Anatomy - 48 - Female Pelvis

True or false: the ovary is covered by peritoneum AND fimbriae.

False. Ovaries open into the body cavity. They are roughly covered by fimbriae; however they are not contiguous with the oviduct directly.

What are fimbriae?

Fimbriae are the sweeping structures meant to pull an egg (after ovulation) into the oviduct. They are usually found encircling the ovary.

What are the three layers of the uterus?

Perimetrium Myometrium Endometrium

Besides the uterus, what other pelvic structures can prolapse?

Really any pelvic structure could prolapse. While the uterus is most common, other forms of prolapse (like rectal prolapse or small bowel prolapse) are real possibilities.

What artery gives rise to the ovarian artery? What ligament carries the ovarian artery to the ovary?

The ovarian artery is (usually) a branch of the abdominal aorta. The ovarian artery is carried to the ovary through the suspensory ligament of the ovary.

What are the three parts of the uterus? Describe their relative location.

1. The fundus - the superior portion of the uterus. 2. The body - the main portion of the uterus 3. The cervix - the inferior portion of the uterus that is contiguous with the vagina. The cervix is delineated from the body by the thickenings of the uterus (internal and external os).

What important structures pass through the broad ligament (female pelvis)? I counted seven.

1. The round ligament of the uterus 2. Fallopian tubes 3. The ovaries 4. The Uterus (body and fundus) 5. Suspensory Ligament (of the ovary - - includes ovarian blood vessels) 6. The proper ovarian ligament. 7. The posterior fornix of the vagina

In terms of anteflexion, retroversion, and retroflexion, label the following images of the uterus.

A. Normal (labeled on image) B. Excessive anteflexion C. Retroverted D. Retroverted and retroflexed

A 32-year-old woman develops fever and left lower abdominal pain 3 days after delivery of a full-term male. Abdominal examination shows a tender, palpable mass. Ultrasonography of the mass shows an ovarian vein thrombosis. The thrombus is most likely to extend into which of the following veins? A. Left internal iliac vein B. Left renal vein C. Left external iliac vein D. Left internal pudendal vein E. Hemiazygous vein

B. Left renal vein. The ovaries descended from superior to inferior during development. This rules out the iliacs and pudendal veins. Hemiazygous is really a pretty ridiculous answer, leaving left renal vein as the best answer. Wikipedia says that the ovarian vein arises from the inferior vena cava or the left renal vein.

What is endometriosis? Discuss the causes, signs, and symptoms of endometriosis.

Every month uterine endometrium grows and thickens. Then it dies and sloughs off. Endometriosis is a condition in which endometrial-like cells are found outside of the uterus (in the body cavity). These cells behave like endometrial cells in response to the same hormones as the uterine endometrial cells. Pelvic pain, scarring (from the cells dying), and infertility are common symptoms of endometriosis. It is believed that endometrial cells regressing through the fallopian tubes and into the body cavity (that seed their surroundings) may be a cause of endometriosis.

True or false: the male pelvis contains structures that are analogous to the fibrous pelvic structures of the female. Both sexes contain thick, fibrous sheets/ligaments that provide support and carry vessels.

False. The male pelvis's fascia is generally considered to be less-fibrous than female pelvic fascia.

True or false: because the ovaries lie superior to the pelvic pain line, they are supported by sympathetic nerves and not parasympathetic nerves.

False. There is an ovarian plexus of mixed nerves (including parasympathetic) that innervate the ovaries. The parasympathetic innervation of the ovaries actually comes from the vagus nerve. (This is possible because, like the testis, the ovaries descended inferiorly during development).

Where does the uterus sit relative to the bladder? How does this compare to the prostate in males?

Immediately superior to the bladder. The relative position of the uterus actually gives support to the female bladder. This is the opposite of the position of the prostate in males. In males, the bladder sits on top of the prostate. In females, the uterus sits on top of the bladder.

What is culdocentesis? Describe how culdocentesis is done? How about culdoscopy?

In the female pelvis, fluid is most likely to accumulate in the recto-uterine pouch. This fluid can be removed through culdocentesis. Culdocentesis involves inserting a needle into the recto-uterine pouch via the posterior fornix (which is very close to the recto-uterine pouch). Once within the pouch, the needle can be used to aspirate fluid. Culdoscopy is the same process; however, a camera is inserted, allowing physicians to visualize the recto-uterine pouch.

