SF28D 09-03-09- Posterior Abdominal Wall, Kidney & Ureters- FLETCHER Posterior Abdominal Wall ** The five lumbar

vertebrae projects forward into the abdominal cavity because the lumbar spine has a normal forward convexity (lordosis) - Inferior vena cava and the abdominal aorta lie in front of the bodies of the vertebrae - Deep paravertebral gutters are found on each side of this convexity - The psoas and quadratus lumborum muscles form the floor of the gutters - Bounded below by the iliac crest and iliacus muscle - The lumbar vertebrae are separated from each other by thick intervertebral discs Psoas Major ** Psoas major is found in the gutter between the bodies and transverse processes of the lumbar vertebrae ** Gains vertebral attachment to: iThe discs above the 5 lumbar vertebrae iiThe adjoining parts of the bodies of the vertebrae iiiFibrous arches that span the concavities of the sides of the upper 4 vertebral bodies ivThe medial ends of all the lumbar transverse processes ** The muscle passes downwards along the pelvic brim - Then beneath the inguinal ligament into the thigh - Its tendon is attached to the lesser trochanter of the femur - The lumbar plexus is embedded within the muscle - The genitofemoral nerve pierces the muscle to emerge anterior to it - The iliohypogastric, ilioinguinal, lateral femoral cutaneous and femoral nerves emerge from its lateral border - The obdurate nerve and the lumbosacral trunk emerge from its medial border ** The four lumbar arteries and veins pass backwards medial to the 4 arches - The vessels then run laterally behind the psoas muscle ** The strong psoas fascia invests the surface of the muscle. The fascia is attached to the: - Vertebral bodies - Transverse processes of the vertebrae - Fibrous arches - Iliopubic eminence Note: The lateral edge of the psoas fascia blends with the anterior layer of the fascia over quadratus lumborum Medial arcuate ligament- is a thickening in the psoas fascia curving obliquely from the body of L1 or L2 vertebrae to the transverse process of L1 vertebrae - Fibers of the diaphragm arise in continuity alongside the crus

Nerve Supply (psoas major)- the first 3 lumbar nerves mainly L2 Quadratus Lumborum - Flat sheet lying deep in the paravertebral gutter. Lies edge to edge with: iPsoas- medially iiTransversus abdominis- laterally ** Found in the anterior compartment of the lumbar fascia - Arises the transverse process of L5 vertebrae - From the iliolumbar ligament and a part of the adjoining iliac crest - The fibers pass upwards to the transverse processes of the upper 4 lumbar vertebrae - Also attached more laterally to the inferior border of the medial half of the 12th rib Nerve Supply: direct branches of the upper 4 lumbar ventral rami ** The quadratus lumborum lies between the anterior and middle layers of the thoracolumbar fascia - These layers fuse at the lateral margins of quadratus lumborum Fascia ** Each muscle of the posterior abdominal wall is covered with a dense and unyielding fascia - quadratus lumborum, psoas, iliacus - The fasciae over adjacent muscles blend at their margins 1

Lumber Fascia- the lumbar part of the thoracolumbar fascia - In the lumbar part of the trunk of the body, three layers of fascia enclose 2 muscular compartments - The anterior and middle layers occupy only the lumbar region - The posterior layer extend above the lumbar region to the lower part of the neck and below to the dorsal surface of the sacrum - Quadratus lumborum occupies the anterior compartment, while erector spinae fills the posterior compartment Anterior Layer- extends from the front of the iliolumbar ligament and adjoining iliac crest to the lower border of the 12th rib - Medially: attached to the front of each lumbar transverse process and adjoins the attachment of the psoas fascia - Laterally: blends with the middle layer along the lateral border of quadratus lumborum Middle Layer- extends from the back of the iliolumbar ligament and adjoining iliac crest up to the 12th rib - Medially- attached to the tips of the lumbar transverse processes - Laterally: blends with both anterior and posterior layers Posterior Layer- lies over the whole erector spinae mass of muscle - Attached medially to the spinouts processes and supraspinous ligaments of all the sacral, lumbar and thoracic vertebrae

** Transversus abdominis and the internal oblique both originate from the thoracolumbar fascia ** As the transversalis fascia approaches the kidney it separates into 2 layers: iAnterior iiPosterior After this the fascia blends with the adventitia of the vessels on both sides

** Psoas major is found on either side of the midline - Covered by its own fascia ** Quadratus lumborum are enclosed by the fascia except at the spinous process Note: The anterior, inferior and posterior layers of fascia from each of the 3 muscles meet to form the thoracolumbar (lumbodorsal) fascia Both transverses abdominis and internal oblique both originate from thoracolumbar fascia

** The tubercle of the 12th rib corresponds to the upper border of quadratus lumborum - This tubercle demarcates the lateral aspect of this muscle ** The sympathetic chain is related to the medial border of psoas major - Genitofemoral nerve pierces psoas major. Passes forwards through psoas and runs inferiorly on the muscle dividing into femoral and genital branches - Subcostal nerve pierces the thoracolumbar fascia - Iliohypogastric nerve emerges from psoas and passes inferolaterally between quadratus lumborum and the kidney - Pierces transverses abdominis superior to the iliac crest and runs in the abdominal wall ** The 5 lumbar nerves emerge through the intervertebral foramina below the corresponding vertebrae - Their ventral rami pass into the posterior part of psoas major Kidneys ** The kidneys are found high up on the posterior abdominal wall behind the peritoneum - Therefore they can be found retroperitoneally and are ovoid in shape - Mostly under cover of the costal margin Dimensions: - 4.5 in long (11 cm) - 2.5 in wide (5-6 cm) - 1 thick (3 cm) - Weight = 130 g ** Each kidney lies obliquely with its long axis parallel with the lateral border of psoas major 2

Lies in the paravertebral gutter The hilum faces forwards and medially The left kidney is usually slightly larger than the right Each kidney is indented on the middle `1/3 of the kidney

** The kidney has: - Upper + lower poles - Lateral + medial borders - Anterior + Posterior surfaces ** The upper pole of the left kidney overlies the 11th rib and the upper pole of the right kidney overlies the 12th rib - Each kidney moves in a vertical range of 2cm during full respiratory excursion of the diaphragm - Anterior surface- faces antero-laterally - Medial Surface- faces antero-medially - Posterior surface- faces postero-medially - Lateral surface- faces postero-laterally

** Therefore the kidneys are tiled to that the upper poles are closer to the midline Note: The distance from the midline of the parts of the kidneys are as follows: - Upper pole = 1 inch - Hilum = 2 inches - Lower pole = 3 inches ** The surfaces of the kidney are covered by its capsule and the surfaces are usually smooth and convex - The pelvis emerges from the hilum, behind the vessels to pass down as the ureter ** The kidney has its own histological capsule, which can be easily removed - The middle 1/3 is envaginated and known as the renal sinus - The fibrous capsule extends down into the sinus - Structures associated with the kidney usually pass through the sinus via the hilum - But in a of persons there is an aberrant renal artery that does not pass through the hilum - 8-10 lymphatic trunks also exit via the hilum - In addition fat, areolar tissue and sympathetics are also found ** The upper pole of the left kidney overlies the 11th rib - The upper pole of the right kidney overlies the 12th rib Radiology - The renal axis passes through the body of the 9th vertebrae - A change in the renal axis implies pathology - The length of a normal kidney is 3x the length of the body of L2 vertebrae and one intervening disc Note: If the kidney is smaller than 3x the body of L2 alone it is a small kidney (undersized) Posterior Relations - Diaphragm - Quadratus lumborum muscles- overlap medially on to psoas and laterally on to transverses abdominis - The upper poles of the kidneys lie on the fibers of the diaphragm which arise from the lateral and medial arcuate ligaments - Costodiaphragmatic recess of the pleura- a small triangular part of the pleura that lies behind the diaphragm ** The subcostal vein, artery and nerve emerge beneath the lateral arcuate ligament - Lie behind the kidney as they emerge from the lateral border of psoas - The hilum of the kidney lies over psoas - The convexity of the lateral border lies on the aponeurosis of the origin of transverses abdominis ** The right kidney is related to the upper border of the 12th rib - The left kidney is related to the upper border of the 11th rib ** The upper half of the kidney on each side rests on the diaphragm and the parietal pleura - Therefore the pleural cavity is an important posterior relation of the kidney 3

** There are 3 muscles, nerves, vertebrae that are related posteriorly to the kidney: 1- 3 Muscles- psoas major, quadratus lumborum, transverses abdominis (intervening lumbodorsal fascia) 2- 3 Nerves- subcostal nerve, iliohypogastric nerve, ilioinguinal nerve 3- 3 Vertebrae- L1, L2, L3 Note: The left kidney may to get to the vertebral level of T12 even though it is related to the 11th rib Clinical Application- If there is a defect in the fibers that arise from the arcuate ligament going to the diaphragm, then there will only be 2 layers of fascia separating the kidney from the pleural cavity - Diaphragmatic fascia + endothoracic fascia - In these cases it is relatively simple to penetrate the fascia and enter the pleural cavity through an anterior approach Note: The commonest surgical approach to the kidney is posteriorly through the 12th rib - Excise the paranephric capsule, through the fat, through the perinephric capsule and to the kidney - Therefore the pleural cavity can be seen on the medial side - If it is injured during surgery, the result can be a tension pneumothorax ** Renal biopsies also have a risk of entering the pleural cavity - Therefore the position of the kidney should be determined by x-ray or ultrasound to avoid entering the pleural cavity Anterior Relations ** The suprarenal glands surmount the superior poles both kidneys and overlap a small part of their anterior surfaces - The rest of the upper halves of each kidney lie in contact with the peritoneum - Right Side- peritoneum of the hepatorenal pouch - Left Side- peritoneum of the lesser sac (medially) and peritoneum of the greater sac (laterally) ** The hilum is separated from the peritoneum on the right side by the second part of the duodenum - Left side- the hilum is separated by the body of the pancreas and the splenic vessels ** The lateral part of the lower pole is separated from the peritoneum by the hepatic and splenic flexures of the colon on the right and left sides respectively - The medial part of the lower pole on each side lies in contact with peritoneum that separates it from coils of jejunum ** The kidney is also enclosed by Gerrotas Fascia (renal fascia) which is different from the histological capsule - The renal fascia usually blends with transversalis fascia - Within the capsule is perinephric (renal) fat - This fat is pale yellow which is distint from the fat of the outside of the kidney (pararenal fat) ** The renal pelvis is the funnel-shaped commencement of the ureter - Normally the most posterior of the 3 main structures in the hilum - The capacity of the average pelvis is <5mL

Summary Table Right Kidney Right suprarenal gland Liver Small gut = duodenum- second part is related to the hilum and medial border of the kidney Right colic flexure = hepatic flexure Upper branches of the right colic artery

Left Kidney Left Suprarenal gland Spleen + splenic ligaments (gastrosplecinc and linorenal) Small gut = jejunum Left colic flexure = splenic flexure Stomach Pancreas (splenic vein + splenic artery)

Kidney Blood Supply ** The kidney receives approximately 20% of the cardiac output. The renal arteries have a blood flow of > 1L per minute - The renal arteries leave the abdominal aorta and lie behind the pancreas and renal veins ** Based on its blood supply, the kidney is divided into 5 segments ** As the renal artery approaches the kidney it divides into 3 branches: 2 anterior + 1 posterior (largest) - The renal vein is anterior to the renal artery before it divides 4

** Each anterior branch divides into 2 divisions but the posterior branch remains undivided - Therefore the renal artery has 4 anterior divisions just as it is entering the hilum - These 5 branches (4 anterior + 1 posterior) supply the 5 vascular segments of the kidney 1- Posterior Division- supplies the posterior segment 2- Anterior Division (x4)- supply the apical, upper, middle and lower segments Note: The pattern of vessel branching may vary but there are always 5 segments with no collateral circulation between them - Therefore the segmental arteries are end arteries and there are no anastamosis between them - Only branches of the same segmental artery anastamose Note: Veins from the renal segments communicate with each other - They eventually form 5 or 6 vessels that unite at the hilum to form the singe renal vein Insert Diagram here ** The posterior minor calyxes are the usual surgical route into the pelvis of the kidney because it is relatively avascular - Line of Smith Note: The posterior surface of the kidney tends to be more flattened because it is resting on psoas major fascia - The left kidney has a bulge in the middle (renal dromedary hump) ** The left kidney is at a higher level in the body than the right kidney. However the right kidney is more easily palpable - The lower pile is at the level of the subcostal plane @ L3 - Therefore at the lower edge of the ribs (9th rib) the kidney may be palpable

** The left renal vein is 3x larger than the right renal vein - Receives the left supra renal vein and left inferior phrenic vein (from above) - From below receives the gonadal veins (testicular or ovarian), upper lumbar veins, small veins of the perinephric tissue Note: Obstruction of the left renal vein can lead to the blood leaving the kidney through the capsule via a plexus of veins - The lumbar, azygos, gonadal system of veins produce a plexus known as the extrarenal arc (plexus) of Marion - In Wilms Tumor this plexus tends to be well developed Clinical Application: Pyelotubular backflow - Slow obstruction to the ureter creates back-pressure - Therefore urine leaves through the capsule into the perinephric tissue and is reabsorbed - Therefore blood urea increases - There is backflow of urine into the perinephric sinus (pyelotubular backflow) - Followed by movement of urine into the interstitial tissue (pyelointersitial backflow) - Then into the sinus of the kidney (pyelosinus backflow) - Drains into the lymphatics (pyelolymphatic) and then into the capillaries Kidneys: Nerve Supply ** Renal nerves are derived from both parts of the autonomic system - The sympathetic preganglionic cells are found in the spinal cord from T10 to L1 segments - Send preganglionic fibers to the thoracic and lumbar splanchnic nerves - These fibers synapse in the celiac and renal ganglia and are vasomotor in function ** Afferent fibers accompany the sympathetic nerves - The path ways for pain passes to the celiac plexus and then by the splanchnic nerves to the sympathetic trunk and via the white rami communicantes to T10-L1 spinal nerves - Then in to the spinal cord by the posterior nerve roots ** Therefore renal pain may be referred to the back and lumbar region, and radiate to the anterior abdominal wall and down to the external genitalia - Loin to groin pain

Lymphatics ** The lymphatics of the kidney drain to para-aortic nodes at the level of the renal arteries (L2) Ureter ** The ureter is 25 cm long. Has 3 points of narrowing: iPelviuriteric junction iiPelvic brim- as it crosses the brim iiiBladder wall- as it passes through the bladder wall ** The ureter is a fibromuscular tube that passes down on psoas major, under cover of the peritoneum - Crosses in front of the genitofemoral nerve - Right: The upper part is behind the 3rd part of the duodenum. Lower down it is crossed anteriorly by the right colic and ilieocolic vessels and by the root of the mesentery - Left: Lateral to the inferior mesenteric vessels. Crossed anteriorly by the left colic vessels - At the pelvic brim it is crossed anteriorly by the apex of the sigmoid mesocolon ** The ureter leaves the psoas muscle at the bifurcation of the common iliac artery, over the sacroiliac joint and passes into the pelvis ** The ureter carries urine from the kidney into the urinary bladder. It begins at the sinus of the kidney as the pelvis of the ureter. ** The ureter has 2 muscular layers: iOuter circular iiInner longitudinal ** The first half of the ureter is on top of psoas major. - Crosses the pelvic brim anterior to the origin of the external iliac artery - On the right side IVC is immediately medial to it - On the left side the inferior mesenteric vein is immediately medial to it ** The ureter then follows internal iliac into the pelvis and at the pelvic brim the ureter foes backward (sacrum) and then downward - The internal iliac artery runs with it - Continues towards the spine of the ischium then goes forward and medial to enter the urinary bladder at a posteriorsuperior angle - Then tunnels obliquely into the wall of the bladder ** In the female the ureter passes close to the fornix of the vagina Therefore during a hysterectomy the ureter is in danger of being damaged when the uterine artery is lighted Blood Supply - The upper end is supplied by the ureteric branch of the renal artery - The lower end is supplied by braches from the inferior + superior vesical and uterine arteries - The middle of the ureter is supplied by branches from the abdominal aorta, gonadal, common iliac and internal iliac arteries - All of these vessels form an anastomosis with each other in the adventitia of the ureter Lymphatics ** The lymphatics run back alongside the arteries - The abdominal part of the ureter drains into the para-aortic nodes - The pelvic part of the ureter drains into common iliac + internal iliac nodes Nerve Supply - Sympathetic fibers from T10-L1 segments via the celiac and hypogastric plexuses - Along with parasympathetic fibers from the pelvic splanchnic nerves Sonia Wheatley Thornia Smith Granualar Layer- input is via the mossy fibers which end here Retina begins at the optic disk and runs peripherally to end at the ora serrata

Inner part of chroirs = chorea capillaries- inner vascular layer - Age related macular dengenetation - Free radical damage---and then new BV proliferate (angiogenesis) - Neo-vasculariozation = patholiogical problem Inner pig layer of retina= prevents scattereing of light rays - Cells- retinal pigemental cells- are scavengers- help to clean and remove old photoreceptors (debris ec) Deep to this is the layer of rods and cones Deep to this are the layer of the nuclei of rods and cones Deep to this is the outer limiting membrane Inner nuclear layer Inner plexiform layer Ganglion layer Inner limiting membrane- formed by the inner process of the Mueller cells. Demarcates the retina from the vitreous Inner part of the retina gets a supply from the central retinal artery - run on the edge of the inner limiting membrane and DO NOT enter the vitreous membrane because this would interfere and become pathological - In diabietc- vasculae nedothlial growth factor is proliferent leading to angiongenses in an attempt to increase O2 capture Prematurty- downreg of VEGF therefore less BV are produced bec of the incubator

SF28D 09-03-09- Urinary Bladder- LODENQUAI ** In young children the urinary bladder is entirely intra-abdominal - By the age of 6 years the bladder is within the greater pelvis - At puberty the bladder is in the lesser pelvis ** The empty bladder is situated in the pelvic cavity - As the bladder distends it enters the level of the abdominal cavity - The empty bladder is a flattened 3-sided pyramid - The apex points forwards to the top of the pubic symphysis - The triangular base faces backwards in front of the rectum or vagina - There are also two inferolateral surfaces - Superior surface- the small intestine and sigmoid colon/uterus lies on top of it - The superior surface is also covered by peritoneum Note: In males the 3-sided pyramid has the base facing posteriorly to the rectum - In the female the base faces the upper vagina Apex- has the remains of the urachus attached to it - The remnants of the urachus forms the median umbilical ligament - This runs up the midline of the anterior abdominal wall in the median umbilical fold of the peritoneum Base- Most of the base (posterior surface) lies below the level of the rectovesical pouch - Only the uppermost portion is converted by peritoneum between the ductus deferens on each side - The seminal vesicles are applied to the posterior surface - The ureters enter at the upper outer corner - Females: The base has a firm connective tissue union with the anterior vaginal wall and upper part of the uterine cervix with no peritoneum intervening Inferolateral Surface- Each inferolateral surface slopes downwards and medially to meet its fellow - Lying against the front part of the pelvic diaphragm and obturator internus Neck- The nexk is the lowest part of the bladder 7

Formed at the point where the base and the two inferolateral surfaces meet The neck is pierced by the urethra at the internal urethral orifice In the male it lies against the upper surface or the base of the prostate Female: the neck is above the urethra in the connective tissue of the anterior vaginal wall

Superior Surface - Covered by peritoneum which is continuous onto the anterior abdominal wall

** When the bladder is collapsed the mucus membrane is thick and folded - When the bladder is distended the mucus membrane apprears thin and smooth - The trabeculae of the muscle fibers can be seen through the mucus membrane Note: The appearance of the trigone does not vary with the state of distention of the organ ** There are 4 ducts associated with the urinary bladder: iUreters- x2 iiUrachus- during surgey, must ligate the urachus first because there may still be a communication with the bladder - The urachus is an embryological connections that bcomes fibrosed after birth iiiUrethra

Rectopubic Space of Retzius - Space behind the pubic symphysis - Formed when the inferolateral surfaces meet below the apex - Contains loose fatty tissue and the fibromuscular pubovescial ligaments - The pubovesical ligaments extend from the bladder neck to the inferior aspect of the pubic bones Rectovesical Pouch - The peritoneum of the lower third of the rectum is reflected forwards onto the upper part of the bladder in males - In front of the rectovesical pouch is the uppermost past of the base of the bladder and the tops of the seminal vesicles - Below the level of the ouch are the rest of the bladder base and seminal vesicles, prostate, and the ends of each ureters and ductus deferens Rectovesical Pouch of Denonvilliers- condensation of fascia found between these structures and the rectum - Connected to the floor of the rectovesical pouch above and to the apex of the prostate below - This fascia is closer to the rectum than to the seminal vesicles and prostate Rectouterine Pouch of Douglas - The peritoneum of the lower 1/3 of the rectum is reflected forwards onto the upper vagina in females ** The bladder is supported by a number of structures: puboprostatic + pubovesical ligaments - These ligaments are fibro-elastic condensations of pelvic fascia - Pass from the back of the bodies of the pubic bones, close to the median plane - Pass to the anterior sheath of the prostate and the neck of the bladder in the male - Or to the neck of the bladder and the urethra in female - The ligaments extend laterally to fuse with the fascia over the medial margins of the levator ani muscles ** These ligaments are important in maintaining the position of the bladder, prostate and urethra Female- the upper part of the urethra is convex anteriorly because of the attachment of the pubourethral ligament Males + Females- condensation of fibromuscular tissue to form pubovesical ligaments - In the male it is also known as medial + lateral puboprostatic ligament Clinical Application: Fractures of the pubic rami can disturb these connections - The ligaments can rupture and pull the bladder and prostate out of place ** The inferior-lateral aspect of the bladder is supported by the levator ani muscles ** Laterally- the lateral ligaments of the bladder extend from the urinary bladder to the side wall of the pelvis - Tendinous arch (arcus tendinous)

** The peritoneal folds or accessory ligaments are not as weak as the above named true ligaments 1- Females: vesicouterine fold- bladder to uterus and rectouterine fold- uterus to sacrum 2- Males- vesicalrectal fold- rectum to bladder Trigone - Triangular area at the base of the bladder - Found between the two urethral orifices and the internal urethral orifice - The trigone is fixed on top of the prostate by the urethra - Therefore the trigone is the least mobile part of the bladder - Female: Stabilized by the connective tissue surrounding the upper urethra at the front of the vagina - The trigone is smooth-walled and the mucus membrane is firmly adherent to the underlying muscle ** The layers of the bladder are: iSerosa- superior surface iiTunica muscularis- consists of the smooth muscles (detrusor) and interlacing network of muscles (inner longitudinal, middle circular, outer longitudinal) iiiSubmucosa ivTrigonal Area- the mucus membrane is attached firmly to the underlying mucosa. Therefore the mucosa appears smooth and is not mobile Note: The mucosa in other parts is loosely attached to the underlying muscle and this allows for distention ** The smooth muscle of the bladder wall (detrusor muscle) is composed of an interlacing network of fibers running in various directions - Receives parasympathetic nerve fibers ** The trigone also possesses a superficial triangular layer of muscle (superficial trigonal muscle) - This muscle is histologically different from the rest of the bladder musculature - Extends into the proximal urethra in both sexes - Supplied by sympathetic (adrenergic) fibers - Contraction of this muscle helps to close the ureteric orifices ** In males at the bladder neck, circular smooth muscle fibers form a collar around the internal urethral orifice - Extends distally to surround the proximal part of the prostatic urethra (pre-prostatic part) - The preprostatic sphincter is also supplied by sympathetic adrenergic fibers ** In females the muscle in this region is arranged longitudinally and extends into the urethral wall - In the male this muscles acts to prevent seminal regurgitation into the bladder during ejaculation ** The mucus membrane is thick and lined by transitional epithelium - Glands are usually absent - Mucus in shed urine comes from urethral glands - No muscularis mucosae Note: Waldeyers sheath surrounds the final 2.5cm of the urethra ** In the deep trigone the circular muscles receive an adrenergic sympathetic supply - At ejaculation these muscles act as a genital sphincter and prevent retrograde ejaculation

** The oblique passage of the ureter through the bladder wall also assists in the preventing the reflux of urine - The ureters pierce the muscle and mucosal walls oblique - This helps to prevent urine reflux when intravesical pressure rises - The ureteric orifices are closed by this pressure - EXCEPT to open rhythmically in response to ureteric peristalsis each time urine is injected into the bladder

Males- The trigone overlies the median part of the central zone of the prostate - After middle age this may project above the internal urethral orifice as a rounded elevation, the uvula of the bladder ** The ureteric orifices are connected by a transverse ridge, interureteric bar - Produced by the continuity of the longitudinal muscle of the 2 ureters across the bladder wall - The orifices of the ureters are at the ends of the bar and are usually in the shape of an oblique slit Blood Supply 9

** The superior + inferior vesical arteries provide most of the arterial supply - Small contributions to the lower part of the bladder from the obturator, inferior gluteal, uterine, and vaginal arteries ** The superior vesical branches of the umbilical arteries- supply the anterosuperior parts of the bladder - Sometimes the superior parts of the seminal vesicles and ductus deferens ** The inferior vesical arteries pass towards the base of the bladder and are joined by branches from the middle rectal arteries ** The veins of the bladder do not follow the arteries. They form a plexus that converges on the vesicoprostatic plexus in the groove between the bladder and prostate - Then drains backwards across the pelvic floor to the internal iliac veins - There is a similar plexus in the female, communicating with veins in the base of the broad ligament Lymphatics - Drain mainly to the external iliac nodes - Some lymph drains to internal iliac nodes, including nodes in the obturator fossa Nerve Supply - Parasympathetic fibers provide the main motor innervation of the bladder, which reach it via the pelvic splanchnic nerves - Sympathetic fibers come from L1 and L2 segments of the cord via the superior + inferior hypogastric plexuses ** For most of the bladder the sympathetic fibers are vasomotor and probably inhibitory to the detrusor muscle - But they are motor to the superficial trigonal muscle and in the male, the muscle of the bladder neck Relations of the Bladder ** The bladder is related to: iSeminal Vesicle- laterally iiUreter- medially iiiVas deferens- most media ** The bladder is extra peritoneal SF28D-ANA 12-03-09- Bony Pelvis & Sexual Dimorphism- SINGH ** The bones of the pelvis consists of the: i2 hip bones iiSacrum iiiCoccyx ** The bones are unite by 4 joints: iSacroiliac joints (x2)- synovial joints found posterosuperiorly iiPubic symphysis- fibrocartilaginous joint found antero-inferiorly iiiSacrococcygeal joint- fibrocartilaginous joint ** In the erect position, the pelvis lies with the upper margin of the pubic symphysis and the anterior superior iliac spines in the same coronal plane ** The pelvis consist of 2 parts that are separated by the place of the superior aperture of the lesser pelvis - This is an oblique plane passing from the sacral promontory to the upper surface of the pubic symphysis - The greater pelvis is the part anterosuperior to the plane - The greater pelvis is formed by the iliac fossae and is part of the wall of the abdomen - The lesser pelvis is the part postero-inferior to the plane Functions 1- Weight transmission - Standing: Weight of vertebral column is transferred to the sacroiliac joint - Sitting- the weight is transmitted to the ischial tuberosities 2- Protection- of organs (rectum, vagina, prostate) 3- Surface for muscle attachments- for the urogenital diaphragm - The perineal muscles are invested into the different regions of the pelvis 4- Female pelvis- parturition- accommodates the fetal head and helps in the process of the parturition - Obstetrician measures the female pelvis to determine if the size is adequate for a normal vaginal delivery - If the doctor is unable to determine, refer the patient to the radiologist - Can use the help of ultrasound to determine if there is cephalo-pelvic disproportion 10

