Normal Female Pelvis Anatomy

Front 1

Space of Retzius

Back 1

AKA Retropubic space

-formed by

transversals &

extraperitoneal fascia

-Anterior to bladder

Front 2

Abdominal or pelvic masses will displace the bladder where?

Back 2

Anteriorly or inferiorly

Front 3

Vesicouterine Pouch

Back 3

AKA anterior cul-de-sac

-space posterior to

bladder, anterior to uterus

Front 4

Posterior Cul-de-sac

Back 4

AKA Pouch of Douglas or Retctouterine

-formed by peritoneum extending to posterior fornix of vagina

-posterior to uterus

Front 5

Sacrum

Back 5

-posterior to pelvis (spine)

Front 6

Coccyx

Back 6

-posterior to pelvis (very end of spine)

Front 7

Innominate Bones

Back 7

AKA Iliac Bones

-anterior and lateral to pelvic space

Front 8

True and False Pelvis

Back 8

made up by drawing an imaginary line from sacral prominence to upper portion of

symphysis pubis

Front 9

False Pelvis

Back 9

-above plane;

bounded by iliac wings

-support the intestines

Front 10

True Pelvis

Back 10

-below plane

-pelvic inlet: bounded by pubic bones ant and sacral prominence post

-pelvic outlet: bounded by ischial tuberosities laterally and coccyx posteriorly

Front 11

What's located in the true pelvis in a nongravid patient?

Back 11

-uterus

-ovaries

-anexa

Front 12

In a nongravid patient the uterus is posterior to what?

Back 12

-bladder & small bowel

Front 13

How can we create a window for pelvic anatomy sonographically?

Back 13

-as the bladder fills, the dome extends into false pelvis and displaces bowel

Front 14

Osseous ligament & the four kinds

Back 14

-pelvic ligament that support boney structures

-sacroiliac: attaches sacrum and iliac

-sacrosciatic: sacrum, iliac& coccyx

-sacrococceygeal: sacrum& coccyx

-pubic: attaches pubic uterus

Front 15

Suspensory ligament & the four kinds

Back 15

-support the uterus

-cardinal

-broad

-sacro-uterine (uterosacral)

-round

Front 16

Cardinal (suspensory ligament)

Back 16

-primary support system for uterus

-superior and lat from uterus

-inferior from vagina

Front 17

Broad (suspensory ligament)

Back 17

-attach to each pelvic side wall

-laterally from each side of uterus

Front 18

Sacro-uterine (suspensory ligament)

Back 18

-attaches to the uterus at the internal os (opening) to the sacrum

Front 19

Round (suspensory ligament)

Back 19

-attaches uterine cornu to ant pelvic wall

-btw broad ligaments ant and inf to fallopian tubes (should not see these!)

Front 20

What are the three False Pelvis Muscles

(Abdomen-pelvic)

Back 20

-Rectus Abdominis

-Psoas Major

-Iliacus

Front 21

What are the four True Pelvis Muscles?

Back 21

-Levator Ani

-Coccygeus

-Obturator Internus

-Piriformis

Front 22

Rectus Abdominis

Back 22

-from costal margin to symphysis pubis

Front 23

What is the major cause of "mirror imaging

artifact" in gravid patients?

Back 23

Rectus Abdominis

Front 24

Iliacus

Back 24

-forms iliac fossa on both sides

-arises at iliac crest, extends inf until merges with p. major

Front 25

Psoas Major

Back 25

-extends from T12 lat and ant through lower abd

-originates in abd into true pelvis

-In TRV: bullseye appearance

Front 26

What's the primary purpose of the true pelvis?

Back 26

Hold pelvic organs in place

Front 27

What's the most inferior structure of the pelvic cavity?

Back 27

Pelvic diaphragm

-can be visualized on TA if angle inf

Front 28

Levator Ani

Back 28

-bilateral muscle

-coccygeus, lleococcygeus, pubococcygeous

-attaches to pelvic side wall, then extends medially and fuses to opp side

-forms pelvic floor

Front 29

Obturator Internus

Back 29

-triangular muscle on lateral pelvic wall

-from anterolateral, passes through lesser sciatic foramen, inserting into greater trochanter

Front 30

Piriformis

Back 30

-found on pelvic side wall

-from sacrum btw pelvic sacral foamen

-inserting into greater trochanter

-US: viewed post within pelvis

Front 31

CIA (Common Iliac Artery)

Back 31

-ant and medially to psoas m.