Relative to the pelvic pain line, what is the difference between a spinal block, a caudal epidural, and a pudendal block?

Spinal Block - the needle is inserted high enough to involve (numb) the nerves that supply the uterus (which are superior to the pelvic pain line). Caudal Epidural - the needle is inserted in such a way (and place) that all of the tissues inferior to the pelvic pain line will be numb. The uterus (which has extended above this line) will retain some feeling. Pudendal block - only the superficial nerves below the pelvic pain line are numb.

What is the cardinal ligament of the uterus? Describe it. How is it significant?

The cardinal ligament is one of the major ligaments of the uterus (really a pair of ligaments). The cardinal ligament contains the uterine artery and vein, making it indispensable to the uterus. The cardinal ligament also provides important support to the uterus.

Describe the cardinal ligament (female).

The cardinal ligament is the superior-most portion of the broad, wide, fibrous paracolpium. It is a lamina that is markedly more substantial and centrally located (relative to other female pelvic laminae).

Mesovarium is a name for a portion of a female pelvic ligament. What is the ligament? What portion of the ligament is called mesovarium?

The mesovarium is the portion of the broad ligament of the uterus that covers the mesentary of the ovaries.

What is the pelvic pain line?

The pelvic pain line is a division between afferent fibers that are sympathetic and those that are parasympathetic. In other words, a certain line in the pelvis separates the structures whose afferent (sensory) innervation is provided by parasympathetic from the structures whose afferent (sensory) innervation is provided by sympathetic fibers. In the female pelvis, structures inferior to the line travel with parasympathetic and those superior to the line travel with sympathetic fibers.

What is the recto-uterine pouch? Where is it located? Why is it significant?

The recto-uterine pouch is one of two pouches of the female pelvic area (males have only one). The recto-uterine pouch lies posterior (between the rectum and the uterus). Fluid, infection, etc. is likely to congregate at this point: it is one of the lowest point of the pelvis. TThe recto-uterine pouch has lateral extensions that go deeper than the vesico-uterine pouch. Females have to pelvic pouches because of the action of the broad ligament and extension of the uterus into the pelvis (it separates the pelvis into two areas). This pouch can be surgically approached via the posterior fornix of the vagina.

What is the suspensory ligament of the ovary?

The suspensory ligament of the ovary is a fold of peritoneum that stretches from the ovary to the wall of the pelvis. The suspensory ligament is important because it houses the blood vessels of the ovary, the nerves of the ovary, and lymphatic drainage of the ovary.

What are vaginal fornices? Why are they important? What are the three types of vaginal fornix?

The vaginal fornices are the deepest portions of the vagina. They extend into the recesses created by the vaginal portion of the cervix. There are three types (that are named): 1. Posterior Fornix - a large recess behind the cervix that is close to the recto-uterine pouch (can be used surgically to approach the recto-uterine pouch). 2. Anterior Fornix - a recess that is close to the vesico-uterine pouch. 3. Lateral Fornix - no explanation given by Dr. Kramer or wikipedia.

What is the vesico-uterine pouch? Where is it located? Why is it significant?

The vesico-uterine pouch is one of two pouches of the female pelvic area (males have only one). The vesico-uterine pouch lies anterior (between the bladder and the uterus). Fluid, infection, etc. is likely to congregate at this point: it is one of the lowest point of the pelvis. The recto-uterine pouch has lateral extensions that go deeper than the vesico-uterine pouch. Females have to pelvic pouches because of the action of the broad ligament and extension of the uterus into the pelvis (it separates the pelvis into two areas).

What is a third degree uterine prolapse?

Third degree prolapse occurs when the uterus descends very deep into the vagina and may even cause the vaginal wall to become everted. This condition tends to be more common in elderly women, and pregnancy, particularly challenging pregnancies, are thought to be the cause. Dr. Kramer said that as many as 50% of women will have some form of uterine prolapse, while only 10-20% will be symptomatic.

What is an ectopic pregnancy?

When an embryo implants anywhere other than the uterus. These can range from cervical implantations to implantations in the body cavity (not in the fallopian tube, uterus, cervix, or anywhere in between).

