Female Reproductive System and the Breast

Question 1

What parts of the female reproductive tract lie in the pelvic cavity?

Answer 1

• Ovaries
• Uterine tubes
• Uterus
• Superior part of vagina

Question 2

What parts of the female reproductive tract lie in the perineum?

Answer 2

• Inferior part of vagina
• Perineal muscles
• Bartholin’s glands
• Clitoris
• Labia

Question 3

What muscle separates the pelvic cavity from the perineum and create the “pelvic floor”?

Answer 3

Levator Ani

Question 4

What covers the superior aspect of the pelvic organs?

Answer 4

draping of parietal peritoneum from abdomen

Question 5

The inferior parietal peritoneum forming a roof over the superior pelvic organs creates pouches. What are these called in both the female AND in the male?

Answer 5

Female
vesico-uterine
recto-uterine (Pouch of Douglas)

MALE
recto-vesical

Question 6

Why are the pouches created by the parietal peritoneum clinically relevant?

Answer 6

• Excess fluid within peritoneal cavity
• collects within pouch of Douglas
• It is most inferior point when a female is standing

(recto-vesical for males)

Question 7

How can excess fluid collecting in the pouch of Douglas be drained?

Answer 7

Needle drainage via the posterior fornix

Question 8

What other areas may be sites of fluid collection in females if the Pouch of Douglas is not the most inferior?

Answer 8

Para-rectal fossae

Question 9

All components of the female reproductive tract are considered “sub-peritoneal” except what structure?

Answer 9

Uterine tubes (intraperitoneal due to broad ligament)

Question 10

What is the broad ligament?

Answer 10

Broad ligament
- double layer of peritoneum
- between the uterus and lateral walls & floor of the pelvis
=> wraps around uterine tubes completely (except fimbrae)

Question 11

What is the function of the broad ligament?

Answer 11

helps maintain the uterus in its correct midline position

Question 12

What is the round ligament?

Answer 12

• embryological remnant from when testes/ovaries descend from posterior abdominal wall
• attaches to the lateral aspect of the uterus
• passes through deep inguinal ring
• attaches to the superficial female perineum

Question 13

What are the 3 layers of the uterus?

Answer 13

perimetrium
myometrium
endometrium

Question 14

What is the function of the muscle in the myometrium?

Answer 14

• allow uterus to tretch during pregnancy

- allow contractions during labour and cramping

Question 15

Where must an ovum implant in the uterus, and what complication arises if not?

Answer 15

• implantation of zygote in BODY of uterus

- implantation anywhere else = ectopic pregnancy

Question 16

What is the most common location of ectopic pregnancy?

Answer 16

In the uterine tubes

Question 17

Ectopic pregnancies in the abdominal cavity may actually survive. TRUE/FALSE?

Answer 17

TRUE

- depending on where the ovum implants and the placenta grows

Question 18

How can ectopic pregnancies end up in the abdominal cavity?

Answer 18

Ovum is released from ovary into peritoneal cavity and if not picked up by fimbrae on end of uterine tube, then can become fertilised/implant in abdomen

Question 19

What are the 3 layers of support which hold the uterus in position?

Answer 19

• Strong ligaments (e.g. uterosacral ligaments - these extend from cervix to sacrum)
• endopelvic fascia
• muscles of the pelvic floor (e.g. levator ani)

Question 20

Weakness of the uterine support can cause what?

Answer 20

uterine prolapse

=> movement of the uterus inferiorly

Question 21

Describe the NORMAL position of the uterus and what these terms actually mean?

Answer 21

• Anteverted and anteflexed (lies on superior bladder)
• Anteverted
  cervix angled anteriorly relative to axis of vagina
• Anteflexed
  uterus angled anteriorly relative to axis of cervix

Question 22

It is a normal variant for the uterus to appear retroverted and retroflexed. What does this mean?

Answer 22

Retroverted
cervix angled posteriorly relative to the axis of the vagina

Retroflexed
uterus angled posteriorly relative to the axis of the cervix

Question 23

Why must a speculum be used in a cervical smear examination?

Answer 23

The walls of the vagina are usually collapsed

=> this holds them open to allow cervix to be viewed adequately

Question 24

What part of the cervix is aiming to be sampled in a cervical smear and how can this area be iidentified on examination?

Answer 24

squamo-columnar junction (transformation zone)

• sampled due to the potential of metaplastic change
• different epitheliums appear different colours (lighter and darker => this is area to sample)

Question 25

Salpinx is Greek for what?

Answer 25

Tube => Salpingectomy is removal of uterine tube

Question 26

What names are given to the different areas of the uterine tube (working form the uterus to the fimbrae)

Answer 26

Isthmus Ampulla Infundibulum (funnel) Fimbrae

Question 27

Where in the uterine tube is fertilisation most likely to occur?

Answer 27

Ampulla

Question 28

What complications could arise as a result of the fimbriated end of the uterine tubes opening into the peritoneal cavity?

Answer 28

- infection spread between abdomen and genital tract - Pelvic Inflammatory Disease can cause peritonitis - Ectopic pregnancy can develop in peritoneal cavity

Question 29

How can the patency of uterine tubes be tested?

Answer 29

- Injecting radio-opaque dye into the genital tract | - scan patient to check dye is coming out into peritoneal cavity

Question 30

The ovary develops on the posterior abdominal wall and then descends into the pelvic cavity. What other structures related to the ovary must also develop on the posterior abdominal wall and descend with it?

Answer 30

Arteries Venous drainage Lymphatics (i.e. ovary drains to lumbar/caval/aortic lymph nodes)

Question 31

Where in the vagina do the walls not touch, and what are these spaces called?

