1 female pelvic anatomy-warda (part 1)

ANATOMY BASIC SCIENCE FOR POSTGRADUATE STUDENTS OF OBSTETRICS AND GYNECOLOGY

1. FEMALE&PELVIC&ANATOMY&
(Part&1&GENERAL&ANATOMY&&)&
Osama&M&Warda&MD&
Prof.&of&OBS/GYN&
Faculty&of&Medicine:Mansoura&University&
O&Warda&

2. O&Warda&

3. &
&
&
&
8 January 2019 Osama M. Warda, MD
Osama&M&Warda&MD&
Prof.&of&OB/GYN&
Faculty&of&Medicine&
Mansoura&University&
EGYPT&

4. ObjecAves&&
• Understand&pelvic&anatomy&&
&&&:&Organs&and&structures&of&the&female&pelvis:&
&&&&&&&&&&&&:&Vascular&Supply&
&&&&&&&&&&&&&:Neurologic&supply&&
&&&&&:&Pelvic&and&retroperitoneal&contents&and&spaces&&&&&
&&&&&&:&Bony&structures&
&&&&&&:&ConnecAve&Assue&(fascia,&ligaments)&
&&&&&&&:&Pelvic&floor&and&abdominal&musculature&&
• Describe&funcAonal&anatomy&and&relevant&pathophysiology&
&&&&&:&Pelvic&support&
&&&&&:&Urinary&&&Fecal&conAnence&&&
&&
&
O&Warda&

5. EXTERNAL&GENITALIA&
The&VULVA&(or&pudendum),&is&the&collecAve&
term&for&female&genitalia&.It&consists&of&the&
following&organs:&mons&pubis,"labia"minora"and"
majora,"clitoris,"ves2bule,"Skene"glands,"greater"
ves2bular"(Bartholin)"glands,"orifice"of"vagina,"
bulb"of"ves2bule."
WQEgipleh(s"BgfiiBhv2e(giuEgimons&pubis&
anteriorly,&the&rectum&posteriorly,&and&the&
genitocrural&folds&(thigh&folds)&laterally.&
O&Warda&

6. O&Warda&

7. MONS&PUBIS&:&
• It&is&a&rounded,&hair:bearing&elevaAon&of&skin,&
found&anterior&to&pubic&symphysis.&&
• !Pubic&hair&in&the&female&has&an&abrupt&horizontal&margin.&&
&
LABIA&MAJORA:&are&2&large,&longitudinal&folds&of&adipose&and&fibrous&
Assue.&
: They&vary&in&size&and&distribuAon&from&female&to&female,&and&the&
size&is&dependent&upon&adipose&content.&
: They&extend&from&the&mons&to&2.5cm&from&the&anus.&The&labia&
majora&have&hair&follicles.&
: &Anteriorly&unite&and&form&anterior&labial&commisure&&
: Posteriorly&separated&by&posterior&labial&commisure.&
EXTERNAL&GENITALIA&
O&Warda&

8. EXTERNAL&GENITALIA&
LABIA&MINORA,&also&known&as&nymphae,&are&2&smaller&
cutaneous&folds&that&lie&between&the&labia&majora&.&
:&They&consist&of&core&of&spongy&Assue&with&blood&
vessels&and&sensory&nerve&endings.&
:&Anteriorly,&the&labia&minora&join&to&form&the&
frenulum(clitoral&hood)anterior&prepuce&above&the&
clitoris.&
The&L.minora&enclose&the&vesAbule&and&unite&
posteriorly&in&the&abrupt&fold&called&the&fourche_e.&
O&Warda&

9. EXTERNAL&GENITALIA&
THE&CLITORIS:&&is&an&erecAle&body.&&
: Its&width&is&±1&cm,&with&length&of&
2–3&cm.&
: The&clitoris&is&made&up&of&a&root,&
a&body&composed&by&2&crura,&2&
corpora&cavernosa,&and&a&glans&
(squamous&epithelium).&
:&It&is&innervated&by&the&dorsal&nerve&
of&the&clitoris,&a&terminal&branch&of&
the&pudendal&nerve.& 3&D&model&of&clitoris&
O&Warda&

