Repro - the female reproductive system and pelvic floor Flashcards
1
Q
Where do the (primordial) gonads develop initially?
A
Mesonephric ridge
2
Q
What is the gubernaculum attached to?
A
Inferior pole of ovary to the labioscrotal folds.
3
Q
What embryological structure fuses to form the fallopian tubes, uterus, cervix and upper vagina?
A
Paraesonephric ducts
4
Q
What ducts degenerate in a female embryo and which remain and develop?
A
- Mullerian/Paramesonephric ducts develop (no MIH secreted)
2. Wolffian/Mesonephric ducts degenerate as no testosterone to sustain them
5
Q
What ducts degenerate in a male embryo and which remain and develop?
A
- Mullerian ducts degenerate (MIH secreted by Sertoli cells)
- Mesonephric ducts develop (as testosterone secreted by interstitial cells)
6
Q
What stops the ovaries descending as far as the testis do?
A
The gubernaculum in the female lies in contact with the fundus of the uterus and adheres to this organ, and thus the ovary can only descend as far as to this level.
7
Q
What size and shape are the ovaries?
A
Almond-sized and shaped
8
Q
How are the ovaries suspended?
A
By a fold of peritoneum called the mesovarium (part of the broad ligament of the uterus).
9
Q
What is the remnant of the superior part of the gubernaculum?
A
The ovarian ligament - it attaches the ovaried to the fundus of the uterus.
10
Q
What is the remnant of the inferior part of the gubernaculum?
A
The round ligament of the uterus - it goes from the uterus to the labia majora (through the inguinal canal).
11
Q
What is the name of the connect tissue capsule of the ovary?
A
Tunica albuginea of the ovary
12
Q
What is the name of the epithelium that covers the tunica albuginea?
A
Smooth layer of ovarian mesothelium.
13
Q
What is the arterial supply to the ovaries?
A
The ovarian arteries which come directly off the abdominal aorta, just below the renal arteries.
14
Q
What is the venous drainage of the ovaries?
A
It is assymetrical (as in males):
- Right ovarian vein -> IVC
- Left ovarian vein -> left renal vein -> IVC
15
Q
What is the lymph drainage from the ovaries?
A
Para-aortic nodes (like that of the testis).
16
Q
What is the name of the pouch of peritoneum that is situated anteriorly to the uterus?
A
Uterovesicular pouch
17
Q
What is the name of the pouch of peritoneum that is situated posteriorly to the uterus?
A
Pouch of Douglas (rectouterine pouch)
18
Q
What covers the majority of the outside of the uterus?
A
A serous membrane of peritoneum.
19
Q
What layers is the endometrium of the uterus functionally divided into?
A
- Stratum basalis - deeper layer, doesn’t undergo cyclic changes
- Stratum functionalis - superficial layer - cyclic growth and shedding
20
Q
What makes up the greater part of the uterine walls?
A
Myometrium - mass of smooth muscle
21
Q
Describe the structure of the glands found in the endometrium:
A
They are tubular glands which extend from the surface into the connective tissue (stroma).
22
Q
Which hormone, secreted by the ovaries during folliculogenesis, stimulates growth and proliferation of the endometrium?
A
Oestrogen
23
Q
After ovulation, which hormone secreted by the newly formed corpus luteum stimulates the endometrium glands to secrete glycogen and causes their extensive coiling, enriching the vascular supply to the mucous membrane i.e. the secretory phase of the endometrium?
A
Progesterone
24
Q
What causes the menstrual phase of the uterine cycle?
A
Withdrawal of hormone support caused by the degeneration of the corpus luteum) and changes in the vascular supply of the endometrium. This leads to breakdown and degeneration of the bulk of the stratum functionalis -> bleeding and shedding of dead tissues.
25
What is the position of the uterus in relation to the vagina?
AntiVerted
26
What is the position of the uterus in relation to the cervix?
AntifleXed
27
What is the broad ligament of the uterus?
A double layer of peritoneum that extends from the sides of the uterus to the lateral walls and floor of the pelvis.
28
What is a function of the broad ligament?
It assists in keeping the uterus in position
29
What is the mesentery that surrounds the uterus called (part of the broad ligament of the uterus)?
Mesometrium
30
What is the mesentery that surrounds the fallopian tubes called (part of the broad ligament of the uterus)?
Mesosalpinx
31
Where does the fundus' lymph drain? Why is this the case?
It drains to the aortic nodes because that is where it originally came from (gubernaculum attached fundus to labia majora).
