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The undescended testis usually lies somewhere along the normal path of its prenatal descent blood pressure medication spironolactone side effects order bystolic 2.5 mg with visa, commonly in the inguinal canal arteria znaczenie buy bystolic online now. The importance of cryptorchidism is a greatly increased risk for developing malignancy in the undescended testis blood pressure medication anxiety discount bystolic online master card, particularly problematic because it is not palpable and is not usually detected until cancer has progressed blood pressure jumping around buy bystolic 2.5mg low cost. Because the testis needs a cooler environment for fertility as well, these are typically surgically corrected in childhood. Postnatal Patency of Umbilical Vein Before the birth of a fetus, the umbilical vein carries well-oxygenated, nutrientrich blood from the placenta to the fetus. Although reference is often made to the "occluded" umbilical vein forming the round ligament of the liver, this vein is patent for some time after birth and is used for umbilical vein catheterization for exchange transfusion during early infancy-for example, in infants with erythroblastosis fetalis or hemolytic disease of the neonate (Kliegman et al. This is also true of the uterus, the veins and lymph vessels of which mostly drain via deep routes. However, some lymphatic vessels follow the course of the round ligament through the inguinal canal. Thus, while occurring less often, metastatic uterine cancer cells (especially from tumors adjacent to the proximal attachment of the round ligament) can spread from the uterus to the labium majus (the developmental homolog of the scrotum and site of distal attachment of the round ligament) and from there to the superficial inguinal nodes, which receive lymph from the skin of the perineum (including the labia). These herniations occur in both sexes, but most inguinal hernias (approximately 86%) occur in males because of the passage of the spermatic cord through the inguinal canal. An inguinal hernia is a protrusion of parietal peritoneum and viscera, such as the small intestine, through a normal or abnormal opening from the cavity in which they belong. Most hernias are reducible, meaning they can be returned to their normal place in the peritoneal cavity by appropriate manipulation. Characteristics of direct and indirect inguinal hernias are listed and illustrated in Table B5. Normally, most of the processus vaginalis obliterates before birth, except for the distal part that forms the tunica vaginalis of the testis (see Table 5. The peritoneal part of the hernial sac of an indirect inguinal hernia is formed by the persisting processus vaginalis. If the entire stalk of the processus vaginalis persists, the hernia extends into the scrotum superior to the testis, forming a complete indirect inguinal hernia (Table B5. The superficial inguinal ring is palpable superolateral to the pubic tubercle by invaginating the skin of the upper scrotum with the index finger. Should a hernia be present, a sudden impulse is felt against either the tip or pad of the examining finger when the patient is asked to cough (Swartz, 2014). However, because both inguinal hernia types exit the superficial ring, palpation of an impulse at this site does not discriminate type. Detection of an impulse at 1036 the superficial ring and a mass at the site of the deep ring suggests an indirect hernia. Palpation of a direct inguinal hernia is performed by placing the palmar surface of the index and/or middle finger over the inguinal triangle and asking the person to cough or bear down (strain). The finger can also be placed in the superficial inguinal ring; if a direct hernia is present, a sudden impulse is felt medial to the finger when the person coughs or bears down. Cremasteric Reflex Contraction of the cremaster muscle is elicited by lightly stroking the skin on the medial aspect of the superior part of the thigh with an applicator stick or tongue depressor. This reflex is extremely active in children; consequently, hyperactive cremasteric reflexes may simulate undescended testes. A hyperactive reflex can be abolished by having the child sit in a cross-legged, squatting position; if the testes are descended, they can then be palpated in the scrotum. Cysts and Hernias of the Processus Vaginalis Indirect inguinal hernias can occur in women; however, they are approximately 20 times more common in men. If the processus vaginalis remains patent in females, it may form a small peritoneal