6 Pubococcygeus Muscle main part of levator ani injuries most likely muscle to be damaged during childbirthsupports the bladder, urethra, vagina, and rectuminjuriescystocelecystourethrocele or urethrocystocelerectoceleurinary stress incontinence (weakening of pubovaginalis part of levator ani) => Kegel exercise
11 Lymph DrainageThe external genitalia, anus, and anal canal drain to the superficial inguinal nodes.The lower one third of the vagina drains to the sacral nodes and the internal and common iliac nodes.The cervix drains to the external or internal iliac and sacral nodes
12 Lymph, cont’d The lower uterus drains to the external iliac nodes The upper uterus drains into the ovarian lymphatics to the lumbar nodes. The lymphatics of the ovaries drain out of the pelvis to the lumbar nodes
16 Pelvic Viscera Urogenital organs… bladder, uterus, adnexa, and rectumAlso have…the sigmoid colon, cecum, and ileum are components of the pelvic anatomy.
17 Pelvic Viscera urinary organs rectum ureters urinary bladder pass medial to origin of uterine artery and continues to level of ischial spine, where is crossed superiorly by the uterine artery. Then passes close to lateral portion of vaginal fornix and enters posterosuperior angle of bladderurinary bladderhollow viscus with strong muscular wallstrigone of bladderurethra - about 4 cm long, anterior to vaginarectum
18 Ligamentsround ligament of uterus - attaches anterior-inferiorly to uterotubal junctionsligament of ovary - attached to uterus, posterior-inferior to uterotubal junctionsbroad ligament - encloses body of uterus, freely moveabletransverse cervical ligaments - extend from cervix and lateral parts of vaginal fornix to lateral walls of pelvisuterosacral ligaments - pass superiorly and slightly posteriorly from sides of cervix to middle of sacrum, can be palpated through rectum as pass posteriorly at sides of rectum. Hold cervix in normal relationship to sacrum.
20 Broad LigamentContains between its layers the fallopian tube; the ovary and the round ligament; the uterine and ovarian blood vessels, nerves, lymphatics, and fibromuscular tissue; and a portion of the ureter as it passes lateral to the uterosacral ligaments over the lateral angles of the vagina and into the base of the bladder
21 Internal Genital Organs vaginafornixrectouterine pouch (pouch of Douglas)sphincters of vaginapubovaginalis muscleurogenital diaphragmbulbospongiosus musclelymphatic drainagesuperior part into internal and external iliac lymph nodesmiddle part into the internal iliac lymph nodesvestibule into superficial inguinal lymph nodes
23 Uterus 7-8 cm long, 5-7 cm wide, 2-3 cm thick projects superior-anteriorly over urinary bladdertwo major partsbody (superior 2/3s)funduscervix (inferior 1/3)internal osexternal osanterior lipposterior liplined with columnar, mucus-secreting epitheliumisthmus = a transitional zone between body and cervix
25 wall of uterus consists of 3 layers: Perimetrium/serosa - outer serous coat, peritoneum supported by thin layer of connective tissuemyometrium mm smooth muscle, main branches of blood vessels and nerves of uterus are in this layerendometrium - inner mucous coat
26 uterine tubes 10-12 cm long, 1 cm diameter extend laterally from cornua of uterus4 partsinfundibulumdistal endabdominal ostium, about 2 mm in diameter20-30 fimbriaeovarian fimbria is attached to ovaryampullatortuous partwidest and longest part, over 1/2 its lengthfertilization occurs hereMost common site for ectopic
28 isthmusshort 2.5 cm, narrow, thick-walled part of tube that enters the uterine cornuuterine partshort segment that passes through thick myometrium of uterusuterine ostium (smaller than abdominal ostium)
30 Ovaries oval, almond-shaped, 3 cm long, 1.5 cm wide, 1 cm thick ligamentssuperior (tubal) end of ovary is connected to lateral wall of pelvis by suspensory ligament of the ovarycontains ovarian vessels and nervesligament of ovary - connects inferior (uterine) end of ovary to lateral angle of uterussurface of ovary is not covered by peritoneumoocyte expelled into peritoneal cavity
31 Pelvis The bony and ligamentous pelvic mechanism is designed to… protect the pelvic viscerasupport the vertebral columnfacilitate locomotionThe pelvic girdle protects the viscera contained within its cavity from all ordinary trauma
32 PelvisThe bony pelvis is formed anteriorly and laterally by the innominate bones and posteriorly by the sacrum and coccyxThe pelvic girdle is adapted for strength, support, and locomotion.In the erect position, the pelvic girdle is inclined forward.
35 Man vs. WomanThe female pelvic inlet is oval; the male pelvic inlet is heart shaped.The female pelvis has a more regular outline than the male pelvis, in which the sacral promontory is more prominent and the sacrum is longer and more curved.
