Professional Documents
Culture Documents
eritus Editars
S, FRCOG (LOND)
edor Professor and Head,
bstetrics and Gynaecology
ge Medica l College, New Delhi
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Shaw's Textbook of Gynecology, 17e, Sunesh Kumar, VG Padubidri, and Shirish N Daftary
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Sevemeenth Edition of this popular book "Shaw's Textbook of helping me reviewing the text, video recording and collect-
O)"wecology" is in your hands. Writing prefuce tO this new ing photographs. P•·ofessor San deep Mathur of Pat110logy at
edition brings me t11e nosta lgic memo•) ' of my studem days AIIMS, New Delhi pr-ovided excellent coloured photomicro-
when all t11e studenlS read t11is book and when each word graphs.
wriuen in the book was like a statemem from experLS. Last l do not have enough words to express my t11anks to my
sixty years since first edition of t11e book has seen lot secreta•)', Ms. Sapna Gulati for doing w•·iting, editing and
of adva nceme nt in t11c speciali ty of gynaecology. fVF and correction work in t11e textbook in a p rofessio nal manne1·.
Endoscopic sw·ge•y arc two ve•) ' im porta nt advances which Special thanks are due to Ms. Shi va ni Pal and Ms. Sheenam
has made speciali ty of gynaecology challe nging with a Agarwal of Elsevier Ind ia for their pa ti e nce and persistence.
bright fullt re. Reali zing ex tre me hardshi p faced by students befo re
I have made best effo rLS to update most of th e topics. final examinatio ns a new secti on of Audi o-vis ual presenta-
Such a n e ndeavo ur was possible o nly wit11 ac tive support tion o n important topics has bee n added.
of Ill)' colleagues, reside nts and other staff. My special Do se nd )'Our comm ents fo r im provingfuu.tre p ublications.
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 Smush Kwrwr
VI
Preface to the 16th Edition
\>\'e, the editors of Huwkins and Bounu Shaw's Textbook of A website of the book has been created for more infor-
OynaecolQ(Jj) are pleased to acknowledge that this book has mation on tlle su~ect in the form of video clips, online
continued tO provide basic foundation of this speciality testing and MCQs for enu-ance tests and tile latest updates
since 1936. Keeping in view of the popularity of the book, on tlle subject.
tl1e first Lndian edition ( I 0'" edition) was published in We owe our special thanks to the entire staff of Elsevier
1989. Since then, tl1e book has been updated ft·om time to for tl1eir wholeheaned support and en couragement. We will
tim e in tl1e ligh t of the adva nces made in tl1is speciality. fail in o ur duty if we did not make a special reference lO
T he 15th editio n was revised in 20 10. O ur comm itm en t to Shabina Nasim with whom we interact o n a daily basis and
tl1 e swd enLS to improve a nd upda te the quali ty of th e also Re nu Rawa L. We appreciate their p rofessional atti tude
boo k, and provide th e m wi tl1 th e adva nced kn owledge and the ir knowledge towards th e prqjec t, tl1e ir effi cie ncy
p ro mp ted us to b ri ng o ut the 16'" ed ition. and enorm o us patience to bring o ut the best for th is
Ln tl1 is editio n, not o nly we have added the latest knowl- p roject.
edge o n tl1e subject, but also inse n ed mo re illustra tio ns, Ou r veqr special tlHt nks and gra tiu.tde go lO Mr YR
flowc harts and tab les to make the read ing easie r and under- Chadh a, Pub lis hi ng Cons ult.'llll, Bl Ch urchill Livingsto ne,
standable. We have added mo re MRI, CT, and man y other New Delhi, who in itiated and gu ided us in tile Firs t Indian
illusu<~tions wherever req uired. Edition in 1989, witho ut whose pers uasion and enco umge-
Considering the high associated morbid ity and mortali ty ment tl1is book wo uld not have seen tile day. There
of gynaecological malignancies, we have approached the are many others who have worked behind tile scene, we
topic of genital tract cancers more exhaustively in tl1is edi- acknowledge our thanks to them.
tion. Emphasis has also been laid on the gynaecological prob- Last. but not ti1e least, we thank our readers and tl1e
lems amongst adolescents and menopausal women. Minimal student communiL) for their unstinted suppon over
invasive surgel} for the benign conditions is now being re- the last 25 ) ears.
placed b) non-surgical tl1emp) such as M RI~uided ablative
tllerapy without the need for hospitaliation. Hopefully ti1ese VG Padubidri
procedures willwrn safe and effective in near future. Shirish N Dajlary
VII
Preface to the 1Oth Edition
Ever since SltaiU~ Ttxtbook of C,•IWI'COiog)• a ppeared in Lhe been incorporated. In additi on , the latest metl1ods of birtlt
United Kingdom in 1936, it has maintained iLS popularity control and a separate chapter on Medical Tennination of
with teachers, exa miners and th e student community. Pregnancy have been added to equip our studenLS wilh Lhe
ll has gone through several editions. The nimh edit.ion, knowledge re qui•·ed to pr·o mote India's fa mil y welfare pro-
edited by Dr J ohn Howkins and Dr Gordon Bourne, was gramme.
brought out in 197 1, and its populat·ity in India has We have also tded to make tlte text more concise by
remained undiminished. It is th erefo re timely and oppor- deleting informati o n that we fell was unnecessa ry for tl1e
tune tha t this standa rd textbook should be revised by Indian undergradua te stude nt, witl10ut substamiall y chang-
Indian teachers of gynaecology to meet th e requirements ing the original style.
of o ur unde rgraduate stude nts. We consider o urselves We are indebted to Mr YR Chad ha, Publis hing Director
fortunate for having bee n assigned thi s challe nging task b)' of Bl Churchill Li vingsto ne, New Delhi for his constant e n-
th e publishers. couragement and inva luable suggesti ons in tl1 e preparation
In revising tl1 e boo k we have e ndeavoured to upda te the of tl1 is edition. Since re thanks are exte nded to Ch urchill
comenLS to include new metJ1ods of investigations and treat- Livingstone, Edinburgh, fo r Lheir assistance in making this
me nt. In particu lat~ recent advances in tlte physiology of edition possible.
me nsu·uatio n and iLS hormonal co ntrol, carcinoma of the
cervix and related preve nLive meas ures, e ndo meuiosis, and VG P(Ulubidri
tlte management of wbe rculosis o f the genital u·act have Shirish N Daftary•
VIII
Table of Content
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
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
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 3. Justice: T his is r en th e ph ysician ma kes
wo man and logos mea ns discou rse) pe11_ains tO th e diseases access LO care, · re, the a ttention provided
of women and is ge nerally llsed for disea es re laLed LO the and t.h e cost to the needs of the paLiem .
fe male gen iLal organs. 4. Avoiding · · dern Lim es, it is imporLant LO
Th e interac ti on of a p ati ent with a p hysician can ofte n be avoid in eatm em which may lead to p os-
an a nxi ety-produ cing event, p articul arly so in Lhe prac ti ce sible - · . For a d eLailed desc riptio n it is
of gynaecology because of t he sensitive naLure of th e p rob- a . oipt.i onsgiven by Ley P, Lipkin Mjt~
le ms tha Lneed LO be disc ussed; he nce, th e o bserva nce of the man R, Lewan M, Todd AD, Fish er S.
hig hes t standards of e thical and profession al be haviow· is
J-Sical examination constitute the ftmda men-
req uired to establish rapport, while no L creaLing a host.li e
h rest th e tentaLive diagn osis, the tests to be
enviro nm enL in which Lhe p aLi em fee ls embarrassed or t in-
and th e treatm em to be recommended (Table 1.1 ).
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. 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.
1. Privacy and respect: Nowadays, co unsel-ling on s an lnvestigaLio n are ma de LO confi rm the di agnosis a nd for
importa nL aspec t of consul tat.i o n. T he th e fo ll ow-up of u·eatm enL
aeco logical ail ment, reason fo r a lt L~ advisable LO ask Lhe pati ent to desc ribe h e r main com-
a nd iLS predi ct.i ve va lHe h ould b ms plainL in her ovm words and take her own Lime narrating the
sion on treatme nt options witif h ir d eritS a nd m er- evo lution of the problem, the aggravating and re lieving fac tors
its will enable a wo ma n tO lOOS 1.h e treatment she and the investigations and treatment she has already 1.mder-
co ns iders besL for he1: The gy 1 co logist sh o11ld, h ow- gone. Good and patie m listening is essenti al to obtain maxi-
ever, guide her in ma king th e right decision. T he clini- mum coop eraLion during th e sub.sequem pelvic examination.
cia n mu.st respect the pa ti em as an individual. Re me m- Hist0ry begin with th e recording of th e basic informa-
be r tha t th e pati e m has th e righL LO make dec ision tio n abo uL t11 e paLient as sh own in the samp le p roforma in
abo ut h er health care. lt is n ot eLhi cally or m orally right Table 1.1.
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 PRESENT ILLNESS
should be prop erly main tain ed and th e doc umen rs T h e clini cian must record th e patie m ' co mplainrs in th e
should be preserved. T h e pa tie nt should fee l assured at sequence in whi ch Lhey occ urred , no t.ing Lhe ir dura ti o n,
a ll tim es a bout ' privacy and confidenti ali L)" . Talkin g th eir aggravating a nd relieving fa ctors and th e ir relati o n to
sofLly a nd pa t.i e ntly lisLening are of a great help . m enstruation , micturiti on a nd defecati on. T he investiga-
2. Beneficence: The medical aLLendant must be vi gil ant tions pe rform ed and th e resp o nse to treatm ent given so far
LO ensure that th e thera peutic advi ce re ndered to Lhe sh ould be noLed.
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-
PAST AND PERSONAL HISTORY
ated on the basis of th e principle of the cosL/ benefit Pas Lm edical and surgica l p roblems may have a bearing o n
ra ti o acc ruing out of th e m edical advice given. th e present complaints. For example, a history of di abetes
2 SHAW'S TEXTBOOK OF GYN AECOLOGY
occur as a resu lt of raised inu·aabdomina l pressure and is pubic hair is distributed in an inverted u·iangle, with the
observed with large wmours, ascites and pregnancy. The base cenu·ed over the mons pubis. The extension of the hair
mobility of the abdominal wall with breathing should be line upwards in tl1e midline along t11 e linea nigra up to tl1e
observed carefully. In case of an intraabdominal tLLmOLLr, tunbilictLS is seen in about 25% of women, especially in
the abdominal wall moves over the tumour during breath- women who are hirsute or mild!) androgenic as in PCOD.
ing so that its upper margin is appare ntly altered. ln case of Witl1 the patient in lithotOm) and he r thighs well paned,
pelvic pe •·ito n iLis. t11 e movements of t11 e lower abdomen note t11e variolLS su·ucwres of th e vulva. Look for the
below the umbilicus are ofte n restricted. The presence of presence of an) discharge or blood. Ask the patient to bear
striae is seen in parous women, pregnam women, in obese down and obsen•e for any p•·oU'LLSion due tO pol) p or genital
suqjects and in women harbouring large tumours. descent such as cystocele, rectocele, ute•·ine descent or
procidentia. Separate t11e labia wide apart and examine
PALPATION the fourcheue to see whether it is intact or reveals an old
'•\lith the clinician standing on the •ight side of tl1e patient, healed tear.
it is desirable LO palpate t11e liver, spleen and kidneys ,,;th the
right hand, and LO use t11e sensitive ulnar border of the left SPECULUM EXAMINATION
hand from above downwards to palpate swellings a•·ising Speculum examination should ideall y precede bimanual
from the pelvis. The upper and lateral margins of such swell- vaginal examination especiall y when the Papanicolaou
ings can be felt, but t11 e lower border ca nnot be reached. ( Pap) smear and vaginal smear need to be taken.
