The Anatomy Of The Pelvis And Perineum-female 14

Question 1

Where is the ovary?

Answer 1

On the posterior surface of the broad ligament
Site of storage of oocytes that undergo maturation in a cyclical manner until they are released once a month
Attached to the uterus by the proper ovarian ligament “Suspended” in the pelvic cavity by the suspensory ligament of the ovary: contains the ovarian vasculature and nerve supply covered by a fold of peritoneum
Attached to the broad ligament by the mesovarium

Question 2

What is the uterine tube?

Answer 2

Enclosed by the broad ligament entirely except at the opening and fimbria The isthmus is the narrowest portion and directly attached to the uterus The next portion is the ampulla where fertilization of the ovum takes place The infundibulum is the widest portion and has fimbria at the opening, the opening is located close to the ovary and the fimbria facilitates movement of the ovum into the tube

Question 3

Summarize the positions of the uterus

Answer 3

ANTEFLEXED
(bent forward) Uterine body in relation to the cervix

   ANTEVERTED (turned forward) Cervix in relation to the vagina

Question 4

How can uterine positions be alternated?

Answer 4

The uterus may be positioned differently in relation to the cervix or vagina. Some suggestions have been made that it has a negative association with fertility

Question 5

Describe the structure of the uterus

Answer 5

Muscular organ attached to the labia majora by the round ligament, covered by the broad ligament Consist of;
• Fundus
• Body
• Uterine tube arises at the junction between the
body and fundus - cornu • Cervix (neck)
• Internal os, external os and canal
• Cavity – Triangular space with the apex leading to
the internal os of the cervix

Question 6

What is the cervix?

Answer 6

The cervix is the “neck” of the uterus it protrudes into the vagina causing the superior most portion of the vagina to dome around it creating a gutter “fornix”
In the nulliparous woman the cervical os and cervical canal is very small
Glands in the cervical canal are responsible for secretions

Question 7

What HPV infection associated with?

Answer 7

HPV infection is associated with an increased risk of developing cancer
Subtle dysplastic changes in the cervical cells can be detected with a pap smear These changes indicate a potential to develop cancer

Question 8

What is the broad ligament?

Answer 8

• Since the pelvic organs extend into the abdominal cavity they are covered by peritoneum
• The fold of peritoneum over the uterus forms the broad ligament that “drapes” over the uterus and tubes (like a rain poncho)
• The ovaries can be seen on the posterior surface of the ligament

Question 9

What are the ligaments of the cervix?

Answer 9

• The cervical ligaments are condensations of pelvic fascia extending; • Anteriorly – pubocervical
• Lateral – transverse cervical/cardinal
• Posterior – uterosacral ligaments
• They support the uterus by acting as stabilizer together with the perineal body, perineal membrane and levator ani

Question 10

What is the vagina?

Answer 10

A fibromusculartube extending from the neck of the uterus to the vestibule
• The tube is collapsed onto itself
• The posterior wall is closely associated with the anterior wall of the rectum forming the rectovaginal septum
• Opens to the external environment at the vestibule

Question 11

Where is the vagina?

Answer 11

Domed around the cervix superiorly to form the two lateral, anterior and posterior fornixes
• The urethra runs in the anterior wall and together they are surrounded by the external urethral sphincter
• The greater vestibular glands drain into this portion

Question 12

Where is the uterus during pregnancy?

Answer 12

During pregnancy, it extends into abdominal cavity

Question 13

What is the clinical significance if fundal height?

Answer 13

Can be used as an indicator to assess the following :
• Intrauterine restriction
• Multiple pregnancy
• Fetal macrosomia
• Oligohydramnios
• Polyhydramnios

Question 14

What is the blood supply of the female reproductive system?

Answer 14

Internal Pudendal artery
exits pelvis through greater sciatic foramen with pudendal n.
enters the lesser sciatic foramen to pass anteriorly through the ischiorectal fossa to finally reach the perineum
gives rise to inferior rectal and perineal arteries

Remember if you can’t see where it goes, you don’t know what it is

Question 15

What’s the clinical significance of the blood supply and veinous drainage of the uterus ?

Answer 15

The blood supply to the uterus, vagina and ovaries form a dense anastomosis around the organs
This provides a channel for metastasis of cancer cells

Question 16

What is an ectopic pregnancy?

Answer 16

Per vaginal (PV) Bleeding in pregnancy is common and can happen for various reasons.
Important: Assume any woman of childbearing age who presents with abdominal pain and vaginal bleeding will have an ectopic pregnancy until proven otherwise.

