anatomy of the female genital tract

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Topographic anatomyTopographic anatomy

2 lines divide the abdomen into:2 lines divide the abdomen into:

• 2 vertical lines:2 vertical lines: (Right and left) extending

from mid clavicular to mid inguinal points

dividing the abdomen into 3 planes.

• 2 Horizontal lines:2 Horizontal lines: The first passing through

the lower costal margin (Subcostal plane),

while the second is the Inter-tubercular plane.

Topographic anatomyTopographic anatomy

The abdomen is divided into 9 quadrants:The abdomen is divided into 9 quadrants: • Right and left hypochondrium

• Right and left lumbar

• Right and left iliac

• Epigastrium

• Umbilical and

• Hypogastrium (or supra pubic regions).

PerineumPerineum• Boundaries: Boundaries: Inferior pubic ligament Pubic ramus Ischeal

tuberosity Sacrotuberous ligament Tip of coccyx.

• Divisions: Divisions: By imaginary line passing

between the 2 Ischeal tuberosities:

1) Anterior division:1) Anterior division: Uro-genital triangle.

2) Posterior division:2) Posterior division: Anal triangle.

Blood supply of PerineumBlood supply of Perineum

4. Dorsal a. of clitoris4. Dorsal a. of clitoris

5. Deep a. of clitoris5. Deep a. of clitoris

2. Artery of the bulb2. Artery of the bulb

3. Labial a.3. Labial a.

1. Inferior rectal a1. Inferior rectal a

Internal pudendal a.Internal pudendal a.

PudendumPudendum

The vulva consists of:The vulva consists of:1.1. The mons pubisThe mons pubis2.2. The labia ( majoraThe labia ( majora and minora)and minora)3.3. External urethal External urethal

meatusmeatus4.4. The clitorisThe clitoris5.5. VestibuleVestibule

PudendumPudendum

Mons Pubis:A mass of fat covered by skin and hair that

overlies the symphysis pubis.

Labia Majora: 2 rounded mass of tissues

covered by skinOriginates in mons pubis

and terminates in perineum.

Deep Structures: Deep Structures: 1.1. Skin:Skin: Thin.2.2. Tunica dartos:Tunica dartos: Poorly

developed muscle layer. 3.3. Fascia:Fascia: Thin layer. 4.4. Sweat and Sebaceous Sweat and Sebaceous

glands:glands: Numerous.

Arterial Supply:Arterial Supply:Internal & external pudendal

arteries

PudendumPudendum

PudendumPudendum

Clitoris:Clitoris:

The clitoris is homologous to the penis and consists of 2 small erectile bodies terminating into glans clitoris.

Labia Minora: Labia Minora: 2 folds of thin flaps of non-keratinized pigmented

skin within labia majora. • Anteriorly:Anteriorly: Divide into 2 flaps unites above

clitoris to form the prepuce. • Posteriorly:Posteriorly: The 2 labia unit to form a sharp

fold of skin called the fourchette

Arterial Supply: Arterial Supply: 1. Superficial perineal artery 2. Dorsal artery of clitoris

PudendumPudendum

VestibuleVestibule

A) External Urethral Meatus:A) External Urethral Meatus:

Present in the anterior part of the vestibule.

• Skene`s tubulesSkene`s tubules are 2 para-urethral ducts which opens in the floor of urethra

VestibuleVestibule

After delivery, the hymen is destroyed leaving the Carunculae Hymenalis.

B) Hymen: B) Hymen: A fold of mucous membrane at the vaginal

orifice covered by squamous epithelium on both sides.

It has one or more opening to allow escape of menstrual blood.

Hymen

VestibuleVestibuleB) Hymen - Types: B) Hymen - Types:

VestibuleVestibule

C) Vestibular Bulbs:C) Vestibular Bulbs:

They are 2 collections of

erectile tissue surrounding

the vaginal orifice.

VestibuleVestibuleD) Bartholin Glands: D) Bartholin Glands: They are 2 glands, lies in

the posterior third of labia majora just inferior and lateral to bulbo-cavernosus muscle.

It is composed of racemose gland. The acini lined by single layer of columnar epithelium, while the duct is lined by transitional epithelium.

Muscles of external genitaliaMuscles of external genitalia

1) Bulbo-Cavernosus muscle:1) Bulbo-Cavernosus muscle: Arise from the middle of the perineal body and

terminate into clitoris

2) Ischeo-Cavernosus muscle:2) Ischeo-Cavernosus muscle:Arise from the ischeal tuberosity and terminate

into the base of clitoris.

3) Transversus muscle:3) Transversus muscle: Arise from ischeal tuberosity and inserted into the

central tendon of perineum.

Muscles of external genitaliaMuscles of external genitalia

The VaginaThe Vagina

Position: Position: It lies between the

bladder and urethra anteriorly while the rectum and anal canal lies posteriorly.

