Textbook of Gynecology for Nurses Anupama Tamrakar
INDEX
Page numbers followed by f refer to figure and t refer to table
A
Abdominal
and laparoscopic repair 170
bloating 112
examination 33, 160
hysterectomy 179, 607
myomectomy 618
pain 233
scar 384
wall pain 578
Abnormal
chromosomal pattern 118
height 569
menopause 102
sperm 299
uterine bleeding 129, 611
vaginal
bleeding 226
discharge 226, 570
Abnormalities of
connective tissue 181
fallopian tubes 79
ovaries 80
Abortion 177
Acanthosis nigricans 346, 347
Accessory breast 416
Acetaminophen 598
Acidification of urine 194
Acne 113, 568, 587
Acquired immunodeficiency syndrome 213, 243, 266, 270, 327
Actinomyces 206
Acute
endometritis 225
inversion of uterus 159
pelvic pain 575
pyelonephritis 231
salpingitis 229
Acyclic bleeding 138
Adenocarcinoma 390, 394, 395, 398
Adenomyosis 108, 373, 385, 385f, 577, 578
Adenosquamous carcinoma 398
Adheisolysis 321, 323
Adhesions 108
in uterine cavity 302
Adjuvant chemotherapy 427, 530
Adnexal
mass 233
tenderness 208, 233
Adrenogenital syndrome 118
Agenesis 81
of vagina 560
Albert Smith's pessary 158f
Allergic reactions 113
Allium sativum 351
Alzheimer's disease 450
Amenorrhea 115, 116, 300
American
Cancer Society 426t
College of Surgeons Committee on Cancer 426t
Fertility Society 76
Society for Reproductive Medicine 376
Amputation of cervix 607
Anal
fistulae 187f
sphincter muscles 16f
Androgen 551
excess 124
insensitivity syndrome 472
Anesthesia 594
Angiokeratoma 349
Anomalies of female reproductive tract 83
Anorectal
manometry 199
ultrasound 199
Anorgasmia 579
Anovular bleeding 140, 141
Anovulation 130, 300, 316
Anterior
repair 171
wall prolapse 167
Antibiotic 324, 599, 600
therapy 195, 232
Antiestrogens 547
Antifibrinolytics 149
Antigonadotropins 149, 551
Anti-incontinence surgery 196
Anti-inflammatory drugs 387
Antiphospholipid antibodies syndrome 304
Antiprogesterone 516, 549
Antituberculosis treatment 223
Antitumor antibiotics 531
Aphthous ulcers 342, 350
Appendicitis 227, 231, 239
Arcuate uterus 77, 77f
Arterial supply 6, 9, 13
Artificial insemination 314, 326
Asherman's syndrome 123, 302
Assisted reproductive technology 223, 315, 326
Asthenospermia 314, 336
Asthenozoospermia 299
Astrocytes of nervous system 269
Asymmetry of breast 416
Atresia upper third of vagina and cervix 118
Atrophic
endometritis 226
vaginitis 463
Atrophied duct of Müller 70f
Atrophy in
females 69
males 71
Autoimmune disease 123, 272
B
Bacillary angiomatosis 272
Bacterial
gastroenteritis 231
vaginosis 225, 242, 244, 255, 266
Bacteriuria 451
Bacteroides bivius 225
Baldy-Webster operation 158
Barium enema 239
Barrier
contraceptives 209
methods 482
Bartholin's
abscess 247, 248
cyst 247, 248, 348
gland 5, 70, 72, 198, 217, 247, 262, 394, 395
cancer 391
carcinoma 394
Bartholinitis 246
Basal
body temperature chart 309
cell carcinoma 342, 389, 390, 391
Basic fibroblast growth factor 355
Behçet's
disease 342, 347, 392
syndrome 347, 463
Belly of rectal muscle 596f
Benefits of contraception 482
Benign
and malignant cysts 406
epithelial neoplastic cysts of ovary 363
fibrocystic breast disease 416
lesions of
cervix 352
genital tract 342
ovary 362
uterus 354
tumor
hematomas and cysts 347
in breast 421
vulvar
lesions 342
melanosis 346
Beta-human chorionic gonadotropin 146f
Bicornuate uterus 76
Bilateral salpingo-oophorectomy 91, 102, 528, 608
Biopsy 138, 236, 391, 396
of endometrial tissue 387
of lump 419
Birth
control pills 243
defect 375
Bladder 70f, 72f, 395, 526
and rectal injury 614
and sphincter muscle 444f
and ureter lesions 384, 385
and urethral prolapse 172f
cancer 450
damage 194, 455
neck surgery 446
stones 450
Bleeding per vagina 560
Blistering diseases 342
Blood
and nerve supply of vulva 3
clots 608
dyscrasia 142
pressure medicines 98
progesterone 310
prolactin 310
supply 3, 6, 9, 11, 13, 21, 25
test 95, 124, 131, 136, 144, 208, 241
urea nitrogen 274
vessels and nerves 27
Body
mass index 119, 144, 313
of uterus 575
Bone
marrow suppression 538
mass density 96
testing 95
Bowel
endometriosis 376
resection 201
vaginoplasty 87
Brachytherapy 522
Breast 414, 414f
cancer 422, 473, 528, 541
disorders 414
implant surgery 427
infection 416
lump 418
pain 416
self-examination 61, 62f
surgery 428
tenderness 112
tissue 416
tumor 549
Breastfeeding 267
Bromocriptine 115, 557
Bulbocavernosus 17
Bulbourethral glands 72
Bullous pemphigoid 342
Burkitt
like lymphoma 270
lymphoma 270
Burning vulva syndrome 350
C
Calendar method 489f
Calymmatobacterium granulomatis 260
Cancer 272, 602
Candida albicans 242, 255, 289, 562
Carcinoma
cervix and endometrial carcinoma 138
in situ 43, 43f, 397
Cardinal ligament 10, 28
Cardiovascular disease 95, 473
Catheter 249
collection 38
drainage 196
Catheterization of urethral meatus 39f
Causes of
abnormal vaginal discharge 571f
amenorrhea 121
dysuria 463t
excessive secretion 570
infertility in
female 299
male 298
menopause 91
pain 105
in dysmenorrhea 105f
retroverted uterus 155
Cavity of
uterus 8
womb 302
Cell cycle 529f
Central nervous system 112, 117, 269, 376, 450
Certain endothelial cells 269
Cervical
abnormalities 611
biopsy 604
cancer 138, 151, 397, 527, 541
cap 486f
cysts 354
cytology 396
dystocia in labor 614
endometriosis 138
eversion 353
fibroids 356
hostility 330
incompetency 614
intraepithelial neoplasia 64, 397
lesions 151
leukorrhea 570
motion tenderness 208, 233
mucus 45, 302
polyp 361
smear 108
stenosis 614
Cervicitis 234, 290, 463
Cervix 7, 213, 575
Chancroid 255, 259, 342
Chemotherapy 123, 222, 408, 427, 518, 528, 529, 540
Cherney incision 595
Chest
wall stretch 434, 435f
X-ray 396, 592
Chlamydia 235
infection 211, 264, 397
trachomatis 205, 229, 255, 258, 264, 562
infections 299
vaginitis 242, 245
Chlamydial swabs 108
Choriocarcinoma 342, 404
Chromosomal sex 469
Chronic
bronchitis 172
constipation 172, 175
cough 166, 172, 175
endometritis 226
human papillomavirus 349
illness 122
inversion of uterus 149, 162
kidney disease 455
liver disease 129, 547
pelvic
infection 211
pain 378, 576, 607, 611
PID 211
salpingitis 229
strain 166
vulvovaginal candidiasis 347
Cicatricial pemphigoid 342
Classification of
intersex 469
perineal tears 437
urinary incontinence 445f
vulvodynia 350
Clitoris 2, 72, 72f
abnormalities 88
Clomiphene citrate 314, 316, 547
Closure of peritoneum 597
Clotrimazole 290
Coagulation disorders 129, 142
Coexisting disorders 358
Coital
failure 304
injuries 440
Coitus interruptus 487
Cold sweats 113
Colles' fascia 27
Colpocleisis 179, 181
Colpoperineorraphy 174
Colporrhaphy 171, 172
Colposcopy 48, 236
Combination patch contraceptive 505
Combined oral contraceptive pills 107, 146
Complete
absence of vagina 118
blood count 131, 146f, 176
Complex choreography of reproductive hormones 14f
Complications of
genital tuberculosis 221
IVF treatment 334
local repairs 202
menopause 94
repair operations 440
sperm donation procedure 329
surgical treatment 202
transabdominal repairs 202
Computed tomography 152
scan 53, 197, 391
Computer assisted semen analysis 308
Computerized tomography 199, 227
Concomitant fistulas 193
Condyloma acuminata 255, 284
Congenital
abnormalities 301, 305, 334
adrenal hyperplasia 120, 470
bilateral absence of vas deference 298, 336
malformations of female genital organ 74
tuberculosis 221
Congestive dysmenorrhea 104
Conization of cervix 64
Conn's syndrome 554
Connective tissue 27
Constipation 443, 539, 608, 612
Constrictor urethrae 17
Contact
bleeding 138
dermatitis 347
irritant 493
Continuous estrogen and progestin therapy 99
Contraception 31, 482
Contraceptive 502, 516
method 517, 517f
Contrast tests 199
Control of
follicle-stimulating hormone and luteinizing hormone 555
postoperative bladder spasms 195
vaginal muscles 583
Copper T 491f, 492f, 516
Corpus luteum cysts 363
Couple instructions 313
Cowper's gland 70f
Crab louse 255
Craniopharyngioma 122
Credé method over bladder 457
Crohn's disease 118, 198200, 221, 342, 346, 392
Cryosurgery 605
Cryptomenorrhea 116
Cryptosporidium 272
Culdocentesis 55, 55f
Culdoscopy 56, 59
Cure of leukorrhea 572
Cusco speculum 35
Cushing's syndrome 124, 586, 587
Cyclic vulvovaginitis 351
Cyclical breast pain 416
Cyst of organ of Rosenmuller 80
Cystic glandular hyperplasia 142
Cystitis 463
Cystocele 167, 167f
Cystogram 197
Cystometrogram 197
Cystoscopy 56, 58, 59f, 196, 391, 396, 455
Cystourethrocele 172f
Cysts 418, 422
Cytomegalovirus 270
infection 272
D
Danazol 115, 381, 551
Deep
dyspareunia 110
muscle layer 17
vein thrombosis 203, 601
Defective spermatogenesis 298
Degrees of
inversion of uterus 158
retroversion 155
Delayed
ejaculation 305
manifestations of intersex 568
onset adrenal hyperplasia 587f
puberty 117, 567
Deoxyribonucleic acid 227, 262
Depot medroxyprogesterone acetate 504
Depression 112
Dermatitis 392
Dermatofibroma 348
Dermatologic disorders 347
Development of
breast 414
external sexual organs in male and female 68f
female gonads 71
genital organs and gonads 66
male and female internal genitalia 470
male gonads 69
Developmental
anomalies 120
defect of genital tract 118
Diaphragm 485f
Diarrhea 539
Didelphys uterus 75f, 76
Diethylstilbestrol 394
exposed uterus 77f
related anomaly 77
Diffuse large B-cell lymphoma 270
Dilatation of cervix 602
Disorders of
menstrual cycles 104
orgasm 579
Displacement of uterus 154
Diverticulitis 231, 239
Division of cloaca 66
Donovania granulomatis 255
Dorsal lithotomy position 192
Double vagina 82
Dual-energy X-ray absorptiometry 95
Duct of
Gartner 72f
Müller 69f
Ductal carcinoma in situ 424
Ductus
deferens 73
epididymis 73
Dye test 189
Dyschezia 378
Dysesthetic vulvodynia 351
Dysfunction of
nerves and tissues 181
thyroid and adrenal cortex 118
Dysfunctional uterine bleeding 138, 139, 140t, 556, 566
Dysmenorrhea 104, 112, 156, 378, 577, 578
Dyspareunia 156, 226, 233, 248, 378, 583, 614
Dysuria 226, 378, 461
E
Econazole 290
Ectoparasitic infections 291
Ectopic
anus 561
pregnancy 78, 177, 221, 231, 334, 584
ureter 88, 88f
Egg collection 332, 336
Ehlers-Danlos syndrome 166
Ejaculatory
defect 299
dysfunctions 326
Elbow winging 433, 433f
Electromyography 455
Electronic brachytherapy 525
Elevated erythrocyte sedimentation rate 208
Embryo
donation 337, 338
replacement 333
transfer 326, 333, 334f, 338
cycle 331f
procedure 338
Embryonic structures 72
Emergency
contraception 515
contraceptive pills 515
Endocervix 395
Endometrial
biopsy 46, 47f, 48t, 131, 144, 151, 310, 396
cancer 151, 528
carcinoma 401
curettage 219
hyperplasia 602, 611
lining 302
polyp 151, 360, 602
resection 150
sampling 144
Endometrioid cystadenocarcinoma 81
Endometriomas 371
Endometriosis 108, 123, 231, 300, 301, 305, 322, 330, 347, 373, 373f, 376, 577, 584, 607
Endometriotic cysts 354
Endometritis 225
Endometrium 8, 213, 395
Endoscopic
instrumentation 196
tests 451
Enlarged breast 560
Enterocele 172, 173f
Enzyme-linked immunosorbent assay 220, 263, 271
Epidermal
growth factor 355
inclusion cyst 348
Epidermolysis bullosa 342
Epididymis 70f
Epididymo-orchitis 463
Epimenorrhagia 140
Epimenorrhea 140
Epithelial
cysts 363
disorders 342
Epoophoron 27, 73
Epstein-Barr virus 347
Erectile
dysfunction 299, 305
layer 22
Erector clitoridis 17
Erythema multiforme 342
Erythrocyte sedimentation rate 230, 577
Escherichia coli 229
Estrogen 13, 374, 545
replacement therapy 178, 194
secreting tumors 151
therapy 169
withdrawal bleeding 139
Ethambutol 223
Ethamsylate 149
Evaluation of couples seeking insemination treatment 326
Excess growth hormone 587
Excision biopsy 391
Exploration of phobia 583
External
beam radiotherapy 521
genitalia 1
radiation therapy 519
sphincter ani 16
Extramammary Paget's disease 391
F
Failure of fertilization in IVF 336
Fallopian
ovaries 575
tube 10, 213, 214, 575
carcinoma 410
contraction 109
Familial benign chronic pemphigus 342
Fatigue 218, 282, 283, 284, 526, 539
Female
condom 484f
infertility 315
intersex 470
pelvis 4
perineum 26, 26f
reproductive organs 1, 2f
sterilization 509
Fenticonazole 290
Fern test 45
Ferning of cervical mucus 125
Fertility
and retroverted uterus 157
awareness method 488
issues 371
Fetal cysts 366
Fever 226, 233, 282
Fibroadenomas 418, 422
Fibrocystic masses 421
Fibroids 108, 354, 607, 611
Fibroma 348
Fibromyoma 348
Fibrous coat 20
FIGO staging
guidelines for cancer of vulva 392
system for
cervical cancer 399
endometrial carcinoma 403
ovarian cancer 408
vaginal carcinoma 396
Fimbriated extremity of left fallopian tube 72f
Finasteride 589
First degree
tear 437
uterine prolapse 177f
Fitz-Hugh-Curtis syndrome 209
Fixed retroverted uterus 156
Flap
method 439
splitting techniques 192
Fluid replacement 598
Foley catheter 161
Follicle
cyst 362, 363f
stimulating hormone 13, 130, 318
Follicular swelling 109
Fothergill operation 180
Fourth degree tear 437
Fulguration of fistula 190
Functional
incontinence 452
menorrhagia 141
Functions of
bladder 20
cervix 8
ureters 21
uterus 9
vagina 5
Fungal infection 392
G
Gabapentin 98
Galactorrhea 419
Gamete intrafallopian 335
transfer 325, 326, 383f, 547
Gamma-aminobutyric acid system 112
Gardnerella vaginalis 206, 225, 244, 255, 266, 562
Gartner's duct 69, 73
Gastroenteritis 576
Gastrointestinal infections 270
Gene therapy 543
Genetic sex 469
Genital
crisis 560
fistulae 186
gland 69
herpes 235, 255, 276, 283, 342
injuries 437
irritation 282
malignancy 389, 413
organs 66, 67
tract injuries 437
tubercle 72
tuberculosis 212
warts 235, 284, 286
Genitofemoral nerve neuralgia 350
Genitourinary fistula 186, 187f
Ginkgo biloba 352
Gland of Bartholin 72f
Glycosuria 451
Glycyrrhiza glabra 351
GnRH
agonists 149, 320
antagonists 320
Gonadal
