Genitourinary System
Content
TERMINOLGIES OF BASIC ANATOMY Pelvic Outlet: is the space enclosed by the following boundaries – anteriorly: the pubic arch (inferior rami of the ischium and pubis on either side) laterally: the ischial tuberosities posterolaterally: the inferior margin of the sacrotuberous ligament posteriorly; the tip of the coccyx
http://en.wikipedia.org/wiki/Pelvic_outlet http://en.wikipedia.org/wiki/Pubic_arch Perineum: is defined to be the inferiormost portion of the trunk (group of soft tissues including skin, muscles, and fasciae) in both males and females corresponding to the pelvic outlet. The perineum has a roof formed by the pelvic diaphragm and a floor of fascia and skin. http://en.wikipedia.org/wiki/Perineum (roof = pelvic diaphragm) http://www.dummies.com/how-to/content/the-anatomy-of-the-perineum.html (roof pelvic diaphragm, floor is fascia and skin) Essentials of Anatomy by I.B. singh 2008 p.241e (corresponding to pelvic outlet) Atlas of Anatomy 2nd edition Thieme p.215 (inferiormost portion of the trunk) http://learnhumananatomy.com/perineum/ (group of soft tissues) BRS Gross Anatomy 2011 p.244e (floor is skin and fascia, roof is pelvic diaphragm) That is, the perineum is defined as the inferiormost portion of the trunk enclosed by and beneath the pelvic outlet. Therefore, it can be said that the perineum has the same boundaries as the pelvic outlet. It is separated from the pelvic cavity by the pelvic diaphragm. Mastery of Surgery, Volume 1, 5th edition p.1873e https://www.dartmouth.edu/~humananatomy/part_6/chapter_38.html
The deep limit of the perineum is the inferior surface of the pelvic diaphragm and its superficial limit is the skin.
http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&dec orator=none&eid=4-u1.0-B978-0-443-06684-9..50071-8--cesec90&isbn=978-0-443-06684-9 Note: Its definition varies: it can refer to only the superficial structures in this region, or it can be used to
include both superficial and deep structures.
http://en.wikipedia.org/wiki/Perineum Note: Some authors denote what we described above as the “perineal region” and reserve the term “perineum” to describe what we called the surgical perineum. See below. https://www.dartmouth.edu/~humananatomy/part_6/chapter_38.html
Urogenital Triangle and Anal Triangle The perineum is divided into an anterior urogenital triangle and a posterior anal triangle by a line connecting the two ischial tuberosities. BRS Gross Anatomy 2011 p.244e
Atlas of Anatomy 2nd edition Thieme p.215
Atlas of Anatomy 2nd edition Thieme p.215
The Diagrams Below is From Deep to Superficial
Atlas of Anatomy 2nd edition Thieme p.224
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
Atlas of Anatomy 2nd edition Thieme p.227
Atlas of Anatomy 2nd edition Thieme p.225
Coronal View
BRS Gross Anatomy 2011 p.244 – 245e
Atlas of Anatomy 2nd edition Thieme p.232
Pelvic Diaphragm (aka pelvic floor): the paired levator ani (consisting of puborectalis, pubococcygeus,
iliococcygeus) and coccygeus muscles together with the fascia above and below them. The pelvic diaphragm separates the pelvic cavity from the perineum.
http://www.medilexicon.com/medicaldictionary.php?t=24474 (fascia) Atlas of Anatomy 2nd edition Thieme p.226 http://en.wikipedia.org/wiki/Pelvic_floor (aka pelvic floor) http://teachmeanatomy.info/pelvis/pelvic-floor/ (separates pelvic cavity from perineum, aka pelvic floor) That is, there are three components of the pelvic floor:
Levator ani muscles (largest component). Coccygeus muscle. Fascia coverings of the muscles (the superior and inferior fascia of pelvic diaphragm)
http://teachmeanatomy.info/pelvis/pelvic-floor/ (fascia) Textbook of Gynecology 2011 p.200e (superior and inferior fasica) Anand’s Human Anatomy for Dental Students p.39e (fascia) The levator ani muscles and coccygeus muscle together is referred to as the muscles of the pelvic diaphragm. http://teachmeanatomy.info/pelvis/pelvic-floor/ Note: some texts consider the pelvic floor to include the perineal membrane and deep perineal pouch. We have considered these as a distinct and separate structures. http://teachmeanatomy.info/pelvis/pelvic-floor/
Some sources do not consider "pelvic floor" and "pelvic diaphragm" to be identical, with the "diaphragm" consisting of only the levator ani and coccygeus, while the "floor" also includes the perineal membrane and deep perineal pouch.
