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Maternal anatomy, 2019

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OBGYN Notes
OBGYN Notes

This is a clinically oriented maternal anatomy, prepared by Dr Gebresilassie Andualem You can get more books from our Telegram channel: https://t.me/OBGYN_Note_Book

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Dr Gebresilassie Andualem Email: bjlomsecond@gmail.com Telegram: https://t.me/OBGYN_Note_Book Maternal Anatomy
Contents • Anterior abdominal wall • Bony Pelvis • Pelvic Wall Muscles and Fascia • Pelvic Floor • Pelvic Blood Supply • Pelvic Innervation • Pelvic Viscera • Retroperitoneal Surgical Spaces 2
Anterior abdominal wall • Function of anterior abdominal wall – core support to the human torso – confines abdominal viscera – contributes muscular action for functions such as respiration and elimination • Knowing anatomy – avoids neurovascular complications 3
4 Layers Skin • Langer lines - orientation of dermal fibers ✓ Primarily transversely ✓ So vertical skin incisions sustain more lateral tension ➔ wider scars Subcutaneous layer - Superficial fascia • Superficial Camper’s (fatty layer) fascia • Deeper Scarpa’s (Membranous layer) fascia ✓ caudally, it is continuous with Colles fascia in the perineum ✓ Clinically, it is better developed in the lower abdomen → during surgery can be best identified in the lateral portions of a low transverse incision, just superficial to the rectus fascia ✓ In contrast, it is rarely recognized during midline incisions Musculoaponeurotic layer - Rectus sheath – Next to SC tissue – holds the abdominal viscera in place – Muscles - two groups: Midline Vertical muscles (RA & pyramidalis); Lateral flank muscles (EO, IO & TA) Transversalis Fascia Preperitoneal fat Peritoneum: a single layer of epithelial cells and supporting connective tissue called the serosa
5 Muscles of the Abdomen Pyramidalis muscle • Small, insignificant, triangular muscles arising from body of pubis inferiorly • Inserts into linea alba medially • Absent in 20% of people
Rectus Sheath •  external oblique, internal oblique, and transversus abdominis muscles (flank muscles) • In the midline, the aponeurotic layers use to create the linea alba – 10 to 15 mm wide below the umbilicus • In the lower abdomen, transition from the muscular to the aponeurotic component of – EOM: @ a vertical line through anterior superior iliac spine – IOM: more medially • Arcuate line – horizontal line defines the level at which the rectus sheath passes only anterior to the rectus abdominis muscle – lies midway between the umbilicus and pubic symphysis • Above arcuate line (Cephalad) – rectus sheath lies both anterior and posterior to the rectus abdominis muscle – Anterior RS aponeurosis of EOM, IOM (split) – Posterior RS  IOM (split) & TAM • Below arcuate line (Caudad) – all aponeurotic layers pass anterior to the rectus abdominis muscle – So posterior surface of the rectus abdominis muscle is in direct contact with the transversalis fascia • Surgical Importance – Midline incision: only linea alba is encountered – Transverse lower abdominal incision: two layers are identified (aponeuroses of the internal oblique and transversus abdominis muscles 6
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• Similar to skin fibers, the flank muscle and rectus sheath fibers are oriented primarily transversely • So suture lines placed in a vertical fascial incision must withstand more tension than those in a transverse incision • Due to this – vertical fascial incisions are more prone to dehiscence and hernia formation – ventral wall hernias are most common along the linea alba • Spiegelian hernia, is rare and forms at the lateral rectus abdominis border, typically at the level of the arcuate line 9
Peritoneum • parietal & visceral peritoneum • Five elevations of parietal peritoneum on anterior abdominal – All converge toward the umbilicus and are known as umbilical ligaments – Median umbilical ligament  urachus (obliterated tube that extends from the apex of the bladder to the umbilicus) • Urachus is a fibrous remnant of allantois – Paired medial umbilical ligaments  obliterated umbilical arteries – Paired lateral umbilical ligaments contain the patent inferior epigastric vessels 10
Surgical importance • Urachus – Transection of a patent urachus can result in extravasation of urine into the abdominal cavity – DDX of a midline anterior abdominal wall cyst includes urachal cyst, urachal sinus, and urachal diverticulum • Umbilical ligaments – serve as valuable laparoscopic landmarks – First, the inferior epigastric vessels can be injured during accessory trocar placement • Thus, direct visualization of the lateral umbilical folds can prevent injury to these vessels during laparoscopic port placement – Second, the medial umbilical ligaments, if followed proximally, can guide a surgeon to the internal iliac artery and then to the uterine arteries – The medial umbilical ligament also forms the medial border of the paravesical space, which is developed during radical hysterectomy to isolate the parametrium 11
Blood Supply Femoral Branches • superficial epigastric, superficial circumflex iliac, and external pudendal arteries arise from the femoral artery just below the inguinal ligament in the femoral triangle, which is bordered by this ligament, the sartorius muscle, and the adductor longus – These vessels supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis • The superficial epigastric vessels course diagonally toward the umbilicus, similar to the inferior “deep” epigastric vessels • Surgically – during low transverse skin incision creation, the superficial epigastric vessels can usually be identified half way between the skin and the rectus fascia, several centimeters from the midline – During laparoscopic procedures in thin patients, these vessels can be identified by transillumination – The external pudendal vessels form rich anastomoses with their contralateral equivalents and with other superficial branches – These anastomoses account for the extensive bleeding often encountered with incisions made in the mons pubis area such as for retropubic midurethral sling incisions. 12
13 Inguinal and upper thigh anatomy
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External Iliac Branches • Inferior “deep” epigastric vessels and deep circumflex iliac vessels are branches of the external iliac vessels • Supply the muscles and fascia of the anterior abdominal wall • Inferior epigastric vessels – initially course lateral to, then posterior to the rectus abdominis muscle – They then pass anterior to the posterior rectus sheath and course between the sheath and the rectus muscles – Near the umbilicus, the inferior epigastric vessels anastomose with the superior epigastric artery and veins, which are branches of the internal thoracic vessels • Hesselbach triangle – bounded inferiorly by the inguinal ligament, medially by lateral border of the rectus muscles, and laterally by the inferior epigastric vessels – Direct hernias through the abdominal wall within Hesselbach triangle – Indirect hernias protrude into the deep inguinal ring lying lateral to this triangle • Surgically importance – low transverse abdominal incisions that extend beyond the lateral margins of the rectus muscles can lead to inferior epigastric vessel laceration with severe hemorrhage or anterior abdominal wall hematoma formation – These vessels should be identified and ligated when performing a Maylard incision – As another surgical landmark, the deep circumflex iliac vein serves as the caudal border during pelvic lymph node dissection 15
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• Direct inguinal hernias – occur through Hesselbach's triangle (outlined in blue) formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus muscle medially – Medial to inferior epigastric vessels – Abdominal Inguinal Ring • the site of congenital direct hernias • Indirect inguinal hernias – develop at the internal inguinal ring and are lateral to the inferior epigastric artery – protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal inguinal ring after the testicle passes through it • Femoral hernias – develop in the empty space at the medial aspect of the femoral canal, inferior to the inguinal ligament 17
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Inguinal Canal ▪ The inguinal canal is an intermuscular passageway that extends from the abdominal ring downward, medially, and somewhat forward to the subcutaneous inguinal ring (about 3–4 cm). In Females • not well demarcated, • but it normally gives passage to the round ligament of the uterus, a vein, an artery from the uterus that forms a cruciate anastomosis with the labial arteries, and extraperitoneal fat. • The processus vaginalis of the female is rudimentary, but occasionally a small diverticulum of peritoneum is found passing partway through the inguinal region; this diverticulum is termed the processus vaginalis peritonei (canal of Nuck) In Males • In the male, the processus vaginalis descends with the testis 19
Anterior abdominal wall Innervation • Abdominal extensions of intercostal nerves (T7-11) – intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the transversus abdominis and internal oblique muscles • This space, termed the transversus abdominis plane, can be used for postcesarean analgesia blockade • Subcostal nerve (T12) • Iliohypogastric and Ilioinguinal nerves (L1) – iliohypogastric nerve provides sensation to the skin over the suprapubic area – ilioinguinal nerve supplies skin of • lower abdominal wall • upper portion of labia majora and • medial portion of the thigh through its inguinal branch ❑ At a site 2 to 3 cm medial to the anterior superior iliac spine, these two nerves pierce through the internal oblique muscle and course superficial to it and toward the midline • T10 dermatome approximates the level of the umbilicus 20
• Clinically – Ilioinguinal and iliohypogastric nerves can be entrapped during closure of low transverse incisions, especially if incisions extend beyond the lateral borders of the rectus abdominis muscle – They may also be wounded by lower abdominal insertion of accessory trocars – Risk of iliohypogastric and ilioinguinal nerve injury can be minimized if • lateral trocars are placed superior to the anterior superior iliac spines and • low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscle 21
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Bony Pelvis • Pelvis is composed of four bones – sacrum, coccyx, and two innominate Bones • Os coxae - hip bones • innominate bones  ilium, ischium, and pubis • sacroiliac joint (synovial joint) • symphysis pubis (cartilaginous joint) • Ischial spines – Project posteromedially – at the level of S5 23 Right os coxae
– Iliac crest— – Anterior superior and inferior spine – Posterior superior and inferior spine – Arcuate line – Iliopectineal eminence (linea terminalis – Iliac fossa— – Body – Symphysis pubis – Superior and inferior pubic rami – Pubic tubercle – Ischial spine • delineates the greater and lesser sciatic notch above and below it • It is the point of fixation for the sacrospinous ligament and the arcus tendineus fasciae pelvis • represents an important landmark in the performance of pudendal nerve block and sacrospinous ligament vaginal suspension • vaginal palpation during labor allows detection of progressive fetal descent – Ischial ramus – Ischial tuberosity 24
Pelvic Bone Articulations • The pelvic bones are joined by four articulations (two pairs): – 1. Two cartilaginous symphyseal joints • sacrococcygeal joint and the symphysis pubis • responsive to the effect of relaxin and facilitate parturition – 2. Two synovial joints • sacroiliac joints • Pelvis is divided into t – Greater and lesser pelvis – divided by an oblique plane passing through the sacral promontory, the linea terminalis (arcuate line of the ilium), the pectineal line of the pubis, the pubic crest, and the upper margin of the symphysis pubis – This plane lies at the level of the superior pelvic aperture (pelvic inlet) or pelvic brim 25
• Which of the following bone(s) forms the pelvis? – A. Innominate B. Sacrum C. Coccyx D. All of the above • The clinical evaluation of the pelvic inlet requires direct measurement of which diameter? – A. True conjugate B. Obstetrical conjugate – C. Diagonal conjugate D. Pelvic inlet transverse diameter • The shortest anteroposterior diameter of the pelvic inlet is which of the following? – A. True conjugate B. Obstetrical conjugate – C. Diagonal conjugate D. None of the above • Which of the following is true regarding relaxation of the pelvic joints at term in pregnancy? – A. It allows for an increase in the transverse diameter of the midpelvis. – B. It results in marked mobility of the pelvis at term because of a downward gliding movement of the sacroiliac (SI) joint. – C. Displacement of the SI joint increases outlet diameters by 1.5 to 2.0 cm in the dorsal lithotomy position. – D. It is permanent and not accentuated in subsequent pregnancies. • Which of the following is true of the midpelvis? – A. It is measured at the level of the ischial tuberosities. – B. It usually measures no more than 9 cm. – C. It is measured at the level of the ischial spines. – D. It usually is the largest pelvic diameter 26
27 In this figure, which of the following is demonstrated? A. Important pelvic outlet diameters B. Ischial tuberosities C. Midpelvis ischial spines D. An inadequate obstetrical conjugate
• What is the narrowest pelvic dimension that must be navigated by the fetal head? – A. Inferior strait – B. Obstetrical conjugate – C. Interspinous diameter – D. Transverse diameter of the pelvic inlet • What is the most common pelvic shape? Gynecoid pelvis • The pubococcygeus muscle is now preferably called which of the following? – Pubovisceral muscle • The posterior triangle of the pelvic outlet is limited at its apex by which of the following? – A. Coccyx B. Last sacral vertebrae – C. S4 D. S3 28
• Obturator foramen – between ischium and pubis – Filled almost completely by obturator membrane – superior to this membrane, a small aperture known as obturator canal allows passage of the obturator neurovascular bundle into the medial (adductor) compartment of the thigh • Posterolateral walls – not covered by bone – Sacrospinous and sacrotuberous ligaments, divide greater and lesser sciatic notches of ischium into ff foramens • Greater sciatic foramen – piriformis muscle, internal pudendal and superior and inferior gluteal vessels, sciatic and pudendal nerve, and other branches of the sacral nerve plexus pass in close proximity to the ischial spines – Surgically, this anatomy is critical to avoid neurovascular injury during sacrospinous fixation procedures and when administering pudendal nerve blockade • Lesser sciatic foramen – internal pudendal vessels, pudendal nerve, and obturator internus tendon pass through the lesser sciatic foramen – Posteriorly, four pairs of pelvic sacral foramina allow passage of the anterior divisions of the first our sacral nerves and lateral sacral arteries and veins 29
30 Bones, ligaments, and openings of the pelvic walls and associated structures • Note the obturator internus muscle extending below the levator ani muscle and then exiting through the lesser sciatic foramen to insert into the lateral femoral trochanter • Ischial spine is marked by an asterisk • L5 = fifth lumbar vertebra; • LST= lumbosacral trunk; • PS = pubic symphysis; • S1–S3 = first through third sacral nerves; • SSL= sacrospinous ligament; • STL= sacrotuberous ligament
31 • cardinal and uterosacral ligaments – Main Support pelvic organs • Round and broad ligaments – consist of smooth muscle and loose areolar tissue, respectively – do not contribute much to the support of pelvic organs • Sacrospinous, sacrotuberous, and anterior longitudinal ligaments of sacrum – consist of dense connective tissue that joins bony structures – contributes significantly to bony pelvis stability • Clinically – sacrospinous and anterior longitudinal ligament • serve as suture fixation sites in suspensory procedures used to correct POP – iliopectineal ligament • also termed Cooper ligament • is a thickening in the pubic bone periosteum • often used to anchor sutures in retropubic bladder neck suspension procedures
Pelvic Joints • Anteriorly - symphysis pubis • limited degree of mobility • During pregnancy, these joints relax remarkably at term – upward gliding of sacroiliac joint • greatest in the dorsal lithotomy position • may increase the diameter of the outlet by 1.5 to 2.0 cm for delivery – Sacroiliac joint mobility • aids McRoberts maneuver to release an obstructed shoulder in cases of shoulder dystocia – These changes may also contribute to the success of the modified squatting position to hasten SSOL • squatting position may ↑ interspinous diameter & pelvic outlet diameter 32
Planes and Diameters of the Pelvis • Pelvis - divided into – False (lesser) pelvis: lies above the linea terminalis • bounded posteriorly by lumbar vertebra; laterally by iliac fossa; Anteriorly by the lower portion of the anterior abdominal wall – True: lies below the linea terminalis 33
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• pelvis is described as having four imaginary planes: – plane of pelvic inlet—the superior strait. • During labor, fetal head engagement is defined by the fetal head’s biparietal diameter passing through this plane • greatest distance = transverse diameter = 13 cm • clinically important: obstetrical conjugate – shortest distance between the sacral promontory and the symphysis pubis – ≥ 10 cm, but unfortunately, it cannot be measured directly – So OC = DC – (1.5 to 2 cm) – plane of the midpelvis—the least pelvic dimensions • measured at the level of the ischial spines • smallest pelvic diameter = Interspinous diameter = ≥ 10 cm – plane of pelvic outlet—the inferior strait • two approximately triangular areas • Subpubic angle = ≥ 90 to 100 degrees • Unless there is significant pelvic bony disease, the pelvic outlet seldom obstructs vaginal delivery – plane of greatest pelvic dimension—of no obstetrical significance 35
36 Station • +1/+3 (old classification), • +2/+5 (new classification)
• Pelvimetry – performed with radiographic (CT/MRI) to determine average and critical limit values • Critical limit values are measurements 37 • In current obstetric practice – Radiographic CT and MRI pelvimetry are rarely used • lack of evidence of benefit • some data that show possible harm – Clinical pelvimetry • the only method of assessing the shape and dimensions of the bony pelvis in labor
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Pelvic Shapes • Caldwell–Moloy (1933, 1934) anatomical classification of the pelvis is based on shape – Gynecoid = found in 50% of females • classic female shape – Anthropoid • exaggerated oval shape of the inlet, largest AP diameter, and limited anterior capacity • more often associated with delivery in OP position – Android = male • increased risk of CPD – Platypelloid • theoretically predisposes to a transverse arrest 41
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Pelvic Wall Muscles and Fascia • Muscles – Piriformis • arises from anterior and lateral surface of sacrum and partially fills posterolateral pelvic walls • exits pelvis through the greater sciatic foramen • attaches to the greater trochanter of femur, • functions as an external or lateral hip rotator • Clinically: stretch injury may cause persistent hip pain that can be confused with other hip or pelvic pathology – Obturator internus • partially fills the sidewalls of the pelvis • arises from pelvic surfaces of ilium and ischium and from the obturator membrane • Exits pelvis through lesser sciatic foramen • attaches to the greater trochanter of femur • functions as an external hip rotator • Fascia – Parietal fascia: invests striated muscles – Pelvic parietal fascia • provides muscle attachment to the bony pelvis • serves as anchoring points or visceral fascia, also termed endopelvic fascia – Arcus tendineus levator ani • is a condensation of parietal fascia covering the medial surface of obturator internus muscle • serves as the point of origin or parts of very important levator ani muscle 44
45 • Muscles and fascia of the pelvic walls and pelvic floor innervation • Ischial spine is marked by an asterisk • L5 = fifth lumbar vertebra; PS = pubic symphysis; R= rectum; S1–S5 = first through fifth sacral nerves; U = urethra; V= vagina
46 Superior view of pelvic floor and pelvic wall muscles
Pelvic Floor • Muscles that span the pelvic floor are collectively known as the pelvic diaphragm – This diaphragm consists of • levator ani – provide critical pelvic organ support – Physiologically, normal levator ani muscles maintain a constant state of contraction, thus providing a stable floor, – consists of: pubococcygeus, puborectalis, and iliococcygeus muscles » Pubococcygeus muscle is further divided into the pubovaginalis, puboperinealis, and puboanalis muscles according to their fiber attachments » Due to the significant attachments of the pubococcygeus muscle to the walls of the pelvic viscera, the term pubovisceral muscle is frequently used • coccygeus muscles, • along with their superior and inferior investing fascial layers – Inferior to the pelvic diaphragm, the perineal membrane and perineal body also contribute to the pelvic floor • Urogenital hiatus is the U-shaped opening in the pelvic floor muscles through which urethra, vagina, and rectum pass 47
48 Inferior view of pelvic floor Muscle fibers of Iliococcygeus Muscle from one side join those from the opposite side in the midline between the anus and the coccyx. This meeting line is termed the iliococcygeal or anococcygeal raphe
• Levator plate in women with normal support has a mean angle of 44 degrees relative to a horizontal reference line during Valsalva – During Valsalva, women with prolapse have a statistically greater levator plate angle compared with controls – This larger angle moderately correlates with larger levator hiatus length and greater displacement of the perineal body in women with prolapse compared with controls • With this in mind, one theory suggests that – levator plate support prevents excessive tension or stretching of the connective tissue pelvic ligaments and fasciae – Neuromuscular injury to the levator muscles may lead to eventual sagging or vertical inclination of the levator plate and opening of the urogenital hiatus – Consequently, the vaginal axis becomes more vertical, and the cervix is oriented over the opened hiatus – The mechanical effect of this change is to increase strain on connective tissues that support the pelvic viscera – Increased urogenital hiatus size has been shown to correlate with increased prolapse severity 49
