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 HOWKINS & BOURNE
SHAW'S TEXTBOOK OF GYNAECOLOGY
 HOWKINS & BOURNE
SHAW'S TEXTBOOK
OF GYNAECOLOGY
Edited by

Sunesh Kumar, MD (AIIMS)

Professor and Chief Gynae Oncdlogj Services,
Depa rtment of Obstetr-lc.;:s ancJ Gynaecology,
All India lnstitut f ed1cal Sciences,
New Delhi

eritus Editars

S, FRCOG (LOND)
edor Professor and Head,
bstetrics and Gynaecology
ge Medica l College, New Delhi

Shirish N ry, , DGO, FICS, FIC, FICOG

er-i us Professor, Formerly Dean and Med1cal Advisor,
Nowrosjee Wadia Ma terni ty Hospi ta l, Mumbai
Past Presiden t, FOGSI

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Shaw's Textbook of Gynecology, 17e, Sunesh Kumar, VG Padubidri, and Shirish N Daftary

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Dedicated to my teachers, esfJecially Late Pmf Vera Hingomni
Preface to the 1 7th Edition
Sevemeenth Edition of this popular book "Shaw's Textbook of
O)"wecology" is in your hands. Writing prefuce tO this new
edition brings me t11e nosta lgic memo•) ' of my studem days
when all t11e studenlS read t11is book and when each word
wriuen in the book was like a statemem from experLS. Last
sixty years since first edition of t11e book has seen lot
of adva nceme nt in t11c speciali ty of gynaecology. fVF and
Endoscopic sw·ge•y arc two ve•) ' im porta nt advances which
has made speciali ty of gynaecology challe nging with a
bright fullt re.
I have made best effo rLS to update most of th e topics.
Such a n e ndeavo ur was possible o nly wit11 ac tive support
of Ill)' colleagues, reside nts and other staff. My special
t11anks are due to Dr. Ans hu Yadav, Dr. Aa nhi S Jayraj,
Dr. Ro hitha C and OLhe r Reside nts in my department for
VI
helping me reviewing the text, video recording and collect-
ing photographs. P•·ofessor San deep Mathur of Pat110logy at
AIIMS, New Delhi pr-ovided excellent coloured photomicro-
graphs.
l do not have enough words to express my t11anks to my
secreta•)', Ms. Sapna Gulati for doing w•·iting, editing and
correction work in t11e textbook in a p rofessio nal manne1·.
Special thanks are due to Ms. Shi va ni Pal and Ms. Sheenam
Agarwal of Elsevier Ind ia for their pa ti e nce and persistence.
Reali zing ex tre me hardshi p faced by students befo re
final examinatio ns a new secti on of Audi o-vis ual presenta-
tion o n important topics has bee n added.
Do se nd )'Our comm ents fo r im provingfuu.tre p ublications.
Smush Kwrwr
 Preface to the 16th Edition
\>\'e, the editors of Huwkins and Bounu Shaw's Textbook of
OynaecolQ(Jj) are pleased to acknowledge that this book has
continued tO provide basic foundation of this speciality
since 1936. Keeping in view of the popularity of the book,
tl1e first Lndian edition ( I 0'" edition) was published in
1989. Since then, tl1e book has been updated ft·om time to
tim e in tl1e ligh t of the adva nces made in tl1is speciality.
T he 15th editio n was revised in 20 10. O ur comm itm en t to
tl1 e swd enLS to improve a nd upda te the quali ty of th e
boo k, and provide th e m wi tl1 th e adva nced kn owledge
p ro mp ted us to b ri ng o ut the 16'" ed ition.
Ln tl1 is editio n, not o nly we have added the latest knowl-
edge o n tl1e subject, but also inse n ed mo re illustra tio ns,
flowc harts and tab les to make the read ing easie r and under-
standable. We have added mo re MRI, CT, and man y other
illusu<~tions wherever req uired.
Considering the high associated morbid ity and mortali ty
of gynaecological malignancies, we have approached the
topic of genital tract cancers more exhaustively in tl1is edi-
tion. Emphasis has also been laid on the gynaecological prob-
lems amongst adolescents and menopausal women. Minimal
invasive surgel} for the benign conditions is now being re-
placed b) non-surgical tl1emp) such as M RI~uided ablative
tllerapy without the need for hospitaliation. Hopefully ti1ese
procedures willwrn safe and effective in near future.
A website of the book has been created for more infor-
mation on tlle su~ect in the form of video clips, online
testing and MCQs for enu-ance tests and tile latest updates
on tlle subject.
We owe our special thanks to the entire staff of Elsevier
for tl1eir wholeheaned support and en couragement. We will
fail in o ur duty if we did not make a special reference lO
Shabina Nasim with whom we interact o n a daily basis and
also Re nu Rawa L. We appreciate their p rofessional atti tude
and the ir knowledge towards th e prqjec t, tl1e ir effi cie ncy
and enorm o us patience to bring o ut the best for th is
p roject.
Ou r veqr special tlHt nks and gra tiu.tde go lO Mr YR
Chadh a, Pub lis hi ng Cons ult.'llll, Bl Ch urchill Livingsto ne,
New Delhi, who in itiated and gu ided us in tile Firs t Indian
Edition in 1989, witho ut whose pers uasion and enco umge-
ment tl1is book wo uld not have seen tile day. There
are many others who have worked behind tile scene, we
acknowledge our thanks to them.
Last. but not ti1e least, we thank our readers and tl1e
student communiL) for their unstinted suppon over
the last 25 ) ears.
VG Padubidri
Shirish N Dajlary
VII
Preface to the 1Oth Edition
Ever since SltaiU~ Ttxtbook of C,•IWI'COiog)• a ppeared in Lhe
United Kingdom in 1936, it has maintained iLS popularity
with teachers, exa miners and th e student community.
ll has gone through several editions. The nimh edit.ion,
edited by Dr J ohn Howkins and Dr Gordon Bourne, was
brought out in 197 1, and its populat·ity in India has
remained undiminished. It is th erefo re timely and oppor-
tune tha t this standa rd textbook should be revised by
Indian teachers of gynaecology to meet th e requirements
of o ur unde rgraduate stude nts. We consider o urselves
fortunate for having bee n assigned thi s challe nging task b)'
th e publishers.
In revising tl1 e boo k we have e ndeavoured to upda te the
comenLS to include new metJ1ods of investigations and treat-
me nt. In particu lat~ recent advances in tlte physiology of
me nsu·uatio n and iLS hormonal co ntrol, carcinoma of the
cervix and related preve nLive meas ures, e ndo meuiosis, and
tlte management of wbe rculosis o f the genital u·act have
VIII
been incorporated. In additi on , the latest metl1ods of birtlt
control and a separate chapter on Medical Tennination of
Pregnancy have been added to equip our studenLS wilh Lhe
knowledge re qui•·ed to pr·o mote India's fa mil y welfare pro-
gramme.
We have also tded to make tlte text more concise by
deleting informati o n that we fell was unnecessa ry for tl1e
Indian undergradua te stude nt, witl10ut substamiall y chang-
ing the original style.
We are indebted to Mr YR Chad ha, Publis hing Director
of Bl Churchill Li vingsto ne, New Delhi for his constant e n-
couragement and inva luable suggesti ons in tl1 e preparation
of tl1 is edition. Since re thanks are exte nded to Ch urchill
Livingstone, Edinburgh, fo r Lheir assistance in making this
edition possible.
VG P(Ulubidri
Shirish N Daftary•
 Table of Content

Preface to the 17th Edition, vi SECTION 3 COMMON CONDITIONS

Preface to the 16th Edition, vii IN GYNAECOLOGY, 201
Preface to the 1Oth Edition, viii
16 Infertility- Male and Female, 202
Approach to a Gynaecological Patient,
0 How to toke Pop Smeor
17 Ectopic Gestation, 22 8
0 VIA ond VILU 0 Ectopic pregnancy

18 Acute and Chronic Pelvic Pain, 245

SECTION 1 ANATOMY, PHYSIOLOGY AND
DEVELOPMENT OF FEMALE 19 Temporary and Permanent M ethods of
REPRODUCTIVE ORGANS, 12 Contraception, 252
2 Anatomy of Female Genital Tract, 13
0 Loporoscopic tubol sterilization

0Bartholin's Abscess 0 Mini lop tubol sterilization

3 Normal Histology of Ovary and 20 Medical Termination of Pregnancy, 279

Endometrium, 37
SECTION 4 BENIGN CONDITIONS IN
4 Physiology of Ovulation and Menstruation, 48 GYNAECOLOGY, 285

5 Development of Female Reproductive Organs 21 Genital Prolapse ~ , 286

and Related Disorders, 61
22 Displacements of the Uterus, 302
6 Puberty, Adolescence and Related
Gynaecological Problems, 75 23 Diseases of the Broad ligament, Fallopian Tubes
and Parametrium, 308
7 Menopause and Related Problems, 86
24 Benign Diseases of the Ovary, 3 12
8 Breast and Gynaecologist, 99
25 Benign Diseases of the Vulva, 3 19
9 Sexual Development and Disorders of Sexual
Development, 106 26 Benign Diseases of the Vagina, 326

SECTION 2 DISORDERS OF SECTION 5 INFECTIONS IN

MENSTRUATION, 121 GYNAECOLOGY, 336

10 Common Disorders of M enstruation, 122 27 Pelvic Inflammatory Disease, 337

11 Abnormal Uterine Bleeding (AUB) 111!1 , 128 28 Tuberculosis of the Female Gen ital Tract, 347

12 Primary and Secondary Amenorrhoea, 141 29 Sexually Transmitted Diseases Including HIV
Infection, 356
13 Fibroid Uterus ~ , 155

14 Endometriosis and Adenomyosis, 174

15 Hormonal Therapy in Gynaecology, 188

IX
x TABLE OF CONTENT

SECTION 6 URINARY AND INTESTINAL TRACT 39 Radiation Therapy, Chemotherapy and Palliative
IN GYNAECOLOGY, 371 Core for Gynaecological Cancers, 494

30 Diseases of the Urinary Tract, 372 SECTION 8 IMAGING MODALITIES,

ENDOSCOPIC PROCEDURES AND
31 Urinary Fistula and Stress Urinary MAJOR AND MINOR OPERATIONS
Incontinence, 379
IN GYNAECOLOGY, 506
32 Injuries of the Genital Tract and Intestinal
40 Imaging M odalities in Gynaecology, 507
Tract, 396
41 Endoscopy in Gynaecology, 519
SECTION 7 GYNAECOLOGICAL 0 Diagnostic laparoscopy
MALIGNANCIES, 407
0 Diagnostic hysteroscopy
33 Preinvasive and Invasive Carcinoma
of Cervix l3,
408 42 Major and Minor Operations in
Gynoecology, 532
0 Colposcopy
0 Cervical biopsy-<:onisation
0 HPV testing
0 Total abdom inal hysterectomy
34 Cancer of the Body of the Uterus I!], 43 2 0 Vaginal hysterectomy for prolapse uterus
35 Pathology of Ovarian Tumours and Benign 43 Obesity and its Significance in
Ovarian Tumours, 44 1 Gynoecology, 54 1
36 Ovarian Malignancies, 459 44 Instruments Used in Gynaecology I!J, 545
37 Vulval and Vaginal Cancer, 472 Index 551
38 Gestational Trophoblastic Diseases, 481

To access th e vid eo:; and lecture PPT•, .can the •rmbols 0 and E prodded in the chapters.
 Approach to a Gynaecological
Patient
History Investigations 6
Physical Examination 3 Key Points 11
Gynaecological Examination 4 Self-Assessment 11
T he term gynaecology (from th e Gree k, gynae meanin g
wo man and logos mea ns discou rse) pe11_ains tO th e diseases
of women and is ge nerally llsed for disea es re laLed LO the
fe male gen iLal organs.
Th e interac ti on of a p ati ent with a p hysician can ofte n be
an a nxi ety-produ cing event, p articul arly so in Lhe prac ti ce
of gynaecology because of t he sensitive naLure of th e p rob-
le ms tha Lneed LO be disc ussed; he nce, th e o bserva nce of the
hig hes t standards of e thical and profession al be haviow· is
req uired to establish rapport, while no L creaLing a host.li e
enviro nm enL in which Lhe p aLi em fee ls embarrassed or t in-
comfo n able LO allow a meaningful assessmem of h er under-
lyin g medica l p roble m.
The fo llowin g fou r ethi cal principl es must be nt -
graLed into t he ca re and n amre of se rvices offered L
pa Lient.
1. Privacy and respect: Nowadays, co unsel-ling on s an
importa nL aspec t of consul tat.i o n. T he
aeco logical ail ment, reason fo r a
a nd iLS predi ct.i ve va lHe h ould b ms
sion on treatme nt options witif h ir d eritS a nd m er-
its will enable a wo ma n tO lOOS 1.h e treatment she
co ns iders besL for he1: The gy 1 co logist sh o11ld, h ow-
ever, guide her in ma king th e right decision. T he clini-
cia n mu.st respect the pa ti em as an individual. Re me m-
be r tha t th e pati e m has th e righL LO make dec ision
abo ut h er health care. lt is n ot eLhi cally or m orally right
to en force Lhe ph ysician 's opinion on the patien t. T l-lis
wil! safeguard agains t any ch arge of n egligen ce, if a
medi colegal problem arise a t a later date. T he records
should be prop erly main tain ed and th e doc umen rs
should be preserved. T h e pa tie nt should fee l assured at
a ll tim es a bout ' privacy and confidenti ali L)" . Talkin g
sofLly a nd pa t.i e ntly lisLening are of a great help .
2. Beneficence: The medical aLLendant must be vi gil ant
LO ensure that th e thera peutic advi ce re ndered to Lhe
pa ti ent should be in ' good faith '. It sh ould be aimed at
be nefiting her. Al l m edical m easu res a dopte d du ring the
course of medical u·eaune nt should be guided and evalu-
ated on the basis of th e principle of the cosL/ benefit
ra ti o acc ruing out of th e m edical advice given.
3. Justice: T his is r en th e ph ysician ma kes
access LO care, · re, the a ttention provided
and t.h e cost to the needs of the paLiem .
4. Avoiding · · dern Lim es, it is imporLant LO
avoid in eatm em which may lead to p os-
sible - · . For a d eLailed desc riptio n it is
a . oipt.i onsgiven by Ley P, Lipkin Mjt~
man R, Lewan M, Todd AD, Fish er S.
J-Sical examination constitute the ftmda men-
h rest th e tentaLive diagn osis, the tests to be
and th e treatm em to be recommended (Table 1.1 ).
Careful histo ry and p hysical examina Lion for m the basis
of pati ent evaluati on, clini cal diagn os is a nd manage ment.
lnvestigaLio n are ma de LO confi rm the di agnosis a nd for
th e fo ll ow-up of u·eatm enL
lt L~ advisable LO ask Lhe pati ent to desc ribe h e r main com-
plainL in her ovm words and take her own Lime narrating the
evo lution of the problem, the aggravating and re lieving fac tors
and the investigations and treatment she has already 1.mder-
gone. Good and patie m listening is essenti al to obtain maxi-
mum coop eraLion during th e sub.sequem pelvic examination.
Hist0ry begin with th e recording of th e basic informa-
tio n abo uL t11 e paLient as sh own in the samp le p roforma in
Table 1.1.
PRESENT ILLNESS
T h e clini cian must record th e patie m ' co mplainrs in th e
sequence in whi ch Lhey occ urred , no t.ing Lhe ir dura ti o n,
th eir aggravating a nd relieving fa ctors and th e ir relati o n to
m enstruation , micturiti on a nd defecati on. T he investiga-
tions pe rform ed and th e resp o nse to treatm ent given so far
sh ould be noLed.
PAST AND PERSONAL HISTORY
Pas Lm edical and surgica l p roblems may have a bearing o n
th e present complaints. For example, a history of di abetes
2 SHAW'S TEXTBOOK OF GYN AECOLOGY

Table 1.1 1 History: Gynaecological Case Record Fonn FAMILY HISTORY

Name
Presenting complaints:
Menstrual History:
Last menstrual period (LMP)
Present menstrual cycles
Previous menstrual cycles
Age at menarchae
Age at Menopause
Previous Obstetric History:
Full term deliveries
Preterm deliveries
Abortions (Spontaneous/
Induced)
Ectopic pregnancy
Living Issues
Contraception used:
Marital Status Cenain problems run in families, e.g. menstrual patterns
Married/Single/ tend to be similar amongst members of 1J1e family. Prema-
Age Unmarried tLtre menopause, menorrhagia and dysmenorrhoea may
occ~.u· in more than one member in a family. Similarly, fe-
male members of some families are more prone to cancer
of the oval'), uterus and breasL Diabetes, hypertension, tlly-
roid disorders, allel'gic diathesis and functional disorders
are often familial in nalllre. Genetic and hereditary disor-
ders affect more than one member in tlle family, e.g. thal-
assaemia. Tuberculosis may affect many members in the
family.
MARITAL AND SEXUAL HISTORY
Note tJ1e details of h er marital life such as the frequency of
coitus, dyspareunia, frigid it)', ac hieve ment of orgasm, libido,
use of contracepLives and the me thod used. T he releva nce
of dyspareunia to infe ttili t)' sho ul d be no ted.

Past Medical History: MENSTRUAL HISTORY

Diabetes
Hypertension
Thyroid disorders
Tuberculosis
Any surgery
Family History:
History of cancers In family
members
History of OM/hypertension
Personal History:
Smoklng
Addictions
Drugs
may suggest that pruritus vulva may be due to gen ital candi-
diasis, and history of sexuall y u·ansm iued disease (STO)
may have a direct bearing on future infertili ty.
History of pelvic inflammatory disease ( PID) or puer-
peral sepsis may be assoc iated with menstrual d isturbances,
lower abdom inal pain, co ngestive dysmenorrhoea and
inferti lity. T ube rculosis ma)' lead to oli go menorrhoea and
infertility. HistOr)' of e ndocrinopathy may affec t her sexual
fun ctions. Medi cal d iseases such as h)'pe n ension, cardiac
disease, anaemia, d iabetes, asthma and Lh e li ke will require
to be controlled before a plann ed st.u·gety Previo us b lood
u·ansfusion and drug a llergy should be noted. This has
special reference to H IV and hepatitis B infection.
Previous abdominal surgery such as caesarean section,
removal of tJ1e appendix and e xcisio n for ovarian cyst may
lead to pelvic adhesions, which may be t11e cause of ab-
dominal pain. backache, retroverted fixed uterus, infertili ty
and menstrual diswrbances. Dyspareunia is often tJ1e result
of pelvic adhesions.
Allergies to an> drug, Cll tTent medication, use of alcohol,
smoking, ch-ug abuse and lifest) le have relevance in t11e
management.
Normal menarche and me nstrua l cycle have been described
in Chapter 4.
The term me1wrrlwgill denotes excessive blood loss (in-
crease in duration ofbleeding/ heavie rblood flow) witho ut
any change in tJ1e cycle length. The term menorrhagia is
now replaced by 'abnormal uterine bleeding' (AU B) and
will be addressed in this chapter. The tenn pdymerwrrhoetl
or epimenorrlwea refers to frequent menstrual cycles as a
resuiL of shortening of the C) cle length. Sometimes women
suffer from a menstrual disorder characteriLed by a shorter
duration of the qcles coupled with a heavier flow or pro-
longation in tJ1e duration of the flow; this condition is
termed as po!Jmtllorrlwgill. The se,e,·ity of AUB can be
assessed by taking into account the number of sanitary pads
required per day, history of passing blood clotS, the pres-
ence of anaemia and evaluating the presence of accompa-
nying symptotns such as fatigue, palpitation, dizziness,
breathlessness on exertion and tJ1e presence of pallor.
Menorrhagia and polymenorrhagia are frequemly present
in women with m)'Oillas, adenomyosis and PI D in women
wearin g intrauterine co ntracep tive devices ( IUCDs) and
also due to hormonal imbalance ca using dysfunc ti o nal
uterine bleeding (DUB) in pcrimenopausa l women. AUB
now rep laces the wo rd DUB.
Oligomenorrlwea is the term used to describe infrequent
menses. ln this condition, the cycle lengtJt is prolonged
without affec ting the d uration and amount of flow. Hyj)(J-
me,wrrlwea refers to tJ1 e condition in which Lhe cycle length
remains unaltered; however, the duration of b leeding or the
amoLLnt of blood loss, or both are substantially red uced.
When the complete cessation of menstruation occurs, tlte
condition is described as amenorrhoea. The problems of
oligrmumorrlwea and h)1JOriU!1Wrrlwe(l are enco untered in con-
ditions such as pol)'l)llic uvamm di.S!XlSI! (PCOD), llyperprvlacti-
ntutmill and (jlmiuiltuberrulrui.s, in women on oral contracep-
Live pills, in association with certain neoplastns of tlle
pituitlll')' or ovary, in functional h) pothalamic disorders
and in ps)chiau·ic disorders. Ot·ugs may occasionally be
implicated. Oligomen01·rhoea and h) pomenorrhoea may
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 3