10. THE&VESTIBULE:&
:&The&area&between&the&inner&aspects&of&the&labia&
minora&and&bounded&anteriorly&by&clitoris&and&
posteriorly&by&the&fourche_e.&
: Structures&that&open&in&the&vesAbule&are:&&
&Urethra,&Bartholin’s&glands&ducts,&The&vagina,&and&&
&Skene’s&glands.&
:&VesAbular&bulbs&lie&beneath&mucus&membrane&of&
vesAbule&on&either&side&of&vagina&and&urethra.&
3:4cm&long,&1:2cm&wide,&0.5:1cm&thick.&
EXTERNAL&GENITALIA&
O&Warda&

11. EXTERNAL&GENITALIA&
O&Warda&

12. EXTERNAL&GENITALIA&
BARTHOLIN&GLAND:&(Greater&VesAbular&Glands):&&
: bilateral&compound&racemose&glands,&0.5&:1&cm&diameter.&
: situated&deep&in&the&labia&majora,&at&the&juncAon&of&the&
posterior&and&the&middle&thirds&
: &&Its&duct&:&2&cm&long&and&opens&between&the&hymen&and&the&
labium&minus&
: &&responsible&for&secreAng&lubricaAon&during&sexual&
excitement&.&&
: Have&cells&of&endocrine&funcAon&:&secrete&
Serotonin,&Calcitonin&,&HCG.&
:&Frequent&site&of&abscess&or&cyst&formaAon.&
&
O&Warda&

13. EXTERNAL&GENITALIA&
• SKENE’S&TUBULES:&&2&blindly&ending&para&:
urethral&tubules&that&open&in&the&floor&of&the&
urethra,few&mm.&&from&the&external&urethral&
meatus.&&The&opening&is&0.5&mm&in&diameter.&
W&
O&Warda&

14. EXTERNAL&GENITALIA&
• THE&HYMEN:&a&membrane,&situated&about&2&
cm&from&the&vesAbule&that&demarcates&the&
external&from&the&internal&genital&organs,&and&
parAally&closes&the&vaginal&orifice.&
O&Warda&

15. EXTERNAL&GENITALIA&
• BLOOD&SUPPLY:&&
Arteries&:&Branches&from&
Femoral&artery&and&
Internal&pudendal&and&
External&pudendal&artery.&
&Veins&drain&into&
corresponding&external&
and&internal&pudendal&
veins.&
&
O&Warda&

16. EXTERNAL&GENITALIA&
NERVE&SUPPLY&OF&THE&
VULVA&
Anterior&:&Ilioinguinal&and&
Genitofemoral&nerves.&&
Posterior:&labial&branch&of&
Perineal&nerve,&branch&of&
Pudendal&nerve,&perineal&
branches&of&femoral&
cutaneous&nerve&of&thigh.&
O&Warda&

17. LYMPHATIC&DRAINAGE&
Medial&group&of&
superficial&inguinal&
lymph&nodes&,&Deep&
inguinal&and&internal&
iliac&lymph&nodes.&
EXTERNAL&GENITALIA&
O&Warda&

18. MALE&REPRODUCTIVE&SYSTEM&
O&Warda&

19. FEMALE&VS.&MALE&&
O&Warda&

20. INTERNAL&GENITALIA&&
O&Warda&

21. THE&VAGINA&
: It&is&musculomembranous&tube&extends&from&
the&vulva&externally&to&the&uterine&cervix&
internally.&
: Is&7:9&cm&long.&
: It&is&located&within&the&pelvis,&anterior&to&the&
rectum&and&posterior&to&the&urinary&bladder.&
: Anterior&and&posterior&walls&in&apposiAon&
except&at&superior&end&where&anterior&wall&
pierced&by&cervix.&
O&Warda&

22. The&vagina&&
• VAGINAL&FORNICES:&
• WQE6&06"=8]&B"#@603;&893#&
the&upper&blind&end&of&
the&vagina&to&forms&a&
pouch&around&the&
cervix&,&divided&into&four&
fornices&:&two&lateral,&
anterior&and&posterior&
(deeper)&fornices.&
O&Warda&