That is if the head is too large to pass through the pelvis

5- Sex determination- measurement and indices Anatomical Position ** The ASIS and the upper end of the pubic symphysis lie in the same coronal plane - The tip of the coccyx corresponds with the upper margin of the pubic symphysis - Therefore the pelvis is placed at a tilted position False Pelvis - Sides: Iliac fossae of the hip bones and the alae of the sacrum - Anterior: The anterior abdominal wall - The false pelvis is incompletely bounded Note: The inlet of the pelvis divides the false pelvis from the true pelvis True Pelvis - Lies below and behind the pelvic inlet (true basin)

** The pelvic brim is formed in continuity by the pubic crest, pectineal line of the pubis, arcuate line of the ileum, and the ala and promontory of the sacrum - The plane of the brim is oblique Pelvic Brim Posterior- Sacral promontory Lateral- anterior margins of the alae of the sacrum (linea terminales) Anterior: Upper end of the pubic symphysis Print Slide #8 ** The linea terminales is formed by: - Iliopubic eminence - Iliopectineal line Note: Pelvic inlet = pelvic brim Inlet Plane of the Inlet- forms an angle of 50-60 degrees with the horizontal Axis of the Inlet- passes perpendicular to the midpoint of the plane of the inlet Note: The axis of the uterus coincides with the axis of the inlet Measurement of Inlet ** The anteroposterior diameter (AP) is also the anatomical/true conjugate is measured from the midpoint of the sacral promontory (posterior) to the upper margin of the pubic symphysis - 11cm- males - 12cm- females ** The oblique diameter- extends from the upper margin of the sacroiliac joint of one side to the iliopubic eminence of the opposite side 11 cm- males - 12 cm- females ** The transverse diameter represents the 2 furthest points lying across from each other on the inlet 11

Sacroiliac articulation

Anterior border of the ala of the sacrum

12.5 cm- males 13 cm- females

** Obstetric Conjugate- The shortest pelvic diameter through which the fetal head must pass during birth - Measured form the promontory of the sacrum to the top of the pubic symphysis - Can add 0.5 cm to the obstetric conjugate to get the true conjugate ** Diagonal Conjugate- measured using a per vaginal exam of the female - Measured from the midpoint of the sacral promontory to the lower border of the pubic symphysis - 12 cm Obstetric conjugate = diagonal conjugate 1.5cm(m) or 2cm (f)

External Conjugate- usually determined by radiometry - Measured from the upper margin of the pubic symphysis to the L5 spine - However this is an obsolete measurement - Anatomical conjugate = external conjugate- 9cm Shape of the Inlet Males- heart shaped or android pelvis- due to the forward projection of the sacral promontory Females- rounded pelvis or gynecoid pelvis Pelvic Cavity ** The segment of the pelvis is bounded above by the inlet and below by the pane of least pelvic dimensions - The plane of least pelvic dimensions is the narrowest point at the lower point of the pelvic cavity - Obstructed labor occurs most commonly at this point 12

The plane of least dimensions is that the level of ischial spines where the transverse diameter is the narrowest

Female Pelvic Cavity Measurements 1- AP Diameter- 13 cm 2- Oblique diameter- 13.1 cm 3- Transverse diameter- 12.5 cm ** The walls are directed downwards and medially. Therefore the canal is longer and narrower in men - In females the lateral walls are vertical - Therefore the pelvic cavity is shaped like a cylinder Anterior: 2 rami + body of the pelvis Posterior- body of the sacrum + coccyx Laterally-quadrangular area bound by the ileum above and below by the ischium ** The plane of least dimensions in the pelvic cavity is at the level of the ischial spines - If the distance between the ischial spines (bispinous diameter) is less than 8.5cm there will be obstructed labor Pelvic Outlet ** The outlet is diamond-shaped and much wider in females - Anterior wall = pubic arch- lower margin of the pubic symphysis - Lateral wall- lower margin of the ischial tuberosities - Posterior wall tip of the coccyx Note: The sacrotuberous ligament on both sides form posterior and lateral boundaries ** The vaginal canal coincides with the axis of the pelvic outlet Measurement of the outlet - AP Diameter- 12.5 cm /8cm - Oblique Diameters- 11.8cm/10cm - Transverse diameter- 11.8cm/8.5 cm

** There are two planes of the pelvic outlet: 1- Directed from the pubic symphysis downwards and backwards 2- From the tip of the coccyx downwards and forwards Note: The plane of the pelvic outlet makes an angle of 10-15 degrees to the horizontal axis Clinical Anatomy ** Difficulties in parturition will occur if: iObstetric conjugate < 10cm iiDistance between the ischial spines < 8.5cm iiiDistance between the ischial tuberosities < 8cm

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Classification of the Pelvis ** The pelvis classified according to the shape of the inlet: - Gynecoid- seen mostly in females (50%) - Android- 20-30% of females have this type - Anthropoid- the AP-diameter is greater than the transverse diameter. Both male and females newborns tend to have this type of pelvis - However as growth occurs, the shape changes - Platypaloid- Seen in Vitamin D deficient cases (osteromalasia or rickets) Note: The android, anthropoid, and platypaloid types are unsuitable for normal labor ** The pelvis can also be classified according to the measurements of the inlet: - Dolicopellic - Mesatipellic - Brachypellic - Platypellic Note: The mesatipellic, brachypellic and platypellic types have transverse diameters that are greater than AP-diameters in the inlet - However dolicopellic types have an AP-diameter that is greater than the transverse diameters

Sexual Differentiation Print Slide #29 ** The sex differences are due to the fact that the female pelvis broader than the male, for easier passage of the fetal head - Also because female bones are more slender than those of the male ** In the male pelvis the bones make an acute sub pubic angle (<60 degrees) ** In the females the bone make a wide subpubic angle (> 80-90 degrees) ** The blade of the ileum is less vertical in males but in the females the ileum is more vertical - The inferior ramus of the pubis is everted more in males because the crus of the penis attaches there ** The greater + lesser sciatic notches are narrow in the males and the ischial spines are directed more medially

HISTOLOGY #1Cortex- ldark Medulla- lighter

Kidney invested by renal capsule that is different from the renal fascia CORTEX Renal corpuses (Malfigian corpuscles)- consist of ibowmans capsule iiGlomeruli- abut on the bowmans. Glo represents a knot of specialized blood vessls (fenestrated) and are lined by a simple squamous epithelium - Fenestrations faciliate ultrafiltration - Epithelial cells- have podocytes- that represent the parietal surface = simple squamous - Epithelial at the parietal cells at the urinary pole become proximal convoluted tubule pi ( low columnar or cuboidal) Tubular struc in the cortex- PCT, DCT, or part of collecting tubules

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Vascular pole of the glomerus- the afferent vessels of the glomeruli are specialized at this pole - Nuceli is rounded- bec the cells of the afferent vessl are sepc to form the juxtaglomerular celsl (produce rennin) - Produce rennin in response to substance produced by the macula densa cells Macula densa- found in the distal tubule---close to the afferent vessesl and become spec and produce a chemi that stimulates rennin prodution - MD cells are sensitive to ionic conc and water volume in the blood Note: Diagnostic feature of PCT that that apical cells have microvill (brush border) - All AA and glucose and some Nacl absorbed here - Large amounts of mitochondeia bec energy is needed for absorp to be efficient - PCT have large cells, therefore the nuclei are spaced out from each other DCT - Have a smaller lumen and no microvilli BV- lined by flat squamous epi NOT cuboidal or columnar MEDULLA - devoid of malfigian corpusces - No PCT or DCT - Composed mainly of collecting tubules and diff parst of Henle loop (thin + thickseg) also numerous sections of the vasa recta - Collecting tubles- are have pale cells with prominent cell boundaries - Which polypeptide acts on the membrane of these cell boundaries? Ans- ADH - ADH enchanees the permeability of the cell membrane leading to water retention Nuclei are rounded and bulginf into the lumen, cell is reddish thick segments of Hen;es loop - The thick segments tend to be more eosinophilic ** Nuclei are flattened but are not classical simple sq ep like blood vessels = thin segment of Henles loop - Usually the medulla of the human kidney has 8-10 triangular s tructures = renal pyramid. Base towards the cortex and apex down into the medulla - Apex of the pyramid (renal papillae) point into minor calyx (space) - Minor calyx drain to major calyx which thenform the pelvis and then the ureters Note- Transitional epi appears FIRST in the minor calyx Medular rays- paler, longitudinal tubules radiationg from medulla into the cortex - Numerous collecting ducts and collecting tubules radiating into the cortex URINARY BLADDER - Highly musc structure with a mucosal lining - Mucosa = epit plus an underlying lamina propria - Muscosa is highly folded - Transitional epi- most superfic cells are globula/umbrella shaped - Some of the cells are binucleate - Trans epi cells are urine proof- to prevent urine from leaking into the connective tissue - Transitional epi = urothelium Lamima Prop- loose CT (thiin fibe collan fibgers, fibrosals) + BV Musculature- smooth mucle - arrangement of muscle fibers into interlacing bundles- into inner long middle circ and outer long ** Most of the bladder lined by adventiation (small portion has serosa) therefore NO mesothelial lining on the surface ** Intramural part of the ureter- supplied by the SAME arteries that supply the bladder (vesical arteries) URETER - upper parts only has 2 musc layers- inner long- outer circ URETHRA - contained withint the corpora spongiosum (in the penis) - Penile urethra is lined by a different epi 15

Prostatic urethera (proximal part)- same lining as bladder transitional - Embryological origin- mesonephric duct Penile urethra- when it enters the shaft it becomes now stratifid columnar Glans penis- 1 cylinger remains - the urethra- epi now necomes stratified squamous (no keratinized) in the glans penis - Embryolog- ectoderm Male urethra = 20 cm FEMALE URETHRA - is NOT in the vagina - found in the anaterior wall of the vagina - 4-5 cm - Lined by either transitional or stratified squamous How to disting between vagina and urethra - The vagina has many thin walled veins (numerous lumens asscoa)- the multiple veins allow the vagina to simulate an erection by becoming engorged with blood - Urethara also has many glands but the vagina has NO glands SF28D 25-03-09- Nephrotic Syndrome- WILLIAMS ** Amount of protein left behind varies. BUT in nephritic syndrome- loss of excessive proteins at >3.5g/day - Proteinuria Causes of Nephrotic Syndrome - DM- type 1 or 2 - Glomerular diseases- Membranoproliferative or mesangiocapillary - SLEInfections- post-streptococall glomerulonephritis- commonest cause of nephritic syndeome in children in underdeveloped countries - After infection with beta hemolytic streptococcus ** Quartan malaria- common cause where malaria is endemic ** Syphillis Drugs- rheumatoid arthritis- gold injections used to be used as a disease modifying treatment. However the S/e was glomeronephritis-- nephritic syndrome NSAIDs- s/e = glomerular disease - more patients prensetn with kidney complications due to NSAIDs - High dose captorpril (ace inhibitor) leads to proteinuria- this kidney complications seems to be unique to captoril not seen with other ACE inhibitors CANCERS Mechanisms of Proteinuria ** Albumin is ve charged - Therefore because the slit pores are also negatively charged - As a result normally albumin is repelled and prevented from exiting - The second mech is that the size of the pores is smaller than most other proteins ** If charge is lost- albumin leaks through BUT the size remains the same so other protesins are unlikely to leak through OTHER conditions may cause the slit pores to enlarge as well as the change in charge. Therefore the result is larger proteins leaking through (non-selective proteinuria)Cellular Mechanism - Production of non-immungog circ permeabitly- tends to only affect the charge leading to minimal change disease

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Humoral Mecha- more common than a cellular mechanism - Circ immune complexes are depostieted in the kidneys and activate the complement system Causes of Edema - Albumin + circ proteins = osmotic pressure- OP is the main mech for holding fluid in the circ and preventing acc of fluid in the interstitial spaces Initial Theory = underfill- low oncoctic pressure- due to low serum albumin= retain fluid in the interstial spaces (3rd space) - Intravascular volume is low Overfill Theory- Intravasucal volume is high Clinical Features - Salt + water retension - Ankle edema, perioribital sacral - Children- manifiests more commonly as periorbital swelling BUT ambulatory adults tend to first present with ankle edema - 3rd space- fills with fluid---ascites, pleural effusions Prone to infections esp by encapsulated org (pneumocacl pneumonia, kliebsella) Prone to thrombus in veins + arteries - embolize to other areas including the lungs Low albumin- means that more free drug is available therefore dosage for drugs that are extinsve plasma protein bound must be adjusted Non-selc proteinuria- losing Ig in the urine- therefore more prone to infection - Factor B- agent that is responsible for opsonisation of org. ex encapsulated organisms- makes it easier for these to be engulged by the spleen etc. Hypercoagulable- liver inc protein production but this is non-selective production. Therefore coagulation factors by the liver will also be increased - Antithrombin III- acts to remove clots expediently - Protein C and S are not lost in nephritic syndromewhy? HyperlipidemiaUrine Microsco- look for rec cells or red cell casts, white cell or white cell casts etc Gold Standard- is 24 hr collection- problem with patient compliance Timed overnight collection More common = urine albumin or urine creatinie in a random sample ** Renal biopsy- definitve test Rapid diuresis- can be problematic if the intravascular volume is low Secondary hyperaldosteronism- designed to be a protectice mech but will worsen the edema . therefore give an antagonist to blow the hyperaldosteronism and prevent sodium retention Low oncotic pressure- the sodium that is re ** If there is associated renal failure- K+ will be high therefore giving an aldoster antagonist will further inc the potass lvels - There an aldos antagonist should only be used if kidney function is normal Note: Statins tend to be bound to albumin- therefore dosage might need to be reduced Hypercoaguable - hep given subcunateous (5,000 units 2x daily)- as prophylaxis - If the serum albumin is <20g/l these patients should be fully anti-coagulated even if they are ambulatory Measure to reduce proteinnuria Glomeruloneph- migh know what the antigen is but cannot remove it because it is endogenous - Therefore reduce the production - Use steroidsusually prednisone - Suppress immune system + reduce inflammation = mega doses of steroids but as the disease becomes more controlled, the dosage of pred is reduced 17

** If the GN is aggressive- must also combine the steroids with a cytoxic drug - Ex: diffuse prolifearat GN (class 4 lupus nephritis - Cyclophasphamide- is the one used most commonly - Mycopheolate- now being used as an alternative

SF28D-ANA 3-10-09- Embryology of the Urinary System- THOMAS ** The urogenital system develops from the intermediate mesoderm - The intermediate mesoderm extends along the dorsal body wall of the embryo - The urogenital ridge is a longitudinal elevation of mesoderm formed on each side of the dorsal aorta ** The urogenital ridge is divided into 2 parts: iNephrogenic cord (ridge)- gives rise to the urinary system iiGonadal ridge- gives rise to the genital system ** In the 3rd week of intrauterine life the mesoderm forms between the endoderm and the ectoderm - The urogenital system develops from MESODERM ** The mesoderm differentiates into 3 layers: 1- Paraxial mesoderm- develops beside the notochord and forms the erector spinae muscles and the thoracolumbar fascia 2- Intermediate mesoderm- develops lateral to the paraxial mesoderm and differentiates to form the urogenital system 3- Lateral Plate mesoderm- develops most laterally and becomes the viscera of the gut. Divided into somatic and somatopleuric parts ** The urinary system begins to develop before the genital system. The urinary system consists of: iKidneys- which excrete urine iiUreters- carry urine from the kidneys to the bladder iiiUrinary bladder- stores urine temporarily ivUrethra- carries urine from the bladder to the exterior Kidneys ** The renal system develops in 3 sequences: iPronephros- above the cervical level and are rudimentary iiMesonephros- from the cervical level to the pelvis level. These are well developed and function briefly iiiMetanephros (metanephric system)- become the permanent kidneys Note: Development of these 3 systems occurs in a cranio-caudal sequence - As this sequence develops there is degeneration of the previous and more rudimentary system - Therefore the protonephros eventually completely degenerates without any remnants and gives rise to the mesonephros and then the metanephros Note: As the mesonephros disappears it leaves the mesonephric duct behind Pronephros - Transitory, non-functional structures that appear in human embryos early in the 4th week - The pronephric ducts run caudally and open into the cloaca - Degenerates Mesonephros - Large, elongated excretory organs that appear late in the 4th week - Found caudal to the rudimentary pronephroi - They are well developed and function as interim kidneys for about 4 weeks until the permanent kidneys develop - The mesonephric kindness consists of glomeruli and mesonephric tubules - The tubules open into the mesonephric ducts - Note: The mesonephric ducts were originally the pronephric ducts - The mesonephric ducts open into the cloaca - The mesonephroi degenerate toward the end of the 1st trimester

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Note: Without the mesonephric ducts no kidney will form. This is because the mesonephric duct gives rise to the ureteric bud Metanephroi - The metanephros are the primordial of the permanent kidneys - Develop early in the 5th week and begin to function about 4 weeks later - Urine formation continues throughout fetal life - Urine is excreted into the amniotic cavity and mixes with the amniotic fluid ** The permanent kidneys develop from 2 sources: - Metanephric diverticulum (ureteric bud) - Metanephric mass of intermediate mesoderm- metanephrogenic blastema ** The metanephric diverticulum (ureteric bud) is an outgrowth from the mesonephric duct near its entrance into the cloaca ** The metanephrogenic blastema is derived from the caudal part of the nephrogenic cord - Both primordia of the metanephros are of mesodermal origin - Therefore the ureteric bud interacts with the metanephrogenic blastema and this interaction is the KEY to kidney development ** The ureteric bud is the primoridum of the following: - Ureter - Renal pelvis - Calices - Collecting tubules ** The metanephric blastema contributes to the formation of: - Glomerulus - Proximal convoluted tubules - Loop of Henle Note: The convoluted parts are derived from the metanephric blastema but the straight parts are from the ureteric bud ** As the ureteric bud elongates, the bud penetrates the metanephric blastema. - The stalk the ureteric bud becomes the ureters and the expanded cranial end forms the renal pelvis ** The straight collecting tubules undergo repeated branching to form successive generations of collecting tubules - The first 4 generations of tubules enlarge and become confluent to form the major calices - The 2nd 4 generations coalesce to form minor calices - The rest of the generations of the tubules form the collecting tubules proper ** The end of each arched collecting tubule includes clusters of mesenchymal cells in the metanephrogenic blastema to form small metanephric vesicles - These vesicles elongate and become metanephric tubules - As these renal tubules develop their proximal ends are invaginated by glomeruli ** The renal corpuscle (glomerulus + glomerular capsule), its PCT, loop of Henle and DCT make up a nephron ** A uriniferous tubule consists of 2 embryologically different parts: iNephron- derived from the metanephric mass of intermediate mesoderm iiCollecting tubule- derived from the metanephric diverticulum

** Branching of the ureteric bud is dependent upon induction by the metanephric mesoderm - Differentiation of the nephrons depends upon induction by the collecting tubules ** The ureteric bud and the metanephric blastema interact and induce each other in a process known as reciprocal induction, - The process of reciprocal induction results in the formation of permanent kidneys ** Before induction, a transcription factor (WT1) is expressed in the metanephric mass 19

WT1 regulates the synthesis of glial-derived neurotropic factor (GDNF) GDNF and other signaling molecules play a roles in the induction and branching of the metanephric diverticulum

** Other branching factors include hepatic transforming factor, WT1 (Wilms Tumor 1) - These factors act on the ureteric bud - Therefore this is an area for potential mutations and other genetic abnormalities ** There is cross-talk (reciprocal induction) between the ureteric bud and the metanephric blastema - This is a reciprocal communications that affects both structures ** Interaction with the receptors on the ureteric bud leads to the production of other factors such as fibroblast growth factor 2 (FG2) and bone morphogenetic protein 7 (BMP7) - These are expressed in the metanephric diverticulum - They prevent apoptosis (cell death) in the metanephric blastema - They also signal metanephros proliferation - Converts metanephric mesenchyme to epithelial cells of the nephron - Induce basal lamina formation, fibronectin, cadherin and syndecain Positional Changes of Kidneys ** Initially the metanephric kidneys lie close to each other in the pelvis, ventral to the sacrum - As the abdomen and pelvis grow, the kidneys gradually come to lie in the abdomen and move farther apart - Come to an adult position by the 9th week - The migration is mainly the result of the growth of the embryos body caudal to the kidneys - Initially the hilum of the kidney faces ventrally - As the kidney ascents it rotates medially (about 90 degrees) - By the 9th week the hilum is directed anteromedially ** As the kidneys ascend from the pelvis they receive their blood supply from vessels that are close to them ** Initially the renal arteries are branches of the common iliac arteries - As they ascend further the kidneys receive their blood supply from the distal end of the aorta - At a higher level they receive new branches from the aorta - Normally caudal branches undergo involution and disappear - In the 9th week the kidneys come into contact with the suprarenal glands and their ascent stops ** The kidneys receive their most cranial arterial branches from the abdominal aorta. These branches become the permanent renal arteries - The right renal artery is longer and often more superior ** The common variations in the blood supply to the kidneys reflect the manner in which blood supply continually changed during the embryonic and early fetal life ** Accessory (supernumerary) renal arteries usually arise from the aorta superior or inferior to the main renal artery and follow it to the hilum - Accessory renal arteries may enter the kidneys directly, usually into superior or inferior poles

Note: An accessory artery to the inferior pole may cross anterior to the ureters and obstruct it. - This results in hydronephrosis - Hydronephrosis is distention of the renal pelvis and calices with urine Note: Accessory renal arteries are end arteries. Therefore if it is damaged or ligated the part of the kidney it supplies will become ischemic Abnormal Development: Kidneys & Ureter ** Congenital anomalies can be classified into: - Abnormalities of number - Abnormalities of ascent - Abnormalities of form + fusion - Abnormalities related to flow Abnormalities of Number 20

1- Unilateral Agenesis- one kidney is missing at birth. Often is asymptomatic and usually not discovered during infancy - The one kidney undergoes compensatory hypertrophy and performs the function of the missing kidney 2- Bilateral Renal Agenesis- associated with oligohydramnios, because little or no urine is excreted into the amniotic cavity - Decreased amniotic fluid volume

** Absence of kidneys results when the metanephric diverticula fail to develop - Failure of the ureteric bud to penetrate the metanephric mesoderm results in the absence of kidney development - This is because no nephrons are induced by the collecting tubules to develop from the metanephric mass of intermediate mesoderm Supernumerary Kidney- Multiple kidneys are formed - Occurs if the branching produces deep clefts that form metanephric caps - Each of these form multiple small kidneys - Therefore it results from the division of the metanephric diverticulum Abnormalities of Volume 1- Hypoplastic Kidneys- small amounts of urine formed at birth 2- Multicystic Kidney- multiple cysts are formed within the kidneys 3- Polycystic Kidney- enlarged kidneys because fluid is filtered and then kept within the kidneys Abnormalities of Ascent ** The kidney does not reach its normal position within the abdominal cavity - Most ectopic kidneys are found in the pelvis - Pelvic kidneys are other forms of ectopia result from failure of the kidneys to ascend - Ectopic kidneys receive their blood supply from blood vessels near them Crossed Renal Ectopia- occurs when the kidney moves to the opposite side, with or without resultant fusion

Abnormalities of Form + Fusion 1- Unilateral fused kidney 2- Sigmoid kidney 3- Lump kidney 4- Discoid kidney 5- Horseshoe kidney- the poles of the kidneys are fused, usually the inferior poles - The large U-shaped kidneys are usually found in the hypogastrium, anterior to the inferior lumbar vertebrae - Normal ascent is prevented because they tend to get stuck on the root of the inferior mesenteric artery - A horseshoe kidney usually produces no symptoms because its collecting system develops normally and the ureters enter the bladder Note: If urinary flow is impeded, signs/symptoms of obstruction and infection may appear - Wilms Tumor are more frequent in children with a horseshoe kidney Abnormalities of Rotation ** Normally the kidney rotates 90 degrees, therefore the calices point laterally and the pelvis faces midline - Rotation is complete at 9 weeks - Therefore abnormal rotation tends to kink the ureter and can lead to obstruction Abnormalities of Collecting System - Extra renal pelvis- the pelvis is found outside the kidney and not in the normal position of the hilum - Bifid pelvis- produces problems because stagnant urine forms inside the bifid pelvis. - Can lead to increased infections or stone formation ** The junction between the ureter and pelvis of the kidney (ureto-pelvic junction) is a point of narrowing and therefore if it becomes stenotins the size of the pelvis increases as urine is stopped from flowing out Uterocoele- the distal end of the ureters is dilated and stenotic ** If the angle of the ureters in the bladder is improper, the result is increased pressure on the ureters - Formation of a hydroureter is possible

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Urinary Bladder ** The urogenital sinus is divided into 3 parts: 1- Vesical part- cranial part that forms most of the bladder and is continuous with the allantois 2- Pelvic part- middle part that becomes the urethra in the bladder neck, the prostatic part of the urethra and the female urethra 3- Phallic part- caudal part that grows towards the genital tubercle ** The bladder develops mainly from the vesical part of the urogenital sinus - But the trigone are is derived from the caudal ends of the mesonephric ducts ** The bladder epithelium is derived from the endoderm of the vesical part of the urogenital sinus - The other layers of the bladder wall develop from the adjacent splanchnic mesenchyme ** Initially the bladder is continuous with the allantois - The allantois constricts and becomes a thick fibrous cord (urachus) - The urachus extends from the apex of the bladder to the umbilicus ** As the bladder enlarges, distal parts of the mesonephric ducts are incorporated into its dorsal wall - These ducts contribute to the formation of the connective tissue in the trigone - As the ducts are absorbed, the ureters open separately into the urinary bladder - Due to the kidneys ascent, the orifices of the ureters more superolaterally and the ureters enter obliquely through the base of the bladder Urethra ** The epithelium of most of the male urethra and the entire female urethra is derived from the endoderm of the urogenital sinus - The distal part of the urethra in the glans of the penis is derived from a cord of ectodermal cells - The connective tissue and smooth muscle in both sexes are derived from splanchnic mesenchyme SF28D 10-03-09- Histology of Kidneys- SINGH Kidneys ** The kidneys are found retroperitoneal on the posterior abdominal wall on either side of the vertebral column - Lumbar vertebrae and rib cage partially protect the kidney - The right kidney is slightly lower than the left ** The right and left kidneys collect the waste products of metabolism. The filtered urine passes through the tubules, into the renal pelvis and into the ureters External Anatomy 1- Renal Capsule- fibrous connective tissue that surrounds each kidney 2- Perineal Fat- engulfs the renal capsule and acts as cushioning 3- Renal fascia- thin layer of loose connective tissue that anchors the kidneys and surrounding adipose to the abdominal wall 4- Hilum- Renal artery and nerves enter the hilum and the renal vein + ureter exit the kidneys - The hilum opens into the renal sinus - Renal sinus- is a cavity filled with fat and loose connective tissue ** The hilum is found on the concave inner border. ** The kidney has 2 regions: iCortex- outer region that is grainy in appearance - A portion of the cortex also extends on each side of the renal pyramids to form the renal columns - The renal columns are part of the cortical tissue that extends into medulla iiMedulla- inner region that surrounds the renal sinus- contains many cone-shaped renal pyramids - The base of each pyramid faces the cortex and forms the corticomedullary boundary - The round apex of each pyramid extends downward to the renal pelvis to form the renal papilla - The renal papilla points towards the sinus ** Each renal papilla is surrounded by a funnel-shaped minor calyx that collects urine from the papilla - The minor calyces join in the renal sinus to form a major calyx - There are often 5-7 minor calyces - Major calyces join to form the larger, funnel-shaped renal pelvis 22