http://en.wikipedia.org/wiki/Pelvic_floor Urogenital Diaphragm Superficial to the pelvic diaphragm is the urogenital diaphragm. Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management 2010 p.122e The urogenital diaphragm is a musculo fascial partition. It is made up of a sheet of muscles namely, sphincter erethrae and a pair of deep transverse perineal muscle. It includes the superior and inferior fascia of the sheet of muscle. Anand’s Human Anatomy for Dental Students p.39e http://learnhumananatomy.com/perineum/
http://www.yogatuneup.com/blog/wp-content/uploads/2013/10/perineal-muscles.jpg
Perineal Membrane The perineal membrane is the inferior fascia of the urogenital diaphragm. BRS Gross Anatomy 2011 p. 245e The perineal membrane forms (inferior fascia of the urogenital diaphragm) forms the inferior boundary of the deep perineal pouch and the superior boundary of the superficial perineal pouch. BRS Gross Anatomy 2011 p. 245e Atlas of Anatomy 2nd edition Thieme p.232
http://en.wikipedia.org/wiki/File:Gray407.png
http://academic.amc.edu/martino/grossanatomy/site/Medical/CASES/Reproduction/Pictures/perineal% 20pouches.jpg External Anal Sphincter Superficial to the pelvic diaphragm (with its fascia), we have the external anal sphincter. http://learnhumananatomy.com/perineum/ Superficial Transverse perineal muscle, Ischiocavernousus muscle, bulbospongiousus muscle These muscles are found superficial to the urogenital diaphragm (with its fascia). http://learnhumananatomy.com/perineum/
The layers and contents are as follows, from superficial to deep: 1) Foreskin 2) superficial perineal fascia: Subcutaneous tissue divided into two layers: (a) A superficial fatty layer, and (b) Colles' fascia, a deeper, membranous layer. 3) deep perineal fascia and muscles: Contains superficial perineal muscles: transversus perinei superficialis,bulbospongiosus, ischiocavernosus
Superficial perineal pouch
Inferior fascia of urogenital diaphragm, orperineal membrane
A membranous layer of the deep fascia.
Deep perineal pouch
Contains the deep perineal muscles: transversus perinei profundus, sphincter urethrae membranaceae
Superior fascia of the urogenital diaphragm
Considered hypothetical by some modern anatomists, but still commonly used to logically divide the contents of the region.
4) fascia and muscles of pelvic floor (levator ani, coccygeus)
http://en.wikipedia.org/wiki/Perineum
Layers of the Urinary Bladder 1. Serous Mucosa: Outermost layer. Epithelium + a layer of CT 2. Muscularis Externa: is the detrusor muscle which forms the wall of the urinary bladder. 3. Submucosa: a thin layer of areolar tissue that loosely connects the muscularis externa with the mucosa. 4. Mucosa: Innermost layer. Transitional epithelium + lamina propria http://www.ivy-rose.co.uk/HumanBody/Urinary/Urinary_System_Bladder.php
TERMINOGIES ON INNERVATIONS
http://en.wikipedia.org/wiki/General_visceral_afferent_fibers http://en.wikipedia.org/wiki/General_visceral_efferent_fibers http://en.wikipedia.org/wiki/General_somatic_afferent_fibers http://en.wikipedia.org/wiki/General_somatic_efferent_fibers
However, unlike the efferent fibers of the autonomic nervous system, the afferent fibers are not classified as either sympathetic or parasympathetic.
http://en.wikipedia.org/wiki/General_visceral_afferent_fibers
Ventral root (or anterior root) is the efferent motor root of a spinal nerve.
http://en.wikipedia.org/wiki/Anterior_root_of_spinal_nerve
Dorsal root (or posterior root) is the afferent sensory root of a spinal nerve.
http://en.wikipedia.org/wiki/Posterior_root_of_spinal_nerve Spinal nerve: At its distal end, the ventral root joins with the dorsal root to form a mixed spinal nerve.
Contains both motor and sensory fibers.
http://en.wikipedia.org/wiki/Anterior_root_of_spinal_nerve
Ventral rami: The ventral rami is the anterior branch (division) of the spinal nerve. It supplies the antero-lateral parts of the trunk and the limbs. Note: The ventral rami also contains both motor and sensory fibers. http://en.wikipedia.org/wiki/Anterior_ramus_of_spinal_nerve http://anatomy.uams.edu/anatomyhtml/intronervsys.html Posterior rami: The posterior rami is the posterior branch (division) of the spinal nerve. They are
directed backward, and, with the exceptions of those of the first cervical, the fourth and fifth sacral, and the coccygeal, divide into medial andlateral branches for the supply of the muscles andskin of the posterior part of the trunk. Note: The posterior rami also contains both motor and sensory fibers.
