Bony pelvis: is made up of four bones: the sacrum(consists of five fused vertebrae), the coccyx, two innominates(ilium ,ischium , pubis)
ilium 髂骨 coccyx 尾骨 ischium 坐骨 sacrum 骶骨 pubis 耻骨
The anterior superior edge of the first sacral vertebra is called the promontory, it protrudes slightly into the cavity of the pelvis
Pelvis Sacro-iliac joint 骶髂关节 Sacro-coccygeal joint 骶尾关节 Symphysis pubica 耻骨联合 The pelvic bone are joined by four articulations: the pubic symphysis, the sacrococcygeal jionts and the sacroiliac jionts
Sacrospinous ligament 骶棘韧带
Extend from the lateral border of the sacrum and coccyx to the spine of the ischium
Sacrotuberous ligament 骶结节韧带
Extend from the posterior aspect of the lower 3 sacral vertebrae to the ischial tuberosity
sacrospinous ligament sacrotuberous ligament
True pelvis and false pelvis
The pelvis is divided into
the pelvis major (false pelvis)
is bounded by the lumbar vertebrae posteriorly,an iliac fossa bilaterally,and the abdominal wall anteriorly
the pelvis minor (true pelvis)
is formed by sacrum and coccyx posteriorly and by the ischium and pubis laterally and anteriorly
Pelvic planes of the inlet
The conjuate ( the anteroposterior diameter ) : from the center of the promontory to the symphysis pubica
The transverse diameter : the greatest width of the pelvic inlet
The oblique diameter from the sacroiliac joint of one side to the iliopectineal eminence of the other
the sacrum is well curved, and the sacrosciatic notch is adequate
occurs in approximately 23.2%-29% women
There is a distinct oval inlet.
very wide subpubic arch.
posterior segmet flat.
the sacrum is normal
the side walls are straight
the sacrosciatic notch is narrower
occurs in only 2% to 5% of women
the side walls converge
the sacrum is inclined forward
the sacrosciatic notch is narrow
narrow anterior segmet, flat posterior segment,
occurs in approximately 20% ;approximately 40% of black women
the inlet is oval, long, and narrow
the side walls are straight(do not converge)
the sacrum is long and narrow
the sacrosciatic notch is wide.
Both the interspinous and intertuberous diameter are somewhat smaller
The tissues closing down the pelvic outlet (muscles and fasciae)
suspend and support the pelvic organs, such as uterus and bladder and rectum
Four bony landmark: the pubic symphysis anteriorly, the coccyx posteriorly, the ischial tuberosities laterally
general conception : the tissues closing down the pelvic outlet
Clinical conception : the tissues between vagina and anus.
The superficial perineal space contains the muscular tissue and erectile tissue needed for female sexual response, as well as for support and stabilization of the perineal body .
Posterior part (anal triangle)
The anal triangle contains the anal canal, external and internal anal sphincters and ischioanal fossae
The line joining the ischial tuberosities forms the anal triangle posteriorly and the urogenital triangle anteriorly. The midpoint of this line is the perineal body.
Anterior part (urogenital triangle)
The urogenital triangle contains the distal parts of the urethra and the external genitalia including the superficial perineal space.
The pelvic floor is formed by three layers of muscles and fasciae: The superficial compartment of the perineum consists of the ischiocavernosus muscles which cover the crura leading to the clitoris; and the bulbocavernosus muscles , which extend from the central tendon of the perineum around each side of the vaginal opening to insert upon the base of the clitoris and which cover the erectile bulbs of the superficial space. Also in the superficial space are the superficial transverse perineal muscles which from the ischial tuberosities to the perineal body, the external sphincter ani , Bartholin’s glands and the perineal vessels and nerves.
It is in the middle layer of the pelvic floor.
It consists of two layers of fasciae ( perior fascia of urogenital diaphram and inferior fascia of urogenital diaphram ) and two muscles ( external urinary sphincter and the deep transverse perineal muscle)
The levator ani muscle is divided into 3 portions:
1. pubococcygeus : main part of the levator ani muscle .it arises from the inner surface of the descending ramus of the pubis to the coccyx.
2. Iliococcygeus : it arises from the arcus tendineus to the coccyx.
3. puborectalis :arises from the body and descending ramus of the pubis to the anococcygeal raphe.
coccygeus muscle : runs from the ischial spine to the fourth and fifth sacral vertebrae and the coccyx.