The renal pelvis leaves each kidney through the hilum and narrows to become a muscular ureter The ureter exits at the hilum and connects to the urinary bladder

** The renal papilla is usually covered with a simple columnar epithelium - As the epithelium reflections onto the outer wall of the minor calyx it becomes a transitional epithelium - A thin layer of connective tissue and smooth muscle under this epithelium merges with the connective tissue of the renal sinus ** In the renal sinus between the pyramids are branches of the renal artery and vein (interlobar artery +vein / interlobar vessels) - The interlobar vessels enter the kidney and arch over the base of the pyramid at the corticomedullary junction as the arcuate arteries - The arcuate arteries give rise to smaller interlobular arteries and veins that pass radially into the kidney cortex - The arcuate arties give rise to the afferent glomerular arteries that form the glomeruli ** The cortex contains the following structures: - Convoluted tubules - Glomeruli - Straight tubules - Medullary rays- are formed by the straight parts of the nephrons and collecting tubules - The rays do not extend to the kidney capsule because of the subcapsular convoluted tubules - The rays are striations projecting into the cortex from the renal pyramid - Interlobular arteries - Interlobular veins Note: The cortical lobule is an area of the renal cortex that caps the renal pyramid ** Therefore part of the nephron is in the cortex and part of it is in the medulla - The Bowmans capsule is the port of entry to the nephron and is found in the cortex - The entrance to the nephron is the renal corpuscle - The renal corpuscles stands out in the cortex as a round, tightly packed mass of cells ** The hilum is the concave, medial border of the kidney. The hilum contains 3 large structures: iRenal artery iiRenal vein iiiRenal pelvis Note: The renal sinus is a fat-filled space that surrounds the structures. - Loose connective tissue surrounds the structures as well Nephron ** Each kidney is made up of small functional units known as uriniferous tubule, that consists of: iNephron iiCollecting duct- empties the filtered contents of the nephron ** The urine continues from the nephron to collecting ducts, papillary ducts, minor calyces, and major calyces and then to the renal pelvis - Collecting ducts, parts of the loop of Henle, and papillary ducts are in the renal medulla

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** The nephron is the functional and histological unit of the kidney. Millions of nephrons are found in each cortex. ** There are two types of nephrons: 1- Cortical Nephrons- found in the cortex of the kidney 2- Juxtamedullary nephrons The nephron is subdivided into 2 components: collecting part + excretory portion - The collecting part consists of a system of tubules - In between the nephrons are small amounts of connective tissue which contains blood vessels iRenal corpuscle (glomerulus)iiRenal tubules ** The exit from the nephron is the distal end of the collecting duct, which is found in the medulla - Fully formed urine drops from the tip of the collecting duct into the renal pelvis - Collects in the renal pelvis and then enters the ureter - The Bowmans Capsule is the entrance into the nephron

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Renal Corpuscle ** The renal corpuscle consists of two parts: iGlomerulus- tuft of capillaries formed from the afferent glomerular arteriole - The capillaries are supported by fine connective tissue (mesangium) and surrounded by the glomerular capsule Note: The afferent arteriole brings blood to the glomerulus and the efferent arteriole carries it away ** The capillaries are contained within a double-layered cup structure known as the Bowmans capsule iiGlomerular capsule (Bowmans Capsule)- a double layer of epithelial cells that surrounds the glomerulus The inner (visceral) layer of the capsule consist of highly modified branching epithelial cells (podocytes) These cells are specialized podocytes that wrap around the glomerular capillaries These cells are adjacent to the glomerular capillaries There the visceral cell layer surrounds the glomerular capillaries The outer (parietal) layer of the capsule consists of simple squamous epithelium At the vascular pole the epithelium of the visceral layer reflects to form the simple squamous parietal layer of the glomerular capsule Simple squamous epithelium of this layer becomes cuboidal where the Bowmans capsule ends and proximal tubule begins Leaving each renal corpuscle are the convoluted renal tubules The urinary space is the space between the two layers of the Bowmans capsule Note: The urinary space is continuous with the lumen of the tubules

** The Bowmans capsule is a microscopic funnel that receives filtered blood plasma (glomerular filtrate) from the glomerulus

** The renal corpuscle is the initial segment of each nephron. Blood is filtered in the renal corpuscles through the capillaries of the glomerulus - The filtrate then enters the capsular (urinary) space - The capsular space is found between the parietal and visceral cell layers of the glomerular capsule - The capsular space is continuous with the lumen of the proximal convoluted tubule at the urinary pole Note: Urine and waste products collect in the urinary space ** Each renal corpuscle has a vascular pole and a urinary pole - Vascular Pole- This the point where the arterial blood vessels that form the glomerulus enter and exit - Urinary Pole- found opposite the vascular pole. Filtrate that is produced by the glomerulus leaves each renal corpuscle at the urinary pole and enters the convoluted renal tubule Note: At the urinary pole the squamous epithelium of the parietal layer changes to cuboidal epithelium of the proximal convoluted tubule ** Filtration of blood in the renal corpuscles is facilitated by the glomerular endothelium - The endothelium in the glomerular capillaries is porous (fenestrated) Types of Nephrons 1- Juxtamedullary Nephrons- found near the junction of the cortex and the medulla - All nephrons participate in urine formation - But these nephrons also produce a hypertonic environment in the interstitium of the kidney medulla - This is necessary for the production of concentrated (hypertonic) urine 25

Found near the cortical-medullary border and the loops of Henle extend deep into the medulla The tubules of this nephron are large than the other types of nephrons

2- Cortical Nephrons- found in the cortex of the kidney, nearer to the periphery of the cortex - Loops of Henle do not extend deep into the medulla - Note: The cortical nephrons are the most peripherally placed structure beneath the capsule 3- Sub-cortical Nephrons Histology of the Nephron ** As the glomerular filtrate leaves the renal corpuscle at the urinary pole, it flows through different parts of the nephron before reaching the renal tubules (collecting tubules) - The glomerular filtrate first enters the renal tubule, which extends from the glomerular capsule to the collecting tubule - The renal tubule has several distinct histologic and functional regions Note: Two types of convoluted tubules surround the renal corpuscles - The convoluted tubules are the initial and terminal segments of the nephron 1- Proximal Convoluted Tubule- the portion of the renal tubule that begins at the renal corpuscle and is highly twisted - Initially the PCT is found in the cortex and then descends into the medulla to become continuous with the loop of Henle - Therefore the proximal convoluted tubule has 2 parts: straight part + convoluted part - Lined by simple cuboidal epithelium with many microvilli - The PCT are longer than the distal convoluted tubules and are more numerous in the cortex - The PCT have a small, uneven lumen and a single layer of cuboidal cells with eosinophilic, granular cytoplasm - A brush border (microvilli) lines the cells - The cell boundaries are not distinct because of the extensive basal and lateral cell membrane interdigitations with neighboring cells 2- Loop of HenleiDescending Limb- first part (thick) is similar to the proximal tubule. Latter part consists of simple squamous epithelium and is thinner iiAscending Limb- first (thin) part is lined by simple squamous epithelium and the distal part is thicker and lined by simple cuboidal The ascending limb of the loop of Henle joins the distal convoluted tubule Therefore the thick limb of the loop of Henle continues into the DCT

Note: The thin segments of the loop of Henle are the distal part of the descending limb and the proximal part of the ascending limb - These thin segments are lined by simple squamous epithelium and resemble the capillaries - Distinguishing features: of the thing segments of the loop of Henle are the thicker epithelial lining and absence of blood cells in the lumina - Most capillaries have blood cells in the lumina 3- Distal Convoluted Tubule- are shorter and fewer in number in the cortex. - The tubules have larger lumina with smaller, cuboidal cells - Their cytoplasms stain less intensely than the PCT cytoplasm. Therefore cells of the DCT appear paler than the cells of the PCT - No brush border is present - The main function of the DCT is to actively resorb sodium ions from the tubular filtrate - This activity is linked to the excretion of hydrogen and potassium ions into the tubular fluid - Sodium reabsoprtion in the DCT is controlled by the hormone aldosterone - In the presence of aldosterone the cells actively absorb sodium + chloride ions and transport them across the cell membrane into the interstitum - Therefore the function of the DCT is vital to the maintenance of acid-base balance of body fluids - The convoluted portion of the distal tubule goes to the renal corpuscle Note: Afferent and efferent arterioles are found in close relation to the transition zone between the straight and convoluted potions of the tubule 4- Collecting Ducts- Formed by the confluence of short collecting tubules. They form where many distal tubules come together

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As the collecting ducts become larger and descend toward the papillae of the medulla they are known as papillary ducts Smaller collecting ducts are lined by light-staining low cuboidal epithelium Have a large lumen and are lined by cells with rounded cell surfaces Deeper in the medulla, the epithelium in these ducts changes to columnar epithelium At the tip of each papilla, the papillary ducts empty their contents into the minor calyx Area cribrosa- is the area on the papilla that exhibits the openings of papillary ducts Note: The collecting ducts form medullar rays and lead to papillary ducts Therefore medullary rays consists primarily of: collecting ducts, blood vessels, straight portions of many nephrons 10 collecting ducts form 1 duct of Bellari which opens into the renal papilla

Note: The medulla contains only: - Straight portions of the tubules (DT +PT) - Segments of the loop of Henle (Thick +thin descending segments + thick +thin ascending segments) ** The cortex contains medullary rays, which include 3 types of tubules: 1- Straight (descending) segments of the proximal tubules 2- Straight (ascending) segments of the distal tubules 3- Collecting tubules- distinct in the cortex due to their lightly-stained cuboidal cells and cell membranes 4- Ascending + Descending limbs of the loop of Henle Summary: - The PCT has a larger lumen than the DCT - The lumen of the PCT is stellate shaped while the lumen of the DCT is rounded - The PCT is lined by low, simple columnar/cuboidal epithelial cells with brush border - The DCT is lined by low cuboidal epithelium with no brush border - The PCT cytoplasm appears darkly eosinophilic - DCT cells have more nuclei and the cytoplasm is lightly eosinophilic Collecting Tubule - Lined by low columnar/cuboidal epithelium - Has a larger diameter and more nuclei than the PCT - Cell boundaries are distinctly demarcated in the collecting tubule - Has the largest diameters of the tubules in the medulla Kidney Cortex ** The cortex contain the interlobular blood vessels and the larger interlobular vein + artery - The interlobular vessels give rise to the afferent glomerular arteriole that enters the glomerular capsule at the vascular pole and forms the capillary tuft of the glomerulus ** An interlobular arteriole ascends in the kidney cortex and gives rise to the afferent glomerular arteriole - Each renal corpuscle has a vascular pole at which the afferent glomerular arteriole enters and the efferent glomerular arteriole exits - The interlobular venule collects blood from the efferent glomerular arteriole - The urinary pole is on the opposite side of the renal corpuscle - At this point the capsular space becomes continuous with the lumen of the proximal convoluted tubule ** At the vascular pole, the smooth muscle cells in the tunica media of the afferent glomerular arteriole are replaced by modified epithelioid-like cells with cytoplasmic granules. - These modified epithelial cells are the juxtaglomerular cells - In the adjacent distal convoluted tubule, the cells that border the JG-cells are narrow, tall columnar cells - These are closely packed and have a darker, dense appearance. These are known as the macula densa - The juxtaglomerular cells in the afferent glomerular arteriole and the macula densa cells in the DCT form the juxtaglomerular apparatus Note: The distal tubule at the junction of the straight and convoluted parts lies close to the vascular pole of the renal corpuscle ** Therefore the JGA consists of two types of cells: 1- Juxtaglomerular cells- modified smooth muscle cells of the afferent arteriole in the vascular pole - They are located in the arteriolar wall just before it enters the glomerular capsule to form the glomerulus - The smooth muscle cells become rounded instead of spindle shaped - The nucleus also becomes spherical rather than spindle shaped 27

Cytoplasm contains secretory granules of the enzyme rennin

2- Macula densa- is a group of modified distal convoluted tubule cells Note: The macula densa cells and the JG-cells are separated by a thin basement membrane- Their close proximity to each other allows integration of their functions - In between the MD-cells and the JG-cells are interlacing networks of cells known as Lacis cells. ** The main function of the JG-apparatus is to maintain normal blood pressure in the kidney for glomerular filtration - The cells of the apparatus act as Baroreceptors and chemoreceptors - The juxtaglomerular cells monitor changes in the systemic BP by responding to stretching in the wall of the afferent arteriole - The macula densa cells respond to changes in sodium chloride concentration and the volume of glomerular filtrate as it flows past them in the DCT ** A decrease in systemic BP or a decrease in sodium concentration in the filtrate induces the JG-cells to release rennin into the bloodstream

Circulation Through the Kidneys 1- Renal Arteries- branch from the abdominal aorta 2- Segmental Arteries- branch from the renal arteries 3- Interlobar arteries- ascend with renal columns toward the cortex - Divide into 2 at the junction of the cortex and the medulla to form arcuate arteries 4- Arcuate arteries- branch and arch over the base of the pyramids - The arcuate arteries are placed at right angles - Further subdivide in the cortex to form interlobular arteries 5- Interlobular arteries- project into the cortex and give rise to afferent arterioles - The afferent arterioles form the glomerular tuft of capillaries and then forms the efferent arterioles, NOT a vein - Therefore the venous system of the kidney forms after the efferent arterioles break up into a plexus ** The parts of the circulation involved with urine formation are: iAfferent arterioles- supply blood to the glomerulus iiGlomerulus iiiEfferent arterioles- exit the renal corpuscle ivPeritubular capillaries- form a plexus around the proximal and distal tubules vVasa recta- specialized parts of the peritubular capillaries that course into the medulla. Along with the loops of Henle and then back toward the cortex Renal Medulla ** The renal medulla has: - Terminal parts of the PCT and DCT - Collecting ducts - Loops of Henle 28

Vasa recta

Note: There are no glomerulus seen in the medulla ** The papillary ducts exhibit large diameters and wide lumina - Lined by tall, pale-staining columnar cells ** The connective tissue surrounding the tubules are more abundant in the papillary region of the kidney and the papillary ducts are spaced further apart ** The contents from the papillary ducts enter the minor calyx that is adjacent to and surrounds the tip of each papilla - The papilla is lined by a stratified covering epithelium - Thin segments of the loops of Henle descend deep into the papilla ** The minor calyces are lined by transitional epithelium - Simple columnar epithelium on one side and transitional epithelium on the other side Glomerular Filtration Barrier iCapillary endothelium iiPodocytes- cells of the visceral layer of the glomerular capsule iiiGlomerular basement membrane

Filtration Membrane 1- Fenestrae- window like openings in the endothelial cells of the glomerular capillaries 2- Filtration slits- gaps between the cell processes of the podocytes. Basement membrane sandwiched between the endothelial cells of the glomerular capillaries and the podocytes 3- Filtration Membrane- capillary endothelium, basement membrane and podocytes - The first stage of urine formation occurs here - Urine is formed when fluid from the blood in the capillaries moves across the filtration membrane into the lumen inside the Bowmans Capsule Ureter ** An undistended ureter exhibits an irregular lumen (stellate-shaped) that is formed by the longitudinal mucosal folds ** The wall of the ureter consists of 3 layers: 1- Mucosa- lined by transitional epithelium and lamina propria - The transitional epithelium has several cell layers (4-5 cell layers) - Outermost- large cuboidal, umbrella shaped cells, flattened - Intermediate- polyhedral in shape - Basal cells- low columnar or cuboidal - The basal surface of the epithelium is smooth and has no indentations by the connective tissue papillae are found - The epithelium rests on a dense collagenous lamina propria Function: of transitional epithelium is stretchability and impermeability to urine - The cells are impermeable to urine because of the tight junctions of the umbrella cells Lamina Propria- contains fibroelastic connective tissue - This connective tissue is denser and has more fibroblasts under the epithelium - Looser near the muscularis - Diffuse lymphatic tissue and small lymphatic nodules are found in the lamina propria 2- Muscularis- In the upper ureter the muscularis consist of 2 layers: Inner longitudinal- smooth muscle layer Outer circular- smooth muscle layer

iii-

Note: In the lower 1/3 has an additional outer longitudinal layer of smooth muscle - The initial 2 layers are not always distinct 3- Adventitia- blends with the surrounding fibroelastic connective tissue and adipose tissue This contains numerous arteries, venules and small nerves

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Urinary Bladder ** The urinary bladder is a hollow organ with a thick muscular wall. Its main function is to store urine - The lumen of the bladder is lined with transitional epithelium - Therefore the wall of the bladder can stretch as the organ fills with urine - When the bladder is empty the epithelium may have 5-6 layers of cells - The superficial cells in the epithelium are cuboidal, large and dome-shaped - When the bladder wall is stretched the superficial cells appear squamous - Therefore the cells appear thinner and squamous to accommodate the increased volume of urine - Some of the superficial cells may be binucleate - The outer plasma membrane of the superficial cells in the epithelium is prominent ** The cells of the epithelium are attached to each other via desmosomes and occluding junctions - The plaques are impermeable to water, salts, and urine - This provides an effective osmotic barrier between the urine and the underlying connective tissue ** Beneath the epithelium is the lamina propria - The lamina propria contains fine connective tissue fibers, numerous fibroblasts and blood vessels - There is no muscularis mucosae or submucosa in the urinary bladder ** The muscularis consists of 3 indistinct muscle layers that are visible as smooth muscle bundles - These muscles are arranged in interlacing network of anastamosing bundles - Between each bundle is interstitial connective tissue with blood vessels and capillaries - Note: The interstitial connective tissue merges with the connective tissue of the serosa - Therefore peritoneal mesothelium is the outermost layer - Well defined muscular layer that is seen is the detrusor muscle Urethra ** The urethra is longer in the male than in the female. In the male the urethra has 3 parts: 1- Membranous urethra- pseudostratified columnar ciliated epithelium - EXCEPT- in the part that is next to the urinary bladder, this is lined by transitional epithelium 2- Prostatic urethra- transitional epithelium 3- Penile urethra- pseudostratified columnar ciliated epithelium Note: At its termination the urethra changes to stratified squamous epithelium Print Slide #42 ** The lamina propria has mucus glands opening into the urethra (bulbourethral glands) - Above the lamina propria is a layer of smooth muscle Note: The lining of the urethra is the same in the female EXCEPT a portion of the vagina that is associated with the female urethra

SF28D 13/03/09 Female Reproductive Organs I: Uterus - DR.SUJ Uterus ** The uterus is the internal organ of the female reproductive system. Size: 8cm x 5cm x 3cm - 3in x 2in x 1 inch ** In the virginal state it is the shape of a flattened pear.

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** The parts of the uterus are: - Fundus- parts above the level of the entrance of the fallopian tubes - Body below the level of the cornua - Cervix- lower part - Cornua- area leading to the fallopian tubes - Isthmus- is the narrow part between the cervix and the body - Uterine cavity- space in the body of the uterus - Cervical canal- space in the cervix. The canal of the cervix is continuous with the cavity of the body (internal os) ** The canal of the cervix is continuous anterosuperiorly with the cavity of the body of the uterus - Inferiorly the canal opens into the vagina through the ostium uteri Internal Os- is the uterine end of the cervical canal External Os- is the vaginal end of the cervical canal - This is the lower opening into the vagina - This is circular in nulliparious women - Usually becomes transverse in parous women with anterior and posterior lips - The anterior lips lie at a lower level than the posterior - The external os is normally on a level with the ischial spines Note: In women after childbirth the cervix becomes stretched and appears transverse and never regains its circular shape

** The uterus receives the uterine tubes and the cervix protrudes into the vagina. - The uterus is the area for the developing fetus - Located on the pelvic floor between the urinary bladder and the rectum Axis and Position of the Uterus ** The uterus overlies the posterior part of the superior surface and the upper part of the base of the bladder ** Therefore when the bladder is empty, the uterus is: iAnteverted- the uterus is tilted forwards at right angles to the vagina and to the plane of the superior aperture of the lesser pelvis - Anteversion- is forward bending on its long axis iiAnteflexed- the body is bent slightly downwards at the isthmus on the firmer, more fibrous cervix - The long axis of the uterus is bent forwards in relation to the long axis of the vagina ** Anteversion and anteflexion is the normal state of the uterus. However the uterus can be found in other positions: iDextroverted- the long axis is slightly tilted to the right or to the left iiDextrorotated- the uterus is slightly rotate to the right or left iiiRetroflexion- the uterus is bent backwards on itself at the isthmus ivRetroverted- the uterus is raised and may be forced back till it lies in line with the vagina - This may be a pathological condition - The uterus may be temporarily retroverted when the bladder is fully distended Fundus - The part of the uterus above the entrance of the tubes - Convex - Has a serous coat of pelvic peritoneum which continues downwards over the front and the back of the body Body -

Tapers downwards from the fundus Flattened anteroposteriorly Each upper angle (cornu) is found at the junction of fundus and body The cornu receives the uterine tubes The body is enclosed by peritoneum. Laterally this peritoneum becomes the broad ligament The intestinal surface of the body faces upwards with coils of intestine lying on it The vesical surface faces downwards resting on the bladder with the peritoneum of the vesicouterine pouch intervening

Note: The cavity of the uterus occupies the body - The cavity is a narrow slit in a virgin - The cavity is a small triangular slit between the intestinal and vesical walls 31

Enlarges during pregnancy by the growth of the uterine walls to accommodate the fetus There is no cavity in the fundus of the uterus only in the body of the uterus

** The body of the uterus is rarely exactly midline. When the body is deviated to one side the cervix becomes deflected to the opposite side - Therefore one ureter may be closer to the cervix than the other ** The body of the uterus has 2 surfaces: 1- Inferior (vesical) surface- is flat and is found in relation to the urinary bladder - The uterovesical pouch of peritoneum extends between it and the bladder to the junction of the body and cervix - The pouch is empty unless the uterus is retroverted 2- Superior (intestinal) surface- convex surface that is covered with peritoneum - Extends posteriorly over the supravaginal part of the cervix and the posterior fornix of the vagina to the recto-uterine pouch - The recto-uterine pouch contains loops of ileum and sigmoid colon - Usually coils of intestine rest on it Print Slide #11 ** The body of the uterus is enclosed between the layers of the broad ligament and is freely mobile Cervix - The cervix tapes below the body of the uterus - The lower end of the cervix is surrounded by the vault of the vagina - The cervix protrudes into the vagina ** The cervix has 2 parts: iVaginal part- lower part iiSupravaginal part- upper part ** The deep sulcus that surrounds the protruding cervix is the fornix of the vagina - Therefore the fornix is the space between the vaginal part of the cervix and the vagina - The fornix of the vagina is deepest posteriorly ** The posterior surface of the cervix is covered by peritoneum that continues from the body on to the upper part of the fornix - This forms the anterior wall of the rectouterine pouch (of Douglas) Note: The anterior surface of the cervix has no peritoneal covering - The surface is deep to the vesicouterine pouch - The anterior surface is attached to the bladder above the trigone by dense connective tissue ** The ureter is about 2cm from the cervix as it passes lateral to and then in front of the fornix ** The cervix is held in position by a number of structures that are principally condensations of fascia and some smooth muscle in the base of the broad ligament ** The antero-inferior surface of the cervix is directly in contact with the upper part of the base of the bladder Borders of the Uterus ** The right and left borders of the uterus are the round ligaments of the uterus and ligaments of the ovary - These are attached near the cornua Structure of the Uterus ** The uterus is a muscular organ with a wide but thin uterine cavity. The wall consists of: 1- Myometrium- smooth muscle that consists of the bulk of the uterus - The fibers are described as being in 3 layers. But the layers are ill-defined - The outer muscle fibers tend to be longitudinal and expulsive in function - Many of those are more deeply placed are circular and act as sphincters around the larger blood vessels, openings of the uterine tubes and the internal os 2- Endometrium (mucus membrane)- inner lining of the uterus (columnar epithelium). - This lining dips down into the endometrial stroma to form the endometrial glands 32

The thickness of course varies with the different stages of the menstrual cycle

Note: The mucosa of the cervix does not take part in the cyclical changes and is not shed at menstruation - The surface cells are mucus-secreting and there are also mucus glands - Just inside the external os the epithelium changes to the stratified squamous variety of the vagina 3- Serous coat- outer covering of the uterus is the peritoneum Peritoneal Reflections of the Uterus ** The parietal peritoneum from the anterior abdominal wall is reflected onto the urinary bladder - The vesical surface and the fundus of uterus forms the uterovesical pouch - Reflected onto the intestinal surface of the uterus - Then onto the supravaginal part of the cervix and the upper part of the vagina (posterior fornix) - Then the peritoneum reflects backwards onto the rectum to form the rectouterine pouch ** The peritoneum from the borders of the uterus form the broad ligaments, up to the lateral walls of the pelvis (2 layers on each side) ** From the posterior fornix, the physician can directly enter the peritoneum ** The pelvic peritoneum hangs the uterus anteriorly and posteriorly - Gets lifted up by the uterus and tubules, forming folds on each side ** The broad ligament extends from the right and left sides and extends to the lateral wall of the pelvis Broad Ligament ** The broad ligament is a lax double fold of peritoneum lying lateral to the uterus - Plays little part in uterine support - The medial edge is attached to the side wall of the uterus and flows over its intestinal and vesical surfaces as its serous coat - The lateral edge is attached to the side wall of the pelvis - The two layers of its inferior edge (base) pass forwards and backwards to line the pelvic cavity - As the posterior layer attaches to the pelvic cavity, it has the ureter adhering to it ** The line of lateral attachment crosses the following structures: - Obturator nerve - Superior vesical or obliterated umbilical vessels - Obturator artery + vein ** The upper border of the broad ligament is free. - This forms the mesosalpinx and containing the uterine tube ** The upper lateral part of the broad ligament contains the ovarian vessels and lymphatics - The upper lateral (superolateral) part is extended over the external iliac vessels as a fold, the suspensory ligament of the ovary - Therefore the ovarian vessels pass in the suspensory ligament

Note: The uterine vessels and nerves are also in the broad ligament ** The anterior layer of the broad ligament is bulged forwards by the round ligament of the uterus, just below the uterine tube ** The posterior layer has a fold projecting backwards suspending the ovary, the mesovarium ** Structures between the 2 layers of the broad ligament are: iParametrium- condensed pelvic fascia. Mass of areolar tissue which contains the uterine vessels + lymphatics, the round ligament, ligament of the ovary, vestigial remnants of the mesonephric tubules Note: The vestigial remnants of the mesonephric tubules are the epoophoron and paroophoron - Epoophoron- may retain a connection to the posterior fornix - Paroophoron- lower part of the broad ligament near the uterus body - These are usually blind-ended tubes but can form large cysts in the broad ligament (para-ovarian cysts) - Gartners duct 33

iiMesosalpinx- upper part, with fallopian tubes iiiMesovarium- in the posterior layer, where the ovarian vessels and nerves pass to the ovary. - Contains the pedicle for the ovary

** The round ligament and the ligament of the ovary are remnants of the gubernaculum - The gubernaculums is the embryological structure that connects the gonads to the labial/scrotal swelling - This swelling develops into either the scrotum or the labia majora Blood Supply- Uterus ** The uterine artery supplies the uterus and it is a branch of the internal iliac - The uterine artery passes medially across the pelvic floor in the base of the broad ligament - Passes above the ureter to reach the side of the supravaginal part of the cervix - The uterine artery gives a branch to the cervix and the vagina, the vessel turns upwards between the layers of the broad ligament - Runs in a torturous manner alongside the uterus as far as the cornu - Gives off branches which penetrate the uterine walls and anastamose across the midline with the corresponding branches of the opposite uterine artery