Question 17

What are the clinical symptoms of an ectopic pregnancy?

Answer 17

Abdominal and pelvic pain, particularly if severe and lateral to the midline.
• Vaginal bleeding with or without clots.
• Dizziness, fainting or syncope.
• Passage of tissue ( products of conception)

Question 18

How is An ectopic pregnancy diagnosed?

Answer 18

Pregnancy test – elevated beta hcg Ultrasound: presence of an adnexal mass

Question 19

What is an adnexa?

Answer 19

the adnexa is the region adjoining the uterus that contains the ovary and fallopian tubes. In addition to the associated vessels, ligaments and connective tissue.

Question 20

How is an ectopic pregnancy treated?

Answer 20

Treatment : salpingectomy-removal of the fallopian tube where the ectopic pregnancy is lodged

Question 21

Describe the neuropathway in parturition

Answer 21

Pain fibers from the uterine body and fundus accompany sympathetic fibers via the hypogastric plexuses via T10-L1
Pain fibers from the cervix and upper vagina accompany pelvic splanchnic nerves to S2-S4
Pain fibers from the lower vagina and perineum accompany somatic fibers via the pudendal nerve to S2-S4

Question 22

What is an episiotomy?

Answer 22

The pelvic and perineal muscles may tear during childbirth
A midline tear will damage the perineal body
Severe post partum complications especially with external anal sphincter
An oblique cut through the bulbospongiosus and superficial transverse perineal muscles may help prevent excessive damage

Question 23

What happens above the perineal pain line?

Answer 23

Above PPL (uterine tubes, uterus fundus and body) the visceral afferents for pain travel via the sympathetics
• They travel in the inferior hypogastric plexus
• Pain is referred to the T10-L1 areas

Question 24

What happens below the pelvic pain line?

Answer 24

(cervix, urinary bladder, upper portion of vagina) the visceral afferents for pain travel via the parasympathetics
• They travel in the inferior hypogastric plexus
• Pain is referred to the S2-S4 areas

Question 25

What innervates the female pelvic organ innervation?

Answer 25

The lower 1/4 of the vagina has somatic pain fibers that travel via the pudendal nerve

Question 26

What is the labia majora?

Answer 26

Female equivalent of the scrotum

Overlies the bulbs of the vestibule

Question 27

What is the labia minora?

Answer 27

Remnant of the urogenital folds

Extends to the clitoris and is fused to the glans

Question 28

What is the vestibule?

Answer 28

Opening between the labia minora

Contains the vaginal and urethral openings

Question 29

What is the body of clitorus (under prepuce)?

Answer 29

Formed by the fusion of the crura

Question 30

What is the urethral orifice?

Answer 30

The urethra lies in the anterior wall of the vagina

Question 31

What are the erectile tissues of the urogenital triangles covered in?

Answer 31

The erectile tissues are covered by muscles

Which are then covered by fascia, subcutaneous tissue and finally skin

Question 32

What is the perineal body?

Answer 32

Perineal body
A fibrous body where all the perineal muscles converge and attach to the perineal membrane. Provides extra strength to the supporting structures of the perineum

Question 33

What is the significance of the pelvic inflammatory disease?

Answer 33

Bacterial infections (gonorrhea and chlamydia)
• Spread to the pelvic cavity through the openings of the uterine tubes => peritonitis
• Continual infection may cause scarring on the uterine tubes which can increase the chances of tubal pregnancies

Question 34

What is Hysterosalpingogram?

Answer 34

Contrast material injected into the uterus via the cervix

Question 35

What is a uterine prolapse(procidentia)?

Answer 35

Due to the loss of support by the cardinal/uterosacral/pubocervical ligaments and by levator ani.
Support structures can no longer counteract typical intra-abdominal pressures.
Various degrees of prolapse may occur

Question 36

What are the clinical symptoms of the uterine prolapse?

Answer 36

Sensation of vaginal fullness, pressure, heaviness “something falling out”
• Sensation of sitting on a ball
• Discomfort in the vaginal area.
• Presence of a soft reducible mass bulging and distending through the vaginal introitus
• With straining and coughing, there is increased bulging and descent into the vaginal wall.
• Back pain and pelvic pain
• Urinary symptoms
• Defecation symptoms
• Symptoms of sexual disfunction – patient describes coital laxity or a sense of feeling “loose”

Question 37

Describe the lymphatic drainage of the uterus

Answer 37

Uterine fundus (with ovaries and uterine tubes) drains to lumbar nodes
Body of uterus, cervix and upper vagina drain to external & internal iliac nodes
Lower vagina drain into superficial inguinal