Female Reproductive System and the Breast Flashcards
What parts of the female reproductive tract lie in the pelvic cavity?
- Ovaries
- Uterine tubes
- Uterus
- Superior part of vagina
What parts of the female reproductive tract lie in the perineum?
- Inferior part of vagina
- Perineal muscles
- Bartholin’s glands
- Clitoris
- Labia
What muscle separates the pelvic cavity from the perineum and create the “pelvic floor”?
Levator Ani
What covers the superior aspect of the pelvic organs?
draping of parietal peritoneum from abdomen
The inferior parietal peritoneum forming a roof over the superior pelvic organs creates pouches. What are these called in both the female AND in the male?
Female
vesico-uterine
recto-uterine (Pouch of Douglas)
MALE
recto-vesical
Why are the pouches created by the parietal peritoneum clinically relevant?
- Excess fluid within peritoneal cavity
- collects within pouch of Douglas
- It is most inferior point when a female is standing
(recto-vesical for males)
How can excess fluid collecting in the pouch of Douglas be drained?
Needle drainage via the posterior fornix
What other areas may be sites of fluid collection in females if the Pouch of Douglas is not the most inferior?
Para-rectal fossae
All components of the female reproductive tract are considered “sub-peritoneal” except what structure?
Uterine tubes (intraperitoneal due to broad ligament)
What is the broad ligament?
Broad ligament
- double layer of peritoneum
- between the uterus and lateral walls & floor of the pelvis
=> wraps around uterine tubes completely (except fimbrae)
What is the function of the broad ligament?
helps maintain the uterus in its correct midline position
What is the round ligament?
- embryological remnant from when testes/ovaries descend from posterior abdominal wall
- attaches to the lateral aspect of the uterus
- passes through deep inguinal ring
- attaches to the superficial female perineum
What are the 3 layers of the uterus?
perimetrium
myometrium
endometrium
What is the function of the muscle in the myometrium?
- allow uterus to tretch during pregnancy
- allow contractions during labour and cramping
Where must an ovum implant in the uterus, and what complication arises if not?
- implantation of zygote in BODY of uterus
- implantation anywhere else = ectopic pregnancy
What is the most common location of ectopic pregnancy?
In the uterine tubes
Ectopic pregnancies in the abdominal cavity may actually survive. TRUE/FALSE?
TRUE
- depending on where the ovum implants and the placenta grows
How can ectopic pregnancies end up in the abdominal cavity?
Ovum is released from ovary into peritoneal cavity and if not picked up by fimbrae on end of uterine tube, then can become fertilised/implant in abdomen
What are the 3 layers of support which hold the uterus in position?
- Strong ligaments (e.g. uterosacral ligaments - these extend from cervix to sacrum)
- endopelvic fascia
- muscles of the pelvic floor (e.g. levator ani)
Weakness of the uterine support can cause what?
uterine prolapse
=> movement of the uterus inferiorly
Describe the NORMAL position of the uterus and what these terms actually mean?
- Anteverted and anteflexed (lies on superior bladder)
- Anteverted
cervix angled anteriorly relative to axis of vagina - Anteflexed
uterus angled anteriorly relative to axis of cervix
It is a normal variant for the uterus to appear retroverted and retroflexed. What does this mean?
Retroverted
cervix angled posteriorly relative to the axis of the vagina
Retroflexed
uterus angled posteriorly relative to the axis of the cervix
Why must a speculum be used in a cervical smear examination?
The walls of the vagina are usually collapsed
=> this holds them open to allow cervix to be viewed adequately
What part of the cervix is aiming to be sampled in a cervical smear and how can this area be iidentified on examination?
squamo-columnar junction (transformation zone)
- sampled due to the potential of metaplastic change
- different epitheliums appear different colours (lighter and darker => this is area to sample)
Salpinx is Greek for what?
Tube => Salpingectomy is removal of uterine tube
What names are given to the different areas of the uterine tube (working form the uterus to the fimbrae)
Isthmus
Ampulla
Infundibulum (funnel)
Fimbrae
Where in the uterine tube is fertilisation most likely to occur?
Ampulla
What complications could arise as a result of the fimbriated end of the uterine tubes opening into the peritoneal cavity?
- infection spread between abdomen and genital tract
- Pelvic Inflammatory Disease can cause peritonitis
- Ectopic pregnancy can develop in peritoneal cavity
How can the patency of uterine tubes be tested?
- Injecting radio-opaque dye into the genital tract
- scan patient to check dye is coming out into peritoneal cavity
The ovary develops on the posterior abdominal wall and then descends into the pelvic cavity. What other structures related to the ovary must also develop on the posterior abdominal wall and descend with it?
Arteries
Venous drainage
Lymphatics (i.e. ovary drains to lumbar/caval/aortic lymph nodes)
Where in the vagina do the walls not touch, and what are these spaces called?