** At the junction of the uterus and uterine tube the artery turns laterally - Ends by anastomosing with the tubal branch of the ovarian artery, which supplies the uterine tube Note: The ureters are found in close association with the uterine artery. Therefore they are in danger of being injured during a hysterectomy ** The arteries are found in the layers of the peritoneum Venous Drainage ** The veins of the uterus pass below the artery at the lower edge of the broad ligament - They form a wide plexus across the pelvic floor - This plexus communicates with the vesical and rectal plexuses and drains to the internal iliac veins - The tubal veins join the ovarian veins ** Therefore the venous drainage of the uterus is to the internal iliac veins via the utero-vaginal plexuses Lymphatic Drainage- Uterus ** The lymph from the cervix drains to external + internal iliac nodes - Also drains to pre-sacral nodes via the uterosacral ligaments ** The lower part of the uterine body drains to external iliac nodes ** Lymphatics from the upper part of the body, fundus + uterine tube accompany those from the ovaries to para-aortic nodes - A few pass to the external iliac nodes 34

A few from the region of the uterine cornua accompany the round ligaments to reach the medial horizontal set of superficial inguinal nodes

Nerve Supply- Uterus ** The nerves of the uterus are branches from the inferior hypogastric plexus - The uterus smooth muscle is sensitive to hormonal influences - The sympathetic supply is vasoconstrictor and also has a facilitating function in relation to the uterine muscle Note: Division of all uterine nerves or high transection of the spinal cord does not affect uterine contractility, even in labor ** The pelvic splanchnic nerves usually carry pain from the cervix. ** The sympathetic supply is from T10- L1 (mostly T12- L1) and pain can be referred to the corresponding dermatomes - Usually uterine pain is referred to the lower abdomen - Cervical pain is referred to the lower back ** Parasympathetic supply- is from the pelvic splanchnic nerves (S2, S3, S4) - Afferents from the cervix ** Distention of the uterus causes pain, but both the cervix and the body are relatively insensitive to cutting and burning - However the uterine tube is sensitive to touching and cutting Print Slide #24 Clinical Aspects ** Due to the proximity of the ureters to the cervix and uterine vessels, care has to be taken to protect the ureters during a hysterectomy ** Retroverted Uterus- the uterine axis bends backwards on the vaginal axis - Retroverted Gravid Uterus- In early pregnancy and anteriorly directed cervix that can compress the upper urethra/bladder-neck against the pubis - This leads to retention of urine in the bladder Pouch of Douglas- has a close proximity to the posterior fornix is a direct access to the peritoneal cavity

SF28D-ANA 13-03-09- Female Reproductive System II: Fallopian Tubes + Ovary - DR. SUJ Fallopian Tube (Uterine Tubes) ** The uterine tubes are found in the upper margin of the mesosalpinx (peritoneal fold) ** Each fallopian tube is 10 cm long. The medial 1 cm (intramural part) is embedded in the uterine wall ** The tube then emerges from the cornu and the tube then lies in the upper edges of the broad ligament - The intramural (uterine) part ** The isthmus of the tube is the part adjacent to the uterus and is straight and narrow - This is the narrowest part of the tube - Therefore ectopic pregnancy can occur here if the passage of the fertilized ovum is blocked ** The wider ampulla is next to the isthmus. - The ampulla forms more than half the length of the tube - The ampulla is 1/3 the length of the uterine tube and fertilization of the ovum takes place here - Thin walled with a tortuous lumen due to the folded lining

** The lateral end of the tube has a trumpet-shaped expansion (infundibulum) or fimbriated end - The infundibulum has a number of finger-like processes (fimbriae) - Ovarian fimbria- One of the fimbriae is longer and usually applied to the ovary. This keeps the mobility of the ovary restricted - This open end lies behind the broad ligament adjacent to the lateral pelvic wall ** The fallopian tubes open into the uterine cavity via the uterine ostium and also opens into the peritoneal cavity via the abdominal ostium 35

Parts of the Fallopian Tube iInfundibulum- fimbriated end iiAmpulla iiiIsthmus ivIntramural- uterine part

Blood Supply- Fallopian Tube - Tubal branch of the ovarian artery - Tubal branch of the uterine artery ** Venous Drainage into the ovarian and uterine veins Note: The vessels pass through the mesovarium to supply the tubule Lymphatics- Fallopian Tube - Para aortic lymph nodes - Internal iliac lymph nodes - Inguinal lymph nodes from the intramural part Nerve Supply: Fallopian Tubes Sympathetics: from T10 to L2 - Therefore pain in the fallopian tubes (e.g ectopic pregnancy) can mimic the pain of appendicitis - Contraction of the smooth muscle of the tubes and blood vessels Parasympathetic- from the pelvic splanchnic nerves (S2, S3, S4), along with some minor vagal influence Note: Fallopian tubes are sensitive to touch, temperature and cutting, in addition to distention and 36

stretching - This sensitivity to touch, temperature and cutting is unlike the abdominal viscera Clinical Aspects 1- Tubal litigation- a method of contraception 2- Infection (salpingitis)- the tubes are exposed to the outside world, therefore may be prone to infection 3- Tubal pregnancy- ectopic gestation Ovary ** Each ovary is ovoid in shape and smaller than the testis - 3 cm long - 2 cm wide - 1 cm thick Note: The ovaries are smaller before menarche and post-menopausally ** The ovaries are found in the ovarian fossa, on the parietal peritoneum of the pelvis Note: Sometimes the ovaries can be found in the Pouch of Douglas ** Also related to the ovarian fossa are the: - External iliac vessels - Ureter - Internal iliac vessels - Obturator nerve Structure of the Ovary ** The ovary has 2 surfaces: iMedial iiLateral ** The ovary has 2 borders: iAnterior iiPosterior ** The ovary also has 2 poles: ** The lower pole of the ovary is tilted towards the uterus - Attached to the uterus by a fibromuscular band- the ligament of the ovary - The ligament of the ovary is continuous with the round ligament - Both ligaments are attached to the cornu of the uterus - Both ligaments are also the remnants of the gubernaculums ** The mesovarium is a double fold of peritoneum that attaches the anterior border of the ovary to the posterior leaf of the broad ligament Note: The peritoneum does not invest the rest of the surface of the ovary - The rest of the ovarian surface is covered with cuboidal epithelium and faces the peritoneal cavity - Therefore the ovary is covered by peritoneum only at the hilum - This is because the surface has to remain open for the release of the ovum from the organ ** The medial surface is mainly related to the uterine tube ** The lateral surface of the ovary lies in the angle between the internal and external iliac vessels, against the parietal peritoneum - The parietal peritoneum separates the lateral surface from the Obturator nerve (laterally) and the ureter (posteriorly) Note: The Obturator nerve supplies the peritoneum of this area - Therefore a diseased ovary may cause referred pain along the cutaneous distribution of the obturator nerve on the inner side of the thigh - Pain can also be related to the knee because the pelvic peritoneum at this point is supplied by the Obturator nerve ** During pregnancy the location and line of the ovary change and usually never return to their original state ** The ovary in its normal position can be reached through the vagina by the tip of the examining finger - Overlaid by the coils of sigmoid colon and ileum that occupy the rectouterine pouch of Douglas

iii-

Tubal pole Lower pole- has the attachment of the ligament of the ovary

** The tubal extremity is the upper pole of the ovary. - This is tilted laterally - Overlapped by the fimbriated end of the uterine tube

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** The functions of the ovaries are: - Production of hormones - Development of ova Blood Supply- Ovary ** An ovarian artery supplies each ovary - Branch of the abdominal aorta from just below the renal artery. At the level of L2 - The ovarian artery runs down behind the peritoneum of the infracolic compartment and the colic vessels - Crosses the ureter obliquely as it descends on the psoas major muscle - Crosses the pelvic brim and enters the suspensory ligament at the lateral extremity of the broad ligament - The ovarian artery gives off a tubal branch to the uterine tube. This tubal branch of the ovary runs medially between the layers of the broad ligament and anastamoses with the tubal branch of the uterine artery The ovarian artery ends by entering the ovary

Note: The ovary is also supplied by the ovarian branch of the uterine artery Venous Drainage- Ovary ** Venous channels form a pampiniform plexus in the mesovarium and the suspensory ligament - The union of these channels form ovarian veins - The plexus drains into a pair of ovarian veins which accompany the ovarian artery - The two veins usually combine as a single trunk before their termination Right Ovarian Vein- joins the inferior vena cava Left Ovarian Vein- joins the left renal vein Lymphatic Drainage- Ovaries ** The lymphatics of the ovary drain to para-aortic nodes alongside the origin of the ovarian artery (L2), just above the level of the umbilicus Note: It is possible for lymph to reach inguinal nodes via the round ligament and the inguinal canal - May also reach the opposite ovary by passing across the fundus of the uterus Note: The lymphatics also can follow anastamotic areas. Therefore some lymph from the ovaries may go towards iliac lymph nodes Nerve Supply: Ovaries ** Ovarian function is under the control of hormones Sympathetic Supply- aortic plexus (T10 + T11) - Sympathetic (vasoconstrictor) fibers reach the ovary from the aortic plexus along its blood vessels - The preganglionic cell bodies are in T10 and 11 segments of the cord - Pain referred to the umbilical region Parasympathetic Supply- some may reach the ovary from the inferior hypogastric plexus Note: Sensory fibers accompany the sympathetic nerves - Therefore ovarian pain may be periumbilical like appendicular pain Print Slide #54- Clinical Aspects Note: Anything that irritate the pelvic peritoneum can be related to the medial aspect of the lower thigh - EX: pelvic appendicitis- pain referred to periumbilical area SF28D-ANA 16-03-09 Perineal Region- THOMAS? ** The perineum consists of the structures that fill the inferior aperture of the pelvis - The inferior aperture of the pelvis is between the upper parts of the thigh and the lower parts of the buttocks ** The perineum consists of the part of the trunk that is caudal to the pelvic diaphragm (levator ani + coccygeus) ** The perineum extends from the inferior margin of the pubic symphysis to the coccyx - Lateral Boundaries- inferior rami of the pubic bones, rami + tuberosities of the ischial, sacrotuberous ligaments 38

Note: The perineum is wider in females than in males ** The perineum is divided into two regions by a transverse line passing through the anterior parts of the ischial tuberosities immediately anterior to the anus: 1- Anal Region- larger posterior region that transmits the terminal 3-4 cm of the large intestine and the anal canal - Contents: anal canal and the ischioanal fossae and their contents 2- Urogenital Region- smaller anterior region that contains the external genitalia of each sex - Bounded laterally by the conjoined ischiopubic rami Male Contents- urethra enclosed in the root of the penis, partly hidden by the scrotum Female Contents- urethral + vaginal orifices, and the clitoris surrounded by the labia minora + majora

** In the male perineum there is a median cutaneous ridge, the raphe of the perineum - This extends from the anus over the inferior surface of the scrotum and the ventral surface of the penis - The raphe marks the line of fusion in the male of the structures that form the separate labia in the female - That is the floor of the urethra by fusion of the labia minora, the scrotum by fusion of the labia majora General Arrangement of the Perineum\ ** The urogenital region has 3 layers of fascia separated by the superficial and deep perineal spaces filled by 2 layers of muscles and other structures iMembranous layer- attached laterally to the ischial tuberosities and to the lateral margins of the ischial and inferior pubic rami with the deep fascia of the thighs Anteriorly- this layer continues its lateral attachments across the front of the bodies of the pubic bones towards the pubic tubercles Continuous with the membranous layer of the superficial fascia of the anterior abdominal wall Between these attachments it forms the fascial sheath and the fundiform ligament of the penis and the dartos layer in the scrotum Anterior to the anal orifice, the membranous layer turns superiorly to fuse with the posterior border of the thick middle fascial layer (inferior fascia of the urogenital diaphragm) Perineal Membrane (inferior fascia of the urogenital diaphragm)- which is the middle fascial layer that is attached laterally to the pubic arch

ii-

** The superficial perineal space lies between the 2 layers of fascia and is closed posteriorly by their fusion - Central perineal tendon- is a fibrous mass to which perineal muscles are attached - Found in the middle of fusion between the anus & vagina (females) or the bulb of the penis (male) ** In the male superficial perineal space contains: - Nerves + blood vessels - Root of the penis - 2 crura attached to the surfaces of the ischiopubic rami - Median bulb of the penis covered by the bulbospongiosus muscles attached to the inferior surface of the perineal membrane - Superficial transverse perineal muscles lie transversely across the posterior margin of the space from the tuberosities of the ischium to the central perineal tendon iiiSuperior fascia of the urogenital diaphragm- limits the latery of muscle that fills the deep perineal space - Superior to the perineal membrane is a thin layer of muscle that stretches across the pubic arch - The main part surrounds the urethra as the voluntary sphincter urethrae - The posterior fibers pass transversely as the deep transverse perineal muscles - The superior fascia is attached laterally to the pubic arch - Fuses anteriorly and posteriorly with the perineal membrane to close the deep perineal space Note: Anteriorly this fusion does not reach the pubic symphysis. Leaves a space through which the deep dorsal vein of the penis (or clitoris) enters the pelvis Anal Region ** The anal region is the triangular area between the posterior margin of the urogenital diaphragm and the coccyx - The inferior aperture of the pelvis in this area is closed by the 2 levator ani muscles

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Levator ani slopes downwards, backwards, + medially to be inserted into the central perineal tendon, anal canal and the anococcygeal ligament The ligament stretches from the anal canal to the coccyx

** The ischiorectal fossa is a space on each side between the levator ani muscle and the lower part of the lateral wall of the bony pelvis - Filled with fatty, superficial fascia that allows distention of the median anal canal - The canal is surrounded by the sphincter ani externus that extends forwards to the central perineal tendon and backwards to the coccyx Cutaneous Nerves ** The skin of each side of the anal region is supplied by: - Inferior rectal nerve (S3, S4) - Perineal branch of S4 - Twigs from the coccygeal plexus (S5) ** In the urogenital region, the ilioinguinal nerve (L1) supplies the anterior 1/3 of the scrotum (labium majus)

** The skin of the penis (clitoris) is mainly supplied by the dorsal nerve (S2) - The dorsal nerve of the penis/clitoris is a branch of the pudendal nerve ** The posterior 2/3rds of the scrotum/labium majus is supplied: 1- Laterally- by the perineal branch of the posterior femoral cutaneous nerve 2- Medially- by scrotal/labial branches of the perineal branch of the pudendal nerve (S3) Clinical Application: A pudendal nerve block will not anesthetize the whole vulva - Therefore the anterior and lateral parts must be locally infiltrated to supplement the main nerve block Perineal Body ** The perineal body is also known as the central tendon of the perineum - Midline fibromuscular mass to which a number of muscles gain attachment - Attached to the posterior border of the perineal membrane - Lies between the anal canal and the vagina/bulb of the penis ** The muscles running into it include: - External anal sphincter - Pubovaginalis (pubourethralis) - Part of levator ani - Bulbospongiosus - Superficial + deep transverse perineal muscles Function: The position and connections of the perineal body provide a stabilizing influence for pelvic and perineal structures - Injury to it during childbirth may weaken the pelvic floor - This contributes to prolapse of the vagina + uterus Male Urogenital Region ** Has 2 layers of fascia: superior + inferior fasciae of the urogenital diaphragm - These two layers enclose the sphincter urethrae and the deep transverse perineal muscles Note: These muscles + the fasciae form the urogenital diaphragm - The superior fascia is thin - The inferior fascia is thicker and known as the perineal membrane ** The fascia of the urogenital diaphragm (superior + inferior) enclose between them a deep perineal space (pouch). This space contains the following structures: - Membranous part of the urethra - Internal pudendal vessels - Dorsal nerve of the penis - Perineal nerve - Paired bulbourethral glands - Sphincter urethrae - Deep transverse perineal muscles

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** The perineal membrane (inferior fascia of the UG diaphragm) is a tough sheet of fibrous tissue, which forms the basis on which the penis and penile musculature are fixed - Attached on either side to the ischiopubic rami from just behind the suprapubic angle back to the level of the anterior part of the ischial tuberosities - The anterior border of the perineal membrane forms the transverse perineal ligament - There is a small gap between this ligament and the arcuate pubic ligament - Therefore the deep dorsal vein of the penis passes through to reach the vesicoprostatic plexus - Posterior Border- of the perineal membrane fuses centrally with the perineal body Note: Superior to the perineal membrane is the membranous urethra surrounded by the urethral sphincter - Membrane is pierced by the urethra, ducts of the bulbourethral glands + nerves ad vessels ** Deep to the skin of the urogenital region is the superficial perineal fascia (of Colles) - This Colles fascia is a continuation into the perineum of the membranous fascia of Scarpa from the anterior abdominal wall - Colless fascia is attached to the ischiopubic rami and the posterior margin of the perineal membrane - This attachment encloses a subfascial space (superficial perineal pouch) - The superficial perineal pouch is in continuity with the space deep to the membranous (Scarpas fascia) of the anterior abdominal wall Note: A deep perineal fascia intimately surrounds the cavernous bodies of the penis and clitoris and the superficial perineal muscles associated with them Superficial Perineal Muscles 1- Bulbospongiosus- arises from the perineal body and from a median raphe that joins the pair together - Posterior fibers are directed forwards and laterally over the bulb to be inserted into the perineal membrane - Also a dorsal fibrous expansion on the penis - Function: Empties the urethra at the end of micturition and assist in erection be compressing the deep dorsal vein of the penis - Also contracts during ejaculation 2- Ischiocavernosus- arises from the posterior part of the perineal membrane and from the ischial ramus - Insertion: via an aponeurosis onto the surface of the corpus cavernosum - Function: to assist in the support of the erect penis 3- Superficial Transverse Perineal Muscle- arises from the ischial tuberosities and is inserted into the perineal body. - Function: Helps to stabilize the perineal body Nerve Supply: of all 3 muscles is via the perineal branch of the pudendal nerve (S2, S3) Perineal Vessels and Nerves ** The internal pudendal artery enters the deep perineal pouch from the anterior end of the pudendal canal - Passes forwards along the ischiopubic ramus above the perineal membrane - The dorsal nerve of the penis is superior to the artery and the perineal nerve is inferior to the artery ** The perineal branch of the internal pudendal artery pierces the posterior angle of the perineal membrane and gives origin to: - Posterior scrotal branches - Transverse perineal branches ** Another branch, artery to the bulb pierces the membrane alongside thee urethra to enter the corpus spongiosum - Gives branches to the cavernous tissue of the corpus spongiosum - Passes forwards to supply the glans penis ** The internal pudendal artery divides into its terminal branches near the anterior margin of the perineal membrane - Deep artery of the penis- pierces the membrane to enter the crus of the penis and supplies the erectile cavernous tissue of the corpus cavernosum Dorsal artery of the penis- pierces the membrane and passes between the crus and the pubic symphysis to pierce the suspensory ligament Runs forward, alongside the median deep dorsal vein and the dorsal nerves laterally, beneath the deep fascia of the penis and the fibrous sheaths of the corpora cavernosa

Note: The two arteries pass to the glans and anastamose with the terminal branches of the arteries to the bulb 41

** The deep dorsal vein of the penis drains most of the blood from the corpora - Runs proximally in the midline - Pierces the suspensory ligament - Passes upwards in the gap between the pubic symphysis and the perineal membrane to enter the pelvis and join the vesicoprostatic plexus ** The pudendal nerve divides within the pudendal canal into its terminal branches: - Dorsal nerve of the penis - Perineal nerve ** Both terminal branches enter the deep perineal pouch and run in association with the internal pudendal artery - The dorsal nerve of the penis is the direct continuation of the pudendal nerve - Pierces the anterior angle of the perineal membrane - Supplies the skin of the penis and the glans - Also gives branches to the corpus cavernosum - NO branches in the deep perineal pouch ** The perineal nerve is the larger terminal branch of the pudendal - Gives muscular branches to the superficial and deep perineal muscles and to the sphincter urethrae - Gives off the posterior scrotal branches before or just after entering the deep perineal pouch - These branches run forwards superficial to the perineal membrane to supply the scrotal skin SF28D- 16/03/09- Supports of the Uterus & Vagina- LODENQUAI Ligaments of the Uterus & Cervix ** The ligaments that attached to the uterus are: 1- Broad ligament 2- Round ligament 3- Cardinal ligament (transverse cervical ligament) 4- Uterosacral (sacrocervical) ligament 5- Posterior uterine (rectovaginal) ligament 6- Pubocervical fascia 7- Utero-ovarian ligament 8- Rectouterine ligament ** The most fixed part of the uterus is the cervix, because of its attachment to the back of the bladder and to the vaginal fornix ** A number of other structures help directly or indirectly to maintain the normal position. These include: - Pelvic diaphragm - Condensations of visceral pelvic fascia- forming ligaments - Peritoneal attachments ** The Pubovaginalis par of levator ani and the perineal body with its inserted muscles support the vagina - Therefore they also indirectly assist in holding the cervix up - If these muscles are stretched (over) or damage during childbirth, the posterior vaginal wall sinks downwards (prolapses) - This is often followed by prolapse or retroversion of the uterus Broad Ligament ** The broad ligament is made up of a double fold of peritoneum lying lateral to the uterus - The medial edge is attached to the side wall of the uterus - The medial edge extends over the intestinal and vesical surfaces as its serous coat - The lateral edge is attached to the side wall of the pelvis ** The two layers of the inferior edge (base) pass forwards and backwards to line the pelvic cavity - As the posterior layer attaches to the pelvic cavity, it has the ureter underneath it Note: The line of lateral attachment crosses the following structures: - Obturator nerve - Superior vesical or obliterated umbilical vessels - Obturator artery + vein 42

** The upper border of the broad ligament is free, forming the mesosalpinx and containing the uterine tube - The mesosalpinx (mesentery of the tube) is the part of the broad ligament between the ovary and the uterine tube - The rest of the broad ligament is the mesovarium (mesentery of the uterus) ** The suspensory ligament of the ovary is the part of the broad ligament lateral to the ovary - This suspensory ligament is the upper lateral part of the broad ligament - Contains the ovarian vessels + lymphatics and extends over the external iliac vessels as a fold

** The anterior layer of the broad ligament is projected forwards by the round ligament of the uterus; just below the uterine tube. ** The posterior layer has a fold that project backwards to suspend the ovary (mesovarium) ** Between the two layers of the broad ligament is a mass of areolar tissue (parametrium). Within the parametrium the following structures are found: - Uterine vessels + lymphatics - Round ligament of the uterus - Ligament of the ovary - Remnants of the mesonephric tubules (epoophoron + paroophoron) Round Ligament ** The round ligament of the uterus extends from the junction of the uterus and tube to the deep inguinal ring - The round ligament is found within the broad ligament below the uterine tube - As a result of its uterine attachment, the round ligament is continuous with the ligament of the ovary - The two round ligament and the ligament of the ovary together represent the gubernaculum - The round ligament passes through the inguinal canal and is attached at is distal extremity to the fibrofatty tissue of the labium majus of the vulva ** The round ligament is supplied by two branches: iBranch of the ovarian artery- in the broad ligament iiBranch of the inferior epigastric artery- in the inguinal canal ** The round ligament consists of smooth muscle and fibrous tissue. Acts to hold the uterus forwards in anteflexion and anteversion - Hold the uterus forwards especially when forces tend to push the uterus backwards - EX: distention of the bladder, gravity when lying down Transverse Cervical Ligament - Also known as the lateral cervical, cardinal or Mackenrodts ligament - This ligament consists of thickenings of connective tissue in the base of each broad ligament - Extends from the cervix and vaginal fornix laterally to the side wall of the pelvis Note: The ureter, uterine artery and inferior hypogastric plexus traverse the connective tissue of the ligament Function: The transverse cervical ligament provides lateral stability to the cervix Uterosacral Ligaments ** Composed of fibrous tissue and smooth muscle - Extends backwards from the cervix below the peritoneum - Surrounds the rectouterine pouch and rectum and becomes attached to the front of the sacrum - These ligaments are palpable on rectal (not vaginal) examination Function: Keep the cervix braced backwards against the forward pull of the round ligament on the fundus - Therefore maintains the body of the uterus in anteversion Rectovaginal Ligament - One of the 4 main uterine support ligaments - Helps hold the uterus in position by maintaining traction on the ligament - Also known as the posterior uterine ligament - The rectovaginal fascia keeps the rectum from protruding into the vagina ** The rectovaginal fascia is the supportive layer of the posterior vaginal wall - Attached distally to the perineal body - Attached laterally to the levator ani muscle 43

Attached proximally to the cervix

Pubocervical Fascia ** The pubocervical fascia is the supportive layer of the anterior vaginal wall - Attached distally to the pubic bone area and proximally to the cervix - Also attached laterally to the pelvic floor muscles (obturator internus muscle) Note: As long as this fascia remains intact, the bladder and urethra will remain in its normal position - When there is break in the pubocervical fascia there is a loss of support of the urethra and bladder ** Therefore both the pubocervical and rectovaginal fascia attach to the uterus and then in turn attached to the uterosacral ligaments - Therefore there is a continuous supportive structure (fascia) from the opening of the vagina to the uterosacral ligaments Utero-ovarian Ligament (Ovarian Ligament) - Fibrous ligament that connects the ovary to the lateral surface of the uterus - This ligament is NOT the suspensory ligament of the ovary. The suspensory ligament extends from the ovary in the opposite direction

** The ovarian ligament is composed of muscular and fibrous tissue - Extends from the uterine extremity of the ovary to the lateral aspect of the uterus - Just below the point where the uterine tube and uterus meet - The ligament runs in the broad ligament of the uterus Rectouterine Ligament ** A fold of peritoneum, containing the rectouterine muscle - Passes from the sacrum to the base of the broad ligament on either side - Forming the lateral boundary of the rectouterine pouch of Douglas Vagina ** The vagina is highly expandable fibromuscular tube - About 10 cm long - Directed upwards and backwards from its lower end (vaginal orifice or introitus) - The anterior and posterior walls are mostly opposite each other and the orifice is an anteroposterior cleft ** The vagina is anterior to the: rectum, anal canal, and perineal body 44

The bladder is posterior to the bladder and the urethra Below the floor of the rectouterine pouch the vagina is separated from the rectum by the thin rectovaginal septum

** The upper end is slightly expanded and receives the uterine cervix - The cervix projects into the vagina, forming a circular groove around it which is the vaginal fornix ** The posterior wall of the vagina is longer than the anterior wall - The posterior fornix is deeper than the other fornices - The posterior fornix is covered by peritoneum of the front of the rectouterine pouch of Douglas - Note: This is the only part of the vagina that has a peritonea covering - The ureter is first adjacent to the lateral fornix and then passes across the front of the anterior fornix to enter the bladder ** Below the cervix the anterior wall of the vagina is in contact with the base (posterior surface) of the bladder - Below the bladder the urethra is embedded in the vaginal wall ** The vagina passes down between the pubovaginalis parts of levator ani - Passes through the urogenital membrane and perineal membrane through the deep perineal space and into the superficial perineal space - The urethra opens immediately in front of the vaginal orifice ** The vagina has a muscular layer of smooth muscle lined internally by mucus membrane - Covered externally by fibrous tissue continuous with the with the pelvic fascia - EXCEPT: at the posterior fornix which has a peritoneal covering Blood Supply ** The vaginal branch of the internal iliac artery is supplemented by the following vessels: - Uterine artery - Inferior vesical artery - Middle rectal artery Note: These branches have good anastomotic connections on the vaginal wall - Veins join the plexuses on the pelvic floor to drain into the internal iliac vein Lymphatic Drainage ** The lymphatics of the vagina drain to external + internal iliac nodes - The lowest part of the vagina drains like other perineal structures to the superficial inguinal nodes Nerve Supply ** The lower end of the vagina receives sensory fibers from the perineal and posterior labial branches of the pudendal nerve - Also receives sensory fibers from the ilioinguinal nerve ** Autonomic nerve fibers from the inferior hypogastric plexuses supply: - Blood vessels - Smooth muscle of the vaginal wall - Vestibular glands Female Urethra - 4 cm long - Passes from the neck of the bladder at the lower angle of the trigone to the external urethral meatus - This meatus is in front of the vaginal orifice and 2.5cm behind the clitoris - The urethra is embedded within the anterior vaginal wall except at its uppermost part - As the urethra leaves the bladder, fibers of the Pubovaginalis lie adjacent to it Blood Supply - Upper part- supplied by the inferior vesical + vaginal arteries - Lower Part- supplied by the internal pudendal artery ** Veins drain to the vesical plexus and the internal pudendal vein Lymph Drainage - Lymph vessels pass mainly to internal iliac nodes but some reach the external iliac group Nerve Supply 45

