Q. Discuss the relations, blood supply, nerve supply and clinical importance of pelvic part of ureter.
Q. Discuss the anatomy of the pelvic part of ureter.
Arises at: The bifurcation of iliac artery
Extent: From pelvic brim to bladder
Length: 13 cm
Diameter: 5 mm
Relations:
In downward course it is related to:
Posteriorly:
- ◼ Internal iliac vein
- ◼ Commencement of anterior division of internal iliac artery
- ◼ Internal iliac artery
- ◼ Lumbosacral trunk
- ◼ Sacroiliac joints
Laterally:
- ◼ Fascia covering obturator internus
- ◼ Superior iliac vessels
- ◼ Inferior vesicular vein
- ◼ Middle rectal veins.
It forms the posterior boundary of ovarian fossa.
Mnemonic: SOFIO (A) come laterally.
In forward course it is related to:
- ◼ Ureter lies in the extraperitoneal connective tissue in the lower and middle part of broad ligament of uterus
- ◼ Uterine artery first lies above and front of the ureter for a distance of about 2.5 cm, then crosses it superiorly from lateral to medial side
- ◼ Ureter lies about 2 cm lateral to the supravaginal part of cervix
- ◼ Terminal portion is anterior to vagina.
Blood supply to pelvic part of ureter: is through vesicle, middle rectal and uterine vessels.
Nerve supply
- ◼ Sympathetic: T10-L1
- ◼ Parasympathetic: S2-S4.
Pelvic part of ureter is identified by using the following points:
- ◼ It has a glistening appearance
- ◼ It is firm cord-like when felt
- ◼ Presence of peristalsis
- ◼ Longitudinal vessels in it.
Clinical importance of the pelvic part of ureter:
- ◼ It may be damaged by/because of:
- – Abnormal course
- – Wertheim's hysterectomy
- – Endometriosis
- – Pelvic inflammatory disease
- – Abdominal hysterectomy
- – Broad ligament tumors.
Mnemonic: PABA—PID, Abdominal hysterectomy, Broad ligament tumors. Abnormal Course/Abnormal number.
- ◼ Damage to its blood supply causes avascular necrosis of the ureter hence causes fistula. In radical hysterectomy damage is not because of direct injury but because of stripping from peritoneum which causes avascular necrosis
- ◼ Site of ureterovaginal, ureterouterine and ureterocervical fistulas.
Q. Describe the origin, incretion, blood supply and functions of pelvic floor.
Q. Describe the anatomy of pelvic diaphragm.
Q. Describe the anatomy of Levator ani.
Pelvic Diaphragm is a muscular partition separating the pelvis from anatomical perineum.
It consists of three sets of muscle on either side:
- ◼ Pubococcygeus
- ◼ Iliococcygeus
- ◼ Ischiococcygeus.
Collectively these muscles are known as Levator ani.
Origin of Levator ani:
- ◼ From back of pubic rami
- ◼ Fascia covering obturator internus (white line)
- ◼ Inner surface of ischial spine.
Insertion of Levator ani: The fibers run downward, backward and medially to get inserted to the following:
- ◼ Perineal body
- ◼ Anal canal
- ◼ Anococcygeal body
- ◼ Lateral part of coccyx
- ◼ Lower sacrum.
Mnemonic: PAALL's
Gaps: Two gaps are noted in the midline:
- ◼ Hiatus urogenitalis: Anteriorly, transmits urethra and vagina
- ◼ Hiatus rectalis: Posteriorly, transmits rectum
Relations:
Superior surface:
- ◼ Pelvic organs: Bladder, vagina, rectum
- ◼ Pelvic cellular tissue
- ◼ Pelvic nerve
- ◼ Ureter lies in the floor
- ◼ Uterine artery.
Inferior surface: It is related to anatomical perineum.
Blood supply: Inferior gluteal vessels.
Nerves supply:
- ◼ Sacral nerve 3rd and 4th
- ◼ Inferior rectal nerve
Functions:
- ◼ Elevation of pelvic floor
- ◼ Support pelvic organs
- ◼ Maintains intra-abdominal pressure by reflexly responding to it
- ◼ Facilitates anterior internal rotation of presenting part
- ◼ Ischiococcyx stabilizes sacroiliac and sacral joints
- ◼ Puborectalis ancillary to external anal sphincter
- ◼ To steady perineal body
- ◼ Pelvic floor and pregnancy.
During pregnancy pelvic floor becomes less rigid and more lax.
In stage two of the labor pubovaginalis and puborectalis relax and levator ani is drawn-up over the advancing presenting part, so as to elongate the birth canal.
Q. Describe the origin, incretion, blood supply and functions. Fallopian tubes/uterine tubes.
Fallopian tubes is a paired structure about 10 cm long.
It is situated in medial 3/4th of the upper free margin of broad ligament.
It has two openings:
- ◼ Uterine ostium
- ◼ Pelvic/abdominal ostium.
Abdominal ostium is surrounded by a number of radiating fimbriae. One of these is longer than the rest and is attached to the outer part of the ovary; this is called as ovarian fimbria.
Histology:
Histologically it consists of three layers:
- ◼ Serosa, covered by peritoneum on all sides
- ◼ Muscular layer: Outer longitudinal and inner circular
- ◼ Mucosa.
Mucosa is thrown into longitudinal folds, lined by columnar epithelium at places ciliated.
Note that there is no submucosa.
Blood supply:
Arterial supply: Ovarian and uterine artery.
Venous drainage: Pampiniform plexus of veins → ovarian veins.
Nerve supply: Uterine and ovarian nerves.
