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Urogenital Anatomy Urinary T ract Consists of: • Paired kidneys, ureters, urinary bladder and urethra • Urine produced in kidneys and drains through the ureters to the urinary bladder, located in the pelvis, for storage. • Eliminated through the urethra Kidneys Reddish brown bean shaped organs that lie in the posterior abdomen Function: • Excrete most of the waste products of metabolism • Role in water and electrolyte balance • Maintain acid-base balance of blood Location • Retroperitoneal • Either side of vertebral column • Level T12-L3 • Right slightly lower than left • Enclosed in several layers of fascia and fat• Smooth anterior and posterior surface covered by a fibrous capsule • Hilum –renal vein, renal artery, ureter, lymphatics, sympathetic fibres • Entrance to the renal sinus Internal Structure 1) Renal Cortex • Outer most layer • Contains about 1 million nephrons 2)Renal Medulla • Middle layer • Divided into Renal pyramids –striated due to parallel bundles of ducts carrying urine from nephrons • Renal columns- areas between the pyramids • Extensions of cortex that provide and route for blood vessels and nerves 3)Renal Pelvis • Funnel Shaped • 2/3 Major calises unite to form the renal pelvis • Collects urine from pyramids • Conveys to ureter to go to urinary bladderRenal Vasculature Abdominal Aorta Renal Artery (L2) Segmental Arteries Lobar Arteries Interlobar Arteries Arcuate Arteries Interlobular Arteries Afferent ArteriolesVenous Drainage • Several renal veins unite to form right and left renal veins • Empty directly into the Inferior Vena Cava • Left renal vein longer • Lateral aortic lymph nodes – located at the origin of the renal arteries • Muscular tubes extending from kidneys to urinary bladder Ureters • Urine propelled by peristaltic contractions of muscle Route • Arise from the renal pelvis • Uteropelvic junction – point where renal pelvis narrows to form the ureter • Descend along anterior surface of psoas major • Cross the bifurcation of common iliac artery • Enters the lateral angle of the bladder 3 Points of Constriction 1) Uteropelvic junction 2) Crossing the common iliac vessels 3) Point of entry into wall of the bladder Kidney stones can become lodged at these constrictions Ureter Stones • Caliculi composed of salts of inorganic or organic acids • May form and become lodges in calicies of kidneys, ureters or urinary bladder • Renal calculus may pass from kidney – renal pelvis-ureter • Stone larger than lumen – ureteric colic, obstruction of urinary flow 1) Uteropelvic junction 2) Crossing the common iliac vessels 3) Point of entry into wall of the bladder Referred pain • Renal pelvis an ureters innervated by T11-L2 • Renal colic – strong peristaltic waves of contraction down the ureter, causes spasm of smooth muscles • Agonising colicky Pain • Referred pain – flank, loin and groin Kidney T ransplant • Usual site for a kidney transplant is at the iliac fossa on the posterior abdominal wall • Iliac fossa exposed through an incision just above the inguinal ligament • Renal artery is anastomosed to the internal iliac artery • Real vein is anastomosed to the external iliac vein • Sufficient anastomosis so that the pelvic viscera are not at risk The Urinary Bladder • Hollow viscus that acts as a reservoir for urine • Sits immediately behind the pubic bones Pyramidal when empty : • Apex – points towards pubis symphysis, connects to umbilicus by median umbilical ligament • Fundus- formed by convex posterior wall , opposite apex, related to anterior wall of vagina • Body – major portion of the bladder • Neck- lies inferiorly , on upper surface of prostate in males Internal structure • Detrusor muscle – muscular coat composed of smooth muscle • Internal Urethral sphincter –in male bladder, contracts during ejaculation Ureters • Internal urethral orifice – opening of bladder into urethra • Open at the superior angles of the trigone • Mucous membrane folded when bladder is empty • Pierce bladder wall obliquely • Trigone – triangular smooth area of mucous membrane • Provides valvelike action – prevents reverse flow of urinePelvic Floor Pelvic Diaphragm Function Coccygeus • Support abdominopelvic viscera - Arise from lateral aspect of sacrum • Resist increases in intrabdominal pressure - Attaches