occasionally progress to ame norrhoea. Amenorrhoea is

physiological during pregnancy, lactation, before puberty
and after menopause. Metrvrrlwgict (now addressed as inter-
menstrual bleeding) means the occurrence of intermen-
strual bleeding, and it rna> occur in association with ovula-
tion (mittelschmer£); however, it is commonly associated
with the presence of neoplasms such as uterine polyps, car-
cinoma cen ix and uterine and lower genital tract malig-
nallC)'· It may occur "ith conditions such as vascular ero-
sions, using intrauterine devices or breakthrough bleeding
in oral pill users. However, this S)lnptom calls for thorough
investigation because of a possible malignam cause. Some-
times the patient may present with the complaint of continu-
O!Ll bleffling, so that the normal pauem can no longer be
distinguished. Sud1 episodes may be of functional origin
due to h ormonal disturbances often willlessed as puberty
bleeding and perimenopausal bleeding disorders ( DUB).
However, during the chil dbearing years, co nditions due to
complications of earl)' pregnancy such as ec topic pregnancy
and abonion often present in this manner. Geni tal tract
neop lasms s uch as sub muco us polyps and ge nital malignan-
cies may present with co ntinuous bleeding. Postme1wpausal
bleeding is often re la ted to genital malignancy in 30%-40%;
hence, this S)'mpto m sho uld not be treated light!)', it sho uld
be evaluated carefulI)' and all efforts made to exclude such
a possibilit)'· Postcoita l b leeding often suggests cervical
lesion, i.e. erosion, polyp and cancer.
The presence of dysmenorrhoea and dyspareunia may
have orga11ic cause in the pelvis, i.e. endometriosis, fibroid
a11d PLD.
Vaginal discharge is common in lower genital u-act
infections.
OBSTETRIC HISTORY
Record the details of e'e•1' conception and its ultimate out-
come, the number of living children, the age of the young-
est child and the details of any obsteu·ic complications
encoume•·ed, e.g. puerpe1-al or postabo•·tal sepsis, postpar-
tum haemo•,·hage (PP H), obsteu·ical ime1ventions, soft
tissue injuries such as cervical tear, an incompetent cervical
os and repeated abortions, genital fistulae, complete peri-
nea l tear and genital prolapse, su·ess urinary inconti nence
and chronic backache. Severe PPH and obsteu·ic sh ock may
lead to pilllita•1' necrosis and 'Sheehan syndrome'. T hus,
man y a gynaecological proble m has its beginni ngs rooted in
earli er inadeq ua te obsteui c ca re.
Medical termination of pregnancy and spontaneous
abortions should also be enquired.
Abdominal pain: Abdom inal pain is a complain t in pelvic
tuberculosis, PID and endometriosis. Ac ute lower abdom i-
nal pain occurs in ectopic pregnancy, torsion or rupture of
all ovariall cyst and chocolate cysL
PHYSICAL EXAMINATION
Physical examination (Table 1.2) includes general exalnina-
tion, S)Stemic examination and gynaecological examination
"ith a female auendam presem to assist the patiem alld reas-
sw·e her, particularly so when t11e attending clinician is a
male doctor.
Table 1.2 Physical Exa mination
General Physical Examination
Height Weight
Pulse BP
Pal or Lymphadenopathy
Thyroid Breast
Systemic Examination
cardiovascular System
Respiratory System
Abdominal Examination
Inspection
Palpation
Percussion
Pelvic Examination
External Genitalia
Per Speculum Examination
Per Vaginal Examination
Per-rectal Examination
Provisional Diagnosis
GENERAL EXAMINATION
General examination includes data mentioned in the pro
forma (Table 1.2). Pallor of the mucous membranes, tl1e
tongue and conjunctivae toget11er witl1 pale appearance
ofthe skin and nails is high I) suggestive of anaemia, fullness
of the neck is suggestive of a thyroid enlargemem a11d
enlal·ged I) mph nodes are indicative of chronic infection,
tuberculosis or metastasis following malignancy. Bilateral
oedema of the feeL ma> be found in women witl1 lal·ge
abdominal tumours, and unilate•-al non pitting oedema is
highly suggesti,·e of malignant growth involving the lpn-
phatics. B•·east examination should be included in general
examination. Hi rsutism is a feature of PCOD. Breast secre-
tion is noted in hyperp•·olactinaemia, an importam feature
in amenon·hoea.
SYSTEMIC EXAMINATION
All gynae patients must be exa mined as a whole. This in-
cludes the examination of the ca rdiovascula r and I-espira-
tory systems. The p resence of any ne urological sy mptoms
calls for a de tailed ne uro logical evaluation, o t11 erwise test-
ing of tl1 e reflexes shoul d generally suffice. Li ve r s ho uld be
palpated in suspected maligna ncy for metastasis.
ABDOMINAL EXAMINATION
INSPECTION
Man y gynaecologicalwmours arising out of the pelvis grow
upwards into tl1e abdominal cavity. They cause enlargement
of the abdomen, particular!) the lower abdomen below tl1e
LUnbilicus. a11d their upper and lateral margins are often
apparent on inspection. Howe,er, very large wmours Call
give rise to a diffuse enlargement of the entire abdomen.
Pseudomucinous CJIIluletwma.s of the ovary can enlal·ge LO
malnmoth proportions, sometimes to an extent of causing
cardiorespiratory distress. E'ersion of the umbilicus Call
4 SHAW'S TEXTBOOK OF GYNAECOLOGY
occur as a resu lt of raised inu·aabdomina l pressure and is
observed with large wmours, ascites and pregnancy. The
mobility of the abdominal wall with breathing should be
observed carefully. In case of an intraabdominal tLLmOLLr,
the abdominal wall moves over the tumour during breath-
ing so that its upper margin is appare ntly altered. ln case of
pelvic pe •·ito n iLis. t11 e movements of t11 e lower abdomen
below the umbilicus are ofte n restricted. The presence of
striae is seen in parous women, pregnam women, in obese
suqjects and in women harbouring large tumours.
PALPATION
'•\lith the clinician standing on the •ight side of tl1e patient,
it is desirable LO palpate t11e liver, spleen and kidneys ,,;th the
right hand, and LO use t11e sensitive ulnar border of the left
hand from above downwards to palpate swellings a•·ising
from the pelvis. The upper and lateral margins of such swell-
ings can be felt, but t11 e lower border ca nnot be reached.
Myo mas feel firm and have a smooth surface, unless they
are mu ltip le, whe n tile)' present a bossed surface. Ovarian
neop lasms often feel cysti c, and may be flucwant. T he upper
margin oftheseswelli ngs is often we ll fe lt, unless the swelli ng
is too large. The pregnant uterus fee l~ soft and is known to
harden intermiuen tly during th e Brax to n Hicks contrac-
tion s; this is characte•istic of pregnanC)'· The fu ll b ladder
bulges in tl1e lower abdomen and feel5 tense and tende1:
£xu·eme tenderness on palpation below the umbi lict.LS is sug-
gestive of peritoneal irrit.ation , seen in women witl1 ectOpic
pregnancy, PLD, twisted ovarian cyst, a mptured corpLLS lu-
tewn haemaLOma or red degeneration in a fibroid often as-
sociated wilh pregnanC). In women witl1 an acute smgical
condition. guarding in th e lower abdomen and •igidity on
attempting deep palpation a re noted.
PERCUSSION
Ute•·ine m)•omas a nd ova•·ian C)SLS are dull tO percussion,
but the flanks a•·e resonanL Dullness in t11e flanks and shift-
ing dullness indicate t11e presence of a free fluid in the
peritoneal cavity. Ascites may be associated with tuberculous
peritonitis, malignancy or pseuclo-Meig S)'ndrome.
AUSCULTATION
This reveals peristalti c bowel sounds, fetal heart sounds in
pregnancy, souffle in vascular neoplasms and pregnant uterus.
Hyperperistalsis may indicate bowel obsuuction; feeble or
absent peristalsis indicates ileus, calli ng for aggressive atten-
tion. Retw·n of peristalti c so unds follo,,ing pelvic surgery is a
welcome sign of recovery and an ind ication to stan oral feeds.
GYNAECOLOGICAL EXAMINATION
Most prefer dorsal position, so that bimanual examination
of the pelvic organs can be concluctecl following abdominal
examination without changing t11e position. Some may pre-
fer left lateral (Sims' position). Verbal consent should be
obtained for bimanual examination.
EXAMINATION OF EXTERNAL GENITAUA
lt is a good practice LO inspect the external genitalia under
a good lighL otice the disu·ibution of pubic hair. Nonnal
pubic hair is distributed in an inverted u·iangle, with the
base cenu·ed over the mons pubis. The extension of the hair
line upwards in tl1e midline along t11 e linea nigra up to tl1e
tunbilictLS is seen in about 25% of women, especially in
women who are hirsute or mild!) androgenic as in PCOD.
Witl1 the patient in lithotOm) and he r thighs well paned,
note t11e variolLS su·ucwres of th e vulva. Look for the
presence of an) discharge or blood. Ask the patient to bear
down and obsen•e for any p•·oU'LLSion due tO pol) p or genital
descent such as cystocele, rectocele, ute•·ine descent or
procidentia. Separate t11e labia wide apart and examine
the fourcheue to see whether it is intact or reveals an old
healed tear.
SPECULUM EXAMINATION
Speculum examination should ideall y precede bimanual
vaginal examination especiall y when the Papanicolaou
( Pap) smear and vaginal smear need to be taken.
A bivalve self-retaining spec ulum such as CtL~co's spec ulum
is ideal for an office exa mination (Figs 1.1 and 1.2). It allows
satisfactory inspection of t11e ce rvix, ta king of a Pap smear,
colleCLion of the vaginal discharge from t11e posterior fornix
for hanging drop/KOI I smear and colposcopic examination.
Sims' vagina l spec ulum (Fig. 1.3) wi tl1 an anterior vagi-
nal wa ll retractor can be used for the above examination. lt
permits an assessment of Lhe vaginal wall for cystocele and
rectocele. However, an assistant is required to help the clini-
cian dttring this examination and t11e woman needs to be
brought to tl1e edge of the table. Stress-incontinence sho uld
be looked for especiall) in t11e presence of vaginal prolapse.
ln tl1is case. tl1e patient is e xamined with a full bladder.
BIMANUAL EXAMINATION
After separating the labia \\ith t11e tluunb and index fingers
of the left hand, two fingers of the •ight hand (index and
forefinger), after lubrication, are gradually introduced
be)ond the introitus to reach the fornices. If the fingers
encounter tl1e anterior lip of the ce•vix first, it denotes the
cervix is pointing dowmvards and back tOwards tl1e poste-
rior vaginal wall, and that t11e uterus is in tl1e antevened
position, conve•'Sely whe n t11e posterior li p of tl1e cervi.x is
encountered fi1'S4 it is indicative of a retroverted uterus.
Flgure 1.1 Cusco's speculum.
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT 5

Rgure 1.2 Speculum examination of the cervix. The patient is lying

in the dorsal position and a Cusco's speculum has been inserted into
the vagina. (Source: Mike Hughey, MD, President, Brookside Associ-
ates, Ltd.)

Rgure 1.4 Bimanual examination of the pelvis In the female. Two

fing ers of the right hand are Introduced Into the vagina and the left
hand is placed well above the symphysis pubi s. (Source: Swartz MH:
Textbook of Physical Diagnosis. Phiadelphia, WB Saunders, 1989,
p 405, Copyright Cl 2007 Saunders, An lmprnt of Elsevier.)

Flgure 1.3 Sims' speculum.

The clinician next observes the consistency of the cervix: it

is soft during pregnancy and firm in the nonpregnant state.
Observe whether the movementS of the cervi.x du•·ing the
examination cause pain; this is seen in an ectopic preg-
nancy, as also in women with acute salpingo-oophoritis. The
examining finge r'S now li ft. up th e cervix and th ereby ele-
vate the uterus towards th e left hand, which is placed over
t11e lower abdomen and bro ught be hind it (Fig. 1.4). T he
uten.rs can thus be brought within reac h of the abdo min al
hand and palpated fo r position, size, shape, mobility,
tenderness and t11e prese nce of any uterine pat11ology, e.g.
fibroids (Fig. 1.5).
ln case of tl1 e retroverted uterus, it will be felt through Rgure 1.5 Bimanual exam ination In the case of mult iple uterine
tlle posterior fornix. myomas. Note how the external hand Is placed high In the abdomen,
Thereafter, the cli nician directS the tips of the examin- well above the level of the tumour. Movements are transmitted
ing fingers in t11e vagina into eac h of the lateral fomices between the two hands directly through the tumour.
and, by lifting it up towards the abdominal hand, attemptS
to feel for masses in the lateral pan of the pelvis between The appendages are normally not palpable unless they
t11e two examining han cis. Should t11 is reveal t11e presence are swollen and enlarged. The ovary is not easily palpable;
of a swelling separate from t11e uterus, t11en t11e presence of however. when palpated, it evinces a peculiar painful sensa-
some adnexal patJ\OIOg) is confirmed. The common swell- Lion t11at makes the patient to wince. ext in tum is tlle
ings identified include ovarian C)St (Fig. 1.6) or neoplasm, palpation of tlle poster·ior fornix. This enables the palpa-
a paraovarian cyst, e.g. fimbr·ial cyst, tubo-<~varian masses tion of tlle contents of the pouch of Douglas. The most
(Fig. 1.7), h)drosalpinx, and swelling in chronic ectopic common swelling is the loaded rectum, panicularly if she
pregnancy. is constipated. Otllers in order of diminishing frequency
6 SHAW'S TEXTBOOK Of GYNAECOLOGY
Figure 1.6 Bimanual exam ination in the case of an ovarian cyst. The
nature of the tumour is determined on bimanual examination because
the uterus can be Identified apart from the abdominal tumour. Com pare
Fig . 1.5. In some cases the pedicle can be distinguished If the fingers
In the vagina are p laced high up in the posterior fornix. Movements of
the abdominal tumour are clearly not transmitted to the cervix.
Figure 1.7 Bimanual examination in the case of a pyosalpinx. Note
that the uterus Is displaced to the opposite side. The fingers in the
vagina are moved to one side of the cervl x, and they feel the lower
pole of the swelling.
include a reLroverted uterus, ovaries prolapsed into the
pouch of Douglas, uterine fibroid, ovarian neoplasm, choco-
late cyst of the ovary, endomeu·iotic nodules, pehic inflam-
matOt')' masses resulting from the adhesions of LUbo-ovarian
masses to the postet·ior surfuce of the uterus and the floor of
the pouch of Douglas, pelvic abscess pointing in the posterior
pouch and pelvic haematocele common!)' associated with a
ntptured ec topic pregnancy. To recogni:te the uterus from
ll1e ad nexal mass, push the cervix upwards, and if th is is trans-
milled to the swelling it is ll1e utems. Alternate!)', p ushing
down t11e ute ms causes the cervix to move down. Adnexal
mass does not move with cervical or uterine movement.
RECTAL EXAMINATION
ln virgins, a 'oaginal examination is avoided. Instead a well-
lubt·icated finger insened into the rectum can be used for a
bimanual assessment of the pelvic structures. No"oada)'S, pt-ac-
tically all gynaecologistS prefer ultrasonic scanning tO recta l
examination, which , apart from being unpleasa nt, is not that
accurate. A rectal examination is a very useful add itional ex-
amination whenever ll1ere is any palpable pathology in the
pouch of Douglas. It often allows the ovaries to be more easily
identified. In parameuitis and endomeu·iosis, t11e uterosacral
ligamentS are often thickened, nodular and tender. It con-
finns t11e swelling to be amerior to the rectum, and if the
rectum is ad herem to that swelling. This is important in case
of carcinoma of t11e ce tYix to detennine the extent of itS pos-
terior spread. A rectal examination is manclatOt')' in women
having rectal symptoms. This should begin by inspecting the
anus in a good light, when lesions such as fissures, fistula-
in-ano, polyps and piles may come to ligl1 L Introduction of
a well-lubricated proctoscope to inspect the rec wm and
anal canal helps to complete the examination. Ulu·asound
nowada)'S has reduced ll1e importance of rect.al exa mination
except in cancer of the cervix and pelvic endomeu·iosis.
INVESTIGATIONS
Detailed history and clinical examination often clinch the
diagnosis or reduce ll1e differential diagnosis to a few pos-
sibilities. However, investigations may be necessary to con-
finn ll1e diagnosis, to assess the extent of t11e disease, tO
establish a baseline for future comparison regarding the
response to a therapy and finall y tO de te rmine t11 e patiem's
fi mess tO undergo surgery.
Common disorders: Age re lated (see table 1.3 )
Table 1.3 Common Gynaecological Disorders-
Age Related
I. Adolescent and Prepubertal Girls
Vaginal d ischarge
Disorders of growth
Precocious puberty
Delayed p uberty
Sexually transm ltted diseases
Tumors of ovary, vagina and vulva
II. Reproductive Age
Disorder of menstruation
Ectopic pregnancy
Abnormal uterine bleeding
Contraception related issues
Infertility
Pelvic inflammatory diseases
Malignancies: GTN, Garcinoma Cervix, Ovarian Tumors
Ill. Menopause and Post Menopausal Age
Menopause related problems
Prolapse of uterus
Post menopausal bleeding
Malignancies: Cancer Cervix, Carcinoma Endometrium,
Carcinoma Ovary and Vulval Cancer
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
Preoperative investigaLions are described in the chapter
on preoperative and posLOperative care. Special investiga-
tions are discussed as follows.
Special investigations:
• Special tests such as LUmour markers: CA-125 in sus-
pected adenocarcinoma of the ovary; carcinoembryonic
amigen (Cf.A), oc-fetoproteins and ~hCG in suspected
ov;uian teratoma and other germ cell tumours of ovary.
• Bacterial examinations of th e genital tract. These include
the following: (a) examination of the vaginal dischru-ge
for trichomoniasis; (b) 10% KO H-treated smear for de-
tecting candida; (c) I% b•illian t creS)'I violet for staining
trichomonad, but not the other bacte•ia and leucocytes;
(d) platinum loop for collection of discha•·ge (in sus-
pected gonon·hoea) from the urethra, ducts of Bartholin
and the endocervical secretio n fo r cul tu re on chocolate
aga•~ (e) immunofluo rescent examination of the dis-
charge of endocervical cells for suspected chl amydia!
infec tion; and (f) mi croscopic exa minati on of the clue
cells for diagnosis of bacte rial vaginosis (Chapter 9) .
Feinberg-Whi tti ngton mediu m is used for u·icho mo nad
and Nickerson-Sabouraud for candiasis. T he presence of
cl ue cells ind icates bacte•ial vaginosis.
Pol>•merase chain reacLion (PC R) staining has been
extensively utilized in the diagnosi.~ of various infections.
SPECIAL TESTS
HANGING DROP PREPARATION
ln women complaining leucon·hoea, the discharge collected
from the postel'ior fornix on the blade of the speculum
should be suspended in saline and submitted to microscopic
ex;unination. ormal 'oaginal discharge shows the presence
of exfoliated 'oaginal epithelial cells and the presence of
large rod-like lacLObacilli known as Doderlein's bacilli. A
fresh suspension of the discharge may reveal the motile flag-
ellated o•-ganisms known as TridwmQIWS vagina.l.is. Another
common cause of \'llginal infection is fungal infection or
vll{,riual cmulidir~:>i:>, this can also be detected f•·om a micro-
scopic examination of the vaginal discharge. To the suspen-
sion of the vaginal discharge, add an eq ua l amount of 10%
KOH soluti on. Place a drop of the mi xtu re o n a slide, cover
it with a cover sli p, wa nn the slide and exa mine it under the
low power of the microscope. T he KO H dissolves all cellular
debris, leaving be hi nd the mo re resista nt yeast-like organ-
isms. Typical h)•p hae o r m>•celia and b udding spores can
be easil)' detec ted. Many C<'lses of vagi nitis are attrib uted to
bacterial Vll{,rim},)i~ (nonspecific vaginiLis); also known as
Garrlnendla voginalil. The vis ua liz.1tion of 'clue cells' seen
preferably in a stained smear of the vaginal d isc harge is
high ly suggestive of the infection. Vaginal infections have
been discussed later in detail in Chapter 9.
PAPANICOLAOU TEST
Screening for Cancer
First described b) Papanicolaou and Traut in 1943, this
screening test is often •·efen·ed to as the 'Pap test' or a sur-
fuce biopsy or exfoliative C) tology (C) to logy is a Greek
word, meaning swdy of cells). It forms a pan of the routine
gynaecological examination in women. All sexually active
7
women older than 2 1 years should undergo an ann ual
check-up witl1 three yearly Pap test. Aside from premalig-
nant and malignant changes, otJ1er local conditions can
oft.en be recognized b) the cytologist. The Pap smear is
only a screening test. Positive test (abnormal cells) requires
further investigations such as colposcop)'• cervical biopsy
and fractional curettage. Unfonunately, the Pap test cru1
detect on I> about60%-70% of precancer and cance•· of the
cen~x and less than 70% of endomeu·ial cance•: Reliability
of the repon depends on the slide preparation and tl1e skiU
of the C) LOiogist. Although a single test yields as much as
10%-15% false-negathe reading, it is reduced to only 1%
with repeated tests. A false-positive finding is reponed in
the presence of infection. A yearly negative Pap sme;u· for
3 years is assuring, and thereafter 5-yearly test is adequate.
Th e Pap smear should be obtained before vaginal
examination, because the nngers may remove tl1 e desqua-
mated cervical cells and give a false-negative repo rt, lubri-
ca m may prevent de tec ti o n of orga nisms a nd a ny vaginal
bleedin g during exa min atio n may preclude a prope r visu-
a li zati o n of th e ce rvix. T he patient s ho uld no t have inte r-
co urse or to uch fo r 24 ho urs befo re the Pap test. T he bes t
time to do Pap smear is a ro und ov ulatio n, b ut any other
time can a lso do. T he patient is placed in th e do rsal posi-
tion, with the lab ia parted, and Cusco's self- retaining
spec ulu m is gemly introd uced witho ut the use of lubrican t
or jelly. The cervix is exposed; the sq uamoco lu mnar ju nc-
tion is now scraped with Ayre's spatula by rotating tl1e
spatula all around (Fig. 1.8 0). The scrapings are evenly
spread onto a glass slide and immediately fixed by dipping
the slide in the jar containing equal parts of 95% ethyl
alcohol and ether. After fixing it for 30 minutes, the slide
is air-d•;ed and stained with Pap or shon stain. The slide is
considered satisfact011, if endocen'ical cells are seen. To
improve the predictive valve, endocen'ix is also scraped
with a brush and added to the slide. owadays, a fixative
spray (cytospray) is a\oailable and can be used conveniently
in an office set-up. For honnonal cytological evaluation,
the scrapings are taken from the upper lateral pan of the
vaginal walls; tlwee types of cells are found in the normal
smear: (i) the basal and pa•-abasal cells are small, •·otmded
and basophilic wi th la •-ge nuclei; (ii) the cells from th e
mi ddle layer are squamous cells, tra nsparent a nd baso-
philic witl1 vesicular nuclei; a nd (iii) th e cells from th e
s uperficial la>•e •· are acidop hilic with charac teris ti c p yk-
noti c nuc lei. ln add ition, endome tri al cells, histiocytes,
blood cells a nd bacteri a ca n be seen . Malignant cells a re
hyperc hro ma ti c with a great increase in c hro matin co n-
te nt. Th e n uclei va11' in size a nd th e re is usua lly o nly a
s ma ll amo unt of C)'top lasm in the un d iffe re miatecl malig-
n am cell (Figs 1.9 and 1.1 0). T he nucle us/cytoplasmic
ratio is increased in malignant cells.
Papru1icolaou classincation:
Grade l Nonnal cells (Fig. 1.9)
Grade ll Slightl) abnonnal, suggestive of inflamma-
tOI") change; repeat smear after treating
tl1e infection
Grade Ill A more se•ious t} pe of abnonnality, usu-
all> indicative of the need for biopsy
Grade IV Distinctly abnonnal, possibly malignruu
and dennitely requi•·ing biopsy
Grade V Malignant cells seen (Fig. 1.1 0)
8 SHAW'S TEXTBOOK OF GYN AECOLOGY

R gure 1.8 (A) Papanicolaou sampling devices. Left to right: Cervix -Brush, Cytobrush, wooden spatula, plastic spatula, tongue blade and
cotton swab applicator. (B) Pap smear with a brush. (Source for (A): From Agure 16, Pre-prooedure. Prooedure ConsUlt. Pap Smear. Editors: Michael
L Tuggy and Jorge Garcia; Source tor (B): From Figure 1, Pre-prooedure. Procedure Consult. Papanicolaou Testing. Editors: Todd W Thomsen and

,,
Gary S Setnik.)
0 Scan to play How to take pap smear

f"T

~~

"
.. ~
.. _,:..\...:
. :·.. '
' 1.;
.
•. ·"o"
·l
1.
~ ' .
fl .'
B
J
.. - .. (,· .. ~

Rgure 1.9 Normal cervical smear showing superficial (pink) and intermediate (blue/green) exfoliated cervical cells (low power magnification).
(Source: From Agure 20·5, ian Symonds a"~d Sab.,.-atnam Arul<umaran: Essential Obstetrics and Gynaecology, 5th Ed. Elsevier, 2013.)

A newer classification (Tahlc I . I) describes the cytology
smears as follows:
1. Normal cyto logy
2. lnflam ma tOr)' smea r
3. Cervical inu·aepitJle lial neoplasia (CLN l) or mi ld dysplasia
4. Cl N ll, Ill and carcinoma in situ nuclear abno rma lities
5. MalignanL cells and tadpole ce ll~ wiLit nuclear abnor-
ma lities
lt is reasonable LO e nquire abo ut the percentage of
Lmsuspected cancers, including carc inoma in situ, that
are likely to be diagnosed on routine cytology. The In-
dian Council of Medical Researc h (LCMR). ew Delhi,
screened the population of women o lder L11an 30 years
and found 5-15 smears to be abnormal per 1000 women
examined. The incidence of d)Splasia reponed at Llle All
india l nsliune of Medical Sciences, ew Delhi, was
16/ 1000 patients screened. In a posunenopausal woman,
if the squamocolumnar junction is indrawn due to
oestrogen defici e ncy, a 10-day co urse of oestrogen cream
exposes th e squamocolumnar j un ction better a nd yields
a n acc urate resu lt. Pos trad iatio n cytology is d ifficu lt to
samp le because of sca rring and atrop hy of th e vagina.
T he cells are often e n larged, vacuo lated with mu ltip le
nucleation and nuc lea r wrinkling. InflammatOry cells
ma)' be present (Tab le 1.5 ).
Liquid-ba~ed C)>
tology us ing a thin preparation is s upe-
rior to Pap smear (Fig. I. II ). T he liq uid is used to screen
for papilloma virus. Cervical ca ncer screening is described
in Fig. 1.12. This is described in detail in Chapter 33.
Outer metJ1ocls of cervical screening are also described in
Chapter 33.
VISUAL INSPECTION AFTER ACETIC ACID APPLICATION
(VIA)
Gross inspection of cen·ix after application of 3% or 5%
acetic acid for I minute helps in detecting acetowhite area
which may harbour Cl / neoplasia.
 CHAPTER 1 - APPROACH TO A GYNAECOLOGICAL PATIENT 9

Table 1.5 Bethesda Classification

Sample-adequate, unsatisfactory
Squamous cell abnonnalities
Atypical squamous cells (ASC)
• Atypical squamous cells of undetermined significance
ASCUS
• ASC-cannot exclude high grade lesion ASC-H
• Low- grade squamous intraepithell al lesion (LSIL)
• Hlghijrade squamous intraepithellal lesion (HSIL)
• Squamous cell carcinoma
Adenocarcinoma

S01.rce: Bethesda G.Jideines.

Rgur e 1.10 Illustration of pathological grades of epidennoid cells in

the squamocolumnar junction of the cervix. Cells arising in this loca-
Figure 1.11 Liquid -based cytology classified as epithelial cell
tion were produced by a unifonn cell- scraping technique. Classifica-
abnormality, IOWiJrade squamous lntraeplt hellal lesion (LSiL) . Note
tion of cell types is based upon thorough study, eval uation of cell
particularly the cells in the centre. They have enlarged nuclei
characteristics and pathological features and Is final ly correlated wit h
compared with those in the cell s to the left and below. This feature is
corresponding histological studies of t he tissue. No attempt is made
required for a diagnosis of LSIL. The nuclear contours are irregular.
to classify cell s exfoliated from other tissue areas, such as the endo-
One cell to the right of centre is binucleated, a common feature in
metrium. The squamocolumnar junction Is a vital zone to the female
because this is the focal point where cancer arises. Grading of cell~
LSIL. (Source: From Figtre 12-1, Barbara S Apgar, Gregory L Brotzman
and Mar1< Spczer: Copoooopy: Prnc.,les and Practice, 2nd Ed.
depends upon knowledge of origin of cell sample, on securing a rich
Saunders Else>Aer, 2008.)
concentration of cells, and of greatest importance, correct correlation
with histological fi ndings.

PAP smear (liquid-based cytology with

HPV testing), start with sexual activity
at 30 years or any time after 2 1 years

Table 1.4 Comparison of Different Classification

System for Pre-Invasive Lesion
Papsm e ar Dysplasia CIN Bethesda

II

Ill M ild LS IL

IV Moderate II HSIL

v Severe Ill HSIL

L, low; H, high; SIL, squamous lntraepithellal lesion.

Figure 1.12 Cervical cancer screening.

10 SHAW'S TEXTBOOK OF GYN AECOLOGY

SCHIUER TEST (VISUAL INSPEOION AFTER LUGOL'S

IODINE APPLICATION - VIU)
0 Scan to play VIA and VILI
This test detects tl1e presence of glycoge n in the superficial
cells of tl1e vaginal epitJ1elium. The vagi nal wall is stained
wilh Ltago l's iodine (Lugol's iodine contains 5% iodine and
10% potassium iodide in water [l g iodine + 2g KI]). The
vaginal epiilielium takes mahogan) brown colour in Lhe
presence of gl)cogen. Unstained areas (nega tive LesL) are
abnormal and require biopsy for hisLological exa mination.