23. The&vagina&
HISTOLOGY&OF&THE&VAGINA&
• The&cut&secAon&of&the&vagina&is&“H”&shaped&with&
approximaAon&of&the&anterior&to&the&posterior&vaginal&
walls.&
• It&is&formed&of&3&layers;&mucosa,&formed&of&straAfied&
squamous&non:keraAnised&epithelium&without&glands,&
musculosa,&which&is&fibromuscular&with&some&fibres&from&
the&levator&ani&inserted&into&it&&&&advenAAa,&which&is&
connecAve&Assue.&&
• Lactobacilli&+&in&vagina,&Acidic&pH&~&4.5&,&provides&protecAon&
O&Warda&

24. THE&VAGINA&;&RELATIONS&
• ANTERIORLY:&&
• Upper&1/3&:&urinary&bladder&Lower&
2/3&:&urethra.&&
• POSTERIORLY:&&
• Upper&1/3&:&pouch&of&Douglas.&Middle&
1/3:&ampulla&of&rectum.&Lower&1/3&:&
the&perineal&body.&&
• LATERALLY:&&
• Upper&part&:&ureters&
Middle&part&:&levator&ani&muscle&
anterior&fibres&
Lower&end:&urogenital&diaphragm&and&
vesAbular&bulb&&
O&Warda&

25. VAGINA&;&BLOOD&SUPPLY&
• Arterial&supply:&
• The&vaginal&artery&(from&internal&iliac&artery&or&uterine&artery)&&
• AddiAonal&branches&from:&Middle&rectal&artery&(both&from&internal&
iliac&artery)&&&Internal&pudendal&artery&
Venous&drainage:&
• &A&plexus&around&the&vagina&(the&vaginal&plexus),&drain&:&internal&
iliac&vein&
O&Warda&

26. THE&VAGINA&
NERVE&SUPPLY;&&to&the&vagina&is&primarily&from&
the&autonomic"nervous"system(UV&plexuses).&
Sensory&fibers&to&the&lower&vagina&arise&from&the&
pudendal&nerve,&and&pain&fibers&are&from&sacral&
nerve&roots.&
LYMPHATIC&DRAINAGE&of&the&vagina&
:&external&iliac&nodes&(upper&third&of&the&vagina),&
:&common&and&internal&iliac&nodes&(middle&
third),&:&superficial&inguinal&nodes&(lower&third).&
O&Warda&

27. UTERUS&
: pear:shaped&organ&within&the&
pelvis&between&the&
bladder&and&the&rectum.&
It&is&thick:walled,&hollow,&
muscular&organ&
: lining&changes&in&response&&
to&hormone&sAmulaAon&
throughout&a&woman’s&monthly&
cycle.&
: 7:8&cm&long,&5:7&cm&wide,&
&2:3&cm&thick.&
O&Warda&

28. THE&UTERUS&&
• upper&muscular&part:&the&
BODY&(corpus&uteri)&
• lower&fibrous&part&:&the&
CERVIX&
• Between&these&2&is&the&
ISTHMUS,&a&fibro:&muscular&
short&area&of&constricAon&
(internal&os).&
• Before&puberty,&body:&cervix&
1:1&
• in&adulthood,&2:1&or&3:1&
O&Warda&

29. THE&UTERUS&&
• THE&CORPUS&UTERI:&Body&that&lies&
above&the&internal&os&
• Cornu&=&the&area&of&inserAon&of&the&
fallopian&tubes&
• Fundus&lies&above&the&inserAon&of&the&
tubes.&Three&structures&are&a_ached&
to&the&cornu&
• Round&ligament&anteriorly,&Fallopian&
tube&centrally,&Ovarian&ligament&
posteriorly&
O&Warda&

