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Home , Perimetrium, Uterosacral ligament

Gross Anatomy & Histology of Female Reproductive System - 2 &

Dr. Sangeeta S Kotrannavar Assistant Professor, Dept. of Anatomy USM-KLE, IMP, Belagavi Learning Objectives

• Explain the parts, location, relations, positions, supports, blood supply, lymphatic drainage and histological features of the uterus

• Describe the peritoneal relations, fornices, lymphatic drainage, innervation and histological features of the vagina

• Describe the applied anatomy of female reproductive system

Female Reproductive System • Internal genital organs • • Uterine tubes • Uterus • Vagina

• External genital organs • Receives Functions • Retains of uterus • Nourishes product of conception till maturity Uterus

• It is a thick walled hollow muscular organ • Site - In the lesser pelvis, between (lies infront) and (behind). • Communicates with the uterine tubes at its upper end, and below with the vagina

Size & shape

• Size • Length--7.5cm. • Breadth--5cm. • Thickness– 2.5 cm. • Body: = 2:1 in adults • Body:cervix = 1:2 in children • Weight - about 30-40gm • Shape - Pyriform • The uterus is flattened from before backwards

Normal Position & angulation Normal position – anteverted & anteflexed • Anteversion: is a forward angle between axis of cervix & that of vagina making an angle of 90 degree at external os of cervix

• Anteflexion: is a forward angle between the body of the uterus & cervix at isthmus making an angle of 125 degree at internal os of cervix. Parts of uterus

1. Fundus 2. Body 3. Cervix 1. Fundus

• The part of the body lies above the entrance of the uterine tube is known as the fundus. • It is convex like a dome. • Fundus does not contain cavity 2. Body

• Extends from fundus to internal os • Contains • Body has following features • Ant. / vesical surface • Post. / intestinal surface • Lateral border • Lateral angle or cornua • Uterine cavity 2. Body – relations

• Ant. / vesical surface • The bladder • Flat & covered with upto isthmus • Forms vesico-uterine pouch. • Post. / intestinal surface • convex & covered with peritoneum. • Related to the sigmoid colon & coils of small intestine • Forms recto-uterine pouch or pouch of Douglas.

2. Body – relations

• Lateral border

• Convex, non peritoneal. • Related to uterine vessels. • Provides attachment to the broad (fold of peritoneum stretches from the margins of the uterus to the lateral wall of the pelvis).

2. Body – relations

• Lateral angle or cornua • Angle made by junction of fundus & body • 3 structures attached to the cornua 1. The uterine tube 2. The round ligament of the uterus (antero-inferior) 3. The ligament of the ovary (postero-inferiorly) 2. Body - Uterine cavity

• Triangular on coronal section • Vertical slit on sagittal section • Base is formed by fundus & apex by internal os that continues with

3. Cervix • It is more fixed & lower cylindrical part, lies below the isthmus • Cervix projects into vagina so divides into 1. Supra-vaginal part above 2. Vaginal part below

• Isthmus (corresponds with internal os)

• An area 4-5 mm in length that lies between anatomical internal os above, & histological internal os below that is lined by low columnar epithelium & few glands. • The isthmus expands during pregnancy forming the lower uterine segment (10 cm) during the last trimester. 3. Cervix – Supra-vaginal part

Relations • Anteriorly: • Non peritoneal & related to posterior surface or base of urinary bladder. • Posteriorly: • The pouch of Douglas with coils of ileum, sigmoid colon & peritoneal

Applied- Recto-uterine (Douglas) pouch.

• This pouch separate it from the rectum. It is most dependent part. • Collection of pus or blood is drained by incision from posterior fornix.

3. Cervix – Supra-vaginal part

Relations • Laterally: • ureter is crossed by the uterine artery (i.e. ureter below the uterine artery). • The uterosacral, cardinal, and pubocervical are attached to its posterior, lateral, and anterior surfaces respectively. 3. Cervix – vaginal part

• Anteriorly: Cervix projects into • Anterior fornix of vagina. vagina & space • Posteriorly: between it & • Posterior fornix. vaginal wall are • Laterally: called vaginal • Lateral fornix of vagina. fornices 3. Cervix – cervical canal • Shape--fusiform • It communicates • above with uterine cavity at internal os • below with the vagina at the external os. • Mucosal membrane of the cervical canal is thrown into folds which resembles branches of a tree known as arbor vitae uteri

3. Cervix – cervical canal

Coronal section TS Supports of uterus • Uterus is supported & prevented from prolapse by number of factors which are chiefly • Muscular supports 1. Pelvic diaphragm 2. Perineal body 3. Urethral sphincter mechanism • Fibromuscular or mechanial supports 1. Uterine axis 2. Round ligament 3. Utero-sacral ligament True ligaments 4. Transverse cervical ligament 5. Pubo-cervical ligament