CYTOHORMONAL EVALUATION
The ovarian hormones oesu·ogen and progesterone influence
ilie vagin al mucosa; thus, the epitltelial cells exfoliaLed in the
vagina reflect the influence of the pt"C\'<liling dominam hor-
mone in the system at that Li me. The oestrogen-dominated
smear appear-s clea n and shows tl1e p r-esence of discreLe corni-
fied polygona l sq ua mes. The progesLerone-dom inaLed smear
appears cUny and reveals tlt e predom inance of in termed iate
cells. During p regnancy, t11e cytology smea r shows interme-
diate cells and navic ul ar cells. After Lhe menopause due to
tlte deficiency of u1e ova ri an ho rmo nes, tlte vaginal mucosa
tltins down and Ule exfo liated cells are predominantly para-
basal and basal t)•pes. In human papilloma virus (HPV)
infection, one can recognize ko ilocyLes with perinuclear
halo and peripheral conde nsatio n of cytoplasm. The
nucleus is irregular and hype rchroma tic (Fig. 1.10).
Karyopyknotic Index or KPI (Maturation Index)
11. is u1e ratio of mature squamous cells over tl1e imennedi-
aLe and basal cells. It is more tl1an 25% in proliferative
(oes u·ogenic) phase (Fig. 1.1 3) and low in secrewry
(progestational) phase (Fig. 1. 11) a nd during pregnancy.
During pregnanC)', a ratio of more tl1an 10% indicaLes
progesterone deficiency. onnally, a peak value of KPI
is reached on Ute day of ovulation (2 days after serum
E..! peak).
UTERINE ASPIRATION CYTOLOGY
Perimenopausal a nd posu11enopa usal women on a h or-
mone therapy are now being screened for endometYial
cancer. T he uterine aspiration syainge o r brush is fo und to
Figure 1.13 Hi stology of proliferative phase. (Courtesy: Dr Sandeep
Mathur, AIIMS.)
be sa ti sfactory for obta ining adeq uaLe sa mp les. lL can be
uti lized as an office p roced ure; abo ut 90% acc uracy with no
false-positi ve findings is cla imed with this proced ure .
COLPOSCOPY
T he colposcope is a b inocular microscope giving a 10-
20 times magnificatio n. It is useful in loca ting abnorma l
areas and accurately obtaining directed biopsy from tlte
suspicious areas on the cervix and vagina in women witlt
positive Pap smears. This wa> the frequency of false-negative
biopsy is reduced. so also the need for con iLaLio n, a proce-
dure Lhat is accompanied witJ1 considerable amoum of
bleeding and morbid it) (Chapter 18).
ENDOMETRIAL BIOPSY (Fig. 1.14A and B)
An office or outpatient procedure was aLone Lime very popu-
lat· in ilie investigations of the female panner for infea·LiliLy. 11.
is performed in Ute premenstrual phase. A fine cureue is in-
troduced into Ul e uterine cavity to obtain a small su·ip ofthe
endometrial lining for histopat11ological examination, sene-
tory endomeuium denotes ovulaLOry cycle. Witlt t11e avail-
abili ty of uluasoamd, a noninvasive method for tlte detection
of ovul ati on, U1is procedure is now generall y not employed.

A
Figure 1.14 (A) Histology of secretory phase. (B) Midsecretory endometrium. (Source for (A): Copyright 2009 by the Unillllrsity of Aorida)
 CHAPTER I - APPROACH TO A GYNAECOLOGICAL PATIENT
It is still used if tubercular endomeu·itis is suspected. It is
useful in the d iagnosis of co•-pus luteal phase defecL
HORMONAL ASSAYS
In presen t-day practi ce, it is possible to swdy the levels of
several hormo nes using radioimmun <><"1Ssays and/o r the
£ LISA tests. T he co mmo nly assayed ho m1 o nes include FSH,
LJ I, PRL, ACTH, T 3, T 4, TSH, p rogestero ne, oestradiol,
testosterone, cortisol, aldosterone, hCG, dehyd roepia nd ros-
terone and androstenedione. These ass;1ys are used in the
(Uagnosis of menopause, PCOD and prolactinomas, and for
monitoring treaunem regimes in induction of ovulation
and in assisted reproduction.
ULTRASONOGRAPHY
Ultrasonography is a simple noninvasive 11nd painless diag-
nostic procedure that has the advantage of being devoid of
any rad iatio n hazard. T he pelvis and the lower abdomen are
sca nned in bo th the lo ngitudinal and tra nsve rse planes.
Generally, th is scan is do ne when the pati e nt's b ladder is full
as it he lps to e levate th e uterus o ut of the pelvis, and dis-
places the gas-fi lled bowel loops away, thus provid ing the
sonologist with a window to image the pelvic organs. ln
most cases, a transvaginal probe can be tLSefully employed to
obtain finer details of the pelvic organs. The bladder need
not be full , if the vaginal probe is tLSed. The scan can
coll<lborate the clin ical impression or uncover a hitheno
tmsuspected pathology. Lately, •·ectal and perineal routes
are 11lso 11vailable. 0 3 ultraSound is now capable of provid-
ing three-dime nsional images of the pelvic o rga ns and is
recent! )' ava ilable especiall y to de tect ge ni tal trac t malfo r-
mati ons and is less costly than MRI. Ultraso un d is also used
in certa in tlterape utic procedu res such as in vitro fertiliza-
tion and asp iratio n of a C)'St or pelvic abscess.
OTHER IMAGING MODALITIES
Radiological investigation such as h)SterosalpingQgJ-aphy is
utilited for stud)ing the patency of the fallopian tubes in an
infertile patient. CT scan and MRI are advanced investiga·
tions that detenn ine the extent of tumours and their
spre<1d. For details, refer to Chapter 40. Sonosalpingog•-a·
ph y is employed in women with infe rti lity and wh en uterine
poi)'P is suspected.
GYNAECOLOGICAL ENDOSCOPY
Botlt diagnostic laparoscopy and hysteroscopy are estab Ushed
use ful tools in the armamentarium of t11e gynaecologist. For
details, refer to Chapter 41 (Endoscop) in Gynaecology).
11
PREGNANCY TEST
The first morning sample of urine is used in a •-apid immu-
nologi cal test to confirm pregnanC)\ by detecting the
presen ce of human cl1o1·ionic honnone. The pregnancy test
becomes positive by the begi nning of 6th week, from th e
last me nsu·ual period. With modem kits, any sample of
urine ca n be used, and it may beco me positi ve with in
1-2 da)'S after missing tl1 e pe riods.
KEY POINTS
• Most mnaecological diseases can be diagnosed by a
proper and detai led histor) and peh ic examination.
• While approaching a female patient, utmost care should
be taken to respect her feeUngs, ensure p•·hoacy and us-
ing simple words LO know details of her sexual hisLO•) ',
contraCeptive used, abortions and suq~ical u·eaunenL
• A wide range of investigati o ns are now <~vai l able with
Ute g)•naecologisLS which finall y co nfi rm the diagno-
sis, detec t the extent of th e d isease a nd help in plan-
ning tlt e managemenL
• Pap smear is now an established scree ning proced ure
in carcinoma cervix.
• Ulu·asound examinations have simplified gynaeco-
logical diagnosis.
• Seleahe ID naecological endoscop) helps defin itive
diagnosis.
• Honnonal assars are necessary in infertilitywork up, in
viu·o ferti litation and v:u·ious hormonal disturbances.
• Cr and MRJ have added to the imaging modalities
and are useful when diagnosis is in do ubt o n the basis
of ph)•Sical exa mina tio n.
SELF-ASSESSMENT
I. List t11e simple steps in history taking of a gynaecological
patient.
2. Describe the imponance of Pap smears in clinical practice.
3. WhaL is t11e role of imaging and endoscopy in the clinical
practice of gynaecolom•?
SUGGESTED READING
Ley P. Commun ications with Patient$. London, Croom I !elm, 1988.
Lipkin M .J r. The me dical interview and related skills. In BrdnCh "WT
(ed). Office Practice ofMedidne. Philadelphia. WB Saunders, 1987;
1287-306.
SirnpM>n M , Buck1nan R. Ste,.lart ~·f, ct al. Doctor paticnl communica-
tion. ThcTor<>nto consensus statcrnem. B:.tj 1991; 30!l: 1386-7.
Todd AD, Fi>hcr S. The Social Orgdnir.ation of Doctor-P:otienL Com-
munication, 2nd ed. ~onvood, ~- Ablex Publi>hing, 199!l; 243-65.
 ANATOMY, PHYSIOLOGY
AND DEVELOPMENT OF FEMALE
REPRODUCTIVE ORGANS

2 Anatomy of Female Genital Tract 6 Puberty, Adolescence and Related

3 Normal Histology of Ovary and
Endometrium
4 Physiology of Ovulation and
Menstruation
5 Development of Female Reproductive
Organs and Related Disorders
Gynaecological Problems
7 Menopause and Related Problems
8 Breast and Gynaecologist
9 Sexual Development and Development
Disorders of Sexual Development

12
 Anatomy of Female
Genital Tract

The Vulva 13 The Pelv ic Musculature 25

The Vagina 15 The Pelv ic Cellular Tissue 28
The Uterus 18 The Pelvic Blood Vessels 29
The Uterine Appendages 2 1 The Lymphatic System 3 1
Fallopian Tubes 21
The Ovaries 23
The Nerve Supply 33
Applied Anatomy and its Clinical 0
The Urethra 23
The Bladder 24
The Ureters 24
The Rectum and Anal Canal 25
Significance 33
Key Points 35
Self-Assessment 35 0
The anat0m ica! knowl edge of th e female genital organ the labia majora are hairless and the skin of
(Fig. 2. 1) and th eir relation to th e neighbouring structures t I area ·s ofter, moister and pinker th an over th e omer
help in the diagnosis of various gynaecological dise.ases~ ----,~ ( Fig. 2.2). T he labia majora are covered wiL11 squa-
and in interpreting the findings of u ltraso und , computed 1 11.s epithelium and contain sebaceous g lands, sweat
LOmography (CT) and magnetic resonance imaging ( glands and ha ir follicles. There are also certa in speci alized
scanning. During gynaeco logical surgery, di ronlons of the sweat glands call ed apocrine glands, which produce a cha r•
pe lvic organs are beuer appreciated and de.alt a d ac terislic aroma and from which th e rare tumour of hidrad-
grave inj1 11• to the sm.1 ctures uch as bladd enoma of the vu lva Ls derived. T he secre ti on in creases
rectum is avoided. Th e understanding of the l)Un hatic during sexual excitement.
drainage of the pelvic o rgans is necessa.i~ 1 rn~·ng arious The presence of all these su·u ctures in the labia majora
gen ital tract malignanc ies and in their ut ical d ssection. renders th em liable LO common skin lesions such as folliculitis,
boils and sebaceou cysLS (Fig. 2.3). LLS masculine coun terpart
i the scrotum.
THE VULVA

T he vulva is an ill-defined area which in gynaecological

practice comprises th e who le of the external gen itali a and
conveniently includes lhe perineum. It is, therefore,
bounded anteriorly by the mons veneris (pubis), laterally by
tl,e labia majora and posteriorly by the perine um.
LABIAMAJORA
T he labia majora pass from the mons veneris tO end poste-
1iorly in the skin over the perinea! body. T h e}' consist of
fo lds of skin which en dose a vairiable amount of fa Land are
best developed in the ch ildb earing period of life. ln chil-
dren before tl1 e age of puberty and in posunenopausal
women, the amo um of s ubcutaneous fa t in the labia majora
is relative!>• camy, and the cleft between the labia is there-
fore conspicuous. At puberty, pudenda! hair appear o n the
mons veneri , the outer surface of the labia majora and in
some cases on th e skin of the perine t:Lm as well. T h e inner
LABIA MINORA
Th e labia minora are thin folds of skin which encl ose ve ins
an d e lastic tissue and lie on the inner aspect of the labia
majora. T he vasc ular labia minora are erec tile during sexual
activity; they do not contain any sebaceotts glands or hair
follicles (Fig. 2.4). Ameriorly, they enclose the cliLOris to
fo rm the prepuce on the upper surface and the frenulum
on iL~ und ersurface. Posteriorly, they join tO form the fo 111~
chette. The fourc h ette is a tlli n fold of skin, iden tified when
th e labia are separated, and it is often rorn during parturi-
tion. The fossa navicnlaris is the small hollow between th e
hyme n and the fo urchette. Labia minora is homologous
with the ven u·a l aspect of the penis.
The clitoris is an erec tile organ and consists of a glans,
covered by tl,e frenulum and prepuce , an d a body whi ch is
ubcutaneous; it corresponds to th e penis and Ls attached LO
the und ersurface of the symph}•sis pubis by th e suspenso11•
ligament. ormally, the clitoris is 1- 11/1 cm long and 5 mm
13
14 SHAW'S TEXTBOOK OF GYN AECOLOGY

Uterus

Ovary
Rgure 2.1 General view of internal genital organs showing t he
normal uterus and ovaries.

Figure 2.3 Hi stological section of the labium majus showing squa-

Mons pubis
mous epit helium with hair follicle and sebaceous gland {X 55).
(wneris)

Prepuce
Frenum Clitoris
Vestibule _ ,._,1---,f+.- Labium majus
Labium minus -~i----+1 l.!l--1+-+1'- External urethral
orific.e
Vaginal introitus -..,.-+--1--SI
Opening of
Bartholin's duct
Hymen
1-+- -- - Perineum

Figure 2.4 Histological section of the labium minus showing squa-

8 Virginal Septate Cribriform Parous mous epithelium. Note complete absence of hair follicles and sebaceous
Rgure 2.2 (A) Anatomy of the vulva. (B) Variations of the hymen. and sweat glands.

in width. Clitoris o f more than 3.5 on in le ngth and I em
in width is called clitoro megaly, and occurs in virilism due to
excess o f androge n ho nno ne. The clitoris is well supplied
with nerve endings and is e xu·emely sensitive . Dlll·ing coiLUs,
it becomes e rect a nd pla)S a conside rable pan in inducing
orgasm in the female. The clito•·is is highl)' vascular. An in-
jury to the clitoris causes profuse bleeding and can be very
painful.
The ve~tibule is the space I) ing be twee n the anterio r and
the inner aspects of the labia minora a nd is bounded poste-
rioliy by the vaginal in troitus. The I'Xf t'rrUllurintt ')' 11U!lt iLIS iies
immediatel) posterio r to the clito •is. The vaginal orifice lies
poste,;or to th e meatus and is surrounded by the hp nen.
In virgins, the h)lne n is re p•-esellled b)• a thin membra ne
cove red o n each surface by sq uamous e pithelium. It gener-
a lly has a small eccenu·ic opening, which is usua lly not wide

enough to admit the fin gertip. Coitus resul ts in the rupture
of tl1e hymen; the resulting lace rations are radially arranged
and are multiple. Occasionally, coital n.apwre can cause a
brisk hae mo rrhage. During childbirtll, further lacerations
occur: tl1e h)lnen is wide!) SU'etched and subsequently is
represe nted b) the tags of skin kn own as the carunculae
myrtiformes. \\'ith the populaait) of tll e use of intemal sani-
tal")' tampons, the loss of in tegait) of tlle hpnen is no longer
an evide nce of loss of virginity.
The ' 'ulval tissues respond to ho nn ones, especially oestrO-
gen , during m e childbeaa·ing)ears. After menopause, auophy
due to oestrogen deficiency m akes me vulval skin tl1inner and
drier, and this m ay lead to atrophi c '~alvitis and itching. Mons
jJUbiJ is an at·ea which overl aps the symphysis pubis and con-
tains f.n. At puberty, abundant hair grow over it.
BARTHOLIN'S GlAND
Bartl1oli n 's gland li es posterolaterall y in relatio n to the vagi nal
otifice, deep to the b ul bospongiosus m uscle and supe rficial to
tl1e o uter layer of tJ1e u·iangu lar ligament. It is e mbedded
in the erec til e tissue of tJ1e vestib ular b ulb at its posterior
ex u·em it)'· It is norma lly impa lpable when healtl1y, but can be
readil)' palpated be twee n the finger and the tl1U mb when
en larged b)' inflammation. Its vascu lar bed accounts for me
brisk bleeding, which always accompan ies its removal. Its
duct passes forwards and inwards to open, external to the
hymen, on tl1e inne r side of the labium minus. The gland
measures about 10 mm in di.'lmeter and lies near tllejunction
of the middle and posterior thirds of tlle labium majus. The
duct of the gland is about 25 mm lo ng and a min mucous
secretio n can be expressed from it by pressure upon me
gland. Barth olin's gland and its duct are infected in acute
gonorrhoea, when the a·eddened mo urn of the duct can easily
be disti nguished on tl1e inner surface of m e labiwn minus to
one side of tl1e vaginal o aifice below the level of tl1e hpnen.
Bat·tllolin's gland is a compound racemose gland and its acini
are lined by low columnar epitllelium (Fig. 2.50 ) . The epi-
theliwn of the duct is cubical near the acini, but becomes
Rgure 2.5 Bartholin's gland. Low-power view showing the structure
of a oompound racemose gland with acini lined by low columnar
epithelium (x92).
0 Scan to play Barthol in's abscess
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 15
u·ansitional and finally squamo us near tl1e mouth oftl1e d uct.
The function of tl1e gland is to sec rete lubricating mucous
dwing coitus. The labia majora j o in at the posterior commis-
Sttre and merge imperceptibl) into tl1e peainea.un.
THE VAGINA
The vagina is a fibronnLSCular passage mat connects tl1e
Lllerus to me introitLLS. The lower end of the vagina lies at
the level of the h) men a nd of the inu·oitus \'llginae. It is sur-
rounded at tllis point by tl1e erectile tissue of tl1e bulb, which
corresponds to tl1e corpus spongiosum of the male. The
direction of the \':!gina is approxim ately parallel tO me
plane of tl1 e brim of tl1e u·ue pelvis; the vagina is slightl y
curved forwards from above downwards, and its anterior
and postetior walls lie in a close co nta ct. It is notofun ifotm
cali bre, being nea rly twi ce as capacious in i t.~ upper part and
somewhat flask shaped. T he vaginal ponio n of the cervix
projects into its upper e nd and leads to the fo rma tio n of th e
anterio •~ poste ri or and latera l forn ices. T he dep th of th e
forn ices depends upon the deve lopmen t of the portio vagi-
na lis of the cervix. In girls before pube r1.)' and in e lderly
women in whom the ute nts has undergone postmenopausal
atroph)', me fornices are shallow whe reas in women wim
congenital elongation of the portio vaginalis of tl1e cervix,
the fornices are deep. The vagina is attached to the cervix
at a higher leve l posteriorly than elsewhere, and this makes
the posterior fornix the deepest o f the fo rnices and tl1e
posterior \':!gina! wall lo nger than tl1e anterio r. The poste-
rior wall is 4.5 inch ( 11.5 em) lo ng, whereas Ll1e antet;or
wall measures 3.5 in ch (9 em). Transve rse folds which are
present in m e \'3ginal walls of nulliparae a llow the \':!gi na to
stretch and dilate during coitLLS and pat1.ut·itio n. These folds
are pa 11.ly o bliterated in women who have bome ma ny
children. In the a nteri or \':lgi nal wall, tllree sulci caa1 be
disting uished. One lies immediately above the meatus aa1d
is called ~ubmeaJal>ulctl> ( Fig. 2.6). About 35 mm above this
Rgure 2.6 A case of prolapse In which the cervix has been drawn
down. Parameatal recess, hymen, submeatal sulcus, paraurethral
recess, oblique vaginal fold , transverse sulcus of the anterior vaginal
wall, arched rugae of the vaginal wall and bladder sulcus.
16 SHAW'S TEXTBOOK OF GYN AECOLOGY

sulcus in tl1e ameli or vaginal wa ll is a second sulc us, known
as the transver:.e vaginal sulws, which corresponds approxi-
mately to the junction of the urethra and the bladder.
fLLrtller upwards is tl1e bltuhkr sulcus, indicating tl1e junction
of tl1e bladder to tl1e an tetior vaginal wall.
The vaginal mucosa is lined by nonkeratized squamous
epithelium which consists of a basal layer of cuboidal cells,
a middle la)er of prickle cells and a superficial layer of
comified cells (Fig. 2. 7). In the newborn, the epitheliwn
is almost transitional in t)pe and cornified cells are scanty
until puberty is reached. No glands open into the vagina,
and the \'3ginal secretion is derived partly from tl1e mu-
cous discharge of the ce•vix and partly from transudation
through tl1e vaginal epithelium. The subepithelial layer is
Epithelium
Submucous
la~r
Smooth muscle
(inner circular
and outer
longitudinal)
- } External
--~ -~ ~-::::::=:- fibrous layer
:::g~ -- -- ~ (endopelvic
--=---~-= -==-~--- tascia)
Rgure 2. 7 (A) Low-power {X36) microscopic appea-ance of the
vaginal wall showing the corrugated squamous epithelium and
bundles of plain muscle cells subjacent to the vascular subepithelial
layer. (B) Structure of the vaginal wall. (Courtesy for (A): Dr Sardeep
Mathur, AJIMS.)
vasc ular and contains much erectile tissue. A muscle
layer consisting of a complex interlac ing lattice of plain
muscle lies external to the subepithelial layer, whereas
the large vessels lie in the connective tissues surrounding
the vagina. If the female fews is exposed LO diethylstil-
boestrol (DES) taken b) the mother during pregnancy,
columnar epithelium appears in the upper two-thirds of
vaginal mucosa, which can develop vaginal adenosis
and vaginal cancer during adolescence. The keratiniza-
tion of vaginal mucosa occurs in prolapse due to the
exposure of vagina to the outside and ulcer may form
over the \'3ginal mucosa (decubitus ulcer). The keratized
mucosa appears skin-like and brown. Menopause causes
atrophy of tl1e vagina.
The vagiual .~ecretion is small in amount in healthy
women and consists of white coagulated material. Wh en it
is examined under a microscope, sq uamous cells sh ed from
the vaginal epi thelium and Doderlein's bacilli alo ne are
fo und. Duderlein~ !Jacillt.t.l is a large Gra m-positive rod-
s haped organism, whi ch grows a nae robicall y on ac id me-
dia. T he vaginal sec retion is ac id ic cl ue to tl1e presence of
lac tic ac id, and tl1is ac id it)' inhi b its th e growth of pa ul o-
ge nic organ isms. T he pl-1 of th e vagina ave rages abo ut
4.5 du ring reprod ucti ve life. T he ac id it)', which is undo ub t-
ed!)' oestrogen dependent, fa lls afte r me nopause to ne utt·a t
or even a lkaline. Before pubert)', the pH i.~ abo ut 7. This
high p l-1 before puberty and after menopause explains the
tendency for the development of mi xed organism infec-
tions in these age groups.
The synthesis of lactic acid is probably influenced by
either enzrme or bacterial activit) {Doderlein 's) on the
glycogen of the epithelial cells, which itself is dependem
on the presence of oestrogen, so that its deficiem activity
can be boosted b) the administration of oral or local
oestrogen. During the pue•·pe•·ium and also in cases of
leucorrhoea, tl1e acidity of the \'llgina is reduced and
pathogenic organisms are then able to survive. The squa-
mous cells of the vagina and cervix stain a deep brown
colour after being painted with iodine solution, owi ng to
the presence of glycogen in healthy cells (positive Schil-
ler's test). Ln a posUllenopausal woma n, because of tl1e
absence of or low glycogen-conta ini ng superficial cells,
Schiller's test becomes negative.
T he vagina l epithelium is under tl1 e ova rian hormo nal
infl ue nces of oestrogen and progestero ne. Oesu-ogen pro-
liferates the gl)'cogen-containing supe rficial cells and pro-
gestero ne causes prolife ratio n of ime rm ediate cells. Lack of
these ho rm ones in a me nopa usal woman leaves only the
basal cells with a thi n vagina l mucosa.
T he abno•mal and malignant cells also do no t con tain
gi)'COgen and do not take up lhe stain. Similarly, these
abnormal cells turn wh ite with acetic ac id d ue tO coagula-
tion of protein. These areas are selected for biopsy in the
detection of cancer.
RELATIONS OF VAGINA
ANTERIOR RELATION
In its lower half. the vagina is close!) related tO tl1e urethra
and the paraurethral glands {Skene's wbules), so closely in
faCL tl1at the urethr0\'3ginal fascia is a fused struCLure and
only separable by a sharp dissection. In its upper half, tl1e

