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7/28/2019 Uterus Broad Ligament Ovary BMJ
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7/28/2019 Uterus Broad Ligament Ovary BMJ
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MOB TCD
Uterus, Broad Ligament, Ovary
Professor Emeritus Moira O’Brien
FRCPI, FFSEM, FFSEM (UK), FTCD
Trinity College
Dublin
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Uterus
• Pear-shaped muscular organ• 8 cm long
• 5 cm wide
• 3 cm thick
• Non-pregnant state
• Pelvic organ
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UterusMOB TCD
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• Fundus• Body
• Cervix opens into vault or
fornices of vagina
• Fundus is the portion aboveentrance of uterine tubes
• Covered with peritoneum
• Body
• Triangular cavity
UterusMOB TCD
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Cervix
• Supravaginal• Isthmus is a circular borderline
area between the body and
cervix
• Isthmus is the supra vaginalportion of cervix lower uterine
segment
• Intravaginal is surrounded by
gutter fornices
• Posterior is deeper covered
with peritoneum
MOB TCD
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• Internal os is the opening fromthe body
• Spindle shaped cavity
• External os is the opening into
vagina• Cervix lined columnar
epithelium
• Arbor vitae in nullipara
• Intravaginal portion of cervixcovered by stratified epithelium
CervixMOB TCD
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• External os• Junction of columnar of the
cervical canal
• Stratified epithelium of the
intravaginal portion• Site of cancer of cervix
• Cervical smear
CervixMOB TCD
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• At birth cervix is larger thanthe body
• Fully developed cervix is
one third of body
CervixMOB TCD
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Peritoneum
• Reflected from the superior surface of the bladder
• Junction of the supravaginal
portion of the cervix and the body
of the uterus
• Uterovesical pouch
• Covers body, fundus
• Covers the posterior surface
body and the supravaginal portionof cervix
• Upper third of posterior surface of
vagina
MOB TCD
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Pouch of Douglas
• Upper third of posterior surface of vagina (posterior
fornix)
• Peritoneum reflected on to
junction of upper two thirds
and lower third of rectum
• Pouch of Douglas is most
dependent part of female
peritoneal cavity
• Broad ligament is lateral
MOB TCD
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• Uterus is anteverted• i.e. anterior to vertical plane
going through the vagina
• Posterior fornix deeper
• Anteflexed• Bent anteriorly at junction of
body and cervix
UterusMOB TCD
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• Serous layer • Myometrium
• No submucous layer
• Endometrium
• Three layers• Basal
• Spongy
• Compact at surface of uterine
cavity
UterusMOB TCD
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Myometrium
• Myometrium makes up bulk of uterine wall
• Blood vessels more evident in
middle layer
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MyometriumMOB TCD
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Uterine MuscleMOB TCD
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Blood Supply
• Uterine• Ovarian
• Vaginal arteries
• Anterior and posterior
arcuate run in middle layer
MOB TCD
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• Radial branches• Basal layer
• Spiral branches to superficial
two layers
• Veins below artery• Plexus in lower edge broad
ligament into internal iliac
Blood SupplyMOB TCD
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Blood SupplyMOB TCD
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Nerve Supply of Uterus
• Pain from cervix viaparasympathetic S2,3
• Pain from body via
sympathetic to T11
and T12
MOB TCD
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LymphaticsMOB TCD
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Supports of Uterus
Upper • Round ligament
• Broad ligament anteverted
Middle
• Transverse ligament• Pubocervical
• Uterosacral
Lower
• Levator ani, coccygeus
• Perineal body
MOB TCD
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Round Ligament
• Round ligament and• Ligament of ovary
• develop from the
gubernaculum
• Side of uterus, junction fundus and
body
• Inguinal canal to
labium majus• Anteversion
MOB TCD
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Broad Ligament
• Fold of peritoneum from sideof uterus to side wall of
pelvis
• Framework of pelvic fascia
• Parametric fat• Anterior surface looks
inferiorly
• Free upper border
• Base on pelvic floor
MOB TCD
MOB TCD
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• Uterine tubes• Ovarian vessels
• Uterine vessels
• Epoophoron
• Paroophoron• Round ligament of uterus
and ligament of ovary
• Transverse ligament
• Ovary attached to posterior layer
• Ureter in base below artery
Broad LigamentMOB TCD
MOB TCD
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• Uterine tube lies in medialfour fifths of free border of
broad ligament
• Lateral one fifth
• Contains ovarian vessels• Infundibulo-pelvic or
suspensory ligament of
ovary
Broad LigamentMOB TCD
MOB TCD
