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Reproduction anatomy (Inguinal Canal (Increased intra-abdominal pressure…

- - - - on ea side of the anal canal are large fascia lined, wedge shaped spaces between skin of anal region and pelvic diaphragm
      - Apex of ea fossa lies superiorly where levator ani muscle arises from obturator fascia
      - is wide inferiorly and narrow superiorly, filled with fat and loose CT
      - two ischio-anal fossae communicate by means of deep postanal space over anococcygeal ligament
      - Bounded by
        
        ischium and overlapping inferior part of obturator internus laterally
        
        Medially by external anal sphincter, with a sloping middle wall or roof formed by levator ani
        
        Posteriorly by sacrotuberous ligament and gluteus maximus
        
        Anteriorly by bodies of pubic bones, inferior to origin of puborectalis
  - - - arteries
        
        Superior rectal artery -> superior to pectinate line
        
        Two inferior rectal arteries inferior to pectinateline
      - Veins
        
        superior to pectinate line drains chiefly to superior rectal vein (Inferior mesenteric vein; portal)
        
        Inferior to pectinate line drains to inferior rectal veins -> IVC
    - - Superior to pectinate line is visceral innervation from inferior hypogastric plexus (sympa, parasymp and visceral afferent) from S2-S4 (inferior to pelvic pain line)
      - Inferior to pectinate line is somatic from inferior anal nerves, branches of pudendal nerve
        
        sensitive to pain, touch and temperature
  - - - Median episotomy runs risk of tearing toward the anus, causing sphincter damage or anovaginal fistulae
      - Mediolateral episotomies have lower incidence, circumventing the perineal body and directing the tear away from the anus
    - - fractures of pelvic girdle, especially from separation of pubic symphysis and puboprostatic ligaments often cause rupture of intermediate part of urethra
      - extravasation of urine and blood into deep perineal pouch
      - Perforation of spongy urethra and extravasation of urine is in the bulb of the penis, normally due to forceful blow to the perineum or due to incorrect passage of transurethral catheter that fails to negotiate the angle of urethra in the bulb of the penis
      - Rupture of corpus spongiosum and spongy urethra results in urine passing from it into superficial pouch
    - - fats in ischio-anal fossa are among last fat reserves to be burned with starvation
      - In its absence, no support, rectal prolapse is common
    - - impt landmark, is visible and approximates level of important anatomical changes related to transition from visceral to parietal
    - - internal hemorrhoids
        
        prolapses of rectal mucosa contained the normally dilated veins of the internal rectal venous plexus
        
        Results from a breakdown of muscularis mucosae
        
        Often compressed by the contracted sphincters, impeding blood flow, tend to strangulate and ulcerate
        
        Due to abundant AV anastomoses, bleeding here is bright red
        
        Not painful
      - External hemorrhoids
        
        thromboses in veins of external rectal venous plexus and are covered by skin
        
        predisposing factors: pregnancym chronic constipation, prolonged toilet sitting and straining, or any disorder that impedes venous return
        
        portal hypertension
        
        Painful
- - - - Internal spermatic fascia
        
        from transversalis fascia
      - Cremasteric fascia from investing fascia of both superficial and deep surfaces of internal oblique (by gential branch of gentiofemoral nerve (L1 L2)
        
        reflexively draw testis superiorly in scrotum in response to cold
        
        mainly to regulate temperature of testis for spermatogenesis which requires a constant temp
        
        acts coincidentally with dartos muscle, smooth muscle of fat free subcutaneous tissue of scortum (dartos facia) which contracts skin to same stimuli
      - External spermatic from external oblique aponeurosis and its investing fascia
    - - Vas deferens
      - testicular artery
      - Artery of Vas Deferens
      - cremasteric artery
      - Pampiniform plexus
      - Sympathatic nerve fibers on arteries and vas deferens
      - Genital branch of genitofemoral nerve supplying cremasteric muscle
      - lymphatic vessels
      - Vestige of processus vaginalis
  - - - heavily pigmented skin
      - Closely related dartos fascia
        
