Endo2: Female Reproductive Anatomy

Front 1

Pelvis role

Back 1

protective bony structure for reproductive organs and structural support for walking

Front 2

Boundaries of pelvic inlet and outlet

Back 2

Inlet - Posteriorly sacral promontory, laterally rims of ileum, pectin pubis (inguinal lig attached) and pubic symphysis

Outlet (Pelvic Floor) - Posteriorly coccyx tipping inward, acetabulum, ischial tuberosity, lower margins of the pubic symphysis

Front 3

Bony Pelvis Male vs Female
a) General structure
b) Greater pelvis
c) Lesser pelvis
d) Pelvic inlet
e) Pelvic outlet
f) Pubic arch
g) Obturator foramen
h) Acetabulum
i) Greater sciatic notch

Back 3

a) General structure - thick and heavy in male, thin and light in female
b) Greater pelvis - Deep in male, shallow in female
c) Lesser pelvis - narrow, deep, tapering in male, WIDE AND SHALLOW (for childbirth) in female
d) Pelvic inlet - HEART-SHAPED in male, Oval and wide in female
e) Pelvic outlet - Small in male, large in female
f) Pubic arch - Narrow (<70 deg) in male, wide (>80 deg) in female
g) Obturator foramen - round in male, oval in female
h) Acetabulum - large in male, small in female
i) Greater sciatic notch - narrow (70 deg); inverted V in male, almost 90 deg in female

Front 4

Pelvic Ligaments in Childbirth

Back 4

Bony pelvis held together by ligaments

Secretion of RELAXIN from ovaries causes laxity of SACROILIAC JOINTS and PUBIC SYMPHYSIS to permit 10-15% increase in diameters mostly transverse in interspinous distance to facilitate fetus passage in pelvic canal

Front 5

Pelvic Cavity Location, Cotents

Back 5

No true separation btw abdomen and pelvis. Pelvis from ilac crest down

Perineum is most inferior part of pelvis with sexual/erectile tissue

Cavity contains terminal part ureters, bladder, lower 1/3 of rectum, genital organs, blood vessels, lymphatics, nerves.

May have abdominal viscera depending on position and fullness (bladder)

Front 6

Cross sectional anatomy of pelvis

Back 6

Anteriorly rectus abdominus muscle on wall
Bladder connected to umbilicus via medial umbilical fold (remnant of urachus)
Also have uterus, uterine tubes (asymmetric), ovaries (posterior and asymmetrical)
Descending colon/sigmoid/rectum sits posterior to uterus
Abdominal aorta splits posterior to rectum

Front 7

Pelvic Peritoneum parts, and intraperitoneal vs subperitoneal organs

Back 7

Parietal parietoneum - associated with body wall
Visceral peritoneum - associated with organs

Abdominal peritoneum - drapes over pelvic organs, covering bladder, reflects off the bladder up and around uterus, extends down to where cervix and vagina meet and reflects on rectum to form rectouterine pouch (in female). Allows bladder expansion

Intraperitoneal organs - portions of the ovaries and uterine tubes
Subperitoneal organs -everything else (uterus, bladder, inferior 1/3 of rectum etc)

Front 8

Female pouches vs male pouches

Back 8

Vesicouterine pouch - btw posterior bladder and anterior uterus

Rectouterine pouch (Pouch of Douglass) - between posterior uterus and anterior rectum

Supravesicle fossa - shallow grove over pubic symphysis where peritoneum reflects onto bladder

MALEs have rectovesical puch - btw posterior bladder and anterior rectum and supravesicle fossa b/c no uterus

Front 9

Broad Ligament and regions

Back 9

Peritoneal folds terminate to create mesentery

Broad Ligament is mesentary that extends from lateral aspect of uterus to the body wall and functions to keep everything together and asa conduit for nerves and blood vessels

Forms partition that separates the paravesical fossae and pararectal fossae of each side

Regions
a) Mesosalpinx - associated with uterine tube
b) Mesovarian - associated with ovary
c) Mesometrium - lateral to uterus

Front 10

Female Pelvic Viscera

Back 10

2 Ovaries, 2 Uterine tubes, 1 Uterus, 1 Vagina

Front 11

Ovaries, Role, Viscera Location, Ligaments

Back 11

Ovaries - release eggs during ovulation (fertilization in TUBE not ovary)

Viscera Location: Loosely covered by peritoneum (intrperitoneal) but not touching ovary itself

