Week 2 - I - Anatomy 2 - Female Reproductive System and Breast

Question 1

The female reproductive system lies within both the pelvic cavity and the perineum What parts of the female reproductive system lie in each region?

Answer 1

• Pelvic cavity
  
  • * Ovaries
  • * Uterus
  • * Fallopian tube (Uterine tubes/oviducts)
  • * Superior part of vagina
• Perineum
  
  • * Inferior part of vagina
  • * Clitoris
  • * Labia
  • * Bartholin’s glands and perineal muscles

Question 2

What part of the pelvic organs does the peritoneum cover?

Answer 2

The peritoneum covers the superior aspect of the pelvic organs by draping over them and this forms pouches Peritoneum is white draping over the bladder, uterus and rectum

Question 3

• inferior part of parietal peritoneum - floor of peritoneal cavity - roof over pelvic organs covers the superior aspect organs What pouches does the peritoneum form in the female and in the male?

Answer 3

In the female - forms the rectouterine pouch (Pouch of Douglas) and the vesicouterine pouch In the male - forms the rectovesicle pouch

Question 4

Excess fluid within the peritoneal cavity tends to collect where and why is this? How is this fluid drained?

Answer 4

Excess fluid in the peritoneal cavity tends to collect within the Pouch of Douglas (rectouterine pouch) - this is because this is the most inferior part of the peritoneal cavity in a female in the anatomical position Fluid can be drained by a needle passed through posterior fornix of vagina

Question 5

Over the uterine tubes, the peritoneum drapes over anteriorly and posteriorly forming a double layer and phases together under the uterine tube What is this known as? Give two other names for the uterine tubes?

Answer 5

The double layer of peritoneum that is formed by the draping anteriorly and posteriorly over the uterine tubes is known as the broad ligament of the uterus Uterine tubes aka fallopian tubes aka oviducts

Question 6

The broad ligament of the uterus extends between the uterus and lateral walls and floor of pelvis What is the function of the broad ligament? What does the broad ligament enclose?

Answer 6

The function of the broad ligament is to help maintain the uterus in its midline position It enclose the uterine tubes and proximal parts of the round ligament of the uterus

Question 7

The round ligament is not peritoneum and is instead an embryological remnant What is it a remnant of? What is the function of it during embryological development?

Answer 7

It is a remnant of the gubernaculum As the scrotum and labia majora form in males and females respectively, the gubernaculum aids in the descent of the gonads (both testes and ovaries).

Question 8

Where does the round ligament attach to? What is the round ligament contained within proximally?

Answer 8

The round ligament attaches to the lateral aspect of the uterus and passes through the deep inguinal ring to attach to the superficial tissue of the female perineum Proximally is contained within the broad ligament of the uterus

Question 9

The oepning into the inguinal canal is the deep inguinal ring and the exit is the superficial inguinal ring Is the round ligament anterior or posterior to the uterine tubes? (remember they are booth contained within the broad ligament)

Answer 9

The round ligament lies anterior to the uterine tubes

Question 10

State what the boxes are labelling

Answer 10

• Red box - the broad ligament of the uterus
• Black box - the ovarian ligament
• Green box - the round ligament of the uterus

Question 11

The uterus has many levels of support Ie the uterosacral ligaments, endopelvic fascia and levator ani muscle What can weakness of these supports result in?

Answer 11

Weakness can result in a uterine prolapse - where the uterus descends inferiorly

Question 12

What are the three layers of the uterus? What layer is shed during the menstrual cycle? (what particular part of this layer is shed) Where does fertilisation normally occur? Where does implnatation of the fertilised egg (zygote) normally occur?

Answer 12

Three layers Perimetrium Myometrium Endometrium - this layer is shed during the menstrual cycle (to be precise it is the stratum fucntionalis layer that is shed) Fertilisation normally occurs in the ampulla of the uterine tube - implnatation normally occurs in the body of uterus

Question 13

What arteries supply the stratum functionalis that go into spasm? (they are responsive to hormones causing this layer of endometrium to slough away) What is the other arterial supply of the stratum basalis layer of endometrium which prevents this sloughing away?