23 Fibromuscular supports 1. Uterine axis

In retroversion the fundus and body of the uterus are bent backward on the vagina leads to prolapse Fibromuscular support

2. Round ligament • A fibromuscular ligament extends from lateral angle of uterus and runs in inguinal canal attaches to labium majus. (remnant of Gubernaculum of ovary). • It pulls the uterus forwards and maintains anteversion position 3. • from cervix to sacral vertebra (S2,S3). • Keep cervix braced backwards against forward pull of round ligament

These two ligaments maintains the uterine axis Fibromuscular support

4. Transverse cervical/ cardianl/Mackenrodt’s ligament • Extends from lateral side of cervix to lateral pelvic wall • Prevents downward displacement of cervix & keeps cervix in median position. 5. Pubocervical ligament • Extends from cervix to pubic bone. Counteracts traction of uterosacral ligament

Muscular supports

1. Pelvic diaphragm • Levator ani & coccygeus forms pelvic diaphragm that fix the perineal body, supports pelvic viscera & resists intra- abdominal pressure Pelvic diaphragm

Prevents any prolapse through 2.Perineal body • Fibromuscular node, to which muscles are attached. • Lies 1.25cm infront of anal margin & anchor for pelvic diaphragm & maintains integrity of pelvic floor 3.Muscles of urogenital diaphragm • Formed by sphincter urethrae along with deep transverse perineal muscles

Peritoneal ligaments

These are mere PERITONEAL FOLDS which do not provide any SUPPORT TO UTERUS Allow the movements & give passage to vessels & ligments Also called as False ligaments • Broad ligament • Uterovesical fold or anterior ligament • Rectovaginal fold or posterior ligament

The broad ligament A double sheet of peritoneum that extends from the lateral border of the uterus to the lateral pelvic wall. Parts; • – connects ovary to post. surface

Contents of the Broad Ligament Clinical aspect - uterus

• Prolapse of uterus • Hysteroscopy • Fibroids • Caesarean section: surgical procedure for delivering the baby by cutting open the and uterus in cases where vaginal delivery is not possible. • IUCD •

VAGINA • Organ of copulation/lower part of birth canal • A fibromuscular tube from to cervix extending upward & backwards. • Length: • anterior wall is 7-8cm • posterior wall is 9-10cm

• Vaginal Fornices: • The cervix projects in the upper blind end of the vagina that forms a pouch (vaginal pouch) around the cervix and is divided into four fornices : two lateral, anterior and posterior (deeper) fornices. Relations of the Vagina

Hymen is mucous fold situated close to external orifice of vagina in virgin Blood Supply of uterus & vagina Arterial Supply of uterus & vagina Uterus • Chiefly by uterine arteries; branch of anterior division of internal iliac artery. • Uterine aretry at base of the broad ligament, crossing above the ureter 1/2 an inch lateral to the supravaginal cervix. • tortuous & parallel to lateral border of the uterus • end by anastomosing with branches of the ovarian arteries • Partly by ovarian A. • Gives branches to : Vagina, medial 2/3rd of tube, ovary, ureter Vagina • The vaginal artery (from internal iliac artery) • Additional branches from: • vaginal branches from uterine artery. • Middle rectal artery • Internal pudendal artery

Venous drainage of uterus & vagina Uterus • Vein forms a plexus along lateral border of uterus • Drains into the uterine, ovarian and vaginal veins into internal iliac vein.

Vagina • A plexus around the vagina (the vaginal plexus), drain into the internal iliac vein by veins that accompany their corresponding arteries.

Nerve supply of uterus & vagina • Sympathetic • from spinal nerves T12 ,L1 for uterus & L1-2 for vagina inferior hypogastric plexus uterovaginal plexuseuterus & vagina • causes uterine contraction & vasoconstriction • Parasympathetic • from S2,3,4 • causes inhibition & vasodilatation • Nerve supply of the vagina: • Upper 2/3 is insensitive to pain, touch & temperature but sensitive to stretch. • Lower 1/3 is sensitive to touch. Pudendal nerve gives sensory fibres to the lower vagina. Lymphatic drainage of uterus & vagina • is clinically important because uterine cancer spreads through lymphatics

Most common cancer in the female Cervical cancer Applied Anatomy

• Vaginal Prolapse: Weakness of the vaginal supports (ligaments, and muscles) may lead to: • Prolapse of anterior vaginal wall drags bladder () & (urethrocele), • posterior vaginal wall (rectocele), Vaginal examination

• Inspection ; speculum examination

• Palpation • by per vagina (PV) • Bimanual examination • Helps in assessment of size, position & pathologies

• Vaginitis Recall

F Fundus contains cavity. Whole anterior surface of uterus is covered by F peritoneum. F Board ligament plays important role in support. F Uterine artery is branch abdominal aorta Anteversion is angle between body of uterus and F vagina F Pelvic diaphragm doesnot support uterus

Histology of Uterus

Uterine wall consists of

• : inner mucosal lining

• : middle muscular layer

• : outer

Low magnification of the entire uterus

Endometrium

Myometrium Endometrium

• Endometrium • Simple columnar (partially ciliated)

• Stroma / lamina propria • Uterine glands: simple tubular • Stromal cells • Blood vessels • Ground substance

Myometrium

Arranged in 3 ill defined muscle layer (101) Myometrium •Outer longitudinal – help in anchorage of uterus & expel uterine content to exterior.