36 Female Bony Pelviswider, shallower, and has larger superior and inferior pelvic apertures than male pelviship bones farther apartischial tuberosities are farther apart because of wider pubic archsacrum is less curved, which increases the size of the inferior pelvic aperture and the diameter of the birth canalobturator foramina is oval
37 Types of Bony Pelvis anthropoid = AP diameter > transverse diameter 23% femalesplatypelloiduncommonandroid = wide transverse diameter, posterior part of aperture is narrow32% femalesgynecoid = most spacious obstetrically43% females
39 Superior Pelvic Aperture AP diameter = measurement from the midpoint of the superior border of pubic symphysis to the midpoint of sacral promontorytransverse diameter = greatest width, measured from linea terminalis on one side to this line on opposite side
40 determine prominence of ischial spines oblique diameter = measurement from one iliopubic eminence to the opposite sacroiliac jointmidplane diameter = interspinous diameter or distance between ischial spines and cannot be measured. Is estimated by palpating the scarospinous ligament through the vagina. The length of this ligament = about half the midplane diameter.determine prominence of ischial spines< 9.5 cm may prevent passage of fetus
42 HypothalamusRelease of GnRH (gonadotropin-releasing hormone), also called LHRH, into the pituitary portal circulation via the pituitary stalkThe menstrual cycle does not ‘begin’ here!! All are inter-related !
43 Hypothalamus What triggers the release of GnRH? Unclear but in animal studies dopamine is inhibitory & norepinephrine is stimulatoryFor normal gonadotropin release, GnRH must be released in pulses. The pulse frequency & amplitude are critical for normal mensesDecrease in pulse frequency will decrease LH release & increase FSHIncrease pulse frequency will increase LH & decrease FSH
44 Anterior PituitaryGonadotrophs respond to the GnRH by producing FSH (follicle stimulating hormone) & LH (Luteinizing hormone) into the general circulationRelease at this level is also controlled by circulating levels of estrogen & progesterone (gonadal steroids)…positive & negative feedback
45 Anterior Pituitary Stores & releases FSH & LH Day 1-7, follicular phase: estrogen from the ovary will stimulate storage of FSH & LH(in the pituitary)…also inhibits secretionLater in follicular phase with increasing estrogen levels (enlarging follicle) effect on gonadotrophs changes to stimulatory allowing for a secretion of LH which triggers ovulation
47 Under the influence of LH, the follicle begins to secrete progesterone shortly before ovulation Low level of progesterone will induce the FSH surge that occurs immediately prior to ovulation
48 FSH Surge matures the oocyte (stimulates gametogenesis produces proteolytic enzymes needed for follicle ruptureIncreases the # of LH receptors(ovarian) required for optimal progesterone production in the luteal phase
49 LH surgeincrease in intrafollicular proteolytic enzymes that destroy the basement membrane and allow follicular ruptureluteinization of the granulosa cells and theca, resulting in increased progesterone productionresumption of meiosis in the oocyte, thus preparing it for fertilizationan influx of blood vessels into the follicle, preparing it to become a corpus luteum.
51 After ovulation, the secretion of estrogen & progesterone in high concentrations from the corpus luteum inhibits both gonadotrophs & GnRHAs the corpus luteum dies off the hormone levels subside & FSH resumes the cycle
52 OvaryBy the fifth week of embryonic life, germ cells have formed the ovaryMaximum # of eggs the ovary is able to produce is at 20 weeks of gestation… 6-7 million!1-2 million at birth300,000 at the onset of puberty!
54 Ovary The functional unit is the FOLLICLE Oocyte (frozen in the first stage of meiosis) surrounded by granulosa cells & adjacent stromal cells…Theca cells.FSH will target the granulosa cellsLH will target the thecal & stromal cells
55 Ovary, cont’dAs the follicle matures, Antrum develops around the oocyteA bunch of follicles will develop around day 7 of cycle…a dominant follicle will win!
57 Ovary cont’dRising estrogen levels from the maturing follicle itself will ‘prime’ the follicle for the LH surge.When estrogen levels reach 200pg/ml or greater for longer than 48 hours, the LH surge occursThe granulosa cells become luteinized just prior to ovulation & begin to produce progesterone
58 Progesterone rise is responsible for... Facilitates the positive feedback action of estradiol in initiating the LH surgeLH surge occurs about 36 hours prior to ovulationResponsible for the FSH peak
60 OvaryAn avascular area will develop on the wall of the follicle & with the help of proteolytic enzymes ovulation occurs.The oocyte is picked up by the fimbriae of the tubeIf not met by a sperm will degenerate in hours!
61 OvaryAfter ovulation, luteinization will transform the ruptured follicle into a corpus luteum which produces estrogen & progesterone for the next daysIf not aided by secretion of hCG, the corpus luteum will become the corpus albicans
62 AndrogensAndrostenedione & testosterone are also secreted & can alter the ability of the ovary to respond to FSH & LH…may create atretic follicles early on
63 TWO CELL THEORY …of ovarian steroidogenesis Theca cells produce androgens under the influence of LHGranulosa cells convert the androgens to estrogen under the influence of FSH
64 Endometrium Contains receptors for both estradiol & progesterone Estradiol causes the proliferation, steady increase in thickness of liningWhen the corpus luteum starts producing progesterone; the proliferative effect of estradiol is neutralized & endometrial growth ceases
66 EndometriumThe lining now becomes SECRETORY with the endometrial vessels coiling & preparing to shedIf no baby… corpus luteum stops producing estrogen & progesterone. This withdrawal of steroid support from the endometrium causes endometrial breakdown
67 Why don’t women bleed to death every month?? Vascular spasmThrombosisResumption of endometrial proliferation under the influence of unopposed estrogenMyometrial ischemia - dysmenorrhea