Anatomy Review File اللهم ال سهل إال ماجعلته سهال وأنت تجعل الحزن

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1 Anatomy Review File اللهم ال سهل إال ماجعلته سهال وأنت تجعل الحزن إذا شئت سهال This work was done by: Alanoud Abuhaimed Dania Alkelabi Ghada Alothaim Jawaher Abanumy Rawan AlWadee Wejdan Alzeid Mohanad Alzahrani Nawaf Alkhudhayri If any topics are unclear we highly recommend visiting: &

2 Base Apex (Nipple) Areola Parts From 2 nd to 6 th rib From sternum (medially) to midaxillary line (laterally) Lies on: (1) pectoralis major (mainly) (2) serratus anterior (3) external oblique muscle Lies opposite 4 th intercostal space. Carries narrow pores of lactiferous duct. The subcutaneous tissues of nipple & areola are devoid of fat. Mammary Gland Non-capsulated & embedded in subcutaneous fatty tissue of superficial fascia. The lobes and lobules are separated by ligaments of cooper that run radially and attach the skin of the breast to the deep fascia of pectoralis major muscle. The glands are separated from the deep fascia by retromammary space. 1. Internal thoracic artery (internal mammary) perforating & mammary branches 2. Lateral thoracic artery mammary branches 3. Intercostal arteries mammary branches Circular venous plexus internal thoracic & axillary Subareolar and deep lymphatic plexus drain into different lymphatics Clinical Points Central & lateral parts Pectoral group Axillary Upper part Apical group (75%) Medial part Infero-medial part 1. Internal thoracic 2. Anastomose with opposite side Other 1. Lymphatic of rectus sheath and linea alba (25%) 2. Sub diaphragmatic lymphatics 60% of breast carcinoma occurs in upper lateral quadrant. Cancer can spread from one side to the other through anastomosing lymphatics. Localized breast cancer is treated by simple mastectomy (+ radio/chemotherapy to lymph). Note that incision should be made radially. Infiltration of ligaments of cooper gives peau d orange. Axillary lymph Drains (part of breast) Related vessel Location Pectoral (anterior) Subscapular (posterior) Central & lateral part of breast Lateral thoracic vessels On pectoralis minor - Subscapular vessel Posterior wall of axilla (lower border of subscapularis) Brachial (lateral) - 3 rd part of axillary vessels Lateral wall of axilla Central - - Base of axilla Apical Upper part - Apex of axilla Subclavian Drains the 5 previous then opens into subclavian vein (right) & thoracic duct (left)

3 Boundaries Boundaries Boundaries Surface Bony Anteriorly Mons pubis Symphysis pubis Posteriorly Intergluteal folds Coccyx Laterally Medial surfaces of the thighs 1. Ischiopubic rami, 2. ischial tuberosities 3. sacrotuberous ligaments Contents Divisions Anterior Posterior Lateral Content Composed of: Layers 1. Lower ends of urethra, vagina & anal canal 2. External genitalia 3. Perineal body (between vaginal vestibule & anal canal) 4. Anococcygeal body (between coccyx & anorectal canal) Urogenital Triangle (anterior) Anal Triangle (posterior) Symphysis pubis Transverse line passing through the 2 ischial tuberosities Transverse line passing through the 2 ischial tuberosities Ischiopubic rami & ischial tuberosities 1. Lower part of urethra & vagina. 2. External genitalia (vulva). Urogenital Diaphragm Coccyx ischial tuberosity & sacrotuberous ligament 1. Lower part of Anal canal 2. Ano-coccygeal body 3. Ischiorectal fossa on each side 1. Sphincter urethrae 2. Deep transverse perineal muscle 3. Superior layers of fascia of the urogenital diaphragm 4. inferior layers of fascia of the urogenital diaphragm (perineal membrane) Perineal fascia Superficial fascia superficial fatty (camper) & deep membranous (colle s) Deep fascia(surrounds muscles in superficial perineal pouch) Pouches Location Superficial Deep Superior Inferior Lateral Content Perineal membrane Membranous layer of superficial fascia Ischiopubic rami 1. Bulbs of vestibule 2. Crura of clitoris 3. Superficial perineal muscle (Bulbospongiosus, Ischiocavernosus, Superficial transverse perineal muscles) 4. Greater vestibular glands 5. Perineal branch of pudendal nerve Superior fascia of the urogenital diaphragm Inferior fascia of the urogenital diaphragm (perineal membrane) Inferior portion of obturator internus fascia 1. Part of urethra 2. Part of vagina 3. Sphincter urethrae & Sphincter vaginae muscles 4. Deep transverse perineal muscles 5. Internal pudendal vessels 6. Dorsal nerve of clitoris

