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The Mercier's bar (interureteric bar or interureteric ridge) is a curved fold of mucous membrane between the two ureteric orifices inside the bladder.

This fold of mucous membrane is formed by the thickening of the superior border of the trigone muscle. In cystoscopy, the interureteric ridge appears as a pale band and acts as a guide to the ureteric orifices.

The mucosal fold running from the uvula vesicae to the ureteric orifice is called the Bell's bar. This fold forms the lateral borders of the trigone. It contains a band of muscle fibres called the Bell's muscle.

The internal urethral orifice lies at the level of the upper border of the pubic symphysis at birth.

At birth, the bladder is an abdominal organ. But as the child grows, the blader descends, and near puberty, it becomes a pelvic organ.

In an adult, the internal urethral orifice lies 3–4 cm behind the lower part of the pubic symphysis. It corresponds to the bladder neck.

Clinical note: As the bladder lies above the symphysis pubis, we can safely perform suprapubic needle punctures to obtain urine samples in children. But in adults, this can only be done if the bladder is fully distended.

The external urethral sphincter is innervated by the neurons present in Onuf's nucleus.

The neurons present in the lamina IX of the grey matter in spinal segments S2, S3, and S4 constitute Onuf's nucleus. These neurons contract the external urethral sphincter.

The external urethral sphincter is made up of skeletal muscle fibers. In the contracted state, they are responsible for the maintenance of urinary continence. Just before the onset of voiding the sphincter is relaxed. This happens because the neurons in the Onuf's nucleus are centrally inhibited by the brain.

The below image shows Onuf's nucleus located in the lamina IX.

Nerve supply of the bladder:

Parasympathetic supply

From S2, S3, and S4 spinal s egments

Richly innervate the fundus o f the bladderSparsely innerva te the bladder neck

They contract the urinary bla dder and aids in the micturiti on

Sympathetic supply

From T10, T11, T12, L1, and

L2 spinal segments

Richly innervate the smooth muscles around the bladder neckSparsely innervate the fu ndus of the bladder

They contract the internal ur ethral sphincter and aids in t he filling of the urinary bladd er

Fascia transversalis forms the internal spermatic fascia.

The ilioinguinal nerve lies outside the internal spermatic fascia of the spermatic cord.

Ilioinguinal nerve is not the content of the spermatic cord but it is the content of the inguinal canal. The ilioinguinal nerve lies inferior to the cord in the inguinal canal. It provides innervation to the groin and medial aspect of the thigh, the upper part of the scrotum, and the penile

root. It may be commonly injured during open hernia repair.

The spermatic cord is a structure that passes through the inguinal canal in males. The inguinal canal is a natural passageway between the muscle layers of the anterior abdominal wall in the region of the groin. It transmits the spermatic cord in males, the round ligament of the uterus in females, and the ilioinguinal nerve in both sexes.

The contents of the spermatic cord include:

• Cremaster muscle fibers
• Testicular artery and pampiniform plexus of veins
• Genital branch of the genitofemoral nerve
• Vas deferens
• Cremasteric vessels
• Lymphatics
• Processus vaginalis

Coverings of the spermatic cord from inside to outside are:

• Internal spermatic fascia from fascia transversalis
• Cremasteric fascia
• External spermatic fascia from external oblique aponeurosis

The inferior epigastric artery, a branch of the external iliac artery gives rise to the cremasteric artery.

The cremasteric artery travels along with the spermatic cord to supply the cremaster muscle and other coverings of the cord.

When the testicular artery is interrupted, there will be formation of collaterals from the cremasteric and deferential arteries. This will prevent the ischemia of the testis.

Note: The Fowler-Stephens orchidopexy done for undescended abdominal testis is based on this collateral formation. In the first stage, testicular vessels are clipped laparoscopically to promote the collateral formation along the vas deferens. In the second stage, the testis along with collaterals and vas deferens are mobilized to the scrotum.

The genitofemoral nerve is likely to be injured. The genital branch of the genitofemoral nerve innervates the anterior one-third of the scrotum, and the femoral branch innervates the anteromedial region of the thigh.

Clinical note: Considering the root values of the nerves supplying the scrotum, the spinal block should be given above the level of L1 to anesthetise it.

Part of the scrotu m

Anterior one-third

Posterior two-thir d

Nerve supply

Ilioinguinal nerveGenital bra nch of genitofemoral nerve

Perineal branch of the poster ior cutaneous nerve of thighP osterior scrotal branches of t he perineal nerve

Root val ue

L1 S3

The tail of the epididymis (marked as C) contains sperms with low amplitude and high-frequency tail movements.

