Transcript Uterus, Broad Ligament, Ovary

MOB TCD
Uterus, Broad Ligament, Ovary
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Uterus
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Pear-shaped muscular organ
8 cm long
5 cm wide
3 cm thick
Non-pregnant state
Pelvic organ
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Uterus
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Uterus
• Fundus
• Body
• Cervix opens into vault or
fornices of vagina
• Fundus is the portion above
entrance of uterine tubes
• Covered with peritoneum
• Body
• Triangular cavity
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Cervix
• Supravaginal
• Isthmus is a circular borderline
area between the body and
cervix
• Isthmus is the supra vaginal
portion of cervix lower uterine
segment
• Intravaginal is surrounded by
gutter fornices
• Posterior is deeper covered
with peritoneum
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Cervix
• Internal os is the opening from
the body
• Spindle shaped cavity
• External os is the opening into
vagina
• Cervix lined columnar
epithelium
• Arbor vitae in nullipara
• Intravaginal portion of cervix
covered by stratified epithelium
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Cervix
• External os
• Junction of columnar of the
cervical canal
• Stratified epithelium of the
intravaginal portion
• Site of cancer of cervix
• Cervical smear
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Cervix
• At birth cervix is larger than
the body
• Fully developed cervix is
one third of body
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Peritoneum
• Reflected from the superior
surface of the bladder
• Junction of the supravaginal
portion of the cervix and the body
of the uterus
• Uterovesical pouch
• Covers body, fundus
• Covers the posterior surface
body and the supravaginal portion
of cervix
• Upper third of posterior surface of
vagina
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Pouch of Douglas
• Upper third of posterior
surface of vagina (posterior
fornix)
• Peritoneum reflected on to
junction of upper two thirds
and lower third of rectum
• Pouch of Douglas is most
dependent part of female
peritoneal cavity
• Broad ligament is lateral
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Uterus
• Uterus is anteverted
• i.e. anterior to vertical plane
going through the vagina
• Posterior fornix deeper
• Anteflexed
• Bent anteriorly at junction of
body and cervix
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Uterus
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Serous layer
Myometrium
No submucous layer
Endometrium
Three layers
Basal
Spongy
Compact at surface of uterine
cavity
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Myometrium
• Myometrium makes up bulk of
uterine wall
• Blood vessels more evident in
middle layer
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Myometrium
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Uterine Muscle
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Blood Supply
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Uterine
Ovarian
Vaginal arteries
Anterior and posterior
arcuate run in middle layer
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Blood Supply
• Radial branches
• Basal layer
• Spiral branches to superficial
two layers
• Veins below artery
• Plexus in lower edge broad
ligament into internal iliac
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Blood Supply
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Nerve Supply of Uterus
• Pain from cervix via
parasympathetic S2,3
• Pain from body via
sympathetic to T11
and T12
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Lymphatics
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Supports of Uterus
Upper
• Round ligament
• Broad ligament anteverted
Middle
• Transverse ligament
• Pubocervical
• Uterosacral
Lower
• Levator ani, coccygeus
• Perineal body
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Round Ligament
• Round ligament and
• Ligament of ovary
• develop from the
gubernaculum
• Side of uterus,
junction fundus and
body
• Inguinal canal to
labium majus
• Anteversion
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Broad Ligament
• Fold of peritoneum from side
of uterus to side wall of
pelvis
• Framework of pelvic fascia
• Parametric fat
• Anterior surface looks
inferiorly
• Free upper border
• Base on pelvic floor
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Broad Ligament
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Uterine tubes
Ovarian vessels
Uterine vessels
Epoophoron
Paroophoron
Round ligament of uterus
and ligament of ovary
• Transverse ligament
• Ovary attached to posterior
layer
• Ureter in base below artery
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Broad Ligament
• Uterine tube lies in medial
four fifths of free border of
broad ligament
• Lateral one fifth
• Contains ovarian vessels
• Infundibulo-pelvic or
suspensory ligament of
ovary
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Broad Ligament
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Mesosalpinx
Mesometrium
Mesoovarian
Epoophoron
Parallel tubules
Gaertners duct remains
mesonephric tubules and