to sacrospinous ligament • Maintaining urinary and faecal continence - Smaller, posterior part of pelvic diaphragm Levator Ani • Larger more anterior part • Attaches to body of pubis, tendinous arch of obturator fascia, ischial spine • Contracted most of the time – support viscera, maintain continence 3 Parts 1) Puborectalis 2) Pubococcygeus 3) Iliococcygeus Penetrated centrally by anal canal Urogenital hiatus – anterior gap between medial boarders of Levator ani Gives passage to urethra, and in females, the vaginaMale PelvisSpermatic Cord 3 layers of Fascia 3 Nerves • External spermatic • Nerve to cremaster • Cremasteric • Sympathetic fibres • Internal spermatic • Genital branch of genitofemoral n. 3 Arteries 3 Other Structures • Testicular artery • Vas deferens • Cremasteric Artery • Pampiniform plexus • Artery of the Vas • Lymphatics Outpouching containing testes, epididymides and lower ends of Scrotum spermatic cord Skin • Thin, wrinkled and pigmented • Dartos muscle attached to skin Temperature regulation • Spermatogenesis occurs one degree cooler than core body temperature • Cremaster muscle – draws testis superiorly, close to body • Dartos muscle - wrinkles skin, reducing surface area • Pampiniform plexus – counter currant heat exchanger cools arterial blood Testis • Firm, mobile organ lying within the scrotum • Left testis usually lower than right • Surrounded by tunica albuginea Internal • Divided by fibrous septa into lobules • Each lobule – 2/3 seminiferous tubules • Rete testis – tubules open into network of channels • Connected to epididymis by efferent ductules Vasculature Epididymis Arterial • Testicular artery (abdominal aorta) • Distinct head, body and tail Venous • Posterior to testis • Much coiled long tube • Testicular veins emerge as pampiniform plexus • Embedded in connective tissue • Reduced to single vein in inguinal canal • Right T. vein – drains into IVC • Stores spermatozoa and allows for maturation • Left T. vein – drains into left renal vein • Emerges from tail as Vas deferens – enters spermatic cord Varicocele • Condition where the veins of the pampiniform plexus are elongated and dilated • Results from defective valves in testicular veins • Usually only visible when standing, disappears when man lies down • Common in adolescents and young adults • Palpation – bag of worms • Right testicular vein joins IVC • Left testicular vein joins left renal vein – higher pressure, tighter angle • Left more susceptible to obstruction or reversal of flowVas Deferens • Thick-walled tube • Conveys sperm from epididymis to ejaculatory duct • Arises from tail of epididymis • Passes through inguinal canal – emerging from deep inguinal ring • Ampulla of vas deferens – dilated terminal part • Joins duct of seminal vesicle to form ejaculatory duct Seminal Vesicles • 2 lobulated organs that lie on the base of the bladder • Produce a nourishing secretion that’s added to seminal fluid • Coiled tubes surrounded by connective tissue • Terminal Vas deferens lies on medial side Ejaculatory Ducts • Inferior end of ampulla of Vas Deferens narrows • Joins duct of seminal vesicle • Pierce the posterior part of prostate • Open into prostatic part of urethra Divided into 5 Lobes 1) Anterior lobe • No glandular tissue 2)Middle lobe • Rich in glands • Fibromuscular glandular organ 3)Posterior lobe • Surrounds prostatic urethra • Behind urethra, contains glands • Fibrous capsule 4&5) Right and left lateral lobes • 2 ejaculatory ducts – pierce upper posterior surface, open into urethra • Separated by shallow vertical groove on posterior surface Function • Contains glands • Produces think, milky fluid containing – citric acid, phosphatase acid • Added to seminal fluid • Helps neutralise acidity in vagina Benign Prostatic Hypertrophy (BPH) • Common after middle age • Enlargement of the prostate • Impedes urination by distorting the prostatic urethra • Middle lobule enlarges the most • Causes – nocturia, dysuria and urgency • Increases risk of cystitis and kidney damage • Examination by digital rectal exam Prostatic Urethra • Continuation of bladder neck • Passes through prostate • Receives ejaculatory and prostatic ducts • Widest part Membranous part • Passes through pelvic floor • Surrounded by external urethral sphincter • Narrowest part Penile Urethra • Passes