rs~ ~~I
extcr ( 01 Co YI GI -ophlYlcTc=r
1---- Peri oll(d (Y~Iodte A- dividE iB-e IsioRech=--l -tolte4c ()+0 2 spA cd
Loamp~ cNOIvJecl ~ ~1 IR spc~
pe~CtYla spcce ) ~-lntl1 ar4(9middot~cl ~T
(ortp tte ~ L _bull~tiutlG rud ~ctc1 h~5 Gep-lo cct)ntu(d -+0 Ihe 6 -V I
V~Scamp
6~ Aal isk10 ry PcU sca c- amp-0 M
ilP -te e +0a lIpound
~ e Is-hie rc~ -p-SSCL
~ ~~~i~te It E)(terlQ U~+oL~ oe~ c ~ pWJ-O ~ ~ale OIO c pevJG lcolt--
~~vy- C 0 1A-5~
Corpo r a 5po~iosu f~~~~O--
cs
3 6v-O
6uJ6Cl Q0(t1 O~LLb~
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf
-- -
fltlolS ~L1 s)
F~ale t()Q I cJ~i-cII~
Bqr~olj~ (J1clJ1
Ushyp-odu~es
~ecret~
a-d 1- 0 1 c-t ad
~ i-n-Peo-i oft
-P- ~Oei~ ~e cr ~+i OYl
~ 1-toriS
bHX)$f-njas~ m ~ LoQbullCl rncUoro ad ~ cJlL sphicter
pJOV-jol f ( r dt 0 (~ laquo3 CIuks
delaquop pernea pltuch
cloeurotd space
rerrl aJ 0 s- b~c(I ~ (hlat
apev sp~ce
Qt1termiddotorlf