dysgenesis 471, 476
sex 469
Gonadotropin releasing hormone 331f, 383f
agonists 115, 381
analogues 319
Gonorrhea 232, 235, 255, 261
Gräfenberg spot 4
Granuloma inguinale 255, 260, 342
Graves' disease 101
Gubernaculum 73
testis 70f, 73
Guinea pig inoculation 220
Gynecologic cancer 607
H
Haemophilus
ducreyi 255, 259
influenzae 206
parainfluenzae 206
vaginalis 255
Hailey-Hailey disease 342
Hair loss 538
Having hysterectomy 173
Headache 106, 112, 283
Heart 33
damage 539
Hemangioma 348
Hematometra 614
Hematuria 451
Hemoglobin 132f
Hemorrhage 81, 601, 608, 612, 614
Heparin 324
Hepatitis
B virus 255, 287
C virus 255, 288
Herpes
genitalis 350
simplex virus 234, 255, 276
virus 235
Heterotopic sebaceous glands 349
Hidradenoma 348
High
blood pressure 587
density lipoprotein 96
dose rate brachytherapy 523
grade squamous intraepithelial lesion 398
risk sexual behavior 232
vaginal swab 108
Hirsutism 568, 585
HIV infections 235
Hodgkin's lymphoma 213
Hormonal
contraception 397
imbalance 142, 602
method 496
sex 469
status 44
therapy 194, 380, 545
Hormone
contraception therapy 381
replacement therapy 97f, 98, 120, 182
tests 307
therapy 98, 387, 533
Hot flashes 113
Huge enlargement of breast 416
Human
chorionic gonadotropin 14, 119, 144, 314, 366
hormone 318, 319
immunodeficiency virus 48, 233, 253, 255, 266, 271, 325, 396, 441, 483
leukocyte antigen DK 324
menopausal gonadotropin 314, 318
papillomavirus 40, 234, 235, 254, 255
infection 397
Hydatid cyst of Morgagni 80
Hydrastis canadensis 351
Hydrocolpos 561f
Hymen 6, 73, 82
abnormalities 81
Hypergonadotropic hypogonadism 117
Hypericum perforatum 352
Hyperinsulinemia 586
Hyperpigmented macules 346
Hyperprolactinemia 587
Hyperstimulation syndrome 576
Hypertension 587
Hyperthyroidism 124
Hypogonadotropic hypogonadism 117
Hypomenorrhea 136
Hypopituitarism 117
Hypospadias 298, 299
Hypothalamic
and pituitary dysfunction 117
hamartoma 122
pituitary-ovarian axis
defect 120
dysfunction 566
Hypothyroidism 124, 142, 587
Hysterectomy 150, 170, 180, 211, 232, 387, 446, 607
Hysterosalpingocontrast sonography 312
Hysterosalpingogram 310
Hysterosalpingography 49, 220
Hysteroscopy 56, 57, 58f, 131, 145, 152, 311
and endometrial curettage 138
I
Idiopathic
hirsutism 586f
thrombocytopenic purpura 129, 566
Immunological infertility 324
Immunosuppression 232
Immunotherapy 324, 518, 533, 540, 541
Impaired urinary elimination 453
Imperforate hymen 82, 83f, 118, 560
In vitro fertilization 53, 303, 322326, 330, 331f, 333, 361, 382, 383f, 547
Incomplete
abortion 602
inversion 159
Incontinence of urine 157
Infections of pelvic organs 225
Inferior opening of vagina 72f
Infertility 78, 227, 297, 306, 314, 378, 527, 614
Infiltrating
ductal carcinoma 424
lobular carcinoma 424
Inflammatory
bowel disease 199, 201
breast cancer 424
diseases 342
Infundibulopelvic ligament 27
Inguinal lymphadenopathy 236
Insemination 328, 329f
Insertion of
Cusco speculum 36f
Mirena 142
mixture of eggs and sperms 335f
Inspection of
cervix and vaginal walls 34
vulva 35f
Instrumental injuries 442
Insulin-like growth factor 355
Internal
anal sphincter 24
female genital organs 4f
genital organs 3
radiation therapy 519
sphincter ani 16
International
Association for Study of Pain 574
Federation of Gynecology and Obstetrics 392
Society for Study of Vulvar Disease 350
Intersex 469, 480, 560
Interstitial cystitis 463
Intestine 70f
Intra-arterial chemotherapy 535
Intracavitary chemotherapy 535
Intracervical
fixing device 490f
insemination 326, 327
Intracytoplasmic sperm injection 303, 308, 326
Intraductal papillomas 422
Intraepithelial neoplasia of vagina 390
Intrafallopian insemination 326, 329
Intramural fibroids 356
Intraoperative radiation therapy 519
Intraperitoneal insemination 326, 329
Intrapleural chemotherapy 536
Intrathecal chemotherapy 536
Intrauterine
adhesions 302
contraceptive device 49, 121
device 130, 133f, 148, 207, 209, 226, 482, 489, 492f, 493, 516
growth restriction 78
insemination 315, 323325, 327
system 107
Intravaginal insemination 326
Intravenous
immunoglobulin 324, 325
pyelogram 396
pyelography 190
urogram 189
urography 196
Intravesical chemotherapy 535
Invasive
carcinoma 43, 43f
cervical cancer 270
Irregular
bleeding per vagina 362
menstrual periods 157, 587
ovulation or infertility 157
periods 108
uterine bleeding 611
vaginal bleeding 92
Irritable
bladder sometimes giving stress incontinence 110
bowel 110
syndrome 378
Ischemia 187
Ischiocavernosus 17
Isoniazid 222, 223
Itching 344
IVF
pregnancy 334
surrogates 339
J
Jack-Knife position 192
Juxtaurethral fistula 188
K
Kallmann's syndrome 117, 120, 299, 314
Kaposi sarcoma 270272, 275
Kartagener's syndrome 298
Kegel exercises 171, 178, 183, 448, 449, 451
Kielland forceps 187
Kissing ulcers 259
Klinefelter's syndrome 299, 472, 473f
Kobelt cyst 80
Koilocytosis 43
L
Labia majora 1, 72
abnormalities 87
Labia minora 1, 72, 259
abnormalities 87
Labioscrotal swelling 72
Lactational amenorrhea 116
method 488
Lactobacillus acidophilus 244
Laparoscopic
ovarian drilling for polycystic ovarian syndrome 320
procedure 194
treatment of endometriosis 383f
Laparoscopically assisted vaginal hysterectomy 611
Laparoscopy 56, 108, 111, 145, 170, 227, 333, 379
and dye test 311
Large fibroids 166, 175
Laser
treatment 589
welding 194
Latzko technique 192, 192f
Lawson positions 192
Le Forts procedure 181f
Leech bite 566
Legal issues surrounding surrogacy 340
Lentiginosis 346
Lentigo 346
Lesions in cervix and vagina 384, 385
Letrozole 548
Leukemia 342, 347
Leukocytosis 239
Leukorrhea 563, 570
Leuprolide 556
acetate 115
Levonorgestrel intrauterine delivery system 99
Leydig cells 472
Lichen
planus 342, 392
sclerosus 342, 343, 343f
Life after
abdominal hysterectomy 610
vaginal hysterectomy 613
Ligaments of pelvis 28f
Ligamentum transversalis colli 28
Lipoma 348
Lipschutz ulcer 342, 347
Liver damage 540
Lobular carcinoma in situ 423
Local
diseases 461
injuries 441
repair methods 201
Localization of referred pain 575t
Location and types of fibroids 356
Longitudinal
incision of rectal muscle 596f
septum 82
Loop electrosurgical excision procedure 286, 398
Loss of
feminine body shape 587
libido 579
Low
pain 230
density lipoprotein 96
dose rate brachytherapy 523
grade
fever 218
squamous intraepithelial lesion 398
platelet count 538
Lowenstein-Jensen media 220
Lower
abdominal
fullness 454
incisions 597t
pain 208, 218, 226, 454
phallic part of urogenital sinus 67
Lugol's iodine 398
Lung 33
cancer 473
damage 539
disease 473
Lupus erythematosus 342
Luteal phase
defect 300, 316
support 337
Luteinized unruptured follicle 300, 316
Luteinizing hormone 13, 91, 318, 369
Lymph
drainage 6, 9, 11, 25
nodes metastases 426
Lymphangiography 49, 50
Lymphangioma 349
Lymphatic spread 213
Lymphedema 527
Lymphocyte immunization treatment 324
Lymphogranuloma venereum 255, 258, 342
Lymphoma 398
Lymphoreticular system 269
M
Mackenrodt's ligament 28
Magnetic resonance imaging 53, 177, 197, 199, 209, 357, 379, 386, 392, 419
Malaise 226
Male
and female derivatives of embryonic urogenital structures 72t
condom 483f
intersex 471
sterilization 513
Malignancy 360
Malignant
cancer 405
melanoma 342
polyps 360
Mammogram 419
Mammography 63
Management of
dysfunctional uterine bleeding 146, 147t
fallopian tube carcinoma 411f
shock 160
Manchester operation 613
Manchester repair 180
Mantoux test 219
Marfan syndrome 166
Marshall-Marchetti-Krantz procedures 449
Marsupialization 249
Mastalgia 416
Masturbation 583
Maternal ovarian cysts 366
Maturation index 45t
Mayer-Rokitansky-Kuster-Hauser syndrome 76, 85
Maylard incision 595, 596f
McIndoe procedure 87
Medium-dose rate brachytherapy 523
Medroxyprogesterone 135
Mefenamic acid 146
Megestrol acetate 135
Melanocytic nevus 346
Melanoma 391, 398
Membranous dysmenorrhea 105
Menarche 15
Menopause 14, 15, 90, 92, 95, 100, 155, 180, 446
Menorrhagia 129, 132f, 133f, 134t, 611
Menstrual
blood analysis 219
cramps 104
cycle 13
disorders 218, 566
irregularities 369
Menstruation 13, 229, 282, 284
Mesonephric
cysts 354
duct 73
tubules 73
Metabolic disorders 118
Metaplasia 374
Metformin 371, 589
Methods of
contraception 482, 483f
egg collection 333
Metropathia hemorrhagica 142
Metroplasty 323
Metrorrhagia 137, 611
Meyer and Lvanoff theory 374
Miconazole 290
Microepididymal sperm aspiration 315
Microglia of nervous system 269
Microperforate hymen 85, 86f
Micturition 22
Middle pelvic part of urogenital sinus 67
Midvaginal fistula 188
Mifepristone 549
Mild dyskaryosis 43
Minimizing valsalva maneuvers 195
Miscarriage 157, 602
Mitotic inhibitors 532
Mittelschmerz
pain 577
syndrome 109
Mixed
agglutination reaction test 307
gonadal dysgenesis 477
Mobile retroverted uterus 156
Mode of
administration 547
infection 206
spread 213, 399
transmission 254, 261, 267, 276, 286
Moderate dyskaryosis 43
Molluscum contagiosum 255, 286
Monilial vaginitis 255, 289
Monitoring of IUI treatment cycle 328
Mons pubis 1
Mood swings 112
Mother-to-child transmission 273
Mucinous cystadenocarcinoma 81
Mucopurulent discharge 233
Mucous
coat 21, 22
cysts 347
membrane 11
polyp of cervix 138
Müllerian
abnormalities 577
agenesis 118, 330
duct 71, 74, 76
tubercle 73
Multiple
fistula 193
pregnancies 334, 397
sclerosis 450
Muscle layers 16
Muscular
coat 20, 22
layer 11
Mycobacterium
avium
complex 272
intracellulare 271
tuberculosis 206, 213, 219
Mycoplasma
hominis 206, 255
infection 255
Myomectomy 323
Myometrium 8
N
Nabothian cysts 354
Nafarelin acetate 115
Narrow introitus 81
National Health Service 43
Natural
conception 334
methods 487
surrogates 339
Nausea 106, 113, 233, 283, 526, 538
Neisseria gonorrhoeae 205, 229, 255, 261
Neoadjuvant chemotherapy 530
Neodymium: yttrium-aluminum-garnet 149
Neonatal leukorrhea 560
Neoplasms 566
Neoplastic transformation 81
Neosalpingostomy 321
Neoureterocystostomy 89
Neoureterostomy 88
Nephroureterectomy 89
Nerve supply 6, 9, 11, 13, 16, 18, 21, 25
of vesicourethral unit 23f
Neuroendocrine carcinoma 398
Neurological disease 450
Neurons of nervous system 269
Neurophysiology of pain 574
Neurosyphilis 257
Nevus cells 346
Night sedation 593
Nipple discharge 61
Non-carcinoma malignancies 398
Non-cyclic breast pain 417
Non-gonococcal urethritis 255
Non-hormonal treatment 96
Non-infectious vaginitis 242, 246
Non-neoplastic enlargement of ovary 362
Non-specific vaginitis 255
Non-steroidal anti-inflammatory
drugs 108, 146, 360, 380, 598
painkillers 106
Norethisterone 146
Normal values of semen variables 307
Nucleic acid amplification 220
Nulliparity 105
Nutritional supplements 114
O
Obesity 105, 130, 166, 173, 175, 181, 566, 568, 586
Offensive vaginal discharge 362
Oligodendrocytes of nervous system 269
Oligomenorrhea 137, 141, 369
Oligoovulation 300
Oocyte
donation 337
retrieval 332
Oophorectomy 211, 232, 614
Oophoritis 216, 232
Opening of Bartholin's ducts 3
Operations of ovary 614
Optimizing irradiation plan 524
Oral
contraceptive 111, 139
pills 115
estrogen regime 99
hormone replacement therapy 195
route 148
steroidal contraception 496
Organ 74
dysfunction 129
of Giraldes 70f
prolapse 183
Organogenesis 75
Osteoporosis 94, 473
Outcome of in vitro fertilization pregnancy 334t
Outer surfaces of bladder 19
Outpatient antibiotic therapy 210
Ovarian
cancer 151, 231, 406, 528, 542
cystectomy 56, 614
cysts 177, 231, 547, 577, 584
enlargement 561
failure 330
follicles 73
hyperstimulation syndrome 319
lesions in
adolescence 367
childhood 367
woman 366
ligament 11, 73
remnant syndrome 577
stimulation with clomiphene citrate 325
tumors 142
vein and pelvic venography 111
wall rupture 109
wedge resection 320
Ovaries 11, 27, 71, 72f, 73, 213, 377, 395
Overall management of
dysfunctional uterine bleeding 146f
menopause 97f
Ovular bleeding 140
Ovulation 229
induction 316, 319
problems 300, 326
tests 309
Ovulatory dysfunction 316
P
Paget's disease 390
Pain 160, 409
during sex 108
management 598, 600
Painful
menstruation 104
scar 305
Palpation 34
of vagina and cervix 35
Pap
smear 40, 42, 125, 144, 236
cytology 176
test 39
test 241
Papanicolaou
grading 41, 41t
test 41, 41t, 176
Papillary
serous cystadenoma 81
vulvar hirsutism 349
Papillomatosis 349
Paracetamol 107
Paradidymis 73
Paramesonephric
cyst 80
duct 73
Parametritis 239
Paraovarian cyst 80
torsion 81
Parkinson disease 450, 454
Parovarium 72f
Partially imperforate hymen 108
Parts of
fallopian tubes 10, 10f
uterus 6, 7f, 8f
Pediculosis 255
pubis 291
Pelvic
abscesses 232, 238
adhesions 578
congestion syndrome 110, 577
examination 34, 138, 391
floor 15
electrical stimulation 452
exercises 183
muscle and stress urinary incontinence 446f
muscle training 448
fracture 446
infections 250
inflammatory disease 108, 127, 134, 155, 188, 205, 205f, 225, 227, 239, 253, 262, 459, 483, 576, 578, 584
injury 454
malignancy 196
muscle rehabilitation 451
organ 177
prolapse 165, 174, 611
pain 233, 574
peritoneum 25
peritonitis 227
pneumography 50
rest 195
sonography 138
ultrasound 108, 111
ureters 20
Pemphigus vulgaris 342
Penetrating pelvic trauma 196
Penicillium marneffei 271
Penis 70f, 72
Percutaneous
epididymal sperm aspiration 315, 330, 329
estrogen gel 99
Perimenopause 90
Perimetrium 9
Perinatal
death 334
transmission 267
Perineal
body 29
tear 438t
Perineoplasty 606
Perineum 3, 88
abnormalities 88
Peritoneal
closure 597
oocyte and sperm transfer 326
Peritoneum 377
Permanent methods 509
Persistent vaginal bleeding 607
Pessary 169
Peutz-Jeghers syndrome 346
Pfannenstiel incision 594
Phthirus pubis 255, 291
Phyllodes tumors 422
Piper methysticum 352
Placental polyp 362
Platelet-derived growth factor 355
Plication of round ligaments 158