Answer 13

The spinalis arteries supplying the endometrium go into spasm The stratum spinalis recieve another blood supply from the striaght arteries which supply this layer with oxygen and nutrients

Question 14

What is the normal position of the uterus?

Answer 14

The normal position of the uterus is anteverted and anteflexed

Question 15

The position of the uterus is to do with the axis in relation to vaginal and cervical axis What does anteverted and anteflexed mean?

Answer 15

Antverted is when the uterus is tipped anteriorly relative to the axis of the vagina (V for vagina)

Anteflexed is when the uterus is tipped anteriorly relative to the axis of the cervix (the mass of the uterus therefore lies over the cervix)

Question 16

Normal variation of the uterus is retroverted and retroflexed Describe what retroverted and retroflexed mean?

Answer 16

Retroverted

• The uterus is tipped postieriorly in relation to the axis of the vagina

Retroflexed

• The uterus is tipped posteriorly in relation to the axis of the cervix

Can make prolapse more likely as not much support from bladder

Question 17

The walls of the vagina are usually collapsed The clinician must be able to see the cervix in order to perform a cervical screening procedure How does the clincian visualise the cervix for the smear? How is this instrument entered?

Answer 17

The clincian uses a speculum Enter the speculum in the 3 oclock position and rotate to 12 oclock Then insert at 45 degrees and open to visualise the cervix

Question 18

What is the cervical hole known as? What is the zone where the cervical smear is taken from?

Answer 18

The hole is known as the external os (external ostium of the uterus) - once entering this you are in the cervical canal The smear is taken from the transformation zone (squamo-columnar junction)

Question 19

How is the smear of the squamo-columnar junction taken? What cell type of cancers are the majority of cervical cancers?

Answer 19

The smear is taken by rotating the smear 10 times in the cervical (external os) clockwise The majority of cervical cancers are squamous carcinomas

Question 20

Uterine tubes extend from the lateral parts of the uterus – usually not as symmetrical What are the regions of the uterine tube? Once eggs are ovulated into the periotneal cavity, what sweeps them up into the uterine tube? Where does fertilisation normally occur?

Answer 20

Uterine tube Fimbrae - infundibulum - ampulla - isthmus The eggs are swept into the uterine tube by the fimbrae Fertilisation normally occurs in the ampulla

Question 21

What is removal of the uterine tube known as? What is bilateral removal of the uterine tubes and the ovaries known as?

Answer 21

Salpingectomy - removal of the uterine tube Bilateral salpingo-oopherectomy - removal of uterine tubes and ovaries

Question 22

Total hysterectomy with bilateral salpingo-oophorectomy is one of the four types of hysterecotmy What are the other three?

Answer 22

Total hysterecotmy - removes the uterus and cervix Subtotal hysterectomy - main body of uterus removed leaving cervix in place Radical hysterecotmy - removes uterus, uterine tubes, ovaries, lymph tisse, part of vagina

Question 23

The fimbriated end of the uterine tubes actually open into the peritoneal cavity communication between the genital tract and the peritoneal cavity How is it that pelvic inflammatory disease can therefore cause peritonisis? or ectopic pregnancy can occur in the peritoneal cavity?

Answer 23

The pelvic inflammatory infection can pass out through the small hole at the fimbriated end and infect the peritoneal cavity Similarly a pregnancy can exit into the peritoneal cavity here and cause an ectopic pregnancy

Question 24

The proximal tubal opening (ostium or os) is located within the uterus at the uterotubal junction and accessible via hysteroscopy. Occlusion at this opening is referred to as proximal tubal occlusion. What is the distal tubal opening known as? (it is at the fimbriated end of the uterine tube)

Answer 24

This is known as the abdominal ostium

Question 25

A test can be done when checking for infertility in a female by checking tubal patency What is this test known as? How is it done? What are you looking for?

Answer 25

This test is known as a hysterosalpingogram

A radio-opaque dye is injected into the uterus via the vagina and cervix and if the tubes are patent, the dye will spill into the peritoneal cavity - no distal tube occlusion

Question 26

The ovaries are Almond sized and shaped, located laterally in the pelvic cavity What do they secrete in response to LH and FSH? Where do they develop and what helps them move onto the lateral walls of the uterus?

