NORMAL ANATOMY & PHYSIOLOGY

OF

THE FEMALE PELVIS

Presentation by Meg Sullivan & Shannon Wright

CHAPTER 39

ULTRASOUND OF THE FEMALE

PELVIS
Two approaches are used to evaluate the female pelvis
sonographically: transabdominal and transvaginal.
The transabdominal approach :
Requires a full urinary bladder.
Uses a 3.5-5 MHz transducer.
Off ers a wider fi eld of view for general screening.

The transvaginal approach :

Performed with an empty bladder.
Uses a higher frequency transducer, typically 7.5-10 MHz.
Off ers a more detailed study but is limited in its fi eld of view and
depth of penetration.

A complete pelvic examination should consist of a

transabominal scan followed by a transvaginal examination.

External Landmarks
The Bony Pelvis
The Pelvic Cavity and Peritoneum

PELVIC
LANDMARKS

EXTERNAL LANDMARKS
The external genitalia in the female, also known as
the vulva or pudendum, consist of the mons pubis,
labia majora, labia minora, clitoris, urethral opening,
and vestibule of the vagina.
The vagina itself is the part of the female genitalia
that forms a canal from the orifi ce through the
vestibule to the uterine cervix. It is behind the
bladder and in front of the rectum.
These external structures are important to recognize
when using translabial and transvaginal scanning
techniquies.

EXTERNAL LANDMARKS

The mons pubis

is a pad of fatty
tissue and thick
skin that overlies
the symphisis
pubis and is
covered by pubic
hair after puberty.

EXTERNAL LANDMARKS
The labia are
folds of skin at
the opening of the
vagina.
The labia majora
is the thicker
external folds.
The labia menora
is the thin folds of
skin between the
labia majora.

EXTERNAL LANDMARKS

The clitoris is
located anterior
to the urethra
and is usually
partially hidden
between the labia
major.

EXTERNAL LANDMARKS
Posterior to the
clitoris, the
urethral opening
and vestibule of
the vagina can be
normally
identifi ed between
the labia minora.
The most
posterior orifi ce is
the anus.

THE BONY PELVIS

The bony pelvis consists of
four bones: two innominate
(coxal) bones, the sacrum,
and the coccyx.
The Ileopectineal Line is an
imaginary line that dissects
the pelvis, dividing it
obliquely into two
anatomical compartments.
Pelvis Major (False Pelvis)
above pelvic brim; communicates
with the abdominal cavity
Pelvis Minor (True Pelvis) below
pelvic brim; considered to be the
Pelvic Cavity

The Abdominal Wall

Muscles of the False Pelvis
Muscles of the True Pelvis

MUSCLES
OF THE
PELVIS

THE ABDOMINAL WALL

These muscles
extend from the
xiphoid process
to the
symphysis
pubis.
Rectus
abdominis,
external
oblique, internal
oblique,
transversus
abdominis.

MUSCLES OF THE FALSE PELVIS

Include the psoas
major and iliacus
muscles, which form
the pelvic side wall.
The psoas major
muscles join with
the iliacus muscles
to form the
iliopsoas muscles,
which do not enter
the true pelvis.

MUSCLES OF THE TRUE PELVIS

Include the piriformis muscles, obturator internus

muscles, and muscles of the pelvic diaphragm.
The piriformis muscles form the posterolateral wall.
The obturator internus muscles form the anterolateral
pelvic side wall.
The pelvic diaphragm is formed by the levator ani and
coccygeus muscles to make up the pelvic fl oor.

MUSCLES OF THE TRUE PELVIS

The ureters are the two tubes that

carry urine inferiorly from the
kidneys to the urinary bladder.
The urinary bladder is located in the
anterior portion of the pelvic cavity.
The function of the bladder is to
collect and store urine until it
empties through the urethra.

BLADDER
&
URETERS

The vagina is a collapsed muscular tube that

extends upward and backward, from the
external genitalia to the cervix of the uterus.

VAGINA

It lies posterior to the urinary bladder and

urethra, and anterior to the rectum.
It is the passageway for menstruation and is
extended during sexual intercourse and
childbirth.

