8132MED - Clinical anatomy Reproductive system 090924.pdf

Clinical Anatomy of Female Reproductive System A/Prof. Lakal Dissabandara  Objectives Understand the bony pelvis anatomy in relation to parturition. Describe the anatomy and the blood supply of the female reproductive organs. Describe the innervation of the female...

Clinical Anatomy of Female Reproductive System A/Prof. Lakal Dissabandara  Objectives Understand the bony pelvis anatomy in relation to parturition. Describe the anatomy and the blood supply of the female reproductive organs. Describe the innervation of the female reproductive system and understand the anatomical basis of labor pains and analgesia/anaesthesia during obstetric/gynaecological practice. Describe the anatomy of the Perineal membrane/perineum and understand the anatomical basis of episiotomy and perineal tears. Describe the uterovaginal supports (pelvic floor, ligaments and pelvic fascia) and understand the anatomical basis of utero-vaginal prolapse and stress incontinence. First Part of this lecture has been uploaded to (module 3) Reproductive Anatomy folder  Mary’s Case Cont…… 2 days after the clinic visit Mary admitted with labour pains. Examination revealed 3cm dilated and 90% effaced cervix. She had a long first stage of labour. She was offered Epidural analgesia but refused. Explain dilatation and effacement of Cx. What are the stages of labour? Which neural elements convey these pain signals? What structures/mechanisms generate pain during labour? Understand the basis of obstetric analgesia. Female reproductive organs TOP Above fallopian tube attachment Fundus Body below Isthmus b/w cervix and body enlarges in last trimester and labour Cervix Cervical anatomy in labour - Dilatation & Effacement head - pressure on cervix, lose height and effaces Hormones Biochemical Changes: Dilatation and effacement of cervix is Oxytocin: Stimulates Prostaglandins & Relaxin important for delivery of the child. uterine contractions → Collagen Breakdown ……………………………. softening is important → Increased Water. Content Cervical ripening (softening) and strong uterine contraction is essential for dilatation and effacement. Push fetus downward Softens cervix, making 2 processes it more elastic. Increases pressure on onset of labour During the last few weeks of pregnancy, the cervix soft = labour under the influence of chemicals such as stretching and thinning the cervix - Effacement Prostaglandins and Relaxin, there is breakingdown of collagen and Opening of the Cx - dilatation. accumulation of water in the Cx making the Dilation & Effacement in a Primi Firm Cx → Soft Cx (A sign of onset of soft cervix result labour) Oxytocin release leads to uterine Not effaced 50% effaced ~ fully effaced contractions that pushes the fetal head - Cx 2cm - Cx 1cm - Cx not against the Cx --> stretching & thinning of palpable palpable palpable Not dilated 0.5cm dilated 4cm dilated the Cx (effacement) and opening of Cx canal (Dilatation) stretch and thin cervix easily palpable pressure cervix stretches and before - thick and closed thins out  Stages of labour & Cx anatomy in Labour There are 3 stages. Stage 1 (Until 10 cm dilatation of until 10cm 0-10 Cx) Latent phase - Cont…Softening of Cx - Effacement of Cx (about ~90%) - Dilatation of Cx up to 3-4 cm (slow dilatation of Cx) Active phase - Stronger, frequent uterine contractions - 4-10 cm dilation (faster 1.5cm/hr) Latent Phase Active Phase complete dilation speed varies Stage 2 8 hours, more or less Full dilatation to Delivery of child complete softening after - strong contractions and the latent is a softening frequent - dilate cervix Stage 3 Delivaery of child to Delivery of placenta then placenta Sensory Innervation of FRT to neural axis T10-L1 Innervated by both autonomic and somatic NS. into superior hypogastric plexus on sacrum Ovaries to inf inside pelvis (pelvic pelxus) T10-11 Sympathetic S2,3,4 sensory - reproductive ovarian vessels SNS PNS and SNS Uterus + Cervix + Upper Vagina Superior hypogastric Pelvic plexus (T10-L1) T10 – L1 Sympathetic splanchnic Ns (Parasympathetic s2,3,4 for upper lateral horn vagina???) insignificant visceral tissues visceral tissues Pelvic plexus Pudendal (Sym →T10-L1) + N Pelvic floor, Lower Vagina & (Parasym →S2,3,4) anterior and posterior horn somatic Perineum levator ani and perineum S2-S4 Pudendal nerve Nerves running in the (Somatic) paracervical region block nerves for analgesia in paracervical  Mechanisms of Pain During labor Visceral Pain increased demand and frequency Early First stage - Uterine contractions → myometrial ischemia (?)