Myo mas feel firm and have a smooth surface, unless they A bivalve self-retaining spec ulum such as CtL~co's spec ulum
are mu ltip le, whe n tile)' present a bossed surface. Ovarian is ideal for an office exa mination (Figs 1.1 and 1.2). It allows
neop lasms often feel cysti c, and may be flucwant. T he upper satisfactory inspection of t11e ce rvix, ta king of a Pap smear,
margin oftheseswelli ngs is often we ll fe lt, unless the swelli ng colleCLion of the vaginal discharge from t11e posterior fornix
is too large. The pregnant uterus fee l~ soft and is known to for hanging drop/KOI I smear and colposcopic examination.
harden intermiuen tly during th e Brax to n Hicks contrac- Sims' vagina l spec ulum (Fig. 1.3) wi tl1 an anterior vagi-
tion s; this is characte•istic of pregnanC)'· The fu ll b ladder nal wa ll retractor can be used for the above examination. lt
bulges in tl1e lower abdomen and feel5 tense and tende1: permits an assessment of Lhe vaginal wall for cystocele and
£xu·eme tenderness on palpation below the umbi lict.LS is sug- rectocele. However, an assistant is required to help the clini-
gestive of peritoneal irrit.ation , seen in women witl1 ectOpic cian dttring this examination and t11e woman needs to be
pregnancy, PLD, twisted ovarian cyst, a mptured corpLLS lu- brought to tl1e edge of the table. Stress-incontinence sho uld
tewn haemaLOma or red degeneration in a fibroid often as- be looked for especiall) in t11e presence of vaginal prolapse.
sociated wilh pregnanC). In women witl1 an acute smgical ln tl1is case. tl1e patient is e xamined with a full bladder.
condition. guarding in th e lower abdomen and •igidity on
attempting deep palpation a re noted.
BIMANUAL EXAMINATION
PERCUSSION After separating the labia \\ith t11e tluunb and index fingers
Ute•·ine m)•omas a nd ova•·ian C)SLS are dull tO percussion, of the left hand, two fingers of the •ight hand (index and
but the flanks a•·e resonanL Dullness in t11e flanks and shift- forefinger), after lubrication, are gradually introduced
ing dullness indicate t11e presence of a free fluid in the be)ond the introitus to reach the fornices. If the fingers
peritoneal cavity. Ascites may be associated with tuberculous encounter tl1e anterior lip of the ce•vix first, it denotes the
peritonitis, malignancy or pseuclo-Meig S)'ndrome. cervix is pointing dowmvards and back tOwards tl1e poste-
rior vaginal wall, and that t11e uterus is in tl1e antevened
AUSCULTATION position, conve•'Sely whe n t11e posterior li p of tl1e cervi.x is
This reveals peristalti c bowel sounds, fetal heart sounds in encountered fi1'S4 it is indicative of a retroverted uterus.
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
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
Figure 1.6 Bimanual exam ination in the case of an ovarian cyst. The a well-lubricated proctoscope to inspect the rec wm and
nature of the tumour is determined on bimanual examination because
anal canal helps to complete the examination. Ulu·asound
the uterus can be Identified apart from the abdominal tumour. Com pare
nowada)'S has reduced ll1e importance of rect.al exa mination
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
except in cancer of the cervix and pelvic endomeu·iosis.
the abdominal tumour are clearly not transmitted to the cervix.
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 )
Preoperative investigaLions are described in the chapter women older than 2 1 years should undergo an ann ual
on preoperative and posLOperative care. Special investiga- check-up witl1 three yearly Pap test. Aside from premalig-
tions are discussed as follows. nant and malignant changes, otJ1er local conditions can
Special investigations: oft.en be recognized b) the cytologist. The Pap smear is
only a screening test. Positive test (abnormal cells) requires
• Special tests such as LUmour markers: CA-125 in sus- further investigations such as colposcop)'• cervical biopsy
pected adenocarcinoma of the ovary; carcinoembryonic and fractional curettage. Unfonunately, the Pap test cru1
amigen (Cf.A), oc-fetoproteins and ~hCG in suspected detect on I> about60%-70% of precancer and cance•· of the
ov;uian teratoma and other germ cell tumours of ovary. cen~x and less than 70% of endomeu·ial cance•: Reliability
• Bacterial examinations of th e genital tract. These include of the repon depends on the slide preparation and tl1e skiU
the following: (a) examination of the vaginal dischru-ge of the C) LOiogist. Although a single test yields as much as
for trichomoniasis; (b) 10% KO H-treated smear for de- 10%-15% false-negathe reading, it is reduced to only 1%
tecting candida; (c) I% b•illian t creS)'I violet for staining with repeated tests. A false-positive finding is reponed in
trichomonad, but not the other bacte•ia and leucocytes; the presence of infection. A yearly negative Pap sme;u· for
(d) platinum loop for collection of discha•·ge (in sus- 3 years is assuring, and thereafter 5-yearly test is adequate.
pected gonon·hoea) from the urethra, ducts of Bartholin Th e Pap smear should be obtained before vaginal
and the endocervical secretio n fo r cul tu re on chocolate examination, because the nngers may remove tl1 e desqua-
aga•~ (e) immunofluo rescent examination of the dis- mated cervical cells and give a false-negative repo rt, lubri-
charge of endocervical cells for suspected chl amydia! ca m may prevent de tec ti o n of orga nisms a nd a ny vaginal
infec tion; and (f) mi croscopic exa minati on of the clue bleedin g during exa min atio n may preclude a prope r visu-
cells for diagnosis of bacte rial vaginosis (Chapter 9) . 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
Feinberg-Whi tti ngton mediu m is used for u·icho mo nad time to do Pap smear is a ro und ov ulatio n, b ut any other
and Nickerson-Sabouraud for candiasis. T he presence of time can a lso do. T he patient is placed in th e do rsal posi-
cl ue cells ind icates bacte•ial vaginosis. tion, with the lab ia parted, and Cusco's self- retaining
Pol>•merase chain reacLion (PC R) staining has been spec ulu m is gemly introd uced witho ut the use of lubrican t
extensively utilized in the diagnosi.~ of various infections. or jelly. The cervix is exposed; the sq uamoco lu mnar ju nc-
tion is now scraped with Ayre's spatula by rotating tl1e
SPECIAL TESTS spatula all around (Fig. 1.8 0). The scrapings are evenly
spread onto a glass slide and immediately fixed by dipping
HANGING DROP PREPARATION the slide in the jar containing equal parts of 95% ethyl
ln women complaining leucon·hoea, the discharge collected alcohol and ether. After fixing it for 30 minutes, the slide
from the postel'ior fornix on the blade of the speculum is air-d•;ed and stained with Pap or shon stain. The slide is
should be suspended in saline and submitted to microscopic considered satisfact011, if endocen'ical cells are seen. To
ex;unination. ormal 'oaginal discharge shows the presence improve the predictive valve, endocen'ix is also scraped
of exfoliated 'oaginal epithelial cells and the presence of with a brush and added to the slide. owadays, a fixative
large rod-like lacLObacilli known as Doderlein's bacilli. A spray (cytospray) is a\oailable and can be used conveniently
fresh suspension of the discharge may reveal the motile flag- in an office set-up. For honnonal cytological evaluation,
ellated o•-ganisms known as TridwmQIWS vagina.l.is. Another the scrapings are taken from the upper lateral pan of the
common cause of \'llginal infection is fungal infection or vaginal walls; tlwee types of cells are found in the normal
vll{,riual cmulidir~:>i:>, this can also be detected f•·om a micro- smear: (i) the basal and pa•-abasal cells are small, •·otmded
scopic examination of the vaginal discharge. To the suspen- and basophilic wi th la •-ge nuclei; (ii) the cells from th e
sion of the vaginal discharge, add an eq ua l amount of 10% mi ddle layer are squamous cells, tra nsparent a nd baso-
KOH soluti on. Place a drop of the mi xtu re o n a slide, cover philic witl1 vesicular nuclei; a nd (iii) th e cells from th e
it with a cover sli p, wa nn the slide and exa mine it under the s uperficial la>•e •· are acidop hilic with charac teris ti c p yk-
low power of the microscope. T he KO H dissolves all cellular noti c nuc lei. ln add ition, endome tri al cells, histiocytes,
debris, leaving be hi nd the mo re resista nt yeast-like organ- blood cells a nd bacteri a ca n be seen . Malignant cells a re
isms. Typical h)•p hae o r m>•celia and b udding spores can hyperc hro ma ti c with a great increase in c hro matin co n-
be easil)' detec ted. Many C<'lses of vagi nitis are attrib uted to te nt. Th e n uclei va11' in size a nd th e re is usua lly o nly a
bacterial Vll{,rim},)i~ (nonspecific vaginiLis); also known as s ma ll amo unt of C)'top lasm in the un d iffe re miatecl malig-
Garrlnendla voginalil. The vis ua liz.1tion of 'clue cells' seen n am cell (Figs 1.9 and 1.1 0). T he nucle us/cytoplasmic
preferably in a stained smear of the vaginal d isc harge is ratio is increased in malignant cells.
high ly suggestive of the infection. Vaginal infections have Papru1icolaou classincation:
been discussed later in detail in Chapter 9.
Grade l Nonnal cells (Fig. 1.9)
Grade ll Slightl) abnonnal, suggestive of inflamma-
PAPANICOLAOU TEST
tOI") change; repeat smear after treating
Screening for Cancer tl1e infection
First described b) Papanicolaou and Traut in 1943, this Grade Ill A more se•ious t} pe of abnonnality, usu-
screening test is often •·efen·ed to as the 'Pap test' or a sur- all> indicative of the need for biopsy
fuce biopsy or exfoliative C) tology (C) to logy is a Greek Grade IV Distinctly abnonnal, possibly malignruu
word, meaning swdy of cells). It forms a pan of the routine and dennitely requi•·ing biopsy
gynaecological examination in women. All sexually active 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 oestrogen defici e ncy, a 10-day co urse of oestrogen cream
smears as follows: 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
1. Normal cyto logy samp le because of sca rring and atrop hy of th e vagina.
2. lnflam ma tOr)' smea r T he cells are often e n larged, vacuo lated with mu ltip le
3. Cervical inu·aepitJle lial neoplasia (CLN l) or mi ld dysplasia nucleation and nuc lea r wrinkling. InflammatOry cells
4. Cl N ll, Ill and carcinoma in situ nuclear abno rma lities ma)' be present (Tab le 1.5 ).
5. MalignanL cells and tadpole ce ll~ wiLit nuclear abnor- Liquid-ba~ed C)>
tology us ing a thin preparation is s upe-
ma lities rior to Pap smear (Fig. I. II ). T he liq uid is used to screen
lt is reasonable LO e nquire abo ut the percentage of for papilloma virus. Cervical ca ncer screening is described
Lmsuspected cancers, including carc inoma in situ, that in Fig. 1.12. This is described in detail in Chapter 33.
are likely to be diagnosed on routine cytology. The In- Outer metJ1ocls of cervical screening are also described in
dian Council of Medical Researc h (LCMR). ew Delhi, Chapter 33.
screened the population of women o lder L11an 30 years
and found 5-15 smears to be abnormal per 1000 women VISUAL INSPECTION AFTER ACETIC ACID APPLICATION
examined. The incidence of d)Splasia reponed at Llle All (VIA)
india l nsliune of Medical Sciences, ew Delhi, was Gross inspection of cen·ix after application of 3% or 5%
16/ 1000 patients screened. In a posunenopausal woman, acetic acid for I minute helps in detecting acetowhite area
if the squamocolumnar junction is indrawn due to which may harbour Cl / neoplasia.