The motility of sperm plays an important role in the process of fertilization. Sperms acquire their motility and maturation in the epididymis.

The epididymis has the following three parts:

Clinical note: Cystic degeneration of epididymis can result in epididymal cysts.

Head of the epididymis

High amplitude and low-freq uency tail movements

Responsible for thesubtle mo tionof the sperms

Tail of the epididymis

Low amplitude and high-freq uency tail movements

Responsible for therapid for ward progressionand aids inf ertilization

Parts of the epididymis Head

Body

Tail

Features

Receives the immature sper matozoa from the superior p ole of the testis through the e fferent ducts

Efferent ducts from the head open into the tubules of the e pididymisThese tubules coale sce forming a single, highly c oiled tubuleThe wall of the b ody contains smooth muscles which propel the sperms tow ards the tail during ejaculatio n

The coiled tubule passes thro ugh the tail and continues as the vas deferens

The left renal vein is likely to be occluded in this case. The left testicular vein drains into the left renal vein. Occlusion of the left renal vein impedes the blood flow in the left testicular veins. As a result, the veins become swollen and cause pain on the affected side.

Venous drainage of the testis:

The pampiniform plexus of veins arising from the testes ascend through the inguinal canal and abdomen. They coalesce to form the testicular veins during their course.

• The left testicular vein drains into the left renal vein at a right angle.
• The right testicular vein drains into the inferior vena cava at an acute angle.

Clinical note: Varicose dilatation of the veins draining the testis is called varicocele. 90 of the varicocele occurs on the left side and mostly this is due to the absence or incompetence of valves in the testicular vein.

The central zone of the prostate primarily surrounds the ejaculatory ducts. The prostate has three distinct zones as follows:

Zone

Transitional zon e

Central zone Peripheral zone

Structures enclosed Urethra

Ejaculatory ducts

Central and transitional zone sPre-prostatic urethra

Clinical significance

Most common site for benign prostatic hyperplasia (BPH)

Rarely diseased

Most common site for prosta tic carcinoma

Note: Some regard fibromuscular stroma as a zone, but as per Gray's anatomy, 41e, there are only three distinct zones in the glandular prostate.

Statements 1, 2 and 5 are false.

The prostatic ducts open into the prostatic sinus in the prostatic urethra. The urethral crest is a midline ridge in the posterior wall of the prostatic urethra. The shallow depressions on either side of the ridge are called prostatic sinuses.

The glandular part of the prostate contains numerous follicles separated by fibromuscular stroma. These follicles are lined by single-layered or pseudostratified columnar epithelium.

Small eosinophilic colloid amyloid bodies called corpora amylacea are frequently seen within a follicle.

The ducts of the prostate follicles are lined by bilayered epithelium (basal cuboidal and apical columnar). The secretions of the prostate are acidic and contain acid phosphatase, amylase, prostate-specific antigen (PSA), fibrinolysis, and zinc.

Seminal vesicles do not store sperms.

Seminal vesicles are paired accessory glandular structures of the male reproductive system located at the base of the prostate. The duct of the seminal vesicle joins with vas deferens to form the ejaculatory duct. The mucosa of the seminal vesicle is highly folded and is lined by pseudostratified columnar epithelium.

They secrete white-yellow viscous fluid and contribute to at least two-thirds of the volume of the semen. Secretions are rich in fructose, coagulation proteins, and prostaglandins. They are alkaline

and play an important role in the motility and metabolism of the sperms.

The vesiculo-deferential artery, a branch of the umbilical artery is the primary arterial supply of the seminal vesicles. Additional blood supply is from the inferior vesical artery. Venous drainage is by the vesiculo-deferential veins and inferior vesical plexus. Lymphatic drainage is to the internal iliac nodes

The deep artery of the penis (cavernosal artery) gives rise to helicine arteries of the penis. They open up into the sinusoidal space of the corpora cavernosa and supply it.

Blood supply of the penis:

• The external pudendal artery supplies the skin of the penis.
• The internal pudendal artery gives the following two branches:
• Perineal artery - supplies the ischiocavernosus, bulbospongiosus and posterior scrotal surface.
• Common penile artery - divides into the following three branches and supplies the shaft of the penis.