Functions:
- ◼ To transport the gamete
- ◼ To facilitate fertilization and survival of zygote by its secretions.
Clinical importance:
- ◼ Commonly affected by PID
- ◼ Common site of ectopic pregnancy
- ◼ Fallopian tubes (TB) is commonest cause of infertility in India.
Q. Describe the anatomy of Pouch of Douglas.
Q. Describe the relations and clinical importance of pouch of Douglas.
Pouch of Douglas is a narrow peritoneal cul-de-sac in the pelvis between rectouterine space, it is continuous with pararectal fossa on either side.7
Relations:
Anteriorly:
- ◼ Peritoneal covering of cervix
- ◼ Posterior vaginal fornix
- ◼ Upper 1/3rd of the posterior vaginal wall.
Posteriorly: Peritoneal covering of anterior surface of the rectum.
Laterally: It is limited by uterosacral folds of peritoneum covering uterosacral ligaments.
Floor: It is formed by reflexion of anterior peritoneum on anterior surface of rectum.
Contents: It is usually empty, may contain coils if intestine or omentum.
Clinical importance:
- ◼ Herniation of pouch causes enterocele
- ◼ It is the site of pelvic abscess and hematocele
- ◼ Site for culdocentesis
- ◼ DD for nodular deposits in pouch are: Endometriosis, pelvic malignancy and TB.
Q. Describe the blood supply of uterus.
Uterus is chiefly supplied by
- ◼ Chiefly by two uterine arteries
- ◼ Partly by ovarian arteries.
Uterine artery is a branch of anterior division of internal iliac artery. It crosses the ureter at about 1.5 cm away at the level of internal os before it ascends upwards along the lateral border of uterus between the layers of broad ligament. It is tortuous hence not affected by enlargement of uterus.8
Ovarian artery is a branch of aorta a little below origin of renal artery.
Venous drainage is into internal iliac veins.
Q. Describe the lymphatic drainage of cervix and its importance.
Primary groups:
- ◼ Parametrial group
- ◼ Obturator group
- ◼ External iliac group
- ◼ Internal iliac group
- ◼ Sacral group.
Secondary group: To which the primary group drain into. They are:
- ◼ Common iliac group
- ◼ Superior lumbar group.
Clinical importance:
- ◼ Carcinoma cervix first spreads to primary group and later to secondary group
- ◼ During radical hysterectomy:
- – Paramedical, obturator group, external iliac group, internal iliac group of lymph nodes are removed, even common iliac group at times
- – Sacral group of lymph nodes are not removed
- – Enlarged para-aortic group of lymph nodes are evaluated, if enlarged frozen section is done.
Q. Nabothian cyst.
Definition: These are cysts formed due to occlusion of cervical glands usually as a result of chronic erosion followed by epidermidization.
- ◼ Usually they are multiple
- ◼ They are microscopic to pea size
- ◼ Lining epithelium is columnar type
- ◼ Presence of the cyst further away from the external os indicates the extent of transformation zone.
Treatment: It is directed towards chronic cervicitis.
Q. Bartholin‘s glands (Fig. 1.3)
- ◼ It lies posteriolateral to vaginal orifice deep to bulbos-pongiosus
- ◼ It is a racemose variety of gland
- ◼ Lined by cuboidal cells, ductal portion by transitional epithelium and outer region by squamous epithelium
- ◼ Opens outside hymen at the junction of the anterior 2/3rd and posterior 1/3rd of the vagina
- ◼ It is female counterpart of bulbo urethral glands
Function: Its secretion acts as a lubricant during intercourse.
Q. Doderlein‘s bacillus.
- ◼ Doderlein's bacillus is a rod shaped gram-positive bacilli
- ◼ It grows anaerobically in acidic medium
Origin: Probably from intestine
- ◼ Its presence in vagina depends on the estrogen
- ◼ It appears in the body at 2–4 days of life and disappears from vagina at 10–14 days
- ◼ Reappears at puberty
- ◼ Disappears at menopause
Glycogen in vaginal mucosa → anaerobic utilization → lactic acid → acidic pH of 4–5 → prevents the growth of other pathological bacteria.
Q. Describe the supports of uterus.
Q. Describe the muscular supports of uterus.
Primary supports:
Muscular or active supports:
- ◼ Pelvic diaphragm has been discussed above
- ◼ Perineal body: It is a fibromuscular node to which 10 muscles are inserted: 2 superficial transverses, 2 deep transverses perinei, 2 pubococcyx and levator ani. It is an encourage for pelvic diaphragm hence maintains integrity of pelvic floor
- ◼ Urogenital diaphragm: Consists of a pair of deep transverses perinei and single sphincter urethral muscles.
Fibromuscular or mechanical support:
- ◼ Uterine axis: That is anteverted position. When abdominal pressure increases this position is exaggerated
- ◼ Pubocervical ligament: Connects cervix to posterior surface of pubis
- ◼ Transverse cervical ligament of Mackenrodt:
- – Also called as cardinal ligament
- – It is a fan shaped ligament
- – It is formed from condensation of pelvic fascia on each side of the cervix above
- – Levator ani and around the uterine vessels
- – It connects lateral part of cervix and upper vagina to the pelvic wall
- ◼ Uterosacral ligament: Extends from cervix to periosteum of sacrum
- ◼ Round ligament:
- – Each ligament starts at the lateral angle of the uterus runs forwards and laterally through the deep inguinal ring and inguinal canal to merge with areolar tissue of labia majora.
Secondary supports:
- ◼ Broad ligament
- ◼ Uterovesical fold of peritoneum
- ◼ Rectovaginal fold of peritoneum.