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Anatomy teaching Session 7 GU anatomy and RadiologyDisclaimer • The following presentation has been made for students by students and we are not held accountable for any inaccuracies. This is a learning tool that has not been reviewed by the University of Sheffield and therefore the use of this session is to facilitate your learning only. Aims and objectives • Identify the adrenal glands, their arterial supply and venous drainage, and understand their function. • Identify the kidneys, their internal features, arterial supply, and venous drainage. • Identify the ureters and the parts of the bladder, describe their functions and innervation. • Understand the anatomical structures and nerves involved in the control of micturition. • Identify the large muscles of the posterior abdominal wall. • Identify the abdominal aorta and inferior vena cava and their main branches as they pass along the posterior abdominal wall. • Identify the individual bones that make up the pelvis, the joints of the pelvis and the bony landmarks that can be identified on palpation. • Identify the muscles of the pelvic floor and understand their role. • Name the major arteries, veins and nerves of the pelvis and perineum. • Locate the rectum. Describe its blood supply and innervation. • Understand the location, boundaries, and contents of the perineum. • Know the boundaries and contents of the urogenital triangle. • Know the boundaries and contents of the anal triangle. • Locate the anal canal. Describe its blood supply and innervation. • Understand the importance of the perineal body. • Recap the muscles of the anterior abdominal wall and the boundaries of the inguinal canal. • Know the contents of the inguinal canal in males and females and the contents of the spermatic cord in males. • Identify the contents of the scrotum including the testis, epididymis and vas deferens. • Identify the individual parts of the penis and understand their specific functions, including which anatomical structures contribute to penile erection. • Know the blood supply and innervation of the penis. • Identify the male pelvic organs. Understand their structure and functions. • Know the course that sperm takes during ejaculation. • Understand how Radiology is used in practice for GU conditions. Highlighted the important ones Adrenal glands • Superior adrenal artery - a branch of the inferior phrenic artery • Middle adrenal artery - a branch of the abdominal aorta T12 • Inferior adrenal artery - a branch of the renal artery. handbook Kidneys and bladder Kidneys: Extra and retro peritoneal. • The ureters carry urine to the urinary bladder. • They run anterior to psoas major. • The bladder wall contains smooth muscle known as the detrusor which contracts to forcibly expel urine. https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-urinary-system • The ureters join the posterior aspect of the bladder near the base. • This triangular area of the bladder has a smooth internal wall and is called the trigone. • The rest of the inside wall of the bladder is corrugated with folds of mucosa called rugae. • What is the function of the rugae? • Is urination stimulated by sympathetic or parasympathetic nerves? https://www.notesforshs.com/2023/04/the-female-urinary-tract.htmlWhich one of the following arteries arises from above L1? • A) Renal artery • B) inferior adrenal artery • C) Superior adrenal artery • D) inferior mesenteric arteryWhich one of the following arteries arises from above L1? • A) Renal artery L1 • B) inferior adrenal artery L1 from renal • C) Superior adrenal artery • D) inferior mesenteric artery L3What vertebral level does the kidneys correspond to? • A)T12-L3 • B)T10—L1 • C)L1-L4 • D)T10-L2What vertebral level does the kidneys correspond to? • A)T12-L3 • B)T10—L1 • C)L1-L4 • D)T10-L2 Innervations of the bladder So is urinating stimulated via parasympathetic or sympathetic nerves? HandbookWhich one of the followings about the bladder is correct? • A) The parasympathetic nerves innervating the bladder originate from L2-L4 • B) The descending pathway from the brain can override the parasympathetic signals to the bladder. • C) Pudendal nerve innervates the bladder and provides sympathetic signals. • D) The bladder is innervated by the peri prostatic nervous plexusWhich one of the followings about the bladder is correct? • A) The parasympathetic nerves innervating the bladder originate from L2-L4 S2-S4 • B) The descending pathway from the brain can