2.1 Clinical Anatomy - Female

Question 1

Give 4 key anatomical structures of the female reproductive tract

Answer 1

• Ovary
• Uterus
• Uterine tubes
• Vagina and external genitalia

Question 2

Name two major purposes of the ovary

Answer 2

1) produce mature ova for fertilisation
2) generate steroid hormones

Question 3

Name the four parts of the uterus from superior-inferior

Answer 3

1) Fundus
2) Uterine tubes
3) Body
4) Cervix

Question 4

Gonads develop within the _________. They descend from the lumbar regions of the _________ following the pathway of the _________ and then relocate into the pelvis

Answer 4

Mesonephric ridge, posterior abdominal wall, Gubernaculum

Question 5

Once in the pelvis compare the decent or the ovaries vs testis

Answer 5

Unlike the testis the Ovary does NOT pass from pelvis into inguinal canals!!

Question 6

What do the cranial and caudal portions of the gubernaculum in females become?

Answer 6

Cranial part: Ovarian Ligament

Caudal part: Round Ligament of the uterus

Question 7

What is the anatomical relationship of the ovaries to the uterus and the pelvic inlet

Answer 7

Just lateral and posterior to the uterus

Inferior to the pelvic inlet

Question 8

What is the arterial supply of the ovary?

Answer 8

Ovarian arteries which are direct branches off the abdominal aorta (L2)

Arising just below the renal arteries

Question 9

What is the venous drainage of the ovary? (2)

Answer 9

Right ovarian vein ➞ IVC
Left ovarian vein ➞ L renal vein ➞ IVC

Question 10

Which lymph nodes drain the ovary?

Answer 10

The lumbar Para-aortic lymph nodes

Question 11

What are the cranial and caudal attachements of the paramesonephric ducts?

When do these ducts persist and what happens in this instance?

Answer 11

• 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

Question 12

The 2 blue arrow below are pointing to 2 Peritoneal Recesses, which are vital relations of the uterus; lable and describe them

Answer 12

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

Question 13

Below is an image of a male, what is the one peritoneal recess the blue arrow is pointing to?

Answer 13

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

Question 14

In unsafe abortions what structure is at risk of damage how?

Answer 14

In females the Recto-uterine Pouch (pouch of douglas) can easily be punctured

Question 15

What are the fallopian tubes and what are they enclosed by?

Give 3 functions

Answer 15

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)

Question 16

Compare the lining of the fallopian tube to that of the uterus?

What is the consequence of this for ectopic implantation?

Answer 16

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

Question 17

What are the 4 sections of the fallopian tubes?

Which is the normal sit for fertilisation

Answer 17

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)

Question 18

What is Tubal Ligation and how is it done?

Answer 18

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

Question 19

What is the medical name for removal of the uterine tubes + ovaries and when might it be done?

Answer 19

Salpingo-Oophorectomy

Removal due to: cancer risks or reproductive disorders

Question 20

What is the most common cause of tubal damage and what are 2 major consequences of this?

Answer 20

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

Question 21

What are the 4 MAJOR sets of Uterine ligaments and what are their anatomical locations

Answer 21

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

Question 22

Give 3 minor uterine ligaments

Answer 22

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.

Question 23

Describe the structure of the broad ligament

How can it be divided into 3 parts?

Answer 23

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)

Question 24

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

Answer 24

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

Question 25

Describe the Cardinal (Transverse Cervical) Ligament

Answer 25

Fascia that extends from the cervix to the lateral pelvic walls

Question 26

Describe the Uterosacral Ligament and state what it assists in?

What other minor ligament also has the same function

Answer 26

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)

Question 27

Give a reason why uterine ligaments may fail and give 2 consequences failure could lead to

Answer 27

Eg. ligaments can get stretched during childbirth

Failure of ligaments can lead to uterine and/or vaginal prolapse (1st, 2nd or 3rd degree)

Question 28

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

Answer 28

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

Question 29

What is the Cervix and what are 2 functions?

Answer 29

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

Question 30

What 2 gutters are formed by the cervix and how?

Answer 30

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

Question 31

What are the 2 openings formed in the cervix?

Answer 31

The internal os: the opening from the cervix to the uterus.

The external os: the opening from the cervix to the vagina

Question 32

What are the 2 parts to the cervix and describe the epithelium of each?

What is the junction where this changes?

Answer 32

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)

Question 33

What disease are cervical carcinomas strongly associated with?

What age group has the highest prevalence?

Answer 33

Strong link with HPV and more common in younger women

Question 34

How do cervical carcinomas commonly metastasize?

Name 3 ways to diagnose this and list one treatment option

Answer 34

Commonly spreads through lymphatics into internal and common iliac lymph nodes

Diagnosis: inspection, imaging, biopsy

Treatment: can include removal of cervix/uterus

Question 35

What is an endometrial carcinoma and where does it usually occur?

What age group has the highest prevelance and list one major symptom

Answer 35

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.

Question 36

How is detection of premalignant cervical cancer usually done and why?

Answer 36

A Pap (Papanicolaou) smear

because this enables visual inspection of the cervix + collection of cellular material which can be microscopically examined

Question 37

What is Endometriosis?

What is the most common symptom?

Answer 37

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

Question 38

What is the arterial supply of the vagina?

(superior and inferior)

Answer 38

Superior portion of the vagina: uterine arteries

Middle/inferior portions: supplied by the vaginal and internal pudendal arteries

Question 39

Which lymph nodes drain the following?

1) Ovary
2) Fundus + Upper body
3) Lower Part (Body) + Cervix

Answer 39

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

Question 40

What are the 3 main structures of the female external genitalia?

Answer 40

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

Question 41

What is the vaginal orifice?

Answer 41

Opening into the vestibule along with the external urethral orifice and the ducts of the greater & lesser vestibular glands

Question 42

What are the greater vestibular glands also known as and what is their function?

What is the equivalent in males?

Answer 42

Bartholin Glands: secrete mucus to provide vaginal lubrication during sex

Equivalent to bulbourethral glands in males

Question 43

What are the 3 muscles in the vagina?

Label diagram below + include one ligament

Answer 43

1) bulbospongiosus muscle
2) perineal body
3) Ischiocavernosus muscle

Diagram also includes the “superficial transverse perineal muscle” and the suspensory ligament of clitorus

Question 44

Below is an image of the structure underlying the muscle layers of the vagina, what is A pointing too?

Answer 44

Corpora Caverosa (YES females also have this)

Question 45

What is a culdocentesis, when is it used and how is it performed?

Answer 45

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

Question 46

Describe the nervous innervation to the uterus and vagina

Answer 46

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)

Question 47

What is the pelvic pain line and why is it important?

How does it determine the course of visceral afferent sensation?

Answer 47

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)

Question 48

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)

Answer 48

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

Question 49

Describe the pathway of the pudendal nerve (3)

What 3 branches does it give off?

Answer 49

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

Question 50

Give an example of when you would use a pudendal nerve block and why?

Answer 50

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)

Question 51

What is the lowest point in the peritoneal cavity of females?

Answer 51

The pouch of Douglas