The pelvic diaphragm is the deepest layer of the pelvic floor. It consists of the levator ani,coccygeus and layers of fasciae.
The external genitalia
The female external genitalia are collectively known as the vulva or pudendum. The vulva consist of the mons pubis, labia majora, labia minora, vestibule of the vagina, clitoris, the greater vestibular glands or Bartholin’s glands, the fourchette, and perineum.
mons pubis The mons pubis is composed of fibro-fatty tissue which covers the bodies of the pubis bones. It is covered with pubic hair, and divides to become continuous with labium majus of each side . THE VULVA
labia majora The most prominent features of the vulva, the labia majora , are large, hair-covered two folds of skin which merge posteriorly into the perineum where they are jioned together by the fourchette, they contain sebaceous glands and lie on either side of the introitus.
labia minora prepuce The labia minora are two thin folds of skin which lie between the labia majora , their inner surfaces are the lateral boundaries of the vestibule. Anteriorly they divide into two thin folds, the upper of which unite over the clitoris to form the prepuce , and the lower of which unite to form the frenulum. They contain no hair but have a rich supply of venous sinuses, sebaceous glands, and nerves. They are very sensitive and contain some erectile tissue. Frenulum labium pudendal Frenulum
The vestibule is the triangular area bounded anterolaterally by the labia minora and posteriorly by the fourchette. At the apex of the triangle is the clitoris. It contains the urethral meatus located approximately 2 to 3 cm posterior to the clitoris, immediately in front of the vaginal opening . Into the vestibule open the ducts of Bartholin’s glands.
Vestibular bulb are two oblong masses of erectile tissue which lie on either side of the vaginal entrance from the vestibule. Each bulb is covered by the bulbocavernosus muscle. These muscles aid in constricting the venous supply to the erectile vestibular bulbs and also act as the sphincter vaginae.
Bartholin‘s glands are two small rounded structures situated just posterior to the vestibular bulbs. During sexual excitation, they secrete a glairy fluid which serves as lubricant. Their ducts open in the groove between the labia minora and the hymen. Each duct is about 0.5cm long , and unless it is inflamed the orifice cannot usually be seen. They are often the site of gonococcal infections and painful abscesses. 开口堵塞可形成囊肿
The clitoris lies just in front of the urethra and consists of the glans, the body, and two crura. Only the glans of the clitoris is visible externally. The glans is covered with modified skin containing many nerve endings. The body extends superiorly for a distance of several centimeters and divides into two crura, which are attached to the undersurface of either pubic ramus. The body and the crura are composed of erectile tissue. Each crus is covered by the corresponding ischiocavernosus muscle and by their contraction produce erection of the clitoris.
Hymen : As the labia minora are spread, the vaginal introitus, guarded by the hymenal ring, is seen. The hymen may take many forms, however, such as perforated centrally,a cribriform plate with many small openings or a completely imperforate diaphragm, and varying in size from a pin-hole to one that admits two fingers. The hymen is partially ruptured at the first coitus and further disrupted during childbirth.
The female external genitalia are supplied on each side by the internal pudendal artery and by the deep and superficial external pudendal arteries.
Most of the vulva is innervated by the branches of the pudendal nerve. Anterior to the urethra, the vulva is innervated by the ilioinguinal and genitofemoral nerves.
The anterior vaginal wall measures approximately 8 cm, while the posterior vaginal wall measures approximately 10 to 11 cm.
Surrounding the cervix are 4 small recesses known as the anterior, posterior, and the lateral fornices.
The vagina is the female organ for sexual intercourse, egress of menstrual flow, and passage of the fetus during labor and delivery. extend from the uterus to the vestibule of the external genitalia. its long axis is almost parallel with that of the lower part of the sacrum. Its epithelium, which is stratified squamous in type, is normally devoid of mucous glands and hair follicles and is nonkeratinized. Deep to the vaginal epithelium are the muscular coats of the vagina, which consist of an inner circular and an outer longitudinal smooth muscle layer. THE VAGINA
The vagina is normally kept moist by the secretion of the uterine and cervical glands, and by a watery transudate through its epithelial lining. It has no glands. During the reproductive period of life the stratified squamous epithelium is thick and contains glycogen from the influence of oestrogens. After puberty ,a PH of vagina is about 4 by lactic acid. The acid reaction persists until the menopause and restricts the growth of pathogenic organisms.
