Female Pelvis Continuation

Question 1

Vulva, Mons pubis, Labia majora/minora

Answer 1

• Vulva – collectively refers to external genitalia of female; best viewed in lithotomy position
• Mons pubis – external hair bearing region of fatty tissue anterior to pubic symphysis
• Labia majora – hair bearing continuation of mons pubis downward to perineal body
• Labia minora – non-hair bearing tissue medial to labia majora that meets superiorly to form prepuce externally covering the clitoris

Question 2

Frenulum, Vestibule, Fourchet, Vaginal Orifice

Answer 2

• Frenulum – internal portion of labia minora; extends from bottom of the clitoris to the ureathral meatus
• Vestibule – area of vulva surrounded by labia minora into which the urethra and vagina open
• Fourchet – inferior margin of vagina where perineal body meets the labia major
• Vaginal orifice – opening to the vagina deep to the vestibule that may be surrounded by hymenal tags

Question 3

Round Ligament

Answer 3

• Round ligament in females = gubernaculum in male testis

o Travels from junction of uterus/fallopian tube through the deep inguinal ring to labia majora

Question 4

Broad Ligament

Answer 4

• Broad ligament – peritoneum around the uterus, ovaries, and fallopian tubes; attach to lateral pelvic wall
o Mesometrium – majority of broad ligament that surround the uterus; contains the ureter
o Mesosalpinx – portion of broad ligament that extends around fallopian tube
o Mesovarium – portion of broad ligament that suspends the ovaries

Question 5

Cardinal Ligament

Answer 5

– laterally envelops the inferior aspect of uterus and contains the uterine vessels

Question 6

Anterior/Posterior cul-de-sac

Answer 6

• Rectouterine pouch (pouch of Douglas) – posterior cul-de-sac – between uterus and rectum
• Vesicouterine pouch - anterior cul-de-sac – between uterus and bladder

Question 7

Physical Exam of Female

Answer 7

o	Retractor (Speculum exam) – place into vagina to view cervix, do pap smear, overall inspection
o	Bimanual (2 fingers in vagina and push on abdomen) – feel uterus (size of fist); most uterus are anteverted (tilt forward)
o	Rectovaginal (1 finger in vagina; 1 in rectum) – examin rectovaginal septum; rectouterine pouch
o	Bimanual exam of adnexa – place finger in fornix of vagina and push on abdomen to feel fallopian tubes and ovary (adnexa)

Question 8

Disorders of Pelvic Support (Prolapse)

Answer 8

– all occur as result of loss of fascial supports secondary to congenital anatomic weakness, stress of child bearing, injury, surgical damage, &/or chronic straining activities relative to lifting or constipation
o Cystocele – protrusion of bladder into vagina; due to weakness of vesicovaginal septum
o Descensus of cervix & uterus (aka prolapse or procedentia) – protrusion of cervix & uterus
o Enterocele – herniation of pouch of Douglas between uterosacral ligament into the rectovaginal septum; usually contains small bowel
o Rectocele – protrusion of rectum into the vagina
o Urethrocele – protrusion of urethra into the vagina

Question 9

Degree of Prolapse

Answer 9

o 1st: prolapse into upper vagina
o 2nd: prolapse to or near the introitus of vagina
o 3rd: complete prolapse through the introitus

Question 10

Hysterosalpingogram

Answer 10

– radiograph of uterus & oviducts with a radiopaque tracing material injected into cervix that outlines the uterine cavity and searches for filling defects of blocked tubes
o Often used on patients with fertilityissues
o Can find bicornuate uterus (Y shaped) AND incompetent cervix (very dilated)

Question 11

Ectopic Pregnancy

Answer 11

– pregnancy in place other than endometrial lining of uterine cavity
o Oviduct/fallopian tube = most common
o Leading cause of maternal mortality (due to hemorrhage)
o Risk factors = pelvic infections, tubal reconstruction surgery, previous ectopic pregnancy
o Symptoms = amenorrhea, slight vaginal bleeding, pelvic pain, +betaHCG
o Diagnosis = +betaHCG, no intrauterine pregnance, adnexal mass on sonogram, diagnostic laparoscopy
o Treatment = methotrexate, salpingectomy (remove of uterine tube), salpingostomy (remove the embryo)
o Oviducts – most common

Question 12

Hysterectomy

Answer 12

– 2nd most common operation formed in US (behind C-section)
o Removal of uterus (and sometimes cervix); ligate the blood vessels in area (be careful of ureter)
o Indications: fibroids, cancer, prolapse, adenomyosis (menorrhage – more blood flow during period), DUB, uncontrolled hemorrhage, endometriosis, chronic pelvic pain
o Complications: infection, hemorrhage, ureteral injury, DVT/PE, injury to bowel/bladder/etc.
o Transvaginal & transabdominal approach

