+RADIOGRAPHIC ANATOMY AND PHYSIOLOGY OF THE REPRODUCTIVE SYSTEM

MALE REPRODUCTIVE SYSTEM:

THE SCROTUM: The scrotum is a pouch which comprises of pigmented skin, fibrous and
connective tissue and smooth muscle. It is divided into two compartments with each
compartment containing one testis, one epididymis and the testicular end of the spermatic cord.

TESTES: The testes are the reproductive gland of the male. It is about 4.5cm long, 2.5cm wide
and 3cm thick and is suspended in the scrotum by the spermatic cord. The testes are made up of
three layers

a. Tunica vaginalis: This is a double membrane which forms the outer covering of the testis
and it is a continuation of the abdominal and pelvic peritoneum. This is because the testis
develops at the lumbar region just below the kidneys in the early stages of life but
descend into the scrotum with the covering of the abdominal peritoneum. They contain
blood vessels, lymphatic vessels, nerve and deferent duct.
b. Tunica Albuginea: This is a fibrous covering beneath the vaginalis which surrounds the
testis and form septa which divides the glandular structures of the testis into lobules.
c. Tunica Vasculosa: This is a network of capillaries supported by delicate connective
tissue.

Structurally, the testis is divided into 200-300 lobules with each lobule having 1-4 convoluted
loops composed of germinal epithelial cells called seminiferous tubule. Between the tubules are
group of interstitial cells (of Leydig) which secretes the testosterone after puberty. At the upper
pole of the testis, the tubules combine to form a single tubule which is about 6m that continues to
fold and are packed into a mass called the epididymis. The epididymis leaves the scrotum as vas
deferens in the spermatic cord which also harbors the blood and lymph vessels.

FUNCTION OF THE TESTIS: The primary function of the testis is to produce spermatozoa.
Spermatozoa are produced by the seminiferous tubules of the testis. These spermatozoa mature
as they pass the long and convoluted epididymis where they are stored ready for ejaculation.
Production of the spermatozoa is under the influence of follicular stimulating hormone (FSH)
which is produced at the anterior pituitary gland. The sperm cell is made up of head, body and
tail. The head contains the nucleus which is filled with the DNA and the mitochondria which
provide the energy for the propelling action of the tail that powers the sperm along the female
genital tract. The process of spermatogenesis thrives successfully at a temperature below the
normal body temperature ( 3°C less) which is the reason why the testis is situated outside the
body cavity and also have thin walled scrotum covering it.

SPERMATIC CORD: The spermatic cord suspends the testis within the scrotal sac. It contains
the testicular artery, testicular veins, lymphatic vessels, deferent duct and testicular nerve. The
spermatic cord is covered by a sheath of smooth muscle, connective and fibrous tissue as it pass
through the inguinal canal to attach at the posterior wall of the testis.

Supply and innervations: The arterial supply is by testicular artery which is a branch of
abdominal aorta just below the renal artery. Venous drainage is by testicular vein with the right
draining into the IVC while the left drains into the left renal vein. Lymph drainage is through the
lymph nodes around the aorta. Nerve supply is by 10th and 11th thoracic nerve.

The Deferent ducts: They pass upwards from each testis through the inguinal canal and ascend
medially through the posterior aspect of the urinary bladder to join the duct of the seminal
vesicle to form ejaculatory duct.

Seminal Vesicles: These are fibromuscular pouches found on the posterior aspect of the urinary
bladder which opens into a short duct that joins with the deferent duct to form the ejaculatory
duct. The seminal vesicle stores the seminal fluid which accounts for 60% of the bulk of fluid
ejaculated during orgasm and contains nutrients which supports the sperm as it moves through
the female reproductive system.

Ejaculatory ducts: They are formed by the union of the deferent duct and seminal duct. They
pass through the prostate gland and joins with the prostatic urethra, carrying seminal fluid and
spermatozoa to the urethra.