through bulb and corpus spongiosum of penis • Ends at external urethral meatus Function Penis • Sexual intercourse • Micturition 3 parts • Root • Body • Glans Anatomical position – penis is erect • The dorsal side - closest to the abdomen, • The ventral side -closest to the testes Root Bulb • Most proximal fixed part • 3 erectile tissues – Bulb, Left and right crura • Bulb – continues to form corpus spongiosum • Crura – continue to form corpora cavernosa Crus Muscles • Bulbospongiosus muscle – covers exterior of bulb • Ischiocavernosus muscle – covers exterior of crus Body Glans • 3 cylindrical bodies of erectile tissue Corpus • Formed by distal expansion of • Corpora Cavernosa – paired, dorsal surface spongiosum • Corpus spongiosum – ventral surface corpus spongiosum • Contained in Buck’s Fascia • External urethral meatus- opening or urethra Corpus • Prepuce - foreskin Suspensory ligament Cavernosa • Supports body of the penis • Linea alba and pubis symphysis – fascia of the penisNeurovasculature Arterial Supply Branches of the internal pudendal artery • Deep artery – crus and corpus cavernosa (paired vessel) • Travels through centre of corpus cavernosum • Dorsal Artery - corpus cavernosa, corpus spongiosum and spongy urethra • On dorsal aspect, deep to the deep fascia • Artery of bulb of penis – bulb and penile urethra Venous Drainage • Venous plexus that drain to the Deep dorsal vein of the penis • Skin and superficial tissue – superficial dorsal veins Innervation • S2-S4 • Dorsal nerve of penis – sensory and sympathetic • Branch of pudendal nerve • Inferior hypogastric plexus – autonomic fibres and smooth muscleFemale Pelvis Ovary Function • Produce female germ cells – ova • Produce female sex hormones – oestrogen and progesterone Location • Ovaria fossa – depression in the lateral wall of the pelvis • Bounded by external iliac above and internal iliac vessels behind Before puberty • Ovary is smooth Structure • Surface is simple cuboidal epithelium – germinal After Puberty epithelium • Ovary becomes progressively more scarred due to repeated • Tunica albuginea – dense connective tissue capsule rupture of ovarian follicles and discharge of oocytes during ovulation • Cortex – ovarian follicles reside • Medulla – rich neurovascular network Menopause • Becomes shrunken and its surface pitted with scarsUterine T ubes Infundibulum • Funnel shaped distal end • Fimbriae – finger lie processes that spread over ovary Ampulla • Widest and longest part • Usually site of fertilisation Isthmus • Thick walled • Enters uterine horn Uterine Part • Short segment • Passes through walls of uterus • Opens into uterine cavityOvary and Uterine tubes Blood supply • Ovarian Artery – A. Aorta (L1) • Ovarian vein - Right: Inferior Vena Cava - Left: Left Renal Vein Ligaments • Ligament of the ovary- connects ovary to body of the uterus • Round ligament - connects to cornu of uterus • Suspensory ligament of ovary – contains ovarian vessels, lymphatics and nerves • Broad ligament – attached to anterior surface of ovaryEctopic T ubal Pregnancy • Blastocyte implants in the mucosa of the uterine tube • Ampulla – most common site • May result in rupture of uterine tube – severe haemorrhage into abdomino - pelvic cavity • Life threatening if not caught early • Misdiagnosed as appendicitis • Appendix lies close to ovary and uterine tube • Both cause right lower quadrant pain and peritonitis Uterus Walls Perimetrium • Outer serous coat of peritoneum Fundus • Surrounds supravaginal cervix • Lies above the entrance of uterine Myometrium tubes • Thick wall of smooth muscle supported Body by connective tissue • Superior 2/3 Endometrium • Lies between layers of broad ligament • Mucous membrane lining the body • Continuous with mucous membrane Cervix lining uterine tubes and cervix • Cylindrical inferior 1/3 • Firmly adhered to myometrium • Isthmus – demarcates body from • Actively involved in menstrual cycle cervixBlood supply Uterine Position • Uterine artery (internal iliac artery ) • Anteversion – anterosuperior in • Runs medially in base of broad ligament, crosses relation to axis of vagina ureters to supply cervix, ascends laterally in b. • Anteflexion – flexed relative to ligament cervix • Ends by anastomosing with ovarian artery • Uterine vein – follows the artery Relations • Drains in