Front 32

What does the CIA bifurcate into?

Back 32

EIA (exteral) and IIA (internal) (aka

hypogastric A.)

Front 33

What does the EIA feed?

IIA?

Back 33

EIA: lower limbs

IIA:pelvic viscera, wall, perineum

Front 34

Do the EIA & IIA have a high or low impedance flow?

Back 34

high

Front 35

Uterine Artery

Back 35

-terminal branch of IIA

-ascends along lat portion of ut giving off several branches to feed myometrium

-high velocity, high resistance

Front 36

Uterine plexus of veins

Back 36

AKA Venous Plexus

-"varicose veins" on US

-along uterine body

-much longer than corresponding artery

Front 37

Ovarian Artery

Back 37

AKA Gondal Arteries

-primary blood supply to ovaries

-dop waveform vary with cycle

Front 38

Just before ovulation and secretory phase, do we have a high or low resistance?

Back 38

low

Front 39

High or low resistance for a Dormant Ovary?

Back 39

high

Front 40

Urinary bladder

Back 40

-musculomembranous sac serves as reservoir for urinary

-inferior

-distends with filling into true pelvis displaying pelvic structures

Front 41

What are the three tissue layers of the urinary bladder?

Back 41

-outer epithelial layer (skin)

-middle musculaus layer

-inner mucosal layer

Front 42

What does the urinary bladder look like on US?

Back 42

-wall is echogenic with uniform thickness

Front 43

Can you see the eval mucosa of the urinary

bladder with a full or empty bladder?

Back 43

-empty

-when empty should be very thick

Front 44

Urethra

Back 44

-excretion of urine

-arises inf mid portion of UB

Front 45

Internal Urethral Sphincter

Back 45

-thickened area of bladder wall surrounding urethra at bladder wall

Front 46

Ureters

Back 46

-muscular tubes 25-30cm long

-course is important bc surrounding pelvic structures can cause problems in UB and kidneys

Front 47

Vagina

Back 47

-hypoechoic tubular structure with echogenic

lumen 7-10cm long

-extends from Cx to Introitus (ext entrance to vag)

-composed of smooth muscle, elastic, connective tissue

Front 48

Fornices

Back 48

-blind pouch (goes nowhere)

Front 49

Posterior Fornix

Back 49

-posterior aspect of external cx

-most common site for free fluid

Front 50

Lateral Fornix

Back 50

-lateral aspects of external cx

-cause shadowing on transverse cx image

Front 51

Anterior Fornix

Back 51

-anterior aspect of external cx

Front 52

Ovaries

Back 52

-ovoid shaped

-suspended by ligaments

-location is variable

Front 53

Nulliparous

Back 53

-someone that's never been pregnant

-ovaries are situated in ovarian fossa

AKA Fossa of Waldeyer

Front 54

How many blind pouches do we have?

Back 54

-posterior (most common spot for free fluid)

-anterior

-2 lateral

Front 55

Suspensory ligament

Back 55

-fold of peritoneum that arises from pelvic

sidewall and contains ovarian vessels& nerves

Front 56

Ovarian ligament

Back 56

-extends between pole of ovary and ipsilateral uterine body

Front 57

Mesovarium

Back 57

-attach ovary to posterior layer of broad

ligament

Front 58

What are some things that cause different size ovaries?

Back 58

-age

-menstrual cycle

-parity

Front 59

What is the size of an ovary for pre-menarche patient?

Back 59

3.0cm3

Front 60

What is the size of an ovary for post-menstrual patient?

Back 60

5.8 cm3

Front 61

Uterus

Back 61

-muscular, suspended by ligaments in midline of true pelvis

Front 62

Fondus

Back 62

-most superior aspect of uterus above insertion of FT; lateral portions form cornu (horns) of uterus

Front 63

Body

Back 63

AKA Corpus

-largest portion of uterus

Front 64

Cervix

Back 64

-uterine neck; more fibrous, less muscular

2-3 cm long in nulliparous patient

-anchored at angle of bladder, less moveable than body of uterus

Dual blood supply: uterine & ovarian artery

Front 65

Size of prepubescent uterus

Back 65

2.8 cm long

0.8 cm AP

Front 66

Size of uterus birth to 4 years

Back 66

decreases in size

Front 67

Size of uterus at 8 years

Back 67

-begins to grow for many years

Front 68

Size of uterus by reproductive age?

