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Reference TEXT BOOK Williams Obstetrics Berek & Novak's Gynecology

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1 Reference TEXT BOOK Williams Obstetrics Berek & Novak's Gynecology
Obstetrics & Gynecology (fifth edition) Author: Tamara L. Callahan, Aaron B .Caughey Williams Obstetrics Berek & Novak's Gynecology Source: Lippincott Williams & Wilkins (LWW)

2 Anatomy of the Female Reproductive System
Ai-Xia Liu Women’s Hospital, School of Medicine, Zhejiang University

3 Outline External genitalia Internal genitalia Adjacent organs
Bony pelvis Pelvic floor

4 External Genital Organs(vulva)
Mons pubis Labia majora Labia minora Clitoris Vestibule of the vagina External urethral orifice Vestibule glands paraurethral glands (Skene’s glands) Bartholin's gland vagina opening hymen the skin of the mons pubis is covered by hair after puberty. as one of the female sencondary sex characteristics,The normal pubic hair in the female is distributed in an inverted triangle. The labia majora are composed of 2 rounded mounds of tissue, originating in the mons pubis and terminating in the perineum. The labia minora are 2 folds of skin medially to the labia majora. Clitoris is the principal female erogenous organ. vestibule: the area that is bordered by the labia minora laterally. In the area of vestibule, we can see 6 opening. External genitalia of adult female (parous)

5 obstructed

6 The hymen has many different shapes.

7 Internal Genital Organs

8 Internal Genital Organs
Vagina: extend from the uterus to the vestibule The wall is composed of a mucosal and a muscular layer Function: sexual intercourse organ, the passage way of labor and menstrual blood Fornix: divided into 4 regions Posterior fornix The vagina is a strong canal of muscle approximately 7.5cm long that extends from the uterus to the vestibule ['vestibju:l] of the external genitalia[.dʒeni'teiliə] , where it opens to the exterior. Fornix is the upper end of the vagina which is around the cervix, we can divide it into 4 portions. Anterior, posterior and two lateral fronices. The posterior fronix provides surgical access to the periptoneal cavity. Toward its lower end, the vagina pierces[piəs] the urogenital diaphragm['daiəfræm ] and is surrounded by the 2 bulbocavernosus muscles and bodies, which act as a sphincter['sfiŋktə] . In the virginal['və:dʒinl] state, an incomplete fold of highly vascular tissue and mucous membrane, the hymen, partially['pɑ:ʃəli] closes the external orifice. Fornix

9 Uterus A pear shaped, thick walled, muscular organ
Situated between bladder and rectum 7-8 cm long, 4-5 cm wide, 2-3 cm thick The uterus is a pear-shaped, thick walled, muscular organ, situated between the base of the bladder and the rectum. Covered on each side by the 2 layers of the broad ligament. isthmus

10 Uterus Divided into 2 main portions Body/Cervix
Ratio: adult, 2:1, infant, 1:2 isthmus a transitional zone between body and cervix Special obstetrical significance (lower uterine segment) Internal orifice(os) anatomical internal os: narrowest position of the cavity histological internal os the columnar epithelium changes into endometrium isthmus The uterus is divided into 2 main portions, the larger portion or body above and the smaller cervix below, connected by a transverse constriction, the isthmus. The body is flattened so that the side-to-side dimension is greater than the anteroposterior dimension and larger in women who have borne children. The communication of the cavity below with the cavity of the cervix corresponds in position to the isthmus and forms the internal orifice. It can be divided into anatomical [ænə'tɔmikəl] internal os and histological internal os. The cervix is somewhat barrel-shaped['bærəl ], its lower end joining the vagina at an angle varying 45 to 90 degrees. It projects into the vagina and is divided into a supravaginal and a vaginal portion by the line of attachment. At the extremity[iks'tremiti ] of the vaginal portion is the opening leading to the vagina, the external orifice, which is round before parturition but takes the form of a transverse slit in women who have borne children.

11 This slide shows the changes of isthmus during pregnancy and labor
This slide shows the changes of isthmus during pregnancy and labor. The isthmus can extend from 1cm to the prepubertal period, it is considerably smaller. In women who have borne children, it is larger. Its shape, size, and characteristics in the pregnant state become considerably modified depending on the stage of gestation.