http://en.wikipedia.org/wiki/Posterior_ramus_of_spinal_nerve http://anatomy.uams.edu/anatomyhtml/intronervsys.html Note: As branches of the mixed spinal nerve, the posterior and anterior rami carry both motor and sensory fibers, as do all their subsequent branches. The terms motor nerve andsensory nerve are almost always relative terms, referring to the majority of fiber types conveyed by that nerve. Nerves supplying muscles of the trunk or limbs (motor nerves) also contain about 40% sensory fibers, which convey pain and proprioceptive information. Conversely, cutaneous (sensory) nerves contain motor fibers, which serve sweat glands and the smooth muscle of blood vessels and hair follicles. https://www.inkling.com/read/clinically-oriented-anatomy-moore-agur-dalley-7th/introduction-toclinically/nervous-system Rammi communicans: refers to the nerve that connects the spinal nerve and the sympathetic trunk. http://en.wikipedia.org/wiki/Ramus_communicans
http://upload.wikimedia.org/wikipedia/commons/8/87/Spinal_nerve_CAT.svg
http://dc363.4shared.com/doc/Xp16yZ2V/preview.html
http://dc363.4shared.com/doc/Xp16yZ2V/preview.html
General Anatomy and Musculoskeletal System (Thieme) 2010 p.63e
http://en.wikipedia.org/wiki/File:Gray799.svg White ramus communicans: is the preganglionic sympathetic outflow nerve tract from the spinal cord. It contains both myelinated and unmyelinated preganglionic sympathetic fibers (GVE and GVA). The white ramus appears white because they are more myelinated than unmyelinated fibers. http://en.wikipedia.org/wiki/White_ramus_communicans Note: The white ramus communicans containing preganglionic sympathetic fibers from the anterior root joins the corresponding sympathetic ganglion, and the gray ramus communicans containing postganglionic sympathetic fibers from the sympathetic ganglion rejoins the spinal nerve. Both white and gray rami communicans contain afferent fibers, which include some for pain. Surgical Management of Pain by Kim Burchiel (Thieme) 2002 p.677e
Abdominal Aortic Plexus (aka intermesenteric plexus): The abdominal aortic plexus, also known as the
intermesenteric plexus, is formed by fibers contributed by the celiac plexus and ganglia and by the L-1 and L-2 splanchnic nerves.
http://drugswell.com/wowo/blog1.php/2011/06/08/general-considerations-of-abdominal-pain?page=3 Bonica’s Management of Pain 2001 p.1250g Essentials of Human Anatomy 1988 p.497Q (L1, L2) Urotext-Lut: Urology 2001 p.123e (splanchnic nerves) Note: the intermesenteric plexus is part of the aortic plexus of nerves between the superior and the interior mesenteric arteries. Clinically Oriented Anatomy 2013 p.305e Superior hypogastric plexus: The superior hypogastric plexus receives contributions from the intermesenteric plexus, as well as contributions from L3 and L4 splanchnic nerves. http://www.surgerytemplates.com/operationnotes.htm (intermesenteric plexus, L3, L4) Instant Anatomy by Robert H. Whitaker 4th edition p.4e (intermesenteric plexus, L3, L4) Anatomy: An Essential Textbook by Anne M Gilroy (Thieme) 2013e (intermesenteric plexus, L3, L4) Chronic Pelvic Pain and Dysfunction: Practical Physical Medicinee (L3, L4) http://www.wikiradiography.com/page/Nerve+Supply+to+the+Pelvis (intermesenteric plexus, L3, L4) http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/modules/pelvic_autonomic_mod ule/pelvic_page04.html (intermesenteric plexus, L3, L4) BRS Gross Anatomy 7th edition p.276e (intermesenteric plexus, L3, L4) http://anatomytopics.wordpress.com/author/sahajap/ (intermesenteric plexus, L3, L4) Note: the superior hypogastirc plexus contains no parasympathetic fibers, so it is a purely sympathetic plexus. http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/modules/pelvic_autonomic_mod ule/pelvic_page04.html http://www.netteranatomy.com/anatomylab/subregions.cfm?subregionID=R511&contentDir=anatomyl ab/contents/region/pelvisandperineum/innervation Note: the superior hypogastric plexus is continuous with the intermesenteric plexus and the inferior mesenteric plexus and lies anterior to the inferior part of the abdominal aorta at its bifurcation. Clinically Oriented Anatomy 2013 p.305e Hypogastric Nerve: The hypogastric nerve begins where the superior hypogastric plexus splits into a right and left plexus. Each of these divisions is considered a hypogastric nerve. The hypogastric nerve continues inferiorly on its corresponding side of the body, where it descends into the pelvis to form the inferior hypogastric plexus. Contents of the right and left hypogastric nerves include pre- and postganglionic sympathetic fibers from vertebral levels of T10-L2. The hypogastric nerve is responsible for emission (prior to ejaculation, which is instead the pudendal nerve); emission is sympathetic nervous system-mediated. http://en.wikipedia.org/wiki/Hypogastric_nerve
Inferior hypogastric plexus: is formed by nerve fibers coming through the following sources:
Hypogastric nerve (from the superior hypogastric plexus) Sacral splanchnic nerves that emerge from the sympathetic chain Pelvic splanchnic nerves that contribute parasympathetic fibers to the plexus (S2, S3, S4). The inferior hypogastric plexus thus contains both sympathetic and parasympathetic fibers as well as visceral afferent fibers.