Back 68

7 cm long, 4 cm wide

Front 69

Size of uterus Parity

Multiparity

Back 69

-increases in size for parity

-8.5 *5.5 cm

Front 70

Size of uterus in Postmeno

Back 70

-usually small

3.5-6.5 cm long

1.2-1.8 cm AP

Front 71

What are the three uterine layers

Back 71

-perimetrium (outermost layer)

-myometrium (middle layer)

-endometrium (innermost layer)

Front 72

Serosa

Back 72

AKA Perimetrium (outer layer)

-covering of uterus, covers fundas& most of body

(Retroperitoneum- anything behind the peritoneum)

Front 73

Muscularis

Back 73

AKA Myometrium (middle layer)

-inner layer: hypoechoic (subendometrial halo)

-middle layer: thicker, more echogenic

-outer layer: separated from middle layer by arcuate plexus of arteries&veins

Front 74

Mucous

Back 74

AKA Endometrium (inner layer)

-varies in thickness and echogenicity dependent on phase of menstrual cycle, parity, age& HRT

Front 75

What's the range of normal thickness of endometrium?

Back 75

1 mm - just after menses

6 mm - just before menses

Front 76

The thickness of the endometrium should not exceed what size in a premenopausal women

Back 76

14-16 mm

Front 77

The thickness of the endometrium should not exceed what size in a postmenopausal women

Back 77

8 mm

(4-5 mm with no hx of bleeding/symptoms)

(8 mm if on HRT or has had bleeding)

Front 78

Early Proliferative Phase

Back 78

Day 5-9

-thin echogenic line

Front 79

Late Proliferative Phase

Back 79

Day 10-14

-functional zone thickens due to estrogen

-hypoechoic compared to echogenic basal layer

Front 80

Secretory Phase

Back 80

Day 15-28

-functional layer becomes thickened, soft and edematous due to progesterone

-increased echogenicity of functional layer, becomes isoechoic to basal layer

Front 81

Version

Back 81

-relationship btw cervix and vagina

anteversion- form 90 degree angle

Front 82

Flexion

Back 82

-relationship btw cervix and uterine body

anteflexion- corpus flexed ant on cervix

-find uterus with empty bladder

Front 83

Anteverted/Anteflexed

Back 83

-corpus, fundus & cx in normal position (NORMAL APPEARANCE)

Front 84

Retroverted

Back 84

-corpus/fundus normal position; cx tilted backwards

Front 85

Retroflexed

Back 85

-corpus/fundus tilted backwards; cx normal position

Front 86

Retroverted/Retroflexed

Back 86

-corpus/fundus and cx all tilt backwards

Front 87

Retroversion& uterine body tilting right or left

Back 87

-obscure evaluation of TV on endo and fundus

-can appear to have fundal fibroid

-normal variant until 14-16 weeks

Front 88

How can you differentiate between a uterus having fundal fibroid and dropout artifact?

Back 88

-if there is a lack of displacement of endometrium then yes

-lack of contour abnormality

Front 89

Incarcerated Uterus

Back 89

-when fundus fails to rise into flse pelvis from sacral hollow during pregnancy

Front 90

What are the signs and symptoms of a patient with a incarcerated uterus?

Back 90

-bladder outlet obstruction

-multiple ER visits btw 13-17 wks (UTI, severe pelvic pain/abdominal pain)

Front 91

What are the three findings on ultrasound of a patient with a incarcerated uterus?

Back 91

-pregnancy deep within cul-de-sac

-mom UB ant to uterus (should be inf)

-soft tissue structure (cx) visualized btw UB and pregnancy

Front 92

What will happen if a incarcerated uterus is not diagnosed& what will happen if it is?

Back 92

Not diagnosed: spontaneous abortion or uterine rupture

Diagnosed: manual reposition of uterus

Front 93

Fallopian tubes

Back 93

-laterally from cornu of uterus to ovaries

-10 cm long

-lies sup potion of broad ligament

Front 94

What are the four parts of the Fallopian tubes

Back 94

-Intramural: nearest portion; traverses cornu

-Isthmic-longest portion; connects intramural and ampullary

-Ampullary: (fimbriated) open portion of tube adjacent to ovary

-fimbria: surround ovary and capture ovum

-ostium: open end into peritoneal cavity

-Infundibulum: inner, funnel shaped cavity of ampullary portion