Female Pelvis

Parity

Number of viable off spring.

True pelvis muscles

Obturator internus muscles, piriformis, pelvic diaphragm (puboccygeous, iliococcygeous, [levator ani], coccygeous).

When does HCG start to show up?

On the 8th day following conception.

Piriformis

Origin- most posterior aspect, travel anterolaterally.

Obturator internus muscles

Originate along the arcuate line of the innominate bons and course parallel to the lateral walls of the true pelvis. narrow inferiorly to pass thru the lesser sciatic notch. Secured to the medial apect of the greater trochanter. Internal surface of it is covered by a tough membranous layer called the obturator fascia.

Piriformis muscles

Originate in most posterior aspect of the true pelvis, along the lower portion of he sacrum, posterior to the uterus. Travel anterolaterally, narrowing to pass thru the greater sciatic notch. They're attached to superior aspect of each greater trochanter.

Adnexa

Outside of the utersus, to the sides of the uterus laterally. Region includes fallopian tubes, broad ligaments and ovaries.

Uterus

Pear shaped organ sits on the dome of the bladder. 4 portions 1) Fundus- most superior portion and widest. 2) Body/corpus- largest portion, central portion. 3) Cervix- Lower portion, connects UT to vagina. 4) Isthmus- Lies between cervix and body, is the short flexible portion where UT can bend.

What's the pelvic anatomy?

Pelvis-bony ring resembling a basin divided into 2 parts. 1) greater pelvis-major-false 2) Lesser pelvis-minor-true

What's should the size of the ovaries be?

Premenopausal: length- 2.5-5 cm AP- 0.6-2.2 cm Width- 1.5-3 cm Post menopausal: length- 2 cm AP- 1 cm Width- 2 cm

Cumulus oophorus

Ring like structure that may be seen in mature follicle. This is the layer of cells that surrounds the ovum.

What's the Space of Retzius?

Seperates the anterior bladder wall from the pubic symphysis; filled with extraperitoneal fat.

Corpus albicans

Small scar left by the regression of the corpus luteum if pregnancy does not occur.

Corpus luteum of pregnancy

Space or crater created after ovulation occurs when pregnancy occurs.Creates the necessary hormones to maintain pregnancy until the placenta takes over.

Where is the greater pelvis located?

Superior aspect of the cavity, from iliac crests to linea terminalis.

False Pelvis

Superior aspect of the pelvice cavity from iliac crests superiorly to the linea terminalis inferiorly.

Normal variants post hysterectomy

Surgical removal of uterus, ovaries can be anywhere, vaginal cuff will be seen on ultrasound.

What is the most common of congenital malformations of the female genital tract?

The bicornuate uterus.

What is the basis of all pregnancy test?

The detection mof HCG. Human chorionic gonadotrophin, can be measured in either urine or plasma.

Pubococcygeous muscles

The most medial and anterior muscle pair of the pelvic diaphragm muscles. Extending from the pubic bones to the coccyx, encircling the urethra, vagina and rectum.

What's the only organ in the abdominopelvic cavity not lined with peritoneum?

The ovaries.

Uterus

3 uterine layers 1) endometrium 2) myometrium 3) perimetrium

Uterine artery

A branch of the internal iliac artery. Uterine artery gives rise to the arcuate artery, these loop around the uterus.

Linea Terminalis

A hypoechoicline dividing the false pelvis (upper) from the true pelvis (lower).

Posterior cul-de-sac

AKA retrouterine pouch, or pouch of Douglas it's the most posterior and deepest point of the peritoneal cavity located between the rectum and the posterior wall of the uterus. The space is long and narrow. Open at the top and closed at the bottom. Because of its position at the bottom it can serve as a drainage point for fluid in the cavity. To visualize a small amount of fluid there is not abnormal, from ovulation. Identification of a large amount of fluid in both of these spaces suggests an abnormal intraperitoneal fluid collection, like blood from a ruptured ectopic, of fluid from OV CA, or a ruptured ovarian cyst.

Anterior Cul-de-sac

AKA vesicouterine pouch is a shallow peritoneal space located between the anterior wall of the uterus and urinary bladder.

What are the blood vessels associated witht he pelvis?

Abdomianl AO bifurcates into common iliac arteris that then enter the greater pelvis. They travel along th iliopsoas muscle and divide into the external and internal arteries. External iliac artery continues along iliopsoas muscle thru the inguinal canal to become the femoral artery in the groin, then the popliteal artery behind the knee and the tibial artery in the posterior calf. Internal artery passes over the pelvic brim, descends into the lesser pelvis, lateral to the ureter and ovary. Iliac vein follows the same course, except slightly posterior and medial.

Ovaries

Almond shaped paired organs, lying on posterior surface of broad ligament. Only organ in the abdominopelvic cavity not lined by peritoneum. Located lateral to uterus.