        fat free fascial layer including smooth muscle fibers responsible for rugose appearance of scrotum (wrinkled)
      - Septum that separates right to left demarcated by scrotal raphe, the line of fusion of embryonic labio-scrotal swellings
    - - Posterior scrotal branches of perineal artery, branch of internal pudendal artery
      - Anterior scrotal branches of deep external pudendal artery (branch of femoral artery)
      - Cremasteric artery, a branch of inferior epigastric artery
    - - genital branch of genitofemoral nerve: supply anterolateral surface
      - Anterior scrotal nerves, branches of ilio-inguinal nerve supply anterior surface
      - Posterior scrotal nerves, branches of pudendal nerve (S2-S4)
      - Perineal branches of posterior cutaneous nerve of the thigh -> supply postero-inferior surface
  - - - Head:
        superior expanded part composed of lobules formed by coiled ends of 12-14 efferent ductules
      - Body:
        Major part consisting of tightly convoluted duct of epididymis
      - Tail:
        tapering continuation with vas deferens
- - - - From abdominal aorta
      - Testicular: transverse inguinal canal and enter scrotum
        
        Abdominal ureter, testis and epididymis
      - Ovarian: cross pelvic brim and descends in suspensory ligament of ovary
        
        Abdominal and/or pelvic ureter, ampullary end of uterine tube and ovary
    - - Continuation of IMA
      - Cross left common iliac and descends into pelvis between layers of sigmoid mesocolon
      - To superior part of rectum
    - - from |Posterior aspect of abdominal aorta
      - Descends close to midline over L4 to coccyx
      - Supplies inferior lumbar vertebrae, sacrum and coccyx
    - - From common iliac, pass medially over pelvic brim, descends into pelvic cavity, forming anterior and posterior divisions
      - Anterior division of internal iliac
        
        Umbilical
        
        Runs a short pelvic course, gives off superior vesical arteries, then obliterates and form medial umbilical ligament
        
        supplies superior aspect of urinary bladder and vas deferens artery
        
        Superior vesical
        
        to superior aspect of bladder, and in some males, vas deferens
        
        Obturator
        
        antero-inferiorly on obturator fascia of lateral pelciv wall, exit pelvis via obturator canal
        
        Pelvic muscles, nutrient artery to ilium, head of femur and muscles of medial compartment of the thigh
        
        Inferior vesicles (males)
        
        pass subperitoneally in lateral ligament of bladder, give rise to prostatic artery and occasionally vas deferens
        
        Inferior aspect of male bladder, pelvic part of ureter, prostate and seminal glands
        
        Artery to vas deferens (males)
        
        Runs subperitoneally to vas deferens
        
        Prostatic branches (male)
        
        from inferior vesical artery
        
        Descends on posterolateral aspect of prostate
        
        to prostate and prostetic urethra
        
        Uterine (female)
        
        anteromedially in base of broad ligament/ superior cardinal ligament (same thing), gives rise to vaginal artery, then crosses ureter superiorly to reach lateral aspect of uterine cervix
        
        Supplies uterus, ligaments of uterus, medial parts of uterine tube and ovary, superior vagina via vaginal branch~
        
        Vaginal (female)
        
        from uterine artery
        
        Descends to arborize around vagina, passing one or more branches into urinary bladder
        
        supplies vagina, vestibular bulb, and adjacent rectum, to fundus and base of bladder
        
        Internal pudendal
        
        Exits pelvis via greater sciatic foramen inferior to piriformis, enters perineum via lesser sciatic foramen (loops around coccygeus/ sacrospinal ligament) pass via pudendal canal to UG triangle
        
        Supplies as main artery of perineum, including muscles and skin of anal and UG triangles and erectile bodies
        
        Middle rectal
        
        descends in pelvis to inferior part of rectum
        
        Inferior part of rectum, seminal glands and prostate (or vagina)
        