→release of potassium, bradykinin, histamine, and serotonin as vessels are compressed → Visceral Pain visceral tissues - dull myometrial ischemia contract - constrict or reduce supply Late first stage /2 stage – Contractions + Stretching and nd distention of the lower segment of the uterus and the cervix stimulate mechanoreceptors → Visceral Pain. foetal skull descends and stretches - stretch mechanoreceptors These pain signals are predominantly carried by the sensory- nerve fibers that accompany sympathetic nerves, traveling through the paracervical region → pelvic and hypogastric plexus predominant neurons →lumbar sympathetic chain → T10 – L1 Spinal cord. somatic not well involved Somatic Pain Late 1st/2nd - mechanoreceptors for visceral pain and stretching for somatic pain Late first stage and during second stage there is increased stretching of Pelvic floor, vagina and other perineal somatic tissues due to descending fetal head → Somatic pain. These somatic pain signals travel through the Pudendal Nerve → S 2, 3,4 segments. late first/2nd block in different areas These neural elements can be blocked in perineum, paracervical region sympathetic chain or more centrally in epidural or subarachnoid space to provide analgesia.  Obstetric Epidural Analgesia - Anatomy SAS The spinal nerve roots passed through the subarachnoid space EDS and then through the epidural dura + arachnoid space before exiting the vertebral column. via dura to 2nd space Spinal Epidural space is outside T10 the dura. block up to T10 This space is filled with fat, blood vessels and traversing nerve roots from spinal cord to the periphery. target in analgesia Therefore, by blocking the nerve roots up to T10 at spinal epidural space would provide analgesia during labour. LA injected into epidural space from Spinal dura T10-S4  Obstetric Epidural Analgesia - Anatomy SAS Epidural space – Not entirely open (vascular, fat and connective tissue) Supraspinous ligament above spinous Ligamentum flavum posterior to spinal canal pass through to space Interspinous ligament b/w spinous Dura Highest Epidural analgesia point of landmarks iliac crest – most common site Level of L4 vertebra intercrestial line vertebral body anterior Usually accessed through L3-L4 interspinous interval. Needle pass through: Skin → SCT → Supraspinous lig → Interspinous lig → ligamentum flavum → Epidural space  Obstetric Epidural Analgesia - Level To achieve analgesia during labour, T10-S4 block T10 – L1 roots (stage 1) early 2nd VISCERAL + block S2- S4 roots (stage 2) late SOMATIC 1st stage and 2nd distension – Usually blocks up to T8 (For Caesarean section upto T4) Appropriate level – – Can be monitored by testing sensory T8 level (Ice /pin prick) T8 - b/w umbilicus and xiphisternum (halfway between Xiphisternum and Use drugs (LA + Opioids) in umbilicus) concentrations which minimally affect motor function. Affect motor activity umbilicus Drug volume/positioning of the patient may affect the level of blockade. Larger volumes may block upper thoracic nerve roots → severe all vasomotor nerves blocked Hypotension/Respiratory problems.  Mary Case Cont…… Since there was a delay in the second stage of labor and early signs of fetal distress the obstetrician decided to perform an instrumental delivery. Pudendal nerve block was used to provide act quick analgesia and Bilateral mediolateral episiotomy was performed. A baby girl weighing 4.4Kg was delivered. Despite episiotomy she suffered a 2nd degree perineal tear. Describe the pudendal block. Describe anatomy related to Episiotomy. Describe Perineal tears.  