12 uterus body (superior 2/3s) Fundus: the widest place of the corpus
Lined with endometrium cervix (inferior 1/3) Supravaginal portion Vaginal portion External cervical os Squamocolumnar junction The cervical canal is covered by columnar epithelium The surface of vaginal portion is covered by squamous epithelium The round portion that extends above the plane pass through the points of attachment of the tubes is termed the fundus. The cavity of the body is lined with endometrium. The cervix projects into the vagina and is divided into 2 part. At the extremity of the vaginal portion is the opening to the vagina, the external os, which is round before vaginal delivery. Transverse slit because of cervical laceration. Squamocolumnar[kə‘lʌmnə] junction: a region of transition from stratified[’strætifaid]分层的 squamous epithelium to columnar[kə'lʌmnə] epithelium in the cervix. : External cervical os

13 fundus cavity isthmus corpus Anatomical os. cervix Histologic os.
fornix Supra-vaginal External os Review the anatomy of uterus. There is a bend in the area of the isthmus, at which the cervix then faces downward. This position is the normal anteversion of the uterus, although it may be placed backward, without angulation, or to one side. There is no sharp line between the normal and pathologic state of anterior angulation. Vaginal part vagina Sagittal view Coronary view uterus

14 Position and Axis Direction
retroversion tipped backwards anteversion: tipped forward The position and axis direction of the uterus varies greatly. Normally , the uterus forms a angle with the vagina, there is a bend in the area of isthmus. retroflexion: the fundus is pointing backwards. Anterior of uterus is convex. anteflexion: the fundus is pointing forwards. The isthmus is bend.

15 perimetrium (serous): peritoneal covering
The wall of the uterus perimetrium (serous): peritoneal covering myometrium (muscular): the out layer, the inner layer the endometrium(mucous): soft and spongy the uterine wall consists of 3 layers:serous, muscular and mucous. The serous layer is simply the peritoneal covering. The muscular layer is extremely thick. The outer layer is weaker and composed of vertical fibers and inner layer, the fibers is interlace. 1 2 The myometrium of the uterus:1. the out layer, 2. the inner layer

16 Ligaments 4 pairs of ligaments ligaments
Round ligament Uterosacral ligament Cardinal ligament (transverse ligament of cervix) Broad ligament ligaments 1. round ligament - attaches anterior-inferiorly to uterotubal junctions, pass in the broad ligaments, end in labia majora. They help to keep uterus in the position of anteversion. Broad lig. Round lig. Cardinal lig. Although the cervix of the uterus is fixed, the body is free to rise and fall with the filling and emptying of the bladder. The so called ligaments supporting the uterus consist of the uterosacral ligaments, the transverse ligaments of the cervix(cardinal ligaments), the round ligaments, and the broad ligaments. The round ligaments of the uterus may assist in maintaining the body of the uterus in its typical position over the bladder.they consist of fibrous cords containing smooth muscle from the outer layer of the corately below that the ovarian ligament, each round ligament extends downward, laterally,and forward between the 2 layer of the mesometrium, toward the abdominal inguinal ring. Ligments of uterus

17 Ligaments 2. Broad ligament – arise from the side of the uterus to the lateral pelvic wall, provide minimal support. Between two leaves of ligaments there lies round ligaments,fallopian tube, ovarian ligament, mesosalpinx, infundibulum ligament, blood vessles and nerves 3. Cardinal ligaments - extend from cervix and lateral parts of vaginal fornix to lateral walls of pelvis. Chief means of support and suspends the uterus from the lateral walls of the pelvis minor Broad lig. Round lig. Cardinal lig. The broad ligment, consisting of a transverse fold of peritoneum that arises from the floor of the pelvis between the rectum and the bladder,provides minimal support. The cervix is embedded in tissue called the parametrium. There are 2 pairs of structures continuous with the parametrium and with the wall of the cervix:the uterosacral ligaments and the cardinal ligament of the neck, the latter is the chief means of support and suspends the uterus from the lateral walls of the pelvis minor. . Ligments of uterus

18 Ligaments 4.Uterosacral ligaments – arise from the sacral fascia, and insert into the posteroinferior portion of the uterus at about the level of the isthmus. They provide important support for the uterus. The uterosacral ligaments are the inferior posterior folds of peritoneum from the broad ligament In addition to the static support of these ligament, the pelvic diaphragm provides an indirect and dynamic support.