        Inferior gluteal
        
        Exits pelvis via greater sciatic foramen inferior to piriformis
        
        supplies pelvic diaphragm, piriformis, quadratus femoris, superior most hamstring, gluteal maximus and sciatic nerve
      - Posterior division
        
        Iliolumbar
        
        ascend anterior to sacro-iliac joint, posterior to common iliac vessels and psoas major, dividing into iliac and lumbar branches
        
        Supplies psoas major, iliacus, quadratus lumborum, cauda equina and vertebral canal
        
        Lateral sacral
        
        run on anteromedial aspect of piriformis to send branches into pelvic foramina
        
        Supplies piriformis, structures in sacral canal, erector spinar and overlying skin (of the back)
        
        Superior gluteal
        
        pass between lumbosacral trunk and anterior ramus of S1 nerve to exit pelvis via greater sciatic foramen superior to piriformis
        
        Supplies piriformis, all 3 gluteal muscles and tenor sadciae latae
  - - - From anterior rami of L2-L4, enters lesser pelvis
      - runs in extraperitoneal fat along lateral wall of pelvis to the obturator canal
      - As it pass through canal and enters thigh, splits into anterior and posterior parts that supply the medial thigh muscles
      - Dont supply pelvic structures
    - - at or immediately superior to pelvic brim
      - Descending part of L4 unites with anterior ramus of L5 to form a thick, cord like lumbosacral trunk, pass inferiorly on anterior surface of the ala of the sacrum to join the sacral plexus
    - - Sciatic
        
        L4-S3
        
        Articular branches to hipjoint and muscular branches to flexors of the knee in the thigh and all muscles in the leg and foot
      - Pudendal
        
        S2-S4
        
        structures in perineum: sensory branches to external genitalia; muscular branches to perineal branches, external urethral sphincter and external anal sphincter
    - - Sacral sympathetic trunks
        
        provide sympathetic innervation to lower limbs
      - peri-arterial plexus
        
        post synaptic, sympathetic vasomotor fibers to superior rectal, ovarian and internal iliac arteries and their derivative branches
      - hypogastric plexus
        
        most impt route by which sympathetic fibers are conveyed to pelvic viscera
        
        lies inferior to aorta bifurcation, carries fibers conveyed to and from intermesenteric plexus by L3 and L4 splanchnic nerves
        
        superior hypogastric plexus enters pelvis and divides into right and left hypogastric nerves, descend lateral to rectum within hypogastric sheaths and spread in a fan like fashion as they merge with pelvic splanchnic nerves to form right and left inferior hypogastric plexuses (mixed autonomic)
      - Pelvic splanchnic nerves
        
        pathway for parasympathetic innervation of pelvic vescera and descending and sigmoid colon
        
        from S2-S4 (mainly S3)
    - - Visceral afferent fibers conducting superior to pain line follow sympathetic fibers , ascending through hypogastric/aortic plexus to reach cell bodies in inferior thoracic/upper lumbar spinal ganglia (T12-L2)
      - Pelvic pain line: inferior limit of peritoneum
      - Afferent fibers conducting pain from inferior the pelvic pain line follow parasympathetic fiber through pelvic and inferior hypogastric plexus and pelvic splanchnic nerves to reach S2-S4
  - - - Ureter is crossed by uterine artery near the lateral part of fornix of vagina is clinically impt
      - uterine artery dont just pass superior to the ureter, but winds 50% or more of the way around the ureter, passing at least both superior and anterior to the ureter
      - Ureter is in danger of being inadvertently clamped, ligated or transected when the uterine artery is ligated (during hysterectomy)
      - Poiunt at which uterine artery and ureter cross lies approx 2cm superior to ischial spine
    - - structures are close to each other as they cross the pelvic brim
    - - occasionally, internal iliac artery becomes stenotic (lumen narrows) due to atherosclerotic cholesterol deposit
      - Or is surgically ligated to control pelvic hemorrhage
      - Due to numerous anastomses between the artery's branches and adjacent arteries, ligation does not stop blood flow but it does reduce blood pressure, allowing hemostasis to occur (arrest of bleeding)
    - - during childbirth, fetal head may compress nerves of mother's sacral plexus, producing pain in lower limbs
      - Obturator nerve is vulnerable to injury during surgery, and injury may cause painful spasms of adductor muscle of thigh and sensory deficits in medial thigh
      - Injury to nerve to levator ani, including its branches to pubococcygeus and/or puborectalis, due to stretching of nerve during vaginal birth, may result in loss of support of pelvic viscera and urinary or fecal incontinens
- - - - isthmus of prostate lies anterior to the urethra
        
