Endocrine and Reproductive System Anatomy

1. The Pituitary Gland Overview of the gross anatomy of the normal pituitary and surrounding structures including: Optic chiasma Cranial nerves Blood vessels Median eminence (be able to identify on cadaver and radiology) Infundibular stem (be able to identify on cadaver and radiology) Pars distalis (be able to identify on cadaver and radiology) Pars nervosa (be able to identify on cadaver and radiology) Sella turcica (be able to identify on cadaver and radiology) 2. The Thyroid and Parathyroid Glands Overview of the gross anatomy of the normal thyroid and parathyroid glands, as well as surrounding structures and associated blood vessels. Be able to identify: Superior and inferior thyroid arteries Superior, middle and inferior thyroid veins Brachiocephalic artery Subclavian artery Common, internal and external carotid arteries Recurrent laryngeal nerve (be able to identify on cadaver) Parathyroid artery (also receive some supply from superior thyroid artery) Parathyroid venous drainage (via superior thyroid vein) The superior thyroid artery arises from the external carotid artery just below the greater horn of the hyoid bone. The inferior thyroid artery arises from the thyrocervical trunk (branch of subclavian artery) immediately distal to the vertebral artery.

3. The structure of the female pelvis Overview of structure with an emphasis on the differences between male and female: The female pelvis has a much wider suprapubic angle The wings of the pelvic bone which are further apart The diameters of the pelvic cavity are longer The apex of the sacrum does not protrude into the outlet of the pelvic cavity Note that the widest diameter of the pelvic inlet is the transverse Note the widest diameter of the pelvic cavity (pelvic brim to pelvic outlet) is the oblique Note the widest diameter of the pelvic outlet is the sagittal Lateral, posterior and inferior (floor) walls of the pelvis The layers of the floor of the pelvis (from inside to outside): Superior fascia (endopelvic fascia) Levator ani muscle Urogenital diaphragm- fascial cover Deep transversus perineal muscle Isochiocavernosus (attached to inferior aspect of urogenital diaphragm) Bulbospongiosus (attached to inferior aspect of urogenital diaphragm) Anal sphincter complex (how can ultrasound be used to assess its integrity?) Be able to say why these dimensions are important. 4. The Ovaries Position of the ovaries (attached to posterior aspect of broad ligament of the uterus) No peritoneal cover, but are attached to the peritoneum by the broad ligament of the uterus along the mesovarium of the ovary (border of the ovary to which the mesovarium is attached. The mesovarium is the portion of the broad ligament of the uterus that covers the ovaries. The suspensory ligaments (lateral) and ligament of the ovary (medial) carry blood vessels to the ovary.

5. The Uterus Position of the uterus (between urinary bladder and rectum). Much of it is covered by peritoneum. Vesico-uterine pouch of the peritoneal cavity. Recto-uterine pouch (Pouch of Douglas) of the peritoneal cavity extends down to posterior fornix of the vagina.

6. Mid-Sagittal Female Pelvis Fundus of the uterus Body of the uterus Isthmus of the uterus Cervix: Supravaginal and vaginal parts.

7. The Fallopian Tubes The fallopian tubes continue with the uterus medially and run in the upper part of the broad ligament of the uterus (part of the peritoneum which is reflected from the lateral aspect of the uterus). Be able to identify: Infundibulum of the fallopian tube Ampulla of the fallopian tube Isthmus of the fallopian tubes Uterine fallopian tubes Be able to outline the path that the ovum takes from ruptured Graafian follicle to the uterus. 8. Cavities and openings of the Uterus Uterine opening of the fallopian tubes Cavity of the uterus- antero-posteriorly flattened. Isthmic canal Cervical canal Internal and external os (osses? Osii? :P) of the uterus.

9. The Vagina Observe the posterior and anterior walls on a cadaver. Posterior wall is longer and encroaches on posterior wall of cervix to form posterior fornix of the vagina. Posterior wall is in direct contact with the Pouch of Douglas (recto-uterine pouch). Rectal prolapse can be caused by an unusually deep Pouch of Douglas, which can form a hernia through the anus by pushing the anterior rectal wall in front of it. If this deep peritoneal pouch bulges into the posterior vaginal wall, a hernia of the Pouch of Douglas results. Anterior wall is in contact with the urethra. Gross anatomy of the external vagina. Be able to identify: Major labia Minor labia Vestibule of the vagina- external ostium of the urethra Clitoris 10. Lymphatic and other points Lymph drainage of breasts and uterus. Changing topography of the uterus during pregnancy Role of the perineal body (central tendon of the perineum) in supporting pelvic structures, in particular the vaginal-uterine complex. Common modalities used to image female pelvis. Structures forming the boundary of the female/male perineum: Anterior: Pubic symphysis Posterior: Coccyx Lateral: Ischial tuberosities Anterolateral: Ischiopubic ramus Posterolateral: Sacrotuberous ligament Prolapse of the vagina, uterus and rectum.

