2.1 Clinical Anatomy - Female Flashcards
Give 4 key anatomical structures of the female reproductive tract
- Ovary
- Uterus
- Uterine tubes
- Vagina and external genitalia
Name two major purposes of the ovary
1) produce mature ova for fertilisation
2) generate steroid hormones
Name the four parts of the uterus from superior-inferior
1) Fundus
2) Uterine tubes
3) Body
4) Cervix
Gonads develop within the _________. They descend from the lumbar regions of the _________ following the pathway of the _________ and then relocate into the pelvis
Mesonephric ridge, posterior abdominal wall, Gubernaculum
Once in the pelvis compare the decent or the ovaries vs testis
Unlike the testis the Ovary does NOT pass from pelvis into inguinal canals!!
What do the cranial and caudal portions of the gubernaculum in females become?
Cranial part: Ovarian Ligament
Caudal part: Round Ligament of the uterus
What is the anatomical relationship of the ovaries to the uterus and the pelvic inlet
Just lateral and posterior to the uterus
Inferior to the pelvic inlet
What is the arterial supply of the ovary?
Ovarian arteries which are direct branches off the abdominal aorta (L2)
Arising just below the renal arteries
What is the venous drainage of the ovary? (2)
Right ovarian vein ➞ IVC
Left ovarian vein ➞ L renal vein ➞ IVC
Which lymph nodes drain the ovary?
The lumbar Para-aortic lymph nodes
What are the cranial and caudal attachements of the paramesonephric ducts?
When do these ducts persist and what happens in this instance?
- Open cranially
- Connect to the urogenital sinus caudally
Persist in the absence of MIH (produced by a testis) ➞ FEMALES
The ducts fuse down the midline to form the uterus and goes on in development to become uterine tubes, cervix and upper vagina
The 2 blue arrow below are pointing to 2 Peritoneal Recesses, which are vital relations of the uterus; lable and describe them
Anteriorly: vesico-uterine (uterovesical) pouch
- double folding of peritoneum between the anterior surface of the uterus and the bladder
Posteriorly: recto-uterine pouch (Pouch of Douglas)
- double folding of peritoneum between the rectum and the posterior wall of the uterus
- this is the LOWEST point in peritoneal cavity
Below is an image of a male, what is the one peritoneal recess the blue arrow is pointing to?
Rectovesical pouch is the forward reflection of the peritoneum from the lower third of the rectum to the upper part of the bladder in males
In unsafe abortions what structure is at risk of damage how?
In females the Recto-uterine Pouch (pouch of douglas) can easily be punctured
What are the fallopian tubes and what are they enclosed by?
Give 3 functions
Open-ended tubes that extend from each side of the superior end of uterus body. They are enclosed within Mesosalpinx (portion of broad ligament)
Functions:
1) conduct the oocyte into uterine cavity
2) site of fertilisation
3) opening into peritoneum (via the ostium of the uterine tube)
Compare the lining of the fallopian tube to that of the uterus?
What is the consequence of this for ectopic implantation?
Lining is NOT that of the uterine cavity
Uterus (inner lining = endometrium): simple columnar epithelium (on a lamina propria) meaning it has a huge number of glands to aid future pregnancy
Fallopian tubes: cilliated columnar epithelium that aid movement of the egg
Ectopic pregnancy: areas other than the uterus are not structurally or functionally able to sustain implantation/growth
What are the 4 sections of the fallopian tubes?
Which is the normal sit for fertilisation
1) Isthmus: narrows and opens into the uterine cavity
2) ampulla: FERTILISATION occurs here
3) infundibulum
4) fimbria: finger like projections (an extension of the infundibulum)
What is Tubal Ligation and how is it done?
A simple, effective means of birth control (it is the most common contraceptive method)
Done through Ligating (clipping) the uterine tubes this prevents the spermatozoa from reaching ova
What is the medical name for removal of the uterine tubes + ovaries and when might it be done?
Salpingo-Oophorectomy
Removal due to: cancer risks or reproductive disorders
What is the most common cause of tubal damage and what are 2 major consequences of this?