override the parasympathetic signals to the bladder. • C) Pudendal nerve innervates the bladder and provides sympathetic signals. Somatic • D) The bladder is innervated by the peri prostatic nervous plexus • Penis supply Abdominal wall Lumbar nerves: • Iliohypogastric and ilioinguinal nerves - supply the anterior abdominal wall muscles and skin of the external genitalia. • Genitofemoral nerve - supplies the skin of the external genitalia. • Lateral femoral cutaneous nerve - this nerve unsurprisingly supplies the skin over the lateral thigh. • Femoral nerve - this large nerve supplies the muscles and skin of the anterior thigh. • Obturator nerve - this nerve supplies the muscles and skin of the medial thigh. • The thoracic aorta pierces the diaphragm at the level of the T12 vertebra and descends through the abdomen as the abdominal aorta. Abdominal Aorta: • Bifurcating into the left and right common iliac arteries at approximately the level of L4. • The abdominal aorta gives rise to several unpaired and paired branches. • Recall that the coeliac trunk, superior mesenteric artery, and inferior mesenteric artery are unpaired branches. Important and common exam question • Paired branches include the renal, adrenal, gonadal, and lumbar arteries • The inferior vena cava is formed by the union of the left and right common iliac veins at approximately the level of L5. • The inferior vena cava also receives the hepatic veins before passing through the diaphragm at the level of T8. Pelvis 1 • ischium and pubis.mposed of three smaller bones that fuse together: the ilium, • Hip joint - between the head of the femur and the acetabulum (socket) of the pelvis. • The ilium, ischium, and pubis of the hip bone fuse at the acetabulum. 3 • Sacroiliac joint – between the sacrum and the ilium of the hip bone.. 2 • Pubic symphysis – between the two pubic bones at the front of the pelvis. Lumbosacral joint – between the 5th lumbar vertebra and the sacrum Sacrococcygeal joint – between the sacrum and the coccyx. • Iliac crest • Anterior superior iliac spine (ASIS) - this is the most anterior point of the ilium • most lateral point of the ilium. A line drawn between the iliac tubercles (the ‘intertubercular line’) • Pubic tubercle • Inguinal ligament - runs from the anterior superior iliac spine to the pubic tubercle. • Mid-inguinal point - the mid-point of a line drawn from the anterior superior iliac spine to the pubic symphysis (not the pubic tubercle). The femoral artery is palpable here. Good to know and an easy MCQ but might not come up. https://www.researchgate.net/figure/Anatomy-of-the-pelvis-a-Anterior-view-b-Lateral-view-c-Medial-view-Orange_fig26_344162076 Pelvic Floor • TLevator ani is itself composed of three smaller paired muscles:coccygeus. • Puborectalis - this U-shaped muscle attaches to the pubic bones anteriorly and forms a sling around the rectum. • Puborectalis is the most anterior levator ani muscle. • Pubococcygeus - It attaches to the pubic bone anteriorly, and the coccyx and sacrum posteriorly. • Iliococcygeus - Its name is slightly misleading, as it attaches to the spines of the ischium (not the ilium) and the coccyx. • Levator ani is innervated by a branch by some branches of the pudendal nerve. HandbookPatient has had an accident and injured their hip bone. Which of the following sections of the pelvis is damaged? • A) Anterior superior iliac spine • B) Posterior superior iliac spine • C) Pelvic brim • D) Iliac crestPatient has had an accident and injured their hip bone. Which of the following sections of the pelvis is damaged? • A) Anterior superior iliac spine • B) Posterior superior iliac spine • C) Pelvic brim • D) Iliac crest Don’t need to know their positions. This picture is to help you visualize it. Iliac artery • Key branches of the internal iliac arteries are the: • Vesical arteries - supply the bladder in both sexes, and the prostate and seminal vesicles in males. • Uterine and vaginal arteries in females. • Middle rectal artery - supplies the rectum. • Internal pudendal artery - exits the pelvis to supply the perineum. • Superior and inferior gluteal arteries - exit the pelvis to supply the gluteal region. • Obturator artery – exits the pelvis to supply the lower limb. https://ditki.com/course/gross-anatomy/glossary/gross-anatomic-microscopic-structure/arteries-internal-iliac-branches Nerves and the perineum • Sciatic nerve - formed by the lower lumbar and sacral spinal nerves L4 - S3. It exits the pelvis and supplies the lower limb.. • Pudendal