Female

Reproductive block-Anatomy-Lecture

Editing file Color guide : Only in boys slides in Green Only in girls slides in Purple Objectives important in Red Notes in Grey

At the end of the lecture, students should be able to:

● Describe the anatomy of the pelvic wall, bones, & muscles. ● Describe the boundaries and subdivisions of the pelvis. ● Differentiate the different types of the female pelvis. ● Describe the pelvic walls & floor. ● Describe the components & function of the pelvic diaphragm. ● List the arterial & nerve supply. ● List the lymph & venous drainage of the pelvis. Introduction

❖ The bony pelvis is composed of 4 bones, connected by 4 joints and lined by 4 muscles. The bony pelvis with its joints and muscles form a strong basin-shaped structure (with multiple foramina). ❖ The pelvis contains and protects the: 1) Lower parts of the alimentary tract. 2) Urinary tract. 3) Internal organs of reproduction.

Four Bones

1. Two hip bones, which form the anterior & lateral walls. Sacroiliac joints 2. and , which form the posterior wall. Four Joints

1. Anteriorly: pubis (2ry Cartilaginous ). Sacrococcygeal joint 2. Posteriorly: Sacrococcygeal joint (2ry Cartilaginous joint). 3. Posterolaterally: Two Sacroiliac joints (Synovial joints, plain variety). Symphysis pubis

3 The pelvis is divided into two parts by the pelvic brim (inlet). Pelvis ABOVE BELOW

False or greater pelvis True or lesser pelvis (Part of the abdominal cavity) (Has 3 parts)

● It supports the lower 02 03 01 Inlet Outlet abdominal contents, it’s Cavity (Oval/circular shape): (Diamond shape): bounded by: ➢ Anteriorly → Lower part of ● The cavity is a short, ➢ Anteriorly → Symphysis pubis ➢ Anteriorly → Symphysis pubis the anterior abdominal curved canal, with a (lower border). (upper border). wall. shallow anterior wall ➢ Posteriorly → Coccyx. ➢ Posteriorly → Promontory & ➢ and a deeper posterior ➢ Anterolaterally → Ischiopubic Posteriorly → Lumbar ala of sacrum. wall. ramus. vertebrae. ➢ Laterally → Iliopectineal ● It lies between the inlet ➢ Posterolaterally → Sacrotuberous ➢ Laterally → Iliac fossae (arcuate) lines. and the outlet. . and the iliacus muscle. ★ ★ ★

★ ★ ★ ★ ★ ★

4 Main difference between & pelvis In Males:

❖ The Sacrum is usually longer, narrowest and curved. ❖ The promontory and the ischial spines are inverted.

In Females: ❖ The Sacrum is usually wider and shorter. ❖ The Angle of the pubic arch is wider ( 80。- 85。). ❖ The promontory and the ischial spines are less projecting. Female Male

❖ Types of Female Bony Pelvis:

Anthropoid (has both male and female ➔ Android (resembles male pelvis) ➔ characteristics)

➔ Gynecoid (typical female type) ➔ Platypelloid (least common)

❖ Information of the shape and dimensions of the female pelvis is of great importance for obstetrics. Why? ➢ because it is the bony canal through which the child passes during birth. Gynaecoid pelvis: considered the most suitable female pelvic shape for childbirth.

5 Pelvic Walls The pelvis has 4 walls. The walls are formed by bones and that are lined with muscles covered with fascia and parietal peritoneum.

Anterior pelvic wall Posterior pelvic wall very narrow deep & wide

❖ It is the shallowest wall and has no muscles, it’s formed by: ❖ It is large & deeper, formed by: 1) The posterior surfaces of the bodies of the pubic bones. 1) Sacrum.

2) The 2 pubic rami. ★ 2) Coccyx. ★ 3) The symphysis pubis. ★ 3) Piriformis muscles & their covering of partial pelvic fascia. ★

Inferior pelvic wall Lateral pelvic wall ★ (pelvic floor) ★

❖ It is formed by: ❖ Basin-like structure which supports the 1) Part of the below the pelvic viscera and is formed by the pelvic inlet. pelvic diaphragm. It stretches across 2) Obturator internus and its the lower part of the true pelvis and ★ covering & obturator fascia. divides it into: ★ ★ 3) Sacrotuberous ligament. ★ 1) Main (true) pelvic cavity above, which 4) . ★ ★ contains the pelvic viscera. ★ 2) below which carries the external genital organs. 6 Pelvic Muscles (4 Muscles)

01 02 03 04

Piriformis Obturator Internus Levator Ani (part of posterior (part of lateral (wide thin sheet-like muscle Coccygeus pelvic wall) pelvic wall) that has a linear origin)

Muscle 01 Piriformis 02 Obturator Internus ★

● Pelvic surface of the middle 3 sacral ● Inner surface of the obturator Origin vertebrae. membrane and the hip bone.