Cavities include:

Anterior cul-de-sac: space between the uterus and bladder Posterior cul-de-sac/ Pouch of Douglas/ rectouterine pouch: Space between uterus and rectum.

Path of blood flow

Arcuate artery gives rise to the radial artery-radial gives rise to the straight artery- straight artery supply 1st layer of endometrium-straight artery gives rise to the spiral arteries-these proliferate into the endometrium.

Retroflexion

Backwards at the level of the isthmus. Fundus is angled back toward cul-de-sac.

Dermoid cyst

Benign, have 1 puts at increased risk for another on the other side. Can be seen on KUB. (Tooth, hair, human tissue, etc).

Normal variants

Bicornate UT, partial duplication of uterus- seen o n ultrasound as 2 endometrial cavities, usually 2 horns, 1 cervix, and 1 vagina.

BX

Biopsy, cervical, endometrial

BHCG

Blood- more sensitive.

Pelvic ligaments

Broad, roundm, cardinal, uterosacral, infundibulopelvic, oavarian, pubovescical, and lateral.

Fallopian tubes and oviducts

Coiled muscular tubes, extend from uterus to cornu to ovaries. Responsible for transport of sperm, eggs and or fertilized egg. Divided into 4 segments: 1) interstitial- 1st segment thru cornu in myometrium 2) isthmus- short straight segment. 3) ampulla- longest and most coiled. 4) infundibulum- fingerlike extensions fimbriae overlie the ovaries and direct releases ovum into tube.

Iliopsoas

Combination of psoas and iliacus muscles, at level of iliac crest, iliopsoas muscle coarses anterior and along the linea terminalis,inserts into the lesser trochanter femur.

Corpus luteum

Crater or space that the ruptured mature follicle leaves after ovulation.

Broad ligamtent

Double folds of peritoneum. Extends from uterus cornu to lateral pelvic walls and provides miniamal suppoert to uterus.

What is the best plane to measure the endometrium?

Endovag is the best way to get the measurement.

Coloposcopy

Examination of the vagina & cervical tissue using a scope.

Vagina

Extends from cervix to external genitalia. Lies posterior to urinary bladder.

Round ligament

Fibromuscular band that originates at the uterine horns (cornu), the point where the uterus and uterine tubes meet. It is located anterior and inferior to the opening of the uterine tubes and courses within the broad ligament to the anterolateral pelvic wall. The round ligament leaves the pelvis via the deep inguinal ring, passes through the inguinal canal (oblique passage through the lower abdominal wall), and is secured at the labia major. The function of the round ligament is to maintain the forward bend (anteversion) of the uterine fundus.

Rectus abdominus muscles

Form most of the anterior wall of the abdominal cavity. These oaired muscles are intersected by transverse tendinous bands and wrapped in a muscular sheath. Rectus sheath arpas w/transverse abdominus forming the linea alba t midline of the body.

Transvers abdominus muscles

Form the anterolateral borders of the abdominopelvic cavity. Lies deep to the internal and external oblique muscles.

Levator ani muscles

Formed by the pubococcygeous and iliococcygeous muscles coming together forming a hammock across the floor of the true pelvis. Provide primary support to the pelvic viscera and aid in the contraction of the vagina and rectum.

Rectus abdominis

Forms the anterior wall of the abdominopelviccavity, they are paired muscles, wrapped in a muscular sheath, the sheath fuses mid-linea alba.

Transvers abdominis muscle

Forms the anterolateral border of the abdominopelvic cavity.

Pelvic diaphragm

Group of muscles lining the floor of the true pelvis, supports pelvic organs, extends from pubic bone to coccyx, encircles urethra, vagina, and rectum, 3 paired muscles-1) pubococcygeus muscle 2) iliococcygeous muscle 3) coccygeus muscle, 1 and 2 form a hammock across the floor termed the levator ani muscles.

Pelvic diaphragm muscles

Group of skeletal mkuscles lining the floor of the true pelvis and supporting the pelvic organs. Composed of 3 paired muscles: puboccocygeous, iliococcygeous, and coccygeous muscles.

What does serial BHCG help to determine?

Helps to determine if pregnancy is progressing normally.

Sonographic appearance of the uterus

Homogeneous- medium level echogenicity. Midline structure. Endometrium appears as a central hyperechoic line. Thickness and echo pattern can vary with cycle. Thickness should be measured endovag, sagittal orientation the AP diameter, do not include fluid in the cavity.

False pelvis muscles

Iliopsoas, rectus abdominis, transverse abdominis.

Where is the lesser pelvis?

Inferior bowl shaped cavity, reproductive organs are located here, from linea terminalis to pelvic diaphragm.

What are the landmarks for finding the ovaries?

Internal iliac arteries and veins, as well as the distal ureter.

What does the linea terminalis do?

It divides the 2 portions of the pelvis and acts as a boundary.

What should happen every 2 days with HCG under normal conditions?

It should double every 2 days.

