Gross anatomy of female internal genitalia Dr Namani satya

Objectives Discus gross anatomy of : Uterus Surgical anatomy and supports of uterus Uterine tube Ovary Vagina

Introduction It is a hallow muscular organ Central organ of female genitalia Situated in pelvis between bladder in front and rectum behind

Shape & Size It is pear shaped Just below the middle there is a constriction called isthmus It divides uterus into upper rounded large part called body and small cylindrical lower part called cervix Cervix is inserted into anterior part of upper end of vagina

Shape & Size Fundus is the free rounded upper part of uterus distal to opening of uterine tubes Uterus has Anterior surface Posterior surface Two lateral borders Size : length – 7.5 cm, breadth – 5 cm and thickness – 2.5 cm During pregnancy it increases 10 times

Position Non pregnant uterus is within the pelvis It is anteverted and anteflexed in position Long axis of cervix is bent on long axis of vagina this is called anteversion Body of uterus is bent forwards over cervix at the isthmus and is known as anteflexion

Position ‘A’ shows the parts of the organ. ‘B’ shows the normal position of anteflexion and anteversion. ‘C’ shows the angle (a) of anteversion. ‘D’ represents a retroverted uterus. ‘E’ shows the uterovesical and recto-uterine pouches.

Relations – anterior surface Fundus and body of uterus is covered by peritoneum and related uterovesical pouch It separates from anterior 2/3 of upper surface of urinary bladder The supravaginal cervix is not covered by peritoneum and related to posterior 1/3 of superior surface of urinary bladder

Relations – posterior surface Entire posterior surface fundus ,body of uterus and supravaginal is covered by peritoneum and related pouch of Douglas The pouch separates uterus from rectum

Lateral borders Broad ligament is attached to lateral borders It stretches from lateral borders to floor and side walls of pelvis It consists of two layers Connective tissue Ovarian ligament- it connects ovary with lateral border of uterus behind fallopian tube Round ligament- it stretches from lateral border of uterus in front of attachment of fallopian tube passes through inguinal canal to skin of labium majus Both are parts of gubernaculum

Lateral borders Uterine vessels Lymphatics Epoophoron Paroophoron Ureters lie at the side of cervix and lateral fornices of vagina They are crossed by uterine arteries The cardinal ligaments stretches from side of cervix and vagina to side walls of pelvis They play an important role in maintaining uterus in position

Lateral borders Epoophoron and paroophron are vestigial structures derived from mesonephric tubules Posterior layer of broad ligament is reflected backwards to form mesovarium It encloses ovary in its free border

Lateral borders Mesometrium- part of broad ligament between lateral border and mesovarium (red) Mesosalpinx - part of broad ligament between fallopian tube and mesovarium(Blue) Suspensory – part of broad ligament between infundibulum and lateral wall of pelvis ’ (Green)

Sagittal section of Broad ligament Fallopian Ovarian Round ovary Mesosalpinx Mesovarium

Fallopian tube They are attached to upper end of lateral borders of uterus Length 10 cm and divided into 4 parts They are 1.Intramural 2.Isthmus 3.Ampulla 4.Infundibulum 2 3 1 4 4

Fallopian tube Parts 1.Intramural – pierces muscular wall of uterus to open into uterine cavity 2.Isthmus, -it is narrow part where tubectomy is done 3.Ampulla is the dilated part where fertilization occurs 4.Infundibulum- expanded funnel shaped part with 4-5 fimbria And in its bottom there is lateral opening into pelvic cavity One fimbria is attached to ovary called as ovarian fimbria 2 3 1 4 4

Interior of uterus Cavity of uterus is a cleft like space triangular in outline At its upper lateral angle end are opening of uterine tubes At the lower angle is opening of internal os Cervical canal is spindle shaped Upper opening is internal os Lower opening is external os Median longitudinal ridges are present in the anterior and posterior walls There are transverse folds from their sides