★ ● It leaves the pelvis through the greater ● It leaves the pelvis through the lesser Insertion sciatic foramen, to be inserted into the sciatic foramen, to be inserted into the Greater trochanter of the femur. Greater trochanter of the femur.

● Nerve to obturator internus (from ● Sacral plexus. ★ Nerve supply sacral plexus) .

★ Action ● Lateral rotator of the femur at the hip joint.

7 Pelvis Diaphragm ★

❖ It is formed by the levator ani and the coccygeus muscles and their covering fasciae. ❖ It is incomplete anteriorly to allow passage of: ★ ★

1) Urethra in males. ★ 2) Urethra and vagina in females. ★

Muscle 03 Levator Ani Muscle 04 Coccygeus

1) Back of the body of the pubis. Origin 2) Tendinous arch of the obturator fascia. Origin ● Ischial spine. 3) Spine of the . Coccygeus muscle has the same ● Its fibers are divided into 3 parts: attachment as the Fibers sacrospinous ➔ Pubococcygeus, Puborectalis & Iliococcygeus. ● Lower end of ligament. Insertion sacrum & Nerve 1) Perineal branch of the 4th sacral nerve (S4) → upper surface. coccyx. supply 2) Perineal branch of the → lower surface.

1) The muscles of the two sides form an efficient muscular sling that Nerve ● branches of the 4th and 5th sacral supports and maintains the pelvic viscera in position. nerves . 2) They resist the rise in intra pelvic pressure during the straining and supply Action expulsive efforts of the abdominal muscles (as in coughing). 3) They have a very important role in maintaining fecal continence ● Assist the levator ani in supporting (puborectalis) by acting as a sphincter at the anorectal junction. Action 4) They serve as a vaginal sphincter in the female. the pelvic viscera.

8

Levatores Ani Muscles (Fibers)

❷

1. Pubococcygeus ❶ 3. Iliococcygeus or (Anterior part) Ischiococcygeus ❸ (Posterior part) ❖ Origin: originates from the posterior surface of the body of the pubis. ❖ Insertion: Inserted into the ❖ Insertion: inserted into the perineal anococcygeal body and the coccyx. body & coccyx. ❖ Origin of Ischiococcygeus: arises ❖ Action: stabilizes the perineal body & from the ischial spine. forms a sling around the prostate or 2. Puborectalis the vagina. (Intermediate part)

Levator prostate: ★ ❖ forms a sling around the recto-anal Junction. 1) Supports prostate. ❖ It has a very important role in maintaining 2) Stabilizes perineal body. fecal continence.

★

Sphincter vaginae: ★ 1) constricts the vagina. Ischiococcygeus ★ 2) Stabilizes perineal body.

★

9 Arterial Supply of the Pelvis

01 Internal iliac artery (IIA): One of the 2 terminal branch of the Common iliac artery. ❖ Course: Arises in front of the → It descends downward & backwards over the pelvic inlet → It divides at the upper border of the greater sciatic foramen into: Anterior & Posterior divisions.

1. Iliolumbar artery Supplies: Posterior abdominal Posterior 2. Lateral Sacral arteries (2 branches) wall, Posterior pelvic wall & Division 3. Superior Gluteal artery Gluteal region. Parietal

1. Obturator artery Supplies: Gluteal region, 2. Perineum, Pelvic viscera, Medial (adductor) region of 1. Umbilical artery: gives the superior vesical artery: the distal part of this artery thigh (by obturator artery), The fibrosed and forms the medial umbilical ligament. fetus (through the umbilical Anterior 2. Inferior Vesical artery in male or vaginal in female: In the male it supplies the arteries). Visceral Division Prostate and the Seminal Vesicles. It also gives the artery of the Vas Deferens. 3. Middle Rectal artery 4. Internal Pudendal artery: It is the main arterial supply to the perineum.