CHAPTER 1 - APPROACH TO A GYNAECOLOGICAL PATIENT 9
II
Ill M ild LS IL
IV Moderate II HSIL
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- Figure 1.13 Hi stology of proliferative phase. (Courtesy: Dr Sandeep
mone in the system at that Li me. The oestrogen-dominated Mathur, AIIMS.)
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 be sa ti sfactory for obta ining adeq uaLe sa mp les. lL can be
cells. During p regnancy, t11e cytology smea r shows interme- uti lized as an office p roced ure; abo ut 90% acc uracy with no
diate cells and navic ul ar cells. After Lhe menopause due to false-positi ve findings is cla imed with this proced ure .
tlte deficiency of u1e ova ri an ho rmo nes, tlte vaginal mucosa
tltins down and Ule exfo liated cells are predominantly para-
COLPOSCOPY
basal and basal t)•pes. In human papilloma virus (HPV)
infection, one can recognize ko ilocyLes with perinuclear T he colposcope is a b inocular microscope giving a 10-
halo and peripheral conde nsatio n of cytoplasm. The 20 times magnificatio n. It is useful in loca ting abnorma l
nucleus is irregular and hype rchroma tic (Fig. 1.10). areas and accurately obtaining directed biopsy from tlte
suspicious areas on the cervix and vagina in women witlt
Karyopyknotic Index or KPI (Maturation Index) positive Pap smears. This wa> the frequency of false-negative
11. is u1e ratio of mature squamous cells over tl1e imennedi- biopsy is reduced. so also the need for con iLaLio n, a proce-
aLe and basal cells. It is more tl1an 25% in proliferative dure Lhat is accompanied witJ1 considerable amoum of
(oes u·ogenic) phase (Fig. 1.1 3) and low in secrewry bleeding and morbid it) (Chapter 18).
(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
ENDOMETRIAL BIOPSY (Fig. 1.14A and B)
is reached on Ute day of ovulation (2 days after serum An office or outpatient procedure was aLone Lime very popu-
E..! peak). 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
UTERINE ASPIRATION CYTOLOGY
endometrial lining for histopat11ological examination, sene-
Perimenopausal a nd posu11enopa usal women on a h or- tory endomeuium denotes ovulaLOry cycle. Witlt t11e avail-
mone therapy are now being screened for endometYial abili ty of uluasoamd, a noninvasive method for tlte detection
cancer. T he uterine aspiration syainge o r brush is fo und to 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 11
OTHER IMAGING MODALITIES I. List t11e simple steps in history taking of a gynaecological
patient.
Radiological investigation such as h)SterosalpingQgJ-aphy is 2. Describe the imponance of Pap smears in clinical practice.
utilited for stud)ing the patency of the fallopian tubes in an 3. WhaL is t11e role of imaging and endoscopy in the clinical
infertile patient. CT scan and MRI are advanced investiga· practice of gynaecolom•?
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 SUGGESTED READING
poi)'P is suspected. 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;
GYNAECOLOGICAL ENDOSCOPY 1287-306.
SirnpM>n M , Buck1nan R. Ste,.lart ~·f, ct al. Doctor paticnl communica-
Botlt diagnostic laparoscopy and hysteroscopy are estab Ushed tion. ThcTor<>nto consensus statcrnem. B:.tj 1991; 30!l: 1386-7.
use ful tools in the armamentarium of t11e gynaecologist. For Todd AD, Fi>hcr S. The Social Orgdnir.ation of Doctor-P:otienL Com-
details, refer to Chapter 41 (Endoscop) in Gynaecology). munication, 2nd ed. ~onvood, ~- Ablex Publi>hing, 199!l; 243-65.
ANATOMY, PHYSIOLOGY
AND DEVELOPMENT OF FEMALE
REPRODUCTIVE ORGANS
12
Anatomy of Female
Genital Tract
Uterus
Ovary
Rgure 2.1 General view of internal genital organs showing t he
normal uterus and ovaries.
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
in width. Clitoris o f more than 3.5 on in le ngth and I em The ve~tibule is the space I) ing be twee n the anterio r and
in width is called clitoro megaly, and occurs in virilism due to the inner aspects of the labia minora a nd is bounded poste-
excess o f androge n ho nno ne. The clitoris is well supplied rioliy by the vaginal in troitus. The I'Xf t'rrUllurintt ')' 11U!lt iLIS iies
with nerve endings and is e xu·emely sensitive . Dlll·ing coiLUs, immediatel) posterio r to the clito •is. The vaginal orifice lies
it becomes e rect a nd pla)S a conside rable pan in inducing poste,;or to th e meatus and is surrounded by the hp nen.
orgasm in the female. The clito•·is is highl)' vascular. An in- In virgins, the h)lne n is re p•-esellled b)• a thin membra ne
jury to the clitoris causes profuse bleeding and can be very cove red o n each surface by sq uamous e pithelium. It gener-
painful. a lly has a small eccenu·ic opening, which is usua lly not wide
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 15
enough to admit the fin gertip. Coitus resul ts in the rupture u·ansitional and finally squamo us near tl1e mouth oftl1e d uct.
of tl1e hymen; the resulting lace rations are radially arranged The function of tl1e gland is to sec rete lubricating mucous
and are multiple. Occasionally, coital n.apwre can cause a dwing coitus. The labia majora j o in at the posterior commis-
brisk hae mo rrhage. During childbirtll, further lacerations Sttre and merge imperceptibl) into tl1e peainea.un.
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- THE VAGINA
tal")' tampons, the loss of in tegait) of tlle hpnen is no longer
an evide nce of loss of virginity. The vagina is a fibronnLSCular passage mat connects tl1e
The ' 'ulval tissues respond to ho nn ones, especially oestrO- Lllerus to me introitLLS. The lower end of the vagina lies at
gen , during m e childbeaa·ing)ears. After menopause, auophy the level of the h) men a nd of the inu·oitus \'llginae. It is sur-
due to oestrogen deficiency m akes me vulval skin tl1inner and rounded at tllis point by tl1e erectile tissue of tl1e bulb, which
drier, and this m ay lead to atrophi c '~alvitis and itching. Mons corresponds to tl1e corpus spongiosum of the male. The
jJUbiJ is an at·ea which overl aps the symphysis pubis and con- direction of the \':!gina is approxim ately parallel tO me
tains f.n. At puberty, abundant hair grow over it. 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
BARTHOLIN'S GlAND cali bre, being nea rly twi ce as capacious in i t.~ upper part and
Bartl1oli n 's gland li es posterolaterall y in relatio n to the vagi nal somewhat flask shaped. T he vaginal ponio n of the cervix
otifice, deep to the b ul bospongiosus m uscle and supe rficial to projects into its upper e nd and leads to the fo rma tio n of th e
tl1e o uter layer of tJ1e u·iangu lar ligament. It is e mbedded anterio •~ poste ri or and latera l forn ices. T he dep th of th e
in the erec til e tissue of tJ1e vestib ular b ulb at its posterior forn ices depends upon the deve lopmen t of the portio vagi-
ex u·em it)'· It is norma lly impa lpable when healtl1y, but can be na lis of the cervix. In girls before pube r1.)' and in e lderly
readil)' palpated be twee n the finger and the tl1U mb when women in whom the ute nts has undergone postmenopausal
en larged b)' inflammation. Its vascu lar bed accounts for me atroph)', me fornices are shallow whe reas in women wim
brisk bleeding, which always accompan ies its removal. Its congenital elongation of the portio vaginalis of tl1e cervix,
duct passes forwards and inwards to open, external to the the fornices are deep. The vagina is attached to the cervix
hymen, on tl1e inne r side of the labium minus. The gland at a higher leve l posteriorly than elsewhere, and this makes
measures about 10 mm in di.'lmeter and lies near tllejunction the posterior fornix the deepest o f the fo rnices and tl1e
of the middle and posterior thirds of tlle labium majus. The posterior \':!gina! wall lo nger than tl1e anterio r. The poste-
duct of the gland is about 25 mm lo ng and a min mucous rior wall is 4.5 inch ( 11.5 em) lo ng, whereas Ll1e antet;or
secretio n can be expressed from it by pressure upon me wall measures 3.5 in ch (9 em). Transve rse folds which are
gland. Barth olin's gland and its duct are infected in acute present in m e \'3ginal walls of nulliparae a llow the \':!gi na to
gonorrhoea, when the a·eddened mo urn of the duct can easily stretch and dilate during coitLLS and pat1.ut·itio n. These folds
be disti nguished on tl1e inner surface of m e labiwn minus to are pa 11.ly o bliterated in women who have bome ma ny
one side of tl1e vaginal o aifice below the level of tl1e hpnen. children. In the a nteri or \':lgi nal wall, tllree sulci caa1 be
Bat·tllolin's gland is a compound racemose gland and its acini disting uished. One lies immediately above the meatus aa1d
are lined by low columnar epitllelium (Fig. 2.50 ) . The epi- is called ~ubmeaJal>ulctl> ( Fig. 2.6). About 35 mm above this
theliwn of the duct is cubical near the acini, but becomes
Rgure 2.5 Bartholin's gland. Low-power view showing the structure Rgure 2.6 A case of prolapse In which the cervix has been drawn
of a oompound racemose gland with acini lined by low columnar down. Parameatal recess, hymen, submeatal sulcus, paraurethral
epithelium (x92). recess, oblique vaginal fold , transverse sulcus of the anterior vaginal
0 Scan to play Barthol in's abscess 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 vasc ular and contains much erectile tissue. A muscle
as the transver:.e vaginal sulws, which corresponds approxi- layer consisting of a complex interlac ing lattice of plain
mately to the junction of the urethra and the bladder. muscle lies external to the subepithelial layer, whereas
fLLrtller upwards is tl1e bltuhkr sulcus, indicating tl1e junction the large vessels lie in the connective tissues surrounding
of tl1e bladder to tl1e an tetior vaginal wall. the vagina. If the female fews is exposed LO diethylstil-
The vaginal mucosa is lined by nonkeratized squamous boestrol (DES) taken b) the mother during pregnancy,
epithelium which consists of a basal layer of cuboidal cells, columnar epithelium appears in the upper two-thirds of
a middle la)er of prickle cells and a superficial layer of vaginal mucosa, which can develop vaginal adenosis
comified cells (Fig. 2. 7). In the newborn, the epitheliwn and vaginal cancer during adolescence. The keratiniza-
is almost transitional in t)pe and cornified cells are scanty tion of vaginal mucosa occurs in prolapse due to the
until puberty is reached. No glands open into the vagina, exposure of vagina to the outside and ulcer may form
and the \'3ginal secretion is derived partly from tl1e mu- over the \'3ginal mucosa (decubitus ulcer). The keratized
cous discharge of the ce•vix and partly from transudation mucosa appears skin-like and brown. Menopause causes
through tl1e vaginal epithelium. The subepithelial layer is 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-
Epithelium 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,
Submucous Schiller's test becomes negative.
la~r
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
Smooth muscle
(inner circular
basal cells with a thi n vagina l mucosa.
and outer T he abno•mal and malignant cells also do no t con tain
longitudinal) 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.
