Theme 10:
Problems in
the pelvis
Summary
,Inhoud
Week 37: Swelling of the groin and testes .............................................................................................. 5
Embryology.......................................................................................................................................... 5
Gonadal descent .............................................................................................................................. 5
Evagination of the abdominal wall .................................................................................................. 8
Further descend of the testes ......................................................................................................... 8
Abnormal descent ........................................................................................................................... 9
Anatomy ............................................................................................................................................ 13
Inguinal region ............................................................................................................................... 16
Posterior abdominal wall .............................................................................................................. 19
The pelvis ....................................................................................................................................... 21
Hernias and the groin problems ........................................................................................................ 23
Lumps in the groin ......................................................................................................................... 23
Inguinal hernia ............................................................................................................................... 24
Femoral hernia .............................................................................................................................. 24
Enlarges inguinal lymph nodes ...................................................................................................... 25
Saphena varix ................................................................................................................................ 25
Femoral artery aneurysm .............................................................................................................. 25
Psoas abscess ................................................................................................................................ 26
Chronic groin pain ......................................................................................................................... 26
Ventral hernias .............................................................................................................................. 26
Gastroschisis .................................................................................................................................. 27
Omphalocele ................................................................................................................................. 27
Umbilical hernia............................................................................................................................. 28
Disorders of the scrotal contents ...................................................................................................... 29
Male sterilisation ........................................................................................................................... 31
Disorders of the penis ....................................................................................................................... 32
Phimosis......................................................................................................................................... 32
Paraphimosis ................................................................................................................................. 33
Balanoposthitis (balanitis) ............................................................................................................. 33
Circumcision .................................................................................................................................. 34
Megaprepuce (megaforeskin) ....................................................................................................... 34
Micropenis ..................................................................................................................................... 35
Peyronie disease ............................................................................................................................ 36
Carcinoma of the penis.................................................................................................................. 36
Priapism ......................................................................................................................................... 36
, Erectile dysfunction ....................................................................................................................... 36
Hypospadias .................................................................................................................................. 36
Epispadias ...................................................................................................................................... 37
Penile duplication .......................................................................................................................... 38
Acute surgical problems in children .................................................................................................. 39
Physiological differences between infants and adults .................................................................. 39
Surgical emergencies in the neonate ............................................................................................ 39
Abdominal emergencies in infants and young children ................................................................ 39
Abdominal emergencies in older children .................................................................................... 40
Week 38: Alarming test result cervical smear ....................................................................................... 41
Benign pelvic mass ............................................................................................................................ 42
Functional cysts ............................................................................................................................. 42
Mature teratoma ........................................................................................................................... 42
Cystadenoma ................................................................................................................................. 42
Ovarian fibroma............................................................................................................................. 43
Endometrioma ............................................................................................................................... 43
Risk of malignancy index ............................................................................................................... 43
Ovarian torsion .............................................................................................................................. 44
Spontaneous rupture of an ovarian cyst ....................................................................................... 44
Ovarian cysts during pregnancy .................................................................................................... 44
Cervical premalignancies and cervical cancer ................................................................................... 45
Uterine cancer and premalignant lesions ......................................................................................... 51
Ovarian cancer................................................................................................................................... 54
Vulvar cancer and vulvar premalignancies........................................................................................ 56
Vaginal cancer ................................................................................................................................... 57
Pathology........................................................................................................................................... 58
Vulva .............................................................................................................................................. 58
Vagina ............................................................................................................................................ 58
Cervix ............................................................................................................................................. 58
Body of the uterus (myometrium) and endometrium .................................................................. 58
Ovaries ........................................................................................................................................... 59
Week 39: Incontinence and prolapse.................................................................................................... 60
Propulsion and mixing of food in the alimentary tract ..................................................................... 60
Ingestion of food ........................................................................................................................... 60
Motor functions of the stomach ................................................................................................... 60
Movements of the small intestine ................................................................................................ 60
, Movements of the colon ............................................................................................................... 60
Normal micturition ............................................................................................................................ 62
Functional anatomy ....................................................................................................................... 62
Urinary incontinence, bladder- and pelvic floor disorders ............................................................... 66
Urinary incontinence ..................................................................................................................... 66
