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Female pelvis(content)

  1. 1. Female pelvis(content) embryology and histology Dr B.H MSUMI
  2. 2. introduction
  3. 3. Paramesonephric duct(mullerian) • 5th and 6th week after oocyte fertilization, longitudinal groove called muller groove arises from coelomic epithelium on each side lateral to mesonephric duct • The edge of this groove fuse to form a canal called a mullerian or paramesonephric duct
  4. 4. Development of ovaries • The ovaries develop from the medial part of genital ridge • At about 4th week gestation,primordial germ cells(that give rise to ova) originate from the primitive hindgut(yolk sac) then migrate to the genital ridge • Failure of its migration give rise to streak gonads
  5. 5. • At 12th weeks gestation,formation of the mesentery of the ovary as the result of projection of the ovary into the coelomic cavity • The ovary descends in the abdominal cavity with the development of two ligaments • The 1st is the suspensory ligament attached to the cephalic pole-infundibulopelvic ligament
  6. 6. • The other ligament is called gubernaculum(tractor) which is attached to the caudal end of the ovary • Attached to the developing uterus forming the future round ligament in its distal part ,while its proximal part form the ovarian ligament
  7. 7. Development of fallopian tube • The fallopian tube develop from the cranial parts of the paramesonephric ducts,with their cranial ends remaining open connecting the duct with the coelomic(peritoneal) cavity and the caudal ends communicating with the uterine cornua
  8. 8. Development of uterus • The uterus develop from the middle part of the mullarian duct after their fusion and canalization • Failure of fusion or canalization or disappearance of formed septum to become a single organ give rise to many of congenital uterine anomalies
  9. 9. Development of the vagina • The upper ¾ to 4/5 of the vagina develops from the fused and canalized part of the caudal ends of the mullarian ducts • While the lower ¼ or 1/5 formed from urogenital sinus
  10. 10. • Note ,congenital malformation occurs when mullerian duct fail to develop(congenital absence of vagina) or fail to fuse(septate of vagina) or fail to canalize(atresia of vagina) • The caudal ends are closed by a septum which is complete at 1st but later become excavated centrally to form the hymen.At least the distal end of the vagina is formed from urogenital sinus
  11. 11. • The urogenital fold is present in early embryo and contain the origin of wolffian and mullerian duct ie the primordial of both urinary tract and genital tract • So if there are genital tract malformation look for associated malformation in the urinary tract and vice versa
  12. 12. Development of urinary system • Most of the urinary system develops from the intermediate mesoderm(around the 4th week) and the caudal hindgut during embryogenesis in the embryonic period. • Derivatives of the intermediate mesoderm include the nephrogenic cord and the ureteric bud, which give rise to the kidneys and ureters, respectively. • The urinary bladder and proximal urethra develop chiefly from the ventral portion of the cloaca.
  13. 13. Congenital anomalies of urogenital tract • The mullerian and wolffian ducts are closely related embryologically • So the association between genital and urinary system anomalies is common • Malformation of genital tract may be represented by,aplasia-atresia-hypoplasia- fusion defects or duplication of accessory organs
  14. 14. • Complete formation and differentiation of the mullerian ducts into segments of the female reproductive tract depend on completion of 3 phases of development as follows i. Organogenesis ii.Fusion iii.Septal resorption
  15. 15. Organogenesis • One or both mullerian ducts may not develop fully ,resulting in abnormalities such as uterine agenesis or hypoplasia(bilateral) or unicornuate uterus
  16. 16. Fusion • the process during which the lower segments of the paired mullerian ducts fuse to form uterus,cervix and upper vagina(lateral fusion) • Failure fusion results to bicornuate or didelphys uterus • The term vertical fusion occasionally is used to refer to fusion of the ascending sinovaginal bulb with the descending mullerian system
  17. 17. Septal resorption • After lower mullerian ducts fuse,a central septum is present ,which subsequently must be resorbed to form a single uterine cavity and cervix • Failure of resorption is the cause of septate uterus
  18. 18. Mullerian duct anomalies • Mullerian duct anomalies are categorized most commonly into 7 classes according to the American Fertility Society(AFS)
  19. 19. Class i(hypoplasia/agenesis) • Uterine/cervical agenesis or hypoplasia • The most common form is the Mayer- Rokitansky-Kuster=Hauser syndrome • Which is combined agenesis of the uterus,cervix and upper portion of the vagina • Patient have no reproductive potential
  20. 20. Class ii(unicornuate uterus) • Complete or almost complete arrest of development of one mullerian duct • If the arrest is incomplete as in 90% of patients,a rudimentary horn with or without functioning endometrium is present • If the rudimentary horn is obstructed it may come to surgical attention when presenting as enlarging pelvic mass • Pregnancy believed to be possible