        fibromuscular, with muscle fibers representing a superior continuation of external urethral sphincter
        
        contains little, if any, glandular tissues
      - Right and left lobes of prostate, separated anteriorly by isthmus and posteriorly by a central, shallow longitudinal furrow
        
        Inferoposterior lobule:
        
        posterior to urethra, inferior to ejaculatory ducts
        
        constitutes aspect of prostate palpable by digital rectal examination
        
        Inferolateral lobule:
        
        directly lateral to urethra, form major part of right and left lobe
        
        Superomedial lobule:
        
        deep to inferoposterior lobule, surrounding ipsilateral ejaculatory duct
        
        Anteromedial lobule:
        
        deep to inferolateral lobule, directly lateral to proximal prostatic urethra
  - - - reversible ligation of vas deferens
    - - Benign hypertrophy of prostate (BHP) happens commonly after middle age
      - Middle lobe most affected, cause urethral obstruction
      - Nocturia, dysuria, urgency, increase risk of bladder infections and kidney damage
      - Examined through digital rectal examination
      - Full bladder offers resistance, holding the gland in place and making it more readily palpable
      - Malignant prostate feels hard and irregulat
      - Obstructions can be removed through transurethral equipments (remove part or the whole prostate through TURP: transurethral resection of prostate)
      - TURP and improved open operative techniques attempt to preserve nerves and blood vessels associated with the prostate that pass to the penis, increasing possibility of patients to retain sexual function and normal urinary control
- - - - From supravaginal cervix and lateral parts of fornix to lateral walls of pelvis
    - - pass superiorly and slightly posteriorly from sides of cervix to middle of sacrum
  - - - tubal sterilization
        
        permanent method
        
        removal of uterine tybe or interupting continuity
      - Hysteroscopic sterilization
        
        placement of nickel titanium alloy inserts into openingn of ea uterine tube
        
        Will cause scar tissue formation around the implants, blocking the tubes, takes 3 months to form
    - - Most commonly in the ampulla as that is the site of fertilization
      - can cause ruptured tubal pregnancy, and could be misdiagnosed as acute appendicitis as in both cases, parietal peritoneum is inflamed in the same general area, and pain is referred to RLQ
    - - incomplete dusion of embryonic paramesonephric ducts, from which the uterus is formed
      - Results in variety of congenital anomalies, from formation of unicornuate uterus (receive uterine duct from only R or L) or duplication in form of bicornuate uterus, doubled uterine cavities or a completely doubled uterus
    - - at birth, is relatively large with adult proportions (Body:cervix = 2:1) due to prepartum influence of maternal hormones
      - Several weeks post partum, reverts to childhood proportion 1:1
      - cevix continues to remain relatively large through childhood, mainly an abdominal organ due to small pelvic cavity
      - during puberty, uterus grows rapidly in size till adult proportions 2:1
      - Multiparous nongravid uterus has a large and nodular body and usually extends into lower abdominal cavity
      - During menopause, uterus shrinks, and in post menopause, again assumes childhood propoertion
    - - For Human Papillo Virus (HPV) as it is the leading cause of cervical cancer in women
    - - removal of uterus
    - - Due to close relation of vagina to adjacent pelvic organs, obsterical trauma during long and difficult labor may result in weakness, necrosis or tears in the vaginal wall and sometimes beyond
      - Insults may form or subsequently develop into abnormal passages between vaginal lumen and the lumina of adjacent bladder, ureter, urethra, bowel or rectum
    - - GA used for emergency procedures
        