1. Vaginal artery: Replaces the inferior vesical artery. Visceral 2. Uterine artery*: Crosses the Ureter superiorly and supplies the uterus & uterine (Female) tube. * May be wrongly ligated in hysterectomy. = damage to ureter, leading to renal failure.

02 Ovarian artery (in female): Arises from the Abdominal aorta. 10

Supply of the Pelvis

Venous drainage Nerve Supply

❖ Internal iliac veins: Somatic ● It collect tributaries corresponding to the branches of the ❖ Sacral plexus: internal iliac artery. ● from ventral (anterior rami) of L4 & L5 ● joins the external iliac vein in front of the sacroiliac joint to ★ ★ (lumbosacral trunk) + S1, S2, S3 and most of S4. form the common iliac vein (the common iliac veins join at ● It gives pudendal nerve to perineum. the level of L5 to give the inferior vena cava). ❖ Ovarian vein: ★ Autonomic ● Right vein drains into IVC. ❖ Sympathetic (Pelvic part of sympathetic trunk): ● Left vein drains into left renal Vein. ● It is the continuation of the abdominal part of sympathetic trunk. It descends in front of the ala of the sacrum. Lymphatic drainage ● The 2 sympathetic trunks unite inferiorly in front of the coccyx and form a single ganglion (Ganglion Impar). ❖ The lymph nodes and vessels are arranged along ● Superior & Inferior Hypogastric plexuses. the main blood vessels. ❖ Parasympathetic (Pelvic splanchnic nerves): ❖ Thus, there are external iliac nodes, internal ★ ● (From S2, 3 & 4): preganglionic fibers to pelvic iliac nodes, and common iliac nodes. ★ ★ viscera & hindgut. ❖ Lymph from Common iliac nodes & the (Ovaries, uterine tubes & fundus of uterus) passes to Lateral aortic (paraaortic) nodes.

11 Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8

QUIZ C A C D C D B C

Q1: The Sacroiliac joints is: Q5: Which of the following is formed by Sacrotuberous ligament? A. Anterolateral - Cartilaginous joint A. Anterior pelvic wall B. Posteriomedial - Cartilaginous joint B. Posterior pelvic wall C. Posterolateral - C. Lateral pelvic wall D. Anteriomedial - Synovial joint D. Inferior pelvic wall (floor) Q2: The False (greater) pelvis is bounded posteriorly by: Q6: The nerve supply of levator ani muscles: A. Lumbar vertebrae A. Branches of 4th and 5th sacral nerves B. Sacral vertebrae B. Branche 4th sacral nerve C. Iliac fossa & iliacus muscle C. Branch of the pudendal nerve D. Promontory D. Both B & C Q3: Which of the following is false about the INLET of true pelvis? Q7: The relaxation of which of the following muscle fibers leads to defecation? A. It’s part of lesser pelvis A. Pubococcygeus B. It’s bounded anteriorly by Symphysis pubis B. Puborectalis C. It’s bounded posteriorly by Coccyx C. Iliococcygeus D. It’s bounded laterally by Iliopectineal (arcuate) lines D. Coccygeus Q4: Which of the following is female pubic arch angle? Q8: The ovarian artery originated from: A. 45。 A. Uterine artery B. 50。- 60。 B. Vaginal artery C. 70。 C. Abdominal aorta D. 80。- 85。 D. Internal iliac artery 12 Members board Team leaders ● Abdulrahman Shadid ● Ateen Almutairi

Boys team: Girls team:

● Mohammed Al-huqbani ● Ajeed Al Rashoud ● Salman Alagla ● Taif Alotaibi ● Ziyad Al-jofan ● Noura Al Turki ● Ali Aldawood ● Amirah Al-Zahrani ● Khalid Nagshabandi ● Alhanouf Al-haluli ● Sameh nuser ● Sara Al-Abdulkarem ● Abdullah Basamh ● Renad Al Haqbani ● Alwaleed Alsaleh ● Nouf Al Humaidhi ● Mohaned Makkawi ● Jude Al Khalifah ● Abdullah Alghamdi ● Nouf Al Hussaini ● Danah Al Halees ● Rema Al Mutawa ● Maha Al Nahdi ● Razan Al zohaifi ● Ghalia Alnufaei

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