From the inferior hypogastric plexus and from the perineal branch of the pudendal nerve

** The mucus membrane is lined proximally by urothelium - Lined distally by non-keratinized stratified squamous epithelium - Paraurethral glands (of Skene)- open by a single duct on each side just inside the external meatus - This gland is the female homologue of the prostate ** Superficial trigonal muscle fibers of the bladder extend into the upper urethra - The urethral smooth muscle is oriented mainly longitudinally - Outside the smooth muscle is the striated circular muscle of the sphincter urethrae (external urethral sphincter) - The sphincter is supplied by the pudendal nerve

SF28D-ANA 20-03-09 Nerves, Blood Vessels & Lymphatics of the Pelvis- FLETCHER ** The major blood supply of the pelvic walls and viscera are the branches of the internal iliac artery - Drain into tributaries of the internal iliac veins - Arteries and veins lie within the parietal pelvic fascia. Therefore only their branches that pass out of the pelvis need to pierce this fascia - EXCEPT: the obturator vessels Note: Some pelvic viscera are NOT supplied by the internal iliac - Ex: rectum supplied by inferior mesenteric - The gonadal artery (ovarian/testicular) is mainly to the perineum ** The common iliac artery bifurcates at the pelvic brim opposite the sacroiliac joint (S2) into internal iliac and external iliac arteries ** The internal iliac artery passes backwards and soon divides into two divisions at the level of the greater sciatic notch (sciatic foramen): - Anterior Division- longer - Posterior Division- shorter ** The posterior division divides into 3 branches. All these branches are parietal iIliolumbar iiLateral sacral iiiSuperior gluteal ** The anterior division usually has 9 branches: 3 Associated with the bladder - Superior vesical - Obliterated umbilical- a continuation of the superior vesical - Inferior vesical 3 Visceral Branches - Middle rectal - Uterine - Vaginal 3 Parietal Branches - Obturator - Internal pudendal - Inferior gluteal Note: The internal pudendal and inferior gluteal vessels are considered to be terminal branches of the anterior division ** Therefore the internal iliac artery supplies the pelvic viscera and the pelvic sidewall via its parietal branches - The artery also supplies the perineum via the internal pudendal artery - Supplies the thigh via the superior + inferior gluteal - Supplies the hip region via the obturator artery - Supplies the sacral spinal meninges and the spinal nerve roots of the cauda equina and the back of the sacrum via the lateral sacral artery 46

Branches of the Posterior Division Iliolumbar Artery- passes upwards out of the pelvis in front of the lumbosacral trunk and behind the obturator nerve - Runs laterally deep to the psoas muscle and divides into two branches: iIliac branch- goes and ramifies around the iliac fossa. Gives an important branch to the ASIS anastomosis - Supplies the iliac fossa: iliacus muscle + iliac bone - Extends to the anastomosis around the ASIS (deep + circumflex iliac arteries, ascending branch of the lateral circumflex femoral artery, upper branch of the deep division of superior gluteal artery) iiLumbar Branch- goes upwards and is really the 5th lumbar segmental artery. This is because the aorta is unable to give off the 5th lumbar artery, only the previous 4 Passes laterally to supply psoas and quadratus lumborum and by its posterior branch (erector spinae) This vessel gives a spinal branch into the foramen between L5 vertebrae and the sacrum

Lateral Sacral Artery-is usually doubled and runs down lateral to the anterior sacral foramina - Runs downwards in front of the roots of the sacral plexus - In the pelvis it supplies the roots and piriformis - Spinal branches enter the anterior sacral foramina and go to the vertebral canal to supply the: sacral spinal meninges, cauda equina + spinal nerve roots - The terminal branches of the spinal branches pass through the posterior sacral foramina to supply the muscles over the back of the sacrum ** Supplies some muscles such as gluteus maximus and some minimal blood supply to erector spinae Superior Gluteal Artery- is the largest of all the branches of the internal iliac - Passes backwards by piercing the pelvic fascia - Usually pierces the fascia between the lumbosacral trunk and S1 nerve - Leaves the pelvis thought ht greater sciatic foramen above the upper border of piriformis Branches of the Anterior Division ** The anterior division gives off both parietal and visceral branches ** The parietal branches are POG: iInternal pudendal- lies in front of the inferior gluteal artery - Pierces the parietal pelvic fascia - Passes out of the pelvis through the greater sciatic foramen - Distributed in the perineum to the anal region and the external genitalia iiObturator- passes along the side wall of the pelvis below the nerve to enter the obturator foramen - Enters the foramina with the nerve, vein and pass into the thigh - The artery gives off a small branch to the periosteum of the back of the pubis - This vessels anastamoses with the pubic branch of the inferior epigastric artery iiiInferior gluteal- runs backwards through the parietal pelvic fascia Passes below S1 nerve root Leaves the pelvis through the greater sciatic foramen below piriformis

** The visceral branches of the anterior division go to the bladder, prostate, seminal vesicles, and ampulla of ductus deferens, uterus and vagina iSuperior Vesical Artery- is the persistent patent proximal part of the fetal umbilical artery - The distal part is obliterated to form the medial umbilical ligament - The medial umbilical ligament appears as the direct continuation of the vesical vessel - The superior vesical artery runs along the side wall of the pelvis and then turns medially to reach the upper part of the bladder - Also supplies the adjacent ureter and ductus deferens iiInferior vesical Artery- arises lower than the superior vesical artery - Runs medially across the pelvic floor - Supplies the trigone + lower part of the bladder, ureter, ductus deferens, seminal vesicles, prostate - Gives rise to the vesiculo deferential artery (artery of Braithwaite) to the seminal vesicles, ampulla of the deferens and part of the ureter iiiMiddle Rectal Artery- is usually absent and small if present. May be replaced by a small branch from an artery that supplies other pelvic viscera (prostate, seminal vesicles, vagina) 47

ivUterine Artery- crosses the pelvis in the base of the broad ligament - Passes superior to the ureter - At the cervix it turns upwards and runs alongside the uterus in the broad ligament - At the entrance of the uterine tube it turns laterally to supply the tube and anastamose with the tubal branch of the ovarian artery vVaginal Artery- supplies the upper part of the vagina. Corresponds to the inferior vesical artery in the male - May be a branch of the uterine artery Note: The internal iliac artery passes through the pudendal canal and by various branches ends up in the perineum Internal Iliac Vein ** The internal iliac vein begins above the greater sciatic notch by the confluence of gluteal veins with others that accompany branches of the internal iliac arteries ** The internal iliac vein passes upwards posteromedial to its artery to join the external iliac vein on the medial surface of psoas major and form the common iliac ** The internal iliac vein also receives tributaries from the following venous plexuses: - Rectal plexus - Vesical plexus - Prostatic plexus - Uterine plexus - Vaginal plexus Note: The presence of these venous plexuses and large draining veins below the pelvic peritoneum accounts for severe retroperitoneal hemorrhage after fracture of pelvic bones ** The internal iliac vein communicates with vertebral venous plexuses ** There are no valves in the pelvic veins - Therefore sudden increases in abdominal pressure may be momentarily more than the IVC can accommodate - This dives blood backwards up the internal vertebral plexus into the posterior intercostals veins and by the azygos veins into the SVC - Therefore emboli from diseases of the pelvic viscera can find their way by reflux blood flow into the vertebrae Pelvic Venous Plexuses 1- Rectal Venous Plexuses- lie on the surface of the rectum and in its submucosa - Drain through the superior, middle and inferior rectal veins - Therefore form a communication between the portal and systemic venous systems 2- Vesical Venous Plexus (Male)- found on the base of the bladder around the seminal vesicles, deferent ducts, ends of the ureters - Drains through the inferior vesical veins to the internal iliac veins - Drains along the rectovesical fold to the anterior surface of the sacrum - Can then drain through the pelvic sacral foramina with tributaries from the rectum into the internal vertebral venous plexus - OR can drain through the lateral sacral veins to the internal iliac vein 3- Prostatic Venous Plexus- lies on the front and sides of the prostate within its fascial sheath - Receives the deep dorsal vein of the penis - Drains into the vesical venous plexus 45Vesical Plexus (Female)- surrounds the pelvic part of the urethra and the neck of the bladder Receives the dorsal vein of the clitoris Drains in to the vaginal plexuses The vaginal plexus are on the sides of the vagina and in its mucosa They communicated with the uterine and rectal plexuses and drain mainly through the vaginal veins Uterine Plexuses- found mainly at the side of the uterus, between the layers of the broad ligament Drain through the uterine veins accompanying the uterine arteries Also communicate through the broad ligament with the pampiniform plexus Therefore they drain partly with the ovarian veins 48

Venous drainage: rectal plexus, utero vaginal plexus, vesico plexus (in female) and prostatic vesical plexus (of Santorini) (in male). All the plexuses inter-connect. NO VALVES. All go into internal pudendal v. However, lateral sacral v. have similar drainage area of lat. a. supply. Reason why cancer in pelvic organs spread to vertical columns at various levels or even higher (skull or brain) etc. in increased abdominal pressure veins flow back via lat. sacral veins to int. and external venous plexuses communication between that and plexus is valveless veretebral venous plexus of BATSON. Prostatic cancer preferentially spreads to bone because of this reason. Can go right up to basilar plexus; and even intra-cranially.

Pelvic Nerves Lumbosacral Trunk ** A thick cord of nerves formed from the: - Entire ventral ramus of the 5th lumbar nerve - Descending part of the 4th lumbar nerve ** The lumbosacral trunk descends obliquely over the lateral part of the sacrum into the pelvis - Descends posterior to the pelvic fascia - Then passes above the superior gluteal vessels across the pelvic surface of the sacroiliac joint - To join the sacral ventral rami on the front of piriformis ** The upper 4 sacral ventral rami emerge through the pelvic sacral foramina - The 5th and coccygeal pierce the sacrospinous ligament and coccygeus - The lumbosacral trunk and the 1st sacral ventral ramus are separated by superior gluteal vessels - Both cross the pelvic surface of the sacroiliac joint before uniting on piriformis ** The ventral rami with the 3rd and part of the 4th sacral, converge on the lower part of the greater sciatic foramen between piriformis and pelvic fascia - Forms a triangular mass of nerve fibers and connective tissue (sacral plexus - The sacral plexus is found on the pelvic side wall ** The sacral plexus splits into: - Pudendal nerve- smaller, medial branch - Sciatic nerve- larger, lateral branch - Other branches- arise from the dorsal and pelvic surfaces of the plexus Note: The inferior part of the 4th sacral ventral ramus descends to the coccygeal plexus on the surface of coccygeus ** Each ventral ramus receives a grey ramus communicans from the sympathetic trunk and gives rise to some branches before uniting in the plexus 1- Twigs to piriformis for the 1st + 2nd ventral rami 2- Irregular branches from the others to coccygeus and levator ani 3- Pelvic splanchnic nerves- are slender branches from the 2nd + 3rd OR 3rd + 4th sacral ventral rami to the inferior hypogastric plexus - They consist of preganglionic parasympathetic nerve fibers that are distributed to peripheral parasympathetic ganglia which innervate the following structures: - Pelvic viscera, descending colon, sigmoid colon, external genitalia Terminal Branches of the Sacral Plexus ** The sciatic nerve (L4, L5, S1, S2, S3) forms on the front of piriformis and leaves the pelvis through the lower part of the greater sciatic foramen ** The pudendal nerve (S1, S2, S3, S4) arises by separate branches from these ventral rami - Leaves the pelvis between piriformis and coccygeus - Hooks around the sacrospinous ligament to enter the perineum Nerves Arising from Pelvic Surface of the Plexus 1- Nerve to quadratus femoris- passes out of the pelvis anterior to the sciatic nerve 2- Nerve to obturator internus (L5, S1, S2)- leaves the pelvis between the sciatic and pudendal nerves - Follows the pudendal nerve into the ischiorectal fossa Nerves Arising from the Dorsal Surface of the Plexus 1- Superior gluteal nerve (L4, L5, S1)- arises above piriformis and accompanies the superior gluteal vessels 49

2- Inferior gluteal nerve (L5, S1, S2) and posterior cutaneous nerve of the thigh- leave the pelvis immediately posterior or medial to the sciatic nerve

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Perforating cutaneous nerve- descends on piriformis and coccygeus. May pierce coccygeus or pass between it and levator ani To reach and pierce the sacrotuberous ligament and gluteus maximus Supplies the gluteal skin

4- Perineal branch of the 4th sacral nerve- descends on coccygeus and pierces it - Appears in the posterior angle of the ischiorectal fossa at the side of the coccyx - Runs on the perineal surface of levator ani to supple the external anal sphincter and the surrounding skin Coccygeal Plexus ** The coccygeal plexus is a small plexus on the pelvic surface of the coccygeus that supplies the muscle and part of levator ani - Pierces coccygeus and supplies the skin from the coccyx to the anus Obturator Nerve ** The obturator nerve is formed in the substance of psoas from the ventral divisions of 2nd to 4th lumbar ventral rami - Descends through psoas - Emerges from its medial aspect deep to the common iliac vessels - Crosses the margin of the superior aperture of the lesser pelvis, lateral to the internal iliac vessels and the ureter - Runs antero-inferiorly on obturator internus, in front of the obturator vessels - Leaves the pelvis through the obturator canal - In the lesser pelvis, the obturator nerve is posterolateral to the ovary and is then crossed by the attachment of the broad ligament Pelvic Autonomic Nerves ** The abdominal aortic plexus consists of 2-3 intercommunicating strands of nerve fibers, which descend over each side of the abdominal aorta - Arise in the celiac and superior mesenteric plexuses - Reinforced by branches (lumbar splanchnic nerves) from each lumbar sympathetic trunk - These descend obliquely at the sides of the aorta and unite with the lowest part of the plexus - The plexus extends along the branches of the abdominal aorta below the superior mesenteric artery - Continues inferior to the bifurcation of the aorta as the superior hypogastric plexus - The superior hypogastric plexus is also known as the pre-sacral nerve - Found on the front of the 5th lumbar vertebrae and the left common iliac vein - Receives input from the aortic fibers and these are pre-ganglionic fibers ** On the sacra promontory, the superior hypogastric plexus divides into right + left inferior hypogastric (pelvic) plexuses - The inferior hypogastric plexus is also known as the plexus of Frankenhusen - These surround the corresponding internal iliac arteries - Distributed with their branches to the pelvic viscera ** Each of the inferior hypogastric plexuses receives small branches from the upper sacral ganglia of the sympathetic trunk. ** The main plexus divides into smaller plexuses (visceral plexuses) around the branches of the internal iliac artery - These plexuses communicate with each other - Receive branches from the pelvic splanchnic nerves Note: S2, S3, $ give parasympathetic branches into the inferior hypogastric plexus - These are pelvic splanchnics (nervi erigentes) - Carry sensory + motor innervation to the urinary bladder

Visceral Plexuses ** The visceral plexuses are the extensions of the inferior hypogastric plexuses on the walls of the pelvic viscera 1- Rectal Plexus- receives a contribution from the inferior mesenteric plexus. - Sends ascending parasympathetic fibers into the plexus and long the wall of the large intestine (sigmoid + descending colon) 50

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Vesical Plexus- continuous with the plexus over the deferent ducts, seminal vesicles + prostate Prostatic Plexus- sends cavernous nerves along the membranous urethra to the penis Uterine & Vaginal Plexuses- accompany the corresponding arteries The vaginal plexus supplies the urethra and sends cavernous nerves to the bulbs of the vestibule and to the clitoris

** The sympathetic trunk cross the pelvic brim behind the common iliac vessels ** The sympathetic trunks descend in the pelvis between the bodies of the sacral vertebrae and the pelvic sacra foramina - The trunks unite in the median ganglion impar on the coccyx - The trunks are posterior to the pelvic fascia and to the peritoneum superiorly and to the rectum below S3 - Each trunk has 4 ganglia - The trunks converge at the front of the coccyx to unite at a small swelling, the ganglion impar - Somatic branches are given off to all the sacral nerves and smaller vascular filaments to the lateral and median sacral vessels - Visceral branches join the inferior hypogastric plexus Branches 1- Grey rami communicantes to all the sacral and coccygeal ventral rami 2- Small branches to the median sacral artery 3- Sacral splanchnic nerves- to the inferior hypogastric plexus from the upper ganglia and to the rectum from the lower ganglia 4- Twigs to the coccygeal body from the ganglion impar Inferior Hypogastric Plexuses ** The inferior hypogastric plexus is an autonomic plexus on the sidewall of the pelvis on each side MALE- lateral to the rectum - Posterolateral to the seminal vesicle, prostate, posterior part of the bladder - The middle of the plexus is level with and just behind the tip of the vesicle FEMALES- the plexus is lateral to the rectum, cervix, and vaginal fornix - Posterolateral- to the bladder ** The sympathetic components of the inferior hypogastric plexus are derived from the superior hypogastric plexus via the hypogastric nerve - The sympathetic component is also from the sacral sympathetic ganglia ** Preganglionic parasympathetic fibers join the plexus from S2, S3, S4 nerves (pelvic splanchnic nerves) ** Visceral branches of the inferior hypogastric plexus accompany visceral branches and tributaries of the internal iliac artery + vein ** Muscles of the bladder (detrusor) and the rectum are innervated by parasympathetic nerves from the pelvic splanchnics

** The smooth muscle of the bladder neck, prostate, seminal vesicles and ductus deferens are innervated by sympathetic nerves from the superior hypogastric plexus ** The smooth muscle of the internal sphincter of the anal canal are supplied by branches from the sacral sympathetic ganglia Note: All these nerves emerge from the inferior hypogastric plexus ** Therefore the pelvic parasympathetics are: 1- Motor- to the emptying muscle of the bladder and of the gut from splenic flexure to rectum 2- Secretomotor- to the gut 3- Vasodilator- to the erectile tissue of the perineum ** The sympathetics are: 1- Motor- to the visceral muscle of the bladder neck and internal anal sphincter, ductus deferens, seminal vesicles and prostatic muscle 51

Note: The sympathetics also have a facilitating function in relation to the uterine muscle - Therefore the uterus stands erect during sexual excitation - During the female orgasm, the uterus, vagina and anal canal contract Note: The level of the pubic symphysis separates L1 territory (ilihypogastrus, ilioinguinal, genital branch of genitofemoral) and S2, S3, S4 territory. Lymphatic Drainage ** The external iliac nodes drain lymph from the lower limb and abdominal wall - Also receives direct vessels from the bladder, prostate, or uterus ** The internal iliac nodes are found along the artery and its branches. Receives lymph from all the pelvic contents. Also receives lymph from the deeper structures: - Perineum - Gluteal region - Back of thigh Note: Both the external and internal iliac nodes drain to the common iliac nodes ** The sacral nodes lie along the median and lateral sacral arteries. They drain the following structures: - Dorsal wall of the pelvis - Rectum - Neck of the bladder - Prostate - Cervix ** The sacral nodes also drain to the common iliac nodes. ** In addition to these groups, small nodes are found in the broad ligament and in the fascial sheaths of the bladder and rectum

SF28D- ANA 17-03-09 Scrotum, Spermatic Cord & Inguinal Canal- LODENQUAI Scrotum ** The scrotum is a pouch of skin containt the testes and the spermatic cords - The subcutaneous tissue has no fat but it contains the dartos muscle - The dartos muscle sends a sheet into the midline fibrous septum of the scrotum - The rugosity of the skin of the scrotym is due to the contraction of the dartos muscle - The dartos is smooth muscle and is supplied by sympathetic fibers probably carried by the genital branch of the genitofemoral nerve Blood Supply ** The blood supply of the skin is from the following arteries: iSuperficial external pudendal (femoral) iiDeep external pudendal (femoral) iiiScrotal branches of the perineal artery (internal pudendal) Venous Drainage- Mainly by the external pudendal veins (superficial + deep) to the great saphenous vein Lymph Drainage - To the superficial inguinal lymph nodes Nerve Supply ** The anterior axial line corsses the scrotum. - Anterior 1/3 of the scrotal skin is supplied by the ilioinguinal nerve (L1) and the genital branch fo the genitofemoral nerve (L1) - Posterior 2/3rds is supplied by scrotal branches of the perineal nerve (S3) - Reinforced laterally by the perineal branch of the posterior femoral cutenous nerve (S2) Male Urethra ** The male urethra has 3 parts and has a total length of about 20 cm 1- Prostatic Part 52

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Membranous Part Penile (spongy) Part- 15 cm long and found within the corpus spongiosum of the penis Can be divided into bulbous and pendulous parts The posterior part of the cirups, attached to the undersurface of the perineal membrane, is enlarged as the bulb After piercing the perineal membrane, the urethra eners the bulb and takes a right-angeld curve forwards within the bulb Urethra contines through the corpus spongiosum beyond the root of the penis into its body

** The navicular fossa is a short dilated region proximal to the external urethral meatus - Lined here by stratified squamous epithelium - This is in contrats to the rest of the urethra which is typically transitional epithelium - The urethral mucosa has numerous mucus urethral glands (of Littre) Blood Supply - The blood supply is via adjacent vessels as it passes through the prostate, sphincter urethrae, corpus spongiosum Nerve Supply - The mucus membrane of the penile part receiv a branch from the perineal nerve - Filaments from the inferior hypogastric plexus reach more proximal parts SEE ATTACHED DIGESTIVE NOTES FOR INGUINAL CANAL AND SPERMATIC CORD

SF28D-ANA 13-03-09- Histology of the Female Reproductive System- SOLOMON ** The female reproductive system consists of: - Paired internal ovaries - Paired uterine tubes (oviducts) - Single uterus - Cervix - Vagina - Mammary Glands Uterus ** Pear shaped organ with a thick muscular wall - The body (corpus) forms the major portion of the uterus - The rounded upper portion of the uterus above the entrance of the uterine tubes is the fundus - Cervix- lower, terminal portion that protrudes into the vagina ** The wall of the uterus is made up of 3 layers: iPerimetrium (serosa)- outer most layer that is lined by serosa or adventitia iiMyometrium (muscle)- thick smooth muscle layer - Consists of bundles of smooth muscles - Separated by thin strands of interstitial connective tissue with numerous blood vessels iiiEndometrium (mucosa)- innermost layer that is lined by simple epithelium - The surface of the endometrium is lined by simple columnar epithelium - The epithelium overlays the thick lamina propria - The lining epithelium extends down into the connective tissue of the lamina propria and forms long tubular uterine glands - Coiled spiral arteries are seen in the deeper regions of the endometrium Note: In the proliferative phase the uterine glands are usually straight in the superficial part of the endometrium - May exhibit branching in the deeper regions near the myometrium ** The endometrium is subdivided into 2 functional layers: iStratum functionalis- luminal layer - In a non-pregnant female, the superficial functionalis layer with the uterine glands is shed during menstruation - Leaves behind the deeper basalis layer with the basal remnants of the uterine glands - During the proliferative phase of the menstrual cycle this player increase in thickness - The uterine glands elongate - The functional part is paler than the stratum basale 53

iiStratum basalis- basal layer that contains the basal remnants of the uterine glands - This is the source of cells for regeneration of a new functional layer - Therefore the stratum basalis is unshed during the menstrual cycle ** The uterine glands are lined by simple columnar epithelium - The uterus has a rich blood supply - Uterine arteries in the broad ligament give rise to the arcuate arteries - These arteries penetrate the myometrium ** Arcuate vessels divide into straight + spiral arteries that supply blood to the endometrium iStraight Arteries- are short and supply the basalis layer of the endometrium iiSpiral arteries- are long and coiled and supply the functionalis layer of endometrium

Note: The spiral arteries are highly sensitive to hormonal levels in the blood - This is unlike the straight arteries Myometrium Composed of smooth muscle. The myometrium is organized into four layers of indistinct muscles in between which is connective tissue Innermost and outermost are longitudinal the other two are circular. The myometrium has a spiral and longitudinal arrangement of fibers arranged in interlacing bundles Note large and small blood vessels. These are branches of the uterine artery. They are called radial branches of the uterine artery. These then give branches to supply the endometrium. Two types spiral (functionale) and straight (basale)

Perimetrium - The remaining part of the anterior surface which consists mainly of adventitia Secretory (Luteal) Phase- Uterus ** The secretory phase of the menstrual cycle is initiated after ovulation of the mature follicle - The changes in the endometrium are due to the influence of estrogen and progesterone secreted by the functioning corpus luteum - Both layers of the endometrium become thicker as a result of increased glandular secretion and edema in the lamina propria - The epithelium of the uterine glands undergo hypertrophy because of the increased accumulation of secretory product Note: The distinctive feature of the secretory phase is the tall glandular cells. - These cells are large and torturous with a corkscrew appearance - Therefore the uterine glands are highly coiled and their lumina become dilated with nutritive secretory material - The coiled arteries continue to extend into the functionalis layer and become prominent because of their thicker walls Note: The alterations in the surface columnar epithelium, uterine glands and lamina propria characterize the functionalis layer of the endometrium during the secretory phase - The basalis layer demonstrates minimal changes Menstrual Uterus ** During the menstrual phase, the endometrium in the functionalis layer degenerates and is shed - The shed endometrium contains fragments of disintegrated stroma, blood clots and uterine glands - Some of the intact uterine glands are filled with blood - In the basalis layer the bases of the uterine glands remain intact during the shedding of the functionalis layer and the menstrual flow ** Therefore the menstrual uterus has no epithelial lining and most of the glands are gone - The remaining intact glands are filled with blood

Note: The basalis layer of the endometrium remains unaffected during this phase

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The distal (superficial) portions of the coiled arteries become necrotic and the deeper parts of the vessels remain intact

