Dr.gamal presentation

Dr. Gamal Said 1
Anatomy of the
Female Genital System
Clinical Pelvic Anatomy
in Cadavers
Dr. Gamal Said
Workshop

Dr. Gamal Said 2
Viscera of ♀
genital system
Ovary
Fallopian
tubes
Uterus
Vagina

Dr. Gamal Said 3
The ovary
It is the primary sex organ. It is grayish pink in color with
smooth surface before puberty, but as age advances it
becomes whitish and rough surfaced.
! Site: lies on the side wall of the pelvis within the
“ovarian fossa” which is bounded by:
–  Anteriorly: obliterated umbilical artery.
–  Posteriorly: internal iliac vessels & ureter.
! Dimensions:
–  Length è 3 cm
–  Breadth è 2 cm
–  Thickness è 1 cm
! Shape: it is almond-shaped having
–  2 ends
–  2 borders
–  2 surfaces
N.B.
The ovary is attached
to superior surface
of the broad ligament
in close relation to
the lateral end of the
Fallopian tube.

Dr. Gamal Said 6
! 2 ends:
–  Upper (tubal) end: is directed up & laterally & attached to:
! Ovarian fimbria of the Falopian tube.
! Suspensory (infundibulo-pelvic) ligament of the ovary, which is a
peritoneal fold that forms the upper lateral part of the broad ligament.
It transmits the ovarian vessels & nerves from the side wall of the
pelvis to the broad ligament.
–  Lower (uterine) end: is directed down & medially. It is
attached to the upper lateral angle of the uterus by the
ligament of the ovary.
! 2 surfaces:
–  Lateral surface: related to the parietal peritoneum of the
lateral pelvic wall & obturator nerve and vessels (in the floor
of the fossa).
–  Medial surface: related to fimbriated end of Fallopian tube.
! 2 borders:
–  Posterior border: free.
–  Anterior border: attached to the upper lateral part of broad
ligament by mesovarium (which transmits the ovarian nerves
& vessels to the hilum of the ovary).

Dr. Gamal Said 7
! Peritoneal covering:
–  It is completely covered by peritoneum which adheres to the
ovary forming its covering epithelium.
–  Therefore, the peritoneal covering is perforated by the ovum
during ovulation.

Dr. Gamal Said 8
Ligaments of the ovary: è 3 ligaments
! Suspensory ligament of the ovary:
–  It extends laterally from the tubal end of the ovary to the side
wall of the pelvis at the external iliac vessels.
–  It is a peritoneal fold which transmits the ovarian vessels,
nerves & lymphatics to the broad ligament.
! Mesovarium:
–  It is peritoneal fold that extends from the upper layer of
broad ligament to the anterior border of the ovary.
–  It transmits the ovarian vessels & nerves to the ovary.
! Ligament of the ovary:
–  It is a fibromuscular cord that extends from the uterine end of
the ovary to the lateral angle of the uterus.

Dr. Gamal Said 9
Arterial
supply
Ø  By the ovarian artery è descends on psoas
major, ureter, external iliac vessels to enter the
suspensory ligament of the ovary è then to the
mesovarium è then to the ovary.
! It also supplies the lateral part of the Fallopian
tube where it anastomoses with the uterine artery.
Venous
drainage
! Rt. ovarian vein: drains into IVC.
! Lt. ovarian vein: drains into left renal vein.
lymph
drainage
To para-aortic L.Ns.
Nerve
supply
Ø  Parasympathetic: From pelvic splanchnic nerves
(S 2, 3, 4).
Ø  Sympathetic: from T 10, 11.