Pneumocystis
carinii pneumonia 272
jiroveci 274
pneumonia 274
Polycystic ovarian
disease 123, 547
syndrome 119, 129, 297, 310, 320, 368, 566, 586f
Polymenorrhea 134, 369
Polypectomy 323
Polyps 301, 566
Position of
pelvic organs 4f
uterus 154
Positron emission tomography 54, 98
Postcoital
fertility test 45
test 45, 312
Posterior
cul-de-sac obliteration 377
repair 174
vaginal fornix 158f
wall prolapse 167
Post-inflammatory
hyperpigmentation 346
hypopigmentation 346
Postmenopausal
bleeding 150
hormone therapy 98
Postoperative failure 193
Postvoid residual volume 451
Pouch of Douglas 37, 60, 172, 238
Poxvirus 255
Precancerous cells 392
Precocious puberty 563, 566
Pregnancy 155, 527, 566
testing 328
Premature
birth 78
menopause 100, 339
ovarian failure 100
Premenarchal disorders 561
Premenopausal menorrhagia 142
Premenopause 90
Premenstrual
dysphoric disorder 98, 111, 113
syndrome 111, 419, 577
Preterm delivery 334
Prevalence of sexually transmitted infections 253f
Preventing
pelvic organ prolapse 182
urinary tract infections 460
Previous
ectopic pregnancy 301
pelvic surgery 175
Primary
amenorrhea 117, 118
central nervous system lymphoma 270
dysmenorrhea 105
fallopian tube carcinoma 410, 412, 412t
vaginismus 580
Principles of
chemotherapy 530
closure of peritoneum 597
immunotherapy 540
surgery 439
vesicovaginal fistula repair 190
Prior pelvic surgery 181
Proctoscopy 56, 60, 391
Progesterone 13, 548
Progestins 99
Progestogen 115, 146
contraceptives 107
only pill 497f
Progressive multifocal leukoencephalopathy 272
Prolactinoma 122, 566
Prolapse of
rectum into vaginal wall 173f
urethra 171
urethral mucosa 566
Prophylactic cranial irradiation 519
Prostate 70, 70f
cancer 463
gland 72
Prostatic utricle 72
Prostatitis 463
Proteinuria 451
Pruritus vulva 572
Pseudofollicular salpingitis 215
Pseudolumps 418
Psoriasis 344, 345f
Psychological
distress 350
sex 469
Puberty menorrhagia 141
Pubic
hair 526
lice 291
Pubocervical ligament 10
Pulmonary infections 270
Pulsatile gonadotropin releasing hormone 319
Punch biopsy 391
Purified protein derivative 219
Pyogenic granuloma 349
Pyrazinamide 222, 223
Pyuria 451
Q
Quadruplets 334
R
Radiation
sources 525
therapy 196, 409
Radical hysterectomy 618
Radiofrequency ablation 359
Radiotherapy 518
techniques 521
Rash 283
Reactive arthritis 463
Rectal electroejaculation 329, 330
Rectocele 172, 173f
Rectovaginal
examination 37
fistula 197, 197f
Rectum 23, 72f, 395
Recurrent fistula formation 193
Reducing anxiety 250, 293
Referred pain 350
Regional chemotherapy 535
Reiter syndrome 265
Remains of Wolffian
duct 72f
tubes 72f
Removal of
ovarian cysts 56
vaginal epithelium and insertion of catheter 192f
Replication cycle of human immunodeficiency virus 269f
Results of three swab tests 189t
Rete
ovarii 73
testis 73
Retention of urine 454
Retrocessed uterus 154
Retrograde
menstruation 374
pyelography 196
Retroverted uterus 154, 155f, 158
Reversal of
sterilization 321
vasectomy 315
Rhythm method 488
Rifampicin 223
Rifampin 222
Right obliterated Wolffian duct 72f
Robotic-assisted abdominal sacrocolpopexy/sacrouteropexy 180
Round ligament 72f, 73
of uterus 27
Rupture 81
of tubo-ovarian abscess 576
S
Sacrocolpopexy 181
Sacrohysteropexy 179
Sacrospinous fixation 179, 181
Saline infusion
sonography 131
sonohysterography 145
Salmonella infection of bloodstream 272
Salpingectomy 210, 232, 616
Salpingitis 228, 228f
Salpingolysis 321
Salpingoscopy 56, 57
Salpingostomy 321
Sarcoma 390
botryoides 395
Sarcoptes scabiei 255
Scabies 255, 291
Schroeder disease 142
Scotoma 547
Scratches in vagina 243
Screening of
donors 337
recipient 337
Scrotum 70f, 72
Sebaceous gland hyperplasia 349
Seborrheic keratosis 348
Second
degree
tear 437
uterine prolapse 177f
layer suture 192
Secondary
amenorrhea 121
dysmenorrhea 107
fallopian tube carcinoma 412
infection 81
sexual characteristics in females 119f
vaginismus 581
Seizures 283
Selection of type of incision 596
Selective
estrogen receptor modulators 96, 97f
salpingography 322
serotonin reuptake inhibitors 98, 112, 114
Self-exploration of sexual anatomy 583
Semen analysis 306
Seminal
colliculus 73
vesicles 73
Seminiferous tubules 73
Sensation of vaginal fullness 160
Sepsis 527
Septal resorption 75
Septate
hymen 85, 86f
uterus 76, 77f
Septic
abortion 239
shock 227
Septicemia 227
Septoplasty 323
Septum 81
Serological tests 220
Serotonin deficiency 112
Serous cystadenocarcinoma 81
Sertoli-cell-only-syndrome 299
Severe
abdominal or pelvic pain 157
anemia 527
dyskaryosis 43
insulin resistance 587
oligospermia 336
uterine atony 162
Severely anteflexed uterus 154
Sex hormone-binding globulin 120
Sexual
contact 272
education 583
intercourse 605
organs of
female embryo 72f
male embryo 70f
relations 526
transmission 267
Sexually transmitted
disease 144, 205, 207, 227, 229, 254, 292, 346, 459, 483
infections 227, 253, 255t
Sheehan's syndrome 122
Shock 601
Shortening of vagina 193
Shortness of breath 409
Shoulder
blade
squeeze 434, 434f
stretch 433, 434, 434f
stretch 436f
Sigmoidoscopy 56, 60, 239, 396
Simple
bone screening 95
cystometry 451
fistulotomy 201
Sims' speculum 35, 188
Sims-Huhner test 45
Sites of origin of breast cancer 424f
Skene's
duct cyst 348
glands 236
Skin
graft 87
hair 526
Small
birth weight 334
bowel prolapse 173f
breast 415
cell carcinoma 398
Smooth muscle cell contraction 109
Solid benign tumors of ovary 364
Somatic nervous system 21
Sonohysterography 52, 52f, 131
Sources of
embryo donors 337
external radiation therapy 519
infection 562
internal radiation therapy 520
radiation therapy 519
Spasmodic dysmenorrhea 105
Sperm
collection 336
function tests 308
injection 336
washing and preparation 328
Spermicides 487
Sphincter
ani
externus 16
internus 16
muscle 446
urethral membrane 17
vaginae 17
Spinal cord
injuries 166, 175, 330
lesions 450
Spinnbarkeit 44
Spondyloarthropathies 463
Spongy part of urethra 70f
Spread of infection 251, 294
Squamous cell
carcinoma 342, 343, 389391, 394, 398
hyperplasia 344
Staging of
breast cancer 426t
primary fallopian tube carcinoma 410t
Staphylococcus aureus 225
Sterilization 509
Steroidal
contraception 496
devices 505
Steroids 243
Stillbirth rate 334
Stimulated emission of radiation 64
Streptococcus
agalactiae 206
faecalis 229
Stress 566
incontinence 445, 453
urinary incontinence 445
Stromal endometriosis 387
Structure of
bladder 19
fallopian tube 11
human immunodeficiency virus 266f
urinary bladder 19f
vagina 5
Subacute inversion 160
Subdermal implants 99
Submucosal fibroids 356
Submucous
fibroid 138
myomas 578
Subserosal fibroids 356
Subzonal insemination 326
Superficial
and deep layer muscles of pelvic floor 18f
muscle layer 16
transverse perineal muscle 16
Suppression of ovarian cycle 115
Surgical
menopause 90, 102
therapy 190, 200, 467
Surrogacy 339
Suture
placement 597
technique 597
Suturing deep layer in transverse axis 192f
Swelling of extremities 112
Swollen legs 409
Swyer's syndrome 478, 479
Symptoms of
menopause 93f
vulvitis 240
Syphilis 254, 255, 342
and HIV infection 256
Syringoma 348
Systemic
disease 342, 347
radiation therapy 519
T
Tamoxifen 317, 548
Technique of manual replacement 161f
Temporary methods 482
Teratospermia 314, 336
Teratozoospermia 299
Termination of urogenital sinus 69f
Testicle 70f
Testicular
biopsy 308
sperm
aspiration 329
extraction 315
Testis 69, 73
Testosterone 551
Thayer-Martin medium 263
Theory of Sampson 374
Thermal cauterization 605
Thinning of skin 587
Third degree tear 437
Threatened abortion 231
Three
paired peritoneal ligaments of uterus 10t
swab test 189
Thyroid 33
and adrenal dysfunction 121
dysfunction 566
function tests 132f
Thyrotropin-releasing hormone 119
Tibolone 99
Timing of
ICI 327
intrauterine insemination 328
Topoisomerase inhibitors 531
Total abdominal hysterectomy 102, 528, 608, 610
Toxoplasmosis 272
Tram flap 427
Transabdominal
sonography 50
ultrasound test 51
Transanal advancement flap repair 201
Transcutaneous electrical nerve stimulation 107
Transdermal patch 99, 505
Transient incontinence 453
Transmission
methods 267
of chlamydia 264
Transmitted infections 253, 254
Transurethral resection of ejaculatory ducts 315
Transvaginal
color Doppler sonography 51
inversion repair 201
sonography 50, 51
ultrasound 111, 151
Transverse
section of ureter 20f
vaginal septum 81, 118
Traumatic fat necrosis 422
Treating
acne 371
anorgasmia 579
hair growth 370
period problems 371
prolapse of bladder and urethra 171
vaginal vault prolapse 181
vaginismus 583
Treatment of
abnormal uterine bleeding 134t
infertility 313, 382
leukorrhea 572
osteoporosis 94
precancerous cells 392
Treponema pallidum 254, 255
Trichomonas vaginalis 39, 234, 255, 290, 562, 573
Trichomoniasis 235, 290
vaginitis 245, 272
True gonadal intersex 469, 474
Tubal
adhesions 232
damage 321
disease 330
factor infertility 326
ligation 511f
surgery 321
Tubercular cervicitis 138
Tuberculosis 272
Tuberculosis of
cervix 216
ovaries 216
pelvis 214
uterus 215
vulva 217
Tuberculous peritonitis 217
Tubo-ovarian abscesses 232, 364
Tubular structure of Wolffian body 69f
Tumor 166, 301, 463
node-metastasis 399
Tunica
adventitia 20
mucosa 21
muscularis 20
Turner's syndrome 118, 120, 475, 476f, 478
Twisted ovarian cysts 576
Two
round ligaments 28
uterosacral ligaments 27
Types of
bleeding 138
cancer 391t
delivery 334
emergency contraceptive pills 515
endometritis 225
fibroids 357f
hysterectomy 607
infections 255
non-neoplastic cysts 362
repair 191
salpingitis 229
steroidal contraception 496f
tuberculosis salpingitis 215
vaginal infections 242
Typical stages of brachytherapy procedure 522f
U
Ulcers 177, 392
of vulva 342t
Ultrasound
examination transvaginal sonogram 577
imaging of uterus 386
scan 310, 312
scanning of scrotum 308
Umbilical scar 384
Undescended testis 298
Undetermined intersex disorders of sexual development 474
Unexplained infertility 305, 315, 325, 330, 336
Unicornuate uterus 75f, 76
Unstriped muscular fibers 27
Upper
respiratory infections 113
vesicourethral part 66
Urachus 70f, 72f
Ureaplasma urealyticum 225, 229
Ureter 70f, 72f, 186
Ureterocervical fistula 186
Ureterouterine fistula 186
Ureterovaginal fistula 186, 189, 196
Urethra 21, 186, 350, 395
except navicular fossa 72
Urethral
and paraurethral glands 72
caruncle 138, 466
opening 2
Urethritis 290, 463
Urethrocele 171
Urethrovaginal fistula 186, 188f, 189, 195
Urge incontinence 449, 453
Urinary
bladder 18, 72
incontinence 443, 453
retention 601, 608, 612
tract
calculi 576
infection 36, 177, 231, 443, 455, 457, 484, 576
urethra 72
Urine
culture and sensitivity test 38
dip-stick 309
sample 455
collection for urine culture and sensitivity test 38
Urodynamic tests 455
Uroflowmetry 451
Urogenital
fistulas 186
folds 72
opening 67
sinus 72
Use of
clomiphene 317
intrauterine device 138
progesterone 548
progestin-only contraceptives 138
Uterine 136
abscess formation 227
artery embolization 359
bleeding 142, 143
contractions 229
fibroid 355f, 556, 602
hernia syndrome 478
inversion 158
malformations 74
polyp 138, 302, 360
problems 300, 301, 323
prolapse 167, 174, 607
rupture 162
tube superiorly 27
tumors 151
ultrasound 144
Uterosacral ligament 10, 575
Uterovaginal
canal 315
prolapse 81
Uterus 6, 72f
V
Vagina 72, 72f, 213, 350
Vaginal
abnormalities 81
adenocarcinoma 395
agenesis 85
births 199
bleeding 160, 398, 549, 563
cancer 394
carcinoma 394
cream 99
cuff excision 193
discharge 108, 182, 233, 243, 526
dryness 101
epithelium 5
examination 108, 160, 219
germ cell tumors 395
hysterectomy 179, 610, 612
infections 244, 245, 443, 575
intraepithelial neoplasia 64, 394, 396
introitus 344
irritation 443
leukorrhea 570
opening 3
operations 593
pessary 178
prolapse 167
repair 170
ring 507
septum 81, 108
spasm 305
ultrasound guided egg collection 333
vault
prolapse 167, 180, 180f
suspension 179
wall 172
weight training 451
yeast infections 242
Vaginismus 305, 580, 581f
involuntary tightness 580f
Vaginitis 177, 242, 290
Vaginoplasty 87
Vaginoscopy 562
Valsalva maneuver 195, 452
Vaporization of pelvic endometriosis 64
Varicocele ligation 314
Varicose veins 110
in pelvis 584
Vas
aberrans 70f
deferens 70f
Vascular
bulb 72f
ectopy of cervix 138
endothelial growth factor 355
Vasectomy 513f
Vasogram 308
Vault prolapse 167
Vecchietti procedure 87
Vein open 594
Venereal disease research laboratory 38
test 209, 230
Venous drainage 6, 9, 13, 21
Ventral aspect of penis 72
Verrucous carcinoma 390
Vertical
incision 596
uterus 154
Vesicocervical fistula 186, 193
Vesicourethral portion 69
Vesicourethrovaginal fistula 186
Vesicouterine fistula 186, 193
Vesicovaginal fistula 186, 188f, 189
Vesicula seminalis 70f
Vestibular bulbs 3
Viral
gastroenteritis 231
hepatitis 245, 255, 287
vaginitis 242
Vitiligo 345
Vomiting 106, 233, 283, 538
Von Willebrand's disease 129
Vulva 2f, 72f, 213
Vulval
cancer 392, 393
carcinoma 389
melanoma 390
Vulvar
cancer 528
dermatoses 350
hygiene 562
intraepithelial neoplasia 64, 390
nevi 346
pain syndrome 349
ulcer 346, 347
ulceration 347
vestibulitis syndrome 350, 351
Vulvitis 240
Vulvodynia 350, 352
Vulvovaginal candidiasis 242
Vulvovaginitis 235, 242, 463, 561
W
Wand exercise 433, 433f
Water and blue staining tests 199
Weakened immune system 41, 243
Weight
gain 112
loss 218
blood
cells 37, 208, 230, 460
count 592
lesions of vulva 345
Wolffian
cyst 80
duct 67, 69f
remnant abnormalities 80
Wound infection 601
X
Xeromammography 63
Y
Yeast infections 242
Yellow-green, pruritic, frothy foul-smelling vaginal discharge 290
Z
Ziehl-Neelsen stain 220
Zoledronic acid 102
Zygote intrafallopian transfer 325, 326
×
Chapter Notes