pouch (canal of Nuck), in the inguinal canal that may extend to the labium majus. In female infants, such remnants can enlarge and form cysts in the inguinal canal. The cysts may produce a bulge in the anterior part of the labium majus and have the potential to develop into an indirect inguinal hernia. The fluid accumulation results from secretion of an abnormal amount of serous fluid from the visceral layer of the tunica vaginalis. The size of the hydrocele depends on how much of the processus vaginalis persists. A hydrocele of the testis is confined to the scrotum and distends the tunica vaginalis. A hydrocele of the spermatic cord is confined to the spermatic cord and distends the persistent part of the stalk of the processus vaginalis. A congenital hydrocele of the cord and testis may communicate with the peritoneal cavity. Detection of a hydrocele requires transillumination, a procedure during which a bright light is applied to the side of the scrotal enlargement in a darkened room. The transmission of light as a red glow indicates excess serous fluid in the scrotum. Newborn male infants often have residual peritoneal fluid in their tunica vaginalis; however, this fluid is usually absorbed during the 1st year of life. Certain pathological conditions, such as injury and/or inflammation of the epididymis, may also produce a hydrocele in adults. Hematocele of Testis 1038 A hematocele of the testis is a collection of blood in the tunica vaginalis that results, for example, from rupture of branches of the testicular artery by trauma to the testis. Trauma may produce a scrotal and/or testicular hematoma (accumulation of blood, usually clotted, in any extravascular location). Blood does not transilluminate; therefore, transillumination can differentiate a hematocele or hematoma from a hydrocele. A hematocele of the testis may be associated with a scrotal hematocele, resulting from effusion of blood into the scrotal tissues.
The ligament splits to surround the penis and then unites and blends inferiorly with 1497 the dartos fascia forming the scrotal septum blood pressure 6050 bystolic 2.5mg. The fibers of the fundiform ligament are relatively long and loose and lie superficial (anterior) to the suspensory ligament pulse pressure deficit buy cheap bystolic 5 mg online. The penis is supplied mainly by branches of the internal pudendal arteries blood pressure chart over a day purchase bystolic 5 mg on-line. Deep arteries of the penis pierce the crura proximally and run distally near the center of the corpora cavernosa prehypertension range chart discount 5 mg bystolic overnight delivery, supplying the erectile tissue in these structures. Arteries of the bulb of the penis supply the posterior (bulbous) part of the corpus spongiosum and the urethra within it as well as the bulbo-urethral gland. In addition, superficial and deep branches of the external pudendal arteries supply the penile skin, anastomosing with branches of the internal pudendal arteries. The deep arteries of the penis are the main vessels supplying the cavernous spaces in the erectile tissue of the corpora cavernosa and are, therefore, involved in the erection of the penis. When the penis is flaccid, these arteries are coiled, restricting blood flow; they are called helicine arteries of the penis (G. Blood from the cavernous spaces is drained by a venous plexus that joins the deep dorsal vein of the penis in the deep fascia. This vein passes between the laminae of the suspensory ligament of the penis, inferior to the inferior pubic ligament and anterior to the perineal membrane, to enter the pelvis, where it drains into the prostatic venous plexus. Blood from the skin and subcutaneous tissue of the penis drains into the superficial dorsal vein(s), which drain(s) into the superficial external pudendal vein. Sensory and sympathetic innervation is provided 1498 primarily by the dorsal nerve of the penis, a terminal branch of the pudendal nerve, which arises in the pudendal canal and passes anteriorly into the deep perineal pouch. It then runs to the dorsum of the penis, where it runs lateral to the dorsal artery. The penis is richly supplied with a variety of sensory nerve endings, especially the glans penis. Cavernous nerves, conveying parasympathetic fibers independently from the prostatic nerve plexus, innervate the helicine arteries of the erectile tissue. The pudendal nerve 1499 conveys the majority of sensory, sympathetic, and somatic motor fibers to the perineum. Although originating from the same spinal cord segments from which the pudendal nerve is