        renders mother unconscious, unaware of labor
        
        childbirth occurs passively under control of maternal hormones with assistance of obstetrician
      - Regional anesthesia or analgesia affects on area of the body
      - Epidural block
        
        anesthetic agent administered using an idwelling catheter into epidural space at L3-L4 level, enabling administration of more anesthetic agent for a deeper or more prolonged anesthesia
        
        Anesthesia bathes spinal nerve roots, including pain fibers from uterine cervix and superior vagina and afferent fibers from pudendal nerve
        
        Thus, entire birth canal, pelvic floor and majority of perineum are anesthetized, but lower limbs usually not affected
        
        Pain fiber from uterine body and above not affected (above pelvin pain line), so mother is aware of her own contractions
      - spinal anesthesia
        
        anesthetic agent introduced through dura and arachnoid mater with a needle into spinal subarachnoid space at L3-L4
        
        Complete anesthesia effect from waist level down
        
        often used for limited duration procedures
        
        Lasts from 30-250 mins depending on type and amt used
        
        if labor is extended or level of anesthesia is inadequate, difficult or impossible to readminister as anesthetic agent is heavier than cerebrospinal fluid, remains in inferior spinal subarachnoid space while patient is inclined
        
        Another consequence is spinal headache that wont occur with epidural
      - Both epidural and spinal anesthesia run risk of CSF leaking out (in epidural, happens when needle inadvertently pierce dura and arachnoid mater)
        As CSF leaks, decrease pressure within canal, leading to severe headache
      - Pudendal nerve block
        
        peripheral nerve block, local anesthesia over S2-4 dermatomes and inferior quarter of vagina
        
        Does not block pain from superior birth canal so mother is able to feel contractions
        
        can be readministered, but doing so could be disruptive and may place sharp needles near the infants head
- - - - usually not palpable but are when infected
      - Occlusion of vestibular gland duct can predispose individual to infection of greater vestibular gland
      - The gland is the site or origin of most vulvular adenocarcinomas
      - Bartholinitis, inflammation of the greater vestibular (bartholin) glands, may results from a no of pathogenic organisms
      - INfected glands may enlarge to a diameter of 4-5cm and impinge on wall of rectum
      - Occlusion without infection can result in accumulation of mucin (bartholin gland cyst)
    - - to relieve perineal pain during childbirth, pudendal nerve block anesthesia may be performed by injecting local anesthetic agent into tissues surrounding pudendal nerve
      - Injection is made where pudendal nerve crosses lateral aspect of sacrospinous ligament, near its attachment to the ischial spine or in the initial part of the pudendal canal
      - Needle may be passed through overlying skin, or more commonly, through the vagina parallel to the palpating finger
      - Because fetus' head is usually stationed within the lesser pelvis at this stage, impt that physicians finger is always positioned between the needle tip and the baby's head
      - To abolish sensation from anterior part of the perineum, ilio-inguinal nerve block is performed
      - when patients still feel pain from these two, it is usually the result of overlapping innervation by the perineal branch at the posterior cutaneous nerve of the thigh
    - - in the absence of functional demands related to urination, penile erection and ejaculation in males, the superficial transverse perineal muscle, bulbospongiosus and external anal sphincter are relatively underdeveloped in women
      - When developed, contribute to the support of the pelvic viscera, and help prevent urinary stress incontinence and post partum prolapse of pelvic viscera
      - Many gynecologists recommend kegel exercises
      - some prepartum classes teach that in learning to voluntarily contract and relax the perineal muscles, women may be able to resist the tendency to contract the musculature during uterine contractions, allowing a less obstructed passage for the fetus and decreasing likelihood of tearing the perineal muscle (controversial)
- - - - formed by right and left hip bones, each of which has an obturator foramen covered by obturator membrane
      - Obturator internus muscles cover and pad most of the lateral pelvic walls. Its fleshy fibers start from the pelvic surface of the ilium and ischium, on the obturator membrane, converge posteriorly, become tendinous and is attached to the greater trochanter of the femur
      - Innervated by obturator nerves (L5-S2), rotates thigh laterally, assist in holding the head of the femur in the acetabulum
      - contains obturator canal at proximal attachment
    - - Piriformis
        