It is directed upwards and backwards.

Canal, which connects the uterus with the Canal, which connects the uterus with the vestibulevestibule

The VaginaThe VaginaVaginal walls:Vaginal walls:Anterior wall:Anterior wall: 7.5 cm longs and directly related to bladder base

and urethra.Posterior wall:Posterior wall: Longer than the anterior wall (9 cm long) and

related to: Upper 1/3:Upper 1/3: Covered by peritoneum of

Douglas pouch. Middle 1/3:Middle 1/3: Related to rectum. Lower 1/3:Lower 1/3: Separated from the anal canal by

the perineal body

The VaginaThe Vagina

Fornices of vagina:Fornices of vagina:The upper vagina surrounds the cervix to form vaginal fornices.

Histology of the VaginaHistology of the Vagina

1) Vaginal mucosa: 1) Vaginal mucosa: It is thrown into folds or rugae, which allows distension of vagina, lined by stratified squamous epithelium containing glycogen. Doderlein`s Bacilli break down glycogen into lactic acid, the reaction of vagina is acidic (PH 4-5) Estrogens stimulate deposition of glycogen into vaginal mucosa. Mucosa does not contain glands but the vagina is kept moist by serous transudation from its wall.

Vaginal rugae

Histology of the VaginaHistology of the Vagina

2) Submucosal layer:2) Submucosal layer: A layer of connective tissue containing elastic

fibers

3) Muscular layer:3) Muscular layer: Outer longitudinal and inner circular smooth

muscle layers

Levator anii muscleLevator anii muscle

Origin: Origin: Body of pubis, white line,

inner surface of ischeal spines.

Insertion:Insertion: The muscles of both sides

meet together forming the greater part of pelvic floor and become differentiated into 3 parts

Levator anii muscleLevator anii muscle

1. Pubo-coccygeous: Arise from the body of pubic bone and meet its opposite side in the mid-line, it is pierced by the urethra, vagina, and rectum.

2. Ilio-coccygeous: Arise from white line to be inserted into the coccyx.

2. Ischeo-coccygeous: Arise from ischeal spines and inserted into the coccyx and last piece of sacrum.

Levator anii muscle - DivisionsLevator anii muscle - Divisions

Ilio-coccygeousIlio-coccygeous

Ischeo-coccygeousIscheo-coccygeous

UrethraUrethraVaginaVaginaPubo-coccygeousPubo-coccygeous

RectumRectum

Levator anii muscle - RelationsLevator anii muscle - Relations

Upper Surface (Pelvic):Upper Surface (Pelvic): • Pelvic diaphragm (Superficial fascia). • Urinary bladder, vagina, rectum, and broad

ligament.

Lower Surface (Perineal):Lower Surface (Perineal): • Pelvic fascia (Inferior fascia). • Forms the medial wall of ischeo-rectal fossa.

Levator anii muscle - RelationsLevator anii muscle - Relations

Anterior border:Anterior border: Separated from opposite muscle by space occupied

by the urethra and vagina

Posterior border:Posterior border: Close to coccyx.

Action: Action: 1. Supports the pelvic organs. 2. Sphincters for the urethra, vagina, and rectum 3. Internal rotation of the head.

The UterusThe UterusA hollow muscular organ, which lies between A hollow muscular organ, which lies between

the urinary bladder and rectumthe urinary bladder and rectum

Dimensions: Dimensions: • LengthLength = 3 inches. • Transverse diameterTransverse diameter = At the fundus 2 inches

and at the cervix = 1 inches. • Antero-posterior diameterAntero-posterior diameter = 1 inch.

Divisions: Divisions: • The fundusThe fundus is the free rounded part. • The bodyThe body of uterus. • Cervix:Cervix: which opens into the vagina.

The Fundus of UterusThe Fundus of Uterus

• Convex in all directions and covered by peritoneum which is continuous with the surfaces of the body.

• It is related to coils of ileum.

The Fundus of UterusThe Fundus of Uterus

• Fallopian tubes:Fallopian tubes: one on each side joins the uterus at the fundus.

• Ovarian ligament:Ovarian ligament:

Attached below and behind the fallopian tubes.

• Round ligament:Round ligament:

Attached below and infront the fallopian tubes.

Body of uterusBody of uterusNarrows from the fundus to cervix, its junction

with the cervix is called isthmus and covered by peritoneum on both sides.

• Flattened • Related to upper surface of bladder. • It’s peritoneal covering is reflected at the junction of the body with the cervix to the superior the surface of bladder to form the utero-vesical pouch

Anterior wall (Vesical)Anterior wall (Vesical)

Body of uterusBody of uterus

• Curved.• Related to coils of ileum.