vagina is related to the b ladder in the region of the u·igone,
and here the vesical and vaginal fasc iae are easily separable
by a blunt dissection via the vesicovaginal space. There is a
considerable vasc ular and lymph atic imercommunication
between the vesical and the vaginal vessels, a sinister rela-
tionship having a bearing on Lhe surgery of a malignam
disease of Lh is area.
POSTERIOR RELATIONS
The lower third of the \'llgina is re lated 1.0 Lhe perineal
body, the middle third 1.0 the ampulla of the reCLum
and the upper third to the anterior \\'llll of the pouch of
Douglas, which comains la•·ge and small bowel loops. This
partition dividing the vagina from the pe•·itOneal cavity is
tl1e thinnest a•·ea in the whole pe•·itOneal surface and,
tl1erefore, a site of election for poim ing and opening of
pelvic abscess or th e productio n of a h ernia or enterocele.
T his is also an ideal site for colpocem esis in th e d iagn osis
of ectOpic pregnancy.
Pouch of Douglas (Fig. 2.8) is a pe rito neal cul-de-sac in
the rec tovaginal space in the pelvis. IL is bo unded anterio rl)'
by the peritone um cove rin g the pos te rio r vaginal wall and
posLerio rl )' b)' tl1e peritone um covering the sigmoid colon
and the recwm. Laterall y, th e uterosacral ligame nts limi t
its bo undary whereas th e floor is Lhe reflection of the
peritoneum o f the pe rito neal cavity.
The endometriotic nod ules and metasmtic growth of
an ovarian cance r are fe lt in tl1 e pouch of Douglas, so
also pelvic inflammatOI') mass. The u1.erosacral ligaments
are thickened and become nodular in advanced cancer
cervix.
LATERAL RELATIONS
The la1.eral relations f•·om below upwa rds are the cavern-
ous tissue of the vestibule; the supe •·ficia l muscles of the
pe•·ineum; the u·iangu lar liga ment and at about 2.5 em
from the inu·oitus t11 e Je,>aLOr ani, lateral tO which is tl1e
ischio•·ectal fossa. Above the levator lies the endopelvic
cellular tissue, and its condensation , called Mackenrodt's
ligament, on tl1 e either side. The ureter traverses this
Uterosacral ligament Pouch of Douglas
Figure 2.8 Pouch of Douglas showing uterosacral ligaments as
upper border.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 17
tissue in the urete ric ca na l and is abou t 12 mm anterolat-
eral to the lateral fo rnix.
SUPERIOR RELATIONS
1l1e cervix with its four fornices - amerior, posterior and
two lateral- are related to tl1 e uLerine vessels, Mackenrodt's
ligament and the ~.u·e ter. PosLe•io rl), surrounding the pouch
of Douglas lie the uterosacral ligaments which can be identi-
fied o n vaginal examination, especiall)• if thickened by
disease such as endomeu·iosis and cance r ce rvix.
Squamocolumnar j unction, also known as u-ansitional
zone, is clinically a ' ery important junction where the squa-
mous epithelium lining tl1e vagina merges witllthe columnar
epithelium of tl1e endocervix and is 1-10 mm (Fig. 2.9) .
Here, tl1e constant cellular activiLy of tl1e cells takes place,
and the cells are highly sensitive to irritants, mutagens and
viral agents such as papilloma virtL5 16, 18. T hese agents cause
nuclear changes tl1at ca n evenLUall y lead tO dysplasia and
carcinoma cervix, which is the most co mmon malignancy of
tl1e female geniLal tra ct in Ind ia. Squamocolumnar junction
is of two types: first one is embryo nic when columnar epithe-
lium spreads over the exte rna l os. Afte r pube rt)\ metaplasia
of colu mnar epitl1e liu m unde r the infl uence of oestroge n
brings sq uamous epitheliu m close to Lhe ex ternal os, thus
creati ng a u·ansitional zone be twee n the two j unc tions. In
women exposed to DES in utero, tl1is zone is well outside the
os, spreading over tl1e \'llgi nal vau lt. In a menopausal woman,
it gets indrawn inside tlle os. During pregnancy and with oral
conu-aceptives, it pouts o uL of os.
The squamoco lumnarjunction is well outside me external
os dLLring tl1 e reprod uctive period, and in Pap smear tl1is area
is scraped and tl1 e C) tolog) of its cells swdied for the nuclear
changes, in me scree ning programme for ca nce r cervix.
Dw·ing pregnane), tl1e ex1.e m al os becomes patulous and
the squamocolumnar junction is well exposed all round.
Pap smear> ields the most accu rate C) tological findings.
ln menopausal women, the cervix sh•·inks and the squa-
mocolumnar junction gets indrawn into the cervical canal.
Columnar
epithelium
Figure 2.9 Squamocolumnar junction. In the 'ideal' cervix, the
original squamous epithelium abuts the columnar epithelium. (Soun::e:
Hacker NF, Ganbone JC, Hobel CJ, Hacker CW'ld Moore's Essentials ot
Obstetres ard Gynecology, 5th ed Pliladelphia: Elsevier, 201 0.)
18 SHAW'S TEXTBOOK OF GYN AECOLOGY
lt is therefore not easily accessib le, and ill exposed to the
vagina, for visua l inspection. This explains high false-nega-
tive findings in Pap smear in older women. Giving oestrogen
locally or orall) or prostaglandin E (misoprosLOI) pessary
allows this junction to pout out and improves t11e efficacy of
t.he Pap smear C) to log).
The squamocolumnarjunction is SLUdied colposcopically
when t.he Pap smear shows abnormal cells, and t11e abnor-
mal areas are biopsied fo•· cancer detection.
THE UTERUS
The uterus is py.-iform in shape and measures approxi-
mate!)' 9 em in length, 6.5 em in width and 3.5 em in
tl1ickness. It is divided anatom icall y and fun ction all y
into body and ce1vix. It weighs I o unce (60 g). T he line
of division correspo nds to the level ofth e intern al os, and
here the muco us membra ne lining the cavity of the
uter us beco mes con tinuo us witl1 that of th e cervical ca nal
(Fig. 2.1 0). At thi s level, the pe ri to ne um of the front of
t11e ute rus is reflected o n to the bladde r, a nd the uterine
artery, after passing a lmost tra nsverse!)' ac ross the pe lvis,
reac hes tl1e uterus, tu rns at r ight angle and passes verti-
cally upwards a long the latera l wa ll of the u terus. T he
ce1vix is divided into vagina l and supravaginal portions.
The fundus of the uterus is that part of the corpus uteri
which lies above the insertion of the fallopian tubes. The
cavity of t11e uterus communicates above wit11 t11e open-
ings of the fallopian tubes, and by way of t11eir abdominal
ostia is in direct con tin uit) with t11e peritOneal cavity. The
uterine caviL) is triangular in shape witll a capacity of
3 mL. The lower angle is formed by the internal os. The
lateral angle connecting to the fallopian tube is called t11e
cornual end. The wall of the uterus consistS of tluee layers,
t.he peritoneal co,·ering called pe•·imetrium, tl1e muscle
layer or myomeu·ium and t.he mucous membrane or
endomeu·ium.
The ute•·us is capable of distension during pregnancy,
haematometra as well as with distended media du.-i ng
hysteroscopic examination. Otherwise tl1e two walls are in
opposition.
Infundibulum Intramural
(Interstitial) par t
-4::::~-- Cervical canal
Vaginal cervix or
(portio vaginalis)
Rgure 2.10 A nulliparous uterus showing the anatomical structures.
PERITONEAL COVERING
The peritoneal covering of the utems is incomplete. Anteri-
orly, t11e whole bod) of t11e ULerus is covered witll peritoneum.
1l1e peritoneum is reflected on to t11e bladder at t11e level of
t.he imemal os. ll1e cen1x of t11e uterus has t11erefore no peri-
toneal covering ameliorl). Post.e•iorl), tl1e whole body of t.he
uterus is covered b) pelitoneum, as is the supravaginal portion
oft.he cen·ix. The pel"itoneum is reflected from t.he supravagi-
nal portion of t.he eel"\ ix on to the poste•·iorvaginal wall in tl1e
region of t.he postelior fomix. The peritOneal la)er is incom-
plete laterally because of the insertion of t.he fallopian tubes,
t.he row1d and ovarian ligaments into t.he uterus, and below
t.his level tl1e two sheets of peritoneum, which constitute t.he
broad ligament, leave a tl1in bare area laterall y on each side.
MYOMETRIUM
T he myome u·ium is the thickest of t11e t11ree laye rs ofthe wall
of the ute n.ts. ln the cen>ix, the m>•ometrium consists of plain
muscle tissue together witJ1 a large amo unt of fibrous tissue,
which gives it a hard consistency. T he muscle fibres and
fibro us tissues are mixed togctJlcrwithout an orderl)' arrange-
menL ln tJ1e bod)' of tJ1e utenJS, tJ1e myomeuium measures
aboutl 0-20 mm in tJ1 ickness, and tJ1ree layers can be d istin-
gu ished which are best marked in tJ1e pregnam and puerperal
uterus. The extemal layer lies immediately beneath the peri-
tonewn and is longitudinal, tJ1e fibres passing from t11e cervix
anteriorly over tl1e ft.uldus to reach tJ1e posterior surface of
the cervix. ll1is la)er is Lhin and cannot easily be identified in
ilie nulliparous uterus. The main function of tJ1is layer is a
dem.ISor action during tJ1e expulsion oftJle fetus. The middle
layer is t.he thickest of the tJwee and consists of bLUldles of
muscle sepamted b) a connecti'e tissue, the exact amow1t of
whid1 varies with age; plain muscle tissue is best marked in tl1e
childbearing pe•iod, especially during pregnancy whereas
before pubeny and after menopause it is much less plentiful.
There is a tendency for tJ1e muscle bundles to imerlace, and
as t.he blood vessels supplying blood to the uterus are dist.lib-
uted in the connective tissues, tJ1e calibre of the vessels is in
part controlled by tJ1e conu<~ction of tJ1e muscle cells. The
purpose of tl1is la>•er is therefore in part haemostatic, tl1ough
its exp ulsive role is equally importa nt. T his layer is clesclibed
as living ligal!tm~ of the uteno, and is responsible for comrol of
bleeding in the thi rd stage of labo ur. Inefficient contrac tion
and re u·act.i on of these muscle fib res ca use prolonged labo ur
and atOni c postpartwn haemo •Thage (PI)I-1).
T he inner muscle la>•er COI1Sists of circula r fib res. T he
layer is never we ll marked and is best rep rese med by tl1 e
circ ular mt.ISc le fibres around the in te rnal os a nd tJ1e ope n-
ings of the fallopian tubes. It can be regarded as sp hin cteric
in action. The myomeui um is th ickest at the fund us
( 1-2 em) and thinnest at tJ1e cornual end (3-4 mm), one
should t11erefore be careful during curettage and endome-
trial ablation not to perforate tJ1e com ual end.
ENDOMETRIUM
The endomeu·ium or mucot.IS membrane lining tJ1e ca'~t:)'
of the uterus has a different structure from that of tl1e
enclocervix. It is described in Chapter 3, ' onnal histology
ofOvaryand Endometdum'.

The cer vix is spind le shaped and measures 2.5 em or a
little more. It is bounded above by the internal os and
below by the external os (Fig. 2. 10). The mucosal lining
of tJ1e cervix differs from that of the body of tJ1e uterus by
tJ1e absence of a submucosa. The endocervix is lined by a
single la)er of high columnar ciliated epitJ1elium \vith
spindle-shaped nuclei I) ing adjacent to the basement
membrane with abundam C)LOplasm and mucin. The
direction of the cilia is downwards towarcls the external
os. The glan<ls are racemose in t) pe (Fig. 2.llA and B)
and secrete mucus with a high content of fructose glyco-
protein, mucopolysaccharide and sodium chlo•·ide. The
secretion is alkaline and has a p H of 7.8 and itS fructose
contem render·s it atu-active to ascend ing spe•·maLOzoa.
This secretion collectS as a plug in the cervical ca nal an d
possibly h inders ascending infections. In gonococcal an d
chl amydia! infections of th e ce rvix, tJ1 e orga nisms collect
amongst t he cryptS of th e cervical glands. In nulli paro us
~ .
" . . .
- - ·. ,~ .
:c..•·
·· "'..
-.•
' between tl1e endomeuium of the body and the mucous
Rgure 2.11 (A) Normal endocervical cells. (B) Normal cervical
glands. These are of the racemose type and are lined by high co-
lumnar epithelium which secretes mucous (X250). (Source tor
(B): Seama Khuni, CervtxPremalignCW"It/preinvasive lesions. 2003-
2017, PalhologyOutlines.com, Inc.)
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 19
women, the external OS is circ ular b ut vagina l de livery
resul tS in tJ1e transverse slit which characterizes the paro us
cervix. The cervix contains more of fibrous tissue and col-
lagen than the muscle fibres, which are dispersed scarcely
amongst the fibrous tissue. Cervix contains mainly colla-
gen and on I) 10% of muscle fibres. Light microscopic ex-
amination reveals 29% muscle fibres in itS upper one-
third, IS% in tJ1e middle one-third and only 6% in the
lower one-tJ1ird, whereas the body of me utems contains
70% muscle fibres. The change from fibrous tissue of cer·
vix to the muscle tissue of the body is quite abrupL ln late
pregnancy and at tenn, under the influence of prostagla n-
din, collagenase dissolves collagen into fluid form a nd
renders tJ1e cervix soft and stretchable during labour.
Functions of the endoce•·vical cell li n ing are as follows:
• T he cilia are directed downwards and prevent ascending
infection.
• T he cells sieve o ut abnormal sperms a nd allow h ealthy
sperms to en ter the uterus.
• It provides nu ui tio n to the sperms.
• It allows capaci tati o n of spe rms.
Structu rall)' and func ti onally, tl1e bOd)' ofLhe ute rus and
that of tl1e cervix are in marked contrast. T he ce rvical epi-
the liu m shows no periodic alteration d uri ng the mensu·ual
cycle, and the decidual reaction of pregnancy is seen o nly
rarely in the cervix. Similarly, t11e malignant disease of tl1e
uterus is an adenocarcinoma of the endometrium, whereas
carcinoma ofthe ce1vix is usuall) a squamous cell growtl1 of
high malignrulC).
An intennediate Lone, tltl' istlm1us, 6 mm in length, lies
membrane of the ce•' ical canal. ItS epitJ1elial lining resem-
bles and behaves like the endomeu·ium of me body. The
isthmic po•·tion stretches cllll·ing pregnanq• and fonns tJ1e
lower uterine segment in late pregnancy. This isthmic por·
tion is less contractile dlll·ing pregnancy and labour but
funher stretches under uterine conu-actions. It is identified
during caesarean delivery by the loose fold of pe•iwneal
lining cove•·ing itS amel"ior surface.
The relationship between the lengtll of the cenrix and that
of me body of tJ1e uterus '"''ies with age. Before pube11.y, the
cervix to co•pus ratio is 2: 1. At pubeny, tJ1is ratio is reversed LO
1:2, and during the reproductive years, ce•vix to corp us ratio
may be 1:3 or even 1:4. Afte r me nopa tL~e. tl1e whole organ
atrophies and tl1e portio vagina lis may eventuall y d isappear.
Al tl1o ugh the endomeui al sec retio n is sca nty and fl uid in
na ture, the cervical sec reti on is abunda nt and itS q ua li ty and
q uantity change in the d ifferen t phases of tl1e menstrua l cy-
cle, under d ifferent hormonal effectS. T he cenrical mucous
is rich in fntctose, glycoprotein a nd mucopolysacc harides.
Fructose is n utritive tO sperms cl uling tl1eir passage in me
cervical canal. Under oesu·ogenic infl uence in the preovula-
LOry phase, tJ1e glycoprotein network is arranged parallel to
each otJ1er and facilitates sperm peneu-ation, whereas under
the progesterone secretion, t11e network forms interlacing
b1idges and prevents their entr) into the cen~cal canal. This
prope•1.) of progesterone is ttSed in a contraceptive pill a11d
progesterone-impregnated in u-aute•ine conu-aceptive de-
vice. Sodium chlol'ide coment in the mucous increases at
ovulation and fonns a fem-like pattern when a drop of mu-
cous is dried on a slide and studied under a microscope.
20 SHAW'S TEXTBOOK OF GYN AECOLOGY
POSITION OF THE UTERUS
The uterus nonnally lies in a posilion of anteversion and ante-
flexion. The bod> of the ULenLS is bem forwards on t11e cenix
approximate!> at t11e level of t11e imemal os, and t11is forward
inclination of t11e bod) of t11e uterus on t11e cervix constiLUtes
anteflexion. The direction of t11e axis of me cervix depends
upon t11e position oft11e uterus. In ameve~io n (Fig. 2.128), me
external os is direcu~d do,,nwards and backwards so t11at on
'aginal examination t11e examining fingers find t11at t11e lowest
pan of me cervix is t11e ame•ior lip. When me uten.tS is reuu-
'ened me cen•ix is directed d0\\11wards and forwards, and t11e
lowest partoft11e ce1vix is eit11er me ex1emal OS or t11e posterior
lip. As a result of its nonnal position of anteflexion, the body of
me uterus lies agai nst t11e bladder. The poud1 of pe•·itOneum
t11at separates t11e bladder from t11e uterus is t11e uterovesical
pouch. The pelitoneum is reflected from t11e from of me
uterus on to t11e bladder at t11e level of t11e ime mal os.
Posteriorly, a large periton eal pouc h lies between the
uterus and the rec tosigmo id colo n. If t11 e ute rus is pulled
forwards, two fo lds of peritone um ca n be see n to pass
Ligament
of ovary
uterus
recess
A
Normal
(anteverted,
8 anteflexed)
Rgure 2.12 (A) The relationship of the female reproductive organs: sagittal section. (B) Anteverted, anteflexed and retroverted uterus.
tor (A): From Fg 7 1. Chris Brooker· AleXCW)de(s Nursing Practice, 4th Ed. Churchill Uvi'lgstone: Else\4er, 2011 .}
backwards from t11 e uterus to reac h the parietal peritone um
lateral to the rectum. These folds, t11e uterosacral folds, lie
at the level of t11e intern al os and pass backwards and up-
wards. The uterosacral ligame nts are condensalion of t11e
pelvic cellular tissues and lie at a lower level and witl1in me
uterosacral folds. The pouch of periLOneum below the level
of me uterosacral folds, which is bounded in from by me
peritoneum covering the upper pan oft11e poste•·ior vaginal
wall and posteriorly by t11e pe•·itoneu m cove•·ing t11e sig-
moid colon and the upper end of t11e recLUm, is the pouch
of Douglas. The posterior fornix of the vagina is in close
relation to me pe•itoneal cavity, as only the posterior vagi-
nal wall and a si ngle la)er ofpe•itoneum separate the vagina
from the pe•·itoneal cavity. Collection of pus in the pouch of
Douglas can t11 erefo•·e be evacuated without difficulty by
incising t11e vagina in t11 e region of the posterior fomix. On
the contrary, t11 e uterovesical pouch is approach ecl wim dif-
ficulty from the vagina; first the vagina must be incised and
the n the bladder sepa rated fro m t11 e ce rvix a nd the vesico-
cervical space u·aversed before t11e ute rovesical fold of the
peritoneum is reac hed (Fig. 2 . 12A).
Ovary
Recto-uterine
fold
Recto-uterine
recess
Posterior part
of fornix
Cervix uteri
Rectal
ampulla
Anal canal
Long axis
of the
vagina
Retroversion
!Soo~e

THE UTERINE APPENDAGES
The uterus projects upwards from the pelvic floor into the
peritoneal cavil) and carries on each side of it two folds of
peritoneum. which pass laterall) to the pelvic wall and fonn
the lmxulligammt.s. The fallopian tubes pass outwards from
the uterine cornua and lie in the upper border of the broad
ligamems. The ov;u·ian ligaments poste•·iorly, and the row1d
ligaments anteriorly, also pass into the ute•·ine cornua, but
at a slightly lower level than the fallopian tubes. Both
these ligaments and the fallopian tubes are covered with
peritoneum.
The round lig<1ment passes from the ute•·ine comua be-
neath the anterior peritoneal fold of the broad ligament tO
reach the intemal abdom ina l •·ing. In tl1is pan of its course
it is cu rved and lies immediately ben eath the peritOn eum,
and is easily distinguished. T he roun d ligament passes
down th e inguinal canal and finally e nds by becoming
adherent to tJ1e skin of the lab ia m"!jora . T he ligamen ts
co nsist of p la in muscle a nd co nnec tive tissue and vary co n-
siderably in tJ1ickn ess. T hey hypenro phy during pregna ncy.
T he roun d ligaments are much beu er developed in
multiparae tJ1an in null ipa rae. T hey are most remarkabl)'
h)'peru·ophied in the presence of large fibro ids whe n th ey
may attain a d iameter of I em. T hey correspond deve lop-
mentally to the gubernac ulu m testis and are morp ho logi-
cally continuous with tJ1e ovarian ligaments, as during
inu-auterine life the ovarian and round ligaments are con-
tinuoLLS and connect tJ1e lower pole of t11e primitive ovary
to the inguinal canal. The round ligaments are lax and,
except during labour, are free of tension. There is no evi-
dence that the nonnal position of anteflexion and amever-
sion of the uterus is produced b) conu-action of the round
ligaments. The ligaments, however, may be shonened by
opemtion or they may be attached to the anterior abdomi-
nal wall, both procedures being used to cause ameversion in
a utems which is pathologically retrovened. The round liga-
ments are supplied by a bmnch oftJ1e ov;u·ian anery de.-ived
from its anastomosis with the uterine anery, h ence there
is the necessity for ligation of tJ1e round ligamem du.-i ng
hysterectomy. Along it lymphatic vessels pass from the
fu ndus, which connect with those d raining t11 e labium
maj us into tJ1e inguinal glands. T his explains the possibility
of metastases in these gla nds in late cases of ca nce r of the
endome u·ium of the fun d us.
T he 111mrirm ligaments pass upwa rds and inwards fro m the
inner poles of tJ1e ova ri es to reac h tJ1 e corn ua of the ute n1s
(Fig. 2. 13) below the level of the au.achment ofLhe fallopian
tubes. They lie beneath the posterior pe riw neal fold of the
broad ligament and measure about 2.5 em in length. Uke
tJ1e ro und ligaments, they consist of plain mt.LScle fibres and
connective tissue, but they are not so prominent becat.LSe
tJ1ey contain less plain muscle tissue. They are morphologi-
cally a continuation of the round ligamem (contents of
broad ligaments are listed in Table 2.1 ).
l nfundibulopelvic ligament is t11at portion of the broad
ligament that extends from tJ1e infundibulum of tlle fallo-
pi;m tube to tJ1e late•-al pelvic wall. It encloses the ov;u;;m
vessels, l)lnphalics and nerYeS of tJ1e ov;u-y. The ureter is
also in a close contact and can be damaged dlll·ing clrunping
of this ligamenL
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 21
Gartner's duct Fallopian tube
Ovarian
fimbria
Ovarian ligament White line
R gure 2.13 The right uterine appendages viewed from behind.
Table 2.1 Contents of Broad Li gament
• Fallopian tube - upper portion
• Round ligament - anteriorly
• Ovari an ligament - posterior fold
• Vestigial structures of Wolffian body - epoophoron and
paroophoron
Vestigial structure of Wolffian duct - Gartner's duct
Ureter
uterine vessels
Pelvic nerves
Parametrial lymph node
Pelvic cellular tissue condensed to form Mackenrodt 's ligament
lnfundibutopellllc ligament
Mesovarium attaches tJ1e ovary to tJ1e poste•·ior fold of
peritoneum of tJ1e broad ligament and contains vessels,
lymphatics and ne•,es of the ovary. Mesosalpinx lies be-
tween tJ1e fallopian tube and tJ1e ovary and contains the
anastomotic vessels between the ovary and uterus and
the vestigial structures of tJ1e Wolffian body and t11e duct
(see section on T he Ovaries).
iFALLOPIAN TUBES
Eac h fa ll opian tube (Figs 2. 13 and 2. 1tJ ) is attached to tJ1e
uterine com u and passes outwa rds and bac kwards in th e
upper pan of the broad ligamem. T he fa llopian Lube mea-
sures 4 inch ( 10 em) or more in lengtJ1 and app roxi mate!)'
8 mm in diameter, but t.he d iameter d imin ishes near the
corn u of the uterus to 1 mm. The fallopian tube is divided
anatomically imo fotu· parts:
I. The irttentitiltl portion is tJ1e innermost pan of tl1e rube
which u-averses the m>ometrium LO open into tlle endo-
metdal cavil). It is the shortest part oftlle tube, its lengtll
being the th ick.ness of tJ1e uterine mLLScle, about 18 mm.
It is also the narrowest part, its intemal diameter being
I mm or less so tJ1aL only tJ1e finest cannula can be passed
imo it during falloscopy examination. There ru·e no
22 SHAW'S TEXTBOOK OF GYN AECOLOGY
Rgure 2.14 Laparoscoplc v iew of t he pelvis showing normal uterus
and bilateral adnexa. (Courtesy: Dr Marwah.)
longiwdinal muscle fibres here but the circular fibres are
well deve loped.
2. The i~lltmu~ comprises the nex t and inner part of the tube
and represents abo ut o ne-third of Lh e LOtal length, i.e.
35 mm. It is narrow but a li Llie wider than the in terstitial
part and its lumen has a diameter of 2 mm. Its muscle
wall contains both longiwdinal and circular fibres, and it
is covered by peritoneum except for a small inferior bare
area related to the broad ligament. It is relatively suaighL
3. TIU! ampul/it is tJ1e lateral, widest and longest part of the
tube and comprises rough I) two-tJ1 irds of the tube, mea-
suring 2.5-3 inch (60-75 mm) in length. Here me mu-
cosa is a•·borescem witJ1 man> complex folds (Fig. 2.15).
Fe•·tiliation occurs in tJ1e ampu llary portion of the
fullopian wbe.
4. The fimbriated e.\1rt'mity or infimdibulwn is where the
abdominal ostium opens into me pe•·iLOneal cavity. The
fimbriae are motile and almost prehensile, and e•"Uoy
a considerable r·a nge of movement and action. One
fimbria- tJ1e ovadan fimb1ia- is larger and longer than
Figure 2.15 Ampullary portion of fallopian tube to show arrange-
ment of plicae (x18) (COO'Iesy Dr Sancleep Mathu-, AIIMS.)
the others and is attached to the region of tJ1e ovary. This
fimbria embraces the ovar>• at ovulatio n, picks up t11e
ovum and carries it to tJ1e ampullary portion.
The fallopian tube represents the crania l e nd of the
Miille 1ian dueL and its lumen is continuous witJ1 t11e ca\~1)'
of the uterus. Consequent!), spe•matoLoa and tJ1e fertilized
ovum can pass along the tube. Fl uids such as d)eS a nd gases
such as carbon dioxide may be injected mrough the ULerus
and by me way of tJ1e fallopian tubes imo me pe•·iwneal
cavity, and by mese means tJ1e patency of tJ1e fallopian tubes
can be investigated clinically by a d)e test (Fig. 2. 16). The
fallopian tubes lie in the upper part of me broad ligamen lS
and are covered witJ1 pedtoneum except along a tJ1in area
inferiorly, which is left bare by the reflection of the pe•ito-
neum to fom1 the two layers of tJ1e broad ligamenL The
blood supply of tJ1 e fa llopia n tube is main ly derived from
the tubal branches of the ova lian artery, but tJ1 e anastomos·
ing branch of the uterine artery s uppli es its inner parL Un-
like the vermiform append ix, the fa llopian tube does not
become ga ngrenous when ac utely inflamed, as it has two
so urces of b lood supp ly whi ch reac h it a t opposite ends. The
lymp ha tics of the fa ll opian tube communicate with tJ1e lym·
phatics of tJ1e fundus of the ULerus and witJ1 those of th e
ovary, and me)' drain along tJ1 e in fund ib ulopelvic ligament
to the para-aortic glands near tJ1e origin of the ovarian
artery from t.he aorta. Some drain into the pelvic glands.
The fallopian tubes have three layers: sero us, muscular
and mucous. The serous la)er consists of l11e mesotJ1elium
of tJ1e pedtoneum. Intervening between th e mesotJ1elium
and me muscle Ia) er is a well-<lefi ned subserous layer in
which numerous small blood vessels and lymphatics can be
demonsu"ated. The muscular la)er consists of ouLer lo ngiLu·
dina! and inner circular fibl'eS. The circular fibres are best.
developed in tJ1e istJm1us and are tJ1inned ouL near the fim-
briaLed ext.remity. The mucous membrane is thrown imo
folds or plicae. ear the isLhmus tlll-ee folds can be recog-
niLed, buL when t.raced lateJ'lllly they divide and subdivide so
thaL in t.he ampullary region mey become highly complex.
Each plica consisLS of su-oma which is covered by epitll e-
lium. The st.roma is cellular and its cells are in some ways
Figure 2.16 Fimbria! end of a patent fallopian tube. Dye test shows
spill.

