Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 1 of 7
Not checked yet
Female Viscera
Dr. Sheedlo has a typed list of what lymph nodes drain what organs. He will give it to the guy with the
computer (Brandon) & he can email it to us. Remember that the dissector in the gross lab has
histology slides & when to look at these.
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Pelvic inlet
o Picture in notes has measurements of various diameters in the pelvic inlet
o Measurements are averages
o People who go into OB will work with these diameters
o Didn’t really sound like these will be tested on
Peritoneum in the Female Pelvis
o Peritoneum starts at the anterior abdominal wall
o The peritoneum in the female pelvis covers all of the following:
 Pubic bone
 Urinary bladder
 Vesicouterine pouch
 Picture in notes shows the 2 pouches
 Vesicouterine pouch lies between the urinary bladder & the uterus
 Uterus (fundus, body)
 Vagina
 Rectouterine pouch
 AKA: Cul-de-Sac of Douglass
 Between the uterus & the rectum
 Rectum
 Continues as sigmoid mesocolon
Ovary
o Functions:
 Produces ova – secondary oocyte
 When ova are released from the ovary, they are released into the peritoneum
 Secretion of estrogen & progesterone
o Nerves:
 Aortic plexus accompanying the ovarian artery
o Arteries & veins:
 Ovarian artery – from the abdominal aorta
 Passes within the suspensory ligament
 Right ovarian vein – drains to the inferior vena cava
 Just as right testicular vein drains into the IVC
 Left ovarian vein – drains to the left renal vein
 Just as the left testicular vein drains into the left renal vein
o Description:
 Almond-shaped organs that are aligned in a vertical position
 Tunica albuginea lies deep to the germinal epithelium, which gives the ovary its
whitish appearance
 Germinal epithelium is continuous with the peritoneum
 Ovaries are attached to the broad ligament by the mesovarium
 Mesovarium not part of broad ligament
 The suspensory ligament of the ovary is a part of the broad ligament that
suspends the lateral & upper pole of ovary from external iliac vessels
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 2 of 7
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The suspensory ligaments also transmits the ovarian artery & vein, lymphatic
vessels, & nerves
The proper ligament of the ovary attaches the medial & lower pole of ovary to
the uterus
Round ligament of uterus (AKA: ligamentum teres uteri) is attached at the
superior uterus, traverses the pelvis & penetrates the abdominal wall through the
inguinal canal
 Ends blindly at the labium majus
Uterine Tube
o AKA: Fallopian tube or oviduct
o Functions:
 Receives the ova from the ovary
 Ova is a 2 oocyte
 Ova is released into the peritoneum & moves into the uterine tubes
 Ova released from the left ovary can travel & enter right uterine tube
(and vice-versa)
 Exact mechanism of ova capture by uterine tube is unknown
 Provides the site for fertilization
 Conduit by which sperm can travel to ova
 Provides nourishment to ova
 Allows movement of ova into the cavity of the uterus for implantation into the
endometrium
o Description:
 Uterine (fallopian) tube is a 4 inch long tube located at the upper border of the
broad ligament
 It connects the peritoneal cavity with the uterine cavity
 Hysterosalpingogram: shows patency of uterine tube
 Radioactive substance is injected into the uterus & travels into uterine
tube & out into peritoneum
 Can detect any occlusions in the uterine tube
o May be a reason that a woman can’t get pregnant
o Regions:
 Infundibulum
 Funnel-shaped structure at the lateral end projecting beyond the broad
ligament
 Terminal part of uterine tube
 Know what this looks like histologically
 Overlies ovary
 Fimbriae
 Finger-like process draped over ovary
 Acts as a catcher’s mitt – catches the ova after it is released from the
ovary
 Ampulla
 Widest part of uterine tube
 Usual site for fertilization
 Common site for ectopic pregnancy
 Fertilized egg implants into uterine tube at the ampulla, causing the