internal iliac Anteriorly Cervix • Uterovesical pouch • Supravaginal part • Superior surface of bladder • Vaginal Part Posteriorly • Rectouterine pouch (pouch of Uterine Cavity Douglas) – separates cervix and • Triangular coronal section rectum • Internal os – cervical canal communicates with Laterally • Broad ligament – uterine artery uterine cavity • External os – cervical canal communicated with and vein vagina • Ureters Ligaments Transverse Cervical (Cardinal) Ligaments • Lateral walls of pelvis -Cervix and upper end of the vagina Pubocervical Ligaments • Pubis – cervix Sacrocervical Ligaments • Lower sacrum – cervix and upper vagina Broad ligament • Double layer of peritoneum • Sides of uterus – lateral wall and floor of pelvis Round ligament of the uterus • Superolateral angle of uterus – deep inguinal ring/inguinal canal – labium majus • May help anteflexion and anteversionVagina Location • Extends from cervix to the vaginal orifice (opening at inferior end) • Lies posterior to urinary bladder and urethra • Urethra projects into posterior walls • Lies Anterior to rectum Vaginal Fornix • Recess around the cervix • Anterior & Posterior • Posterior – deeper, closely related to rectouterine pouch Blood Supply • Uterine arteries – superior part • Vaginal and internal pudendal arteries – middle and inferior parts • Vaginal venous plexus- continuous with uterine venous plexus (uterovaginal venous plexus) • Drains into internal iliac veins through uterine vein Vulva • Collective name for female external genitalia Mons pubis • Subcutaneous fat pad • Anterior to pubis symphysis Labia majora • 2 hair bearing external folds Labia minora • 2 hairless folds of skin • Within labia majora • Fuse to form hood of clitoris Vestibule Neurovascular • Space posterior to glans clitoris • Internal and external pudendal arteries • Ilioinguinal n. and genital branch of genitofemoral. – anterior vulva • Contains openings of the vagina, urethra and ducts of vestibular glands • Perineal and posterior femoral cutaneous n. – posterior vulvaClitoris • Female phallic organ • Apex of vestibule Root Vestibular Bulbs • Paired erectile bodies • 2 columns of erectile tissue • Right and left corpora cavernosa • On each side of vestibule • Ichiocavernosus muscles surrounds • Bulbospongiosus muscle covers each each bulb • Inferiorly – attach to perineal • Form the crura of the clitoris Body membrane • Formed by corpora cavernosa joining • Anteriorly – connect to each at level of pubic symphysis other and glans clitoris Glans Clitoris Greater Vestibular glands • Small mass of Erectile tissue • Pair of small mucous secreting glands • Prepuce – partly covers glans • Lie under vestibular bulbs • Epithelium – numerous sensory • Secretion drained into vestibule by small duct endings • Secretes lubricating mucus during sexual intercourseUterine prolapse • When intrabdominal pressure is increase, the normally anteverted and anteflexed uterus is pressed against the bladder • Uterus may assume other positions – excessive anteflexion with retroversion, retroflexion with retroversion • Increased abdominal pressure therefore can push the retroverted uterus into or even through the vagina • Situation is exacerbated in someone with atrophic pelvic floor musclesCervical examination and Pap smear • Vagina is distended with a vagina speculum in the vaginal fornix to enable examination of the cervix • Spatula is placed in the external os and rotated to scrape cellular material from the mucosa of the virginal cervix • Cytobrush inserted into the cervical canal and rotated to gather cellular material from the supravaginal cervix • Placed on glass slide for microscopic examination Manual Examination • Cervix can be palpated with gloved digits in the vagina • Pulsation of the uterine arteries may also be felt through the lateral parts of the fornix • As well as irregularities of the varies – e.g. cystsQuestions A varicoele is an abnormal dilatation of the pampiniform venous plexus within the spermatic cord. It is much more commonly found on the left side. What is the most likely reason for this? (a)The left testicular vein lies behind the external iliac artery and is likely to be compressed by it. (b) The left testicular vein drains into the left renal vein, where it is most likely compressed. (c) The left testicular