Anatomy & Embryology

Anatomy and Embryology

• Embryology
• Pelvic Structure
• Blood supply
•
Clinical
Lymphatics
Significance
• Nerves
• External genitalia
• Pelvic Viscera (including supports of the
uterus)
 Embryology
• Mullerian system is stimulated to develop
preferentially over the Wolffian system

• Mullerian ducts: Fallopian tubes, uterine

corpus, cervix, upper vagina
• Lower vagina: Urogenital sinus

• Wolffian duct remnants: Epoophoron,

Paroophoron, Gartners duct
Embryology: Clinical Relevance

Mullerian Anomalies
 Embryology: clinical relevance
• Gartners cyst
- Arises from the
remnants of the
mesonephric duct
- Anterolateral wall of
the vaginal wall
 Embryology…
Ovary:
• Develops by the 5th week
• The coelomic epithelium on the medial side of the
mesonephros becomes thickened to form genital
ridges
• Cords of cells (sex cords) proliferate from this
germinal epithelium, and grow into the underlying
mesoderm
 Embryology..

• Due to the intertwined development of the

genital and the urinary systems, anomalies of
one system are usually associated with the other

• Common associated anomalies

 Unilateral renal agenesis
 Abnormalities of renal position (pelvic kidney)
 Duplication anomalies
Bony Pelvis

Importance:
Pelvic Assessment
 Blood Supply
• The pelvic vasculature is a high volume high
flow system with enormous expansive
capabilities
• Blood flow increases to 500ml/min in term
pregnancy
• Extensive collateral circulation; anastomoses
between different major vessels
 Blood Supply (internal genitalia)
• Uterus
uterine artery (main)
ovarian artery
• Fallopian tube
medial 2/3rd - uterine artery
lateral 1/3rd - ovarian artery
• Ovary
ovarian artery (main)
uterine artery
 Blood Supply-Clinical Relevance
• Post partum haemorrhage:
Devascularization: uterine artery, internal iliac artery
Uterine artery embolization

• During hysterectomy:
Uterine artery ligation:
place the lowest clamp first
place it at right angles to the uterus
place it at the level of the internal cervical os

Ligation of infundibulopelvic ligament: Transfixing sutures

 Blood supply: External genitalia

• Internal pudendal
(Branch of internal
iliac)

• Branches: Lacerations: Severe bleeding

Vulval hematoma: blood loss limited by
Inferior haemorrhoidal Colle’s fascia and urogenital diaphragm
Transverse perineal
Labial branch
Dorsal artery of clitoris
 Lymphatic Drainage
• Ovary, fallopian tubes, uterine corpus: Aortic/Para
aortic nodes

• Fundus of the uterus: Superficial inguinal (through

the round ligament)

• Upper vagina, cervix, uterine corpus (lower):

External iliac, internal iliac, sacral and obturator
nodes
• Vulva, lower vagina :Superficial inguinal
Lymphatic Drainage
 Lymphatic Drainage-Clinical Significance

• Natural history of most genital tract

malignancies directly reflects the lymphatic
drainage

• Regional lymph node metastasis: imp factor in

formulation of treatment plans for
malignancies and predictors of outcome
Q. What are the lymph nodes
removed in Wertheims
Answer:
Hysterectomy?
Nerve Supply
 External Genitalia
Vulva: All structures
visible externally
from the pubis to the
Perineum

Vestibule: Cavity b/w

labia minora, contains
Vaginal and urethral
orifices
 External genitalia
• Mons Pubis:
subcutaneous adipose tissue
• Labia majora:
– Termination of the round
ligament
– Sebaceous glands, sweat
glands and
hair follicles:
folliculitis, boils and
sebaceous cysts
 External Genitalia
Clitoris

• Erectile structure
• Body of clitoris
• Glans - spongy erectile tissue with
high cutaneous sensitivity
• Suspensory ligament and
ischiocavernosi attached to crura

Clitoromegaly: > 1cm

 External genitalia
• Greater vestibular glands: accessory genital gland

Bartholins cyst

• Infection leads to
palpable
cyst in 2% of adult women
• Develops rapidly over 2-4
days
• Organism:N.Gonorrhoeae
Swelling on the inner side of the junction of
The anterior 2/3 with posterior 1/3 of the
labium minus
 External genitalia
Imperforate hymen

Due to failure of endoderm of the urogenital sinus

and epithelium of the vestibule to fuse and
perforate during embryonic development
 External genitalia: clinical correlates
Vulvar hematoma

• Straddle injuries
• Trauma of child birth.
 External genitalia: clinical correlates
• Episiotomy:

Q. What
Ans: are the muscles
Superficial
cut in anperineal,
transverse episiotomy?
bulbocavernosus
Pelvic Floor
Levator Ani

