Internal genitalia of Female

1. Internal genitalia of Female Dr Rania Gabr

2. objectives • 1. Identify the uterus, its normal site, shape, parts, size and position. • 2. Discuss its peritoneal coverings and relations. • 3. Discuss the uterine relations. • 4. Determine the factors supporting the uterus. • 5. Discuss its blood, nerve supply and lymphatic drainage. • 6. Enumerate the parts of the fallopian tube • 7. Discuss its blood, nerve supply and lymphatic drainage. • 8. Discuss the site, size, shape, peritoneal covering and relation of the ovary.

3. 9. Enumerate the ligaments attached to the ovary. • 10. Mention its blood & nerve supply and lymphatic drainage. • 11. Discuss the site, position, length, peritoneal covering and relation of the vagina. • 12. Mention its blood & nerve supply and lymphatic drainage.

4. Uterus • This is a hollow, thick-walled, pear-shaped muscular organ located between the bladder and the rectum (in non-pregnant women). • It is 7 to 8 cm long, 5 to 7 cm wide, and 2 to 3 cm thick. • The non-gravid (not pregnant) uterus usually lies in the lesser pelvis,

5. The uterus consists of 2 major parts: • The expanded superior 2/3 is known as the body • The cylindrical inferior 1/3 is called the cervix(L. neck). • The uterus is usually bent anteriorly (anteflexed) between the cervix and body. • The entire uterus is normally bent or inclined anteriorly (anteverted). • It is frequently retroverted(inclined posteriorly) in older women.

6. Different parts of the uterine tube and the uterus. B. External os of the cervix: (above) nulliparous; (below) parous. C. Anteverted position of the uterus. D. Anteverted and anteflexed position of the uterus

7. The Fundus of the Uterus • The fundus of the uterus is the rounded superior part of the body. • It is located superior to the line joining the points of entrance of the uterine tubes. • The regions of the body where the uterine tubes enter are called the cornua(L. horns).

9. The Cervix of the Uterus • Is the cylindrical, narrow inferior part of the uterus, which has a: • 1-supravaginal part: • between the isthmus and the vagina(isthmus of uterus the constricted part of the uterus between the cervix and the body of the uterus),and a

10. 2- vaginal part : • that protrudes into the vagina and surrounds the external osof the uterus. • The supravaginal part of the cervix is separated from the bladder anteriorly by loose connective tissue and from the rectum posteriorly by the rectouterine pouch • The cervix is mostly fibrous, with a small amount of smooth muscle and elastin

12. The wall of the body of the uterus consists of three layers • The outer serous coatcalled the perimetrium, consists of peritoneum • The middle muscular coatcalled the myometrium consists of 12 to 15 mm of smooth muscle. The myometrium increases greatly during pregnancy. The main branches of the blood vessels and nerves of the uterus are located in this layer; • The inner mucous coatcalled endometriumis firmly adherent to the underlying myometrium. • The endometrium is partly sloughed off each month during menstruation. • It lines onlythe body of the uterus

13. The Ligaments of the Uterus • 1- The Round Ligaments of the Uterus • These ligaments are 10 to 12 cm long and extend from the lateral aspect of the uterus, passing anteriorly between the layers of the broad ligament. • They leave the abdominal cavity through the inguinal canal and insert into the labia majora. • 2- The ligament of the ovary • Externally, attaches to the uterus posteroinferior to the uterotubal junction • These two ligaments are vestiges of the ovarian gubernaculum, related to the descent of the gonad from its developmental position on the posterior abdominal wall

14. 3- The Broad Ligament • The broad ligament of the uterus is the wide fold of peritoneum that connects the sides of the uterus to the walls and floor of the pelvis • The broad ligament holds the uterus in its normal position. • The 2 layers of the broad ligament are continuous with each other at a free edge. • This is directed anteriorly and superiorly to surround the uterine tube.

15. Laterally, the broad ligament is prolonged superiorly over the ovarian vessels as the suspensory ligament of the ovary. • The broad ligament contains extraperitoneal tissue (connective tissue and smooth muscle) called parametrium. • It gives attachment to the ovary through the mesovarium. • The mesosalpinxis a mesentery supporting the uterine tube.