Pudendal Nerve – S2, 3, 4 iRAT - posterior to Pudendal nerve → travels posterior to the ischial spine/Sacrospinous lig. ischial spine Re-enters the pelvis → passes through Alcock’s canal (inner aspect of ischiopubic ramus → form inside pelvis Multiple branches (Inferior rectal N, Perineal Brs, Dorsal N of clitoris/penis) also behind this behind ischial spine then block goes out pudendal nerve along medial surface of ischiopubic ramus covered by connective tissue - Alcock's canal back into perineum Ex urethral sphincter, Bulbospongiosus supplies deep perineal Ischiocavernous pouch Tr. Perineal muscles first branch - anorectal canal Sensory innervation branches to Clitoris/Penis Perineal skin/mucosa  Pudendal Nerve Block (PNB) Locate the ischial spine transvaginally (or perineal) and infiltrate LA around the ischial spine. also via perineal skin find laterally block pudendal nerve PNB does not anaesthetize the whole perineum. Other Ns – Ilioinguinal, Genitofemoral, posterior cutaneous N of thigh, Inferior gluteal N PNB does not abolish labor pains (mostly sympathetic fibers T10-L1) visceral Type te as uterine contractions Sensory Innervation of Perineum pudendal nerve block for late first stage and early 2nd not entire perineum Perineal Brs + Dorsal nerve of clitoris from Pudendal nerve includes most external genitalia adequate for some procedures  Female Perineum Perineum lies inferior to the pelvic diaphragm. Perineal membrane divides the perineum into superficial perineal pouch by perineal membrane deep perineal pouch Peripheral boundaries - Boundaries of pelvic outlet diamond shape Pubis symphysis Ischiopubic ramus Pelvis Urogenital ant Triangle Ischial GIT tuberositiy Perineum Anal Triangle Deep perineal Perineal Sacrotuberous pouch membrane ligament posterolateral Superficial perineal pouch superficial to the perineum Coccyx  Perineal Membrane & Deep perineal space Perineal membrane is a triangular, fibrous membrane that occupies the urogenital triangle; attached to ischiopubic rami. ant post In female, the perineal membrane is pierced by the urethra and vagina. Deep perineal space is between the perineal membrane & pelvic diaphragm. Levator ani pulled up anterior Contents of DPS External Urethral sphincter complex obturator internus Sphincter urethrae around membranous urethra Compressor Urethrae part of external urethral sphincter Urethro-vaginal sphincter to posterior perineal membrane attach to perineal body above pelvic cavity Perineal membrane triangle, pelvic diaphragm above Deep Transverse completes perineum below, then deep perineal space b/w diaphragm and membrane structures anchor Perineal muscle Structures in Superficial perineal space - Deep Female – Exterior view crus to ischiopubic ramus Ischiocavernosus Glans Clitoris Clitorislike crus of penis covering the Crus of Crus of clitoris same on Corpus clitoris crus of penis cavernosum vaginal opening Bulbospongiosus same covering the bulb Bulb of the structure of the vestibule Vestibule female - erectile superficial entirely run outside urethral opening female in two parts deep in pouch 4' and 8' membrane - deeper structure attach to this body Perineal Body Superficial Tr. Perineal muscle Deep Layer covered in fascia Superficial Layer fatty tissue + skin Male – Exterior view Bulb of the Penis raphe in males from bulbospongiosus w/ spongy urethra A 30-year-old patient presents with painful swelling of labia for 2 weeks. This lump is in lower medial aspect of labia majora This is the location of the Bartholin glands (4-8’ O glands at opening clock position) of vagina Paired glands open into the vaginal vestibule. fat tissues Secretions moisten the vaginal epithelium. present Obstruction of the ducts →Accumulation of secretions → Bartholin gland Cyst → Abscess swelling present DD for Vulval lump Bartholin cyst Lipoma Sebaceous cyst Dermoid cyst Vulval malignancy Gartner’s cyst – Remnant of Wolfian duct Openings of Bartholin openings of glands glands https://www.omicsonline.org/ireland/bartholins-cyst-peer-reviewed-pdf-ppt-articles/  Perineal Body (PB) A fibromuscular tissue which acts as the skeleton of the perineum. Located between rectum & vagina in female. Continuous with the rectovaginal septum/fascia. Provides attachment to many important muscles including – External anal sphincter – External urethral sphincter through urethrovaginal sphincter. – Transverse