Superiorly in vagina the cervix holds the walls apart
=> forming a fornix
4 parts:
- anterior
- posterior
- 2x lateral
What bilateral structures can be palpated at the 4 and 8 o’clock positions of the lateral fornix on pelvic examination?
Ischial spines can be palpated
How can the position of the uterus be palpated on pelvic examination?
- bimanual palpation
- two fingers inserted into posterior fornix
- non-dominant hand over abdomen to feel anteverted uterus
What are adnexae and how are they palpated on a pelvic examination?
adnexae = uterine tubes and ovaries together
- place examining fingers into lateral fornix
- press deeply with other hand in the iliac fossa
When would adnexae be palpable on pelvic examination?
If enlarged e.g. by a mass or inflammation
- patient may also be tender in the area on palpation
What is the perineum defined as?
- shallow space between pelvic diaphragm and the skin
What 4 points form the diamond shape of the Perineum?
Pubic symphysis
ischial spines X2
Coccyx
The diamond shaped perineum is split into an anterior and posterior triangle. What are the other names for these?
Urogenital Triangle
Anal Triangle
What openings are found in the pelvic floor?
- end of digestive tract => rectum and anus
- end of urinary tract => external urethral meatus
- end of reproductive tracts => vagina
The levator ani is mainly made up of skeletal muscle. Does this predominate on the medial or lateral aspect of the muscle?
Lateral = more skeletal
=> voluntary
How does the levator ani provide continual support for the pelvic organs?
- tonic contraction
- contracts further during increased intra-abdominal pressure (sneeze/cough)
Weakness of the levator ani muscle can cause hwat complications?
Incontinence
OR prolapse of the pelvic organs
What nerves supply the levator ani?
“nerve to levator ani” S3, 4, 5 (sacral plexus)
dual supply from pudendal nerve (S2,3,4)
Both the superficial and deep perineal muscles are supplied by what nerve?
pudendal nerve (S2,3,4)
What is the perineal body?
- bundle of collagenous and elastic tissue
- perineal muscles attach to this
- important for pelvic floor strength
- located just deep to skin
What is an episiotomy and why is it completed during labour?
- Labour can stretch/tear the perineal body => leaving women with incontinence/prolapse
- an episiotomy allows cuts to be made laterally in the perineum to prevent damage to the perineal body
=> pelvic floor remains intact
Where is Bartholins gland located and what is the name of the identical gland in the male?
- posterior L+R of vagina
- also known as Greater vestibular gland
- Homologous to Bulbourethral (Cowper’s) gland in males
What is the main function of Bartholin’s and Cowper’s glands?
- secrete mucous for lubrication in female and for smooth ejaculation in males
When can Bartholins gland become enlarged?
Due to infection
Where does breast tissue extend from/to?
- from ribs 2-6
- lateral border of sternum to mid-axillary line (remember axillary tail)
What does breast tissue lie on top of?
- On top of the deep fascia covering pec major
What space lies between the deep fascia of pec major, and the breast tissue, and why is this clinically relevant?
- Retromammary space between fascia and breast
- Allows breast to move relative to Pec Major muscle
- Clinical Relevance = if pt has an invasive cancer which has grown through this space, the lump will be “fixed”
What connects the breast tissue to the skin?
Suspensory ligaments
Non-lactating lobules are found in all areas of the breast tissue. TRUE/FALSE?
TRUE
How are the quadrants of the breast named?
Upper outer and inner
Lower outer and inner
- *axillary tail in Upper outer**
- *can also refer to it like a clock face**
How can we accurately assess if a lump in the breast is fixed to the underlying structures?
- Ask patient to place hands firmly on her hips (to contract pectoral muscles)
- this will fix any lump which has invaded through deeper structures
What areas should also be checked when assessing a breast lump?
axillae and supraclavicular areas
Where does most lymph from the breast drain to?
Ipsilateral axillary lymph nodes
then goes to supraclavicular
Where does some lymph from the inner breast quadrants drain to?
parasternal lymph nodes
OR lower inner breast quadrant can drain to ABDOMINAL lymph nodes
What complication can occur in the upper limb if complete axillary lymph node clearance is completed?
Lymph from the upper limb drains to the axillary lymph nodes
=> if axillary nodes are removed to treat some breast cancers then “lymphedema” may occur in the arm
How do surgeons describe the extent of axillary node clearance that is being carried out?
- Different “Levels” described in relation to pectoralis minor muscle
Level I – inferior and lateral to pectoralis minor
Level II – deep to pectoralis minor
Level III – superior and medial to pectoralis minor
What is the arterial supply to the breast tissue?
- Branches of axillary and internal thoracic/mammary arteries
- Also posterior intercostal branches supply lateral tissue
Describe the venous drainage of the breast tissue?
- axillary vein
- internal thoracic vein
- posterior intercostals
