abdominal wall akmal abbasi. abdominal wall the muscles of the abdomen may be divided into two...

Abdominal Wall

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Abdominal Wall

• The muscles of the abdomen may be divided into two groups:

• (1) the anterolateral muscles• (2) the posterior muscles.   • Antero-lateral Muscles of the Abdomen—The

muscles of this group are:   *Obliquus externus. *Rectus.*Transversus. *Obliquus internus.*Pyramidalis.

Abdominal Wall

• The Superficial Fascia.—divisible into two layers.

• The superficial layer (fascia of Camper).

• The deep layer (fascia of Scarpa).

Abdominal Wall

• The Posterior Muscles of the Abdominal wall are:

• Psoas major.

• Iliacus.

• Psoas minor.

• Quadratus lumborum.

Pelvis---Boundaries, Types & Contents

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Anatomy of the bony pelvis

• It is composed of inlet, cavity and outlet.• (I) The Pelvic Inlet (Brim):• Boundaries:• Sacral promontory, alae of the sacrum, sacroiliac

joints, iliopectineal lines.• iliopectineal eminencies, upper border of the

superior pubic rami.• pubic tubercles, pubic crests and upper border of

symphysis pubis.

Anatomy of the bony pelvis

• (II) The Pelvic Cavity:• It is a segment , the boundaries of which

are:• - the roof is the plane of pelvic brim,• - the floor is the plane of least pelvic

dimension,• - anteriorly the shorter symphysis pubis,• - posteriorly the longer sacrum.

Anatomy of the bony pelvis

• (III) The Pelvic Outlet:• (A) Anatomical outlet:• It is lozenge-shaped bounded by; • the lower border of symphysis pubis,    • pubic arch, • ischial tuberosities,• sacrotuberous and sacrospinous ligaments and,      • tip of the coccyx.

Anatomy of the bony pelvis

• (B) Obstetric outlet:• It is a segment, the boundaries of which are:• - the roof is the plane of least pelvic dimension,• - the floor is the anatomical outlet,• - anteriorly the lower border of symphysis pubis,• - posteriorly the coccyx.• - laterally the ischial spines.

Diameters of superior aperture of lesser pelvis (female).

Diameters of inferior aperture of lesser pelvis (female).

Bony Pelvis

Types of True Pelvis

• Four types of female pelvis were described. Actually, the majority of pelvis are of mixed types:

• (I) Gynecoid pelvis(50%) :• It is the normal female type.• 1.     Inlet is slightly transverse oval.• 2.     Sacrum is wide with average concavity and

inclination.• 3.     Side walls are straight with blunt ischial spines.• 4.     Sacro- sciatic notch is wide.• 5.     Subpubic angle is 90-100o.

Types of True Pelvis

• (II) Anthropoid pelvis (25%):• It is ape-like type.

• 1.     All anteroposterior diameters are long.

• 2.     All transverse diameters are short.

• 3.     Sacrum is long and narrow.

• 4.     Sacro-sciatic notch is wide.

• 5.     Subpubic angle is narrow.

Types of True Pelvis

• (III) Android pelvis (20%):• It is a male type.• 1.     Inlet is triangular or heart-shaped with

anterior narrow apex.• 2.     Side walls are converging (funnel

pelvis) with projecting ischial spines.• 3.     Sacro-sciatic notch is narrow.• 4.     Subpubic angle is narrow <90o.

Types of True Pelvis

• (IV) Platypelloid pelvis (5%): • It is a flat female type.

• 1.     All anteroposterior diameters are short.

• 2.     All transverse diameters are long.

• 3.     Sacro-sciatic notch is narrow.

• 4.     Subpubic angle is wide.

Contents of Pelvis

Bones, Muscles, Urinary system, Reproductive system, GI tract.

Female Reproductive System

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External structures of the female reproductive anatomy include the labium minora and majora, the vagina and the clitoris. Internal structures include the uterus, ovaries and cervix.

External Structures

• Following are the external female genitalia (vulva, pudenda).

