Anatomy Clinical Perineum

Gross Anatomy

Clinical Correlations

Pelvis & Perineum

1. Urethral Catheterization a. Balloon inflated after insertion into bladder to prevent it from sliding out b. Male i. External orifice of glans penis is more narrow, prostatic part is widest ii. Patient lies supine, gentle traction on penis perpendicular to wall, catheter is lubricated iii. Membranous part of urethra may have resistance due to tone of urethral sphincter and surrounding rigid perineal membrane c. Female i. Urethra is shorter, wider, and more dilatable ii. Catheterization is much easier than in males iii. Urethra is straight, and only minor resistance is felt as the catheter passes through the urethral sphincter 2. Cystoscope a. For viewing mucous membrane of the bladder, the two ureteric orifices, and the urethral meatus b. Bladder distended with fluid, illuminated tube introduced through urethra c. Trigone should have smooth, pink mucous membrane d. Ureteric orifices are slitlike and eject a drop of urine per minute e. Interureteric ridge and uvula vesicae can be seen 3. Cystograph a. X-ray study of the bladder with contrast dye b. Can be done with motion (voiding-cystograph) c. Evaluates the bladder for size and contour, the presence of any diverticula, the anatomy of the bladder neck, and the presence of vesicoureteral reflux

d. 4. Ischioanal Abscesses a. Produced by fecal trauma to the anal mucosa b. Infection may gain entrance to the submucosa through a small mucosal lesion, or the abscess may complicate an anal fissure or the infection of an anal mucosal gland c. Abscess is a pocket or pouch of pus (dead white cells) d. Close off fistula and than drain the abscess e. Should be drained via ischioanal fossa

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Gross Anatomy

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f. 5. Circumcision a. Removal of greater part of prepuce (foreskin) b. Metal device (plastibell clamp) put on and incision is made c. Reasons for circumcision include cultural, reducing the spread of HIV/STDs and if there is restriction of the glands d. A clinical (and maybe controversial) reason: i. In many newborn males, the prepuce cannot be retracted over the glans. This can result in infection of the secretions beneath the prepuce, leading to inflammation, swelling, and fibrosis of the prepuce. ii. Repeated inflammation leads to constriction of the orifice of the prepuce (phimosis) with obstruction to urination. iii. It is now generally believed that chronic inflammation of the prepuce predisposes to carcinoma of the glans penis. For these reasons prophylactic circumcision is commonly practiced. 6. Vasectomy a. Birth control method (permanent) for men; ligation of vas deferens b. Procedures include scalpel and non-scalpel (key-hole) c. Procedures are often less than 30 minutes

d. e. Reattachment is not very successful, compared with female procedure 7. Prostatic Enlargement a. Benign version is common for men older than 50 years b. Leakage of urine into prostatic urethra causes reflex desire to micturate c. Micturation is difficult, stream is weak, possible back-pressure on kidneys Version: 09Apr2009

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Gross Anatomy

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d. Enlarged median lobe (of prostate) enlarges uvula vesicae and results in stagnant urine, which becomes infected (cystitis = inflamed bladder)

e. 8. Prostate Cancer a. Can be detected via DRE b. Four stages associated with prostate cancer detection c. PSA (prostate-specific antigen) test is a simple measure of increased protein due to certain prostate diseases, such as cancer i. Just an indicator as other tissues can give a positive test d. Many connections between the prostatic venous plexus and the vertebral veins exist. During coughing and sneezing or abdominal straining, it is possible for prostatic venous blood to flow in a reverse direction and enter the vertebral veins. This explains the frequent occurrence of skeletal metastases in the lower vertebral column and pelvic bones of patients with carcinoma of the prostate. Cancer cells enter the skull via this route by floating up the valve-less prostatic and vertebral veins. 9. Digital Rectal Examination (DRE) a. Anteriorly i. Opposite the terminal phalanx 1. Contents of the rectovesical pouch, the posterior surface of the bladder, the seminal vesicles, and the vasa deferentia 2. Rectouterine pouch, the vagina, and the cervix ii. Opposite the middle phalanx 1. Rectoprostatic fascia and the prostate 2. Urogenital diaphragm and the vagina iii. Opposite the proximal phalanx 1. Perineal body, the urogenital diaphragm, and the bulb of the penis 2. Perineal body and the lower part of the vagina b. Posteriorly i. sacrum, coccyx, and anococcygeal body can be felt. c. Laterally i. Ischiorectal fossae and ischial spines

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Gross Anatomy

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Pelvis & Perineum

d. 10. Varicocele a. Pampiniform plexus (testicles) becomes dilated b. Common in adolescents c. Described as feeling “like a bag of worms” d. Mostly left side due to connection with renal vein vs. right side, which joins with IVC; pressure difference i. If patient supine, varicocele should disappear e. Could be caused by primary kidney disease f. Presents with infertility (plexus not cooling) 11. Distention and Examination of the Vagina a. Anteriorly i. Bladder and urethra b. Posteriorly i. Loops of ileum and the sigmoid colon in the rectouterine peritoneal pouch (pouch of Douglas), the rectal ampulla, and the perineal body c. Laterally i. Ureters, the pelvic fascia and the anterior fibers of the levatores ani muscles, and the urogenital diaphragm

d.