• Middle circular layer - is thickest, contains blood vessels called stratum vasculare. Forms sphincter close to internal os to retain product of conception

• Inner longitudinal - contains reticular fibers along with blood vessels. The contraction of these muscle fibers results in stoppage of uterine bleeding during menstruation and separation of placenta  it acts as “living ligature of the uterus”. Myometrium • Myometrium undergo changes in pregnancy

• Hypertrophy - enlargement of muscle fibers

• Hyperplasia – formation of new muscle cells

• Menstrual cycle • Uterus - Has 3 Phase • Proliferative - concurrent with follicular maturation of ovarian cycle and influenced by estrogens • Secretary - concurrent with luteal phase of ovarian cycle and influenced by progesterone • Menstrual • Endometrium - Has 2 main layers / strata • Stratum Functionale (Superficial layer) • Stratum Basale (Deep layer)

• ONLY Stratum Functionalis undergoes cyclic changes  Uterine cycle Uterine cycle changes • In the proliferative stage the glands are straight tubules, and their cells show no secretory activity. • In the initial secretory phase the glands begin to coil, and their cells accumulate glycogen in the basal region. • In the late secretory phase the glands are highly coiled, and their cells present secretory activity at their apical portion. Blood Supply to the Uterus internal iliac A

uterine artery

several arcuate arteries w/i the myometrium.

radial branches

straight arteries to the stratum basalis

spiral arteries to the stratum functionalis Endometrium; Blood supply

Coiled / spiral arteries: • extend into the functional zone (stratum functionalis) (superficial layer) F • cyclic changes

Straight arteries: B -- terminate in basal zone (stratum basalis) • no cyclic changes

Note: Uterine glands, Uterine arteries

Proliferative phase

• 5th -14th day of menstrual cycle • Cells in basal layer begin to proliferate to regenerate functional layer.

• Lined by simple columnar epithelium. • Thin endometrium 2-3mm

• Simple, Straight tubular uterine glands.- no synthesis of glycogen

• Stroma - cellular • Few spiral arteries in basal layer

UTERUS PROLIFERATIVE LP PHASE Simple straight tubular uterine glands simple columnar lining LS of uterine gland

TS of uterine gland

lumen Secretary phase • 14th -28th day of cycle • Thick endometrium 4-6mm • Lined by hypertrophied columnar epithelium

• Uterine glands become coiled with dilated lumen with secretion

• Numerous Spiral arteries reach upper part & are more coiled.

• Stroma contains large quantities of secretory product glycogen.

UTERUS

SECRETORY PHASE functional layer thickens COILED UTERINE GLANDS coiled gland Sloughed Menstrual phase gland • 1st -5th day of cycle • It begins with vaginal discharge ; contains blood, uterine fluid & necrotic tissue of functionalis

• Occurs when fertilization does not take place & Functionalis atrophies, causing the levels of estrogen & progesterone to fall Basalis • Causes rupture of coiled arteries, ischemia, necrosis of functionalis then shedding of endometrium Cervix • Simple columnar changes to Stratified squamous nonkeratinized epithelium (SSE) at vaginal part of cervix

• Branched tubular cervical glands in lamina propria

Cervix Vagina

• Adventitia • Muscular layer • Inner circular • Outer longitudinal

• Mucosa • Stratified squamous nonkeratinized epi. • Lamina propria • No glands • its surface is lubricated mainly by mucus produced by the cervical glands Vagina - Epi

 Epithelium(E) : Is stratified squamous nonkeratinized (or parakeratinized), cells release large amounts of glycogen which is anaerobically metabolized to lactic acid by the resident vaginal flora. This creates an acidic environment that inhibits growth of pathogenic microorganisms.  Lamina propria(LP) : rich in elastic fibers , has no glands. Pap smears Is a valuable diagnostic tool in evaluating the pathology of vaginal and cervical mucosae

Papanicolaou stain

A B

A - Negative cervical smear. The surface squamous cells reveal small pyknotic nuclei and abundant cytoplasm B- Abnormal smear. Many of the cells in this specimen contain large nuclei with no evidence of pyknosis (arrows). The cytoplasm is relatively scant OSPE ; Identify the different phases

secretory phase SEQ –Describe structural differences in the endometrium of proliferative phase and secretory phase