  21. 21. Class iii (didelphys uterus) • Result from complete non-fusion of both mullerian ducts • The individual horns are fully developed and almost normal in size • Two cervices are inevitably present • A longitudinal or transverse vaginal septum may be noted as well • Since each horn is almost a fully developed uterus,patients have been known to carry pregnancies to full term
  22. 22. Class iv(bicornuate uterus) • Result from partial non-fusion of the mullerian ducts • The central myometrium may extend to the level of internal cervical os (bicornuate unicolis) or extend cervical os(bicornuate bicollis) • The latter is distinguished from didelphys uterus because it demostrates some degree of fusion between the two horns
  23. 23. • While in classic didelphysis uterus ,the two horns and cervices are separated completely • In addition the horns of the bicornuate uteri are not fully developed typically • They are small than those bicornuate bicollisunicollis • Some patients are surgical candidates for metoplasty of didelphys uteri
  24. 24. Class v(septate uterus) • A septate uterus results from failure of resorption of the septum between the two uterine horns • The septum can be partial or complete in which case it extends to the internal cervical os • Histologically the septum may be composed of myometrium or fibrous tissue
  25. 25. • The uterine fundus is typically convex but may be flat or slightly concave(1cm fundal cleft) • Women with septate uterus have the highest incidence of reproductive complications
  26. 26. • Differentiation between a septate and a bicornuate uterus is important because septate uteri are treated using transvaginal hysteroscopic resection of the septum • While if surgery is possible and/or indicated for bicornuate uterus ,an abdominal approach is required to perform metroplasty
  27. 27. Class vi(arcuate uterus) • Arcuate uterus has a single uterine cavity with the outer contour of the uterus convex or flat • This form is often considered a normal variant since it is not significantly associated with increased risks of pregnancy loss and the other complications found in other subtypes
  28. 28. • The uterine anomaly is seen the female offspring of as many as 15% women exposed to DES during pregnancy • Female fetuses who are affected have a variety of abnormal findings that include uterine hypoplasia and T-shaped uterine cavity Class vii(diethylstilbestrol related)
  29. 29. • Patients also may have abnormal transverse ridges,hoods,stenosis of cervix and adenosis of the vagina with increased risk of vagina clear cell carcinoma
  30. 30. Fallopian tube anomaly • Include aplasia,atresia,hypoplasia,accessory horn or ostia and tubal diverticulum • It may cause infertility or ectopic pregnancy
  31. 31. Vaginal anomalies Longitudinal septa • Partial or complete septa extending antroposteriorly in the vagina results from failure of disppearance of the fused Mullerian structure • This may be associated with normal uterus or duplicate uterus • Occasionally the septum may not be in the midline and may not communicate externally leading to lateral pouch containing menstrual blood
  32. 32. Transverse vagina septum • Transverse or perforated • Rare occurs at the junction of upper and middle 1/3 of vagina • When there is no perforation in the septum retention of mucoid material may occur before puberty leading to mucocolpos • After puberty menstrual flow becomes hidden and accumulate in the vagina,uterus and giving picture like imperforate hymen
  33. 33. Double or separate vagina • Vaginal agenesis(absence) • This could be partial or complete • Complete vaginal agenesis may be part of mullerian agenesis • Here vagina is represented by small pouch • Ovaries are normally developed • Present usually with primary amenorhoea
  34. 34. • Treatment is usually construction of new vagina or gradual dilatation • A non-operative progressive larger dilators inserted by the patient to gradually deepen and widen the canal
  35. 35. Imperforate hymen • The vaginal plate develops near the junction of the lower part of the vagina and vestibule • Canalization of this plate is generally completed by the 6th month of fetal life • Failure of the final process of canalization occurs and results in imperforate hymen • treatment-cruciate incision of excision of hymen
  36. 36. Abnormality of ovary • Agenesis or complete absence • Gonadal dysgenesis,streak gonads as in Turner syndrome • Failure of descent into the pelvis • Ovotestis true hermaphrodite in which combined ovarian and testicular tissue seen
  37. 37. Bladder exstrophy • Bladder exstrophy, is a congenital anomality in which part of the bladder is present outside the body. • It occurs due to failure of the abdominal wall to close during fetal development and results in protrusion of the posterior bladder wall through the lower abdominal wall.
  38. 38. Bladder exstrophy
  39. 39. Ectopic ureter • Ectopic ureter is an abnormally located terminal portion of the ureter. • Instead of the ureter opening in the bladder, it opens in the urethra, vagina, or uterus. • The result is constant dribbling of urine.