Salpingitis (Inflammation of tubes commonly due to infection)
- causes fusions or adhesions of the mucosa which can partially/completely block the tubes
Blocked or dysfunctional tubes can result in ectopic pregnancy or infertility
What are the 4 MAJOR sets of Uterine ligaments and what are their anatomical locations
1) Broad ligament: largest ligament, composed of a double layer of peritoneum
2) Round ligament of the uterus: attached from the ovary, travels through the inguinal canal and splays out on the labia majora
3) Cardinal (transverse cervical) Ligament: extends from circular cervix to lateral pelvic walls
4) Uterosacral Ligaments: extends from circular cervix to posterior pelvic wall, assists in maintaining anterversion
Give 3 minor uterine ligaments
1) Ovarian ligament (from uterus to ovary)
2) Suspensory ligament of Ovary (carries ovarian blood vessels and nerves from abdomen into pelvis)
3) Pubocervical Ligament: attach the cervix to the posterior surface of the pubic symphysis. They function to support the uterus within the pelvic cavity.
Describe the structure of the broad ligament
How can it be divided into 3 parts?
Double fold of peritoneum that extends laterally to sidewalls
of pelvis
1) Mesovarium: the mesentery covering the ovary
2) Mesosalpinx: the mesentery covering the uterine tubes
3) Mesometrium: largest part of ligament, the mesentery covering of the uterus body (inferior to the mesovarium and mesosalpinx)
Where is the Round Ligament embryologically derived from?
What are its anatomical attachemnts and insertions?
This is the only ligament to __________ and hence what can be said about the anatomical location of lymph nodes
Embryologically derived from the caudal end of gubernaculum
Attached from ovary, travels through inguinal canal and splays out on the labia majora
ONLY ligament to pass through the inguinal canal!!
The upper body of uterus is supplied by lymph nodes based around the round ligament, hence through embryological development this is why lymphatic drainage also passes through the inguinal canal
Describe the Cardinal (Transverse Cervical) Ligament
Fascia that extends from the cervix to the lateral pelvic walls
Describe the Uterosacral Ligament and state what it assists in?
What other minor ligament also has the same function
Fascia that extends from the cervix to the posterior pelvic walls and functions to support the uterus
Assists in maintaining anteversion
** Pubocervical ligament also supports uterus (from cervix to anterior pelvic walls)
Give a reason why uterine ligaments may fail and give 2 consequences failure could lead to
Eg. ligaments can get stretched during childbirth
Failure of ligaments can lead to uterine and/or vaginal prolapse (1st, 2nd or 3rd degree)
What is the normal position for the uterus to be in?
Name two terms can be used to describe an abnormally placed uterus and explain
Anteverted and Anteflexed
- Anteverted (bends forward) relative to axis of vagina
- Anteflexed (tilts forward) relative to axis of the cervix
Abnormal:
- *Retroverted** uterus: points upwards towards the head
- *Retroflexed** Uterus: flexes backwards at the cervix, so that the body and fundus point toward back
What is the Cervix and what are 2 functions?
The cervix is the inferior part of the uterus, it is a broad cylinder with a narrow central channel
Functions to:
- allow sperm to enter the uterine cavity to the site of fertilisation
- protect the uterus and upper genital tract from bacterial invasion
What 2 gutters are formed by the cervix and how?
The Inferior end of cervix is DOME shaped ➞ BULGES into vagina and forms two gutters (fornixes)
- Anterior Fornix
- Posterior Fornix
Fornixes = recesses of vagina around the cervix
What are the 2 openings formed in the cervix?
The internal os: the opening from the cervix to the uterus.
The external os: the opening from the cervix to the vagina
What are the 2 parts to the cervix and describe the epithelium of each?
What is the junction where this changes?
1) Endocervix: tall mucus-secreting columnar epithelium
2) Exocervix: stratified squamous non-keratinised epithelium (same as vagina)
Epithelium change is abrupt and occurs at the squamo-columnar junction (transformation zone)
What disease are cervical carcinomas strongly associated with?
What age group has the highest prevalence?
Strong link with HPV and more common in younger women
How do cervical carcinomas commonly metastasize?
Name 3 ways to diagnose this and list one treatment option
Commonly spreads through lymphatics into internal and common iliac lymph nodes
Diagnosis: inspection, imaging, biopsy
Treatment: can include removal of cervix/uterus
What is an endometrial carcinoma and where does it usually occur?
What age group has the highest prevelance and list one major symptom
A malignancy of the endometrium that most commonly occurs at the junction between the columnar cells of the endocervix and the squamous cells of the exocervix
Usually occurs in postmenopausal women
Major symptom is abnormal uterine bleeding.
How is detection of premalignant cervical cancer usually done and why?
A Pap (Papanicolaou) smear
because this enables visual inspection of the cervix + collection of cellular material which can be microscopically examined
What is Endometriosis?