- } External
--~ -~ ~-::::::=:- fibrous layer
:::g~ -- -- ~ (endopelvic RELATIONS OF VAGINA
--=---~-= -==-~--- tascia)
ANTERIOR RELATION
Rgure 2. 7 (A) Low-power {X36) microscopic appea-ance of the
vaginal wall showing the corrugated squamous epithelium and In its lower half. the vagina is close!) related tO tl1e urethra
bundles of plain muscle cells subjacent to the vascular subepithelial and the paraurethral glands {Skene's wbules), so closely in
layer. (B) Structure of the vaginal wall. (Courtesy for (A): Dr Sardeep faCL tl1at the urethr0\'3ginal fascia is a fused struCLure and
Mathur, AJIMS.) only separable by a sharp dissection. In its upper half, tl1e
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 17
vagina is related to the b ladder in the region of the u·igone, tissue in the urete ric ca na l and is abou t 12 mm anterolat-
and here the vesical and vaginal fasc iae are easily separable eral to the lateral fo rnix.
by a blunt dissection via the vesicovaginal space. There is a
considerable vasc ular and lymph atic imercommunication SUPERIOR RELATIONS
between the vesical and the vaginal vessels, a sinister rela- 1l1e cervix with its four fornices - amerior, posterior and
tionship having a bearing on Lhe surgery of a malignam two lateral- are related to tl1 e uLerine vessels, Mackenrodt's
disease of Lh is area. ligament and the ~.u·e ter. PosLe•io rl), surrounding the pouch
of Douglas lie the uterosacral ligaments which can be identi-
POSTERIOR RELATIONS fied o n vaginal examination, especiall)• if thickened by
The lower third of the \'llgina is re lated 1.0 Lhe perineal disease such as endomeu·iosis and cance r ce rvix.
body, the middle third 1.0 the ampulla of the reCLum Squamocolumnar j unction, also known as u-ansitional
and the upper third to the anterior \\'llll of the pouch of zone, is clinically a ' ery important junction where the squa-
Douglas, which comains la•·ge and small bowel loops. This mous epithelium lining tl1e vagina merges witllthe columnar
partition dividing the vagina from the pe•·itOneal cavity is epithelium of tl1e endocervix and is 1-10 mm (Fig. 2.9) .
tl1e thinnest a•·ea in the whole pe•·itOneal surface and, Here, tl1e constant cellular activiLy of tl1e cells takes place,
tl1erefore, a site of election for poim ing and opening of and the cells are highly sensitive to irritants, mutagens and
pelvic abscess or th e productio n of a h ernia or enterocele. viral agents such as papilloma virtL5 16, 18. T hese agents cause
T his is also an ideal site for colpocem esis in th e d iagn osis nuclear changes tl1at ca n evenLUall y lead tO dysplasia and
of ectOpic pregnancy. carcinoma cervix, which is the most co mmon malignancy of
Pouch of Douglas (Fig. 2.8) is a pe rito neal cul-de-sac in tl1e female geniLal tra ct in Ind ia. Squamocolumnar junction
the rec tovaginal space in the pelvis. IL is bo unded anterio rl)' is of two types: first one is embryo nic when columnar epithe-
by the peritone um cove rin g the pos te rio r vaginal wall and lium spreads over the exte rna l os. Afte r pube rt)\ metaplasia
posLerio rl )' b)' tl1e peritone um covering the sigmoid colon of colu mnar epitl1e liu m unde r the infl uence of oestroge n
and the recwm. Laterall y, th e uterosacral ligame nts limi t brings sq uamous epitheliu m close to Lhe ex ternal os, thus
its bo undary whereas th e floor is Lhe reflection of the creati ng a u·ansitional zone be twee n the two j unc tions. In
peritoneum o f the pe rito neal cavity. women exposed to DES in utero, tl1is zone is well outside the
The endometriotic nod ules and metasmtic growth of os, spreading over tl1e \'llgi nal vau lt. In a menopausal woman,
an ovarian cance r are fe lt in tl1 e pouch of Douglas, so it gets indrawn inside tlle os. During pregnancy and with oral
also pelvic inflammatOI') mass. The u1.erosacral ligaments conu-aceptives, it pouts o uL of os.
are thickened and become nodular in advanced cancer The squamoco lumnarjunction is well outside me external
cervix. 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
LATERAL RELATIONS changes, in me scree ning programme for ca nce r cervix.
The la1.eral relations f•·om below upwa rds are the cavern- Dw·ing pregnane), tl1e ex1.e m al os becomes patulous and
ous tissue of the vestibule; the supe •·ficia l muscles of the the squamocolumnar junction is well exposed all round.
pe•·ineum; the u·iangu lar liga ment and at about 2.5 em Pap smear> ields the most accu rate C) tological findings.
from the inu·oitus t11 e Je,>aLOr ani, lateral tO which is tl1e ln menopausal women, the cervix sh•·inks and the squa-
ischio•·ectal fossa. Above the levator lies the endopelvic mocolumnar junction gets indrawn into the cervical canal.
cellular tissue, and its condensation , called Mackenrodt's
ligament, on tl1 e either side. The ureter traverses this
Columnar
epithelium
Figure 2.9 Squamocolumnar junction. In the 'ideal' cervix, the
Uterosacral ligament Pouch of Douglas original squamous epithelium abuts the columnar epithelium. (Soun::e:
Figure 2.8 Pouch of Douglas showing uterosacral ligaments as Hacker NF, Ganbone JC, Hobel CJ, Hacker CW'ld Moore's Essentials ot
upper border. Obstetres ard Gynecology, 5th ed Pliladelphia: Elsevier, 201 0.)
18 SHAW'S TEXTBOOK OF GYN AECOLOGY
The cer vix is spind le shaped and measures 2.5 em or a women, the external OS is circ ular b ut vagina l de livery
little more. It is bounded above by the internal os and resul tS in tJ1e transverse slit which characterizes the paro us
below by the external os (Fig. 2. 10). The mucosal lining cervix. The cervix contains more of fibrous tissue and col-
of tJ1e cervix differs from that of the body of tJ1e uterus by lagen than the muscle fibres, which are dispersed scarcely
tJ1e absence of a submucosa. The endocervix is lined by a amongst the fibrous tissue. Cervix contains mainly colla-
single la)er of high columnar ciliated epitJ1elium \vith gen and on I) 10% of muscle fibres. Light microscopic ex-
spindle-shaped nuclei I) ing adjacent to the basement amination reveals 29% muscle fibres in itS upper one-
membrane with abundam C)LOplasm and mucin. The third, IS% in tJ1e middle one-third and only 6% in the
direction of the cilia is downwards towarcls the external lower one-tJ1ird, whereas the body of me utems contains
os. The glan<ls are racemose in t) pe (Fig. 2.llA and B) 70% muscle fibres. The change from fibrous tissue of cer·
and secrete mucus with a high content of fructose glyco- vix to the muscle tissue of the body is quite abrupL ln late
protein, mucopolysaccharide and sodium chlo•·ide. The pregnancy and at tenn, under the influence of prostagla n-
secretion is alkaline and has a p H of 7.8 and itS fructose din, collagenase dissolves collagen into fluid form a nd
contem render·s it atu-active to ascend ing spe•·maLOzoa. renders tJ1e cervix soft and stretchable during labour.
This secretion collectS as a plug in the cervical ca nal an d Functions of the endoce•·vical cell li n ing are as follows:
possibly h inders ascending infections. In gonococcal an d
• T he cilia are directed downwards and prevent ascending
chl amydia! infections of th e ce rvix, tJ1 e orga nisms collect
infection.
amongst t he cryptS of th e cervical glands. In nulli paro us
• 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
- - ·. ,~ .
:c..•·
·· "'..
-.•
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
' between tl1e endomeuium of the body and the mucous
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
Rgure 2.11 (A) Normal endocervical cells. (B) Normal cervical
prope•1.) of progesterone is ttSed in a contraceptive pill a11d
glands. These are of the racemose type and are lined by high co- progesterone-impregnated in u-aute•ine conu-aceptive de-
lumnar epithelium which secretes mucous (X250). (Source tor vice. Sodium chlol'ide coment in the mucous increases at
(B): Seama Khuni, CervtxPremalignCW"It/preinvasive lesions. 2003- ovulation and fonns a fem-like pattern when a drop of mu-
2017, PalhologyOutlines.com, Inc.) cous is dried on a slide and studied under a microscope.
20 SHAW'S TEXTBOOK OF GYN AECOLOGY
Ovary
Recto-uterine
Ligament
fold
of ovary
Recto-uterine
recess
uterus
Posterior part
of fornix
recess
Cervix uteri
Rectal
ampulla
Anal canal
A
Long axis
of the
vagina
Normal
(anteverted,
8 anteflexed) Retroversion
Rgure 2.12 (A) The relationship of the female reproductive organs: sagittal section. (B) Anteverted, anteflexed and retroverted uterus. !Soo~e
tor (A): From Fg 7 1. Chris Brooker· AleXCW)de(s Nursing Practice, 4th Ed. Churchill Uvi'lgstone: Else\4er, 2011 .}
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 21
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 Ovarian
ligaments anteriorly, also pass into the ute•·ine cornua, but fimbria
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
Ovarian ligament White line
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,
R gure 2.13 The right uterine appendages viewed from behind.
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- Table 2.1 Contents of Broad Li gament
siderably in tJ1ickn ess. T hey hypenro phy during pregna ncy.
T he roun d ligaments are much beu er developed in • Fallopian tube - upper portion
multiparae tJ1an in null ipa rae. T hey are most remarkabl)' • Round ligament - anteriorly
h)'peru·ophied in the presence of large fibro ids whe n th ey • Ovari an ligament - posterior fold
may attain a d iameter of I em. T hey correspond deve lop- • Vestigial structures of Wolffian body - epoophoron and
paroophoron
mentally to the gubernac ulu m testis and are morp ho logi-
Vestigial structure of Wolffian duct - Gartner's duct
cally continuous with tJ1e ovarian ligaments, as during Ureter
inu-auterine life the ovarian and round ligaments are con- uterine vessels
tinuoLLS and connect tJ1e lower pole of t11e primitive ovary Pelvic nerves
to the inguinal canal. The round ligaments are lax and, Parametrial lymph node
except during labour, are free of tension. There is no evi- Pelvic cellular tissue condensed to form Mackenrodt 's ligament
dence that the nonnal position of anteflexion and amever- lnfundibutopellllc ligament
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 Mesovarium attaches tJ1e ovary to tJ1e poste•·ior fold of
a utems which is pathologically retrovened. The round liga- peritoneum of tJ1e broad ligament and contains vessels,
ments are supplied by a bmnch oftJ1e ov;u·ian anery de.-ived lymphatics and ne•,es of the ovary. Mesosalpinx lies be-
from its anastomosis with the uterine anery, h ence there tween tJ1e fallopian tube and tJ1e ovary and contains the
is the necessity for ligation of tJ1e round ligamem du.-i ng anastomotic vessels between the ovary and uterus and
hysterectomy. Along it lymphatic vessels pass from the the vestigial structures of tJ1e Wolffian body and t11e duct
fu ndus, which connect with those d raining t11 e labium (see section on T he Ovaries).
