Applied Anatomy Of The Female Reproductive System

Front 1

What two compartments do the pelvic floor separate?

Back 1

Main pelvic cavity superiorly and perineum inferiorly

Front 2

What is the pelvic floor composed of?

Back 2

The diaphragm is formed by levator ani
muscles, coccygeus muscles and their
covering fascia.

Incomplete anteriorly – urethra and vagina
in females

Front 3

Remember this diagram

Back 3

Front 4

Remember the sacral plexus in relation to the pelvic floor.

Back 4

Front 5

What are the anatomical components of the levator ani and their origins and insertions?

Back 5

• Sphincter vaginae
– Form a sling around prostate or vagina and insert into the perineal body (supports constrict vagina)
• Puborectalis
– sling from pubic bone around rectoanal junction
• Pubococcygeus
– pubis to anococcygeal body (a fibrous mass between tip of coccyx and the anal canal)
• Iliococcygeus
– Ilium to anococcygeal body and coccyx
JOIN TOGETHER IN MIDDLE AT MIDLINE
(LEVATOR) RAPHE

Front 6

Describe the female pelvic floor when viewed superiorly.

Back 6

Front 7

Be able to describe the order from superior to inferior of the pelvic floor muscles when viewed laterally - female.

Back 7

Front 8

What is the function of the levator ani?

Back 8

• Supports and maintains pelvic viscera in
position
• Resist intrapelvic pressure and expulsive
efforts of abdominal muscles
• Assists sphinter urethrae (eus)
• Important sphincter action on the anorectal
junction (also sphincter of the vagina)

Front 9

What are the anatomical features of the ureter?

Back 9

• Retroperitoneal, muscular tubes
• Pass over the pelvic brim at bifurcation of common iliac arteries in front of the
sarcoilliac joint
• Run on lateral walls of pelvis
• Opposite ischial spine, curve anteromedially
• Oblique entrance into bladder
– one way flap valve
• posterosuperior angles of thebladder

Front 10

What are the anatomical features of the bladder?

Back 10

• Extraperitoneal
• Pyramidal
– Apex – median umbilical ligament (urachus)
– Trigone posteriorly, between 2 superior ureteric orifices
• Relations:
– Inferolaterally – fat filled retropubic space, levator ani muscle and obturator internus
– ♀ superior and posterior surface– uterus, inferiorly – urogenital diaphragm.
– ♂ superior surface – rectum, posteriorly - seminal vesicles and ducta deferentia, inferiorly - prostate

Front 11

What is the clinical relevance of the pouch of Douglas?

Back 11

– Accumulation of blood or pus
– Commonly violated by misguided instruments that pierce the posterior fornix

Front 12

Describe the ligaments of the female reproductive system.

Back 12

Front 13

What are the remnants of the gubernaculum in females and what do they connect?

Back 13

• Ovarian ligament (cranial gubernaculum)

– Ovary to uterus

• Round ligament of uterus - can be source of pain in pregnancy if tight - caudal gubernaculum).

– Uterus to labium majorum via inguinal canal

Front 14

Describe the anatomy of the blood vessels supplying the uterus.

Back 14

Front 15

What supports does the uterus have?

Back 15

• Levator ani muscles and the perineal body
• Transverse cervical (cardinal) ligaments
– Fibromusc from lat. Pelvic walls to cervix and upper vagina
• Pubocervical Ligaments
– 2 firm bands CT from pubis to cervix (either side of bladder
• Sacrocervical ligaments
– Fibro musc bands cervix to sacrum

Front 16

What are anatomical features of the vagina?

Back 16

• Thin muscular tube extending backwards from the vulva to the uterus
• Upper half above pelvic floor, lower perineum
• Upper end of vagina pierced by cervix. The lumen surrounding cervix divided into fornices – ant, post, and 2 lats

Front 17

What are the anatomical relations of the vagina?

Back 17

Relations of the Vagina
• Ant – bladder/urethra
• Post – pouch of douglas, ampulla of rectum, perineal body
• Lat – ureters,levator ani, urogenital
- diaphragm and bulb of vestibule

Front 18

Describe the pelvic floor when viewed sagitally.

Back 18

Front 19

What is in the female superficial perineal pouch?

Back 19

• 3 masses of erectile tissue
– Bulb of vestibule – attached to urogenital diaphragm - Divided by vagina
– Crura of clitoris (respond to crura of penis (corpus cavernosa)
• 3 muscles
– Bulbospongiosus – surrounds vaginal orifice and covers vestibular bulbs
– Ischiocavernosus
– Superficial transverse perineal muscle
• Greater Vestibular Gland (Bartholin’s gland)
• Perineal Body

Front 20

Describe the deep and superficial dissections of the perineum.