  40. 40. Vesicoureteric reflux • Vesicoureteral reflux (VUR) is an abnormal movement of urine from the bladder into ureters and kidneys. • It follows inadequecy of valvular mechanism due to a congenital defect/lack of longitudinal muscle of the intravesical ureter resulting in an ureterovesicular junction (UVJ) anomaly.
  41. 41. Histology
  42. 42. vagina • The mucosa: – Non-keratinized stratified squamous epithelium – Glycogens is deposited in the cells (estrogen) – The mucosa is thrown into folds or rugae →allow distended of vagina • The submucosa A layer of lamina propria,which is rich in elastic fibres and does not have any gland
  43. 43. • The musculosa: – Layer of smooth muscle,which has inner circular and outer longitudinal layer . • Adventitia: – Merges with that of the bladder(anteriorly) and rectum (posteriorly)
  44. 44. Cervix: Endocervix: – Is the cavity of cervix ,connect the external os with internal os – Is lined by tall columnar epithelium with basal nuclei and the mucus membrane is thrown into branching crypts, – It secrets mucous that undergo changes in response to hormonal changes – It is fusiform in shape and has posterior and anterior oblique longitudinal ridges,the plicae palmatae – They interlock like a zipper so the canal is kept closed
  45. 45. • Exocervix: Lined by non-keratinizing stratified squamous epithelium. Composed of several layers divided into basal,parabasal,intermediate and superficial – • Muscle layer –outer longitudinal and inner circular
  46. 46. uterus • The endometrium –Single layer of columnar epithelium, tubular glands and stroma. –Varies during the menstrual cycle. • The myometrium: 3 distinct layers –The outer longitudinal layer –The middle layer is of interlacing criss cross muscle fibers in which lie large vessels. (hemostasis) –The inner circular layer (well developed over tubal orifices and isthmus uteri)
  47. 47. uterus Peritoneal covering or perimetrium: • From the anterior surface of the uterus, the peritoneum is reflected to the superior surface of the bladder forming shallow uterovesical pouch • From the posterior surface of the uterus, peritoneum is continued down it is reflected to the anterior surface of the rectum forming the R.V.P. • From the lateral border of the uterus, two layers of peritoneum of the uterus (
  48. 48. Fallopian tube Like the wall of the uterus it is formed of 3 layers: • The mucus membrane layer (endosalpinx): – Forming longitudinal folds (plicae). – The tube is lined by a single layer of columnar epithelium, ciliated and secretory. • The muscular layer: – inner circular & outer longitudinal smooth muscle layers. • The peritoneal layer (mesosalpinx) – Carries blood supply to the tube. – It covers the fallopian tube except its inferior surface.
  49. 49. ovary • The germinal epithelium: –Single layer of flattened cells (surface epithelium of the ovary). • Tunica albuginea: –Condensed ovarian stroma beneath the germinal epithelium (thickened in PCOD).
  50. 50. ovary (cont……) • The ovarian cortex – Main functional part of the ovary and surrounds the medulla . – It contains collection of primordial follicles supported by a stroma. • The ovarian medulla: – is the central core of the ovary& continuous with the hilum – is composed of ordinary fibrous tissue. • The hilum: – the area of entrance and exit of vessels and nerves & the site of attachment of the mesovarium.
  51. 51. Ureters • The ureteric lumen is star-shaped. Like the bladder, it is lined with transitional epithelium, and contains layers of smooth muscle, thereby being under autonomic control. • There are two spiral layers of smooth muscle in the ureter wall, an inner longitudinal and loose, and an outer circular and tight. • The adventitia of the ureter, like elsewhere is composed of fibrous connective tissue, that binds it to adjacent tissues
  52. 52. Urinary bladder • The wall of the urinary bladder consists of three layers, an outer adventitial layer of soft connective tissue (which in some regions possesses a serosal covering of peritoneum), a smooth muscle coat (the detrusor muscle), and an inner mucosal layer which lines the interior of the bladder. • The mucosa has a structure similar to that of the ureters. •
  53. 53. Urethra • The wall of the female urethra consists of an outer muscle coat and an inner mucosa, which lines the lumen and is continuous with that of the bladder. • The muscle coat consists of an outer sheath of striated muscle (external urethral sphincter or distal sphincter mechanism) together with an inner coat of smooth muscle fibres
  54. 54. references • Textbook of medical embryology by F.Fasana,pg 262-265 • Textbook of medical embryology by keith moore,8th ed • DC Gutta textbook of gynaecology 6E pg 320- 335