Remnants of the mesonephric ducts may sometimes be demonstrated along the vaginal wall in the subepithelial layers and may give rise to Gartner‘s duct cysts. The vagina, anteriorly and posteriorly has multiple transverse rugae. 阴道可以伸展当胎儿通过时 The upper two-thirds of the vagina is almost vertical in its orientation. An important anatomic feature is the immediate proximity of the posterior fornix of the vagina to the pouch of Douglas, which allows easy access to the peritoneal cavity from the vagina, by either culdocentesis or colpotomy. THE VAGINA
The lower third of the vagina passes perpendicularly through the levator hiatus and the perineum, the musculature of superficial space as well as the perineal membrane. THE VAGINA During sexual excitement, the parasympathetic supply, via the pelvic nerves effects elongation of the vagina, transudation of a lubricating fluid from the vaginal mucosa, vasocongestion of the distal third of the vagina, and further lubrication from the greater vestibular glands in the vestibule of the vagina.
The Vagina Blood Supply
The vaginal arteries arise from the anterior portions of the internal iliac arteries. They anastomose with the vaginal branch of the uterine arteries and the branch of the internal pudendal arteries.
The upper of the vagina is supplied by the cervical –vaginal branch of the uterine arteries.
The middle part of the vagina is supplied by the vaginal arteries .
The lower of the vagina is supplied by internal pudendal arteries and middle hemorrhoidal arteries.
The uterus consists of two unequal parts: an upper corpus, and a lower cervix.
The cervix is cylindrical in shape and continuous above with the body of the uterus. The cervix canal is spindle shaped, being constricted below at the internal os and above at the external os, where it opens into the vagina.
In women who have not borne children the external os is circular, but after labour it has the form of a transverse slit.
In adult, the cervix is approximately 2.5-3 cm in length
The wall of the cervix consists of fibromuscular tissue.
The cervix consists of a vaginal portion , which is easily seen during speculum examination of the vagina, and a supravaginal portion , which is very important in the endopelvic fascial support system of the cervix and upper vagina. The vaginal portion protrudes into the vagina and is surrounded by the fornices is covered with a nonkeratinizing squamous epithelium. The cervical epithelium is of tall columnar type. At about the external cervical os, the squamous epithelium covering the exocervix changes to simple columnar epithelium, the site of transition being referred to as the squamo-columnar junction, and it is at this site that carcinoma is particularly liable to arise. THE CERVIX Surrounding the supravaginal portion of the cervix is a dense ring of endo-pelvic fascia into which is anchored the pubocervical fascia, as well as the uterosacral and cardinal ligaments. This endopelvic fascial ring has also been called the “paracervical fascia.
The “paracervical ring” is the key link in the important mechanical continuity of the endopelvic fascia to the vagina and cervix from both the upper vertical and horizontal support axes. Here, both cardinal ligaments – uterosacral ligament complexes of the vertical support axis merge with the pubocervical fascia of the horizontal support axis. “ PARACERVICAL RING” THE CERVIX relationship to the vagina The cervix enters the vagina by coursing perpendicularly to the anterior vaginal wall, thus explaining the shorter length of the anterior vaginal wall [8cm] when compared to the posterior vaginal wall [10-11cm].
The uterus is classically pear-shaped , somewhat flattened anteroposteriorly. It consists of largely interlacing smooth muscle fibers, and weighs 40 to 50 grams in the nulliparous patient and approximately 60 to 80 grams in the multiparous patient.
The cavity of the uterus is triangular with the base uppermost ,and the apex at the junction with the cervix where it is narrowed to form the internal os. The wall of the cavity are normally in contact. The part of the body of the uterus which is above the points of entrance of the fallopian tubes is known as the fundus.
The uterus consists of the cervix and the uterine corpus, which are joined by the isthmus. The isthmus is obstetrically known as the lower uterine segment where the endocervical epithelium gradually changes into the endometrial lining. It is about 1 cm long. superior extremity – anatomical internal os ， inferior extremity – histological internal os. In late pregnancy, this area elongates and is referred to as the lower uterine segment.