Bladder dysfunction ...................................................................................................................... 66
Pelvic floor disorders ..................................................................................................................... 67
Pelvic organ prolapse ........................................................................................................................ 68
Functional anatomy ....................................................................................................................... 68
Presentation .................................................................................................................................. 69
Classification .................................................................................................................................. 69
Normal defecation............................................................................................................................. 73
Anatomy ........................................................................................................................................ 73
Abnormal defaecation ....................................................................................................................... 75
Constipation .................................................................................................................................. 75
Obstructed defaecation................................................................................................................. 75
Faecal incontinence ....................................................................................................................... 75
Relation other pelvic organs.......................................................................................................... 76
Anal and perianal disorders............................................................................................................... 77
Haemorrhoids ................................................................................................................................ 77
Perianal abcess .............................................................................................................................. 77
Perianal fistula ............................................................................................................................... 78
Anal fissure .................................................................................................................................... 79
Sinus pilonidalis.............................................................................................................................. 80
External rectal prolapse................................................................................................................. 80
Anal carcinoma .............................................................................................................................. 80
Proctalgia fugax ............................................................................................................................. 81
Pruritis Ani ..................................................................................................................................... 81
Treating function: do’s and don’t .................................................................................................. 81
,Week 37: Swelling of the groin and testes
Embryology
Gonadal descent
- Testes = intraperitoneal
- Gonads develop in the posterior abdominal wall: superior lumbar region = pelvic
region
- Inguinal canal acts as a passage for the testes to descend into the scrotum =
entrance: fascia transversalis and exit: external oblique muscle
- Gubernaculum attaches to inferior pole of the gonads and helps guide their descent
into the scrotum/pelvis
- Formation of processes vaginalis: an outpouching of the peritoneum through the
anterior abdominal musculature
➔ Takes layers of the abdominal wall with it = creation of the inguinal canal
,Males:
• Gubernaculum projects through the peritoneal cavity between the abdominal
wall musculature into the labioscrotal swellings
• The pathway formed guides the descent of the gonads
• Testes descend between the processes vaginalis and the muscular layers of the
anterior abdominal wall into the scrotal sac
Females:
• Descent of the gonads is considerably less
• Gubernaculum attaches to the primordial ovaries and the future labia majora
• Finally, the ovaries lie just below the rim of the pelvis laterally within the pelvic cavity
• Gubernaculum forms the round ligament, extending into the labia majora →
protrusion of the peritoneum: Canal of Nuck
,
, Evagination of the abdominal wall
The gubernaculum is accompanied by an extension of the parietal cavity caller the process
vaginalis → will become the tunica vaginalis layers that cover the testes
Further descend of the testes
- Transversalis fascia is stretched and pushed ahead of the process vaginalis towards
the labia scrotal swellings → outpouching of the transversalis fascia will create the
deep inguinal ring
- Internal abdominal oblique: also be drawn toward the labioscrotal swellings →
cremasteric muscle
- External abdominal oblique: will form the superficial ring
Problems in
the pelvis
Summary
,Inhoud
Week 37: Swelling of the groin and testes .............................................................................................. 5
Embryology.......................................................................................................................................... 5
Gonadal descent .............................................................................................................................. 5
Evagination of the abdominal wall .................................................................................................. 8
Further descend of the testes ......................................................................................................... 8
Abnormal descent ........................................................................................................................... 9
Anatomy ............................................................................................................................................ 13
Inguinal region ............................................................................................................................... 16
Posterior abdominal wall .............................................................................................................. 19
The pelvis ....................................................................................................................................... 21
Hernias and the groin problems ........................................................................................................ 23
Lumps in the groin ......................................................................................................................... 23
Inguinal hernia ............................................................................................................................... 24
Femoral hernia .............................................................................................................................. 24
Enlarges inguinal lymph nodes ...................................................................................................... 25
Saphena varix ................................................................................................................................ 25
Femoral artery aneurysm .............................................................................................................. 25
Psoas abscess ................................................................................................................................ 26
Chronic groin pain ......................................................................................................................... 26
Ventral hernias .............................................................................................................................. 26
Gastroschisis .................................................................................................................................. 27
Omphalocele ................................................................................................................................. 27
Umbilical hernia............................................................................................................................. 28
Disorders of the scrotal contents ...................................................................................................... 29
Male sterilisation ........................................................................................................................... 31
Disorders of the penis ....................................................................................................................... 32
Phimosis......................................................................................................................................... 32
Paraphimosis ................................................................................................................................. 33
Balanoposthitis (balanitis) ............................................................................................................. 33
Circumcision .................................................................................................................................. 34
Megaprepuce (megaforeskin) ....................................................................................................... 34
Micropenis ..................................................................................................................................... 35
Peyronie disease ............................................................................................................................ 36
Carcinoma of the penis.................................................................................................................. 36
Priapism ......................................................................................................................................... 36
, Erectile dysfunction ....................................................................................................................... 36
Hypospadias .................................................................................................................................. 36