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Anatomy and Physiology of Female Reproductive OrgansChapter 1

The human female reproductive system is a series of organs primarily located inside the body and around the pelvic region of a female that contribute towards the reproductive process. The female reproductive system is located entirely in the pelvis. The external part of the female reproductive organs is called the vulva, which means covering. Located between the legs the vulva covers the opening to the vagina and other reproductive organs located inside the body. The female reproductive organs (Fig. 1.1) are divided into external genitalia, which are visible from outside and the internal genitalia, which include the gonads and those supporting organs, which cannot be seen from outside.
 
EXTERNAL GENITALIA
The entrance to the vagina is surrounded by external parts that generally serve to protect the internal organs, this area is called ‘the vulva’ (Fig. 1.2). The vulva is made up of several female organs, which are external. The vulva is bounded anteriorly by the mons pubis, laterally by the labia majora and posteriorly by the perineum. The vulva consists of the following.
 
Mons Pubis
Mons pubis (mons veneris) is the fatty mound of tissue, made up of subcutaneous adipose connective tissues. It covers the pubic bone. Often called the ‘mons’. In the adult female it is covered by hair.
 
Labia Majora
Labia majora are the elevations of skin and subcutaneous tissue and are also called ‘large lips’. The labia majora pass from the mons pubis to end posteriorly in the skin over the perineal body. This flap of skin protects the vagina from foreign particles. The labia majora are covered with squamous epithelium and contain sebaceous glands, sweat glands and hair follicles. Below the skin, there are dense connective tissue and adipose tissue, which are richly supplied with venous plexus. The inner surface of the labia majora is hairless. The labia majora are homologous with the scrotum in the male.
 
Labia Minora
The labia minora are two thin folds of skin also named as ‘small lips’, which surround and protect the vaginal opening.2
zoom view
Fig. 1.1: Female reproductive organs showing external and internal organs
The labia (singular labium) minora are flattened lengthwise into folds located with the cleft between the labia majora. These folds extend along either side of the vestibule. They are composed of connective tissue that is richly supplied with blood vessels, causing a pinkish appearance. In the back, near the anus, the labia minora merge with the labia majora, while in the front they converge to form a hood-like covering around the clitoris. It is homologous with the ventral aspect of the penis in the male.
 
Clitoris
The clitoris is a small cylindrical, erectile organ measuring about 2.5 cm located above the vaginal opening. It consists of a glans, covered by the frenulum of prepuce. The glans is covered by squamous epithelium and is richly supplied with nerves. The clitoris corresponds to the penis. The clitoris is well supplied with nerve endings and is extremely sensitive. During the coitus it becomes erect and plays an important role in inducing the orgasm in the female. It is also highly vascular. An injury to this causes heavy bleeding and can be very painful.
 
Vestibule
Vestibule is a triangular space bounded by clitoris anteriorly, fourchette in the posterior and labia minora on the either sides.
 
Openings in the Vestibule
There are three openings into the vestibule.
Urethral opening: This lies just posterior to the clitoris about 1.5 cm below the pubic arch. The paraurethral ducts open either on the posterior wall of the urethral orifice or directly into the vestibule.
zoom view
Fig. 1.2: Vulva
3
Vaginal opening: This is situated in the posterior end of the vestibule. In virgins and nulliparae, the opening is closed by the labia minora, but in parous, it may be exposed.
Opening of Bartholin's ducts: Bartholin's glands are situated in the superficial perineal pouch close to the posterior end of the vestibule bulb. Bartholin's glands are pea sized (about 0.5 cm) and yellowish white in color. The Bartholin's gland corresponds to the bulbourethral gland of male. During sexual excitement, these glands produce alkaline mucus, which helps in lubrication. Each gland consists of a duct, which measures about 2 cm and opens into the groove between the hymen and the labium minus. The duct is lined by columnar epithelium, but near its opening, by stratified squamous epithelium.
 
