Assoc. Prof. Gazi YILDIRIM, M.D.

1. Introduction to Obstetrics and Gynecology Anatomy and Physiology Assoc. Prof. Gazi YILDIRIM, M.D.

2. Objectives • To learn • female reproductive anatomy • Pelvic anatomy • Pelvic innervation • Pelvic blood supply • Basic hormon knowledge • Steroid hormon pathways • Female reproductive endocrinology

3. Abdominal Wall • Skin • Subcutaneous fat (superficial fascia), which below the navel can be considered as two layers: • Camper’s fascia; the superficial layer containing fat, • Scarpa’s fascia; fibroelastic membrane. • Muscles, The abdominal muscular wall can be considered a group of 4 paired muscles along with their aponeurosis: • The three lateral muscles (from superficial to deep) are the • External abdominal oblique • Internal abdominal oblique • Transversus abdominis muscle • Medially muscles are the: • Rectus Abdominis • Pyramidalis muscles • Preperitoneal fat • Peritoneum • Parietal peritoneum peritoneum of anterior abdominal wall • Visceral peritoneum peritoneum investing the viscera

5. Anatomy: Perineum • Clitoris • Urethra • Vagina • Anus • Labia majora and minora • Bartholin’s and Skene’s glands • Hymen

6. Elements comprising the Pelvis • Bones • Ilium, ischium and pubis fusion • Ligaments • Muscles • Obturator internis muscle • Arcus tendineus levator ani or white line • Levator ani muscles • Urethral and anal sphincter muscles

7. Bony pelvis • Composition: formed by paired hip bones, sacrum, coccyx, and their articulations • Two portions • Greater pelvis • Lesser pelvis • Terminal line ( pelvic inlet): formed by promontory of sacrum, arcuate line, pectin of pubis, pubic tubercle, upper border of pubic symphysis • Pelvic outlet: formed by tip of coccyx, sacrotuberous ligament, ischial tuberosity, ramus of ischium, inferior ramus of pubic symphysis

8. Anatomy: Bones of Pelvis • Sacrum • Coccyx • Innominates (2) • Ilium • Ischium • Pubis

11. Anatomical antero-posterior diameter (true conjugate) = 11cm • Obstetric conjugate = 10.5 cm (-2cm from diagonal conj) • Diagonal conjugate = 12.5 cm

13. Pelvic Floor Muscles Levator Ani • Puborectalis • Pubococcygeus • Ileococcygeus Obturator Internus Piriformis Coccygeus Levator Plate Netter F Atlas of Human Anatomy Novartis 1997

14. “Ligaments and Fascia” Cardinal/Uterosacral Complex (Delancy level I) Paracervical Ring Arcus Tendineus Fascia Pelvis ATFP Pubocervical “fascia” Rectovaginal “fascia”

15. Perineal Body Superficial Transverse perineus Pyramidal Fibrous Body Internal Anal Sphincter External Anal Sphincter Perineal Membrane Bulbocavernosis (urethrovaginal sphincter) Cleveland Clinic Foundation Burnett Novack’s Gynecology 2004

16. Sphincter urethrae externus • Bulbospongiosus • Ischiocavernosus • Transversus perinei profundus • Transversus perinei superficialis

17. Bony structures of a pelvis

18. Perineal muscles Urethra Vagina M. ischiocavernosus M. bulbospongiosus M. transversus perinei superficialis M. sphincter ani externus

19. Urogenital fascia Urethra Vagina M. transversus perinei profundus M. transversus perinei superficialis M. sphincter ani externus

20. Pelvic floor ATFP

21. Add rectum

22. Rectal connections

23. Vaginal connections

24. Urethra Bladder Cervix

25. lig.cardinale

26. Lig. sacrouterina Lig. cardinale

28. Layers of the Anterior Triangle of the Perineum • Skin • Subcutaneous tissue.Camper's fascia.Colles fascia • Superficial space.Clitoris and its crura.Ischiocavernous muscle.Vestibular bulb.Bulbocavernous muscle.Greater vestibular gland.Superficial transverse perineal muscle • Deep space-perineal membrane.Compressor urethrae.Urethrovaginal sphincter

29. Ürogenital trigon: • M. Transversus perinei superficialis • M. İschiocavernosus • M. Bulbocavernosus • M. Transversus perinei profundus • Anal trigon: • M. Levator ani • M. Sphincter ani externus

30. FIGURE 7.2. Superficial compartment and perineal membrane.

31. EKSTERNAL ACCESSORY ORGANS(Vulva – Pudendum) • Monspubis • Labiummajus • Labiumminus • Clitoris • Bulbusvestibuli • Gl. vestibularismajor • Gl. vestibularesminor

32. Labium Majus Pudendi • Correspond to the scrotum • Includes numerous hairs • Rima pudendi • Commisura labiorum ant. • Commisura labiorum post. • Lig.rotundum Rima pudendi Commissura post

33. Labium Minus Pudendi (Nymphae) • Includes sweat glands • Preputium clitoridis • Frenilum clitoridis • Sulcus nympholabialis • Frenulum labiorum pudendi • Fossa navicularis • Fourchette Sulcus nympholabialis Frenulum clitoridis Frenulum labiorum pudendi

34. Clitoris • Corresponds to the male penis • Corpus, crus, glans • Attach to the side of the pubic arch with Lig. Suspansorium

35. Vestibüle- Introitus(Vestibulum Vaginae) • The Vaginae and ostium urethra externa opens vestibüle • Covered by stratified squamous epithelium Vestibül

36. Glandula Vestibularis Major (Bartholin’s glands) • Correspond to the male bulbourethral glands • Covered by M.bulbocavernosus • Secrete fluid that moistens and lubricates vestibule

37. Glandula Vestibularis Minor (Skene glands) • Opening either side of the urethra • To get Gonore retansiyon abscess Skene kanalları

38. FIGURE 7.2. Superficial compartment and perineal membrane.

39. Hymen Feminus • Mucosal fold • Carunculae myrtiformis

40. Anatomy: Pelvic Innervation • Pelvic splanchnic nerves from 2nd to 4th sacral nerves • Pudendal nerve supplies vulva and lower vagina

41. Vulva blood supply comes from a terminal branch of the a.iliaca interna - a.pudenda interna • N. pudendus

43. INTERNAL ACCESSORY ORGANS • Vagina • Uterus • Uterine tubes • Overies

45. Vagina (Kolpos) • Fibromuscular tube about 9 cm • Fornix vaginae • Columna rugarum • Tunica mucosa • Tunica muscularis • Tunica adventisya • A. vaginalis • V.iliaca interna Vajina

46. Uterus (Metra - Hystera) • 8 x 6 x 4 cm 40-50 g. • Corpus, isthmus, collum (cervix) • Portio vaginalis uteri

47. Serosal layer (perimetrium) • Muscular layer (myometrium) • Mucosal layer (endometrium) • Excavatio vesicouterina • Excavatio rectouterina (Douglas )

48. Squamocolumnar Junction

49. Tuba Uterina (Fallop Tüpleri-Salpinx) • İnfundibulum (fimbria, fimbriae ovarica) pars ampullaris, isthmica, interstitialis • A.ovarica ve A.uterina