4 External Genitala (Vulva) Composed of: 1. Mons pubis 2. Labia majora 3. Labia minora. 4. Clitoris 5. Vestibule of vagina 6. Vagina & urethra openings Anal Canal Reمations Anterior Posterior Lateral Perineal body, urogenital diaphragm, lower part of vagina Anococcygeal body Ischiorectal fossae Divisions Upper half (endoderm) Lower half (ectoderm) Arterial Superior rectal (inferior mesenteric) Inferior rectal (internal pudendal) Venous Superior rectal (inferior mesenteric) Inferior rectal (internal pudendal) Lymphatic Para-rectal Superficial inguinal Innervation Inferior hypogastric visceral Inferior rectal (pudendal) somatic Ischiorectal Fosaa Boundaries Base Medial Lateral Skin of the perineum. Levator ani & anal canal. Obturator internus, covered with fascia. Contents: 1. Dense fat. 2. Pudendal canal (Pudendal nerve & internal pudendal vessels) 3. Inferior rectal nerve & vessels. 4 bones 4 joints Division 2 hip bones anterior & lateral walls Sacrum posterior wall Coccyx Symphysis pubis anterior 2 Sacroiliac posterior-lateral Sacrococcygeal posterior Divided into false and true pelvis by pelvic brim (inlet) True pelvis is divided into pelvic cavity and perineum by outlet. False Pelvis True pelvis (Inlet) True Pelvis (Outlet) Anteriorly Lower part of the anterior abdominal wall. Symphysis pubis Symphysis pubis Relations Posteriorly Lateral Lumbar vertebrae Iliac fossae and the iliacus muscle Promontory of sacrum, ala of sacrum. Ileopectineal (arcuate) lines Coccyx Anterolaterally: ischiopubic ramus. Posterolaterally: Sacrotuberous ligament

5 Pelvic Walls Levator ani Anterior Posterior Lateral Inferior (floor) bodies of the pubic bones, 2 pubic rami, symphysis pubis sacrum, coccyx piriformis muscles covering of parietal pelvic fascia Pelvic Diaphragm Part of the hip bone below the pelvic inlet Obturator internus and covering fascia, Sacrotuberous ligament. Sacrospinous ligament. pelvic diaphragm: levator ani and coccygeus (divides it into main pelvis and perineum) Muscle Origin Insertion Action Innervation Pubococcygeus Puborectalis Iliococcygeus Coccygeus 1. Back of the body of the pubis 2. Tendinous arch of the obturator fascia 3. Spine of the ischium. Ischial spine 1. Perineal body 2. Anococcygeal body 3. Coccyx Lower end of sacrum and coccyx : Internal Iliac Artery 1. Support and maintain the pelvic viscera. 2. They resist the rise in intra pelvic pressure 3. Maintaining fecal continence. 4. Vaginal sphincter. Assist the levator ani in supporting the pelvic viscera Division Anterior Division Posterior Division Parietal Branches Visceral Branches 1. Obturator artery. 2. Inferior Gluteal artery. 1. Umbilical artery superior vesical artery + Medial Umbilical Ligament. 2. Inferior Vesical (male) / vaginal (female) artery 3. Middle rectal artery 4. Internal pudendal artery (to perineum) 5. Uterine artery (female) 6. Ovarian artery (from abdominal aorta In female) 1. perineal branch of S4 2. perineal branch of the pudendal nerve. S4 & S5 1. Iliolumbar artery. 2. Lateral sacral arteries (2 branches.) 3. Superior gluteal artery. 1. NO visceral branches Supply (1) Posterior abdominal wall (2) Posterior pelvic wall (3) Gluteal region (4) Perineum (5) Pelvic viscera (6) Medial region of thigh (7) Fetus 1. Internal iliac vein (join external iliac) common iliac vein 2. Ovarian vein (right IVC / left left renal) Innervation External iliac, internal iliac, and common iliac lateral (paraortic) lymph Somatic: Sacral plexus (L4. L5. S1. S2. S3. most of S4) Gives pudendal nerve to perineum Autonomic: Sympathetic: Ganglion Impar, Superior & Inferior Hypogastric plexuses Parasympathetic: Pelvic splanchnic (S2, S3, S4) to pelvic viscera and hind gut.