similar to those of the endome u·iu m. T he b lood vessels of
t11e sLroma are plentiful and are parl.icularly well marked in
t11e ampullary region. The epithelium of the mucous mem-
brane consists of three t)'Pes of cells: t11e most common is
ciliated. and is either columnar or cubical in I:)'Pe. Its func-
tion is to propel a fluid currentLOwarcls the uterus and plays
some part in the u-anspon of the inen ovum which, unlike
t11e sperm, has no motile power of its own. ext in order of
frequency is a goblet-shaped cell, not ciliated, which does
not give the histochemical reactions for mucin. Its funclion
is lubricant and possibly nutritive to the ovum. A cell inter·
mediate in type to the two already mentioned can be d isti n-
guished, and small t·O<I-shaped cells are also presen L These
are the so-called peg cells whose purpose is not known. lL
has been possible to demonsLrate differences in the hisLO·
logical appeamnces of the epit11elium oft11e fallopian tubes
during the mensu·ual cycle. T he hyst.erosalpingogram, sOJwsal-
fJiugogrmn and litparo:.tojJic chro11wtubation are t11e clinical
me tl1ods of testing tJ1c patency of tJ1 e fallopia n tubes. Lapa-
roscopy also ide nti Fies ex te rnal tubal adhesions.
THE OVARIES
Eac h ovary we ighs 4-8 g and measures abo ut 35 mm in
lengt11, 25 mm in width and 18 mm in thickness. The ovat)'
(Figs 2 .11 and 2. 17) is almond shaped, pearly grey d ue to
a compact tunica a lbuginea, and tJ1e surface is slightly cor-
rugated. Before pubert), the ovaries are small and located
near t11e pelvic brim. After menopause t11ey aLrophy and
become shrunken and t11e grooves and furrows on ilie
surface become well marked. The menopausal ovary mea-
sures 20 mm X 10 mm X 15 mm witJ1 a volume of8 mL or
less. An ovaq larger than this as measured ullrasonically is
Paroophoron Epoophoron
(distal tubules of (proximal tubules of
the mesonephros)
the mesonephros)
; 1 - - - Gartner's duct
(vestigial remnant)
Fig ure 2.17 Remnants of the mesonephric (Wolffian) ducts that may
persist in the anterolateral vagina or adjacent to the uterus within the
broad ligament or mesosalpinx.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 23
of great concern in menopausal women. The ovary is at-
tached to t11e back of the broad ligament by a th in mesen-
tery, t11e me~>ovaritm~ Latet<lll), t11e ovat)' is related LO t11e
fossa below the bifurcation of the common iliac artery and
t11e LLreter. Medial I), it is close to t11e Fimbria of t11e fallo-
pian tube. which sLretches over it around ovulalion. It is
attached to the com u of the uterus by the ovarian liga-
ment. The inflUlCiibulopelvic ligament is the outer bordet·
of the broad ligament and contains tlle ov:u·ian vessels,
nerves and l)lnphatics. The ov:u·ies are not nonnally palpa-
ble during bimanual examination, but cause pain on LOudl.
The epoophoron, also known as the organ of Rosenmiiller,
represents the CJ-anial end of tlle 'v\'olffian body. It consistS
of a set·ies of vet·tical tubules in t11e mesovarium and meso-
salpinx between t11e fallopian tube above and t11e ovary
below. Each wbule is surrounded by pla in muscle and is
lined by cubical cells.
T he paroop horon represe nts t he caudal end of t11 e
Wolffi an body and similarly co nta ins ve n.i cal tubules. It
so metimes forms pa raovarian C)'SL.
T he Wolffoan duct (Ga rt ne r's duct) is an impe rfec t d uct
which runs parallel to, but below, tJ1e fa llopian wbe in t11 e
mesosalp in x. T he d uct passes downwa rds b)' tJ1e side of t11 e
uterus LO the level of the irHernal os whe re it passes into
the tissues of t11e ce rvix. It tJ1en runs fo rwards to reac h me
amerolateral aspect of the vagi nal wall and may reac h as far
down as t11e hymen. The duct some Limes forms a cyst, called
Gartner cyst, in ll1e broad ligament or in the vagina, and
may need surgical enucleation (Fig. 2. 17). HistOlogy of t11e
ovary is described in Chapter 3.
THE URETHRA
The urethra measures 35 mm in length and 5-6 mm in
diameter. It passes downwards and forwards from the base
of the bladder behind the S)lnph)Sis pubis to end in the
external meatus. lts epithelial lining consists of squamous
epithelium at the extemal meatus, bm becomes tran si-
tional in the canal. Deep to the epit11elium is a larer •·ich
in small vessels and connective tissue. Th e urethral wall
comprises inner longiwdina l and outer circul at· involun-
tary mt.LScle fibres, which arc arra nged as crisscross spirals.
T he lo ngitudinal Fibres co ntract and sh on e n t11 e ure tl1ra
du ring mi cturiti o n. T he o ute r circular Fi bres keep the in-
te rnal sphincter closed.
T he nec k of tJ1e bladde r (inte rnal urethral sph incte r)
lies above ll1e leva to r an i muscles and thus maintains t11e
co ntin ence of urine b)' receiving the sa me abdomina l p res-
sure as the b ladde t: T he b ladder base fo tms an angle of
100• with t11e poste tior ure tJua l wall (poste rior urethrovesi-
cal angle), wh ich is also respo nsib le for ma in taining utin at)'
continence.
RELATIONS
Postedorl). upper portion of the urethra is loosely con-
nected to the vagina b) 'esicovaginal fascia and can be
dissected easil). In its lower one-third, it is finnly auached
LO the vagina by pubou•·etht-al ligament and requires a
sharp dissection. Laterally, it is surrounded by tlle areol:u·
tissue, the compressor uretht-a and the supe t·Ficial perineal
24 SHAW'S TEXTBOOK OF GYN AECOLOGY
muscles. PuboureLhral ligament fixes the mid- urethra to
t11e pubic bone and Lhe lateral pelvic wall and maintains
continence of urine. Anteriorly, t11e uret11ra is separated
from the pubic bone b) Lhe areolar tissue.
The external urinal") meaLus lies in t11e vestibule, 2 em
below the clitoris and is part!> concealed by t11e upper end
of the labia minora. umerous periuretl1ral glands sur-
round tl1e urethra and open b) till)' duelS into iiS lumen.
These are analogues of Lhe prosLaLe in males. The paraure-
mral glands of Skene are imporLanL paired glands which lie
alongside me floor of Lhe urethra and open by tiny duelS
close to me external meatus. The glands when infeCLed
form periuretlual abscess and cysiS.
The proximal tu·etlwa derives blood supply from me
inferior vesical anery and distal uret11ra from in temal puden-
dal ane•l'· The veins drain into t11e vesical plexus and intemal
pudendal vein. T he uretlwa is innervated by the internal
pudendal nerve. T he uretlwa is developed from the cloaca.
T he proximity of tl1e uret11 ra to the vagina makes it
suscep ti ble to infection sp reading from the lower ge niLal tract.
T he commonest infec ti ve orga nisms are N. go norrhoea, Chla-
m>•dia u-ac homatis and trichomonads. T he ure t11ral swab,
cultw·e and uri ne Cl ~turc can iden ti fy Lhe o rganisms.
THE BLADDER
The bladder is a smooLh muscle organ witl1 a body and a
trigone. It lies between Lhe spnphysis pubis in from and t11e
uterus behind, being separated from tl1e uterus by t11e
uterovesical peritoneum. It is a pelvic organ with a capacity
to hold 500-600 mL of urine. The bladder distends upwards
with a fixed base at tl1e Lrigone, and t11en becomes palpable
abdominal!).
The bladder has an apex, a base, a supe•·ior and L\1'0
inferolaLeral surfaces. The neck of the bladder (internal
Ulinary sphincter) lies abo1e the lev~nor ani muscles, so
mal me raised abdominal pressure transmitS me pressure
equall)' Lo Lhe bladder and itS neck, hence mainLaining uri-
nal")' cominence dur-ing coughing and sneezing. Ameriorly,
lies tl1e cave of Reuius (t'Cu·opubic space). Posteriorly, iLis
in proximity to tl1e uterus and supt·avaginal portion of the
cervix, sepamted from them by t11e uterovesical pouch of
peritone um.
T he ureters en ter tl1e bladde r obliquely, and t11e area
be tween tl1e ure te ric openin gs and the inte rnal urinar y
sphincter fo rms a fixed tri angular a rea called u·igo ne. T he
apex is co nti nuo us witl1 tJ1e urac hus.
T he b ladder receives b lood suppl)' from the s uperior and
inferior vesical arteries, and the pub ic branc h of the infe rior
epigastric anery. T he venous plex us drains in to in te m al
iliac vein. T he lymphatics dra in into interna l and extemal
iliac glands.
NERVESUPPLY
The spnpathetic outflow is from first and second ltunbar
segmeniS of tl1e spinal cord which inhibiiS conu-act.ions of
me detrusor (bladder) mtLScle and main Lains internal
sphincteric contraction. The pa•-as)lnpathetic outflow from
52, 53 and 5 I stimulates tl1e detnLSor muscle and relaxes tl1e
internal sphincter, tlnLS initiating micw•·ition. The sensory
nerve fibres reach the cenu·al nervous system via the
splanchnic nerves (p<11<1S)1npathetic S2-S4). The somatic
afferent fibres travel witl1 S)'lnpathetic nerves via hypogasu·ic
plextLS and enter the first and second lumbar segmentS of
tl1e spinal corcl The bladder wall is lined by u-ansit.ional
epimelium. which gets folded when empty but allows blad-
der distension. The lining membrane of 1he trigone is fixed
1.0 the muscle wall. The mtLScular coat of t11e bladder is com-
posed ofsmoom muscle kno11n as deu·tLSor. The neck oftl1e
bladder (internal Ulinarysphincter) is suiTounded by circu-
lar muscle fib•·es.
THE URETERS
£vel")' gynaecologist should be fam iliar witl1 t11e anawmy of
the pelvic portion of tl1e UI'Cter, as iflj u ry ca n occu r el uti ng
pelvic s urge •/'· T he 1u·eter needs to be dissected d l.lling
Wertheim 's hys terec tomy for ca ncer of tl1e ce rvix. T he ure-
ter may run in a close re latio n to tl1 e broad liga ment cyst
a nd myoma.
T he pelvic poni on of tl1e ureter is 13 em lo ng a nd 5 mm
in dia me ter. It passes over th e b ifurcatio n of 1.h e co mmo n
iliac artel")• and ru ns downwards and fo rwards in the ovar-
ian fossa deep to the peritoneum, where it e me rs the true
pelvis at tl1e brim, it is crossed by the ovarian vesse ls, and
on tl1e left side the mesosigmoid is an anterior relation. In
this sitLtation, tl1e obturator vessels and nerve lie laterally,
and tl1e h)pogastric lymph nodes are closely related. The
cottrse of tl1e ureter is then dowmvards and forwards
immediately beneatl1 tl1e peritoneum to which it is always
closely atLached.
O n the pelvic floor, the ureter pierces MackenrodL's
ligament where a canal, the Lu·ete•·ic canal, is developed. IL
is necessary that the ureter mLLSL have room for normal
peristalsis without any pressure from me SUITOundingsu·uc-
Lures, and the ureteric canal protects me ureter from t11e
outside pressure. In its passage through me urete•·ic canal,
the ureter is crossed by 1he uterine aner)' above and t11e
uterine plexus of veins below, thus being forked between
the uterine vessels. After leaving the ureteric canal, t11e
ureter passes fot·wards and mediall y LO reach t11 e bladder,
being separated from tl1e cervix by a disLa nce of 1-2 em
(Fig. 2. 18). T he co urse of the ureter thro ugh the pelvis is
not always consta nt. At ope ratio n, t11 e ureter is recogn ized
by iiS pale gliste ni ng appea rance and by a fine lo ngitud inal
p lexus of vesse ls o n its surface, b ut mo re parti cula rly b)' its
peristalti c move men ts. It can also be recognized by palpa-
tion between the fi nger and th e thu mb as a firm co rd,
which, as it escapes, gives a characteristic snap. T he ureter
is rare ly d up licated. In advanced stage of cancer of th e cer-
vix witl1 extensive involvement of the parame u·iu m, su·ic-
ture of t11e ureter causes hydronephrosis and uraemia.
The ureter derives its blood supply from the common,
external and internal iliac arteries in addition LOa consLam
vessel from the uterine and inferior vesical anery. The ves-
sels fo1m a longitudinal anastomosis up and down me ure-
Ler which protects the ureter from ischaemia if one vessel is
ligaLed or i•'\iured. Howe. er, damage of seveml small vessels
can cause avascular necrosis and urete•·ic fistula. TI1e small
branches of tl1e renal a•·teL}' also suppl)' blood LO me ureLer
above the peh·ic brim.

External iliac
artery & vein
Obliterated ----...1
umbilical and sup.
vesical artery
Obturator nerve
Obturator artery--~#-~:...._~
Inferior
epigastric
artery
Round
ligament
Figure 2.1 8 Relation of the ureter to the pelvic vessels in the ovarian fossa.
Th e b lood supply to iJ1e pelvic ureter is principally from
ilie lateral side, and iJ1e urete ric d issec tion sho uld be done
along iLS medial side.
The ir"tiury to iJ1e ureter occurs at the infun dib ulopelvic
ligament on the lateral pelvic wall, in iJ1e ureteric canal
when the Ulerine vessels are ligated, near the internal cervi-
cal os and near the uterosacralligamenL It is imponam w
identif) the ureter during WeriJ1eim hysterectomy, broad
ligamem nunour dissection and while ligating the imernal
iliac anef).
The l)lnphatics drain intO intemal and extemal iliac
glands. The S) mpaiJ1etic nerve supply comes from hypogas-
tric and peh·ic plexus; paraS) mpathetic from sao-a I plexus.
THE RECTUM AND ANAL CANAL
The rectwn is the continuation of the pelvic colon and lies
in the pelvis at the level of third sacral vertebrae. It mea-
sures 12-15 em and co ntinues as anal canal. It is covered
anteriorly and latera ll y by pelvic peritOneum which forms
iJ1e posterior s urface of the pouch of Douglas. Lower down,
it is in a close contact wiiJ1 the posterior vaginal wall, sepa-
ra ted by rec tovaginal septu m. The a nal ca nal is separated
from the lower one-third of posteri or vagina l wall by the
perineal bod)'· Poste tiorly, it lies close to the sac rum and
coCC)'X wi iJ1 loose a rt icular tissue, middle sacral anery and
pelvic nerve p lexus. Lmemlly lie the two uterosacral liga-
menLS above and levator ani muscles below and ischiorectal
fossa. The rectum is surrounded by rectal fascia. The ana l
canal measures 2.5 em. Anteriorly, it is related to the peri-
neal body and posteriorly to iJ1e anococcygeal body. It has
two sphinCLers: (i) irwoluntal") intemal sphincter in the up·
per two-thirds and (ii) voluntary external sphincter sur-
rounded b) puborectalis muscle of the levator ani muscle
below.
The rectum and anal canal receive ilie blood supply from
(i) superior rectal br-anch of imerior mesemeric artery
and (ii) midcUe and inferior rectal branches of internal iliac
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 25
~1--.....::::=--~-1- Internal
Iliac artery
'--1-__:::,.__ Obturator
lnternus muscle
artery. The rectum and upper one-third of anal canal drain
via superior rectal veins into ponal circ ula tion. Lower one-
third portion of anal canal drains in tO inferior rectal vein
(systemic ci1·culaLion).
THE LYMPHATICS
The rectum and upper one-iJ1 ird of anus drain in tO imen1al
iliac and preaortic I) mphatic nodes. Lower one-third dr-ains
imo superficial inguinal I) mph nodes.
AutOnomic pehic plexus innerYates iJ1e recwm and up-
per portion of iJ1e anal canal. The lower por·tion of the anal
canal is innenmed by the inferior haemont10idal ner\'e.
The rectum and upper two-thirds of ilie ana l canal develop
from ilie dorsal portion of the cloaca. The lower anal canal
is derived fi·om ectodenn.
THE PELVIC MUSCULATURE
T he pelvic muscles of importance in gynaecology are those
of the pelvic floor. T hese muscles are grouped into three
layers: (i) those of the pe lvic d iap hragm, (ii) iJ1ose of th e
urogenital di ap hragm and (iii ) iJ1e superficial muscles of
the pe Ivic floor.
PELVIC DIAPHRAGM
The pelvic diaphragm consists of two levator an i muscles.
Each levator ani muscle co nsists of iJHee main d ivisions: the
pubococcygeus, tl1e iliococcygeus and iJ1e ischiococcygeus.
The pubococcygeus muscle arises from the posterior sur-
face of the bod) of iJ1e pubic bone and passes backwards,
later-al to the vagina and iJ1e rectum, to be inserted into tl1e
anococc)geal raphe and into iJ1e COCC)'X. The inner· fibres
which come together posterior to iJ1e rectum are known as
the puborectalis ponion of the muscle: the)' sling up and
support ilie rectum. Some of the inner fibres of the pu-
borectalis fuse wiili the outer wall of the vagina as they pass
26 SHAW'S TEXTBOOK OF GYN AECOLOGY
lateral to iL Other fibres decussate between the vagina and
t11e rectum in tl1e siwatio n of the perineal body. These de-
cussat.ing fibres divide the space between t11e two levatOr ani
muscles in to a n amerior portion, tJ1e hiatus uroge nitalis,
mro ugh which passes t11e urethra and vagina, and a poste-
•ior portion. the hiaws rectalis, t11rough which passes the
recttLm. The dimensions of the hiaLUs uroge nitalis depend
upon two main factors: the tone of t11e levator muscles and
me existence of tlle decussating fibres of me puborectalis
muscle.
Pe1ineal tears occtu·•·ing during panu•·ition divide tltese
decussating fibres, causing the hiatus urogenitalis to become
patulous and lead to prolapse. In visceroptosis and asmenic
states, tlte levator muscles become lax, tlt e dimensions ofthe
hiatus urogenitalis are increased and there is a tendency for
t11e pelvic viscera to p•·olapse. The iliococcygeus is a fan-
shaped muscle a !ising from a broad o rigin along the white
li ne of tl1 e pelvic fascia and passing backwards and inwards
to be inse•ted into tlte coccyx. T he isc hi ococcyge us or coc-
cyge us muscle has a narrow o rigin from t11e isc hial spine and
spreads o ut posteri ori)' to be inserted into tlte front of the
coccyx (Figs 2. 19 and 2.20).
T he leva tor muscles toge t11 er co nstiune the pelvic dia-
phragm and support the pelvic viscera: co nu·action of the
levatOr muscle p ul ls th e rec LUm and vagina towards me sym-
p hysis p ubis; the recwm is thereby kinked and closed, and
tlte vagina na11·owed ante roposte rio rly. T he origin of the
levatOr muscle is faxed because the muscle arises ante1iorly
eitJ1er from bone or from fascia which is attached LO ll1e
bone; posteriori) the insertion is e itJ1er imo me anococcy-
geal raphe or into the COCC)'X, botl1 of which are moveable.
It follows tl1atthe conuaction of t11e levator muscles leads to
t11e poste•·ior attachments being pulled wwards ll1e S)1nphy-
sis pubis. The movement of the intemal rota tion of the
presenting part during panurition is assisted by ll1is prop-
erty of me levator muscles. Ute•ine contracti ons push the
presenting pan down upon the le,>ator ani (pelvic floor)
and cause the muscles to contract as a result of tlte direct
pressu•·e of tlt e presenting part. The lowest pan of the fetus
is carried forwards during t11e contracti ons of the levator
muscles, and as the anterior fibres of the muscles are
Obturator lnternus -!~--f
lllococcygeus 4----"7' - - - -
White line
Figure 2.19 The muscular peMc floor seen from above alter the removal of the pelvic viscera and pelvic fascia.
directed inwards as well as fo rwa rds, t11 e presenting part
rotates forwards and inwards.
The superior and inferior surfaces of tJ1e levatOr muscles
are covered by the pelvic fascia, which separates t11e muscles
from t11e cellular tissues of t11e parametrium above and from
the fibrous and fat!) tissues of t11e ischiorectal fossa below.
UROGENITAL DIAPHRAGM
The urogenital diaphragm is also called the u·iangular liga-
ment. It is not so well de,eloped in me female as in tlte
male. It extends from the pubic arch anteriorly to t11e cen-
tral point of the pe.-ineum posteriorly a nd consists of two
layers of fascia tltrough which pass t11e vagina and t11e ure-
thr-a. The central point of the female perineum lies be-
tween the vagina and th e rccwm. Within t11e two fascial
layers of th e urogenita l diaphragm lies the deep transverse
perineal muscle, whi ch ex te nds latera ll y o n each side to
reac h t11 e ramus of the pubic bone. This muscle is so poorly
developed th at it is diffi cult to dissec t in anatom ical speci-
mens a nd needs a specia l histological tec hnique for its
de monstratio n . Its functiona l significa nce is dubious. The
s triped muscle or vo lu ntary sp hincter of the urethra also
lies between tl1 e two la)'ei'S of the u·ia ngular ligame nt.
SUPERFICIAL MUSCLES
FoLu· muscles are ide ntified in tl1is layer. The external
sphincter mLLScle of t11 e anus is aLtac hed anteriorly to Ute
cenual point of the perineum and su•To unds the antLS.
The bulbospongiosus muscle, or as it is sometimes called
the sphincter vaginae, extends from the central point of the
pe1inewn along each side of t11e '>agina to be attached ame-
.-iorly to the S) mph) sis pubis. It lies arou nd and lateral to the
urethml bulb. The ischioca,ernosus mtt~cle exte nds on each
side of me ischial tuberosity in •-elatio n to me cmra of ll1e
clitOris to reach it in the midline. The supe•·ficial u-ansverse
muscle of me perineum passes late•-ally on each side from the
central point of the perineum to the pubic mmus (Fig. 2.21 ).
Deep to mese superficial muscles and between them and the
infelior la yer oftlte u·iangt~ar ligament lie t11e vestibular bulb
and tlte greater vestibular glands of &1rrlwlin.
 CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 27

Fallopian tube

Obturator internus muscle

.......__ _ _ _ ___ Superficial perineal pouch

Rgure 2.20 Anatomy of the pelvic floor in coronal section.

Subpubic angle

Body of clitoris - - -- - - - -,.---_., , - - - -- - - - Ischiocavernosus muscle

Glans of clitoris -- - - -+--...

