Female Reproductive System PDF

XY2141. ANATOMY. FEMALE REPRODUCTIVE SYSTEM Dr Viktoriia Yerokhina Lecturer in Medical Sciences  LEARNING OUTCOMES ANAT.29- Female U/G tract ANAT.29.01 - Describe the relationships of the bladder, uterus, uterine tubes, ovaries, vaginal canal an...

XY2141. ANATOMY. FEMALE REPRODUCTIVE SYSTEM Dr Viktoriia Yerokhina Lecturer in Medical Sciences  LEARNING OUTCOMES ANAT.29- Female U/G tract ANAT.29.01 - Describe the relationships of the bladder, uterus, uterine tubes, ovaries, vaginal canal and rectum in the pelvic cavity. ANAT.29.02 - Discuss the reflections of the peritoneum over the bladder, uterus, uterine tubes, ovaries, vaginal canal and rectum in the pelvic cavity. ANAT.29.03 - Describe the fornices of the vagina. ANAT.29.04 - Explain the clinical importance of the relationship of the posterior fornix to the rectouterine pouch ANAT.29.05 - Compare the differences in sensory innervation of the pelvic part of the vagina versus the perineal part of the vagina. ANAT.29.06 - Review the regions of the uterus and uterine tubes. ANAT.29.07 - Discuss the ovaries and ovarian ligaments. ANAT.29.08 - Describe the typical relationship of the cervix to the vaginal canal. ANAT.29.09 - Describe the typical relationship of the body of uterus to the cervix ANAT.29.10 - Define the terms anteverted, anteflexed, retroverted, and retroflexed with respect to the position of the uterus. ANAT.29.11 - Discuss the broad ligament of the uterus and its subdivisions in the relationship to the body and fundus of the uterus, the uterine tubes and their fimbriated ends, the ovaries, the ovarian ligament, and the round ligament of the uterus. ANAT.29.12 - Explain how/where the female ureter is at risk during ligation of uterine vessels. ANAT.29.13 - Define the transverse cervical (cardinal), pubocervical and uterosacral ligamenta and explain their relative importance in uterine support. ANAT.29.14 - Review the course of the uterine arteries across the pelvic floor. ANAT.29.15 - Define the term "uterine prolapse" and explain why it is more common in (multiple vaginal deliveries) women. ANAT.29.16 - Define the term "stress urinary incontinence" and explain which structures may be injured during vaginal delivery to lead to this condition.  INTERNAL GENITAL ORGANS 1. Ovary (ovarium) – intraperitoneally located pair of glands that contain maturing oocytes 2. Uterine tube (tuba uterina) – paired tubular organ attached to the uterine horn – partially covers the ovary – the most common location of fertilisation 3. Uterus (uterus) – unpaired hollow organ – houses the developing embryo and fetus 4. Vagina (vagina) – terminal segment of the FRS – female organ of copulation and part of the birth canal.  EXTERNAL GENITAL ORGANS 5. Vestibule (vestibulum vaginae) – area containing the external openings of the vagina, urethra, and paired accessory glands 6.Greater vestibular gland / Bartholin’s gland (glandula vestibularis major Bartholini) – paired gland emptying into the vestibule 7. Lesser vestibular glands (glandulae vestibulares minores) – small glands emptying into the vestible  EXTERNAL GENITAL ORGANS 8. Labia majora (labia majora pudendi) – cover the labia minora 9. Labia minora (labia minora pudendi) – cover the vestibule 10. Clitoris (clitoris) – unpaired female erectile body 11. Bulb of vestibule (bulbus vestibuli) – pair of female erectile bodies located around the vestibule. FEMALE REPRODUCTIVE SYSTEM  OVARY – OVARIUM Female genital gland (gonad). Paired intraperitoneal organ located in the pelvis. Contains oocytes within follicles, undergoing the process of maturation. Produces various steroids and polypeptide hormones. Oophoron is the Greek term for ovary.  