Question 13

Ureter

Answer 13

– muscular tube connecting kidney  bladder
o Right – crosses at birfurcation of common iliac artery
o Left – crosses 1-2cm above bifurcation of common iliac
o Ureter descends along convex curvature of posterolateral pelvic sidewall & becomes retroperitoneal
o Ureter crosses underneath uterine artery (water under the bridge)
o At ischial spine it runs forward and medial from uterosacral ligament to base of broad ligament where it enters the cardinal ligament (1-2 cm lateral to uterine cervix)
o Runs upward and medially to enter bladder wall at base near anterior vagina

Question 14

Ureteral Injury

Answer 14

o Common at uretovesical junction; junction of uterine artery & ureter; infundibulopelvic ligament

Question 15

Inferior Mesenteric Artery

Answer 15

– arises 3 cm above bifurcation of aorta
 Supplies: trans/descending/sigmoid colon; rectum
 Terminates: as superior hemorrhoidal artery

Question 16

Ovarian Artery

Answer 16

– arises from aorta below renal vessels; courses into retroperitoneal space, crosses anterior to ureter and enters infundibulopelvic ligament
 Branches into mesovarium artery to supply ovary and tube
 Unites with ascending branch of uterine artery

Question 17

Common Iliac Artery

Answer 17

– formed as aorta bifurcates at level L4

 5cm long before dividing into external and internal (hypogastric) iliac arteries

Question 18

Internal Iliac Artery

Answer 18

• 3-4cm I nlength; close to ureters entire cours
  • Posterior trunk: iliolumbar, lateral sacral, superior gluteal
  • Anterior Trunk
  o 3 parietal branches – obturator, internal pudendal, inferior gluteal
  o 6 visceral branches – umbilical, middle vesical, inferior vesical, middle hemorrhoidal, uterine, vaginal

Question 19

External Iliac Artery

Answer 19

– 15-20% of women gives rise to obturator artery

Question 20

Uterine Artery

Answer 20

– arises from internal iliac and runs medially toward isthmus of uterus
o 2cm lateral to endocervix it crosses over ureter and reaches sidewalls of uterus
o Divides into:
 Ascending branch – up broad ligament to anastomose with ovarian artery
 Arcuate arteries – branch to meet contralateral equivalent and form spiral arteries of corpus and endometrium
 Descending branch – supplies vagina

Question 21

Vaginal Artery

Answer 21

– arises from internal iliac or uterine arteries
o Supplies vagina, bladder, and rectum
o Anastomoses with other side to form azygos arteries of cervix and vagina

Question 22

Internal Pudendal Artery

Answer 22

– terminal branch of internal iliac

o Supplies branch to rectum, labia, clitoris, and perineum

Question 23

Veins

Answer 23

– follow course of arteries with exception of ovarian drainage
o R ovarian vein  IVC directly; L ovarian vein  L renal vein  IVC

Question 24

Post-partum Hemorrhage

Answer 24

– blood loss greater than 500cc for vaginal delivery (normally 300cc); 1000cc for C-section (normally 800cc); OR 10% drop in hematocrit
o Causes: uterine atony (multigravida patient, multiple gestations), retained placenta, uterine rupture, uterine inversion, abnormal placentation, coagulopathies
o Treatment: IV access and hydration, bimanual exam vagina and uterus; oxytototics (pitocin, methergine, hemabate); blood products; surgical therapy (curettage, vessel ligation-hypogastric/uterine, hysterectomy)

Question 25

Leiomyomas

Answer 25

• fibroids
  o 25% of women over 35
  o Non-cancerous (benign) tumors of smooth muscle located in uterus
  o Intramural, subserosal, submucosal, pedunculated
  o Symptoms: bleeding, pain, pressure, urinary frequency, constipation, enlarged abdomen, dyspareunia
  o Diagnosis: physical exam, bimanual exam, ultrasonography, CT, MRI
  o Treatment: observation, medical management, surgical management with myomectomy (remove fibroids) vs hysterectomy, uterine artery embolization

Question 26

Uterine Artery Embolization

Answer 26

– new alternative treatment
o Performed outpatient with conscious sedation by interventional radiologist
o Catheter inserted into external iliac artery in groin and guided to uterus
o Inject tiny plastic or gelatin sponge particle into uterine artery  cuts off blood to area of uterus and causes tumor to shrink
o Side effects: pain and cramping
o Risks: pain, infection, hemorrhage, need for hysterectomy, embolization of wrong vessel

Question 27

Urogenital Sinus, Paramesonephric duct, Mesonephric duct, Metanephric duct

Answer 27

o Urogenital sinus – urinary bladder, urethral & paraurethral glands, lower 1/3rd vagina, vestibular glands, hymen
o Paramesonephric duct (Mullerian) – uterus, cervix, fallopian tubes, hydatid of Morgagni
o Mesonephric duct (Wolffian) – appendix vesiculosis, duct of epoophoron, Gartner’s duct
o Metanephric duct – ureter, renal pelvic, calyces, collecting system of kidney, epoophoron, paroophoron