http://www.mananatomy.com/body-systems/nervous-system/inferior-hypogastric-plexus Farquharon’s Textbook of Operative General Surgery 9th edition p.379e http://en.wikipedia.org/wiki/Inferior_hypogastric_plexus Clinically Oriented Anatomy 2013 p.360e Note: Both superior and inferior hypogastric plexuses are networks of sympathetic and visceral afferent nerve fibers. Clinically Oriented Anatomy by Moore 2013 p.360e
Innervation of the Bladder & Urethra Sympathetic innervation (to bladder & urethra): sympathetic fibers arise from T10 – L2 cord segments, then travel through the sympathetic trunk. After that, travel via lumbar splanchnic nerves, and then through the superior hypogastric plexus, and supply the bladder via the right and left hypogastric nerves. (Note: some fibers of the hypogastric nerve may directly innervate the bladder, while some fibers travel through the inferior hypogastric plexus, before innervating the bladder and urethra) http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm http://www.medscape.com/viewarticle/772264_4 Urinary Tract by Karl-Erik Andersson 2011 p.101e The sympathetic innervation of the bladder is divided into two distinct groups, those that innervate the main portion of the bladder and those that innervate the bladder neck and the urethra (including the internal urethral sphincter). Of these two areas, the bladder neck and sphincter receive the strongest innervation. Urinary Tract by Karl-Erik Andersson 2011 p.101e Sympathetic innervation to the bladder causes relaxation of the detrusor muscle (have little effect though). Sympathetic innervation to the bladder neck causes bladder neck closure which is necessary for bladder filling. Finally, sympathetic innervation also cause the internal urethral sphincter to constrict. Urinary Tract by Karl-Erik Andersson 2011 p.101e Handbook of Neurosurgery (Thieme) 7th edition p.117e Parasympathetic innervation (to bladder & urethra): parasympathetic fibers arise from S2 – S4 cord segments, forming pelvic splanchnic nerves which supply the bladder & urethra through the inteferior hypogastric plexus. Parasympathetic fibers provide motor innervation to the detrusor muscle and inhibit the internal urethral sphincter. http://www.medscape.com/viewarticle/772264_4 http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm Note: Parasympathetic fibers are the main motor supply to the bladder (with the exception of the
trigone) and hence far outnumber the sympathetic fibers in the bladder.
http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm http://www.medscape.com/viewarticle/772264_4 Somatic innervation (to the external urethral sphincter): somatic fibers arise from the motor neurons in the S2-4 cord segments and travel to the external urethral sphincter via the pudendal nerve. http://www.medscape.com/viewarticle/772264_4 Note: The pudendal nerve is a nerve in the pelvic region that carries sensory and motor fibres. It
does not carry parasympathetic fibres. The pudendal nerve innervates the external genitalia of both sexes, as well as sphincters for thebladder and the rectum.
[1]
http://en.wikipedia.org/wiki/Pudendal_nerve
Sensory innervation: The parasympathetic, sympathetic and somatic nerve fibers all have accompanying afferent nerve fibers, which then pass through the dorsal root to the spinal cord. http://www.urology-textbook.com/bladder-anatomy.html
GVA fibers on the superior surface follow the course of the sympathetic efferent fibers back to the CNS, while GVA fibers on the inferior portion of the bladder follow the course of the parasympathetic efferents & somatic fibers.
http://en.wikipedia.org/wiki/Urinary_bladder#Innervation
http://classconnection.s3.amazonaws.com/340/flashcards/550340/jpg/bladder_innervation131539136 0068.jpg
http://www.netterimages.com/image/4474.htm
http://www.pinterest.com/pin/565905509397250413/
Storage Reflex As urine accumulates, distension of the bladder activates stretch receptors, which trigger spinal reflexes, resulting in storage of urine.
http://classes.midlandstech.edu/carterp/Courses/bio211/chap25/chap25.htm
http://www.austincc.edu/apreview/PhysText/Renal.html
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
Urine storage reflexes. During the storage of urine, distention of the bladder produces low-level vesical afferent firing. This in turn stimulates the sympathetic outflow in the hypogastric nerve to the bladder outlet (the bladder base and the urethra) and the pudendal outflow to the external urethral sphincter. These responses occur by spinal reflex pathways and represent guarding reflexes, which promote continence.
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
Micturition Reflex
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html [Not that correct. I think]
Voiding reflexes. During the elimination of urine, intense bladder-afferent firing in the pelvic nerve activates spinobulbospinal reflex pathways (shown in blue) that pass through the pontine micturition centre. This stimulates the parasympathetic outflow to the bladder and to the urethral smooth muscle (shown in green) and inhibits the sympathetic and pudendal outflow to the urethral outlet (shown in red).
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html Note: Note that these diagrams do not address the generation of conscious bladder sensations, nor the
mechanisms that underlie the switch from storage to voiding, both of which presumably involve cerebral circuits above the PAG. R represents receptors on afferent nerve terminals.