Epispadias ...................................................................................................................................... 37
Penile duplication .......................................................................................................................... 38
Acute surgical problems in children .................................................................................................. 39
Physiological differences between infants and adults .................................................................. 39
Surgical emergencies in the neonate ............................................................................................ 39
Abdominal emergencies in infants and young children ................................................................ 39
Abdominal emergencies in older children .................................................................................... 40
Week 38: Alarming test result cervical smear ....................................................................................... 41
Benign pelvic mass ............................................................................................................................ 42
Functional cysts ............................................................................................................................. 42
Mature teratoma ........................................................................................................................... 42
Cystadenoma ................................................................................................................................. 42
Ovarian fibroma............................................................................................................................. 43
Endometrioma ............................................................................................................................... 43
Risk of malignancy index ............................................................................................................... 43
Ovarian torsion .............................................................................................................................. 44
Spontaneous rupture of an ovarian cyst ....................................................................................... 44
Ovarian cysts during pregnancy .................................................................................................... 44
Cervical premalignancies and cervical cancer ................................................................................... 45
Uterine cancer and premalignant lesions ......................................................................................... 51
Ovarian cancer................................................................................................................................... 54
Vulvar cancer and vulvar premalignancies........................................................................................ 56
Vaginal cancer ................................................................................................................................... 57
Pathology........................................................................................................................................... 58
Vulva .............................................................................................................................................. 58
Vagina ............................................................................................................................................ 58
Cervix ............................................................................................................................................. 58
Body of the uterus (myometrium) and endometrium .................................................................. 58
Ovaries ........................................................................................................................................... 59
Week 39: Incontinence and prolapse.................................................................................................... 60
Propulsion and mixing of food in the alimentary tract ..................................................................... 60
Ingestion of food ........................................................................................................................... 60
Motor functions of the stomach ................................................................................................... 60
Movements of the small intestine ................................................................................................ 60
, Movements of the colon ............................................................................................................... 60
Normal micturition ............................................................................................................................ 62
Functional anatomy ....................................................................................................................... 62
Urinary incontinence, bladder- and pelvic floor disorders ............................................................... 66
Urinary incontinence ..................................................................................................................... 66
Bladder dysfunction ...................................................................................................................... 66
Pelvic floor disorders ..................................................................................................................... 67
Pelvic organ prolapse ........................................................................................................................ 68
Functional anatomy ....................................................................................................................... 68
Presentation .................................................................................................................................. 69
Classification .................................................................................................................................. 69
Normal defecation............................................................................................................................. 73
Anatomy ........................................................................................................................................ 73
Abnormal defaecation ....................................................................................................................... 75
Constipation .................................................................................................................................. 75
Obstructed defaecation................................................................................................................. 75
Faecal incontinence ....................................................................................................................... 75
Relation other pelvic organs.......................................................................................................... 76
Anal and perianal disorders............................................................................................................... 77
Haemorrhoids ................................................................................................................................ 77
Perianal abcess .............................................................................................................................. 77
Perianal fistula ............................................................................................................................... 78
Anal fissure .................................................................................................................................... 79
Sinus pilonidalis.............................................................................................................................. 80
External rectal prolapse................................................................................................................. 80
Anal carcinoma .............................................................................................................................. 80
Proctalgia fugax ............................................................................................................................. 81
Pruritis Ani ..................................................................................................................................... 81
Treating function: do’s and don’t .................................................................................................. 81
,Week 37: Swelling of the groin and testes
Embryology
Gonadal descent
- Testes = intraperitoneal
- Gonads develop in the posterior abdominal wall: superior lumbar region = pelvic
region
- Inguinal canal acts as a passage for the testes to descend into the scrotum =
entrance: fascia transversalis and exit: external oblique muscle
- Gubernaculum attaches to inferior pole of the gonads and helps guide their descent
into the scrotum/pelvis
- Formation of processes vaginalis: an outpouching of the peritoneum through the
anterior abdominal musculature
➔ Takes layers of the abdominal wall with it = creation of the inguinal canal
,Males:
• Gubernaculum projects through the peritoneal cavity between the abdominal
wall musculature into the labioscrotal swellings
• The pathway formed guides the descent of the gonads
• Testes descend between the processes vaginalis and the muscular layers of the
anterior abdominal wall into the scrotal sac
Females:
• Descent of the gonads is considerably less
• Gubernaculum attaches to the primordial ovaries and the future labia majora
• Finally, the ovaries lie just below the rim of the pelvis laterally within the pelvic cavity
• Gubernaculum forms the round ligament, extending into the labia majora →
protrusion of the peritoneum: Canal of Nuck
,
, Evagination of the abdominal wall
The gubernaculum is accompanied by an extension of the parietal cavity caller the process
vaginalis → will become the tunica vaginalis layers that cover the testes
Further descend of the testes
- Transversalis fascia is stretched and pushed ahead of the process vaginalis towards
the labia scrotal swellings → outpouching of the transversalis fascia will create the
deep inguinal ring
- Internal abdominal oblique: also be drawn toward the labioscrotal swellings →
cremasteric muscle
- External abdominal oblique: will form the superficial ring
