Chapter 39 Flashcards
Pelvic landmarks
mons pubis
labia majora
labia minora
clitoris
urethral opening
vestibule of vagina
Bony pelvis
2 coxal bones
sacrum
coccyx
true and flase pelvis
true pelvis
situated inferior to caudal portion of parietal peritoneum
condisered pelvic cavity
pelvic cavity
posterior wall formed by sacrum and coccyx
posterolateral wall formed by piriformis and coccygeus muscles
anteriolateral walls formed by hip bones and obturator internus muscles, which rim ischium and pubis
lower margin formed by levator ani and coccygeus muscles
known as pelvic diapraghm
perineum
area below pelvic floor
pelvic cavity
posterior: rectum, colon and ileum
anterior: bladder, ureters, ovaries, fallopian tubes, uterus, vagina
muscles of pelvis
psoas major: sidewall
iliacus: sidewall
Piriformis: posterolateral wall
Obturator internus: anterolateral pelvic sidewall
Levator ani: pelvic floor (diaphragm)
Coccygeus: posterior pelvic floor (diaphragm)
Abdominal wall
muscles extend superiorly from xyphoid process to symphysis pubis inferiorly
paried rectus abdominis anteriorly
external obliques
internal obliques
transvers abdominis anteriolaterally
muscles of false pelvis
Psoas major
iliacus muscles
psoas muscles join with iliacus muscles to form iliopsoas muscles
Muscles of true pelvis
Piriformis muscles
obturator internus muscles
muscles of the pelvic diaphragm
muscles of pelvic diaphragm
Levator ani (pubococcygeus, iliococcygeus and puborectalis muscles)
Coccygeus muscles
Bladder
apex: located posterior to pubic bones
Base: anterior to vagina, superior surface related to uterus
Neck: rests on upper surface of urogenital diaphragm; inferiolateral surfaces relate to retropubic fat, obturator internus, levator ani muscles, pubic bone
Ureters
cross pelvic inlet anterior to bifurcation of common iliac arteries
run anterior to internal iliac arteries and posterior to the ovaries
coarse anteriorly and medially under base of broad ligament where crossed by uterine artery
run anterior and lateral to upper vagina to ender posteroinferior bladder
Vagina physical description
collapsed musclular tube that extends from external genitalia to cervix of uterus
approx 9cm in length
l
Vagina landmarks
normally directed up and back fromning 90 with uterine cervix
extends up and back from vulva
upper half lies above pelvic floor
lower half lies within perineum
vaginal lumen surrounding cervix divided into 4 fornices
Vaginal blood supply
from vaginal and uterine arteries
drains into internal iliac vein
Cervix
projects into vaginal canal
endocervix
exocervix
protrudes into upper portion of vaginal canal forming 4 recess (fornices)
continuous ring shaped space with posterior fornix running deeper than ints anterior counterpart
Endocervix
cervical canal
communicates with uterine cavity by internal os
with vagina by external os
exocervix
continuous with vagina
Uterus
hollow pear shaped organ
fundus
body
cervix
usually anteflexed and anteverted
covered with peritoneum except anteriorly below os where peritoneum reflected onto bladder
supported by levator ani muscles, cardinal and uterosacral ligaments
round ligaments hold uterus in anteverted position
Uterine size
premenarchal: 1-3 cm long by .5-1 cm wide
menarchal: 6-8 cm long by 3-5 cm wide
w/multiparity: increases by 1-2 cm
postmenapausal: 3.5-5.5 cm long by 2-3 cm wide
uterine body
posterior to vesicouterine pouch and superior surface of bladder
anterior to rectouterine pouch (of Douglas), ilium, colon
medial to broad ligaments and uterine vessels
uterine cavity is funnel shaped in coronal plane, slitlike in sagital plane
layers of uterus
perimetrium
myometrium
endometrium
perimetrium
serous outer layer of uterous
serosa
myometrium
muscular middle layer of uterus composed of thick smooth muschle supported by connective tissue
endometrium
inner mucous membrane
glandular portion of uterine body
uterine ligaments
broad
mesovarium
mesosalpinx
round
cardinal
uterosacral