What is the most common symptom?
A condition where ectopic endometrial tissue is dispersed to various sites within the peritoneal cavity and beyond (e.g. near to the umbilicus)
It may be associated with the ovaries or the attachments of the uterus
It is often associated with severe period pain (dysmenorrhoea), infertility, or both
What is the arterial supply of the vagina?
(superior and inferior)
Superior portion of the vagina: uterine arteries
Middle/inferior portions: supplied by the vaginal and internal pudendal arteries
Which lymph nodes drain the following?
1) Ovary
2) Fundus + Upper body
3) Lower Part (Body) + Cervix
1) Ovary → Lumbar Para-aortic nodes
2) Fundus + Upper body → Para-aortic and Superficial inguinal nodes
3) Lower Part (Body) + Cervix → External + Internal iliac nodes and Sacral nodes
What are the 3 main structures of the female external genitalia?
1) Labia majora: encloses the pudendal cleft and comes together to form mons pubis
2) Labia minora: encloses the vestibule of the vagina, bulbs of the vestibule and clitoris
3) Vestibule: contains orifices of the urethra, vagina and greater and lesser vestibular glands
What is the vaginal orifice?
Opening into the vestibule along with the external urethral orifice and the ducts of the greater & lesser vestibular glands
What are the greater vestibular glands also known as and what is their function?
What is the equivalent in males?
Bartholin Glands: secrete mucus to provide vaginal lubrication during sex
Equivalent to bulbourethral glands in males
What are the 3 muscles in the vagina?
Label diagram below + include one ligament
1) bulbospongiosus muscle
2) perineal body
3) Ischiocavernosus muscle
Diagram also includes the “superficial transverse perineal muscle” and the suspensory ligament of clitorus
Below is an image of the structure underlying the muscle layers of the vagina, what is A pointing too?
Corpora Caverosa (YES females also have this)
What is a culdocentesis, when is it used and how is it performed?
Peritoneal fluid is aspirated from the Pouch of Douglas (rectouterine pouch) through the posterior vaginal fornix
Used to evaluate women with pain in the lower abdomen/pelvis to determine whether intra-abdominal fluid is present
Describe the nervous innervation to the uterus and vagina
Superior 4/5: visceral innervation from UTEROVAGINAL PLEXUS (both PNS and SNS)
- pain afferents vary depending on pelvic pain line
Inferior 1/5: somatic innervation from the PUDENDAL nerve (S2-S4)
What is the pelvic pain line and why is it important?
How does it determine the course of visceral afferent sensation?
viceral afferent (VA) fibers from organs in the pelvis, depends on the organ’s position relative to the pelvic pain line. Important in determining reffered pain. If an organ in the pelvis is in contact with the peritoneum it is said to be “above” the pelvic pain line
Above: uterine fundus and body (most of uterus)
- VA fibres conducting pain impulses follow sympathetic fibres (via the inferior thoracic lumbar spinal ganglia)
Below: uterine cervix and vagina
- VA fibres conducting pain impulses follow parasympathetic fibres (via S2-S4 spinal ganglia)
Would you use a pudendal nerve block for a C-section?
Explain your answer in terms of what a pudendal nerve block would do to pain perceived in the uterus (target of C-section)
(if required give an alternative)
NO!! It will NOT do anything to uteral visceral pain because the pudendal nerve (S2-S4) only contains VA fibres from structures below the pelvic pain line.
Most of the uterus is above the pelvic pain line hence in order to “numb” the uterus we should target the sympathetic fibres of the uterovaginal plexus
This is because the superior 4/5ths of the uterus recieve visceral innervation from the uterovaginal plexus AND as the uterus is above the pelvic pain line the VA fibres travel with SNS fibres
eg. spinal block
Describe the pathway of the pudendal nerve (3)
What 3 branches does it give off?
1) Exits pelvis via greater sciatic foramen
2) Enters perineum via lesser sciatic foramen
3) Travels through pudendal canal
Gives off multiple branches:
- Perineal n: innervates perineum
- Inferior rectal nerve
- Dorsal nerve of penis/clitoris; purely sensory
Give an example of when you would use a pudendal nerve block and why?
During an Episiotomy (cutting on the perineum during childbirth) because the pudendal nerve innervates the perineum and is below the pelvic pain line (VA follow PNS fibres)
What is the lowest point in the peritoneal cavity of females?
The pouch of Douglas
