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1) Define pelvic cavity and review its boundaries Lesser/Greater Sciatic Foramen → gluteal region Obturator foramen → medial thigh Inguinal Ligament → anterior thigh Bladder – most anterior - abdominal and pelvic structure Uterus (female) Rectum – most posterior Pelvic Inlet = Pelvic Brim - Sacral Promontory - Margins of ala - Linea Terminalis - Arcuate line - Pectineal line - Pubic crest Layers - Bony Wall - Musculature - Nerves - Parietal Pelvic Fascia - Vessels - Arteries (medial) - Veins - N
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  1)   Define pelvic cavity and review its boundaries Lesser/Greater Sciatic Foramen → gluteal regionObturator foramen → medial thighInguinal Ligament → anterior thighBladder – most anterior  - abdominal and pelvic structureUterus (female)Rectum – most posterior Pelvic Inlet = Pelvic Brim- Sacral Promontory- Margins of ala- Linea Terminalis- Arcuate line- Pectineal line- Pubic crestLayers- Bony Wall- Musculature- Nerves- Parietal Pelvic Fascia- Vessels- Arteries (medial)- Veins- Nerves (lateral)- PeritoneumGreater Sciatic Foramen- Superior Gluteal nerves/vessels------Prirformis------------------------------------ Inferior Gluteal nerves/vessels- Sciatic Nerve- Posterior cutaneous nerve of thigh- Nerve to quadratus femoris- P udendal nerve → exit pelvis –  only sensory  - I nternal pudendal vessels → exit pelvis- N erve to obturator internus → exit pelvisLesser Sciatic Foramen- Obturator internus- P udendal nerve → return into pelvis- I nternal pudendal vessels → return into pelvis- N erve to obturator internus → return into pelvis 2)   Review blood supply and lymphatic drainage of the pelvis and perineum Arteries of Female PelvisInternal Iliac a. (anterior branch) → Obturator a. *** may arise from external pudendal artery    → Umbillical a. → Superior Vesicle a. → Uterine a.- similar to artery to ductus deferens in men- tortuous- ureter runs under – “water under the bridge” → Ascending branch → uterus → Descending branch → cervix and vagina → Vaginal a. → Inferior Vesicle a. → Middle Rectal a. → Internal Pudendal a. → Inferior Rectal a. → Inferior Gluteal a. –  pass between S2 and S3 Internal Iliac a. (posterior branch) –  parietal branches – supply posterior wall  → Iliolumbar a. → Lateral Sacral a. → Superior Gluteal a. –  pass between lumbar sacral trunk and S1 Arteries of Male PelvisInternal Iliac a. (anterior branch) → Obturator a. *** may arise from external pudendal artery → Umbilical a.  → Superior Vesicle a. → Artery of ductus deferens → Inferior Vesicle a. → Middle Rectal a. → Internal Pudendal a. → Inferior Rectal a. → Inferior Gluteal –  pass between S2 and S3 Internal Iliac a. (posterior branch) –  parietal branches – supply posterior wall  → Iliolumbar a. → Lateral Sacral a. → Superior Gluteal a. –  pass between lumbar sacral trunk and S1LymphaticsInferior Phrenic lymph nodesLumbar lymph nodes- Pre-aortic – celiac, superior mesenteric, inferior mesenteric- Left Lateral Aortic- Right Lateral Aortic (Caval)- RetroaorticIliac lymph nodes- Common Iliac- External Iliac- Internal IliacInguinal lymph nodes- Superficial – horizontal, vertical (T-shaped)- Deep  Sacral lymph nodesCollateral Circulation in PelvisLumbar a. ↔ Iliolumbar a.Median Sacral a. ↔ Lateral Sacral a.Superior Rectal a. ↔ Middle Rectal a.Inferior Gluteal a. ↔ Deep artery of the thighVeins of PelvisPelvic Organs →   Internal Vertebral (Batson’s) Venous Plexus - cancer can metastasize to brain and spinal cord- cancer can spread to heart and lungsLymphatic Drainage- Fundus of Uterus near Round Ligament – superficial inguinal lymph nodes- Lower Uterine body, Cervix, and Bladder – internal and external iliac lymph nodes- Ovaries, Uterine Tubes, Upper Uterine Body, Testis – para-aortic lymph nodes- Glands Penis (Clitoris) and Labium minor – deep inguinal and external iliac lymph nodes- Prostate and Lower Rectum – internal iliac lymph nodes 3)   Nerves of the pelvis (somatic, autonomic – SNS, PNS) Pelvic Nerves- Somatic – ventral rami →  motor  - Sacral Plexus – Lumbosacral trunk (L4, L5) + S1-S4- Coccygeal Plexus – S4, S5 + Coccygeal nerves- Autonomic- Sacral Splanchnic (Sacral Plexus) – SNS– lower limb  - Pudendal Nerve – S2, S3, S4- Coccygeal Ganglion (Impar)- Periarterial Plexus – SNS – vasomotor   - Hypogastric Plexus –  pelvic organs - Superior Hypogastric plexus (SNS)- Right and Left Hypogastric Nerves (SNS)- Inferior Hypogastric plexus → join pelvic splanchnic (   mixed –SNS / PNS )- Pelvic Splanchnic (Pelvic Plexus) – PNS - name changes depending on location ( ex: prostatic plexus, vesicle plexus, etc .)-Cavernous nerve  → supplies penisInnervation of Bladder - SNS (T11-L2) → contract internal sphincter  → relax detrusor muscle- PNS (S2-S4) → relax internal sphincter  → contract detrusor muscle- Pudendal → voluntary control of external sphincter    4)   Concept of the pelvic pain line*Pelvic Pain Line – corresponds with inferior limit of peritoneum- Above – SNS (T12-L2)- Below – PNS (S2-S4)- Large Intestine pain does not correlate with peritoneum- pain line occurs in middle of sigmoid colon 5)   Review the innervation of pelvic organs6)   Clinical Correlates*Suprapubic Cystostomy – drain bladder if urethra is obstructed ( ex: enlarged prostate ) or injured ( torn urethra ) *Pelvic Ultrasound – require full bladder to help sound waves travel better  → better visualization of pelvic organs *Digital Rectal Exam - Females – palpate Rectouterine (Douglas) pouch- Males – palpate posterior lobe of prostate *Culdoscopy  – insertion through posterior vaginal fornix to examine ovaries or uterine tubes *Culdocentesis – drainage of pelvic abscess, fluid, or blood through the posterior vaginal fornix *Anal Reflex – S4, S5 *Anesthesia for Childbirth -Spinal Anesthesia– lumbar puncture → anesthesia inferior to waist – cannot feel contractions-Caudal Epidural Block – catheter into sacral canal → feel contractions but not pain of childbirth-Pudendal Nerve Block – ischial spine landmark  → S2-S4 dermatomes + ¼ of vagina *Benign Prostatic Hyperplasia – middle/intermediate lobe most commonly enlarged *Atonic Bladder – L2 injury → detrusor and external sphincter relax, internal sphincter contracted → urine dribble- usually present in early stages of spinal shock  *Automatic Reflex Bladder – reflex contraction every 2-4 hours- loss of voluntary emptying of bladder  *Autonomous Bladder – detrusor flaccid → bladder overfills → overflows
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