Prostate gland: The prostate consist of smooth muscle and glandular substance which is made of
columnar epithelial cells. It secretes thin and milky fluid that makes up the 30% of semen and
gives the semen a milky appearance. It also has clotting enzyme which thickens the semen in the
vagina making it possible for the semen to be retained close to the cervix

Urethra: The urethra which is about 19-20cm long is a common pathway for the flow of urine
and semen together with other secretion of the male reproductive organs. It consist of three parts
– the prostatic urethra, membranous urethra and penile or spongiose urethra. The prostatic
urethra originates from the urethral orifice of the urinary bladder and pass through the prostate
gland. The membranous urethra is the shortest and narrowest part and extends from the prostate
to the bulb of the penis while the spongiose or penile urethra lies within the spongiosum of the
penis and terminates at the orifice of glans penis.

Penis: The penis consists of a root and a body. The root lies in the peritoneum while the body
surrounds the urethra. It is made up of three cylindrical masses of erectile tissue and smooth
muscle. The erectile tissue is supported by fibrous tissue and covered with skin and has rich
blood supply. The two lateral columns are called the corpora cavernosa while the column
between them is the corpus spongiosum. At its tip, it expands into a triangular structure known as
glans penis above which the skin folds upon itself and forms a moveable double layer called the
prepuce.
Indications for male reproductive system includes

1. Primary infertility
2. Secondary infertility
3. Infection
4. Hydrocele
5. Testicular torsion
6. Tumor
7. Undescended testis (cryptorchidism)
8. Penile erectile dysfunction.
9. Enlarged prostate

Due to the effect of ionizing radiation on the testis, ultrasound has become the main imaging
modality for the assessment of the disorder of the male reproductive system

FEMALE REPRODUCTIVE ORGAN:

The female reproductive organ can be divided into two- the external genitalia and internal
genitalia.

The external genitalia which is also known as the vulva includes the labia majora, minora,
clitoris, vaginal orifice, vestibule, hymen and the vestibular gland.

Internal genitalia include the vagina, uterus, two uterine tubes and two ovaries.

VAGINA: This is a fibromuscular tube line with stratified squamous epithelium which connects
the external with the internal organs of reproduction. It runs obliquely upwards and backward at
an angle of 45° and lies between the urinary bladder anteriorly and rectum and anus posteriorly.
It is made of three layers; the outer covering of areolar tissue, middle layer of smooth muscle and
an inner layer of stratified squamous epithelium.

Arterial supply is from uterine and vaginal arteries which are branches of internal iliac artery.
Venous drainage is into the internal iliac vein. Lymphatic drainage is through the deep and iliac
lymph nodes. Sympathetic nerve supply is from the lumbar outflow and somatic sensory fibre
from the pudendal nerve while parasympathetic fibre is from sacral outflow.

UTERUS: The uterus is a muscular pear shaped organ, flattened anteroposteriorly and lies in the
pelvis between the urinary bladder and the rectum. It can lean forward (anteversion) or bend
forward (anteflexion). It can also lean backwards (retroflexion) or bend backward (retroflexion).
The uterus is made up of 3 parts- the fundus, the body and the cervix. Structurally, the uterus is
made up of three layers- the perimetrium, the myometrium and the endometrium.
PERIMETRIUM: This is the outer covering of the uterus. It is unevenly distributed on the
various surfaces of the uterus. Anteriorly, it covers the fundus and the body and fold unto the
upper surface of the urinary bladder to form the vesicouterine pouch. Posteriorly, it covers the
fundus, body and the cervix and fold unto the rectum to form the rectouterine pouch (of
Douglas). Laterally, only the fundus was covered because of the double folds with the tubes in
the upper free border.

MYOMETRIUM: This is the thickest part of the uterus. It consists of smooth muscle fibres
interlaced with areolar tissue, blood vessels and nerves.

ENDOMETRIUM: This is made of columnar epithelium containing large number of mucus

secreting tubular glands. Functionally, the endometrium is divided into two layers- the functional
layer and the basal layer. The functional layer is the upper layer which thickens and become rich
in blood vessels in the first half of the menstrual cycle. If the ovum is not fertilized and
implanted, the layer is shed during menstruation. The basal layer lies between the functional
layer and the myometrium and is not shed during menstruation and from this layer, the functional
layer regenerates during each cycle.

Arterial supply of the uterus is from the uterine artery which is a branch of the internal iliac
artery. This artery also supplies the uterine tubes and part of the ovary. Venous drainage is into
the internal iliac vein. Deep and superficial lymph nodes from the uterus and tube drains into the
aortic lymph nodes and the group of nodes associated with the iliac blood vessels.
Parasympathetic nerve supply is from sacral outflow while the sympathetic fibre is from lumbar
outflow.