Crus of clitoris - - - - -- -,.<.._;

~~------Bu lbocavernosus muscle

Bulb of vestibule - -- - -.,L---,1£,
_.....1,__~....,..---- Perineal muscle
Perineal membrane ------,-.4----J
/~---+---Superfici al transverse
muscle

Perineal body

Anus
' -- - - Sphincter ani
" - - - - - Levator ani
Anococcygeal body
' - - - - - - Gluteus maximus
Coccyx
Figure 2.21 The perineum.
28 SHAW'S TEXTBOOK OF GYN AECOLOGY
The perineal body intervenes between the posterior vagi-
nal wall and the anal canal. It is pyramidal in shape with itS
apex on a level with the j unclion of 1J1e middle and lower
thirds of the posterior vaginal wall. The three layers of the
muscles of the pelvic floor are represented in the perineal
body, and the intenening lissue consisli ng offatand fibrous
lissue. Superficial!), passing from the ce ntral point of the
perineum are the external sphincter of the anus, the bulbo-
spongiosus and the superficial transverse muscle of the
pe.-ineum. Deep to this la)er lies the fascialla)er of the uro-
genital diaphragm (triangular ligamem) enclosing the deep
transverse nntSCle of the perineum. Deeper still, the pelvic
diaphragm is represented by the fibres of the levator ani
muscl es which decussate between the vagina and the rec-
tum. The perineal body is exa mined by inspeclion and by
palpation. Two fingers arc placed in the vagina and flexed
laterally; the thumb being applied externally over the
labium majus, the leva tor muscles ca n be palpated with a
remarkable ease and the si:.te of the hi a tus urogenitalis can
be assessed . On asking the palient to co nu·act her pelvic
floor muscles, tl1e LOne of these muscles ca n be estimated.
Pro lapse of tl1e ge nita l tract. stress inco nlinence of
urine and faecal inconlin c nce a re all re lated LO laxity and
aton icity of the muscles of th e pe lvic floor as well as dener-
vation of pelvic ne rves d uring childbirth. Late ly, perineal
ulu·aso und and M Rl have grea tly im proved o ur knowledge
of these supportive su·uctures in maintaining the uterine
position and co nLinence of urine a nd faeces.
THE PELVIC CELLULAR TISSUE
The pelvic cellular lissue consistS of loose areolar lissue
which imenenes between tJ1e peh·ic pe•itoneum above and
the peh·ic fascia below. It is conlinuous with the subperito-
neal connecti,·e tissue and witJ1 the loose lissue of tl1e peri-
nephric •·egion. The areolar tissue is loose, and when
inflamed in the condition of pelvic cellulilis it may lead to
the form ation of a palpable swelling. As tl1ere is a direct
continuation between tJ1e pe•inephric and pelvic cellulru·
tissues, effusions a.-isi ng in eitJ1er of these situalions may
u-ack to point as an abscess in tJ1e other. In tl1e pelvis, the
pelvic cellular tissue is bo unded above by the peritOneum
and below by tl1e fascia which covers the upper surface of the
levator an i muscles. Late rail )' it is bounded by tl1 e pelvic wall,
mainl y by the fascia whi ch cove rs tJ1 e inner surface of the
obturator internus whereas mediall y it comes in tO contact
with tl1e uterus and th e up pe r part of the vagina.
T he paraiiU!trium is tJ1at part of the pelvic cellular tissue
which surro unds tl1 e uterus. It is b)' definition extraperito-
neal and is most plenlifu l on eac h side of tl1 e uterus below
tl1e level of the internal os. The e ndopelvic fascia in this
region thickens to form ligamento us s upportS called Mack-
enrodt ~or cardilwlligammt~ Above tll is level, the presence
of the broad ligamentS reduces the amount of pa•-ame-
t.-iLUn to a minimum. It should be remembered that the
level of the levator an i muscle is well below the level of the
ce•·,-ix. being more than halfwa) down the vagina. The pel-
,.jc cellular tissue is usuall) ve•') plen liful o n each side of
the vagina, where it is called pa•-avaginal cellular lissue or
paJ-acolpos.
A distinction is drawn between the pelvic fascia and the
endopelvic fascia. The pelvic fascia co nsistS of tl1e dense
connective tissue which covers tJ1e surfaces above and below
the levator ani and the obturator inte rnus muscles. On the
contrary. the endopelvic fascia forms the connective tissue
cove1ings for tl1e vagina, tJ1e sup•-avagina l ponion of the
cen-ix, 1.he uterus. the bladder, the uretJ1ra and the rectum.
In addjtion, condensed bands of e ndopeh.jc fascia pass
from these mo,·eable organs to tJ1e back of the pubic bones,
to the lateral walls of tl1e pelvis and to the from of the sa-
crum. The function of tl1e endopelvic fascia is pan.ly to
convey blood ' 'essels to the pelvic o•·gans and panly 1.0 sup-
pon tl1em. Be1.ween tl1e different tarers of t11e endopelvic
fascia are bloocUess spaces which are imponam 1.0 identify
in vaginal plastic ope•-ations. The term pelvic cellular tissue
should be restricted to cellular tissue wh icl1 intervenes be-
tween tl1 e differe nt layers of tJ1 e endopelvic fascia and
which lies between the peritone um above and tl1e u·ue pel-
vic fascia below.
Anteriorly, the b ladde r is cove red by an e ndopelvic fas-
cial layer called the vesical fascia, whereas be hind it lie the
vagina a nd the supravagina l portio n of the cervix covered
by 1.heir own enclopelvic fasc ial layers.
lmmediaLel)' behind the ute rus and vagina, tl1e perito-
neum which covers tl1e back of tJ1e ute ms and tl1e posterior
vaginal fornix red uces the pelvic cellular lissue to a mini-
lllLUll in tl1ese situations. Deep to tJ1e uterosacral folds of
peritoneum the endopelvic fascia is plentiful, and here it is
condensed to form tl1 e uterosacral ligamentS which pass
backwards and upwards from the uterus in the from to
reach the sao·um lateral to the rectosigmoid. The uterosac-
ralligrunen tS help to support tJ1e utenLS a nd prevent it from
being forced down b) inu-aabdominal pressure. By their
wne tlle)• also tend to pull back tJ1e cervix and tl1ereby aJ1-
teven the ULerus. Plain muscle fibres can be demonsu-ated
in them. They contain S)lnpatlletic and pa•<~S)Inpatlletic
nerves. Mackenrodt's ligamentS, similar to uterosacral liga-
ments, help 1.0 suppon the uterus and prevent it from being
forced down when tl1e intraabdominal pressure is raised.
The)' are composed almost entirely of conneclive tissue and
contain very liule plai n muscle (Fig. 2.22).
A third and equally important pan of tl1e supporting
mechanism of tl1e pelvic viscera is tJ1 e p ubovesicocervical
Vesicocervical
space
Paravesical
space
- --+-r+t- Rectovaginal
space
.,/,,t-.::;::::_ Pararectal
space
Retrorectal
space
fascia
Figure 2.22 The pelvic cellular tissue shown in the cross-section of
the pelvis.

fascia or the pubocervical fascia. This is a condensation of
tlte endopelvic fascia which passes from tlte anterolateral
aspect of tlte cervix to be attached to tlte back of tlte pubic
bone lateral to tlte symphysis. Some of its cervical attach-
ment fans out lateral!) and imperceptibly into the lt'ans-
verse cervical or Mackenrodt's ligament. It can, merefore,
be regarded morphological!) and functionally as a pan of
tltis structure.
If Fig. 2.22 is studied, the suppons of me uterus and the
bladder are seen to be triradiate condensation of endopeh~c
fuscia:
I. The anterior spoke is the pubocervical fascia or so-called
pubocervical ligament.
2. The lateral spoke is Mackenrodt's ligament.
3. The poster·ior spoke is the uterosacral ligamenL
All these three embrace and insen imo the cervix and,
when in tact, operate on it suc h as t11e strin gs of a hammock,
preventing desce nt. If one o r two su·ings are torn, t11 e co n-
tentS of t11e ha mm oc k prolapse with resulting descent of the
bladder and t11e ute rus.
The endopelvic fasc ial tissue contains tlt e uterine arter-
ies and veins, toge ther with the venous plex us aro und the
cervix and the la teral fornices of the vagina. The lymphat-
ics from tlt e upper two-thirds of the vagina and from the
uterus, the ovaries and the fa llopian tubes also pass through
tlte pelvic cellular tissue. On each side of the uterus tltere
is sometimes a small inconstant lymphatic gland known as
tlte gland of tlte parametrium, about the size of tlte pin's
head. near the ureteric canal. The tHeter passes mrough
me parametrium' ia the ureteric canal in an ameroposte-
lior direction, about I em lateral to t11e cen~x tO reach the
bladder. It passes below the level of me utet;ne \'essels,
which cross it as they nut transversely mrough the peh~s tO
reach the uterus. S)mpathetic nen•e ganglia and nen·e fi-
bres are plentiful in the parameu·ium (Frankenhauser's
plexus).
In the condition of parametritis, tlte parametrium is
inflamed and thickened. Rarely a large swelling forms
which extends as far down as the fascia covet·ing the leva-
Lor ani muscles, and mediall y it comes d irectly into contact
witlt t11 e uterus and the upper pan of t11e vagina. Laterally
it extends as far out as the pelvic wa ll. Posteriorly it ex-
tends along th e ute rosac ral ligamentS in a close relation to
t11 e rectosigmoid. Suc h a swelli ng may trac k upwards
out of the pelvis to reac h the subpe ri wneal tissues of t11 e
iliac region whe n the effus ions may point above Poup art's
ligament latera l tO tlt c g reat vesse ls. In o t11 e r cases, the
swelli ng may trac k upwards to the perinephric region. In
advanced cases of carcinoma of the ce rvix, the cancer cells
infilu·ate the parametrium when they spread e ither later-
ally along Mackenrodt's ligamentS or posteriorly along the
uterosacral ligaments. Clinically, infiltration oftlte parame-
trium is detected by determining the mobility of tlte cervix
and the bod) of the uteniS, b) palpating in the situation of
Mackenrodt's ligament through the lateral fornix of the
vagina and b) examining the uterosacral ligamentS by rec-
tal examination. The fibrosis resulting from chronic para-
meu·itis causes chronic peh·ic pain and uretet·ic obstruction
(Table 2.2).
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 29
Ta ble 2.2 Supports of the Genital Organs
Levell uterosacral ligaments and ca-dinalligaments
support the uterus and vaginal vault
Level II Pelvic fascia and pa-acolpos which connect the
vagina to the white line on the lateral pelvic
wall through arcus tendinous
Level Ill Levator ani muscles support the lower one-third
of vagina
THE PELVIC BLOOD VESSELS
The ovarian aneries atise from t11e aona, just below me
level ofthe rena l aneties. They pass downwards tO cross first
the ureter and t11 en t11 e external iliac anet)', and tlt en mey
pass into t11e infundibulopelvic fold. T he ovarian artery
sends branches to the ovaries and tO tlte o ute r pa tt of t11 e
fallopian tubes; it e nds b)' anastomosing witlt tlt e terminal
part of the ute rin e artery after giving off a branch to t11 e
corn u and one to the round liga ment.
Internal iliac artery is one of the b ifurcations of the com-
mon iliac a11.ery. lt is 2 ern in le ngth. T he ureter lies anterior
and the internal iliac vein posterior to it. lt d ivides into an
anterior and a posterior branch. The anterior branch sup-
plies the pelvic organs. In obstetric and gynaecological
surgery. profuse haemorrhage is conu·olled by ligating tlte
internal iliac arte11 on the either side. During tllis proce-
dLLre, the anterior relation of the ureter to the artery should
be remembered and injut') to the ureter avoided.
The uterine artery arises from t11e anterior tnmk of me
internal iliac (or h)pogastric ane•1 ). LLS course is at first
do"~1wards and fon,•;utls until it reaches the parameu·iwn
when it turns medially towards the uterus. It reaches tlte
ULerus at the Je,el of t11e internal os, where ittut't\S upwards,
at right angles, and follows a spiral course along tlte lateral
border of t11e uterus to the region of the uterine cornu;
here it sell(ls a branch to supply t11e fallopian tube and ends
by anastomosing with tlte ovarian artery. The tOrtuosity is
lost when tlte uterus enlarges during pregnancy. During t11e
vertical pan ofiLS course, it sends branches whi ch run u·ans-
versely and pass into the myometrium ( Fig. 2.23). T hese are
called t11 e arcuate a rte ti es and from t11em a tises a series of
radial arteries almost at right angles. T hese rad ial arteries
reach the basal layers of the endometrium where t11ey are
termed as t11 e basal a ttelies. From these the te nnina l spiral
and su·aight arterioles of tJt c e ndom etrium are derived. T he
least vascu lar pa rt of t11e uterus is in the mid line. T he vagi-
nal branch of the uterine anery arises before the utetine
artery passes vertica lly upwards at tJt e level of the internal
os. lt passes downwards tlHough the parameu·ium to reach
tlte vagina in tlte region of tJte lateral fornix. This descend-
ing vaginal artery is of great importance during t11e opera-
tion oftotal h)sterecLOm) because, ifnotseparatelyclamped
and Lied. it ma> lead to dangerOLIS operative haemorrhage.
The arcuate arteries that suppl) the cen~x are sometimes
called me circular artet') of tJ1e cervix. From these or me
descending vaginal branches the ante t·ior and posterior
U)gos atteties of me vagina are de•·ived (Fig. 2.21).
30 SHAW'S TEXTBOOK OF GYN AECOLOGY

The relation of tl1e uterine anery to the ureter is of great

Rgure 2.23 The uterine artery and its branches In t he uterus.
T he fo ll owing are the branc hes of the ute rine artery:
o Ure te ri c
o Descending vagina l - these unite to fo rm th e ante rior
and posterior azygos artery of t.he vagina
o Circ ular cervical
o Arcuate-+ rad ial -+ basal -+ spira l and straight arterioles
of tl1 e functional layer of the endo metrium
o Anastomotic with tl1e ovarian anery
importance. The uterine anery crosses above the ureter in
the parameLJ'ium where it gives off an importam ureteric
branch to tl1at su·ucture. The anery runs u-an sversely
whereas tl1e ureter runs approximately ameroposteriorly
tlu-ough tl1e ureteric canal of the parameLrium.
Middle sacral artet') is a single anery wh ich arises from
the terminal aorta. It descends in the middle of ll1e lumbar
vertebra and tlle sact'\tm to the Lip of the coccp:.
There is an extenshe network of collatera l connections
in the pelvic anel'ial vasculature that provides a r·ich anasto-
motic communication between major vessel systems. This
degree of communication is importam to ensure adequate
suppl )• of ox)gen and nutl'ients in the event of major u-auma
or· other vascular compr·omise. Hypogastric (imemal iliac)
anery ligation continues to be used as a su-ategy for the
managemem of massive pelvic haemorrhage when other
measures have fai led. Bilate r-al h ypogasu·ic anery ligatio n
effectively reduces p ulse pressure in tl1e pelvis, co nve rting
flow characteristi cs from that of an an erial LO a venous sys-
tem and a ll owing collatera l chan nels of circul ati o n to pro-
vide with adeq uate b lood suppl y to the pelvic su·uctures.
T his function is best illusu·a tccl by the examp le of preserva-
tion of reprod ucti ve functions, fo llowed b)' successful preg-
nancies occuning afte r unclenaking th e lifesaving opera-
tion of bilateral ligation, of both hypogastric and ovarian
ar'\eries for unconLro lled ato nic PPH after de livery. Details
of collateral circulation are given in Table 2.3.

From posterior trunk of

Internal iliac artery

_,---Anterior trunk of
internal iliac artery

. - - - - Inferior gluteal
ar tery

~-- Middle rectal

Right urete r ---+--.;....- - - - - - - -- ....,.:'11 ar tery
Internal pudendal
ar tery

Uterine artery _ _ _ _ _.....,-

Umbilical artery _ _ _ _..../
Vaginal artery----"'
Obturator artery - - - - '
Superior vesical artery ---~""

Ftgure 2.24 Major and Mi'lor pelvis vessels seen in the picture are the branches of anterior and posterior division of internal liac artery. (Srun::e:
Raveartanath Veerarnari, Sunl Jonathan Hola, PM<ash Chand, Suril Olumber: Q-ay's Anatcrny br Students, 11'st South Asia Ed. Else.1er, 2017 J
 CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 31

t11e crw·a of tJ1e clitolis contain a large amount of erectile tis-

Table 2.3 Co llateral Arterial Alrc ulation of the Pelvis sue. Lacerations of the ante •ior pa•"L of tJ1 e vulva duling clliid-
Prima ry Arte ries Collateral Arte ries birtll may be accompanied b) severe bleeding. The tenninal
branches of tJ1e internal pudendal ane•)' anastomose witl1
Aorta superficial and deep pudendal aneries whicl1 are branches of
Ovarian artery Uterine artery t11e femoral ane•)· This anastomosis is important as it pro, ides
an altemaLive blood suppl) to t11 e bladder in extended peh~c
Superior rectal artery Middle rectal artery Inferior surge•)' when the vesical b1-anches of tJ1e hypogasuic :u·e Lied
(inferior mesenteric artery) rectal artery (internal
off or eve n the main u·w1k of t11e h) pogasu·ic itself may have
pudeodaO
been ligated at iiS source.
Lumbar arteries Iliolumbar artery

Vertebral arteries Iliolumbar artery THE PElVIC VEINS

Middle sacral artery Lateral sacral artery
External lilac
Deep iliac c ircumflex artery Iliolumbar artery; superior
g luteal artery
In feri or epigastric artery Obturator artery
Fe moral
Medial femoral circum flex Obturator artery; inferior
artery gluteal artery
Lateral femoral circumflex Superior gluteal; iliolumbar
artery artery
THE VAGINAL ARTERIES
Usual I) the blood suppl) of the uppe r pan o f the vagina is
de •·ived from the ,·aginal branch of the uterine anery. This
vessel reaches the lateral fornix of the vagina and then
passes downwards along the lateral vaginal wall. It sends
branches U"ai1S\ersely across the vagina, which anastomoses
\lith b1-anches on the opposite side to fonn the :U)gos :u·ter·
ies of the vagina, which run down longitudinally, one in
front of the vagina and one behind. These small vessels :u·e
encountered in th e operations of anterior and posterior
colporrhaphy. In some cases, the vaginal ane•)' does not
arise direct from the uterine an e•)' but at·ises from the ante·
ti or division of th e hypogastric anet)', when it corresponds
to the inferior vesical arte t) ' in the male.
THE ARTERIES Of THE VULVA AND PERINEUM
The blood vessels of the perineum and ex te mal genitalia are
detived from tl1e interna l pudendal an er)•, a terminal branch
of t11e an terior division of t11e in Lerna! iliac an.et)'· The artery
leaves the pelvis through greater sciaLic foramen, winds round
t11e ischial spine and e nLers t11e ischiorectal fossa. The main
vessel passes forwards in t11e ischiorec tal fossa adjacent to the
obturator ime mus muscle in Alcoc k's canal. it gives off the
infetior haemorrhoidal anery and the u-ansverse perineal ar·
tery which supplies t11e perineum and t11e region of the exter·
nal sphincter. it t11en pierces t11e urogenital diaphragm and
sends anotJ1er u-anS\erse branch to supply tl1e posterior pat"t
of the labia and to suppl) the erecLile tissue which stu"l·ounds
tJ1e ' aginal orifice. The inte mal pudenclal an e •)' ends as t11e
dorsal at"Let) ' of t11e clitot·is, suppl) ing tlle clitotis atld vesLi-
bule. The Lissues around t11 e ' oaginal orifice, the clitOris and
The left ovari:u1 vein ends by passing intO tl1e left renal
vein. The right ovar·ian vein terminates in t11e infeti or vena
cava. The most impor"tant fcawre of the pelvic veit1S is that
they form plexuses. These a rc well marked in tl1e case of
the ovarian veins in t11e infundibulopelvic fold where they
form a pampinifonn plexus a nd ca use chronic pelvic pain .
Occasionall y, this p lexus beco mes varicose and the large
di lated veins form a va ri cocele s imi lar LO the condiLi on seen
in the ma le. The ute rine plexus is fo und aro und the uter-
ine artet)' near the ute rus and Ll1 e vagina l plex us aro und
the latera l fornix of the vagina. These veno us p lex uses are
we ll deve loped in tl1 e presence of large myomas and also
during pregnancy when a venous plexus can be distin-
guished between tl1 e base of t11 e bladder and tl1e uterus.
The uterine plexus of vein drains into tl1e internal iliac
vein. There are two add itional cha nn els of venous drain-
age which are of interest in explaining une xpected sites of
metastases in malignant disease of tl1e ge nital u-act:
• A portal systemic anastomosis e xistS between tl1e hypogas-
uic vein a nd the po•·tal system 'ia the middle and infetior
haemorrh oidal ,.ei11S of t11e systemic a nd tlle superior
haemorrhoidal ' ei11S of the portal system. This accow11S
for some liver metastases of t11e genital u-act malignancies.
• A combinaLion between t11 e middle a nd latet-al sacral atld
lateral lwnbar ven ous S)Stem and t11 e vertebral plexus,
which tn ll)' explain some vertebral and even inu-acranial
metastases, is rarely seen in genital tract cancers. in such
patieniS, the lungs may escape metastases as t11ey are by-
passed by tl1 e malignant emboli.
• Uterine veins communica te witJ1 the vaginal veins. This
explains vagina l metastasis in ute rine ca ncer and endome-
triosis. T he midcUe sacl"ill veins are two in number on the
eitJ1erside of the anet")' and d rain into t11e left common iliac
vein. These veins are encountered duri ng presacral neurec-
I.Otn)', vaginal vat J t sac ropcxy and exemeraLion operaLion.
THE LYMPHATIC SYSTEM
The lymphaLics and lymphatic glands which drain tl1e fe-
male ge nital organs are o f special impo rtance in malignam
disease. The surgical re moval o r radiation should include
all tlle regio nal glands for curative effect.
THE LYMPHATIC GlANDS OR NODES
The I) mphaLic gla nds which ch-ain the fe ma le ge nital orgat1S
are as follows (Fig. 2.25).
32 SHAW'S TEXTBOOK OF GYN AECOLOGY