vein drains directly into the inferior vena cava, where it is most likely compressed by the aorta. (d)The left testicular artery lies anterior to the left testicular vein and compresses it. (e) The left testicular vein lacks valves to prevent back flow, unlike the right testicular veinA varicoele is an abnormal dilatation of the pampiniform venous plexus within the spermatic cord. It is much more commonly found on the left side. What is the most likely reason for this? (a)The left testicular vein lies behind the external iliac artery and is likely to be compressed by it. (b) The left testicular vein drains into the left renal vein, where it is most likely compressed. (c) The left testicular vein drains directly into the inferior vena cava, where it is most likely compressed by the aorta. (d)The left testicular artery lies anterior to the left testicular vein and compresses it. (e) The left testicular vein lacks valves to prevent back flow, unlike the right testicular veinA 60-year-old man is undergoing a right nephrectomy. The surgeons divide the renal artery. At what level does this usually branch off the abdominal aorta A) T9 B) L4 C) T12 D) T10 E) L2A 60-year-old man is undergoing a right nephrectomy. The surgeons divide the renal artery. At what level does this usually branch off the abdominal aorta A) T9 B) L4 C) T12 D) T10 E) L2You are working in the emergency department. A 25-year-old woman comes in with vomiting and abdominal pain. On examination, she is tender on palpation at all lower quadrants of the abdomen. Her temperature is 38ºC. On ultrasound, there is fluid in the rectouterine pouch. What anatomical structure would a needle be passed via to extract this fluid? A) Anterior fornix of the vagina B) Round ligament C) Urethra D) Posterior fornix of the vagina E) BladderYou are working in the emergency department. A 25-year-old woman comes in with vomiting and abdominal pain. On examination, she is tender on palpation at all lower quadrants of the abdomen. Her temperature is 38ºC. On ultrasound, there is fluid in the rectouterine pouch. What anatomical structure would a needle be passed via to extract this fluid? A) Anterior fornix of the vagina B) Round ligament C) Urethra D) Posterior fornix of the vagina E) BladderA 17-year-old woman presents to the Emergency Department with right iliac fossa pain and dizziness, having done a home pregnancy test yesterday which showed a positive result. A diagnosis of ectopic pregnancy is made. In which part of the most likely affected structure does fertilisation most commonly occur? A) Ampulla B) Endometrium C) Infundibulum D) Isthmus E) MyometriumA 17-year-old woman presents to the Emergency Department with right iliac fossa pain and dizziness, having done a home pregnancy test yesterday which showed a positive result. A diagnosis of ectopic pregnancy is made. In which part of the most likely affected structure does fertilisation most commonly occur? A) Ampulla B) Endometrium C) Infundibulum D) Isthmus E) MyometriumA 60-year-old woman attends the GP with symptoms suggestive of a vaginal prolapse. On internal examination, it is found that the uterus has prolapsed into the vagina. What is the normal anatomical position of the uterus? A) Anteverted and retroflexed B) Retroverted and retroflexed C) Anteverted and Anteflexed D) Retroverted and AnteflexedA 60-year-old woman attends the GP with symptoms suggestive of a vaginal prolapse. On internal examination, it is found that the uterus has prolapsed into the vagina. What is the normal anatomical position of the uterus? A) Anteverted and retroflexed B) Retroverted and retroflexed C) Anteverted and Anteflexed D) Retroverted and AnteflexedA 53-year-old man with a chronically infected right kidney is due to undergo a nephrectomy. Which one of the following structures would be encountered first during a posterior approach to the hilum of the right kidney? A) Right Renal Artery B) Ureter C) Inferior Vena Cava D) Right Renal Vein E) Right testicular veinA 53-year-old man with a chronically infected right kidney is due to undergo a nephrectomy. Which one of the following structures would be encountered first during a posterior approach to the hilum of the right kidney? A) Right Renal Artery B) Ureter C) Inferior Vena Cava D) Right Renal Vein E) Right testicular vein