perinei muscles – Bulbospongiosus – Pubovaginalis muscle (See the diagrams in the slides describing the deep perineal space) Thereby, PB provides structural support to the distal urethra, vagina, rectum and anal canal. Structures attached to the Perineal body Perineal Body remember extend upwards very superficial at back Bladder Uterus Rectum around vagina 4,5 to perineal body 4. Pubovaginalis Rectovaginal septum/fascia inferior relation - perineal body 3. External 5. Puborectalis urethral sphincter rectum through urethrovaginal sph. indirectly 6. External anal sphincter attach to perineal body 1. Bulbospongiosus orifice of vagina 2. Transverse perineal muscles ISL slide  Episiotomy A surgical incision (cut) made in the posterior vaginal wall to widen the vaginal opening. Indications Foetal distress due to prolonged labour – to speed up delivery Stiff perineum affecting delivery open vaginal orifice Shoulder dystocia tucked under pubic symphysis, need to widen perineum Instrumental delivery To reduce maternal pushing efforts Eg. In cardiac disease reduce maternal pushing There are 2 types Mediolateral (Right/left) Median  Mediolateral episiotomy is the Tissue layers Cut preferred method. Superficial - Skin and Vaginal mucosa posterior Deep – Bulbospongiosus & Tr. ant Perineal muscles Mediolateral episiotomy careful with perineal body R/Mediolateral b/w anal canal and vagina outside mucus membrane preferred Median Cut through the bulbospongiosus and avoids midline structures and transverse perineal cut via skin, vaginal mucosa, subcutaneous tissue crowning stretched, analgesia, may need pudendal block - anaesthesia  Perineal Tears First degree – Laceration of the vaginal skin only epithelium or perineal skin Bulbospongiosus Muscle only. small laceration - only skin Perineal body Second degreein addition to mucosa – Perineal muscles (Bulbospongiosus/transverse perineals) + PB are damaged 1st Degree 2nd Degree mediolateral cut to avoid damage to Third degree perineal body – External anal sphincter is damaged. further back to sphincter Bulbospongiosus Muscle Fourth degree – Disruption of the ano-rectal epithelium (Full thickness vaginal and rectal tear). full thickness tear 3rd Degree 4th Degree  Mary undergoes LSCS ………………… During her last pregnancy she had an agonizing labour which ended up with a Lower Segment Caesarian Section (LSCS) due to prolonged 2nd stage. Type text here What is the Lower Segment of the uterus? What are the tissue layers encountered during LSCS? Female reproductive organs Fundus Body Isthmus small region in non-pregnant labour - rapid growth to 10cm height Cervix  Formation of the lower segment strongest contraction in fundus and retract. quite tight above very thick up Obstructe (Due to retraction) Pathological ring – contract then Bandle’s ring relax shorter with each contraction, push down identified - peritoneum is loosely attached surgery in lower segment not relaxation rather than upper During labour - Upper segment powerfully contracts and retracts (does not fully relax) and gets thicker → Exert powerful downward Push against Cx. upper segment thicker and thicker → Lengthening and thinning of Isthmus region → Formation of lower stretch lower segment (~10cm) Leads to opening of Cx canal → Cx dilatation. Leads to shortening of Cx → Cx effacement  Bandle’s Ring In obstructed labour, the uterine muscle continues contract after full dilatation of Cx → Increased retraction + Thickness of upper segment → the junction between the upper & lower segment can become abnormally prominent and seen from outside (Bandle’s ring) visible contraction ring, rare these days Obstructed labour thick and thin Not palpable Pathological ring – Bandle’s ring  Tissue Layers encountered during LSCS Skin incision – Pfannenstiel incision Skin, Camper’s, Scarpa’s (Transverse Suprapubic incision) Anterior rectus sheath Cut through Skin, Camper’s and Rectus muscle Tr. fascia Scarpa’s fascia. Open the Anterior rectus sheath Lower segment of Parietal (Transverse incision) Uterus with Fetus Peritoneum Separate the Rectus muscles from lined by Visceral the midline below arcuate line - only anterior rectus sheath no posterior rectus