Vestibular Bulbs
Vestibular bulbs are elongated masses of erectile tissues situated below the mucous membrane of the vestibule. Each bulb lies on either side of the vaginal orifice in front of the Bartholin's gland. They are similar to the single bulb of the penis and the corpus spongiosum in the male.
 
Perineum
A stretch of hairless, sensitive skin that extends from the bottom of the vagina till the anus. During childbirth, there may be injury in the perineum due to stretching.
 
Blood and Nerve Supply of the Vulva
 
Blood Supply
The internal and external pudendal arteries supply the vulvar areas. The veins from plexuses drain into internal pudendal vein, vesical venous plexus and long saphenous vein.
 
Nerve Supply
Bilateral spinal somatic nerves supply the vulva. The vulva is supplied by the labial and perineal branches of the pudendal nerve (S2–S4).
 
INTERNAL GENITAL ORGANS
The internal genital organs in female include vagina, uterus, fallopian tubes and the ovaries (Fig. 1.3). The midsagittal section of the female pelvis showing relative position of the pelvic organs is shown in Figure 1.4.
 
Vagina
The vagina (Latin: sheath) is a muscular tube or passage, which forms a part of the female sex organs and connects the neck of the uterus (called the ‘cervix’) with the external genitals. The vagina, which is approximately 2½ to 4 inches long, has muscular walls, which are supplied with numerous blood vessels. The posterior wall is 9 cm long and the anterior wall is 7 cm. These walls become erect when a woman is aroused, as extra blood is pumped into these vessels. The birth canal is directed upward and backwards forming an angle of 45° with the horizontal in erect posture. The long axis of the vagina is almost parallel to the plane of the pelvic inlet and at right angles to that of the uterus. The diameter of the canal is about 2.5 cm, which is widest in the upper part and narrowest at its introitus.
Transverse folds, which are present in the vaginal walls of nulliparae allow the vagina to stretch and dilate during coitus and parturition. These folds are partly obliterated in women who have borne many children.4
zoom view
Fig. 1.3: Internal female genital organs
zoom view
Fig. 1.4: Midsagittal section of the female pelvis showing relative position of the pelvic organs
Many women (perhaps all) have a certain sensitive spot, a cluster of tissue surrounding the urethra, which can be felt and stimulated through the anterior vaginal wall. This tissue (which is probably identical or at least connected with the system of urethral glands) first swells under intense stimulation and then contributes to a specially intense orgasmic release. Anatomically, this sensitive area is known as the ‘Gräfenberg spot (G-spot)‘, after Ernst Gräfenberg who first described it in 1950.5
 
Fornices
The fornices are the clefts formed at the top of vagina due to the projection of the cervix through the anterior vaginal wall. There are four fornices—one anterior, one posterior and two lateral. The posterior fornix is deeper and the anterior is shallow.
Relations
Anterior: The upper one-third is related with the base of the bladder, the lower two-thirds are related with the urethra, the lower half of which is firmly embedded with its wall.
Posterior: The lower third of the vagina is related to the perineal body, the middle third to the ampulla of the rectum and the upper third to the anterior wall of the pouch of Douglas.
Lateral walls: The upper one-third is related to the pelvic cellular tissue at the base of broad ligament in which the ureter and the uterine artery lie about 2 cm from the lateral fornices. The middle third is blended with the levator ani and the lower third is related with the bulbocavernosus muscles, vestibular bulbs and Bartholin's glands.
 
Structure of Vagina
The layers of vagina are:
  1. Mucous coat, which is lined by stratified squamous epithelium without any secretory gland.
  2. Submucosal layer of loose areolar vascular tissues.
  3. Muscular layer consisting of inner circular and outer longitudinal layers.
  4. Fibrous coat derived from endopelvic fascia, which is tough and highly vascular.
 
Vaginal Epithelium
The vaginal epithelium is stratified squamous from birth till 10 to 14 days, which will become thinner with two layers during prepuberty and postmenopause due to the effect of decreased estrogen hormone. After puberty till menopause, the epithelium consists of three layers; basal cells, intermediate cells and superficial cornified cells. The intermediate and superficial cells contain glycogen under the influence of estrogen. These cells become continuous with the cells that cover the vaginal portion of the cervix. The superficial cells exfoliate constantly and more, so in inflammatory or neoplastic condition, replacement of the cells occurs from the basal cells.
 
Secretion
Just prior to the menstruation or in mid-menstrual period, during pregnancy and sexual excitement, the glands of the cervix, uterus, transudation of the vaginal epithelium and Bartholin's glands produce secretions. Normally, there is a presence of Doderlein's bacilli, which changes glycogen in the exfoliated squamous cells to lactic acid and maintains the pH between 4.9 and 3.5. The vaginal secretion consists of tissue fluid, epithelial debris, some leukocytes, electrolytes, proteins and lactic acid.
 
Functions of Vagina
The vagina serves four main functions:
  1. It provides a passageway for the menstrual flow from the uterus to the outside.
  2. It serves as a receptacle for a man's penis and his ejaculated sperm, which then may move on through the cervix.
  3. It provides a passageway for the baby during birth from the uterus to the outside.
  4. The vagina cleanses itself with its own secretions. It also possesses a special protection against infection.
    6
 
Hymen
Hymen is a mucous membrane and is usually circular or crescentic in virgins. It usually ruptures at first coitus. It is a thin membrane of connective tissue, which is situated at the opening of the vagina. This hymen covers the opening of the vagina from birth until it is ruptured during sexual or non-sexual activity. The tissue may also be ruptured by vaginal penetration, pelvic examination, injury or certain types of activities such as horseback riding or gymnastics. Similarly, the presence does not necessarily indicate a lack of prior sexual activity, as it is possible for light activity to not rupture it or for it to be surgically restored. During childbirth, the hymen gets lacerated, which later becomes cicatrized nodules of varying sizes called the ‘carunculae myrtiformes’.
 
Blood Supply, Lymph Drainage and Nerve Supply
Arterial supply: Cervicovaginal branch of uterine artery, vaginal artery (branch of internal iliac artery), middle rectal artery and internal pudendal artery anastomose to form two azygos arteries (anterior and posterior). These two azygos arteries supply blood to vagina.
Venous drainage: A venous plexus, situated in the muscular wall, drains into the internal iliac veins.
Lymph drainage: This is through the deep and superficial iliac glands.
Nerve supply: The vagina is supplied by sympathetic and parasympathetic fibers from the pelvic plexus. The lower part is supplied by the pudendal nerve.
 
Uterus
The uterus (Latin word for womb) is a major female hormone-responsive reproductive sex organ. The uterus is a hollow, muscular pear-shaped structure situated deep in the pelvis and well protected by the pelvic bones. It lies in the pelvic cavity behind the bladder and in front of the bowel.
 
Position
Under normal circumstances the uterus is both ‘anteflexed’ (pointing forward relative to the cervix) and ‘anteverted’ (tipped forward).
 
Measurements
The uterus is about 3 inches (7.6 cm) long, 5 cm wide at the fundus and its walls are about 1.25 cm thick. Its weight varies from 50 to 80 g.
 
Relations
  1. Anteriorly, there is the presence of uterovesical pouch and below the internal os, it is separated from the base of the bladder by loose areolar tissues.
  2. Posteriorly, it is covered with peritoneum and forms the anterior wall of the pouch of Douglas.
  3. Laterally, the double folds of peritoneum (Fig. 1.5) of the broad ligament are attached between which the uterine arteries run up. Mackenrodt's ligament extends from the internal os down to the supravaginal cervix and lateral vaginal wall. At the left side, about 1.5 cm away of internal os, there is the crossing of the uterine artery and the ureter.
 
Parts of Uterus
A female uterus can be divided anatomically into four parts: the corpus, cervix and the isthmus.
Corpus or body: This is further divided into fundus and the body. The fundus is the part, which lies above the openings of fallopian tubes.7
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Fig. 1.5: Coronal section showing different parts of uterus
The body lies between the openings of the tubes and the isthmus, and is triangular in shape. The superolateral angles of the body of the uterus that project outwards from the junction of the fundus and body are called cornua.
Isthmus: The isthmus is a constricted part measuring about 0.5 cm situated between the body and the cervix. It is limited above by the anatomical internal os and below by the histological internal os (Aschoff).
Cervix: The word cervix in Latin means ‘neck’. The cervix (or neck of the uterus) is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall.
The portion projecting into the vagina is referred to as the portio vaginalis or ectocervix. On average, the ectocervix is 3 cm long and 2.5 cm wide. It has a convex, elliptical surface and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the external os and the ectocervix varies widely with age, hormonal state and whether the woman has had a vaginal birth. In women who have not had a vaginal birth, the external os appears as a small, circular opening. In women who have had a vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping.
The passageway between the external os and the uterine cavity is referred to as the endocervical canal. The endocervical canal terminates at the internal os, which is the opening of the cervix inside the uterine cavity. There are pockets in the lining of the cervix known as cervical crypts, which function to produce cervical fluid.
The epithelium of the cervix is varied. The ectocervix is composed of non-keratinized stratified squamous epithelium. The endocervix is composed of simple columnar epithelium.
During most of the menstrual cycle, the cervix remains firm like the tip of the nose and is positioned low and closed. However, as woman approaches ovulation, the cervix becomes softer, and rises and opens in response to the high levels of estrogen present at ovulation. These changes, accompanied by 8the production of fertile types of cervical mucus, support the survival and movement of sperm.
Functions of the cervix
  1. During menstruation the cervix stretches open slightly to allow the endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience.
  2. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm in diameter to allow the child to pass through.
  3. Stimulation of the cervix leads to orgasm for some women. During orgasm, the cervix convulses and the external os dilates.
 
Cavity of the Uterus
The uterine cavity is triangular with the base above and the apex below. It measures about 3.5 cm in length. The cervical canal is fusiform and measures about 2.5 cm.
 
Structure
The layers of the uterine body from innermost to outermost are as follows.
Endometrium: The lining of the uterine cavity is called the ‘endometrium’ (Fig. 1.6). It consists of the functional endometrium and the basal endometrium from which the former arises. The endometrium consists of lamina propria and surface epithelium. This surface epithelium is made up of ciliated columnar epithelium. The lamina propria contains stromal cells, endometrial glands, blood vessels and nerves. The gland contains mucus-secreting non-ciliated columnar epithelium that penetrates stroma.
The endometrium builds a lining periodically, which is shed or reabsorbed, if no pregnancy occurs. Shedding of the functional endometrial lining in humans is responsible for menstrual bleeding throughout the fertile years of a female. During pregnancy, it is designed to provide a home and nutrition for the baby. Endometrium during pregnancy is called ‘decidua’.
Myometrium: The uterus mostly consists of thick bundle of smooth muscle known as ‘myometrium’. The myometrium allows the uterus to expand as the baby grows. During pregnancy, three layers can be identified in myometrium, outer longitudinal layer, middle interlacing layer and inner circular layer.
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Fig. 1.6: Showing different layers and parts of the uterus
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These muscles contract during labor in order to push the baby out of the birth canal.
Perimetrium: The serous coat that surrounds the uterus except on the lateral border is called the ‘perimetrium’. The job of the perimetrium is to protect the other linings of the uterus. Various ligaments help to keep the perimetrium in place inside the uterus.
 
Secretions
A little amount of watery substance is secreted by the endometrium. The cervical glands secrete alkaline mucus with pH 7.8. This mucus is rich in fructose, glycoprotein and mucopolysaccharides. It also contains sodium chloride. Fructose is nutrition for the spermatozoa. With the help of estrogenic effect, glycoprotein facilitates the sperm ascent. Cervical mucus contributes in the formation of mucus plug to close the cervical canal during pregnancy.
 
Functions of the Uterus
The uterus provides structural integrity and support to the bladder, bowel, pelvic bones and organs. The uterus helps to separate and keep the bladder in its natural position above the pubic bone and the bowel in its natural configuration behind the uterus. The uterus is essential in sexual response by directing blood flow to the pelvis and to the external genitalia including the ovaries, vagina, labia and clitoris. The uterus is needed for uterine orgasm to occur.
The reproductive function of the uterus is to accept a fertilized ovum, which passes through the uterotubal junction from the fallopian tube. It then becomes implanted into the endometrium and derives nourishment from blood vessels, which develop exclusively for this purpose. The fertilized ovum becomes an embryo, develops into a fetus and gestates until the childbirth.
 
Blood Supply, Lymph Drainage and Nerve Supply
Arterial supply: Blood is supplied by uterine arteries, branches of the internal iliac arteries. The uterine arteries pass up the lateral aspects of the uterus between the two layers of the broad ligaments. These arteries also supply the fallopian tubes and join with the ovarian arteries to supply the ovaries.
Venous drainage: The veins follow the same route as the arteries and eventually drain into the internal iliac veins.
Lymph drainage: Deep and superficial lymph vessels drain lymph from the uterus and fallopian tubes to the aortic lymph nodes and group of nodes associated with the iliac blood vessels.
Nerve supply: The parasympathetic nerves supplying the uterus and the uterine tubes consist of fibers from S2 to S4 and ends in the ganglia of Frankenhauser that lies on the either sides of the cervix. The sympathetic nerves supplying the uterus consist of the fibers from T10 to L1 spinal segments.
 