Internal rotation of the

Presenting part
 Levator sagging

Levator plate is horizontal during standing and

supports the pelvic viscera
Weakness of the muscle causes sagging and leads to prolapse
 Urogenital Diaphragm
• Also called the triangular ligament

• Superficial perineal space

• Deep perineal space

• Bulbocavernosus and transverse

perinei
• Muscles are responsible for
vaginismus
 Vagina
• Fibro muscular tube
• Approximately 10cm long
• Lined by non-keratinised
stratified epithelium
• Ascends posteriorly and
superiorly at an angle of 90
• Anterior wall-7.5 cm
• Posterior wall-9 cm
 Vagina

• Culdocentesis & posterior

colpotomy is done through
POD
 Vagina…

Nonkeratinised Stratified
squamous epithelium

Lactobacillus
 Vagina… Developmental defects
Transverse vaginal septum
• Incomplete canalization of
Mullerian tubercle and
sinovaginal bulb

Septate Vagina Vaginal

agenesis
 Pelvic Viscera

• Uterus
• Cervix
• Fallopian tube
• Ovary
• Ureter
 Uterus
• Hollow, pear shaped organ
• Fibromuscular
• Adult non pregnant uterus:
7 – 8cm length
6cm wide at the fundus
2.5cm thickness of walls
 Uterus
• Change in size with age

Infantile
Pubertal

Adult Menopause: Atrophy

 Uterus
• Change in size with
pregnancy
 Uterus…
• Divided into 3 parts
corpus uteri (body)
isthmus
cervix

Isthmus:
Lower Uterine Segment
 Uterus: position
• Normal position is
Anteversion and
Anteflexion
 Retroversion of the uterus

• Retroversion: 10-15% of
normal
• Acquired retroversion
- Endometriosis
(fixed) - PID
 Uterus…

Rectovaginal fold
of peritoneum

UV fold of
peritoneum
 Uterus… Relations
• Anterior:
Above the internal os:
UV pouch
Below the internal os:
separated from base of
bladder by loose
connective tissue
• Posterior:
Pouch of douglas
• Lateral
 Structure of the uterus
• The uterus has 3 layers: Perimetrium, Myometrium
and endometrium
• Myometrium has 3 layers:
Superficial fibres – longitudinally arranged
Middle layer – fibres which run obliqueli in a criss
cross fashion
 LIVING LIGATURES

Inner layer – circular fibres

Uterus: Endometrium
Uterus: On Ultrasound
 Supports of the uterus
• Supports of the uterus
Primary
Muscular:
Urogenital and pelvic diaphragm,
perineal body
Mechanical:
Uterine axis, pubocervical ligament,
uterosacral and cardinal ligaments
Secondary
Supports of the uterus
Supports of uterus…
Uterus: Prolapse
 Cervix

Cervix: External os

Arbor Vitae
 Cervix…
Squamocolumnar junction (SCJ)
• Cervix is composed of
- columnar epithelium: lines the endocervical
canal
- squamous epithelium: covers the exocervix
• The point at which they meet is called the SCJ
 Cervix
Transformation zone
• Metaplasia advances
from the original SCJ
inward toward the
external os and over the
columnar villi:
Transformation zone
established
 Cervix: Clinical Correlates
• Pap smear; CIN

• Cervical erosion

• Nabothian cyst

• Cervical polyp
 Fallopian tube
• lie on each side of the uterus
in upper margin of the broad
ligament
• about 10 cm long
 Fallopian Tube
Parts of the tube
 Fallopian tube: Clinical Correlates

• Transport of ovum
• Site of fertilization
• Ectopic pregnancy
• Sterilization
• Tubal factors for
infertility
 Ovary
• 3 x 1.5cm
• Meso ovarium – from
the posterior leaf of
broad ligament
• Attached to uterus by
ovarian ligament
• Histology:
- Medulla (vascular)
- Cortex (stroma)
 Ovary…
N
Number of oocytes decrease with age
 Ovary – Clinical relevance
• Ovarian cyst
• Ovarian tumors
benign
malignant
• PCOS
 Ovary…

Ans.
1. Infundibulopelvic ligament with ovarian vessels
Q. What are the contents of the
2. Ovarian ligament
3. Meso ovarium ovarian pedicle in torsion?
4. Part of fallopian tube
5. Utero-ovarian anastomosis
 Ureter: Anatomy
• 2 major components
abdominal
pelvic

• 25-30cm in length

• Course of ureter
Ureter: Course in the pelvis

Ureter
 Ureter: Clinical Relevance
• Operative injury:

The most common sites of injury:

• Lateral to the uterine vessels
• The area of the ureterovesical junction
• Base of the infundibulopelvic ligament as the ureters
cross the pelvic brim
• At the level of the uterosacral ligaments
Ureter: Operative injury