• Pelvic diaphragm muscles – primarily innervated by direct somatic efferents from sacral nerve roots (S2-5) • Traditionally, a dual innervation has been described – Efferents from S2-5 • Supply Pelvic or superior surface of the muscles – Pudendal nerve branches • Supply perineal or inferior surface • investigators suggest that the pudendal nerve does not contribute to levator muscle innervation • Pudendal branches do, however, innervate parts of the striated urethral sphincter and external anal sphincter muscles • Such separate innervation may explain why some women develop pelvic organ prolapse and others develop urinary or fecal incontinence 50
• Parietal fascia – invests most striated muscles • Visceral or endopelvic fascia – intimately associated with the walls of the viscera and cannot be dissected in the same way that parietal fascia can be separated from its skeletal muscle – Condensations ➔ • cardinal and uterosacral ligaments • vesicovaginal and rectovaginal fascia 51
Pelvic Blood Supply • Novak 16th – There is significant variation in the branching pattern of pelvic blood vessels between individuals • patterns of blood flow may be asymmetric from side to side in the same individual – The pelvic surgeon should be prepared for deviations from “textbook” vascular patterns 52
• Pelvic organs are supplied by visceral branches of the internal iliac (hypogastric) artery and by direct branches from abdominal aorta • Internal iliac artery has two divisions o Separated in the area of the greater sciatic foramen – Anterior division • Three parietal branches • Visceral branches – Posterior division • Three parietal branches • Internal iliac branches that supply the inferior and middle portions of the bladder are present in women, but their origin is highly variable • The middle rectal arteries are generally very small-caliber vessels but may be absent • They usually contribute to posterior vaginal wall blood supply 53
54 Each division has three parietal branches
55 Collateral Arterial Circulation of the Pelvis
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• two most important direct branches of aorta – Superior rectal arteries • terminal branch of inferior mesenteric artery • anastomoses with the middle rectal arteries, thus contributing blood supply to the rectum and vagina – Ovarian arteries • arise directly from aorta just inferior to the renal vessels • anastomose with the ascending branch of the uterine artery • These anastomoses contribute to the blood supply of the uterus and adnexa 60
• The femoral artery gives rise to all EXCEPT which of the following vessels? – A. Superficial circumflex iliac artery – B. External pudendal artery C. Inferior epigastric artery D. Superficial epigastric artery • The internal pudendal artery supplies which of the following? – A. Proximal vagina B. Posterior vaginal wall C. Distal vaginal wall D. Bladder trigone • The vagina and its investing musculature are supplied by all EXCEPT which of the following arteries? – A. Inferior rectal artery B. Perineal artery C. Pudendal artery D. Posterior labial artery • The right ovarian vein empties into which of the following veins? – A. Vena cava B. Renal vein C. Internal iliac vein D. External iliac vein • Ovarian vessels are found in which of the following ligaments? – A. Broad B. Round C. Uterosacral D. Infundibulopelvic • The internal pudendal artery arises from which of the following vessels? – Internal iliac artery 61
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Pelvic Innervation 65 • Pelvis is innervated by both • both sympathetic (adrenergic) and parasympathetic (cholinergic) fibers • provide the primary innervation for genital, urinary, and gastrointestinal visceral structures and blood vessels • Component: Efferent and afferent (sensory) component • Efferent fibers of the autonomic nervous system 1. Sympathetic (thoracolumbar) division » prepares the body for physical activity and can be thought of as the “fight or flight” reaction 2. Parasympathetic (craniosacral) division » has a calming effect on body functions and can be thought of as the “resting and digesting” state – The two systems innervate the same target organs but have opposing effects on them to maintain homeostasis
• lumbosacral plexus and its branches provide motor and sensory somatic innervation to the lower abdominal wall, the pelvic and urogenital diaphragms, perineum, and the hips and lower extremities • pelvic splanchnic nerve • obturator nerve • pudendal nerve • ilioinguinal nerve • genitofemoral nerve 66
• Nerve supply to the visceral structures in the pelvis (bladder, urethra, vagina, uterus, adnexa, and rectum) arises from the autonomic nervous system • The two most important components of autonomic nervous system in the pelvis include – Superior hypogastric plexus • also known as the presacral nerve • is an extension of the aortic plexus found below the aortic bifurcation • This plexus primarily contains sympathetic fibers and sensory afferent fibers from the uterus • terminates by dividing into the hypogastric nerves. These nerves join parasympathetic efferents from S2-4 nerve roots (pelvic splanchnic nerves) to form the inferior hypogastric plexus – Inferior hypogastric plexuses • also known as the pelvic plexus • generally receives contributions from the sacral sympathetic trunk • fibers of this plexus accompany branches of the internal iliac artery to the pelvic viscera. Accordingly, they are divided into three portions: Vesical, uterovaginal (Frankenhäuser ganglion), and middle rectal plexuses • Its Extension reach the perineum along the vagina and urethra to innervate the clitoris and vestibular bulbs 67
• The course of general visceral afferent (GVA) fibers from organs in the pelvis, in general, depends on the organ's position relative to the pelvic pain line – An organ, or part of an organ, in the pelvis is said to be "above the pelvic pain line" if it is in contact with the peritoneum, except in the case of the large intestine, where the pelvic pain line is said to be located in the middle of the sigmoid colon • GVA fibers from structures above the pain line follow the course of the sympathetic efferent fibers, and • GVA fibers from structures below the pain line follow the course of the parasympathetic efferents – Pain from the latter fibers is less likely to be consciously experienced 68
69 Pelvic autonomic nerves • Superior and inferior hypogastric plexuses • S1–S4 = first through fourth sacral nerves
Innervation of female internal genital organs 70 ❑ uterus is innervated by fibers of the uterovaginal plexus, also known as Frankenhäuser ganglion ❑ These fibers travel along the uterine arteries and are found in the connective tissue of the cardinal ligaments
• Pelvic splanchnic nerves, – arising from the S2–S4 anterior rami, – supply parasympathetic motor fibers to the uterus and vagina (and vasodilator fibers to the erectile tissue of the clitoris and bulb of the vestibule; not shown) • Presynaptic sympathetic fibers traverse the sympathetic trunk and pass through the lumbar splanchnic nerves to synapse in prevertebral ganglia with postsynaptic fibers; the latter fibers travel through the superior and inferior hypogastric plexuses to reach the pelvic viscera • Visceral afferent fibers conducting pain from intraperitoneal structures (such as the uterine body) travel with the sympathetic fibers to the T12–L2 spinal ganglia • Visceral afferent fibers conducting pain from subperitoneal structures, such as the cervix and vagina (i.e., the birth canal), travel with parasympathetic fibers to the S2–S4 spinal ganglia • Somatic sensation from the opening of the vagina also passes to the S2–S4 spinal ganglia via the pudendal nerve • In addition, muscular contractions of the uterus are hormonally induced 71
Nerve supply of ovaries and female internal genital organs In addition to autonomic (visceral motor) fibers, these nerves convey visceral afferent fibers from these organs. The inferior part of the vagina is not depicted because it receives somatic innervation 72
• Clinically – presacral neurectomy, a surgical procedure performed to treat central pelvic pain • sensory afferent fibers contained within the superior hypogastric plexus – Complete interruption of superior hypogastric plexus • visceral and sexual dysfunction – Injury to the branches of the inferior hypogastric plexus during cancer debulking or other extensive pelvic surgeries • varying degrees of voiding, sexual, and defecatory dysfunction 73
Pelvic Viscera Uterus Cervix Ovaries and Fallopian Tubes External Generative Organs Lower Urinary Tract Structures 74
Uterus • is a fibromuscular hollow organ • Anatomically divided into two – Body of uterus • Forms the upper 2/3rd of uterus • Includes – Fundus: the part above the insertion of the tube – Body: lies between the two layers of the broad ligament; freely movable – Isthmus: relatively constricted segment, 1cm long; found between the cervix and the uterus • Isthmus – The transition between the corpus and the cervix is known as the uterine isthmus » This also marks the transition from endocervical canal to endometrial cavity – portion of uterus between internal cervical os and endometrial cavity – It is of special obstetrical significance because it forms the lower uterine segment during pregnancy – Cervix • Cylindrical, relatively narrow lower 1/3rd part • Has – Supra vaginal part: separated from the bladder by loose connective tissue and from the rectum by the recto uterine pouch. – Vaginal part: 75
• adult uterus is usually ➔ anteverted & anteflexed – anteverted (tipped anterosuperiorly relative to the axis of the vagina) – anteflexed (bent anteriorly relative to the cervix) so that its mass lies over the bladder • when bladder is empty, uterus typically lies in a nearly transverse plane • Adult, nonpregnant uterus – Approximately 7.5 cm long, 5 cm wide, and 2 cm thick • 6 to 8 cm in adult nulliparous & 9 to 10 cm in multiparous women • Endometrial thickness = 0.5mm – Weighs: 50 to 70 g (in parous women it averages 80 g or more 76
• Shape, weight, and dimensions - vary according to parity and estrogen stimulation – Before menarche & after menopause: corpus = cervix in size – During reproductive years: uterine corpus >> cervix – In nulliparous women: fundus = cervix in length • in multiparous women, cervix ~ 1/3rd third of its length 77
• Pregnancy-Induced Uterine Changes – weight increases from 70 g to approximately 1100 g at term – total volume averages about 5 L – The uterine fundus, a previously flattened convexity between tubal insertions, now becomes dome shaped – The round ligaments now appear to insert at the junction of the middle and upper thirds of the organ. The fallopian tubes elongate, but the ovaries grossly appear unchanged. 78
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• Ureter is found slightly superior to lateral part of vaginal fornix; below uterine artery, 2 cm lateral from supravaginal part of cervix 82
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Neurovascular structures of uterus • Artery: – mainly uterine artery; some collateral from ovarian artery • Vein – Utero vaginal venous plexus to Uterine vein to internal iliac vein • Uterine Lymphatic Drainage of uterus – primarily to the obturator and internal and external iliac nodes – However, some lymphatic channels from the uterine corpus may pass along the round ligaments to the supericial inguinal nodes, and others may extend along the uterosacral ligaments to the lateral sacral nodes – From fundus and superior body: along ovarian vessels and through suspensory ligament – lumbar LNs – Some from fundus, from uterotubal junction and insertion of round ligament,-- along round ligament - to superficial inguinal LNs – From most of the body and cervix – along broad ligament- external iliac LNs – From cervix • Along cardinal ligament – internal iliac LNs • Along uterosacral ligament – sacral LNs 85
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88 o Uterine artery approaches the uterus in the area of the uterine isthmus o Clinically, because the uterus receives dual blood supply from both ovarian and uterine vessels, some surgeons during myomectomy place tourniquets at both the infundibulopelvic ligament and uterine isthmus o This decreases blood flow from ovarian and uterine arteries, respectively
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Layers of Uterine Wall • The wall of the uterus is very thick and consists of 3 layers: – Serous layer : perimetrium • is simply the peritoneal covering • Peritoneum + thin layer of connective tissue • Peritoneal serosa overlies the uterus, except at two sites. –First, the anterior portion o the cervix is covered by the bladder –Second, the lateral portions o the corpus and cervix attach to the broad and cardinal ligaments 92
– Muscular layer : myometrium • is extremely thick and continuous with that of the tubes and vagina • also extends into the ovarian and round ligaments, into the cardinal ligaments at the cervix, and minimally into the uterosacral ligaments • Two principal layers of the muscular coat can be distinguished: – (1) Outer layer: weaker and composed of longitudinal fibers – (2) Inner layer: stronger and composed of fibers running in various directions – Mucous layer: endometrium • Endometrium can be classified into • Basalis layer – Found near the myometrium – Contains the blind end of the glands and CT – Mostly unchanged during menses – Supplied by straight aa branches of arcuate aa(found in the myometrium) • Functionalis layer – Found above the basalis layer – Contains the gland and the rest of the CT – Profoundly changed during menses – Supplied by spiral aa branches of arcuat aa • spiral arterioles located in the endometrium undergo hormonally mediated constriction or spasm that promotes shedding of the superficial portion of the endometrium with each menstrual cycle • The amount of smooth muscle decreases and the amount of collagen increases as we go down from the body of the uterus to the cervix 93
• During pregnancy, myometrium undergoes growth due to – Hyperplasia – Hypertrophy and – Collagen synthesis by the smooth muscles • After pregnancy, myometrium decreases in size due to – Destruction of smooth muscle cells – Reduction in the size of the remaining cells – Enzymatic degradation of the collagen • Makes it a unique organ with ability to increase and decrease its size several times during the life time 94
Histological changes during menses • Menstrual cycle – Starts at age of 13 – 15 and ends at age of 45 – 50 – Lasts for 28 days and flows for 3 – 4 days – 1st day of bleeding = 1st day of menstrual cycle – Classified into • Proliferative and • Secretory phases • Proliferative phase – Estrogen mediated – Covered by simple columnar epithelium – Straight tubes with narrow lumen are formed – Cells prepare for the next phase • Accumulate more cisternae of ER and GA – 0.5 mm → 2 – 3mm • Secretory Phase – Progesterone mediated – Cells accumulate glycogen – Lumen expands • Due to accumulation of glycoprotein secreting products – Glands become highly twisted – 2-3mm → 5mm • Menses Vs Fertilization 95
Ligaments supporting uterus 96
97 Connective tissue and surgical spaces of the pelvis
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• Ligaments supporting the uterus consist of – Uterosacral ligaments, – Transverse ligaments of the cervix • (cardinal ligaments, cardinal supports, ligamentum transversum colli, ligaments of Mackenrodt), – Round ligaments, and • Attaches the uterus(antero inferior to the uterotubal junction, passes through the deep inguinal ring, through the inguinal canal, continuous into labia majora where its fibers spread and mix with mons pubis) – Ovarian ligament • Attaches the ovary and the uterus (postero inferior to utero tubal junction) – broad ligaments • Note: Round ligament and ovarian ligaments are remnants of ovarian gubernaculum – (used to attach the ovary to the labio sacral swelling in the embryo) • Uterine support – Active support : pelvic diaphragm – Passive support: its anteverted, anteflexed position • because of its attachment to the above ligaments (condensations of the endopelvic fascia), cervix is the least mobile part of uterus 99
• Mackenrodt ligament • is the chief means of support and suspends the uterus from the lateral walls of the pelvis minor • are composed of longitudinal smooth muscle fibers originating – superiorly from the uterus and – inferiorly from the vagina, fanning out toward the fascia visceralis to form, with the internal os of the cervix, the primary support of the uterus • attach to the posterolateral pelvic walls near the origin of the internal iliac artery and surround the vessels supplying the uterus and vagina 100
101 o Pelvic viscera and their connective tissue support o Relationship of the urethra, bladder trigone, and distal ureter to the anterior vaginal wall and to the uterine cervix o Parametrium consists of what is clinically known as the cardinal ligament and uterosacral ligament
• are, in fact, the inferior posterior folds of peritoneum from the broad ligament • consist primarily of smooth muscle and contain some pelvic autonomic nerves • consist primarily of nerve bundles from the inferior hypogastric plexus and contain preganglionic and postganglionic fibers and C fibers of the sympathetic lumbar segments, parasympathetic in part from sacral components and in part from sensory or C fibers of the spinal segments • extends from an attachment posterolaterally to the supravaginal portion of the cervix and inserts into the fascia over the sacrum • covered by peritoneum and form the lateral boundaries of the pouch of Douglas • uterosacral ligaments – attachment sites for vaginal apex (reconstructive surgeries) 102
• are smooth muscle extensions of the uterine corpus • no real support – But, may assist in maintaining the body of the uterus in its typical position over the bladder • extend laterally to the pelvic sidewall ➔ enter the retroperitoneal space and pass lateral to the inferior epigastric vessels before entering the inguinal canal through the internal inguinal ring • traverses and the inguinal canal, to terminate in a fanlike manner in the labia majora and become continuous with connective tissue • The round ligament is the gubernaculum (ligamentum teres uteri), vestigial in the female – corresponds embryologically to the gubernaculum testis of men • It is accompanied by a funicular branch of the ovarian artery • Through the inguinal canal, it is accompanied by the ilioinguinal nerve and the external spermatic branch of the genitofemoral nerve • In nonpregnant women, it varies from 3 to 5 mm in diameter and is composed of smooth muscle • During pregnancy, the round ligaments undergo considerable hypertrophy and increase appreciably in both length and diameter • blood supply from a small branch of the uterine or ovarian artery known as Sampson artery 103
• Clinically importance of round ligament – Location anterior to the fallopian tube • can assist a surgeon during tubal sterilization through a minilaparotomy incision • especially true if pelvic adhesions limit tubal mobility and thus hinder identication of fimbria prior to tubal ligation – Division of round ligament • An initial step in abdominal and laparoscopic hysterectomy • Its transection opens the broad ligament leaves and provides access to the pelvic sidewall retroperitoneum • This access allows direct visualization of the ureter and permits isolation of the uterine artery for safe ligation 104
• a transverse fold of peritoneum that arises from the floor of the pelvis between the rectum and the bladder, provides minimal support – double layers of peritoneum that extend from the lateral walls of the uterus to the pelvic walls • Broad ligament can be divided into regions as follows: Peritoneum that overlies – fallopian tube is termed mesosalpinx, – around round ligament is mesoteres, and – over uterovarian ligament is mesovarium – Uterus: mesometrium • Peritoneum that extends beneath the fimbriated end of the fallopian tube to the pelvic wall forms the infundibulopelvic ligament or suspensory ligament of the ovary, through which the ovarian vessels traverse – During pregnancy, these vessels, especially the venous plexuses, are dramatically hypertrophied 105
• The artery that runs through this structure (arrow) directly arises from which of the following? 106 A. Sampson artery B. Internal iliac artery C. Uterine artery D. Obturator artery • In the nonpregnant woman, the uterus is an almost solid structure weighing approximately which of the following? • A. 40 g B. 70 g • C. 100 g D. 130 g • Uterine blood flow near term is which of the following? • A. 50–100 mL/min • B. 100–300 mL/min • C. 450 to 600 mL/min • D. 1,000–1,400 mL/min
• Fetoplacental blood volume at term is which of the following? – A. 125 mL/kg B. 100 mL/kg – C. 75 mL/kg D. 50 mL/kg • Which of the following is true regarding the uterus? – A. It measures 8 to 9 cm in length in nulliparous women. – B. It weighs 50 to 70 g in the parous woman. – C. In the nullipara, the fundus and the cervix are of equal length – D. The cervix is composed mainly of muscle. • Concerning the endometrium, which of the following is true? – A. The basal artery comes directly from the arcuate artery. – B. Spiral arteries extend directly from radial arteries. – C. The functionalis layer contains spiral arteries and radial arteries. – D. The spiral arteries extend directly from the arcuate artery. 107
• The uterine artery is a main branch of which of the following vessels? – Internal iliac artery • The ovarian artery is a direct branch of which of the following vessels? – Aorta • The cervix contains little of which of the follow components? – A. Smooth muscle B. Collagen – C. Proteoglycans D. Elastin • From proximal (uterus) to distal (fimbria), the correct progression of fallopian tube anatomy is which of the following? – Isthmus, ampulla, infundibulum • Which of the following is the endometrial layer that is shed with every menstrual cycle? Functionalis layer 108
• In the following figure, the spiral arteries are identified by which letter? – A. A: Spiral – B. B: Basal – C. C: Radial – D. D: Arcuate • Regarding the orientation of spiral blood vessels in relationship to the uterus, which of the following is true? – Arteries are perpendicular, and veins are parallel to the uterine wall 109
• Compared with the uterine body, the cervix has a significantly lower percentage of which of the following? – A. Collagen – B. Proteoglycans – C. Smooth muscle – D. Glycosaminoglycans • In the image below, cervical eversion is demonstrated. What kind of epithelium makes up this portion of the cervix? – A. Columnar – B. Squamous – C. Serous – D. Brush border cells 110
Cervix • the lower third of the uterus • wall of the cervix consists primarily of fibrous tissue and a smaller amount of smooth muscle – smooth muscle is found on the cervical wall periphery and serves as the attachment point or the cardinal and uterosacral ligaments and or the fibromuscular walls o the vagina • In a non-pregnant woman of fertile age, it measures approximately – 3 cm in length and 2.5 cm in diameter • Two parts – Upper two thirds of the cervix (endocervix) • lies above the vagina and is not visible – Lower part of the cervix (ectocervix) • lies within the vagina • visible with a speculum 111
