Female reproductive anatomy, pelvis and peritoneum

Question 1

What two halves does the pelvic inlet (brim) divide the pelvis into?

Answer 1

1. False (greater) pelvis

2. True (lesser) pelvis - pelvic cavity

Question 2

What two regions can the perineum be divided into? What are its boundaries?

Answer 2

Urogenital triangle and Anal triangle

Pubic symphysis, Ischial tuberosities, coccyx

Question 3

Complete the sentence:

When standing upright, the plane of the pelvic inlet lies at … to the …

Answer 3

When standing upright, the plane of the pelvic inlet lies at 60 degrees to the horizontal

Question 4

What are the differences in pelvic girdle shapes between males and females?

Answer 4

Males (android): Narrower, thicker boned, wedge-shaped, acute pubic arch
Females (gynaecoid): Wider, thinner bones, cylindrical cavity, broad pubic arch

Question 5

What muscles makes up the pelvic floor?

Answer 5

Levator ani group (iliococcygeus, pubococcygeus and puborectalis)
Coccygeus

Question 6

What are the functions of the pelvic floor muscles?

Answer 6

Supporting and pulling pelvic organs UP and FORWARDS
Preventing prolapse
Puborectalis - mainting anorectal angle and helps keep you continent

Question 7

What is the urogenital hiatus covered by?

Answer 7

Perineal membrane (urogenital diaphragm) - tough fibrous sheet - has openings for urethra and vagina - space above it DPP and below it SPP

Question 8

What are the functions of the perineal body?

Answer 8

Strong union between pelvic floor muscles and perineal membrane
Pelvic floor integrity
Supports posterior vaginal wall in females
Attachment point for anal sphincters

Question 9

What are the boundaries of the DPP and what does it contain? mention innervation

Answer 9

Pelvic floor and perineal membrane
Contains voluntary (skeletal) muscles - innervated by the Pudendal nerve (S2-4)
Males: Bulbourethral glands/Cowper’s glands

Question 10

What do the bulbourethral glands/cowper’s glands do and what happens if they become infected?

Answer 10

Secrete lubricating mucus
Can become infected/develop stones
Intense pain exacerbated by defecation/rectal exam

Question 11

What are the boundaries of the SPP and what does it contain?

Answer 11

Between perineal membrane and fascia bound surrounding genitalia
Bulb of vestibule + Paired corpora cavernosa = crura of clitoris
Bulbosponiosis + ishiocavernosus muscles = cover erectile bodies
Greater vestibular glands/Bartholin’s glands

Question 12

What are the vulva?

Answer 12

Folds of tissue guarding the urethral opening, vagina and clitoris

Question 13

Describe the function of the greater vestibular (bartholin’s) glands and what happens if they are infected?

Answer 13

Drain into the vestibule at 5 and 7 o’clock position relative to vaginal opening
Can become inflamed, infected and form cysts or abscesses

Question 14

What positions are episiotomies usually carried out?

Answer 14

Mediolateral position

Question 15

Where can you find the ischioanal (ischiorectal) fossae?

Answer 15

In the Anal triangle (posterior)
Contains fat
Anterior extensions into the urogenital triangle

Question 16

In the female, the peritoneum drapes over the pelvic organs, what two pouches does it form? Which pouch is more likely to get an infection?

Answer 16

1. Vesicouterine pouch
2. Rectouterine pouch/ Pouch of Douglas
   Rectouterine is the most GRAVITY dependent - intraperitoneal fluid/blood/pus will accumulate - infection

Question 17

Describe the vagina, mention its innervation.

Answer 17

Distensible fibromuscular tube - between bladder and rectum
Connects vestibule (space between labia minora) to the external os of the uterine cervix
Runs posterosuperiorly
Prox vag - pelvic splanchnic n - parasymp - S2-4
Dist vag - pudendal n - somatic - S2-4

Question 18

What is the name of a prolapsed bladder and rectum through the vagina?

Answer 18

Cystocele

Rectocele

Question 19

What can you use the posterior fornix of the uterus for?

Answer 19

Posterior fornix is DEEPEST, lying adjacent to rectouterine pouch - can pass a needle through the posterior fornix to access this

Question 20

What are the thick smooth muscle layer and outer serosal layer of the uterus called?

Answer 20

Thick smooth muscle layer - myometrium

Outer serosal layer - perimetrium

Question 21

What is the bimanual palpation procedure used for?

Answer 21

Check approx size and position of the uterus:

2 digits in vagina, one hand on abdo - check if uterus is anterverted and anteflexed

Question 22

Describe the normal position of the uterus (mention angles).