        Proximal attachment: pelvic surface of S2-S4 segments (lateral margins), pass laterally and leaving lesser pelvis through greater sciatic foramen to attach to superior border of the greater trochanter of femur
        
        occupy much of the greater sciatic foramenm forming posterolateral walls of the pelvic cavity
        
        Innervated by anterior rami of S1 and S2, rotates thigh laterally, abducts thigh, assist in holding head of femur in acetabulum
    - - Coccygeous (Ishciococcygeus)
        
        from ischial spine to inferior end of saccrum and coccyx
        
        Innervated by branches of S4 and S5, forms small part of pelvis diaphragm that supports pelvic viscera, flexes coccyx
      - Levator ani
        
        Consist of puborectalis, pubococcygeus and iliococcygeus (medial to lateral)
        
        Proximal attachment: body of pubis, tendinous arch of obturator fascia, ischial spine
        
        Attached to the perineal body, coccyx, anococcygeal ligament, walls of prostate or vagina, rectum and anal canal
        
        Innervated by nerve to levator ani (branches of S4), inferior anal (rectal) and coccygeal plexus.
        Form most of pelvic diaphragm that help support pelvic viscera, resist changes in intra-abdominal pressure (actively contracted during activities that will increase P
        
        Part not covered is the urogenital hiatus
        
        need to relax to allow urination and defecation
  - - - during childbirth, pelvic floor supports fetal head while cervix of uterus is dilating to perform delivery of fetus
      - Perineum, levator ani and ligaments of the pelvic fascia may be injured during childbirth
      - Pubococcygeus and puborectalis, the main and most medial parts of the levator ani, are the ones most commonly injured
      - injury from stretching or tearing may decrease support for the vagina, bladder, uterus or rectum, or alter position of the neck of the bladder and urethra
      - may cause urinary stress incontinence (dribbling of urine when intra-abdominal pressure is raised during coughing.
      - Tearing of puborectalis, which produces the anorectal angleand increase the angle to maintain fecal continence, is likely to result in various degrees of fecal incontinence
- - - - variable, from common iliac, internal iliac, overian arteries
        
        anastamose along the ureter
      - Terminal parts: uterine artery in females and inferior vesical arteries in males
    - - superior to pelvic pain line, afferent follows sympathetics, to T10-L2
        
        ureteric pain usually referred to ipsilateral lower quadrant of abdomen
  - - - superior rectal artery from IMA, right and left middle rectal arteries from anterior divisions of internal iliac, supply middle and inferior parts,
      - inferior rectal artery from internal pudendal arteries supply anorectal junction and anal canal
      - Drains through superior, middle and inferior rectal veins
        -portocaval anastamoses (superior to portal, middle inferior to caval)
      - Rectal venous plexus
        
        surrounds rectum
        
        internal: just deep to mucosa of anorectal junction
        
        Subcutaneous external: external to muscular wall of rectum
    - - sympathetic from T12-L2 (aortic plexus -> hypogastric)
      - Parasympathetic from S2-S4, pelvic splanchnic nerves and R and L inferior hypogastric plexus
      - Inferior to pelvic pain line, all afferent fibers follow para fibers to S2-S4
  - - - ureters may be injured during operations as a results of inadvertently interrupting their blood supply
        
