Anatomy and applied aspects of Female genital tract

Anatomy of female genital tract

1. ANATOMY OF FEMALE GENITAL TRACT AND APPLIED ASPECTS GUIDE:DR. HEMA PATIL PRESENTER:DR.PRIYADARSHINI METI DR.PRITI CHAMPAVAT

2. EXAM QUESTIONS Describe briefly anatomy of the pelvic floor. Discuss management of a third degree perineal tear ( O ct 2014). Surgical anatomy of ureter. How will you prevent ureteric injuries during obstetric and gynecological surgery?(May 2012, May 09) Describe the supports of uterus and conservative management of uterine prolapse (April 2014). Describe the course of pelvic ureter in the female. What are the causes and sites of pelvic ureteric injury? (April,2013 , May 2010 ).

3. Pelvic diaphragm (May 2011) Describe anatomy of pelvic floor and its clinical importance (May 2011). Describe supports of the uterus. Discuss conservative treatments of uterine prolapse (May 2011). Supports of uterus and vagina (May 2010). Describe anatomy of internal iliac artery. Discuss indications of ligation of anterior branch of it (May 2008, A pril 08 ).

4. Perineal body ( A pril 2007). Lymphatic drainage of vulva ( A pril 07). Lymphatic drainage of uterus and cervix ( Sept 07) Describe lymphatic drainage of cervix. Discuss the chemoradiation in cervical cancer(May 08, May 06). Anatomy of fallopian tube and its relevance to fertility (April 2007). Describe briefly anatomy of the pelvic floor. Its role in labor (April,2006).

5. FEMALE GENITAL ORGANS Anatomy: Gross anatomy, histology Blood supply Nerve supply Lymphatics Applied aspects

6. External genital organs – mons veneris , labia majora , labia minora,clitoris , vestibule and perineum Internal genital organs – vagina, uterus, fallopian tube, ovary, female urethra

7. EXTERNAL GENITAL ORGANS (SYN:VULVA,PUDENDUM) MONS VENERIS (MONS PUBIS) Pad of subcutaneous adipose connective tissue lying infront of the pubis

8. LABIA MAJORA Two thick folds of skin enclosing fat Covered with squamous epithelium Contains distal ends of the round ligaments, hair follicles, sebaceous, apocrine , eccrine sweat glands Anterior commissure , posterior commissure

9. LABIA MAJORA

10. LABIA MAJORA

11. LABIA MAJORA

12. LABIA MINORA Two thin folds of skin, devoid of fat, on either side within the labia majora - Do not contain hair follicles and sweat glands Contains numerous connective tissues, sebaceous glands, erectile muscle fibers, vessels and nerve endings

13. Anteriorly divided to enclose the clitoris (prepuce and frenulum ) Posteriorly - fourchette Fossa navicularis Homologous to the ventral aspect of the penis

14. LABIA MINORA

15. CLITORIS Erectile body, homologous with the penis Consists of glans , body and two crura Glans : covered by squamous epithelium, richly supplied with nerves Body: two corpora cavernosa Attached to the pubic symphysis by suspensory ligament

16. VESTIBULE Triangular space : anteriorly – clitoris, posteriorly – fourchette , either sides – labia minora - Openings : - urethral opening - vaginal orifice and hymen - opening of Bartholin ducts - skene’s glands

17. BARTHOLIN’S GLAND Situated in the superficial perineal pouch Two pea sized (2cm) glands, located in the groove between hymen and labia minora at 5 o’clock and 7 o’clock position of the vagina Compound racemose variety, lined by columnar epithelium

18. Bartholin’s duct measures about 2cm, opens into the vestibule outside the hymen at the junction of anterior 2/3 rd and posterior 1/3 rd in the groove between hymen and labia minora Duct lined by columnar epithelium but near its opening by stratified squamous epithelium

19. TYPES OF HYMEN

20. PERINEUM ( ANATOMICAL AND OBSTETRICAL ) ANATOMICAL Boundaries: - above: inferior surface of pelvic floor - below: skin between buttocks and thighs - laterally: ischiopubic rami , ischial tuberosities , sacrotuberous ligament - posteriorly : coccyx

21. UROGENITAL TRIANGLE - Superficial perineal pouch : formed by the colle’s fascia and inferior layer of urogenital diaphragm Contents : paired superficial transverse perinei , bulbocavernosus , paired ischiocavernosus , paired Bartholin’s gland

22. Deep perineal pouch: formed by sup. & inf. layer of the urogenital diaphragm Contents : paired deep transverse perinei and sphincter urethra membranaceae

23. ANAL TRINGLE - no obstetric importance - contents: terminal part of anal canal with external anal sphincter, anococcygeal body, ischiorectal fossa .