derived, the parasympathetic fibers of the cavernous nerves course independently of the pudendal nerve. With the exception of the cavernous nerves, parasympathetic fibers do not occur outside the head, neck, or cavities of the trunk. The cavernous nerves arise from the prostatic plexus of males and from the vesical plexus of females. They terminate on the arteriovenous anastomoses and helicine arteries of the erectile bodies, which, when stimulated, produce erection of the penis or engorgement of the clitoris and vestibular bulb in females. Reflective of their abdominal origins, lymph from the testes follow a route, independent of the scrotal drainage, along the testicular veins to the intermesenteric portion of the lumbar (caval/aortic) and pre-aortic lymph nodes. Lymphatic drainage from the intermediate and proximal parts of the urethra and cavernous bodies drains into the internal iliac lymph nodes, whereas most vessels from the distal spongy urethra and glans penis pass to the deep inguinal nodes, but some lymph passes to the external inguinal nodes. Details about the attachments, innervation, and actions of these muscles are provided in Tables 6. Lymphatic drainage of male urogenital triangle-penis, spongy urethra, scrotum, and testis. They cross the pelvic outlet like intersecting beams, supporting the perineal body to aid the pelvic diaphragm in supporting the pelvic viscera. Simultaneous contraction of the superficial perineal muscles (plus the deep transverse perineal muscle) during penile erection provides a firmer base for the penis. The bulbospongiosus muscles form a constrictor that compresses the bulb of the penis and the corpus spongiosum, thereby aiding in emptying the spongy urethra of residual urine and/or semen. The anterior fibers of the bulbospongiosus, encircling the most proximal part of the body of the penis, also assist erection by increasing the pressure on the erectile tissue in the root of the penis. At the same time, they also compress the deep dorsal vein of the penis, impeding venous drainage of the cavernous spaces and helping promote enlargement and turgidity of the penis. They force blood from the cavernous spaces in the crura into the distal parts of the corpora cavernosa, which increases the turgidity (firm distension) of the penis during erection. Contraction of the ischiocavernosus muscles also 1503 compresses the tributaries of deep dorsal vein of the penis leaving the crus of the penis, thereby restricting venous outflow from the penis and helping maintain the erection. Because of their function during erection and the activity of the bulbospongiosus subsequent to urination and ejaculation to expel the last drops of urine and semen, the perineal muscles are generally more developed in males than in females. Consequently, the helicine arteries straighten, enlarging their lumina and allowing blood to flow into and dilate the cavernous spaces in the corpora of the penis. The bulbospongiosus and ischiocavernosus muscles compress veins egressing from the corpora cavernosa, impeding the return of venous blood. As a result, the corpora cavernosa and corpus spongiosum become engorged with blood near arterial pressure, causing the erectile bodies to become turgid (enlarged and rigid), and an erection occurs. During emission, semen (sperms and glandular secretions) is delivered to the prostatic urethra through the ejaculatory ducts after peristalsis of the ductus deferentes and seminal glands.
Most adrenergic receptors on coronary blood vessels are 2-receptors arrhythmia flowchart cheap bystolic line, which blood pressure 9040 order 5 mg bystolic fast delivery, when activated blood pressure medication kinds buy 5mg bystolic with amex, cause relaxation (or perhaps inhibition) of vascular smooth muscle and hypertension and headaches generic 2.5mg bystolic mastercard, therefore, dilation of the arteries (Wilson-Pauwels et al. This supplies more oxygen and nutrients to the myocardium during periods of increased activity. Parasympathetic stimulation slows the heart rate, reduces the force of the contraction, and constricts the coronary arteries, saving energy between periods of increased demand. Postsynaptic parasympathetic fibers release acetylcholine, which binds with muscarinic receptors to slow the rates of depolarization of the pacemaker cells and atrioventricular conduction and decrease atrial contractility. Using this technique, intracardiac pressures can be recorded and blood samples may be removed. If a radiopaque contrast medium is injected, it can be followed through the heart