In the child, the cervix forms about two-thirds of the total length of the uterus, and the body but one-third, whereas in the adult these proportions are reversed. In old age the uterus shrinks ,the muscular walls atrophy.
The uterus is typically 7 cm in length from the external os to the top of the fundus and approximately 5 cm in width at the level of the uterine ostia, which define the widest part of the uterus. The endometrial cavity is a potential space which is triangular in shape. The walls of the uterus are approximately 2.5 cm in thickness. 6 THE UTERUS
The perimetrium is the peritoneal covering, it is firmly adherent over the fundus and most of the body.
The myometrium is thick and continuous with that of the tubes and vagina. The muscle fibres are arranged in three layers.The outer longitudinal and inner circular layers are thin.Inthe thick middle layer , the muscle bundles are arranged in a criss-cross fashion.
The endometrium is soft and spongy which contains glands that open into the cavity of the uterus
serous muscular mucous isthmus
The endometrial lining of the uterine corpus may vary from 2 to 10 mm in thickness (which may be measured by ultrasound imaging), depending on the stage of the menstrual cycle. The superficial two-thirds of the endometrium which slough in menstrual period is called functional stratum. The deep layer which has no change in menstrual period is called basal stratum. THE UTERUS
In most women the uterus is anteverted, the long axis of the uterus is directed forwards. The body of the uterus is also bent forwards on the cervix(anteflexed). The opposite condition of retroversion with retroflexion is found in about 20% of normal women.
retroflexed and retroverted uterus
Four paired sets of ligaments are attached to the uterus: round ligament : inserts on the anterior surface of the uterus just in front of the fallopian tube, passes to the pelvic side wall in a fold of the broad ligament, traverses the inguinal canal, and ends in the labium majus. The round ligaments are of little supportive value in preventing uterine prolapse but help to keep the uterus anteverted.
The uterosacral ligaments are condensations of the endopelvic fascia that 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 and are also significant in precluding the development of an enterocele. THE UTERUS
The cardinal ligaments are the other important supporting structures of the uterus that prevent prolapse. They extend from the pelvic fascia on the lateral pelvic walls and insert into the lateral portion of the cervix and vagina, reaching superiorly to the level of the isthmus. The pubocervical ligaments pass anteriorly around the bladder to the posterior surface of the pubic symphysis.
Broad ligament : the body of the uterus covered with peritoneum except for a narrow area on each side where the peritoneum sweeps away laterally to form the broad ligament. Between the two leaves of each broad ligament are contained the fallopian tube, the round ligament, and the ovarian ligament, in addition to nerves, blood vessels, and lymphatics.
The fold of broad ligament containing the fallopian tube is called the mesosalpinx. Between the end of the tube and ovary and the pelvic side wall, where the ureter passes over the common iliac vessels, is the infundibulopelvic ligament, which contains the vessels and nerves for the ovary. The ureter may be injured when this ligament is ligated during a salpingo-oophorectomy procedure.
THE PERITONEAL FOLDS Anteriorly, the uterus is covered with peritoneum only as far down as the level of the uterine isthmus, below this the peritoneum is reflected onto the bladder, forming the uterovesical pouch. The supravaginal cervix is below this peritoneal reflection, and is only separated from the bladder by a thin layer of connective tissue. Posteriorly, the peritoneum passes downwards from the uterine body to cover the posterior surface of the supravaginal cervix and upper third of the posterior vaginal wall. This peritoneum forms the anterior boundary of the rectovaginal pouch of Douglas.
The blood supply to the uterus arises from the uterine arteries which arise from the anterior portions of the internal iliac arteries. They also anastomose along the superior and lateral aspect of the uterus with the ovarian arteries which come down through the infundibulopelvic ligaments to the ovaries and tubes. The supply to the cervix is primarily throuth the cervical branches of the right and left uterine arteries. THE UTERUS Blood Supply
THE FALLOPIAN TUBE
The oviducts are bilateral muscular tubes (about 10 cm in length) with lumina that connect the uterine cavity with the peritoneal cavity. The muscle fibres of the wall of the tube are arranged in an inner circular and an outer longitudinal layer.The tubes are lined by a ciliated, columnar epithelium, most of the cilia act in the direction of the uterus. The function of the fallopian tube is to convey the ova from the Graafian follicles to the uterus.