Normal Anatomy
Endometrium
UTERUS

Uterine Ligaments
Positions

UTERUS

NORMAL ANATOMY
The uterus is a pearshaped organ that consists
of a fundus, body, and
cervix.
Size varies with age and
parity; 6-8 cm in length and
3-5 cm in anteroposterior
and transverse dimensions.
The uterine cavity is a
potential space for fl uid
accumulation, allowing for
dynamic changes during
menstrual cycle and
pregnancy.

UTERUS

NORMAL ANATOMY
At the lateral borders of
the fundus (widest, most
superior portion) are the
cornua, where the fallopian
tubes enter the uterine
cavity.
The body (corpus) lies
between the fundus and the
cervix and is the largest
portion of the uterus.
The cervix is the lower
cylindrical portion that
projects into the vaginal
canal.

UTERUS

NORMAL ANATOMY
The uterine wall
consists of 3
histologic layers:
The serosa or
perimetrium, is the
external layer.
The myometrium is the
muscular middle layer
(thickest).
The endometrium is a
mucous membrane lining
the glandular tissue.

UTERUS

ENDOMETRIUM
The endometrium changes dynamically in
response to the cyclic hormonal fl ux of ovulation.
It varies in sonographic appearance and
histologic structure.
Two primary layers:
Superfi cial functional layer: consisting of glands and
stroma (supporting tissue) that sheds with menses.
Basal layer: the thin layer of the ends of endometrial
glands that regenerates new endometrium after menses.

UTERINE LIGAMENTS

The uterus is
supported in its
midline position
by paired broad
ligaments,
round
ligaments,
uterosacral
ligaments, and
cardinal
ligaments.

UTERINE LIGAMENTS
Bro ad L i g a m en ts a re a
double fold of
p e r i t on e u m t h a t d r a p e
o v e r th e f al l o p i a n
tu b e s , u te r u s , a n d
ovaries.
Ex t e n d f ro m t h e l a te r a l
s i d e s o f t h e u te r u s to
th e s i d e wa l l of th e
pelvis.
C on ta i n u t e r i n e b l oo d
vessels and nerves.
Me s o s a l p i n x : u p p e r
f ol d t h a t e n c l os e s
f al l o p i a n tu b e .
Me s o v a r i u m : p o s te r i or
p o r t i on t h a t e n c l os e s
th e o v ar y.

UTERINE LIGAMENTS
Round ligaments are
fi brous cords that
occur in front of and
below the fallopian
tubes between the
layers of the broad
ligament.
These two cords
commence on each
side of the superior
aspect of the uterus,
course upward and
lateral to the inguina l
canal and insert into
the labia majora.
Helps hold the
uterine fundus and
body in a forward
position.

UTERINE LIGAMENTS
The cervix is the
only portion of
the uterus that is
fi rmly supported.
It is fi xed in
position by the
cardinal
ligaments
(continuation of
broad ligaments)
and the
uterosacral
ligaments.

POSITIONS OF THE UTERUS

Although variable, the average uterus position is
considered to be anteverted and antefl exed.
It is not unusual to see a uterus that has variations of
version and fl exion.
Abnormal dropping of the uterus ( uterine prolapse ) occurs
if the uterine ligaments and pelvic fl oor muscles are weak.
The uterus may also tilt to the right (dextro) or left (levo)
of the midline.
Filling of the bladder will aff ect uterine position; a full
bladder will tip the average anteverted, antefl exed uterus
backward.

POSITIONS OF THE UTERUS

Anteversion
Most common
position
The cervical
canal forms a 90degree or smaller
angle with the
vaginal canal.

POSITIONS OF THE UTERUS

Antefl exion
The body and
fundus of the
uterus are curved
forward upon the
cervix.

POSITIONS OF THE UTERUS

Retrofl exion
The uterine
fundus or body
curves backward
upon the cervix.

POSITIONS OF THE UTERUS

Retroversion
The cervical canal
forms an angle less
than 90-degrees with
the vaginal canal.
In multiparous
females, the entire
uterus may tip
backward rather
than forward.