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. iFALLOPIAN TUBES
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 Eac h fa ll opian tube (Figs 2. 13 and 2. 1tJ ) is attached to tJ1e
(Fig. 2. 13) below the level of the au.achment ofLhe fallopian uterine com u and passes outwa rds and bac kwards in th e
tubes. They lie beneath the posterior pe riw neal fold of the upper pan of the broad ligamem. T he fa llopian Lube mea-
broad ligament and measure about 2.5 em in length. Uke sures 4 inch ( 10 em) or more in lengtJ1 and app roxi mate!)'
tJ1e ro und ligaments, they consist of plain mt.LScle fibres and 8 mm in diameter, but t.he d iameter d imin ishes near the
connective tissue, but they are not so prominent becat.LSe corn u of the uterus to 1 mm. The fallopian tube is divided
tJ1ey contain less plain muscle tissue. They are morphologi- anatomically imo fotu· parts:
cally a continuation of the round ligamem (contents of
broad ligaments are listed in Table 2.1 ). I. The irttentitiltl portion is tJ1e innermost pan of tl1e rube
l nfundibulopelvic ligament is t11at portion of the broad which u-averses the m>ometrium LO open into tlle endo-
ligament that extends from tJ1e infundibulum of tlle fallo- metdal cavil). It is the shortest part oftlle tube, its lengtll
pi;m tube to tJ1e late•-al pelvic wall. It encloses the ov;u;;m being the th ick.ness of tJ1e uterine mLLScle, about 18 mm.
vessels, l)lnphalics and nerYeS of tJ1e ov;u-y. The ureter is It is also the narrowest part, its intemal diameter being
also in a close contact and can be damaged dlll·ing clrunping I mm or less so tJ1aL only tJ1e finest cannula can be passed
of this ligamenL imo it during falloscopy examination. There ru·e no
22 SHAW'S TEXTBOOK OF GYN AECOLOGY
Figure 2.15 Ampullary portion of fallopian tube to show arrange- Figure 2.16 Fimbria! end of a patent fallopian tube. Dye test shows
ment of plicae (x18) (COO'Iesy Dr Sancleep Mathu-, AIIMS.) spill.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 23
similar to those of the endome u·iu m. T he b lood vessels of of great concern in menopausal women. The ovary is at-
t11e sLroma are plentiful and are parl.icularly well marked in tached to t11e back of the broad ligament by a th in mesen-
t11e ampullary region. The epithelium of the mucous mem- tery, t11e me~>ovaritm~ Latet<lll), t11e ovat)' is related LO t11e
brane consists of three t)'Pes of cells: t11e most common is fossa below the bifurcation of the common iliac artery and
ciliated. and is either columnar or cubical in I:)'Pe. Its func- t11e LLreter. Medial I), it is close to t11e Fimbria of t11e fallo-
tion is to propel a fluid currentLOwarcls the uterus and plays pian tube. which sLretches over it around ovulalion. It is
some part in the u-anspon of the inen ovum which, unlike attached to the com u of the uterus by the ovarian liga-
t11e sperm, has no motile power of its own. ext in order of ment. The inflUlCiibulopelvic ligament is the outer bordet·
frequency is a goblet-shaped cell, not ciliated, which does of the broad ligament and contains tlle ov:u·ian vessels,
not give the histochemical reactions for mucin. Its funclion nerves and l)lnphatics. The ov:u·ies are not nonnally palpa-
is lubricant and possibly nutritive to the ovum. A cell inter· ble during bimanual examination, but cause pain on LOudl.
mediate in type to the two already mentioned can be d isti n- The epoophoron, also known as the organ of Rosenmiiller,
guished, and small t·O<I-shaped cells are also presen L These represents the CJ-anial end of tlle 'v\'olffian body. It consistS
are the so-called peg cells whose purpose is not known. lL of a set·ies of vet·tical tubules in t11e mesovarium and meso-
has been possible to demonsLrate differences in the hisLO· salpinx between t11e fallopian tube above and t11e ovary
logical appeamnces of the epit11elium oft11e fallopian tubes below. Each wbule is surrounded by pla in muscle and is
during the mensu·ual cycle. T he hyst.erosalpingogram, sOJwsal- lined by cubical cells.
fJiugogrmn and litparo:.tojJic chro11wtubation are t11e clinical T he paroop horon represe nts t he caudal end of t11 e
me tl1ods of testing tJ1c patency of tJ1 e fallopia n tubes. Lapa- Wolffi an body and similarly co nta ins ve n.i cal tubules. It
roscopy also ide nti Fies ex te rnal tubal adhesions. 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
THE OVARIES 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
Eac h ovary we ighs 4-8 g and measures abo ut 35 mm in the tissues of t11e ce rvix. It tJ1en runs fo rwards to reac h me
lengt11, 25 mm in width and 18 mm in thickness. The ovat)' amerolateral aspect of the vagi nal wall and may reac h as far
(Figs 2 .11 and 2. 17) is almond shaped, pearly grey d ue to down as t11e hymen. The duct some Limes forms a cyst, called
a compact tunica a lbuginea, and tJ1e surface is slightly cor- Gartner cyst, in ll1e broad ligament or in the vagina, and
rugated. Before pubert), the ovaries are small and located may need surgical enucleation (Fig. 2. 17). HistOlogy of t11e
near t11e pelvic brim. After menopause t11ey aLrophy and ovary is described in Chapter 3.
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 THE URETHRA
less. An ovaq larger than this as measured ullrasonically is
The urethra measures 35 mm in length and 5-6 mm in
diameter. It passes downwards and forwards from the base
Paroophoron Epoophoron of the bladder behind the S)lnph)Sis pubis to end in the
(distal tubules of (proximal tubules of
the mesonephros)
external meatus. lts epithelial lining consists of squamous
the mesonephros)
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.
; 1 - - - Gartner's duct
(vestigial remnant)
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
Fig ure 2.17 Remnants of the mesonephric (Wolffian) ducts that may LO the vagina by pubou•·etht-al ligament and requires a
persist in the anterolateral vagina or adjacent to the uterus within the sharp dissection. Laterally, it is surrounded by tlle areol:u·
broad ligament or mesosalpinx. 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 nerve fibres reach the cenu·al nervous system via the
t11e pubic bone and Lhe lateral pelvic wall and maintains splanchnic nerves (p<11<1S)1npathetic S2-S4). The somatic
continence of urine. Anteriorly, t11e uret11ra is separated afferent fibres travel witl1 S)'lnpathetic nerves via hypogasu·ic
from the pubic bone b) Lhe areolar tissue. plextLS and enter the first and second lumbar segmentS of
The external urinal") meaLus lies in t11e vestibule, 2 em tl1e spinal corcl The bladder wall is lined by u-ansit.ional
below the clitoris and is part!> concealed by t11e upper end epimelium. which gets folded when empty but allows blad-
of the labia minora. umerous periuretl1ral glands sur- der distension. The lining membrane of 1he trigone is fixed
round tl1e urethra and open b) till)' duelS into iiS lumen. 1.0 the muscle wall. The mtLScular coat of t11e bladder is com-
These are analogues of Lhe prosLaLe in males. The paraure- posed ofsmoom muscle kno11n as deu·tLSor. The neck oftl1e
mral glands of Skene are imporLanL paired glands which lie bladder (internal Ulinarysphincter) is suiTounded by circu-
alongside me floor of Lhe urethra and open by tiny duelS lar muscle fib•·es.
close to me external meatus. The glands when infeCLed
form periuretlual abscess and cysiS.
The proximal tu·etlwa derives blood supply from me THE URETERS
inferior vesical anery and distal uret11ra from in temal puden-
dal ane•l'· The veins drain into t11e vesical plexus and intemal £vel")' gynaecologist should be fam iliar witl1 t11e anawmy of
pudendal vein. T he uretlwa is innervated by the internal the pelvic portion of tl1e UI'Cter, as iflj u ry ca n occu r el uti ng
pudendal nerve. T he uretlwa is developed from the cloaca. pelvic s urge •/'· T he 1u·eter needs to be dissected d l.lling
T he proximity of tl1e uret11 ra to the vagina makes it Wertheim 's hys terec tomy for ca ncer of tl1e ce rvix. T he ure-
suscep ti ble to infection sp reading from the lower ge niLal tract. ter may run in a close re latio n to tl1 e broad liga ment cyst
T he commonest infec ti ve orga nisms are N. go norrhoea, Chla- a nd myoma.
m>•dia u-ac homatis and trichomonads. T he ure t11ral swab, T he pelvic poni on of tl1e ureter is 13 em lo ng a nd 5 mm
cultw·e and uri ne Cl ~turc can iden ti fy Lhe o rganisms. 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
THE BLADDER pelvis at tl1e brim, it is crossed by the ovarian vesse ls, and
on tl1e left side the mesosigmoid is an anterior relation. In
The bladder is a smooLh muscle organ witl1 a body and a this sitLtation, tl1e obturator vessels and nerve lie laterally,
trigone. It lies between Lhe spnphysis pubis in from and t11e and tl1e h)pogastric lymph nodes are closely related. The
uterus behind, being separated from tl1e uterus by t11e cottrse of tl1e ureter is then dowmvards and forwards
uterovesical peritoneum. It is a pelvic organ with a capacity immediately beneatl1 tl1e peritoneum to which it is always
to hold 500-600 mL of urine. The bladder distends upwards closely atLached.
