Dr.

Heba Tutoring Anatomy

Gonadal drainage
A. Venous drainage:
 Left ovary/testis → left gonadal vein → left renal vein → IVC.

 Right ovary/testis → right gonadal vein → IVC.

 “Left gonadal vein takes the Longest way”.

 Because the left spermatic vein enters the left renal vein at a 90°
angle, flow is less laminar on left than on right → left venous
pressure > right venous pressure → varicocele more common on the
left.

B. Lymphatic drainage:
 Ovaries/testes → para-aortic lymph nodes.

 Body of uterus/cervix/superior bladder → external iliac nodes.

 Prostate/cervix/corpus cavernosum/proximal vagina → internal iliac

nodes.

 Distal vagina/vulva/scrotum/distal anus → superficial inguinal nodes.

 Due to its intra-abdominal origin, lymphatic drainage of the testis is to

the para-aortic lymph nodes, contrast, lymph drainage from the
scrotum goes into the superficial inguinal lymph nodes.

 Glans penis → deep inguinal nodes.

 Dr. Heba Tutoring Anatomy

 N.B:
 Lymphatic drainage of the scrotum occurs via the superficial inguinal
lymph nodes.

 These lymph nodes drain nearly all cutaneous lymph from the
umbilicus to the feet, including the external genitalia and anus (up to
the dentate line).

 The exceptions are the testis, glans penis, and the cutaneous portion
of the posterior calf.

 Lymph from the testes drains directly into the para-aortic

(retroperitoneal) lymph nodes.

 During fetal development, the testes originate within

theretroperitoneum and establish their arterial supply from the
abdominal aorta. The testes subsequently descend through the
inguinal canals into the scrotum, taking with them their arterial, venous,
and lymphatic supplies. Thus, lymph from the testes drains through
lymph channels directly back to the para-aortic (retroperitoneal) lymph
nodes.

 Lymph from the glans penis and the cutaneous portion of the posterior
calf drains into the deep inguinal lymph nodes.

 The superficial inguinal lymph nodes also drain into the deep inguinal
lymph nodes.
Dr. Heba Tutoring Anatomy

Female Reproductive Anatomy

 Dr. Heba Tutoring Anatomy

 Female reproductive system is held in place by several peritoneal

ligaments, of which the following are the most important:

1. Broad ligament:
 Fold of peritoneum that comprises the mesosalpinx (a subdivision of
broad ligament that suspends Fallopian tubes), mesometrium (a
subdivision of broad ligament that suspends uterus), and mesovarium
(a subdivision of broad ligament that suspends ovaries).

 Connects: Uterus, fallopian tubes, and ovaries to pelvic side wall.

 Structures contained: Ovaries, fallopian tubes, round ligaments of

uterus.

2. Ovarian ligament:
 Connects: Medial pole of ovary to lateral uterus.

 Derivative of gubernaculum.

3. Infundibulopelvic ligament (suspensory ligament of the ovary):

 Connects: Ovaries to lateral pelvic wall.

 Structures contained:
 The nerves, arteries, veins, and lymphatics supplying the ovary are
all delivered by the suspensory ligament of the ovary.

 The ovarian blood supply is provided by the ovarian arteries, which

arise from the abdominal aorta bilaterally.

 Ligate vessels during oophorectomy to avoid bleeding.

 Ureter courses retroperitoneally, close to gonadal vessels → at risk

of injury during ligation of ovarian vessels.

 Rotation of the ovary around the IP ligament results in ovarian

torsion.

4. Round ligament of the uterus:

 Connects: Uterine fundus to labia majora.

 It contains the artery of Sampson which rarely is a source of a major

bleeding.

 Derivative of gubernaculum.
 Dr. Heba Tutoring Anatomy

5. Cardinal ligament:
 Also known as transverse cervical ligaments.

 Connects: Cervix to side wall of pelvis.

 Structures contained: Uterine vessels.