nerve – this somatic nerve is derived from spinal nerves S2 - S4. It exits the pelvis and is the major nerve of the perineum. • Superior and inferior gluteal nerves - these nerves exit the pelvis and innervate the gluteal region. • Pelvic splanchnic nerves – these nerves carry parasympathetic fibres from the S2 - S4 spinal cord segments to the pelvic viscera. • Viewed from below, the perineum is roughly diamond-shaped and can be split into two triangles : • The urogenital triangle (anteriorly) - this area is complicated and has several layers. • The anal triangle (posteriorly) - contains the anus and the external anal sphincter. handbook Inguinal canal Two nerves: • Genital branch of the genitofemoral nerve • Sympathetic nerve fibres • Three arteries: • Testicular artery • Cremasteric artery • Artery to the vas deferens Three fascial layers: • External spermatic fascia (derived from the external oblique aponeurosis) https://oscestop.education/learning/inguinal-hernias/ • Cremaster muscle and fascia (derived from the internal oblique muscle) • Internal spermatic fascia (derived from the transversalis fascia) • Four other structures: • Pampiniform venous plexus • Lymphatics • Vas deferens (plural: vasa deferentia) • Processus vaginalis (derived from the peritoneum). https://www.kayawell.com/health-conditions-diseases/inguinal-hernia Male genitalia • The epididymis is a coiled tube lying along the posterior border of each testis. • Spermatozoa are formed in the testis and stored in the epididymis. • The vas deferens carries sperm from the epididymis and travels with the testicular vessels in the spermatic cord. • The testicular arteries are direct branches of the abdominal aorta. • Venous blood from the testis and epididymis enters the pampiniform venous plexus. The pampiniform venous plexus forms the testicular vein. • The right testicular vein enters the inferior vena cava. The left testicular vein joins the left renal vein. The penis is composed of three cylinders of erectile tissue: two corpora cavernosa dorsally (along the ‘top’ of the penis) and one corpus spongiosum ventrally (along the ‘bottom’ of the penis). The end of the penis is called the glans and is an expansion of the corpus spongiosum. The circular base of the glans is called the corona. Anatomy handbook Penile anatomy The corpora cavernosa are covered by the ischiocavernosus muscles, and the corpus spongiosum is covered by the bulbospongiosus muscle. Ischiocavernosus forces blood into the body of the penis from the crura. Bulbospongiosus forces blood into the glans penis, assists in maintaining erection by compressing the veins that drain erectile tissues and it contracts to squeeze any remaining urine or semen from the urethra. • The arterial supply to the penis is via the internal pudendal arteries • The nerve supply to the penis is from the S2-S4 nerves. • Both general sensation and sympathetic • nerve. Parasympathetic nerve fibres (responsible for causing erection by dilating the arteries of the corpora) arise from the peri-prostatic nerve plexus. Anatomy handbook Identify from the picture What anatomical plane is this? What is this organ? HandbookVulva Highlighted the important ones. https://theconversation.com/four-things-you-need-to-know-about-your-s-vagina-s-vulva-211395 Clitoris and the muscles Know that these structures exist it can be in the SBA but functions don’t matter as such. Handbook Structures in the pelvis • Ovary - The ovaries are almond-shaped organs about 4cm long and 2cm wide. They are attached to the posterior aspect of the broad ligament by a short mesentery; the mesovarium. • Uterus - The pear-shaped uterus is a hollow muscular organ. It communicates laterally with the uterine tubes and inferiorly with the vagina. The uterus has a fundus, a body and a cervix. • Uterine tubes (Fallopian tubes) – Know that fertilisation of the egg occurs here. Common question. • Cervix - The cervix has a narrow lumen, the cervical canal. • All these structures receive arterial blood via branches of the internal iliac artery, except the ovary which is supplied by the ovarian artery that comes from abdominal aorta. Female pelvic organs How is this different from the male organs? What is this arrow pointing to? Handbook Case • Interactive Radiology Case: Acetabular Fracture • Case Presentation: • A 25-year-old male presents to the emergency department following a high-speed motor vehicle accident. He complains of severe pain in his right hip and inability to bear weight on the leg. On