Anatomy of uterus and appendages

ANATOMY OF UTERUS
ANATOMY OF OVARY
ANATOMY OF FALLOPIAN TUBES
ANATOMY OF UTERUS &ITS APPENDAGES
ANATOMY OF CERVIX
ANATOMY OF UTERUS PPT
BLOOD SUPPLY, NERVE SUPPLY, LYMPHATIC DRAINAGE
HISTOLOGY

1. Anatomy of Uterus & its Appendages DR. SRAVANI KOMMURU, 1 ST YR PG DEP T OF OBSTETRICS & GYNAECOLOGY NRIIMS

2. UTERUS:  thick-walled, muscula r organ with na rrow lumen.  present in the pelvis between the urinary bladder and the rectum.  Superiorly, on each side -- uterine tube inferiorly -- vagina . Shape and Size :  pear-shaped , being f lattened anter oposteriorly Measurements :  Length: 3 inches (7.5 cm).  Breadth (at fundus): 2 inches (5 cm).  Thickness : 1 inch ( 2. 5 cm).

3. PARTS OF THE UTERUS :  DI vided into two main parts :  (a) large upper pear-shaped part—the body.  (b) small lower cylindrical part—the cervix.  The body forms upper 2/3 rd and cervix forms the lower 1/3rd .  J unction between body and cervix is a circular constriction called isthmus (0.5cm) .  The point of fusion between the uterine tube an d body is called cornu of the uterus .

4. B ODY Ab o ve the openings of the uterine tubes, dome -like end is called fundus. smooth muscle tissue of body is 2.5cm thick Outer –longitudinal fibres , middle- crisscross-which contain openings of blood vessels- living ligature. inner –circular muscle fibres . ISTHMUS: F orms LUS(LOWER UTERINE SEGMENT), at 24week s & completes at labour . At term[ 70% isthmus &30%cervix] forms LUS measures 5cm In labour , LUS measures 10cm

5. Anterior surface : flat , directed downward& forward.  C overed by the peritoneum up to isthmus, reflects on the upper surface of urinary bladder as uterovesical pouc h. Anterior relations:  B ody - uterovesical pouch & superior surface of urinary bladder.  S upravaginal portion of cervix - posterior surface of urinary bladder –loose areolar tissue.  vaginal portion of cervix - anterior fornix of the vagina.

6. Posterior surface : covered by the peritoneum -to posterior fornix. reflects- anterior aspect of rectum forming rectouterine pouch ( or pouch of Douglas ). Posterior relations : Body - rectouterine pouch with coils of ileum and sigmoid colon. S upravaginal portion of cervix - rectouterine pouch with coils of ileum and sigmoid colon. V aginal portion of cervix - posterior fornix.

7. Right and left lateral border : rounded and related to the uterine artery provides attachment to the broad ligament of uterus. round ligament is attached anteroinferior to the tube ligament of the ovary is attached posteroinferior to the tube . Mackendrot ligament - from internal os down to supravaginal cervix to lateral vaginal wall. Laterally  B ody of uterus - broad ligament , uterine artery & vein.  S upravaginal portion of cervix - ureter & uterine artery.  V aginal portion of cervix - lateral fornices of the vagina.

8. BROAD LIGAMENTS : Double layer peritoneum, Side of uterus to lateral wall of pelvis. 2 layers: posterior layer: forms mesovarium pierced by lateral end of fallopian tube anterior layer: free CONTENTS OF BROAD LIGAMENT : Fallopian tubes Ovarian vessels Uterine vessels Round ligament &ovarian ligament Epoophoron & paroophoron Ovary attatched to posterior layer

9. Cervix Cylindrical, measures 2.5cm  cervix is divided into two parts:  (a) upper supravaginal part.  (b) lower vaginal part. Cervical wall made of outer stroma- connective tissue containing collagen ; only 10-15% smooth muscle Secretions- alkaline,thick ,scanty- rich in mucoprotein , fructose,NaCl .

10. Cavity Of The Uterus  small in comparison to its size due to thick muscular wall. Base above ,apex below: Cavity of the Body (Uterine Cavity Proper ) :  It is a triangular in coronal section.  The implantation commonly occurs in the upper part of its posterior wall.  It is slit in sagittal section , because the uterus is compressed anteroposteriorly and its both walls are almost in contact.

11. Cavity of the Cervix (Cervical Canal):  It is a spindle-shaped canal , broader in middle , narrow at the ends .  nulliparous women - external os is small and circular .  multiparous women - external os is large & transverse , and presents anterior and posterior lips. ANATOMICAL INTERNAL OS: HISTOLOGICAL INTERNAL OS: slight change in epithelium, lies below anatomical internal os ,distance from isthmus 0.5cm

12. Ligaments  The ligaments of the uterus are classified into two types: false and true.  The false ligaments are peritoneal folds whereas the true ligaments are fibromuscular bands.  The false ligaments do not provide support to the uterus while true ligaments provide support to the uterus.

13. Supports Of The Uterus : UPPER: 1.ROUND LIGAM ENT – Fibrous chord (12cm) from uterine end ->internal inguinal ring ->inguinal canal ->external inguinal ring->labia majora Hooks around Inferior epigastric artery Peritoneum- processus vaginalis-canal of nuck 2.BROAD LIGAMENT MIDDLE : 1.TRANSVERSE CERVICAL LIGAMENT- supravaginal cervix &vaginal vault ->parietal fascia on pelvic wall 2. PUBOCERVICAL -cervix&vagina->pubic bones supports bladder ,urethra.

