Pelvic Viscera II

1. Where are the testes and epididymis located?

2. Describe sperm production and storage

3. Differentiate between the Tunica Albuginea and Vaginalis

Location:

• scrotum of perineum (homologous to labia majora in female)

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Sperm production & storage

• produced in the seminiferous tubules

• stored in the body of the epididymis

• Transported via vas deferens, a continuation of tail of the epididymis

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Tunica albuginea vs Tunica Vaginalis:

• Albuginea: Tough outer surface of testes

• Vaginalis: Peritoneal sac

  • Visceral layer covering testes & epididymis

  • Parietal layer adjacent to internal spermatic fascia

  • cavity w/ small amount of liquid between 2 layers

Describe the Embryonic descent of testes

Testes descent

• posterior abdominal wall → inguinal canal → scrotum

  • Carry vessels, nerves, vas deferent found in spermatic cord

• Testes and spermatic cord acquire coverings from inguinal canal

• Processus vaginalis (peritoneum) close off to become the tunica vaginalis

1. what are the three layers of the sperm cord and which muscles/fascia covers each layer

2. What are the contents of the spermatic cord?

Layer/Covering of Sperm Cord:

1. Internal spermatic fascia: transversalis fascia

2. Cremaster muscles & fascia: internal oblique

3. External spermatic fascia: external oblique aponeurosis

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Contents:

• ductus (vas) deferens

• artery to ductus deferens (inf. or sup. vesical artery)

• testicular artery

• pampiniform plexus of vv.

• lymphatic vessels

• autonomic nerves

• remnants of processus vaginalis

• cremasteric artery (br inf. epigastric a.)

• genital branch of genitofemoral nerve- motor component of “cremaster reflex

Describe the Cremasteric reflex

lightly stroking superior and medial thigh → GSA of femoral branch of genitofemoral nerve & ilioinguinal nerve → GSE of genital branch of genitofemoral nerve →

cremasteric muscle contraction → pulls up ipsilateral testes

Describe the NVL (neurovascular Lymphatics) of the testes & spermatic cord

Arterial supply:

• testicular artery

• artery to ductus deferens

Venous drainage:

• pampiniform plexus of veins → testicular vein @ deep inguinal ring

Lymph Drainage

• lateral aortic nodes in abdominal cavity >

  • testicular cancer metastases to abdomen

Nerve Supply

• sympathetic fibers (GVE, T10-11) for sperm transport & vasoconstriction

• accompanied by afferent sensory fibers (GVA)

• genital branch of genitofemoral nerve (GSE) to cremaster muscles of cord

Describe these diseases of the testes:

• Hydrocele and hematocele of testis

• Spermatocoele*

• Varicocoele (of the spermatic cord):

• Testicular cancer:

• Vasectomy

Hydrocele and hematocele of testis

• Accumulation of serous fluid1 or blood2 within cavity of tunica vaginalis

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Spermatocoele*

• sperm-filled cyst near the head of the epididymis; is usually asymptomatic.

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Varicocoele (of the spermatic cord):

• elongation and dilatation of the pampiniform plexus of veins (bag of worms);

• common in teens;

• majority occur on the left side;

• due to bad valves

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Testicular cancer:

• Most common & most curable form of cancer in males between 18-35 years of age

• Many different stages – once past tunica albuginea, spread is more extensive

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Vasectomy:

• Ductus deferens between testis & superficial inguinal ring can be dissected & divided bilaterally because of easy access through skin & superficial fascia of scrotum;

Describe the vas deferens:

• Pathway

• Function

Describe the seminal vesicles and its function

Vas Deferens:

• Pathway:

  • Passes through the inguinal canal → abdominal cavity → courses posterior to urinary bladder

    • @ distal end → ampulla of the ductus deferens

• Function: Transmits sperm from the epididymis to the ejaculatory duct

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Seminal vesicles

• tortuous, coiled tube

• Function: contributes thick, alkaline fluid containing fructose to seminal fluid

  • (essential for nutrition of spermatozoa)

  • does not store sperm

Describe the ejaculatory ducts:

• Union of

• Pathway

• opens into

Each ejaculatory duct:

• union: seminal vesicle + ductus deferens

• Pathway: Traverses posterior part of prostate

  • Seperates middle lobe (superomedial lobule) and posterior lobe (inferoposterior lobule)

• Opens into the prostatic urethra on the seminal colliculus

1. Describe the Prostatic Urethra

2. Function of prostate

Prostatic urethra:

• Fibrous capsule with neurovascular plexuses

• Urethral crest

• Prostatic colliculus: utricle & opening of ejaculatory ducts

• Urethral sinuses: opening of prostatic ducts

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Prostate Function:

• Produces alkaline fluid containing nutrients for spermatozoids & enzymes that is added to seminal fluid.

  • helps liquify semen & neutralize vaginal acidity

• Prostatic fluids empty into the prostatic urethra through individual duct openings

Describe the various problems with the prostate

• BPH

• Cancer

benign prostatic hyperplasia or BPH

• enlargement in middle aged and older males @ transition zone (surrounds urethra)

• Symptoms: nocturia, urgency, and dysuria

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Prostate Cancer:

• Elderly males in peripheral Zone

• The area posterior (P) to urethra & inferior to ejaculatory duct is palpable by digital rectal examination.