32
What is the shape of the uterine tube from its attachemnt to the uterus to the region nearest the ovaries?
It starts narrow at the isthmus and widens into an expanded intermediate section (ampulla) and then becomes the funnel-shaped infundibulum near the ovary - the margins of which are drawn into finger-like projections called fimbria. The opening to the abdominal cavity is called the ostium.
33
What is the function of the uterine tubes?
Is to assist in the transfer and transport of the ovum from the ovary to the uterus.
34
What is the name of the cavity that connect the uterine cavity with the vagina?
endocervical canal
35
What is the function of the cervix?
1. Allow sperms, deposited in the vagina at coitus, to enter the uterine cavity and proceed to the site of fertilisation.
2. Protect the uterus and upper genital tract from bacterial invasion.
36
What are the two regions composing the cervix?
endocervix and exocervix
37
Describe the epithelium and mucosa of the endocervix:
Tall columnar epithelia, basal nuclei, greater part of cytoplasm filled with mucus. The mucosa contains lots of large glands that are also lined with tall, mucus-secreting columnar cells.
38
Describe the epithelium of the exocervix:
Stratified squamous non-keratinised epithelium (like the vagina).
39
What composes the cervix deep to the mucosa?
Circularly arranged smooth muscle fibres in abundant dense connective tissue.
40
Describe the change in epithelium between the endo- and exo-cervix:
Abrupt change from the columnar to stratified non-keratinised squamous epithelium.
41
Describe the arterial supply to the uterus:
Similar to the supply to the penis:
Uterine artery
(abdominal aorta -> common iliac -> internal iliac -> anterior division of internal iliac -> uterine)
42
What is the relationship between the uterine artery and the ureter?
The ureter passes inferiorly to the uterine artery: "water under the bridge".
43
Describe the venous drainage of the uterus:
Uterine venous plexus -> uterine veins -> internal iliac vein -> common iliac -> IVC (very similar to the penis)
44
Describe the lymph drainage of the uterus:
Fundus -> aortic lymph nodes
Body -> external iliac lymph nodes
Cervix -> external and internal iliac, sacral lymph nodes
45
Describe the layers that compose the vaginal wall:
Three layers:
1. Mucous membrane
2. Muscular coat
3. Adventitia - fibrous connective tissue
46
Describe the mucous membrane of the vagina:
Stratified squamous epithelium and underlying lamina propria (dense connective tissue) - with its projections (papillae) into the epithelium
47
Why does vaginal epithelium appear vacuolated upon microscopy?
Due to the loss of some of the tissue components (mainly glycogen) during tissue preparation.
48
Describe the muscular component of the vagina:
Two muscular layers of smooth muscle: inner circular-arranged layers and outer longitudinal layer.
49
Describe the glandular component of the vagina:
There are no glands in the vaginal mucosa, just large veins in the outer regions of the lamina propria. The mucus that lubricates the vagina originates from the cervical glands.
50
What are vaginal fornices?
Vault-like recesses formed by the protrusion of the cervic into the vagina.
51
Describe the vaginal fornices:
There are four named fornices:
1. Posterior - closest to rectouterine pouch
2 and 3 - lateral pouches
4. Anterior - closest to uterovesicular pouch
52
Describe the arterial supply to the vagina:
1. Superior vagina - derived from uterine arteries
| 2. Middle and inferior vagina - vaginal and internal pudendal arteries
53
Describe the route blood takes to reach the uterine artery that supplies the superior vagina:
abdominal aorta -> common iliac -> anterior division of internal iliac -> uterine artery
54
Describe the route blood takes to reach the vaginal artery and pudenal artery that supplies the middle and inferior vagina:
1. Vaginal artery: (abdominal aorta -> common iliac -> anterior division of internal iliac -> uterine -> vaginal artery
2. Pudenal artery: ( abdominal aorta -> common iliac -> internal iliac -> anterior division of internal iliac -> pudenal artery).
55
Describe the venous drainage of the vagina:
Vaginal plexus -> vaginal vein -> uterine vein -> internal iliac vein -> common iliac -> IVC
(The vaginal venous plexus also communicates with the rectal plexus and the vesicular plexus).
56
Describe the innervation of the vagina:
1. Inferior (1/5) - somatic innervation from pudenal nerve (S2-S4)
2. Superior (4/5) - uterovaginal plexus
57
Describe the innervation of the uterus:
Uterovaginal plexus
58
What does the labia majora enclose?
The pudenal cleft
59
What does the labia minor enclose?
1. The vestibule of the vagina
2. Bulbs of vestibule
3. Clitoris
60
What does the vestibule contain?