Ligaments
a) Suspensory ligament of ovary - attaches ovary to lateral body wall, conduit for ovarian vessels (come off aorta/IVC at L1)
b) Ligament of ovary - connects ovary to the lateral aspect of uterus
c) Mesovarium - lies btween uterine tube and these two ligaments

Gubernaculum - in females, ovarian ligament and round ligament of uterus make up remnant of gubernaculum, attaches to mons pubis to anchor uterus to anterior abdominal wall (NO STRUCTURES)

In males gubernaculum extends into the scrotal sac and carries spermatic cord

Front 12

Uterine Tubes Role, Viscera Location, Regions

Back 12

Role: Conduit for the eggs to pass into uterus, not usually same length

Viscera location: some parts or intrauterine

Regions:
a) Intramuscular portion - portion most medial extending from uterus
b) Isthmus - narrow portion of uterine tube
c) Ampulla - expanded portion of uterine tube (largest region), fertilization here
d) Infundibulum - wide area of uterine tube opening near ovaries
e) Fimbria - projections that direct the egg into uterine tube.

OPEN system, Ovary IS NOT connected with uterine tube. Allows infections that begin in vagina to spread to peritoneum in females

Mesosalpinx - mesentary that runs along inferior border of uterine tube

Front 13

Abdominal ostium

Back 13

portion of uterine tube is an opening into peritoneal cavity

Sits by infundibular where receives egg by ovary

Front 14

Ectopic Pregnancy

Back 14

Normally fertilizatoin in the ampulla and then egg should move into cervix

Ectopic pregnancy elsewhere. Most commonly:
a) Uterine tube
b) Abdomen
c) Ovary

If not identified, can get rupture of uterine tube and massive hemorrhage that could be lethal

Front 15

Vagina Structure, Role, Location

Back 15

Connects the external environment to the cervix

Role: Hollow, flexible tube that can stretch and lengthen, collapses anterior to posterior and creates a "H" shape

Canal for menstrual fluid, forms inferior part of birth canal

Location: Sits posterior to the urethra and anterior to anus, urethra is in close proximity to vaginal opening, which is why females prone to urinary infections especially after intercourse

Front 16

Uterus Role, Location, Regions

Back 16

Solid muscular organ, pear shaped, receives uterine tubes and vagina at cervix

Regions
a) Body - upper portion, superior 2/3s include fundus with vesical surface (bladder) and intestinal.
b) Cervix - lower, narrow portion projecting into vagina. Opens into the vagina at external os
c) Fundus - uppermost portion (roof)
d) Isthmus - narrowed region
e) Uterine Ostium - opening for uterine tubes
f) Internal Os - separates cervix from body of uterus
g) Cervical canal - between internal and external os
h) External canal - cervix to vagina

Front 17

Anterior and Posterior Fornix, Instrumentation risk

Back 17

Anterior Fornix - cup that develops anterior to cervix and vagina

Posterior Fornix - pouch that encircles back of the cervix and vagina

When inserting an instrument, natural angle is such that may pierce posterior fornix, entering abdomen (in the rectouterine pouch), Cervix turns anteriorly to avoid piercing the posterior fornix

Front 18

Changes of Uterus in pregnancy

Back 18

Over 9 months expands to accomodate fetus, wall thins,

By end of pregnancy the fetus "drops" as the head becomes enlarged in lesser pelvis, uterus is nearly membranous, with fundus dropping below it's highest level achieved in 9th month

Highest level is near costal margin

Front 19

Uterus changes
a) Neonate
b) Toddler
c) Puberty
d) Adult (nulliparous)
e) Adult (parous)
f) Postemenopausal (no hormones)

Back 19

a) Neonate - uterine body: cervical region ratio is 2:1, due to maternal hormones passed to fetus
b) Toddler - ratio is 1:1
c) Puberty - ratio is 2:1 (estrogen made)
d) Adult (nulliparous) - UC ratio is 2:1, narrower and thinner than women who have children
e) Adult (parous) - UC ratio is 2:1, wider and thicker after having children
f) Postemenopausal (no hormones) - 1:1 ratio

Front 20

Angle of flexion, angle of anteversion, Perineal flexure

Normal Uterus position and abnormal positions

Back 20

Uterus normally sits on top of bladder, providing passive support for uterus

Angle of Flexion - angle between cervix and body of uterus is 160-170 towards bladder
Angle of Anteversion - angle between vaginal canal and cervical canal is 90 towards bladder
Perineal flexure - flexure of rectum that can increase and protrude into vaginal canal (painful intercourse, esp with constipation)

