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Uterus, Broad Ligament, Ovary

Professor Emeritus Moira OBrien FRCPI, FFSEM, FFSEM (UK), FTCD Trinity College Dublin

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Uterus
Pear-shaped muscular organ 8 cm long 5 cm wide 3 cm thick Non-pregnant state Pelvic organ

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Uterus

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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

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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

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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

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Cervix
External os Junction of columnar of the cervical canal Stratified epithelium of the intravaginal portion Site of cancer of cervix Cervical smear

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Cervix
At birth cervix is larger than the body Fully developed cervix is one third of body

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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

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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

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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

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Uterus
Serous layer Myometrium No submucous layer Endometrium Three layers Basal Spongy Compact at surface of uterine cavity

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Myometrium
Myometrium makes up bulk of uterine wall Blood vessels more evident in middle layer

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Myometrium

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Uterine Muscle

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Blood Supply
Uterine Ovarian Vaginal arteries Anterior and posterior arcuate run in middle layer

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Blood Supply
Radial branches Basal layer Spiral branches to superficial two layers Veins below artery Plexus in lower edge broad ligament into internal iliac

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Blood Supply

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Nerve Supply of Uterus

Pain from cervix via parasympathetic S2,3 Pain from body via sympathetic to T11 and T12

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Lymphatics

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Supports of Uterus
Upper Round ligament Broad ligament anteverted Middle Transverse ligament Pubocervical Uterosacral Lower Levator ani, coccygeus Perineal body

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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

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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

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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

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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

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Broad Ligament
Mesosalpinx Mesometrium Mesoovarian Epoophoron Parallel tubules Gaertners duct remains mesonephric tubules and duct, may form cysts

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Uterine Artery
Uterine artery lies superior to the ureter at lateral fornix of vagina Base of broad ligament

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Pubocervical Ligament
Attached Anteriorly to posterior aspect of body of body of pubis Passes to neck of bladder Anterior fornix of vagina

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Pubocervical Ligament
Pubocervical ligaments help to maintain normal angle of 45between the vagina and horizontal Decrease may cause a cystocoele

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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

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Uterosacral Ligament
Uterosacral contains fibrous tissue Nonstriated muscle Attached from the cervix to the middle of sacrum Contains lymphatics draining cervix to sacral glands

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Uterosacral Ligament
Uterosacral help to keep uterus anteverted If uterus is anteverted it cannot prolapse

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Uterine Tube
Intramural Isthmus Ampulla Infundibulum Lined ciliated columnar epithelium Beats towards uterus

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Uterine Tube
Peritoneum Loosely attached to ampulla Tightly to isthmus Fimbria surrounding opening into peritoneal cavity Ovarian fimbria

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Embryology of Uterus

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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

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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

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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

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Vagina
Fornices surround cervix Anterior wall shorter posterior Walls in contact except superior External os Opens into vestibule of vagina

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Vagina
Pelvis Lateral uterine artery above ureter Levator ani Deep pouch Sphincter urethrae Bulbs of vestibule Greater vestibular glands

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Vagina
Urethra embedded in lower two thirds of anterior wall Posterior fornix peritoneum of pouch of Douglas Rectum Perineal body

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Vagina
Pelvic fascia Erectile tissue Muscular wall Non-keratinised stratified squamous epithelium

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Blood and Nerve Supply Vagina

Uterine artery Vaginal Internal pudendal Labial Ilio Inguinal nerve supplies the anterior wall Labial nerves supply the posterior wall

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Lymphatics of Vagina
Internal iliac Lower third Medial group of proximal superficial inguinal glands

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Pelvic Sympathetic

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Pelvic Plexuses
Supply pelvic organs Contains Sympathetic Preganglionic parasympathetic nerves Lateral column S2,3,4

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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

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Sympathetic
Ejaculation is via sympathetic impulses from L1-L2 Contraction of sphincters of bladder and anal canal

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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

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Pelvic Parasympathetic
Supplies bladder Rectum Motor to walls inhibitory to sphincters Male and female genitalia Parasympathetic causes erection

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