EXTERNAL STRUCTURE OF THE OVARY 1. Medial surface – faces the pelvic viscera 2. Lateral surface – lies on the lateral wall of the lesser pelvis 3. Mesovarian border – anterior margin facing the peritoneal fold of the ovary 3.1 Hilum of ovary – a slit through which the ovarian vessels and nerves enter the ovarian parenchyma 4. Free border – posterior free margin 5. Tubal extremity – upper pole facing the abdominal opening of the uterine tube 6. Uterine extremity – lower pole facing the uterine horn. PERITONEAL FOLDS AND THEIR CORRESPONDING ARTERIAL SUPPLY 1. Mesovarium – peritoneal fold of the ovary – attaches to the posterior aspect of the broad ligament of the uterus 2. Suspensory ligament of ovary (ligamentum suspensorium ovarii) / infindibulopelvic ligament – attaches the tubal extremity of the ovary to the lateral pelvic wall – contains the ovarian artery and veins, ovarian nervous plexus and lymphatic vessels 3. Ligament of ovary (lig. ovarii proprium) – attaches the uterine extremity of the ovary to the uterine horns – contains the ovarian branch of the uterine artery and its corresponding veins and lymphatic vessels 4. Ovarian arcade – anastomosis of the ovarian branch of the uterine artery with the ovarian artery.  VASCULAR SUPPLY OF THE OVARY Arterial supply: ovarian artery (from the abdominal aorta) and ovarian branch of the uterine artery (from the internal iliac artery). VASCULAR SUPPLY OF THE OVARY Venous drainage: left ovarian vein (to left renal vein) and right ovarian vein (to inferior vena cava) Lymphatic drainage: lumbar nodes CLINICAL CORRELATION  UTERINE TUBE – TUBA UTERINE / FALLOPIAN TUBE Paired muscular tube uniting the uterine horn with the ovary. Its abdominal ostium is freely open to the peritoneal cavity, where it captures released oocytes, which are transported along the tube by peristaltic contractions to the uterine cavity. Fertilisations of an oocyte by a spermatozoon usually happens within the uterine tube. Salpinx is the Greek term for uterine tube.  EXTERNAL STRUCTURE OF THE UTERINE TUBE 1. Abdominal ostium – faces the ovary – directly communicates with the peritoneal cavity – inlet of the uterine tube 2. Infundibulum – dilated part adjacent to the abdominal ostium – contains the fimbriae 2.1 Fimbriae – mucosal appendages projecting from the abdominal ostium 2.2 Ovarian fimbria – the most distinct and longest fimbria, reaches the ovary 3. Ampulla – the wider lateral 2/3 of the uterine tube, decorated by many mucosal folds.  EXTERNAL STRUCTURE OF THE UTERINE TUBE 4. Isthmus – narrower medial 1/3 of the uterine tube, contains scant mucosal folds 5. Uterine part (pars uterina) – intramural segment of the uterine tube, located inside the wall of the uterus 6. Uterine ostium (ostium uterinum) – located within the uterine horn 7. Mesosalpinx – peritoneal fold of the uterine tube 7.1 cranial part of the broad ligament of the uterus 7.2 contains anastomosis between ovarian artery and ovarian branch of the uterine artery (ovarian arcade) and its branches. VASCULAR SUPPLY OF THE UTERINE TUBE Arterial supply: – lateral 1/3 of the uterine tube: tubal branch of the ovarian artery (from the abdominal aorta) – medial 2/3 of the uterine tube: tubal branch of the uterine artery (from the internal iliac artery) Venous drainage: – ovarian artery (to the left renal vein) – right ovarian artery (to the inferior vena cava) – uterine venous plexus (to the uterine vein, internal iliac vein) Lymphatic drainage: – major part of the uterine tube: lumbar nodes – isthmus: superficial inguinal nodes.  CLINICAL CORRELATIONS Oophorectomy is the surgical removal of the ovary. Salpingectomy is the surgical removal of the uterine tube. Salpingo-oophorectomy / adnexectomy is the surgical removal of both the ovary and the uterine tube. Adnexitis / pelvic inflammatory disease is inflammation of both the uterine tube and ovary. It may be caused by spread of infection from the appendix. Salpingitis is inflammation of the uterine tube. It can spread to the peritoneum via the abdominal ostium and thus cause peritonitis. Ovarian cyst is a collection of fluid covered by a thin membrane located in the ovary.  