FEMALE REPRODUCTIVE ORGANS

Origin of the Ovary:

The uterus and ovary have a diverse origin. They arise from two different places developmentally.

When the distal ends of the paramesonephric duct contact the urogenital sinus, they fuse and pull the rest of the paramesonephric duct away from the posterior

wall, forming the broad ligament of the uterus.

OVARIES:

It is located more on the posterior aspect of the peritoneum -- posterolateral to the uterus and to the broad ligament.

Ovulation: The ovum is actually released into the peritoneal cavity and then picked up by the ovarian tubes.

Ovarian Fossa: The location of the ovaries. A depression in the lateral wall of the pelvis.

NERVE / BLOOD SUPPLY TO OVARIES -- Once again, they come from back around L2 and L2.

Left ovarian vein drains into the left renal. The right ovarian vein drains into the IVC.

Left and Right ovarian arteries drain into the abdominal aorta directly.

Lymph for the ovaries, therefore, is through the lumbar aortic nodes.

Parasympathetic supply comes from the Vagus nerve rather than the pelvic splanchnic, because of the embryonic origin of the ovaries.

Sympathetics are from T10, the Lesser Thoracic Splanchnics, via the hypogastric plexus ------> ovarian plexus.

UTERINE TUBES:

Structures:

Fimbriae: The finger-like projections going into the peritoneum, which surround each ovary to aid in the deposition of the ovum.

Infundibulum: The neck of the uterine tube, where it turns, nearest the ovary. Funnel-shaped opening.

It has a heavily ciliated lining which produces a current which sweeps the ovum in a distal-proximal direction, toward the uterus.

Ampulla: The main part of the tube, where fertilization normally takes place.

Isthmus: The stretch of tube nearest the proper ovarian ligament, close to the uterine junction.

Intramural: The part of the uterine tube within the myometrium of the uterus.

CLINICAL:

Ectopic Pregnancy more common occurs in the uterine tube than in the peritoneum. It is dangerous because the normal cause of pregnancy causes

tissues to be digested as the embryo implants in the peritoneal wall somewhere. A tubal pregnancy will eventually cause the tubes to erupt.

Hysterosalpingogram: An X-Ray given into the endopelvic space to determine whether or not there is an opening in the fallopian tubes.

Peritonitis / Salpingitis: Infection in the peritoneum can spread to the fallopian tubes, and infection in the fallopian tubes can spread to the peritoneum.

When the fallopian tubes are infected (Salpingitis), a tubal pregnancy can easily results due to adhesions in the tube.

BLOOD SUPPLY:

It has a dual blood supply from the ovarian artery and uterine artery. The ovarian and uterine arteries anastomose with each other at the fallopian

tubes.

Veins, nerves, and lymphatics are associated with those of the ovaries.

UTERUS:

Relations -- Anteriorly related to the bladder and posteriorly related to the rectum. When the bladder is filled, the uterus is more posteriorly located.

STRUCTURES

Fundus: The top portion of the uterus, above the level of the uterine tubes.

Body: Main part, with thick wall.

Isthmic Portion: The lower one third, which leads down into the cervical canal.

Myometrium: Muscular wall of the uterus.

Perimetrium: Outer lining of uterine wall.

Endometrium: Inner lining of uterine wall.

POSITIONS

Anteflexed: Bent anteriorly with respect to the isthmus of the uterus. The cervix may be pointing posteriorly.

Anteverted: Bent anteriorly at the level of the cervix. The cervix and isthmus point anteriorly.

Retroflexed: Bent posteriorly with respect to the isthmus.

Ligaments and Peritoneum:

Suspensory Ligament of the Ovary: Connects the ovary to lateral wall. It covers the external iliacs.

It brings the vessels, nerves, and lymph supply to the ovaries.

It is not a true ligament, but rather a condensation of endopelvic fascia.

Proper Ovarian Ligament: Remnant of the gubernaculum. The ligament that connects the ovary to the uterus, running inferior to the uterine tubes.

Round Ligament: Remnant of the gubernaculum. It runs from the fundus of the uterus, inferolaterally to the labia major, joining up with the inguinal ligament

about halfway through its course.