with a fixed base at tl1e Lrigone, and t11en becomes palpable O n the pelvic floor, the ureter pierces MackenrodL's
abdominal!). ligament where a canal, the Lu·ete•·ic canal, is developed. IL
The bladder has an apex, a base, a supe•·ior and L\1'0 is necessary that the ureter mLLSL have room for normal
inferolaLeral surfaces. The neck of the bladder (internal peristalsis without any pressure from me SUITOundingsu·uc-
Ulinary sphincter) lies abo1e the lev~nor ani muscles, so Lures, and the ureteric canal protects me ureter from t11e
mal me raised abdominal pressure transmitS me pressure outside pressure. In its passage through me urete•·ic canal,
equall)' Lo Lhe bladder and itS neck, hence mainLaining uri- the ureter is crossed by 1he uterine aner)' above and t11e
nal")' cominence dur-ing coughing and sneezing. Ameriorly, uterine plexus of veins below, thus being forked between
lies tl1e cave of Reuius (t'Cu·opubic space). Posteriorly, iLis the uterine vessels. After leaving the ureteric canal, t11e
in proximity to tl1e uterus and supt·avaginal portion of the ureter passes fot·wards and mediall y LO reach t11 e bladder,
cervix, sepamted from them by t11e uterovesical pouch of being separated from tl1e cervix by a disLa nce of 1-2 em
peritone um. (Fig. 2. 18). T he co urse of the ureter thro ugh the pelvis is
T he ureters en ter tl1e bladde r obliquely, and t11e area not always consta nt. At ope ratio n, t11 e ureter is recogn ized
be tween tl1e ure te ric openin gs and the inte rnal urinar y by iiS pale gliste ni ng appea rance and by a fine lo ngitud inal
sphincter fo rms a fixed tri angular a rea called u·igo ne. T he p lexus of vesse ls o n its surface, b ut mo re parti cula rly b)' its
apex is co nti nuo us witl1 tJ1e urac hus. peristalti c move men ts. It can also be recognized by palpa-
T he b ladder receives b lood suppl)' from the s uperior and tion between the fi nger and th e thu mb as a firm co rd,
inferior vesical arteries, and the pub ic branc h of the infe rior which, as it escapes, gives a characteristic snap. T he ureter
epigastric anery. T he venous plex us drains in to in te m al is rare ly d up licated. In advanced stage of cancer of th e cer-
iliac vein. T he lymphatics dra in into interna l and extemal vix witl1 extensive involvement of the parame u·iu m, su·ic-
iliac glands. 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
NERVESUPPLY vessel from the uterine and inferior vesical anery. The ves-
The spnpathetic outflow is from first and second ltunbar sels fo1m a longitudinal anastomosis up and down me ure-
segmeniS of tl1e spinal cord which inhibiiS conu-act.ions of Ler which protects the ureter from ischaemia if one vessel is
me detrusor (bladder) mtLScle and main Lains internal ligaLed or i•'\iured. Howe. er, damage of seveml small vessels
sphincteric contraction. The pa•-as)lnpathetic outflow from can cause avascular necrosis and urete•·ic fistula. TI1e small
52, 53 and 5 I stimulates tl1e detnLSor muscle and relaxes tl1e branches of tl1e renal a•·teL}' also suppl)' blood LO me ureLer
internal sphincter, tlnLS initiating micw•·ition. The sensory above the peh·ic brim.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 25
~1--.....::::=--~-1- Internal
Iliac artery
External iliac
artery & vein
Obliterated ----...1
umbilical and sup.
vesical artery
Obturator nerve
Obturator artery--~#-~:...._~
Inferior
epigastric
artery
Round
ligament
'--1-__:::,.__ Obturator
lnternus muscle
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 artery. The rectum and upper one-third of anal canal drain
ilie lateral side, and iJ1e urete ric d issec tion sho uld be done via superior rectal veins into ponal circ ula tion. Lower one-
along iLS medial side. third portion of anal canal drains in tO inferior rectal vein
The ir"tiury to iJ1e ureter occurs at the infun dib ulopelvic (systemic ci1·culaLion).
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
THE LYMPHATICS
identif) the ureter during WeriJ1eim hysterectomy, broad The rectum and upper one-iJ1 ird of anus drain in tO imen1al
ligamem nunour dissection and while ligating the imernal iliac and preaortic I) mphatic nodes. Lower one-third dr-ains
iliac anef). imo superficial inguinal I) mph nodes.
The l)lnphatics drain intO intemal and extemal iliac AutOnomic pehic plexus innerYates iJ1e recwm and up-
glands. The S) mpaiJ1etic nerve supply comes from hypogas- per portion of iJ1e anal canal. The lower por·tion of the anal
tric and peh·ic plexus; paraS) mpathetic from sao-a I plexus. 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
THE RECTUM AND ANAL CANAL is derived fi·om ectodenn.
lateral to iL Other fibres decussate between the vagina and directed inwards as well as fo rwa rds, t11 e presenting part
t11e rectum in tl1e siwatio n of the perineal body. These de- rotates forwards and inwards.
cussat.ing fibres divide the space between t11e two levatOr ani The superior and inferior surfaces of tJ1e levatOr muscles
muscles in to a n amerior portion, tJ1e hiatus uroge nitalis, are covered by the pelvic fascia, which separates t11e muscles
mro ugh which passes t11e urethra and vagina, and a poste- from t11e cellular tissues of t11e parametrium above and from
•ior portion. the hiaws rectalis, t11rough which passes the the fibrous and fat!) tissues of t11e ischiorectal fossa below.
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
UROGENITAL DIAPHRAGM
muscle. The urogenital diaphragm is also called the u·iangular liga-
Pe1ineal tears occtu·•·ing during panu•·ition divide tltese ment. It is not so well de,eloped in me female as in tlte
decussating fibres, causing the hiatus urogenitalis to become male. It extends from the pubic arch anteriorly to t11e cen-
patulous and lead to prolapse. In visceroptosis and asmenic tral point of the pe.-ineum posteriorly a nd consists of two
states, tlte levator muscles become lax, tlt e dimensions ofthe layers of fascia tltrough which pass t11e vagina and t11e ure-
hiatus urogenitalis are increased and there is a tendency for thr-a. The central point of the female perineum lies be-
t11e pelvic viscera to p•·olapse. The iliococcygeus is a fan- tween the vagina and th e rccwm. Within t11e two fascial
shaped muscle a !ising from a broad o rigin along the white layers of th e urogenita l diaphragm lies the deep transverse
li ne of tl1 e pelvic fascia and passing backwards and inwards perineal muscle, whi ch ex te nds latera ll y o n each side to
to be inse•ted into tlte coccyx. T he isc hi ococcyge us or coc- reac h t11 e ramus of the pubic bone. This muscle is so poorly
cyge us muscle has a narrow o rigin from t11e isc hial spine and developed th at it is diffi cult to dissec t in anatom ical speci-
spreads o ut posteri ori)' to be inserted into tlte front of the mens a nd needs a specia l histological tec hnique for its
coccyx (Figs 2. 19 and 2.20). de monstratio n . Its functiona l significa nce is dubious. The
T he leva tor muscles toge t11 er co nstiune the pelvic dia- s triped muscle or vo lu ntary sp hincter of the urethra also
phragm and support the pelvic viscera: co nu·action of the lies between tl1 e two la)'ei'S of the u·ia ngular ligame nt.
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 SUPERFICIAL MUSCLES
tlte vagina na11·owed ante roposte rio rly. T he origin of the FoLu· muscles are ide ntified in tl1is layer. The external
levatOr muscle is faxed because the muscle arises ante1iorly sphincter mLLScle of t11 e anus is aLtac hed anteriorly to Ute
eitJ1er from bone or from fascia which is attached LO ll1e cenual point of the perineum and su•To unds the antLS.
bone; posteriori) the insertion is e itJ1er imo me anococcy- The bulbospongiosus muscle, or as it is sometimes called
geal raphe or into the COCC)'X, botl1 of which are moveable. the sphincter vaginae, extends from the central point of the
It follows tl1atthe conuaction of t11e levator muscles leads to pe1inewn along each side of t11e '>agina to be attached ame-
t11e poste•·ior attachments being pulled wwards ll1e S)1nphy- .-iorly to the S) mph) sis pubis. It lies arou nd and lateral to the
sis pubis. The movement of the intemal rota tion of the urethml bulb. The ischioca,ernosus mtt~cle exte nds on each
presenting part during panurition is assisted by ll1is prop- side of me ischial tuberosity in •-elatio n to me cmra of ll1e
erty of me levator muscles. Ute•ine contracti ons push the clitOris to reach it in the midline. The supe•·ficial u-ansverse
presenting pan down upon the le,>ator ani (pelvic floor) muscle of me perineum passes late•-ally on each side from the
and cause the muscles to contract as a result of tlte direct central point of the perineum to the pubic mmus (Fig. 2.21 ).
pressu•·e of tlt e presenting part. The lowest pan of the fetus Deep to mese superficial muscles and between them and the
is carried forwards during t11e contracti ons of the levator infelior la yer oftlte u·iangt~ar ligament lie t11e vestibular bulb
muscles, and as the anterior fibres of the muscles are and tlte greater vestibular glands of &1rrlwlin.
White line
Figure 2.19 The muscular peMc floor seen from above alter the removal of the pelvic viscera and pelvic fascia.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 27
Fallopian tube
Subpubic angle
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- A distinction is drawn between the pelvic fascia and the
nal wall and the anal canal. It is pyramidal in shape with itS endopelvic fascia. The pelvic fascia co nsistS of tl1e dense
apex on a level with the j unclion of 1J1e middle and lower connective tissue which covers tJ1e surfaces above and below
thirds of the posterior vaginal wall. The three layers of the the levator ani and the obturator inte rnus muscles. On the
muscles of the pelvic floor are represented in the perineal contrary. the endopelvic fascia forms the connective tissue
body, and the intenening lissue consisli ng offatand fibrous cove1ings for tl1e vagina, tJ1e sup•-avagina l ponion of the
lissue. Superficial!), passing from the ce ntral point of the cen-ix, 1.he uterus. the bladder, the uretJ1ra and the rectum.
perineum are the external sphincter of the anus, the bulbo- In addjtion, condensed bands of e ndopeh.jc fascia pass
spongiosus and the superficial transverse muscle of the from these mo,·eable organs to tJ1e back of the pubic bones,
pe.-ineum. Deep to this la)er lies the fascialla)er of the uro- to the lateral walls of tl1e pelvis and to the from of the sa-
genital diaphragm (triangular ligamem) enclosing the deep crum. The function of tl1e endopelvic fascia is pan.ly to
transverse nntSCle of the perineum. Deeper still, the pelvic convey blood ' 'essels to the pelvic o•·gans and panly 1.0 sup-
diaphragm is represented by the fibres of the levator ani pon tl1em. Be1.ween tl1e different tarers of t11e endopelvic
muscl es which decussate between the vagina and the rec- fascia are bloocUess spaces which are imponam 1.0 identify
tum. The perineal body is exa mined by inspeclion and by in vaginal plastic ope•-ations. The term pelvic cellular tissue
palpation. Two fingers arc placed in the vagina and flexed should be restricted to cellular tissue wh icl1 intervenes be-
laterally; the thumb being applied externally over the tween tl1 e differe nt layers of tJ1 e endopelvic fascia and
labium majus, the leva tor muscles ca n be palpated with a which lies between the peritone um above and tl1e u·ue pel-
remarkable ease and the si:.te of the hi a tus urogenitalis can vic fascia below.
be assessed . On asking the palient to co nu·act her pelvic Anteriorly, the b ladde r is cove red by an e ndopelvic fas-
floor muscles, tl1e LOne of these muscles ca n be estimated. cial layer called the vesical fascia, whereas be hind it lie the
Pro lapse of tl1e ge nita l tract. stress inco nlinence of vagina a nd the supravagina l portio n of the cervix covered
urine and faecal inconlin c nce a re all re lated LO laxity and by 1.heir own enclopelvic fasc ial layers.