and great vessels using serially exposed X-ray films. Alternatively, cineradiography or cardiac ultrasonography can be performed to observe the flow of dye in real time. Both techniques permit study of the circulation through the functioning heart and are helpful in the study of congenital cardiac defects. Embryology of Right Atrium the primordial atrium is represented in the adult by the right auricle. The definitive atrium is enlarged by incorporation of most of the embryonic sinus venosus. The part of the venous sinus incorporated into the primordial atrium becomes the smooth-walled sinus venarum of the adult right atrium. The line of fusion of the primordial atrium (the adult auricle) and the sinus venarum (the derivative of the venous sinus) is indicated internally by the crista terminalis and externally by the sulcus terminalis. Right sinual horn incorporated into right atrium; left sinual horn has become coronary sinus. Pressures opening oval foramen before birth (D) and closing foramen to become oval fossa after birth (E). The oval foramen has a flap-like valve that permits a right-to-left shunt of blood but prevents a left-to-right shunt. At birth, when the baby takes its first breath, the lungs expand with air and pressure in the right atrium falls below that in the left atrium. Consequently, the oval foramen closes for its first and last time, and its valve usually fuses with the interatrial septum. The closed oval foramen is represented in the postnatal interatrial septum by the depressed oval fossa. This left-toright shunt of blood overloads the pulmonary vascular system, resulting in hypertrophy of the right atrium and ventricle and pulmonary arteries. A large shunt increases pulmonary blood flow, which causes severe pulmonary disease (hypertension, or increased blood pressure) and may cause cardiac failure. The classical percussion technique is to create vibration by tapping the chest with a finger while listening and feeling for differences in sound wave conduction. Cardiac percussion is performed at the 3rd, 4th, and 5th intercostal spaces from the left anterior axillary line to the right anterior axillary line. Normally, the percussion note changes from resonance to dullness (because of the presence of the heart) approximately 6 cm lateral to the left border of the sternum. Stroke or Cerebrovascular Accident 898 Thrombi (clots) form on the walls of the left atrium in certain types of heart disease. If these thrombi detach, or pieces break off from them, they pass into the systemic circulation and occlude peripheral arteries. Basis for Naming Cusps and Sinuses of Aortic and Pulmonary Valves the following account explains the embryological basis for naming the pulmonary and aortic valves. The truncus arteriosus, the common arterial trunk from both ventricles of the embryonic heart, has four cusps. The truncus arteriosus divides into two vessels, each with its own three-cusp valve (pulmonary and aortic). The heart undergoes partial rotation so that its apex becomes directed to the left, resulting in the arrangement of cusps as shown in Figure B4. Consequently, the cusps are named according to their embryological origin, not their postnatal anatomical position. Thus, the pulmonary valve has right, left, and anterior cusps, and the aortic valve has right, left, and posterior cusps. The right coronary artery usually arises from the right aortic sinus, superior to the right cusp of the aortic valve, and the left coronary usually has a similar relation to the left cusp and sinus. The posterior cusp and sinus do not give rise to a coronary artery; thus, they are also referred to as a "noncoronary" cusp and sinus. Valvular Heart Disease Disorders involving the valves of the heart disturb the pumping efficiency of the heart. Stenosis is the failure of a valve to open fully, slowing blood flow from a chamber. Insufficiency or regurgitation, on the other hand, is failure of the valve to close completely, usually owing to nodule formation on (or scarring and contraction of) the cusps so that the edges do not meet or align. This allows a variable amount of blood (depending on the severity) to flow back into the chamber it was just ejected from. Restriction of high-pressure blood flow (stenosis) or passage of blood through a narrow opening into a larger vessel or chamber (stenosis and regurgitation) produces turbulence. Turbulence sets up eddies (small 901 whirlpools) that produce vibrations that are audible as murmurs. Superficial vibratory sensations (thrills) may be felt on the skin over an area of turbulence.