Answer 22

Anterversion, Anteflexed
Angle of version = Vagina and Cervix
Angle of flexion = Cervix and Uterus

Question 23

What can be the associated pathology with a retroverted and/or retroflexed uterus?

Answer 23

Subfertility problems

Endometriosis

Question 24

What is the function of the fimbriae?

Answer 24

From the infundibulum lie over the ovary, ready to receive/collect the ovum at ovulation

Question 25

Where does fertilisation usually occue?

Answer 25

Ampulla of the uterine tubes

Question 26

What method can you use to view the shape and patency of the uterine cavity and tubes?

Answer 26

Hysterosalpingogram - inject dye into vagina - travels up uterus, through uterine tubes and into peritoneal cavity

Question 27

Where do the paired uterine (fallopian) tubes open into?

Answer 27

Open into the peritoneal cavity

Question 28

What might happen if there is an undetected ectopic pregnancy?

Answer 28

Rupture and cause haemoperitoneum

Question 29

How might pelvic inflammatory disease (PID) be a risk for ectopic pregnancies and subfertility?

Answer 29

Uterine tubes may present a route of spread for infections from the vagina - PID Salpingitis to tubal or tuboovarian abscesses

Question 30

Embryologically, where and from what do the ovaries develop from?

Answer 30

Intermediate mesoderm Posterior abdominal wall (L2 vertebral level) Descend to lateral pelvic wall and drag blood supply and lymphatics with them to final position

Question 31

Which ligament of the ovary contains the blood supply and lymphatics?

Answer 31

Suspensory ligament of the ovary

Question 32

Why can you get medial thigh pain with ovarian pathology?

Answer 32

The ovaries are close to the obturator nerve - supplies the medial thigh. Can become impinged with ovarian pathology

Question 33

Where do ovaries drain lymph to?

Answer 33

Para-aortic nodes

Question 34

What do the ovarian and round ligaments connect? What are they a remnant of?

Answer 34

Both are remnant of the gubernaculum Ovarian lig - connects ovary to uterus Round lig - connect uterus to labia majora (runs via inguinal canal)

Question 35

What might be a route of metastatic spread from the uterus to the inguinal lymph nodes?

Answer 35

Round ligament of the uterus

Question 36

What three regions is the broad ligament separated into?

Answer 36

1. Mesosalpinx (uterine tube) 2. Mesovarium (ovaries) 3. Mesometrium (endometrium)

Question 37

What is the point where pelvic fascia come together?

Answer 37

Tendinous arch

Question 38

What are the three parametrial ligaments that support the uterus?

Answer 38

1. Uterosacral 2. Cardinal ligament 3. Pubocervical

Question 39

What is the name of the fascia which surrounds the vagina and connects it to the tendinous arch?

Answer 39

Paracolpium

Question 40

What is the golden rule for blood supply to the pelvic organs and perineum?

Answer 40

From branches of the internal iliac artery Internal pudendal artery supplies perineum Rich anastomoses between all organs - inc flow/demand during pregnancy

Question 41

What passes below the uterine artery? Hint: Water flow under the bridge

Answer 41

Ureter passes below uterine artery (lateral to cervix)

Question 42

What is at damage during a hysterectomy?

Answer 42

Ureter

Question 43

Where do the following structures drain to? | Ovary, fallopian tubes, fundus of uterus, body of uterus, cervix, prox vagina, distal vagina, external genitalia

Answer 43

Ovary, fallopian tubes, fundus of uterus - paraortic nodes Body of uterus, cervix, prox vagina - internal and external iliac nodes distal vagina, external genitalia - superficial and deep inguinal nodes P.S. round lig of uterus drains part of uterus to superficial inguinal nodes

Question 44

What is the pelvic pain line?

Answer 44

The lowest point of peritoneal reflection over the pelvic organs. Determines the route visceral pain fibres takes from pelvic structures back into the CNS

Question 45

Describe the innervation in the pelvic cavity below and above pelvic pain lines...

Answer 45

Above - pelvic organs covered in peritoneum, visceral sensory nerves travel alongside sympathetic nerves (refer pain T11-L2) Below - not covered, visceral sensory n. - alongside parasymp nerves (refer pain S2-4) External genitalia/distal vagina, perineal pouch muscles, sphincters - somatic innervation - pudendal nerve (S2-4)

Question 46

How does the pudendal nerve pass in/out of the pelvic cavity?

Answer 46

Via the greater sciatic foramen and back in towards the perineum via lesser sciatic foramen. Runs close to the ischial spine and sacrospinous ligament

Question 47

How do you access the pudendal nerve when doing a nerve block?

Answer 47

Runs close to ischial spine, palpate through vagina - estimate location - anaesthesia for perineum, distal vagina and anal canal