Branches of the common pen ile artery

Bulbourethral artery

Deep artery of the penis (cav ernosal artery)

Dorsal artery of the penis

Structures supplied

Bulb of the penisCorpus spon giosum with the urethraGlan s penis

Corpora cavernosa

Glans penisCorpus spongiosu m (through the circumferenti al branches)

The below image shows a cross-section of the shaft of the penis and the arteries supplying them.

Littre glands are the periurethral glands in males. These glands are numerous in the penile urethra. They secrete mucus prior to ejaculation which helps in lubrication.

Option A: Cowper's glands are the bulbourethral glands found in males. They are located lateral to the membranous urethra and opens via a duct into the bulbar urethra by piercing the perineal membrane. Their function is to secrete mucin during sexual arousal.

Option C: Skene's glands are the paraurethral glands found in females. These open on either side of the urethra. They are considered homologous to the male prostate.

Option B: Bartholin's glands are known as the greater vestibular glands in females. These glands are located in the posterior part of the vestibule and open through a duct into the vaginal orifice. They secrete mucus during sexual arousal for lubrication.

Clinical note: Since all these glands open via a duct into the orifices, any obstruction in the duct can result in cyst formation. They can get infected and necessitate removal.

The most likely primary cause of an enlarged inguinal lymph node is anal cancer.

Lymphatics from the anal canal distal to the dentate line (anal margin) drains into the inguinal lymph nodes. Hence, anal cancer arising distal to dentate line can cause enlarged inguinal lymph nodes. Lymphatics proximal to the dentate line (anal canal) drains into internal iliac lymph nodes through superior rectal lymphatics.

Option A: In testicular cancer, lymphatic spread occurs to the paraaortic lymph nodes.

Option C: In sigmoid colon cancer, lymphatic spread occurs to the regional lymph node and then to the central lymph node.

Option D: In prostate cancer, lymphatic spread occurs to the:

• Lymph nodes beside the internal iliac vein and in the hollow of the sacrum
• External iliac lymph nodes.

The angle of anteversion is formed between the long axis of the cervix and the long axis of the vagina.

The angle of anteflexion which is formed by the body of the uterus and the long axis of the cervix.

When the whole of the uterus leans backwards at an angle to the vagina, it is called retroversion. If the uterus angles backwards in relation to cervix it is called retroflexion.

The ovaries are not the contents of the broad ligament.

Ovaries are suspended in the pelvic cavity by the mesovarium. It attaches only the hilum of the ovary to the posterior surface of the broad ligament. The majority of the ovarian surface is covered by a single layer of cuboidal epithelium which imparts a dull white color to the ovaries.

The ovarian ligament (ligament of the ovary) attaches the inferomedial extremity of the ovary to the lateral angle of the uterus.

Other ligamentous supports of the ovaries:

• Infundibulo pelvic ligament (suspensory ligament) - attaches the lateral surface of the ovary to the peritoneum lining the lateral pelvic wall. It contains the ovarian vessels and nerves.
• Mesovarium - a short peritoneal fold that attaches the ovary to the back of the broad ligament.
• This carries blood vessels and nerves to the hilum of the ovary.

The given clinical scenario is suggestive of serous cystadenocarcinoma of the ovary. It spreads to the para-aortic nodes as the ovary is drained by them alongside the origin of the ovarian arteries.

Lymphatic drainage of the fe male reproductive tract

Vulva

Vagina

Cervix Uterus

Fallopian Tubes

Ovaries

Skin of labia, clitoris, and per ineum - Superficial inguinal nodesClitoris - Deep inguinal (Cloquet's) node, internal ilia c nodes

Upper vagina - Internal and External Iliac nodesMiddle v agina - Internal Iliac nodesLo wer vagina (below hymen) - S uperficial Inguinal nodes

External iliac, internal iliac a nd obturator nodes

Fundus -Para-aortic nodesIst hmus of the tube and round l igament - Superficial inguinal lymph nodesBody -External iliac, internal iliac and obtura tor nodes

Para-aortic, internal iliac, an d superficial inguinal nodes(v ia round ligament)

Para-aortic lymph nodes

The lining epithelium of the fallopian tube is a single layer of ciliated columnar epithelium. It is similar to the epithelium of the bronchioles.

The ciliated epithelial cells are predominant in the distal part of the fallopian tube. There is an increase in the height and number of cilia in these cells during the estrogenic phase of the menstrual cycle.