30. THE&UTERUS&&
• THE&CERVIX:&is&about&2.5&cm&long.&&
• Divided&into&supravaginal&porVon&
&&&vaginal&porVon&
• The&cervical&canal&is&the&cavity&that&
communicates&above&with&the&uterine&
cavity&at&the&internal&os&and&below&with&
the&vagina&at&the&external&os.&
• The&external&os&is&round&in&nulliparas&
and&transverse&slit&shaped&in&mulVparas.&
• Supravaginal&part&expands&a[er&24&
weeks&gestaVon&^&lower&uterine&
segment.&
O&Warda&

31. THE&UTERUS&&
RELATIONS&OF&&BODY&OF&THE&UTERUS&
• WAnteriorly:&The&
&bladder&and&VU&pouch.&
• Posteriorly:&&
• &pouch&of&Douglas&
• Laterally:&&
The&broad&ligament&on&&
each&side&
O&Warda&

32. THE&UTERUS&&
HISTOLOGY&OF&THE&
UTERUS:&
• Three&layers:&
1.&Endometrium&
(mucosa)&
2.&Myometrium&
(musculosa)&
3.&Perimetrium&or&the&
peritoneal&covering&
O&Warda&

33. THE&UTERUS&&
Endometrium:&
: columnar&epithelium&resAng&on&thick&lamina&propria&made&
of&connecAve&Assue&called&endometrial&stroma.&
: Contains&tubular&endometrial&glands.&
:&Shows&cyclic&changes&with&the&menstrual&cycle&under&the&
influence&of&ovarian&hormones&
O&Warda&

34. THE&UTERUS&&
Myometrium&
Three&layers:&&
:outer&longitudinal&muscle&
layer&
:middle&layer&of&interlacing&
criss:cross&muscle&fibres&
surrounding&the&blood&
vessels&
:inner&circular&muscle&layer&
O&Warda&

35. THE&UTERUS&
Perimetrium:&(peritoneal&covering)&
&Anteriorly:&firmly&a_ached&to&the&fundus&and&body&
All&the&isthmus,&becomes&loose&,&is&reflected&on&the&
superior&surface&of&the&&bladder&forming&the&UV&
pouch.&
Posteriorly:firmly&a_ached&to&the&fundus,&body,&
cervix,&and&posterior&vaginal&fornix&then&is&reflected&
on&the&pelvic&colon&forming&the&Douglas&pouch.&
Laterally:&the&anterior&and&posterior&peritoneal&
coverings&blend&as&the&anterior&and&posterior&layers&
of&the&broad&ligaments.&
O&Warda&

36. THE&UTERUS&
HISTOLOGY&OF&THE&CERVIX&
Endocervix:&Lined&by&simple&columnar&epithelium&with&
compound&racemose&glands&or&crypts&prone&chronic&infecAon.&
It&secretes&alkaline&cervical&mucus.&
Muscle&layer:Outer&longitudinal&and&
&inner&circular&muscles.&
Ectocervix:&straAfied&squamous&&
epithelium&covers&outer&porAon&of&the&
&cervix.&
The&juncAon&between&squamous&and&columnar&epithelium&at&
the&external&os&may&form&a&transiAonal&zone&1:3&mm&:&
transformaAon&zone&(&TZ).&
O&Warda&

37. THE&UTERUS&
ARTERIAL&SUPPLY&
• The&uterine&vessels&arise&from&the&
anterior&division&of&the&internal&iliac.&
• The&ascending&branches:upwards&in&a&
tortuous&manner&parallel&to&the&lateral&
border&of&the&uterus&between&the&broad&
ligament&anastomoses&with&branches&of&
ovarian&arteries&near&the&uterine&cornu.&
• The&descending&cervical&branch&–&Cervix.&
&
VENOUS&DRAINAGE:&
• W)3/"3;&/;&/&B26]1;&?63V669&3E6&[&2/46";&#$&
the&broad&ligament&(Pampiniform&plexus)&
that&communicate&with&the&vesical&plexus&
and&drains&into&the&uterine&and&ovarian&
veins.&
O&Warda&

