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Transcript
Uterus, Cervix and vagina
Learning objectives
At the end of the lecture the student should be able to:
Know the details of uterus, cervix and vagina.
Enumerate the parts of uterus, ligaments of uterus and relations of uterus.
Identify the clinical correlates of uterus, cervix and vagina.
Female reproductive organs:
Include the uterus, fallopian tubes, and the ovaries.
Their position, size, and anatomic relations vary considerably with
age and the physiologic changes of menstruation, pregnancy, and
menopause.
Uterus :
Commonly referred to as the womb
A pear shaped organ about the size of a clenched fist
The uterus is a fibromuscular organ
The uterus varies considerably in size, shape and weight
depending on the status of parturition and estrogenic stimulation.
Uterus is divided into:
 Upper 2/3 rd expanded part – body
 Lower 1/3 rd narrow part – cervix.
Junction of the 2 parts is marked by a circular constriction.
It is made up of the endometrium, myometrium and perimetrium
AXIS OF UTERUS:
Long axis of the uterus forms an angle of 90 degrees with the long
axis of vagina.
Forward bending of uterus relative to vagina is called anteversion.
The uterus is also slightly bent on itself ---this is referred to as
anteflexion.
Angle of anteflexion is 120 degrees.
BODY OF UTERUS:
Fundus
2 surfaces
 Anterior surface
 Posterior surface
2 lateral borders
FUNDUS
Formed by upper free end of uterus
Convex in all directions
Covered by peritoneum continuous with that on the
vesical and intestinal surfaces
Directed forwards when the bladder is empty
Fertilized ovum is implanted in its posterior wall.
SURFACES OF UTERUS
ANTERIOR / VESICAL SURFACE:
Flattened
Covered by peritoneum, this is reflected on to the
bladder to form the vesicouterine pouch
The surface lies in apposition with the bladder.
POSTERIOR / INTESTINAL SURFACE:
Convex transversely
Covered by peritoneum, which is continued down on
to the cervix and vagina
Forms anterior wall of rectouterine pouch
It is in relation with the sigmoid colon, from which it is
usually separated by some coils of small intestine.
Cervix
Cervix (or neck of the uterus) is the lower, narrow portion of the
uterus where it joins with the top end of the vagina
Cylindrical or conical in shape
It is called "cervix uteri". Cervix means neck in Latin
Parts of cervix
The cervix projects through the anterior wall of the vagina, which
divides it into:

An upper, supravaginal portion.
 A lower, vaginal portion.
Supravaginal part is related:
 Anteriorly-- bladder
 Posteriorly — rectouterine pouch and rectum.
 Laterally– ureter and uterine artery
Parametrium is most abundant near cervix and vagina.
Vaginal part of cervix
Projects free into the anterior wall of the vagina between the anterior and posterior fornices.
On its rounded extremity is a small, depressed, somewhat circular aperture, the
external orifice of the uterus, through which the cavity of the cervix communicates
with that of the vagina.
Cervical canal
Endocervical canal
The passageway between the external os and the uterine
cavity
Somewhat fusiform
Flattened anterior to posterior
The endocervical canal measures 7 to 8 mm at its widest in
reproductive-aged women.
Internal os
The endocervical canal terminates at the internal os which is
the opening of the cervix inside the uterine cavity.
Ectocervix and endocervix
Ectocervix :
The portion projecting into the vagina
3 cm long and 2.5 cm wide
The ectocervix (more distal, by the vagina) is
composed of nonkeratinized stratified squamous
epithelium. The endocervix (more proximal, within the
uterus) is composed of simple columnar epithelium.
Transformation zone:
The area adjacent to the border of the endocervix and ectocervix is the
transformation zone
It undergoes metaplasia numerous times during normal life.
When the endocervix is exposed to the harsh acidic environment of the vagina
it undergoes metaplasia to squamous epithelium which is better suited to the
vaginal environment.
When the ectocervix enters the less harsh uterine area it undergoes
metaplasia to become columnar epithelium.
Function of cervix
During menstruation the cervix stretches
open slightly to allow the endometrium to
be shed.
During childbirth, contractions of the
uterus will dilate the cervix up to 10 cm in
diameter to allow the child to pass
through.
Blood supply:




Uterine artery: from anterior division of internal iliac artery.
Ovarian artery: from the abdominal aorta.
Runs tortuous course in the substance of the organ, and for their
frequent anastomoses.
SUPPLY:
•
•
•
•
•
•
Uterus
Vagina
Medial 2/3rd of uterine tube
Ovary
Ureter
Structures in broad ligament
Lymphatic drainage
•
•
•
Upper lymphatics-from fundus and upper part of the body pass to aortic nodes and only
partly to superficial inguinal nodes.
Lower lymphatics from cervix pass to external iliac and sacral nodes.
Middle lymphatics from lower part of body pass to external iliac nodes.
Nerve supply