Answer 26

In response to LH and FSH, the ovaries secrete oestrogen and progestogen They develop on the posterior abdominal wall and move onto the lateral wall of the uterus via the gubernaculum which becomes the round ligament of the uterus (contained proximally within the broad ligament of the uterus)

Question 27

Where does lymph from the ovaries drain to?

Answer 27

Lymph from the ovaries drains to the lumbar nodes (also knnow as the paraaortic lymph nodes)

Question 28

Where does lymph from the uterus drain? (fundus, body and uterine cervix)

Answer 28

* Fundus - drains to the paraarotic lymph nodes mainly but some vessels pass in the round ligament to the superficial inguinal lymph nodes * Body - vessels from the body pass within the broad ligament drains to the external iliac lymph nodes * Uterine cervix - drain to the internal iliac lymph nodes but can drain to the sacral lymph nodes if passing along the uterosacral ligament

Question 29

What is the green line in the bottom picture pointing to? What embryological feature forms the uterus? (what else does it form)

Answer 29

This points to the round ligament of the uterus - it lies anterior to the uterine tubes Mullerian duct becomes the uterus, uterine tubes and superior apsect of the vagina

Question 30

The vagina is a muscular tube whose walls are normally in contact except superiorly where the cervix holds them apart forming a fornix (space around the cervix) What are the 4 parts to the fornix?

Answer 30

This is the anterior, posterior and 2 lateral fornices - important for palpation

Question 31

How can the ischial spines be felt on vaginal palpation? (what fornices are used) How can the position of the uterus be palpated?

Answer 31

Ischial spines can be felt in the 4 and 8oclock positions in an internal vaginal examination - push deeply in lateral fornices Position of uterus can be palpated by placing the two fingers of dominant hand in posterior fornix - non dominant hand suprapubically and feel for uterus between - if can feel then uterus is anteverted (and anteflexed)

Question 32

How is palpation of the adnexae carried out? What is the adnexae?

Answer 32

Put fingers in the lateral fornix - push with dominant hand in iliac fossa and palpate for any large masses or tenderness affecting these structures - repeat on the other side The adnexae is the uterine tubes and ovaries

Question 33

What forms the floor of the pelvis but the roof of the peirneum?

Answer 33

This would be the levator ani muscle - the pelvic diaphragm

Question 34

What structures pass through the levator ani muscle in the male? What is the anterior part of the perineum known as? What is the posterior part known as? (what single structure passes through here)?

Answer 34

The rectum and urethra passes through the levator ani in the male Anterior part of the perineum is the urogenital triangle (passage of uro and genital tract) Posterior part of the perineum is the anal triagnle - contains the anal canal

Question 35

The levator ani is made up of many smaller muscles What control is it under? What is thought to be the dual nerve supply to the levator ani muscle?

Answer 35

Levator ani is skeletal muscle and under voluntary control Thought to have dual supply from: S3,4,5 - nerve to the levator ani S2,3,4 - pudendal nerve

Question 36

The levator ani provides continual support for the pelvic organs Is levator ani normally slightly contracted or relaxed? What does an increase in intra-abdominal pressure cause? What can weakness of the muscle cause?

Answer 36

Levator ani is said to be in tonic contraction (always slightly contracted) Increase in intra-abdominal pressure causes the muscle to contract further Weakness can be a factor in pelvic organ prolapse

Question 37

What are all the perineal muscles supplied by? Where do all the perineal muscles attach?

Answer 37

They are all supplied by the pudendal nerve and all attach to the perineal body

The perineal body is a bundle of collagenous and elastic tissue for the attachment of the muscles

Question 38

What is the importance of the perineal muscles in females? When can the perineal body be disrupted?

Answer 38

It is important to the pelvic floor strength It can be disrupted during labour as a tear can extend here Perineal body is located just deep to the skin

Question 39

The perineal muscles in both female and male cover the erectile tissue What is the function of the perineal muscles in males and females?

Answer 39

In males- assistance in erection and helps in final part of micturition In females -usually underdevloped but assists in pelvic floor support

Question 40

What are the glands located to the left and right of the vagina? They function to secrete mucous to lubricate the vagina

Answer 40

These are Bartholin’s glands - homologous to the bulbourethral glands in males

Question 41

What does the vestibule of the vagina enclose?

