Lecture 6 - Female Pelvis and Perineum

Question 1

What are the female pelvic organs?

Answer 1

Ovary, uterine tubes, uterus, cervix, vagina, ureter, bladder, urethra, rectum, caecum, appendix, sigmoid colon and ileum, vessels, nerves and lymphatics

Question 2

What is the structure of the female pelvic organs?

Answer 2

Question 3

What are the boundaries of the peritoneum and pelvic fascia?

Answer 3

Parietal peritoneum continues into pelvic cavity without touching the pelvic floor; uterine tubes are completely enveloped by peritoneum (broad ligament). Pelvic fascial condensation form ‘ligaments’ supporting viscera (cervix, vagina)

Question 4

How are the ovaries suspended?

Answer 4

By the mesovarium from posterior of broad ligament

Question 5

How are the broad ligament, uterus, uterine tubes and ovary organised?

Answer 5

Question 6

What are the broad ligaments?

Answer 6

Transverse mesentries joining the uterus to the pelvic walls -> contain the uterine tubes and uterine arteries

Question 7

How are the ligaments arranged around the uterus?

Answer 7

Question 8

How is the cervix and vagina maintained stable?

Answer 8

3 sets of fibrous bands (cervical ligaments) anchor the cervix in position with the pelvis -> prevent uterus from prolapsing through the vagina

Question 9

What is the structure of the uterus and uterine tube?

Answer 9

Uterus consists of fundus, body, lower segment and cervix. Uterine tubes consist of infundibulum, ampulla, isthmus and uterine parts

Question 10

Where is there potential communication between peritoneal cavity and exterior?

Answer 10

Via the reproductive passage -> abdominal ostium of uterine tube and vaginal opening

Question 11

How is the uterus arranged?

Answer 11

Question 12

How does the uterus change size in pregnancy?

Answer 12

Question 13

What is the cervix?

Answer 13

Fibro-muscular cylinder with internal/external os -> projects into anterior vaginal wall at right angle to vaginal axis

Question 14

What lines the cervical canal?

Answer 14

Mucus secreting simple columnar epithelium

Question 15

What cells line the vaginal surface of the cervix?

Answer 15

Covered in stratified squamous non-keratinized epithelium -> no glands in vaginal wall

Question 16

How is the cervix held up?

Answer 16

By strong cervical ligaments attached to the pelvis and sacrum -> part of pelvic fascia

Question 17

What is the vagina?

Answer 17

Fibromuscular canal -> 7-9cm; vaginal fornices at upper end -> posterior fornix is important clinically and urethra is fused with the anterior wall

Question 18

What structures can be palpated via the vagina wall?

Answer 18

Cervix, ischial spine, sacral promontory, uterine arterial pulse (lateral fornix), ovary [some can be felt through rectal examination]

Question 19

What is the arterial supply to the female pelvic viscera?

Answer 19

Superior vesicle, uterine and middle rectal

Question 20

What is the arterial blood supply to the walls of the pelvis?

Answer 20

Sacral, gluteal and obturator branches

Question 21

What does the pudendal artery supply?

Answer 21

Perineum and recto-anal region (via inferior rectal branch)

Question 22

How does the internal iliac artery divide to supply the pelvis in the female?

Answer 22

Question 23

What does the uterine artery supply?

Answer 23

Main blood supply to the uterus and enlarges during pregnancy

Question 24

Where does the uterine artery run from and close to?

Answer 24

Runs medially to cervix and crosses ureter about 1cm from cervix -> uterine segment runs close to uterus in broad ligament

Question 25

What does the ascending branch of the uterine artery supply?

Answer 25

Uterine tubes and ovary (ovary also has ovarian artery from abdominal aorta)

Question 26

What does the descending branch of the uterine artery supply?

Answer 26

Vagina

Question 27

Where do the ovaries lie?

Answer 27

Close to openings of the uterine tubes into the peritoneal cavity; on the posterior surface of broad ligament facing into the peritoneal cavity into which eggs are first released -\> supplied by ovarian artey

Question 28

What is the structure of the ovaries?

Answer 28

Question 29

What are the superficial perineal structures of the female?

Answer 29

Perineal membrane fills the urogenital triangle -\> erectile tissues and associated skeletal muscles are anchored to this

Question 30

What are the deep perineal structures of the female?

Answer 30

Question 31

How do the urethral sphincters differ in females and males?

Answer 31

Females don't have a well organised IUS but the EUS is more intricate in women than men and is crucial for maintaining urinary continence in women

Question 32

What are the 3 perineal spaces or pouches present in females?

Answer 32

Perineal membrane, deep perineal space and superficial perineal space -\> Potential spaces and are real only when fluid leaks into them

Question 33

What is the perineal membrane?

Answer 33

Thick triangular fascial structure attached to pubic arch -\> posteriorly free margin and a small gap anteriorly

Question 34

What is the deep/superficial perineal space?

Answer 34

Deep: above the perineal membrane and below the fascia of pelvic diaphragm. Superficial: Below perineal membrane and perineal fascia (subcutaneous tissue)

Question 35

What is in the superficial perineal pouch?

Answer 35

Median erectile tissue masses, lateral erectile tissue masses -\> these erectile tissues within perineum are surrounded by skeletal muscles

Question 36

What are median erectile tissue masses in females?

Answer 36

Corpus spongiosum -\> divides around the vestibule to form 2 vestibular bulbs, surrounding the lower vestibule and vagina -\> derives the glans of clitoris

Question 37

What are the lateral erectile tissue masses in females?

Answer 37

Corpora cavernosum -\> Paired cylinders, attached to ischipubic rami -\> derives the body of clitoris

Question 38

What is the vulva?

Answer 38

Collective name for female external genitalia -\> mons pubis, labia majora/minora, clitoris, vestibule of vagina, vestibular bulbs and vestibular glands

Question 39

What is the hymen?

Answer 39

The vaginal orifice in a virgin possesses a thin mucosal fold (hymen) which is normally perforated at the centre. Following intercourse and child birth the hymen is torn and only a few tags may remain

Question 40

What is the arrangement of the urethra in a female?

Answer 40

Question 41

What nerves supply the pelvis in females?

Answer 41

Autonomic nerves only -\> SNS from lower thoracic and upper lumbar segments via hypogastric plexus; PSNS from S2-4 outflow; pudendal (somatic) S2-4

Question 42

Where is pelvic pain referred to?

Answer 42

Visceral and poorly localised -\> referred to suprapubic region and perineum

Question 43

What does the pudendal nerve innervate?

Answer 43

Motor: to perineal muscles, anal/urethral sphincters, levator ani. Sensory: External genitalia (vestibule, labia minora and part of labia majora), lower vagina, clitoris, lower anal canal

Question 44

How are the external genitalia of the female innervated?

Answer 44

Question 45

How is the pelvic lymphatic drainage organised?

Answer 45

Pelvic organs: mainly to external/internal iliac nodes. Ovary/Testis: para-aortic nodes. Perineum (inc. anal canal) and external genitalia: superficial inguinal nodes [subcutaneous below inguinal ligament]

Question 46

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Answer 46

Question 47

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Answer 47