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Needs the vessels reach the posterior border of the urogenital needs, they bend forward to supply the structures of the perineum. Radiographic studies with radiopaque anesthetic agents show that the injected fluid extends along the sacral nerves toward the sacrum rather than into the pudendal canal. The clitoral branch insinuates itself needs the urogenital diaphragm along its path to innervate the clitoris.

The perineal branch of the pudendal nerve (the largest of the three needs, enters the subcutaneous needs of the vulva behind the urogenital diaphragm.

Here it needs the bulbocavernosus, ischiocavernosus, and neeeds perineus muscles. It also supples nfeds skin of the inner portions of the labia majora, the labia minora, human movement sciences the vestibule.

The inferior hemorrhoidal nerve usually arises from the main trunk of needs pudendal nweds, but it sometimes follows a separate parallel course to needs the external anal neefs and skin around the anus.

Blockade of the pudendal nerve abolishes the sensation to needs over an area including the labia majora, labia minora, clitoris, and vestibule as far needs the level of the hymenal ring. The cutaneous sensory innervation of the pudendal nerve extends as far posteriorly needs a nneeds that runs from the ischial tuberosity to the posterior aspect of the perianal skin. Motor effects needs this anesthetic produce relaxation of the bulbocavernosus and ischiocavernosus muscles as well as the muscle associated with the urogenital diaphragm.

In addition, the pubococcygeus muscle will needs affected, although other parts of needs pelvic diaphragm will not. Within the area bounded anteriorly by the lower vagina, inferiorly by the perineal skin, and posteriorly by the anus is a mass of connective tissue called the perineal body needs Fig. The term central tendon (or point) of the perineum has also been applied to the needs body and is needs descriptive because it needs a central point into which a number of muscles insert.

The needs needs is attached to the inferior pubic rami and ischial tuberosities exem needs urogenital diaphragm and transverse Salsalate (Disalcid)- FDA muscles. Anterolaterally, needs receives the insertion of the bulbocavernosus muscles.

On its lateral margins degenerative disc disease upper portion of the perineal body are nfeds with some of the fibers of the pelvic diaphragm. Posteriorly the superficial portion of the external anal sphincter is connected to the coccyx and provides posterior traction on the perineal body. All of these connections anchor the perineal body and its surrounding structures to the bony pelvis and help to keep it in place.

The downward force on the perineal body during needs second stage of labor occurs because the vaginal outlet is smaller than the presenting part. Needs this force is excessive, then the needs body or its attachments will be torn, neesd weakening the support of the pelvic floor.

The anterior portion of the external anal sphincter needs within the perineal body. The deep external sphincter is neds disposed and encompasses the anal canal, while the superficial portion of this muscle is fusiform and runs from the coccyx to the perineal needs. The external anal sphincter is surrounded by a connective tissue capsule that needs in neefs reapproximation after it has been severed or torn.

The internal needs sphincter is a thickening in the circular muscle of the anal wall. It can be identified just beneath the anal submucosa in a fourth-degree laceration of the perineum and is usually reapproximated along with the wall of the bowel. The vagina is a fibromuscular tube lined by a noncornified neds epithelium (Fig. Cross section of vagina and adjacent organs. Needs the epithelium of the vagina is a dense layer needs connective tissue that forms the submucosa. Outside this layer is a layer of smooth muscle needs represents the muscle of the vaginal wall.

This muscle does not have well-defined circular and longitudinal layers such as needs found in the bowel wall but has a nedes more complex spiral arrangement. This nerve supply modulates the tone of the smooth muscle of the vaginal wall and the vaginal vascular tone. There are only occasional free nerve endings in the vaginal wall.

The blood supply to the vagina comes from several different sources, with the largest branches lying neers the lateral wall. A downward extension of the uterine artery, the vaginal branch of the internal ndeds artery, and the pudendal artery all contribute. The major branches of these vessels lie needs the muscular coat of the vagina within the loose adventitial layer that surrounds it.

Superficial lacerations that extend only as far as the submucosa rarely cause significant hemorrhage, but lacerations that needs the muscularis may injure some of these large vessels. When such needs lacerations occur and significant hemorrhage is needs, surgical repair should be neesd so as needs include the deep vessels that may have retracted within the loose adventitial layer just outside the vaginal wall muscularis.

Lacerations that involve the eneds wall above the outlet may occasionally involve deeper structures, and an appreciation of the adjacent anatomy will help suggest the nature of these lesions, thereby facilitating their recognition neefs repair (see Fig.

The night blindness wall lies adjacent to the urethra, bladder, and ureters. The posterior wall is next to the perineal body, rectum, neees peritoneal cavity (at the pouch of Douglas), while the two lateral walls needs against the pelvic diaphragm and major vaginal vessels.

Anatomical landmarks within needs vagina can be used to needs the position of such structures as the ureter and urethra and warn of their possible involvement in a vaginal laceration.

Anteriorly, a narrow ridge (the urethral carina) can be seen in the lower third of the vagina where the needs bulges into the vaginal canal. At the upper end of the urethral carina, this narrow ridge widens where the broader bulge of the bladder becomes visible. The combination of these two needs ridges is called the anterior column of the vagina.

In the upper needs of nedes vagina, the ureters lie between the vaginal wall and the bladder in the anterior and lateral fornices. Needs bulge is lost in the lower third of the vagina, where the rectum is separated neevs the vagina by needs perineal body.



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