Normally - anteverted and anteflexed uterus

Abnormal
1) Excessive anteflexion - not a huge problem (more of an angle between cervix and body of uterus
2) Retroverted and retroflexed - uterus body pushing back on rectum and rectouterine pouch. Can cause constipation
3) Retroverted - steeper angle between vaginal canal and cervical canal, increased risk of uterine prolapse

Front 21

Uterine Prolapse, Treatment

Back 21

Rectum, bladder, vagina or uterus can invert and prolapse

More common with more pregnancies, can be caused by weak pelvic floor or abnormal position of the uterus

Treat with surgery to tack the uterus into the body, or provide implants (GELLHORN PESSARY) to prevent prolapse

Front 22

Uterine Support Passive and Active

Back 22

Passive Support - provided by anatomical position of uterus within pelvis. Rests on top of bladder

Active Support = Pelvic Diaphragm = pelvic floor sling of muscles surrounding vaginal opening.

Front 23

Location and Components of Pelvic Diaphragm

Back 23

Runs from pubic symphysis (anterior) to laterally along sides to sacrum (posterior)

Components
a) Coccygeus muscle - posterior triangular muscle, supports pelvic visera and flexes coccyx. Bilaterally running near coccyx
b) Levator ani - 3 muscles that are important for resisting pressure (coughing or sneezing) increases intra-abdominally

Also serves to separate pelvis from perineum (erectile tissues)

Front 24

Levator Ani parts and Role

Back 24

3 muscles
Iliococcygeus
Pubococcygeus
Puborectalis - most impt for fecal continence

Role: Tonically contracted most of the time to support abdominopelvic viscera, forms a sling that causes flexure in rectum as exits body.

Penetrated centrally by anal canal of which the puborectalis forms a sling for defecation control

Front 25

Pelvic Fascia,

Back 25

Parietal pelvic fascia - lines the deep aspect of the muscles forming the walls and floor of the pelvis (obturator internus, piriformis, coccygeus, levator ani, part of urethral sphincter muscles)

Visceral pelvic fasia - directly ensheaths the pelvic organs forming adventitial layer of each (includes vesicle fascia on bladder, utero-vaginal fascia, rectal fascia)

Front 26

Tendinous Arch of the Levator Ani

Back 26

Medial to obturator fascia, where levator ani muscle begins

Front 27

Tendinous Arch of the Pelvic Fascia, Portions

Back 27

Where the visceral and parietal fascia become continuous, the parietal fascia is thickened forming the tendinous arch of pelvic fascia. BIL continuous band running from pubis to the sacrum along pelvic floor adjacent to viscera

Viscera penetrate pelvic floor here.

Portions
a) Broad ligament (mesentery) - connects to pelvic fascia
b) Transverse cervical ligaments

Differ in females and males. Females have more holes in sheath, ligaments in front of and behind uterus to anchor. Broader

Front 28

Hypogastric Sheath, Functions, Regions

Back 28

Thick band of condensed pelvic fascia that gives passage to all vessels and nerves passing from the lateral wall of the pelvis to the pelvic viscera along with ureters and in male ductus deferens

Regions: Retropubic (prevesical) space, Paravesical space, retrorectal space, lateral ligament of bladder, cardinal ligament, retrovesical septum (males), lateral ligament of rectum

Front 29

Cardinal Ligament (Female)

Back 29

Aka transverse cervical ligament

Lies above mesentary. Part of hypogastric sheath. Runs from supravaginal cervix and lateral parts of fornix of the vagina to lateral walls of the pelvis

Taut ligament, holds vagina and cervix to lateral abdominal walls, impt b/c can hold sutures in surgery

Front 30

Female Perineum Boundaries, Contents

Back 30

Boundaries: pubic symphysis (anterior), posteriorly bound by an imaginary line between urogenital triangle and anal triangle

Contents: muscles, erectile bodies, nerves, arteries, veins, lymphatics, glands

Front 31

External Genitalia and Role

Back 31

Vulva - opening between thighs, functions for sexual arousal, intercourse, excretion of urine (via urethra) and conduit to prevent foreign material from entering peritoneum

Mons Pubis - fatty, cushioned area containing most of the pubic hair in females, end of gubernaculum/round ligament of the uterus

Labia Majora - 2 large tissue folds that enclose pudendal cleft (labia minora and vaginal opening). Analogous to scrotal sack and penile shaft.

Labia Minora - hairless regions that enclose the vaginal vestibule, raphe of penis analog

Clitoris - Housed in small amount of skin on most anterior and superior aspect of region, analogous to male glans penis. Prepuse = skin that covers the majority of the clitoris. Includes 2 Crus that extend along the bottom of the symphysis pubis, glans and body. Functions as sexual organ of arousal. Highly innervated and sensitive.