A 29-yo woman with a ruptured ectopic pregnancy is admitted for culdocentesis. A needle is most efficiently inserted through which of the following structures? A. Umbilicus B. Posterior fornix of the vagina C. Anterior fornix of the vagina D. Anterior wall of the rectum E. Posterior wall of the bladder

B. Posterior fornix of the vagina. This is the structure closest to the recto-uterine pouch.

True or false: the broad ligament of the female pelvis is analogous to ligaments of the skeletal system: it is strong, wide, and fibrous.

False. The broad ligament is the opposite of the kind of ligaments that we saw in bones and skeletal muscle: it is not strong at all. The broad ligament is simply composed of two layers of peritoneum. The broad ligament is essentially a serous membrane.

What is a first degree uterine prolapse?

First degree prolapse occurs when the uterus begins to descend into the vagina. This condition tends to be more common in elderly women, and pregnancy, particularly challenging pregnancies, are thought to be the cause. Dr. Kramer said that as many as 50% of women will have some form of uterine prolapse, while only 10-20% will be symptomatic.

What is a second degree uterine prolapse?

Second degree prolapse occurs when the uterus descends deep into the vagina. This condition tends to be more common in elderly women, and pregnancy, particularly challenging pregnancies, are thought to be the cause. Dr. Kramer said that as many as 50% of women will have some form of uterine prolapse, while only 10-20% will be symptomatic.

Typically, the arteries that feed the uterus and vagina come from which branch of the internal iliac artery?

The anterior branch of the internal iliac artery.

What term defines the part of the uterus that sits closest to the vagina?

The cervix.

To which lymph node do the lymph vessels that drain the ovaries empty?

The lumbar lymph node. This is exactly like the testicles.

Mesometrium is a name for a portion of a female pelvic ligament. What is the ligament? What portion of the ligament is called mesometrium?

The mesometrium is the portion of the broad ligament of the uterus that covers the mesentary of the uterus. This is the largest single portion of the broad ligament.

True or false: the uterus is drained by several different lymph nodes. This makes staging uterine cancer difficult unless the location of the uterine tumor is very well known.

True. Dr. Kramer listed three common lymph nodes into which the uterus drains. See the attached image.

Ectopic pregnancies are rare. What is the most common site for an ectopic pregnancy?

Tubal ampular ectopic pregnancies are the most common (around 80%). This means that the embryo has implanted in the fallopian tube. Because the fallopian tube is very vascular, this can be incredibly dangerous for the mother.

A 22 year old woman receives a deep cut in the inguinal canal 2 inches lateral to the pubic symphysis. Which ligament is lacerated? A. Suspensory ligament of the ovary B. Ovarian ligament C. Mesosalpinx D. Round ligament of the uterus E. Rectouterine ligament

D. The round ligament of the uterus. The round ligament sits anterior to most of the structures of the female pelvis. Additionally, the round ligament runs through the inguinal canal, which sits anterior.

Describe the difference between the fascia of the female pelvis and the peritoneum of the female pelvis.

The fascia of the female pelvis is very thick and strong. Often, it serves a supportive role. Peritoneum on the other hand is very serous and is often translucent. A lot of vascularization is visible through the peritoneum.

Mesosalpinx is a name for a portion of a female pelvic ligament. What is the ligament? What portion of the ligament is called mesosalpinx?

The mesosalpinx is the portion of the broad ligament of the uterus that covers the mesentary of the Fallopian tubes.

What is the proper ligament of the ovary (also called the ovarian ligament)?

The proper ligament of the ovary is a fibrous ligament that attaches the ovary to the lateral surface of the uterus.

What factors increase the likelihood of ectopic pregnancy?

Trouble with the cilia of the fallopian tube. Often, ectopic pregnancy is the result of failure among the cilia of the fimbriae and fallopian tube. Cilia can be damaged or dysfunctional through environmental factors, genetics, etc. Pelvic inflammatory disease, some sexually transmitted diseases, etc. can also contribute to ectopic pregnancy. The cause of many ectopic pregnancies is not known.

True or false: as is the case in males, the female bladder sits just posterior to the pubic symphysis.

True. The position of the male and female bladder (relative to the pubic symphysis and pelvic brim) are essentially the same. This means that the bladder typically sits behind the pubic symphysis, but often extends above it (toward the pelvic brim) when it is full.

True or false: during pregnancy, the uterus grows so much that it can stretch as high as the xiphoid process.

True. Wow.