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MOB TCD Uterus, Broad Ligament, Ovary Professor Emeritus Moira O’Brien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin MOB TCD Uterus • • • • • • Pear-shaped muscular organ 8 cm long 5 cm wide 3 cm thick Non-pregnant state Pelvic organ MOB TCD Uterus MOB TCD Uterus • Fundus • Body • Cervix opens into vault or fornices of vagina • Fundus is the portion above entrance of uterine tubes • Covered with peritoneum • Body • Triangular cavity MOB TCD Cervix • Supravaginal • Isthmus is a circular borderline area between the body and cervix • Isthmus is the supra vaginal portion of cervix lower uterine segment • Intravaginal is surrounded by gutter fornices • Posterior is deeper covered with peritoneum MOB TCD Cervix • Internal os is the opening from the body • Spindle shaped cavity • External os is the opening into vagina • Cervix lined columnar epithelium • Arbor vitae in nullipara • Intravaginal portion of cervix covered by stratified epithelium MOB TCD Cervix • External os • Junction of columnar of the cervical canal • Stratified epithelium of the intravaginal portion • Site of cancer of cervix • Cervical smear MOB TCD Cervix • At birth cervix is larger than the body • Fully developed cervix is one third of body MOB TCD Peritoneum • Reflected from the superior surface of the bladder • Junction of the supravaginal portion of the cervix and the body of the uterus • Uterovesical pouch • Covers body, fundus • Covers the posterior surface body and the supravaginal portion of cervix • Upper third of posterior surface of vagina MOB TCD Pouch of Douglas • Upper third of posterior surface of vagina (posterior fornix) • Peritoneum reflected on to junction of upper two thirds and lower third of rectum • Pouch of Douglas is most dependent part of female peritoneal cavity • Broad ligament is lateral MOB TCD Uterus • Uterus is anteverted • i.e. anterior to vertical plane going through the vagina • Posterior fornix deeper • Anteflexed • Bent anteriorly at junction of body and cervix MOB TCD Uterus • • • • • • • • Serous layer Myometrium No submucous layer Endometrium Three layers Basal Spongy Compact at surface of uterine cavity MOB TCD Myometrium • Myometrium makes up bulk of uterine wall • Blood vessels more evident in middle layer MOB TCD Myometrium MOB TCD Uterine Muscle MOB TCD Blood Supply • • • • Uterine Ovarian Vaginal arteries Anterior and posterior arcuate run in middle layer MOB TCD Blood Supply • Radial branches • Basal layer • Spiral branches to superficial two layers • Veins below artery • Plexus in lower edge broad ligament into internal iliac MOB TCD Blood Supply MOB TCD Nerve Supply of Uterus • Pain from cervix via parasympathetic S2,3 • Pain from body via sympathetic to T11 and T12 MOB TCD Lymphatics MOB TCD Supports of Uterus Upper • Round ligament • Broad ligament anteverted Middle • Transverse ligament • Pubocervical • Uterosacral Lower • Levator ani, coccygeus • Perineal body MOB TCD Round Ligament • Round ligament and • Ligament of ovary • develop from the gubernaculum • Side of uterus, junction fundus and body • Inguinal canal to labium majus • Anteversion MOB TCD Broad Ligament • Fold of peritoneum from side of uterus to side wall of pelvis • Framework of pelvic fascia • Parametric fat • Anterior surface looks inferiorly • Free upper border • Base on pelvic floor MOB TCD Broad Ligament • • • • • • Uterine tubes Ovarian vessels Uterine vessels Epoophoron Paroophoron Round ligament of uterus and ligament of ovary • Transverse ligament • Ovary attached to posterior layer • Ureter in base below artery MOB TCD Broad Ligament • Uterine tube lies in medial four fifths of free border of broad ligament • Lateral one fifth • Contains ovarian vessels • Infundibulo-pelvic or suspensory ligament of ovary MOB TCD Broad Ligament • • • • • • Mesosalpinx Mesometrium Mesoovarian