Dr. Gamal Said 10
The uterine (Fallopian) tube
! Site: in the medial 4/5 of the upper free border of the broad
ligament, extending from the superior angle of the uterus to the
ovary on the side wall of the pelvis.
! Length: 10 cm.
Posterior view

Dr. Gamal Said 11
! Parts: (from medial to lateral)
–  Intramural (uterine) part:
! It is the shortest (1 cm) and narrowest part.
! It passes through the wall of the superoateral angle of the uterus
to open into the uterine cavity.
–  Isthmus:
! It is 2 cm in length, rounded, narrow and thick-walled.
–  Ampulla:
! It is the longest (5 cm), thin-walled, tortuous and widest part.
! It is the site of fertilization.
–  Infundibulum (fimbriated end):
! It is 2 cm in length and funnel-shaped.
! It pierces the broad ligament to open into the peritoneal cavity
near the ovary.
! Its margins carry fimbria which spread over the medial surface
of the ovary.
! The largest fimbria is called the ovarian fimbria which is
attached to the upper end of the ovary.

Dr. Gamal Said 12
! Course and relations
–  Each tube runs upwards laterally & backwards from the uterus to
the side wall of the pelvis.
–  Then, it curves backwards piercing the upper layer of the broad
ligament to end on the medial surface of the ovary by the
infundibulum.
–  Along its whole course, it is related to coils of ileum & sigmoid
colon.
! Blood supply:
–  Medial 2/3: by the uterine artery.
–  Lateral 1/3 : by the ovarian artery.
! Venous drainage:
–  By veins accompanying the arteries into the uterine and ovarian
veins.
! Lymph drainage:
–  Most of the tubal lymphatics pass to the paraaortic L.Ns.
–  Lymphatics of the isthmus pass to the superficial inguinal L.Ns.

Dr. Gamal Said 13
The uterus
! Shape: pear-shaped hollow thick-walled muscular organ.
! Site: between the rectum & U.B.
! Dimensions:
–  Length: 3 inches (cervix = 1 inch & body and fundus = 2
inches)
–  Width: 2 inches
–  Thickness: 1 inch
! Parts:
–  Fundus
! It is dome-shaped part that lies above the level of the opening of
the Fallopian tubes.
! It is completely covered by peritoneum.
! It is related to coils of small intestine & sigmoid colon.

Dr. Gamal Said 15
! Body: is the part extending from level of opening of the
Fallopian tubes to the constriction called “ isthmus”. It has:
–  Anterior (vesical) surface:
! It is related to the upper surface of U.B.
! It is covered by peritoneum, which is reflected at the isthmus on
the upper surface of U.B. forming the utero-vesical pouch.
–  Posterior (intestinal) surface:
! It is related to coils of small intestine & sigmoid colon.
! It is covered by peritoneum, which extends to the back of the
cervix & upper part of the vagina; then reflected backwards
forming the rectovaginal pouch.
–  Lateral margin:
! It gives attachment to the broad ligament.
! The uterine artery ascends along it.
! It is penetrated above by the Fallopian tube.
! Its upper part gives attachment to:
–  Round ligament of uterus in front of the fallopian tube.
–  Ligament of ovary behind the Fallopian tube.

Dr. Gamal Said 16
! Isthmus:
! Slight constriction between the body and the cervix.
! Opposite its anterior aspect, the peritoneum is reflected to
the U.B. to form the utero-vesical pouch.
! It is covered by peritoneum from the back.
! Cervix: it has supra-vaginal & vaginal parts
–  Supra-vaginal part:
! Anteriorly: it is not covered by peritoneum and related to
the U.B.
! Posteriorly: it is covered by peritoneum of Douglas pouch
which separates it from the rectum.
! Laterally: it gives attachment to the broad ligament and is
related to the ureter and uterine vessels just below the
root of the broad ligament.
–  Vaginal part: is surrounded by the vaginal fornices.

Dr. Gamal Said 18
Peritoneal covering of the uterus

Dr. Gamal Said 19
Supporting factors of uterus
! Position:
–  Normally, the uterus is anteverted anteflexed
! anteverted: the whole uterus makes a right angle with the
longitudinal axis of the vagina.
! anteflexed: the longitudinal axis of the body makes an angle = 170
with the longitudinal axis of cervix.