19 Fallopian tube serves to convey the ova to the uterus, running in the superior border of the broad ligments (mesosalpinx). divided into 4 parts: interstitial portion: embodied within the muscular wall of uterus isthmus: narrowest portion ampulla: wide and tortuous infundibulum: fringed by numerous diverging processes (open to cavity). The fallopian tubes serve to convey the ova to the uterus. They extend from the superior angles['æŋglz] of the uterus to the region of the ovaries, running in the superior border of the broad ligament(mesosalpinx).Each tube is 7-14 cm long and may be divided into 4 parts: interstitial portion, isthmus, ampulla and infundibulum. Interstitial portion: embodied within the muscular wall of uterus The isthmus is the anrrowest portion. Following the isthmus is the wider, more tortuous ampulla. It terminates in a funnel like dilatation, the infundibulum. The margins of the infundibulum are fringed[frindʒd] by numerous diverging processes, the fimbriae['fimbriə] , the longest of which is attached to the ovary. The funnel shaped mouth of the infundibulum, the abdominal ostium['ɔstiəm ] is about 3mm in diameter and actually leads into the peritoneal cavity.

20 mucous: ciliated columnar epithelium
Layers of the tube wall serous subserous muscular mucous: ciliated columnar epithelium The wall of the tube has 4 coats: serous, subserous , muscular, and mucous. After ovulation, the egg goes into the fallopian tube. Frequently at the portion of ampulla, the egg meets with sperm and become fertilization. Then the zygote['zaigəut] passes through the tube to the uterine cavity, where the zygote develops into blastocyst and implant into the uterus.

21 Left and right tube uterine ostium in the hysteroscopy
Hysteroscopy [histə'rɔskəpi] Ostium ['ɔstiəm] Left and right tube uterine ostium in the hysteroscopy


23 Ovary: Oval shaped, 2.5-5 cm long, 1.5-3 cm wide, 0.7-1.5 cm thick
Covered by cuboid or low columnar epithelium and white fibrial tissue, no peritoneum corvered Consists of cortex and medulla cortex: contains oocytes in various stages of maturity medulla: made up of blood vessels, nerves, lymphatic vessels, and supporting tissue. ligaments superior (tubal) end of ovary is connected to lateral wall of pelvis by suspensory ligament of the ovary (infundibulum ligament) contains ovarian vessels and nerves ligament of ovary - connects inferior (uterine) end of ovary to lateral angle of uterus Mesovarium: attach to the posteroanterior layer of the broad ligament, connected with suspensory ligament Hilum: vessels , nerves and lympatics enter the ovary The ovaries are paired organs situated close to the wall on either side of the pelvis minor, a little below the brim. Each measures 2.5-5cm in length, 3 cm in breadth, and 1.5cm in width.

24 The ovary is covered by cuboid['kju:bɔid] or low columnar[kə'lʌmnə ] epithelium and consists of a cortex['kɔ:teks] and a medulla[mi'dʌlə] . The medulla is made up of connective tissue fibers, smooth muscle cells, and numerous blood vessels, lymphatic vessels, and supporting tissue. The cortex is composed of a fine areolar stroma, with many vessels and scattered follicles of epithelial cells with which are the oocytes in various stages of maturity. The more mature follicles enlarge and project onto the free surface of the ovary, where they are visible to the naked eye. They are called graafian follicles. When fully mature, the follicle bursts, releasing the ovum and becoming transfromed into a corpus luteum. The corpus luteum, in turn, is later replaced by scar tissue, forming a corpus albican.

25 Ligaments of ovary The ovary is suspended by means of the mesovarium[.mezə'vɛəriəm, .mezə'veriəm] , the suspensory ligament of the ovary, and the ovarian ligament. The mesovarium consists of 2 layers of peritoneum, continuous with both the epithelial coat of the ovary and the posterosuperior layer of the broad ligament. It is short and wide and contains branches of the ovarian and uterine arteries, with plexuses of nerves, the veins, and the lateral end of the ovarian ligament. the suspensory ligament of the ovary is a triangular fold of peritoneum and is actually the upper lateral corner of the broad ligament, which becomes confluent with the parietal peritoneum at the pelvic brim. It contains the ovarian artery, veins and nerves after they pass over the pelvic brim and before they enter the mesovarium. The ovarian ligament is a band of connective tissue, with numerous small muscle fiber, that lies between the 2 lays of the broad ligament on the boundary line between the mesosalpinx and the mesometrium, connecting the lower pole of the ovary with the lateral wall of the uterus. It is attached just below the uterine tube and above the attachment of the round ligament of the uterus and is continuous with the latter.