• It’s peritoneal covering extends on the back of cervix and 1/3 of vagina, then reflected to cover the rectum to form the recto-vaginal pouch.

Posterior wall (Intestinal)Posterior wall (Intestinal)

Cervix of uterusCervix of uterus

About 1 inch long and 1 inch width, the cervix project through the anterior vaginal wall of vagina which divide it into 2 portions:2 portions:

1.1. Supra-vaginal portionSupra-vaginal portion2.2. Portio-vaginalisPortio-vaginalis

Structure of the body of uterusStructure of the body of uterus

1. Endometrium

2. Myometrium

3. Peritoneal coat

Ligaments attached to uterusLigaments attached to uterus(1) Ovarian ligament: Connect the lower pole of

the ovary to the cornu of uterus.

(2) Round ligament:Attached from the cornu of

uterus close to fallopian tube.

Then passes forwards and laterally through the inguinal canal to be inserted into labia majora.

(3) Broad ligament: A fold of peritoneum extends from the lateral

wall of uterus to lateral pelvic wall, one on each side.

Ligaments attached to uterusLigaments attached to uterus

Contents: Contents: 1. Uterine tube: Running in the free border. 2. Ligament of the ovary. 3. Proximal part of round ligament. 4. Uterine artery: running along the lateral border

of uterus and finally passe below the fallopian tube to anastomose with the ovarian artery.

5. Ovarian vessels. 6. Epoophron and paraoophron. 7. Extra peritoneal fat.

Ligaments attached to uterusLigaments attached to uterus

Divisions: Divisions: 1. Mesosalpinx.2. Mesometrium.3. Suspensory ligament.

Ligaments attached to uterusLigaments attached to uterus

2

1

3

(4) Cervical ligaments: 3 pairs of ligaments:

1. The transverse ligament: or "Mackenrodt`s"

2. Uterosacral ligament

3. Pubo-cervical ligament

Ligaments attached to uterusLigaments attached to uterus

1. The transverse ligament: "Mackenrodt`s" "Mackenrodt`s"

Extends from lateral sides of supra-vaginal cervix and vaginal vault and passes laterally to be inserted in the white line at the lateral pelvic wall

Cervical ligamentsCervical ligaments

2. Uterosacral ligament: Extends from supra-vaginal cervix and vaginal

vault and pass backwards surrounding the rectum to be inserted in the rectum and the third piece of sacrum.

3. Pubo-cervical ligament: Extends from the supra-vaginal cervix and

vaginal vault to pass beneath the bladder surrounding the urethra to be inserted into the back of symphysis pubis.

Cervical ligamentsCervical ligaments

Cervical ligamentsCervical ligaments

• The Fallopian tube (Oviduct) is a vital structure extending between the uterus and the ovary

• It is 10-12 cm in length

Fallopian tubesFallopian tubes

Fallopian tubesFallopian tubes

The tube is dThe tube is divided into 4 parts:ivided into 4 parts: (1) Interstitial (Intramural) part:(1) Interstitial (Intramural) part: Begins at the

cornu and penetrate the myometrium, it is 1 cm in length

(2) Isthmus:(2) Isthmus: It is straight and narrow, 2 cm in length

(3) Ampulla:(3) Ampulla: It is the largest and longest part of the tube, 5 cm in length

(4) Fimbria (Infundibulum): It is trumpet shaped, and has an abdominal opening (ostium) surrounded by finger like process (fimbria)It is 3-5 cm in length

Blood Supply:Blood Supply:Uterine artery branches at the fundus to give the

uterine branch for the tube which runs in the mesosalpinix to supply the proximal 2/3 and anastomose with the tubal branch from the ovarian artery.

Fallopian tubesFallopian tubes

OvaryOvaryThe ovary is almond shaped, grayish pink in color

It has a smooth surface before puberty, with age advance the surface become irregular and puckered

Dimensions:Dimensions: 3 x 2 x 1 cm in 3 dimensions

Surfaces:Surfaces: 1.1. Upper pole:Upper pole: attached

to lateral pelvic wall by infundibulo-pelvic ligament.

2.2. Lower pole:Lower pole: attached to cornu of uterus by ovarian ligament.

3.3. Anterior Surface:Anterior Surface: attached to peritoneum of posterior surface of broad ligament

4.4. Posterior Surface:Posterior Surface: Free and related to tubal fimbria.

OvaryOvary

Structure:Structure: divided into 3 divided into 3 regionsregions. .

1.Hilum:1.Hilum: Where the blood vessels, lymphatic and nerves enter.

2.Medulla:2.Medulla: Connective tissue core contains blood vessels, lymphatic and nerves.

3.Cortex:3.Cortex: Contains primary follicles in various degrees of development

The ovary is covered by The ovary is covered by tunica albuginea,tunica albuginea, which which is a dense connective tissue.is a dense connective tissue.