UTERUS Pear-shaped organ located in the lesser pelvis between the urinary bladder and rectum. Its mucosa undergoes cyclic transformation, synchronised with the ovarian cycle. This ensures that the uterus is ready for implantation and the subsequent development of the fertilised ovum. Metra and hystera are Greek terms for uterus.  POSITION OF THE UTERUS It is positioned in anteversion and anteflexion and is almost completely covered by peritoneum. Flexion: angle between the uterine body and isthmus. Version: angle between the cervical canal and the vagina.  POSITION OF THE UTERUS Due to uterine position, spermatozoa can easily reach the uterine cavity and it provides sufficient space for a growing embryo/fetus.  CLINICAL CORRELATION Uterine prolapse occurs when the muscles and tissue in the pelvis weaken. Uterus may assume other dispositions: excessive anteflexion, anteflexion with retroversion, and retroflexion with retroversion. Retroversion was thought to be a potential predisposing factor in uterine prolapse or to present a potential complication in pregnancy.  EXTERNAL STRUCTURE OF THE UTERUS Body Fundus Isthmus Cervix  EXTERNAL STRUCTURE OF THE UTERUS 1. Body of uterus – middle and largest part of the uterus 1.1 Fundus of uterus – ventro-cranial part of the body of the uterus 1.2 Uterine horn – a paired structure through which the uterine tubes enter the uterus 1.3 Border of uterus – attachment of the broad ligament of the uterus – uterine artery ascends to the uterine horns from the isthmus of uterus 1.4 Uterine cavity – houses the developing embryo and foetus  EXTERNAL STRUCTURE OF THE UTERUS 2. Isthmus of uterus – narrow transitional area between the body and cervix 2.1 Canalis isthmi – cavity of the isthmus, its upper border forms the internal os 2.2 Anatomical os – internal os  EXTERNAL STRUCTURE OF THE UTERUS 3. Cervix of uterus 3.1 Supravaginal part – cranial part of the cervix above the attachment of the vagina – contains mucosal folds called the palmate folds 3.2 Vaginal part – caudal part of the cervix protruding into the vagina 3.3 Cervical canal – the continuation of the uterine cavity inside the cervix 3.4 External os of uterus – opening of the cervical canal to the vagina EXTERNAL STRUCTURE OF THE UTERUS  SUPPORTING APPARATUS OF THE UTERUS Supporting apparatus of the uterus consists of the muscles of the pelvic floor. These are more important than the parametral ligaments. 1. Levator ani/pubovaginalis 2. Ischiococcygeus 3. Perineal muscles *The details will be mentioned in the lecture ‘Perineum’.  PERITONEAL FOLDS Broad ligament of uterus (lig. latum uteri) – double peritoneal fold located in the frontal plane of the lesser pelvis, consists of the three parts Attached to the uterine border medially and is laterally continuous with the parietal peritoneum of the pelvic wall Parts: 1. Mesovarium (dorsally) – peritoneal fold of the ovary 2. Mesosalpinx (cranially) – peritoneal fold of the uterine tube 3. Mesometrium (caudally) – peritoneal fold of the uterus  CLINICAL CORRELATIONS During ligation of the ovarian artery and vein, care must be taken not to damage the ureter, which is located directly posterior to the infundibulopelvic (suspensory ligament of ovary) ligament, close to the medial leaf of the broad ligament. The phrase ‘water under the bridge’ is sometimes used by clinicians to describe how the ureter (the "water") runs posterior to the infundibulopelvic ligament, which contains the ovarian artery and vein (the "bridge"). This is important to know during surgery because care must be taken not to injure the ureter while ligating the ovarian vessels, as the ureter runs directly beneath them. In essence, the ureter is the "water" running under the "bridge" formed by the ovarian vessels.  