Orifices for:
1. urethra
2. vagina
3. greater (Bartholin) and lesser vestibular glands
61
Where are the greater (Bartholin) and lesser vestibular glands located? What is their function?
Located slightly posterior and left and right of the opening to the vagina. They secrete mucus to lubricate the vagina.
62
What is the homologous structure to Bartholin glands in males?
The bulbourethral glands - though they are located within the urogenital diaphragm.
63
What structures do ovarian cysts usually develop from?
Follicles
64
What types of cell do ovarian tumours usually derive from?
Epithelial components or germ cells.
65
What is the name of the syndrome, where the ovaries contain more than ten cysts? What is this syndrome associated with?
Polycystic Ovarian syndome. It is associated with infertility.
66
What is salpingitis? What are its clinical consequences?
Inflammation of the uterine tubes caused by microorganisms. This can cause fusion or adhesions of the mucosa and therefore can partially block the lumen, causing infertility. This can also result in ectopic pregnancy.
67
What is endometriosis? What are its clinical consequences?
It is a condition in which ectopic endometrial tissue is dispersed to various sites along the peritoneal cavity and beyond (e.g. near to the umbilicus). These may be associated with the ovaries or attachments of the uterus. It is associated with severe period pain (dysmenorrhoea), infertility or both.
68
What type of cancer can develop in the cervix? Where is it most likely to originate from?
Endometrial carcinoma (malignancy of the endometrium (epithelium). The transformation zone is where the majority of neoplasms form. This is the junction between the columnar epithelium of the endocervix and the stratified non-keratinised squamous epithelium of the exocervix.
69
What group of women are most likely to get endometrial carcinoma? What is the major symptom of it?
It usually occurs in post-menopausal women. The major symptom is abnormal uterine bleeding.
70
How would you examine the cervix?
With the use of a speculum to enlarge the vaginal orifice and isolate the external os of the cervix.
71
What is a bimanual examination?
This is when two fingers are inserted into the vagina until they isolate the cervix. This can be used to test for:
1. Cervical motion tenderness (sign of PID)
2. Palpating the uterus
3. Assessing the diagonal conjugate (pelvic inlet size)
72
What clinical problems can affect the Bartholin glands?
1. Batholinitis - inflammation/infection of Bartholin glands
| 2. Bartholin gland cyst - occurs when duct of gland gets blocked
73
What is the role of Lactobacillus in the vagina?
It is part of normal vaginal flora. It uses glycogen (secreted by vaginal epithelium) as a substrate for lactic acid production and therefore maintains a low pH environment, protecting against bacterial infection.
74
What is vaginismus?
Vaginismus is the term used to describe recurrent or persistent involuntary tightening of the pubococcygeus muscle around the vagina whenever penetration is attempted (sexual intercourse or tampon insertion).
75
Why is the peritoneal cavity not fully sealed in women as it is in men?
The ostium of the fallopian tubes enters the peritoneal cavity in order for it to collect ovums that have broken through the wall of the ovary (tunica albuginea and ovarian mesothelium) into the peritoneal cavity.
76
What two layers make up the pelvic floor?
1. Pelvic diaphragm
| 2. Superficial muscles and structures: urogenital and anal perineum
77
What makes up the pelvic floor?
1. Levator ani muscles
2. Coccygeous muscle
3. Fascial coverings of these muscles - superifical and inferior aspects
78
Which muscles make up the levator ani muscles?
1. Pubococcygeous
2. Puborectalis
3. Iliococcygeous
79
Where does the pelvic floor lie? What does it separate superiorly from inferiorly?
It lies in the lesser pelvis and seperates the pelvic cavity from the perineum.
80
What is the function of the pelvic floor?
It supports the pelvic viscera and exerts a sphincter action on the rectum and vagina - this can resist increases in intra-abdominal pressure associated with coughing, defecation, heavy lifting etc...
81
Where is the urogenital diaphragm found?
It fills the gap of the pubic arch stretching between the converging ischiopibic rami.
82
What layers make up the urogenital diaphragm?
It is a triangular sandwich, with striated muscle fibres between two layers of fascia:
1. Superior fascia
2. Shincter urethrae - striated muscle fibres
3. Inferior/ superficial fascia - thickened (aka perineal membrane)
83
What does the urogenital diaphragm contain? Which structures pierce it?
Contains - bulbourethral glands (in male)
| Piercing it - urethra and vagina
84
Which muscles lie beneath the perineal membrane?