• internal and external os • Ectocervix/ cervix exterior – lined predominantly by nonkeratinized stratified squamous epithelium • Endocervical canal – a single layer of mucin-secreting columnar epithelium, which creates deep cleftlike infoldings or “glands.” – Mucus produced by the endocervical epithelia changes during pregnancy – It becomes thick and forms a mucus plug within the endocervical canal – Commonly during pregnancy, the endocervical epithelia moves out and onto the ectocervix during enlargement of the cervix in a process termed eversion • With time, this everted columnar epithelium, under the influence of vaginal acidity or during reparative healing, may be replaced by squamous epithelium in a process termed squamous metaplasia • This replacement with squamous epithelium may block endocervical clefts. If so, accumulated mucus from the underlying clefts forms nabothian cysts, which are benign, firm, smooth, rounded, opaque-yellow or ground glass gray elevations on the ectocervix 112
• attachments of the vaginal walls to the outer cervix divide it into – a vaginal part known as the portio vaginalis and – a supravaginal part known as the portio supravaginalis • This part is covered by nonkeratinizing squamous epithelium • The endocervical canal is lined by columnar, mucus-secreting epithelium • The lower border of the canal, called the external cervical os, contains a transition from the squamous epithelium of the portio vaginalis to the columnar epithelium of the cervical canal • The exact location of this transition, termed the squamocolumnar junction, varies depending on hormonal status • At the upper border of the endocervical canal is the internal cervical os, where the narrow cervical canal becomes continuous with the wider endometrial cavity 113
For specimen acquisition it is important that cells are acquired from both the endocervical and ectocervical regions, that is, both above and below the region known as the transformation zone Differences in cervical os apperance due to labor and delivery A. Nulliparous cervix: regular, oval opening B. Parous cervix: transverse slit with anterior and posterior lips 114
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• The cervical stroma is composed • mainly of – collagen, – elastin, and – proteoglycans, • but very little smooth muscle. – Changes in the amount, composition, and orientation of these components lead to cervical ripening prior to labor onset • In early pregnancy, increased vascularity and edema within the cervix stroma leads to the blue tint and softening characteristics of Chadwick and Hegar signs, respectively 116
Ovaries and Fallopian Tubes • ovaries and fallopian tubes constitute the uterine adnexa 117
• Ovaries are paired organs situated close to the wall on either side of the pelvis minor, a little below the brim • Each measures • 2.5–5 cm in length, • 1.5–3 cm in breadth, and 0.7–1.5 cm in width, – weighing about 4–8 g • The ovary has 2 surfaces, medial and lateral; 2 borders, anterior or mesovarian and posterior or free; and 2 poles, upper or tubal and lower or uterine. • When the uterus and adnexa are in the normal position, the long axis of the ovary is nearly vertical, but it bends somewhat medially and forward at the lower end so that the lower pole tends to point toward the uterus • The medial surface is rounded and, posteriorly, may have numerous scars or elevations that mark the position of developing follicles and sites of ruptured ones • ovary is suspended by means of the mesovarium, the suspensory ligament of the ovary, and the ovarian 118
Ovarian: outer cortex and inner medully • ovarian cortex – lined single layer of germinal epithelium of waldayer (cuboidal epithelium) – tunica albuginea: stromal cells thickened beneath germinal epithelium – Contains: primordial follicles, corpus albicans /atretic follicles/ • Medulla – loose connection tissues, blood vessels, nerves, muscles. – Hilus cells- homologous to interstitial cells of testes 119
120 ▪ Uteroovarian ligament ▪ Infundibulopelvic ligament(suspensory ligament of the ovary) Functions of ovaries • Reproductive : produce oocyte(female gamates) • endocrine: produce estrogen, progesterone and other hormones
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Pre pubertal vs post pubertal ovary • Pre pubertal – surface of the ovary comprised of connective tissue capsule which is covered by smooth layer of mesothelium – ovarian surface or germinal epithelium: a single layer of cuboidal cells so that it gives the surface of ovary dull and grayish appearance as it contrasts with shinny adjacent peritoneal mesovarium. • Post pubertal: – repeated ovarian rupture and oocyte release during ovulation resulted progressive scarring and surface epithelium become distorted . – ovulation inhibiting contraceptives decrease this scarring. . 122
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Innervation of Ovaries and Uterine Tubes • nerve supply derives partly from the ovarian plexus, descending with the ovarian vessels, and partly from the uterine (pelvic) plexus • The ovaries and uterine tubes are intra peritoneal and, therefore, are superior to the pelvic pain line • Thus, visceral afferent pain fibers ascend retrogradely with the descending sympathetic fibers of the ovarian plexus and lumbar splanchnic nerves to cell bodies in the T11–L1 spinal sensory ganglia • Visceral afferent reflex fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) and inferior hypogastric plexuses and the pelvic splanchnic nerves to cell bodies in the S2–S4 spinal sensory ganglia. 125
Clinical correlates • Tubal patency • Salpingitis and TOA • Ectopic pregnancy • Infertility • Salpingo ophorectomy and due care given to the ureter as it courses just medial to suspensory ligament 126
Fallopian Tubes • Uterine (Fallopian) Tubes (Oviducts) • serve to convey the ova to the uterus • Each tube is 7–14 cm long • uterine appendages located bilaterally at superior portion of the uterine cavity • exit the uterus through an area referred to as cornua forming connection between endomerial and peritonial cavities. • approximately 10cm long and 1cm wide found situated within meso salpinx 127
• Divided into 4 parts: – Isthmus • the narrow and nearly straight portion • has a rather long intramural course, and its opening into the uterus, the uterine ostium, is approximately 1 mm in diameter – Ampulla • wider, more tortuous ampulla → widest and largest part at medial end of infundibulum • where fertilization usually occurs • has multiple longitudinal mucosal folds called plicae [responsible for reason why gonorheal salpingitis and TOA is common – Infundibulum • margins are fringed by numerous diverging processes, the fimbriae, the longest of which, the fimbria ovarica, is attached to the ovary • Mouth = abdominal ostium, is about 3 mm in diameter and actually leads into the peritoneal cavity, although it probably is closely applied to the surface of the ovary during ovulation • is suspended from the pelvic brim by the infundibulopelvic ligament (suspensory ligament of the ovary) – Uterine part: short intramural segment of the tube • Tubal mucosa is lined by columnar epithelium surrounding the lumen • This columnar cells have cilia 128
129 • The ovarian artery runs along the ovary’s hilum and sends several branches through the mesosalpinx to supply the fallopian tubes • The venous plexus, lymphatic drainage, and nerve supply of the fallopian tubes follow a similar course to that of the ovaries
• wall of the tube has 4 coats: serous (peritoneal), subserous or adventitial (fibrous and vascular), muscular, and mucous • Three layers of musculature- – Inner longitudinal layer – Middle circular layer • thickest at isthmus and thinnest at infundibulum • it , therefore isthmus is called sphincter of the tube b/c it is in this part of the tube that spasm may occur and close the lumen. – Outer longitudinal layer • Functions of the tubes – Transport of Gametes –pick the ovum up and transport it and of sperm as well. – Final maturation of Gametes –post ovulate oocyte maturation and sperm capacitation . – Provides fluid environment for early embryonic development. – Transport of fertilized and un fertilized ovum to the uterus . 130
External Generative Organs • Vulva • Vagina • Perineum – Pelvic floor ❑Urogenital Triangle o Pelvic diaphragm o Perineal Membrane o Deep perineal pouch o Superficial Perineal Pouch o Fasciae of UG Triangle ❑Anal Triangle o Perineal body o Ischioanal fossa o Anal sphincter 131
• Homologous – Labia majora → male scrotum • Vestibule – is derived from embryonic urogenital membranes. • Femoral artery → external pudendal artery – supplies skin and subcutaneous tissue of mons pubis • Internal iliac artery → internal pudendal artery – Exits pelvis through the greater sciatic foramen, passes behind the ischial spines, and reenters the perineum through the lesser sciatic foramen – It then has a variable course through the pudendal or Alcock canal, and then divides into terminal branches (inferior rectal, perineal, and clitoral arteries) – Branches to the perineum sometimes arise from the pudendal artery before it exits the pelvis. T ese vessels are called accessory pudendal arteries. Other accessory vessels may also arise directly from the anterior or posterior division of the internal iliac artery 132
Veins that drain vulva and perineum • have courses and names similar to those of the arteries – vestibular bulbs and other structures, with the exception of the erectile tissue of the clitoris, drains into the internal pudendal veins – Th e erectile tissue drains into the dorsal vein of the clitoris → periurethral–perivesical venous plexus – rectum and anal canal empties into the superior, middle, and inferior rectal veins • superior rectal vein drains into the inferior mesenteric vein, a tributary o the portal vein • middle rectal vein drains into the internal iliac vein • inferior rectal vein drains into the internal pudendal and then the internal iliac vein 133
Lymphatic Drainage of vulva and perineum • drain into the inguinal lymph nodes, which are located below the inguinal ligament in the upper anterior and medial thigh • There are 10 to 20 inguinal nodes, which are divided into a superficial and a deep group • Nodes of the superficial inguinal group – are more numerous, and they are found in the membranous layer of the subcutaneous tissue of the anterior thigh, just superficial to the fascia lata – Drains skin of the labia, clitoris, and remainder of the perineum • Deep inguinal nodes – located deep to the fascia lata in the femoral triangle – From lateral to medial: Femoral nerve, artery, vein, and deep inguinal lymphatics • The femoral canal is the space that lies on the medial side of the femoral vein and that contains the deep inguinal nodes • The femoral ring is the abdominal opening of the femoral canal. The fossa ovalis or saphenous opening is an oval opening in the fascia lata and allows communication between superficial and deep inguinal nodes – Of the deep inguinal nodes, the highest one—Cloquet or Rosenmüller node—is located in the lateral part of the femoral ring – Drains glans and corpora cavernosa of the clitoris • Efferent channels from the deep inguinal nodes pass through the femoral canal and femoral ring to the external iliac nodes • Clinical - radical vulvectomy ?? 134
Innervation of vulva and perineum • pudendal nerve – is a branch of sacral plexus and is formed by anterior rami of S2-4 – Branches: Inferior anal, perineal, and dorsal nerve of the clitoris – provide sensory and motor innervation to the perineum – course and distribution similar to internal pudendal artery Clinical can be performed transvaginally or transgluteally • injecting local anesthesia just medial and inferior to the ischial spine in the distribution of the dorsal nerve of the clitoris has been reported following midurethral sling procedures • requires parasympathetic visceral efferents derived from the pelvic plexus nerves, sometimes called nervi erigentes – These arise from S2-4 sacral spinal cord segments – They reach the perineum along the urethra and vagina, passing through the urogenital hiatus • Sympathetic fibers reach the perineum with the pudendal nerve 135
• The inferior gluteal artery, with extensive collateral circulation, is found between the sacrospinous and sacrotuberous ligaments and may be injured during sacrospinous suspension – Injury to the inferior gluteal artery, and to the pudendal nerve and internal pudendal vessels, during sacrospinous ligament suspension may be minimized by careful and controlled retraction and suture placement, at least two fingerbreadths medial to the ischial spine 136
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Vulva Pudenda = vulva – includes • All structures visible externally from the symphysis pubis to the perineal body • Mons pubis, labia majora and minora, clitoris, hymen, vestibule, urethral opening, greater vestibular or Bartholin glands, minor vestibular glands, and paraurethral glands Mons Pubis: fat-filled cushion overlying the symphysis pubis – also called mons veneris Labia – Majora: usually are 7 to 8 cm long, 2 to 3 cm wide, and 1 to 1.5 cm thick – Minora: lengths from 2 to 10 cm and widths from 1 to 5 cm • Hart line: A line demarcating the keratinized stratified squamous epithelium on the outer surface of each labium from the medial nonkeratinized squamous epithelium • labia minora lack hair follicles, eccrine glands, and apocrine glands. However, sebaceous glands are numerous 139
140 Embryonic Urogenital Structures and Their Adult Homologues
Labia Majora • prominent folds of skin that indirectly protect (clitoris + urethral + vagina) • round ligament and obliterated processus vaginalis, which is also termed the canal of Nuck, exit the inguinal canal and attach to the adipose tissue or skin of the labia majora • Anterior & posterior commissure • Clinical – a mass found in one labium majus may be a leiomyoma arising from the distal round ligament, a persistent processus vaginalis, or breast tissue along the distal milk line – An indirect inguinal hernia may also reach the labium majus by passing through the deep inguinal ring and inguinal canal 141
Labia Minora • Rounded folds of fat-free, hairless skin • Medial laminae of each side unite ➔ frenulum of clitoris • Lateral laminae unite ➔ prepuce (foreskin) of clitoris • In young women, especially virgins – labia minora are connected posteriorly by a small transverse fold, the frenulum of the labia minora (fourchette) • In contrast to the skin that overlies the labia majora, skin of labia minora does not contain hair. Also, the subcutaneous tissue is devoid of at and consists primarily of loose connective tissue – This latter attribute allows mobility of the skin during sex and accounts for the ease of dissection with vulvectomy • Clinically – If winglike structures are pendulous & results dyspareunia → labia can be surgically reduced 142
143 Vulvar structures and subcutaneous layer of anterior perineal triangle Note the continuity of Colles and Scarpa fasciae Inset: Vestibule boundaries and openings onto vestibule
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Clinical • The subcutaneous layer consists of a superficial fatty layer similar to Camper fascia, and a deeper membranous layer, Colles fascia – Also known as the superficial perineal fascia, Colles fascia is similar to and continuous with Scarpa fascia of the anterior abdominal wall • Posteriorly – Colles fascia attaches firmly to the ischiopubic rami laterally and perineal membrane – These attachments prevent the spread of fluid, blood, or infection from superficial perineal space to the thighs or posterior perineal triangle • Anteriorly, – Colles fascia has no attachments to the pubic rami, and it is therefore continuous with the lower anterior abdominal wall – This continuity may allow the spread of fluid, blood, and infection between these compartments 145
Clitoris – principal female erogenous organ – consists • root + corpus or body – Body • 2 crura + 2 corpora cavernosa + glans clitoris • glans is usually < 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated • body measures approximately 2 cm and is connected to the pubic ramus by crura – Clitoral blood supply  branches of internal pudendal artery • Specifically, the deep artery of the clitoris supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce. – L = ~ 2 cm & D <1 cm – Highly sensitive • Glans: most highly innervated part 146
Vestibule – an almond-shaped area – the area between the two labia minora – is bounded laterally by the line of Hart and medially by hymeneal ring • Hart line represents the demarcation between the skin and mucous membrane on the inner surface of the labia minora – Perforated by six openings • 1-urethra, • 1-vagina, • 2-Bartholin gland ducts, and • 2-ducts of the largest paraurethral glands—the Skene glands – Clinical o Localized vulvar dysesthesia (vulvar Vestibulitis) is characterized by pain with vaginal penetration, localized point tenderness, and erythema of the vestibular mucosa o In other women, when choosing incision sites for Bartholin gland drainage or marsupialization, Hart line is clinically relevant • That is, in attempts to recreate near-normal gland duct anatomy following these procedures, incisions placed external to Hart line are avoided 147
Bartholin glands • Also → greater vestibular glands • homologues of the male bulbourethral or Cowper glands • located in superficial perineal pouch • Secrete mucus into vestibule during sexual arousal – Ducts open onto vestibule @ four and eight o'clock positions • William: 5 & 7 o'clock positions • A normal Bartholin gland is not palpable (D ~ 0.5 cm ), except possibly in very thin women • Partly overlapped posteriorly by bulbs of vestibule – partially surrounded by bulbospongiosus mu • contain columnar cells that secrete clear or whitish mucus with lubricant properties – stimulated by sexual arousal – Contraction of bulbospongiosus muscle - expresses gland secretions • Clinical: obstruction of Bartholin ducts 148
Vagina Musculomembranous tube Length – Anterior = 6 to 8 cm; Posterior = 7 to 10 cm Lined = nonkeratinized stratified squamous epithelium Premenopausal women → Rugae lacks glands – But lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium Due to increased vascularity during pregnancy, vaginal secretions are notably increased Blood supply  cervical branch of the uterine artery and vaginal artery.  Middle rectal artery  internal pudendal artery Lymphatics from – Upper 2/3rd → similar to that of the uterus • drain into the external, internal, and common iliac nodes – Lower 1/3rd → inguinal lymph nodes Vaginal innervation – from inferior extensions of uterovaginal plexus, a component of inferior hypogastric plexus 149
• vagina is composed of three layers: – 1. Mucosa—nonkeratinized stratified squamous epithelium – 2. Muscularis— – 3. Adventitia—endopelvic fascia, adherent to the underlying muscularis. • These latter two form the fibromuscular component of the vagina • Rectovaginal fascia or fascia of Denonvilliers • Surgically, dissections in the anterior vaginal wall or in the posterior vaginal wall separate portions of the vaginal muscularis from the epithelium or surgeries such as anterior and posterior colporrhaphy • In contrast, posterior or anterior access to the coccygeus-sacrospinous ligament complex is accomplished by incising the full thickness of the anterior or posterior fibromuscular wall of the vagina, respectively • This deeper dissection allows access to the vesicovaginal or rectovaginal space and lateral dissection from these spaces allows access to the pararectal space • Because there is no true histologic “fascial” layer between the vagina and the bladder and between the vagina and the rectum, some recommend that terms such as “pubocervical/pubovesical fascia” or “rectovaginal fascia” be abandoned • They propose that these be replaced by more accurate descriptive terms such as vaginal muscularis or fibromuscular layer of the anterior and posterior vaginal walls 150
• during abdominal hysterectomy or cesarean delivery – lift and incise the vesicouterine peritoneal fold to create a bladder flap and then open the vesicocervical space • For vaginal hysterectomy, the distance between the anterior vaginal fornix and the anterior cul-de-sac peritoneum spans several centimeters • Thus, to successfully enter the peritoneal cavity anteriorly, proper identification and sharp dissection of the loose connective tissue that lies within the vesicovaginal and then vesicocervical spaces is necessary 151
• cul-de-sac • Clinically, the rectovaginal space contains loose areolar tissue and is easily opened with finger dissection during abdominal surgery • Perforation of the rectal pillar fibers allows access to the sacrospinous ligaments used in vaginal suspension procedures • Posterior cul-de-sac peritoneum extends down the posterior vaginal wall 2 to 3 cm inferior to the posterior vaginal fornix • Thus, during vaginal hysterectomy, in contrast to anterior peritoneal cavity entry, entering the peritoneal cavity posteriorly is readily done by incising the vaginal wall in the area of the posterior fornix 152
• main support - provided by • levator ani muscles • connective tissue that attaches the lateral walls of the vagina to the pelvic walls – cardinal and uterosacral ligaments • DeLancey (1992) has described three levels of vaginal connective tissue support that help explain pelvic support dysfunction – Level I support (suspensory axis) • vertically oriented • consists of paracolpium that suspends the apical portion of the vagina and is comprised of the cardinal–uterosacral ligament complex • Defect: uterine prolapse or posthysterectomy vaginal vault prolapse – level II support or the attachment axis • Midvaginal support • comprises the paracolpium that is attached to the vagina laterally via the arcus tendineus fasciae pelvis and superior fascia of the levator ani • endopelvic fascia, arcus tendineus fascia pelvis • give vagina “H” shape when viewed in cross section • Defects → anterior and posterior vaginal wall prolapse and stress urinary incontinence – level III support or Fusion axis • consists of the distal vaginal attachments: anteriorly, via fusion of the urethra to the vagina; laterally, to the levators; and posteriorly, with the perineal body • strongest vaginal support components • Clinically, failure → distal rectoceles or perineal descent 153
DeLancey levels of support • There are three levels of vaginal support as described by DeLancey • Disruption of – level I support → prolapse of uterus or vaginal vault – level II and III supports → anterior and posterior vaginal prolapse • All levels of defective support should be repaired during reconstructive surgery 154