Iliposoas muscles

Join the iliac muscles at the iliac crests becoming the iliopsoas muscles. Then course anteriorly along the linea terminalis, over the brim and insert into the lesser trochanter of the femur.

Uterine cornu

Laqteral aspect of the uterus where the fallopian tubes attach.

What size should the uterus measure?

Length 6-8 cm AP (thickness) 1.5-3 cm Width 5 cm

Where are the ovaries located?

Located in the adnexa. Appear slightly hypechoic and more heterogeneous then the UT. Small follicles can be seen. Mature follicles can be seen 18-22 mm, also called dominant follice.

True Pelvis

Lower, curved bony canal, which includes the inlet, the cavity, and the outlet through which the fetus passes during the vaginal birth.

What are the ovaries made up of?

Made up of cortex and medulla. Cortex is the site of oogenesis-production and gametes.

What are the muscles included in the true pelvis?

Major muscles included are obturator internus, piriformis, and pelvic diaphragm.

Anteflexion

Marked anterior flexion at the isthmus.

Normal uterus

Midline, anteverted. Uterine body is bent slightly forward, towards the AAW.

Multiparous

Multiple viable births.

Urinary bladder

Muscular sac that recieves and stores urine. Posterior to the pubic symphysis, anterior to uterus and vagina. Space between bladder and anterior abdominal wall is called Space of Retzius. Most anterior organ in the lesser pelvis.

Nulliparous

No births.

At what point is something considered a cyst?

Not until > 25 mm.

When are you considered post-menopausal?

Not until you've gone 1 year without a period.

Why do you need a full bladder to do a pelvic ultrasound?

1) Acts as a good medium to conduct US. 2) Bladder acts as an acoustic window. 3) Bladder pushes uterus down so beam can hit at a 90 degree angle. 4) Bladder pushes bowel out of the way. 5) Bladder can be used for comparison for other cystic structures.

What's the prep for a female pelvic ultrasound?

1) Drink 32 oz. fluid 1 hr prior to test. 2) Do Not void. Test must be done with a full bladder. 3) Endo vaginal portion will be done with an empty bladder.

X-rays associated with the female pelvis

1) KUB- Plain film-flat plate, kidneys-ureter-bladder. 2) Pyelogram-IVP 3) BE- Barium enema. Replaced with colonoscopy. 4) Hysterosalpingography- Looking ofr patency of tubes. 5) CT 6) MRI 7) Laparascopy- incision at umbilicus. 8) Sonohysterogram

What are some endocrine lab tests?

1) Pituitary 2) Hormones, estrogen, progesterone.

Endometrium

1) inner layer 2) mucosal lining of the uterus. 3) appearance can vary with cycle. 4) should measure less than 19 mm in mestruating patient. 5) should measure less then 5mm in post menopausal patient.

Myometrium

1) largest portion 2) middle layer 3) smooth muscle fibers, vascular supply, and supporting connective tissue.

Perimetrium

1) outer layer 2) thin membranous layer

What has a dual blood supply?

The ovary. 1) Ovarian artery off the AO. 2) Ovarian branch of the uterine artery.

What maintains the forward bend of the uterine fundus?

The round ligaments.

What are the 3 paired ligaments that provide support to the uterus?

The round, cardinal, and uterosacral ligaments.

Ligaments

There are 3 paired ligaments that provide support to the uterus. 1) round 2) cardianl 3) uteroscaral ligaments

How do you see the fallopian tubes

They're not routinely seen sonographically. To small and serpinguous.

Ovary location

Typically posterolateral to the uterus within adnexa. Variable position, but NEVER move anterior to the uterus or broad ligaments.

UHC

Urine

Retroversion

Uterus bends backwards at the cervix. Uterus fundus extends posterior to rectum.

Broad ligament

a) Double fold of peritoneum that connects the sides of the uterus to the wall and floor of the pelvis. b) It may be divided into 3 sub-components 1) Mesometrium- mesentry of the uterus, the largest portion 2) Mesosalpinx- mesentry of the fallopian tubes. 3) Mesovarium- mesentry of the ovaries. c) The broad ligament serves as a mesentry for the uterus, ovaries and tubes. d) It helps in maintaing the uterus in position, but not a major contributing factor.

Adnexa

a) Region on the side of the uterus. b) Made up of the ovaries, fallopian tubes, and there associated blood vessels, ligaments, and connective tissue. c) This can also be more specifically referred to adnexa uteri

Gonadal arteries

a) They originate from the anterior aspect of the aorta and travel inferiorly to there respective organs. b) In males these are called the testicualar arteries. c) In females these are called the ovarian arteries.

Culdocentesis

aspiration of fluid from cul-de-sac, puncture of peritoneum.

What are the major muscles included in the false pelvis?

iliopsoas, rectus abdominus, and transverse abdominis.

Obturator internus

origin-innominate bones, course parallel to lateral walls of the true pelvis.