The potential space between the perineal membrane superiorly and the perineal fascia inferiorly contains the erectile tissue that forms the penis and clitoris:
Ischiocavernosus, bulbospongiosus and superficial transverse perineal membrane. (in females Bartholin's glands are also located here).
85
What can collect in the superificial perineal pouch (area between the perineal membrane superiorly and the perineal fascia inferior, which contains the erectile tissue)?
Urine can collect here, if the urethra is ruptured below the perineal membrane.
86
Where is the posterior anal perineum located?
It forms a triangle between the ischial tuberosities and the coccyx.
87
What are the contents of the anal perineum?
Anal aperture, ischioanal fossae (either side of anus) and external anal sphincter.
88
What is the purpose of the ischioanal fossae? What can happen to it?
They are spaces located laterally, either side of the anus that consist of fat and connective tissue, which aid expansion of the anal canal during defecation. They can become infected.
89
What is the anatomical relationship between the ischioanal fossa and the pudenal nerve?
The pudenal nerve passes alond the lateral wall of the fossa.
90
The levator ani are paired muscles that form three slings of muscle that extend from the posterior aspect of the pubic bond, the fascia over obturator internus and the ischial spines. What are these three slings?
1. Anterior fibres around the vagina or prostate
2. Intermediate fibres around the rectum (puborectalis) and into the annoccygeal body (pubococcygeous)
3. Posterior fibres into the anoccygeal body and coccyx (iliococcygeus).
91
Apart from the levator ani muscles, which other muscle makes up the pelvic floor?
Coccygeus
92
Where is coccygeus located?
Posterior to the levator ani muscles, overlying the sacrospinous ligament. They originate from the ischial spina and sacrospinous ligament and attach at the lateral border of the sacrum and superior region of the coccyx.
93
What is the perineal body? Where is it found?
It is a pyramidal fibromuscular mass found at the junction between the urogenital and anal triangles.
94
What structures in males and females can the perineal body be found inbetween?
Males - bulb of penis and anus.
| Females - between vagina and anus (~1.25cm in front of the anus).
95
What is the function of the perineal body?
It is essential for the integrity of the pelvic floor, especially in females - anchoring the perineal muscles and the rectum.
96
Which muscles use the perineal body as a point of attachment?
1. Anal sphincters
2. Bulbospongiosus
3. Superficial transverse perineal muscles
4. Fibres of levator ani
97
What is the purpose of an episiotomy?
It is a cut into the perineal body that is made when the perineal body is at risk of rupture during childbirth. This controls the tear and enables it to be more effectively repaired afterwards. It therefore helps prevent weakness in the pelvic floor caused by perineal body damage which can lead to prolapse of structures such as the vagina and uterus.
98
Stretching of which nerves, muscles and ligaments can lead to damage to the pelvic floor during childbirth?
1. Stretching of the pudenal nerve -> neuropraxia (reversible nerve damage) and muscle weakness
2. Stretch and damage to the pelvic floor and perineal muscles -> muscle weakness
3. Stetch/rupture of ligaments-> ineffective muscle action
99
What are risk factors, other than childbirth, for pelvic floor dysfunction:
1. Age
2. Menopause - atrophy of tissues after oestrogen withdrawal
3. Obesity
4. Chronic cough
5. Intrinsic connective tissue laxity
100
How can pelvic floor dysfunction be treated?
1. Pelvic floor muscle exercises
2. Continence surgeries
3. Prolapse procedures
101
What are the benefits of pelvic floor exercises?
They are easy, safe and effective. They cure incontinence in 50-75% of patients along with preventing or delaying worsening prolapse.
102
What is the purpose of continence surgeries? How effective are they?
They increase support to the sphincter mechanism and prevent descent of bladder neck. 85-90% cure rate.
103
What is colposuspension?
An type of continence surgery which uses stitches to support the neck of the bladder so
that it can’t move about and cause stress incontinence.
104
What is tension-free vaginal tape surgery?
A type of continence surgery in which a mesh tape is placed under your urethra like a sling or hammock to keep it in its normal position. The tape is inserted through tiny incisions in your abdomen and vaginal wall. No sutures are required to hold the tape in place.
105
What are the complications with continence surgeries?
1. Voiding difficulty/ urinary retention
| 2. Overactive bladder disease (obstruction)
106
What is the purpose of prolapse procedures?
To replace prolapsed organs and restore connective tissue supports, in order to maintain function.
107
What are the side effects of prolapse procedures?
1. Recurrence of prolapse
2. New incontinence
3. Dyspareunia (painful sexual intercourse).