PARAMETRIAL LIGAMENTS Hold the uterus in its proper position in the pelvis. 4. Round ligament of uterus (ligamentum teres uteri) – keeps the uterus in anteversion during pregnancy 5. Cardinal ligament / transverse cervical ligament (lig. cardinale Mackenrodti / lig. transversum cervicis) – paired fibrous band extending laterally from the cervix and isthmus to the pelvic wall – enables antero-posterior movements of the uterus. CARDINAL LIGAMENTS PARAMETRIAL LIGAMENTS 6. Pubocervical ligament (l. pubocervicale) – extends from the pubic symphysis to the cervix 7. Vesico-uterine ligament (l. vesicouterinum) – extends from the uterus to the urinary bladder 8. Recto-uterine ligament (l. rectouterinum) – extends from the rectum to the uterus 9. Uterosacral ligaments (ll. sacrouterina) – continuation of the recto-uterine ligament to the sacrum, contain the inferior hypogastric plexus; provide resistance against prolapse. PARAMETRIAL LIGAMENTS  ARTERIAL SUPPLY OF THE UTERUS Arterial supply: internal iliac artery 1. Uterine artery – approaches the isthmus from the side and ascends tortuously along the uterine border Venous drainage: uterine venous plexus (into the uterine vein and internal iliac vein)  LYMPHATIC DRAINAGE 1. From fundus and upper part of the body - pre- and para-aortic lymph nodes; superficial inguinal lymph nodes. 2. From the lower part of the body - external iliac nodes 3. From cervix: a) Laterally - external iliac and obturator nodes b) Posterolaterally - internal iliac nodes c) Posteriorly - sacral nodes.  VAGINA A hollow muscular tube that serves as the terminal part of the female genital tract. It facilitates copulation and partuition. Kolpos is the Greek term for vagina.  VAGINA Location Extraperitoneal, in the pelvis Extends from the uterus to the vaginal vestibule Neighboring structures Supported by the levator ani muscle, urogenital diaphragm, and several ligaments: transverse cervical ligament, pubocervical ligament, and sacrocervical ligament Anteriorly: urethra and bladder Posteriorly: rectum and anal canal (separated by perineal body) Superiorly: rectouterine pouch Distally: pelvic floor and vulva Ureter courses close to the lateral fornices.  VAGINA 1. Vaginal orifice – external opening of the vagina in the vesti bule 2. Vestibule – a space borderd by the labia minora 3. Vaginal canal – cavity of the vagina 4. Vaginal fornix – encloses the vaginal part of the cervix uteri  VAGINA The shape of the vagina is not a round tunnel. In the transverse plane it is more like an “H” lying on the side. At the upper ending, the vagina surrounds the cervix, creating two domes (fornices or vaults): Anterior Posterior (deeper) Posterior fornix is important as it acts like a natural reservoir for semen after intravaginal ejaculation. Semen retained in the fornix liquefies in the next 20-30 mins, allowing for easier permeation through the cervical canal.  VASCULAR SUPPLY Arterial supply: – vaginal artery, which arises either directly from the internal iliac or from the uterine artery – vaginal branches from the uterine artery, middle rectal artery and internal pudendal artery Venous drainage: internal iliac vein via the uterine venous plexus (into uterine and vaginal veins), middle rectal and internal pudendal veins.  