Below glans of the clitoris, have urethral opening, vestibule and vaginal opening

Front 32

Vestibular Bulbs

Back 32

Paired erectile tissue sitting on either side of the vestibule. Each continues anteriorly and meets its partner on other side near shaft of clitoris

Covered by bulbospongiosus muscles which form a weak sphincter around the vagina, when contracted the bulbs become engorged


Two bulbs anteriorly near the base of the clitoris

Front 33

Bartholin's Gland

Back 33

Greater vestibular glands - mucinous in nature, occlusion of its duct allows mucin to accumulate and can become a bartholin cyst

Sit on either side of vestibule over vestibular bulbs

Analogous to bulbourethral/Cowper's glands in male

Front 34

Perineal Membrane Functions, Summary of Layers (KNOW)

Back 34

Anchors all muscles, provides attachment for erectile tissues (penis and scrotom in males, vulva or pudendum in females) and separates the superficial perineal pouch from deep perineal pouch; conducts neurovascular structures

Perforated by urethra in both sexes, and vagina in females

Layers
Abdomen to Pelvis to Pelvic Diaphragm to Perineum to deep perineal pouch to perineal membrane to superficial perineal pouch

Front 35

Urogenital hiatus

Back 35

anterior gap between medial borders of levator ani on each side giving passage for urthra and in females teh vagina

Spanned by external urethral sphincter and deep transverse perineal muscles

Front 36

Superficial Perineal Pouch Contents, Gender differences (KNOW)

Back 36

Male
a) Root of penis and associate muscles (ischiocavernosus & bulbospongiosus)
b) Proximal (bulbous) part of spongy urethra
c) Superficial transverse perineal muscles
d) Deep perineal branches of internal pudendal vessels and pudendal nerves

Females
a) Clitoris & associated muscles (ischiocavernosus)
b) Bulbs of the vestibule & surrounding muscle (bulbospongiosus)
c) Greater vestibular glands (UNIQUE)
d) Superficial transverse perineal muscles
e) Deep perineal branches of the internal pudendal vessels and pudendal nerves

Greater vestibular glands in superficial perineal pouch in females, while analog glands in males in deep pouch of males

Front 37

Deep Perineal Pouch, Gender Differences (KNOW)

Back 37

Female - urehtra, smooth muscle, neurovascular structures of clitoris. DEEP PERINEAL MUSCLE around urethra replacing male deep perineal muscle

Male - bulbourethral glands (UNIQUE), deep perineal muscles, neurovascular structures

Front 38

Ischicavernous muscle role, Superficial transverse perineal muscle role, Bulbiospongiosus muscle role, Perineal body

Back 38

maintain erect state by forcing blood into cavernous spaces in crura. Contract and compress venous outflow of penis

Superficial transverse perineal muscle - simultaneously contract to provide firmer base of the penis during erection

Bulbospongiosus - pared muscles covering bulb of penis or bulb of vesibule - constrict to expel ejaculate or urine from bulb. Anterior most fibers assist in erection by increasing pressure on cavernous tissue

Perineal body - convergence site for bulbospongiosus, external anal sphincher, superficial and deep transverse perineal muscles, smooth and voluntary slips of muscle from external urethral sphincter, levator ani and muscular coats of rectum

Front 39

External Urethral Sphincter Role

Back 39

Male - external urethral sphincter is more like a tube or trough than a disc, only inferior muscle part forms investment sphincter for part of urethra inferior to prostate, other part extends up to bladder as part of isthmus of prostate

Female - sphincter is a urogenital sphincter, superior part to neck of bladder. Also wraps around vagina in females in addition to urethra so more problems with urinary incontinence than in males

Front 40

4 muscles compressing vagina and acting as sphincters

Back 40

pubovaginalis
external urethral sphincter
urethrovaginal sphincter
bulbospongiosus

Front 41

Kegel exercises

Back 41

Important to prevent urinary incontinence in females

Contract levator ani muscles to strengthen sphincter

Front 42

Pelvic Floor Injury

Back 42

Pelvic diaphragm susceptible to tearing during birth

PUBOCOCCYGEUS MUSCLE most commonly injured. Same muscle weakens in multiple childbirths and can lead to incontinence

Front 43

Episiotomies

Back 43

Purposeful incision through muscle mediolateral to midline to avoid perineal body and directs tearing away from anus, and to and prevent tearing in region during child birth or damage to levator ani