uterine tube to eventually rupture
 Isthmus
 Narrowest part of uterine tube
 Found lateral to uterus
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 3 of 7
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Uterine part (intramural portion)
 Pierces uterine wall
Arterial supply:
 Uterine artery from the anterior division of the internal iliac artery
 Ovarian artery from the abdominal aorta in the suspensory ligament
Nerves:
 Ovarian plexus
 Travels with the ovarian vessels
Venous drainage:
 Corresponding veins (corresponding to arteries)
Lymphatic drainage:
 Internal iliac nodes
 Drains areas supplied by uterine vessels
 Paraaortic nodes
 Drains areas supplied by ovarian vessels
Uterus
o Functions:
 Receives fertilized ovum
 Site of implantation
 Retains & nourishes ovum
o Description:
 Pear-shaped & hollow organ
 3 inches long x 2 inches wide x 1 inch thick
o Segments:
 Fundus
 Above the entrance of the uterine tubes
 Body
 Larges portion of the uterus
 Below the entrance of the uterine tubes
 Narrows below & continuous with the cervix
o Internal os enters the cervix
 Cervix
 Pierces the anterior vaginal wall
 Forms fornices
o Anterior, posterior, & lateral fornices
o Rims on the superior portion of the vagina
Uterus & Cervix
o Segments:
 Cavity of uterine body
 Triangular
 Cleft sagitally
 Cervical canal
 Cavity of cervix
 Communicates with cavity of body of the uterus by the internal os and
with vagina by external os
Uterus
o Structure:
 Covered by peritoneum
 Perimetrium (outer layer)
 The outer serous layer of the uterus consisting of the peritoneum & an
underlying connective tissue layer
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 4 of 7
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Myometrium
 Thick smooth muscle wall
Endometrium
 Mucous membrane continuous with the uterine tube & the cervix
 Lost & regained with menses
 Look at the Netter picture showing different shapes of the uterus
Support of Uterus
o Muscle tone of levator ani muscles
 Iliococcygeus, pubococcygeus, & puborectalis muscles
o Three ligaments of pelvic fascia (Snell, Figure 7-15)
 Can be damaged during childbirth – may cause a prolapsed uterus
 All work to maintain the uterus in the proper position
 1. Transverse cervical ligaments (Cardinal)
 Lateral pelvic walls to cervix and vagina
 Thickened peritoneum
 Uterine vessels travel in this ligament
 2. Pubocervical ligaments
 Posterior surface of pubis (pubic bone) to cervix
 3. Sacrocervical ligaments
 Lower sacrum to cervix
o All 3 ligaments meet at the uterus/cervix junction
Ligaments of Uterus
o Broad ligament
 Two-layered fold of peritoneum over the pelvic cavity from the uterus to the
lateral pelvic wall
 Mesovarium
 Attaches the ovary to posterior layer of broad ligament
 Suspensory ligament of ovary
 Lies lateral to the attachment of the mesovarium
 Part of broad ligament
 Mesometrium
 Largest segment of broad ligament
 Attaches to the uterus
 Mesosalphinx
 Part of the broad ligament between the uterine tube & the mesovarium
o Round ligament
 Extends from the superior/lateral region of the uterus, through the inguinal ring
to the labium majus
 Maintains position of uterus, ie. anteverted and anteflexed
Position of Uterus
o Anteversion of uterus
 Long axis of body of uterus is bent forward on long axis of the vagina
 Folds over the bladder
 Forms 90° angle with the vagina
o Anteflexion of uterus
 Long axis of body of uterus is bent forward with long axis of cervix at the
internal os
 Forms 170° angle with the cervix
o Look at the picture from the notes
 C (on the left) is anteversion
 D (on the right) is anteflexion
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 5 of 7
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Arteries, Veins and Lymphatics of Uterus
o Arteries:
 Uterine artery
 Ovarian artery
o Veins:
 Uterine vein drains into the internal iliac vein
o Lymphatic drainage:
 Paraaortic nodes – fundus & ovaries
 Internal & external iliac nodes - body & cervix
Nerves of Uterus