14. LOWER: 3 .UTEROSACRAL- cervix ->S2 vertebra maintain anteversion of uterus. Hypertrophy-pregnancy, atropy -after menopause 1.UROGENITAL DIAPHRAGM : Two layered fibrous sheath between ischiopubic rami Inserted posteriorly b/w 2 ischial tuberosities .

15. 2 .LEVATOR ANI : 3.PERINEAL BODY : Pyramid shaped fibromuscular mass 4*4Cm, Separates vulva,vagina from anus Many blend –a) pubococcygeus b)superficial &deep transverse perinei c)eternal anal spinchter d) bulbocavernosus e)posterior border of urogenital diaphragm

16. DELANCEY’S 3 LEVELS OF SUPPORT:

17. Normal Position And Axes Of The Uterus  Normally the uterus lies in position of anteversion and anteflexion. Anteversion : The long axis of the cervix is bent on long axis of vagina at an angle of 90°. Anteflexion : The long axis of the body of uterus is bent at the level of isthmus (internal os) on long axis of cervix f orming an angle of 170°.

18. Fundus pointing towards bladder(anteriorly )= ANTEFLEXION ANGLE of cervix &vagina= straightened obtuse angle = RETROVERSION Fundus pointing towards rectum = RETROFLEXION

19. Arterial Supply  The uterus - two uterine arteries and partly by two ovarian arteries .  The uterine artery is a branch of anterior division of internal iliac artery.  It crosses the ureter from above ,(WATER UNDER THE BRIDGE) At the superolateral angle of uterus it turns laterally, runs along the uterine tube, and terminates by anastomosing with the ovarian artery.

20. Arcuate branches:surface to outer 1/3 rd of myometrium Radial branches: inner 2/3 rd of myometrium Basal arteries: basal part of endometrium Spiral arteries:superficial part of endometrium UTERINE ARTERY &ITS BRANCHES : BLOOD SUPPLY OF CERVIX: DESCENDING CERVICAL ARTERIES AT 3’0 & 9’0 POSITIONS

21. VENOUS DRAINAGE :   They form venous plexus ( pampiniform plexuses) along with ovarian veins drains into internal iliac veins uter ine veins  1. The sympathetic fibres - T10–L1 spinal segments. somatic pain distribution in abdomen area of T10-L8 The sympathetic fibres cause uterine contraction and vasoconstriction.  2. The parasympathetic fibres - S2–S4 spinal segments ends in GANGLION FRANKENHAUSER. The parasympathetic fibres inhibit the uterine muscles and cause vasodilatation . NERVE SUPPLY :

22. Dr . V i b ha s h

23. Histology SINGLE LAYER OF COLUMNAR EPITHELIUM & SIMPLE TUBULAR GLANDS SINGLE LAYER OF COLUMNAR EPITHELIUM &COMPOUND RACEMOSE GLANDS STRATIFIED SQUAMOUS EPITHELIUM

24. SQUAMO COLUMNAR JUNCTION : Physiological- metaplasia As age increases, SCJ move inwards into endocervix . New SCJ arise from external os Transformation zone is most dynamic area, pap smear taken from it.

25. Ovary: Each ovary is whitish in color,3*2*1cm,intraperitoneal located along lateral wall of the  uterus  in a region called ovarian fossa . The ovarian fossa is an area of 4  cm x 3 cm x 2 cm in size.The ovaries are surrounded by a capsule, and have an outer cortex and an inner medulla .

26. Ovary is attatched to lateral pelvic wall by infundibulo -pelvic ligament carries blood vessels. Volume of ovary: In reproductive age normal upto 20cc ( avg 7-8cc) Postmenopausal age normal upto10cc( avg 3-4cc)

27. HISTOLOGY OF OVARY CAPSULE: lining epithelium- single layer of cuboidal epithelium CORTEX: contains different stages of follicles MEDULLA: vascular layer No. of oocytes at birth 2 million At puberty, 4lakhs Ovulate during life 100, Undergo atresia-1000/every month

28. BLOOD SUPPLY : Ovarian artery –branch of Abdominal Aorta at L2 Ovarian vein -on left side drains into Left R enal vein -on right side drains into IVC LYMPHATIC DRAINAGE : NERVE SUPPLY : Sympathetic T10,T11 by Aorticorenal plexuses.(OVARIES ARE SENSITIVE TO MANUAL SQUEEZING) Parasympathetic by left and right inferior hypogastric plexuses

29. FALLOPIAN TUBES ITS different segments are ( lateral   to   medial ): the   infundibulum  with its associated  fimbriae  near the ovary the  ampullary (5cm)  region is the major portion of the lateral tube(WIDEST 6mm), the  isthmus(3cm)   segment is the narrower part(1mm) the interstitia l(1-2cm) ( also Known as intramural) part is narrowest(0.7mm). The   ostium  is the point where the tubal canal meets the peritoneal cavity, The average length of a fallopian tube is 11-12 cm .

30. The uterine tubes receive both sympathetic and parasympathetic innervation via nerve fibres from the  ovarian  and  uterine (pelvic) plexuses . Sensory afferent fibres run from  T11- L1 . NERVE SUPPLY BLOOD SUPPLY : Dual blood supply Medial 2/3 rd - uterine artery Lateral 1/3 rd -ovarian artery LYMPHATIC DRAINAGE : Ostia &interstitial part : Superficial I nguinal LN Rest of tube: Para Aortic LN DECREASED PERISTALSIS IS RISK FOR ECTOPIC PREGNANCY.

31. REFERENCES: GRAY’S ANATOMY . MUDALIAR & MENON TEXTBOOK OF OBSTETRICS.