1. Mons veneris (monspubis)2. Labia majora and minora3. Clitoris4. Vestibule• ¨  Urinary meatus, or urethral orifice• ¨  Lesser vestibular, para urethral, or Skene’s

glands

External Structures

• ¨  Hymen and vaginal introitus ,orrifice

• ¨  Greater vestibular, vulvovaginal, or Bartholin’s glands

1. Fourchet

2. Perineum

The mons veneris or mons pubis

• Rounded, soft fullness of subcutaneous fatty tissue and loose connective tissue over the symphysis pubis.

• It contains many sebaceous (oil) glands and develops coarse, dark, curly hair at pubarche, about 1 to 2 years before the onset of the menses.

• The function of the mons are to play a role in sensuality and to protect the symphysis pubis during coitus.

Labia majora

• Are two rounded length wise folds of skin-covered fat and connective tissue that merge with the mons.

• Extend from the mons downward around the labia minora, ending in the perineum in the midline, and act as protection for the labia minora, urinary meatus, and vaginal introitus.

• On their lateral surfaces, the labial skin is thick, usually pigmented darker than the surrounding tissue, and covered with coarse hair.

• The medial (inner) surfaces of the labia majora are smooth, thick, and without hair.

clitoris

• The clitoris is a short, cylindric, erectile organ liked just beneath the arch of the pubis; the visible portion is about 6 x 6 mm.

• Its rich vascularity and innervation make the clitoris highly sensitive to temperature, touch, and pressure sensation.

• The vestibule is an ovoid or boat-shaped area formed between the labia minora, clitoris, and fourchet. 

• The vestibule contains the openings to the urethra, paraurethral (lesser vestibule, Skene’s) glands, the vagina, (greater vestibular or Bartholin’s) glands.

• The hymen is a partial, rarely complete, elastic but mucosa-covered fold around the vaginal introitus.

Greater vestibular (Bartholin’s) glands

• The greater vestibular (Bartholin’s) glands are two compound glands at the base of the labia majora, one on either side of the vaginal orifice.

• Each gland is drained by several ducts, about 1.5 cm long and opens into the groove between the hymen and the labia minora.

• The glands secrete a small amount of clear, viscid mucus, especially during coitus.

• The alkaline pH of the mucus is supportive of sperm. These glands are susceptible to gonorrheal infection and to abscess and cyst formation.

• The fourchet is a thin, flat, transverse fold of tissue formed where the tapering labia majora and minora merge in the midline below the vaginal orifice.

• The perineum is the skin-covered muscular area between the vaginal introitus and the anus.

• The perineum forms the base of the perineal body.

• Pelvic floor and perineum.The pelvic and perineum are composed of the pelvic diaphragm, the urogenital diaphragm or triangle, and the muscle of the external genitalia and anus.

• The upper pelvic diaphragm, composed of muscles and their fascia and ligaments, extends across the lowest part of the pelvic cavity.

• The largest and most significant portion of the diaphragm is formed by the pair of broad, thin levator ani muscles that extend sheet like between the ischial spines and coccyx, and the sacrum.

• The levator ani group of muscle is made up of three muscle pairs: puborectalis, iliococcygeus, and pubococcygeus muscles.

• The pubococcygeus muscle is particularly significant for women.

• Its importance lies on bladder control and during labor for controlling perineal relaxation and explanation of the fetus during birth.

• The urogenital (lowerpelvic) is located in the hollow of the pubic arch and consists of the transverse perineal muscles.

• The transverse perineal muscles originate at the ischial tuberosities and insert into the perineal body.

• The strong muscle fibers provide support to the anal canal during defecation and to the lower vagina during delivery.

• The deep transverse perineal muscles join to form a central seamor raphe.

• Some of their fibers encircle the urinary meatus and vaginal sphincters.

Perineum

• The perineum is located below the upper and lower pelvic diaphragm.

• Its muscles and fascia reinforce the strength of the pelvic diaphragm and aid in constricting the urinary, vaginal, and anal openings.