6 Female Reproductive System Relations Notes Medial End Lateral End Primary sex organ It is attached to the back of the broad ligament by a peritoneal fold (mesovarium). attached to uterus by ligament of ovary. attached to fimbriae of the uterine tube. Innervation Ovarian (abdominal aorta) Ovarian (right inferior vena cava / left left renal vein) Paraaortic lymph Ovarian plexus Parts Notes Intramural Isthmus Ampulla Infundibulum Innervation Enclosed in the broad ligament of uterus opening into the uterine wall. narrowest part. widest part (site of fertilization) Has finger-like processes (fimbriae) & related to ovary Ovarian & uterine arteries Ovarian & uterine veins Paraaortic & internal iliac lymph Ovarian & inferior hypogastric plexuses Relations Notes Extend from external os (along pelvis & perineum) to the vulva Function: birth canal & copulatory organ Location Pelvis Perineum Anterior urinary bladder urethra Posterior Rectum anal canal Lateral Ureters - Innervation 1. Vaginal artery (internal iliac) 2. Vaginal branch of the uterine artery Vaginal plexus internal iliac veins. Internal iliac lymph Inferior hypogastric plexus

7 Parts Fundus (above uterine tubes level) Body (from uterine tube level isthmus of uterus) Supravaginal Cervix (below isthmus) Vaginal Relations Anterior Superior surface of urinary bladder Anterior fornix Posterior Sigmoid colon Posterior fornix Lateral Uterine artery Lateral fornices Position Ligament Innervation Anteverted: whole uterus bent forward on vagina Anteflexed: body of uterus bent forward on cervix Retroverted: fundus & body bent backward on vagina Retroflexed: body of uterus bent backward on cervix Level of uterine tube: 1. Round ligament of uterus* 2. Ligament of ovary Ligament of cervix: 1. Pubocervical 2. Transverse cervical/cardinal* 3. Uterosacral/sacrocervical *Support of uterus: 1. round ligament of uterus 2. cardinal ligament 3. levator ani Damage = uterine prolapse Uterine artery (internal iliac) Uterine plexus internal iliac veins. Internal iliac lymph Inferior hypogastric plexus Ante Forward Retro Backward Verted Vagina Flexed Cervix Rectouterine (Douglas) pouch Uterovesical (vesicouterine) pouch Broad ligament of uterus Reflection of peritoneum from rectum to upper part of posterior surface of vagina. Reflection of peritoneum from uterus to upper surface of urinary bladder. Extension of peritoneum from lateral wall of uterus to lateral wall of pelvis. (encloses the uterine tubes) Male Reproductive System Function Houses and protects the testis. Regulates testicular temperature (no superficial fat). It has thin skin with sparse hairs and sweat glands. The Dartos muscle lies within the superficial fascia and replaces Scarpa s fascia of the anterior abdominal wall. Superficial inguinal

8 Notes Function Paired almond-shape gonads that suspended in the scrotum by the spermatic cord. Spermatogenesis (primary sex organ). Hormone production: (Androgens--testosterone). Structure Coverings 1. Tunica vaginalis Peritoneal covering (parietal and visceral layers) that allows free movement of testes in scrotum 2. Tunica albuginea White fibrous capsule Testicular artery from abdominal aorta. Internal Divided by fibrous septa into lobules containing seminiferous tubules: Site of spermatogenesis & form the bulk of testicular tissue. Seminiferous tubules merge to give rete testis Cremasteric reflex Pampiniform plexus (at inguinal canal) testicular vein IVC (right) / Left renal (left) Lumbar (par aortic). When to do it? Evaluate testicular pain How? Pinch or stroke the skin in the upper medial thigh Finding? Contraction of cremasteric muscle & rise of testis on same side What does it mean? If present = normal or epididymitis. If absent = Testicular torsion (99% sensitivity) Limitation? Not used on patient under 30 month Nerve involved? Genitofemoral nerve (L1 & 2): Motor (genital branch) Sensory (femoral branch + ilioinguinal nerve) Parts Function Single coiled tube located at superior-posterior margin of testis and has 3 parts: 1. Head: receives efferent ductules 2. Body 3. Tail: continuous with vas deferens 1. Secretes and absorbs the nourishing fluid. 2. Recycles damaged spermatozoa. 3. Stores spermatozoa up to 2 weeks to allow for physiological maturation of sperms Course Carries sperms from the epididymis to the pelvis: Passes through the inguinal canal ( in spermatic cord) It crosses the lower end of the ureter. Terminal part is dilated to form the ampulla of the vas deferens on the base of the urinary bladder. It joins the duct of the seminal vesicle to form ejaculatory duct which opens into the prostatic urethra.

