Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

2. MOB TCD Uterus, Broad Ligament, Ovary Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

3. MOB TCD Uterus • Pear-shaped muscular organ • 8 cm long • 5 cm wide • 3 cm thick • Non-pregnant state • Pelvic organ

4. MOB TCD Uterus

5. MOB TCD Uterus • Fundus • Body • Cervix opens into vault or fornices of vagina • Fundus is the portion above entrance of uterine tubes • Covered with peritoneum • Body • Triangular cavity

6. MOB TCD Cervix • Supravaginal • Isthmus is a circular borderline area between the body and cervix • Isthmus is the supra vaginal portion of cervix lower uterine segment • Intravaginal is surrounded by gutter fornices • Posterior is deeper covered with peritoneum

7. MOB TCD Cervix • Internal os is the opening from the body • Spindle shaped cavity • External os is the opening into vagina • Cervix lined columnar epithelium • Arbor vitae in nullipara • Intravaginal portion of cervix covered by stratified epithelium

8. MOB TCD Cervix • External os • Junction of columnar of the cervical canal • Stratified epithelium of the intravaginal portion • Site of cancer of cervix • Cervical smear

9. MOB TCD Cervix • At birth cervix is larger than the body • Fully developed cervix is one third of body

10. MOB TCD Peritoneum • Reflected from the superior surface of the bladder • Junction of the supravaginal portion of the cervix and the body of the uterus • Uterovesical pouch • Covers body, fundus • Covers the posterior surface body and the supravaginal portion of cervix • Upper third of posterior surface of vagina

11. MOB TCD Pouch of Douglas • Upper third of posterior surface of vagina (posterior fornix) • Peritoneum reflected on to junction of upper two thirds and lower third of rectum • Pouch of Douglas is most dependent part of female peritoneal cavity • Broad ligament is lateral

12. MOB TCD Uterus • Uterus is anteverted • i.e. anterior to vertical plane going through the vagina • Posterior fornix deeper • Anteflexed • Bent anteriorly at junction of body and cervix

13. MOB TCD Uterus • Serous layer • Myometrium • No submucous layer • Endometrium • Three layers • Basal • Spongy • Compact at surface of uterine cavity

14. MOB TCD Myometrium • Myometrium makes up bulk of uterine wall • Blood vessels more evident in middle layer

15. Myometrium MOB TCD

16. MOB TCD Uterine Muscle

17. MOB TCD Blood Supply • Uterine • Ovarian • Vaginal arteries • Anterior and posterior arcuate run in middle layer

18. MOB TCD Blood Supply • Radial branches • Basal layer • Spiral branches to superficial two layers • Veins below artery • Plexus in lower edge broad ligament into internal iliac

19. MOB TCD Blood Supply

20. MOB TCD Nerve Supply of Uterus • Pain from cervix via parasympathetic S2,3 • Pain from body via sympathetic to T11 and T12

21. MOB TCD Lymphatics

22. MOB TCD Supports of Uterus Upper • Round ligament • Broad ligament anteverted Middle • Transverse ligament • Pubocervical • Uterosacral Lower • Levator ani, coccygeus • Perineal body

23. MOB TCD Round Ligament • Round ligament and • Ligament of ovary • develop from the gubernaculum • Side of uterus, junction fundus and body • Inguinal canal to labium majus • Anteversion

24. MOB TCD Broad Ligament • Fold of peritoneum from side of uterus to side wall of pelvis • Framework of pelvic fascia • Parametric fat • Anterior surface looks inferiorly • Free upper border • Base on pelvic floor

25. MOB TCD Broad Ligament • Uterine tubes • Ovarian vessels • Uterine vessels • Epoophoron • Paroophoron • Round ligament of uterus and ligament of ovary • Transverse ligament • Ovary attached to posterior layer • Ureter in base below artery

26. MOB TCD Broad Ligament • Uterine tube lies in medial four fifths of free border of broad ligament • Lateral one fifth • Contains ovarian vessels • Infundibulo-pelvic or suspensory ligament of ovary