examination, there is noticeable swelling and bruising around the hip, with limited range of motion. • You’re given the following imaging: • Pelvis X-ray (AP view): Shows disruption of the pelvic ring with abnormal orientation of the acetabulum. • CT Scan: Clearly delineates a posterior wall acetabular fracture with slight displacement. • Questions: • 1. What is the acetabulum, and why is it clinically important? • 2. What are the common mechanisms of acetabular fractures? • 3. What key radiological signs should you look for on an X-ray? • 4. How does CT help in this case? • 5. What are the treatment options for an acetabular fracture? • Follow-up Question: • What are potential long-term complications of untreated or poorly managed acetabular fractures? • (Think about joint degeneration and mobility issues!) https://ota.org/for-patients/find-info-body-part/4187#/+/0/score,date_na_dt/desc/Answer • 1. What is the acetabulum, and why is it clinically important? • • Answer: The acetabulum is the cup-shaped socket of the hip joint that articulates with the femoral head. It is crucial for weight-bearing and mobility. • 2. What are the common mechanisms of acetabular fractures? • • Answer: High-energy trauma, such as motor vehicle accidents or falls from a significant height. Posterior wall fractures are commonly associated with dashboard injuries. • 3. What key radiological signs should you look for on an X-ray? • • Look for: • • Disruption of the iliopectineal or ilioischial lines (indicative of acetabular fractures). • • Posterior wall fragment displacement. • • Widening of the joint space. • 4. How does CT help in this case? • • Answer: CT provides detailed visualization of fracture patterns, displacement, and intra-articular fragments that may not be visible on plain X-rays. • 5. What are the treatment options for an acetabular fracture? • • Answer: • • Non-operative: For non-displaced or minimally displaced fractures with intact joint congruency. • • Operative: Open reduction and internal fixation (ORIF) for displaced fractures, especially those involving the posterior wall. Which of the following structures transports sperm from epididymis to the ejaculatory duct? A) Fallopian tube B) Rete Testis C) Pampiniform plexus D) Vas Deferens Which of the following structures transports sperm from epididymis to the ejaculatory duct? A) Fallopian tube B) Rete Testis C) Pampiniform plexus D) Vas DeferensAt what vertebral level does the inferior Vena Cava form from joining of the iliac veins? A) L3 B) L4 C) L5 D) L6At what vertebral level does the inferior Vena Cava form from joining of the iliac veins? A) L3 B) L4 This is where the iliac arteries form which is slightly higher C) L5 D) L6A patient has Polycystic kidney disease which has obstructed their loop of Henle. Which part of the Kidney is the loop of Henle located in? A) Cortex B) Medulla C) Pelvis D) Renal fasciaA patient has Polycystic kidney disease which has obstructed their loop of Henle. Which part of the Kidney is the loop of Henle located in? A) Cortex B) Medulla Most structures except for PCT and distal tubules are in the medulla. C) Pelvis D) Renal fascia What is the arrow pointing to? A) Iliac Crest B) Ischium C) Pubis D) ASIS What is the arrow pointing to? A) Iliac Crest B) Ischium C) Pubis D) ASISWhich one of the following is a branch of the sacral plexus? • Iliohypogastric and ilioinguinal nerves • Pudendal nerve • Femoral nerve • Obturator nerveWhich one of the following is a branch of the sacral plexus? • Iliohypogastric and ilioinguinal nerves • Pudendal nerve • Femoral nerve • Obturator nerve • The rest are from the lumbar plexus.Thanks for listening Session 7 psanikhani1@Sheffield.ac.ukReferences • Anatomy handbook. University of Sheffield. School of medicine and population health. Genitourinary anatomy. • https://www.hopkinsmedicine.org/health/wellness-and-prevention/anatomy-of-the-urinary-system • https://www.notesforshs.com/2023/04/the-female-urinary-tract.html • https://www.researchgate.net/figure/Anatomy-of-the-pelvis-a-Anterior-view-b-Lateral-view-c-Medial-view-Orange_fig26_344162076 • https://ditki.com/course/gross-anatomy/glossary/gross-anatomic-microscopic-structure/arteries-internal-iliac-branches • https://oscestop.education/learning/inguinal-hernias/ • https://www.kayawell.com/health-conditions-diseases/inguinal-hernia • https://theconversation.com/four-things-you-need-to-know-about-your-s-vagina-s-vulva-211395 • https://ota.org/for-patients/find-info-body-part/4187#/+/0/score,date_na_dt/desc/