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• Mesosalpinx• Mesometrium
• Mesoovarian
• Epoophoron
• Parallel tubules• Gaertners duct remains
mesonephric tubules and
duct, may form cysts
Broad LigamentMOB TCD
MOB TCD
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Uterine Artery
• Uterine artery lies superior tothe ureter at lateral fornix of
vagina
• Base of broad ligament
MOB TCD
MOB TCD
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Pubocervical Ligament
• Attached• Anteriorly to posterior aspect
of body of body of pubis
• Passes to neck of bladder
• Anterior fornix of vagina
MOB TCD
MOB TCD
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• Pubocervical ligaments help tomaintain normal angle of
45°between the vagina and
horizontal
• Decrease may cause a
cystocoele
Pubocervical LigamentMOB TCD
MOB TCD
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Transverse Ligament
• Transverse or cardinal or mackenrodt ligament
• Thickening of visceral layer
of pelvic fascia around
uterine artery
• Lateral to medial in base of
broad ligament
MOB TCD
MOB TCD
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Uterosacral Ligament
• Uterosacral contains fibroustissue
• Nonstriated muscle
• Attached from the cervix to
the middle of sacrum• Contains lymphatics draining
cervix to sacral glands
MOB TCD
MOB TCD
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• Uterosacral help to keep uterusanteverted
• If uterus is anteverted it cannot
prolapse
Uterosacral LigamentO C
MOB TCD
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Uterine Tube
• Intramural• Isthmus
• Ampulla
• Infundibulum
• Lined ciliated columnar epithelium• Beats towards uterus
MOB TCD
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• Peritoneum• Loosely attached to ampulla
• Tightly to isthmus
• Fimbria surrounding opening into
peritoneal cavity• Ovarian fimbria
Uterine Tube
MOB TCD
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Embryology of Uterus
MOB TCD
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Ovary
• Attached to posterior layer of
broad ligament mesoovarian
• Covered with germinal
epithelium
• Side wall of pelvis covered
with peritoneum
• Obturator internus muscle
• Obturator nerve supplies the
parietal peritoneum• Ureter posterior
• Ligament of ovary medially
MOB TCD
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• Obturator nerve supplies theparietal peritoneum
• Irritation of the peritoneum of
the side wall by bleeding at
ovulation or by lesions
involving the ovary, may result
in referred pain to medial side
of the thigh or the knee
Ovary
MOB TCD
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• Blood supply
• One ovarian artery from
lateral aspects of aorta L2
• Right vein drains into IVC
• Left drains into left renal vein• Lymphatics into paraaortic
glands L2
Ovary
MOB TCD
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Vagina
• Fornices surround cervix
• Anterior wall shorter posterior
• Walls in contact except superior
• External os
• Opens into vestibule of vagina
MOB TCD
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• Pelvis
• Lateral uterine artery above
ureter
• Levator ani
• Deep pouch• Sphincter urethrae
• Bulbs of vestibule
• Greater vestibular glands
Vagina
MOB TCD
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• Urethra embedded in lower two thirds of anterior wall
• Posterior fornix
peritoneum of pouch of
Douglas
• Rectum
• Perineal body
Vagina
MOB TCD
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• Pelvic fascia• Erectile tissue
• Muscular wall
• Non-keratinised stratified squamous
epithelium
Vagina
MOB TCD
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Blood and Nerve Supply Vagina
• Uterine artery
• Vaginal
• Internal pudendal
• Labial
• Ilio Inguinal nerve supplies theanterior wall
• Labial nerves supply the
posterior wall
MOB TCD
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Lymphatics of Vagina
• Internal iliac• Lower third
• Medial group of proximal
superficial inguinal glands
MOB TCD
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Pelvic Sympathetic
MOB TCD
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Pelvic Plexuses
• Supply pelvic organs• Contains
• Sympathetic
• Preganglionic parasympathetic
nerves• Lateral column S2,3,4
MOB TCD
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• Hypogastric plexus• Lumbar splanchnics
• Presacral nerve
• Anterior to body of L5
• Divide into pelvic plexuses• Postganglionic of sympathetic
that relayed in lumbar and
sacral ganglia
Pelvic Plexus
MOB TCD
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Sympathetic
• Ejaculation is viasympathetic impulses from
L1-L2
• Contraction of sphincters of
bladder and anal canal
MOB TCD
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Pelvic Parasympathetic
• Preganglionic have cell bodies in
lateral column of segments
S2,3,4
• Ganglia found close to or in wall
of organ
• Supplies intestine from splenic
flexure to upper two thirds of anal
canal
MOB TCD
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• Supplies bladder
• Rectum
• Motor to walls inhibitory to
sphincters
• Male and female genitalia• Parasympathetic causes
erection
Pelvic Parasympathetic
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