Supplied from inferior hypogastric and ovarian plexus
Sympathetic nerves (T12,L1)
Parasympathetic nerves (S2,3,4)
Pain sensations from body pass along sympathetic nerves.
Pain sensations from cervix pass along parasympathetic nerves.
Uterine ligaments
Two types of ligaments
• Peritoneal ligaments
1. Anterior ligament
Consist of uterovesical fold of peritoneum
2. Posterior ligament
Consist of rectovaginal fold of peritoneum.
3. Right and Left broad ligaments.
•
Fibromuscular ligaments
Round ligaments of the uterus
Transverse cervical ligaments
Uterosacral ligaments
Broad ligament
They attach the uterus to lateral pelvic wall.
Upper border is free, contain uterine tubes
Anterior and posterior layers of peritoneum forming
ligament become continuous at upper border.
Lateral and inferior borders of ligament are attached to
corresponding part of pelvic wall.
Medial border is attached to lateral margin of uterus.
Divisions of broad ligament
Mesosalpinx
Lie between uterine tube and ovarian ligament
Mesovarium
Attaches ovary to uterus
Mesometrium
Lie below the ovarian ligament
Supports of the uterus
•
Primary supports
Muscular or active
•
•
•
Pelvic diaphragm
Perineal body.
Urogenital diaphragm
Fibromuscular or mechanical
•
•
•
•
•
Uterine axis
Pubocervical ligament
Tranverse cervical ligament
Uterosacral ligament
Round ligament of uterus
Secondary supports are formed by peritoneal
ligaments
•
•
•
Broad ligaments
Uterovesical fold of peritoneum
Rectovaginal fold of peritoneum
Uterine fibroid
Benign (non-cancerous) tumor that originates from the
smooth muscle layer (myometrium) and the
accompanying connective tissue of the uterus
Cervical cancer
Human papillomavirus (HPV) infection is a necessary factor in the
development of nearly 70% cases of cervical cancer.
Potentially pre-cancerous changes in the cervix can be detected by a
Pap smear
Worldwide, cervical cancer is the 5th most deadly cancer in women
The Papanicolau test (also called Pap smear, Pap test, cervical smear, or smear test) is a screening test used in
gynecology to detect premalignant and malignant (cancerous) processes in the ectocervix
Cervical polyp
A cervical polyp is a common benign polyp or tumour on the surface
of the cervical canal.
Can cause irregular menstrual bleeding but often show no
symptoms.
Treatment consists of simple removal of the polyp
About 1% of cervical polyps will show neoplastic change which may
lead to cancer
VAGINA
Is a fibromuscular canal
EXTENT:
From vulva---to the uterus
SITUATION:
Situated behind the bladder and in front of the rectum
6 to 7.5 cm (2.5 to 3 in) across the anterior wall (front) and 9 cm (3.5 in)
long across the posterior wall
Its axis forming an angle of over 90°, with uterus
Lumen-


at the upper end = circular
(b/c of the protusion of the cervix into it)
In middle part = transverse slit
(Anterior posterior walls are in contact)

In lower part = H shaped
In virgins
Lower end is closed by a thin annular fold of mucus membrane called the hymen
In married women:
Hymen is represented by rounded elevations called caruncular hymenale
Vagina
Upper end is slightly expanded
Interior of the upper end of vagina is in the form of circular
groove that surrounds the protuding cervix
The groove becomes progressively deeper from before
backwards
The groove is divided into 4 parts:
Anterior fornix-shallowest
Posterior fornix-deepest
2 lateral fornix-1 on each side
Relations of vagina
Anterior surface
Upper half -- bladder
Lower half -- urethra
Posterior surface
Upper ¼seperated from bladder by rectouterine
pouch
Middle 2/4 seperated from
Rectum by loose C.T
Lower1/4 seperated from anal canal by perineal body
7muscles attached to it
Lateral surface
Levator ani muscle
Blood supply
Main artery = Vaginal artery
Additional arteries =
Uterine artery
Middle rectal artery
Uterovaginal venous plexus
Lymph drainage
Upper 1/3external L.N
Middle 1/3internal iliac L.N
Lower 1/3medial group of inguinal L.N
NERVE SUPPLY
Lower 1/3pain sensitive
Pudendal nerve through inferior rectal & posterior branches of
perineal nerves
Upper 1/3 pain insensitive
Sympathetic
Septate vagina
A vaginal septum is a congenital partition within the
vagina; such a septum could be either longitudinal
or transverse.