24. OBSTETRIC PERINEUM( PERINEAL BODY, CENTRAL POINT OF PERINEUM ) - Pyramidal shaped tissue where the pelvic floor, perineal muscles and fascia meet in between the vagina and the anal canal - Measures about 4x4 cm

25. Musculofascial structures involved Fasciae : 1) two layers of superficial perineal fascia 2) inferior and superior layers of urogenital diaphragm ( triangular ligament )

26. Muscles: 1) superficial & deep transverse perinei (paired) 2) pubococcygeus part of the levator ani (paired) 3) bulbospongiosus (paired) 4) few fibers of external anal sphincter 5) few fibres of the longitudinal muscle of anal canal

27. LEVATOR ANI Muscle of pelvic diaphragm 3 main divisions: Pubococcygeus , iliococcygeus and ischiococcygeus Inner fibres of puboccygeus form puborectalis , other fibres decussate between the vagina and the rectum divide the lelator ani into anterior portion ( hiatus urogenitalis ) and posterior portion ( hiatus rectalis )

28. NEW CONCEPTS OF LEVATOR ANI Levator ani : pubococcygeus , puborectalis , iliococcygeus Pubococcygeus divided into pubovaginalis , puboperinealis and puboanalis which provide additional support to the urethra and anus Puborectalis : U-shaped muscular sling encircling the junction between the rectum and anus

29. BLOOD SUPPLY OF VULVA Arteries: a) Branches of internal pudendal artery- labial, transverse perineal , artery to the vestibular bulb, dorsal arteries to the clitoris b) Branches of femoral artery- superficial and deep external pudendal

30. Veins: The veins from plexus drain in to Internal pudendal vein Vesical or vaginal venous plexus Long saphenous vein

31. LYMPHATICS OF VULVA Lymphatics of each side freely communicate with each other Anastomose with the lymphatics of the lower third of the vagina and drain in to the external iliac nodes Deep tissues of the vulva drain into the internal iliac nodes

32. Superficial inguinal lymph nodes-sentinel nodes of the vulva, deep inguinal – secondarily involved. It is unusual to find positive pelvic glands without metastatic disease in the inguinal nodes

33. NERVE SUPPLY OF VULVA Through b/l spinal somatic nerves Anterio superior part- ilioinguinal and genital branch of genioto femoral nerve ( L1, L2 ) Postero inferior part – pudendal branches from post. Cutaneous nerve of thigh( S123) Vulva is supplied by labial and perineal branches of pudendal nerve ( S234)

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35. APPLIED ANATOMY OF VULVA Infections : bacterial, viral, fungal, parasitic Benign lesions : vulvar epithelial disorders, vulvar ulcers, vulvar cyst,cyst of the canal of the Nuck , benign tumours of the vulva Premalignant conditions Malignancy Others : episiotomy, pelvic hematoma, pudendal block or saddle block

36. VULVITIS DUE TO SPECIFIC INFECTION BACTERIAL- Pyogenic STDs - gonorrhoea, syphilis, chancroid , LGV, granuloma inguinale Tubercular VIRAL- condyloma accuminata , herpes genitalis , molluscum contageosum,herpes zoster

37. FUNGAL- Moniliasis Ring worms PARASITIC- Pediculosis pubis Scabies Thread worm

38. CHANCROID

39. LYMPHOGRANULOMA VENEREUM

40. GRANULOMA INGUINALE

41. CONDYLOMA CCCUMINATA

42. GAINT CONDYLOMA ACCUMINATA

43. HERPES GENITALIS

44. MOLLUSCUM CONTAGIOSUM

45. INFECTION OF BARTHOLIN’S GLANDS Causative organism- gonococci, E coli, staphylococcus, streptococcus, C. trachomatis Fate- Complete resolution Recurrence Abcess formation Cyst formation

46. Clinical features- local pain, discomfort causing difficulty in walking or sitting O/E: tenderness and induration at post. half of the labia, secretion may come out through the gland opening when pressed T/t: hot compression, analgesics and systemic antibiotics