Dr. Gamal Said 20
N.B.:
Abnormal position of uterus = retroverted , retroflexed uterus

Dr. Gamal Said 21
! Muscles:
–  Pelvic diaphragm è supports the pelvic organs by resisting
their downward push during increased intra-abdominal
pressure.
–  Urogenital diaphragm è the muscles of the deep perineal
pouch.
–  Perineal body è is a fibromuscular body between the
vagina & anal canal; receiving the insertions of all perineal
muscles. Thus, maintains the integrity of the pelvic floor.

Dr. Gamal Said 22
! Ligaments of uterus:
Round ligament
of uterus
Ligament of ovary
Broad ligament
Pubocervical
ligament
Uterosacral
ligament
Transverse
cervical ligament
3 ligaments of body
3 ligaments of cervix

Dr. Gamal Said 23
Ligaments of the body of uterus:
1.  Round ligament of uterus:
–  It is attached to the upper part of lateral margin of body of
uterus (in front of uterine tube).
–  It passes down and laterally between the 2 layers of the
broad ligament to reach the side wall of the pelvis where it
crosses over:
! Obturator nerve & vessels.
! Obliterated umbilical artery. Same as vas deferens in male
! External iliac artery & vein.
–  It enters through the inguinal canal where it emerges from
the superficial inguinal ring to attach to labia majora.
2.  Ligament of ovary:
–  It is attached between the upper part of lateral margin of
body of uterus (behind uterine tube) and uterine end of the
ovary.
“Both these 2 ligaments represents the remnant of the gubernaculum”

Dr. Gamal Said 25
3.  Broad ligament:
–  It is a double-layered fold of peritoneum which extends
from the side of the uterus to the side wall of pelvis.
–  It has:
! 2 layers:
–  upper (posterior) layer:
! is related to the coils of small intestine
! is connected to the ovary by mesovarium
! is pierced by the lateral end of Fallopian tube
–  lower (anterior layer)
–  4 borders:
–  upper free border:
! its medial 4/5 surrounds Fallopian tube
! its lateral 1/5 forms the suspensory ligament of the ovary
–  lower border: rests on the pelvic floor
–  medial border: attached to the side of the uterus
–  lateral border: attached to the side wall of the pelvis

Dr. Gamal Said 27
! Parts of the broad ligament:
–  Mesosalpinx: the part between Fallopian tube &
mesovarium & and round ligament of ovary.
–  Suspensory ligament of ovary: the part lateral to the ovary.
–  Mesometrium: the remaining medial lower part on the side
of the uterus.
! Contents of the broad ligament:
–  2 tubes:
! Fallopian tube: in the medial 4/5 of the upper free border.
! Ureter: in the root of broad ligament, 2 cm lateral to the cervix.
–  2 ligaments: round ligament of ovary & round lig. of uterus.
–  2 arteries:
! Uterine A. (in the root then along the medial border then along the
upper border).
! Ovarian A. (in the suspensory ligament of ovary).
–  2 sympathetic nerve plexus: uterovaginal & ovarian nerve plexus.
–  2 embryological remnants: epioophoron & paraoophoron.
–  Connective tissue (parametrium) & lymphatics & L.Ns.

Dr. Gamal Said 28
Parts of broad ligament

Dr. Gamal Said 29
Contents of broad ligament

Dr. Gamal Said 30
Ligaments of the cervix:
1.  Transverse cervical (Mackenrodt’s ) ligament:
! It is the main supporting factor of the uterus.
! It a fan-shaped ligament, which is formed of condensed
extraperitoneal tissue between the side wall of the
pelvis and side of cervix & vagina.
2.  Pubo-cervical ligament:
l  It is a condensation of extraperitoneal tissue, which
extends from the front of cervix & upper part of vagina
to the back of the pubis, around the sides of the urethra.
3.  Utero-sacral ligament:
l  It is a condensation of extraperitoneal tissue, which
extends from the back of the cervix to the front of 2nd &
3rd pieces of sacrum, around the sides of the rectum.