• can spread to spine & CNS via vertebral venous plexuses.

Describe the NVL of the prostate, ampula* of vas deferent & seminal vesicles

Blood Supply:

• inferior vesical A/V

• artery to ductus deferens*

• prostatic plexus of veins* that drains via vesical plexus in internal iliac vein or vertebral venous plexus

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Lymphatic:

• internal iliac nodes

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Prostatic Plexus; Contains:

• Sympathetic fibers (preganglionic fibers T11-L2)

  • Rich innervation of internal genital organs

  • Semen transport in vas deferens

• Parasympathetic fibers (S2-4)

  • Gland secretion

  • formthe cavernous nerves → erectile tissues of penis in perineum

• GVA fibers

  • Above pain line, travel with sympathetic fibers: vas deferent, upper part of seminal vesicles

  • Below pain line, travel with parasympathetics fibers: prostate, lower part of seminal vesicles & ampulla of vas deferent

  • Other visceral sensations travel with parasympathetic fibers

Describe the formation and transport of semen

• Emission

• Gland secretion

Emission:

• Delivery of semen to urethra

• via peristalsis of vas deferens and ducts of accessory glands (sympathetic, GVE)

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Gland secretion (parasympathetic, GVE )

• Seminal fluids

• seminal vesicles

• Prostate

• Ejaculatory fluid

• bulbourethral (Cowper’s) glands in perineum

What is prostatectomy and its potential consequences

Prostatectomy: Radical surgery to cure prostate cancer that involves removing prostate & seminal vesicles

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Possible Complication:

• damage parasympathetic fibers of prostatic plexus & cavernous nerves

  • innervate erectile tissues

  • cause impotence (erectile dysfunction)

• also damage sympathetic fibers of vesical plexus

  • controls internal urethral sphincter → retrograde ejaculation → decreased fertility

  • emission → low volume ejaculate → decreased fertility

• Can also cause urinary incontinence (damage to nerves & muscles of bladder, urethra and external urinary sphincter)

1. What is the round ligament of the uterus

2. What are the 3 broad ligaments

Round ligament of uterus

• passes into inguinal canal to labium majorum (embryological remnant, called gubernaculum, used for ovaries descent from abdomen to pelvis) & assists in keeping uterus in position

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Broad ligament of the uterus is peritoneum divided in

• Mesosalpinx around & below the uterine tube

• Mesovarium, suspends the ovary

• Mesometrium over & lateral to the body of the uterus

1. Describe the uterus

   • What are its parts

2. What is the vagina

   • Vaginal Fornix?

Uterus:

• thick-walled, hollow, muscular organ; consists of:

  • Body with rounded fundus superiorly & containing the uterine cavity & ostia of uterine tubes

  • Isthmus is the junction between the body and the cervix

  • Cervix containing the cervical canal that connects internal and external ostia

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Vagina:

• distensible tube that connects cervix of uterus to vestibule in perineum.

• Mostly a pelvic structure except for inferiormost part in perineum

• cervix forms a continuous recess around the vagina, the vaginal fornix, which is divided into anterior, posterior, and lateral fornices.

How can you describe the position of the uterus

Position of the uterus:

• Angle of anteversion: between the axis of the uterine cervix and the axis of the vagina

• Angle of anteflexion: between the axis of the uterine body and the axis of the cervix

• Normal position is: anteverted and anteflexed

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Can be described as…:

• Anteverted (A)

• Anteflexed (B)

• Retroverted (C)

• Retroflexed (D)

1. Describe what may happens if there is Obstetrical trauma to vagina

2. What happens if there is a weakening of walls?

3. Tumor?

Obstetrical trauma

• open communications → Fistulas:

  • vagina and urethra (urethrovaginal fistula),

  • bladder (vesicovaginal fistula)

  • rectum (rectovaginal fistula).

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Weakening of walls of vagina w/o open communication → prolapse into vagina

• bladder (cystocele),

• urethra (urethocele)

• rectum (rectocele) into vagina.

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Tumor: Tumor on the posterior part of the bladder may bulge into the vaginal vault

Describe pelvic organ prolapses:

• Due to?

  • Support?

• Incidence increases w/?

Pelvic Organ Prolapses:

• Protrusion or herniation of pelvic viscera into the vagina.

• Due to: weakness of supporting musculature, ligaments, and fascia

  • Active support: levator ani m.

  • Passive support: uterosacral, transverse cervical, and pubocervical ligaments

• Incidence increases: w/ age and parity

Describe the ligaments supporting the uterus

Supporting Ligaments:

• from cervix to the anterior (pubocervical),

• lateral (transverse cervical or cardinal ligament or Mackenrodt ligament )

  • provides the main passive support of the uterus.

• posterior (uterosacral ligament) pelvic walls.

Describe pap smears:

• Official Name

• Purpose

• samples taken

Papanicolaou Exam

• Purpose: Evaluates condition of the cervical cells;

  • important for early detection of premalignant lesions and cervical cancer

• Minimum of two samples taken:

  • Ectocervical specimen

  • Endocervical specimen

Describe Carcinoma of the cervix and body of uterus

• Diagnoses

• Spread

What is Hysterectomy and when is it used?

