Female Pelvis Continuation Flashcards
(27 cards)
Vulva, Mons pubis, Labia majora/minora
- Vulva – collectively refers to external genitalia of female; best viewed in lithotomy position
- Mons pubis – external hair bearing region of fatty tissue anterior to pubic symphysis
- Labia majora – hair bearing continuation of mons pubis downward to perineal body
- Labia minora – non-hair bearing tissue medial to labia majora that meets superiorly to form prepuce externally covering the clitoris
Frenulum, Vestibule, Fourchet, Vaginal Orifice
- Frenulum – internal portion of labia minora; extends from bottom of the clitoris to the ureathral meatus
- Vestibule – area of vulva surrounded by labia minora into which the urethra and vagina open
- Fourchet – inferior margin of vagina where perineal body meets the labia major
- Vaginal orifice – opening to the vagina deep to the vestibule that may be surrounded by hymenal tags
Round Ligament
• Round ligament in females = gubernaculum in male testis
o Travels from junction of uterus/fallopian tube through the deep inguinal ring to labia majora
Broad Ligament
• Broad ligament – peritoneum around the uterus, ovaries, and fallopian tubes; attach to lateral pelvic wall
o Mesometrium – majority of broad ligament that surround the uterus; contains the ureter
o Mesosalpinx – portion of broad ligament that extends around fallopian tube
o Mesovarium – portion of broad ligament that suspends the ovaries
Cardinal Ligament
– laterally envelops the inferior aspect of uterus and contains the uterine vessels
Anterior/Posterior cul-de-sac
- Rectouterine pouch (pouch of Douglas) – posterior cul-de-sac – between uterus and rectum
- Vesicouterine pouch - anterior cul-de-sac – between uterus and bladder
Physical Exam of Female
o Retractor (Speculum exam) – place into vagina to view cervix, do pap smear, overall inspection o Bimanual (2 fingers in vagina and push on abdomen) – feel uterus (size of fist); most uterus are anteverted (tilt forward) o Rectovaginal (1 finger in vagina; 1 in rectum) – examin rectovaginal septum; rectouterine pouch o Bimanual exam of adnexa – place finger in fornix of vagina and push on abdomen to feel fallopian tubes and ovary (adnexa)
Disorders of Pelvic Support (Prolapse)
– all occur as result of loss of fascial supports secondary to congenital anatomic weakness, stress of child bearing, injury, surgical damage, &/or chronic straining activities relative to lifting or constipation
o Cystocele – protrusion of bladder into vagina; due to weakness of vesicovaginal septum
o Descensus of cervix & uterus (aka prolapse or procedentia) – protrusion of cervix & uterus
o Enterocele – herniation of pouch of Douglas between uterosacral ligament into the rectovaginal septum; usually contains small bowel
o Rectocele – protrusion of rectum into the vagina
o Urethrocele – protrusion of urethra into the vagina
Degree of Prolapse
o 1st: prolapse into upper vagina
o 2nd: prolapse to or near the introitus of vagina
o 3rd: complete prolapse through the introitus
Hysterosalpingogram
– radiograph of uterus & oviducts with a radiopaque tracing material injected into cervix that outlines the uterine cavity and searches for filling defects of blocked tubes
o Often used on patients with fertilityissues
o Can find bicornuate uterus (Y shaped) AND incompetent cervix (very dilated)
Ectopic Pregnancy
– pregnancy in place other than endometrial lining of uterine cavity
o Oviduct/fallopian tube = most common
o Leading cause of maternal mortality (due to hemorrhage)
o Risk factors = pelvic infections, tubal reconstruction surgery, previous ectopic pregnancy
o Symptoms = amenorrhea, slight vaginal bleeding, pelvic pain, +betaHCG
o Diagnosis = +betaHCG, no intrauterine pregnance, adnexal mass on sonogram, diagnostic laparoscopy
o Treatment = methotrexate, salpingectomy (remove of uterine tube), salpingostomy (remove the embryo)
o Oviducts – most common
Hysterectomy
– 2nd most common operation formed in US (behind C-section)
o Removal of uterus (and sometimes cervix); ligate the blood vessels in area (be careful of ureter)
o Indications: fibroids, cancer, prolapse, adenomyosis (menorrhage – more blood flow during period), DUB, uncontrolled hemorrhage, endometriosis, chronic pelvic pain
o Complications: infection, hemorrhage, ureteral injury, DVT/PE, injury to bowel/bladder/etc.
o Transvaginal & transabdominal approach
Ureter
– muscular tube connecting kidney bladder
o Right – crosses at birfurcation of common iliac artery
o Left – crosses 1-2cm above bifurcation of common iliac
o Ureter descends along convex curvature of posterolateral pelvic sidewall & becomes retroperitoneal
o Ureter crosses underneath uterine artery (water under the bridge)
o At ischial spine it runs forward and medial from uterosacral ligament to base of broad ligament where it enters the cardinal ligament (1-2 cm lateral to uterine cervix)
o Runs upward and medially to enter bladder wall at base near anterior vagina
Ureteral Injury
o Common at uretovesical junction; junction of uterine artery & ureter; infundibulopelvic ligament
Inferior Mesenteric Artery
– arises 3 cm above bifurcation of aorta
Supplies: trans/descending/sigmoid colon; rectum
Terminates: as superior hemorrhoidal artery
Ovarian Artery
– arises from aorta below renal vessels; courses into retroperitoneal space, crosses anterior to ureter and enters infundibulopelvic ligament
Branches into mesovarium artery to supply ovary and tube
Unites with ascending branch of uterine artery
Common Iliac Artery
– formed as aorta bifurcates at level L4
5cm long before dividing into external and internal (hypogastric) iliac arteries
Internal Iliac Artery
- 3-4cm I nlength; close to ureters entire cours
• Posterior trunk: iliolumbar, lateral sacral, superior gluteal
• Anterior Trunk
o 3 parietal branches – obturator, internal pudendal, inferior gluteal
o 6 visceral branches – umbilical, middle vesical, inferior vesical, middle hemorrhoidal, uterine, vaginal
External Iliac Artery
– 15-20% of women gives rise to obturator artery
Uterine Artery
– arises from internal iliac and runs medially toward isthmus of uterus
o 2cm lateral to endocervix it crosses over ureter and reaches sidewalls of uterus
o Divides into:
Ascending branch – up broad ligament to anastomose with ovarian artery
Arcuate arteries – branch to meet contralateral equivalent and form spiral arteries of corpus and endometrium
Descending branch – supplies vagina
Vaginal Artery
– arises from internal iliac or uterine arteries
o Supplies vagina, bladder, and rectum
o Anastomoses with other side to form azygos arteries of cervix and vagina
Internal Pudendal Artery
– terminal branch of internal iliac
o Supplies branch to rectum, labia, clitoris, and perineum
Veins
– follow course of arteries with exception of ovarian drainage
o R ovarian vein IVC directly; L ovarian vein L renal vein IVC
Post-partum Hemorrhage
– blood loss greater than 500cc for vaginal delivery (normally 300cc); 1000cc for C-section (normally 800cc); OR 10% drop in hematocrit
o Causes: uterine atony (multigravida patient, multiple gestations), retained placenta, uterine rupture, uterine inversion, abnormal placentation, coagulopathies
o Treatment: IV access and hydration, bimanual exam vagina and uterus; oxytototics (pitocin, methergine, hemabate); blood products; surgical therapy (curettage, vessel ligation-hypogastric/uterine, hysterectomy)