Dr. Gamal Said 31
Ligaments of
the cervix

Dr. Gamal Said 32
! Uterine cavity:
– The cavity of the body appears triangular
(the upper angles are the openings of the
uterine tubes & the lower angle is the
opening of the internal os.
– The cervix contains fusiform cervical canal:
! Its upper end is called internal os.
! Its lower end is called external os.
The external os is
rounded in nulliparous,
slit-like in multiparous.

Dr. Gamal Said 34
Arterial
supply
by the uterine artery:
! It is a branch of the anterior division of internal iliac artery.
! It passes medially on the floor of the pelvis in the root of the broad
ligament crossing the ureter, about 2 cm lateral to the cervix.
! It ascends along the side of the uterus in a tortuous course
between the 2 layers of the broad ligament.
! It turns laterally below the Fallopian tube to end by anastomosis
with ovarian artery.
! It supplies: uterus + medial ¾ of Fallopian tube + vagina.
Venous
drainage
! The veins draining uterus form 2 venous plexuses along its lateral
borders.
! Each venous plexus is drained by a pair of uterine veins which
ends into internal iliac vein.
Lymphatic
drainage
q  Fundus + upper part of the body + uterine tube è para-aortic L.Ns
q  Lower part of the body è external iliac L.Ns.
q  Cornu of the uterus è its lymphatics pass along the round
ligament of uterus into the superficial inguinal L.Ns.
q  Cervix è internal iliac & external iliac & sacral L.Ns.
Nerve
supply
q Sympathetic è from T12 & L1 (produce uterine contraction &
vasoconstriction).
q  Parasympathetic è from S2, 3, 4. (produce uterine relaxation &
vasodilatation).

Dr. Gamal Said 35
Arterial supply of the uterus

Dr. Gamal Said 36Lymphatic drainage of the uterus

Dr. Gamal Said 37
The vagina
! It is fibro-muscular tube between the cervix and vestibule (the
cleft between the 2 labia minora).
! It is directed up & backwards forming a right angle with the
uterus.

Dr. Gamal Said 38
! Relations:
–  Anterior wall: (7 cm)
! Not covered by peritoneum
! Its upper 1/3 è is pierced by the cervix.
! Its middle 1/3 è is related to the base of U.B.
! Its lower 1/3 è is intimately related to the urethra.
–  Posterior wall: (9 cm)
! Its upper1/4 is covered by peritoneum which is reflected
to the rectum to form the recto-vaginal (Douglas pouch)
which contains coils of ileum
! Its middle 2/4 related to rectum.
! Its lower 1/4 is related to perineal body and anal canal.

Dr. Gamal Said 41
–  Lateral relations (from above downwards):
! Upper part è uterine artery & ureter.
! Middle part è levator ani (sphincter vaginae).
! Lower part è greater vestibular gland (in the perineum).

Dr. Gamal Said 42
! Fornices of vagina:
–  These are 4 pouches formed by the upper part of vagina
around the vaginal part of cervix
–  (2 lateral, 1 anterior & 1 posterior)
–  The posterior fornix is the deepest one & the only one
covered by peritoneum

Dr. Gamal Said 43
Arterial
supply
It is supplied by:
– Uterine artery.
– Vaginal artery.
– Middle rectal artery.
– Internal pudendal artery.
These arteries Anastomose in front & behind the
vagina to form anterior & posterior “azygos arteries”.
Venous
drainage
The vaginal veins form plexuses that drains into
internal iliac vein.
Lymphatic
drainage
! Upper 1/3 è external iliac L.Ns.
! Middle 1/3 è internal iliac L.Ns.
! Lower 1/3 è superficial inguinal L.Ns.
Nerve
supply
! Upper 2/3 (pain insensitive) è by autonomic fibers
– Sympathetic: L1, 2
– Parasympathetic: S 2, 3

Dr. Gamal Said 44
Arterial supply
Venous drainage
Lymphatic drainage

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