POSITIONS OF THE UTERUS

Retroversion
with retrofl exion
The entire uterus
is tilted backward
with the fundus
and body folded
posteriorly upon
the cervix.

The fallopian tubes are oviducts that are

coiled, muscular tubes that open into the
peritoneal cavity and their lateral end.
Approximately 10-12 cm in length;
1-4 mm in diameter.
Four anatomic portions:
Infundibulum
Ampulla
Isthmus
Interstitial

Fimbriae: fringe-like extensions which move

over the ovary, directing the ovum into the
fallopian tube after ovulation.

FALLOPIAN
TUBES

FALLOPIAN TUBES

Infundibulum
Wide
trumpetshaped
lateral
portion
Contains
fi mbriae

FALLOPIAN TUBES
Ampulla
Longest and
most coiled
portion of the
fallopian tube
Area in which
fertilization of
the ovum most
often occurs

FALLOPIAN TUBES

Isthmus
Medial
segment of
the fallopian
tube

FALLOPIAN TUBES
Interstitial
Segment that
passes
through the
uterine cornua
Narrowest
segment of
the fallopian
tube

Position & Size

Normal Anatomy
Ovarian Ligaments

OVARIES

OVARIE
S

Position & Size

Almond-shaped structures
Measure approximately 3 cm long
Lie in ovarian fossa, posterior to the
uterus
Dual blood supply:
ovarian artery
uterine artery

The ovarian vein drains blood into IVC

on the right, and into the renal vein on
the left.

OVARIE
S

Normal Anatomy
Outer cortex
Consists of follicles in various developmental stages
Tunica albuginea: dense covering connective tissue of cortex
Germinal epithelium: thin layer of cells surrounding tunica
albuginea

Central medulla
Connective tissue containing blood, nerves, lymphatic vessels,
and some smooth muscle at the region of the hilum

Ovaries produce the reproductive cell, the ovum

Two steroidal hormones:
Estrogen secreted by the follicles
Progesterone secreted by the corpus luteum
Responsible for producing and maintaining secondary gender
characteristics and for preparing the uterus for implantation of a
fertilized ovum and for development of the mammory glands in
the female.

OVARIE
S

Ovarian Ligaments
Supported medially by the ovarian
ligaments.
Originate bilaterally at the cornua of the uterus

Supported laterally by the suspensory

(infundibulopelvic) ligaments.
Extend from infundibulum of the fallopain tube
and ovary to the sidewall of the pelvis

The ovaries are also attached to the

posterior aspect of the broad ligament by
a fold of peritoneum called the
mesovarium.

Aorta
Ovarian
Arteries
Common
Iliac Arteries

External
Iliac Arteries
Common
Femoral
Arteries

PELVIC
VASCULATUR
E

Internal Iliac
Arteries
Uterine
Artery

Arcuate
Arteries
Radial
Arteries
Straight &
Spiral
Arteries

PELVIC VASCULATURE
Vessel

Location

External iliac
arteries

Medial psoas border

External iliac veins

Medial and posterior to arteries

Internal iliac arteries

Posterior to ureters & ovaries

Internal iliac veins

Posterior to arteries

Uterine arteries &

veins

Between layers of broad ligaments, lateral to uterus

Arcuate arteries

Arclike arteries that encircle uterus in outer third of

myometrium

Radial arteries

Branches of arcuate arteries that extend from

myometrium to base of endometrium

Straight & Spiral

arteries

Branches of radial arteries that supply zona basalis of

endometrium

Ovarian arteries

Branch laterally off aorta, run within suspensory

ligaments and anastomose with uterine arteries

PELVIC VASCULATURE

PELVIC VASCULATURE

The Menstrual Cycle

Follicular Development & Ovulation
PHYSIOLOGY

Endometrial Changes
Abnormal Menstrual Cycles

PHYSIOLOGY

THE MENSTRUAL CYCLE

Reproductive years begin with onset and end with cessation of menses

Menses: periodic flow of blood & cellular debris that occurs during menstruation
Average length: ~ 28 days
Regulated by hypothalamus
Dependent on cyclic release of estrogen & progesterone from ovaries