Carcinoma of the cervix and body of uterus

• diagnosed by

  • inspection,

  • PAP smear,

  • imaging,

  • dilatation

  • curettage of uterus

• Spread to internal & common iliac nodes

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Hysterectomy:

• surgical removal of the uterus.

• Indicated in patient with uterine, cervical & ovarian cancers; endometriosis & excessive bleeding; excessive postpartum bleeding.

Describe the uterine tubes:

• location and clinical consequence of that

• Parts

Fallopian tubes:

Location:

• Extend laterally from the uterus in the mesosalpinx;

• open to the peritoneal cavity (risk of peritonitis if infection of genital tract)

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Parts:

• Funnel-shaped infundibulum laterally, end with fimbriae & abdominal ostium

• Ampulla, the widest part; usual site of fertilization

• Narrow isthmus

• Uterine part, intramural part, pierces uterine wall

1. Explain what ectopic pregnancy is

   • Stats?

2. Placenta Previa?

Ectopic pregnancy:

• Development of a fertilized ovum outside of the uterine cavity

• Most (95%) develop in the uterine tube - aka tubal pregnancy

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Placenta previa:

• implantation close to the internal os

  • growing placenta may later bridge the opening

• results in hemorrhaging late in pregnancy

Describe the Ovary:

• Ligaments

Ovaries:

• gonad and endocrine gland

• Ligaments:

  • Mesovarium:

    • from the posterior lamina

    • ovarian cancer can metastasize directly into peritoneal cavity

  • Ligament of the ovary

    • attached to uterus

  • Suspensory ligament

    • Connects to posterior abdominal wall

      • Contains NVL

Describe:

• Salpingitis

• tubal ligation

• Salpingectomy & oophorectomy

• Ovarian cancer

Salpingitis:

• Inflammation of fallopian tubes

  • May be come obstructed

  • increases risk of infertily or ectopic pregnancy

  • Secondary to:

    • STDs/ abdominal infections

Tubal Ligation:

• surgical ligation of uterine tubes to prevent spermatozoa to reach ampula

Salpingectomy & oophorectomy

• surgical removal of uterine tubes & ovaries, respectively

Ovarian Cancer:

• can spread via blood & lymphatics and can metastazise directly into peritoneal cavity

Describe the NVL of femal internal organs

Blood supply:

• Ovaries: ovarian a. & v.

  • right ovarian vein drains to the IVC, but the left ovarian vein drains into the left renal vein

• Uterus: uterine a. & v.

  • anastomoses with ovarian and vaginal arteries;

  • vaginal artery often branches from the uterine artery

• Tubes: tubal br of ovarian a. & v. & ascending br of uterine a & v.

• Upper vagina: vaginal a. & v.

• Lower vagina in perineum: internal pudendal a. & v.

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Lymphatics:

• Ovaries: lateral aortic nodes

• Uterus, tubes & upper vagina: internal iliac nodes

• Lower vagina in perineum: superficial inguinal nodes

• Some lymph vessels follow the round ligament of the uterus from the uterus to the labium majus, which then drains to superficial inguinal nodes.

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Nerves:

Plexuses

• Ovarian plexus associated with ovaries (periarterial plexus follows ovarian vessels )

• uterovaginal plexus associated with uterus, tubes & vagina

contains

• Sympathetic fibers (T11-L2)

• Parasympathetic fibers (S2-4)

• GVA fibers

  • Above pain line, travel with sympathetic fibers: ovaries, uterine tubes, body of uterus

  • Below pain line, travel with parasympathetics fibers: cervix, upper vagina

  • Other visceral sensations with parasympathetic fibers

Describe the three methods of Anesthesia during delivery

1. Spinal block via lumbar puncture in subarachnoid space (L3-4)

   • From waist down

   • Sensory block // visceral (GVA at both lumbar L1,2 and sacral S2-4 levels) & somatic (GSA) from L1 to Co levels

   • Perineum, pelvic floor, upper vagina, uterine cervix, body of uterus / no sensation of uterine contraction

   • Also motor & sensory functions of lower limbs

2. Epidural block via catheter into epidural space (L3-4)

   • has replaced caudal epidural block via sacral hiatus (arrow) that had similar action

   • Sensory block / / visceral (GVA S2-4) & somatic (GSA L4-Co)

   • Perineum, pelvic floor, upper vagina, uterine cervix

3. Pudendal nerve block via local injection in tissues surrounding nerve (more in perineum lecture)

   • Sensory block, somatic (GSA S2-4 level)

   • Perineum including lower vagina

Describe the Sympathetic & parasympathetic innervation of female internal genital organs

Gestation & delivery: under hormonal control

Female sex response

• Parasympathetic

  • Arousal

    • Dilation of upper vagina

    • Vaginal “sweating” (transudate from blood vessels)

• Sympathetic

  • orgasm: increase uterus contraction (induced by oxytocin) that may have a role in sperm transport to uterine tubes

  • Resolution: tissues return to pre-arousal state