Femal genital system II
Pelvic floor, urogenital diaphragm
Mayer-Rokitansky-Küster-Hauser syndrome
The cause of MRKH syndrome is unknown, although it
probably results from a combination of genetic and
environmental factors.
The reproductive abnormalities of MRKH syndrome are due
to incomplete development of the Müllerian duct from which
develops the uterus, fallopian tubes, and the upper part of
the vagina..
It is unclear why some affected individuals have
abnormalities in parts of the body other than the
reproductive system.
Most cases of MRKH syndrome occur in people with no history of
the disorder in their family.
The uterus in place in the pelvis of the recipient with bilateral
end-to side anastomoses on the recipient's external iliac
vessels. Br€annstr€om. Uterus transplantation trial. Fertil Steril 2014.
Brännström M et al.: Livebirth after uterus transplantation
The Lancet, 385: 9968, pp.607 - 616 (2015)
http://dx.doi.org/10.1016/S0140-6736(14)61728-1
Vagina (kolpos) fornix, ostium, hymen, rugae, columns, urethral
carina, trigonal area of vagina, mucous membrane, muscular layer,
spongy layer, parakolpium, urogenital hiatus, pubovaginal m.,
promontorium of vagina, urethrovaginal sphincter muscle,
bulbospongiosus muscle,
Magnetic resonance image of female pelvis in sagittal plane
Sling of the pubovaginalis muscle
Magnetic resonance image of female pelvis in plane of urogenital
hiatus (level 2 according to DeLancey)
Anatomy of the pelvic outlet (scheme based on MRI)
Symphysis
Urogenital
hiatus
Urethra
Vagina
Anal canal
Puborectal
sling
(levator ani)
Tendinous arch
of levator ani
Tendinous arch
of pelvic fascia
Vagina
The vagina has mucosal, muscular, and adventitial layers.
There are no secretory glands, but the cells of the thick,
nonkeratinized stratified squamous epithelium become
filled with glycogen before desquamation.
The lamina propria mucosae contains thin—walled veins
and muscular layers exude fluid on the surface
of the epithelium.
The papillae and entire lamina propria are very rich
in protective lymphocytes and neutrophils.
The muscular layer has bundles of smooth muscle
arranged in a circular manner near the mucosa and
longitudinally near the adventitia.
The wall of vagina (mucosal, muscular, and adventitial layers)
(a): The micrograph shows the lamina propria (L) is highly cellular and
extends narrow papillae into the epithelium (E).
(b): Higher magnification of the epithelium and lamina propria (LP) shows
invasion of leukocytes (arrows) between epithelial cells from the
connective tissue
External genital organs
Pudendum (vulva)
Mons pubis
Labium majus
Labium minus
Pudendal cleft
Vestibule
Bulb of vestibule
Clitoris
Female external genitalia (vulva):
mons pubis, pudendal cleft, labia majora,
praepuce of clitoris, glans of clitoris,
frenulum of clitoris, labia minora, ostium
urethrae externum, ostium vaginae,
carunculae hymenales, commisura
labiorum posterior, perineum, ostium of
greater vestibular gland
n. ilioinguinalis, n. genitofemoralis,
n.cutaneus femoris posterior, n. pudendus
Clitoris, bulbus vestibuli
glans clitoridis, corpus clitoridis, crus clitoridis,
bulbus vestibuli
Perineal muscles in urogenital region:
bulbospongiosus, ischocavernosus, compressor of urethra,
urethrovaginal sphincter, superficial transverse perineal m.
Sources of illustrations used :
Gray´s Anatomy,
Sobotta: Atlas der Anatomie des Menschen
Grim, Druga: Regional Anatomy, Galen, Prague 2012
Benninghoff, Drenckhahn: Anatomie I., II.