155 Surgical cleavage planes and vaginal wall layers
156 Midsagittal view of pelvic structures and associated anatomy
Hymen – a membrane of varying thickness that surrounds the vaginal opening 157
Perineum • Perineum refers to diamond-shaped external surface area – bounded by the pelvic outlet – separated from pelvic cavity by pelvic diaphragm 158
Perineum – Superficial Space of the Anterior Triangle Bulbs of Vestibule • Paired masses of elongated erectile tissue • ~ 3 cm in length • Covered by bulbospongiosus muscles • homologous with the bulb of penis – Deep Space of the Anterior Triangle – Pelvic Diaphragm – Posterior Triangle: Ischioanal Fossae; Anal Canal; Anal Sphincter Complex – Pudendal Nerve 159
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Pelvic floor • formed by – Muscles (pelvic diaphragm) and – Fascia • supported anteriorly by: 1. perineal membrane; and 2. muscles in the deep perineal pouch • An imaginary line between the ischial tuberosities divides the perineum into two triangular regions A. Anteriorly – Urogenital triangle – Roots of Ex/genitalia – Genital openings B. Posteriorly – anal triangle 161
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Pelvic diaphragm  Coccygeus + levator ani mu + covering fascia separate pelvic cavity from perineum roof of perineum – 2 defects – Ant ➔U-shaped defect ✓ Urogenital hiatus – Pos ➔ Circular anal aperture • In contrast to anal triangle – UG triangle contains strong fibromuscular support platform 1. Perineal membrane and 2. Deep perineal pouch Action of pelvic diaphragm • support pelvic viscera – forms a dynamic floor for supporting the abdominopelvic viscera • Descends when relaxed to allow defecation and urination • acting together, raise the pelvic floor, by active contraction after defecation restoring its normal position • resist the increased intra-abdominal pressure that would otherwise force the abdominopelvic contents through the pelvic outlet – This action occurs reflexively during forced expiration, coughing, sneezing, vomiting 166
Defects of Pelvic diaphragm 167
Perineal Membrane • a thick, triangular fascial sheet – between arms of pubic arch • fills anterior gap in the pelvic diaphragm (urogenital hiatus) • perforated by urethra (both sexes) and vagina • same as male, – Except: external urethral sphincter + Pierced by vagina and urethra • has a free posterior border • Function – The membrane and ischiopubic rami to which it attaches provide a foundation for • penis and scrotum of males, and • pudendum or vulva of females 168
Deep perineal pouch • Space between perineal membrane and pelvic diaphragm • In contrast to the superficial space, which is a closed compartment, the deep space is continuous superiorly with the pelvic cavity • Boundaries – Inferiorly: perineal membrane – Superiorly: inferior fascia of pelvic diaphragm, – Laterally: inferior portion of obturator fascia • Ischio-anal fossae extend anteriorly into this space (anterior recesses ) • Contains: – Proximal part of urethra – External sphincter urethrae muscle – Deep transverse perineal muscles – Vessels and nerves: branches of internal pudendal artery, and dorsal nerve and vein of the clitoris 169
Deep perineal space External urethral sphincter 170
171
172 Deep space of anterior perineal triangle
Dorsal nerve and vessels of clitoris Anterior trunk of internal iliac artery → internal pudendal artery ▪ Is the main artery of the perineum. ▪ Leaves the pelvic cavity through the greater sciatic foramen and then enter to the perineum through the lesser sciatic foramen ▪ Terminal branches are the perineal artery and dorsal arteries of the penis or clitoris. 173
174
175
• Muscles within the deep perineal pouch Muscle Origin Insertion Innervation Function External urethral sphincter From the inferior ramus of the pubis on each side and adjacent walls of the deep perineal pouch Surrounds membranous part of urethra Perineal branches of the pudendal nerve (S2 to S4) Compresses the membranous urethra. Relaxes during micturition Deep transverse perineal Medial aspect of ischial ramus Perineal body Perineal branches of the pudendal nerve (S2 to S4) Stabilizes the position of the perineal body Compressor urethrae (in women only) Ischiopubic ramus on each side Blends with partner on other side anterior to the urethra Perineal branches of the pudendal nerve (S2 to S4) Functions as an accessory sphincter of the urethra Sphincter urethrovaginalis Perineal body Passes forward lateral to the vagina to blend with partner on other side anterior to the urethra Perineal branches of the pudendal nerve (S2 to S4) Functions as an accessory sphincter of the urethra (also may facilitate closing the vagina) 176
Superficial Perineal Pouch • lies between Colles fascia (membranous layer of superficial fascia) and perineal membrane • is a closed compartment (Unlike deep) • Boundaries – Superiorly: perineal membrane – Inferiorly: Superficial perineal (Colles’) fascia – Laterally: Ischiopubic rami • Contains: – Crura of clitoris and associated muscles – Bulbs of vestibule and associated muscles – Superficial transverse perineal muscles – Branches of internal pudendal vessels and pudendal nerves – Greater vestibular glands 177
Structures of Superficial perineal space Arterial Supply • External pudendal arteries (branches of femoral artery) • Internal pudendal arteries 178
179
180
181
• Ischiocavernosus Muscle – O: Ischial tuberosity and ramus – I: Crus of clitoris – Fn: Move blood from crura into the body of the erect clitoris • Bulbospongiosus Muscle – O: Perineal body – I: Bulb of vestibule, perineal membrane, body of clitoris and corpus cavernosum – Fn: Move blood from attached parts of the clitoris into the glans • Superficial transverse perineal Muscle – O: Ischial tuberosity and ramus – I: Perineal body – Fn: Stabilize the perineal body All muscles - Pudendal nerve (S2 to S4) 182
Fasciae of UG Triangle • Fascias – Superior fascia of Urogenital diaphragm – Inferior fascia of Urogenital diaphragm • Deep perineal (Gallaudet’s) fascia – Superficial perineal (Colles’) fascia • Covering Superficial perineal space 183
184
185
Anal Triangle • This triangle contains the – Ischioanal fossae, – Anal canal and – Anal sphincter complex, – Branches of the pudendal nerve and internal pudendal vessels • A splitting of the obturator internus fascia in this area is known as the pudendal or Alcock canal – This canal allows passage of the internal pudendal vessels and pudendal nerve before these structures split into terminal branches to supply the structures of the vulva and perineum 186
187 Pudendal nerve and vessels. Nerve supply to striated urogenital sphincter and external anal sphincter muscles
• rectum is continuous with the sigmoid colon approximately at the level of S3 • It descends on the anterior surface of the sacrum for approximately 12 cm and ends in the anal canal after passing through the levator hiatus • The anterior and lateral portions of the proximal two thirds of the rectum are covered by peritoneum • peritoneum is then reflected onto the posterior vaginal wall to form the posterior cul-de-sac of Douglas (rectouterine pouch) – In women, the cul-de-sac is located approximately 5 to 6 cm from the anal orifice and can be palpated manually during rectal or vaginal examination – At its commencement, the rectal wall is similar to that of the sigmoid, but near its termination it becomes dilated to form the rectal ampulla, which begins below the posterior cul-de-sac peritoneum • rectum contains several, usually three, transverse folds called the plicae transversales recti, also termed valves of Houston – largest and most constant - located anteriorly and to the right, approximately 8 cm from the anal orifice – These folds may contribute to fecal continence by supporting fecal matter above the anal canal – Clinically, in the empty state, the transverse rectal folds overlap each other, making it difficult at times to manipulate an examining finger or endoscopy tube past this level 188
Perineal body • Is the a mass of connective tissue found in between urogenital and anal triangle • Central tendon of the perineum • marks the point of convergence of – bulbospongiosus muscles, – superficial and deep transverse perinei, – perineal membrane, – external anal sphincter, posterior vaginal muscularis and fibers from the puborectalis and pubococcygeus muscles • plays an important role in support of the distal vagina and in normal anorectal function • The anterior to posterior and the superior-to-inferior extents of the perineal body each measure approximately 2 to 4 cm • Clinically, during vaginal laceration repairs and with pelvic reconstructive procedures, particular attention is given to perineal body reconstruction 189
Ischioanal fossa • Ischioanal fosssae is a fat-filled wedge shaped spaces found on either side of the anal canal and comprise the bulk of the posterior triangle. • Each ischioanal fossa is bounded: – Laterally by the ischium and overlapping inferior part of the obturator internus, covered with obturator fascia. – Medially by the external anal sphincter, with a sloping superior medial wall or roof formed by the levator ani as it descends to blend with the sphincter; both structures surround the anal canal. – Posteriorly by the sacrotuberous ligament and gluteus maximus. – Anteriorly by the bodies of the pubic bones, inferior to the origin of the puborectalis. These parts of the fossae, extending into the UG triangle superior to the perineal membrane (and musculature on its superior surface), are known as the anterior recesses of the ischioanal fossae 190
191
Ischio-anal fossae and their anterior recesses. A. Anterolateral view with left pelvic wall removed. B. Inferior view. C. Anterolateral view with pelvic walls and diaphragm removed. 192
• The fat found within each fossa – provides support – allows rectal distention during defecation and vaginal stretching during delivery. • Potential space for – Collection of hematoma – Collection of abscess – Extension of abscess • Moreover, the two fossae communicate dorsally, behind the anal canal. This can be especially important because an episiotomy infection or hematoma may extend from one fossa into the other. • Clinically, injury to vessels in the posterior triangle can lead to hematoma formation in the ischioanal fossa, and the potential for large accumulation in these easily distensible spaces. 193
Anal sphincter Anal Canal • This distal continuation of the rectum begins at the level of levator ani attachment to the rectum and ends at the anal skin • 4- to 5-cm in length, • Dentate or pectinate line, • The canal is collapsed, except during passage of feces 194
• Which of the following is true concerning the anal sphincters? – A. The external anal sphincter receives blood supply from the superior rectal artery. – B. The internal anal sphincter contributes the bulk of anal canal resting pressure. – C. The external anal sphincter measures 3 to 4 cm in length. – D. The external sphincter remains in a state of constant relaxation 195
196 This orientation reflects the embryological development of the anorectum
197
The external anal sphincter • Is a striated muscle ring that anteriorly attaches to the perineal body and that posteriorly connects to the coccyx via the anococcygeal ligament • Consists of three parts : – Deep, • The deep part is a thick ring-shaped muscle that circles the upper part of the anal canal and blends with the fibers of levator ani muscle – superficial and • The superficial part also surrounds the anal canal, but is anchored anteriorly to the perineal body and posteriorly to coccyx and anococcygeal ligament . – subcutaneous arranged sequentially along the canal from the superior to inferior • The subcutaneous part is a horizontally flattened disc of muscle that surrounds the anal aperture just beneath the skin. 198
The internal anal sphincter • is an involuntary sphincter surrounding the superior two thirds of the anal canal. • Its contraction is stimulated and maintained by sympathetic fibers from the superior rectal (periarterial) and hypogastric plexuses. • Contraction is inhibited by parasympathetic fiber stimulation • This sphincter is tonically contracted most of the time to prevent leakage of fluid or flatus. – External Anal Sphincter (EAS) • voluntary (striated) muscle • inferior rectal artery • inferior rectal branch of the pudendal nerve – Internal Anal Sphincter (IAS) • not under voluntary control 199
Lower Urinary Tract Structures • The pelvic urinary organs are – Pelvic portions of the ureter – Urinary bladder – Urethra 200
Ureter • A 25–30 cm long muscular tube • Connect the kidneys to the urinary bladder. • It is retroperitoneal organ • Has two portions – abdominal + pelvic • Has several layers – Mucosa: uroepithelium – Sub mucosa – muscles-two layers • 1-Outer circularly oriented layer • 2-Iner longitudinal oriented layer • The three constriction sites ??? • About 75% of all iatrogenic injuries to ureter result from gynecologic procedures, most commonly laparoscopic hysterectomy; risk is increased with distortions of pelvic anatomy, including adnexal masses, endometriosis, other pelvic adhesive disease, or fibroids Pelvic ureter • The part of ureter after crossing the bifurcation of the common iliac artery at the pelvic brim. • two parts – Posterolateral – Anetromedial Course • It runs on the lateral walls of the pelvis • Parallel to internal iliac arteries , across anterior margin of greater sciatic notch and parietal peritoneum • It is crossed superiorly by the uterine artery at the level of ischial spine, around 2 cm lateral to cervix. • It then passes close to the lateral part of the fornix of the vagina and enters the poster superior angle of the bladder 201
Arterial Supply and Venous Drainage • Ureteric branches from the common iliac, internal iliac, and ovarian arteries. • The most constant arteries supplying the terminal parts are branches of the uterine arteries. • Venous drainage from pelvic ureter parallels to its arterial supply and has corresponding names • Lymphatic vessels drain to common iliac and internal iliac nodes Innervation of Ureters • From adjacent autonomic plexuses – renal, aortic, superior and inferior hypogastric plexuses 202
• 75% of all iatrogenic injuries result from gynecologic procedures – Most commonly abdominal hysterectomy • Risk is increased with distortions of pelvic anatomy 203
Urinary bladder • A hollow viscus with strong muscular walls. • Temporary reservoir for urine. • Known for its distenisbility. • Variable in its size, shape, position, and relationships according to its content, and the state of neighboring viscera. 204
• Position – The position of the bladder varies with age • In infants and young children –abdomen • By age 6- enters the greater pelvis • At puberty –it will be at true pelvis. • The position of the empty bladder in the adult is described as lying on the front part of pelvic floor, below the peritoneum and behind the pubic symphysis • Parts – Apex: part of the bladder that pointes towards the posterior edge of pubic bone – Fundus: opposite to apex which forms convex posterior wall – Body: major part of the bladder between the apex and fundus – Neck: part of the bladder that connects with urethra 205
• The bladder wall consists of coarse bundles of smooth muscle known as the detrusor muscle, which extends into the upper part of the urethra – Although separate layers of the detrusor are described, they are not as well defined as the layers of other viscous structures – The innermost layer of the bladder wall is plexiform, which can be seen from the pattern of trabeculations noted during cystoscopy – The mucosa of the bladder consists of transitional epithelium and underlying lamina propria – A submucosal layer intervenes between this mucosa and the detrusor muscle 206
The bladder has four surfaces, angles, borders and parts 207
208
• The bladder is often divided into two areas – bladder is divided into a dome and a base approximately at the level of the ureteral orifices – Dome • thin walled and distensible • Remaining bladder area above the bladder base. • It has parasympathetic innervation • Responsible for micturition – Base o consists of – Vesical trigone » – Detrusor loops » These loops are two U-shaped bands of fibers found at the vesical neck, where the urethra enters the bladder wall o thicker and undergoes less distention during filling o Ureteral orifices lie within the trigone and empty here into the bladder o The pelvic ureter courses in the pelvic sidewall retroperitoneum o Urinary trigone and a thickened area of detrusor . o Trigone -two ureteral orifices and the opening of the urethra into the bladder. o Receives α-adrenergic sympathetic innervation o Responsible for maintaining continence. 209
• Arterial supply – superior vesical arteries • branches of the patent portion of the umbilical artery – The vaginal arteries – The obturator – Inferior gluteal • Venous Drainage – Via vesical , vaginal or uterovaginal venous plexus to internal iliac vein 210
Innervation of Bladder from inferior thoracic and upper lumbar spinal cord levels to the vesical (pelvic) plexuses primarily through the hypogastric plexuses from sacral spinal cord levels via the pelvic splanchnic nerves and the inferior hypogastric plexus – The parasympathetic fibers are motor to the detrusor muscle and inhibitory to the internal urethral sphincter and is vise versa for sympathetic fibers • The nerve supply to the bladder arises from the vesical plexus, a component of the inferior hypogastric plexus Inadvertent bladder injury may occur • during dissection of the vesicovaginal space – commonly located just superior to the intraureteric ridge in the midline. • during peritoneal entry for laparotomy or suprapubic port placement during a laparoscopy. • Risk factors for this type of injury include conditions that cause scar tissue in the vesicouterine pouch 211
• Clinical – intentional cystotomy can be made to – confirm patency of the ureteral orifices, – assist with surgical dissection, or – place ureteral stents • The incision is ideally placed in the retropubic extraperitoneal portion of the bladder close to the apex • This avoids direct contact between the abdominopelvic viscera and the cystotomy site and minimizes the risk of fistula formation 212
Urethra • begins at the internal urinary meatus • The region where the urethral lumen traverses the bladder base is called the bladder neck • The distal two thirds of the urethra are used with the anterior vaginal wall • 3-4 cm long and 6 mm in diameter • fused to the vagina for its distal two-thirds • has two orifice – Internal urethral orifice – External urethral orifice • Histologically: has four distinct layers – Mucosa – Submucosa • Parauretral glands(sken’s gland) – Muscularies • Internal urethral sphincter • striated external urethral sphincter. Supportive structures • Hammock like supportive layer made up of – Periurethral endopelvic fascia – Anterior vaginal wall • NB: Defects in these attachments can result in urethral hypermobility and cystocele, and stress urinary incontinence Arterial Supply and Venous Drainage • Internal pudendal and vaginal arteries • The veins follow the arteries and have similar names . • Innervation of Female Urethra. – vesical nerve plexus and the pudendal nerve 213
• The walls of the urethra begin outside the bladder wall • They consist of two layers of smooth muscle, • an inner longitudinal and • an outer circular, – which are in turn surrounded by a circular layer of skeletal muscle referred to as the sphincter urethrae or rhabdosphincter • Approximately at the junction of the middle and lower third of the urethra, and just above or deep to the perineal membrane, two strap skeletal muscles called the urethrovaginal sphincter and compressor urethrae are found • These muscles were previously known as the deep transverse perineal muscles in females • Together with the sphincter urethrae, they constitute the striated urogenital sphincter complex • Together, these three muscles function as a unit and have a complex and controversial innervation • Their fibers act cumulatively to supply constant tonus and to provide emergency refex activity mainly in the distal half of the urethra to sustain continence 214
• Distal to the depth of the perineal membrane, the walls of the urethra consist of fibrous tissue, serving as the nozzle that directs the urine stream • The urethra has a prominent submucosal layer that is lined by hormonally sensitive stratified squamous epithelium • Within the submucosal layer on the dorsal (vaginal) surface of the urethra is a group of glands known as the paraurethral glands, which open into the urethral lumen • Duct openings of the two most prominent glands, termed Skene glands, are seen on the inner surface of the external urethral orifice 215
• The urethra receives its blood supply from branches of the inferior vesical/vaginal and internal pudendal arteries – Although still controversial, the pudendal nerve is believed to innervate the most distal part of the striated urogenital sphincter complex. – Somatic efferent branches from S2–S4 that course along the inferior hypogastric plexus variably innervate the sphincter urethrae • Clinical – Chronic infection of the paraurethral glands can lead to urethral diverticula – Due to the multiple openings of these glands along the length of the urethra, diverticula may develop at various sites along the urethra 216
217 Urethra and associated muscles
Urethral Sphincter Physiology 218
Retroperitoneal Surgical Spaces 219
220 Schematic cross section of the pelvis showing cleavage planes and spaces including the retropubic (prevesical), vesicovaginal, pararectal, rectovaginal, and retrorectal spaces
• During surgery, – entering the retroperitoneum at the pelvic sidewall can be used to identify the ureter – Moreover, it is an essential step for many of the surgeries described in gynecologic oncology • contains – Major pelvic vessels – Pelvic ureter – Obturator nerve 221
• Major pelvic vessels – internal iliac and external iliac vessels and their corresponding lymph node groups – Clinical • If severe hemorrhage during pelvic surgery → internal iliac artery may be ligated – internal iliac artery is ligated distal to the origin of its posterior division branches. – This helps to prevent significant devascularization of the gluteal muscles – These posterior division branches generally arise from the posterolateral wall of the internal iliac artery at a site 3 to 4 cm rom its origin of the common iliac artery • When this vessel is dissected, the ureter is also identified and avoided 222
Maternal anatomy, 2019
Maternal anatomy, 2019
Maternal anatomy, 2019
Maternal anatomy, 2019
Maternal anatomy, 2019
Maternal anatomy, 2019
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Maternal anatomy, 2019

  • 1. Dr Gebresilassie Andualem Email: bjlomsecond@gmail.com Telegram: https://t.me/OBGYN_Note_Book Maternal Anatomy