Back 20

Front 21

What is the anatomical relevance of the perineal body in females?

Back 21

• Perineal Body
– Larger than in male. Clinically very important. Wedge shaped mass fibrous tissue between vagina and anus. Supports vaginal wall
– Point of attachment of muscles that assist perineal body to support vaginal wall
• Levator ani
• External anal sphincter
• Bulbospongiosus
• Superficial transverse perineal

Front 22

What occurs upon injury to the pevlic floor during pregnancy?

Back 22

• Difficult childbirth – levator ani muscles fail
to recoil and take up previous position
– Uterine and vaginal prolapse
– Heriation of the bladder (cytocele)
– Alteration of position of bladder neck – stress
incontinence
– Prolapse of the rectum

Front 23

Describe first and second degree prolapse of the uterus and the muscles that resist this.

Back 23

Front 24

What enters the pudendal canal?

Back 24

• Pudendal nerve branch of the sacral plexus
• Internal Pudendal artery/vein branch internal iliac artery
• Leave pelvis through greater sciatic foramen
• Enters the perineum through the lesser sciatic foramen
• Pudendal Nerve
– Inferior rectal nerve
– Dorsal nerve of penis/clitoris
– Perineal nerve
• Internal Pudendal Artery
– inferior rectal
– Branches to penis, labia + clitoris

Front 25

Describe the nerves that cover the pubic area in women.

Back 25

Remember ischial spine is site of pudendal nerve blockade

Front 26

What are general visceral afferents?

Back 26

• Visceral afferents conduct impulses from
organs, glands and blood vessels which
travel via sympathetic and parasympathetic
neurons.
• We are not conscious of MOST of these
impulses (afferent part of most visceral
reflexes e.g. the brain sensing the need for
the secretion of bile

Front 27

How do GVA impulses reach the spinal cord?

Back 27

• GVA impulses reach the spinal cord through
sympathetic pathways through T1-5 from the
thoracic viscera, and T5-L2 for most of the
abdomen
• GVA impulses travel with parasympathetic
splanchnic nerves in the pelvis S2-4

Front 28

What are the characteristics of spinal anaesthesia?

Back 28

– Subarachnoid space L4-5. Complete anaethesia
below waist monitoring of uterine contractions.
Commonly followed by headache

Front 29

What are the characteristics of pudendal nerve block?

Back 29

– Peripheral nerve block S2-4 – perineum and lower ¼ vagina – mother can feel/assist contractions

Front 30

What are the characteristics of caudal epidural block?

Back 30

– Anaesthetic administered to catheter in sacral

canal (but must be done in advance). More

anesthetic can be administered if necessary, limbs still unaffected

Affects the pelvic SPLANCHNIC nerves - during childbirth still have abdominal muscles and can move leg as legs - lumbar and upper sacral

Front 31

Describe the sites of administration of the above mentioned anaesthetic blocks.

Back 31

Front 32

What is the function of the obturator internus?

Back 32

Lateral rotation of the hip - attachment to greater troch

+ fascia allows attachment tendinous arch of levator ani to ischial spine - pelvic floor attachment

Front 33

Where does the sciatic nerve emerge?

Back 33

Inferior to the pirirformis

Front 34

Where does the sciatic nerve emerge?

Back 34

Inferior to the pirirformis

Front 35

What is the route of the pudendal nerve?

Back 35

Deep to the pelvic floor

Front 36

What is the broad ligament?

Back 36

Double folded sheet of peritoneum.

Aka mesometrium

Connects uterus to walls and floor of pelvis

Front 37

What is the suspensory ligament of the ovary?

Back 37

Carries ovarian vessels

Ovary to walls of pelvis

Front 38

Describe the blood vessels of the pelvis.

Back 38

Bifurcation of abdo aorta

Bifurcation int and ext iliac.

Lots of lumbar venous plexi cf sacral fracture

Front 39

Where does the ovarian artery come from?

Back 39

L2 near renal arteries

Nb anastomoses with uterine artery

Front 40

What is the relevance of water under the bridge?

Back 40

0.5-2% of hysterectomies/routine uterine surgeries damage Ureter - only covered by slight amount of peritoneum

Check for extravasation of urine

Front 41

What is the clinical significance of a retroverted/retroflexed uterus?

Back 41

Painful intercourse - cervix is directly facing vagina