aton icity of the muscles of th e pe lvic floor as well as dener- lmmediaLel)' behind the ute rus and vagina, tl1e perito-
vation of pelvic ne rves d uring childbirth. Late ly, perineal neum which covers tl1e back of tJ1e ute ms and tl1e posterior
ulu·aso und and M Rl have grea tly im proved o ur knowledge vaginal fornix red uces the pelvic cellular lissue to a mini-
of these supportive su·uctures in maintaining the uterine lllLUll in tl1ese situations. Deep to tJ1e uterosacral folds of
position and co nLinence of urine a nd faeces. 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
THE PELVIC CELLULAR TISSUE reach the sao·um lateral to the rectosigmoid. The uterosac-
ralligrunen tS help to support tJ1e utenLS a nd prevent it from
The pelvic cellular lissue consistS of loose areolar lissue being forced down b) inu-aabdominal pressure. By their
which imenenes between tJ1e peh·ic pe•itoneum above and wne tlle)• also tend to pull back tJ1e cervix and tl1ereby aJ1-
the peh·ic fascia below. It is conlinuous with the subperito- teven the ULerus. Plain muscle fibres can be demonsu-ated
neal connecti,·e tissue and witJ1 the loose lissue of tl1e peri- in them. They contain S)lnpatlletic and pa•<~S)Inpatlletic
nephric •·egion. The areolar tissue is loose, and when nerves. Mackenrodt's ligamentS, similar to uterosacral liga-
inflamed in the condition of pelvic cellulilis it may lead to ments, help 1.0 suppon the uterus and prevent it from being
the form ation of a palpable swelling. As tl1ere is a direct forced down when tl1e intraabdominal pressure is raised.
continuation between tJ1e pe•inephric and pelvic cellulru· The)' are composed almost entirely of conneclive tissue and
tissues, effusions a.-isi ng in eitJ1er of these situalions may contain very liule plai n muscle (Fig. 2.22).
u-ack to point as an abscess in tJ1e other. In tl1e pelvis, the A third and equally important pan of tl1e supporting
pelvic cellular tissue is bo unded above by the peritOneum mechanism of tl1e pelvic viscera is tJ1 e p ubovesicocervical
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- Vesicocervical
neal and is most plenlifu l on eac h side of tl1 e uterus below space
tl1e level of the internal os. The e ndopelvic fascia in this Paravesical
region thickens to form ligamento us s upportS called Mack- space
enrodt ~or cardilwlligammt~ Above tll is level, the presence - --+-r+t- Rectovaginal
of the broad ligamentS reduces the amount of pa•-ame- space
t.-iLUn to a minimum. It should be remembered that the .,/,,t-.::;::::_ Pararectal
space
level of the levator an i muscle is well below the level of the
Retrorectal
ce•·,-ix. being more than halfwa) down the vagina. The pel- space
,.jc cellular tissue is usuall) ve•') plen liful o n each side of fascia
the vagina, where it is called pa•-avaginal cellular lissue or Figure 2.22 The pelvic cellular tissue shown in the cross-section of
paJ-acolpos. the pelvis.
CHAPTER 2 - ANATOMY OF FEMALE GENITAL TRACT 29
_,---Anterior trunk of
internal iliac artery
. - - - - Inferior gluteal
ar tery
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
External
~~~cglands
, '
lntemal '
iliac glands ,' ' :
,, '
1 Hypogastric ,'
,,
I 1 I
Superficial I
I
I
1
inguinal glands I
I
1
I
,
,'
,
11
(} • • • • ;~Jurator
--
I
CeiVix
Rgure 2.25 Pelv ic lymphatic drainage of the ceNix.
THE INGUINAL GLANDS situated in tl1e obturator fossa is ofte n called the obu..rawr
This group of glands consists of a horizo ntal and a venical glands and is freq uen U)' the most obvio usly involved in
group. The horuontal gnoup lies superficially, parallel to carcinoma of tl1 e cervix. These drain into external and
Poupart's ligament whereas the vertical group, otherwise common iliac glands.
known as the deep femoral glands, follows the saphenous
and femoral veins. The uppermost of the deep femoral EXTERNAL IUAC GLANDS
glands, called the gland of Cloquet or the gland of Rosen- This group of glands, several in number, is situated in rela-
muller, lies beneath Poupa•t ·s ligamem in the femoral canal t.ion 1.0 the external iliac anery and ,·ein. A clean clissect.ion
between Gimbernat's ligamem and the femoral vein. lncon- oflhe extemal iliac glands can only be made if both vessels
stant deep inguinal nodes a re found in the inguinal canal, are completely mobilit.ed as some of the glancls lie lateral to
along the course of the round ligament, a nd in the tissues the vessels between tl1em and the latera l pelvic wall. These
of the mons veneris. In such conditi ons, as p•·imary sore and glands receive drainage from the obturator and hypogastric
Banholin's abscess, the ho•iL.Ontal inguinal group becomes glands and a•·e involved in late cervical ca ncer.
inflamed. There is some evidence that lymphatics from the
fundus of t11e uterus pass along t11e round ligament and COMMON ILIAC GLANDS
drain into the hori:wntal inguin al group. It is more likely T his gro up is the upward co ntinuation of the external and
t11at these glands will beco me in volved after the appearance h ypogastric group and, t11erefore, involved next in genital
of t11 e la te subure thral metaSL<'l.Sis see n in advanced carci- trac t cance1:
no ma corporis ute ri, whe re t11e growth has spread clown the
vagina by a retrograde l)•mphatic spread. The inguinal THE SACRAL GROUP
gla nds drain the vulva a nd lowe r t11ird of t11e vagina, the T hese gla nds lie o n eac h side of the rec tum and receive
lymp hati cs of t11 e medial portion of the vulva co mmunicate lympha tics fro m the ce rvix of the uterus and from the up-
with l)•mphatics of th e opposite side. It is the refore neces- per third of the vagina whi ch have pas.sed backwards along
sary to perform bilate ral inguinal lymphadenectomy when the uterosacral ligaments. Two gno ups of glands can be
cancer occurs in t11e medial portion of the vulva. 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-
THE GLANDS OF THE PARAMETRIUM crum. The lymphatics from these glands pass directly either
The h)pogastric group (internal iliac glands ) contains all to tl1e inferior lumbar gro up or to the commo n iliac group.
t11e regional glands for t11e cervix, the bladder, t11e upper
third of t11e vagina and also t11e greater pan of the body of THE LUMBAR GROUP OF GLANDS
the uterus. This group of glands may be extensively involved These lymphatic glands are divided into a n inferior gJ"Oup
in carcinoma of t11e uterus, cervix and vagina. The glands that lies in from of tl1e aorta below the o rigin of tl1e infe.;or
are most numerotLS immediate!)' below the bifurcat.ion of mesenteric ane•) ' and a superior lumbar group which lies
the common iliac group. A further group of t11ese glands near the origin of the ovarian ane•·ies. The supe•·ior group
CHAPTER 2- ANATOMY OF FEMALE GENITAL TRACT 33
of lumbar glands receives lympha l.ics from the ovaries and The sympathe tic sys te m co nsists o f the presacral nerve
fallopian tubes as we ll as fro m the inferio r lumbar glands. which lies in fro nt of the sac ral promo ntory. This nerve
The lymphatics from th e fundus of th e uterus j oin the ovar- plexus divides into two h)'POgastric nerves which pass down-
ian lymph al.ics to pass to the same gro up. wards and latera II) a lo ng the pe lvic wa ll to te rmin ate in t11e
The l)lnphal.ic glands already menl.ioned, namely, t11e inferio r h)pogasuic plex us. This ple xus is diffuse and lies in
glands of t11 e parametrium, t11 e superficial inguinal, t11e hypo- the situation of t11 e uterosacral ligamen tS. It also receives
gasu·ic, external and co mmon iliac, t11e sao-a! and t11e lumbar fibres from t11 e paras)ln pathetic S)Stem co nsisting of sacral
receive l) mphatics 'direct' from the female generative organs fibres 2, 3 and 4. Fro m here, the nerve fibres pass tO all the
and are known as t11e ' regio nal l)lnphati c glands' o f t11e pe lvic organs.
female genitalia. The cen·ix is well surrounded by a •·ich plexus of nerves
Th ese regional I) mph nodes are n ot palpable clinica Uy, called Frankenhause•·'s plexus. The lower vagina is inner-
but can be identi fied on Cr and MRJ scan if t11ey :u·e en- \'<l ted b)• pudendal nen e.
la rged to I em or more. At su•·ger y, these glands should be The O\'<lries derh e their n en ·e supply from the coeliac
palpated, 1-emoved or biopsied. This helps in staging the atld ren al ganglia which follow the course of the ovarian
ca ncer and in the postoperative •-adi ot11erapy. 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
THE NERVE SUPPLY mons, the uppe r and outer aspec t of the labia majora and
the perineum.
Both sympatheti c a nd pan\S)•mpathetic systems supply the T he pudendal ne rve derived fro m sacral second, third
fema le gen ital orga ns as we ll as the bladder (Fig. 2.26) . 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) .
Upper vag ina, cervix, lower uterine segment, posterior 82-4 Pelvic parasympathetlcs
urethra, bladder trigone, uterosacral and cardinal
li gaments, rectosigmoid , lower ureter
Uterin e fundus, proximal fallopian tubes, broad ligament, T11 - 12, L1 Sympathetlcs via hypogastric plexus
upper bladder, caecum, appendix, terminal large bowel
Outer two-thirds of fallopian tubes, upper ureter T9-10 Sympathetics via aortic and superior
mesenteric plexus
T12- L1 Ilioinguinal
L1 - 2 Genhofemoral
34 SHAW'S TEXTBOOK OF GYN AECOLOGY
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Corporation. 14 min., sd., b&w, 16 mm. (Screen News Digest, vol. 16,
issue 8) NM: compilation & additions. © Hearst Metrotone News, a
division of the Hearst Corporation; 2Apr74; MP25536.
MP25537.
House of wonders. Hearst Metrotone News, a division of the
Hearst Corporation. 14 min., sd., color, 16 mm. (Screen News Digest,
vol. 16, issue 5) NM: compilation & additions. © Hearst Metrotone
News, a division of the Hearst Corporation; 3Jan74; MP25537.
MP25538.
Servant of the people. Hearst Metrotone News, a division of the
Hearst Corporation. 14 min., sd., color, 16 mm. (Screen News Digest,
vol. 16, issue 7) © Hearst Metrotone News, a division of the Hearst
Corporation; 4Mar74; MP25538.
MP25539.
Peron’s return. Hearst Metrotone News, a division of the Hearst
Corporation. 14 min., sd., b&w, 16 mm. (Screen News Digest, vol. 16,
issue 3) NM: compilation & additions. © Hearst Metrotone News, a
division of the Hearst Corporation; 5Nov73; MP25539.
MP25540.
Promised land, troubled land. Hearst Metrotone News, a division
of the Hearst Corporation. 14 min., sd., b&w, 16 mm. (Screen News
Digest, vol. 16, issue 4) NM: compilation & additions. © Hearst
Metrotone News, a division of the Hearst Corporation; 3Dec73;
MP25540.
MP25541.
The Energy challenge. Hearst Metrotone News, a division of the
Hearst Corporation. 24 min., sd., color, 16 mm. (Screen News Digest,
vol. 16, issues 1–2) NM: compilation & additions. © Hearst
Metrotone News, a division of Hearst Corporation; 24Sep73;
MP25541.
MP25542.