suspensory
ovarian
broad uterine ligament
lateral aspect of uterus to pelvic sidewall
mesovarium uterine ligament
posterior fold of broad ligament
encloses ovary
mesosalpinx uterine ligament
upper fold of broad ligament
encloses fallopian tube
Round uterine ligament
fundus to anterior pelvic sidewalls
holds uterus forward
cardinal uterine ligament
extend across pelvic floor laterally
firmly supporst cervix
uterosacral ligament
extend from uterine isthmus downward
along side rectum to sacrum
firmly supports cervix
suspensatory uterine ligament
extends from lateral aspect of ovary to pelvic sidewall
ovarian uterine ligament
extends medially from ovary to uterine cornua
Uterine postions
anteversion
dextroversion
retroversion
retroflexion
Anteversion uterus
most common position
fundus and body bent forward toward cervix
Dextroversion uterus
levoversion
normal variant in absence of pelvic masses
retroversion uterus
entire uterus tilted posteriorly
retroflexion uterus
fundus and body bent backward towards cervix
Fallopian tubes
infundibulum
ampulla
isthmus
interstitial portion
12 cm in length
blood supplied by ovarian arteries and veins
fallopian infundibulum
funner shaped lateral tube projects beyond broad ligament to overlie ovaries
free edge of the funnel has fimbriae
Ampulla of fallopian tube
widest part of tube where fertilization occurs
isthmus of fallopian tube
hardest part
lies lateral to uterus
interstitial of fallopian tube
pierces uterine wall ar cornua
Ovaries
almond shaped
attached at posterior aspect of broad ligament by mesovarium
lie in ovarian fossa
fossa bounded by ext iliacs, ureter obturator nerve
dual blood supply ovarian and uterine artery
blood drained by ovarian vein into IVC on right and renal vein on left
Variable postinos of ovaries
anterior to internal iliac artery and vein
medial to external iliac artery and vein
ellipsoid shape with long azis oriented vertically
location highly variable as ligaments loosen, especially after pregnancy
Ovaries normal anatomy
outer layer (cortex)
medulla
ovary cortex
primarily follicles in varying stages of development
covered by layer of dense connective tissue
tunica albuginea
tunica albuginea surrounded by single layer of cells germinal epithelium
medulla of ovary
composed of connective tissue containing blood, nerves, lymphatic vessels and some smooth muscle at region of hilum
Ovarie reproductive cell
ovum
two known hormones
estrogen: secreted by follicles
progesterone: secreted by corpus luteum
ovarian hormone responisibility
responsible for producing and maintaining secondary gender characteristics
preparing uterus for implantation of fertilized ovum
development of mammary glands in female
ovarian ligaments
supported medially by ovarian ligaments originating bilaterally at cornua of uterus
laterally by suspensory (infundibulopelvic) ligament extending from infundibulim of fallopian tubke and ovary to sidewall of pelvis
Ovary also attached to posterior aspect of broad ligament via mesovarium
Pelvic vasculature
ext iliacs arteries: medial psoas border
ext iliac veins: medial and posterior to arteries
Int iliac arteries: posterior to ureters and ovaries
Int iliac veins: posterior to arteries
uterine arteries and veins: between layers of broad ligaments, lateral to uterus
Pelvic vasculature branches
arcuate arteriers
radial arteries
straight and spiral arteries
ovarian arteries
ovarian veins
arcuate arteries
arclike arteries that encircle uterus in outer third of myometrium
radial arteries
branches of arcuate arteries that extend from myometrium to base of endometrium
Straight and spiral arteries
branches of radial arteries that supply zona basalis of endometrium
ovarian arteries
branch laterally off aorta
run within suspensatory ligaments and anstomose with uterine arteries
ovarian veins
right vein drains into IVC
left drains into left renal vein
Mestrual cycle
reproductive years begin around 11-13 at onset of menses