16. The contents of the broad ligament include the following: • Reproductive • Uterine tubes • ovary (some sources consider the ovary to be on the broad ligament, but not in it.) • vessels • ovarian artery (in the suspensory ligament) • uterine artery • ligaments • ovarian ligament • round ligament of uterus • suspensory ligament of the ovary

19. 4- The Uterosacral Ligaments • pass superiorly and slightly posteriorly from the sides of the cervix to the middle of the sacrum; they are palpable on rectal examination • The Principal Support of the Uterus • 1- This is the pelvic floor, formed by the pelvic diaphragm. • 2- The pelvic viscera surrounding the uterus and the visceral fascia (endopelvic fascia) bind the pelvic viscera together. • The two levatorani muscles, the two coccygeus muscles, and the muscles of the urogenital diaphragm are particularly important in supporting the uterus.

21. The Relationships of the Uterus • 1- Anteriorlythe body of the uterus is separated from the urinary bladder by the vesicouterine pouch. • 2-Posteriorlythe body of the uterus and the supravaginal part of the cervix are separated from the sigmoid colon by a layer of peritoneum and the peritoneal cavity. • The uterus is separated from the rectum by the rectouterine pouch(of Douglas).

22. The inferior part of this pouch is closely related to the posterior part of the fornix of the vagina. • 3- Laterallythe relationship of the ureter to the uterine artery is very important. • The ureter is crossed superiorly by the uterine artery at the side of the cervix.

23. Arterial Supply of the Uterus • 1- This is derived mainly from the uterine arteries, which are branches of the internal iliac arteries. • They enter the broad ligaments beside the lateral parts of the fornix of the vagina, superior to the ureters. • At the isthmus of the uterus, the uterine artery divides into a large ascending branch that supplies the body of the uterus and a small descending branch that supplies the cervix and vagina. • 2- The uterus is also supplied by the ovarian arteries, which are branches of the aorta. • The uterine arteries pass along the sides of the uterus within the broad ligament and then turn laterally at the entrance to the uterine tubes, where they anastomose with the ovarian arteries.

25. Venous Drainage of the Uterus • The uterine veinsenter the broad ligaments with the uterine arteries. • They form a uterine venous plexuson each side of the cervix and its tributaries drain into the internal iliac vein.

26. Lymphatic Drainage of the Uterus • The uterine lymphatic vessels follow three main routes : • 1- Most vessels from the uterine fundus and superior uterine body pass along the ovarian vessels to the lumbar (caval/aortic) lymph nodes, but some vessels pass along the round ligament of the uterus to the superficial inguinal lymph nodes. • 2- Vessels from most of the uterine body pass within the broad ligament to the external iliac lymph nodes. • 3- Vessels from the uterine cervix pass along the uterine vessels, to the internal iliac lymph nodes and along the uterosacral ligaments to the sacral lymph nodes.

27. Innervation of the Uterus • The nerves of the uterus arise from the inferior hypogastric plexus, largely from the partknown as the uterovaginal plexus. • This lies in the broad ligament on each side of the cervix. • Parasympathetic fibresare from the pelvic splanchnic nerves (S2-4), and sympathetic fibresare from the above plexus. • The nerves to the cervixform a plexus in which are located small paracervical ganglia.

29. The Uterine Tubes • These are 10 cm longand 1 cm in diameter. • They extend laterally from the cornua of the uterus. • The uterine tubes carry oocytes from the ovaries and sperm cells from the uterus to the fertilization site in the ampulla of the uterine tube. • The uterine tube also conveys the dividing zygote to the uterine cavity. • Each tube opens at its proximal end into the cornua or horn of the uterus. • At its distal end, it opens into the peritoneal cavity near the ovary. • The uterine tubes allow communication between the peritoneal cavity and the exterior of the body. • The uterine tube is divided into 4 parts: infundibulum, ampulla, isthmus, and intramural or uterine parts.

31. The infundibulum is the funnel-shaped distal end that opens into the peritoneal cavity through the abdominal ostium. The finger-like processes of the infundibulum, the fimbriae, spread over the medial surface of the ovary; one large ovarian fimbria is attached to the superior pole of the ovary. About 2 mm in diameter • The ampulla, the widest and longest part, making up over half of its length,begins at the medial end of the infundibulum. • The isthmus, the thick-walled part, enters the uterine cornu.(about 2.5 cm) • The uterine part is the short intramural segment that passes through the wall of the uterus and opens through the uterine ostium into the uterine cavity at the uterine horn.