Supporting Structures
The uterus is primarily supported by the pelvic diaphragm, perineal body and the urogenital diaphragm. Secondarily, it is supported by ligaments and the peritoneum (broad ligament of uterus).
 
Major Ligaments
Major ligaments are held in place by several peritoneal ligaments, of which the most important (there are two of each) are given in Table 1.1.10
Table 1.1   Three paired peritoneal ligaments of the uterus
Name
From
To
Uterosacral ligament
The posterior cervix
The sacrum of pelvis
Cardinal ligament
The side of the cervix
The ischial spines
Pubocervical ligament
The side of the cervix
The pubic symphysis
Other ligaments near the uterus, i.e. the broad ligament, the round ligament and the suspensory ligament of the ovary, the infundibulopelvic ligament have no role in the support of the uterus.
 
Fallopian Tubes
The fallopian tubes (named after the 16th century anatomist Fallopius) are also called the ‘oviducts’ or ‘uterine tubes’. There are two fallopian tubes on either side of the uterus. They extend out from the uterus, like arms reaching for the ovaries, which are positioned near them. Each of these tubes is roughly 10 cm long and ranges in width from about 1 inch at the end next to the ovary to the diameter of a strand of thin spaghetti. The width varies at different parts along the length, being more towards the ovarian side and thinner, but more muscular towards the uterine side. Its widest part, the ampulla lies next to the fimbria and its importance lies in the fact that fertilization of the ovum by the sperm usually occurs in this region.
Each tube has two openings. One opening connects to the uterus. The other opening is larger, wider and has a number of finger-like projections all around it called the ‘fimbriae’. The fimbriae lie near the ovary of the same side and picks up the ovum at the time it is released from the ovary (ovulation). It is the fimbria that each month urges an egg to exit the ovary and begin its trip towards the uterus. Microscopic hairs called ‘cilia’ line the inner side of the tube and help in propelling the ovum towards the uterus.
 
Parts of Fallopian Tubes
There are four parts (Fig. 1.7), from medial to lateral they are:
  1. Intramural or interstitial lying in the uterine wall, which measures 1.25 cm in length and 1 mm in diameter.
  2. Isthmus almost straight and measures about 2.5 cm long and 2.5 mm in diameter.
  3. Ampulla—tortuous part, which is 5 cm long and is the widest part where most of the time fertilization takes place.
  4. Infundibulum, which measures 1.25 cm in length and 6 mm in diameter.
The beating projections, along with muscle contractions, force the ovum down into the funnel's small end, which opens into the uterus. Inside the tube, there are innumerable hair-like growths called cilia (singular: cilium) whose movements, together with muscular contractions of the tubal wall, sweep the egg towards the uterus. After sexual intercourse, sperm swim up into this funnel from the uterus.
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Fig. 1.7: Cut section of the tube showing different parts of fallopian tubes
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The lining of the tube and its secretions sustain both the egg and the sperm, encouraging fertilization and nourishing the egg until it reaches the uterus.
 
Structure of Fallopian Tube
Fallopian tube consists of three layers:
  1. Serous: This layer consists of peritoneum on all sides except along the attachment of mesosalpinx.
  2. Muscular layer: This layer is arranged in two layers, outer longitudinal and inner circular layer.
  3. Mucous membrane: It is a longitudinal folds lined by columnar epithelium, partly ciliated, others secretary non-ciliated and ‘peg cells’. Below the epithelium is the delicate vascular reticulum of connective tissue. During the menstrual cycle, there are changes in this tubal epithelium.
 
Functions
The functions of the uterine tubes are as follows:
  1. Transport of the gametes.
  2. Facilitates the fertilization.
  3. Survival of zygote through its secretion.
 
Blood Supply, Lymph Drainage and Nerve Supply
Blood supply: Arterial supply is from the uterine and ovarian arteries. Venous drainage is through the pampiniform plexus into the ovarian veins.
Lymph drainage: Deep and superficial lymph vessels drain lymph from the uterus and fallopian tubes to the aortic lymph nodes and group of nodes associated with the iliac blood vessels.
Nerve supply: The nerve supply is derived from the uterine and ovarian nerves.
 
Ovaries
The ovaries are a pair of oval or almond-shaped glands, which lie on either side of the uterus and just below the opening to the fallopian tubes. They are pinkish-white in color and is 3 cm in length, 2 cm in breadth and 1 cm in width approximately. The ovary is located in the lateral wall of the pelvis in a region called the ovarian fossa. The fossa usually lies beneath the external iliac artery in front of the ureter and the internal iliac artery. They are not attached to the fallopian tubes, but to the outer layer of the uterus via the ovarian ligaments.
Each ovary has an outer thick lining called the ‘cortex’ and an inner part called the ‘medulla’. Ovaries in females are homologous to testes in males, in that they are both gonads and endocrine glands.
 
Ovarian Ligaments
In human, the paired ovaries lie within the pelvic cavity on either side of the uterus to which they are attached via a fibrous cord called the ovarian ligament. The ovaries are uncovered in the peritoneal cavity, but are tethered to the body wall via the suspensory ligament of the ovary. The part of the broad ligament of the uterus that covers the ovary is known as the mesovarium. Thus, the ovary is the only organ in human body, which is totally invaginated into the peritoneum, making it the only interperitoneal organ (not to be confused with intraperitoneal).
 
Structure
The surface of the ovaries is covered with epithelial tissue. Beneath the ovarian epithelium there are thousands of microscopic structures called ovarian follicles (Fig. 1.8), which are embedded in a connective tissue matrix known as ‘stroma’.12
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Fig. 1.8: Section of the ovary of a newly born child
The follicles contain the ova and after puberty they are present in varying stages of development.
The section of the ovary in a newly born child shows the following:
  1. The outermost layer is called the germinal epithelium.
  2. The tunica albuginea covers the cortex.
  3. The ovarian cortex consists of ovarian follicles and stroma in between them. Follicles include the cumulus oophorus, membrana granulosa (the granulosa cells inside it), corona radiata, zona pellucida and primary oocyte. The zona pellucida, theca of follicle, antrum and liquor folliculi are also contained in the follicle. Also, in the cortex is the corpus luteum derived from the follicles.
  4. The innermost layer is the ovarian medulla. It can be hard to distinguish between the cortex and medulla, but follicles are usually not found in the medulla.
 
Functions
The ovaries have two primary functions:
  1. They produce and store the female gametes (ova) that are contained in small spheres called primary follicles (primordial follicles). A girl baby is born with about 60,000 of these cells, which are contained in sac-like depressions in the ovaries. During the reproductive life, i.e. from puberty to menopause, the cortex contains numerous ‘graafian follicles’ at different stages of development. Every month a graafian follicle in one of the ovaries matures and releases an ovum. This phenomenon is called ‘ovulation’. During woman's lifetime, only about 400 follicles reach maturity. A woman attains menopause when the number of follicles 13in her ovaries decreases below a critical level. The ovaries shrink in size and become whitish in color. They also secrete lesser amounts of estrogen and progesterone.
  2. They also serve as endocrine glands by releasing the female sex hormones, the estrogens (primarily estradiol) and progesterone. Estrogen is responsible for the appearance of secondary sex characteristics of females at puberty and for the maturation and maintenance of the reproductive organs. Progesterone functions with estrogen by promoting cyclic changes in the endometrium (it prepares the endometrium for pregnancy), as well as by helping to maintain the endometrium in a healthy state during pregnancy.
 
Blood Supply
Arterial supply: This is by ovarian arteries, which branch from the abdominal aorta.
Venous drainage: The pampiniform plexus join to form the ovarian veins, which drain into inferior vena cava in the right side and the left renal vein in the left side.
Nerve supply: The ovaries are supplied by parasympathetic nerves from the sacral and sympathetic nerves from the lumbar outflow.
 
MENSTRUATION
Females at reproductive age experience cycles of hormonal activity that repeat at about 1-month intervals (menstru means ‘monthly’, hence the term menstrual cycle). With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention.
The term menstruation refers to the periodic shedding of uterine lining. Menstruation is the periodic discharge of blood, mucus and epithelial cells from the uterus. It usually occurs at monthly intervals throughout the reproductive period, except during pregnancy and lactation, when it is usually suppressed.
There are four major hormones involved in the menstrual cycle:
  1. Follicle-stimulating hormone (FSH).
  2. Luteinizing hormone (LH).
  3. Estrogen.
  4. Progesterone.
The menstrual cycle is controlled by the cyclic activity of the FSH and LH from the anterior pituitary and progesterone and estrogen from the ovaries. In other words, FSH acts upon the ovary to stimulate the maturation of a follicle and during this development, the follicular cells secrete increasing amounts of estrogen.
 
Menstrual Cycle
The average menstrual cycle takes about 28 days and occurs in phases—the menstrual phase, the follicular/proliferative phase (ov-ulation) and the luteal/secretory phase.
 
Menstrual Phase
Days 1 to 5—this is known as the menstrual phase. A lack of signal from a fertilized egg influences the drop in estrogen and progesterone production. A drop in progesterone results in the sloughing off of the thick endometrial lining, which is the menstrual flow. This occurs for 3 to 5 days.
 
Follicular/Proliferative Phase
Days 6 to 14—this is known as the proliferative phase. A drop in progesterone and estrogen stimulates the release of FSH from the 14anterior pituitary. FSH stimulates the maturation of an ovum with graafian follicle. Near the end of this phase, the release of LH increases causing a sudden burst like release of the ovum, which is known as ovulation.
 
Luteal/Secretory Phase
Days 15 to 28—this is known as the secretory phase. High levels of LH cause the empty graafian follicle to develop into the corpus luteum. The corpus luteum releases progesterone, which increases the endometrial blood supply, endometrial arrival of the fertilized egg. If the egg is fertilized, the embryo produces human chorionic gonadotropin (hCG). The hCG signals the corpus luteum to continue to supply progesterone to maintain the uterine lining. Continuous levels of progesterone prevent the release of FSH and ovulation ceases (Fig. 1.9).
 
Menopause
Menopause is the cessation of menstruation. This usually occurs in women between the ages of 45 and 50. Some women may reach menopause before the age of 45 and some after the age of 50. In common use, menopause generally means cessation of regular menstruation. Ovulation may occur sporadically or may cease abruptly.
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Fig. 1.9: Complex choreography of the reproductive hormones
15
Periods may end suddenly, may become scanty or irregular or may be intermittently heavy before ceasing altogether. Markedly diminished ovarian activity, i.e. significantly decreased estrogen production and cessation of ovulation causes menopause.
 
From Menarche to Menopause
While we tend to think that the female reproductive system remains dormant until a girl is somewhere between 10 and 14 years of age, her sex hormones actually begin to function in the first few months after conception. In fact, gonadotropin-releasing hormone (GnRH), FSH and LH start to circulate in the fetus shortly after the ovaries develop. The levels of FSH and LH in the developing baby are very similar to those found in postmenopausal women.
After a rather turbulent first year during which the newborn baby's system makes the final transition from reliance on her mother's hormones to her own, the reproductive system enters a dormant phase. FSH and LH levels fall to their lowest levels, by the time girls are about 2 years old and then start to rise slowly again between the ages of 4 and 10.
At the age of 6, circulating levels of the male hormone androgen starts to increase. This rise in androgen causes the development of hair under the arms and in the pubic area. Meanwhile, estrogen stimulates breast development and the sex hormones and glands begin to gear up for menarche, the onset of menses. However, at some point between the ages of 8 and 14, LH is secreted at a rate 2 to 4 times higher at night than during the day. This causes estrogen and FSH levels to rise and puberty is underway.
Puberty is traditionally defined by three events—development of the breasts, appearance of pubic hair and the beginning of menstruation. It is important to remember that the time it takes for these changes to occur is extremely variable. While one girl may appear to be fully developed by age 11, her friend next door may not reach puberty until age 14 or 15. Both schedules are considered ‘normal’.
After puberty, the reproductive system continues its regular cycles until around age 40 after which the perimenopausal years begin. At this point, ovarian function and the monthly menstrual cycle tend to become less regular and many of the effects of estrogen in the body start to wane. Menopause (the cessation of the monthly cycle and the end of reproductive capacity) usually occurs between the ages of 45 and 55 in American women, the average age is about 51.
During fetal life, there are about 6 to 7 million eggs. From this time, no new eggs are produced. The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills and in the presence or absence of regular menstrual cycles.
 
PELVIC FLOOR
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus and associated connective tissue, which span the area underneath the pelvis. The pelvic floor separates the pelvic cavity above from the perineal region (including perineum) below.
 
Functions
  1. Pelvic floor is important in providing support for pelvic viscera (organs), e.g. 16the bladder, intestines, the uterus (in females) and in maintenance of continence as part of the urinary and anal sphincters.
  2. Pelvic floor plays an important role during the coitus.
  3. During childbirth, the pelvic floor influences the movements of the fetus through the birth canal and relaxes to allow delivery of the baby.
 
Muscle Layers
The muscles of the pelvic floor are arranged in two layers, the superficial layer and the deep layer.
 