SUPPORTING STRUCTURES OF THE UTERUS:

The uterus is supported in the pelvic cavity by the following:

BROAD LIGAMENT: This is formed by the double fold of peritoneum on each side of the
uterus. They hang down from the uterine tube while the lateral end attaches to the side of the
pelvis. The tube pierces the posterior wall of the ligament and opens into the peritoneal cavity at
the lateral end. Blood vessels, lymphatic vessels and nerves passes to the uterus and tubes
between the layers of the broad ligament.

ROUND LIGAMENT: This is a band of fibrous tissue between the two layers of the broad
ligament, one on each side of the uterus. It passes to the side of the pelvis and through the
inguinal canal, fuse with the labia majora.

UTEROSACRAL LIGAMENT: This originates from the posterior aspect of the cervix and
vagina, extends backwards on each side of the rectum to the sacrum.

TRANSVERSE CERVICAL LIGAMENT: This extends from each side of the cervix and vagina
to the wall of the pelvis.
PUBOCERVICAL FASCIA: This extends forward from the transverse cervical ligament on each
side of the bladder and attaches to the posterior surface of the pubic bone.

FUNCTION OF THE UTERUS:

After puberty, the endometrium of the uterus undergoes a regular monthly cycle of change called
the menstrual cycle. The menstrual cycle is under the influence of hormones from the
hypothalamus and anterior pituitary gland. Menstruation cycle lasts between 26-30 days and
helps to prepare the uterus to receive, nourish and protect the fertilized ovum. If the ovum is not
fertilized, a new cycle begins with a short period of bleeding but if the ovum is fertilized, the
zygote is nourished by the uterine secretions. After implantation, uterine secretion continues to
nourish the zygote until after few weeks before the placenta takes up the role. The placenta
which is attached to the uterine wall and is connected to the fetus through the umbilical cord
provides a route by which the fetus receives oxygen and nutrients and get rid of the waste
products. During pregnancy which last for about 40 weeks, the muscular walls of the uterus are
prevented from contracting and expelling the baby early by high level of progesterone secreted
by the placenta. At the end of the pregnancy, increase in estrogen hormone which becomes the
predominant sex hormone in the blood increases uterine contractility. Additionally, oxytocin
released by the posterior pituitary gland also stimulates contraction of the uterus. These rhythmic
contraction increases during labour to expel the baby during the process of parturition.

UTERINE TUBES: The uterine tubes extend from the sides of the uterus between the body and
the fundus. They lie in the upper free border of the broad ligament and their trumpet shaped
lateral ends penetrate the posterior wall, opening into the peritoneal cavity close to the ovaries.
The end of each tube has fingerlike projections called the fimbriae. The uterine tube has three
layers- the outer covering of peritoneum (broad ligament), a middle layer of smooth muscle and
an inner layer of ciliated epithelium. Blood supply, lymph drainage and nerve supply are the
same with the uterus.

FUNCTION OF THE UTERINE TUBE: The tube moves the ovum from the ovary to the uterus
by peristalsis and ciliary movement. The mucus secretion provides ideal condition for movement
of ova and spermatozoa. Fertilization occurs in the tube and fertilized ovum is moved to the
uterus for implantation.

OVARIES: The ovaries lie in a shallow fossa on the lateral wall of the pelvis and are gonads
producing the ova and female sex hormone. It is about 3.5cm long, 2cm wide and 1cm thick.
They are attached to the uterus by the ovarian ligament and to the back of broad ligament by a
band of tissue called the mesovarium. Blood vessels and nerves passes through the mesovarium.

Structurally, the ovary has two layers- the medulla and the cortex.

MEDULLA: This lies in the centre and consists of fibrous tissue, blood vessels and nerves.
CORTEX: This surrounds the medulla and is made of connective tissue covered by germinal
epithelium. It contains ovarian follicles at various stages of maturity, each of which contains the
ovum. During child bearing age, one ovarian follicle called the Graafian follicle matures,
ruptures and releases its ovum into the peritoneal cavity in a process called ovulation. Following
ovulation, the ruptured follicle develops into the corpus luteum which will leave a small
permanent scar of fibrous tissue called corpus albicans on the surface of the ovary.