38. THE&UTERUS&
LYMPHATIC&DRAINAGE:&
:Fundus:&To&the&para:aorAc&lymph&nodes&
:Cornu:&To&the&superficial&inguinal&lymph&
nodes&
:Body:&To&the&internal&then&external&iliac&
lymph&nodes&
:Isthmus&and&Cervix:&Two&groups&of&
lymphaAcs:&
• Primary&groups:&Paracervical&(1st),&
parametrial,&obturator,&internal&and&
external&iliac&nodes.&
• Secondary&groups:&Common&iliac,&para:
aorAc,&and&lateral&sacral&lymph&nodes.&
O&Warda&

39. THE&UTERUS&
NERVE&SUPPLY&
WSympatheAc&from&T12&and&L1:&
"Uterine&contracAon&and&
vasoconstricAon&
ParasympatheAc&from&
S2,3,4"Inhibits&uterine&
contracAons&and&causes&
vasodilataAon.&
Both&reach&the&uterus&through&
branches&of&inferior"hypogastric"
and"ovarian"plexus.&
O&Warda&

40. THE&FALLOPIAN&TUBE&
:&2&tortuous&tubes&(10:12&cm&in&
length)&lie&in&the&free&upper&
part&of&the&broad&ligament&
(&mesosalphinx&).&
:Infundibulum(3mm&wide)&
:Ampulla(more&than&half&of&
tube&length,&wider&lumen)&
:Isthmus&(0.1:0.5mm,thickest)&
:Intramural&(1:2mm)&
O&Warda&

41. THE&FALLOPIAN&TUBE&
HISTOLOGY&OF&THE&FALLOPIAN&TUBES&
• Mucosa&(endosalpnix):&Composed&of&
&secretory&and&ciliated&columnar&cells.&
&Invaginated&into&folds&called&major&
&plicae&with&20&and&30&folds.&
• Muscle&layer:&Outer&longitudinal&and&
&inner&circular&involuntary&smooth&
&muscles.Thick&:&isthmus&and&thin&ampulla.&
• Serosa&(peritoneal&covering):&&
The&extrauterine&part&is&covered&by&peritoneum&in&the&upper&
margin&of&the&broad&ligament.&
O&Warda&

42. THE&FALLOPIAN&TUBE&
• ARTERIAL&SUPPLY:&Tubal&branches&of&uterine&
and&ovarian&arteries.&
• VENOUS&DRAINAGE:&Tubal&branches&into&
uterine&and&ovarian&veins&
• LYMPHATIC&DRAINAGE:&para:aorAc&LNs&
• NERVE&SUPPLY:&&
:&ovarian&and&uterine&plexuses.&
:&Afferent&fibres&inT11,T12,L1&nerve&roots.&
O&Warda&

43. THE&OVARY&
ANATOMICAL&RELATIONS&
WThe&ovary&is&bounded&
: medially&by&the&Fallopian&tube,&
: laterally&by&the&lateral&pelvic&wall.&
:&&&&superiorly&and&anteriorly&it&is&&
surrounded&by&the&small&intesAne&
:&&&&inferiorly&by&the&ovarian&fossa&where&the&
ureter&and&the&internal&iliac&vessels&pass.&
O&Warda&

44. O&Warda&

45. THE&OVARY&&
• Blood&supply&to&the&ovary&is&via&the&ovarian&artery;&
Both&right&and&les&ovarian&arteries&originate&directly&
from&the&descending&aorta&at&the&level&of&the&L2&
vertebra.&The&ovarian&artery&and&vein&enter&and&exit&
the&ovary&at&the&hilum.&
:The&les&ovarian&vein&drains&into&the&les&renal&vein,&and&
:The&right&ovarian&vein&empAes&directly&into&the&inferior&
vena&cava.&
• LYMPHATIC&DRAINAGE:&pre:aorAc&and&para:aorAc&LNs.&
• NERVE&SUPPLY&:&Ovarian&plexus&nerves&communicates&
with&uterine&plexus.&SympatheAc&fibers&:from&T10:T11&.&
&&ParasympatheAc&fibers&:&vagus&nerve.&
O&Warda&

