Lecture 20 - Clinical Correlations to Female Pelvic Anatomy Flashcards
What is the hair bearing area of the female pelvis? Where is it?
Mons pubis
Overlies the inferior aspect of the pubic symphysis
What is the frenulum of the clitoris?
Medial fold of labia minora uniting to join the glans clitoris
What is the prepuce? Other name?
Lateral folds of labia minora uniting over the glans clitoris and body of clitoris
Hood of clitoris
Where is the body of the clitoris in relation to the glans?
Anterior extension deep to the prepuce
What is the frenulum of the labia minora? Other name?
Small transverse fold posterior to the vestibule, formed by the union of the labia minora
= posterior fourchette
What is the anterior wall of the vagina related to?
- Base of the bladder
2. Urethra: embedded in, or fused to, the anterior vaginal wall
What fringes the vaginal opening?
Hymen tags: irregular remnants of the rupture of the hymen
What do the labia majora contain?
- Skin
- Adipose tissue
- Termination of the round ligament of the uterus
Which part of the uterus growth the most during puberty?
Fundus
What is the adnexa?
Fallopian tubes + ovaries
2 parts of female pelvic exam?
- Speculum exam: walls of the vagina, and cervix
- Bimanual exam: to feel internal structures by putting 2 fingers inside vagina and pushing up against cervix while another hand is palpating above the pubic symphysis => looks for fibroids, tumors + feel adnexa by placing finger in fornix
What is a retroflexed uterus? How is it palpated during a pelvic exam?
Uterus with backwards tilt towards spine
Place one finger in rectum and one finger in vagina
3 degrees of pelvic prolapses?
- First degree: prolapse into upper vagina
- Second degree: prolapse to or near the introitus of vagina
- Third degree: complete prolapse through the introitus
Other than through surgeries, how can patients with pelvic prolapses be treated?
Pessary: mechanical dish that supports pelvic organs
What is an incompetent uterus? Treatment?
Cervix begins to dilate and thin causing miscarriages
Treatment: stitch
What is a bicornuate uterus? Consequences?
Failure of Mullerian ducts to fuse to form the uterus forming 2 cavities
Risks of miscarriages and preterm labor
4 different ways of performing a hysterectomy? How do we pick one?
- Abdominally
- Laparoscopically
- Robotically
- Vaginally
Depends on size of the uterus
7 indications for hysterectomy?
- Fibroids
- Cancer
- Adenomyosis: endometrial glands growing into myometrium
- Uncontrolled hemorrhage
- Endometriosis
- Chronic pelvic pain
- Dysfunctional uterine bleeding
5 complications due to hysterectomy?
- Infection
- Hemorrhage
- Ureteral injury
- Injury to bowel/bladder/etc
- Deep vein thrombosis/pulmonary embolism
What % of women have fibroids in their lifetime?
70%
List the steps of a laparotomy hysterectomy.
- Pfannenstiel incision: transverse incision that allow for further incisions if there is a need for more room
- Identify the inferior epigastric vessels on both sides and ligate them in order to do a muscle splitting incision
- Split through rectus abdominus muscles
- Tent the peritenum to enter the abdominal cavity safely
- Enter abdominal cavity
- Deliver uterus
- Grasp the round ligament which allows access to divide the anterior and posterior reflection of broad ligament
- Divide round ligament of the uterus
- Remove anterior sheath of the broad ligament to access space between uterus and bladder
- Space is created through the broad ligament to allow access to divide the uteroovarian ligament to spare the ovaries and fallopian tubes
- Reflect the bladder anteriorly before skeletonizing and clamping the uterine vessels
- Remove cardinal and uterosacral ligaments
- Amputate uterus
- Elevate cervix and push bladder anteriorly
- Amputate cervix at the cervical-vaginal junction = trachelectomy
- Close vaginal cuff
- Close abdominal incision
Other name for internal iliac artery?
Hypogastric artery
At what level is the uterine artery divided during a hysterectomy?
Cervical internal ostium
Major concern of hyterectomies?
Ureteral injuries
Difference between left and right ureters?
Right ureter crosses from abdomen to pelvis anterior to the bifurcation of common iliac artery into internal and external
Left ureter crosses 1-2cm above this bifurcation
3 common sites of ureteral injuries during hysterectomies?
- Ureterovesical junction
- Junction uterine artery and ureter
- Infundibulopelvic ligament
What does the IMA supply? What does it terminate as?
Transverse, descending, and sigmoid colon, rectum
Terminates as superior rectal artery
Other name for superior rectal artery?
Superior hemorrhoidal artery
How long is the common iliac artery?
5 cm
How long is the internal iliac artery?
3-4 cm
What is close to the internal iliac artery through its length?
Ureter
Does the external iliac artery supply the pelvis?
Not directly but in 15-20% women it gives rise to obturator artery
How far from the cervix does the uterine artery cross over the ureter?
2 cm laterally
3 branches of the uterine artery? Describe each.
- Ascending branch: tortuous route up broad ligament to anastomose with ovarian artery via the tubal branch
- Arcuate arteries: branch to meet contralateral equivalent & together form spiral arteries of corpus and endometrium
- Descending branch: branches to supply vagina
Describe pelvic veins.
Follow course of arteries with exception of ovarian drainage
Definition of post-partum hemorrhage?
Blood loss greater than 500cc for vaginal delivery & greater than 1000cc for cesarean delivery
OR drop in hematocrit greater than 10%
What can cause post-partum hemorrhage? 6 possible causes.
- Uterine atony (multigravid patient, multiple gestations)
- Retained placenta
- Uterine rupture
- Uterine inversion
- Abnormal placentation
- Coagulopathies
Normal blood flow to uterus?
500 mL/min
Treatment for post-partum hemorrhage?
- IV access and hydration
- Exam of vagina for lacerations & repair if needed
- Exam uterus with manual evacuation products & internal & external massage (full fist inside vagina = bimanual uterine compression)
- Oxytotics: pitocin, methergine, hemabate
- Blood products
- Surgical therapy (currettage, vessel ligation, hysterectomy)
In cases of severe post-partum hemorrhage, what is performed? 2 names?
- Uterine artery ligation = O’Leary Suture
2. Hypogastric artery ligation
Describe a uterine artery ligation. Goal?
- Open broad ligament at level of vesico-uterine peritoneal reflection
- Identify the ascending branch uterine artery by palpation
- Pass needle in and through myometrium around uterine artery and vein
- Secure ligature
GOAL: reduces uterine perfusion and collateral supply maintains uterus
Describe a hypogastric artery ligation.
- Pack bowel and gain adequate exposure
- Ligate round ligament and divide it
- Open retroperitoneal space
- Identify vasculature and ureters
- Ligate hypogastric artery 3-4 cm from bifurcation site to ensure affecting only anterior division of hypogastric
- Avoid hypogastric vein!!!
- Palpate for distal pulses to insure against inadvertent ligation external iliac artery