Interior of uterus Mucous lining of upper 1/3 is similar to uterus and undergoes changes during mestruration During pregnancy by 2nd month this part is taken up by uterine cavity and is called as lower uterine segment During labor lower uterine segment is elongated to form conducting part while upper part forms the propulsive part

Blood supply of uterus Anterior division of Internal iliac artery branch : Uterine arteries ascend along lateral border of uterus and fallopian tubes to supply them Nonpregnant uterus is supplied by uterine arteries Uterine artery cross ureter Anastomoses with vaginal artery and ovarian artery The arteries are tortuous which allows for enlargement of uterus

Short straight vessels end in basal part of endometrium Uterine Wall Short straight vessels end in basal part of endometrium Long spiral vessels reach innermost part of endometrium Figure 27.15b

Venous drainge Utero vaginal plexus draining into ovarian and internal iliac veins Uterine and vaginal vein drain into internal iliac veins

Nerve supply Utero vaginal plexus reach along uterine and vaginal arteries Sympathetic are from lower thoracic and L1&2 Parasympathetic are from S2,S3,S4 Pain afferents are in Sympathetic so paravertebral block is applied in cancer of uterus and labor pains Action of sympathetic Uterine contraction and vasoconstriction Action of parasympathetic Uterine inhibition and vasodilatation Labor pains are due to vasoconstriction leading to ischemia Referred pain to T11&12

Lymphatic drainage Cervix drains to Posteriorly to sacral lymph nodes Postero laterally to internal iliac lymph nodes Laterally to external iliac lymph nodes Body of lower uterus drains to external iliac lymph nodes Fundus & fallopian tube drain to Along ovarian vessels to lateral aortic lymph nodes A few to external iliac lymph nodes Along round ligament of uterus to superficial inguinal lymph nodes

Supports of uterus 1.Uterine Axis. 2.Pelvic muscles 3.Perineal body 4.Urogenital diaphragm 5.Pubocervical ligament 6.Transverse cervical ligament or Mackendrot’s ligament 7.Uterosacral ligament 8.Round ligament of uterus Mackendrot’s

True Uterine supports Perineal body Figure 27.11

Supports of uterus

Radiological anatomy Laparoscopy

Normal hysterosalpingogram A smooth triangular uterine cavity and spill from the ends of both tubes

Hysterosalpingogram Showing a normal uterus and blocked tubes No "spill" of dye is seen at the ends of the tubes

Applied anatomy Intra Uterine Contraceptive Device (IUCD) Caesarean section Retroverted Uterus Prolapse of uterus

IUCD

Caesarean section done after 28 weeks -by that time respiratory system also develops

Retroverted Uterus

Prolapse of uterus

Ovary

Ovary Female gonad Two situated on each side of uterus in a fossa in the lateral pelvic wall During pregnancy it is dislodged never to return

Boundaries of ovarian fossa Behind by ureter In front by obliterated umbilical artery Floor by obturator fascia ,obturator nerve and vessels

Shape Shape is ovoid Size 3X1.5X1 cm With two poles Two surfaces Upper pole Lower pole Two surfaces Lateral surface Medial surface Two borders Anterior & posterior borders

As age advances due to repeated ovulation Surface & color In adults it is pink With smooth surface As age advances due to repeated ovulation Surface becomes irregular scared and grayish

Relations – upper end Is called tubal end Gives attachment to ovarian fimbria of the infundibulum of uterine tube Infundibulopelvic ligament extends from this end to lateral pelvic wall

Relations – lower end Is called uterine end Ovarian ligament extends from this end to upper end of lateral border of uterus

Relations – lateral & medial surfaces Lateral surface is related to floor of ovarian fossa With obturator nerve and vessels Medial surface is overlapped by uterine tube

Relations – anterior &posterior borders Posterior border is the free border Anterior border gives attachment to mesovarium Which is continuous with posterior layer of broad ligament There is hilum in this border

Blood supply Ovarian artery Passes through infudibulopelvic ligament and mesovarium to enter hilum of ovary Right ovarian vein ends in inferior vena cava Left vein in left renal vein