9 Gland Seminal Vesicle Bulbourethral Gland Location posterior & inferior to the urinary bladder. At the base of the penis Function Secrete 60% of seminal fluid. Secrete alkaline mucus Relations Function Capsule Lobes Hypertrophy Prostatic Urethra Anterior Posterior Superior (base) Inferior (apex) Lateral Symphysis pubis. Rectum (PR exam) Neck of the bladder Urogenital diaphragm levator ani muscles It secretes enzymes (acid phosphatase) which has the following functions: Aid in activating sperm motility, mucus degradation, & Antibiotic. Neutralize the acidity of urine & female reproductive tract (Alkaline fluid). Internal prostatic fibrous capsule External prostatic fibrous sheath (continuous with levator prostate) In between them there is prostatic venous plexus. Anatomically 5 lobes: anterior (isthmus), posterior, 2 lateral, and middle (median). The median lobe is closely related to neck of urinary bladder & elevates fold of mucous membrane (uvulae vesicae) Benign Common: middle lobe often enlarges and obstructs the internal urethral orifice and causes symptoms Radiology & urology Central and peripheral zone. Central is represented by middle lobe. Malignant Felt during PR exam as hard & irregular. May metastasize via lymph (to internal iliac & sacral lymph ) or venous to bone & brain through (IVVP) Urethral crest Prostatic sinus Prostatic utricle elevated ridge prostatic gland opens ejaculatory ducts open Inferior vesical artery (Internal Iliac Artery) Prostatic venous plexus internal iliac veins Note: continuous with vesical venous plexus & internal vertebral plexus Internal iliac lymph Notes Copulatory & excretory organ composed of 3 cylindrical masses of erectile tissue. Two Corpora Cavernosa One Corpus spongiosum Division Primary erectile tissue Posterior expansions forms the 2 Crurae Superficial inguinal Secondary erectile tissue It is traversed by the penile urethra. Anterior glans penis Posterior bulb of penis

10 Structures/ Organs Nerve Supply Ovaries Ovarian artery (abdominal aorta) Ovarian (right inferior vena cava / left left renal vein) Paraaortic lymph Ovarian plexus Uterine Duct Ovarian & uterine arteries Ovarian & uterine veins Paraaortic & internal iliac lymph Ovarian & Inferior hypogastric Uterus Uterine artery (internal iliac) Uterine plexus internal iliac veins. Internal iliac lymph Inferior hypogastric plexus Vagina 1. Vaginal artery (internal iliac) 2. Vaginal branch of the uterine artery Vaginal plexus internal iliac veins. Internal iliac lymph Inferior hypogastric plexus Scrotum Penis Prepuce - - Superficial inguinal - Testis Testicular artery (abdominal aorta) Pampiniform plexus (at inguinal canal) testicular vein IVC (right) / Left renal (left) Lumbar (paraaortic). - Prostate Inferior vesical artery (Internal Iliac Artery) Prostatic venous plexus internal iliac veins Internal iliac lymph - Anal Canal Upper Lower Superior rectal (inferior mesenteric) Inferior rectal (internal pudendal) Superior rectal (inferior mesenteric) Inferior rectal (internal pudendal) Para-rectal Superficial inguinal Inferior hypogastric visceral Inferior rectal (pudendal) somatic Paraaortic Lymph Node Female Male Internal Iliac 1. Ovaries 2. Uterine duct 1. Uterine duct 2. Uterus 3. Vagina 1. Testis 1. Prostate Superficial inguinal 1. Lower anal canal 1. Lower anal canal 2. Scrotum 3. Penis 4. Prepuce Pararectal Upper anal canal Good Luck!