  • 2. Contents • Anterior abdominal wall • Bony Pelvis • Pelvic Wall Muscles and Fascia • Pelvic Floor • Pelvic Blood Supply • Pelvic Innervation • Pelvic Viscera • Retroperitoneal Surgical Spaces 2
  • 3. Anterior abdominal wall • Function of anterior abdominal wall – core support to the human torso – confines abdominal viscera – contributes muscular action for functions such as respiration and elimination • Knowing anatomy – avoids neurovascular complications 3
  • 4. 4 Layers Skin • Langer lines - orientation of dermal fibers ✓ Primarily transversely ✓ So vertical skin incisions sustain more lateral tension ➔ wider scars Subcutaneous layer - Superficial fascia • Superficial Camper’s (fatty layer) fascia • Deeper Scarpa’s (Membranous layer) fascia ✓ caudally, it is continuous with Colles fascia in the perineum ✓ Clinically, it is better developed in the lower abdomen → during surgery can be best identified in the lateral portions of a low transverse incision, just superficial to the rectus fascia ✓ In contrast, it is rarely recognized during midline incisions Musculoaponeurotic layer - Rectus sheath – Next to SC tissue – holds the abdominal viscera in place – Muscles - two groups: Midline Vertical muscles (RA & pyramidalis); Lateral flank muscles (EO, IO & TA) Transversalis Fascia Preperitoneal fat Peritoneum: a single layer of epithelial cells and supporting connective tissue called the serosa
  • 5. 5 Muscles of the Abdomen Pyramidalis muscle • Small, insignificant, triangular muscles arising from body of pubis inferiorly • Inserts into linea alba medially • Absent in 20% of people
  • 6. Rectus Sheath •  external oblique, internal oblique, and transversus abdominis muscles (flank muscles) • In the midline, the aponeurotic layers use to create the linea alba – 10 to 15 mm wide below the umbilicus • In the lower abdomen, transition from the muscular to the aponeurotic component of – EOM: @ a vertical line through anterior superior iliac spine – IOM: more medially • Arcuate line – horizontal line defines the level at which the rectus sheath passes only anterior to the rectus abdominis muscle – lies midway between the umbilicus and pubic symphysis • Above arcuate line (Cephalad) – rectus sheath lies both anterior and posterior to the rectus abdominis muscle – Anterior RS aponeurosis of EOM, IOM (split) – Posterior RS  IOM (split) & TAM • Below arcuate line (Caudad) – all aponeurotic layers pass anterior to the rectus abdominis muscle – So posterior surface of the rectus abdominis muscle is in direct contact with the transversalis fascia • Surgical Importance – Midline incision: only linea alba is encountered – Transverse lower abdominal incision: two layers are identified (aponeuroses of the internal oblique and transversus abdominis muscles 6
  • 7. 7
  • 8. 8
  • 9. • Similar to skin fibers, the flank muscle and rectus sheath fibers are oriented primarily transversely • So suture lines placed in a vertical fascial incision must withstand more tension than those in a transverse incision • Due to this – vertical fascial incisions are more prone to dehiscence and hernia formation – ventral wall hernias are most common along the linea alba • Spiegelian hernia, is rare and forms at the lateral rectus abdominis border, typically at the level of the arcuate line 9
  • 10. Peritoneum • parietal & visceral peritoneum • Five elevations of parietal peritoneum on anterior abdominal – All converge toward the umbilicus and are known as umbilical ligaments – Median umbilical ligament  urachus (obliterated tube that extends from the apex of the bladder to the umbilicus) • Urachus is a fibrous remnant of allantois – Paired medial umbilical ligaments  obliterated umbilical arteries – Paired lateral umbilical ligaments contain the patent inferior epigastric vessels 10
  • 11. Surgical importance • Urachus – Transection of a patent urachus can result in extravasation of urine into the abdominal cavity – DDX of a midline anterior abdominal wall cyst includes urachal cyst, urachal sinus, and urachal diverticulum • Umbilical ligaments – serve as valuable laparoscopic landmarks – First, the inferior epigastric vessels can be injured during accessory trocar placement • Thus, direct visualization of the lateral umbilical folds can prevent injury to these vessels during laparoscopic port placement – Second, the medial umbilical ligaments, if followed proximally, can guide a surgeon to the internal iliac artery and then to the uterine arteries – The medial umbilical ligament also forms the medial border of the paravesical space, which is developed during radical hysterectomy to isolate the parametrium 11
  • 12. Blood Supply Femoral Branches • superficial epigastric, superficial circumflex iliac, and external pudendal arteries arise from the femoral artery just below the inguinal ligament in the femoral triangle, which is bordered by this ligament, the sartorius muscle, and the adductor longus – These vessels supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis • The superficial epigastric vessels course diagonally toward the umbilicus, similar to the inferior “deep” epigastric vessels • Surgically – during low transverse skin incision creation, the superficial epigastric vessels can usually be identified half way between the skin and the rectus fascia, several centimeters from the midline – During laparoscopic procedures in thin patients, these vessels can be identified by transillumination – The external pudendal vessels form rich anastomoses with their contralateral equivalents and with other superficial branches – These anastomoses account for the extensive bleeding often encountered with incisions made in the mons pubis area such as for retropubic midurethral sling incisions. 12
  • 13. 13 Inguinal and upper thigh anatomy
  • 14. 14
  • 15. External Iliac Branches • Inferior “deep” epigastric vessels and deep circumflex iliac vessels are branches of the external iliac vessels • Supply the muscles and fascia of the anterior abdominal wall • Inferior epigastric vessels – initially course lateral to, then posterior to the rectus abdominis muscle – They then pass anterior to the posterior rectus sheath and course between the sheath and the rectus muscles – Near the umbilicus, the inferior epigastric vessels anastomose with the superior epigastric artery and veins, which are branches of the internal thoracic vessels • Hesselbach triangle – bounded inferiorly by the inguinal ligament, medially by lateral border of the rectus muscles, and laterally by the inferior epigastric vessels – Direct hernias through the abdominal wall within Hesselbach triangle – Indirect hernias protrude into the deep inguinal ring lying lateral to this triangle • Surgically importance – low transverse abdominal incisions that extend beyond the lateral margins of the rectus muscles can lead to inferior epigastric vessel laceration with severe hemorrhage or anterior abdominal wall hematoma formation – These vessels should be identified and ligated when performing a Maylard incision – As another surgical landmark, the deep circumflex iliac vein serves as the caudal border during pelvic lymph node dissection 15
  • 16. 16
  • 17. • Direct inguinal hernias – occur through Hesselbach's triangle (outlined in blue) formed by the inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus muscle medially – Medial to inferior epigastric vessels – Abdominal Inguinal Ring • the site of congenital direct hernias • Indirect inguinal hernias – develop at the internal inguinal ring and are lateral to the inferior epigastric artery – protrudes through the inguinal ring and is ultimately the result of the failure of embryonic closure of the internal inguinal ring after the testicle passes through it • Femoral hernias – develop in the empty space at the medial aspect of the femoral canal, inferior to the inguinal ligament 17
  • 18. 18
  • 19. Inguinal Canal ▪ The inguinal canal is an intermuscular passageway that extends from the abdominal ring downward, medially, and somewhat forward to the subcutaneous inguinal ring (about 3–4 cm). In Females • not well demarcated, • but it normally gives passage to the round ligament of the uterus, a vein, an artery from the uterus that forms a cruciate anastomosis with the labial arteries, and extraperitoneal fat. • The processus vaginalis of the female is rudimentary, but occasionally a small diverticulum of peritoneum is found passing partway through the inguinal region; this diverticulum is termed the processus vaginalis peritonei (canal of Nuck) In Males • In the male, the processus vaginalis descends with the testis 19
  • 20. Anterior abdominal wall Innervation • Abdominal extensions of intercostal nerves (T7-11) – intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the transversus abdominis and internal oblique muscles • This space, termed the transversus abdominis plane, can be used for postcesarean analgesia blockade • Subcostal nerve (T12) • Iliohypogastric and Ilioinguinal nerves (L1) – iliohypogastric nerve provides sensation to the skin over the suprapubic area – ilioinguinal nerve supplies skin of • lower abdominal wall • upper portion of labia majora and • medial portion of the thigh through its inguinal branch ❑ At a site 2 to 3 cm medial to the anterior superior iliac spine, these two nerves pierce through the internal oblique muscle and course superficial to it and toward the midline • T10 dermatome approximates the level of the umbilicus 20
  • 21. • Clinically – Ilioinguinal and iliohypogastric nerves can be entrapped during closure of low transverse incisions, especially if incisions extend beyond the lateral borders of the rectus abdominis muscle – They may also be wounded by lower abdominal insertion of accessory trocars – Risk of iliohypogastric and ilioinguinal nerve injury can be minimized if • lateral trocars are placed superior to the anterior superior iliac spines and • low transverse fascial incisions are not extended beyond the lateral borders of the rectus muscle 21
  • 22. 22
  • 23. Bony Pelvis • Pelvis is composed of four bones – sacrum, coccyx, and two innominate Bones • Os coxae - hip bones • innominate bones  ilium, ischium, and pubis • sacroiliac joint (synovial joint) • symphysis pubis (cartilaginous joint) • Ischial spines – Project posteromedially – at the level of S5 23 Right os coxae
  • 24. – Iliac crest— – Anterior superior and inferior spine – Posterior superior and inferior spine – Arcuate line – Iliopectineal eminence (linea terminalis – Iliac fossa— – Body – Symphysis pubis – Superior and inferior pubic rami – Pubic tubercle – Ischial spine • delineates the greater and lesser sciatic notch above and below it • It is the point of fixation for the sacrospinous ligament and the arcus tendineus fasciae pelvis • represents an important landmark in the performance of pudendal nerve block and sacrospinous ligament vaginal suspension • vaginal palpation during labor allows detection of progressive fetal descent – Ischial ramus – Ischial tuberosity 24
  • 25. Pelvic Bone Articulations • The pelvic bones are joined by four articulations (two pairs): – 1. Two cartilaginous symphyseal joints • sacrococcygeal joint and the symphysis pubis • responsive to the effect of relaxin and facilitate parturition – 2. Two synovial joints • sacroiliac joints • Pelvis is divided into t – Greater and lesser pelvis – divided by an oblique plane passing through the sacral promontory, the linea terminalis (arcuate line of the ilium), the pectineal line of the pubis, the pubic crest, and the upper margin of the symphysis pubis – This plane lies at the level of the superior pelvic aperture (pelvic inlet) or pelvic brim 25
  • 26. • Which of the following bone(s) forms the pelvis? – A. Innominate B. Sacrum C. Coccyx D. All of the above • The clinical evaluation of the pelvic inlet requires direct measurement of which diameter? – A. True conjugate B. Obstetrical conjugate – C. Diagonal conjugate D. Pelvic inlet transverse diameter • The shortest anteroposterior diameter of the pelvic inlet is which of the following? – A. True conjugate B. Obstetrical conjugate – C. Diagonal conjugate D. None of the above • Which of the following is true regarding relaxation of the pelvic joints at term in pregnancy? – A. It allows for an increase in the transverse diameter of the midpelvis. – B. It results in marked mobility of the pelvis at term because of a downward gliding movement of the sacroiliac (SI) joint. – C. Displacement of the SI joint increases outlet diameters by 1.5 to 2.0 cm in the dorsal lithotomy position. – D. It is permanent and not accentuated in subsequent pregnancies. • Which of the following is true of the midpelvis? – A. It is measured at the level of the ischial tuberosities. – B. It usually measures no more than 9 cm. – C. It is measured at the level of the ischial spines. – D. It usually is the largest pelvic diameter 26
  • 27. 27 In this figure, which of the following is demonstrated? A. Important pelvic outlet diameters B. Ischial tuberosities C. Midpelvis ischial spines D. An inadequate obstetrical conjugate
  • 28. • What is the narrowest pelvic dimension that must be navigated by the fetal head? – A. Inferior strait – B. Obstetrical conjugate – C. Interspinous diameter – D. Transverse diameter of the pelvic inlet • What is the most common pelvic shape? Gynecoid pelvis • The pubococcygeus muscle is now preferably called which of the following? – Pubovisceral muscle • The posterior triangle of the pelvic outlet is limited at its apex by which of the following? – A. Coccyx B. Last sacral vertebrae – C. S4 D. S3 28
  • 29. • Obturator foramen – between ischium and pubis – Filled almost completely by obturator membrane – superior to this membrane, a small aperture known as obturator canal allows passage of the obturator neurovascular bundle into the medial (adductor) compartment of the thigh • Posterolateral walls – not covered by bone – Sacrospinous and sacrotuberous ligaments, divide greater and lesser sciatic notches of ischium into ff foramens • Greater sciatic foramen – piriformis muscle, internal pudendal and superior and inferior gluteal vessels, sciatic and pudendal nerve, and other branches of the sacral nerve plexus pass in close proximity to the ischial spines – Surgically, this anatomy is critical to avoid neurovascular injury during sacrospinous fixation procedures and when administering pudendal nerve blockade • Lesser sciatic foramen – internal pudendal vessels, pudendal nerve, and obturator internus tendon pass through the lesser sciatic foramen – Posteriorly, four pairs of pelvic sacral foramina allow passage of the anterior divisions of the first our sacral nerves and lateral sacral arteries and veins 29
  • 30. 30 Bones, ligaments, and openings of the pelvic walls and associated structures • Note the obturator internus muscle extending below the levator ani muscle and then exiting through the lesser sciatic foramen to insert into the lateral femoral trochanter • Ischial spine is marked by an asterisk • L5 = fifth lumbar vertebra; • LST= lumbosacral trunk; • PS = pubic symphysis; • S1–S3 = first through third sacral nerves; • SSL= sacrospinous ligament; • STL= sacrotuberous ligament
  • 31. 31 • cardinal and uterosacral ligaments – Main Support pelvic organs • Round and broad ligaments – consist of smooth muscle and loose areolar tissue, respectively – do not contribute much to the support of pelvic organs • Sacrospinous, sacrotuberous, and anterior longitudinal ligaments of sacrum – consist of dense connective tissue that joins bony structures – contributes significantly to bony pelvis stability • Clinically – sacrospinous and anterior longitudinal ligament • serve as suture fixation sites in suspensory procedures used to correct POP – iliopectineal ligament • also termed Cooper ligament • is a thickening in the pubic bone periosteum • often used to anchor sutures in retropubic bladder neck suspension procedures
  • 32. Pelvic Joints • Anteriorly - symphysis pubis • limited degree of mobility • During pregnancy, these joints relax remarkably at term – upward gliding of sacroiliac joint • greatest in the dorsal lithotomy position • may increase the diameter of the outlet by 1.5 to 2.0 cm for delivery – Sacroiliac joint mobility • aids McRoberts maneuver to release an obstructed shoulder in cases of shoulder dystocia – These changes may also contribute to the success of the modified squatting position to hasten SSOL • squatting position may ↑ interspinous diameter & pelvic outlet diameter 32
  • 33. Planes and Diameters of the Pelvis • Pelvis - divided into – False (lesser) pelvis: lies above the linea terminalis • bounded posteriorly by lumbar vertebra; laterally by iliac fossa; Anteriorly by the lower portion of the anterior abdominal wall – True: lies below the linea terminalis 33
  • 34. 34
  • 35. • pelvis is described as having four imaginary planes: – plane of pelvic inlet—the superior strait. • During labor, fetal head engagement is defined by the fetal head’s biparietal diameter passing through this plane • greatest distance = transverse diameter = 13 cm • clinically important: obstetrical conjugate – shortest distance between the sacral promontory and the symphysis pubis – ≥ 10 cm, but unfortunately, it cannot be measured directly – So OC = DC – (1.5 to 2 cm) – plane of the midpelvis—the least pelvic dimensions • measured at the level of the ischial spines • smallest pelvic diameter = Interspinous diameter = ≥ 10 cm – plane of pelvic outlet—the inferior strait • two approximately triangular areas • Subpubic angle = ≥ 90 to 100 degrees • Unless there is significant pelvic bony disease, the pelvic outlet seldom obstructs vaginal delivery – plane of greatest pelvic dimension—of no obstetrical significance 35
  • 36. 36 Station • +1/+3 (old classification), • +2/+5 (new classification)
  • 37. • Pelvimetry – performed with radiographic (CT/MRI) to determine average and critical limit values • Critical limit values are measurements 37 • In current obstetric practice – Radiographic CT and MRI pelvimetry are rarely used • lack of evidence of benefit • some data that show possible harm – Clinical pelvimetry • the only method of assessing the shape and dimensions of the bony pelvis in labor
  • 38. 38
  • 39. 39
  • 40. 40
  • 41. Pelvic Shapes • Caldwell–Moloy (1933, 1934) anatomical classification of the pelvis is based on shape – Gynecoid = found in 50% of females • classic female shape – Anthropoid • exaggerated oval shape of the inlet, largest AP diameter, and limited anterior capacity • more often associated with delivery in OP position – Android = male • increased risk of CPD – Platypelloid • theoretically predisposes to a transverse arrest 41
  • 42. 42
  • 43. 43
  • 44. Pelvic Wall Muscles and Fascia • Muscles – Piriformis • arises from anterior and lateral surface of sacrum and partially fills posterolateral pelvic walls • exits pelvis through the greater sciatic foramen • attaches to the greater trochanter of femur, • functions as an external or lateral hip rotator • Clinically: stretch injury may cause persistent hip pain that can be confused with other hip or pelvic pathology – Obturator internus • partially fills the sidewalls of the pelvis • arises from pelvic surfaces of ilium and ischium and from the obturator membrane • Exits pelvis through lesser sciatic foramen • attaches to the greater trochanter of femur • functions as an external hip rotator • Fascia – Parietal fascia: invests striated muscles – Pelvic parietal fascia • provides muscle attachment to the bony pelvis • serves as anchoring points or visceral fascia, also termed endopelvic fascia – Arcus tendineus levator ani • is a condensation of parietal fascia covering the medial surface of obturator internus muscle • serves as the point of origin or parts of very important levator ani muscle 44
  • 45. 45 • Muscles and fascia of the pelvic walls and pelvic floor innervation • Ischial spine is marked by an asterisk • L5 = fifth lumbar vertebra; PS = pubic symphysis; R= rectum; S1–S5 = first through fifth sacral nerves; U = urethra; V= vagina
  • 46. 46 Superior view of pelvic floor and pelvic wall muscles
  • 47. Pelvic Floor • Muscles that span the pelvic floor are collectively known as the pelvic diaphragm – This diaphragm consists of • levator ani – provide critical pelvic organ support – Physiologically, normal levator ani muscles maintain a constant state of contraction, thus providing a stable floor, – consists of: pubococcygeus, puborectalis, and iliococcygeus muscles » Pubococcygeus muscle is further divided into the pubovaginalis, puboperinealis, and puboanalis muscles according to their fiber attachments » Due to the significant attachments of the pubococcygeus muscle to the walls of the pelvic viscera, the term pubovisceral muscle is frequently used • coccygeus muscles, • along with their superior and inferior investing fascial layers – Inferior to the pelvic diaphragm, the perineal membrane and perineal body also contribute to the pelvic floor • Urogenital hiatus is the U-shaped opening in the pelvic floor muscles through which urethra, vagina, and rectum pass 47
  • 48. 48 Inferior view of pelvic floor Muscle fibers of Iliococcygeus Muscle from one side join those from the opposite side in the midline between the anus and the coccyx. This meeting line is termed the iliococcygeal or anococcygeal raphe
  • 49. • Levator plate in women with normal support has a mean angle of 44 degrees relative to a horizontal reference line during Valsalva – During Valsalva, women with prolapse have a statistically greater levator plate angle compared with controls – This larger angle moderately correlates with larger levator hiatus length and greater displacement of the perineal body in women with prolapse compared with controls • With this in mind, one theory suggests that – levator plate support prevents excessive tension or stretching of the connective tissue pelvic ligaments and fasciae – Neuromuscular injury to the levator muscles may lead to eventual sagging or vertical inclination of the levator plate and opening of the urogenital hiatus – Consequently, the vaginal axis becomes more vertical, and the cervix is oriented over the opened hiatus – The mechanical effect of this change is to increase strain on connective tissues that support the pelvic viscera – Increased urogenital hiatus size has been shown to correlate with increased prolapse severity 49
  • 50. • Pelvic diaphragm muscles – primarily innervated by direct somatic efferents from sacral nerve roots (S2-5) • Traditionally, a dual innervation has been described – Efferents from S2-5 • Supply Pelvic or superior surface of the muscles – Pudendal nerve branches • Supply perineal or inferior surface • investigators suggest that the pudendal nerve does not contribute to levator muscle innervation • Pudendal branches do, however, innervate parts of the striated urethral sphincter and external anal sphincter muscles • Such separate innervation may explain why some women develop pelvic organ prolapse and others develop urinary or fecal incontinence 50