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
http://www.austincc.edu/apreview/NursingPics/RenalPics/Picture30.jpg [Not that correct. I think]
http://urologycochin.com/diseases/DiseasesDetails.aspx?disID=1 [CORRECT. I think] http://urologycochin.com/UserFiles/urology/urinary(1).jpg
http://www.alilamedicalimages.org/BrowseImages/browse-topics/ [CORRECT. I think]
http://users.atw.hu/blp6/BLP6/HTML/common/M9780323045827-011-f003.jpg [CORRECT] Note: The three correct diagrams are supported by the following source: http://highered.mcgrawhill.com/sites/0072495855/student_view0/chapter27/animation__micturition_reflex.html
Nursing Care Plan & Documentation: Nursing Diagnoses and Collaborative Problems 5th edition p.275e
Rehabilitation Nursing: Prevention, Intervention, and Outcomes 2008 p.346e READ Rehabilitation Nursing: Prevention, Intervention, and Outcomes 2008 p.345 - 348e
http://en.wikipedia.org/wiki/Pelvic_outlet http://en.wikipedia.org/wiki/Pubic_arch Perineum: is defined to be the inferiormost portion of the trunk (group of soft tissues including skin, muscles, and fasciae) in both males and females corresponding to the pelvic outlet. The perineum has a roof formed by the pelvic diaphragm and a floor of fascia and skin. http://en.wikipedia.org/wiki/Perineum (roof = pelvic diaphragm) http://www.dummies.com/how-to/content/the-anatomy-of-the-perineum.html (roof pelvic diaphragm, floor is fascia and skin) Essentials of Anatomy by I.B. singh 2008 p.241e (corresponding to pelvic outlet) Atlas of Anatomy 2nd edition Thieme p.215 (inferiormost portion of the trunk) http://learnhumananatomy.com/perineum/ (group of soft tissues) BRS Gross Anatomy 2011 p.244e (floor is skin and fascia, roof is pelvic diaphragm) That is, the perineum is defined as the inferiormost portion of the trunk enclosed by and beneath the pelvic outlet. Therefore, it can be said that the perineum has the same boundaries as the pelvic outlet. It is separated from the pelvic cavity by the pelvic diaphragm. Mastery of Surgery, Volume 1, 5th edition p.1873e https://www.dartmouth.edu/~humananatomy/part_6/chapter_38.html
The deep limit of the perineum is the inferior surface of the pelvic diaphragm and its superficial limit is the skin.
http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&dec orator=none&eid=4-u1.0-B978-0-443-06684-9..50071-8--cesec90&isbn=978-0-443-06684-9 Note: Its definition varies: it can refer to only the superficial structures in this region, or it can be used to
include both superficial and deep structures.
http://en.wikipedia.org/wiki/Perineum Note: Some authors denote what we described above as the “perineal region” and reserve the term “perineum” to describe what we called the surgical perineum. See below. https://www.dartmouth.edu/~humananatomy/part_6/chapter_38.html
Urogenital Triangle and Anal Triangle The perineum is divided into an anterior urogenital triangle and a posterior anal triangle by a line connecting the two ischial tuberosities. BRS Gross Anatomy 2011 p.244e
Atlas of Anatomy 2nd edition Thieme p.215
Atlas of Anatomy 2nd edition Thieme p.215
The Diagrams Below is From Deep to Superficial
Atlas of Anatomy 2nd edition Thieme p.224
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
https://www.inkling.com/read/gray-anatomy-students-drake-vogl-mitchell-2nd/chapter-5/regionalanatomy-perineum
Atlas of Anatomy 2nd edition Thieme p.227
Atlas of Anatomy 2nd edition Thieme p.225
Coronal View
BRS Gross Anatomy 2011 p.244 – 245e
Atlas of Anatomy 2nd edition Thieme p.232
Pelvic Diaphragm (aka pelvic floor): the paired levator ani (consisting of puborectalis, pubococcygeus,
iliococcygeus) and coccygeus muscles together with the fascia above and below them. The pelvic diaphragm separates the pelvic cavity from the perineum.
http://www.medilexicon.com/medicaldictionary.php?t=24474 (fascia) Atlas of Anatomy 2nd edition Thieme p.226 http://en.wikipedia.org/wiki/Pelvic_floor (aka pelvic floor) http://teachmeanatomy.info/pelvis/pelvic-floor/ (separates pelvic cavity from perineum, aka pelvic floor) That is, there are three components of the pelvic floor:
Levator ani muscles (largest component). Coccygeus muscle. Fascia coverings of the muscles (the superior and inferior fascia of pelvic diaphragm)
http://teachmeanatomy.info/pelvis/pelvic-floor/ (fascia) Textbook of Gynecology 2011 p.200e (superior and inferior fasica) Anand’s Human Anatomy for Dental Students p.39e (fascia) The levator ani muscles and coccygeus muscle together is referred to as the muscles of the pelvic diaphragm. http://teachmeanatomy.info/pelvis/pelvic-floor/ Note: some texts consider the pelvic floor to include the perineal membrane and deep perineal pouch. We have considered these as a distinct and separate structures. http://teachmeanatomy.info/pelvis/pelvic-floor/
Some sources do not consider "pelvic floor" and "pelvic diaphragm" to be identical, with the "diaphragm" consisting of only the levator ani and coccygeus, while the "floor" also includes the perineal membrane and deep perineal pouch.
