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APPLIED ANATOMY OF THE FEMALE GENITAL SYSTEM
Understand concepts and associated principles, functional and clinical applications of:
1. The significance of the recto-uterine pouch (of Douglas) noting its relationship to
the posterior fornix of the vagina.
The rectouterine pouch (Pouch of Douglas) is the
extension of the peritoneal cavity between the rectum
and back wall of the uterus.
As it is the lowest part of the peritoneal cavity in a
woman when standing, it is a common site for the
spread of pathology such as ascities, tumour and
endometriosis. Pus and blood may also gravitate here.
It is directly related primarily to the posterior vaginal
fornix and is palpable by PV.
Due to differences in axis between vagina and cervix,
the rectouterine pouch may be inadvertently entered by
instruments – thereby exposing the peritoneal cavity.
The rectouterine pouch is used in the treatment of endstage renal failure in patients who are treated by
peritoneal dialysis, with the tip of the dialysis catheter
being placed into the deepest point of the pouch
2. Retroversion of the uterus (a common variation)
A retroverted uterus is a uterus that is tilted backwards towards the spine instead of forwards.
One in about 3-5 women have a retroverted uterus.
A slightly ‘anteverted’ uterus is more common and is tipped forwards towards the bladder
with the anterior end slightly concave.
A retroverted uterus is usually congenital, but it can be caused by pelvic surgery, pelvic
adhesions, fibroids, PID or childbirth.
It is usually diagnosed during a routine pelvic examination and does not cause any medical
problems – however it can be associated with dyspareunia (pain during intercourse) and
dysmenorrhoea (pain during menstruation).
The uterus will usually correct itself during the 10th to 12th week of pregnancy. If not,
treatment options include exercises, a pessary, manual repositioning or surgery.
3. The supports of the uterus and discuss the mechanism and effects of prolapse
into the vagina of part of: uterus; bladder (cystocele); rectum (rectocele)
DIRECT SUPPORTS OF THE UTERUS:
 MAJOR SUPPORTS
At the cervix – are condensations of pelvic fascia which form 3 ligaments:
1) Transverse cervical + + +
2) Pubocervical + +
3) Sacrocervical (uterosacral) + +
 MINOR SUPPORTS
Not at the cervix are the round ligament and broad ligement
INDITECT SUPPORT OF UTERUS
Vaginal support:
 Tone of Levator ani muscle + + +
 Perineal body +
 Urogenital diaphragm +
The structures that may prolapse (‘abnormal bulge due to weakness in muscle wall’) into the
vagina are:
 Bladder (cystocele) – upper anterior vaginal wall
 Urethra (urethrocele) – lower anterior vaginal wall
 Rectum (rectocele) – posterior vaginal wall
VAGINAL PROLAPSE – ‘abnormal protrusion due to weakness in supporting structures’
 Descent and prolapsed of uterus into the vagina. If it its sever enough, it may possibly
protrude through introitus (procidentia)
4. The lymph drainage of the cervix and uterus (noting the significance regarding
tumour spread)
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Para-aortic nodes – lymphatics accompany ovarian vessels
Internal and external iliac nodes – lymphatics accompany uterine and vaginal
vessels
Sacral nodes – lymphatics accompany lateral and median sacral vessels
WATERSHED ARES OF DRAINAGE
CERVIX – to internal iliac, external iliac and sacral nodes
HYMEN – to superficial inguinal nodes (accompany external pudendal vessels) and to
internal iliac nodes (accompany vaginal vessels).