46. Urogenital&triangle&
• Deep&pouch&
•&Superficial&pouch&
&Perineal&membrane&separates&the&two&
•&Deep&is&superior&to&perineal&membrane&
•&Roof&is&pelvic&fascia&
O&Warda&

47. Superficial&compartment&
Space&between&subcutaneous&Vssues&and&perineal&
membrane&
• Clitoris&
• Crura&
• VesAbular&bulb/Bartholin’s&gland&
• Ischicavernosus&(from&ischial&tuberosity)&
• Bulbospongiosus&(from&perineal&body)&
• Superficial&transverse&perineal&muscle&
• Muscles&contained&in&superficial&perineal&pouch&

49. The&Perineal&Membrane&
• Triagular&sheet&in&anterior&half&of&pelvic&outlet&
• Dense&fibro:muscular&Assue&
• Previously&called&urogenital"diaphragm"
• FuncAons:&
• Supports&pelvic&floor&
• Counteracts&effects&of&raised&intra:abdominal&pressure&
• Counteracts&effects&of&gravity&

50. The&Perineal&Membrane&
• Complete&sheet&in&males&
• Arises&from&ischiopubic&rami&
• A_achments&
• Urethra&
• Vagina&
• Perineal&body&
• Limits&downward&descent&

51. Perineal&Body&
• Mass&of&connecAve&Assue&
• Synonym:&central&tendon&of&the&perineum&
• Located&between&vagina&and&anus&
• A_achments&
• Perineal&membrane&
• Superficial&transverse&perineal&muscle&
• Bulbospongiosus&
• Levator&ani&
• Coccyx&(via&external&anal&sphincter)&

52. Posterior&Perineum&

53. Posterior&triangle&
• Anus&
• Anal&sphincter&
• Levator&ani&
• Ischio:rectal&fossa&

54. Ischio^rectal&fossa&
• Lateral&:&Pudendal&vessels/
nerve&(Pudendal&canal)&
• Medial&–&Fascial&covering&of&
levator&ani/external&anal&
sphincter&
• Posterior&–&sacrotuberous&
ligament&
• Anterior&–&urogenital&
perineum&
• Floor&–&skin/&subcutaneous&
fat&

55. Pudendal&Nerve/Vessels&
• Similar&channels&
• Nerve&arises&from&sacral&plexus&(S2:&S4)&
• Sensory&
• Motor&
• Artery:&anterior&division&of&internal&iliac&artery&
• Branches&
• Clitoral&
• Perineal&(largest&branch:&muscles/skin)&
• Inferior&rectal&

56. Anal&Sphincter&
• External&anal&sphincter&
• Superficial&porAon&
• Deep&porAon&
• Internal&anal&sphincter&
• Thickening&of&circular&smooth&muscle&of&anal&wall&
• Important&during&repair&of&third&(fourth)&
degree&perineal&laceraAon&&

57. The&Pelvic&Floor&
• Demands&of&upright&posture&
• Support&for&pelvic&structures&
• Passage&of&fetus&
• Openings&for&waste&eliminaAon&
• Fibro:muscular&floor&
• Visceral&ligaments/fascia&

58. Levator&ani/Pelvic&Wall&
Levator&ani&most&important&muscle&
• Pubo:rectal&
• Pubo:coccygeal&
• Coccygeal&
• Origin:&Posterior&aspect&of&pubic&bone,&fascia&of&pelvic&
side&wall,&ischial&spine&
• InserAon:&Perineal&body,&anal&sphincter,&coccyx&
• ConsAtute&pelvic&diaphragm&
• Surfaces&covered&by&fascia&

59. Pelvic&Floor&
• Pubo:rectal&and&pubo:coccygeal&most&medial&
• Pelvic&diaphragm&forms&U:shaped&layer&of&
muscle&
• Opening&end&of&U&directed&anteriorly&
(urogenital&sinus)&
• Urethra&
• Vagina&
• rectum&&

61. • THANK&YOU&&
• BUT&TAKE&A&BREAK&BEFORE&PART&2&(SPECIAL&
GYNECOLOGIC&ANATOMY)&
O&Warda&