duct, may form cysts
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Uterine Artery
• Uterine artery lies superior to
the ureter at lateral fornix of
vagina
• Base of broad ligament
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Pubocervical Ligament
• Attached
• Anteriorly to posterior aspect
of body of body of pubis
• Passes to neck of bladder
• Anterior fornix of vagina
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Pubocervical Ligament
• Pubocervical ligaments help to
maintain normal angle of
45°between the vagina and
horizontal
• Decrease may cause a
cystocoele
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Transverse Ligament
• Transverse or cardinal or
mackenrodt ligament
• Thickening of visceral layer
of pelvic fascia around
uterine artery
• Lateral to medial in base of
broad ligament
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Uterosacral Ligament
• Uterosacral contains fibrous
tissue
• Nonstriated muscle
• Attached from the cervix to
the middle of sacrum
• Contains lymphatics draining
cervix to sacral glands
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Uterosacral Ligament
• Uterosacral help to keep uterus
anteverted
• If uterus is anteverted it cannot
prolapse
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Uterine Tube
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Intramural
Isthmus
Ampulla
Infundibulum
Lined ciliated columnar epithelium
Beats towards uterus
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Uterine Tube
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Peritoneum
Loosely attached to ampulla
Tightly to isthmus
Fimbria surrounding opening into
peritoneal cavity
• Ovarian fimbria
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Embryology of Uterus
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Ovary
• Attached to posterior layer of
broad ligament mesoovarian
• Covered with germinal
epithelium
• Side wall of pelvis covered
with peritoneum
• Obturator internus muscle
• Obturator nerve supplies the
parietal peritoneum
• Ureter posterior
• Ligament of ovary medially
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Ovary
• Obturator nerve supplies the
parietal peritoneum
• Irritation of the peritoneum of
the side wall by bleeding at
ovulation or by lesions
involving the ovary, may result
in referred pain to medial side
of the thigh or the knee
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Ovary
• Blood supply
• One ovarian artery from
lateral aspects of aorta L2
• Right vein drains into IVC
• Left drains into left renal vein
• Lymphatics into paraaortic
glands L2
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Vagina
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Fornices surround cervix
Anterior wall shorter posterior
Walls in contact except superior
External os
Opens into vestibule of vagina
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Vagina
• Pelvis
• Lateral uterine artery above
ureter
• Levator ani
• Deep pouch
• Sphincter urethrae
• Bulbs of vestibule
• Greater vestibular glands
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Vagina
• Urethra embedded in lower
two thirds of anterior wall
• Posterior fornix
peritoneum of pouch of
Douglas
• Rectum
• Perineal body
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Vagina
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Pelvic fascia
Erectile tissue
Muscular wall
Non-keratinised stratified squamous
epithelium
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Blood and Nerve Supply Vagina
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Uterine artery
Vaginal
Internal pudendal
Labial
Ilio Inguinal nerve supplies the
anterior wall
• Labial nerves supply the
posterior wall
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Lymphatics of Vagina
• Internal iliac
• Lower third
• Medial group of proximal
superficial inguinal glands
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Pelvic Sympathetic
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Pelvic Plexuses
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Supply pelvic organs
Contains
Sympathetic
Preganglionic parasympathetic
nerves
• Lateral column S2,3,4
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Pelvic Plexus
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Hypogastric plexus
Lumbar splanchnics
Presacral nerve
Anterior to body of L5
Divide into pelvic plexuses
Postganglionic of sympathetic
that relayed in lumbar and
sacral ganglia
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Sympathetic
• Ejaculation is via
sympathetic impulses from
L1-L2
• Contraction of sphincters of
bladder and anal canal
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Pelvic Parasympathetic
• Preganglionic have cell bodies in
lateral column of segments
S2,3,4
• Ganglia found close to or in wall
of organ
• Supplies intestine from splenic
flexure to upper two thirds of anal
canal
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Pelvic Parasympathetic
• Supplies bladder
• Rectum
• Motor to walls inhibitory to
sphincters
• Male and female genitalia
• Parasympathetic causes
erection
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