32. The Mesosalpinx • The uterine tubes lie in the free edges of the broad ligaments of the uterus. • The part of the broad ligament attached to the uterine tube is called the mesentery of the tube or mesosalpinx

33. Arterial Supply of the Uterine Tubes • The arteries to the tubes are derived from the uterine and ovarian arteries. • The tubal branches pass to the tube between the layers of the mesosalpinx.

34. Venous Drainage of the Uterine Tubes • The veins of the tubes are arranged similarly to the arteries and drain into the uterine and ovarian veins. • Lymphatic Drainage of the Uterine Tubes • The lymph vessels of the uterine tubes follow those of the fundus of the uterus and ovary and ascend with ovarian veins to the aortic lymph nodes in the lumbar region. • Innervation of the Uterine Tubes • The nerve supply of the uterine tubes comes partly from the ovarian plexus of nervesand partly from the uterine plexus.

35. Ovaries • The almond-shaped ovaries are typically located near the attachment of the broad ligament to the lateral pelvic walls, suspended from both by peritoneal folds, the mesovarium from the posterosuperior aspect of the broad ligament and the suspensory ligament of the ovary from the pelvic wall • The suspensory ligament conveys the ovarian vessels, lymphatics, and nerves to and from the ovary and constitutes the lateral part of the mesovarium. • Peritoneal coverings • Because the ovary is suspended in the peritoneal cavity, the oocyte expelled at ovulation passes into the peritoneal cavity but is usually trapped by the fimbriae of the uterine tube and carried to the ampulla.

37. The ovary also attaches to the uterus by the ligament of ovary, which runs within the mesovarium. • This ligament is a remnant of the superior part of the ovarian gubernaculum of the fetus and connects the proximal (uterine) end of the ovary to the lateral angle of the uterus, just inferior to the entrance of the uterine tube.

39. Blood supply of the ovary: • The ovarian arteries arise from the abdominal aorta • Ovarian veins draining the ovary form a pampiniform plexus of veins in the broad ligament near the ovary . • The veins of the plexus merge to form a singular ovarian vein, which leaves the lesser pelvis with the ovarian artery. • The right ovarian vein ascends to enter the inferior vena cava; the left ovarian vein drains into the left renal vein

41. The lymphatic vessels from the ovary: • join those from the uterine tubes and fundus of the uterus as they ascend to the right and left (caval/aortic) lumbar lymph nodes • Innervation: • The nerves descend along the ovarian vessels from the ovarian plexus, and from the uterine (pelvic) plexus

42. Vagina • It extends from the cervix of the uterus to the vestibule of the vagina. • The vagina communicates superiorly with the cervical canal and opens inferiorly into the vestibule of the vagina. • In the anatomical position, the vagina descends anteroinferiorly. • The posterior wall is about 1 cm longer than the anterior wall and is in contact with the external uterine ostium (external os).

43. The vagina is located posterior to the urinary bladder and anterior to the rectum and passes between the medial margins of the levatorani muscles. • It pierces the urogenital diaphragm with the sphincter urethrae muscle. • The posterior fibres of the sphincter urethrae muscle are attached to the vaginal wall. • The cervix of the uterus projects into the superior part of the anterior wall, separating the walls of the vagina.

45. The uterus lies almost at a right angle to the axis of the vagina (anteverted position). This uterine angle increases as the urinary bladderfills. • The vaginal recess around the cervix is called the fornix • It is divided into anterior, posterior, and lateral parts. • The posterior part of the fornix is the deepest and is related to the rectouterine pouch

47. Four muscles compress the vagina and act like sphincters: pubovaginalis, external urethral sphincter, urethrovaginal sphincter, and bulbospongiosus Relations: • Anteriorly: the fundus of the urinary bladder and urethra. • Laterally: the levatorani, visceral pelvic fascia, and ureters. • Posteriorly (inferior to superior): the anal canal, rectum, and rectouterine pouch.

48. Vasculature of Vagina • The arteries supplying the superior part of the vagina derive from the uterine arteries; • the arteries supplying the middle and inferior parts of the vagina derive from the vaginal arteries and internal pudendal arteries • The veins form the vaginal venous plexuses along the sides of the vagina and within the vaginal mucosa. • These veins communicate with the uterine venous plexus as the uterovaginal plexus and drain into the internal iliac veins through the uterine vein.

50. The lymphatic vessels drain from the vagina as follows : • Superior part: to the internal and external iliac lymph nodes. • Middle part: to the internal iliac lymph nodes. • Inferior part: to the sacral and common iliac nodes. • External orifice: to the superficial inguinal lymph nodes.