 Ureter at risk of injury during ligation of uterine vessels in

hysterectomy.

A. Vesicouterine pouch: a peritoneal sac between bladder and uterus.

B. Rectouterine pouch (of Douglas):

 A peritoneal sac between uterus and rectum.

 Lies behind posterior fornix of vagina.

 Lowest portion of peritoneal cavity.

 As it is the furthest point of the abdominopelvic cavity in women, it is a

site where infection and fluids typically collect.

 Culdocentesis is aspiration of fluid from rectouterine pouch by a

needle puncture of posterior fornix of n vagina.
 Dr. Heba Tutoring Anatomy

Tissue Histology
Vulva Stratified squamous epithelium
Stratified squamous epithelium
Ectocervix Stratified squamous epithelium, nonkeratinized
Transformation zone Squamocolumnar junction (most commonarea for
cervical cancer)
Endocervix Simple columnar epithelium
Uterus Simple columnar epithelium with long tubularglands in
proliferative phase; coiled glands insecretory phase
Fallopian tube Simple columnar epithelium, ciliated
Ovary, outer surface Simple cuboidal epithelium (germinal epithelium covering
surface of ovary)

❖ N.B:
1. The perineal body is essential to the integrity of the pelvic floor.
 This tendinous center point of the perineum separates the urogenital
and anal triangles.

 Episiotomies are used to enlarge the vaginal outlet to facilitate

delivery and reduce the risk of severe perineal laceration.

 A midline episiotomy is a vertical incision from the posterior vaginal

opening to the perineal body. It transects the vaginal lining and the
submucosal tissue but not the external anal sphincter or the rectal
mucosa.
 Dr. Heba Tutoring Anatomy

2. Postpartum hemorrhage is an obstetrical emergency and a leading

cause of maternal mortality.
 Postpartum hemorrhage is frequently caused by failure of the uterus
to contract and compress the placental site blood vessels.

 Risk factors include prolonged labor and twin gestation. These

conditions lead to uterine atony (loss of uterine tone), characterized
by a boggy uterus that cannot contract effectively after placental
delivery.

 Surgery is indicated when medical management (uterine massage,

uterotonic medications) of postpartum hemorrhage fails to control
bleeding.

 The pelvic organs are mainly supplied by the internal iliac arteries
(also known as the hypogastric arteries).

 The uterine arteries, the major blood supply to the uterus, are
branches of the internal iliac arteries. Bilateral ligation (suturing) of the
internal iliac arteries should stop uterine blood flow and hemorrhage,
thereby preventing the need for hysterectomy. The uterus has
collateral blood flow from the ovarian arteries, which is sufficient to
maintain uterine function after internal iliac ligation.

3. A pudendal nerve block is one method of providing anesthesia during

childbirth.
 The pudendal nerve is derived from the S2 - S4 nerve roots and
provides sensory innervation to the perineum and genitals (of both
sexes) as well as motor innervation to the sphincter urethrae (external
urethral sphincter) and the external anal sphincter.

 When administering a pudendal nerve block, the physician generally

palpates intravaginally for the ischial spines and attempts to
administer the anesthetic agent in that location.
Dr. Heba Tutoring Anatomy
 Dr. Heba Tutoring Anatomy

Male Reproductive Anatomy

 Pathway of sperm during ejaculation
(SEVEN UP):
 Seminiferous tubules.
 Epididymis.
 Vas deferens.
 Ejaculatory ducts.
 (Nothing).
 Urethra.
 Penis.

Retrograde ejaculation
 The urethral sphincters are used to control the exit of urine and
semen through the urethra.

 In males and females, both internal and external urethral sphincters

function to inhibit the release of urine.

 In males, the internal sphincter muscle of urethra functions to prevent

reflux of seminal fluids into the male bladder during ejaculation.

 Normally, the sphincter of the bladder contracts before ejaculation

forcing the semen to exit via the urethra, the path of least resistance.