Superficial Muscle Layer
The superficial fascia is very thick, areolar in texture and contains much fat in its meshes. This layer is composed of five muscles, which are as follows.
Sphincter ani externus (external sphincter ani): This is a flat plane of muscular fibers, elliptical in shape. It measures about 8 to 10 cm in length, from its anterior to its posterior extremity and is about 2.5 cm broad opposite the anus. It consists of two strata, superficial and deep. The superficial constituting the main portion of the muscle arises from a narrow tendinous band, the anococcygeal raphé, which stretches from the tip of the coccyx to the posterior margin of the anus, it forms two flattened planes of muscular tissue, which encircle the anus and meet in front to be inserted into the central tendinous point of the perineum. The deeper portion forms a complete sphincter to the anal canal. Its fibers surround the canal, closely applied to the sphincter ani internus and in front blend with the other muscles at the central point of the perineum. Posteriorly, they are continuous with those of the opposite side behind the anal canal.
Nerve supply: A branch from the fourth sacral and twigs from the inferior hemorrhoidal branch of the pudendal supply the muscle.
The action of this muscle is as follows:
  • It keeps the anal canal and orifice closed
  • It can be put into under the influence of the will, so as more firmly to occlude the anus, in expiratory efforts unconnected with defecation
  • Taking its fixed point at the coccyx, it helps to fix the central point of the perineum, so that the bulbocavernosus may act from this fixed point.
Sphincter ani internus (internal sphincter ani): It is a muscular ring, which surrounds about 2.5 cm of the anal canal. It is about 5 mm thick and is formed by involuntary circular fibers of the intestine. Its lower border is about 6 mm from the orifice of the anus. Its action is entirely involuntary. It helps the sphincter ani externus to occlude the anal aperture and aids in the expulsion of the feces (Fig. 1.10).
Superficial transverse perineal muscle: This is a narrow muscular slip, which arises by a small tendon from the inner and forepart of the tuberosity of the ischium.
zoom view
Fig. 1.10: Anal sphincter muscles
17
This is inserted into the central tendinous point of the perineum, joining in this situation with the muscle of the opposite side, the sphincter ani externus behind and the bulbocavernosus in front. The simultaneous contraction of the two muscles serves to fix the central tendinous point of the perineum.
Bulbocavernosus (sphincter vaginae): This surrounds the orifice of the vagina. It covers the lateral parts of the vestibular bulbs and is attached posteriorly to the central tendinous point of the perineum, where it blends with the sphincter ani externus. Its fibers pass forward on either side of the vagina to be inserted into the corpora cavernosa clitoridis, a fasciculus crossing over the body of the organ so as to compress the deep dorsal vein. The bulbocavernosus diminishes the orifice of the vagina. The anterior fibers contribute to the erection of the clitoris, as they are inserted into and are continuous with the fascia of the clitoris, compressing the deep dorsal vein during the contraction of the muscle.
Ischiocavernosus (erector clitoridis): This is smaller than the corresponding muscle in the male. It covers the unattached surface of the crus clitoridis. It is an elongated muscle, situated on the side of the lateral boundary of the perineum. It arises by tendinous and fleshy fibers from the inner surface of the tuberosity of the ischium, behind the crus clitoridis, from the surface of the crus and from the adjacent portion of the ramus of the ischium. The ischiocavernosus compresses the crus clitoridis and retards the return of blood through the veins and thus serves to maintain the organ erect.
Sphincter urethral membrane (constrictor urethrae): This like the corresponding muscle on the male, consists of external and internal fibers. The external fibers arise on either side from the margin of the inferior ramus of the pubis. They are directed across the pubic arch in front of the urethra and pass around it to blend with the muscular fibers of the opposite side, between the urethra and vagina. The innermost fibers encircle the lower end of the urethra.
 
Deep Muscle Layer
The deep muscle layer consists of levator ani muscles. The levator ani is a broad, thin muscle, situated on the side of the pelvis. It is attached to the inner surface of the side of the lesser pelvis and unites with its fellow of the opposite side to form the greater part of the floor of the pelvic cavity (Fig. 1.11). It supports the viscera in pelvic cavity and surrounds the various structures, which pass through it. The right and left levator ani lie almost horizontally in the floor of the pelvis, separated by a narrow gap that transmits the urethra, vagina and anal canal. The levator ani is usually considered in three parts: pubococcygeus, puborectalis and iliococcygeus. In combination with the coccygeus muscle, it forms the pelvic diaphragm.
The pubococcygeus arises from the back of the pubis and from the anterior part of the obturator fascia and is directed backward almost horizontally along the side of the anal canal towards the coccyx and sacrum to which it finds attachment. Between the termination of the vertebral column and the anus, the two pubococcygei muscles come together and form a thick, fibromuscular layer lying on the raphé (anococcygeal raphé) formed by the iliococcygei. The greater part of this muscle is inserted into the coccyx and into the last one or two pieces of the sacrum. The fibers, which form a sling for the rectum, are named the ‘puborectalis or sphincter’ recti. They arise from the lower part of the symphysis pubis and from the superior fascia of the urogenital diaphragm.18
zoom view
Fig. 1.11: Superficial and deep layer muscles of pelvic floor
They meet with the corresponding fibers of the opposite side around the lower part of the rectum and form a strong sling. Relaxation reduces the angle between rectum and anus, allowing defecation in conjunction with relaxation of the internal and external sphincters.
The iliococcygeus arises from the ischial spine and from the posterior part of the tendinous arch of the obturator fascia and is attached to the coccyx and anococcygeal raphé, it is usually thin and may fail entirely or largely replaced by fibrous tissue. It is part of the levator ani group of muscles. Puborectalis is part of the levator ani group of muscles.
Nerve supply: The levator ani muscles are mostly innervated by the pudendal nerve, perineal nerve and inferior rectal nerve in concert. In addition, sacral spinal nerves (S3, S4) innervate the muscles directly as well. Sometimes, the inferior rectal nerve innervates the levator ani muscles independently of the pudendal nerve.
 
ANATOMY OF OTHER ORGANS RELATED TO GYNECOLOGY
 
Urinary Bladder
The urinary bladder is a musculomembranous sac, whose shape is affected by factors including the person's age and sex as well as the volume of urine it contains at the time. It has a considerable power of distension. Its capacity is about 450 mL, but can retain as much as 3 to 4 L of urine. When it distends it gives ovoid shape. The bladder is located on the floor of the pelvic cavity, in front of the uterus and upper vagina. The bladder consists of an apex, superior surface, base, two inferolateral surfaces and neck, which is continuous with the urethra.
 
Relations
The superior surface is related with the peritoneum of the uterovesical pouch. The base is infront of the supravaginal cervix and the anterior fornix. The ureters enter the bladder on its lateral angles. The inferolateral surfaces 19are related with the space of Retzius. The neck lies over the superior layer of the urogenital diaphragm.
 
Structure of Bladder
The bladder consists of four layers (Fig. 1.12):
  1. Outer surfaces of the bladder: The upper and side surfaces of the bladder are covered by peritoneum. This is the serous membrane of the abdominal cavity, sometimes referred to as ‘serosa’. This transparent membrane consists of mesothelium and elastic fibrous connective tissue. It is ‘visceral peritoneum’ that covers the bladder and other abdominal organs, while ‘parietal peritoneum’ lines the abdomen walls.
  2. Muscular: The detrusor muscle is the muscle of the urinary bladder wall. It consists of three layers of smooth (involuntary) muscle fibers. Most of the fibers of the external layer are arranged longitudinally. Those of the middle layer are mostly arranged in a circular configuration and the muscle fibers of the internal layer have a longitudinal arrangement.
  3. Submucous: This is a thin layer of areolar tissue that loosely connects the muscular layer with the mucous layer, being itself intimately attached to the mucous layer.
  4. Mucus: The innermost layer of the wall of the urinary bladder is the mucous membrane, which contains transitional epithelium tissue that can stretch. The stretching ability of this tissue allows variability of the bladder when it is filled and emptied several times per day. Because it is only loosely attached to the muscular layer, the mucosa falls into many folds known as ‘rugae’ when the bladder is empty or is only filled to a small extent.
The features observable inside the bladder are the ureter orifices, the trigone and the internal orifice of the urethra. The trigone is a smooth triangular region between the openings of the two ureters and the urethra.
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Fig. 1.12: Structure of urinary bladder
20
This area has a pale color than the rest of the interior of the bladder and does not present at any rugae even when the bladder is empty—because this area is more tightly bound to its outer layer of bladder tissue.
The internal urethral sphincter is a sphincter (circular) muscle located at the neck of the bladder and formed by a thickening of the detrusor muscle. It closes the urethra when the bladder has emptied.
 
Functions of the Bladder
  1. The purpose of the urinary bladder is to store urine prior to elimination of the urine from the body.
  2. The bladder also expels urine into the urethra by a process called micturition (also known as urination). Micturition involves the actions of both voluntary and involuntary muscles. Lack of voluntary control over this process is referred to as incontinence.
 
Pelvic Ureters
The ureters are the two tubes, which convey the urine from the kidneys to the urinary bladder. It is usually placed on a level with the spinous process of the first lumbar vertebra. The ureter proper measures from 25 to 30 cm in length and is a thick-walled narrow cylindrical tube, which is directly continuous near the lower end of the kidney with the tapering extremity of the renal pelvis.
 
Course and Relations
In female, the ureter forms, as it lies in relation to the wall of the pelvis, the posterior boundary of a shallow depression named the ovarian fossa in which the ovary is situated. It then runs medialward and forward on the lateral aspect of the cervix uteri and upper part of the vagina to reach the fundus of the bladder. In this part of its course, it is accompanied for about 2.5 cm by the uterine artery, which then crosses in front of the ureter and ascends between the two layers of the broad ligament. The ureter is distant about 2 cm from the side of the cervix of the uterus. The ureter is sometimes duplicated on one or both sides and the two tubes may remain distinct as far as the fundus of the bladder. On rare occasions, they open separately into the bladder cavity.
 
Structure
The ureter is composed of three coats: fibrous, muscular and mucous coats (Fig. 1.13).
Fibrous coat (tunica adventitia): This is continuous at one end with the fibrous tunic of the kidney on the floor of the sinus, while at the other it is lost in the fibrous structure of the bladder.
Muscular coat (tunica muscularis): It consists of two layers, longitudinal and circular. The longitudinal fibers become lost upon the sides of the papilla at the extremities of the calyces.
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Fig. 1.13: Transverse section of ureter
21
The circular fibers may be traced surrounding the medullary substance in the same situation. In the ureter proper the muscular fibers are very distinct and are arranged in three layers: an external longitudinal, middle circular and an internal, less distinct than the other two, but having a general longitudinal direction.
Mucous coat (tunica mucosa): This is smooth and presents a few longitudinal folds, which become effaced by distension. It is continuous with the mucous membrane of the bladder below, while it is prolonged over the papilla of the kidney above. Its epithelium is of a transitional character and resembles that found in the bladder. It consists of several layers of cells of which the innermost cells are in contact with the urine are somewhat flattened, with concavities on their deep surfaces into which the rounded ends of the cells of the second layer fit. The intermediate cells more or less resemble columnar epithelium and are pear shaped with rounded internal extremities, which fit into the concavities of the cells of the first layer, and narrow external extremities, which are wedged in between the cells of the third layer. The external or third layer consists of conical or oval cells varying in number in different parts and presenting processes, which extend down into the basement membrane. Beneath the epithelium and separating it from the muscular coats, is a dense layer of fibrous tissue containing many elastic fibers.
 
Functions of the Ureters
  1. The ureters transport urine from the renal pelvis of the kidney to the bladder.
  2. Both the ureters pass beneath the urinary bladder, which results in the bladder compressing the ureters and hence preventing backflow of urine when pressure in the bladder is high during urination.
 
Blood Supply and Nerve Supply
Blood supply: The arteries supplying the ureter are branches from the renal, internal spermatic, hypogastric and inferior vesical.
Venous drainage: It corresponds to the arterial supply.
Nerve supply: The nerves are derived from the inferior mesenteric, spermatic and pelvic plexuses.
 
Urethra
The female urethra is a narrow membranous canal, about 4 cm long, extending from the internal to the external urethral orifice. It is placed behind the symphysis pubis, imbedded in the anterior wall of the vagina and its direction is obliquely downward and forward. It is slightly curved with the concavity directed forward. Its diameter when undilated is about 6 mm. It perforates the fascia of the urogenital diaphragm. The passage of urine along the urethra through the urogenital diaphragm is controlled by the external urethral sphincter, which is a circular muscle under voluntary control [i.e. it is innervated by the somatic nervous system (SNS)]. Its external orifice is situated directly in front of the vaginal opening and about 2.5 cm behind the glans clitoridis. The lining membrane is thrown into longitudinal folds one of which is placed along the floor of the canal is termed the urethral crest. Many small urethral glands open into the urethra.
 
Structure
The urethra consists of three layers—muscular layer, erectile layer and the mucous layer.22
Muscular coat: This is continuous with that of the bladder. It extends the whole length of the tube and consists of circular fibers. In addition to this, between the superior and inferior fascia of the urogenital diaphragm, the female urethra is surrounded by the sphincter urethral membrane.
Erectile layer: It is a thin layer of spongy erectile tissue, containing a plexus of large veins, intermixed with bundles of unstriped muscular fibers, lies immediately beneath the mucous coat.
Mucous coat: It is pale and is continuous externally with that of the vulva and internally with that of the bladder. It is lined by stratified squamous epithelium, which becomes transitional near the bladder. Its external orifice is surrounded by a few mucous follicles.
 
Functions
The urethra is the passageway through which urine is discharged from the body.
 