Answer 41

The vestibule of the vagina encloses the external urethral orifice and the vagina

Question 42

State what is behind the boxes, start with black box and work clockwise to yellow

Answer 42

• Black - clitoris
• Red - external urethral orifice
• Green - vaginal orifice
• Blue - anus
• Purple - labia minora and labia majora
• Yellow - mons pubis

Question 43

What does the bed of the female breast extend between?

Answer 43

Extends from ribs 2-6 along the lateral border of the sternum to mid axillary line

Question 44

The breasts lie on fascia covering the pec major and serratus anterior What is the space that lies between the fascia covering the undelrying muscles (pec major) and breast?

Answer 44

The space that lies between the fascia covering the pectoralis major and breast is the retromammary space The retromammary space is often the site of breast implantation due to its location away from key nerves and structures that support the breast.

Question 45

The ffemale breast is split into 4 quadrants - upper outer, inner and lower outer, inner The centre is the nipple What is the small circular area, in particular the ring of pigmented skin surrounding a nipple?

Answer 45

The small circular area surrounding the nipple is known as the areola

Question 46

What is the extension of tissue of the breast into the axilla known as? What quadrant of the breast does it extend from?

Answer 46

This extension is known as the axillary tail of spence It extends from the upper outer quadrant of the breast

Question 47

What is the foramen in the deep pectoralis fascia though which this extension extends to reach the axilla known as?

Answer 47

The is the foramen of langer

Question 48

The breast is mobile on the wall of the chest due to the retromammary space Therefore if there is a lump you can check to see if it fixed to any pectoral fascia or not (fixed lump has worse prognosis) How does the patient fix the pectoral muscle before palpation the lump begins?

Answer 48

The patient is asked to place hands firmly on hips to contract the pecs If lump is fixed, then makes you think it has invaded the fascia and is attaching the breast to the muscle - more likely to be cancerous

Question 49

Where does 75% drainage of lymph from the breast go to? Where does the majority of the rest drain to?

Answer 49

75% of lymph from the breasts drain to the ipsilateral axillary lymph nodes which go on to drain into the supraclavicular lymph nodes The majority of the rest of the 25% is when the inner quadrants drain to the parasternal lymph nodes (Lymph from the lower inner breast quadrant can drain to abdominal lymph nodes )

Question 50

implications if axillary nodes are removed (“axillary node clearance”) e.g. in treatment for some breast cancers What can this cause in relevance to the lymph drainage?

Answer 50

This can cause lymphoedema as the axillary node drains not only the breast lymph bout also lymph from the upper limbs

Question 51

There are three different axillary node clearances ie surgeones use a muscle to describe the extent as to which the axillary node clearance has been carried out The level of axillary node clearance is done in relevance to which muscle?

Answer 51

It is done in relevance to the pectoralis minor

Question 52

Describe the surgical levels of the axillary lymph nodes? Where does the pectoralis minor muscle attaches?

Answer 52

Level 1 axillary nodes - these are inferior and lateral to the pec minor (anterior axillary group) Level 2 - these are deep to the pec minor (central group) Level 3 - these are superior and medial to the pec minor (apical group) Pec minor attaches to ribs 3,4,5 and coracoid process of the scapula

Question 53

What is the arterial supply to the breasts?

Answer 53

Most from the axillary and internal thoracic arteries (internal thoracic becomes internal mammary) There is some contribution from the posterior intercostal arteries Venous drainage is mostly medially - internal thoracic vein

Question 54

What nerves supply the pectoralis major and minor? Which supply the serratus anterior?

Answer 54

Pectorlais major - medial and lateral pectoral nerve Pectoralis minor - medial pectoral nerve Serratus anterior - long thoracic nerve (C5,6,7)

Question 55

What are the different drainage sites of the uterus?

Answer 55

Most of the fundus and superior uterus drains to the para-aortic lymph nodes but some will run on the round ligament to the superficial inguinal nodes

Vessels from the uterine body drain to the external iliac lymph nodes

Vessels from the uterine cervix drain to the internal iliac & the sacral nodes