LYMPHATIC DRAINAGE Lymphatic drainage: internal and external iliac nodes, sacral nodes – caudally below the hymen: superficial inguinal nodes  CLINICAL CORRELATION Ectopic pregnancy (graviditas extrauterina / GEU) a pregnancy in which the fertilised egg attaches in a location other than the uterine endometrium Tubal pregnancy: a pregnancy that occurs within the fallopian tube Interstitial pregnancy: a pregnancy that occurs within the interstitial portion of the fallopian tube Complicated ectopic pregnancy Associated with severe bleeding, rupture (e.g., tubal rupture), or hemodynamic compromise Gynecological emergency that requires surgical treatment Uncomplicated ectopic pregnancy Ectopic pregnancy without any features of complicated ectopic pregnancy May resolve spontaneously in some cases Heterotopic pregnancy: rare condition involving multiple gestations, in which one is intrauterine and another is ectopic. Occurs more frequently in patients undergoing infertility treatments, e.g., in vitro fertilization.  CLINICAL CORRELATION Metrorrhagia is uterine bleeding that differs in timing or intensity to normal menstrual bleeding. Metralgia is the Latin term for “pain of the uterus”. Hysterectomy is the surgical removal of the uterus. Myoma / leiomyoma is a benign tumor of the myometrium. It is the most common tumour of the body of the uterus.  FEMALE EXTERNAL GENITALIA (VULVA) Vulva is a term for the female external genitalia. It includes: labia majora, labia minora, clitoris, erectile bodies vestibule (with it’s associated glands). Vestibule is an area bordered by the labia minora. Labia majora are covered with skin and pubic hair. Round ligament of the uterus inserts into the fat tissue of the labia majora. Labia minora do not contain fat tissue and are lined with mucosa on their medial surfaces. They divide ventrally into two folds, forming the prepuce and frenulum of the clitoris. Clitoris is an erectile organ connected to the two erectile bodies of the bulb of the vestibule. VESTIBULE – VESTIBULUM VAGINAE 1. Vestibule 1.1 Vaginal orifice – external opening of the vagina 1.2 Greater vestibular gland / Bartholin’s gland – a paired mucous gland embedded in the perineal membrane – opens into the posterior part of the vestibule 1.3 Lesser vestibular glands 1.4 External urethral orifice – external opening of the female urethra  INTERNAL STRUCTURES 2. Labia majora 2.1 Anterior commissure – anterior connection of the two labia majora – located ventral to the prepuce of the clitoris 2.2 Posterior commissure – posterior connection of the two labia majora, behind the vestibule 3. Labia minora  CLITORIS 4. Clitoris – female erectile organ, erectile tissue composed of corpora cavernosa consists of a visible glans, body hidden in the subcutaneous CT and paired arms 4.1 Crura of clitoris – paired bodies of erectile tissue attached to periosteum at the inferior ramus of the pubic bone – meet in the midline at the body of the clitoris 4.2 Body of clitoris – is formed by fusion of the crura of the clitoris 4.3 Glans of clitoris – terminal part of the clitoris 5. Bulb of vestibule – pair of erectile bodies encircling the vestibule – ventrally connected at the commissure of the bulbs.  STRESS URINARY INCONTINENCE Stress incontinence is the involuntary leakage of urine following any activity associated with raised intra-abdominal pressure (e.g., coughing, sneezing). It is twice as common in women than in men and its prevalence increases with age. An increase in bladder pressure (e.g., pelvic floor weakness, intrinsic sphincter deficiency, etc.)) that exceeds sphincter resistance, which leads to expelling of urine. Individuals with the condition have predictable, small-volume urinary loss, typically during physical exertion, with no history of irritative symptoms of the bladder (urgency or frequency).  INNERVATION OF FRS Internal genitalia: thoracolumbar nerves, lesser splanchnic nerves, hypogastric nerve (sympathetic), pelvic splanchnic nerves, vagus nerve (parasympathetic) External genitalia: ilioinguinal nerve, genitofemoral nerve, pudendal nerve, posterior cutaneous nerve of the thigh (sensory), uterovaginal nerve plexus (parasympathetic). REFERENCES