Carries with it a vascular supply -- the phrenicular branch of the ovarian artery or Samson's Artery.

Broad Ligament: The sweeping peritoneum that overlies the ovaries and the uterus anteriorly.

Mesovarium: That portion of broad ligament that suspends the ovaries in place. It comes out from the broad ligament, wraps around the ovaries, and goes

back to the broad ligament on the posterior wall.

Mesometrium: That portion of broad ligament that is associated with the uterus directly.

Mesosalpinx: That portion of broad ligament that directly overlies the fallopian tubes.

Cardinal Ligament: The ligament connecting to the uterus at the level of the cervix. It provides support to the uterus, but not the primary support -- that

comes from the pelvic diaphragm.

The ureters pass right underneath the uterine artery at the location of the cervix -- at the cardinal ligament. "Water under the bridge" -- don't

cut that ureter!

VASCULAR / LYMPH SUPPLY

Vascular supply is from the uterine artery a branch of the anterior internal iliac approaching the uterus at the level of the cervix. The vaginal may

branch off it too.

Also gets vascular supply from the Ovarian arteries -- from L1 level!

Also gets vascular supply from Vaginal artery.

LYMPH is on two places too -- Mostly back to the external iliac nodes, but a small portion goes back to the superficial inguinal nodes because of

the presence of the round ligament.

Third place -- the lower potion of uterus drains back to the internal iliac nodes, then onto external iliacs.

NERVES -- dual nerve supply, divided approx. upper (lumbar plexus) / lower (pelvic splanchnic).

Parasympathetic from the pelvic splanchnics.

Sympathetic from the hypogastric plexus, from the lumbar.

Pain (GVA) afferent receptors go back to T10-L1!

CLINICAL:

Pain from uterine contractions goes back to T10-L1. This means that uterine contraction pain is sympathetic.

But for the lower portion of the uterus and upper vagina (the cervix) -- it is parasympathetic back to the pelvic splanchnics.

VAGINA:

STRUCTURES:

Rugae: Muscular folds on internal wall -- unlike the stomach which has mucosal rugae folds.

Cervix:

Supravaginal Portion: Portion of the cervix above the vagina.

Vaginal Portion: Portion of the cervix in the vagina.

Urethral (Skene's) Glands: They lubricate the urethra, have openings into the urethra.

Vestibular Bulbs: Two of them, analogous to the corpora cavernosa of the penis.

Clitoris: The clitoris has no corpus spongiosum, because the urethra does no run through the clitoris. There is a crus in the superficial perineal space, on

either side of the clitoris and separated by the vagina.

PERITONEUM / RECESSES: Only a very small part of the vagina is covered with peritoneum -- the very edge of the posterior fornix, just inferior to the

rectovaginal pouch of Douglas.

MUSCLES:

Urethrovaginal Sphincter: Helps in the compression of the vagina (and urethra) in an anteroposterior direction.

Bulbospongiosus muscles to either side of the vagina, help in the compression of the vagina along the lateral axis.

FORNICES: Spaces surrounding the external vaginal wall.

Lateal Fornices: The ureters run along the lateral aspects of the vagina.

Since the ureters are there, we know the uterine vessels are also approx at that location -- near the vaginal cervix.

Posterior Fornix: Covered with peritoneum, it is just inferior to the Pouch of Douglas and hence clinically important. Directly related to the rectum.

Anterior Fornix: Very thin space, and the anterior vaginal wall (related to bladder) is far thicker than the posterior vaginal wall. This makes it

impractical to pierce that wall clinically.

CLINICAL

Culdocentesis: Aspirate fluid out of the rectouterine pouch by passing a needle through the posterior fornix of the vagina.

Culdoscopy: Pass a fiber-optic scope through the posterior fornix of the vagina to look around.

Rectocele: With a weakened pelvic diaphragm, the anterior wall of the rectum could invade the posterior wall of the vagina, bulging it inward.

Cystocele: Invasion of the bladder wall, posteriorly, to the anterior vaginal wall.

Enterocele: Invasion of loops of small intestine into the rectouterine or vesicouterine pouch. This is less common.

RELATIONS:

The anterior wall of the vagina is intimately related to the posterior wall of the bladder, and the lower part to the urethra.