  • 51. • Parietal fascia – invests most striated muscles • Visceral or endopelvic fascia – intimately associated with the walls of the viscera and cannot be dissected in the same way that parietal fascia can be separated from its skeletal muscle – Condensations ➔ • cardinal and uterosacral ligaments • vesicovaginal and rectovaginal fascia 51
  • 52. Pelvic Blood Supply • Novak 16th – There is significant variation in the branching pattern of pelvic blood vessels between individuals • patterns of blood flow may be asymmetric from side to side in the same individual – The pelvic surgeon should be prepared for deviations from “textbook” vascular patterns 52
  • 53. • Pelvic organs are supplied by visceral branches of the internal iliac (hypogastric) artery and by direct branches from abdominal aorta • Internal iliac artery has two divisions o Separated in the area of the greater sciatic foramen – Anterior division • Three parietal branches • Visceral branches – Posterior division • Three parietal branches • Internal iliac branches that supply the inferior and middle portions of the bladder are present in women, but their origin is highly variable • The middle rectal arteries are generally very small-caliber vessels but may be absent • They usually contribute to posterior vaginal wall blood supply 53
  • 54. 54 Each division has three parietal branches
  • 56. 56
  • 58. 58
  • 59. 59
  • 60. • two most important direct branches of aorta – Superior rectal arteries • terminal branch of inferior mesenteric artery • anastomoses with the middle rectal arteries, thus contributing blood supply to the rectum and vagina – Ovarian arteries • arise directly from aorta just inferior to the renal vessels • anastomose with the ascending branch of the uterine artery • These anastomoses contribute to the blood supply of the uterus and adnexa 60
  • 61. • The femoral artery gives rise to all EXCEPT which of the following vessels? – A. Superficial circumflex iliac artery – B. External pudendal artery C. Inferior epigastric artery D. Superficial epigastric artery • The internal pudendal artery supplies which of the following? – A. Proximal vagina B. Posterior vaginal wall C. Distal vaginal wall D. Bladder trigone • The vagina and its investing musculature are supplied by all EXCEPT which of the following arteries? – A. Inferior rectal artery B. Perineal artery C. Pudendal artery D. Posterior labial artery • The right ovarian vein empties into which of the following veins? – A. Vena cava B. Renal vein C. Internal iliac vein D. External iliac vein • Ovarian vessels are found in which of the following ligaments? – A. Broad B. Round C. Uterosacral D. Infundibulopelvic • The internal pudendal artery arises from which of the following vessels? – Internal iliac artery 61
  • 62. 62
  • 63. 63
  • 64. 64
  • 65. Pelvic Innervation 65 • Pelvis is innervated by both • both sympathetic (adrenergic) and parasympathetic (cholinergic) fibers • provide the primary innervation for genital, urinary, and gastrointestinal visceral structures and blood vessels • Component: Efferent and afferent (sensory) component • Efferent fibers of the autonomic nervous system 1. Sympathetic (thoracolumbar) division » prepares the body for physical activity and can be thought of as the “fight or flight” reaction 2. Parasympathetic (craniosacral) division » has a calming effect on body functions and can be thought of as the “resting and digesting” state – The two systems innervate the same target organs but have opposing effects on them to maintain homeostasis
  • 66. • lumbosacral plexus and its branches provide motor and sensory somatic innervation to the lower abdominal wall, the pelvic and urogenital diaphragms, perineum, and the hips and lower extremities • pelvic splanchnic nerve • obturator nerve • pudendal nerve • ilioinguinal nerve • genitofemoral nerve 66
  • 67. • Nerve supply to the visceral structures in the pelvis (bladder, urethra, vagina, uterus, adnexa, and rectum) arises from the autonomic nervous system • The two most important components of autonomic nervous system in the pelvis include – Superior hypogastric plexus • also known as the presacral nerve • is an extension of the aortic plexus found below the aortic bifurcation • This plexus primarily contains sympathetic fibers and sensory afferent fibers from the uterus • terminates by dividing into the hypogastric nerves. These nerves join parasympathetic efferents from S2-4 nerve roots (pelvic splanchnic nerves) to form the inferior hypogastric plexus – Inferior hypogastric plexuses • also known as the pelvic plexus • generally receives contributions from the sacral sympathetic trunk • fibers of this plexus accompany branches of the internal iliac artery to the pelvic viscera. Accordingly, they are divided into three portions: Vesical, uterovaginal (Frankenhäuser ganglion), and middle rectal plexuses • Its Extension reach the perineum along the vagina and urethra to innervate the clitoris and vestibular bulbs 67
  • 68. • The course of general visceral afferent (GVA) fibers from organs in the pelvis, in general, depends on the organ's position relative to the pelvic pain line – An organ, or part of an organ, in the pelvis is said to be "above the pelvic pain line" if it is in contact with the peritoneum, except in the case of the large intestine, where the pelvic pain line is said to be located in the middle of the sigmoid colon • GVA fibers from structures above the pain line follow the course of the sympathetic efferent fibers, and • GVA fibers from structures below the pain line follow the course of the parasympathetic efferents – Pain from the latter fibers is less likely to be consciously experienced 68
  • 69. 69 Pelvic autonomic nerves • Superior and inferior hypogastric plexuses • S1–S4 = first through fourth sacral nerves
  • 70. Innervation of female internal genital organs 70 ❑ uterus is innervated by fibers of the uterovaginal plexus, also known as Frankenhäuser ganglion ❑ These fibers travel along the uterine arteries and are found in the connective tissue of the cardinal ligaments
  • 71. • Pelvic splanchnic nerves, – arising from the S2–S4 anterior rami, – supply parasympathetic motor fibers to the uterus and vagina (and vasodilator fibers to the erectile tissue of the clitoris and bulb of the vestibule; not shown) • Presynaptic sympathetic fibers traverse the sympathetic trunk and pass through the lumbar splanchnic nerves to synapse in prevertebral ganglia with postsynaptic fibers; the latter fibers travel through the superior and inferior hypogastric plexuses to reach the pelvic viscera • Visceral afferent fibers conducting pain from intraperitoneal structures (such as the uterine body) travel with the sympathetic fibers to the T12–L2 spinal ganglia • Visceral afferent fibers conducting pain from subperitoneal structures, such as the cervix and vagina (i.e., the birth canal), travel with parasympathetic fibers to the S2–S4 spinal ganglia • Somatic sensation from the opening of the vagina also passes to the S2–S4 spinal ganglia via the pudendal nerve • In addition, muscular contractions of the uterus are hormonally induced 71
  • 72. Nerve supply of ovaries and female internal genital organs In addition to autonomic (visceral motor) fibers, these nerves convey visceral afferent fibers from these organs. The inferior part of the vagina is not depicted because it receives somatic innervation 72
  • 73. • Clinically – presacral neurectomy, a surgical procedure performed to treat central pelvic pain • sensory afferent fibers contained within the superior hypogastric plexus – Complete interruption of superior hypogastric plexus • visceral and sexual dysfunction – Injury to the branches of the inferior hypogastric plexus during cancer debulking or other extensive pelvic surgeries • varying degrees of voiding, sexual, and defecatory dysfunction 73
  • 74. Pelvic Viscera Uterus Cervix Ovaries and Fallopian Tubes External Generative Organs Lower Urinary Tract Structures 74
  • 75. Uterus • is a fibromuscular hollow organ • Anatomically divided into two – Body of uterus • Forms the upper 2/3rd of uterus • Includes – Fundus: the part above the insertion of the tube – Body: lies between the two layers of the broad ligament; freely movable – Isthmus: relatively constricted segment, 1cm long; found between the cervix and the uterus • Isthmus – The transition between the corpus and the cervix is known as the uterine isthmus » This also marks the transition from endocervical canal to endometrial cavity – portion of uterus between internal cervical os and endometrial cavity – It is of special obstetrical significance because it forms the lower uterine segment during pregnancy – Cervix • Cylindrical, relatively narrow lower 1/3rd part • Has – Supra vaginal part: separated from the bladder by loose connective tissue and from the rectum by the recto uterine pouch. – Vaginal part: 75
  • 76. • adult uterus is usually ➔ anteverted & anteflexed – anteverted (tipped anterosuperiorly relative to the axis of the vagina) – anteflexed (bent anteriorly relative to the cervix) so that its mass lies over the bladder • when bladder is empty, uterus typically lies in a nearly transverse plane • Adult, nonpregnant uterus – Approximately 7.5 cm long, 5 cm wide, and 2 cm thick • 6 to 8 cm in adult nulliparous & 9 to 10 cm in multiparous women • Endometrial thickness = 0.5mm – Weighs: 50 to 70 g (in parous women it averages 80 g or more 76
  • 77. • Shape, weight, and dimensions - vary according to parity and estrogen stimulation – Before menarche & after menopause: corpus = cervix in size – During reproductive years: uterine corpus >> cervix – In nulliparous women: fundus = cervix in length • in multiparous women, cervix ~ 1/3rd third of its length 77
  • 78. • Pregnancy-Induced Uterine Changes – weight increases from 70 g to approximately 1100 g at term – total volume averages about 5 L – The uterine fundus, a previously flattened convexity between tubal insertions, now becomes dome shaped – The round ligaments now appear to insert at the junction of the middle and upper thirds of the organ. The fallopian tubes elongate, but the ovaries grossly appear unchanged. 78
  • 79. 79
  • 80. 80
  • 81. 81
  • 82. • Ureter is found slightly superior to lateral part of vaginal fornix; below uterine artery, 2 cm lateral from supravaginal part of cervix 82
  • 83. 83
  • 84. 84
  • 85. Neurovascular structures of uterus • Artery: – mainly uterine artery; some collateral from ovarian artery • Vein – Utero vaginal venous plexus to Uterine vein to internal iliac vein • Uterine Lymphatic Drainage of uterus – primarily to the obturator and internal and external iliac nodes – However, some lymphatic channels from the uterine corpus may pass along the round ligaments to the supericial inguinal nodes, and others may extend along the uterosacral ligaments to the lateral sacral nodes – From fundus and superior body: along ovarian vessels and through suspensory ligament – lumbar LNs – Some from fundus, from uterotubal junction and insertion of round ligament,-- along round ligament - to superficial inguinal LNs – From most of the body and cervix – along broad ligament- external iliac LNs – From cervix • Along cardinal ligament – internal iliac LNs • Along uterosacral ligament – sacral LNs 85
  • 86. 86
  • 87. 87
  • 88. 88 o Uterine artery approaches the uterus in the area of the uterine isthmus o Clinically, because the uterus receives dual blood supply from both ovarian and uterine vessels, some surgeons during myomectomy place tourniquets at both the infundibulopelvic ligament and uterine isthmus o This decreases blood flow from ovarian and uterine arteries, respectively
  • 89. 89
  • 90. 90
  • 91. 91
  • 92. Layers of Uterine Wall • The wall of the uterus is very thick and consists of 3 layers: – Serous layer : perimetrium • is simply the peritoneal covering • Peritoneum + thin layer of connective tissue • Peritoneal serosa overlies the uterus, except at two sites. –First, the anterior portion o the cervix is covered by the bladder –Second, the lateral portions o the corpus and cervix attach to the broad and cardinal ligaments 92
  • 93. – Muscular layer : myometrium • is extremely thick and continuous with that of the tubes and vagina • also extends into the ovarian and round ligaments, into the cardinal ligaments at the cervix, and minimally into the uterosacral ligaments • Two principal layers of the muscular coat can be distinguished: – (1) Outer layer: weaker and composed of longitudinal fibers – (2) Inner layer: stronger and composed of fibers running in various directions – Mucous layer: endometrium • Endometrium can be classified into • Basalis layer – Found near the myometrium – Contains the blind end of the glands and CT – Mostly unchanged during menses – Supplied by straight aa branches of arcuate aa(found in the myometrium) • Functionalis layer – Found above the basalis layer – Contains the gland and the rest of the CT – Profoundly changed during menses – Supplied by spiral aa branches of arcuat aa • spiral arterioles located in the endometrium undergo hormonally mediated constriction or spasm that promotes shedding of the superficial portion of the endometrium with each menstrual cycle • The amount of smooth muscle decreases and the amount of collagen increases as we go down from the body of the uterus to the cervix 93
  • 94. • During pregnancy, myometrium undergoes growth due to – Hyperplasia – Hypertrophy and – Collagen synthesis by the smooth muscles • After pregnancy, myometrium decreases in size due to – Destruction of smooth muscle cells – Reduction in the size of the remaining cells – Enzymatic degradation of the collagen • Makes it a unique organ with ability to increase and decrease its size several times during the life time 94
  • 95. Histological changes during menses • Menstrual cycle – Starts at age of 13 – 15 and ends at age of 45 – 50 – Lasts for 28 days and flows for 3 – 4 days – 1st day of bleeding = 1st day of menstrual cycle – Classified into • Proliferative and • Secretory phases • Proliferative phase – Estrogen mediated – Covered by simple columnar epithelium – Straight tubes with narrow lumen are formed – Cells prepare for the next phase • Accumulate more cisternae of ER and GA – 0.5 mm → 2 – 3mm • Secretory Phase – Progesterone mediated – Cells accumulate glycogen – Lumen expands • Due to accumulation of glycoprotein secreting products – Glands become highly twisted – 2-3mm → 5mm • Menses Vs Fertilization 95
  • 97. 97 Connective tissue and surgical spaces of the pelvis
  • 98. 98
  • 99. • Ligaments supporting the uterus consist of – Uterosacral ligaments, – Transverse ligaments of the cervix • (cardinal ligaments, cardinal supports, ligamentum transversum colli, ligaments of Mackenrodt), – Round ligaments, and • Attaches the uterus(antero inferior to the uterotubal junction, passes through the deep inguinal ring, through the inguinal canal, continuous into labia majora where its fibers spread and mix with mons pubis) – Ovarian ligament • Attaches the ovary and the uterus (postero inferior to utero tubal junction) – broad ligaments • Note: Round ligament and ovarian ligaments are remnants of ovarian gubernaculum – (used to attach the ovary to the labio sacral swelling in the embryo) • Uterine support – Active support : pelvic diaphragm – Passive support: its anteverted, anteflexed position • because of its attachment to the above ligaments (condensations of the endopelvic fascia), cervix is the least mobile part of uterus 99
  • 100. • Mackenrodt ligament • is the chief means of support and suspends the uterus from the lateral walls of the pelvis minor • are composed of longitudinal smooth muscle fibers originating – superiorly from the uterus and – inferiorly from the vagina, fanning out toward the fascia visceralis to form, with the internal os of the cervix, the primary support of the uterus • attach to the posterolateral pelvic walls near the origin of the internal iliac artery and surround the vessels supplying the uterus and vagina 100
  • 101. 101 o Pelvic viscera and their connective tissue support o Relationship of the urethra, bladder trigone, and distal ureter to the anterior vaginal wall and to the uterine cervix o Parametrium consists of what is clinically known as the cardinal ligament and uterosacral ligament
  • 102. • are, in fact, the inferior posterior folds of peritoneum from the broad ligament • consist primarily of smooth muscle and contain some pelvic autonomic nerves • consist primarily of nerve bundles from the inferior hypogastric plexus and contain preganglionic and postganglionic fibers and C fibers of the sympathetic lumbar segments, parasympathetic in part from sacral components and in part from sensory or C fibers of the spinal segments • extends from an attachment posterolaterally to the supravaginal portion of the cervix and inserts into the fascia over the sacrum • covered by peritoneum and form the lateral boundaries of the pouch of Douglas • uterosacral ligaments – attachment sites for vaginal apex (reconstructive surgeries) 102
  • 103. • are smooth muscle extensions of the uterine corpus • no real support – But, may assist in maintaining the body of the uterus in its typical position over the bladder • extend laterally to the pelvic sidewall ➔ enter the retroperitoneal space and pass lateral to the inferior epigastric vessels before entering the inguinal canal through the internal inguinal ring • traverses and the inguinal canal, to terminate in a fanlike manner in the labia majora and become continuous with connective tissue • The round ligament is the gubernaculum (ligamentum teres uteri), vestigial in the female – corresponds embryologically to the gubernaculum testis of men • It is accompanied by a funicular branch of the ovarian artery • Through the inguinal canal, it is accompanied by the ilioinguinal nerve and the external spermatic branch of the genitofemoral nerve • In nonpregnant women, it varies from 3 to 5 mm in diameter and is composed of smooth muscle • During pregnancy, the round ligaments undergo considerable hypertrophy and increase appreciably in both length and diameter • blood supply from a small branch of the uterine or ovarian artery known as Sampson artery 103
  • 104. • Clinically importance of round ligament – Location anterior to the fallopian tube • can assist a surgeon during tubal sterilization through a minilaparotomy incision • especially true if pelvic adhesions limit tubal mobility and thus hinder identication of fimbria prior to tubal ligation – Division of round ligament • An initial step in abdominal and laparoscopic hysterectomy • Its transection opens the broad ligament leaves and provides access to the pelvic sidewall retroperitoneum • This access allows direct visualization of the ureter and permits isolation of the uterine artery for safe ligation 104
  • 105. • a transverse fold of peritoneum that arises from the floor of the pelvis between the rectum and the bladder, provides minimal support – double layers of peritoneum that extend from the lateral walls of the uterus to the pelvic walls • Broad ligament can be divided into regions as follows: Peritoneum that overlies – fallopian tube is termed mesosalpinx, – around round ligament is mesoteres, and – over uterovarian ligament is mesovarium – Uterus: mesometrium • Peritoneum that extends beneath the fimbriated end of the fallopian tube to the pelvic wall forms the infundibulopelvic ligament or suspensory ligament of the ovary, through which the ovarian vessels traverse – During pregnancy, these vessels, especially the venous plexuses, are dramatically hypertrophied 105
  • 106. • The artery that runs through this structure (arrow) directly arises from which of the following? 106 A. Sampson artery B. Internal iliac artery C. Uterine artery D. Obturator artery • In the nonpregnant woman, the uterus is an almost solid structure weighing approximately which of the following? • A. 40 g B. 70 g • C. 100 g D. 130 g • Uterine blood flow near term is which of the following? • A. 50–100 mL/min • B. 100–300 mL/min • C. 450 to 600 mL/min • D. 1,000–1,400 mL/min
  • 107. • Fetoplacental blood volume at term is which of the following? – A. 125 mL/kg B. 100 mL/kg – C. 75 mL/kg D. 50 mL/kg • Which of the following is true regarding the uterus? – A. It measures 8 to 9 cm in length in nulliparous women. – B. It weighs 50 to 70 g in the parous woman. – C. In the nullipara, the fundus and the cervix are of equal length – D. The cervix is composed mainly of muscle. • Concerning the endometrium, which of the following is true? – A. The basal artery comes directly from the arcuate artery. – B. Spiral arteries extend directly from radial arteries. – C. The functionalis layer contains spiral arteries and radial arteries. – D. The spiral arteries extend directly from the arcuate artery. 107
  • 108. • The uterine artery is a main branch of which of the following vessels? – Internal iliac artery • The ovarian artery is a direct branch of which of the following vessels? – Aorta • The cervix contains little of which of the follow components? – A. Smooth muscle B. Collagen – C. Proteoglycans D. Elastin • From proximal (uterus) to distal (fimbria), the correct progression of fallopian tube anatomy is which of the following? – Isthmus, ampulla, infundibulum • Which of the following is the endometrial layer that is shed with every menstrual cycle? Functionalis layer 108
  • 109. • In the following figure, the spiral arteries are identified by which letter? – A. A: Spiral – B. B: Basal – C. C: Radial – D. D: Arcuate • Regarding the orientation of spiral blood vessels in relationship to the uterus, which of the following is true? – Arteries are perpendicular, and veins are parallel to the uterine wall 109
  • 110. • Compared with the uterine body, the cervix has a significantly lower percentage of which of the following? – A. Collagen – B. Proteoglycans – C. Smooth muscle – D. Glycosaminoglycans • In the image below, cervical eversion is demonstrated. What kind of epithelium makes up this portion of the cervix? – A. Columnar – B. Squamous – C. Serous – D. Brush border cells 110
  • 111. Cervix • the lower third of the uterus • wall of the cervix consists primarily of fibrous tissue and a smaller amount of smooth muscle – smooth muscle is found on the cervical wall periphery and serves as the attachment point or the cardinal and uterosacral ligaments and or the fibromuscular walls o the vagina • In a non-pregnant woman of fertile age, it measures approximately – 3 cm in length and 2.5 cm in diameter • Two parts – Upper two thirds of the cervix (endocervix) • lies above the vagina and is not visible – Lower part of the cervix (ectocervix) • lies within the vagina • visible with a speculum 111