o Inferior hypogastric plexus
Vagina
o Functions:
 Excretory duct for menstrual flow
 Part of birth canal
o Location
 From the uterus to the uvula
 3 inches long
 Upper half lies above pelvic floor & lower half in perineum
 Area of vaginal lumen around the cervix divided into anterior, posterior & right
& left lateral fornices
o Nerves:
 Inferior hypogastric plexus
Vulva
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Mons pubis
 Elevated region anterior to pubis
o Labium majus
 Lateral
o Labium minus
 Medial
 Vestibule is medial to labium
o Round ligament of uterus
o Clitoris
 Apex
 Superior
Nerves and Lympathics of Vulva
o The vulva is analogous to the scrotum in males because in is innervated by 4 nerves
o Nerves:
 Ilioinguinal nerve (anterior labial branches)
 Perineal nerve (posterior labial branches)
 Genital branch of genitofemoral nerve
 Perineal branch of posterior cutaneous nerve of thigh
Vestibule of Vagina
o Cleft between labium minus
o The contents of the vestibule of the vagina include:
 External urethral orifice
 Vaginal orifice
 Hymenal caruncles
 Openings of Bartholin’s gland
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 6 of 7
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Rectal Examination in Female
o Done primarily to palpate/inspect cervix
o Several structures can be palpated in during a rectal exam in the female:
 Cervix – anterior
 Pregnant woman’s cervix is soft
 Non-pregnant woman’s cervix is hard (feels like cartilage)
 Ischial spine & tuberosity - lateral
 Ureter - thickened by disease
 Sacrum & coccyx - posterior
 Enlarged internal iliac lymph nodes
Bimanual Examination
o Something done frequently if you go into family medicine
o In this examination, one finger is placed in the vagina & pressure is placed on the lower
abdomen
o Structures that are palpable include:
 Ovaries & uterine tubes
 Position & size of the uterus
 Pelvic inflammations & cancerous growths
o When performing this exam, you should note the size & position of the uterus
Complications of a Hysterectomy
o A hysterectomy is performed to remove the uterus
 Ovaries are left in the body
 Complete hysterectomy is a complete removal of uterur
o This procedure can be performed through the lower anterior abdominal wall or through
the vagina
o The ureter can be damaged because it lies within the transverse cardinal ligament inferior
to the uterine artery
 The uterine artery must be clamped or excised during this surgery & the ureter is
right next to the artery and may be damaged
o The uterine artery crosses anterior to the ureter near the lateral fornix of the vagina
o The artery passes ~2cm superior to the ischial spine
o Remember that the ureter passes UNDER the uterine artery
Pudendal Nerve Block
o The pudenal nerve block is given to anesthesize skin of perineum to relieve pain during
childbirth
o 2 methods for giving the block:
 1. Transvaginal method
 Bony landmark is the ischial spine
 Needle inserted through vaginal mucosal membrane & through
sacrospinous ligament
 Anesthetic is injected around pudendal nerve
 2. Perineal method
 Bony landmark is the ischial tuberosity
 Needle inserted through the buttock & medial to ischial tuberosity
 The pudendal canal is approximately 1 inch superior to the inferior
segment of the ischial tuberosity
o Don’t know which method is better, we should ask Dr. Buchanan
Episiotomy
o An episiotomy is a surgical incision of the uvula to prevent laceration at the time of
delivery or to facilitate vaginal surgery
 Opens the birth canal
Repro, #25
Thursday, April 3, 1 pm
Dr. Sheedlo
Kevin Stancoven for Melissa Pennington
Page 7 of 7
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 Especially useful for birth of 1 st child
This surgery is performed to prevent an irregular tear of the perineal muscles
The incision is made through perineal skin, bulbous spongeousus, & the transverse
perineal muscles
 Cut is made in a posterolateral direction
This incision is made to avoid the anal sphincter muscles & the perineal body