Carlson,B.M.: Human Embryology and Developmental
Anatomy
Recommended Textbooks:
R. S. Snell: Clinical Anatomy. 7th Edition, Lippincott Williams
& Wilkins, 2004, pp. 478 – 562
or
K. L. Moore: Clinically oriented Anatomy, 3rd Edition,
Williams & Wilkins 1992, pp. 501 – 635
and
W. Kahle: Color Atlas/Text of Human Anatomy, Vol. 2 Internal
organs. Thieme, 4th English Edition, 1993
Langman´s Medical Embryology,11th Edition, 2010
Junqueira´s Basic Histology 12th Edition, 2010
Ross MH, Pawlina W: Histology, 5th edition, Lippincott
Wiliams, Wilkins, 2005
Vessels and lymphatics of organs of urogenital systems
Pelvic floor, Perineum
Internal iliac artery
Internal iliac artery, blood vessels of the pelvis
Perineal region - blood supply, innervation
Internal iliac vein
Parietal pelvic lymph nodes
Lymph nodes in the retroperitoneal space and pelvic cavity
Lymph nodes: common iliac, external iliac, inguinal
Vessels of pelvic organs
venous vesical plexus, venous vesicovaginal plexus
Nerves of retroperitoneal and subperitoneal spaces
Lumbar and sacral plexuses,
Abdominal and pelvic plexuses and
ganglia of autonomic system
Suprapiriform foramen
infrapiriform foramen
Retroperitoneal space, topography of its organs and main vessels
Pelvic floor
Pelvic diaphragm
Urogenital diaphragm
Perineal muscles
Pelvic diaphragm
Levator ani muscle
Pubic part – pubovisceral m.
pubovaginal m.
puboprostatic m.
puboperineal m.
puborectal m.
- pubococcygeal m.
Iliac part – iliococcygeal m.
Urogenital hiatus, Anal hiatus
Coccygeal muscle
Fibrous structures:
anococcygeal lig., perineal body,
tendinous arch of levator ani,
tendinous arch of pelvic fascia,
Levator ani
Ischioanal fossa, middle part
Levator ani (1,2,3) and cocygeus (4)
1 – pubococygeus
2 – iliococcygeus
3 – puborectal
4 – coccygeus
5 – obturatorius int.
Pelvic diaphragm
Pelvic diaphragm
Levator ani, tendinous arch of levator ani
Anatomy of the pelvic outlet (scheme based on MRI)
Symphysis
Urogenital
hiatus
Urethra
Vagina
Anal canal
Puborectal
sling
(levator ani)
Tendinous arch
of levator ani
Tendinous arch
of pelvic fascia
The levator hiatus in axial plane with minimally distensible (left) and
highly distensible puborectalis muscle (middle) compared to the
dimensions of fetal head at the term (right).
The ultrasound data sets of 227 nulliparous women examined at 36–38 week’s
gestation were investigated. Minimal hiatal diameters were measured at rest, on
Valsalva and pelvic floor muscle contraction. Results: some women will have to
distend only 25%, others by 245%.
Since childbirth-related trauma to the levator ani is common and clinically
important, one should consider potential preventative measures. One
approach would be to avoid vaginal delivery by performing elective
Caesarean Section.
(Švabik et al. 2009)
MRI picture of levator ani muscle
Normal condition
Avulsion after childbirth
Urogenital diapragm
Deep transverse perineal muscle (in male only)
+ variable superficial transversal perineal muscle,
perineal membrane
Fibrous structure - perineal body
Perineal muscles of female, blood supply, inmnervation
Perineal region, regio perinealis - Urogenital triangle, regio
urogenitalis - Anal triangle, regio analis, - Ischio-anal
fossa, fossa ischioanalis (ischiorectalis) Perineum
Ischioanal fossa
Female external genitalia and perineal muscles - Bulbospongiosus,
Ischocavernosus, Compressor of urethra, Urethrovaginal sphincter,
Superficial transverse perineal muscle
Perineal muscles
Mm. of urogenital triangle:
External urethral sphincter
(+ Urethrovaginal sphincter +
Compressor urethrae )
Ischiocavernosus,
Bulbospongiosus,
M. of anal triangle
External anal sphincter
Fibrous structures:
Perineal body, Anococcygeal lig.
Sources of illustrations used :
Gray´s Anatomy,
Sobotta: Atlas der Anatomie des Menschen
Grim, Druga: Regional Anatomy, Galen, Prague 2012
Benninghoff, Drenckhahn: Anatomie I., II.
Carlson,B.M.: Human Embryology and Developmental
Anatomy
Recommended Textbooks:
R. S. Snell: Clinical Anatomy. 7th Edition, Lippincott Williams
& Wilkins, 2004, pp. 478 – 562
or
K. L. Moore: Clinically oriented Anatomy, 3rd Edition,
Williams & Wilkins 1992, pp. 501 – 635
and
W. Kahle: Color Atlas/Text of Human Anatomy, Vol. 2 Internal
organs. Thieme, 4th English Edition, 1993
Langman´s Medical Embryology,11th Edition, 2010
Junqueira´s Basic Histology 12th Edition, 2010