Epoophoron Parallel tubules Gaertners duct remains mesonephric tubules and duct, may form cysts MOB TCD Uterine Artery • Uterine artery lies superior to the ureter at lateral fornix of vagina • Base of broad ligament MOB TCD Pubocervical Ligament • Attached • Anteriorly to posterior aspect of body of body of pubis • Passes to neck of bladder • Anterior fornix of vagina MOB TCD Pubocervical Ligament • Pubocervical ligaments help to maintain normal angle of 45°between the vagina and horizontal • Decrease may cause a cystocoele MOB TCD Transverse Ligament • Transverse or cardinal or mackenrodt ligament • Thickening of visceral layer of pelvic fascia around uterine artery • Lateral to medial in base of broad ligament MOB TCD Uterosacral Ligament • Uterosacral contains fibrous tissue • Nonstriated muscle • Attached from the cervix to the middle of sacrum • Contains lymphatics draining cervix to sacral glands MOB TCD Uterosacral Ligament • Uterosacral help to keep uterus anteverted • If uterus is anteverted it cannot prolapse MOB TCD Uterine Tube • • • • • • Intramural Isthmus Ampulla Infundibulum Lined ciliated columnar epithelium Beats towards uterus MOB TCD Uterine Tube • • • • Peritoneum Loosely attached to ampulla Tightly to isthmus Fimbria surrounding opening into peritoneal cavity • Ovarian fimbria MOB TCD Embryology of Uterus MOB TCD Ovary • Attached to posterior layer of broad ligament mesoovarian • Covered with germinal epithelium • Side wall of pelvis covered with peritoneum • Obturator internus muscle • Obturator nerve supplies the parietal peritoneum • Ureter posterior • Ligament of ovary medially MOB TCD Ovary • Obturator nerve supplies the parietal peritoneum • Irritation of the peritoneum of the side wall by bleeding at ovulation or by lesions involving the ovary, may result in referred pain to medial side of the thigh or the knee MOB TCD Ovary • Blood supply • One ovarian artery from lateral aspects of aorta L2 • Right vein drains into IVC • Left drains into left renal vein • Lymphatics into paraaortic glands L2 MOB TCD Vagina • • • • • Fornices surround cervix Anterior wall shorter posterior Walls in contact except superior External os Opens into vestibule of vagina MOB TCD Vagina • Pelvis • Lateral uterine artery above ureter • Levator ani • Deep pouch • Sphincter urethrae • Bulbs of vestibule • Greater vestibular glands MOB TCD Vagina • Urethra embedded in lower two thirds of anterior wall • Posterior fornix peritoneum of pouch of Douglas • Rectum • Perineal body MOB TCD Vagina • • • • Pelvic fascia Erectile tissue Muscular wall Non-keratinised stratified squamous epithelium MOB TCD Blood and Nerve Supply Vagina • • • • • Uterine artery Vaginal Internal pudendal Labial Ilio Inguinal nerve supplies the anterior wall • Labial nerves supply the posterior wall MOB TCD Lymphatics of Vagina • Internal iliac • Lower third • Medial group of proximal superficial inguinal glands MOB TCD Pelvic Sympathetic MOB TCD Pelvic Plexuses • • • • Supply pelvic organs Contains Sympathetic Preganglionic parasympathetic nerves • Lateral column S2,3,4 MOB TCD Pelvic Plexus • • • • • • Hypogastric plexus Lumbar splanchnics Presacral nerve Anterior to body of L5 Divide into pelvic plexuses Postganglionic of sympathetic that relayed in lumbar and sacral ganglia MOB TCD Sympathetic • Ejaculation is via sympathetic impulses from L1-L2 • Contraction of sphincters of bladder and anal canal MOB TCD Pelvic Parasympathetic • Preganglionic have cell bodies in lateral column of segments S2,3,4 • Ganglia found close to or in wall of organ • Supplies intestine from splenic flexure to upper two thirds of anal canal MOB TCD Pelvic Parasympathetic • Supplies bladder • Rectum • Motor to walls inhibitory to sphincters • Male and female genitalia • Parasympathetic causes erection “BMJ Publishing Group Limited (“BMJ Group”) 2012. All rights reserved.”