External
~~~cglands
, '
lntemal '
iliac glands ,' ' :
,, '
1 Hypogastric ,'
,,
I 1 I
Superficial I
I
I
1

inguinal glands I
I
1
I
,
,'
,
11
(} • • • • ;~Jurator
--
I

,-0 --- ----- Parametrial

gland

CeiVix
Rgure 2.25 Pelv ic lymphatic drainage of the ceNix.

THE INGUINAL GLANDS
This group of glands consists of a horizo ntal and a venical
group. The horuontal gnoup lies superficially, parallel to
Poupart's ligament whereas the vertical group, otherwise
known as the deep femoral glands, follows the saphenous
and femoral veins. The uppermost of the deep femoral
glands, called the gland of Cloquet or the gland of Rosen-
muller, lies beneath Poupa•t ·s ligamem in the femoral canal
between Gimbernat's ligamem and the femoral vein. lncon-
stant deep inguinal nodes a re found in the inguinal canal,
along the course of the round ligament, a nd in the tissues
of the mons veneris. In such conditi ons, as p•·imary sore and
Banholin's abscess, the ho•iL.Ontal inguinal group becomes
inflamed. There is some evidence that lymphatics from the
fundus of t11e uterus pass along t11e round ligament and
drain into the hori:wntal inguin al group. It is more likely
t11at these glands will beco me in volved after the appearance
of t11 e la te subure thral metaSL<'l.Sis see n in advanced carci-
no ma corporis ute ri, whe re t11e growth has spread clown the
vagina by a retrograde l)•mphatic spread. The inguinal
gla nds drain the vulva a nd lowe r t11ird of t11e vagina, the
lymp hati cs of t11 e medial portion of the vulva co mmunicate
with l)•mphatics of th e opposite side. It is the refore neces-
sary to perform bilate ral inguinal lymphadenectomy when
cancer occurs in t11e medial portion of the vulva.
THE GLANDS OF THE PARAMETRIUM
The h)pogastric group (internal iliac glands ) contains all
t11e regional glands for t11e cervix, the bladder, t11e upper
third of t11e vagina and also t11e greater pan of the body of
the uterus. This group of glands may be extensively involved
in carcinoma of t11e uterus, cervix and vagina. The glands
are most numerotLS immediate!)' below the bifurcat.ion of
the common iliac group. A further group of t11ese glands
situated in tl1e obturator fossa is ofte n called the obu..rawr
glands and is freq uen U)' the most obvio usly involved in
carcinoma of tl1 e cervix. These drain into external and
common iliac glands.
EXTERNAL IUAC GLANDS
This group of glands, several in number, is situated in rela-
t.ion 1.0 the external iliac anery and ,·ein. A clean clissect.ion
oflhe extemal iliac glands can only be made if both vessels
are completely mobilit.ed as some of the glancls lie lateral to
the vessels between tl1em and the latera l pelvic wall. These
glands receive drainage from the obturator and hypogastric
glands and a•·e involved in late cervical ca ncer.
COMMON ILIAC GLANDS
T his gro up is the upward co ntinuation of the external and
h ypogastric group and, t11erefore, involved next in genital
trac t cance1:
THE SACRAL GROUP
T hese gla nds lie o n eac h side of the rec tum and receive
lympha tics fro m the ce rvix of the uterus and from the up-
per third of the vagina whi ch have pas.sed backwards along
the uterosacral ligaments. Two gno ups of glands can be
recognized, a lateral group lying late ral 1.0 the rectum and
a medial group lyi ng in front of t11e promontory of tl1e sa-
crum. The lymphatics from these glands pass directly either
to tl1e inferior lumbar gro up or to the commo n iliac group.
THE LUMBAR GROUP OF GLANDS
These lymphatic glands are divided into a n inferior gJ"Oup
that lies in from of tl1e aorta below the o rigin of tl1e infe.;or
mesenteric ane•) ' and a superior lumbar group which lies
near the origin of the ovarian ane•·ies. The supe•·ior group

of lumbar glands receives lympha l.ics from the ovaries and
fallopian tubes as we ll as fro m the inferio r lumbar glands.
The lymphatics from th e fundus of th e uterus j oin the ovar-
ian lymph al.ics to pass to the same gro up.
The l)lnphal.ic glands already menl.ioned, namely, t11e
glands of t11 e parametrium, t11 e superficial inguinal, t11e hypo-
gasu·ic, external and co mmon iliac, t11e sao-a! and t11e lumbar
receive l) mphatics 'direct' from the female generative organs
and are known as t11e ' regio nal l)lnphati c glands' o f t11e
female genitalia.
Th ese regional I) mph nodes are n ot palpable clinica Uy,
but can be identi fied on Cr and MRJ scan if t11ey :u·e en-
la rged to I em or more. At su•·ger y, these glands should be
palpated, 1-emoved or biopsied. This helps in staging the
ca ncer and in the postoperative •-adi ot11erapy.
THE NERVE SUPPLY
Both sympatheti c a nd pan\S)•mpathetic systems supply the
fema le gen ital orga ns as we ll as the bladder (Fig. 2.26) .
Rgure 2.26 Lymphatic drainage of the peMc lymph nodes.
Table 2.4 Nerve Supply In the Pelvis
Organ
Perineum, vulva, lower vagina
Upper vag ina, cervix, lower uterine segment, posterior
urethra, bladder trigone, uterosacral and cardinal
li gaments, rectosigmoid , lower ureter
Uterin e fundus, proximal fallopian tubes, broad ligament,
upper bladder, caecum, appendix, terminal large bowel
Outer two-thirds of fallopian tubes, upper ureter
Ovaries
Abdominal wall
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 33
The sympathe tic sys te m co nsists o f the presacral nerve
which lies in fro nt of the sac ral promo ntory. This nerve
plexus divides into two h)'POgastric nerves which pass down-
wards and latera II) a lo ng the pe lvic wa ll to te rmin ate in t11e
inferio r h)pogasuic plex us. This ple xus is diffuse and lies in
the situation of t11 e uterosacral ligamen tS. It also receives
fibres from t11 e paras)ln pathetic S)Stem co nsisting of sacral
fibres 2, 3 and 4. Fro m here, the nerve fibres pass tO all the
pe lvic organs.
The cen·ix is well surrounded by a •·ich plexus of nerves
called Frankenhause•·'s plexus. The lower vagina is inner-
\'<l ted b)• pudendal nen e.
The O\'<lries derh e their n en ·e supply from the coeliac
atld ren al ganglia which follow the course of the ovarian
vessels.
The ilioinguinal ne•·ve, derived from Ll , and t11e genital
branch of the genitofe mo ral n erve (LI and L2) s upply t11e
mons, the uppe r and outer aspec t of the labia majora and
the perineum.
T he pudendal ne rve derived fro m sacral second, third
and fourth segmentS supplies th e lowe r vagina, cliwlis, pos-
terior pa11. of the labia m~ora a nd th e pe rineum. Presacral
neurecLOm)' is rarel)' pe 1fonn ed to re lieve chronic pelvic
pain, and pain due to e ndo metliosis. Pudendal b lock is
needed in operative vaginal de liveries (Table 2.<1) .
APPLIED ANATOMY AND ITS CUNICAL
SIGNIFICANCE
I . Vulva. The skin of the extern al genitalia is prone LO local
atld ge neral de nnatitis. The moist ime nrigi nous pan s o f
the vulva are susceptible to d u onic infection. Mucous
glatlcls in the ' estibula•· locatio n ma) become cystic. A
cyst of t11e canal of uck may be mista ken fo r atl indirect
inguinal h ernia. The loose areolar tiss ue o f the ,•uh'<l atld
iLS ri ch vascul arity account for the large haemawmas t11a t
Spinal Segments Nerves
S2-4 Pudendal, Inguinal, genitofemoral, postero-
femoral cutaneous
82-4 Pelvic parasympathetlcs
T11 - 12, L1 Sympathetlcs via hypogastric plexus
T9-10 Sympathetics via aortic and superior
mesenteric plexus
T9-10 Sympathetics via renal and aortic plexus
and celiac and mesenteric ganglia
T12- L1 Iliohypogastric
T12- L1 Ilioinguinal
L1 - 2 Genhofemoral
34 SHAW'S TEXTBOOK OF GYN AECOLOGY
are formed as a co nseq uence of vasc ular it~ ury dttring
childbinh or accide nLal it~uries. Vulval cancer is rare
and occurs in old age. Lymphatic drainage of vulva is
relevam in radical vulvectOmy for cancer. Pudendal nerve
block is required in episiotOm) and forceps delivery. The
imet·nal pudendal block is perfonned by it~ecung local
anaeSLheLic drug into the nerve at the level of ischial
spine, as the net'\e winds round this spine.
2. Vagina. The posteriot· '-aginal fomix lies in proximity to
the pet·iwneal pouch of Douglas. It is a conveniem site
for access to the petitoneal caviL)\ colpopunCLure, colpo-
cemesis and diagnostic culdoscopy in the diagnosis of
pelvic abscess, ectopic pregnancy and pelvic endomeu·io-
sis. The ureters have a close relation to the lateral vaginal
fornices, panicularly in patients with uterine prolapse.
Ureteric injw)' sh ould be guarded against during vaginal
surger)' on the uterus, as also when anempting LO suture
vaginal lacerations (colporrhexis) hi gh in th e vaginal
vault. T he a natom ic proximity of the bladde r base, ure-
thra and vagina and th e inte rrelalions hip between their
vascu lar and lymphatic networks result in inflammation
of the vagina (vaginitis) ca using wina t)' u·act symptoms
such as frequenC)' and dys uria. Ga rtne r's duct cysts repre-
sen t a C)'Stic di lata tion of the re mnants of the embryo nic
mesonephros. T hey are presem in the lateral walls of the
vagina. T hese are ge ne ra lly asymp tomatic, but they may
cause dyspareunia o r vagina l discomfort. ln the lower
third of the vagina, Gartner's duct cysts are located ante-
riorly and ma) mimic a large ure thral diverticulum.
Squamous cell carci noma of vagina is very rare and oc-
CLu·s usuall) over the decubitus ulcer in a woman wit11
\<aginal prolapse. Adenocarcinoma of '-agina has been
repo11.ed in )Oung girls who were exposed to DES in
utero and can occu t· in the upper pan of the \<agi na.
L) mphatic drainage of nth-a is rele,<am in radical vulvec-
tOm)' for cancer. Pudendal nerve block is required in
episiotomy and forceps delivet)'. The internal pudendal
block is performed by irtiecting local anaesthetist drug
into the nel'\'e at t11e level of ischial spine as t11e nen•e
winds round this spine.
3. Cervix. The major \<aSCular supply ofthe cen•i.x is located
laterally. Deep lateral sutu res placed latet·all y to include
the vaginal mucosa and the substance of t11 e cervix would
help tO con u·ol bleeding du ring surgical procedures on
t11e cervix such as co ni :~.mio n o r the surgical evac uation
of t11e cen>ical ca na l in cervi cal ec topic pregnancy. The
su·oma of tl1e e ndoce rvix un like the ectOce rvix is rich in
nerve endings; hence, manipu lati o n of tl1e cervical canal
can cause an un ex pected vasovagal attack and severe
brad)•carclia or eve n cardiac arresL T he lymp ha tics of the
cen•ix are ver>' co mp lex invo lving m ultip le chains of
nodes. The principal regio nal nodes are the obturator,
common iliac, intern al iliac and visceral nodes of the
parametria; others ma)' also be occasionally involved,
hence th e need for a wide nocla l disseCLion during the
treaunent of cancer cervi.x employing radical surgery.
Squamocolumnar junction is tJ1e site of cancer of ilie
cervi.x. Precancerous lesio n of the cervix needs ablalion
or excisio n depending upon the age of t11e woman and
its grade (Fig. 2.27).
Superior
mesenteric
rJI....a.-- Renal ganglion
L1
/ Inferior
/ mesenteric artery
Inferior
hypogastric
plexus
52
53
l'.ll'~--- Pelvic p lexus
54
Rgure 2.27 Pelvic innervation.
4. Uterus. Dysmenon-I10ea is not an uncommon spnpwm,
necessitating u·eaunent in cla)-tO-da)' practice. Although
most cases of pl'imat)' drsmenon·hoea are treated suc-
cessfully by prostaglandinS) nthetase inhibitors, there are
occasional cases \\i1ere oral medications may not suffice.
ln these women, the division of the sensory nen•es t11at
accompany t11e S)•mpathetic nerves can lead to relief.
The oper·a tions of pr-esacral neurectOm)' and the endo-
scopic division of the uterosacral ligamentS near the
uterine attachment (laparoscopic uterosacr·al nen•e abla-
tion) have bee n designed to meet t11is end. Th e surgeon
must be careful to avoid irtiury to tl1 e ure te i'S. The uterus
receives itS main blood suppl )' fro m t11e laterall y placed
uterine arteries, so the opera ti o n of myo mec tomy of an-
terior wall uterine Fibroids through a mid li ne incision is
a ue nded witl1 the leas t amo ulll of blood loss. Earlier, it
has been d iscussed tllatthc uterus has a rich b lood sup-
ply from tl1 e branches of the vasc ular anastomotic arcade
between the uterine arte ries and the ovarian arteries.
There is also presence of an ex tensive pelvic collatera l
circ ulation to e nsure e no ugh blood supply in emer-
gency situations wherein bilateral surgical ligation of t11e
hypogasll'ic vessels becomes necessary as a life-saving
procedure. such as postpartum haemorrhage.
5. Fallopian tubes. The right fallopian tube lies in proxim-
ity to the appendix. Therefore, it is ofte n difficult to dif-
ferenliate between acute appe ndicilis and acute salpingi-
Lis. The wide mesosalpinx of the ampu lla t) ' portion of
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Napoleon. His soldiers in drinking at pools sucked up the small leeches not thicker
than a horse's hair, whose presence in the hinder part of the mouth cavity produced
divers objectionable results, such as spitting of blood and hindered respiration.

Fam. 2. Herpobdellidae.—Pharynx without denticulate jaws, with three unarmed

chitinous plates.

A characteristic genus of this family is Trocheta, which is so common at the

Zoological Society's Gardens and in the Regent's Park, and which has been met
with in other places near London; it is in this country an introduced species, but is
found in many parts of the continent. It is a land-leech, and lives upon earthworms.

The genus Haemadipsa, which M. Blanchard places in a special sub-family,

contains a number of species which are for the most part land-leeches. Land-
leeches occur in many parts of the world, but chiefly in the tropics—in India, Ceylon,
Java, South America, etc. They lie in wait for their prey, upon the ground as a rule;
but they may ascend herbs and shrubs to gain a better outlook when they are aware
of an approaching footstep. A vivid account of the ferocity of these tiny Annelids in
Ceylon can be read in Sir J. E. Tennent's Natural History of Ceylon. They have been
said to be so pugnacious and so poisonous that persons surprised in their sleep by
the pests have succumbed to their united efforts. A whole battalion of English
soldiers decamped on one occasion from a wood which was overflowing with land-
leeches. The familiar misquotation "lethalis hirudo" might well be applied to this
species. Professor Whitman has written much upon the habits of the land-leech of
Japan (Haemadipsa japonica), which bites so softly that its presence cannot be
detected except for the stream of blood which trickles from the wound. While it is
feeding it emits from the pores of the nephridia a clear fluid, which, as it appears, is
used to keep the skin moist; when unduly dried the same phenomenon occurs. It is
curious that in this and other leeches the nephridia should play a part which in the
earthworm is played by the dorsal pores; in both animals the glands of the skin are
also concerned with the same duty.

The purely aquatic leeches swim by undulations, and also crawl by the help of the
two suckers, like a "Geometer" caterpillar. But when a land-leech is dropped into the
water it at once sinks to the bottom and crawls out; it does not swim, but can survive
immersion for a long period. In this it resembles the earthworms, which can also
survive a prolonged immersion, and even in the case of some are indifferent to the
medium, land or water, in which they live; the land-leech, however, is entirely
dependent upon damp surroundings; a dry air is fatal to it. The land-leech of Japan
leaves a slimy trail behind it as it crawls, in this respect recalling the land Planarian
Bipalium kewense.
 GEPHYREA AND PHORONIS

BY

ARTHUR E. SHIPLEY, M.A.

Fellow and Tutor of Christ's College, Cambridge

CHAPTER XV

GEPHYREA

INTRODUCTION—ANATOMY—DEVELOPMENT—SIPUNCULOIDEA—PRIAPULOIDEA—
ECHIUROIDEA—EPITHETOSOMATOIDEA—AFFINITIES OF THE GROUP.

The animals included in the above-named group were formerly associated with the
Echinodermata. Delle Chiaje[468] states that Bohadsch of Prague in 1757 was the
first to give an accurate description of Sipunculus under the name of Syrinx, but
Linnaeus, who noted that in captivity the animal always kept its anus directed
upwards, re-named it Sipunculus. Lamarck[469] placed the Gephyrea near the
Holothurians; and Cuvier[470] also assigned them a position amongst the
Echinoderms. He mentions Bonellia, Thalassema, Echiurus, Sternaspis, and three
species of Sipunculus, one of which, S. edulis, "sert de nourriture aux Chinois qui
habitent Java, et qui vont la chercher dans le sable au moyen de petits bambous
préparés."

The name Gephyrea[471] was first used by Quatrefages, who regarded these
animals as bridging the gulf between the Worms and the Echinoderms. He included
in this group the genus Sternaspis (vide p. 335), now more usually classed with the
Chaetopoda.

The Gephyrea are exclusively marine. They are subcylindrical animals, which can
either retract the anterior end of their body—the introvert—carrying the mouth into
the interior; or are provided with a long flexible but non-retractile proboscis. The
latter is easily cast off. They usually bear spines or hooks of a hard chitinous
character, secreted by the epidermis or outermost layer of cells. The mouth is at the
base of the proboscis or at the end of the protractile part, the anus is at the other
end of the body or on the dorsal surface. The nervous system consists of a ring
round the mouth and of a ventral nerve-cord. A vascular system is present as a rule.
Nephridia are found which act as excretory organs, and in most cases also as ducts
for the generative cells. The Gephyrea are bisexual, and the male is sometimes
degenerate.

The group may be divided into four Orders:—(i.) Sipunculoidea; (ii.) Priapuloidea;
(iii.) Echiuroidea; (iv.) Epithetosomatoidea; of these the first is by far the largest,
both in number of genera and of species.

The Anatomy of Sipunculus nudus.

External Characters.—The body of S. nudus when fully extended may attain a

length of a foot, or even a little more; in this condition it is seen to consist of two
portions, the anterior of which is, however, retracted into the other when the animal
is disturbed. The retractile portion is sometimes termed the proboscis, but as its
nature is entirely different from that of the proboscis of the Echiuroidea, it is better to
refer to it as the introvert. Special retractor muscles are attached on the one hand to
the body-wall about half-way down the body, and on the other hand are fused into a
muscular sheath which surrounds the gullet, just behind the mouth. When these
muscles contract, they withdraw the introvert into the rest of the body or trunk in
much the same way as the finger of a glove may be drawn into the hand, by a
thread fastened to the inside of its apex. The introvert is protruded by the
contraction of the circular muscles of the body-wall. These exert a pressure on the
fluid which fills the body-cavity, and by this means the sides of the introvert are
forced forward until finally the head is exposed.

The introvert occupies about one-sixth or one-fifth of the total body length. It is
somewhat narrower than the trunk, and is covered by a number of small flattened
papillae, some of which lie with their free ends directed backward, overlapping one
another like tiles on a roof. In some other genera, as Phymosoma, the introvert
bears rows of horny hooks, which are apt to fall off as the animal grows old.

The trunk has from thirty to thirty-two longitudinal furrows, the elevations between
which correspond with a similar number of muscles lying in the skin. This
longitudinal marking is crossed at right angles by a circular marking of similar origin,
the elevations of which correspond with the circular muscles in the skin. These two
sets of markings thus divide the skin of the trunk into a number of small square
areas, very regularly arranged (Fig. 212).

The outline of the trunk is more or less uniform, but it is capable of considerable
change according to the state of contraction of its muscles. The circular muscles, for
instance, may be contracted at one level, thus causing a constriction at this spot.
The colour of S. nudus is a somewhat glistening greyish-white.
 Fig. 211.—Right half of the anterior end of Sipunculus nudus L., seen from the inner
side and magnified. a, Funnel-shaped grooved tentacular crown leading to the
mouth; b, oesophagus; c, strands breaking up the cavity of the tentacular crown
into vascular spaces; c', heart; d, brain; e, ventral, and e', dorsal retractor
muscles; f, ventral nerve-cord; G, vascular spaces in tentacular crown.

The anterior end of the fully-expanded Sipunculus may be termed the head; here
the skin is produced into a frayed fringe which stands up in the shape of a funnel
round the mouth. This fringe is grooved on its internal surface with numerous little
gutters, all of them lined with cilia, which by their constant motion keep up a current
which sweeps food into the mouth. The fringe may be in the form of a simple ring
round the mouth, or the ring may be folded in at the dorsal side so as to take the
form of a double horse-shoe (Figs. 211 and 212).

Body-wall.—The glistening appearance of Sipunculus is due to the cuticle, a

chitinoid layer which is secreted by the external layer of cells, the epidermis.
Beneath this lies a layer of connective tissue, which is not always present in other
Gephyrea; within this lies a layer of circular muscles arranged in bundles, then
comes a very thin sheath of oblique muscular fibres, then a thicker layer of
longitudinal muscles, and finally a layer of peritoneal epithelial cells, which in
Sipunculus are for the most part ciliated.

Scattered over the surface of the body, and opening by narrow tubes which pierce
the cuticle, are a number of glandular bodies which may be either bi- or multi-
cellular. The glandular cells are apparently enlarged and modified epidermal cells;
they are arranged in a cup-shaped manner, with their apices directed towards the
orifice. They are crowded with granules, which are presumably poured out over the
cuticle, but the exact function of the secretion is entirely unknown. They have a well-
developed nerve supply.

Digestive System.—The mouth lies in the centre of the fringe, and is not provided
with any kind of jaw or biting armature; it leads directly into the thin-walled
alimentary canal, the first part of which is ciliated. The alimentary canal is not
marked out into definite regions, but passes as a thin-walled semi-transparent tube
to the posterior end of the body, and then turns forward again and opens to the
exterior by an anus situated about an inch below the junction of the introvert with the
trunk, on the median dorsal line. The descending and ascending limbs of the
alimentary canal are coiled together in a spiral, which may be more or less close in
different individuals. The whole is supported by numerous fine muscular strands,
which pass from the walls of the intestine to the skin, and by a spindle-muscle,
which runs from the extreme posterior end of the trunk up the axis of the spiral and
terminates in the skin close to the anus.

No glands open into the alimentary canal at any point of its course, but near the
anus a simple diverticulum, or pocket, of unknown function arises. The size of this
outgrowth differs enormously in different individuals. The alimentary canal near the
anus also bears two tuft-like organs, which, however, do not open into the intestine,
but probably have some function in connexion with the fluid in the body-cavity.

Along the whole course of the alimentary canal there runs a ciliated groove, into
which the food does not pass, but the cilia of which probably keep in motion a
current of water whose function may be respiratory.

Fig. 212.—Sipunculus nudus L., with introvert and head fully extended, laid open by
an incision along the right side to show the internal organs. × 2. a, Mouth; b,
 ventral nerve-cord; c, heart; d, oesophagus; e, intestine; f, position of anus; g,
tuft-like organs; h, right nephridium; i, retractor muscles; j, diverticulum on
rectum. The spindle-muscle is seen overlying the rectum.

Vascular System.—On the dorsal surface of the anterior end of the alimentary
canal lies a contractile vessel, usually termed the heart. It is a tube about an inch
long, ending blindly behind, but opening in front into a ring-shaped space
surrounding the mouth and partially enveloping the brain. From this ring-like vessel
numerous branches are given off which pass into the fringe round the mouth, and
probably the chief function of the heart is by its contraction to force fluid into this
fringe, and so to extend it. The heart contains a corpusculated fluid. A similar but
shorter tube is found on the ventral surface of the anterior end of the alimentary
canal in the species in question; it also opens into the ring which surrounds the
mouth.

Respiratory System.—There are no special respiratory organs, and it has long

been a matter of dispute where the respiration of Gephyrea is carried on. The
oxygenation of the blood probably takes place to some extent through the walls of
the oral fringe, but the blood which receives its oxygen at this spot is limited in its
distribution, and could only supply the brain and head. It seems probable that the
remaining organs are supplied with oxygen by the fluid of the body-cavity, which
bathes them on all sides. This might obtain its oxygen from the blood in the heart, or
more probably, through the thin walls of the intestine, from the stream of water
which is maintained by the ciliated groove described above. Quite recently a form—
S. mundanus, var. branchiata—has been described[472] with thin-walled papillae
covering parts of the skin. These papillae are full of corpuscles, and are regarded by
their discoverer as branchiae.

Body-Cavity.—The pinkish fluid of the body-cavity contains numerous corpuscles,

the products of the reproductive organs (either ova or spermatozoa), and some
curious unicellular bodies known as "urns." The latter are shaped like a bowl with a
ciliated rim, and are formed from the budding of certain cells on the walls of the
dorsal blood-vessel.[473] Their function is unknown, but they resemble certain
multicellular bodies found in the body-cavity of Phascolosoma. The generative cells
found in the body-cavity are further considered below. The true corpuscles are
either biconcave round corpuscles coloured with a chemical substance, the
haemerythrin of Krukenberg, which apparently plays the same rôle as haemoglobin
in other animals; or amoeboid corpuscles, which, though rare in Sipunculus, are
very numerous in Phascolosoma.

Nervous System.—The nervous system of Sipunculus consists of a brain or

cerebral ganglion, a circumoesophageal ring surrounding the gullet, and a ventral
nerve-cord. The brain is a small bi-lobed nervous mass situated on the dorsal
surface of the oesophagus, in the angle between the right and left dorsal retractor
muscles close to their point of insertion. Numerous nerves arise from it, and pass to
the fringe surrounding the mouth and to neighbouring parts. At the sides, the brain
is continued into two stout nerve-cords which encircle the oesophagus, and
meeting, fuse together in the median ventral line to form the ventral nerve-cord (Fig.
211). The latter is of the same diameter throughout, and shows no signs of
segmentation; it is oval in section, and consists of small ganglion cells heaped up on
the ventral surface, i.e. next the skin, and of numerous fibres situated dorsally. The
cord gives off many nerves, which usually arise in pairs. These pass into the skin,
and forming rings, run round the body, and give off finer nerves as they go.

The nerve-cord is supported by numerous strands of muscle which pass to it from

the skin. These are especially long in the region where the introvert joins the trunk,
and thus allow free play to the nerve-cord when the former is being protruded or
retracted.

Sipunculus is not well provided with sense-organs, but in an animal which lives
buried in sand we should not expect to find these very highly developed. On the
introvert there are certain patches of epithelium bearing long stout cilia, which have
been regarded as tactile in function, and there is a tubular infolding reaching the
brain, which almost certainly has some sensory function. Ward[474] has termed this
"the cerebral organ." It consists of a duct lined with ciliated cells, which opens to the
exterior in the middle dorsal line outside the tentacular fringe. The duct leads down
to the brain, and expands at its lower end into a saucer-shaped space, covering that
portion of the brain where its substance is continuous with the external epithelium.
In Phymosoma this cavity is produced into two finger-shaped processes, which are
sunk into the brain and are lined by cells crowded with a dense black pigment.[475]
They are probably rudimentary eyes, perhaps distinguishing only between darkness
and light. The pits appear to be absent in Sipunculus nudus, but Andrews states
they are found, although without pigment, in S. gouldii.[476]

Excretory System.—The excretory organs or "brown tubes" are typical nephridia,

that is to say, they consist of tubes with glandular walls which open on the one side
to the exterior, and on the other by means of a ciliated funnel-shaped opening into
the body-cavity. In Gephyrea one wall of the tube is produced into a long
diverticulum or sac which hangs down into the body-cavity, and is usually supported
by muscle-fibres running to the body-wall. The lower end of the sac is broken up
into a number of crypts or pits, lined by large glandular cells crowded with brown
pigment. The pigment-granules are secreted into the cavity of the sac, and leave the
body through the external opening; they probably consist of the nitrogenous excreta
of the animal. The upper end of the sac, into which both the external and internal
orifices open, is usually enlarged, and its walls are very muscular. As in so many
other animals, the nephridia serve as ducts through which the reproductive cells
leave the body of the parent.
Reproductive System.—The Gephyrea are bisexual. In Sipunculus the testes and
ovaries are found in the same position in the two sexes, and are indistinguishable
without microscopic investigation. They each consist of small ridges situated at the
lower end of the ventral retractor muscles, just where the latter take their origin from