OvaryOvary

Blood Supply:Blood Supply: Ovarian artery arises from the anterior wall of abdominal aorta. Branches of the uterine artery anastemose with the tubal branch from the ovarian artery.

OvaryOvary

Ovarian Ovarian arteryartery

Urinary BladderUrinary Bladder

Position: Position: • Hallow muscular organ,

which lay behind the symphysis pubis and anterior to the uterus and broad ligament.

• Its form, size and position vary with the amount of urine.

• When empty, it is pyramid in shape, having a base, vertex (apex), superior surface and 2 convex infero-lateral surfaces.

Urinary BladderUrinary Bladder

Blood Supply: Blood Supply: 1.1. Hypogastric arteryHypogastric artery

Umbilical artery Superior vesical artery.

2.2. Middle vesical artery:Middle vesical artery: Arise from superior vesical or umbilical artery.

3.3. Inferior vesical artery:Inferior vesical artery: From hypogastric artery.

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Female UrethraFemale Urethra• Length: 4 cm. • Wider and more dilatable than male urethra, it

begins at the bladder neck and descends downwards and forwards

• It traverses the deep and superficial perineal pouches and opens into the vestibule in front of vaginal orifice.

Pelvic part of ureterPelvic part of ureter

• 15-20 cm longs.

• It enters the pelvis by crossing the external iliac vessels, obturator nerve and vessels.

• Then passes downwards and backwards along the lower border of internal iliac artery to the level of ischeal spines.

Pelvic part of ureterPelvic part of ureter

• Then it curves forward and medially below the root of broad ligament to reach the postero-superior angle of the bladder.

• It passes close to the upper end of vagina where it is crossed by uterine vessels.

ureterureter

Dangerous points of the ureterDangerous points of the ureter

During gynecological operations the ureter is During gynecological operations the ureter is liable for injury in the following sites: liable for injury in the following sites:

1. At clamping of infandibulo-pelvic ligamentinfandibulo-pelvic ligament2. At clamping of utero-sacral ligamentutero-sacral ligament. 3. At clamping of uterine arteryuterine artery4. Removal of broad ligament tumorsbroad ligament tumors or cervical cervical

fibroidfibroid that displaces the ureter from it’s normal position.

5. During closing the peritoneum of the pelvic peritoneum of the pelvic floorfloor after hysterectomy.

6. Vaginal operations for prolapseoperations for prolapse.

Methods for protecting the uretersMethods for protecting the ureters

1.1. I.V.PI.V.P before operations, the ureter is liable for displacement by pelvic pathology

2.2. Ureteric catheterizationUreteric catheterization during operation to allow ureteric palpation.

3.3. Direct exposureDirect exposure of the ureter at the pelvic brim posterior to the infandibulo-pelvic ligament of the ovary after mobilization of the colon to follow its course downwards.

4.4. PedicelsPedicels andand ligamentsligaments should be clamped under vision.

5.5. Subcapsular removal of fibroidsSubcapsular removal of fibroids as the ureter lies outside its capsule.

Pelvic (Sigmoid) ColonPelvic (Sigmoid) Colon• It is a continuation of the descending colon at the

pelvic brim.• Finally it curves backwards to end at the 3rd piece of

sacrum where it continue as the rectum.

RectumRectum• Ends at the ano-rectal angle where it continues

as the anal canal. • Blood supply:Blood supply: Superior, middle and inferior

hemorroidal arteries

Blood Supply of the pelvisBlood Supply of the pelvis

Median Sacral arteryMedian Sacral artery Median Sacral arteryMedian Sacral artery Superior Rectal arterySuperior Rectal artery Superior Rectal arterySuperior Rectal artery

Ovarian arteryOvarian artery Ovarian arteryOvarian artery Internal Iliac arteryInternal Iliac arteryInternal Iliac arteryInternal Iliac artery

Arterial SupplyArterial SupplyArterial SupplyArterial Supply

Internal iliac artery - BranchesInternal iliac artery - Branches

A) From Posterior DivisionA) From Posterior Division(Parietal branches)(Parietal branches)

1. Ilio-lumbar artery2. Lateral sacral artery3. Superior Gluteal artery

2

1

3

Internal iliac artery - BranchesInternal iliac artery - Branches

B) From anterior Division:B) From anterior Division:a. Parietal branches:a. Parietal branches:

1. Obturator artery2. Internal pudendal artery3. Inferior Gluteal arteries.

b. Visceral branches:b. Visceral branches: 1. Umbilical artery Superior vesical

artery2. Middle Rectal artery3. Uterine artery4. Vaginal artery Inferior vesical artery

Blood Supply Blood Supply of the pelvisof the pelvis

Blood Supply of Female genitalBlood Supply of Female genital