end around age 50 whn menses ceases
cycle approx 28 days in length
begins with first day of menstrual bleeding
polymenorrheic
mestrual cycle occurs less than 21 days
oligomenorrheic
menstrual sycel occurs longer than 35 days
menstrual status
premenarche: prepuberty
menarche: menstruating approx every 28 days
menopause: cessastion of menses
Ovulation
explosive release of ovum from ruptured graafian follicle
rupture associated with small amounts of fliud in posterior cul-de-sac midcycle
midcycle dull ache on either side of lower ab lasting a few hrs
“mittelschmerz” middle pain
luteal phase
begins with ovulatoin and about 14 days in length
menstruation almost always occurs 14 days aftern ovulation
cells in lining of ruptured ovarian follicle begin to multiply and create corpus luteum (yellow body)
luteinization and is stimulated by LH surge
corpus luteum begins secreting progesterone
9-11 days after ovulation
corpus luteum degenerates causing progesterone levels to decline
this decline causes menstration to occur and the cycle begins again
conception and implantation
human chorionic gonadotropin (HCG) produced by the zygote causes corpus luteum to persist
it will continue to secrete progesterone for 3 more months until placenta takes over
endometrial changes
varying levels of estrogen/progesterone levels induce changes
changes correlate with ovulatory cycles of ovary
3 phases
menstrual phase
proliferative phase
secratory phase
Endometrial menstrual phase
lasta approx 1-5 dyas and begins with declining progesterone levels
causes spiral arterioles to constrict
decreased blood flow to endometrium resulting in ischemia and shedding of zona functionalis
first 5 days coincide with follicular phase of ovarian cycle
as follicles produce estrogen they stimulate the superficial layer of endometrium to regenerate and grow
Endometrial proliferative phase
lasts until luteiniation of graafian follicle around ovulation
with ovulation and luteinization of graafian follicle progesterone secreted by ovary causes spiral arteries and endometrial glands to enlarge
prepares endometrium for implanation should conception occur
Endometrial secretory phase
extends from approx day 15 to onset of menses (day 28)
secretory phase corresponds to luteal phase of ovarian cycle
Proliferative phase summary
days 1-14
corresponds to follicular phase of ovarina cycle
mestruation occurs on days 1-4
thin endometrium
estrogen level increases as ovarian follicles develope
‘increasing estrogen causes uterine lining to regenerate and thicken
ovulation occurs on day 14
Secretory phase summary
days 15-28
corresponds to uteal phase of ovarian cycle
ruptured follicle becomes corpus luteum
corpus luteum secretes progesterone
endometrium thickens
no pregnancy, estrogne/progesterone decrease
menses day 28
Endometrial changes
during menses not uncommon to see varying levels of fluid and debris with uterine cavity
with menstruation endometrium becomes thin echogenic line during early proliferative phase
as regeneration occurs endometrium will thicken to 4-8mm in proliferative phase
endometrium sonogram appearance
hypoechoic
3 line sign
Zona basalis anteriorly and posteriorly
central line representing the cavity
Endometrium at ovulation
measures 6-10 mm and becomes isoechoic with myometrium just before ovulation
after ovulation thickest dimension avg 7-14 mm
becomes echogenic blurring 3 line appearance
postmenopausal endometrium
patients NOT on HRT thickness of
patients on HRT or taking tamoxifen may be up to 8 mm
menorrhagia
abnormally heavy or long periods
dysmenorrhea
painful periods
amenorrhea
absence of menstruation
pelvic recess
vesicouterine pouch
rectouterine pouch
\retropubic space
vesicouterine pouch
anterior cul-de-sac
anterior to fundus between uterus and bladder
rectouterine pouch
posterior cul-de-sac
posterior to uterine body and cervix
between uterus and rectum
retropubic space
space of retzius
between bladder and symphysis pubis