  • 112. • internal and external os • Ectocervix/ cervix exterior – lined predominantly by nonkeratinized stratified squamous epithelium • Endocervical canal – a single layer of mucin-secreting columnar epithelium, which creates deep cleftlike infoldings or “glands.” – Mucus produced by the endocervical epithelia changes during pregnancy – It becomes thick and forms a mucus plug within the endocervical canal – Commonly during pregnancy, the endocervical epithelia moves out and onto the ectocervix during enlargement of the cervix in a process termed eversion • With time, this everted columnar epithelium, under the influence of vaginal acidity or during reparative healing, may be replaced by squamous epithelium in a process termed squamous metaplasia • This replacement with squamous epithelium may block endocervical clefts. If so, accumulated mucus from the underlying clefts forms nabothian cysts, which are benign, firm, smooth, rounded, opaque-yellow or ground glass gray elevations on the ectocervix 112
  • 113. • attachments of the vaginal walls to the outer cervix divide it into – a vaginal part known as the portio vaginalis and – a supravaginal part known as the portio supravaginalis • This part is covered by nonkeratinizing squamous epithelium • The endocervical canal is lined by columnar, mucus-secreting epithelium • The lower border of the canal, called the external cervical os, contains a transition from the squamous epithelium of the portio vaginalis to the columnar epithelium of the cervical canal • The exact location of this transition, termed the squamocolumnar junction, varies depending on hormonal status • At the upper border of the endocervical canal is the internal cervical os, where the narrow cervical canal becomes continuous with the wider endometrial cavity 113
  • 114. For specimen acquisition it is important that cells are acquired from both the endocervical and ectocervical regions, that is, both above and below the region known as the transformation zone Differences in cervical os apperance due to labor and delivery A. Nulliparous cervix: regular, oval opening B. Parous cervix: transverse slit with anterior and posterior lips 114
  • 115. 115
  • 116. • The cervical stroma is composed • mainly of – collagen, – elastin, and – proteoglycans, • but very little smooth muscle. – Changes in the amount, composition, and orientation of these components lead to cervical ripening prior to labor onset • In early pregnancy, increased vascularity and edema within the cervix stroma leads to the blue tint and softening characteristics of Chadwick and Hegar signs, respectively 116
  • 117. Ovaries and Fallopian Tubes • ovaries and fallopian tubes constitute the uterine adnexa 117
  • 118. • Ovaries are paired organs situated close to the wall on either side of the pelvis minor, a little below the brim • Each measures • 2.5–5 cm in length, • 1.5–3 cm in breadth, and 0.7–1.5 cm in width, – weighing about 4–8 g • The ovary has 2 surfaces, medial and lateral; 2 borders, anterior or mesovarian and posterior or free; and 2 poles, upper or tubal and lower or uterine. • When the uterus and adnexa are in the normal position, the long axis of the ovary is nearly vertical, but it bends somewhat medially and forward at the lower end so that the lower pole tends to point toward the uterus • The medial surface is rounded and, posteriorly, may have numerous scars or elevations that mark the position of developing follicles and sites of ruptured ones • ovary is suspended by means of the mesovarium, the suspensory ligament of the ovary, and the ovarian 118
  • 119. Ovarian: outer cortex and inner medully • ovarian cortex – lined single layer of germinal epithelium of waldayer (cuboidal epithelium) – tunica albuginea: stromal cells thickened beneath germinal epithelium – Contains: primordial follicles, corpus albicans /atretic follicles/ • Medulla – loose connection tissues, blood vessels, nerves, muscles. – Hilus cells- homologous to interstitial cells of testes 119
  • 120. 120 ▪ Uteroovarian ligament ▪ Infundibulopelvic ligament(suspensory ligament of the ovary) Functions of ovaries • Reproductive : produce oocyte(female gamates) • endocrine: produce estrogen, progesterone and other hormones
  • 121. 121
  • 122. Pre pubertal vs post pubertal ovary • Pre pubertal – surface of the ovary comprised of connective tissue capsule which is covered by smooth layer of mesothelium – ovarian surface or germinal epithelium: a single layer of cuboidal cells so that it gives the surface of ovary dull and grayish appearance as it contrasts with shinny adjacent peritoneal mesovarium. • Post pubertal: – repeated ovarian rupture and oocyte release during ovulation resulted progressive scarring and surface epithelium become distorted . – ovulation inhibiting contraceptives decrease this scarring. . 122
  • 123. 123
  • 124. 124
  • 125. Innervation of Ovaries and Uterine Tubes • nerve supply derives partly from the ovarian plexus, descending with the ovarian vessels, and partly from the uterine (pelvic) plexus • The ovaries and uterine tubes are intra peritoneal and, therefore, are superior to the pelvic pain line • Thus, visceral afferent pain fibers ascend retrogradely with the descending sympathetic fibers of the ovarian plexus and lumbar splanchnic nerves to cell bodies in the T11–L1 spinal sensory ganglia • Visceral afferent reflex fibers follow parasympathetic fibers retrogradely through the uterine (pelvic) and inferior hypogastric plexuses and the pelvic splanchnic nerves to cell bodies in the S2–S4 spinal sensory ganglia. 125
  • 126. Clinical correlates • Tubal patency • Salpingitis and TOA • Ectopic pregnancy • Infertility • Salpingo ophorectomy and due care given to the ureter as it courses just medial to suspensory ligament 126
  • 127. Fallopian Tubes • Uterine (Fallopian) Tubes (Oviducts) • serve to convey the ova to the uterus • Each tube is 7–14 cm long • uterine appendages located bilaterally at superior portion of the uterine cavity • exit the uterus through an area referred to as cornua forming connection between endomerial and peritonial cavities. • approximately 10cm long and 1cm wide found situated within meso salpinx 127
  • 128. • Divided into 4 parts: – Isthmus • the narrow and nearly straight portion • has a rather long intramural course, and its opening into the uterus, the uterine ostium, is approximately 1 mm in diameter – Ampulla • wider, more tortuous ampulla → widest and largest part at medial end of infundibulum • where fertilization usually occurs • has multiple longitudinal mucosal folds called plicae [responsible for reason why gonorheal salpingitis and TOA is common – Infundibulum • margins are fringed by numerous diverging processes, the fimbriae, the longest of which, the fimbria ovarica, is attached to the ovary • Mouth = abdominal ostium, is about 3 mm in diameter and actually leads into the peritoneal cavity, although it probably is closely applied to the surface of the ovary during ovulation • is suspended from the pelvic brim by the infundibulopelvic ligament (suspensory ligament of the ovary) – Uterine part: short intramural segment of the tube • Tubal mucosa is lined by columnar epithelium surrounding the lumen • This columnar cells have cilia 128
  • 129. 129 • The ovarian artery runs along the ovary’s hilum and sends several branches through the mesosalpinx to supply the fallopian tubes • The venous plexus, lymphatic drainage, and nerve supply of the fallopian tubes follow a similar course to that of the ovaries
  • 130. • wall of the tube has 4 coats: serous (peritoneal), subserous or adventitial (fibrous and vascular), muscular, and mucous • Three layers of musculature- – Inner longitudinal layer – Middle circular layer • thickest at isthmus and thinnest at infundibulum • it , therefore isthmus is called sphincter of the tube b/c it is in this part of the tube that spasm may occur and close the lumen. – Outer longitudinal layer • Functions of the tubes – Transport of Gametes –pick the ovum up and transport it and of sperm as well. – Final maturation of Gametes –post ovulate oocyte maturation and sperm capacitation . – Provides fluid environment for early embryonic development. – Transport of fertilized and un fertilized ovum to the uterus . 130
  • 131. External Generative Organs • Vulva • Vagina • Perineum – Pelvic floor ❑Urogenital Triangle o Pelvic diaphragm o Perineal Membrane o Deep perineal pouch o Superficial Perineal Pouch o Fasciae of UG Triangle ❑Anal Triangle o Perineal body o Ischioanal fossa o Anal sphincter 131
  • 132. • Homologous – Labia majora → male scrotum • Vestibule – is derived from embryonic urogenital membranes. • Femoral artery → external pudendal artery – supplies skin and subcutaneous tissue of mons pubis • Internal iliac artery → internal pudendal artery – Exits pelvis through the greater sciatic foramen, passes behind the ischial spines, and reenters the perineum through the lesser sciatic foramen – It then has a variable course through the pudendal or Alcock canal, and then divides into terminal branches (inferior rectal, perineal, and clitoral arteries) – Branches to the perineum sometimes arise from the pudendal artery before it exits the pelvis. T ese vessels are called accessory pudendal arteries. Other accessory vessels may also arise directly from the anterior or posterior division of the internal iliac artery 132
  • 133. Veins that drain vulva and perineum • have courses and names similar to those of the arteries – vestibular bulbs and other structures, with the exception of the erectile tissue of the clitoris, drains into the internal pudendal veins – Th e erectile tissue drains into the dorsal vein of the clitoris → periurethral–perivesical venous plexus – rectum and anal canal empties into the superior, middle, and inferior rectal veins • superior rectal vein drains into the inferior mesenteric vein, a tributary o the portal vein • middle rectal vein drains into the internal iliac vein • inferior rectal vein drains into the internal pudendal and then the internal iliac vein 133
  • 134. Lymphatic Drainage of vulva and perineum • drain into the inguinal lymph nodes, which are located below the inguinal ligament in the upper anterior and medial thigh • There are 10 to 20 inguinal nodes, which are divided into a superficial and a deep group • Nodes of the superficial inguinal group – are more numerous, and they are found in the membranous layer of the subcutaneous tissue of the anterior thigh, just superficial to the fascia lata – Drains skin of the labia, clitoris, and remainder of the perineum • Deep inguinal nodes – located deep to the fascia lata in the femoral triangle – From lateral to medial: Femoral nerve, artery, vein, and deep inguinal lymphatics • The femoral canal is the space that lies on the medial side of the femoral vein and that contains the deep inguinal nodes • The femoral ring is the abdominal opening of the femoral canal. The fossa ovalis or saphenous opening is an oval opening in the fascia lata and allows communication between superficial and deep inguinal nodes – Of the deep inguinal nodes, the highest one—Cloquet or Rosenmüller node—is located in the lateral part of the femoral ring – Drains glans and corpora cavernosa of the clitoris • Efferent channels from the deep inguinal nodes pass through the femoral canal and femoral ring to the external iliac nodes • Clinical - radical vulvectomy ?? 134
  • 135. Innervation of vulva and perineum • pudendal nerve – is a branch of sacral plexus and is formed by anterior rami of S2-4 – Branches: Inferior anal, perineal, and dorsal nerve of the clitoris – provide sensory and motor innervation to the perineum – course and distribution similar to internal pudendal artery Clinical can be performed transvaginally or transgluteally • injecting local anesthesia just medial and inferior to the ischial spine in the distribution of the dorsal nerve of the clitoris has been reported following midurethral sling procedures • requires parasympathetic visceral efferents derived from the pelvic plexus nerves, sometimes called nervi erigentes – These arise from S2-4 sacral spinal cord segments – They reach the perineum along the urethra and vagina, passing through the urogenital hiatus • Sympathetic fibers reach the perineum with the pudendal nerve 135
  • 136. • The inferior gluteal artery, with extensive collateral circulation, is found between the sacrospinous and sacrotuberous ligaments and may be injured during sacrospinous suspension – Injury to the inferior gluteal artery, and to the pudendal nerve and internal pudendal vessels, during sacrospinous ligament suspension may be minimized by careful and controlled retraction and suture placement, at least two fingerbreadths medial to the ischial spine 136
  • 137. 137
  • 138. 138
  • 139. Vulva Pudenda = vulva – includes • All structures visible externally from the symphysis pubis to the perineal body • Mons pubis, labia majora and minora, clitoris, hymen, vestibule, urethral opening, greater vestibular or Bartholin glands, minor vestibular glands, and paraurethral glands Mons Pubis: fat-filled cushion overlying the symphysis pubis – also called mons veneris Labia – Majora: usually are 7 to 8 cm long, 2 to 3 cm wide, and 1 to 1.5 cm thick – Minora: lengths from 2 to 10 cm and widths from 1 to 5 cm • Hart line: A line demarcating the keratinized stratified squamous epithelium on the outer surface of each labium from the medial nonkeratinized squamous epithelium • labia minora lack hair follicles, eccrine glands, and apocrine glands. However, sebaceous glands are numerous 139
  • 140. 140 Embryonic Urogenital Structures and Their Adult Homologues
  • 141. Labia Majora • prominent folds of skin that indirectly protect (clitoris + urethral + vagina) • round ligament and obliterated processus vaginalis, which is also termed the canal of Nuck, exit the inguinal canal and attach to the adipose tissue or skin of the labia majora • Anterior & posterior commissure • Clinical – a mass found in one labium majus may be a leiomyoma arising from the distal round ligament, a persistent processus vaginalis, or breast tissue along the distal milk line – An indirect inguinal hernia may also reach the labium majus by passing through the deep inguinal ring and inguinal canal 141
  • 142. Labia Minora • Rounded folds of fat-free, hairless skin • Medial laminae of each side unite ➔ frenulum of clitoris • Lateral laminae unite ➔ prepuce (foreskin) of clitoris • In young women, especially virgins – labia minora are connected posteriorly by a small transverse fold, the frenulum of the labia minora (fourchette) • In contrast to the skin that overlies the labia majora, skin of labia minora does not contain hair. Also, the subcutaneous tissue is devoid of at and consists primarily of loose connective tissue – This latter attribute allows mobility of the skin during sex and accounts for the ease of dissection with vulvectomy • Clinically – If winglike structures are pendulous & results dyspareunia → labia can be surgically reduced 142
  • 143. 143 Vulvar structures and subcutaneous layer of anterior perineal triangle Note the continuity of Colles and Scarpa fasciae Inset: Vestibule boundaries and openings onto vestibule
  • 144. 144
  • 145. Clinical • The subcutaneous layer consists of a superficial fatty layer similar to Camper fascia, and a deeper membranous layer, Colles fascia – Also known as the superficial perineal fascia, Colles fascia is similar to and continuous with Scarpa fascia of the anterior abdominal wall • Posteriorly – Colles fascia attaches firmly to the ischiopubic rami laterally and perineal membrane – These attachments prevent the spread of fluid, blood, or infection from superficial perineal space to the thighs or posterior perineal triangle • Anteriorly, – Colles fascia has no attachments to the pubic rami, and it is therefore continuous with the lower anterior abdominal wall – This continuity may allow the spread of fluid, blood, and infection between these compartments 145
  • 146. Clitoris – principal female erogenous organ – consists • root + corpus or body – Body • 2 crura + 2 corpora cavernosa + glans clitoris • glans is usually < 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated • body measures approximately 2 cm and is connected to the pubic ramus by crura – Clitoral blood supply  branches of internal pudendal artery • Specifically, the deep artery of the clitoris supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce. – L = ~ 2 cm & D <1 cm – Highly sensitive • Glans: most highly innervated part 146
  • 147. Vestibule – an almond-shaped area – the area between the two labia minora – is bounded laterally by the line of Hart and medially by hymeneal ring • Hart line represents the demarcation between the skin and mucous membrane on the inner surface of the labia minora – Perforated by six openings • 1-urethra, • 1-vagina, • 2-Bartholin gland ducts, and • 2-ducts of the largest paraurethral glands—the Skene glands – Clinical o Localized vulvar dysesthesia (vulvar Vestibulitis) is characterized by pain with vaginal penetration, localized point tenderness, and erythema of the vestibular mucosa o In other women, when choosing incision sites for Bartholin gland drainage or marsupialization, Hart line is clinically relevant • That is, in attempts to recreate near-normal gland duct anatomy following these procedures, incisions placed external to Hart line are avoided 147
  • 148. Bartholin glands • Also → greater vestibular glands • homologues of the male bulbourethral or Cowper glands • located in superficial perineal pouch • Secrete mucus into vestibule during sexual arousal – Ducts open onto vestibule @ four and eight o'clock positions • William: 5 & 7 o'clock positions • A normal Bartholin gland is not palpable (D ~ 0.5 cm ), except possibly in very thin women • Partly overlapped posteriorly by bulbs of vestibule – partially surrounded by bulbospongiosus mu • contain columnar cells that secrete clear or whitish mucus with lubricant properties – stimulated by sexual arousal – Contraction of bulbospongiosus muscle - expresses gland secretions • Clinical: obstruction of Bartholin ducts 148
  • 149. Vagina Musculomembranous tube Length – Anterior = 6 to 8 cm; Posterior = 7 to 10 cm Lined = nonkeratinized stratified squamous epithelium Premenopausal women → Rugae lacks glands – But lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium Due to increased vascularity during pregnancy, vaginal secretions are notably increased Blood supply  cervical branch of the uterine artery and vaginal artery.  Middle rectal artery  internal pudendal artery Lymphatics from – Upper 2/3rd → similar to that of the uterus • drain into the external, internal, and common iliac nodes – Lower 1/3rd → inguinal lymph nodes Vaginal innervation – from inferior extensions of uterovaginal plexus, a component of inferior hypogastric plexus 149
  • 150. • vagina is composed of three layers: – 1. Mucosa—nonkeratinized stratified squamous epithelium – 2. Muscularis— – 3. Adventitia—endopelvic fascia, adherent to the underlying muscularis. • These latter two form the fibromuscular component of the vagina • Rectovaginal fascia or fascia of Denonvilliers • Surgically, dissections in the anterior vaginal wall or in the posterior vaginal wall separate portions of the vaginal muscularis from the epithelium or surgeries such as anterior and posterior colporrhaphy • In contrast, posterior or anterior access to the coccygeus-sacrospinous ligament complex is accomplished by incising the full thickness of the anterior or posterior fibromuscular wall of the vagina, respectively • This deeper dissection allows access to the vesicovaginal or rectovaginal space and lateral dissection from these spaces allows access to the pararectal space • Because there is no true histologic “fascial” layer between the vagina and the bladder and between the vagina and the rectum, some recommend that terms such as “pubocervical/pubovesical fascia” or “rectovaginal fascia” be abandoned • They propose that these be replaced by more accurate descriptive terms such as vaginal muscularis or fibromuscular layer of the anterior and posterior vaginal walls 150
  • 151. • during abdominal hysterectomy or cesarean delivery – lift and incise the vesicouterine peritoneal fold to create a bladder flap and then open the vesicocervical space • For vaginal hysterectomy, the distance between the anterior vaginal fornix and the anterior cul-de-sac peritoneum spans several centimeters • Thus, to successfully enter the peritoneal cavity anteriorly, proper identification and sharp dissection of the loose connective tissue that lies within the vesicovaginal and then vesicocervical spaces is necessary 151
  • 152. • cul-de-sac • Clinically, the rectovaginal space contains loose areolar tissue and is easily opened with finger dissection during abdominal surgery • Perforation of the rectal pillar fibers allows access to the sacrospinous ligaments used in vaginal suspension procedures • Posterior cul-de-sac peritoneum extends down the posterior vaginal wall 2 to 3 cm inferior to the posterior vaginal fornix • Thus, during vaginal hysterectomy, in contrast to anterior peritoneal cavity entry, entering the peritoneal cavity posteriorly is readily done by incising the vaginal wall in the area of the posterior fornix 152
  • 153. • main support - provided by • levator ani muscles • connective tissue that attaches the lateral walls of the vagina to the pelvic walls – cardinal and uterosacral ligaments • DeLancey (1992) has described three levels of vaginal connective tissue support that help explain pelvic support dysfunction – Level I support (suspensory axis) • vertically oriented • consists of paracolpium that suspends the apical portion of the vagina and is comprised of the cardinal–uterosacral ligament complex • Defect: uterine prolapse or posthysterectomy vaginal vault prolapse – level II support or the attachment axis • Midvaginal support • comprises the paracolpium that is attached to the vagina laterally via the arcus tendineus fasciae pelvis and superior fascia of the levator ani • endopelvic fascia, arcus tendineus fascia pelvis • give vagina “H” shape when viewed in cross section • Defects → anterior and posterior vaginal wall prolapse and stress urinary incontinence – level III support or Fusion axis • consists of the distal vaginal attachments: anteriorly, via fusion of the urethra to the vagina; laterally, to the levators; and posteriorly, with the perineal body • strongest vaginal support components • Clinically, failure → distal rectoceles or perineal descent 153
  • 154. DeLancey levels of support • There are three levels of vaginal support as described by DeLancey • Disruption of – level I support → prolapse of uterus or vaginal vault – level II and III supports → anterior and posterior vaginal prolapse • All levels of defective support should be repaired during reconstructive surgery 154
  • 155. 155 Surgical cleavage planes and vaginal wall layers