Other cells in the fallopian tube epithelium include:

• Secretory or peg cells - maximally located in the proximal portion of the tube. These cells are active around the time of ovulation, and their secretions help in the capacitation of sperms.
• Intraepithelial lymphocytes - may present occasionally.
• Option A: Epithelium of stomach - simple columnar

Option B: Epithelium of trachea - Pseudostratified ciliated columnar

Option D: Epithelium of proximal convoluted tubule - cuboidal with microvilli.

The cardinal ligament (transverse cervical ligament or ligament of Mackenrodt) extends from the side of the cervix and lateral fornix of the vagina to the pelvic wall.

Other ligaments of the uterus:

• Broad ligament - peritoneal fold covering the ovaries and fallopian tubes. It has three parts named after the structures it covers, i.e., mesosalpinx, mesovarium, and mesometrium (largest part).
• Pubocervical ligament - attaches the anterior aspect of the cervix and upper vagina to the posterior aspect of the pubic bones.
• Round ligaments - arises from the lateral cornua of the uterus, passes through the inguinal canal, and attaches to the labia majora.
• Uterosacral ligaments - passes from the back of the uterus and cervix to the anterior surface of the sacrum.

Waldeyer's fascia (presacral fascia) forms the posterior relationship of the rectum and is not related to the vagina. It lines the anterior surface of the sacrum.

Relations of the vagina:

Parts of vagin a

Upper third

Middle third

Anterior relatio n

Bladder

Bladder

Posterior relation

Peritoneum of the rectouteri ne pouch

Rectovaginal fascia/septum

Lateral relation

Levator aniTransverse cervic al ligamentPubocervical liga mentUterosacral ligamentUr eter and uterine artery (relate d to the lateral fornix)

Pubovaginalis muscle

Parts of vagin a

Anterior relatio n

Posterior relation Lateral relation

Lower third

Urethra

Perineal body

Bulbospongiosus

The internal iliac artery gives rise to the azygous arteries of the vagina.

The azygous arteries are longitudinal median vessels and run on the anterior and posterior surfaces of the vagina. The vagina also receives blood supply from the uterine, internal pudendal, and middle rectal branches of the internal iliac artery.

Blood supply of the female reproductive system:

Structure Vulva

Clitoris

Vagina

Uterus

Fallopian tu be

Ovary

Arterial supply

Superficial and deep external pudendal arteries of the fem oral arteryInternal pudendal artery (inferior part of the vul va)

Branches of the internal pud endal artery

Azygous arteries of the vagin a from the internal iliac arter y

Uterine artery from the anter ior division of the internal ili ac artery

Medial two-third - uterine art eryLateral one-third - ovarian artery

Ovarian artery (direct branch of the abdominal aorta)

Venous drainage

Via external pudendal veins t o the long saphenous vein

Via deep dorsal veins into the internal pudendal veinVia su perficial dorsal veins into the external pudendal and long s aphenous veins

Via vaginal vein into the inte rnal iliac vein

Via uterine veins into the int ernal iliac vein

Medial two-third - via uterine plexus into the internal iliac veinLateral one third - via th e pampiniform plexus into th e IVC on the right and the re nal vein on the left

Ovarian veins emerge as a pa mpiniform plexus and form t he ovarian veins draining int o the IVC on the right, and th e renal vein on the left side.

The structure marked is the lacunar ligament.

Lacunar (Gimbernat's) ligament - It is a thick triangular band of tissue formed from fibres of the medial end of the inguinal ligament and fascia lata. It forms the medial wall of the femoral canal. The apex of the triangle is attached to the pubic tubercle.

Inguinal (Poupart’s) ligament - The thick external oblique aponeurosis stretched between ASIS

(anterior superior iliac spine) and pubic tubercle.

Pectineal (Astley-Cooper's) ligament - A strong fibrous band that extends laterally along the pectineal line from the pectineal attachment of the lacunar ligament.

Conjoint tendon - It is a condensation of tissue that runs through the lateral edge of the lower rectus sheath. It is formed from the common aponeurosis of the internal oblique muscle and transverse abdominis muscle. The fibers turn inferiorly and insert into the crest of the pubis at the pectineal line immediately deep to the superficial inguinal ring.

The L5 lumbar vertebra does not form the bony pelvis. The bony pelvis consists of four bones:

• two hip bones
• sacrum
• coccyx

The articulations of these bones form four joints which are:

• Two sacroiliac joints – Between the ilium of the hip bones, and the sacrum.
• Sacrococcygeal symphysis – Between the sacrum and the coccyx.
• Pubic symphysis – Between the pubis bodies of the two hip bones.