Proliferative Phase ** The proliferative phase is characterized by rapid growth and development of the endometrium - Increased mitotic activity of the lamina propria and in the remnants of the uterine glands in the basalis layer - This produces cells that begin to cover the surface of the uterine mucosa that was shed during menstruation - This produces a new functionalis layer of the endometrium - As the layer thickens, the uterine glands proliferate and become closely packed - The spiral arteries begin to grow towards the endometrial surface and show light coiling - The epithelium is simple cuboidal but does not have a glandular appearance because there is no secretory material - The glands are also straight - The resurfacing and growth of the endometrium during the proliferative phase coincides with the rapid growth of the ovarian follicles and their increased production of estrogen Cervix ** The cervix is found in the lower part of the uterus that projects into the vaginal canal as the portico vaginalis - A narrow cervical canal passes through the cervix - Internal os- the opening of the cervical canal that directly communicates with the uterus - External os- the opening of the cervical canal that communicates with the vagina Note: The cervical mucosa undergoes only minimal changes during the menstrual cycle and is not shed during menstruation - The cervix has numerous branched cervical glands that exhibit altered secretory activities during the different phases of the menstrual cycle ** The cervix is a fibroelastic structure not a muscular structure - The body of the cervix has the same epithelium as the uterus - BUT the part of the cervix that juts into the vagina demonstrate an epithelium change from simple columnar to stratified squamous non-keratinized epithelium - Therefore the portico vaginalis represents a junction where there is epithelial change ** The cervical canal is lined with tall, mucus-secreting columnar epithelium that is continuous with the uterine epithelium ** The connective tissue in the lamina propria of the cervix is more fibrous than in the uterus - Blood vessels, nerves and occasional lymphatic nodules can be seen Note: The glands in the cervix are related to the uterine surface not the vaginal surface - But the mucus that is found in the vagina is from the cervix - There are NO glands in the vagina - The outer lining of the cervix is the parametrium not perimetrium Note: The paramesomephric duct forms the: iEndometrium of the uterus iiCervix iiiUpper 1/3 of the vagina ** The vagina has a dual embryological origin because the lower 1/3 is from the urogenital sinus ** During the proliferative phase of the menstrual cycle, the secretion of the cervical glands is thin and watery - This allows easier passage of sperm through the cervical canal into the uterus

** During the luteal phase the cervical gland secretions change and become highly viscus - This forms a mucus plug in the cervical canal - The plug is a protective mechanism that stops the passage of sperm and microorganism from the vagina into the body of the uterus - The increased viscosity of cervical secretions depends on higher levels of progesterone in the plasma Vagina - The vaginal mucosa is irregular and folded - The surface epithelium is stratified squamous non-keratinized epithelium 55

The underlying connective tissue papillae are prominent and indent the epithelium The lamina propria contains loose connective tissue with elastic fibers These elastic fibers extend into the muscularis layer as interstitial connective tissue Lamina propria contains diffuse lymphatic tissue, nodules and small blood vessels

** The muscularis of the vaginal wall consists predominantly of longitudinal bundles and oblique bundles of smooth muscle - The transverse bundles of smooth muscle are more frequently found in the inner layers Note: There may be some skeletal muscle seen in association with the vagina on the periphery - This skeletal muscle is from the pelvic diaphragm - The Pubovaginalis is the muscle from the pelvic diaphragm that surrounds the vagina - Just before menstruation, the vaginal epithelium may become slightly keratinized - During the follicular phase, glycogen accumulates in the vaginal epithelium and reaches its maximum level before ovulation ** Therefore during the follicular phase, the glycogen content increases in the intermediate and superficial cell layers - Bacterial flora in the vagina metabolize glycogen into lactic acid - The increased acidity in the vaginal canal protects it against microorganisms Uterine Tube - Extensive mucosal fold form an irregular lumen - No glands in the uterine tube - The lumen of the tube extends between the mucosal folds and forms deep grooves - Lining epithelium is simple columnar - Loose connective tissue within the lamina propria ** The muscularis of the uterine tube consists of 2 smooth muscle layers: iInner circular layer iiOuter layer of longitudinal fibers Note: The interstitial connective tissue latter tends to blend with the two smooth muscle layers - Therefore the outer layer especially is not distinct - The serosa is the outermost layer on the uterine tube - The muscularis produces the propulsive force needed to move the ovum ** The lining epithelium consists of ciliated cells and non-ciliated peg cells - The peg cells are secretory cells - During the early proliferative phase, under estrogen influence, the ciliated cells under go hypertrophy - In addition the secretory activity of the peg cells increase ** The lamina propria of the uterine tube is a cellular, loose connective tissue with fine collagen and reticular fibers

Ovary ** The ovarian surface is covered by a single layer of cells (germinal epithelium) - The germinal epithelium as the covering peritoneum and it has no relation to the germ cells of the ovary. - The germinal epithelium overlies the dense, irregular connective tissue (tunica albuginea) - This surface lining is simple cuboidal and it is formed from the mesothelial lining from the peritoneum that condenses on the surface The tunica albuginea is the dense connective tissue layer Within the tunica are primordial follicles and the flat layer of epithelium is known as follicular epithelium Primordial follicles are present at birth and one reaches maturity at each cycle Below the tunica albuginea is the cortex of the ovary Deep to the cortex is the medulla The medulla is the highly vascularized connective tissue core of the ovary Note: There is no distinct boundary line between the cortex and medulla; these two regions blend together

** The cortex is normally filled with numerous ovarian follicles in different stages of development - Including the large mature follicles that extend deep into the medulla 56

Also contains fibrocytes with collagen and reticular fibers The primordial follicles are the most numerous and found in the periphery of the cortex and under the tunica albuginea The primordial follicles are surrounded by a squamous layer of follicular cells

Primary Follicles- are smaller follicles with the oocyte surrounded by cuboidal, columnar or stratified cuboidal cells - Single layer of cells - No antrum and no follicular fluid Secondary Follicles- are larger and have antral cavities - These are found deeper in the cortex - Surrounded by modified stromal cells (theca folliculi) - Theca folliculi cells eventually differentiate into two layers: theca interna (inner secretory layer) + theca externa (outer connective tissue layer) ** The theca interna cells are under the influence of FSH - Specialized cells that appear pale - Have numerous Golgi bodies - Have large amounts of smooth endoplasmic reticulum therefore are involved in the production of steroid hormones (estrogen) ** The largest ovarian follicle is the mature follicle. These consists of the theca interna and externa, grnulosa cells, a large antrum and the cumulus oophorus - The cumulus oophorus anchors the egg to the follicular wall Atretic Follicle- a degenerating follicle - The granulose cells have began to atrophy and degenerate Corpus Luteum- highly vascular - Granulosa luteal cells- produce progesterone and are found centrally - Theca luteal cells- produce estrogen and supply the periphery of the corpus

Note: Eventually the corpus luteum degenerates and gives rise to the corpus albicans - This is a fibrous structure - Avascular and relatively acellular because it is no longer producing hormones

** The medulla is the smaller portion, which contains connective tissue, blood vessels and nerves - The medulla is made up of dense, irregular connective tissue that is continuous with the mesovarium ligament SF28D 02-04-09 Development of the Female Reproductive System- DR. SUJ ** The chromosomal sex of an embryo is determined at fertilization of the ovum - Primordial germ cells are visible early in the 4th week - The germ cells migrate to the genital ridge during the 4-6th weeks - The initial stages of gonadal development occur during the 5th week as the gonadal ridge forms on the posterior abdominal wall Print Slide #5- REVIEW ** Male and female morphological features begin to develop in the 7th week - Therefore sex can be determined at this time by using genetic testing, to determine if there is testicular tissue or ovarian tissue - However macroscopic differences are not visible yet Development of Ovaries ** Initially the gonadal cords extend into the medulla to form medullary cords and rete ovarii of a genetically destined female embryo - The rete ovarii and medullary cords degenerated leaving the vascular medulla - The cortical cords develop and differentiate into an ovary ** The ovary is not identifiable histologically until the 10th week - The X chromosomes have genes for ovarian development 57

** The cortical cords extend from the surface epithelium (mesothelium) of the developing ovary into the underlying mesenchyme - As the cortical cords increase in size, the primordial germ cells are incorporated into them Development of Follicles ** At 16 weeks these cortical cods begin to break up into isolated cell clusters known as primordial follicles - Each primordial follicle consists of an oogonium derived from a primordial germ cell - Surrounded by a single layer of flattened follicular cells derived from surface epithelium - Active mitosis of oogonia occurs during fetal life to produce thousands of primordial follicles - No oogonia are formed post-natally ** However many oogonia degenerate before birth and the rest become primary oocytes - After birth the surface epithelium of the ovary flattens to a single layer of cells continuous with the mesothelium of the peritoneum at the hilum of the ovary - The surface epithelium becomes separated from the follicles in the cortex by a thin fibrous capsule (tunica albuginea) - As the ovary separates from the regressing mesonephros, it is suspended by a mesentery (mesovarium)

Descent of the Ovaries ** The ovaries descend from the posterior abdominal wall to the pelvis - The gubernaculum is attached to the uterus near the attachment of the uterine tube (proximally) - The distal end is of the gubernaculum is attached to the labioscrotal swellings in the perineum Note: The labioscrotal swellings becomes either the scrotum (males) or the labia majus (females) - The cranial part of the gubernaculum becomes the ovarian ligament - The caudal part of the gubernaculum becomes the round ligament of the uterus Note: The round ligament passes through the inguinal canals on each side and terminates in the labia majora Development of the Female Genital Ducts ** The paramesonephric ducts develop lateral to the gonads and the mesonephric ducts - The paramesonephric ducts form on each side from the longitudinal invagination of the mesothelium on the lateral aspects of the mesonephroi - The edges of these paramesonephric grooves approach each other and fuse to form the paramesonephric ducts (Mullerian ducts) - The cranial ends of these ducts open into the peritoneal cavity - The PM-ducts pass caudally, parallel to the mesonephric ducts until they reach the future pelvic region - At this point they cross anterior to the mesonephric ducts and approach each other in the median plane - Fuse to form a Y-shaped uterovaginal primordium ** The uterovaginal primordium is a tube shaped structure that projects into the dorsal wall of the urogenital sinus - This produces an elevation (Muller tubercle) ** During the 8th week the mesonephric duct system in female embryos, disappear except for the ureteric bud and nonfunctional remnants - These remnants are found in the region of the broad ligament ** The non-functional remnants of the mesonephric ducts in females are: iEpoophoron iiDuct of Gartner- an opening into the lateral fornix of the vagina iiiParoophoron- found near the base of the broad ligament ** Therefore in female embryos, the mesonephric ducts regress because of the absence of testosterone - The paramesonephric ducts develop due to the absence of MIS - Therefore female sexual development does not depend on the presence of ovaries of hormones - The paramesonephric ducts form the majority of the female genital tract ** The uterine tubes develop from the unfused cranial parts of the paramesonephric ducts - The caudal fused portions of the ducts from the uterovaginal primordium ** Therefore the incorporation of the lower part of the ducts leads to the formation of the uterus and the upper part of the vagina - The upper part of the ducts remain as uterine tubes Note: Only the lining of these structures comes from the ducts 58

The actual body of the structures are derived from the splanchnic mesenchyme surrounding these ducts Also the lower part of the vagina is from the urogenital sinus The UG sinus is the anterior portion of the cloacal membrane The cloaca is the last part of the hindgut and gets divided into the UG sinus + anal region

** The endometrial stroma and the myometrium are derived from the splanchnic mesenchyme Note: Fusion of the paramesonephric ducts also brings together a peritoneal fold that forms the broad ligament and 2 peritoneal compartments: - Rectouterine pouch - Vesicouterine pouch ** Along the sides of the uterus, between the layers of the broad ligament, the mesenchyme proliferates and differentiates into the parametrium - This is made up of loose connective tissue and smooth muscle

** Fusion of the paramesonephric ducts to form the uterus and the fallopian tubes results in the disposition of peritoneum to form: - Broad ligaments - Rectouterine pouch - Uterovesical pouch Note: The pouches are formed due to the movement of the paramesonephric duct towards the midline ** Along the sides of the uterus, between the layers of the broad ligament, the mesenchyme proliferates and differentiates into the parametrium - The parametrium is made up of loose connective tissue and smooth muscle Paramesonephric Duct Remnants Females - Hydatid of Morgagni- the part of the cranial end of the PM-duct that does not contribute to the infundibulum of the uterine tube - May persist as a vesicular appendage - Can produce cysts - Found at the most proximal point and is separated from the fimbria

Paramesonephric Duct Remnants: Males iAppendix of the testis- the persistence of the cranial end of the paramesonephric duct - Attached to the superior pole of the testis iiProstatic utricle- small sac-like structure that opens into the prostatic urethra and is homologous to the vagina 59

The lining is derived from the epithelium of the urogenital sinus

iiiSeminal colliculus- small elevation in the posterior wall of the prostatic urethra - Homologous to the hymen in the female Mesonephric Duct Remnants in MalesiAppendix of the Epididymis- cranial end of the mesonephric duct that persists - Usually attached to the head of the epididymis iiParadidymis- persistence of some mesonephric tubules caudal to the efferent ductules

Mesonephric Remnants in Females ** The remnants of the mesonephric tubules are: - Epoophoron - Paroophoron ** The remnants of the mesonephric duct are: - Appendix vesiculosa - Gartners duct- between the layers of the broad ligament along the lateral wall of the uterus and in the wall of the vagina Anomalies of Development: Uterus & Uterine Tubes ** Various types of uterine duplication and vaginal anomalies result from arrests of development of the uterovaginal primordium during the 8th week iIncomplete fusion of the paramesonephric ducts iiIncomplete development of a paramesonephric duct iiiFailure of parts of one or both paramesonephric ducts to develop ivIncomplete canalization of the vaginal plate to form the vagina Double Uterus (uterus didelphys)- results from failure of fusion of the inferior parts of the paramesonephric ducts - May be associated with a double or single vagina Bicornuate Uterus- the uterus is divided internally by a thin septum Uterus Arcuatus- Dimpling or indentation of the fundus externally Unicornuate Uterus- develops when one paramesonephric duct fails to develop - This results in a uterus with one uterine tube Development of Vagina ** The vaginal epithelium is derived from two sources: 1- Upper part- develops from paramesonephric ducts (uterovaginal primordium) 2- Lower part- develops from endoderm of the urogenital sinus ** The fibromuscular wall of the vagina develops from the surrounding mesenchyme ** Contact of the uterovaginal primordium with the urogenital sinus forms the sinus tubercle. - The sinus tubercle induces the formation of paired endodermal outgrowths known as the sinovaginal bulbs - These extend from the urogenital sinus to the caudal end of the uterovaginal primordium - The sinovaginal bulbs fuse to form the vaginal plate ** The vaginal plate is a solid structure that contains proliferating cells - Derived from the UG sinus - Elongates via proliferation at the cranial end of the plate - This increases the distance between the uterovaginal primordium and the urogenital sinus - By the 5th month the vaginal plate becomes canalized via vacuolation - This forms the lumen of the vagina and the peripheral cells form the inferior 2/3rds of the vaginal epithelium ** A thin plate of cells of the vaginal plate persists. Until late fetal life, the lumen of the vagina is separated from the cavity of the UG sinus by a membrane (hymen) - The hymen is formed by invagination of the posterior wall of the UG sinus - Usually ruptures during the perinatal period and remains as a thin fold of mucus membrane just within the vaginal orifice 60

** Failure of canalization of the vaginal plate results in blockage of the vagina (vaginal atresia) - Failure of the inferior end of the vaginal plate to perforate results in an imperforate hymen - Cribriform hymen- the result of incomplete canalization Development of External Genitalia ** Up to the 7th week of development, the external genitalia is similar in both sexes - Distinguishing sexual characteristics begin during the 9th week - The external genitalia is fully differentiated at the 12th week - Detect by ultrasound at 22-34 weeks ** The female external genitalia consists of: - Clitoris - Labia minora + majora

Greater vestibular gland Vestibule

** Early in the 4th week the proliferating mesenchyme produces a genital tubercle in both sexes at the cranial end of the cloacal membrane ** Labioscrotal swellings and urogenital folds (urethral folds) develop on either side of the cloacal membrane - The genital tubercles elongate to forms a phallus - However in the female growth of the primordial phallus ceases and it becomes the clitoris ** The urorectal septum fuses with the cloacal membrane and divides the membrane into anal membrane and urogenital membrane - The urogenital membrane is in the floor of urogenital groove - The urogenital groove is bounded by urogenital folds - On the medial aspect the UG folds come together to form the urethra ** In the female fetus the urethra and vagina open into a common area called the vestibule of the vagina - Greater vestibular glands develop from the UG sinus ** The unfused parts of the urogenital folds form the labia minora - The labioscrotal folds fuse posteriorly to form the posterior labial commissure - The labioscrotal folds fuse anteriorly to form the anterior labial commissure and the mons pubis - Most parts of the labioscrotal folds remain unfused and form the labia majora Note: Bartholinis glands are derived from the UG sinus and open in to the vestibule

SF28D 27-03-09- Testis, Epididymis & Seminal Vesicles- LODENQUAI Development & Descent of the Testis ** The testis develops from the gonadal ridge. The gonadal ridge is formed by the proliferation of the coelomic epithelium and a condensation of underlying mesoderm, on the medial side of the mesonephros - Primordial germ cells from the yolk sac migrate to the gonadal ridge and become incorporated in the developing gonad ** At first the testis and mesonephros are found on the posterior abdominal wall, attached by the urogenital mesentery ** As the testis enlarges its cranial end degenerates and the remaining organ is found more caudally - Most of the mesonephros atrophies ** In the male, the mesonephric duct forms the canal of the epididymis, ductus deferens, ejaculatory duct and the appendix of the epididymis ** The gubernaculums is a condensation of mesodermal cells that connects the lower pole of the testis to the region of the anterior abdominal wall that later forms the scrotum ** The gubernaculum precedes the descent of the testis. There are several theories that relate to the descent of the gubernaculums 1- Theory #1- Mesenchymal tissue that removes tissue distally to create a path that the testes will eventually travel 2- Theory #2- The gubernaculum acts as a soft landing for the testes as it descends 61

3- Theory # 3- Fibromuscular component that attaches and drags the testes into the scrotum Note: The remnants of the gubernaculums in the female is the round ligament ** The gubernaculums traverses the site of the future inguinal canal, which is formed around it by the developing muscles of the abdominal wall - The processus vaginalis is a sac of peritoneum that protrudes down the inguinal canal anterosuperior to the gubernaculums - By the 7th month of fetal life the testis is in the deep inguinal ring - As the testis descend it is accompanied by the processus vaginalis - The testis projects into the distal part of the processus, which forms the tunica vaginalis - The rest of this peritoneal sac becomes obliterated Note: Persistence of the whole or proximal part of the sac maintains it connection with the peritoneal cavity and forms a hernial sac - Persistence of a segment of the processus may lead to development of a hydrocele of the cord - Accumulation of serous fluid between the layers of the tunica vaginalis forms the more common hydrocele of the testis ** Failure of the testis to descend may result in cryptorchid testis, where it remains in the abdomen - Descent may be arrested anywhere from the deep inguinal ring downwards - Undescended testis are prone to malignant disease ** The processus vaginalis precedes the descent of the testis. But when testes reach its location most of the processus fuses and only a fibrous remnant is left behind in the inguinal canal

Ectopic Testis ** An ectopic testis is a testicle outside the scrotum. There are two types of ectopic testis: 1- Undescended- the testis is arrested at some point in the normal pathway of descent. 2- Maldescended- the testis is found outside its normal pathway. Therefore it is a testis that ends up somewhere else outside the normal descent pathway ** The five sites of ectopic testis are: iScarpas femoral triangle iiCrossed to the other side of the femoral triangle iiiRoot of the penis ivPerineum vThrough the superficial ring- then curving over the external oblique aponeurosis Lockwood- 5 tails of gubernaculum ** The abnormalities in the development of the testis may lead to the ectopic location ** Ectopic testes are more prone to the following: iTrauma- because they are more superficial iiTorsion- because they are not well-anchored iiiTumor- Increased chance of malignancy (22%) ivInfertility- because they are not in the normal position, therefore they are affected by the higher body temperature Note: If by year 2 the testis is not descended, their position must be corrected surgically - If the testis does not enter the scrotum the processus vaginalis does not close - Therefore an undescended testis is always associated with an indirect inguinal hernia - Failure of fusion of the processus vaginalis results in a child born with a congenital indirect inguinal hernia - If the gut enters the patent area the result can be strangulation ** If there is incomplete closure of the processus and only a small entrance is left, gut will not be able to enter BUT fluid can enter - When the child cries or there is increased pressure peritoneal fluid can enter the small entrance - Fluid enters the scrotum and there is scrotal swelling (communicating hydrocele) ** Ancystic hydrocele of the Cord- appears as a 3rd testicle ** Vaginal hydrocele- tends to occur in older men. Presents as a collection of fluid in the tunica vaginalis surrounding the testicle 62

Note: A hydrocele is an accumulation of fluid - The tunica vaginalis covers the testis at the front and sides but not posteriorly - Therefore the fluid collects anteriorly and laterally ** The left testicle is lower than the right testicle - The two testicles are separated by a midline raphe of the scrotum - To visualize the testes, you have to open the visceral layer of the tunica vaginalis - The testes lie off-center in an antero-lateral direction Testis ** The testis is an oval organ with a thick covering of fibrous tissue, the tunica albuginea - The epididymis is attached to its posterolateral surface - The vas deferens (ductus deferens) arises from the lower pole of the epididymis and runs up medial to it behind the testis

** The front and sides of the testis are free in a serous space formed by the overlying tunica vaginalis - The tunica vaginalis is a remnant of the fetal processus vaginalis ** The serous membrane covers also the anterolateral part of the epididymis and lines a space, the sinus of the epididymis - The sinus is found between the testis and the epididymis ** Therefore the testis, epididymis and tunica vaginalis lie in the scrotum surrounded by thin membranes, adherent to each other - These membranes are downward prolongations of the coverings of the spermatic cord - The right and left sides are separated by the median scrotal septum - The appendix testis is a minute sessile cyst attached to the upper pole of the testis within the tunica vaginalis - This is a remnant of the paramesonephric duct Blood Supply- Testis ** The testicular artery from the aorta runs in the spermatic cord - Gives off a branch to the epididymis and reaches the back of the testis - At the back of the testis it divides into medial and lateral branches Note: These branches do not penetrate the mediastinum testis - They sweep around horizontally within the tunica albuginea - Branches from these vessels penetrate the organ ** The testicular artery gives off the epididymal artery and also gives off an internal testicular artery - This internal testicular artery gives rise to the branches that form the tunica vasculosum - The centripetal artery runs with the septae to supply the testes ** In the epididymis region there is an anastomosis between the testicular, cremasteric and ductal arteries - Therefore the 3 arteries form an anastomosis at the head of the epididymis ** Venules reach the mediastinum, from which several veins pass upwards in the spermatic cord as a mass of intercommunicating veins (pampiniform plexus), which surround the testicular artery ** Vessels that form the pampiniform plexus tend to be anteriorly placed ** In the inguinal canal the plexus separates into about four veins, which join to form two that leave the deep inguinal ring - Becomes single on psoas major on the posterior abdominal wall ** The left testicular vein joins the left renal vein at a right angle - The right testicular vein drains directly into the IVC at an acute angle - The testicular vein usually have valves Note: Varicosisties of the pampiniform and cremasteric veins (varicocele) occurs much more frequently on the left side than the right - The varicosities are more common on the left because the left testicular vein is immediately opposite the left adrenal vein - Therefore vasoconstrictive products from the adrenal medulla can have an effect on the left testicular vein - This leads to increased chance of varicosity formation ** There is a testicle-blood barrier that helps to keep sperm from entering the blood stream 63

Testicular torsion can disrupt the barriers Therefore sperm can enter the blood and antibodies are formed This can lead to a lowered sperm count and is a part of the long-term sequelae in torsion

** The venous drainage of the testis is important in temperature regulation - Plays a part in counter-current flow - The testicular artery brings warmth to the area and the veins absorb the heat and cools the area by removing the heat as the venous blood drains away Lymph Drainage - Lymphatics from the testis run back with the testicular artery to para-aortic nodes - The para-aortic nodes are lying alongside the aorta at the level of the origin of the testicular arteries (L2 vertebrae) - Therefore the testicular lymph does not drain to inguinal nodes - However the overlying scrotal skin drains to inguinal nodes Nerve Supply ** Sympathetic nerves supply the testis. Most of the connector cells lie in the T10 segment of the cord - Passing in the greater or lesser splanchnic nerve to the celiac ganglia the efferent fibers synapse there - Postganglionic grey fibers reach the testis along the testicular artery - Sensory fibers run up along the testicular artery and through the celiac plexus and lesser splanchnic nerve, and its white ramus to cell bodies in the posterior root ganglion of T10 spinal nerve Epididymis ** The epididymis is a structure attached posterior to the testis - The ductus deferens is attached to the medial side of the epididymis - The epididymis consists of a single highly coiled tube packed together by fibrous tissue - Has a large head at tits upper end, connected by a body to a pointed tail at its lower end ** The head (globus major, caput epididymis) of the epididymis is connected to the upper pole of the testis by the vasa efferentia and the tail to the lower pole by loose connective tissue ** The body (corpora) of the epididymis is partly separated from the testis by a recess which is open laterally, the sinus of the epididymis The lateral surface of the epididymis is covered by the tunica vaginalis

** The tail (globus minor) or cauda epididima Structure ** The upper pole of the epididymis is attached high on the posterolateral surface of the testis - On the posterior side of the testicle the tunica albuginea is thickened and forms the mediastinum testis - The fibrous mass of the mediastinum testis from which septa radiate to reach the tunica albuginea - The septa divides the testis into 200-300 lobules, - Each lobule contains 1-4 convoluted seminiferous tubules - The seminiferous tubules open into the rete testis - The rete testis is a network of intercommunicating channels lying in the mediastinum testis - From the rete 12-20 vasa efferentia (mesonephric tubules) enter the commencement of the canal of the epididymis - Therefore this attaches the head of the epididymis to the testis ** Each seminifeous tubule ends by a straight duct and then the vasa efferentia leads to the epididymis ** The seminiferous tubules have several layers of cells - The outermost layer consists of spermatogonia, which divide to produce primary spermatocytes - These divide to form secondary spermatocytes and these divide to form spermatids - The spermatids develop into spermatozoa Blood Supply ** The epididymis is supplied by a branch of the testicular artery - This enters the upper pole and runs down to the lower pole - It anastamoses with the tiny artery to the ductus Note: The same venous and lymphatic drainage are for the testis Nerve Supply- the epididymis is supplied by sympathetic fibers from the celiac ganglion via the testicular artery

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Note: The external spermatic fascia is from the fascia inominata NOT the fascia of the external oblique aponeurosis Ductus Deferens & Seminal Vesicles ** The ductus deferens is a direct continuation of the canal of the epididymis - Continues from the tail of the epididymis - The ductus contains a thick wall of smooth muscle, and passes up medially - Enters the spermatic cord, and passes through the inguinal canal - Enters the abdomen at the deep inguinal ring - Passes across the side wall of the pelvis just under the peritoneum and floor of the pelvis to reach the back of the bladder - Note: IN its course no other structure intervenes between it and the peritoneum - Hooks around the inferior epigastric artery at the deep inguinal ring - Crosses the external iliac artery and vein, obliterated umbilical artery and obturator nerve, artery and vein on the obturator fascia - The vas curves medially and forwards, crosses above the ureter and approaches it opposite fellow - The ducts turn downward and lie side by side and each dilates - The dilatation is the ampulla and is the storehouse of spermatozoa ** The ampulla is parallel and medial to the seminal vesicles - At their lower ends each loses its thick muscular wall - Joins with the outlet of the seminal vesicle to form the ejaculatory duct Pierces the prostate and opens by the ejaculatory duct into the prostatic urethra