• The bulbocavernosus muscle (sphincter vagina fig.) fibers originate in the perineal body and surround the vaginal openings as the muscle fibers pass forward to insert into the pubis.

• The ischiocavernous muscle originate in the tuberosities of the ischium and continue at an angle to insert next to the bulbocavernosus muscle.

• These muscle fibers contrac to cause erection of the clitoris.

• Anal sphincter muscle fibers originate at the coccyx, separate to pass on either side of the anus, fuse, and then insert into the transverse perineal muscles.

• The bulbocavernosus, transverse perineal, and anal sphincter muscle fibers can be strengthened through Kegel exercises.

• The perineal body, the wedge-shaped mass between the vaginal and anal openings, serves as an anchor point for the muscle, fascia, and ligaments of the upper and lower pelvic diaphragm.

• The skin-covered base of the body is known as the perineum.

• The perineal body, about cm wide by cm deep, is continuous with the septum between the rectum and vagina.

Gross appearance of a normal uterus with fundus, cervix, vaginal cuff, right fallopian tube, left fallopian tube, right ovary, and left ovary.

Normal cervix with a smooth, glistening mucosal surface. There is asmall rim of vaginal cuff from this hysterectomy specimen. The cervical os is small and round, typical for a nulliparous woman. The os will have a fish-mouth shape after one or more pregnancies.

Internal Genitalia-Vagina

• Location and support.• The vagina is a tubular structure located in front of

the rectum and behind the bladder and urethra. • The vagina extends from the interoitus, the

external opening in the vestibule between the labia minora of the vulva, to the cervix.

• It is supported mainly by its attachment to the pelvic floor musculature and fascia.

Structure.

•  The vagina is a thin-walled, collapsible tube that is capable of great distention. Because of the way the cervix protrudes into the upper most portion of the vagina, the length of the anterior wall of the vagina is only about 7 to 8 cm while that of the posterior wall is about 10 cm.

• The recesses for med all around the protruding cervix are called fornices: right, left, anterior, and posterior.

• The posterior fornix is deeper than the other three.

• The smooth muscle walls are lined with glandular mucosa is arranged in transverse folds called rugae.

• Innervation. The vagina is relatively insensitive. There is some innervation from the pudendal and hemorrhoidal nerves to the lowest one third. The nerve supply is mainly autonomic. Sensations arising in the vagina terminate at the level of S2, S3, and S4.

• Blood supply. descending branches of the uterine artery, the middle hemorrhoidal artery, and the internal pudendal arteries. The venous return of the vaginal blood is through the pudendal, external hemorrhoidal, and uterine veins.

• Lymphatics. The lymphatics of the upper vagina drain to the recto vaginal septal, presacral, externaliliac, and hypogastric nods.

• The lower vaginal lymphatic are directed to the superficial inguinal nodes.

Internal Genitalia-Uterus

• The uterus is a hollow viscus composed of plain muscle whose sole function is gestation. It lies between the rectum and the bladder and is continuous with the vagina.

• Structure • Shape, size, and divisions. The uterus is a

fattened, hollow, muscular, thick-walled organ that looks some what like an upside-down pear.

• Its length,width, and thickness vary, averaging about. 7.5 cm 3.5 cm x 2 cm.

Internal Genitalia-Uterus

• In adult woman who has never been pregnant, the uterus weighs 60 g(2 oz).

• The uterus has three parts : the fundus, the upper, rounded prominence above the insertion of the fallopian tubes; the corpus, or main portion, encircling the intra-uterine cavity; and the isthmus, the slightly constricted portion that joins the corpus to the cervix and is known as the lower uterine segment during pregnancy.

Internal Genitalia-Uterus

• Uterine wall. The wall of the uterus is made up of three layers: the endometrium, the myometrium, and a partial outer layer of parietal peritoneum.

• Cervix The lower most portion of the uterus is the cervix, or neck.