Arterial supply is by ovarian artery which is a branch of abdominal aorta just below the renal
artery. Venous drainage is by plexus of vein behind the uterus from which ovarian vein arise.
The right ovarian vein opens into the IVC while the left open into the left renal vein. Lymphatic
drainage is to the lateral aortic and pre-aortic nodes. Parasympathetic nerve supply is from sacral
outflow while sympathetic is from lumbar outflow.

FUNCTION OF THE OVARY: The ovary is the organ in which the female gametes are stored
and developed prior to ovulation. Maturation of the gamete is controlled by the hypothalamus
and anterior pituitary gland which releases the follicular stimulating hormone and the luteinizing
hormone. The ovary itself has an endocrine functions and releases hormone essential for the
physiological changes during reproductive cycle. The follicle itself is also a source of hormone
as they produce the estrogen and progesterone.

RADIOGRAPHIC EXAMINATION OF THE REPRODUCTIVE SYSTEM:

Radiography has played an important role in the diagnoses of problems of the female
reproductive system.

Indications for the radiographic examination of the female reproductive systems are as follows

1. Primary (1o ) infertility

2. Secondary (20 ) infertility
3. Irregular menstruation
4. Tumor
5. Infection
6. Uterine prolapse
7. Vulvular dystrophies
8. Imperforate hymen
9. Disorders of the cervix
10. Disorders of the uterine body
11. Disorders of the tubes and ovaries.

Ultrasound and hysterosalpingography have contributed immensely to the diagnosis of these

diseases of the female reproductive system.
Ultrasound is the first choice modality for the diagnosis of female reproductive system anomalies
because of its availability, low cost and non ionizing nature. It can reliably diagnose problems of
structural defect of the reproductive system.

Other imaging modalities that can be use in the diagnoses of reproductive system anomalies
include CT, MRI and Radionuclide imaging.

Hysterosalpingography has been used mainly to assess the patency of the uterine cervix, uterine
cavity and the uterine tubes. Hysterosalpingography is the radiographic examination of the uterus
and uterine tubes following the introduction of contrast medium.
PREPARATION OF PATIENT:
Patient should be given a suitable aperient on each of the two nights preceding the exam.
Patient should micturate immediately before the examination.
PREMEDICATIONS:
No premedication is required except on apprehensive patient where sedation may be required.
PRELIMINARY FILM: Preliminary film is taken with the patient supine on the couch with the
pelvis in symmetry. Beam is centered in the mid line, 2.5cm below the ASIS. Cassette size is
24x30cm.
RADIATION PROTECTION: Strict adherence must be paid to radiation protection by keeping
the dose to the gonads as low as reasonably achievable. 10 day rule should also be observed
when booking a patient for HSG.
CONTRAST MEDIUM: Oil and water soluble contrast medium can be used although water
soluble contrast is more preferred than oil soluble contrast medium. Urografin 60% is mostly
used contrast medium.
TECHNIQUE: The patient lies supine on the couch with the knee and hip flexed. Cold light
vaginal speculum is inserted to open up the vagina. The anterior lip of the cervix is gripped using
vulsellum forceps and uterine sound is inserted to determine the depth and direction of the
uterus. The injection cannula is inserted into the cervical canal after which the speculum is
removed. The contrast medium is injected into the uterus through the cervical and the flow of
contrast is monitored using fluoroscopy. Spot film radiographs can also be taken. After tubal
filling is observed, injection of contrast is continued until there is spillage of contrast. Post
injection radiograph is taken at 15 minutes to assess whether the contrast is fully absorbed or
whether residual contrast medium has pooled in loculated areas of adhesions.
AFTER CARE OF PATIENT: Patient must not leave the department until a check has
established that there is no hemorrhage and the she has fully recovered.
TROLLEY SETTING
UPPER (STERILE SHELF): The content of the upper shelf includes:-
Vulsellum forceps
Vaginal speculum
Uterine sound
Uterine cannula
Sponge holding forceps
Tissue forceps
One 10ml syringe (usually with finger grip and screw cap)
Lotion bowl
Gallipot
Towels
Gauze swabs
Gown
Rubber gloves
LOWER (UNSTERILIZED) SHELF: The content of this shelf includes:-
Cleansing lotion
Ampoule of contrast medium
File (for opening ampoule)
Masks
Pad and bandage or tampon
Emergency drugs