  • 156. 156 Midsagittal view of pelvic structures and associated anatomy
  • 157. Hymen – a membrane of varying thickness that surrounds the vaginal opening 157
  • 158. Perineum • Perineum refers to diamond-shaped external surface area – bounded by the pelvic outlet – separated from pelvic cavity by pelvic diaphragm 158
  • 159. Perineum – Superficial Space of the Anterior Triangle Bulbs of Vestibule • Paired masses of elongated erectile tissue • ~ 3 cm in length • Covered by bulbospongiosus muscles • homologous with the bulb of penis – Deep Space of the Anterior Triangle – Pelvic Diaphragm – Posterior Triangle: Ischioanal Fossae; Anal Canal; Anal Sphincter Complex – Pudendal Nerve 159
  • 160. 160
  • 161. Pelvic floor • formed by – Muscles (pelvic diaphragm) and – Fascia • supported anteriorly by: 1. perineal membrane; and 2. muscles in the deep perineal pouch • An imaginary line between the ischial tuberosities divides the perineum into two triangular regions A. Anteriorly – Urogenital triangle – Roots of Ex/genitalia – Genital openings B. Posteriorly – anal triangle 161
  • 162. 162
  • 163. 163
  • 164. 164
  • 165. 165
  • 166. Pelvic diaphragm  Coccygeus + levator ani mu + covering fascia separate pelvic cavity from perineum roof of perineum – 2 defects – Ant ➔U-shaped defect ✓ Urogenital hiatus – Pos ➔ Circular anal aperture • In contrast to anal triangle – UG triangle contains strong fibromuscular support platform 1. Perineal membrane and 2. Deep perineal pouch Action of pelvic diaphragm • support pelvic viscera – forms a dynamic floor for supporting the abdominopelvic viscera • Descends when relaxed to allow defecation and urination • acting together, raise the pelvic floor, by active contraction after defecation restoring its normal position • resist the increased intra-abdominal pressure that would otherwise force the abdominopelvic contents through the pelvic outlet – This action occurs reflexively during forced expiration, coughing, sneezing, vomiting 166
  • 167. Defects of Pelvic diaphragm 167
  • 168. Perineal Membrane • a thick, triangular fascial sheet – between arms of pubic arch • fills anterior gap in the pelvic diaphragm (urogenital hiatus) • perforated by urethra (both sexes) and vagina • same as male, – Except: external urethral sphincter + Pierced by vagina and urethra • has a free posterior border • Function – The membrane and ischiopubic rami to which it attaches provide a foundation for • penis and scrotum of males, and • pudendum or vulva of females 168
  • 169. Deep perineal pouch • Space between perineal membrane and pelvic diaphragm • In contrast to the superficial space, which is a closed compartment, the deep space is continuous superiorly with the pelvic cavity • Boundaries – Inferiorly: perineal membrane – Superiorly: inferior fascia of pelvic diaphragm, – Laterally: inferior portion of obturator fascia • Ischio-anal fossae extend anteriorly into this space (anterior recesses ) • Contains: – Proximal part of urethra – External sphincter urethrae muscle – Deep transverse perineal muscles – Vessels and nerves: branches of internal pudendal artery, and dorsal nerve and vein of the clitoris 169
  • 170. Deep perineal space External urethral sphincter 170
  • 171. 171
  • 172. 172 Deep space of anterior perineal triangle
  • 173. Dorsal nerve and vessels of clitoris Anterior trunk of internal iliac artery → internal pudendal artery ▪ Is the main artery of the perineum. ▪ Leaves the pelvic cavity through the greater sciatic foramen and then enter to the perineum through the lesser sciatic foramen ▪ Terminal branches are the perineal artery and dorsal arteries of the penis or clitoris. 173
  • 174. 174
  • 175. 175
  • 176. • Muscles within the deep perineal pouch Muscle Origin Insertion Innervation Function External urethral sphincter From the inferior ramus of the pubis on each side and adjacent walls of the deep perineal pouch Surrounds membranous part of urethra Perineal branches of the pudendal nerve (S2 to S4) Compresses the membranous urethra. Relaxes during micturition Deep transverse perineal Medial aspect of ischial ramus Perineal body Perineal branches of the pudendal nerve (S2 to S4) Stabilizes the position of the perineal body Compressor urethrae (in women only) Ischiopubic ramus on each side Blends with partner on other side anterior to the urethra Perineal branches of the pudendal nerve (S2 to S4) Functions as an accessory sphincter of the urethra Sphincter urethrovaginalis Perineal body Passes forward lateral to the vagina to blend with partner on other side anterior to the urethra Perineal branches of the pudendal nerve (S2 to S4) Functions as an accessory sphincter of the urethra (also may facilitate closing the vagina) 176
  • 177. Superficial Perineal Pouch • lies between Colles fascia (membranous layer of superficial fascia) and perineal membrane • is a closed compartment (Unlike deep) • Boundaries – Superiorly: perineal membrane – Inferiorly: Superficial perineal (Colles’) fascia – Laterally: Ischiopubic rami • Contains: – Crura of clitoris and associated muscles – Bulbs of vestibule and associated muscles – Superficial transverse perineal muscles – Branches of internal pudendal vessels and pudendal nerves – Greater vestibular glands 177
  • 178. Structures of Superficial perineal space Arterial Supply • External pudendal arteries (branches of femoral artery) • Internal pudendal arteries 178
  • 179. 179
  • 180. 180
  • 181. 181
  • 182. • Ischiocavernosus Muscle – O: Ischial tuberosity and ramus – I: Crus of clitoris – Fn: Move blood from crura into the body of the erect clitoris • Bulbospongiosus Muscle – O: Perineal body – I: Bulb of vestibule, perineal membrane, body of clitoris and corpus cavernosum – Fn: Move blood from attached parts of the clitoris into the glans • Superficial transverse perineal Muscle – O: Ischial tuberosity and ramus – I: Perineal body – Fn: Stabilize the perineal body All muscles - Pudendal nerve (S2 to S4) 182
  • 183. Fasciae of UG Triangle • Fascias – Superior fascia of Urogenital diaphragm – Inferior fascia of Urogenital diaphragm • Deep perineal (Gallaudet’s) fascia – Superficial perineal (Colles’) fascia • Covering Superficial perineal space 183
  • 184. 184
  • 185. 185
  • 186. Anal Triangle • This triangle contains the – Ischioanal fossae, – Anal canal and – Anal sphincter complex, – Branches of the pudendal nerve and internal pudendal vessels • A splitting of the obturator internus fascia in this area is known as the pudendal or Alcock canal – This canal allows passage of the internal pudendal vessels and pudendal nerve before these structures split into terminal branches to supply the structures of the vulva and perineum 186
  • 187. 187 Pudendal nerve and vessels. Nerve supply to striated urogenital sphincter and external anal sphincter muscles
  • 188. • rectum is continuous with the sigmoid colon approximately at the level of S3 • It descends on the anterior surface of the sacrum for approximately 12 cm and ends in the anal canal after passing through the levator hiatus • The anterior and lateral portions of the proximal two thirds of the rectum are covered by peritoneum • peritoneum is then reflected onto the posterior vaginal wall to form the posterior cul-de-sac of Douglas (rectouterine pouch) – In women, the cul-de-sac is located approximately 5 to 6 cm from the anal orifice and can be palpated manually during rectal or vaginal examination – At its commencement, the rectal wall is similar to that of the sigmoid, but near its termination it becomes dilated to form the rectal ampulla, which begins below the posterior cul-de-sac peritoneum • rectum contains several, usually three, transverse folds called the plicae transversales recti, also termed valves of Houston – largest and most constant - located anteriorly and to the right, approximately 8 cm from the anal orifice – These folds may contribute to fecal continence by supporting fecal matter above the anal canal – Clinically, in the empty state, the transverse rectal folds overlap each other, making it difficult at times to manipulate an examining finger or endoscopy tube past this level 188
  • 189. Perineal body • Is the a mass of connective tissue found in between urogenital and anal triangle • Central tendon of the perineum • marks the point of convergence of – bulbospongiosus muscles, – superficial and deep transverse perinei, – perineal membrane, – external anal sphincter, posterior vaginal muscularis and fibers from the puborectalis and pubococcygeus muscles • plays an important role in support of the distal vagina and in normal anorectal function • The anterior to posterior and the superior-to-inferior extents of the perineal body each measure approximately 2 to 4 cm • Clinically, during vaginal laceration repairs and with pelvic reconstructive procedures, particular attention is given to perineal body reconstruction 189
  • 190. Ischioanal fossa • Ischioanal fosssae is a fat-filled wedge shaped spaces found on either side of the anal canal and comprise the bulk of the posterior triangle. • Each ischioanal fossa is bounded: – Laterally by the ischium and overlapping inferior part of the obturator internus, covered with obturator fascia. – Medially by the external anal sphincter, with a sloping superior medial wall or roof formed by the levator ani as it descends to blend with the sphincter; both structures surround the anal canal. – Posteriorly by the sacrotuberous ligament and gluteus maximus. – Anteriorly by the bodies of the pubic bones, inferior to the origin of the puborectalis. These parts of the fossae, extending into the UG triangle superior to the perineal membrane (and musculature on its superior surface), are known as the anterior recesses of the ischioanal fossae 190
  • 191. 191
  • 192. Ischio-anal fossae and their anterior recesses. A. Anterolateral view with left pelvic wall removed. B. Inferior view. C. Anterolateral view with pelvic walls and diaphragm removed. 192
  • 193. • The fat found within each fossa – provides support – allows rectal distention during defecation and vaginal stretching during delivery. • Potential space for – Collection of hematoma – Collection of abscess – Extension of abscess • Moreover, the two fossae communicate dorsally, behind the anal canal. This can be especially important because an episiotomy infection or hematoma may extend from one fossa into the other. • Clinically, injury to vessels in the posterior triangle can lead to hematoma formation in the ischioanal fossa, and the potential for large accumulation in these easily distensible spaces. 193
  • 194. Anal sphincter Anal Canal • This distal continuation of the rectum begins at the level of levator ani attachment to the rectum and ends at the anal skin • 4- to 5-cm in length, • Dentate or pectinate line, • The canal is collapsed, except during passage of feces 194
  • 195. • Which of the following is true concerning the anal sphincters? – A. The external anal sphincter receives blood supply from the superior rectal artery. – B. The internal anal sphincter contributes the bulk of anal canal resting pressure. – C. The external anal sphincter measures 3 to 4 cm in length. – D. The external sphincter remains in a state of constant relaxation 195
  • 196. 196 This orientation reflects the embryological development of the anorectum
  • 197. 197
  • 198. The external anal sphincter • Is a striated muscle ring that anteriorly attaches to the perineal body and that posteriorly connects to the coccyx via the anococcygeal ligament • Consists of three parts : – Deep, • The deep part is a thick ring-shaped muscle that circles the upper part of the anal canal and blends with the fibers of levator ani muscle – superficial and • The superficial part also surrounds the anal canal, but is anchored anteriorly to the perineal body and posteriorly to coccyx and anococcygeal ligament . – subcutaneous arranged sequentially along the canal from the superior to inferior • The subcutaneous part is a horizontally flattened disc of muscle that surrounds the anal aperture just beneath the skin. 198
  • 199. The internal anal sphincter • is an involuntary sphincter surrounding the superior two thirds of the anal canal. • Its contraction is stimulated and maintained by sympathetic fibers from the superior rectal (periarterial) and hypogastric plexuses. • Contraction is inhibited by parasympathetic fiber stimulation • This sphincter is tonically contracted most of the time to prevent leakage of fluid or flatus. – External Anal Sphincter (EAS) • voluntary (striated) muscle • inferior rectal artery • inferior rectal branch of the pudendal nerve – Internal Anal Sphincter (IAS) • not under voluntary control 199
  • 200. Lower Urinary Tract Structures • The pelvic urinary organs are – Pelvic portions of the ureter – Urinary bladder – Urethra 200
  • 201. Ureter • A 25–30 cm long muscular tube • Connect the kidneys to the urinary bladder. • It is retroperitoneal organ • Has two portions – abdominal + pelvic • Has several layers – Mucosa: uroepithelium – Sub mucosa – muscles-two layers • 1-Outer circularly oriented layer • 2-Iner longitudinal oriented layer • The three constriction sites ??? • About 75% of all iatrogenic injuries to ureter result from gynecologic procedures, most commonly laparoscopic hysterectomy; risk is increased with distortions of pelvic anatomy, including adnexal masses, endometriosis, other pelvic adhesive disease, or fibroids Pelvic ureter • The part of ureter after crossing the bifurcation of the common iliac artery at the pelvic brim. • two parts – Posterolateral – Anetromedial Course • It runs on the lateral walls of the pelvis • Parallel to internal iliac arteries , across anterior margin of greater sciatic notch and parietal peritoneum • It is crossed superiorly by the uterine artery at the level of ischial spine, around 2 cm lateral to cervix. • It then passes close to the lateral part of the fornix of the vagina and enters the poster superior angle of the bladder 201
  • 202. Arterial Supply and Venous Drainage • Ureteric branches from the common iliac, internal iliac, and ovarian arteries. • The most constant arteries supplying the terminal parts are branches of the uterine arteries. • Venous drainage from pelvic ureter parallels to its arterial supply and has corresponding names • Lymphatic vessels drain to common iliac and internal iliac nodes Innervation of Ureters • From adjacent autonomic plexuses – renal, aortic, superior and inferior hypogastric plexuses 202
  • 203. • 75% of all iatrogenic injuries result from gynecologic procedures – Most commonly abdominal hysterectomy • Risk is increased with distortions of pelvic anatomy 203
  • 204. Urinary bladder • A hollow viscus with strong muscular walls. • Temporary reservoir for urine. • Known for its distenisbility. • Variable in its size, shape, position, and relationships according to its content, and the state of neighboring viscera. 204
  • 205. • Position – The position of the bladder varies with age • In infants and young children –abdomen • By age 6- enters the greater pelvis • At puberty –it will be at true pelvis. • The position of the empty bladder in the adult is described as lying on the front part of pelvic floor, below the peritoneum and behind the pubic symphysis • Parts – Apex: part of the bladder that pointes towards the posterior edge of pubic bone – Fundus: opposite to apex which forms convex posterior wall – Body: major part of the bladder between the apex and fundus – Neck: part of the bladder that connects with urethra 205
  • 206. • The bladder wall consists of coarse bundles of smooth muscle known as the detrusor muscle, which extends into the upper part of the urethra – Although separate layers of the detrusor are described, they are not as well defined as the layers of other viscous structures – The innermost layer of the bladder wall is plexiform, which can be seen from the pattern of trabeculations noted during cystoscopy – The mucosa of the bladder consists of transitional epithelium and underlying lamina propria – A submucosal layer intervenes between this mucosa and the detrusor muscle 206
  • 207. The bladder has four surfaces, angles, borders and parts 207
  • 208. 208
  • 209. • The bladder is often divided into two areas – bladder is divided into a dome and a base approximately at the level of the ureteral orifices – Dome • thin walled and distensible • Remaining bladder area above the bladder base. • It has parasympathetic innervation • Responsible for micturition – Base o consists of – Vesical trigone » – Detrusor loops » These loops are two U-shaped bands of fibers found at the vesical neck, where the urethra enters the bladder wall o thicker and undergoes less distention during filling o Ureteral orifices lie within the trigone and empty here into the bladder o The pelvic ureter courses in the pelvic sidewall retroperitoneum o Urinary trigone and a thickened area of detrusor . o Trigone -two ureteral orifices and the opening of the urethra into the bladder. o Receives α-adrenergic sympathetic innervation o Responsible for maintaining continence. 209
  • 210. • Arterial supply – superior vesical arteries • branches of the patent portion of the umbilical artery – The vaginal arteries – The obturator – Inferior gluteal • Venous Drainage – Via vesical , vaginal or uterovaginal venous plexus to internal iliac vein 210
  • 211. Innervation of Bladder from inferior thoracic and upper lumbar spinal cord levels to the vesical (pelvic) plexuses primarily through the hypogastric plexuses from sacral spinal cord levels via the pelvic splanchnic nerves and the inferior hypogastric plexus – The parasympathetic fibers are motor to the detrusor muscle and inhibitory to the internal urethral sphincter and is vise versa for sympathetic fibers • The nerve supply to the bladder arises from the vesical plexus, a component of the inferior hypogastric plexus Inadvertent bladder injury may occur • during dissection of the vesicovaginal space – commonly located just superior to the intraureteric ridge in the midline. • during peritoneal entry for laparotomy or suprapubic port placement during a laparoscopy. • Risk factors for this type of injury include conditions that cause scar tissue in the vesicouterine pouch 211
  • 212. • Clinical – intentional cystotomy can be made to – confirm patency of the ureteral orifices, – assist with surgical dissection, or – place ureteral stents • The incision is ideally placed in the retropubic extraperitoneal portion of the bladder close to the apex • This avoids direct contact between the abdominopelvic viscera and the cystotomy site and minimizes the risk of fistula formation 212
  • 213. Urethra • begins at the internal urinary meatus • The region where the urethral lumen traverses the bladder base is called the bladder neck • The distal two thirds of the urethra are used with the anterior vaginal wall • 3-4 cm long and 6 mm in diameter • fused to the vagina for its distal two-thirds • has two orifice – Internal urethral orifice – External urethral orifice • Histologically: has four distinct layers – Mucosa – Submucosa • Parauretral glands(sken’s gland) – Muscularies • Internal urethral sphincter • striated external urethral sphincter. Supportive structures • Hammock like supportive layer made up of – Periurethral endopelvic fascia – Anterior vaginal wall • NB: Defects in these attachments can result in urethral hypermobility and cystocele, and stress urinary incontinence Arterial Supply and Venous Drainage • Internal pudendal and vaginal arteries • The veins follow the arteries and have similar names . • Innervation of Female Urethra. – vesical nerve plexus and the pudendal nerve 213
  • 214. • The walls of the urethra begin outside the bladder wall • They consist of two layers of smooth muscle, • an inner longitudinal and • an outer circular, – which are in turn surrounded by a circular layer of skeletal muscle referred to as the sphincter urethrae or rhabdosphincter • Approximately at the junction of the middle and lower third of the urethra, and just above or deep to the perineal membrane, two strap skeletal muscles called the urethrovaginal sphincter and compressor urethrae are found • These muscles were previously known as the deep transverse perineal muscles in females • Together with the sphincter urethrae, they constitute the striated urogenital sphincter complex • Together, these three muscles function as a unit and have a complex and controversial innervation • Their fibers act cumulatively to supply constant tonus and to provide emergency refex activity mainly in the distal half of the urethra to sustain continence 214
  • 215. • Distal to the depth of the perineal membrane, the walls of the urethra consist of fibrous tissue, serving as the nozzle that directs the urine stream • The urethra has a prominent submucosal layer that is lined by hormonally sensitive stratified squamous epithelium • Within the submucosal layer on the dorsal (vaginal) surface of the urethra is a group of glands known as the paraurethral glands, which open into the urethral lumen • Duct openings of the two most prominent glands, termed Skene glands, are seen on the inner surface of the external urethral orifice 215
  • 216. • The urethra receives its blood supply from branches of the inferior vesical/vaginal and internal pudendal arteries – Although still controversial, the pudendal nerve is believed to innervate the most distal part of the striated urogenital sphincter complex. – Somatic efferent branches from S2–S4 that course along the inferior hypogastric plexus variably innervate the sphincter urethrae • Clinical – Chronic infection of the paraurethral glands can lead to urethral diverticula – Due to the multiple openings of these glands along the length of the urethra, diverticula may develop at various sites along the urethra 216
  • 220. 220 Schematic cross section of the pelvis showing cleavage planes and spaces including the retropubic (prevesical), vesicovaginal, pararectal, rectovaginal, and retrorectal spaces
  • 221. • During surgery, – entering the retroperitoneum at the pelvic sidewall can be used to identify the ureter – Moreover, it is an essential step for many of the surgeries described in gynecologic oncology • contains – Major pelvic vessels – Pelvic ureter – Obturator nerve 221
  • 222. • Major pelvic vessels – internal iliac and external iliac vessels and their corresponding lymph node groups – Clinical • If severe hemorrhage during pelvic surgery → internal iliac artery may be ligated – internal iliac artery is ligated distal to the origin of its posterior division branches. – This helps to prevent significant devascularization of the gluteal muscles – These posterior division branches generally arise from the posterolateral wall of the internal iliac artery at a site 3 to 4 cm rom its origin of the common iliac artery • When this vessel is dissected, the ureter is also identified and avoided 222