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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) 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).