Nerve supply Ovarian plexus Consist of Vagus fibers Sympathetic T 10 &11

Lymphatic drainage Lateral aortic lymph nodes near the origin of ovarian arteries

Vagina

Vagina Extent Relations Blood supply Nerve supply Lymphatic drainage

Extent Lower part of female genital tract Extends from cervix to vaginal opening in the vestibule

Shape It is a musculomembranous canal directed downwards and forwards The long axis of vagina makes 90 degrees with the long axis of uterus In transverse section lower 1/3 is collapsed with H shaped lumen In the middle 1/3 the lumen is transverse slit In the upper 1/3 circular in outline

Length Posterior wall of vagina is longer Posterior wall is 9 cm Anterior wall 8 cm It can dilate to a very great extent during delivery of fetal head Its lower end is narrowest It has two ends and four walls – anterior posterior and two lateral walls

Lower end of vagina Lower end opens at the vaginal opening in the vestibule In virgins the opening is guarded by a fold of mucous membrane called hymen It is ruptures during first penetration The hymen may be imperforate Leading to collection of menstrual fluid in the vaginal canal the condition called – HAEMATOCOLPOS and requires surgical intervention

Upper end of vagina Upper end is pierced by anteriorly by cervix and uterus Between cervix and upper end of vagina a blind recess exists called VAGINAL FORNICES There are four fornices anterior, posterior and two lateral

Anterior wall It is related from above downwards to Cervix of uterus Base of urinary bladder Terminal parts of ureters Urethra

Posterior wall The upper most part of posterior wall and posterior fornix are covered by peritoneum and related to pouch of Douglas Below it is related to rectum Perineal body is behind the lower end of posterior wall

Lateral wall The upper end gives attachment to broad ligament Ureter is crossed by uterine arteries

Lateral wall Cardinal ligaments are attached to side of vagina and cervix Attached to urogenital diaphragm Greater vestibular glands and Bulb of vestibule is on its side

Interior of vagina There are two median longitudinal folds One in the anterior wall and other in the posterior wall From these a number of transverse rugae arise which help expansion of vagina

Blood supply Uterine Vaginal Internal pudendal- below levator ani Forms anastomosis in the middle of anterior and posterior walls

Venous drainage By a plexus of veins which drain into internal iliac veins

Lymphatic drainage Upper 4/5 above the urogenital diaphargm end in internal iliac nodes Lower 1/5 emerge out of the margin of vagina to end in superficial inguinal lymph nodes

Nerve supply Upper 4/5 above the urogenital diaphargm by vaginal plexus – parasympathetic from S2,S3,S4and sympathetic from lumbar Pain fibers pass in parasympathetic Lower 1/5 from pudendal nerve

Applied anatomy In semi sitting posture secretions collect in pouch of Douglas A perforating injury can occur through posterior fornix involving peritoneum Supports of uterus also form support of vaginal wall Any weakness can lead to prolapse

Vaginal exmaination Per vaginum PV digital examination Palpated structures Anteriorly – urethra bladder pubic symphysis Posteriorly – rectum and pouch of Douglas Superiorly – cervix Laterally – ovary ,fallopian tube, lateral wall of pelvis and ureter

To find size of pelvis Diagonal conjugate is measured Distance between lower border of pubic symphysis and sacral promontory If the pelvis is normal size the finger will not touch sacral promontory Bimanual abdominopelvic vaginal examination helps in finding size and position of uterus , organ's and other masses

At the end of the lecture student be able to : Outline the different parts of female internal genitalia Explain the location , normal position, parts ,relations ,ligaments ,blood supply, nerve supply and lymphatic drainage of uterus Describe the primary and secondary supports of uterus and their clinical importance

Describe the parts , blood supply , nerve supply and lymphatic drainage of uterine tube Describe the parts, blood supply , nerve supply and lymphatic drainage of ovary Explain the extent, relations ,blood supply , nerve supply and lymphatic drainage of vagina