** The seminal vesicle is a thin-walled, elongated sac. The pair produces about 60% of the seminal fluid - 5 cm- coiled and 10 cm uncoiled - Found at the junction of the superior prostate and the bladder - These are applied to the base of the bladder above the prostate - The rectovesical fascia lies behind them and their tops are covered by the peritoneum of the rectovesical pouch - Each lies lateral to the ampulla of the ductus deferens of its own send Blood Supply - The artery to the ductus deferens is a branch of the superior vesical artery - Accompanies the ductus to the lower pole of the epididymis and anastamoses with the testicular artery ** The seminal vesicles are supplied by branches from the inferior vesicle and middle rectal arteries Lymphatic Drainage- Lymphatics accompany the blood vessels to the nearest iliac nodes Nerve Supplies- The smooth muscles of the ductus and seminal vesicles receives fibers from the inferior hypogastric plexus - Mainly sympathetic fibers from the first lumbar ganglion and are motor fibers - Their division produces sterility because the paralyzed muscle cannot contract to expel the stored secretion and spermatozoa (anejaculation) Embryology ** The remnant equivalent of the female uterus is the prostatic utricle and the appendage of the testable AU- GOLD SF28D- 30-03-09- Gross Anatomy of Prostate- THOMAS ** The prostate is a partly glandular, partly fibromuscular organ - Lies beneath the bladder and above the urogenital diaphragm - Penetrated by the proximal part of the urethra - 4 x 3 x 2 cm - Female homologue- the small group of paraurethal glands of Skene - Prostate provides about 30% of the volume of the seminal fluid ** The prostate has: - Base - Apex - Anterior surface - Posterior surface - Inferolateral surface

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** The base of the prostate is the upper surface and is continuous and contiguous with the bladder - The base is fused with the neck of the bladder - Therefore it is sometimes difficult to tell where the prostate ends and the bladder begins - Perforated by the urethra - The urethra runs in the base of the prostate on a superficial plane. Therefore most of the gland is posterior to the urethra ** The apex of the prostate is the lowest part and is blunt - The prostatic urethra emerges from the front of the apex to become the membranous urethra - The membranous urethra is surrounded by the sphincter urethrae (external urethral sphincter) - The apex of the prostate sits on the urogenital diaphragm and is surrounded by levator ani (pubourethralis fibers) - The pubourethral fibers are the internal fibers of the levator ani that forms a sling for the prostate ** The anterior surface is at the back of the retropubic space (Cave of Retzius) - Connected to the bodies of the pubic bones by the puboprostatic ligaments - Note: The prostatic plexus is related to the anterior surface ** The inferolateral surfaces are clasped by the pubourethralis parts of the levator ani ** The posterior surface is in front of the lower rectum but separated from it by the rectovesical fascia (Fascia of Denonvillier) - The ejaculatory ducts pierce the posterior surface just below the bladder - Pass obliquely through the gland for about 2 cm to open into the prostatic urethra - Note: The prostates own ducts also open into this part of the urethra ** The true capsule of the prostate is a thin strong layer of connective tissue at the periphery of the gland - This is made up of collagen, elastin + smooth muscles - Outside the true capsule is a condensation of pelvic fascia that forms the false capsule - Between these two capsules is the prostatic plexus of veins Note: The prostate gland consists of acini embedded in a fibromuscular stroma - The fibromuscular stroma is a mixture of connective tissue + smooth muscle

Prostatic Urethra - 3-4 cm in length - Passes through the substance of the prostate closer to the anterior than the posterior surface of the gland - Runs downwards and backwards from the internal meatus - Bends at the middle of its length - Continues downwards + forwards to emerge from the anterior aspect of the apex ** The urethral crest is a midline ridge that projects into the lumen from the posterior wall throughout most of the length of the prostatic urethra - Note: The ejaculatory ducts enter on the urethral crest ** Prostatic sinus is a shallow depression on either side of the crest - Seminal colliculus (verumontanum)- is a midline rounded eminence found at the mid-length of the crest - Verumontanum has a depression on it that leads into a blind sac (utriculus masculinus) - The prostatic utricle (utriculus)- is a small recess (depression) the represents the fused ends of the paramesonephric (Mullerian) ducts) - The ejaculatory ducts open on either side of the utricle ** The proximal part of the prostatic urethra is also known as the preprostatic part - Surrounded by a cylinder of smooth muscle - This smooth muscle is an extension of the circular muscle at the bladder neck - The function of the smooth muscle around the preprostatic part is contraction to prevent seminal regurgitation into the bladder during ejaculation **The prostate is divided into zones: iPeripheral zone- 70%- surrounds the central zone from behind and below - But does not reach up the base - Extends downwards to form the lower part of the gland - Ducts of the peripheral zone open into the prostatic sinuses

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iiCentral zone- 20%- wedge shaped and forms the base of the gland - With its apex at the verumontanum - Surrounds the ejaculatory ducts as they pass through the gland iiiTransition zone- 5%- found around the distal part of the pre-prostatic urethra, just proximal to the apex of the central zone The ducts of the transition zone open on to the verumontanum, just above where the ducts of the peripheral zone open to the prostatic sinuses

Note: Benign prostatic hyperplasia affects the transition zone - This may increase markedly in size and compress the peripheral zone - The peripheral zone is almost exclusively the site of origin for carcinoma of the prostate - In a PR exam the physician is feeling the peripheral zone - The central zone is rarely involved in any disease process ** There is very little glandular tissue anterior to the prostatic urethra - The anterior part of the gland is mainly fibromuscular - Overlapped from above by the detrusor muscle of the bladder and from below by the striated muscle of the urethral sphincter Blood Supply ** The main arterial supply is from the prostatic branch of the inferior vesical artery - Branches from the middle rectal + internal pudendal vessels ** The veins run into a plexus between the true and false capsules. - This plexus joins the vesicoprostatic plexus situated at the groove between bladder and prostate - This plexus receives the deep dorsal vein of the penis and drains backwards into the internal iliac veins Batsons Veins- are veins that connect the pelvic veins to the internal vertebral venous plexuses - The pelvic veins drain the inferior end of the urinary bladder and the prostate - Batsons venous plexus are veins without valves that run paravertebrally from the pelvic region up to the dural sinuses - Therefore they are a common pathway for metastasis of prostate and breast cancer to the vertebrae and brain - Allow for metastasis of cancer from pelvic organs to the vertebral column ** The anterosuperior part of the bladder may drain to the external iliac vein and veins of the bladder and prostate, together with the deep dorsal vein of the penis drain through the prostatic plexus to the inferior vesical veins - These drain to the internal iliac veins and communicate through the lateral sacral veins and pelvic sacral foramina with the internal vertebral venous plexuses in the vertebral canal - Therefore the blood they transmit can ascend either through the inferior vena cava or through the veins of the vertebral column Lymph Drainage - The lymphatics of the prostate pass across the pelvic floor mainly to internal iliac nodes - A few may reach external iliac nodes Nerve Supply - The acini receive parasympathetic innervation from the pelvic splanchnic nerves via the inferior hypogastric plexus - The muscle fibers of the stroma are under sympathetic control from the inferior hypogastric plexus - These muscle fibers contract to empty the glands during ejaculation SF28D 31-03-09- Gross Anatomy of the Penis & Urethra- THOMAS Male Urethra ** The urethra consists of a layer of fibroelastic tissue and smooth muscle lined by a vascular mucus membrane (stratified columnar epithelium) - Superior to the prostatic utricle the epithelium is transitional - The epithelium is stratified squamous in the navicular fossa ** The parts of the male urethra are: iPre-prostatic urethra- first 1.5 cm. Functions as a sphincter to prevent retrograde ejaculation and is under sympathetic control iiProstatic Urethra- 3-4 cm- passes through the prostate gland - Widest and most dilatable part of the urethra - Concave anteriorly - Has a narrow median ridge (urethral crest) with a groove on each side (prostatic sinus) 67

The urethral crest extends inferiorly on the posterior wall from the internal urethral orifice to a rounded eminence (seminal colliculus) on the crest The crest then diminishes and is absent in the membranous part

** The seminal colliculus has 3 small openings on it - Median prostatic utricle- blind ended sac - Ejaculatory ducts (x2)- on either side of the utricle iiiMembranous urethra- 1.5 cm long and pierces the perineal membrane Narrowest, shortest and least dilatable part of the urethra Pierces the superior + inferior fasciae of the urogenital diaphragm Surrounded by the sphincter urethrae The muscle fibers of the sphincter urethrae are slow twitch muscle fibers therefore they have sustained contractile ability Have an acid stable ATPase therefore the acidity of urine does not prevent the muscle fibers from contracting The bulbourethral glands (of Cowper) lie one on each side of the membranous urethra in the deep perineal pouch This is above (deep to) the perineal membrane and is covered by the urethral sphincter The duct pierces the perineal membrane to open into the bulb of the penile urethra ivPenile Urethra- is the longest part of the male urethra. (15 cm or 6 inches) Begins at the bulb of the penis and ends at the external urethral meatus Before reaching the meatus there is a penultimate dilatation of the urethra known as the navicular fossa After piercing the perineal membrane the urethra inclines forwards and enters the corpus spongiosum obliquely Passes longitudinally through the corpus spongiosum In the glans penis it expands dorsoventrally to form the navicular fossa

Sphincter Urethrae- also known as the external urethral sphincter - Some of the fibers arise from the pubic rami and pass as U-shaped loops in front of and behind the urethra - Some run from the transverse perineal ligament to the perineal body - Some fibers completely encircle the urethra - Made up of striated muscle but they are slow twitch - Supplied by the perineal branch of the pudendal nerve

Note: Although the pudendal nerve is the main supply to the sphincter, even if the nerve is damaged the patient remains continent - This is because the sacral nerve also has a direct somatic supply to the sphincter - Runs of the pelvic diaphragm and goes to the sphincter Female Urethra - 4 cm long - Wider and more dilatable than the male urethra - Lined by transitional, stratified columnar & squamous epithelia from above downwards - Para-urethral glands open near the margin of the external urethral orifice - S-shaped and each part is held in position by a pubourethral ligament which also supports the anterior vaginal wall - The female urethra is sensitive to estrogens - Therefore a decrease in estrogen is related to problems with incontinence because the periurethral tissues are sensitive to estrogen - Mucosa, submucosa and muscles are estrogen-dependent - The zone of highest urethral closure pressure is at the urethral sphincter. This is a sphincter of striated muscle that surrounds the distal 2/3rds of the urethra Note: Nerves going to supply the female urethra run in the anterior vaginal wall Penis ** The penis has a root and a body - The root of the penis is attached to the inferior surface of the perineal membrane - Consists of a the central bulb of the penis with a crus on each side ** Each crus is attached to the angle between the perineal membrane and the everted margin of the ischiopubic ramus - Each crus receives the deep artery of the penis near its anterior end - The crus continues forwards to become the corpus cavernosum - The bulb is the posterior end of the corpus spongiosum

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** At the front of the root area, below the subpubic angle, the two corpora cavernosa are bound together side by side with the corpus spongiosum behind them to form the body of the penis ** The glans penis forms the tip of the penis, overlapping the distal ends of the corpora cavernosa - The arteries of the bulb enter it near the urethra ** The corpus spongiosum and the 2 corpora cavernosa are each surrounded by a tough, fibrous sheath, the tunica albuginea of the corpus - The tunica albuginea of the c. spongiosum enlarges distally to enclose the glans - From the tunica fibrous trabeculae pass into the corpora - This divides their substance into numerous endothelial cell-lined cavernous spaces into which the helicine arteries open ** There is a septum between the 2-corpus cavernosa. The fibrous sheaths of the corpora are encircled by the deep fascia of the penis, which is an extension of the deep perineal fascia - The septum between the two corpora are incomplete and pectinated - Therefore pressure changes from one cavernosa column can be transmitted to the other column - Attached to the front surface of the pubic symphysis by the suspensory ligament of the penis - The midline deep dorsal vein with a dorsal artery on each side and a dorsal nerve lies deep to the deep fascia of the penis ** The skin of the penis is hairless and prolonged forwards in a fold (prepuce/foreskin) that overlaps the glans and is attached to the neck of the glans - Therefore the skin of the penis has no hair or sebaceous glands - EXCEPT: the sebaceous glands on the prepuce (foreskin) - There is also no fat in the penis and this allows for expansion during erection ** Beneath the skin is the superficial fascia of the penis (Bucks fascia) - Bucks fascia is a cylindrical prolongation of Colles fascia - In the midline is the superficial dorsal vein which is accompanied by lymphatics from the skin and the anterior apart of the urethra Frenulum- is a fold of skin on the inferior aspect of the glans - Passes from the prepuce to the posterior end of the urethral orifice Blood Supply: Penis ** The penis receives 3 pairs of arteries, which are branches of the internal pudendals iArtery to the bulb- supplies the corpus spongiosum including the glans iiDeep artery of the penis- supplies the corpus cavernosum iiiDorsal artery of the penis- supplies skin, fascia and the glans ** The internal pudendal is the main supplier of blood to the penis: - Scrotal - Bulbourethral - Cavernosal x2 - Then terminates as the dorsal artery of the penis Note: The penis receives some inconstant supply from the femoral artery - Superficial external pudendal - Deep external pudendal - These provide a more superficial supply to the skin of the penis Note: There is an anastomosis between the artery of the bulb and the dorsal artery - This is via the continuity between the corpus spongiosum and the glans - The deep arteries supply the corpora cavernosa only - The skin of the penis is also supplied by the superficial external pudendal branches of the femoral arteries Venous Drainage ** Venous return from the corpora is partly by way of veins that accompany the arteries and join the internal pudendal veins - But most of the venous drainage is by the deep dorsal vein - The deep dorsal vein pierces the suspensory ligament - Passes above the perineal membrane and enters the vesicoprostatic venous plexus - The superficial dorsal vein drains the dorsal skin of the penis and divides to join the superficial external pudendal tributaries of the great saphenous vein 69

** Therefore the superficial dorsal vein and deep external pudendal veins can drain back to the great saphenous vein ** The following veins have valves in them and are therefore important in maintaining erection - Cavernosal veins - Emissary veins - Dorsal veins Muscles ** Each of the 3 penile corpora has a muscle associated with them 1- Ischiocavernosus (x2)- arises from the posterior part of the perineal membrane and from the ischial ramus - Inserted by an aponeurosis onto the surface of the corpus cavernosum - Function: to assist in the support of the erect penis 2- Bulbospongiosus (bulbocavernosus)- arises from the perineal body and in front of the median raphe that joins the pair together - Posterior fibers are directed forwards and laterally over the bulb to be inserted into the perineal membrane - Has a dorsal fibrous expansion on the penis - The more posterior fibers surround the corpus spongiosum and the more anterior fibs extend to the corpora cavernosa - Function: empty the urethra at the end of micturition, assists in erection by compressing the deep dorsal vein of the penis Lymphatic Drainage - Lymphatics from the penile skin drain to superficial inguinal nodes - Lymphatics from the glans and corpora drain to deep inguinal lymph nodes Note: As the lymph runs back on the dorsum of the penis it can drain bilaterally - Therefore a lesion in the glans penis may drain to either side of the deep inguinal nodes Nerve Supply ** The skin of the penis is supplied by the pudendal nerves via the posterior scrotal and dorsal nerves - The dorsal nerve of the penis supplies the glans - S2 dermatome - A small area of skin on the dorsum of the base of the penis is supplied by ilioinguinal nerve - The bulbocavernosus and Ischiocavernosus muscles contract spasmodically during ejaculation are supplied by the perineal nerve from the pudendal nerve ** The sympathetic nerves necessary for ejaculation are derived from the L1 segment of the spinal cord via the superior + inferior hypogastric plexuses ** The pelvic splanchnic nerves (S2, S3) provide the parasympathetic supply to the cavernous tissue of all 3 corpora - This allows increased blood flow for erection

SF28D 31-03-09- Gross Anatomy & Development of the Breast- SHETTY Found in the pectoral region Found in both sexes However the breast is rudimentary in males and well developed in females Provides nutrition to the new born in the form of milk

** The adult female breast is found in the superficial fascia of the anterior thoracic wall - The base of the breast is from the sternal edge to near the mid-axillary line and from the 2nd to the 6th ribs - The breast overlies pectoralis major, serratus anterior and a small part of the rectus sheath and external oblique muscle - The axillary tail (of Spence) is a small part of the upper, outer quadrant that is prolonged towards the axilla - This extension is usually in the subcutaneous fat - The axillary tail pierces the Foramen of Langer and lies in the deep fascia of the axilla ** Other external relations of the breast are the: - Clavicle- superiorly - Deltopectoral triangle- clavicle (base), pectoralis major, deltoid (laterally) 70

** The nipple is found at the level of the 4th intercostals space about 10 cm from the mid-sternal line ** The retromammary space is the space between the breast and the pectoral fascia - Contains loose areolar tissue - Therefore allows movement of the breast on the pectoral region ** The female breasts is a secondary sexual organ and is a modified sweat gland - Vertical Extent = 2nd to 6th rib (mid clavicular line) - Horizontal extent = lateral border of the sternum to the mid-axillary line Deep Relations Pectoralis fascia Pectoralis major Serratus anterior External oblique muscle Retromammary space

Structure of the Breast - Skin Print Slide #12 +13

Parenchyma

Stroma (fatty)

** There are 15-20 lactiferous ducts and each drain a lobe of the breast - The ducts converge in a radial direction to open individually on the tip of the nipple - The nipple is a projection just below the center of the breast that is surrounded by an area of pigmented skin (areola) - Each lactiferous duct has a dilated sinus at its terminal portion in the nipple - Smooth muscle cells are present in the nipple and their contraction causes erection of the nipple

** The lactiferous ducts drain the lobes of the breast - Consists of circular and longitudinal muscle fibers to make the nipple erect or flattened - There are sebaceous and sweat glands around the area of the areola - The secretion of these sebaceous glands prevent the nipple from cracking during lactation and pregnancy ** The accessory sebaceous glands are also known as the accessory glands of Montgomery - Montgomerys tubercle is formed during lactation when the sebaceous glands increase in size around the areola Parenchyma - 15-20 lobes that each consists of a cluster of alveoli - Secretions pass through the alveolar duct ** The alveoli have different epithelium depending on their stage of activity iInactive epithelium- cuboidal epithelium iiActive epithelium- columnar epithelium but sometimes appears cuboidal due to stretching of the breast 71

** The lactiferous ducts are lined by stratified squamous epithelium ** The inactive mammary gland is characterized by an abundance of connective tissue and a scarcity of glandular elements

** A glandular lobule consists of small tubules or intralobular ducts lined with a cuboidal or low columnar epithelium - Contractile myoepithelial cells are found at the base of the epithelium - The larger interlobular ducts surround the lobules and the intralobular ducts ** The intralobular ducts are surrounded by loose intralobular connective tissue that contains: - Fibroblasts, lymphocytes, plasma cells and eosinophils ** Surrounding the lobules is a dense interlobular connective tissue that contains blood vessels (arterioles + venules) ** The mammary gland consists of 15-25 lobes, each of which is an individual compound tubuloalveolar type of gland - Each lobe is separated by dense interlobar connective tissue - A lactiferous duct emerges from each lobe at the surface of the nipple ** In preparation for lactation the mammary gland undergoes extensive structural changes - During the first half of pregnancy the intralobular ducts undergo rapid proliferation and form terminal buds that differentiate into alveoli - The intralobular excretory ducts appear more regular, with a more distinct epithelial lining - The interlobular excretory ducts become lined with taller, columnar cells - The lactiferous duct enlarges and is now lined by low pseudostratified columnar epithelium ** Therefore during pregnancy the alveolar cells become secretory and the ducts enlarge - As pregnancy progresses, the amount of intralobular connective tissue decreases - The amount of interlobular connective tissue increase due to enlargement of the glandular tissue ** The lactating mammary gland consists of distended alveoli filled with secretions and vacuoles - The active alveoli are lined with low epithelium and filled with milk - The milk appears as an eosinophilic material with large vacuoles of fat Muscles Deep to the Breast 1- Pectoralis Major- Origin from the anterior surface of the medial of the clavicle and anterior surface of the manubrium - Insertion into the bicep groove on the humerus - Nerve supply- medial + lateral pectoral nerves 2- Serratus Anterior- Origin from the upper 8 ribs and inserted into the costal surface of the scapula - Nerve supply- nerve to serratus anterior (C5, C6, C7) 3- External Oblique- Origin from the lower 8 ribs. Inserted via a broad aponeurosis into the: xiphoid process, linea alba, pubic symphysis, pubic crest, pectineal line Blood Supply ** The breast receives its blood supply from perforating branches of the intercostals and internal thoracic arteries (medially) - From the lateral thoracic artery laterally ** The internal thoracic is branch of the first part of subclavian. Gives perforating branches to the breast - Runs downwards 1 cm from the sternal border - Divides at the 6th intercostals space into superior epigastric artery and musculophrenic

** The breast is also supplied by: - Lateral, superior thoracic and acromiothoracic arteries - Lateral branch of the posterior intercostals artery

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Venous Drainage - Superficial Veins- internal thoracic and superficial veins of the neck - Deep Veins- internal thoracic, axillary and posterior intercostals veins ** The veins form an anastomotic circle deep to the areola

Lymphatic Drainage ** The lymph vessels drain mainly to the axillary lymph nodes. Drainage also occurs: iPectoral lymph nodes- along the axillary tail to these pectoral nodes

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Apical axillary nodes (central axillary nodes)- through the pectoralis major and clavipectoral fascia via the infraclavicular nodes - These nodes are located in the clavipectoral fascia iiiParasternal nodes (internal mammary nodes)- on the internal thoracic artery Note: The axillary group of nodes is close to the lateral thoracic vessels and the lower border of pectoralis major - Posterior axillary nodes drain the axillary tail of the breast ** The lateral axillary (humeral nodes) are found close to the humerus and drain most of the upper part - Close to the axillary vein Note: Some of the lymph also drains to intercostals vessels + nodes - Posterior intercostals node - Supraclavicular nodes ** There is also a subaerolar lymphatic plexus that drains to anterior axillary lymph nodes ** Lymphatics from the overlying skin drain in the following manner:

ii-

Deltopectoral node

** Lymphatics from the parenchyma:

** The inner quadrant of the breast drains to the parasternal group - The outer quadrant drains to the axillary group - Upper quadrant has superficial drainage to the infraclavicular and supraclavicular lymph nodes Note: The nipple and areola are drained by deep lymphatics 74

75% of breast drainage goes to the axillary apical group

Nerve Supply - Anterior and lateral cutaneous branches of 4-6th intercostals nerves - Sensory fibers to the skin - Autonomic fibers to smooth muscle and blood vessels Clinical Anatomy - Incisions are made radially - Malignancy may infiltrate the suspensory ligaments and results in fixation of the skin of the breast to underlying structures ** If superficial lymphatics are blocked due to malignancy, the skin of the breast gains a peau drorange appearance - Therefore the skin appears like an orange peel ** The early signs of breast cancer is a single, non-tender, hard, palpable mass with irregular margins - Associated lymphadenopathy - Cancer of the breast tends to spread to the: liver, pelvis, brain

Incidence of Malignancies

Upper Outer Quadrant (Includes the axillary tail) 60%

Upper Inner Quadrant 15%

Lower Outer Quad 15%

Lower Inner Quad 5%

Embryology of the Breast ** Mammary buds begin to develop during the 6th week as solid down growths of the epidermis into the underlying mesenchyme ** The mammary buds develop as down growths from thickened mammary crests (milk lines) - These are thickened strips of ectoderm extending from the axillary to the inguinal regions - Mammary crests appear during the 4th week, but normally persist in humans only in the pectoral region ** Each primary bud gives rise to several secondary mammary buds - These secondary buds develop into the lactiferous ducts and their branches - Canalization of the buds is induced by placental sex hormones - Process continues until late gestation and by birth 15-20 lactiferous ducts are formed ** The fibrous connective tissue + fat (fibrofatty stroma) develop from the underlying somatopleuric mesoderm ** Invagination of the thoracic mammary bud occurs by the 49th day to form a shallow mammary pit - Nipple is formed by mesenchymal proliferation by the 56th day

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After birth the nipples rise from the mammary pits due to the proliferation of the surrounding connective tissue of the areola During the fetal period the nipple is not formed. Emerges from the mammary pits after the fetus is born due to proliferation of connective tissue around the areola Therefore the mammary pit demarcates the point at which the nipple develops

Note: The smooth muscle fibers of the nipple and areola differentiate from surrounding mesenchymal cells - The nipple is not formed during intrauterine life ** Therefore the development of the breasts involve 3 processes: 1- Milk Lines- ectodermal thickenings that develop in the 35-37th weeks and extend from the axilla to the inguinal region 2- Epidermis- epithelial lining of the ducts and alveoli from the surface ectoderm. The epidermis grows inward into the mesenchyme to form the primary bud - The primary bud proliferates to form the secondary bud 3- Formation of lactiferous ducts- the buds forms the ducts via canalization due to the presence of placental hormones Post-natal Development 1- Phase I- Elevation of the nipple 2- Phase II- Glandular subaerolar tissue is present, nipple and areola project as a single mass from the chest wall 3- Phase III- increase in diameter and pigmentation of the areola and proliferation of breast tissue - Occurs as the child approaches adolescence 4- Phase IV- increase in pigmentation and size of the areola and nipple - The areola forms a secondary mass anterior to the main part of the breast 5- Phase V- smooth contour to the breast ** Growth of the duct system also occurs because of the raised levels of circulating estrogens - IN females the breasts enlarge rapidly during puberty - Due to the development of the mammary glands and the accumulation of fat associated with them Amastia- Absence of the breast - Occurs from the failure of development of the milk lines (mammary crests)

SF28D 01-04-09- Embryology of the Male Reproductive System- THOMAS ** The gonads do not acquire male or female morphological characteristics until the 7th week of development - Gonads appear initially as a pair of longitudinal ridges (genital/gonadal ridges) - Formed by proliferation of the epithelium and a condensation of underlying mesenchyme - Germ cells do not appear in the genital ridges until the 6th week of development - Primordial germ cells first appear among the endoderm cells in the wall of the yolk sac close to the allantois - Migrate along the dorsal mesentery of the hindgut to reach the genital ridges - Note: If they fail to reach the ridges, the gonads do not develop - Before the arrival of the primordial germ cells, the epithelium of the genital ridge proliferates and epithelial cells penetrate the underlying mesenchyme - Form the primitive sex cords - In both male + female embryos, these cords are connected to surface epithelium - Therefore the gonad at this time is the indifferent gonad Development of Gonads ** The gonads (testes + ovaries) are derived from 3 sources: iMesothelium- mesodermal epithelium lining the posterior abdominal wall iiMesenchyme- the underlying embryonic connective tissue iiiPrimordial germ cells Indifferent Gonads ** The initial stages of gonadal development occur during the 5th week when a thickened area of mesothelium develops on the medial side of the mesonephros - Proliferation of this epithelium + underlying mesenchyme produces the gonadal ridge - This is a bulge on the medial side of the mesonephros - Gonadal cords- finger like epithelial cords grow from the ridge into the underlying mesenchyme - The indifferent gonad now consists of an external cortex and an internal medulla 76

In XX embryos, the cortex of the indifferent gonad differentiates into an ovary and the medulla regresses In XY embryos, the medulla differentiates into a testis and the cortex regresses, except for vestigial remnants