 When the bladder sphincter does not function properly, retrograde

ejaculation may occur.
 Dr. Heba Tutoring Anatomy

Urethral injury
 Suspect if blood seen at urethral meatus.

 Urethral injuries most commonly occur in men because of their longer

urethral length and are divided into anterior and posterior urethral
injuries.

 The posterior urethra is located above the bulb of the penis, and the
anterior urethra lies within the bulb and the remainder of the corpus
spongiosum.

 The posterior urethra is further divided into the prostatic and

membranous segments; the anterior urethra is divided into bulbous
and penile segments.

 If urethral injury is suspected, placement of a Foley catheter is

contraindicated and should not be attempted as it can worsen the
injury; a retrograde urethrogram should be performed first to assess
urethral integrity.
 Dr. Heba Tutoring Anatomy

A. Anterior urethral injury:

 Part of urethra: Bulbar (spongy) urethra.

 Mechanism of injury: Perineal straddle injury.

 Location of urine leak/blood accumulation:

 Blood accumulates in scrotum.

 If Buck fascia is torn, urine escapes into perineal space.

 Presentation: Blood at urethral meatus and scrotal hematoma.

B. Posterior urethral injury:

 Part of urethra:
 Membranous urethra.

 In contrast to the prostatic and bulbous segments, the membranous

segment is relatively unsupported by the adjacent tissues and is the
weakest point of the posterior urethra.

 Mechanism of injury: Pelvic fracture.

 Location of urine leak/blood accumulation: Urine leaks into retropubic

space.

 Presentation:
 Inability to void with a full bladder sensation, a high-riding boggy
prostate (caused by hematoma formation below the gland), and blood
at the urethral meatus are suggestive of urethral injury, particularly in
the presence of a pelvic fracture.
 Dr. Heba Tutoring Anatomy

Penis Anatomy
 The penis is made of several parts:
A. Glans (head) of the penis.

B. Corpus cavernosum:
 Two columns of tissue running along the sides of the penis.

 Blood fills this tissue to cause an erection.

C. Corpus spongiosum:
 A column of sponge-like tissue running along the front of the penis and
ending at the glans penis.

 The urethra runs through the corpus spongiosum, conducting urine

out of the body.

 An erection results from changes in blood flow in the penis. When a

man becomes sexually aroused, nerves cause penis blood vessels to
expand → More blood flows in and less flows out of the penis,
hardening the tissue in the corpus cavernosum.
 Dr. Heba Tutoring Anatomy

Autonomic innervation of the male sexual response

A. Erection:
 Parasympathetic nervous system (pelvic splanchnic nerves, S2-S4).

 NO →↑ cGMP → smooth muscle relaxation → vasodilation →

proerectile.

 Norepinephrine →↑ [Ca] → smooth muscle contraction →

vasoconstriction → antierectile.

 Emission:
 Phase when sperm moves from testes up to prostatic urethra.

 Sympathetic nervous system (hypogastric nerve, T11-L2).

 Ejaculation:
 Phase when sperm moves from prostatic urethra to the outside.

 Visceral and Somatic nerves (pudendal nerve).

 Point, Squeeze, and Shoot.

 S2, 3, 4 keep the penis off the floor.

 PDE-5 inhibitors (sildenafil) →↓ cGMP breakdown.

 Dr. Heba Tutoring Anatomy

 N.B:
 The lesser and greater cavernous nerves arise from the prostatic
plexus and pass beneath the pubic arch to innervate the corpora
cavernosa of the penis and urethra.

 The cavernous nerves carry post-ganglionic parasympathetic fibers

that facilitate penile erection.

 The prostatic plexus lies within the fascia of the prostate and
originates from the inferior hypogastric plexus (which itself is a
continuation of the hypogastric nerve with additional input from the
pelvic and sacral splanchnic nerves).

 Prostatectomy or injury to the prostatic plexus can cause erectile

dysfunction; as a result, surgeons attempt to preserve the integrity of
the prostatic fascial shell during surgery.