Physiology of Micturition
Micturition is fundamentally a spinobulbospinal reflex facilitated and inhibited by higher brain centers such as the pontine micturition center and like defecation, subject to voluntary facilitation and inhibition.
In healthy individuals, the lower urinary tract has two discrete phases of activity—the storage (or guarding) phase, when urine is stored in the bladder and the voiding phase, when urine is released through the urethra.
Storage phase
The urine comes into the bladder drop by drop at the rate of 0.5 to 5 mL/minute through the ureteric openings. When the bladder fills, the walls of the bladder stretches to maintain a constant muscle tone. The intravesical pressure is raised to remain almost steady at the level of 10 cm.
The muscles controlling micturition are controlled by the autonomic and somatic nervous systems. During the storage phase, the internal urethral sphincter remains tense and the detrusor muscle relaxed by sympathetic stimulation. During micturition, parasympathetic stimulation causes the detrusor muscle to contract and the internal urethral sphincter to relax. The external urethral sphincter (sphincter urethrae) is under somatic control and is consciously relaxed during micturition.
It is commonly believed that in infants, voiding occurs involuntarily (as a reflex). However, the practice of elimination communication (EC), suggests otherwise. The ability to voluntarily inhibit the micturition develops by the age of 2 to 3 years, as control at higher levels of the central nervous system develops. In adult, the volume of urine in the bladder that normally initiates a reflex contraction is about 300 to 400 mL.
Voiding phase
Voiding begins when a voluntary signal is sent from the brain to begin urination and continues until the bladder is empty. Nerve supply of the vesicourethral unit is shown in Figure 1.14.
Bladder afferent signals ascend the spinal cord to the periaqueductal gray, where they project both to the pontine micturition center and to the cerebrum. At a certain level of afferent activity, the conscious urge to void and becomes difficult to ignore. Once the voluntary signal to begin voiding has been issued, neurons in pontine micturition center fire maximally causing excitation of sacral preganglionic neurons.23
zoom view
Fig. 1.14: Nerve supply of the vesicourethral unit
The firing of these neurons causes the wall of the bladder to contract. As a result a sudden, sharp rise in intravesical pressure occurs. The pontine micturition center also causes inhibition of Onuf's nucleus, resulting in relaxation of the external urinary sphincter. When the external urinary sphincter is relaxed, urine flows from the urinary bladder when the pressure is great enough to force urine to flow through the urethra. The micturition reflex normally produces a series of contractions of the urinary bladder.
The flow of urine through the urethra has an overall excitatory role in micturition, which helps to sustain voiding until the bladder is empty. After urination, the female urethra empties by gravity. Urine remaining in the urethra of the male is expelled by several contractions of the bulbospongiosus muscle.
 
Rectum
At the level of the middle sacrum, the sigmoid colon loses its mesentery and gradually becomes the rectum. At the upper limit of the pelvic diaphragm it ends in the anal canal. It is about 15 cm long and widens below as the ampulla, which is very distensible. The rectum follows the sacrococcygeal curve. At the anorectal junction, the gut curves backward and its concavity is held by the puborectal sling, which can be palpated per anum. The rectum presents three or more lateral curvatures, which correspond to transverse rectal folds in the interior of the gut. It has neither 24mesentery nor haustra and it has an almost complete outer longitudinal muscular coat rather than taenia.
 
Relations
In the upper third of the rectum, its front and sides are covered by peritoneum; in its middle third, the front only; its lower third is devoid of peritoneum. The rectovesical and rectouterine pouches descend within about 7 to 8 cm and 5 to 6 cm, respectively of the anus. Below the pouches, condensations of parietal pelvic fascia are found and the rectum is surrounded by visceral pelvic fascia from the superior fascia of the pelvic diaphragm. Anteriorly, the rectum is related to coils of small intestine in the rectouterine pouch above and to the back of the vagina below. Laterally, the rectum is related to the ileum or sigmoid colon. Posteriorly, the rectum is related to the sacrum, coccyx and pelvic diaphragm.
 
Structure
Rectum consists of three layers—muscular layer, submucous layer and mucous membrane. Rectum is surrounded by rectal fascia. Muscles of rectum consist of outer longitudinal and inner circular fibers. Submucosal layer is loose and contains venous plexuses. Mucous membrane is lined by columnar epithelium.
The median section of rectum and anal canal is given in Figure 1.15.
 
Anal Canal
The anal canal is the terminal part of the large intestine. It is situated between the rectum and anus below the level of the pelvic diaphragm. It lies in the anal triangle of perineum in between the right and left ischiorectal fossa. It is approximately 2.5 to 4 cm long, extending from the anorectal junction to the anus and is directed downwards and backwards. It is surrounded by inner involuntary and outer voluntary sphincters, which keep the lumen closed in the form of an anteroposterior slit. It is differentiated from the rectum by the transition of the internal surface from endodermal to skin-like ectodermal tissue.
 
Relations
The anal canal is surrounded by the levatores ani the anal canal passes through the pelvic diaphragm and the anorectal junction is held forward by the puborectal sling. Below the pelvic diaphragm, the anal canal is surrounded by the sphincter ani externus and the ischiorectal fossa is situated laterally.
 
Anal Sphincters
Internal anal sphincter: It is involuntary in nature, which is formed by thickening of circular layer of the upper two third of the anal canal.
External anal sphincter: It is voluntary in nature and surrounds the entire length of the canal. It consists of three parts:
The subcutaneous part surrounds the lowermost portion of the canal.
The superficial part, situated above the subcutaneous division, is attached to the perineal body and coccyx.
The deep part, more or less continuous with the superficial division, surrounds the uppermost portion of the canal and is associated with the puborectalis posteriorly.
 
Epithelial Linings
The upper two third is lined by columnar epithelium, but the lower third is lined by stratified squamous epithelium.25
zoom view
Fig. 1.15: Median section of the rectum and anal canal
 
Blood Supply, Nerve Supply and Lymph Drainage
Blood supply: The rectum and anal canal are supplied by the superior rectal artery (the continuation of the inferior mesenteric artery) with assistance from the middle and inferior rectal arteries and by the median sacral artery. The submucosal venous plexus above the pectinate line drains into the superior rectal veins (portal system). The submucosal plexus below the pectinate line drains into the inferior rectal veins, which may become varicose resulting in hemorrhoids or piles.
Nerve supply: Parasympathetic fibers supply the smooth muscle including the internal sphincter. Sympathetic fibers are mainly vasomotor. Somatic motor fibers supply the external sphincter. Sensory fibers are concerned with the reflex control of the sphincters and with pain. The anal canal is very sensitive below the pectinate line, so that external hemorrhoids may be very painful.
Lymphatics: The lymphatics from the rectum and upper third of the anal canal drain into internal iliac and preaortic nodes, while the lower third of the anal canal drains into the superficial inguinal nodes.
 
Pelvic Peritoneum
The pelvis is covered internally with a thin, translucent, serous peritoneal membrane, continuous with that of the abdominal cavity. 26It is described as either parietal or visceral, depending on the underlying structures. The vesical peritoneum anteriorly is hardly noticeable unless the bladder is filled and when it remains as extraperitoneal organ covered by parietal peritoneum. Thus, the inferior most portion of the vesicouterine pouch represents the anterior junction of the parietal and visceral parts. As the membrane drapes upward anteriorly over the uterus, round ligaments and uterine tubes, it invests these organs with visceral peritoneum. Posteriorly, these organs and their ligamentous structures continue to be covered by visceral peritoneum as it drapes abruptly, medially and continues downward to the uterine cervix. There it becomes parietal peritoneum, covering the sacrouterine ligaments, which form as a condensation of endopelvic fascia posterolaterally to the cervix and between them. As it reaches the rectum, the visceral peritoneum is reflected upward and circumferentially covering the upper half of the rectum and sigmoid colon, and forming their respective mesenteries posterolaterally. The ‘broad ligament’ actually a mesentery, adjacent to the uterus laterally on either side, is comprised of anterior and posterior parietal peritoneum, with vessels between them. Only the ovaries remain without peritoneum. The small mesentery for the uterine tube is called the mesosalpinx and that for the ovary, the mesovarium. During pregnancy, the peritoneal sac is greatly distorted as the body and fundus grow and distend upward carrying the adnexa and adjacent structures with them.
 
Female Perineum
The perineum in the female is much like that of the male (Fig. 1.16). It has a central point, which converge the external sphincter ani from behind the superficial transverse perinei muscles from each side and the bulbocavernosus muscles from the front. The ischiocavernosus muscles lie along the rami of the pubes. These superficial muscles are reinforced by the deep transverse perinei muscle, which comes from the ramus of the ischium on the side to insert by its anterior fibers around the urethra (compressor urethra), its middle fibers into the vaginal wall and its posterior fibers at the central point of the perineum.
zoom view
Fig. 1.16: Female perineum
27
Also, the levator ani muscle inserts into the lower end of the vagina anteriorly then into the central point of the perineum, next into the lower end of the rectum and finally into the coccyx. The deep layer of the superficial fascia (Colles’ fascia) and the triangular ligament being pierced by the vagina are not so marked as in the male between them lies the ischiocavernosus, bulbocavernosus and superficial transverse perinei muscles.
 
Ligaments
The ligaments of the uterus are eight in number—one anterior, one posterior, two lateral or broad, two uterosacral and two round ligaments.
 
One Anterior Ligament
The anterior ligament consists of the vesicouterine fold of peritoneum, which is reflected to the bladder from the front of the uterus, at the junction of the cervix and body.
 
One Posterior Ligament
The posterior ligament consists of the rectovaginal fold of peritoneum, which is reflected from the back of the posterior fornix of the vagina on to the front of the rectum. It forms the bottom of a deep pouch called the rectouterine excavation, which is bounded in front by the posterior wall of the uterus, the supravaginal cervix and the posterior fornix of the vagina. Behind, it is bounded by the rectum and laterally by two crescentic folds of peritoneum.
 
Two Uterosacral Ligaments
The rectouterine excavation is bounded laterally by two folds of peritoneum, which pass backward from the cervix uteri on either side of the rectum to the posterior wall of the pelvis. These folds are named the sacrogenital or rectouterine folds. They contain a considerable amount of fibrous tissue and non-striped muscular fibers, which are attached to the front of the sacrum and constitute the uterosacral ligaments.
 
Two Lateral/Broad Ligaments
The two lateral or broad ligaments (ligamentum latum uteri) pass from the sides of the uterus to the lateral walls of the pelvis. Together with the uterus they form a septum across the female pelvis dividing that cavity into two portions. In the anterior part contains the bladder, in the posterior part the rectum and in certain conditions some coils of the small intestine and a part of the sigmoid colon. Between the two layers of each broad ligament it contains:
  1. The uterine tube superiorly.
  2. The round ligament of the uterus.
  3. The ovary and its ligament.
  4. The epoöphoron and paroöphoron.
  5. Connective tissue.
  6. Unstriped muscular fibers.
  7. Blood vessels and nerves.
The portion of the broad ligament, which stretches from the uterine tube to the level of the ovary is known by the name of the mesosalpinx. Between the fimbriated extremity of the tube and the lower attachment of the broad ligament is a concave rounded margin called the infundibulopelvic ligament.
Infundibulopelvic ligament (suspensory ligament of the ovary) includes the portion of the broad ligament, which extends from the infundibulum of the fallopian tube to the lateral pelvic wall. It contains ovarian vessels, nerves and lymphatics from the ovary, fallopian tube and body of the uterus.28
Ligamentum transversalis colli (Mackenrodt's ligament/cardinal ligament) is located at the base of the broad ligament of the uterus on either side of the cervix uteri. It is attached to the side of the cervix uteri, vault and lateral fornix of the vagina and is continuous externally with the fibrous tissue, which surrounds the pelvic blood vessels.
Importantly, it contains the uterine artery and uterine vein. There is a pair of cardinal ligaments in the female human body. It thus provides support to the uterus and also provides lateral stabilization to the cervix at the level of ischial spine. It may be of clinical significance in hysterectomy.
 
Two Round Ligaments
The round ligaments (ligamentum teres uteri) are two flattened bands of 10 to 12 cm in length, situated between the layers of the broad ligament in front and below the uterine tubes. Commencing on either side at the lateral angle of the uterus, this ligament is directed forward, upward and lateralward over the external iliac vessels. It then passes through the abdominal inguinal ring and along the inguinal canal to the labium majus in which it becomes lost. The round ligaments consists principally of muscular tissue prolonged from the uterus, also some fibrous and areolar tissue besides blood vessels, lymphatics and nerves enclosed in a duplicature of peritoneum, which in the fetus is prolonged in the form of a tubular process for a short distance into the inguinal canal. This process is called the canal of Nuck. It is generally obliterated in the adult, but sometimes remains pervious even in advanced life. It is analogous to the saccus vaginalis, which precedes the descent of the testis.
Different ligaments of the pelvis are shown in Figure 1.17.
zoom view
Fig. 1.17: Different ligaments of the pelvis
29
The function of the round ligament is maintenance of the anteversion of the uterus (a position where the fundus of the uterus leans ventrally). When the uterus grows during pregnancy, these ligaments can stretch causing pain.
 
Perineal Body
The perineal body is a pyramidal fibromuscular structure in the midline between the anus and vagina with the rectovaginal septum at its cephalad apex. Below this, muscles and their fascia converge and interlace through the structure. Attached to the perineal body are the rectum, vaginal slips from the pubococcygeus, perineal muscles and the anal sphincter, it also contains smooth muscle, elastic fibers and nerve endings. During childbirth, the perineal body distends and then recoils. It is an important part of the pelvic floor; just above it is the vagina and the uterus. Acquired weakness of the perineal body gives rise to elongation and predisposes to defects such as rectocele and enterocele.
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