Primordial Germ Cells - Found early in the 4th week among the endodermal cells of the yolk sac near the origin of the allantois - As the embryo is folded, the dorsal part of the yolk sac is incorporated into the embryo - As this occurs the primordial germ cells migrate along the dorsal mesentery of the hindgut to the gonadal ridges - During the 6th week the primordial germ cells enter the underlying mesenchyme and are incorporated into the gonadal cords Sex Determination ** Development of the male phenotype requires a Y-chromosome - The SRY gene codes for testis-determining factor (TDF) - SRY gene localized in the sex-determining region of the Y chromosome - Two XX chromosomes are required for the development of the female phenotype - Therefore the Y chromosome has a testis determining effect on the medulla of the indifferent gonad - The TDF regulated by the Y chromosome have special roles in sex determination - Under the influence of TDF the gonadal cords differentiate into seminiferous cords - The seminiferous cords are the primordia of the seminiferous tubules - The lack of a Y chromosome results in the formation of an ovary - The type of gonads present determines the type of sexual differentiation that occurs in the genital ducts and external genitalia Note: Testosterone, produced by the fetal testes determines maleness - However primary female sexual differentiation in the fetus does not depend on hormones - Female differentiation can occur even if the ovaries are absent Development of Testes ** The SRY gene for TDF on the short arm of the Y chromosome acts as the switch that directs development of the indifferent gonad into a testis ** TDF induces the gonadal cords to condense and extend into the medulla of the indifferent gonad - The cords branch and anastamose to form the rete testis - The connection of the gonadal cords (seminiferous cords) with the surface epithelium is lost, when a thick fibrous capsule is formed - The development of the capsule (tunica albuginea) is the characteristic feature of testicular development in the fetus - Eventually the testis separates from the degenerating mesonephros and becomes suspended by its own mesentery (mesorchium) - The seminiferous cords develop into the: seminiferous tubules, tubuli recti, and rete testis ** The seminiferous tubules are separated by mesenchyme that gives rise to the interstitial cells (of Leydig) - 8th week these cells begin to secrete androgenic hormones (testosterone + androstenedione) - These hormones induce masculine differentiation of the mesonephric ducts and the external genitalia ** Testosterone production is stimulated by human chorionic gonadotrophin (hCG) - hCG peaks during the 8-12 week period ** The fetal testes also produce a glycoprotein known as anti-mullerian hormone (AMH) or mullerian inhibiting substance (MIS) - AMH is produced by the sustentacular cells (Sertoli) - AMH suppresses the development of the paramesonephric (Mullerian) ducts which form the uterus and uterine tubes ** The seminiferous tubules remain uncanalized i.e. without a lumen until puberty. The walls of the tubules are made up of two types of cells: iSertoli Cells- supporting cells derived from the surface epithelium of the testis iiSpermatogonia- primordial sperm cells derived from primordial germ cells Note: Sertoli cells make up the majority of the seminiferous epithelium in the fetal testis - Later in development the surface epithelium of the testis flattens to form the mesothelium on the external surface of he adult testis - The rete testis becomes continuous with the 15-20 mesonephric tubules that become efferent ductules - These ductules are connected with the mesonephric duct which becomes the duct of the epididymis

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Development of Genital Ducts ** Both male and female embryos have 2 pairs of genital ducts: iMesonephric ducts (Wolffian ducts)- play a role in the development of the male reproductive system - The mesonephric ducts drained urine from the mesonephric kidneys iiParamesonephric ducts (Mullerian ducts)- have a role in the development of the female reproductive system

** Under the influence of testosterone produced by the fetal testes (t8th week), the proximal part of each mesonephric duct becomes highly convoluted to form the epididymis - The rest of the duct forms the ductus deferens and the ejaculatory duct Note: In female fetuses the mesonephric ducts almost completely disappear, only a few non-functional remnants persist ** Sertoli cells begin to produce MIS at 6-7 weeks - Interstitial cells begin producing testosterone at 8 week - Testosterone stimulates the mesonephric ducts to form male genital ducts - MIS causes the paramesonephric ducts to disappear by epithelial mesenchymal transformation ** As the mesonephros degenerates, some mesonephric tubules persist and are converted into efferent ductules - These ductules open into the mesonephric duct which as become the duct of the epididymis - Distal to the epididymis, the mesonephric duct acquires an investment of smooth muscle and becomes the ductus deferens - The seminal gland forms as a lateral outgrowth from the caudal end of each mesonephric duct - The ejaculatory duct is formed from the part of the mesonephric duct between the duct of this gland and the urethra Development of Prostate ** Multiple endodermal outgrowths arise from the prostatic part of the urethra and grow into the surrounding mesenchyme - The glandular epithelium differentiates from these endodermal cells - The associated mesenchyme differentiates into the dense stroma and smooth muscle of the prostate Development of External Genitalia ** The external genitalia begins to appear in the 9th week, but are not fully differentiated until the 12th week - In the 4th week a proliferating mesenchyme produces a genital tubercle in both sexes at the cranial end of the cloacal membrane - Labioscrotal swellings and urogenital folds soon develop on each side of the cloacal membrane ** Maculinization of the indifferent external genitalia is produced by testosterone - As the phallus enlarges and elongates to become the penis, the urogenital folds form the lateral walls of the urethral groove on the ventral surface of the penis - The groove ins lined by a proliferation of endodermal cells, urethral plate, which extends form the phallic part of the UG sinus - The urogenital folds fuse with each other along the ventral surface of the penis to form the penile urethra - The surface ectoderm fuses in the median plane to form the penile raphe and enclose the spongy urethra in the penis ** At the tip of the glans penis, an ectodermal in growth forms a cellular ectodermal cord - This grows towards the root of the penis to meet the spongy urethra - This ectodermal cord canalizes and joins the previously formed spongy urethra - This completes the terminal part of the urethra and moves the external urethral orifice to the up of the glans penis ** Week 12- a circular ingrowth of ectoderm forms at the periphery of the glans penis - This ingrowth forms the prepuce - The prepuce is adherent to the glans initially and is not easy to retract at birth - Breakdown of the adherent surfaces normally occurs during infancy

** The corpora cavernosa and corpora spongiosum develop from mesenchyme in the phallus - The labioscrotal swellings grow toward each other and fuse to form the scrotum - The line of fusion of the these folds is visible on the surface as the scrotal raphe SF28D 30-03-09- Histology of the Male Reproductive System- SOLOMON

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** The accessory glands of the male reproductive system are paired seminal vesicles, bulbourethral glands, and single prostate gland. - These structures are directly associated with the male reproductive tract - Produce numerous secretory products that mix with the sperm to produce a fluid (semen) Prostate Gland - Inferior to the neck of the bladder - Urethra exists the bladder and passes through the prostate gland as the prostatic urethra - The ejaculatory ducts and the numerous excretory ducts from the prostatic glands open in to the prostatic urethra ** The prostate is an encapsulated organ. Surrounded by a well-developed true fibroelastic capsule with smooth muscle - Septae with blood vessels penetrate the gland and divide it into indistinct lobules - Characteristic fibromuscular stroma with smooth muscle bundles mixed with collagen + elastic fibers surrounds the prostatic glands and the prostatic urethra - Collection of 30-50 branched tubuloalveolar glands - The ducts of the glands empty into the prostatic urethra - A condensation of pelvic fascia forms the false capsule superficial to the true capsule - Between the two capsules is the prostatic venous plexus Note: The fibromuscular stroma consists of fibroblasts and smooth muscle cells - Some skeletal muscle fibers may be seen - These are the fibers of puboprostatic found in association with the prostate ** The size of the glandular acini is variable. The lumina are wide and irregular due to the protrusion of the epithelium covered connective tissue folds. - Glandular epithelium varies from simple columnar to pseudostratified columnar - The size of the epithelium depends on the activity of the glands - Cells of the glands are light-staining - The excretory ducts may resemble glandular acini except in the terminal portions the epithelium is usually columnar and stains darker before entering the urethra - Therefore the ducts of the prostate are usually darker than the glands - The prostatic urethra is lined by transitional epithelium ** Some glands contain proteinaceous secretions. Other glandular acini contains spherical prostatic concretions (corpora amylacea) - These are formed by concentric layers of condensed prostatic secretion - Increase with age and become calcified ** The prostate has 3 distinct zones: iCentral zone- occupies 25% of the glands volume iiPeripheral zone- occupies 70% of volume, major site of prostatic cancer iiiTransitional zone- small are. Site where most benign prostatic hyperplasia originates ** The prostate produces 30% of the seminal fluid Testis -

Each testis is enclosed in a thick connective tissue capsule (tunica albuginea) Internal to the capsule is a vascular layer of loose connective tissue (tunica vasculosa) The connective tissue extends inward from the tunica vasculosa into the testis to form the interstitial connective tissue The interstitial connective tissue surrounds and supports the seminiferous tubules

** The tunica albuginea is thickened on the posterior surface to form the mediastinum testis - Extending fro the mediastinum testis are thin fibrous septae - This penetrates the testis to form 250 incomplete compartments known as testicular lobules - Within each lobule are 1-4 seminiferous tubules - These seminiferous tubules are surrounded by a network of loose connective tissue that contains blood vessels, nerves, lymphatics and interstitial cells of Leydig - Each testis has bout 250-1000 seminiferous tubules ** The seminiferous tubules are long, convoluted tubules. Lined by a stratified cuboidal epithelium: - There are two cell types within the epithelium: spermatogenic cells + Sertoli cells 79

The interstitial connective tissue is continuous with the mediastinum testis In the mediastinum the seminiferous tubules narrows and terminates in the straight tubules Straight tubules are short, narrow ducts lined with cuboidal or low columnar epithelium that are devoid of spermatogenic cells The straight tubules mark the beginning of the duct system The cells of the straight tubules are known as Sertoli-like cells. This is because they do not look like Sertoli cells but they produce a secretion that is similar to the Sertoli cells

** The straight tubules continue into the rete testis of the mediastinum testis - The rete testis is an irregular, anastomosing network of tubules with wide lumina - Lined by simple squamous to low cuboidal/columnar epithelium - The rete testis open into the efferent ductules (ductuli efferents) - The efferent ductules connect the rete testis with the epididymis Note: Some tubules in the rete testis + ductuli efferents contain accumulations of sperm - The epithelium of the efferent ductules consists of groups of tall columnar cells that alternate with groups of shorter cuboidal cells - Due to the alternating cell heights, the lumina of the ductuli efferents are uneven - Therefore gives it a pseudostratified appearance - The tall cells have cilia and the cuboidal cells have microvilli ** Each seminiferous tubule is surrounded by: iOuter layer- of fibrous connective tissue containing fibroblasts iiInner layer- basement membrane ** There are two types of epithelial cells: a- Germ cells- give rise to the spermatozoa b- Sertoli cells- provide support and nutrition to the developing sperm ** Germ cells mature from the basal lamina towards the lumen - Therefore the most immature cells are closest to the basal lamina - Spermatogonium primary spermatocytes- secondary spermatocytes- spermatids- spermatozoa (mature) ** The primary spermatocytes are the largest germ cells in the seminiferous tubules - They occupy the middle region of the germinal epithelium - As the spermatocytes mature they become smaller in size - The spermatids are found in the adluminal compartment of the seminiferous tubule. - Tend to be in close association with the Sertoli cells - The small, dark-staining heads of the maturing spermatids are embedded in the cytoplasm of Sertoli cells - Their tails extend into the lumen of the seminiferous tubule ** The germ cells are characterized by an abundance of chromatin material because they are mitotically and meiotically active - Note: The nuclei of the Sertoli cells have relatively little or NO chromatin ** The Sertoli cells have triangular nuclei. The bases adhere to the basal lamina and apical ends project into the lumen - The heads of the spermatozoa tend to aggregate around the cells - Sertoli cells have large amounts of smooth endoplasmic reticulum, well developed Golgi complexes and many mitochondria - Cells appear vacuolated to contain the secretory material ** The spaces between the tubules is filled with connective tissue, blood vessels, nerves, lymphatics - The capillaries are fenestrated to allow the free passage of macromolecules ( eg blood proteins) - The spaces also contains fibroblasts, macrophages, plasma cells, Leydig cells - Leydig cells are pale clusters of cells with well-developed smooth ER, Golgi and mitochondria - Embryological origin- of Leydig cells is local mesenchymal cells Seminal Vesicle - Paired elongated glands on the posterior side of the bladder - The excretory duct from each seminal vesicle joins the ampulla of each vas (ductus) deferens to form the ejaculatory duct - The ejaculatory duct runs through the prostate and opens into the prostatic urethra - Appears like the thyroid gland BUT the epithelium is low pseudostratified type - The gland demonstrates primary + secondary mucosal folds 80

The secondary folds form irregular cavities or mucosal crypts The lamina propria projects into and forms the core of the larger primary folds and the smaller secondary folds Deep to the epithelium is the muscularis layer Consists of an inner circular layer + outer longitudinal layer The adventitia surrounds the muscularis and blends with the connective tissue 70% of the seminal fluid is produced by the seminal vesicles

Vas & Ductus Deferens ** The efferent ductules emerge from the mediastinum on the posterior-superior surface of the testis - Connect the rete testis to the ductus epididymis - The efferent ductules are found on the connective tissue and form a part of the head of the epididymis - Lined by pseudostratified columnar epithelium with stereocilia - Smooth muscle and connective tissue found on the outside Note: The epididymis has a wide regular lumen in comparison to the efferent ductules - Lined also by pseudostratified columnar epithelium - Consist of tall columnar principal cells with long non-motile stereocilia and small basal cells - Function: storage and maturation of sperm ** The ductus deferens has narrow, irregular lumen with longitudinal mucosal folds, thin mucosa, thick muscularis and an adventitia - Lumen lined by pseudostratified columnar epithelium with stereocilia - Underlying lamina propria consists of compact collagen fibers and a fine network of elastic fibers ** The vas deferens has a thick muscularis with 3 smooth muscle layers - Inner longitudinal - Middle circular - Outer longitudinal

** The msuclaris is surrounded by adventitia. The adventitia of the vas merges with the connective tissue of the spermatic cord ** The terminal portion of the ductus deferens enlarges into an ampulla. The ampulla differs from the ductus deferens in the mucosa structure - The lumen of the ampulla is larger than the ductus - Mucosa of the ampulla has numerous, irregular branching mucosal folds - Also has deep glandular diverticula (crypts) between the folds that extend to the surrounding muscle layer - The secretory epithelium that lines the lumen and the glandular diverticula is simple columnar or cuboidal - The ampulla joins the duct of the seminal vesicles to form the ejaculatory duct and empty into the prostatic urethra Penis ** The penis consists of 3 cylinders: iCorpora cavernosa (x2)- dorsal iiCorpus spongiosum- ventral ** Each of the corpora cavernosa is surrounded by a well-developed tunica albuginea. This capsule also forms as median septum between the two corpora - A thinner tunica albuginea with smooth muscle fibers and elastic fibers surrounds the corpus spongiosum ** All 3 cavernous bodies are surrounded by loose connective tissue known as the deep penile fascia (Bucks fascia) - This is surrounded by the connective tissue of the dermis - Followed by the stratified squamous keratinized epithelium of the epidermis Note: The 3 cylinders are made up of true cavernous tissue. (Contains veins) - Trabeculae with collagenous, elastic, nerve and smooth muscle fibers surround and form the core of the cavernous sinuses in the corpora ** The cavernous sinuses of the corpora cavernosa are lined with endothelium - Receive blood from the dorsal arteries and deep arteries of the penis - The deep arteries branch in the corpora cavernosa and form helicine arteries which empty directly in the cavernous sinuses 81

** The cavernous sinuses in the corpus spongiosum receive their blood form the bulbourethral artery that is branch of the internal pudendal artery Note: Blood leaving the cavernous sinuses exit mainly through the superficial dorsal vein and the deep dorsal vein Note: The skin of the prepuce is made of stratified squamous epithelium - The female homologue of the skin of the penis is the labia minora - The female homologue of the scrotum is the labia majora ** From medial to lateral outside of Bucks fascia is VAN - Deep dorsal vein - Dorsal artery - Dorsal nerve Note: The deep artery of the penis is a branch of the internal pudendal artery - Provides blood supply to the corpora cavernosa - The artery to the bulb supplies the corpora spongiosum - Dorsal artery- supplies the glans + superficial fascia + skin ** Therefore there are 3 arteries that supply the penis and they are all branches of the internal pudendal artery Venous Drainage - Superficial dorsal vein drains the skin and fascia - Cavernous tissue is drained by the deep dorsal vein ** The glans penis does not have 3 cylinders and lacks cavernous tissue - The glans is an enlargement of the corpus spongiosum - In adults there is a space beneath the prepuce - However in infants there is no prepusal space fuses with the epithelium of the glans penis - But at the age of 2 years the inner surface of the prepuce separates from the glans penis to form a space ** The navicular fossa is formed as the urethra enlarges to form this fossa in the glans penis - At this point the epithelium of the urethra becomes stratified squamous - Pacinian corpuscles are abundant on the inner surface of the prepuce of the glans penis ** Most of the penile urethra is lined by stratified columnar epithelium and has an embryological origin from the urogenital sinus - However the navicular fossa is lined by stratified squamous epithelium and the embryological origin is from ectoderm Sacrum - Made up of 5 progressively smaller sacral vertebrae and their costal elements that fuse to form this bone - Lateral Aspect: has an auricular surface for articulation with the ilium to form the upper posterior wall of the pelvis - Below the sacroiliac joints the sacrum tapers off down its apex - The upper surface of the first sacral vertebra forms the base of the sacrum - The body of S1 is large and wider transversely - The body has an anterior projection which is the sacral promontory - Lateral to the body is the wing-like ala of the sacrum on each side - The ala consists of fused costal elements and transverse processes ** The ala is crossed anteriorly by the following structures from medial to lateral - Sympathetic trunk - Lumbosacral trunk

Obturator nerve

Pelvic Surface of the Sacrum - Smooth concave surface - Across the midline the 5 bodies are fused - On each side are the 4 anterior sacral foramina - Above the first sacral foramen the arcuate line of the ilium continues to form the posterior part of the pelvic brim - The anterior rami of the upper 4 sacral nerve pass laterally from the anterior sacral foramina Piriformis- arises from the 3 ridges that separate the anterior foramina and from the lateral mass nearby - The sacral anterior primary rami that emerge from these foramina lie on piriformis behind its covering fascia ** From the front of the lower sacrum, the presacral fascia passes downwards and forwards to fuse with the mesorectum above the anorectal junction 82

** Behind the presacral fascia the median sacral artery and vein lie in the midline with some lymph nodes - On each side the sacral sympathetic trunk is medial to the sacral foramina - The lateral sacral vessels lie in front of the piriformis fascia Dorsal Surface of the Sacrum - Irregular, rough convex surface - The gap above the first sacral laminae is closed by the ligamenta flava attached to the lamina of L5 vertebrae ** The sacral hiatus indicates the failure of fusion of the laminae of S5 and S4 - Hiatus is closed by fibrous tissue that forms the superficial Sacrococcygeal ligament ** Adjacent spinous processes fuse to form a midline ridge (median sacral crest) - The superior articular process on S1 has a backward facing facet for the synovial joint with L5 - The transverse processes are fused to form the lateral sacral crest which is lateral to the posterior foramina Note: The gutter between the medial and lateral sacral crests is filled by erector spinae - The posterior layer of the lumbar fascia that covers erector spinae is attached to both crests Sacral Canal ** The sacral canal contains the meninges, which extend down to S2 - The filum terminale pierces the dura and runs down to blend with the periosteum on the back of the coccyx - The space around the dura mater is filled with loose fat + internal vertebral venous plexus - The posterior root ganglia are within the sacral canal - The sacral nerves emerge separately from the anterior + posterior sacral foramina Bony Pelvis ** The hipbone, sacrum and coccyx articulate to form a cavity - From the brim of the concavity the ala of each ilium projects upwards to form the iliac fossae ** The pelvic brim is formed in continuity by the following structures: iPubic crest iiiArcuate line of the ilium iiPectineal line of the pubis Pelvic Joints & Ligaments Netters #352 ** The joints of the pelvis are the: - Sacroiliac joint - Sacrococcygeal joint - Pubic symphysis ** The main ligaments of the pelvis are: - Sacrotuberous ligament - Sacrospinous ligament - Iliolumbar ligament

iv-

Ala + promontory of the sacrum

Sacroiliac Joint ** Synovial joint between the auricular surfaces of the ilium and the sacrum ** The capsule is attached to the articular margins. Ligamentous bands surround the capsule: - The anterior sacroiliac ligament is a flat band that joins the bones above and below the pelvic brim - Mass of ligaments attaches the sacrum to the ilium behind the joint ** The stability of the sacroiliac articulation depends entirely on ligaments - The sacroiliac ligaments soften towards the later months of pregnancy and allow slight rotation of the sacrum during parturition Sacrotuberous Ligament - Blends with the posterior sacroiliac ligament - Attached to the posterior border of the ilium and the posterior superior + posterior inferior iliac spines - Also attached to the transverse tubercles of the sacrum below the auricular surface and to the upper part of the coccyx - The ligament is pierced by the perforating cutaneous nerve and branches of the inferior gluteal vessels and coccygeal nerves Sacrospinous Ligament 83

Lies on the pelvic aspect of the sacrotuberous ligament Base is attached to the side of the lower part of the sacrum and the upper part of the coccyx Narrows as it passes laterally and its apex is attached to the spine of the ischium The coccygeus muscle lies n the pelvic surface of the sacrospinous ligament

Note: The sacrotuberous + sacrospinous ligaments with the lesser sciatic notch of the ischium, enclose the lesser sciatic foramen = The lateral part of the lesser sciatic foramen is occupied by the obturator internus muscle - The medial part leads forwards into the pudendal canal

Iliolumbar Ligament - Shaped like a V- lying sideways - Apex attached to the transverse process of L5 - The upper band passes to the iliac crest - Gives partial origin to quadratus lumborum and becoming continuous with the anterior layer of the lumbar fascia - The lower band runs laterally and down to blend with the front of the anterior sacroiliac ligament Sacrococcygeal Joint - Symphysis between the apex of the sacrum and the base of the coccyx - Anterior Sacrococcygeal ligament- unites the bones at the front - 2 Posterior Sacrococcygeal ligament- Lateral Sacrococcygeal ligament- that runs from the transverse process of the coccyx to the inferolateral angle of the sacrum - This completes a foramen for the anterior ramus of the 5th sacral nerve Pelvic Walls ** The muscles of the pelvis are: - Obturator internus - Piriformis

Levator ani Coccygeus

** The sidewall of the pelvis is formed by the hipbone with obturator internus and its fascia ** The posterior wall is formed by the sacrum with piriformis passing laterally into the greater sciatic foramen Piriformis - Arises from the middle 3 pieces of its half of the sacrum and the lateral mass - Extends medially between the anterior sacral foramina - Therefore the merging sacral nerves and sacral plexus lie on the muscle Pelvic Floor ** The pelvic floor consists of a gutter-shaped sheet of muscle, the pelvic diaphragm that is slung around the midline body structures: urethra, anal canal, and vagina

** The muscles of the pelvic floor are the: levator ani + coccygeus (ischiococcygeus) ** Arise in continuity from the following: - Body of the pubis - Tendinous arch over the obturator fascia - Spine of the ischium ** The muscles are inserted into the coccyx and the postanal plate. From their origin the muscle fibers slope down and backwards to the midline Levator ani - Consists of two main parts: pubococcygeus + iliococcygeus - Their fibers arise in continuity from the body of the pubis to the ischial spine across the obturator fascia Note: The tendinous arch of origin of levator ani slopes across the obturator internus fascia - The pelvic cavity is above this line - The ischioanal fossae is below this line

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** The pubococcygeus part of levator ani arises from the anterior half of the tendinous arch and from the posterior surface of the body of the pubis - Most of the posterior fibers pass backwards in a flat sheet on the pelvic surface of the iliococcygeus and are inserted in front of the coccyx - Some fibers arise anteriorly from the body of the pubis and pass more medially and inferiorly to join with the fibers of the opposite side and the external anal sphincter - This part is the puborectalis and this forms a U-shaped sling that holds the anorectal junction forward Note: The most medial fibers of the pubococcygeus pass backwards alongside the prostate and the sphincter urethrae in the male - These decussate behind the urethra and are known as pubourethralis - In the female these fibers are around the posterior wall of the vagina and are referred to as the pubovaginalis ** The iliococcygeus part arises from the posterior half of the tendinous arch and the pelvic surface of the ischial spine - Fibers are inserted into the side of the coccyx and the anococcygeal raphe - The anococcygeal raphe extends from the tip of the coccyx to the junction of the rectum and anal canal Nerve Supply: Levator ani is supplied from the sacral plexus by branches of S3 and S4 which enter the pelvic surface of the muscle - Puborectalis, pubourethralis (pubovaginalis) are supplied from below by the perineal branch of S4 and the inferior rectal branch of the pudendal nerve Coccygeus - Also known as ischiococcygeus - Arises from the tip of the ischial spine and its fibers fan out to be inserted into the side of the coccyx and the lowest piece of the sacrum - Lies edge to edge with the lower border of piriformis - Overlapped anteriorly by iliococcygeus Nerve Supply: Branches of S3 and S4 Lumbar Plexus- Branches- L1- iliohypogastric + ilioinguinal - L2, L2- genitofemoral - L2, L3- (posterior divisions)- Lateral femoral cutaneous

L2, L3, L4- (posterior divisions)- Femoral L2, L3, L4- (posterior divisions)- Obturator

Obturator Nerve- Emerges from the medial side of psoas major - Lies on the ala of the sacrum, lateral to the lumbosacral trunk - Slants down to the side wall of the pelvis between the origin of the internal iliac artery and the ilium - Enters the obturator foramen and supplies of the parietal peritoneum of the side wall of the pelvis ** In the obturator canal it splits into two divisions: iAnterior Division- passes over obturator externus and enters the thigh to supply the hip joint iiPosterior Division- supplies and pierces obturator externus - Runs into the thigh - Branch accompanies the femoral artery into the popliteal fossa to supply the knee joint Sacral Plexus - Formed on the front of piriformis - Formed by the lumbosacral trunk (L4, L5) and the upper 4 anterior sacral rami ** The branches of the sacral plexus are: 1- Nerves to Piriformis (S1, S2)- twigs that pass back from the upper sacral nerves into the muscle 2- Perforating cutaneous nerve (S2, S3)- pierces the sacrotuberous ligament 3- Posterior femoral cutaneous nerve (S1, S2, S3)- runs down below piriformis on the sciatic nerve 4- Pelvic splanchnic nerves (S2, S3, S4)- make up the sacral parasympathetic outflow and the fibers join the inferior hypogastric plexus - Motor to the bladder ad to the large intestine from the level of the splenic flexure and below - Responsible for erection - Afferent fibers include those for distention + pain from the bladder, lower cervix, lower colon and rectum

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5- Pudendal Nerve (S2, S3, S4)- Runs down and curls around the gluteal surface of the sacrospinous ligament to enter the pudendal canal - Nerve of the pelvic floor + perineum At the posterior end of the pudendal canal it gives off the inferior rectal nerve The inferior rectal arches over the fat of the ischioanal fossa. Its branches supply the external anal sphincter, anal canal + perianal skin The perineal nerve exits from the anterior end of the canal as the terminal branch of the pudendal Runs forward and breaks up to supply the skin of the posterior 2/3rds of the scrotum + vulva and mucus membrane of the urethra and vagina The perineal nerve is motor to the perineal muscles: Ischiocavernosus, bulbospongiosus, superficial + deep transversus perninei + sphincter urethrae The dorsal nerve of the penis (clitoris) is the other terminal branch of the pudendal Runs forward deep to the perineal membrane Pierces the membrane below the pubis symphysis to supply the skin of the penis (clitoris)

6- Perineal branch of S4- passes between levator ani and coccygeus to supply the puborectalis, pubourethralis (pubovaginalis) parts of levator ani and the skin over the ischioanal fossa 7- Nerve to Quadratus Femoris (L4, L5, S1)- lies on the ischium deep to the sciatic nerve - Runs down deep to obturator internus to enter the deep surface of the quadratus femoris 8- Nerve to obturator internus (L5, S1, S2)- passes below piriformis, curls around the base of the ischial spine and enters obturator internus 9- Superior gluteal nerve (L4, L5, S1)- passes through the greater sciatic notch above piriformis 10- Inferior gluteal nerve (L5, S1, S2)- passes backwards below piriformis to enter the deep surface of gluteus maximus

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