Answer 31

Superiorly in vagina the cervix holds the walls apart => forming a fornix 4 parts: - anterior - posterior - 2x lateral

Question 32

What bilateral structures can be palpated at the 4 and 8 o'clock positions of the lateral fornix on pelvic examination?

Answer 32

Ischial spines can be palpated

Question 33

How can the position of the uterus be palpated on pelvic examination?

Answer 33

- bimanual palpation - two fingers inserted into posterior fornix - non-dominant hand over abdomen to feel anteverted uterus

Question 34

What are adnexae and how are they palpated on a pelvic examination?

Answer 34

adnexae = uterine tubes and ovaries together - place examining fingers into lateral fornix - press deeply with other hand in the iliac fossa

Question 35

When would adnexae be palpable on pelvic examination?

Answer 35

If enlarged e.g. by a mass or inflammation | - patient may also be tender in the area on palpation

Question 36

What is the perineum defined as?

Answer 36

- shallow space between pelvic diaphragm and the skin

Question 37

What 4 points form the diamond shape of the Perineum?

Answer 37

Pubic symphysis ischial spines X2 Coccyx

Question 38

The diamond shaped perineum is split into an anterior and posterior triangle. What are the other names for these?

Answer 38

Urogenital Triangle Anal Triangle

Question 39

What openings are found in the pelvic floor?

Answer 39

- end of digestive tract => rectum and anus - end of urinary tract => external urethral meatus - end of reproductive tracts => vagina

Question 40

The levator ani is mainly made up of skeletal muscle. Does this predominate on the medial or lateral aspect of the muscle?

Answer 40

Lateral = more skeletal | => voluntary

Question 41

How does the levator ani provide continual support for the pelvic organs?

Answer 41

- tonic contraction | - contracts further during increased intra-abdominal pressure (sneeze/cough)

Question 42

Weakness of the levator ani muscle can cause hwat complications?

Answer 42

Incontinence | OR prolapse of the pelvic organs

Question 43

What nerves supply the levator ani?

Answer 43

"nerve to levator ani” S3, 4, 5 (sacral plexus) | dual supply from pudendal nerve (S2,3,4)

Question 44

Both the superficial and deep perineal muscles are supplied by what nerve?

Answer 44

pudendal nerve (S2,3,4)

Question 45

What is the perineal body?

Answer 45

- bundle of collagenous and elastic tissue - perineal muscles attach to this - important for pelvic floor strength - located just deep to skin

Question 46

What is an episiotomy and why is it completed during labour?

Answer 46

- Labour can stretch/tear the perineal body => leaving women with incontinence/prolapse - an episiotomy allows cuts to be made laterally in the perineum to prevent damage to the perineal body => pelvic floor remains intact

Question 47

Where is Bartholins gland located and what is the name of the identical gland in the male?

Answer 47

- posterior L+R of vagina - also known as Greater vestibular gland - Homologous to Bulbourethral (Cowper's) gland in males

Question 48

What is the main function of Bartholin's and Cowper's glands?

Answer 48

- secrete mucous for lubrication in female and for smooth ejaculation in males

Question 49

When can Bartholins gland become enlarged?

Answer 49

Due to infection

Question 50

Where does breast tissue extend from/to?

Answer 50

- from ribs 2-6 | - lateral border of sternum to mid-axillary line (remember axillary tail)

Question 51

What does breast tissue lie on top of?

Answer 51

- On top of the deep fascia covering pec major

Question 52

What space lies between the deep fascia of pec major, and the breast tissue, and why is this clinically relevant?

Answer 52

- Retromammary space between fascia and breast - Allows breast to move relative to Pec Major muscle - Clinical Relevance = if pt has an invasive cancer which has grown through this space, the lump will be "fixed"

Question 53

What connects the breast tissue to the skin?

Answer 53

Suspensory ligaments

Question 54

Non-lactating lobules are found in all areas of the breast tissue. TRUE/FALSE?

Answer 54

TRUE

Question 55

How are the quadrants of the breast named?

Answer 55

Upper outer and inner Lower outer and inner * *axillary tail in Upper outer** * *can also refer to it like a clock face**

Question 56

How can we accurately assess if a lump in the breast is fixed to the underlying structures?

Answer 56

- Ask patient to place hands firmly on her hips (to contract pectoral muscles) - this will fix any lump which has invaded through deeper structures

Question 57

What areas should also be checked when assessing a breast lump?

Answer 57

axillae and supraclavicular areas

Question 58

Where does most lymph from the breast drain to?

Answer 58

Ipsilateral axillary lymph nodes | then goes to supraclavicular

Question 59

Where does some lymph from the inner breast quadrants drain to?

Answer 59

parasternal lymph nodes OR lower inner breast quadrant can drain to ABDOMINAL lymph nodes

Question 60

What complication can occur in the upper limb if complete axillary lymph node clearance is completed?

Answer 60

Lymph from the upper limb drains to the axillary lymph nodes | => if axillary nodes are removed to treat some breast cancers then “lymphedema” may occur in the arm

Question 61

How do surgeons describe the extent of axillary node clearance that is being carried out?

Answer 61

- Different "Levels" described in relation to pectoralis minor muscle Level I – inferior and lateral to pectoralis minor Level II – deep to pectoralis minor Level III – superior and medial to pectoralis minor

Question 62

What is the arterial supply to the breast tissue?

Answer 62

- Branches of axillary and internal thoracic/mammary arteries - Also posterior intercostal branches supply lateral tissue

Question 63

Describe the venous drainage of the breast tissue?

Answer 63

- axillary vein - internal thoracic vein - posterior intercostals