sheath peritoneum Visualize the transversalis fascia, extraperitoneal fat and the parietal Parietal cut further down peritoneum peritoneum and open vertically Visceral (avoiding extending inferiorly onto the peritoneum full bladder and bladder!) Bladder cut into Symphysis Identify the Lower segment of the Uterus covered by visceral peritoneum Peritoneum is loosely attached to loosely Lower lower segment attached segment Uterus Vagina Open the lower segment using a Transverse incision  Tissue Layers encountered during LSCS Pfannenstiel Rectus muscles Transverse incision Lower segment incision covered by anterior made on rectus identified. Skin rectus sheath sheath. Visceral peritoneum Campers and reveal rectus Recti are separated. and myometrium Scarpa's move to sides Transversalis fascia opened using Fascia and Parietal transverse incision. transverse first peritoneum is see uterus and baby inside visualized No Posterior rectus sheath** Type text here Lanowski, J., & Kaisenberg, C. S. v. (2018). The Surgical Technique of Caesarean Section: What is Evidence Based?. In (Ed.), Caesarean Section. IntechOpen. https://doi.org/10.5772/intechopen.78040  Back to Mary again………………… Mary is now 65 years old. She comes to see the GP complaining of a lump appearing in vulva which is prominent when straining. Examination reveals a 3rd degree Uterovaginal prolapse. She has given birth to 6 children. 6 children - damage connective tissue and muscles after menopause - increased weakness lack of oestrogen She reached the menopause at the age of 51. POH – Last pregnancy LSCS due to prolonged labour. She has also been on Asthma medication for the last 12 years. steroids - weaken connective tissues risk of prolapse Describe the Pathophysiology & Anatomy related to UVP.  Uterovaginal Supports 1. Pelvic floor key structure levator ani Main support mechanism 2. Connective tissue in pelvic fascia 3. Perineal supports (Perineal body/Perineal membrane) 4. Other – Bladder/Round ligament/ Broad Ligament?? not for significant support  Pelvic floor Pelvic floor consists of musculo-fascial tissues that demarcates the pelvic cavity from the perineum. Muscles arise in relation to the 3 pelvic bones and insert into a midline raphe and the coccyx. – Levator ani pubic bone and iliac bone Pubococcygeus – Puborectalis – Pubovaginalis sling – Pubourethralis two together Pelvic diaphragm – Pubococcygeus proper to coccyx Iliococcygeus – Ischiococcygeus part of pelvic diaphragm  Pelvic floor muscles Pelvic diaphragm attachments - Coccygeus + Levator ani Interior View from above Anterior sacrococcygeal lig. right and left form raphe Obturator internus. Anococcygeal raphe cover obturator forame 3 tubes behind Rectum Obturator internus Fascia overlying the obturator internus muscle Vagina tendinous connective tissue Arcus Tendineus – A thickening of the obturator internus fascia – Iliococcygeus attaches here ISL slide Biodigital human  Pelvic floor Pelvic diaphragm muscles - Coccygeus + Levator ani View from above Ischiococcygeus anatomy of pelvic floor Ischial spine Iliococcygeus holds most pubic organs Pubococcygeus sphincteric muscle most anterior - Puborectalis sling - Pubovaginalis - Pubourethralis Pubic bone ISL slide Pelvic floor - inferior View Pubococcygeus Pubourethralis PuboVaginalis Puborectalis Iliococcygeus Anocoocygeal raphe Ischiococcygeus outside  Levator ani – Innervation Levator ani nerve (S3,4 ) on surface, but not compressed Note the nerve runs on the levator ani – Susceptible to injury during labour. runs on surface Pudendal nerve Levator ani nerve runs deep to LA  Levator ani - Functions Sphincteric effect on orifices – Puborectalis, Pubovaginalis & pubourethralis – Help urinary and fecal continence during coughing and sneezing Support the pelvic organs (including vagina) Pelvic floor tone alters according to the intraabdominal pressure. – Tone of the muscle directly support the uterus and vagina (& other organs) when there is raised intra abdominal pressure Proximal 2/3 vagina lies horizontally on the levator ani. When intraabdominal pressure rise this part of the vagina get compressed against the pelvic floor –> Prevents uterus from prolapsing (see next slide) Relieves and protect the connective tissues (Ligaments) takes main role of support 2/3 of vagina is intrapelvic! Running almost horizontally in pelvic cavity on the levator ani. “Almost” Levator ani horizontal pelvic portion of Pubovaginalis Pull → Angulate & Make vagina vagina on surface horizontal If the vagina is vertical Normal position of Vagina Pressure has angle Pressure more pressure, Pressure can prolapse Pressure Increase risk if vertical pressure on Reduced risk of Prolapse pelvic floor of Prolapse almost horizontal position of vagina Pahva et al., Clinical Anatomy 28:305–313 (2015) Pelvic floor Relieves and protects the ligaments from tension. Ship in the Berth lose diaphragm, damage ligaments lose support maintained by ropes ropes are ligament pelvic diaphragm is water  Connective tissue Supports Assume endopelvic fascia as a Mainly by the endopelvic fascia and packing material in the pelvis its perineal extensions. – Endopelvic fascia is a connective tissue consists of collagen and elastic fibres & transmits blood vessels, nerves, lymphatics. This fascial tissue connects the pelvic organs to the walls and Pelvic floor. Over time during development Exist in different forms. thickenings appear (to support) in some areas. – Act as an effective packing substance for expandable pelvic organs. distinct membranes membranes cover – Discrete ligaments - pelvic walls – Membranous fasciae -  Ligamentous & membranous endopelvic fascia Axial section Pubovesical lig. bladder of the pelvis Pubocervical lig. thickened fascia Urethra Urethrovaginal fascia/septum attach to wall support anterior vaginal wall lateral cervical Cx cervix Rectovaginal Mckenrodt lig fascia/septum (Lateral cervical lig) (Cardinal lig.) continue perineal body up Rectum to cervix and upper vagina in superior cardinal lig. Uterine artery above thickened Uterosacral posterior ligament Sacrum Ureter runs below water under the bridge relationship Uterus itself is not directly supported. It is the cervix and vagina which receive ligamentous/fascial attachments. ISL Where is the broad ligament in relation to these structures? slide Posterior view to show the ligaments broad ligament higher level ligate uterine artery but not damage the ureter lower level inferior to broad ligament 'water under the bridge' relationship here further down UVF and RVF are located at this level.  Lateral View to show the ligaments/Fasciae USL and CL pull the uterine cervix and upper vagina posterior wards. Pubocervical Helps to make intrapelvic lig portion of vagina horizontal Utero sacral lig Helps maintain anteverted anteflexed position of higher level Uterus Urethrovaginal Cardinal septum Ligament posterolateral attach pelvic diaphragm Rectovaginal septum perineal body upward avoid collapse cervix and vagina posterior  Uterine Anteversion and anteflexion There are normal variations in uterine position – Commonest Anteverted Anteflexed Anteversion – Anterior tilting of uterine cervix in relation to the vagina Anteflexion – Anterior tilting of uterine body in relation to the uterine cervix Anteverted Anteflexed flexion of uterine body on cervix Anteflexion angle with vagina and cervical axis Anteversion backwards Anteverted Retroverted Retroflexed Retroflexed body back  Delancey’s Classification of connective tissue supports not pelvic diaphragm Level 1 (Supports Cx and Upper part of Vagina) Cardinal-Uterosacral (USL/CL) Weakness → Utero-vaginal prolapse damage - to prolapse Level 2 (Supports middle part of vagina) Level 1 Endopelvic fascia - Connect vagina to Level 2 lateral pelvic wall/levator ani USL anterior and posterior vagina Rectovaginal septum CL anterior – urethrovaginal fascia (UVF) Supports bladder and urethra as well Urethrovaginal septum posterior – Rectovaginal fascia (RVF) Supports the rectum/anal canal Weakness → Anterior & Posterior vaginal prolapse (Cystocoele & rectocoele) three levels Level 3 Level 3 (Supports lowest part of vagina) Perineal Body Lower part of UVF and RVF, Perineal Perineal membrane membrane + perineal body Weakness → Anterior & Posterior vaginal wall prolapse (Cystocoele & rectocoele)  UV Prolapses Anterior vaginal wall prolapse