        abdominal, retroperitoneal, pelvic or gynecological operations
      - Identification of ureters during their full course through the pelvis is impt preventive measure
      - Although there are longitudinal anastomoses between arterial branches of the ureter to maintain adequate blood supply, sometimes it is not enough
      - ureters should be retracted according to blood supply(from medial superiorly, from lateral inferiorly)
    - - acute obstruction from presence of ureteric calculus (stone)
      - symptoms and severity depend on location, type and size of calculus and when it is smooth and spiky
      - Although passage of smaller stones usually cause little or no pain, large ones produce severe pain
      - pain migrating from loin to groin (colicky pain (severe)) which results from hyperperistalsis in ureter superior to obstruction
      - Occurs most often at three sites
        
        junction of ureter and pelvis
        
        cross external iliac artery at pelvic brim
        
        Passage through wall of urinary bladder
    - - damage to pelvic floor during childbirth, a lesion of nerves or rupture of fascial support of vagina can result in loss of bladder support, leading to collapse of bladder onto anterior vaginal wall
      - When intra-abdominal P increase, base of bladder and upper urethra pushed against anterior wall of vagina, which lacking support will in turn bulge into the vaginal lumen and protrude through vaginal orifice into vestibule
        
        Cystocele (herniation of urinary bladder)
      - Even in absence of cystocele, weakened support will result in lack of support for urethra, altering normal placement, direction or angle of the urethra (urethrocele), diminishing the usual passive compression of urethra that helps maintain urine continence during temporary increase in intra-abdominal P
      - non surgical: pelvic floor muscle exercise, pharmacotherapy
      - Surgery: rethetering of vagina and/or placement of support directly into urethra to restore direction and enable passive compression
    - - although superior border of empty bladder lies at level of superior margin of pubic symphysis, as bladder fills, it extends superiorly
      - Bladder then lies adjacent to wall without intervention of peritoneum
      - May be punctured (suprapubic cystotomy) or approached surgically superior to pubic symphysis for introduction of indwelling catheters or instruments without transversing peritoneum and entering the peritoneal cavity
      - Rupture of bladder due to injuries in inferior part of abdominal wall, may result in escape of urine extraperitoneally or intraperitoneally as it frequently tears the peritoneum, resulting in extravasation of urine into the peritoneum
    - - interior of bladder and three orifices can be imagined with a cystoscope
      - During transurethral resection of a tumor, instrument is passed into bladder through urethra
    - - female urethra is distensible as it contains considerable elastic tissue and smooth muscle
      - can be easily dilated without injury
      - Consequently, passage of catheters or cystoscopes is easier in females
      - UTI more common in women as femal urethra is short, more distensible and is open to the exterior
- - - - right and left hip bones which develop from another three bones, the ilium, ischium and pubis
        
        three bones joined together by the triradiate cartilage at the acetabulum
      - Sacrum, formed by fusion of five sacral vertebrae, bounded by the promontory and ala of the sacrum
    - - superior, fan-shaped part of the hip bone
      - ala: wing of ilium represents the spread of the fan, body of ilium is the handle of the fan
      - Iliac crest is the rim that extends between ASIS and PSIS
      - Iliac fossa: anteromedial concave surface
      - Posteriorly, sacropelvic surface of ilium features an auricular surface and iliac tuberosity for synovial and syndesmotic articulation with the sacrum respectively
    - - Body of ischium helps form part of the acetabulum
      - ramus (branch) of ischium forms part of obturator formane
      - Large postero-inferior protuberance of ischium called ischial tuberosity
      - Small pointed postero-medial projection near junction of ramus and body is ischial spine, concavity between spine and tuberosity is the lesser sciatic notch, while the larger concavity formed superiorly is the greater sciatic notch (partly by ilium)
    - - Superior ramus that help form the acetabulum
      - inferior ramus that contributes to bony borders of obturator foramen
      - thickening of anterior part part of body of pubis is the pubic crest, which ends laterally as a prominent swelling called the pubic tubercle
      - Pubic arch formed by right and left ischiopubic rami (conjoined inferior rami of pubis and ischium) which meet at the pubic symphysis, and their inferior borders defining the subpubic angle (~70 deg in males, almost 90 deg in females)
    - - In anatomical position, right and left ASIS and anterior aspect of pubic symphysis lie in same vertical plane
      - When viewed anteriorly, coccyx appears close to center of pelvic inlet, and pubic bones and pubic symhpysis constitute more of a weight bearing floor than an anterior wall
      - sacral promontory located directly superior to center of pelvic outlet
    - - due to heavier build and larger muscles of most men and adaptation of pelvis in women for parturition
      - Males have greater dimension and volume
      - gynecoid pelvis is normal female type, with a typically rounded oval shape and wide transverse diameter
      - Platypelloid or android (masculine or funnel shaped) pelvis in woman present hazards to successful vaginal delivery
      - Type A and C most common in males
        B and A in white females
        B and C in black females
        D uncommon in both sexes
    - - Sacro-iliac joints
        