11. The Male Perineum The perineum consists of structures within a diamond shaped boundary (see 10.) Anterior triangle (urogenital triangle): External genitalia Posterior triangle (anal triangle): Anus The layers of the pelvic floor are the same as those in the female. However, they are pierced only by the urethra. Hence, the urogenital diaphragm provides much firmer support for the pelvic viscera in the male. The bulbospongiosus muscles are fused around the bulb of the urethra. 12. The Scrotum On a cadaver, note that the scrotum is divided into two compartments (right and left), each of which contain a testis, epididymis and lower part of the spermatic cord and coverings. Be able to identify the layers of the scrotum (superficial to deep): Skin Dartos fascia (contains smooth muscle- the dartos muscles). External spermatic fascia Cremaster muscle (internal oblique muscle-reflex draws testis superiorly) Cremasteric fascia Internal spermatic fascia Tunica vaginalis (peritoneum) 13. The Penis Corpus cavernosa and crura penis (and insertions into rami of ischial and pubic bones). Corpus spongiosum: Urethra External urethral orifice Glans penis Follow course of male urethra and establish its parts, curvatures and distensions.

14. The Testis and Epididymis Note size and shape of these structures and their relationship. Anteriorly each testis is invaginated by a double serous covering, the tunica vaginalis. Tunic albuginea: Note septa which extend into testis forming the testicular lobules. Testicular lobules: 2-4 seminiferous tubules (which drain into small channelsefferent ductules of the testis), the rete testis and the mediastinum testis. Efferent ductules of the testis leave hilum of the testis and are continuous with head of epididymis. The epididymis: Head, body and tail (continues as ductus deferens). 15. The Ductus Deferens Note sections and course of ductus deferens: Testicular Funicular Inguinal Pelvic Ampulla: Distended and runs in close proximity to seminal vesicle and prostate. The spermatic cord and its coverings: The ductus deferens Testicular artery Pampinform plexus Cremaster muscle Tunica vaginalis testis (scrotal part of the peritoneum)

16. Blood, nerve and lymphatic supply to external genitalia Blood supply: The testis and epididymis are supplied by the testicular artery (analogous to ovarian artery in females). Their veins drain into the pampiniform plexus, which forms the bulk of the spermatic cord. The penile shaft and prepuce are supplied by vessels arising from the inferior external pudendal artery (branch of femoral artery). At the coronal sulcus, there is communication with branches of the internal pudendal artery (deep arterial system). The deep arterial system arises from the internal pudendal artery, which is the final branch of the anterior trunk of the internal iliac artery. It passes through the Pudendal Canal (structure in the pelvis through which internal pudendal artery, internal pudendal veins and the pudendal nerve pass). As it emerges from the canal, it branches into the perineal and penile arteries. It then divides into the bulbourethral artery, the urethral artery, and the cavernous artery (or deep artery of the penis). The urethral artery: Usually arises from penile artery. Runs on ventral surface of corpus spongiosum beneath tunica albuginea. The cavernous artery (deep artery): Usually arises from the penile artery. Runs lateral to cavernous vein. Continues to enter the center of the corpora cavernosa (corpus cavernosum penis, corpus cavernosum urethra). The bulbourethral artery: Supplies bulb of urethra, corpus spongiosum and glans penis. The dorsal artery (superficial and deep): Termination of the penile artery. The prostate: Supplied by inferior vesical artery which is a branch of internal iliac artery. Nerve supply: Somatic innervation: Arises from S2-S4 via pudendal nerve. Perineal branch supplies posterior scrotum. Pudendal nerve continues as dorsal nerve of penis alongside the dorsal vein and artery. The anterior scrotum and proximal penis supplied by ilioinguinal nerve after it leaves superficial inguinal ring. Autonomic innervation: Sympathetic and parasympathetic inferior pelvic plexus adjacent to the base of the bladder, prostate, seminal vesicles and rectum supplies prostate, seminal vesicles, epididymis, membranous and penile urethra and bulbourethral gland.

Lymphatic supply: Internal and external iliac nodes.

17. Other points On ultrasound what would you expect to see: Hydrocele of the testis. Testicular torsion. Infection of spermatic cord or testis. How does a fluid filled, distended tunica vaginalis develop and what are its consequences?