• The attachment site of the uterine cervix to the vaginal vault divides the cervix into the longer supera vaginal (above the vagina) portion and the shorter vaginal portion. The length of the cervix is about 2.5 to 3 cm, of which about 1cm protrudes into the vagina in the non gravid woman.

Internal Genitalia-Uterus

• The external os is small before parturition.

• After the birth of a child it becomes a transverse slit ‘the parous os’

Uterine position

• For the majority of normal women, with the urinary bladder empty, the uterus is anteverted and slightly anteflexed. The cervix is directed downward and backward the tip of the sacrum so that it is usually at approximately a right angle to the plane of the vagina.

• For other women the uterus may be in the middle position or tipped backward (retroverted).

Uterine position

• A full bladder pushes the uterus back toward the rectum, while a full rectum moves the uterus forward against the bladder.

• Uterine position also changes depending on the woman’s position (e.g., lying supine, prone, on her side, or standing), her age, and pregnancy.

Uterine support.

• The uterus is supported by ligaments and by muscles of the pelvic floor, including the perineal body. A total of ligaments stabilize the uterus within the pelvic cavity: four paired ligaments (broad, round, uterosacral, and cardinal) and two single ligaments (anterior and posterior).

• The paired broad ligaments are double folds of parietal peritoneum that extend wing-like from the sides of the uterus to the pelvic walls.

Uterine support.

• These ligaments divide the pelvic cavity into anterior and posterior components.In the upper portion of the broad ligaments are suspended the fallopian tubes, ovaries, round ligaments, and ovarian ligaments.

Uterine support.

• The two round ligaments extend from the upper outer angles formed where the fallopian tubes join the uterine corpus (at the cornua), through the inguinal canals, and ending in the labia majora.

• The single anterior (uterovesical or pubocervical) ligament is a continuation of parietal peritoneum that forms the anterior fold of the broad ligament, extending from the anterior surface of the supra vaginal cervix of the uterus to the posterior surface of the bladder.

Uterine support.

• The denser connective tissue of the lower portion of the broad ligaments is sometimes known as the cardinal, transverse, or Mackenrodt’s

• The cardinal ligaments form the upper portion of the posterior ligament.

• The single posterior (or rectovaginal) ligament is a continuation of parietal peritoneum (posterior fold of broad ligament) extending from the posterior surface of the uterus to the rectum.

Uterine support.

• The posterior ligament forms the deep recto uterine pouch also known as the cul-de sac of Douglas

• This pouch is the lowest part of the abdominal cavity so that blood, pus, or other drainage collects here.

• The pouch can be reached through the posterior vaginal fornix.

Uterine support.

• The two uterosacral ligaments are cord like folds of peritoneum extending from the supravaginal cervical portion of the uterus to the fascia over the second and third sacral vertebrae passing on each side of the rectum.

• These ligaments hold the uterus in position by maintaining traction on the cervix.

• In summary the main uterine support are the ligaments surrounding the supravaginal cervix:

• Anterior (pubocervical)• Cardinal (transverse,Mackenrodt’s)• Posterior (rectovaginal)• Uterosacral

Uterine lymphatics.

• The lymphatics of the uterus are extensive.

• They are contained in three networks: at the base of the endometrium,within the myometrium,and just under the peritoneal coat of the uterus.

• Lymphatic drainage occurs mainly at the isthmus along the uterine vessels.

Uterine blood supply

• The abdominal aorta divides at about the level of the umbilicus and forms the two iliac arteries. Each iliac artery divides to forms the two iliac arteries,the major one of which is the hypogastric artery.The uterine arteries branch off from the hypogastric arteries.

• In the non pregnant state the uterine blood vessels are coiled and tortuous.With advancing pregnancy and enlarging uterus,these blood vessels straighten out.The uterine veins follow along the arteries and empty into the internal iliac veins.

Fallopian tubes.

• The paired Fallopian (uterine) tubes  measure about 12 cm in length.

• Each tube has an outer coat of peritoneum, a middle thin muscular coat, and an inner mucosa. 

• The smooth muscle fibers are arranged in an inner circular and an outer longitudinal layer.