26 Neighbor organs Douglas pouch uterovesical pouch
The organs that occupy the female pelvis are the bladder, ther ureters, the urethra, the uterus, the fallopian tubes, the ovaries, the vagina, and the rectum. With the exception of the inferior portion of the rectum and most of the vagina, all lie immediately beneath the peritoneum. The uterus, uterine tubes, and ovaries are almost completely covered with peritoneum and are suspended in peritoneal ligaments. The remainder are partially covered. These organs do not completely fill the cavity, the remaining space is occupied by ilium and sigmoid colon. The vesicouterine pouch [pautʃ] .the peritoneum passes onto the uterus at the junction of the cervix and corpus, continuing upward on the anterior surface of bladder to form the vesicouterine pouch. Rectouterine pouch or Douglas pouch:the entire posterior surface of the uterus is covered by peritoneum, and the convex posterior wall is separated from the rectum by the Douglas pouch. Neighbor organs

27 Water flows under a bridge
ureter Uterine artery About 2cm lateral to the cervix,. The uterine artery crosses over the ureter, the proximity of the uterine vessels to the ureter at this point is of great surgical singnificance. The ureter may be injured or ligated during a hysterectomy. Water flows under a bridge

28 4 4 1 3 3 7 2 5 5 2 6 Figure: internal organs in female pelvis. 1. uterus, 2. ovaries, 3. fallopian tubes, 4. round ligaments, 5. utersacral ligaments, 6. rectouterine pouch (pouch of Douglas) , 7.broad ligaments.


30 Blood supply for female genitalia
Arterial system Ovarian artery: the chief source of the blood for ovaries. Uterine artery: corpus branch cervical-vaginal branch 3. Vaginal artery: main source of the blood for the middle part of vagina 4. Internal pudendal artery: supply for superficial perineum, labia majora, labia minora, lower part of the vagina, clitoris

31 The chief blood supply to the vagina is through the vaginal branch of the uterine artery. After forming the coronary or circular artery of the cerix, it passes medially, behind the ureter, to send 5 main branches onto the anterior wall to the midline. The blood supply to the uterus is from the uterine and ovarian arteries. As a terminal branch of the hypogastric artery, the uterine artery runs downward and medially to cross the ureter near the cervix. It then ascends along the lateral border of the uterus to join with the ovarian artery in the mesometrium. The blood supply to the tubes is derived from the ovarian and uterine arteries. The ovarian artery is the chief source of blood for the ovary. Though both arteries may originate as branches of the abdominal aorta, the left frequently originates from the left renal artery; the right, less frequently.

32 The lymphatic drainage of pelvis
Internal iliac lymph node Surround internal iliac vessels Receive afferents from pelvic viscera, perineum, buttock and back of thigh External iliac lymph nodes Lie along external iliac artery Receive afferents from lower limb and some parts of pelvic viscera Sacral lymph node Common iliac lymph node Lie along common iliac artery Receive afferents from all the above nodes Efferents pass to lumbar lymph node

33 Lymphatic drainage: External genital organ lymph group: 1. superficial inguinal lymph nodes. 2. deep inguinal lymph nodes Pelvic lymph group: 1. iliac lymph group. 2. presacral lymph group. 3. lumbar lymph group.

34 The nerve of external genitalia
Pudendal nerve Obstetric local anesthesia Divided into 3 branches beside tuberosity Inferior hemorrhoid nerve Dorsal nerve Perineal nerve

35 The nerve of internal genitalia
Sympathetic and parasympathetic nerves from lumbar and sacral spinal cord Sympathetic nerve are derived from Plexus Sacral plexus Ovarian plexus The innervation of the vagina contains both sympathetic and parasympathetic fibers. Only occasional free nerve endings are seen in the mucosa. Genitalia [.dʒeni'teiliə ]



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