http://en.wikipedia.org/wiki/Pelvic_floor Urogenital Diaphragm Superficial to the pelvic diaphragm is the urogenital diaphragm. Pelvic Floor Disorders: Imaging and Multidisciplinary Approach to Management 2010 p.122e The urogenital diaphragm is a musculo fascial partition. It is made up of a sheet of muscles namely, sphincter erethrae and a pair of deep transverse perineal muscle. It includes the superior and inferior fascia of the sheet of muscle. Anand’s Human Anatomy for Dental Students p.39e http://learnhumananatomy.com/perineum/
http://www.yogatuneup.com/blog/wp-content/uploads/2013/10/perineal-muscles.jpg
Perineal Membrane The perineal membrane is the inferior fascia of the urogenital diaphragm. BRS Gross Anatomy 2011 p. 245e The perineal membrane forms (inferior fascia of the urogenital diaphragm) forms the inferior boundary of the deep perineal pouch and the superior boundary of the superficial perineal pouch. BRS Gross Anatomy 2011 p. 245e Atlas of Anatomy 2nd edition Thieme p.232
http://en.wikipedia.org/wiki/File:Gray407.png
http://academic.amc.edu/martino/grossanatomy/site/Medical/CASES/Reproduction/Pictures/perineal% 20pouches.jpg External Anal Sphincter Superficial to the pelvic diaphragm (with its fascia), we have the external anal sphincter. http://learnhumananatomy.com/perineum/ Superficial Transverse perineal muscle, Ischiocavernousus muscle, bulbospongiousus muscle These muscles are found superficial to the urogenital diaphragm (with its fascia). http://learnhumananatomy.com/perineum/
The layers and contents are as follows, from superficial to deep: 1) Foreskin 2) superficial perineal fascia: Subcutaneous tissue divided into two layers: (a) A superficial fatty layer, and (b) Colles' fascia, a deeper, membranous layer. 3) deep perineal fascia and muscles: Contains superficial perineal muscles: transversus perinei superficialis,bulbospongiosus, ischiocavernosus
Superficial perineal pouch
Inferior fascia of urogenital diaphragm, orperineal membrane
A membranous layer of the deep fascia.
Deep perineal pouch
Contains the deep perineal muscles: transversus perinei profundus, sphincter urethrae membranaceae
Superior fascia of the urogenital diaphragm
Considered hypothetical by some modern anatomists, but still commonly used to logically divide the contents of the region.
4) fascia and muscles of pelvic floor (levator ani, coccygeus)
http://en.wikipedia.org/wiki/Perineum
Layers of the Urinary Bladder 1. Serous Mucosa: Outermost layer. Epithelium + a layer of CT 2. Muscularis Externa: is the detrusor muscle which forms the wall of the urinary bladder. 3. Submucosa: a thin layer of areolar tissue that loosely connects the muscularis externa with the mucosa. 4. Mucosa: Innermost layer. Transitional epithelium + lamina propria http://www.ivy-rose.co.uk/HumanBody/Urinary/Urinary_System_Bladder.php
TERMINOGIES ON INNERVATIONS
http://en.wikipedia.org/wiki/General_visceral_afferent_fibers http://en.wikipedia.org/wiki/General_visceral_efferent_fibers http://en.wikipedia.org/wiki/General_somatic_afferent_fibers http://en.wikipedia.org/wiki/General_somatic_efferent_fibers
However, unlike the efferent fibers of the autonomic nervous system, the afferent fibers are not classified as either sympathetic or parasympathetic.
http://en.wikipedia.org/wiki/General_visceral_afferent_fibers
Ventral root (or anterior root) is the efferent motor root of a spinal nerve.
http://en.wikipedia.org/wiki/Anterior_root_of_spinal_nerve
Dorsal root (or posterior root) is the afferent sensory root of a spinal nerve.
http://en.wikipedia.org/wiki/Posterior_root_of_spinal_nerve Spinal nerve: At its distal end, the ventral root joins with the dorsal root to form a mixed spinal nerve.
Contains both motor and sensory fibers.
http://en.wikipedia.org/wiki/Anterior_root_of_spinal_nerve
Ventral rami: The ventral rami is the anterior branch (division) of the spinal nerve. It supplies the antero-lateral parts of the trunk and the limbs. Note: The ventral rami also contains both motor and sensory fibers. http://en.wikipedia.org/wiki/Anterior_ramus_of_spinal_nerve http://anatomy.uams.edu/anatomyhtml/intronervsys.html Posterior rami: The posterior rami is the posterior branch (division) of the spinal nerve. They are
directed backward, and, with the exceptions of those of the first cervical, the fourth and fifth sacral, and the coccygeal, divide into medial andlateral branches for the supply of the muscles andskin of the posterior part of the trunk. Note: The posterior rami also contains both motor and sensory fibers.