        strong, weight bearing compound joints,, consisting of an anterior synovial joint (between auricular surfaces of sacrum and ilium, covered with articular cartilage) and a posterior syndesmosis (fibrous joint between tuberosities of the bones)
        
        Limited mobility is allowed, consequence of their role intransmitting the weight of most of the body to the hip bones, then to the femurs during standing, and to ischial tuberosities during sitting
        
        Thin anterior sacro-iliac ligaments: anterior part of fibrous capsule of synovial part of joints
        
        Abundant interosseous sacro-iliac ligaments (lying deep between tuberosities of sacrum and ilium and occupying area of approx 10cm2) are the primary structures involved in transferring of weight
        
        Posterior sacro-iliac ligaments are posterior continuation of the same mass of fibrous tissue
        
        as fibers of interosseous and posterior sacro-iliac ligaments run obliquely upward and outward from sacrum, axial weight pushing down on sacrum pulls the ilia inward so that they can compress the sacrum between them, locking th eirregular but congruent surfaces of sacro-iliac joints together
        
        inferiorly, posterior sacro-iliac ligaments are joined by a massive sacro-tuberous ligament that pass from posterior ilium and lateral sacrum and coccyx to the ischial tuberosity, transforming the sciatic notch of hip bone into a large sciatic foramen
        
        Sacrospinous ligament pass from lateral sacrum and coccyx to ischial spine, further subdividing the foramen into greater and lesser sciatic foramina
      - Pubic symphysis
        
        fibrocartilaginous interpubic disc and surrounding ligaments uniting the bodies of the pubis in the medial plane
        
        Interpubic disc generally wider in woman
        
        ligaments thickened at superior and inferior margins of symphysis, forming the superior and inferior pubic ligaments
      - Lumbosacral joints
        
        L5 and S1 articulate at the anterior intervertebral joint by L5/S1 IV disc
    - - pelvic diameters
        
        Interspinous 10cm
        
        Transverse diameter 13.5cm
        
        Diagonal conjugate (measured by hand) ~13cm
        
        Anatomical conjugate 11.5cm
        
        Obstetric conjugate >11cm
      - Pelvic fractures
        
        Damage underlying pelvic soft tissues, blood vessels, nerves and organs e.g. relationship to urinary bladder and urethra with puboobturator area
      - Relaxation of pelvic ligaments and increased joint mobility in late pregnancy
        
        Larger cavity of interpubic disc in females increases in size during pregnancy. -> increase circumference of lesser pelvis and increased flexibility of pubic symphysis
        
        Increased levels of sex hormones and presence of relaxin cause pelvic ligaments to relax during latter half of pregnancy, allowing increased movement at pelvic joints
        
        Relaxation of sacro-iliac joints and pubic symphysis permits 10-15% increase in diameters, facilitating fetus through pelvic canal
        
        One diameter that doesnt change is the true diameter between sacral promontory and posterosuperior aspect of pubic symphysis
        
        relaxation of sacro-iliac ligament permit greater rotation of pelvis -> contribute to lordosis