27. MOB TCD Broad Ligament • Mesosalpinx • Mesometrium • Mesoovarian • Epoophoron • Parallel tubules • Gaertners duct remains mesonephric tubules and duct, may form cysts

28. MOB TCD Uterine Artery • Uterine artery lies superior to the ureter at lateral fornix of vagina • Base of broad ligament

29. MOB TCD Pubocervical Ligament • Attached • Anteriorly to posterior aspect of body of body of pubis • Passes to neck of bladder • Anterior fornix of vagina

30. MOB TCD Pubocervical Ligament • Pubocervical ligaments help to maintain normal angle of 45°between the vagina and horizontal • Decrease may cause a cystocoele

31. MOB TCD Transverse Ligament • Transverse or cardinal or mackenrodt ligament • Thickening of visceral layer of pelvic fascia around uterine artery • Lateral to medial in base of broad ligament

32. MOB TCD Uterosacral Ligament • Uterosacral contains fibrous tissue • Nonstriated muscle • Attached from the cervix to the middle of sacrum • Contains lymphatics draining cervix to sacral glands

33. MOB TCD Uterosacral Ligament • Uterosacral help to keep uterus anteverted • If uterus is anteverted it cannot prolapse

34. MOB TCD Uterine Tube • Intramural • Isthmus • Ampulla • Infundibulum • Lined ciliated columnar epithelium • Beats towards uterus

35. MOB TCD Uterine Tube • Peritoneum • Loosely attached to ampulla • Tightly to isthmus • Fimbria surrounding opening into peritoneal cavity • Ovarian fimbria

36. MOB TCD Embryology of Uterus

37. MOB TCD Ovary • Attached to posterior layer of broad ligament mesoovarian • Covered with germinal epithelium • Side wall of pelvis covered with peritoneum • Obturator internus muscle • Obturator nerve supplies the parietal peritoneum • Ureter posterior • Ligament of ovary medially

38. Obturator nerve supplies the parietal peritoneum Irritation of the peritoneum of the side wall by bleeding at ovulation or by lesions involving the ovary, may result in referred pain to medial side of the thigh or the knee MOB TCD Ovary

39. MOB TCD Ovary • Blood supply • One ovarian artery from lateral aspects of aorta L2 • Right vein drains into IVC • Left drains into left renal vein • Lymphatics into paraaortic glands L2

40. MOB TCD Vagina • Fornices surround cervix • Anterior wall shorter posterior • Walls in contact except superior • External os • Opens into vestibule of vagina

41. MOB TCD Vagina • Pelvis • Lateral uterine artery above ureter • Levator ani • Deep pouch • Sphincter urethrae • Bulbs of vestibule • Greater vestibular glands

42. MOB TCD Vagina • Urethra embedded in lower two thirds of anterior wall • Posterior fornix peritoneum of pouch of Douglas • Rectum • Perineal body

43. MOB TCD Vagina • Pelvic fascia • Erectile tissue • Muscular wall • Non-keratinised stratified squamous epithelium

44. MOB TCD Blood and Nerve Supply Vagina • Uterine artery • Vaginal • Internal pudendal • Labial • Ilio Inguinal nerve supplies the anterior wall • Labial nerves supply the posterior wall

45. MOB TCD Lymphatics of Vagina • Internal iliac • Lower third • Medial group of proximal superficial inguinal glands

46. MOB TCD Pelvic Sympathetic

47. MOB TCD Pelvic Plexuses • Supply pelvic organs • Contains • Sympathetic • Preganglionic parasympathetic nerves • Lateral column S2,3,4

48. MOB TCD Pelvic Plexus • Hypogastric plexus • Lumbar splanchnics • Presacral nerve • Anterior to body of L5 • Divide into pelvic plexuses • Postganglionic of sympathetic that relayed in lumbar and sacral ganglia

49. MOB TCD Sympathetic • Ejaculation is via sympathetic impulses from L1-L2 • Contraction of sphincters of bladder and anal canal

50. MOB TCD Pelvic Parasympathetic • Preganglionic have cell bodies in lateral column of segments S2,3,4 • Ganglia found close to or in wall of organ • Supplies intestine from splenic flexure to upper two thirds of anal canal