The needle is inserted superior to the empty urinary bladder hypertension kidney damage order cheap bystolic online, in a location that avoids the inferior epigastric artery blood pressure 8850 order line bystolic. Peritoneal Dialysis the peritoneum is a semipermeable membrane with an extensive surface area blood pressure xanax withdrawal buy bystolic mastercard, much of which (subdiaphragmatic portions in particular) overlies blood and lymphatic capillary beds arrhythmia heart buy bystolic 2.5 mg mastercard. In renal failure, waste products such as urea accumulate in the blood and tissues and ultimately reach fatal levels. Peritoneal dialysis may be performed in which soluble substances and excess water are removed from the system by transfer across the peritoneum, using a dilute sterile solution that is introduced into the peritoneal cavity on one side and then drained from the other side. Diffusible solutes and water are transferred between the blood and the peritoneal cavity as a result of concentration gradients between the two fluid compartments. For the long term, it is preferable to use direct blood flow through a renal dialysis machine. Functions of Greater Omentum the greater omentum, large and fat-laden, prevents the visceral peritoneum from adhering to the parietal peritoneum. It has considerable mobility and moves around the peritoneal cavity with peristaltic movements of the viscera. It 1061 is called the "policeman of the abdomen" because it goes to the site of trouble. It often forms adhesions adjacent to an inflamed organ, such as the appendix, sometimes walling it off and thereby protecting other viscera from it. Thus, it is common when entering the abdominal cavity, in either dissection or surgery, to find the omentum markedly displaced from the "normal" position in which it is almost always depicted in anatomical illustrations. The greater omentum also cushions the abdominal organs against injury and forms insulation against loss of body heat. Abscess Formation Perforation of a duodenal ulcer, rupture of the gallbladder, or perforation of the appendix may lead to the formation of an abscess (circumscribed collection of purulent exudate, i. The abscess may be walled inferiorly by adhesions of the greater omentum (see the Clinical Box "Subphrenic Abscesses," p. Spread of Pathological Fluids Peritoneal recesses are of clinical importance in connection with the spread of pathological fluids such as pus, a product of inflammation. The recesses determine the extent and direction of the spread of fluids that may enter the peritoneal cavity when an organ is diseased or injured. Flow of Ascitic Fluid and Pus the paracolic gutters are of clinical importance because they provide pathways for the flow of ascitic fluid and the spread of intraperitoneal infections. Purulent material (consisting of or containing pus) in the abdomen can be transported along the paracolic gutters into the pelvis, especially when the person is upright. Conversely, infections in the pelvis may extend superiorly to a subphrenic recess situated under the diaphragm (see the Clinical Box "Subphrenic Abscesses," p. Similarly, the paracolic gutters provide pathways for the spread of cancer cells that have sloughed from the ulcerated surface of a tumor and entered the peritoneal cavity. Fluid in Omental Bursa Perforation of the posterior wall of the stomach results in the passage of its fluid contents into the omental bursa. An inflamed or injured pancreas can also result in the passage of pancreatic fluid into the bursa, forming a pancreatic pseudocyst. Internal Foramen Hernia Through Omental Although uncommon, a loop of small intestine may pass through the omental foramen into the omental bursa and be strangulated by the edges of the foramen. As none of the boundaries of the foramen can be incised because each contains blood vessels, the swollen intestine must be decompressed using a needle so it can be returned to the greater sac of the peritoneal cavity through the omental foramen. Temporary Control of Hemorrhage from Cystic Artery the cystic artery must be ligated or clamped and then severed during cholecystectomy, removal of the gallbladder. Sometimes, however, the artery is 1063 accidentally severed before it has been adequately ligated. The surgeon can control the hemorrhage by compressing the hepatic artery as it traverses the hepatoduodenal ligament. The index finger is placed in the omental foramen and the thumb on its anterior wall. Alternate compression and release of pressure on the hepatic artery allows the surgeon to identify the bleeding artery and clamp it. This is also done sometimes to provide temporary control during cases of severe trauma to the liver or associated structures ("Pringle maneuver"). This arrangement allows the gut the freedom of movement required for alimentation (digestion). Peritoneal formations and subdivisions of peritoneal cavity: Continuities and connections between the visceral and parietal peritoneum occur where the gut enters and exits the abdominopelvic cavity. The main part of the peritoneal cavity (greater sac) is divided by the transverse mesocolon into supracolic and infracolic compartments. When the abdominal cavity is opened to study these organs, it becomes evident that the liver, stomach, and spleen almost fill the domes of the diaphragm. Because they bulge into the thoracic cage, they receive protection from the lower thoracic cage. It is also evident that the falciform ligament normally attaches along a continuous line to the anterior abdominal wall as far inferiorly as the umbilicus. The fat-laden greater omentum, when in its typical position, conceals almost all of the intestine. Some abdominal organs extend superiorly into the thoracic cage and are protected by it. Partially protected by the lowest ribs, the right kidney is lower than the left kidney, owing to the mass of the liver on the right side. The falciform ligament is severed at its attachment to the anterior abdominal wall. Overview of alimentary system, consisting of the digestive tract from the mouth to the anus, with all of its accessory glands and organs.
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