the longitudinal muscles of the skin. At this level the cells which line the body-cavity
on the inside of the skin are heaped up, and become modified in the one case into
ova or eggs, and in the other into the mother-cells of the spermatozoa. This method
of forming the reproductive organs from modified cells lining the body-cavity is very
common in the higher animals; but it is seen in its simplest and least modified form
in the Sipunculidae.

The eggs break away from the ovary in a very undeveloped condition, but whilst
floating about in the body-cavity they increase in size and secrete a thick membrane
around them. They have a well-marked nucleus, and are oval in outline.

The mother-cells of the spermatozoa also break away in an immature condition, and
complete their development in the nutritive fluid of the body-cavity. They divide into
a number of spermatozoa, usually eight or sixteen, which remain in contact. They
each develop a tail, which projects outwards, and aids the cluster in swimming
along. These clusters of spermatozoa are about the same size as the ova of the
female, and, like them, make their way into the "brown tubes." The exact way in
which this is accomplished is not very clear, but the cilia on the funnel-shaped
internal opening of the tube seem to have some power of selecting the generative
cells when they come within their reach, and of passing them on, whilst they reject
the much smaller corpuscles of the perivisceral fluid, which are never found in the
nephridia.[477] Once inside the internal opening, the clusters break up and the
spermatozoa escape singly into the sea. Here they meet with and fertilise the eggs
which have escaped from the body of the female.

Fig. 213.—Larva of Sipunculus nudus L. × 150. (After Hatschek.) a, Mouth; b, anus; c,

excretory organ; d, glandular appendage of oesophagus; e, wall of stomach over
which the retractor muscle runs; f, invaginated sense-organ at aboral pole.
Development.—Hatschek,[478] who investigated the development of Sipunculus
nudus at Pantano, an inlet of the sea near Messina, states that the spawning takes
place during the night, and ceases about July 10. The rate of development depends
upon the temperature, but the larvae usually free themselves from the egg-
membrane during the third day. When hatched the embryos lengthen out a good
deal, and take the form represented in Fig. 213. The larva swims actively by means
of a ring of stout cilia, which encircle the body just behind the mouth. Other shorter
cilia are found on the head, continuing into the lining of the mouth, and a little bunch
of them is situated at the extreme posterior end. The alimentary canal is already
formed, and is twisted, so that the anus lies dorsally, but not so far forward as it
does in the adult. A glandular structure opens into the mouth, and another body of
unknown function is connected with the oesophagus; both these disappear during
larval life. A pair of excretory tubules, the forerunners of the brown tubes, are found,
and the chief muscle tracts are already established. The nervous system is still in
close connexion with the skin, from the outer part of which it is derived; the cerebral
thickening bears two eye-spots.

The fluid of the body-cavity contains corpuscles, which are kept in active circulation
by the constant contractions of the body-wall, and by numerous tufts of cilia which
are borne on the inner surface of the skin. The dorsal blood-vessel is one of the
latest organs to arise.

The larva swims actively about for a month, during which time it increases greatly in
size; it then undergoes a somewhat sudden metamorphosis. The ciliated ring and
the structures related to the oesophagus begin to disappear, the distinction between
the head and the rest of the body is obliterated, and the head becomes relatively
small. The mouth changes its position, and becomes terminal instead of being
somewhat ventral, and the tentacular membrane begins to appear. At the same time
the larva relinquishes its free-swimming life, and sinks to the bottom; it begins
creeping amongst the sand by protruding and retracting the anterior part of its body,
and takes on all the characters and habits of the adult.

I. Order Sipunculoidea.

Besides the genus Sipunculus, the Order Sipunculoidea includes ten other genera.
A key to these, taken for the most part from Selenka's admirable monograph, is
given on page 424.

Phascolosoma contains, in comparison with Sipunculus, only small species, and it is

easily distinguished by the fact that the longitudinal muscles are fused into a
continuous sheath. As a rule the skin is smooth. A few species bear hooks, which
are generally scattered irregularly and not arranged in transverse rows, as in
Phymosoma (Fig. 214) and most of the other genera.
The fold which in S. nudus surrounds the mouth may be in the same species bent in
so as to take the form of a double horse-shoe, the opening of which is always
dorsal, just above the brain; in this case the mouth is crescentiform. In other genera
the fold is broken up into discrete tentacles, and these are variously arranged; in
Dendrostoma they are grouped together in four or six bundles round the mouth, but
the more usual arrangement is the horse-shoe-like row of tentacles which overhang
the crescentiform mouth, as in Phymosoma and some species of Aspidosiphon.

The ventral side of each tentacle is grooved and ciliated, and the grooves are
continued into the ciliated mouth. Their dorsal surface is pigmented, and in the
hollow of the horse-shoe lies a deeply pigmented epithelium covering the brain.

A blood-vessel courses up each tentacle, and usually two channels return the blood
to the vascular ring which surrounds the mouth. In those forms which possess
tentacles on the dorsal side of the mouth only, the ventral part of the vascular ring
lies in the lower lip, which is tumid and swollen. The brain supplies a nerve to each
tentacle.

When the introvert is retracted the tentacular ring is withdrawn and to some extent
collapsed; in this condition it would be almost touching the rough external surface of
the introvert. In some species of Phymosoma the delicate appendages of the head
are guarded from the hooks on the introvert by a thin membrane or collar,[479] which
completely ensheaths the retracted head.

Fig. 214.—A, Phymosoma granulatum F. S. Leuck. × 2. B, Head of the same. × 4. a,

Pigmented pit leading to brain. The crescentiform mouth on the lower side of the
figure is overhung by the tentacles.

When the introvert is fully extended the dorsal blood-vessel contracts and sends its
blood forward into the vascular ring, and thence into the tentacles or tentacular fold,
which are thus erected. In several species of Sipunculus, as S. nudus, S.
norvegicus, S. robustus, S. tesselatus, there is a ventral blind tube as well as a
dorsal, into which the blood is withdrawn when the head is retracted. In many other
species in various genera, such as Phymosoma weldonii and Ph. asser,
Dendrostoma signifer, S. vastus, the lumen of the dorsal vessel is increased by
numerous hollow blind processes which it bears, hanging freely into the body-cavity.
Three very small genera of Sipunculids—Onchnesoma, Petalostoma, and Tylosoma
—are devoid of all trace of vascular system and of tentacles; the mouth opens in the
centre of the anterior end of the introvert. In Onchnesoma the dorsal part of the lip is
somewhat produced, so that the head has somewhat the shape of a Doge's cap,
and in Petalostoma there are two leaf-like processes of the body-wall which guard
the mouth.

The extent to which the intestine is coiled varies very much even in the same
species; the axis of the coil is often supported by a spindle-muscle, but this is
sometimes absent. The caecum, which opens into the rectum of S. nudus, is again
a very variable structure, and when it is present varies remarkably in size.

The food of Sipunculids seems to consist almost entirely of sand, and their only
nourishment must be such small microscopic organisms or particles of animal and
vegetable débris as are to be found mixed with the sand. The alimentary canal is, as
a rule, quite full of sand, and yet in spite of the tenuity of its walls they never seem
to be ruptured. If the contents of the digestive tube be washed out with a pipette, it
will be found that it requires considerable force to dislodge many of the sand-
particles lying next the wall. These are more or less embedded in crypts or pockets
of the wall, and as the sand passes along the intestine they probably serve as more
or less fixed hard points, against which the sharp edges of the sand particles are
worn off. Amongst the sand are usually to be found pieces of shell, sometimes with
a diameter equal to that of the alimentary canal; these are usually rounded, but their
angles may have been removed by attrition before they entered the mouth of the
Sipunculid.

In S. tesselatus the sand is to some extent held together by a mucous deposit; in

those cases where there is no sand in the intestine, there is always a coagulum of
mucus, and the walls are contracted and thick; when full of sand the walls are
tensely stretched and very thin. This thinness of the wall of the alimentary canal
seems ill-adapted to a diet of sand, nevertheless it is also met with in other great
sand-eating groups of animals, such as the Echinids and the Holothurians.

The enormous amount of sand and mud which passes through the bodies of the
Sipunculids shows that they must take a considerable part in modifying the mineral
substances which form the bottom of the sea. Just as earthworms, as shown by
Darwin, play a considerable rôle in the formation of soil, so must these animals, in
conjunction with Echinids and Holothurians, effect considerable modifications in the
sand and mud which pass through their bodies. Mr. J. Y. Buchanan[480] is "led to
believe that the principal agent in the comminution of the mineral matter found at the
bottom of both deep and shallow seas and oceans, is the ground fauna of the sea,
which depends for its subsistence on the organic matter which it can extract from
the mud." The minerals at the bottom of the sea are exposed to a reducing process
in passing through the bodies of the animals which eat them, and subsequently to
an oxidising process due to the oxygen dissolved in the sea-water acting on the
minerals extruded from the animals' bodies.

The rate at which the sand passes through the body of Sipunculus is unfortunately
unknown, but that at any one moment a considerable quantity is contained in the
intestine is shown by the fact that the average weight of five specimens of S. nudus
from Naples, taken at random, was 19.08 grms., whilst the average weight of sand
washed out of their alimentary canal was 10.03 grms. The sand contained in five
other specimens of the same species measured respectively 6 c.c., 7 c.c., 6.5 c.c.,
7.5 c.c., and 7.5 c.c., giving an average of 6.9 c.c. for each individual.

Onchnesoma and Tylosoma have only one retractor muscle; Aspidosiphon and
Phascolion have, as a rule, two; Phymosoma and Sipunculus have four, and
perhaps this is the more usual number.

Phascolion, Tylosoma, and Onchnesoma have but one "brown tube"; in Phascolion
this is the right, in Onchnesoma it is sometimes the right and sometimes the left that
persists. Most other genera retain two, but there are many exceptions; for instance,
Phascolosoma squamatum has but one, and so has Aspidosiphon tortus, and in
both cases it is that of the left side. No Sipunculid has more than two. It has been
pointed out by Selenka that those species which have but one brown tube are, as a
rule, inhabitants of tubes or shells, and do not move actively about in the sand.

The eggs of all members of the family, with the exception of the genus Phymosoma,
are spherical, but those of the last-named genus are elliptical. They are always
surrounded by a thick membrane, the "zona radiata," pierced by numerous pores.

Aspidosiphon (Fig. 215) is easily recognised by the presence of two symmetrically-

arranged cuticular shields, one at each end of the trunk. These are formed by the
fusion of minute cuticular plates, such as exist in the skin of most Sipunculids. The
posterior shield is radially symmetrical, but the anterior is somewhat like the shell of
a Pecten, and symmetrical only about one plane. The introvert is protruded from the
acute angle of the anterior shield, and when extended lies almost at right angles to
the trunk, instead of being, as is usually the case, in the same straight line with it. In
many specimens, and these seem as a rule to be the older ones, a deposit of
calcium carbonate takes place over these shields, covering over and concealing
their external markings.
Cloeosiphon (Echinosiphon) has a calcareous ring, consisting of four or five rows of
lozenge-shaped calcareous bodies forming a close mosaic, arranged round the
base of the introvert, which when extended is in the same straight line as the trunk.
Each piece bears a brown spot, which is said to be the pore of a gland (Fig. 217).
Golfingia Lankester, has a cylindrical horny thickening at the anterior end of the
trunk and another at the posterior.

Fig. 215.—Aspidosiphon truncatus Kef. × 2. a, Introvert partially extended, but not

sufficiently to show the head.

Key to the Genera of Sipunculoidea.[481]

I. The longitudinal muscles in the body-wall divided into 17-41 distinct bundles.
Four retractor muscles.

A. Body covered with papillae. Numerous filiform tentacles which seldom (or
never?) surround the mouth, but stand above and dorsal to it in a horse-
shoe, with the opening dorsal. No rectal caecum. Hooks usually present.
Four retractors (in Ph. Rupellii only two?). Heart almost always without
caeca. Eye-spots always present. Eggs oval, flat, reddish. Almost entirely
small tropical species
1. Phymosoma

B. Body devoid of papillae. Tentacular membrane surrounds the mouth in a

circlet. Rectum with one or more caeca (except S. edulis?). Hooks absent
except in S. australis. Eggs spherical. The tentacular membrane contains a
vascular network. A ventral contractile vessel usually present in addition to
the heart. Mostly large forms. Found in all seas
2. Sipunculus

II. The longitudinal muscles in the body-wall form a continuous sheath, and are
not split up into bundles.

A. Two brown tubes. Numerous tentacles form a wreath round the mouth.
Alimentary canal forms a complete spiral, free behind except in Ph. Hanseni.
 Spindle-muscle usually present. One or more ligaments present, but only on
the anterior convolutions of the intestine. Adhesive papillae always absent.
Hooks very frequently absent. Eggs spherical. Found in all seas.
3. Phascolosoma

B. Two free brown tubes. Only four or six plumed tentacles. A complete
intestinal spiral, not attached behind. Spindle-muscle always present. One or
more ligaments present, but only on the anterior convolutions of the
intestine. Hooks are present, but sometimes fall off early in life. Heart usually
bears caeca. Found only in the tropics.
4. Dendrostoma

C. Only one brown tube, that of the right side, present; it is attached to the
body-wall throughout its entire length. Numerous tentacles form a circle
round the mouth. The alimentary canal forms no spiral, or an incomplete
one. No spindle-muscle, but the intestine is attached to the body-wall
throughout its length by numerous ligaments. Adhesive papillae often
present. Not more than two retractors. Spherical eggs. Inhabits Mollusc
shells or tubes. Found in all seas
5. Phascolion

III. At both ends of the trunk a distinct horny shield, or tube-like cornification, or
a calcareous ring at the anterior end of the trunk. Hooks sometimes present.
Longitudinal muscles continuous or split up into bundles.

A. A shield at both ends of the trunk. Introvert excentric, arising from the
ventral side of the anterior shield. Tentacles small and few in number,
arranged in a horse-shoe above the mouth. A spindle-muscle, which arises
from the posterior end of the body, traverses the intestinal coil. Two
retractors only, these are the ventral; they are frequently fused together from
their point of origin.
6. Aspidosiphon

B. A calcareous ring surrounds the anterior end of the trunk, from the middle
of which the introvert is extruded. Longitudinal muscles continuous. Hooks
bifid. Tropical.
7. Cloeosiphon

C. A corneous ring, from which the introvert issues, surrounds the anterior
end of the trunk, and the posterior end of the trunk is produced into a
corneous spike. Six pinnate tentacles encircle the mouth. Four retractors.
Hooks present on the introvert. Longitudinal muscles continuous. Intestine
 not coiled throughout in a spiral nor fastened posteriorly. Spindle muscle
present.
8. Golfingia

IV. No tentacles, but two leaf-like extensions of the body-wall guard the mouth.
Four retractors. Few intestinal loops, quite free. No vascular system.
9. Petalostoma

V. No tentacles, no vascular system. One retractor, and one segmental organ.

A. Introvert long. Body small, pear-shaped.

10. Onchnesoma

B. No introvert (?). Body cylindrical, thickly covered with papillae, which are
larger and more crowded at both ends of the trunk.
11. Tylosoma

Species of Sipunculoidea.—The genus Phymosoma (Fig. 214) contains more

species than any other genus of Sipunculoidea, and they are all of fair size. Twenty-
seven species are known, of which seventeen occur in the Malay Archipelago,
thirteen being found there alone. Phymosoma affects shallow water, the deepest
specimens being taken at a depth of about 50 fathoms; this may be due to the fact
that they flourish only in comparatively warm water. With very few exceptions, they
are found only in tropical seas, very often living in tubular excavations made in soft
coral rock.

The genus Sipunculus contains sixteen species. They are the largest and the most
conspicuous members of the group. They have a very wide distribution, some
species, as S. nudus (Fig. 212) and S. australis, being almost cosmopolitan. They
are most common in temperate and tropical seas, but S. norvegicus and S.
priapuloides are found far north, but always at considerable depths, 100 to 200
fathoms.

The following account of the habits of Sipunculus gouldii is taken from Mr.
Andrews'[482] paper on that species:—

"This Sipunculus is very abundant in certain small areas of compact, fine sand
darkened by organic matter and not laid bare at ordinary low tide. In such places,
only a few square metres in extent, they pierce the sand in all directions to a depth
of more than half a metre, making burrows with persistent lumen running from the
surface downward and then laterally, but with no regularity in direction.
"Kept in aquaria, the dependence of the animal upon the nature of the sand and its
method of locomotion may be readily observed. A vigorous individual buries itself in
a few moments in the following manner: Running out the introvert to nearly its full
extent, and applying it to the surface of the sand till some spot of less resistance is
found, the animal still further expands the introvert so that it penetrates the sand,
provided this is not too dense and firm, for then the body is merely shoved
backward. When the introvert is inserted, the contraction of the longitudinal muscles
of the body-wall brings the whole body forward somewhat, in case the introvert is
fixed in the sand. In case soft ooze was present, this fixation did not take place, and
the introvert was merely pulled out again, but when the sand was of the right
consistency the introvert was fixed by becoming much swollen at the tip, and then
constricted just posterior to this swollen area. This bulb-like area exerts lateral
pressure on the sand, as could be seen by movements of the grains. The swelling
of the anterior end of the introvert is brought about by the body-wall contracting
elsewhere, and forcing in liquid to distend that end. Owing to the curved form
assumed by the body in the normal contracted state when first removed from its
burrow, the entrance of the introvert may often be nearly vertical, and hence the
entire body is soon raised nearly upright in the water above the sand. If the body
has thus been warped forward sufficiently to become somewhat fixed in the sand,
the introvert is rolled in and again thrust forward from this new point of resistance,
and so on till the animal is entirely buried. This locomotion increases in speed as the
creature becomes more completely surrounded by sand, and is the only means of
moving from place to place.

"On a smooth surface, or on one not presenting the right degree of resistance, the
Sipunculus does not change its position, but remains till death finally occurs, rolling
its introvert in and out and contracting its body-wall to no purpose.

"The essential factors in the mechanism bringing about this hydrostatic locomotion
are an elongated contractile sac filled with liquid, and some means of definitely co-
ordinating the contractions of the sac.

"In natural environment the animals are found with sometimes one, sometimes the
other end nearer the surface of the sand: in the aquaria the same was observed, but
when the water became stagnant and impure the anterior end with expanded
branchiae was often protruded somewhat above the surface of the sand."

The genus Phascolosoma contains at least twenty-five species, for the most part
small. Ph. margaritaceum, however, measures[483] 10 cm. in length, and Ph.
flagriferum, 13 cm. The latter is produced at the hinder end of its trunk into a long
whip-like process, which recalls the horny spike of Golfingia. Most species live free,
but a few inhabit the shells of dead Gasteropods or of Dentalium, or the abandoned
tubes of worms. They occur in practically all seas.
 Fig. 216.—Specimens of the Coral Heteropsammia cochlea, with Aspidosiphon
heteropsammiarum or A. michelini living in a state of commensalism with them.
(From Bouvier.)

Dendrostoma contains but five species, which are all found within the tropics in the
Pacific or in the West Atlantic. They are shallow-water forms, and some are found
between tide-marks.

Phascolion is a smaller genus, containing but ten species, which may have been
derived independently from different species of Phascolosoma, and in this case the
genus should be broken up. The members of this genus live in Mollusc shells, such
as Dentalium, Turritella, Buccinum, Chenopus (Aporrhais), Nassa, Strombus, and
generally acquire the coiled shape of their host. They are usually attached to the
shell by means of certain adhesive papillae found on their posterior end. Ph. strombi
fills its shell with mud, which must be kept together by some secretion of the animal.
The body lies in a tube in this mud, and the introvert projects from the small round
opening at the end of the tube, and explores the ground in every direction. They are
found in all seas, but more especially in the colder waters.

Fig. 217.—Cloeosiphon aspergillum Quatr. × ½. a, Introvert covered with spines and

partially extended, but not sufficiently to show the head; b, calcareous plates
surrounding the point of origin of the introvert.

The genus Aspidosiphon includes nineteen species, which are, with few exceptions,
exclusively confined to the Indian Ocean and neighbouring seas, including the Red
Sea. The exceptions are A. armatus from the Norwegian coast, and A. mülleri from
the Mediterranean and Adriatic. A. truncatus is also stated to occur at Panama, the
Bahamas, and at Mauritius. The remaining species almost all occur in the Malay
Archipelago and neighbouring islands, and as was the case with Phymosoma, this
part of the world seems to be the headquarters of the genus. A. mülleri lives in the
interstices of rocks and stones, and occasionally in disused Mollusc shells.

Two species of Aspidosiphon have been described by Bouvier[484] living in a state

of commensalism with two species of Madreporarian corals, Stephanoceris
rousseaui and Heteropsammia cochlea, which live on and surrounding the shells of
certain Molluscs at Aden (Fig. 216). Apparently the Gephyrean takes up its abode
within its house at a tender age, and according to Bouvier, it provides for its
increasing bulk by secreting a coiled calcareous tube, the outer surface of which
affords space for the growth of the coral.

The genus Cloeosiphon, the Echinosiphon of Sluiter, includes three species: C.

aspergillum (Fig. 217), C. molle, and C. javanicum. The first named occurs at
Mauritius, the Malay Archipelago, and neighbouring islands; the others are confined
to the last-named area, which thus again forms the headquarters of a genus.

Golfingia, described by Lankester from a single specimen, was dredged in St.

Andrews Bay, at the depth of 10 fathoms.

Petalostoma comprises but one species, P. minutum, which is found in the English
Channel.

Onchnesoma comprises two species, O. steenstrupii and O. sarsii, both found off
the coast of Norway at considerable depths between 200 and 300 fathoms.

Tylosoma comprises one species, T. lütkenii, also from the Norwegian coast. It is
dredged from stony ground in 50 to 80 fathoms.

II. Order Priapuloidea.

Anatomy.—This Order consists of the two genera Priapulus and Halicryptus. Both
are cylindrical animals with the mouth at one end and the anus at the other. The
introvert is short, and is covered with rows of chitinous spines, which are continued
to some extent over the body.

The skin is folded in a series of rings, and the body is usually somewhat swollen
posteriorly. P. caudatus bears a curious caudal appendage, beset with a number of
hollow lobes somewhat grape-like in appearance. This is situated ventral to the
anus; its lumen is continuous with that of the body-cavity, but it can be separated
from it by the action of a sphincter muscle. Two such appendages exist in P.
bicaudatus.

There cannot be said to be any head in the Priapuloidea; they have no tentacles or
tentacular fringe, no proboscis, and no distinct brain; simply a round aperture, the
mouth, which is surrounded by a groove in the skin, at the bottom of which the
circumoesophageal nerve-cord lies. The mouth leads into a very muscular pharynx
lined with stout chitinous teeth; this passes into an intestine, which is as a rule
straight, but in P. glandifer it has a single loop.

The Priapuloidea possess no vascular system and no brown tubes. Their skin has in
the main the same structure as that of the Sipunculids, with spines, glandular
bodies, and papillae with sensory hairs which resemble similar structures on
Phymosoma varians. Retractor muscles arise from the longitudinal muscles of the
skin, and are inserted into the pharynx; they are short and not constant in number.

The nervous system has retained throughout its primitive connexion with the
epidermis. In almost all animals the nervous system is formed from the epiblast or
outermost cellular layer of the embryo; it usually, however, breaks away from this
and sinks into the body. Thus in Sipunculus it lies within the body-cavity, and has
retained its primitive connexion with the outer layers of the skin only in the region of
the brain; but in the Priapulids the nervous system, which consists of a ring round
the mouth and of a ventral cord, lies embedded in the skin, and the nerve cells are
directly continuous with the cells of the epidermis. The nerve-ring lies at the base of
a groove in the skin, which forms a kind of gutter round the mouth; the ventral
nerve-cord is visible exteriorly as a light line which marks the ventral surface of the
animal. In no place is the ring or cord differentiated in any way, and there cannot be
said to be any brain or special sense-organs. Numerous nerves are given off from
the ring to the pharynx and intestine, and from the cord to the body-wall.

Fig. 218.—Priapulus caudatus Lam. Nat. size. a, Mouth surrounded by spines.

The sexes are distinct, but they differ from the other Gephyrea in the nature of their
reproductive organs. In mature specimens the ovaries or testes are easily
recognisable, lying to the right and left of the alimentary canal. The reproductive
glands are continuous with ducts, which act as oviducts and vasa deferentia
respectively. Both glands and ducts are attached to the body-wall by a mesentery.

The excretory function is performed in the Priapuloidea by the ducts of the

generative organs. These are primarily connected with a number of branching
canals of small size which project into the body-cavity. According to Schauinsland,
[485] one or more pear-shaped cells are found at the end of each branch, and each
is continued into a long cilium which hangs down into the lumen of the canal, and by
its movement produces a flickering motion. Beyond the free end of the large cilium
the canal is lined with ciliated cells. The remarkable resemblance this form of
excretory organ presents to that of the Platyhelminthes (vide p. 25) and of certain
Chaetopods is worthy of attention. In the young Priapuloidea the duct with its
branching canals is not masked by the generative organs, but as the animals
become mature, diverticula from the duct arise, and the cells covering these
become modified into ova in the female, and into spermatozoa in the male. The
presence of these follicles masks the excretory part of the gland. The ova and
spermatozoa escape through the ciliated ducts which open to the exterior one on
each side of the anus, and, contrary to what is the case with other Gephyrea, leave
the body without having ever been in the body-cavity.

Nothing is known of the embryology of either member of this family, but both genera
appear to be sexually mature from the end of May until October.

Classification.—The two genera which make up the Order Priapuloidea are

characterised as follows:—

Priapulus.—The body is continued into one or two caudal appendages, beset with
hollow papillae; these are ventral to the anus. The introvert forms ¼ to ⅓ of the total
body-length; it is covered with spines in conspicuous longitudinal rows, the rest of
the body being ringed. The retractor muscles are numerous, and are attached to the
body-wall, some anteriorly and some posteriorly.

The genus includes the following five species:—

P. caudatus Lam. (Fig. 218). Hab. Coasts of Greenland, Norway, Great Britain,
the North Sea, and the Baltic.

P. bicaudatus Dan. Hab. North Sea and Arctic Ocean.

P. glandifer Ehlers. Hab. Coast of Greenland, North Sea.