• The mucosal lining consists of columnar cells some of which are ciliated and others of which are secretory.

• The structure of the fallopian tube changes along its length.

Fallopian tubes.

• Four distinctive segments can be identified:• The infundibulum,• The ampulla,• The isthmus,and• The interstitial part.• The infundibulum, is the most distal portion. Its

funnel-shaped opening is encircled with fimbria. • The fimbria are 2 cm long. The function of these

finger like projections is to pull the ovum into the tube.

Fallopian tubes.

• The ampulla makes up the distal and middle segment of the tube.

• It is in the ampulla that the sperm and ovum meet, where fertilization occurs.

• The isthmus is proximal to the ampulla. • The interstitial portion passes through the

myometrium between the fundus and the body of the uterus and is very narrow.

Menstrual Cycle

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Menstrual Cycle

• The idealized menstrual cycle lasts 28 days, with ovulation occurring at approximately day 14.

• The first day of menses is considered to be the first day of a new menstrual cycle.

• At the level of the endometrium, the menstrual cycle consists of four main phases:

• (1) the menses; • (2) the proliferative phase; • (3) the ovulatory phase, when the proliferative

endometrium is transformed into a secretory endometrium;

Menstrual Cycle

• (4) the secretory phase, when the endometrium is prepared for the implantation of the embryo.

• The proliferative endometrium is characterized by a high rate of cell division in the endometrial glands, whereas the secretory endometrium is characterized by a low rate of cell division in the glands.

• The secretory epithelium fills the luminal spaces with carbohydrates and proteins essential to implantation of the embryo.

Menstrual Cycle

• At the level of the ovary, the menstrual cycle can be characterized by two main phases.

• The first half of the cycle is the follicular phase. • The second half of the cycle is the luteal phase.• Corresponding to the endometrial phases of

menses and proliferation is the ovarian follicular phase.

• During the middle and late follicular phases of the cycle, the ovary is dominated by a fluid-filled cyst that contains the maturing oocyte.

Menstrual Cycle

• Corresponding to the endometrial secretory phase of the cycle is the ovarian luteal phase.

• Before and after ovulation, the follicle is transformed into the corpus luteum, which is yellow-orange because of the high concentration of cholesterol esters and other lipids.

CYCLE LENGTH

• Menstruation is the cyclic uterine bleeding experienced by most women of reproductive age.

• Normal menstruation represents the cyclic shedding of the uterine secretory endometrium because of a decline in estradiol and progesterone production caused by the regressing corpus luteum.

• Menstrual cycle average length is 28 days. • In general, polymenorrhea is present if the cycle

length is shorter than 22 days, and oligomenorrhea is present if the cycle length is longer than 35 days.

Diagrammatic representation of the menstrual cycle showing the relationships of the pituitary secretion of the gonadotropins follicle-stimulating hormone (FSH) and luteinizing hormone (LH) with ovarian follicular estradiol production and of luteal progesterone and estradiol production. In addition, the progressive response of the endometrium to the sequential change in steroids is portrayed.

Ultrasonographic signs of ovulation: complete disappearance (left), loss of volume and thickening of wall (middle), and replacement by irregular spongy area (right).

MENSTRUAL FLOW

• The average duration of menstruation is between 3 and 7 days.

• Menstruation that is shorter (hypomenorrhea) or longer (hypermenorrhea) than this range is abnormal.

• The amount of blood loss is generally 80 mL or less.

• When menstrual blood loss exceeds 80 mL, there is a good correlation with anemia (hemoglobin concentration less than 120 g/L).

Hypothalamus and Pituitary

• The predominant hormones involved in the menstrual cycle are gonadotropin releasing hormone (GnRH), follicle stimulating hormone (FSH), luteinizing hormone (LH), estrogen, and progesterone.

• GnRH is secreted by the hypothalamus, the gonadotropins FSH and LH are secreted by the anterior pituitary gland, and estrogen and progestin are secreted at the level of the ovary.