http://en.wikipedia.org/wiki/Posterior_ramus_of_spinal_nerve http://anatomy.uams.edu/anatomyhtml/intronervsys.html Note: As branches of the mixed spinal nerve, the posterior and anterior rami carry both motor and sensory fibers, as do all their subsequent branches. The terms motor nerve andsensory nerve are almost always relative terms, referring to the majority of fiber types conveyed by that nerve. Nerves supplying muscles of the trunk or limbs (motor nerves) also contain about 40% sensory fibers, which convey pain and proprioceptive information. Conversely, cutaneous (sensory) nerves contain motor fibers, which serve sweat glands and the smooth muscle of blood vessels and hair follicles. https://www.inkling.com/read/clinically-oriented-anatomy-moore-agur-dalley-7th/introduction-toclinically/nervous-system Rammi communicans: refers to the nerve that connects the spinal nerve and the sympathetic trunk. http://en.wikipedia.org/wiki/Ramus_communicans
http://upload.wikimedia.org/wikipedia/commons/8/87/Spinal_nerve_CAT.svg
http://dc363.4shared.com/doc/Xp16yZ2V/preview.html
http://dc363.4shared.com/doc/Xp16yZ2V/preview.html
General Anatomy and Musculoskeletal System (Thieme) 2010 p.63e
http://en.wikipedia.org/wiki/File:Gray799.svg White ramus communicans: is the preganglionic sympathetic outflow nerve tract from the spinal cord. It contains both myelinated and unmyelinated preganglionic sympathetic fibers (GVE and GVA). The white ramus appears white because they are more myelinated than unmyelinated fibers. http://en.wikipedia.org/wiki/White_ramus_communicans Note: The white ramus communicans containing preganglionic sympathetic fibers from the anterior root joins the corresponding sympathetic ganglion, and the gray ramus communicans containing postganglionic sympathetic fibers from the sympathetic ganglion rejoins the spinal nerve. Both white and gray rami communicans contain afferent fibers, which include some for pain. Surgical Management of Pain by Kim Burchiel (Thieme) 2002 p.677e
Abdominal Aortic Plexus (aka intermesenteric plexus): The abdominal aortic plexus, also known as the
intermesenteric plexus, is formed by fibers contributed by the celiac plexus and ganglia and by the L-1 and L-2 splanchnic nerves.
http://drugswell.com/wowo/blog1.php/2011/06/08/general-considerations-of-abdominal-pain?page=3 Bonica’s Management of Pain 2001 p.1250g Essentials of Human Anatomy 1988 p.497Q (L1, L2) Urotext-Lut: Urology 2001 p.123e (splanchnic nerves) Note: the intermesenteric plexus is part of the aortic plexus of nerves between the superior and the interior mesenteric arteries. Clinically Oriented Anatomy 2013 p.305e Superior hypogastric plexus: The superior hypogastric plexus receives contributions from the intermesenteric plexus, as well as contributions from L3 and L4 splanchnic nerves. http://www.surgerytemplates.com/operationnotes.htm (intermesenteric plexus, L3, L4) Instant Anatomy by Robert H. Whitaker 4th edition p.4e (intermesenteric plexus, L3, L4) Anatomy: An Essential Textbook by Anne M Gilroy (Thieme) 2013e (intermesenteric plexus, L3, L4) Chronic Pelvic Pain and Dysfunction: Practical Physical Medicinee (L3, L4) http://www.wikiradiography.com/page/Nerve+Supply+to+the+Pelvis (intermesenteric plexus, L3, L4) http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/modules/pelvic_autonomic_mod ule/pelvic_page04.html (intermesenteric plexus, L3, L4) BRS Gross Anatomy 7th edition p.276e (intermesenteric plexus, L3, L4) http://anatomytopics.wordpress.com/author/sahajap/ (intermesenteric plexus, L3, L4) Note: the superior hypogastirc plexus contains no parasympathetic fibers, so it is a purely sympathetic plexus. http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/modules/pelvic_autonomic_mod ule/pelvic_page04.html http://www.netteranatomy.com/anatomylab/subregions.cfm?subregionID=R511&contentDir=anatomyl ab/contents/region/pelvisandperineum/innervation Note: the superior hypogastric plexus is continuous with the intermesenteric plexus and the inferior mesenteric plexus and lies anterior to the inferior part of the abdominal aorta at its bifurcation. Clinically Oriented Anatomy 2013 p.305e Hypogastric Nerve: The hypogastric nerve begins where the superior hypogastric plexus splits into a right and left plexus. Each of these divisions is considered a hypogastric nerve. The hypogastric nerve continues inferiorly on its corresponding side of the body, where it descends into the pelvis to form the inferior hypogastric plexus. Contents of the right and left hypogastric nerves include pre- and postganglionic sympathetic fibers from vertebral levels of T10-L2. The hypogastric nerve is responsible for emission (prior to ejaculation, which is instead the pudendal nerve); emission is sympathetic nervous system-mediated. http://en.wikipedia.org/wiki/Hypogastric_nerve
Inferior hypogastric plexus: is formed by nerve fibers coming through the following sources:
Hypogastric nerve (from the superior hypogastric plexus) Sacral splanchnic nerves that emerge from the sympathetic chain Pelvic splanchnic nerves that contribute parasympathetic fibers to the plexus (S2, S3, S4). The inferior hypogastric plexus thus contains both sympathetic and parasympathetic fibers as well as visceral afferent fibers.