47. BARTHOLIN’S ABSCESS End result of acute bartholinitis , duct gets blocked by fibrosis and exudate pent up inside to produce abscess C/F : intense pain and local discomfort, fever O/E: unilateral tender swelling beneath the post half of the labia majora , red and edematous T/T: rest , analgesics, sitz bath, systemic antibiotics

48. BARTHOLIN CYST C/F : small size swelling, unnoticed mostly if enlarged cause discomfort and dyspareunia O/E: unilateral non tender swelling on the post half of the labia majora which opens at post end of labia minora T/t: Marsupialization

49. BARTHOLIN’S CYST

50. EXCISION OF BARTHOLIN’S CYST

51. OTHER BENIGN CONDITIONS OF VULVA Sebaceous cyst Vulvar varicosities Elephantiasis of vulva Fibroma , lipoma , neurofibroma , hydradenoma

52. LIPOMA OF VULVA

53. HYDRADENOMA OF VULVA

54. VULVAR FIBROMA

55. VULVAR ELEPHANTIASIS

56. VULVAR VARICOSITIES

57. PREMALIGNANT CONDITIONS OF VULVA Vulvar intra epithelial neoplasia Paget’s disease Lichen sclerosis Squamous cell hyperplasia Condyloma accuminata

58. MALIGNANCY: HISTOLOGICAL TYPES Squamous cell carcinoma Melanoma Adenocarcinoma of Bartholin’s gland Basal cell carcinoma Sarcoma

59. LEVATOR ANI APPLIED ASPECTS Pubovaginalis supports the vagina, bladder and uterus. Weakness or tear may lead to prolapse of concerned organs Counteracts the downward thrust of increased intra abdominal pressure and guards the hiatus urogenitalis

60. Facilitates anterior internal rotation of the presenting part whwn it presses on the pelvic floor Puborectalis supports rectum Ischiococcygeus helps to stabilize sacroilial and sacrococcygeal joints To steady the perineal body

61. PELVIC FLOOR DURING PREGNANCY AND PARTURITION During pregnancy levator muscles hypertrophy, become less rigid and more distensible In the second stage, the pubovaginalis and puborectalis relax and the levator ani is drawn upover the advancing presenting part

62. Failure of the levator ani to relax at the crucial movement may lead to extensive pelvic structure damage Perineal tears occuring during parturition divide decussating fibres , causing the hiatus urogenitalis to become patulus and lead to prolapse

63. EPISIOTOMY ( PERINEOTOMY ) A surgically planned incision on the perineum and the post vaginal wall during 2 nd stage of labour

64. TIMING When perineum is bulging, when 3-4 cm fetal scalp is visible during contraction and when the presenting part will be delivered with next 3-4 contractions TYPES 1) Mediolateral 3) Lateral 2) Midline 4) J shaped

65. STRUCTURES CUT Skin and sub cutaneous tissue Tranverse perineal branches of pudendal nerves and vessels Bulbospongiosus muscle and fascia Superficial and deep transverse perineal muscles Part of levator ani Posterior vaginal wall

66. CLASSIFICATION OF OBSTETRIC ANAL SPHINCTER INJURY ( RCOG – 2007 ) First degree- injury to perineal skin only Second degree – injury to perineum involving perineal body, no anal sphincter involvement Third degree – injury to perineum involving the anal sphincter complex 3a : <50% of EAS thickness torn 3b : >50% of EAS thickness torn 3c : both EAS and IAS torn Fourth degree – injury to perineum involving the anal sphincter complex and anal epithelium

67. PELVIC HEMATOMA Collection of blood anywhere in the area between the pelvic peritoneum and the perineal skin Commonest: vulval hematoma Etiology: improper hemostasis , rupture of paravaginal venous plexus Symptoms:persistent severe perineal pain, rectal tenesmus , retention of urine Signs:tense swelling at vulva T/t: <5 cm, conservative Larger hematoma explored

68. PUDENDAL NERVE BLOCK Safe and simple method of analgesia during delivery Does not relieve pain of labour but affords perineal analgesia and relaxation Used for forceps and vaginal breech delivery Simultaneous perineal and vulvar infiltration is needed to block the perineal branch of posterior cutaneous nerve of thigh, labial branches of the ilioinguinal and genitofemoral nerve

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