weakness in urethrovaginal septum – Urethrocoele urethra in Anterior – Cystocoele bladder in wall – Cysto-urethrocoele both Type text here via anterior wall anterior wall Cystocoele  UV Prolapses Posterior vaginal wall prolapse weakness in rectovaginal Posterior septum wall – Rectocoele rectum prolapse – Enterocoele with intestine Rectocoele  UV Prolapses UV prolapse + Cystocoele + rectocoele Apical prolapse – Uterovaginal prolapse all prolapse urogenital prolapse anterior and posterior wall out  Other Ligaments & peritoneal folds Broad Ligament Note the peritoneum reflecting from Posterior pelvic wall (rectum) onto the posterior aspect of uterus → fundus → anterior uterus → bladder refelct → anterior abdominal wall. These 2 layers fuses on the lateral border of the uterus to form the Broad ligament. come together into broad ligament Pouch of Douglas (Rectouterine pouch) Uterovesical pouch Posterior vaginal fornix Anterior Posterior layer Anterior layer vaginal fornix BL BL  There are 3 structures attached to the lateral aspect of the uterus: from anterior to posterior,gubernaculum round ligament, fallopian top tube, ovary/Ovarian ligament. suspensory ligament The peritoneum folds over the Uterine tube and ovary forms the Mesosalpinx and Mesovarium respectively. Rest of the broad ligament is called mesometrium. Round ligament continuation is ovarian lig. Uterus Ovarian ligament Anterior Posterior Fallopian tube Mesovarium subcomponent Mesosalpinx of broad ligament up and surround double fold Ovary Mesometrium Round ligament and Ovarian ligament These are derived from Gubernaculum of the ovary. During ovarian descent it is anchored to the developing uterus → Prevented further descent of ovary.  Interior view - Pelvis Anterior Bladder blood vessels for uterine tube Round ligament Mesosalpinx from fallopian tube Ovarian Lig Mesovarium from ovary pouch of Douglas vessels Mesometrium back onto rectum removed on side Ureter Suspensory Cardinal Ligament more posterior Lig. of Ovary Uterosacral uterine into broad lig. Rectum Ligament back to sacrum post ovarian and uterine vessels anastomose top part of cardinal ligament Aorta Round ligament extends into the inguinal canal and then to the labia majora. Ovarian ligament anchors ovary to the uterus. Suspensory ligament anchors ovary to lateral pelvic wall ovarian vessels, ligate suspensory ligaments, Ovarian vessels run through the suspensory ligament of ovary Uterine vessels runs at the base of the broad ligament (inside Cardinal Lig) and ascend up in side the broad ligament. The ureter runs below the uterine artery in the cardinal ligament – “Water under the bridge”  Back to Mary…one last time! Additionally, she complains about minor loss of urine at rest, which becomes significant following laughing, sneezing or slight coughing. Initially this was tolerable with leaking occurred only with heavy coughing. stress incontinence Describe the anatomical basis of stress incontinence.  Stress incontinence 1 2 causes 1. Intrinsic sphincter deficiency – Uncommon – maybe caused by surgery/neuropathies damage nerves supply external sphincter 2. Urethral hypermobility – Commoner – caused by damage to pelvic support mechanisms (Levator ani/urethrovaginal septum/pubovesical lig) damage to pelvic floor movement of urethra Normal Anatomy and Function Proximal urethra is located within the abdomino-pelvic cavity (together with the bladder). When abdominal pressure increases (eg. coughing) → increase in pressure inside the bladder. important connective tissue supports However, the urethra also being inside the pelvis, subjected to the same part in perineum pressure and it closes off → prevent leaking of urine (Together with other sphincteric mechanisms). close off  Stress incontinence 2 Abnormal Anatomy and dysfunction urethra moves out squeeze and not press urethra When the pelvic supports to the urethra (Pubovesical lig, Levator ani, Urethrovaginal septum) are compromised → hypermobile urethra → proximal part goes into perineum → not subjected to increased abdominal pressure → Ex. Sphincter alone may not be able to withstand the magnitude of force → leaking. levator ani dysfunction not able to support