Menstruation: days 1 4 of the menstrual cycle

Menstrual Status
Premenarche pre-puberty; before onset of menses
Menarche post-puberty; menses occurs every 28 days
Menopause - cessation of menses

PHYSIOLOGY

FOLLICULAR DEVELOPMENT &

OVULATION
Development of ovarian follicles monthly release of an ovum (ovulation)

PHYSIOLOGY

FOLLICULAR DEVELOPMENT &

OVULATION
Ovulatory Cycle: cyclic release of estrogen & progesterone from ovaries
Lasts ~28 days
Determines course of menstrual cycle
Occurs in 2 phases Follicular and Luteal

PHYSIOLOGY

FOLLICULAR DEVELOPMENT &

OVULATION
Follicular Phase
Days 1-14 first day of menstruation through ovulation
FSH stimulates follicular development
Follicles secrete increasing amounts
of estrogen as they grow
One follicle, the graafian follicle,
reaches maturity
High estrogen levels trigger pituitary
LH secretion
LH triggers ovulation on about day
14
Graafian follicle ruptures, releasing
an ovum

PHYSIOLOGY

FOLLICULAR DEVELOPMENT &

OVULATION
Luteal Phase
Days 15-28 corresponds to secretory phase of menstrual cycle
Ruptured follicle cells form corpus
luteum (luteinization)
Corpus luteum secretes progesterone
Progesterone stimulates endometrial
growth
Corpus luteum degenerates (9-11
days after ovulation)
Progesterone declines
Menstruation occurs; cycle begins
again

PHYSIOLOGY

ENDOMETRIAL CHANGES

Varying levels of EE & P endometrial

change
Endometrial Cycle: characteristic
changes in endometrium
Changes occur during menstrual
cycle
Determined by hormonal changes
during ovulatory cycle

PHYSIOLOGY

ENDOMETRIAL CHANGES
3 phases of endometrial
cycle:
Menstrual
Proliferative
Secretory

PHYSIOLOGY

ENDOMETRIAL CHANGES
Menstruation
Days 1-4
Declining P spiral arteriole constriction
Decreased blood to endometrium ischemia & shedding of zona
functionalis

PHYSIOLOGY

ENDOMETRIAL CHANGES
Proliferative Phase
Days 5-14 corresponds to follicular phase of ovarian cycle
Thin endometrium
Ovarian follicles develop; estrogen increases
Uterine lining regenerates & thickens
Ovulation on day 14

PHYSIOLOGY

ENDOMETRIAL CHANGES
Secretory Phase
Days 15-28 corresponds to luteal phase of ovarian cycle
Ruptured follicle becomes corpus luteum
Corpus luteum secretes progesterone
Endometrium thickens
If no pregnancy, estrogen and progesterone decrease
Menses on day 28

PHYSIOLOGY

ENDOMETRIAL CHANGES
Phase

Sonographic Appearance of Endometrium

Menstrual

Varying levels of fluid & debris

Thickness decreases

Proliferative

Early: thin echogenic line

Mid-Phase: thickens to 4-8 mm; hypoechoic with three
line sign
Before ovulation: 6-10 mm; becomes isoechoic with
myometrium

Secretory

7-10 mm (thickest dimension)

Echogenic; three line appearance blurred

PHYSIOLOGY

ABNORMAL MENSTRUAL CYCLES

Menorrhagia: Abnormally heavy or long periods
Oligomenorrhea: Menstrual cycles prolonged >35 days
Polymenorrhea: Menstrual cycles with interval <21 days
Dysmenorrhea: Painful periods
Amenorrhea: Absence of menstruation

Recess

Alt Name

Location

Vesicouterine
Pouch

Anterior
cul-de-sac

anterior to
fundus between
uterus and
bladder

Rectouterine
Pouch

Posterior
cul-de-sac

posterior to
uterine body
and cervix,
between uterus
and rectum

Retropubic
Space

Space of
Retzius

between
bladder and
symphysis
pubis

PELVIC
RECESSES
&
BOWEL