Ray Lum: mule trader. Center for Southern Folklore. 18 min., sd.,
color, 16 mm. Appl. au.: Bill Ferris & Judy Peiser. © Bill Ferris &
Judy Peiser; 27Mar73; MP25542.
MP25543.
Highlights of British dog shows. An In-sight production. Released
by the Gaines Dog Research Center & Top Choice. 26 min., sd., color,
16 mm. © Gaines Dog Research Center; 1Mar74; MP25543.
MP25544.
Journey to the outer limits. The National Geographic Society &
Wolper Productions. 50 min., sd., color, 16 mm. © National
Geographic Society; 2Jan74; MP25544.
MP25545.
Careers: it’s all up to you. Independent School District Number
112. 140 min., sd., b&w, videotape (1/2 inch) in reel. Appl. au.:
Chaska Public Schools. © Chaska Public Schools; 15May74;
MP25545.
MP25546.
A Very natural thing. Released by Montage Creations. 88 min., sd.,
color, 16 mm. Appl. au.: Christopher Larkin & Joseph Coencas. ©
Montage Creations, Inc.; 2May74; MP25546.
MP25547.
Detroit’s Emergency Medical Service. American Film House. 27
min., sd., color, 16 mm. © American Film House, Inc.; 1Jul74;
MP25547.
MP25548.
Rowls/Woodcrafter. William Esty Company, Inc. 30 sec., sd.,
color, 16 mm. © Colgate Palmolive Company; 10Jan74; MP25548.
MP25549.
Sound out films. No. 1–34. Houghton Mifflin Company. 57 min.,
sd., color, Super 8 mm. (Interaction: a student centered language
arts and reading program) © Houghton Mifflin Company; 16Jan74
(in notice: 1973); MP25549.
MP25550.
The Star system Xi Ursae Majoris. A Houghton Mifflin film. 8
min., sd., color, 16 mm. (Explorations in space and time) ©
Houghton Mifflin Company; 5Jul73; MP25550.
MP25551.
The Motion of stars. A Houghton Mifflin film. 8 min., sd., color, 16
mm. (Explorations in space and time) © Houghton Mifflin
Company; 19Sep73; MP25551.
MP25552.
Algol, the demon star. A Houghton Mifflin film. 8 min., sd., color,
16 mm. (Explorations in space and time) © Houghton Mifflin
Company; 1Nov73; MP25552.
MP25553.
Sirius and the White Dwarf. A Houghton Mifflin film. 8 min., sd.,
color, 16 mm. (Explorations in space and time) © Houghton Mifflin
Company; 2Nov73; MP25553.
MP25554.
Planetary motion and Kepler’s laws. A Houghton Mifflin film. 8
min., sd., color, 16 mm. (Explorations in space and time) ©
Houghton Mifflin Company; 12Feb74 (in notice: 1973); MP25554.
MP25555.
Star clusters. A Houghton Mifflin film. 8 min., sd., color, 16 mm.
(Explorations in space and time) Appl. states all new except some
photos. © Houghton Mifflin Company; 20Feb74 (in notice: 1973);
MP25555.
MP25556.
The Motions of attracting bodies. A Houghton Mifflin film. 8 min.,
sd., color, 16 mm. (Explorations in space and time) © Houghton
Mifflin Company; 2May74 (in notice: 1973); MP25556.
MP25557.
The Doppler effect in sound and light. A Houghton Mifflin film. 8
min., sd., color, 16 mm. (Explorations in space and time) ©
Houghton Mifflin Company; 6May74 (in notice: 1973); MP25557.
MP25558.
I’d like to see the world. Vision Associates, Inc. 7 min., sd., color,
16 mm. © The Coca-Cola Company; 1Dec73 (in notice: 1972);
MP25558.
MP25559.
In white collar America. National Broadcasting Company, Inc. 51
min., sd., color, 16 mm. © The National Broadcasting Company,
Inc.; 14Mar74; MP25559.
MP25560.
Oxygen and iron atoms combining. Doubleday Multimedia,
division of Doubleday and Company, Inc. 4 min., si., color, Super 8
mm. in cartridge. © Doubleday Multimedia, division of Doubleday
and Company, Inc. (in notice: Doubleday and Company, Inc.);
5Sep73; MP25560.
MP25561.
Water expands into gas. Doubleday Multimedia, division of
Doubleday and Company, Inc. 3 min., si., color, Super 8 mm. in
cartridge. © Doubleday Multimedia, division of Doubleday and
Company, Inc. (in notice: Doubleday and Company, Inc.); 3Oct71;
MP25561.
MP25562.
Doctor Tom and his magic tree. An Allend’or production.
Produced for Southern Council of Optometrists. Produced in
cooperation with University of South Carolina, Division of
Educational Services. 15 min., sd., color, 16 mm. From a story idea by
E. H. Brown, Jr. © Southern Council of Optometrists, Inc.; 17Feb74;
MP25562.
MP25563.
Winter. XGMR 3669. Grain Belt Breweries, Inc. 1 min., sd., color,
16 mm. © Grain Belt Breweries, Inc.; 1Apr74; MP25563.
MP25564.
Transition-lift. XGMR 3939. Grain Belt Breweries, Inc. 30 sec., sd.,
color, 16 mm. © Grain Belt Breweries, Inc.; 1Apr74; MP25564.
MP25565.
Transition. XGMR 3769. Grain Belt Breweries, Inc. 1 min., sd.,
color, 16 mm. © Grain Belt Breweries, Inc.; 1Apr74; MP25565.
MP25566.
Winter-lift. XGMR 3839. Grain Belt Breweries, Inc. 30 sec., sd.,
color, 16 mm. © Grain Belt Breweries, Inc.; 1Apr74; MP25566.
MP25567.
Opportunities in life insurance. Professional Selling Institute, Inc.
17 min., sd., color, Super 8 mm. in cartridge. (Series of the greats) ©
Professional Selling Institute, Inc.; 7Mar74; MP25567.
MP25568.
Closely held corporation stock plans. Professional Selling Institute,
Inc. 18 min., sd., color, Super 8 mm. in cartridge. (Series of the
greats) © Professional Selling Institute, Inc.; 7Mar74; MP25568.
MP25569.
Prospecting the million dollar year. Professional Selling Institute,
Inc. 18 min., sd., color, Super 8 mm. in cartridge. (Series of the
greats) © Professional Selling Institute, Inc.; 7Mar74; MP25569.
MP25570.
The Twenty-one cent bet and a positive slump eliminator.
Professional Selling Institute, Inc. 17 min., sd., color, Super 8 mm. in
cartridge. (Series of the greats) © Professional Selling Institute, Inc.;
7Mar74; MP25570.
MP25571.
How I developed a multi-million dollar production in a town of
12,000. Professional Selling Institute, Inc. 16 min., sd., color, Super
8 mm. in cartridge. (Series of the greats) © Professional Selling
Institute, Inc.; 20Mar74; MP25571.
MP25572.
Steps to success in selling life insurance. Professional Selling
Institute, Inc. 17 min., sd., color, Super 8 mm. in cartridge. (Series of
the greats) © Professional Selling Institute, Inc.; 20Mar74;
MP25572.
MP25573.
How to reach the million dollar production goal. Professional
Selling Institute, Inc. 18 min., sd., color, Super 8 mm. in cartridge.
(Series of the greats) © Professional Selling Institute, Inc.; 3Apr74;
MP25573.
MP25574.
How to sell a complicated trust plan. Professional Selling Institute,
Inc. 19 min., sd., color, Super 8 mm. in cartridge. (Series of the
greats) © Professional Selling Institute, Inc.; 3Apr74; MP25574.
MP25575.
Secrets of success and how you can take advantage of inflation.
Professional Selling Institute, Inc. 17 min., sd., color, Super 8 mm. in
cartridge. (Series of the greats) © Professional Selling Institute, Inc.;
3Apr74; MP25575.
MP25576.
How to use a simple check list to measure your daily progress.
Professional Selling Institute, Inc. 19 min., sd., color, Super 8 mm. in
cartridge. (Series of the greats) © Professional Selling Institute, Inc.;
3Apr74; MP25576.
MP25577.
Picnic. The Rath Packing Company. 30 sec., sd., color, 16 mm. ©
The Rath Packing Company; 15Oct73; MP25577.
MP25578.
Kid. The Rath Packing Company. 30 sec., sd., color, 16 mm. © The
Rath Packing Company; 15Oct73; MP25578.
MP25579.
Lunch. The Rath Packing Company. 30 sec., sd., color, 16 mm. ©
The Rath Packing Company; 15Oct73; MP25579.
MP25580.
The Science of glass packaging and handling. PPG Industries
presents. A William G. Beal production. 21 min., sd., color, 16 mm. ©
PPG Industries, Inc.; 10Apr74; MP25580.
MP25581.
An Animated class project. The Dolores Kohl Educational
Foundation & Otter Productions. 15 min., sd., color, 16 mm. © The
Dolores Kohl Foundation a.a.d. for Dolores Kohl Educational
Foundation; 27Dec73; MP25581.
MP25582.
Executing programs in VS. Edutronics Systems International, Inc.
10 min., sd., color, 16 mm. (Virtual storage concepts, lesson 819.6, pt.
1) © Edutronics Systems International, Inc.; 9May74; MP25582.
MP25583.
Programming in a VS environment. Edutronics Systems
International, Inc. 12 min., sd., color, 16 mm. (Virtual storage
concepts, lesson 819.4, pt. 1) © Edutronics Systems International,
Inc.; 9May74; MP25583.
MP25584.
Bushmen of the Kalahari. The National Geographic Society &
Wolper Productions. 50 min., sd., color, 16 mm. © National
Geographic Society; 9May74; MP25584.
MP25585.
Africa next door. Gardner Advertising Company. 14 min., sd.,
color, 16 mm. © Anheuser-Busch, Inc.; 1Apr74; MP25585.
MP23586.
Alcoholism in industry. The Bureau of Business Practice, Inc. 24
min., sd., color, 16 mm. © Bureau of Business Practice, Inc.;
14Jun74; MP25586.
MP25587.
Garner Ted Armstrong. Program no. P540. Ambassador College.
29 min., sd., color, videotape. © Ambassador College; 21Jan74;
MP25587.
MP25588.
Garner Ted Armstrong. Program no. P597. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
21May74; MP25588.
MP25589.
Garner Ted Armstrong. Program no. P602. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
28May74; MP25589.
MP25590.
Garner Ted Armstrong. Program no. P593. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
8May74; MP25590.
MP25591.
Garner Ted Armstrong. Program no. P591. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
6May74; MP25591.
MP25592.
Garner Ted Armstrong. Program no. P585. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
23Apr74; MP25592.
MP25593.
Garner Ted Armstrong. Program no. P595. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
10May74; MP25593.
MP25594.
Garner Ted Armstrong. Program no. P583. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
19Apr74; MP25594.
MP25595.
Garner Ted Armstrong. Program no. P600. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
24May74; MP25595.
MP23596.
Garner Ted Armstrong. Program no. P588. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
26May74; MP25596.
MP25597.
Garner Ted Armstrong. Program no. P605. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
31May74; MP25597.
MP25598.
Garner Ted Armstrong. Program no. P607. Worldwide Church of
God. 29 min., sd., color, videotape. © Worldwide Church of God;
4Jun74; MP25598.
MP25599.