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Gross Anatomy

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e. Distention of vagina i. 0-4 cm: Early Labor ii. 4-8 cm: Active Labor iii. 8-10 cm: Transition iv. 10 cm: Fully Dilated 12. Cervical Examination and Pap Smear a. Speculum is inserted and opened for view of cervix and fornix b. Pap smear for detection of cancerous and precancerous conditions i. Epithelial cells; normal cells and dysplastic (abnormal) cells c. Cervix can also be palpated via DRE on posterior wall

d. 13. Uterine Prolapse a. Uterus held by tone of levatores ani muscles b. Transverse cervical, pubocervical, and sacrocervical ligaments position the cervix within the pelvic cavity c. Damage to these structures or poor muscular tone can result in downward displacement of the uterus d. Most common after menopause e. Always involves some prolapse of the vagina f. Solutions are inflatable pessary, structural surgery, and hysterectomy 14. Cystocele a. Sagging of bladder results in bulging of the anterior wall of the vagina 15. Rectocele a. Ampulla of the rectum sags against the posterior wall of the vagina 16. Hysterectomy (two approaches) a. Surgical removal of the uterus b. Laprotomy technique (open technique); ensures complete removal c. Supracervical technique (through cervix); better healing times i. Through navel or via vaginal canal ii. Ovaries not removed in this procedure (want hormones) 17. Culdocentesis a. For draining a pelvic abscess through the vagina b. Proximity of peritoneal cavity to the posterior vaginal fornix i. Rectouterine pouch

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Gross Anatomy

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c. Also possible to identify blood or pus in the peritoneal cavity by the passage of a needle through the posterior fornix 18. Caudal Epidural Block a. Injection of anesthetics into the sacral canal through the sacral hiatus b. For surgical procedures in the sacral region and childbirth c. Sacral hiatus is palpated midline above the coccyx d. Needle pierces skin, fascia, sacrococcygeal membrane

e. 19. Ligation of Uterine Tubes a. Birth control method (permanent) for women b. Usually restricted to women who already have children c. Ova that are discharged from the ovarian follicles degenerate in the tube proximal to the obstruction d. About 20% success (fertilization) rate upon reattaching tubes 20. Patency of Uterine Tubes a. Hysterosalpingogram i. Contrast injected into uterine cavity ii. Part of basic infertility evaluation

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Gross Anatomy

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21. Episiotomy a. Planned surgical incision when it is obvious (to the obstetrician) that the perineum will tear during birth (e.g. breech and forceps deliveries) b. Incision made through perineal skin in a posterolateral direction to avoid the anal sphincters and perineal body (muscles attached to central tendon)

c. d. Research shows natural tears are less severe 22. Pudendal and Ilioinguinal Nerve Block a. Pudendal i. Second stage of a difficult labor, when the presenting part of the fetus, usually the head, is descending through the vulva, forceps delivery and episiotomy may be necessary ii. Transvaginal (1) and Perineal (2) procedures

iii. iv. Anesthesia of perineum only 1. Rest of the area is covered by ilioinguinal and genitofemoral b. Ilioinguinal i. Anterior part of perineum (uterine contractions the ascend to the spinal cord via sympathetic afferent nerves) c. Dorsal nerve of penis i. For circumcisions; where shaft meets wall Version: 09Apr2009

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ii. 23. Pelvic Laparoscopy a. Incision near/below umbilicus, abdomen filled with carbon dioxide b. Normally under general anesthesia c. Laproscopic camera and instruments inserted to accomplish procedure 24. Pelvic Fractures a. False pelvis fractures occasionally occur due to direct trauma and the upper part of the ilium is seldom displaced b. True pelvis fractures of a “ring” will be stable. Fractures of two “rings” results in instability and displacement i. Anteroposterior compression, lateral compression, or shearing ii. A heavy fall on the greater trochanter of the femur may drive the head of the femur through the floor of the acetabulum into the pelvic cavity c. Fractures of the true pelvis are commonly associated with injuries to the soft pelvic viscera i. May damage urethra due to shearing forces (near urogenital diaphragm) ii. Extraperitoneal rupture (bladder) involves the anterior part of the bladder wall below the level of the peritoneal reflection

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Gross Anatomy

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Pelvis & Perineum

25. Somatic Dysfunction a. Primary pelvic dysfunctions are superior-inferior or abducted-adducted b. Dysfunctions of motion created by the sacrum moving on the ilium are commonly unilateral anterior or posterior sacral dysfunctions i. A unilateral shear of the sacrum along the articulation or oblique rotational sacral dysfunctions ii. If L5 is not involved in the oblique rotation, the dysfunction is called sacral rotation dysfunction iii. If L5 is involved, it is sacral torsion c. Dysfunction created by the ilium moving on the sacrum usually involves anteroposterior ilial rotation or superoinferior ilial shear along the articulation James Lamberg

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