http://www.mananatomy.com/body-systems/nervous-system/inferior-hypogastric-plexus Farquharon’s Textbook of Operative General Surgery 9th edition p.379e http://en.wikipedia.org/wiki/Inferior_hypogastric_plexus Clinically Oriented Anatomy 2013 p.360e Note: Both superior and inferior hypogastric plexuses are networks of sympathetic and visceral afferent nerve fibers. Clinically Oriented Anatomy by Moore 2013 p.360e
Innervation of the Bladder & Urethra Sympathetic innervation (to bladder & urethra): sympathetic fibers arise from T10 – L2 cord segments, then travel through the sympathetic trunk. After that, travel via lumbar splanchnic nerves, and then through the superior hypogastric plexus, and supply the bladder via the right and left hypogastric nerves. (Note: some fibers of the hypogastric nerve may directly innervate the bladder, while some fibers travel through the inferior hypogastric plexus, before innervating the bladder and urethra) http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm http://www.medscape.com/viewarticle/772264_4 Urinary Tract by Karl-Erik Andersson 2011 p.101e The sympathetic innervation of the bladder is divided into two distinct groups, those that innervate the main portion of the bladder and those that innervate the bladder neck and the urethra (including the internal urethral sphincter). Of these two areas, the bladder neck and sphincter receive the strongest innervation. Urinary Tract by Karl-Erik Andersson 2011 p.101e Sympathetic innervation to the bladder causes relaxation of the detrusor muscle (have little effect though). Sympathetic innervation to the bladder neck causes bladder neck closure which is necessary for bladder filling. Finally, sympathetic innervation also cause the internal urethral sphincter to constrict. Urinary Tract by Karl-Erik Andersson 2011 p.101e Handbook of Neurosurgery (Thieme) 7th edition p.117e Parasympathetic innervation (to bladder & urethra): parasympathetic fibers arise from S2 – S4 cord segments, forming pelvic splanchnic nerves which supply the bladder & urethra through the inteferior hypogastric plexus. Parasympathetic fibers provide motor innervation to the detrusor muscle and inhibit the internal urethral sphincter. http://www.medscape.com/viewarticle/772264_4 http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm Note: Parasympathetic fibers are the main motor supply to the bladder (with the exception of the
trigone) and hence far outnumber the sympathetic fibers in the bladder.
http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/anesthesia/site/content/v04/040149r00.htm http://www.medscape.com/viewarticle/772264_4 Somatic innervation (to the external urethral sphincter): somatic fibers arise from the motor neurons in the S2-4 cord segments and travel to the external urethral sphincter via the pudendal nerve. http://www.medscape.com/viewarticle/772264_4 Note: The pudendal nerve is a nerve in the pelvic region that carries sensory and motor fibres. It
does not carry parasympathetic fibres. The pudendal nerve innervates the external genitalia of both sexes, as well as sphincters for thebladder and the rectum.
[1]
http://en.wikipedia.org/wiki/Pudendal_nerve
Sensory innervation: The parasympathetic, sympathetic and somatic nerve fibers all have accompanying afferent nerve fibers, which then pass through the dorsal root to the spinal cord. http://www.urology-textbook.com/bladder-anatomy.html
GVA fibers on the superior surface follow the course of the sympathetic efferent fibers back to the CNS, while GVA fibers on the inferior portion of the bladder follow the course of the parasympathetic efferents & somatic fibers.
http://en.wikipedia.org/wiki/Urinary_bladder#Innervation
http://classconnection.s3.amazonaws.com/340/flashcards/550340/jpg/bladder_innervation131539136 0068.jpg
http://www.netterimages.com/image/4474.htm
http://www.pinterest.com/pin/565905509397250413/
Storage Reflex As urine accumulates, distension of the bladder activates stretch receptors, which trigger spinal reflexes, resulting in storage of urine.
http://classes.midlandstech.edu/carterp/Courses/bio211/chap25/chap25.htm
http://www.austincc.edu/apreview/PhysText/Renal.html
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
Urine storage reflexes. During the storage of urine, distention of the bladder produces low-level vesical afferent firing. This in turn stimulates the sympathetic outflow in the hypogastric nerve to the bladder outlet (the bladder base and the urethra) and the pudendal outflow to the external urethral sphincter. These responses occur by spinal reflex pathways and represent guarding reflexes, which promote continence.
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
Micturition Reflex
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html [Not that correct. I think]
Voiding reflexes. During the elimination of urine, intense bladder-afferent firing in the pelvic nerve activates spinobulbospinal reflex pathways (shown in blue) that pass through the pontine micturition centre. This stimulates the parasympathetic outflow to the bladder and to the urethral smooth muscle (shown in green) and inhibits the sympathetic and pudendal outflow to the urethral outlet (shown in red).
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html Note: Note that these diagrams do not address the generation of conscious bladder sensations, nor the
mechanisms that underlie the switch from storage to voiding, both of which presumably involve cerebral circuits above the PAG. R represents receptors on afferent nerve terminals.
http://www.nature.com/nrn/journal/v9/n6/fig_tab/nrn2401_F5.html
http://www.austincc.edu/apreview/NursingPics/RenalPics/Picture30.jpg [Not that correct. I think]
http://urologycochin.com/diseases/DiseasesDetails.aspx?disID=1 [CORRECT. I think] http://urologycochin.com/UserFiles/urology/urinary(1).jpg
http://www.alilamedicalimages.org/BrowseImages/browse-topics/ [CORRECT. I think]
http://users.atw.hu/blp6/BLP6/HTML/common/M9780323045827-011-f003.jpg [CORRECT] Note: The three correct diagrams are supported by the following source: http://highered.mcgrawhill.com/sites/0072495855/student_view0/chapter27/animation__micturition_reflex.html
Nursing Care Plan & Documentation: Nursing Diagnoses and Collaborative Problems 5th edition p.275e
Rehabilitation Nursing: Prevention, Intervention, and Outcomes 2008 p.346e READ Rehabilitation Nursing: Prevention, Intervention, and Outcomes 2008 p.345 - 348e
