1. Gross anatomy of female internal genitalia
Dr Namani satya

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

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

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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)

14. Sagittal section of Broad ligament
Fallopian
Ovarian
Round
ovary
Mesosalpinx
Mesovarium

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. True Uterine supports
Perineal body
Figure 27.11

26. Supports of uterus

29. Radiological anatomy
Laparoscopy

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

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

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

34. IUCD

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

36. Retroverted Uterus

37. Prolapse of uterus

38. Ovary

40. 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

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

42. 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

43. 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

44. 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

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

46. 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

47. 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

48. 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

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

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

51. Vagina

52. Vagina
Extent
Relations
Blood supply
Nerve supply
Lymphatic drainage

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

54. 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

55. 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

56. 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

57. 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

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

59. 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

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

61. 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

62. 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

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

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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. 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