THE FALLOPIAN TUBE It is described in four parts: the interstitial portion : the segment of the tube within the wall of the uterus the isthmus : the portion of the tube has a fairly narrow lumen The medial portion of each tube is superior to the round ligament, anterior to the ovarian ligament. As the tube proceeds laterally, it is located anterior to the ovary; it then passes around the lateral portion of the ovary and partly embraces the ovary. The ampulla is the widest and longest portion fimbriae portions : the funnel-shaped opening of the tube into the peritoneal cavity, surrounded by finger-like processes. .
The ampullary and fimbriae portions of the tube are suspended from the broad ligament by the mesosalpinx and are quite mobile. The mobility of the fimbriated end of the tube plays an important role in fertility. The ampullary portion of the tube is the most common site of ectopic pregnancies
fluid accumulated in the pelvic cavity
THE OVARIES The ovaries are situated on the superior surface of the broad ligament and are suspended between the ovarian ligament medially and the suspensory ligament of the ovary or infundibulopelvic ligament laterally and superiorly. They are oval, white in color, flattened organs, approximately 3 cm in length, 2 cm in depth and 1 cm in thickness. The ovaries are an important endocrine organ for the female, as well as producing her ova.
Columnar epithelium Cortex: various stages of follicles Medulla: connective tissue , fibers, smooth muscle cells, blood vessels, nerves, lymphatic vessels (1) primodial follicles ( 2) oocyte (3)nucleus of oocyte ( 4) zona pellcida (5) Corpora radiata (6) Zona granulosa (7)Follicular space (8) Theca interna (9) theca externa (10) Stroma (11) germinal epithelium
The blood supply to the ovaries is provided by the long ovarian arteries, which arise from the abdominal aorta immediately below the renal arteries. These vessels course downward and cross laterally over the ureter at the level of the pelvic brim, The ovary also receives substantial blood supply from the uterine artery through the uterine-ovarian arterial anastomosis.
The venous drainage from the right ovary is directly into the inferior vena cava, and the drainage from the left ovary is into the renal vein.
lower part of the vagina superficial inguinal nodes
obturator nodes exterior iliac nodes and common iliac nodes
utero-sacral ligaments pre-sacral lymph nodes
broad ligament nodes
body of the uterus internal iliac nodes pre-aortic nodes
exterior iliac nodes
lateral part of uterine body round ligament superficial inguinal nodes exterior iliac
fundus of the uterus
body of the uterus lumbar nodes
vulva superficial and deep inguinal nodes superficial and deep femoral nodes
The external orifice is situated inferiorly and posteriorly from the lower border of the symphysis
Applied to the anterior wall of the vagina
Lies posterior to the pubic bones, anterior to the uterus, the base of the bladder is adjacent to the cervix and anterior fornix of the vagina
The superior surface of the bladder is covered with peritoneum
The base of the bladder is below the peritoneum
THE URETER The ureter in the average female is approximately 26-28 cm in length from the renal pelvis to its entry into the bladder. Half the length is in the abdominal cavity, and half is in the pelvic cavity. The ureter passes into the pelvis very near and just superficial to the bifurcation of the common iliac artery, yet just underneath and just medial to the ovaian vessels as they travel into the pelvis through the infundibulo-pelvic ligament.
At the level of the ischial spine, the ureter passes just lateral to the uterosacral ligament, and courses obliquely just beneath the uterine artery at the side of the cervix and very near the anterolaterral fornix of the vagina. In the area, where the uterine artery across it superiorly, the ureter forms a “knee” bend and turns medially and anteriorly, and passes towards the bladder in its own “tunnel”. The ureters enter the empty bladder approximately 5 cm apart, obliquely course through the bladder wall for approximately 1.5 to 2 cm, and then enter the bladder at the corners of the trigone approximately 2.5 cm apart. THE URETER
During any pelvic surgery, whether ab-dominal, laparoscopic, or vaginal, the ureter may be injured anywhere along its travel. These areas are: at the pelvic brim just beneath the infundibulopelvic ligament; along the lateral pelvic sidewall during difficult pelvic dissections; just as the ureter passes lateral to the uterosacral ligaments; for instance, during cul-de-sac obliteration or transection of the uterosacral ligaments; as the ureter passes underneath the uterine vessels, during uterine artery ligation; or as the ureter passes just next to the anterolateral vaginal fornix during vaginal procedures. THE URETER