Hypothalamus and Pituitary

• GnRH stimulates the release of LH and FSH from the anterior pituitary, which in turn stimulate release of estrogen and progestin at the level of the ovary.

Hypothalamic-Pituitary-Ovary Axis

Menopause

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Definition

• Menopause is the transition period in a woman's life when the ovaries stop producing eggs, the body decreases the production of the female hormones estrogen and progesterone, and menstrual activity diminishes and eventually ceases.

Causes, incidence, and risk factors

• Menopause is a natural event which normally occurs between the ages of 45 and 55, beginning, on average, at age 51.

• During menopause, ovulation (egg production) stops and menstruation becomes less frequent, eventually stopping altogether.

• The symptoms of menopause are caused by changes in estrogen and progesterone levels.

• As the ovaries become less functional, they produce less of these hormones and the body responds accordingly.

Causes, incidence, and risk factors

• In some women, menstrual flow comes to a sudden halt.

• More commonly, however, it tapers off, both in amount and duration of flow.

• During this time, often called perimenopause, menstrual periods generally become either more closely or more widely spaced.

• This irregularity may last for 1 to 3 years before menstruation finally ends completely.

Symptoms 

• The potential symptoms of menopause, which can last from 1 to 3 years, include:

• Hot flashes and skin flushing• Night sweats• Insomnia• Mood changes including frequent swings of

irritability, depression, and anxiety• Irregular menstrual periods• Spotting of blood in between periods

Symptoms 

• Vaginal dryness and painful sexual intercourse• Decreased sex drive• Vaginal infections• Urinary tract infections• In addition, the long-term risks of menopause

include:• Bone loss and eventual osteoporosis• Changes in cholesterol levels and heart disease

Signs and tests

• Blood and urine tests can be used to measure hormone levels that may indicate when a woman is close to menopause or has already gone through menopause, for e.g.

• Estradiol • FSH, LH• A Pap smear may indicate changes in the vaginal

lining caused by changes in estrogen levels. • A bone density test may be performed to screen for

low bone density levels seen with osteoporosis.

Treatment

• Menopause is a natural process. It does not necessarily require treatment unless menopausal symptoms, such as hot flashes or vaginal dryness, are particularly bothersome.

• HORMONE REPLACEMENT THERAPY• For years, hormone replacement therapy (HRT) was the

main treatment for menopause symptoms. • Many physicians believed that HRT was not only the

best treatment available for reducing menopausal symptoms, but also reduced the risk of heart disease and bone fractures from osteoporosis.

Treatment

• However, the results of a major study -- called the Women's Health Initiative (WHI) -- has led physicians to revise their recommendations regarding HRT.

• In fact, one part of this important study was stopped early because the health risks outweighed the health benefits for women taking both estrogen and progesterone.

• Women taking both of these hormones did see benefit as far as their bones were concerned.

Treatment

• However, they greatly increased their risk for breast cancer, heart attacks, strokes, and blood clots.

• If the symptoms are severe, may still want to consider HRT for short-term use (two to four years) to reduce vaginal dryness, hot flashes, and other symptoms.

• To reduce the risks of estrogen replacement therapy and still gain the benefits of the treatment, may use estrogen/progesterone regimens that do not contain the form of progesterone used in this arm of the study.

Treatment

• Using a lower dose of estrogen or a different estrogen preparation (for instance, a vaginal cream rather than a pill).

• There are also some medications available to help with mood swings, hot flashes and other symptoms. These include low doses of antidepressants such as paroxetine (Paxil), venlafaxine (Effexor) and fluoxetine (Prozac), or clonidine, which normally used to control high blood pressure.

Prevention  

• Menopause is a natural and expected part of a woman's development and does not need to be prevented. However, there are ways to reduce or eliminate some of the symptoms that accompany menopause.

• NO SMOKING.• Exercise regularly, including activity against the

resistance of gravity, to strengthen your bones.• Low-fat diet, calcium and vitamin D.• Control blood pressure, cholesterol, and other risk

factors for heart disease.